hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|TX,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Carrollton Regional Medical Center,12/2/2024,2.0.0,Carrollton Regional Medical Center,"4343 N Josey Ln Carrollton, TX 75010",843683956,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|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA_EXCHANGE|MEDICARE|negotiated_dollar,standard_charge|AETNA_EXCHANGE|MEDICARE|negotiated_percentage,standard_charge|AETNA_EXCHANGE|MEDICARE|negotiated_algorithm,estimated_amount|AETNA_EXCHANGE|MEDICARE,standard_charge|AETNA_EXCHANGE|MEDICARE|methodology,additional_payer_notes|AETNA_EXCHANGE|MEDICARE,standard_charge|AETNA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|AETNA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|AETNA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|AETNA_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|AETNA_MEDICARE_ADVANTAGE|MEDICARE|methodology,additional_payer_notes|AETNA_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|AMERIGROUP|MEDICAID|negotiated_dollar,standard_charge|AMERIGROUP|MEDICAID|negotiated_percentage,standard_charge|AMERIGROUP|MEDICAID|negotiated_algorithm,estimated_amount|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|MEDICAID|methodology,additional_payer_notes|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|AMERIGROUP_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|AMERIGROUP_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|AMERIGROUP_MEDICARE|MEDICARE,standard_charge|AMERIGROUP_MEDICARE|MEDICARE|methodology,additional_payer_notes|AMERIGROUP_MEDICARE|MEDICARE,standard_charge|BCBS_BLUE_ADVANTAGE|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_BLUE_ADVANTAGE|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_BLUE_ADVANTAGE|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_BLUE_ADVANTAGE|COMMERCIAL,standard_charge|BCBS_BLUE_ADVANTAGE|COMMERCIAL|methodology,additional_payer_notes|BCBS_BLUE_ADVANTAGE|COMMERCIAL,standard_charge|BCBS_BLUE_ESSENTIALS|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_BLUE_ESSENTIALS|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_BLUE_ESSENTIALS|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_BLUE_ESSENTIALS|COMMERCIAL,standard_charge|BCBS_BLUE_ESSENTIALS|COMMERCIAL|methodology,additional_payer_notes|BCBS_BLUE_ESSENTIALS|COMMERCIAL,standard_charge|BCBS_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|BCBS_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|BCBS_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|BCBS_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|BCBS_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|BCBS_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|BCBS_POS|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_POS|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_POS|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_POS|COMMERCIAL,standard_charge|BCBS_POS|COMMERCIAL|methodology,additional_payer_notes|BCBS_POS|COMMERCIAL,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_PPO|COMMERCIAL,standard_charge|BCBS_PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS_PPO|COMMERCIAL,standard_charge|BCBS_TRADITIONAL|commercial|negotiated_dollar,standard_charge|BCBS_TRADITIONAL|commercial|negotiated_percentage,standard_charge|BCBS_TRADITIONAL|commercial|negotiated_algorithm,estimated_amount|BCBS_TRADITIONAL|commercial,standard_charge|BCBS_TRADITIONAL|commercial|methodology,additional_payer_notes|BCBS_TRADITIONAL|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|COOKS_CHILDREN|MEDICAID|negotiated_dollar,standard_charge|COOKS_CHILDREN|MEDICAID|negotiated_percentage,standard_charge|COOKS_CHILDREN|MEDICAID|negotiated_algorithm,estimated_amount|COOKS_CHILDREN|MEDICAID,standard_charge|COOKS_CHILDREN|MEDICAID|methodology,additional_payer_notes|COOKS_CHILDREN|MEDICAID,standard_charge|HUMANA_MEDICARE_HMO|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE_HMO|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE_HMO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE_HMO|MEDICARE,standard_charge|HUMANA_MEDICARE_HMO|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE_HMO|MEDICARE,standard_charge|HUMANA_MEDICARE_PFFS|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE_PFFS|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE_PFFS|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE_PFFS|MEDICARE,standard_charge|HUMANA_MEDICARE_PFFS|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE_PFFS|MEDICARE,standard_charge|HUMANA_MEDICARE_POS|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE_POS|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE_POS|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE_POS|MEDICARE,standard_charge|HUMANA_MEDICARE_POS|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE_POS|MEDICARE,standard_charge|HUMANA_MEDICARE_PPO|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE_PPO|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE_PPO|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE_PPO|MEDICARE,standard_charge|HUMANA_MEDICARE_PPO|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE_PPO|MEDICARE,standard_charge|HUMANA_MILTARY|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MILTARY|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MILTARY|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MILTARY|MEDICARE,standard_charge|HUMANA_MILTARY|MEDICARE|methodology,additional_payer_notes|HUMANA_MILTARY|MEDICARE,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|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|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE|negotiated_dollar,standard_charge|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE|negotiated_percentage,standard_charge|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE|negotiated_algorithm,estimated_amount|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE,standard_charge|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE|methodology,additional_payer_notes|MOLINA_HEALTH_INSURANCE_MARKETPLACE|MEDICARE,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MOLINA_MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|MOLINA_MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MOLINA_MEDICAID_CHIP|MEDICAID|negotiated_dollar,standard_charge|MOLINA_MEDICAID_CHIP|MEDICAID|negotiated_percentage,standard_charge|MOLINA_MEDICAID_CHIP|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA_MEDICAID_CHIP|MEDICAID,standard_charge|MOLINA_MEDICAID_CHIP|MEDICAID|methodology,additional_payer_notes|MOLINA_MEDICAID_CHIP|MEDICAID,standard_charge|MOLINA_MEDICAID_STAR_PLUS|MEDICAID|negotiated_dollar,standard_charge|MOLINA_MEDICAID_STAR_PLUS|MEDICAID|negotiated_percentage,standard_charge|MOLINA_MEDICAID_STAR_PLUS|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|MOLINA_MEDICAID_STAR_PLUS|MEDICAID|methodology,additional_payer_notes|MOLINA_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|MOLINA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|MOLINA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|MOLINA_MEDICARE_ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|MOLINA_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|MOLINA_MEDICARE_ADVANTAGE|MEDICARE|methodology,additional_payer_notes|MOLINA_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|MOLINA_MEDICARE_STAR_PLUS|MEDICARE|negotiated_dollar,standard_charge|MOLINA_MEDICARE_STAR_PLUS|MEDICARE|negotiated_percentage,standard_charge|MOLINA_MEDICARE_STAR_PLUS|MEDICARE|negotiated_algorithm,estimated_amount|MOLINA_MEDICARE_STAR_PLUS|MEDICARE,standard_charge|MOLINA_MEDICARE_STAR_PLUS|MEDICARE|methodology,additional_payer_notes|MOLINA_MEDICARE_STAR_PLUS|MEDICARE,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|SCOTT_AND_WHITE_EPO|COMMERCIAL|negotiated_dollar,standard_charge|SCOTT_AND_WHITE_EPO|COMMERCIAL|negotiated_percentage,standard_charge|SCOTT_AND_WHITE_EPO|COMMERCIAL|negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_EPO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_EPO|COMMERCIAL|methodology,additional_payer_notes|SCOTT_AND_WHITE_EPO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_HMO|COMMERCIAL|negotiated_dollar,standard_charge|SCOTT_AND_WHITE_HMO|COMMERCIAL|negotiated_percentage,standard_charge|SCOTT_AND_WHITE_HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_HMO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_HMO|COMMERCIAL|methodology,additional_payer_notes|SCOTT_AND_WHITE_HMO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID| methodology,additional_payer_notes|SCOTT_AND_WHITE_MEDICAID_CHIP|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID| methodology,additional_payer_notes|SCOTT_AND_WHITE_MEDICAID_STAR|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID| methodology,additional_payer_notes|SCOTT_AND_WHITE_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE| methodology,additional_payer_notes|SCOTT_AND_WHITE_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|SCOTT_AND_WHITE_PPO|COMMERCIAL| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_PPO|COMMERCIAL| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_PPO|COMMERCIAL| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_PPO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_PPO|COMMERCIAL| methodology,additional_payer_notes|SCOTT_AND_WHITE_PPO|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_SWHP|COMMERCIAL| negotiated_dollar,standard_charge|SCOTT_AND_WHITE_SWHP|COMMERCIAL| negotiated_percentage,standard_charge|SCOTT_AND_WHITE_SWHP|COMMERCIAL| negotiated_algorithm,estimated_amount|SCOTT_AND_WHITE_SWHP|COMMERCIAL,standard_charge|SCOTT_AND_WHITE_SWHP|COMMERCIAL| methodology,additional_payer_notes|SCOTT_AND_WHITE_SWHP|COMMERCIAL,standard_charge|SUPERIOR|MEDICARE| negotiated_dollar,standard_charge|SUPERIOR|MEDICARE| negotiated_percentage,standard_charge|SUPERIOR|MEDICARE| negotiated_algorithm,estimated_amount|SUPERIOR|MEDICARE,standard_charge|SUPERIOR|MEDICARE| methodology,additional_payer_notes|SUPERIOR|MEDICARE,standard_charge|SUPERIOR_MEDICAID|MEDICAID| negotiated_dollar,standard_charge|SUPERIOR_MEDICAID|MEDICAID| negotiated_percentage,standard_charge|SUPERIOR_MEDICAID|MEDICAID| negotiated_algorithm,estimated_amount|SUPERIOR_MEDICAID|MEDICAID,standard_charge|SUPERIOR_MEDICAID|MEDICAID| methodology,additional_payer_notes|SUPERIOR_MEDICAID|MEDICAID,standard_charge|SUPERIOR_MEDICAID_CHIP|MEDICAID| negotiated_dollar,standard_charge|SUPERIOR_MEDICAID_CHIP|MEDICAID| negotiated_percentage,standard_charge|SUPERIOR_MEDICAID_CHIP|MEDICAID| negotiated_algorithm,estimated_amount|SUPERIOR_MEDICAID_CHIP|MEDICAID,standard_charge|SUPERIOR_MEDICAID_CHIP|MEDICAID| methodology,additional_payer_notes|SUPERIOR_MEDICAID_CHIP|MEDICAID,standard_charge|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE| negotiated_dollar,standard_charge|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE| negotiated_algorithm,estimated_amount|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE| methodology,additional_payer_notes|SUPERIOR_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|UHC|COMMERCIAL| negotiated_dollar,standard_charge|UHC|COMMERCIAL| negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL| methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UHC_MEDICAID|MEDICAID| negotiated_dollar,standard_charge|UHC_MEDICAID|MEDICAID| negotiated_percentage,standard_charge|UHC_MEDICAID|MEDICAID| negotiated_algorithm,estimated_amount|UHC_MEDICAID|MEDICAID,standard_charge|UHC_MEDICAID|MEDICAID| methodology,additional_payer_notes|UHC_MEDICAID|MEDICAID,standard_charge|UHC_MEDICAID_CHIP|MEDICAID| negotiated_dollar,standard_charge|UHC_MEDICAID_CHIP|MEDICAID| negotiated_percentage,standard_charge|UHC_MEDICAID_CHIP|MEDICAID| negotiated_algorithm,estimated_amount|UHC_MEDICAID_CHIP|MEDICAID,standard_charge|UHC_MEDICAID_CHIP|MEDICAID| methodology,additional_payer_notes|UHC_MEDICAID_CHIP|MEDICAID,standard_charge|UHC_MEDICAID_STAR|MEDICAID| negotiated_dollar,standard_charge|UHC_MEDICAID_STAR|MEDICAID| negotiated_percentage,standard_charge|UHC_MEDICAID_STAR|MEDICAID| negotiated_algorithm,estimated_amount|UHC_MEDICAID_STAR|MEDICAID,standard_charge|UHC_MEDICAID_STAR|MEDICAID| methodology,additional_payer_notes|UHC_MEDICAID_STAR|MEDICAID,standard_charge|UHC_MEDICAID_STAR_PLUS|MEDICAID| negotiated_dollar,standard_charge|UHC_MEDICAID_STAR_PLUS|MEDICAID| negotiated_percentage,standard_charge|UHC_MEDICAID_STAR_PLUS|MEDICAID| negotiated_algorithm,estimated_amount|UHC_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|UHC_MEDICAID_STAR_PLUS|MEDICAID| methodology,additional_payer_notes|UHC_MEDICAID_STAR_PLUS|MEDICAID,standard_charge|UHC_MEDICARE_ADVANTAGE|MEDICARE| negotiated_dollar,standard_charge|UHC_MEDICARE_ADVANTAGE|MEDICARE| negotiated_percentage,standard_charge|UHC_MEDICARE_ADVANTAGE|MEDICARE| negotiated_algorithm,estimated_amount|UHC_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|UHC_MEDICARE_ADVANTAGE|MEDICARE| methodology,additional_payer_notes|UHC_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|WORK_COMP|COMMERCIAL| negotiated_dollar,standard_charge|WORK_COMP|COMMERCIAL| negotiated_percentage,standard_charge|WORK_COMP|COMMERCIAL| negotiated_algorithm,estimated_amount|WORK_COMP|COMMERCIAL,standard_charge|WORK_COMP|COMMERCIAL| methodology,additional_payer_notes|WORK_COMP|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
BINDER ABDOMINAL 45 IN CIRCUMFERENCE 9 IN WIDTH LA,21000001,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,49.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,45588.31,
BINDER ABDOMINAL 46 TO 62 IN CIRCUMFERENCE 9 IN W,21000002,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,49.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,45588.31,
DRESSING HYDROCOLLOID THIN SQUARE 4 INCH WIDTH 4,21000003,CDM,272,RC,,,Outpatient,,,152.93,91.76,,91.76,60,,73.408,Percent of Total Billed Charges,60% of Total Billed Charges,68.82,45,,55.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.82,28,,34.256,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,36,,44.04,Percent of Total Billed Charges,36% of Total Billed Charges,55.05,36,,44.04,Percent of Total Billed Charges,36% Total Bille Charges,55.05,36,,44.04,Percent of Total Billed Charges,36% of Total Billed Charges,91.76,60,,73.408,Percent of Total Billed Charges,60% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.93,100,,122.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14.42,,17.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.7,75,,91.76,Percent of Total Billed Charges,75% of Total Billed Charges,76.47,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,76.47,50,,61.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.47,50,,61.176,Percent of Total Billed Charges,50% of Total Billed Charges,76.47,50,,61.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.05,70,,85.64,Percent of Total Billed Charges,70% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,21.41,14,,17.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.93,100,,122.344,Percent of Total Billed Charges,100% of Total Billed Charges,21.41,45588.31,
PI CVC KIT 3 L 7 FR X 20 CM,21000004,CDM,278,RC,C1751,HCPCS,Outpatient,,,508.62,305.17,,627.14,110,,501.712,Percent of Total Billed Charges,110% of Total Billed Charges,228.88,45,,183.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.41,28,,113.928,Percent of Total Billed Charges,28% of Total Billed Charges,214.7,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,183.1,36,,146.48,Percent of Total Billed Charges,36% of Total Billed Charges,183.1,36,,146.48,Percent of Total Billed Charges,36% Total Bille Charges,183.1,36,,146.48,Percent of Total Billed Charges,36% of Total Billed Charges,279.74,55,,223.792,Percent of Total Billed Charges,55% Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.62,100,,406.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,73.34,14.42,,58.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.9,80,,325.52,Percent of Total Billed Charges,80% of Total Billed Charges,254.31,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,254.31,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.31,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,254.31,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.03,70,,284.824,Percent of Total Billed Charges,70% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.62,100,,406.896,Percent of Total Billed Charges,100% of Total Billed Charges,71.21,627.14,
DECLOGGER CATH CLGZAPPER 6ML,21000006,CDM,271,RC,,,Outpatient,,,203.12,121.87,,121.87,60,,97.496,Percent of Total Billed Charges,60% of Total Billed Charges,91.4,45,,73.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.87,28,,45.496,Percent of Total Billed Charges,28% of Total Billed Charges,214.7,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,73.12,36,,58.496,Percent of Total Billed Charges,36% of Total Billed Charges,73.12,36,,58.496,Percent of Total Billed Charges,36% Total Bille Charges,73.12,36,,58.496,Percent of Total Billed Charges,36% of Total Billed Charges,121.87,60,,97.496,Percent of Total Billed Charges,60% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.12,100,,162.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.34,75,,121.872,Percent of Total Billed Charges,75% of Total Billed Charges,101.56,50,,61.176,Percent of Total Billed Charges,50% of Total Billed Charges,101.56,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.56,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,101.56,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.18,70,,113.744,Percent of Total Billed Charges,70% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.12,100,,162.496,Percent of Total Billed Charges,100% of Total Billed Charges,28.44,214.7,
PAD DEFIBRILLATION ADULT RADIOTRANSPARENT WITH CAR,21000007,CDM,271,RC,,,Outpatient,,,284.2,170.52,,170.52,60,,136.416,Percent of Total Billed Charges,60% of Total Billed Charges,127.89,45,,102.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.58,28,,63.664,Percent of Total Billed Charges,28% of Total Billed Charges,214.7,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% Total Bille Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,170.52,60,,136.416,Percent of Total Billed Charges,60% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.2,100,,227.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.98,14.42,,32.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.15,75,,170.52,Percent of Total Billed Charges,75% of Total Billed Charges,142.1,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.94,70,,159.152,Percent of Total Billed Charges,70% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.2,100,,227.36,Percent of Total Billed Charges,100% of Total Billed Charges,39.79,284.2,
BAG PRESSURE INFUS 1000ML DISP,21000008,CDM,271,RC,,,Outpatient,,,185.36,111.22,,111.22,60,,88.976,Percent of Total Billed Charges,60% of Total Billed Charges,83.41,45,,66.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.9,28,,41.52,Percent of Total Billed Charges,28% of Total Billed Charges,881.54,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,66.73,36,,53.384,Percent of Total Billed Charges,36% of Total Billed Charges,66.73,36,,53.384,Percent of Total Billed Charges,36% Total Bille Charges,66.73,36,,53.384,Percent of Total Billed Charges,36% of Total Billed Charges,111.22,60,,88.976,Percent of Total Billed Charges,60% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.36,100,,148.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,26.73,14.42,,21.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.02,75,,111.216,Percent of Total Billed Charges,75% of Total Billed Charges,92.68,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,92.68,50,,74.144,Percent of Total Billed Charges,50% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.68,50,,74.144,Percent of Total Billed Charges,50% of Total Billed Charges,92.68,50,,74.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.75,70,,103.8,Percent of Total Billed Charges,70% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14,,20.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.36,100,,148.288,Percent of Total Billed Charges,100% of Total Billed Charges,25.95,881.54,
CATHETER PACING 5FR L110CM 1CM ELECTRODE SPACING 5,21000009,CDM,271,RC,,,Outpatient,,,367,220.20,,220.2,60,,176.16,Percent of Total Billed Charges,60% of Total Billed Charges,165.15,45,,132.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.76,28,,82.208,Percent of Total Billed Charges,28% of Total Billed Charges,881.54,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,36,,105.696,Percent of Total Billed Charges,36% of Total Billed Charges,132.12,36,,105.696,Percent of Total Billed Charges,36% Total Bille Charges,132.12,36,,105.696,Percent of Total Billed Charges,36% of Total Billed Charges,220.2,60,,176.16,Percent of Total Billed Charges,60% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367,100,,293.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14.42,,42.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.25,75,,220.2,Percent of Total Billed Charges,75% of Total Billed Charges,183.5,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.9,70,,205.52,Percent of Total Billed Charges,70% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367,100,,293.6,Percent of Total Billed Charges,100% of Total Billed Charges,51.38,881.54,
CATH ART FEM TWL BLD 18GX6IN,21000010,CDM,271,RC,,,Outpatient,,,157.68,94.61,,94.61,60,,75.688,Percent of Total Billed Charges,60% of Total Billed Charges,70.96,45,,56.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.15,28,,35.32,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,56.76,36,,45.408,Percent of Total Billed Charges,36% of Total Billed Charges,56.76,36,,45.408,Percent of Total Billed Charges,36% Total Bille Charges,56.76,36,,45.408,Percent of Total Billed Charges,36% of Total Billed Charges,94.61,60,,75.688,Percent of Total Billed Charges,60% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.68,100,,126.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.74,14.42,,18.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.26,75,,94.608,Percent of Total Billed Charges,75% of Total Billed Charges,78.84,50,,74.144,Percent of Total Billed Charges,50% of Total Billed Charges,78.84,50,,63.072,Percent of Total Billed Charges,50% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.84,50,,63.072,Percent of Total Billed Charges,50% of Total Billed Charges,78.84,50,,63.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.38,70,,88.304,Percent of Total Billed Charges,70% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,22.08,14,,17.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.68,100,,126.144,Percent of Total Billed Charges,100% of Total Billed Charges,22.08,1744.63,
TUBE CHEST 28 FR TROCAR TIP STRAIGHT REGULAR 9.3 M,21000011,CDM,271,RC,,,Outpatient,,,127.8,76.68,,76.68,60,,61.344,Percent of Total Billed Charges,60% of Total Billed Charges,57.51,45,,46.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.78,28,,28.624,Percent of Total Billed Charges,28% of Total Billed Charges,238.44,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,46.01,36,,36.808,Percent of Total Billed Charges,36% of Total Billed Charges,46.01,36,,36.808,Percent of Total Billed Charges,36% Total Bille Charges,46.01,36,,36.808,Percent of Total Billed Charges,36% of Total Billed Charges,76.68,60,,61.344,Percent of Total Billed Charges,60% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.8,100,,102.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.43,14.42,,14.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.85,75,,76.68,Percent of Total Billed Charges,75% of Total Billed Charges,63.9,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.9,50,,51.12,Percent of Total Billed Charges,50% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.9,50,,51.12,Percent of Total Billed Charges,50% of Total Billed Charges,63.9,50,,51.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.46,70,,71.568,Percent of Total Billed Charges,70% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14,,14.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.8,100,,102.24,Percent of Total Billed Charges,100% of Total Billed Charges,17.89,238.44,
DEVICE CLOSURE 24CM HEMOSTASIS ADHESIVE PROCEDURA,21000012,CDM,271,RC,,,Outpatient,,,425.15,255.09,,255.09,60,,204.072,Percent of Total Billed Charges,60% of Total Billed Charges,191.32,45,,153.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.04,28,,95.232,Percent of Total Billed Charges,28% of Total Billed Charges,222.94,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,153.05,36,,122.44,Percent of Total Billed Charges,36% of Total Billed Charges,153.05,36,,122.44,Percent of Total Billed Charges,36% Total Bille Charges,153.05,36,,122.44,Percent of Total Billed Charges,36% of Total Billed Charges,255.09,60,,204.072,Percent of Total Billed Charges,60% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.15,100,,340.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,61.31,14.42,,49.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.86,75,,255.088,Percent of Total Billed Charges,75% of Total Billed Charges,212.58,50,,63.072,Percent of Total Billed Charges,50% of Total Billed Charges,212.58,50,,170.064,Percent of Total Billed Charges,50% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.58,50,,170.064,Percent of Total Billed Charges,50% of Total Billed Charges,212.58,50,,170.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.61,70,,238.088,Percent of Total Billed Charges,70% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.52,14,,47.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.15,100,,340.12,Percent of Total Billed Charges,100% of Total Billed Charges,59.52,425.15,
CATHETER VENTRICULAR 1.5 MM DIAMETER EVD WITHOUT R,21000014,CDM,271,RC,,,Outpatient,,,2300.64,1380.38,,1380.38,60,,1104.304,Percent of Total Billed Charges,60% of Total Billed Charges,1035.29,45,,828.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.18,28,,515.344,Percent of Total Billed Charges,28% of Total Billed Charges,222.94,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,828.23,36,,662.584,Percent of Total Billed Charges,36% of Total Billed Charges,828.23,36,,662.584,Percent of Total Billed Charges,36% Total Bille Charges,828.23,36,,662.584,Percent of Total Billed Charges,36% of Total Billed Charges,1380.38,60,,1104.304,Percent of Total Billed Charges,60% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2300.64,100,,1840.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,331.75,14.42,,265.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1725.48,75,,1380.384,Percent of Total Billed Charges,75% of Total Billed Charges,1150.32,50,,51.12,Percent of Total Billed Charges,50% of Total Billed Charges,1150.32,50,,920.256,Percent of Total Billed Charges,50% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1150.32,50,,920.256,Percent of Total Billed Charges,50% of Total Billed Charges,1150.32,50,,920.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1610.45,70,,1288.36,Percent of Total Billed Charges,70% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,322.09,14,,257.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2300.64,100,,1840.512,Percent of Total Billed Charges,100% of Total Billed Charges,222.94,2300.64,
KIT BASIC MICROSENSOR FOR SUBDURAL/INTRAPARENCHYM,21000015,CDM,271,RC,,,Outpatient,,,2989.92,1793.95,,1793.95,60,,1435.16,Percent of Total Billed Charges,60% of Total Billed Charges,1345.46,45,,1076.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,837.18,28,,669.744,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,1076.37,36,,861.096,Percent of Total Billed Charges,36% of Total Billed Charges,1076.37,36,,861.096,Percent of Total Billed Charges,36% Total Bille Charges,1076.37,36,,861.096,Percent of Total Billed Charges,36% of Total Billed Charges,1793.95,60,,1435.16,Percent of Total Billed Charges,60% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2989.92,100,,2391.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,431.15,14.42,,344.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2242.44,75,,1793.952,Percent of Total Billed Charges,75% of Total Billed Charges,1494.96,50,,170.064,Percent of Total Billed Charges,50% of Total Billed Charges,1494.96,50,,1195.968,Percent of Total Billed Charges,50% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1494.96,50,,1195.968,Percent of Total Billed Charges,50% of Total Billed Charges,1494.96,50,,1195.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2092.94,70,,1674.352,Percent of Total Billed Charges,70% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,418.59,14,,334.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2989.92,100,,2391.936,Percent of Total Billed Charges,100% of Total Billed Charges,418.59,3925.64,
NEEDLE GUIDE KIT 21GX1-2CM,21000016,CDM,271,RC,,,Outpatient,,,219.08,131.45,,131.45,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,98.59,45,,78.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.34,28,,49.072,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,78.87,36,,63.096,Percent of Total Billed Charges,36% of Total Billed Charges,78.87,36,,63.096,Percent of Total Billed Charges,36% Total Bille Charges,78.87,36,,63.096,Percent of Total Billed Charges,36% of Total Billed Charges,131.45,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.08,100,,175.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.59,14.42,,25.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.31,75,,131.448,Percent of Total Billed Charges,75% of Total Billed Charges,109.54,50,,920.256,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.54,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.36,70,,122.688,Percent of Total Billed Charges,70% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.08,100,,175.264,Percent of Total Billed Charges,100% of Total Billed Charges,30.67,3925.64,
DRAIN CHST CHST PLR-EV PED,21000017,CDM,271,RC,,,Outpatient,,,500,300.00,,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,225,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,180,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,180,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,180,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500,100,,400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,72.1,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,1195.968,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,70,,280,Percent of Total Billed Charges,70% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,70,3925.64,
THORACENTESIS TY ARROW-CLARKE,21000018,CDM,271,RC,,,Outpatient,,,379.75,227.85,,227.85,60,,182.28,Percent of Total Billed Charges,60% of Total Billed Charges,170.89,45,,136.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.33,28,,85.064,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.71,36,,109.368,Percent of Total Billed Charges,36% of Total Billed Charges,136.71,36,,109.368,Percent of Total Billed Charges,36% Total Bille Charges,136.71,36,,109.368,Percent of Total Billed Charges,36% of Total Billed Charges,227.85,60,,182.28,Percent of Total Billed Charges,60% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.75,100,,303.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,54.76,14.42,,43.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.81,75,,227.848,Percent of Total Billed Charges,75% of Total Billed Charges,189.88,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,189.88,50,,151.904,Percent of Total Billed Charges,50% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.88,50,,151.904,Percent of Total Billed Charges,50% of Total Billed Charges,189.88,50,,151.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.83,70,,212.664,Percent of Total Billed Charges,70% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.17,14,,42.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.75,100,,303.8,Percent of Total Billed Charges,100% of Total Billed Charges,53.17,1744.63,
SET TRACHEOSTOMY 8FR PERCUTANEOUS INTRODUCER CIAG,21000019,CDM,271,RC,,,Outpatient,,,2158,1294.80,,1294.8,60,,1035.84,Percent of Total Billed Charges,60% of Total Billed Charges,971.1,45,,776.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,604.24,28,,483.392,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,776.88,36,,621.504,Percent of Total Billed Charges,36% of Total Billed Charges,776.88,36,,621.504,Percent of Total Billed Charges,36% Total Bille Charges,776.88,36,,621.504,Percent of Total Billed Charges,36% of Total Billed Charges,1294.8,60,,1035.84,Percent of Total Billed Charges,60% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2158,100,,1726.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,311.18,14.42,,248.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1618.5,75,,1294.8,Percent of Total Billed Charges,75% of Total Billed Charges,1079,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,1079,50,,863.2,Percent of Total Billed Charges,50% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1079,50,,863.2,Percent of Total Billed Charges,50% of Total Billed Charges,1079,50,,863.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1510.6,70,,1208.48,Percent of Total Billed Charges,70% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,302.12,14,,241.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2158,100,,1726.4,Percent of Total Billed Charges,100% of Total Billed Charges,302.12,2158,
DRSG FM GRNFM TRAC 15X10CM,21000020,CDM,272,RC,,,Outpatient,,,212.16,127.30,,127.3,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,95.47,45,,76.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.4,28,,47.52,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,76.38,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,76.38,36,,61.104,Percent of Total Billed Charges,36% Total Bille Charges,76.38,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,127.3,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.16,100,,169.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.59,14.42,,24.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.12,75,,127.296,Percent of Total Billed Charges,75% of Total Billed Charges,106.08,50,,151.904,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.51,70,,118.808,Percent of Total Billed Charges,70% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.16,100,,169.728,Percent of Total Billed Charges,100% of Total Billed Charges,29.7,1744.63,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESIVE,21000021,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,46.08,45,,36.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,22.936,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.4,100,,81.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,863.2,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,14.34,1744.63,
CANISTR SUC GEL INFOVAC 1000ML,21000022,CDM,271,RC,,,Outpatient,,,484.7,290.82,,290.82,60,,232.656,Percent of Total Billed Charges,60% of Total Billed Charges,218.12,45,,174.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.72,28,,108.576,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,174.49,36,,139.592,Percent of Total Billed Charges,36% of Total Billed Charges,174.49,36,,139.592,Percent of Total Billed Charges,36% Total Bille Charges,174.49,36,,139.592,Percent of Total Billed Charges,36% of Total Billed Charges,290.82,60,,232.656,Percent of Total Billed Charges,60% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484.7,100,,387.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,69.89,14.42,,55.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.53,75,,290.824,Percent of Total Billed Charges,75% of Total Billed Charges,242.35,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,242.35,50,,193.88,Percent of Total Billed Charges,50% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,242.35,50,,193.88,Percent of Total Billed Charges,50% of Total Billed Charges,242.35,50,,193.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339.29,70,,271.432,Percent of Total Billed Charges,70% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.86,14,,54.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.7,100,,387.76,Percent of Total Billed Charges,100% of Total Billed Charges,67.86,1744.63,
SENSOR ELECTROENCEPHALOGRAPH FOR SEDLINE MOC9,21000023,CDM,271,RC,,,Outpatient,,,750,450.00,,450,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,450,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,375,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,105,1744.63,
IV KT MONITORING POLE MOUNT,21000024,CDM,271,RC,,,Outpatient,,,134,80.40,,80.4,60,,64.32,Percent of Total Billed Charges,60% of Total Billed Charges,60.3,45,,48.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.52,28,,30.016,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,48.24,36,,38.592,Percent of Total Billed Charges,36% of Total Billed Charges,48.24,36,,38.592,Percent of Total Billed Charges,36% Total Bille Charges,48.24,36,,38.592,Percent of Total Billed Charges,36% of Total Billed Charges,80.4,60,,64.32,Percent of Total Billed Charges,60% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,100,,107.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14.42,,15.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.5,75,,80.4,Percent of Total Billed Charges,75% of Total Billed Charges,67,50,,193.88,Percent of Total Billed Charges,50% of Total Billed Charges,67,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,67,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.8,70,,75.04,Percent of Total Billed Charges,70% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,15.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134,100,,107.2,Percent of Total Billed Charges,100% of Total Billed Charges,18.76,1744.63,
FECAL MGMT FLEXISEAL SIGNAL,21000025,CDM,271,RC,,,Outpatient,,,1336.52,801.91,,801.91,60,,641.528,Percent of Total Billed Charges,60% of Total Billed Charges,601.43,45,,481.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.23,28,,299.384,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,481.15,36,,384.92,Percent of Total Billed Charges,36% of Total Billed Charges,481.15,36,,384.92,Percent of Total Billed Charges,36% Total Bille Charges,481.15,36,,384.92,Percent of Total Billed Charges,36% of Total Billed Charges,801.91,60,,641.528,Percent of Total Billed Charges,60% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1336.52,100,,1069.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14.42,,154.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1002.39,75,,801.912,Percent of Total Billed Charges,75% of Total Billed Charges,668.26,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,668.26,50,,534.608,Percent of Total Billed Charges,50% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,668.26,50,,534.608,Percent of Total Billed Charges,50% of Total Billed Charges,668.26,50,,534.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,935.56,70,,748.448,Percent of Total Billed Charges,70% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,187.11,14,,149.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1336.52,100,,1069.216,Percent of Total Billed Charges,100% of Total Billed Charges,187.11,1744.63,
TRAY HEMODIALYSIS ADULT L15CM DIA13FR POLYURETHANE,21000026,CDM,271,RC,,,Outpatient,,,1014.4,608.64,,608.64,60,,486.912,Percent of Total Billed Charges,60% of Total Billed Charges,456.48,45,,365.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.03,28,,227.224,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% Total Bille Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,608.64,60,,486.912,Percent of Total Billed Charges,60% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1014.4,100,,811.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,146.28,14.42,,117.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.8,75,,608.64,Percent of Total Billed Charges,75% of Total Billed Charges,507.2,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,710.08,70,,568.064,Percent of Total Billed Charges,70% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1014.4,100,,811.52,Percent of Total Billed Charges,100% of Total Billed Charges,142.02,1744.63,
TRAY HEMODIALYSIS ADULT L20CM DIA13FR POLYURETHANE,21000027,CDM,271,RC,,,Outpatient,,,1014.4,608.64,,608.64,60,,486.912,Percent of Total Billed Charges,60% of Total Billed Charges,456.48,45,,365.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.03,28,,227.224,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% Total Bille Charges,365.18,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,608.64,60,,486.912,Percent of Total Billed Charges,60% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1014.4,100,,811.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,146.28,14.42,,117.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.8,75,,608.64,Percent of Total Billed Charges,75% of Total Billed Charges,507.2,50,,534.608,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,710.08,70,,568.064,Percent of Total Billed Charges,70% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1014.4,100,,811.52,Percent of Total Billed Charges,100% of Total Billed Charges,142.02,1744.63,
DRESSING SURGICAL 4X4IN ISLAND ANTIMICROBIAL SILVE,21000028,CDM,272,RC,,,Outpatient,,,106.7,64.02,,64.02,60,,51.216,Percent of Total Billed Charges,60% of Total Billed Charges,48.02,45,,38.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.88,28,,23.904,Percent of Total Billed Charges,28% of Total Billed Charges,86.72,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,38.41,36,,30.728,Percent of Total Billed Charges,36% of Total Billed Charges,38.41,36,,30.728,Percent of Total Billed Charges,36% Total Bille Charges,38.41,36,,30.728,Percent of Total Billed Charges,36% of Total Billed Charges,64.02,60,,51.216,Percent of Total Billed Charges,60% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.7,100,,85.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,15.39,14.42,,12.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.03,75,,64.024,Percent of Total Billed Charges,75% of Total Billed Charges,53.35,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,53.35,50,,42.68,Percent of Total Billed Charges,50% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.35,50,,42.68,Percent of Total Billed Charges,50% of Total Billed Charges,53.35,50,,42.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.69,70,,59.752,Percent of Total Billed Charges,70% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.7,100,,85.36,Percent of Total Billed Charges,100% of Total Billed Charges,14.94,106.7,
DRESSING ALGINATE W4XL10IN ISLAND ANTIMICROBIAL WA,21000029,CDM,272,RC,,,Outpatient,,,226.85,136.11,,136.11,60,,108.888,Percent of Total Billed Charges,60% of Total Billed Charges,102.08,45,,81.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.52,28,,50.816,Percent of Total Billed Charges,28% of Total Billed Charges,101.16,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,81.67,36,,65.336,Percent of Total Billed Charges,36% of Total Billed Charges,81.67,36,,65.336,Percent of Total Billed Charges,36% Total Bille Charges,81.67,36,,65.336,Percent of Total Billed Charges,36% of Total Billed Charges,136.11,60,,108.888,Percent of Total Billed Charges,60% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.85,100,,181.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,32.71,14.42,,26.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.14,75,,136.112,Percent of Total Billed Charges,75% of Total Billed Charges,113.43,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,113.43,50,,90.744,Percent of Total Billed Charges,50% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.43,50,,90.744,Percent of Total Billed Charges,50% of Total Billed Charges,113.43,50,,90.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.8,70,,127.04,Percent of Total Billed Charges,70% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.76,14,,25.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.85,100,,181.48,Percent of Total Billed Charges,100% of Total Billed Charges,31.76,226.85,
DRESSING ALGINATE RECTANGLE ISLAND 4 INCH LENGTH 6,21000030,CDM,272,RC,,,Outpatient,,,124.06,74.44,,74.44,60,,59.552,Percent of Total Billed Charges,60% of Total Billed Charges,55.83,45,,44.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.74,28,,27.792,Percent of Total Billed Charges,28% of Total Billed Charges,71.21,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,44.66,36,,35.728,Percent of Total Billed Charges,36% of Total Billed Charges,44.66,36,,35.728,Percent of Total Billed Charges,36% Total Bille Charges,44.66,36,,35.728,Percent of Total Billed Charges,36% of Total Billed Charges,74.44,60,,59.552,Percent of Total Billed Charges,60% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.06,100,,99.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14.42,,14.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.05,75,,74.44,Percent of Total Billed Charges,75% of Total Billed Charges,62.03,50,,42.68,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.03,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.84,70,,69.472,Percent of Total Billed Charges,70% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.06,100,,99.248,Percent of Total Billed Charges,100% of Total Billed Charges,17.37,124.06,
CODMAN MICROSENSOR METAL BOLT KIT,21000031,CDM,271,RC,,,Outpatient,,,3066.78,1840.07,,1840.07,60,,1472.056,Percent of Total Billed Charges,60% of Total Billed Charges,1380.05,45,,1104.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,858.7,28,,686.96,Percent of Total Billed Charges,28% of Total Billed Charges,71.21,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,1104.04,36,,883.232,Percent of Total Billed Charges,36% of Total Billed Charges,1104.04,36,,883.232,Percent of Total Billed Charges,36% Total Bille Charges,1104.04,36,,883.232,Percent of Total Billed Charges,36% of Total Billed Charges,1840.07,60,,1472.056,Percent of Total Billed Charges,60% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3066.78,100,,2453.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,442.23,14.42,,353.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2300.09,75,,1840.072,Percent of Total Billed Charges,75% of Total Billed Charges,1533.39,50,,90.744,Percent of Total Billed Charges,50% of Total Billed Charges,1533.39,50,,1226.712,Percent of Total Billed Charges,50% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1533.39,50,,1226.712,Percent of Total Billed Charges,50% of Total Billed Charges,1533.39,50,,1226.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2146.75,70,,1717.4,Percent of Total Billed Charges,70% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,429.35,14,,343.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3066.78,100,,2453.424,Percent of Total Billed Charges,100% of Total Billed Charges,71.21,3066.78,
TRAY ELECTRODE 5FRX115CM ELECTRODE PACING TEMPOR,21000032,CDM,271,RC,,,Outpatient,,,895.76,537.46,,537.46,60,,429.968,Percent of Total Billed Charges,60% of Total Billed Charges,403.09,45,,322.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.81,28,,200.648,Percent of Total Billed Charges,28% of Total Billed Charges,74.3,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,322.47,36,,257.976,Percent of Total Billed Charges,36% of Total Billed Charges,322.47,36,,257.976,Percent of Total Billed Charges,36% Total Bille Charges,322.47,36,,257.976,Percent of Total Billed Charges,36% of Total Billed Charges,537.46,60,,429.968,Percent of Total Billed Charges,60% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,895.76,100,,716.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,129.17,14.42,,103.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.82,75,,537.456,Percent of Total Billed Charges,75% of Total Billed Charges,447.88,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,447.88,50,,358.304,Percent of Total Billed Charges,50% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.88,50,,358.304,Percent of Total Billed Charges,50% of Total Billed Charges,447.88,50,,358.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,627.03,70,,501.624,Percent of Total Billed Charges,70% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,125.41,14,,100.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,895.76,100,,716.608,Percent of Total Billed Charges,100% of Total Billed Charges,74.3,895.76,
KIT HEMODIALYSIS 13FR L20CM SHORT TERM CURVED EXTE,21000033,CDM,271,RC,,,Outpatient,,,877.2,526.32,,526.32,60,,421.056,Percent of Total Billed Charges,60% of Total Billed Charges,394.74,45,,315.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.62,28,,196.496,Percent of Total Billed Charges,28% of Total Billed Charges,74.3,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% of Total Billed Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% Total Bille Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% of Total Billed Charges,526.32,60,,421.056,Percent of Total Billed Charges,60% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.2,100,,701.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.49,14.42,,101.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.9,75,,526.32,Percent of Total Billed Charges,75% of Total Billed Charges,438.6,50,,1226.712,Percent of Total Billed Charges,50% of Total Billed Charges,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.04,70,,491.232,Percent of Total Billed Charges,70% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.2,100,,701.76,Percent of Total Billed Charges,100% of Total Billed Charges,74.3,877.2,
KIT HEMODIALYSIS 13FR L15CM SHORT TERM CURVED EXTE,21000034,CDM,271,RC,,,Outpatient,,,877.2,526.32,,526.32,60,,421.056,Percent of Total Billed Charges,60% of Total Billed Charges,394.74,45,,315.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.62,28,,196.496,Percent of Total Billed Charges,28% of Total Billed Charges,133.16,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% of Total Billed Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% Total Bille Charges,315.79,36,,252.632,Percent of Total Billed Charges,36% of Total Billed Charges,526.32,60,,421.056,Percent of Total Billed Charges,60% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.2,100,,701.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.49,14.42,,101.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.9,75,,526.32,Percent of Total Billed Charges,75% of Total Billed Charges,438.6,50,,358.304,Percent of Total Billed Charges,50% of Total Billed Charges,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,438.6,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.04,70,,491.232,Percent of Total Billed Charges,70% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,122.81,14,,98.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.2,100,,701.76,Percent of Total Billed Charges,100% of Total Billed Charges,122.81,877.2,
CODMAN MICROSENSOR VENTRICULAR KIT,21000035,CDM,271,RC,,,Outpatient,,,3160.11,1896.07,,1896.07,60,,1516.856,Percent of Total Billed Charges,60% of Total Billed Charges,1422.05,45,,1137.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,884.83,28,,707.864,Percent of Total Billed Charges,28% of Total Billed Charges,133.16,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,1137.64,36,,910.112,Percent of Total Billed Charges,36% of Total Billed Charges,1137.64,36,,910.112,Percent of Total Billed Charges,36% Total Bille Charges,1137.64,36,,910.112,Percent of Total Billed Charges,36% of Total Billed Charges,1896.07,60,,1516.856,Percent of Total Billed Charges,60% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3160.11,100,,2528.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,455.69,14.42,,364.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2370.08,75,,1896.064,Percent of Total Billed Charges,75% of Total Billed Charges,1580.06,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,1580.06,50,,1264.048,Percent of Total Billed Charges,50% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1580.06,50,,1264.048,Percent of Total Billed Charges,50% of Total Billed Charges,1580.06,50,,1264.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212.08,70,,1769.664,Percent of Total Billed Charges,70% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,442.42,14,,353.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3160.11,100,,2528.088,Percent of Total Billed Charges,100% of Total Billed Charges,133.16,3160.11,
BAG DRAINAGE 1000CC PERICARDIOCENTESIS SPARE FOR E,21000036,CDM,271,RC,,,Outpatient,,,126.7,76.02,,76.02,60,,60.816,Percent of Total Billed Charges,60% of Total Billed Charges,57.02,45,,45.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.48,28,,28.384,Percent of Total Billed Charges,28% of Total Billed Charges,88.77,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,45.61,36,,36.488,Percent of Total Billed Charges,36% of Total Billed Charges,45.61,36,,36.488,Percent of Total Billed Charges,36% Total Bille Charges,45.61,36,,36.488,Percent of Total Billed Charges,36% of Total Billed Charges,76.02,60,,60.816,Percent of Total Billed Charges,60% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.7,100,,101.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.27,14.42,,14.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.03,75,,76.024,Percent of Total Billed Charges,75% of Total Billed Charges,63.35,50,,350.88,Percent of Total Billed Charges,50% of Total Billed Charges,63.35,50,,50.68,Percent of Total Billed Charges,50% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.35,50,,50.68,Percent of Total Billed Charges,50% of Total Billed Charges,63.35,50,,50.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.69,70,,70.952,Percent of Total Billed Charges,70% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14,,14.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.7,100,,101.36,Percent of Total Billed Charges,100% of Total Billed Charges,17.74,126.7,
TUBE FEEDING 10FR FFIN CORTAK,21000037,CDM,271,RC,,,Outpatient,,,450.85,270.51,,270.51,60,,216.408,Percent of Total Billed Charges,60% of Total Billed Charges,202.88,45,,162.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.24,28,,100.992,Percent of Total Billed Charges,28% of Total Billed Charges,88.77,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,162.31,36,,129.848,Percent of Total Billed Charges,36% of Total Billed Charges,162.31,36,,129.848,Percent of Total Billed Charges,36% Total Bille Charges,162.31,36,,129.848,Percent of Total Billed Charges,36% of Total Billed Charges,270.51,60,,216.408,Percent of Total Billed Charges,60% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.85,100,,360.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,65.01,14.42,,52.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.14,75,,270.512,Percent of Total Billed Charges,75% of Total Billed Charges,225.43,50,,1264.048,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.43,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.6,70,,252.48,Percent of Total Billed Charges,70% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.85,100,,360.68,Percent of Total Billed Charges,100% of Total Billed Charges,63.12,450.85,
"SENSOR FLOTRAC 84"" PRESSURE LN",21000038,CDM,271,RC,,,Outpatient,,,1857.8,1114.68,,1114.68,60,,891.744,Percent of Total Billed Charges,60% of Total Billed Charges,836.01,45,,668.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.18,28,,416.144,Percent of Total Billed Charges,28% of Total Billed Charges,88.77,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,668.81,36,,535.048,Percent of Total Billed Charges,36% of Total Billed Charges,668.81,36,,535.048,Percent of Total Billed Charges,36% Total Bille Charges,668.81,36,,535.048,Percent of Total Billed Charges,36% of Total Billed Charges,1114.68,60,,891.744,Percent of Total Billed Charges,60% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1857.8,100,,1486.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,267.89,14.42,,214.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1393.35,75,,1114.68,Percent of Total Billed Charges,75% of Total Billed Charges,928.9,50,,50.68,Percent of Total Billed Charges,50% of Total Billed Charges,928.9,50,,743.12,Percent of Total Billed Charges,50% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,928.9,50,,743.12,Percent of Total Billed Charges,50% of Total Billed Charges,928.9,50,,743.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1300.46,70,,1040.368,Percent of Total Billed Charges,70% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,260.09,14,,208.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1857.8,100,,1486.24,Percent of Total Billed Charges,100% of Total Billed Charges,88.77,1857.8,
NORMAL GEL AG,21000039,CDM,271,RC,,,Outpatient,,,150.56,90.34,,90.34,60,,72.272,Percent of Total Billed Charges,60% of Total Billed Charges,67.75,45,,54.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.16,28,,33.728,Percent of Total Billed Charges,28% of Total Billed Charges,149.66,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,54.2,36,,43.36,Percent of Total Billed Charges,36% of Total Billed Charges,54.2,36,,43.36,Percent of Total Billed Charges,36% Total Bille Charges,54.2,36,,43.36,Percent of Total Billed Charges,36% of Total Billed Charges,90.34,60,,72.272,Percent of Total Billed Charges,60% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.56,100,,120.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.71,14.42,,17.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.92,75,,90.336,Percent of Total Billed Charges,75% of Total Billed Charges,75.28,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,75.28,50,,60.224,Percent of Total Billed Charges,50% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.28,50,,60.224,Percent of Total Billed Charges,50% of Total Billed Charges,75.28,50,,60.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.39,70,,84.312,Percent of Total Billed Charges,70% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.08,14,,16.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.56,100,,120.448,Percent of Total Billed Charges,100% of Total Billed Charges,21.08,150.56,
TRAY DRN FUHRMAN FLR/PNMPRCRDL,21000040,CDM,271,RC,,,Outpatient,,,904,542.40,,542.4,60,,433.92,Percent of Total Billed Charges,60% of Total Billed Charges,406.8,45,,325.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.12,28,,202.496,Percent of Total Billed Charges,28% of Total Billed Charges,149.66,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,325.44,36,,260.352,Percent of Total Billed Charges,36% of Total Billed Charges,325.44,36,,260.352,Percent of Total Billed Charges,36% Total Bille Charges,325.44,36,,260.352,Percent of Total Billed Charges,36% of Total Billed Charges,542.4,60,,433.92,Percent of Total Billed Charges,60% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,904,100,,723.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,130.36,14.42,,104.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,678,75,,542.4,Percent of Total Billed Charges,75% of Total Billed Charges,452,50,,743.12,Percent of Total Billed Charges,50% of Total Billed Charges,452,50,,361.6,Percent of Total Billed Charges,50% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452,50,,361.6,Percent of Total Billed Charges,50% of Total Billed Charges,452,50,,361.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.8,70,,506.24,Percent of Total Billed Charges,70% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.56,14,,101.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904,100,,723.2,Percent of Total Billed Charges,100% of Total Billed Charges,126.56,904,
RESUSC MASK ADLT RESVR MED,21000041,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,59.8,45,,47.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,582.41,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.88,100,,106.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,15.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,60.224,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,74.416,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,18.6,582.41,
TRAY LUMBAR PUNCTURE AD 22X3.5,21000042,CDM,271,RC,,,Outpatient,,,212.08,127.25,,127.25,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,95.44,45,,76.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.38,28,,47.504,Percent of Total Billed Charges,28% of Total Billed Charges,582.41,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% Total Bille Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,127.25,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.08,100,,169.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,30.58,14.42,,24.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.06,75,,127.248,Percent of Total Billed Charges,75% of Total Billed Charges,106.04,50,,361.6,Percent of Total Billed Charges,50% of Total Billed Charges,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.46,70,,118.768,Percent of Total Billed Charges,70% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.08,100,,169.664,Percent of Total Billed Charges,100% of Total Billed Charges,29.69,582.41,
KIT CMB 60 VMPARM MNT PRESS,21000043,CDM,271,RC,,,Outpatient,,,263.62,158.17,,158.17,60,,126.536,Percent of Total Billed Charges,60% of Total Billed Charges,118.63,45,,94.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.81,28,,59.048,Percent of Total Billed Charges,28% of Total Billed Charges,4091.54,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,94.9,36,,75.92,Percent of Total Billed Charges,36% of Total Billed Charges,94.9,36,,75.92,Percent of Total Billed Charges,36% Total Bille Charges,94.9,36,,75.92,Percent of Total Billed Charges,36% of Total Billed Charges,158.17,60,,126.536,Percent of Total Billed Charges,60% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.62,100,,210.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,38.01,14.42,,30.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.72,75,,158.176,Percent of Total Billed Charges,75% of Total Billed Charges,131.81,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,131.81,50,,105.448,Percent of Total Billed Charges,50% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.81,50,,105.448,Percent of Total Billed Charges,50% of Total Billed Charges,131.81,50,,105.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,70,,147.624,Percent of Total Billed Charges,70% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,36.91,14,,29.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.62,100,,210.896,Percent of Total Billed Charges,100% of Total Billed Charges,36.91,4091.54,
BOTTLE DRAIN ACCEL EVC 1000ML,21000044,CDM,271,RC,,,Outpatient,,,105.58,63.35,,63.35,60,,50.68,Percent of Total Billed Charges,60% of Total Billed Charges,47.51,45,,38.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.56,28,,23.648,Percent of Total Billed Charges,28% of Total Billed Charges,4091.54,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,38.01,36,,30.408,Percent of Total Billed Charges,36% of Total Billed Charges,38.01,36,,30.408,Percent of Total Billed Charges,36% Total Bille Charges,38.01,36,,30.408,Percent of Total Billed Charges,36% of Total Billed Charges,63.35,60,,50.68,Percent of Total Billed Charges,60% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.58,100,,84.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.22,14.42,,12.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.19,75,,63.352,Percent of Total Billed Charges,75% of Total Billed Charges,52.79,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,50,,42.232,Percent of Total Billed Charges,50% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.79,50,,42.232,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,50,,42.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.91,70,,59.128,Percent of Total Billed Charges,70% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14,,11.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.58,100,,84.464,Percent of Total Billed Charges,100% of Total Billed Charges,14.78,4091.54,
BLANKET REFLECTIVE FULL BODY,21000045,CDM,271,RC,,,Outpatient,,,127.04,76.22,,76.22,60,,60.976,Percent of Total Billed Charges,60% of Total Billed Charges,57.17,45,,45.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.57,28,,28.456,Percent of Total Billed Charges,28% of Total Billed Charges,236.04,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% Total Bille Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,76.22,60,,60.976,Percent of Total Billed Charges,60% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.04,100,,101.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14.42,,14.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.28,75,,76.224,Percent of Total Billed Charges,75% of Total Billed Charges,63.52,50,,105.448,Percent of Total Billed Charges,50% of Total Billed Charges,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.93,70,,71.144,Percent of Total Billed Charges,70% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.04,100,,101.632,Percent of Total Billed Charges,100% of Total Billed Charges,17.79,236.04,
TUBE FEEDING NASOGASTRIC 8 FR 109 CM ANTI IV CONNE,21000046,CDM,271,RC,,,Outpatient,,,419.44,251.66,,251.66,60,,201.328,Percent of Total Billed Charges,60% of Total Billed Charges,188.75,45,,151,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.44,28,,93.952,Percent of Total Billed Charges,28% of Total Billed Charges,4024.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,151,36,,120.8,Percent of Total Billed Charges,36% of Total Billed Charges,151,36,,120.8,Percent of Total Billed Charges,36% Total Bille Charges,151,36,,120.8,Percent of Total Billed Charges,36% of Total Billed Charges,251.66,60,,201.328,Percent of Total Billed Charges,60% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,419.44,100,,335.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,60.48,14.42,,48.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.58,75,,251.664,Percent of Total Billed Charges,75% of Total Billed Charges,209.72,50,,42.232,Percent of Total Billed Charges,50% of Total Billed Charges,209.72,50,,167.776,Percent of Total Billed Charges,50% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.72,50,,167.776,Percent of Total Billed Charges,50% of Total Billed Charges,209.72,50,,167.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.61,70,,234.888,Percent of Total Billed Charges,70% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,58.72,14,,46.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,419.44,100,,335.552,Percent of Total Billed Charges,100% of Total Billed Charges,58.72,4024.02,
CUFF BLOOD PRESSURE L FINGER DISPOSABLE MULTIPACK,21000047,CDM,271,RC,,,Outpatient,,,1370,822.00,,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,616.5,45,,493.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.6,28,,306.88,Percent of Total Billed Charges,28% of Total Billed Charges,4024.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% Total Bille Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,197.55,14.42,,158.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1027.5,75,,822,Percent of Total Billed Charges,75% of Total Billed Charges,685,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,959,70,,767.2,Percent of Total Billed Charges,70% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,100% of Total Billed Charges,191.8,4024.02,
CUFF BLOOD PRESSURE M FINGER DISPOSABLE MULTIPAC,21000048,CDM,271,RC,,,Outpatient,,,1370,822.00,,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,616.5,45,,493.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.6,28,,306.88,Percent of Total Billed Charges,28% of Total Billed Charges,4024.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% Total Bille Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,197.55,14.42,,158.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1027.5,75,,822,Percent of Total Billed Charges,75% of Total Billed Charges,685,50,,167.776,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,959,70,,767.2,Percent of Total Billed Charges,70% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,100% of Total Billed Charges,191.8,4024.02,
CUFF BLOOD PRESSURE SM GREEN FINGER DISPOSABLE CLE,21000049,CDM,271,RC,,,Outpatient,,,1370,822.00,,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,616.5,45,,493.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.6,28,,306.88,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% Total Bille Charges,493.2,36,,394.56,Percent of Total Billed Charges,36% of Total Billed Charges,822,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,197.55,14.42,,158.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1027.5,75,,822,Percent of Total Billed Charges,75% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,685,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,959,70,,767.2,Percent of Total Billed Charges,70% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,191.8,14,,153.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1370,100,,1096,Percent of Total Billed Charges,100% of Total Billed Charges,191.8,4665.03,
KIT DRESSING CHANGE POWERGLIDE,21000050,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,38.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,100,,85.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,64.416,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,85.888,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,4665.03,
ECG 5 LEAD GRABBER,21000051,CDM,271,RC,,,Outpatient,,,144.8,86.88,,86.88,60,,69.504,Percent of Total Billed Charges,60% of Total Billed Charges,65.16,45,,52.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.54,28,,32.432,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.13,36,,41.704,Percent of Total Billed Charges,36% of Total Billed Charges,52.13,36,,41.704,Percent of Total Billed Charges,36% Total Bille Charges,52.13,36,,41.704,Percent of Total Billed Charges,36% of Total Billed Charges,86.88,60,,69.504,Percent of Total Billed Charges,60% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.8,100,,115.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.88,14.42,,16.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.6,75,,86.88,Percent of Total Billed Charges,75% of Total Billed Charges,72.4,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,72.4,50,,57.92,Percent of Total Billed Charges,50% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.4,50,,57.92,Percent of Total Billed Charges,50% of Total Billed Charges,72.4,50,,57.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.36,70,,81.088,Percent of Total Billed Charges,70% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,20.27,14,,16.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.8,100,,115.84,Percent of Total Billed Charges,100% of Total Billed Charges,20.27,4665.03,
TRAY URINE METER SURESTEP 16FR,21000052,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,61.16,45,,48.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,30.448,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.92,100,,108.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,81.552,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,108.736,Percent of Total Billed Charges,100% of Total Billed Charges,19.03,4665.03,
TUBE FEEDING NASOGASTRIC 10 FR 139 CM WITH STYLET,21000053,CDM,271,RC,,,Outpatient,,,446.4,267.84,,267.84,60,,214.272,Percent of Total Billed Charges,60% of Total Billed Charges,200.88,45,,160.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.99,28,,99.992,Percent of Total Billed Charges,28% of Total Billed Charges,731.82,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,160.7,36,,128.56,Percent of Total Billed Charges,36% of Total Billed Charges,160.7,36,,128.56,Percent of Total Billed Charges,36% Total Bille Charges,160.7,36,,128.56,Percent of Total Billed Charges,36% of Total Billed Charges,267.84,60,,214.272,Percent of Total Billed Charges,60% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.4,100,,357.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14.42,,51.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.8,75,,267.84,Percent of Total Billed Charges,75% of Total Billed Charges,223.2,50,,57.92,Percent of Total Billed Charges,50% of Total Billed Charges,223.2,50,,178.56,Percent of Total Billed Charges,50% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.2,50,,178.56,Percent of Total Billed Charges,50% of Total Billed Charges,223.2,50,,178.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.48,70,,249.984,Percent of Total Billed Charges,70% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,62.5,14,,50,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,446.4,100,,357.12,Percent of Total Billed Charges,100% of Total Billed Charges,62.5,731.82,
SPONGE TOPICAL HEMOSTATIC 3.8 CM LENGTH 3.8 CM WID,21000055,CDM,271,RC,,,Outpatient,,,263.05,157.83,,157.83,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,118.37,45,,94.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.65,28,,58.92,Percent of Total Billed Charges,28% of Total Billed Charges,101.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,94.7,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,94.7,36,,75.76,Percent of Total Billed Charges,36% Total Bille Charges,94.7,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,157.83,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.05,100,,210.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,14.42,,30.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.29,75,,157.832,Percent of Total Billed Charges,75% of Total Billed Charges,131.53,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.14,70,,147.312,Percent of Total Billed Charges,70% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.05,100,,210.44,Percent of Total Billed Charges,100% of Total Billed Charges,36.83,263.05,
DISC STATSEAL DISC MEDIUM,21000056,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,43.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,1803.26,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,96.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,178.56,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,1803.26,
AGENT TOPICAL HEMOSTATIC FOAM DISC STATSEAL LARG,21000057,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,43.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,1803.26,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,96.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,1803.26,
WAFFLE SEAT CUSHION 17X17X2,21000058,CDM,271,RC,,,Outpatient,,,350.44,210.26,,210.26,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,157.7,45,,126.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.12,28,,78.496,Percent of Total Billed Charges,28% of Total Billed Charges,7925.86,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.16,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,126.16,36,,100.928,Percent of Total Billed Charges,36% Total Bille Charges,126.16,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.44,100,,280.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,50.53,14.42,,40.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.83,75,,210.264,Percent of Total Billed Charges,75% of Total Billed Charges,175.22,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.31,70,,196.248,Percent of Total Billed Charges,70% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.44,100,,280.352,Percent of Total Billed Charges,100% of Total Billed Charges,49.06,7925.86,
KIT ORAL CARE Q4 W/OUT CHG,21000059,CDM,271,RC,,,Outpatient,,,154.8,92.88,,92.88,60,,74.304,Percent of Total Billed Charges,60% of Total Billed Charges,69.66,45,,55.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.34,28,,34.672,Percent of Total Billed Charges,28% of Total Billed Charges,7925.86,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,55.73,36,,44.584,Percent of Total Billed Charges,36% of Total Billed Charges,55.73,36,,44.584,Percent of Total Billed Charges,36% Total Bille Charges,55.73,36,,44.584,Percent of Total Billed Charges,36% of Total Billed Charges,92.88,60,,74.304,Percent of Total Billed Charges,60% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.8,100,,123.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,22.32,14.42,,17.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.1,75,,92.88,Percent of Total Billed Charges,75% of Total Billed Charges,77.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,77.4,50,,61.92,Percent of Total Billed Charges,50% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,50,,61.92,Percent of Total Billed Charges,50% of Total Billed Charges,77.4,50,,61.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.36,70,,86.688,Percent of Total Billed Charges,70% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.8,100,,123.84,Percent of Total Billed Charges,100% of Total Billed Charges,21.67,7925.86,
KIT PORT ACCESS CLEAR SEQUENCE CHANGE CUSTOM,21000060,CDM,272,RC,,,Outpatient,,,206.48,123.89,,123.89,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,92.92,45,,74.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.81,28,,46.248,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% Total Bille Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,123.89,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.48,100,,165.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,29.77,14.42,,23.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.86,75,,123.888,Percent of Total Billed Charges,75% of Total Billed Charges,103.24,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.54,70,,115.632,Percent of Total Billed Charges,70% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.48,100,,165.184,Percent of Total Billed Charges,100% of Total Billed Charges,28.91,4665.03,
TRAY PICC DRSG,21000061,CDM,272,RC,,,Outpatient,,,222.3,133.38,,133.38,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,100.04,45,,80.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.24,28,,49.792,Percent of Total Billed Charges,28% of Total Billed Charges,1640.1,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,80.03,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,80.03,36,,64.024,Percent of Total Billed Charges,36% Total Bille Charges,80.03,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,133.38,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.3,100,,177.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14.42,,25.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.73,75,,133.384,Percent of Total Billed Charges,75% of Total Billed Charges,111.15,50,,61.92,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.61,70,,124.488,Percent of Total Billed Charges,70% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.3,100,,177.84,Percent of Total Billed Charges,100% of Total Billed Charges,31.12,1640.1,
TRAY CVC DRSG,21000062,CDM,272,RC,,,Outpatient,,,173.12,103.87,,103.87,60,,83.096,Percent of Total Billed Charges,60% of Total Billed Charges,77.9,45,,62.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.47,28,,38.776,Percent of Total Billed Charges,28% of Total Billed Charges,1640.1,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,62.32,36,,49.856,Percent of Total Billed Charges,36% of Total Billed Charges,62.32,36,,49.856,Percent of Total Billed Charges,36% Total Bille Charges,62.32,36,,49.856,Percent of Total Billed Charges,36% of Total Billed Charges,103.87,60,,83.096,Percent of Total Billed Charges,60% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.12,100,,138.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.96,14.42,,19.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.84,75,,103.872,Percent of Total Billed Charges,75% of Total Billed Charges,86.56,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,86.56,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.56,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,86.56,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.18,70,,96.944,Percent of Total Billed Charges,70% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.12,100,,138.496,Percent of Total Billed Charges,100% of Total Billed Charges,24.24,1640.1,
CORGRIP NASOINTESTINAL FEED,21000063,CDM,271,RC,,,Outpatient,,,552.45,331.47,,331.47,60,,265.176,Percent of Total Billed Charges,60% of Total Billed Charges,248.6,45,,198.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.69,28,,123.752,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,198.88,36,,159.104,Percent of Total Billed Charges,36% of Total Billed Charges,198.88,36,,159.104,Percent of Total Billed Charges,36% Total Bille Charges,198.88,36,,159.104,Percent of Total Billed Charges,36% of Total Billed Charges,331.47,60,,265.176,Percent of Total Billed Charges,60% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,552.45,100,,441.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14.42,,63.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.34,75,,331.472,Percent of Total Billed Charges,75% of Total Billed Charges,276.23,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,276.23,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.23,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,276.23,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.72,70,,309.376,Percent of Total Billed Charges,70% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.45,100,,441.96,Percent of Total Billed Charges,100% of Total Billed Charges,77.34,14168.18,
KIT CATH CENTRAL VENOUS TRIPLE,21000064,CDM,272,RC,,,Outpatient,,,505.9,303.54,,303.54,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,227.66,45,,182.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.65,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,303.54,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.9,100,,404.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,72.95,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.43,75,,303.544,Percent of Total Billed Charges,75% of Total Billed Charges,252.95,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.13,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.9,100,,404.72,Percent of Total Billed Charges,100% of Total Billed Charges,70.83,28338.25,
POWERPICC SOLO PROVENA CATH 5F,21000065,CDM,271,RC,,,Outpatient,,,1101.87,661.12,,661.12,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,495.84,45,,396.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.52,28,,246.816,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,396.67,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,396.67,36,,317.336,Percent of Total Billed Charges,36% Total Bille Charges,396.67,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,661.12,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1101.87,100,,881.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,158.89,14.42,,127.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.4,75,,661.12,Percent of Total Billed Charges,75% of Total Billed Charges,550.94,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.94,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.31,70,,617.048,Percent of Total Billed Charges,70% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1101.87,100,,881.496,Percent of Total Billed Charges,100% of Total Billed Charges,154.26,14168.18,
NOVAPLUS SENSOR CHAIR,21000066,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,73.55,45,,58.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,36.608,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.44,100,,130.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,22.88,28338.25,
NOVAPLUS PEEK-A-BOO MITTS,21000067,CDM,271,RC,,,Outpatient,,,110.56,66.34,,66.34,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,49.75,45,,39.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,28,,24.768,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,39.8,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,39.8,36,,31.84,Percent of Total Billed Charges,36% Total Bille Charges,39.8,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,66.34,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.56,100,,88.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.94,14.42,,12.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,75,,66.336,Percent of Total Billed Charges,75% of Total Billed Charges,55.28,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,70,,61.912,Percent of Total Billed Charges,70% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.56,100,,88.448,Percent of Total Billed Charges,100% of Total Billed Charges,15.48,45588.31,
MIDLINE MAX PROVENA 3F,21000068,CDM,271,RC,,,Outpatient,,,751.56,450.94,,450.94,60,,360.752,Percent of Total Billed Charges,60% of Total Billed Charges,338.2,45,,270.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.44,28,,168.352,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,270.56,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,270.56,36,,216.448,Percent of Total Billed Charges,36% Total Bille Charges,270.56,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,450.94,60,,360.752,Percent of Total Billed Charges,60% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.56,100,,601.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,108.37,14.42,,86.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.67,75,,450.936,Percent of Total Billed Charges,75% of Total Billed Charges,375.78,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.78,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,526.09,70,,420.872,Percent of Total Billed Charges,70% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,751.56,100,,601.248,Percent of Total Billed Charges,100% of Total Billed Charges,105.22,14168.18,
POWERPICC  SOLO PROVENA CATH 4F,21000069,CDM,271,RC,,,Outpatient,,,1050.3,630.18,,630.18,60,,504.144,Percent of Total Billed Charges,60% of Total Billed Charges,472.64,45,,378.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.08,28,,235.264,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,378.11,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,378.11,36,,302.488,Percent of Total Billed Charges,36% Total Bille Charges,378.11,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,630.18,60,,504.144,Percent of Total Billed Charges,60% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050.3,100,,840.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,151.45,14.42,,121.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.73,75,,630.184,Percent of Total Billed Charges,75% of Total Billed Charges,525.15,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.21,70,,588.168,Percent of Total Billed Charges,70% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.3,100,,840.24,Percent of Total Billed Charges,100% of Total Billed Charges,147.04,45588.31,
CATH KIT CV ART LN AR 20GX3IN,21000070,CDM,272,RC,,,Outpatient,,,157.76,94.66,,94.66,60,,75.728,Percent of Total Billed Charges,60% of Total Billed Charges,70.99,45,,56.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.17,28,,35.336,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,56.79,36,,45.432,Percent of Total Billed Charges,36% of Total Billed Charges,56.79,36,,45.432,Percent of Total Billed Charges,36% Total Bille Charges,56.79,36,,45.432,Percent of Total Billed Charges,36% of Total Billed Charges,94.66,60,,75.728,Percent of Total Billed Charges,60% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.76,100,,126.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.75,14.42,,18.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.32,75,,94.656,Percent of Total Billed Charges,75% of Total Billed Charges,78.88,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,78.88,50,,63.104,Percent of Total Billed Charges,50% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.88,50,,63.104,Percent of Total Billed Charges,50% of Total Billed Charges,78.88,50,,63.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.43,70,,88.344,Percent of Total Billed Charges,70% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,22.09,14,,17.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.76,100,,126.208,Percent of Total Billed Charges,100% of Total Billed Charges,22.09,28338.25,
DRSG BORDER HEEL,21000071,CDM,272,RC,,,Outpatient,,,99.76,59.86,,59.86,60,,47.888,Percent of Total Billed Charges,60% of Total Billed Charges,44.89,45,,35.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.93,28,,22.344,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,35.91,36,,28.728,Percent of Total Billed Charges,36% of Total Billed Charges,35.91,36,,28.728,Percent of Total Billed Charges,36% Total Bille Charges,35.91,36,,28.728,Percent of Total Billed Charges,36% of Total Billed Charges,59.86,60,,47.888,Percent of Total Billed Charges,60% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.76,100,,79.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.39,14.42,,11.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.82,75,,59.856,Percent of Total Billed Charges,75% of Total Billed Charges,49.88,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,49.88,50,,39.904,Percent of Total Billed Charges,50% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.88,50,,39.904,Percent of Total Billed Charges,50% of Total Billed Charges,49.88,50,,39.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.83,70,,55.864,Percent of Total Billed Charges,70% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,13.97,14,,11.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.76,100,,79.808,Percent of Total Billed Charges,100% of Total Billed Charges,13.97,28338.25,
SLEEVE COMPR SCD-EXPR KNEE MED,21000072,CDM,271,RC,,,Outpatient,,,85.8,51.48,,51.48,60,,41.184,Percent of Total Billed Charges,60% of Total Billed Charges,38.61,45,,30.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.02,28,,19.216,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,30.89,36,,24.712,Percent of Total Billed Charges,36% of Total Billed Charges,30.89,36,,24.712,Percent of Total Billed Charges,36% Total Bille Charges,30.89,36,,24.712,Percent of Total Billed Charges,36% of Total Billed Charges,51.48,60,,41.184,Percent of Total Billed Charges,60% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.8,100,,68.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14.42,,9.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.35,75,,51.48,Percent of Total Billed Charges,75% of Total Billed Charges,42.9,50,,63.104,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.9,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.06,70,,48.048,Percent of Total Billed Charges,70% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.8,100,,68.64,Percent of Total Billed Charges,100% of Total Billed Charges,12.01,28338.25,
SLEEVE COMPR SCD-EXPR KNEE LG,21000073,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,47.23,45,,37.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,23.512,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,30.232,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.96,100,,83.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,39.904,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,14.69,28338.25,
MIDLINE MAX PROVENA 4F,21000074,CDM,271,RC,,,Outpatient,,,686.04,411.62,,411.62,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,308.72,45,,246.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.09,28,,153.672,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,246.97,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,246.97,36,,197.576,Percent of Total Billed Charges,36% Total Bille Charges,246.97,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,411.62,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.04,100,,548.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,98.93,14.42,,79.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.53,75,,411.624,Percent of Total Billed Charges,75% of Total Billed Charges,343.02,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.23,70,,384.184,Percent of Total Billed Charges,70% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,686.04,100,,548.832,Percent of Total Billed Charges,100% of Total Billed Charges,96.05,28338.25,
COMPRESSION SYS FEM FEMSTP,21000701,CDM,271,RC,,,Outpatient,,,384,230.40,,230.4,60,,184.32,Percent of Total Billed Charges,60% of Total Billed Charges,172.8,45,,138.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.52,28,,86.016,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,138.24,36,,110.592,Percent of Total Billed Charges,36% of Total Billed Charges,138.24,36,,110.592,Percent of Total Billed Charges,36% Total Bille Charges,138.24,36,,110.592,Percent of Total Billed Charges,36% of Total Billed Charges,230.4,60,,184.32,Percent of Total Billed Charges,60% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384,100,,307.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,55.37,14.42,,44.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288,75,,230.4,Percent of Total Billed Charges,75% of Total Billed Charges,192,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,192,50,,153.6,Percent of Total Billed Charges,50% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192,50,,153.6,Percent of Total Billed Charges,50% of Total Billed Charges,192,50,,153.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.8,70,,215.04,Percent of Total Billed Charges,70% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14,,43.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384,100,,307.2,Percent of Total Billed Charges,100% of Total Billed Charges,53.76,14168.18,
DRSG BURN ACTCT SLCR 4X4,21000702,CDM,272,RC,A6206,HCPCS,Outpatient,,,57.62,34.57,,2.35,100,,76.608,Fee Schedule,100% of Aetna Fee Schedule,25.93,45,,20.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.13,28,,12.904,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% Total Bille Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,34.57,60,,27.656,Percent of Total Billed Charges,60% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.62,100,,46.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.31,14.42,,6.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.22,75,,34.576,Percent of Total Billed Charges,75% of Total Billed Charges,28.81,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.33,70,,32.264,Percent of Total Billed Charges,70% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.62,100,,46.096,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,14168.18,
DRSG MEPITEL 4 X7.2 LATEX FREE,21000703,CDM,272,RC,A6207,HCPCS,Outpatient,,,61.45,36.87,,6.24,100,,65.792,Fee Schedule,100% of Aetna Fee Schedule,27.65,45,,22.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,35.752,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,45.968,Fee Schedule,360% of BCBS POS Rate,30.71,360,,45.968,Fee schedule,360% of BCBS PPO Rate,30.71,360,,45.968,Fee Schedule,360% of BCBS Traditional Rate,36.87,60,,29.496,Percent of Total Billed Charges,60% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.45,100,,49.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.86,14.42,,7.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.09,75,,36.872,Percent of Total Billed Charges,75% of Total Billed Charges,30.73,50,,153.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.73,50,,24.584,Percent of Total Billed Charges,50% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.73,50,,24.584,Percent of Total Billed Charges,50% of Total Billed Charges,30.73,50,,24.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.02,70,,34.416,Percent of Total Billed Charges,70% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.6,14,,6.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.45,100,,49.16,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,61.45,
DRSG GRMCDL BIOPTCH 1IN 4MM C-,21000704,CDM,272,RC,A6209,HCPCS,Outpatient,,,40.06,24.04,,6.35,100,,14.704,Fee Schedule,100% of Aetna Fee Schedule,18.03,45,,14.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,8.864,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,11.392,Fee Schedule,360% of BCBS POS Rate,31.25,360,,11.392,Fee schedule,360% of BCBS PPO Rate,31.25,360,,11.392,Fee Schedule,360% of BCBS Traditional Rate,24.04,60,,19.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.06,100,,32.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14.42,,4.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.05,75,,24.04,Percent of Total Billed Charges,75% of Total Billed Charges,20.03,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.04,70,,22.432,Percent of Total Billed Charges,70% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.06,100,,32.048,Percent of Total Billed Charges,100% of Total Billed Charges,5.61,40.06,
BOOT PROTCT HL FT INFL VI,21000707,CDM,271,RC,,,Outpatient,,,159.6,95.76,,95.76,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,71.82,45,,57.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.69,28,,30.704,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,57.46,36,,39.48,Percent of Total Billed Charges,36% of Total Billed Charges,57.46,36,,39.48,Percent of Total Billed Charges,36% Total Bille Charges,57.46,36,,39.48,Percent of Total Billed Charges,36% of Total Billed Charges,95.76,60,,76.608,Percent of Total Billed Charges,60% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.6,100,,127.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,23.01,14.42,,18.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,75,,95.76,Percent of Total Billed Charges,75% of Total Billed Charges,79.8,50,,24.584,Percent of Total Billed Charges,50% of Total Billed Charges,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.72,70,,89.376,Percent of Total Billed Charges,70% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,100,,127.68,Percent of Total Billed Charges,100% of Total Billed Charges,22.34,14168.18,
STOCKING COMPR THG-TED LG REG,21000708,CDM,272,RC,A6549,HCPCS,Outpatient,,,39.56,23.74,,70,100,,972.176,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.08,28,,6.864,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.24,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,14.24,36,,8.824,Percent of Total Billed Charges,36% Total Bille Charges,14.24,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,23.74,60,,18.992,Percent of Total Billed Charges,60% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.7,14.42,,4.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.67,75,,23.736,Percent of Total Billed Charges,75% of Total Billed Charges,19.78,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,19.78,50,,15.824,Percent of Total Billed Charges,50% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.78,50,,15.824,Percent of Total Billed Charges,50% of Total Billed Charges,19.78,50,,15.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.69,70,,22.152,Percent of Total Billed Charges,70% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.56,100,,31.648,Percent of Total Billed Charges,100% of Total Billed Charges,5.54,14168.18,
THORACENTESIS TY 14 G X 2IN,21000710,CDM,272,RC,,,Outpatient,,,137.07,82.24,,82.24,60,,76.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.38,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.35,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,49.35,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,49.35,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,82.24,60,,65.792,Percent of Total Billed Charges,60% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14.42,,15.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.8,75,,82.24,Percent of Total Billed Charges,75% of Total Billed Charges,68.54,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,68.54,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.54,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,68.54,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.95,70,,76.76,Percent of Total Billed Charges,70% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.07,100,,109.656,Percent of Total Billed Charges,100% of Total Billed Charges,19.19,14168.18,
DRSG FM ALVN 5X5 PU ADH,21000714,CDM,272,RC,,,Outpatient,,,30.64,18.38,,18.38,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.58,28,,453.68,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,11.03,36,,583.304,Percent of Total Billed Charges,36% of Total Billed Charges,11.03,36,,583.304,Percent of Total Billed Charges,36% Total Bille Charges,11.03,36,,583.304,Percent of Total Billed Charges,36% of Total Billed Charges,18.38,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.42,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,75,,18.384,Percent of Total Billed Charges,75% of Total Billed Charges,15.32,50,,15.824,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.45,70,,17.16,Percent of Total Billed Charges,70% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.64,100,,24.512,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,14168.18,
CATH CV COO SVO2 SWN 8FRX110CM,21000716,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,52.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,35.728,Percent of Total Billed Charges,28% of Total Billed Charges,6632.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,45.936,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,45.936,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,45.936,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,6632.03,
NEUROMONITOR BASIC KIT,21000718,CDM,272,RC,,,Outpatient,,,2025.36,1215.22,,1215.22,60,,63.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567.1,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,729.13,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,729.13,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,729.13,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1215.22,60,,972.176,Percent of Total Billed Charges,60% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,292.06,14.42,,233.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1519.02,75,,1215.216,Percent of Total Billed Charges,75% of Total Billed Charges,1012.68,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,1012.68,50,,810.144,Percent of Total Billed Charges,50% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1012.68,50,,810.144,Percent of Total Billed Charges,50% of Total Billed Charges,1012.68,50,,810.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1417.75,70,,1134.2,Percent of Total Billed Charges,70% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,283.55,14,,226.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2025.36,100,,1620.288,Percent of Total Billed Charges,100% of Total Billed Charges,283.55,3925.64,
DRAIN CHST CHST PLR-EV PED,21000719,CDM,272,RC,,,Outpatient,,,159.49,95.69,,95.69,60,,84.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.66,28,,24.576,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,36,,31.592,Percent of Total Billed Charges,36% of Total Billed Charges,57.42,36,,31.592,Percent of Total Billed Charges,36% Total Bille Charges,57.42,36,,31.592,Percent of Total Billed Charges,36% of Total Billed Charges,95.69,60,,76.552,Percent of Total Billed Charges,60% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,23,14.42,,18.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.62,75,,95.696,Percent of Total Billed Charges,75% of Total Billed Charges,79.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,79.75,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.75,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,79.75,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.64,70,,89.312,Percent of Total Billed Charges,70% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.49,100,,127.592,Percent of Total Billed Charges,100% of Total Billed Charges,22.33,3925.64,
TRAY CHEST TUBE INSERTION,21000720,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,47.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,12.544,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,16.128,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,16.128,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,16.128,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,810.144,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,3925.64,
DRSG BURN ARGLS 10GM PWDR,21000721,CDM,272,RC,,,Outpatient,,,109.7,65.82,,65.82,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.72,28,,29.592,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,39.49,36,,38.048,Percent of Total Billed Charges,36% of Total Billed Charges,39.49,36,,38.048,Percent of Total Billed Charges,36% Total Bille Charges,39.49,36,,38.048,Percent of Total Billed Charges,36% of Total Billed Charges,65.82,60,,52.656,Percent of Total Billed Charges,60% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14.42,,12.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.28,75,,65.824,Percent of Total Billed Charges,75% of Total Billed Charges,54.85,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,54.85,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.85,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,54.85,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.79,70,,61.432,Percent of Total Billed Charges,70% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.7,100,,87.76,Percent of Total Billed Charges,100% of Total Billed Charges,15.36,3925.64,
CATH KT RAD ART 20GX1.75IN LF,21000722,CDM,272,RC,C1769,HCPCS,Outpatient,,,55.99,33.59,,55.13,100,,19.336,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.68,28,,39.64,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,20.16,36,,50.968,Percent of Total Billed Charges,36% of Total Billed Charges,20.16,36,,50.968,Percent of Total Billed Charges,36% Total Bille Charges,20.16,36,,50.968,Percent of Total Billed Charges,36% of Total Billed Charges,33.59,60,,26.872,Percent of Total Billed Charges,60% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14.42,,6.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.99,75,,33.592,Percent of Total Billed Charges,75% of Total Billed Charges,28,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,28,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,28,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.19,70,,31.352,Percent of Total Billed Charges,70% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,7.84,14,,6.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.99,100,,44.792,Percent of Total Billed Charges,100% of Total Billed Charges,7.84,3925.64,
SLEEVE COMPR SCD EXPR KNEE MED,21000726,CDM,271,RC,,,Outpatient,,,132.12,79.27,,79.27,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.99,28,,6.48,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,47.56,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,47.56,36,,8.336,Percent of Total Billed Charges,36% Total Bille Charges,47.56,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,79.27,60,,63.416,Percent of Total Billed Charges,60% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.05,14.42,,15.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.09,75,,79.272,Percent of Total Billed Charges,75% of Total Billed Charges,66.06,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,66.06,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.06,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,66.06,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.48,70,,73.984,Percent of Total Billed Charges,70% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.12,100,,105.696,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,3925.64,
SLEEVE COMPR SCD EXPR KNEE LG,21000727,CDM,271,RC,,,Outpatient,,,176.97,106.18,,106.18,60,,142.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.55,28,,7.736,Percent of Total Billed Charges,28% of Total Billed Charges,4454.16,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,63.71,36,,9.944,Percent of Total Billed Charges,36% of Total Billed Charges,63.71,36,,9.944,Percent of Total Billed Charges,36% Total Bille Charges,63.71,36,,9.944,Percent of Total Billed Charges,36% of Total Billed Charges,106.18,60,,84.944,Percent of Total Billed Charges,60% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14.42,,20.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.73,75,,106.184,Percent of Total Billed Charges,75% of Total Billed Charges,88.49,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,88.49,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.49,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,88.49,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.88,70,,99.104,Percent of Total Billed Charges,70% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.97,100,,141.576,Percent of Total Billed Charges,100% of Total Billed Charges,24.78,4454.16,
OINTMENT BARRIER PERINL 2.5OZ,21000728,CDM,271,RC,A6250,HCPCS,Outpatient,,,28.94,17.36,,0.03,100,,75.664,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.1,28,,22.064,Percent of Total Billed Charges,28% of Total Billed Charges,2247.73,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,36,,28.368,Percent of Total Billed Charges,36% of Total Billed Charges,10.42,36,,28.368,Percent of Total Billed Charges,36% Total Bille Charges,10.42,36,,28.368,Percent of Total Billed Charges,36% of Total Billed Charges,17.36,60,,13.888,Percent of Total Billed Charges,60% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.17,14.42,,3.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.71,75,,17.368,Percent of Total Billed Charges,75% of Total Billed Charges,14.47,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,14.47,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.47,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,14.47,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.26,70,,16.208,Percent of Total Billed Charges,70% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.94,100,,23.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,2247.73,
OINTMENT BARRIER PERINL 20Z,21000729,CDM,271,RC,A6250,HCPCS,Outpatient,,,34.52,20.71,,0.03,100,,288,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.67,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,12.43,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,12.43,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,12.43,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,20.71,60,,16.568,Percent of Total Billed Charges,60% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.98,14.42,,3.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.89,75,,20.712,Percent of Total Billed Charges,75% of Total Billed Charges,17.26,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,17.26,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.26,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,17.26,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.16,70,,19.328,Percent of Total Billed Charges,70% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.52,100,,27.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,8892.71,
BAG DRNGE STOOL DIGINCARE,21000730,CDM,272,RC,A4357,HCPCS,Outpatient,,,25.09,15.05,,7.02,100,,180,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.85,280,,9.024,Fee Schedule,280% of BCBS BULE Fee Schedule,30.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,34.52,360,,11.6,Fee Schedule,360% of BCBS POS Rate,34.52,360,,11.6,Fee schedule,360% of BCBS PPO Rate,34.52,360,,11.6,Fee Schedule,360% of BCBS Traditional Rate,15.05,60,,12.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.62,14.42,,2.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,75,,15.056,Percent of Total Billed Charges,75% of Total Billed Charges,12.55,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,12.55,50,,10.04,Percent of Total Billed Charges,50% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.55,50,,10.04,Percent of Total Billed Charges,50% of Total Billed Charges,12.55,50,,10.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.56,70,,14.048,Percent of Total Billed Charges,70% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.09,100,,20.072,Percent of Total Billed Charges,100% of Total Billed Charges,3.51,34.52,
BMCC CATH INTMT BARDX 16FR 10M,21000733,CDM,272,RC,,,Outpatient,,,98.5,59.10,,59.1,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.58,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,35.46,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,35.46,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,35.46,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,59.1,60,,47.28,Percent of Total Billed Charges,60% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,14.2,14.42,,11.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.88,75,,59.104,Percent of Total Billed Charges,75% of Total Billed Charges,49.25,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,49.25,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.25,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.25,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.95,70,,55.16,Percent of Total Billed Charges,70% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.5,100,,78.8,Percent of Total Billed Charges,100% of Total Billed Charges,13.79,8892.71,
PARACENTESIS THOR 8FRX4.75IN,21000734,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,10.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,24.968,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,32.104,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,32.104,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,32.104,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,10.04,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,8892.71,
BMCC DRESSING WOUND 4X3.6,21000735,CDM,272,RC,,,Outpatient,,,40.29,24.17,,24.17,60,,1047.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,28,,66.52,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,36,,85.528,Percent of Total Billed Charges,36% of Total Billed Charges,14.5,36,,85.528,Percent of Total Billed Charges,36% Total Bille Charges,14.5,36,,85.528,Percent of Total Billed Charges,36% of Total Billed Charges,24.17,60,,19.336,Percent of Total Billed Charges,60% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14.42,,4.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.22,75,,24.176,Percent of Total Billed Charges,75% of Total Billed Charges,20.15,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.15,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.2,70,,22.56,Percent of Total Billed Charges,70% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.29,100,,32.232,Percent of Total Billed Charges,100% of Total Billed Charges,5.64,8892.71,
INTRO KT PERCUT SHTH 8.5,21000739,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,398.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,35.312,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,45.4,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,45.4,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,45.4,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,8892.71,
CATH KT RADPQ 20GX1.75IN LF,21000740,CDM,272,RC,C1769,HCPCS,Outpatient,,,111.48,66.89,,55.13,100,,72,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.21,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,8892.71,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.13,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,40.13,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,40.13,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,66.89,60,,53.512,Percent of Total Billed Charges,60% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14.42,,12.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.61,75,,66.888,Percent of Total Billed Charges,75% of Total Billed Charges,55.74,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,55.74,50,,44.592,Percent of Total Billed Charges,50% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.74,50,,44.592,Percent of Total Billed Charges,50% of Total Billed Charges,55.74,50,,44.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.04,70,,62.432,Percent of Total Billed Charges,70% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.48,100,,89.184,Percent of Total Billed Charges,100% of Total Billed Charges,15.61,8892.71,
HEEL PROTECTOR W/ FOOT & LEG,21000742,CDM,271,RC,,,Outpatient,,,296.96,178.18,,178.18,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.15,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,2247.73,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,106.91,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,106.91,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,106.91,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,178.18,60,,142.544,Percent of Total Billed Charges,60% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,42.82,14.42,,34.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.72,75,,178.176,Percent of Total Billed Charges,75% of Total Billed Charges,148.48,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,148.48,50,,118.784,Percent of Total Billed Charges,50% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.48,50,,118.784,Percent of Total Billed Charges,50% of Total Billed Charges,148.48,50,,118.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.87,70,,166.296,Percent of Total Billed Charges,70% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,41.57,14,,33.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.96,100,,237.568,Percent of Total Billed Charges,100% of Total Billed Charges,41.57,2247.73,
BNDG QUICK CLOT W/O SLIT,21000743,CDM,272,RC,,,Outpatient,,,157.63,94.58,,94.58,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.14,28,,16.296,Percent of Total Billed Charges,28% of Total Billed Charges,13824.41,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,56.75,36,,20.952,Percent of Total Billed Charges,36% of Total Billed Charges,56.75,36,,20.952,Percent of Total Billed Charges,36% Total Bille Charges,56.75,36,,20.952,Percent of Total Billed Charges,36% of Total Billed Charges,94.58,60,,75.664,Percent of Total Billed Charges,60% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.73,14.42,,18.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.22,75,,94.576,Percent of Total Billed Charges,75% of Total Billed Charges,78.82,50,,44.592,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,50,,63.056,Percent of Total Billed Charges,50% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.82,50,,63.056,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,50,,63.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.34,70,,88.272,Percent of Total Billed Charges,70% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,14,,17.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.63,100,,126.104,Percent of Total Billed Charges,100% of Total Billed Charges,22.07,13824.41,
DRAINAGE CSF EXT SYSTEM,21000746,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,13824.41,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,118.784,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,13824.41,
MONITOR IAP DEVICE,21000748,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,4.848,Percent of Total Billed Charges,28% of Total Billed Charges,13824.41,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,6.232,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,6.232,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,6.232,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,63.056,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,13824.41,
DRESSING SILVERLON 4X4 ISLAND,21000749,CDM,272,RC,A6206,HCPCS,Outpatient,,,72.76,43.66,,2.35,100,,73.776,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.37,28,,488.88,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.19,36,,628.56,Percent of Total Billed Charges,36% of Total Billed Charges,26.19,36,,628.56,Percent of Total Billed Charges,36% Total Bille Charges,26.19,36,,628.56,Percent of Total Billed Charges,36% of Total Billed Charges,43.66,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.57,75,,43.656,Percent of Total Billed Charges,75% of Total Billed Charges,36.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,36.38,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.38,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,36.38,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.93,70,,40.744,Percent of Total Billed Charges,70% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.76,100,,58.208,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,1744.63,
DRESSING SILVERLON 4X10 ISLAND,21000750,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,185.776,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,238.856,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,238.856,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,238.856,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,3925.64,
DRESSING SILVERLON 4X6 ISLAND,21000751,CDM,272,RC,A6255,HCPCS,Outpatient,,,87.3,52.38,,2.58,100,,49.88,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.88,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,11.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.71,360,,43.2,Fee Schedule,360% of BCBS POS Rate,12.71,360,,43.2,Fee schedule,360% of BCBS PPO Rate,12.71,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,52.38,60,,41.904,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.59,14.42,,10.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.48,75,,52.384,Percent of Total Billed Charges,75% of Total Billed Charges,43.65,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.11,70,,48.888,Percent of Total Billed Charges,70% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.3,100,,69.84,Percent of Total Billed Charges,100% of Total Billed Charges,2.58,87.3,
DRSG ALGISITE M 4 X 4,21000755,CDM,272,RC,,,Outpatient,,,21.64,12.98,,12.98,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.06,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,7.79,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,7.79,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,12.98,60,,10.384,Percent of Total Billed Charges,60% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,14.42,,2.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.23,75,,12.984,Percent of Total Billed Charges,75% of Total Billed Charges,10.82,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.15,70,,12.12,Percent of Total Billed Charges,70% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.64,100,,17.312,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,3925.64,
CATH KIT MICROSENSOR VENT,21000758,CDM,272,RC,,,Outpatient,,,2182.5,1309.50,,1309.5,60,,381.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,611.1,28,,328.344,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,785.7,36,,422.16,Percent of Total Billed Charges,36% of Total Billed Charges,785.7,36,,422.16,Percent of Total Billed Charges,36% Total Bille Charges,785.7,36,,422.16,Percent of Total Billed Charges,36% of Total Billed Charges,1309.5,60,,1047.6,Percent of Total Billed Charges,60% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,314.72,14.42,,251.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1636.88,75,,1309.504,Percent of Total Billed Charges,75% of Total Billed Charges,1091.25,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,1091.25,50,,873,Percent of Total Billed Charges,50% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1091.25,50,,873,Percent of Total Billed Charges,50% of Total Billed Charges,1091.25,50,,873,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1527.75,70,,1222.2,Percent of Total Billed Charges,70% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,305.55,14,,244.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2182.5,100,,1746,Percent of Total Billed Charges,100% of Total Billed Charges,305.55,3925.64,
ACCESS CRANIAL W/O DRUG KIT,21000760,CDM,272,RC,,,Outpatient,,,829.35,497.61,,497.61,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.22,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3925.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,298.57,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,298.57,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,298.57,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,497.61,60,,398.088,Percent of Total Billed Charges,60% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,119.59,14.42,,95.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.01,75,,497.608,Percent of Total Billed Charges,75% of Total Billed Charges,414.68,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,414.68,50,,331.744,Percent of Total Billed Charges,50% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.68,50,,331.744,Percent of Total Billed Charges,50% of Total Billed Charges,414.68,50,,331.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580.55,70,,464.44,Percent of Total Billed Charges,70% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,116.11,14,,92.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,829.35,100,,663.48,Percent of Total Billed Charges,100% of Total Billed Charges,116.11,3925.64,
CATH ARTERIAL LINE FEMORAL,21000761,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,2247.73,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,873,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,2247.73,
CATHETER DRAIN LUMBAR KIT II,21000762,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,666.49,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,331.744,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,666.49,
CATH CSF VENT 3-15CM BACTISEAL,21000763,CDM,272,RC,C1729,HCPCS,Outpatient,,,1465.83,879.50,,11.1,100,,71.504,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.43,28,,34.432,Percent of Total Billed Charges,28% of Total Billed Charges,1744.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,527.7,36,,44.264,Percent of Total Billed Charges,36% of Total Billed Charges,527.7,36,,44.264,Percent of Total Billed Charges,36% Total Bille Charges,527.7,36,,44.264,Percent of Total Billed Charges,36% of Total Billed Charges,879.5,60,,703.6,Percent of Total Billed Charges,60% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,211.37,14.42,,169.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1099.37,75,,879.496,Percent of Total Billed Charges,75% of Total Billed Charges,732.92,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,732.92,50,,586.336,Percent of Total Billed Charges,50% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,732.92,50,,586.336,Percent of Total Billed Charges,50% of Total Billed Charges,732.92,50,,586.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1026.08,70,,820.864,Percent of Total Billed Charges,70% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,205.22,14,,164.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1465.83,100,,1172.664,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,1744.63,
CARTRIDGE EXPRS ARTERIAL EXTRA,21000764,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,1591.68,
CATHETER KIT POWER TL 15CM PC,21000765,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,23.28,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,29.928,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,29.928,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,29.928,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,586.336,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,1591.68,
CATH TRIALYSIS CURVED EXT 20CM,21000766,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,52.616,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,67.648,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,67.648,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,67.648,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,1591.68,
SOLUTION PUREFLOW-B BICARBON,21000776,CDM,250,RC,,,Outpatient,,,153.7,92.22,,92.22,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.04,28,,178.08,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,55.33,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,55.33,36,,228.96,Percent of Total Billed Charges,36% Total Bille Charges,55.33,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,92.22,60,,73.776,Percent of Total Billed Charges,60% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,22.16,14.42,,17.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.28,75,,92.224,Percent of Total Billed Charges,75% of Total Billed Charges,76.85,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,76.85,50,,61.48,Percent of Total Billed Charges,50% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.85,50,,61.48,Percent of Total Billed Charges,50% of Total Billed Charges,76.85,50,,61.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.59,70,,86.072,Percent of Total Billed Charges,70% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,21.52,14,,17.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.7,100,,122.96,Percent of Total Billed Charges,100% of Total Billed Charges,21.52,1591.68,
PERICARDIOCENTESIS KT W/8.3FR,21000777,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,246.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,84,1591.68,
KIT TRANSDUCER PRES MONITOR,21000779,CDM,272,RC,,,Outpatient,,,103.92,62.35,,62.35,60,,152.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.1,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,37.41,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,37.41,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,37.41,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,62.35,60,,49.88,Percent of Total Billed Charges,60% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14.42,,11.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,75,,62.352,Percent of Total Billed Charges,75% of Total Billed Charges,51.96,50,,61.48,Percent of Total Billed Charges,50% of Total Billed Charges,51.96,50,,41.568,Percent of Total Billed Charges,50% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.96,50,,41.568,Percent of Total Billed Charges,50% of Total Billed Charges,51.96,50,,41.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.74,70,,58.192,Percent of Total Billed Charges,70% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14,,11.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.92,100,,83.136,Percent of Total Billed Charges,100% of Total Billed Charges,14.55,1591.68,
DRSG FM GRNFM VAC 26X15CM LG,21000780,CDM,272,RC,,,Outpatient,,,234.9,140.94,,140.94,60,,155.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.77,28,,46.736,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,84.56,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,84.56,36,,60.088,Percent of Total Billed Charges,36% Total Bille Charges,84.56,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,140.94,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,33.87,14.42,,27.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.18,75,,140.944,Percent of Total Billed Charges,75% of Total Billed Charges,117.45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.43,70,,131.544,Percent of Total Billed Charges,70% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.9,100,,187.92,Percent of Total Billed Charges,100% of Total Billed Charges,32.89,1591.68,
FLORTRAC SENSOR 84 INCHES,21000781,CDM,272,RC,,,Outpatient,,,795,477.00,,477,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.6,28,,33.368,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,286.2,36,,42.904,Percent of Total Billed Charges,36% of Total Billed Charges,286.2,36,,42.904,Percent of Total Billed Charges,36% Total Bille Charges,286.2,36,,42.904,Percent of Total Billed Charges,36% of Total Billed Charges,477,60,,381.6,Percent of Total Billed Charges,60% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.64,14.42,,91.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,596.25,75,,477,Percent of Total Billed Charges,75% of Total Billed Charges,397.5,50,,41.568,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.5,70,,445.2,Percent of Total Billed Charges,70% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,795,100,,636,Percent of Total Billed Charges,100% of Total Billed Charges,111.3,1591.68,
BINDER ABDOMINAL 45 IN CIRCUMFERENCE 9 IN WIDTH LA,30000000,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,33.656,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,43.272,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,1591.68,
BINDER ABDOMINAL 46 TO 62 IN CIRCUMFERENCE 9 IN W,30000001,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,47.52,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,61.104,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,1591.68,
MATTRESS WFL OVRLAY 75X30X3IN,30000002,CDM,271,RC,,,Outpatient,,,208.64,125.18,,125.18,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.42,28,,22.936,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,75.11,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,75.11,36,,29.488,Percent of Total Billed Charges,36% Total Bille Charges,75.11,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,125.18,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.09,14.42,,24.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.48,75,,125.184,Percent of Total Billed Charges,75% of Total Billed Charges,104.32,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.32,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.05,70,,116.84,Percent of Total Billed Charges,70% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.64,100,,166.912,Percent of Total Billed Charges,100% of Total Billed Charges,29.21,1591.68,
CUSHION WHEELCHAIR,30000003,CDM,271,RC,,,Outpatient,,,148.96,89.38,,89.38,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.71,28,,64.184,Percent of Total Billed Charges,28% of Total Billed Charges,1591.68,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,53.63,36,,82.52,Percent of Total Billed Charges,36% of Total Billed Charges,53.63,36,,82.52,Percent of Total Billed Charges,36% Total Bille Charges,53.63,36,,82.52,Percent of Total Billed Charges,36% of Total Billed Charges,89.38,60,,71.504,Percent of Total Billed Charges,60% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.48,14.42,,17.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.72,75,,89.376,Percent of Total Billed Charges,75% of Total Billed Charges,74.48,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.27,70,,83.416,Percent of Total Billed Charges,70% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.96,100,,119.168,Percent of Total Billed Charges,100% of Total Billed Charges,20.85,1591.68,
COVER DRSNG ADH 10X12IN CLR LF,30000004,CDM,272,RC,,,Outpatient,,,150.24,90.14,,90.14,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.07,28,,115,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,54.09,36,,147.856,Percent of Total Billed Charges,36% of Total Billed Charges,54.09,36,,147.856,Percent of Total Billed Charges,36% Total Bille Charges,54.09,36,,147.856,Percent of Total Billed Charges,36% of Total Billed Charges,90.14,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14.42,,17.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.68,75,,90.144,Percent of Total Billed Charges,75% of Total Billed Charges,75.12,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.12,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.17,70,,84.136,Percent of Total Billed Charges,70% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.24,100,,120.192,Percent of Total Billed Charges,100% of Total Billed Charges,21.03,5066.63,
DRSG FM GRNFM TRAC 15X10CM,30000005,CDM,272,RC,,,Outpatient,,,212.16,127.30,,127.3,60,,38.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.4,28,,71.296,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,76.38,36,,91.664,Percent of Total Billed Charges,36% of Total Billed Charges,76.38,36,,91.664,Percent of Total Billed Charges,36% Total Bille Charges,76.38,36,,91.664,Percent of Total Billed Charges,36% of Total Billed Charges,127.3,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.59,14.42,,24.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.12,75,,127.296,Percent of Total Billed Charges,75% of Total Billed Charges,106.08,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.51,70,,118.808,Percent of Total Billed Charges,70% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.16,100,,169.728,Percent of Total Billed Charges,100% of Total Billed Charges,29.7,5066.63,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESIV,30000006,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,72.72,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,93.496,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,93.496,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,93.496,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,14.34,5066.63,
DRSG FM GRNFM VAC 18X12/5 MED,30000007,CDM,272,RC,,,Outpatient,,,286.54,171.92,,171.92,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,103.15,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,103.15,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,103.15,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,171.92,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,14.42,,33.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.91,75,,171.928,Percent of Total Billed Charges,75% of Total Billed Charges,143.27,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.27,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.58,70,,160.464,Percent of Total Billed Charges,70% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.54,100,,229.232,Percent of Total Billed Charges,100% of Total Billed Charges,40.12,5066.63,
DRSG FM GRNFM VAC 18X12.5IN,30000008,CDM,272,RC,,,Outpatient,,,513.4,308.04,,308.04,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.75,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,184.82,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,184.82,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,184.82,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,308.04,60,,246.432,Percent of Total Billed Charges,60% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,74.03,14.42,,59.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,385.05,75,,308.04,Percent of Total Billed Charges,75% of Total Billed Charges,256.7,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,256.7,50,,205.36,Percent of Total Billed Charges,50% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.7,50,,205.36,Percent of Total Billed Charges,50% of Total Billed Charges,256.7,50,,205.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.38,70,,287.504,Percent of Total Billed Charges,70% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,71.88,14,,57.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,513.4,100,,410.72,Percent of Total Billed Charges,100% of Total Billed Charges,71.88,5066.63,
CANISTR SUC GEL INFOVAC 500ML,30000009,CDM,271,RC,,,Outpatient,,,318.28,190.97,,190.97,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.12,28,,30.448,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,114.58,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,114.58,36,,39.144,Percent of Total Billed Charges,36% Total Bille Charges,114.58,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,190.97,60,,152.776,Percent of Total Billed Charges,60% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,45.9,14.42,,36.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.71,75,,190.968,Percent of Total Billed Charges,75% of Total Billed Charges,159.14,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,159.14,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.14,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,159.14,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.8,70,,178.24,Percent of Total Billed Charges,70% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.28,100,,254.624,Percent of Total Billed Charges,100% of Total Billed Charges,44.56,5066.63,
CUSHION WAFFLE WHEELCHAIR,30000010,CDM,271,RC,,,Outpatient,,,324.64,194.78,,194.78,60,,43.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.9,28,,78.496,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,116.87,36,,100.928,Percent of Total Billed Charges,36% Total Bille Charges,116.87,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,194.78,60,,155.824,Percent of Total Billed Charges,60% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,46.81,14.42,,37.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.48,75,,194.784,Percent of Total Billed Charges,75% of Total Billed Charges,162.32,50,,205.36,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.25,70,,181.8,Percent of Total Billed Charges,70% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.64,100,,259.712,Percent of Total Billed Charges,100% of Total Billed Charges,45.45,8633.02,
RESUSC MASK ADLT RESVR MED,30000011,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,65,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,58.92,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,75.76,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,15.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,74.416,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,18.6,8633.02,
KIT DRESSING CHANGE POWERGLIDE,30000012,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,49.792,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,64.024,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,64.416,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,85.888,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,8633.02,
TRAY URINE METER SURESTEP 16FR,30000013,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,18.048,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,23.208,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,23.208,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,23.208,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,81.552,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,108.736,Percent of Total Billed Charges,100% of Total Billed Charges,19.03,8633.02,
WAFFLE SEAT CUSHION 17X17X2,30000014,CDM,271,RC,,,Outpatient,,,350.44,210.26,,210.26,60,,34.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.12,28,,23.512,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.16,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,126.16,36,,30.232,Percent of Total Billed Charges,36% Total Bille Charges,126.16,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,50.53,14.42,,40.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.83,75,,210.264,Percent of Total Billed Charges,75% of Total Billed Charges,175.22,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.31,70,,196.248,Percent of Total Billed Charges,70% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.44,100,,280.352,Percent of Total Billed Charges,100% of Total Billed Charges,49.06,8633.02,
SPONGE TOPICAL HEMOSTATIC 3.8 CM LENGTH 3.8 CM WI,30000015,CDM,271,RC,,,Outpatient,,,263.05,157.83,,157.83,60,,83.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.65,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,94.7,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,94.7,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,94.7,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,157.83,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,14.42,,30.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.29,75,,157.832,Percent of Total Billed Charges,75% of Total Billed Charges,131.53,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.14,70,,147.312,Percent of Total Billed Charges,70% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.05,100,,210.44,Percent of Total Billed Charges,100% of Total Billed Charges,36.83,8633.02,
SPONGE TOPICAL HEMOSTATIC 3.8 CM LENGTH 3.8 CM WI,30000016,CDM,272,RC,,,Outpatient,,,222.3,133.38,,133.38,60,,46.688,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.24,28,,36.608,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,80.03,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,80.03,36,,47.072,Percent of Total Billed Charges,36% Total Bille Charges,80.03,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,133.38,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14.42,,25.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.73,75,,133.384,Percent of Total Billed Charges,75% of Total Billed Charges,111.15,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.61,70,,124.488,Percent of Total Billed Charges,70% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.3,100,,177.84,Percent of Total Billed Charges,100% of Total Billed Charges,31.12,5066.63,
SLEEVE COMPR SCD EXPR KNEE MED,30000017,CDM,271,RC,,,Outpatient,,,80.58,48.35,,48.35,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.56,28,,24.768,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.01,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,29.01,36,,31.84,Percent of Total Billed Charges,36% Total Bille Charges,29.01,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,48.35,60,,38.68,Percent of Total Billed Charges,60% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.62,14.42,,9.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.44,75,,48.352,Percent of Total Billed Charges,75% of Total Billed Charges,40.29,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,40.29,50,,32.232,Percent of Total Billed Charges,50% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.29,50,,32.232,Percent of Total Billed Charges,50% of Total Billed Charges,40.29,50,,32.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.41,70,,45.128,Percent of Total Billed Charges,70% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.58,100,,64.464,Percent of Total Billed Charges,100% of Total Billed Charges,11.28,5066.63,
IMMUNIZATION INJECT INFLUENZA,30000018,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,60.304,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,378.112,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,20.224,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,26.008,Fee Schedule,360% of BCBS POS Rate,85.64,360,,26.008,Fee schedule,360% of BCBS PPO Rate,85.64,360,,26.008,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,840.24,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IMMUNIZATION INJECT PNEUMOVAX,30000019,CDM,771,RC,G0009,HCPCS,Outpatient,,,70.83,42.50,,10.31,100,,51.408,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,396.672,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,79.6,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,172.55,360,,102.344,Fee Schedule,360% of BCBS POS Rate,172.55,360,,102.344,Fee schedule,360% of BCBS PPO Rate,172.55,360,,102.344,Fee Schedule,360% of BCBS Traditional Rate,42.5,60,,34,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,881.496,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.12,75,,42.496,Percent of Total Billed Charges,75% of Total Billed Charges,35.42,50,,32.232,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,70,,39.664,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,100,,56.664,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,172.55,
SLEEVE COMPR SCD EXPR KNEE LG,30000021,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,77.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,57.44,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,73.856,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,14.69,5066.63,
KIT CATH CENTRAL VENOUS TRIPLE,30000023,CDM,271,RC,,,Outpatient,,,505.9,303.54,,303.54,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.65,28,,357.776,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,182.12,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,182.12,36,,460,Percent of Total Billed Charges,36% Total Bille Charges,182.12,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,303.54,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,72.95,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.43,75,,303.544,Percent of Total Billed Charges,75% of Total Billed Charges,252.95,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.13,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.9,100,,404.72,Percent of Total Billed Charges,100% of Total Billed Charges,70.83,5066.63,
NOVAPLUS SENSOR CHAIR,30000024,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,128.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,30.336,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,39,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,39,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,39,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,22.88,5066.63,
NOVAPLUS PEEK-A-BOO MITTS,30000025,CDM,271,RC,,,Outpatient,,,110.56,66.34,,66.34,60,,84.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,39.8,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,39.8,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,39.8,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,66.34,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.94,14.42,,12.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,75,,66.336,Percent of Total Billed Charges,75% of Total Billed Charges,55.28,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,70,,61.912,Percent of Total Billed Charges,70% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.56,100,,88.448,Percent of Total Billed Charges,100% of Total Billed Charges,15.48,5066.63,
PAD HET THER MAX-THM 16X22IN,30000026,CDM,271,RC,,,Outpatient,,,90.3,54.18,,54.18,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.28,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,32.51,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,32.51,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,32.51,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,54.18,60,,43.344,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,13.02,14.42,,10.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.73,75,,54.184,Percent of Total Billed Charges,75% of Total Billed Charges,45.15,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,45.15,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.15,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,45.15,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.21,70,,50.568,Percent of Total Billed Charges,70% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,100,,72.24,Percent of Total Billed Charges,100% of Total Billed Charges,12.64,5066.63,
INSERT FOLEY CATHETER,30000188,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,76.552,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,37.784,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,16.32,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,20.976,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,20.976,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,20.976,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,100.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,83.968,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,199,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,24.49,5066.63,
POST VOID RESID BLADDER SCAN,30000196,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,75.472,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,1338.128,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,38.744,Percent of Total Billed Charges,28% of Total Billed Charges,5066.63,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,49.808,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,49.808,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,49.808,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,287.056,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,2973.624,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,143.608,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,10.26,5066.63,
INJECTION SQ OR IM,30000221,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,72,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,93.496,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,21.784,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,28.008,Fee Schedule,360% of BCBS POS Rate,217.69,360,,28.008,Fee schedule,360% of BCBS PPO Rate,217.69,360,,28.008,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,207.776,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,894.448,Case Rate,Pays based on per visit rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
IV INFUSION HYDRATION 1ST HR,30000222,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,72,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,89.904,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,52.616,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,67.648,Fee Schedule,360% of BCBS POS Rate,138.82,360,,67.648,Fee schedule,360% of BCBS PPO Rate,138.82,360,,67.648,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,199.784,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,75.832,Case Rate,Pays based on per visit rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,30000223,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,65.792,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,337.744,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,28.144,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,36.184,Fee Schedule,360% of BCBS POS Rate,49.28,360,,36.184,Fee schedule,360% of BCBS PPO Rate,49.28,360,,36.184,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,750.544,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,39.2,Case Rate,Pays based on per visit rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,30000224,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,63.416,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,306,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,23.992,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,30.848,Fee Schedule,360% of BCBS POS Rate,262.08,360,,30.848,Fee schedule,360% of BCBS PPO Rate,262.08,360,,30.848,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,680,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,84,Case Rate,Pays based on per visit rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,30000225,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,52.656,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,555.664,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,36.264,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,46.624,Fee Schedule,360% of BCBS POS Rate,79.13,360,,46.624,Fee schedule,360% of BCBS PPO Rate,79.13,360,,46.624,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,125.376,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,1234.8,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,40.792,Case Rate,Pays based on per visit rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV PUSH THER INITIAL MED,30000226,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,47.28,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,37.664,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,197.816,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,254.328,Fee Schedule,360% of BCBS POS Rate,142.7,360,,254.328,Fee schedule,360% of BCBS PPO Rate,142.7,360,,254.328,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,119.872,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,83.704,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,96.856,Case Rate,Pays based on per visit rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA ADD NEW MED,30000227,CDM,940,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,35.736,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,276.16,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,355.064,Fee Schedule,360% of BCBS POS Rate,60.98,360,,355.064,Fee schedule,360% of BCBS PPO Rate,60.98,360,,355.064,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,173.8,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,54.464,Case Rate,Pays based on per visit rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,30000228,CDM,940,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,19.336,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,832.616,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,1070.504,Fee Schedule,360% of BCBS POS Rate,85.64,360,,1070.504,Fee schedule,360% of BCBS PPO Rate,85.64,360,,1070.504,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,124.664,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,131.544,Case Rate,Pays based on per visit rate,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
IV INF THERAP ADDL SEQUENTIAL,30000229,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,17.032,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,213.696,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,274.752,Fee Schedule,360% of BCBS POS Rate,114.16,360,,274.752,Fee schedule,360% of BCBS PPO Rate,114.16,360,,274.752,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,65,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,173.8,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,70.36,Case Rate,Pays based on per visit rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,30000230,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,14.704,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,153.672,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,197.576,Fee Schedule,360% of BCBS POS Rate,76.54,360,,197.576,Fee schedule,360% of BCBS PPO Rate,76.54,360,,197.576,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,59.976,Case Rate,Pays based on per visit rate,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
THORACENTESIS ASP WO IMAGING,30000256,CDM,761,RC,32554,HCPCS,Outpatient,,,1597.23,958.34,,85.56,100,,13.76,Fee Schedule,100% of Aetna Fee Schedule,864.52,150,,110.896,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,447.22,28,,182.12,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,575,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,575,36,,234.16,Percent of Total Billed Charges,36% Total Bille Charges,575,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,72,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,246.44,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,230.32,14.42,,184.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1197.92,75,,958.336,Percent of Total Billed Charges,75% of Total Billed Charges,798.62,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,798.62,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.06,70,,90.664,Percent of Total Billed Charges,70% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1597.23,100,,1277.784,Percent of Total Billed Charges,100% of Total Billed Charges,85.56,8633.02,
THORACENTESIS TY 14 G X 2IN,30000481,CDM,272,RC,,,Outpatient,,,135.42,81.25,,81.25,60,,12.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.92,28,,160.384,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,48.75,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,48.75,36,,206.208,Percent of Total Billed Charges,36% Total Bille Charges,48.75,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,81.25,60,,34.96,Percent of Total Billed Charges,60% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,19.53,14.42,,15.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.57,75,,81.256,Percent of Total Billed Charges,75% of Total Billed Charges,67.71,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,67.71,50,,54.168,Percent of Total Billed Charges,50% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.71,50,,54.168,Percent of Total Billed Charges,50% of Total Billed Charges,67.71,50,,54.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.79,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,18.96,14,,15.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.42,100,,108.336,Percent of Total Billed Charges,100% of Total Billed Charges,18.96,8633.02,
BIOPSY SET SFT TISS BASC LF,30000483,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,10.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,718.6,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,923.912,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,923.912,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,923.912,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,83.016,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,8633.02,
PARACENTESIS THOR 8FRX4.75IN,30000484,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,88.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,282.424,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,363.12,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,363.12,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,363.12,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,46.688,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,54.168,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,8633.02,
SLEEVE COMPR SCD EXPR KNEE MED,30000485,CDM,271,RC,,,Outpatient,,,72.84,43.70,,43.7,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.4,28,,70.696,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.22,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,26.22,36,,90.888,Percent of Total Billed Charges,36% Total Bille Charges,26.22,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,43.7,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.5,14.42,,8.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.63,75,,43.704,Percent of Total Billed Charges,75% of Total Billed Charges,36.42,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,36.42,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.42,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,36.42,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.99,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.84,100,,58.272,Percent of Total Billed Charges,100% of Total Billed Charges,10.2,8633.02,
DRSG GEL IDSRB 40G 0.9 CDXMR,30000486,CDM,272,RC,,,Outpatient,,,172.95,103.77,,103.77,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.43,28,,79.6,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,62.26,36,,102.344,Percent of Total Billed Charges,36% Total Bille Charges,62.26,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,103.77,60,,60.304,Percent of Total Billed Charges,60% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.94,14.42,,19.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.71,75,,103.768,Percent of Total Billed Charges,75% of Total Billed Charges,86.48,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.48,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.07,70,,494.528,Percent of Total Billed Charges,70% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.95,100,,138.36,Percent of Total Billed Charges,100% of Total Billed Charges,24.21,8633.02,
CATH INTMT BARDX 16FR 10M,30000487,CDM,272,RC,,,Outpatient,,,97.26,58.36,,58.36,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.23,28,,57.44,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,35.01,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,35.01,36,,73.856,Percent of Total Billed Charges,36% Total Bille Charges,35.01,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,58.36,60,,51.408,Percent of Total Billed Charges,60% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14.42,,11.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.95,75,,58.36,Percent of Total Billed Charges,75% of Total Billed Charges,48.63,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,48.63,50,,38.904,Percent of Total Billed Charges,50% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.63,50,,38.904,Percent of Total Billed Charges,50% of Total Billed Charges,48.63,50,,38.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,70,,690.4,Percent of Total Billed Charges,70% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,13.62,14,,10.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.26,100,,77.808,Percent of Total Billed Charges,100% of Total Billed Charges,13.62,8633.02,
DRSG FM GRNFM VAC 26X15CM LG,30000488,CDM,272,RC,,,Outpatient,,,234.9,140.94,,140.94,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.77,28,,245.304,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,84.56,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,84.56,36,,315.392,Percent of Total Billed Charges,36% Total Bille Charges,84.56,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,140.94,60,,77.712,Percent of Total Billed Charges,60% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,33.87,14.42,,27.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.18,75,,140.944,Percent of Total Billed Charges,75% of Total Billed Charges,117.45,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.43,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.9,100,,187.92,Percent of Total Billed Charges,100% of Total Billed Charges,32.89,8633.02,
SLEEVE COMPR SCD EXPR KNEE LG,30000489,CDM,271,RC,,,Outpatient,,,125.64,75.38,,75.38,60,,71.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.18,28,,158.472,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.23,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,45.23,36,,203.752,Percent of Total Billed Charges,36% Total Bille Charges,45.23,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,75.38,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.12,14.42,,14.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.23,75,,75.384,Percent of Total Billed Charges,75% of Total Billed Charges,62.82,50,,38.904,Percent of Total Billed Charges,50% of Total Billed Charges,62.82,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.82,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,62.82,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.95,70,,534.24,Percent of Total Billed Charges,70% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.64,100,,100.512,Percent of Total Billed Charges,100% of Total Billed Charges,17.59,8633.02,
DRSG BURN ARGLS 10GM PWDR,30000501,CDM,271,RC,,,Outpatient,,,107.1,64.26,,64.26,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.99,28,,249.264,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,38.56,36,,320.488,Percent of Total Billed Charges,36% of Total Billed Charges,38.56,36,,320.488,Percent of Total Billed Charges,36% Total Bille Charges,38.56,36,,320.488,Percent of Total Billed Charges,36% of Total Billed Charges,64.26,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,15.44,14.42,,12.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.33,75,,64.264,Percent of Total Billed Charges,75% of Total Billed Charges,53.55,50,,93.96,Percent of Total Billed Charges,50% of Total Billed Charges,53.55,50,,42.84,Percent of Total Billed Charges,50% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.55,50,,42.84,Percent of Total Billed Charges,50% of Total Billed Charges,53.55,50,,42.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.97,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,14.99,14,,11.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.1,100,,85.68,Percent of Total Billed Charges,100% of Total Billed Charges,14.99,8633.02,
CHEST DRAIN UNIT PLEUR EVAC,30000506,CDM,272,RC,,,Outpatient,,,161.9,97.14,,97.14,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.33,28,,357.776,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,58.28,36,,460,Percent of Total Billed Charges,36% Total Bille Charges,58.28,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,97.14,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,23.35,14.42,,18.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.43,75,,97.144,Percent of Total Billed Charges,75% of Total Billed Charges,80.95,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,80.95,50,,64.76,Percent of Total Billed Charges,50% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.95,50,,64.76,Percent of Total Billed Charges,50% of Total Billed Charges,80.95,50,,64.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.33,70,,39.664,Percent of Total Billed Charges,70% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.9,100,,129.52,Percent of Total Billed Charges,100% of Total Billed Charges,22.67,8633.02,
MOD SED ONE PHYS INIT 15MIN 5+,30001000,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,49.152,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,160.6,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,206.488,Fee Schedule,360% of BCBS POS Rate,45.4,360,,206.488,Fee schedule,360% of BCBS PPO Rate,45.4,360,,206.488,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,42.84,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
MOD SED ONE PHYS ADDL 15 MIN,30001001,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,137.536,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,59.792,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,76.872,Fee Schedule,360% of BCBS POS Rate,38.92,360,,76.872,Fee schedule,360% of BCBS PPO Rate,38.92,360,,76.872,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,64.76,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,384.184,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
MOD SED SEP PHYS INIT 15MIN 5+,30001002,CDM,370,RC,99156,HCPCS,Outpatient,,,217.25,130.35,,55.94,100,,152.776,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.04,280,,39.64,Fee Schedule,280% of BCBS BULE Fee Schedule,258.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,290.63,360,,50.968,Fee Schedule,360% of BCBS POS Rate,290.63,360,,50.968,Fee schedule,360% of BCBS PPO Rate,290.63,360,,50.968,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,455.312,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,30.42,290.63,
MOD SED SEP PHYS ADDL 15 MIN,30001003,CDM,370,RC,99157,HCPCS,Outpatient,,,137,82.20,,46.39,100,,180.784,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.65,280,,39.224,Fee Schedule,280% of BCBS BULE Fee Schedule,209.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,236.12,360,,50.432,Fee Schedule,360% of BCBS POS Rate,236.12,360,,50.432,Fee schedule,360% of BCBS PPO Rate,236.12,360,,50.432,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,400.968,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,236.12,
I&D FB REMOVAL SQ SIMPLE,30001004,CDM,761,RC,10120,HCPCS,Outpatient,,,883.09,529.85,,79.77,100,,224.64,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,89.904,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,247.27,28,,35.728,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,317.91,36,,45.936,Percent of Total Billed Charges,36% of Total Billed Charges,317.91,36,,45.936,Percent of Total Billed Charges,36% Total Bille Charges,317.91,36,,45.936,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,98.528,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,199.784,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,127.34,14.42,,101.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,662.32,75,,529.856,Percent of Total Billed Charges,75% of Total Billed Charges,441.55,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,441.55,50,,353.24,Percent of Total Billed Charges,50% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,441.55,50,,353.24,Percent of Total Billed Charges,50% of Total Billed Charges,441.55,50,,353.24,Percent of Total Billed Charges,50% of Total Billed Charges,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,618.16,70,,1796.496,Percent of Total Billed Charges,70% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14,,98.904,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,883.09,100,,706.472,Percent of Total Billed Charges,100% of Total Billed Charges,79.77,8633.02,
PSEUDOANEURYSM INJ LT,30001005,CDM,761,RC,36002,HCPCS,Outpatient,,,1232.86,739.72,,93.93,100,,110.984,Fee Schedule,100% of Aetna Fee Schedule,864.52,150,,49.88,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,345.2,28,,35.224,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,443.83,36,,45.288,Percent of Total Billed Charges,36% of Total Billed Charges,443.83,36,,45.288,Percent of Total Billed Charges,36% Total Bille Charges,443.83,36,,45.288,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,152.712,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,110.848,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,177.78,14.42,,142.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,924.65,75,,739.72,Percent of Total Billed Charges,75% of Total Billed Charges,616.43,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,493.144,Percent of Total Billed Charges,50% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,616.43,50,,493.144,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,493.144,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,863,70,,706.064,Percent of Total Billed Charges,70% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,138.08,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.86,100,,986.288,Percent of Total Billed Charges,100% of Total Billed Charges,93.93,8633.02,
INSERT PICC CATH W/IMAGE >5YO,30200000,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,216.408,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,49.88,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,124.664,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,110.848,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,353.24,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,176.728,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,76.76,8633.02,
CHEMO ADMIN SQ OR IM,30200001,CDM,331,RC,96401,HCPCS,Outpatient,,,458.85,275.31,,47.67,100,,155.824,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,75.112,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,43.2,Fee Schedule,360% of BCBS POS Rate,217.69,360,,43.2,Fee schedule,360% of BCBS PPO Rate,217.69,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,674,100,,100.208,Case Rate,Pays based on per visit rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,166.912,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,66.17,14.42,,52.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,344.14,75,,275.312,Percent of Total Billed Charges,75% of Total Billed Charges,229.43,50,,493.144,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,229.43,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,199,Case Rate,Pays based on per visit rate,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,458.85,100,,367.08,Percent of Total Billed Charges,100% of Total Billed Charges,47.67,674,
CHEMO ADMIN SQ OR IM HORMONAL,30200002,CDM,331,RC,96402,HCPCS,Outpatient,,,410.11,246.07,,19.18,100,,63.784,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,53.624,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,30.704,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,39.48,Fee Schedule,360% of BCBS POS Rate,217.69,360,,39.48,Fee schedule,360% of BCBS PPO Rate,217.69,360,,39.48,Fee Schedule,360% of BCBS Traditional Rate,674,100,,134.52,Case Rate,Pays based on per visit rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,119.168,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,59.14,14.42,,47.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,307.58,75,,246.064,Percent of Total Billed Charges,75% of Total Billed Charges,205.06,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,143.608,Case Rate,Pays based on per visit rate,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,410.11,100,,328.088,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,674,
IV PUSH CHEMO INITIAL MED,30200003,CDM,335,RC,96409,HCPCS,Outpatient,,,694.67,416.80,,65.73,100,,51.168,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,54.088,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,307.78,280,,29.592,Fee Schedule,280% of BCBS BULE Fee Schedule,351.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,395.71,360,,38.048,Fee Schedule,360% of BCBS POS Rate,395.71,360,,38.048,Fee schedule,360% of BCBS PPO Rate,395.71,360,,38.048,Fee Schedule,360% of BCBS Traditional Rate,674,100,,125.376,Case Rate,Pays based on per visit rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,120.192,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.17,14.42,,80.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,521,75,,416.8,Percent of Total Billed Charges,75% of Total Billed Charges,347.34,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,347.34,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,613.256,Case Rate,Pays based on per visit rate,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,694.67,100,,555.736,Percent of Total Billed Charges,100% of Total Billed Charges,65.73,694.67,
IV PUSH CHEMO EA AD MED,30200004,CDM,335,RC,96411,HCPCS,Outpatient,,,535.83,321.50,,35.93,100,,51.536,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,168.48,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,166.49,280,,24.576,Fee Schedule,280% of BCBS BULE Fee Schedule,190.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,214.06,360,,31.592,Fee Schedule,360% of BCBS POS Rate,214.06,360,,31.592,Fee schedule,360% of BCBS PPO Rate,214.06,360,,31.592,Fee Schedule,360% of BCBS Traditional Rate,674,100,,119.872,Case Rate,Pays based on per visit rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,374.4,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,77.27,14.42,,61.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,401.87,75,,321.496,Percent of Total Billed Charges,75% of Total Billed Charges,267.92,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,267.92,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,396.176,Case Rate,Pays based on per visit rate,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,535.83,100,,428.664,Percent of Total Billed Charges,100% of Total Billed Charges,35.93,674,
IV INFUSION CHEMO 1ST HR,30200005,CDM,335,RC,96413,HCPCS,Outpatient,,,1081.92,649.15,,85.85,100,,65.24,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,165.512,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,400.62,280,,22.064,Fee Schedule,280% of BCBS BULE Fee Schedule,457.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,515.09,360,,28.368,Fee Schedule,360% of BCBS POS Rate,515.09,360,,28.368,Fee schedule,360% of BCBS PPO Rate,515.09,360,,28.368,Fee Schedule,360% of BCBS Traditional Rate,674,100,,34.072,Case Rate,Pays based on per visit rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,367.8,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,156.01,14.42,,124.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,811.44,75,,649.152,Percent of Total Billed Charges,75% of Total Billed Charges,540.96,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,540.96,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,623.168,Case Rate,Pays based on per visit rate,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.92,100,,865.536,Percent of Total Billed Charges,100% of Total Billed Charges,85.85,1081.92,
IV INFUSION CHEMO EA AD HR,30200006,CDM,335,RC,96415,HCPCS,Outpatient,,,448.95,269.37,,18.16,100,,126.264,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,76.376,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,280,,16.68,Fee Schedule,280% of BCBS BULE Fee Schedule,99.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,111.56,360,,21.44,Fee Schedule,360% of BCBS POS Rate,111.56,360,,21.44,Fee schedule,360% of BCBS PPO Rate,111.56,360,,21.44,Fee Schedule,360% of BCBS Traditional Rate,674,100,,34,Case Rate,Pays based on per visit rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,169.728,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.74,14.42,,51.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,336.71,75,,269.368,Percent of Total Billed Charges,75% of Total Billed Charges,224.48,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.48,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,71.12,Case Rate,Pays based on per visit rate,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,448.95,100,,359.16,Percent of Total Billed Charges,100% of Total Billed Charges,18.16,674,
CHEMO INF EACH ADD SEQ 1ST HR,30200007,CDM,335,RC,96417,HCPCS,Outpatient,,,561.5,336.90,,41.64,100,,57.984,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,36.864,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,193.76,280,,16.296,Fee Schedule,280% of BCBS BULE Fee Schedule,221.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,249.12,360,,20.952,Fee Schedule,360% of BCBS POS Rate,249.12,360,,20.952,Fee schedule,360% of BCBS PPO Rate,249.12,360,,20.952,Fee Schedule,360% of BCBS Traditional Rate,674,100,,1784.176,Case Rate,Pays based on per visit rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,81.92,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,80.97,14.42,,64.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,421.13,75,,336.904,Percent of Total Billed Charges,75% of Total Billed Charges,280.75,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,280.75,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,62.504,Case Rate,Pays based on per visit rate,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,561.5,100,,449.2,Percent of Total Billed Charges,100% of Total Billed Charges,41.64,674,
IV INFUSION HYDRATION 1ST HR,30200008,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,168.208,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,103.152,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,12.904,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,16.592,Fee Schedule,360% of BCBS POS Rate,138.82,360,,16.592,Fee schedule,360% of BCBS PPO Rate,138.82,360,,16.592,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,229.232,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,894.448,Case Rate,Pays based on per visit rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,30200009,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,47.856,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,44.664,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,12.256,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,15.752,Fee Schedule,360% of BCBS POS Rate,49.28,360,,15.752,Fee schedule,360% of BCBS PPO Rate,49.28,360,,15.752,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,99.248,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,401.496,Case Rate,Pays based on per visit rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,30200010,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,106.704,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,162.304,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,11.944,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,15.36,Fee Schedule,360% of BCBS POS Rate,262.08,360,,15.36,Fee schedule,360% of BCBS PPO Rate,262.08,360,,15.36,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,53.576,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,360.68,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,149.48,Case Rate,Pays based on per visit rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,30200011,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,83.096,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,116.872,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,11.944,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,15.36,Fee Schedule,360% of BCBS POS Rate,79.13,360,,15.36,Fee schedule,360% of BCBS PPO Rate,79.13,360,,15.36,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,128.128,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,259.712,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,99.104,Case Rate,Pays based on per visit rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV INF THERAP ADDL SEQUENTIAL,30200012,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,265.176,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,47.84,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,11.944,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,15.36,Fee Schedule,360% of BCBS POS Rate,114.16,360,,15.36,Fee schedule,360% of BCBS PPO Rate,114.16,360,,15.36,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,84.944,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,106.304,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,98.056,Case Rate,Pays based on per visit rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,30200013,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,242.832,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,11.944,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,15.36,Fee Schedule,360% of BCBS POS Rate,76.54,360,,15.36,Fee schedule,360% of BCBS PPO Rate,76.54,360,,15.36,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,89.312,Case Rate,Pays based on per visit rate,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
INJECTION SQ OR IM,30200014,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,504.144,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,126.16,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,9.024,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,11.6,Fee Schedule,360% of BCBS POS Rate,217.69,360,,11.6,Fee schedule,360% of BCBS PPO Rate,217.69,360,,11.6,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,76.552,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,280.352,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,88.056,Case Rate,Pays based on per visit rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
IV PUSH THER INITIAL MED,30200015,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,528.896,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,74.336,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,7.944,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,10.216,Fee Schedule,360% of BCBS POS Rate,142.7,360,,10.216,Fee schedule,360% of BCBS PPO Rate,142.7,360,,10.216,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,75.472,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,165.184,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,84,Case Rate,Pays based on per visit rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA ADD NEW MED,30200016,CDM,940,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,78.448,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,80.28,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,7.736,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,9.944,Fee Schedule,360% of BCBS POS Rate,60.98,360,,9.944,Fee schedule,360% of BCBS PPO Rate,60.98,360,,9.944,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,178.408,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,84,Case Rate,Pays based on per visit rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,30200017,CDM,940,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,53.072,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,6.864,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,8.824,Fee Schedule,360% of BCBS POS Rate,85.64,360,,8.824,Fee schedule,360% of BCBS PPO Rate,85.64,360,,8.824,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,76.76,Case Rate,Pays based on per visit rate,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
EMERGENT ET INTUBATION,30200018,CDM,761,RC,31500,HCPCS,Outpatient,,,954,572.40,,134,100,,360.752,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,58.84,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,267.12,28,,6.48,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,343.44,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,343.44,36,,8.336,Percent of Total Billed Charges,36% Total Bille Charges,343.44,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,65.792,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,130.752,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,137.57,14.42,,110.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,715.5,75,,572.4,Percent of Total Billed Charges,75% of Total Billed Charges,477,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,667.8,70,,73.984,Percent of Total Billed Charges,70% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,954,100,,763.2,Percent of Total Billed Charges,100% of Total Billed Charges,133.56,8633.02,
IMMUNIZATION INJECT INFLUENZA,30200019,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,240,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,39.8,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,6.424,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,8.256,Fee Schedule,360% of BCBS POS Rate,85.64,360,,8.256,Fee schedule,360% of BCBS PPO Rate,85.64,360,,8.256,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,63.416,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,88.448,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,61.432,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IMMUNIZATION INJECT PNEUMOVAX,30200020,CDM,771,RC,G0009,HCPCS,Outpatient,,,70.83,42.50,,10.31,100,,57.984,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,37.784,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,6.008,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,172.55,360,,7.72,Fee Schedule,360% of BCBS POS Rate,172.55,360,,7.72,Fee schedule,360% of BCBS PPO Rate,172.55,360,,7.72,Fee Schedule,360% of BCBS Traditional Rate,42.5,60,,52.656,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,83.968,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.12,75,,42.496,Percent of Total Billed Charges,75% of Total Billed Charges,35.42,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,70,,55.16,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,100,,56.664,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,172.55,
INSERT MIDLINE W/IMAGE >5 YO,30200021,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,50.384,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,47.28,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,48.888,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
MIDLINE MAX PROVENA 4F,30200023,CDM,271,RC,,,Outpatient,,,686.04,411.62,,411.62,60,,408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.09,28,,41.08,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,246.97,36,,52.824,Percent of Total Billed Charges,36% of Total Billed Charges,246.97,36,,52.824,Percent of Total Billed Charges,36% Total Bille Charges,246.97,36,,52.824,Percent of Total Billed Charges,36% of Total Billed Charges,411.62,60,,41.904,Percent of Total Billed Charges,60% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,98.93,14.42,,79.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.53,75,,411.624,Percent of Total Billed Charges,75% of Total Billed Charges,343.02,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.23,70,,41.696,Percent of Total Billed Charges,70% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,686.04,100,,548.832,Percent of Total Billed Charges,100% of Total Billed Charges,96.05,8633.02,
TRACHEOTOMY TUBE CHANGE,30200026,CDM,761,RC,31502,HCPCS,Outpatient,,,813.05,487.83,,33.19,100,,740.88,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,84.568,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,227.65,28,,703.248,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,292.7,36,,904.176,Percent of Total Billed Charges,36% of Total Billed Charges,292.7,36,,904.176,Percent of Total Billed Charges,36% Total Bille Charges,292.7,36,,904.176,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,35.736,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,187.92,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,117.24,14.42,,93.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,609.79,75,,487.832,Percent of Total Billed Charges,75% of Total Billed Charges,406.53,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,569.14,70,,40.744,Percent of Total Billed Charges,70% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,813.05,100,,650.44,Percent of Total Billed Charges,100% of Total Billed Charges,33.19,8633.02,
LARYNGOSCOPYFLEX/RIGID DX,30200027,CDM,761,RC,31575,HCPCS,Outpatient,,,716.01,429.61,,63.82,100,,50.224,Fee Schedule,100% of Aetna Fee Schedule,272.58,150,,58.288,Fee Schedule ,150% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,28,,470.288,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,257.76,36,,604.656,Percent of Total Billed Charges,36% of Total Billed Charges,257.76,36,,604.656,Percent of Total Billed Charges,36% Total Bille Charges,257.76,36,,604.656,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,34.928,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,129.52,Fee Schedule,100% of CMS OPPS Rate,163.55,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,236.24,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,103.25,14.42,,82.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,537.01,75,,429.608,Percent of Total Billed Charges,75% of Total Billed Charges,358.01,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.01,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,272.58,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.21,70,,32.264,Percent of Total Billed Charges,70% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.01,100,,572.808,Percent of Total Billed Charges,100% of Total Billed Charges,63.82,8633.02,
INSERT PICC CATH W/O IMG >5YO,30200067,CDM,761,RC,36569,HCPCS,Outpatient,,,3208.03,1924.82,,85.23,100,,147.864,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,23.536,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,898.25,28,,207.28,Percent of Total Billed Charges,28% of Total Billed Charges,8633.02,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1154.89,36,,266.496,Percent of Total Billed Charges,36% of Total Billed Charges,1154.89,36,,266.496,Percent of Total Billed Charges,36% Total Bille Charges,1154.89,36,,266.496,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,27.656,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,52.304,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,462.6,14.42,,370.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2406.02,75,,1924.816,Percent of Total Billed Charges,75% of Total Billed Charges,1604.02,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.02,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2245.62,70,,30.632,Percent of Total Billed Charges,70% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3208.03,100,,2566.424,Percent of Total Billed Charges,100% of Total Billed Charges,85.23,8633.02,
BONE MARROW BIOPSY(IES),30200075,CDM,761,RC,38221,HCPCS,Outpatient,,,1260.83,756.50,,67.48,100,,180,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,25.2,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,353.03,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,12102.43,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,453.9,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,453.9,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,453.9,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,26.256,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,56,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,181.81,14.42,,145.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,945.62,75,,756.496,Percent of Total Billed Charges,75% of Total Billed Charges,630.42,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,630.42,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,882.58,70,,29.864,Percent of Total Billed Charges,70% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.83,100,,1008.664,Percent of Total Billed Charges,100% of Total Billed Charges,67.48,12102.43,
INSERT STRAIGHT CATHETER,30200091,CDM,761,RC,51701,HCPCS,Outpatient,,,315.59,189.35,,24.67,100,,180,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,20.488,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.37,28,,61.6,Percent of Total Billed Charges,28% of Total Billed Charges,249.79,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,113.61,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,113.61,36,,79.2,Percent of Total Billed Charges,36% Total Bille Charges,113.61,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,25.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,45.528,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,45.51,14.42,,36.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,236.69,75,,189.352,Percent of Total Billed Charges,75% of Total Billed Charges,157.8,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,157.8,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,70,,29.864,Percent of Total Billed Charges,70% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,315.59,100,,252.472,Percent of Total Billed Charges,100% of Total Billed Charges,24.67,515,
INSERT FOLEY CATHETER,30200109,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,180,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,18.976,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,198.248,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,254.888,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,254.888,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,254.888,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,25.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,42.168,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,29.864,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,24.49,1787.64,
POST VOID RESID BLADDER SCAN,30200117,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,224.208,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,12.048,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,137.624,Percent of Total Billed Charges,28% of Total Billed Charges,1659.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,176.944,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,25.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,26.768,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,29.864,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,10.26,1659.46,
LUMBAR PUNCTURE DIAGNOSTIC,30200125,CDM,761,RC,62270,HCPCS,Outpatient,,,1095.1,657.06,,52.08,100,,198.336,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,58.104,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,306.63,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,722.52,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,25.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,129.12,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,766.57,70,,22.56,Percent of Total Billed Charges,70% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,52.08,1184.5,
I&D OF SKIN ABSCESS SIMPLE,30200130,CDM,761,RC,10060,HCPCS,Outpatient,,,707.46,424.48,,79.09,100,,57.6,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,135,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,254.69,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,254.69,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,254.69,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,19.336,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,300,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,102.02,14.42,,81.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,530.6,75,,424.48,Percent of Total Billed Charges,75% of Total Billed Charges,353.73,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,353.73,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,353.73,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,353.73,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.22,70,,22.432,Percent of Total Billed Charges,70% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,707.46,100,,565.968,Percent of Total Billed Charges,100% of Total Billed Charges,79.09,1787.64,
LUMBAR PUNCTURE THERAPEUTIC,30200133,CDM,761,RC,62272,HCPCS,Outpatient,,,1112.8,667.68,,73.22,100,,97.92,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,135,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,311.58,28,,46.736,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% Total Bille Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,19.232,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,300,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,160.47,14.42,,128.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,834.6,75,,667.68,Percent of Total Billed Charges,75% of Total Billed Charges,556.4,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,556.4,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,778.96,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.8,100,,890.24,Percent of Total Billed Charges,100% of Total Billed Charges,73.22,1787.64,
IMMUNIZATION IM/SQ INITIAL VAC,30200141,CDM,771,RC,90471,HCPCS,Outpatient,,,127,76.20,,10,100,,97.92,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,367.208,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,33.368,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,217.69,360,,42.904,Fee Schedule,360% of BCBS POS Rate,217.69,360,,42.904,Fee schedule,360% of BCBS PPO Rate,217.69,360,,42.904,Fee Schedule,360% of BCBS Traditional Rate,76.2,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,816.024,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,95.25,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,63.5,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.9,70,,19.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,127,100,,101.6,Percent of Total Billed Charges,100% of Total Billed Charges,10,217.69,
IMMUNIZE INJECT HEP B,30200208,CDM,771,RC,G0010,HCPCS,Outpatient,,,111.62,66.97,,10.31,100,,100.176,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,135,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,145.32,280,,49.072,Fee Schedule,280% of BCBS BULE Fee Schedule,166.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,186.84,360,,63.096,Fee Schedule,360% of BCBS POS Rate,186.84,360,,63.096,Fee schedule,360% of BCBS PPO Rate,186.84,360,,63.096,Fee Schedule,360% of BCBS Traditional Rate,66.97,60,,16.568,Percent of Total Billed Charges,60% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,300,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.1,14.42,,184.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,83.72,75,,66.976,Percent of Total Billed Charges,75% of Total Billed Charges,55.81,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,55.81,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,78.13,70,,17.16,Percent of Total Billed Charges,70% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,111.62,100,,89.296,Percent of Total Billed Charges,100% of Total Billed Charges,10.31,186.84,
THORACENTESIS ASP WO IMAGING,30200258,CDM,761,RC,32554,HCPCS,Outpatient,,,1597.23,958.34,,85.56,100,,914.168,Fee Schedule,100% of Aetna Fee Schedule,864.52,150,,14.944,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,447.22,28,,84.368,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,575,36,,108.472,Percent of Total Billed Charges,36% of Total Billed Charges,575,36,,108.472,Percent of Total Billed Charges,36% Total Bille Charges,575,36,,108.472,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,10.384,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,33.208,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,230.32,14.42,,20.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1197.92,75,,106.184,Percent of Total Billed Charges,75% of Total Billed Charges,798.62,50,,286.784,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,798.62,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.06,70,,11.888,Percent of Total Billed Charges,70% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1597.23,100,,141.576,Percent of Total Billed Charges,100% of Total Billed Charges,85.56,1787.64,
INTRATHECAL CHEMO,30200273,CDM,331,RC,96450,HCPCS,Outpatient,,,1196.5,717.90,,44.79,100,,360.752,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,28.968,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.07,280,,104.832,Fee Schedule,280% of BCBS BULE Fee Schedule,261.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,294.52,360,,134.784,Fee Schedule,360% of BCBS POS Rate,294.52,360,,134.784,Fee schedule,360% of BCBS PPO Rate,294.52,360,,134.784,Fee Schedule,360% of BCBS Traditional Rate,674,100,,10.192,Case Rate,Pays based on per visit rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,64.368,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,172.54,14.42,,18.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,897.38,75,,105.064,Percent of Total Billed Charges,75% of Total Billed Charges,598.25,50,,106.776,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,598.25,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,102.712,Case Rate,Pays based on per visit rate,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,17.864,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.5,100,,140.08,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,1196.5,
ARTHRO/ASP/INJ SM JOINT,30200281,CDM,761,RC,20600,HCPCS,Outpatient,,,716.96,430.18,,29.89,100,,106.704,Fee Schedule,100% of Aetna Fee Schedule,407.6,150,,887.272,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.75,28,,51.792,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,258.11,36,,66.592,Percent of Total Billed Charges,36% of Total Billed Charges,258.11,36,,66.592,Percent of Total Billed Charges,36% Total Bille Charges,258.11,36,,66.592,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,88.04,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,1971.712,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,103.39,14.42,,18.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,537.72,75,,95.696,Percent of Total Billed Charges,75% of Total Billed Charges,358.48,50,,70.792,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.48,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.87,70,,1758.12,Percent of Total Billed Charges,70% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.96,100,,127.592,Percent of Total Billed Charges,100% of Total Billed Charges,29.89,1787.64,
DRSG FM GRNFM VAC 26X15CM LG,30201001,CDM,272,RC,,,Outpatient,,,266.93,160.16,,160.16,60,,41.184,Percent of Total Billed Charges,60% of Total Billed Charges,120.12,45,,3647.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.74,28,,100.992,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,96.09,36,,129.848,Percent of Total Billed Charges,36% of Total Billed Charges,96.09,36,,129.848,Percent of Total Billed Charges,36% Total Bille Charges,96.09,36,,129.848,Percent of Total Billed Charges,36% of Total Billed Charges,160.16,60,,227.152,Percent of Total Billed Charges,60% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.93,100,,8105.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.49,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.2,75,,94.344,Percent of Total Billed Charges,75% of Total Billed Charges,133.47,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,133.47,50,,62.896,Percent of Total Billed Charges,50% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.47,50,,62.896,Percent of Total Billed Charges,50% of Total Billed Charges,133.47,50,,62.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.85,70,,1175.72,Percent of Total Billed Charges,70% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.93,100,,125.792,Percent of Total Billed Charges,100% of Total Billed Charges,37.37,1787.64,
SLEEVE COMPR SCD EXPR KNEE LG,30201002,CDM,271,RC,,,Outpatient,,,176.97,106.18,,106.18,60,,97.344,Percent of Total Billed Charges,60% of Total Billed Charges,79.64,45,,1193.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.55,28,,72.72,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,63.71,36,,93.496,Percent of Total Billed Charges,36% of Total Billed Charges,63.71,36,,93.496,Percent of Total Billed Charges,36% Total Bille Charges,63.71,36,,93.496,Percent of Total Billed Charges,36% of Total Billed Charges,106.18,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.97,100,,2652,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.73,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,88.49,50,,63.8,Percent of Total Billed Charges,50% of Total Billed Charges,88.49,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.49,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,88.49,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.88,70,,518.192,Percent of Total Billed Charges,70% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.97,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,24.78,1787.64,
DRSG GEL IDSRB 40G 0.9 CDXMR,30201003,CDM,272,RC,,,Outpatient,,,175.1,105.06,,105.06,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,78.8,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.03,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,63.04,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,63.04,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,105.06,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.1,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,25.25,14.42,,15.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.33,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,87.55,50,,62.896,Percent of Total Billed Charges,50% of Total Billed Charges,87.55,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.55,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,87.55,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.57,70,,265.016,Percent of Total Billed Charges,70% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.1,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,24.51,1787.64,
DRAIN CHST CHST PLR-EV PED,30201004,CDM,272,RC,,,Outpatient,,,159.49,95.69,,95.69,60,,504.144,Percent of Total Billed Charges,60% of Total Billed Charges,71.77,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.66,28,,23.88,Percent of Total Billed Charges,28% of Total Billed Charges,17695.19,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,36,,30.704,Percent of Total Billed Charges,36% of Total Billed Charges,57.42,36,,30.704,Percent of Total Billed Charges,36% Total Bille Charges,57.42,36,,30.704,Percent of Total Billed Charges,36% of Total Billed Charges,95.69,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.49,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,23,14.42,,15.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.62,75,,82.24,Percent of Total Billed Charges,75% of Total Billed Charges,79.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,79.75,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.75,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,79.75,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.64,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,22.33,14,,14.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.49,100,,109.656,Percent of Total Billed Charges,100% of Total Billed Charges,22.33,17695.19,
BANDAGE TUB SZ D MULTIPURPOSE,30201005,CDM,271,RC,,,Outpatient,,,157.24,94.34,,94.34,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,70.76,45,,553.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.03,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,94.95,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,56.61,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,56.61,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,56.61,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,94.34,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.24,100,,1229.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14.42,,12.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.93,75,,79.272,Percent of Total Billed Charges,75% of Total Billed Charges,78.62,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,78.62,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.62,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,78.62,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.07,70,,153.992,Percent of Total Billed Charges,70% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,12.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.24,100,,105.696,Percent of Total Billed Charges,100% of Total Billed Charges,22.01,157.24,
DRNGE KT THOR H2O SEAL SGL,30201006,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,30.448,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,39.144,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,71.504,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,11.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,65.824,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,54.832,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,495.608,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,87.76,Percent of Total Billed Charges,100% of Total Billed Charges,21,1787.64,
PARACENTESIS THOR 8FRX4.75IN,30201007,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,5183.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,58.92,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,75.76,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,75.76,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,11518.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,10.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,59.104,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,52.848,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,344.056,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,78.8,Percent of Total Billed Charges,100% of Total Billed Charges,21,2322.46,
THORACENTESIS TY 14 G X 2IN,30201008,CDM,272,RC,,,Outpatient,,,137.07,82.24,,82.24,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,61.68,45,,314.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.38,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,214.7,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,49.35,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,49.35,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,49.35,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,82.24,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.07,100,,698.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14.42,,8.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.8,75,,52.384,Percent of Total Billed Charges,75% of Total Billed Charges,68.54,50,,43.88,Percent of Total Billed Charges,50% of Total Billed Charges,68.54,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.54,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,68.54,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.95,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,8.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.07,100,,69.84,Percent of Total Billed Charges,100% of Total Billed Charges,19.19,214.7,
SLEEVE COMPR SCD EXPR KNEE MED,30201009,CDM,271,RC,,,Outpatient,,,132.12,79.27,,79.27,60,,108.536,Percent of Total Billed Charges,60% of Total Billed Charges,59.45,45,,237.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.99,28,,78.496,Percent of Total Billed Charges,28% of Total Billed Charges,255.97,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,47.56,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,47.56,36,,100.928,Percent of Total Billed Charges,36% Total Bille Charges,47.56,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,79.27,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.12,100,,528.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,19.05,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.09,75,,44.672,Percent of Total Billed Charges,75% of Total Billed Charges,66.06,50,,39.4,Percent of Total Billed Charges,50% of Total Billed Charges,66.06,50,,29.784,Percent of Total Billed Charges,50% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.06,50,,29.784,Percent of Total Billed Charges,50% of Total Billed Charges,66.06,50,,29.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.48,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.5,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.12,100,,59.56,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,255.97,
DRSG BURN ARGLS 10GM PWDR,30201010,CDM,271,RC,,,Outpatient,,,109.7,65.82,,65.82,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,49.37,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.72,28,,22.336,Percent of Total Billed Charges,28% of Total Billed Charges,138.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,39.49,36,,28.712,Percent of Total Billed Charges,36% of Total Billed Charges,39.49,36,,28.712,Percent of Total Billed Charges,36% Total Bille Charges,39.49,36,,28.712,Percent of Total Billed Charges,36% of Total Billed Charges,65.82,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.7,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14.42,,6.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.28,75,,43.656,Percent of Total Billed Charges,75% of Total Billed Charges,54.85,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,54.85,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.85,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,54.85,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.79,70,,116.84,Percent of Total Billed Charges,70% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.7,100,,58.208,Percent of Total Billed Charges,100% of Total Billed Charges,15.36,138.31,
BMCC CATH INTMT BARDX 16FR 10M,30201011,CDM,272,RC,,,Outpatient,,,98.5,59.10,,59.1,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,44.33,45,,4605.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.58,28,,49.792,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.46,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,35.46,36,,64.024,Percent of Total Billed Charges,36% Total Bille Charges,35.46,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,59.1,60,,152.776,Percent of Total Billed Charges,60% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.5,100,,10233.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,14.2,14.42,,6.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.88,75,,34.576,Percent of Total Billed Charges,75% of Total Billed Charges,49.25,50,,29.784,Percent of Total Billed Charges,50% of Total Billed Charges,49.25,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.25,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,49.25,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.95,70,,83.416,Percent of Total Billed Charges,70% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14,,6.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.5,100,,46.096,Percent of Total Billed Charges,100% of Total Billed Charges,13.79,2322.46,
DRESSING SILVERLON 4X6 ISLAND,30201012,CDM,272,RC,A6255,HCPCS,Outpatient,,,87.3,52.38,,2.58,100,,100.144,Fee Schedule,100% of Aetna Fee Schedule,39.29,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.88,280,,38.776,Fee Schedule,280% of BCBS BULE Fee Schedule,11.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.71,360,,49.856,Fee Schedule,360% of BCBS POS Rate,12.71,360,,49.856,Fee schedule,360% of BCBS PPO Rate,12.71,360,,49.856,Fee Schedule,360% of BCBS Traditional Rate,52.38,60,,180.784,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.3,100,,372,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.59,14.42,,6.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.48,75,,32.824,Percent of Total Billed Charges,75% of Total Billed Charges,43.65,50,,29.104,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,21.88,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.65,50,,21.88,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,21.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.11,70,,122.688,Percent of Total Billed Charges,70% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.3,100,,43.76,Percent of Total Billed Charges,100% of Total Billed Charges,2.58,87.3,
DRESSING AQUACEL AG R 1X45CM,30201013,CDM,272,RC,,,Outpatient,,,74.45,44.67,,44.67,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,33.5,45,,902.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,28,,123.752,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,26.8,36,,159.104,Percent of Total Billed Charges,36% of Total Billed Charges,26.8,36,,159.104,Percent of Total Billed Charges,36% Total Bille Charges,26.8,36,,159.104,Percent of Total Billed Charges,36% of Total Billed Charges,44.67,60,,224.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.45,100,,2004.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.74,14.42,,6.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.84,75,,32,Percent of Total Billed Charges,75% of Total Billed Charges,37.23,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,37.23,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.23,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,37.23,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.12,70,,118.808,Percent of Total Billed Charges,70% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.45,100,,42.664,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,2322.46,
DRESSING SILVERLON 4X4 ISLAND,30201014,CDM,272,RC,A6206,HCPCS,Outpatient,,,72.76,43.66,,2.35,100,,72.112,Fee Schedule,100% of Aetna Fee Schedule,32.74,45,,234.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.37,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,26.19,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,26.19,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,26.19,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,43.66,60,,110.984,Percent of Total Billed Charges,60% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.76,100,,521.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14.42,,6.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.57,75,,32,Percent of Total Billed Charges,75% of Total Billed Charges,36.38,50,,21.88,Percent of Total Billed Charges,50% of Total Billed Charges,36.38,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.38,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,36.38,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.93,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.76,100,,42.664,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,2322.46,
DRSG BURN ACTCT SLCR 4X4,30201018,CDM,272,RC,A6206,HCPCS,Outpatient,,,57.62,34.57,,2.35,100,,66.512,Fee Schedule,100% of Aetna Fee Schedule,25.93,45,,51.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.13,28,,235.264,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,20.74,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,20.74,36,,302.488,Percent of Total Billed Charges,36% Total Bille Charges,20.74,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,34.57,60,,216.408,Percent of Total Billed Charges,60% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.62,100,,113.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.31,14.42,,6.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.22,75,,32,Percent of Total Billed Charges,75% of Total Billed Charges,28.81,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.33,70,,160.464,Percent of Total Billed Charges,70% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,5.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.62,100,,42.664,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,2322.46,
CATH URET BARDX 18FR 30ML HYGE,30201020,CDM,272,RC,C1758,HCPCS,Outpatient,,,54.7,32.82,,69,100,,66.512,Fee Schedule,100% of Aetna Fee Schedule,24.62,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,28,,246.816,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.69,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,19.69,36,,317.336,Percent of Total Billed Charges,36% Total Bille Charges,19.69,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,32.82,60,,155.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.7,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14.42,,4.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.03,75,,32,Percent of Total Billed Charges,75% of Total Billed Charges,27.35,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,27.35,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.35,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,27.35,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.29,70,,178.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,7.66,14,,4.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.7,100,,42.664,Percent of Total Billed Charges,100% of Total Billed Charges,7.66,2322.46,
CATH URET BARDX 12FR 5ML HYGEL,30201021,CDM,272,RC,C1758,HCPCS,Outpatient,,,53.33,32.00,,69,100,,59.552,Fee Schedule,100% of Aetna Fee Schedule,24,45,,1143.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.93,28,,36.608,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,19.2,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,19.2,36,,47.072,Percent of Total Billed Charges,36% Total Bille Charges,19.2,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,32,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.33,100,,2541,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.69,14.42,,4.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,75,,24.176,Percent of Total Billed Charges,75% of Total Billed Charges,26.67,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.67,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.33,70,,210.92,Percent of Total Billed Charges,70% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.33,100,,32.232,Percent of Total Billed Charges,100% of Total Billed Charges,7.47,2322.46,
CATH URET BARDX 14FR 5ML HYGEL,30201022,CDM,272,RC,C1758,HCPCS,Outpatient,,,53.33,32.00,,69,100,,53.072,Fee Schedule,100% of Aetna Fee Schedule,24,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.93,28,,24.768,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,19.2,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,19.2,36,,31.84,Percent of Total Billed Charges,36% Total Bille Charges,19.2,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,32,60,,51.168,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.33,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.69,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,75,,24.04,Percent of Total Billed Charges,75% of Total Billed Charges,26.67,50,,21.336,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.67,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.33,70,,262.08,Percent of Total Billed Charges,70% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.33,100,,32.048,Percent of Total Billed Charges,100% of Total Billed Charges,7.47,2322.46,
CATH URET BARDX IC SH 16FRX5ML,30201023,CDM,272,RC,C1758,HCPCS,Outpatient,,,53.33,32.00,,69,100,,51.224,Fee Schedule,100% of Aetna Fee Schedule,24,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.93,28,,168.352,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,19.2,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,19.2,36,,216.448,Percent of Total Billed Charges,36% Total Bille Charges,19.2,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,32,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.33,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.69,14.42,,3.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,75,,21.288,Percent of Total Billed Charges,75% of Total Billed Charges,26.67,50,,16.12,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.67,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.33,70,,129.48,Percent of Total Billed Charges,70% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.33,100,,28.384,Percent of Total Billed Charges,100% of Total Billed Charges,7.47,2322.46,
CATH URET BARDX 18FR 5ML HYGEL,30201024,CDM,272,RC,C1758,HCPCS,Outpatient,,,53.33,32.00,,69,100,,48.576,Fee Schedule,100% of Aetna Fee Schedule,24,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.93,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,204.38,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,19.2,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,19.2,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,19.2,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,32,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.33,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.69,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,75,,20.712,Percent of Total Billed Charges,75% of Total Billed Charges,26.67,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.67,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.33,70,,252.48,Percent of Total Billed Charges,70% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.47,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.33,100,,27.616,Percent of Total Billed Charges,100% of Total Billed Charges,7.47,204.38,
BMCC DRESSING WOUND 4X3.6,30201028,CDM,272,RC,,,Outpatient,,,40.29,24.17,,24.17,60,,43.344,Percent of Total Billed Charges,60% of Total Billed Charges,18.13,45,,2444.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,14.5,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,14.5,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,24.17,60,,126.264,Percent of Total Billed Charges,60% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.29,100,,5431.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14.42,,3.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.22,75,,18.384,Percent of Total Billed Charges,75% of Total Billed Charges,20.15,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.15,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.2,70,,181.8,Percent of Total Billed Charges,70% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.29,100,,24.512,Percent of Total Billed Charges,100% of Total Billed Charges,5.64,2322.46,
DRSG GRMCDL BIOPTCH 1IN 4MM C-,30201029,CDM,272,RC,A6209,HCPCS,Outpatient,,,40.06,24.04,,6.35,100,,39.36,Fee Schedule,100% of Aetna Fee Schedule,18.03,45,,1002.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,23.512,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,30.232,Fee Schedule,360% of BCBS POS Rate,31.25,360,,30.232,Fee schedule,360% of BCBS PPO Rate,31.25,360,,30.232,Fee Schedule,360% of BCBS Traditional Rate,24.04,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.06,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.05,75,,17.368,Percent of Total Billed Charges,75% of Total Billed Charges,20.03,50,,13.808,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.03,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.04,70,,74.416,Percent of Total Billed Charges,70% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.06,100,,23.152,Percent of Total Billed Charges,100% of Total Billed Charges,5.61,40.06,
DRSG FOAM 4 X 8 SILICONE,30201032,CDM,272,RC,,,Outpatient,,,35.48,21.29,,21.29,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,15.97,45,,40.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.93,28,,213.696,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,12.77,36,,274.752,Percent of Total Billed Charges,36% of Total Billed Charges,12.77,36,,274.752,Percent of Total Billed Charges,36% Total Bille Charges,12.77,36,,274.752,Percent of Total Billed Charges,36% of Total Billed Charges,21.29,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.48,100,,2228.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,5.12,14.42,,3.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,75,,17.2,Percent of Total Billed Charges,75% of Total Billed Charges,17.74,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,17.74,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.74,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,17.74,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.84,70,,59.696,Percent of Total Billed Charges,70% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.48,100,,22.936,Percent of Total Billed Charges,100% of Total Billed Charges,4.97,2322.46,
OINTMENT BARRIER PERINL 20Z,30201033,CDM,271,RC,A6250,HCPCS,Outpatient,,,34.52,20.71,,0.03,100,,39.312,Fee Schedule,100% of Aetna Fee Schedule,15.53,45,,2783.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.67,28,,182.12,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,12.43,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,12.43,36,,234.16,Percent of Total Billed Charges,36% Total Bille Charges,12.43,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,20.71,60,,47.856,Percent of Total Billed Charges,60% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.52,100,,89.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.98,14.42,,2.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.89,75,,16.088,Percent of Total Billed Charges,75% of Total Billed Charges,17.26,50,,11.576,Percent of Total Billed Charges,50% of Total Billed Charges,17.26,50,,10.728,Percent of Total Billed Charges,50% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.26,50,,10.728,Percent of Total Billed Charges,50% of Total Billed Charges,17.26,50,,10.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.16,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.52,100,,21.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,2322.46,
DRSG FM ALVN 5X5 PU ADH,30201034,CDM,272,RC,,,Outpatient,,,30.64,18.38,,18.38,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,13.79,45,,1940.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.58,28,,1400.104,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.03,36,,1800.128,Percent of Total Billed Charges,36% of Total Billed Charges,11.03,36,,1800.128,Percent of Total Billed Charges,36% Total Bille Charges,11.03,36,,1800.128,Percent of Total Billed Charges,36% of Total Billed Charges,18.38,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.64,100,,6186.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.42,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,75,,12.984,Percent of Total Billed Charges,75% of Total Billed Charges,15.32,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.45,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.64,100,,17.312,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,2322.46,
OINTMENT BARRIER PERINL 2.5OZ,30201035,CDM,271,RC,A6250,HCPCS,Outpatient,,,28.94,17.36,,0.03,100,,72.672,Fee Schedule,100% of Aetna Fee Schedule,13.02,45,,4688.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.1,28,,411.736,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,36,,529.376,Percent of Total Billed Charges,36% of Total Billed Charges,10.42,36,,529.376,Percent of Total Billed Charges,36% Total Bille Charges,10.42,36,,529.376,Percent of Total Billed Charges,36% of Total Billed Charges,17.36,60,,83.096,Percent of Total Billed Charges,60% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.94,100,,4313.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.17,14.42,,21.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.71,75,,12.736,Percent of Total Billed Charges,75% of Total Billed Charges,14.47,50,,10.728,Percent of Total Billed Charges,50% of Total Billed Charges,14.47,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.47,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,14.47,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.26,70,,147.312,Percent of Total Billed Charges,70% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.94,100,,16.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,2322.46,
PASTE OST 2OZ /57 G TB,30201036,CDM,271,RC,,,Outpatient,,,28.67,17.20,,17.2,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,45,,1448.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.03,28,,1023.904,Percent of Total Billed Charges,28% of Total Billed Charges,4917.34,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,10.32,36,,1316.448,Percent of Total Billed Charges,36% of Total Billed Charges,10.32,36,,1316.448,Percent of Total Billed Charges,36% Total Bille Charges,10.32,36,,1316.448,Percent of Total Billed Charges,36% of Total Billed Charges,17.2,60,,265.176,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.67,100,,10419.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14.42,,362.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,75,,110.048,Percent of Total Billed Charges,75% of Total Billed Charges,14.34,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,50,,73.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,50,,73.368,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,50,,73.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.07,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,100,,146.728,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,4917.34,
POUCH 3/8-21/4 EASI CLS SNSURA,30201038,CDM,272,RC,,,Outpatient,,,26.81,16.09,,16.09,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,12.06,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.51,28,,596.032,Percent of Total Billed Charges,28% of Total Billed Charges,4917.34,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,9.65,36,,766.32,Percent of Total Billed Charges,36% of Total Billed Charges,9.65,36,,766.32,Percent of Total Billed Charges,36% Total Bille Charges,9.65,36,,766.32,Percent of Total Billed Charges,36% of Total Billed Charges,16.09,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.81,100,,3218.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14.42,,242.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.11,75,,1883.704,Percent of Total Billed Charges,75% of Total Billed Charges,13.41,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,13.41,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.41,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,13.41,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.77,70,,196.248,Percent of Total Billed Charges,70% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.81,100,,2511.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.75,4917.34,
DRSG ALGISITE M 4 X 4,30201040,CDM,272,RC,,,Outpatient,,,21.64,12.98,,12.98,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,9.74,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.06,28,,832.616,Percent of Total Billed Charges,28% of Total Billed Charges,4917.34,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,7.79,36,,1070.504,Percent of Total Billed Charges,36% Total Bille Charges,7.79,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,12.98,60,,504.144,Percent of Total Billed Charges,60% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.64,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,14.42,,106.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.23,75,,1259.704,Percent of Total Billed Charges,75% of Total Billed Charges,10.82,50,,73.368,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.82,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.15,70,,55.832,Percent of Total Billed Charges,70% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,103.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.64,100,,1679.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,4917.34,
DRSG FM MPLX 4X4IN SIL ADH,30201041,CDM,272,RC,A6214,HCPCS,Outpatient,,,21.23,12.74,,8.75,100,,71.504,Fee Schedule,100% of Aetna Fee Schedule,9.55,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,280,,282.424,Fee Schedule,280% of BCBS BULE Fee Schedule,38.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,43.06,360,,363.12,Fee Schedule,360% of BCBS POS Rate,43.06,360,,363.12,Fee schedule,360% of BCBS PPO Rate,43.06,360,,363.12,Fee Schedule,360% of BCBS Traditional Rate,12.74,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,14.42,,54.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.92,75,,555.208,Percent of Total Billed Charges,75% of Total Billed Charges,10.62,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.62,50,,370.136,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.62,50,,370.136,Percent of Total Billed Charges,50% of Total Billed Charges,10.62,50,,370.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.86,70,,124.488,Percent of Total Billed Charges,70% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.23,100,,740.272,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,43.06,
CANISTR SUC GEL INFOVAC 500ML,30201049,CDM,272,RC,,,Outpatient,,,183.41,110.05,,110.05,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,82.53,45,,238.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.35,28,,70.696,Percent of Total Billed Charges,28% of Total Billed Charges,4917.34,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,66.03,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,66.03,36,,90.888,Percent of Total Billed Charges,36% Total Bille Charges,66.03,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,110.05,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.41,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,26.45,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.56,75,,283.944,Percent of Total Billed Charges,75% of Total Billed Charges,91.71,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,91.71,50,,189.296,Percent of Total Billed Charges,50% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.71,50,,189.296,Percent of Total Billed Charges,50% of Total Billed Charges,91.71,50,,189.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.39,70,,96.944,Percent of Total Billed Charges,70% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.41,100,,378.592,Percent of Total Billed Charges,100% of Total Billed Charges,25.68,4917.34,
I&D RECTAL ABSCESS,30202000,CDM,761,RC,46040,HCPCS,Outpatient,,,3139.5,1883.70,,412.77,100,,224.64,Fee Schedule,100% of Aetna Fee Schedule,1623.99,150,,94.432,Fee Schedule ,150% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,879.06,28,,79.6,Percent of Total Billed Charges,28% of Total Billed Charges,504.73,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1130.22,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,1130.22,36,,102.344,Percent of Total Billed Charges,36% Total Bille Charges,1130.22,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,3347.5,103,,53.072,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,529.832,Fee Schedule,100% of CMS OPPS Rate,974.39,90,,,Fee Schedule,90% of CMS OPPS Rate,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.46,130,,,Fee Schedule,130% of CMS OPPS Rate,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,452.72,14.42,,31.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,1115.14,103,,,Fee Schedule,103% of CMS OPPS Rate,1115.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2354.63,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1569.75,50,,370.136,Percent of Total Billed Charges,50% of Total Billed Charges,1569.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1569.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1623.99,150,,,Fee Schedule,150% of CMS OPPS Rate,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2197.65,70,,309.376,Percent of Total Billed Charges,70% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3139.5,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,412.77,3347.5,
I&D PERIANAL ABSCESS,30202001,CDM,761,RC,46050,HCPCS,Outpatient,,,2099.5,1259.70,,97.24,100,,220.68,Fee Schedule,100% of Aetna Fee Schedule,1257.77,150,,149.44,Fee Schedule ,150% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,587.86,28,,57.44,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,755.82,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,755.82,36,,73.856,Percent of Total Billed Charges,36% Total Bille Charges,755.82,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,360.752,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,209.856,Fee Schedule,100% of CMS OPPS Rate,754.65,90,,,Fee Schedule,90% of CMS OPPS Rate,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1090.07,130,,,Fee Schedule,130% of CMS OPPS Rate,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,302.75,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,863.67,103,,,Fee Schedule,103% of CMS OPPS Rate,863.67,103,,,Fee Schedule,103% of CMS OPPS Rate,1574.63,75,,164.992,Percent of Total Billed Charges,75% of Total Billed Charges,1049.75,50,,189.296,Percent of Total Billed Charges,50% of Total Billed Charges,1049.75,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.75,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,1049.75,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,1257.77,150,,,Fee Schedule,150% of CMS OPPS Rate,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.65,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2099.5,100,,219.992,Percent of Total Billed Charges,100% of Total Billed Charges,97.24,2322.46,
I&D OF SKIN ABSCESS COMP/MULTI,30202002,CDM,761,RC,10061,HCPCS,Outpatient,,,925.34,555.20,,139.03,100,,101.84,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,238.424,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,259.1,28,,245.304,Percent of Total Billed Charges,28% of Total Billed Charges,2322.46,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,333.12,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,333.12,36,,315.392,Percent of Total Billed Charges,36% Total Bille Charges,333.12,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,240,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,332.096,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,133.43,14.42,,70.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,694.01,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,462.67,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,462.67,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,462.67,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,462.67,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,647.74,70,,588.168,Percent of Total Billed Charges,70% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,129.55,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,925.34,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,129.55,2322.46,
SELECT DEBRIDEMENT 1ST 20 CM,30202003,CDM,761,RC,97597,HCPCS,Outpatient,,,473.24,283.94,,26.51,100,,49.152,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,238.424,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,68.63,280,,249.264,Fee Schedule,280% of BCBS BULE Fee Schedule,78.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,88.24,360,,320.488,Fee Schedule,360% of BCBS POS Rate,88.24,360,,320.488,Fee schedule,360% of BCBS PPO Rate,88.24,360,,320.488,Fee Schedule,360% of BCBS Traditional Rate,283.94,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,0.008,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,68.24,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,354.93,75,,368.632,Percent of Total Billed Charges,75% of Total Billed Charges,236.62,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,236.62,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,236.62,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,236.62,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,331.27,70,,617.048,Percent of Total Billed Charges,70% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,473.24,100,,491.504,Percent of Total Billed Charges,100% of Total Billed Charges,26.51,473.24,
BRIDLE AMT SPARE CLIP,30202005,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,238.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,358.704,Percent of Total Billed Charges,28% of Total Billed Charges,4665.03,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,461.192,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,529.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,4665.03,
DEBRIDEMENT OF NAILS 1-5,30202006,CDM,761,RC,11720,HCPCS,Outpatient,,,274.99,164.99,,10.28,100,,59.552,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,1881.36,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,77,28,,357.776,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,99,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,99,36,,460,Percent of Total Billed Charges,36% Total Bille Charges,99,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,1273.44,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,529.832,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,39.65,14.42,,24.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,206.24,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,137.5,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,137.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,137.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,137.5,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,192.49,70,,61.912,Percent of Total Billed Charges,70% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,274.99,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,10.28,14168.18,
ARTHRO/ASP/INJ MAJOR JOINT,30202007,CDM,761,RC,20610,HCPCS,Outpatient,,,885.02,531.01,,37.94,100,,216.408,Fee Schedule,100% of Aetna Fee Schedule,407.6,150,,243.792,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,247.81,28,,381.248,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,318.61,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,318.61,36,,490.176,Percent of Total Billed Charges,36% Total Bille Charges,318.61,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,1896.96,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,529.832,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,17.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,663.77,75,,125.184,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,442.51,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,619.51,70,,420.872,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,885.02,100,,166.912,Percent of Total Billed Charges,100% of Total Billed Charges,37.94,14168.18,
PUNCTURE ASP ABSCESS,30202008,CDM,761,RC,10160,HCPCS,Outpatient,,,614.38,368.63,,72.39,100,,155.824,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,527.776,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,172.03,28,,190.4,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,221.18,36,,244.8,Percent of Total Billed Charges,36% of Total Billed Charges,221.18,36,,244.8,Percent of Total Billed Charges,36% Total Bille Charges,221.18,36,,244.8,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,1784.176,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,4180.8,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,88.59,14.42,,25.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,460.79,75,,89.376,Percent of Total Billed Charges,75% of Total Billed Charges,307.19,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,307.19,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,430.07,70,,280,Percent of Total Billed Charges,70% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,614.38,100,,119.168,Percent of Total Billed Charges,100% of Total Billed Charges,72.39,14168.18,
BINDER ABDOMINAL 45 IN CIRCUMFERENCE 9 IN WIDTH LA,30202009,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,236.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,345.744,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,444.528,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,444.528,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,444.528,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,541.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,24.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,131.448,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,175.264,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,14168.18,
BINDER ABDOMINAL 46 TO 62 IN CIRCUMFERENCE 9 IN W,30202010,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,206.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,23.44,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,30.136,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,30.136,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,30.136,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,1172.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,127.296,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,169.728,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,14168.18,
MATTRESS WFL OVRLAY 75X30X3IN,30202011,CDM,271,RC,,,Outpatient,,,208.64,125.18,,125.18,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,93.89,45,,907.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.42,28,,532.888,Percent of Total Billed Charges,28% of Total Billed Charges,14168.18,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,75.11,36,,685.144,Percent of Total Billed Charges,36% of Total Billed Charges,75.11,36,,685.144,Percent of Total Billed Charges,36% Total Bille Charges,75.11,36,,685.144,Percent of Total Billed Charges,36% of Total Billed Charges,125.18,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.64,100,,525.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,30.09,14.42,,33.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.48,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,104.32,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.32,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.05,70,,1485.68,Percent of Total Billed Charges,70% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.64,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,29.21,14168.18,
CUSHION WHEELCHAIR,30202012,CDM,271,RC,,,Outpatient,,,148.96,89.38,,89.38,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,67.03,45,,119.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.71,28,,344.352,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,53.63,36,,442.736,Percent of Total Billed Charges,36% of Total Billed Charges,53.63,36,,442.736,Percent of Total Billed Charges,36% Total Bille Charges,53.63,36,,442.736,Percent of Total Billed Charges,36% of Total Billed Charges,89.38,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.96,100,,457.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,21.48,14.42,,36.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.72,75,,171.928,Percent of Total Billed Charges,75% of Total Billed Charges,74.48,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.27,70,,2213.12,Percent of Total Billed Charges,70% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,35.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.96,100,,229.232,Percent of Total Billed Charges,100% of Total Billed Charges,20.85,28338.25,
NEEDLE GUIDE KIT 21GX1-2CM,30202013,CDM,271,RC,,,Outpatient,,,219.08,131.45,,131.45,60,,107.048,Percent of Total Billed Charges,60% of Total Billed Charges,98.59,45,,173.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.34,28,,160.384,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,78.87,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,78.87,36,,206.208,Percent of Total Billed Charges,36% Total Bille Charges,78.87,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,131.45,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.08,100,,2016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,31.59,14.42,,43.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.31,75,,190.968,Percent of Total Billed Charges,75% of Total Billed Charges,109.54,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.54,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.36,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,42.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.08,100,,254.624,Percent of Total Billed Charges,100% of Total Billed Charges,30.67,28338.25,
DRSG FM GRNFM TRAC 15X10CM,30202014,CDM,272,RC,,,Outpatient,,,212.16,127.30,,127.3,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,95.47,45,,288.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.4,28,,862.448,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,76.38,36,,1108.856,Percent of Total Billed Charges,36% of Total Billed Charges,76.38,36,,1108.856,Percent of Total Billed Charges,36% Total Bille Charges,76.38,36,,1108.856,Percent of Total Billed Charges,36% of Total Billed Charges,127.3,60,,124.664,Percent of Total Billed Charges,60% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.16,100,,266.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,30.59,14.42,,53.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.12,75,,225.984,Percent of Total Billed Charges,75% of Total Billed Charges,106.08,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,150.656,Percent of Total Billed Charges,50% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,50,,150.656,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,150.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.51,70,,534.24,Percent of Total Billed Charges,70% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.16,100,,301.312,Percent of Total Billed Charges,100% of Total Billed Charges,29.7,28338.25,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESIV,30202015,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,46.08,45,,1922.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,748.624,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,962.512,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,962.512,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,962.512,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,100.208,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.4,100,,385.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,26.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,280.8,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,127.312,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,25.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,374.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.34,28338.25,
DRSG FM GRNFM VAC 18X12/5 MED,30202016,CDM,272,RC,,,Outpatient,,,286.54,171.92,,171.92,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,128.94,45,,717.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,28,,413.872,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,103.15,36,,532.12,Percent of Total Billed Charges,36% of Total Billed Charges,103.15,36,,532.12,Percent of Total Billed Charges,36% Total Bille Charges,103.15,36,,532.12,Percent of Total Billed Charges,36% of Total Billed Charges,171.92,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.54,100,,641.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,14.42,,52.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.91,75,,138.736,Percent of Total Billed Charges,75% of Total Billed Charges,143.27,50,,150.656,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,92.488,Percent of Total Billed Charges,50% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.27,50,,92.488,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,92.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.58,70,,39.664,Percent of Total Billed Charges,70% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.54,100,,184.976,Percent of Total Billed Charges,100% of Total Billed Charges,40.12,28338.25,
CANISTR SUC GEL INFOVAC 500ML,30202017,CDM,271,RC,,,Outpatient,,,318.28,190.97,,190.97,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,143.23,45,,747.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.12,28,,69,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,114.58,36,,88.72,Percent of Total Billed Charges,36% of Total Billed Charges,114.58,36,,88.72,Percent of Total Billed Charges,36% Total Bille Charges,114.58,36,,88.72,Percent of Total Billed Charges,36% of Total Billed Charges,190.97,60,,125.376,Percent of Total Billed Charges,60% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.28,100,,4272.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,45.9,14.42,,37.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.71,75,,270.512,Percent of Total Billed Charges,75% of Total Billed Charges,159.14,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,159.14,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.14,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,159.14,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.8,70,,455.312,Percent of Total Billed Charges,70% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,44.56,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.28,100,,360.68,Percent of Total Billed Charges,100% of Total Billed Charges,44.56,28338.25,
VALVE DRN THOR 1 W FILTER,30202018,CDM,271,RC,,,Outpatient,,,376.64,225.98,,225.98,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,169.49,45,,326.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.46,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,135.59,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135.59,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135.59,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225.98,60,,119.872,Percent of Total Billed Charges,60% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.64,100,,1593.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,54.31,14.42,,15.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.48,75,,194.784,Percent of Total Billed Charges,75% of Total Billed Charges,188.32,50,,92.488,Percent of Total Billed Charges,50% of Total Billed Charges,188.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,188.32,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.65,70,,3500.256,Percent of Total Billed Charges,70% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,52.73,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.64,100,,259.712,Percent of Total Billed Charges,100% of Total Billed Charges,52.73,28338.25,
HEEL PROTECTOR W/FOOT AND LEG,30202019,CDM,271,RC,,,Outpatient,,,468,280.80,,280.8,60,,77.712,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,45,,307.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.04,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,28338.25,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,168.48,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,168.48,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,168.48,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,280.8,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468,100,,1660.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,14.42,,12.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,234,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.6,70,,1029.336,Percent of Total Billed Charges,70% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,11.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,65.52,28338.25,
COVER DRESSING TUBULAR SIZE D 11 YD BEIGE LATEX TU,30202020,CDM,271,RC,,,Outpatient,,,231.22,138.73,,138.73,60,,77.472,Percent of Total Billed Charges,60% of Total Billed Charges,104.05,45,,220.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.74,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,83.24,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,83.24,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,83.24,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,138.73,60,,34,Percent of Total Billed Charges,60% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.22,100,,725.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,33.34,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.42,75,,63.96,Percent of Total Billed Charges,75% of Total Billed Charges,115.61,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,115.61,50,,42.64,Percent of Total Billed Charges,50% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.61,50,,42.64,Percent of Total Billed Charges,50% of Total Billed Charges,115.61,50,,42.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.85,70,,1490.072,Percent of Total Billed Charges,70% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,32.37,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.22,100,,85.28,Percent of Total Billed Charges,100% of Total Billed Charges,32.37,45588.31,
TUBE FEEDING 10FR FFIN CORTAK,30202021,CDM,271,RC,,,Outpatient,,,450.85,270.51,,270.51,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,202.88,45,,987.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.24,28,,147.624,Percent of Total Billed Charges,28% of Total Billed Charges,45588.31,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,162.31,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,162.31,36,,189.8,Percent of Total Billed Charges,36% Total Bille Charges,162.31,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,270.51,60,,2194.08,Percent of Total Billed Charges,60% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.85,100,,684,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,65.01,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.14,75,,64.416,Percent of Total Billed Charges,75% of Total Billed Charges,225.43,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.43,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.6,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.85,100,,85.888,Percent of Total Billed Charges,100% of Total Billed Charges,63.12,45588.31,
CUSHION WAFFLE WHEELCHAIR,30202022,CDM,271,RC,,,Outpatient,,,324.64,194.78,,194.78,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,146.09,45,,1921.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.9,28,,104.632,Percent of Total Billed Charges,28% of Total Billed Charges,28722.81,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,36,,134.528,Percent of Total Billed Charges,36% of Total Billed Charges,116.87,36,,134.528,Percent of Total Billed Charges,36% Total Bille Charges,116.87,36,,134.528,Percent of Total Billed Charges,36% of Total Billed Charges,194.78,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.64,100,,489.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,46.81,14.42,,30.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.48,75,,81.552,Percent of Total Billed Charges,75% of Total Billed Charges,162.32,50,,42.64,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.32,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.25,70,,525.384,Percent of Total Billed Charges,70% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.64,100,,108.736,Percent of Total Billed Charges,100% of Total Billed Charges,45.45,28722.81,
RESUSC MASK ADLT RESVR MED,30202023,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,59.8,45,,149.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,92.56,Percent of Total Billed Charges,28% of Total Billed Charges,28722.81,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,119,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,119,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,119,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,768.648,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.88,100,,2194.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,157.832,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,706.064,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,210.44,Percent of Total Billed Charges,100% of Total Billed Charges,18.6,28722.81,
BOTTLE DRAIN ACCEL EVC 1000ML,30202024,CDM,271,RC,,,Outpatient,,,106.6,63.96,,63.96,60,,34.96,Percent of Total Billed Charges,60% of Total Billed Charges,47.97,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.85,28,,26.88,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,38.38,36,,34.56,Percent of Total Billed Charges,36% of Total Billed Charges,38.38,36,,34.56,Percent of Total Billed Charges,36% Total Bille Charges,38.38,36,,34.56,Percent of Total Billed Charges,36% of Total Billed Charges,63.96,60,,557,Percent of Total Billed Charges,60% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.6,100,,4271.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14.42,,40.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,53.3,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,53.3,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.3,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,53.3,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.62,70,,176.728,Percent of Total Billed Charges,70% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.6,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,14.92,1787.64,
KIT DRESSING CHANGE POWERGLIDE,30202025,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,60.304,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,45.696,Percent of Total Billed Charges,28% of Total Billed Charges,1787.64,286,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,58.752,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,58.752,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,58.752,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,816.96,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,100,,332.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,11.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,210.264,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,199,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,11.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,280.352,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,1787.64,
TRAY URINE METER SURESTEP 16FR,30202026,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,501.712,Percent of Total Billed Charges,60% of Total Billed Charges,61.16,45,,10.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,45.696,Percent of Total Billed Charges,28% of Total Billed Charges,360.97,32,,288.776,Percent of Total Billed Charges,32% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,58.752,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,58.752,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,58.752,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,408,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.92,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,25.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,59.824,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,39.88,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,39.88,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,39.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,143.608,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,79.76,Percent of Total Billed Charges,100% of Total Billed Charges,19.03,360.97,
SPONGE TOPICAL HEMOSTATIC 3.8 CM LENGTH 3.8 CM WID,30202027,CDM,271,RC,,,Outpatient,,,263.05,157.83,,157.83,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,118.37,45,,1917.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.65,28,,46.752,Percent of Total Billed Charges,28% of Total Billed Charges,360.97,32,,288.776,Percent of Total Billed Charges,32% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,94.7,36,,60.104,Percent of Total Billed Charges,36% of Total Billed Charges,94.7,36,,60.104,Percent of Total Billed Charges,36% Total Bille Charges,94.7,36,,60.104,Percent of Total Billed Charges,36% of Total Billed Charges,157.83,60,,740.88,Percent of Total Billed Charges,60% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.05,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,14.42,,19.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.29,75,,133.384,Percent of Total Billed Charges,75% of Total Billed Charges,131.53,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.53,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.14,70,,613.256,Percent of Total Billed Charges,70% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,19.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.05,100,,177.84,Percent of Total Billed Charges,100% of Total Billed Charges,36.83,360.97,
DISC STATSEAL DISC MEDIUM,30202028,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,2168.88,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,18.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,104.832,Percent of Total Billed Charges,28% of Total Billed Charges,360.97,32,,288.776,Percent of Total Billed Charges,32% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,134.784,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,134.784,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,134.784,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,50.224,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,23.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,63.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,103.872,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,39.88,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,623.168,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,61.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,138.496,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,360.97,
WAFFLE SEAT CUSHION 17X17X2,30202029,CDM,271,RC,,,Outpatient,,,350.44,210.26,,210.26,60,,8915.904,Percent of Total Billed Charges,60% of Total Billed Charges,157.7,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.12,28,,78.672,Percent of Total Billed Charges,28% of Total Billed Charges,360.97,32,,288.776,Percent of Total Billed Charges,32% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,126.16,36,,101.144,Percent of Total Billed Charges,36% of Total Billed Charges,126.16,36,,101.144,Percent of Total Billed Charges,36% Total Bille Charges,126.16,36,,101.144,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.44,100,,4261.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,50.53,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.83,75,,331.472,Percent of Total Billed Charges,75% of Total Billed Charges,175.22,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.22,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.31,70,,896.76,Percent of Total Billed Charges,70% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.44,100,,441.96,Percent of Total Billed Charges,100% of Total Billed Charges,49.06,360.97,
DRSG BORDER HEEL,30202030,CDM,272,RC,,,Outpatient,,,99.7,59.82,,59.82,60,,2917.2,Percent of Total Billed Charges,60% of Total Billed Charges,44.87,45,,53.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.92,28,,227.224,Percent of Total Billed Charges,28% of Total Billed Charges,360.97,32,,288.776,Percent of Total Billed Charges,32% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.89,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,35.89,36,,292.144,Percent of Total Billed Charges,36% Total Bille Charges,35.89,36,,292.144,Percent of Total Billed Charges,36% of Total Billed Charges,59.82,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.7,100,,41.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,14.38,14.42,,121.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.78,75,,303.544,Percent of Total Billed Charges,75% of Total Billed Charges,49.85,50,,69.248,Percent of Total Billed Charges,50% of Total Billed Charges,49.85,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.85,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,49.85,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.79,70,,894.448,Percent of Total Billed Charges,70% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.96,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.7,100,,404.72,Percent of Total Billed Charges,100% of Total Billed Charges,13.96,360.97,
TRAY PICC DRSG,30202031,CDM,272,RC,,,Outpatient,,,222.3,133.38,,133.38,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,100.04,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.24,28,,832.616,Percent of Total Billed Charges,28% of Total Billed Charges,594.08,32,,475.264,Percent of Total Billed Charges,32% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,80.03,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,80.03,36,,1070.504,Percent of Total Billed Charges,36% Total Bille Charges,80.03,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,133.38,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.3,100,,98.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14.42,,127.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.73,75,,630.184,Percent of Total Billed Charges,75% of Total Billed Charges,111.15,50,,220.984,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.61,70,,476,Percent of Total Billed Charges,70% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.3,100,,840.24,Percent of Total Billed Charges,100% of Total Billed Charges,31.12,594.08,
TRAY CVC DRSG,30202032,CDM,272,RC,,,Outpatient,,,173.12,103.87,,103.87,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,77.9,45,,0.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.47,28,,344.352,Percent of Total Billed Charges,28% of Total Billed Charges,594.08,32,,475.264,Percent of Total Billed Charges,32% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,62.32,36,,442.736,Percent of Total Billed Charges,36% of Total Billed Charges,62.32,36,,442.736,Percent of Total Billed Charges,36% Total Bille Charges,62.32,36,,442.736,Percent of Total Billed Charges,36% of Total Billed Charges,103.87,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.12,100,,119.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.96,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.84,75,,661.12,Percent of Total Billed Charges,75% of Total Billed Charges,86.56,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,86.56,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.56,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,86.56,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.18,70,,864.36,Percent of Total Billed Charges,70% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.12,100,,881.496,Percent of Total Billed Charges,100% of Total Billed Charges,24.24,594.08,
CORGRIP NASOINTESTINAL FEED,30202033,CDM,271,RC,,,Outpatient,,,552.45,331.47,,331.47,60,,737.512,Percent of Total Billed Charges,60% of Total Billed Charges,248.6,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.69,28,,70.696,Percent of Total Billed Charges,28% of Total Billed Charges,594.08,32,,475.264,Percent of Total Billed Charges,32% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,198.88,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,198.88,36,,90.888,Percent of Total Billed Charges,36% Total Bille Charges,198.88,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,331.47,60,,147.864,Percent of Total Billed Charges,60% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,552.45,100,,73.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14.42,,12.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.34,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,276.23,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,276.23,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.23,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,276.23,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.72,70,,58.592,Percent of Total Billed Charges,70% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,77.34,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.45,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,77.34,594.08,
KIT CATH CENTRAL VENOUS TRIPLE,30202034,CDM,271,RC,,,Outpatient,,,505.9,303.54,,303.54,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,227.66,45,,42.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.65,28,,79.6,Percent of Total Billed Charges,28% of Total Billed Charges,594.08,32,,475.264,Percent of Total Billed Charges,32% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,182.12,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,182.12,36,,102.344,Percent of Total Billed Charges,36% Total Bille Charges,182.12,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,303.54,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.9,100,,1.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,72.95,14.42,,86.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.43,75,,66.336,Percent of Total Billed Charges,75% of Total Billed Charges,252.95,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.95,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.13,70,,1332.232,Percent of Total Billed Charges,70% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.9,100,,88.448,Percent of Total Billed Charges,100% of Total Billed Charges,70.83,594.08,
POWERPICC SOLO PROVENA CATH 4F,30202035,CDM,271,RC,,,Outpatient,,,1050.3,630.18,,630.18,60,,12670.24,Percent of Total Billed Charges,60% of Total Billed Charges,472.64,45,,50.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.08,28,,57.44,Percent of Total Billed Charges,28% of Total Billed Charges,594.08,32,,475.264,Percent of Total Billed Charges,32% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,378.11,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,378.11,36,,73.856,Percent of Total Billed Charges,36% Total Bille Charges,378.11,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,630.18,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050.3,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,151.45,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.73,75,,450.936,Percent of Total Billed Charges,75% of Total Billed Charges,525.15,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525.15,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.21,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.3,100,,601.248,Percent of Total Billed Charges,100% of Total Billed Charges,147.04,1050.3,
POWERPICC SOLO PROVENA CATH 5F,30202036,CDM,271,RC,,,Outpatient,,,1101.87,661.12,,661.12,60,,768.872,Percent of Total Billed Charges,60% of Total Billed Charges,495.84,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.52,28,,245.304,Percent of Total Billed Charges,28% of Total Billed Charges,639.41,32,,511.528,Percent of Total Billed Charges,32% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,396.67,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,396.67,36,,315.392,Percent of Total Billed Charges,36% Total Bille Charges,396.67,36,,315.392,Percent of Total Billed Charges,36% of Total Billed Charges,661.12,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1101.87,100,,94,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,158.89,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.4,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,550.94,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.94,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.31,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1101.87,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,154.26,1101.87,
NOVAPLUS SENSOR CHAIR,30202037,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,943.536,Percent of Total Billed Charges,60% of Total Billed Charges,73.55,45,,54.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,470.288,Percent of Total Billed Charges,28% of Total Billed Charges,639.41,32,,511.528,Percent of Total Billed Charges,32% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,604.656,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,604.656,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,604.656,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.44,100,,112.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,22.88,639.41,
NOVAPLUS PEEK-A-BOO MITTS,30202038,CDM,271,RC,,,Outpatient,,,110.56,66.34,,66.34,60,,11440,Percent of Total Billed Charges,60% of Total Billed Charges,49.75,45,,6372,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,28,,297.36,Percent of Total Billed Charges,28% of Total Billed Charges,639.41,32,,511.528,Percent of Total Billed Charges,32% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,39.8,36,,382.32,Percent of Total Billed Charges,36% of Total Billed Charges,39.8,36,,382.32,Percent of Total Billed Charges,36% Total Bille Charges,39.8,36,,382.32,Percent of Total Billed Charges,36% of Total Billed Charges,66.34,60,,224.208,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.56,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.94,14.42,,306.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,55.28,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.28,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,297.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.56,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,15.48,639.41,
MIDLINE MAX PROVENA 3F,30202039,CDM,271,RC,,,Outpatient,,,751.56,450.94,,450.94,60,,11256.96,Percent of Total Billed Charges,60% of Total Billed Charges,338.2,45,,6372,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.44,28,,246.816,Percent of Total Billed Charges,28% of Total Billed Charges,639.41,32,,511.528,Percent of Total Billed Charges,32% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,270.56,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,270.56,36,,317.336,Percent of Total Billed Charges,36% Total Bille Charges,270.56,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,450.94,60,,198.336,Percent of Total Billed Charges,60% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.56,100,,122.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,108.37,14.42,,455.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.67,75,,1697.92,Percent of Total Billed Charges,75% of Total Billed Charges,375.78,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,1061.2,Percent of Total Billed Charges,50% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.78,50,,1061.2,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,1061.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,526.09,70,,860.872,Percent of Total Billed Charges,70% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,442.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,751.56,100,,2122.4,Percent of Total Billed Charges,100% of Total Billed Charges,105.22,751.56,
DRAIN CHST CHST PLR-EV PED,30202040,CDM,271,RC,,,Outpatient,,,500,300.00,,300,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,225,45,,3555,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,28,,426.616,Percent of Total Billed Charges,28% of Total Billed Charges,703.35,32,,562.68,Percent of Total Billed Charges,32% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,180,36,,548.504,Percent of Total Billed Charges,36% of Total Billed Charges,180,36,,548.504,Percent of Total Billed Charges,36% Total Bille Charges,180,36,,548.504,Percent of Total Billed Charges,36% of Total Billed Charges,300,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500,100,,14160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,72.1,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,75,,2371.2,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,1580.8,Percent of Total Billed Charges,50% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,50,,1580.8,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,1580.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,70,,400.968,Percent of Total Billed Charges,70% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500,100,,3161.6,Percent of Total Billed Charges,100% of Total Billed Charges,70,703.35,
POWERLOC MAX 20G X 3/4 IN.,30202041,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,1202.88,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,5688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,168.352,Percent of Total Billed Charges,28% of Total Billed Charges,703.35,32,,562.68,Percent of Total Billed Charges,32% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,216.448,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,97.92,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,14160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,1061.2,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,2156.112,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,703.35,
SLEEVE COMPR SCD,30202042,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,730.08,Percent of Total Billed Charges,60% of Total Billed Charges,47.23,45,,5688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,49.792,Percent of Total Billed Charges,28% of Total Billed Charges,881.32,32,,705.056,Percent of Total Billed Charges,32% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,64.024,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,64.024,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,97.92,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.96,100,,7900,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,1580.8,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,1871.552,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,14.69,881.32,
ARITIC SUN PADS,30400000,CDM,279,RC,E0310,HCPCS,Outpatient,,,2653,1591.80,,111.22,100,,5716.584,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.46,280,,19.216,Fee Schedule,280% of BCBS BULE Fee Schedule,486.24,320,,705.056,Fee Schedule,320% of BCBS Blue Essentials Rate,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,547.02,360,,24.712,Fee Schedule,360% of BCBS POS Rate,547.02,360,,24.712,Fee schedule,360% of BCBS PPO Rate,547.02,360,,24.712,Fee Schedule,360% of BCBS Traditional Rate,1591.8,60,,100.176,Percent of Total Billed Charges,60% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,382.56,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2122.4,80,,114.168,Percent of Total Billed Charges,80% of Total Billed Charges,1326.5,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1326.5,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1326.5,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,1326.5,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1857.1,70,,1034.672,Percent of Total Billed Charges,70% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,371.42,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2653,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,111.22,2653,
ROTOPRONE-BED,30400001,CDM,290,RC,E0265,HCPCS,Outpatient,,,3952,2371.20,,1394.52,100,,4447.984,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.6,280,,45.424,Fee Schedule,280% of BCBS BULE Fee Schedule,553.82,320,,909.84,Fee Schedule,320% of BCBS Blue Essentials Rate,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,623.05,360,,58.408,Fee Schedule,360% of BCBS POS Rate,623.05,360,,58.408,Fee schedule,360% of BCBS PPO Rate,623.05,360,,58.408,Fee Schedule,360% of BCBS Traditional Rate,2371.2,60,,224.64,Percent of Total Billed Charges,60% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,569.88,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2964,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,1976,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,1976,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1976,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,1976,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2766.4,70,,172.512,Percent of Total Billed Charges,70% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,553.28,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,484.6,3952,
INSERT MIDLINE W/IMAGE > 5 YO,30400002,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,4437.736,Fee Schedule,100% of Aetna Fee Schedule,1672.66,45,,6615.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,909.84,Other,Not Seperately Reimbusable,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,168.576,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3717.03,100,,164.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
IV INFUSION HYDRATION 1ST HR,30400007,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,854.104,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,9157.32,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,235.264,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,202.32,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,302.488,Fee Schedule,360% of BCBS POS Rate,138.82,360,,302.488,Fee schedule,360% of BCBS PPO Rate,138.82,360,,302.488,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,486.912,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,12640,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,210,Case Rate,Pays based on per visit rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,30400008,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,120.24,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,4196.16,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,30.448,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,202.32,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,39.144,Fee Schedule,360% of BCBS POS Rate,49.28,360,,39.144,Fee schedule,360% of BCBS PPO Rate,49.28,360,,39.144,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,1784.176,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,14701.6,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,210,Case Rate,Pays based on per visit rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,30400009,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,691.632,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,127.08,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,78.496,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,244.72,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,100.928,Fee Schedule,360% of BCBS POS Rate,262.08,360,,100.928,Fee schedule,360% of BCBS PPO Rate,262.08,360,,100.928,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,20349.6,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,110.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,369.048,Case Rate,Pays based on per visit rate,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,30400010,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,150.248,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,331.56,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,64.184,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,244.72,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,82.52,Fee Schedule,360% of BCBS POS Rate,79.13,360,,82.52,Fee schedule,360% of BCBS PPO Rate,79.13,360,,82.52,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,9324.8,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,572.4,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,261.576,Case Rate,Pays based on per visit rate,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,763.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV INF THERAP ADDL SEQUENTIAL,30400011,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,117.096,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,718.2,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,58.92,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,75.76,Fee Schedule,360% of BCBS POS Rate,114.16,360,,75.76,Fee schedule,360% of BCBS PPO Rate,114.16,360,,75.76,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,282.4,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,231.392,Case Rate,Pays based on per visit rate,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,30400012,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,151.752,Fee Schedule,100% of Aetna Fee Schedule,116.87,45,,2057.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,50.648,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,65.12,Fee Schedule,360% of BCBS POS Rate,76.54,360,,65.12,Fee schedule,360% of BCBS PPO Rate,76.54,360,,65.12,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.72,100,,736.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,67.2,Case Rate,Pays based on per visit rate,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
INJECTION SQ OR IM,30400013,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,133.032,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,3151.44,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,49.072,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,63.096,Fee Schedule,360% of BCBS POS Rate,217.69,360,,63.096,Fee schedule,360% of BCBS PPO Rate,217.69,360,,63.096,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,1596,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,114.24,Case Rate,Pays based on per visit rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
EMERGENT ET INTUBATION,30400014,CDM,761,RC,31500,HCPCS,Outpatient,,,954,572.40,,134,100,,1398.144,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,4946.76,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,267.12,28,,47.52,Percent of Total Billed Charges,28% of Total Billed Charges,881.32,32,,0.008,Percent of Total Billed Charges,32% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,343.44,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,343.44,36,,61.104,Percent of Total Billed Charges,36% Total Bille Charges,343.44,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,124.664,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,4572.8,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,137.57,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,715.5,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,477,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,477,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,667.8,70,,114.24,Percent of Total Billed Charges,70% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,954,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,133.56,1184.5,
IV PUSH THER INITIAL MED,30400015,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,7736.432,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,7977.24,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,46.736,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,60.088,Fee Schedule,360% of BCBS POS Rate,142.7,360,,60.088,Fee schedule,360% of BCBS PPO Rate,142.7,360,,60.088,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,100.208,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,7003.2,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,93.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,42.496,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,116.872,Case Rate,Pays based on per visit rate,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,56.664,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA ADD NEW MED,30400016,CDM,940,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,166.256,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,13192.2,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,36.608,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,47.072,Fee Schedule,360% of BCBS POS Rate,60.98,360,,47.072,Fee schedule,360% of BCBS PPO Rate,60.98,360,,47.072,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,10992.8,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,721.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,487.832,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,262.08,Case Rate,Pays based on per visit rate,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,700.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,650.44,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,30400017,CDM,940,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,2626.8,Fee Schedule,100% of Aetna Fee Schedule,112.38,45,,23100.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,33.656,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.008,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,43.272,Fee Schedule,360% of BCBS POS Rate,85.64,360,,43.272,Fee schedule,360% of BCBS PPO Rate,85.64,360,,43.272,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,125.376,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.73,100,,17727.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,212.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,3750.272,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,2500.184,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,2500.184,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,2500.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,196.672,Case Rate,Pays based on per visit rate,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,5000.36,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
IMMUNIZATION INJECT INFLUENZA,30400018,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,3973.2,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,1303.2,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,31.04,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.016,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,39.904,Fee Schedule,360% of BCBS POS Rate,85.64,360,,39.904,Fee schedule,360% of BCBS PPO Rate,85.64,360,,39.904,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,119.872,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,29316,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,285.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,1102.864,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,568.064,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,277.008,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,1470.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IMMUNIZATION INJECT PNEUMOVAX,30400019,CDM,771,RC,G0009,HCPCS,Outpatient,,,70.83,42.50,,10.31,100,,1188,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,88.648,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,31.04,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,0.016,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,172.55,360,,39.904,Fee Schedule,360% of BCBS POS Rate,172.55,360,,39.904,Fee schedule,360% of BCBS PPO Rate,172.55,360,,39.904,Fee Schedule,360% of BCBS Traditional Rate,42.5,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,51333.6,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,527.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.12,75,,1483.96,Percent of Total Billed Charges,75% of Total Billed Charges,35.42,50,,2500.184,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,989.304,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.42,50,,989.304,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,989.304,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,100,,1978.608,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,172.55,
TRACHEOTOMY TUBE CHANGE,30400022,CDM,761,RC,31502,HCPCS,Outpatient,,,813.05,487.83,,33.19,100,,63.936,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,63,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,227.65,28,,27.792,Percent of Total Billed Charges,28% of Total Billed Charges,1137.3,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,292.7,36,,35.728,Percent of Total Billed Charges,36% of Total Billed Charges,292.7,36,,35.728,Percent of Total Billed Charges,36% Total Bille Charges,292.7,36,,35.728,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,34,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,2896,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.24,14.42,,306.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,609.79,75,,2742.6,Percent of Total Billed Charges,75% of Total Billed Charges,406.53,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,406.53,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,569.14,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,813.05,100,,3656.8,Percent of Total Billed Charges,100% of Total Billed Charges,33.19,1184.5,
TRACHEOSTOMY,30400030,CDM,761,RC,31600,HCPCS,Outpatient,,,6250.45,3750.27,,288.13,100,,3296.256,Fee Schedule,100% of Aetna Fee Schedule,4430.8,150,,192.456,Fee Schedule ,150% of CMS OPPS Rate,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1750.13,28,,24.768,Percent of Total Billed Charges,28% of Total Billed Charges,1137.3,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2250.16,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,2250.16,36,,31.84,Percent of Total Billed Charges,36% Total Bille Charges,2250.16,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,2575,103,,53.576,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2953.87,100,,197,Fee Schedule,100% of CMS OPPS Rate,2658.47,90,,,Fee Schedule,90% of CMS OPPS Rate,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3840.02,130,,,Fee Schedule,130% of CMS OPPS Rate,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,901.31,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,3042.48,103,,,Fee Schedule,103% of CMS OPPS Rate,3042.48,103,,,Fee Schedule,103% of CMS OPPS Rate,4687.84,75,,1596.504,Percent of Total Billed Charges,75% of Total Billed Charges,3125.23,50,,989.304,Percent of Total Billed Charges,50% of Total Billed Charges,3125.23,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.23,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,3125.23,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,4430.8,150,,,Fee Schedule,150% of CMS OPPS Rate,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4375.32,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,875.06,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2953.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6250.45,100,,2128.672,Percent of Total Billed Charges,100% of Total Billed Charges,288.13,6250.45,
CHEST TUBE INSERTION,30400063,CDM,761,RC,32551,HCPCS,Outpatient,,,1838.1,1102.86,,146.85,100,,299.52,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,50.08,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,514.67,28,,23.904,Percent of Total Billed Charges,28% of Total Billed Charges,252.9,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,661.72,36,,30.736,Percent of Total Billed Charges,36% of Total Billed Charges,661.72,36,,30.736,Percent of Total Billed Charges,36% Total Bille Charges,661.72,36,,30.736,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,450.328,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,140,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,265.05,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1378.58,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,919.05,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,919.05,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,919.05,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,919.05,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1286.67,70,,39.664,Percent of Total Billed Charges,70% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.1,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,146.85,2204.01,
IABP REMOVAL,30400097,CDM,360,RC,33968,HCPCS,Outpatient,,,2473.26,1483.96,,2601,100,,259.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2473.26,100,,40.208,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,82.3,233,,22.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,252.9,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,113.73,322,,29.144,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,113.73,322,,29.144,Fee schedule,Pays based on ASC Tier Groupings fee schedule,113.73,322,,29.144,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,424.808,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,427.68,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,356.64,14.42,,145.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1854.95,75,,562.912,Percent of Total Billed Charges,75% of Total Billed Charges,1236.63,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,1236.63,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1236.63,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,1236.63,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,28171,100,,62.504,Fee Schedule,100% of ASC Tier Groupings fee schedule,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,346.26,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,2473.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.26,100,,750.544,Percent of Total Billed Charges,100% of Total Billed Charges,82.3,28171,
APHERESIS PLASMA,30400105,CDM,940,RC,36514,HCPCS,Outpatient,,,4571,2742.60,,87.13,100,,265.68,Fee Schedule,100% of Aetna Fee Schedule,2111.52,150,,41.584,Fee Schedule ,150% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1279.88,28,,20.224,Percent of Total Billed Charges,28% of Total Billed Charges,305.9,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1645.56,36,,26.008,Percent of Total Billed Charges,36% of Total Billed Charges,1645.56,36,,26.008,Percent of Total Billed Charges,36% Total Bille Charges,1645.56,36,,26.008,Percent of Total Billed Charges,36% of Total Billed Charges,2742.6,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,111.28,Fee Schedule,100% of CMS OPPS Rate,1266.91,90,,,Fee Schedule,90% of CMS OPPS Rate,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.98,130,,,Fee Schedule,130% of CMS OPPS Rate,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,659.14,14.42,,36.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,3428.25,75,,756.496,Percent of Total Billed Charges,75% of Total Billed Charges,2285.5,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,2285.5,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,2285.5,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,2285.5,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,2111.52,150,,,Fee Schedule,150% of CMS OPPS Rate,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,860.872,Case Rate,Pays based on per visit rate,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,4571,100,,1008.664,Percent of Total Billed Charges,100% of Total Billed Charges,87.13,4571,
INSERT NON-TUNNEL CV CATH >5YO,30400113,CDM,761,RC,36556,HCPCS,Outpatient,,,2660.84,1596.50,,76.78,100,,381.6,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,105.536,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,745.04,28,,18.368,Percent of Total Billed Charges,28% of Total Billed Charges,305.9,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,957.9,36,,23.616,Percent of Total Billed Charges,36% of Total Billed Charges,957.9,36,,23.616,Percent of Total Billed Charges,36% Total Bille Charges,957.9,36,,23.616,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,914.168,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,89.344,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,383.69,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1995.63,75,,189.352,Percent of Total Billed Charges,75% of Total Billed Charges,1330.42,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.42,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.59,70,,176.728,Percent of Total Billed Charges,70% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2660.84,100,,252.472,Percent of Total Billed Charges,100% of Total Billed Charges,76.78,4386.59,
INSERT PICC CATH W/IMAGE > 5 YO,30400121,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,878.4,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,37.392,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,18.368,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.016,Percent of Total Billed Charges,32% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,23.616,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,23.616,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,23.616,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,360.752,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,92.408,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,199,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,4892.5,
INSERTION CATHETER ARTERY,30400139,CDM,761,RC,36620,HCPCS,Outpatient,,,938.18,562.91,,40.56,100,,128.64,Fee Schedule,100% of Aetna Fee Schedule,422.18,45,,101.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.016,Other,Not Seperately Reimbusable,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.91,60,,106.704,Percent of Total Billed Charges,60% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,938.18,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,135.29,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.64,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,469.09,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,469.09,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,656.73,70,,143.608,Percent of Total Billed Charges,70% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,938.18,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,40.56,938.18,
BONE MARROW BIOPSY(IES),30400147,CDM,761,RC,38221,HCPCS,Outpatient,,,1260.83,756.50,,67.48,100,,228,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,71.936,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,353.03,28,,153.672,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,453.9,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,453.9,36,,197.576,Percent of Total Billed Charges,36% Total Bille Charges,453.9,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,41.184,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,83.088,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,181.81,14.42,,128.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,945.62,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,630.42,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,630.42,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,882.58,70,,613.256,Percent of Total Billed Charges,70% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.83,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,2231.19,
INSERT STRAIGHT CATHETER,30400170,CDM,761,RC,51701,HCPCS,Outpatient,,,315.59,189.35,,24.67,100,,576,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,91.304,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.37,28,,33.912,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,113.61,36,,43.6,Percent of Total Billed Charges,36% of Total Billed Charges,113.61,36,,43.6,Percent of Total Billed Charges,36% Total Bille Charges,113.61,36,,43.6,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,97.344,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,226.056,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,45.51,14.42,,184.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,236.69,75,,667.68,Percent of Total Billed Charges,75% of Total Billed Charges,157.8,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,157.8,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,70,,525.384,Percent of Total Billed Charges,70% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,315.59,100,,890.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,515,
INSERT FOLEY CATHETER,30400188,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,589.752,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,68.44,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,213.696,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,274.752,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,274.752,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,274.752,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,50.384,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,159.864,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,184.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,960.808,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,1175.72,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,1281.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,515,
POST VOID RESID BLADDER SCAN,30400196,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,125.28,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,105.304,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,504.144,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,202.904,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,133.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,958.336,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,743.408,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,1277.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,515,
LUMBAR PUNCTURE DIAGNOSTIC,30400204,CDM,761,RC,62270,HCPCS,Outpatient,,,1095.1,657.06,,52.08,100,,5673.6,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,117,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,306.63,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,394.24,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,65.24,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,152.08,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,196.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,696.248,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,766.57,70,,495.608,Percent of Total Billed Charges,70% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,928.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1184.5,
LUMBAR PUNCTURE THERAPEUTIC,30400212,CDM,761,RC,62272,HCPCS,Outpatient,,,1112.8,667.68,,73.22,100,,4748.64,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,130.536,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,311.58,28,,46.736,Percent of Total Billed Charges,28% of Total Billed Charges,0.01,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% Total Bille Charges,400.61,36,,60.088,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,168.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,234,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,160.47,14.42,,98.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,834.6,75,,1021.2,Percent of Total Billed Charges,75% of Total Billed Charges,556.4,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,556.4,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,778.96,70,,617.048,Percent of Total Billed Charges,70% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,95.2,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.8,100,,1361.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1184.5,
CRRT,30400253,CDM,804,RC,90945,HCPCS,Outpatient,,,1601.35,960.81,,63.73,100,,487.544,Fee Schedule,100% of Aetna Fee Schedule,609.52,150,,342.088,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,448.38,28,,33.368,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,576.49,36,,42.904,Percent of Total Billed Charges,36% of Total Billed Charges,576.49,36,,42.904,Percent of Total Billed Charges,36% Total Bille Charges,576.49,36,,42.904,Percent of Total Billed Charges,36% of Total Billed Charges,960.81,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,260,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,230.91,14.42,,178.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1201.01,75,,510,Percent of Total Billed Charges,75% of Total Billed Charges,800.68,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,340,Percent of Total Billed Charges,50% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,800.68,50,,340,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,340,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.95,70,,1066.528,Percent of Total Billed Charges,70% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1601.35,100,,680,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1601.35,
THORACENTESIS ASP WO IMAGING,30400256,CDM,761,RC,32554,HCPCS,Outpatient,,,1597.23,958.34,,85.56,100,,1396.824,Fee Schedule,100% of Aetna Fee Schedule,864.52,150,,610.488,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,447.22,28,,33.656,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,575,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,575,36,,43.272,Percent of Total Billed Charges,36% Total Bille Charges,575,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,126.264,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,290.08,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,230.32,14.42,,12.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1197.92,75,,926.104,Percent of Total Billed Charges,75% of Total Billed Charges,798.62,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,798.62,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.06,70,,420.872,Percent of Total Billed Charges,70% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1597.23,100,,1234.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1597.23,
TRANSCUTANEOUS PACING,30400279,CDM,480,RC,92953,HCPCS,Outpatient,,,1160.41,696.25,,0.62,100,,1966.8,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,155.12,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1502.09,280,,182.12,Fee Schedule,280% of BCBS BULE Fee Schedule,1716.67,320,,0.024,Fee Schedule,320% of BCBS Blue Essentials Rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,1931.26,360,,234.16,Fee Schedule,360% of BCBS POS Rate,1931.26,360,,234.16,Fee schedule,360% of BCBS PPO Rate,1931.26,360,,234.16,Fee Schedule,360% of BCBS Traditional Rate,696.25,60,,108.536,Percent of Total Billed Charges,60% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,760.192,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,167.33,14.42,,274.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,870.31,75,,62.776,Percent of Total Billed Charges,75% of Total Billed Charges,580.21,50,,340,Percent of Total Billed Charges,50% of Total Billed Charges,580.21,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,580.21,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,580.21,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,124.488,Case Rate,Pays based on per visit rate,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,266.448,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.41,100,,83.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1931.26,
CARDIOVERSION EXTERNAL,30400287,CDM,480,RC,92960,HCPCS,Outpatient,,,1702,1021.20,,76.18,100,,1302.72,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,151.848,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,476.56,28,,160.384,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,612.72,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,612.72,36,,206.208,Percent of Total Billed Charges,36% Total Bille Charges,612.72,36,,206.208,Percent of Total Billed Charges,36% of Total Billed Charges,1021.2,60,,105.16,Percent of Total Billed Charges,60% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,1356.64,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,245.43,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,1276.5,75,,1427.392,Percent of Total Billed Charges,75% of Total Billed Charges,851,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,951.592,Percent of Total Billed Charges,50% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,851,50,,951.592,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,951.592,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,48.048,Case Rate,Pays based on per visit rate,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1702,100,,1903.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1702,
FLORTRAC SENSOR 84 INCHES,30400351,CDM,272,RC,,,Outpatient,,,850,510.00,,510,60,,75.456,Percent of Total Billed Charges,60% of Total Billed Charges,382.5,45,,222.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238,28,,104.832,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,306,36,,134.784,Percent of Total Billed Charges,36% of Total Billed Charges,306,36,,134.784,Percent of Total Billed Charges,36% Total Bille Charges,306,36,,134.784,Percent of Total Billed Charges,36% of Total Billed Charges,510,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,850,100,,344.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,122.57,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,637.5,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,425,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,425,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,425,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595,70,,113.568,Percent of Total Billed Charges,70% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,119,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,850,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,850,
RECOVERY RM 0-60 MIN,30400378,CDM,710,RC,,,Outpatient,,,1543.5,926.10,,926.1,60,,3501.888,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,45,,219.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.18,28,,102.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,555.66,36,,132.408,Percent of Total Billed Charges,36% of Total Billed Charges,555.66,36,,132.408,Percent of Total Billed Charges,36% Total Bille Charges,555.66,36,,132.408,Percent of Total Billed Charges,36% of Total Billed Charges,926.1,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1543.5,100,,337.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,222.57,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1157.63,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,771.75,50,,951.592,Percent of Total Billed Charges,50% of Total Billed Charges,771.75,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.75,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,771.75,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.45,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1543.5,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1543.5,
RECOVERY RM EA ADD 30 MIN,30400386,CDM,710,RC,,,Outpatient,,,104.63,62.78,,62.78,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,47.08,45,,271.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.3,28,,47.52,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,37.67,36,,61.104,Percent of Total Billed Charges,36% Total Bille Charges,37.67,36,,61.104,Percent of Total Billed Charges,36% of Total Billed Charges,62.78,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.63,100,,494,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,15.09,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.47,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,52.32,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,52.32,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.32,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,52.32,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.24,70,,588.168,Percent of Total Billed Charges,70% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.63,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,104.63,
THORACENTESIS W/TUBE WO IMAGE,30400478,CDM,761,RC,32556,HCPCS,Outpatient,,,2378.98,1427.39,,117.42,100,,322.96,Fee Schedule,100% of Aetna Fee Schedule,2618.64,150,,194.4,Fee Schedule ,150% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,666.11,28,,22.936,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.024,Percent of Total Billed Charges,32% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,856.43,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,856.43,36,,29.488,Percent of Total Billed Charges,36% Total Bille Charges,856.43,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,72.112,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,487.304,Fee Schedule,100% of CMS OPPS Rate,1571.18,90,,,Fee Schedule,90% of CMS OPPS Rate,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.48,130,,,Fee Schedule,130% of CMS OPPS Rate,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.05,14.42,,177.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,1798.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1798.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1784.24,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,1189.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,1189.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,1189.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,2618.64,150,,,Fee Schedule,150% of CMS OPPS Rate,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.29,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,333.06,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2378.98,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,2618.64,
MOD SED ONE PHYS INIT 15MIN 5+,30401000,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,773.984,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,61.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,64.184,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,82.52,Fee Schedule,360% of BCBS POS Rate,45.4,360,,82.52,Fee schedule,360% of BCBS PPO Rate,45.4,360,,82.52,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,604.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,82.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,922.36,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,196.248,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,1229.816,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
MOD SED ONE PHYS ADDL 15 MIN,30401001,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,1865.76,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,283.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,27.792,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,35.728,Fee Schedule,360% of BCBS POS Rate,38.92,360,,35.728,Fee schedule,360% of BCBS PPO Rate,38.92,360,,35.728,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,444.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,429.608,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,160.464,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,572.808,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
MOD SED SEP PHYS INIT 15MIN 5+,30401002,CDM,370,RC,99156,HCPCS,Outpatient,,,217.25,130.35,,55.94,100,,629.28,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,245.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.04,280,,100.992,Fee Schedule,280% of BCBS BULE Fee Schedule,258.34,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,290.63,360,,129.848,Fee Schedule,360% of BCBS POS Rate,290.63,360,,129.848,Fee schedule,360% of BCBS PPO Rate,290.63,360,,129.848,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,59.552,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,136.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,385.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,2310.12,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,147.312,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,3080.16,Percent of Total Billed Charges,100% of Total Billed Charges,30.42,290.63,
MOD SED SEP PHYS ADDL 15 MIN,30401003,CDM,370,RC,99157,HCPCS,Outpatient,,,137,82.20,,46.39,100,,1839.552,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.65,280,,72.72,Fee Schedule,280% of BCBS BULE Fee Schedule,209.89,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,236.12,360,,93.496,Fee Schedule,360% of BCBS POS Rate,236.12,360,,93.496,Fee schedule,360% of BCBS PPO Rate,236.12,360,,93.496,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,628.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,213.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,2005.24,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,126.624,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,2673.648,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,236.12,
PARACENTESIS WO IMAGING GUIDE,30401004,CDM,761,RC,49082,HCPCS,Outpatient,,,1537.27,922.36,,70.35,100,,419.384,Fee Schedule,100% of Aetna Fee Schedule,1247.49,150,,392.96,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,430.44,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,553.42,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,553.42,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,553.42,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,51.224,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,545.776,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,221.67,14.42,,355.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1152.95,75,,1108.576,Percent of Total Billed Charges,75% of Total Billed Charges,768.64,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,768.64,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.09,70,,122.688,Percent of Total Billed Charges,70% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,345.408,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1537.27,100,,1478.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1537.27,
LARYNGOSCOPYFLEX/RIGID DX,30401005,CDM,761,RC,31575,HCPCS,Outpatient,,,716.01,429.61,,63.82,100,,281.088,Fee Schedule,100% of Aetna Fee Schedule,272.58,150,,781.656,Fee Schedule ,150% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,257.76,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,257.76,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,257.76,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,48.576,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,480,Fee Schedule,100% of CMS OPPS Rate,163.55,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,236.24,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,103.25,14.42,,35.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,537.01,75,,1850.392,Percent of Total Billed Charges,75% of Total Billed Charges,358.01,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,1233.592,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.01,50,,1233.592,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,1233.592,Percent of Total Billed Charges,50% of Total Billed Charges,272.58,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.21,70,,118.808,Percent of Total Billed Charges,70% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.01,100,,2467.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,716.01,
BRONCHOSCOPY,30401006,CDM,761,RC,31622,HCPCS,Outpatient,,,3850.2,2310.12,,125.71,100,,3203.512,Fee Schedule,100% of Aetna Fee Schedule,2335.76,150,,256.128,Fee Schedule ,150% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1078.06,28,,78.496,Percent of Total Billed Charges,28% of Total Billed Charges,0.02,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1386.07,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,1386.07,36,,100.928,Percent of Total Billed Charges,36% Total Bille Charges,1386.07,36,,100.928,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,43.344,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,873.24,Fee Schedule,100% of CMS OPPS Rate,1401.45,90,,,Fee Schedule,90% of CMS OPPS Rate,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.32,130,,,Fee Schedule,130% of CMS OPPS Rate,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,555.2,14.42,,196.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2887.65,75,,184.832,Percent of Total Billed Charges,75% of Total Billed Charges,1925.1,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,1925.1,50,,123.224,Percent of Total Billed Charges,50% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1925.1,50,,123.224,Percent of Total Billed Charges,50% of Total Billed Charges,1925.1,50,,123.224,Percent of Total Billed Charges,50% of Total Billed Charges,2335.76,150,,,Fee Schedule,150% of CMS OPPS Rate,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2695.14,70,,116.84,Percent of Total Billed Charges,70% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,191.2,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3850.2,100,,246.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,3850.2,
BRONCH LAVAGE,30401007,CDM,761,RC,31624,HCPCS,Outpatient,,,3342.06,2005.24,,128.54,100,,3966.016,Fee Schedule,100% of Aetna Fee Schedule,2335.76,150,,497.824,Fee Schedule ,150% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,935.78,28,,46.248,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1203.14,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,1203.14,36,,59.464,Percent of Total Billed Charges,36% Total Bille Charges,1203.14,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,2575,103,,39.36,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,1737.008,Fee Schedule,100% of CMS OPPS Rate,1401.45,90,,,Fee Schedule,90% of CMS OPPS Rate,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.32,130,,,Fee Schedule,130% of CMS OPPS Rate,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,481.93,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2506.55,75,,1024.288,Percent of Total Billed Charges,75% of Total Billed Charges,1671.03,50,,1233.592,Percent of Total Billed Charges,50% of Total Billed Charges,1671.03,50,,682.864,Percent of Total Billed Charges,50% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.03,50,,682.864,Percent of Total Billed Charges,50% of Total Billed Charges,1671.03,50,,682.864,Percent of Total Billed Charges,50% of Total Billed Charges,2335.76,150,,,Fee Schedule,150% of CMS OPPS Rate,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2339.44,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3342.06,100,,1365.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,3342.06,
PARACENTESIS W IMAGING GUIDE,30401008,CDM,761,RC,49083,HCPCS,Outpatient,,,1847.63,1108.58,,102.92,100,,6411.888,Fee Schedule,100% of Aetna Fee Schedule,1247.49,150,,243,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,517.34,28,,49.952,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,665.15,36,,64.224,Percent of Total Billed Charges,36% of Total Billed Charges,665.15,36,,64.224,Percent of Total Billed Charges,36% Total Bille Charges,665.15,36,,64.224,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,39.36,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,569.168,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,266.43,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1385.72,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,923.82,50,,123.224,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,923.82,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.34,70,,84.136,Percent of Total Billed Charges,70% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1847.63,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1847.63,
DILATION URETHRA STRICTUR MALE,30401009,CDM,361,RC,53620,HCPCS,Outpatient,,,3083.98,1850.39,,2601,100,,763.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,737.272,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,203.5,233,,596.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,281.23,322,,766.32,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,281.23,322,,766.32,Fee schedule,Pays based on ASC Tier Groupings fee schedule,281.23,322,,766.32,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,39.312,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,1106.28,Fee Schedule,100% of CMS OPPS Rate,564.04,90,,,Fee Schedule,90% of CMS OPPS Rate,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.73,130,,,Fee Schedule,130% of CMS OPPS Rate,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,444.71,14.42,,52.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2312.99,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1541.99,50,,682.864,Percent of Total Billed Charges,50% of Total Billed Charges,1541.99,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1541.99,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1541.99,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,77.592,Fee Schedule,100% of ASC Tier Groupings fee schedule,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,431.76,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,3083.98,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,3862.5,
URETHRAL WOVE FOLLOWER CATH,30401010,CDM,272,RC,,,Outpatient,,,308.05,184.83,,184.83,60,,3203.368,Percent of Total Billed Charges,60% of Total Billed Charges,138.62,45,,499.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.25,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,110.9,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,110.9,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,110.9,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,184.83,60,,329.296,Percent of Total Billed Charges,60% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.05,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.42,14.42,,47.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.04,75,,275.312,Percent of Total Billed Charges,75% of Total Billed Charges,154.03,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,154.03,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.03,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,154.03,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.64,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.05,100,,367.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,308.05,
"BIOPSY, NEEDLE CORE",30401011,CDM,361,RC,19100,HCPCS,Outpatient,,,1707.15,1024.29,,2601,100,,1041.6,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,535.88,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,36.608,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,47.072,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,47.072,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,47.072,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,72.672,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,1638.384,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,246.17,14.42,,80.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.36,75,,246.064,Percent of Total Billed Charges,75% of Total Billed Charges,853.58,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,853.58,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,853.58,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,853.58,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,69.472,Fee Schedule,100% of ASC Tier Groupings fee schedule,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,239,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1707.15,100,,328.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,4419.77,
BRIDLE AMT SPARE CLIP,30401012,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,3146.456,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,344.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,24.768,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,31.84,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,31.84,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1111.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,61.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,416.8,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,61.912,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,555.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,375,
FEEDING TUBE CORTRAK EAS,30401013,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,302.688,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,649.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,23.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.032,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,30.232,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1190.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,124.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,321.496,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,59.76,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,428.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,375,
CHEMO ADMIN SQ OR IM,30401014,CDM,331,RC,96401,HCPCS,Outpatient,,,458.85,275.31,,47.67,100,,398.88,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,991.296,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,411.736,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,529.376,Fee Schedule,360% of BCBS POS Rate,217.69,360,,529.376,Fee schedule,360% of BCBS PPO Rate,217.69,360,,529.376,Fee Schedule,360% of BCBS Traditional Rate,674,100,,287.912,Case Rate,Pays based on per visit rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,765.6,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,66.17,14.42,,51.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,344.14,75,,649.152,Percent of Total Billed Charges,75% of Total Billed Charges,229.43,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,56.672,Case Rate,Pays based on per visit rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,458.85,100,,865.536,Percent of Total Billed Charges,100% of Total Billed Charges,47.67,674,
CHEMO ADMIN SQ OR IM HORMONAL,30401015,CDM,331,RC,96402,HCPCS,Outpatient,,,410.11,246.07,,19.18,100,,47.12,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,492.768,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,832.616,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,1070.504,Fee Schedule,360% of BCBS POS Rate,217.69,360,,1070.504,Fee schedule,360% of BCBS PPO Rate,217.69,360,,1070.504,Fee Schedule,360% of BCBS Traditional Rate,674,100,,98.528,Case Rate,Pays based on per visit rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,1442.408,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,59.14,14.42,,64.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,307.58,75,,269.368,Percent of Total Billed Charges,75% of Total Billed Charges,205.06,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,50.568,Case Rate,Pays based on per visit rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,410.11,100,,359.16,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,674,
IV PUSH CHEMO INITIAL MED,30401016,CDM,335,RC,96409,HCPCS,Outpatient,,,694.67,416.80,,65.73,100,,271.68,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,508.744,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,307.78,280,,282.424,Fee Schedule,280% of BCBS BULE Fee Schedule,351.74,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,395.71,360,,363.12,Fee Schedule,360% of BCBS POS Rate,395.71,360,,363.12,Fee schedule,360% of BCBS PPO Rate,395.71,360,,363.12,Fee Schedule,360% of BCBS Traditional Rate,674,100,,152.712,Case Rate,Pays based on per visit rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,2202.888,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,100.17,14.42,,138.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,521,75,,336.904,Percent of Total Billed Charges,75% of Total Billed Charges,347.34,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,45.92,Case Rate,Pays based on per visit rate,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,694.67,100,,449.2,Percent of Total Billed Charges,100% of Total Billed Charges,65.73,694.67,
IV PUSH CHEMO EA AD MED,30401017,CDM,335,RC,96411,HCPCS,Outpatient,,,535.83,321.50,,35.93,100,,672.736,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,2637.648,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,166.49,280,,344.352,Fee Schedule,280% of BCBS BULE Fee Schedule,190.27,320,,0.032,Fee Schedule,320% of BCBS Blue Essentials Rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,214.06,360,,442.736,Fee Schedule,360% of BCBS POS Rate,214.06,360,,442.736,Fee schedule,360% of BCBS PPO Rate,214.06,360,,442.736,Fee Schedule,360% of BCBS Traditional Rate,674,100,,124.664,Case Rate,Pays based on per visit rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,1095.048,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,77.27,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,401.87,75,,717.904,Percent of Total Billed Charges,75% of Total Billed Charges,267.92,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,267.92,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,45.92,Case Rate,Pays based on per visit rate,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,535.83,100,,957.2,Percent of Total Billed Charges,100% of Total Billed Charges,35.93,674,
IV INFUSION CHEMO 1ST HR,30401018,CDM,335,RC,96413,HCPCS,Outpatient,,,1081.92,649.15,,85.85,100,,3444.48,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,4044.456,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,400.62,280,,70.696,Fee Schedule,280% of BCBS BULE Fee Schedule,457.86,320,,0.04,Fee Schedule,320% of BCBS Blue Essentials Rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,515.09,360,,90.888,Fee Schedule,360% of BCBS POS Rate,515.09,360,,90.888,Fee schedule,360% of BCBS PPO Rate,515.09,360,,90.888,Fee Schedule,360% of BCBS Traditional Rate,674,100,,100.208,Case Rate,Pays based on per visit rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,1130.536,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.01,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,811.44,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,540.96,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,540.96,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,45.864,Case Rate,Pays based on per visit rate,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.92,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,85.85,1081.92,
IV INFUSION CHEMO EA AD HR,30401019,CDM,335,RC,96415,HCPCS,Outpatient,,,448.95,269.37,,18.16,100,,3992.144,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,6163.92,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,280,,79.6,Fee Schedule,280% of BCBS BULE Fee Schedule,99.17,320,,0.04,Fee Schedule,320% of BCBS Blue Essentials Rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,111.56,360,,102.344,Fee Schedule,360% of BCBS POS Rate,111.56,360,,102.344,Fee schedule,360% of BCBS PPO Rate,111.56,360,,102.344,Fee Schedule,360% of BCBS Traditional Rate,674,100,,134.52,Case Rate,Pays based on per visit rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,5861.44,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.74,14.42,,53.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,336.71,75,,395.416,Percent of Total Billed Charges,75% of Total Billed Charges,224.48,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.48,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,384.184,Case Rate,Pays based on per visit rate,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,52.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,448.95,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,18.16,674,
CHEMO INF EACH ADD SEQ 1ST HR,30401020,CDM,335,RC,96417,HCPCS,Outpatient,,,561.5,336.90,,41.64,100,,111.192,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,7704,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,193.76,280,,57.44,Fee Schedule,280% of BCBS BULE Fee Schedule,221.44,320,,0.04,Fee Schedule,320% of BCBS Blue Essentials Rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,249.12,360,,73.856,Fee Schedule,360% of BCBS POS Rate,249.12,360,,73.856,Fee schedule,360% of BCBS PPO Rate,249.12,360,,73.856,Fee Schedule,360% of BCBS Traditional Rate,674,100,,125.376,Case Rate,Pays based on per visit rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,8987.68,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,80.97,14.42,,47.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,421.13,75,,280.264,Percent of Total Billed Charges,75% of Total Billed Charges,280.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,186.84,Percent of Total Billed Charges,50% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,280.75,50,,186.84,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,186.84,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,84.784,Case Rate,Pays based on per visit rate,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,46.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,561.5,100,,373.68,Percent of Total Billed Charges,100% of Total Billed Charges,41.64,674,
INTRATHECAL CHEMO,30401021,CDM,331,RC,96450,HCPCS,Outpatient,,,1196.5,717.90,,44.79,100,,2640.176,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,330.8,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.07,280,,245.304,Fee Schedule,280% of BCBS BULE Fee Schedule,261.79,320,,0.04,Fee Schedule,320% of BCBS Blue Essentials Rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,294.52,360,,315.392,Fee Schedule,360% of BCBS POS Rate,294.52,360,,315.392,Fee schedule,360% of BCBS PPO Rate,294.52,360,,315.392,Fee Schedule,360% of BCBS Traditional Rate,674,100,,119.872,Case Rate,Pays based on per visit rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,13697.6,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,172.54,14.42,,13.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,897.38,75,,247.92,Percent of Total Billed Charges,75% of Total Billed Charges,598.25,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,165.28,Percent of Total Billed Charges,50% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,598.25,50,,165.28,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,165.28,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,534.24,Case Rate,Pays based on per visit rate,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.5,100,,330.56,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,1196.5,
CORGRIP NASO FEED TUBE,30401022,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1022.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,158.472,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,203.752,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,17120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,23.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,186.84,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,96,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,375,
HEMOSTAT SURGICEL 8 IN X 4 IN,30405051,CDM,250,RC,99070,HCPCS,Outpatient,,,659.02,395.41,,16.5,100,,168,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,28,,249.264,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,237.25,36,,320.488,Percent of Total Billed Charges,36% of Total Billed Charges,237.25,36,,320.488,Percent of Total Billed Charges,36% Total Bille Charges,237.25,36,,320.488,Percent of Total Billed Charges,36% of Total Billed Charges,395.41,60,,34,Percent of Total Billed Charges,60% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,95.03,14.42,,23.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.27,75,,122.4,Percent of Total Billed Charges,75% of Total Billed Charges,329.51,50,,165.28,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.51,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.31,70,,39.664,Percent of Total Billed Charges,70% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,22.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.02,100,,163.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,659.02,
SLING SUSPENSION REPOS BAR,30405052,CDM,271,RC,,,Outpatient,,,467.1,280.26,,280.26,60,,957.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.79,28,,358.704,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,168.16,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,168.16,36,,461.192,Percent of Total Billed Charges,36% Total Bille Charges,168.16,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,280.26,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14.42,,24.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.33,75,,122.4,Percent of Total Billed Charges,75% of Total Billed Charges,233.55,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,233.55,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.55,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,233.55,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.97,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,65.39,14,,23.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.1,100,,163.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,467.1,
SLING SUSPENSION REPOS LG,30405053,CDM,271,RC,,,Outpatient,,,413.2,247.92,,247.92,60,,122.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.7,28,,357.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,148.75,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,148.75,36,,460,Percent of Total Billed Charges,36% Total Bille Charges,148.75,36,,460,Percent of Total Billed Charges,36% of Total Billed Charges,247.92,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,59.58,14.42,,53.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.9,75,,125.224,Percent of Total Billed Charges,75% of Total Billed Charges,206.6,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,206.6,50,,83.48,Percent of Total Billed Charges,50% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.6,50,,83.48,Percent of Total Billed Charges,50% of Total Billed Charges,206.6,50,,83.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.24,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,57.85,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.2,100,,166.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,413.2,
CARTRIDGE HEMO APPARATUS ACC,30405054,CDM,271,RC,,,Outpatient,,,120,72.00,,72,60,,4747.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,28,,1023.904,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,43.2,36,,1316.448,Percent of Total Billed Charges,36% of Total Billed Charges,43.2,36,,1316.448,Percent of Total Billed Charges,36% Total Bille Charges,43.2,36,,1316.448,Percent of Total Billed Charges,36% of Total Billed Charges,72,60,,100.144,Percent of Total Billed Charges,60% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,17.3,14.42,,40.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,75,,280.8,Percent of Total Billed Charges,75% of Total Billed Charges,60,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,60,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,60,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,70,,116.84,Percent of Total Billed Charges,70% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,39.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120,100,,374.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,120,
SOL HEMO DIALYSATE,30405055,CDM,271,RC,,,Outpatient,,,204,122.40,,122.4,60,,2175.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.12,28,,160.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,73.44,36,,206.488,Percent of Total Billed Charges,36% of Total Billed Charges,73.44,36,,206.488,Percent of Total Billed Charges,36% Total Bille Charges,73.44,36,,206.488,Percent of Total Billed Charges,36% of Total Billed Charges,122.4,60,,71.504,Percent of Total Billed Charges,60% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,29.42,14.42,,117.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,75,,210.72,Percent of Total Billed Charges,75% of Total Billed Charges,102,50,,83.48,Percent of Total Billed Charges,50% of Total Billed Charges,102,50,,140.48,Percent of Total Billed Charges,50% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102,50,,140.48,Percent of Total Billed Charges,50% of Total Billed Charges,102,50,,140.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,70,,83.416,Percent of Total Billed Charges,70% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,113.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204,100,,280.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,204,
SOL HEMO DIALYSATE 1.32 GA,30405056,CDM,271,RC,,,Outpatient,,,204,122.40,,122.4,60,,845.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.12,28,,52.616,Percent of Total Billed Charges,28% of Total Billed Charges,0.03,32,,0.04,Percent of Total Billed Charges,32% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,73.44,36,,67.648,Percent of Total Billed Charges,36% of Total Billed Charges,73.44,36,,67.648,Percent of Total Billed Charges,36% Total Bille Charges,73.44,36,,67.648,Percent of Total Billed Charges,36% of Total Billed Charges,122.4,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.42,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,75,,608.64,Percent of Total Billed Charges,75% of Total Billed Charges,102,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,102,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,102,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,70,,84.136,Percent of Total Billed Charges,70% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.56,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204,100,,811.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,204,
MATTRESS WFL OVLY 75X30X3 IN,30405057,CDM,271,RC,,,Outpatient,,,208.7,125.22,,125.22,60,,845.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.44,28,,36.264,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.048,Percent of Total Billed Charges,32% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,75.13,36,,46.624,Percent of Total Billed Charges,36% of Total Billed Charges,75.13,36,,46.624,Percent of Total Billed Charges,36% Total Bille Charges,75.13,36,,46.624,Percent of Total Billed Charges,36% of Total Billed Charges,125.22,60,,224.64,Percent of Total Billed Charges,60% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,30.09,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.53,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,104.35,50,,140.48,Percent of Total Billed Charges,50% of Total Billed Charges,104.35,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.35,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,104.35,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.09,70,,455.312,Percent of Total Billed Charges,70% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.7,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,208.7,
HEEL PROTECT W/FOOT AND LEG,30405058,CDM,271,RC,,,Outpatient,,,468,280.80,,280.8,60,,845.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.04,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.048,Percent of Total Billed Charges,32% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,168.48,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,168.48,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,168.48,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,280.8,60,,220.68,Percent of Total Billed Charges,60% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,234,50,,405.76,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.6,70,,400.968,Percent of Total Billed Charges,70% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,468,
CHEST TUBE INSERTION TRAY,30405059,CDM,271,RC,,,Outpatient,,,351.2,210.72,,210.72,60,,574.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.34,28,,12.744,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.048,Percent of Total Billed Charges,32% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,126.43,36,,16.392,Percent of Total Billed Charges,36% of Total Billed Charges,126.43,36,,16.392,Percent of Total Billed Charges,36% Total Bille Charges,126.43,36,,16.392,Percent of Total Billed Charges,36% of Total Billed Charges,210.72,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.64,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.4,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,175.6,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,175.6,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.6,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,175.6,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.84,70,,262.08,Percent of Total Billed Charges,70% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.2,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,351.2,
TRAY HEMO ADULT L24,30405060,CDM,271,RC,,,Outpatient,,,1014.4,608.64,,608.64,60,,574.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.03,28,,11.808,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.048,Percent of Total Billed Charges,32% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,365.18,36,,15.184,Percent of Total Billed Charges,36% of Total Billed Charges,365.18,36,,15.184,Percent of Total Billed Charges,36% Total Bille Charges,365.18,36,,15.184,Percent of Total Billed Charges,36% of Total Billed Charges,608.64,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,146.28,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.8,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,507.2,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.2,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,507.2,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,710.08,70,,257.464,Percent of Total Billed Charges,70% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,142.02,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1014.4,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1014.4,
INSERT MIDLINE W/IMAGE > 5 YO,30900000,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,1208.64,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.048,Other,Not Seperately Reimbusable,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,137.536,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,118.808,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
INSERT PICC CATH W/IMAGE > 5 YO,30900001,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,539.496,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,247.632,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,36.152,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.048,Percent of Total Billed Charges,32% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,46.48,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,46.48,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,46.48,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,59.552,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,1075.96,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,4892.5,
IV INFUSION HYDRATION 1ST HR,30900006,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,1316.72,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,56.952,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,703.248,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,0.048,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,904.176,Fee Schedule,360% of BCBS POS Rate,138.82,360,,904.176,Fee schedule,360% of BCBS PPO Rate,138.82,360,,904.176,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,216.408,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,1169.472,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,160.464,Case Rate,Pays based on per visit rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,30900007,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,253.816,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,2403.648,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,160.384,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,0.048,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,206.208,Fee Schedule,360% of BCBS POS Rate,49.28,360,,206.208,Fee schedule,360% of BCBS PPO Rate,49.28,360,,206.208,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,155.824,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,550.296,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,69.472,Case Rate,Pays based on per visit rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,30900008,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,5060.384,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,249.912,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,0.048,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,108,Fee Schedule,360% of BCBS POS Rate,262.08,360,,108,Fee schedule,360% of BCBS PPO Rate,262.08,360,,108,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,126.56,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,252.48,Case Rate,Pays based on per visit rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,30900009,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,9810.44,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,154.808,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,0.048,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,108,Fee Schedule,360% of BCBS POS Rate,79.13,360,,108,Fee schedule,360% of BCBS PPO Rate,79.13,360,,108,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,5341.44,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,181.8,Case Rate,Pays based on per visit rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV INF THERAP ADDL SEQUENTIAL,30900010,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,704.488,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,877.144,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,304.648,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,391.688,Fee Schedule,360% of BCBS POS Rate,114.16,360,,391.688,Fee schedule,360% of BCBS PPO Rate,114.16,360,,391.688,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,168.208,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,555.368,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,74.416,Case Rate,Pays based on per visit rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,30900011,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,1187.456,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,108,Fee Schedule,360% of BCBS POS Rate,76.54,360,,108,Fee schedule,360% of BCBS PPO Rate,76.54,360,,108,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,60.12,Case Rate,Pays based on per visit rate,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
INJECTION SQ OR IM,30900012,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,60.4,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,39.6,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,16.32,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,20.976,Fee Schedule,360% of BCBS POS Rate,217.69,360,,20.976,Fee schedule,360% of BCBS PPO Rate,217.69,360,,20.976,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,107.048,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,1949.2,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,196.248,Case Rate,Pays based on per visit rate,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
IV PUSH THER INITIAL MED,30900014,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,323.984,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,92.16,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,28.144,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,36.184,Fee Schedule,360% of BCBS POS Rate,142.7,360,,36.184,Fee schedule,360% of BCBS PPO Rate,142.7,360,,36.184,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,36,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,12.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,42.496,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,115.632,Case Rate,Pays based on per visit rate,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,56.664,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA ADD NEW MED,30900015,CDM,940,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,792,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,190.8,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,113.928,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,146.48,Fee Schedule,360% of BCBS POS Rate,60.98,360,,146.48,Fee schedule,360% of BCBS PPO Rate,60.98,360,,146.48,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,88,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,177.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,66.976,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,124.888,Case Rate,Pays based on per visit rate,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,89.296,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,30900016,CDM,940,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,293.76,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,43.2,Fee Schedule,360% of BCBS POS Rate,85.64,360,,43.2,Fee schedule,360% of BCBS PPO Rate,85.64,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,53.072,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,36.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,922.36,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,1490.072,Case Rate,Pays based on per visit rate,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,1229.816,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
IMMUNIZATION INJECT INFLUENZA,30900017,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,68.192,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,688.32,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,552.08,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,709.816,Fee Schedule,360% of BCBS POS Rate,85.64,360,,709.816,Fee schedule,360% of BCBS PPO Rate,85.64,360,,709.816,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,424,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,189.352,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,252.472,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IMMUNIZATION INJECT PNEUMOVAX,30900018,CDM,771,RC,G0009,HCPCS,Outpatient,,,70.83,42.50,,10.31,100,,1169.52,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,1041.12,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,2269.504,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,172.55,360,,2917.936,Fee Schedule,360% of BCBS POS Rate,172.55,360,,2917.936,Fee schedule,360% of BCBS PPO Rate,172.55,360,,2917.936,Fee Schedule,360% of BCBS Traditional Rate,42.5,60,,1784.176,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,972,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.12,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,35.42,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.42,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,172.55,
IMMUNIZE INJECT HEP B,30900019,CDM,771,RC,G0010,HCPCS,Outpatient,,,111.62,66.97,,10.31,100,,1524.6,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,1461.96,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,145.32,280,,742.56,Fee Schedule,280% of BCBS BULE Fee Schedule,166.08,320,,0.056,Fee Schedule,320% of BCBS Blue Essentials Rate,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,186.84,360,,954.72,Fee Schedule,360% of BCBS POS Rate,186.84,360,,954.72,Fee schedule,360% of BCBS PPO Rate,186.84,360,,954.72,Fee Schedule,360% of BCBS Traditional Rate,66.97,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,1529.6,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,16.1,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,83.72,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,55.81,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,55.81,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,78.13,70,,61.912,Percent of Total Billed Charges,70% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,111.62,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,10.31,186.84,
PARACENTESIS WO IMAGING GUIDE,30900088,CDM,761,RC,49082,HCPCS,Outpatient,,,1537.27,922.36,,70.35,100,,2402.336,Fee Schedule,100% of Aetna Fee Schedule,1247.49,150,,2056.68,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,430.44,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.056,Percent of Total Billed Charges,32% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,553.42,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,553.42,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,553.42,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,41.336,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,2313.6,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,221.67,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1152.95,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,768.64,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.09,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1537.27,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1537.27,
INSERT STRAIGHT CATHETER,30900096,CDM,761,RC,51701,HCPCS,Outpatient,,,315.59,189.35,,24.67,100,,3985.016,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,2840.04,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.37,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.056,Percent of Total Billed Charges,32% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,113.61,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,113.61,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,113.61,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,768.648,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,3248.8,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,45.51,14.42,,242.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,236.69,75,,562.912,Percent of Total Billed Charges,75% of Total Billed Charges,157.8,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,157.8,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,235.144,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,315.59,100,,750.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,515,
INSERT FOLEY CATHETER,30900104,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,3726.8,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,4251.24,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,344.168,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.056,Percent of Total Billed Charges,32% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,442.504,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,442.504,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,442.504,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,557,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,4570.4,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,153.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,1259.704,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,1029.336,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,148.68,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,1679.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,515,
POST VOID RESID BLADDER SCAN,30900112,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,5975.056,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,6013.44,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,53.576,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,6311.2,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,796.504,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,531.008,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,531.008,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,531.008,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,1062.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,515,
LUMBAR PUNCTURE DIAGNOSTIC,30900120,CDM,761,RC,62270,HCPCS,Outpatient,,,1095.1,657.06,,52.08,100,,3087.344,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,8820.36,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,306.63,28,,3225.152,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,394.24,36,,4146.624,Percent of Total Billed Charges,36% of Total Billed Charges,394.24,36,,4146.624,Percent of Total Billed Charges,36% Total Bille Charges,394.24,36,,4146.624,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,2194.08,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,9447.2,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,127.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,839.8,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,766.57,70,,706.064,Percent of Total Billed Charges,70% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1184.5,
INSERTION CATHETER ARTERY,30901000,CDM,761,RC,36620,HCPCS,Outpatient,,,938.18,562.91,,40.56,100,,2451.68,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.064,Other,Not Seperately Reimbusable,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.91,60,,112.752,Percent of Total Billed Charges,60% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,135.29,14.42,,219.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.64,75,,661.12,Percent of Total Billed Charges,75% of Total Billed Charges,469.09,50,,531.008,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,469.09,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,656.73,70,,860.872,Percent of Total Billed Charges,70% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,213.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,938.18,100,,881.496,Percent of Total Billed Charges,100% of Total Billed Charges,40.56,938.18,
I&D PERIANAL ABSCESS,30901001,CDM,761,RC,46050,HCPCS,Outpatient,,,2099.5,1259.70,,97.24,100,,98.152,Fee Schedule,100% of Aetna Fee Schedule,1257.77,150,,18176.04,Fee Schedule ,150% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,587.86,28,,147.976,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,755.82,36,,190.256,Percent of Total Billed Charges,36% of Total Billed Charges,755.82,36,,190.256,Percent of Total Billed Charges,36% Total Bille Charges,755.82,36,,190.256,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,77.712,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,838.52,100,,19600.8,Fee Schedule,100% of CMS OPPS Rate,754.65,90,,,Fee Schedule,90% of CMS OPPS Rate,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1090.07,130,,,Fee Schedule,130% of CMS OPPS Rate,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,302.75,14.42,,86.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,863.67,103,,,Fee Schedule,103% of CMS OPPS Rate,863.67,103,,,Fee Schedule,103% of CMS OPPS Rate,1574.63,75,,1142.712,Percent of Total Billed Charges,75% of Total Billed Charges,1049.75,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,1049.75,50,,761.808,Percent of Total Billed Charges,50% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.75,50,,761.808,Percent of Total Billed Charges,50% of Total Billed Charges,1049.75,50,,761.808,Percent of Total Billed Charges,50% of Total Billed Charges,1257.77,150,,,Fee Schedule,150% of CMS OPPS Rate,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.65,70,,176.728,Percent of Total Billed Charges,70% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,293.93,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,838.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2099.5,100,,1523.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,2099.5,
ARTHRO/ASP/INJ MAJOR JOINT BI,30901002,CDM,761,RC,20610,HCPCS,Outpatient,,,1327.51,796.51,,37.94,100,,7058.608,Fee Schedule,100% of Aetna Fee Schedule,407.6,150,,15.48,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,371.7,28,,2912,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,477.9,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,477.9,36,,3744,Percent of Total Billed Charges,36% Total Bille Charges,477.9,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,31.384,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,25802.4,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,191.43,14.42,,25.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,995.63,75,,450.936,Percent of Total Billed Charges,75% of Total Billed Charges,663.76,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,663.76,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,663.76,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,663.76,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,929.26,70,,199,Percent of Total Billed Charges,70% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,185.85,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1327.51,100,,601.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1327.51,
ARTHRO/ASP/INJ MAJOR JOINT,30901003,CDM,761,RC,27093,HCPCS,Outpatient,,,885.02,531.01,,57.67,100,,4998.416,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.064,Other,Not Seperately Reimbusable,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.01,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,9.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.77,75,,133.384,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,761.808,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.51,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.51,70,,143.608,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885.02,100,,177.84,Percent of Total Billed Charges,100% of Total Billed Charges,57.67,885.02,
POWERPICC SOLO PROVENA CATH 5F,30901004,CDM,271,RC,,,Outpatient,,,1101.87,661.12,,661.12,60,,11715.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.52,28,,104.16,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,396.67,36,,133.92,Percent of Total Billed Charges,36% of Total Billed Charges,396.67,36,,133.92,Percent of Total Billed Charges,36% Total Bille Charges,396.67,36,,133.92,Percent of Total Billed Charges,36% of Total Billed Charges,661.12,60,,27.32,Percent of Total Billed Charges,60% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,158.89,14.42,,23.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.4,75,,51.48,Percent of Total Billed Charges,75% of Total Billed Charges,550.94,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.94,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.31,70,,613.256,Percent of Total Billed Charges,70% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,22.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1101.87,100,,68.64,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1101.87,
KIT NEG PRESSURE DRESSING WITH PRESSURE INDICATOR,30901005,CDM,271,RC,,,Outpatient,,,1904.52,1142.71,,1142.71,60,,3622.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.27,28,,561.344,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,685.63,36,,721.728,Percent of Total Billed Charges,36% of Total Billed Charges,685.63,36,,721.728,Percent of Total Billed Charges,36% Total Bille Charges,685.63,36,,721.728,Percent of Total Billed Charges,36% of Total Billed Charges,1142.71,60,,25.304,Percent of Total Billed Charges,60% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,274.63,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1428.39,75,,121.68,Percent of Total Billed Charges,75% of Total Billed Charges,952.26,50,,88.92,Percent of Total Billed Charges,50% of Total Billed Charges,952.26,50,,81.12,Percent of Total Billed Charges,50% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,952.26,50,,81.12,Percent of Total Billed Charges,50% of Total Billed Charges,952.26,50,,81.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1333.16,70,,396.176,Percent of Total Billed Charges,70% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,266.63,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1904.52,100,,162.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1904.52,
MIDLINE MAX PROVENA 3F,30901006,CDM,271,RC,,,Outpatient,,,751.56,450.94,,450.94,60,,4192.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.44,28,,146.112,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,270.56,36,,187.856,Percent of Total Billed Charges,36% of Total Billed Charges,270.56,36,,187.856,Percent of Total Billed Charges,36% Total Bille Charges,270.56,36,,187.856,Percent of Total Billed Charges,36% of Total Billed Charges,450.94,60,,16.064,Percent of Total Billed Charges,60% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,108.37,14.42,,121.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.67,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,375.78,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.78,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,526.09,70,,623.168,Percent of Total Billed Charges,70% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,751.56,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,751.56,
TRAY PICC DRSG,30901007,CDM,272,RC,,,Outpatient,,,222.3,133.38,,133.38,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.24,28,,147.624,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.03,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,80.03,36,,189.8,Percent of Total Billed Charges,36% Total Bille Charges,80.03,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,133.38,60,,77.472,Percent of Total Billed Charges,60% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.73,75,,630.184,Percent of Total Billed Charges,75% of Total Billed Charges,111.15,50,,81.12,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,111.15,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.61,70,,71.12,Percent of Total Billed Charges,70% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.3,100,,840.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,222.3,
SLEEVE COMPR SCD EXPR KNEE MED,30901008,CDM,271,RC,,,Outpatient,,,85.8,51.48,,51.48,60,,1142.352,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.02,28,,340.704,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,30.89,36,,438.048,Percent of Total Billed Charges,36% of Total Billed Charges,30.89,36,,438.048,Percent of Total Billed Charges,36% Total Bille Charges,30.89,36,,438.048,Percent of Total Billed Charges,36% of Total Billed Charges,51.48,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14.42,,40.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.35,75,,81.552,Percent of Total Billed Charges,75% of Total Billed Charges,42.9,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.9,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.06,70,,48.224,Percent of Total Billed Charges,70% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.8,100,,108.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,85.8,
CUFF FOOT EXPRESS REG SLEEVE,30901009,CDM,271,RC,,,Outpatient,,,202.8,121.68,,121.68,60,,253.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.78,28,,1362.936,Percent of Total Billed Charges,28% of Total Billed Charges,0.04,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,73.01,36,,1752.344,Percent of Total Billed Charges,36% of Total Billed Charges,73.01,36,,1752.344,Percent of Total Billed Charges,36% Total Bille Charges,73.01,36,,1752.344,Percent of Total Billed Charges,36% of Total Billed Charges,121.68,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,29.24,14.42,,33.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.1,75,,210.264,Percent of Total Billed Charges,75% of Total Billed Charges,101.4,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,101.4,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.4,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,101.4,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.96,70,,896.76,Percent of Total Billed Charges,70% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.8,100,,280.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,202.8,
SLEEVE COMPR SCD EXPR KNEE LG,30901010,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,2508.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,1131.064,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.064,Percent of Total Billed Charges,32% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,1454.224,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,1454.224,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,1454.224,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,489.616,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,30.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,171.928,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,62.504,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,29.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,229.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,104.96,
POWERPICC SOLO PROVENA CATH 4F,30901011,CDM,271,RC,,,Outpatient,,,1050.3,630.18,,630.18,60,,325.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.08,28,,2070.944,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,378.11,36,,2662.64,Percent of Total Billed Charges,36% of Total Billed Charges,378.11,36,,2662.64,Percent of Total Billed Charges,36% Total Bille Charges,378.11,36,,2662.64,Percent of Total Billed Charges,36% of Total Billed Charges,630.18,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,151.45,14.42,,26.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.73,75,,157.832,Percent of Total Billed Charges,75% of Total Billed Charges,525.15,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525.15,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.21,70,,894.448,Percent of Total Billed Charges,70% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,25.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.3,100,,210.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,1050.3,
TRAY URINE METER SURESTEP 16FR,30901012,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,703.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,398.584,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,512.464,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,512.464,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,512.464,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,34.96,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,25.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,135.672,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,90.448,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,90.448,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,90.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,401.496,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,24.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,180.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,135.92,
WAFFLE SEAT CUSHION 17X17X2,30901013,CDM,271,RC,,,Outpatient,,,350.44,210.26,,210.26,60,,315.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.12,28,,56.112,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,126.16,36,,72.144,Percent of Total Billed Charges,36% of Total Billed Charges,126.16,36,,72.144,Percent of Total Billed Charges,36% Total Bille Charges,126.16,36,,72.144,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,60,,60.304,Percent of Total Billed Charges,60% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,50.53,14.42,,24.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.83,75,,131.448,Percent of Total Billed Charges,75% of Total Billed Charges,175.22,50,,105.224,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.22,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.31,70,,131.544,Percent of Total Billed Charges,70% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.44,100,,175.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,350.44,
DRSG FM GRNFM VAC 18X12/5 MED,30901014,CDM,272,RC,,,Outpatient,,,286.54,171.92,,171.92,60,,274.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,28,,322.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,103.15,36,,414.976,Percent of Total Billed Charges,36% of Total Billed Charges,103.15,36,,414.976,Percent of Total Billed Charges,36% Total Bille Charges,103.15,36,,414.976,Percent of Total Billed Charges,36% of Total Billed Charges,171.92,60,,223.792,Percent of Total Billed Charges,60% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,14.42,,24.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.91,75,,127.296,Percent of Total Billed Charges,75% of Total Billed Charges,143.27,50,,90.448,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.27,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.58,70,,90.664,Percent of Total Billed Charges,70% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.54,100,,169.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,286.54,
SPONGE TOPICAL HEMOSTATIC 3.8 CM LENGTH 3.8 CM WID,30901015,CDM,271,RC,,,Outpatient,,,263.05,157.83,,157.83,60,,2683.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.65,28,,70.12,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,94.7,36,,90.152,Percent of Total Billed Charges,36% of Total Billed Charges,94.7,36,,90.152,Percent of Total Billed Charges,36% Total Bille Charges,94.7,36,,90.152,Percent of Total Billed Charges,36% of Total Billed Charges,157.83,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.29,75,,125.184,Percent of Total Billed Charges,75% of Total Billed Charges,131.53,50,,87.632,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.53,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,131.53,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.14,70,,36.616,Percent of Total Billed Charges,70% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.05,100,,166.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,263.05,
DRESSING ALGINATE W4XL10IN ISLAND ANTIMICROBIAL W,30901016,CDM,271,RC,,,Outpatient,,,226.12,135.67,,135.67,60,,231.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.31,28,,54.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,81.4,36,,70.256,Percent of Total Billed Charges,36% of Total Billed Charges,81.4,36,,70.256,Percent of Total Billed Charges,36% Total Bille Charges,81.4,36,,70.256,Percent of Total Billed Charges,36% of Total Billed Charges,135.67,60,,19.928,Percent of Total Billed Charges,60% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.61,14.42,,17.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.59,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,113.06,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,113.06,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.06,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,113.06,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.28,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,31.66,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.12,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,226.12,
NEEDLE GUIDE KIT 21GX1-2CM,30901017,CDM,271,RC,,,Outpatient,,,219.08,131.45,,131.45,60,,384.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.34,28,,70.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,78.87,36,,91.048,Percent of Total Billed Charges,36% of Total Billed Charges,78.87,36,,91.048,Percent of Total Billed Charges,36% Total Bille Charges,78.87,36,,91.048,Percent of Total Billed Charges,36% of Total Billed Charges,131.45,60,,38.624,Percent of Total Billed Charges,60% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,31.59,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.31,75,,90.144,Percent of Total Billed Charges,75% of Total Billed Charges,109.54,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.54,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,109.54,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.36,70,,31.872,Percent of Total Billed Charges,70% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.08,100,,120.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,219.08,
DRSG FM GRNFM TRAC 15X10CM,30901018,CDM,271,RC,,,Outpatient,,,212.16,127.30,,127.3,60,,4699.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.4,28,,62.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,76.38,36,,79.816,Percent of Total Billed Charges,36% of Total Billed Charges,76.38,36,,79.816,Percent of Total Billed Charges,36% Total Bille Charges,76.38,36,,79.816,Percent of Total Billed Charges,36% of Total Billed Charges,127.3,60,,1084.44,Percent of Total Billed Charges,60% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.59,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.12,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,106.08,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.51,70,,29.52,Percent of Total Billed Charges,70% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.16,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,212.16,
MATTRESS WFL OVRLAY 75X30X3IN,30901019,CDM,271,RC,,,Outpatient,,,208.64,125.18,,125.18,60,,1752.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.42,28,,263.696,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.072,Percent of Total Billed Charges,32% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,75.11,36,,339.032,Percent of Total Billed Charges,36% of Total Billed Charges,75.11,36,,339.032,Percent of Total Billed Charges,36% Total Bille Charges,75.11,36,,339.032,Percent of Total Billed Charges,36% of Total Billed Charges,125.18,60,,4457.952,Percent of Total Billed Charges,60% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,30.09,14.42,,14.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.48,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,104.32,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.32,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.05,70,,18.736,Percent of Total Billed Charges,70% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.64,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,208.64,
SENSOR CHAIR,30901020,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,996.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,1877.072,Percent of Total Billed Charges,28% of Total Billed Charges,0.05,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,2413.384,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,2413.384,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,2413.384,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,1458.6,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,12.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,74.44,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,90.384,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,99.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,163.44,
COVER DRSNG ADH 10X12IN CLR LF,30901021,CDM,271,RC,,,Outpatient,,,150.24,90.14,,90.14,60,,435.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.07,28,,77.584,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,54.09,36,,99.752,Percent of Total Billed Charges,36% of Total Billed Charges,54.09,36,,99.752,Percent of Total Billed Charges,36% Total Bille Charges,54.09,36,,99.752,Percent of Total Billed Charges,36% of Total Billed Charges,90.14,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14.42,,12.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.68,75,,66.336,Percent of Total Billed Charges,75% of Total Billed Charges,75.12,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.12,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.17,70,,1758.12,Percent of Total Billed Charges,70% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,11.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.24,100,,88.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,150.24,
"BINDER ABDOMINAL, TRI-PANEL SIZE L AND XL 46 TO 62",30901022,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,668.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,859.68,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,859.68,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,859.68,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,11.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,64.032,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,42.688,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,42.688,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,42.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,400.968,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,11.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,85.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,138.56,
BINDER ABDOMINAL 45 IN CIRCUMFERENCE 9 IN WIDTH LA,30901023,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,1011.36,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,1300.32,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,1300.32,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,1300.32,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,737.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,10.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,60.72,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,40.48,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,40.48,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,40.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,10.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,80.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,138.56,
DRESSING ALGINATE RECTANGLE ISLAND 4 INCH LENGTH 6,30901024,CDM,271,RC,,,Outpatient,,,124.06,74.44,,74.44,60,,1316.72,Percent of Total Billed Charges,60% of Total Billed Charges,55.83,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.74,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,44.66,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,44.66,36,,388.8,Percent of Total Billed Charges,36% Total Bille Charges,44.66,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,74.44,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.06,100,,459.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14.42,,9.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.05,75,,54.184,Percent of Total Billed Charges,75% of Total Billed Charges,62.03,50,,42.688,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.03,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.84,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.06,100,,72.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,124.06,
NOVAPLUS PEEK-A-BOO MITTS,30901025,CDM,271,RC,,,Outpatient,,,110.56,66.34,,66.34,60,,5060.384,Percent of Total Billed Charges,60% of Total Billed Charges,49.75,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,28,,29.84,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.08,Percent of Total Billed Charges,32% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,39.8,36,,38.36,Percent of Total Billed Charges,36% of Total Billed Charges,39.8,36,,38.36,Percent of Total Billed Charges,36% Total Bille Charges,39.8,36,,38.36,Percent of Total Billed Charges,36% of Total Billed Charges,66.34,60,,6335.12,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.56,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.94,14.42,,9.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,75,,49.2,Percent of Total Billed Charges,75% of Total Billed Charges,55.28,50,,40.48,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.28,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,70,,761.624,Percent of Total Billed Charges,70% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,9.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.56,100,,65.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,110.56,
DRESSING SURGICAL 4X4IN ISLAND ANTIMICROBIAL SILVE,30901026,CDM,271,RC,,,Outpatient,,,106.72,64.03,,64.03,60,,365.48,Percent of Total Billed Charges,60% of Total Billed Charges,48.02,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.88,28,,757.12,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.088,Percent of Total Billed Charges,32% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,38.42,36,,973.44,Percent of Total Billed Charges,36% of Total Billed Charges,38.42,36,,973.44,Percent of Total Billed Charges,36% Total Bille Charges,38.42,36,,973.44,Percent of Total Billed Charges,36% of Total Billed Charges,64.03,60,,384.44,Percent of Total Billed Charges,60% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.72,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.39,14.42,,9.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.04,75,,49.2,Percent of Total Billed Charges,75% of Total Billed Charges,53.36,50,,36.12,Percent of Total Billed Charges,50% of Total Billed Charges,53.36,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.36,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,53.36,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.7,70,,571.216,Percent of Total Billed Charges,70% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.72,100,,65.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,106.72,
SPLINT TRAC BOOT LEG UN FM BKS,30901027,CDM,271,RC,,,Outpatient,,,101.2,60.72,,60.72,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,45.54,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.34,28,,139.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.088,Percent of Total Billed Charges,32% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,36.43,36,,179.712,Percent of Total Billed Charges,36% of Total Billed Charges,36.43,36,,179.712,Percent of Total Billed Charges,36% Total Bille Charges,36.43,36,,179.712,Percent of Total Billed Charges,36% of Total Billed Charges,60.72,60,,290.664,Percent of Total Billed Charges,60% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.2,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.59,14.42,,79.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.9,75,,49.144,Percent of Total Billed Charges,75% of Total Billed Charges,50.6,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,50.6,50,,32.76,Percent of Total Billed Charges,50% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.6,50,,32.76,Percent of Total Billed Charges,50% of Total Billed Charges,50.6,50,,32.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.84,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.2,100,,65.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,101.2,
PAD HET THER MAX-THM 16X22IN,30901028,CDM,271,RC,,,Outpatient,,,90.3,54.18,,54.18,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,40.64,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.28,28,,120.96,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.088,Percent of Total Billed Charges,32% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,32.51,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,32.51,36,,155.52,Percent of Total Billed Charges,36% Total Bille Charges,32.51,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,54.18,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.3,100,,108,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,13.02,14.42,,17.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.73,75,,411.624,Percent of Total Billed Charges,75% of Total Billed Charges,45.15,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.15,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.15,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,45.15,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.21,70,,40.792,Percent of Total Billed Charges,70% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.64,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,100,,548.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,90.3,
BRACE ORTHOPEDIC L8IN FOR 10IN WRIST UNIVERSAL RIG,30901029,CDM,271,RC,,,Outpatient,,,82,49.20,,49.2,60,,14.008,Percent of Total Billed Charges,60% of Total Billed Charges,36.9,45,,131.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.96,28,,123.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.096,Percent of Total Billed Charges,32% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.52,36,,159.408,Percent of Total Billed Charges,36% of Total Billed Charges,29.52,36,,159.408,Percent of Total Billed Charges,36% Total Bille Charges,29.52,36,,159.408,Percent of Total Billed Charges,36% of Total Billed Charges,49.2,60,,5628.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,108,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14.42,,52.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,75,,90.84,Percent of Total Billed Charges,75% of Total Billed Charges,41,50,,32.76,Percent of Total Billed Charges,50% of Total Billed Charges,41,50,,60.56,Percent of Total Billed Charges,50% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41,50,,60.56,Percent of Total Billed Charges,50% of Total Billed Charges,41,50,,60.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.4,70,,70.36,Percent of Total Billed Charges,70% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,51.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82,100,,121.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,82,
SPLINT WRIST UNIVERSAL LEFT QUICK-FIT II,30901030,CDM,271,RC,,,Outpatient,,,82,49.20,,49.2,60,,2557.152,Percent of Total Billed Charges,60% of Total Billed Charges,36.9,45,,133.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.96,28,,178.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.06,32,,0.096,Percent of Total Billed Charges,32% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,29.52,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,29.52,36,,228.96,Percent of Total Billed Charges,36% Total Bille Charges,29.52,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,49.2,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,100,,108,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14.42,,47.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,75,,275.312,Percent of Total Billed Charges,75% of Total Billed Charges,41,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,41,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,41,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.4,70,,284.824,Percent of Total Billed Charges,70% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14,,45.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82,100,,367.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,82,
RETAINER DRESSING TUBULAR SIZE 7 LATEX FREE 900 IN,30901031,CDM,271,RC,,,Outpatient,,,81.9,49.14,,49.14,60,,25.032,Percent of Total Billed Charges,60% of Total Billed Charges,36.86,45,,291.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.93,28,,409.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.096,Percent of Total Billed Charges,32% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,36,,527.04,Percent of Total Billed Charges,36% of Total Billed Charges,29.48,36,,527.04,Percent of Total Billed Charges,36% Total Bille Charges,29.48,36,,527.04,Percent of Total Billed Charges,36% of Total Billed Charges,49.14,60,,1202.88,Percent of Total Billed Charges,60% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.9,100,,292.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.81,14.42,,80.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.43,75,,246.064,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,50,,60.56,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.95,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.33,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,77.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.9,100,,328.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,81.9,
MIDLINE MAX  PROVENA 4F,30901032,CDM,271,RC,,,Outpatient,,,686.04,411.62,,411.62,60,,71.768,Percent of Total Billed Charges,60% of Total Billed Charges,308.72,45,,297.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.09,28,,60.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.096,Percent of Total Billed Charges,32% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,246.97,36,,77.184,Percent of Total Billed Charges,36% of Total Billed Charges,246.97,36,,77.184,Percent of Total Billed Charges,36% Total Bille Charges,246.97,36,,77.184,Percent of Total Billed Charges,36% of Total Billed Charges,411.62,60,,313.096,Percent of Total Billed Charges,60% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.04,100,,297.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,98.93,14.42,,61.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.53,75,,416.8,Percent of Total Billed Charges,75% of Total Billed Charges,343.02,50,,183.544,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.02,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.23,70,,23.248,Percent of Total Billed Charges,70% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,60.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,686.04,100,,555.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,686.04,
HIP KIT (526636),30901034,CDM,271,RC,,,Outpatient,,,151.4,90.84,,90.84,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,68.13,45,,275.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.39,28,,106.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.096,Percent of Total Billed Charges,32% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,36,,136.8,Percent of Total Billed Charges,36% of Total Billed Charges,54.5,36,,136.8,Percent of Total Billed Charges,36% Total Bille Charges,54.5,36,,136.8,Percent of Total Billed Charges,36% of Total Billed Charges,90.84,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.4,100,,648.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.83,14.42,,124.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.55,75,,321.496,Percent of Total Billed Charges,75% of Total Billed Charges,75.7,50,,164.048,Percent of Total Billed Charges,50% of Total Billed Charges,75.7,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.7,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,75.7,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.98,70,,45.056,Percent of Total Billed Charges,70% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,121.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.4,100,,428.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,151.4,
CHEMO ADMIN SQ OR IM,31200001,CDM,331,RC,96401,HCPCS,Outpatient,,,458.85,275.31,,47.67,100,,61.912,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,297.36,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,268.8,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,345.6,Fee Schedule,360% of BCBS POS Rate,217.69,360,,345.6,Fee schedule,360% of BCBS PPO Rate,217.69,360,,345.6,Fee Schedule,360% of BCBS Traditional Rate,674,100,,730.08,Case Rate,Pays based on per visit rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,660.792,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,66.17,14.42,,51.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,344.14,75,,649.152,Percent of Total Billed Charges,75% of Total Billed Charges,229.43,50,,277.872,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,229.43,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,1380.2,Case Rate,Pays based on per visit rate,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14,,50.28,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,458.85,100,,865.536,Percent of Total Billed Charges,100% of Total Billed Charges,47.67,674,
CHEMO ADMIN SQ OR IM HORMONAL,31200002,CDM,331,RC,96402,HCPCS,Outpatient,,,410.11,246.07,,19.18,100,,357.208,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,366.512,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,275.216,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,353.848,Fee Schedule,360% of BCBS POS Rate,217.69,360,,353.848,Fee schedule,360% of BCBS PPO Rate,217.69,360,,353.848,Fee Schedule,360% of BCBS Traditional Rate,674,100,,2677.192,Case Rate,Pays based on per visit rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,611.64,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,59.14,14.42,,64.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,307.58,75,,269.368,Percent of Total Billed Charges,75% of Total Billed Charges,205.06,50,,214.336,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,205.06,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,5673.76,Case Rate,Pays based on per visit rate,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,57.42,14,,62.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,410.11,100,,359.16,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,674,
IV PUSH CHEMO INITIAL MED,31200003,CDM,335,RC,96409,HCPCS,Outpatient,,,694.67,416.80,,65.73,100,,67.272,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,340.848,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,307.78,280,,58.464,Fee Schedule,280% of BCBS BULE Fee Schedule,351.74,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,395.71,360,,75.168,Fee Schedule,360% of BCBS POS Rate,395.71,360,,75.168,Fee schedule,360% of BCBS PPO Rate,395.71,360,,75.168,Fee Schedule,360% of BCBS Traditional Rate,674,100,,2221.728,Case Rate,Pays based on per visit rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,660.792,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,100.17,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,521,75,,336.904,Percent of Total Billed Charges,75% of Total Billed Charges,347.34,50,,432.768,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,1856.4,Case Rate,Pays based on per visit rate,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,97.25,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,694.67,100,,449.2,Percent of Total Billed Charges,100% of Total Billed Charges,65.73,694.67,
IV PUSH CHEMO EA AD MED,31200004,CDM,335,RC,96411,HCPCS,Outpatient,,,535.83,321.50,,35.93,100,,60.4,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,305.048,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,166.49,280,,2647.68,Fee Schedule,280% of BCBS BULE Fee Schedule,190.27,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,214.06,360,,3404.16,Fee Schedule,360% of BCBS POS Rate,214.06,360,,3404.16,Fee schedule,360% of BCBS PPO Rate,214.06,360,,3404.16,Fee Schedule,360% of BCBS Traditional Rate,674,100,,4437.736,Case Rate,Pays based on per visit rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,814.464,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,77.27,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,401.87,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,267.92,50,,179.584,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,267.92,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,267.92,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,84,Case Rate,Pays based on per visit rate,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,75.02,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,535.83,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,35.93,674,
IV INFUSION CHEMO 1ST HR,31200005,CDM,335,RC,96413,HCPCS,Outpatient,,,1081.92,649.15,,85.85,100,,73.32,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,374.144,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,400.62,280,,2216.032,Fee Schedule,280% of BCBS BULE Fee Schedule,457.86,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,515.09,360,,2849.184,Fee Schedule,360% of BCBS POS Rate,515.09,360,,2849.184,Fee schedule,360% of BCBS PPO Rate,515.09,360,,2849.184,Fee Schedule,360% of BCBS Traditional Rate,674,100,,854.104,Case Rate,Pays based on per visit rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,757.44,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,156.01,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,811.44,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,540.96,50,,224.6,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,540.96,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,540.96,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,210,Case Rate,Pays based on per visit rate,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,151.47,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.92,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,85.85,1081.92,
IV INFUSION CHEMO EA AD HR,31200006,CDM,335,RC,96415,HCPCS,Outpatient,,,448.95,269.37,,18.16,100,,3087.336,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,135,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,280,,227.52,Fee Schedule,280% of BCBS BULE Fee Schedule,99.17,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,111.56,360,,292.528,Fee Schedule,360% of BCBS POS Rate,111.56,360,,292.528,Fee schedule,360% of BCBS PPO Rate,111.56,360,,292.528,Fee Schedule,360% of BCBS Traditional Rate,674,100,,120.24,Case Rate,Pays based on per visit rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,677.88,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.74,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,336.71,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,224.48,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.48,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,224.48,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,860.432,Case Rate,Pays based on per visit rate,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,62.85,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,448.95,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,18.16,674,
CHEMO INF EACH ADD SEQ 1ST HR,31200007,CDM,335,RC,96417,HCPCS,Outpatient,,,561.5,336.90,,41.64,100,,18663.336,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,284.344,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,193.76,280,,651.848,Fee Schedule,280% of BCBS BULE Fee Schedule,221.44,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,249.12,360,,838.096,Fee Schedule,360% of BCBS POS Rate,249.12,360,,838.096,Fee schedule,360% of BCBS PPO Rate,249.12,360,,838.096,Fee Schedule,360% of BCBS Traditional Rate,674,100,,691.632,Case Rate,Pays based on per visit rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,831.432,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,80.97,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,421.13,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,280.75,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,280.75,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,280.75,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,210,Case Rate,Pays based on per visit rate,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.61,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,561.5,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,41.64,674,
IV INFUSION HYDRATION 1ST HR,31200008,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,18663.336,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,145.256,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,500.64,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,0.096,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,643.68,Fee Schedule,360% of BCBS POS Rate,138.82,360,,643.68,Fee schedule,360% of BCBS PPO Rate,138.82,360,,643.68,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,150.248,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,300,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,8062.88,Case Rate,Pays based on per visit rate,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,31200009,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,11777.336,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,216,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,607.936,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,781.632,Fee Schedule,360% of BCBS POS Rate,49.28,360,,781.632,Fee schedule,360% of BCBS PPO Rate,49.28,360,,781.632,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,117.096,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,631.872,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,489.28,Case Rate,Pays based on per visit rate,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,31200010,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,16991.336,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,145.256,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,35.216,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,45.272,Fee Schedule,360% of BCBS POS Rate,262.08,360,,45.272,Fee schedule,360% of BCBS PPO Rate,262.08,360,,45.272,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,151.752,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,322.784,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,369.936,Case Rate,Pays based on per visit rate,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,31200011,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,16991.336,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,223.656,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,1634.216,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,2101.136,Fee Schedule,360% of BCBS POS Rate,79.13,360,,2101.136,Fee schedule,360% of BCBS PPO Rate,79.13,360,,2101.136,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,133.032,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,480,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,7280,Case Rate,Pays based on per visit rate,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV INF THERAP ADDL SEQUENTIAL,31200012,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,98.504,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,89.104,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,56,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,72,Fee Schedule,360% of BCBS POS Rate,114.16,360,,72,Fee schedule,360% of BCBS PPO Rate,114.16,360,,72,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,517.968,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,322.784,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,7163.52,Case Rate,Pays based on per visit rate,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,31200013,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,16991.336,Fee Schedule,100% of Aetna Fee Schedule,116.87,45,,85.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,82.208,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,105.696,Fee Schedule,360% of BCBS POS Rate,76.54,360,,105.696,Fee schedule,360% of BCBS PPO Rate,76.54,360,,105.696,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,3687.112,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.72,100,,497.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,110.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,260.4,Case Rate,Pays based on per visit rate,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
INJECTION SQ OR IM,31200014,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,19259.096,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,135,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,361.192,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,464.392,Fee Schedule,360% of BCBS POS Rate,217.69,360,,464.392,Fee schedule,360% of BCBS PPO Rate,217.69,360,,464.392,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,166.256,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,198,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,572.4,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,1403.36,Case Rate,Pays based on per visit rate,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,763.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
IV PUSH THER INITIAL MED,31200015,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,25471.896,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,76.504,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,870.688,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,0.104,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,1119.456,Fee Schedule,360% of BCBS POS Rate,142.7,360,,1119.456,Fee schedule,360% of BCBS PPO Rate,142.7,360,,1119.456,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,1313.4,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,189.312,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,365.28,Case Rate,Pays based on per visit rate,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA ADD NEW MED,31200016,CDM,940,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,13344.616,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,126.504,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,293.664,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,0.112,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,377.568,Fee Schedule,360% of BCBS POS Rate,60.98,360,,377.568,Fee schedule,360% of BCBS PPO Rate,60.98,360,,377.568,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,1986.6,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,300,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,42.496,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,369.048,Case Rate,Pays based on per visit rate,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,56.664,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,31200017,CDM,940,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,564.448,Fee Schedule,100% of Aetna Fee Schedule,112.38,45,,189.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,858.456,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.112,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,1103.728,Fee Schedule,360% of BCBS POS Rate,85.64,360,,1103.728,Fee schedule,360% of BCBS PPO Rate,85.64,360,,1103.728,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,594,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.73,100,,170,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,851.76,Case Rate,Pays based on per visit rate,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
EMERGENT ET INTUBATION,31200018,CDM,761,RC,31500,HCPCS,Outpatient,,,954,572.40,,134,100,,1064.288,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,128.976,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,267.12,28,,195.712,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.112,Percent of Total Billed Charges,32% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,343.44,36,,251.632,Percent of Total Billed Charges,36% of Total Billed Charges,343.44,36,,251.632,Percent of Total Billed Charges,36% Total Bille Charges,343.44,36,,251.632,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,63.936,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,281.112,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,137.57,14.42,,24.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,715.5,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,477,50,,28.336,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,477,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,667.8,70,,3407.328,Percent of Total Billed Charges,70% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,23.368,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,954,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1184.5,
IMMUNIZATION INJECT INFLUENZA,31200019,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,2009.408,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,174.136,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,131.176,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,0.12,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,168.656,Fee Schedule,360% of BCBS POS Rate,85.64,360,,168.656,Fee schedule,360% of BCBS PPO Rate,85.64,360,,168.656,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,1487.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,421.72,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,17.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,125.184,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,2827.656,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,16.68,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,166.912,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IMMUNIZATION INJECT PNEUMOVAX,31200020,CDM,771,RC,G0009,HCPCS,Outpatient,,,70.83,42.50,,10.31,100,,5283.888,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,372.792,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,1494.968,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,0.12,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,172.55,360,,1922.104,Fee Schedule,360% of BCBS POS Rate,172.55,360,,1922.104,Fee schedule,360% of BCBS PPO Rate,172.55,360,,1922.104,Fee Schedule,360% of BCBS Traditional Rate,42.5,60,,299.52,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,286.616,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,17.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.12,75,,89.376,Percent of Total Billed Charges,75% of Total Billed Charges,35.42,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.42,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,35.42,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,70,,5177.36,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,16.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,100,,119.168,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,172.55,
BINDER ABDOMINAL 45 IN CIRCUMFERENCE 9 IN WIDTH LA,31200021,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,7957.328,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,68.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,1009.536,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.12,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,1297.968,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,1297.968,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,1297.968,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,386.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,93.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,90.144,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,83.456,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,996.456,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,120.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,138.56,
BINDER ABDOMINAL 46 TO 62 IN CIRCUMFERENCE 9 IN WI,31200022,CDM,271,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,12345.888,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,1632.12,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.12,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,2098.44,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,2098.44,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,2098.44,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,265.68,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,828.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,82.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,487.832,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,59.584,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,140.28,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,650.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,138.56,
MATTRESS WFL OVRLAY 75X30X3IN,31200023,CDM,271,RC,,,Outpatient,,,208.64,125.18,,125.18,60,,19753.728,Percent of Total Billed Charges,60% of Total Billed Charges,93.89,45,,107.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.42,28,,356.16,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,75.11,36,,457.92,Percent of Total Billed Charges,36% of Total Billed Charges,75.11,36,,457.92,Percent of Total Billed Charges,36% Total Bille Charges,75.11,36,,457.92,Percent of Total Billed Charges,36% of Total Billed Charges,125.18,60,,381.6,Percent of Total Billed Charges,60% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.64,100,,153.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,30.09,14.42,,53.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.48,75,,429.608,Percent of Total Billed Charges,75% of Total Billed Charges,104.32,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.32,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.05,70,,806.904,Percent of Total Billed Charges,70% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,29.21,14,,52.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.64,100,,572.808,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,208.64,
CUSHION WHEELCHAIR,31200024,CDM,271,RC,,,Outpatient,,,148.96,89.38,,89.38,60,,32501.408,Percent of Total Billed Charges,60% of Total Billed Charges,67.03,45,,110.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.71,28,,1494.904,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,53.63,36,,1922.016,Percent of Total Billed Charges,36% of Total Billed Charges,53.63,36,,1922.016,Percent of Total Billed Charges,36% Total Bille Charges,53.63,36,,1922.016,Percent of Total Billed Charges,36% of Total Billed Charges,89.38,60,,878.4,Percent of Total Billed Charges,60% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.96,100,,108,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,21.48,14.42,,53.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.72,75,,280.8,Percent of Total Billed Charges,75% of Total Billed Charges,74.48,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.27,70,,175.288,Percent of Total Billed Charges,70% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.85,14,,51.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.96,100,,374.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,148.96,
COVER DRSNG ADH 10X12IN CLR LF,31200025,CDM,271,RC,,,Outpatient,,,150.24,90.14,,90.14,60,,56720.768,Percent of Total Billed Charges,60% of Total Billed Charges,67.61,45,,84.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.07,28,,486.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,54.09,36,,624.96,Percent of Total Billed Charges,36% of Total Billed Charges,54.09,36,,624.96,Percent of Total Billed Charges,36% Total Bille Charges,54.09,36,,624.96,Percent of Total Billed Charges,36% of Total Billed Charges,90.14,60,,128.64,Percent of Total Billed Charges,60% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.24,100,,238.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14.42,,24.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.68,75,,275.848,Percent of Total Billed Charges,75% of Total Billed Charges,75.12,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,183.904,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.12,50,,183.904,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,183.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.17,70,,136.616,Percent of Total Billed Charges,70% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,23.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.24,100,,367.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,150.24,
TRACHEOTOMY TUBE CHANGE,31200026,CDM,761,RC,31502,HCPCS,Outpatient,,,813.05,487.83,,33.19,100,,3439.408,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,108,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,227.65,28,,800.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,292.7,36,,1029.752,Percent of Total Billed Charges,36% of Total Billed Charges,292.7,36,,1029.752,Percent of Total Billed Charges,36% Total Bille Charges,292.7,36,,1029.752,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,228,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,246,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,117.24,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,609.79,75,,127.296,Percent of Total Billed Charges,75% of Total Billed Charges,406.53,50,,187.2,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,406.53,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,569.14,70,,177.048,Percent of Total Billed Charges,70% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,813.05,100,,169.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1184.5,
LARYNGOSCOPYFLEX/RIGID DX,31200027,CDM,761,RC,31575,HCPCS,Outpatient,,,716.01,429.61,,63.82,100,,118.2,Fee Schedule,100% of Aetna Fee Schedule,272.58,150,,48.6,Fee Schedule ,150% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,28,,141.256,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,257.76,36,,181.616,Percent of Total Billed Charges,36% of Total Billed Charges,257.76,36,,181.616,Percent of Total Billed Charges,36% Total Bille Charges,257.76,36,,181.616,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,576,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,188.6,Fee Schedule,100% of CMS OPPS Rate,163.55,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,236.24,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,103.25,14.42,,33.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,537.01,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,358.01,50,,183.904,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.01,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,272.58,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.21,70,,155.208,Percent of Total Billed Charges,70% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,32.096,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.01,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,716.01,
HEEL PROTECTOR W/FOOT AND LEG,31200028,CDM,271,RC,,,Outpatient,,,468,280.80,,280.8,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,45,,37.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.04,28,,186.144,Percent of Total Billed Charges,28% of Total Billed Charges,0.07,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,168.48,36,,239.328,Percent of Total Billed Charges,36% of Total Billed Charges,168.48,36,,239.328,Percent of Total Billed Charges,36% Total Bille Charges,168.48,36,,239.328,Percent of Total Billed Charges,36% of Total Billed Charges,280.8,60,,589.752,Percent of Total Billed Charges,60% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468,100,,240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,14.42,,14.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351,75,,171.928,Percent of Total Billed Charges,75% of Total Billed Charges,234,50,,84.864,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,234,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.6,70,,659.232,Percent of Total Billed Charges,70% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,65.52,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468,100,,229.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,468,
THORACENTESIS TY ARROW-CLARKE,31200029,CDM,271,RC,,,Outpatient,,,459.75,275.85,,275.85,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,206.89,45,,83.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.73,28,,21.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.128,Percent of Total Billed Charges,32% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,165.51,36,,28.272,Percent of Total Billed Charges,36% of Total Billed Charges,165.51,36,,28.272,Percent of Total Billed Charges,36% Total Bille Charges,165.51,36,,28.272,Percent of Total Billed Charges,36% of Total Billed Charges,275.85,60,,125.28,Percent of Total Billed Charges,60% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.75,100,,108,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,66.3,14.42,,52.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.81,75,,74.44,Percent of Total Billed Charges,75% of Total Billed Charges,229.88,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,229.88,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.88,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,229.88,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.83,70,,4692.688,Percent of Total Billed Charges,70% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,64.37,14,,50.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.75,100,,99.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,459.75,
DRSG FM GRNFM TRAC 15X10CM,31200030,CDM,271,RC,,,Outpatient,,,212.16,127.30,,127.3,60,,66.768,Percent of Total Billed Charges,60% of Total Billed Charges,95.47,45,,146.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.4,28,,126.784,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,76.38,36,,163.008,Percent of Total Billed Charges,36% of Total Billed Charges,76.38,36,,163.008,Percent of Total Billed Charges,36% Total Bille Charges,76.38,36,,163.008,Percent of Total Billed Charges,36% of Total Billed Charges,127.3,60,,5673.6,Percent of Total Billed Charges,60% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.16,100,,82.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,30.59,14.42,,37.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.12,75,,270.512,Percent of Total Billed Charges,75% of Total Billed Charges,106.08,50,,114.616,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,106.08,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.51,70,,193.96,Percent of Total Billed Charges,70% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,14,,36.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.16,100,,360.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,212.16,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESIV,31200031,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,53.608,Percent of Total Billed Charges,60% of Total Billed Charges,46.08,45,,179.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,313.944,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,403.64,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,403.64,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,403.64,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,4748.64,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.4,100,,185.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,15.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,194.784,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,49.624,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,1671.6,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,259.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,102.4,
DRSG FM GRNFM VAC 18X12/5 MED,31200033,CDM,271,RC,,,Outpatient,,,286.54,171.92,,171.92,60,,355.456,Percent of Total Billed Charges,60% of Total Billed Charges,128.94,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,28,,1607.424,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,103.15,36,,2066.688,Percent of Total Billed Charges,36% of Total Billed Charges,103.15,36,,2066.688,Percent of Total Billed Charges,36% Total Bille Charges,103.15,36,,2066.688,Percent of Total Billed Charges,36% of Total Billed Charges,171.92,60,,487.544,Percent of Total Billed Charges,60% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.54,100,,325.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.91,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,143.27,50,,180.344,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.27,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,143.27,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.58,70,,2528.4,Percent of Total Billed Charges,70% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.12,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.54,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,286.54,
DRESSING ALGINATE RECTANGLE ISLAND 4 INCH LENGTH 6,31200034,CDM,271,RC,,,Outpatient,,,124.06,74.44,,74.44,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,55.83,45,,169.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.74,28,,1863,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,44.66,36,,2395.288,Percent of Total Billed Charges,36% of Total Billed Charges,44.66,36,,2395.288,Percent of Total Billed Charges,36% Total Bille Charges,44.66,36,,2395.288,Percent of Total Billed Charges,36% of Total Billed Charges,74.44,60,,1396.824,Percent of Total Billed Charges,60% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.06,100,,399.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14.42,,40.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.05,75,,64.416,Percent of Total Billed Charges,75% of Total Billed Charges,62.03,50,,129.856,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.03,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,62.03,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.84,70,,756,Percent of Total Billed Charges,70% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,39.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.06,100,,85.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,124.06,
TUBE FEEDING 10FR FFIN CORTAK,31200035,CDM,271,RC,,,Outpatient,,,450.85,270.51,,270.51,60,,49.856,Percent of Total Billed Charges,60% of Total Billed Charges,202.88,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.24,28,,51.888,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,162.31,36,,66.712,Percent of Total Billed Charges,36% of Total Billed Charges,162.31,36,,66.712,Percent of Total Billed Charges,36% Total Bille Charges,162.31,36,,66.712,Percent of Total Billed Charges,36% of Total Billed Charges,270.51,60,,983.4,Percent of Total Billed Charges,60% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.85,100,,400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,65.01,14.42,,23.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.14,75,,210.264,Percent of Total Billed Charges,75% of Total Billed Charges,225.43,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.43,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,225.43,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.6,70,,74.592,Percent of Total Billed Charges,70% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,63.12,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.85,100,,280.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,450.85,
CUSHION WAFFLE WHEELCHAIR,31200036,CDM,271,RC,,,Outpatient,,,324.64,194.78,,194.78,60,,135.632,Percent of Total Billed Charges,60% of Total Billed Charges,146.09,45,,201.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.9,28,,579.848,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,36,,745.52,Percent of Total Billed Charges,36% of Total Billed Charges,116.87,36,,745.52,Percent of Total Billed Charges,36% Total Bille Charges,116.87,36,,745.52,Percent of Total Billed Charges,36% of Total Billed Charges,194.78,60,,1302.72,Percent of Total Billed Charges,60% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.64,100,,375.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,46.81,14.42,,25.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.48,75,,123.888,Percent of Total Billed Charges,75% of Total Billed Charges,162.32,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.32,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,162.32,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.25,70,,1892.8,Percent of Total Billed Charges,70% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,45.45,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.64,100,,165.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,324.64,
RESUSC MASK ADLT RESVR MED,31200037,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,95.92,Percent of Total Billed Charges,60% of Total Billed Charges,59.8,45,,194.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,75.456,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.88,100,,400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,306.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,133.808,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,140.176,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,89.208,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,89.208,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,89.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,349.44,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,178.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,132.88,
KIT DRESSING CHANGE POWERGLIDE,31200038,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,121.744,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,182.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,78.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,100.8,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,100.8,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,100.8,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,3501.888,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,100,,448.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,1596.504,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,302.4,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,2128.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,107.36,
WAFFLE SEAT CUSHION 17X17X2,31200039,CDM,271,RC,,,Outpatient,,,350.44,210.26,,210.26,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,157.7,45,,194.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.12,28,,446.992,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,126.16,36,,574.704,Percent of Total Billed Charges,36% of Total Billed Charges,126.16,36,,574.704,Percent of Total Billed Charges,36% Total Bille Charges,126.16,36,,574.704,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.44,100,,432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,50.53,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.83,75,,303.544,Percent of Total Billed Charges,75% of Total Billed Charges,175.22,50,,89.208,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.22,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,175.22,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.31,70,,309.96,Percent of Total Billed Charges,70% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,49.06,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.44,100,,404.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,350.44,
KIT PORT ACCESS CLEAR SEQUENCE CHANGE CUSTOM,31200040,CDM,271,RC,,,Outpatient,,,206.48,123.89,,123.89,60,,140.4,Percent of Total Billed Charges,60% of Total Billed Charges,92.92,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.81,28,,57.208,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.136,Percent of Total Billed Charges,32% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,74.33,36,,73.552,Percent of Total Billed Charges,36% of Total Billed Charges,74.33,36,,73.552,Percent of Total Billed Charges,36% Total Bille Charges,74.33,36,,73.552,Percent of Total Billed Charges,36% of Total Billed Charges,123.89,60,,773.984,Percent of Total Billed Charges,60% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.48,100,,406.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.77,14.42,,12.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.86,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,103.24,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.24,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.54,70,,445.2,Percent of Total Billed Charges,70% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,12.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.48,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,206.48,
TRAY PICC DRSG,31200041,CDM,272,RC,,,Outpatient,,,223.01,133.81,,133.81,60,,156,Percent of Total Billed Charges,60% of Total Billed Charges,100.35,45,,351.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.44,28,,1208.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.144,Percent of Total Billed Charges,32% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.28,36,,1553.76,Percent of Total Billed Charges,36% of Total Billed Charges,80.28,36,,1553.76,Percent of Total Billed Charges,36% Total Bille Charges,80.28,36,,1553.76,Percent of Total Billed Charges,36% of Total Billed Charges,133.81,60,,1865.76,Percent of Total Billed Charges,60% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.01,100,,432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,32.16,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.26,75,,66.336,Percent of Total Billed Charges,75% of Total Billed Charges,111.51,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,111.51,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.51,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,111.51,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.11,70,,1024.8,Percent of Total Billed Charges,70% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.01,100,,88.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,223.01,
INSERT NON-TUNNEL CV CATH >5YO,31200042,CDM,761,RC,36556,HCPCS,Outpatient,,,2660.84,1596.50,,76.78,100,,174.048,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,328.992,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,745.04,28,,553.704,Percent of Total Billed Charges,28% of Total Billed Charges,0.08,32,,0.144,Percent of Total Billed Charges,32% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,957.9,36,,711.904,Percent of Total Billed Charges,36% of Total Billed Charges,957.9,36,,711.904,Percent of Total Billed Charges,36% Total Bille Charges,957.9,36,,711.904,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,629.28,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,480,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,383.69,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1995.63,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,1330.42,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.42,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.59,70,,150.08,Percent of Total Billed Charges,70% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2660.84,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,4386.59,
KIT CATH CENTRAL VENOUS TRIPLE,31200043,CDM,272,RC,,,Outpatient,,,505.9,303.54,,303.54,60,,456.112,Percent of Total Billed Charges,60% of Total Billed Charges,227.66,45,,431.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.65,28,,123.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.144,Percent of Total Billed Charges,32% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,182.12,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,182.12,36,,158.208,Percent of Total Billed Charges,36% Total Bille Charges,182.12,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,303.54,60,,1839.552,Percent of Total Billed Charges,60% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.9,100,,781.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,72.95,14.42,,212.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.43,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,252.95,50,,44.224,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.95,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.13,70,,266,Percent of Total Billed Charges,70% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,205.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.9,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,505.9,
NOVAPLUS SENSOR CHAIR,31200044,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,1854.512,Percent of Total Billed Charges,60% of Total Billed Charges,73.55,45,,494.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,123.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.144,Percent of Total Billed Charges,32% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,158.208,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,419.384,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.44,100,,731.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,1102.864,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,672,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,1470.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,163.44,
NOVAPLUS PEEK-A-BOO MITTS,31200046,CDM,271,RC,,,Outpatient,,,110.56,66.34,,66.34,60,,206.824,Percent of Total Billed Charges,60% of Total Billed Charges,49.75,45,,470.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,28,,123.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.144,Percent of Total Billed Charges,32% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,39.8,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,39.8,36,,158.208,Percent of Total Billed Charges,36% Total Bille Charges,39.8,36,,158.208,Percent of Total Billed Charges,36% of Total Billed Charges,66.34,60,,281.088,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.56,100,,957.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.94,14.42,,145.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.92,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,55.28,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.28,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,55.28,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,70,,688.048,Percent of Total Billed Charges,70% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.56,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,110.56,
SLEEVE COMPR SCD,31200047,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,202.464,Percent of Total Billed Charges,60% of Total Billed Charges,47.23,45,,852.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,268.128,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.152,Percent of Total Billed Charges,32% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,344.736,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,344.736,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,344.736,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,3203.512,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.96,100,,1099.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,177.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,756.496,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,735.24,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,146.16,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,172.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,1008.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,104.96,
INSERT MIDLINE W/IMAGE > 5 YO,31200048,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,296.4,Fee Schedule,100% of Aetna Fee Schedule,1672.66,45,,63.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.152,Other,Not Seperately Reimbusable,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,1983.008,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3717.03,100,,1045.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,36.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,922.36,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,6619.2,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,1229.816,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
CHEST TUBE INSERTION,31200059,CDM,761,RC,32551,HCPCS,Outpatient,,,1838.1,1102.86,,146.85,100,,292.384,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,135,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,514.67,28,,564.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.152,Percent of Total Billed Charges,32% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,661.72,36,,725.184,Percent of Total Billed Charges,36% of Total Billed Charges,661.72,36,,725.184,Percent of Total Billed Charges,36% Total Bille Charges,661.72,36,,725.184,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,3205.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,1894.208,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,265.05,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1378.58,75,,189.352,Percent of Total Billed Charges,75% of Total Billed Charges,919.05,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,919.05,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,919.05,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,919.05,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1286.67,70,,5540.08,Percent of Total Billed Charges,70% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.33,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.1,100,,252.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,2204.01,
INSERT PICC CATH W/IMG>5 YO,31200067,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,362.456,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,59.488,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,251.768,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.152,Percent of Total Billed Charges,32% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,323.696,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,323.696,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,323.696,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,763.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,141.6,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,614.912,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,568.8,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,4892.5,
BONE MARROW BIOPSY(IES),31200075,CDM,761,RC,38221,HCPCS,Outpatient,,,1260.83,756.50,,67.48,100,,259.2,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,66.424,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,353.03,28,,614.464,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,453.9,36,,790.032,Percent of Total Billed Charges,36% of Total Billed Charges,453.9,36,,790.032,Percent of Total Billed Charges,36% Total Bille Charges,453.9,36,,790.032,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,3203.368,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,300,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,181.81,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,945.62,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,630.42,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,630.42,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,882.58,70,,1629.632,Percent of Total Billed Charges,70% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.83,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,2231.19,
PARACENTESIS WO IMAGING GUIDE,31200083,CDM,761,RC,49082,HCPCS,Outpatient,,,1537.27,922.36,,70.35,100,,377.368,Fee Schedule,100% of Aetna Fee Schedule,1247.49,150,,135,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,430.44,28,,1195.904,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,553.42,36,,1537.584,Percent of Total Billed Charges,36% of Total Billed Charges,553.42,36,,1537.584,Percent of Total Billed Charges,36% Total Bille Charges,553.42,36,,1537.584,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,1041.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,132.2,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,221.67,14.42,,81.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1152.95,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,768.64,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,768.64,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.09,70,,1251.6,Percent of Total Billed Charges,70% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,215.22,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1537.27,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,1537.27,
INSERT STRAIGHT CATHETER,31200091,CDM,761,RC,51701,HCPCS,Outpatient,,,315.59,189.35,,24.67,100,,327.464,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,135,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.37,28,,2432.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.09,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,113.61,36,,3127.624,Percent of Total Billed Charges,36% of Total Billed Charges,113.61,36,,3127.624,Percent of Total Billed Charges,36% Total Bille Charges,113.61,36,,3127.624,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,1573.232,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,147.6,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,45.51,14.42,,128.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,236.69,75,,424.48,Percent of Total Billed Charges,75% of Total Billed Charges,157.8,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,157.8,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,70,,1519.84,Percent of Total Billed Charges,70% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,124.632,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,315.59,100,,565.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,515,
INSERT FOLEY CATHETER,31200109,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,288,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,54,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,328.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,422.696,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,422.696,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,422.696,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,302.688,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,300,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,184.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,667.68,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,88.032,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,890.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,515,
POST VOID RESID BLADDER SCAN,31200117,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,963.336,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,54,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,302.264,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,388.624,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,388.624,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,388.624,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,398.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,300,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,133.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,282.984,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,4085.536,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,129.968,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,101.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,515,
LUMBAR PUNCTURE DIAGNOSTIC,31200125,CDM,761,RC,62270,HCPCS,Outpatient,,,1095.1,657.06,,52.08,100,,1042.208,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,284.584,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,306.63,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.16,Percent of Total Billed Charges,32% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,394.24,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,394.24,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,394.24,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,47.12,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,120,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,12.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,51.672,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,445.12,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,766.57,70,,140,Percent of Total Billed Charges,70% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,12.504,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,68.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1184.5,
I&D OF SKIN ABSCESS SIMPLE,31200130,CDM,761,RC,10060,HCPCS,Outpatient,,,707.46,424.48,,79.09,100,,341.504,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,70.2,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,28,,151.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.168,Percent of Total Billed Charges,32% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,254.69,36,,194.392,Percent of Total Billed Charges,36% of Total Billed Charges,254.69,36,,194.392,Percent of Total Billed Charges,36% Total Bille Charges,254.69,36,,194.392,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,271.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,120,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,102.02,14.42,,184.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,530.6,75,,960.808,Percent of Total Billed Charges,75% of Total Billed Charges,353.73,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,353.73,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,353.73,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,353.73,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.22,70,,205.52,Percent of Total Billed Charges,70% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,178.888,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,707.46,100,,1281.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,707.46,
LUMBAR PUNCTURE THERAPEUTIC,31200133,CDM,761,RC,62272,HCPCS,Outpatient,,,1112.8,667.68,,73.22,100,,1579.12,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,70.2,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,311.58,28,,369.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.168,Percent of Total Billed Charges,32% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,400.61,36,,475.2,Percent of Total Billed Charges,36% of Total Billed Charges,400.61,36,,475.2,Percent of Total Billed Charges,36% Total Bille Charges,400.61,36,,475.2,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,672.736,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,632.4,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,160.47,14.42,,527.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,834.6,75,,696.248,Percent of Total Billed Charges,75% of Total Billed Charges,556.4,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,556.4,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,556.4,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,778.96,70,,902.984,Percent of Total Billed Charges,70% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,155.79,14,,511.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.8,100,,928.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1184.5,
IMMUNIZATION IM/SQ INITIAL VAC,31200141,CDM,771,RC,90471,HCPCS,Outpatient,,,127,76.20,,10,100,,324,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,78.408,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,137.088,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,0.168,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,217.69,360,,176.256,Fee Schedule,360% of BCBS POS Rate,217.69,360,,176.256,Fee schedule,360% of BCBS PPO Rate,217.69,360,,176.256,Fee Schedule,360% of BCBS Traditional Rate,76.2,60,,3444.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,156,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,95.25,75,,66.976,Percent of Total Billed Charges,75% of Total Billed Charges,63.5,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.9,70,,2176.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,127,100,,89.296,Percent of Total Billed Charges,100% of Total Billed Charges,10,217.69,
IMMUNIZATION IM/SQ EA AD VAC,31200158,CDM,771,RC,90472,HCPCS,Outpatient,,,86.12,51.67,,10,100,,666.632,Fee Schedule,100% of Aetna Fee Schedule,38.75,45,,37.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.32,280,,31.824,Fee Schedule,280% of BCBS BULE Fee Schedule,41.5,320,,0.168,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,46.69,360,,40.912,Fee Schedule,360% of BCBS POS Rate,46.69,360,,40.912,Fee schedule,360% of BCBS PPO Rate,46.69,360,,40.912,Fee Schedule,360% of BCBS Traditional Rate,51.67,60,,3992.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.12,100,,156,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.59,75,,958.336,Percent of Total Billed Charges,75% of Total Billed Charges,43.06,50,,464.168,Percent of Total Billed Charges,50% of Total Billed Charges,43.06,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.06,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,43.06,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,70,,734.16,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.12,100,,1277.784,Percent of Total Billed Charges,100% of Total Billed Charges,10,86.12,
PERITONEAL DIALYSIS,31200166,CDM,802,RC,90945,HCPCS,Outpatient,,,1601.35,960.81,,63.73,100,,714.512,Fee Schedule,100% of Aetna Fee Schedule,609.52,150,,31.92,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,448.38,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.1,32,,0.176,Percent of Total Billed Charges,32% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,576.49,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,576.49,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,576.49,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,960.81,60,,111.192,Percent of Total Billed Charges,60% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,174.24,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,230.91,14.42,,27.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1201.01,75,,2742.6,Percent of Total Billed Charges,75% of Total Billed Charges,800.68,50,,44.648,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,800.68,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.95,70,,2146.144,Percent of Total Billed Charges,70% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,26.312,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1601.35,100,,3656.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1601.35,
TRANSCUTANEOUS PACING,31200174,CDM,480,RC,92953,HCPCS,Outpatient,,,1160.41,696.25,,0.62,100,,1204.368,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,26.072,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1502.09,280,,711.48,Fee Schedule,280% of BCBS BULE Fee Schedule,1716.67,320,,0.176,Fee Schedule,320% of BCBS Blue Essentials Rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,1931.26,360,,914.76,Fee Schedule,360% of BCBS POS Rate,1931.26,360,,914.76,Fee schedule,360% of BCBS PPO Rate,1931.26,360,,914.76,Fee Schedule,360% of BCBS Traditional Rate,696.25,60,,1138.984,Percent of Total Billed Charges,60% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,82.32,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,167.33,14.42,,18.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,870.31,75,,717.904,Percent of Total Billed Charges,75% of Total Billed Charges,580.21,50,,638.896,Percent of Total Billed Charges,50% of Total Billed Charges,580.21,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,580.21,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,580.21,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,489.28,Case Rate,Pays based on per visit rate,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,162.46,14,,18.136,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.41,100,,957.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1931.26,
IMMUNIZE INJECT HEP B,31200208,CDM,771,RC,G0010,HCPCS,Outpatient,,,111.62,66.97,,10.31,100,,1321.736,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,26.976,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,145.32,280,,545.776,Fee Schedule,280% of BCBS BULE Fee Schedule,166.08,320,,0.176,Fee Schedule,320% of BCBS Blue Essentials Rate,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,186.84,360,,701.712,Fee Schedule,360% of BCBS POS Rate,186.84,360,,701.712,Fee schedule,360% of BCBS PPO Rate,186.84,360,,701.712,Fee Schedule,360% of BCBS Traditional Rate,66.97,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,70.928,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,16.1,14.42,,7.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,83.72,75,,430.176,Percent of Total Billed Charges,75% of Total Billed Charges,55.81,50,,1828.4,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,286.784,Percent of Total Billed Charges,50% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,55.81,50,,286.784,Percent of Total Billed Charges,50% of Total Billed Charges,55.81,50,,286.784,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,78.13,70,,327.936,Percent of Total Billed Charges,70% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14,,7.32,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,111.62,100,,573.568,Percent of Total Billed Charges,100% of Total Billed Charges,10.31,186.84,
THORACENTESIS ASP WO IMAGING,31200258,CDM,761,RC,32554,HCPCS,Outpatient,,,1597.23,958.34,,85.56,100,,9886.448,Fee Schedule,100% of Aetna Fee Schedule,864.52,150,,88.92,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,447.22,28,,624.064,Percent of Total Billed Charges,28% of Total Billed Charges,0.11,32,,0.184,Percent of Total Billed Charges,32% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,575,36,,802.368,Percent of Total Billed Charges,36% of Total Billed Charges,575,36,,802.368,Percent of Total Billed Charges,36% Total Bille Charges,575,36,,802.368,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,2373.8,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,830.592,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,230.32,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1197.92,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,798.62,50,,64.76,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,798.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,798.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.06,70,,890.4,Percent of Total Billed Charges,70% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,223.61,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1597.23,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,1597.23,
APHERESIS PLASMA,31200265,CDM,940,RC,36514,HCPCS,Outpatient,,,4571,2742.60,,87.13,100,,15067.36,Fee Schedule,100% of Aetna Fee Schedule,2111.52,150,,89.312,Fee Schedule ,150% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1279.88,28,,24.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.11,32,,0.184,Percent of Total Billed Charges,32% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1645.56,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,1645.56,36,,32.12,Percent of Total Billed Charges,36% Total Bille Charges,1645.56,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,2742.6,60,,1087.64,Percent of Total Billed Charges,60% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,131.08,Fee Schedule,100% of CMS OPPS Rate,1266.91,90,,,Fee Schedule,90% of CMS OPPS Rate,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.98,130,,,Fee Schedule,130% of CMS OPPS Rate,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,659.14,14.42,,18.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,3428.25,75,,34.144,Percent of Total Billed Charges,75% of Total Billed Charges,2285.5,50,,26.152,Percent of Total Billed Charges,50% of Total Billed Charges,2285.5,50,,22.768,Percent of Total Billed Charges,50% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,2285.5,50,,22.768,Percent of Total Billed Charges,50% of Total Billed Charges,2285.5,50,,22.768,Percent of Total Billed Charges,50% of Total Billed Charges,2111.52,150,,,Fee Schedule,150% of CMS OPPS Rate,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,3737.264,Case Rate,Pays based on per visit rate,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,639.94,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,4571,100,,45.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,4571,
INTRATHECAL CHEMO,31200273,CDM,331,RC,96450,HCPCS,Outpatient,,,1196.5,717.90,,44.79,100,,18832,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,125.936,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.07,280,,1732.128,Fee Schedule,280% of BCBS BULE Fee Schedule,261.79,320,,0.184,Fee Schedule,320% of BCBS Blue Essentials Rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,294.52,360,,2227.024,Fee Schedule,360% of BCBS POS Rate,294.52,360,,2227.024,Fee schedule,360% of BCBS PPO Rate,294.52,360,,2227.024,Fee Schedule,360% of BCBS Traditional Rate,674,100,,241.704,Case Rate,Pays based on per visit rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,197.592,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.54,14.42,,362.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,897.38,75,,31.624,Percent of Total Billed Charges,75% of Total Billed Charges,598.25,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,21.088,Percent of Total Billed Charges,50% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,598.25,50,,21.088,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,21.088,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,1215.2,Case Rate,Pays based on per visit rate,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,351.624,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.5,100,,42.168,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,1196.5,
ARTHRO/ASP/INJ SM JOINT,31200281,CDM,761,RC,20600,HCPCS,Outpatient,,,716.96,430.18,,29.89,100,,1062.424,Fee Schedule,100% of Aetna Fee Schedule,407.6,150,,135,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.75,28,,1207.72,Percent of Total Billed Charges,28% of Total Billed Charges,0.11,32,,0.184,Percent of Total Billed Charges,32% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,258.11,36,,1552.784,Percent of Total Billed Charges,36% of Total Billed Charges,258.11,36,,1552.784,Percent of Total Billed Charges,36% Total Bille Charges,258.11,36,,1552.784,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,241.704,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,198.472,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,103.39,14.42,,82.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,537.72,75,,20.08,Percent of Total Billed Charges,75% of Total Billed Charges,358.48,50,,22.768,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,13.384,Percent of Total Billed Charges,50% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.48,50,,13.384,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,13.384,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.87,70,,2002.288,Percent of Total Billed Charges,70% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,80.192,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.96,100,,26.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,1184.5,
DRSG FM GRNFM VAC 26X15CM LG,31201001,CDM,272,RC,,,Outpatient,,,234.9,140.94,,140.94,60,,2752.504,Percent of Total Billed Charges,60% of Total Billed Charges,105.71,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.77,28,,2917.448,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.192,Percent of Total Billed Charges,32% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84.56,36,,3751.008,Percent of Total Billed Charges,36% of Total Billed Charges,84.56,36,,3751.008,Percent of Total Billed Charges,36% Total Bille Charges,84.56,36,,3751.008,Percent of Total Billed Charges,36% of Total Billed Charges,140.94,60,,241.704,Percent of Total Billed Charges,60% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.9,100,,279.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,33.87,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.18,75,,96.84,Percent of Total Billed Charges,75% of Total Billed Charges,117.45,50,,21.088,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,64.56,Percent of Total Billed Charges,50% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.45,50,,64.56,Percent of Total Billed Charges,50% of Total Billed Charges,117.45,50,,64.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.43,70,,353.136,Percent of Total Billed Charges,70% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.89,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.9,100,,129.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,234.9,
DRAIN CHST CHST PLR-EV PED,31201004,CDM,272,RC,,,Outpatient,,,161.9,97.14,,97.14,60,,4435.72,Percent of Total Billed Charges,60% of Total Billed Charges,72.86,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.33,28,,901.208,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.192,Percent of Total Billed Charges,32% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,36,,1158.696,Percent of Total Billed Charges,36% of Total Billed Charges,58.28,36,,1158.696,Percent of Total Billed Charges,36% Total Bille Charges,58.28,36,,1158.696,Percent of Total Billed Charges,36% of Total Billed Charges,97.14,60,,574.56,Percent of Total Billed Charges,60% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.9,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.35,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.43,75,,1883.704,Percent of Total Billed Charges,75% of Total Billed Charges,80.95,50,,13.384,Percent of Total Billed Charges,50% of Total Billed Charges,80.95,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.95,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,80.95,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.33,70,,465.36,Percent of Total Billed Charges,70% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.9,100,,2511.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,161.9,
DRESSING AQUACEL AG R 1X45CM,31201013,CDM,272,RC,A6197,HCPCS,Outpatient,,,65.38,39.23,,13.97,100,,6937.496,Fee Schedule,100% of Aetna Fee Schedule,29.42,45,,77.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.48,280,,948.64,Fee Schedule,280% of BCBS BULE Fee Schedule,61.12,320,,0.192,Fee Schedule,320% of BCBS Blue Essentials Rate,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,68.76,360,,1219.68,Fee Schedule,360% of BCBS POS Rate,68.76,360,,1219.68,Fee schedule,360% of BCBS PPO Rate,68.76,360,,1219.68,Fee Schedule,360% of BCBS Traditional Rate,39.23,60,,574.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.38,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14.42,,156.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.04,75,,429.608,Percent of Total Billed Charges,75% of Total Billed Charges,32.69,50,,64.56,Percent of Total Billed Charges,50% of Total Billed Charges,32.69,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.69,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,32.69,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.77,70,,54.968,Percent of Total Billed Charges,70% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.38,100,,572.808,Percent of Total Billed Charges,100% of Total Billed Charges,9.15,68.76,
DRESSING SILVERLON 4X4 ISLAND,31201014,CDM,272,RC,A6206,HCPCS,Outpatient,,,70,42.00,,2.35,100,,12299.176,Fee Schedule,100% of Aetna Fee Schedule,31.5,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.192,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,1208.64,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,117.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,1255.8,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,316.96,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,70,
DRSG BURN ACTCT SLCR 4X4,31201018,CDM,272,RC,A6206,HCPCS,Outpatient,,,56.91,34.15,,2.35,100,,20006.736,Fee Schedule,100% of Aetna Fee Schedule,25.61,45,,136.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.93,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.192,Percent of Total Billed Charges,32% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.49,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,20.49,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,20.49,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,34.15,60,,539.496,Percent of Total Billed Charges,60% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.91,100,,172.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,8.21,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.68,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,28.46,50,,286.408,Percent of Total Billed Charges,50% of Total Billed Charges,28.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,28.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.84,70,,784.864,Percent of Total Billed Charges,70% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.91,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,56.91,
CATHETER URET BARDX 5ML HYGEL,31201021,CDM,272,RC,C1758,HCPCS,Outpatient,,,52.71,31.63,,69,100,,29755.048,Fee Schedule,100% of Aetna Fee Schedule,23.72,45,,220.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.76,28,,148.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.192,Percent of Total Billed Charges,32% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,18.98,36,,190.736,Percent of Total Billed Charges,36% Total Bille Charges,18.98,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,31.63,60,,1316.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.71,100,,157,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.6,14.42,,485.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.53,75,,816.024,Percent of Total Billed Charges,75% of Total Billed Charges,26.36,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,26.36,50,,544.016,Percent of Total Billed Charges,50% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.36,50,,544.016,Percent of Total Billed Charges,50% of Total Billed Charges,26.36,50,,544.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.9,70,,4018.56,Percent of Total Billed Charges,70% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,7.38,14,,471.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.71,100,,1088.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,69,
DRSG FOAM 4 X 8 SILICONE,31201032,CDM,272,RC,A6213,HCPCS,Outpatient,,,33.46,20.08,,11.24,100,,45297.472,Fee Schedule,100% of Aetna Fee Schedule,15.06,45,,406.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.37,28,,58.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,12.05,36,,75.552,Percent of Total Billed Charges,36% of Total Billed Charges,12.05,36,,75.552,Percent of Total Billed Charges,36% Total Bille Charges,12.05,36,,75.552,Percent of Total Billed Charges,36% of Total Billed Charges,20.08,60,,2349.088,Percent of Total Billed Charges,60% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.46,100,,304.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14.42,,8.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.1,75,,612.016,Percent of Total Billed Charges,75% of Total Billed Charges,16.73,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,16.73,50,,408.016,Percent of Total Billed Charges,50% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.73,50,,408.016,Percent of Total Billed Charges,50% of Total Billed Charges,16.73,50,,408.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.42,70,,4657.496,Percent of Total Billed Charges,70% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,8.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.46,100,,816.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,33.46,
CANISTR SUC GEL INFOVAC 500ML,31201049,CDM,272,RC,,,Outpatient,,,161.4,96.84,,96.84,60,,67787.728,Percent of Total Billed Charges,60% of Total Billed Charges,72.63,45,,432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.19,28,,92.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,36,,119.552,Percent of Total Billed Charges,36% of Total Billed Charges,58.1,36,,119.552,Percent of Total Billed Charges,36% Total Bille Charges,58.1,36,,119.552,Percent of Total Billed Charges,36% of Total Billed Charges,96.84,60,,4778.32,Percent of Total Billed Charges,60% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.4,100,,489.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14.42,,14.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.05,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,80.7,50,,544.016,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.7,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.98,70,,129.728,Percent of Total Billed Charges,70% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,14.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.4,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,161.4,
I&D RECTAL ABSCESS,31202000,CDM,761,RC,46040,HCPCS,Outpatient,,,3139.5,1883.70,,412.77,100,,104111,Fee Schedule,100% of Aetna Fee Schedule,1623.99,150,,219.08,Fee Schedule ,150% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,879.06,28,,148.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1130.22,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,1130.22,36,,190.736,Percent of Total Billed Charges,36% Total Bille Charges,1130.22,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,3347.5,103,,704.488,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.65,100,,903.048,Fee Schedule,100% of CMS OPPS Rate,974.39,90,,,Fee Schedule,90% of CMS OPPS Rate,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.46,130,,,Fee Schedule,130% of CMS OPPS Rate,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,452.72,14.42,,58.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,1115.14,103,,,Fee Schedule,103% of CMS OPPS Rate,1115.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2354.63,75,,2523.792,Percent of Total Billed Charges,75% of Total Billed Charges,1569.75,50,,408.016,Percent of Total Billed Charges,50% of Total Billed Charges,1569.75,50,,1682.528,Percent of Total Billed Charges,50% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.75,50,,1682.528,Percent of Total Billed Charges,50% of Total Billed Charges,1569.75,50,,1682.528,Percent of Total Billed Charges,50% of Total Billed Charges,1623.99,150,,,Fee Schedule,150% of CMS OPPS Rate,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2197.65,70,,1449.616,Percent of Total Billed Charges,70% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,439.53,14,,56.968,Percent of Total Billed Charges,14% of Total Billed Charges,1082.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3139.5,100,,3365.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,3347.5,
LARYNGOSCOPYFLEX/RIGID DX,31202001,CDM,761,RC,31575,HCPCS,Outpatient,,,716.01,429.61,,63.82,100,,445.2,Fee Schedule,100% of Aetna Fee Schedule,272.58,150,,1065.168,Fee Schedule ,150% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,28,,148.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,257.76,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,257.76,36,,190.736,Percent of Total Billed Charges,36% Total Bille Charges,257.76,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,593.728,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,100,,960,Fee Schedule,100% of CMS OPPS Rate,163.55,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,236.24,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,103.25,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,187.18,103,,,Fee Schedule,103% of CMS OPPS Rate,537.01,75,,43.704,Percent of Total Billed Charges,75% of Total Billed Charges,358.01,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.01,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,358.01,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,272.58,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,501.21,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,100.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,181.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.01,100,,58.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,716.01,
BRIDLE AMT SPARE CLIP,31202002,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,1670.608,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,44.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,148.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,190.736,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,190.736,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,486.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,4.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,75.384,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,1682.528,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,196,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,100.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,375,
FEEDING TUBE CORTRAK EAS,31202003,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,701.68,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,2802.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,1170.624,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.2,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,1505.088,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,1505.088,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,1505.088,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,323.984,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2367.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,9.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,325.52,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,29.136,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1117.48,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,9.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,406.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,375,
DEBRIDEMENT SUB TIS 1ST 20SQCM,31202004,CDM,761,RC,11042,HCPCS,Outpatient,,,1360.04,816.02,,45.54,100,,330.176,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,3837.6,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,380.81,28,,151.696,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.208,Percent of Total Billed Charges,32% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,489.61,36,,195.032,Percent of Total Billed Charges,36% of Total Billed Charges,489.61,36,,195.032,Percent of Total Billed Charges,36% Total Bille Charges,489.61,36,,195.032,Percent of Total Billed Charges,36% of Total Billed Charges,2575,103,,792,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,99.264,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,196.12,14.42,,284.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,1020.03,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,680.02,50,,50.256,Percent of Total Billed Charges,50% of Total Billed Charges,680.02,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,680.02,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,680.02,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,952.03,70,,143.024,Percent of Total Billed Charges,70% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,276.04,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.04,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,2575,
DEBRIDE SUB TIS EA ADD 20SQCM,31202005,CDM,761,RC,11045,HCPCS,Outpatient,,,1020.03,612.02,,19.5,100,,75.936,Fee Schedule,100% of Aetna Fee Schedule,459.01,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.208,Other,Not Seperately Reimbusable,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.02,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020.03,100,,6227.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,147.09,14.42,,1168.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.02,75,,24.904,Percent of Total Billed Charges,75% of Total Billed Charges,510.02,50,,203.448,Percent of Total Billed Charges,50% of Total Billed Charges,510.02,50,,16.608,Percent of Total Billed Charges,50% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.02,50,,16.608,Percent of Total Billed Charges,50% of Total Billed Charges,510.02,50,,16.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,714.02,70,,3021.2,Percent of Total Billed Charges,70% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,1134.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1020.03,100,,33.208,Percent of Total Billed Charges,100% of Total Billed Charges,19.5,1020.03,
CORGRIP NASO FEED TUBE,31202006,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,5875.584,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,147.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.12,32,,0.208,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,189.04,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,189.04,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,189.04,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,68.192,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,8528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,382.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,48.28,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,32.184,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,32.184,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,32.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1384.264,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,371.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,64.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,375,
I&D OF BREAST ABSCESS,31202007,CDM,361,RC,19020,HCPCS,Outpatient,,,4206.32,2523.79,,4162,100,,864.712,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,1872,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,128.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.13,32,,0.208,Percent of Total Billed Charges,32% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,164.832,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,164.832,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,164.832,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,1169.52,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,300,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,606.55,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,3154.74,75,,1577.368,Percent of Total Billed Charges,75% of Total Billed Charges,2103.16,50,,16.608,Percent of Total Billed Charges,50% of Total Billed Charges,2103.16,50,,985.856,Percent of Total Billed Charges,50% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2103.16,50,,985.856,Percent of Total Billed Charges,50% of Total Billed Charges,2103.16,50,,985.856,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,307.616,Fee Schedule,100% of ASC Tier Groupings fee schedule,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,588.88,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,4206.32,100,,1971.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,4419.77,
SLEEVE COMPR SCD EXPR KNEE MED,31203020,CDM,271,RC,,,Outpatient,,,72.84,43.70,,43.7,60,,790.344,Percent of Total Billed Charges,60% of Total Billed Charges,32.78,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.4,28,,564.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.216,Percent of Total Billed Charges,32% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,26.22,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,26.22,36,,725.76,Percent of Total Billed Charges,36% Total Bille Charges,26.22,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,43.7,60,,1524.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.84,100,,2240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.5,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.63,75,,6484.296,Percent of Total Billed Charges,75% of Total Billed Charges,36.42,50,,32.184,Percent of Total Billed Charges,50% of Total Billed Charges,36.42,50,,4052.688,Percent of Total Billed Charges,50% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.42,50,,4052.688,Percent of Total Billed Charges,50% of Total Billed Charges,36.42,50,,4052.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.99,70,,307.616,Percent of Total Billed Charges,70% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.84,100,,8105.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,72.84,
SLEEVE COMPR SCD EXPR KNEE LG,31203021,CDM,271,RC,,,Outpatient,,,125.64,75.38,,75.38,60,,1169.52,Percent of Total Billed Charges,60% of Total Billed Charges,56.54,45,,1029.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.18,28,,74.56,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.216,Percent of Total Billed Charges,32% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,45.23,36,,95.856,Percent of Total Billed Charges,36% of Total Billed Charges,45.23,36,,95.856,Percent of Total Billed Charges,36% Total Bille Charges,45.23,36,,95.856,Percent of Total Billed Charges,36% of Total Billed Charges,75.38,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.64,100,,4160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.12,14.42,,177.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.23,75,,2121.6,Percent of Total Billed Charges,75% of Total Billed Charges,62.82,50,,985.856,Percent of Total Billed Charges,50% of Total Billed Charges,62.82,50,,1326,Percent of Total Billed Charges,50% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.82,50,,1326,Percent of Total Billed Charges,50% of Total Billed Charges,62.82,50,,1326,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.95,70,,307.616,Percent of Total Billed Charges,70% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,17.59,14,,172.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.64,100,,2652,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,125.64,
PI CVC KIT 3 L 7 FR X 20 CM,31203022,CDM,278,RC,C1751,HCPCS,Outpatient,,,508.62,305.17,,627.14,110,,293.408,Percent of Total Billed Charges,110% of Total Billed Charges,228.88,45,,1029.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.41,28,,108.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.216,Percent of Total Billed Charges,32% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,183.1,36,,138.92,Percent of Total Billed Charges,36% of Total Billed Charges,183.1,36,,138.92,Percent of Total Billed Charges,36% Total Bille Charges,183.1,36,,138.92,Percent of Total Billed Charges,36% of Total Billed Charges,279.74,55,,1863.4,Percent of Total Billed Charges,55% Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.62,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,73.34,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.9,80,,90,Percent of Total Billed Charges,80% of Total Billed Charges,254.31,50,,4052.688,Percent of Total Billed Charges,50% of Total Billed Charges,254.31,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.31,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,254.31,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.03,70,,670.32,Percent of Total Billed Charges,70% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.62,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,627.14,
PARACENTESIS THOR 8FRX4.75IN,31205161,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,350.608,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,12600,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,179.56,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.216,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,230.864,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,230.864,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,230.864,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,2288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,1660.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,1326,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,670.32,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,1612.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,150,
DRSG GRMCDL BIOPTCH 1IN 4MM,31208100,CDM,272,RC,A6209,HCPCS,Outpatient,,,41.51,24.91,,6.35,100,,479.088,Fee Schedule,100% of Aetna Fee Schedule,18.68,45,,12528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,1196.248,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,0.216,Fee Schedule,320% of BCBS Blue Essentials Rate,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,1538.032,Fee Schedule,360% of BCBS POS Rate,31.25,360,,1538.032,Fee schedule,360% of BCBS PPO Rate,31.25,360,,1538.032,Fee Schedule,360% of BCBS Traditional Rate,24.91,60,,2987.528,Percent of Total Billed Charges,60% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.51,100,,2288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14.42,,100.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.13,75,,921.888,Percent of Total Billed Charges,75% of Total Billed Charges,20.76,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,20.76,50,,614.592,Percent of Total Billed Charges,50% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.76,50,,614.592,Percent of Total Billed Charges,50% of Total Billed Charges,20.76,50,,614.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.06,70,,1410.08,Percent of Total Billed Charges,70% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,5.81,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.51,100,,1229.184,Percent of Total Billed Charges,100% of Total Billed Charges,5.81,41.51,
SILVERLON SURGICAL DRESSING,31260142,CDM,272,RC,A6207,HCPCS,Outpatient,,,80.46,48.28,,6.24,100,,720.208,Fee Schedule,100% of Aetna Fee Schedule,36.21,45,,61.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,446.208,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,0.216,Fee Schedule,320% of BCBS Blue Essentials Rate,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,573.696,Fee Schedule,360% of BCBS POS Rate,30.71,360,,573.696,Fee schedule,360% of BCBS PPO Rate,30.71,360,,573.696,Fee Schedule,360% of BCBS Traditional Rate,48.28,60,,1225.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.46,100,,28000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.6,14.42,,76.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.35,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,40.23,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,40.23,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.23,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,40.23,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.32,70,,629.416,Percent of Total Billed Charges,70% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.26,14,,73.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.46,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,80.46,
VALVE HAKIM PRESSURE RIGHTANGLE,32100000,CDM,278,RC,A4649,HCPCS,Outpatient,,,2464.64,1478.78,,2711.1,110,,1323.008,Percent of Total Billed Charges,110% of Total Billed Charges,1109.09,45,,856.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690.1,28,,464.864,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.216,Percent of Total Billed Charges,32% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,887.27,36,,597.68,Percent of Total Billed Charges,36% of Total Billed Charges,887.27,36,,597.68,Percent of Total Billed Charges,36% Total Bille Charges,887.27,36,,597.68,Percent of Total Billed Charges,36% of Total Billed Charges,1355.55,55,,3402.4,Percent of Total Billed Charges,55% Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2464.64,100,,27840,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,355.4,14.42,,1499.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1971.71,80,,9214.72,Percent of Total Billed Charges,80% of Total Billed Charges,1232.32,50,,614.592,Percent of Total Billed Charges,50% of Total Billed Charges,1232.32,50,,5759.2,Percent of Total Billed Charges,50% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1232.32,50,,5759.2,Percent of Total Billed Charges,50% of Total Billed Charges,1232.32,50,,5759.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1725.25,70,,1536.168,Percent of Total Billed Charges,70% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,345.05,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2464.64,100,,11518.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,2711.1,
VALVE PROGRAMMABLE CERTAS PLUS,32100001,CDM,278,RC,A4649,HCPCS,Outpatient,,,10131.71,6079.03,,11144.88,110,,1936.368,Percent of Total Billed Charges,110% of Total Billed Charges,4559.27,45,,1934.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2836.88,28,,203.112,Percent of Total Billed Charges,28% of Total Billed Charges,0.13,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,3647.42,36,,261.144,Percent of Total Billed Charges,36% of Total Billed Charges,3647.42,36,,261.144,Percent of Total Billed Charges,36% Total Bille Charges,3647.42,36,,261.144,Percent of Total Billed Charges,36% of Total Billed Charges,5572.44,55,,2372.304,Percent of Total Billed Charges,55% Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10131.71,100,,136.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1460.99,14.42,,1475.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8105.37,80,,559.184,Percent of Total Billed Charges,80% of Total Billed Charges,5065.86,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,5065.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5065.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,5065.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7092.2,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,1418.44,14,,1432.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10131.71,100,,698.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,11144.88,
MATRICCELLECT 100 DMB PUTTY SCC,32100002,CDM,278,RC,A4649,HCPCS,Outpatient,,,3315,1989.00,,3646.5,110,,2798.768,Percent of Total Billed Charges,110% of Total Billed Charges,1491.75,45,,1076.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,928.2,28,,191.52,Percent of Total Billed Charges,28% of Total Billed Charges,0.14,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,1193.4,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,1193.4,36,,246.24,Percent of Total Billed Charges,36% Total Bille Charges,1193.4,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,1823.25,55,,5730.704,Percent of Total Billed Charges,55% Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3315,100,,1904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,478.02,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2652,80,,422.784,Percent of Total Billed Charges,80% of Total Billed Charges,1657.5,50,,5759.2,Percent of Total Billed Charges,50% of Total Billed Charges,1657.5,50,,264.24,Percent of Total Billed Charges,50% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1657.5,50,,264.24,Percent of Total Billed Charges,50% of Total Billed Charges,1657.5,50,,264.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2320.5,70,,2989.752,Percent of Total Billed Charges,70% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,464.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3315,100,,528.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,3646.5,
SUTURE V-LOC 3-0,32100003,CDM,272,RC,A4649,HCPCS,Outpatient,,,150,90.00,,90,60,,3827.488,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,1428.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,137.088,Percent of Total Billed Charges,28% of Total Billed Charges,0.14,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,176.256,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,176.256,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,176.256,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,1770.232,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,4298.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,289.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,8320,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,6081.496,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,280.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,150,
SUTURE V-LOC 2-0,32100004,CDM,272,RC,A4649,HCPCS,Outpatient,,,375,225.00,,225,60,,5281.248,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,717.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,614.464,Percent of Total Billed Charges,28% of Total Billed Charges,0.14,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,790.032,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,790.032,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,790.032,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,75.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,8186.88,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,264.24,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,5116.8,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,5116.8,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,5116.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,821.904,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,73.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,10233.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,375,
STAPLER RELOAD 30MM,32100005,CDM,272,RC,A4649,HCPCS,Outpatient,,,1536.48,921.89,,921.89,60,,7196.128,Percent of Total Billed Charges,60% of Total Billed Charges,691.42,45,,277.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.21,28,,1195.904,Percent of Total Billed Charges,28% of Total Billed Charges,0.15,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,553.13,36,,1537.584,Percent of Total Billed Charges,36% of Total Billed Charges,553.13,36,,1537.584,Percent of Total Billed Charges,36% Total Bille Charges,553.13,36,,1537.584,Percent of Total Billed Charges,36% of Total Billed Charges,921.89,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1536.48,100,,3174.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,221.56,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1152.36,75,,279,Percent of Total Billed Charges,75% of Total Billed Charges,768.24,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,768.24,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.24,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,768.24,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1075.54,70,,755.656,Percent of Total Billed Charges,70% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,215.11,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1536.48,100,,372,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,1536.48,
SUTURE V-LOC 180,32100006,CDM,272,RC,A4649,HCPCS,Outpatient,,,375,225.00,,225,60,,10645.728,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,89.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,93.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.15,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,119.616,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,119.616,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,119.616,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1593.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,175.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1503.6,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,5116.8,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1002.4,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1002.4,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1002.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,170.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2004.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,375,
8MM ORTHOFIX CERVICAL CANCELLOUS BONE,32100007,CDM,278,RC,A4649,HCPCS,Outpatient,,,14398,8638.80,,15837.8,110,,14953.328,Percent of Total Billed Charges,110% of Total Billed Charges,6479.1,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4031.44,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.15,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,5183.28,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,5183.28,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,5183.28,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,7918.9,55,,317.896,Percent of Total Billed Charges,55% Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14398,100,,616.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2076.19,14.42,,701.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11518.4,80,,391.376,Percent of Total Billed Charges,80% of Total Billed Charges,7199,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,7199,50,,260.92,Percent of Total Billed Charges,50% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7199,50,,260.92,Percent of Total Billed Charges,50% of Total Billed Charges,7199,50,,260.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10078.6,70,,377.984,Percent of Total Billed Charges,70% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,2015.72,14,,681.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14398,100,,521.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,15837.8,
ALLOPATCH PILABLE 2X2CM,32100008,CDM,278,RC,A4649,HCPCS,Outpatient,,,873.72,524.23,,961.09,110,,21814.688,Percent of Total Billed Charges,110% of Total Billed Charges,393.17,45,,3837.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.64,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.15,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,314.54,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,314.54,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,314.54,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,480.55,55,,125.912,Percent of Total Billed Charges,55% Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.72,100,,198.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,125.99,14.42,,582.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,698.98,80,,395.416,Percent of Total Billed Charges,80% of Total Billed Charges,436.86,50,,1002.4,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.86,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,611.6,70,,924,Percent of Total Billed Charges,70% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,565.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.72,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,961.09,
MESH MARLEX FLAT 6X6,32100009,CDM,278,RC,C1781,HCPCS,Outpatient,,,660.6,396.36,,1179.42,110,,28636.448,Percent of Total Billed Charges,110% of Total Billed Charges,297.27,45,,577.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.97,28,,6.536,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,36,,8.408,Percent of Total Billed Charges,36% of Total Billed Charges,237.82,36,,8.408,Percent of Total Billed Charges,36% Total Bille Charges,237.82,36,,8.408,Percent of Total Billed Charges,36% of Total Billed Charges,363.33,55,,199.256,Percent of Total Billed Charges,55% Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,660.6,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,95.26,14.42,,1066.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.48,80,,912.6,Percent of Total Billed Charges,80% of Total Billed Charges,330.3,50,,260.92,Percent of Total Billed Charges,50% of Total Billed Charges,330.3,50,,608.4,Percent of Total Billed Charges,50% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330.3,50,,608.4,Percent of Total Billed Charges,50% of Total Billed Charges,330.3,50,,608.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462.42,70,,342.72,Percent of Total Billed Charges,70% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,92.48,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660.6,100,,1216.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,1179.42,
PRO-DENSE 12CC,32100010,CDM,278,RC,A4649,HCPCS,Outpatient,,,13000,7800.00,,14300,110,,44684.128,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,1166.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,1193.336,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.224,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,1534.288,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,317.896,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,8528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,205.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10400,80,,3894.096,Percent of Total Billed Charges,80% of Total Billed Charges,6500,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,2433.808,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,2433.808,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,2433.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,79.552,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,4867.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,14300,
HUMERAL HEAD RIGHT,32100011,CDM,278,RC,A4649,HCPCS,Outpatient,,,12792,7675.20,,14071.2,110,,291.648,Percent of Total Billed Charges,110% of Total Billed Charges,5756.4,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3581.76,28,,11.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.232,Percent of Total Billed Charges,32% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,4605.12,36,,15.016,Percent of Total Billed Charges,36% of Total Billed Charges,4605.12,36,,15.016,Percent of Total Billed Charges,36% Total Bille Charges,4605.12,36,,15.016,Percent of Total Billed Charges,36% of Total Billed Charges,7035.6,55,,317.896,Percent of Total Billed Charges,55% Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12792,100,,1284.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1844.61,14.42,,28.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10233.6,80,,3231.6,Percent of Total Billed Charges,80% of Total Billed Charges,6396,50,,608.4,Percent of Total Billed Charges,50% of Total Billed Charges,6396,50,,2019.752,Percent of Total Billed Charges,50% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6396,50,,2019.752,Percent of Total Billed Charges,50% of Total Billed Charges,6396,50,,2019.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8954.4,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,1790.88,14,,28.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12792,100,,4039.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,14071.2,
ENDO STAPLER RELOAD 60MM,32100012,CDM,272,RC,A4649,HCPCS,Outpatient,,,465,279.00,,279,60,,393.728,Percent of Total Billed Charges,60% of Total Billed Charges,209.25,45,,66.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.2,28,,27.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.232,Percent of Total Billed Charges,32% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,167.4,36,,35.424,Percent of Total Billed Charges,36% of Total Billed Charges,167.4,36,,35.424,Percent of Total Billed Charges,36% Total Bille Charges,167.4,36,,35.424,Percent of Total Billed Charges,36% of Total Billed Charges,279,60,,317.896,Percent of Total Billed Charges,60% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465,100,,2593.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,67.05,14.42,,166.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.75,75,,5547.168,Percent of Total Billed Charges,75% of Total Billed Charges,232.5,50,,2433.808,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.5,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.5,70,,1778.704,Percent of Total Billed Charges,70% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,161.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465,100,,7396.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,465,
ENDO STAPLER SLEEVE KIT,32100013,CDM,272,RC,A4649,HCPCS,Outpatient,,,2506,1503.60,,1503.6,60,,677.088,Percent of Total Billed Charges,60% of Total Billed Charges,1127.7,45,,1922.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,701.68,28,,33.488,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.232,Percent of Total Billed Charges,32% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,902.16,36,,43.056,Percent of Total Billed Charges,36% of Total Billed Charges,902.16,36,,43.056,Percent of Total Billed Charges,36% Total Bille Charges,902.16,36,,43.056,Percent of Total Billed Charges,36% of Total Billed Charges,1503.6,60,,2508.48,Percent of Total Billed Charges,60% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2506,100,,280,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,361.37,14.42,,36.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1879.5,75,,1067.632,Percent of Total Billed Charges,75% of Total Billed Charges,1253,50,,2019.752,Percent of Total Billed Charges,50% of Total Billed Charges,1253,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1253,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,1253,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1754.2,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,350.84,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2506,100,,1423.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,2506,
MESH DUATENE 10CM RND,32100014,CDM,272,RC,C1781,HCPCS,Outpatient,,,652.29,391.37,,452.76,100,,1601.088,Fee Schedule,100% of Aetna Fee Schedule,293.53,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.64,28,,20.496,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.232,Percent of Total Billed Charges,32% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,234.82,36,,26.352,Percent of Total Billed Charges,36% of Total Billed Charges,234.82,36,,26.352,Percent of Total Billed Charges,36% Total Bille Charges,234.82,36,,26.352,Percent of Total Billed Charges,36% of Total Billed Charges,391.37,60,,325.056,Percent of Total Billed Charges,60% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.29,100,,147.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.06,14.42,,28.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,489.22,75,,150.304,Percent of Total Billed Charges,75% of Total Billed Charges,326.15,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,326.15,50,,100.2,Percent of Total Billed Charges,50% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.15,50,,100.2,Percent of Total Billed Charges,50% of Total Billed Charges,326.15,50,,100.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,456.6,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,91.32,14,,27.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,652.29,100,,200.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,652.29,
HEMOSTAT SURGICEL 8 IN X 4 IN,32100015,CDM,250,RC,99070,HCPCS,Outpatient,,,659.02,395.41,,16.5,100,,2631.568,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,0.16,32,,0.24,Percent of Total Billed Charges,32% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,237.25,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,237.25,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,237.25,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,395.41,60,,703.696,Percent of Total Billed Charges,60% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,95.03,14.42,,36.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.27,75,,864.544,Percent of Total Billed Charges,75% of Total Billed Charges,329.51,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,576.36,Percent of Total Billed Charges,50% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.51,50,,576.36,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,576.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.31,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.02,100,,1152.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,659.02,
SECURESTRAP OPEN,32100016,CDM,272,RC,,,Outpatient,,,1521,912.60,,912.6,60,,3986.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.88,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.24,Percent of Total Billed Charges,32% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,547.56,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,547.56,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,547.56,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,912.6,60,,315.064,Percent of Total Billed Charges,60% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,219.33,14.42,,31.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1140.75,75,,187.816,Percent of Total Billed Charges,75% of Total Billed Charges,760.5,50,,100.2,Percent of Total Billed Charges,50% of Total Billed Charges,760.5,50,,125.208,Percent of Total Billed Charges,50% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.5,50,,125.208,Percent of Total Billed Charges,50% of Total Billed Charges,760.5,50,,125.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1064.7,70,,3802.312,Percent of Total Billed Charges,70% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,212.94,14,,31.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1521,100,,250.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1521,
PATCH VENTRIO ST,32100017,CDM,278,RC,C1781,HCPCS,Outpatient,,,6084.52,3650.71,,7145.73,110,,5741.488,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1703.67,28,,26.32,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.24,Percent of Total Billed Charges,32% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,2190.43,36,,33.84,Percent of Total Billed Charges,36% of Total Billed Charges,2190.43,36,,33.84,Percent of Total Billed Charges,36% Total Bille Charges,2190.43,36,,33.84,Percent of Total Billed Charges,36% of Total Billed Charges,3346.49,55,,274.72,Percent of Total Billed Charges,55% Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,877.39,14.42,,135.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4867.62,80,,146.368,Percent of Total Billed Charges,80% of Total Billed Charges,3042.26,50,,576.36,Percent of Total Billed Charges,50% of Total Billed Charges,3042.26,50,,97.584,Percent of Total Billed Charges,50% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3042.26,50,,97.584,Percent of Total Billed Charges,50% of Total Billed Charges,3042.26,50,,97.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4259.16,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,851.83,14,,131.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6084.52,100,,195.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,7145.73,
GRAFT 160MM FLEX FROZEN,32100018,CDM,278,RC,Q4130,HCPCS,Outpatient,,,5049.38,3029.63,,5559.98,110,,7617.648,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.83,28,,31.392,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.24,Percent of Total Billed Charges,32% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,1817.78,36,,40.36,Percent of Total Billed Charges,36% of Total Billed Charges,1817.78,36,,40.36,Percent of Total Billed Charges,36% Total Bille Charges,1817.78,36,,40.36,Percent of Total Billed Charges,36% of Total Billed Charges,2777.16,55,,1108.8,Percent of Total Billed Charges,55% Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,728.12,14.42,,966.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4039.5,80,,189.688,Percent of Total Billed Charges,80% of Total Billed Charges,2524.69,50,,125.208,Percent of Total Billed Charges,50% of Total Billed Charges,2524.69,50,,126.464,Percent of Total Billed Charges,50% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2524.69,50,,126.464,Percent of Total Billed Charges,50% of Total Billed Charges,2524.69,50,,126.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3534.57,70,,1560.16,Percent of Total Billed Charges,70% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,706.91,14,,938.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5049.38,100,,252.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,5559.98,
147289 SYS BNCMNT KYPHOPAK XPR,32100019,CDM,272,RC,,,Outpatient,,,9245.28,5547.17,,5547.17,60,,10983.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2588.68,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,3328.3,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,3328.3,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,3328.3,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,5547.17,60,,159.76,Percent of Total Billed Charges,60% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1333.17,14.42,,39.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6933.96,75,,166.288,Percent of Total Billed Charges,75% of Total Billed Charges,4622.64,50,,97.584,Percent of Total Billed Charges,50% of Total Billed Charges,4622.64,50,,110.864,Percent of Total Billed Charges,50% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4622.64,50,,110.864,Percent of Total Billed Charges,50% of Total Billed Charges,4622.64,50,,110.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6471.7,70,,62.464,Percent of Total Billed Charges,70% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9245.28,100,,221.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,9245.28,
227179 TIP SOFAMOR CURETTE MED,32100020,CDM,272,RC,,,Outpatient,,,1779.38,1067.63,,1067.63,60,,16651.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.23,28,,34.216,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,640.58,36,,43.992,Percent of Total Billed Charges,36% of Total Billed Charges,640.58,36,,43.992,Percent of Total Billed Charges,36% Total Bille Charges,640.58,36,,43.992,Percent of Total Billed Charges,36% of Total Billed Charges,1067.63,60,,231.536,Percent of Total Billed Charges,60% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.59,14.42,,344.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1334.54,75,,753.408,Percent of Total Billed Charges,75% of Total Billed Charges,889.69,50,,126.464,Percent of Total Billed Charges,50% of Total Billed Charges,889.69,50,,470.88,Percent of Total Billed Charges,50% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,889.69,50,,470.88,Percent of Total Billed Charges,50% of Total Billed Charges,889.69,50,,470.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1245.57,70,,4330.328,Percent of Total Billed Charges,70% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,334.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.38,100,,941.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1779.38,
153004 BUR SLOTTED WHISKERS 5.,32100022,CDM,272,RC,,,Outpatient,,,250.5,150.30,,150.3,60,,26119.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.14,28,,3964.8,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,90.18,36,,5097.6,Percent of Total Billed Charges,36% of Total Billed Charges,90.18,36,,5097.6,Percent of Total Billed Charges,36% Total Bille Charges,90.18,36,,5097.6,Percent of Total Billed Charges,36% of Total Billed Charges,150.3,60,,384.776,Percent of Total Billed Charges,60% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,36.12,14.42,,520.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.88,75,,5363.072,Percent of Total Billed Charges,75% of Total Billed Charges,125.25,50,,110.864,Percent of Total Billed Charges,50% of Total Billed Charges,125.25,50,,3351.92,Percent of Total Billed Charges,50% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.25,50,,3351.92,Percent of Total Billed Charges,50% of Total Billed Charges,125.25,50,,3351.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.35,70,,3019.296,Percent of Total Billed Charges,70% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,35.07,14,,505.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.5,100,,6703.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,250.5,
148578 BUR ROUND 4.0MM ARTHROS,32100023,CDM,272,RC,,,Outpatient,,,1440.9,864.54,,864.54,60,,37661.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.45,28,,3964.8,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,518.72,36,,5097.6,Percent of Total Billed Charges,36% of Total Billed Charges,518.72,36,,5097.6,Percent of Total Billed Charges,36% Total Bille Charges,518.72,36,,5097.6,Percent of Total Billed Charges,36% of Total Billed Charges,864.54,60,,2349.776,Percent of Total Billed Charges,60% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.78,14.42,,155.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1080.68,75,,207.816,Percent of Total Billed Charges,75% of Total Billed Charges,720.45,50,,470.88,Percent of Total Billed Charges,50% of Total Billed Charges,720.45,50,,138.544,Percent of Total Billed Charges,50% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,720.45,50,,138.544,Percent of Total Billed Charges,50% of Total Billed Charges,720.45,50,,138.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1008.63,70,,7293.616,Percent of Total Billed Charges,70% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,201.73,14,,151.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.9,100,,277.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1440.9,
154298 4.0MM BARREL BUR,32100027,CDM,272,RC,,,Outpatient,,,313.02,187.81,,187.81,60,,50239.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.65,28,,2212,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,112.69,36,,2844,Percent of Total Billed Charges,36% of Total Billed Charges,112.69,36,,2844,Percent of Total Billed Charges,36% Total Bille Charges,112.69,36,,2844,Percent of Total Billed Charges,36% of Total Billed Charges,187.81,60,,876.48,Percent of Total Billed Charges,60% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14.42,,15.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.77,75,,1910.4,Percent of Total Billed Charges,75% of Total Billed Charges,156.51,50,,3351.92,Percent of Total Billed Charges,50% of Total Billed Charges,156.51,50,,1194,Percent of Total Billed Charges,50% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.51,50,,1194,Percent of Total Billed Charges,50% of Total Billed Charges,156.51,50,,1194,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.11,70,,2253.024,Percent of Total Billed Charges,70% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.02,100,,2388,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,313.02,
120700 5.0MM RESECTOR,32100029,CDM,272,RC,,,Outpatient,,,243.95,146.37,,146.37,60,,72427.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.31,28,,3539.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,87.82,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,87.82,36,,4550.4,Percent of Total Billed Charges,36% Total Bille Charges,87.82,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,146.37,60,,996.136,Percent of Total Billed Charges,60% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,35.18,14.42,,389.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.96,75,,2889.6,Percent of Total Billed Charges,75% of Total Billed Charges,121.98,50,,138.544,Percent of Total Billed Charges,50% of Total Billed Charges,121.98,50,,1806,Percent of Total Billed Charges,50% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.98,50,,1806,Percent of Total Billed Charges,50% of Total Billed Charges,121.98,50,,1806,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.77,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,378.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.95,100,,3612,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,243.95,
200079 5.5 BARREL BUR,32100031,CDM,272,RC,,,Outpatient,,,316.15,189.69,,189.69,60,,118052.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.52,28,,3539.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.17,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,113.81,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,113.81,36,,4550.4,Percent of Total Billed Charges,36% Total Bille Charges,113.81,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,189.69,60,,435.24,Percent of Total Billed Charges,60% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,45.59,14.42,,71.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.11,75,,864,Percent of Total Billed Charges,75% of Total Billed Charges,158.08,50,,1194,Percent of Total Billed Charges,50% of Total Billed Charges,158.08,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.08,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,158.08,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.31,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,69.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.15,100,,1080,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,316.15,
154373 5.5 AGGRESSIVE SHAVER,32100032,CDM,272,RC,,,Outpatient,,,277.15,166.29,,166.29,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.6,28,,45.968,Percent of Total Billed Charges,28% of Total Billed Charges,0.18,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,99.77,36,,59.104,Percent of Total Billed Charges,36% of Total Billed Charges,99.77,36,,59.104,Percent of Total Billed Charges,36% Total Bille Charges,99.77,36,,59.104,Percent of Total Billed Charges,36% of Total Billed Charges,166.29,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.97,14.42,,62.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.86,75,,79.92,Percent of Total Billed Charges,75% of Total Billed Charges,138.58,50,,1806,Percent of Total Billed Charges,50% of Total Billed Charges,138.58,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.58,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,138.58,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.01,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,38.8,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.15,100,,106.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,277.15,
MESH ONFLEX  LGE 10.2 X 15.7CM,32100033,CDM,278,RC,C1781,HCPCS,Outpatient,,,1177.2,706.32,,1747.68,110,,120.4,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.62,28,,3539.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.18,32,,0.248,Percent of Total Billed Charges,32% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,423.79,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,423.79,36,,4550.4,Percent of Total Billed Charges,36% Total Bille Charges,423.79,36,,4550.4,Percent of Total Billed Charges,36% of Total Billed Charges,647.46,55,,293.76,Percent of Total Billed Charges,55% Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,169.75,14.42,,63.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,941.76,80,,2163.2,Percent of Total Billed Charges,80% of Total Billed Charges,588.6,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,588.6,50,,1352,Percent of Total Billed Charges,50% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,588.6,50,,1352,Percent of Total Billed Charges,50% of Total Billed Charges,588.6,50,,1352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,824.04,70,,370.88,Percent of Total Billed Charges,70% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,164.81,14,,61.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1177.2,100,,2704,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,1747.68,
STRATTICE CONTOUR MESH,32100040,CDM,278,RC,C1781,HCPCS,Outpatient,,,8379.8,5027.88,,9670.54,110,,119.08,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2346.34,28,,4116.448,Percent of Total Billed Charges,28% of Total Billed Charges,0.18,32,,257.28,Percent of Total Billed Charges,32% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,3016.73,36,,5292.576,Percent of Total Billed Charges,36% of Total Billed Charges,3016.73,36,,5292.576,Percent of Total Billed Charges,36% Total Bille Charges,3016.73,36,,5292.576,Percent of Total Billed Charges,36% of Total Billed Charges,4608.89,55,,1316.72,Percent of Total Billed Charges,55% Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1208.37,14.42,,91.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6703.84,80,,374.4,Percent of Total Billed Charges,80% of Total Billed Charges,4189.9,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,4189.9,50,,249.6,Percent of Total Billed Charges,50% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4189.9,50,,249.6,Percent of Total Billed Charges,50% of Total Billed Charges,4189.9,50,,249.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5865.86,70,,146.896,Percent of Total Billed Charges,70% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,1173.17,14,,89.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8379.8,100,,499.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,9670.54,
V-LOC ENDOSTITCH 2-0,32100041,CDM,272,RC,,,Outpatient,,,346.36,207.82,,207.82,60,,176.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.98,28,,5697.888,Percent of Total Billed Charges,28% of Total Billed Charges,0.18,32,,257.536,Percent of Total Billed Charges,32% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,124.69,36,,7325.856,Percent of Total Billed Charges,36% of Total Billed Charges,124.69,36,,7325.856,Percent of Total Billed Charges,36% Total Bille Charges,124.69,36,,7325.856,Percent of Total Billed Charges,36% of Total Billed Charges,207.82,60,,2349.088,Percent of Total Billed Charges,60% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,49.95,14.42,,211.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.77,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,173.18,50,,1352,Percent of Total Billed Charges,50% of Total Billed Charges,173.18,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.18,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,173.18,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,242.45,70,,232.464,Percent of Total Billed Charges,70% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,14,,204.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.36,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,346.36,
MEMBRANE GRAFIX PRIME 1.5X2CM,32100043,CDM,278,RC,,,Outpatient,,,2985,1791.00,,3283.5,110,,275.824,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.8,28,,2610.944,Percent of Total Billed Charges,28% of Total Billed Charges,0.18,32,,259.688,Percent of Total Billed Charges,32% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,1074.6,36,,3356.928,Percent of Total Billed Charges,36% of Total Billed Charges,1074.6,36,,3356.928,Percent of Total Billed Charges,36% Total Bille Charges,1074.6,36,,3356.928,Percent of Total Billed Charges,36% of Total Billed Charges,1641.75,55,,33.6,Percent of Total Billed Charges,55% Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,430.44,14.42,,30.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2388,80,,332.104,Percent of Total Billed Charges,80% of Total Billed Charges,1492.5,50,,249.6,Percent of Total Billed Charges,50% of Total Billed Charges,1492.5,50,,221.4,Percent of Total Billed Charges,50% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.5,50,,221.4,Percent of Total Billed Charges,50% of Total Billed Charges,1492.5,50,,221.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.5,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,417.9,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2985,100,,442.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,3283.5,
MEMBRANE GRAFIX PRIME 3X4CM,32100044,CDM,278,RC,,,Outpatient,,,4515,2709.00,,4966.5,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1264.2,28,,79.072,Percent of Total Billed Charges,28% of Total Billed Charges,0.19,32,,259.688,Percent of Total Billed Charges,32% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,1625.4,36,,101.664,Percent of Total Billed Charges,36% of Total Billed Charges,1625.4,36,,101.664,Percent of Total Billed Charges,36% Total Bille Charges,1625.4,36,,101.664,Percent of Total Billed Charges,36% of Total Billed Charges,2483.25,55,,33.6,Percent of Total Billed Charges,55% Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,651.06,14.42,,54.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3612,80,,477,Percent of Total Billed Charges,80% of Total Billed Charges,2257.5,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,2257.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2257.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,2257.5,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3160.5,70,,370.88,Percent of Total Billed Charges,70% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.1,14,,53.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4515,100,,636,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,4966.5,
DBM PRIME HD 5CC,32100049,CDM,278,RC,A4649,HCPCS,Outpatient,,,1350,810.00,,1485,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,28,,206.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.19,32,,259.688,Percent of Total Billed Charges,32% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,486,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,486,36,,265.248,Percent of Total Billed Charges,36% Total Bille Charges,486,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,742.5,55,,14.008,Percent of Total Billed Charges,55% Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,194.67,14.42,,138.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1080,80,,1098,Percent of Total Billed Charges,80% of Total Billed Charges,675,50,,221.4,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,732,Percent of Total Billed Charges,50% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,50,,732,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,732,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,70,,370.88,Percent of Total Billed Charges,70% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1350,100,,1464,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,1485,
V-LOC 3-0 SH,32100050,CDM,272,RC,,,Outpatient,,,133.2,79.92,,79.92,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.3,28,,446.88,Percent of Total Billed Charges,28% of Total Billed Charges,0.19,32,,260.024,Percent of Total Billed Charges,32% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,36,,574.56,Percent of Total Billed Charges,36% of Total Billed Charges,47.95,36,,574.56,Percent of Total Billed Charges,36% Total Bille Charges,47.95,36,,574.56,Percent of Total Billed Charges,36% of Total Billed Charges,79.92,60,,2557.152,Percent of Total Billed Charges,60% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,19.21,14.42,,141.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.9,75,,160.8,Percent of Total Billed Charges,75% of Total Billed Charges,66.6,50,,318,Percent of Total Billed Charges,50% of Total Billed Charges,66.6,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.6,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,66.6,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.24,70,,370.88,Percent of Total Billed Charges,70% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,137.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.2,100,,214.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,133.2,
BREAST IMPLANT,32100051,CDM,278,RC,C1789,HCPCS,Outpatient,,,3380,2028.00,,4120.32,110,,64.8,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,946.4,28,,1280.384,Percent of Total Billed Charges,28% of Total Billed Charges,0.19,32,,260.632,Percent of Total Billed Charges,32% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,1216.8,36,,1646.208,Percent of Total Billed Charges,36% of Total Billed Charges,1216.8,36,,1646.208,Percent of Total Billed Charges,36% Total Bille Charges,1216.8,36,,1646.208,Percent of Total Billed Charges,36% of Total Billed Charges,1859,55,,25.032,Percent of Total Billed Charges,55% Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,487.4,14.42,,30.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2704,80,,285,Percent of Total Billed Charges,80% of Total Billed Charges,1690,50,,732,Percent of Total Billed Charges,50% of Total Billed Charges,1690,50,,190,Percent of Total Billed Charges,50% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1690,50,,190,Percent of Total Billed Charges,50% of Total Billed Charges,1690,50,,190,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2366,70,,2926.56,Percent of Total Billed Charges,70% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,29.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3380,100,,380,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,4120.32,
VISIGI 40FR (5240B),32100052,CDM,272,RC,,,Outpatient,,,624,374.40,,374.4,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.72,28,,1960.896,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,261.12,Percent of Total Billed Charges,32% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,224.64,36,,2521.152,Percent of Total Billed Charges,36% of Total Billed Charges,224.64,36,,2521.152,Percent of Total Billed Charges,36% Total Bille Charges,224.64,36,,2521.152,Percent of Total Billed Charges,36% of Total Billed Charges,374.4,60,,59.048,Percent of Total Billed Charges,60% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,89.98,14.42,,1363.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468,75,,720,Percent of Total Billed Charges,75% of Total Billed Charges,312,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,312,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,312,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,70,,379.232,Percent of Total Billed Charges,70% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,87.36,14,,1323.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,624,100,,960,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,624,
VISIGI 32FR (5232),32100053,CDM,272,RC,,,Outpatient,,,540,324.00,,324,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.2,28,,3077.984,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,263.576,Percent of Total Billed Charges,32% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,194.4,36,,3957.408,Percent of Total Billed Charges,36% of Total Billed Charges,194.4,36,,3957.408,Percent of Total Billed Charges,36% Total Bille Charges,194.4,36,,3957.408,Percent of Total Billed Charges,36% of Total Billed Charges,324,60,,71.768,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,77.87,14.42,,1141.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,737.192,Percent of Total Billed Charges,75% of Total Billed Charges,270,50,,190,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,491.464,Percent of Total Billed Charges,50% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,50,,491.464,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,491.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,70,,820.984,Percent of Total Billed Charges,70% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,1108.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540,100,,982.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,540,
ENDO BAG SPECIMEN RETRIEVAL SYSTEM,32100054,CDM,272,RC,,,Outpatient,,,553.5,332.10,,332.1,60,,175.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.98,28,,4963.616,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,264.984,Percent of Total Billed Charges,32% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,199.26,36,,6381.792,Percent of Total Billed Charges,36% of Total Billed Charges,199.26,36,,6381.792,Percent of Total Billed Charges,36% Total Bille Charges,199.26,36,,6381.792,Percent of Total Billed Charges,36% of Total Billed Charges,332.1,60,,43.92,Percent of Total Billed Charges,60% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,79.81,14.42,,117.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.13,75,,156.6,Percent of Total Billed Charges,75% of Total Billed Charges,276.75,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,276.75,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.75,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,276.75,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,387.45,70,,367.576,Percent of Total Billed Charges,70% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,14,,113.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553.5,100,,208.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,553.5,
PHOTON GUIDE LIGHTED RETRACTOR,32100055,CDM,272,RC,,,Outpatient,,,795,477.00,,477,60,,178.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.6,28,,8208.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,265.096,Percent of Total Billed Charges,32% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,286.2,36,,10553.76,Percent of Total Billed Charges,36% of Total Billed Charges,286.2,36,,10553.76,Percent of Total Billed Charges,36% Total Bille Charges,286.2,36,,10553.76,Percent of Total Billed Charges,36% of Total Billed Charges,477,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,114.64,14.42,,335.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,596.25,75,,7092,Percent of Total Billed Charges,75% of Total Billed Charges,397.5,50,,491.464,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,4728,Percent of Total Billed Charges,50% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.5,50,,4728,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,4728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.5,70,,320.504,Percent of Total Billed Charges,70% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,325.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,795,100,,9456,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,795,
LIGASURE RETRACTABLE L-HOOK,32100056,CDM,271,RC,,,Outpatient,,,1830,1098.00,,1098,60,,388.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,512.4,28,,14373.408,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,265.792,Percent of Total Billed Charges,32% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,658.8,36,,18480.096,Percent of Total Billed Charges,36% of Total Billed Charges,658.8,36,,18480.096,Percent of Total Billed Charges,36% Total Bille Charges,658.8,36,,18480.096,Percent of Total Billed Charges,36% of Total Billed Charges,1098,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,263.89,14.42,,257.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1372.5,75,,5935.8,Percent of Total Billed Charges,75% of Total Billed Charges,915,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,3957.2,Percent of Total Billed Charges,50% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,915,50,,3957.2,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,3957.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1281,70,,1411.2,Percent of Total Billed Charges,70% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,256.2,14,,250.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1830,100,,7914.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1830,
GARMENT COMP WEAR VEST LG,32100057,CDM,271,RC,,,Outpatient,,,268,160.80,,160.8,60,,396.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.04,28,,810.88,Percent of Total Billed Charges,28% of Total Billed Charges,0.2,32,,266.056,Percent of Total Billed Charges,32% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,96.48,36,,1042.56,Percent of Total Billed Charges,36% of Total Billed Charges,96.48,36,,1042.56,Percent of Total Billed Charges,36% Total Bille Charges,96.48,36,,1042.56,Percent of Total Billed Charges,36% of Total Billed Charges,160.8,60,,67.272,Percent of Total Billed Charges,60% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14.42,,313.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201,75,,609.424,Percent of Total Billed Charges,75% of Total Billed Charges,134,50,,4728,Percent of Total Billed Charges,50% of Total Billed Charges,134,50,,406.288,Percent of Total Billed Charges,50% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134,50,,406.288,Percent of Total Billed Charges,50% of Total Billed Charges,134,50,,406.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.6,70,,186.392,Percent of Total Billed Charges,70% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,303.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268,100,,812.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,268,
GARMENT COMP ABV KNEE HG BAG,32100058,CDM,271,RC,,,Outpatient,,,475,285.00,,285,60,,366.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133,28,,55.16,Percent of Total Billed Charges,28% of Total Billed Charges,0.21,32,,266.24,Percent of Total Billed Charges,32% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,171,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,171,36,,70.92,Percent of Total Billed Charges,36% Total Bille Charges,171,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,285,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,68.5,14.42,,18.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356.25,75,,1746.032,Percent of Total Billed Charges,75% of Total Billed Charges,237.5,50,,3957.2,Percent of Total Billed Charges,50% of Total Billed Charges,237.5,50,,1164.024,Percent of Total Billed Charges,50% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.5,50,,1164.024,Percent of Total Billed Charges,50% of Total Billed Charges,237.5,50,,1164.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.5,70,,270.12,Percent of Total Billed Charges,70% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,66.5,14,,17.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,475,100,,2328.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,475,
THUNDERBEAT 5MM (TB-0545FCS),32100060,CDM,271,RC,,,Outpatient,,,1200,720.00,,720,60,,396.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336,28,,39.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.21,32,,267.776,Percent of Total Billed Charges,32% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,432,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,432,36,,50.4,Percent of Total Billed Charges,36% Total Bille Charges,432,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,720,60,,73.32,Percent of Total Billed Charges,60% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,173.04,14.42,,841.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900,75,,1430.4,Percent of Total Billed Charges,75% of Total Billed Charges,600,50,,406.288,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,894,Percent of Total Billed Charges,50% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,50,,894,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,894,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,70,,448.904,Percent of Total Billed Charges,70% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,817.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200,100,,1788,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,1200,
VISTASEAL FIBRIN SEALANT 10ML,32100061,CDM,272,RC,,,Outpatient,,,1228.65,737.19,,737.19,60,,488.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.02,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,0.21,32,,268.184,Percent of Total Billed Charges,32% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,442.31,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,442.31,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,442.31,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,737.19,60,,7788,Percent of Total Billed Charges,60% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,177.17,14.42,,28.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921.49,75,,1628.4,Percent of Total Billed Charges,75% of Total Billed Charges,614.33,50,,1164.024,Percent of Total Billed Charges,50% of Total Billed Charges,614.33,50,,1085.6,Percent of Total Billed Charges,50% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.33,50,,1085.6,Percent of Total Billed Charges,50% of Total Billed Charges,614.33,50,,1085.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,860.06,70,,2990.624,Percent of Total Billed Charges,70% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,172.01,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.65,100,,2171.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,1228.65,
VISTASEAL APLLICATOR 35CM,32100062,CDM,271,RC,,,Outpatient,,,261,156.60,,156.6,60,,454.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.08,28,,31.16,Percent of Total Billed Charges,28% of Total Billed Charges,0.21,32,,268.8,Percent of Total Billed Charges,32% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,93.96,36,,40.064,Percent of Total Billed Charges,36% of Total Billed Charges,93.96,36,,40.064,Percent of Total Billed Charges,36% Total Bille Charges,93.96,36,,40.064,Percent of Total Billed Charges,36% of Total Billed Charges,156.6,60,,7788,Percent of Total Billed Charges,60% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14.42,,42.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.75,75,,94.32,Percent of Total Billed Charges,75% of Total Billed Charges,130.5,50,,894,Percent of Total Billed Charges,50% of Total Billed Charges,130.5,50,,62.88,Percent of Total Billed Charges,50% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.5,50,,62.88,Percent of Total Billed Charges,50% of Total Billed Charges,130.5,50,,62.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.7,70,,1115.52,Percent of Total Billed Charges,70% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,36.54,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261,100,,125.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,261,
KIT BONE GRAFT INFS II LG,32100063,CDM,271,RC,,,Outpatient,,,11820,7092.00,,7092,60,,406.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3309.6,28,,25.016,Percent of Total Billed Charges,28% of Total Billed Charges,0.22,32,,268.88,Percent of Total Billed Charges,32% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,4255.2,36,,32.16,Percent of Total Billed Charges,36% of Total Billed Charges,4255.2,36,,32.16,Percent of Total Billed Charges,36% Total Bille Charges,4255.2,36,,32.16,Percent of Total Billed Charges,36% of Total Billed Charges,7092,60,,4345,Percent of Total Billed Charges,60% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1704.44,14.42,,186.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8865,75,,4377.36,Percent of Total Billed Charges,75% of Total Billed Charges,5910,50,,1085.6,Percent of Total Billed Charges,50% of Total Billed Charges,5910,50,,2918.24,Percent of Total Billed Charges,50% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5910,50,,2918.24,Percent of Total Billed Charges,50% of Total Billed Charges,5910,50,,2918.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8274,70,,1162.16,Percent of Total Billed Charges,70% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,1654.8,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11820,100,,5836.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,11820,
KIT BONE GRAFT INFS SMALL,32100064,CDM,271,RC,,,Outpatient,,,9893,5935.80,,5935.8,60,,498.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2770.04,28,,25.872,Percent of Total Billed Charges,28% of Total Billed Charges,0.22,32,,268.88,Percent of Total Billed Charges,32% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,3561.48,36,,33.264,Percent of Total Billed Charges,36% of Total Billed Charges,3561.48,36,,33.264,Percent of Total Billed Charges,36% Total Bille Charges,3561.48,36,,33.264,Percent of Total Billed Charges,36% of Total Billed Charges,5935.8,60,,6952,Percent of Total Billed Charges,60% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1426.57,14.42,,448.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7419.75,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,4946.5,50,,62.88,Percent of Total Billed Charges,50% of Total Billed Charges,4946.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4946.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,4946.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6925.1,70,,507.784,Percent of Total Billed Charges,70% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,1385.02,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9893,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,9893,
ABSORBATACK FIXATION 5MM,32100065,CDM,271,RC,,,Outpatient,,,1015.71,609.43,,609.43,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.4,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,0.22,32,,268.88,Percent of Total Billed Charges,32% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,365.66,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,365.66,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,365.66,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,609.43,60,,6952,Percent of Total Billed Charges,60% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,146.47,14.42,,151.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,761.78,75,,234.88,Percent of Total Billed Charges,75% of Total Billed Charges,507.86,50,,2918.24,Percent of Total Billed Charges,50% of Total Billed Charges,507.86,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.86,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,507.86,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711,70,,478.8,Percent of Total Billed Charges,70% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,142.2,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1015.71,100,,293.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,1015.71,
LYNX BLUE SUPRAPUBIC SLING,32100066,CDM,271,RC,,,Outpatient,,,2910.05,1746.03,,1746.03,60,,379.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,814.81,28,,23.264,Percent of Total Billed Charges,28% of Total Billed Charges,0.22,32,,268.88,Percent of Total Billed Charges,32% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,1047.62,36,,29.912,Percent of Total Billed Charges,36% of Total Billed Charges,1047.62,36,,29.912,Percent of Total Billed Charges,36% Total Bille Charges,1047.62,36,,29.912,Percent of Total Billed Charges,36% of Total Billed Charges,1746.03,60,,98.504,Percent of Total Billed Charges,60% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,419.63,14.42,,442.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2182.54,75,,967.48,Percent of Total Billed Charges,75% of Total Billed Charges,1455.03,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,1455.03,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1455.03,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,1455.03,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2037.04,70,,342.72,Percent of Total Billed Charges,70% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,407.41,14,,429.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2910.05,100,,1289.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,2910.05,
VENTRALEX ST HERNIA PATCH,32100067,CDM,278,RC,,,Outpatient,,,2235,1341.00,,2458.5,110,,193.672,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,625.8,28,,63.296,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,271.952,Percent of Total Billed Charges,32% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,804.6,36,,81.384,Percent of Total Billed Charges,36% of Total Billed Charges,804.6,36,,81.384,Percent of Total Billed Charges,36% Total Bille Charges,804.6,36,,81.384,Percent of Total Billed Charges,36% of Total Billed Charges,1229.25,55,,6952,Percent of Total Billed Charges,55% Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,322.29,14.42,,100.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1788,80,,2332.2,Percent of Total Billed Charges,80% of Total Billed Charges,1117.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,1117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,1117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1564.5,70,,1536.168,Percent of Total Billed Charges,70% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,312.9,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2235,100,,3109.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,2458.5,
ADIPOSE MATRIX,32100068,CDM,272,RC,,,Outpatient,,,2714,1628.40,,1628.4,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,759.92,28,,44.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,272.2,Percent of Total Billed Charges,32% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,977.04,36,,57.552,Percent of Total Billed Charges,36% of Total Billed Charges,977.04,36,,57.552,Percent of Total Billed Charges,36% Total Bille Charges,977.04,36,,57.552,Percent of Total Billed Charges,36% of Total Billed Charges,1628.4,60,,8085.88,Percent of Total Billed Charges,60% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,391.36,14.42,,67.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2035.5,75,,786.6,Percent of Total Billed Charges,75% of Total Billed Charges,1357,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,1357,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1357,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,1357,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1899.8,70,,2989.752,Percent of Total Billed Charges,70% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,379.96,14,,65.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2714,100,,1048.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,2714,
PERITONEAL DIALYSIS CATH,32100069,CDM,272,RC,,,Outpatient,,,157.2,94.32,,94.32,60,,193.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.02,28,,56.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,272.2,Percent of Total Billed Charges,32% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,56.59,36,,73.048,Percent of Total Billed Charges,36% of Total Billed Charges,56.59,36,,73.048,Percent of Total Billed Charges,36% Total Bille Charges,56.59,36,,73.048,Percent of Total Billed Charges,36% of Total Billed Charges,94.32,60,,11192.28,Percent of Total Billed Charges,60% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.67,14.42,,769.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.9,75,,2299.44,Percent of Total Billed Charges,75% of Total Billed Charges,78.6,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,78.6,50,,1532.96,Percent of Total Billed Charges,50% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.6,50,,1532.96,Percent of Total Billed Charges,50% of Total Billed Charges,78.6,50,,1532.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.04,70,,232.576,Percent of Total Billed Charges,70% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,22.01,14,,747.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.2,100,,3065.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,157.2,
VASCULAR GRAFT 8X70,32100070,CDM,272,RC,,,Outpatient,,,7295.6,4377.36,,4377.36,60,,298.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2042.77,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,274.448,Percent of Total Billed Charges,32% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,2626.42,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,2626.42,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,2626.42,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,4377.36,60,,5128.64,Percent of Total Billed Charges,60% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1052.03,14.42,,519.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5471.7,75,,524.232,Percent of Total Billed Charges,75% of Total Billed Charges,3647.8,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,3647.8,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3647.8,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,3647.8,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5106.92,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,1021.38,14,,504.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7295.6,100,,698.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,7295.6,
PEEL AWAY INTRODUCER 16 FR,32100071,CDM,271,RC,,,Outpatient,,,250,150.00,,150,60,,118.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,28,,65.52,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,274.448,Percent of Total Billed Charges,32% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,90,36,,84.24,Percent of Total Billed Charges,36% of Total Billed Charges,90,36,,84.24,Percent of Total Billed Charges,36% Total Bille Charges,90,36,,84.24,Percent of Total Billed Charges,36% of Total Billed Charges,150,60,,405.24,Percent of Total Billed Charges,60% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,36.05,14.42,,840.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.5,75,,351.36,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,1532.96,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,234.24,Percent of Total Billed Charges,50% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125,50,,234.24,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,234.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,816.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,100,,468.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,250,
MESH 6X6,32100072,CDM,278,RC,,,Outpatient,,,367,220.20,,403.7,110,,113.584,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.76,28,,72.8,Percent of Total Billed Charges,28% of Total Billed Charges,0.23,32,,275.696,Percent of Total Billed Charges,32% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,36,,93.6,Percent of Total Billed Charges,36% of Total Billed Charges,132.12,36,,93.6,Percent of Total Billed Charges,36% Total Bille Charges,132.12,36,,93.6,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14.42,,183.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.6,80,,4004.392,Percent of Total Billed Charges,80% of Total Billed Charges,183.5,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,2669.592,Percent of Total Billed Charges,50% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.5,50,,2669.592,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,2669.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.9,70,,16.344,Percent of Total Billed Charges,70% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,178.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367,100,,5339.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,403.7,
HEMASHIELD GRAFT 18X9,32100073,CDM,272,RC,,,Outpatient,,,1612.47,967.48,,967.48,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.49,28,,81.224,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,275.696,Percent of Total Billed Charges,32% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,580.49,36,,104.432,Percent of Total Billed Charges,36% of Total Billed Charges,580.49,36,,104.432,Percent of Total Billed Charges,36% Total Bille Charges,580.49,36,,104.432,Percent of Total Billed Charges,36% of Total Billed Charges,967.48,60,,2515.04,Percent of Total Billed Charges,60% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,232.52,14.42,,769.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1209.35,75,,2884.376,Percent of Total Billed Charges,75% of Total Billed Charges,806.24,50,,234.24,Percent of Total Billed Charges,50% of Total Billed Charges,806.24,50,,1802.736,Percent of Total Billed Charges,50% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,806.24,50,,1802.736,Percent of Total Billed Charges,50% of Total Billed Charges,806.24,50,,1802.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1128.73,70,,2983.344,Percent of Total Billed Charges,70% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,747.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1612.47,100,,3605.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,1612.47,
SYNDESMOIS TIGHTROPE,32100074,CDM,271,RC,,,Outpatient,,,3887,2332.20,,2332.2,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,28,,212.856,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,275.696,Percent of Total Billed Charges,32% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,1399.32,36,,273.672,Percent of Total Billed Charges,36% of Total Billed Charges,1399.32,36,,273.672,Percent of Total Billed Charges,36% Total Bille Charges,1399.32,36,,273.672,Percent of Total Billed Charges,36% of Total Billed Charges,2332.2,60,,3851.76,Percent of Total Billed Charges,60% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,560.51,14.42,,250.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2915.25,75,,4663.192,Percent of Total Billed Charges,75% of Total Billed Charges,1943.5,50,,2669.592,Percent of Total Billed Charges,50% of Total Billed Charges,1943.5,50,,2914.496,Percent of Total Billed Charges,50% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1943.5,50,,2914.496,Percent of Total Billed Charges,50% of Total Billed Charges,1943.5,50,,2914.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2720.9,70,,29.208,Percent of Total Billed Charges,70% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,243.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3887,100,,5828.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,3887,
BONE CEMENT HERAEUS,32100075,CDM,272,RC,,,Outpatient,,,1311,786.60,,786.6,60,,168.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.08,28,,379.856,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,275.696,Percent of Total Billed Charges,32% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,471.96,36,,488.392,Percent of Total Billed Charges,36% of Total Billed Charges,471.96,36,,488.392,Percent of Total Billed Charges,36% Total Bille Charges,471.96,36,,488.392,Percent of Total Billed Charges,36% of Total Billed Charges,786.6,60,,6046.04,Percent of Total Billed Charges,60% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,189.05,14.42,,412.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,983.25,75,,954,Percent of Total Billed Charges,75% of Total Billed Charges,655.5,50,,1802.736,Percent of Total Billed Charges,50% of Total Billed Charges,655.5,50,,636,Percent of Total Billed Charges,50% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,655.5,50,,636,Percent of Total Billed Charges,50% of Total Billed Charges,655.5,50,,636,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917.7,70,,68.888,Percent of Total Billed Charges,70% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,400.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1311,100,,1272,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,1311,
VASCULAR GRAFT 7X80,32100076,CDM,272,RC,,,Outpatient,,,3832.4,2299.44,,2299.44,60,,253.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1073.07,28,,96.52,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,276.896,Percent of Total Billed Charges,32% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,1379.66,36,,124.096,Percent of Total Billed Charges,36% of Total Billed Charges,1379.66,36,,124.096,Percent of Total Billed Charges,36% Total Bille Charges,1379.66,36,,124.096,Percent of Total Billed Charges,36% of Total Billed Charges,2299.44,60,,9749.96,Percent of Total Billed Charges,60% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,552.63,14.42,,72.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2874.3,75,,4004.208,Percent of Total Billed Charges,75% of Total Billed Charges,1916.2,50,,2914.496,Percent of Total Billed Charges,50% of Total Billed Charges,1916.2,50,,2669.472,Percent of Total Billed Charges,50% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1916.2,50,,2669.472,Percent of Total Billed Charges,50% of Total Billed Charges,1916.2,50,,2669.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2682.68,70,,83.728,Percent of Total Billed Charges,70% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,536.54,14,,70.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3832.4,100,,5338.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,3832.4,
ALLOPATCH 2X2,32100077,CDM,272,RC,,,Outpatient,,,873.72,524.23,,524.23,60,,171.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.64,28,,94.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,277.248,Percent of Total Billed Charges,32% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,314.54,36,,121.48,Percent of Total Billed Charges,36% of Total Billed Charges,314.54,36,,121.48,Percent of Total Billed Charges,36% Total Bille Charges,314.54,36,,121.48,Percent of Total Billed Charges,36% of Total Billed Charges,524.23,60,,16123.8,Percent of Total Billed Charges,60% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,125.99,14.42,,95.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,655.29,75,,1302,Percent of Total Billed Charges,75% of Total Billed Charges,436.86,50,,636,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,868,Percent of Total Billed Charges,50% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.86,50,,868,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,868,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,611.6,70,,51.24,Percent of Total Billed Charges,70% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,93.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.72,100,,1736,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,873.72,
PNEUMOTHORAX SET,32100078,CDM,272,RC,,,Outpatient,,,585.6,351.36,,351.36,60,,232.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.97,28,,138.32,Percent of Total Billed Charges,28% of Total Billed Charges,0.24,32,,278.216,Percent of Total Billed Charges,32% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,210.82,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,210.82,36,,177.84,Percent of Total Billed Charges,36% Total Bille Charges,210.82,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,351.36,60,,28233.48,Percent of Total Billed Charges,60% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,84.44,14.42,,11.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.2,75,,2288.336,Percent of Total Billed Charges,75% of Total Billed Charges,292.8,50,,2669.472,Percent of Total Billed Charges,50% of Total Billed Charges,292.8,50,,1430.208,Percent of Total Billed Charges,50% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.8,50,,1430.208,Percent of Total Billed Charges,50% of Total Billed Charges,292.8,50,,1430.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,409.92,70,,1.336,Percent of Total Billed Charges,70% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,81.98,14,,10.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585.6,100,,2860.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,585.6,
MTB BTB HEMI 10MM,32100079,CDM,272,RC,,,Outpatient,,,6673.98,4004.39,,4004.39,60,,497.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1868.71,28,,136.448,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,278.688,Percent of Total Billed Charges,32% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,2402.63,36,,175.432,Percent of Total Billed Charges,36% of Total Billed Charges,2402.63,36,,175.432,Percent of Total Billed Charges,36% Total Bille Charges,2402.63,36,,175.432,Percent of Total Billed Charges,36% of Total Billed Charges,4004.39,60,,1592.8,Percent of Total Billed Charges,60% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,962.39,14.42,,65.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5005.49,75,,378.36,Percent of Total Billed Charges,75% of Total Billed Charges,3336.99,50,,868,Percent of Total Billed Charges,50% of Total Billed Charges,3336.99,50,,252.24,Percent of Total Billed Charges,50% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3336.99,50,,252.24,Percent of Total Billed Charges,50% of Total Billed Charges,3336.99,50,,252.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4671.79,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,934.36,14,,63.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6673.98,100,,504.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,6673.98,
VENTRIO MESH 5X7,32100080,CDM,278,RC,,,Outpatient,,,4506.84,2704.10,,4957.52,110,,91.92,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1261.92,28,,169.144,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,279.2,Percent of Total Billed Charges,32% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,1622.46,36,,217.472,Percent of Total Billed Charges,36% of Total Billed Charges,1622.46,36,,217.472,Percent of Total Billed Charges,36% Total Bille Charges,1622.46,36,,217.472,Percent of Total Billed Charges,36% of Total Billed Charges,2478.76,55,,118.2,Percent of Total Billed Charges,55% Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,649.89,14.42,,161.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3605.47,80,,498.6,Percent of Total Billed Charges,80% of Total Billed Charges,2253.42,50,,1430.208,Percent of Total Billed Charges,50% of Total Billed Charges,2253.42,50,,332.4,Percent of Total Billed Charges,50% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2253.42,50,,332.4,Percent of Total Billed Charges,50% of Total Billed Charges,2253.42,50,,332.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3154.79,70,,65.8,Percent of Total Billed Charges,70% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,630.96,14,,156.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4506.84,100,,664.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,4957.52,
VENTRIO MESH 8X10,32100081,CDM,278,RC,,,Outpatient,,,7286.24,4371.74,,8014.86,110,,64.8,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2040.15,28,,120.96,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,279.232,Percent of Total Billed Charges,32% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,2623.05,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,2623.05,36,,155.52,Percent of Total Billed Charges,36% Total Bille Charges,2623.05,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,4007.43,55,,84,Percent of Total Billed Charges,55% Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1050.68,14.42,,827.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5828.99,80,,58.896,Percent of Total Billed Charges,80% of Total Billed Charges,3643.12,50,,252.24,Percent of Total Billed Charges,50% of Total Billed Charges,3643.12,50,,39.264,Percent of Total Billed Charges,50% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3643.12,50,,39.264,Percent of Total Billed Charges,50% of Total Billed Charges,3643.12,50,,39.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5100.37,70,,78.488,Percent of Total Billed Charges,70% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,1020.07,14,,803.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7286.24,100,,78.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,8014.86,
CRICOTHYROTOMY CATHETER,32100082,CDM,272,RC,,,Outpatient,,,1590,954.00,,954,60,,143.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,445.2,28,,38.088,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,279.264,Percent of Total Billed Charges,32% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,572.4,36,,48.968,Percent of Total Billed Charges,36% of Total Billed Charges,572.4,36,,48.968,Percent of Total Billed Charges,36% Total Bille Charges,572.4,36,,48.968,Percent of Total Billed Charges,36% of Total Billed Charges,954,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,229.28,14.42,,959.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1192.5,75,,339.6,Percent of Total Billed Charges,75% of Total Billed Charges,795,50,,332.4,Percent of Total Billed Charges,50% of Total Billed Charges,795,50,,226.4,Percent of Total Billed Charges,50% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,795,50,,226.4,Percent of Total Billed Charges,50% of Total Billed Charges,795,50,,226.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1113,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,222.6,14,,931.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1590,100,,452.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,1590,
BONE TENDON BONE 10MM,32100083,CDM,272,RC,,,Outpatient,,,6673.68,4004.21,,4004.21,60,,147.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1868.63,28,,176.104,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,279.6,Percent of Total Billed Charges,32% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,2402.52,36,,226.416,Percent of Total Billed Charges,36% of Total Billed Charges,2402.52,36,,226.416,Percent of Total Billed Charges,36% Total Bille Charges,2402.52,36,,226.416,Percent of Total Billed Charges,36% of Total Billed Charges,4004.21,60,,66.768,Percent of Total Billed Charges,60% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,962.34,14.42,,26.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5005.26,75,,840.928,Percent of Total Billed Charges,75% of Total Billed Charges,3336.84,50,,39.264,Percent of Total Billed Charges,50% of Total Billed Charges,3336.84,50,,560.616,Percent of Total Billed Charges,50% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3336.84,50,,560.616,Percent of Total Billed Charges,50% of Total Billed Charges,3336.84,50,,560.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4671.58,70,,85.544,Percent of Total Billed Charges,70% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,934.32,14,,25.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6673.68,100,,1121.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,6673.68,
EVARREST FIBRIN PATCH 2X4,32100084,CDM,272,RC,,,Outpatient,,,2170,1302.00,,1302,60,,113.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,607.6,28,,152.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.25,32,,280.32,Percent of Total Billed Charges,32% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,781.2,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,781.2,36,,196.48,Percent of Total Billed Charges,36% Total Bille Charges,781.2,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,1302,60,,53.608,Percent of Total Billed Charges,60% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,312.91,14.42,,298.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1627.5,75,,4305.6,Percent of Total Billed Charges,75% of Total Billed Charges,1085,50,,226.4,Percent of Total Billed Charges,50% of Total Billed Charges,1085,50,,2870.4,Percent of Total Billed Charges,50% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1085,50,,2870.4,Percent of Total Billed Charges,50% of Total Billed Charges,1085,50,,2870.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1519,70,,9912,Percent of Total Billed Charges,70% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,303.8,14,,289.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2170,100,,5740.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,2170,
VENTRIO MESH 4X5,32100085,CDM,278,RC,,,Outpatient,,,3575.52,2145.31,,3933.07,110,,144,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1001.15,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.26,32,,280.32,Percent of Total Billed Charges,32% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1287.19,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1287.19,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1287.19,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1966.54,55,,140.712,Percent of Total Billed Charges,55% Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,515.59,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2860.42,80,,4990.176,Percent of Total Billed Charges,80% of Total Billed Charges,1787.76,50,,560.616,Percent of Total Billed Charges,50% of Total Billed Charges,1787.76,50,,3326.784,Percent of Total Billed Charges,50% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1787.76,50,,3326.784,Percent of Total Billed Charges,50% of Total Billed Charges,1787.76,50,,3326.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2502.86,70,,9912,Percent of Total Billed Charges,70% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,500.57,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3575.52,100,,6653.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,3933.07,
ARISTA POWDER 3G,32100086,CDM,271,RC,,,Outpatient,,,630.6,378.36,,378.36,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.57,28,,486.36,Percent of Total Billed Charges,28% of Total Billed Charges,0.26,32,,280.344,Percent of Total Billed Charges,32% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,227.02,36,,625.32,Percent of Total Billed Charges,36% of Total Billed Charges,227.02,36,,625.32,Percent of Total Billed Charges,36% Total Bille Charges,227.02,36,,625.32,Percent of Total Billed Charges,36% of Total Billed Charges,378.36,60,,49.856,Percent of Total Billed Charges,60% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,90.93,14.42,,40.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.95,75,,138.992,Percent of Total Billed Charges,75% of Total Billed Charges,315.3,50,,2870.4,Percent of Total Billed Charges,50% of Total Billed Charges,315.3,50,,92.664,Percent of Total Billed Charges,50% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.3,50,,92.664,Percent of Total Billed Charges,50% of Total Billed Charges,315.3,50,,92.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,441.42,70,,5530,Percent of Total Billed Charges,70% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,88.28,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630.6,100,,185.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,630.6,
ARISTA POWDER 5G,32100087,CDM,271,RC,,,Outpatient,,,831,498.60,,498.6,60,,49.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.68,28,,159.368,Percent of Total Billed Charges,28% of Total Billed Charges,0.26,32,,280.344,Percent of Total Billed Charges,32% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,299.16,36,,204.904,Percent of Total Billed Charges,36% of Total Billed Charges,299.16,36,,204.904,Percent of Total Billed Charges,36% Total Bille Charges,299.16,36,,204.904,Percent of Total Billed Charges,36% of Total Billed Charges,498.6,60,,135.632,Percent of Total Billed Charges,60% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,119.83,14.42,,230.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.25,75,,1656.704,Percent of Total Billed Charges,75% of Total Billed Charges,415.5,50,,3326.784,Percent of Total Billed Charges,50% of Total Billed Charges,415.5,50,,1035.44,Percent of Total Billed Charges,50% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,415.5,50,,1035.44,Percent of Total Billed Charges,50% of Total Billed Charges,415.5,50,,1035.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.7,70,,8848,Percent of Total Billed Charges,70% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,116.34,14,,223.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,831,100,,2070.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,831,
INSUFFLATION NEEDLE 14G,32100088,CDM,271,RC,,,Outpatient,,,98.16,58.90,,58.9,60,,111.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.48,28,,309.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.26,32,,280.344,Percent of Total Billed Charges,32% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,35.34,36,,398.264,Percent of Total Billed Charges,36% of Total Billed Charges,35.34,36,,398.264,Percent of Total Billed Charges,36% Total Bille Charges,35.34,36,,398.264,Percent of Total Billed Charges,36% of Total Billed Charges,58.9,60,,95.92,Percent of Total Billed Charges,60% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.15,14.42,,29.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.62,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,49.08,50,,92.664,Percent of Total Billed Charges,50% of Total Billed Charges,49.08,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.08,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,49.08,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.71,70,,8848,Percent of Total Billed Charges,70% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,13.74,14,,28.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.16,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,98.16,
VERSASTEP PLUS TROCAR,32100089,CDM,271,RC,,,Outpatient,,,566,339.60,,339.6,60,,195.352,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.48,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,280.344,Percent of Total Billed Charges,32% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,203.76,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,203.76,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,203.76,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,339.6,60,,121.744,Percent of Total Billed Charges,60% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,81.62,14.42,,622.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,424.5,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,283,50,,1035.44,Percent of Total Billed Charges,50% of Total Billed Charges,283,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,283,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,396.2,70,,114.92,Percent of Total Billed Charges,70% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,79.24,14,,604.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,566,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,566,
FORCEP TIPS ISOCOOL,32100090,CDM,272,RC,,,Outpatient,,,1401.54,840.92,,840.92,60,,239.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.43,28,,458.744,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,280.88,Percent of Total Billed Charges,32% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,504.55,36,,589.816,Percent of Total Billed Charges,36% of Total Billed Charges,504.55,36,,589.816,Percent of Total Billed Charges,36% Total Bille Charges,504.55,36,,589.816,Percent of Total Billed Charges,36% of Total Billed Charges,840.92,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,202.1,14.42,,285.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1051.16,75,,1197.304,Percent of Total Billed Charges,75% of Total Billed Charges,700.77,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,700.77,50,,798.2,Percent of Total Billed Charges,50% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700.77,50,,798.2,Percent of Total Billed Charges,50% of Total Billed Charges,700.77,50,,798.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,981.08,70,,8848,Percent of Total Billed Charges,70% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,196.22,14,,276.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1401.54,100,,1596.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1401.54,
HUMAN TISSUE MATRIX 5ML,32100091,CDM,272,RC,,,Outpatient,,,7176,4305.60,,4305.6,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2009.28,28,,311.096,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,280.976,Percent of Total Billed Charges,32% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,2583.36,36,,399.976,Percent of Total Billed Charges,36% of Total Billed Charges,2583.36,36,,399.976,Percent of Total Billed Charges,36% Total Bille Charges,2583.36,36,,399.976,Percent of Total Billed Charges,36% of Total Billed Charges,4305.6,60,,140.4,Percent of Total Billed Charges,60% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1034.78,14.42,,63.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5382,75,,153.24,Percent of Total Billed Charges,75% of Total Billed Charges,3588,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,3588,50,,102.16,Percent of Total Billed Charges,50% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3588,50,,102.16,Percent of Total Billed Charges,50% of Total Billed Charges,3588,50,,102.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5023.2,70,,10291.12,Percent of Total Billed Charges,70% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1004.64,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7176,100,,204.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,7176,
PATELLAR LIGAMENT,32100092,CDM,272,RC,,,Outpatient,,,8316.96,4990.18,,4990.18,60,,225.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2328.75,28,,333.44,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,281.08,Percent of Total Billed Charges,32% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,2994.11,36,,428.704,Percent of Total Billed Charges,36% of Total Billed Charges,2994.11,36,,428.704,Percent of Total Billed Charges,36% Total Bille Charges,2994.11,36,,428.704,Percent of Total Billed Charges,36% of Total Billed Charges,4990.18,60,,156,Percent of Total Billed Charges,60% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1199.31,14.42,,63.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6237.72,75,,3452.8,Percent of Total Billed Charges,75% of Total Billed Charges,4158.48,50,,798.2,Percent of Total Billed Charges,50% of Total Billed Charges,4158.48,50,,2158,Percent of Total Billed Charges,50% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4158.48,50,,2158,Percent of Total Billed Charges,50% of Total Billed Charges,4158.48,50,,2158,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5821.87,70,,14244.72,Percent of Total Billed Charges,70% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,1164.37,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8316.96,100,,4316,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,8316.96,
ENDO SHEARS 5MM,32100093,CDM,272,RC,,,Outpatient,,,231.65,138.99,,138.99,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.86,28,,214.368,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,282.08,Percent of Total Billed Charges,32% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,83.39,36,,275.616,Percent of Total Billed Charges,36% of Total Billed Charges,83.39,36,,275.616,Percent of Total Billed Charges,36% Total Bille Charges,83.39,36,,275.616,Percent of Total Billed Charges,36% of Total Billed Charges,138.99,60,,174.048,Percent of Total Billed Charges,60% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,33.4,14.42,,63.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.74,75,,1582.016,Percent of Total Billed Charges,75% of Total Billed Charges,115.83,50,,102.16,Percent of Total Billed Charges,50% of Total Billed Charges,115.83,50,,988.76,Percent of Total Billed Charges,50% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.83,50,,988.76,Percent of Total Billed Charges,50% of Total Billed Charges,115.83,50,,988.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.16,70,,6527.36,Percent of Total Billed Charges,70% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,32.43,14,,61.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.65,100,,1977.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,231.65,
MESH VENTRIO ST HERNIA PATCH,32100094,CDM,278,RC,C1781,HCPCS,Outpatient,,,2588.6,1553.16,,3300.22,110,,269.024,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.81,28,,403.872,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,282.08,Percent of Total Billed Charges,32% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,931.9,36,,519.264,Percent of Total Billed Charges,36% of Total Billed Charges,931.9,36,,519.264,Percent of Total Billed Charges,36% Total Bille Charges,931.9,36,,519.264,Percent of Total Billed Charges,36% of Total Billed Charges,1423.73,55,,456.112,Percent of Total Billed Charges,55% Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,373.28,14.42,,138.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.88,80,,351.568,Percent of Total Billed Charges,80% of Total Billed Charges,1294.3,50,,2158,Percent of Total Billed Charges,50% of Total Billed Charges,1294.3,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1294.3,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,1294.3,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1812.02,70,,197.68,Percent of Total Billed Charges,70% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,362.4,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2588.6,100,,439.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,3300.22,
INZII  RETRIEVAL BAG 10MM,32100095,CDM,271,RC,,,Outpatient,,,375,225.00,,225,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,616.808,Percent of Total Billed Charges,28% of Total Billed Charges,0.27,32,,282.08,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,793.04,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,793.04,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,793.04,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,746.152,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,138.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,351.568,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,988.76,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,515.76,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,134.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,439.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,375,
TROCAR APPLIED MEDICAL,32100096,CDM,271,RC,,,Outpatient,,,350,210.00,,210,60,,243.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98,28,,306.616,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,282.08,Percent of Total Billed Charges,32% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,126,36,,394.216,Percent of Total Billed Charges,36% of Total Billed Charges,126,36,,394.216,Percent of Total Billed Charges,36% Total Bille Charges,126,36,,394.216,Percent of Total Billed Charges,36% of Total Billed Charges,210,60,,206.824,Percent of Total Billed Charges,60% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,50.47,14.42,,290.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.5,75,,351.568,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245,70,,1117.2,Percent of Total Billed Charges,70% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,282.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,100,,439.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,350,
ACELLULAR AMNION 2.0ML,32100097,CDM,272,RC,,,Outpatient,,,1995.5,1197.30,,1197.3,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,558.74,28,,316.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,282.08,Percent of Total Billed Charges,32% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,718.38,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,718.38,36,,406.992,Percent of Total Billed Charges,36% Total Bille Charges,718.38,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,1197.3,60,,202.464,Percent of Total Billed Charges,60% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,287.75,14.42,,129.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1496.63,75,,718.2,Percent of Total Billed Charges,75% of Total Billed Charges,997.75,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,997.75,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,997.75,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,997.75,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1396.85,70,,3200.96,Percent of Total Billed Charges,70% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,279.37,14,,125.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1995.5,100,,957.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1995.5,
CURVED SCISSORS WITH MONOPOLAR,32100098,CDM,272,RC,,,Outpatient,,,255.4,153.24,,153.24,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.51,28,,1641.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.08,Percent of Total Billed Charges,32% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,91.94,36,,2110.12,Percent of Total Billed Charges,36% of Total Billed Charges,91.94,36,,2110.12,Percent of Total Billed Charges,36% Total Bille Charges,91.94,36,,2110.12,Percent of Total Billed Charges,36% of Total Billed Charges,153.24,60,,296.4,Percent of Total Billed Charges,60% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,36.83,14.42,,316.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.55,75,,718.2,Percent of Total Billed Charges,75% of Total Billed Charges,127.7,50,,219.728,Percent of Total Billed Charges,50% of Total Billed Charges,127.7,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.7,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,127.7,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.78,70,,4902.24,Percent of Total Billed Charges,70% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,35.76,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.4,100,,957.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,255.4,
PROSTHESIS TOROSA TESTICULAR,32100099,CDM,274,RC,,,Outpatient,,,5395,3237.00,,5934.5,110,,468.856,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1510.6,28,,2516.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.16,Percent of Total Billed Charges,32% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,1942.2,36,,3235.568,Percent of Total Billed Charges,36% of Total Billed Charges,1942.2,36,,3235.568,Percent of Total Billed Charges,36% Total Bille Charges,1942.2,36,,3235.568,Percent of Total Billed Charges,36% of Total Billed Charges,2967.25,55,,292.384,Percent of Total Billed Charges,55% Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,777.96,14.42,,615.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4316,80,,1510.8,Percent of Total Billed Charges,80% of Total Billed Charges,2697.5,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,2697.5,50,,1007.2,Percent of Total Billed Charges,50% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2697.5,50,,1007.2,Percent of Total Billed Charges,50% of Total Billed Charges,2697.5,50,,1007.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3776.5,70,,7694.96,Percent of Total Billed Charges,70% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,755.3,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5395,100,,2014.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,5934.5,
DURASEAL EXACT (206520),32100100,CDM,278,RC,,,Outpatient,,,2471.9,1483.14,,2719.09,110,,438.656,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,692.13,28,,3835.328,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.776,Percent of Total Billed Charges,32% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,889.88,36,,4931.136,Percent of Total Billed Charges,36% of Total Billed Charges,889.88,36,,4931.136,Percent of Total Billed Charges,36% Total Bille Charges,889.88,36,,4931.136,Percent of Total Billed Charges,36% of Total Billed Charges,1359.55,55,,362.456,Percent of Total Billed Charges,55% Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,356.45,14.42,,1252.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1977.52,80,,674.368,Percent of Total Billed Charges,80% of Total Billed Charges,1235.95,50,,478.8,Percent of Total Billed Charges,50% of Total Billed Charges,1235.95,50,,449.584,Percent of Total Billed Charges,50% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.95,50,,449.584,Percent of Total Billed Charges,50% of Total Billed Charges,1235.95,50,,449.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1730.33,70,,12409.04,Percent of Total Billed Charges,70% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,346.07,14,,1216.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2471.9,100,,899.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,2719.09,
DEXTILE RIGHT ANATOMICAL MESH 13X9,32100101,CDM,278,RC,C1781,HCPCS,Outpatient,,,549.32,329.59,,1057.01,110,,574.792,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.81,28,,4793.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.776,Percent of Total Billed Charges,32% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,197.76,36,,6163.2,Percent of Total Billed Charges,36% of Total Billed Charges,197.76,36,,6163.2,Percent of Total Billed Charges,36% Total Bille Charges,197.76,36,,6163.2,Percent of Total Billed Charges,36% of Total Billed Charges,302.13,55,,259.2,Percent of Total Billed Charges,55% Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,79.21,14.42,,169.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.46,80,,1645.896,Percent of Total Billed Charges,80% of Total Billed Charges,274.66,50,,1007.2,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.66,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.52,70,,20521.2,Percent of Total Billed Charges,70% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,164.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,549.32,100,,2194.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1057.01,
DEXTILE RT ANATOMICAL MESH DXT 1309AR,32100102,CDM,278,RC,C1781,HCPCS,Outpatient,,,549.32,329.59,,1057.01,110,,659.92,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.81,28,,205.832,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.88,Percent of Total Billed Charges,32% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,197.76,36,,264.64,Percent of Total Billed Charges,36% of Total Billed Charges,197.76,36,,264.64,Percent of Total Billed Charges,36% Total Bille Charges,197.76,36,,264.64,Percent of Total Billed Charges,36% of Total Billed Charges,302.13,55,,81.616,Percent of Total Billed Charges,55% Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,79.21,14.42,,155.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.46,80,,0.008,Percent of Total Billed Charges,80% of Total Billed Charges,274.66,50,,449.584,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.66,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.52,70,,35933.52,Percent of Total Billed Charges,70% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,151.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,549.32,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1057.01,
DEXTILE LT ANATOMICAL MESH DXT 1309AL,32100103,CDM,278,RC,C1781,HCPCS,Outpatient,,,549.32,329.59,,1057.01,110,,627.264,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.81,28,,636.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.88,Percent of Total Billed Charges,32% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,197.76,36,,817.752,Percent of Total Billed Charges,36% of Total Billed Charges,197.76,36,,817.752,Percent of Total Billed Charges,36% Total Bille Charges,197.76,36,,817.752,Percent of Total Billed Charges,36% of Total Billed Charges,302.13,55,,377.368,Percent of Total Billed Charges,55% Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,79.21,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.46,80,,3416.856,Percent of Total Billed Charges,80% of Total Billed Charges,274.66,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.66,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,274.66,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.52,70,,2027.2,Percent of Total Billed Charges,70% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,76.9,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,549.32,100,,4271.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1057.01,
SYMPHION FLUID MANAGEMENT (FG-0202),32100104,CDM,272,RC,,,Outpatient,,,1197,718.20,,718.2,60,,1136.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.16,28,,1064.488,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,284.88,Percent of Total Billed Charges,32% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,430.92,36,,1368.624,Percent of Total Billed Charges,36% of Total Billed Charges,430.92,36,,1368.624,Percent of Total Billed Charges,36% Total Bille Charges,430.92,36,,1368.624,Percent of Total Billed Charges,36% of Total Billed Charges,718.2,60,,327.464,Percent of Total Billed Charges,60% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,172.61,14.42,,77.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,897.75,75,,6950.28,Percent of Total Billed Charges,75% of Total Billed Charges,598.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,598.5,50,,4343.928,Percent of Total Billed Charges,50% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,50,,4343.928,Percent of Total Billed Charges,50% of Total Billed Charges,598.5,50,,4343.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,837.9,70,,137.904,Percent of Total Billed Charges,70% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1197,100,,8687.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1197,
SYMPHION RESECTING DEVISE (FG-0201),32100105,CDM,272,RC,,,Outpatient,,,1197,718.20,,718.2,60,,84.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.16,28,,1701.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.28,32,,286.92,Percent of Total Billed Charges,32% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,430.92,36,,2187.392,Percent of Total Billed Charges,36% of Total Billed Charges,430.92,36,,2187.392,Percent of Total Billed Charges,36% Total Bille Charges,430.92,36,,2187.392,Percent of Total Billed Charges,36% of Total Billed Charges,718.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,172.61,14.42,,190.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,897.75,75,,880.616,Percent of Total Billed Charges,75% of Total Billed Charges,598.5,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,598.5,50,,587.08,Percent of Total Billed Charges,50% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,50,,587.08,Percent of Total Billed Charges,50% of Total Billed Charges,598.5,50,,587.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,837.9,70,,98,Percent of Total Billed Charges,70% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.58,14,,184.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1197,100,,1174.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,1197,
MINERVA HANDPIECE (MIN9770),32100106,CDM,272,RC,,,Outpatient,,,2518,1510.80,,1510.8,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.04,28,,3066.096,Percent of Total Billed Charges,28% of Total Billed Charges,0.29,32,,286.968,Percent of Total Billed Charges,32% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,906.48,36,,3942.12,Percent of Total Billed Charges,36% of Total Billed Charges,906.48,36,,3942.12,Percent of Total Billed Charges,36% Total Bille Charges,906.48,36,,3942.12,Percent of Total Billed Charges,36% of Total Billed Charges,1510.8,60,,480.28,Percent of Total Billed Charges,60% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,363.1,14.42,,70.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1888.5,75,,863.6,Percent of Total Billed Charges,75% of Total Billed Charges,1259,50,,4343.928,Percent of Total Billed Charges,50% of Total Billed Charges,1259,50,,539.752,Percent of Total Billed Charges,50% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1259,50,,539.752,Percent of Total Billed Charges,50% of Total Billed Charges,1259,50,,539.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1762.6,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,352.52,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2518,100,,1079.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,2518,
DISPOSABLE BIPOLAR FORCEPTS (286-102),32100107,CDM,272,RC,,,Outpatient,,,1123.95,674.37,,674.37,60,,79.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.71,28,,5028.016,Percent of Total Billed Charges,28% of Total Billed Charges,0.29,32,,287.728,Percent of Total Billed Charges,32% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,404.62,36,,6464.592,Percent of Total Billed Charges,36% of Total Billed Charges,404.62,36,,6464.592,Percent of Total Billed Charges,36% Total Bille Charges,404.62,36,,6464.592,Percent of Total Billed Charges,36% of Total Billed Charges,674.37,60,,1042.208,Percent of Total Billed Charges,60% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,162.07,14.42,,16.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,842.96,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,561.98,50,,587.08,Percent of Total Billed Charges,50% of Total Billed Charges,561.98,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,561.98,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,561.98,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.77,70,,77.896,Percent of Total Billed Charges,70% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,157.35,14,,15.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1123.95,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1123.95,
OPTIFIX AT FIXATION SYSTEM (0113330),32100108,CDM,272,RC,,,Outpatient,,,2743.16,1645.90,,1645.9,60,,88.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.08,28,,7509.408,Percent of Total Billed Charges,28% of Total Billed Charges,0.29,32,,287.968,Percent of Total Billed Charges,32% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,987.54,36,,9654.952,Percent of Total Billed Charges,36% of Total Billed Charges,987.54,36,,9654.952,Percent of Total Billed Charges,36% Total Bille Charges,987.54,36,,9654.952,Percent of Total Billed Charges,36% of Total Billed Charges,1645.9,60,,341.504,Percent of Total Billed Charges,60% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,395.56,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2057.37,75,,404.984,Percent of Total Billed Charges,75% of Total Billed Charges,1371.58,50,,539.752,Percent of Total Billed Charges,50% of Total Billed Charges,1371.58,50,,269.992,Percent of Total Billed Charges,50% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1371.58,50,,269.992,Percent of Total Billed Charges,50% of Total Billed Charges,1371.58,50,,269.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1920.21,70,,62.544,Percent of Total Billed Charges,70% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2743.16,100,,539.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,2743.16,
ORTHO IMPLANT,32100109,CDM,278,RC,C1713,HCPCS,Outpatient,,,0.01,0.01,,317.27,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,288.408,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,990,Percent of Total Billed Charges,80% of Total Billed Charges,0.01,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,660,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,660,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,660,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,64.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,1320,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,317.27,
PHASIX ST MESH (1200011),32100110,CDM,278,RC,C1781,HCPCS,Outpatient,,,5338.84,3203.30,,6325.48,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1494.88,28,,17190.456,Percent of Total Billed Charges,28% of Total Billed Charges,0.29,32,,288.976,Percent of Total Billed Charges,32% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1921.98,36,,22102.008,Percent of Total Billed Charges,36% of Total Billed Charges,1921.98,36,,22102.008,Percent of Total Billed Charges,36% Total Bille Charges,1921.98,36,,22102.008,Percent of Total Billed Charges,36% of Total Billed Charges,2936.36,55,,324,Percent of Total Billed Charges,55% Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,769.86,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4271.07,80,,367.2,Percent of Total Billed Charges,80% of Total Billed Charges,2669.42,50,,269.992,Percent of Total Billed Charges,50% of Total Billed Charges,2669.42,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2669.42,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,2669.42,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3737.19,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5338.84,100,,489.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,6325.48,
913436 KIT BONE MARROW ASP,32100111,CDM,278,RC,C1713,HCPCS,Outpatient,,,10859.81,6515.89,,12263.05,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3040.75,28,,26436.376,Percent of Total Billed Charges,28% of Total Billed Charges,0.3,32,,289.616,Percent of Total Billed Charges,32% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,3909.53,36,,33989.624,Percent of Total Billed Charges,36% of Total Billed Charges,3909.53,36,,33989.624,Percent of Total Billed Charges,36% Total Bille Charges,3909.53,36,,33989.624,Percent of Total Billed Charges,36% of Total Billed Charges,5972.9,55,,983.032,Percent of Total Billed Charges,55% Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1565.98,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8687.85,80,,85.24,Percent of Total Billed Charges,80% of Total Billed Charges,5429.91,50,,660,Percent of Total Billed Charges,50% of Total Billed Charges,5429.91,50,,56.824,Percent of Total Billed Charges,50% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5429.91,50,,56.824,Percent of Total Billed Charges,50% of Total Billed Charges,5429.91,50,,56.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7601.87,70,,58.16,Percent of Total Billed Charges,70% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1520.37,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10859.81,100,,113.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,12263.05,
782705 STAPLER VASCULAR POWER,32100112,CDM,272,RC,,,Outpatient,,,1467.69,880.61,,880.61,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.95,28,,207.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.3,32,,289.616,Percent of Total Billed Charges,32% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,528.37,36,,267.12,Percent of Total Billed Charges,36% of Total Billed Charges,528.37,36,,267.12,Percent of Total Billed Charges,36% Total Bille Charges,528.37,36,,267.12,Percent of Total Billed Charges,36% of Total Billed Charges,880.61,60,,666.632,Percent of Total Billed Charges,60% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,211.64,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100.77,75,,1461.904,Percent of Total Billed Charges,75% of Total Billed Charges,733.85,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,733.85,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.85,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,733.85,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1027.38,70,,158.24,Percent of Total Billed Charges,70% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,205.48,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.69,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,1467.69,
251164 DURAFORM 2X2,32100113,CDM,278,RC,,,Outpatient,,,1349.38,809.63,,1484.32,110,,379.44,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,377.83,28,,301.272,Percent of Total Billed Charges,28% of Total Billed Charges,0.3,32,,289.936,Percent of Total Billed Charges,32% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,485.78,36,,387.344,Percent of Total Billed Charges,36% of Total Billed Charges,485.78,36,,387.344,Percent of Total Billed Charges,36% Total Bille Charges,485.78,36,,387.344,Percent of Total Billed Charges,36% of Total Billed Charges,742.16,55,,714.512,Percent of Total Billed Charges,55% Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14.42,,783.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1079.5,80,,1905.752,Percent of Total Billed Charges,80% of Total Billed Charges,674.69,50,,56.824,Percent of Total Billed Charges,50% of Total Billed Charges,674.69,50,,1270.504,Percent of Total Billed Charges,50% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,674.69,50,,1270.504,Percent of Total Billed Charges,50% of Total Billed Charges,674.69,50,,1270.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,944.57,70,,111.904,Percent of Total Billed Charges,70% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,188.91,14,,760.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1349.38,100,,2541,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,1484.32,
864119 SUTURE STRATAFIX,32100114,CDM,272,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,327.456,Percent of Total Billed Charges,28% of Total Billed Charges,0.3,32,,290.56,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,421.008,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,421.008,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,421.008,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,421.08,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,321.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,1559.36,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,142.032,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,125.84,
789233 RELOAD ENDOPATH VASCULA,32100115,CDM,272,RC,,,Outpatient,,,674.97,404.98,,404.98,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.99,28,,154.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,291.784,Percent of Total Billed Charges,32% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,242.99,36,,198.104,Percent of Total Billed Charges,36% of Total Billed Charges,242.99,36,,198.104,Percent of Total Billed Charges,36% Total Bille Charges,242.99,36,,198.104,Percent of Total Billed Charges,36% of Total Billed Charges,404.98,60,,865.448,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,97.33,14.42,,12.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.23,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,337.49,50,,1270.504,Percent of Total Billed Charges,50% of Total Billed Charges,337.49,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.49,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,337.49,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.48,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,12.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,674.97,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,674.97,
1073731 HEADER ACCESORY KIT,32100116,CDM,272,RC,,,Outpatient,,,1650,990.00,,990,60,,104.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462,28,,35.44,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,291.84,Percent of Total Billed Charges,32% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,594,36,,45.56,Percent of Total Billed Charges,36% of Total Billed Charges,594,36,,45.56,Percent of Total Billed Charges,36% Total Bille Charges,594,36,,45.56,Percent of Total Billed Charges,36% of Total Billed Charges,990,60,,1321.736,Percent of Total Billed Charges,60% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,237.93,14.42,,892.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1237.5,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,825,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,825,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,825,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1155,70,,163.8,Percent of Total Billed Charges,70% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,231,14,,866.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1650,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,1650,
CARBO JET HANDPIECE (27-100-1010),32100117,CDM,272,RC,,,Outpatient,,,612,367.20,,367.2,60,,49.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.36,28,,1495.6,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,295.4,Percent of Total Billed Charges,32% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,220.32,36,,1922.92,Percent of Total Billed Charges,36% of Total Billed Charges,220.32,36,,1922.92,Percent of Total Billed Charges,36% Total Bille Charges,220.32,36,,1922.92,Percent of Total Billed Charges,36% of Total Billed Charges,367.2,60,,602.28,Percent of Total Billed Charges,60% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,88.25,14.42,,621.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459,75,,4345.496,Percent of Total Billed Charges,75% of Total Billed Charges,306,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,2715.936,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306,50,,2715.936,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,2715.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.4,70,,182,Percent of Total Billed Charges,70% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,603.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612,100,,5431.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,612,
837899 STRATAFIX SYMMETRIC PDS,32100118,CDM,272,RC,,,Outpatient,,,142.06,85.24,,85.24,60,,42.56,Percent of Total Billed Charges,60% of Total Billed Charges,63.93,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.78,28,,155.504,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,295.656,Percent of Total Billed Charges,32% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,51.14,36,,199.936,Percent of Total Billed Charges,36% of Total Billed Charges,51.14,36,,199.936,Percent of Total Billed Charges,36% Total Bille Charges,51.14,36,,199.936,Percent of Total Billed Charges,36% of Total Billed Charges,85.24,60,,621.792,Percent of Total Billed Charges,60% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.06,100,,6512.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.49,14.42,,1502.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.55,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,71.03,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,71.03,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.03,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,71.03,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.44,70,,203.056,Percent of Total Billed Charges,70% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,19.89,14,,1458.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.06,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,142.06,
1070980 ENSEAL X1 LARGE JAW,32100119,CDM,272,RC,,,Outpatient,,,2436.5,1461.90,,1461.9,60,,34.76,Percent of Total Billed Charges,60% of Total Billed Charges,1096.43,45,,2709.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,96.328,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,296.072,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,123.848,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,123.848,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,123.848,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,3223.792,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,1234.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,464.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,1783.04,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,2715.936,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,532.136,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,2228.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,2436.5,
1071336 SEALANT ADHERUS DURAL,32100120,CDM,272,RC,,,Outpatient,,,3176.25,1905.75,,1905.75,60,,35.968,Percent of Total Billed Charges,60% of Total Billed Charges,1429.31,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,889.35,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,298.408,Percent of Total Billed Charges,32% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1143.45,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,1143.45,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,1143.45,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,1905.75,60,,4943.224,Percent of Total Billed Charges,60% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,458.02,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2382.19,75,,71.384,Percent of Total Billed Charges,75% of Total Billed Charges,1588.13,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,1588.13,50,,44.616,Percent of Total Billed Charges,50% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1588.13,50,,44.616,Percent of Total Billed Charges,50% of Total Billed Charges,1588.13,50,,44.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2223.38,70,,949.648,Percent of Total Billed Charges,70% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,444.68,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3176.25,100,,89.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,3176.25,
0003088 GRAFT GORETEX VASULAR,32100121,CDM,278,RC,C1768,HCPCS,Outpatient,,,2436.5,1461.90,,3002.92,110,,316.656,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,7142.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,10.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,298.784,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,12.96,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,12.96,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,12.96,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,7533.68,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,6020.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,4948.944,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,3093.096,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,3093.096,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,3093.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,241.296,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,6186.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,3002.92,
409917 GRAFT GORE VASCULAR PRO,32100122,CDM,278,RC,C1768,HCPCS,Outpatient,,,4235,2541.00,,4981.27,110,,498.352,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,3273.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,24.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,298.784,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,31.68,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,31.68,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,31.68,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,9416,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,3450.624,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,44.616,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,2156.64,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,2156.64,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,2156.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,236.208,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,4313.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,4981.27,
381517 BONE MTF FEMORAL 1 HALF,32100123,CDM,278,RC,,,Outpatient,,,4235,2541.00,,4658.5,110,,78.648,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,1500.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,57.344,Percent of Total Billed Charges,28% of Total Billed Charges,0.31,32,,299.096,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,73.728,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,73.728,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,73.728,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,404.304,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,15871.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,76.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,8335.568,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,3093.096,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,5209.728,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,5209.728,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,5209.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,345.8,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,10419.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,4658.5,
381520 BONE MTF FEMORAL 2 HALF,32100124,CDM,278,RC,,,Outpatient,,,6789.84,4073.90,,7468.82,110,,118.552,Percent of Total Billed Charges,110% of Total Billed Charges,3055.43,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1901.16,28,,118.72,Percent of Total Billed Charges,28% of Total Billed Charges,321.6,32,,299.728,Percent of Total Billed Charges,32% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,2444.34,36,,152.64,Percent of Total Billed Charges,36% of Total Billed Charges,2444.34,36,,152.64,Percent of Total Billed Charges,36% Total Bille Charges,2444.34,36,,152.64,Percent of Total Billed Charges,36% of Total Billed Charges,3734.41,55,,1249.352,Percent of Total Billed Charges,55% Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6789.84,100,,7273.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,979.09,14.42,,30.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5431.87,80,,2574.88,Percent of Total Billed Charges,80% of Total Billed Charges,3394.92,50,,2156.64,Percent of Total Billed Charges,50% of Total Billed Charges,3394.92,50,,1609.304,Percent of Total Billed Charges,50% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3394.92,50,,1609.304,Percent of Total Billed Charges,50% of Total Billed Charges,3394.92,50,,1609.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4752.89,70,,341.112,Percent of Total Billed Charges,70% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,950.58,14,,29.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6789.84,100,,3218.6,Percent of Total Billed Charges,100% of Total Billed Charges,321.6,7468.82,
TOTAL JOINT REVISION,32100125,CDM,278,RC,C1776,HCPCS,Outpatient,,,0.01,0.01,,3859.18,110,,119.08,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,301.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,3333.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,2710.4,Percent of Total Billed Charges,80% of Total Billed Charges,0.01,50,,5209.728,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,422.864,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3859.18,
1010430 IMPLANT NASAL LATERA,32100126,CDM,278,RC,,,Outpatient,,,2786,1671.60,,3064.6,110,,167.92,Percent of Total Billed Charges,110% of Total Billed Charges,1253.7,45,,1080,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780.08,28,,428.288,Percent of Total Billed Charges,28% of Total Billed Charges,321.92,32,,302.856,Percent of Total Billed Charges,32% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1002.96,36,,550.656,Percent of Total Billed Charges,36% of Total Billed Charges,1002.96,36,,550.656,Percent of Total Billed Charges,36% Total Bille Charges,1002.96,36,,550.656,Percent of Total Billed Charges,36% of Total Billed Charges,1532.3,55,,3341.848,Percent of Total Billed Charges,55% Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2786,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,401.74,14.42,,76.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2228.8,80,,90,Percent of Total Billed Charges,80% of Total Billed Charges,1393,50,,1609.304,Percent of Total Billed Charges,50% of Total Billed Charges,1393,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1393,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1393,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1950.2,70,,302.4,Percent of Total Billed Charges,70% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2786,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,321.92,3064.6,
1110270 VENT TUBE ACTIVENT,32100127,CDM,278,RC,,,Outpatient,,,111.54,66.92,,122.69,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,50.19,45,,2340,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.23,28,,647.808,Percent of Total Billed Charges,28% of Total Billed Charges,324.61,32,,303.136,Percent of Total Billed Charges,32% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,40.15,36,,832.896,Percent of Total Billed Charges,36% of Total Billed Charges,40.15,36,,832.896,Percent of Total Billed Charges,36% Total Bille Charges,40.15,36,,832.896,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.54,100,,4534.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14.42,,76.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.23,80,,384,Percent of Total Billed Charges,80% of Total Billed Charges,55.77,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,55.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,55.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.08,70,,95.216,Percent of Total Billed Charges,70% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,15.62,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.54,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,15.62,324.61,
1106888 BONE GRAFT SUBSTITUTE,32100128,CDM,278,RC,C1713,HCPCS,Outpatient,,,7732.73,4639.64,,8823.26,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,3479.73,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2165.16,28,,909.664,Percent of Total Billed Charges,28% of Total Billed Charges,324.61,32,,304.384,Percent of Total Billed Charges,32% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,2783.78,36,,1169.568,Percent of Total Billed Charges,36% of Total Billed Charges,2783.78,36,,1169.568,Percent of Total Billed Charges,36% Total Bille Charges,2783.78,36,,1169.568,Percent of Total Billed Charges,36% of Total Billed Charges,4253,55,,9876.464,Percent of Total Billed Charges,55% Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7732.73,100,,2400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1115.06,14.42,,76.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6186.18,80,,397.376,Percent of Total Billed Charges,80% of Total Billed Charges,3866.37,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,3866.37,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3866.37,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,3866.37,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5412.91,70,,440.264,Percent of Total Billed Charges,70% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,1082.58,14,,74.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7732.73,100,,529.832,Percent of Total Billed Charges,100% of Total Billed Charges,324.61,8823.26,
193299 BONE STRYKER 10CC HYDR,32100129,CDM,278,RC,C1713,HCPCS,Outpatient,,,5391.6,3234.96,,6248.02,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,2426.22,45,,5400,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1509.65,28,,1279.712,Percent of Total Billed Charges,28% of Total Billed Charges,324.61,32,,304.824,Percent of Total Billed Charges,32% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,1940.98,36,,1645.344,Percent of Total Billed Charges,36% of Total Billed Charges,1940.98,36,,1645.344,Percent of Total Billed Charges,36% Total Bille Charges,1940.98,36,,1645.344,Percent of Total Billed Charges,36% of Total Billed Charges,2965.38,55,,14750.624,Percent of Total Billed Charges,55% Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5391.6,100,,5200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,777.47,14.42,,602.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4313.28,80,,157.392,Percent of Total Billed Charges,80% of Total Billed Charges,2695.8,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2695.8,50,,104.928,Percent of Total Billed Charges,50% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2695.8,50,,104.928,Percent of Total Billed Charges,50% of Total Billed Charges,2695.8,50,,104.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3774.12,70,,382.04,Percent of Total Billed Charges,70% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,754.82,14,,585.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5391.6,100,,209.856,Percent of Total Billed Charges,100% of Total Billed Charges,324.61,6248.02,
419374 BONE STRYKER HYDROSET,32100130,CDM,278,RC,C1713,HCPCS,Outpatient,,,13024.32,7814.59,,14644.01,110,,103.688,Percent of Total Billed Charges,110% of Total Billed Charges,5860.94,45,,5454,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3646.81,28,,1767.136,Percent of Total Billed Charges,28% of Total Billed Charges,325.03,32,,304.824,Percent of Total Billed Charges,32% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,4688.76,36,,2272.032,Percent of Total Billed Charges,36% of Total Billed Charges,4688.76,36,,2272.032,Percent of Total Billed Charges,36% Total Bille Charges,4688.76,36,,2272.032,Percent of Total Billed Charges,36% of Total Billed Charges,7163.38,55,,22521.832,Percent of Total Billed Charges,55% Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13024.32,100,,6000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1878.11,14.42,,78.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10419.46,80,,249.072,Percent of Total Billed Charges,80% of Total Billed Charges,6512.16,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,6512.16,50,,166.048,Percent of Total Billed Charges,50% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6512.16,50,,166.048,Percent of Total Billed Charges,50% of Total Billed Charges,6512.16,50,,166.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9117.02,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,1823.4,14,,75.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13024.32,100,,332.096,Percent of Total Billed Charges,100% of Total Billed Charges,325.03,14644.01,
1123619 BIOZORB MARKER,32100131,CDM,278,RC,A4648,HCPCS,Outpatient,,,4023.25,2413.95,,4527.72,110,,94.2,Percent of Total Billed Charges,110% of Total Billed Charges,1810.46,45,,7020,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1126.51,28,,2645.216,Percent of Total Billed Charges,28% of Total Billed Charges,325.79,32,,304.824,Percent of Total Billed Charges,32% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,1448.37,36,,3400.992,Percent of Total Billed Charges,36% of Total Billed Charges,1448.37,36,,3400.992,Percent of Total Billed Charges,36% Total Bille Charges,1448.37,36,,3400.992,Percent of Total Billed Charges,36% of Total Billed Charges,2212.79,55,,33766.96,Percent of Total Billed Charges,55% Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4023.25,100,,12000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,580.15,14.42,,169.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3218.6,80,,0.008,Percent of Total Billed Charges,80% of Total Billed Charges,2011.63,50,,104.928,Percent of Total Billed Charges,50% of Total Billed Charges,2011.63,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2011.63,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,2011.63,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2816.28,70,,611.272,Percent of Total Billed Charges,70% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,164.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4023.25,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,325.79,4527.72,
1137993 LEAD BLUE 50B,32100134,CDM,278,RC,C1778,HCPCS,Outpatient,,,4235,2541.00,,5241.1,110,,182.648,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,9720,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,3741.696,Percent of Total Billed Charges,28% of Total Billed Charges,326.4,32,,305.048,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,4810.752,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,4810.752,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,4810.752,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,51928.6,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,12120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,75.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,397.376,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,166.048,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1215.904,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,73.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,529.832,Percent of Total Billed Charges,100% of Total Billed Charges,326.4,5241.1,
160356 TUBE GASTRMY MIC 20FR,32100135,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,792.368,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,12420,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,5488.224,Percent of Total Billed Charges,28% of Total Billed Charges,329.47,32,,305.632,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,7056.288,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,7056.288,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,7056.288,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,445.2,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,15600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,66.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,397.376,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,398.416,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,64.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,529.832,Percent of Total Billed Charges,100% of Total Billed Charges,21,329.47,
1137992 ANCHOR N300 LEAD,32100136,CDM,278,RC,C1897,HCPCS,Outpatient,,,600,360.00,,1427.94,110,,576,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,7224.672,Percent of Total Billed Charges,28% of Total Billed Charges,331.23,32,,306.432,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,9288.864,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,9288.864,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,9288.864,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,591.776,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,21600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,290.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,397.376,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,774.4,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,529.832,Percent of Total Billed Charges,100% of Total Billed Charges,84,1427.94,
590889 SHEATH NAVIGATOR HD ACC,32100138,CDM,272,RC,C1894,HCPCS,Outpatient,,,662.29,397.37,,82.29,100,,292.104,Fee Schedule,100% of Aetna Fee Schedule,298.03,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.44,28,,11309.536,Percent of Total Billed Charges,28% of Total Billed Charges,331.37,32,,306.432,Percent of Total Billed Charges,32% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,238.42,36,,14540.832,Percent of Total Billed Charges,36% of Total Billed Charges,238.42,36,,14540.832,Percent of Total Billed Charges,36% Total Bille Charges,238.42,36,,14540.832,Percent of Total Billed Charges,36% of Total Billed Charges,397.37,60,,701.68,Percent of Total Billed Charges,60% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.29,100,,27600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,95.5,14.42,,38.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.72,75,,3135.6,Percent of Total Billed Charges,75% of Total Billed Charges,331.15,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,2090.4,Percent of Total Billed Charges,50% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.15,50,,2090.4,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,2090.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.6,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,37.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.29,100,,4180.8,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,662.29,
370320 GUIDEWIRE SUPER STIFF,32100139,CDM,272,RC,C1769,HCPCS,Outpatient,,,262.32,157.39,,55.13,100,,1420.224,Fee Schedule,100% of Aetna Fee Schedule,118.04,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.45,28,,9.632,Percent of Total Billed Charges,28% of Total Billed Charges,332.24,32,,306.552,Percent of Total Billed Charges,32% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,94.44,36,,12.384,Percent of Total Billed Charges,36% of Total Billed Charges,94.44,36,,12.384,Percent of Total Billed Charges,36% Total Bille Charges,94.44,36,,12.384,Percent of Total Billed Charges,36% of Total Billed Charges,157.39,60,,330.176,Percent of Total Billed Charges,60% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.32,100,,80,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,37.83,14.42,,55.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.74,75,,406.32,Percent of Total Billed Charges,75% of Total Billed Charges,131.16,50,,264.92,Percent of Total Billed Charges,50% of Total Billed Charges,131.16,50,,270.88,Percent of Total Billed Charges,50% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.16,50,,270.88,Percent of Total Billed Charges,50% of Total Billed Charges,131.16,50,,270.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.62,70,,1146.872,Percent of Total Billed Charges,70% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,14,,54.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.32,100,,541.76,Percent of Total Billed Charges,100% of Total Billed Charges,36.72,332.24,
112926 CATHETER URETERAL DUAL,32100140,CDM,272,RC,C1758,HCPCS,Outpatient,,,415.12,249.07,,69,100,,59.56,Fee Schedule,100% of Aetna Fee Schedule,186.8,45,,67.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.23,28,,35.616,Percent of Total Billed Charges,28% of Total Billed Charges,332.57,32,,307.184,Percent of Total Billed Charges,32% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,149.44,36,,45.792,Percent of Total Billed Charges,36% of Total Billed Charges,149.44,36,,45.792,Percent of Total Billed Charges,36% Total Bille Charges,149.44,36,,45.792,Percent of Total Billed Charges,36% of Total Billed Charges,249.07,60,,75.936,Percent of Total Billed Charges,60% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.12,100,,84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,59.86,14.42,,92.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.34,75,,879.624,Percent of Total Billed Charges,75% of Total Billed Charges,207.56,50,,2090.4,Percent of Total Billed Charges,50% of Total Billed Charges,207.56,50,,586.416,Percent of Total Billed Charges,50% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.56,50,,586.416,Percent of Total Billed Charges,50% of Total Billed Charges,207.56,50,,586.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.58,70,,777.736,Percent of Total Billed Charges,70% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,58.12,14,,89.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,415.12,100,,1172.832,Percent of Total Billed Charges,100% of Total Billed Charges,58.12,415.12,
TOTAL SPINE IMPL,32100141,CDM,278,RC,C1713,HCPCS,Outpatient,,,0.01,0.01,,317.27,110,,3736.216,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,307.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,393.832,Percent of Total Billed Charges,80% of Total Billed Charges,0.01,50,,270.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,262.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,262.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,262.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,833.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,525.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,317.27,
600784 SHEATH NAVIGATOR HD ACC,32100142,CDM,272,RC,C1894,HCPCS,Outpatient,,,662.29,397.37,,82.29,100,,9380.8,Fee Schedule,100% of Aetna Fee Schedule,298.03,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.44,28,,342.944,Percent of Total Billed Charges,28% of Total Billed Charges,332.8,32,,307.2,Percent of Total Billed Charges,32% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.42,36,,440.928,Percent of Total Billed Charges,36% of Total Billed Charges,238.42,36,,440.928,Percent of Total Billed Charges,36% Total Bille Charges,238.42,36,,440.928,Percent of Total Billed Charges,36% of Total Billed Charges,397.37,60,,305.456,Percent of Total Billed Charges,60% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.29,100,,150.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,95.5,14.42,,229.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.72,75,,343.4,Percent of Total Billed Charges,75% of Total Billed Charges,331.15,50,,586.416,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,228.936,Percent of Total Billed Charges,50% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.15,50,,228.936,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,228.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.6,70,,535.92,Percent of Total Billed Charges,70% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.29,100,,457.864,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,662.29,
590891 SHEATH NAVIGATOR HD ACC,32100143,CDM,272,RC,C1894,HCPCS,Outpatient,,,662.29,397.37,,82.29,100,,583.808,Fee Schedule,100% of Aetna Fee Schedule,298.03,45,,145.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.44,28,,605.248,Percent of Total Billed Charges,28% of Total Billed Charges,334.72,32,,307.2,Percent of Total Billed Charges,32% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,238.42,36,,778.176,Percent of Total Billed Charges,36% of Total Billed Charges,238.42,36,,778.176,Percent of Total Billed Charges,36% Total Bille Charges,238.42,36,,778.176,Percent of Total Billed Charges,36% of Total Billed Charges,397.37,60,,1169.52,Percent of Total Billed Charges,60% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.29,100,,151.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.5,14.42,,239.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.72,75,,1612.8,Percent of Total Billed Charges,75% of Total Billed Charges,331.15,50,,262.56,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.15,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.6,70,,1009.688,Percent of Total Billed Charges,70% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,232.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.29,100,,2016,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,662.29,
717958 SHEATH NAVIGATOR HD ACC,32100144,CDM,272,RC,C1894,HCPCS,Outpatient,,,662.29,397.37,,82.29,100,,2464,Fee Schedule,100% of Aetna Fee Schedule,298.03,45,,186.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.44,28,,950.208,Percent of Total Billed Charges,28% of Total Billed Charges,335.23,32,,308.768,Percent of Total Billed Charges,32% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,238.42,36,,1221.696,Percent of Total Billed Charges,36% of Total Billed Charges,238.42,36,,1221.696,Percent of Total Billed Charges,36% Total Bille Charges,238.42,36,,1221.696,Percent of Total Billed Charges,36% of Total Billed Charges,397.37,60,,233.2,Percent of Total Billed Charges,60% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.29,100,,244.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,95.5,14.42,,104.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.72,75,,199.704,Percent of Total Billed Charges,75% of Total Billed Charges,331.15,50,,228.936,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,133.136,Percent of Total Billed Charges,50% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.15,50,,133.136,Percent of Total Billed Charges,50% of Total Billed Charges,331.15,50,,133.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.6,70,,1542.024,Percent of Total Billed Charges,70% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,92.72,14,,101.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.29,100,,266.272,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,662.29,
1145521 TUBE EUST BALLOON,32100145,CDM,272,RC,,,Outpatient,,,5226,3135.60,,3135.6,60,,5042.08,Percent of Total Billed Charges,60% of Total Billed Charges,2351.7,45,,3780,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1463.28,28,,1396.864,Percent of Total Billed Charges,28% of Total Billed Charges,336,32,,311.04,Percent of Total Billed Charges,32% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,1881.36,36,,1795.968,Percent of Total Billed Charges,36% of Total Billed Charges,1881.36,36,,1795.968,Percent of Total Billed Charges,36% Total Bille Charges,1881.36,36,,1795.968,Percent of Total Billed Charges,36% of Total Billed Charges,3135.6,60,,534.6,Percent of Total Billed Charges,60% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5226,100,,324,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,753.59,14.42,,98.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3919.5,75,,289.416,Percent of Total Billed Charges,75% of Total Billed Charges,2613,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,2613,50,,192.944,Percent of Total Billed Charges,50% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2613,50,,192.944,Percent of Total Billed Charges,50% of Total Billed Charges,2613,50,,192.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3658.2,70,,766.536,Percent of Total Billed Charges,70% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,731.64,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5226,100,,385.888,Percent of Total Billed Charges,100% of Total Billed Charges,336,5226,
411384 STAPLER RELOAD WHITE,32100146,CDM,272,RC,,,Outpatient,,,677.2,406.32,,406.32,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,304.74,45,,4140,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.62,28,,1874.432,Percent of Total Billed Charges,28% of Total Billed Charges,336.1,32,,311.872,Percent of Total Billed Charges,32% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,243.79,36,,2409.984,Percent of Total Billed Charges,36% of Total Billed Charges,243.79,36,,2409.984,Percent of Total Billed Charges,36% Total Bille Charges,243.79,36,,2409.984,Percent of Total Billed Charges,36% of Total Billed Charges,406.32,60,,841.28,Percent of Total Billed Charges,60% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,677.2,100,,414.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,97.65,14.42,,70.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.9,75,,480.968,Percent of Total Billed Charges,75% of Total Billed Charges,338.6,50,,133.136,Percent of Total Billed Charges,50% of Total Billed Charges,338.6,50,,320.648,Percent of Total Billed Charges,50% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.6,50,,320.648,Percent of Total Billed Charges,50% of Total Billed Charges,338.6,50,,320.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.04,70,,791.376,Percent of Total Billed Charges,70% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,94.81,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,677.2,100,,641.288,Percent of Total Billed Charges,100% of Total Billed Charges,94.81,677.2,
1094623 STAPLER POWER 45,32100147,CDM,272,RC,,,Outpatient,,,1466.04,879.62,,879.62,60,,32104.144,Percent of Total Billed Charges,60% of Total Billed Charges,659.72,45,,5940,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.49,28,,2731.232,Percent of Total Billed Charges,28% of Total Billed Charges,336.1,32,,311.872,Percent of Total Billed Charges,32% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,527.77,36,,3511.584,Percent of Total Billed Charges,36% of Total Billed Charges,527.77,36,,3511.584,Percent of Total Billed Charges,36% Total Bille Charges,527.77,36,,3511.584,Percent of Total Billed Charges,36% of Total Billed Charges,879.62,60,,1272.48,Percent of Total Billed Charges,60% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.04,100,,8400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14.42,,316.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1099.53,75,,3417.856,Percent of Total Billed Charges,75% of Total Billed Charges,733.02,50,,192.944,Percent of Total Billed Charges,50% of Total Billed Charges,733.02,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.02,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,733.02,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1026.23,70,,4103.008,Percent of Total Billed Charges,70% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,14,,307.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1466.04,100,,4272.32,Percent of Total Billed Charges,100% of Total Billed Charges,205.25,1466.04,
1041012 STAPLER RELOAD BLUE,32100148,CDM,272,RC,,,Outpatient,,,656.39,393.83,,393.83,60,,31928.144,Percent of Total Billed Charges,60% of Total Billed Charges,295.38,45,,6840,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.79,28,,4174.016,Percent of Total Billed Charges,28% of Total Billed Charges,336.1,32,,311.872,Percent of Total Billed Charges,32% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,236.3,36,,5366.592,Percent of Total Billed Charges,36% of Total Billed Charges,236.3,36,,5366.592,Percent of Total Billed Charges,36% Total Bille Charges,236.3,36,,5366.592,Percent of Total Billed Charges,36% of Total Billed Charges,393.83,60,,1786.84,Percent of Total Billed Charges,60% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,656.39,100,,9200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,94.65,14.42,,615.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.29,75,,1274.88,Percent of Total Billed Charges,75% of Total Billed Charges,328.2,50,,320.648,Percent of Total Billed Charges,50% of Total Billed Charges,328.2,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,328.2,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,328.2,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.47,70,,6291.376,Percent of Total Billed Charges,70% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,91.89,14,,597.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,656.39,100,,1593.6,Percent of Total Billed Charges,100% of Total Billed Charges,91.89,656.39,
518063 STAPLER RELOAD GRAY,32100149,CDM,272,RC,,,Outpatient,,,572.33,343.40,,343.4,60,,81.84,Percent of Total Billed Charges,60% of Total Billed Charges,257.55,45,,8460,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.25,28,,6584.032,Percent of Total Billed Charges,28% of Total Billed Charges,336.1,32,,313.632,Percent of Total Billed Charges,32% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,206.04,36,,8465.184,Percent of Total Billed Charges,36% of Total Billed Charges,206.04,36,,8465.184,Percent of Total Billed Charges,36% Total Bille Charges,206.04,36,,8465.184,Percent of Total Billed Charges,36% of Total Billed Charges,343.4,60,,2513.72,Percent of Total Billed Charges,60% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,572.33,100,,13200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,82.53,14.42,,47.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,429.25,75,,1245.168,Percent of Total Billed Charges,75% of Total Billed Charges,286.17,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,286.17,50,,830.112,Percent of Total Billed Charges,50% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.17,50,,830.112,Percent of Total Billed Charges,50% of Total Billed Charges,286.17,50,,830.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.63,70,,9588.32,Percent of Total Billed Charges,70% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,80.13,14,,46.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,572.33,100,,1660.224,Percent of Total Billed Charges,100% of Total Billed Charges,80.13,572.33,
1153364 LEAD TRIAL ALGOVITA,32100150,CDM,278,RC,C1778,HCPCS,Outpatient,,,2520,1512.00,,3354.6,110,,2197.464,Percent of Total Billed Charges,110% of Total Billed Charges,1134,45,,11160,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.6,28,,9522.016,Percent of Total Billed Charges,28% of Total Billed Charges,339.94,32,,314.024,Percent of Total Billed Charges,32% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,907.2,36,,12242.592,Percent of Total Billed Charges,36% of Total Billed Charges,907.2,36,,12242.592,Percent of Total Billed Charges,36% Total Bille Charges,907.2,36,,12242.592,Percent of Total Billed Charges,36% of Total Billed Charges,1386,55,,3471.16,Percent of Total Billed Charges,55% Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2520,100,,15200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,363.38,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2016,80,,544.048,Percent of Total Billed Charges,80% of Total Billed Charges,1260,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,362.704,Percent of Total Billed Charges,50% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260,50,,362.704,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,362.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1764,70,,11984,Percent of Total Billed Charges,70% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2520,100,,725.4,Percent of Total Billed Charges,100% of Total Billed Charges,339.94,3354.6,
572729 CATHETER 6FR,32100151,CDM,272,RC,C1758,HCPCS,Outpatient,,,332.84,199.70,,69,100,,4727.952,Fee Schedule,100% of Aetna Fee Schedule,149.78,45,,13860,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.2,28,,12723.648,Percent of Total Billed Charges,28% of Total Billed Charges,340.25,32,,314.536,Percent of Total Billed Charges,32% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,119.82,36,,16358.976,Percent of Total Billed Charges,36% of Total Billed Charges,119.82,36,,16358.976,Percent of Total Billed Charges,36% Total Bille Charges,119.82,36,,16358.976,Percent of Total Billed Charges,36% of Total Billed Charges,199.7,60,,5195.96,Percent of Total Billed Charges,60% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.84,100,,18800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,48,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.63,75,,513,Percent of Total Billed Charges,75% of Total Billed Charges,166.42,50,,830.112,Percent of Total Billed Charges,50% of Total Billed Charges,166.42,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.42,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,166.42,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.99,70,,514.576,Percent of Total Billed Charges,70% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.6,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.84,100,,684,Percent of Total Billed Charges,100% of Total Billed Charges,46.6,340.25,
822691 DUAL EDGE CUTTER CROSSB,32100152,CDM,272,RC,,,Outpatient,,,482.36,289.42,,289.42,60,,2631.2,Percent of Total Billed Charges,60% of Total Billed Charges,217.06,45,,56.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.06,28,,18371.36,Percent of Total Billed Charges,28% of Total Billed Charges,340.25,32,,314.88,Percent of Total Billed Charges,32% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,173.65,36,,23620.32,Percent of Total Billed Charges,36% of Total Billed Charges,173.65,36,,23620.32,Percent of Total Billed Charges,36% Total Bille Charges,173.65,36,,23620.32,Percent of Total Billed Charges,36% of Total Billed Charges,289.42,60,,7349.76,Percent of Total Billed Charges,60% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,482.36,100,,24800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,69.56,14.42,,3.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.77,75,,367.2,Percent of Total Billed Charges,75% of Total Billed Charges,241.18,50,,362.704,Percent of Total Billed Charges,50% of Total Billed Charges,241.18,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.18,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,241.18,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.65,70,,1590.08,Percent of Total Billed Charges,70% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,67.53,14,,3.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.36,100,,489.6,Percent of Total Billed Charges,100% of Total Billed Charges,67.53,482.36,
182787 COMPACT CEMENT MIXER,32100153,CDM,272,RC,,,Outpatient,,,801.61,480.97,,480.97,60,,3491.904,Percent of Total Billed Charges,60% of Total Billed Charges,360.72,45,,64.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.45,28,,29985.088,Percent of Total Billed Charges,28% of Total Billed Charges,343.06,32,,314.88,Percent of Total Billed Charges,32% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,288.58,36,,38552.256,Percent of Total Billed Charges,36% of Total Billed Charges,288.58,36,,38552.256,Percent of Total Billed Charges,36% Total Bille Charges,288.58,36,,38552.256,Percent of Total Billed Charges,36% of Total Billed Charges,480.97,60,,10780.44,Percent of Total Billed Charges,60% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,801.61,100,,30800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,115.59,14.42,,614.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.21,75,,1645.896,Percent of Total Billed Charges,75% of Total Billed Charges,400.81,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,400.81,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.81,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,400.81,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,561.13,70,,2661.216,Percent of Total Billed Charges,70% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,112.23,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,801.61,100,,2194.528,Percent of Total Billed Charges,100% of Total Billed Charges,112.23,801.61,
1164538 OSTEOSURGE 10CC,32100154,CDM,278,RC,,,Outpatient,,,5340.4,3204.24,,5874.44,110,,2006.768,Percent of Total Billed Charges,110% of Total Billed Charges,2403.18,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1495.31,28,,101.416,Percent of Total Billed Charges,28% of Total Billed Charges,343.06,32,,315.616,Percent of Total Billed Charges,32% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,1922.54,36,,130.392,Percent of Total Billed Charges,36% of Total Billed Charges,1922.54,36,,130.392,Percent of Total Billed Charges,36% Total Bille Charges,1922.54,36,,130.392,Percent of Total Billed Charges,36% of Total Billed Charges,2937.22,55,,14191.32,Percent of Total Billed Charges,55% Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5340.4,100,,126.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,770.09,14.42,,6.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4272.32,80,,3416.856,Percent of Total Billed Charges,80% of Total Billed Charges,2670.2,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,2670.2,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2670.2,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,2670.2,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3738.28,70,,4253.256,Percent of Total Billed Charges,70% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,5.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5340.4,100,,4271.072,Percent of Total Billed Charges,100% of Total Billed Charges,343.06,5874.44,
1164539 OSTEOSURGE 2.5CC,32100155,CDM,278,RC,,,Outpatient,,,1992,1195.20,,2191.2,110,,370.04,Percent of Total Billed Charges,110% of Total Billed Charges,896.4,45,,86.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,557.76,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,344.62,32,,315.616,Percent of Total Billed Charges,32% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,717.12,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,717.12,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,717.12,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1095.6,55,,22215.16,Percent of Total Billed Charges,55% Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1992,100,,143.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,287.25,14.42,,14.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1593.6,80,,265.808,Percent of Total Billed Charges,80% of Total Billed Charges,996,50,,1097.264,Percent of Total Billed Charges,50% of Total Billed Charges,996,50,,166.128,Percent of Total Billed Charges,50% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,996,50,,166.128,Percent of Total Billed Charges,50% of Total Billed Charges,996,50,,166.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1394.4,70,,7665.232,Percent of Total Billed Charges,70% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1992,100,,332.256,Percent of Total Billed Charges,100% of Total Billed Charges,278.88,2191.2,
195670 PROBE LITHOCLAST,32100156,CDM,272,RC,,,Outpatient,,,2075.28,1245.17,,1245.17,60,,119.352,Percent of Total Billed Charges,60% of Total Billed Charges,933.88,45,,127.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.08,28,,56.192,Percent of Total Billed Charges,28% of Total Billed Charges,344.62,32,,315.744,Percent of Total Billed Charges,32% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,747.1,36,,72.24,Percent of Total Billed Charges,36% of Total Billed Charges,747.1,36,,72.24,Percent of Total Billed Charges,36% Total Bille Charges,747.1,36,,72.24,Percent of Total Billed Charges,36% of Total Billed Charges,1245.17,60,,673.64,Percent of Total Billed Charges,60% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2075.28,100,,160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,299.26,14.42,,17.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1556.46,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,1037.64,50,,2135.536,Percent of Total Billed Charges,50% of Total Billed Charges,1037.64,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.64,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1037.64,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1452.7,70,,12570.048,Percent of Total Billed Charges,70% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,290.54,14,,16.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2075.28,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,290.54,2075.28,
195669 PROBE LITHOCLST ULTRA,32100157,CDM,272,RC,,,Outpatient,,,906.75,544.05,,544.05,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,408.04,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.89,28,,55.576,Percent of Total Billed Charges,28% of Total Billed Charges,344.62,32,,318.112,Percent of Total Billed Charges,32% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,326.43,36,,71.448,Percent of Total Billed Charges,36% of Total Billed Charges,326.43,36,,71.448,Percent of Total Billed Charges,36% Total Bille Charges,326.43,36,,71.448,Percent of Total Billed Charges,36% of Total Billed Charges,544.05,60,,1188.88,Percent of Total Billed Charges,60% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,906.75,100,,192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,130.75,14.42,,10.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,680.06,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,453.38,50,,166.128,Percent of Total Billed Charges,50% of Total Billed Charges,453.38,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.38,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,453.38,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,634.73,70,,18773.52,Percent of Total Billed Charges,70% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,126.95,14,,10.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,906.75,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,126.95,906.75,
PHOTONSABER Y (ES1Y),32100159,CDM,272,RC,,,Outpatient,,,855,513.00,,513,60,,9380.8,Percent of Total Billed Charges,60% of Total Billed Charges,384.75,45,,208.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.4,28,,82.376,Percent of Total Billed Charges,28% of Total Billed Charges,344.62,32,,320.216,Percent of Total Billed Charges,32% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,307.8,36,,105.912,Percent of Total Billed Charges,36% of Total Billed Charges,307.8,36,,105.912,Percent of Total Billed Charges,36% Total Bille Charges,307.8,36,,105.912,Percent of Total Billed Charges,36% of Total Billed Charges,513,60,,1866.48,Percent of Total Billed Charges,60% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855,100,,282.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,123.29,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.25,75,,17.512,Percent of Total Billed Charges,75% of Total Billed Charges,427.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,11.68,Percent of Total Billed Charges,50% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,50,,11.68,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,11.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,70,,28664.152,Percent of Total Billed Charges,70% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,855,100,,23.352,Percent of Total Billed Charges,100% of Total Billed Charges,119.7,855,
CARBO JET HANDPIECE (27-100-1010),32100160,CDM,272,RC,,,Outpatient,,,612,367.20,,367.2,60,,1412.456,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,45,,123.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.36,28,,128.72,Percent of Total Billed Charges,28% of Total Billed Charges,346.12,32,,322.768,Percent of Total Billed Charges,32% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,220.32,36,,165.496,Percent of Total Billed Charges,36% of Total Billed Charges,220.32,36,,165.496,Percent of Total Billed Charges,36% Total Bille Charges,220.32,36,,165.496,Percent of Total Billed Charges,36% of Total Billed Charges,367.2,60,,2743.84,Percent of Total Billed Charges,60% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612,100,,372,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,88.25,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459,75,,3196.44,Percent of Total Billed Charges,75% of Total Billed Charges,306,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.4,70,,42976.128,Percent of Total Billed Charges,70% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612,100,,4261.92,Percent of Total Billed Charges,100% of Total Billed Charges,85.68,612,
OPTIFIX AT FIXATION SYSTEM (011330),32100161,CDM,272,RC,,,Outpatient,,,2743.16,1645.90,,1645.9,60,,1555.84,Percent of Total Billed Charges,60% of Total Billed Charges,1234.42,45,,18.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.08,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,346.56,32,,322.776,Percent of Total Billed Charges,32% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,987.54,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,987.54,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,987.54,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1645.9,60,,3681.92,Percent of Total Billed Charges,60% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2743.16,100,,462.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,395.56,14.42,,13.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2057.37,75,,31.288,Percent of Total Billed Charges,75% of Total Billed Charges,1371.58,50,,11.68,Percent of Total Billed Charges,50% of Total Billed Charges,1371.58,50,,20.864,Percent of Total Billed Charges,50% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1371.58,50,,20.864,Percent of Total Billed Charges,50% of Total Billed Charges,1371.58,50,,20.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1920.21,70,,66090.944,Percent of Total Billed Charges,70% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,384.04,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2743.16,100,,41.72,Percent of Total Billed Charges,100% of Total Billed Charges,346.56,2743.16,
PHASIX ST MESH (1200011),32100162,CDM,278,RC,C1781,HCPCS,Outpatient,,,5338.84,3203.30,,6325.48,110,,168,Percent of Total Billed Charges,110% of Total Billed Charges,2402.48,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1494.88,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,347.77,32,,322.776,Percent of Total Billed Charges,32% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,1921.98,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1921.98,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1921.98,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2936.36,55,,5364.92,Percent of Total Billed Charges,55% Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5338.84,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,769.86,14.42,,16.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4271.07,80,,73.808,Percent of Total Billed Charges,80% of Total Billed Charges,2669.42,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,2669.42,50,,49.208,Percent of Total Billed Charges,50% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2669.42,50,,49.208,Percent of Total Billed Charges,50% of Total Billed Charges,2669.42,50,,49.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3737.19,70,,519.4,Percent of Total Billed Charges,70% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,747.44,14,,15.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5338.84,100,,98.408,Percent of Total Billed Charges,100% of Total Billed Charges,347.77,6325.48,
LACRIMAL TUBE WITH SUTURE (28-0174),32100163,CDM,274,RC,L8699,HCPCS,Outpatient,,,415.32,249.19,,456.85,110,,88.608,Percent of Total Billed Charges,110% of Total Billed Charges,186.89,45,,8.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.29,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,348.36,32,,322.776,Percent of Total Billed Charges,32% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,149.52,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,149.52,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,149.52,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.32,100,,275.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.26,80,,89.704,Percent of Total Billed Charges,80% of Total Billed Charges,207.66,50,,20.864,Percent of Total Billed Charges,50% of Total Billed Charges,207.66,50,,59.808,Percent of Total Billed Charges,50% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.66,50,,59.808,Percent of Total Billed Charges,50% of Total Billed Charges,207.66,50,,59.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.72,70,,753.176,Percent of Total Billed Charges,70% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.14,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,415.32,100,,119.608,Percent of Total Billed Charges,100% of Total Billed Charges,58.14,456.85,
SUTURE NUROLON 2,32100299,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,4953.36,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,30.24,Percent of Total Billed Charges,28% of Total Billed Charges,349,32,,322.776,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,12932.92,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,40.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,17.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,54.904,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,49.208,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,36.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,36.6,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,36.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,818.632,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,17.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,73.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,349,
SUTURE VICRYL 1,32100315,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,330,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,30.24,Percent of Total Billed Charges,28% of Total Billed Charges,349.04,32,,323.432,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,18703.96,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,2041.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,1.432,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,59.808,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,385.208,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,1.904,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,349.04,
BARD,32100398,CDM,272,RC,A4649,HCPCS,Outpatient,,,29.19,17.51,,17.51,60,,19360,Percent of Total Billed Charges,60% of Total Billed Charges,13.14,45,,959.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.17,28,,30.24,Percent of Total Billed Charges,28% of Total Billed Charges,349.08,32,,323.632,Percent of Total Billed Charges,32% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,10.51,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,10.51,36,,38.88,Percent of Total Billed Charges,36% Total Bille Charges,10.51,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,17.51,60,,24992.88,Percent of Total Billed Charges,60% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.19,100,,19.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14.42,,2041.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.89,75,,77.392,Percent of Total Billed Charges,75% of Total Billed Charges,14.6,50,,36.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.43,70,,88.592,Percent of Total Billed Charges,70% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14,,1982.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.19,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,4.09,349.08,
TRUMATCH ATTUNE RIGHT,32100400,CDM,272,RC,,,Outpatient,,,5327.4,3196.44,,3196.44,60,,1676.928,Percent of Total Billed Charges,60% of Total Billed Charges,2397.33,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1491.67,28,,81.808,Percent of Total Billed Charges,28% of Total Billed Charges,349.5,32,,324.344,Percent of Total Billed Charges,32% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,1917.86,36,,105.176,Percent of Total Billed Charges,36% of Total Billed Charges,1917.86,36,,105.176,Percent of Total Billed Charges,36% Total Bille Charges,1917.86,36,,105.176,Percent of Total Billed Charges,36% of Total Billed Charges,3196.44,60,,36086.6,Percent of Total Billed Charges,60% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5327.4,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,768.21,14.42,,1139.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3995.55,75,,75.2,Percent of Total Billed Charges,75% of Total Billed Charges,2663.7,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,47,Percent of Total Billed Charges,50% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2663.7,50,,47,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,47,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3729.18,70,,3739.008,Percent of Total Billed Charges,70% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,1106,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5327.4,100,,94,Percent of Total Billed Charges,100% of Total Billed Charges,349.5,5327.4,
DRAIN HEMOVAC,32100471,CDM,272,RC,,,Outpatient,,,52.15,31.29,,31.29,60,,959.984,Percent of Total Billed Charges,60% of Total Billed Charges,23.47,45,,36.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,28,,83.296,Percent of Total Billed Charges,28% of Total Billed Charges,350.4,32,,324.696,Percent of Total Billed Charges,32% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,18.77,36,,107.096,Percent of Total Billed Charges,36% of Total Billed Charges,18.77,36,,107.096,Percent of Total Billed Charges,36% Total Bille Charges,18.77,36,,107.096,Percent of Total Billed Charges,36% of Total Billed Charges,31.29,60,,58899.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.15,100,,37.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14.42,,1822.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.11,75,,84.088,Percent of Total Billed Charges,75% of Total Billed Charges,26.08,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.08,50,,56.064,Percent of Total Billed Charges,50% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.08,50,,56.064,Percent of Total Billed Charges,50% of Total Billed Charges,26.08,50,,56.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.51,70,,388.76,Percent of Total Billed Charges,70% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.3,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.15,100,,112.12,Percent of Total Billed Charges,100% of Total Billed Charges,7.3,350.4,
GUIDE WIRE FLX T,32100521,CDM,272,RC,C1769,HCPCS,Outpatient,,,123.01,73.81,,55.13,100,,55.64,Fee Schedule,100% of Aetna Fee Schedule,55.35,45,,151.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.44,28,,181.504,Percent of Total Billed Charges,28% of Total Billed Charges,350.4,32,,325.136,Percent of Total Billed Charges,32% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,44.28,36,,233.36,Percent of Total Billed Charges,36% of Total Billed Charges,44.28,36,,233.36,Percent of Total Billed Charges,36% Total Bille Charges,44.28,36,,233.36,Percent of Total Billed Charges,36% of Total Billed Charges,73.81,60,,217.328,Percent of Total Billed Charges,60% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.01,100,,2131.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14.42,,1822.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,61.51,50,,47,Percent of Total Billed Charges,50% of Total Billed Charges,61.51,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.51,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,61.51,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.11,70,,240.816,Percent of Total Billed Charges,70% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.01,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,17.22,350.4,
FISH (3206),32100562,CDM,272,RC,,,Outpatient,,,149.51,89.71,,89.71,60,,522.536,Percent of Total Billed Charges,60% of Total Billed Charges,67.28,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.86,28,,185.024,Percent of Total Billed Charges,28% of Total Billed Charges,350.43,32,,326.4,Percent of Total Billed Charges,32% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,53.82,36,,237.888,Percent of Total Billed Charges,36% of Total Billed Charges,53.82,36,,237.888,Percent of Total Billed Charges,36% Total Bille Charges,53.82,36,,237.888,Percent of Total Billed Charges,36% of Total Billed Charges,89.71,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.51,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,21.56,14.42,,23.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.13,75,,91.648,Percent of Total Billed Charges,75% of Total Billed Charges,74.76,50,,56.064,Percent of Total Billed Charges,50% of Total Billed Charges,74.76,50,,61.104,Percent of Total Billed Charges,50% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.76,50,,61.104,Percent of Total Billed Charges,50% of Total Billed Charges,74.76,50,,61.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.66,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,20.93,14,,22.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.51,100,,122.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.93,350.43,
BLAKE DRAIN 15FR,32100646,CDM,272,RC,C1729,HCPCS,Outpatient,,,91.5,54.90,,11.1,100,,288,Fee Schedule,100% of Aetna Fee Schedule,41.18,45,,252.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.62,28,,171.256,Percent of Total Billed Charges,28% of Total Billed Charges,350.43,32,,327.344,Percent of Total Billed Charges,32% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,32.94,36,,220.192,Percent of Total Billed Charges,36% of Total Billed Charges,32.94,36,,220.192,Percent of Total Billed Charges,36% Total Bille Charges,32.94,36,,220.192,Percent of Total Billed Charges,36% of Total Billed Charges,54.9,60,,120.4,Percent of Total Billed Charges,60% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.5,100,,80.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,13.19,14.42,,1822.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.63,75,,11328,Percent of Total Billed Charges,75% of Total Billed Charges,45.75,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,45.75,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.75,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,45.75,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.05,70,,25.2,Percent of Total Billed Charges,70% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,12.81,14,,1769.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.5,100,,14160,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,350.43,
ESU PENCIL HANDSWITCH W/ROCKER SWITCH (E2515H),32100703,CDM,272,RC,A4649,HCPCS,Outpatient,,,2.38,1.43,,1.43,60,,1980,Percent of Total Billed Charges,60% of Total Billed Charges,1.07,45,,11.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,185.024,Percent of Total Billed Charges,28% of Total Billed Charges,350.43,32,,328.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,36,,237.888,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,36,,237.888,Percent of Total Billed Charges,36% Total Bille Charges,0.86,36,,237.888,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,60,,119.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,100,,336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,2119.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,75,,11328,Percent of Total Billed Charges,75% of Total Billed Charges,1.19,50,,61.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,70,,61.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,2058.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,100,,14160,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,350.43,
FIBERWIRE 2-0,32100745,CDM,272,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,760.688,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,228.048,Percent of Total Billed Charges,28% of Total Billed Charges,350.43,32,,330.704,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,293.208,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,293.208,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,293.208,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,176.52,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,2934.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,6320,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,3950,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,3950,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,3950,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,143.36,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,2848.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,7900,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,350.43,
117522 WIRE C WIRE FX,32100752,CDM,278,RC,C1713,HCPCS,Outpatient,,,117.5,70.50,,446.51,110,,869.144,Percent of Total Billed Charges,110% of Total Billed Charges,52.88,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.9,28,,212.08,Percent of Total Billed Charges,28% of Total Billed Charges,351.1,32,,332.8,Percent of Total Billed Charges,32% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,42.3,36,,272.68,Percent of Total Billed Charges,36% of Total Billed Charges,42.3,36,,272.68,Percent of Total Billed Charges,36% Total Bille Charges,42.3,36,,272.68,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.5,100,,560.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.94,14.42,,1344.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94,80,,10112,Percent of Total Billed Charges,80% of Total Billed Charges,58.75,50,,7080,Percent of Total Billed Charges,50% of Total Billed Charges,58.75,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.75,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,58.75,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.25,70,,296.8,Percent of Total Billed Charges,70% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,1305.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.5,100,,12640,Percent of Total Billed Charges,100% of Total Billed Charges,16.45,446.51,
SUTURE CHROMIC 4,32100844,CDM,272,RC,,,Outpatient,,,140.15,84.09,,84.09,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,63.07,45,,30.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.24,28,,189.808,Percent of Total Billed Charges,28% of Total Billed Charges,351.22,32,,333.072,Percent of Total Billed Charges,32% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,50.45,36,,244.04,Percent of Total Billed Charges,36% of Total Billed Charges,50.45,36,,244.04,Percent of Total Billed Charges,36% Total Bille Charges,50.45,36,,244.04,Percent of Total Billed Charges,36% of Total Billed Charges,84.09,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.15,100,,26.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,20.21,14.42,,40.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.11,75,,10112,Percent of Total Billed Charges,75% of Total Billed Charges,70.08,50,,3950,Percent of Total Billed Charges,50% of Total Billed Charges,70.08,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.08,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,70.08,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.11,70,,680.4,Percent of Total Billed Charges,70% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.62,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.15,100,,12640,Percent of Total Billed Charges,100% of Total Billed Charges,19.62,351.22,
PDO 2-0 24 X 24,32100935,CDM,272,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,65.176,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,232.8,Percent of Total Billed Charges,28% of Total Billed Charges,351.35,32,,333.072,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,299.312,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,299.312,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,299.312,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,106.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,123.128,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,82.088,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,82.088,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,82.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,1070.72,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,103.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,164.168,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,351.35,
BOVIE BLADE DR.,32100992,CDM,272,RC,,,Outpatient,,,152.75,91.65,,91.65,60,,781.808,Percent of Total Billed Charges,60% of Total Billed Charges,68.74,45,,965.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.77,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,352.6,32,,334.08,Percent of Total Billed Charges,32% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,54.99,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,54.99,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,54.99,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,91.65,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.75,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,22.03,14.42,,230.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.56,75,,10112,Percent of Total Billed Charges,75% of Total Billed Charges,76.38,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,76.38,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.38,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,76.38,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.93,70,,1619.52,Percent of Total Billed Charges,70% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,21.39,14,,223.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.75,100,,12640,Percent of Total Billed Charges,100% of Total Billed Charges,21.39,352.6,
IMPLANT SHOULDER REVISION,32101009,CDM,278,RC,C1776,HCPCS,Outpatient,,,,,,3859.17,110,,1911.592,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,334.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3859.17,3859.17,
TOTAL HIP 1 DUAL MBILTY IMPLNT,32101010,CDM,278,RC,C1776,HCPCS,Outpatient,,,17700,10620.00,,23329.17,110,,778.8,Percent of Total Billed Charges,110% of Total Billed Charges,7965,45,,642.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4956,28,,90.376,Percent of Total Billed Charges,28% of Total Billed Charges,352.6,32,,334.544,Percent of Total Billed Charges,32% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,6372,36,,116.2,Percent of Total Billed Charges,36% of Total Billed Charges,6372,36,,116.2,Percent of Total Billed Charges,36% Total Bille Charges,6372,36,,116.2,Percent of Total Billed Charges,36% of Total Billed Charges,9735,55,,64.8,Percent of Total Billed Charges,55% Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17700,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2552.34,14.42,,1009.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14160,80,,16279.68,Percent of Total Billed Charges,80% of Total Billed Charges,8850,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,8850,50,,10174.8,Percent of Total Billed Charges,50% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8850,50,,10174.8,Percent of Total Billed Charges,50% of Total Billed Charges,8850,50,,10174.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12390,70,,3199.28,Percent of Total Billed Charges,70% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,980.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17700,100,,20349.6,Percent of Total Billed Charges,100% of Total Billed Charges,352.6,23329.17,
TOTAL HIP 2 PRIMARY IMPLANT,32101011,CDM,278,RC,C1776,HCPCS,Outpatient,,,17700,10620.00,,23329.17,110,,1309.44,Percent of Total Billed Charges,110% of Total Billed Charges,7965,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4956,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,352.6,32,,334.576,Percent of Total Billed Charges,32% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,6372,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,6372,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,6372,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,9735,55,,64.8,Percent of Total Billed Charges,55% Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17700,100,,2144.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2552.34,14.42,,1585.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14160,80,,7459.84,Percent of Total Billed Charges,80% of Total Billed Charges,8850,50,,7350.8,Percent of Total Billed Charges,50% of Total Billed Charges,8850,50,,4662.4,Percent of Total Billed Charges,50% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8850,50,,4662.4,Percent of Total Billed Charges,50% of Total Billed Charges,8850,50,,4662.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12390,70,,4417.84,Percent of Total Billed Charges,70% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,2478,14,,1538.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17700,100,,9324.8,Percent of Total Billed Charges,100% of Total Billed Charges,352.6,23329.17,
TOTAL HIP 3 OR 4 HEMIARTHRO,32101012,CDM,278,RC,C1776,HCPCS,Outpatient,,,9875,5925.00,,14721.67,110,,2464,Percent of Total Billed Charges,110% of Total Billed Charges,4443.75,45,,139.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2765,28,,90.376,Percent of Total Billed Charges,28% of Total Billed Charges,352.6,32,,335.176,Percent of Total Billed Charges,32% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,3555,36,,116.2,Percent of Total Billed Charges,36% of Total Billed Charges,3555,36,,116.2,Percent of Total Billed Charges,36% Total Bille Charges,3555,36,,116.2,Percent of Total Billed Charges,36% of Total Billed Charges,5431.25,55,,175.296,Percent of Total Billed Charges,55% Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9875,100,,1497.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1423.98,14.42,,2556.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7900,80,,225.92,Percent of Total Billed Charges,80% of Total Billed Charges,4937.5,50,,10174.8,Percent of Total Billed Charges,50% of Total Billed Charges,4937.5,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4937.5,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,4937.5,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6912.5,70,,6613.04,Percent of Total Billed Charges,70% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,1382.5,14,,2481.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9875,100,,282.4,Percent of Total Billed Charges,100% of Total Billed Charges,352.6,14721.67,
TOTAL KNEE 2 CEMENTED IMPLANT,32101014,CDM,278,RC,C1776,HCPCS,Outpatient,,,15800,9480.00,,21239.17,110,,6473.408,Percent of Total Billed Charges,110% of Total Billed Charges,7110,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4424,28,,139.168,Percent of Total Billed Charges,28% of Total Billed Charges,352.6,32,,335.336,Percent of Total Billed Charges,32% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,5688,36,,178.928,Percent of Total Billed Charges,36% of Total Billed Charges,5688,36,,178.928,Percent of Total Billed Charges,36% Total Bille Charges,5688,36,,178.928,Percent of Total Billed Charges,36% of Total Billed Charges,8690,55,,178.488,Percent of Total Billed Charges,55% Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15800,100,,1428,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2278.36,14.42,,4227.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12640,80,,589.44,Percent of Total Billed Charges,80% of Total Billed Charges,7900,50,,4662.4,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7900,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11060,70,,9354.24,Percent of Total Billed Charges,70% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,4104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15800,100,,736.8,Percent of Total Billed Charges,100% of Total Billed Charges,352.6,21239.17,
TOTAL KNEE 3 POLY IMPLANT,32101015,CDM,278,RC,C1776,HCPCS,Outpatient,,,15800,9480.00,,21239.17,110,,4301.44,Percent of Total Billed Charges,110% of Total Billed Charges,7110,45,,290.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4424,28,,55.44,Percent of Total Billed Charges,28% of Total Billed Charges,355.1,32,,335.616,Percent of Total Billed Charges,32% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,5688,36,,71.28,Percent of Total Billed Charges,36% of Total Billed Charges,5688,36,,71.28,Percent of Total Billed Charges,36% Total Bille Charges,5688,36,,71.28,Percent of Total Billed Charges,36% of Total Billed Charges,8690,55,,388.936,Percent of Total Billed Charges,55% Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15800,100,,72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2278.36,14.42,,7402.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12640,80,,1276.8,Percent of Total Billed Charges,80% of Total Billed Charges,7900,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,798,Percent of Total Billed Charges,50% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7900,50,,798,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,798,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11060,70,,13720.56,Percent of Total Billed Charges,70% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,7186.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15800,100,,1596,Percent of Total Billed Charges,100% of Total Billed Charges,355.1,21239.17,
0007360 SUTURE FIBERWIRE #2,32101016,CDM,272,RC,,,Outpatient,,,205.21,123.13,,123.13,60,,10394.112,Percent of Total Billed Charges,60% of Total Billed Charges,92.34,45,,26.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.46,28,,53.008,Percent of Total Billed Charges,28% of Total Billed Charges,355.2,32,,335.616,Percent of Total Billed Charges,32% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,73.88,36,,68.152,Percent of Total Billed Charges,36% of Total Billed Charges,73.88,36,,68.152,Percent of Total Billed Charges,36% Total Bille Charges,73.88,36,,68.152,Percent of Total Billed Charges,36% of Total Billed Charges,123.13,60,,396.472,Percent of Total Billed Charges,60% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.21,100,,310.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,29.59,14.42,,417.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.91,75,,3658.24,Percent of Total Billed Charges,75% of Total Billed Charges,102.61,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.61,50,,2286.4,Percent of Total Billed Charges,50% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.61,50,,2286.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.61,50,,2286.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.65,70,,18061.68,Percent of Total Billed Charges,70% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,405.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,100,,4572.8,Percent of Total Billed Charges,100% of Total Billed Charges,28.73,355.2,
TOTAL KNEE 1 NON-CEM IMPLANT,32101017,CDM,278,RC,C1776,HCPCS,Outpatient,,,15800,9480.00,,21239.17,110,,365.08,Percent of Total Billed Charges,110% of Total Billed Charges,7110,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4424,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,355.97,32,,336.824,Percent of Total Billed Charges,32% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,5688,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,5688,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,5688,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,8690,55,,366.984,Percent of Total Billed Charges,55% Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15800,100,,76.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2278.36,14.42,,28.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12640,80,,5602.56,Percent of Total Billed Charges,80% of Total Billed Charges,7900,50,,798,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,3501.6,Percent of Total Billed Charges,50% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7900,50,,3501.6,Percent of Total Billed Charges,50% of Total Billed Charges,7900,50,,3501.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11060,70,,28273.84,Percent of Total Billed Charges,70% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,2212,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15800,100,,7003.2,Percent of Total Billed Charges,100% of Total Billed Charges,355.97,21239.17,
IMPLANT SHOULDER TOTAL,32101018,CDM,278,RC,C1776,HCPCS,Outpatient,,,18377,11026.20,,24073.87,110,,5401.808,Percent of Total Billed Charges,110% of Total Billed Charges,8269.65,45,,161.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5145.56,28,,47.6,Percent of Total Billed Charges,28% of Total Billed Charges,355.97,32,,336.824,Percent of Total Billed Charges,32% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,6615.72,36,,61.2,Percent of Total Billed Charges,36% of Total Billed Charges,6615.72,36,,61.2,Percent of Total Billed Charges,36% Total Bille Charges,6615.72,36,,61.2,Percent of Total Billed Charges,36% of Total Billed Charges,10107.35,55,,396.472,Percent of Total Billed Charges,55% Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18377,100,,645.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2649.96,14.42,,20.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14701.6,80,,8794.24,Percent of Total Billed Charges,80% of Total Billed Charges,9188.5,50,,2286.4,Percent of Total Billed Charges,50% of Total Billed Charges,9188.5,50,,5496.4,Percent of Total Billed Charges,50% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9188.5,50,,5496.4,Percent of Total Billed Charges,50% of Total Billed Charges,9188.5,50,,5496.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12863.9,70,,24.08,Percent of Total Billed Charges,70% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2572.78,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18377,100,,10992.8,Percent of Total Billed Charges,100% of Total Billed Charges,355.97,24073.87,
IMPLANT SHOULDER REVERSE,32101019,CDM,278,RC,C1776,HCPCS,Outpatient,,,25437,15262.20,,31839.87,110,,799.928,Percent of Total Billed Charges,110% of Total Billed Charges,11446.65,45,,97.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7122.36,28,,78.712,Percent of Total Billed Charges,28% of Total Billed Charges,356.1,32,,337.336,Percent of Total Billed Charges,32% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,9157.32,36,,101.2,Percent of Total Billed Charges,36% of Total Billed Charges,9157.32,36,,101.2,Percent of Total Billed Charges,36% Total Bille Charges,9157.32,36,,101.2,Percent of Total Billed Charges,36% of Total Billed Charges,13990.35,55,,488.68,Percent of Total Billed Charges,55% Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25437,100,,58,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3668.02,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20349.6,80,,14181.76,Percent of Total Billed Charges,80% of Total Billed Charges,12718.5,50,,3501.6,Percent of Total Billed Charges,50% of Total Billed Charges,12718.5,50,,8863.6,Percent of Total Billed Charges,50% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12718.5,50,,8863.6,Percent of Total Billed Charges,50% of Total Billed Charges,12718.5,50,,8863.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17805.9,70,,89.04,Percent of Total Billed Charges,70% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,3561.18,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25437,100,,17727.2,Percent of Total Billed Charges,100% of Total Billed Charges,356.1,31839.87,
IMPLANT SHOULDER HEMI,32101020,CDM,278,RC,C1776,HCPCS,Outpatient,,,11656,6993.60,,16680.77,110,,34.816,Percent of Total Billed Charges,110% of Total Billed Charges,5245.2,45,,191.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3263.68,28,,118.08,Percent of Total Billed Charges,28% of Total Billed Charges,356.1,32,,337.848,Percent of Total Billed Charges,32% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,4196.16,36,,151.816,Percent of Total Billed Charges,36% of Total Billed Charges,4196.16,36,,151.816,Percent of Total Billed Charges,36% Total Bille Charges,4196.16,36,,151.816,Percent of Total Billed Charges,36% of Total Billed Charges,6410.8,55,,454.464,Percent of Total Billed Charges,55% Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11656,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1680.8,14.42,,16.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9324.8,80,,23452.8,Percent of Total Billed Charges,80% of Total Billed Charges,5828,50,,5496.4,Percent of Total Billed Charges,50% of Total Billed Charges,5828,50,,14658,Percent of Total Billed Charges,50% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5828,50,,14658,Percent of Total Billed Charges,50% of Total Billed Charges,5828,50,,14658,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8159.2,70,,269.36,Percent of Total Billed Charges,70% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,1631.84,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11656,100,,29316,Percent of Total Billed Charges,100% of Total Billed Charges,356.1,16680.77,
CMF IMPLANT LEVEL 1,32101021,CDM,278,RC,C1713,HCPCS,Outpatient,,,353,211.80,,705.56,110,,834.608,Percent of Total Billed Charges,110% of Total Billed Charges,158.85,45,,983.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.84,28,,80.256,Percent of Total Billed Charges,28% of Total Billed Charges,356.1,32,,337.92,Percent of Total Billed Charges,32% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,127.08,36,,103.184,Percent of Total Billed Charges,36% of Total Billed Charges,127.08,36,,103.184,Percent of Total Billed Charges,36% Total Bille Charges,127.08,36,,103.184,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,353,100,,358,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,50.9,14.42,,12.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.4,80,,41066.88,Percent of Total Billed Charges,80% of Total Billed Charges,176.5,50,,8863.6,Percent of Total Billed Charges,50% of Total Billed Charges,176.5,50,,25666.8,Percent of Total Billed Charges,50% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.5,50,,25666.8,Percent of Total Billed Charges,50% of Total Billed Charges,176.5,50,,25666.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.1,70,,857.36,Percent of Total Billed Charges,70% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,12.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353,100,,51333.6,Percent of Total Billed Charges,100% of Total Billed Charges,49.42,705.56,
CMF IMPLANT LEVEL 2,32101022,CDM,278,RC,C1713,HCPCS,Outpatient,,,921,552.60,,1330.36,110,,478.8,Percent of Total Billed Charges,110% of Total Billed Charges,414.45,45,,250.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.88,28,,108.352,Percent of Total Billed Charges,28% of Total Billed Charges,358.65,32,,337.92,Percent of Total Billed Charges,32% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,331.56,36,,139.312,Percent of Total Billed Charges,36% of Total Billed Charges,331.56,36,,139.312,Percent of Total Billed Charges,36% Total Bille Charges,331.56,36,,139.312,Percent of Total Billed Charges,36% of Total Billed Charges,506.55,55,,498.856,Percent of Total Billed Charges,55% Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921,100,,217.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,132.81,14.42,,13.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736.8,80,,2316.8,Percent of Total Billed Charges,80% of Total Billed Charges,460.5,50,,14658,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,1448,Percent of Total Billed Charges,50% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,50,,1448,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,1448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.7,70,,1513.12,Percent of Total Billed Charges,70% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,12.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,921,100,,2896,Percent of Total Billed Charges,100% of Total Billed Charges,128.94,1330.36,
CMF IMPLANT LEVEL 3,32101023,CDM,278,RC,C1713,HCPCS,Outpatient,,,1995,1197.00,,2511.76,110,,3015.688,Percent of Total Billed Charges,110% of Total Billed Charges,897.75,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,558.6,28,,231.96,Percent of Total Billed Charges,28% of Total Billed Charges,358.71,32,,337.92,Percent of Total Billed Charges,32% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,718.2,36,,298.232,Percent of Total Billed Charges,36% of Total Billed Charges,718.2,36,,298.232,Percent of Total Billed Charges,36% Total Bille Charges,718.2,36,,298.232,Percent of Total Billed Charges,36% of Total Billed Charges,1097.25,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1995,100,,425.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,287.68,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1596,80,,147.752,Percent of Total Billed Charges,80% of Total Billed Charges,997.5,50,,25666.8,Percent of Total Billed Charges,50% of Total Billed Charges,997.5,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,997.5,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,997.5,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1396.5,70,,2375.52,Percent of Total Billed Charges,70% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,279.3,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1995,100,,197,Percent of Total Billed Charges,100% of Total Billed Charges,279.3,2511.76,
CMF IMPLANT LEVEL 5,32101025,CDM,278,RC,C1713,HCPCS,Outpatient,,,5716,3429.60,,6604.86,110,,7669.048,Percent of Total Billed Charges,110% of Total Billed Charges,2572.2,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.48,28,,42.896,Percent of Total Billed Charges,28% of Total Billed Charges,359.66,32,,339.84,Percent of Total Billed Charges,32% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,2057.76,36,,55.152,Percent of Total Billed Charges,36% of Total Billed Charges,2057.76,36,,55.152,Percent of Total Billed Charges,36% Total Bille Charges,2057.76,36,,55.152,Percent of Total Billed Charges,36% of Total Billed Charges,3143.8,55,,379.12,Percent of Total Billed Charges,55% Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5716,100,,2185.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,824.25,14.42,,11.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4572.8,80,,105,Percent of Total Billed Charges,80% of Total Billed Charges,2858,50,,1448,Percent of Total Billed Charges,50% of Total Billed Charges,2858,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2858,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,2858,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4001.2,70,,3492.16,Percent of Total Billed Charges,70% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,800.24,14,,11.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5716,100,,140,Percent of Total Billed Charges,100% of Total Billed Charges,359.66,6604.86,
CMF IMPLANT LEVEL 6,32101026,CDM,278,RC,C1713,HCPCS,Outpatient,,,8754,5252.40,,9946.66,110,,315.408,Percent of Total Billed Charges,110% of Total Billed Charges,3939.3,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2451.12,28,,30.24,Percent of Total Billed Charges,28% of Total Billed Charges,359.96,32,,340.152,Percent of Total Billed Charges,32% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,3151.44,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,3151.44,36,,38.88,Percent of Total Billed Charges,36% Total Bille Charges,3151.44,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,4814.7,55,,193.672,Percent of Total Billed Charges,55% Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8754,100,,557.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1262.33,14.42,,32.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7003.2,80,,320.76,Percent of Total Billed Charges,80% of Total Billed Charges,4377,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,4377,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4377,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,4377,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6127.8,70,,4686.08,Percent of Total Billed Charges,70% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,1225.56,14,,31.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8754,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,359.96,9946.66,
CMF IMPLANT LEVEL 7,32101027,CDM,278,RC,C1713,HCPCS,Outpatient,,,13741,8244.60,,15432.36,110,,2471.408,Percent of Total Billed Charges,110% of Total Billed Charges,6183.45,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3847.48,28,,66.84,Percent of Total Billed Charges,28% of Total Billed Charges,360.51,32,,340.152,Percent of Total Billed Charges,32% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,4946.76,36,,85.936,Percent of Total Billed Charges,36% of Total Billed Charges,4946.76,36,,85.936,Percent of Total Billed Charges,36% Total Bille Charges,4946.76,36,,85.936,Percent of Total Billed Charges,36% of Total Billed Charges,7557.55,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13741,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1981.45,14.42,,23.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10992.8,80,,83.464,Percent of Total Billed Charges,80% of Total Billed Charges,6870.5,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,6870.5,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6870.5,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,6870.5,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9618.7,70,,6828.08,Percent of Total Billed Charges,70% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,1923.74,14,,22.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13741,100,,111.28,Percent of Total Billed Charges,100% of Total Billed Charges,360.51,15432.36,
CMF IMPLANT LEVEL 8,32101028,CDM,278,RC,C1713,HCPCS,Outpatient,,,22159,13295.40,,24692.16,110,,6118.272,Percent of Total Billed Charges,110% of Total Billed Charges,9971.55,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6204.52,28,,68.88,Percent of Total Billed Charges,28% of Total Billed Charges,361.22,32,,340.48,Percent of Total Billed Charges,32% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,7977.24,36,,88.56,Percent of Total Billed Charges,36% of Total Billed Charges,7977.24,36,,88.56,Percent of Total Billed Charges,36% Total Bille Charges,7977.24,36,,88.56,Percent of Total Billed Charges,36% of Total Billed Charges,12187.45,55,,193.672,Percent of Total Billed Charges,55% Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22159,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3195.33,14.42,,29.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17727.2,80,,67.008,Percent of Total Billed Charges,80% of Total Billed Charges,11079.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,11079.5,50,,44.672,Percent of Total Billed Charges,50% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11079.5,50,,44.672,Percent of Total Billed Charges,50% of Total Billed Charges,11079.5,50,,44.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15511.3,70,,10435.04,Percent of Total Billed Charges,70% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,3102.26,14,,28.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22159,100,,89.344,Percent of Total Billed Charges,100% of Total Billed Charges,361.22,24692.16,
CMF IMPLANT LEVEL 9,32101029,CDM,278,RC,C1713,HCPCS,Outpatient,,,36645,21987.00,,40626.76,110,,146.88,Percent of Total Billed Charges,110% of Total Billed Charges,16490.25,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10260.6,28,,52.808,Percent of Total Billed Charges,28% of Total Billed Charges,362.02,32,,340.712,Percent of Total Billed Charges,32% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,13192.2,36,,67.896,Percent of Total Billed Charges,36% of Total Billed Charges,13192.2,36,,67.896,Percent of Total Billed Charges,36% Total Bille Charges,13192.2,36,,67.896,Percent of Total Billed Charges,36% of Total Billed Charges,20154.75,55,,298.208,Percent of Total Billed Charges,55% Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36645,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5284.21,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29316,80,,73.928,Percent of Total Billed Charges,80% of Total Billed Charges,18322.5,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,18322.5,50,,46.208,Percent of Total Billed Charges,50% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18322.5,50,,46.208,Percent of Total Billed Charges,50% of Total Billed Charges,18322.5,50,,46.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25651.5,70,,16460.08,Percent of Total Billed Charges,70% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,5130.3,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36645,100,,92.408,Percent of Total Billed Charges,100% of Total Billed Charges,362.02,40626.76,
CMF IMPLANT LEVEL 10,32101030,CDM,278,RC,C1713,HCPCS,Outpatient,,,64167,38500.20,,70900.96,110,,2562.56,Percent of Total Billed Charges,110% of Total Billed Charges,28875.15,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17966.76,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,362.02,32,,340.712,Percent of Total Billed Charges,32% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,23100.12,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,23100.12,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,23100.12,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,35291.85,55,,118.8,Percent of Total Billed Charges,55% Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64167,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,9252.88,14.42,,33.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51333.6,80,,175.888,Percent of Total Billed Charges,80% of Total Billed Charges,32083.5,50,,44.672,Percent of Total Billed Charges,50% of Total Billed Charges,32083.5,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32083.5,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,32083.5,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44916.9,70,,23805.04,Percent of Total Billed Charges,70% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,8983.38,14,,32.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64167,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,362.02,70900.96,
CMF IMPLANT LEVEL 4,32101031,CDM,278,RC,C1713,HCPCS,Outpatient,,,3620,2172.00,,4299.26,110,,1213.656,Percent of Total Billed Charges,110% of Total Billed Charges,1629,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1013.6,28,,30.24,Percent of Total Billed Charges,28% of Total Billed Charges,362.42,32,,341.728,Percent of Total Billed Charges,32% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,1303.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,1303.2,36,,38.88,Percent of Total Billed Charges,36% Total Bille Charges,1303.2,36,,38.88,Percent of Total Billed Charges,36% of Total Billed Charges,1991,55,,113.584,Percent of Total Billed Charges,55% Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3620,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,522,14.42,,37.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2896,80,,62.32,Percent of Total Billed Charges,80% of Total Billed Charges,1810,50,,46.208,Percent of Total Billed Charges,50% of Total Billed Charges,1810,50,,41.544,Percent of Total Billed Charges,50% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1810,50,,41.544,Percent of Total Billed Charges,50% of Total Billed Charges,1810,50,,41.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2534,70,,31809.12,Percent of Total Billed Charges,70% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,506.8,14,,36.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3620,100,,83.088,Percent of Total Billed Charges,100% of Total Billed Charges,362.42,4299.26,
137538 DEVICE TK-5 QUICK LOAD,32101107,CDM,272,RC,,,Outpatient,,,246.25,147.75,,147.75,60,,781.808,Percent of Total Billed Charges,60% of Total Billed Charges,110.81,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.95,28,,23.16,Percent of Total Billed Charges,28% of Total Billed Charges,363.2,32,,341.728,Percent of Total Billed Charges,32% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,88.65,36,,29.776,Percent of Total Billed Charges,36% of Total Billed Charges,88.65,36,,29.776,Percent of Total Billed Charges,36% Total Bille Charges,88.65,36,,29.776,Percent of Total Billed Charges,36% of Total Billed Charges,147.75,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14.42,,41.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.69,75,,169.544,Percent of Total Billed Charges,75% of Total Billed Charges,123.13,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,113.032,Percent of Total Billed Charges,50% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.13,50,,113.032,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,113.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.38,70,,45928.4,Percent of Total Billed Charges,70% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,40.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.25,100,,226.056,Percent of Total Billed Charges,100% of Total Billed Charges,34.48,363.2,
SUTURE RETRIEVER,32101115,CDM,272,RC,,,Outpatient,,,175,105.00,,105,60,,5940.336,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,28,,52.048,Percent of Total Billed Charges,28% of Total Billed Charges,364.73,32,,342.152,Percent of Total Billed Charges,32% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,63,36,,66.92,Percent of Total Billed Charges,36% of Total Billed Charges,63,36,,66.92,Percent of Total Billed Charges,36% Total Bille Charges,63,36,,66.92,Percent of Total Billed Charges,36% of Total Billed Charges,105,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.24,14.42,,109.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.25,75,,119.896,Percent of Total Billed Charges,75% of Total Billed Charges,87.5,50,,41.544,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,79.936,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,50,,79.936,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,79.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.5,70,,74962.72,Percent of Total Billed Charges,70% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,100,,159.864,Percent of Total Billed Charges,100% of Total Billed Charges,24.5,364.73,
FIBERTAPE 2MM (A,32101123,CDM,272,RC,,,Outpatient,,,534.6,320.76,,320.76,60,,145.8,Percent of Total Billed Charges,60% of Total Billed Charges,240.57,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,91.16,Percent of Total Billed Charges,28% of Total Billed Charges,364.8,32,,344.304,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,117.208,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,117.208,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,117.208,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,168.664,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,195.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,152.176,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,113.032,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,101.456,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,101.456,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,101.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,253.544,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,189.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,202.904,Percent of Total Billed Charges,100% of Total Billed Charges,74.84,534.6,
TUBE TRACHLOW PRESSURE,32101206,CDM,272,RC,,,Outpatient,,,139.1,83.46,,83.46,60,,695.304,Percent of Total Billed Charges,60% of Total Billed Charges,62.6,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.95,28,,111.976,Percent of Total Billed Charges,28% of Total Billed Charges,369.25,32,,344.304,Percent of Total Billed Charges,32% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,50.08,36,,143.968,Percent of Total Billed Charges,36% of Total Billed Charges,50.08,36,,143.968,Percent of Total Billed Charges,36% Total Bille Charges,50.08,36,,143.968,Percent of Total Billed Charges,36% of Total Billed Charges,83.46,60,,253.032,Percent of Total Billed Charges,60% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.1,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.06,14.42,,49.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.33,75,,114.064,Percent of Total Billed Charges,75% of Total Billed Charges,69.55,50,,79.936,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.55,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.37,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,48.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.1,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,19.47,369.25,
ENDOSTITCH POLYS,32101222,CDM,272,RC,,,Outpatient,,,111.68,67.01,,67.01,60,,476.64,Percent of Total Billed Charges,60% of Total Billed Charges,50.26,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.27,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,369.57,32,,344.304,Percent of Total Billed Charges,32% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,40.2,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,40.2,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,40.2,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,67.01,60,,171.968,Percent of Total Billed Charges,60% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.68,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,16.1,14.42,,48.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.76,75,,175.504,Percent of Total Billed Charges,75% of Total Billed Charges,55.84,50,,101.456,Percent of Total Billed Charges,50% of Total Billed Charges,55.84,50,,117,Percent of Total Billed Charges,50% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.84,50,,117,Percent of Total Billed Charges,50% of Total Billed Charges,55.84,50,,117,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.18,70,,140.472,Percent of Total Billed Charges,70% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14,,47.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.68,100,,234,Percent of Total Billed Charges,100% of Total Billed Charges,15.64,369.57,
114602 FIBERWIRE #2,32101255,CDM,278,RC,C1713,HCPCS,Outpatient,,,115.51,69.31,,444.32,110,,10687.64,Percent of Total Billed Charges,110% of Total Billed Charges,51.98,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.34,28,,105.248,Percent of Total Billed Charges,28% of Total Billed Charges,370.09,32,,345.44,Percent of Total Billed Charges,32% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.58,36,,135.312,Percent of Total Billed Charges,36% of Total Billed Charges,41.58,36,,135.312,Percent of Total Billed Charges,36% Total Bille Charges,41.58,36,,135.312,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.51,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.66,14.42,,71.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.41,80,,195,Percent of Total Billed Charges,80% of Total Billed Charges,57.76,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,57.76,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.76,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,57.76,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.86,70,,138.928,Percent of Total Billed Charges,70% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,16.17,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.51,100,,260,Percent of Total Billed Charges,100% of Total Billed Charges,16.17,444.32,
FIBERWIRE TIGERL,32101289,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,17992.168,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,373.01,32,,345.6,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,497.056,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,70.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,217.56,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,117,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,145.04,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,145.04,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,145.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,205.944,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,68.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,290.08,Percent of Total Billed Charges,100% of Total Billed Charges,41.04,373.01,
TROCAR THORACOPO,32101297,CDM,272,RC,,,Outpatient,,,103.86,62.32,,62.32,60,,358.56,Percent of Total Billed Charges,60% of Total Billed Charges,46.74,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.08,28,,125.544,Percent of Total Billed Charges,28% of Total Billed Charges,373.48,32,,345.6,Percent of Total Billed Charges,32% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,37.39,36,,161.416,Percent of Total Billed Charges,36% of Total Billed Charges,37.39,36,,161.416,Percent of Total Billed Charges,36% Total Bille Charges,37.39,36,,161.416,Percent of Total Billed Charges,36% of Total Billed Charges,62.32,60,,91.92,Percent of Total Billed Charges,60% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.86,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.98,14.42,,87.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.9,75,,570.144,Percent of Total Billed Charges,75% of Total Billed Charges,51.93,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,51.93,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.93,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,51.93,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.7,70,,321.8,Percent of Total Billed Charges,70% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,14.54,14,,84.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.86,100,,760.192,Percent of Total Billed Charges,100% of Total Billed Charges,14.54,373.48,
0007198 STIMULATOR NERVE,32101313,CDM,272,RC,,,Outpatient,,,282.57,169.54,,169.54,60,,2168.856,Percent of Total Billed Charges,60% of Total Billed Charges,127.16,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.12,28,,120.96,Percent of Total Billed Charges,28% of Total Billed Charges,373.48,32,,345.6,Percent of Total Billed Charges,32% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.73,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,101.73,36,,155.52,Percent of Total Billed Charges,36% Total Bille Charges,101.73,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,169.54,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.57,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,40.75,14.42,,62.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.93,75,,1085.312,Percent of Total Billed Charges,75% of Total Billed Charges,141.29,50,,145.04,Percent of Total Billed Charges,50% of Total Billed Charges,141.29,50,,678.32,Percent of Total Billed Charges,50% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.29,50,,678.32,Percent of Total Billed Charges,50% of Total Billed Charges,141.29,50,,678.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.8,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,39.56,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,282.57,100,,1356.64,Percent of Total Billed Charges,100% of Total Billed Charges,39.56,373.48,
ENDOCLOSE,32101321,CDM,272,RC,,,Outpatient,,,199.83,119.90,,119.9,60,,811.008,Percent of Total Billed Charges,60% of Total Billed Charges,89.92,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.95,28,,113.688,Percent of Total Billed Charges,28% of Total Billed Charges,373.87,32,,345.944,Percent of Total Billed Charges,32% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,71.94,36,,146.168,Percent of Total Billed Charges,36% of Total Billed Charges,71.94,36,,146.168,Percent of Total Billed Charges,36% Total Bille Charges,71.94,36,,146.168,Percent of Total Billed Charges,36% of Total Billed Charges,119.9,60,,143.232,Percent of Total Billed Charges,60% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.83,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.82,14.42,,19.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.87,75,,258.536,Percent of Total Billed Charges,75% of Total Billed Charges,99.92,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,99.92,50,,172.36,Percent of Total Billed Charges,50% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.92,50,,172.36,Percent of Total Billed Charges,50% of Total Billed Charges,99.92,50,,172.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.88,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.83,100,,344.712,Percent of Total Billed Charges,100% of Total Billed Charges,27.98,373.87,
0004405 SUTURE RETRIEVER PASSE,32101362,CDM,272,RC,,,Outpatient,,,253.63,152.18,,152.18,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,114.13,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.02,28,,120.96,Percent of Total Billed Charges,28% of Total Billed Charges,374.66,32,,347.904,Percent of Total Billed Charges,32% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,91.31,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,91.31,36,,155.52,Percent of Total Billed Charges,36% Total Bille Charges,91.31,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,152.18,60,,147.6,Percent of Total Billed Charges,60% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.63,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14.42,,90.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.22,75,,253.08,Percent of Total Billed Charges,75% of Total Billed Charges,126.82,50,,678.32,Percent of Total Billed Charges,50% of Total Billed Charges,126.82,50,,168.72,Percent of Total Billed Charges,50% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.82,50,,168.72,Percent of Total Billed Charges,50% of Total Billed Charges,126.82,50,,168.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.54,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14,,88.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.63,100,,337.44,Percent of Total Billed Charges,100% of Total Billed Charges,35.51,374.66,
TRACH TUBE SIZE 4 LOW PRESSURE CUFFED (4LPC),32101370,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,2718.8,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,376.7,32,,348.168,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,113.16,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,78.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,370.504,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,172.36,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,75.6,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,494,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,376.7,
ULTRASLING II LG,32101479,CDM,270,RC,,,Outpatient,,,292.5,175.50,,175.5,60,,1652.72,Percent of Total Billed Charges,60% of Total Billed Charges,131.63,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.9,28,,218.8,Percent of Total Billed Charges,28% of Total Billed Charges,378.57,32,,348.168,Percent of Total Billed Charges,32% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,105.3,36,,281.312,Percent of Total Billed Charges,36% of Total Billed Charges,105.3,36,,281.312,Percent of Total Billed Charges,36% Total Bille Charges,105.3,36,,281.312,Percent of Total Billed Charges,36% of Total Billed Charges,175.5,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,42.18,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.38,75,,365.48,Percent of Total Billed Charges,75% of Total Billed Charges,146.25,50,,168.72,Percent of Total Billed Charges,50% of Total Billed Charges,146.25,50,,243.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.25,50,,243.656,Percent of Total Billed Charges,50% of Total Billed Charges,146.25,50,,243.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.75,70,,75.6,Percent of Total Billed Charges,70% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,100,,487.304,Percent of Total Billed Charges,100% of Total Billed Charges,40.95,378.57,
STAPLER MENISCAL,32101560,CDM,272,RC,,,Outpatient,,,325,195.00,,195,60,,6847.352,Percent of Total Billed Charges,60% of Total Billed Charges,146.25,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91,28,,204.704,Percent of Total Billed Charges,28% of Total Billed Charges,378.92,32,,348.856,Percent of Total Billed Charges,32% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,117,36,,263.192,Percent of Total Billed Charges,36% of Total Billed Charges,117,36,,263.192,Percent of Total Billed Charges,36% Total Bille Charges,117,36,,263.192,Percent of Total Billed Charges,36% of Total Billed Charges,195,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,46.87,14.42,,125.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.75,75,,453.072,Percent of Total Billed Charges,75% of Total Billed Charges,162.5,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,162.5,50,,302.048,Percent of Total Billed Charges,50% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.5,50,,302.048,Percent of Total Billed Charges,50% of Total Billed Charges,162.5,50,,302.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.5,70,,75.6,Percent of Total Billed Charges,70% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.5,14,,122.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325,100,,604.096,Percent of Total Billed Charges,100% of Total Billed Charges,45.5,378.92,
SUTURE VICRYL 2-,32101578,CDM,272,RC,,,Outpatient,,,362.6,217.56,,217.56,60,,268.8,Percent of Total Billed Charges,60% of Total Billed Charges,163.17,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.53,28,,268.232,Percent of Total Billed Charges,28% of Total Billed Charges,380.48,32,,349.296,Percent of Total Billed Charges,32% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,130.54,36,,344.872,Percent of Total Billed Charges,36% of Total Billed Charges,130.54,36,,344.872,Percent of Total Billed Charges,36% Total Bille Charges,130.54,36,,344.872,Percent of Total Billed Charges,36% of Total Billed Charges,217.56,60,,49.624,Percent of Total Billed Charges,60% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.6,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14.42,,250.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.95,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,181.3,50,,243.656,Percent of Total Billed Charges,50% of Total Billed Charges,181.3,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.3,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,181.3,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.82,70,,204.512,Percent of Total Billed Charges,70% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.6,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,50.76,380.48,
LSI TK5 TITANIUM,32101669,CDM,272,RC,,,Outpatient,,,950.24,570.14,,570.14,60,,3540.32,Percent of Total Billed Charges,60% of Total Billed Charges,427.61,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.07,28,,307.968,Percent of Total Billed Charges,28% of Total Billed Charges,381.03,32,,349.296,Percent of Total Billed Charges,32% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,342.09,36,,395.952,Percent of Total Billed Charges,36% of Total Billed Charges,342.09,36,,395.952,Percent of Total Billed Charges,36% Total Bille Charges,342.09,36,,395.952,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,60,,111.528,Percent of Total Billed Charges,60% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,950.24,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,137.02,14.42,,82.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.68,75,,102.016,Percent of Total Billed Charges,75% of Total Billed Charges,475.12,50,,302.048,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,475.12,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.17,70,,208.24,Percent of Total Billed Charges,70% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,79.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,950.24,100,,136.024,Percent of Total Billed Charges,100% of Total Billed Charges,133.03,950.24,
505804 MESH ATRIUM MED SMALL,32101693,CDM,278,RC,C1781,HCPCS,Outpatient,,,1695.8,1017.48,,2318.14,110,,3714.944,Percent of Total Billed Charges,110% of Total Billed Charges,763.11,45,,261.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.82,28,,292.72,Percent of Total Billed Charges,28% of Total Billed Charges,381.03,32,,349.296,Percent of Total Billed Charges,32% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,610.49,36,,376.36,Percent of Total Billed Charges,36% of Total Billed Charges,610.49,36,,376.36,Percent of Total Billed Charges,36% Total Bille Charges,610.49,36,,376.36,Percent of Total Billed Charges,36% of Total Billed Charges,932.69,55,,195.352,Percent of Total Billed Charges,55% Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1695.8,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,244.53,14.42,,159.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1356.64,80,,471.712,Percent of Total Billed Charges,80% of Total Billed Charges,847.9,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,847.9,50,,314.472,Percent of Total Billed Charges,50% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,847.9,50,,314.472,Percent of Total Billed Charges,50% of Total Billed Charges,847.9,50,,314.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1187.06,70,,453.76,Percent of Total Billed Charges,70% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,237.41,14,,154.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1695.8,100,,628.944,Percent of Total Billed Charges,100% of Total Billed Charges,237.41,2318.14,
0001505 CLIP APPLIER ENDO,32101727,CDM,272,RC,,,Outpatient,,,430.89,258.53,,258.53,60,,5994.664,Percent of Total Billed Charges,60% of Total Billed Charges,193.9,45,,201.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.65,28,,530.376,Percent of Total Billed Charges,28% of Total Billed Charges,381.03,32,,349.544,Percent of Total Billed Charges,32% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,155.12,36,,681.912,Percent of Total Billed Charges,36% of Total Billed Charges,155.12,36,,681.912,Percent of Total Billed Charges,36% Total Bille Charges,155.12,36,,681.912,Percent of Total Billed Charges,36% of Total Billed Charges,258.53,60,,239.944,Percent of Total Billed Charges,60% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.89,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,62.13,14.42,,77.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.17,75,,409.336,Percent of Total Billed Charges,75% of Total Billed Charges,215.45,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,215.45,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.45,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,215.45,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.62,70,,462.552,Percent of Total Billed Charges,70% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.32,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.89,100,,545.776,Percent of Total Billed Charges,100% of Total Billed Charges,60.32,430.89,
0005215 RELOAD ENDOPATH BLUE,32101842,CDM,272,RC,,,Outpatient,,,421.8,253.08,,253.08,60,,3160.304,Percent of Total Billed Charges,60% of Total Billed Charges,189.81,45,,245.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.1,28,,39.648,Percent of Total Billed Charges,28% of Total Billed Charges,381.31,32,,349.664,Percent of Total Billed Charges,32% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,151.85,36,,50.976,Percent of Total Billed Charges,36% of Total Billed Charges,151.85,36,,50.976,Percent of Total Billed Charges,36% Total Bille Charges,151.85,36,,50.976,Percent of Total Billed Charges,36% of Total Billed Charges,253.08,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.8,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,60.82,14.42,,236.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.35,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,210.9,50,,314.472,Percent of Total Billed Charges,50% of Total Billed Charges,210.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,210.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.26,70,,428.152,Percent of Total Billed Charges,70% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,59.05,14,,229.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421.8,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,59.05,421.8,
131406 STAPLER RELOAD E,32101925,CDM,272,RC,,,Outpatient,,,617.5,370.50,,370.5,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,277.88,45,,1204.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.9,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,382.04,32,,349.736,Percent of Total Billed Charges,32% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,222.3,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,222.3,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,222.3,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,370.5,60,,225.52,Percent of Total Billed Charges,60% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.5,100,,580.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.04,14.42,,160.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.13,75,,698.592,Percent of Total Billed Charges,75% of Total Billed Charges,308.75,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,436.624,Percent of Total Billed Charges,50% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.75,50,,436.624,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,436.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.25,70,,462.552,Percent of Total Billed Charges,70% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,155.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,617.5,100,,873.24,Percent of Total Billed Charges,100% of Total Billed Charges,86.45,617.5,
407687 KNOT PUSHER CUTTER,32101990,CDM,272,RC,,,Outpatient,,,609.13,365.48,,365.48,60,,9037.992,Percent of Total Billed Charges,60% of Total Billed Charges,274.11,45,,245.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,28,,37.016,Percent of Total Billed Charges,28% of Total Billed Charges,383.04,32,,349.792,Percent of Total Billed Charges,32% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,219.29,36,,47.592,Percent of Total Billed Charges,36% of Total Billed Charges,219.29,36,,47.592,Percent of Total Billed Charges,36% Total Bille Charges,219.29,36,,47.592,Percent of Total Billed Charges,36% of Total Billed Charges,365.48,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,609.13,100,,448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,87.84,14.42,,171.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,456.85,75,,1302.76,Percent of Total Billed Charges,75% of Total Billed Charges,304.57,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,304.57,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.57,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,304.57,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.39,70,,570.128,Percent of Total Billed Charges,70% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,85.28,14,,166.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609.13,100,,1737.008,Percent of Total Billed Charges,100% of Total Billed Charges,85.28,609.13,
PROBE VULCAN ABL,32102055,CDM,272,RC,,,Outpatient,,,755.12,453.07,,453.07,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,339.8,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.43,28,,41.328,Percent of Total Billed Charges,28% of Total Billed Charges,383.04,32,,350.416,Percent of Total Billed Charges,32% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,271.84,36,,53.136,Percent of Total Billed Charges,36% of Total Billed Charges,271.84,36,,53.136,Percent of Total Billed Charges,36% Total Bille Charges,271.84,36,,53.136,Percent of Total Billed Charges,36% of Total Billed Charges,453.07,60,,269.024,Percent of Total Billed Charges,60% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.12,100,,545.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,108.89,14.42,,110.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.34,75,,426.88,Percent of Total Billed Charges,75% of Total Billed Charges,377.56,50,,436.624,Percent of Total Billed Charges,50% of Total Billed Charges,377.56,50,,284.584,Percent of Total Billed Charges,50% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,377.56,50,,284.584,Percent of Total Billed Charges,50% of Total Billed Charges,377.56,50,,284.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,528.58,70,,530.208,Percent of Total Billed Charges,70% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,105.72,14,,107.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,755.12,100,,569.168,Percent of Total Billed Charges,100% of Total Billed Charges,105.72,755.12,
STAPLER MENISCAL,32102089,CDM,272,RC,,,Outpatient,,,540,324.00,,324,60,,319.752,Percent of Total Billed Charges,60% of Total Billed Charges,243,45,,672.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.2,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,383.19,32,,350.72,Percent of Total Billed Charges,32% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,194.4,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,194.4,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,194.4,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,324,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,100,,2676.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,77.87,14.42,,207.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,885.024,Percent of Total Billed Charges,75% of Total Billed Charges,270,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,553.144,Percent of Total Billed Charges,50% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,50,,553.144,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,553.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,70,,474.52,Percent of Total Billed Charges,70% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540,100,,1106.28,Percent of Total Billed Charges,100% of Total Billed Charges,75.6,540,
438112 GUIDEWIRE GLIDEWIRE,32102162,CDM,272,RC,C1769,HCPCS,Outpatient,,,170.03,102.02,,55.13,100,,3216.928,Fee Schedule,100% of Aetna Fee Schedule,76.51,45,,3638.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.61,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,383.98,32,,350.72,Percent of Total Billed Charges,32% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,61.21,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,61.21,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,102.02,60,,243.608,Percent of Total Billed Charges,60% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.03,100,,545.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14.42,,317.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.52,75,,405,Percent of Total Billed Charges,75% of Total Billed Charges,85.02,50,,284.584,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.02,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.02,70,,582,Percent of Total Billed Charges,70% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,308.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.03,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,23.8,383.98,
194409 SEAMGUARD STAPLE LINE,32102279,CDM,272,RC,,,Outpatient,,,786.18,471.71,,471.71,60,,2728.544,Percent of Total Billed Charges,60% of Total Billed Charges,353.78,45,,1505.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.13,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,384,32,,350.72,Percent of Total Billed Charges,32% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,283.02,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,283.02,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,283.02,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,471.71,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.18,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,113.37,14.42,,157.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.64,75,,1228.792,Percent of Total Billed Charges,75% of Total Billed Charges,393.09,50,,553.144,Percent of Total Billed Charges,50% of Total Billed Charges,393.09,50,,819.192,Percent of Total Billed Charges,50% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,393.09,50,,819.192,Percent of Total Billed Charges,50% of Total Billed Charges,393.09,50,,819.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.33,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,110.07,14,,153.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.18,100,,1638.384,Percent of Total Billed Charges,100% of Total Billed Charges,110.07,786.18,
117740 SUT LASSO 25 DEGREE,32102311,CDM,272,RC,,,Outpatient,,,682.22,409.33,,409.33,60,,7040.176,Percent of Total Billed Charges,60% of Total Billed Charges,307,45,,143.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,384,32,,351.576,Percent of Total Billed Charges,32% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,245.6,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,245.6,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,245.6,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,409.33,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.22,100,,1493.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,98.38,14.42,,163.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.67,75,,833.288,Percent of Total Billed Charges,75% of Total Billed Charges,341.11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,555.528,Percent of Total Billed Charges,50% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,50,,555.528,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,555.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,70,,442.312,Percent of Total Billed Charges,70% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,100,,1111.048,Percent of Total Billed Charges,100% of Total Billed Charges,95.51,682.22,
SUTURE LASSO 25,32102329,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,2658.712,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,6197.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,177.072,Percent of Total Billed Charges,28% of Total Billed Charges,384,32,,351.96,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,227.664,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,227.664,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,227.664,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,468.856,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,8086.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,845.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,893.136,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,819.192,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,595.424,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,595.424,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,595.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,225.952,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,820.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,1190.848,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
568665 SURGIWRAP,32102345,CDM,278,RC,C1765,HCPCS,Outpatient,,,1091.55,654.93,,1204.17,110,,11693.808,Percent of Total Billed Charges,110% of Total Billed Charges,491.2,45,,508.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,352.352,Other,Not Seperately Reimbusable,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.35,55,,438.656,Percent of Total Billed Charges,55% Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1091.55,100,,3344.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,157.4,14.42,,1296.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.24,80,,612.48,Percent of Total Billed Charges,80% of Total Billed Charges,545.78,50,,555.528,Percent of Total Billed Charges,50% of Total Billed Charges,545.78,50,,382.8,Percent of Total Billed Charges,50% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,50,,382.8,Percent of Total Billed Charges,50% of Total Billed Charges,545.78,50,,382.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.09,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.82,14,,1258.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1091.55,100,,765.6,Percent of Total Billed Charges,100% of Total Billed Charges,152.82,1204.17,
182479 LIGASURE IMPACT,32102386,CDM,272,RC,,,Outpatient,,,2171.26,1302.76,,1302.76,60,,605.192,Percent of Total Billed Charges,60% of Total Billed Charges,977.07,45,,33.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,607.95,28,,43.68,Percent of Total Billed Charges,28% of Total Billed Charges,385.96,32,,352.416,Percent of Total Billed Charges,32% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,781.65,36,,56.16,Percent of Total Billed Charges,36% of Total Billed Charges,781.65,36,,56.16,Percent of Total Billed Charges,36% Total Bille Charges,781.65,36,,56.16,Percent of Total Billed Charges,36% of Total Billed Charges,1302.76,60,,574.792,Percent of Total Billed Charges,60% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2171.26,100,,319.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,313.1,14.42,,1975.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1628.45,75,,1081.808,Percent of Total Billed Charges,75% of Total Billed Charges,1085.63,50,,595.424,Percent of Total Billed Charges,50% of Total Billed Charges,1085.63,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1085.63,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,1085.63,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1519.88,70,,225.952,Percent of Total Billed Charges,70% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,1917.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2171.26,100,,1442.408,Percent of Total Billed Charges,100% of Total Billed Charges,303.98,2171.26,
113390 ENDOSTITCH INSTRUMENT,32102402,CDM,272,RC,,,Outpatient,,,711.46,426.88,,426.88,60,,10773.208,Percent of Total Billed Charges,60% of Total Billed Charges,320.16,45,,36.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.21,28,,48.784,Percent of Total Billed Charges,28% of Total Billed Charges,388.8,32,,353.28,Percent of Total Billed Charges,32% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.13,36,,62.728,Percent of Total Billed Charges,36% of Total Billed Charges,256.13,36,,62.728,Percent of Total Billed Charges,36% Total Bille Charges,256.13,36,,62.728,Percent of Total Billed Charges,36% of Total Billed Charges,426.88,60,,659.92,Percent of Total Billed Charges,60% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,711.46,100,,13772.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.59,14.42,,2468.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.6,75,,1652.168,Percent of Total Billed Charges,75% of Total Billed Charges,355.73,50,,382.8,Percent of Total Billed Charges,50% of Total Billed Charges,355.73,50,,1101.448,Percent of Total Billed Charges,50% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.73,50,,1101.448,Percent of Total Billed Charges,50% of Total Billed Charges,355.73,50,,1101.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.02,70,,347.912,Percent of Total Billed Charges,70% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,99.6,14,,2396.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711.46,100,,2202.888,Percent of Total Billed Charges,100% of Total Billed Charges,99.6,711.46,
118230 MESH PERIFX PLUG MED,32102485,CDM,278,RC,C1781,HCPCS,Outpatient,,,1382.85,829.71,,1973.9,110,,429.808,Percent of Total Billed Charges,110% of Total Billed Charges,622.28,45,,15066,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,387.2,28,,23.048,Percent of Total Billed Charges,28% of Total Billed Charges,389.84,32,,353.544,Percent of Total Billed Charges,32% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,497.83,36,,29.632,Percent of Total Billed Charges,36% of Total Billed Charges,497.83,36,,29.632,Percent of Total Billed Charges,36% Total Bille Charges,497.83,36,,29.632,Percent of Total Billed Charges,36% of Total Billed Charges,760.57,55,,627.264,Percent of Total Billed Charges,55% Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1382.85,100,,1130.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,199.41,14.42,,106,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1106.28,80,,876.04,Percent of Total Billed Charges,80% of Total Billed Charges,691.43,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,691.43,50,,547.528,Percent of Total Billed Charges,50% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.43,50,,547.528,Percent of Total Billed Charges,50% of Total Billed Charges,691.43,50,,547.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,968,70,,138.6,Percent of Total Billed Charges,70% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,193.6,14,,102.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1382.85,100,,1095.048,Percent of Total Billed Charges,100% of Total Billed Charges,193.6,1973.9,
TRANSTIBIAL ACL,32102501,CDM,272,RC,,,Outpatient,,,675,405.00,,405,60,,1111.808,Percent of Total Billed Charges,60% of Total Billed Charges,303.75,45,,1676.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,28,,19.856,Percent of Total Billed Charges,28% of Total Billed Charges,389.84,32,,353.544,Percent of Total Billed Charges,32% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,243,36,,25.536,Percent of Total Billed Charges,36% of Total Billed Charges,243,36,,25.536,Percent of Total Billed Charges,36% Total Bille Charges,243,36,,25.536,Percent of Total Billed Charges,36% of Total Billed Charges,405,60,,1136.528,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,74.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,97.34,14.42,,327.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.25,75,,904.432,Percent of Total Billed Charges,75% of Total Billed Charges,337.5,50,,1101.448,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.5,70,,132.52,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,318.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,1130.536,Percent of Total Billed Charges,100% of Total Billed Charges,94.5,675,
525986 CATH UROMAX,32102642,CDM,272,RC,C1726,HCPCS,Outpatient,,,2047.98,1228.79,,396.8,100,,528,Fee Schedule,100% of Aetna Fee Schedule,921.59,45,,3332.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,573.43,28,,16.224,Percent of Total Billed Charges,28% of Total Billed Charges,389.84,32,,354.008,Percent of Total Billed Charges,32% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,737.27,36,,20.856,Percent of Total Billed Charges,36% of Total Billed Charges,737.27,36,,20.856,Percent of Total Billed Charges,36% Total Bille Charges,737.27,36,,20.856,Percent of Total Billed Charges,36% of Total Billed Charges,1228.79,60,,84.96,Percent of Total Billed Charges,60% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2047.98,100,,82,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.32,14.42,,548.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1535.99,75,,4689.152,Percent of Total Billed Charges,75% of Total Billed Charges,1023.99,50,,547.528,Percent of Total Billed Charges,50% of Total Billed Charges,1023.99,50,,2930.72,Percent of Total Billed Charges,50% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1023.99,50,,2930.72,Percent of Total Billed Charges,50% of Total Billed Charges,1023.99,50,,2930.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1433.59,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,286.72,14,,532.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2047.98,100,,5861.44,Percent of Total Billed Charges,100% of Total Billed Charges,286.72,2047.98,
399494 CINCH ARTHREX MENISCAL,32102659,CDM,272,RC,,,Outpatient,,,1388.81,833.29,,833.29,60,,1755.744,Percent of Total Billed Charges,60% of Total Billed Charges,624.96,45,,2190.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.87,28,,16.784,Percent of Total Billed Charges,28% of Total Billed Charges,392.04,32,,355.488,Percent of Total Billed Charges,32% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,499.97,36,,21.584,Percent of Total Billed Charges,36% of Total Billed Charges,499.97,36,,21.584,Percent of Total Billed Charges,36% Total Bille Charges,499.97,36,,21.584,Percent of Total Billed Charges,36% of Total Billed Charges,833.29,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1388.81,100,,33480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,200.27,14.42,,876.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1041.61,75,,7190.144,Percent of Total Billed Charges,75% of Total Billed Charges,694.41,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,694.41,50,,4493.84,Percent of Total Billed Charges,50% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.41,50,,4493.84,Percent of Total Billed Charges,50% of Total Billed Charges,694.41,50,,4493.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.17,70,,119,Percent of Total Billed Charges,70% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.43,14,,850.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1388.81,100,,8987.68,Percent of Total Billed Charges,100% of Total Billed Charges,194.43,1388.81,
370749 CUTTER LINEAR FLEX,32102733,CDM,272,RC,,,Outpatient,,,1488.56,893.14,,893.14,60,,1068.576,Percent of Total Billed Charges,60% of Total Billed Charges,669.85,45,,692.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.8,28,,147.776,Percent of Total Billed Charges,28% of Total Billed Charges,392.53,32,,355.536,Percent of Total Billed Charges,32% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,535.88,36,,189.992,Percent of Total Billed Charges,36% of Total Billed Charges,535.88,36,,189.992,Percent of Total Billed Charges,36% Total Bille Charges,535.88,36,,189.992,Percent of Total Billed Charges,36% of Total Billed Charges,893.14,60,,79.32,Percent of Total Billed Charges,60% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1488.56,100,,3725.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,214.65,14.42,,1579.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1116.42,75,,10958.08,Percent of Total Billed Charges,75% of Total Billed Charges,744.28,50,,2930.72,Percent of Total Billed Charges,50% of Total Billed Charges,744.28,50,,6848.8,Percent of Total Billed Charges,50% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,744.28,50,,6848.8,Percent of Total Billed Charges,50% of Total Billed Charges,744.28,50,,6848.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.99,70,,196.776,Percent of Total Billed Charges,70% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,208.4,14,,1533.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1488.56,100,,13697.6,Percent of Total Billed Charges,100% of Total Billed Charges,208.4,1488.56,
527928 MESH ATRIUM CQUR,32102758,CDM,278,RC,C1781,HCPCS,Outpatient,,,957,574.20,,1505.46,110,,4590.936,Percent of Total Billed Charges,110% of Total Billed Charges,430.65,45,,199.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.96,28,,232.568,Percent of Total Billed Charges,28% of Total Billed Charges,393.17,32,,355.8,Percent of Total Billed Charges,32% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,344.52,36,,299.016,Percent of Total Billed Charges,36% of Total Billed Charges,344.52,36,,299.016,Percent of Total Billed Charges,36% Total Bille Charges,344.52,36,,299.016,Percent of Total Billed Charges,36% of Total Billed Charges,526.35,55,,88.56,Percent of Total Billed Charges,55% Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,957,100,,7404.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,138,14.42,,2589.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.6,80,,13696,Percent of Total Billed Charges,80% of Total Billed Charges,478.5,50,,4493.84,Percent of Total Billed Charges,50% of Total Billed Charges,478.5,50,,8560,Percent of Total Billed Charges,50% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,478.5,50,,8560,Percent of Total Billed Charges,50% of Total Billed Charges,478.5,50,,8560,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,669.9,70,,295.208,Percent of Total Billed Charges,70% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,133.98,14,,2514.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,957,100,,17120,Percent of Total Billed Charges,100% of Total Billed Charges,133.98,1505.46,
SINUS GUIDE CATH,32102790,CDM,272,RC,C1887,HCPCS,Outpatient,,,1803.01,1081.81,,43.86,100,,1025.688,Fee Schedule,100% of Aetna Fee Schedule,811.35,45,,639.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,504.84,28,,36.704,Percent of Total Billed Charges,28% of Total Billed Charges,393.6,32,,358.792,Percent of Total Billed Charges,32% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,649.08,36,,47.192,Percent of Total Billed Charges,36% of Total Billed Charges,649.08,36,,47.192,Percent of Total Billed Charges,36% Total Bille Charges,649.08,36,,47.192,Percent of Total Billed Charges,36% of Total Billed Charges,1081.81,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1803.01,100,,4867.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,259.99,14.42,,3867.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1352.26,75,,588.08,Percent of Total Billed Charges,75% of Total Billed Charges,901.51,50,,6848.8,Percent of Total Billed Charges,50% of Total Billed Charges,901.51,50,,367.552,Percent of Total Billed Charges,50% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,901.51,50,,367.552,Percent of Total Billed Charges,50% of Total Billed Charges,901.51,50,,367.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1262.11,70,,200.632,Percent of Total Billed Charges,70% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,3754.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1803.01,100,,735.104,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1803.01,
119692 STAPLER CURVED GREEN,32102865,CDM,272,RC,,,Outpatient,,,2753.61,1652.17,,1652.17,60,,2601.696,Percent of Total Billed Charges,60% of Total Billed Charges,1239.12,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.01,28,,55.328,Percent of Total Billed Charges,28% of Total Billed Charges,393.6,32,,359.272,Percent of Total Billed Charges,32% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,991.3,36,,71.136,Percent of Total Billed Charges,36% of Total Billed Charges,991.3,36,,71.136,Percent of Total Billed Charges,36% Total Bille Charges,991.3,36,,71.136,Percent of Total Billed Charges,36% of Total Billed Charges,1652.17,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2753.61,100,,1539.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,397.07,14.42,,5904.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2065.21,75,,1817.232,Percent of Total Billed Charges,75% of Total Billed Charges,1376.81,50,,8560,Percent of Total Billed Charges,50% of Total Billed Charges,1376.81,50,,1135.776,Percent of Total Billed Charges,50% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1376.81,50,,1135.776,Percent of Total Billed Charges,50% of Total Billed Charges,1376.81,50,,1135.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1927.53,70,,270.88,Percent of Total Billed Charges,70% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,385.51,14,,5732.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2753.61,100,,2271.544,Percent of Total Billed Charges,100% of Total Billed Charges,385.51,2753.61,
203496 MESH PATCH PROCEED VTRL,32102881,CDM,278,RC,C1781,HCPCS,Outpatient,,,1368.81,821.29,,1958.45,110,,3622.176,Percent of Total Billed Charges,110% of Total Billed Charges,615.96,45,,59.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.27,28,,55.576,Percent of Total Billed Charges,28% of Total Billed Charges,394.52,32,,360.528,Percent of Total Billed Charges,32% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,492.77,36,,71.448,Percent of Total Billed Charges,36% of Total Billed Charges,492.77,36,,71.448,Percent of Total Billed Charges,36% Total Bille Charges,492.77,36,,71.448,Percent of Total Billed Charges,36% of Total Billed Charges,752.85,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1368.81,100,,443.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,197.38,14.42,,8853.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1095.05,80,,3041.392,Percent of Total Billed Charges,80% of Total Billed Charges,684.41,50,,367.552,Percent of Total Billed Charges,50% of Total Billed Charges,684.41,50,,1900.872,Percent of Total Billed Charges,50% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.41,50,,1900.872,Percent of Total Billed Charges,50% of Total Billed Charges,684.41,50,,1900.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,958.17,70,,579.904,Percent of Total Billed Charges,70% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,14,,8595.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1368.81,100,,3801.736,Percent of Total Billed Charges,100% of Total Billed Charges,191.63,1958.45,
139808 PORT POWERPORT TITAN,32102915,CDM,278,RC,C1788,HCPCS,Outpatient,,,1413.17,847.90,,2163.3,110,,53648.744,Percent of Total Billed Charges,110% of Total Billed Charges,635.93,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.69,28,,78.36,Percent of Total Billed Charges,28% of Total Billed Charges,394.52,32,,361.768,Percent of Total Billed Charges,32% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,508.74,36,,100.752,Percent of Total Billed Charges,36% of Total Billed Charges,508.74,36,,100.752,Percent of Total Billed Charges,36% Total Bille Charges,508.74,36,,100.752,Percent of Total Billed Charges,36% of Total Billed Charges,777.24,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1422.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,203.78,14.42,,13614.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1130.54,80,,4860.864,Percent of Total Billed Charges,80% of Total Billed Charges,706.59,50,,1135.776,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,3038.04,Percent of Total Billed Charges,50% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.59,50,,3038.04,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,3038.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,989.22,70,,107.24,Percent of Total Billed Charges,70% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,13218.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.17,100,,6076.08,Percent of Total Billed Charges,100% of Total Billed Charges,197.84,2163.3,
478340 KIT REALIZE BAND,32103236,CDM,278,RC,,,Outpatient,,,7326.8,4396.08,,8059.48,110,,2202.552,Percent of Total Billed Charges,110% of Total Billed Charges,3297.06,45,,86.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2051.5,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,394.68,32,,361.768,Percent of Total Billed Charges,32% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,2637.65,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,2637.65,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,2637.65,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,4029.74,55,,379.44,Percent of Total Billed Charges,55% Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7326.8,100,,1559.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1056.52,14.42,,107,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5861.44,80,,8760.272,Percent of Total Billed Charges,80% of Total Billed Charges,3663.4,50,,1900.872,Percent of Total Billed Charges,50% of Total Billed Charges,3663.4,50,,5475.168,Percent of Total Billed Charges,50% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3663.4,50,,5475.168,Percent of Total Billed Charges,50% of Total Billed Charges,3663.4,50,,5475.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5128.76,70,,75.6,Percent of Total Billed Charges,70% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,1025.75,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7326.8,100,,10950.336,Percent of Total Billed Charges,100% of Total Billed Charges,394.68,8059.48,
196616 STRATTICE MATRIX FIRM,32103251,CDM,278,RC,,,Outpatient,,,11234.6,6740.76,,12358.06,110,,1407.488,Percent of Total Billed Charges,110% of Total Billed Charges,5055.57,45,,602.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3145.69,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,397.64,32,,361.768,Percent of Total Billed Charges,32% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,4044.46,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,4044.46,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,4044.46,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,6179.03,55,,93.6,Percent of Total Billed Charges,55% Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11234.6,100,,131.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1620.03,14.42,,155.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8987.68,80,,14365.768,Percent of Total Billed Charges,80% of Total Billed Charges,5617.3,50,,3038.04,Percent of Total Billed Charges,50% of Total Billed Charges,5617.3,50,,8978.608,Percent of Total Billed Charges,50% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5617.3,50,,8978.608,Percent of Total Billed Charges,50% of Total Billed Charges,5617.3,50,,8978.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7864.22,70,,167.104,Percent of Total Billed Charges,70% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,1572.84,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11234.6,100,,17957.208,Percent of Total Billed Charges,100% of Total Billed Charges,397.64,12358.06,
193286 STRATTICE MATRIX FIRM,32103269,CDM,278,RC,,,Outpatient,,,17122,10273.20,,18834.2,110,,5880.208,Percent of Total Billed Charges,110% of Total Billed Charges,7704.9,45,,1676.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4794.16,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,400.27,32,,361.768,Percent of Total Billed Charges,32% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,6163.92,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,6163.92,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,6163.92,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,9417.1,55,,93.6,Percent of Total Billed Charges,55% Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17122,100,,12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2468.99,14.42,,168.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13697.6,80,,21455.448,Percent of Total Billed Charges,80% of Total Billed Charges,8561,50,,5475.168,Percent of Total Billed Charges,50% of Total Billed Charges,8561,50,,13409.656,Percent of Total Billed Charges,50% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8561,50,,13409.656,Percent of Total Billed Charges,50% of Total Billed Charges,8561,50,,13409.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11985.4,70,,172.2,Percent of Total Billed Charges,70% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,2397.08,14,,163.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17122,100,,26819.312,Percent of Total Billed Charges,100% of Total Billed Charges,400.27,18834.2,
196620 STRATTICE GRAFT,32103277,CDM,278,RC,,,Outpatient,,,21400,12840.00,,23540,110,,2459.688,Percent of Total Billed Charges,110% of Total Billed Charges,9630,45,,1552.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5992,28,,48.384,Percent of Total Billed Charges,28% of Total Billed Charges,403.46,32,,362.496,Percent of Total Billed Charges,32% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,7704,36,,62.208,Percent of Total Billed Charges,36% of Total Billed Charges,7704,36,,62.208,Percent of Total Billed Charges,36% Total Bille Charges,7704,36,,62.208,Percent of Total Billed Charges,36% of Total Billed Charges,11770,55,,104.544,Percent of Total Billed Charges,55% Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21400,100,,191.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,3085.88,14.42,,79.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17120,80,,32759.024,Percent of Total Billed Charges,80% of Total Billed Charges,10700,50,,8978.608,Percent of Total Billed Charges,50% of Total Billed Charges,10700,50,,20474.392,Percent of Total Billed Charges,50% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10700,50,,20474.392,Percent of Total Billed Charges,50% of Total Billed Charges,10700,50,,20474.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14980,70,,132.024,Percent of Total Billed Charges,70% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,2996,14,,77.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21400,100,,40948.784,Percent of Total Billed Charges,100% of Total Billed Charges,403.46,23540,
SPINE IMPLANT LEVEL 1,32103351,CDM,278,RC,C1713,HCPCS,Outpatient,,,918.88,551.33,,1328.03,110,,4109.144,Percent of Total Billed Charges,110% of Total Billed Charges,413.5,45,,469.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.29,28,,43.96,Percent of Total Billed Charges,28% of Total Billed Charges,403.47,32,,362.872,Percent of Total Billed Charges,32% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,330.8,36,,56.52,Percent of Total Billed Charges,36% of Total Billed Charges,330.8,36,,56.52,Percent of Total Billed Charges,36% Total Bille Charges,330.8,36,,56.52,Percent of Total Billed Charges,36% of Total Billed Charges,505.38,55,,49.392,Percent of Total Billed Charges,55% Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,918.88,100,,1337.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,132.5,14.42,,18.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,735.1,80,,49115.576,Percent of Total Billed Charges,80% of Total Billed Charges,459.44,50,,13409.656,Percent of Total Billed Charges,50% of Total Billed Charges,459.44,50,,30697.24,Percent of Total Billed Charges,50% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.44,50,,30697.24,Percent of Total Billed Charges,50% of Total Billed Charges,459.44,50,,30697.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,643.22,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.64,14,,17.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,918.88,100,,61394.472,Percent of Total Billed Charges,100% of Total Billed Charges,128.64,1328.03,
SPINE IMPLANT LEVEL 2,32103352,CDM,278,RC,C1713,HCPCS,Outpatient,,,2839.43,1703.66,,3440.63,110,,310.632,Percent of Total Billed Charges,110% of Total Billed Charges,1277.74,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,795.04,28,,85.24,Percent of Total Billed Charges,28% of Total Billed Charges,403.47,32,,364.128,Percent of Total Billed Charges,32% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,1022.19,36,,109.592,Percent of Total Billed Charges,36% of Total Billed Charges,1022.19,36,,109.592,Percent of Total Billed Charges,36% Total Bille Charges,1022.19,36,,109.592,Percent of Total Billed Charges,36% of Total Billed Charges,1561.69,55,,42.56,Percent of Total Billed Charges,55% Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2839.43,100,,3725.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,409.45,14.42,,770.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2271.54,80,,75532.504,Percent of Total Billed Charges,80% of Total Billed Charges,1419.72,50,,20474.392,Percent of Total Billed Charges,50% of Total Billed Charges,1419.72,50,,47207.816,Percent of Total Billed Charges,50% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1419.72,50,,47207.816,Percent of Total Billed Charges,50% of Total Billed Charges,1419.72,50,,47207.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1987.6,70,,75.6,Percent of Total Billed Charges,70% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,397.52,14,,747.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2839.43,100,,94415.632,Percent of Total Billed Charges,100% of Total Billed Charges,397.52,3440.63,
SPINE IMPLANT LEVEL 3,32103353,CDM,278,RC,C1713,HCPCS,Outpatient,,,4752.17,2851.30,,5544.65,110,,823.992,Percent of Total Billed Charges,110% of Total Billed Charges,2138.48,45,,22025.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1330.61,28,,137.088,Percent of Total Billed Charges,28% of Total Billed Charges,403.47,32,,364.8,Percent of Total Billed Charges,32% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,1710.78,36,,176.256,Percent of Total Billed Charges,36% of Total Billed Charges,1710.78,36,,176.256,Percent of Total Billed Charges,36% Total Bille Charges,1710.78,36,,176.256,Percent of Total Billed Charges,36% of Total Billed Charges,2613.69,55,,34.76,Percent of Total Billed Charges,55% Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4752.17,100,,3450.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,685.26,14.42,,80.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3801.74,80,,556.504,Percent of Total Billed Charges,80% of Total Billed Charges,2376.09,50,,30697.24,Percent of Total Billed Charges,50% of Total Billed Charges,2376.09,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2376.09,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,2376.09,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3326.52,70,,57.896,Percent of Total Billed Charges,70% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,665.3,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4752.17,100,,742,Percent of Total Billed Charges,100% of Total Billed Charges,403.47,5544.65,
SPINE IMPLANT LEVEL 4,32103354,CDM,278,RC,C1713,HCPCS,Outpatient,,,7595.1,4557.06,,8671.87,110,,3652.264,Percent of Total Billed Charges,110% of Total Billed Charges,3417.8,45,,1660.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2126.63,28,,252.856,Percent of Total Billed Charges,28% of Total Billed Charges,403.47,32,,366.616,Percent of Total Billed Charges,32% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,2734.24,36,,325.096,Percent of Total Billed Charges,36% of Total Billed Charges,2734.24,36,,325.096,Percent of Total Billed Charges,36% Total Bille Charges,2734.24,36,,325.096,Percent of Total Billed Charges,36% of Total Billed Charges,4177.31,55,,35.968,Percent of Total Billed Charges,55% Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7595.1,100,,1044,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1095.21,14.42,,49.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6076.08,80,,860.768,Percent of Total Billed Charges,80% of Total Billed Charges,3797.55,50,,47207.816,Percent of Total Billed Charges,50% of Total Billed Charges,3797.55,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3797.55,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,3797.55,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5316.57,70,,130.12,Percent of Total Billed Charges,70% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,1063.31,14,,48.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7595.1,100,,1075.96,Percent of Total Billed Charges,100% of Total Billed Charges,403.47,8671.87,
SPINE IMPLANT LEVEL 5,32103355,CDM,278,RC,C1713,HCPCS,Outpatient,,,13687.92,8212.75,,15373.97,110,,7191.752,Percent of Total Billed Charges,110% of Total Billed Charges,6159.56,45,,1713.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3832.62,28,,268.8,Percent of Total Billed Charges,28% of Total Billed Charges,404.29,32,,366.96,Percent of Total Billed Charges,32% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,4927.65,36,,345.6,Percent of Total Billed Charges,36% of Total Billed Charges,4927.65,36,,345.6,Percent of Total Billed Charges,36% Total Bille Charges,4927.65,36,,345.6,Percent of Total Billed Charges,36% of Total Billed Charges,7528.36,55,,316.656,Percent of Total Billed Charges,55% Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13687.92,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1973.8,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10950.34,80,,877.104,Percent of Total Billed Charges,80% of Total Billed Charges,6843.96,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,6843.96,50,,584.736,Percent of Total Billed Charges,50% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6843.96,50,,584.736,Percent of Total Billed Charges,50% of Total Billed Charges,6843.96,50,,584.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9581.54,70,,227.912,Percent of Total Billed Charges,70% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1916.31,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13687.92,100,,1169.472,Percent of Total Billed Charges,100% of Total Billed Charges,404.29,15373.97,
SPINE IMPLANT LEVEL 6,32103356,CDM,278,RC,C1713,HCPCS,Outpatient,,,22446.51,13467.91,,25008.42,110,,740.608,Percent of Total Billed Charges,110% of Total Billed Charges,10100.93,45,,4344.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6285.02,28,,136.312,Percent of Total Billed Charges,28% of Total Billed Charges,404.54,32,,367.016,Percent of Total Billed Charges,32% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,8080.74,36,,175.264,Percent of Total Billed Charges,36% of Total Billed Charges,8080.74,36,,175.264,Percent of Total Billed Charges,36% Total Bille Charges,8080.74,36,,175.264,Percent of Total Billed Charges,36% of Total Billed Charges,12345.58,55,,498.352,Percent of Total Billed Charges,55% Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22446.51,100,,48945.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3236.79,14.42,,5.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17957.21,80,,412.72,Percent of Total Billed Charges,80% of Total Billed Charges,11223.26,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,11223.26,50,,275.152,Percent of Total Billed Charges,50% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11223.26,50,,275.152,Percent of Total Billed Charges,50% of Total Billed Charges,11223.26,50,,275.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15712.56,70,,279.936,Percent of Total Billed Charges,70% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,3142.51,14,,5.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22446.51,100,,550.296,Percent of Total Billed Charges,100% of Total Billed Charges,404.54,25008.42,
SPINE IMPLANT LEVEL 7,32103357,CDM,278,RC,C1713,HCPCS,Outpatient,,,33524.14,20114.48,,37193.81,110,,3729.256,Percent of Total Billed Charges,110% of Total Billed Charges,15085.86,45,,2324.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9386.76,28,,662.768,Percent of Total Billed Charges,28% of Total Billed Charges,405.43,32,,367.096,Percent of Total Billed Charges,32% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,12068.69,36,,852.136,Percent of Total Billed Charges,36% of Total Billed Charges,12068.69,36,,852.136,Percent of Total Billed Charges,36% Total Bille Charges,12068.69,36,,852.136,Percent of Total Billed Charges,36% of Total Billed Charges,18438.28,55,,78.648,Percent of Total Billed Charges,55% Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33524.14,100,,3689.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4834.18,14.42,,12.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26819.31,80,,94.92,Percent of Total Billed Charges,80% of Total Billed Charges,16762.07,50,,584.736,Percent of Total Billed Charges,50% of Total Billed Charges,16762.07,50,,63.28,Percent of Total Billed Charges,50% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16762.07,50,,63.28,Percent of Total Billed Charges,50% of Total Billed Charges,16762.07,50,,63.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23466.9,70,,280,Percent of Total Billed Charges,70% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,4693.38,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33524.14,100,,126.56,Percent of Total Billed Charges,100% of Total Billed Charges,405.43,37193.81,
SPINE IMPLANT LEVEL 8,32103358,CDM,278,RC,C1713,HCPCS,Outpatient,,,51185.98,30711.59,,56621.84,110,,6624.8,Percent of Total Billed Charges,110% of Total Billed Charges,23033.69,45,,2324.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14332.07,28,,27.792,Percent of Total Billed Charges,28% of Total Billed Charges,405.87,32,,368.248,Percent of Total Billed Charges,32% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,18426.95,36,,35.736,Percent of Total Billed Charges,36% of Total Billed Charges,18426.95,36,,35.736,Percent of Total Billed Charges,36% Total Bille Charges,18426.95,36,,35.736,Percent of Total Billed Charges,36% of Total Billed Charges,28152.29,55,,118.552,Percent of Total Billed Charges,55% Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51185.98,100,,3806.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7381.02,14.42,,29.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40948.78,80,,4273.152,Percent of Total Billed Charges,80% of Total Billed Charges,25592.99,50,,275.152,Percent of Total Billed Charges,50% of Total Billed Charges,25592.99,50,,2670.72,Percent of Total Billed Charges,50% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25592.99,50,,2670.72,Percent of Total Billed Charges,50% of Total Billed Charges,25592.99,50,,2670.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35830.19,70,,263.112,Percent of Total Billed Charges,70% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,7166.04,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51185.98,100,,5341.44,Percent of Total Billed Charges,100% of Total Billed Charges,405.87,56621.84,
SPINE IMPLANT LEVEL 9,32103359,CDM,278,RC,C1713,HCPCS,Outpatient,,,76743.09,46045.85,,84734.66,110,,3980.608,Percent of Total Billed Charges,110% of Total Billed Charges,34534.39,45,,387.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21488.07,28,,1743.568,Percent of Total Billed Charges,28% of Total Billed Charges,406.42,32,,368.872,Percent of Total Billed Charges,32% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,27627.51,36,,2241.728,Percent of Total Billed Charges,36% of Total Billed Charges,27627.51,36,,2241.728,Percent of Total Billed Charges,36% Total Bille Charges,27627.51,36,,2241.728,Percent of Total Billed Charges,36% of Total Billed Charges,42208.7,55,,119.08,Percent of Total Billed Charges,55% Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76743.09,100,,9655.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,11066.35,14.42,,61.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61394.47,80,,444.296,Percent of Total Billed Charges,80% of Total Billed Charges,38371.55,50,,63.28,Percent of Total Billed Charges,50% of Total Billed Charges,38371.55,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38371.55,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,38371.55,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53720.16,70,,280,Percent of Total Billed Charges,70% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,10744.03,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76743.09,100,,555.368,Percent of Total Billed Charges,100% of Total Billed Charges,406.42,84734.66,
SPINE IMPLANT LEVEL 10,32103360,CDM,278,RC,C1713,HCPCS,Outpatient,,,118019.54,70811.72,,130138.75,110,,17459.168,Percent of Total Billed Charges,110% of Total Billed Charges,53108.79,45,,387.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33045.47,28,,2387.84,Percent of Total Billed Charges,28% of Total Billed Charges,408,32,,369.208,Percent of Total Billed Charges,32% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,42487.03,36,,3070.08,Percent of Total Billed Charges,36% of Total Billed Charges,42487.03,36,,3070.08,Percent of Total Billed Charges,36% Total Bille Charges,42487.03,36,,3070.08,Percent of Total Billed Charges,36% of Total Billed Charges,64910.75,55,,167.92,Percent of Total Billed Charges,55% Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118019.54,100,,5166.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,17018.42,14.42,,140.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94415.63,80,,275.216,Percent of Total Billed Charges,80% of Total Billed Charges,59009.77,50,,2670.72,Percent of Total Billed Charges,50% of Total Billed Charges,59009.77,50,,172.016,Percent of Total Billed Charges,50% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59009.77,50,,172.016,Percent of Total Billed Charges,50% of Total Billed Charges,59009.77,50,,172.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82613.68,70,,313.864,Percent of Total Billed Charges,70% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,16522.74,14,,136.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118019.54,100,,344.024,Percent of Total Billed Charges,100% of Total Billed Charges,408,130138.75,
STAPLER INT. CIR,32103376,CDM,272,RC,,,Outpatient,,,927.5,556.50,,556.5,60,,8104.312,Percent of Total Billed Charges,60% of Total Billed Charges,417.38,45,,587.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.7,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,409.18,32,,370.832,Percent of Total Billed Charges,32% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,333.9,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,333.9,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,333.9,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,556.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.5,100,,5166.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,133.75,14.42,,220.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,695.63,75,,1461.904,Percent of Total Billed Charges,75% of Total Billed Charges,463.75,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,463.75,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.75,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,463.75,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.25,70,,302.4,Percent of Total Billed Charges,70% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,214.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.5,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,129.85,927.5,
0003390 PORT DUAL CATH. 10FR,32103442,CDM,278,RC,C1788,HCPCS,Outpatient,,,1344.95,806.97,,2088.26,110,,3667.168,Percent of Total Billed Charges,110% of Total Billed Charges,605.23,45,,297,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.59,28,,627.2,Percent of Total Billed Charges,28% of Total Billed Charges,410.24,32,,371.096,Percent of Total Billed Charges,32% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,484.18,36,,806.4,Percent of Total Billed Charges,36% of Total Billed Charges,484.18,36,,806.4,Percent of Total Billed Charges,36% Total Bille Charges,484.18,36,,806.4,Percent of Total Billed Charges,36% of Total Billed Charges,739.72,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344.95,100,,861.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,193.94,14.42,,333.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1075.96,80,,28.8,Percent of Total Billed Charges,80% of Total Billed Charges,672.48,50,,172.016,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.48,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,941.47,70,,284.208,Percent of Total Billed Charges,70% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,323.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344.95,100,,36,Percent of Total Billed Charges,100% of Total Billed Charges,188.29,2088.26,
HARMONIC ACE CUR,32103566,CDM,272,RC,,,Outpatient,,,1461.84,877.10,,877.1,60,,3741.536,Percent of Total Billed Charges,60% of Total Billed Charges,657.83,45,,1369.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,409.32,28,,1164.8,Percent of Total Billed Charges,28% of Total Billed Charges,413.38,32,,372.16,Percent of Total Billed Charges,32% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,526.26,36,,1497.6,Percent of Total Billed Charges,36% of Total Billed Charges,526.26,36,,1497.6,Percent of Total Billed Charges,36% Total Bille Charges,526.26,36,,1497.6,Percent of Total Billed Charges,36% of Total Billed Charges,877.1,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1461.84,100,,861.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,210.8,14.42,,468.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1096.38,75,,70.4,Percent of Total Billed Charges,75% of Total Billed Charges,730.92,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,730.92,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,730.92,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,730.92,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1023.29,70,,302.4,Percent of Total Billed Charges,70% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,204.66,14,,454.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1461.84,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,204.66,1461.84,
128385 CLIP APPLIERS LAP AUTO,32103616,CDM,272,RC,,,Outpatient,,,687.87,412.72,,412.72,60,,4992.824,Percent of Total Billed Charges,60% of Total Billed Charges,309.54,45,,1029.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.6,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,416,32,,373.248,Percent of Total Billed Charges,32% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,247.63,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,247.63,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,247.63,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,412.72,60,,103.688,Percent of Total Billed Charges,60% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.87,100,,1305.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.19,14.42,,659.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,515.9,75,,163.84,Percent of Total Billed Charges,75% of Total Billed Charges,343.94,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,343.94,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.94,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,343.94,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.51,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,96.3,14,,639.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.87,100,,204.8,Percent of Total Billed Charges,100% of Total Billed Charges,96.3,687.87,
SUT PROL 0 30IN,32103848,CDM,272,RC,,,Outpatient,,,158.2,94.92,,94.92,60,,1440,Percent of Total Billed Charges,60% of Total Billed Charges,71.19,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.3,28,,640.64,Percent of Total Billed Charges,28% of Total Billed Charges,416.34,32,,374.232,Percent of Total Billed Charges,32% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,56.95,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,56.95,36,,823.68,Percent of Total Billed Charges,36% Total Bille Charges,56.95,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,94.92,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.2,100,,660,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.81,14.42,,910.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.65,75,,339.2,Percent of Total Billed Charges,75% of Total Billed Charges,79.1,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,79.1,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.1,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,79.1,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.74,70,,547,Percent of Total Billed Charges,70% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14,,883.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.2,100,,424,Percent of Total Billed Charges,100% of Total Billed Charges,22.15,416.34,
223501 STRATTICE MATRIX FIRM,32103863,CDM,278,RC,,,Outpatient,,,6676.8,4006.08,,7344.48,110,,3120,Percent of Total Billed Charges,110% of Total Billed Charges,3004.56,45,,284.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1869.5,28,,640.64,Percent of Total Billed Charges,28% of Total Billed Charges,416.34,32,,375.256,Percent of Total Billed Charges,32% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,2403.65,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,2403.65,36,,823.68,Percent of Total Billed Charges,36% Total Bille Charges,2403.65,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,3672.24,55,,182.648,Percent of Total Billed Charges,55% Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6676.8,100,,3044.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,962.79,14.42,,1362.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5341.44,80,,777.6,Percent of Total Billed Charges,80% of Total Billed Charges,3338.4,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,3338.4,50,,486,Percent of Total Billed Charges,50% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3338.4,50,,486,Percent of Total Billed Charges,50% of Total Billed Charges,3338.4,50,,486,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4673.76,70,,511.76,Percent of Total Billed Charges,70% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,934.75,14,,1322.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6676.8,100,,972,Percent of Total Billed Charges,100% of Total Billed Charges,416.34,7344.48,
571068 SMART PINS,32103913,CDM,278,RC,C1713,HCPCS,Outpatient,,,694.21,416.53,,1080.89,110,,3600,Percent of Total Billed Charges,110% of Total Billed Charges,312.39,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.38,28,,7840,Percent of Total Billed Charges,28% of Total Billed Charges,417.6,32,,375.304,Percent of Total Billed Charges,32% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,249.92,36,,10080,Percent of Total Billed Charges,36% of Total Billed Charges,249.92,36,,10080,Percent of Total Billed Charges,36% Total Bille Charges,249.92,36,,10080,Percent of Total Billed Charges,36% of Total Billed Charges,381.82,55,,269.28,Percent of Total Billed Charges,55% Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,694.21,100,,2288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,100.11,14.42,,1926.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.37,80,,1223.68,Percent of Total Billed Charges,80% of Total Billed Charges,347.11,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,347.11,50,,764.8,Percent of Total Billed Charges,50% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.11,50,,764.8,Percent of Total Billed Charges,50% of Total Billed Charges,347.11,50,,764.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,485.95,70,,670.592,Percent of Total Billed Charges,70% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,1870.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.21,100,,1529.6,Percent of Total Billed Charges,100% of Total Billed Charges,97.19,1080.89,
110976 CATH. QUINTON CURL PERI,32103962,CDM,278,RC,C1750,HCPCS,Outpatient,,,430.03,258.02,,987.93,110,,7200,Percent of Total Billed Charges,110% of Total Billed Charges,193.51,45,,456.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.41,28,,7795.2,Percent of Total Billed Charges,28% of Total Billed Charges,417.6,32,,375.728,Percent of Total Billed Charges,32% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,154.81,36,,10022.4,Percent of Total Billed Charges,36% of Total Billed Charges,154.81,36,,10022.4,Percent of Total Billed Charges,36% Total Bille Charges,154.81,36,,10022.4,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.03,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,62.01,14.42,,2826.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.02,80,,1850.88,Percent of Total Billed Charges,80% of Total Billed Charges,215.02,50,,486,Percent of Total Billed Charges,50% of Total Billed Charges,215.02,50,,1156.8,Percent of Total Billed Charges,50% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.02,50,,1156.8,Percent of Total Billed Charges,50% of Total Billed Charges,215.02,50,,1156.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.02,70,,769.912,Percent of Total Billed Charges,70% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,14,,2744.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.03,100,,2313.6,Percent of Total Billed Charges,100% of Total Billed Charges,60.2,987.93,
454756 STRAP SECURE ABSORB,32103996,CDM,272,RC,,,Outpatient,,,2436.5,1461.90,,1461.9,60,,7272,Percent of Total Billed Charges,60% of Total Billed Charges,1096.43,45,,907.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,38.192,Percent of Total Billed Charges,28% of Total Billed Charges,418.18,32,,379.352,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,49.104,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,49.104,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,49.104,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,576,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,632.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,3720.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,2599.04,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,764.8,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1624.4,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,1624.4,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1624.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,731.808,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,3612.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,3248.8,Percent of Total Billed Charges,100% of Total Billed Charges,341.11,2436.5,
ORIF IMPLANTS LEVEL 1,32104501,CDM,278,RC,C1713,HCPCS,Outpatient,,,45,27.00,,366.76,110,,9360,Percent of Total Billed Charges,110% of Total Billed Charges,20.25,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,28,,533.12,Percent of Total Billed Charges,28% of Total Billed Charges,418.22,32,,380.16,Percent of Total Billed Charges,32% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,16.2,36,,685.44,Percent of Total Billed Charges,36% of Total Billed Charges,16.2,36,,685.44,Percent of Total Billed Charges,36% Total Bille Charges,16.2,36,,685.44,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.49,14.42,,5824.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,80,,3656.32,Percent of Total Billed Charges,80% of Total Billed Charges,22.5,50,,1156.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.5,50,,2285.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.5,50,,2285.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.5,50,,2285.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,70,,1325.944,Percent of Total Billed Charges,70% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.3,14,,5654.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45,100,,4570.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.3,418.22,
ORIF IMPLANTS LEVEL 2,32104502,CDM,278,RC,C1713,HCPCS,Outpatient,,,110,66.00,,438.26,110,,12960,Percent of Total Billed Charges,110% of Total Billed Charges,49.5,45,,71.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.8,28,,1203.48,Percent of Total Billed Charges,28% of Total Billed Charges,418.97,32,,380.488,Percent of Total Billed Charges,32% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,39.6,36,,1547.328,Percent of Total Billed Charges,36% of Total Billed Charges,39.6,36,,1547.328,Percent of Total Billed Charges,36% Total Bille Charges,39.6,36,,1547.328,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,100,,1013.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.86,14.42,,4.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88,80,,5048.96,Percent of Total Billed Charges,80% of Total Billed Charges,55,50,,1624.4,Percent of Total Billed Charges,50% of Total Billed Charges,55,50,,3155.6,Percent of Total Billed Charges,50% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,50,,3155.6,Percent of Total Billed Charges,50% of Total Billed Charges,55,50,,3155.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,70,,99.12,Percent of Total Billed Charges,70% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,4.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,100,,6311.2,Percent of Total Billed Charges,100% of Total Billed Charges,15.4,438.26,
ORIF IMPLANTS LEVEL 3,32104503,CDM,278,RC,C1713,HCPCS,Outpatient,,,256,153.60,,598.86,110,,16560,Percent of Total Billed Charges,110% of Total Billed Charges,115.2,45,,71.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,28,,669.76,Percent of Total Billed Charges,28% of Total Billed Charges,419.17,32,,380.488,Percent of Total Billed Charges,32% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.16,36,,861.12,Percent of Total Billed Charges,36% of Total Billed Charges,92.16,36,,861.12,Percent of Total Billed Charges,36% Total Bille Charges,92.16,36,,861.12,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256,100,,2015.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,36.92,14.42,,18.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.8,80,,7557.76,Percent of Total Billed Charges,80% of Total Billed Charges,128,50,,2285.2,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,4723.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128,50,,4723.6,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,4723.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.2,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,17.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256,100,,9447.2,Percent of Total Billed Charges,100% of Total Billed Charges,35.84,598.86,
ORIF IMPLANTS LEVEL 4,32104504,CDM,278,RC,C1713,HCPCS,Outpatient,,,530,318.00,,900.26,110,,48,Percent of Total Billed Charges,110% of Total Billed Charges,238.5,45,,52.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.4,28,,888.848,Percent of Total Billed Charges,28% of Total Billed Charges,419.52,32,,380.488,Percent of Total Billed Charges,32% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,190.8,36,,1142.808,Percent of Total Billed Charges,36% of Total Billed Charges,190.8,36,,1142.808,Percent of Total Billed Charges,36% Total Bille Charges,190.8,36,,1142.808,Percent of Total Billed Charges,36% of Total Billed Charges,291.5,55,,3736.216,Percent of Total Billed Charges,55% Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,76.43,14.42,,55.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,424,80,,10690.56,Percent of Total Billed Charges,80% of Total Billed Charges,265,50,,3155.6,Percent of Total Billed Charges,50% of Total Billed Charges,265,50,,6681.6,Percent of Total Billed Charges,50% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265,50,,6681.6,Percent of Total Billed Charges,50% of Total Billed Charges,265,50,,6681.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371,70,,92.544,Percent of Total Billed Charges,70% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,53.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,530,100,,13363.2,Percent of Total Billed Charges,100% of Total Billed Charges,74.2,900.26,
ORIF IMPLANTS LEVEL 5,32104505,CDM,278,RC,C1713,HCPCS,Outpatient,,,1215,729.00,,1653.76,110,,50.4,Percent of Total Billed Charges,110% of Total Billed Charges,546.75,45,,84.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.2,28,,446.208,Percent of Total Billed Charges,28% of Total Billed Charges,419.52,32,,380.488,Percent of Total Billed Charges,32% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,437.4,36,,573.696,Percent of Total Billed Charges,36% of Total Billed Charges,437.4,36,,573.696,Percent of Total Billed Charges,36% Total Bille Charges,437.4,36,,573.696,Percent of Total Billed Charges,36% of Total Billed Charges,668.25,55,,4690.4,Percent of Total Billed Charges,55% Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1215,100,,159.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,175.2,14.42,,176.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,972,80,,15680.64,Percent of Total Billed Charges,80% of Total Billed Charges,607.5,50,,4723.6,Percent of Total Billed Charges,50% of Total Billed Charges,607.5,50,,9800.4,Percent of Total Billed Charges,50% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,607.5,50,,9800.4,Percent of Total Billed Charges,50% of Total Billed Charges,607.5,50,,9800.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,850.5,70,,103.32,Percent of Total Billed Charges,70% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,170.1,14,,171.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1215,100,,19600.8,Percent of Total Billed Charges,100% of Total Billed Charges,170.1,1653.76,
ORIF IMPLANTS LEVEL 6,32104506,CDM,278,RC,C1713,HCPCS,Outpatient,,,1912,1147.20,,2420.46,110,,52.8,Percent of Total Billed Charges,110% of Total Billed Charges,860.4,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,535.36,28,,172.68,Percent of Total Billed Charges,28% of Total Billed Charges,421.03,32,,380.928,Percent of Total Billed Charges,32% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,688.32,36,,222.024,Percent of Total Billed Charges,36% of Total Billed Charges,688.32,36,,222.024,Percent of Total Billed Charges,36% Total Bille Charges,688.32,36,,222.024,Percent of Total Billed Charges,36% of Total Billed Charges,1051.6,55,,1232,Percent of Total Billed Charges,55% Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1912,100,,159.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,275.71,14.42,,311.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1529.6,80,,20641.92,Percent of Total Billed Charges,80% of Total Billed Charges,956,50,,6681.6,Percent of Total Billed Charges,50% of Total Billed Charges,956,50,,12901.2,Percent of Total Billed Charges,50% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,956,50,,12901.2,Percent of Total Billed Charges,50% of Total Billed Charges,956,50,,12901.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1338.4,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,267.68,14,,302.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1912,100,,25802.4,Percent of Total Billed Charges,100% of Total Billed Charges,267.68,2420.46,
ORIF IMPLANTS LEVEL 7,32104507,CDM,278,RC,C1713,HCPCS,Outpatient,,,2892,1735.20,,3498.46,110,,90.048,Percent of Total Billed Charges,110% of Total Billed Charges,1301.4,45,,38.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,809.76,28,,55.696,Percent of Total Billed Charges,28% of Total Billed Charges,421.03,32,,381.072,Percent of Total Billed Charges,32% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,1041.12,36,,71.608,Percent of Total Billed Charges,36% of Total Billed Charges,1041.12,36,,71.608,Percent of Total Billed Charges,36% Total Bille Charges,1041.12,36,,71.608,Percent of Total Billed Charges,36% of Total Billed Charges,1590.6,55,,2288,Percent of Total Billed Charges,55% Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2892,100,,117.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,417.03,14.42,,489.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2313.6,80,,32312.96,Percent of Total Billed Charges,80% of Total Billed Charges,1446,50,,9800.4,Percent of Total Billed Charges,50% of Total Billed Charges,1446,50,,20195.6,Percent of Total Billed Charges,50% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1446,50,,20195.6,Percent of Total Billed Charges,50% of Total Billed Charges,1446,50,,20195.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2024.4,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,404.88,14,,475.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2892,100,,40391.2,Percent of Total Billed Charges,100% of Total Billed Charges,404.88,3498.46,
ORIF IMPLANTS LEVEL 8,32104508,CDM,278,RC,C1713,HCPCS,Outpatient,,,4061,2436.60,,4784.36,110,,90.72,Percent of Total Billed Charges,110% of Total Billed Charges,1827.45,45,,135.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1137.08,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,421.67,32,,382.464,Percent of Total Billed Charges,32% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,1461.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1461.96,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1461.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2233.55,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4061,100,,187.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,585.6,14.42,,719.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3248.8,80,,27.52,Percent of Total Billed Charges,80% of Total Billed Charges,2030.5,50,,12901.2,Percent of Total Billed Charges,50% of Total Billed Charges,2030.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2030.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,2030.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2842.7,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,568.54,14,,698.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4061,100,,34.4,Percent of Total Billed Charges,100% of Total Billed Charges,421.67,4784.36,
ORIF IMPLANTS LEVEL 9,32104509,CDM,278,RC,C1713,HCPCS,Outpatient,,,5713,3427.80,,6601.56,110,,146.88,Percent of Total Billed Charges,110% of Total Billed Charges,2570.85,45,,135.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1599.64,28,,2387.84,Percent of Total Billed Charges,28% of Total Billed Charges,422.31,32,,384,Percent of Total Billed Charges,32% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,2056.68,36,,3070.08,Percent of Total Billed Charges,36% of Total Billed Charges,2056.68,36,,3070.08,Percent of Total Billed Charges,36% Total Bille Charges,2056.68,36,,3070.08,Percent of Total Billed Charges,36% of Total Billed Charges,3142.15,55,,1372.8,Percent of Total Billed Charges,55% Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5713,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,823.81,14.42,,965.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4570.4,80,,101.76,Percent of Total Billed Charges,80% of Total Billed Charges,2856.5,50,,20195.6,Percent of Total Billed Charges,50% of Total Billed Charges,2856.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2856.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,2856.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3999.1,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,799.82,14,,937.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5713,100,,127.2,Percent of Total Billed Charges,100% of Total Billed Charges,422.31,6601.56,
ORIF IMPLANTS LEVEL 10,32104510,CDM,278,RC,C1713,HCPCS,Outpatient,,,7889,4733.40,,8995.16,110,,194.4,Percent of Total Billed Charges,110% of Total Billed Charges,3550.05,45,,135.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2208.92,28,,359.536,Percent of Total Billed Charges,28% of Total Billed Charges,422.4,32,,384.224,Percent of Total Billed Charges,32% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,2840.04,36,,462.256,Percent of Total Billed Charges,36% of Total Billed Charges,2840.04,36,,462.256,Percent of Total Billed Charges,36% Total Bille Charges,2840.04,36,,462.256,Percent of Total Billed Charges,36% of Total Billed Charges,4338.95,55,,1372.8,Percent of Total Billed Charges,55% Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7889,100,,85.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1137.59,14.42,,1406.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6311.2,80,,307.84,Percent of Total Billed Charges,80% of Total Billed Charges,3944.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,3944.5,50,,192.4,Percent of Total Billed Charges,50% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3944.5,50,,192.4,Percent of Total Billed Charges,50% of Total Billed Charges,3944.5,50,,192.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5522.3,70,,442.68,Percent of Total Billed Charges,70% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,1104.46,14,,1365.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7889,100,,384.8,Percent of Total Billed Charges,100% of Total Billed Charges,422.4,8995.16,
ORIF IMPLANTS LEVEL 11,32104511,CDM,278,RC,C1713,HCPCS,Outpatient,,,11809,7085.40,,13307.16,110,,248.64,Percent of Total Billed Charges,110% of Total Billed Charges,5314.05,45,,249.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3306.52,28,,726.064,Percent of Total Billed Charges,28% of Total Billed Charges,422.4,32,,386.56,Percent of Total Billed Charges,32% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,4251.24,36,,933.504,Percent of Total Billed Charges,36% of Total Billed Charges,4251.24,36,,933.504,Percent of Total Billed Charges,36% Total Bille Charges,4251.24,36,,933.504,Percent of Total Billed Charges,36% of Total Billed Charges,6494.95,55,,15400,Percent of Total Billed Charges,55% Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11809,100,,300.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1702.86,14.42,,2149.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9447.2,80,,979.84,Percent of Total Billed Charges,80% of Total Billed Charges,5904.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,5904.5,50,,612.4,Percent of Total Billed Charges,50% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5904.5,50,,612.4,Percent of Total Billed Charges,50% of Total Billed Charges,5904.5,50,,612.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8266.3,70,,109.2,Percent of Total Billed Charges,70% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,1653.26,14,,2087.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11809,100,,1224.8,Percent of Total Billed Charges,100% of Total Billed Charges,422.4,13307.16,
ORIF IMPLANTS LEVEL 12,32104512,CDM,278,RC,C1713,HCPCS,Outpatient,,,16704,10022.40,,18691.66,110,,5040,Percent of Total Billed Charges,110% of Total Billed Charges,7516.8,45,,1872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4677.12,28,,78.4,Percent of Total Billed Charges,28% of Total Billed Charges,422.4,32,,386.72,Percent of Total Billed Charges,32% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,6013.44,36,,100.8,Percent of Total Billed Charges,36% of Total Billed Charges,6013.44,36,,100.8,Percent of Total Billed Charges,36% Total Bille Charges,6013.44,36,,100.8,Percent of Total Billed Charges,36% of Total Billed Charges,9187.2,55,,15312,Percent of Total Billed Charges,55% Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16704,100,,300.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2408.72,14.42,,3390.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13363.2,80,,1729.28,Percent of Total Billed Charges,80% of Total Billed Charges,8352,50,,192.4,Percent of Total Billed Charges,50% of Total Billed Charges,8352,50,,1080.8,Percent of Total Billed Charges,50% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8352,50,,1080.8,Percent of Total Billed Charges,50% of Total Billed Charges,8352,50,,1080.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11692.8,70,,109.2,Percent of Total Billed Charges,70% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,2338.56,14,,3292.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16704,100,,2161.6,Percent of Total Billed Charges,100% of Total Billed Charges,422.4,18691.66,
ORIF IMPLANTS LEVEL 13,32104513,CDM,278,RC,C1713,HCPCS,Outpatient,,,24501,14700.60,,27268.36,110,,5520,Percent of Total Billed Charges,110% of Total Billed Charges,11025.45,45,,385.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6860.28,28,,41.352,Percent of Total Billed Charges,28% of Total Billed Charges,424.8,32,,386.72,Percent of Total Billed Charges,32% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,8820.36,36,,53.168,Percent of Total Billed Charges,36% of Total Billed Charges,8820.36,36,,53.168,Percent of Total Billed Charges,36% Total Bille Charges,8820.36,36,,53.168,Percent of Total Billed Charges,36% of Total Billed Charges,13475.55,55,,81.84,Percent of Total Billed Charges,55% Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24501,100,,300.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3533.04,14.42,,4903.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19600.8,80,,2714.88,Percent of Total Billed Charges,80% of Total Billed Charges,12250.5,50,,612.4,Percent of Total Billed Charges,50% of Total Billed Charges,12250.5,50,,1696.8,Percent of Total Billed Charges,50% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12250.5,50,,1696.8,Percent of Total Billed Charges,50% of Total Billed Charges,12250.5,50,,1696.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17150.7,70,,121.968,Percent of Total Billed Charges,70% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,3430.14,14,,4761.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24501,100,,3393.6,Percent of Total Billed Charges,100% of Total Billed Charges,424.8,27268.36,
ORIF IMPLANTS LEVEL 14,32104514,CDM,278,RC,C1713,HCPCS,Outpatient,,,32253,19351.80,,35795.56,110,,7920,Percent of Total Billed Charges,110% of Total Billed Charges,14513.85,45,,428.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9030.84,28,,1196.248,Percent of Total Billed Charges,28% of Total Billed Charges,425.19,32,,388.584,Percent of Total Billed Charges,32% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,11611.08,36,,1538.032,Percent of Total Billed Charges,36% of Total Billed Charges,11611.08,36,,1538.032,Percent of Total Billed Charges,36% Total Bille Charges,11611.08,36,,1538.032,Percent of Total Billed Charges,36% of Total Billed Charges,17739.15,55,,1047.2,Percent of Total Billed Charges,55% Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32253,100,,555.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4650.88,14.42,,6552.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25802.4,80,,3991.04,Percent of Total Billed Charges,80% of Total Billed Charges,16126.5,50,,1080.8,Percent of Total Billed Charges,50% of Total Billed Charges,16126.5,50,,2494.4,Percent of Total Billed Charges,50% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16126.5,50,,2494.4,Percent of Total Billed Charges,50% of Total Billed Charges,16126.5,50,,2494.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22577.1,70,,57.624,Percent of Total Billed Charges,70% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,4515.42,14,,6361.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32253,100,,4988.8,Percent of Total Billed Charges,100% of Total Billed Charges,425.19,35795.56,
ORIF IMPLANTS LEVEL 15,32104515,CDM,278,RC,C1713,HCPCS,Outpatient,,,50489,30293.40,,55855.16,110,,9120,Percent of Total Billed Charges,110% of Total Billed Charges,22720.05,45,,49.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14136.92,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,425.19,32,,389.376,Percent of Total Billed Charges,32% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,18176.04,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,18176.04,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,18176.04,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,27768.95,55,,2363.976,Percent of Total Billed Charges,55% Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50489,100,,4160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7280.51,14.42,,9461.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40391.2,80,,5355.52,Percent of Total Billed Charges,80% of Total Billed Charges,25244.5,50,,1696.8,Percent of Total Billed Charges,50% of Total Billed Charges,25244.5,50,,3347.2,Percent of Total Billed Charges,50% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25244.5,50,,3347.2,Percent of Total Billed Charges,50% of Total Billed Charges,25244.5,50,,3347.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35342.3,70,,49.648,Percent of Total Billed Charges,70% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,7068.46,14,,9185.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50489,100,,6694.4,Percent of Total Billed Charges,100% of Total Billed Charges,425.19,55855.16,
ORTHO IMPLANT LEVEL 1,32104516,CDM,278,RC,C1713,HCPCS,Outpatient,,,43,25.80,,364.56,110,,11280,Percent of Total Billed Charges,110% of Total Billed Charges,19.35,45,,23.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,28,,4928,Percent of Total Billed Charges,28% of Total Billed Charges,425.6,32,,391.168,Percent of Total Billed Charges,32% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,36,,6336,Percent of Total Billed Charges,36% of Total Billed Charges,15.48,36,,6336,Percent of Total Billed Charges,36% Total Bille Charges,15.48,36,,6336,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43,100,,857.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.2,14.42,,15442.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.4,80,,7803.52,Percent of Total Billed Charges,80% of Total Billed Charges,21.5,50,,2494.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.5,50,,4877.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.5,50,,4877.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.5,50,,4877.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.1,70,,40.552,Percent of Total Billed Charges,70% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14,,14992.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43,100,,9754.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.02,425.6,
ORTHO IMPLANT LEVEL 2,32104517,CDM,278,RC,C1713,HCPCS,Outpatient,,,159,95.40,,492.16,110,,14880,Percent of Total Billed Charges,110% of Total Billed Charges,71.55,45,,438.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.52,28,,334.656,Percent of Total Billed Charges,28% of Total Billed Charges,425.89,32,,391.936,Percent of Total Billed Charges,32% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,57.24,36,,430.272,Percent of Total Billed Charges,36% of Total Billed Charges,57.24,36,,430.272,Percent of Total Billed Charges,36% Total Bille Charges,57.24,36,,430.272,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159,100,,951.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.93,14.42,,52.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.2,80,,11925.76,Percent of Total Billed Charges,80% of Total Billed Charges,79.5,50,,3347.2,Percent of Total Billed Charges,50% of Total Billed Charges,79.5,50,,7453.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.5,50,,7453.6,Percent of Total Billed Charges,50% of Total Billed Charges,79.5,50,,7453.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.3,70,,41.968,Percent of Total Billed Charges,70% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,22.26,14,,50.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159,100,,14907.2,Percent of Total Billed Charges,100% of Total Billed Charges,22.26,492.16,
ORTHO IMPLANT LEVEL 3,32104518,CDM,278,RC,C1713,HCPCS,Outpatient,,,481,288.60,,846.36,110,,18480,Percent of Total Billed Charges,110% of Total Billed Charges,216.45,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.68,28,,244.36,Percent of Total Billed Charges,28% of Total Billed Charges,425.89,32,,393.336,Percent of Total Billed Charges,32% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,173.16,36,,314.176,Percent of Total Billed Charges,36% of Total Billed Charges,173.16,36,,314.176,Percent of Total Billed Charges,36% Total Bille Charges,173.16,36,,314.176,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481,100,,108.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,69.36,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.8,80,,18811.52,Percent of Total Billed Charges,80% of Total Billed Charges,240.5,50,,4877.2,Percent of Total Billed Charges,50% of Total Billed Charges,240.5,50,,11757.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.5,50,,11757.2,Percent of Total Billed Charges,50% of Total Billed Charges,240.5,50,,11757.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.7,70,,369.432,Percent of Total Billed Charges,70% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.34,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481,100,,23514.4,Percent of Total Billed Charges,100% of Total Billed Charges,67.34,846.36,
ORTHO IMPLANT LEVEL 4,32104519,CDM,278,RC,C1713,HCPCS,Outpatient,,,1531,918.60,,2001.36,110,,75.84,Percent of Total Billed Charges,110% of Total Billed Charges,688.95,45,,4350.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.68,28,,25.968,Percent of Total Billed Charges,28% of Total Billed Charges,427.16,32,,393.544,Percent of Total Billed Charges,32% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,551.16,36,,33.384,Percent of Total Billed Charges,36% of Total Billed Charges,551.16,36,,33.384,Percent of Total Billed Charges,36% Total Bille Charges,551.16,36,,33.384,Percent of Total Billed Charges,36% of Total Billed Charges,842.05,55,,370.04,Percent of Total Billed Charges,55% Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1531,100,,51.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,220.77,14.42,,28.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1224.8,80,,27205.76,Percent of Total Billed Charges,80% of Total Billed Charges,765.5,50,,7453.6,Percent of Total Billed Charges,50% of Total Billed Charges,765.5,50,,17003.6,Percent of Total Billed Charges,50% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,765.5,50,,17003.6,Percent of Total Billed Charges,50% of Total Billed Charges,765.5,50,,17003.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1071.7,70,,581.416,Percent of Total Billed Charges,70% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,214.34,14,,28.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1531,100,,34007.2,Percent of Total Billed Charges,100% of Total Billed Charges,214.34,2001.36,
ORTHO IMPLANT LEVEL 5,32104520,CDM,278,RC,C1713,HCPCS,Outpatient,,,2702,1621.20,,3289.46,110,,85.92,Percent of Total Billed Charges,110% of Total Billed Charges,1215.9,45,,153.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,756.56,28,,243.848,Percent of Total Billed Charges,28% of Total Billed Charges,427.16,32,,393.544,Percent of Total Billed Charges,32% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,972.72,36,,313.52,Percent of Total Billed Charges,36% of Total Billed Charges,972.72,36,,313.52,Percent of Total Billed Charges,36% Total Bille Charges,972.72,36,,313.52,Percent of Total Billed Charges,36% of Total Billed Charges,1486.1,55,,119.352,Percent of Total Billed Charges,55% Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2702,100,,974.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,389.63,14.42,,28.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2161.6,80,,36353.28,Percent of Total Billed Charges,80% of Total Billed Charges,1351,50,,11757.2,Percent of Total Billed Charges,50% of Total Billed Charges,1351,50,,22720.8,Percent of Total Billed Charges,50% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1351,50,,22720.8,Percent of Total Billed Charges,50% of Total Billed Charges,1351,50,,22720.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1891.4,70,,91.76,Percent of Total Billed Charges,70% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,378.28,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2702,100,,45441.6,Percent of Total Billed Charges,100% of Total Billed Charges,378.28,3289.46,
ORTHO IMPLANT LEVEL 6,32104521,CDM,278,RC,C1713,HCPCS,Outpatient,,,4242,2545.20,,4983.46,110,,96,Percent of Total Billed Charges,110% of Total Billed Charges,1908.9,45,,491.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1187.76,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,427.69,32,,393.544,Percent of Total Billed Charges,32% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,1527.12,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1527.12,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1527.12,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2333.1,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4242,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,611.7,14.42,,42.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3393.6,80,,52489.6,Percent of Total Billed Charges,80% of Total Billed Charges,2121,50,,17003.6,Percent of Total Billed Charges,50% of Total Billed Charges,2121,50,,32806,Percent of Total Billed Charges,50% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2121,50,,32806,Percent of Total Billed Charges,50% of Total Billed Charges,2121,50,,32806,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2969.4,70,,138.312,Percent of Total Billed Charges,70% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,593.88,14,,41.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4242,100,,65612,Percent of Total Billed Charges,100% of Total Billed Charges,427.69,4983.46,
ORTHO IMPLANT LEVEL 7,32104522,CDM,278,RC,C1713,HCPCS,Outpatient,,,6236,3741.60,,7176.86,110,,115.2,Percent of Total Billed Charges,110% of Total Billed Charges,2806.2,45,,14292.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1746.08,28,,504,Percent of Total Billed Charges,28% of Total Billed Charges,430.38,32,,394.992,Percent of Total Billed Charges,32% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,2244.96,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,2244.96,36,,648,Percent of Total Billed Charges,36% Total Bille Charges,2244.96,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,3429.8,55,,4690.4,Percent of Total Billed Charges,55% Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6236,100,,9666.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,899.23,14.42,,66.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4988.8,80,,85671.68,Percent of Total Billed Charges,80% of Total Billed Charges,3118,50,,22720.8,Percent of Total Billed Charges,50% of Total Billed Charges,3118,50,,53544.8,Percent of Total Billed Charges,50% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3118,50,,53544.8,Percent of Total Billed Charges,50% of Total Billed Charges,3118,50,,53544.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4365.2,70,,138.928,Percent of Total Billed Charges,70% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,873.04,14,,64.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6236,100,,107089.6,Percent of Total Billed Charges,100% of Total Billed Charges,430.38,7176.86,
ORTHO IMPLANT LEVEL 8,32104523,CDM,278,RC,C1713,HCPCS,Outpatient,,,8368,5020.80,,9522.06,110,,169.44,Percent of Total Billed Charges,110% of Total Billed Charges,3765.6,45,,2552.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2343.04,28,,129.024,Percent of Total Billed Charges,28% of Total Billed Charges,430.38,32,,395.136,Percent of Total Billed Charges,32% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,3012.48,36,,165.888,Percent of Total Billed Charges,36% of Total Billed Charges,3012.48,36,,165.888,Percent of Total Billed Charges,36% Total Bille Charges,3012.48,36,,165.888,Percent of Total Billed Charges,36% of Total Billed Charges,4602.4,55,,706.224,Percent of Total Billed Charges,55% Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8368,100,,342.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1206.67,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6694.4,80,,271.656,Percent of Total Billed Charges,80% of Total Billed Charges,4184,50,,32806,Percent of Total Billed Charges,50% of Total Billed Charges,4184,50,,181.104,Percent of Total Billed Charges,50% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4184,50,,181.104,Percent of Total Billed Charges,50% of Total Billed Charges,4184,50,,181.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5857.6,70,,195.904,Percent of Total Billed Charges,70% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1171.52,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8368,100,,362.208,Percent of Total Billed Charges,100% of Total Billed Charges,430.38,9522.06,
ORTHO IMPLANT LEVEL 9,32104524,CDM,278,RC,C1713,HCPCS,Outpatient,,,12193,7315.80,,13729.56,110,,223.2,Percent of Total Billed Charges,110% of Total Billed Charges,5486.85,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3414.04,28,,221.232,Percent of Total Billed Charges,28% of Total Billed Charges,430.38,32,,395.136,Percent of Total Billed Charges,32% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,4389.48,36,,284.448,Percent of Total Billed Charges,36% of Total Billed Charges,4389.48,36,,284.448,Percent of Total Billed Charges,36% Total Bille Charges,4389.48,36,,284.448,Percent of Total Billed Charges,36% of Total Billed Charges,6706.15,55,,1555.84,Percent of Total Billed Charges,55% Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12193,100,,1091.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1758.23,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9754.4,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,6096.5,50,,53544.8,Percent of Total Billed Charges,50% of Total Billed Charges,6096.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6096.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,6096.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8535.1,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1707.02,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12193,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,430.38,13729.56,
ORTHO IMPLANT LEVEL 10,32104525,CDM,278,RC,C1713,HCPCS,Outpatient,,,18634,11180.40,,20814.66,110,,277.44,Percent of Total Billed Charges,110% of Total Billed Charges,8385.3,45,,95.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5217.52,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,431.8,32,,395.592,Percent of Total Billed Charges,32% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,6708.24,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,6708.24,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,6708.24,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,10248.7,55,,168,Percent of Total Billed Charges,55% Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18634,100,,31760.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2687.02,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14907.2,80,,150.504,Percent of Total Billed Charges,80% of Total Billed Charges,9317,50,,181.104,Percent of Total Billed Charges,50% of Total Billed Charges,9317,50,,100.336,Percent of Total Billed Charges,50% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9317,50,,100.336,Percent of Total Billed Charges,50% of Total Billed Charges,9317,50,,100.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13043.8,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2608.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18634,100,,200.672,Percent of Total Billed Charges,100% of Total Billed Charges,431.8,20814.66,
ORTHO IMPLANT LEVEL 11,32104526,CDM,278,RC,C1713,HCPCS,Outpatient,,,29393,17635.80,,32649.56,110,,253.816,Percent of Total Billed Charges,110% of Total Billed Charges,13226.85,45,,95.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8230.04,28,,30.416,Percent of Total Billed Charges,28% of Total Billed Charges,432,32,,396.936,Percent of Total Billed Charges,32% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,10581.48,36,,39.104,Percent of Total Billed Charges,36% of Total Billed Charges,10581.48,36,,39.104,Percent of Total Billed Charges,36% Total Bille Charges,10581.48,36,,39.104,Percent of Total Billed Charges,36% of Total Billed Charges,16166.15,55,,88.608,Percent of Total Billed Charges,55% Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29393,100,,5672.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4238.47,14.42,,15.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23514.4,80,,148.856,Percent of Total Billed Charges,80% of Total Billed Charges,14696.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,14696.5,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14696.5,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,14696.5,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20575.1,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,4115.02,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29393,100,,198.472,Percent of Total Billed Charges,100% of Total Billed Charges,432,32649.56,
ORTHO IMPLANT LEVEL 12,32104527,CDM,278,RC,C1713,HCPCS,Outpatient,,,42509,25505.40,,47077.16,110,,165.088,Percent of Total Billed Charges,110% of Total Billed Charges,19129.05,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11902.52,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,432,32,,398.064,Percent of Total Billed Charges,32% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,15303.24,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,15303.24,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,15303.24,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,23379.95,55,,2349.776,Percent of Total Billed Charges,55% Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42509,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,6129.8,14.42,,15.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34007.2,80,,220.648,Percent of Total Billed Charges,80% of Total Billed Charges,21254.5,50,,100.336,Percent of Total Billed Charges,50% of Total Billed Charges,21254.5,50,,147.104,Percent of Total Billed Charges,50% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21254.5,50,,147.104,Percent of Total Billed Charges,50% of Total Billed Charges,21254.5,50,,147.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29756.3,70,,120.968,Percent of Total Billed Charges,70% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,5951.26,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42509,100,,294.2,Percent of Total Billed Charges,100% of Total Billed Charges,432,47077.16,
ORTHO IMPLANT LEVEL 13,32104528,CDM,278,RC,C1713,HCPCS,Outpatient,,,56802,34081.20,,62799.46,110,,37.152,Percent of Total Billed Charges,110% of Total Billed Charges,25560.9,45,,90.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15904.56,28,,420.864,Percent of Total Billed Charges,28% of Total Billed Charges,432,32,,398.464,Percent of Total Billed Charges,32% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,20448.72,36,,541.104,Percent of Total Billed Charges,36% of Total Billed Charges,20448.72,36,,541.104,Percent of Total Billed Charges,36% Total Bille Charges,20448.72,36,,541.104,Percent of Total Billed Charges,36% of Total Billed Charges,31241.1,55,,9680,Percent of Total Billed Charges,55% Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56802,100,,211.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,8190.85,14.42,,15.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45441.6,80,,344.784,Percent of Total Billed Charges,80% of Total Billed Charges,28401,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,28401,50,,229.856,Percent of Total Billed Charges,50% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28401,50,,229.856,Percent of Total Billed Charges,50% of Total Billed Charges,28401,50,,229.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39761.4,70,,109.904,Percent of Total Billed Charges,70% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,7952.28,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56802,100,,459.712,Percent of Total Billed Charges,100% of Total Billed Charges,432,62799.46,
ORTHO IMPLANT LEVEL 14,32104529,CDM,278,RC,C1713,HCPCS,Outpatient,,,82015,49209.00,,90533.76,110,,45.304,Percent of Total Billed Charges,110% of Total Billed Charges,36906.75,45,,3537.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22964.2,28,,198.24,Percent of Total Billed Charges,28% of Total Billed Charges,432.43,32,,399.2,Percent of Total Billed Charges,32% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,29525.4,36,,254.88,Percent of Total Billed Charges,36% of Total Billed Charges,29525.4,36,,254.88,Percent of Total Billed Charges,36% Total Bille Charges,29525.4,36,,254.88,Percent of Total Billed Charges,36% of Total Billed Charges,45108.25,55,,657.36,Percent of Total Billed Charges,55% Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82015,100,,211.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11826.56,14.42,,42.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65612,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,41007.5,50,,147.104,Percent of Total Billed Charges,50% of Total Billed Charges,41007.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41007.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,41007.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57410.5,70,,213.088,Percent of Total Billed Charges,70% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,11482.1,14,,40.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82015,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,432.43,90533.76,
ORTHO IMPLANT LEVEL 15,32104530,CDM,278,RC,C1713,HCPCS,Outpatient,,,133862,80317.20,,147565.46,110,,2344.744,Percent of Total Billed Charges,110% of Total Billed Charges,60237.9,45,,3537.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37481.36,28,,333.312,Percent of Total Billed Charges,28% of Total Billed Charges,434.88,32,,400.168,Percent of Total Billed Charges,32% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,48190.32,36,,428.544,Percent of Total Billed Charges,36% of Total Billed Charges,48190.32,36,,428.544,Percent of Total Billed Charges,36% Total Bille Charges,48190.32,36,,428.544,Percent of Total Billed Charges,36% of Total Billed Charges,73624.1,55,,479.992,Percent of Total Billed Charges,55% Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133862,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,19302.9,14.42,,42.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107089.6,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,66931,50,,229.856,Percent of Total Billed Charges,50% of Total Billed Charges,66931,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66931,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,66931,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93703.4,70,,342.72,Percent of Total Billed Charges,70% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,18740.68,14,,41.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133862,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,434.88,147565.46,
112764 CATHETER MALECOT,32104731,CDM,272,RC,C1729,HCPCS,Outpatient,,,452.76,271.66,,11.1,100,,33.6,Fee Schedule,100% of Aetna Fee Schedule,203.74,45,,34.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.77,28,,627.2,Percent of Total Billed Charges,28% of Total Billed Charges,435.21,32,,400.896,Percent of Total Billed Charges,32% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,162.99,36,,806.4,Percent of Total Billed Charges,36% of Total Billed Charges,162.99,36,,806.4,Percent of Total Billed Charges,36% Total Bille Charges,162.99,36,,806.4,Percent of Total Billed Charges,36% of Total Billed Charges,271.66,60,,55.64,Percent of Total Billed Charges,60% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,452.76,100,,201.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.29,14.42,,93.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339.57,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,226.38,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,226.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,226.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.93,70,,632.136,Percent of Total Billed Charges,70% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,63.39,14,,90.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.76,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,452.76,
111995 STONE CATCHER,32104732,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,31.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,1094.912,Percent of Total Billed Charges,28% of Total Billed Charges,435.21,32,,403.2,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,1407.744,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,1407.744,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,1407.744,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,522.536,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,7861.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,95.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,672,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,435.21,
1159614 CLIP APPLIER PREMIUM,32104733,CDM,272,RC,,,Outpatient,,,250.84,150.50,,150.5,60,,623.408,Percent of Total Billed Charges,60% of Total Billed Charges,112.88,45,,731.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.24,28,,2645.776,Percent of Total Billed Charges,28% of Total Billed Charges,436.07,32,,403.2,Percent of Total Billed Charges,32% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,36,,3401.712,Percent of Total Billed Charges,36% of Total Billed Charges,90.3,36,,3401.712,Percent of Total Billed Charges,36% Total Bille Charges,90.3,36,,3401.712,Percent of Total Billed Charges,36% of Total Billed Charges,150.5,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.84,100,,7861.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,36.17,14.42,,88.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.13,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,125.42,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,125.42,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.42,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,125.42,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.59,70,,340.792,Percent of Total Billed Charges,70% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,35.12,14,,85.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.84,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,35.12,436.07,
1159616 CLIP APPLIER PREMIUM,32104734,CDM,272,RC,,,Outpatient,,,248.09,148.85,,148.85,60,,1111.456,Percent of Total Billed Charges,60% of Total Billed Charges,111.64,45,,1190.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.47,28,,170.376,Percent of Total Billed Charges,28% of Total Billed Charges,436.62,32,,405.432,Percent of Total Billed Charges,32% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,89.31,36,,219.048,Percent of Total Billed Charges,36% of Total Billed Charges,89.31,36,,219.048,Percent of Total Billed Charges,36% Total Bille Charges,89.31,36,,219.048,Percent of Total Billed Charges,36% of Total Billed Charges,148.85,60,,990,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.09,100,,76.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,35.77,14.42,,95.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.07,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,124.05,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,124.05,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.05,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,124.05,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.66,70,,1656.928,Percent of Total Billed Charges,70% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,92.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.09,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,34.73,436.62,
1159813 CLIP APPLIER PISTOL,32104735,CDM,272,RC,,,Outpatient,,,367.75,220.65,,220.65,60,,336.04,Percent of Total Billed Charges,60% of Total Billed Charges,165.49,45,,62.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.97,28,,1310.4,Percent of Total Billed Charges,28% of Total Billed Charges,436.62,32,,405.432,Percent of Total Billed Charges,32% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,132.39,36,,1684.8,Percent of Total Billed Charges,36% of Total Billed Charges,132.39,36,,1684.8,Percent of Total Billed Charges,36% Total Bille Charges,132.39,36,,1684.8,Percent of Total Billed Charges,36% of Total Billed Charges,220.65,60,,253.44,Percent of Total Billed Charges,60% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367.75,100,,69.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,53.03,14.42,,117.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.81,75,,219.12,Percent of Total Billed Charges,75% of Total Billed Charges,183.88,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,183.88,50,,146.08,Percent of Total Billed Charges,50% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.88,50,,146.08,Percent of Total Billed Charges,50% of Total Billed Charges,183.88,50,,146.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.43,70,,69.488,Percent of Total Billed Charges,70% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.49,14,,114.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.75,100,,292.16,Percent of Total Billed Charges,100% of Total Billed Charges,51.49,436.62,
309246 CLIP APPLIER ENDO CLIP,32104736,CDM,272,RC,,,Outpatient,,,574.64,344.78,,344.78,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,258.59,45,,62.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.9,28,,164.2,Percent of Total Billed Charges,28% of Total Billed Charges,436.62,32,,405.432,Percent of Total Billed Charges,32% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,206.87,36,,211.12,Percent of Total Billed Charges,36% of Total Billed Charges,206.87,36,,211.12,Percent of Total Billed Charges,36% Total Bille Charges,206.87,36,,211.12,Percent of Total Billed Charges,36% of Total Billed Charges,344.78,60,,434.568,Percent of Total Billed Charges,60% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574.64,100,,1626.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,82.86,14.42,,109.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.98,75,,223.112,Percent of Total Billed Charges,75% of Total Billed Charges,287.32,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,287.32,50,,148.744,Percent of Total Billed Charges,50% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.32,50,,148.744,Percent of Total Billed Charges,50% of Total Billed Charges,287.32,50,,148.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.25,70,,4358.92,Percent of Total Billed Charges,70% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,80.45,14,,106.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,574.64,100,,297.48,Percent of Total Billed Charges,100% of Total Billed Charges,80.45,574.64,
591354 CLIP APPLIER ENDO CLIP,32104737,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,148.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,16.248,Percent of Total Billed Charges,28% of Total Billed Charges,436.93,32,,405.432,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,20.888,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2646.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,97.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,486.168,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,146.08,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,324.112,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,324.112,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,324.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,5969.6,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,94.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,648.224,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,436.93,
178423 STAPLER ROTICULATOR,32104738,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,40.432,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,561.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,147.84,Percent of Total Billed Charges,28% of Total Billed Charges,437.08,32,,405.432,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,190.08,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,190.08,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,190.08,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,65.176,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,138.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,119.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,495.592,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,148.744,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,116.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,660.792,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
1159422 STAPLER ROTICULATOR,32104739,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,528,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,1792.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,223.44,Percent of Total Billed Charges,28% of Total Billed Charges,437.17,32,,407.04,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,287.28,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,287.28,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,287.28,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,138.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,458.728,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,324.112,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,305.824,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,305.824,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,305.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,1568,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,611.64,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
1166311 TROCAR VERSAPORT,32104740,CDM,272,RC,,,Outpatient,,,135,81.00,,81,60,,2612.88,Percent of Total Billed Charges,60% of Total Billed Charges,60.75,45,,236.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,28,,741.392,Percent of Total Billed Charges,28% of Total Billed Charges,437.24,32,,408.072,Percent of Total Billed Charges,32% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,48.6,36,,953.224,Percent of Total Billed Charges,36% of Total Billed Charges,48.6,36,,953.224,Percent of Total Billed Charges,36% Total Bille Charges,48.6,36,,953.224,Percent of Total Billed Charges,36% of Total Billed Charges,81,60,,826.688,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,100,,329.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14.42,,91.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,75,,495.592,Percent of Total Billed Charges,75% of Total Billed Charges,67.5,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.5,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,70,,2912,Percent of Total Billed Charges,70% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,88.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135,100,,660.792,Percent of Total Billed Charges,100% of Total Billed Charges,18.9,437.24,
1166320 TROCAR VERSAONE BLADED,32104741,CDM,272,RC,,,Outpatient,,,135,81.00,,81,60,,1647.36,Percent of Total Billed Charges,60% of Total Billed Charges,60.75,45,,355.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,438.02,32,,408.304,Percent of Total Billed Charges,32% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,48.6,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,48.6,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,48.6,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,81,60,,389.4,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,100,,1247.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14.42,,46.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,75,,610.848,Percent of Total Billed Charges,75% of Total Billed Charges,67.5,50,,305.824,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,407.232,Percent of Total Billed Charges,50% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.5,50,,407.232,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,407.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135,100,,814.464,Percent of Total Billed Charges,100% of Total Billed Charges,18.9,438.02,
1166374 TROCAR VERSAONE BLADED,32104742,CDM,272,RC,,,Outpatient,,,135,81.00,,81,60,,856.8,Percent of Total Billed Charges,60% of Total Billed Charges,60.75,45,,351.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,28,,564.48,Percent of Total Billed Charges,28% of Total Billed Charges,438.4,32,,408.888,Percent of Total Billed Charges,32% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,48.6,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,48.6,36,,725.76,Percent of Total Billed Charges,36% Total Bille Charges,48.6,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,81,60,,654.72,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,100,,3982.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,75,,568.08,Percent of Total Billed Charges,75% of Total Billed Charges,67.5,50,,330.4,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,378.72,Percent of Total Billed Charges,50% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.5,50,,378.72,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,378.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,70,,1601.6,Percent of Total Billed Charges,70% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135,100,,757.44,Percent of Total Billed Charges,100% of Total Billed Charges,18.9,438.4,
1166383 TROCAR VERSAONE BLUNT,32104743,CDM,272,RC,,,Outpatient,,,365.2,219.12,,219.12,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,164.34,45,,495.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.26,28,,1113.84,Percent of Total Billed Charges,28% of Total Billed Charges,438.4,32,,408.888,Percent of Total Billed Charges,32% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,131.47,36,,1432.08,Percent of Total Billed Charges,36% of Total Billed Charges,131.47,36,,1432.08,Percent of Total Billed Charges,36% Total Bille Charges,131.47,36,,1432.08,Percent of Total Billed Charges,36% of Total Billed Charges,219.12,60,,1232,Percent of Total Billed Charges,60% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,365.2,100,,526.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,52.66,14.42,,46.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.9,75,,508.408,Percent of Total Billed Charges,75% of Total Billed Charges,182.6,50,,407.232,Percent of Total Billed Charges,50% of Total Billed Charges,182.6,50,,338.944,Percent of Total Billed Charges,50% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.6,50,,338.944,Percent of Total Billed Charges,50% of Total Billed Charges,182.6,50,,338.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.64,70,,1601.6,Percent of Total Billed Charges,70% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,51.13,14,,45.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.2,100,,677.88,Percent of Total Billed Charges,100% of Total Billed Charges,51.13,438.4,
692768 RELIACATCH RETRVL BAG,32104744,CDM,272,RC,,,Outpatient,,,371.85,223.11,,223.11,60,,186.568,Percent of Total Billed Charges,60% of Total Billed Charges,167.33,45,,72.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.12,28,,68.544,Percent of Total Billed Charges,28% of Total Billed Charges,438.4,32,,408.888,Percent of Total Billed Charges,32% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,133.87,36,,88.128,Percent of Total Billed Charges,36% of Total Billed Charges,133.87,36,,88.128,Percent of Total Billed Charges,36% Total Bille Charges,133.87,36,,88.128,Percent of Total Billed Charges,36% of Total Billed Charges,223.11,60,,3204.344,Percent of Total Billed Charges,60% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.85,100,,790.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,53.62,14.42,,71.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.89,75,,623.576,Percent of Total Billed Charges,75% of Total Billed Charges,185.93,50,,378.72,Percent of Total Billed Charges,50% of Total Billed Charges,185.93,50,,415.72,Percent of Total Billed Charges,50% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.93,50,,415.72,Percent of Total Billed Charges,50% of Total Billed Charges,185.93,50,,415.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.3,70,,19600,Percent of Total Billed Charges,70% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.06,14,,69.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371.85,100,,831.432,Percent of Total Billed Charges,100% of Total Billed Charges,52.06,438.4,
1159951 STAPLER EEA DST,32104745,CDM,272,RC,,,Outpatient,,,810.28,486.17,,486.17,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,364.63,45,,600.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.88,28,,652.288,Percent of Total Billed Charges,28% of Total Billed Charges,439.47,32,,408.888,Percent of Total Billed Charges,32% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,291.7,36,,838.656,Percent of Total Billed Charges,36% of Total Billed Charges,291.7,36,,838.656,Percent of Total Billed Charges,36% Total Bille Charges,291.7,36,,838.656,Percent of Total Billed Charges,36% of Total Billed Charges,486.17,60,,2150.72,Percent of Total Billed Charges,60% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810.28,100,,781.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14.42,,28.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.71,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,405.14,50,,338.944,Percent of Total Billed Charges,50% of Total Billed Charges,405.14,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.14,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,405.14,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567.2,70,,19488,Percent of Total Billed Charges,70% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,113.44,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.28,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,113.44,810.28,
195605 STAPLER EEA DST,32104746,CDM,272,RC,,,Outpatient,,,825.99,495.59,,495.59,60,,387.16,Percent of Total Billed Charges,60% of Total Billed Charges,371.7,45,,205.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.28,28,,244.328,Percent of Total Billed Charges,28% of Total Billed Charges,439.95,32,,409.336,Percent of Total Billed Charges,32% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,297.36,36,,314.136,Percent of Total Billed Charges,36% of Total Billed Charges,297.36,36,,314.136,Percent of Total Billed Charges,36% Total Bille Charges,297.36,36,,314.136,Percent of Total Billed Charges,36% of Total Billed Charges,495.59,60,,5197.056,Percent of Total Billed Charges,60% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825.99,100,,1101.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,119.11,14.42,,27.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619.49,75,,473.904,Percent of Total Billed Charges,75% of Total Billed Charges,413,50,,415.72,Percent of Total Billed Charges,50% of Total Billed Charges,413,50,,315.936,Percent of Total Billed Charges,50% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413,50,,315.936,Percent of Total Billed Charges,50% of Total Billed Charges,413,50,,315.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.19,70,,95.48,Percent of Total Billed Charges,70% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,26.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825.99,100,,631.872,Percent of Total Billed Charges,100% of Total Billed Charges,115.64,825.99,
195606 STAPLER EEA DST,32104747,CDM,272,RC,,,Outpatient,,,764.55,458.73,,458.73,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,344.05,45,,249.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.07,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,440.44,32,,409.336,Percent of Total Billed Charges,32% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,275.24,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,275.24,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,275.24,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,458.73,60,,365.08,Percent of Total Billed Charges,60% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,764.55,100,,161.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.25,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,573.41,75,,242.088,Percent of Total Billed Charges,75% of Total Billed Charges,382.28,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,382.28,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.28,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,382.28,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,535.19,70,,1332.8,Percent of Total Billed Charges,70% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,107.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.55,100,,322.784,Percent of Total Billed Charges,100% of Total Billed Charges,107.04,764.55,
1159763 STAPLER EEA DST,32104748,CDM,272,RC,,,Outpatient,,,825.99,495.59,,495.59,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,371.7,45,,107.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.28,28,,1456,Percent of Total Billed Charges,28% of Total Billed Charges,440.52,32,,409.336,Percent of Total Billed Charges,32% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,297.36,36,,1872,Percent of Total Billed Charges,36% of Total Billed Charges,297.36,36,,1872,Percent of Total Billed Charges,36% Total Bille Charges,297.36,36,,1872,Percent of Total Billed Charges,36% of Total Billed Charges,495.59,60,,2574,Percent of Total Billed Charges,60% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825.99,100,,1335.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.11,14.42,,24.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619.49,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,413,50,,315.936,Percent of Total Billed Charges,50% of Total Billed Charges,413,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,413,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.19,70,,3008.696,Percent of Total Billed Charges,70% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,14,,23.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825.99,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,115.64,825.99,
205466 STAPLER EEA DST,32104749,CDM,272,RC,,,Outpatient,,,1018.08,610.85,,610.85,60,,214.8,Percent of Total Billed Charges,60% of Total Billed Charges,458.14,45,,96.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.06,28,,68.04,Percent of Total Billed Charges,28% of Total Billed Charges,441.6,32,,409.336,Percent of Total Billed Charges,32% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,366.51,36,,87.48,Percent of Total Billed Charges,36% of Total Billed Charges,366.51,36,,87.48,Percent of Total Billed Charges,36% Total Bille Charges,366.51,36,,87.48,Percent of Total Billed Charges,36% of Total Billed Charges,610.85,60,,322.544,Percent of Total Billed Charges,60% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1018.08,100,,455.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,146.81,14.42,,40.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,763.56,75,,242.088,Percent of Total Billed Charges,75% of Total Billed Charges,509.04,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,509.04,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,509.04,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,509.04,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,712.66,70,,1674.4,Percent of Total Billed Charges,70% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,142.53,14,,39.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1018.08,100,,322.784,Percent of Total Billed Charges,100% of Total Billed Charges,142.53,1018.08,
163504 STAPLER EEA DST,32104750,CDM,272,RC,,,Outpatient,,,946.8,568.08,,568.08,60,,130.4,Percent of Total Billed Charges,60% of Total Billed Charges,426.06,45,,2246.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.1,28,,324.472,Percent of Total Billed Charges,28% of Total Billed Charges,441.93,32,,409.656,Percent of Total Billed Charges,32% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,340.85,36,,417.184,Percent of Total Billed Charges,36% of Total Billed Charges,340.85,36,,417.184,Percent of Total Billed Charges,36% Total Bille Charges,340.85,36,,417.184,Percent of Total Billed Charges,36% of Total Billed Charges,568.08,60,,34.816,Percent of Total Billed Charges,60% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,946.8,100,,555.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,136.53,14.42,,60.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,710.1,75,,372.76,Percent of Total Billed Charges,75% of Total Billed Charges,473.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,473.4,50,,248.512,Percent of Total Billed Charges,50% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.4,50,,248.512,Percent of Total Billed Charges,50% of Total Billed Charges,473.4,50,,248.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.76,70,,2222.12,Percent of Total Billed Charges,70% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,132.55,14,,59.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,946.8,100,,497.016,Percent of Total Billed Charges,100% of Total Billed Charges,132.55,946.8,
532769 STAPLER EEA DST,32104751,CDM,272,RC,,,Outpatient,,,847.35,508.41,,508.41,60,,526.856,Percent of Total Billed Charges,60% of Total Billed Charges,381.31,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.26,28,,222.432,Percent of Total Billed Charges,28% of Total Billed Charges,441.93,32,,409.944,Percent of Total Billed Charges,32% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,305.05,36,,285.984,Percent of Total Billed Charges,36% of Total Billed Charges,305.05,36,,285.984,Percent of Total Billed Charges,36% Total Bille Charges,305.05,36,,285.984,Percent of Total Billed Charges,36% of Total Billed Charges,508.41,60,,290.4,Percent of Total Billed Charges,60% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,847.35,100,,238.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,122.19,14.42,,41.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,635.51,75,,148.504,Percent of Total Billed Charges,75% of Total Billed Charges,423.68,50,,161.392,Percent of Total Billed Charges,50% of Total Billed Charges,423.68,50,,99,Percent of Total Billed Charges,50% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,423.68,50,,99,Percent of Total Billed Charges,50% of Total Billed Charges,423.68,50,,99,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.15,70,,1115.52,Percent of Total Billed Charges,70% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,118.63,14,,40.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,847.35,100,,198,Percent of Total Billed Charges,100% of Total Billed Charges,118.63,847.35,
1159787 STAPLER EEA DST,32104752,CDM,272,RC,,,Outpatient,,,1039.29,623.57,,623.57,60,,2403.792,Percent of Total Billed Charges,60% of Total Billed Charges,467.68,45,,859.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291,28,,2620.216,Percent of Total Billed Charges,28% of Total Billed Charges,442.51,32,,409.944,Percent of Total Billed Charges,32% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,374.14,36,,3368.848,Percent of Total Billed Charges,36% of Total Billed Charges,374.14,36,,3368.848,Percent of Total Billed Charges,36% Total Bille Charges,374.14,36,,3368.848,Percent of Total Billed Charges,36% of Total Billed Charges,623.57,60,,478.8,Percent of Total Billed Charges,60% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1039.29,100,,213.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,149.87,14.42,,55.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.47,75,,141.984,Percent of Total Billed Charges,75% of Total Billed Charges,519.65,50,,248.512,Percent of Total Billed Charges,50% of Total Billed Charges,519.65,50,,94.656,Percent of Total Billed Charges,50% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,519.65,50,,94.656,Percent of Total Billed Charges,50% of Total Billed Charges,519.65,50,,94.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,727.5,70,,431.712,Percent of Total Billed Charges,70% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,145.5,14,,54.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1039.29,100,,189.312,Percent of Total Billed Charges,100% of Total Billed Charges,145.5,1039.29,
429495 STAPLER ENDO GIA SHORT,32104753,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,334.368,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,722.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,4479.552,Percent of Total Billed Charges,28% of Total Billed Charges,444.36,32,,409.944,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,5759.424,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,5759.424,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,5759.424,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1456.312,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,4992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,119.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,99,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,139.248,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,115.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,444.36,
385407 STAPLER HANDLE GIA STD,32104754,CDM,272,RC,,,Outpatient,,,789.84,473.90,,473.9,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,355.43,45,,2077.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.16,28,,167.328,Percent of Total Billed Charges,28% of Total Billed Charges,444.42,32,,410.424,Percent of Total Billed Charges,32% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,284.34,36,,215.136,Percent of Total Billed Charges,36% of Total Billed Charges,284.34,36,,215.136,Percent of Total Billed Charges,36% Total Bille Charges,284.34,36,,215.136,Percent of Total Billed Charges,36% of Total Billed Charges,473.9,60,,3816.016,Percent of Total Billed Charges,60% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,789.84,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,113.89,14.42,,22.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.38,75,,127.504,Percent of Total Billed Charges,75% of Total Billed Charges,394.92,50,,94.656,Percent of Total Billed Charges,50% of Total Billed Charges,394.92,50,,85,Percent of Total Billed Charges,50% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.92,50,,85,Percent of Total Billed Charges,50% of Total Billed Charges,394.92,50,,85,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.89,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,110.58,14,,21.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,789.84,100,,170,Percent of Total Billed Charges,100% of Total Billed Charges,110.58,789.84,
174881 GIA LOADING UNIT,32104755,CDM,272,RC,,,Outpatient,,,403.48,242.09,,242.09,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,181.57,45,,830.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.97,28,,503.328,Percent of Total Billed Charges,28% of Total Billed Charges,444.75,32,,410.896,Percent of Total Billed Charges,32% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,145.25,36,,647.136,Percent of Total Billed Charges,36% of Total Billed Charges,145.25,36,,647.136,Percent of Total Billed Charges,36% Total Bille Charges,145.25,36,,647.136,Percent of Total Billed Charges,36% of Total Billed Charges,242.09,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.48,100,,1910.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,58.18,14.42,,15.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.61,75,,210.832,Percent of Total Billed Charges,75% of Total Billed Charges,201.74,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,201.74,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.74,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,201.74,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,282.44,70,,5969.6,Percent of Total Billed Charges,70% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.48,100,,281.112,Percent of Total Billed Charges,100% of Total Billed Charges,56.49,444.75,
174875 STAPLER GIA DST,32104756,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,393.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,378.472,Percent of Total Billed Charges,28% of Total Billed Charges,448.49,32,,411.848,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,486.608,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,486.608,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,486.608,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,2187.904,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1606.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,34.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,316.288,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,85,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,210.864,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,210.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,210.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,898.832,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,33.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,421.72,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
601297 LOADING UNIT GIA,32104757,CDM,272,RC,,,Outpatient,,,403.48,242.09,,242.09,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,181.57,45,,51.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.97,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,449.09,32,,411.968,Percent of Total Billed Charges,32% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,145.25,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,145.25,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,145.25,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,242.09,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,403.48,100,,4617.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,58.18,14.42,,35.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.61,75,,214.96,Percent of Total Billed Charges,75% of Total Billed Charges,201.74,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,201.74,50,,143.312,Percent of Total Billed Charges,50% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.74,50,,143.312,Percent of Total Billed Charges,50% of Total Billed Charges,201.74,50,,143.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,282.44,70,,1815.152,Percent of Total Billed Charges,70% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.48,100,,286.616,Percent of Total Billed Charges,100% of Total Billed Charges,56.49,449.09,
423518 STAPLER GIA DST,32104758,CDM,272,RC,,,Outpatient,,,621.27,372.76,,372.76,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,279.57,45,,4561.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.96,28,,786.24,Percent of Total Billed Charges,28% of Total Billed Charges,450.66,32,,412.792,Percent of Total Billed Charges,32% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,223.66,36,,1010.88,Percent of Total Billed Charges,36% of Total Billed Charges,223.66,36,,1010.88,Percent of Total Billed Charges,36% Total Bille Charges,223.66,36,,1010.88,Percent of Total Billed Charges,36% of Total Billed Charges,372.76,60,,1281.28,Percent of Total Billed Charges,60% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.27,100,,1845.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,89.59,14.42,,27.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.95,75,,290.232,Percent of Total Billed Charges,75% of Total Billed Charges,310.64,50,,210.864,Percent of Total Billed Charges,50% of Total Billed Charges,310.64,50,,193.488,Percent of Total Billed Charges,50% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,310.64,50,,193.488,Percent of Total Billed Charges,50% of Total Billed Charges,310.64,50,,193.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.89,70,,196,Percent of Total Billed Charges,70% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.98,14,,26.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,621.27,100,,386.976,Percent of Total Billed Charges,100% of Total Billed Charges,86.98,621.27,
1164838 GIA LOADING UNIT,32104759,CDM,272,RC,,,Outpatient,,,247.5,148.50,,148.5,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,111.38,45,,1372.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.3,28,,1659.84,Percent of Total Billed Charges,28% of Total Billed Charges,452.21,32,,412.792,Percent of Total Billed Charges,32% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,89.1,36,,2134.08,Percent of Total Billed Charges,36% of Total Billed Charges,89.1,36,,2134.08,Percent of Total Billed Charges,36% Total Bille Charges,89.1,36,,2134.08,Percent of Total Billed Charges,36% of Total Billed Charges,148.5,60,,479.928,Percent of Total Billed Charges,60% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.5,100,,873.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.69,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.63,75,,621.328,Percent of Total Billed Charges,75% of Total Billed Charges,123.75,50,,143.312,Percent of Total Billed Charges,50% of Total Billed Charges,123.75,50,,414.216,Percent of Total Billed Charges,50% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.75,50,,414.216,Percent of Total Billed Charges,50% of Total Billed Charges,123.75,50,,414.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.25,70,,103.376,Percent of Total Billed Charges,70% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.5,100,,828.432,Percent of Total Billed Charges,100% of Total Billed Charges,34.65,452.21,
1015918 LOADING UNIT GIA,32104760,CDM,272,RC,,,Outpatient,,,236.64,141.98,,141.98,60,,812.696,Percent of Total Billed Charges,60% of Total Billed Charges,106.49,45,,128.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.26,28,,125.44,Percent of Total Billed Charges,28% of Total Billed Charges,452.21,32,,412.92,Percent of Total Billed Charges,32% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,85.19,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,85.19,36,,161.28,Percent of Total Billed Charges,36% Total Bille Charges,85.19,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,141.98,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.64,100,,114.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.12,14.42,,15.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.48,75,,114.904,Percent of Total Billed Charges,75% of Total Billed Charges,118.32,50,,193.488,Percent of Total Billed Charges,50% of Total Billed Charges,118.32,50,,76.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.32,50,,76.6,Percent of Total Billed Charges,50% of Total Billed Charges,118.32,50,,76.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.65,70,,2990.624,Percent of Total Billed Charges,70% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,33.13,14,,15.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.64,100,,153.2,Percent of Total Billed Charges,100% of Total Billed Charges,33.13,452.21,
807185 STAPLER GIA DST,32104761,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,1747.2,Percent of Total Billed Charges,28% of Total Billed Charges,452.21,32,,412.944,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,2246.4,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,2246.4,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,2246.4,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,2860,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,10137.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,11.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,414.216,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,11.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,452.21,
793898 GIA LOADING UNIT,32104762,CDM,272,RC,,,Outpatient,,,212.5,127.50,,127.5,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,95.63,45,,540.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.5,28,,938.488,Percent of Total Billed Charges,28% of Total Billed Charges,452.21,32,,412.944,Percent of Total Billed Charges,32% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,36,,1206.632,Percent of Total Billed Charges,36% of Total Billed Charges,76.5,36,,1206.632,Percent of Total Billed Charges,36% Total Bille Charges,76.5,36,,1206.632,Percent of Total Billed Charges,36% of Total Billed Charges,127.5,60,,145.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.5,100,,3049.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.64,14.42,,26.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.38,75,,179.04,Percent of Total Billed Charges,75% of Total Billed Charges,106.25,50,,76.6,Percent of Total Billed Charges,50% of Total Billed Charges,106.25,50,,119.36,Percent of Total Billed Charges,50% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.25,50,,119.36,Percent of Total Billed Charges,50% of Total Billed Charges,106.25,50,,119.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.75,70,,12320,Percent of Total Billed Charges,70% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.75,14,,26.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.5,100,,238.72,Percent of Total Billed Charges,100% of Total Billed Charges,29.75,452.21,
195641 RELOAD STAPLER GIA,32104763,CDM,272,RC,,,Outpatient,,,351.39,210.83,,210.83,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,158.13,45,,5346.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.39,28,,1499.68,Percent of Total Billed Charges,28% of Total Billed Charges,453.12,32,,413.528,Percent of Total Billed Charges,32% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,126.5,36,,1928.16,Percent of Total Billed Charges,36% of Total Billed Charges,126.5,36,,1928.16,Percent of Total Billed Charges,36% Total Bille Charges,126.5,36,,1928.16,Percent of Total Billed Charges,36% of Total Billed Charges,210.83,60,,695.304,Percent of Total Billed Charges,60% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.39,100,,285.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,50.67,14.42,,46.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.54,75,,184.504,Percent of Total Billed Charges,75% of Total Billed Charges,175.7,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,175.7,50,,123,Percent of Total Billed Charges,50% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.7,50,,123,Percent of Total Billed Charges,50% of Total Billed Charges,175.7,50,,123,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.97,70,,836.64,Percent of Total Billed Charges,70% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.19,14,,45.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.39,100,,246,Percent of Total Billed Charges,100% of Total Billed Charges,49.19,453.12,
195642 STAPLER GIA DST,32104764,CDM,272,RC,,,Outpatient,,,527.15,316.29,,316.29,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,237.22,45,,6369.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.6,28,,804.44,Percent of Total Billed Charges,28% of Total Billed Charges,453.59,32,,415.944,Percent of Total Billed Charges,32% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,189.77,36,,1034.28,Percent of Total Billed Charges,36% of Total Billed Charges,189.77,36,,1034.28,Percent of Total Billed Charges,36% Total Bille Charges,189.77,36,,1034.28,Percent of Total Billed Charges,36% of Total Billed Charges,316.29,60,,476.64,Percent of Total Billed Charges,60% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.15,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,76.02,14.42,,57.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.36,75,,141.448,Percent of Total Billed Charges,75% of Total Billed Charges,263.58,50,,119.36,Percent of Total Billed Charges,50% of Total Billed Charges,263.58,50,,94.304,Percent of Total Billed Charges,50% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.58,50,,94.304,Percent of Total Billed Charges,50% of Total Billed Charges,263.58,50,,94.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.01,70,,610.896,Percent of Total Billed Charges,70% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,73.8,14,,55.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.15,100,,188.6,Percent of Total Billed Charges,100% of Total Billed Charges,73.8,527.15,
201876 LOADING UNIT GIA,32104765,CDM,272,RC,,,Outpatient,,,358.27,214.96,,214.96,60,,812.696,Percent of Total Billed Charges,60% of Total Billed Charges,161.22,45,,2968.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.32,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,455.16,32,,417.912,Percent of Total Billed Charges,32% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,128.98,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,128.98,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,128.98,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,214.96,60,,5146.856,Percent of Total Billed Charges,60% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,358.27,100,,1200.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,51.66,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.7,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,179.14,50,,123,Percent of Total Billed Charges,50% of Total Billed Charges,179.14,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.14,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,179.14,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.79,70,,64.912,Percent of Total Billed Charges,70% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,50.16,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,358.27,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,50.16,455.16,
201867 STAPLER GIA DST,32104766,CDM,272,RC,,,Outpatient,,,483.72,290.23,,290.23,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,217.67,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.44,28,,2200.304,Percent of Total Billed Charges,28% of Total Billed Charges,456,32,,417.912,Percent of Total Billed Charges,32% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,174.14,36,,2828.968,Percent of Total Billed Charges,36% of Total Billed Charges,174.14,36,,2828.968,Percent of Total Billed Charges,36% Total Bille Charges,174.14,36,,2828.968,Percent of Total Billed Charges,36% of Total Billed Charges,290.23,60,,8799.12,Percent of Total Billed Charges,60% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.72,100,,11880.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,69.75,14.42,,54.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.79,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,241.86,50,,94.304,Percent of Total Billed Charges,50% of Total Billed Charges,241.86,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.86,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,241.86,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.6,70,,609.624,Percent of Total Billed Charges,70% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,67.72,14,,52.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483.72,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,67.72,483.72,
407321 STAPLER EEA HEMRRHD PRO,32104767,CDM,272,RC,,,Outpatient,,,1035.54,621.32,,621.32,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,465.99,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.95,28,,148.416,Percent of Total Billed Charges,28% of Total Billed Charges,458.27,32,,420.168,Percent of Total Billed Charges,32% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,372.79,36,,190.816,Percent of Total Billed Charges,36% of Total Billed Charges,372.79,36,,190.816,Percent of Total Billed Charges,36% Total Bille Charges,372.79,36,,190.816,Percent of Total Billed Charges,36% of Total Billed Charges,621.32,60,,358.56,Percent of Total Billed Charges,60% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1035.54,100,,14153.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,149.32,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.66,75,,62.032,Percent of Total Billed Charges,75% of Total Billed Charges,517.77,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,517.77,50,,41.352,Percent of Total Billed Charges,50% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.77,50,,41.352,Percent of Total Billed Charges,50% of Total Billed Charges,517.77,50,,41.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.88,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,144.98,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.54,100,,82.704,Percent of Total Billed Charges,100% of Total Billed Charges,144.98,1035.54,
1166390 TROCAR VERSAONE BLDLSS,32104768,CDM,272,RC,,,Outpatient,,,191.5,114.90,,114.9,60,,812.696,Percent of Total Billed Charges,60% of Total Billed Charges,86.18,45,,4178.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.62,28,,149.216,Percent of Total Billed Charges,28% of Total Billed Charges,458.7,32,,421.024,Percent of Total Billed Charges,32% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,68.94,36,,191.848,Percent of Total Billed Charges,36% of Total Billed Charges,68.94,36,,191.848,Percent of Total Billed Charges,36% Total Bille Charges,68.94,36,,191.848,Percent of Total Billed Charges,36% of Total Billed Charges,114.9,60,,988.68,Percent of Total Billed Charges,60% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.5,100,,6596.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,27.61,14.42,,64.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.63,75,,139.408,Percent of Total Billed Charges,75% of Total Billed Charges,95.75,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,95.75,50,,92.944,Percent of Total Billed Charges,50% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.75,50,,92.944,Percent of Total Billed Charges,50% of Total Billed Charges,95.75,50,,92.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.05,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.81,14,,62.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.5,100,,185.88,Percent of Total Billed Charges,100% of Total Billed Charges,26.81,458.7,
1166397 TROCAR VERSAONE BLDLSS,32104769,CDM,272,RC,,,Outpatient,,,135,81.00,,81,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,60.75,45,,6840,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,28,,818.856,Percent of Total Billed Charges,28% of Total Billed Charges,458.77,32,,421.024,Percent of Total Billed Charges,32% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,48.6,36,,1052.816,Percent of Total Billed Charges,36% of Total Billed Charges,48.6,36,,1052.816,Percent of Total Billed Charges,36% Total Bille Charges,48.6,36,,1052.816,Percent of Total Billed Charges,36% of Total Billed Charges,81,60,,811.008,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14.42,,62.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,75,,244.192,Percent of Total Billed Charges,75% of Total Billed Charges,67.5,50,,41.352,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,162.792,Percent of Total Billed Charges,50% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.5,50,,162.792,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,162.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,70,,322.56,Percent of Total Billed Charges,70% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135,100,,325.584,Percent of Total Billed Charges,100% of Total Billed Charges,18.9,458.77,
1166410 TROCAR VERSA ONE OPTIC,32104770,CDM,272,RC,,,Outpatient,,,298.4,179.04,,179.04,60,,812.696,Percent of Total Billed Charges,60% of Total Billed Charges,134.28,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.55,28,,668.304,Percent of Total Billed Charges,28% of Total Billed Charges,458.87,32,,422.4,Percent of Total Billed Charges,32% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,107.42,36,,859.248,Percent of Total Billed Charges,36% of Total Billed Charges,107.42,36,,859.248,Percent of Total Billed Charges,36% Total Bille Charges,107.42,36,,859.248,Percent of Total Billed Charges,36% of Total Billed Charges,179.04,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.4,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,43.03,14.42,,58.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.8,75,,299.936,Percent of Total Billed Charges,75% of Total Billed Charges,149.2,50,,92.944,Percent of Total Billed Charges,50% of Total Billed Charges,149.2,50,,199.96,Percent of Total Billed Charges,50% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.2,50,,199.96,Percent of Total Billed Charges,50% of Total Billed Charges,149.2,50,,199.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,70,,553.088,Percent of Total Billed Charges,70% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,41.78,14,,56.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.4,100,,399.912,Percent of Total Billed Charges,100% of Total Billed Charges,41.78,458.87,
1166415 TROCAR VERSA ONE OPTIC,32104771,CDM,272,RC,,,Outpatient,,,307.5,184.50,,184.5,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,138.38,45,,7360.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.1,28,,1792.048,Percent of Total Billed Charges,28% of Total Billed Charges,460.31,32,,423.584,Percent of Total Billed Charges,32% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,110.7,36,,2304.056,Percent of Total Billed Charges,36% of Total Billed Charges,110.7,36,,2304.056,Percent of Total Billed Charges,36% Total Bille Charges,110.7,36,,2304.056,Percent of Total Billed Charges,36% of Total Billed Charges,184.5,60,,1327.04,Percent of Total Billed Charges,60% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.5,100,,9286.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,44.34,14.42,,62.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.63,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,153.75,50,,162.792,Percent of Total Billed Charges,50% of Total Billed Charges,153.75,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.75,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,153.75,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.25,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,60.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.5,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,43.05,460.31,
1166428 TROCAR VERSA ONE OPTIC,32104772,CDM,272,RC,,,Outpatient,,,235.75,141.45,,141.45,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,106.09,45,,727.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.01,28,,669.632,Percent of Total Billed Charges,28% of Total Billed Charges,461.09,32,,424.144,Percent of Total Billed Charges,32% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84.87,36,,860.952,Percent of Total Billed Charges,36% of Total Billed Charges,84.87,36,,860.952,Percent of Total Billed Charges,36% Total Bille Charges,84.87,36,,860.952,Percent of Total Billed Charges,36% of Total Billed Charges,141.45,60,,1544.4,Percent of Total Billed Charges,60% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.75,100,,15200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,34,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.81,75,,281.904,Percent of Total Billed Charges,75% of Total Billed Charges,117.88,50,,199.96,Percent of Total Billed Charges,50% of Total Billed Charges,117.88,50,,187.936,Percent of Total Billed Charges,50% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.88,50,,187.936,Percent of Total Billed Charges,50% of Total Billed Charges,117.88,50,,187.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.03,70,,76.04,Percent of Total Billed Charges,70% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.01,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.75,100,,375.872,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,461.09,
1166439 TROCAR VERSA ONE OPTIC,32104773,CDM,272,RC,,,Outpatient,,,300,180.00,,180,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,135,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,2912,Percent of Total Billed Charges,28% of Total Billed Charges,461.51,32,,425.392,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,3744,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,3260.4,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,112.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,109.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,42,461.51,
1166443 TROCAR VERSA ONE OPTIC,32104774,CDM,272,RC,,,Outpatient,,,135,81.00,,81,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,60.75,45,,1871.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,28,,282.424,Percent of Total Billed Charges,28% of Total Billed Charges,463.54,32,,426.816,Percent of Total Billed Charges,32% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,48.6,36,,363.112,Percent of Total Billed Charges,36% of Total Billed Charges,48.6,36,,363.112,Percent of Total Billed Charges,36% Total Bille Charges,48.6,36,,363.112,Percent of Total Billed Charges,36% of Total Billed Charges,81,60,,268.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135,100,,16355.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14.42,,105.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,75,,336.28,Percent of Total Billed Charges,75% of Total Billed Charges,67.5,50,,187.936,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,224.192,Percent of Total Billed Charges,50% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.5,50,,224.192,Percent of Total Billed Charges,50% of Total Billed Charges,67.5,50,,224.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,70,,1052.152,Percent of Total Billed Charges,70% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,14,,102.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135,100,,448.376,Percent of Total Billed Charges,100% of Total Billed Charges,18.9,463.54,
1166450 TROCAR VERSA ONE OPTIC,32104775,CDM,272,RC,,,Outpatient,,,103.38,62.03,,62.03,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,46.52,45,,4564.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.95,28,,2298.736,Percent of Total Billed Charges,28% of Total Billed Charges,463.87,32,,428.072,Percent of Total Billed Charges,32% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,37.22,36,,2955.512,Percent of Total Billed Charges,36% of Total Billed Charges,37.22,36,,2955.512,Percent of Total Billed Charges,36% Total Bille Charges,37.22,36,,2955.512,Percent of Total Billed Charges,36% of Total Billed Charges,62.03,60,,3432,Percent of Total Billed Charges,60% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.38,100,,1617.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14.42,,138.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.54,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,51.69,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,51.69,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.69,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,51.69,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.37,70,,495.6,Percent of Total Billed Charges,70% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,14.47,14,,134.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.38,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,14.47,463.87,
1166454 TROCAR VERSA ONE OPTIC,32104776,CDM,272,RC,,,Outpatient,,,232.35,139.41,,139.41,60,,701.744,Percent of Total Billed Charges,60% of Total Billed Charges,104.56,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.06,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,465.2,32,,428.136,Percent of Total Billed Charges,32% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.65,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,83.65,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,83.65,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,139.41,60,,1843.464,Percent of Total Billed Charges,60% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.35,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14.42,,158.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.26,75,,304.512,Percent of Total Billed Charges,75% of Total Billed Charges,116.18,50,,224.192,Percent of Total Billed Charges,50% of Total Billed Charges,116.18,50,,203.008,Percent of Total Billed Charges,50% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.18,50,,203.008,Percent of Total Billed Charges,50% of Total Billed Charges,116.18,50,,203.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.65,70,,833.28,Percent of Total Billed Charges,70% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14,,153.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.35,100,,406.016,Percent of Total Billed Charges,100% of Total Billed Charges,32.53,465.2,
1160911 RELOAD STPLR TRISTAPLE,32104777,CDM,272,RC,,,Outpatient,,,406.98,244.19,,244.19,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,183.14,45,,205.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.95,28,,218.4,Percent of Total Billed Charges,28% of Total Billed Charges,466.56,32,,430.256,Percent of Total Billed Charges,32% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,146.51,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,146.51,36,,280.8,Percent of Total Billed Charges,36% Total Bille Charges,146.51,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,244.19,60,,2945.8,Percent of Total Billed Charges,60% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.98,100,,4159.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,58.69,14.42,,150.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.24,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,203.49,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,203.49,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.49,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,203.49,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.89,70,,1568,Percent of Total Billed Charges,70% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,56.98,14,,146.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.98,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,56.98,466.56,
1163441 CARTRIDGE INTELL TRI,32104778,CDM,272,RC,,,Outpatient,,,499.89,299.93,,299.93,60,,728.128,Percent of Total Billed Charges,60% of Total Billed Charges,224.95,45,,333.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.97,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,467.79,32,,430.384,Percent of Total Billed Charges,32% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,179.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,179.96,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,179.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,299.93,60,,1580.152,Percent of Total Billed Charges,60% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.89,100,,10144.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,72.08,14.42,,273.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.92,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,249.95,50,,203.008,Percent of Total Billed Charges,50% of Total Billed Charges,249.95,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.95,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,249.95,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.92,70,,4078.256,Percent of Total Billed Charges,70% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,69.98,14,,265.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.89,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,69.98,499.89,
1163442 CARTRIDGE INTELL TRI,32104779,CDM,272,RC,,,Outpatient,,,500,300.00,,300,60,,492.8,Percent of Total Billed Charges,60% of Total Billed Charges,225,45,,826.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,28,,444.656,Percent of Total Billed Charges,28% of Total Billed Charges,469.07,32,,430.384,Percent of Total Billed Charges,32% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,180,36,,571.704,Percent of Total Billed Charges,36% of Total Billed Charges,180,36,,571.704,Percent of Total Billed Charges,36% Total Bille Charges,180,36,,571.704,Percent of Total Billed Charges,36% of Total Billed Charges,300,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,72.1,14.42,,20.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,75,,586.072,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,390.72,Percent of Total Billed Charges,50% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,50,,390.72,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,390.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,70,,2737.28,Percent of Total Billed Charges,70% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,19.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500,100,,781.432,Percent of Total Billed Charges,100% of Total Billed Charges,70,500,
1163444 CARTRIDGE INTELL TRI,32104780,CDM,272,RC,,,Outpatient,,,469.84,281.90,,281.9,60,,327.464,Percent of Total Billed Charges,60% of Total Billed Charges,211.43,45,,15.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.56,28,,207.392,Percent of Total Billed Charges,28% of Total Billed Charges,469.13,32,,431.968,Percent of Total Billed Charges,32% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,169.14,36,,266.648,Percent of Total Billed Charges,36% of Total Billed Charges,169.14,36,,266.648,Percent of Total Billed Charges,36% Total Bille Charges,169.14,36,,266.648,Percent of Total Billed Charges,36% of Total Billed Charges,281.9,60,,4322.032,Percent of Total Billed Charges,60% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,469.84,100,,456.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,67.75,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.38,75,,548.32,Percent of Total Billed Charges,75% of Total Billed Charges,234.92,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,234.92,50,,365.544,Percent of Total Billed Charges,50% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.92,50,,365.544,Percent of Total Billed Charges,50% of Total Billed Charges,234.92,50,,365.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,328.89,70,,6614.432,Percent of Total Billed Charges,70% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,65.78,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,469.84,100,,731.088,Percent of Total Billed Charges,100% of Total Billed Charges,65.78,469.84,
1165841 CARTRIDGE INTELL TRI,32104781,CDM,272,RC,,,Outpatient,,,500,300.00,,300,60,,2944.656,Percent of Total Billed Charges,60% of Total Billed Charges,225,45,,960.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,28,,1103.992,Percent of Total Billed Charges,28% of Total Billed Charges,469.66,32,,432.536,Percent of Total Billed Charges,32% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,180,36,,1419.424,Percent of Total Billed Charges,36% of Total Billed Charges,180,36,,1419.424,Percent of Total Billed Charges,36% Total Bille Charges,180,36,,1419.424,Percent of Total Billed Charges,36% of Total Billed Charges,300,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500,100,,742,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,72.1,14.42,,19.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,75,,718.488,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,390.72,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,478.992,Percent of Total Billed Charges,50% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,50,,478.992,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,478.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,70,,425.928,Percent of Total Billed Charges,70% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,18.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500,100,,957.984,Percent of Total Billed Charges,100% of Total Billed Charges,70,500,
1163445 CARTRIDGE INTELL TRI,32104782,CDM,272,RC,,,Outpatient,,,560.47,336.28,,336.28,60,,327.464,Percent of Total Billed Charges,60% of Total Billed Charges,252.21,45,,870.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.93,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,474.19,32,,432.952,Percent of Total Billed Charges,32% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,201.77,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,201.77,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,201.77,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,336.28,60,,319.752,Percent of Total Billed Charges,60% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.47,100,,1836.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14.42,,21.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.35,75,,824.904,Percent of Total Billed Charges,75% of Total Billed Charges,280.24,50,,365.544,Percent of Total Billed Charges,50% of Total Billed Charges,280.24,50,,549.936,Percent of Total Billed Charges,50% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.24,50,,549.936,Percent of Total Billed Charges,50% of Total Billed Charges,280.24,50,,549.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.33,70,,3276,Percent of Total Billed Charges,70% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.47,14,,20.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560.47,100,,1099.872,Percent of Total Billed Charges,100% of Total Billed Charges,78.47,560.47,
1165839 CARTRIDGE INTELL TRI,32104783,CDM,272,RC,,,Outpatient,,,540,324.00,,324,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,243,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.2,28,,597.64,Percent of Total Billed Charges,28% of Total Billed Charges,475.2,32,,432.992,Percent of Total Billed Charges,32% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,194.4,36,,768.4,Percent of Total Billed Charges,36% of Total Billed Charges,194.4,36,,768.4,Percent of Total Billed Charges,36% Total Bille Charges,194.4,36,,768.4,Percent of Total Billed Charges,36% of Total Billed Charges,324,60,,1608.464,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,100,,34.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,77.87,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,784.08,Percent of Total Billed Charges,75% of Total Billed Charges,270,50,,478.992,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,522.72,Percent of Total Billed Charges,50% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,50,,522.72,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,522.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,70,,410.512,Percent of Total Billed Charges,70% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540,100,,1045.44,Percent of Total Billed Charges,100% of Total Billed Charges,75.6,540,
1163446 CARTRIDGE INTELL TRI,32104784,CDM,272,RC,,,Outpatient,,,507.52,304.51,,304.51,60,,1652.256,Percent of Total Billed Charges,60% of Total Billed Charges,228.38,45,,1840.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.11,28,,901.208,Percent of Total Billed Charges,28% of Total Billed Charges,475.61,32,,434.128,Percent of Total Billed Charges,32% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,182.71,36,,1158.696,Percent of Total Billed Charges,36% of Total Billed Charges,182.71,36,,1158.696,Percent of Total Billed Charges,36% Total Bille Charges,182.71,36,,1158.696,Percent of Total Billed Charges,36% of Total Billed Charges,304.51,60,,1312.744,Percent of Total Billed Charges,60% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.52,100,,2134.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,73.18,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.64,75,,1420.656,Percent of Total Billed Charges,75% of Total Billed Charges,253.76,50,,549.936,Percent of Total Billed Charges,50% of Total Billed Charges,253.76,50,,947.104,Percent of Total Billed Charges,50% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.76,50,,947.104,Percent of Total Billed Charges,50% of Total Billed Charges,253.76,50,,947.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.26,70,,40.624,Percent of Total Billed Charges,70% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.52,100,,1894.208,Percent of Total Billed Charges,100% of Total Billed Charges,71.05,507.52,
1165840 CARTRIDGE INTELL TRI,32104785,CDM,272,RC,,,Outpatient,,,540,324.00,,324,60,,8895.2,Percent of Total Billed Charges,60% of Total Billed Charges,243,45,,248.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.2,28,,758.912,Percent of Total Billed Charges,28% of Total Billed Charges,475.61,32,,434.872,Percent of Total Billed Charges,32% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,194.4,36,,975.744,Percent of Total Billed Charges,36% of Total Billed Charges,194.4,36,,975.744,Percent of Total Billed Charges,36% Total Bille Charges,194.4,36,,975.744,Percent of Total Billed Charges,36% of Total Billed Charges,324,60,,3520.088,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,100,,1933.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,77.87,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,106.2,Percent of Total Billed Charges,75% of Total Billed Charges,270,50,,522.72,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,70.8,Percent of Total Billed Charges,50% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,50,,70.8,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,70.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,70,,369.6,Percent of Total Billed Charges,70% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540,100,,141.6,Percent of Total Billed Charges,100% of Total Billed Charges,75.6,540,
1163439 SIGNIA LOADING UNIT,32104786,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,3679.104,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,164.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,13324.08,Percent of Total Billed Charges,28% of Total Billed Charges,475.61,32,,435.376,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,17130.96,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,17130.96,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,17130.96,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1315.352,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,947.104,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,558.6,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
1163449 RELOAD INTELL TRI STPL,32104787,CDM,272,RC,,,Outpatient,,,976.79,586.07,,586.07,60,,351.68,Percent of Total Billed Charges,60% of Total Billed Charges,439.56,45,,2185.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.5,28,,1027.856,Percent of Total Billed Charges,28% of Total Billed Charges,475.61,32,,435.712,Percent of Total Billed Charges,32% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,351.64,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,351.64,36,,1321.528,Percent of Total Billed Charges,36% Total Bille Charges,351.64,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,586.07,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,976.79,100,,4089.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,140.85,14.42,,91.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,732.59,75,,99.152,Percent of Total Billed Charges,75% of Total Billed Charges,488.4,50,,70.8,Percent of Total Billed Charges,50% of Total Billed Charges,488.4,50,,66.104,Percent of Total Billed Charges,50% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,488.4,50,,66.104,Percent of Total Billed Charges,50% of Total Billed Charges,488.4,50,,66.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,683.75,70,,1853.488,Percent of Total Billed Charges,70% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,136.75,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,976.79,100,,132.2,Percent of Total Billed Charges,100% of Total Billed Charges,136.75,976.79,
1163450 SIGNIA POWER SHELL,32104788,CDM,272,RC,,,Outpatient,,,913.86,548.32,,548.32,60,,15616.104,Percent of Total Billed Charges,60% of Total Billed Charges,411.24,45,,3249.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.88,28,,293.664,Percent of Total Billed Charges,28% of Total Billed Charges,476.16,32,,435.712,Percent of Total Billed Charges,32% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,328.99,36,,377.568,Percent of Total Billed Charges,36% of Total Billed Charges,328.99,36,,377.568,Percent of Total Billed Charges,36% Total Bille Charges,328.99,36,,377.568,Percent of Total Billed Charges,36% of Total Billed Charges,548.32,60,,605.192,Percent of Total Billed Charges,60% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,913.86,100,,551.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,131.78,14.42,,22.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,685.4,75,,110.704,Percent of Total Billed Charges,75% of Total Billed Charges,456.93,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,456.93,50,,73.8,Percent of Total Billed Charges,50% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,456.93,50,,73.8,Percent of Total Billed Charges,50% of Total Billed Charges,456.93,50,,73.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.7,70,,4856.752,Percent of Total Billed Charges,70% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,127.94,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,913.86,100,,147.6,Percent of Total Billed Charges,100% of Total Billed Charges,127.94,913.86,
1145128 RELOAD STPLR TRISTAPLE,32104789,CDM,272,RC,,,Outpatient,,,1197.48,718.49,,718.49,60,,1730.64,Percent of Total Billed Charges,60% of Total Billed Charges,538.87,45,,577.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.29,28,,1484.68,Percent of Total Billed Charges,28% of Total Billed Charges,476.34,32,,435.712,Percent of Total Billed Charges,32% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,431.09,36,,1908.88,Percent of Total Billed Charges,36% of Total Billed Charges,431.09,36,,1908.88,Percent of Total Billed Charges,36% Total Bille Charges,431.09,36,,1908.88,Percent of Total Billed Charges,36% of Total Billed Charges,718.49,60,,4515.368,Percent of Total Billed Charges,60% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1197.48,100,,364.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,172.68,14.42,,22.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,898.11,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,598.74,50,,66.104,Percent of Total Billed Charges,50% of Total Billed Charges,598.74,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.74,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,598.74,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,838.24,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,167.65,14,,21.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1197.48,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,167.65,1197.48,
1145127 RELOAD TRISTAPLE BLACK,32104790,CDM,272,RC,,,Outpatient,,,1374.84,824.90,,824.9,60,,44.672,Percent of Total Billed Charges,60% of Total Billed Charges,618.68,45,,7231.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.96,28,,626.104,Percent of Total Billed Charges,28% of Total Billed Charges,478.08,32,,436.624,Percent of Total Billed Charges,32% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,494.94,36,,804.992,Percent of Total Billed Charges,36% of Total Billed Charges,494.94,36,,804.992,Percent of Total Billed Charges,36% Total Bille Charges,494.94,36,,804.992,Percent of Total Billed Charges,36% of Total Billed Charges,824.9,60,,429,Percent of Total Billed Charges,60% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1374.84,100,,4856.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,198.25,14.42,,25.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1031.13,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,687.42,50,,73.8,Percent of Total Billed Charges,50% of Total Billed Charges,687.42,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.42,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,687.42,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,962.39,70,,1411.2,Percent of Total Billed Charges,70% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,192.48,14,,24.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1374.84,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,192.48,1374.84,
581589 SILS FLEXIBLE PORT,32104791,CDM,272,RC,,,Outpatient,,,1306.8,784.08,,784.08,60,,49.2,Percent of Total Billed Charges,60% of Total Billed Charges,588.06,45,,611.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.9,28,,38.088,Percent of Total Billed Charges,28% of Total Billed Charges,480,32,,436.624,Percent of Total Billed Charges,32% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,470.45,36,,48.968,Percent of Total Billed Charges,36% of Total Billed Charges,470.45,36,,48.968,Percent of Total Billed Charges,36% Total Bille Charges,470.45,36,,48.968,Percent of Total Billed Charges,36% of Total Billed Charges,784.08,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1306.8,100,,7220.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,188.44,14.42,,11.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980.1,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,653.4,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,653.4,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.4,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,653.4,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,914.76,70,,2784.6,Percent of Total Billed Charges,70% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,182.95,14,,11.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1306.8,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,182.95,1306.8,
1166459 SILS FLEXIBLE PORT,32104792,CDM,272,RC,,,Outpatient,,,2367.76,1420.66,,1420.66,60,,38132.144,Percent of Total Billed Charges,60% of Total Billed Charges,1065.49,45,,392.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.97,28,,1045.96,Percent of Total Billed Charges,28% of Total Billed Charges,480.28,32,,436.808,Percent of Total Billed Charges,32% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,852.39,36,,1344.808,Percent of Total Billed Charges,36% of Total Billed Charges,852.39,36,,1344.808,Percent of Total Billed Charges,36% Total Bille Charges,852.39,36,,1344.808,Percent of Total Billed Charges,36% of Total Billed Charges,1420.66,60,,873.432,Percent of Total Billed Charges,60% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2367.76,100,,1282.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,341.43,14.42,,10.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1775.82,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,1183.88,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1183.88,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1183.88,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1183.88,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1657.43,70,,171.36,Percent of Total Billed Charges,70% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.49,14,,9.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2367.76,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,331.49,2367.76,
334471 RELOAD TA DST,32104793,CDM,272,RC,,,Outpatient,,,177,106.20,,106.2,60,,4563.912,Percent of Total Billed Charges,60% of Total Billed Charges,79.65,45,,382.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.56,28,,14.464,Percent of Total Billed Charges,28% of Total Billed Charges,483.2,32,,438.952,Percent of Total Billed Charges,32% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,63.72,36,,18.6,Percent of Total Billed Charges,36% of Total Billed Charges,63.72,36,,18.6,Percent of Total Billed Charges,36% Total Bille Charges,63.72,36,,18.6,Percent of Total Billed Charges,36% of Total Billed Charges,106.2,60,,407.384,Percent of Total Billed Charges,60% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177,100,,16070.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14.42,,8.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.75,75,,474.304,Percent of Total Billed Charges,75% of Total Billed Charges,88.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,88.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,88.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,70,,1630.72,Percent of Total Billed Charges,70% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,24.78,14,,8.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177,100,,632.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.78,483.2,
163209 STAPLER TA DST,32104794,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,4442.88,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,6485.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,207.48,Percent of Total Billed Charges,28% of Total Billed Charges,483.4,32,,438.952,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,266.76,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,266.76,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,266.76,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,2168.56,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1358.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,8.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,117,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,610.816,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,8.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,156,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,483.4,
163210 RELOAD TA DST,32104795,CDM,272,RC,,,Outpatient,,,165.25,99.15,,99.15,60,,5607.912,Percent of Total Billed Charges,60% of Total Billed Charges,74.36,45,,84.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.27,28,,929.664,Percent of Total Billed Charges,28% of Total Billed Charges,483.4,32,,440.32,Percent of Total Billed Charges,32% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,59.49,36,,1195.288,Percent of Total Billed Charges,36% of Total Billed Charges,59.49,36,,1195.288,Percent of Total Billed Charges,36% Total Bille Charges,59.49,36,,1195.288,Percent of Total Billed Charges,36% of Total Billed Charges,99.15,60,,385.944,Percent of Total Billed Charges,60% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.25,100,,872.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.83,14.42,,76.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.94,75,,117,Percent of Total Billed Charges,75% of Total Billed Charges,82.63,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,82.63,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.63,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,82.63,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.68,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14,,73.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.25,100,,156,Percent of Total Billed Charges,100% of Total Billed Charges,23.14,483.4,
163212 RELOAD TA DST,32104796,CDM,272,RC,,,Outpatient,,,184.5,110.70,,110.7,60,,1947.664,Percent of Total Billed Charges,60% of Total Billed Charges,83.03,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.66,28,,1823.496,Percent of Total Billed Charges,28% of Total Billed Charges,485.73,32,,441.6,Percent of Total Billed Charges,32% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,66.42,36,,2344.496,Percent of Total Billed Charges,36% of Total Billed Charges,66.42,36,,2344.496,Percent of Total Billed Charges,36% Total Bille Charges,66.42,36,,2344.496,Percent of Total Billed Charges,36% of Total Billed Charges,110.7,60,,1173.944,Percent of Total Billed Charges,60% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.5,100,,850.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,26.6,14.42,,119.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.38,75,,130.68,Percent of Total Billed Charges,75% of Total Billed Charges,92.25,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,92.25,50,,87.12,Percent of Total Billed Charges,50% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.25,50,,87.12,Percent of Total Billed Charges,50% of Total Billed Charges,92.25,50,,87.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.15,70,,3640,Percent of Total Billed Charges,70% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.83,14,,116.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.5,100,,174.24,Percent of Total Billed Charges,100% of Total Billed Charges,25.83,485.73,
163214 STAPLER TA DST,32104797,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,488.296,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,598.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,345.616,Percent of Total Billed Charges,28% of Total Billed Charges,486.72,32,,441.6,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,444.368,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,444.368,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,444.368,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1770.232,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,14411.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,18.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,61.744,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,78,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,41.16,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,41.16,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,41.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,170.104,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,18.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,82.32,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,486.72,
163215 STAPLER TA DST,32104799,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,853.28,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,488.96,32,,449.792,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1626.24,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,187.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,28.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,53.2,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,87.12,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,35.464,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,35.464,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,35.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,811.192,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,70.928,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,488.96,
1166463 CANNULA VERSAONE UNVSL,32104800,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,935.616,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,781.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,4444.152,Percent of Total Billed Charges,28% of Total Billed Charges,489.92,32,,449.8,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,5713.912,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,5713.912,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,5713.912,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,26172.304,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,1559.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,28.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,43.456,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,41.16,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,28.968,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,28.968,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,28.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,556.08,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,27.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,57.936,Percent of Total Billed Charges,100% of Total Billed Charges,21,489.92,
1166469 CANNULA VERSAONE UNVSL,32104801,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,123.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,2036.68,Percent of Total Billed Charges,28% of Total Billed Charges,491.67,32,,455.08,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,2618.592,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,2618.592,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,2618.592,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,2202.552,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,1329.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,40.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,44.968,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,35.464,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,29.976,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,29.976,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,29.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,6550.544,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,39.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,59.952,Percent of Total Billed Charges,100% of Total Billed Charges,21,491.67,
1166471 CANNULA VERSAONE UNVSL,32104802,CDM,272,RC,,,Outpatient,,,790.5,474.30,,474.3,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,355.73,45,,39.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.34,28,,933.464,Percent of Total Billed Charges,28% of Total Billed Charges,491.93,32,,455.52,Percent of Total Billed Charges,32% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,284.58,36,,1200.168,Percent of Total Billed Charges,36% of Total Billed Charges,284.58,36,,1200.168,Percent of Total Billed Charges,36% Total Bille Charges,284.58,36,,1200.168,Percent of Total Billed Charges,36% of Total Billed Charges,474.3,60,,576.84,Percent of Total Billed Charges,60% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.5,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,113.99,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.88,75,,395.824,Percent of Total Billed Charges,75% of Total Billed Charges,395.25,50,,28.968,Percent of Total Billed Charges,50% of Total Billed Charges,395.25,50,,263.88,Percent of Total Billed Charges,50% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.25,50,,263.88,Percent of Total Billed Charges,50% of Total Billed Charges,395.25,50,,263.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553.35,70,,11198.88,Percent of Total Billed Charges,70% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,790.5,100,,527.76,Percent of Total Billed Charges,100% of Total Billed Charges,110.67,790.5,
1166476 SURGISLEEVE WND PRTCTR,32104803,CDM,272,RC,,,Outpatient,,,195,117.00,,117,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,87.75,45,,123.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.6,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,491.93,32,,455.52,Percent of Total Billed Charges,32% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,70.2,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,70.2,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,70.2,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,117,60,,2916.344,Percent of Total Billed Charges,60% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,100,,1737.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,28.12,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.25,75,,622.944,Percent of Total Billed Charges,75% of Total Billed Charges,97.5,50,,29.976,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,50,,415.296,Percent of Total Billed Charges,50% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,50,,415.296,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,50,,415.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,70,,418.32,Percent of Total Billed Charges,70% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195,100,,830.592,Percent of Total Billed Charges,100% of Total Billed Charges,27.3,491.93,
718180 SURGISLEEVE WND PROTCTR,32104804,CDM,272,RC,,,Outpatient,,,195,117.00,,117,60,,1725.528,Percent of Total Billed Charges,60% of Total Billed Charges,87.75,45,,105.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.6,28,,1269.752,Percent of Total Billed Charges,28% of Total Billed Charges,491.93,32,,455.808,Percent of Total Billed Charges,32% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,70.2,36,,1632.536,Percent of Total Billed Charges,36% of Total Billed Charges,70.2,36,,1632.536,Percent of Total Billed Charges,36% Total Bille Charges,70.2,36,,1632.536,Percent of Total Billed Charges,36% of Total Billed Charges,117,60,,1229.848,Percent of Total Billed Charges,60% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,100,,274.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,28.12,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.25,75,,98.312,Percent of Total Billed Charges,75% of Total Billed Charges,97.5,50,,263.88,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,50,,65.544,Percent of Total Billed Charges,50% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,50,,65.544,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,50,,65.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,70,,1258.32,Percent of Total Billed Charges,70% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195,100,,131.08,Percent of Total Billed Charges,100% of Total Billed Charges,27.3,491.93,
1166479 SURGISLEEVE WND PRTCTR,32104805,CDM,272,RC,,,Outpatient,,,217.8,130.68,,130.68,60,,4563.912,Percent of Total Billed Charges,60% of Total Billed Charges,98.01,45,,1628.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.98,28,,672,Percent of Total Billed Charges,28% of Total Billed Charges,493.74,32,,456.512,Percent of Total Billed Charges,32% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,78.41,36,,864,Percent of Total Billed Charges,36% of Total Billed Charges,78.41,36,,864,Percent of Total Billed Charges,36% Total Bille Charges,78.41,36,,864,Percent of Total Billed Charges,36% of Total Billed Charges,130.68,60,,81.616,Percent of Total Billed Charges,60% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.8,100,,86.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,31.41,14.42,,24.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.35,75,,148.192,Percent of Total Billed Charges,75% of Total Billed Charges,108.9,50,,415.296,Percent of Total Billed Charges,50% of Total Billed Charges,108.9,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.9,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.9,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.46,70,,946.176,Percent of Total Billed Charges,70% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,30.49,14,,24.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.8,100,,197.592,Percent of Total Billed Charges,100% of Total Billed Charges,30.49,493.74,
1163451 STAPLER MULTIFIRE PRM,32104806,CDM,272,RC,,,Outpatient,,,102.9,61.74,,61.74,60,,4157.552,Percent of Total Billed Charges,60% of Total Billed Charges,46.31,45,,6583.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,28,,1456,Percent of Total Billed Charges,28% of Total Billed Charges,493.92,32,,456.512,Percent of Total Billed Charges,32% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.04,36,,1872,Percent of Total Billed Charges,36% of Total Billed Charges,37.04,36,,1872,Percent of Total Billed Charges,36% Total Bille Charges,37.04,36,,1872,Percent of Total Billed Charges,36% of Total Billed Charges,61.74,60,,2054.568,Percent of Total Billed Charges,60% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.9,100,,274.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14.42,,22.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.18,75,,148.856,Percent of Total Billed Charges,75% of Total Billed Charges,51.45,50,,65.544,Percent of Total Billed Charges,50% of Total Billed Charges,51.45,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.45,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,51.45,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.03,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,14.41,14,,21.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.9,100,,198.472,Percent of Total Billed Charges,100% of Total Billed Charges,14.41,493.92,
309267 ENDO PEANUT,32104807,CDM,272,RC,,,Outpatient,,,88.66,53.20,,53.2,60,,1148.4,Percent of Total Billed Charges,60% of Total Billed Charges,39.9,45,,201.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.82,28,,1680,Percent of Total Billed Charges,28% of Total Billed Charges,493.92,32,,456.512,Percent of Total Billed Charges,32% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,36,,2160,Percent of Total Billed Charges,36% of Total Billed Charges,31.92,36,,2160,Percent of Total Billed Charges,36% Total Bille Charges,31.92,36,,2160,Percent of Total Billed Charges,36% of Total Billed Charges,53.2,60,,407.552,Percent of Total Billed Charges,60% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.66,100,,235.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.78,14.42,,43.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.5,75,,209.896,Percent of Total Billed Charges,75% of Total Billed Charges,44.33,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,44.33,50,,139.936,Percent of Total Billed Charges,50% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.33,50,,139.936,Percent of Total Billed Charges,50% of Total Billed Charges,44.33,50,,139.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.06,70,,1688.96,Percent of Total Billed Charges,70% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,12.41,14,,42.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.66,100,,279.864,Percent of Total Billed Charges,100% of Total Billed Charges,12.41,493.92,
1166228 SURGINEEDLE PNEUMOPERI,32104808,CDM,272,RC,,,Outpatient,,,72.42,43.45,,43.45,60,,55144.304,Percent of Total Billed Charges,60% of Total Billed Charges,32.59,45,,196.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.28,28,,3360,Percent of Total Billed Charges,28% of Total Billed Charges,494.49,32,,456.512,Percent of Total Billed Charges,32% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,26.07,36,,4320,Percent of Total Billed Charges,36% of Total Billed Charges,26.07,36,,4320,Percent of Total Billed Charges,36% Total Bille Charges,26.07,36,,4320,Percent of Total Billed Charges,36% of Total Billed Charges,43.45,60,,1826.136,Percent of Total Billed Charges,60% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.42,100,,3619.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14.42,,70.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.32,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,36.21,50,,99.24,Percent of Total Billed Charges,50% of Total Billed Charges,36.21,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.21,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,36.21,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.69,70,,1965.6,Percent of Total Billed Charges,70% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.14,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.42,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,10.14,494.49,
1166272 SURGINEEDLE PNEUMOPERI,32104809,CDM,272,RC,,,Outpatient,,,74.94,44.96,,44.96,60,,4080.8,Percent of Total Billed Charges,60% of Total Billed Charges,33.72,45,,48.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.98,28,,3393.6,Percent of Total Billed Charges,28% of Total Billed Charges,496.17,32,,456.512,Percent of Total Billed Charges,32% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,36,,4363.2,Percent of Total Billed Charges,36% of Total Billed Charges,26.98,36,,4363.2,Percent of Total Billed Charges,36% Total Bille Charges,26.98,36,,4363.2,Percent of Total Billed Charges,36% of Total Billed Charges,44.96,60,,3581.872,Percent of Total Billed Charges,60% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.94,100,,14630.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.81,14.42,,130.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.21,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,37.47,50,,139.936,Percent of Total Billed Charges,50% of Total Billed Charges,37.47,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.47,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,37.47,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.46,70,,4149.6,Percent of Total Billed Charges,70% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14,,126.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.94,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,10.49,496.17,
1167689 STAPLER ENDO TA MLTIFR,32104810,CDM,272,RC,,,Outpatient,,,659.7,395.82,,395.82,60,,10643.624,Percent of Total Billed Charges,60% of Total Billed Charges,296.87,45,,1201.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.72,28,,4368,Percent of Total Billed Charges,28% of Total Billed Charges,497.58,32,,456.96,Percent of Total Billed Charges,32% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,237.49,36,,5616,Percent of Total Billed Charges,36% of Total Billed Charges,237.49,36,,5616,Percent of Total Billed Charges,36% Total Bille Charges,237.49,36,,5616,Percent of Total Billed Charges,36% of Total Billed Charges,395.82,60,,740.608,Percent of Total Billed Charges,60% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.7,100,,448.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,95.13,14.42,,138.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.78,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,329.85,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,329.85,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.85,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,329.85,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.79,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,92.36,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.7,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,92.36,659.7,
580655 RELOAD RADIAL EGIA,32104811,CDM,272,RC,,,Outpatient,,,1038.24,622.94,,622.94,60,,5903.464,Percent of Total Billed Charges,60% of Total Billed Charges,467.21,45,,123.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.71,28,,6048,Percent of Total Billed Charges,28% of Total Billed Charges,498.08,32,,460.8,Percent of Total Billed Charges,32% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,373.77,36,,7776,Percent of Total Billed Charges,36% of Total Billed Charges,373.77,36,,7776,Percent of Total Billed Charges,36% Total Bille Charges,373.77,36,,7776,Percent of Total Billed Charges,36% of Total Billed Charges,622.94,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1038.24,100,,437.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,149.71,14.42,,70.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,778.68,75,,129.608,Percent of Total Billed Charges,75% of Total Billed Charges,519.12,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,519.12,50,,86.408,Percent of Total Billed Charges,50% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,519.12,50,,86.408,Percent of Total Billed Charges,50% of Total Billed Charges,519.12,50,,86.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.77,70,,4368,Percent of Total Billed Charges,70% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,145.35,14,,68.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1038.24,100,,172.808,Percent of Total Billed Charges,100% of Total Billed Charges,145.35,1038.24,
1168422 SURGISLEEVE WND PRTCTR,32104812,CDM,272,RC,,,Outpatient,,,163.85,98.31,,98.31,60,,5903.464,Percent of Total Billed Charges,60% of Total Billed Charges,73.73,45,,101.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.88,28,,7728,Percent of Total Billed Charges,28% of Total Billed Charges,499,32,,460.8,Percent of Total Billed Charges,32% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,58.99,36,,9936,Percent of Total Billed Charges,36% of Total Billed Charges,58.99,36,,9936,Percent of Total Billed Charges,36% Total Bille Charges,58.99,36,,9936,Percent of Total Billed Charges,36% of Total Billed Charges,98.31,60,,3311.168,Percent of Total Billed Charges,60% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.85,100,,107.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,23.63,14.42,,341.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.89,75,,117.752,Percent of Total Billed Charges,75% of Total Billed Charges,81.93,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,81.93,50,,78.504,Percent of Total Billed Charges,50% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.93,50,,78.504,Percent of Total Billed Charges,50% of Total Billed Charges,81.93,50,,78.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.7,70,,2346.224,Percent of Total Billed Charges,70% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,22.94,14,,331.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.85,100,,157,Percent of Total Billed Charges,100% of Total Billed Charges,22.94,499,
1159609 CLIP APPLIER PREMIUM,32104813,CDM,272,RC,,,Outpatient,,,246.99,148.19,,148.19,60,,2045.92,Percent of Total Billed Charges,60% of Total Billed Charges,111.15,45,,20116.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.16,28,,22.4,Percent of Total Billed Charges,28% of Total Billed Charges,500.21,32,,461.568,Percent of Total Billed Charges,32% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,88.92,36,,28.8,Percent of Total Billed Charges,36% of Total Billed Charges,88.92,36,,28.8,Percent of Total Billed Charges,36% Total Bille Charges,88.92,36,,28.8,Percent of Total Billed Charges,36% of Total Billed Charges,148.19,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.99,100,,2669.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,35.62,14.42,,14.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.24,75,,228.312,Percent of Total Billed Charges,75% of Total Billed Charges,123.5,50,,86.408,Percent of Total Billed Charges,50% of Total Billed Charges,123.5,50,,152.208,Percent of Total Billed Charges,50% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.5,50,,152.208,Percent of Total Billed Charges,50% of Total Billed Charges,123.5,50,,152.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.89,70,,3749.2,Percent of Total Billed Charges,70% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,34.58,14,,13.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.99,100,,304.416,Percent of Total Billed Charges,100% of Total Billed Charges,34.58,500.21,
1159747 CLIP APPLIER PREMIUM,32104914,CDM,272,RC,,,Outpatient,,,248.09,148.85,,148.85,60,,2045.92,Percent of Total Billed Charges,60% of Total Billed Charges,111.64,45,,1957.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.47,28,,23.52,Percent of Total Billed Charges,28% of Total Billed Charges,501.12,32,,461.568,Percent of Total Billed Charges,32% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,89.31,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,89.31,36,,30.24,Percent of Total Billed Charges,36% Total Bille Charges,89.31,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,148.85,60,,8729.584,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.09,100,,274.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,35.77,14.42,,897.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.07,75,,391.68,Percent of Total Billed Charges,75% of Total Billed Charges,124.05,50,,78.504,Percent of Total Billed Charges,50% of Total Billed Charges,124.05,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.05,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,124.05,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.66,70,,2011.104,Percent of Total Billed Charges,70% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,34.73,14,,871.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.09,100,,489.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.73,501.12,
1159901 RELIACATCH BAG RETRVL,32104915,CDM,272,RC,,,Outpatient,,,349.83,209.90,,209.9,60,,396,Percent of Total Billed Charges,60% of Total Billed Charges,157.42,45,,1002.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.95,28,,24.64,Percent of Total Billed Charges,28% of Total Billed Charges,504,32,,464.688,Percent of Total Billed Charges,32% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,125.94,36,,31.68,Percent of Total Billed Charges,36% of Total Billed Charges,125.94,36,,31.68,Percent of Total Billed Charges,36% Total Bille Charges,125.94,36,,31.68,Percent of Total Billed Charges,36% of Total Billed Charges,209.9,60,,4000.624,Percent of Total Billed Charges,60% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.83,100,,225.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,50.45,14.42,,1229.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.37,75,,677.288,Percent of Total Billed Charges,75% of Total Billed Charges,174.92,50,,152.208,Percent of Total Billed Charges,50% of Total Billed Charges,174.92,50,,451.528,Percent of Total Billed Charges,50% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.92,50,,451.528,Percent of Total Billed Charges,50% of Total Billed Charges,174.92,50,,451.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.88,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.98,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.83,100,,903.048,Percent of Total Billed Charges,100% of Total Billed Charges,48.98,504,
163213 STAPLER TA DST,32104916,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,2516.8,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,506.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,42.024,Percent of Total Billed Charges,28% of Total Billed Charges,504,32,,467.808,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,54.032,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,54.032,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,54.032,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1833.584,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,44703.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,720,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,244.8,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,5500.768,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,960,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,504,
117864 STAPLER TA DST,32104917,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,467.808,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,14683.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,42.336,Percent of Total Billed Charges,28% of Total Billed Charges,506.79,32,,468.48,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,54.432,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,54.432,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,54.432,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,4350.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,323.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,365.128,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,451.528,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,243.424,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,243.424,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,243.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,371.032,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,486.84,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,506.79,
163211 STAPLER DST TA,32104918,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,379.704,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,68.544,Percent of Total Billed Charges,28% of Total Billed Charges,506.79,32,,468.912,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,88.128,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,88.128,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,88.128,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,2494.152,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2228.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,599.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1775.28,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1183.52,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1183.52,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1183.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,373.048,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2367.04,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,506.79,
480295 LOADING UNIT RELOAD TA,32104919,CDM,272,RC,,,Outpatient,,,216.01,129.61,,129.61,60,,467.808,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,45,,252.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.48,28,,90.72,Percent of Total Billed Charges,28% of Total Billed Charges,506.79,32,,470.552,Percent of Total Billed Charges,32% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,77.76,36,,116.64,Percent of Total Billed Charges,36% of Total Billed Charges,77.76,36,,116.64,Percent of Total Billed Charges,36% Total Bille Charges,77.76,36,,116.64,Percent of Total Billed Charges,36% of Total Billed Charges,129.61,60,,1440,Percent of Total Billed Charges,60% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.01,100,,1126.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,31.15,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.01,75,,74.448,Percent of Total Billed Charges,75% of Total Billed Charges,108.01,50,,243.424,Percent of Total Billed Charges,50% of Total Billed Charges,108.01,50,,49.632,Percent of Total Billed Charges,50% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.01,50,,49.632,Percent of Total Billed Charges,50% of Total Billed Charges,108.01,50,,49.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.21,70,,2047.136,Percent of Total Billed Charges,70% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,30.24,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.01,100,,99.264,Percent of Total Billed Charges,100% of Total Billed Charges,30.24,506.79,
119356 LOADING UNIT RELOAD TA,32104920,CDM,272,RC,,,Outpatient,,,196.25,117.75,,117.75,60,,608.152,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,45,,160.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,28,,116.032,Percent of Total Billed Charges,28% of Total Billed Charges,506.79,32,,470.552,Percent of Total Billed Charges,32% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,70.65,36,,149.184,Percent of Total Billed Charges,36% of Total Billed Charges,70.65,36,,149.184,Percent of Total Billed Charges,36% Total Bille Charges,70.65,36,,149.184,Percent of Total Billed Charges,36% of Total Billed Charges,117.75,60,,3120,Percent of Total Billed Charges,60% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.25,100,,32630.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,28.3,14.42,,329.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.19,75,,4670.272,Percent of Total Billed Charges,75% of Total Billed Charges,98.13,50,,1183.52,Percent of Total Billed Charges,50% of Total Billed Charges,98.13,50,,3113.512,Percent of Total Billed Charges,50% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.13,50,,3113.512,Percent of Total Billed Charges,50% of Total Billed Charges,98.13,50,,3113.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.38,70,,1670.76,Percent of Total Billed Charges,70% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.48,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.25,100,,6227.024,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,506.79,
174866 STAPLER TA DST,32104921,CDM,272,RC,,,Outpatient,,,380.52,228.31,,228.31,60,,1209.52,Percent of Total Billed Charges,60% of Total Billed Charges,171.23,45,,1334.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.55,28,,2352,Percent of Total Billed Charges,28% of Total Billed Charges,506.79,32,,472.992,Percent of Total Billed Charges,32% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,136.99,36,,3024,Percent of Total Billed Charges,36% of Total Billed Charges,136.99,36,,3024,Percent of Total Billed Charges,36% Total Bille Charges,136.99,36,,3024,Percent of Total Billed Charges,36% of Total Billed Charges,228.31,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.52,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.87,14.42,,329.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.39,75,,6822.4,Percent of Total Billed Charges,75% of Total Billed Charges,190.26,50,,49.632,Percent of Total Billed Charges,50% of Total Billed Charges,190.26,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.26,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,190.26,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.36,70,,4480.112,Percent of Total Billed Charges,70% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,53.27,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.52,100,,8528,Percent of Total Billed Charges,100% of Total Billed Charges,53.27,506.79,
0000835 CEMENT STRYKER SIMPLEX,32105440,CDM,278,RC,C1713,HCPCS,Outpatient,,,612,367.20,,990.46,110,,60.4,Percent of Total Billed Charges,110% of Total Billed Charges,275.4,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.36,28,,2576,Percent of Total Billed Charges,28% of Total Billed Charges,508.8,32,,472.992,Percent of Total Billed Charges,32% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,220.32,36,,3312,Percent of Total Billed Charges,36% of Total Billed Charges,220.32,36,,3312,Percent of Total Billed Charges,36% Total Bille Charges,220.32,36,,3312,Percent of Total Billed Charges,36% of Total Billed Charges,336.6,55,,7200,Percent of Total Billed Charges,55% Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612,100,,561.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,88.25,14.42,,4037.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,489.6,80,,240,Percent of Total Billed Charges,80% of Total Billed Charges,306,50,,3113.512,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,306,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.4,70,,1674.08,Percent of Total Billed Charges,70% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,3920,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,85.68,990.46,
607975 CATHETER NEPHRO,32105441,CDM,272,RC,C1726,HCPCS,Outpatient,,,1128.81,677.29,,396.8,100,,95.48,Fee Schedule,100% of Aetna Fee Schedule,507.96,45,,5867.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.07,28,,3696,Percent of Total Billed Charges,28% of Total Billed Charges,510.09,32,,472.992,Percent of Total Billed Charges,32% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.37,36,,4752,Percent of Total Billed Charges,36% of Total Billed Charges,406.37,36,,4752,Percent of Total Billed Charges,36% Total Bille Charges,406.37,36,,4752,Percent of Total Billed Charges,36% of Total Billed Charges,677.29,60,,7272,Percent of Total Billed Charges,60% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.81,100,,356.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,162.77,14.42,,4014.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,846.61,75,,1792,Percent of Total Billed Charges,75% of Total Billed Charges,564.41,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,564.41,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,564.41,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,564.41,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,790.17,70,,7280,Percent of Total Billed Charges,70% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.03,14,,3897.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1128.81,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,158.03,1128.81,
1025065 LASER FIBER,32105442,CDM,272,RC,,,Outpatient,,,1200,720.00,,720,60,,95.48,Percent of Total Billed Charges,60% of Total Billed Charges,540,45,,47.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336,28,,4256,Percent of Total Billed Charges,28% of Total Billed Charges,510.38,32,,473.296,Percent of Total Billed Charges,32% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,432,36,,5472,Percent of Total Billed Charges,36% of Total Billed Charges,432,36,,5472,Percent of Total Billed Charges,36% Total Bille Charges,432,36,,5472,Percent of Total Billed Charges,36% of Total Billed Charges,720,60,,9360,Percent of Total Billed Charges,60% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1200,100,,2964.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,173.04,14.42,,19.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900,75,,3328,Percent of Total Billed Charges,75% of Total Billed Charges,600,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,70,,706.056,Percent of Total Billed Charges,70% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200,100,,4160,Percent of Total Billed Charges,100% of Total Billed Charges,168,1200,
552267 RELOAD 45 CURV,32105443,CDM,272,RC,,,Outpatient,,,608.55,365.13,,365.13,60,,70.36,Percent of Total Billed Charges,60% of Total Billed Charges,273.85,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.39,28,,5264,Percent of Total Billed Charges,28% of Total Billed Charges,511.11,32,,475.12,Percent of Total Billed Charges,32% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,219.08,36,,6768,Percent of Total Billed Charges,36% of Total Billed Charges,219.08,36,,6768,Percent of Total Billed Charges,36% Total Bille Charges,219.08,36,,6768,Percent of Total Billed Charges,36% of Total Billed Charges,365.13,60,,12960,Percent of Total Billed Charges,60% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,608.55,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,87.75,14.42,,619.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,456.41,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,304.28,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,304.28,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.28,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,304.28,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.99,70,,5746.832,Percent of Total Billed Charges,70% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.2,14,,601.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,608.55,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,85.2,608.55,
778602 DEVICE HOLOGIC NOVASURE,32105444,CDM,272,RC,,,Outpatient,,,2958.8,1775.28,,1775.28,60,,112.568,Percent of Total Billed Charges,60% of Total Billed Charges,1331.46,45,,1917.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.46,28,,6944,Percent of Total Billed Charges,28% of Total Billed Charges,511.11,32,,475.6,Percent of Total Billed Charges,32% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,1065.17,36,,8928,Percent of Total Billed Charges,36% of Total Billed Charges,1065.17,36,,8928,Percent of Total Billed Charges,36% Total Bille Charges,1065.17,36,,8928,Percent of Total Billed Charges,36% of Total Billed Charges,1775.28,60,,16560,Percent of Total Billed Charges,60% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2958.8,100,,13038.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,426.66,14.42,,344.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2219.1,75,,1716,Percent of Total Billed Charges,75% of Total Billed Charges,1479.4,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,1479.4,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1479.4,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,1479.4,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2071.16,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,414.23,14,,334.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2958.8,100,,2288,Percent of Total Billed Charges,100% of Total Billed Charges,414.23,2958.8,
1120897 TRAY CATH SURESTEP LAT,32105445,CDM,272,RC,,,Outpatient,,,124.08,74.45,,74.45,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,55.84,45,,1917.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.74,28,,8624,Percent of Total Billed Charges,28% of Total Billed Charges,511.11,32,,476.16,Percent of Total Billed Charges,32% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,44.67,36,,11088,Percent of Total Billed Charges,36% of Total Billed Charges,44.67,36,,11088,Percent of Total Billed Charges,36% Total Bille Charges,44.67,36,,11088,Percent of Total Billed Charges,36% of Total Billed Charges,74.45,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.08,100,,105.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.89,14.42,,457.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,75,,1716,Percent of Total Billed Charges,75% of Total Billed Charges,62.04,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,62.04,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.04,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,62.04,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.86,70,,546,Percent of Total Billed Charges,70% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,17.37,14,,444.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.08,100,,2288,Percent of Total Billed Charges,100% of Total Billed Charges,17.37,511.11,
1045951 BONE TAMP KIT,32105446,CDM,272,RC,,,Outpatient,,,7783.78,4670.27,,4670.27,60,,51.344,Percent of Total Billed Charges,60% of Total Billed Charges,3502.7,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2179.46,28,,35.392,Percent of Total Billed Charges,28% of Total Billed Charges,511.11,32,,478.072,Percent of Total Billed Charges,32% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,2802.16,36,,45.504,Percent of Total Billed Charges,36% of Total Billed Charges,2802.16,36,,45.504,Percent of Total Billed Charges,36% Total Bille Charges,2802.16,36,,45.504,Percent of Total Billed Charges,36% of Total Billed Charges,4670.27,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7783.78,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1122.42,14.42,,229.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5837.84,75,,22400,Percent of Total Billed Charges,75% of Total Billed Charges,3891.89,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,3891.89,50,,14000,Percent of Total Billed Charges,50% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3891.89,50,,14000,Percent of Total Billed Charges,50% of Total Billed Charges,3891.89,50,,14000,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5448.65,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,1089.73,14,,223.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7783.78,100,,28000,Percent of Total Billed Charges,100% of Total Billed Charges,511.11,7783.78,
1120112 STEM CELL OSTEOVIVE,32105447,CDM,278,RC,,,Outpatient,,,10660,6396.00,,11726,110,,180.112,Percent of Total Billed Charges,110% of Total Billed Charges,4797,45,,60.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2984.8,28,,40.096,Percent of Total Billed Charges,28% of Total Billed Charges,511.67,32,,479.032,Percent of Total Billed Charges,32% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,3837.6,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,3837.6,36,,51.552,Percent of Total Billed Charges,36% Total Bille Charges,3837.6,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,5863,55,,52.8,Percent of Total Billed Charges,55% Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10660,100,,4261.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1537.17,14.42,,88.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8528,80,,22272,Percent of Total Billed Charges,80% of Total Billed Charges,5330,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,5330,50,,13920,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5330,50,,13920,Percent of Total Billed Charges,50% of Total Billed Charges,5330,50,,13920,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7462,70,,1111.64,Percent of Total Billed Charges,70% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,86.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10660,100,,27840,Percent of Total Billed Charges,100% of Total Billed Charges,511.67,11726,
1175577 CEMENT COBALT HV BONE,32105448,CDM,278,RC,C1713,HCPCS,Outpatient,,,375,225.00,,729.76,110,,180.112,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,52.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,511.67,32,,479.232,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,4261.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,28.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,102.304,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,14000,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,518.488,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,27.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,136.4,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,729.76,
1179327 CORTICAL FIBERS 10CC,32105449,CDM,278,RC,,,Outpatient,,,2800,1680.00,,3080,110,,180.112,Percent of Total Billed Charges,110% of Total Billed Charges,1260,45,,80.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784,28,,53.76,Percent of Total Billed Charges,28% of Total Billed Charges,511.67,32,,480,Percent of Total Billed Charges,32% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1008,36,,69.12,Percent of Total Billed Charges,36% of Total Billed Charges,1008,36,,69.12,Percent of Total Billed Charges,36% Total Bille Charges,1008,36,,69.12,Percent of Total Billed Charges,36% of Total Billed Charges,1540,55,,90.72,Percent of Total Billed Charges,55% Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2800,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,403.76,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2240,80,,1523.2,Percent of Total Billed Charges,80% of Total Billed Charges,1400,50,,13920,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,2149.072,Percent of Total Billed Charges,50% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,50,,2149.072,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,2149.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1960,70,,2759.992,Percent of Total Billed Charges,70% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2800,100,,1904,Percent of Total Billed Charges,100% of Total Billed Charges,392,3080,
1179329 KIT 12 ELECTRODE LEAD,32105450,CDM,278,RC,C1778,HCPCS,Outpatient,,,5200,3120.00,,6302.6,110,,333.312,Percent of Total Billed Charges,110% of Total Billed Charges,2340,45,,122.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1456,28,,79.072,Percent of Total Billed Charges,28% of Total Billed Charges,511.67,32,,480.984,Percent of Total Billed Charges,32% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,1872,36,,101.664,Percent of Total Billed Charges,36% of Total Billed Charges,1872,36,,101.664,Percent of Total Billed Charges,36% Total Bille Charges,1872,36,,101.664,Percent of Total Billed Charges,36% of Total Billed Charges,2860,55,,146.88,Percent of Total Billed Charges,55% Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5200,100,,133.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,749.84,14.42,,1229.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4160,80,,3438.512,Percent of Total Billed Charges,80% of Total Billed Charges,2600,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,2600,50,,1196,Percent of Total Billed Charges,50% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2600,50,,1196,Percent of Total Billed Charges,50% of Total Billed Charges,2600,50,,1196,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,70,,491.2,Percent of Total Billed Charges,70% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,1193.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5200,100,,4298.136,Percent of Total Billed Charges,100% of Total Billed Charges,511.67,6302.6,
1178802 PAD POLAR KNEE WRAP,32105451,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,2496,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,790.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,104.16,Percent of Total Billed Charges,28% of Total Billed Charges,512.07,32,,483.84,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,133.92,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,133.92,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,133.92,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,194.4,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,116.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,185.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,1913.6,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,2149.072,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1587.232,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,1587.232,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1587.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,1494.112,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,179.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,2392,Percent of Total Billed Charges,100% of Total Billed Charges,21,512.07,
1179336 PROGRAMMER/CHARGER,32105452,CDM,272,RC,C1787,HCPCS,Outpatient,,,2860,1716.00,,59.4,100,,514.592,Fee Schedule,100% of Aetna Fee Schedule,1287,45,,2519.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.8,28,,129.472,Percent of Total Billed Charges,28% of Total Billed Charges,512.43,32,,483.84,Percent of Total Billed Charges,32% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,1029.6,36,,166.464,Percent of Total Billed Charges,36% of Total Billed Charges,1029.6,36,,166.464,Percent of Total Billed Charges,36% Total Bille Charges,1029.6,36,,166.464,Percent of Total Billed Charges,36% of Total Billed Charges,1716,60,,248.64,Percent of Total Billed Charges,60% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2860,100,,179.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,412.41,14.42,,373.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2145,75,,2539.568,Percent of Total Billed Charges,75% of Total Billed Charges,1430,50,,1196,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1430,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2002,70,,2253.024,Percent of Total Billed Charges,70% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,363.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2860,100,,3174.456,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,2860,
1179339 REMOTE PROGRAMMER,32105453,CDM,272,RC,C1787,HCPCS,Outpatient,,,2860,1716.00,,59.4,100,,570.728,Fee Schedule,100% of Aetna Fee Schedule,1287,45,,407.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.8,28,,77.04,Percent of Total Billed Charges,28% of Total Billed Charges,512.43,32,,483.84,Percent of Total Billed Charges,32% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,1029.6,36,,99.048,Percent of Total Billed Charges,36% of Total Billed Charges,1029.6,36,,99.048,Percent of Total Billed Charges,36% Total Bille Charges,1029.6,36,,99.048,Percent of Total Billed Charges,36% of Total Billed Charges,1716,60,,5040,Percent of Total Billed Charges,60% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2860,100,,272.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,412.41,14.42,,40.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2145,75,,1274.88,Percent of Total Billed Charges,75% of Total Billed Charges,1430,50,,1587.232,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,308.368,Percent of Total Billed Charges,50% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1430,50,,308.368,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,308.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2002,70,,1897.28,Percent of Total Billed Charges,70% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,39.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2860,100,,1593.6,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,2860,
1179328 BATTERY IPG STIMULATOR,32105454,CDM,278,RC,C1820,HCPCS,Outpatient,,,35000,21000.00,,40130.18,110,,65.352,Percent of Total Billed Charges,110% of Total Billed Charges,15750,45,,359.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9800,28,,11.24,Percent of Total Billed Charges,28% of Total Billed Charges,512.43,32,,483.84,Percent of Total Billed Charges,32% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,12600,36,,14.456,Percent of Total Billed Charges,36% of Total Billed Charges,12600,36,,14.456,Percent of Total Billed Charges,36% Total Bille Charges,12600,36,,14.456,Percent of Total Billed Charges,36% of Total Billed Charges,19250,55,,5520,Percent of Total Billed Charges,55% Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35000,100,,1755.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,5047,14.42,,21.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28000,80,,462.544,Percent of Total Billed Charges,80% of Total Billed Charges,17500,50,,796.8,Percent of Total Billed Charges,50% of Total Billed Charges,17500,50,,99.464,Percent of Total Billed Charges,50% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17500,50,,99.464,Percent of Total Billed Charges,50% of Total Billed Charges,17500,50,,99.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24500,70,,33310.2,Percent of Total Billed Charges,70% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,4900,14,,20.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35000,100,,616.728,Percent of Total Billed Charges,100% of Total Billed Charges,512.43,40130.18,
1179326 BATTERY SENSOR,32105455,CDM,278,RC,C1820,HCPCS,Outpatient,,,34800,20880.00,,39910.18,110,,1325.872,Percent of Total Billed Charges,110% of Total Billed Charges,15660,45,,903.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9744,28,,17.336,Percent of Total Billed Charges,28% of Total Billed Charges,513.03,32,,483.84,Percent of Total Billed Charges,32% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,12528,36,,22.288,Percent of Total Billed Charges,36% of Total Billed Charges,12528,36,,22.288,Percent of Total Billed Charges,36% Total Bille Charges,12528,36,,22.288,Percent of Total Billed Charges,36% of Total Billed Charges,19140,55,,7920,Percent of Total Billed Charges,55% Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34800,100,,5599.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,5018.16,14.42,,616.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27840,80,,149.192,Percent of Total Billed Charges,80% of Total Billed Charges,17400,50,,308.368,Percent of Total Billed Charges,50% of Total Billed Charges,17400,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17400,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,17400,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24360,70,,2569.648,Percent of Total Billed Charges,70% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,4872,14,,598.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34800,100,,198.92,Percent of Total Billed Charges,100% of Total Billed Charges,513.03,39910.18,
413799 DRESSING GRANUFOAM VAC,32105456,CDM,272,RC,,,Outpatient,,,170.5,102.30,,102.3,60,,11099.52,Percent of Total Billed Charges,60% of Total Billed Charges,76.73,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.74,28,,5.536,Percent of Total Billed Charges,28% of Total Billed Charges,513.62,32,,485.624,Percent of Total Billed Charges,32% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,61.38,36,,7.12,Percent of Total Billed Charges,36% of Total Billed Charges,61.38,36,,7.12,Percent of Total Billed Charges,36% Total Bille Charges,61.38,36,,7.12,Percent of Total Billed Charges,36% of Total Billed Charges,102.3,60,,9120,Percent of Total Billed Charges,60% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.5,100,,906.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,24.59,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.88,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,85.25,50,,99.464,Percent of Total Billed Charges,50% of Total Billed Charges,85.25,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.25,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,85.25,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.35,70,,734.16,Percent of Total Billed Charges,70% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.5,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,23.87,513.62,
819714 AMNIO 2X2 MEMBRANE,32105457,CDM,278,RC,Q4151,HCPCS,Outpatient,,,2380,1428.00,,2746.83,110,,205.288,Percent of Total Billed Charges,110% of Total Billed Charges,1071,45,,535.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.4,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,514.81,32,,485.624,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,856.8,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,856.8,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,856.8,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,1309,55,,11280,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2380,100,,799.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1904,80,,6822.4,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,240,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,642.024,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,642.024,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,642.024,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1666,70,,3711.712,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2380,100,,8528,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,2746.83,
128384 GRAFT DURAGEN,32105458,CDM,278,RC,,,Outpatient,,,5372.67,3223.60,,5909.94,110,,42862.944,Percent of Total Billed Charges,110% of Total Billed Charges,2417.7,45,,429.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1504.35,28,,10.472,Percent of Total Billed Charges,28% of Total Billed Charges,514.96,32,,486.008,Percent of Total Billed Charges,32% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,1934.16,36,,13.464,Percent of Total Billed Charges,36% of Total Billed Charges,1934.16,36,,13.464,Percent of Total Billed Charges,36% Total Bille Charges,1934.16,36,,13.464,Percent of Total Billed Charges,36% of Total Billed Charges,2954.97,55,,14880,Percent of Total Billed Charges,55% Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5372.67,100,,2007.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,774.74,14.42,,172.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4298.14,80,,1027.24,Percent of Total Billed Charges,80% of Total Billed Charges,2686.34,50,,4264,Percent of Total Billed Charges,50% of Total Billed Charges,2686.34,50,,1296.536,Percent of Total Billed Charges,50% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2686.34,50,,1296.536,Percent of Total Billed Charges,50% of Total Billed Charges,2686.34,50,,1296.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3760.87,70,,1565.256,Percent of Total Billed Charges,70% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,752.17,14,,167.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5372.67,100,,1284.048,Percent of Total Billed Charges,100% of Total Billed Charges,514.96,5909.94,
1175174 SPACER CORTICAL,32105459,CDM,278,RC,,,Outpatient,,,2990,1794.00,,3289,110,,6497.592,Percent of Total Billed Charges,110% of Total Billed Charges,1345.5,45,,115.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,837.2,28,,596.84,Percent of Total Billed Charges,28% of Total Billed Charges,515.99,32,,486.008,Percent of Total Billed Charges,32% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,1076.4,36,,767.368,Percent of Total Billed Charges,36% of Total Billed Charges,1076.4,36,,767.368,Percent of Total Billed Charges,36% Total Bille Charges,1076.4,36,,767.368,Percent of Total Billed Charges,36% of Total Billed Charges,1644.5,55,,18480,Percent of Total Billed Charges,55% Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2990,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,431.16,14.42,,125.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2392,80,,1944.808,Percent of Total Billed Charges,80% of Total Billed Charges,1495,50,,642.024,Percent of Total Billed Charges,50% of Total Billed Charges,1495,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1495,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,1495,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2093,70,,95.216,Percent of Total Billed Charges,70% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,418.6,14,,122.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2990,100,,2593.072,Percent of Total Billed Charges,100% of Total Billed Charges,418.6,3289,
128383 GRAFT DRUAGEN PLUS,32105460,CDM,278,RC,,,Outpatient,,,3968.07,2380.84,,4364.88,110,,3985.016,Percent of Total Billed Charges,110% of Total Billed Charges,1785.63,45,,118.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1111.06,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,515.99,32,,487.56,Percent of Total Billed Charges,32% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,1428.51,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1428.51,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,1428.51,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,2182.44,55,,75.84,Percent of Total Billed Charges,55% Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3968.07,100,,1189.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,572.2,14.42,,13.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3174.46,80,,210,Percent of Total Billed Charges,80% of Total Billed Charges,1984.04,50,,1296.536,Percent of Total Billed Charges,50% of Total Billed Charges,1984.04,50,,73.84,Percent of Total Billed Charges,50% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1984.04,50,,73.84,Percent of Total Billed Charges,50% of Total Billed Charges,1984.04,50,,73.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2777.65,70,,2614.912,Percent of Total Billed Charges,70% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,555.53,14,,12.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3968.07,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,515.99,4364.88,
800344 BONE ISOTIS ACCELL EVO3,32105461,CDM,278,RC,C1713,HCPCS,Outpatient,,,1992,1195.20,,2508.46,110,,126.696,Percent of Total Billed Charges,110% of Total Billed Charges,896.4,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,557.76,28,,22.624,Percent of Total Billed Charges,28% of Total Billed Charges,516.15,32,,489.472,Percent of Total Billed Charges,32% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,717.12,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,717.12,36,,29.088,Percent of Total Billed Charges,36% Total Bille Charges,717.12,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,1095.6,55,,85.92,Percent of Total Billed Charges,55% Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1992,100,,955.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,287.25,14.42,,125.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1593.6,80,,110.76,Percent of Total Billed Charges,80% of Total Billed Charges,996,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,996,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,996,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,996,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1394.4,70,,36.16,Percent of Total Billed Charges,70% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,278.88,14,,121.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1992,100,,147.68,Percent of Total Billed Charges,100% of Total Billed Charges,278.88,2508.46,
689187 ACCUDRAIN CSF EXT,32105462,CDM,272,RC,,,Outpatient,,,770.91,462.55,,462.55,60,,126.696,Percent of Total Billed Charges,60% of Total Billed Charges,346.91,45,,4107.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.85,28,,94.08,Percent of Total Billed Charges,28% of Total Billed Charges,516.18,32,,490.496,Percent of Total Billed Charges,32% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,277.53,36,,120.96,Percent of Total Billed Charges,36% of Total Billed Charges,277.53,36,,120.96,Percent of Total Billed Charges,36% Total Bille Charges,277.53,36,,120.96,Percent of Total Billed Charges,36% of Total Billed Charges,462.55,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,770.91,100,,256.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,111.17,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,578.18,75,,3417.856,Percent of Total Billed Charges,75% of Total Billed Charges,385.46,50,,73.84,Percent of Total Billed Charges,50% of Total Billed Charges,385.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,385.46,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,539.64,70,,518.704,Percent of Total Billed Charges,70% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,770.91,100,,4272.32,Percent of Total Billed Charges,100% of Total Billed Charges,107.93,770.91,
847864 BAG DRAINAGE CSF EXT,32105463,CDM,272,RC,,,Outpatient,,,248.65,149.19,,149.19,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,111.89,45,,127.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.62,28,,218.312,Percent of Total Billed Charges,28% of Total Billed Charges,516.18,32,,490.496,Percent of Total Billed Charges,32% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,89.51,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,89.51,36,,280.688,Percent of Total Billed Charges,36% Total Bille Charges,89.51,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,149.19,60,,115.2,Percent of Total Billed Charges,60% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.65,100,,263.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,35.86,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.49,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,124.33,50,,2136.16,Percent of Total Billed Charges,50% of Total Billed Charges,124.33,50,,8800,Percent of Total Billed Charges,50% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.33,50,,8800,Percent of Total Billed Charges,50% of Total Billed Charges,124.33,50,,8800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.06,70,,2324.168,Percent of Total Billed Charges,70% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,34.81,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.65,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,34.81,516.18,
1189470 CATHETER LUMBAR DR,32105464,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,121.104,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,698.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,156.824,Percent of Total Billed Charges,28% of Total Billed Charges,516.91,32,,492.76,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,201.624,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,201.624,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,201.624,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,169.44,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,66.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,14080,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,597.6,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,597.6,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,597.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,4558.744,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,64.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,17600,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
1193216 OSTEOVIVE 5CC,32105465,CDM,278,RC,,,Outpatient,,,10660,6396.00,,11726,110,,8905.544,Percent of Total Billed Charges,110% of Total Billed Charges,4797,45,,2600.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2984.8,28,,7.336,Percent of Total Billed Charges,28% of Total Billed Charges,519.93,32,,492.76,Percent of Total Billed Charges,32% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,3837.6,36,,9.432,Percent of Total Billed Charges,36% of Total Billed Charges,3837.6,36,,9.432,Percent of Total Billed Charges,36% Total Bille Charges,3837.6,36,,9.432,Percent of Total Billed Charges,36% of Total Billed Charges,5863,55,,223.2,Percent of Total Billed Charges,55% Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10660,100,,9127.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1537.17,14.42,,113.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8528,80,,956.16,Percent of Total Billed Charges,80% of Total Billed Charges,5330,50,,8800,Percent of Total Billed Charges,50% of Total Billed Charges,5330,50,,436.36,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5330,50,,436.36,Percent of Total Billed Charges,50% of Total Billed Charges,5330,50,,436.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7462,70,,864.048,Percent of Total Billed Charges,70% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,1492.4,14,,110.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10660,100,,1195.2,Percent of Total Billed Charges,100% of Total Billed Charges,519.93,11726,
883023 RESERVOIR ACCU-FLO,32105466,CDM,278,RC,,,Outpatient,,,1605.06,963.04,,1765.57,110,,8905.544,Percent of Total Billed Charges,110% of Total Billed Charges,722.28,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,449.42,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,522.39,32,,494.312,Percent of Total Billed Charges,32% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,577.82,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,577.82,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,577.82,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,882.78,55,,277.44,Percent of Total Billed Charges,55% Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1605.06,100,,282.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,231.45,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1284.05,80,,698.168,Percent of Total Billed Charges,80% of Total Billed Charges,802.53,50,,597.6,Percent of Total Billed Charges,50% of Total Billed Charges,802.53,50,,46.368,Percent of Total Billed Charges,50% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,802.53,50,,46.368,Percent of Total Billed Charges,50% of Total Billed Charges,802.53,50,,46.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1123.54,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,224.71,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1605.06,100,,872.712,Percent of Total Billed Charges,100% of Total Billed Charges,224.71,1765.57,
1087111 DEVICE MYOSURE TISS,32105468,CDM,272,RC,,,Outpatient,,,3241.34,1944.80,,1944.8,60,,45.904,Percent of Total Billed Charges,60% of Total Billed Charges,1458.6,45,,21522.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,907.58,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,522.39,32,,494.312,Percent of Total Billed Charges,32% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,1166.88,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1166.88,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,1166.88,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1944.8,60,,165.088,Percent of Total Billed Charges,60% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3241.34,100,,1552.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,467.4,14.42,,15.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2431.01,75,,69.552,Percent of Total Billed Charges,75% of Total Billed Charges,1620.67,50,,436.36,Percent of Total Billed Charges,50% of Total Billed Charges,1620.67,50,,435.448,Percent of Total Billed Charges,50% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1620.67,50,,435.448,Percent of Total Billed Charges,50% of Total Billed Charges,1620.67,50,,435.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2268.94,70,,4214.216,Percent of Total Billed Charges,70% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,453.79,14,,15.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3241.34,100,,92.736,Percent of Total Billed Charges,100% of Total Billed Charges,453.79,3241.34,
545402 TUBING HOLOGIC INFLOW,32105469,CDM,272,RC,,,Outpatient,,,350,210.00,,210,60,,41.416,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98,28,,18.872,Percent of Total Billed Charges,28% of Total Billed Charges,525.21,32,,495.056,Percent of Total Billed Charges,32% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,126,36,,24.264,Percent of Total Billed Charges,36% of Total Billed Charges,126,36,,24.264,Percent of Total Billed Charges,36% Total Bille Charges,126,36,,24.264,Percent of Total Billed Charges,36% of Total Billed Charges,210,60,,24.088,Percent of Total Billed Charges,60% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350,100,,5778.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,50.47,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.5,75,,653.168,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,46.368,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,100,,870.888,Percent of Total Billed Charges,100% of Total Billed Charges,49,525.21,
760286 SMOKE EVACUATOR CAUTERY,32105470,CDM,272,RC,,,Outpatient,,,184.6,110.76,,110.76,60,,1788.864,Percent of Total Billed Charges,60% of Total Billed Charges,83.07,45,,1536.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.69,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,526.28,32,,495.256,Percent of Total Billed Charges,32% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,66.46,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,66.46,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,66.46,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,110.76,60,,37.152,Percent of Total Billed Charges,60% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.6,100,,701.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14.42,,216.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.45,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,92.3,50,,435.448,Percent of Total Billed Charges,50% of Total Billed Charges,92.3,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.3,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,92.3,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.22,70,,11110.376,Percent of Total Billed Charges,70% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.84,14,,210.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.6,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,25.84,526.28,
791912 DEMINERALIZED BONE,32105471,CDM,278,RC,C1713,HCPCS,Outpatient,,,5340.4,3204.24,,6191.7,110,,82.936,Percent of Total Billed Charges,110% of Total Billed Charges,2403.18,45,,1181.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1495.31,28,,600.488,Percent of Total Billed Charges,28% of Total Billed Charges,526.28,32,,495.52,Percent of Total Billed Charges,32% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,1922.54,36,,772.056,Percent of Total Billed Charges,36% of Total Billed Charges,1922.54,36,,772.056,Percent of Total Billed Charges,36% Total Bille Charges,1922.54,36,,772.056,Percent of Total Billed Charges,36% of Total Billed Charges,2937.22,55,,11.864,Percent of Total Billed Charges,55% Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5340.4,100,,47828.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,770.09,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4272.32,80,,1440,Percent of Total Billed Charges,80% of Total Billed Charges,2670.2,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2670.2,50,,230.4,Percent of Total Billed Charges,50% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2670.2,50,,230.4,Percent of Total Billed Charges,50% of Total Billed Charges,2670.2,50,,230.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3738.28,70,,5091.704,Percent of Total Billed Charges,70% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,747.66,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5340.4,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,526.28,6191.7,
1209834 DOWEL TREADED FACET,32105472,CDM,278,RC,,,Outpatient,,,375,225.00,,412.5,110,,82.936,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,4463.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,419.328,Percent of Total Billed Charges,28% of Total Billed Charges,528,32,,495.912,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,539.136,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,539.136,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,539.136,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,171.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,368.64,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,395.064,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,395.064,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,395.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,2333.656,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,166.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,460.8,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,528,
1034193 STENT GRAFT BIFORCATED,32105473,CDM,278,RC,,,Outpatient,,,22000,13200.00,,24200,110,,197.416,Percent of Total Billed Charges,110% of Total Billed Charges,9900,45,,1569.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6160,28,,399.84,Percent of Total Billed Charges,28% of Total Billed Charges,529.48,32,,496.896,Percent of Total Billed Charges,32% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,7920,36,,514.08,Percent of Total Billed Charges,36% of Total Billed Charges,7920,36,,514.08,Percent of Total Billed Charges,36% Total Bille Charges,7920,36,,514.08,Percent of Total Billed Charges,36% of Total Billed Charges,12100,55,,22.44,Percent of Total Billed Charges,55% Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22000,100,,3413.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3172.4,14.42,,323.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17600,80,,632.104,Percent of Total Billed Charges,80% of Total Billed Charges,11000,50,,230.4,Percent of Total Billed Charges,50% of Total Billed Charges,11000,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11000,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,11000,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15400,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,3080,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22000,100,,790.128,Percent of Total Billed Charges,100% of Total Billed Charges,529.48,24200,
837898 MESH SYMBOTEX COMPOSITE,32105474,CDM,278,RC,C1781,HCPCS,Outpatient,,,1494,896.40,,2096.16,110,,4846.752,Percent of Total Billed Charges,110% of Total Billed Charges,672.3,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.32,28,,20.16,Percent of Total Billed Charges,28% of Total Billed Charges,530.18,32,,497.664,Percent of Total Billed Charges,32% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,537.84,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,537.84,36,,25.92,Percent of Total Billed Charges,36% Total Bille Charges,537.84,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,821.7,55,,1172.368,Percent of Total Billed Charges,55% Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1494,100,,2625.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,215.43,14.42,,840.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1195.2,80,,90,Percent of Total Billed Charges,80% of Total Billed Charges,747,50,,395.064,Percent of Total Billed Charges,50% of Total Billed Charges,747,50,,54.312,Percent of Total Billed Charges,50% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747,50,,54.312,Percent of Total Billed Charges,50% of Total Billed Charges,747,50,,54.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1045.8,70,,3174.368,Percent of Total Billed Charges,70% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,209.16,14,,815.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1494,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,209.16,2096.16,
806803 BOVINE PERICARDIUM 4X5,32105475,CDM,278,RC,,,Outpatient,,,1090.89,654.53,,1199.98,110,,832.728,Percent of Total Billed Charges,110% of Total Billed Charges,490.9,45,,951.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.45,28,,87.064,Percent of Total Billed Charges,28% of Total Billed Charges,531.74,32,,498.712,Percent of Total Billed Charges,32% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,392.72,36,,111.936,Percent of Total Billed Charges,36% of Total Billed Charges,392.72,36,,111.936,Percent of Total Billed Charges,36% Total Bille Charges,392.72,36,,111.936,Percent of Total Billed Charges,36% of Total Billed Charges,599.99,55,,33.6,Percent of Total Billed Charges,55% Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.89,100,,9919.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,157.31,14.42,,563.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,872.71,80,,81.472,Percent of Total Billed Charges,80% of Total Billed Charges,545.45,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,545.45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,545.45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,763.62,70,,1680,Percent of Total Billed Charges,70% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,152.72,14,,547.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.89,100,,108.624,Percent of Total Billed Charges,100% of Total Billed Charges,152.72,1199.98,
585086 STRATAFIX 4.0 FS-2,32105476,CDM,272,RC,,,Outpatient,,,115.92,69.55,,69.55,60,,474.472,Percent of Total Billed Charges,60% of Total Billed Charges,52.16,45,,2518.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.46,28,,21.504,Percent of Total Billed Charges,28% of Total Billed Charges,533.52,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.73,36,,27.648,Percent of Total Billed Charges,36% of Total Billed Charges,41.73,36,,27.648,Percent of Total Billed Charges,36% Total Bille Charges,41.73,36,,27.648,Percent of Total Billed Charges,36% of Total Billed Charges,69.55,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.92,100,,3488.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14.42,,1362.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.94,75,,384,Percent of Total Billed Charges,75% of Total Billed Charges,57.96,50,,54.312,Percent of Total Billed Charges,50% of Total Billed Charges,57.96,50,,751.536,Percent of Total Billed Charges,50% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.96,50,,751.536,Percent of Total Billed Charges,50% of Total Billed Charges,57.96,50,,751.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.14,70,,3640,Percent of Total Billed Charges,70% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,16.23,14,,1322.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.92,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,16.23,533.52,
198672 STAPLER COVIDIEN,32105477,CDM,272,RC,,,Outpatient,,,1088.61,653.17,,653.17,60,,468.976,Percent of Total Billed Charges,60% of Total Billed Charges,489.87,45,,773.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.81,28,,180.672,Percent of Total Billed Charges,28% of Total Billed Charges,535.09,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,391.9,36,,232.296,Percent of Total Billed Charges,36% of Total Billed Charges,391.9,36,,232.296,Percent of Total Billed Charges,36% Total Bille Charges,391.9,36,,232.296,Percent of Total Billed Charges,36% of Total Billed Charges,653.17,60,,428.824,Percent of Total Billed Charges,60% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1088.61,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,156.98,14.42,,87.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,816.46,75,,1202.456,Percent of Total Billed Charges,75% of Total Billed Charges,544.31,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,544.31,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.31,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,544.31,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,762.03,70,,4200,Percent of Total Billed Charges,70% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,152.41,14,,85.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.61,100,,1503.072,Percent of Total Billed Charges,100% of Total Billed Charges,152.41,1088.61,
143075 RELOAD 60MM ENDO ROT,32105478,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,660.776,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,508.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,16.24,Percent of Total Billed Charges,28% of Total Billed Charges,535.17,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,20.88,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,20.88,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,20.88,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,336.04,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,2114.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,674.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,566.4,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,751.536,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,595.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,595.2,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,595.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,8400,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,655.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,708,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
806799 BOVINE PERICARDIUM 8X12,32105479,CDM,278,RC,,,Outpatient,,,2250,1350.00,,2475,110,,96.912,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,455.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,537.82,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,15.728,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,5597.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,84.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,952.32,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,8484,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,82.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,1190.4,Percent of Total Billed Charges,100% of Total Billed Charges,315,2475,
687299 BONE CEMENT SIMPLEX HV,32105480,CDM,278,RC,C1713,HCPCS,Outpatient,,,576,345.60,,950.86,110,,1471.84,Percent of Total Billed Charges,110% of Total Billed Charges,259.2,45,,1281.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.28,28,,100.24,Percent of Total Billed Charges,28% of Total Billed Charges,537.98,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,207.36,36,,128.88,Percent of Total Billed Charges,36% of Total Billed Charges,207.36,36,,128.88,Percent of Total Billed Charges,36% Total Bille Charges,207.36,36,,128.88,Percent of Total Billed Charges,36% of Total Billed Charges,316.8,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,576,100,,1719.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,83.06,14.42,,8.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.8,80,,1792,Percent of Total Billed Charges,80% of Total Billed Charges,288,50,,595.2,Percent of Total Billed Charges,50% of Total Billed Charges,288,50,,2913.04,Percent of Total Billed Charges,50% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288,50,,2913.04,Percent of Total Billed Charges,50% of Total Billed Charges,288,50,,2913.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.2,70,,10920,Percent of Total Billed Charges,70% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,80.64,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,576,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,80.64,950.86,
806798 BOVINE PERIC 2X7,32105481,CDM,278,RC,,,Outpatient,,,987.66,592.60,,1086.43,110,,501.456,Percent of Total Billed Charges,110% of Total Billed Charges,444.45,45,,4506.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.54,28,,60.856,Percent of Total Billed Charges,28% of Total Billed Charges,537.98,32,,498.992,Percent of Total Billed Charges,32% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,355.56,36,,78.24,Percent of Total Billed Charges,36% of Total Billed Charges,355.56,36,,78.24,Percent of Total Billed Charges,36% Total Bille Charges,355.56,36,,78.24,Percent of Total Billed Charges,36% of Total Billed Charges,543.21,55,,33.6,Percent of Total Billed Charges,55% Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,987.66,100,,1130.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,142.42,14.42,,76.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.13,80,,4660.864,Percent of Total Billed Charges,80% of Total Billed Charges,493.83,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,493.83,50,,1955.2,Percent of Total Billed Charges,50% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.83,50,,1955.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.83,50,,1955.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.36,70,,15120,Percent of Total Billed Charges,70% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,138.27,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,987.66,100,,5826.08,Percent of Total Billed Charges,100% of Total Billed Charges,138.27,1086.43,
424645 INTRODUCER DEVICE AUTO,32105482,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,864.712,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,84.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,119.232,Percent of Total Billed Charges,28% of Total Billed Charges,539.96,32,,499.2,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,153.304,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,153.304,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,153.304,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,40.432,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,1011.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,115.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,3128.32,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,2913.04,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,4724.6,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,4724.6,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,4724.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,19320,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,111.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,3910.4,Percent of Total Billed Charges,100% of Total Billed Charges,21,539.96,
1199480 LAPAROSCOPIC L-HOOK,32105483,CDM,272,RC,,,Outpatient,,,135.78,81.47,,81.47,60,,142.992,Percent of Total Billed Charges,60% of Total Billed Charges,61.1,45,,351,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.02,28,,611.872,Percent of Total Billed Charges,28% of Total Billed Charges,540.67,32,,503.136,Percent of Total Billed Charges,32% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,48.88,36,,786.696,Percent of Total Billed Charges,36% of Total Billed Charges,48.88,36,,786.696,Percent of Total Billed Charges,36% Total Bille Charges,48.88,36,,786.696,Percent of Total Billed Charges,36% of Total Billed Charges,81.47,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.78,100,,2847.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14.42,,1000.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.84,75,,7559.352,Percent of Total Billed Charges,75% of Total Billed Charges,67.89,50,,1955.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.89,50,,304.24,Percent of Total Billed Charges,50% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.89,50,,304.24,Percent of Total Billed Charges,50% of Total Billed Charges,67.89,50,,304.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,19.01,14,,971.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.78,100,,9449.192,Percent of Total Billed Charges,100% of Total Billed Charges,19.01,540.67,
1234826 CEMENT BONE COBALT,32105484,CDM,278,RC,C1713,HCPCS,Outpatient,,,600,360.00,,977.26,110,,128.112,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,1695.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,156.04,Percent of Total Billed Charges,28% of Total Billed Charges,541.19,32,,503.984,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,200.624,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,200.624,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,200.624,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,1179.536,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,10015.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,456.352,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,4724.6,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,2340,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,2340,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,2340,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,58.8,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,608.472,Percent of Total Billed Charges,100% of Total Billed Charges,84,977.26,
754984 GRAFT HEMASHIELD GOLD,32105485,CDM,278,RC,C1768,HCPCS,Outpatient,,,1878.84,1127.30,,2389.49,110,,7233.672,Percent of Total Billed Charges,110% of Total Billed Charges,845.48,45,,204.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,526.08,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,541.24,32,,508.176,Percent of Total Billed Charges,32% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,676.38,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,676.38,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,676.38,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1033.36,55,,823.68,Percent of Total Billed Charges,55% Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1878.84,100,,186.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,270.93,14.42,,290.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1503.07,80,,3744,Percent of Total Billed Charges,80% of Total Billed Charges,939.42,50,,304.24,Percent of Total Billed Charges,50% of Total Billed Charges,939.42,50,,293.224,Percent of Total Billed Charges,50% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,939.42,50,,293.224,Percent of Total Billed Charges,50% of Total Billed Charges,939.42,50,,293.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1315.19,70,,61.6,Percent of Total Billed Charges,70% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,263.04,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1878.84,100,,4680,Percent of Total Billed Charges,100% of Total Billed Charges,263.04,2389.49,
994120 CELLERATERX POWDER,32105486,CDM,278,RC,,,Outpatient,,,885,531.00,,973.5,110,,3980.608,Percent of Total Billed Charges,110% of Total Billed Charges,398.25,45,,224.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.8,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,542.66,32,,509.2,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,318.6,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,318.6,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,318.6,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,486.75,55,,856.8,Percent of Total Billed Charges,55% Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885,100,,780,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,573.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,708,80,,469.152,Percent of Total Billed Charges,80% of Total Billed Charges,442.5,50,,2340,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.5,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.5,70,,105.056,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,556.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885,100,,586.44,Percent of Total Billed Charges,100% of Total Billed Charges,123.9,973.5,
1241587 GRAFT NONMESHED SKIN,32105487,CDM,278,RC,,,Outpatient,,,1488,892.80,,1636.8,110,,2355.048,Percent of Total Billed Charges,110% of Total Billed Charges,669.6,45,,24.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.64,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,543.59,32,,509.952,Percent of Total Billed Charges,32% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,535.68,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,535.68,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,535.68,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,818.4,55,,43.2,Percent of Total Billed Charges,55% Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1488,100,,3768.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,214.57,14.42,,35.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1190.4,80,,43.528,Percent of Total Billed Charges,80% of Total Billed Charges,744,50,,293.224,Percent of Total Billed Charges,50% of Total Billed Charges,744,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,744,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,744,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.6,70,,105.84,Percent of Total Billed Charges,70% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,208.32,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1488,100,,58.032,Percent of Total Billed Charges,100% of Total Billed Charges,208.32,1636.8,
293996 BONE HUMERAL SHAFT,32105488,CDM,278,RC,,,Outpatient,,,2800,1680.00,,3080,110,,2020.568,Percent of Total Billed Charges,110% of Total Billed Charges,1260,45,,469.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,544.22,32,,509.952,Percent of Total Billed Charges,32% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,1008,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1008,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1008,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1540,55,,186.568,Percent of Total Billed Charges,55% Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2800,100,,454.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,403.76,14.42,,335.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2240,80,,422.4,Percent of Total Billed Charges,80% of Total Billed Charges,1400,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,399,Percent of Total Billed Charges,50% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,50,,399,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,399,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1960,70,,171.36,Percent of Total Billed Charges,70% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,326.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2800,100,,528,Percent of Total Billed Charges,100% of Total Billed Charges,392,3080,
771490 GRAFT JACKET,32105489,CDM,278,RC,Q4107,HCPCS,Outpatient,,,7282.6,4369.56,,8091.76,110,,5332.728,Percent of Total Billed Charges,110% of Total Billed Charges,3277.17,45,,8010,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.07,280,,162.64,Fee Schedule,280% of BCBS BULE Fee Schedule,103.07,320,,510.72,Fee Schedule,320% of BCBS Blue Essentials Rate,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,103.07,360,,209.112,Fee Schedule,360% of BCBS POS Rate,103.07,360,,209.112,Fee schedule,360% of BCBS PPO Rate,103.07,360,,209.112,Fee Schedule,360% of BCBS Traditional Rate,4005.43,55,,46.08,Percent of Total Billed Charges,55% Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7282.6,100,,498.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1050.15,14.42,,125.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5826.08,80,,598.504,Percent of Total Billed Charges,80% of Total Billed Charges,3641.3,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,3641.3,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3641.3,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,3641.3,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5097.82,70,,226.8,Percent of Total Billed Charges,70% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,1019.56,14,,122.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7282.6,100,,798,Percent of Total Billed Charges,100% of Total Billed Charges,103.07,8091.76,
663708 WRAP AXOGUARD 7X40,32105490,CDM,278,RC,,,Outpatient,,,4888,2932.80,,5376.8,110,,1214.936,Percent of Total Billed Charges,110% of Total Billed Charges,2199.6,45,,1179.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1368.64,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,544.64,32,,510.848,Percent of Total Billed Charges,32% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1759.68,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1759.68,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,1759.68,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,2688.4,55,,387.16,Percent of Total Billed Charges,55% Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4888,100,,55.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,704.85,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3910.4,80,,2118.272,Percent of Total Billed Charges,80% of Total Billed Charges,2444,50,,399,Percent of Total Billed Charges,50% of Total Billed Charges,2444,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2444,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,2444,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3421.6,70,,290.08,Percent of Total Billed Charges,70% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,684.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4888,100,,2647.84,Percent of Total Billed Charges,100% of Total Billed Charges,544.64,5376.8,
857834 VALVE PROGRAMMABLE,32105491,CDM,278,RC,,,Outpatient,,,11811.49,7086.89,,12992.64,110,,68.976,Percent of Total Billed Charges,110% of Total Billed Charges,5315.17,45,,222.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3307.22,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,544.64,32,,511.472,Percent of Total Billed Charges,32% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,4252.14,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,4252.14,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,4252.14,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,6496.32,55,,34.8,Percent of Total Billed Charges,55% Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11811.49,100,,1044,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1703.22,14.42,,749.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9449.19,80,,5550.576,Percent of Total Billed Charges,80% of Total Billed Charges,5905.75,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,5905.75,50,,1989,Percent of Total Billed Charges,50% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5905.75,50,,1989,Percent of Total Billed Charges,50% of Total Billed Charges,5905.75,50,,1989,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8268.04,70,,5880,Percent of Total Billed Charges,70% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,1653.61,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11811.49,100,,6938.216,Percent of Total Billed Charges,100% of Total Billed Charges,544.64,12992.64,
856687 RELOAD COVIDIEN CURVED,32105492,CDM,272,RC,,,Outpatient,,,760.59,456.35,,456.35,60,,11150.896,Percent of Total Billed Charges,60% of Total Billed Charges,342.27,45,,253.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.97,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,544.64,32,,0.256,Percent of Total Billed Charges,32% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,273.81,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,273.81,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,273.81,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,456.35,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.59,100,,17800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,109.68,14.42,,35.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.44,75,,44.8,Percent of Total Billed Charges,75% of Total Billed Charges,380.3,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,380.3,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.3,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,380.3,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532.41,70,,6440,Percent of Total Billed Charges,70% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,106.48,14,,34.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.59,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,106.48,760.59,
766820 MATRIX GLOBUS KINEX,32105493,CDM,278,RC,C1713,HCPCS,Outpatient,,,5850,3510.00,,6752.26,110,,3354.12,Percent of Total Billed Charges,110% of Total Billed Charges,2632.5,45,,253.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1638,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,545.78,32,,0.256,Percent of Total Billed Charges,32% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,2106,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2106,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,2106,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,3217.5,55,,214.8,Percent of Total Billed Charges,55% Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5850,100,,2622.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,843.57,14.42,,167.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4680,80,,1612.8,Percent of Total Billed Charges,80% of Total Billed Charges,2925,50,,1989,Percent of Total Billed Charges,50% of Total Billed Charges,2925,50,,1164.8,Percent of Total Billed Charges,50% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2925,50,,1164.8,Percent of Total Billed Charges,50% of Total Billed Charges,2925,50,,1164.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4095,70,,9240,Percent of Total Billed Charges,70% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,819,14,,162.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5850,100,,2016,Percent of Total Billed Charges,100% of Total Billed Charges,545.78,6752.26,
546240 STENT URETERAL 5FRX28CM,32105494,CDM,278,RC,C2617,HCPCS,Outpatient,,,733.05,439.83,,999.91,110,,171.072,Percent of Total Billed Charges,110% of Total Billed Charges,329.87,45,,253.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.25,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,545.78,32,,0.264,Percent of Total Billed Charges,32% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,263.9,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,263.9,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,263.9,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,403.18,55,,130.4,Percent of Total Billed Charges,55% Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,733.05,100,,493.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,105.71,14.42,,114.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,586.44,80,,3182.4,Percent of Total Billed Charges,80% of Total Billed Charges,366.53,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,366.53,50,,436.296,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.53,50,,436.296,Percent of Total Billed Charges,50% of Total Billed Charges,366.53,50,,436.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,513.14,70,,10640,Percent of Total Billed Charges,70% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,102.63,14,,111.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.05,100,,3978,Percent of Total Billed Charges,100% of Total Billed Charges,102.63,999.91,
177856 SUTURE VICRYL PLUS 1,32105495,CDM,272,RC,,,Outpatient,,,72.54,43.52,,43.52,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,45,,834.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.31,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,546.01,32,,0.264,Percent of Total Billed Charges,32% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,26.11,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,26.11,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,43.52,60,,234.216,Percent of Total Billed Charges,60% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.54,100,,563.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.46,14.42,,1349.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.41,75,,183.6,Percent of Total Billed Charges,75% of Total Billed Charges,36.27,50,,1164.8,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.78,70,,13160,Percent of Total Billed Charges,70% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,1310.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.54,100,,244.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.16,546.01,
183689 CEMENT ZIMMER PALACOS R,32105496,CDM,278,RC,C1713,HCPCS,Outpatient,,,660,396.00,,1043.26,110,,14810.672,Percent of Total Billed Charges,110% of Total Billed Charges,297,45,,253.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,548.69,32,,0.264,Percent of Total Billed Charges,32% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,237.6,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,237.6,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,237.6,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,363,55,,1201.896,Percent of Total Billed Charges,55% Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,660,100,,563.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.17,14.42,,2306.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528,80,,1863.68,Percent of Total Billed Charges,80% of Total Billed Charges,330,50,,436.296,Percent of Total Billed Charges,50% of Total Billed Charges,330,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,330,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462,70,,17360,Percent of Total Billed Charges,70% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,2239.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660,100,,2329.6,Percent of Total Billed Charges,100% of Total Billed Charges,92.4,1043.26,
199092 BLADE BONE MILL MEDIUM,32105497,CDM,272,RC,,,Outpatient,,,997.5,598.50,,598.5,60,,17311.256,Percent of Total Billed Charges,60% of Total Billed Charges,448.88,45,,601.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.3,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,548.69,32,,0.264,Percent of Total Billed Charges,32% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,359.1,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,359.1,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,359.1,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,598.5,60,,334.368,Percent of Total Billed Charges,60% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,997.5,100,,563.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,143.84,14.42,,86.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,748.13,75,,698.072,Percent of Total Billed Charges,75% of Total Billed Charges,498.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,498.75,50,,121.504,Percent of Total Billed Charges,50% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.75,50,,121.504,Percent of Total Billed Charges,50% of Total Billed Charges,498.75,50,,121.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,698.25,70,,21560,Percent of Total Billed Charges,70% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,139.65,14,,83.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,997.5,100,,872.592,Percent of Total Billed Charges,100% of Total Billed Charges,139.65,997.5,
1291204 IMPLANT AMNIO 2X4,32105498,CDM,278,RC,Q4151,HCPCS,Outpatient,,,3309.8,1985.88,,3769.61,110,,8998.928,Percent of Total Billed Charges,110% of Total Billed Charges,1489.41,45,,576.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,926.74,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,550.4,32,,0.264,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1191.53,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1191.53,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,1191.53,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1820.39,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3309.8,100,,1853.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2647.84,80,,384,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,2600,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,579.424,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,579.424,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,579.424,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2316.86,70,,88.48,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3309.8,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,3769.61,
1291859 IMPLANT DERMAL REGEN,32105499,CDM,278,RC,Q4105,HCPCS,Outpatient,,,8672.77,5203.66,,9586.31,110,,3886.592,Percent of Total Billed Charges,110% of Total Billed Charges,3902.75,45,,1241.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.46,280,,162.64,Fee Schedule,280% of BCBS BULE Fee Schedule,46.46,320,,0.272,Fee Schedule,320% of BCBS Blue Essentials Rate,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,46.46,360,,209.112,Fee Schedule,360% of BCBS POS Rate,46.46,360,,209.112,Fee schedule,360% of BCBS PPO Rate,46.46,360,,209.112,Fee Schedule,360% of BCBS Traditional Rate,4770.02,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8672.77,100,,563.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1250.61,14.42,,194.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6938.22,80,,3900,Percent of Total Billed Charges,80% of Total Billed Charges,19.07,80,,121.504,Fee Schedule,80% of Scott and White EPO fee schedule,19.07,80,,397.2,Fee Schedule,80% of Scott and White HMO fee schedule,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.07,80,,397.2,Fee Schedule,80% of Scott and White PPO fee schedule,19.07,80,,397.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6070.94,70,,100.24,Percent of Total Billed Charges,70% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,1214.19,14,,189.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8672.77,100,,5200,Percent of Total Billed Charges,100% of Total Billed Charges,19.07,9586.31,
191191 CEMENT SMARTSET GHV,32105500,CDM,278,RC,C1713,HCPCS,Outpatient,,,70,42.00,,394.26,110,,10472.896,Percent of Total Billed Charges,110% of Total Billed Charges,31.5,45,,519.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,552,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,1337.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,80,,182.248,Percent of Total Billed Charges,80% of Total Billed Charges,35,50,,579.424,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,4678.96,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,4678.96,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,4678.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,243,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,552,
489357 KIT BIOCOMOSITES,32105501,CDM,278,RC,C1713,HCPCS,Outpatient,,,2520,1512.00,,3089.26,110,,16720,Percent of Total Billed Charges,110% of Total Billed Charges,1134,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.6,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,552,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,907.2,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,907.2,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,907.2,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1386,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2520,100,,1280.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,363.38,14.42,,347.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2016,80,,869.128,Percent of Total Billed Charges,80% of Total Billed Charges,1260,50,,397.2,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,7999.2,Percent of Total Billed Charges,50% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260,50,,7999.2,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,7999.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1764,70,,134.4,Percent of Total Billed Charges,70% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2520,100,,1158.84,Percent of Total Billed Charges,100% of Total Billed Charges,352.8,3089.26,
859669 GRAFT ARTHROFLEX,32105502,CDM,278,RC,C1762,HCPCS,Outpatient,,,4972.5,2983.50,,7647.84,110,,61.6,Percent of Total Billed Charges,110% of Total Billed Charges,2237.63,45,,2447.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.3,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,562.24,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,1790.1,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1790.1,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,1790.1,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,2734.88,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4972.5,100,,2757.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,717.03,14.42,,854.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3978,80,,595.8,Percent of Total Billed Charges,80% of Total Billed Charges,2486.25,50,,4678.96,Percent of Total Billed Charges,50% of Total Billed Charges,2486.25,50,,298.8,Percent of Total Billed Charges,50% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.25,50,,298.8,Percent of Total Billed Charges,50% of Total Billed Charges,2486.25,50,,298.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3480.75,70,,197.68,Percent of Total Billed Charges,70% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,696.15,14,,829.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4972.5,100,,794.4,Percent of Total Billed Charges,100% of Total Billed Charges,562.24,7647.84,
313592 DELIVERY NEEDLE 10GA,32105503,CDM,272,RC,,,Outpatient,,,306,183.60,,183.6,60,,18457.672,Percent of Total Billed Charges,60% of Total Billed Charges,137.7,45,,5016.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,562.25,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,110.16,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,110.16,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,110.16,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,183.6,60,,348.52,Percent of Total Billed Charges,60% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306,100,,1153.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,44.13,14.42,,64.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.5,75,,7486.336,Percent of Total Billed Charges,75% of Total Billed Charges,153,50,,7999.2,Percent of Total Billed Charges,50% of Total Billed Charges,153,50,,898.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153,50,,898.8,Percent of Total Billed Charges,50% of Total Billed Charges,153,50,,898.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.2,70,,260.4,Percent of Total Billed Charges,70% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306,100,,9357.92,Percent of Total Billed Charges,100% of Total Billed Charges,42.84,562.25,
1150922 IMPLANT OSTEOSPONGE,32105504,CDM,278,RC,,,Outpatient,,,2912,1747.20,,3203.2,110,,1779.36,Percent of Total Billed Charges,110% of Total Billed Charges,1310.4,45,,1123.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,815.36,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,568.85,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,1048.32,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1048.32,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,1048.32,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,1601.6,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2912,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,419.91,14.42,,483.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2329.6,80,,12798.72,Percent of Total Billed Charges,80% of Total Billed Charges,1456,50,,298.8,Percent of Total Billed Charges,50% of Total Billed Charges,1456,50,,675.84,Percent of Total Billed Charges,50% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1456,50,,675.84,Percent of Total Billed Charges,50% of Total Billed Charges,1456,50,,675.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2038.4,70,,323.68,Percent of Total Billed Charges,70% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,407.68,14,,469.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2912,100,,15998.4,Percent of Total Billed Charges,100% of Total Billed Charges,407.68,3203.2,
1164805 CEMENT VERTAPLEX,32105505,CDM,278,RC,C1713,HCPCS,Outpatient,,,1090.74,654.44,,1517.07,110,,1472,Percent of Total Billed Charges,110% of Total Billed Charges,490.83,45,,2936.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.41,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,569.4,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,392.67,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,392.67,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,392.67,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,599.91,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.74,100,,5438.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,157.28,14.42,,414.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,872.59,80,,448.2,Percent of Total Billed Charges,80% of Total Billed Charges,545.37,50,,898.8,Percent of Total Billed Charges,50% of Total Billed Charges,545.37,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.37,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,545.37,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,763.52,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,152.7,14,,402.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.74,100,,597.6,Percent of Total Billed Charges,100% of Total Billed Charges,152.7,1517.07,
935336 CEMENT S&N HV AB BONE,32105506,CDM,278,RC,C1713,HCPCS,Outpatient,,,600,360.00,,977.26,110,,5879.88,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,4963.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,569.4,32,,0.272,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,11148.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,1438.08,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,675.84,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,192.6,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,1797.6,Percent of Total Billed Charges,100% of Total Billed Charges,84,977.26,
1308778 ESSENTIO PACEMAKER,32105507,CDM,275,RC,C1785,HCPCS,Outpatient,,,6500,3900.00,,7425.42,110,,6086.632,Percent of Total Billed Charges,110% of Total Billed Charges,2925,45,,7416.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,569.76,32,,0.28,Percent of Total Billed Charges,32% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,2340,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2340,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,2340,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,3575,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6500,100,,2496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,937.3,14.42,,1133.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4875,75,,1013.76,Percent of Total Billed Charges,75% of Total Billed Charges,3250,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,3250,50,,1488.976,Percent of Total Billed Charges,50% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3250,50,,1488.976,Percent of Total Billed Charges,50% of Total Billed Charges,3250,50,,1488.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4550,70,,28.104,Percent of Total Billed Charges,70% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,1100.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,100,,1351.68,Percent of Total Billed Charges,100% of Total Billed Charges,569.76,7425.42,
1312656 SOLUTION WOUND DEBRID,32105508,CDM,272,RC,,,Outpatient,,,303.75,182.25,,182.25,60,,2397.928,Percent of Total Billed Charges,60% of Total Billed Charges,136.69,45,,605.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.05,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,570.64,32,,0.28,Percent of Total Billed Charges,32% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,109.35,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,109.35,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,109.35,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,182.25,60,,348.52,Percent of Total Billed Charges,60% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.75,100,,6526.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,43.8,14.42,,76.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.81,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,151.88,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,151.88,50,,2964,Percent of Total Billed Charges,50% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.88,50,,2964,Percent of Total Billed Charges,50% of Total Billed Charges,151.88,50,,2964,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.63,70,,43.344,Percent of Total Billed Charges,70% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.53,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.75,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,42.53,570.64,
1306471 PLASMA MEDIUM 12 DEG,32105509,CDM,272,RC,,,Outpatient,,,1448.55,869.13,,869.13,60,,273.664,Percent of Total Billed Charges,60% of Total Billed Charges,651.85,45,,653.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.59,28,,162.64,Percent of Total Billed Charges,28% of Total Billed Charges,570.64,32,,0.28,Percent of Total Billed Charges,32% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,521.48,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,521.48,36,,209.112,Percent of Total Billed Charges,36% Total Bille Charges,521.48,36,,209.112,Percent of Total Billed Charges,36% of Total Billed Charges,869.13,60,,348.52,Percent of Total Billed Charges,60% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.55,100,,11029.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,208.88,14.42,,76.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1086.41,75,,1930.24,Percent of Total Billed Charges,75% of Total Billed Charges,724.28,50,,1488.976,Percent of Total Billed Charges,50% of Total Billed Charges,724.28,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.28,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,724.28,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1013.99,70,,13.84,Percent of Total Billed Charges,70% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.8,14,,74.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1448.55,100,,2412.8,Percent of Total Billed Charges,100% of Total Billed Charges,202.8,1448.55,
487026 SNARE ENDOLOGIX,32105510,CDM,272,RC,,,Outpatient,,,993,595.80,,595.8,60,,445.2,Percent of Total Billed Charges,60% of Total Billed Charges,446.85,45,,508.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.04,28,,125.44,Percent of Total Billed Charges,28% of Total Billed Charges,570.64,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,357.48,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,357.48,36,,161.28,Percent of Total Billed Charges,36% Total Bille Charges,357.48,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,595.8,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,993,100,,16481.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,143.19,14.42,,421.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,744.75,75,,2106,Percent of Total Billed Charges,75% of Total Billed Charges,496.5,50,,2964,Percent of Total Billed Charges,50% of Total Billed Charges,496.5,50,,3204.976,Percent of Total Billed Charges,50% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,496.5,50,,3204.976,Percent of Total Billed Charges,50% of Total Billed Charges,496.5,50,,3204.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,695.1,70,,52.856,Percent of Total Billed Charges,70% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,139.02,14,,409.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,993,100,,2808,Percent of Total Billed Charges,100% of Total Billed Charges,139.02,993,
1330641 SHUNT OVATION,32105511,CDM,278,RC,C1874,HCPCS,Outpatient,,,11697.4,7018.44,,13359.55,110,,2382.688,Percent of Total Billed Charges,110% of Total Billed Charges,5263.83,45,,233.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3275.27,28,,152.816,Percent of Total Billed Charges,28% of Total Billed Charges,570.64,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,4211.06,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,4211.06,36,,196.48,Percent of Total Billed Charges,36% Total Bille Charges,4211.06,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,6433.57,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11697.4,100,,1344.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1686.77,14.42,,922.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9357.92,80,,4742.4,Percent of Total Billed Charges,80% of Total Billed Charges,5848.7,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,5848.7,50,,1436.504,Percent of Total Billed Charges,50% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5848.7,50,,1436.504,Percent of Total Billed Charges,50% of Total Billed Charges,5848.7,50,,1436.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8188.18,70,,26.184,Percent of Total Billed Charges,70% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,1637.64,14,,896.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11697.4,100,,5928,Percent of Total Billed Charges,100% of Total Billed Charges,570.64,13359.55,
1330639 SHUNT OVATION IX,32105512,CDM,278,RC,C1874,HCPCS,Outpatient,,,19998,11998.80,,22490.21,110,,2601.696,Percent of Total Billed Charges,110% of Total Billed Charges,8999.1,45,,33.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5599.44,28,,749.552,Percent of Total Billed Charges,28% of Total Billed Charges,570.64,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,7199.28,36,,963.704,Percent of Total Billed Charges,36% of Total Billed Charges,7199.28,36,,963.704,Percent of Total Billed Charges,36% Total Bille Charges,7199.28,36,,963.704,Percent of Total Billed Charges,36% of Total Billed Charges,10998.9,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19998,100,,1452.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2883.71,14.42,,344.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15998.4,80,,336,Percent of Total Billed Charges,80% of Total Billed Charges,9999,50,,3204.976,Percent of Total Billed Charges,50% of Total Billed Charges,9999,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9999,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,9999,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13998.6,70,,1492.112,Percent of Total Billed Charges,70% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,2799.72,14,,334.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19998,100,,448,Percent of Total Billed Charges,100% of Total Billed Charges,570.64,22490.21,
13330644 AUTO INJECTOR,32105513,CDM,272,RC,,,Outpatient,,,747,448.20,,448.2,60,,2380.928,Percent of Total Billed Charges,60% of Total Billed Charges,336.15,45,,683.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.16,28,,152.816,Percent of Total Billed Charges,28% of Total Billed Charges,571.2,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,268.92,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,268.92,36,,196.48,Percent of Total Billed Charges,36% Total Bille Charges,268.92,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,448.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747,100,,1130.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,107.72,14.42,,1499.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.25,75,,4680,Percent of Total Billed Charges,75% of Total Billed Charges,373.5,50,,1436.504,Percent of Total Billed Charges,50% of Total Billed Charges,373.5,50,,3929.12,Percent of Total Billed Charges,50% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.5,50,,3929.12,Percent of Total Billed Charges,50% of Total Billed Charges,373.5,50,,3929.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,522.9,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747,100,,6240,Percent of Total Billed Charges,100% of Total Billed Charges,104.58,747,
1330643 KIT FILL POLYMER,32105514,CDM,278,RC,C2615,HCPCS,Outpatient,,,2247,1348.20,,2711.07,110,,2506.328,Percent of Total Billed Charges,110% of Total Billed Charges,1011.15,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,629.16,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,576,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,808.92,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,808.92,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,808.92,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1235.85,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2247,100,,519.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,324.02,14.42,,145.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1797.6,80,,2681.4,Percent of Total Billed Charges,80% of Total Billed Charges,1123.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1123.5,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1123.5,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,1123.5,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1572.9,70,,56.56,Percent of Total Billed Charges,70% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,314.58,14,,141.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2247,100,,3351.752,Percent of Total Billed Charges,100% of Total Billed Charges,314.58,2711.07,
1328089 PLASMA OVAL BUTTON,32105515,CDM,272,RC,,,Outpatient,,,1689.6,1013.76,,1013.76,60,,4498.648,Percent of Total Billed Charges,60% of Total Billed Charges,760.32,45,,497.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.09,28,,418.312,Percent of Total Billed Charges,28% of Total Billed Charges,576,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,608.26,36,,537.832,Percent of Total Billed Charges,36% of Total Billed Charges,608.26,36,,537.832,Percent of Total Billed Charges,36% Total Bille Charges,608.26,36,,537.832,Percent of Total Billed Charges,36% of Total Billed Charges,1013.76,60,,348.52,Percent of Total Billed Charges,60% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1689.6,100,,74.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,243.64,14.42,,1183.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1267.2,75,,4284.8,Percent of Total Billed Charges,75% of Total Billed Charges,844.8,50,,3929.12,Percent of Total Billed Charges,50% of Total Billed Charges,844.8,50,,266.464,Percent of Total Billed Charges,50% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.8,50,,266.464,Percent of Total Billed Charges,50% of Total Billed Charges,844.8,50,,266.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1182.72,70,,235.2,Percent of Total Billed Charges,70% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,236.54,14,,1149.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1689.6,100,,5356,Percent of Total Billed Charges,100% of Total Billed Charges,236.54,1689.6,
493778 SPRAY NEOMEND,32105516,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,762.016,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,497.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,2264.232,Percent of Total Billed Charges,28% of Total Billed Charges,576.96,32,,0.288,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,2911.152,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,2911.152,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,2911.152,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,348.52,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1518.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,2298.4,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1462.24,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1462.24,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1462.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2873,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,576.96,
162675 GRAFT SFT TISSUE,32105517,CDM,278,RC,Q4107,HCPCS,Outpatient,,,3016,1809.60,,3398.5,110,,556.12,Percent of Total Billed Charges,110% of Total Billed Charges,1357.2,45,,763.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.07,280,,936.496,Fee Schedule,280% of BCBS BULE Fee Schedule,103.07,320,,0.288,Fee Schedule,320% of BCBS Blue Essentials Rate,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,103.07,360,,1204.072,Fee Schedule,360% of BCBS POS Rate,103.07,360,,1204.072,Fee schedule,360% of BCBS PPO Rate,103.07,360,,1204.072,Fee Schedule,360% of BCBS Traditional Rate,1658.8,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3016,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,434.91,14.42,,112.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2412.8,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,1508,50,,266.464,Percent of Total Billed Charges,50% of Total Billed Charges,1508,50,,3200.08,Percent of Total Billed Charges,50% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1508,50,,3200.08,Percent of Total Billed Charges,50% of Total Billed Charges,1508,50,,3200.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2111.2,70,,392.048,Percent of Total Billed Charges,70% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3016,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,103.07,3398.5,
992504 GRAFT OSIRIS 3X4CM,32105518,CDM,636,RC,Q4133,HCPCS,Outpatient,,,3510,2106.00,,2065.9,110,,5342.136,Percent of Total Billed Charges,110% of Total Billed Charges,1579.5,45,,64.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,982.8,28,,89.52,Percent of Total Billed Charges,28% of Total Billed Charges,576.96,32,,0.296,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1263.6,36,,115.096,Percent of Total Billed Charges,36% of Total Billed Charges,1263.6,36,,115.096,Percent of Total Billed Charges,36% Total Bille Charges,1263.6,36,,115.096,Percent of Total Billed Charges,36% of Total Billed Charges,1930.5,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3510,100,,1104.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2632.5,75,,6286.592,Percent of Total Billed Charges,75% of Total Billed Charges,1861.22,50,,1462.24,Percent of Total Billed Charges,50% of Total Billed Charges,1861.22,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1861.22,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,1861.22,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2457,70,,18.344,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3510,100,,7858.24,Percent of Total Billed Charges,100% of Total Billed Charges,576.96,3510,
1344972 PUTTY BONE VOID FILLER,32105519,CDM,278,RC,C1763,HCPCS,Outpatient,,,7410,4446.00,,8559.19,110,,9685.384,Percent of Total Billed Charges,110% of Total Billed Charges,3334.5,45,,587.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2074.8,28,,3856.368,Percent of Total Billed Charges,28% of Total Billed Charges,580.86,32,,0.296,Percent of Total Billed Charges,32% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,2667.6,36,,4958.192,Percent of Total Billed Charges,36% of Total Billed Charges,2667.6,36,,4958.192,Percent of Total Billed Charges,36% Total Bille Charges,2667.6,36,,4958.192,Percent of Total Billed Charges,36% of Total Billed Charges,4075.5,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7410,100,,1104.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1068.52,14.42,,692.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5928,80,,397.536,Percent of Total Billed Charges,80% of Total Billed Charges,3705,50,,3200.08,Percent of Total Billed Charges,50% of Total Billed Charges,3705,50,,504.328,Percent of Total Billed Charges,50% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3705,50,,504.328,Percent of Total Billed Charges,50% of Total Billed Charges,3705,50,,504.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5187,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,1037.4,14,,672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7410,100,,530.048,Percent of Total Billed Charges,100% of Total Billed Charges,580.86,8559.19,
1352847 SPLINT INTRANASAL,32105520,CDM,272,RC,,,Outpatient,,,560,336.00,,336,60,,1897.88,Percent of Total Billed Charges,60% of Total Billed Charges,252,45,,824.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.8,28,,316.552,Percent of Total Billed Charges,28% of Total Billed Charges,584.76,32,,0.296,Percent of Total Billed Charges,32% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,201.6,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,201.6,36,,406.992,Percent of Total Billed Charges,36% Total Bille Charges,201.6,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,336,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,1695.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14.42,,229,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420,75,,399.688,Percent of Total Billed Charges,75% of Total Billed Charges,280,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,4104.88,Percent of Total Billed Charges,50% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,50,,4104.88,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,4104.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,222.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560,100,,532.92,Percent of Total Billed Charges,100% of Total Billed Charges,78.4,584.76,
1364981 MEMBRANE GRAFIX,32105525,CDM,636,RC,Q4133,HCPCS,Outpatient,,,7800,4680.00,,4425.4,110,,17931.328,Percent of Total Billed Charges,110% of Total Billed Charges,3510,45,,335.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2184,28,,20.848,Percent of Total Billed Charges,28% of Total Billed Charges,585.6,32,,0.296,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2808,36,,26.8,Percent of Total Billed Charges,36% of Total Billed Charges,2808,36,,26.8,Percent of Total Billed Charges,36% Total Bille Charges,2808,36,,26.8,Percent of Total Billed Charges,36% of Total Billed Charges,4290,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7800,100,,144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5850,75,,2339.584,Percent of Total Billed Charges,75% of Total Billed Charges,4006.22,50,,504.328,Percent of Total Billed Charges,50% of Total Billed Charges,4006.22,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4006.22,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,4006.22,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5460,70,,47.176,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7800,100,,2924.48,Percent of Total Billed Charges,100% of Total Billed Charges,585.6,7800,
1219551 GRAFT ALLOPATCH,32105526,CDM,278,RC,Q4128,HCPCS,Outpatient,,,4189.69,2513.81,,4643.68,110,,815.392,Percent of Total Billed Charges,110% of Total Billed Charges,1885.36,45,,96.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1173.11,28,,22.96,Percent of Total Billed Charges,28% of Total Billed Charges,586.14,32,,0.296,Percent of Total Billed Charges,32% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,1508.29,36,,29.52,Percent of Total Billed Charges,36% of Total Billed Charges,1508.29,36,,29.52,Percent of Total Billed Charges,36% Total Bille Charges,1508.29,36,,29.52,Percent of Total Billed Charges,36% of Total Billed Charges,2304.33,55,,348.52,Percent of Total Billed Charges,55% Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4189.69,100,,1305.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,604.15,14.42,,568.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3351.75,80,,1909.44,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,4104.88,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,390,Fee Schedule,80% of Scott and White HMO fee schedule,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,390,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,390,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2932.78,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,586.56,14,,552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4189.69,100,,2386.8,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,4643.68,
1243243 GRAFT ALLOPATCH,32105527,CDM,278,RC,Q4151,HCPCS,Outpatient,,,6695,4017.00,,7493.33,110,,523.504,Percent of Total Billed Charges,110% of Total Billed Charges,3012.75,45,,763.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1874.6,28,,9374.4,Percent of Total Billed Charges,28% of Total Billed Charges,588.19,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2410.2,36,,12052.8,Percent of Total Billed Charges,36% of Total Billed Charges,2410.2,36,,12052.8,Percent of Total Billed Charges,36% Total Bille Charges,2410.2,36,,12052.8,Percent of Total Billed Charges,36% of Total Billed Charges,3682.25,55,,246.4,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6695,100,,1832.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5356,80,,5120.128,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,80,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,240,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,240,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,240,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4686.5,70,,1501.224,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6695,100,,6400.16,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,7493.33,
1295409 AMNIOBAND PARTICULATE,32105537,CDM,278,RC,Q4168,HCPCS,Outpatient,,,3591.25,2154.75,,3950.38,110,,510.376,Percent of Total Billed Charges,110% of Total Billed Charges,1616.06,45,,3537.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1005.55,28,,1043.088,Percent of Total Billed Charges,28% of Total Billed Charges,588.19,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,1292.85,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,1292.85,36,,1341.112,Percent of Total Billed Charges,36% Total Bille Charges,1292.85,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,1975.19,55,,327.464,Percent of Total Billed Charges,55% Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3591.25,100,,744.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,517.86,14.42,,307.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2873,80,,1913.232,Percent of Total Billed Charges,80% of Total Billed Charges,1795.63,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,1795.63,50,,2400,Percent of Total Billed Charges,50% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1795.63,50,,2400,Percent of Total Billed Charges,50% of Total Billed Charges,1795.63,50,,2400,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.88,70,,1048.32,Percent of Total Billed Charges,70% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,502.78,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3591.25,100,,2391.544,Percent of Total Billed Charges,100% of Total Billed Charges,502.78,3950.38,
1370449 CAPTURA FORCEP GRASP,32105538,CDM,272,RC,C1889,HCPCS,Outpatient,,,600,360.00,,360,60,,16106.744,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,824.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,2073.344,Percent of Total Billed Charges,28% of Total Billed Charges,591.24,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,2665.728,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,2665.728,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,2665.728,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1472.328,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,215.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,464.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,8320,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,794.032,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,794.032,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,794.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,999.6,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,450.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
1370445 ENDOGRAFT AO,32105539,CDM,278,RC,C1874,HCPCS,Outpatient,,,9822.8,5893.68,,11297.49,110,,1969.104,Percent of Total Billed Charges,110% of Total Billed Charges,4420.26,45,,222.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2750.38,28,,1362.864,Percent of Total Billed Charges,28% of Total Billed Charges,591.24,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,3536.21,36,,1752.256,Percent of Total Billed Charges,36% of Total Billed Charges,3536.21,36,,1752.256,Percent of Total Billed Charges,36% Total Bille Charges,3536.21,36,,1752.256,Percent of Total Billed Charges,36% of Total Billed Charges,5402.54,55,,327.464,Percent of Total Billed Charges,55% Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9822.8,100,,1695.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1416.45,14.42,,390.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7858.24,80,,756.488,Percent of Total Billed Charges,80% of Total Billed Charges,4911.4,50,,2400,Percent of Total Billed Charges,50% of Total Billed Charges,4911.4,50,,370.352,Percent of Total Billed Charges,50% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4911.4,50,,370.352,Percent of Total Billed Charges,50% of Total Billed Charges,4911.4,50,,370.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6875.96,70,,50.4,Percent of Total Billed Charges,70% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,1375.19,14,,379.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9822.8,100,,1008.648,Percent of Total Billed Charges,100% of Total Billed Charges,591.24,11297.49,
PICO 7 2 DRESSING KIT,32105540,CDM,272,RC,,,Outpatient,,,662.56,397.54,,397.54,60,,1716.096,Percent of Total Billed Charges,60% of Total Billed Charges,298.15,45,,224.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.52,28,,431.168,Percent of Total Billed Charges,28% of Total Billed Charges,591.24,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,238.52,36,,554.352,Percent of Total Billed Charges,36% of Total Billed Charges,238.52,36,,554.352,Percent of Total Billed Charges,36% Total Bille Charges,238.52,36,,554.352,Percent of Total Billed Charges,36% of Total Billed Charges,397.54,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.56,100,,7861.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14.42,,6861.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.92,75,,6567.808,Percent of Total Billed Charges,75% of Total Billed Charges,331.28,50,,794.032,Percent of Total Billed Charges,50% of Total Billed Charges,331.28,50,,1971.424,Percent of Total Billed Charges,50% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.28,50,,1971.424,Percent of Total Billed Charges,50% of Total Billed Charges,331.28,50,,1971.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.79,70,,217.664,Percent of Total Billed Charges,70% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,6662.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.56,100,,8209.76,Percent of Total Billed Charges,100% of Total Billed Charges,92.76,662.56,
PICO 7 2 DRESSING KIT,32105541,CDM,272,RC,,,Outpatient,,,666.15,399.69,,399.69,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,299.77,45,,229.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.52,28,,124.296,Percent of Total Billed Charges,28% of Total Billed Charges,591.62,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,239.81,36,,159.808,Percent of Total Billed Charges,36% of Total Billed Charges,239.81,36,,159.808,Percent of Total Billed Charges,36% Total Bille Charges,239.81,36,,159.808,Percent of Total Billed Charges,36% of Total Billed Charges,399.69,60,,821.688,Percent of Total Billed Charges,60% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.15,100,,1832.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,96.06,14.42,,529.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.61,75,,128,Percent of Total Billed Charges,75% of Total Billed Charges,333.08,50,,370.352,Percent of Total Billed Charges,50% of Total Billed Charges,333.08,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.08,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,333.08,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.31,70,,53.76,Percent of Total Billed Charges,70% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.26,14,,513.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.15,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,93.26,666.15,
1374885 SKIN NON-MESHED,32105542,CDM,278,RC,,,Outpatient,,,3655.6,2193.36,,4021.16,110,,1042.208,Percent of Total Billed Charges,110% of Total Billed Charges,1645.02,45,,249.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1023.57,28,,398.2,Percent of Total Billed Charges,28% of Total Billed Charges,593.9,32,,0.304,Percent of Total Billed Charges,32% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,1316.02,36,,511.968,Percent of Total Billed Charges,36% of Total Billed Charges,1316.02,36,,511.968,Percent of Total Billed Charges,36% Total Bille Charges,1316.02,36,,511.968,Percent of Total Billed Charges,36% of Total Billed Charges,2010.58,55,,4447.6,Percent of Total Billed Charges,55% Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3655.6,100,,494,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,527.14,14.42,,151.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2924.48,80,,624,Percent of Total Billed Charges,80% of Total Billed Charges,1827.8,50,,1971.424,Percent of Total Billed Charges,50% of Total Billed Charges,1827.8,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1827.8,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,1827.8,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2558.92,70,,451.688,Percent of Total Billed Charges,70% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,511.78,14,,146.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3655.6,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,511.78,4021.16,
975270 MEMBRANE AMNIOTIC,32105543,CDM,278,RC,Q4151,HCPCS,Outpatient,,,2983.5,1790.10,,3410.68,110,,52.024,Percent of Total Billed Charges,110% of Total Billed Charges,1342.58,45,,249.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,835.38,28,,436.624,Percent of Total Billed Charges,28% of Total Billed Charges,594.5,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1074.06,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,1074.06,36,,561.368,Percent of Total Billed Charges,36% Total Bille Charges,1074.06,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,1640.93,55,,1839.552,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2983.5,100,,499.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2386.8,80,,384,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,350.856,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,1609.304,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,1609.304,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,1609.304,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2088.45,70,,40.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2983.5,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,3410.68,
1346782 OSTEOS MEDIUM,32105544,CDM,278,RC,,,Outpatient,,,8000.2,4800.12,,8800.22,110,,141.136,Percent of Total Billed Charges,110% of Total Billed Charges,3600.09,45,,495.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2240.06,28,,36.736,Percent of Total Billed Charges,28% of Total Billed Charges,595.2,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,2880.07,36,,47.232,Percent of Total Billed Charges,36% of Total Billed Charges,2880.07,36,,47.232,Percent of Total Billed Charges,36% Total Bille Charges,2880.07,36,,47.232,Percent of Total Billed Charges,36% of Total Billed Charges,4400.11,55,,7575.016,Percent of Total Billed Charges,55% Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8000.2,100,,511.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1153.63,14.42,,322.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6400.16,80,,3600,Percent of Total Billed Charges,80% of Total Billed Charges,4000.1,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,4000.1,50,,1355.2,Percent of Total Billed Charges,50% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4000.1,50,,1355.2,Percent of Total Billed Charges,50% of Total Billed Charges,4000.1,50,,1355.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5600.14,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.03,14,,313.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8000.2,100,,4800,Percent of Total Billed Charges,100% of Total Billed Charges,595.2,8800.22,
1226807 PATCH PIABLE,32105545,CDM,278,RC,Q4128,HCPCS,Outpatient,,,2989.43,1793.66,,3323.39,110,,4239.4,Percent of Total Billed Charges,110% of Total Billed Charges,1345.24,45,,3752.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,837.04,28,,3.36,Percent of Total Billed Charges,28% of Total Billed Charges,597.59,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,1076.19,36,,4.32,Percent of Total Billed Charges,36% of Total Billed Charges,1076.19,36,,4.32,Percent of Total Billed Charges,36% Total Bille Charges,1076.19,36,,4.32,Percent of Total Billed Charges,36% of Total Billed Charges,1644.19,55,,621.792,Percent of Total Billed Charges,55% Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2989.43,100,,553.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,431.08,14.42,,19.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2391.54,80,,1270.448,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,1609.304,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,23793,Fee Schedule,80% of Scott and White HMO fee schedule,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,23793,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,23793,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2092.6,70,,250.6,Percent of Total Billed Charges,70% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,418.52,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2989.43,100,,1588.056,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,3323.39,
1346778 OSTEOS LG MATRIX,32105546,CDM,278,RC,C1713,HCPCS,Outpatient,,,13000,7800.00,,14617.26,110,,16093.096,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,191.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,53.536,Percent of Total Billed Charges,28% of Total Billed Charges,598.79,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,68.832,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,68.832,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,68.832,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,44.672,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,553.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,538.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10400,80,,592.56,Percent of Total Billed Charges,80% of Total Billed Charges,6500,50,,1355.2,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,152.136,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,522.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,740.696,Percent of Total Billed Charges,100% of Total Billed Charges,598.79,14617.26,
112744 DILATOR SET RENAL,32105547,CDM,272,RC,,,Outpatient,,,1260.81,756.49,,756.49,60,,268.992,Percent of Total Billed Charges,60% of Total Billed Charges,567.36,45,,673.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.03,28,,374.616,Percent of Total Billed Charges,28% of Total Billed Charges,599.04,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,453.89,36,,481.656,Percent of Total Billed Charges,36% of Total Billed Charges,453.89,36,,481.656,Percent of Total Billed Charges,36% Total Bille Charges,453.89,36,,481.656,Percent of Total Billed Charges,36% of Total Billed Charges,756.49,60,,49.2,Percent of Total Billed Charges,60% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1260.81,100,,1101.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,181.81,14.42,,7.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,945.61,75,,3154.272,Percent of Total Billed Charges,75% of Total Billed Charges,630.41,50,,23793,Percent of Total Billed Charges,50% of Total Billed Charges,630.41,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630.41,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,630.41,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,882.57,70,,298.088,Percent of Total Billed Charges,70% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,176.51,14,,7.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260.81,100,,3942.84,Percent of Total Billed Charges,100% of Total Billed Charges,176.51,1260.81,
1019657 DERMIS GRAFT DECELLULA,32105548,CDM,278,RC,C1762,HCPCS,Outpatient,,,10262.2,6157.32,,13466.51,110,,262.52,Percent of Total Billed Charges,110% of Total Billed Charges,4617.99,45,,113.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2873.42,28,,1043.088,Percent of Total Billed Charges,28% of Total Billed Charges,600,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,3694.39,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,3694.39,36,,1341.112,Percent of Total Billed Charges,36% Total Bille Charges,3694.39,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,5644.21,55,,18414,Percent of Total Billed Charges,55% Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10262.2,100,,8339.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1479.81,14.42,,106.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8209.76,80,,561.368,Percent of Total Billed Charges,80% of Total Billed Charges,5131.1,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,5131.1,50,,2651.224,Percent of Total Billed Charges,50% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5131.1,50,,2651.224,Percent of Total Billed Charges,50% of Total Billed Charges,5131.1,50,,2651.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7183.54,70,,1529.688,Percent of Total Billed Charges,70% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,1436.71,14,,103.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10262.2,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,600,13466.51,
1384789 CEMENT S&N RALLY MV,32105549,CDM,278,RC,C1713,HCPCS,Outpatient,,,200,120.00,,537.26,110,,64.448,Percent of Total Billed Charges,110% of Total Billed Charges,90,45,,614,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,28,,966.088,Percent of Total Billed Charges,28% of Total Billed Charges,601.23,32,,0.312,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,1242.112,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,1242.112,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,1242.112,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,100,,424.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,478.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,80,,1707.552,Percent of Total Billed Charges,80% of Total Billed Charges,100,50,,524.4,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,1118.04,Percent of Total Billed Charges,50% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,50,,1118.04,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,1118.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,70,,390.096,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,464.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,100,,2134.44,Percent of Total Billed Charges,100% of Total Billed Charges,28,601.23,
883276 ANCHOR SUTURE,32105550,CDM,278,RC,C1713,HCPCS,Outpatient,,,975,585.00,,1389.76,110,,1601.744,Percent of Total Billed Charges,110% of Total Billed Charges,438.75,45,,3426.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,292.32,Percent of Total Billed Charges,28% of Total Billed Charges,604.8,32,,0.32,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,375.84,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,375.84,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,375.84,Percent of Total Billed Charges,36% of Total Billed Charges,536.25,55,,4442.88,Percent of Total Billed Charges,55% Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,1496.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,939.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780,80,,2574.88,Percent of Total Billed Charges,80% of Total Billed Charges,487.5,50,,2651.224,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,911.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,3218.6,Percent of Total Billed Charges,100% of Total Billed Charges,136.5,1389.76,
1388766 MATRIX BONE GEL,32105551,CDM,278,RC,,,Outpatient,,,600,360.00,,660,110,,501.456,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,1617.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,604.8,32,,0.32,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,2677.056,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,252.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,177.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,2032.8,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,1118.04,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1867.792,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,1867.792,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1867.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,172.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2710.4,Percent of Total Billed Charges,100% of Total Billed Charges,84,660,
LITHOTRIPSY- ADD ON,32105552,CDM,790,RC,52356,HCPCS,Outpatient,,,6000,3600.00,,6763,100,,50478.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7120.9,150,,2514.4,Fee Schedule ,150% of CMS OPPS Rate,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,9859.67,233,,13704.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,604.8,32,,0.32,Percent of Total Billed Charges,32% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,13625.82,322,,17620.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,13625.82,322,,17620.416,Fee schedule,Pays based on ASC Tier Groupings fee schedule,13625.82,322,,17620.416,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,846.928,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4747.27,100,,1364.44,Fee Schedule,100% of CMS OPPS Rate,4272.54,90,,,Fee Schedule,90% of CMS OPPS Rate,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6171.45,130,,,Fee Schedule,130% of CMS OPPS Rate,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,865.2,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,4889.68,103,,,Fee Schedule,103% of CMS OPPS Rate,4889.68,103,,,Fee Schedule,103% of CMS OPPS Rate,4500,75,,38068.8,Percent of Total Billed Charges,75% of Total Billed Charges,3000,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,3000,50,,25.832,Percent of Total Billed Charges,50% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,50,,25.832,Percent of Total Billed Charges,50% of Total Billed Charges,3000,50,,25.832,Percent of Total Billed Charges,50% of Total Billed Charges,7120.9,150,,,Fee Schedule,150% of CMS OPPS Rate,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,336,Fee Schedule,100% of ASC Tier Groupings fee schedule,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4747.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6000,100,,47586,Percent of Total Billed Charges,100% of Total Billed Charges,604.8,13625.82,
1395650 RESERVOIR DRAIN NATUS,32105553,CDM,278,RC,C1729,HCPCS,Outpatient,,,1985.07,1191.04,,2194.68,110,,4785.792,Percent of Total Billed Charges,110% of Total Billed Charges,893.28,45,,943.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.82,28,,1032.936,Percent of Total Billed Charges,28% of Total Billed Charges,604.8,32,,0.32,Percent of Total Billed Charges,32% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,714.63,36,,1328.056,Percent of Total Billed Charges,36% of Total Billed Charges,714.63,36,,1328.056,Percent of Total Billed Charges,36% Total Bille Charges,714.63,36,,1328.056,Percent of Total Billed Charges,36% of Total Billed Charges,1091.79,55,,244.144,Percent of Total Billed Charges,55% Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1985.07,100,,7613.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,286.25,14.42,,868.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1588.06,80,,2753.192,Percent of Total Billed Charges,80% of Total Billed Charges,992.54,50,,1867.792,Percent of Total Billed Charges,50% of Total Billed Charges,992.54,50,,370.504,Percent of Total Billed Charges,50% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,992.54,50,,370.504,Percent of Total Billed Charges,50% of Total Billed Charges,992.54,50,,370.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1389.55,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,277.91,14,,842.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1985.07,100,,3670.92,Percent of Total Billed Charges,100% of Total Billed Charges,277.91,2194.68,
1307618 CEMENT BIOMET BONE REF,32105554,CDM,278,RC,C1713,HCPCS,Outpatient,,,925.87,555.52,,1335.72,110,,2451.68,Percent of Total Billed Charges,110% of Total Billed Charges,416.64,45,,288.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.24,28,,1065.928,Percent of Total Billed Charges,28% of Total Billed Charges,604.8,32,,0.328,Percent of Total Billed Charges,32% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,333.31,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,333.31,36,,1370.48,Percent of Total Billed Charges,36% Total Bille Charges,333.31,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,509.23,55,,853.28,Percent of Total Billed Charges,55% Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,925.87,100,,3594.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,133.51,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,740.7,80,,839.04,Percent of Total Billed Charges,80% of Total Billed Charges,462.94,50,,25.832,Percent of Total Billed Charges,50% of Total Billed Charges,462.94,50,,1660.12,Percent of Total Billed Charges,50% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462.94,50,,1660.12,Percent of Total Billed Charges,50% of Total Billed Charges,462.94,50,,1660.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.11,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,129.62,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,925.87,100,,1048.8,Percent of Total Billed Charges,100% of Total Billed Charges,129.62,1335.72,
1048505 CEMENT SPINAL CONFIDEN,32105556,CDM,278,RC,C1713,HCPCS,Outpatient,,,4928.55,2957.13,,5738.67,110,,2337.528,Percent of Total Billed Charges,110% of Total Billed Charges,2217.85,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1379.99,28,,2703.472,Percent of Total Billed Charges,28% of Total Billed Charges,607.03,32,,0.328,Percent of Total Billed Charges,32% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,1774.28,36,,3475.888,Percent of Total Billed Charges,36% of Total Billed Charges,1774.28,36,,3475.888,Percent of Total Billed Charges,36% Total Bille Charges,1774.28,36,,3475.888,Percent of Total Billed Charges,36% of Total Billed Charges,2710.7,55,,935.616,Percent of Total Billed Charges,55% Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4928.55,100,,5587.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,710.7,14.42,,2288.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3942.84,80,,4241.952,Percent of Total Billed Charges,80% of Total Billed Charges,2464.28,50,,370.504,Percent of Total Billed Charges,50% of Total Billed Charges,2464.28,50,,617.176,Percent of Total Billed Charges,50% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2464.28,50,,617.176,Percent of Total Billed Charges,50% of Total Billed Charges,2464.28,50,,617.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3449.99,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,690,14,,2222.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4928.55,100,,5302.44,Percent of Total Billed Charges,100% of Total Billed Charges,607.03,5738.67,
1405622 CEMENT BONE HV AB,32105557,CDM,278,RC,C1713,HCPCS,Outpatient,,,877.14,526.28,,1282.11,110,,37197.584,Percent of Total Billed Charges,110% of Total Billed Charges,394.71,45,,491.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,1446.616,Percent of Total Billed Charges,28% of Total Billed Charges,607.03,32,,0.328,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,1859.936,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,1859.936,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,1859.936,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,55,,78.72,Percent of Total Billed Charges,55% Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,2096.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,480.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,701.71,80,,1788.864,Percent of Total Billed Charges,80% of Total Billed Charges,438.57,50,,1660.12,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,466.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,2236.08,Percent of Total Billed Charges,100% of Total Billed Charges,122.8,1282.11,
1228557 OSTEOMED STAPLE,32105558,CDM,278,RC,C1713,HCPCS,Outpatient,,,2668.05,1600.83,,3252.12,110,,511.784,Percent of Total Billed Charges,110% of Total Billed Charges,1200.62,45,,4899.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.05,28,,1446.616,Percent of Total Billed Charges,28% of Total Billed Charges,607.51,32,,0.328,Percent of Total Billed Charges,32% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,960.5,36,,1859.936,Percent of Total Billed Charges,36% of Total Billed Charges,960.5,36,,1859.936,Percent of Total Billed Charges,36% Total Bille Charges,960.5,36,,1859.936,Percent of Total Billed Charges,36% of Total Billed Charges,1467.43,55,,7.2,Percent of Total Billed Charges,55% Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2668.05,100,,641.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,384.73,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2134.44,80,,102.016,Percent of Total Billed Charges,80% of Total Billed Charges,1334.03,50,,617.176,Percent of Total Billed Charges,50% of Total Billed Charges,1334.03,50,,7935.984,Percent of Total Billed Charges,50% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334.03,50,,7935.984,Percent of Total Billed Charges,50% of Total Billed Charges,1334.03,50,,7935.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1867.64,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2668.05,100,,136.024,Percent of Total Billed Charges,100% of Total Billed Charges,373.53,3252.12,
1209405 BIOZORB MARKER,32105559,CDM,278,RC,A4648,HCPCS,Outpatient,,,4023.25,2413.95,,4527.72,110,,871.312,Percent of Total Billed Charges,110% of Total Billed Charges,1810.46,45,,135.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1126.51,28,,241.232,Percent of Total Billed Charges,28% of Total Billed Charges,607.51,32,,0.328,Percent of Total Billed Charges,32% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,1448.37,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,1448.37,36,,310.152,Percent of Total Billed Charges,36% Total Bille Charges,1448.37,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,2212.79,55,,114.72,Percent of Total Billed Charges,55% Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4023.25,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,580.15,14.42,,653.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3218.6,80,,2988.464,Percent of Total Billed Charges,80% of Total Billed Charges,2011.63,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,2011.63,50,,1666.896,Percent of Total Billed Charges,50% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2011.63,50,,1666.896,Percent of Total Billed Charges,50% of Total Billed Charges,2011.63,50,,1666.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2816.28,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,563.26,14,,634.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4023.25,100,,3735.584,Percent of Total Billed Charges,100% of Total Billed Charges,563.26,4527.72,
1374880 REMOTE CTRL FREELINK,32105560,CDM,272,RC,C1787,HCPCS,Outpatient,,,3388,2032.80,,59.4,100,,213.84,Fee Schedule,100% of Aetna Fee Schedule,1524.6,45,,1271.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.64,28,,241.232,Percent of Total Billed Charges,28% of Total Billed Charges,609.45,32,,0.336,Percent of Total Billed Charges,32% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.68,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,1219.68,36,,310.152,Percent of Total Billed Charges,36% Total Bille Charges,1219.68,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,2032.8,60,,735.864,Percent of Total Billed Charges,60% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,100,,1092.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,488.55,14.42,,346.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2541,75,,41.328,Percent of Total Billed Charges,75% of Total Billed Charges,1694,50,,7935.984,Percent of Total Billed Charges,50% of Total Billed Charges,1694,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1694,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,1694,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2371.6,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,474.32,14,,336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3388,100,,51.656,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,3388,
1374875 SPECTRA WAVEWRITER,32105561,CDM,278,RC,C1820,HCPCS,Outpatient,,,59482.5,35689.50,,67060.93,110,,3442,Percent of Total Billed Charges,110% of Total Billed Charges,26767.13,45,,347.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16655.1,28,,365.672,Percent of Total Billed Charges,28% of Total Billed Charges,611.84,32,,0.336,Percent of Total Billed Charges,32% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,21413.7,36,,470.152,Percent of Total Billed Charges,36% of Total Billed Charges,21413.7,36,,470.152,Percent of Total Billed Charges,36% Total Bille Charges,21413.7,36,,470.152,Percent of Total Billed Charges,36% of Total Billed Charges,32715.38,55,,2048.92,Percent of Total Billed Charges,55% Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59482.5,100,,10888.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8577.38,14.42,,749.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47586,80,,592.808,Percent of Total Billed Charges,80% of Total Billed Charges,29741.25,50,,1666.896,Percent of Total Billed Charges,50% of Total Billed Charges,29741.25,50,,2267.408,Percent of Total Billed Charges,50% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29741.25,50,,2267.408,Percent of Total Billed Charges,50% of Total Billed Charges,29741.25,50,,2267.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41637.75,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,8327.55,14,,728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59482.5,100,,741.008,Percent of Total Billed Charges,100% of Total Billed Charges,611.84,67060.93,
COLLAGEN POWDER 5GM,32105562,CDM,272,RC,,,Outpatient,,,4588.65,2753.19,,2753.19,60,,890.208,Percent of Total Billed Charges,60% of Total Billed Charges,2064.89,45,,11012.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1284.82,28,,184.8,Percent of Total Billed Charges,28% of Total Billed Charges,613.12,32,,0.336,Percent of Total Billed Charges,32% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,1651.91,36,,237.6,Percent of Total Billed Charges,36% of Total Billed Charges,1651.91,36,,237.6,Percent of Total Billed Charges,36% Total Bille Charges,1651.91,36,,237.6,Percent of Total Billed Charges,36% of Total Billed Charges,2753.19,60,,1897.672,Percent of Total Billed Charges,60% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4588.65,100,,300.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,661.68,14.42,,865.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3441.49,75,,2656.192,Percent of Total Billed Charges,75% of Total Billed Charges,2294.33,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,2294.33,50,,1200,Percent of Total Billed Charges,50% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2294.33,50,,1200,Percent of Total Billed Charges,50% of Total Billed Charges,2294.33,50,,1200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3212.06,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4588.65,100,,3320.24,Percent of Total Billed Charges,100% of Total Billed Charges,613.12,4588.65,
1425630 BONE CEMENT HERAEUS,32105563,CDM,278,RC,C1713,HCPCS,Outpatient,,,1311,786.60,,1759.36,110,,14342.216,Percent of Total Billed Charges,110% of Total Billed Charges,589.95,45,,325.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.08,28,,852.4,Percent of Total Billed Charges,28% of Total Billed Charges,613.12,32,,0.336,Percent of Total Billed Charges,32% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,471.96,36,,1095.944,Percent of Total Billed Charges,36% of Total Billed Charges,471.96,36,,1095.944,Percent of Total Billed Charges,36% Total Bille Charges,471.96,36,,1095.944,Percent of Total Billed Charges,36% of Total Billed Charges,721.05,55,,574.2,Percent of Total Billed Charges,55% Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1311,100,,2825.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,189.05,14.42,,1730.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1048.8,80,,5209.992,Percent of Total Billed Charges,80% of Total Billed Charges,655.5,50,,2267.408,Percent of Total Billed Charges,50% of Total Billed Charges,655.5,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,655.5,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,655.5,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917.7,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,183.54,14,,1680,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1311,100,,6512.488,Percent of Total Billed Charges,100% of Total Billed Charges,183.54,1759.36,
1335411 KIT PATIENT PROGRAMMER,32105564,CDM,278,RC,C1787,HCPCS,Outpatient,,,6628.05,3976.83,,7350.26,110,,63.36,Percent of Total Billed Charges,110% of Total Billed Charges,2982.62,45,,1346.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1855.85,28,,640.64,Percent of Total Billed Charges,28% of Total Billed Charges,615.95,32,,0.336,Percent of Total Billed Charges,32% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,2386.1,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,2386.1,36,,823.68,Percent of Total Billed Charges,36% Total Bille Charges,2386.1,36,,823.68,Percent of Total Billed Charges,36% of Total Billed Charges,3645.43,55,,1169.52,Percent of Total Billed Charges,55% Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6628.05,100,,772.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,955.76,14.42,,1747.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5302.44,80,,925.768,Percent of Total Billed Charges,80% of Total Billed Charges,3314.03,50,,1200,Percent of Total Billed Charges,50% of Total Billed Charges,3314.03,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3314.03,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,3314.03,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4639.64,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,1696.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6628.05,100,,1234.352,Percent of Total Billed Charges,100% of Total Billed Charges,615.95,7350.26,
182999 GRAFT BIODESIGN DURASIS,32105565,CDM,278,RC,,,Outpatient,,,2795.1,1677.06,,3074.61,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,1257.8,45,,153.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,782.63,28,,218.312,Percent of Total Billed Charges,28% of Total Billed Charges,615.95,32,,0.344,Percent of Total Billed Charges,32% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,1006.24,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,1006.24,36,,280.688,Percent of Total Billed Charges,36% Total Bille Charges,1006.24,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,1537.31,55,,26920.08,Percent of Total Billed Charges,55% Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2795.1,100,,24472.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,403.05,14.42,,2249.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2236.08,80,,2710.4,Percent of Total Billed Charges,80% of Total Billed Charges,1397.55,50,,2600,Percent of Total Billed Charges,50% of Total Billed Charges,1397.55,50,,6000,Percent of Total Billed Charges,50% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1397.55,50,,6000,Percent of Total Billed Charges,50% of Total Billed Charges,1397.55,50,,6000,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1956.57,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,391.31,14,,2184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2795.1,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,391.31,3074.61,
544265 GLIDEWIRE TERUMO RADIFO,32105566,CDM,272,RC,C1769,HCPCS,Outpatient,,,170.03,102.02,,55.13,100,,2557.152,Fee Schedule,100% of Aetna Fee Schedule,76.51,45,,2800.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.61,28,,177.192,Percent of Total Billed Charges,28% of Total Billed Charges,617.89,32,,0.344,Percent of Total Billed Charges,32% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,36,,227.824,Percent of Total Billed Charges,36% of Total Billed Charges,61.21,36,,227.824,Percent of Total Billed Charges,36% Total Bille Charges,61.21,36,,227.824,Percent of Total Billed Charges,36% of Total Billed Charges,102.02,60,,2028.976,Percent of Total Billed Charges,60% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.03,100,,722.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14.42,,3114.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.52,75,,4816.248,Percent of Total Billed Charges,75% of Total Billed Charges,85.02,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,6060,Percent of Total Billed Charges,50% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.02,50,,6060,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,6060,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.02,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.03,100,,6020.312,Percent of Total Billed Charges,100% of Total Billed Charges,23.8,617.89,
565108 VALVE CODMAN HAKIM PREC,32105567,CDM,278,RC,,,Outpatient,,,4669.48,2801.69,,5136.43,110,,2557.152,Percent of Total Billed Charges,110% of Total Billed Charges,2101.27,45,,757.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1307.45,28,,218.312,Percent of Total Billed Charges,28% of Total Billed Charges,617.89,32,,0.352,Percent of Total Billed Charges,32% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,1681.01,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,1681.01,36,,280.688,Percent of Total Billed Charges,36% Total Bille Charges,1681.01,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,2568.21,55,,2284.128,Percent of Total Billed Charges,55% Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4669.48,100,,2991.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,673.34,14.42,,3979.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3735.58,80,,2710.4,Percent of Total Billed Charges,80% of Total Billed Charges,2334.74,50,,6000,Percent of Total Billed Charges,50% of Total Billed Charges,2334.74,50,,7800,Percent of Total Billed Charges,50% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2334.74,50,,7800,Percent of Total Billed Charges,50% of Total Billed Charges,2334.74,50,,7800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3268.64,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,653.73,14,,3864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4669.48,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,617.89,5136.43,
1426138 BONE CEMENT W/GENT,32105568,CDM,278,RC,C1713,HCPCS,Outpatient,,,64.57,38.74,,388.29,110,,1169.52,Percent of Total Billed Charges,110% of Total Billed Charges,29.06,45,,11012.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.08,28,,283.8,Percent of Total Billed Charges,28% of Total Billed Charges,618.82,32,,0.352,Percent of Total Billed Charges,32% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,36,,364.888,Percent of Total Billed Charges,36% of Total Billed Charges,23.25,36,,364.888,Percent of Total Billed Charges,36% Total Bille Charges,23.25,36,,364.888,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.57,100,,342.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.31,14.42,,11.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.66,80,,12697.576,Percent of Total Billed Charges,80% of Total Billed Charges,32.29,50,,6060,Percent of Total Billed Charges,50% of Total Billed Charges,32.29,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.29,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.29,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.2,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.57,100,,15871.968,Percent of Total Billed Charges,100% of Total Billed Charges,9.04,618.82,
847860 CATH SET VENTRICULAR 35,32105569,CDM,278,RC,C1729,HCPCS,Outpatient,,,926.26,555.76,,1029.99,110,,80.16,Percent of Total Billed Charges,110% of Total Billed Charges,416.82,45,,952.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.35,28,,564.44,Percent of Total Billed Charges,28% of Total Billed Charges,619.07,32,,0.352,Percent of Total Billed Charges,32% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,333.45,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,333.45,36,,725.712,Percent of Total Billed Charges,36% Total Bille Charges,333.45,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,509.44,55,,2841.568,Percent of Total Billed Charges,55% Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,926.26,100,,6223.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,133.57,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.01,80,,5819.088,Percent of Total Billed Charges,80% of Total Billed Charges,463.13,50,,7800,Percent of Total Billed Charges,50% of Total Billed Charges,463.13,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.13,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,463.13,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.38,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,129.68,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,926.26,100,,7273.864,Percent of Total Billed Charges,100% of Total Billed Charges,129.68,1029.99,
789690 BIOCARTILAGE ARTHREX,32105570,CDM,278,RC,,,Outpatient,,,4150.3,2490.18,,4565.33,110,,69.784,Percent of Total Billed Charges,110% of Total Billed Charges,1867.64,45,,990.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1162.08,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,619.4,32,,0.352,Percent of Total Billed Charges,32% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,1494.11,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,1494.11,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,1494.11,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,2282.67,55,,2841.568,Percent of Total Billed Charges,55% Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4150.3,100,,1684.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,598.47,14.42,,12.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3320.24,80,,2667.032,Percent of Total Billed Charges,80% of Total Billed Charges,2075.15,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,2075.15,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2075.15,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,2075.15,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2905.21,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,581.04,14,,12.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4150.3,100,,3333.792,Percent of Total Billed Charges,100% of Total Billed Charges,581.04,4565.33,
1337956 MESH ALLOPATCH PLIABLE,32105571,CDM,278,RC,Q4128,HCPCS,Outpatient,,,8140.61,4884.37,,8989.69,110,,559.288,Percent of Total Billed Charges,110% of Total Billed Charges,3663.27,45,,1341.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2279.37,28,,44.56,Percent of Total Billed Charges,28% of Total Billed Charges,619.89,32,,0.352,Percent of Total Billed Charges,32% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,2930.62,36,,57.288,Percent of Total Billed Charges,36% of Total Billed Charges,2930.62,36,,57.288,Percent of Total Billed Charges,36% Total Bille Charges,2930.62,36,,57.288,Percent of Total Billed Charges,36% of Total Billed Charges,4477.34,55,,473.848,Percent of Total Billed Charges,55% Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8140.61,100,,24472.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1173.88,14.42,,21.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6512.49,80,,2710.4,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,42,Fee Schedule,80% of Scott and White HMO fee schedule,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,42,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,42,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5698.43,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,1139.69,14,,21.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8140.61,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,8989.69,
1385940 STAPLE TRI CIRC EEA,32105572,CDM,272,RC,,,Outpatient,,,1542.94,925.76,,925.76,60,,662.16,Percent of Total Billed Charges,60% of Total Billed Charges,694.32,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.02,28,,44.56,Percent of Total Billed Charges,28% of Total Billed Charges,621.12,32,,0.36,Percent of Total Billed Charges,32% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,555.46,36,,57.288,Percent of Total Billed Charges,36% of Total Billed Charges,555.46,36,,57.288,Percent of Total Billed Charges,36% Total Bille Charges,555.46,36,,57.288,Percent of Total Billed Charges,36% of Total Billed Charges,925.76,60,,473.848,Percent of Total Billed Charges,60% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1542.94,100,,2116.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,222.49,14.42,,21.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1157.21,75,,3627.856,Percent of Total Billed Charges,75% of Total Billed Charges,771.47,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,771.47,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.47,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,771.47,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.06,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,216.01,14,,21.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1542.94,100,,4534.816,Percent of Total Billed Charges,100% of Total Billed Charges,216.01,1542.94,
425336 MICROMATRIX ACELL,32105573,CDM,278,RC,Q4118,HCPCS,Outpatient,,,4235,2541.00,,4661.57,110,,1053.36,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,21841.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,280,,32.832,Fee Schedule,280% of BCBS BULE Fee Schedule,3.19,320,,0.368,Fee Schedule,320% of BCBS Blue Essentials Rate,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,3.19,360,,42.216,Fee Schedule,360% of BCBS POS Rate,3.19,360,,42.216,Fee schedule,360% of BCBS PPO Rate,3.19,360,,42.216,Fee Schedule,360% of BCBS Traditional Rate,2329.25,55,,783.584,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,2202.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,35.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,1800,Percent of Total Billed Charges,80% of Total Billed Charges,1.99,80,,42,Fee Schedule,80% of Scott and White EPO fee schedule,1.99,80,,75.04,Fee Schedule,80% of Scott and White HMO fee schedule,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,80,,75.04,Fee Schedule,80% of Scott and White PPO fee schedule,1.99,80,,75.04,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,34.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,2400,Percent of Total Billed Charges,100% of Total Billed Charges,1.99,4661.57,
447502 MICROMATRIX ACELL,32105574,CDM,278,RC,Q4118,HCPCS,Outpatient,,,7525.39,4515.23,,8281,110,,6625.488,Percent of Total Billed Charges,110% of Total Billed Charges,3386.43,45,,13613,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,280,,52.536,Fee Schedule,280% of BCBS BULE Fee Schedule,3.19,320,,0.368,Fee Schedule,320% of BCBS Blue Essentials Rate,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.19,360,,67.544,Fee Schedule,360% of BCBS POS Rate,3.19,360,,67.544,Fee schedule,360% of BCBS PPO Rate,3.19,360,,67.544,Fee Schedule,360% of BCBS Traditional Rate,4138.96,55,,396,Percent of Total Billed Charges,55% Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7525.39,100,,2981.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1085.16,14.42,,46.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6020.31,80,,3900,Percent of Total Billed Charges,80% of Total Billed Charges,1.99,80,,44,Fee Schedule,80% of Scott and White EPO fee schedule,1.99,80,,75.6,Fee Schedule,80% of Scott and White HMO fee schedule,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,80,,75.6,Fee Schedule,80% of Scott and White PPO fee schedule,1.99,80,,75.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5267.77,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,1053.55,14,,45.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7525.39,100,,5200,Percent of Total Billed Charges,100% of Total Billed Charges,1.99,8281,
1460518 FILLER OSTEOVATION EX,32105575,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235,2541.00,,4975.76,110,,1358.864,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,4263.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,622.08,32,,0.368,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,1826.576,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,59.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,4500,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,75.04,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,406.608,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,58.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,6000,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,4975.76,
1462164 VALVE CERTAS,32105576,CDM,278,RC,,,Outpatient,,,19839.96,11903.98,,21823.96,110,,479.504,Percent of Total Billed Charges,110% of Total Billed Charges,8927.98,45,,8337.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5555.19,28,,23.96,Percent of Total Billed Charges,28% of Total Billed Charges,623.39,32,,0.368,Percent of Total Billed Charges,32% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,7142.39,36,,30.808,Percent of Total Billed Charges,36% of Total Billed Charges,7142.39,36,,30.808,Percent of Total Billed Charges,36% Total Bille Charges,7142.39,36,,30.808,Percent of Total Billed Charges,36% of Total Billed Charges,10911.98,55,,1258.4,Percent of Total Billed Charges,55% Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19839.96,100,,48537.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2860.92,14.42,,1211.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15871.97,80,,9000,Percent of Total Billed Charges,80% of Total Billed Charges,9919.98,50,,75.6,Percent of Total Billed Charges,50% of Total Billed Charges,9919.98,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9919.98,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,9919.98,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13887.97,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,2777.59,14,,1176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19839.96,100,,12000,Percent of Total Billed Charges,100% of Total Billed Charges,623.39,21823.96,
896569 AMNIOBAND,32105577,CDM,278,RC,Q4151,HCPCS,Outpatient,,,9092.33,5455.40,,10130.39,110,,2207.744,Percent of Total Billed Charges,110% of Total Billed Charges,4091.55,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2545.85,28,,84.056,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.376,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3273.24,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,3273.24,36,,108.072,Percent of Total Billed Charges,36% Total Bille Charges,3273.24,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,5000.78,55,,467.808,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9092.33,100,,30251.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7273.86,80,,9090,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,122.4,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,207.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,207.2,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,207.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6364.63,70,,382.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9092.33,100,,12120,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,10130.39,
1463820 MATRIX ADIPOSE LENEVA,32105578,CDM,278,RC,Q4100,HCPCS,Outpatient,,,4167.24,2500.34,,4583.96,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,1875.26,45,,1074.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1166.83,28,,84.056,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.376,Percent of Total Billed Charges,32% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,1500.21,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,1500.21,36,,108.072,Percent of Total Billed Charges,36% Total Bille Charges,1500.21,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,2291.98,55,,379.704,Percent of Total Billed Charges,55% Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4167.24,100,,9474.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,600.92,14.42,,1903.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3333.79,80,,11700,Percent of Total Billed Charges,80% of Total Billed Charges,2083.62,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,2083.62,50,,4200,Percent of Total Billed Charges,50% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2083.62,50,,4200,Percent of Total Billed Charges,50% of Total Billed Charges,2083.62,50,,4200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2917.07,70,,1873.872,Percent of Total Billed Charges,70% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,583.41,14,,1848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4167.24,100,,15600,Percent of Total Billed Charges,100% of Total Billed Charges,583.41,4583.96,
577384 MATRISTEM BURN MATRIX,32105579,CDM,278,RC,Q4166,HCPCS,Outpatient,,,4235,2541.00,,4676.92,110,,1561.728,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,9936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,84.056,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.376,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,108.072,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,467.808,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,18528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,2191.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,16200,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,207.2,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,4600,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,4600,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,4600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,382.04,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,21600,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,4676.92,
STRATTICE FIRM,32110397,CDM,278,RC,Q4130,HCPCS,Outpatient,,,5668.52,3401.11,,6241.03,110,,1304.432,Percent of Total Billed Charges,110% of Total Billed Charges,2550.83,45,,3367.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1587.19,28,,155.544,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.376,Percent of Total Billed Charges,32% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,2040.67,36,,199.984,Percent of Total Billed Charges,36% of Total Billed Charges,2040.67,36,,199.984,Percent of Total Billed Charges,36% Total Bille Charges,2040.67,36,,199.984,Percent of Total Billed Charges,36% of Total Billed Charges,3117.69,55,,608.152,Percent of Total Billed Charges,55% Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5668.52,100,,1559.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,817.4,14.42,,2710.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4534.82,80,,20700,Percent of Total Billed Charges,80% of Total Billed Charges,2834.26,50,,4200,Percent of Total Billed Charges,50% of Total Billed Charges,2834.26,50,,6600,Percent of Total Billed Charges,50% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2834.26,50,,6600,Percent of Total Billed Charges,50% of Total Billed Charges,2834.26,50,,6600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3967.96,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,793.59,14,,2632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5668.52,100,,27600,Percent of Total Billed Charges,100% of Total Billed Charges,623.74,6241.03,
OR GROUP LEVEL 1,32110505,CDM,360,RC,,,Outpatient,,,3000,1800.00,,1800,60,,10039.744,Percent of Total Billed Charges,60% of Total Billed Charges,1350,45,,331.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,28,,266.336,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.384,Percent of Total Billed Charges,32% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,1080,36,,342.432,Percent of Total Billed Charges,36% of Total Billed Charges,1080,36,,342.432,Percent of Total Billed Charges,36% Total Bille Charges,1080,36,,342.432,Percent of Total Billed Charges,36% of Total Billed Charges,1800,60,,95.48,Percent of Total Billed Charges,60% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3000,100,,7483.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,432.6,14.42,,18.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,1500,50,,7600,Percent of Total Billed Charges,50% of Total Billed Charges,1500,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1500,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,1500,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,70,,2341.248,Percent of Total Billed Charges,70% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,420,14,,17.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3000,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,420,3000,
OR GROUP LEVEL 2,32110506,CDM,360,RC,,,Outpatient,,,6500,3900.00,,3900,60,,1961.896,Percent of Total Billed Charges,60% of Total Billed Charges,2925,45,,3369.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,28,,30.496,Percent of Total Billed Charges,28% of Total Billed Charges,623.74,32,,0.384,Percent of Total Billed Charges,32% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,2340,36,,39.208,Percent of Total Billed Charges,36% of Total Billed Charges,2340,36,,39.208,Percent of Total Billed Charges,36% Total Bille Charges,2340,36,,39.208,Percent of Total Billed Charges,36% of Total Billed Charges,3900,60,,95.48,Percent of Total Billed Charges,60% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6500,100,,4486.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,937.3,14.42,,20.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4875,75,,112.56,Percent of Total Billed Charges,75% of Total Billed Charges,3250,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,3250,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3250,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,3250,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4550,70,,223.8,Percent of Total Billed Charges,70% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,910,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,100,,150.08,Percent of Total Billed Charges,100% of Total Billed Charges,623.74,6500,
OR GROUP LEVEL 3,32110507,CDM,360,RC,,,Outpatient,,,7500,4500.00,,4500,60,,6576.472,Percent of Total Billed Charges,60% of Total Billed Charges,3375,45,,997.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,28,,14.408,Percent of Total Billed Charges,28% of Total Billed Charges,624,32,,0.384,Percent of Total Billed Charges,32% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2700,36,,18.52,Percent of Total Billed Charges,36% of Total Billed Charges,2700,36,,18.52,Percent of Total Billed Charges,36% Total Bille Charges,2700,36,,18.52,Percent of Total Billed Charges,36% of Total Billed Charges,4500,60,,70.36,Percent of Total Billed Charges,60% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7500,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1081.5,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5625,75,,113.4,Percent of Total Billed Charges,75% of Total Billed Charges,3750,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,3750,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3750,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,3750,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5250,70,,9640.928,Percent of Total Billed Charges,70% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7500,100,,151.2,Percent of Total Billed Charges,100% of Total Billed Charges,624,7500,
OR GROUP LEVEL 4,32110508,CDM,360,RC,,,Outpatient,,,15000,9000.00,,9000,60,,1386.232,Percent of Total Billed Charges,60% of Total Billed Charges,6750,45,,4904.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4200,28,,272.888,Percent of Total Billed Charges,28% of Total Billed Charges,628.92,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,5400,36,,350.856,Percent of Total Billed Charges,36% of Total Billed Charges,5400,36,,350.856,Percent of Total Billed Charges,36% Total Bille Charges,5400,36,,350.856,Percent of Total Billed Charges,36% of Total Billed Charges,9000,60,,112.568,Percent of Total Billed Charges,60% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15000,100,,736.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2163,14.42,,27.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11250,75,,183.6,Percent of Total Billed Charges,75% of Total Billed Charges,7500,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,7500,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7500,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,7500,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10500,70,,791.376,Percent of Total Billed Charges,70% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,2100,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15000,100,,244.8,Percent of Total Billed Charges,100% of Total Billed Charges,628.92,15000,
OR GROUP LEVEL 5,32110509,CDM,360,RC,,,Outpatient,,,15150,9090.00,,9090,60,,53914.952,Percent of Total Billed Charges,60% of Total Billed Charges,6817.5,45,,3661.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4242,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,629.98,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,5454,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,5454,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,5454,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,9090,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15150,100,,7488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2184.63,14.42,,40.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11362.5,75,,243,Percent of Total Billed Charges,75% of Total Billed Charges,7575,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,7575,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7575,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,7575,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10605,70,,52.112,Percent of Total Billed Charges,70% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,2121,14,,39.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15150,100,,324,Percent of Total Billed Charges,100% of Total Billed Charges,629.98,15150,
OR GROUP LEVEL 6,32110510,CDM,360,RC,,,Outpatient,,,19500,11700.00,,11700,60,,3210.128,Percent of Total Billed Charges,60% of Total Billed Charges,8775,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5460,28,,2706.696,Percent of Total Billed Charges,28% of Total Billed Charges,635.22,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,7020,36,,3480.032,Percent of Total Billed Charges,36% of Total Billed Charges,7020,36,,3480.032,Percent of Total Billed Charges,36% Total Bille Charges,7020,36,,3480.032,Percent of Total Billed Charges,36% of Total Billed Charges,11700,60,,51.344,Percent of Total Billed Charges,60% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19500,100,,2217.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2811.9,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14625,75,,310.8,Percent of Total Billed Charges,75% of Total Billed Charges,9750,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,9750,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9750,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,9750,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13650,70,,57.4,Percent of Total Billed Charges,70% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,2730,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19500,100,,414.4,Percent of Total Billed Charges,100% of Total Billed Charges,635.22,19500,
OR GROUP LEVEL 7,32110511,CDM,360,RC,,,Outpatient,,,27000,16200.00,,16200,60,,10911.472,Percent of Total Billed Charges,60% of Total Billed Charges,12150,45,,640.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7560,28,,95.8,Percent of Total Billed Charges,28% of Total Billed Charges,636.5,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,9720,36,,123.168,Percent of Total Billed Charges,36% of Total Billed Charges,9720,36,,123.168,Percent of Total Billed Charges,36% Total Bille Charges,9720,36,,123.168,Percent of Total Billed Charges,36% of Total Billed Charges,16200,60,,180.112,Percent of Total Billed Charges,60% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27000,100,,10898.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3893.4,14.42,,66.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20250,75,,6300,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18900,70,,23436,Percent of Total Billed Charges,70% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,64.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27000,100,,8400,Percent of Total Billed Charges,100% of Total Billed Charges,636.5,27000,
OR GROUP LEVEL 8,32110512,CDM,360,RC,,,Outpatient,,,34500,20700.00,,20700,60,,4159.464,Percent of Total Billed Charges,60% of Total Billed Charges,15525,45,,434.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9660,28,,305.632,Percent of Total Billed Charges,28% of Total Billed Charges,637.44,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,12420,36,,392.96,Percent of Total Billed Charges,36% of Total Billed Charges,12420,36,,392.96,Percent of Total Billed Charges,36% Total Bille Charges,12420,36,,392.96,Percent of Total Billed Charges,36% of Total Billed Charges,20700,60,,180.112,Percent of Total Billed Charges,60% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34500,100,,8137.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4974.9,14.42,,39.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25875,75,,6900,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24150,70,,2607.712,Percent of Total Billed Charges,70% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,4830,14,,38.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34500,100,,9200,Percent of Total Billed Charges,100% of Total Billed Charges,637.44,34500,
OR TIME LEVEL 1 EA 15 MIN,32110513,CDM,360,RC,,,Outpatient,,,100,60.00,,60,60,,3980.608,Percent of Total Billed Charges,60% of Total Billed Charges,45,45,,605.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,28,,8892.872,Percent of Total Billed Charges,28% of Total Billed Charges,637.44,32,,0.392,Percent of Total Billed Charges,32% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,36,36,,11433.696,Percent of Total Billed Charges,36% of Total Billed Charges,36,36,,11433.696,Percent of Total Billed Charges,36% Total Bille Charges,36,36,,11433.696,Percent of Total Billed Charges,36% of Total Billed Charges,60,60,,180.112,Percent of Total Billed Charges,60% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14.42,14.42,,5.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,75,,9900,Percent of Total Billed Charges,75% of Total Billed Charges,50,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,70,,5183.36,Percent of Total Billed Charges,70% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,5.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,100,,13200,Percent of Total Billed Charges,100% of Total Billed Charges,14,637.44,
OR TIME LEVEL 2 EA 15 MIN,32110514,CDM,360,RC,,,Outpatient,,,105,63.00,,63,60,,2579.328,Percent of Total Billed Charges,60% of Total Billed Charges,47.25,45,,166.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,28,,1588.208,Percent of Total Billed Charges,28% of Total Billed Charges,638.4,32,,0.4,Percent of Total Billed Charges,32% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,37.8,36,,2041.976,Percent of Total Billed Charges,36% of Total Billed Charges,37.8,36,,2041.976,Percent of Total Billed Charges,36% Total Bille Charges,37.8,36,,2041.976,Percent of Total Billed Charges,36% of Total Billed Charges,63,60,,333.312,Percent of Total Billed Charges,60% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,1423.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.75,75,,11400,Percent of Total Billed Charges,75% of Total Billed Charges,52.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.5,70,,3407.16,Percent of Total Billed Charges,70% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,100,,15200,Percent of Total Billed Charges,100% of Total Billed Charges,14.7,638.4,
OR TIME LEVEL 3 EA 15 MIN,32110515,CDM,360,RC,,,Outpatient,,,110,66.00,,66,60,,6157.008,Percent of Total Billed Charges,60% of Total Billed Charges,49.5,45,,745.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.8,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,638.56,32,,0.4,Percent of Total Billed Charges,32% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,39.6,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,39.6,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,39.6,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,66,60,,2496,Percent of Total Billed Charges,60% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,100,,964.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.86,14.42,,2.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.5,75,,14100,Percent of Total Billed Charges,75% of Total Billed Charges,55,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,55,50,,137.576,Percent of Total Billed Charges,50% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,50,,137.576,Percent of Total Billed Charges,50% of Total Billed Charges,55,50,,137.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,70,,1077.912,Percent of Total Billed Charges,70% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.4,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,100,,18800,Percent of Total Billed Charges,100% of Total Billed Charges,15.4,638.56,
OR TIME LEVEL 4 EA 15 MIN,32110516,CDM,360,RC,,,Outpatient,,,187.6,112.56,,112.56,60,,1031.432,Percent of Total Billed Charges,60% of Total Billed Charges,84.42,45,,760.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,28,,59.128,Percent of Total Billed Charges,28% of Total Billed Charges,639.34,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,67.54,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,67.54,36,,76.016,Percent of Total Billed Charges,36% Total Bille Charges,67.54,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,112.56,60,,514.592,Percent of Total Billed Charges,60% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.6,100,,1344.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,27.05,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.7,75,,18600,Percent of Total Billed Charges,75% of Total Billed Charges,93.8,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,93.8,50,,20.08,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.8,50,,20.08,Percent of Total Billed Charges,50% of Total Billed Charges,93.8,50,,20.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.32,70,,310.736,Percent of Total Billed Charges,70% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.6,100,,24800,Percent of Total Billed Charges,100% of Total Billed Charges,26.26,639.34,
OR TIME LEVEL 5 EA 15 MIN,32110517,CDM,360,RC,,,Outpatient,,,189,113.40,,113.4,60,,1730.64,Percent of Total Billed Charges,60% of Total Billed Charges,85.05,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.92,28,,59.128,Percent of Total Billed Charges,28% of Total Billed Charges,0.32,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.04,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,68.04,36,,76.016,Percent of Total Billed Charges,36% Total Bille Charges,68.04,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,113.4,60,,570.728,Percent of Total Billed Charges,60% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,100,,369.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,27.25,14.42,,5.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.75,75,,23100,Percent of Total Billed Charges,75% of Total Billed Charges,94.5,50,,137.576,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.3,70,,995.496,Percent of Total Billed Charges,70% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,26.46,14,,5.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,100,,30800,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,189,
OR TIME LEVEL 6 EA 15 MIN,32110518,CDM,360,RC,,,Outpatient,,,306,183.60,,183.6,60,,606.816,Percent of Total Billed Charges,60% of Total Billed Charges,137.7,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.32,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,110.16,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,110.16,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,110.16,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,183.6,60,,65.352,Percent of Total Billed Charges,60% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306,100,,1656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,44.13,14.42,,307.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.5,75,,94.8,Percent of Total Billed Charges,75% of Total Billed Charges,153,50,,20.08,Percent of Total Billed Charges,50% of Total Billed Charges,153,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,153,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.2,70,,1091.552,Percent of Total Billed Charges,70% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,42.84,14,,298.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306,100,,126.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,306,
OR TIME LEVEL 7 EA 15 MIN,32110519,CDM,360,RC,,,Outpatient,,,405,243.00,,243,60,,1708.384,Percent of Total Billed Charges,60% of Total Billed Charges,182.25,45,,1643.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,28,,56.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.33,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,145.8,36,,72.664,Percent of Total Billed Charges,36% of Total Billed Charges,145.8,36,,72.664,Percent of Total Billed Charges,36% Total Bille Charges,145.8,36,,72.664,Percent of Total Billed Charges,36% of Total Billed Charges,243,60,,30.872,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,100,,1690.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,58.4,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.75,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,202.5,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,202.5,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.5,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,202.5,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.5,70,,91.84,Percent of Total Billed Charges,70% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,405,
OR TIME LEVEL 8 EA 15 MIN,32110520,CDM,360,RC,,,Outpatient,,,518,310.80,,310.8,60,,11016.72,Percent of Total Billed Charges,60% of Total Billed Charges,233.1,45,,1263.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.04,28,,2201.136,Percent of Total Billed Charges,28% of Total Billed Charges,0.33,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,186.48,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,186.48,36,,2830.032,Percent of Total Billed Charges,36% Total Bille Charges,186.48,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,310.8,60,,536.032,Percent of Total Billed Charges,60% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,74.7,14.42,,11.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.5,75,,120,Percent of Total Billed Charges,75% of Total Billed Charges,259,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,259,50,,18.704,Percent of Total Billed Charges,50% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259,50,,18.704,Percent of Total Billed Charges,50% of Total Billed Charges,259,50,,18.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.6,70,,8.4,Percent of Total Billed Charges,70% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,72.52,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,518,
OR GROUP LEVEL 2 ROBOTIC,32110521,CDM,360,RC,,,Outpatient,,,10500,6300.00,,6300,60,,112.088,Percent of Total Billed Charges,60% of Total Billed Charges,4725,45,,51.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2940,28,,2201.136,Percent of Total Billed Charges,28% of Total Billed Charges,0.33,32,,0.408,Percent of Total Billed Charges,32% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,3780,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,3780,36,,2830.032,Percent of Total Billed Charges,36% Total Bille Charges,3780,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,6300,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10500,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1514.1,14.42,,48.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7875,75,,144,Percent of Total Billed Charges,75% of Total Billed Charges,5250,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,5250,50,,1065.792,Percent of Total Billed Charges,50% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5250,50,,1065.792,Percent of Total Billed Charges,50% of Total Billed Charges,5250,50,,1065.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7350,70,,133.84,Percent of Total Billed Charges,70% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1470,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10500,100,,192,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,10500,
OR GROUP LEVEL 3 ROBOTIC,32110522,CDM,360,RC,,,Outpatient,,,11500,6900.00,,6900,60,,1111.808,Percent of Total Billed Charges,60% of Total Billed Charges,5175,45,,8640,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3220,28,,21.424,Percent of Total Billed Charges,28% of Total Billed Charges,0.33,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,4140,36,,27.544,Percent of Total Billed Charges,36% of Total Billed Charges,4140,36,,27.544,Percent of Total Billed Charges,36% Total Bille Charges,4140,36,,27.544,Percent of Total Billed Charges,36% of Total Billed Charges,6900,60,,5316.72,Percent of Total Billed Charges,60% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11500,100,,3653.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1658.3,14.42,,112.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8625,75,,211.8,Percent of Total Billed Charges,75% of Total Billed Charges,5750,50,,18.704,Percent of Total Billed Charges,50% of Total Billed Charges,5750,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5750,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,5750,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8050,70,,936.552,Percent of Total Billed Charges,70% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,1610,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11500,100,,282.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,11500,
OR GROUP LEVEL 4 ROBOTIC,32110523,CDM,360,RC,,,Outpatient,,,16500,9900.00,,9900,60,,4398.808,Percent of Total Billed Charges,60% of Total Billed Charges,7425,45,,1287,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4620,28,,19.328,Percent of Total Billed Charges,28% of Total Billed Charges,0.33,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,5940,36,,24.848,Percent of Total Billed Charges,36% of Total Billed Charges,5940,36,,24.848,Percent of Total Billed Charges,36% Total Bille Charges,5940,36,,24.848,Percent of Total Billed Charges,36% of Total Billed Charges,9900,60,,205.288,Percent of Total Billed Charges,60% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16500,100,,2808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2379.3,14.42,,80.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12375,75,,279,Percent of Total Billed Charges,75% of Total Billed Charges,8250,50,,1065.792,Percent of Total Billed Charges,50% of Total Billed Charges,8250,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8250,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,8250,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11550,70,,2607.712,Percent of Total Billed Charges,70% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,2310,14,,78.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16500,100,,372,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,16500,
OR GROUP LEVEL 5 ROBOTIC,32110524,CDM,360,RC,,,Outpatient,,,19000,11400.00,,11400,60,,557.496,Percent of Total Billed Charges,60% of Total Billed Charges,8550,45,,26.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5320,28,,455.344,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,6840,36,,585.448,Percent of Total Billed Charges,36% of Total Billed Charges,6840,36,,585.448,Percent of Total Billed Charges,36% Total Bille Charges,6840,36,,585.448,Percent of Total Billed Charges,36% of Total Billed Charges,11400,60,,654.928,Percent of Total Billed Charges,60% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19000,100,,113.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2739.8,14.42,,3.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14250,75,,346.8,Percent of Total Billed Charges,75% of Total Billed Charges,9500,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9500,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9500,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,9500,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13300,70,,2415.216,Percent of Total Billed Charges,70% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,3.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19000,100,,462.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,19000,
OR GROUP LEVEL 6 ROBOTIC,32110525,CDM,360,RC,,,Outpatient,,,23500,14100.00,,14100,60,,33.312,Percent of Total Billed Charges,60% of Total Billed Charges,10575,45,,3153.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6580,28,,740.888,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,8460,36,,952.568,Percent of Total Billed Charges,36% of Total Billed Charges,8460,36,,952.568,Percent of Total Billed Charges,36% Total Bille Charges,8460,36,,952.568,Percent of Total Billed Charges,36% of Total Billed Charges,14100,60,,17468.144,Percent of Total Billed Charges,60% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23500,100,,19200,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3388.7,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17625,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16450,70,,730.8,Percent of Total Billed Charges,70% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,3290,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23500,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,23500,
OR GROUP LEVEL 7 ROBOTIC,32110526,CDM,360,RC,,,Outpatient,,,31000,18600.00,,18600,60,,626.4,Percent of Total Billed Charges,60% of Total Billed Charges,13950,45,,1769.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8680,28,,38.704,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,11160,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,11160,36,,49.76,Percent of Total Billed Charges,36% Total Bille Charges,11160,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,18600,60,,3119.688,Percent of Total Billed Charges,60% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31000,100,,2860,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4470.2,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23250,75,,206.36,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,280.04,Percent of Total Billed Charges,50% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,280.04,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,280.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21700,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,4340,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31000,100,,275.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,31000,
OR GROUP LEVEL 8 ROBOTIC,32110527,CDM,360,RC,,,Outpatient,,,38500,23100.00,,23100,60,,20046.08,Percent of Total Billed Charges,60% of Total Billed Charges,17325,45,,2991.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10780,28,,38.704,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,13860,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,13860,36,,49.76,Percent of Total Billed Charges,36% Total Bille Charges,13860,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,23100,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38500,100,,59.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5551.7,14.42,,9.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28875,75,,30.112,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,13.104,Percent of Total Billed Charges,50% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,13.104,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,13.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26950,70,,34261.92,Percent of Total Billed Charges,70% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,5390,14,,9.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38500,100,,40.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,38500,
OR TIME LEVEL 2 EA 15MIN ROBOT,32110528,CDM,360,RC,,,Outpatient,,,158,94.80,,94.8,60,,2884.32,Percent of Total Billed Charges,60% of Total Billed Charges,71.1,45,,943.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.24,28,,92.128,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.88,36,,118.448,Percent of Total Billed Charges,36% of Total Billed Charges,56.88,36,,118.448,Percent of Total Billed Charges,36% Total Bille Charges,56.88,36,,118.448,Percent of Total Billed Charges,36% of Total Billed Charges,94.8,60,,126.696,Percent of Total Billed Charges,60% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158,100,,7008.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.78,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.5,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,79,50,,280.04,Percent of Total Billed Charges,50% of Total Billed Charges,79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.6,70,,2582.336,Percent of Total Billed Charges,70% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.12,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,158,
OR TIME LEVEL 3 EA 15MIN ROBOT,32110529,CDM,360,RC,,,Outpatient,,,179,107.40,,107.4,60,,296.392,Percent of Total Billed Charges,60% of Total Billed Charges,80.55,45,,2084.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.12,28,,349.296,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.416,Percent of Total Billed Charges,32% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,36,,449.096,Percent of Total Billed Charges,36% of Total Billed Charges,64.44,36,,449.096,Percent of Total Billed Charges,36% Total Bille Charges,64.44,36,,449.096,Percent of Total Billed Charges,36% of Total Billed Charges,107.4,60,,126.696,Percent of Total Billed Charges,60% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179,100,,3931.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.81,14.42,,309.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.25,75,,14.824,Percent of Total Billed Charges,75% of Total Billed Charges,89.5,50,,13.104,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.3,70,,2664.816,Percent of Total Billed Charges,70% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,300.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179,100,,19.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,179,
OR TIME LEVEL 4 EA 15MIN ROBOT,32110530,CDM,360,RC,,,Outpatient,,,200,120.00,,120,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,90,45,,4526.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,28,,1115.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.424,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,1433.672,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,1433.672,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,1433.672,Percent of Total Billed Charges,36% of Total Billed Charges,120,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,100,,6646.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,215.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,75,,56.632,Percent of Total Billed Charges,75% of Total Billed Charges,100,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,33.696,Percent of Total Billed Charges,50% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,50,,33.696,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,33.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,70,,6758.672,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,209.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,200,
OR TIME LEVEL 5 EA 15MIN ROBOT,32110531,CDM,360,RC,,,Outpatient,,,240,144.00,,144,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,108,45,,1682.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.2,28,,147.36,Percent of Total Billed Charges,28% of Total Billed Charges,0.34,32,,0.424,Percent of Total Billed Charges,32% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,86.4,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,86.4,36,,189.464,Percent of Total Billed Charges,36% Total Bille Charges,86.4,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,144,60,,121.104,Percent of Total Billed Charges,60% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240,100,,2096.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,34.61,14.42,,205.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,75,,28.048,Percent of Total Billed Charges,75% of Total Billed Charges,120,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,120,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,120,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,70,,3616.536,Percent of Total Billed Charges,70% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,199.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240,100,,37.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,240,
OR TIME LEVEL 6 EA 15MIN ROBOT,32110532,CDM,360,RC,,,Outpatient,,,353,211.80,,211.8,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,158.85,45,,680.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.84,28,,221.424,Percent of Total Billed Charges,28% of Total Billed Charges,0.35,32,,0.424,Percent of Total Billed Charges,32% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,127.08,36,,284.688,Percent of Total Billed Charges,36% of Total Billed Charges,127.08,36,,284.688,Percent of Total Billed Charges,36% Total Bille Charges,127.08,36,,284.688,Percent of Total Billed Charges,36% of Total Billed Charges,211.8,60,,4323.664,Percent of Total Billed Charges,60% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,353,100,,4631.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,50.9,14.42,,10.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.75,75,,1705.264,Percent of Total Billed Charges,75% of Total Billed Charges,176.5,50,,33.696,Percent of Total Billed Charges,50% of Total Billed Charges,176.5,50,,1072.304,Percent of Total Billed Charges,50% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.5,50,,1072.304,Percent of Total Billed Charges,50% of Total Billed Charges,176.5,50,,1072.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.1,70,,3616.536,Percent of Total Billed Charges,70% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,49.42,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353,100,,2131.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,353,
OR TIME LEVEL 7 EA 15MIN ROBOT,32110533,CDM,360,RC,,,Outpatient,,,465,279.00,,279,60,,1112.224,Percent of Total Billed Charges,60% of Total Billed Charges,209.25,45,,2439.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.2,28,,218.856,Percent of Total Billed Charges,28% of Total Billed Charges,0.35,32,,0.424,Percent of Total Billed Charges,32% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,167.4,36,,281.384,Percent of Total Billed Charges,36% of Total Billed Charges,167.4,36,,281.384,Percent of Total Billed Charges,36% Total Bille Charges,167.4,36,,281.384,Percent of Total Billed Charges,36% of Total Billed Charges,279,60,,4323.664,Percent of Total Billed Charges,60% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465,100,,10058.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,67.05,14.42,,44.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.75,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,232.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,748.8,Percent of Total Billed Charges,50% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.5,50,,748.8,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,748.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.5,70,,603.08,Percent of Total Billed Charges,70% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,43.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,465,
OR TIME LEVEL 8 EA 15MIN ROBOT,32110534,CDM,360,RC,,,Outpatient,,,578,346.80,,346.8,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,260.1,45,,11624.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.84,28,,308.36,Percent of Total Billed Charges,28% of Total Billed Charges,0.35,32,,0.424,Percent of Total Billed Charges,32% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,36,,396.464,Percent of Total Billed Charges,36% of Total Billed Charges,208.08,36,,396.464,Percent of Total Billed Charges,36% Total Bille Charges,208.08,36,,396.464,Percent of Total Billed Charges,36% of Total Billed Charges,346.8,60,,45.904,Percent of Total Billed Charges,60% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,578,100,,3738.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.35,14.42,,11.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.5,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,289,50,,1072.304,Percent of Total Billed Charges,50% of Total Billed Charges,289,50,,714,Percent of Total Billed Charges,50% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289,50,,714,Percent of Total Billed Charges,50% of Total Billed Charges,289,50,,714,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.6,70,,603.08,Percent of Total Billed Charges,70% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,80.92,14,,10.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578,100,,80.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,578,
TOTAL MAXILLO CRANIOTOMY,32110967,CDM,278,RC,C1713,HCPCS,Outpatient,,,0.01,0.01,,317.27,110,,802.64,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.432,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,1512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,268.8,Percent of Total Billed Charges,80% of Total Billed Charges,0.01,50,,748.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,914.176,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,336,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,317.27,
PURSESTRING 65,32111155,CDM,272,RC,,,Outpatient,,,343.93,206.36,,206.36,60,,768.104,Percent of Total Billed Charges,60% of Total Billed Charges,154.77,45,,3153.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.3,28,,127.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.432,Percent of Total Billed Charges,32% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,123.81,36,,164.112,Percent of Total Billed Charges,36% of Total Billed Charges,123.81,36,,164.112,Percent of Total Billed Charges,36% Total Bille Charges,123.81,36,,164.112,Percent of Total Billed Charges,36% of Total Billed Charges,206.36,60,,894.432,Percent of Total Billed Charges,60% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,343.93,100,,5420.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14.42,,8.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.95,75,,623.744,Percent of Total Billed Charges,75% of Total Billed Charges,171.97,50,,714,Percent of Total Billed Charges,50% of Total Billed Charges,171.97,50,,155.472,Percent of Total Billed Charges,50% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.97,50,,155.472,Percent of Total Billed Charges,50% of Total Billed Charges,171.97,50,,155.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.75,70,,462,Percent of Total Billed Charges,70% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.15,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.93,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,343.93,
CATHETER URETERA,32111452,CDM,272,RC,C1758,HCPCS,Outpatient,,,50.19,30.11,,69,100,,1654.768,Fee Schedule,100% of Aetna Fee Schedule,22.59,45,,351,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.05,28,,155.504,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.44,Percent of Total Billed Charges,32% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,18.07,36,,199.936,Percent of Total Billed Charges,36% of Total Billed Charges,18.07,36,,199.936,Percent of Total Billed Charges,36% Total Bille Charges,18.07,36,,199.936,Percent of Total Billed Charges,36% of Total Billed Charges,30.11,60,,1587.616,Percent of Total Billed Charges,60% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.19,100,,25832.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.24,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.64,75,,420.056,Percent of Total Billed Charges,75% of Total Billed Charges,25.1,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,25.1,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.1,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.1,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.13,70,,2131.008,Percent of Total Billed Charges,70% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.19,100,,560.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,69,
CATHETER FOLEY 2,32111502,CDM,272,RC,A4649,HCPCS,Outpatient,,,77.4,46.44,,46.44,60,,692.264,Percent of Total Billed Charges,60% of Total Billed Charges,34.83,45,,1410.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,28,,66.728,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.44,Percent of Total Billed Charges,32% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,27.86,36,,85.792,Percent of Total Billed Charges,36% of Total Billed Charges,27.86,36,,85.792,Percent of Total Billed Charges,36% Total Bille Charges,27.86,36,,85.792,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,60,,82.936,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,8881.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,51.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,19.656,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,155.472,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,322.632,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,322.632,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,322.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.18,70,,1601.6,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,50.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,26.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,77.4,
CATHETER RED RUB,32111924,CDM,272,RC,C1729,HCPCS,Outpatient,,,24.71,14.83,,11.1,100,,5982.24,Fee Schedule,100% of Aetna Fee Schedule,11.12,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.92,28,,59.784,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.44,Percent of Total Billed Charges,32% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,8.9,36,,76.864,Percent of Total Billed Charges,36% of Total Billed Charges,8.9,36,,76.864,Percent of Total Billed Charges,36% Total Bille Charges,8.9,36,,76.864,Percent of Total Billed Charges,36% of Total Billed Charges,14.83,60,,82.936,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.71,100,,7008.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.56,14.42,,31.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.53,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,12.36,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,12.36,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.36,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,12.36,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.3,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,30.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.71,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,24.71,
CATHETER TIEMANN,32112005,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,12263.592,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,1397.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.44,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,1797.12,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,1797.12,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,1797.12,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,197.416,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,780,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,61.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,322.632,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,442.992,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,59.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,94.38,
CATH URETERAL CO,32112559,CDM,272,RC,C1758,HCPCS,Outpatient,,,46.75,28.05,,69,100,,2745.6,Fee Schedule,100% of Aetna Fee Schedule,21.04,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.09,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.44,Percent of Total Billed Charges,32% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.83,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,16.83,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,16.83,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,28.05,60,,748.496,Percent of Total Billed Charges,60% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.75,100,,3133.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.74,14.42,,315.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.06,75,,50.544,Percent of Total Billed Charges,75% of Total Billed Charges,23.38,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,23.38,50,,179,Percent of Total Billed Charges,50% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.38,50,,179,Percent of Total Billed Charges,50% of Total Billed Charges,23.38,50,,179,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.73,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14,,305.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.75,100,,67.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,69,
GRAFTON GEL 10CC,32112609,CDM,278,RC,,,Outpatient,,,2664.48,1598.69,,2930.93,110,,7178.688,Percent of Total Billed Charges,110% of Total Billed Charges,1199.02,45,,43.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,746.05,28,,534.864,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.448,Percent of Total Billed Charges,32% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,959.21,36,,687.68,Percent of Total Billed Charges,36% of Total Billed Charges,959.21,36,,687.68,Percent of Total Billed Charges,36% Total Bille Charges,959.21,36,,687.68,Percent of Total Billed Charges,36% of Total Billed Charges,1465.46,55,,2190.336,Percent of Total Billed Charges,55% Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2664.48,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,384.22,14.42,,80.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2131.58,80,,384,Percent of Total Billed Charges,80% of Total Billed Charges,1332.24,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1332.24,50,,108.672,Percent of Total Billed Charges,50% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.24,50,,108.672,Percent of Total Billed Charges,50% of Total Billed Charges,1332.24,50,,108.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1865.14,70,,709.512,Percent of Total Billed Charges,70% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,373.03,14,,78.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2664.48,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,2930.93,
BOVIE SUCTION,32114407,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,12390.192,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,449.72,Percent of Total Billed Charges,28% of Total Billed Charges,0.36,32,,0.448,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,578.208,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,578.208,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,578.208,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,289.456,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,701.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,1715.688,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,179,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,212.92,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,212.92,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,212.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,1411.104,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,2144.608,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,70,
BOVIE BLADE EXTE,32114605,CDM,272,RC,,,Outpatient,,,101,60.60,,60.6,60,,18387.976,Percent of Total Billed Charges,60% of Total Billed Charges,45.45,45,,3153.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.28,28,,1292.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.37,32,,0.448,Percent of Total Billed Charges,32% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,36,,1662.192,Percent of Total Billed Charges,36% of Total Billed Charges,36.36,36,,1662.192,Percent of Total Billed Charges,36% Total Bille Charges,36.36,36,,1662.192,Percent of Total Billed Charges,36% of Total Billed Charges,60.6,60,,474.472,Percent of Total Billed Charges,60% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,100,,701.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.56,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.75,75,,1198.08,Percent of Total Billed Charges,75% of Total Billed Charges,50.5,50,,108.672,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,50,,1092.632,Percent of Total Billed Charges,50% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.5,50,,1092.632,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,50,,1092.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.7,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101,100,,1497.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,101,
569096 CEMENT BONE CMW3,32115214,CDM,278,RC,C1713,HCPCS,Outpatient,,,420,252.00,,779.26,110,,806.728,Percent of Total Billed Charges,110% of Total Billed Charges,189,45,,109.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.6,28,,516.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.37,32,,0.456,Percent of Total Billed Charges,32% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,151.2,36,,664.424,Percent of Total Billed Charges,36% of Total Billed Charges,151.2,36,,664.424,Percent of Total Billed Charges,36% Total Bille Charges,151.2,36,,664.424,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420,100,,95.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,60.56,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336,80,,1071,Percent of Total Billed Charges,80% of Total Billed Charges,210,50,,212.92,Percent of Total Billed Charges,50% of Total Billed Charges,210,50,,278.64,Percent of Total Billed Charges,50% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,50,,278.64,Percent of Total Billed Charges,50% of Total Billed Charges,210,50,,278.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,70,,111.392,Percent of Total Billed Charges,70% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,100,,1428,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,779.26,
250381 CEMENT SMARTSET BONE HP,32115230,CDM,278,RC,C1713,HCPCS,Outpatient,,,974.6,584.76,,1389.32,110,,1959.576,Percent of Total Billed Charges,110% of Total Billed Charges,438.57,45,,560.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,244.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.37,32,,0.456,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,314.552,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,314.552,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,314.552,Percent of Total Billed Charges,36% of Total Billed Charges,536.03,55,,660.776,Percent of Total Billed Charges,55% Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.68,80,,54,Percent of Total Billed Charges,80% of Total Billed Charges,487.3,50,,1092.632,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,111.392,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,72,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,1389.32,
COLPO-PNEUMO OCC,32115404,CDM,272,RC,,,Outpatient,,,700.09,420.05,,420.05,60,,1605.8,Percent of Total Billed Charges,60% of Total Billed Charges,315.04,45,,26.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.03,28,,32.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.37,32,,0.456,Percent of Total Billed Charges,32% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,252.03,36,,41.384,Percent of Total Billed Charges,36% of Total Billed Charges,252.03,36,,41.384,Percent of Total Billed Charges,36% Total Bille Charges,252.03,36,,41.384,Percent of Total Billed Charges,36% of Total Billed Charges,420.05,60,,96.912,Percent of Total Billed Charges,60% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.09,100,,7008.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,100.95,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525.07,75,,233.208,Percent of Total Billed Charges,75% of Total Billed Charges,350.05,50,,278.64,Percent of Total Billed Charges,50% of Total Billed Charges,350.05,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.05,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,350.05,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,490.06,70,,82.088,Percent of Total Billed Charges,70% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.01,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700.09,100,,310.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,700.09,
FLAT DRAIN 10MM,32121055,CDM,272,RC,C1729,HCPCS,Outpatient,,,32.76,19.66,,11.1,100,,311.56,Fee Schedule,100% of Aetna Fee Schedule,14.74,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.17,28,,2838.408,Percent of Total Billed Charges,28% of Total Billed Charges,0.37,32,,0.464,Percent of Total Billed Charges,32% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,36,,3649.384,Percent of Total Billed Charges,36% of Total Billed Charges,11.79,36,,3649.384,Percent of Total Billed Charges,36% Total Bille Charges,11.79,36,,3649.384,Percent of Total Billed Charges,36% of Total Billed Charges,19.66,60,,734.536,Percent of Total Billed Charges,60% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.76,100,,242.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.72,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.57,75,,57.6,Percent of Total Billed Charges,75% of Total Billed Charges,16.38,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,16.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,16.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.93,70,,131.328,Percent of Total Billed Charges,70% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.76,100,,76.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,32.76,
598044 LENS INTRAOCULAR,32121352,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,82.264,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,64.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,853.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,1097.712,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,1097.712,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,1097.712,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,250.728,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,1245.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,483.952,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,52.856,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,645.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,910.16,
334308 CEMENT BOWL,32127359,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,1670.656,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,1180.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,79.832,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,102.64,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,102.64,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,102.64,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,305.456,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,59.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,59.896,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,70,
NEEDLE JAMSIDI,32127607,CDM,272,RC,,,Outpatient,,,84.24,50.54,,50.54,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,37.91,45,,649.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.59,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,30.33,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,30.33,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,30.33,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,50.54,60,,142.992,Percent of Total Billed Charges,60% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.24,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,12.15,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.18,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,42.12,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,42.12,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.12,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,42.12,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.97,70,,210.136,Percent of Total Billed Charges,70% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.24,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,84.24,
253883 GRAFTON GEL DBM,32129009,CDM,278,RC,,,Outpatient,,,600,360.00,,660,110,,1577.504,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,6515.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,336.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,432.256,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,432.256,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,432.256,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,128.112,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,142.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,268.504,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,210.136,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,358,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,660,
PRO OSTEM (2B045,32129017,CDM,278,RC,C1713,HCPCS,Outpatient,,,2680.76,1608.46,,3266.1,110,,1577.504,Percent of Total Billed Charges,110% of Total Billed Charges,1206.34,45,,1488.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750.61,28,,3326.448,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,965.07,36,,4276.864,Percent of Total Billed Charges,36% of Total Billed Charges,965.07,36,,4276.864,Percent of Total Billed Charges,36% Total Bille Charges,965.07,36,,4276.864,Percent of Total Billed Charges,36% of Total Billed Charges,1474.42,55,,2745.6,Percent of Total Billed Charges,55% Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2680.76,100,,2623.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,386.57,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2144.61,80,,163,Percent of Total Billed Charges,80% of Total Billed Charges,1340.38,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,1340.38,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1340.38,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,1340.38,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1876.53,70,,210.136,Percent of Total Billed Charges,70% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,375.31,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2680.76,100,,217.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,3266.1,
610343 GRAFTON GEL 5CC,32129033,CDM,278,RC,,,Outpatient,,,1872,1123.20,,2059.2,110,,2119.2,Percent of Total Billed Charges,110% of Total Billed Charges,842.4,45,,1112.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,524.16,28,,3962.96,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,673.92,36,,5095.24,Percent of Total Billed Charges,36% of Total Billed Charges,673.92,36,,5095.24,Percent of Total Billed Charges,36% Total Bille Charges,673.92,36,,5095.24,Percent of Total Billed Charges,36% of Total Billed Charges,1029.6,55,,1863.4,Percent of Total Billed Charges,55% Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1872,100,,1442.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,269.94,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1497.6,80,,340.672,Percent of Total Billed Charges,80% of Total Billed Charges,936,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,936,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,936,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,936,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1310.4,70,,388.864,Percent of Total Billed Charges,70% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1872,100,,425.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,2059.2,
ARTHRO TUNNELER,32130098,CDM,272,RC,,,Outpatient,,,1785,1071.00,,1071,60,,158.4,Percent of Total Billed Charges,60% of Total Billed Charges,803.25,45,,3548.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.8,28,,1847.096,Percent of Total Billed Charges,28% of Total Billed Charges,0.38,32,,0.472,Percent of Total Billed Charges,32% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,642.6,36,,2374.84,Percent of Total Billed Charges,36% of Total Billed Charges,642.6,36,,2374.84,Percent of Total Billed Charges,36% Total Bille Charges,642.6,36,,2374.84,Percent of Total Billed Charges,36% of Total Billed Charges,1071,60,,1050.616,Percent of Total Billed Charges,60% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1785,100,,14479.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,257.4,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1338.75,75,,1748.208,Percent of Total Billed Charges,75% of Total Billed Charges,892.5,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,892.5,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,892.5,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,892.5,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1249.5,70,,2912,Percent of Total Billed Charges,70% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,249.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1785,100,,2185.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,1785,
CANNULA SHOULDER,32130106,CDM,272,RC,,,Outpatient,,,90,54.00,,54,60,,1690.376,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,45,,68.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.48,Percent of Total Billed Charges,32% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,32.4,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,32.4,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,32.4,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,54,60,,883.376,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,100,,3307.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,75,,417.96,Percent of Total Billed Charges,75% of Total Billed Charges,45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,70,,600.352,Percent of Total Billed Charges,70% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,100,,557.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,90,
EXPRESS SEW SUTU,32130940,CDM,272,RC,,,Outpatient,,,388.68,233.21,,233.21,60,,2269.28,Percent of Total Billed Charges,60% of Total Billed Charges,174.91,45,,86.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.83,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.48,Percent of Total Billed Charges,32% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,139.92,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,139.92,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,139.92,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,233.21,60,,2539.464,Percent of Total Billed Charges,60% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.68,100,,2473.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,56.05,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.51,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,194.34,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,194.34,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.34,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,194.34,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.08,70,,665.848,Percent of Total Billed Charges,70% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.68,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,388.68,
KIT FOLEY 16FR.,32131351,CDM,272,RC,,,Outpatient,,,96,57.60,,57.6,60,,1306.096,Percent of Total Billed Charges,60% of Total Billed Charges,43.2,45,,62.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.88,28,,2600.104,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.488,Percent of Total Billed Charges,32% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,34.56,36,,3342.984,Percent of Total Billed Charges,36% of Total Billed Charges,34.56,36,,3342.984,Percent of Total Billed Charges,36% Total Bille Charges,34.56,36,,3342.984,Percent of Total Billed Charges,36% of Total Billed Charges,57.6,60,,1107.368,Percent of Total Billed Charges,60% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,100,,7885.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.84,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,48,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,48,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,48,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.2,70,,76.248,Percent of Total Billed Charges,70% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.44,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,96,
119660 PERFORATER DISP,32140659,CDM,272,RC,,,Outpatient,,,806.58,483.95,,483.95,60,,236.592,Percent of Total Billed Charges,60% of Total Billed Charges,362.96,45,,77.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.84,28,,4256,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.488,Percent of Total Billed Charges,32% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,290.37,36,,5472,Percent of Total Billed Charges,36% of Total Billed Charges,290.37,36,,5472,Percent of Total Billed Charges,36% Total Bille Charges,290.37,36,,5472,Percent of Total Billed Charges,36% of Total Billed Charges,483.95,60,,480.56,Percent of Total Billed Charges,60% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,806.58,100,,153,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,116.31,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.94,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,403.29,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,403.29,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.29,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,403.29,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,564.61,70,,36.016,Percent of Total Billed Charges,70% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,112.92,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,806.58,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,806.58,
SUTURE CHROMIC,32140709,CDM,272,RC,,,Outpatient,,,72.5,43.50,,43.5,60,,2119.2,Percent of Total Billed Charges,60% of Total Billed Charges,32.63,45,,62.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.3,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,26.1,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,26.1,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,26.1,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,43.5,60,,68.976,Percent of Total Billed Charges,60% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.5,100,,191.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.38,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,36.25,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,36.25,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.25,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,36.25,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.75,70,,682.224,Percent of Total Billed Charges,70% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.5,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,72.5,
ENDOHOOK (0020),32143059,CDM,270,RC,,,Outpatient,,,150,90.00,,90,60,,8905.544,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,158.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,4579.68,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,5888.16,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,5888.16,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,5888.16,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,5575.448,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,138.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,150,
SUTURE ETHILON,32143307,CDM,272,RC,,,Outpatient,,,447.5,268.50,,268.5,60,,2269.28,Percent of Total Billed Charges,60% of Total Billed Charges,201.38,45,,151.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.3,28,,452.928,Percent of Total Billed Charges,28% of Total Billed Charges,0.39,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,161.1,36,,582.336,Percent of Total Billed Charges,36% of Total Billed Charges,161.1,36,,582.336,Percent of Total Billed Charges,36% Total Bille Charges,161.1,36,,582.336,Percent of Total Billed Charges,36% of Total Billed Charges,268.5,60,,1677.064,Percent of Total Billed Charges,60% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,447.5,100,,171.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,64.53,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.63,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,223.75,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,223.75,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.75,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,223.75,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.25,70,,6766.736,Percent of Total Billed Charges,70% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,62.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.5,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,447.5,
111372 SUTURE RETRIEVER HEWSON,32145450,CDM,272,RC,,,Outpatient,,,271.67,163.00,,163,60,,296.4,Percent of Total Billed Charges,60% of Total Billed Charges,122.25,45,,73.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.07,28,,218.312,Percent of Total Billed Charges,28% of Total Billed Charges,0.4,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.8,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,97.8,36,,280.688,Percent of Total Billed Charges,36% Total Bille Charges,97.8,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,163,60,,171.072,Percent of Total Billed Charges,60% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.67,100,,138.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,39.17,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.75,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,135.84,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,135.84,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.84,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,135.84,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.17,70,,239.504,Percent of Total Billed Charges,70% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.03,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.67,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,271.67,
0007753 SUPRAPUBIC FOLEY TRAY,32149304,CDM,278,RC,C2627,HCPCS,Outpatient,,,532.3,319.38,,658.57,110,,299.792,Percent of Total Billed Charges,110% of Total Billed Charges,239.54,45,,359.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.04,28,,1164.736,Percent of Total Billed Charges,28% of Total Billed Charges,0.4,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,191.63,36,,1497.512,Percent of Total Billed Charges,36% of Total Billed Charges,191.63,36,,1497.512,Percent of Total Billed Charges,36% Total Bille Charges,191.63,36,,1497.512,Percent of Total Billed Charges,36% of Total Billed Charges,292.77,55,,2032.8,Percent of Total Billed Charges,55% Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.3,100,,351.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,76.76,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.84,80,,435.648,Percent of Total Billed Charges,80% of Total Billed Charges,266.15,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,266.15,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.15,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,266.15,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.61,70,,764.088,Percent of Total Billed Charges,70% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,74.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532.3,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,658.57,
168962 LAP BAND SYSTEM VG,32149320,CDM,278,RC,,,Outpatient,,,2731.58,1638.95,,3004.74,110,,306.656,Percent of Total Billed Charges,110% of Total Billed Charges,1229.21,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.84,28,,2840.424,Percent of Total Billed Charges,28% of Total Billed Charges,0.4,32,,0.496,Percent of Total Billed Charges,32% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,983.37,36,,3651.976,Percent of Total Billed Charges,36% of Total Billed Charges,983.37,36,,3651.976,Percent of Total Billed Charges,36% Total Bille Charges,983.37,36,,3651.976,Percent of Total Billed Charges,36% of Total Billed Charges,1502.37,55,,720.424,Percent of Total Billed Charges,55% Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2731.58,100,,337.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,393.89,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2185.26,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,1365.79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,1365.79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365.79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,1365.79,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1912.11,70,,22232.176,Percent of Total Billed Charges,70% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2731.58,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,3004.74,
MIDAS REX BONE M,32149411,CDM,272,RC,,,Outpatient,,,696.6,417.96,,417.96,60,,332.272,Percent of Total Billed Charges,60% of Total Billed Charges,313.47,45,,313.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.05,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.4,32,,0.504,Percent of Total Billed Charges,32% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,250.78,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,250.78,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,250.78,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,417.96,60,,6534.104,Percent of Total Billed Charges,60% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696.6,100,,162.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,100.45,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,522.45,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,348.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,348.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,348.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,348.3,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.62,70,,3970.512,Percent of Total Billed Charges,70% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.52,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.6,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,696.6,
LENS INTRAOCULAR 19D SN60WF,32150006,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,332.272,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,204.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,127.712,Percent of Total Billed Charges,28% of Total Billed Charges,0.41,32,,0.512,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,164.2,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,164.2,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,164.2,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,7784.392,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,799.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,83.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,81.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,910.16,
LENS INTRAOCULAR 21.5D SN60WF,32150007,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,660.664,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,5100.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,207.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.41,32,,2587.696,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,267.12,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,267.12,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,267.12,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,3628.224,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,64.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,147.816,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,910.16,
LENS INTRAOCULAR 27D SN60WF,32150010,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,9173.76,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,284.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,514.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.41,32,,2593.72,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,661.248,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,661.248,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,661.248,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,78.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,147.816,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,877.18,
LENS INTRAOCULAR 26.5D SN60WF,32150012,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,254.704,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,9.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.41,32,,2596.288,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,12.28,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,12.28,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,12.28,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,454.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,386.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,877.18,
LENS INTRAOCULAR 23.5D SN60WF,32150013,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1900.488,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,5812.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,597.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.41,32,,2603.904,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,768.4,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,768.4,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,768.4,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,5107.336,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,11334.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,78.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,141.288,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,76.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,910.16,
LENS INTRAOCULAR 20D SN60WF,32150014,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,531.368,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,1713.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,541.448,Percent of Total Billed Charges,28% of Total Billed Charges,0.42,32,,2608.488,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,696.144,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,696.144,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,696.144,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,8360,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,631.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,290.432,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,5502.848,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,910.16,
LENS INTRAOCULAR 20.D SN60WF,32150015,CDM,276,RC,C1780,HCPCS,Outpatient,,,726.08,435.65,,1015.87,110,,1754.696,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,592.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.42,32,,2610.432,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,8995.792,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,215.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1338.48,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,1338.48,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1338.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,5502.848,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,209.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,1015.87,
LENS INTRAOCULAR 21D SN60WF,32150016,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,8628.944,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,535.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,1145.112,Percent of Total Billed Charges,28% of Total Billed Charges,0.42,32,,2610.432,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,1472.288,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,1472.288,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,1472.288,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,889.68,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,12916.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,1166.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,53.56,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1132.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,910.16,
LENS INTRAOCULAR 13.5D SN60WF,32150017,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,4315.872,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,184.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,154.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.42,32,,2610.432,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,198.712,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,198.712,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,198.712,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,428.824,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,3806.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,482.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,1338.48,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,48.32,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,468.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,877.18,
LENS INTRAOCULAR 24D SN60WF,32150018,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,6508.512,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,362.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,102.144,Percent of Total Billed Charges,28% of Total Billed Charges,0.42,32,,2627.12,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,131.328,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,2287.872,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,1315.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,46.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,746.992,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,746.992,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,746.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,1138.368,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,44.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,910.16,
LENS INTRAOCULAR 23D SN60WF,32150020,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1257.984,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,1359.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.43,32,,2668.728,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,1748.336,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,1748.336,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,1748.336,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,6086.632,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,1189.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,1986.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,4043.272,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,4043.272,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,4043.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,1852.224,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1928.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.43,910.16,
LENS INTRAOCULAR 27.5D SN60WF,32150021,CDM,276,RC,C1780,HCPCS,Outpatient,,,726.08,435.65,,1015.87,110,,384.96,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,870.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,2021.832,Percent of Total Billed Charges,28% of Total Billed Charges,0.43,32,,2668.728,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,2599.496,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,2599.496,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,2599.496,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,409.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,163.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,746.992,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1672.32,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,1672.32,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1672.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,96.76,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.43,1015.87,
LENS INTRAOCULAR 13D SN60WF,32150025,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,2397.928,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,29.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,359.12,Percent of Total Billed Charges,28% of Total Billed Charges,0.44,32,,2668.728,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,461.728,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,461.728,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,461.728,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,273.664,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,804.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,10.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,4043.272,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,159.856,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,159.856,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,159.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,96.76,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,877.18,
LENS INTRAOCULAR 22.5D SN60WF,32150027,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1456.04,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,4499.736,Percent of Total Billed Charges,28% of Total Billed Charges,0.44,32,,2688,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,5785.368,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,5785.368,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,5785.368,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,445.2,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,11.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,1672.32,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,6886.376,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,6886.376,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,6886.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,230.32,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,11.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,910.16,
LENS INTRAOCULAR 25.5D SN60WF,32150028,CDM,276,RC,C1780,HCPCS,Outpatient,,,726.08,435.65,,1015.87,110,,11977.608,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,914.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,380.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.44,32,,2703.104,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,489.232,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,489.232,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,489.232,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,1010.24,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,1935.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,4827.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,435.648,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,159.856,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,873.24,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,4687.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,580.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,1015.87,
LENS INTRAOCULAR 16.5D SN60WF,32150029,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,180.112,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,244.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.44,32,,2728.96,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,314.104,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,314.104,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,314.104,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,20.464,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,65.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,537.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,358.4,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,6886.376,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,2787.704,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,448,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,877.18,
LENS INTRAOCULAR 12D SN60WF,32150030,CDM,276,RC,C1780,HCPCS,Outpatient,,,726.08,435.65,,1015.87,110,,1695.352,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,3134.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,238.176,Percent of Total Billed Charges,28% of Total Billed Charges,0.44,32,,2728.96,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,306.224,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,306.224,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,306.224,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,1173.944,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,1067.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,409.336,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,41,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,41,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,41,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,368.4,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1036.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,545.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,1015.87,
LENS INTRAOCULAR 17D SN60WF,32150034,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,849.248,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,62.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,4035.296,Percent of Total Billed Charges,28% of Total Billed Charges,0.45,32,,2764.448,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,5188.232,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,5188.232,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,5188.232,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,1063.56,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,2032.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,701.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,2141.568,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,16740,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,16740,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,16740,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,553.552,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,681.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,2676.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,910.16,
LENS INTRAOCULAR 17.5D SN60WF,32150035,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,27386.16,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,7844.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,52.536,Percent of Total Billed Charges,28% of Total Billed Charges,0.46,32,,2780.112,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,67.544,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,67.544,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,67.544,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,222.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,409.336,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,41,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,547.144,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,215.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,545.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,910.16,
LENS INTRAOCULAR 16D SN60WF,32150036,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1157.48,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,1399.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,436.624,Percent of Total Billed Charges,28% of Total Billed Charges,0.46,32,,2795.52,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,561.368,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,2249.328,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,6965.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,64.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,2541,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,16740,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,3702.4,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,3702.4,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,3702.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,770.904,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,62.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,910.16,
LENS INTRAOCULAR 15D SN60WF,32150038,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1794.72,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,23261.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,372.216,Percent of Total Billed Charges,28% of Total Billed Charges,0.46,32,,2795.52,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,478.568,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,478.568,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,478.568,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,303.584,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,138.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,205.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,1195.184,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,2433.688,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,2433.688,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,2433.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,113.064,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,199.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,1493.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,910.16,
LENS INTRAOCULAR 15.5D SN60WF,32150039,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,630.168,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,2007.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,0.46,32,,2.56,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,2671.072,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,17432.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,6469.232,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,3702.4,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,769.936,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,769.936,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,769.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,934.864,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,8086.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,910.16,
LENS INTRAOCULAR 22D SN60WF,32150040,CDM,276,RC,C1780,HCPCS,Outpatient,,,600,360.00,,877.18,110,,3734.016,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,256.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,486.36,Percent of Total Billed Charges,28% of Total Billed Charges,0.47,32,,2.56,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,625.32,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,625.32,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,625.32,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,3971.456,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,3109.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,18.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2675.712,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,2433.688,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,221.952,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,221.952,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,221.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,319.112,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,18.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,3344.64,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,877.18,
LENS INTRAOCULAR 19.5D SN60WF,32150041,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,1852.864,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,516.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,76.728,Percent of Total Billed Charges,28% of Total Billed Charges,0.47,32,,2.592,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,98.648,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,705.416,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,51691.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,1.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,255.768,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,769.936,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,711.072,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,711.072,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,711.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,388.76,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,1.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,319.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,910.16,
LENS INTRAOCULAR 18D SN60WF,32150043,CDM,276,RC,V2632,HCPCS,Outpatient,,,726.08,435.65,,910.16,110,,27386.16,Percent of Total Billed Charges,110% of Total Billed Charges,326.74,45,,23004,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,28,,24.28,Percent of Total Billed Charges,28% of Total Billed Charges,0.47,32,,2.6,Percent of Total Billed Charges,32% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,261.39,36,,31.216,Percent of Total Billed Charges,36% of Total Billed Charges,261.39,36,,31.216,Percent of Total Billed Charges,36% Total Bille Charges,261.39,36,,31.216,Percent of Total Billed Charges,36% of Total Billed Charges,435.65,60,,8838.76,Percent of Total Billed Charges,60% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.08,100,,4461.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,104.7,14.42,,27.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.56,75,,11018.2,Percent of Total Billed Charges,75% of Total Billed Charges,363.04,50,,221.952,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.04,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,363.04,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.26,70,,166.824,Percent of Total Billed Charges,70% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,101.65,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.08,100,,13772.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,910.16,
121552 SUTURELASSO CURVED RIGH,32150044,CDM,278,RC,,,Outpatient,,,560,336.00,,616,110,,1269.728,Percent of Total Billed Charges,110% of Total Billed Charges,252,45,,1309.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.8,28,,76.728,Percent of Total Billed Charges,28% of Total Billed Charges,0.47,32,,2.608,Percent of Total Billed Charges,32% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,201.6,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,201.6,36,,98.648,Percent of Total Billed Charges,36% Total Bille Charges,201.6,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,308,55,,815.392,Percent of Total Billed Charges,55% Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,569.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14.42,,192.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,448,80,,904.432,Percent of Total Billed Charges,80% of Total Billed Charges,280,50,,711.072,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,70,,149.464,Percent of Total Billed Charges,70% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,187.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560,100,,1130.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,616,
114597 SUTURELASSO CURVED LEFT,32150046,CDM,272,RC,,,Outpatient,,,682.22,409.33,,409.33,60,,1321.32,Percent of Total Billed Charges,60% of Total Billed Charges,307,45,,871.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,28,,65.864,Percent of Total Billed Charges,28% of Total Billed Charges,0.48,32,,2.624,Percent of Total Billed Charges,32% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,245.6,36,,84.68,Percent of Total Billed Charges,36% of Total Billed Charges,245.6,36,,84.68,Percent of Total Billed Charges,36% Total Bille Charges,245.6,36,,84.68,Percent of Total Billed Charges,36% of Total Billed Charges,409.33,60,,523.504,Percent of Total Billed Charges,60% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.22,100,,1146.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,98.38,14.42,,537.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.67,75,,55.84,Percent of Total Billed Charges,75% of Total Billed Charges,341.11,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,70,,3494.4,Percent of Total Billed Charges,70% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,100,,74.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,682.22,
324463 STRATTICE RECON BREAST,32150047,CDM,278,RC,,,Outpatient,,,3346.2,2007.72,,3680.82,110,,3533.392,Percent of Total Billed Charges,110% of Total Billed Charges,1505.79,45,,1565.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,936.94,28,,1013.392,Percent of Total Billed Charges,28% of Total Billed Charges,0.48,32,,2.624,Percent of Total Billed Charges,32% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,1204.63,36,,1302.936,Percent of Total Billed Charges,36% of Total Billed Charges,1204.63,36,,1302.936,Percent of Total Billed Charges,36% Total Bille Charges,1204.63,36,,1302.936,Percent of Total Billed Charges,36% of Total Billed Charges,1840.41,55,,510.376,Percent of Total Billed Charges,55% Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3346.2,100,,51120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,482.52,14.42,,497.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2676.96,80,,61.504,Percent of Total Billed Charges,80% of Total Billed Charges,1673.1,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,1673.1,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1673.1,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,1673.1,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2342.34,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,468.47,14,,483.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3346.2,100,,82,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,3680.82,
121551 SUTURELASSO CURVED LEFT,32150048,CDM,272,RC,,,Outpatient,,,682.22,409.33,,409.33,60,,54695.64,Percent of Total Billed Charges,60% of Total Billed Charges,307,45,,50.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,28,,4096.424,Percent of Total Billed Charges,28% of Total Billed Charges,0.48,32,,2.632,Percent of Total Billed Charges,32% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,245.6,36,,5266.832,Percent of Total Billed Charges,36% of Total Billed Charges,245.6,36,,5266.832,Percent of Total Billed Charges,36% Total Bille Charges,245.6,36,,5266.832,Percent of Total Billed Charges,36% of Total Billed Charges,409.33,60,,7926.472,Percent of Total Billed Charges,60% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.22,100,,2910.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.38,14.42,,150.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.67,75,,26784,Percent of Total Billed Charges,75% of Total Billed Charges,341.11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,668.968,Percent of Total Billed Charges,50% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,50,,668.968,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,668.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,70,,1337.152,Percent of Total Billed Charges,70% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,100,,33480,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,682.22,
436180 GREEN LIGHT MOXY FIBER,32150049,CDM,272,RC,,,Outpatient,,,4235,2541.00,,2541,60,,33742.296,Percent of Total Billed Charges,60% of Total Billed Charges,1905.75,45,,1820.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,125.528,Percent of Total Billed Charges,28% of Total Billed Charges,0.48,32,,2.632,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,161.392,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,161.392,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,161.392,Percent of Total Billed Charges,36% of Total Billed Charges,2541,60,,112.568,Percent of Total Billed Charges,60% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,1937.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,75,,2980.24,Percent of Total Billed Charges,75% of Total Billed Charges,2117.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1124.304,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,3725.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,4235,
BACTISEAL CATHATER (NS5075),32150050,CDM,278,RC,C1729,HCPCS,Outpatient,,,1867.47,1120.48,,2065.32,110,,10815.768,Percent of Total Billed Charges,110% of Total Billed Charges,840.36,45,,1676.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,522.89,28,,122.504,Percent of Total Billed Charges,28% of Total Billed Charges,0.48,32,,2.648,Percent of Total Billed Charges,32% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,672.29,36,,157.512,Percent of Total Billed Charges,36% of Total Billed Charges,672.29,36,,157.512,Percent of Total Billed Charges,36% Total Bille Charges,672.29,36,,157.512,Percent of Total Billed Charges,36% of Total Billed Charges,1027.11,55,,857.648,Percent of Total Billed Charges,55% Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1867.47,100,,3477.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,269.29,14.42,,7057.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1493.98,80,,5553.6,Percent of Total Billed Charges,80% of Total Billed Charges,933.74,50,,668.968,Percent of Total Billed Charges,50% of Total Billed Charges,933.74,50,,1725.16,Percent of Total Billed Charges,50% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,933.74,50,,1725.16,Percent of Total Billed Charges,50% of Total Billed Charges,933.74,50,,1725.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1307.23,70,,3232.04,Percent of Total Billed Charges,70% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,261.45,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1867.47,100,,7404.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,2065.32,
447878 VALVE HAKIM PROGRAMMAB,32150051,CDM,278,RC,,,Outpatient,,,10108.18,6064.91,,11119,110,,20490.776,Percent of Total Billed Charges,110% of Total Billed Charges,4548.68,45,,1923.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2830.29,28,,30.08,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.656,Percent of Total Billed Charges,32% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,3638.94,36,,38.672,Percent of Total Billed Charges,36% of Total Billed Charges,3638.94,36,,38.672,Percent of Total Billed Charges,36% Total Bille Charges,3638.94,36,,38.672,Percent of Total Billed Charges,36% of Total Billed Charges,5559.5,55,,731.144,Percent of Total Billed Charges,55% Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10108.18,100,,111.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1457.6,14.42,,531.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8086.54,80,,3893.896,Percent of Total Billed Charges,80% of Total Billed Charges,5054.09,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,5054.09,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5054.09,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,5054.09,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7075.73,70,,1291.928,Percent of Total Billed Charges,70% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,1415.15,14,,516.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10108.18,100,,4867.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,11119,
212895 STRATTICE RECON STOMA,32150055,CDM,278,RC,,,Outpatient,,,4180.8,2508.48,,4598.88,110,,1969.104,Percent of Total Billed Charges,110% of Total Billed Charges,1881.36,45,,592.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1170.62,28,,747.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.704,Percent of Total Billed Charges,32% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,1505.09,36,,961.048,Percent of Total Billed Charges,36% of Total Billed Charges,1505.09,36,,961.048,Percent of Total Billed Charges,36% Total Bille Charges,1505.09,36,,961.048,Percent of Total Billed Charges,36% of Total Billed Charges,2299.44,55,,140.712,Percent of Total Billed Charges,55% Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4180.8,100,,4045.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,602.87,14.42,,548.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3344.64,80,,1231.896,Percent of Total Billed Charges,80% of Total Billed Charges,2090.4,50,,1725.16,Percent of Total Billed Charges,50% of Total Billed Charges,2090.4,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2090.4,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,2090.4,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2926.56,70,,611.624,Percent of Total Billed Charges,70% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,585.31,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4180.8,100,,1539.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,4598.88,
195755 CATHETER BACTISEAL,32150059,CDM,278,RC,,,Outpatient,,,399.64,239.78,,439.6,110,,2881.208,Percent of Total Billed Charges,110% of Total Billed Charges,179.84,45,,22025.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.9,28,,76.728,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.72,Percent of Total Billed Charges,32% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,143.87,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,143.87,36,,98.648,Percent of Total Billed Charges,36% Total Bille Charges,143.87,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.64,100,,3725.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14.42,,1392.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.71,80,,355.12,Percent of Total Billed Charges,80% of Total Billed Charges,199.82,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,199.82,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.82,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,199.82,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.75,70,,80.472,Percent of Total Billed Charges,70% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,55.95,14,,1351.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399.64,100,,443.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,439.6,
345629 LEAD SJM PENTA,32150060,CDM,278,RC,C1778,HCPCS,Outpatient,,,17215.94,10329.56,,19520.13,110,,24650.208,Percent of Total Billed Charges,110% of Total Billed Charges,7747.17,45,,1253.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4820.46,28,,63.04,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.72,Percent of Total Billed Charges,32% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,6197.74,36,,81.048,Percent of Total Billed Charges,36% of Total Billed Charges,6197.74,36,,81.048,Percent of Total Billed Charges,36% Total Bille Charges,6197.74,36,,81.048,Percent of Total Billed Charges,36% of Total Billed Charges,9468.77,55,,164.416,Percent of Total Billed Charges,55% Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17215.94,100,,4274.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2482.54,14.42,,745.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13772.75,80,,1066.6,Percent of Total Billed Charges,80% of Total Billed Charges,8607.97,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,8607.97,50,,1844.528,Percent of Total Billed Charges,50% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8607.97,50,,1844.528,Percent of Total Billed Charges,50% of Total Billed Charges,8607.97,50,,1844.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12051.16,70,,7096.024,Percent of Total Billed Charges,70% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,2410.23,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17215.94,100,,1422.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,19520.13,
450240 POWER SLIM 6FR,32150064,CDM,278,RC,C1788,HCPCS,Outpatient,,,1413.17,847.90,,2163.3,110,,8485.968,Percent of Total Billed Charges,110% of Total Billed Charges,635.93,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.69,28,,12517.024,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,508.74,36,,16093.312,Percent of Total Billed Charges,36% of Total Billed Charges,508.74,36,,16093.312,Percent of Total Billed Charges,36% Total Bille Charges,508.74,36,,16093.312,Percent of Total Billed Charges,36% of Total Billed Charges,777.24,55,,52.024,Percent of Total Billed Charges,55% Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1315.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,203.78,14.42,,745.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1130.54,80,,1169.52,Percent of Total Billed Charges,80% of Total Billed Charges,706.59,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.59,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,989.22,70,,2134.44,Percent of Total Billed Charges,70% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,723.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,2163.3,
SURGIBRA S-XL,32150065,CDM,271,RC,,,Outpatient,,,93.06,55.84,,55.84,60,,5189.16,Percent of Total Billed Charges,60% of Total Billed Charges,41.88,45,,39.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.06,28,,1218.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.49,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,36,,1566.256,Percent of Total Billed Charges,36% of Total Billed Charges,33.5,36,,1566.256,Percent of Total Billed Charges,36% Total Bille Charges,33.5,36,,1566.256,Percent of Total Billed Charges,36% of Total Billed Charges,55.84,60,,164.408,Percent of Total Billed Charges,60% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.06,100,,48945.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14.42,,124.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.8,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,46.53,50,,1844.528,Percent of Total Billed Charges,50% of Total Billed Charges,46.53,50,,4827.624,Percent of Total Billed Charges,50% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.53,50,,4827.624,Percent of Total Billed Charges,50% of Total Billed Charges,46.53,50,,4827.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.14,70,,199.584,Percent of Total Billed Charges,70% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.06,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,93.06,
SURGIBRA XXL-XXXL,32150066,CDM,271,RC,,,Outpatient,,,102.5,61.50,,61.5,60,,4089.008,Percent of Total Billed Charges,60% of Total Billed Charges,46.13,45,,391.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.7,28,,624.064,Percent of Total Billed Charges,28% of Total Billed Charges,0.5,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.9,36,,802.368,Percent of Total Billed Charges,36% of Total Billed Charges,36.9,36,,802.368,Percent of Total Billed Charges,36% Total Bille Charges,36.9,36,,802.368,Percent of Total Billed Charges,36% of Total Billed Charges,61.5,60,,141.136,Percent of Total Billed Charges,60% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.5,100,,2785.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.78,14.42,,124.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.88,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,51.25,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,51.25,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.25,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,51.25,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.75,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,14.35,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.5,100,,12,Percent of Total Billed Charges,100% of Total Billed Charges,0.5,102.5,
296645 KIT BOSTON SCIENTIFIC P,32150067,CDM,278,RC,C1820,HCPCS,Outpatient,,,41850,25110.00,,47665.18,110,,442.024,Percent of Total Billed Charges,110% of Total Billed Charges,18832.5,45,,68.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11718,28,,315.456,Percent of Total Billed Charges,28% of Total Billed Charges,0.5,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,15066,36,,405.592,Percent of Total Billed Charges,36% of Total Billed Charges,15066,36,,405.592,Percent of Total Billed Charges,36% Total Bille Charges,15066,36,,405.592,Percent of Total Billed Charges,36% of Total Billed Charges,23017.5,55,,1990.592,Percent of Total Billed Charges,55% Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41850,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,6034.77,14.42,,188.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33480,80,,143.4,Percent of Total Billed Charges,80% of Total Billed Charges,20925,50,,4827.624,Percent of Total Billed Charges,50% of Total Billed Charges,20925,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20925,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,20925,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29295,70,,840.496,Percent of Total Billed Charges,70% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,5859,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41850,100,,191.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.5,47665.18,
598643 KIT BOSTON SCIENTIFIC C,32150069,CDM,278,RC,C1778,HCPCS,Outpatient,,,4656.63,2793.98,,5704.89,110,,8599.008,Percent of Total Billed Charges,110% of Total Billed Charges,2095.48,45,,982.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1303.86,28,,9136.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,1676.39,36,,11746.944,Percent of Total Billed Charges,36% of Total Billed Charges,1676.39,36,,11746.944,Percent of Total Billed Charges,36% Total Bille Charges,1676.39,36,,11746.944,Percent of Total Billed Charges,36% of Total Billed Charges,2561.15,55,,8046.552,Percent of Total Billed Charges,55% Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4656.63,100,,87.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,671.49,14.42,,95.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3725.3,80,,1070.344,Percent of Total Billed Charges,80% of Total Billed Charges,2328.32,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2328.32,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3259.64,70,,8316.128,Percent of Total Billed Charges,70% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4656.63,100,,1337.928,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,5704.89,
447877 KIT CHARGING,32150070,CDM,272,RC,,,Outpatient,,,9256,5553.60,,5553.6,60,,2693,Percent of Total Billed Charges,60% of Total Billed Charges,4165.2,45,,121.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2591.68,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,2.744,Percent of Total Billed Charges,32% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,3332.16,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,3332.16,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,3332.16,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,5553.6,60,,268.992,Percent of Total Billed Charges,60% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9256,100,,869.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1334.72,14.42,,438.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6942,75,,2980.24,Percent of Total Billed Charges,75% of Total Billed Charges,4628,50,,2583.24,Percent of Total Billed Charges,50% of Total Billed Charges,4628,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4628,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,4628,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6479.2,70,,9907.408,Percent of Total Billed Charges,70% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,1295.84,14,,426.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9256,100,,3725.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,9256,
604943 FIXATE SUTURE,32150072,CDM,278,RC,C1713,HCPCS,Outpatient,,,6084.21,3650.53,,7009.89,110,,11988.408,Percent of Total Billed Charges,110% of Total Billed Charges,2737.89,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1703.58,28,,157.184,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,2.752,Percent of Total Billed Charges,32% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,2190.32,36,,202.096,Percent of Total Billed Charges,36% of Total Billed Charges,2190.32,36,,202.096,Percent of Total Billed Charges,36% Total Bille Charges,2190.32,36,,202.096,Percent of Total Billed Charges,36% of Total Billed Charges,3346.32,55,,262.52,Percent of Total Billed Charges,55% Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6084.21,100,,151.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,877.34,14.42,,329.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4867.37,80,,2760.248,Percent of Total Billed Charges,80% of Total Billed Charges,3042.11,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,3042.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3042.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,3042.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4258.95,70,,4617.744,Percent of Total Billed Charges,70% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,851.79,14,,320.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6084.21,100,,3450.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,7009.89,
456770 ANCHOR BOSTON SCIENTIFI,32150073,CDM,278,RC,C1713,HCPCS,Outpatient,,,1924.84,1154.90,,2434.58,110,,4882.328,Percent of Total Billed Charges,110% of Total Billed Charges,866.18,45,,1825.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.96,28,,99.792,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,2.816,Percent of Total Billed Charges,32% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,692.94,36,,128.304,Percent of Total Billed Charges,36% of Total Billed Charges,692.94,36,,128.304,Percent of Total Billed Charges,36% Total Bille Charges,692.94,36,,128.304,Percent of Total Billed Charges,36% of Total Billed Charges,1058.66,55,,64.448,Percent of Total Billed Charges,55% Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1924.84,100,,2184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,277.56,14.42,,112.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1539.87,80,,835.2,Percent of Total Billed Charges,80% of Total Billed Charges,962.42,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,962.42,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,962.42,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,962.42,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1347.39,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1924.84,100,,1044,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,2434.58,
252371 DURAFORM J&J COD,32150075,CDM,278,RC,,,Outpatient,,,554.88,332.93,,610.37,110,,256.608,Percent of Total Billed Charges,110% of Total Billed Charges,249.7,45,,143.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.37,28,,830.064,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,25.6,Percent of Total Billed Charges,32% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,199.76,36,,1067.224,Percent of Total Billed Charges,36% of Total Billed Charges,199.76,36,,1067.224,Percent of Total Billed Charges,36% Total Bille Charges,199.76,36,,1067.224,Percent of Total Billed Charges,36% of Total Billed Charges,305.18,55,,1601.744,Percent of Total Billed Charges,55% Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,554.88,100,,268.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,80.01,14.42,,91.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,443.9,80,,1461.904,Percent of Total Billed Charges,80% of Total Billed Charges,277.44,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,277.44,50,,1522.152,Percent of Total Billed Charges,50% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.44,50,,1522.152,Percent of Total Billed Charges,50% of Total Billed Charges,277.44,50,,1522.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.42,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,77.68,14,,88.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,554.88,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,610.37,
162819 PIN XTRNFX SKL,32150076,CDM,272,RC,,,Outpatient,,,1777.67,1066.60,,1066.6,60,,1819.664,Percent of Total Billed Charges,60% of Total Billed Charges,799.95,45,,311.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,497.75,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.51,32,,25.632,Percent of Total Billed Charges,32% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,639.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,639.96,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,639.96,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1066.6,60,,164.408,Percent of Total Billed Charges,60% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1777.67,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.34,14.42,,112.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1333.25,75,,39156.48,Percent of Total Billed Charges,75% of Total Billed Charges,888.84,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,888.84,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,888.84,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,888.84,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1244.37,70,,6500.248,Percent of Total Billed Charges,70% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,248.87,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1777.67,100,,48945.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,1777.67,
476147 STYLET BRAINLAB DISP.,32150077,CDM,272,RC,,,Outpatient,,,1949.2,1169.52,,1169.52,60,,1315.192,Percent of Total Billed Charges,60% of Total Billed Charges,877.14,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,3650.744,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.736,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,4693.816,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,4693.816,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,4693.816,Percent of Total Billed Charges,36% of Total Billed Charges,1169.52,60,,24587.008,Percent of Total Billed Charges,60% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,4056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,146.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1461.9,75,,2951.24,Percent of Total Billed Charges,75% of Total Billed Charges,974.6,50,,1522.152,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,10640,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,141.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,3689.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,1949.2,
112947 TOURNIQUET CUFF 34 INCH,32150078,CDM,272,RC,,,Outpatient,,,164,98.40,,98.4,60,,1733.256,Percent of Total Billed Charges,60% of Total Billed Charges,73.8,45,,220.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.92,28,,29.568,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.832,Percent of Total Billed Charges,32% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,59.04,36,,38.016,Percent of Total Billed Charges,36% of Total Billed Charges,59.04,36,,38.016,Percent of Total Billed Charges,36% Total Bille Charges,59.04,36,,38.016,Percent of Total Billed Charges,36% of Total Billed Charges,98.4,60,,2392.896,Percent of Total Billed Charges,60% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164,100,,319.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,23.65,14.42,,290.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123,75,,2855.16,Percent of Total Billed Charges,75% of Total Billed Charges,82,50,,1144,Percent of Total Billed Charges,50% of Total Billed Charges,82,50,,316.424,Percent of Total Billed Charges,50% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82,50,,316.424,Percent of Total Billed Charges,50% of Total Billed Charges,82,50,,316.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.8,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,22.96,14,,282.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164,100,,3806.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,164,
ZIMMER,32150079,CDM,272,RC,A4649,HCPCS,Outpatient,,,15,9.00,,9,60,,660.224,Percent of Total Billed Charges,60% of Total Billed Charges,6.75,45,,75.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.856,Percent of Total Billed Charges,32% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,5.4,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,5.4,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,5.4,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,9,60,,1225.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,100,,693.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,75,,7724.2,Percent of Total Billed Charges,75% of Total Billed Charges,7.5,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,7.5,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,7.5,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.5,70,,11449.192,Percent of Total Billed Charges,70% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,100,,9655.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,15,
406724 TOURNIQUET CUFF 24 INCH,32150080,CDM,272,RC,,,Outpatient,,,239,143.40,,143.4,60,,2183.808,Percent of Total Billed Charges,60% of Total Billed Charges,107.55,45,,1234.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.92,28,,1193.336,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.856,Percent of Total Billed Charges,32% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,86.04,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,86.04,36,,1534.288,Percent of Total Billed Charges,36% Total Bille Charges,86.04,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,143.4,60,,619.656,Percent of Total Billed Charges,60% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239,100,,1559.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,34.46,14.42,,22.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.25,75,,3874.864,Percent of Total Billed Charges,75% of Total Billed Charges,119.5,50,,316.424,Percent of Total Billed Charges,50% of Total Billed Charges,119.5,50,,506.792,Percent of Total Billed Charges,50% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.5,50,,506.792,Percent of Total Billed Charges,50% of Total Billed Charges,119.5,50,,506.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.3,70,,1132.32,Percent of Total Billed Charges,70% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239,100,,5166.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,239,
540433 GRAFTON PUTTY DBM,32150083,CDM,278,RC,C1713,HCPCS,Outpatient,,,1672.41,1003.45,,2156.91,110,,1014.128,Percent of Total Billed Charges,110% of Total Billed Charges,752.58,45,,305.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468.27,28,,1193.336,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.904,Percent of Total Billed Charges,32% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,602.07,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,602.07,36,,1534.288,Percent of Total Billed Charges,36% Total Bille Charges,602.07,36,,1534.288,Percent of Total Billed Charges,36% of Total Billed Charges,919.83,55,,17946.72,Percent of Total Billed Charges,55% Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1672.41,100,,490.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,241.16,14.42,,22.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.93,80,,3874.864,Percent of Total Billed Charges,80% of Total Billed Charges,836.21,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,836.21,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,836.21,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,836.21,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1170.69,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,234.14,14,,22.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1672.41,100,,5166.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,2156.91,
431956 CONTACT LEAD LINEAR ST,32150084,CDM,278,RC,C1778,HCPCS,Outpatient,,,4656.63,2793.98,,5704.89,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,2095.48,45,,47.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1303.86,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.976,Percent of Total Billed Charges,32% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,1676.39,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,1676.39,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,1676.39,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,2561.15,55,,308.752,Percent of Total Billed Charges,55% Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4656.63,100,,168.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,671.49,14.42,,16.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3725.3,80,,646.16,Percent of Total Billed Charges,80% of Total Billed Charges,2328.32,50,,506.792,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2328.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3259.64,70,,2911.832,Percent of Total Billed Charges,70% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4656.63,100,,861.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,5704.89,
393660 MESH PHYSIO 15X20CM,32150086,CDM,278,RC,C1781,HCPCS,Outpatient,,,4312.89,2587.73,,5196.94,110,,1169.52,Percent of Total Billed Charges,110% of Total Billed Charges,1940.8,45,,2080.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.61,28,,37.408,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,25.992,Percent of Total Billed Charges,32% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,1552.64,36,,48.096,Percent of Total Billed Charges,36% of Total Billed Charges,1552.64,36,,48.096,Percent of Total Billed Charges,36% Total Bille Charges,1552.64,36,,48.096,Percent of Total Billed Charges,36% of Total Billed Charges,2372.09,55,,213.84,Percent of Total Billed Charges,55% Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4312.89,100,,2743.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,621.92,14.42,,27.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3450.31,80,,646.16,Percent of Total Billed Charges,80% of Total Billed Charges,2156.45,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,2156.45,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2156.45,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,2156.45,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3019.02,70,,7101.072,Percent of Total Billed Charges,70% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,603.8,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4312.89,100,,861.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,5196.94,
0004413 PATCH DURAGUARD BOVINE,32150087,CDM,278,RC,,,Outpatient,,,1305,783.00,,1435.5,110,,2191.936,Percent of Total Billed Charges,110% of Total Billed Charges,587.25,45,,1366.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.4,28,,32.568,Percent of Total Billed Charges,28% of Total Billed Charges,0.52,32,,26.112,Percent of Total Billed Charges,32% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,469.8,36,,41.872,Percent of Total Billed Charges,36% of Total Billed Charges,469.8,36,,41.872,Percent of Total Billed Charges,36% Total Bille Charges,469.8,36,,41.872,Percent of Total Billed Charges,36% of Total Billed Charges,717.75,55,,1630.48,Percent of Total Billed Charges,55% Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1305,100,,679.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,188.18,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1044,80,,979.48,Percent of Total Billed Charges,80% of Total Billed Charges,652.5,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,652.5,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,652.5,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,652.5,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,913.5,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1305,100,,1305.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,1435.5,
613338 BACTISEAL EVD CATH,32150088,CDM,272,RC,C1729,HCPCS,Outpatient,,,2436.5,1461.90,,11.1,100,,3088.8,Fee Schedule,100% of Aetna Fee Schedule,1096.43,45,,1713.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,50.168,Percent of Total Billed Charges,28% of Total Billed Charges,0.53,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,64.496,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,64.496,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,64.496,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,106.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,12.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,495,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,58.632,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,58.632,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,58.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,319.28,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,660,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,2436.5,
587684 KIT BOSTON GENERATOR,32150091,CDM,278,RC,C1820,HCPCS,Outpatient,,,61182,36709.20,,68930.38,110,,68.048,Percent of Total Billed Charges,110% of Total Billed Charges,27531.9,45,,811.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17130.96,28,,76.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.53,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,22025.52,36,,98.168,Percent of Total Billed Charges,36% of Total Billed Charges,22025.52,36,,98.168,Percent of Total Billed Charges,36% Total Bille Charges,22025.52,36,,98.168,Percent of Total Billed Charges,36% of Total Billed Charges,33650.1,55,,7171.104,Percent of Total Billed Charges,55% Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61182,100,,4622.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8822.44,14.42,,43.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48945.6,80,,2283.224,Percent of Total Billed Charges,80% of Total Billed Charges,30591,50,,79.568,Percent of Total Billed Charges,50% of Total Billed Charges,30591,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30591,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,30591,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42827.4,70,,519.4,Percent of Total Billed Charges,70% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61182,100,,3044.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,68930.38,
569876 SPLITTER BOSTON SCIENTI,32150092,CDM,278,RC,C1883,HCPCS,Outpatient,,,4611.31,2766.79,,5101,110,,21132.36,Percent of Total Billed Charges,110% of Total Billed Charges,2075.09,45,,899.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1291.17,28,,491.568,Percent of Total Billed Charges,28% of Total Billed Charges,0.53,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,1660.07,36,,632.016,Percent of Total Billed Charges,36% of Total Billed Charges,1660.07,36,,632.016,Percent of Total Billed Charges,36% Total Bille Charges,1660.07,36,,632.016,Percent of Total Billed Charges,36% of Total Billed Charges,2536.22,55,,63.36,Percent of Total Billed Charges,55% Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4611.31,100,,3036.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,664.95,14.42,,43.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3689.05,80,,1830.4,Percent of Total Billed Charges,80% of Total Billed Charges,2305.66,50,,58.632,Percent of Total Billed Charges,50% of Total Billed Charges,2305.66,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2305.66,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,2305.66,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3227.92,70,,1285.76,Percent of Total Billed Charges,70% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,645.58,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4611.31,100,,2288,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,5101,
587685 KIT BOSTON REMOTE,32150094,CDM,272,RC,C1787,HCPCS,Outpatient,,,4758.6,2855.16,,59.4,100,,3146,Fee Schedule,100% of Aetna Fee Schedule,2141.37,45,,23261.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,28,,1567.848,Percent of Total Billed Charges,28% of Total Billed Charges,0.53,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,1713.1,36,,2015.808,Percent of Total Billed Charges,36% of Total Billed Charges,1713.1,36,,2015.808,Percent of Total Billed Charges,36% Total Bille Charges,1713.1,36,,2015.808,Percent of Total Billed Charges,36% of Total Billed Charges,2855.16,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4758.6,100,,3806.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,686.19,14.42,,43.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3568.95,75,,584.76,Percent of Total Billed Charges,75% of Total Billed Charges,2379.3,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,42.784,Percent of Total Billed Charges,50% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,50,,42.784,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,42.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3331.02,70,,23.872,Percent of Total Billed Charges,70% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,4758.6,
569875 LEAD BOSTON SCIENTIFIC,32150095,CDM,278,RC,C1883,HCPCS,Outpatient,,,12069.06,7241.44,,13304.53,110,,65.68,Percent of Total Billed Charges,110% of Total Billed Charges,5431.08,45,,1790.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3379.34,28,,253.696,Percent of Total Billed Charges,28% of Total Billed Charges,0.53,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,4344.86,36,,326.176,Percent of Total Billed Charges,36% of Total Billed Charges,4344.86,36,,326.176,Percent of Total Billed Charges,36% Total Bille Charges,4344.86,36,,326.176,Percent of Total Billed Charges,36% of Total Billed Charges,6637.98,55,,2557.152,Percent of Total Billed Charges,55% Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12069.06,100,,1804.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1740.36,14.42,,80.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9655.25,80,,474.632,Percent of Total Billed Charges,80% of Total Billed Charges,6034.53,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,6034.53,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6034.53,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,6034.53,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8448.34,70,,1494.112,Percent of Total Billed Charges,70% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,1689.67,14,,77.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12069.06,100,,632.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,13304.53,
ZEPHYR DR GENERATOR,32150096,CDM,275,RC,C1785,HCPCS,Outpatient,,,6458.1,3874.86,,7379.33,110,,4205.264,Percent of Total Billed Charges,110% of Total Billed Charges,2906.15,45,,1817.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1808.27,28,,223.768,Percent of Total Billed Charges,28% of Total Billed Charges,0.54,32,,26.216,Percent of Total Billed Charges,32% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,2324.92,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,2324.92,36,,287.704,Percent of Total Billed Charges,36% Total Bille Charges,2324.92,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,3551.96,55,,2557.152,Percent of Total Billed Charges,55% Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6458.1,100,,1998.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,931.26,14.42,,599.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4843.58,75,,584.76,Percent of Total Billed Charges,75% of Total Billed Charges,3229.05,50,,42.784,Percent of Total Billed Charges,50% of Total Billed Charges,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4520.67,70,,1353.624,Percent of Total Billed Charges,70% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,582.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6458.1,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,7379.33,
617040 ZEPHYR XL DR GENERATOR,32150097,CDM,275,RC,C1785,HCPCS,Outpatient,,,6458.1,3874.86,,7379.33,110,,6066.792,Percent of Total Billed Charges,110% of Total Billed Charges,2906.15,45,,30591,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1808.27,28,,561.968,Percent of Total Billed Charges,28% of Total Billed Charges,0.54,32,,26.24,Percent of Total Billed Charges,32% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,2324.92,36,,722.536,Percent of Total Billed Charges,36% of Total Billed Charges,2324.92,36,,722.536,Percent of Total Billed Charges,36% Total Bille Charges,2324.92,36,,722.536,Percent of Total Billed Charges,36% of Total Billed Charges,3551.96,55,,1169.52,Percent of Total Billed Charges,55% Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6458.1,100,,51691.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,931.26,14.42,,123.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4843.58,75,,760.192,Percent of Total Billed Charges,75% of Total Billed Charges,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,3229.05,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4520.67,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,904.13,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6458.1,100,,1013.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,7379.33,
TENDRIL ST A-LEAD 1888TC-46,32150098,CDM,275,RC,C1898,HCPCS,Outpatient,,,1076.93,646.16,,2557.4,110,,3988.088,Percent of Total Billed Charges,110% of Total Billed Charges,484.62,45,,1790.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.54,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.55,32,,26.344,Percent of Total Billed Charges,32% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,387.69,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,387.69,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,387.69,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,592.31,55,,80.16,Percent of Total Billed Charges,55% Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1076.93,100,,3979.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,155.29,14.42,,137.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,807.7,75,,1511.896,Percent of Total Billed Charges,75% of Total Billed Charges,538.47,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,277.76,Percent of Total Billed Charges,50% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.47,50,,277.76,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,277.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,753.85,70,,2862.776,Percent of Total Billed Charges,70% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,133.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1076.93,100,,2015.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,2557.4,
TENDRIL ST V-LEAD 1888TC-52,32150099,CDM,275,RC,C1898,HCPCS,Outpatient,,,1076.93,646.16,,2557.4,110,,1257.984,Percent of Total Billed Charges,110% of Total Billed Charges,484.62,45,,248.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.54,28,,332.928,Percent of Total Billed Charges,28% of Total Billed Charges,0.55,32,,26.464,Percent of Total Billed Charges,32% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,387.69,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,387.69,36,,428.048,Percent of Total Billed Charges,36% Total Bille Charges,387.69,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,592.31,55,,69.784,Percent of Total Billed Charges,55% Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1076.93,100,,4039.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,155.29,14.42,,15.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,807.7,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,538.47,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.47,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,753.85,70,,386.384,Percent of Total Billed Charges,70% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,15.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1076.93,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,2557.4,
487028 SHEATH ENDOLOGIX 17FR,32150102,CDM,272,RC,C1894,HCPCS,Outpatient,,,1632.46,979.48,,82.29,100,,2779.168,Fee Schedule,100% of Aetna Fee Schedule,734.61,45,,1289.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,457.09,28,,267.432,Percent of Total Billed Charges,28% of Total Billed Charges,0.55,32,,26.472,Percent of Total Billed Charges,32% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,587.69,36,,343.84,Percent of Total Billed Charges,36% of Total Billed Charges,587.69,36,,343.84,Percent of Total Billed Charges,36% Total Bille Charges,587.69,36,,343.84,Percent of Total Billed Charges,36% of Total Billed Charges,979.48,60,,1053.36,Percent of Total Billed Charges,60% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1632.46,100,,67980,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,235.4,14.42,,7.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1224.35,75,,119.352,Percent of Total Billed Charges,75% of Total Billed Charges,816.23,50,,277.76,Percent of Total Billed Charges,50% of Total Billed Charges,816.23,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,816.23,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,816.23,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.72,70,,255.36,Percent of Total Billed Charges,70% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1632.46,100,,159.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,1632.46,
580991 ANCHOR MEDTRONIC INJEX,32150109,CDM,272,RC,,,Outpatient,,,825,495.00,,495,60,,6035.24,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,45,,1525.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231,28,,71.848,Percent of Total Billed Charges,28% of Total Billed Charges,0.55,32,,26.496,Percent of Total Billed Charges,32% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,297,36,,92.376,Percent of Total Billed Charges,36% of Total Billed Charges,297,36,,92.376,Percent of Total Billed Charges,36% Total Bille Charges,297,36,,92.376,Percent of Total Billed Charges,36% of Total Billed Charges,495,60,,3079.704,Percent of Total Billed Charges,60% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825,100,,3979.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.97,14.42,,140.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,618.75,75,,119.352,Percent of Total Billed Charges,75% of Total Billed Charges,412.5,50,,2080,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,475.608,Percent of Total Billed Charges,50% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,412.5,50,,475.608,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,475.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,577.5,70,,3399.544,Percent of Total Billed Charges,70% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825,100,,159.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,825,
PROGRAMMER MEDTRONIC,32150112,CDM,272,RC,C1787,HCPCS,Outpatient,,,3805.37,2283.22,,59.4,100,,4112.792,Fee Schedule,100% of Aetna Fee Schedule,1712.42,45,,276.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1065.5,28,,73.848,Percent of Total Billed Charges,28% of Total Billed Charges,0.55,32,,26.496,Percent of Total Billed Charges,32% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1369.93,36,,94.944,Percent of Total Billed Charges,36% of Total Billed Charges,1369.93,36,,94.944,Percent of Total Billed Charges,36% Total Bille Charges,1369.93,36,,94.944,Percent of Total Billed Charges,36% of Total Billed Charges,2283.22,60,,498.328,Percent of Total Billed Charges,60% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3805.37,100,,552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,548.73,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2854.03,75,,87.952,Percent of Total Billed Charges,75% of Total Billed Charges,1902.69,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,1902.69,50,,54.464,Percent of Total Billed Charges,50% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1902.69,50,,54.464,Percent of Total Billed Charges,50% of Total Billed Charges,1902.69,50,,54.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2663.76,70,,5054.584,Percent of Total Billed Charges,70% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,532.75,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3805.37,100,,117.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,3805.37,
600427 OSSEOPERM (OP-001),32150123,CDM,278,RC,,,Outpatient,,,2860,1716.00,,3146,110,,1986.504,Percent of Total Billed Charges,110% of Total Billed Charges,1287,45,,26.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.8,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.56,32,,26.496,Percent of Total Billed Charges,32% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,1029.6,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1029.6,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,1029.6,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1573,55,,479.504,Percent of Total Billed Charges,55% Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2860,100,,2866.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,412.41,14.42,,1393.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2288,80,,140.712,Percent of Total Billed Charges,80% of Total Billed Charges,1430,50,,475.608,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1430,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,1430,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2002,70,,897.8,Percent of Total Billed Charges,70% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,400.4,14,,1353.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2860,100,,187.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,3146,
385412 STAPLER RELOAD COVIDIEN,32150125,CDM,272,RC,,,Outpatient,,,974.6,584.76,,584.76,60,,6356.456,Percent of Total Billed Charges,60% of Total Billed Charges,438.57,45,,3752.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,2555.568,Percent of Total Billed Charges,28% of Total Billed Charges,0.56,32,,26.52,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,3285.736,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,3285.736,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,3285.736,Percent of Total Billed Charges,36% of Total Billed Charges,584.76,60,,1103.872,Percent of Total Billed Charges,60% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,3390.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,49.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.95,75,,56.632,Percent of Total Billed Charges,75% of Total Billed Charges,487.3,50,,54.464,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,11249.328,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,974.6,
406257 STAPLER HANDLE COVIDIEN,32150126,CDM,272,RC,,,Outpatient,,,791.05,474.63,,474.63,60,,28673.856,Percent of Total Billed Charges,60% of Total Billed Charges,355.97,45,,41.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.49,28,,79.04,Percent of Total Billed Charges,28% of Total Billed Charges,0.56,32,,26.592,Percent of Total Billed Charges,32% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,284.78,36,,101.616,Percent of Total Billed Charges,36% of Total Billed Charges,284.78,36,,101.616,Percent of Total Billed Charges,36% Total Bille Charges,284.78,36,,101.616,Percent of Total Billed Charges,36% of Total Billed Charges,474.63,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,791.05,100,,614.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,114.07,14.42,,157.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,593.29,75,,64.176,Percent of Total Billed Charges,75% of Total Billed Charges,395.53,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,395.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,395.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553.74,70,,951.288,Percent of Total Billed Charges,70% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,110.75,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.05,100,,85.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,791.05,
379067 KIT INTUITIVE DISPOSABL,32150127,CDM,272,RC,,,Outpatient,,,974.6,584.76,,584.76,60,,10163.688,Percent of Total Billed Charges,60% of Total Billed Charges,438.57,45,,101.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,434.784,Percent of Total Billed Charges,28% of Total Billed Charges,0.57,32,,26.6,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,559.008,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,559.008,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,559.008,Percent of Total Billed Charges,36% of Total Billed Charges,584.76,60,,653.96,Percent of Total Billed Charges,60% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,59.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,4579.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.95,75,,225.144,Percent of Total Billed Charges,75% of Total Billed Charges,487.3,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,4833.384,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,4833.384,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,4833.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,610.752,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,4446.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,300.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,974.6,
379068 KIT INTUITIVE DISPOSABL,32150128,CDM,272,RC,,,Outpatient,,,1266.98,760.19,,760.19,60,,4205.264,Percent of Total Billed Charges,60% of Total Billed Charges,570.14,45,,154.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.75,28,,1617.928,Percent of Total Billed Charges,28% of Total Billed Charges,0.57,32,,26.656,Percent of Total Billed Charges,32% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,456.11,36,,2080.192,Percent of Total Billed Charges,36% of Total Billed Charges,456.11,36,,2080.192,Percent of Total Billed Charges,36% Total Bille Charges,456.11,36,,2080.192,Percent of Total Billed Charges,36% of Total Billed Charges,760.19,60,,525.312,Percent of Total Billed Charges,60% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1266.98,100,,8339.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14.42,,817.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,950.24,75,,225.144,Percent of Total Billed Charges,75% of Total Billed Charges,633.49,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,633.49,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,633.49,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,633.49,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,886.89,70,,595.44,Percent of Total Billed Charges,70% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,177.38,14,,794.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1266.98,100,,300.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,1266.98,
542855 SEALER DAVINCI VESSEL E,32150129,CDM,272,RC,,,Outpatient,,,2519.83,1511.90,,1511.9,60,,468,Percent of Total Billed Charges,60% of Total Billed Charges,1133.92,45,,23.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.55,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,0.57,32,,26.712,Percent of Total Billed Charges,32% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,907.14,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,907.14,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,907.14,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,1511.9,60,,153.968,Percent of Total Billed Charges,60% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2519.83,100,,91.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,363.36,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1889.87,75,,225.144,Percent of Total Billed Charges,75% of Total Billed Charges,1259.92,50,,4833.384,Percent of Total Billed Charges,50% of Total Billed Charges,1259.92,50,,545.776,Percent of Total Billed Charges,50% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1259.92,50,,545.776,Percent of Total Billed Charges,50% of Total Billed Charges,1259.92,50,,545.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1763.88,70,,10088.232,Percent of Total Billed Charges,70% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2519.83,100,,300.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,2519.83,
195989 COVER HOT SHEARS TIP (R,32150131,CDM,272,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,8.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,13391.84,Percent of Total Billed Charges,28% of Total Billed Charges,0.58,32,,26.736,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,17218.08,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,17218.08,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,17218.08,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,158.24,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,225.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,30.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,416.64,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,15880.128,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,15880.128,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,15880.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,131.328,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,555.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,125.84,
116324 CLIP HEMOLOCK MEDIUM-LA,32150132,CDM,272,RC,,,Outpatient,,,198.92,119.35,,119.35,60,,421.024,Percent of Total Billed Charges,60% of Total Billed Charges,89.51,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.7,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.784,Percent of Total Billed Charges,32% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,71.61,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,71.61,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,71.61,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,119.35,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.92,100,,342.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,28.68,14.42,,30.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.19,75,,3120,Percent of Total Billed Charges,75% of Total Billed Charges,99.46,50,,545.776,Percent of Total Billed Charges,50% of Total Billed Charges,99.46,50,,2836.08,Percent of Total Billed Charges,50% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.46,50,,2836.08,Percent of Total Billed Charges,50% of Total Billed Charges,99.46,50,,2836.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.24,70,,1091.552,Percent of Total Billed Charges,70% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,29.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.92,100,,4160,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,198.92,
182723 CLIP HEMOLOCK LARGE PUR,32150133,CDM,272,RC,,,Outpatient,,,198.92,119.35,,119.35,60,,421.024,Percent of Total Billed Charges,60% of Total Billed Charges,89.51,45,,186.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.7,28,,955.904,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.784,Percent of Total Billed Charges,32% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,71.61,36,,1229.024,Percent of Total Billed Charges,36% of Total Billed Charges,71.61,36,,1229.024,Percent of Total Billed Charges,36% Total Bille Charges,71.61,36,,1229.024,Percent of Total Billed Charges,36% of Total Billed Charges,119.35,60,,5019.872,Percent of Total Billed Charges,60% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.92,100,,51.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,28.68,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.19,75,,643.24,Percent of Total Billed Charges,75% of Total Billed Charges,99.46,50,,15880.128,Percent of Total Billed Charges,50% of Total Billed Charges,99.46,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.46,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,99.46,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.24,70,,930.544,Percent of Total Billed Charges,70% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.85,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.92,100,,857.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,198.92,
313080 TROCAR BLADELESS OBTURA,32150134,CDM,272,RC,,,Outpatient,,,146.58,87.95,,87.95,60,,153.208,Percent of Total Billed Charges,60% of Total Billed Charges,65.96,45,,534.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,28,,735.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.848,Percent of Total Billed Charges,32% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.77,36,,945.256,Percent of Total Billed Charges,36% of Total Billed Charges,52.77,36,,945.256,Percent of Total Billed Charges,36% Total Bille Charges,52.77,36,,945.256,Percent of Total Billed Charges,36% of Total Billed Charges,87.95,60,,169.36,Percent of Total Billed Charges,60% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.58,100,,18.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,21.14,14.42,,29.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.94,75,,713.408,Percent of Total Billed Charges,75% of Total Billed Charges,73.29,50,,2836.08,Percent of Total Billed Charges,50% of Total Billed Charges,73.29,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.29,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,73.29,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.61,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,28.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,100,,951.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,146.58,
344774 SEAL INTUITIVE CANNULA,32150135,CDM,272,RC,,,Outpatient,,,234.52,140.71,,140.71,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.53,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.67,28,,2777.464,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,84.43,36,,3571.024,Percent of Total Billed Charges,36% of Total Billed Charges,84.43,36,,3571.024,Percent of Total Billed Charges,36% Total Bille Charges,84.43,36,,3571.024,Percent of Total Billed Charges,36% of Total Billed Charges,140.71,60,,854.048,Percent of Total Billed Charges,60% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.52,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,33.82,14.42,,1133.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.89,75,,81.688,Percent of Total Billed Charges,75% of Total Billed Charges,117.26,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,117.26,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.26,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,117.26,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.16,70,,1215.904,Percent of Total Billed Charges,70% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.52,100,,108.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,234.52,
147746 SEAL INTUITIVE DAVINCI,32150136,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,4205.264,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,976.848,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,1255.944,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,1255.944,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,1255.944,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,3178.064,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,413.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,1133.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,38.584,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,191.816,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,51.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,94.38,
528863 CANNULA SEAL DAVINCI 5M,32150137,CDM,272,RC,,,Outpatient,,,106.96,64.18,,64.18,60,,145.656,Percent of Total Billed Charges,60% of Total Billed Charges,48.13,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.95,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,38.51,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,38.51,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,38.51,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,64.18,60,,385.944,Percent of Total Billed Charges,60% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.96,100,,1188,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,15.42,14.42,,11.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.22,75,,779.68,Percent of Total Billed Charges,75% of Total Billed Charges,53.48,50,,105.584,Percent of Total Billed Charges,50% of Total Billed Charges,53.48,50,,100.92,Percent of Total Billed Charges,50% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.48,50,,100.92,Percent of Total Billed Charges,50% of Total Billed Charges,53.48,50,,100.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.87,70,,60.696,Percent of Total Billed Charges,70% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,14,,10.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.96,100,,974.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,106.96,
575099 MANIPULATOR CONMED V-CA,32150141,CDM,272,RC,,,Outpatient,,,375.24,225.14,,225.14,60,,1369.712,Percent of Total Billed Charges,60% of Total Billed Charges,168.86,45,,115.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.07,28,,591.952,Percent of Total Billed Charges,28% of Total Billed Charges,0.59,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,135.09,36,,761.08,Percent of Total Billed Charges,36% of Total Billed Charges,135.09,36,,761.08,Percent of Total Billed Charges,36% Total Bille Charges,135.09,36,,761.08,Percent of Total Billed Charges,36% of Total Billed Charges,225.14,60,,26305.408,Percent of Total Billed Charges,60% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.24,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,54.11,14.42,,9.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.43,75,,2541,Percent of Total Billed Charges,75% of Total Billed Charges,187.62,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.67,70,,191.808,Percent of Total Billed Charges,70% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,9.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.24,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,375.24,
537963 MANIPULATOR CONMED VCAR,32150142,CDM,272,RC,,,Outpatient,,,375.24,225.14,,225.14,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,168.86,45,,1198.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.07,28,,1567.24,Percent of Total Billed Charges,28% of Total Billed Charges,0.6,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,135.09,36,,2015.024,Percent of Total Billed Charges,36% of Total Billed Charges,135.09,36,,2015.024,Percent of Total Billed Charges,36% Total Bille Charges,135.09,36,,2015.024,Percent of Total Billed Charges,36% of Total Billed Charges,225.14,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.24,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,54.11,14.42,,234.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.43,75,,7733.408,Percent of Total Billed Charges,75% of Total Billed Charges,187.62,50,,100.92,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.67,70,,164.656,Percent of Total Billed Charges,70% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,227.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.24,100,,9666.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,375.24,
541064 MANIPULATOR CONMED VCAR,32150143,CDM,272,RC,,,Outpatient,,,375.24,225.14,,225.14,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,168.86,45,,1129.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.07,28,,481.336,Percent of Total Billed Charges,28% of Total Billed Charges,0.6,32,,26.872,Percent of Total Billed Charges,32% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,135.09,36,,618.864,Percent of Total Billed Charges,36% of Total Billed Charges,135.09,36,,618.864,Percent of Total Billed Charges,36% Total Bille Charges,135.09,36,,618.864,Percent of Total Billed Charges,36% of Total Billed Charges,225.14,60,,2048.368,Percent of Total Billed Charges,60% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.24,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,54.11,14.42,,381.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.43,75,,256.608,Percent of Total Billed Charges,75% of Total Billed Charges,187.62,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,38.256,Percent of Total Billed Charges,50% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.62,50,,38.256,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,38.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.67,70,,2533.48,Percent of Total Billed Charges,70% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,370.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.24,100,,342.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,375.24,
543450 PORT INTUITIVE SINGLE S,32150144,CDM,272,RC,,,Outpatient,,,694.4,416.64,,416.64,60,,85.408,Percent of Total Billed Charges,60% of Total Billed Charges,312.48,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.43,28,,316.552,Percent of Total Billed Charges,28% of Total Billed Charges,0.61,32,,26.88,Percent of Total Billed Charges,32% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,249.98,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,249.98,36,,406.992,Percent of Total Billed Charges,36% Total Bille Charges,249.98,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,416.64,60,,1444.136,Percent of Total Billed Charges,60% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,694.4,100,,257.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,100.13,14.42,,19.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.8,75,,818.664,Percent of Total Billed Charges,75% of Total Billed Charges,347.2,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,347.2,50,,34.512,Percent of Total Billed Charges,50% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.2,50,,34.512,Percent of Total Billed Charges,50% of Total Billed Charges,347.2,50,,34.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.08,70,,10241.064,Percent of Total Billed Charges,70% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.22,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.4,100,,1091.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,694.4,
379059 GRASPER INTUITIVE DOUBL,32150145,CDM,272,RC,,,Outpatient,,,5200,3120.00,,3120,60,,2886.032,Percent of Total Billed Charges,60% of Total Billed Charges,2340,45,,164.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1456,28,,283.184,Percent of Total Billed Charges,28% of Total Billed Charges,0.61,32,,26.88,Percent of Total Billed Charges,32% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,1872,36,,364.088,Percent of Total Billed Charges,36% of Total Billed Charges,1872,36,,364.088,Percent of Total Billed Charges,36% Total Bille Charges,1872,36,,364.088,Percent of Total Billed Charges,36% of Total Billed Charges,3120,60,,5455.736,Percent of Total Billed Charges,60% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5200,100,,2662.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,749.84,14.42,,19.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3900,75,,25408.208,Percent of Total Billed Charges,75% of Total Billed Charges,2600,50,,38.256,Percent of Total Billed Charges,50% of Total Billed Charges,2600,50,,813.12,Percent of Total Billed Charges,50% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2600,50,,813.12,Percent of Total Billed Charges,50% of Total Billed Charges,2600,50,,813.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,70,,313.824,Percent of Total Billed Charges,70% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,728,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5200,100,,31760.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,5200,
533194 IRRIGATOR INTUITIVE END,32150146,CDM,272,RC,,,Outpatient,,,1072.06,643.24,,643.24,60,,16181.528,Percent of Total Billed Charges,60% of Total Billed Charges,482.43,45,,840.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.18,28,,797.248,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,26.976,Percent of Total Billed Charges,32% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,385.94,36,,1025.032,Percent of Total Billed Charges,36% of Total Billed Charges,385.94,36,,1025.032,Percent of Total Billed Charges,36% Total Bille Charges,385.94,36,,1025.032,Percent of Total Billed Charges,36% of Total Billed Charges,643.24,60,,1918.808,Percent of Total Billed Charges,60% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1072.06,100,,2510.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,154.59,14.42,,47.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,75,,4537.728,Percent of Total Billed Charges,75% of Total Billed Charges,536.03,50,,34.512,Percent of Total Billed Charges,50% of Total Billed Charges,536.03,50,,1323.016,Percent of Total Billed Charges,50% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.03,50,,1323.016,Percent of Total Billed Charges,50% of Total Billed Charges,536.03,50,,1323.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750.44,70,,306.272,Percent of Total Billed Charges,70% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,46.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1072.06,100,,5672.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1072.06,
441061 EXPRESSEW MITEK,32150149,CDM,272,RC,,,Outpatient,,,1189.01,713.41,,713.41,60,,3637.92,Percent of Total Billed Charges,60% of Total Billed Charges,535.05,45,,805.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.92,28,,2804.256,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,26.976,Percent of Total Billed Charges,32% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,428.04,36,,3605.472,Percent of Total Billed Charges,36% of Total Billed Charges,428.04,36,,3605.472,Percent of Total Billed Charges,36% Total Bille Charges,428.04,36,,3605.472,Percent of Total Billed Charges,36% of Total Billed Charges,713.41,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.01,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,171.46,14.42,,179.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,891.76,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,594.51,50,,813.12,Percent of Total Billed Charges,50% of Total Billed Charges,594.51,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.51,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,594.51,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,832.31,70,,75.192,Percent of Total Billed Charges,70% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,166.46,14,,174.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.01,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1189.01,
SUTURE STRATAFIX SPIRAL 3-0,32150154,CDM,272,RC,,,Outpatient,,,136.15,81.69,,81.69,60,,2974.376,Percent of Total Billed Charges,60% of Total Billed Charges,61.27,45,,524.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.12,28,,52.312,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,26.992,Percent of Total Billed Charges,32% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,49.01,36,,67.256,Percent of Total Billed Charges,36% of Total Billed Charges,49.01,36,,67.256,Percent of Total Billed Charges,36% Total Bille Charges,49.01,36,,67.256,Percent of Total Billed Charges,36% of Total Billed Charges,81.69,60,,1162.76,Percent of Total Billed Charges,60% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.15,100,,365.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.63,14.42,,574.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.11,75,,158.368,Percent of Total Billed Charges,75% of Total Billed Charges,68.08,50,,1323.016,Percent of Total Billed Charges,50% of Total Billed Charges,68.08,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,68.08,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.31,70,,1868.704,Percent of Total Billed Charges,70% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.06,14,,557.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.15,100,,211.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,136.15,
115962 CATHETER MALECOT 4WING,32150156,CDM,272,RC,C1729,HCPCS,Outpatient,,,64.31,38.59,,11.1,100,,8928.056,Fee Schedule,100% of Aetna Fee Schedule,28.94,45,,1276.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.01,28,,218.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,26.992,Percent of Total Billed Charges,32% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,23.15,36,,280.8,Percent of Total Billed Charges,36% Total Bille Charges,23.15,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,38.59,60,,3078.504,Percent of Total Billed Charges,60% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.31,100,,1867.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14.42,,75.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.23,75,,158.368,Percent of Total Billed Charges,75% of Total Billed Charges,32.16,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,32.16,50,,164.512,Percent of Total Billed Charges,50% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.16,50,,164.512,Percent of Total Billed Charges,50% of Total Billed Charges,32.16,50,,164.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.02,70,,191.808,Percent of Total Billed Charges,70% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,73.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.31,100,,211.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,64.31,
118367 CEMENT BONE COBALT G HV,32150169,CDM,278,RC,C1713,HCPCS,Outpatient,,,1218.25,730.95,,1657.34,110,,91.8,Percent of Total Billed Charges,110% of Total Billed Charges,548.21,45,,2494.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,28,,1055.088,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,27.032,Percent of Total Billed Charges,32% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,438.57,36,,1356.544,Percent of Total Billed Charges,36% of Total Billed Charges,438.57,36,,1356.544,Percent of Total Billed Charges,36% Total Bille Charges,438.57,36,,1356.544,Percent of Total Billed Charges,36% of Total Billed Charges,670.04,55,,1031.432,Percent of Total Billed Charges,55% Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1218.25,100,,1790.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,175.67,14.42,,114.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,609.13,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,623.744,Percent of Total Billed Charges,50% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609.13,50,,623.744,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,623.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,70,,157.592,Percent of Total Billed Charges,70% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,110.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1657.34,
195611 PROGRAM INTERSTIM SLIM,32150174,CDM,272,RC,C1787,HCPCS,Outpatient,,,4235,2541.00,,59.4,100,,115.032,Fee Schedule,100% of Aetna Fee Schedule,1905.75,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,127.152,Percent of Total Billed Charges,28% of Total Billed Charges,0.62,32,,27.088,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,163.488,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,163.488,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,163.488,Percent of Total Billed Charges,36% of Total Billed Charges,2541,60,,621.792,Percent of Total Billed Charges,60% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,1166.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,112.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,75,,151.384,Percent of Total Billed Charges,75% of Total Billed Charges,2117.5,50,,164.512,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1991.216,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,1991.216,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1991.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,31292.552,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,109.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,201.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,4235,
477401 LEAD INTERSTIM,32150175,CDM,278,RC,C1778,HCPCS,Outpatient,,,12083.45,7250.07,,13874.4,110,,406.016,Percent of Total Billed Charges,110% of Total Billed Charges,5437.55,45,,193.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3383.37,28,,139.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.63,32,,27.104,Percent of Total Billed Charges,32% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,4350.04,36,,179.544,Percent of Total Billed Charges,36% of Total Billed Charges,4350.04,36,,179.544,Percent of Total Billed Charges,36% Total Bille Charges,4350.04,36,,179.544,Percent of Total Billed Charges,36% of Total Billed Charges,6645.9,55,,606.816,Percent of Total Billed Charges,55% Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12083.45,100,,2837.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1742.43,14.42,,158.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9666.76,80,,6288.968,Percent of Total Billed Charges,80% of Total Billed Charges,6041.73,50,,623.744,Percent of Total Billed Charges,50% of Total Billed Charges,6041.73,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6041.73,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,6041.73,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8458.42,70,,3045.504,Percent of Total Billed Charges,70% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,1691.68,14,,154.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12083.45,100,,7861.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.63,13874.4,
195671 ANTENNA ICON PATIENT,32150176,CDM,270,RC,,,Outpatient,,,427.68,256.61,,256.61,60,,102.976,Percent of Total Billed Charges,60% of Total Billed Charges,192.46,45,,3328.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.75,28,,15.544,Percent of Total Billed Charges,28% of Total Billed Charges,0.64,32,,27.136,Percent of Total Billed Charges,32% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,153.96,36,,19.984,Percent of Total Billed Charges,36% of Total Billed Charges,153.96,36,,19.984,Percent of Total Billed Charges,36% Total Bille Charges,153.96,36,,19.984,Percent of Total Billed Charges,36% of Total Billed Charges,256.61,60,,1708.384,Percent of Total Billed Charges,60% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.68,100,,5543.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,61.67,14.42,,23.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.76,75,,6288.968,Percent of Total Billed Charges,75% of Total Billed Charges,213.84,50,,1991.216,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,395.4,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.84,50,,395.4,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,395.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.38,70,,1560.16,Percent of Total Billed Charges,70% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,22.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.68,100,,7861.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,427.68,
0003381 KIT LEAD INTRODUCER,32150177,CDM,272,RC,C1894,HCPCS,Outpatient,,,1364.44,818.66,,82.29,100,,406.016,Fee Schedule,100% of Aetna Fee Schedule,614,45,,271.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.04,28,,292.32,Percent of Total Billed Charges,28% of Total Billed Charges,3234.62,32,,27.24,Percent of Total Billed Charges,32% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,491.2,36,,375.84,Percent of Total Billed Charges,36% of Total Billed Charges,491.2,36,,375.84,Percent of Total Billed Charges,36% Total Bille Charges,491.2,36,,375.84,Percent of Total Billed Charges,36% of Total Billed Charges,818.66,60,,5508.36,Percent of Total Billed Charges,60% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1364.44,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,196.75,14.42,,192.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1023.33,75,,57.384,Percent of Total Billed Charges,75% of Total Billed Charges,682.22,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,390.816,Percent of Total Billed Charges,50% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,50,,390.816,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,390.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.11,70,,788.648,Percent of Total Billed Charges,70% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,186.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,100,,76.512,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,3234.62,
192100 NEUROSTIMULATOR INS 305,32150178,CDM,278,RC,C1767,HCPCS,Outpatient,,,39700.32,23820.19,,53578.68,110,,210.816,Percent of Total Billed Charges,110% of Total Billed Charges,17865.14,45,,187.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11116.09,28,,4984,Percent of Total Billed Charges,28% of Total Billed Charges,3242.15,32,,27.288,Percent of Total Billed Charges,32% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,14292.12,36,,6408,Percent of Total Billed Charges,36% of Total Billed Charges,14292.12,36,,6408,Percent of Total Billed Charges,36% Total Bille Charges,14292.12,36,,6408,Percent of Total Billed Charges,36% of Total Billed Charges,21835.18,55,,112.088,Percent of Total Billed Charges,55% Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39700.32,100,,430.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5724.79,14.42,,65.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31760.26,80,,51.768,Percent of Total Billed Charges,80% of Total Billed Charges,19850.16,50,,395.4,Percent of Total Billed Charges,50% of Total Billed Charges,19850.16,50,,550.648,Percent of Total Billed Charges,50% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19850.16,50,,550.648,Percent of Total Billed Charges,50% of Total Billed Charges,19850.16,50,,550.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27790.22,70,,22841.28,Percent of Total Billed Charges,70% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,5558.04,14,,63.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39700.32,100,,69.024,Percent of Total Billed Charges,100% of Total Billed Charges,3242.15,53578.68,
418302 GRAFT GORE VASULAR PRO,32150179,CDM,278,RC,C1768,HCPCS,Outpatient,,,7090.2,4254.12,,8121.99,110,,97.48,Percent of Total Billed Charges,110% of Total Billed Charges,3190.59,45,,237.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1985.26,28,,734.192,Percent of Total Billed Charges,28% of Total Billed Charges,3245.36,32,,27.312,Percent of Total Billed Charges,32% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,2552.47,36,,943.96,Percent of Total Billed Charges,36% of Total Billed Charges,2552.47,36,,943.96,Percent of Total Billed Charges,36% Total Bille Charges,2552.47,36,,943.96,Percent of Total Billed Charges,36% of Total Billed Charges,3899.61,55,,429,Percent of Total Billed Charges,55% Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7090.2,100,,7396.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,1022.41,14.42,,80.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5672.16,80,,1300.992,Percent of Total Billed Charges,80% of Total Billed Charges,3545.1,50,,390.816,Percent of Total Billed Charges,50% of Total Billed Charges,3545.1,50,,80.76,Percent of Total Billed Charges,50% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3545.1,50,,80.76,Percent of Total Billed Charges,50% of Total Billed Charges,3545.1,50,,80.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4963.14,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,992.63,14,,77.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7090.2,100,,1626.24,Percent of Total Billed Charges,100% of Total Billed Charges,992.63,8121.99,
405698 GRAFT GORTEX RINGED STD,32150188,CDM,278,RC,C1768,HCPCS,Outpatient,,,4235,2541.00,,4981.27,110,,479.504,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,1128.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,138.32,Percent of Total Billed Charges,28% of Total Billed Charges,3254.88,32,,27.32,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,177.84,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,2072.504,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,603.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,34.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,1984.528,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,550.648,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,667.76,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,667.76,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,667.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,392.96,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,33.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,2646.032,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,4981.27,
TUBE TRACH CUFFED,32150203,CDM,272,RC,,,Outpatient,,,263.95,158.37,,158.37,60,,3980.608,Percent of Total Billed Charges,60% of Total Billed Charges,118.78,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.91,28,,157.688,Percent of Total Billed Charges,28% of Total Billed Charges,3260.61,32,,27.384,Percent of Total Billed Charges,32% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% Total Bille Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,158.37,60,,272.48,Percent of Total Billed Charges,60% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.95,100,,416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,38.06,14.42,,30.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.96,75,,103.672,Percent of Total Billed Charges,75% of Total Billed Charges,131.98,50,,80.76,Percent of Total Billed Charges,50% of Total Billed Charges,131.98,50,,227.936,Percent of Total Billed Charges,50% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.98,50,,227.936,Percent of Total Billed Charges,50% of Total Billed Charges,131.98,50,,227.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.77,70,,249.48,Percent of Total Billed Charges,70% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,29.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.95,100,,138.224,Percent of Total Billed Charges,100% of Total Billed Charges,36.95,3260.61,
TUBE TRACH PROX CUFFED 7 (70XLTCP),32150206,CDM,270,RC,,,Outpatient,,,263.95,158.37,,158.37,60,,765.6,Percent of Total Billed Charges,60% of Total Billed Charges,118.78,45,,1991.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.91,28,,157.688,Percent of Total Billed Charges,28% of Total Billed Charges,3263.04,32,,27.416,Percent of Total Billed Charges,32% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% Total Bille Charges,95.02,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,158.37,60,,274.312,Percent of Total Billed Charges,60% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.95,100,,528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,38.06,14.42,,719.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.96,75,,103.672,Percent of Total Billed Charges,75% of Total Billed Charges,131.98,50,,667.76,Percent of Total Billed Charges,50% of Total Billed Charges,131.98,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.98,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,131.98,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.77,70,,2075.152,Percent of Total Billed Charges,70% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,698.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.95,100,,138.224,Percent of Total Billed Charges,100% of Total Billed Charges,36.95,3263.04,
IRIS DISPOSABLE FLEX,32150208,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,499.84,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,719.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,157.688,Percent of Total Billed Charges,28% of Total Billed Charges,3263.04,32,,27.44,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,202.736,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,33.312,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2507.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,246.768,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,227.936,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,119.16,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,119.16,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,119.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,329.024,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,3263.04,
TUBE TRACH CUFFLESS,32150209,CDM,272,RC,,,Outpatient,,,252.3,151.38,,151.38,60,,12468.456,Percent of Total Billed Charges,60% of Total Billed Charges,113.54,45,,149.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,28,,519.04,Percent of Total Billed Charges,28% of Total Billed Charges,3263.04,32,,27.48,Percent of Total Billed Charges,32% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,36,,667.336,Percent of Total Billed Charges,36% of Total Billed Charges,90.83,36,,667.336,Percent of Total Billed Charges,36% Total Bille Charges,90.83,36,,667.336,Percent of Total Billed Charges,36% of Total Billed Charges,151.38,60,,626.4,Percent of Total Billed Charges,60% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.3,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.38,14.42,,275.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.23,75,,935.616,Percent of Total Billed Charges,75% of Total Billed Charges,126.15,50,,277.688,Percent of Total Billed Charges,50% of Total Billed Charges,126.15,50,,106.76,Percent of Total Billed Charges,50% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.15,50,,106.76,Percent of Total Billed Charges,50% of Total Billed Charges,126.15,50,,106.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.61,70,,9126.864,Percent of Total Billed Charges,70% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.32,14,,267.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.3,100,,1247.488,Percent of Total Billed Charges,100% of Total Billed Charges,35.32,3263.04,
531638 GRAFT GORE VASCULAR PRO,32150211,CDM,278,RC,C1768,HCPCS,Outpatient,,,9826.51,5895.91,,11131.93,110,,379.008,Percent of Total Billed Charges,110% of Total Billed Charges,4421.93,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2751.42,28,,157.688,Percent of Total Billed Charges,28% of Total Billed Charges,3283.9,32,,27.48,Percent of Total Billed Charges,32% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,3537.54,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,3537.54,36,,202.736,Percent of Total Billed Charges,36% Total Bille Charges,3537.54,36,,202.736,Percent of Total Billed Charges,36% of Total Billed Charges,5404.58,55,,9790,Percent of Total Billed Charges,55% Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9826.51,100,,4426.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1416.98,14.42,,231.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7861.21,80,,3185.944,Percent of Total Billed Charges,80% of Total Billed Charges,4913.26,50,,119.16,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,2496,Percent of Total Billed Charges,50% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4913.26,50,,2496,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,2496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6878.56,70,,73.92,Percent of Total Billed Charges,70% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,224.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9826.51,100,,3982.432,Percent of Total Billed Charges,100% of Total Billed Charges,1375.71,11131.93,
629867 GRAFT VASCULAR PROPATEN,32150213,CDM,278,RC,C1768,HCPCS,Outpatient,,,9826.51,5895.91,,11131.93,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,4421.93,45,,96.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2751.42,28,,374.568,Percent of Total Billed Charges,28% of Total Billed Charges,3335.91,32,,27.48,Percent of Total Billed Charges,32% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,3537.54,36,,481.584,Percent of Total Billed Charges,36% of Total Billed Charges,3537.54,36,,481.584,Percent of Total Billed Charges,36% Total Bille Charges,3537.54,36,,481.584,Percent of Total Billed Charges,36% of Total Billed Charges,5404.58,55,,1442.16,Percent of Total Billed Charges,55% Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9826.51,100,,1598.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1416.98,14.42,,665.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7861.21,80,,421.032,Percent of Total Billed Charges,80% of Total Billed Charges,4913.26,50,,106.76,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4913.26,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6878.56,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,646.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9826.51,100,,526.288,Percent of Total Billed Charges,100% of Total Billed Charges,1375.71,11131.93,
TUBE TRACHLOW PRESSURE,32150215,CDM,272,RC,,,Outpatient,,,95.64,57.38,,57.38,60,,7749.72,Percent of Total Billed Charges,60% of Total Billed Charges,43.04,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,28,,358.448,Percent of Total Billed Charges,28% of Total Billed Charges,3335.91,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,34.43,36,,460.864,Percent of Total Billed Charges,36% of Total Billed Charges,34.43,36,,460.864,Percent of Total Billed Charges,36% Total Bille Charges,34.43,36,,460.864,Percent of Total Billed Charges,36% of Total Billed Charges,57.38,60,,296.392,Percent of Total Billed Charges,60% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.64,100,,333.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.79,14.42,,266.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.73,75,,593.096,Percent of Total Billed Charges,75% of Total Billed Charges,47.82,50,,2496,Percent of Total Billed Charges,50% of Total Billed Charges,47.82,50,,955.112,Percent of Total Billed Charges,50% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.82,50,,955.112,Percent of Total Billed Charges,50% of Total Billed Charges,47.82,50,,955.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.95,70,,2983.344,Percent of Total Billed Charges,70% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,13.39,14,,258.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,100,,790.792,Percent of Total Billed Charges,100% of Total Billed Charges,13.39,3335.91,
572739 SONO GUIDES,32150218,CDM,272,RC,,,Outpatient,,,86.28,51.77,,51.77,60,,1470.128,Percent of Total Billed Charges,60% of Total Billed Charges,38.83,45,,68.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.16,28,,772.224,Percent of Total Billed Charges,28% of Total Billed Charges,3335.91,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,31.06,36,,992.864,Percent of Total Billed Charges,36% of Total Billed Charges,31.06,36,,992.864,Percent of Total Billed Charges,36% Total Bille Charges,31.06,36,,992.864,Percent of Total Billed Charges,36% of Total Billed Charges,51.77,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.28,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14.42,,125.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.71,75,,586.224,Percent of Total Billed Charges,75% of Total Billed Charges,43.14,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,43.14,50,,803.072,Percent of Total Billed Charges,50% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.14,50,,803.072,Percent of Total Billed Charges,50% of Total Billed Charges,43.14,50,,803.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,70,,2983.344,Percent of Total Billed Charges,70% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,12.08,14,,122.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.28,100,,781.632,Percent of Total Billed Charges,100% of Total Billed Charges,12.08,3335.91,
568984 FIBULAR SHAFT 6MM LX14,32150221,CDM,278,RC,,,Outpatient,,,2032.8,1219.68,,2236.08,110,,1561.728,Percent of Total Billed Charges,110% of Total Billed Charges,914.76,45,,403.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,569.18,28,,323.056,Percent of Total Billed Charges,28% of Total Billed Charges,3360,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,731.81,36,,415.36,Percent of Total Billed Charges,36% of Total Billed Charges,731.81,36,,415.36,Percent of Total Billed Charges,36% Total Bille Charges,731.81,36,,415.36,Percent of Total Billed Charges,36% of Total Billed Charges,1118.04,55,,337.896,Percent of Total Billed Charges,55% Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2032.8,100,,215.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14.42,,16.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1626.24,80,,825.976,Percent of Total Billed Charges,80% of Total Billed Charges,1016.4,50,,955.112,Percent of Total Billed Charges,50% of Total Billed Charges,1016.4,50,,2308.6,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1016.4,50,,2308.6,Percent of Total Billed Charges,50% of Total Billed Charges,1016.4,50,,2308.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1422.96,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,284.59,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2032.8,100,,1101.296,Percent of Total Billed Charges,100% of Total Billed Charges,284.59,3360,
521403 CATHETER SINUS RELIEVA,32150224,CDM,272,RC,C1726,HCPCS,Outpatient,,,3307.54,1984.52,,396.8,100,,704.544,Fee Schedule,100% of Aetna Fee Schedule,1488.39,45,,416.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,926.11,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,3378.88,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,1190.71,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,1190.71,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,1190.71,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,1984.52,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3307.54,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,476.95,14.42,,1461.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2480.66,75,,121.144,Percent of Total Billed Charges,75% of Total Billed Charges,1653.77,50,,803.072,Percent of Total Billed Charges,50% of Total Billed Charges,1653.77,50,,922.808,Percent of Total Billed Charges,50% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1653.77,50,,922.808,Percent of Total Billed Charges,50% of Total Billed Charges,1653.77,50,,922.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2315.28,70,,93.52,Percent of Total Billed Charges,70% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,463.06,14,,1419.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3307.54,100,,161.52,Percent of Total Billed Charges,100% of Total Billed Charges,396.8,3378.88,
614836 DEVICE COVIDIEN V-LOC,32150231,CDM,272,RC,,,Outpatient,,,172.78,103.67,,103.67,60,,482.88,Percent of Total Billed Charges,60% of Total Billed Charges,77.75,45,,1675.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.38,28,,1522.752,Percent of Total Billed Charges,28% of Total Billed Charges,3411.2,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,62.2,36,,1957.824,Percent of Total Billed Charges,36% of Total Billed Charges,62.2,36,,1957.824,Percent of Total Billed Charges,36% Total Bille Charges,62.2,36,,1957.824,Percent of Total Billed Charges,36% of Total Billed Charges,103.67,60,,1112.224,Percent of Total Billed Charges,60% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.78,100,,151.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14.42,,439.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.59,75,,1068.416,Percent of Total Billed Charges,75% of Total Billed Charges,86.39,50,,2308.6,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,436.88,Percent of Total Billed Charges,50% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.39,50,,436.88,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,436.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.95,70,,81.416,Percent of Total Billed Charges,70% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,426.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.78,100,,1335.52,Percent of Total Billed Charges,100% of Total Billed Charges,24.19,3411.2,
567889 DEVICE COVIDIEN V-LOC,32150232,CDM,272,RC,,,Outpatient,,,172.78,103.67,,103.67,60,,11906.08,Percent of Total Billed Charges,60% of Total Billed Charges,77.75,45,,723.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.38,28,,3121.64,Percent of Total Billed Charges,28% of Total Billed Charges,3411.2,32,,27.488,Percent of Total Billed Charges,32% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,62.2,36,,4013.536,Percent of Total Billed Charges,36% of Total Billed Charges,62.2,36,,4013.536,Percent of Total Billed Charges,36% Total Bille Charges,62.2,36,,4013.536,Percent of Total Billed Charges,36% of Total Billed Charges,103.67,60,,337.896,Percent of Total Billed Charges,60% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.78,100,,896.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14.42,,41.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.59,75,,364.696,Percent of Total Billed Charges,75% of Total Billed Charges,86.39,50,,922.808,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,57.48,Percent of Total Billed Charges,50% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.39,50,,57.48,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,57.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.95,70,,125.416,Percent of Total Billed Charges,70% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,39.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.78,100,,455.872,Percent of Total Billed Charges,100% of Total Billed Charges,24.19,3411.2,
TUNNELER CATH 65CM,32150233,CDM,272,RC,,,Outpatient,,,411.28,246.77,,246.77,60,,1161.056,Percent of Total Billed Charges,60% of Total Billed Charges,185.08,45,,26.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.16,28,,698.88,Percent of Total Billed Charges,28% of Total Billed Charges,3455.56,32,,27.648,Percent of Total Billed Charges,32% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,148.06,36,,898.56,Percent of Total Billed Charges,36% of Total Billed Charges,148.06,36,,898.56,Percent of Total Billed Charges,36% Total Bille Charges,148.06,36,,898.56,Percent of Total Billed Charges,36% of Total Billed Charges,246.77,60,,802.64,Percent of Total Billed Charges,60% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.28,100,,925.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,59.31,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.46,75,,444.296,Percent of Total Billed Charges,75% of Total Billed Charges,205.64,50,,436.88,Percent of Total Billed Charges,50% of Total Billed Charges,205.64,50,,5068.592,Percent of Total Billed Charges,50% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.64,50,,5068.592,Percent of Total Billed Charges,50% of Total Billed Charges,205.64,50,,5068.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.9,70,,190.88,Percent of Total Billed Charges,70% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,57.58,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,411.28,100,,555.368,Percent of Total Billed Charges,100% of Total Billed Charges,57.58,3455.56,
555172 TIP ACCLARENT SINUS,32150237,CDM,272,RC,C1887,HCPCS,Outpatient,,,1559.36,935.62,,43.86,100,,72.088,Fee Schedule,100% of Aetna Fee Schedule,701.71,45,,24.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.62,28,,1827.304,Percent of Total Billed Charges,28% of Total Billed Charges,3475.14,32,,27.648,Percent of Total Billed Charges,32% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,561.37,36,,2349.392,Percent of Total Billed Charges,36% of Total Billed Charges,561.37,36,,2349.392,Percent of Total Billed Charges,36% Total Bille Charges,561.37,36,,2349.392,Percent of Total Billed Charges,36% of Total Billed Charges,935.62,60,,768.104,Percent of Total Billed Charges,60% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1559.36,100,,3722.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,224.86,14.42,,173.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1169.52,75,,178.744,Percent of Total Billed Charges,75% of Total Billed Charges,779.68,50,,57.48,Percent of Total Billed Charges,50% of Total Billed Charges,779.68,50,,1524.6,Percent of Total Billed Charges,50% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.68,50,,1524.6,Percent of Total Billed Charges,50% of Total Billed Charges,779.68,50,,1524.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1091.55,70,,1228.92,Percent of Total Billed Charges,70% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,218.31,14,,168.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1559.36,100,,238.32,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,3475.14,
505824 KIT ST JUDE LEAD SJM 60,32150241,CDM,278,RC,C1778,HCPCS,Outpatient,,,4978.04,2986.82,,6058.44,110,,11440,Percent of Total Billed Charges,110% of Total Billed Charges,2240.12,45,,28.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1393.85,28,,3088.144,Percent of Total Billed Charges,28% of Total Billed Charges,3494.4,32,,27.744,Percent of Total Billed Charges,32% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,1792.09,36,,3970.464,Percent of Total Billed Charges,36% of Total Billed Charges,1792.09,36,,3970.464,Percent of Total Billed Charges,36% Total Bille Charges,1792.09,36,,3970.464,Percent of Total Billed Charges,36% of Total Billed Charges,2737.92,55,,1654.768,Percent of Total Billed Charges,55% Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4978.04,100,,1608.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,717.83,14.42,,1713.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3982.43,80,,160.144,Percent of Total Billed Charges,80% of Total Billed Charges,2489.02,50,,5068.592,Percent of Total Billed Charges,50% of Total Billed Charges,2489.02,50,,142.56,Percent of Total Billed Charges,50% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2489.02,50,,142.56,Percent of Total Billed Charges,50% of Total Billed Charges,2489.02,50,,142.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3484.63,70,,3919.624,Percent of Total Billed Charges,70% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,696.93,14,,1663.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4978.04,100,,213.52,Percent of Total Billed Charges,100% of Total Billed Charges,696.93,6058.44,
505825 ANCHOR ST JUDE SWIFT LO,32150242,CDM,278,RC,C1713,HCPCS,Outpatient,,,657.86,394.72,,1040.91,110,,2850.432,Percent of Total Billed Charges,110% of Total Billed Charges,296.04,45,,109.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,28,,4614.848,Percent of Total Billed Charges,28% of Total Billed Charges,3494.4,32,,27.768,Percent of Total Billed Charges,32% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.83,36,,5933.376,Percent of Total Billed Charges,36% of Total Billed Charges,236.83,36,,5933.376,Percent of Total Billed Charges,36% Total Bille Charges,236.83,36,,5933.376,Percent of Total Billed Charges,36% of Total Billed Charges,361.82,55,,692.264,Percent of Total Billed Charges,55% Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,100,,58.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,94.86,14.42,,2040.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,526.29,80,,3993.6,Percent of Total Billed Charges,80% of Total Billed Charges,328.93,50,,1524.6,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,328.93,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,70,,634.232,Percent of Total Billed Charges,70% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,1981.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.86,100,,4992,Percent of Total Billed Charges,100% of Total Billed Charges,92.1,3494.4,
431182 RELOAD COVIDIEN CURVED,32150245,CDM,272,RC,,,Outpatient,,,988.49,593.09,,593.09,60,,3980.608,Percent of Total Billed Charges,60% of Total Billed Charges,444.82,45,,317.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.78,28,,376.472,Percent of Total Billed Charges,28% of Total Billed Charges,3.2,32,,27.776,Percent of Total Billed Charges,32% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,355.86,36,,484.032,Percent of Total Billed Charges,36% of Total Billed Charges,355.86,36,,484.032,Percent of Total Billed Charges,36% Total Bille Charges,355.86,36,,484.032,Percent of Total Billed Charges,36% of Total Billed Charges,593.09,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,988.49,100,,54.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,142.54,14.42,,951.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.37,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,494.25,50,,142.56,Percent of Total Billed Charges,50% of Total Billed Charges,494.25,50,,600.352,Percent of Total Billed Charges,50% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.25,50,,600.352,Percent of Total Billed Charges,50% of Total Billed Charges,494.25,50,,600.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.94,70,,559.424,Percent of Total Billed Charges,70% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,138.39,14,,923.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,988.49,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,988.49,
493698 STAPLER COVIDIEN EGIA,32150246,CDM,272,RC,,,Outpatient,,,977.04,586.22,,586.22,60,,7661.752,Percent of Total Billed Charges,60% of Total Billed Charges,439.67,45,,315.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.57,28,,406.6,Percent of Total Billed Charges,28% of Total Billed Charges,3.2,32,,27.856,Percent of Total Billed Charges,32% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,351.73,36,,522.776,Percent of Total Billed Charges,36% of Total Billed Charges,351.73,36,,522.776,Percent of Total Billed Charges,36% Total Bille Charges,351.73,36,,522.776,Percent of Total Billed Charges,36% of Total Billed Charges,586.22,60,,2991.12,Percent of Total Billed Charges,60% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,977.04,100,,62.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,140.89,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,732.78,75,,1528.176,Percent of Total Billed Charges,75% of Total Billed Charges,488.52,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,488.52,50,,5940.096,Percent of Total Billed Charges,50% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,488.52,50,,5940.096,Percent of Total Billed Charges,50% of Total Billed Charges,488.52,50,,5940.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,683.93,70,,1404.928,Percent of Total Billed Charges,70% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,136.79,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,977.04,100,,1910.216,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,977.04,
428635 STAPLER AUTOSUTURE GIA,32150247,CDM,272,RC,,,Outpatient,,,1376.62,825.97,,825.97,60,,82.936,Percent of Total Billed Charges,60% of Total Billed Charges,619.48,45,,315.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.45,28,,316.552,Percent of Total Billed Charges,28% of Total Billed Charges,3.24,32,,27.888,Percent of Total Billed Charges,32% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,495.58,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,495.58,36,,406.992,Percent of Total Billed Charges,36% Total Bille Charges,495.58,36,,406.992,Percent of Total Billed Charges,36% of Total Billed Charges,825.97,60,,6131.8,Percent of Total Billed Charges,60% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1376.62,100,,243.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,198.51,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1032.47,75,,1284.912,Percent of Total Billed Charges,75% of Total Billed Charges,688.31,50,,600.352,Percent of Total Billed Charges,50% of Total Billed Charges,688.31,50,,7076.72,Percent of Total Billed Charges,50% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688.31,50,,7076.72,Percent of Total Billed Charges,50% of Total Billed Charges,688.31,50,,7076.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,963.63,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,192.73,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1376.62,100,,1606.144,Percent of Total Billed Charges,100% of Total Billed Charges,3.24,1376.62,
STRYKER ENDO,32150251,CDM,272,RC,A4649,HCPCS,Outpatient,,,201.9,121.14,,121.14,60,,19502.368,Percent of Total Billed Charges,60% of Total Billed Charges,90.86,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.53,28,,145.392,Percent of Total Billed Charges,28% of Total Billed Charges,3.25,32,,28.08,Percent of Total Billed Charges,32% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,72.68,36,,186.936,Percent of Total Billed Charges,36% of Total Billed Charges,72.68,36,,186.936,Percent of Total Billed Charges,36% Total Bille Charges,72.68,36,,186.936,Percent of Total Billed Charges,36% of Total Billed Charges,121.14,60,,1372.8,Percent of Total Billed Charges,60% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.9,100,,705.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,29.11,14.42,,1339.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.43,75,,3693.76,Percent of Total Billed Charges,75% of Total Billed Charges,100.95,50,,5940.096,Percent of Total Billed Charges,50% of Total Billed Charges,100.95,50,,3298.392,Percent of Total Billed Charges,50% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.95,50,,3298.392,Percent of Total Billed Charges,50% of Total Billed Charges,100.95,50,,3298.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.33,70,,832.312,Percent of Total Billed Charges,70% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.27,14,,1300.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.9,100,,4617.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.25,201.9,
0002075 BARRIER TISS ADH PREVN,32150252,CDM,278,RC,C1765,HCPCS,Outpatient,,,1669.4,1001.64,,1839.8,110,,3420.56,Percent of Total Billed Charges,110% of Total Billed Charges,751.23,45,,122.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.08,Other,Not Seperately Reimbusable,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,918.17,55,,3589.344,Percent of Total Billed Charges,55% Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1669.4,100,,701.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,240.73,14.42,,2191.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1335.52,80,,1384.216,Percent of Total Billed Charges,80% of Total Billed Charges,834.7,50,,7076.72,Percent of Total Billed Charges,50% of Total Billed Charges,834.7,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.7,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,834.7,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1168.58,70,,668.576,Percent of Total Billed Charges,70% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,233.72,14,,2128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1669.4,100,,1845.616,Percent of Total Billed Charges,100% of Total Billed Charges,233.72,1839.8,
177771 ROD BIOFIX PLA 1.5X30,32150253,CDM,278,RC,,,Outpatient,,,569.84,341.90,,626.82,110,,64787.856,Percent of Total Billed Charges,110% of Total Billed Charges,256.43,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.56,28,,425.256,Percent of Total Billed Charges,28% of Total Billed Charges,3.26,32,,28.112,Percent of Total Billed Charges,32% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,205.14,36,,546.76,Percent of Total Billed Charges,36% of Total Billed Charges,205.14,36,,546.76,Percent of Total Billed Charges,36% Total Bille Charges,205.14,36,,546.76,Percent of Total Billed Charges,36% of Total Billed Charges,313.41,55,,6065.992,Percent of Total Billed Charges,55% Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,569.84,100,,701.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,82.17,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.87,80,,699,Percent of Total Billed Charges,80% of Total Billed Charges,284.92,50,,3298.392,Percent of Total Billed Charges,50% of Total Billed Charges,284.92,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.92,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,284.92,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.89,70,,179.624,Percent of Total Billed Charges,70% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,79.78,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,569.84,100,,873.752,Percent of Total Billed Charges,100% of Total Billed Charges,3.26,626.82,
695115 ROD BIOFIX PLA,32150254,CDM,278,RC,C1713,HCPCS,Outpatient,,,694.21,416.53,,1080.89,110,,4907.76,Percent of Total Billed Charges,110% of Total Billed Charges,312.39,45,,20.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.38,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3.28,32,,2816.984,Percent of Total Billed Charges,32% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,249.92,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,249.92,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,249.92,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,381.82,55,,9064.88,Percent of Total Billed Charges,55% Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,694.21,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,100.11,14.42,,2358.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.37,80,,86.224,Percent of Total Billed Charges,80% of Total Billed Charges,347.11,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,347.11,50,,4643.04,Percent of Total Billed Charges,50% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.11,50,,4643.04,Percent of Total Billed Charges,50% of Total Billed Charges,347.11,50,,4643.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,485.95,70,,184.616,Percent of Total Billed Charges,70% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,97.19,14,,2289.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.21,100,,114.96,Percent of Total Billed Charges,100% of Total Billed Charges,3.28,1080.89,
DRESSING WOUND HILL CONTOUR,32150255,CDM,272,RC,,,Outpatient,,,297.9,178.74,,178.74,60,,989.152,Percent of Total Billed Charges,60% of Total Billed Charges,134.06,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.41,28,,309.352,Percent of Total Billed Charges,28% of Total Billed Charges,3.28,32,,2842.112,Percent of Total Billed Charges,32% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,36,,397.736,Percent of Total Billed Charges,36% of Total Billed Charges,107.24,36,,397.736,Percent of Total Billed Charges,36% Total Bille Charges,107.24,36,,397.736,Percent of Total Billed Charges,36% of Total Billed Charges,178.74,60,,806.728,Percent of Total Billed Charges,60% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.9,100,,273.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,42.96,14.42,,233.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.43,75,,8109.744,Percent of Total Billed Charges,75% of Total Billed Charges,148.95,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,148.95,50,,7600,Percent of Total Billed Charges,50% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.95,50,,7600,Percent of Total Billed Charges,50% of Total Billed Charges,148.95,50,,7600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.53,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,41.71,14,,226.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.9,100,,10137.176,Percent of Total Billed Charges,100% of Total Billed Charges,3.28,297.9,
GRANUFOAM DRESSING LARGE,32150257,CDM,272,RC,,,Outpatient,,,266.9,160.14,,160.14,60,,1623.84,Percent of Total Billed Charges,60% of Total Billed Charges,120.11,45,,123.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.73,28,,309.352,Percent of Total Billed Charges,28% of Total Billed Charges,3.29,32,,2876.056,Percent of Total Billed Charges,32% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,96.08,36,,397.736,Percent of Total Billed Charges,36% of Total Billed Charges,96.08,36,,397.736,Percent of Total Billed Charges,36% Total Bille Charges,96.08,36,,397.736,Percent of Total Billed Charges,36% of Total Billed Charges,160.14,60,,798.68,Percent of Total Billed Charges,60% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.9,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,38.49,14.42,,112.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.18,75,,2439.36,Percent of Total Billed Charges,75% of Total Billed Charges,133.45,50,,4643.04,Percent of Total Billed Charges,50% of Total Billed Charges,133.45,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.45,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,133.45,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.83,70,,6388.928,Percent of Total Billed Charges,70% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,37.37,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.9,100,,3049.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.29,266.9,
498569 MEMBRANE MUSCU TRANS,32150261,CDM,278,RC,C1762,HCPCS,Outpatient,,,6240,3744.00,,9042.09,110,,57536.144,Percent of Total Billed Charges,110% of Total Billed Charges,2808,45,,144.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1747.2,28,,474.824,Percent of Total Billed Charges,28% of Total Billed Charges,3.29,32,,2883.456,Percent of Total Billed Charges,32% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,2246.4,36,,610.488,Percent of Total Billed Charges,36% of Total Billed Charges,2246.4,36,,610.488,Percent of Total Billed Charges,36% Total Bille Charges,2246.4,36,,610.488,Percent of Total Billed Charges,36% of Total Billed Charges,3432,55,,621.792,Percent of Total Billed Charges,55% Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6240,100,,45.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,899.81,14.42,,599.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4992,80,,213.84,Percent of Total Billed Charges,80% of Total Billed Charges,3120,50,,7600,Percent of Total Billed Charges,50% of Total Billed Charges,3120,50,,8178,Percent of Total Billed Charges,50% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3120,50,,8178,Percent of Total Billed Charges,50% of Total Billed Charges,3120,50,,8178,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4368,70,,197.592,Percent of Total Billed Charges,70% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,873.6,14,,582.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6240,100,,285.12,Percent of Total Billed Charges,100% of Total Billed Charges,3.29,9042.09,
437311 BONE OSTEOCONDUCTIVE VO,32150262,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235,2541.00,,4975.76,110,,3563.304,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,471.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,40.32,Percent of Total Billed Charges,28% of Total Billed Charges,3.31,32,,2920.656,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,51.84,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,311.56,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,1462.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,2541,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,808.8,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,808.8,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,808.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1086.968,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,1420.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,3.31,4975.76,
437309 BONE OSTEOCONDUCTIVE VO,32150263,CDM,278,RC,C1713,HCPCS,Outpatient,,,2387.77,1432.66,,2943.81,110,,2493.448,Percent of Total Billed Charges,110% of Total Billed Charges,1074.5,45,,510.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,668.58,28,,365.672,Percent of Total Billed Charges,28% of Total Billed Charges,3.32,32,,2939.48,Percent of Total Billed Charges,32% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,859.6,36,,470.152,Percent of Total Billed Charges,36% of Total Billed Charges,859.6,36,,470.152,Percent of Total Billed Charges,36% Total Bille Charges,859.6,36,,470.152,Percent of Total Billed Charges,36% of Total Billed Charges,1313.27,55,,835.328,Percent of Total Billed Charges,55% Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2387.77,100,,274.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,344.32,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1910.22,80,,900.528,Percent of Total Billed Charges,80% of Total Billed Charges,1193.89,50,,8178,Percent of Total Billed Charges,50% of Total Billed Charges,1193.89,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1193.89,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,1193.89,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1671.44,70,,4044.816,Percent of Total Billed Charges,70% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,334.29,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2387.77,100,,1200.704,Percent of Total Billed Charges,100% of Total Billed Charges,3.32,2943.81,
437304 BONE OSTEOCONDUCTIVE VO,32150264,CDM,278,RC,C1713,HCPCS,Outpatient,,,2007.68,1204.61,,2525.71,110,,4083.856,Percent of Total Billed Charges,110% of Total Billed Charges,903.46,45,,442.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.15,28,,513.032,Percent of Total Billed Charges,28% of Total Billed Charges,3.38,32,,2944,Percent of Total Billed Charges,32% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,722.76,36,,659.608,Percent of Total Billed Charges,36% of Total Billed Charges,722.76,36,,659.608,Percent of Total Billed Charges,36% Total Bille Charges,722.76,36,,659.608,Percent of Total Billed Charges,36% of Total Billed Charges,1104.22,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2007.68,100,,320.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,289.51,14.42,,65.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1606.14,80,,9504.144,Percent of Total Billed Charges,80% of Total Billed Charges,1003.84,50,,808.8,Percent of Total Billed Charges,50% of Total Billed Charges,1003.84,50,,2079.88,Percent of Total Billed Charges,50% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1003.84,50,,2079.88,Percent of Total Billed Charges,50% of Total Billed Charges,1003.84,50,,2079.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1405.38,70,,491.2,Percent of Total Billed Charges,70% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,281.08,14,,63.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2007.68,100,,11880.184,Percent of Total Billed Charges,100% of Total Billed Charges,3.38,2525.71,
420617 BONE BIOACTIVE SCAFFOLD,32150265,CDM,278,RC,C1713,HCPCS,Outpatient,,,5771.5,3462.90,,6665.91,110,,66.768,Percent of Total Billed Charges,110% of Total Billed Charges,2597.18,45,,590.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1616.02,28,,208.488,Percent of Total Billed Charges,28% of Total Billed Charges,3.4,32,,2958.936,Percent of Total Billed Charges,32% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,2077.74,36,,268.056,Percent of Total Billed Charges,36% of Total Billed Charges,2077.74,36,,268.056,Percent of Total Billed Charges,36% Total Bille Charges,2077.74,36,,268.056,Percent of Total Billed Charges,36% of Total Billed Charges,3174.33,55,,607.648,Percent of Total Billed Charges,55% Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5771.5,100,,1047.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,832.25,14.42,,107,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4617.2,80,,11322.752,Percent of Total Billed Charges,80% of Total Billed Charges,2885.75,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,2885.75,50,,5072.192,Percent of Total Billed Charges,50% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2885.75,50,,5072.192,Percent of Total Billed Charges,50% of Total Billed Charges,2885.75,50,,5072.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4040.05,70,,33479.608,Percent of Total Billed Charges,70% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,808.01,14,,103.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5771.5,100,,14153.44,Percent of Total Billed Charges,100% of Total Billed Charges,3.4,6665.91,
699432 LG VENT CATH BACTISEAL,32150266,CDM,272,RC,C1729,HCPCS,Outpatient,,,2307.02,1384.21,,11.1,100,,4916.24,Fee Schedule,100% of Aetna Fee Schedule,1038.16,45,,347.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645.97,28,,60.224,Percent of Total Billed Charges,28% of Total Billed Charges,3.4,32,,2958.936,Percent of Total Billed Charges,32% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,830.53,36,,77.432,Percent of Total Billed Charges,36% of Total Billed Charges,830.53,36,,77.432,Percent of Total Billed Charges,36% Total Bille Charges,830.53,36,,77.432,Percent of Total Billed Charges,36% of Total Billed Charges,1384.21,60,,607.648,Percent of Total Billed Charges,60% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2307.02,100,,1134.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,332.67,14.42,,264.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1730.27,75,,5277.424,Percent of Total Billed Charges,75% of Total Billed Charges,1153.51,50,,2079.88,Percent of Total Billed Charges,50% of Total Billed Charges,1153.51,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1153.51,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,1153.51,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1614.91,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,322.98,14,,257.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2307.02,100,,6596.776,Percent of Total Billed Charges,100% of Total Billed Charges,3.4,2307.02,
113708 CEMENT BONE 80G,32150269,CDM,278,RC,C1713,HCPCS,Outpatient,,,1092.19,655.31,,1518.67,110,,4563.912,Percent of Total Billed Charges,110% of Total Billed Charges,491.49,45,,28.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.81,28,,474.824,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2970.456,Percent of Total Billed Charges,32% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,393.19,36,,610.488,Percent of Total Billed Charges,36% of Total Billed Charges,393.19,36,,610.488,Percent of Total Billed Charges,36% Total Bille Charges,393.19,36,,610.488,Percent of Total Billed Charges,36% of Total Billed Charges,600.7,55,,932.696,Percent of Total Billed Charges,55% Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1092.19,100,,984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,157.49,14.42,,4.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.75,80,,1559.36,Percent of Total Billed Charges,80% of Total Billed Charges,546.1,50,,5072.192,Percent of Total Billed Charges,50% of Total Billed Charges,546.1,50,,228.056,Percent of Total Billed Charges,50% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.1,50,,228.056,Percent of Total Billed Charges,50% of Total Billed Charges,546.1,50,,228.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.53,70,,2389.768,Percent of Total Billed Charges,70% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,152.91,14,,4.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092.19,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,1518.67,
SUTURE MONODERM 3.0,32150270,CDM,272,RC,,,Outpatient,,,143.7,86.22,,86.22,60,,5167.92,Percent of Total Billed Charges,60% of Total Billed Charges,64.67,45,,359.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.24,28,,2201.136,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2971.544,Percent of Total Billed Charges,32% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,51.73,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,51.73,36,,2830.032,Percent of Total Billed Charges,36% Total Bille Charges,51.73,36,,2830.032,Percent of Total Billed Charges,36% of Total Billed Charges,86.22,60,,718.28,Percent of Total Billed Charges,60% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.7,100,,1313.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14.42,,307.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.78,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,71.85,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,71.85,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.85,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,71.85,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.59,70,,1837.992,Percent of Total Billed Charges,70% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,298.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.7,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,143.7,
650971 VALVE MEDTRONIC STRAT I,32150272,CDM,278,RC,,,Outpatient,,,12671.47,7602.88,,13938.62,110,,1470.128,Percent of Total Billed Charges,110% of Total Billed Charges,5702.16,45,,184.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3548.01,28,,513.032,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2983.936,Percent of Total Billed Charges,32% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,4561.73,36,,659.608,Percent of Total Billed Charges,36% of Total Billed Charges,4561.73,36,,659.608,Percent of Total Billed Charges,36% Total Bille Charges,4561.73,36,,659.608,Percent of Total Billed Charges,36% of Total Billed Charges,6969.31,55,,1007.736,Percent of Total Billed Charges,55% Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12671.47,100,,772.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1827.23,14.42,,278.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10137.18,80,,7428.856,Percent of Total Billed Charges,80% of Total Billed Charges,6335.74,50,,228.056,Percent of Total Billed Charges,50% of Total Billed Charges,6335.74,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6335.74,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,6335.74,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8870.03,70,,6943.664,Percent of Total Billed Charges,70% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,1774.01,14,,270.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12671.47,100,,9286.072,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,13938.62,
487640 MEMBRANE DRY AMNIOTIC,32150280,CDM,278,RC,,,Outpatient,,,3811.5,2286.90,,4192.65,110,,55144.304,Percent of Total Billed Charges,110% of Total Billed Charges,1715.18,45,,249.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1067.22,28,,138.32,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2990.768,Percent of Total Billed Charges,32% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1372.14,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,1372.14,36,,177.84,Percent of Total Billed Charges,36% Total Bille Charges,1372.14,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,2096.33,55,,409.528,Percent of Total Billed Charges,55% Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3811.5,100,,63.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,549.62,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3049.2,80,,12160,Percent of Total Billed Charges,80% of Total Billed Charges,1905.75,50,,371,Percent of Total Billed Charges,50% of Total Billed Charges,1905.75,50,,17.056,Percent of Total Billed Charges,50% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1905.75,50,,17.056,Percent of Total Billed Charges,50% of Total Billed Charges,1905.75,50,,17.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2668.05,70,,2442.112,Percent of Total Billed Charges,70% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,533.61,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3811.5,100,,15200,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,4192.65,
513937 DRILL HAND 10GA,32150282,CDM,272,RC,,,Outpatient,,,356.4,213.84,,213.84,60,,3064.36,Percent of Total Billed Charges,60% of Total Billed Charges,160.38,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.79,28,,139.904,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2993.872,Percent of Total Billed Charges,32% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,128.3,36,,179.88,Percent of Total Billed Charges,36% of Total Billed Charges,128.3,36,,179.88,Percent of Total Billed Charges,36% Total Bille Charges,128.3,36,,179.88,Percent of Total Billed Charges,36% of Total Billed Charges,213.84,60,,932.696,Percent of Total Billed Charges,60% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356.4,100,,799.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.39,14.42,,589.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.3,75,,44.8,Percent of Total Billed Charges,75% of Total Billed Charges,178.2,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,178.2,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.2,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,178.2,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.48,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,14,,572.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.4,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,356.4,
528211 ACCESS SYSTEM 10G,32150284,CDM,272,RC,,,Outpatient,,,4235,2541.00,,2541,60,,2144.12,Percent of Total Billed Charges,60% of Total Billed Charges,1905.75,45,,132.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,143.104,Percent of Total Billed Charges,28% of Total Billed Charges,3.43,32,,2994.536,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,183.992,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,183.992,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,183.992,Percent of Total Billed Charges,36% of Total Billed Charges,2541,60,,4323.664,Percent of Total Billed Charges,60% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,408.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,79.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,75,,13084.792,Percent of Total Billed Charges,75% of Total Billed Charges,2117.5,50,,17.056,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,966.872,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,966.872,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,966.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1479.88,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,16355.992,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,4235,
674119 CATHETER MEDTRONIC PERI,32150285,CDM,272,RC,C1752,HCPCS,Outpatient,,,1500.88,900.53,,6,100,,52.704,Fee Schedule,100% of Aetna Fee Schedule,675.4,45,,184.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420.25,28,,155.056,Percent of Total Billed Charges,28% of Total Billed Charges,3.44,32,,2998.68,Percent of Total Billed Charges,32% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,540.32,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,540.32,36,,199.36,Percent of Total Billed Charges,36% Total Bille Charges,540.32,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,900.53,60,,1007.736,Percent of Total Billed Charges,60% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1500.88,100,,553.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,216.43,14.42,,52.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1125.66,75,,1294.08,Percent of Total Billed Charges,75% of Total Billed Charges,750.44,50,,1067.224,Percent of Total Billed Charges,50% of Total Billed Charges,750.44,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750.44,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,750.44,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.62,70,,3918.096,Percent of Total Billed Charges,70% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,210.12,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1500.88,100,,1617.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.44,1500.88,
610174 BONE MTF TRINITY ELITE,32150286,CDM,278,RC,C1762,HCPCS,Outpatient,,,14850.23,8910.14,,18513.34,110,,521.656,Percent of Total Billed Charges,110% of Total Billed Charges,6682.6,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4158.06,28,,155.056,Percent of Total Billed Charges,28% of Total Billed Charges,3.52,32,,3023.104,Percent of Total Billed Charges,32% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,5346.08,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,5346.08,36,,199.36,Percent of Total Billed Charges,36% Total Bille Charges,5346.08,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,8167.63,55,,296.4,Percent of Total Billed Charges,55% Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14850.23,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2141.4,14.42,,700.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11880.18,80,,623.744,Percent of Total Billed Charges,80% of Total Billed Charges,7425.12,50,,966.872,Percent of Total Billed Charges,50% of Total Billed Charges,7425.12,50,,2044.84,Percent of Total Billed Charges,50% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7425.12,50,,2044.84,Percent of Total Billed Charges,50% of Total Billed Charges,7425.12,50,,2044.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10395.16,70,,1203.336,Percent of Total Billed Charges,70% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,2079.03,14,,679.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14850.23,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,3.52,18513.34,
616970 BONE MTF TRINITY ELITE,32150287,CDM,278,RC,C1762,HCPCS,Outpatient,,,17691.8,10615.08,,21639.07,110,,90.816,Percent of Total Billed Charges,110% of Total Billed Charges,7961.31,45,,129.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4953.7,28,,308.312,Percent of Total Billed Charges,28% of Total Billed Charges,32,32,,3023.744,Percent of Total Billed Charges,32% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,6369.05,36,,396.4,Percent of Total Billed Charges,36% of Total Billed Charges,6369.05,36,,396.4,Percent of Total Billed Charges,36% Total Bille Charges,6369.05,36,,396.4,Percent of Total Billed Charges,36% of Total Billed Charges,9730.49,55,,299.792,Percent of Total Billed Charges,55% Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17691.8,100,,293.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2551.16,14.42,,1041.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14153.44,80,,3327.808,Percent of Total Billed Charges,80% of Total Billed Charges,8845.9,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,8845.9,50,,275.992,Percent of Total Billed Charges,50% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8845.9,50,,275.992,Percent of Total Billed Charges,50% of Total Billed Charges,8845.9,50,,275.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12384.26,70,,791.376,Percent of Total Billed Charges,70% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,2476.85,14,,1010.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17691.8,100,,4159.76,Percent of Total Billed Charges,100% of Total Billed Charges,32,21639.07,
616971 BONE MTF TRINITY ELITE,32150288,CDM,278,RC,C1762,HCPCS,Outpatient,,,8245.97,4947.58,,11248.66,110,,1310.4,Percent of Total Billed Charges,110% of Total Billed Charges,3710.69,45,,96.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2308.87,28,,2335.136,Percent of Total Billed Charges,28% of Total Billed Charges,32.04,32,,3025.92,Percent of Total Billed Charges,32% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,2968.55,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,2968.55,36,,3002.32,Percent of Total Billed Charges,36% Total Bille Charges,2968.55,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,4535.28,55,,306.656,Percent of Total Billed Charges,55% Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8245.97,100,,408.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1189.07,14.42,,184.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6596.78,80,,7608.288,Percent of Total Billed Charges,80% of Total Billed Charges,4122.99,50,,2044.84,Percent of Total Billed Charges,50% of Total Billed Charges,4122.99,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4122.99,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,4122.99,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5772.18,70,,707.952,Percent of Total Billed Charges,70% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,1154.44,14,,179.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8245.97,100,,10144.384,Percent of Total Billed Charges,100% of Total Billed Charges,32.04,11248.66,
656893 BONE MTF TRINITY ELITE,32150289,CDM,278,RC,C1762,HCPCS,Outpatient,,,2436.5,1461.90,,4858.24,110,,33.6,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,103.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,118.864,Percent of Total Billed Charges,28% of Total Billed Charges,32.17,32,,3031.808,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,152.824,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,152.824,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,152.824,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,332.272,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,2317.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,1559.36,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,275.992,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,2428.248,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,2428.248,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,2428.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,1993.112,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,2249.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,32.17,4858.24,
487022 GUIDEWIRE ENDOLOGIX,32150290,CDM,272,RC,C1769,HCPCS,Outpatient,,,600,360.00,,55.13,100,,191.48,Fee Schedule,100% of Aetna Fee Schedule,270,45,,96.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,419.152,Percent of Total Billed Charges,28% of Total Billed Charges,32.29,32,,3041.152,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,538.912,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,538.912,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,538.912,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,332.272,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,288.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,195.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,342.088,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,3610.416,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,3610.416,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,3610.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,7010.64,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,190.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,456.112,Percent of Total Billed Charges,100% of Total Billed Charges,32.29,600,
912160 TRIPPLE AAA STENT GRAFT,32150291,CDM,278,RC,C1768,HCPCS,Outpatient,,,11607.59,6964.55,,13091.12,110,,1016.424,Percent of Total Billed Charges,110% of Total Billed Charges,5223.42,45,,103.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3250.13,28,,70.648,Percent of Total Billed Charges,28% of Total Billed Charges,32.32,32,,3045.504,Percent of Total Billed Charges,32% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,4178.73,36,,90.84,Percent of Total Billed Charges,36% of Total Billed Charges,4178.73,36,,90.84,Percent of Total Billed Charges,36% Total Bille Charges,4178.73,36,,90.84,Percent of Total Billed Charges,36% of Total Billed Charges,6384.17,55,,660.664,Percent of Total Billed Charges,55% Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11607.59,100,,213.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1673.81,14.42,,125.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9286.07,80,,556.504,Percent of Total Billed Charges,80% of Total Billed Charges,5803.8,50,,2428.248,Percent of Total Billed Charges,50% of Total Billed Charges,5803.8,50,,641.288,Percent of Total Billed Charges,50% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5803.8,50,,641.288,Percent of Total Billed Charges,50% of Total Billed Charges,5803.8,50,,641.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8125.31,70,,130.768,Percent of Total Billed Charges,70% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,1625.06,14,,122.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11607.59,100,,742,Percent of Total Billed Charges,100% of Total Billed Charges,32.32,13091.12,
703486 MAIN BODY STENT GRAFT,32150292,CDM,278,RC,,,Outpatient,,,19000,11400.00,,20900,110,,935.616,Percent of Total Billed Charges,110% of Total Billed Charges,8550,45,,982.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5320,28,,382.04,Percent of Total Billed Charges,28% of Total Billed Charges,32.32,32,,3061.504,Percent of Total Billed Charges,32% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,6840,36,,491.2,Percent of Total Billed Charges,36% of Total Billed Charges,6840,36,,491.2,Percent of Total Billed Charges,36% Total Bille Charges,6840,36,,491.2,Percent of Total Billed Charges,36% of Total Billed Charges,10450,55,,4586.88,Percent of Total Billed Charges,55% Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19000,100,,230.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2739.8,14.42,,122.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15200,80,,1469.44,Percent of Total Billed Charges,80% of Total Billed Charges,9500,50,,3610.416,Percent of Total Billed Charges,50% of Total Billed Charges,9500,50,,8035.24,Percent of Total Billed Charges,50% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9500,50,,8035.24,Percent of Total Billed Charges,50% of Total Billed Charges,9500,50,,8035.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13300,70,,546,Percent of Total Billed Charges,70% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,2660,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19000,100,,1836.8,Percent of Total Billed Charges,100% of Total Billed Charges,32.32,20900,
580265 SHEATH HEMOSTASIS VALVE,32150293,CDM,278,RC,,,Outpatient,,,70,42.00,,77,110,,294.272,Percent of Total Billed Charges,110% of Total Billed Charges,31.5,45,,389.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,2131.856,Percent of Total Billed Charges,28% of Total Billed Charges,32.38,32,,3062.064,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,2740.952,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,2740.952,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,2740.952,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,213.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,2078.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,80,,25.576,Percent of Total Billed Charges,80% of Total Billed Charges,35,50,,641.288,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,679.496,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,679.496,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,679.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,2637.728,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,2017.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,34.104,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,77,
307978 KIT MEDTRONIC LEAD,32150295,CDM,278,RC,C1778,HCPCS,Outpatient,,,20444.99,12266.99,,23072.09,110,,407.976,Percent of Total Billed Charges,110% of Total Billed Charges,9200.25,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5724.6,28,,1006.384,Percent of Total Billed Charges,28% of Total Billed Charges,32.47,32,,2.824,Percent of Total Billed Charges,32% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,7360.2,36,,1293.928,Percent of Total Billed Charges,36% of Total Billed Charges,7360.2,36,,1293.928,Percent of Total Billed Charges,36% Total Bille Charges,7360.2,36,,1293.928,Percent of Total Billed Charges,36% of Total Billed Charges,11244.74,55,,823.344,Percent of Total Billed Charges,55% Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20444.99,100,,230.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2948.17,14.42,,27.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16355.99,80,,1707.552,Percent of Total Billed Charges,80% of Total Billed Charges,10222.5,50,,8035.24,Percent of Total Billed Charges,50% of Total Billed Charges,10222.5,50,,436.256,Percent of Total Billed Charges,50% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10222.5,50,,436.256,Percent of Total Billed Charges,50% of Total Billed Charges,10222.5,50,,436.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14311.49,70,,317.888,Percent of Total Billed Charges,70% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,2862.3,14,,26.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20444.99,100,,2134.44,Percent of Total Billed Charges,100% of Total Billed Charges,32.47,23072.09,
192824 KIT EXTENSION 1X8 40CM,32150296,CDM,278,RC,,,Outpatient,,,2022,1213.20,,2224.2,110,,63.824,Percent of Total Billed Charges,110% of Total Billed Charges,909.9,45,,415.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,566.16,28,,1564.512,Percent of Total Billed Charges,28% of Total Billed Charges,32.49,32,,2.832,Percent of Total Billed Charges,32% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,727.92,36,,2011.52,Percent of Total Billed Charges,36% of Total Billed Charges,727.92,36,,2011.52,Percent of Total Billed Charges,36% Total Bille Charges,727.92,36,,2011.52,Percent of Total Billed Charges,36% of Total Billed Charges,1112.1,55,,750.44,Percent of Total Billed Charges,55% Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2022,100,,2184.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,291.57,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1617.6,80,,1546.992,Percent of Total Billed Charges,80% of Total Billed Charges,1011,50,,679.496,Percent of Total Billed Charges,50% of Total Billed Charges,1011,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1011,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,1011,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1415.4,70,,349.12,Percent of Total Billed Charges,70% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,283.08,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2022,100,,1933.744,Percent of Total Billed Charges,100% of Total Billed Charges,32.49,2224.2,
416167 CABLE SNAPLID TRIAL,32150297,CDM,278,RC,C1897,HCPCS,Outpatient,,,974.6,584.76,,1840,110,,5978.256,Percent of Total Billed Charges,110% of Total Billed Charges,438.57,45,,420.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,587.056,Percent of Total Billed Charges,28% of Total Billed Charges,32.64,32,,2.848,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,754.792,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,754.792,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,754.792,Percent of Total Billed Charges,36% of Total Billed Charges,536.03,55,,4187.568,Percent of Total Billed Charges,55% Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,865.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,191.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.68,80,,1559.36,Percent of Total Billed Charges,80% of Total Billed Charges,487.3,50,,436.256,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,7205.88,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,7205.88,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,7205.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,38.864,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,186.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,32.64,1840,
689219 CHARGING SYSTEM MEDTRON,32150298,CDM,278,RC,C1820,HCPCS,Outpatient,,,5199.7,3119.82,,7349.85,110,,3410.472,Percent of Total Billed Charges,110% of Total Billed Charges,2339.87,45,,186.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1455.92,28,,179.648,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.864,Percent of Total Billed Charges,32% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,1871.89,36,,230.976,Percent of Total Billed Charges,36% of Total Billed Charges,1871.89,36,,230.976,Percent of Total Billed Charges,36% Total Bille Charges,1871.89,36,,230.976,Percent of Total Billed Charges,36% of Total Billed Charges,2859.84,55,,1976.832,Percent of Total Billed Charges,55% Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5199.7,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,749.8,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4159.76,80,,3271.744,Percent of Total Billed Charges,80% of Total Billed Charges,2599.85,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,2599.85,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2599.85,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,2599.85,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3639.79,70,,730.8,Percent of Total Billed Charges,70% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,727.96,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5199.7,100,,4089.68,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,7349.85,
489365 KYPHON FIRST FRACTURE K,32150299,CDM,272,RC,,,Outpatient,,,12680.48,7608.29,,7608.29,60,,2007.6,Percent of Total Billed Charges,60% of Total Billed Charges,5706.22,45,,156.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3550.53,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.872,Percent of Total Billed Charges,32% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,4564.97,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,4564.97,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,4564.97,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,7608.29,60,,3073.152,Percent of Total Billed Charges,60% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12680.48,100,,923.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1828.53,14.42,,250.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9510.36,75,,441.584,Percent of Total Billed Charges,75% of Total Billed Charges,6340.24,50,,7205.88,Percent of Total Billed Charges,50% of Total Billed Charges,6340.24,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6340.24,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,6340.24,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8876.34,70,,12460,Percent of Total Billed Charges,70% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,1775.27,14,,243.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12680.48,100,,551.976,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,12680.48,
117440 BONE CANCELLOUS CRUSHED,32150300,CDM,278,RC,C1713,HCPCS,Outpatient,,,2436.5,1461.90,,2997.41,110,,2664.896,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,306.024,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.88,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,393.456,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,393.456,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,393.456,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,1257.984,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,933.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,39.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,291.84,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,93.808,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,664.68,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,664.68,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,664.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,1835.48,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,364.8,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,2997.41,
114704 BEVICE KYHPHX BONE BIOP,32150301,CDM,272,RC,,,Outpatient,,,570.14,342.08,,342.08,60,,64787.856,Percent of Total Billed Charges,60% of Total Billed Charges,256.56,45,,262.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.64,28,,3048.848,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.912,Percent of Total Billed Charges,32% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,205.25,36,,3919.944,Percent of Total Billed Charges,36% of Total Billed Charges,205.25,36,,3919.944,Percent of Total Billed Charges,36% Total Bille Charges,205.25,36,,3919.944,Percent of Total Billed Charges,36% of Total Billed Charges,342.08,60,,384.96,Percent of Total Billed Charges,60% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.14,100,,414.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.21,14.42,,12.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.61,75,,3885.192,Percent of Total Billed Charges,75% of Total Billed Charges,285.07,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,285.07,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.07,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,285.07,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399.1,70,,345.792,Percent of Total Billed Charges,70% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,79.82,14,,12.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,570.14,100,,4856.488,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,570.14,
STAPLER ENDOPATH,32150302,CDM,272,RC,,,Outpatient,,,927.5,556.50,,556.5,60,,2387.424,Percent of Total Billed Charges,60% of Total Billed Charges,417.38,45,,182.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.7,28,,84.056,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.912,Percent of Total Billed Charges,32% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,333.9,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,333.9,36,,108.072,Percent of Total Billed Charges,36% Total Bille Charges,333.9,36,,108.072,Percent of Total Billed Charges,36% of Total Billed Charges,556.5,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.5,100,,347.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,133.75,14.42,,39.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,695.63,75,,5776.664,Percent of Total Billed Charges,75% of Total Billed Charges,463.75,50,,664.68,Percent of Total Billed Charges,50% of Total Billed Charges,463.75,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.75,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,463.75,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.25,70,,394.216,Percent of Total Billed Charges,70% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,129.85,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.5,100,,7220.832,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,927.5,
544692 MESH ATRIUM C-QUR TACSH,32150304,CDM,278,RC,C1781,HCPCS,Outpatient,,,2296,1377.60,,2978.36,110,,4513.584,Percent of Total Billed Charges,110% of Total Billed Charges,1033.2,45,,189.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.88,28,,791.168,Percent of Total Billed Charges,28% of Total Billed Charges,32.77,32,,2.952,Percent of Total Billed Charges,32% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,826.56,36,,1017.216,Percent of Total Billed Charges,36% of Total Billed Charges,826.56,36,,1017.216,Percent of Total Billed Charges,36% Total Bille Charges,826.56,36,,1017.216,Percent of Total Billed Charges,36% of Total Billed Charges,1262.8,55,,601.112,Percent of Total Billed Charges,55% Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2296,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,331.08,14.42,,33.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1836.8,80,,1026.064,Percent of Total Billed Charges,80% of Total Billed Charges,1148,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,1148,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1148,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,1148,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1607.2,70,,394.216,Percent of Total Billed Charges,70% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2296,100,,1282.576,Percent of Total Billed Charges,100% of Total Billed Charges,32.77,2978.36,
0000817 CATHETER URETERAL WHIS,32150309,CDM,272,RC,C1758,HCPCS,Outpatient,,,42.63,25.58,,69,100,,74836.672,Fee Schedule,100% of Aetna Fee Schedule,19.18,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.94,28,,216.168,Percent of Total Billed Charges,28% of Total Billed Charges,32.8,32,,2.96,Percent of Total Billed Charges,32% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.35,36,,277.936,Percent of Total Billed Charges,36% of Total Billed Charges,15.35,36,,277.936,Percent of Total Billed Charges,36% Total Bille Charges,15.35,36,,277.936,Percent of Total Billed Charges,36% of Total Billed Charges,25.58,60,,5988.808,Percent of Total Billed Charges,60% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.63,100,,583.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,6.15,14.42,,521.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.97,75,,12856.376,Percent of Total Billed Charges,75% of Total Billed Charges,21.32,50,,868.504,Percent of Total Billed Charges,50% of Total Billed Charges,21.32,50,,43.352,Percent of Total Billed Charges,50% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.32,50,,43.352,Percent of Total Billed Charges,50% of Total Billed Charges,21.32,50,,43.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.84,70,,394.216,Percent of Total Billed Charges,70% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,14,,506.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.63,100,,16070.472,Percent of Total Billed Charges,100% of Total Billed Charges,5.97,69,
313450 SUPER QUICKANCHOR PLUS,32150312,CDM,278,RC,C1713,HCPCS,Outpatient,,,2668.05,1600.83,,3252.12,110,,4991.296,Percent of Total Billed Charges,110% of Total Billed Charges,1200.62,45,,164.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,747.05,28,,6852.384,Percent of Total Billed Charges,28% of Total Billed Charges,32.93,32,,2.96,Percent of Total Billed Charges,32% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,960.5,36,,8810.208,Percent of Total Billed Charges,36% of Total Billed Charges,960.5,36,,8810.208,Percent of Total Billed Charges,36% Total Bille Charges,960.5,36,,8810.208,Percent of Total Billed Charges,36% of Total Billed Charges,1467.43,55,,180.112,Percent of Total Billed Charges,55% Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2668.05,100,,406.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,384.73,14.42,,2109.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2134.44,80,,1019.24,Percent of Total Billed Charges,80% of Total Billed Charges,1334.03,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,1334.03,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334.03,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,1334.03,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1867.64,70,,1297.6,Percent of Total Billed Charges,70% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,373.53,14,,2048.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2668.05,100,,1358.984,Percent of Total Billed Charges,100% of Total Billed Charges,32.93,3252.12,
381729 BONE MTF CANCELLOUS BLO,32150313,CDM,278,RC,C1713,HCPCS,Outpatient,,,2417.18,1450.31,,2976.16,110,,331.2,Percent of Total Billed Charges,110% of Total Billed Charges,1087.73,45,,59.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,676.81,28,,202.432,Percent of Total Billed Charges,28% of Total Billed Charges,33.08,32,,2.976,Percent of Total Billed Charges,32% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,870.18,36,,260.272,Percent of Total Billed Charges,36% of Total Billed Charges,870.18,36,,260.272,Percent of Total Billed Charges,36% Total Bille Charges,870.18,36,,260.272,Percent of Total Billed Charges,36% of Total Billed Charges,1329.45,55,,1695.352,Percent of Total Billed Charges,55% Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2417.18,100,,420.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,348.56,14.42,,64.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1933.74,80,,654.376,Percent of Total Billed Charges,80% of Total Billed Charges,1208.59,50,,43.352,Percent of Total Billed Charges,50% of Total Billed Charges,1208.59,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1208.59,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,1208.59,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1692.03,70,,394.216,Percent of Total Billed Charges,70% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,338.41,14,,62.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2417.18,100,,872.504,Percent of Total Billed Charges,100% of Total Billed Charges,33.08,2976.16,
540649 MESH ATRIUM MED C-QUR,32150314,CDM,278,RC,C1781,HCPCS,Outpatient,,,2436.5,1461.90,,3132.91,110,,3752.288,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,37.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,837.536,Percent of Total Billed Charges,28% of Total Billed Charges,33.09,32,,2.976,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,1076.832,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,1076.832,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,1076.832,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,424.624,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,98.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,63.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,637.976,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1809.632,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,1809.632,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,1809.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,936.416,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,61.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,850.632,Percent of Total Billed Charges,100% of Total Billed Charges,33.09,3132.91,
0007655 TENDON SEMI T,32150315,CDM,278,RC,,,Outpatient,,,5112.1,3067.26,,5623.31,110,,368.864,Percent of Total Billed Charges,110% of Total Billed Charges,2300.45,45,,37.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1431.39,28,,95.8,Percent of Total Billed Charges,28% of Total Billed Charges,33.12,32,,2.984,Percent of Total Billed Charges,32% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1840.36,36,,123.168,Percent of Total Billed Charges,36% of Total Billed Charges,1840.36,36,,123.168,Percent of Total Billed Charges,36% Total Bille Charges,1840.36,36,,123.168,Percent of Total Billed Charges,36% of Total Billed Charges,2811.66,55,,13460.04,Percent of Total Billed Charges,55% Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5112.1,100,,364.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,737.16,14.42,,15.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4089.68,80,,11529.408,Percent of Total Billed Charges,80% of Total Billed Charges,2556.05,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,2556.05,50,,7315.048,Percent of Total Billed Charges,50% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2556.05,50,,7315.048,Percent of Total Billed Charges,50% of Total Billed Charges,2556.05,50,,7315.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3578.47,70,,896.12,Percent of Total Billed Charges,70% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,715.69,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5112.1,100,,14411.76,Percent of Total Billed Charges,100% of Total Billed Charges,33.12,5623.31,
112897 STENT URETRAL 8X24CM,32150316,CDM,278,RC,C2617,HCPCS,Outpatient,,,689.97,413.98,,952.52,110,,65.784,Percent of Total Billed Charges,110% of Total Billed Charges,310.49,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.19,28,,1742.544,Percent of Total Billed Charges,28% of Total Billed Charges,33.12,32,,2.992,Percent of Total Billed Charges,32% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,248.39,36,,2240.408,Percent of Total Billed Charges,36% of Total Billed Charges,248.39,36,,2240.408,Percent of Total Billed Charges,36% Total Bille Charges,248.39,36,,2240.408,Percent of Total Billed Charges,36% of Total Billed Charges,379.48,55,,397.64,Percent of Total Billed Charges,55% Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.97,100,,132.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,99.49,14.42,,384.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,551.98,80,,140.712,Percent of Total Billed Charges,80% of Total Billed Charges,344.99,50,,1809.632,Percent of Total Billed Charges,50% of Total Billed Charges,344.99,50,,224.16,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.99,50,,224.16,Percent of Total Billed Charges,50% of Total Billed Charges,344.99,50,,224.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.98,70,,1930.568,Percent of Total Billed Charges,70% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,373.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.97,100,,187.616,Percent of Total Billed Charges,100% of Total Billed Charges,33.12,952.52,
112898 STENT URETERAL 8X26CM,32150318,CDM,278,RC,C2617,HCPCS,Outpatient,,,456,273.60,,695.15,110,,9173.76,Percent of Total Billed Charges,110% of Total Billed Charges,205.2,45,,37.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.68,28,,471.64,Percent of Total Billed Charges,28% of Total Billed Charges,33.12,32,,3.008,Percent of Total Billed Charges,32% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,164.16,36,,606.392,Percent of Total Billed Charges,36% of Total Billed Charges,164.16,36,,606.392,Percent of Total Billed Charges,36% Total Bille Charges,164.16,36,,606.392,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,456,100,,83.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,65.76,14.42,,39.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.8,80,,1247.488,Percent of Total Billed Charges,80% of Total Billed Charges,228,50,,7315.048,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,218.768,Percent of Total Billed Charges,50% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228,50,,218.768,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,218.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.2,70,,807.64,Percent of Total Billed Charges,70% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,456,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,33.12,695.15,
370696 TENDON POSTERIOR TIBIAL,32150320,CDM,278,RC,,,Outpatient,,,6070.61,3642.37,,6677.67,110,,54.72,Percent of Total Billed Charges,110% of Total Billed Charges,2731.77,45,,29.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1699.77,28,,6852.384,Percent of Total Billed Charges,28% of Total Billed Charges,33.15,32,,3.008,Percent of Total Billed Charges,32% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,2185.42,36,,8810.208,Percent of Total Billed Charges,36% of Total Billed Charges,2185.42,36,,8810.208,Percent of Total Billed Charges,36% Total Bille Charges,2185.42,36,,8810.208,Percent of Total Billed Charges,36% of Total Billed Charges,3338.84,55,,3734.016,Percent of Total Billed Charges,55% Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6070.61,100,,84.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,875.38,14.42,,32.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4856.49,80,,1063.48,Percent of Total Billed Charges,80% of Total Billed Charges,3035.31,50,,224.16,Percent of Total Billed Charges,50% of Total Billed Charges,3035.31,50,,53.712,Percent of Total Billed Charges,50% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3035.31,50,,53.712,Percent of Total Billed Charges,50% of Total Billed Charges,3035.31,50,,53.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4249.43,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,849.89,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6070.61,100,,1329.352,Percent of Total Billed Charges,100% of Total Billed Charges,33.15,6677.67,
381726 BONE MTF BONE-TENDON,32150321,CDM,278,RC,C1762,HCPCS,Outpatient,,,9026.04,5415.62,,12106.73,110,,205.44,Percent of Total Billed Charges,110% of Total Billed Charges,4061.72,45,,35.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2527.29,28,,592.544,Percent of Total Billed Charges,28% of Total Billed Charges,33.24,32,,3.024,Percent of Total Billed Charges,32% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,3249.37,36,,761.84,Percent of Total Billed Charges,36% of Total Billed Charges,3249.37,36,,761.84,Percent of Total Billed Charges,36% Total Bille Charges,3249.37,36,,761.84,Percent of Total Billed Charges,36% of Total Billed Charges,4964.32,55,,926.432,Percent of Total Billed Charges,55% Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9026.04,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1301.55,14.42,,6446.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7220.83,80,,175.888,Percent of Total Billed Charges,80% of Total Billed Charges,4513.02,50,,218.768,Percent of Total Billed Charges,50% of Total Billed Charges,4513.02,50,,1334.792,Percent of Total Billed Charges,50% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4513.02,50,,1334.792,Percent of Total Billed Charges,50% of Total Billed Charges,4513.02,50,,1334.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6318.23,70,,3806.88,Percent of Total Billed Charges,70% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,1263.65,14,,6258.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9026.04,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,33.24,12106.73,
0003411 KIT SLIMPORT 7FR DOUBL,32150322,CDM,278,RC,C1788,HCPCS,Outpatient,,,1603.22,961.93,,2372.35,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,721.45,45,,1085.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.9,28,,616.616,Percent of Total Billed Charges,28% of Total Billed Charges,33.25,32,,3.024,Percent of Total Billed Charges,32% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,577.16,36,,792.792,Percent of Total Billed Charges,36% of Total Billed Charges,577.16,36,,792.792,Percent of Total Billed Charges,36% Total Bille Charges,577.16,36,,792.792,Percent of Total Billed Charges,36% of Total Billed Charges,881.77,55,,13460.04,Percent of Total Billed Charges,55% Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1603.22,100,,83.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,231.18,14.42,,627.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1282.58,80,,1302.76,Percent of Total Billed Charges,80% of Total Billed Charges,801.61,50,,53.712,Percent of Total Billed Charges,50% of Total Billed Charges,801.61,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,801.61,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,801.61,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1122.25,70,,7804.104,Percent of Total Billed Charges,70% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14,,609.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1603.22,100,,1737.008,Percent of Total Billed Charges,100% of Total Billed Charges,33.25,2372.35,
0003365 KIT BONE GRAFT INFUSE,32150326,CDM,278,RC,C1713,HCPCS,Outpatient,,,20088.09,12052.85,,22414.16,110,,708.768,Percent of Total Billed Charges,110% of Total Billed Charges,9039.64,45,,52.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5624.67,28,,834.8,Percent of Total Billed Charges,28% of Total Billed Charges,33.32,32,,3.04,Percent of Total Billed Charges,32% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,7231.71,36,,1073.32,Percent of Total Billed Charges,36% of Total Billed Charges,7231.71,36,,1073.32,Percent of Total Billed Charges,36% Total Bille Charges,7231.71,36,,1073.32,Percent of Total Billed Charges,36% of Total Billed Charges,11048.45,55,,1269.728,Percent of Total Billed Charges,55% Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20088.09,100,,65.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2896.7,14.42,,321.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16070.47,80,,205.52,Percent of Total Billed Charges,80% of Total Billed Charges,10044.05,50,,1334.792,Percent of Total Billed Charges,50% of Total Billed Charges,10044.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10044.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,10044.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14061.66,70,,1747.2,Percent of Total Billed Charges,70% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,2812.33,14,,312.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20088.09,100,,274.024,Percent of Total Billed Charges,100% of Total Billed Charges,33.32,22414.16,
195485 BASKET STN 1.9X12X120,32150327,CDM,272,RC,,,Outpatient,,,1698.73,1019.24,,1019.24,60,,712.8,Percent of Total Billed Charges,60% of Total Billed Charges,764.43,45,,233.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,475.64,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,33.39,32,,3.048,Percent of Total Billed Charges,32% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,611.54,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,611.54,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,611.54,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1019.24,60,,1321.32,Percent of Total Billed Charges,60% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1698.73,100,,78.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,244.96,14.42,,162.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1274.05,75,,65.032,Percent of Total Billed Charges,75% of Total Billed Charges,849.37,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,849.37,50,,22351.824,Percent of Total Billed Charges,50% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,849.37,50,,22351.824,Percent of Total Billed Charges,50% of Total Billed Charges,849.37,50,,22351.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.11,70,,4568.256,Percent of Total Billed Charges,70% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,237.82,14,,157.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1698.73,100,,86.704,Percent of Total Billed Charges,100% of Total Billed Charges,33.39,1698.73,
112924 BASKET STONE NITINOL,32150328,CDM,272,RC,,,Outpatient,,,1090.63,654.38,,654.38,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,490.78,45,,192.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.38,28,,13590.56,Percent of Total Billed Charges,28% of Total Billed Charges,33.42,32,,3.072,Percent of Total Billed Charges,32% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,392.63,36,,17473.576,Percent of Total Billed Charges,36% of Total Billed Charges,392.63,36,,17473.576,Percent of Total Billed Charges,36% Total Bille Charges,392.63,36,,17473.576,Percent of Total Billed Charges,36% of Total Billed Charges,654.38,60,,1639.792,Percent of Total Billed Charges,60% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.63,100,,2412.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,157.27,14.42,,4705.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,817.97,75,,205.512,Percent of Total Billed Charges,75% of Total Billed Charges,545.32,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,545.32,50,,2175.36,Percent of Total Billed Charges,50% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.32,50,,2175.36,Percent of Total Billed Charges,50% of Total Billed Charges,545.32,50,,2175.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,763.44,70,,7720.352,Percent of Total Billed Charges,70% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,152.69,14,,4568.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.63,100,,274.016,Percent of Total Billed Charges,100% of Total Billed Charges,33.42,1090.63,
510541 BASKET STN 3X14X120CM,32150330,CDM,272,RC,,,Outpatient,,,1063.29,637.97,,637.97,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,478.48,45,,52.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.72,28,,8470.312,Percent of Total Billed Charges,28% of Total Billed Charges,33.48,32,,28.16,Percent of Total Billed Charges,32% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,382.78,36,,10890.4,Percent of Total Billed Charges,36% of Total Billed Charges,382.78,36,,10890.4,Percent of Total Billed Charges,36% Total Bille Charges,382.78,36,,10890.4,Percent of Total Billed Charges,36% of Total Billed Charges,637.97,60,,2032.8,Percent of Total Billed Charges,60% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1063.29,100,,115.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,153.33,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,797.47,75,,176.416,Percent of Total Billed Charges,75% of Total Billed Charges,531.65,50,,22351.824,Percent of Total Billed Charges,50% of Total Billed Charges,531.65,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.65,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,531.65,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,744.3,70,,11537.12,Percent of Total Billed Charges,70% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1063.29,100,,235.224,Percent of Total Billed Charges,100% of Total Billed Charges,33.48,1063.29,
0003366 KIT BONE GRAFT INFUSE,32150333,CDM,278,RC,C1713,HCPCS,Outpatient,,,18014.7,10808.82,,20133.43,110,,840.36,Percent of Total Billed Charges,110% of Total Billed Charges,8106.62,45,,52.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5044.12,28,,2652.832,Percent of Total Billed Charges,28% of Total Billed Charges,33.48,32,,28.16,Percent of Total Billed Charges,32% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,6485.29,36,,3410.784,Percent of Total Billed Charges,36% of Total Billed Charges,6485.29,36,,3410.784,Percent of Total Billed Charges,36% Total Bille Charges,6485.29,36,,3410.784,Percent of Total Billed Charges,36% of Total Billed Charges,9908.09,55,,26695.744,Percent of Total Billed Charges,55% Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18014.7,100,,519.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2597.72,14.42,,80.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14411.76,80,,2895.408,Percent of Total Billed Charges,80% of Total Billed Charges,9007.35,50,,2175.36,Percent of Total Billed Charges,50% of Total Billed Charges,9007.35,50,,563.32,Percent of Total Billed Charges,50% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9007.35,50,,563.32,Percent of Total Billed Charges,50% of Total Billed Charges,9007.35,50,,563.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12610.29,70,,941.184,Percent of Total Billed Charges,70% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,2522.06,14,,78.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18014.7,100,,3619.256,Percent of Total Billed Charges,100% of Total Billed Charges,33.48,20133.43,
479375 FIBERWIRE ARTHREX 5,32150335,CDM,272,RC,C1713,HCPCS,Outpatient,,,234.52,140.71,,317.26,100,,3187.48,Fee Schedule,100% of Aetna Fee Schedule,105.53,45,,491.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.67,28,,5187.84,Percent of Total Billed Charges,28% of Total Billed Charges,33.56,32,,28.168,Percent of Total Billed Charges,32% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,84.43,36,,6670.08,Percent of Total Billed Charges,36% of Total Billed Charges,84.43,36,,6670.08,Percent of Total Billed Charges,36% Total Bille Charges,84.43,36,,6670.08,Percent of Total Billed Charges,36% of Total Billed Charges,140.71,60,,16638.104,Percent of Total Billed Charges,60% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.52,100,,428.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,33.82,14.42,,51.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.89,75,,11704.072,Percent of Total Billed Charges,75% of Total Billed Charges,117.26,50,,1114.4,Percent of Total Billed Charges,50% of Total Billed Charges,117.26,50,,16315.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.26,50,,16315.2,Percent of Total Billed Charges,50% of Total Billed Charges,117.26,50,,16315.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.16,70,,1016.504,Percent of Total Billed Charges,70% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,32.83,14,,49.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.52,100,,14630.088,Percent of Total Billed Charges,100% of Total Billed Charges,32.83,317.26,
388901 ANCHOR BIO SWIVELOCK,32150342,CDM,278,RC,C1713,HCPCS,Outpatient,,,1949.2,1169.52,,2461.38,110,,2761.52,Percent of Total Billed Charges,110% of Total Billed Charges,877.14,45,,43.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,436.624,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.304,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,561.368,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,1072.06,55,,5210.92,Percent of Total Billed Charges,55% Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,115.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,427.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1559.36,80,,336.24,Percent of Total Billed Charges,80% of Total Billed Charges,974.6,50,,563.32,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,791.376,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,448.32,Percent of Total Billed Charges,100% of Total Billed Charges,33.59,2461.38,
004469 PIN ORTHOSORB ABSORBAB,32150344,CDM,278,RC,C1713,HCPCS,Outpatient,,,1661.69,997.01,,2145.12,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,747.76,45,,166.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465.27,28,,668.792,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.304,Percent of Total Billed Charges,32% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,598.21,36,,859.872,Percent of Total Billed Charges,36% of Total Billed Charges,598.21,36,,859.872,Percent of Total Billed Charges,36% Total Bille Charges,598.21,36,,859.872,Percent of Total Billed Charges,36% of Total Billed Charges,913.93,55,,10190.4,Percent of Total Billed Charges,55% Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1661.69,100,,115.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,239.62,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1329.35,80,,328.144,Percent of Total Billed Charges,80% of Total Billed Charges,830.85,50,,16315.2,Percent of Total Billed Charges,50% of Total Billed Charges,830.85,50,,280.688,Percent of Total Billed Charges,50% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,830.85,50,,280.688,Percent of Total Billed Charges,50% of Total Billed Charges,830.85,50,,280.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1163.18,70,,363.488,Percent of Total Billed Charges,70% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.64,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1661.69,100,,437.528,Percent of Total Billed Charges,100% of Total Billed Charges,33.59,2145.12,
300612 SUTURE TIGERTAPE ARTHRE,32150345,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,219.456,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,26.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,6182.4,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.304,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,7948.8,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,7948.8,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,7948.8,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,857.648,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,1093.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,1880.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,80.56,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,178.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,178.2,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,178.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,52.352,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,1825.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,107.416,Percent of Total Billed Charges,100% of Total Billed Charges,33.59,293.15,
595649 LIGASURE IMPACT CURVED,32150346,CDM,272,RC,,,Outpatient,,,2171.26,1302.76,,1302.76,60,,1120.528,Percent of Total Billed Charges,60% of Total Billed Charges,977.07,45,,697.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,607.95,28,,2095.456,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.304,Percent of Total Billed Charges,32% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,781.65,36,,2694.16,Percent of Total Billed Charges,36% of Total Billed Charges,781.65,36,,2694.16,Percent of Total Billed Charges,36% Total Bille Charges,781.65,36,,2694.16,Percent of Total Billed Charges,36% of Total Billed Charges,1302.76,60,,1313.696,Percent of Total Billed Charges,60% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2171.26,100,,95.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,313.1,14.42,,15.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1628.45,75,,2002.184,Percent of Total Billed Charges,75% of Total Billed Charges,1085.63,50,,280.688,Percent of Total Billed Charges,50% of Total Billed Charges,1085.63,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1085.63,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,1085.63,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1519.88,70,,1063.144,Percent of Total Billed Charges,70% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,303.98,14,,14.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2171.26,100,,2669.576,Percent of Total Billed Charges,100% of Total Billed Charges,33.59,2171.26,
587948 GUIDEWIRE BOSTON SCI ZI,32150347,CDM,272,RC,C1769,HCPCS,Outpatient,,,342.53,205.52,,55.13,100,,1074.16,Fee Schedule,100% of Aetna Fee Schedule,154.14,45,,67.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.91,28,,1256.272,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.304,Percent of Total Billed Charges,32% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,123.31,36,,1615.208,Percent of Total Billed Charges,36% of Total Billed Charges,123.31,36,,1615.208,Percent of Total Billed Charges,36% Total Bille Charges,123.31,36,,1615.208,Percent of Total Billed Charges,36% of Total Billed Charges,205.52,60,,12144,Percent of Total Billed Charges,60% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.53,100,,369.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,49.39,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.9,75,,205.512,Percent of Total Billed Charges,75% of Total Billed Charges,171.27,50,,178.2,Percent of Total Billed Charges,50% of Total Billed Charges,171.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,171.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.77,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.53,100,,274.016,Percent of Total Billed Charges,100% of Total Billed Charges,33.59,342.53,
652302 SUTURE STRATAFIX SPIRAL,32150348,CDM,272,RC,,,Outpatient,,,108.38,65.03,,65.03,60,,699.84,Percent of Total Billed Charges,60% of Total Billed Charges,48.77,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.35,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,33.59,32,,28.408,Percent of Total Billed Charges,32% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,39.02,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,39.02,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,39.02,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,65.03,60,,4116.08,Percent of Total Billed Charges,60% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.38,100,,58.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.63,14.42,,614.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.29,75,,180.112,Percent of Total Billed Charges,75% of Total Billed Charges,54.19,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,54.19,50,,6519.192,Percent of Total Billed Charges,50% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.19,50,,6519.192,Percent of Total Billed Charges,50% of Total Billed Charges,54.19,50,,6519.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.87,70,,773.368,Percent of Total Billed Charges,70% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.17,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.38,100,,225.136,Percent of Total Billed Charges,100% of Total Billed Charges,15.17,108.38,
599643 ZIPWIRE BOS SCI G WIRE,32150349,CDM,272,RC,C1769,HCPCS,Outpatient,,,342.52,205.51,,55.13,100,,3375,Fee Schedule,100% of Aetna Fee Schedule,154.13,45,,382.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.91,28,,206.28,Percent of Total Billed Charges,28% of Total Billed Charges,33.6,32,,28.416,Percent of Total Billed Charges,32% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,123.31,36,,265.216,Percent of Total Billed Charges,36% of Total Billed Charges,123.31,36,,265.216,Percent of Total Billed Charges,36% Total Bille Charges,123.31,36,,265.216,Percent of Total Billed Charges,36% of Total Billed Charges,205.51,60,,2467.672,Percent of Total Billed Charges,60% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.52,100,,1549.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,49.39,14.42,,614.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.89,75,,35762.92,Percent of Total Billed Charges,75% of Total Billed Charges,171.26,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.26,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.76,70,,773.368,Percent of Total Billed Charges,70% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,596.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.52,100,,44703.648,Percent of Total Billed Charges,100% of Total Billed Charges,33.6,342.52,
407689 SUTURE FIBERLINK W/LOOP,32150352,CDM,272,RC,,,Outpatient,,,294.03,176.42,,176.42,60,,6563.6,Percent of Total Billed Charges,60% of Total Billed Charges,132.31,45,,558.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.33,28,,2096.64,Percent of Total Billed Charges,28% of Total Billed Charges,33.6,32,,28.48,Percent of Total Billed Charges,32% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,105.85,36,,2695.68,Percent of Total Billed Charges,36% of Total Billed Charges,105.85,36,,2695.68,Percent of Total Billed Charges,36% Total Bille Charges,105.85,36,,2695.68,Percent of Total Billed Charges,36% of Total Billed Charges,176.42,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.03,100,,151.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.52,75,,3480.576,Percent of Total Billed Charges,75% of Total Billed Charges,147.02,50,,6519.192,Percent of Total Billed Charges,50% of Total Billed Charges,147.02,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.02,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,147.02,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.82,70,,1187.064,Percent of Total Billed Charges,70% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.03,100,,4350.72,Percent of Total Billed Charges,100% of Total Billed Charges,33.6,294.03,
112991 GRAFT GORETEX PTFE REMR,32150354,CDM,278,RC,C1768,HCPCS,Outpatient,,,4524.07,2714.44,,5299.25,110,,890.208,Percent of Total Billed Charges,110% of Total Billed Charges,2035.83,45,,98.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1266.74,28,,620.888,Percent of Total Billed Charges,28% of Total Billed Charges,33.72,32,,28.536,Percent of Total Billed Charges,32% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,1628.67,36,,798.28,Percent of Total Billed Charges,36% of Total Billed Charges,1628.67,36,,798.28,Percent of Total Billed Charges,36% Total Bille Charges,1628.67,36,,798.28,Percent of Total Billed Charges,36% of Total Billed Charges,2488.24,55,,442.024,Percent of Total Billed Charges,55% Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4524.07,100,,108.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,652.37,14.42,,19.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3619.26,80,,1783.04,Percent of Total Billed Charges,80% of Total Billed Charges,2262.04,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,2262.04,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2262.04,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,2262.04,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3166.85,70,,100.8,Percent of Total Billed Charges,70% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,633.37,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4524.07,100,,2228.8,Percent of Total Billed Charges,100% of Total Billed Charges,33.72,5299.25,
234732 VALVE HAKIM J&J PROGRAM,32150355,CDM,278,RC,,,Outpatient,,,18287.61,10972.57,,20116.37,110,,473.44,Percent of Total Billed Charges,110% of Total Billed Charges,8229.42,45,,144.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5120.53,28,,3051.592,Percent of Total Billed Charges,28% of Total Billed Charges,33.72,32,,28.552,Percent of Total Billed Charges,32% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,6583.54,36,,3923.48,Percent of Total Billed Charges,36% of Total Billed Charges,6583.54,36,,3923.48,Percent of Total Billed Charges,36% Total Bille Charges,6583.54,36,,3923.48,Percent of Total Billed Charges,36% of Total Billed Charges,10058.19,55,,4118.4,Percent of Total Billed Charges,55% Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18287.61,100,,850.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2637.07,14.42,,16.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14630.09,80,,844.984,Percent of Total Billed Charges,80% of Total Billed Charges,9143.81,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,9143.81,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9143.81,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,9143.81,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12801.33,70,,914.176,Percent of Total Billed Charges,70% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,2560.27,14,,16.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18287.61,100,,1126.64,Percent of Total Billed Charges,100% of Total Billed Charges,33.72,20116.37,
704421 ARTHREX COOLCUT 45 BALL,32150357,CDM,272,RC,,,Outpatient,,,560.4,336.24,,336.24,60,,4437.736,Percent of Total Billed Charges,60% of Total Billed Charges,252.18,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.91,28,,2278.416,Percent of Total Billed Charges,28% of Total Billed Charges,33.74,32,,28.552,Percent of Total Billed Charges,32% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,201.74,36,,2929.392,Percent of Total Billed Charges,36% of Total Billed Charges,201.74,36,,2929.392,Percent of Total Billed Charges,36% Total Bille Charges,201.74,36,,2929.392,Percent of Total Billed Charges,36% of Total Billed Charges,336.24,60,,1219.6,Percent of Total Billed Charges,60% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.4,100,,1240.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,80.81,14.42,,25.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.3,75,,26104.32,Percent of Total Billed Charges,75% of Total Billed Charges,280.2,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,280.2,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.2,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,280.2,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.28,70,,1282.576,Percent of Total Billed Charges,70% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14,,25.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560.4,100,,32630.4,Percent of Total Billed Charges,100% of Total Billed Charges,33.74,560.4,
547189 SUTURE COVIDEN V-LOC 18,32150359,CDM,272,RC,,,Outpatient,,,546.91,328.15,,328.15,60,,917.496,Percent of Total Billed Charges,60% of Total Billed Charges,246.11,45,,48.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.13,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,33.74,32,,28.592,Percent of Total Billed Charges,32% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.89,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,196.89,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,196.89,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,328.15,60,,5994.2,Percent of Total Billed Charges,60% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.91,100,,219.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,78.86,14.42,,39.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.18,75,,187.616,Percent of Total Billed Charges,75% of Total Billed Charges,273.46,50,,2130.96,Percent of Total Billed Charges,50% of Total Billed Charges,273.46,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.46,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,273.46,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.84,70,,521.216,Percent of Total Billed Charges,70% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,76.57,14,,38.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.91,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,33.74,546.91,
622565 SUTURE STRATAFIX SPIRAL,32150362,CDM,272,RC,,,Outpatient,,,134.27,80.56,,80.56,60,,316.8,Percent of Total Billed Charges,60% of Total Billed Charges,60.42,45,,32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.6,28,,398.584,Percent of Total Billed Charges,28% of Total Billed Charges,33.79,32,,28.728,Percent of Total Billed Charges,32% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,48.34,36,,512.464,Percent of Total Billed Charges,36% of Total Billed Charges,48.34,36,,512.464,Percent of Total Billed Charges,36% Total Bille Charges,48.34,36,,512.464,Percent of Total Billed Charges,36% of Total Billed Charges,80.56,60,,4882.328,Percent of Total Billed Charges,60% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.27,100,,320.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14.42,,253.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.7,75,,449.096,Percent of Total Billed Charges,75% of Total Billed Charges,67.14,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,67.14,50,,58.152,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.14,50,,58.152,Percent of Total Billed Charges,50% of Total Billed Charges,67.14,50,,58.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.99,70,,150.56,Percent of Total Billed Charges,70% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,245.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.27,100,,561.368,Percent of Total Billed Charges,100% of Total Billed Charges,18.8,134.27,
704416 MICROSENSOR VENT CATH,32150367,CDM,272,RC,,,Outpatient,,,3336.97,2002.18,,2002.18,60,,1504.272,Percent of Total Billed Charges,60% of Total Billed Charges,1501.64,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.35,28,,270.168,Percent of Total Billed Charges,28% of Total Billed Charges,33.86,32,,28.728,Percent of Total Billed Charges,32% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,1201.31,36,,347.36,Percent of Total Billed Charges,36% of Total Billed Charges,1201.31,36,,347.36,Percent of Total Billed Charges,36% Total Bille Charges,1201.31,36,,347.36,Percent of Total Billed Charges,36% of Total Billed Charges,2002.18,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3336.97,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,481.19,14.42,,807.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2502.73,75,,267.304,Percent of Total Billed Charges,75% of Total Billed Charges,1668.49,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,1668.49,50,,89.584,Percent of Total Billed Charges,50% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1668.49,50,,89.584,Percent of Total Billed Charges,50% of Total Billed Charges,1668.49,50,,89.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2335.88,70,,1187.064,Percent of Total Billed Charges,70% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,467.18,14,,783.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3336.97,100,,356.4,Percent of Total Billed Charges,100% of Total Billed Charges,33.86,3336.97,
704423 ZIPWIRE .32X150CM,32150368,CDM,272,RC,C1769,HCPCS,Outpatient,,,342.52,205.51,,55.13,100,,72,Fee Schedule,100% of Aetna Fee Schedule,154.13,45,,444.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.91,28,,376.584,Percent of Total Billed Charges,28% of Total Billed Charges,33.88,32,,28.88,Percent of Total Billed Charges,32% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,123.31,36,,484.184,Percent of Total Billed Charges,36% of Total Billed Charges,123.31,36,,484.184,Percent of Total Billed Charges,36% Total Bille Charges,123.31,36,,484.184,Percent of Total Billed Charges,36% of Total Billed Charges,205.51,60,,782.928,Percent of Total Billed Charges,60% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.52,100,,108.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,49.39,14.42,,130.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.89,75,,2371.6,Percent of Total Billed Charges,75% of Total Billed Charges,171.26,50,,58.152,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,136.344,Percent of Total Billed Charges,50% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.26,50,,136.344,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,136.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.76,70,,5502.848,Percent of Total Billed Charges,70% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,126.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.52,100,,2964.504,Percent of Total Billed Charges,100% of Total Billed Charges,33.88,342.52,
184910 CEMENT STRYKER SIMPLEX,32150369,CDM,278,RC,C1713,HCPCS,Outpatient,,,281.42,168.85,,626.82,110,,5127.08,Percent of Total Billed Charges,110% of Total Billed Charges,126.64,45,,425.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.8,28,,103.456,Percent of Total Billed Charges,28% of Total Billed Charges,33.92,32,,28.928,Percent of Total Billed Charges,32% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,101.31,36,,133.008,Percent of Total Billed Charges,36% of Total Billed Charges,101.31,36,,133.008,Percent of Total Billed Charges,36% Total Bille Charges,101.31,36,,133.008,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.42,100,,71.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,40.58,14.42,,115.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.14,80,,384,Percent of Total Billed Charges,80% of Total Billed Charges,140.71,50,,89.584,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,877.8,Percent of Total Billed Charges,50% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.71,50,,877.8,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,877.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.99,70,,1282.576,Percent of Total Billed Charges,70% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.42,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,33.92,626.82,
693621 SENSOR BATTERY,32150370,CDM,278,RC,C1820,HCPCS,Outpatient,,,55879.56,33527.74,,63097.7,110,,959.008,Percent of Total Billed Charges,110% of Total Billed Charges,25145.8,45,,696.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15646.28,28,,463.68,Percent of Total Billed Charges,28% of Total Billed Charges,34.05,32,,28.928,Percent of Total Billed Charges,32% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,20116.64,36,,596.16,Percent of Total Billed Charges,36% of Total Billed Charges,20116.64,36,,596.16,Percent of Total Billed Charges,36% Total Bille Charges,20116.64,36,,596.16,Percent of Total Billed Charges,36% of Total Billed Charges,30733.76,55,,739.72,Percent of Total Billed Charges,55% Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55879.56,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,8057.83,14.42,,289.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44703.65,80,,10430.704,Percent of Total Billed Charges,80% of Total Billed Charges,27939.78,50,,136.344,Percent of Total Billed Charges,50% of Total Billed Charges,27939.78,50,,2799.736,Percent of Total Billed Charges,50% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27939.78,50,,2799.736,Percent of Total Billed Charges,50% of Total Billed Charges,27939.78,50,,2799.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39115.69,70,,345.8,Percent of Total Billed Charges,70% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,7823.14,14,,280.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55879.56,100,,13038.376,Percent of Total Billed Charges,100% of Total Billed Charges,34.05,63097.7,
477795 MEMBRANE DRY AMNIOTIC,32150372,CDM,278,RC,,,Outpatient,,,5438.4,3263.04,,5982.24,110,,199.816,Percent of Total Billed Charges,110% of Total Billed Charges,2447.28,45,,716.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1522.75,28,,473.256,Percent of Total Billed Charges,28% of Total Billed Charges,34.11,32,,28.928,Percent of Total Billed Charges,32% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1957.82,36,,608.472,Percent of Total Billed Charges,36% of Total Billed Charges,1957.82,36,,608.472,Percent of Total Billed Charges,36% Total Bille Charges,1957.82,36,,608.472,Percent of Total Billed Charges,36% of Total Billed Charges,2991.12,55,,910.8,Percent of Total Billed Charges,55% Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5438.4,100,,986.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,784.22,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4350.72,80,,79.2,Percent of Total Billed Charges,80% of Total Billed Charges,2719.2,50,,877.8,Percent of Total Billed Charges,50% of Total Billed Charges,2719.2,50,,453.024,Percent of Total Billed Charges,50% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2719.2,50,,453.024,Percent of Total Billed Charges,50% of Total Billed Charges,2719.2,50,,453.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3806.88,70,,349.76,Percent of Total Billed Charges,70% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,761.38,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5438.4,100,,105.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.11,5982.24,
487573 THERASKIN LIFENET LG,32150373,CDM,278,RC,,,Outpatient,,,2786,1671.60,,3064.6,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,1253.7,45,,55.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780.08,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,34.14,32,,29.032,Percent of Total Billed Charges,32% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,1002.96,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1002.96,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,1002.96,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1532.3,55,,1014.128,Percent of Total Billed Charges,55% Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2786,100,,946.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,401.74,14.42,,171.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2228.8,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,1393,50,,2799.736,Percent of Total Billed Charges,50% of Total Billed Charges,1393,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1393,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,1393,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1950.2,70,,357.768,Percent of Total Billed Charges,70% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,390.04,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2786,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,34.14,3064.6,
1882TC46 TENDRILLEAD,32150375,CDM,275,RC,C1898,HCPCS,Outpatient,,,1408.3,844.98,,2921.91,110,,129.24,Percent of Total Billed Charges,110% of Total Billed Charges,633.74,45,,113.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.32,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,34.15,32,,29.12,Percent of Total Billed Charges,32% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,506.99,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,506.99,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,506.99,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,774.57,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1408.3,100,,1547.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,203.08,14.42,,137.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1056.23,75,,3196.44,Percent of Total Billed Charges,75% of Total Billed Charges,704.15,50,,453.024,Percent of Total Billed Charges,50% of Total Billed Charges,704.15,50,,1003.52,Percent of Total Billed Charges,50% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,704.15,50,,1003.52,Percent of Total Billed Charges,50% of Total Billed Charges,704.15,50,,1003.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,985.81,70,,387.648,Percent of Total Billed Charges,70% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,197.16,14,,133.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1408.3,100,,4261.92,Percent of Total Billed Charges,100% of Total Billed Charges,34.15,2921.91,
655611 GENERATOR MEDTRONIC RES,32150376,CDM,278,RC,C1820,HCPCS,Outpatient,,,40788,24472.80,,46496.98,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,18354.6,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11420.64,28,,1022.904,Percent of Total Billed Charges,28% of Total Billed Charges,34.23,32,,29.184,Percent of Total Billed Charges,32% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,14683.68,36,,1315.16,Percent of Total Billed Charges,36% of Total Billed Charges,14683.68,36,,1315.16,Percent of Total Billed Charges,36% Total Bille Charges,14683.68,36,,1315.16,Percent of Total Billed Charges,36% of Total Billed Charges,22433.4,55,,1169.52,Percent of Total Billed Charges,55% Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40788,100,,1591.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5881.63,14.42,,37,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32630.4,80,,3196.44,Percent of Total Billed Charges,80% of Total Billed Charges,20394,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,20394,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20394,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,20394,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28551.6,70,,387.648,Percent of Total Billed Charges,70% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,5710.32,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40788,100,,4261.92,Percent of Total Billed Charges,100% of Total Billed Charges,34.23,46496.98,
697925 CEMENT BONE SIMPLEX HV,32150381,CDM,278,RC,C1713,HCPCS,Outpatient,,,293.15,175.89,,639.73,110,,91.032,Percent of Total Billed Charges,110% of Total Billed Charges,131.92,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,786.24,Percent of Total Billed Charges,28% of Total Billed Charges,34.27,32,,29.184,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,1010.88,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,1010.88,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,1010.88,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,123.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,38.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.52,80,,1461.904,Percent of Total Billed Charges,80% of Total Billed Charges,146.58,50,,1003.52,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,770.776,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,36.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,34.27,639.73,
685193 CEMENT BONE SIMPLEX HV,32150382,CDM,278,RC,C1713,HCPCS,Outpatient,,,701.71,421.03,,1089.14,110,,538.072,Percent of Total Billed Charges,110% of Total Billed Charges,315.77,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.48,28,,31.76,Percent of Total Billed Charges,28% of Total Billed Charges,34.3,32,,29.384,Percent of Total Billed Charges,32% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,252.62,36,,40.832,Percent of Total Billed Charges,36% of Total Billed Charges,252.62,36,,40.832,Percent of Total Billed Charges,36% Total Bille Charges,252.62,36,,40.832,Percent of Total Billed Charges,36% of Total Billed Charges,385.94,55,,1544.4,Percent of Total Billed Charges,55% Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,701.71,100,,252.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,561.37,80,,100.2,Percent of Total Billed Charges,80% of Total Billed Charges,350.86,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,350.86,50,,477.56,Percent of Total Billed Charges,50% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.86,50,,477.56,Percent of Total Billed Charges,50% of Total Billed Charges,350.86,50,,477.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.2,70,,5837.848,Percent of Total Billed Charges,70% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,701.71,100,,133.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.3,1089.14,
347438 CEMENT MIXING SYSTEM,32150383,CDM,272,RC,,,Outpatient,,,445.5,267.30,,267.3,60,,555.136,Percent of Total Billed Charges,60% of Total Billed Charges,200.48,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.74,28,,5376,Percent of Total Billed Charges,28% of Total Billed Charges,34.35,32,,29.384,Percent of Total Billed Charges,32% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,160.38,36,,6912,Percent of Total Billed Charges,36% of Total Billed Charges,160.38,36,,6912,Percent of Total Billed Charges,36% Total Bille Charges,160.38,36,,6912,Percent of Total Billed Charges,36% of Total Billed Charges,267.3,60,,68.048,Percent of Total Billed Charges,60% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.5,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,64.24,14.42,,1316.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,334.13,75,,87.232,Percent of Total Billed Charges,75% of Total Billed Charges,222.75,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,222.75,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.75,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,222.75,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.85,70,,297.152,Percent of Total Billed Charges,70% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,62.37,14,,1277.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,445.5,100,,116.304,Percent of Total Billed Charges,100% of Total Billed Charges,34.35,445.5,
606194 STENT INTERSECT PROPEL,32150385,CDM,278,RC,C2625,HCPCS,Outpatient,,,3705.63,2223.38,,4302.5,110,,2233.336,Percent of Total Billed Charges,110% of Total Billed Charges,1667.53,45,,29.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.58,28,,800.8,Percent of Total Billed Charges,28% of Total Billed Charges,34.35,32,,29.4,Percent of Total Billed Charges,32% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,1334.03,36,,1029.6,Percent of Total Billed Charges,36% of Total Billed Charges,1334.03,36,,1029.6,Percent of Total Billed Charges,36% Total Bille Charges,1334.03,36,,1029.6,Percent of Total Billed Charges,36% of Total Billed Charges,2038.1,55,,10560,Percent of Total Billed Charges,55% Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3705.63,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,534.35,14.42,,40.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2964.5,80,,143.328,Percent of Total Billed Charges,80% of Total Billed Charges,1852.82,50,,477.56,Percent of Total Billed Charges,50% of Total Billed Charges,1852.82,50,,131.872,Percent of Total Billed Charges,50% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1852.82,50,,131.872,Percent of Total Billed Charges,50% of Total Billed Charges,1852.82,50,,131.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2593.94,70,,1047.888,Percent of Total Billed Charges,70% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,39.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3705.63,100,,179.16,Percent of Total Billed Charges,100% of Total Billed Charges,34.35,4302.5,
709133 MESH MYCRO OVAL 5X10,32150386,CDM,278,RC,C1781,HCPCS,Outpatient,,,600,360.00,,1112.76,110,,965.248,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,123.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,16.72,Percent of Total Billed Charges,28% of Total Billed Charges,34.35,32,,29.408,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,21.496,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,21.496,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,21.496,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,1573,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,223.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,218.144,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,176.632,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,217.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,272.68,Percent of Total Billed Charges,100% of Total Billed Charges,34.35,1112.76,
713511 VALVE HAKIM PROG,32150387,CDM,278,RC,,,Outpatient,,,16297.97,9778.78,,17927.77,110,,37.456,Percent of Total Billed Charges,110% of Total Billed Charges,7334.09,45,,67.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4563.43,28,,1962.456,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.568,Percent of Total Billed Charges,32% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,5867.27,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,5867.27,36,,2523.16,Percent of Total Billed Charges,36% Total Bille Charges,5867.27,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,8963.88,55,,4205.264,Percent of Total Billed Charges,55% Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16297.97,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2350.17,14.42,,833.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13038.38,80,,1316.704,Percent of Total Billed Charges,80% of Total Billed Charges,8148.99,50,,131.872,Percent of Total Billed Charges,50% of Total Billed Charges,8148.99,50,,4563.52,Percent of Total Billed Charges,50% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8148.99,50,,4563.52,Percent of Total Billed Charges,50% of Total Billed Charges,8148.99,50,,4563.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11408.58,70,,955.112,Percent of Total Billed Charges,70% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,2281.72,14,,808.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16297.97,100,,1755.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.36,17927.77,
REVOLUTION 90 DEG. NOZZLE,32150388,CDM,272,RC,,,Outpatient,,,132,79.20,,79.2,60,,146.336,Percent of Total Billed Charges,60% of Total Billed Charges,59.4,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.96,28,,1100.736,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.672,Percent of Total Billed Charges,32% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.52,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,47.52,36,,1415.232,Percent of Total Billed Charges,36% Total Bille Charges,47.52,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,79.2,60,,2162.16,Percent of Total Billed Charges,60% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132,100,,66.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14.42,,101.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99,75,,4479.568,Percent of Total Billed Charges,75% of Total Billed Charges,66,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,66,50,,141.136,Percent of Total Billed Charges,50% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66,50,,141.136,Percent of Total Billed Charges,50% of Total Billed Charges,66,50,,141.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,70,,5329.632,Percent of Total Billed Charges,70% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.48,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132,100,,5599.464,Percent of Total Billed Charges,100% of Total Billed Charges,18.48,132,
SURGIFLO HEMOSTATIC MAT,32150390,CDM,272,RC,A4649,HCPCS,Outpatient,,,600,360.00,,360,60,,423.28,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,1861.112,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.696,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,2392.856,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,2392.856,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,2392.856,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,3988.088,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,274.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,6896.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,724.84,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,4563.52,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,776.408,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,776.408,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,776.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,2515.968,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,6695.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,906.048,Percent of Total Billed Charges,100% of Total Billed Charges,34.36,600,
TRUMATCH ATTUNE TIB LEFT,32150392,CDM,272,RC,,,Outpatient,,,5327.4,3196.44,,3196.44,60,,421.16,Percent of Total Billed Charges,60% of Total Billed Charges,2397.33,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1491.67,28,,587.056,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.696,Percent of Total Billed Charges,32% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1917.86,36,,754.792,Percent of Total Billed Charges,36% of Total Billed Charges,1917.86,36,,754.792,Percent of Total Billed Charges,36% Total Bille Charges,1917.86,36,,754.792,Percent of Total Billed Charges,36% of Total Billed Charges,3196.44,60,,1257.984,Percent of Total Billed Charges,60% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5327.4,100,,149.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,768.21,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3995.55,75,,599.384,Percent of Total Billed Charges,75% of Total Billed Charges,2663.7,50,,141.136,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,2889.152,Percent of Total Billed Charges,50% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2663.7,50,,2889.152,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,2889.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3729.18,70,,3911.288,Percent of Total Billed Charges,70% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5327.4,100,,799.176,Percent of Total Billed Charges,100% of Total Billed Charges,34.36,5327.4,
TRUMATCH ATTUNE LEFT,32150395,CDM,272,RC,,,Outpatient,,,5327.4,3196.44,,3196.44,60,,421.16,Percent of Total Billed Charges,60% of Total Billed Charges,2397.33,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1491.67,28,,1296.944,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.92,Percent of Total Billed Charges,32% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,1917.86,36,,1667.504,Percent of Total Billed Charges,36% of Total Billed Charges,1917.86,36,,1667.504,Percent of Total Billed Charges,36% Total Bille Charges,1917.86,36,,1667.504,Percent of Total Billed Charges,36% of Total Billed Charges,3196.44,60,,2779.168,Percent of Total Billed Charges,60% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5327.4,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,768.21,14.42,,492.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3995.55,75,,1605.632,Percent of Total Billed Charges,75% of Total Billed Charges,2663.7,50,,776.408,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2663.7,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,2663.7,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3729.18,70,,1467.648,Percent of Total Billed Charges,70% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,745.84,14,,477.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5327.4,100,,2007.04,Percent of Total Billed Charges,100% of Total Billed Charges,34.36,5327.4,
313499 CABLE S&N E-FLEX,32150399,CDM,272,RC,,,Outpatient,,,2436.5,1461.90,,1461.9,60,,982.688,Percent of Total Billed Charges,60% of Total Billed Charges,1096.43,45,,68.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,2816.44,Percent of Total Billed Charges,28% of Total Billed Charges,34.36,32,,29.952,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,3621.144,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,3621.144,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,3621.144,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,6035.24,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,378.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,2889.152,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,23914.008,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,23914.008,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,23914.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,449.12,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,367.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,34.36,2436.5,
538776 S&N DISP BEARER,32150401,CDM,272,RC,,,Outpatient,,,167,100.20,,100.2,60,,163.872,Percent of Total Billed Charges,60% of Total Billed Charges,75.15,45,,66.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.76,28,,1046.896,Percent of Total Billed Charges,28% of Total Billed Charges,34.56,32,,29.952,Percent of Total Billed Charges,32% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,60.12,36,,1346.008,Percent of Total Billed Charges,36% of Total Billed Charges,60.12,36,,1346.008,Percent of Total Billed Charges,36% Total Bille Charges,60.12,36,,1346.008,Percent of Total Billed Charges,36% of Total Billed Charges,100.2,60,,2056.4,Percent of Total Billed Charges,60% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14.42,,1430.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.25,75,,951.216,Percent of Total Billed Charges,75% of Total Billed Charges,83.5,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,83.5,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.5,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,83.5,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.9,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,1388.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167,100,,1189.016,Percent of Total Billed Charges,100% of Total Billed Charges,23.38,167,
SLIT KNIFE 2.75MM ANGLED,32150403,CDM,272,RC,,,Outpatient,,,145.38,87.23,,87.23,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,65.42,45,,78.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.71,28,,423.36,Percent of Total Billed Charges,28% of Total Billed Charges,34.56,32,,30.08,Percent of Total Billed Charges,32% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,52.34,36,,544.32,Percent of Total Billed Charges,36% of Total Billed Charges,52.34,36,,544.32,Percent of Total Billed Charges,36% Total Bille Charges,52.34,36,,544.32,Percent of Total Billed Charges,36% of Total Billed Charges,87.23,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.38,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.96,14.42,,503.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.04,75,,764.088,Percent of Total Billed Charges,75% of Total Billed Charges,72.69,50,,23914.008,Percent of Total Billed Charges,50% of Total Billed Charges,72.69,50,,1706.976,Percent of Total Billed Charges,50% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.69,50,,1706.976,Percent of Total Billed Charges,50% of Total Billed Charges,72.69,50,,1706.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.77,70,,765.056,Percent of Total Billed Charges,70% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,20.35,14,,488.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.38,100,,955.112,Percent of Total Billed Charges,100% of Total Billed Charges,20.35,145.38,
108921 MESH PROLENE KEYHOLE,32150405,CDM,278,RC,C1781,HCPCS,Outpatient,,,223.95,134.37,,699.11,110,,3985.016,Percent of Total Billed Charges,110% of Total Billed Charges,100.78,45,,31.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.71,28,,1517.736,Percent of Total Billed Charges,28% of Total Billed Charges,34.68,32,,30.088,Percent of Total Billed Charges,32% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,80.62,36,,1951.376,Percent of Total Billed Charges,36% of Total Billed Charges,80.62,36,,1951.376,Percent of Total Billed Charges,36% Total Bille Charges,80.62,36,,1951.376,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.95,100,,152.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,32.29,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.16,80,,192.456,Percent of Total Billed Charges,80% of Total Billed Charges,111.98,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,111.98,50,,1312.856,Percent of Total Billed Charges,50% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.98,50,,1312.856,Percent of Total Billed Charges,50% of Total Billed Charges,111.98,50,,1312.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.77,70,,7622.112,Percent of Total Billed Charges,70% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,31.35,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.95,100,,256.608,Percent of Total Billed Charges,100% of Total Billed Charges,31.35,699.11,
0003608 MESH PROLENE LARGE,32150406,CDM,278,RC,C1781,HCPCS,Outpatient,,,340.85,204.51,,827.7,110,,1250.32,Percent of Total Billed Charges,110% of Total Billed Charges,153.38,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.44,28,,7233.072,Percent of Total Billed Charges,28% of Total Billed Charges,34.71,32,,30.184,Percent of Total Billed Charges,32% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,122.71,36,,9299.664,Percent of Total Billed Charges,36% of Total Billed Charges,122.71,36,,9299.664,Percent of Total Billed Charges,36% Total Bille Charges,122.71,36,,9299.664,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.85,100,,146.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,49.15,14.42,,304.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.68,80,,197.8,Percent of Total Billed Charges,80% of Total Billed Charges,170.43,50,,1706.976,Percent of Total Billed Charges,50% of Total Billed Charges,170.43,50,,4959.76,Percent of Total Billed Charges,50% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.43,50,,4959.76,Percent of Total Billed Charges,50% of Total Billed Charges,170.43,50,,4959.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.6,70,,210.136,Percent of Total Billed Charges,70% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.72,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.85,100,,263.736,Percent of Total Billed Charges,100% of Total Billed Charges,34.71,827.7,
387796 KIT NUVASIVE M5 XLIF,32150407,CDM,272,RC,,,Outpatient,,,2194.5,1316.70,,1316.7,60,,1444.608,Percent of Total Billed Charges,60% of Total Billed Charges,987.53,45,,18.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.46,28,,2486.848,Percent of Total Billed Charges,28% of Total Billed Charges,34.72,32,,30213,Percent of Total Billed Charges,32% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,790.02,36,,3197.376,Percent of Total Billed Charges,36% of Total Billed Charges,790.02,36,,3197.376,Percent of Total Billed Charges,36% Total Bille Charges,790.02,36,,3197.376,Percent of Total Billed Charges,36% of Total Billed Charges,1316.7,60,,4884.88,Percent of Total Billed Charges,60% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2194.5,100,,173.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,316.45,14.42,,807.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1645.88,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,1097.25,50,,1312.856,Percent of Total Billed Charges,50% of Total Billed Charges,1097.25,50,,1744.368,Percent of Total Billed Charges,50% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.25,50,,1744.368,Percent of Total Billed Charges,50% of Total Billed Charges,1097.25,50,,1744.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1536.15,70,,1977.912,Percent of Total Billed Charges,70% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,307.23,14,,783.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2194.5,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,34.72,2194.5,
693620 LEAD KIT,32150409,CDM,278,RC,C1778,HCPCS,Outpatient,,,6999.33,4199.60,,8281.86,110,,1444.328,Percent of Total Billed Charges,110% of Total Billed Charges,3149.7,45,,516.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1959.81,28,,1962.456,Percent of Total Billed Charges,28% of Total Billed Charges,34.82,32,,30.608,Percent of Total Billed Charges,32% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,2519.76,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,2519.76,36,,2523.16,Percent of Total Billed Charges,36% Total Bille Charges,2519.76,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,3849.63,55,,4205.264,Percent of Total Billed Charges,55% Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6999.33,100,,70.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,1009.3,14.42,,247.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5599.46,80,,7301.632,Percent of Total Billed Charges,80% of Total Billed Charges,3499.67,50,,4959.76,Percent of Total Billed Charges,50% of Total Billed Charges,3499.67,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3499.67,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,3499.67,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4899.53,70,,540.432,Percent of Total Billed Charges,70% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,979.91,14,,240.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6999.33,100,,9127.04,Percent of Total Billed Charges,100% of Total Billed Charges,34.82,8281.86,
728303 PARIETEX VENTRAL PATCH,32150410,CDM,278,RC,C1781,HCPCS,Outpatient,,,1132.56,679.54,,1698.58,110,,849.248,Percent of Total Billed Charges,110% of Total Billed Charges,509.65,45,,1105.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.12,28,,218.4,Percent of Total Billed Charges,28% of Total Billed Charges,34.86,32,,30.624,Percent of Total Billed Charges,32% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,407.72,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,407.72,36,,280.8,Percent of Total Billed Charges,36% Total Bille Charges,407.72,36,,280.8,Percent of Total Billed Charges,36% of Total Billed Charges,622.91,55,,468,Percent of Total Billed Charges,55% Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1132.56,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,163.32,14.42,,163.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,906.05,80,,211.704,Percent of Total Billed Charges,80% of Total Billed Charges,566.28,50,,1744.368,Percent of Total Billed Charges,50% of Total Billed Charges,566.28,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,566.28,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,566.28,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,792.79,70,,17130.96,Percent of Total Billed Charges,70% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,158.56,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1132.56,100,,282.272,Percent of Total Billed Charges,100% of Total Billed Charges,34.86,1698.58,
501416 REAMER ARTHREX HEADED,32150411,CDM,272,RC,,,Outpatient,,,998.97,599.38,,599.38,60,,70.344,Percent of Total Billed Charges,60% of Total Billed Charges,449.54,45,,298.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.71,28,,877.496,Percent of Total Billed Charges,28% of Total Billed Charges,35.1,32,,30.656,Percent of Total Billed Charges,32% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,359.63,36,,1128.208,Percent of Total Billed Charges,36% of Total Billed Charges,359.63,36,,1128.208,Percent of Total Billed Charges,36% Total Bille Charges,359.63,36,,1128.208,Percent of Total Billed Charges,36% of Total Billed Charges,599.38,60,,1880.344,Percent of Total Billed Charges,60% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,998.97,100,,41.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,144.05,14.42,,145.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,749.23,75,,1242.248,Percent of Total Billed Charges,75% of Total Billed Charges,499.49,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,2798.64,Percent of Total Billed Charges,50% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.49,50,,2798.64,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,2798.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.28,70,,506.08,Percent of Total Billed Charges,70% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,141.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,998.97,100,,1552.808,Percent of Total Billed Charges,100% of Total Billed Charges,35.1,998.97,
290993 STRATTICE STOMA PATCH,32150413,CDM,278,RC,Q4100,HCPCS,Outpatient,,,2508.8,1505.28,,2759.68,110,,479.504,Percent of Total Billed Charges,110% of Total Billed Charges,1128.96,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,702.46,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,35.1,32,,30.696,Percent of Total Billed Charges,32% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,903.17,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,903.17,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,903.17,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,1379.84,55,,60.4,Percent of Total Billed Charges,55% Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2508.8,100,,1147.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,361.77,14.42,,410.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2007.04,80,,4333.728,Percent of Total Billed Charges,80% of Total Billed Charges,1254.4,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,1254.4,50,,859.528,Percent of Total Billed Charges,50% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1254.4,50,,859.528,Percent of Total Billed Charges,50% of Total Billed Charges,1254.4,50,,859.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1756.16,70,,2093.84,Percent of Total Billed Charges,70% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,351.23,14,,398.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2508.8,100,,5778.304,Percent of Total Billed Charges,100% of Total Billed Charges,35.1,2759.68,
493726 KIT SPECIALTY ADVANCED,32150417,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,245.376,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,27.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,35.14,32,,3089.68,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,421.024,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2456.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,1444.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,561.368,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,2798.64,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,239.504,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1402.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,35.14,375,
469727 CEMENT KYPHONE EXPEDE,32150418,CDM,278,RC,C1713,HCPCS,Outpatient,,,1486.27,891.76,,1952.16,110,,332.272,Percent of Total Billed Charges,110% of Total Billed Charges,668.82,45,,29.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.16,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,3521.23,32,,3093.36,Percent of Total Billed Charges,32% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,535.06,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,535.06,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,535.06,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,817.45,55,,421.024,Percent of Total Billed Charges,55% Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1486.27,100,,662.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,214.32,14.42,,26.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.02,80,,38262.408,Percent of Total Billed Charges,80% of Total Billed Charges,743.14,50,,859.528,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,505.68,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.14,50,,505.68,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,505.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1040.39,70,,4356.352,Percent of Total Billed Charges,70% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,26.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1486.27,100,,47828.008,Percent of Total Billed Charges,100% of Total Billed Charges,208.08,3521.23,
694999 XEMPLIFI DBM GEL,32150419,CDM,278,RC,C1713,HCPCS,Outpatient,,,1193.89,716.33,,1630.54,110,,140.712,Percent of Total Billed Charges,110% of Total Billed Charges,537.25,45,,125.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,334.29,28,,26.776,Percent of Total Billed Charges,28% of Total Billed Charges,3552.64,32,,3121.408,Percent of Total Billed Charges,32% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,429.8,36,,34.432,Percent of Total Billed Charges,36% of Total Billed Charges,429.8,36,,34.432,Percent of Total Billed Charges,36% Total Bille Charges,429.8,36,,34.432,Percent of Total Billed Charges,36% of Total Billed Charges,656.64,55,,60.4,Percent of Total Billed Charges,55% Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1193.89,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,172.16,14.42,,112.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,955.11,80,,2541,Percent of Total Billed Charges,80% of Total Billed Charges,596.95,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,596.95,50,,1423.656,Percent of Total Billed Charges,50% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.95,50,,1423.656,Percent of Total Billed Charges,50% of Total Billed Charges,596.95,50,,1423.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.72,70,,1179.096,Percent of Total Billed Charges,70% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,167.14,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1193.89,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,167.14,3552.64,
0007951 GUIDEWIRE SYNTHES,32150420,CDM,272,RC,C1769,HCPCS,Outpatient,,,320.76,192.46,,55.13,100,,176.264,Fee Schedule,100% of Aetna Fee Schedule,144.34,45,,89.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.81,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,3595.07,32,,3128.32,Percent of Total Billed Charges,32% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,115.47,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,115.47,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,115.47,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,60,,4205.264,Percent of Total Billed Charges,60% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.76,100,,62.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,46.25,14.42,,543.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.57,75,,2560.464,Percent of Total Billed Charges,75% of Total Billed Charges,160.38,50,,505.68,Percent of Total Billed Charges,50% of Total Billed Charges,160.38,50,,5007.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.38,50,,5007.6,Percent of Total Billed Charges,50% of Total Billed Charges,160.38,50,,5007.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.53,70,,17130.96,Percent of Total Billed Charges,70% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,527.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.76,100,,3413.952,Percent of Total Billed Charges,100% of Total Billed Charges,44.91,3595.07,
296634 ELEVATOR BOSTON SCIEN,32150422,CDM,272,RC,,,Outpatient,,,329.67,197.80,,197.8,60,,245.376,Percent of Total Billed Charges,60% of Total Billed Charges,148.35,45,,951.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.31,28,,1962.456,Percent of Total Billed Charges,28% of Total Billed Charges,3604.32,32,,3174.248,Percent of Total Billed Charges,32% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,118.68,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,118.68,36,,2523.16,Percent of Total Billed Charges,36% Total Bille Charges,118.68,36,,2523.16,Percent of Total Billed Charges,36% of Total Billed Charges,197.8,60,,145.656,Percent of Total Billed Charges,60% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.67,100,,65.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14.42,,65.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.25,75,,2100.56,Percent of Total Billed Charges,75% of Total Billed Charges,164.84,50,,1423.656,Percent of Total Billed Charges,50% of Total Billed Charges,164.84,50,,93.408,Percent of Total Billed Charges,50% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.84,50,,93.408,Percent of Total Billed Charges,50% of Total Billed Charges,164.84,50,,93.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.77,70,,1481.352,Percent of Total Billed Charges,70% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,46.15,14,,63.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.67,100,,2625.704,Percent of Total Billed Charges,100% of Total Billed Charges,46.15,3604.32,
231342 EXPANDER BREAST TI,32150423,CDM,278,RC,C1789,HCPCS,Outpatient,,,4235,2541.00,,5060.82,110,,140.712,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,113.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,67.976,Percent of Total Billed Charges,28% of Total Billed Charges,3650.82,32,,3187.392,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,87.392,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,87.392,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,87.392,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,684.856,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,278.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,71.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,7935.616,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,5007.6,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1541.544,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,69.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,9919.52,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,5060.82,
495152 ALLODERM TISSUE RTU,32150424,CDM,278,RC,,,Outpatient,,,11408.8,6845.28,,12549.68,110,,172.88,Percent of Total Billed Charges,110% of Total Billed Charges,5133.96,45,,43.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3194.46,28,,348.656,Percent of Total Billed Charges,28% of Total Billed Charges,3674.35,32,,3191.552,Percent of Total Billed Charges,32% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,4107.17,36,,448.272,Percent of Total Billed Charges,36% of Total Billed Charges,4107.17,36,,448.272,Percent of Total Billed Charges,36% Total Bille Charges,4107.17,36,,448.272,Percent of Total Billed Charges,36% of Total Billed Charges,6274.84,55,,35.792,Percent of Total Billed Charges,55% Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11408.8,100,,198.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1645.15,14.42,,8.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9127.04,80,,2790.992,Percent of Total Billed Charges,80% of Total Billed Charges,5704.4,50,,93.408,Percent of Total Billed Charges,50% of Total Billed Charges,5704.4,50,,1884.096,Percent of Total Billed Charges,50% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5704.4,50,,1884.096,Percent of Total Billed Charges,50% of Total Billed Charges,5704.4,50,,1884.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7986.16,70,,2087.008,Percent of Total Billed Charges,70% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,1597.23,14,,7.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11408.8,100,,3488.736,Percent of Total Billed Charges,100% of Total Billed Charges,1597.23,12549.68,
749054 SET INTRODUCER,32150429,CDM,272,RC,C1892,HCPCS,Outpatient,,,352.84,211.70,,0.57,100,,128.312,Fee Schedule,100% of Aetna Fee Schedule,158.78,45,,556.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.8,28,,16.704,Percent of Total Billed Charges,28% of Total Billed Charges,3680,32,,3204.864,Percent of Total Billed Charges,32% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,127.02,36,,21.472,Percent of Total Billed Charges,36% of Total Billed Charges,127.02,36,,21.472,Percent of Total Billed Charges,36% Total Bille Charges,127.02,36,,21.472,Percent of Total Billed Charges,36% of Total Billed Charges,211.7,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.84,100,,2114.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14.42,,150.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.63,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,176.42,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,176.42,50,,227.064,Percent of Total Billed Charges,50% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.42,50,,227.064,Percent of Total Billed Charges,50% of Total Billed Charges,176.42,50,,227.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.99,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,49.4,14,,146.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.84,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,3680,
488657 SUTURE ANCHOR,32150430,CDM,278,RC,C1713,HCPCS,Outpatient,,,1941.01,1164.61,,2452.37,110,,138.2,Percent of Total Billed Charges,110% of Total Billed Charges,873.45,45,,570.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.48,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,3698.67,32,,3218.792,Percent of Total Billed Charges,32% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,698.76,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,698.76,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,698.76,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,1067.56,55,,85.408,Percent of Total Billed Charges,55% Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1941.01,100,,252.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,279.89,14.42,,2566.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.81,80,,1691.288,Percent of Total Billed Charges,80% of Total Billed Charges,970.51,50,,1884.096,Percent of Total Billed Charges,50% of Total Billed Charges,970.51,50,,249.376,Percent of Total Billed Charges,50% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,970.51,50,,249.376,Percent of Total Billed Charges,50% of Total Billed Charges,970.51,50,,249.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1358.71,70,,33976.408,Percent of Total Billed Charges,70% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,271.74,14,,2492,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1941.01,100,,2114.112,Percent of Total Billed Charges,100% of Total Billed Charges,271.74,3698.67,
227090 PACEMAKER DUAL CHAMBER,32150433,CDM,275,RC,C1785,HCPCS,Outpatient,,,7222.88,4333.73,,8220.59,110,,128.312,Percent of Total Billed Charges,110% of Total Billed Charges,3250.3,45,,3535.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2022.41,28,,39.856,Percent of Total Billed Charges,28% of Total Billed Charges,3698.67,32,,3243.896,Percent of Total Billed Charges,32% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,2600.24,36,,51.248,Percent of Total Billed Charges,36% of Total Billed Charges,2600.24,36,,51.248,Percent of Total Billed Charges,36% Total Bille Charges,2600.24,36,,51.248,Percent of Total Billed Charges,36% of Total Billed Charges,3972.58,55,,1443.016,Percent of Total Billed Charges,55% Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7222.88,100,,95.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1041.54,14.42,,378.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5417.16,75,,4477.824,Percent of Total Billed Charges,75% of Total Billed Charges,3611.44,50,,227.064,Percent of Total Billed Charges,50% of Total Billed Charges,3611.44,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3611.44,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,3611.44,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5056.02,70,,21175.776,Percent of Total Billed Charges,70% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,1011.2,14,,367.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7222.88,100,,5597.28,Percent of Total Billed Charges,100% of Total Billed Charges,1011.2,8220.59,
652345 CABLE ST JUDE,32150435,CDM,278,RC,C1897,HCPCS,Outpatient,,,877.14,526.28,,1732.79,110,,138.2,Percent of Total Billed Charges,110% of Total Billed Charges,394.71,45,,1474.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,734.624,Percent of Total Billed Charges,28% of Total Billed Charges,3713.07,32,,3246.2,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,944.52,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,944.52,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,944.52,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,55,,865.448,Percent of Total Billed Charges,55% Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,1236.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,71.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,701.71,80,,1289.296,Percent of Total Billed Charges,80% of Total Billed Charges,438.57,50,,249.376,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,6632.08,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,1719.056,Percent of Total Billed Charges,100% of Total Billed Charges,122.8,3713.07,
705043 GENERATOR ST. JUDE,32150436,CDM,278,RC,C1820,HCPCS,Outpatient,,,59785.01,35871.01,,67393.69,110,,1310.608,Percent of Total Billed Charges,110% of Total Billed Charges,26903.25,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16739.8,28,,403.872,Percent of Total Billed Charges,28% of Total Billed Charges,3714.43,32,,3254.432,Percent of Total Billed Charges,32% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,21522.6,36,,519.264,Percent of Total Billed Charges,36% of Total Billed Charges,21522.6,36,,519.264,Percent of Total Billed Charges,36% Total Bille Charges,21522.6,36,,519.264,Percent of Total Billed Charges,36% of Total Billed Charges,32881.76,55,,7963.856,Percent of Total Billed Charges,55% Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59785.01,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8621,14.42,,81.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47828.01,80,,904.432,Percent of Total Billed Charges,80% of Total Billed Charges,29892.51,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,29892.51,50,,8900,Percent of Total Billed Charges,50% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29892.51,50,,8900,Percent of Total Billed Charges,50% of Total Billed Charges,29892.51,50,,8900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41849.51,70,,12969.6,Percent of Total Billed Charges,70% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,8369.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59785.01,100,,1130.536,Percent of Total Billed Charges,100% of Total Billed Charges,3714.43,67393.69,
705042 CHARGING SYSTEM ST,32150437,CDM,272,RC,C1787,HCPCS,Outpatient,,,4235,2541.00,,59.4,100,,519.184,Fee Schedule,100% of Aetna Fee Schedule,1905.75,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,4054.328,Percent of Total Billed Charges,28% of Total Billed Charges,3729.92,32,,3254.432,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,5212.704,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,5212.704,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,5212.704,Percent of Total Billed Charges,36% of Total Billed Charges,2541,60,,1818.96,Percent of Total Billed Charges,60% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,7855.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,81.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,75,,758.52,Percent of Total Billed Charges,75% of Total Billed Charges,2117.5,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1311.056,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,1311.056,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1311.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1091.552,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,1011.36,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,4235,
705108 PROGRAMMER ST,32150438,CDM,272,RC,C1787,HCPCS,Outpatient,,,4267.44,2560.46,,59.4,100,,256.608,Fee Schedule,100% of Aetna Fee Schedule,1920.35,45,,342.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1194.88,28,,926.016,Percent of Total Billed Charges,28% of Total Billed Charges,3738.46,32,,3274.752,Percent of Total Billed Charges,32% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1536.28,36,,1190.592,Percent of Total Billed Charges,36% of Total Billed Charges,1536.28,36,,1190.592,Percent of Total Billed Charges,36% Total Bille Charges,1536.28,36,,1190.592,Percent of Total Billed Charges,36% of Total Billed Charges,2560.46,60,,1360.28,Percent of Total Billed Charges,60% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4267.44,100,,3276.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,615.36,14.42,,81.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3200.58,75,,2135.48,Percent of Total Billed Charges,75% of Total Billed Charges,2133.72,50,,8900,Percent of Total Billed Charges,50% of Total Billed Charges,2133.72,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2133.72,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,2133.72,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2987.21,70,,1671.984,Percent of Total Billed Charges,70% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,597.44,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4267.44,100,,2847.304,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,4267.44,
632042 BREAST SMOOTH ROUND,32150439,CDM,278,RC,C1789,HCPCS,Outpatient,,,3282.13,1969.28,,4012.66,110,,553.88,Percent of Total Billed Charges,110% of Total Billed Charges,1476.96,45,,489.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,919,28,,692.504,Percent of Total Billed Charges,28% of Total Billed Charges,3742.34,32,,3294.888,Percent of Total Billed Charges,32% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,1181.57,36,,890.368,Percent of Total Billed Charges,36% of Total Billed Charges,1181.57,36,,890.368,Percent of Total Billed Charges,36% Total Bille Charges,1181.57,36,,890.368,Percent of Total Billed Charges,36% of Total Billed Charges,1805.17,55,,4337.128,Percent of Total Billed Charges,55% Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3282.13,100,,1559.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,473.28,14.42,,267.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2625.7,80,,8012.16,Percent of Total Billed Charges,80% of Total Billed Charges,1641.07,50,,1311.056,Percent of Total Billed Charges,50% of Total Billed Charges,1641.07,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1641.07,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,1641.07,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2297.49,70,,15456,Percent of Total Billed Charges,70% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,459.5,14,,259.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3282.13,100,,10015.2,Percent of Total Billed Charges,100% of Total Billed Charges,459.5,4012.66,
745844 ALLODERM CONTOUR PERFOR,32150442,CDM,278,RC,,,Outpatient,,,12399.4,7439.64,,13639.34,110,,560.224,Percent of Total Billed Charges,110% of Total Billed Charges,5579.73,45,,167.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3471.83,28,,2207.992,Percent of Total Billed Charges,28% of Total Billed Charges,3743.17,32,,3294.888,Percent of Total Billed Charges,32% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,4463.78,36,,2838.848,Percent of Total Billed Charges,36% of Total Billed Charges,4463.78,36,,2838.848,Percent of Total Billed Charges,36% Total Bille Charges,4463.78,36,,2838.848,Percent of Total Billed Charges,36% of Total Billed Charges,6819.67,55,,91.8,Percent of Total Billed Charges,55% Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12399.4,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1787.99,14.42,,81.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9919.52,80,,140.112,Percent of Total Billed Charges,80% of Total Billed Charges,6199.7,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,6199.7,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6199.7,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,6199.7,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8679.58,70,,5238.648,Percent of Total Billed Charges,70% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,1735.92,14,,78.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12399.4,100,,186.816,Percent of Total Billed Charges,100% of Total Billed Charges,1735.92,13639.34,
454664 TISSUE EXPANDER,32150443,CDM,278,RC,C1789,HCPCS,Outpatient,,,4360.92,2616.55,,5199.33,110,,248.456,Percent of Total Billed Charges,110% of Total Billed Charges,1962.41,45,,419.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1221.06,28,,42.84,Percent of Total Billed Charges,28% of Total Billed Charges,3748.35,32,,3.072,Percent of Total Billed Charges,32% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,1569.93,36,,55.08,Percent of Total Billed Charges,36% of Total Billed Charges,1569.93,36,,55.08,Percent of Total Billed Charges,36% Total Bille Charges,1569.93,36,,55.08,Percent of Total Billed Charges,36% of Total Billed Charges,2398.51,55,,115.032,Percent of Total Billed Charges,55% Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4360.92,100,,760.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,628.84,14.42,,192.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3488.74,80,,624,Percent of Total Billed Charges,80% of Total Billed Charges,2180.46,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,2180.46,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2180.46,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,2180.46,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3052.64,70,,3140.68,Percent of Total Billed Charges,70% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,610.53,14,,187.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4360.92,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,610.53,5199.33,
501736 MATRIX GLOBUS CONDUCT,32150444,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235,2541.00,,4975.76,110,,208.4,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,27.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,53.68,Percent of Total Billed Charges,28% of Total Billed Charges,3778.88,32,,3.08,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,69.016,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,69.016,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,69.016,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,102.976,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,1087.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,184.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,3014.544,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,926.856,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,926.856,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,926.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,179.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,3768.184,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,4975.76,
191127 PUTTY MEDTRONIC 5CC,32150446,CDM,278,RC,C1713,HCPCS,Outpatient,,,2642.64,1585.58,,3224.16,110,,256.608,Percent of Total Billed Charges,110% of Total Billed Charges,1189.19,45,,881.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,739.94,28,,38.744,Percent of Total Billed Charges,28% of Total Billed Charges,3779.68,32,,3.088,Percent of Total Billed Charges,32% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,951.35,36,,49.816,Percent of Total Billed Charges,36% of Total Billed Charges,951.35,36,,49.816,Percent of Total Billed Charges,36% Total Bille Charges,951.35,36,,49.816,Percent of Total Billed Charges,36% of Total Billed Charges,1453.45,55,,210.816,Percent of Total Billed Charges,55% Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2642.64,100,,371.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,381.07,14.42,,397.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2114.11,80,,340.6,Percent of Total Billed Charges,80% of Total Billed Charges,1321.32,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,1321.32,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1321.32,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,1321.32,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1849.85,70,,515.696,Percent of Total Billed Charges,70% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,386.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2642.64,100,,454.128,Percent of Total Billed Charges,100% of Total Billed Charges,369.97,3779.68,
396325 MESH INTEGRA,32150447,CDM,278,RC,,,Outpatient,,,6996.6,4197.96,,7696.26,110,,350.392,Percent of Total Billed Charges,110% of Total Billed Charges,3148.47,45,,389.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1959.05,28,,48.056,Percent of Total Billed Charges,28% of Total Billed Charges,3782.4,32,,3.096,Percent of Total Billed Charges,32% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,2518.78,36,,61.784,Percent of Total Billed Charges,36% of Total Billed Charges,2518.78,36,,61.784,Percent of Total Billed Charges,36% Total Bille Charges,2518.78,36,,61.784,Percent of Total Billed Charges,36% of Total Billed Charges,3848.13,55,,202.616,Percent of Total Billed Charges,55% Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6996.6,100,,932.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,1008.91,14.42,,166.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5597.28,80,,398.992,Percent of Total Billed Charges,80% of Total Billed Charges,3498.3,50,,926.856,Percent of Total Billed Charges,50% of Total Billed Charges,3498.3,50,,668.872,Percent of Total Billed Charges,50% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3498.3,50,,668.872,Percent of Total Billed Charges,50% of Total Billed Charges,3498.3,50,,668.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4897.62,70,,5241.6,Percent of Total Billed Charges,70% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,979.52,14,,161.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6996.6,100,,498.744,Percent of Total Billed Charges,100% of Total Billed Charges,979.52,7696.26,
771666 ELECT ROLLER 12/30,32150448,CDM,272,RC,,,Outpatient,,,2148.82,1289.29,,1289.29,60,,243.728,Percent of Total Billed Charges,60% of Total Billed Charges,966.97,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,601.67,28,,38.744,Percent of Total Billed Charges,28% of Total Billed Charges,3789.76,32,,3.104,Percent of Total Billed Charges,32% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,773.58,36,,49.816,Percent of Total Billed Charges,36% of Total Billed Charges,773.58,36,,49.816,Percent of Total Billed Charges,36% Total Bille Charges,773.58,36,,49.816,Percent of Total Billed Charges,36% of Total Billed Charges,1289.29,60,,97.48,Percent of Total Billed Charges,60% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2148.82,100,,62.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,309.86,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1611.62,75,,41.64,Percent of Total Billed Charges,75% of Total Billed Charges,1074.41,50,,281.584,Percent of Total Billed Charges,50% of Total Billed Charges,1074.41,50,,640.088,Percent of Total Billed Charges,50% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1074.41,50,,640.088,Percent of Total Billed Charges,50% of Total Billed Charges,1074.41,50,,640.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1504.17,70,,1552.216,Percent of Total Billed Charges,70% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,300.83,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2148.82,100,,55.52,Percent of Total Billed Charges,100% of Total Billed Charges,300.83,3789.76,
273624 POWERPORT BARD STANDARD,32150449,CDM,278,RC,C1788,HCPCS,Outpatient,,,1413.17,847.90,,2163.3,110,,252.04,Percent of Total Billed Charges,110% of Total Billed Charges,635.93,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.69,28,,98.384,Percent of Total Billed Charges,28% of Total Billed Charges,3801.44,32,,3.104,Percent of Total Billed Charges,32% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,508.74,36,,126.488,Percent of Total Billed Charges,36% of Total Billed Charges,508.74,36,,126.488,Percent of Total Billed Charges,36% Total Bille Charges,508.74,36,,126.488,Percent of Total Billed Charges,36% of Total Billed Charges,777.24,55,,479.504,Percent of Total Billed Charges,55% Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1959.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,203.78,14.42,,784.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1130.54,80,,783,Percent of Total Billed Charges,80% of Total Billed Charges,706.59,50,,668.872,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,1378.976,Percent of Total Billed Charges,50% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.59,50,,1378.976,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,1378.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,989.22,70,,7628.984,Percent of Total Billed Charges,70% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,761.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1044,Percent of Total Billed Charges,100% of Total Billed Charges,197.84,3801.44,
OLYMPUS LOOP GYRUS ACMI,32150451,CDM,272,RC,A4649,HCPCS,Outpatient,,,1264.2,758.52,,758.52,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,568.89,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.98,28,,94.552,Percent of Total Billed Charges,28% of Total Billed Charges,3806.88,32,,3.12,Percent of Total Billed Charges,32% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,455.11,36,,121.568,Percent of Total Billed Charges,36% of Total Billed Charges,455.11,36,,121.568,Percent of Total Billed Charges,36% Total Bille Charges,455.11,36,,121.568,Percent of Total Billed Charges,36% of Total Billed Charges,758.52,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1264.2,100,,866.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,182.3,14.42,,1607.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,948.15,75,,14240,Percent of Total Billed Charges,75% of Total Billed Charges,632.1,50,,640.088,Percent of Total Billed Charges,50% of Total Billed Charges,632.1,50,,576.888,Percent of Total Billed Charges,50% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.1,50,,576.888,Percent of Total Billed Charges,50% of Total Billed Charges,632.1,50,,576.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,884.94,70,,5696.048,Percent of Total Billed Charges,70% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,176.99,14,,1560.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1264.2,100,,17800,Percent of Total Billed Charges,100% of Total Billed Charges,176.99,3806.88,
771919 RELOAD COVIDIEN REINFOR,32150453,CDM,272,RC,,,Outpatient,,,3559.13,2135.48,,2135.48,60,,556.12,Percent of Total Billed Charges,60% of Total Billed Charges,1601.61,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,996.56,28,,45.496,Percent of Total Billed Charges,28% of Total Billed Charges,3826.88,32,,3.12,Percent of Total Billed Charges,32% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,1281.29,36,,58.488,Percent of Total Billed Charges,36% of Total Billed Charges,1281.29,36,,58.488,Percent of Total Billed Charges,36% Total Bille Charges,1281.29,36,,58.488,Percent of Total Billed Charges,36% of Total Billed Charges,2135.48,60,,382.8,Percent of Total Billed Charges,60% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3559.13,100,,68.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,513.23,14.42,,359.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2669.35,75,,2097.688,Percent of Total Billed Charges,75% of Total Billed Charges,1779.57,50,,1378.976,Percent of Total Billed Charges,50% of Total Billed Charges,1779.57,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.57,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,1779.57,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2491.39,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,498.28,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3559.13,100,,2622.112,Percent of Total Billed Charges,100% of Total Billed Charges,498.28,3826.88,
576277 ALLODERM CONTOUR TISSUE,32150454,CDM,278,RC,,,Outpatient,,,12519,7511.40,,13770.9,110,,79.768,Percent of Total Billed Charges,110% of Total Billed Charges,5633.55,45,,105.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3505.32,28,,223.768,Percent of Total Billed Charges,28% of Total Billed Charges,3827.58,32,,3.12,Percent of Total Billed Charges,32% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,4506.84,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,4506.84,36,,287.704,Percent of Total Billed Charges,36% Total Bille Charges,4506.84,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,6885.45,55,,249.92,Percent of Total Billed Charges,55% Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12519,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1805.24,14.42,,941.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10015.2,80,,370.496,Percent of Total Billed Charges,80% of Total Billed Charges,6259.5,50,,576.888,Percent of Total Billed Charges,50% of Total Billed Charges,6259.5,50,,2719.2,Percent of Total Billed Charges,50% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6259.5,50,,2719.2,Percent of Total Billed Charges,50% of Total Billed Charges,6259.5,50,,2719.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8763.3,70,,996.456,Percent of Total Billed Charges,70% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,1752.66,14,,913.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12519,100,,493.992,Percent of Total Billed Charges,100% of Total Billed Charges,1752.66,13770.9,
555171 SUTURE VLOC 180,32150456,CDM,272,RC,,,Outpatient,,,233.52,140.11,,140.11,60,,50.128,Percent of Total Billed Charges,60% of Total Billed Charges,105.08,45,,2263.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.39,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,3.53,32,,3.128,Percent of Total Billed Charges,32% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,84.07,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,84.07,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,84.07,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,140.11,60,,6234.232,Percent of Total Billed Charges,60% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.52,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,33.67,14.42,,1590.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.14,75,,422.368,Percent of Total Billed Charges,75% of Total Billed Charges,116.76,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,116.76,50,,5574.36,Percent of Total Billed Charges,50% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.76,50,,5574.36,Percent of Total Billed Charges,50% of Total Billed Charges,116.76,50,,5574.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.46,70,,675.424,Percent of Total Billed Charges,70% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,32.69,14,,1544.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.52,100,,563.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.53,233.52,
549705 ANCHOR ARTHREX,32150457,CDM,278,RC,C1713,HCPCS,Outpatient,,,975,585.00,,1389.76,110,,50.608,Percent of Total Billed Charges,110% of Total Billed Charges,438.75,45,,3752.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,194.88,Percent of Total Billed Charges,28% of Total Billed Charges,3.54,32,,3.136,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,250.56,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,250.56,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,250.56,Percent of Total Billed Charges,36% of Total Billed Charges,536.25,55,,379.008,Percent of Total Billed Charges,55% Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,2376.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780,80,,422.368,Percent of Total Billed Charges,80% of Total Billed Charges,487.5,50,,2719.2,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,941.464,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,2307.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,563.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.54,1389.76,
313487 CEMENT BONE SUBSTITUTE,32150458,CDM,278,RC,C1713,HCPCS,Outpatient,,,4710.23,2826.14,,5498.51,110,,61.912,Percent of Total Billed Charges,110% of Total Billed Charges,2119.6,45,,3448.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1318.86,28,,127.232,Percent of Total Billed Charges,28% of Total Billed Charges,3.56,32,,3.144,Percent of Total Billed Charges,32% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,1695.68,36,,163.584,Percent of Total Billed Charges,36% of Total Billed Charges,1695.68,36,,163.584,Percent of Total Billed Charges,36% Total Bille Charges,1695.68,36,,163.584,Percent of Total Billed Charges,36% of Total Billed Charges,2590.63,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4710.23,100,,235.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,679.22,14.42,,193.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3768.18,80,,422.368,Percent of Total Billed Charges,80% of Total Billed Charges,2355.12,50,,5574.36,Percent of Total Billed Charges,50% of Total Billed Charges,2355.12,50,,3263.04,Percent of Total Billed Charges,50% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2355.12,50,,3263.04,Percent of Total Billed Charges,50% of Total Billed Charges,2355.12,50,,3263.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3297.16,70,,258.632,Percent of Total Billed Charges,70% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,659.43,14,,188.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4710.23,100,,563.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.56,5498.51,
780683 CATH VENTRICULAR CSF,32150459,CDM,272,RC,C1729,HCPCS,Outpatient,,,567.66,340.60,,11.1,100,,50.08,Fee Schedule,100% of Aetna Fee Schedule,255.45,45,,415.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.94,28,,3173.792,Percent of Total Billed Charges,28% of Total Billed Charges,3.58,32,,3.16,Percent of Total Billed Charges,32% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,204.36,36,,4080.584,Percent of Total Billed Charges,36% of Total Billed Charges,204.36,36,,4080.584,Percent of Total Billed Charges,36% Total Bille Charges,204.36,36,,4080.584,Percent of Total Billed Charges,36% of Total Billed Charges,340.6,60,,7749.72,Percent of Total Billed Charges,60% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,567.66,100,,5030.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,81.86,14.42,,209.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.75,75,,1390.288,Percent of Total Billed Charges,75% of Total Billed Charges,283.83,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,283.83,50,,5514.536,Percent of Total Billed Charges,50% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.83,50,,5514.536,Percent of Total Billed Charges,50% of Total Billed Charges,283.83,50,,5514.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.36,70,,1159.2,Percent of Total Billed Charges,70% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.47,14,,203.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567.66,100,,1853.712,Percent of Total Billed Charges,100% of Total Billed Charges,3.58,567.66,
414078 CATHETER CODMAN HOLTER,32150461,CDM,278,RC,C1729,HCPCS,Outpatient,,,623.43,374.06,,696.87,110,,39.416,Percent of Total Billed Charges,110% of Total Billed Charges,280.54,45,,233.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.56,28,,176.872,Percent of Total Billed Charges,28% of Total Billed Charges,3.59,32,,3.16,Percent of Total Billed Charges,32% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,224.43,36,,227.408,Percent of Total Billed Charges,36% of Total Billed Charges,224.43,36,,227.408,Percent of Total Billed Charges,36% Total Bille Charges,224.43,36,,227.408,Percent of Total Billed Charges,36% of Total Billed Charges,342.89,55,,2284.128,Percent of Total Billed Charges,55% Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.43,100,,8339.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.9,14.42,,163.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,498.74,80,,422.368,Percent of Total Billed Charges,80% of Total Billed Charges,311.72,50,,3263.04,Percent of Total Billed Charges,50% of Total Billed Charges,311.72,50,,8240.8,Percent of Total Billed Charges,50% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.72,50,,8240.8,Percent of Total Billed Charges,50% of Total Billed Charges,311.72,50,,8240.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.4,70,,1183.144,Percent of Total Billed Charges,70% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.28,14,,158.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,623.43,100,,563.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.59,696.87,
BINDER ABD 4 PNL 72-96 IN LF,32150463,CDM,271,RC,,,Outpatient,,,69.4,41.64,,41.64,60,,47.36,Percent of Total Billed Charges,60% of Total Billed Charges,31.23,45,,173.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.43,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,3.6,32,,3.168,Percent of Total Billed Charges,32% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,24.98,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,24.98,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,24.98,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,41.64,60,,723.64,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.4,100,,7662.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,10.01,14.42,,74.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.05,75,,1003.304,Percent of Total Billed Charges,75% of Total Billed Charges,34.7,50,,5514.536,Percent of Total Billed Charges,50% of Total Billed Charges,34.7,50,,672.272,Percent of Total Billed Charges,50% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.7,50,,672.272,Percent of Total Billed Charges,50% of Total Billed Charges,34.7,50,,672.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.58,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14,,72.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.4,100,,1337.736,Percent of Total Billed Charges,100% of Total Billed Charges,3.6,69.4,
KIT KCI PREVENA INCISION,32150472,CDM,272,RC,,,Outpatient,,,1305,783.00,,783,60,,1447.68,Percent of Total Billed Charges,60% of Total Billed Charges,587.25,45,,395.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.4,28,,3616.536,Percent of Total Billed Charges,28% of Total Billed Charges,3.64,32,,3.168,Percent of Total Billed Charges,32% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,469.8,36,,4649.832,Percent of Total Billed Charges,36% of Total Billed Charges,469.8,36,,4649.832,Percent of Total Billed Charges,36% Total Bille Charges,469.8,36,,4649.832,Percent of Total Billed Charges,36% of Total Billed Charges,783,60,,653.96,Percent of Total Billed Charges,60% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1305,100,,923.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,188.18,14.42,,10.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,978.75,75,,960.136,Percent of Total Billed Charges,75% of Total Billed Charges,652.5,50,,8240.8,Percent of Total Billed Charges,50% of Total Billed Charges,652.5,50,,726.08,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,652.5,50,,726.08,Percent of Total Billed Charges,50% of Total Billed Charges,652.5,50,,726.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,913.5,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,182.7,14,,10.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1305,100,,1280.176,Percent of Total Billed Charges,100% of Total Billed Charges,3.64,1305,
784840 SIMULATOR LEAD 70CM,32150475,CDM,278,RC,C1778,HCPCS,Outpatient,,,22250,13350.00,,25057.6,110,,69.432,Percent of Total Billed Charges,110% of Total Billed Charges,10012.5,45,,1355.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6230,28,,1065.928,Percent of Total Billed Charges,28% of Total Billed Charges,3.64,32,,3.184,Percent of Total Billed Charges,32% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,8010,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,8010,36,,1370.48,Percent of Total Billed Charges,36% Total Bille Charges,8010,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,12237.5,55,,225.368,Percent of Total Billed Charges,55% Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22250,100,,518.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3208.45,14.42,,219.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17800,80,,2068.464,Percent of Total Billed Charges,80% of Total Billed Charges,11125,50,,672.272,Percent of Total Billed Charges,50% of Total Billed Charges,11125,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11125,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,11125,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15575,70,,2557.264,Percent of Total Billed Charges,70% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,3115,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22250,100,,2757.952,Percent of Total Billed Charges,100% of Total Billed Charges,3.64,25057.6,
251169 DURAFORM 4X5,32150493,CDM,278,RC,,,Outpatient,,,3277.64,1966.58,,3605.4,110,,311.992,Percent of Total Billed Charges,110% of Total Billed Charges,1474.94,45,,605.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917.74,28,,368.4,Percent of Total Billed Charges,28% of Total Billed Charges,3.69,32,,3.208,Percent of Total Billed Charges,32% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1179.95,36,,473.656,Percent of Total Billed Charges,36% of Total Billed Charges,1179.95,36,,473.656,Percent of Total Billed Charges,36% Total Bille Charges,1179.95,36,,473.656,Percent of Total Billed Charges,36% of Total Billed Charges,1802.7,55,,482.88,Percent of Total Billed Charges,55% Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3277.64,100,,386.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,472.64,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2622.11,80,,865.328,Percent of Total Billed Charges,80% of Total Billed Charges,1638.82,50,,726.08,Percent of Total Billed Charges,50% of Total Billed Charges,1638.82,50,,259.632,Percent of Total Billed Charges,50% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1638.82,50,,259.632,Percent of Total Billed Charges,50% of Total Billed Charges,1638.82,50,,259.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2294.35,70,,1965.6,Percent of Total Billed Charges,70% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,458.87,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3277.64,100,,1153.768,Percent of Total Billed Charges,100% of Total Billed Charges,3.69,3605.4,
763302 WHITE RELOAD,32150495,CDM,272,RC,,,Outpatient,,,617.49,370.49,,370.49,60,,69.432,Percent of Total Billed Charges,60% of Total Billed Charges,277.87,45,,752.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.9,28,,332.928,Percent of Total Billed Charges,28% of Total Billed Charges,3.7,32,,3.216,Percent of Total Billed Charges,32% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,222.3,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,222.3,36,,428.048,Percent of Total Billed Charges,36% Total Bille Charges,222.3,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,370.49,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.49,100,,878.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,89.04,14.42,,159.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.12,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,308.75,50,,565.272,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,37.392,Percent of Total Billed Charges,50% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.75,50,,37.392,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,37.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.24,70,,79.392,Percent of Total Billed Charges,70% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,617.49,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,3.7,617.49,
776388 BLACK ECHELON RELOAD,32150497,CDM,272,RC,,,Outpatient,,,703.95,422.37,,422.37,60,,69.432,Percent of Total Billed Charges,60% of Total Billed Charges,316.78,45,,701.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.11,28,,114.736,Percent of Total Billed Charges,28% of Total Billed Charges,3.7,32,,3.24,Percent of Total Billed Charges,32% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,253.42,36,,147.512,Percent of Total Billed Charges,36% of Total Billed Charges,253.42,36,,147.512,Percent of Total Billed Charges,36% Total Bille Charges,253.42,36,,147.512,Percent of Total Billed Charges,36% of Total Billed Charges,422.37,60,,1161.056,Percent of Total Billed Charges,60% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.95,100,,3012.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14.42,,159.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.96,75,,4350.72,Percent of Total Billed Charges,75% of Total Billed Charges,351.98,50,,259.632,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.98,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.77,70,,13440,Percent of Total Billed Charges,70% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,154.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.95,100,,5438.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.7,703.95,
764880 LINEAR CUTTER ETHICON,32150499,CDM,272,RC,,,Outpatient,,,703.95,422.37,,422.37,60,,1202.424,Percent of Total Billed Charges,60% of Total Billed Charges,316.78,45,,570.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.11,28,,225.344,Percent of Total Billed Charges,28% of Total Billed Charges,3.72,32,,3.248,Percent of Total Billed Charges,32% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,253.42,36,,289.728,Percent of Total Billed Charges,36% of Total Billed Charges,253.42,36,,289.728,Percent of Total Billed Charges,36% Total Bille Charges,253.42,36,,289.728,Percent of Total Billed Charges,36% of Total Billed Charges,422.37,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.95,100,,1344.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14.42,,244.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.96,75,,8918.976,Percent of Total Billed Charges,75% of Total Billed Charges,351.98,50,,37.392,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.98,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.77,70,,2002,Percent of Total Billed Charges,70% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.95,100,,11148.72,Percent of Total Billed Charges,100% of Total Billed Charges,3.72,703.95,
763295 GREEN ECHELON RELOAD,32150500,CDM,272,RC,,,Outpatient,,,703.95,422.37,,422.37,60,,57.56,Percent of Total Billed Charges,60% of Total Billed Charges,316.78,45,,932.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.11,28,,2912,Percent of Total Billed Charges,28% of Total Billed Charges,3.72,32,,3.256,Percent of Total Billed Charges,32% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,253.42,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,253.42,36,,3744,Percent of Total Billed Charges,36% Total Bille Charges,253.42,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,422.37,60,,1118.04,Percent of Total Billed Charges,60% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.95,100,,1672.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14.42,,20.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.96,75,,1996.8,Percent of Total Billed Charges,75% of Total Billed Charges,351.98,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.98,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.77,70,,41.8,Percent of Total Billed Charges,70% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.95,100,,2496,Percent of Total Billed Charges,100% of Total Billed Charges,3.72,703.95,
719931 HARMONIC ACE PLUS,32150502,CDM,272,RC,,,Outpatient,,,2317.14,1390.28,,1390.28,60,,221.76,Percent of Total Billed Charges,60% of Total Billed Charges,1042.71,45,,612.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.8,28,,541.824,Percent of Total Billed Charges,28% of Total Billed Charges,3.73,32,,3.256,Percent of Total Billed Charges,32% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,834.17,36,,696.632,Percent of Total Billed Charges,36% of Total Billed Charges,834.17,36,,696.632,Percent of Total Billed Charges,36% Total Bille Charges,834.17,36,,696.632,Percent of Total Billed Charges,36% of Total Billed Charges,1390.28,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2317.14,100,,1558.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,334.13,14.42,,188.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1737.86,75,,5220.864,Percent of Total Billed Charges,75% of Total Billed Charges,1158.57,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1158.57,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1158.57,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,1158.57,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1622,70,,4906.136,Percent of Total Billed Charges,70% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,324.4,14,,182.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2317.14,100,,6526.08,Percent of Total Billed Charges,100% of Total Billed Charges,3.73,2317.14,
776386 ENDOPATH RELOAD,32150503,CDM,272,RC,,,Outpatient,,,703.95,422.37,,422.37,60,,34.952,Percent of Total Billed Charges,60% of Total Billed Charges,316.78,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.11,28,,18.352,Percent of Total Billed Charges,28% of Total Billed Charges,3.74,32,,3.264,Percent of Total Billed Charges,32% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,253.42,36,,23.592,Percent of Total Billed Charges,36% of Total Billed Charges,253.42,36,,23.592,Percent of Total Billed Charges,36% Total Bille Charges,253.42,36,,23.592,Percent of Total Billed Charges,36% of Total Billed Charges,422.37,60,,3830.88,Percent of Total Billed Charges,60% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.95,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14.42,,264.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.96,75,,8823.256,Percent of Total Billed Charges,75% of Total Billed Charges,351.98,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.98,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,351.98,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.77,70,,2751.84,Percent of Total Billed Charges,70% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,98.55,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.95,100,,11029.072,Percent of Total Billed Charges,100% of Total Billed Charges,3.74,703.95,
782036 ENDOSCOPIC LINEAR CUTTE,32150505,CDM,272,RC,,,Outpatient,,,1672.17,1003.30,,1003.3,60,,929.84,Percent of Total Billed Charges,60% of Total Billed Charges,752.48,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468.21,28,,2912,Percent of Total Billed Charges,28% of Total Billed Charges,3.76,32,,3.264,Percent of Total Billed Charges,32% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,601.98,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,601.98,36,,3744,Percent of Total Billed Charges,36% Total Bille Charges,601.98,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,1003.3,60,,82.936,Percent of Total Billed Charges,60% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1672.17,100,,2072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,241.13,14.42,,107.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1254.13,75,,13185.28,Percent of Total Billed Charges,75% of Total Billed Charges,836.09,50,,552.408,Percent of Total Billed Charges,50% of Total Billed Charges,836.09,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,836.09,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,836.09,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1170.52,70,,4652.768,Percent of Total Billed Charges,70% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,234.1,14,,104.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1672.17,100,,16481.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.76,1672.17,
182481 ENSEAL 35CM 5MM ROUND J,32150506,CDM,272,RC,,,Outpatient,,,1600.22,960.13,,960.13,60,,90.632,Percent of Total Billed Charges,60% of Total Billed Charges,720.1,45,,324.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.06,28,,569.184,Percent of Total Billed Charges,28% of Total Billed Charges,3.76,32,,3.288,Percent of Total Billed Charges,32% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,576.08,36,,731.808,Percent of Total Billed Charges,36% of Total Billed Charges,576.08,36,,731.808,Percent of Total Billed Charges,36% Total Bille Charges,576.08,36,,731.808,Percent of Total Billed Charges,36% of Total Billed Charges,960.13,60,,9587.912,Percent of Total Billed Charges,60% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600.22,100,,1360.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,230.75,14.42,,31.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1200.17,75,,1008.408,Percent of Total Billed Charges,75% of Total Billed Charges,800.11,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,800.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,800.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1120.15,70,,1467.648,Percent of Total Billed Charges,70% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,224.03,14,,30.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.22,100,,1344.544,Percent of Total Billed Charges,100% of Total Billed Charges,3.76,1600.22,
641706 ENSEAL J&J ARTICULATING,32150507,CDM,272,RC,,,Outpatient,,,3447.44,2068.46,,2068.46,60,,65.088,Percent of Total Billed Charges,60% of Total Billed Charges,1551.35,45,,465.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,965.28,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,3.78,32,,3.304,Percent of Total Billed Charges,32% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,1241.08,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1241.08,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,1241.08,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,2068.46,60,,1710.28,Percent of Total Billed Charges,60% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3447.44,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,497.12,14.42,,244.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2585.58,75,,1161.72,Percent of Total Billed Charges,75% of Total Billed Charges,1723.72,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,1723.72,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1723.72,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,1723.72,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2413.21,70,,3242.368,Percent of Total Billed Charges,70% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,482.64,14,,237.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3447.44,100,,1452.152,Percent of Total Billed Charges,100% of Total Billed Charges,3.78,3447.44,
534585 ENSEAL G2 TISS 35ST,32150510,CDM,272,RC,,,Outpatient,,,1442.21,865.33,,865.33,60,,510.376,Percent of Total Billed Charges,60% of Total Billed Charges,648.99,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.82,28,,1950.264,Percent of Total Billed Charges,28% of Total Billed Charges,3.78,32,,3.32,Percent of Total Billed Charges,32% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,519.2,36,,2507.48,Percent of Total Billed Charges,36% of Total Billed Charges,519.2,36,,2507.48,Percent of Total Billed Charges,36% Total Bille Charges,519.2,36,,2507.48,Percent of Total Billed Charges,36% of Total Billed Charges,865.33,60,,28430.592,Percent of Total Billed Charges,60% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1442.21,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,207.97,14.42,,1133.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1081.66,75,,904.432,Percent of Total Billed Charges,75% of Total Billed Charges,721.11,50,,652.984,Percent of Total Billed Charges,50% of Total Billed Charges,721.11,50,,372.296,Percent of Total Billed Charges,50% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,721.11,50,,372.296,Percent of Total Billed Charges,50% of Total Billed Charges,721.11,50,,372.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1009.55,70,,7041.112,Percent of Total Billed Charges,70% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,201.91,14,,1100.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1442.21,100,,1130.536,Percent of Total Billed Charges,100% of Total Billed Charges,3.78,1442.21,
428830 SHEATH ACESS 12/14 35CM,32150515,CDM,272,RC,C1894,HCPCS,Outpatient,,,534.6,320.76,,82.29,100,,744.256,Fee Schedule,100% of Aetna Fee Schedule,240.57,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,38.704,Percent of Total Billed Charges,28% of Total Billed Charges,3.8,32,,30.72,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,49.76,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,49.76,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,2453.88,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,720.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,264.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,389.448,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,107.544,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,107.544,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,107.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,2617.232,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,256.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,519.264,Percent of Total Billed Charges,100% of Total Billed Charges,3.8,534.6,
790624 STRIP STEM CELL 50X20MM,32150516,CDM,278,RC,,,Outpatient,,,6798,4078.80,,7477.8,110,,65.2,Percent of Total Billed Charges,110% of Total Billed Charges,3059.1,45,,1835.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1903.44,28,,4881.12,Percent of Total Billed Charges,28% of Total Billed Charges,3.81,32,,30.72,Percent of Total Billed Charges,32% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,2447.28,36,,6275.72,Percent of Total Billed Charges,36% of Total Billed Charges,2447.28,36,,6275.72,Percent of Total Billed Charges,36% Total Bille Charges,2447.28,36,,6275.72,Percent of Total Billed Charges,36% of Total Billed Charges,3738.9,55,,313.472,Percent of Total Billed Charges,55% Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6798,100,,1033.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,980.27,14.42,,71.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5438.4,80,,59.824,Percent of Total Billed Charges,80% of Total Billed Charges,3399,50,,372.296,Percent of Total Billed Charges,50% of Total Billed Charges,3399,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3399,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,3399,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,70,,1058.4,Percent of Total Billed Charges,70% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,951.72,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6798,100,,74.784,Percent of Total Billed Charges,100% of Total Billed Charges,3.81,7477.8,
790619 MORSELIZED CELL 10CC,32150518,CDM,278,RC,,,Outpatient,,,13935.9,8361.54,,15329.49,110,,42.664,Percent of Total Billed Charges,110% of Total Billed Charges,6271.16,45,,479.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3902.05,28,,870.688,Percent of Total Billed Charges,28% of Total Billed Charges,3.84,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,5016.92,36,,1119.456,Percent of Total Billed Charges,36% of Total Billed Charges,5016.92,36,,1119.456,Percent of Total Billed Charges,36% Total Bille Charges,5016.92,36,,1119.456,Percent of Total Billed Charges,36% of Total Billed Charges,7664.75,55,,630.816,Percent of Total Billed Charges,55% Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13935.9,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,2009.56,14.42,,72.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11148.72,80,,1215.024,Percent of Total Billed Charges,80% of Total Billed Charges,6967.95,50,,107.544,Percent of Total Billed Charges,50% of Total Billed Charges,6967.95,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6967.95,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,6967.95,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9755.13,70,,3794.336,Percent of Total Billed Charges,70% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,1951.03,14,,69.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13935.9,100,,1518.776,Percent of Total Billed Charges,100% of Total Billed Charges,3.84,15329.49,
790613 LRG BLOCK STEM CELL,32150524,CDM,278,RC,,,Outpatient,,,3120,1872.00,,3432,110,,91.248,Percent of Total Billed Charges,110% of Total Billed Charges,1404,45,,479.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.6,28,,14473.76,Percent of Total Billed Charges,28% of Total Billed Charges,35.2,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,1123.2,36,,18609.12,Percent of Total Billed Charges,36% of Total Billed Charges,1123.2,36,,18609.12,Percent of Total Billed Charges,36% Total Bille Charges,1123.2,36,,18609.12,Percent of Total Billed Charges,36% of Total Billed Charges,1716,55,,28116,Percent of Total Billed Charges,55% Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3120,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,449.9,14.42,,73.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2496,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,1560,50,,847.904,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1560,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2184,70,,18082.68,Percent of Total Billed Charges,70% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,71.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3120,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,35.2,3432,
790622 MORSELIZED CELL 5CC,32150526,CDM,278,RC,,,Outpatient,,,8157.6,4894.56,,8973.36,110,,592.024,Percent of Total Billed Charges,110% of Total Billed Charges,3670.92,45,,596.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2284.13,28,,1249.248,Percent of Total Billed Charges,28% of Total Billed Charges,35.2,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,2936.74,36,,1606.176,Percent of Total Billed Charges,36% of Total Billed Charges,2936.74,36,,1606.176,Percent of Total Billed Charges,36% Total Bille Charges,2936.74,36,,1606.176,Percent of Total Billed Charges,36% of Total Billed Charges,4486.68,55,,1600.552,Percent of Total Billed Charges,55% Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8157.6,100,,4078.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1176.33,14.42,,79.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6526.08,80,,883.856,Percent of Total Billed Charges,80% of Total Billed Charges,4078.8,50,,3930.608,Percent of Total Billed Charges,50% of Total Billed Charges,4078.8,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4078.8,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,4078.8,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5710.32,70,,6217.12,Percent of Total Billed Charges,70% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1142.06,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8157.6,100,,1104.816,Percent of Total Billed Charges,100% of Total Billed Charges,35.2,8973.36,
584416 EXCLUDER GORE AAA,32150529,CDM,278,RC,C1768,HCPCS,Outpatient,,,13786.34,8271.80,,15487.74,110,,1041.056,Percent of Total Billed Charges,110% of Total Billed Charges,6203.85,45,,280.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3860.18,28,,159.584,Percent of Total Billed Charges,28% of Total Billed Charges,35.21,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,4963.08,36,,205.184,Percent of Total Billed Charges,36% of Total Billed Charges,4963.08,36,,205.184,Percent of Total Billed Charges,36% Total Bille Charges,4963.08,36,,205.184,Percent of Total Billed Charges,36% of Total Billed Charges,7582.49,55,,1065.616,Percent of Total Billed Charges,55% Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13786.34,100,,1064.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1987.99,14.42,,79.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11029.07,80,,883.856,Percent of Total Billed Charges,80% of Total Billed Charges,6893.17,50,,916.128,Percent of Total Billed Charges,50% of Total Billed Charges,6893.17,50,,249.832,Percent of Total Billed Charges,50% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6893.17,50,,249.832,Percent of Total Billed Charges,50% of Total Billed Charges,6893.17,50,,249.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9650.44,70,,4906.136,Percent of Total Billed Charges,70% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,1930.09,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13786.34,100,,1104.816,Percent of Total Billed Charges,100% of Total Billed Charges,35.21,15487.74,
726331 EXCLUDER AAA ENDO,32150530,CDM,278,RC,C1768,HCPCS,Outpatient,,,20602,12361.20,,22984.97,110,,1701.744,Percent of Total Billed Charges,110% of Total Billed Charges,9270.9,45,,297.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5768.56,28,,321.144,Percent of Total Billed Charges,28% of Total Billed Charges,35.38,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,7416.72,36,,412.896,Percent of Total Billed Charges,36% of Total Billed Charges,7416.72,36,,412.896,Percent of Total Billed Charges,36% Total Bille Charges,7416.72,36,,412.896,Percent of Total Billed Charges,36% of Total Billed Charges,11331.1,55,,1912.824,Percent of Total Billed Charges,55% Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20602,100,,1064.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2970.81,14.42,,158.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16481.6,80,,1356.648,Percent of Total Billed Charges,80% of Total Billed Charges,10301,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,10301,50,,255.552,Percent of Total Billed Charges,50% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10301,50,,255.552,Percent of Total Billed Charges,50% of Total Billed Charges,10301,50,,255.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14421.4,70,,546,Percent of Total Billed Charges,70% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,2884.28,14,,154.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20602,100,,1695.808,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,22984.97,
793382 ECHELON PLUS STAPLER,32150531,CDM,272,RC,,,Outpatient,,,1680.68,1008.41,,1008.41,60,,1750.376,Percent of Total Billed Charges,60% of Total Billed Charges,756.31,45,,38.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,470.59,28,,14313.6,Percent of Total Billed Charges,28% of Total Billed Charges,35.38,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,605.04,36,,18403.2,Percent of Total Billed Charges,36% of Total Billed Charges,605.04,36,,18403.2,Percent of Total Billed Charges,36% Total Bille Charges,605.04,36,,18403.2,Percent of Total Billed Charges,36% of Total Billed Charges,1008.41,60,,66.768,Percent of Total Billed Charges,60% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1680.68,100,,1325.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,242.35,14.42,,1202.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1260.51,75,,115.2,Percent of Total Billed Charges,75% of Total Billed Charges,840.34,50,,249.832,Percent of Total Billed Charges,50% of Total Billed Charges,840.34,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840.34,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,840.34,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.48,70,,2193.736,Percent of Total Billed Charges,70% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,235.3,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1680.68,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,1680.68,
795924 MESH PARIETEX COMP. 8.6,32150532,CDM,278,RC,C1781,HCPCS,Outpatient,,,1815.19,1089.11,,2449.47,110,,74.296,Percent of Total Billed Charges,110% of Total Billed Charges,816.84,45,,4210.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.25,28,,814.824,Percent of Total Billed Charges,28% of Total Billed Charges,35.38,32,,30.928,Percent of Total Billed Charges,32% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,653.47,36,,1047.632,Percent of Total Billed Charges,36% of Total Billed Charges,653.47,36,,1047.632,Percent of Total Billed Charges,36% Total Bille Charges,653.47,36,,1047.632,Percent of Total Billed Charges,36% of Total Billed Charges,998.35,55,,2225.08,Percent of Total Billed Charges,55% Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1815.19,100,,623.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,261.75,14.42,,61.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1452.15,80,,1044.776,Percent of Total Billed Charges,80% of Total Billed Charges,907.6,50,,255.552,Percent of Total Billed Charges,50% of Total Billed Charges,907.6,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,907.6,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,907.6,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1270.63,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,254.13,14,,59.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1815.19,100,,1305.968,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,2449.47,
795922 MESH PARIETEX COMP. 6.6,32150533,CDM,278,RC,C1781,HCPCS,Outpatient,,,1413.17,847.90,,2007.25,110,,151.712,Percent of Total Billed Charges,110% of Total Billed Charges,635.93,45,,608.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.69,28,,542.496,Percent of Total Billed Charges,28% of Total Billed Charges,35.38,32,,31.064,Percent of Total Billed Charges,32% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,508.74,36,,697.496,Percent of Total Billed Charges,36% of Total Billed Charges,508.74,36,,697.496,Percent of Total Billed Charges,36% Total Bille Charges,508.74,36,,697.496,Percent of Total Billed Charges,36% of Total Billed Charges,777.24,55,,2048.92,Percent of Total Billed Charges,55% Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1413.17,100,,660.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,203.78,14.42,,215.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1130.54,80,,1465.8,Percent of Total Billed Charges,80% of Total Billed Charges,706.59,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,550.552,Percent of Total Billed Charges,50% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.59,50,,550.552,Percent of Total Billed Charges,50% of Total Billed Charges,706.59,50,,550.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,989.22,70,,491.2,Percent of Total Billed Charges,70% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,197.84,14,,209.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.17,100,,1832.248,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,2007.25,
400221 PROBE MEDTRONIC STIM,32150535,CDM,272,RC,,,Outpatient,,,649.08,389.45,,389.45,60,,3797.128,Percent of Total Billed Charges,60% of Total Billed Charges,292.09,45,,222.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.74,28,,973.8,Percent of Total Billed Charges,28% of Total Billed Charges,35.38,32,,31.2,Percent of Total Billed Charges,32% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,233.67,36,,1252.032,Percent of Total Billed Charges,36% of Total Billed Charges,233.67,36,,1252.032,Percent of Total Billed Charges,36% Total Bille Charges,233.67,36,,1252.032,Percent of Total Billed Charges,36% of Total Billed Charges,389.45,60,,2350.92,Percent of Total Billed Charges,60% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,649.08,100,,85.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,93.6,14.42,,36.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.81,75,,595.672,Percent of Total Billed Charges,75% of Total Billed Charges,324.54,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,324.54,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.54,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,324.54,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,454.36,70,,491.2,Percent of Total Billed Charges,70% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,90.87,14,,35.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.08,100,,744.592,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,649.08,
0004785 TUBE EAR ARMSTRONG BEV,32150536,CDM,278,RC,,,Outpatient,,,93.48,56.09,,102.83,110,,61.912,Percent of Total Billed Charges,110% of Total Billed Charges,42.07,45,,85.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.17,28,,31.16,Percent of Total Billed Charges,28% of Total Billed Charges,35.51,32,,31.336,Percent of Total Billed Charges,32% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,33.65,36,,40.064,Percent of Total Billed Charges,36% of Total Billed Charges,33.65,36,,40.064,Percent of Total Billed Charges,36% Total Bille Charges,33.65,36,,40.064,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.48,100,,9355.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14.42,,196.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.78,80,,172.064,Percent of Total Billed Charges,80% of Total Billed Charges,46.74,50,,550.552,Percent of Total Billed Charges,50% of Total Billed Charges,46.74,50,,212.256,Percent of Total Billed Charges,50% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.74,50,,212.256,Percent of Total Billed Charges,50% of Total Billed Charges,46.74,50,,212.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.44,70,,66.952,Percent of Total Billed Charges,70% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,13.09,14,,191.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.48,100,,215.08,Percent of Total Billed Charges,100% of Total Billed Charges,13.09,102.83,
795923 HOLTER SELKER,32150537,CDM,278,RC,,,Outpatient,,,1898.47,1139.08,,2088.32,110,,61.912,Percent of Total Billed Charges,110% of Total Billed Charges,854.31,45,,167.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.57,28,,1132.768,Percent of Total Billed Charges,28% of Total Billed Charges,35.52,32,,31.488,Percent of Total Billed Charges,32% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,683.45,36,,1456.416,Percent of Total Billed Charges,36% of Total Billed Charges,683.45,36,,1456.416,Percent of Total Billed Charges,36% Total Bille Charges,683.45,36,,1456.416,Percent of Total Billed Charges,36% of Total Billed Charges,1044.16,55,,26920.08,Percent of Total Billed Charges,55% Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1898.47,100,,1353.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,273.76,14.42,,1097.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1518.78,80,,1356.648,Percent of Total Billed Charges,80% of Total Billed Charges,949.24,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,949.24,50,,748.496,Percent of Total Billed Charges,50% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,949.24,50,,748.496,Percent of Total Billed Charges,50% of Total Billed Charges,949.24,50,,748.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1328.93,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1898.47,100,,1695.808,Percent of Total Billed Charges,100% of Total Billed Charges,35.52,2088.32,
800912 URETHRAL DILATION/ASSE,32150540,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,399.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,1043.088,Percent of Total Billed Charges,28% of Total Billed Charges,35.6,32,,31.488,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,1341.112,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,1341.112,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1532.184,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,494,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,518.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,6288.968,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,212.256,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,126.168,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,126.168,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,126.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,4906.136,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,503.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,7861.208,Percent of Total Billed Charges,100% of Total Billed Charges,35.6,600,
724227 MESH LAPAROSCOPIC SELF,32150541,CDM,278,RC,C1781,HCPCS,Outpatient,,,1381.02,828.61,,1971.88,110,,89.864,Percent of Total Billed Charges,110% of Total Billed Charges,621.46,45,,25.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.69,28,,1196.832,Percent of Total Billed Charges,28% of Total Billed Charges,35.67,32,,31.488,Percent of Total Billed Charges,32% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,497.17,36,,1538.784,Percent of Total Billed Charges,36% of Total Billed Charges,497.17,36,,1538.784,Percent of Total Billed Charges,36% Total Bille Charges,497.17,36,,1538.784,Percent of Total Billed Charges,36% of Total Billed Charges,759.56,55,,1072.064,Percent of Total Billed Charges,55% Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1381.02,100,,190.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,199.14,14.42,,805.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1104.82,80,,1465.8,Percent of Total Billed Charges,80% of Total Billed Charges,690.51,50,,748.496,Percent of Total Billed Charges,50% of Total Billed Charges,690.51,50,,682.224,Percent of Total Billed Charges,50% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690.51,50,,682.224,Percent of Total Billed Charges,50% of Total Billed Charges,690.51,50,,682.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,966.71,70,,169.936,Percent of Total Billed Charges,70% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,782.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1381.02,100,,1832.248,Percent of Total Billed Charges,100% of Total Billed Charges,35.67,1971.88,
724230 MESH LAPAROSCOPIC SELF,32150542,CDM,278,RC,C1781,HCPCS,Outpatient,,,1381.02,828.61,,1971.88,110,,91.248,Percent of Total Billed Charges,110% of Total Billed Charges,621.46,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.69,28,,368.4,Percent of Total Billed Charges,28% of Total Billed Charges,35.69,32,,31.68,Percent of Total Billed Charges,32% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,497.17,36,,473.656,Percent of Total Billed Charges,36% of Total Billed Charges,497.17,36,,473.656,Percent of Total Billed Charges,36% Total Bille Charges,497.17,36,,473.656,Percent of Total Billed Charges,36% of Total Billed Charges,759.56,55,,52.704,Percent of Total Billed Charges,55% Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1381.02,100,,372.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,199.14,14.42,,302.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1104.82,80,,370.504,Percent of Total Billed Charges,80% of Total Billed Charges,690.51,50,,126.168,Percent of Total Billed Charges,50% of Total Billed Charges,690.51,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690.51,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,690.51,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,966.71,70,,871.632,Percent of Total Billed Charges,70% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,193.34,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1381.02,100,,494,Percent of Total Billed Charges,100% of Total Billed Charges,35.69,1971.88,
548965 SWIVELOCK TENODESIS 7MM,32150544,CDM,278,RC,C1713,HCPCS,Outpatient,,,2119.76,1271.86,,2649,110,,91.248,Percent of Total Billed Charges,110% of Total Billed Charges,953.89,45,,428.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.53,28,,13704.768,Percent of Total Billed Charges,28% of Total Billed Charges,35.69,32,,31.68,Percent of Total Billed Charges,32% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,763.11,36,,17620.416,Percent of Total Billed Charges,36% of Total Billed Charges,763.11,36,,17620.416,Percent of Total Billed Charges,36% Total Bille Charges,763.11,36,,17620.416,Percent of Total Billed Charges,36% of Total Billed Charges,1165.87,55,,521.656,Percent of Total Billed Charges,55% Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2119.76,100,,888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,305.67,14.42,,92.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1695.81,80,,374.744,Percent of Total Billed Charges,80% of Total Billed Charges,1059.88,50,,682.224,Percent of Total Billed Charges,50% of Total Billed Charges,1059.88,50,,1797.12,Percent of Total Billed Charges,50% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1059.88,50,,1797.12,Percent of Total Billed Charges,50% of Total Billed Charges,1059.88,50,,1797.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1483.83,70,,41.752,Percent of Total Billed Charges,70% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2119.76,100,,499.656,Percent of Total Billed Charges,100% of Total Billed Charges,35.69,2649,
478347 SHEATH INTERFERENCE,32150545,CDM,278,RC,,,Outpatient,,,180,108.00,,198,110,,91.248,Percent of Total Billed Charges,110% of Total Billed Charges,81,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,28,,780.016,Percent of Total Billed Charges,28% of Total Billed Charges,35.74,32,,31.76,Percent of Total Billed Charges,32% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,64.8,36,,1002.88,Percent of Total Billed Charges,36% of Total Billed Charges,64.8,36,,1002.88,Percent of Total Billed Charges,36% Total Bille Charges,64.8,36,,1002.88,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,100,,56.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.96,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144,80,,383.32,Percent of Total Billed Charges,80% of Total Billed Charges,90,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,90,50,,2793.776,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,50,,2793.776,Percent of Total Billed Charges,50% of Total Billed Charges,90,50,,2793.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180,100,,511.096,Percent of Total Billed Charges,100% of Total Billed Charges,25.2,198,
569337 SUTURE CORKSCREW 7MM,32150547,CDM,278,RC,C1713,HCPCS,Outpatient,,,1632.46,979.48,,2112.97,110,,33.6,Percent of Total Billed Charges,110% of Total Billed Charges,734.61,45,,512.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,457.09,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,35.91,32,,31.76,Percent of Total Billed Charges,32% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,587.69,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,587.69,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,587.69,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,897.85,55,,1310.4,Percent of Total Billed Charges,55% Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1632.46,100,,103.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,235.4,14.42,,157.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1305.97,80,,415.336,Percent of Total Billed Charges,80% of Total Billed Charges,816.23,50,,1797.12,Percent of Total Billed Charges,50% of Total Billed Charges,816.23,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,816.23,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,816.23,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.72,70,,99.648,Percent of Total Billed Charges,70% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,228.54,14,,153.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1632.46,100,,553.784,Percent of Total Billed Charges,100% of Total Billed Charges,35.91,2112.97,
493631 ANCHOR SWIVELOCK C,32150549,CDM,278,RC,C1713,HCPCS,Outpatient,,,2290.31,1374.19,,2836.6,110,,91.248,Percent of Total Billed Charges,110% of Total Billed Charges,1030.64,45,,761.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641.29,28,,24.592,Percent of Total Billed Charges,28% of Total Billed Charges,35.91,32,,31.76,Percent of Total Billed Charges,32% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,824.51,36,,31.624,Percent of Total Billed Charges,36% of Total Billed Charges,824.51,36,,31.624,Percent of Total Billed Charges,36% Total Bille Charges,824.51,36,,31.624,Percent of Total Billed Charges,36% of Total Billed Charges,1259.67,55,,161.376,Percent of Total Billed Charges,55% Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2290.31,100,,952.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,330.26,14.42,,1570.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1832.25,80,,415.336,Percent of Total Billed Charges,80% of Total Billed Charges,1145.16,50,,2793.776,Percent of Total Billed Charges,50% of Total Billed Charges,1145.16,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1145.16,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,1145.16,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1603.22,70,,1836.568,Percent of Total Billed Charges,70% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,1524.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2290.31,100,,553.784,Percent of Total Billed Charges,100% of Total Billed Charges,35.91,2836.6,
799376 PORT INFUS IMP,32150551,CDM,278,RC,C1788,HCPCS,Outpatient,,,930.74,558.44,,1632.62,110,,88.048,Percent of Total Billed Charges,110% of Total Billed Charges,418.83,45,,101.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.61,28,,243.44,Percent of Total Billed Charges,28% of Total Billed Charges,36.1,32,,31.768,Percent of Total Billed Charges,32% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,335.07,36,,312.992,Percent of Total Billed Charges,36% of Total Billed Charges,335.07,36,,312.992,Percent of Total Billed Charges,36% Total Bille Charges,335.07,36,,312.992,Percent of Total Billed Charges,36% of Total Billed Charges,511.91,55,,33.6,Percent of Total Billed Charges,55% Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,930.74,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,134.21,14.42,,43.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,744.59,80,,825.832,Percent of Total Billed Charges,80% of Total Billed Charges,465.37,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,465.37,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465.37,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,465.37,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.52,70,,1009.688,Percent of Total Billed Charges,70% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,130.3,14,,42.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930.74,100,,1101.104,Percent of Total Billed Charges,100% of Total Billed Charges,36.1,1632.62,
571104 COTTONY II DACRON 3MM,32150552,CDM,278,RC,,,Outpatient,,,268.85,161.31,,295.74,110,,552.912,Percent of Total Billed Charges,110% of Total Billed Charges,120.98,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.28,28,,42.384,Percent of Total Billed Charges,28% of Total Billed Charges,36.16,32,,31.88,Percent of Total Billed Charges,32% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.79,36,,54.488,Percent of Total Billed Charges,36% of Total Billed Charges,96.79,36,,54.488,Percent of Total Billed Charges,36% Total Bille Charges,96.79,36,,54.488,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.85,100,,1137.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,38.77,14.42,,407.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.08,80,,6671.824,Percent of Total Billed Charges,80% of Total Billed Charges,134.43,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,134.43,50,,546.472,Percent of Total Billed Charges,50% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.43,50,,546.472,Percent of Total Billed Charges,50% of Total Billed Charges,134.43,50,,546.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.2,70,,10135.824,Percent of Total Billed Charges,70% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,37.64,14,,395.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.85,100,,8339.784,Percent of Total Billed Charges,100% of Total Billed Charges,36.16,295.74,
501421 ANCHOR TENODESIS 8MM,32150553,CDM,278,RC,C1713,HCPCS,Outpatient,,,2119.76,1271.86,,2649,110,,42.408,Percent of Total Billed Charges,110% of Total Billed Charges,953.89,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.53,28,,611.52,Percent of Total Billed Charges,28% of Total Billed Charges,36.16,32,,31.912,Percent of Total Billed Charges,32% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,763.11,36,,786.24,Percent of Total Billed Charges,36% of Total Billed Charges,763.11,36,,786.24,Percent of Total Billed Charges,36% Total Bille Charges,763.11,36,,786.24,Percent of Total Billed Charges,36% of Total Billed Charges,1165.87,55,,191.48,Percent of Total Billed Charges,55% Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2119.76,100,,1692,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,305.67,14.42,,111.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1695.81,80,,318.376,Percent of Total Billed Charges,80% of Total Billed Charges,1059.88,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,1059.88,50,,5444.368,Percent of Total Billed Charges,50% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1059.88,50,,5444.368,Percent of Total Billed Charges,50% of Total Billed Charges,1059.88,50,,5444.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1483.83,70,,2315.04,Percent of Total Billed Charges,70% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,296.77,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2119.76,100,,424.504,Percent of Total Billed Charges,100% of Total Billed Charges,36.16,2649,
408239 GRAFT VASCULAR PROPATEN,32150554,CDM,278,RC,C1768,HCPCS,Outpatient,,,9826.51,5895.91,,11131.93,110,,140.712,Percent of Total Billed Charges,110% of Total Billed Charges,4421.93,45,,1267.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2751.42,28,,75.312,Percent of Total Billed Charges,28% of Total Billed Charges,36.16,32,,32.136,Percent of Total Billed Charges,32% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,3537.54,36,,96.824,Percent of Total Billed Charges,36% of Total Billed Charges,3537.54,36,,96.824,Percent of Total Billed Charges,36% Total Bille Charges,3537.54,36,,96.824,Percent of Total Billed Charges,36% of Total Billed Charges,5404.58,55,,381.312,Percent of Total Billed Charges,55% Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9826.51,100,,226.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1416.98,14.42,,3528.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7861.21,80,,1197.584,Percent of Total Billed Charges,80% of Total Billed Charges,4913.26,50,,546.472,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4913.26,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,4913.26,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6878.56,70,,1731.272,Percent of Total Billed Charges,70% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,1375.71,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9826.51,100,,1496.984,Percent of Total Billed Charges,100% of Total Billed Charges,36.16,11131.93,
440104 SUTURE ANCHOR SWIVEL,32150555,CDM,278,RC,C1713,HCPCS,Outpatient,,,2290.31,1374.19,,2836.6,110,,688.304,Percent of Total Billed Charges,110% of Total Billed Charges,1030.64,45,,916.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641.29,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,36.29,32,,32.16,Percent of Total Billed Charges,32% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,824.51,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,824.51,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,824.51,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1259.67,55,,935.616,Percent of Total Billed Charges,55% Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2290.31,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,330.26,14.42,,104.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1832.25,80,,201.864,Percent of Total Billed Charges,80% of Total Billed Charges,1145.16,50,,5444.368,Percent of Total Billed Charges,50% of Total Billed Charges,1145.16,50,,1412.8,Percent of Total Billed Charges,50% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1145.16,50,,1412.8,Percent of Total Billed Charges,50% of Total Billed Charges,1145.16,50,,1412.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1603.22,70,,5519.976,Percent of Total Billed Charges,70% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,320.64,14,,101.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2290.31,100,,252.328,Percent of Total Billed Charges,100% of Total Billed Charges,36.29,2836.6,
140488 RELOAD ECHELON GREEN,32150565,CDM,272,RC,,,Outpatient,,,617.5,370.50,,370.5,60,,1140.456,Percent of Total Billed Charges,60% of Total Billed Charges,277.88,45,,86.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.9,28,,1135.68,Percent of Total Billed Charges,28% of Total Billed Charges,36.4,32,,32.16,Percent of Total Billed Charges,32% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,222.3,36,,1460.16,Percent of Total Billed Charges,36% of Total Billed Charges,222.3,36,,1460.16,Percent of Total Billed Charges,36% Total Bille Charges,222.3,36,,1460.16,Percent of Total Billed Charges,36% of Total Billed Charges,370.5,60,,294.272,Percent of Total Billed Charges,60% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.5,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,89.04,14.42,,431.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.13,75,,1091.552,Percent of Total Billed Charges,75% of Total Billed Charges,308.75,50,,150.096,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.75,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.25,70,,107.104,Percent of Total Billed Charges,70% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,617.5,100,,1364.44,Percent of Total Billed Charges,100% of Total Billed Charges,36.4,617.5,
125754 RELOAD ECHELON GOLD,32150566,CDM,272,RC,,,Outpatient,,,624.57,374.74,,374.74,60,,467.808,Percent of Total Billed Charges,60% of Total Billed Charges,281.06,45,,115.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.88,28,,89.36,Percent of Total Billed Charges,28% of Total Billed Charges,36.48,32,,32.192,Percent of Total Billed Charges,32% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,224.85,36,,114.888,Percent of Total Billed Charges,36% of Total Billed Charges,224.85,36,,114.888,Percent of Total Billed Charges,36% Total Bille Charges,224.85,36,,114.888,Percent of Total Billed Charges,36% of Total Billed Charges,374.74,60,,100.848,Percent of Total Billed Charges,60% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,624.57,100,,2816.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,90.06,14.42,,49.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.43,75,,6091.008,Percent of Total Billed Charges,75% of Total Billed Charges,312.29,50,,1412.8,Percent of Total Billed Charges,50% of Total Billed Charges,312.29,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.29,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,312.29,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.2,70,,134.208,Percent of Total Billed Charges,70% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,87.44,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,624.57,100,,7613.76,Percent of Total Billed Charges,100% of Total Billed Charges,36.48,624.57,
125755 RELOAD ECHELON WHITE,32150567,CDM,272,RC,,,Outpatient,,,638.87,383.32,,383.32,60,,39.592,Percent of Total Billed Charges,60% of Total Billed Charges,287.49,45,,37.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.88,28,,194.12,Percent of Total Billed Charges,28% of Total Billed Charges,36.48,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,229.99,36,,249.584,Percent of Total Billed Charges,36% of Total Billed Charges,229.99,36,,249.584,Percent of Total Billed Charges,36% Total Bille Charges,229.99,36,,249.584,Percent of Total Billed Charges,36% of Total Billed Charges,383.32,60,,1646.24,Percent of Total Billed Charges,60% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,638.87,100,,2036.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,92.13,14.42,,897.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,479.15,75,,2875.392,Percent of Total Billed Charges,75% of Total Billed Charges,319.44,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,319.44,50,,361.488,Percent of Total Billed Charges,50% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.44,50,,361.488,Percent of Total Billed Charges,50% of Total Billed Charges,319.44,50,,361.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.21,70,,96.856,Percent of Total Billed Charges,70% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,89.44,14,,871.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,638.87,100,,3594.24,Percent of Total Billed Charges,100% of Total Billed Charges,36.48,638.87,
0005220 RELOAD ENDOPATH WHITE,32150569,CDM,272,RC,,,Outpatient,,,692.23,415.34,,415.34,60,,166.912,Percent of Total Billed Charges,60% of Total Billed Charges,311.5,45,,51.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.82,28,,436.624,Percent of Total Billed Charges,28% of Total Billed Charges,36.73,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.2,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,249.2,36,,561.368,Percent of Total Billed Charges,36% Total Bille Charges,249.2,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,415.34,60,,407.976,Percent of Total Billed Charges,60% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.23,100,,191.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14.42,,242.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.17,75,,4470.04,Percent of Total Billed Charges,75% of Total Billed Charges,346.12,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,1495.6,Percent of Total Billed Charges,50% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.12,50,,1495.6,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,1495.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.56,70,,120.136,Percent of Total Billed Charges,70% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,235.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,692.23,100,,5587.552,Percent of Total Billed Charges,100% of Total Billed Charges,36.73,692.23,
0005213 RELOAD ENDOPATH BLUE,32150570,CDM,272,RC,,,Outpatient,,,692.23,415.34,,415.34,60,,119.152,Percent of Total Billed Charges,60% of Total Billed Charges,311.5,45,,36.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.82,28,,137.328,Percent of Total Billed Charges,28% of Total Billed Charges,36.73,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,249.2,36,,176.568,Percent of Total Billed Charges,36% of Total Billed Charges,249.2,36,,176.568,Percent of Total Billed Charges,36% Total Bille Charges,249.2,36,,176.568,Percent of Total Billed Charges,36% of Total Billed Charges,415.34,60,,63.824,Percent of Total Billed Charges,60% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.23,100,,256.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14.42,,3528.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.17,75,,1572.48,Percent of Total Billed Charges,75% of Total Billed Charges,346.12,50,,361.488,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.12,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.56,70,,96.856,Percent of Total Billed Charges,70% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,3426.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,692.23,100,,2096.64,Percent of Total Billed Charges,100% of Total Billed Charges,36.73,692.23,
0007131 ENDO STAPLER CURVED,32150572,CDM,272,RC,,,Outpatient,,,1376.38,825.83,,825.83,60,,2579.328,Percent of Total Billed Charges,60% of Total Billed Charges,619.37,45,,165.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.39,28,,47.064,Percent of Total Billed Charges,28% of Total Billed Charges,36.75,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,495.5,36,,60.512,Percent of Total Billed Charges,36% of Total Billed Charges,495.5,36,,60.512,Percent of Total Billed Charges,36% Total Bille Charges,495.5,36,,60.512,Percent of Total Billed Charges,36% of Total Billed Charges,825.83,60,,2542.456,Percent of Total Billed Charges,60% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1376.38,100,,82.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14.42,,305.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1032.29,75,,481.2,Percent of Total Billed Charges,75% of Total Billed Charges,688.19,50,,1495.6,Percent of Total Billed Charges,50% of Total Billed Charges,688.19,50,,3111.68,Percent of Total Billed Charges,50% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688.19,50,,3111.68,Percent of Total Billed Charges,50% of Total Billed Charges,688.19,50,,3111.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,963.47,70,,245.952,Percent of Total Billed Charges,70% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,192.69,14,,296.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1376.38,100,,641.6,Percent of Total Billed Charges,100% of Total Billed Charges,36.75,1376.38,
178290 LAP BAND SYSTEM AP STRD,32150573,CDM,278,RC,,,Outpatient,,,10424.73,6254.84,,11467.2,110,,151.712,Percent of Total Billed Charges,110% of Total Billed Charges,4691.13,45,,116.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2918.92,28,,768.248,Percent of Total Billed Charges,28% of Total Billed Charges,36.76,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,3752.9,36,,987.744,Percent of Total Billed Charges,36% of Total Billed Charges,3752.9,36,,987.744,Percent of Total Billed Charges,36% Total Bille Charges,3752.9,36,,987.744,Percent of Total Billed Charges,36% of Total Billed Charges,5733.6,55,,1670.072,Percent of Total Billed Charges,55% Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10424.73,100,,114.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1503.25,14.42,,317.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8339.78,80,,1559.36,Percent of Total Billed Charges,80% of Total Billed Charges,5212.37,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,842.216,Percent of Total Billed Charges,50% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5212.37,50,,842.216,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,842.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7297.31,70,,236.384,Percent of Total Billed Charges,70% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,308.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10424.73,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,11467.2,
0001504 CLIP APPLIER ENDO,32150574,CDM,272,RC,,,Outpatient,,,530.63,318.38,,318.38,60,,57.488,Percent of Total Billed Charges,60% of Total Billed Charges,238.78,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.58,28,,190.392,Percent of Total Billed Charges,28% of Total Billed Charges,36.96,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,191.03,36,,244.784,Percent of Total Billed Charges,36% of Total Billed Charges,191.03,36,,244.784,Percent of Total Billed Charges,36% Total Bille Charges,191.03,36,,244.784,Percent of Total Billed Charges,36% of Total Billed Charges,318.38,60,,2284.128,Percent of Total Billed Charges,60% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530.63,100,,80.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,76.52,14.42,,429.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.97,75,,874.352,Percent of Total Billed Charges,75% of Total Billed Charges,265.32,50,,3111.68,Percent of Total Billed Charges,50% of Total Billed Charges,265.32,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.32,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,265.32,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371.44,70,,113.728,Percent of Total Billed Charges,70% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,74.29,14,,417.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,530.63,100,,1092.936,Percent of Total Billed Charges,100% of Total Billed Charges,36.96,530.63,
538770 ANCHOR QUICK MICRO,32150575,CDM,278,RC,C1713,HCPCS,Outpatient,,,1871.23,1122.74,,2375.61,110,,741.736,Percent of Total Billed Charges,110% of Total Billed Charges,842.05,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.94,28,,29.784,Percent of Total Billed Charges,28% of Total Billed Charges,37.09,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,673.64,36,,38.296,Percent of Total Billed Charges,36% of Total Billed Charges,673.64,36,,38.296,Percent of Total Billed Charges,36% Total Bille Charges,673.64,36,,38.296,Percent of Total Billed Charges,36% of Total Billed Charges,1029.18,55,,992.376,Percent of Total Billed Charges,55% Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1871.23,100,,367.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,269.83,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1496.98,80,,8710.992,Percent of Total Billed Charges,80% of Total Billed Charges,935.62,50,,842.216,Percent of Total Billed Charges,50% of Total Billed Charges,935.62,50,,1058.112,Percent of Total Billed Charges,50% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,935.62,50,,1058.112,Percent of Total Billed Charges,50% of Total Billed Charges,935.62,50,,1058.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1309.86,70,,559.424,Percent of Total Billed Charges,70% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,261.97,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1871.23,100,,10888.736,Percent of Total Billed Charges,100% of Total Billed Charges,37.09,2375.61,
659261 CEMENT BONE SMARTSET,32150577,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.41,189.25,,664.21,110,,1647.488,Percent of Total Billed Charges,110% of Total Billed Charges,141.93,45,,113.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.31,28,,1294.336,Percent of Total Billed Charges,28% of Total Billed Charges,37.12,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,113.55,36,,1664.152,Percent of Total Billed Charges,36% of Total Billed Charges,113.55,36,,1664.152,Percent of Total Billed Charges,36% Total Bille Charges,113.55,36,,1664.152,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.41,100,,257.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,45.48,14.42,,6999.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.33,80,,225.144,Percent of Total Billed Charges,80% of Total Billed Charges,157.71,50,,12236.4,Percent of Total Billed Charges,50% of Total Billed Charges,157.71,50,,1101.104,Percent of Total Billed Charges,50% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.71,50,,1101.104,Percent of Total Billed Charges,50% of Total Billed Charges,157.71,50,,1101.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.79,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,44.16,14,,6795.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.41,100,,300.192,Percent of Total Billed Charges,100% of Total Billed Charges,37.12,664.21,
447710 TIGHTROPE ARTHREX ACL,32150578,CDM,278,RC,C1713,HCPCS,Outpatient,,,1705.55,1023.33,,2193.37,110,,8641.344,Percent of Total Billed Charges,110% of Total Billed Charges,767.5,45,,66.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,28,,850.216,Percent of Total Billed Charges,28% of Total Billed Charges,37.12,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,614,36,,1093.136,Percent of Total Billed Charges,36% of Total Billed Charges,614,36,,1093.136,Percent of Total Billed Charges,36% Total Bille Charges,614,36,,1093.136,Percent of Total Billed Charges,36% of Total Billed Charges,938.05,55,,28430.592,Percent of Total Billed Charges,55% Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1705.55,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,245.94,14.42,,4362.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1364.44,80,,2119.192,Percent of Total Billed Charges,80% of Total Billed Charges,852.78,50,,1058.112,Percent of Total Billed Charges,50% of Total Billed Charges,852.78,50,,1490.72,Percent of Total Billed Charges,50% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,50,,1490.72,Percent of Total Billed Charges,50% of Total Billed Charges,852.78,50,,1490.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1193.89,70,,487.2,Percent of Total Billed Charges,70% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,4235.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,100,,2825.592,Percent of Total Billed Charges,100% of Total Billed Charges,37.12,2193.37,
761444 KIT STIMULAN RAPID CURE,32150581,CDM,278,RC,C1713,HCPCS,Outpatient,,,9517.2,5710.32,,10786.18,110,,3857.632,Percent of Total Billed Charges,110% of Total Billed Charges,4282.74,45,,30.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2664.82,28,,1065.928,Percent of Total Billed Charges,28% of Total Billed Charges,37.4,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,3426.19,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,3426.19,36,,1370.48,Percent of Total Billed Charges,36% Total Bille Charges,3426.19,36,,1370.48,Percent of Total Billed Charges,36% of Total Billed Charges,5234.46,55,,2387.424,Percent of Total Billed Charges,55% Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9517.2,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1372.38,14.42,,1366.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7613.76,80,,617.632,Percent of Total Billed Charges,80% of Total Billed Charges,4758.6,50,,1101.104,Percent of Total Billed Charges,50% of Total Billed Charges,4758.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,4758.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6662.04,70,,318.08,Percent of Total Billed Charges,70% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,1326.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9517.2,100,,772.04,Percent of Total Billed Charges,100% of Total Billed Charges,37.4,10786.18,
664267 MESH SURGIMEND COLLAGEN,32150583,CDM,278,RC,C1781,HCPCS,Outpatient,,,4492.8,2695.68,,5394.84,110,,2202.344,Percent of Total Billed Charges,110% of Total Billed Charges,2021.76,45,,40.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1257.98,28,,505.208,Percent of Total Billed Charges,28% of Total Billed Charges,37.44,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,1617.41,36,,649.552,Percent of Total Billed Charges,36% of Total Billed Charges,1617.41,36,,649.552,Percent of Total Billed Charges,36% Total Bille Charges,1617.41,36,,649.552,Percent of Total Billed Charges,36% of Total Billed Charges,2471.04,55,,2221.624,Percent of Total Billed Charges,55% Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4492.8,100,,252.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,647.86,14.42,,2671.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3594.24,80,,19578.24,Percent of Total Billed Charges,80% of Total Billed Charges,2246.4,50,,1490.72,Percent of Total Billed Charges,50% of Total Billed Charges,2246.4,50,,24268.864,Percent of Total Billed Charges,50% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2246.4,50,,24268.864,Percent of Total Billed Charges,50% of Total Billed Charges,2246.4,50,,24268.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3144.96,70,,7934.472,Percent of Total Billed Charges,70% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,628.99,14,,2593.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4492.8,100,,24472.8,Percent of Total Billed Charges,100% of Total Billed Charges,37.44,5394.84,
394070 MESH ECTHICON PHYSIO,32150584,CDM,278,RC,C1781,HCPCS,Outpatient,,,6984.44,4190.66,,8135.64,110,,140.712,Percent of Total Billed Charges,110% of Total Billed Charges,3143,45,,166.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1955.64,28,,559.696,Percent of Total Billed Charges,28% of Total Billed Charges,37.44,32,,32.216,Percent of Total Billed Charges,32% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,2514.4,36,,719.608,Percent of Total Billed Charges,36% of Total Billed Charges,2514.4,36,,719.608,Percent of Total Billed Charges,36% Total Bille Charges,2514.4,36,,719.608,Percent of Total Billed Charges,36% of Total Billed Charges,3841.44,55,,37389,Percent of Total Billed Charges,55% Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6984.44,100,,147.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,1007.16,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5587.55,80,,578.384,Percent of Total Billed Charges,80% of Total Billed Charges,3492.22,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,3492.22,50,,15125.552,Percent of Total Billed Charges,50% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3492.22,50,,15125.552,Percent of Total Billed Charges,50% of Total Billed Charges,3492.22,50,,15125.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4889.11,70,,442.176,Percent of Total Billed Charges,70% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,977.82,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6984.44,100,,722.976,Percent of Total Billed Charges,100% of Total Billed Charges,37.44,8135.64,
641085 INTRODUCER OSTEO,32150585,CDM,272,RC,,,Outpatient,,,2620.8,1572.48,,1572.48,60,,1090.016,Percent of Total Billed Charges,60% of Total Billed Charges,1179.36,45,,273.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.82,28,,14473.76,Percent of Total Billed Charges,28% of Total Billed Charges,37.6,32,,32.256,Percent of Total Billed Charges,32% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,943.49,36,,18609.12,Percent of Total Billed Charges,36% of Total Billed Charges,943.49,36,,18609.12,Percent of Total Billed Charges,36% Total Bille Charges,943.49,36,,18609.12,Percent of Total Billed Charges,36% of Total Billed Charges,1572.48,60,,2188.472,Percent of Total Billed Charges,60% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2620.8,100,,68.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,377.92,14.42,,344.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1965.6,75,,2243.4,Percent of Total Billed Charges,75% of Total Billed Charges,1310.4,50,,24268.864,Percent of Total Billed Charges,50% of Total Billed Charges,1310.4,50,,4737.2,Percent of Total Billed Charges,50% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1310.4,50,,4737.2,Percent of Total Billed Charges,50% of Total Billed Charges,1310.4,50,,4737.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1834.56,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,334.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2620.8,100,,2991.2,Percent of Total Billed Charges,100% of Total Billed Charges,37.6,2620.8,
799361 CATH INTRODUCER GRO,32150587,CDM,272,RC,,,Outpatient,,,802,481.20,,481.2,60,,1522.472,Percent of Total Billed Charges,60% of Total Billed Charges,360.9,45,,370.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.56,28,,1114.128,Percent of Total Billed Charges,28% of Total Billed Charges,37.61,32,,32.344,Percent of Total Billed Charges,32% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,288.72,36,,1432.456,Percent of Total Billed Charges,36% of Total Billed Charges,288.72,36,,1432.456,Percent of Total Billed Charges,36% Total Bille Charges,288.72,36,,1432.456,Percent of Total Billed Charges,36% of Total Billed Charges,481.2,60,,331.2,Percent of Total Billed Charges,60% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,802,100,,90.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14.42,,3183.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.5,75,,273.712,Percent of Total Billed Charges,75% of Total Billed Charges,401,50,,15125.552,Percent of Total Billed Charges,50% of Total Billed Charges,401,50,,9264,Percent of Total Billed Charges,50% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401,50,,9264,Percent of Total Billed Charges,50% of Total Billed Charges,401,50,,9264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,561.4,70,,9041.344,Percent of Total Billed Charges,70% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,3091.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,802,100,,342.144,Percent of Total Billed Charges,100% of Total Billed Charges,37.61,802,
0000152 ANCHOR MINI GII,32150588,CDM,278,RC,C1713,HCPCS,Outpatient,,,2436.5,1461.90,,2997.41,110,,559.512,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,44.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,1131.008,Percent of Total Billed Charges,28% of Total Billed Charges,37.73,32,,32.432,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,1454.152,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,1454.152,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,1454.152,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,1719.744,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,370.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,1079.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,4667.52,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,4737.2,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,2664.816,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,1047.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,6223.36,Percent of Total Billed Charges,100% of Total Billed Charges,37.73,2997.41,
814749 CEMENT BONE VERTAPLEX,32150589,CDM,278,RC,C1713,HCPCS,Outpatient,,,1366.17,819.70,,1820.05,110,,37.304,Percent of Total Billed Charges,110% of Total Billed Charges,614.78,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.53,28,,19034.4,Percent of Total Billed Charges,28% of Total Billed Charges,37766.25,32,,32.52,Percent of Total Billed Charges,32% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,491.82,36,,24472.8,Percent of Total Billed Charges,36% of Total Billed Charges,491.82,36,,24472.8,Percent of Total Billed Charges,36% Total Bille Charges,491.82,36,,24472.8,Percent of Total Billed Charges,36% of Total Billed Charges,751.39,55,,1864.72,Percent of Total Billed Charges,55% Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1366.17,100,,608.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,197,14.42,,646.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1092.94,80,,1347.536,Percent of Total Billed Charges,80% of Total Billed Charges,683.09,50,,9264,Percent of Total Billed Charges,50% of Total Billed Charges,683.09,50,,1194.272,Percent of Total Billed Charges,50% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,683.09,50,,1194.272,Percent of Total Billed Charges,50% of Total Billed Charges,683.09,50,,1194.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,956.32,70,,921,Percent of Total Billed Charges,70% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,191.26,14,,628.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1366.17,100,,1684.424,Percent of Total Billed Charges,100% of Total Billed Charges,191.26,37766.25,
501579 VALVE CERTAS PROGRA,32150590,CDM,278,RC,,,Outpatient,,,13610.92,8166.55,,14972.01,110,,1175.648,Percent of Total Billed Charges,110% of Total Billed Charges,6124.91,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3811.06,28,,1114.128,Percent of Total Billed Charges,28% of Total Billed Charges,38.26,32,,32.52,Percent of Total Billed Charges,32% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4899.93,36,,1432.456,Percent of Total Billed Charges,36% of Total Billed Charges,4899.93,36,,1432.456,Percent of Total Billed Charges,36% Total Bille Charges,4899.93,36,,1432.456,Percent of Total Billed Charges,36% of Total Billed Charges,7486.01,55,,368.864,Percent of Total Billed Charges,55% Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13610.92,100,,823.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1962.69,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10888.74,80,,19578.24,Percent of Total Billed Charges,80% of Total Billed Charges,6805.46,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,6805.46,50,,11040,Percent of Total Billed Charges,50% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6805.46,50,,11040,Percent of Total Billed Charges,50% of Total Billed Charges,6805.46,50,,11040,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9527.64,70,,832.312,Percent of Total Billed Charges,70% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1905.53,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13610.92,100,,24472.8,Percent of Total Billed Charges,100% of Total Billed Charges,38.26,14972.01,
547187 MANIPULATOR UTERINE,32150591,CDM,272,RC,,,Outpatient,,,375.24,225.14,,225.14,60,,519.84,Percent of Total Billed Charges,60% of Total Billed Charges,168.86,45,,420.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.07,28,,154.56,Percent of Total Billed Charges,28% of Total Billed Charges,38.28,32,,32.56,Percent of Total Billed Charges,32% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,135.09,36,,198.72,Percent of Total Billed Charges,36% of Total Billed Charges,135.09,36,,198.72,Percent of Total Billed Charges,36% Total Bille Charges,135.09,36,,198.72,Percent of Total Billed Charges,36% of Total Billed Charges,225.14,60,,4586.88,Percent of Total Billed Charges,60% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.24,100,,97.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,54.11,14.42,,106.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.43,75,,1587.16,Percent of Total Billed Charges,75% of Total Billed Charges,187.62,50,,1194.272,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3741.896,Percent of Total Billed Charges,50% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.62,50,,3741.896,Percent of Total Billed Charges,50% of Total Billed Charges,187.62,50,,3741.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.67,70,,286.832,Percent of Total Billed Charges,70% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,52.53,14,,103.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.24,100,,2116.216,Percent of Total Billed Charges,100% of Total Billed Charges,38.28,375.24,
417033 SEALER AQUAMANTYS,32150592,CDM,272,RC,,,Outpatient,,,3531.99,2119.19,,2119.19,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,1589.4,45,,111.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,988.96,28,,802.544,Percent of Total Billed Charges,28% of Total Billed Charges,38.32,32,,32.72,Percent of Total Billed Charges,32% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,1271.52,36,,1031.848,Percent of Total Billed Charges,36% of Total Billed Charges,1271.52,36,,1031.848,Percent of Total Billed Charges,36% Total Bille Charges,1271.52,36,,1031.848,Percent of Total Billed Charges,36% of Total Billed Charges,2119.19,60,,54.72,Percent of Total Billed Charges,60% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3531.99,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,509.31,14.42,,1079.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2648.99,75,,1651.648,Percent of Total Billed Charges,75% of Total Billed Charges,1766,50,,11040,Percent of Total Billed Charges,50% of Total Billed Charges,1766,50,,2243.344,Percent of Total Billed Charges,50% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1766,50,,2243.344,Percent of Total Billed Charges,50% of Total Billed Charges,1766,50,,2243.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2472.39,70,,563.36,Percent of Total Billed Charges,70% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,494.48,14,,1048.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3531.99,100,,2202.2,Percent of Total Billed Charges,100% of Total Billed Charges,38.32,3531.99,
801511 VASCU-GUARD 8X8CM,32150594,CDM,278,RC,,,Outpatient,,,965.05,579.03,,1061.56,110,,45.304,Percent of Total Billed Charges,110% of Total Billed Charges,434.27,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.21,28,,949.312,Percent of Total Billed Charges,28% of Total Billed Charges,38.37,32,,32.736,Percent of Total Billed Charges,32% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,347.42,36,,1220.544,Percent of Total Billed Charges,36% of Total Billed Charges,347.42,36,,1220.544,Percent of Total Billed Charges,36% Total Bille Charges,347.42,36,,1220.544,Percent of Total Billed Charges,36% of Total Billed Charges,530.78,55,,135.08,Percent of Total Billed Charges,55% Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,965.05,100,,167.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,139.16,14.42,,319.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,772.04,80,,2385.152,Percent of Total Billed Charges,80% of Total Billed Charges,482.53,50,,3741.896,Percent of Total Billed Charges,50% of Total Billed Charges,482.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,482.53,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675.54,70,,7280,Percent of Total Billed Charges,70% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,310.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,965.05,100,,2981.44,Percent of Total Billed Charges,100% of Total Billed Charges,38.37,1061.56,
821828 LEAD 32 CONTRACT,32150595,CDM,278,RC,C1778,HCPCS,Outpatient,,,30591,18354.60,,34232.7,110,,45.304,Percent of Total Billed Charges,110% of Total Billed Charges,13765.95,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,28,,172.136,Percent of Total Billed Charges,28% of Total Billed Charges,3862.1,32,,32.768,Percent of Total Billed Charges,32% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,11012.76,36,,221.32,Percent of Total Billed Charges,36% of Total Billed Charges,11012.76,36,,221.32,Percent of Total Billed Charges,36% Total Bille Charges,11012.76,36,,221.32,Percent of Total Billed Charges,36% of Total Billed Charges,16825.05,55,,205.44,Percent of Total Billed Charges,55% Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30591,100,,933.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4411.22,14.42,,1571.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24472.8,80,,2541,Percent of Total Billed Charges,80% of Total Billed Charges,15295.5,50,,2243.344,Percent of Total Billed Charges,50% of Total Billed Charges,15295.5,50,,368.352,Percent of Total Billed Charges,50% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15295.5,50,,368.352,Percent of Total Billed Charges,50% of Total Billed Charges,15295.5,50,,368.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21413.7,70,,1354.56,Percent of Total Billed Charges,70% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,1525.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30591,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,3862.1,34232.7,
394048 MESH ETHI. PHYSIO 7X15,32150596,CDM,278,RC,C1781,HCPCS,Outpatient,,,903.72,542.23,,1446.85,110,,45.304,Percent of Total Billed Charges,110% of Total Billed Charges,406.67,45,,181.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.04,28,,16.744,Percent of Total Billed Charges,28% of Total Billed Charges,3866.7,32,,32.92,Percent of Total Billed Charges,32% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,325.34,36,,21.528,Percent of Total Billed Charges,36% of Total Billed Charges,325.34,36,,21.528,Percent of Total Billed Charges,36% Total Bille Charges,325.34,36,,21.528,Percent of Total Billed Charges,36% of Total Billed Charges,497.05,55,,30.872,Percent of Total Billed Charges,55% Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,903.72,100,,247.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,130.32,14.42,,1173.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,722.98,80,,38830.176,Percent of Total Billed Charges,80% of Total Billed Charges,451.86,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,451.86,50,,3744,Percent of Total Billed Charges,50% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.86,50,,3744,Percent of Total Billed Charges,50% of Total Billed Charges,451.86,50,,3744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.6,70,,45.872,Percent of Total Billed Charges,70% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14,,1139.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,903.72,100,,48537.72,Percent of Total Billed Charges,100% of Total Billed Charges,126.52,3866.7,
476232 DURASEAL CONFLUENT,32150597,CDM,272,RC,,,Outpatient,,,3739,2243.40,,2243.4,60,,141.136,Percent of Total Billed Charges,60% of Total Billed Charges,1682.55,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1046.92,28,,2335.136,Percent of Total Billed Charges,28% of Total Billed Charges,3901.76,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,1346.04,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,1346.04,36,,3002.32,Percent of Total Billed Charges,36% Total Bille Charges,1346.04,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,2243.4,60,,11.008,Percent of Total Billed Charges,60% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3739,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,539.16,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2804.25,75,,24200.88,Percent of Total Billed Charges,75% of Total Billed Charges,1869.5,50,,368.352,Percent of Total Billed Charges,50% of Total Billed Charges,1869.5,50,,1108.728,Percent of Total Billed Charges,50% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1869.5,50,,1108.728,Percent of Total Billed Charges,50% of Total Billed Charges,1869.5,50,,1108.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2617.3,70,,7280,Percent of Total Billed Charges,70% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3739,100,,30251.104,Percent of Total Billed Charges,100% of Total Billed Charges,523.46,3901.76,
162818 SYSTEM KYPHON BONE,32150598,CDM,278,RC,C1713,HCPCS,Outpatient,,,427.68,256.61,,787.71,110,,9173.76,Percent of Total Billed Charges,110% of Total Billed Charges,192.46,45,,307.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.75,28,,25.536,Percent of Total Billed Charges,28% of Total Billed Charges,3910.4,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,153.96,36,,32.832,Percent of Total Billed Charges,36% of Total Billed Charges,153.96,36,,32.832,Percent of Total Billed Charges,36% Total Bille Charges,153.96,36,,32.832,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.68,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,61.67,14.42,,205.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.14,80,,7579.52,Percent of Total Billed Charges,80% of Total Billed Charges,213.84,50,,3744,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,5449.28,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.84,50,,5449.28,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,5449.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.38,70,,1422.96,Percent of Total Billed Charges,70% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,199.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.68,100,,9474.4,Percent of Total Billed Charges,100% of Total Billed Charges,59.88,3910.4,
SHEARTIP INTEGRA CUSA 1.5MM,32150599,CDM,272,RC,,,Outpatient,,,7779.2,4667.52,,4667.52,60,,8428.976,Percent of Total Billed Charges,60% of Total Billed Charges,3500.64,45,,683.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2178.18,28,,63.04,Percent of Total Billed Charges,28% of Total Billed Charges,3967.81,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,2800.51,36,,81.048,Percent of Total Billed Charges,36% of Total Billed Charges,2800.51,36,,81.048,Percent of Total Billed Charges,36% Total Bille Charges,2800.51,36,,81.048,Percent of Total Billed Charges,36% of Total Billed Charges,4667.52,60,,227.48,Percent of Total Billed Charges,60% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7779.2,100,,404.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1121.76,14.42,,139.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5834.4,75,,14822.4,Percent of Total Billed Charges,75% of Total Billed Charges,3889.6,50,,1108.728,Percent of Total Billed Charges,50% of Total Billed Charges,3889.6,50,,4068.608,Percent of Total Billed Charges,50% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3889.6,50,,4068.608,Percent of Total Billed Charges,50% of Total Billed Charges,3889.6,50,,4068.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5445.44,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,1089.09,14,,135.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7779.2,100,,18528,Percent of Total Billed Charges,100% of Total Billed Charges,1089.09,7779.2,
806801 BOVINE PERICARDIUM,32150600,CDM,278,RC,,,Outpatient,,,2105.53,1263.32,,2316.08,110,,311.04,Percent of Total Billed Charges,110% of Total Billed Charges,947.49,45,,206.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,589.55,28,,95.872,Percent of Total Billed Charges,28% of Total Billed Charges,3984.24,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,757.99,36,,123.264,Percent of Total Billed Charges,36% of Total Billed Charges,757.99,36,,123.264,Percent of Total Billed Charges,36% Total Bille Charges,757.99,36,,123.264,Percent of Total Billed Charges,36% of Total Billed Charges,1158.04,55,,712.8,Percent of Total Billed Charges,55% Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2105.53,100,,658.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,303.62,14.42,,193.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1684.42,80,,1247.488,Percent of Total Billed Charges,80% of Total Billed Charges,1052.77,50,,5449.28,Percent of Total Billed Charges,50% of Total Billed Charges,1052.77,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1052.77,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,1052.77,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1473.87,70,,4875.664,Percent of Total Billed Charges,70% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,294.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2105.53,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,294.77,3984.24,
766810 KIT BOSTON LEAD 50CM,32150601,CDM,278,RC,C1778,HCPCS,Outpatient,,,30591,18354.60,,34232.7,110,,231.936,Percent of Total Billed Charges,110% of Total Billed Charges,13765.95,45,,280.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,28,,14.408,Percent of Total Billed Charges,28% of Total Billed Charges,3989.44,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,11012.76,36,,18.52,Percent of Total Billed Charges,36% of Total Billed Charges,11012.76,36,,18.52,Percent of Total Billed Charges,36% Total Bille Charges,11012.76,36,,18.52,Percent of Total Billed Charges,36% of Total Billed Charges,16825.05,55,,91.248,Percent of Total Billed Charges,55% Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30591,100,,684,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4411.22,14.42,,53.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24472.8,80,,1910.832,Percent of Total Billed Charges,80% of Total Billed Charges,15295.5,50,,4068.608,Percent of Total Billed Charges,50% of Total Billed Charges,15295.5,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15295.5,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,15295.5,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21413.7,70,,96.76,Percent of Total Billed Charges,70% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,14,,51.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30591,100,,2388.544,Percent of Total Billed Charges,100% of Total Billed Charges,3989.44,34232.7,
830952 HALO CROWN W/SKULL PIN,32150602,CDM,270,RC,,,Outpatient,,,2645.27,1587.16,,1587.16,60,,1219.656,Percent of Total Billed Charges,60% of Total Billed Charges,1190.37,45,,428.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,740.68,28,,5.136,Percent of Total Billed Charges,28% of Total Billed Charges,4006.08,32,,33.024,Percent of Total Billed Charges,32% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,952.3,36,,6.6,Percent of Total Billed Charges,36% of Total Billed Charges,952.3,36,,6.6,Percent of Total Billed Charges,36% Total Bille Charges,952.3,36,,6.6,Percent of Total Billed Charges,36% of Total Billed Charges,1587.16,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2645.27,100,,1518.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,381.45,14.42,,238.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1983.95,75,,17664,Percent of Total Billed Charges,75% of Total Billed Charges,1322.64,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,1322.64,50,,482.448,Percent of Total Billed Charges,50% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1322.64,50,,482.448,Percent of Total Billed Charges,50% of Total Billed Charges,1322.64,50,,482.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1851.69,70,,12202.792,Percent of Total Billed Charges,70% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,370.34,14,,231.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2645.27,100,,22080,Percent of Total Billed Charges,100% of Total Billed Charges,370.34,4006.08,
540670 AQUAMANTYS SBS5.0,32150606,CDM,272,RC,,,Outpatient,,,2752.75,1651.65,,1651.65,60,,1733.256,Percent of Total Billed Charges,60% of Total Billed Charges,1238.74,45,,621,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,770.77,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,4023.49,32,,33.16,Percent of Total Billed Charges,32% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,990.99,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,990.99,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,990.99,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1651.65,60,,342.76,Percent of Total Billed Charges,60% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2752.75,100,,459.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,396.95,14.42,,243.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2064.56,75,,5987.024,Percent of Total Billed Charges,75% of Total Billed Charges,1376.38,50,,711.752,Percent of Total Billed Charges,50% of Total Billed Charges,1376.38,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1376.38,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,1376.38,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1926.93,70,,2176.72,Percent of Total Billed Charges,70% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,385.39,14,,236.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2752.75,100,,7483.784,Percent of Total Billed Charges,100% of Total Billed Charges,385.39,4023.49,
483771 KNOTLESS TIGHTROPE,32150608,CDM,278,RC,C1713,HCPCS,Outpatient,,,3726.8,2236.08,,4416.74,110,,1003.448,Percent of Total Billed Charges,110% of Total Billed Charges,1677.06,45,,247.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1043.5,28,,115.808,Percent of Total Billed Charges,28% of Total Billed Charges,4054.87,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1341.65,36,,148.896,Percent of Total Billed Charges,36% of Total Billed Charges,1341.65,36,,148.896,Percent of Total Billed Charges,36% Total Bille Charges,1341.65,36,,148.896,Percent of Total Billed Charges,36% of Total Billed Charges,2049.74,55,,154.384,Percent of Total Billed Charges,55% Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3726.8,100,,623.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,537.4,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2981.44,80,,3589.344,Percent of Total Billed Charges,80% of Total Billed Charges,1863.4,50,,482.448,Percent of Total Billed Charges,50% of Total Billed Charges,1863.4,50,,184.736,Percent of Total Billed Charges,50% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1863.4,50,,184.736,Percent of Total Billed Charges,50% of Total Billed Charges,1863.4,50,,184.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2608.76,70,,36184.392,Percent of Total Billed Charges,70% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,521.75,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3726.8,100,,4486.68,Percent of Total Billed Charges,100% of Total Billed Charges,521.75,4416.74,
833613 ST JUDE CHARGING SYSTEM,32150609,CDM,272,RC,C1787,HCPCS,Outpatient,,,4235,2541.00,,59.4,100,,1805.848,Fee Schedule,100% of Aetna Fee Schedule,1905.75,45,,621,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,332.64,Percent of Total Billed Charges,28% of Total Billed Charges,4057.75,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,427.68,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,427.68,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,427.68,Percent of Total Billed Charges,36% of Total Billed Charges,2541,60,,1464.632,Percent of Total Billed Charges,60% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,952.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3176.25,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,2117.5,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,828,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,828,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,828,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,3123.12,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,59.4,4235,
833615 IMPLANT ST JUDE IPG 16,32150610,CDM,278,RC,C1820,HCPCS,Outpatient,,,60672.15,36403.29,,68369.55,110,,1647.488,Percent of Total Billed Charges,110% of Total Billed Charges,27302.47,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16988.2,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4068.04,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,21841.97,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,21841.97,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,21841.97,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,33369.68,55,,1380.76,Percent of Total Billed Charges,55% Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60672.15,100,,1380,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8748.92,14.42,,526.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48537.72,80,,552.528,Percent of Total Billed Charges,80% of Total Billed Charges,30336.08,50,,184.736,Percent of Total Billed Charges,50% of Total Billed Charges,30336.08,50,,845.104,Percent of Total Billed Charges,50% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30336.08,50,,845.104,Percent of Total Billed Charges,50% of Total Billed Charges,30336.08,50,,845.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42470.51,70,,398.968,Percent of Total Billed Charges,70% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,8494.1,14,,511.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60672.15,100,,736.704,Percent of Total Billed Charges,100% of Total Billed Charges,4068.04,68369.55,
834977 BOSTON KIT LEAD 50,32150611,CDM,278,RC,C1778,HCPCS,Outpatient,,,37813.88,22688.33,,42177.87,110,,2349.528,Percent of Total Billed Charges,110% of Total Billed Charges,17016.25,45,,67.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10587.89,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,4068.04,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,13613,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,13613,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,13613,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,20797.63,55,,288,Percent of Total Billed Charges,55% Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37813.88,100,,550.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5452.76,14.42,,404.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30251.1,80,,5990.4,Percent of Total Billed Charges,80% of Total Billed Charges,18906.94,50,,828,Percent of Total Billed Charges,50% of Total Billed Charges,18906.94,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18906.94,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,18906.94,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26469.72,70,,802.856,Percent of Total Billed Charges,70% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,5293.94,14,,393.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37813.88,100,,7488,Percent of Total Billed Charges,100% of Total Billed Charges,4068.04,42177.87,
809710 STENT ENDOLOGIX,32150612,CDM,278,RC,C1874,HCPCS,Outpatient,,,11843,7105.80,,13519.71,110,,816.328,Percent of Total Billed Charges,110% of Total Billed Charges,5329.35,45,,27.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3316.04,28,,174.496,Percent of Total Billed Charges,28% of Total Billed Charges,4093.44,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,4263.48,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,4263.48,36,,224.352,Percent of Total Billed Charges,36% Total Bille Charges,4263.48,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,6513.65,55,,219.456,Percent of Total Billed Charges,55% Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11843,100,,1380,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1707.76,14.42,,16.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9474.4,80,,1773.96,Percent of Total Billed Charges,80% of Total Billed Charges,5921.5,50,,845.104,Percent of Total Billed Charges,50% of Total Billed Charges,5921.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5921.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,5921.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8290.1,70,,35784,Percent of Total Billed Charges,70% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1658.02,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11843,100,,2217.448,Percent of Total Billed Charges,100% of Total Billed Charges,1658.02,13519.71,
836726 ENDOLOGIX AFX MAIN,32150613,CDM,278,RC,C1766,HCPCS,Outpatient,,,23160,13896.00,,25613.47,110,,1499,Percent of Total Billed Charges,110% of Total Billed Charges,10422,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6484.8,28,,72.048,Percent of Total Billed Charges,28% of Total Billed Charges,4118.61,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,8337.6,36,,92.632,Percent of Total Billed Charges,36% of Total Billed Charges,8337.6,36,,92.632,Percent of Total Billed Charges,36% Total Bille Charges,8337.6,36,,92.632,Percent of Total Billed Charges,36% of Total Billed Charges,12738,55,,1120.528,Percent of Total Billed Charges,55% Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23160,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3339.67,14.42,,412.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18528,80,,8718.84,Percent of Total Billed Charges,80% of Total Billed Charges,11580,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,11580,50,,1826.616,Percent of Total Billed Charges,50% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11580,50,,1826.616,Percent of Total Billed Charges,50% of Total Billed Charges,11580,50,,1826.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16212,70,,2037.064,Percent of Total Billed Charges,70% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,3242.4,14,,400.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23160,100,,10898.552,Percent of Total Billed Charges,100% of Total Billed Charges,3242.4,25613.47,
479368 SWIVELOCK ARTHREX BIO,32150614,CDM,278,RC,C1713,HCPCS,Outpatient,,,1949.2,1169.52,,2461.38,110,,840.36,Percent of Total Billed Charges,110% of Total Billed Charges,877.14,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,745.632,Percent of Total Billed Charges,28% of Total Billed Charges,4118.61,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,958.672,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,958.672,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,958.672,Percent of Total Billed Charges,36% of Total Billed Charges,1072.06,55,,1074.16,Percent of Total Billed Charges,55% Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,150.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,8.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1559.36,80,,6102.904,Percent of Total Billed Charges,80% of Total Billed Charges,974.6,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,1404,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,1404,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,1404,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,1356.24,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,8.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,8137.208,Percent of Total Billed Charges,100% of Total Billed Charges,272.89,4118.61,
222858 CHRONOS(SYNTHES TM) GRA,32150615,CDM,278,RC,C1713,HCPCS,Outpatient,,,2985.68,1791.41,,3601.51,110,,840.36,Percent of Total Billed Charges,110% of Total Billed Charges,1343.56,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.99,28,,702.936,Percent of Total Billed Charges,28% of Total Billed Charges,3.84,32,,3328,Percent of Total Billed Charges,32% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,1074.84,36,,903.768,Percent of Total Billed Charges,36% of Total Billed Charges,1074.84,36,,903.768,Percent of Total Billed Charges,36% Total Bille Charges,1074.84,36,,903.768,Percent of Total Billed Charges,36% of Total Billed Charges,1642.12,55,,699.84,Percent of Total Billed Charges,55% Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2985.68,100,,60.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,430.54,14.42,,1010.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2388.54,80,,320.76,Percent of Total Billed Charges,80% of Total Billed Charges,1492.84,50,,1826.616,Percent of Total Billed Charges,50% of Total Billed Charges,1492.84,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.84,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,1492.84,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.98,70,,2434.496,Percent of Total Billed Charges,70% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,418,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2985.68,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,3.84,3601.51,
501089 MESH TEI ACELLULAR COLL,32150617,CDM,278,RC,C1781,HCPCS,Outpatient,,,27600,16560.00,,30812.76,110,,4740.488,Percent of Total Billed Charges,110% of Total Billed Charges,12420,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7728,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3.85,32,,3334.224,Percent of Total Billed Charges,32% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,9936,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,9936,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,9936,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,15180,55,,1560.6,Percent of Total Billed Charges,55% Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27600,100,,68.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3979.92,14.42,,566.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22080,80,,1138.8,Percent of Total Billed Charges,80% of Total Billed Charges,13800,50,,1404,Percent of Total Billed Charges,50% of Total Billed Charges,13800,50,,9600,Percent of Total Billed Charges,50% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13800,50,,9600,Percent of Total Billed Charges,50% of Total Billed Charges,13800,50,,9600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19320,70,,77.896,Percent of Total Billed Charges,70% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,3864,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27600,100,,1423.504,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,30812.76,
643644 NORIAN DRILLABLE INJECT,32150619,CDM,278,RC,C1713,HCPCS,Outpatient,,,9354.73,5612.84,,10607.46,110,,1533.416,Percent of Total Billed Charges,110% of Total Billed Charges,4209.63,45,,907.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2619.32,28,,102.416,Percent of Total Billed Charges,28% of Total Billed Charges,3.86,32,,3350.056,Percent of Total Billed Charges,32% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,3367.7,36,,131.672,Percent of Total Billed Charges,36% of Total Billed Charges,3367.7,36,,131.672,Percent of Total Billed Charges,36% Total Bille Charges,3367.7,36,,131.672,Percent of Total Billed Charges,36% of Total Billed Charges,5145.1,55,,3048.76,Percent of Total Billed Charges,55% Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9354.73,100,,68.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1348.95,14.42,,958.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7483.78,80,,771.92,Percent of Total Billed Charges,80% of Total Billed Charges,4677.37,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,4677.37,50,,1430,Percent of Total Billed Charges,50% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4677.37,50,,1430,Percent of Total Billed Charges,50% of Total Billed Charges,4677.37,50,,1430,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6548.31,70,,2831.92,Percent of Total Billed Charges,70% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,1309.66,14,,930.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9354.73,100,,964.896,Percent of Total Billed Charges,100% of Total Billed Charges,3.86,10607.46,
746580 SYSTEM IMPLANT DELIVERY,32150620,CDM,278,RC,C1713,HCPCS,Outpatient,,,5608.35,3365.01,,6486.45,110,,1533.416,Percent of Total Billed Charges,110% of Total Billed Charges,2523.76,45,,284.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1570.34,28,,522.912,Percent of Total Billed Charges,28% of Total Billed Charges,3.87,32,,3353.536,Percent of Total Billed Charges,32% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,2019.01,36,,672.32,Percent of Total Billed Charges,36% of Total Billed Charges,2019.01,36,,672.32,Percent of Total Billed Charges,36% Total Bille Charges,2019.01,36,,672.32,Percent of Total Billed Charges,36% of Total Billed Charges,3084.59,55,,264,Percent of Total Billed Charges,55% Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5608.35,100,,68.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,808.72,14.42,,302.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4486.68,80,,1075.96,Percent of Total Billed Charges,80% of Total Billed Charges,2804.18,50,,9600,Percent of Total Billed Charges,50% of Total Billed Charges,2804.18,50,,29.856,Percent of Total Billed Charges,50% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2804.18,50,,29.856,Percent of Total Billed Charges,50% of Total Billed Charges,2804.18,50,,29.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3925.85,70,,2607.712,Percent of Total Billed Charges,70% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,293.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5608.35,100,,1344.952,Percent of Total Billed Charges,100% of Total Billed Charges,3.87,6486.45,
452661 SET COOK BIODESIGN,32150621,CDM,278,RC,C1781,HCPCS,Outpatient,,,4235,2541.00,,5111.26,110,,1711.808,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,232.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,501.28,Percent of Total Billed Charges,28% of Total Billed Charges,3.88,32,,3466.24,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,644.496,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,644.496,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,644.496,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,236.72,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,68.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,667.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,295.576,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,1430,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,2992.08,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,648.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,369.472,Percent of Total Billed Charges,100% of Total Billed Charges,3.88,5111.26,
PACK BMCC DR. LEE,32150623,CDM,272,RC,,,Outpatient,,,920.88,552.53,,552.53,60,,939.928,Percent of Total Billed Charges,60% of Total Billed Charges,414.4,45,,232.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.85,28,,326.592,Percent of Total Billed Charges,28% of Total Billed Charges,3.88,32,,3472.944,Percent of Total Billed Charges,32% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,331.52,36,,419.904,Percent of Total Billed Charges,36% of Total Billed Charges,331.52,36,,419.904,Percent of Total Billed Charges,36% Total Bille Charges,331.52,36,,419.904,Percent of Total Billed Charges,36% of Total Billed Charges,552.53,60,,4437.736,Percent of Total Billed Charges,60% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,920.88,100,,2016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,132.79,14.42,,1450.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,690.66,75,,1324.8,Percent of Total Billed Charges,75% of Total Billed Charges,460.44,50,,29.856,Percent of Total Billed Charges,50% of Total Billed Charges,460.44,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.44,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,460.44,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.62,70,,921,Percent of Total Billed Charges,70% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.92,14,,1408.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,920.88,100,,1656,Percent of Total Billed Charges,100% of Total Billed Charges,3.88,920.88,
659636 MESH SURGIMEND 3.0 10CM,32150624,CDM,278,RC,C1781,HCPCS,Outpatient,,,9360,5616.00,,10748.76,110,,51.528,Percent of Total Billed Charges,110% of Total Billed Charges,4212,45,,49.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2620.8,28,,794.488,Percent of Total Billed Charges,28% of Total Billed Charges,3.9,32,,3484.392,Percent of Total Billed Charges,32% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,3369.6,36,,1021.48,Percent of Total Billed Charges,36% of Total Billed Charges,3369.6,36,,1021.48,Percent of Total Billed Charges,36% Total Bille Charges,3369.6,36,,1021.48,Percent of Total Billed Charges,36% of Total Billed Charges,5148,55,,331.84,Percent of Total Billed Charges,55% Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9360,100,,632.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1349.71,14.42,,539.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7488,80,,1267.656,Percent of Total Billed Charges,80% of Total Billed Charges,4680,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,4680,50,,3323.408,Percent of Total Billed Charges,50% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4680,50,,3323.408,Percent of Total Billed Charges,50% of Total Billed Charges,4680,50,,3323.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6552,70,,34261.92,Percent of Total Billed Charges,70% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.4,14,,523.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9360,100,,1690.208,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,10748.76,
636590 ALLOGRAFT STRYKER VITOS,32150625,CDM,278,RC,C1713,HCPCS,Outpatient,,,2771.81,1663.09,,3366.25,110,,10291.424,Percent of Total Billed Charges,110% of Total Billed Charges,1247.31,45,,174.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.11,28,,1552.096,Percent of Total Billed Charges,28% of Total Billed Charges,3.9,32,,3487.536,Percent of Total Billed Charges,32% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,997.85,36,,1995.552,Percent of Total Billed Charges,36% of Total Billed Charges,997.85,36,,1995.552,Percent of Total Billed Charges,36% Total Bille Charges,997.85,36,,1995.552,Percent of Total Billed Charges,36% of Total Billed Charges,1524.5,55,,249.6,Percent of Total Billed Charges,55% Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2771.81,100,,517.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,399.7,14.42,,218.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2217.45,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,1385.91,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,1385.91,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1385.91,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,1385.91,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1940.27,70,,1950.048,Percent of Total Billed Charges,70% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,388.05,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2771.81,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,3366.25,
542030 VALVE CODMAN PROGRAM,32150626,CDM,278,RC,,,Outpatient,,,13623.19,8173.91,,14985.51,110,,811.856,Percent of Total Billed Charges,110% of Total Billed Charges,6130.44,45,,562.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3814.49,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,3.9,32,,3504.072,Percent of Total Billed Charges,32% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,4904.35,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,4904.35,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,4904.35,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,7492.75,55,,316.8,Percent of Total Billed Charges,55% Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13623.19,100,,517.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1964.46,14.42,,781.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10898.55,80,,1461.904,Percent of Total Billed Charges,80% of Total Billed Charges,6811.6,50,,3323.408,Percent of Total Billed Charges,50% of Total Billed Charges,6811.6,50,,2315.976,Percent of Total Billed Charges,50% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6811.6,50,,2315.976,Percent of Total Billed Charges,50% of Total Billed Charges,6811.6,50,,2315.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9536.23,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,1907.25,14,,758.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13623.19,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,14985.51,
833155 KYPHOPAK EXPRESS,32150627,CDM,272,RC,,,Outpatient,,,10171.51,6102.91,,6102.91,60,,296.4,Percent of Total Billed Charges,60% of Total Billed Charges,4577.18,45,,93.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2848.02,28,,120.512,Percent of Total Billed Charges,28% of Total Billed Charges,3.91,32,,3504.104,Percent of Total Billed Charges,32% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,3661.74,36,,154.944,Percent of Total Billed Charges,36% of Total Billed Charges,3661.74,36,,154.944,Percent of Total Billed Charges,36% Total Bille Charges,3661.74,36,,154.944,Percent of Total Billed Charges,36% of Total Billed Charges,6102.91,60,,1504.272,Percent of Total Billed Charges,60% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10171.51,100,,109.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1466.73,14.42,,3725.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7628.63,75,,2739.928,Percent of Total Billed Charges,75% of Total Billed Charges,5085.76,50,,1048.32,Percent of Total Billed Charges,50% of Total Billed Charges,5085.76,50,,5029.368,Percent of Total Billed Charges,50% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5085.76,50,,5029.368,Percent of Total Billed Charges,50% of Total Billed Charges,5085.76,50,,5029.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7120.06,70,,61.488,Percent of Total Billed Charges,70% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,1424.01,14,,3616.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10171.51,100,,3653.232,Percent of Total Billed Charges,100% of Total Billed Charges,3.91,10171.51,
549275 CARTRIGES MDTRONIC KY,32150628,CDM,272,RC,,,Outpatient,,,534.6,320.76,,320.76,60,,114.424,Percent of Total Billed Charges,60% of Total Billed Charges,240.57,45,,420.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,2070.944,Percent of Total Billed Charges,28% of Total Billed Charges,3.92,32,,3517.696,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,2662.64,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,2662.64,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,2662.64,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,387.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,1280.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,2246.4,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,2315.976,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,1869.456,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,1869.456,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,1869.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,608.6,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1243.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,2808,Percent of Total Billed Charges,100% of Total Billed Charges,3.92,534.6,
570198 GUN SOFAMOR CEMENT,32150629,CDM,278,RC,C1713,HCPCS,Outpatient,,,1779.38,1067.63,,2274.58,110,,532.8,Percent of Total Billed Charges,110% of Total Billed Charges,800.72,45,,460.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.23,28,,168.936,Percent of Total Billed Charges,28% of Total Billed Charges,3.93,32,,3529.304,Percent of Total Billed Charges,32% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,640.58,36,,217.208,Percent of Total Billed Charges,36% of Total Billed Charges,640.58,36,,217.208,Percent of Total Billed Charges,36% Total Bille Charges,640.58,36,,217.208,Percent of Total Billed Charges,36% of Total Billed Charges,978.66,55,,2434.432,Percent of Total Billed Charges,55% Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1779.38,100,,1250.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,256.59,14.42,,1010.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1423.5,80,,85.064,Percent of Total Billed Charges,80% of Total Billed Charges,889.69,50,,5029.368,Percent of Total Billed Charges,50% of Total Billed Charges,889.69,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,889.69,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,889.69,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1245.57,70,,105.952,Percent of Total Billed Charges,70% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,249.11,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.38,100,,113.416,Percent of Total Billed Charges,100% of Total Billed Charges,3.93,2274.58,
490027 ANCHOR CONMED LINVATEC,32150631,CDM,278,RC,C1713,HCPCS,Outpatient,,,1206.12,723.67,,1643.99,110,,61.912,Percent of Total Billed Charges,110% of Total Billed Charges,542.75,45,,877.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.71,28,,116.48,Percent of Total Billed Charges,28% of Total Billed Charges,3.95,32,,3532.8,Percent of Total Billed Charges,32% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,434.2,36,,149.76,Percent of Total Billed Charges,36% of Total Billed Charges,434.2,36,,149.76,Percent of Total Billed Charges,36% Total Bille Charges,434.2,36,,149.76,Percent of Total Billed Charges,36% of Total Billed Charges,663.37,55,,959.008,Percent of Total Billed Charges,55% Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1206.12,100,,208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,173.92,14.42,,112.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,964.9,80,,15360,Percent of Total Billed Charges,80% of Total Billed Charges,603.06,50,,1869.456,Percent of Total Billed Charges,50% of Total Billed Charges,603.06,50,,2710.24,Percent of Total Billed Charges,50% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,603.06,50,,2710.24,Percent of Total Billed Charges,50% of Total Billed Charges,603.06,50,,2710.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.28,70,,1528.8,Percent of Total Billed Charges,70% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,168.86,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1206.12,100,,19200,Percent of Total Billed Charges,100% of Total Billed Charges,3.95,1643.99,
376927 SCREW ARTHREX BIO-COMP,32150632,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681.19,1008.71,,2166.57,110,,1202.672,Percent of Total Billed Charges,110% of Total Billed Charges,756.54,45,,188.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,470.73,28,,147.84,Percent of Total Billed Charges,28% of Total Billed Charges,3.95,32,,3567.592,Percent of Total Billed Charges,32% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,605.23,36,,190.08,Percent of Total Billed Charges,36% of Total Billed Charges,605.23,36,,190.08,Percent of Total Billed Charges,36% Total Bille Charges,605.23,36,,190.08,Percent of Total Billed Charges,36% of Total Billed Charges,924.65,55,,199.816,Percent of Total Billed Charges,55% Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1681.19,100,,934.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,242.43,14.42,,451.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344.95,80,,2288,Percent of Total Billed Charges,80% of Total Billed Charges,840.6,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,840.6,50,,12916.2,Percent of Total Billed Charges,50% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840.6,50,,12916.2,Percent of Total Billed Charges,50% of Total Billed Charges,840.6,50,,12916.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.83,70,,188.272,Percent of Total Billed Charges,70% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,438.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1681.19,100,,2860,Percent of Total Billed Charges,100% of Total Billed Charges,3.95,2166.57,
160649 WIRE FX KRSH 450MM,32150633,CDM,278,RC,C1713,HCPCS,Outpatient,,,461.84,277.10,,825.28,110,,256.608,Percent of Total Billed Charges,110% of Total Billed Charges,207.83,45,,2850.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.32,28,,701.992,Percent of Total Billed Charges,28% of Total Billed Charges,3.96,32,,3572.608,Percent of Total Billed Charges,32% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,166.26,36,,902.56,Percent of Total Billed Charges,36% of Total Billed Charges,166.26,36,,902.56,Percent of Total Billed Charges,36% Total Bille Charges,166.26,36,,902.56,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,461.84,100,,1022.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,66.6,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.47,80,,47.768,Percent of Total Billed Charges,80% of Total Billed Charges,230.92,50,,2710.24,Percent of Total Billed Charges,50% of Total Billed Charges,230.92,50,,4440.8,Percent of Total Billed Charges,50% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.92,50,,4440.8,Percent of Total Billed Charges,50% of Total Billed Charges,230.92,50,,4440.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.29,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,64.66,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.84,100,,59.712,Percent of Total Billed Charges,100% of Total Billed Charges,3.96,825.28,
860230 MESH SURGIMEND 5X6CM,32150634,CDM,278,RC,C1781,HCPCS,Outpatient,,,2070,1242.00,,2729.76,110,,2119.416,Percent of Total Billed Charges,110% of Total Billed Charges,931.5,45,,155.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.6,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,3.96,32,,3.336,Percent of Total Billed Charges,32% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,745.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,745.2,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,745.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,1138.5,55,,129.24,Percent of Total Billed Charges,55% Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070,100,,1949.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,298.49,14.42,,101.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1656,80,,5256.576,Percent of Total Billed Charges,80% of Total Billed Charges,1035,50,,12916.2,Percent of Total Billed Charges,50% of Total Billed Charges,1035,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,1035,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449,70,,2839.2,Percent of Total Billed Charges,70% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.8,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070,100,,7008.768,Percent of Total Billed Charges,100% of Total Billed Charges,3.96,2729.76,
759085 CARTIDGE VERTEPORT MA,32150635,CDM,272,RC,,,Outpatient,,,2112.76,1267.66,,1267.66,60,,135.92,Percent of Total Billed Charges,60% of Total Billed Charges,950.74,45,,2761.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,591.57,28,,1239.344,Percent of Total Billed Charges,28% of Total Billed Charges,3.98,32,,3.352,Percent of Total Billed Charges,32% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,760.59,36,,1593.448,Percent of Total Billed Charges,36% of Total Billed Charges,760.59,36,,1593.448,Percent of Total Billed Charges,36% Total Bille Charges,760.59,36,,1593.448,Percent of Total Billed Charges,36% of Total Billed Charges,1267.66,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2112.76,100,,419.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,304.66,14.42,,101.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1584.57,75,,3144.96,Percent of Total Billed Charges,75% of Total Billed Charges,1056.38,50,,4440.8,Percent of Total Billed Charges,50% of Total Billed Charges,1056.38,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1056.38,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,1056.38,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1478.93,70,,223.392,Percent of Total Billed Charges,70% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2112.76,100,,3931.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.98,2112.76,
818789 10G BONE BX KIT,32150636,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,840.36,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,49.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,447.536,Percent of Total Billed Charges,28% of Total Billed Charges,4.01,32,,3.36,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,575.4,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,575.4,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,575.4,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,91.032,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,6333.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,13.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,4985.112,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1566.952,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1566.952,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1566.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,485.304,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,13.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,6646.816,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,375,
759087 CARTRIDGE VERTEPORT,32150637,CDM,272,RC,,,Outpatient,,,2436.5,1461.90,,1461.9,60,,840.36,Percent of Total Billed Charges,60% of Total Billed Charges,1096.43,45,,49.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,93.248,Percent of Total Billed Charges,28% of Total Billed Charges,4.02,32,,3.376,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,119.888,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,119.888,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,119.888,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,538.072,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,345.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,1572.48,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,1091.552,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,2096.64,Percent of Total Billed Charges,100% of Total Billed Charges,4.02,2436.5,
862437 KIT 10G VAS BALLOON,32150638,CDM,272,RC,,,Outpatient,,,4566.54,2739.92,,2739.92,60,,3356.168,Percent of Total Billed Charges,60% of Total Billed Charges,2054.94,45,,120.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1278.63,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,4.05,32,,3.4,Percent of Total Billed Charges,32% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,1643.95,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1643.95,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,1643.95,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2739.92,60,,555.136,Percent of Total Billed Charges,60% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4566.54,100,,6136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,658.5,14.42,,1010.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3424.91,75,,3473.968,Percent of Total Billed Charges,75% of Total Billed Charges,2283.27,50,,1566.952,Percent of Total Billed Charges,50% of Total Billed Charges,2283.27,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2283.27,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,2283.27,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3196.58,70,,343.32,Percent of Total Billed Charges,70% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,639.32,14,,981.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4566.54,100,,4631.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.05,4566.54,
863728 GRAFT ALPHATEC BIOLOGIC,32150639,CDM,278,RC,,,Outpatient,,,3510,2106.00,,3861,110,,2239.776,Percent of Total Billed Charges,110% of Total Billed Charges,1579.5,45,,307.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,982.8,28,,60.312,Percent of Total Billed Charges,28% of Total Billed Charges,4.06,32,,3.432,Percent of Total Billed Charges,32% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,1263.6,36,,77.544,Percent of Total Billed Charges,36% of Total Billed Charges,1263.6,36,,77.544,Percent of Total Billed Charges,36% Total Bille Charges,1263.6,36,,77.544,Percent of Total Billed Charges,36% of Total Billed Charges,1930.5,55,,2233.336,Percent of Total Billed Charges,55% Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3510,100,,110.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,14.42,,35.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2808,80,,7544.048,Percent of Total Billed Charges,80% of Total Billed Charges,1755,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,1755,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1755,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,1755,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2457,70,,117.656,Percent of Total Billed Charges,70% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,491.4,14,,33.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3510,100,,10058.728,Percent of Total Billed Charges,100% of Total Billed Charges,4.06,3861,
864268 SUTURE STRATAFIX 3-0 SP,32150640,CDM,272,RC,,,Outpatient,,,141.77,85.06,,85.06,60,,114.824,Percent of Total Billed Charges,60% of Total Billed Charges,63.8,45,,442.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.7,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,4.07,32,,3.448,Percent of Total Billed Charges,32% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,51.04,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,51.04,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,51.04,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,85.06,60,,965.248,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.77,100,,110.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,20.44,14.42,,179.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.33,75,,2991.12,Percent of Total Billed Charges,75% of Total Billed Charges,70.89,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,70.89,50,,47.824,Percent of Total Billed Charges,50% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.89,50,,47.824,Percent of Total Billed Charges,50% of Total Billed Charges,70.89,50,,47.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.24,70,,1920.616,Percent of Total Billed Charges,70% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,174.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.77,100,,3738.904,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,141.77,
665061 MESH SURGIMEND COLLAGEN,32150641,CDM,278,RC,C9360,HCPCS,Outpatient,,,24000,14400.00,,26415.45,110,,154.184,Percent of Total Billed Charges,110% of Total Billed Charges,10800,45,,580.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6720,28,,42.48,Percent of Total Billed Charges,28% of Total Billed Charges,4.07,32,,3.464,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8640,36,,54.616,Percent of Total Billed Charges,36% of Total Billed Charges,8640,36,,54.616,Percent of Total Billed Charges,36% Total Bille Charges,8640,36,,54.616,Percent of Total Billed Charges,36% of Total Billed Charges,13200,55,,34.888,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24000,100,,266.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19200,80,,1209.6,Percent of Total Billed Charges,80% of Total Billed Charges,12000,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,12000,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12000,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,12000,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16800,70,,475.976,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24000,100,,1512,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,26415.45,
655616 GRAFT GLOBUS FORGE CERV,32150644,CDM,278,RC,,,Outpatient,,,3575,2145.00,,3932.5,110,,49.64,Percent of Total Billed Charges,110% of Total Billed Charges,1608.75,45,,812.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1001,28,,251.096,Percent of Total Billed Charges,28% of Total Billed Charges,4.08,32,,3.472,Percent of Total Billed Charges,32% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,1287,36,,322.84,Percent of Total Billed Charges,36% of Total Billed Charges,1287,36,,322.84,Percent of Total Billed Charges,36% Total Bille Charges,1287,36,,322.84,Percent of Total Billed Charges,36% of Total Billed Charges,1966.25,55,,32.512,Percent of Total Billed Charges,55% Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3575,100,,684,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,515.52,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2860,80,,4336.384,Percent of Total Billed Charges,80% of Total Billed Charges,1787.5,50,,47.824,Percent of Total Billed Charges,50% of Total Billed Charges,1787.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1787.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,1787.5,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2502.5,70,,74.464,Percent of Total Billed Charges,70% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,500.5,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3575,100,,5420.48,Percent of Total Billed Charges,100% of Total Billed Charges,4.08,3932.5,
869811 TUBE RUBE VENTILATION,32150645,CDM,278,RC,,,Outpatient,,,74.64,44.78,,82.1,110,,68.984,Percent of Total Billed Charges,110% of Total Billed Charges,33.59,45,,454.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.9,28,,259.064,Percent of Total Billed Charges,28% of Total Billed Charges,4.08,32,,3.472,Percent of Total Billed Charges,32% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.87,36,,333.08,Percent of Total Billed Charges,36% of Total Billed Charges,26.87,36,,333.08,Percent of Total Billed Charges,36% Total Bille Charges,26.87,36,,333.08,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.64,100,,984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.76,14.42,,20.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.71,80,,20665.92,Percent of Total Billed Charges,80% of Total Billed Charges,37.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,37.32,50,,121.384,Percent of Total Billed Charges,50% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.32,50,,121.384,Percent of Total Billed Charges,50% of Total Billed Charges,37.32,50,,121.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.25,70,,3235.848,Percent of Total Billed Charges,70% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14,,19.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.64,100,,25832.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.08,82.1,
FIRST FRACTURE KYPHOPAK,32150646,CDM,272,RC,,,Outpatient,,,8760.96,5256.58,,5256.58,60,,48.256,Percent of Total Billed Charges,60% of Total Billed Charges,3942.43,45,,555.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2453.07,28,,1042.224,Percent of Total Billed Charges,28% of Total Billed Charges,4.11,32,,3.48,Percent of Total Billed Charges,32% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,3153.95,36,,1340,Percent of Total Billed Charges,36% of Total Billed Charges,3153.95,36,,1340,Percent of Total Billed Charges,36% Total Bille Charges,3153.95,36,,1340,Percent of Total Billed Charges,36% of Total Billed Charges,5256.58,60,,146.336,Percent of Total Billed Charges,60% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8760.96,100,,1289.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1263.33,14.42,,378.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6570.72,75,,7105.28,Percent of Total Billed Charges,75% of Total Billed Charges,4380.48,50,,3504.384,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,622.6,Percent of Total Billed Charges,50% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4380.48,50,,622.6,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,622.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6132.67,70,,2125.544,Percent of Total Billed Charges,70% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,367.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8760.96,100,,8881.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.11,8760.96,
871078 ALLOGRAFT AMNIO,32150647,CDM,278,RC,C1762,HCPCS,Outpatient,,,4914,2948.40,,7583.49,110,,154.76,Percent of Total Billed Charges,110% of Total Billed Charges,2211.3,45,,37.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.92,28,,450.448,Percent of Total Billed Charges,28% of Total Billed Charges,4.13,32,,3.488,Percent of Total Billed Charges,32% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,1769.04,36,,579.152,Percent of Total Billed Charges,36% of Total Billed Charges,1769.04,36,,579.152,Percent of Total Billed Charges,36% Total Bille Charges,1769.04,36,,579.152,Percent of Total Billed Charges,36% of Total Billed Charges,2702.7,55,,423.28,Percent of Total Billed Charges,55% Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4914,100,,1806.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,708.6,14.42,,207.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.2,80,,5256.576,Percent of Total Billed Charges,80% of Total Billed Charges,2457,50,,121.384,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2457,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3439.8,70,,2664.816,Percent of Total Billed Charges,70% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,201.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4914,100,,7008.768,Percent of Total Billed Charges,100% of Total Billed Charges,4.13,7583.49,
489361 KYPHON ADD FRACT,32150648,CDM,272,RC,,,Outpatient,,,8308.52,4985.11,,4985.11,60,,151.736,Percent of Total Billed Charges,60% of Total Billed Charges,3738.83,45,,67.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2326.39,28,,16.28,Percent of Total Billed Charges,28% of Total Billed Charges,4.15,32,,3.504,Percent of Total Billed Charges,32% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,2991.07,36,,20.928,Percent of Total Billed Charges,36% of Total Billed Charges,2991.07,36,,20.928,Percent of Total Billed Charges,36% Total Bille Charges,2991.07,36,,20.928,Percent of Total Billed Charges,36% of Total Billed Charges,4985.11,60,,421.16,Percent of Total Billed Charges,60% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8308.52,100,,1010.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1198.09,14.42,,2087.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6231.39,75,,585,Percent of Total Billed Charges,75% of Total Billed Charges,4154.26,50,,622.6,Percent of Total Billed Charges,50% of Total Billed Charges,4154.26,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4154.26,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,4154.26,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5815.96,70,,1263.024,Percent of Total Billed Charges,70% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,1163.19,14,,2027.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8308.52,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,4.15,8308.52,
874987 KIT INTRODUCER KYPHO,32150649,CDM,272,RC,,,Outpatient,,,2620.8,1572.48,,1572.48,60,,88.696,Percent of Total Billed Charges,60% of Total Billed Charges,1179.36,45,,79.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.82,28,,15.168,Percent of Total Billed Charges,28% of Total Billed Charges,38.4,32,,3.528,Percent of Total Billed Charges,32% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,943.49,36,,19.504,Percent of Total Billed Charges,36% of Total Billed Charges,943.49,36,,19.504,Percent of Total Billed Charges,36% Total Bille Charges,943.49,36,,19.504,Percent of Total Billed Charges,36% of Total Billed Charges,1572.48,60,,421.16,Percent of Total Billed Charges,60% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2620.8,100,,1234.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,377.92,14.42,,476.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1965.6,75,,2350.432,Percent of Total Billed Charges,75% of Total Billed Charges,1310.4,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,1310.4,50,,71.176,Percent of Total Billed Charges,50% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1310.4,50,,71.176,Percent of Total Billed Charges,50% of Total Billed Charges,1310.4,50,,71.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1834.56,70,,1399.248,Percent of Total Billed Charges,70% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,366.91,14,,463.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2620.8,100,,3133.904,Percent of Total Billed Charges,100% of Total Billed Charges,38.4,2620.8,
489374 KYPHON FRACTURE KIT,32150650,CDM,272,RC,,,Outpatient,,,5789.94,3473.96,,3473.96,60,,41.2,Percent of Total Billed Charges,60% of Total Billed Charges,2605.47,45,,76.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1621.18,28,,17.48,Percent of Total Billed Charges,28% of Total Billed Charges,38.4,32,,3.544,Percent of Total Billed Charges,32% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,2084.38,36,,22.472,Percent of Total Billed Charges,36% of Total Billed Charges,2084.38,36,,22.472,Percent of Total Billed Charges,36% Total Bille Charges,2084.38,36,,22.472,Percent of Total Billed Charges,36% of Total Billed Charges,3473.96,60,,163.872,Percent of Total Billed Charges,60% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5789.94,100,,83.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,834.91,14.42,,356.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4342.46,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,2894.97,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,2894.97,50,,1311.832,Percent of Total Billed Charges,50% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2894.97,50,,1311.832,Percent of Total Billed Charges,50% of Total Billed Charges,2894.97,50,,1311.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4052.96,70,,36184.392,Percent of Total Billed Charges,70% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,810.59,14,,346.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5789.94,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,38.4,5789.94,
489358 KYPHON FIRST FRACTURE,32150651,CDM,272,RC,,,Outpatient,,,12573.41,7544.05,,7544.05,60,,54.144,Percent of Total Billed Charges,60% of Total Billed Charges,5658.03,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3520.55,28,,68.288,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,3.56,Percent of Total Billed Charges,32% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,4526.43,36,,87.8,Percent of Total Billed Charges,36% of Total Billed Charges,4526.43,36,,87.8,Percent of Total Billed Charges,36% Total Bille Charges,4526.43,36,,87.8,Percent of Total Billed Charges,36% of Total Billed Charges,7544.05,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12573.41,100,,149.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1813.09,14.42,,1137.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9430.06,75,,526.288,Percent of Total Billed Charges,75% of Total Billed Charges,6286.71,50,,71.176,Percent of Total Billed Charges,50% of Total Billed Charges,6286.71,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6286.71,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,6286.71,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8801.39,70,,2785.328,Percent of Total Billed Charges,70% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,1760.28,14,,1103.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12573.41,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,12573.41,
682201 CERVICAL SPACER 12X14,32150652,CDM,278,RC,,,Outpatient,,,4673.63,2804.18,,5140.99,110,,222.008,Percent of Total Billed Charges,110% of Total Billed Charges,2103.13,45,,43.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1308.62,28,,197.528,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,3.576,Percent of Total Billed Charges,32% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,1682.51,36,,253.968,Percent of Total Billed Charges,36% of Total Billed Charges,1682.51,36,,253.968,Percent of Total Billed Charges,36% Total Bille Charges,1682.51,36,,253.968,Percent of Total Billed Charges,36% of Total Billed Charges,2570.5,55,,27.312,Percent of Total Billed Charges,55% Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4673.63,100,,175.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,673.94,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3738.9,80,,526.288,Percent of Total Billed Charges,80% of Total Billed Charges,2336.82,50,,1311.832,Percent of Total Billed Charges,50% of Total Billed Charges,2336.82,50,,7239.872,Percent of Total Billed Charges,50% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2336.82,50,,7239.872,Percent of Total Billed Charges,50% of Total Billed Charges,2336.82,50,,7239.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3271.54,70,,2827.528,Percent of Total Billed Charges,70% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.31,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4673.63,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,5140.99,
871077 AMNIOSHIELD 2X2,32150653,CDM,278,RC,V2790,HCPCS,Outpatient,,,1890,1134.00,,2483.13,110,,922.776,Percent of Total Billed Charges,110% of Total Billed Charges,850.5,45,,38.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.2,28,,196.544,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,3.576,Percent of Total Billed Charges,32% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,680.4,36,,252.696,Percent of Total Billed Charges,36% of Total Billed Charges,680.4,36,,252.696,Percent of Total Billed Charges,36% Total Bille Charges,680.4,36,,252.696,Percent of Total Billed Charges,36% of Total Billed Charges,1039.5,55,,1863.4,Percent of Total Billed Charges,55% Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1890,100,,170.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,272.54,14.42,,27.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1512,80,,76.512,Percent of Total Billed Charges,80% of Total Billed Charges,945,50,,721.208,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,1653.6,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,50,,1653.6,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,1653.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323,70,,47586,Percent of Total Billed Charges,70% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,26.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1890,100,,95.64,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,2483.13,
874988 IMPLANT VIA VASC 120CM,32150654,CDM,278,RC,C1874,HCPCS,Outpatient,,,6775.6,4065.36,,7945.57,110,,906.048,Percent of Total Billed Charges,110% of Total Billed Charges,3049.02,45,,48.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1897.17,28,,196.544,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,3.584,Percent of Total Billed Charges,32% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,2439.22,36,,252.696,Percent of Total Billed Charges,36% of Total Billed Charges,2439.22,36,,252.696,Percent of Total Billed Charges,36% Total Bille Charges,2439.22,36,,252.696,Percent of Total Billed Charges,36% of Total Billed Charges,3726.58,55,,164.416,Percent of Total Billed Charges,55% Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6775.6,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,977.04,14.42,,19.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5420.48,80,,75.504,Percent of Total Billed Charges,80% of Total Billed Charges,3387.8,50,,7239.872,Percent of Total Billed Charges,50% of Total Billed Charges,3387.8,50,,1236.624,Percent of Total Billed Charges,50% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3387.8,50,,1236.624,Percent of Total Billed Charges,50% of Total Billed Charges,3387.8,50,,1236.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4742.92,70,,2785.328,Percent of Total Billed Charges,70% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,948.58,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6775.6,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,7945.57,
592553 STENT GRAFT SYSTEM ENDO,32150655,CDM,278,RC,C1768,HCPCS,Outpatient,,,32290.5,19374.30,,35842.32,110,,58.752,Percent of Total Billed Charges,110% of Total Billed Charges,14530.73,45,,74.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9041.34,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,33.304,Percent of Total Billed Charges,32% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,11624.58,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,11624.58,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,11624.58,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,17759.78,55,,192.28,Percent of Total Billed Charges,55% Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32290.5,100,,96.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4656.29,14.42,,24.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25832.4,80,,5256.576,Percent of Total Billed Charges,80% of Total Billed Charges,16145.25,50,,1653.6,Percent of Total Billed Charges,50% of Total Billed Charges,16145.25,50,,3942.84,Percent of Total Billed Charges,50% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16145.25,50,,3942.84,Percent of Total Billed Charges,50% of Total Billed Charges,16145.25,50,,3942.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22603.35,70,,386.4,Percent of Total Billed Charges,70% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4520.67,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32290.5,100,,7008.768,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,35842.32,
809770 AORTIC EXTENSION ENDOLO,32150656,CDM,278,RC,C1874,HCPCS,Outpatient,,,11102,6661.20,,12704.61,110,,61.6,Percent of Total Billed Charges,110% of Total Billed Charges,4995.9,45,,80.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3108.56,28,,76.472,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,33.504,Percent of Total Billed Charges,32% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,3996.72,36,,98.32,Percent of Total Billed Charges,36% of Total Billed Charges,3996.72,36,,98.32,Percent of Total Billed Charges,36% Total Bille Charges,3996.72,36,,98.32,Percent of Total Billed Charges,36% of Total Billed Charges,6106.1,55,,628.456,Percent of Total Billed Charges,55% Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11102,100,,85.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1600.91,14.42,,19.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8881.6,80,,182.072,Percent of Total Billed Charges,80% of Total Billed Charges,5551,50,,1236.624,Percent of Total Billed Charges,50% of Total Billed Charges,5551,50,,76.504,Percent of Total Billed Charges,50% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5551,50,,76.504,Percent of Total Billed Charges,50% of Total Billed Charges,5551,50,,76.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7771.4,70,,2006.368,Percent of Total Billed Charges,70% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,1554.28,14,,19.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11102,100,,242.76,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,12704.61,
874502 TRAY FIRST FRACTURE KY,32150661,CDM,272,RC,,,Outpatient,,,8760.96,5256.58,,5256.58,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,3942.43,45,,43.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2453.07,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,38.66,32,,33.52,Percent of Total Billed Charges,32% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,3153.95,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,3153.95,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,3153.95,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,5256.58,60,,623.776,Percent of Total Billed Charges,60% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8760.96,100,,108.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1263.33,14.42,,50.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6570.72,75,,996.152,Percent of Total Billed Charges,75% of Total Billed Charges,4380.48,50,,3942.84,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,95.864,Percent of Total Billed Charges,50% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4380.48,50,,95.864,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,95.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6132.67,70,,2373.28,Percent of Total Billed Charges,70% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,49.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8760.96,100,,1245.192,Percent of Total Billed Charges,100% of Total Billed Charges,38.66,8760.96,
881399 GATRISAIL MEDRONIC,32150662,CDM,272,RC,,,Outpatient,,,975,585.00,,585,60,,560.224,Percent of Total Billed Charges,60% of Total Billed Charges,438.75,45,,30.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,12.744,Percent of Total Billed Charges,28% of Total Billed Charges,38.83,32,,33.52,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,16.384,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,16.384,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,16.384,Percent of Total Billed Charges,36% of Total Billed Charges,585,60,,541.2,Percent of Total Billed Charges,60% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,165.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,48.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,731.25,75,,44.736,Percent of Total Billed Charges,75% of Total Billed Charges,487.5,50,,76.504,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,430.344,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,47.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,59.648,Percent of Total Billed Charges,100% of Total Billed Charges,38.83,975,
355501 SEALANT NEOMEND PROGEL,32150663,CDM,272,RC,C2615,HCPCS,Outpatient,,,3917.38,2350.43,,239.37,100,,148.512,Fee Schedule,100% of Aetna Fee Schedule,1762.82,45,,37.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1096.87,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,39,32,,33.536,Percent of Total Billed Charges,32% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,1410.26,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,1410.26,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,1410.26,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,2350.43,60,,722.16,Percent of Total Billed Charges,60% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3917.38,100,,177.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,564.89,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2938.04,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,1958.69,50,,95.864,Percent of Total Billed Charges,50% of Total Billed Charges,1958.69,50,,85.816,Percent of Total Billed Charges,50% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1958.69,50,,85.816,Percent of Total Billed Charges,50% of Total Billed Charges,1958.69,50,,85.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2742.17,70,,41.864,Percent of Total Billed Charges,70% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,548.43,14,,22.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3917.38,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,39,3917.38,
617774 SEAL ENDOWRIST STAPLER,32150664,CDM,272,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,49.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,76.728,Percent of Total Billed Charges,28% of Total Billed Charges,39.17,32,,33.792,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,98.648,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,424.624,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,96.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,115.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,106.768,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,5837.848,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,142.352,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,125.84,
617060 RELOAD ENDOWRIST STAPLE,32150665,CDM,272,RC,,,Outpatient,,,877.14,526.28,,526.28,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,394.71,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,89.728,Percent of Total Billed Charges,28% of Total Billed Charges,39.36,32,,33.824,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,115.368,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,115.368,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,115.368,Percent of Total Billed Charges,36% of Total Billed Charges,526.28,60,,479.504,Percent of Total Billed Charges,60% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,68.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,75,,2098.928,Percent of Total Billed Charges,75% of Total Billed Charges,438.57,50,,85.816,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,175.68,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,175.68,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,175.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,2623.664,Percent of Total Billed Charges,100% of Total Billed Charges,39.36,877.14,
617771 RELOAD ENDOWRIST STAPLE,32150667,CDM,272,RC,,,Outpatient,,,877.14,526.28,,526.28,60,,242.496,Percent of Total Billed Charges,60% of Total Billed Charges,394.71,45,,93.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,293.28,Percent of Total Billed Charges,28% of Total Billed Charges,39.36,32,,33.824,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,377.072,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,377.072,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,377.072,Percent of Total Billed Charges,36% of Total Billed Charges,526.28,60,,245.376,Percent of Total Billed Charges,60% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,83.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,100.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,75,,1081.808,Percent of Total Billed Charges,75% of Total Billed Charges,438.57,50,,69.184,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,168.848,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,168.848,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,168.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,157.592,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,1442.408,Percent of Total Billed Charges,100% of Total Billed Charges,39.36,877.14,
522823 NDL LOC BRST GHAITAS 9C,32150668,CDM,278,RC,C1819,HCPCS,Outpatient,,,119.55,71.73,,191.51,110,,394.808,Percent of Total Billed Charges,110% of Total Billed Charges,53.8,45,,26.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.47,28,,275.52,Percent of Total Billed Charges,28% of Total Billed Charges,39.36,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,43.04,36,,354.24,Percent of Total Billed Charges,36% of Total Billed Charges,43.04,36,,354.24,Percent of Total Billed Charges,36% Total Bille Charges,43.04,36,,354.24,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.55,100,,109.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,17.24,14.42,,65.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.64,80,,11583.792,Percent of Total Billed Charges,80% of Total Billed Charges,59.78,50,,175.68,Percent of Total Billed Charges,50% of Total Billed Charges,59.78,50,,81.24,Percent of Total Billed Charges,50% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.78,50,,81.24,Percent of Total Billed Charges,50% of Total Billed Charges,59.78,50,,81.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.69,70,,239.68,Percent of Total Billed Charges,70% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,14,,63.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.55,100,,14479.744,Percent of Total Billed Charges,100% of Total Billed Charges,16.74,191.51,
617776 SHEATH ENDOWRIST STPL,32150669,CDM,272,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,367.648,Percent of Total Billed Charges,28% of Total Billed Charges,39.6,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,472.688,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,472.688,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,472.688,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,110.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,1634.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,2645.76,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,168.848,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,36.016,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,1586.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,3307.2,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,125.84,
822505 TRAY KYPN BLN,32150670,CDM,272,RC,,,Outpatient,,,8760.96,5256.58,,5256.58,60,,1670.656,Percent of Total Billed Charges,60% of Total Billed Charges,3942.43,45,,41.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2453.07,28,,216.168,Percent of Total Billed Charges,28% of Total Billed Charges,39.6,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,3153.95,36,,277.936,Percent of Total Billed Charges,36% of Total Billed Charges,3153.95,36,,277.936,Percent of Total Billed Charges,36% Total Bille Charges,3153.95,36,,277.936,Percent of Total Billed Charges,36% of Total Billed Charges,5256.58,60,,176.264,Percent of Total Billed Charges,60% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8760.96,100,,207.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1263.33,14.42,,91.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6570.72,75,,1978.592,Percent of Total Billed Charges,75% of Total Billed Charges,4380.48,50,,81.24,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4380.48,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,4380.48,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6132.67,70,,12.84,Percent of Total Billed Charges,70% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,1226.53,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8760.96,100,,2473.24,Percent of Total Billed Charges,100% of Total Billed Charges,39.6,8760.96,
405617 SUTURE COVIDIEN ENDO,32150673,CDM,272,RC,,,Outpatient,,,303.45,182.07,,182.07,60,,659.96,Percent of Total Billed Charges,60% of Total Billed Charges,136.55,45,,41.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.97,28,,17.904,Percent of Total Billed Charges,28% of Total Billed Charges,39.7,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,109.24,36,,23.024,Percent of Total Billed Charges,36% of Total Billed Charges,109.24,36,,23.024,Percent of Total Billed Charges,36% Total Bille Charges,109.24,36,,23.024,Percent of Total Billed Charges,36% of Total Billed Charges,182.07,60,,245.376,Percent of Total Billed Charges,60% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.45,100,,59.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,43.76,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.59,75,,6308.544,Percent of Total Billed Charges,75% of Total Billed Charges,151.73,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,151.73,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.73,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,151.73,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.42,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,42.48,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.45,100,,7885.68,Percent of Total Billed Charges,100% of Total Billed Charges,39.7,303.45,
903574 MESH SYMBOTEX COMPOSITE,32150674,CDM,278,RC,,,Outpatient,,,1556.49,933.89,,1712.14,110,,840.36,Percent of Total Billed Charges,110% of Total Billed Charges,700.42,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435.82,28,,223.768,Percent of Total Billed Charges,28% of Total Billed Charges,39.7,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,560.34,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,560.34,36,,287.704,Percent of Total Billed Charges,36% Total Bille Charges,560.34,36,,287.704,Percent of Total Billed Charges,36% of Total Billed Charges,856.07,55,,140.712,Percent of Total Billed Charges,55% Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1556.49,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,224.45,14.42,,1862.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1245.19,80,,114.752,Percent of Total Billed Charges,80% of Total Billed Charges,778.25,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,778.25,50,,227.2,Percent of Total Billed Charges,50% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,778.25,50,,227.2,Percent of Total Billed Charges,50% of Total Billed Charges,778.25,50,,227.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1089.54,70,,289.52,Percent of Total Billed Charges,70% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,217.91,14,,1808.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1556.49,100,,153,Percent of Total Billed Charges,100% of Total Billed Charges,39.7,1712.14,
172372 SLEEVE SEQUENTIAL COMP,32150675,CDM,271,RC,,,Outpatient,,,74.56,44.74,,44.74,60,,1202.672,Percent of Total Billed Charges,60% of Total Billed Charges,33.55,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.88,28,,114.512,Percent of Total Billed Charges,28% of Total Billed Charges,39.7,32,,34.016,Percent of Total Billed Charges,32% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,26.84,36,,147.224,Percent of Total Billed Charges,36% of Total Billed Charges,26.84,36,,147.224,Percent of Total Billed Charges,36% Total Bille Charges,26.84,36,,147.224,Percent of Total Billed Charges,36% of Total Billed Charges,44.74,60,,172.88,Percent of Total Billed Charges,60% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.56,100,,91.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.75,14.42,,548.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.92,75,,143.792,Percent of Total Billed Charges,75% of Total Billed Charges,37.28,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,50,,5667.48,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.28,50,,5667.48,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,50,,5667.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.19,70,,831.6,Percent of Total Billed Charges,70% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.56,100,,191.72,Percent of Total Billed Charges,100% of Total Billed Charges,10.44,74.56,
174268 SLEEVE COMPRESSION,32150676,CDM,271,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,210.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,155.056,Percent of Total Billed Charges,28% of Total Billed Charges,39.71,32,,34.04,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,199.36,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,199.36,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,128.312,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,91.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,189.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,110.696,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,227.2,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,138.368,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,125.84,
803516 COVIDIEN SUTURE GS21,32150677,CDM,272,RC,,,Outpatient,,,177.94,106.76,,106.76,60,,760.536,Percent of Total Billed Charges,60% of Total Billed Charges,80.07,45,,102.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.82,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,39.85,32,,34268.672,Percent of Total Billed Charges,32% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,64.06,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,64.06,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,64.06,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,106.76,60,,138.2,Percent of Total Billed Charges,60% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.94,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,25.66,14.42,,171.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.46,75,,128.72,Percent of Total Billed Charges,75% of Total Billed Charges,88.97,50,,5667.48,Percent of Total Billed Charges,50% of Total Billed Charges,88.97,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.97,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,88.97,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.56,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14,,166.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.94,100,,171.624,Percent of Total Billed Charges,100% of Total Billed Charges,24.91,177.94,
381530 BONE MTF FIBULA SHAFT,32150678,CDM,278,RC,,,Outpatient,,,3279.58,1967.75,,3607.54,110,,828,Percent of Total Billed Charges,110% of Total Billed Charges,1475.81,45,,408.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,918.28,28,,82.256,Percent of Total Billed Charges,28% of Total Billed Charges,39.89,32,,34.048,Percent of Total Billed Charges,32% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,1180.65,36,,105.76,Percent of Total Billed Charges,36% of Total Billed Charges,1180.65,36,,105.76,Percent of Total Billed Charges,36% Total Bille Charges,1180.65,36,,105.76,Percent of Total Billed Charges,36% of Total Billed Charges,1803.77,55,,128.312,Percent of Total Billed Charges,55% Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3279.58,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,472.92,14.42,,59.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2623.66,80,,110.696,Percent of Total Billed Charges,80% of Total Billed Charges,1639.79,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,1639.79,50,,6458.104,Percent of Total Billed Charges,50% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1639.79,50,,6458.104,Percent of Total Billed Charges,50% of Total Billed Charges,1639.79,50,,6458.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2295.71,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,459.14,14,,57.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3279.58,100,,138.368,Percent of Total Billed Charges,100% of Total Billed Charges,39.89,3607.54,
345698 CATHETER SINUS GUIDE,32150679,CDM,272,RC,C1887,HCPCS,Outpatient,,,1803.01,1081.81,,43.86,100,,288,Fee Schedule,100% of Aetna Fee Schedule,811.35,45,,89.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,504.84,28,,114.512,Percent of Total Billed Charges,28% of Total Billed Charges,40.17,32,,34.096,Percent of Total Billed Charges,32% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,649.08,36,,147.224,Percent of Total Billed Charges,36% of Total Billed Charges,649.08,36,,147.224,Percent of Total Billed Charges,36% Total Bille Charges,649.08,36,,147.224,Percent of Total Billed Charges,36% of Total Billed Charges,1081.81,60,,138.2,Percent of Total Billed Charges,60% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1803.01,100,,467.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,259.99,14.42,,116.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1352.26,75,,263.52,Percent of Total Billed Charges,75% of Total Billed Charges,901.51,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,901.51,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,901.51,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,901.51,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1262.11,70,,180.112,Percent of Total Billed Charges,70% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,252.42,14,,112.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1803.01,100,,351.36,Percent of Total Billed Charges,100% of Total Billed Charges,40.17,1803.01,
915090 BIO4 BONE MATRIX,32150680,CDM,278,RC,C1713,HCPCS,Outpatient,,,18099.68,10859.81,,20226.91,110,,41.04,Percent of Total Billed Charges,110% of Total Billed Charges,8144.86,45,,247.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5067.91,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,40.2,32,,34.096,Percent of Total Billed Charges,32% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,6515.88,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,6515.88,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,6515.88,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,9954.82,55,,1310.608,Percent of Total Billed Charges,55% Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18099.68,100,,226.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2609.97,14.42,,1499.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14479.74,80,,253.272,Percent of Total Billed Charges,80% of Total Billed Charges,9049.84,50,,6458.104,Percent of Total Billed Charges,50% of Total Billed Charges,9049.84,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9049.84,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,9049.84,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12669.78,70,,1864.08,Percent of Total Billed Charges,70% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,2533.96,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18099.68,100,,337.696,Percent of Total Billed Charges,100% of Total Billed Charges,40.2,20226.91,
915091 BIO4 BONE MATRIX,32150681,CDM,278,RC,,,Outpatient,,,4134,2480.40,,4547.4,110,,41.04,Percent of Total Billed Charges,110% of Total Billed Charges,1860.3,45,,294.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1157.52,28,,80.672,Percent of Total Billed Charges,28% of Total Billed Charges,40.2,32,,34.304,Percent of Total Billed Charges,32% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,1488.24,36,,103.728,Percent of Total Billed Charges,36% of Total Billed Charges,1488.24,36,,103.728,Percent of Total Billed Charges,36% Total Bille Charges,1488.24,36,,103.728,Percent of Total Billed Charges,36% of Total Billed Charges,2273.7,55,,519.184,Percent of Total Billed Charges,55% Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4134,100,,907.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,596.12,14.42,,279.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3307.2,80,,121.856,Percent of Total Billed Charges,80% of Total Billed Charges,2067,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,2067,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2067,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,2067,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2893.8,70,,1757.328,Percent of Total Billed Charges,70% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,578.76,14,,270.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4134,100,,162.472,Percent of Total Billed Charges,100% of Total Billed Charges,40.2,4547.4,
915409 BIO4 BONE MATRIX,32150682,CDM,278,RC,C1713,HCPCS,Outpatient,,,3091.55,1854.93,,3717.97,110,,41.04,Percent of Total Billed Charges,110% of Total Billed Charges,1391.2,45,,87.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,865.63,28,,59.88,Percent of Total Billed Charges,28% of Total Billed Charges,40.24,32,,34.304,Percent of Total Billed Charges,32% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,1112.96,36,,76.992,Percent of Total Billed Charges,36% of Total Billed Charges,1112.96,36,,76.992,Percent of Total Billed Charges,36% Total Bille Charges,1112.96,36,,76.992,Percent of Total Billed Charges,36% of Total Billed Charges,1700.35,55,,256.608,Percent of Total Billed Charges,55% Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3091.55,100,,199.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,445.8,14.42,,9.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2473.24,80,,599.384,Percent of Total Billed Charges,80% of Total Billed Charges,1545.78,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,1545.78,50,,204.88,Percent of Total Billed Charges,50% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1545.78,50,,204.88,Percent of Total Billed Charges,50% of Total Billed Charges,1545.78,50,,204.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2164.09,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,432.82,14,,9.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3091.55,100,,799.176,Percent of Total Billed Charges,100% of Total Billed Charges,40.24,3717.97,
886028 BIO4 BONE MATRIX,32150683,CDM,278,RC,C1713,HCPCS,Outpatient,,,9857.1,5914.26,,11160.07,110,,41.04,Percent of Total Billed Charges,110% of Total Billed Charges,4435.7,45,,30.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2759.99,28,,64.496,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.376,Percent of Total Billed Charges,32% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,3548.56,36,,82.92,Percent of Total Billed Charges,36% of Total Billed Charges,3548.56,36,,82.92,Percent of Total Billed Charges,36% Total Bille Charges,3548.56,36,,82.92,Percent of Total Billed Charges,36% of Total Billed Charges,5421.41,55,,553.88,Percent of Total Billed Charges,55% Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9857.1,100,,550.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1421.39,14.42,,1499.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7885.68,80,,2710.4,Percent of Total Billed Charges,80% of Total Billed Charges,4928.55,50,,594.512,Percent of Total Billed Charges,50% of Total Billed Charges,4928.55,50,,402.4,Percent of Total Billed Charges,50% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4928.55,50,,402.4,Percent of Total Billed Charges,50% of Total Billed Charges,4928.55,50,,402.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6899.97,70,,256.032,Percent of Total Billed Charges,70% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,1379.99,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9857.1,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,11160.07,
124098 CATHETER STAMEY SUPRAPU,32150684,CDM,272,RC,,,Outpatient,,,191.25,114.75,,114.75,60,,2544.152,Percent of Total Billed Charges,60% of Total Billed Charges,86.06,45,,59.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.55,28,,59.88,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.384,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,68.85,36,,76.992,Percent of Total Billed Charges,36% of Total Billed Charges,68.85,36,,76.992,Percent of Total Billed Charges,36% Total Bille Charges,68.85,36,,76.992,Percent of Total Billed Charges,36% of Total Billed Charges,114.75,60,,560.224,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.25,100,,655.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,293.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.44,75,,556.8,Percent of Total Billed Charges,75% of Total Billed Charges,95.63,50,,204.88,Percent of Total Billed Charges,50% of Total Billed Charges,95.63,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.63,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,95.63,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.88,70,,1307.288,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,284.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.25,100,,696,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,191.25,
918017 LUBRI GW .035X150,32150686,CDM,272,RC,,,Outpatient,,,239.65,143.79,,143.79,60,,379.44,Percent of Total Billed Charges,60% of Total Billed Charges,107.84,45,,79.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.1,28,,64.496,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.384,Percent of Total Billed Charges,32% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,86.27,36,,82.92,Percent of Total Billed Charges,36% of Total Billed Charges,86.27,36,,82.92,Percent of Total Billed Charges,36% Total Bille Charges,86.27,36,,82.92,Percent of Total Billed Charges,36% of Total Billed Charges,143.79,60,,248.456,Percent of Total Billed Charges,60% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.65,100,,195.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.56,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.74,75,,363.52,Percent of Total Billed Charges,75% of Total Billed Charges,119.83,50,,402.4,Percent of Total Billed Charges,50% of Total Billed Charges,119.83,50,,967.544,Percent of Total Billed Charges,50% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.83,50,,967.544,Percent of Total Billed Charges,50% of Total Billed Charges,119.83,50,,967.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.76,70,,1253.192,Percent of Total Billed Charges,70% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,33.55,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.65,100,,454.4,Percent of Total Billed Charges,100% of Total Billed Charges,33.55,239.65,
0004453 PIN CASPAR DISTRACTION,32150687,CDM,278,RC,C1713,HCPCS,Outpatient,,,172.96,103.78,,507.52,110,,310.496,Percent of Total Billed Charges,110% of Total Billed Charges,77.83,45,,134.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.43,28,,611.616,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.464,Percent of Total Billed Charges,32% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,62.27,36,,786.36,Percent of Total Billed Charges,36% of Total Billed Charges,62.27,36,,786.36,Percent of Total Billed Charges,36% Total Bille Charges,62.27,36,,786.36,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.96,100,,68.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.94,14.42,,1004.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.37,80,,9067.968,Percent of Total Billed Charges,80% of Total Billed Charges,86.48,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,32.768,Percent of Total Billed Charges,50% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.48,50,,32.768,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,32.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.07,70,,816.48,Percent of Total Billed Charges,70% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,975.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.96,100,,11334.96,Percent of Total Billed Charges,100% of Total Billed Charges,24.21,507.52,
918005 KT ULTRA INFUSION SLEE,32150688,CDM,272,RC,,,Outpatient,,,214.53,128.72,,128.72,60,,310.496,Percent of Total Billed Charges,60% of Total Billed Charges,96.54,45,,134.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.07,28,,242.288,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.48,Percent of Total Billed Charges,32% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,77.23,36,,311.512,Percent of Total Billed Charges,36% of Total Billed Charges,77.23,36,,311.512,Percent of Total Billed Charges,36% Total Bille Charges,77.23,36,,311.512,Percent of Total Billed Charges,36% of Total Billed Charges,128.72,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.53,100,,132.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.94,14.42,,19.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.9,75,,473.76,Percent of Total Billed Charges,75% of Total Billed Charges,107.27,50,,967.544,Percent of Total Billed Charges,50% of Total Billed Charges,107.27,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.27,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,107.27,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.17,70,,1986.216,Percent of Total Billed Charges,70% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,19.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.53,100,,631.68,Percent of Total Billed Charges,100% of Total Billed Charges,30.03,214.53,
0004454 PIN CASPAR DISTRACTION,32150696,CDM,278,RC,C1713,HCPCS,Outpatient,,,172.96,103.78,,507.52,110,,120.056,Percent of Total Billed Charges,110% of Total Billed Charges,77.83,45,,37.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.43,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.56,Percent of Total Billed Charges,32% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,62.27,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,62.27,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,62.27,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.96,100,,175.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.94,14.42,,2513.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.37,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,86.48,50,,32.768,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,1016.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.48,50,,1016.4,Percent of Total Billed Charges,50% of Total Billed Charges,86.48,50,,1016.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.07,70,,3880.24,Percent of Total Billed Charges,70% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.21,14,,2440.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.96,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,24.21,507.52,
TUBE FEEDING JEJUNAL 12FR (0200-12LV),32150697,CDM,272,RC,,,Outpatient,,,439.2,263.52,,263.52,60,,232.224,Percent of Total Billed Charges,60% of Total Billed Charges,197.64,45,,95.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.98,28,,258.472,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.56,Percent of Total Billed Charges,32% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,158.11,36,,332.328,Percent of Total Billed Charges,36% of Total Billed Charges,158.11,36,,332.328,Percent of Total Billed Charges,36% Total Bille Charges,158.11,36,,332.328,Percent of Total Billed Charges,36% of Total Billed Charges,263.52,60,,243.728,Percent of Total Billed Charges,60% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.2,100,,298.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,63.33,14.42,,448.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.4,75,,9687.152,Percent of Total Billed Charges,75% of Total Billed Charges,219.6,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,219.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,219.6,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.44,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14,,435.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.2,100,,12916.2,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,439.2,
0007941 GUIDEWIRE 3.2MMX400M,32150699,CDM,272,RC,C1769,HCPCS,Outpatient,,,422.12,253.27,,55.13,100,,1629.392,Fee Schedule,100% of Aetna Fee Schedule,189.95,45,,82.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.19,28,,261.44,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.56,Percent of Total Billed Charges,32% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,151.96,36,,336.136,Percent of Total Billed Charges,36% of Total Billed Charges,151.96,36,,336.136,Percent of Total Billed Charges,36% Total Bille Charges,151.96,36,,336.136,Percent of Total Billed Charges,36% of Total Billed Charges,253.27,60,,252.04,Percent of Total Billed Charges,60% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.12,100,,298.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,60.87,14.42,,7453.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.59,75,,2855.16,Percent of Total Billed Charges,75% of Total Billed Charges,211.06,50,,1016.4,Percent of Total Billed Charges,50% of Total Billed Charges,211.06,50,,3482.616,Percent of Total Billed Charges,50% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.06,50,,3482.616,Percent of Total Billed Charges,50% of Total Billed Charges,211.06,50,,3482.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.48,70,,301.28,Percent of Total Billed Charges,70% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.12,100,,3806.88,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,422.12,
572480 L-HOOK VL LAP FLAT ELE,32150708,CDM,272,RC,,,Outpatient,,,203.09,121.85,,121.85,60,,124.8,Percent of Total Billed Charges,60% of Total Billed Charges,91.39,45,,143.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.87,28,,115.944,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.56,Percent of Total Billed Charges,32% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,73.11,36,,149.072,Percent of Total Billed Charges,36% of Total Billed Charges,73.11,36,,149.072,Percent of Total Billed Charges,36% Total Bille Charges,73.11,36,,149.072,Percent of Total Billed Charges,36% of Total Billed Charges,121.85,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.09,100,,82.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,643.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.32,75,,1052.568,Percent of Total Billed Charges,75% of Total Billed Charges,101.55,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,101.55,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.55,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,101.55,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.16,70,,5177.36,Percent of Total Billed Charges,70% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,28.43,14,,624.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.09,100,,1315.712,Percent of Total Billed Charges,100% of Total Billed Charges,28.43,203.09,
548963 REAMER 7.5,32150712,CDM,272,RC,,,Outpatient,,,998.97,599.38,,599.38,60,,560.808,Percent of Total Billed Charges,60% of Total Billed Charges,449.54,45,,190.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.71,28,,97.256,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.56,Percent of Total Billed Charges,32% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,359.63,36,,125.04,Percent of Total Billed Charges,36% of Total Billed Charges,359.63,36,,125.04,Percent of Total Billed Charges,36% Total Bille Charges,359.63,36,,125.04,Percent of Total Billed Charges,36% of Total Billed Charges,599.38,60,,79.768,Percent of Total Billed Charges,60% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,998.97,100,,211.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,144.05,14.42,,82.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,749.23,75,,951.216,Percent of Total Billed Charges,75% of Total Billed Charges,499.49,50,,3482.616,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,8716.28,Percent of Total Billed Charges,50% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.49,50,,8716.28,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,8716.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.28,70,,422.344,Percent of Total Billed Charges,70% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,79.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,998.97,100,,1189.016,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,998.97,
921188 CEMENT OSSEOPERM 2.0,32150713,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235,2541.00,,4975.76,110,,1487.456,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.632,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,50.128,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,183.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,165.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,327.808,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,69.112,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,291.2,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,160.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,409.76,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,4975.76,
924116 PORT 6FR. POWER LOW PR,32150715,CDM,278,RC,,,Outpatient,,,870,522.00,,957,110,,2144.12,Percent of Total Billed Charges,110% of Total Billed Charges,391.5,45,,128.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.6,28,,163.512,Percent of Total Billed Charges,28% of Total Billed Charges,40.27,32,,34.664,Percent of Total Billed Charges,32% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.2,36,,210.232,Percent of Total Billed Charges,36% of Total Billed Charges,313.2,36,,210.232,Percent of Total Billed Charges,36% Total Bille Charges,313.2,36,,210.232,Percent of Total Billed Charges,36% of Total Billed Charges,478.5,55,,50.608,Percent of Total Billed Charges,55% Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,870,100,,319,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,125.45,14.42,,7371.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696,80,,603.6,Percent of Total Billed Charges,80% of Total Billed Charges,435,50,,8716.28,Percent of Total Billed Charges,50% of Total Billed Charges,435,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,435,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609,70,,369.6,Percent of Total Billed Charges,70% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,7156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,870,100,,804.8,Percent of Total Billed Charges,100% of Total Billed Charges,40.27,957,
352840 ALLODERM GRAFT TISSUE,32150723,CDM,278,RC,,,Outpatient,,,568,340.80,,624.8,110,,251.48,Percent of Total Billed Charges,110% of Total Billed Charges,255.6,45,,224.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.04,28,,113.736,Percent of Total Billed Charges,28% of Total Billed Charges,40.32,32,,34.712,Percent of Total Billed Charges,32% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,204.48,36,,146.232,Percent of Total Billed Charges,36% of Total Billed Charges,204.48,36,,146.232,Percent of Total Billed Charges,36% Total Bille Charges,204.48,36,,146.232,Percent of Total Billed Charges,36% of Total Billed Charges,312.4,55,,61.912,Percent of Total Billed Charges,55% Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568,100,,423.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,81.91,14.42,,419.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,454.4,80,,8320,Percent of Total Billed Charges,80% of Total Billed Charges,284,50,,1554.8,Percent of Total Billed Charges,50% of Total Billed Charges,284,50,,2230.8,Percent of Total Billed Charges,50% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284,50,,2230.8,Percent of Total Billed Charges,50% of Total Billed Charges,284,50,,2230.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.6,70,,1754.984,Percent of Total Billed Charges,70% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,79.52,14,,407.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,568,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,40.32,624.8,
897373 VALVE INLINE PROGRAMMAB,32150724,CDM,278,RC,,,Outpatient,,,14168.7,8501.22,,15585.57,110,,3800.16,Percent of Total Billed Charges,110% of Total Billed Charges,6375.92,45,,270.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3967.24,28,,117.616,Percent of Total Billed Charges,28% of Total Billed Charges,40.43,32,,34.76,Percent of Total Billed Charges,32% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,5100.73,36,,151.224,Percent of Total Billed Charges,36% of Total Billed Charges,5100.73,36,,151.224,Percent of Total Billed Charges,36% Total Bille Charges,5100.73,36,,151.224,Percent of Total Billed Charges,36% of Total Billed Charges,7792.79,55,,50.08,Percent of Total Billed Charges,55% Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14168.7,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,2043.13,14.42,,279.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11334.96,80,,1451.32,Percent of Total Billed Charges,80% of Total Billed Charges,7084.35,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,7084.35,50,,284.976,Percent of Total Billed Charges,50% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7084.35,50,,284.976,Percent of Total Billed Charges,50% of Total Billed Charges,7084.35,50,,284.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9918.09,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,1983.62,14,,271.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14168.7,100,,1935.088,Percent of Total Billed Charges,100% of Total Billed Charges,40.43,15585.57,
920546 KIT PORTAL ENTRY HIP,32150725,CDM,272,RC,,,Outpatient,,,789.6,473.76,,473.76,60,,207.592,Percent of Total Billed Charges,60% of Total Billed Charges,355.32,45,,1338.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.09,28,,27.552,Percent of Total Billed Charges,28% of Total Billed Charges,40.54,32,,34.776,Percent of Total Billed Charges,32% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,284.26,36,,35.424,Percent of Total Billed Charges,36% of Total Billed Charges,284.26,36,,35.424,Percent of Total Billed Charges,36% Total Bille Charges,284.26,36,,35.424,Percent of Total Billed Charges,36% of Total Billed Charges,473.76,60,,39.416,Percent of Total Billed Charges,60% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,789.6,100,,285.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,113.86,14.42,,501.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.2,75,,52.432,Percent of Total Billed Charges,75% of Total Billed Charges,394.8,50,,2230.8,Percent of Total Billed Charges,50% of Total Billed Charges,394.8,50,,573.472,Percent of Total Billed Charges,50% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.8,50,,573.472,Percent of Total Billed Charges,50% of Total Billed Charges,394.8,50,,573.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.72,70,,3098.368,Percent of Total Billed Charges,70% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,486.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,789.6,100,,65.536,Percent of Total Billed Charges,100% of Total Billed Charges,40.54,789.6,
565621 CANNULA PIVOT TRANSPORT,32150726,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,6811.504,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,31.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,102.144,Percent of Total Billed Charges,28% of Total Billed Charges,40.65,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,131.328,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,47.36,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,498.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,16.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,8320,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,284.976,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,25560,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,25560,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,25560,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1118.84,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,15.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,40.65,375,
777870 KYPHOPAK EXPRESS,32150728,CDM,272,RC,,,Outpatient,,,16145.25,9687.15,,9687.15,60,,66.128,Percent of Total Billed Charges,60% of Total Billed Charges,7265.36,45,,246.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4520.67,28,,37.224,Percent of Total Billed Charges,28% of Total Billed Charges,40.65,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,5812.29,36,,47.864,Percent of Total Billed Charges,36% of Total Billed Charges,5812.29,36,,47.864,Percent of Total Billed Charges,36% Total Bille Charges,5812.29,36,,47.864,Percent of Total Billed Charges,36% of Total Billed Charges,9687.15,60,,1447.68,Percent of Total Billed Charges,60% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16145.25,100,,601.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2328.15,14.42,,583.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12108.94,75,,1626.24,Percent of Total Billed Charges,75% of Total Billed Charges,8072.63,50,,573.472,Percent of Total Billed Charges,50% of Total Billed Charges,8072.63,50,,1455.048,Percent of Total Billed Charges,50% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8072.63,50,,1455.048,Percent of Total Billed Charges,50% of Total Billed Charges,8072.63,50,,1455.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11301.68,70,,233.12,Percent of Total Billed Charges,70% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,2260.34,14,,566.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16145.25,100,,2032.8,Percent of Total Billed Charges,100% of Total Billed Charges,40.65,16145.25,
945657 REMOTE CONTROL FREELINK,32150729,CDM,272,RC,C1787,HCPCS,Outpatient,,,4758.6,2855.16,,59.4,100,,66.128,Fee Schedule,100% of Aetna Fee Schedule,2141.37,45,,164.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,28,,23.392,Percent of Total Billed Charges,28% of Total Billed Charges,40.7,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,1713.1,36,,30.072,Percent of Total Billed Charges,36% of Total Billed Charges,1713.1,36,,30.072,Percent of Total Billed Charges,36% Total Bille Charges,1713.1,36,,30.072,Percent of Total Billed Charges,36% of Total Billed Charges,2855.16,60,,69.432,Percent of Total Billed Charges,60% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4758.6,100,,2973.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,686.19,14.42,,537.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3568.95,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,2379.3,50,,25560,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,968.744,Percent of Total Billed Charges,50% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,50,,968.744,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,968.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3331.02,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,521.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,40.7,4758.6,
945666 ANCHOR BOSTON SCIENTIF,32150730,CDM,278,RC,C1883,HCPCS,Outpatient,,,1644.64,986.78,,1837.66,110,,160.128,Percent of Total Billed Charges,110% of Total Billed Charges,740.09,45,,191.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,28,,23.616,Percent of Total Billed Charges,28% of Total Billed Charges,40.9,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.07,36,,30.36,Percent of Total Billed Charges,36% of Total Billed Charges,592.07,36,,30.36,Percent of Total Billed Charges,36% Total Bille Charges,592.07,36,,30.36,Percent of Total Billed Charges,36% of Total Billed Charges,904.55,55,,311.992,Percent of Total Billed Charges,55% Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1644.64,100,,69.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,237.16,14.42,,616.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1315.71,80,,5572.184,Percent of Total Billed Charges,80% of Total Billed Charges,822.32,50,,1455.048,Percent of Total Billed Charges,50% of Total Billed Charges,822.32,50,,1738.928,Percent of Total Billed Charges,50% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,822.32,50,,1738.928,Percent of Total Billed Charges,50% of Total Billed Charges,822.32,50,,1738.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1151.25,70,,150.784,Percent of Total Billed Charges,70% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,598.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1644.64,100,,6965.232,Percent of Total Billed Charges,100% of Total Billed Charges,40.9,1837.66,
435414 BONE KYPHON CEMENT,32150731,CDM,278,RC,C1713,HCPCS,Outpatient,,,1486.27,891.76,,1952.16,110,,1006.208,Percent of Total Billed Charges,110% of Total Billed Charges,668.82,45,,252.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.16,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,40.92,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,535.06,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,535.06,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,535.06,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,817.45,55,,257.16,Percent of Total Billed Charges,55% Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1486.27,100,,548.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,214.32,14.42,,189.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.02,80,,103.672,Percent of Total Billed Charges,80% of Total Billed Charges,743.14,50,,968.744,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.14,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1040.39,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,184.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1486.27,100,,138.224,Percent of Total Billed Charges,100% of Total Billed Charges,40.92,1952.16,
178600 SYSTEM BONE CEMENT,32150732,CDM,278,RC,C1713,HCPCS,Outpatient,,,512.2,307.32,,880.68,110,,1336.208,Percent of Total Billed Charges,110% of Total Billed Charges,230.49,45,,136.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.42,28,,23.368,Percent of Total Billed Charges,28% of Total Billed Charges,40.96,32,,34.792,Percent of Total Billed Charges,32% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,184.39,36,,30.048,Percent of Total Billed Charges,36% of Total Billed Charges,184.39,36,,30.048,Percent of Total Billed Charges,36% Total Bille Charges,184.39,36,,30.048,Percent of Total Billed Charges,36% of Total Billed Charges,281.71,55,,69.432,Percent of Total Billed Charges,55% Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,512.2,100,,364.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,73.86,14.42,,7057.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.76,80,,13946.048,Percent of Total Billed Charges,80% of Total Billed Charges,256.1,50,,1738.928,Percent of Total Billed Charges,50% of Total Billed Charges,256.1,50,,2022.8,Percent of Total Billed Charges,50% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.1,50,,2022.8,Percent of Total Billed Charges,50% of Total Billed Charges,256.1,50,,2022.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,358.54,70,,106.208,Percent of Total Billed Charges,70% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,71.71,14,,6852.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,512.2,100,,17432.56,Percent of Total Billed Charges,100% of Total Billed Charges,40.96,880.68,
772432 INTRODUCER BLUE RHINO G,32150733,CDM,272,RC,A4649,HCPCS,Outpatient,,,1006,603.60,,603.6,60,,1677.192,Percent of Total Billed Charges,60% of Total Billed Charges,452.7,45,,300.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.68,28,,18.392,Percent of Total Billed Charges,28% of Total Billed Charges,41.15,32,,34.816,Percent of Total Billed Charges,32% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,362.16,36,,23.648,Percent of Total Billed Charges,36% of Total Billed Charges,362.16,36,,23.648,Percent of Total Billed Charges,36% Total Bille Charges,362.16,36,,23.648,Percent of Total Billed Charges,36% of Total Billed Charges,603.6,60,,69.432,Percent of Total Billed Charges,60% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1006,100,,425.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,145.07,14.42,,401.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,754.5,75,,2487.68,Percent of Total Billed Charges,75% of Total Billed Charges,503,50,,55.64,Percent of Total Billed Charges,50% of Total Billed Charges,503,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,503,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,503,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,704.2,70,,627.752,Percent of Total Billed Charges,70% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,140.84,14,,390.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1006,100,,3109.6,Percent of Total Billed Charges,100% of Total Billed Charges,41.15,1006,
948458 LEAD LAMINECTOMY MRI 5,32150735,CDM,278,RC,C1778,HCPCS,Outpatient,,,13000,7800.00,,14882.6,110,,2349.424,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,239.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,22.096,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,34.856,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,28.416,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,28.416,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,28.416,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,601.208,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,561.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10400,80,,41353.592,Percent of Total Billed Charges,80% of Total Billed Charges,6500,50,,2022.8,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,2137.2,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,2137.2,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,2137.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,647.656,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,51691.992,Percent of Total Billed Charges,100% of Total Billed Charges,41.28,14882.6,
661675 LIGASURE MARYLAND LAP,32150736,CDM,272,RC,,,Outpatient,,,2418.86,1451.32,,1451.32,60,,1370.024,Percent of Total Billed Charges,60% of Total Billed Charges,1088.49,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,677.28,28,,675.584,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,34.928,Percent of Total Billed Charges,32% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,870.79,36,,868.608,Percent of Total Billed Charges,36% of Total Billed Charges,870.79,36,,868.608,Percent of Total Billed Charges,36% Total Bille Charges,870.79,36,,868.608,Percent of Total Billed Charges,36% of Total Billed Charges,1451.32,60,,57.56,Percent of Total Billed Charges,60% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2418.86,100,,304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,348.8,14.42,,12.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1814.15,75,,3569.28,Percent of Total Billed Charges,75% of Total Billed Charges,1209.43,50,,1862.656,Percent of Total Billed Charges,50% of Total Billed Charges,1209.43,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1209.43,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,1209.43,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1693.2,70,,2605.56,Percent of Total Billed Charges,70% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,338.64,14,,12.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2418.86,100,,4461.6,Percent of Total Billed Charges,100% of Total Billed Charges,41.28,2418.86,
115969 TUBE TOUMA T GROMMET,32150738,CDM,278,RC,,,Outpatient,,,81.92,49.15,,90.11,110,,740.88,Percent of Total Billed Charges,110% of Total Billed Charges,36.86,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.94,28,,32.4,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,35.088,Percent of Total Billed Charges,32% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,29.49,36,,41.656,Percent of Total Billed Charges,36% Total Bille Charges,29.49,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.92,100,,667.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.81,14.42,,125.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.54,80,,455.96,Percent of Total Billed Charges,80% of Total Billed Charges,40.96,50,,2137.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.96,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.96,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,40.96,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.34,70,,1126.128,Percent of Total Billed Charges,70% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,14,,121.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.92,100,,569.952,Percent of Total Billed Charges,100% of Total Billed Charges,11.47,90.11,
961939 TIBIA RIGHT DISTAL,32150739,CDM,278,RC,,,Outpatient,,,13000,7800.00,,14300,110,,50.224,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,56.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,145.592,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,35.088,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,187.192,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,187.192,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,187.192,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,34.952,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,533.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,21.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10400,80,,917.552,Percent of Total Billed Charges,80% of Total Billed Charges,6500,50,,657.856,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,1392.896,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,1392.896,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,1392.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,40.704,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,21.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,1146.936,Percent of Total Billed Charges,100% of Total Billed Charges,41.28,14300,
964070 LEAD KIT TRL NERVE SIM,32150740,CDM,278,RC,C1897,HCPCS,Outpatient,,,2541,1524.60,,3563.04,110,,89.52,Percent of Total Billed Charges,110% of Total Billed Charges,1143.45,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711.48,28,,120.008,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,35.096,Percent of Total Billed Charges,32% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,914.76,36,,154.296,Percent of Total Billed Charges,36% of Total Billed Charges,914.76,36,,154.296,Percent of Total Billed Charges,36% Total Bille Charges,914.76,36,,154.296,Percent of Total Billed Charges,36% of Total Billed Charges,1397.55,55,,929.84,Percent of Total Billed Charges,55% Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2541,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,366.41,14.42,,314.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2032.8,80,,40896,Percent of Total Billed Charges,80% of Total Billed Charges,1270.5,50,,24472.8,Percent of Total Billed Charges,50% of Total Billed Charges,1270.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1270.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,1270.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1778.7,70,,37.928,Percent of Total Billed Charges,70% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,355.74,14,,305.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2541,100,,51120,Percent of Total Billed Charges,100% of Total Billed Charges,41.28,3563.04,
0005159 PUTTY BONE GRAFT,32150741,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235,2541.00,,4975.76,110,,105.36,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,378.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,32.4,Percent of Total Billed Charges,28% of Total Billed Charges,41.28,32,,35.208,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,41.656,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,90.632,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,38.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,2328.072,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,1392.896,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,43.92,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,43.92,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,43.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,43.696,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,37.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,2910.088,Percent of Total Billed Charges,100% of Total Billed Charges,41.28,4975.76,
950692 TENDON ACHILLES,32150743,CDM,278,RC,,,Outpatient,,,8706.54,5223.92,,9577.19,110,,102.12,Percent of Total Billed Charges,110% of Total Billed Charges,3917.94,45,,396.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2437.83,28,,32.4,Percent of Total Billed Charges,28% of Total Billed Charges,41.45,32,,35.208,Percent of Total Billed Charges,32% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,3134.35,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,3134.35,36,,41.656,Percent of Total Billed Charges,36% Total Bille Charges,3134.35,36,,41.656,Percent of Total Billed Charges,36% of Total Billed Charges,4788.6,55,,65.088,Percent of Total Billed Charges,55% Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8706.54,100,,125.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1255.48,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6965.23,80,,1549.992,Percent of Total Billed Charges,80% of Total Billed Charges,4353.27,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,4353.27,50,,434.712,Percent of Total Billed Charges,50% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4353.27,50,,434.712,Percent of Total Billed Charges,50% of Total Billed Charges,4353.27,50,,434.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6094.58,70,,170.72,Percent of Total Billed Charges,70% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1218.92,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8706.54,100,,1937.488,Percent of Total Billed Charges,100% of Total Billed Charges,41.45,9577.19,
442451 SUTURE VLOC TAPER POINT,32150744,CDM,272,RC,,,Outpatient,,,172.78,103.67,,103.67,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,77.75,45,,102.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.38,28,,306.072,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.224,Percent of Total Billed Charges,32% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,62.2,36,,393.52,Percent of Total Billed Charges,36% of Total Billed Charges,62.2,36,,393.52,Percent of Total Billed Charges,36% Total Bille Charges,62.2,36,,393.52,Percent of Total Billed Charges,36% of Total Billed Charges,103.67,60,,510.376,Percent of Total Billed Charges,60% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.78,100,,168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.91,14.42,,584.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.59,75,,2782.288,Percent of Total Billed Charges,75% of Total Billed Charges,86.39,50,,43.92,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,75.68,Percent of Total Billed Charges,50% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.39,50,,75.68,Percent of Total Billed Charges,50% of Total Billed Charges,86.39,50,,75.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.95,70,,493.824,Percent of Total Billed Charges,70% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.19,14,,567.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.78,100,,3477.856,Percent of Total Billed Charges,100% of Total Billed Charges,24.19,4160,
324372 STRATTICE RECON AB WALL,32150745,CDM,278,RC,C1763,HCPCS,Outpatient,,,21790.7,13074.42,,24377.96,110,,57.984,Percent of Total Billed Charges,110% of Total Billed Charges,9805.82,45,,133.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6101.4,28,,26.856,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.264,Percent of Total Billed Charges,32% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,7844.65,36,,34.536,Percent of Total Billed Charges,36% of Total Billed Charges,7844.65,36,,34.536,Percent of Total Billed Charges,36% Total Bille Charges,7844.65,36,,34.536,Percent of Total Billed Charges,36% of Total Billed Charges,11984.89,55,,744.256,Percent of Total Billed Charges,55% Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21790.7,100,,840.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3142.22,14.42,,46.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17432.56,80,,83.464,Percent of Total Billed Charges,80% of Total Billed Charges,10895.35,50,,434.712,Percent of Total Billed Charges,50% of Total Billed Charges,10895.35,50,,1092,Percent of Total Billed Charges,50% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10895.35,50,,1092,Percent of Total Billed Charges,50% of Total Billed Charges,10895.35,50,,1092,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15253.49,70,,491.352,Percent of Total Billed Charges,70% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,3050.7,14,,44.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21790.7,100,,111.28,Percent of Total Billed Charges,100% of Total Billed Charges,3050.7,24377.96,
586031 TISSUE AMNIOTIC MEMBRN,32150746,CDM,278,RC,,,Outpatient,,,3887,2332.20,,4275.7,110,,51.536,Percent of Total Billed Charges,110% of Total Billed Charges,1749.15,45,,1123.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,28,,103.488,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.264,Percent of Total Billed Charges,32% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,1399.32,36,,133.056,Percent of Total Billed Charges,36% of Total Billed Charges,1399.32,36,,133.056,Percent of Total Billed Charges,36% Total Bille Charges,1399.32,36,,133.056,Percent of Total Billed Charges,36% of Total Billed Charges,2137.85,55,,131.856,Percent of Total Billed Charges,55% Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3887,100,,881.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,560.51,14.42,,99.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3109.6,80,,3236.48,Percent of Total Billed Charges,80% of Total Billed Charges,1943.5,50,,75.68,Percent of Total Billed Charges,50% of Total Billed Charges,1943.5,50,,134.48,Percent of Total Billed Charges,50% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1943.5,50,,134.48,Percent of Total Billed Charges,50% of Total Billed Charges,1943.5,50,,134.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2720.9,70,,491.352,Percent of Total Billed Charges,70% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,544.18,14,,97.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3887,100,,4045.6,Percent of Total Billed Charges,100% of Total Billed Charges,544.18,4275.7,
978364 STIMULATOR AND BATTERY,32150747,CDM,278,RC,C1767,HCPCS,Outpatient,,,64614.99,38768.99,,80984.82,110,,65.24,Percent of Total Billed Charges,110% of Total Billed Charges,29076.75,45,,4970.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18092.2,28,,16.312,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.328,Percent of Total Billed Charges,32% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,23261.4,36,,20.968,Percent of Total Billed Charges,36% of Total Billed Charges,23261.4,36,,20.968,Percent of Total Billed Charges,36% Total Bille Charges,23261.4,36,,20.968,Percent of Total Billed Charges,36% of Total Billed Charges,35538.24,55,,192.28,Percent of Total Billed Charges,55% Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64614.99,100,,227.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9317.48,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51691.99,80,,2980.24,Percent of Total Billed Charges,80% of Total Billed Charges,32307.5,50,,1092,Percent of Total Billed Charges,50% of Total Billed Charges,32307.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32307.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,32307.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45230.49,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64614.99,100,,3725.304,Percent of Total Billed Charges,100% of Total Billed Charges,4160,80984.82,
479470 AMNIOTIC MEMBRANE,32150748,CDM,278,RC,,,Outpatient,,,5577,3346.20,,6134.7,110,,99.112,Percent of Total Billed Charges,110% of Total Billed Charges,2509.65,45,,4487.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1561.56,28,,433.92,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.328,Percent of Total Billed Charges,32% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,2007.72,36,,557.904,Percent of Total Billed Charges,36% of Total Billed Charges,2007.72,36,,557.904,Percent of Total Billed Charges,36% Total Bille Charges,2007.72,36,,557.904,Percent of Total Billed Charges,36% of Total Billed Charges,3067.35,55,,1169.52,Percent of Total Billed Charges,55% Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5577,100,,296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,804.2,14.42,,70.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4461.6,80,,3419.52,Percent of Total Billed Charges,80% of Total Billed Charges,2788.5,50,,134.48,Percent of Total Billed Charges,50% of Total Billed Charges,2788.5,50,,2028,Percent of Total Billed Charges,50% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2788.5,50,,2028,Percent of Total Billed Charges,50% of Total Billed Charges,2788.5,50,,2028,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3903.9,70,,191.184,Percent of Total Billed Charges,70% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,780.78,14,,68.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5577,100,,4274.4,Percent of Total Billed Charges,100% of Total Billed Charges,780.78,6134.7,
163132 MESH PROCEED 4X2,32150749,CDM,278,RC,C1781,HCPCS,Outpatient,,,712.44,427.46,,1236.44,110,,106.688,Percent of Total Billed Charges,110% of Total Billed Charges,320.6,45,,2672.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.48,28,,42.296,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.424,Percent of Total Billed Charges,32% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,256.48,36,,54.384,Percent of Total Billed Charges,36% of Total Billed Charges,256.48,36,,54.384,Percent of Total Billed Charges,36% Total Bille Charges,256.48,36,,54.384,Percent of Total Billed Charges,36% of Total Billed Charges,391.84,55,,65.2,Percent of Total Billed Charges,55% Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.44,100,,2496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,102.73,14.42,,24.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,569.95,80,,1052.568,Percent of Total Billed Charges,80% of Total Billed Charges,356.22,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,356.22,50,,159.568,Percent of Total Billed Charges,50% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.22,50,,159.568,Percent of Total Billed Charges,50% of Total Billed Charges,356.22,50,,159.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.71,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.74,14,,23.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,712.44,100,,1315.712,Percent of Total Billed Charges,100% of Total Billed Charges,99.74,4160,
163135 MESH PROCEED 10X15,32150750,CDM,278,RC,C1781,HCPCS,Outpatient,,,1433.67,860.20,,2029.8,110,,57.984,Percent of Total Billed Charges,110% of Total Billed Charges,645.15,45,,4399.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.43,28,,30.376,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.44,Percent of Total Billed Charges,32% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,516.12,36,,39.056,Percent of Total Billed Charges,36% of Total Billed Charges,516.12,36,,39.056,Percent of Total Billed Charges,36% Total Bille Charges,516.12,36,,39.056,Percent of Total Billed Charges,36% of Total Billed Charges,788.52,55,,42.664,Percent of Total Billed Charges,55% Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1433.67,100,,11045.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,206.74,14.42,,395.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1146.94,80,,39156.48,Percent of Total Billed Charges,80% of Total Billed Charges,716.84,50,,2028,Percent of Total Billed Charges,50% of Total Billed Charges,716.84,50,,346.648,Percent of Total Billed Charges,50% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,716.84,50,,346.648,Percent of Total Billed Charges,50% of Total Billed Charges,716.84,50,,346.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1003.57,70,,31.864,Percent of Total Billed Charges,70% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,200.71,14,,384.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1433.67,100,,48945.6,Percent of Total Billed Charges,100% of Total Billed Charges,200.71,4160,
914978 GENERATOR AND CHARGE KT,32150751,CDM,278,RC,C1820,HCPCS,Outpatient,,,63900,38340.00,,71920.18,110,,41.184,Percent of Total Billed Charges,110% of Total Billed Charges,28755,45,,4488.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17892,28,,238.176,Percent of Total Billed Charges,28% of Total Billed Charges,4160,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,23004,36,,306.224,Percent of Total Billed Charges,36% of Total Billed Charges,23004,36,,306.224,Percent of Total Billed Charges,36% Total Bille Charges,23004,36,,306.224,Percent of Total Billed Charges,36% of Total Billed Charges,35145,55,,91.248,Percent of Total Billed Charges,55% Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63900,100,,9971.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,9214.38,14.42,,98.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51120,80,,2228.624,Percent of Total Billed Charges,80% of Total Billed Charges,31950,50,,159.568,Percent of Total Billed Charges,50% of Total Billed Charges,31950,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31950,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,31950,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44730,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,8946,14,,95.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63900,100,,2785.784,Percent of Total Billed Charges,100% of Total Billed Charges,4160,71920.18,
109130 MESH PROCEED OVAL 8X10,32150752,CDM,278,RC,C1781,HCPCS,Outpatient,,,3637.61,2182.57,,4454.13,110,,50.384,Percent of Total Billed Charges,110% of Total Billed Charges,1636.92,45,,1650.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1018.53,28,,347.32,Percent of Total Billed Charges,28% of Total Billed Charges,4167.78,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,1309.54,36,,446.552,Percent of Total Billed Charges,36% of Total Billed Charges,1309.54,36,,446.552,Percent of Total Billed Charges,36% Total Bille Charges,1309.54,36,,446.552,Percent of Total Billed Charges,36% of Total Billed Charges,2000.69,55,,592.024,Percent of Total Billed Charges,55% Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3637.61,100,,5938.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,524.54,14.42,,15.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2910.09,80,,1559.36,Percent of Total Billed Charges,80% of Total Billed Charges,1818.81,50,,346.648,Percent of Total Billed Charges,50% of Total Billed Charges,1818.81,50,,245.232,Percent of Total Billed Charges,50% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1818.81,50,,245.232,Percent of Total Billed Charges,50% of Total Billed Charges,1818.81,50,,245.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2546.33,70,,191.816,Percent of Total Billed Charges,70% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,509.27,14,,14.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3637.61,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,509.27,4454.13,
109132 MESH PROCEED OVAL,32150753,CDM,278,RC,C1781,HCPCS,Outpatient,,,2421.86,1453.12,,3116.81,110,,65.808,Percent of Total Billed Charges,110% of Total Billed Charges,1089.84,45,,2312.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,678.12,28,,61.536,Percent of Total Billed Charges,28% of Total Billed Charges,4187.57,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,871.87,36,,79.112,Percent of Total Billed Charges,36% of Total Billed Charges,871.87,36,,79.112,Percent of Total Billed Charges,36% Total Bille Charges,871.87,36,,79.112,Percent of Total Billed Charges,36% of Total Billed Charges,1332.02,55,,520.528,Percent of Total Billed Charges,55% Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2421.86,100,,9776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,349.23,14.42,,666.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1937.49,80,,65.88,Percent of Total Billed Charges,80% of Total Billed Charges,1210.93,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,1210.93,50,,84.04,Percent of Total Billed Charges,50% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1210.93,50,,84.04,Percent of Total Billed Charges,50% of Total Billed Charges,1210.93,50,,84.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1695.3,70,,224.328,Percent of Total Billed Charges,70% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,339.06,14,,647.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2421.86,100,,87.84,Percent of Total Billed Charges,100% of Total Billed Charges,339.06,4187.57,
548389 GRAFT PROPATEN,32150754,CDM,278,RC,C1768,HCPCS,Outpatient,,,4347.32,2608.39,,5104.82,110,,66.008,Percent of Total Billed Charges,110% of Total Billed Charges,1956.29,45,,6480,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1217.25,28,,89.728,Percent of Total Billed Charges,28% of Total Billed Charges,4191.92,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,1565.04,36,,115.368,Percent of Total Billed Charges,36% of Total Billed Charges,1565.04,36,,115.368,Percent of Total Billed Charges,36% Total Bille Charges,1565.04,36,,115.368,Percent of Total Billed Charges,36% of Total Billed Charges,2391.03,55,,850.872,Percent of Total Billed Charges,55% Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4347.32,100,,9973.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,626.88,14.42,,437.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3477.86,80,,652.072,Percent of Total Billed Charges,80% of Total Billed Charges,2173.66,50,,245.232,Percent of Total Billed Charges,50% of Total Billed Charges,2173.66,50,,1371.872,Percent of Total Billed Charges,50% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2173.66,50,,1371.872,Percent of Total Billed Charges,50% of Total Billed Charges,2173.66,50,,1371.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3043.12,70,,733.2,Percent of Total Billed Charges,70% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,608.62,14,,425.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4347.32,100,,869.424,Percent of Total Billed Charges,100% of Total Billed Charges,608.62,5104.82,
TRACH TUBE CUFFLESS 8 SHILEY (8CFS),32150755,CDM,272,RC,,,Outpatient,,,139.1,83.46,,83.46,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,62.6,45,,702,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.95,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,4332.8,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,50.08,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,50.08,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,50.08,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,83.46,60,,875.184,Percent of Total Billed Charges,60% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.1,100,,3667.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,20.06,14.42,,548.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.33,75,,113.52,Percent of Total Billed Charges,75% of Total Billed Charges,69.55,50,,84.04,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,50,,339.984,Percent of Total Billed Charges,50% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.55,50,,339.984,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,50,,339.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.37,70,,793.896,Percent of Total Billed Charges,70% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.47,14,,532.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.1,100,,151.36,Percent of Total Billed Charges,100% of Total Billed Charges,19.47,4332.8,
987263 KIT LEAD STIMULATION,32150756,CDM,278,RC,C1778,HCPCS,Outpatient,,,5057,3034.20,,6145.3,110,,60.4,Percent of Total Billed Charges,110% of Total Billed Charges,2275.65,45,,2054.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1415.96,28,,30.424,Percent of Total Billed Charges,28% of Total Billed Charges,4341.18,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,1820.52,36,,39.12,Percent of Total Billed Charges,36% of Total Billed Charges,1820.52,36,,39.12,Percent of Total Billed Charges,36% Total Bille Charges,1820.52,36,,39.12,Percent of Total Billed Charges,36% of Total Billed Charges,2781.35,55,,74.296,Percent of Total Billed Charges,55% Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5057,100,,5138.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,729.22,14.42,,260.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4045.6,80,,1638,Percent of Total Billed Charges,80% of Total Billed Charges,2528.5,50,,1371.872,Percent of Total Billed Charges,50% of Total Billed Charges,2528.5,50,,53.192,Percent of Total Billed Charges,50% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2528.5,50,,53.192,Percent of Total Billed Charges,50% of Total Billed Charges,2528.5,50,,53.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3539.9,70,,688.8,Percent of Total Billed Charges,70% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,707.98,14,,252.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5057,100,,2184,Percent of Total Billed Charges,100% of Total Billed Charges,707.98,6145.3,
988460 LEAD LINEAR WITH STYLET,32150757,CDM,278,RC,C1778,HCPCS,Outpatient,,,4656.63,2793.98,,5704.89,110,,55.088,Percent of Total Billed Charges,110% of Total Billed Charges,2095.48,45,,2803.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1303.86,28,,19.912,Percent of Total Billed Charges,28% of Total Billed Charges,4355.49,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,1676.39,36,,25.6,Percent of Total Billed Charges,36% of Total Billed Charges,1676.39,36,,25.6,Percent of Total Billed Charges,36% Total Bille Charges,1676.39,36,,25.6,Percent of Total Billed Charges,36% of Total Billed Charges,2561.15,55,,151.712,Percent of Total Billed Charges,55% Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4656.63,100,,14400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,671.49,14.42,,288.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3725.3,80,,201.72,Percent of Total Billed Charges,80% of Total Billed Charges,2328.32,50,,339.984,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,2311.32,Percent of Total Billed Charges,50% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2328.32,50,,2311.32,Percent of Total Billed Charges,50% of Total Billed Charges,2328.32,50,,2311.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3259.64,70,,919.12,Percent of Total Billed Charges,70% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,651.93,14,,279.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4656.63,100,,268.96,Percent of Total Billed Charges,100% of Total Billed Charges,651.93,5704.89,
995181 LEAD CONTACT MRI AVISTA,32150758,CDM,278,RC,C1778,HCPCS,Outpatient,,,5343,3205.80,,6459.9,110,,55.088,Percent of Total Billed Charges,110% of Total Billed Charges,2404.35,45,,959.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1496.04,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4359.42,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,1923.48,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,1923.48,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,1923.48,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,2938.65,55,,1863.4,Percent of Total Billed Charges,55% Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5343,100,,1560,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,770.46,14.42,,7453.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4274.4,80,,42,Percent of Total Billed Charges,80% of Total Billed Charges,2671.5,50,,53.192,Percent of Total Billed Charges,50% of Total Billed Charges,2671.5,50,,1518.248,Percent of Total Billed Charges,50% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2671.5,50,,1518.248,Percent of Total Billed Charges,50% of Total Billed Charges,2671.5,50,,1518.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3740.1,70,,540.432,Percent of Total Billed Charges,70% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,748.02,14,,7236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5343,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,748.02,6459.9,
995180 ANCHOR CLIK X MRI,32150759,CDM,278,RC,C1883,HCPCS,Outpatient,,,1644.64,986.78,,1837.66,110,,180,Percent of Total Billed Charges,110% of Total Billed Charges,740.09,45,,2499.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,28,,276.28,Percent of Total Billed Charges,28% of Total Billed Charges,4380.09,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,592.07,36,,355.216,Percent of Total Billed Charges,36% of Total Billed Charges,592.07,36,,355.216,Percent of Total Billed Charges,36% Total Bille Charges,592.07,36,,355.216,Percent of Total Billed Charges,36% of Total Billed Charges,904.55,55,,61.912,Percent of Total Billed Charges,55% Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1644.64,100,,4565.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,237.16,14.42,,573.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1315.71,80,,3042,Percent of Total Billed Charges,80% of Total Billed Charges,822.32,50,,2311.32,Percent of Total Billed Charges,50% of Total Billed Charges,822.32,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,822.32,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,822.32,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1151.25,70,,44.768,Percent of Total Billed Charges,70% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,230.25,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1644.64,100,,4056,Percent of Total Billed Charges,100% of Total Billed Charges,230.25,4380.09,
995179 GENERATOR MONTAGE MRI,32150760,CDM,278,RC,C1820,HCPCS,Outpatient,,,61182,36709.20,,68930.38,110,,331.088,Percent of Total Billed Charges,110% of Total Billed Charges,27531.9,45,,4874.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17130.96,28,,265,Percent of Total Billed Charges,28% of Total Billed Charges,4380.13,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,22025.52,36,,340.712,Percent of Total Billed Charges,36% of Total Billed Charges,22025.52,36,,340.712,Percent of Total Billed Charges,36% Total Bille Charges,22025.52,36,,340.712,Percent of Total Billed Charges,36% of Total Billed Charges,33650.1,55,,61.912,Percent of Total Billed Charges,55% Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61182,100,,6229.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8822.44,14.42,,582.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48945.6,80,,239.352,Percent of Total Billed Charges,80% of Total Billed Charges,30591,50,,1518.248,Percent of Total Billed Charges,50% of Total Billed Charges,30591,50,,902.16,Percent of Total Billed Charges,50% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30591,50,,902.16,Percent of Total Billed Charges,50% of Total Billed Charges,30591,50,,902.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42827.4,70,,559.424,Percent of Total Billed Charges,70% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,8565.48,14,,565.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61182,100,,319.136,Percent of Total Billed Charges,100% of Total Billed Charges,4380.13,68930.38,
576820 ALLOGRAFT CANCELLOUS,32150761,CDM,278,RC,,,Outpatient,,,3482.23,2089.34,,3830.45,110,,280.352,Percent of Total Billed Charges,110% of Total Billed Charges,1567,45,,1773.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975.02,28,,433.168,Percent of Total Billed Charges,28% of Total Billed Charges,4397.12,32,,35.472,Percent of Total Billed Charges,32% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,1253.6,36,,556.936,Percent of Total Billed Charges,36% of Total Billed Charges,1253.6,36,,556.936,Percent of Total Billed Charges,36% Total Bille Charges,1253.6,36,,556.936,Percent of Total Billed Charges,36% of Total Billed Charges,1915.23,55,,61.912,Percent of Total Billed Charges,55% Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3482.23,100,,2132,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,502.14,14.42,,9802.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2785.78,80,,554.632,Percent of Total Billed Charges,80% of Total Billed Charges,1741.12,50,,1903.44,Percent of Total Billed Charges,50% of Total Billed Charges,1741.12,50,,999.464,Percent of Total Billed Charges,50% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1741.12,50,,999.464,Percent of Total Billed Charges,50% of Total Billed Charges,1741.12,50,,999.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2437.56,70,,286.272,Percent of Total Billed Charges,70% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,487.51,14,,9517.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3482.23,100,,693.288,Percent of Total Billed Charges,100% of Total Billed Charges,487.51,4397.12,
576818 ALLOGRAFT CANCELLOUS,32150762,CDM,278,RC,,,Outpatient,,,2436.5,1461.90,,2680.15,110,,136.192,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,1006.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,445.552,Percent of Total Billed Charges,28% of Total Billed Charges,4411.63,32,,35.48,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,572.848,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,572.848,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,572.848,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,39.712,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,5553.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,573.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,1169.52,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,902.16,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,387.648,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,557.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,341.11,4411.63,
989934 GRASPER SUTURE CLOSURE,32150764,CDM,272,RC,,,Outpatient,,,109.8,65.88,,65.88,60,,544.792,Percent of Total Billed Charges,60% of Total Billed Charges,49.41,45,,378,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.74,28,,34.672,Percent of Total Billed Charges,28% of Total Billed Charges,4416,32,,35.584,Percent of Total Billed Charges,32% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,39.53,36,,44.576,Percent of Total Billed Charges,36% of Total Billed Charges,39.53,36,,44.576,Percent of Total Billed Charges,36% Total Bille Charges,39.53,36,,44.576,Percent of Total Billed Charges,36% of Total Billed Charges,65.88,60,,164.408,Percent of Total Billed Charges,60% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.8,100,,10832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.83,14.42,,79.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.35,75,,367.84,Percent of Total Billed Charges,75% of Total Billed Charges,54.9,50,,999.464,Percent of Total Billed Charges,50% of Total Billed Charges,54.9,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.9,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,54.9,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,15.37,14,,77.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.8,100,,490.456,Percent of Total Billed Charges,100% of Total Billed Charges,15.37,4416,
834014 INFERIOR TURBINATE,32150766,CDM,272,RC,,,Outpatient,,,1086.78,652.07,,652.07,60,,119.64,Percent of Total Billed Charges,60% of Total Billed Charges,489.05,45,,194.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.3,28,,70.8,Percent of Total Billed Charges,28% of Total Billed Charges,4459.49,32,,35.608,Percent of Total Billed Charges,32% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,391.24,36,,91.032,Percent of Total Billed Charges,36% of Total Billed Charges,391.24,36,,91.032,Percent of Total Billed Charges,36% Total Bille Charges,391.24,36,,91.032,Percent of Total Billed Charges,36% of Total Billed Charges,652.07,60,,89.864,Percent of Total Billed Charges,60% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1086.78,100,,3941.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.71,14.42,,413.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,815.09,75,,126.064,Percent of Total Billed Charges,75% of Total Billed Charges,543.39,50,,25846,Percent of Total Billed Charges,50% of Total Billed Charges,543.39,50,,2019.664,Percent of Total Billed Charges,50% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.39,50,,2019.664,Percent of Total Billed Charges,50% of Total Billed Charges,543.39,50,,2019.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.75,70,,205.64,Percent of Total Billed Charges,70% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,152.15,14,,401.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1086.78,100,,168.08,Percent of Total Billed Charges,100% of Total Billed Charges,152.15,4459.49,
NEEDLE BX BONE OSTEO,32150767,CDM,272,RC,A4649,HCPCS,Outpatient,,,189.2,113.52,,113.52,60,,393.24,Percent of Total Billed Charges,60% of Total Billed Charges,85.14,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,28,,948.64,Percent of Total Billed Charges,28% of Total Billed Charges,4465.76,32,,35.608,Percent of Total Billed Charges,32% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,68.11,36,,1219.68,Percent of Total Billed Charges,36% Total Bille Charges,68.11,36,,1219.68,Percent of Total Billed Charges,36% of Total Billed Charges,113.52,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.2,100,,2237.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,27.28,14.42,,488.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.9,75,,2057.8,Percent of Total Billed Charges,75% of Total Billed Charges,94.6,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,94.6,50,,33990,Percent of Total Billed Charges,50% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.6,50,,33990,Percent of Total Billed Charges,50% of Total Billed Charges,94.6,50,,33990,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.44,70,,286.272,Percent of Total Billed Charges,70% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,26.49,14,,474.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.2,100,,2743.736,Percent of Total Billed Charges,100% of Total Billed Charges,26.49,4465.76,
1006440 GASTRISAIL,32150770,CDM,272,RC,,,Outpatient,,,2730,1638.00,,1638,60,,117.24,Percent of Total Billed Charges,60% of Total Billed Charges,1228.5,45,,1731.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.4,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,4.17,32,,3627.184,Percent of Total Billed Charges,32% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,982.8,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,982.8,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,982.8,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,1638,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2730,100,,840,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,393.67,14.42,,88.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2047.5,75,,509.968,Percent of Total Billed Charges,75% of Total Billed Charges,1365,50,,2019.664,Percent of Total Billed Charges,50% of Total Billed Charges,1365,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,1365,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1911,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,382.2,14,,86.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2730,100,,679.96,Percent of Total Billed Charges,100% of Total Billed Charges,4.17,2730,
1007137 INTRODUCER SUPRAPUBIC,32150772,CDM,272,RC,C1894,HCPCS,Outpatient,,,336.2,201.72,,82.29,100,,41.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.14,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,4.19,32,,3676.728,Percent of Total Billed Charges,32% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,121.03,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,121.03,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,121.03,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,201.72,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.2,100,,432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,48.48,14.42,,8.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.15,75,,79.784,Percent of Total Billed Charges,75% of Total Billed Charges,168.1,50,,33990,Percent of Total Billed Charges,50% of Total Billed Charges,168.1,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.1,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,168.1,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.34,70,,201.688,Percent of Total Billed Charges,70% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,47.07,14,,8.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.2,100,,106.376,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,336.2,
0003422 KIT VEIN STRIPPER,32150774,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,79.56,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,26.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,4.2,32,,3685.888,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,140,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,1202.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,3466.984,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,1989.52,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,1433.12,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,1433.12,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,1433.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,149.696,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,4622.64,Percent of Total Billed Charges,100% of Total Billed Charges,4.2,70,
1007767 SYS BALLOON SINUPLASTY,32150775,CDM,272,RC,C1726,HCPCS,Outpatient,,,5070,3042.00,,396.8,100,,105.36,Fee Schedule,100% of Aetna Fee Schedule,2281.5,45,,2522.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1419.6,28,,18.536,Percent of Total Billed Charges,28% of Total Billed Charges,4.22,32,,3767.296,Percent of Total Billed Charges,32% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,1825.2,36,,23.832,Percent of Total Billed Charges,36% of Total Billed Charges,1825.2,36,,23.832,Percent of Total Billed Charges,36% Total Bille Charges,1825.2,36,,23.832,Percent of Total Billed Charges,36% of Total Billed Charges,3042,60,,91.248,Percent of Total Billed Charges,60% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5070,100,,3848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,731.09,14.42,,13.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3802.5,75,,2429.2,Percent of Total Billed Charges,75% of Total Billed Charges,2535,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,2535,50,,1695.2,Percent of Total Billed Charges,50% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2535,50,,1695.2,Percent of Total Billed Charges,50% of Total Billed Charges,2535,50,,1695.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3549,70,,161.232,Percent of Total Billed Charges,70% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,709.8,14,,12.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5070,100,,3036.496,Percent of Total Billed Charges,100% of Total Billed Charges,4.22,5070,
765823 DERMABOND PRINEO WOUND,32150776,CDM,272,RC,,,Outpatient,,,398.92,239.35,,239.35,60,,179.28,Percent of Total Billed Charges,60% of Total Billed Charges,179.51,45,,14976.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.7,28,,76.728,Percent of Total Billed Charges,28% of Total Billed Charges,4.25,32,,3767.296,Percent of Total Billed Charges,32% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,143.61,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,143.61,36,,98.648,Percent of Total Billed Charges,36% Total Bille Charges,143.61,36,,98.648,Percent of Total Billed Charges,36% of Total Billed Charges,239.35,60,,88.048,Percent of Total Billed Charges,60% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.92,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,57.52,14.42,,32.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.19,75,,2855.16,Percent of Total Billed Charges,75% of Total Billed Charges,199.46,50,,1433.12,Percent of Total Billed Charges,50% of Total Billed Charges,199.46,50,,307.392,Percent of Total Billed Charges,50% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.46,50,,307.392,Percent of Total Billed Charges,50% of Total Billed Charges,199.46,50,,307.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.24,70,,149.696,Percent of Total Billed Charges,70% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,55.85,14,,31.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.92,100,,3806.88,Percent of Total Billed Charges,100% of Total Billed Charges,4.25,398.92,
160444 BONE GRFT DBM DBX PTTY,32150777,CDM,278,RC,C1713,HCPCS,Outpatient,,,866.61,519.97,,1270.53,110,,179.28,Percent of Total Billed Charges,110% of Total Billed Charges,389.97,45,,3961.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,242.65,28,,41.936,Percent of Total Billed Charges,28% of Total Billed Charges,4.29,32,,3801.656,Percent of Total Billed Charges,32% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,311.98,36,,53.92,Percent of Total Billed Charges,36% of Total Billed Charges,311.98,36,,53.92,Percent of Total Billed Charges,36% Total Bille Charges,311.98,36,,53.92,Percent of Total Billed Charges,36% of Total Billed Charges,476.64,55,,42.408,Percent of Total Billed Charges,55% Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,866.61,100,,58.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,124.97,14.42,,49.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,693.29,80,,1443.456,Percent of Total Billed Charges,80% of Total Billed Charges,433.31,50,,1695.2,Percent of Total Billed Charges,50% of Total Billed Charges,433.31,50,,29.904,Percent of Total Billed Charges,50% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,433.31,50,,29.904,Percent of Total Billed Charges,50% of Total Billed Charges,433.31,50,,29.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,606.63,70,,161.232,Percent of Total Billed Charges,70% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.33,14,,47.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,866.61,100,,1804.32,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,1270.53,
736960 NEUROSTIMULATOR EXTERNA,32150778,CDM,270,RC,,,Outpatient,,,1949.2,1169.52,,1169.52,60,,49.68,Percent of Total Billed Charges,60% of Total Billed Charges,877.14,45,,675,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4.31,32,,3833.304,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,1169.52,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,5605.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,7.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1461.9,75,,1599.136,Percent of Total Billed Charges,75% of Total Billed Charges,974.6,50,,307.392,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,1529.04,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,7.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,1998.92,Percent of Total Billed Charges,100% of Total Billed Charges,4.31,1949.2,
220397 PROBE LAP ARGON COAG,32150780,CDM,272,RC,,,Outpatient,,,613.07,367.84,,367.84,60,,126.84,Percent of Total Billed Charges,60% of Total Billed Charges,275.88,45,,2456.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.66,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4.33,32,,3.584,Percent of Total Billed Charges,32% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,220.71,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,220.71,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,220.71,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,367.84,60,,24.8,Percent of Total Billed Charges,60% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.07,100,,33280.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,88.4,14.42,,2.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.8,75,,41353.592,Percent of Total Billed Charges,75% of Total Billed Charges,306.54,50,,29.904,Percent of Total Billed Charges,50% of Total Billed Charges,306.54,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.54,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,306.54,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429.15,70,,605.712,Percent of Total Billed Charges,70% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,85.83,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,613.07,100,,51691.992,Percent of Total Billed Charges,100% of Total Billed Charges,4.33,613.07,
1007138 GWIRE ZIPWIRE STANDARD,32150781,CDM,272,RC,C1769,HCPCS,Outpatient,,,210.1,126.06,,55.13,100,,109.92,Fee Schedule,100% of Aetna Fee Schedule,94.55,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.83,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4.34,32,,3.6,Percent of Total Billed Charges,32% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.64,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,75.64,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,75.64,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,126.06,60,,688.304,Percent of Total Billed Charges,60% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.1,100,,8803.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,30.3,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.58,75,,2984.28,Percent of Total Billed Charges,75% of Total Billed Charges,105.05,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,105.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,105.05,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.07,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.41,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.1,100,,3979.04,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,210.1,
373015 KIT CODMAN BACTISEAL,32150782,CDM,272,RC,C1729,HCPCS,Outpatient,,,3429.67,2057.80,,11.1,100,,191.4,Fee Schedule,100% of Aetna Fee Schedule,1543.35,45,,1575,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,960.31,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,4.34,32,,3.608,Percent of Total Billed Charges,32% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,1234.68,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1234.68,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,1234.68,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,2057.8,60,,1473.824,Percent of Total Billed Charges,60% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3429.67,100,,1500,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,494.56,14.42,,59.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2572.25,75,,3231.456,Percent of Total Billed Charges,75% of Total Billed Charges,1714.84,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,1714.84,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1714.84,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,1714.84,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2400.77,70,,646.192,Percent of Total Billed Charges,70% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,480.15,14,,57.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3429.67,100,,4039.32,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,3429.67,
0007117 STAPLER ACCESS ARTICUL,32150783,CDM,272,RC,,,Outpatient,,,849.95,509.97,,509.97,60,,254.16,Percent of Total Billed Charges,60% of Total Billed Charges,382.48,45,,2849.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.99,28,,42.584,Percent of Total Billed Charges,28% of Total Billed Charges,4.35,32,,3.608,Percent of Total Billed Charges,32% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,305.98,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,305.98,36,,54.752,Percent of Total Billed Charges,36% Total Bille Charges,305.98,36,,54.752,Percent of Total Billed Charges,36% of Total Billed Charges,509.97,60,,364.264,Percent of Total Billed Charges,60% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.95,100,,5459.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,122.56,14.42,,171.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,637.46,75,,54384,Percent of Total Billed Charges,75% of Total Billed Charges,424.98,50,,112.568,Percent of Total Billed Charges,50% of Total Billed Charges,424.98,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,424.98,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,424.98,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.97,70,,653.592,Percent of Total Billed Charges,70% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,118.99,14,,166.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,849.95,100,,67980,Percent of Total Billed Charges,100% of Total Billed Charges,4.35,849.95,
1021833 ELECTRODE LEEP 12CM 5,32150784,CDM,272,RC,,,Outpatient,,,132.97,79.78,,79.78,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,59.84,45,,660.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.23,28,,41.088,Percent of Total Billed Charges,28% of Total Billed Charges,4.36,32,,3.648,Percent of Total Billed Charges,32% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,47.87,36,,52.832,Percent of Total Billed Charges,36% of Total Billed Charges,47.87,36,,52.832,Percent of Total Billed Charges,36% Total Bille Charges,47.87,36,,52.832,Percent of Total Billed Charges,36% of Total Billed Charges,79.78,60,,467.808,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.97,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,19.17,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.73,75,,3183.232,Percent of Total Billed Charges,75% of Total Billed Charges,66.49,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,66.49,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.49,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,66.49,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.08,70,,289.864,Percent of Total Billed Charges,70% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.97,100,,3979.04,Percent of Total Billed Charges,100% of Total Billed Charges,4.36,132.97,
1041468 PACEMAKER SGL CHMBR ZE,32150785,CDM,275,RC,C1786,HCPCS,Outpatient,,,5778.3,3466.98,,7472.82,110,,171.48,Percent of Total Billed Charges,110% of Total Billed Charges,2600.24,45,,866.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1617.92,28,,48.544,Percent of Total Billed Charges,28% of Total Billed Charges,4.38,32,,3.664,Percent of Total Billed Charges,32% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2080.19,36,,62.416,Percent of Total Billed Charges,36% of Total Billed Charges,2080.19,36,,62.416,Percent of Total Billed Charges,36% Total Bille Charges,2080.19,36,,62.416,Percent of Total Billed Charges,36% of Total Billed Charges,3178.07,55,,37.24,Percent of Total Billed Charges,55% Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5778.3,100,,3500,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,833.23,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4333.73,75,,414,Percent of Total Billed Charges,75% of Total Billed Charges,2889.15,50,,25.728,Percent of Total Billed Charges,50% of Total Billed Charges,2889.15,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2889.15,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,2889.15,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4044.81,70,,243.136,Percent of Total Billed Charges,70% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,808.96,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5778.3,100,,552,Percent of Total Billed Charges,100% of Total Billed Charges,4.38,7472.82,
815415 SLING RETROPUBIC SYSTEM,32150786,CDM,278,RC,C1771,HCPCS,Outpatient,,,3795.62,2277.37,,4263.09,110,,298.92,Percent of Total Billed Charges,110% of Total Billed Charges,1708.03,45,,442.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1062.77,28,,19.792,Percent of Total Billed Charges,28% of Total Billed Charges,4.41,32,,3.696,Percent of Total Billed Charges,32% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,1366.42,36,,25.448,Percent of Total Billed Charges,36% of Total Billed Charges,1366.42,36,,25.448,Percent of Total Billed Charges,36% Total Bille Charges,1366.42,36,,25.448,Percent of Total Billed Charges,36% of Total Billed Charges,2087.59,55,,39.592,Percent of Total Billed Charges,55% Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3795.62,100,,6331.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,547.33,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3036.5,80,,2149.68,Percent of Total Billed Charges,80% of Total Billed Charges,1897.81,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,1897.81,50,,206.8,Percent of Total Billed Charges,50% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1897.81,50,,206.8,Percent of Total Billed Charges,50% of Total Billed Charges,1897.81,50,,206.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2656.93,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,531.39,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3795.62,100,,2866.24,Percent of Total Billed Charges,100% of Total Billed Charges,4.41,4263.09,
1021854 FREELINK REMOTE,32150787,CDM,272,RC,C1787,HCPCS,Outpatient,,,4758.6,2855.16,,59.4,100,,360.752,Fee Schedule,100% of Aetna Fee Schedule,2141.37,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,4.43,32,,3.696,Percent of Total Billed Charges,32% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,1713.1,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,1713.1,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,1713.1,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,2855.16,60,,166.912,Percent of Total Billed Charges,60% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4758.6,100,,1467.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,686.19,14.42,,37.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3568.95,75,,2712.32,Percent of Total Billed Charges,75% of Total Billed Charges,2379.3,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,594,Percent of Total Billed Charges,50% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,50,,594,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,594,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3331.02,70,,408.792,Percent of Total Billed Charges,70% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,36.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,100,,3390.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.43,4758.6,
438192 EXTENS LEAD NEUROSTIM,32150788,CDM,278,RC,C1883,HCPCS,Outpatient,,,2255.4,1353.24,,2509.5,110,,329.296,Percent of Total Billed Charges,110% of Total Billed Charges,1014.93,45,,49.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.51,28,,11.568,Percent of Total Billed Charges,28% of Total Billed Charges,4.45,32,,3.696,Percent of Total Billed Charges,32% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,811.94,36,,14.88,Percent of Total Billed Charges,36% of Total Billed Charges,811.94,36,,14.88,Percent of Total Billed Charges,36% Total Bille Charges,811.94,36,,14.88,Percent of Total Billed Charges,36% of Total Billed Charges,1240.47,55,,119.152,Percent of Total Billed Charges,55% Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2255.4,100,,1926.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,325.23,14.42,,384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1804.32,80,,461.08,Percent of Total Billed Charges,80% of Total Billed Charges,1127.7,50,,206.8,Percent of Total Billed Charges,50% of Total Billed Charges,1127.7,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1127.7,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,1127.7,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1578.78,70,,284.344,Percent of Total Billed Charges,70% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,315.76,14,,372.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2255.4,100,,614.776,Percent of Total Billed Charges,100% of Total Billed Charges,4.45,2509.5,
1051253 LEAD TRL 8X60ML,32150789,CDM,278,RC,C1778,HCPCS,Outpatient,,,2498.65,1499.19,,3331.12,110,,504.144,Percent of Total Billed Charges,110% of Total Billed Charges,1124.39,45,,443.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.62,28,,321.208,Percent of Total Billed Charges,28% of Total Billed Charges,4.47,32,,3.72,Percent of Total Billed Charges,32% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,899.51,36,,412.984,Percent of Total Billed Charges,36% of Total Billed Charges,899.51,36,,412.984,Percent of Total Billed Charges,36% Total Bille Charges,899.51,36,,412.984,Percent of Total Billed Charges,36% of Total Billed Charges,1374.26,55,,1162.76,Percent of Total Billed Charges,55% Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2498.65,100,,983.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,360.31,14.42,,362.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.92,80,,47.84,Percent of Total Billed Charges,80% of Total Billed Charges,1249.33,50,,594,Percent of Total Billed Charges,50% of Total Billed Charges,1249.33,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1249.33,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1249.33,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1749.06,70,,294.048,Percent of Total Billed Charges,70% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,349.81,14,,351.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2498.65,100,,59.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.47,3331.12,
1056453 GENERATOR PROCLAIM,32150790,CDM,278,RC,C1767,HCPCS,Outpatient,,,64614.99,38768.99,,80984.82,110,,528.896,Percent of Total Billed Charges,110% of Total Billed Charges,29076.75,45,,1001.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18092.2,28,,687.784,Percent of Total Billed Charges,28% of Total Billed Charges,4.47,32,,3.72,Percent of Total Billed Charges,32% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,23261.4,36,,884.296,Percent of Total Billed Charges,36% of Total Billed Charges,23261.4,36,,884.296,Percent of Total Billed Charges,36% Total Bille Charges,23261.4,36,,884.296,Percent of Total Billed Charges,36% of Total Billed Charges,35538.24,55,,151.712,Percent of Total Billed Charges,55% Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64614.99,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9317.48,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51691.99,80,,6671.824,Percent of Total Billed Charges,80% of Total Billed Charges,32307.5,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,32307.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32307.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,32307.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45230.49,70,,68.88,Percent of Total Billed Charges,70% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9046.1,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64614.99,100,,8339.784,Percent of Total Billed Charges,100% of Total Billed Charges,4.47,80984.82,
1061085 CHARGER IPG,32150791,CDM,271,RC,,,Outpatient,,,4973.8,2984.28,,2984.28,60,,75.592,Percent of Total Billed Charges,60% of Total Billed Charges,2238.21,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.66,28,,185.448,Percent of Total Billed Charges,28% of Total Billed Charges,4.48,32,,3.744,Percent of Total Billed Charges,32% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,1790.57,36,,238.432,Percent of Total Billed Charges,36% of Total Billed Charges,1790.57,36,,238.432,Percent of Total Billed Charges,36% Total Bille Charges,1790.57,36,,238.432,Percent of Total Billed Charges,36% of Total Billed Charges,2984.28,60,,57.488,Percent of Total Billed Charges,60% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4973.8,100,,109.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,717.22,14.42,,52.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3730.35,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,2486.9,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,2486.9,50,,128.656,Percent of Total Billed Charges,50% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,50,,128.656,Percent of Total Billed Charges,50% of Total Billed Charges,2486.9,50,,128.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3481.66,70,,255.36,Percent of Total Billed Charges,70% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,51.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4973.8,100,,91.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.48,4973.8,
414730 SLING TRANSOBTUR OBTRYX,32150792,CDM,278,RC,C1771,HCPCS,Outpatient,,,5049.15,3029.49,,5641.98,110,,147.856,Percent of Total Billed Charges,110% of Total Billed Charges,2272.12,45,,1661.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1413.76,28,,218.312,Percent of Total Billed Charges,28% of Total Billed Charges,41.63,32,,3.752,Percent of Total Billed Charges,32% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,1817.69,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,1817.69,36,,280.688,Percent of Total Billed Charges,36% Total Bille Charges,1817.69,36,,280.688,Percent of Total Billed Charges,36% of Total Billed Charges,2777.03,55,,741.736,Percent of Total Billed Charges,55% Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5049.15,100,,986.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,728.09,14.42,,269.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4039.32,80,,168.856,Percent of Total Billed Charges,80% of Total Billed Charges,2524.58,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,2524.58,50,,1331.488,Percent of Total Billed Charges,50% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2524.58,50,,1331.488,Percent of Total Billed Charges,50% of Total Billed Charges,2524.58,50,,1331.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3534.41,70,,93.064,Percent of Total Billed Charges,70% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,706.88,14,,261.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5049.15,100,,225.136,Percent of Total Billed Charges,100% of Total Billed Charges,41.63,5641.98,
1061087 GENERATOR IPG SENZA,32150793,CDM,278,RC,C1822,HCPCS,Outpatient,,,84975,50985.00,,93545.84,110,,96,Percent of Total Billed Charges,110% of Total Billed Charges,38238.75,45,,1661.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23793,28,,17.384,Percent of Total Billed Charges,28% of Total Billed Charges,41.88,32,,3.776,Percent of Total Billed Charges,32% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,30591,36,,22.344,Percent of Total Billed Charges,36% of Total Billed Charges,30591,36,,22.344,Percent of Total Billed Charges,36% Total Bille Charges,30591,36,,22.344,Percent of Total Billed Charges,36% of Total Billed Charges,46736.25,55,,696.84,Percent of Total Billed Charges,55% Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84975,100,,2226.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,12253.4,14.42,,258.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67980,80,,256.8,Percent of Total Billed Charges,80% of Total Billed Charges,42487.5,50,,128.656,Percent of Total Billed Charges,50% of Total Billed Charges,42487.5,50,,1255.24,Percent of Total Billed Charges,50% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42487.5,50,,1255.24,Percent of Total Billed Charges,50% of Total Billed Charges,42487.5,50,,1255.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59482.5,70,,58.48,Percent of Total Billed Charges,70% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,11896.5,14,,250.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84975,100,,342.4,Percent of Total Billed Charges,100% of Total Billed Charges,41.88,93545.84,
1061086 LEAD BLUE PERC,32150794,CDM,278,RC,C1897,HCPCS,Outpatient,,,4973.8,2984.28,,6239.12,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,2238.21,45,,2849.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.66,28,,18.48,Percent of Total Billed Charges,28% of Total Billed Charges,41.9,32,,3.792,Percent of Total Billed Charges,32% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,1790.57,36,,23.76,Percent of Total Billed Charges,36% of Total Billed Charges,1790.57,36,,23.76,Percent of Total Billed Charges,36% Total Bille Charges,1790.57,36,,23.76,Percent of Total Billed Charges,36% of Total Billed Charges,2735.59,55,,4320.672,Percent of Total Billed Charges,55% Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4973.8,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,717.22,14.42,,168.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3979.04,80,,38.584,Percent of Total Billed Charges,80% of Total Billed Charges,2486.9,50,,1331.488,Percent of Total Billed Charges,50% of Total Billed Charges,2486.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2486.9,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3481.66,70,,59.04,Percent of Total Billed Charges,70% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,696.33,14,,163.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4973.8,100,,51.448,Percent of Total Billed Charges,100% of Total Billed Charges,41.9,6239.12,
1061083 ANCHOR NEVRO LEAD,32150795,CDM,272,RC,,,Outpatient,,,690,414.00,,414,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,310.5,45,,2849.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.2,28,,77.888,Percent of Total Billed Charges,28% of Total Billed Charges,41.9,32,,3.808,Percent of Total Billed Charges,32% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,248.4,36,,100.144,Percent of Total Billed Charges,36% of Total Billed Charges,248.4,36,,100.144,Percent of Total Billed Charges,36% Total Bille Charges,248.4,36,,100.144,Percent of Total Billed Charges,36% of Total Billed Charges,414,60,,1801.912,Percent of Total Billed Charges,60% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,690,100,,3692.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,99.5,14.42,,409.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.5,75,,13.76,Percent of Total Billed Charges,75% of Total Billed Charges,345,50,,1255.24,Percent of Total Billed Charges,50% of Total Billed Charges,345,50,,182.88,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345,50,,182.88,Percent of Total Billed Charges,50% of Total Billed Charges,345,50,,182.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,96.6,14,,397.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690,100,,18.344,Percent of Total Billed Charges,100% of Total Billed Charges,41.9,690,
1061084 REMOTE KIT SENZA NEVRO,32150797,CDM,271,RC,C1787,HCPCS,Outpatient,,,3582.8,2149.68,,59.4,100,,72,Fee Schedule,100% of Aetna Fee Schedule,1612.26,45,,7489.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1003.18,28,,55.608,Percent of Total Billed Charges,28% of Total Billed Charges,41.92,32,,3.816,Percent of Total Billed Charges,32% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,1289.81,36,,71.496,Percent of Total Billed Charges,36% of Total Billed Charges,1289.81,36,,71.496,Percent of Total Billed Charges,36% Total Bille Charges,1289.81,36,,71.496,Percent of Total Billed Charges,36% of Total Billed Charges,2149.68,60,,857.648,Percent of Total Billed Charges,60% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3582.8,100,,3692.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,516.64,14.42,,799.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2687.1,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1791.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1791.4,50,,933.776,Percent of Total Billed Charges,50% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1791.4,50,,933.776,Percent of Total Billed Charges,50% of Total Billed Charges,1791.4,50,,933.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2507.96,70,,58.424,Percent of Total Billed Charges,70% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,501.59,14,,776.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3582.8,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,41.92,3582.8,
1061079 ADAPTER CHANNEL 8 LEAD,32150798,CDM,278,RC,C1883,HCPCS,Outpatient,,,4238,2542.80,,4690.36,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,1907.1,45,,4875.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1186.64,28,,591.952,Percent of Total Billed Charges,28% of Total Billed Charges,42.24,32,,35.84,Percent of Total Billed Charges,32% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1525.68,36,,761.08,Percent of Total Billed Charges,36% of Total Billed Charges,1525.68,36,,761.08,Percent of Total Billed Charges,36% Total Bille Charges,1525.68,36,,761.08,Percent of Total Billed Charges,36% of Total Billed Charges,2330.9,55,,140.712,Percent of Total Billed Charges,55% Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4238,100,,6331.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,611.12,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3390.4,80,,330.88,Percent of Total Billed Charges,80% of Total Billed Charges,2119,50,,182.88,Percent of Total Billed Charges,50% of Total Billed Charges,2119,50,,895.136,Percent of Total Billed Charges,50% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2119,50,,895.136,Percent of Total Billed Charges,50% of Total Billed Charges,2119,50,,895.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2966.6,70,,45.984,Percent of Total Billed Charges,70% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,593.32,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4238,100,,413.6,Percent of Total Billed Charges,100% of Total Billed Charges,42.24,4690.36,
VITRECTOMY SET,32153942,CDM,272,RC,,,Outpatient,,,768.47,461.08,,461.08,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,345.81,45,,4875.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.17,28,,70.8,Percent of Total Billed Charges,28% of Total Billed Charges,42.28,32,,35.84,Percent of Total Billed Charges,32% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,276.65,36,,91.032,Percent of Total Billed Charges,36% of Total Billed Charges,276.65,36,,91.032,Percent of Total Billed Charges,36% Total Bille Charges,276.65,36,,91.032,Percent of Total Billed Charges,36% of Total Billed Charges,461.08,60,,418.104,Percent of Total Billed Charges,60% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,768.47,100,,6331.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,110.81,14.42,,62.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,576.35,75,,891,Percent of Total Billed Charges,75% of Total Billed Charges,384.24,50,,933.776,Percent of Total Billed Charges,50% of Total Billed Charges,384.24,50,,583.2,Percent of Total Billed Charges,50% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.24,50,,583.2,Percent of Total Billed Charges,50% of Total Billed Charges,384.24,50,,583.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,537.93,70,,55.248,Percent of Total Billed Charges,70% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,107.59,14,,60.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.47,100,,1188,Percent of Total Billed Charges,100% of Total Billed Charges,42.28,768.47,
572396 PERIBULAR NEEDLE,32154254,CDM,278,RC,,,Outpatient,,,74.75,44.85,,82.23,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,33.64,45,,4875.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.93,28,,26.824,Percent of Total Billed Charges,28% of Total Billed Charges,42.28,32,,35.88,Percent of Total Billed Charges,32% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,26.91,36,,34.488,Percent of Total Billed Charges,36% of Total Billed Charges,26.91,36,,34.488,Percent of Total Billed Charges,36% Total Bille Charges,26.91,36,,34.488,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.75,100,,16643.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.78,14.42,,1066.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.8,80,,114.064,Percent of Total Billed Charges,80% of Total Billed Charges,37.38,50,,895.136,Percent of Total Billed Charges,50% of Total Billed Charges,37.38,50,,1418.728,Percent of Total Billed Charges,50% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.38,50,,1418.728,Percent of Total Billed Charges,50% of Total Billed Charges,37.38,50,,1418.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.33,70,,1688.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14,,1035.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.75,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,10.47,82.23,
168961 LAP BAND SYSTEM AP LG,32156283,CDM,278,RC,,,Outpatient,,,10424.73,6254.84,,11467.2,110,,864,Percent of Total Billed Charges,110% of Total Billed Charges,4691.13,45,,4875.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2918.92,28,,346.144,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,35.912,Percent of Total Billed Charges,32% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,3752.9,36,,445.04,Percent of Total Billed Charges,36% of Total Billed Charges,3752.9,36,,445.04,Percent of Total Billed Charges,36% Total Bille Charges,3752.9,36,,445.04,Percent of Total Billed Charges,36% of Total Billed Charges,5733.6,55,,222.944,Percent of Total Billed Charges,55% Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10424.73,100,,10833.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1503.25,14.42,,87,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8339.78,80,,42,Percent of Total Billed Charges,80% of Total Billed Charges,5212.37,50,,583.2,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,2771.6,Percent of Total Billed Charges,50% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5212.37,50,,2771.6,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,2771.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7297.31,70,,81.008,Percent of Total Billed Charges,70% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,84.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10424.73,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,42.52,11467.2,
TUBING ASC Y EXT,32161051,CDM,272,RC,,,Outpatient,,,114,68.40,,68.4,60,,2347.528,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,45,,9544.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,28,,354.752,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,36.056,Percent of Total Billed Charges,32% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,41.04,36,,456.112,Percent of Total Billed Charges,36% Total Bille Charges,41.04,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,68.4,60,,559.512,Percent of Total Billed Charges,60% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,100,,10833.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,16.44,14.42,,59.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,75,,498.56,Percent of Total Billed Charges,75% of Total Billed Charges,57,50,,1418.728,Percent of Total Billed Charges,50% of Total Billed Charges,57,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,57,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,70,,363.992,Percent of Total Billed Charges,70% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,15.96,114,
CATHETER EMBOLEC,32163172,CDM,272,RC,C1757,HCPCS,Outpatient,,,281.42,168.85,,16.33,100,,1702.432,Fee Schedule,100% of Aetna Fee Schedule,126.64,45,,8612.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.8,28,,2199.616,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,36.096,Percent of Total Billed Charges,32% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,101.31,36,,2828.08,Percent of Total Billed Charges,36% of Total Billed Charges,101.31,36,,2828.08,Percent of Total Billed Charges,36% Total Bille Charges,101.31,36,,2828.08,Percent of Total Billed Charges,36% of Total Billed Charges,168.85,60,,37.304,Percent of Total Billed Charges,60% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.42,100,,10833.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,40.58,14.42,,76.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,75,,192.976,Percent of Total Billed Charges,75% of Total Billed Charges,140.71,50,,2771.6,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,215.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.71,50,,215.2,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,215.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.99,70,,300.024,Percent of Total Billed Charges,70% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,73.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.42,100,,257.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,281.42,
CHOLANGIOCATH AM,32163453,CDM,272,RC,,,Outpatient,,,428,256.80,,256.8,60,,11736.152,Percent of Total Billed Charges,60% of Total Billed Charges,192.6,45,,8612.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.84,28,,917.336,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,36.144,Percent of Total Billed Charges,32% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,154.08,36,,1179.432,Percent of Total Billed Charges,36% of Total Billed Charges,154.08,36,,1179.432,Percent of Total Billed Charges,36% Total Bille Charges,154.08,36,,1179.432,Percent of Total Billed Charges,36% of Total Billed Charges,256.8,60,,1175.648,Percent of Total Billed Charges,60% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,428,100,,10833.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,61.72,14.42,,361.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321,75,,2130.376,Percent of Total Billed Charges,75% of Total Billed Charges,214,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,214,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,214,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.6,70,,81.008,Percent of Total Billed Charges,70% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,59.92,14,,351,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428,100,,2662.968,Percent of Total Billed Charges,100% of Total Billed Charges,42.52,428,
CATHETER MALE,32167108,CDM,272,RC,C1729,HCPCS,Outpatient,,,64.31,38.59,,11.1,100,,3027.936,Fee Schedule,100% of Aetna Fee Schedule,28.94,45,,8612.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.01,28,,436.624,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,36.288,Percent of Total Billed Charges,32% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,23.15,36,,561.368,Percent of Total Billed Charges,36% Total Bille Charges,23.15,36,,561.368,Percent of Total Billed Charges,36% of Total Billed Charges,38.59,60,,519.84,Percent of Total Billed Charges,60% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.31,100,,21210.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.23,75,,2008.376,Percent of Total Billed Charges,75% of Total Billed Charges,32.16,50,,215.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.16,50,,301.68,Percent of Total Billed Charges,50% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.16,50,,301.68,Percent of Total Billed Charges,50% of Total Billed Charges,32.16,50,,301.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.02,70,,81.008,Percent of Total Billed Charges,70% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.31,100,,2510.472,Percent of Total Billed Charges,100% of Total Billed Charges,9,64.31,
162599 CATH DRN THOR ARG 9IN,32167801,CDM,272,RC,C1729,HCPCS,Outpatient,,,22.93,13.76,,11.1,100,,3027.936,Fee Schedule,100% of Aetna Fee Schedule,10.32,45,,304.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.42,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,42.52,32,,36.296,Percent of Total Billed Charges,32% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,8.25,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,8.25,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,8.25,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,13.76,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.93,100,,19138.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14.42,,638.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,11.47,50,,3698.112,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.05,70,,765.176,Percent of Total Billed Charges,70% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,619.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.93,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,3.21,42.52,
PULSE LAVAGE (00,32170300,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,3027.936,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,298.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,212.856,Percent of Total Billed Charges,28% of Total Billed Charges,42.55,32,,36.368,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,273.672,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,273.672,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,273.672,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,19138.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,230.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,274.32,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,301.68,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,67.152,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,223.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,365.76,Percent of Total Billed Charges,100% of Total Billed Charges,42.55,375,
C-WIRE .035X5.0,32171001,CDM,278,RC,C1713,HCPCS,Outpatient,,,517,310.20,,885.96,110,,2962.96,Percent of Total Billed Charges,110% of Total Billed Charges,232.65,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.76,28,,304.416,Percent of Total Billed Charges,28% of Total Billed Charges,42835.84,32,,36.784,Percent of Total Billed Charges,32% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,186.12,36,,391.392,Percent of Total Billed Charges,36% of Total Billed Charges,186.12,36,,391.392,Percent of Total Billed Charges,36% Total Bille Charges,186.12,36,,391.392,Percent of Total Billed Charges,36% of Total Billed Charges,284.35,55,,45.304,Percent of Total Billed Charges,55% Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517,100,,19138.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,74.55,14.42,,48.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.6,80,,1400.664,Percent of Total Billed Charges,80% of Total Billed Charges,258.5,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,258.5,50,,1253.56,Percent of Total Billed Charges,50% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.5,50,,1253.56,Percent of Total Billed Charges,50% of Total Billed Charges,258.5,50,,1253.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.9,70,,258.72,Percent of Total Billed Charges,70% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,72.38,14,,46.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517,100,,1867.552,Percent of Total Billed Charges,100% of Total Billed Charges,72.38,42835.84,
VERSAJET PLUS HA,32171027,CDM,272,RC,,,Outpatient,,,1485,891.00,,891,60,,638.4,Percent of Total Billed Charges,60% of Total Billed Charges,668.25,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,415.8,28,,104.04,Percent of Total Billed Charges,28% of Total Billed Charges,42.56,32,,36.792,Percent of Total Billed Charges,32% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,534.6,36,,133.768,Percent of Total Billed Charges,36% of Total Billed Charges,534.6,36,,133.768,Percent of Total Billed Charges,36% Total Bille Charges,534.6,36,,133.768,Percent of Total Billed Charges,36% of Total Billed Charges,891,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1485,100,,676.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,214.14,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1113.75,75,,1342.704,Percent of Total Billed Charges,75% of Total Billed Charges,742.5,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,742.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,742.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,742.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1039.5,70,,40.776,Percent of Total Billed Charges,70% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.9,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1485,100,,1790.272,Percent of Total Billed Charges,100% of Total Billed Charges,42.56,1485,
TUBE TRACHSHILEY,32173007,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,615.36,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,804.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,261.104,Percent of Total Billed Charges,28% of Total Billed Charges,42.62,32,,36.928,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,335.704,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,335.704,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,335.704,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,141.136,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,663.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,31.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,874.8,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,1253.56,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,2213.12,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,2213.12,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,2213.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,1084.808,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,30.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,1166.4,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,190.1,
TUBING HEATED IN,32177057,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,177.6,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,570.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,17.408,Percent of Total Billed Charges,28% of Total Billed Charges,42.62,32,,37.032,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,22.384,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,22.384,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,22.384,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,3018.312,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,2269.96,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,799.176,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,799.176,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,799.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,105.736,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,2837.448,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,70,
414237 STENT POLARIS ULTRA URT,32187502,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,421.44,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,548.64,Percent of Total Billed Charges,28% of Total Billed Charges,42.88,32,,37.032,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,705.392,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,705.392,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,705.392,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,4586.88,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,21.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,4434.56,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,2213.12,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,166.512,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,166.512,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,166.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,75.936,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,21.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,5543.2,Percent of Total Billed Charges,100% of Total Billed Charges,42.88,1050.45,
596830 GLIDE WIRE 035,32187569,CDM,272,RC,C1769,HCPCS,Outpatient,,,321.63,192.98,,55.13,100,,432,Fee Schedule,100% of Aetna Fee Schedule,144.73,45,,68.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.06,28,,242.592,Percent of Total Billed Charges,28% of Total Billed Charges,42.88,32,,37.032,Percent of Total Billed Charges,32% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,115.79,36,,311.904,Percent of Total Billed Charges,36% of Total Billed Charges,115.79,36,,311.904,Percent of Total Billed Charges,36% Total Bille Charges,115.79,36,,311.904,Percent of Total Billed Charges,36% of Total Billed Charges,192.98,60,,4214.488,Percent of Total Billed Charges,60% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.63,100,,1786.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.38,14.42,,129.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.22,75,,384,Percent of Total Billed Charges,75% of Total Billed Charges,160.82,50,,799.176,Percent of Total Billed Charges,50% of Total Billed Charges,160.82,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.82,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,160.82,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.14,70,,595.44,Percent of Total Billed Charges,70% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,45.03,14,,125.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.63,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,42.88,321.63,
593207 GRAFT ARTEGRAFT 7X45,32187643,CDM,278,RC,C1768,HCPCS,Outpatient,,,3328.71,1997.23,,3984.35,110,,352.8,Percent of Total Billed Charges,110% of Total Billed Charges,1497.92,45,,13.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,932.04,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,42.97,32,,37.072,Percent of Total Billed Charges,32% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,1198.34,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,1198.34,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,1198.34,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,1830.79,55,,554.352,Percent of Total Billed Charges,55% Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3328.71,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,480,14.42,,133.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2662.97,80,,344.32,Percent of Total Billed Charges,80% of Total Billed Charges,1664.36,50,,166.512,Percent of Total Billed Charges,50% of Total Billed Charges,1664.36,50,,107.704,Percent of Total Billed Charges,50% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1664.36,50,,107.704,Percent of Total Billed Charges,50% of Total Billed Charges,1664.36,50,,107.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2330.1,70,,868.304,Percent of Total Billed Charges,70% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,466.02,14,,129.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3328.71,100,,430.4,Percent of Total Billed Charges,100% of Total Billed Charges,42.97,3984.35,
114675 GRAFT DURAGEN PLUS,32187692,CDM,278,RC,,,Outpatient,,,3138.09,1882.85,,3451.9,110,,295.68,Percent of Total Billed Charges,110% of Total Billed Charges,1412.14,45,,756,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,878.67,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,42.98,32,,37.088,Percent of Total Billed Charges,32% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,1129.71,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,1129.71,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,1129.71,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,1725.95,55,,311.04,Percent of Total Billed Charges,55% Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3138.09,100,,86.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,452.51,14.42,,536.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2510.47,80,,5547.168,Percent of Total Billed Charges,80% of Total Billed Charges,1569.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1569.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1569.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1569.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2196.66,70,,153.832,Percent of Total Billed Charges,70% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,439.33,14,,521.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3138.09,100,,7396.224,Percent of Total Billed Charges,100% of Total Billed Charges,42.98,3451.9,
LP BX CANNULA AN,32187734,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,291.36,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,210.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,42.98,32,,37.12,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,231.936,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,152.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,231.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,482.68,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,107.704,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,75.864,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,75.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,75.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,224.328,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,225.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,603.352,Percent of Total Billed Charges,100% of Total Billed Charges,42.98,600,
TAMP HANDLE BIOM,32187809,CDM,272,RC,,,Outpatient,,,457.2,274.32,,274.32,60,,679.68,Percent of Total Billed Charges,60% of Total Billed Charges,205.74,45,,403.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.02,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,43.08,32,,37.216,Percent of Total Billed Charges,32% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,164.59,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,164.59,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,164.59,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,274.32,60,,482.92,Percent of Total Billed Charges,60% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,457.2,100,,30.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,65.93,14.42,,8.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.9,75,,312,Percent of Total Billed Charges,75% of Total Billed Charges,228.6,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,228.6,50,,448.392,Percent of Total Billed Charges,50% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228.6,50,,448.392,Percent of Total Billed Charges,50% of Total Billed Charges,228.6,50,,448.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.04,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14,,8.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,457.2,100,,416,Percent of Total Billed Charges,100% of Total Billed Charges,43.08,457.2,
GYRUS PK BUTTON,32187841,CDM,272,RC,,,Outpatient,,,2334.44,1400.66,,1400.66,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,1050.5,45,,983.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.64,28,,65.864,Percent of Total Billed Charges,28% of Total Billed Charges,43.1,32,,37.48,Percent of Total Billed Charges,32% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,840.4,36,,84.68,Percent of Total Billed Charges,36% of Total Billed Charges,840.4,36,,84.68,Percent of Total Billed Charges,36% Total Bille Charges,840.4,36,,84.68,Percent of Total Billed Charges,36% of Total Billed Charges,1400.66,60,,1807.288,Percent of Total Billed Charges,60% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2334.44,100,,1680,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,336.63,14.42,,7.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1750.83,75,,396,Percent of Total Billed Charges,75% of Total Billed Charges,1167.22,50,,75.864,Percent of Total Billed Charges,50% of Total Billed Charges,1167.22,50,,462.616,Percent of Total Billed Charges,50% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.22,50,,462.616,Percent of Total Billed Charges,50% of Total Billed Charges,1167.22,50,,462.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634.11,70,,76.064,Percent of Total Billed Charges,70% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,326.82,14,,7.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2334.44,100,,528,Percent of Total Billed Charges,100% of Total Billed Charges,43.1,2334.44,
GYRUS SUPERLOOP,32187866,CDM,272,RC,,,Outpatient,,,2237.84,1342.70,,1342.7,60,,273.12,Percent of Total Billed Charges,60% of Total Billed Charges,1007.03,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,626.6,28,,1408.544,Percent of Total Billed Charges,28% of Total Billed Charges,43.2,32,,37.528,Percent of Total Billed Charges,32% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,805.62,36,,1810.984,Percent of Total Billed Charges,36% of Total Billed Charges,805.62,36,,1810.984,Percent of Total Billed Charges,36% Total Bille Charges,805.62,36,,1810.984,Percent of Total Billed Charges,36% of Total Billed Charges,1342.7,60,,739.72,Percent of Total Billed Charges,60% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2237.84,100,,467.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,322.7,14.42,,9,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1678.38,75,,1880.344,Percent of Total Billed Charges,75% of Total Billed Charges,1118.92,50,,448.392,Percent of Total Billed Charges,50% of Total Billed Charges,1118.92,50,,1861.12,Percent of Total Billed Charges,50% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1118.92,50,,1861.12,Percent of Total Billed Charges,50% of Total Billed Charges,1118.92,50,,1861.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1566.49,70,,49.776,Percent of Total Billed Charges,70% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,313.3,14,,8.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2237.84,100,,2507.12,Percent of Total Billed Charges,100% of Total Billed Charges,43.2,2237.84,
STAINLES STEEL L,32187882,CDM,272,RC,,,Outpatient,,,1458,874.80,,874.8,60,,270.24,Percent of Total Billed Charges,60% of Total Billed Charges,656.1,45,,289.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,408.24,28,,2335.136,Percent of Total Billed Charges,28% of Total Billed Charges,43.2,32,,37.528,Percent of Total Billed Charges,32% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,524.88,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,524.88,36,,3002.32,Percent of Total Billed Charges,36% Total Bille Charges,524.88,36,,3002.32,Percent of Total Billed Charges,36% of Total Billed Charges,874.8,60,,1003.448,Percent of Total Billed Charges,60% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1458,100,,896.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,210.24,14.42,,35.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1093.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,729,50,,462.616,Percent of Total Billed Charges,50% of Total Billed Charges,729,50,,804.376,Percent of Total Billed Charges,50% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729,50,,804.376,Percent of Total Billed Charges,50% of Total Billed Charges,729,50,,804.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1020.6,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,204.12,14,,34.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1458,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,43.2,1458,
693109 CEMENT BONE VERTAPLEX H,32187890,CDM,278,RC,C1713,HCPCS,Outpatient,,,3546.81,2128.09,,4218.75,110,,245.28,Percent of Total Billed Charges,110% of Total Billed Charges,1596.06,45,,491.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,993.11,28,,2145.56,Percent of Total Billed Charges,28% of Total Billed Charges,43.2,32,,37.728,Percent of Total Billed Charges,32% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,1276.85,36,,2758.576,Percent of Total Billed Charges,36% of Total Billed Charges,1276.85,36,,2758.576,Percent of Total Billed Charges,36% Total Bille Charges,1276.85,36,,2758.576,Percent of Total Billed Charges,36% of Total Billed Charges,1950.75,55,,857.152,Percent of Total Billed Charges,55% Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3546.81,100,,2185.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,511.45,14.42,,101.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2837.45,80,,3540.992,Percent of Total Billed Charges,80% of Total Billed Charges,1773.41,50,,1861.12,Percent of Total Billed Charges,50% of Total Billed Charges,1773.41,50,,29.072,Percent of Total Billed Charges,50% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1773.41,50,,29.072,Percent of Total Billed Charges,50% of Total Billed Charges,1773.41,50,,29.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2482.77,70,,690.696,Percent of Total Billed Charges,70% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,496.55,14,,98.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3546.81,100,,4426.24,Percent of Total Billed Charges,100% of Total Billed Charges,43.2,4218.75,
388657 KIT SURGICEL LEAD,32188088,CDM,278,RC,C1778,HCPCS,Outpatient,,,6929,4157.40,,8204.5,110,,242.4,Percent of Total Billed Charges,110% of Total Billed Charges,3118.05,45,,134.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1940.12,28,,258.696,Percent of Total Billed Charges,28% of Total Billed Charges,43.2,32,,37.864,Percent of Total Billed Charges,32% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,2494.44,36,,332.608,Percent of Total Billed Charges,36% of Total Billed Charges,2494.44,36,,332.608,Percent of Total Billed Charges,36% Total Bille Charges,2494.44,36,,332.608,Percent of Total Billed Charges,36% of Total Billed Charges,3810.95,55,,696.84,Percent of Total Billed Charges,55% Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6929,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,999.16,14.42,,101.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5543.2,80,,1198.76,Percent of Total Billed Charges,80% of Total Billed Charges,3464.5,50,,804.376,Percent of Total Billed Charges,50% of Total Billed Charges,3464.5,50,,27.096,Percent of Total Billed Charges,50% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3464.5,50,,27.096,Percent of Total Billed Charges,50% of Total Billed Charges,3464.5,50,,27.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4850.3,70,,662.488,Percent of Total Billed Charges,70% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,970.06,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6929,100,,1598.344,Percent of Total Billed Charges,100% of Total Billed Charges,43.2,8204.5,
115929 MESH MARLEX PLUG LRG,32188096,CDM,278,RC,C1781,HCPCS,Outpatient,,,600,360.00,,1112.76,110,,206.88,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,1236.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,145.152,Percent of Total Billed Charges,28% of Total Billed Charges,43.2,32,,37.888,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,186.624,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,186.624,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,186.624,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,1139.6,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,643.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,101.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,249.768,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,29.072,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,31.216,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,31.216,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,31.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,1082.928,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,98.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,333.024,Percent of Total Billed Charges,100% of Total Billed Charges,43.2,1112.76,
295055 KIT GYRUS FALOPE RING,32188179,CDM,278,RC,,,Outpatient,,,538,322.80,,591.8,110,,204.48,Percent of Total Billed Charges,110% of Total Billed Charges,242.1,45,,81.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.64,28,,108.24,Percent of Total Billed Charges,28% of Total Billed Charges,43.29,32,,38.08,Percent of Total Billed Charges,32% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,193.68,36,,139.16,Percent of Total Billed Charges,36% of Total Billed Charges,193.68,36,,139.16,Percent of Total Billed Charges,36% Total Bille Charges,193.68,36,,139.16,Percent of Total Billed Charges,36% of Total Billed Charges,295.9,55,,816.328,Percent of Total Billed Charges,55% Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538,100,,1091.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,77.58,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.4,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,269,50,,27.096,Percent of Total Billed Charges,50% of Total Billed Charges,269,50,,121.944,Percent of Total Billed Charges,50% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269,50,,121.944,Percent of Total Billed Charges,50% of Total Billed Charges,269,50,,121.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.6,70,,1113.872,Percent of Total Billed Charges,70% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.32,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,43.29,591.8,
KYPHONPAK EXPRES,32188203,CDM,272,RC,,,Outpatient,,,9245.28,5547.17,,5547.17,60,,196.8,Percent of Total Billed Charges,60% of Total Billed Charges,4160.38,45,,692.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2588.68,28,,245.848,Percent of Total Billed Charges,28% of Total Billed Charges,43.33,32,,38.08,Percent of Total Billed Charges,32% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,3328.3,36,,316.096,Percent of Total Billed Charges,36% of Total Billed Charges,3328.3,36,,316.096,Percent of Total Billed Charges,36% Total Bille Charges,3328.3,36,,316.096,Percent of Total Billed Charges,36% of Total Billed Charges,5547.17,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9245.28,100,,299.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1333.17,14.42,,39.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6933.96,75,,161.552,Percent of Total Billed Charges,75% of Total Billed Charges,4622.64,50,,31.216,Percent of Total Billed Charges,50% of Total Billed Charges,4622.64,50,,352.736,Percent of Total Billed Charges,50% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4622.64,50,,352.736,Percent of Total Billed Charges,50% of Total Billed Charges,4622.64,50,,352.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6471.7,70,,86.68,Percent of Total Billed Charges,70% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,1294.34,14,,38.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9245.28,100,,215.4,Percent of Total Billed Charges,100% of Total Billed Charges,43.33,9245.28,
BONE CEMENT AND,32188211,CDM,278,RC,C1713,HCPCS,Outpatient,,,754.19,452.51,,1146.87,110,,115.68,Percent of Total Billed Charges,110% of Total Billed Charges,339.39,45,,952.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.17,28,,843.4,Percent of Total Billed Charges,28% of Total Billed Charges,43.39,32,,38.136,Percent of Total Billed Charges,32% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,271.51,36,,1084.368,Percent of Total Billed Charges,36% of Total Billed Charges,271.51,36,,1084.368,Percent of Total Billed Charges,36% Total Bille Charges,271.51,36,,1084.368,Percent of Total Billed Charges,36% of Total Billed Charges,414.8,55,,256.608,Percent of Total Billed Charges,55% Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,754.19,100,,2747.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,108.75,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.35,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,377.1,50,,121.944,Percent of Total Billed Charges,50% of Total Billed Charges,377.1,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,377.1,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,377.1,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.93,70,,177,Percent of Total Billed Charges,70% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,105.59,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,754.19,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,43.39,1146.87,
EXPRESS BONE BIO,32188229,CDM,272,RC,C1713,HCPCS,Outpatient,,,520,312.00,,317.26,100,,136.32,Fee Schedule,100% of Aetna Fee Schedule,234,45,,753.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.6,28,,376.584,Percent of Total Billed Charges,28% of Total Billed Charges,43.45,32,,38.136,Percent of Total Billed Charges,32% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,187.2,36,,484.184,Percent of Total Billed Charges,36% of Total Billed Charges,187.2,36,,484.184,Percent of Total Billed Charges,36% Total Bille Charges,187.2,36,,484.184,Percent of Total Billed Charges,36% of Total Billed Charges,312,60,,432.208,Percent of Total Billed Charges,60% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520,100,,180.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,74.98,14.42,,6.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,390,75,,113.792,Percent of Total Billed Charges,75% of Total Billed Charges,260,50,,352.736,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364,70,,2371.6,Percent of Total Billed Charges,70% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520,100,,151.72,Percent of Total Billed Charges,100% of Total Billed Charges,43.45,520,
NGAGE NITINOL ST,32188245,CDM,272,RC,,,Outpatient,,,660,396.00,,396,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,297,45,,456.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,28,,468.28,Percent of Total Billed Charges,28% of Total Billed Charges,43.47,32,,38.136,Percent of Total Billed Charges,32% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,237.6,36,,602.072,Percent of Total Billed Charges,36% of Total Billed Charges,237.6,36,,602.072,Percent of Total Billed Charges,36% Total Bille Charges,237.6,36,,602.072,Percent of Total Billed Charges,36% of Total Billed Charges,396,60,,568.4,Percent of Total Billed Charges,60% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,660,100,,1539.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,95.17,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,495,75,,672.592,Percent of Total Billed Charges,75% of Total Billed Charges,330,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,330,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,330,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,92.4,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660,100,,896.784,Percent of Total Billed Charges,100% of Total Billed Charges,43.47,660,
AQUAMANTYS SEALE,32188260,CDM,272,RC,,,Outpatient,,,3133.9,1880.34,,1880.34,60,,105.6,Percent of Total Billed Charges,60% of Total Billed Charges,1410.26,45,,157.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.49,28,,436.368,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,38.272,Percent of Total Billed Charges,32% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,1128.2,36,,561.048,Percent of Total Billed Charges,36% of Total Billed Charges,1128.2,36,,561.048,Percent of Total Billed Charges,36% Total Bille Charges,1128.2,36,,561.048,Percent of Total Billed Charges,36% of Total Billed Charges,1880.34,60,,342.76,Percent of Total Billed Charges,60% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3133.9,100,,2117.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,451.91,14.42,,39.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2350.43,75,,693.92,Percent of Total Billed Charges,75% of Total Billed Charges,1566.95,50,,350.968,Percent of Total Billed Charges,50% of Total Billed Charges,1566.95,50,,136.56,Percent of Total Billed Charges,50% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1566.95,50,,136.56,Percent of Total Billed Charges,50% of Total Billed Charges,1566.95,50,,136.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.73,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,438.75,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3133.9,100,,925.224,Percent of Total Billed Charges,100% of Total Billed Charges,43.49,3133.9,
DRESSING CURA SILVERLON 4X10,32188294,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,1002.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,354.752,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,38.392,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,456.112,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,342.76,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,1675.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,46.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,2791.672,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,3722.232,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
601337 VASCULAR GRAFT,32188336,CDM,278,RC,C1768,HCPCS,Outpatient,,,5532.8,3319.68,,6408.85,110,,71.04,Percent of Total Billed Charges,110% of Total Billed Charges,2489.76,45,,813.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1549.18,28,,580.16,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,3840,Percent of Total Billed Charges,32% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,1991.81,36,,745.92,Percent of Total Billed Charges,36% of Total Billed Charges,1991.81,36,,745.92,Percent of Total Billed Charges,36% Total Bille Charges,1991.81,36,,745.92,Percent of Total Billed Charges,36% of Total Billed Charges,3043.04,55,,2243.344,Percent of Total Billed Charges,55% Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5532.8,100,,1014.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,797.83,14.42,,151.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4426.24,80,,1206.568,Percent of Total Billed Charges,80% of Total Billed Charges,2766.4,50,,136.56,Percent of Total Billed Charges,50% of Total Billed Charges,2766.4,50,,22.76,Percent of Total Billed Charges,50% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2766.4,50,,22.76,Percent of Total Billed Charges,50% of Total Billed Charges,2766.4,50,,22.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3872.96,70,,46.336,Percent of Total Billed Charges,70% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.59,14,,146.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5532.8,100,,1608.752,Percent of Total Billed Charges,100% of Total Billed Charges,43.49,6408.85,
437878 LIGASURE SMALL JAW,32188440,CDM,272,RC,,,Outpatient,,,1997.93,1198.76,,1198.76,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,899.07,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,559.42,28,,380.952,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,3878.4,Percent of Total Billed Charges,32% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,719.25,36,,489.792,Percent of Total Billed Charges,36% of Total Billed Charges,719.25,36,,489.792,Percent of Total Billed Charges,36% Total Bille Charges,719.25,36,,489.792,Percent of Total Billed Charges,36% of Total Billed Charges,1198.76,60,,585.608,Percent of Total Billed Charges,60% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1997.93,100,,350.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,288.1,14.42,,163.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1498.45,75,,43.608,Percent of Total Billed Charges,75% of Total Billed Charges,998.97,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,998.97,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,998.97,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,998.97,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1398.55,70,,191.808,Percent of Total Billed Charges,70% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,279.71,14,,158.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1997.93,100,,58.144,Percent of Total Billed Charges,100% of Total Billed Charges,43.49,1997.93,
BEACH CHAIR PACK,32188521,CDM,272,RC,,,Outpatient,,,416.28,249.77,,249.77,60,,65.28,Percent of Total Billed Charges,60% of Total Billed Charges,187.33,45,,350.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.56,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,3887.728,Percent of Total Billed Charges,32% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,149.86,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,149.86,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,149.86,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,249.77,60,,585.608,Percent of Total Billed Charges,60% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.28,100,,2227.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,60.03,14.42,,141.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.21,75,,40.64,Percent of Total Billed Charges,75% of Total Billed Charges,208.14,50,,22.76,Percent of Total Billed Charges,50% of Total Billed Charges,208.14,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.14,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,208.14,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.4,70,,104.84,Percent of Total Billed Charges,70% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.28,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.28,100,,54.184,Percent of Total Billed Charges,100% of Total Billed Charges,43.49,416.28,
NEURO PACK,32188531,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,63.84,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,43.49,32,,3887.728,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,729,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1806.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,189.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,46.816,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,183.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,62.424,Percent of Total Billed Charges,100% of Total Billed Charges,43.49,600,
GENERAL LAPAROSCOPY PACK,32188541,CDM,272,RC,,,Outpatient,,,269.25,161.55,,161.55,60,,62.88,Percent of Total Billed Charges,60% of Total Billed Charges,121.16,45,,665.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.39,28,,201.696,Percent of Total Billed Charges,28% of Total Billed Charges,43.52,32,,3887.728,Percent of Total Billed Charges,32% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,96.93,36,,259.32,Percent of Total Billed Charges,36% of Total Billed Charges,96.93,36,,259.32,Percent of Total Billed Charges,36% Total Bille Charges,96.93,36,,259.32,Percent of Total Billed Charges,36% of Total Billed Charges,161.55,60,,343.056,Percent of Total Billed Charges,60% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.25,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,38.83,14.42,,111.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.94,75,,182.92,Percent of Total Billed Charges,75% of Total Billed Charges,134.63,50,,137.016,Percent of Total Billed Charges,50% of Total Billed Charges,134.63,50,,523.72,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.63,50,,523.72,Percent of Total Billed Charges,50% of Total Billed Charges,134.63,50,,523.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.48,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.7,14,,108.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.25,100,,243.888,Percent of Total Billed Charges,100% of Total Billed Charges,37.7,269.25,
CRANIOTOMY PACK,32188551,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,61.44,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,95.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,289.368,Percent of Total Billed Charges,28% of Total Billed Charges,43.57,32,,3887.728,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,372.04,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,372.04,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,372.04,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,396.512,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,779.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,9.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,529.096,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,567.072,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,567.072,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,567.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,8.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,705.464,Percent of Total Billed Charges,100% of Total Billed Charges,43.57,600,
LAPAROTOMY PACK,32188561,CDM,272,RC,,,Outpatient,,,189.65,113.79,,113.79,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,45,,584.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.1,28,,174.496,Percent of Total Billed Charges,28% of Total Billed Charges,43.66,32,,3887.728,Percent of Total Billed Charges,32% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,68.27,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,68.27,36,,224.352,Percent of Total Billed Charges,36% Total Bille Charges,68.27,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,113.79,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.65,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,27.35,14.42,,115.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.24,75,,526.456,Percent of Total Billed Charges,75% of Total Billed Charges,94.83,50,,523.72,Percent of Total Billed Charges,50% of Total Billed Charges,94.83,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.83,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,94.83,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.76,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,26.55,14,,111.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.65,100,,701.936,Percent of Total Billed Charges,100% of Total Billed Charges,26.55,189.65,
TOTAL KNEE PACK,32188581,CDM,272,RC,,,Outpatient,,,1120.98,672.59,,672.59,60,,283.2,Percent of Total Billed Charges,60% of Total Billed Charges,504.44,45,,161.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.87,28,,174.496,Percent of Total Billed Charges,28% of Total Billed Charges,43.86,32,,4044.8,Percent of Total Billed Charges,32% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,403.55,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,403.55,36,,224.352,Percent of Total Billed Charges,36% Total Bille Charges,403.55,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,672.59,60,,5145.712,Percent of Total Billed Charges,60% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1120.98,100,,1478.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,161.65,14.42,,58.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,840.74,75,,526.456,Percent of Total Billed Charges,75% of Total Billed Charges,560.49,50,,567.072,Percent of Total Billed Charges,50% of Total Billed Charges,560.49,50,,656.512,Percent of Total Billed Charges,50% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560.49,50,,656.512,Percent of Total Billed Charges,50% of Total Billed Charges,560.49,50,,656.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784.69,70,,106.456,Percent of Total Billed Charges,70% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,156.94,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1120.98,100,,701.936,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1120.98,
TOTAL HIP PACK,32188601,CDM,272,RC,,,Outpatient,,,1156.53,693.92,,693.92,60,,288.48,Percent of Total Billed Charges,60% of Total Billed Charges,520.44,45,,318.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.83,28,,1142.064,Percent of Total Billed Charges,28% of Total Billed Charges,43.86,32,,4044.8,Percent of Total Billed Charges,32% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,416.35,36,,1468.368,Percent of Total Billed Charges,36% of Total Billed Charges,416.35,36,,1468.368,Percent of Total Billed Charges,36% Total Bille Charges,416.35,36,,1468.368,Percent of Total Billed Charges,36% of Total Billed Charges,693.92,60,,811.856,Percent of Total Billed Charges,60% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1156.53,100,,212.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,166.77,14.42,,79.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,867.4,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,578.27,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,578.27,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.27,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,578.27,50,,386.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,809.57,70,,102.728,Percent of Total Billed Charges,70% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,161.91,14,,77.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1156.53,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1156.53,
0000210 CATH BLLN ABLAT ENDOMT,32190004,CDM,272,RC,,,Outpatient,,,4652.79,2791.67,,2791.67,60,,843.36,Percent of Total Billed Charges,60% of Total Billed Charges,2093.76,45,,4282.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302.78,28,,371.128,Percent of Total Billed Charges,28% of Total Billed Charges,43.87,32,,4069.312,Percent of Total Billed Charges,32% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,1675,36,,477.168,Percent of Total Billed Charges,36% of Total Billed Charges,1675,36,,477.168,Percent of Total Billed Charges,36% Total Bille Charges,1675,36,,477.168,Percent of Total Billed Charges,36% of Total Billed Charges,2791.67,60,,223.248,Percent of Total Billed Charges,60% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4652.79,100,,708,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,670.93,14.42,,58.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3489.59,75,,34.144,Percent of Total Billed Charges,75% of Total Billed Charges,2326.4,50,,31.976,Percent of Total Billed Charges,50% of Total Billed Charges,2326.4,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2326.4,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,2326.4,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3256.95,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,651.39,14,,57.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4652.79,100,,45.52,Percent of Total Billed Charges,100% of Total Billed Charges,43.87,4652.79,
0000237 BSKT STN NITINOL COIL,32190005,CDM,272,RC,,,Outpatient,,,2010.94,1206.56,,1206.56,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,904.92,45,,4276.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.06,28,,174.648,Percent of Total Billed Charges,28% of Total Billed Charges,44.01,32,,3.84,Percent of Total Billed Charges,32% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,723.94,36,,224.544,Percent of Total Billed Charges,36% of Total Billed Charges,723.94,36,,224.544,Percent of Total Billed Charges,36% Total Bille Charges,723.94,36,,224.544,Percent of Total Billed Charges,36% of Total Billed Charges,1206.56,60,,532.8,Percent of Total Billed Charges,60% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2010.94,100,,5302.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,289.98,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1508.21,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,1005.47,50,,399.592,Percent of Total Billed Charges,50% of Total Billed Charges,1005.47,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1005.47,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,1005.47,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1407.66,70,,28.928,Percent of Total Billed Charges,70% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,281.53,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2010.94,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,44.01,2010.94,
754 CATH CONCL BARDX 22FR 5,32190011,CDM,272,RC,C1758,HCPCS,Outpatient,,,72.68,43.61,,69,100,,3592.8,Fee Schedule,100% of Aetna Fee Schedule,32.71,45,,614,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.35,28,,185.04,Percent of Total Billed Charges,28% of Total Billed Charges,44.01,32,,3.888,Percent of Total Billed Charges,32% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,36,,237.912,Percent of Total Billed Charges,36% of Total Billed Charges,26.16,36,,237.912,Percent of Total Billed Charges,36% Total Bille Charges,26.16,36,,237.912,Percent of Total Billed Charges,36% of Total Billed Charges,43.61,60,,33.984,Percent of Total Billed Charges,60% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.68,100,,717.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14.42,,41.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.51,75,,205.52,Percent of Total Billed Charges,75% of Total Billed Charges,36.34,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,36.34,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.34,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,36.34,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.88,70,,803.024,Percent of Total Billed Charges,70% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,10.18,14,,40.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.68,100,,274.024,Percent of Total Billed Charges,100% of Total Billed Charges,10.18,72.68,
813 CATH URET CNTIP FLXM 6F,32190014,CDM,272,RC,C1758,HCPCS,Outpatient,,,67.73,40.64,,69,100,,3592.8,Fee Schedule,100% of Aetna Fee Schedule,30.48,45,,2882.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.96,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,44.03,32,,3.92,Percent of Total Billed Charges,32% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,24.38,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,24.38,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,24.38,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,40.64,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.73,100,,9517.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.77,14.42,,30.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.8,75,,240.352,Percent of Total Billed Charges,75% of Total Billed Charges,33.87,50,,276.896,Percent of Total Billed Charges,50% of Total Billed Charges,33.87,50,,146.888,Percent of Total Billed Charges,50% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.87,50,,146.888,Percent of Total Billed Charges,50% of Total Billed Charges,33.87,50,,146.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.41,70,,1719.456,Percent of Total Billed Charges,70% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.48,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.73,100,,320.464,Percent of Total Billed Charges,100% of Total Billed Charges,9.48,69,
818 CATH URET WHSTL TIP 6FR,32190015,CDM,272,RC,,,Outpatient,,,78.03,46.82,,46.82,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,35.11,45,,23.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.85,28,,2619.632,Percent of Total Billed Charges,28% of Total Billed Charges,44.08,32,,3.928,Percent of Total Billed Charges,32% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,28.09,36,,3368.104,Percent of Total Billed Charges,36% of Total Billed Charges,28.09,36,,3368.104,Percent of Total Billed Charges,36% Total Bille Charges,28.09,36,,3368.104,Percent of Total Billed Charges,36% of Total Billed Charges,46.82,60,,523.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.03,100,,9503.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14.42,,33.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.52,75,,785.576,Percent of Total Billed Charges,75% of Total Billed Charges,39.02,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,39.02,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.02,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,39.02,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.62,70,,463.616,Percent of Total Billed Charges,70% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.03,100,,1047.432,Percent of Total Billed Charges,100% of Total Billed Charges,10.92,78.03,
0001506 CLIP APPLIER ENDO MUL,32190020,CDM,272,RC,,,Outpatient,,,304.86,182.92,,182.92,60,,3916.8,Percent of Total Billed Charges,60% of Total Billed Charges,137.19,45,,1216.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.36,28,,378.864,Percent of Total Billed Charges,28% of Total Billed Charges,44.08,32,,3.928,Percent of Total Billed Charges,32% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,109.75,36,,487.112,Percent of Total Billed Charges,36% of Total Billed Charges,109.75,36,,487.112,Percent of Total Billed Charges,36% Total Bille Charges,109.75,36,,487.112,Percent of Total Billed Charges,36% of Total Billed Charges,182.92,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.86,100,,1364.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.96,14.42,,30.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.65,75,,907.312,Percent of Total Billed Charges,75% of Total Billed Charges,152.43,50,,146.888,Percent of Total Billed Charges,50% of Total Billed Charges,152.43,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.43,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,152.43,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.4,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,42.68,14,,29.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.86,100,,1134.136,Percent of Total Billed Charges,100% of Total Billed Charges,42.68,304.86,
0001507 CLIP APPLIER ENDO MUL,32190021,CDM,272,RC,,,Outpatient,,,881.83,529.10,,529.1,60,,3916.8,Percent of Total Billed Charges,60% of Total Billed Charges,396.82,45,,182.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.91,28,,138.32,Percent of Total Billed Charges,28% of Total Billed Charges,44.16,32,,3.928,Percent of Total Billed Charges,32% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,317.46,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,317.46,36,,177.84,Percent of Total Billed Charges,36% Total Bille Charges,317.46,36,,177.84,Percent of Total Billed Charges,36% of Total Billed Charges,529.1,60,,682.744,Percent of Total Billed Charges,60% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,881.83,100,,6406.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,127.16,14.42,,33.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,661.37,75,,787.2,Percent of Total Billed Charges,75% of Total Billed Charges,440.92,50,,204.48,Percent of Total Billed Charges,50% of Total Billed Charges,440.92,50,,144.064,Percent of Total Billed Charges,50% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,440.92,50,,144.064,Percent of Total Billed Charges,50% of Total Billed Charges,440.92,50,,144.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,617.28,70,,43.448,Percent of Total Billed Charges,70% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,123.46,14,,32.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,881.83,100,,984,Percent of Total Billed Charges,100% of Total Billed Charges,44.16,881.83,
0001508 CLIP APPLIER ENDO,32190022,CDM,272,RC,,,Outpatient,,,877.42,526.45,,526.45,60,,381.6,Percent of Total Billed Charges,60% of Total Billed Charges,394.84,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.68,28,,53.4,Percent of Total Billed Charges,28% of Total Billed Charges,44.16,32,,3.952,Percent of Total Billed Charges,32% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,315.87,36,,68.656,Percent of Total Billed Charges,36% of Total Billed Charges,315.87,36,,68.656,Percent of Total Billed Charges,36% Total Bille Charges,315.87,36,,68.656,Percent of Total Billed Charges,36% of Total Billed Charges,526.45,60,,930.6,Percent of Total Billed Charges,60% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.42,100,,51.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14.42,,314.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,658.07,75,,1050.416,Percent of Total Billed Charges,75% of Total Billed Charges,438.71,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,438.71,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.71,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,438.71,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.19,70,,46.192,Percent of Total Billed Charges,70% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,305.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.42,100,,1313.024,Percent of Total Billed Charges,100% of Total Billed Charges,44.16,877.42,
0001509 CLIP APPLIER MULTI,32190023,CDM,272,RC,,,Outpatient,,,877.42,526.45,,526.45,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,394.84,45,,95.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.68,28,,104.184,Percent of Total Billed Charges,28% of Total Billed Charges,44.28,32,,3.96,Percent of Total Billed Charges,32% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,315.87,36,,133.952,Percent of Total Billed Charges,36% of Total Billed Charges,315.87,36,,133.952,Percent of Total Billed Charges,36% Total Bille Charges,315.87,36,,133.952,Percent of Total Billed Charges,36% of Total Billed Charges,526.45,60,,135.92,Percent of Total Billed Charges,60% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.42,100,,2704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,126.52,14.42,,124.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,658.07,75,,617.632,Percent of Total Billed Charges,75% of Total Billed Charges,438.71,50,,144.064,Percent of Total Billed Charges,50% of Total Billed Charges,438.71,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.71,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,438.71,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.19,70,,194.728,Percent of Total Billed Charges,70% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,122.84,14,,121.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.42,100,,772.04,Percent of Total Billed Charges,100% of Total Billed Charges,44.28,877.42,
FILSHIE TUBAL LIGATION SYSTEM (AVM-851J),32190025,CDM,278,RC,A4264,HCPCS,Outpatient,,,375,225.00,,1228.36,110,,1794.72,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,95.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,248.64,Percent of Total Billed Charges,28% of Total Billed Charges,44.3,32,,3.968,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,319.68,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,319.68,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,319.68,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,406.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,51.16,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,139.016,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,63.952,Percent of Total Billed Charges,100% of Total Billed Charges,44.3,1228.36,
0002145 ELCTRD ELSURG ELT 24FR,32190028,CDM,272,RC,,,Outpatient,,,341.4,204.84,,204.84,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,153.63,45,,968.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.59,28,,15.856,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,3.976,Percent of Total Billed Charges,32% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,122.9,36,,20.392,Percent of Total Billed Charges,36% of Total Billed Charges,122.9,36,,20.392,Percent of Total Billed Charges,36% Total Bille Charges,122.9,36,,20.392,Percent of Total Billed Charges,36% of Total Billed Charges,204.84,60,,342.76,Percent of Total Billed Charges,60% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.4,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,49.23,14.42,,133.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.05,75,,599.384,Percent of Total Billed Charges,75% of Total Billed Charges,170.7,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,170.7,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.7,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,170.7,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.98,70,,1479.88,Percent of Total Billed Charges,70% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,47.8,14,,129.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.4,100,,799.176,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,341.4,
0002156 ELCTRD ESURG 28FR .01,32190030,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,177.6,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,20190.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,28.896,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,4.016,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,37.152,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,37.152,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1548.976,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,212.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,134.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,306.72,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,106.928,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1092.176,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1092.176,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1092.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,177,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,408.96,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,375,
0002224 DRAIN WOUND SUCTION,32190032,CDM,272,RC,C1729,HCPCS,Outpatient,,,56.9,34.14,,11.1,100,,1497.6,Fee Schedule,100% of Aetna Fee Schedule,25.61,45,,657.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.93,28,,266.72,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,4.016,Percent of Total Billed Charges,32% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,20.48,36,,342.928,Percent of Total Billed Charges,36% of Total Billed Charges,20.48,36,,342.928,Percent of Total Billed Charges,36% Total Bille Charges,20.48,36,,342.928,Percent of Total Billed Charges,36% of Total Billed Charges,34.14,60,,1119.888,Percent of Total Billed Charges,60% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.9,100,,212.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,8.2,14.42,,59.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.68,75,,415.336,Percent of Total Billed Charges,75% of Total Billed Charges,28.45,50,,115.168,Percent of Total Billed Charges,50% of Total Billed Charges,28.45,50,,432.656,Percent of Total Billed Charges,50% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.45,50,,432.656,Percent of Total Billed Charges,50% of Total Billed Charges,28.45,50,,432.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.83,70,,67.064,Percent of Total Billed Charges,70% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,57.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.9,100,,553.784,Percent of Total Billed Charges,100% of Total Billed Charges,7.97,56.9,
0003039 GRAFT NERVE PROTECTOR,32190033,CDM,278,RC,C1768,HCPCS,Outpatient,,,4235,2541.00,,4981.27,110,,5865.6,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,2160,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,119.752,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,4.048,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,153.968,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,114.824,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,2151.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,50.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,175.888,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,1092.176,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,865.36,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,48.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,4981.27,
0003121 GUIDEWIRE ZIPWIRE .035,32190037,CDM,272,RC,C1769,HCPCS,Outpatient,,,342.53,205.52,,55.13,100,,816,Fee Schedule,100% of Aetna Fee Schedule,154.14,45,,30.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.91,28,,318.616,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,4.088,Percent of Total Billed Charges,32% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.31,36,,409.648,Percent of Total Billed Charges,36% of Total Billed Charges,123.31,36,,409.648,Percent of Total Billed Charges,36% Total Bille Charges,123.31,36,,409.648,Percent of Total Billed Charges,36% of Total Billed Charges,205.52,60,,154.184,Percent of Total Billed Charges,60% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.53,100,,44866.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,49.39,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.9,75,,220.336,Percent of Total Billed Charges,75% of Total Billed Charges,171.27,50,,432.656,Percent of Total Billed Charges,50% of Total Billed Charges,171.27,50,,461.568,Percent of Total Billed Charges,50% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.27,50,,461.568,Percent of Total Billed Charges,50% of Total Billed Charges,171.27,50,,461.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.77,70,,886.888,Percent of Total Billed Charges,70% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.53,100,,293.776,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,342.53,
0003130 GW ESCP SNSR 150CM.038,32190038,CDM,272,RC,C1769,HCPCS,Outpatient,,,400.58,240.35,,55.13,100,,936,Fee Schedule,100% of Aetna Fee Schedule,180.26,45,,2753.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.16,28,,473.76,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,4.088,Percent of Total Billed Charges,32% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,144.21,36,,609.12,Percent of Total Billed Charges,36% of Total Billed Charges,144.21,36,,609.12,Percent of Total Billed Charges,36% Total Bille Charges,144.21,36,,609.12,Percent of Total Billed Charges,36% of Total Billed Charges,240.35,60,,49.64,Percent of Total Billed Charges,60% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.58,100,,1461.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.76,14.42,,84.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.44,75,,306.72,Percent of Total Billed Charges,75% of Total Billed Charges,200.29,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,200.29,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.29,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,200.29,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.41,70,,5499.04,Percent of Total Billed Charges,70% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,81.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.58,100,,408.96,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,400.58,
3419 CATH UROMX ULT BLLN 15F,32190040,CDM,272,RC,C1725,HCPCS,Outpatient,,,1309.29,785.57,,99.47,100,,2739.36,Fee Schedule,100% of Aetna Fee Schedule,589.18,45,,1544.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.6,28,,63.424,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,471.34,36,,81.552,Percent of Total Billed Charges,36% of Total Billed Charges,471.34,36,,81.552,Percent of Total Billed Charges,36% Total Bille Charges,471.34,36,,81.552,Percent of Total Billed Charges,36% of Total Billed Charges,785.57,60,,68.984,Percent of Total Billed Charges,60% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1309.29,100,,4800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,188.8,14.42,,58.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,981.97,75,,175.888,Percent of Total Billed Charges,75% of Total Billed Charges,654.65,50,,461.568,Percent of Total Billed Charges,50% of Total Billed Charges,654.65,50,,207.048,Percent of Total Billed Charges,50% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.65,50,,207.048,Percent of Total Billed Charges,50% of Total Billed Charges,654.65,50,,207.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,916.5,70,,2293.344,Percent of Total Billed Charges,70% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,183.3,14,,56.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1309.29,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,1309.29,
0003583 SEPRAFILM BIORESORB,32190042,CDM,278,RC,C1765,HCPCS,Outpatient,,,1417.67,850.60,,1562.9,110,,3737.76,Percent of Total Billed Charges,110% of Total Billed Charges,637.95,45,,300.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.4,Other,Not Seperately Reimbusable,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.72,55,,48.256,Percent of Total Billed Charges,55% Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1417.67,100,,68.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,204.43,14.42,,60.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1134.14,80,,216.096,Percent of Total Billed Charges,80% of Total Billed Charges,708.84,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,708.84,50,,173.672,Percent of Total Billed Charges,50% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,708.84,50,,173.672,Percent of Total Billed Charges,50% of Total Billed Charges,708.84,50,,173.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,992.37,70,,1091.552,Percent of Total Billed Charges,70% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,198.47,14,,58.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1417.67,100,,288.128,Percent of Total Billed Charges,100% of Total Billed Charges,198.47,1562.9,
0003587 MESH DUAL 1MM 10X15CM,32190044,CDM,278,RC,C1781,HCPCS,Outpatient,,,1230,738.00,,1805.76,110,,504,Percent of Total Billed Charges,110% of Total Billed Charges,553.5,45,,2995.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.4,28,,174.496,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,442.8,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,442.8,36,,224.352,Percent of Total Billed Charges,36% Total Bille Charges,442.8,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,676.5,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1230,100,,6118.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,177.37,14.42,,14.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,984,80,,160.392,Percent of Total Billed Charges,80% of Total Billed Charges,615,50,,207.048,Percent of Total Billed Charges,50% of Total Billed Charges,615,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,615,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,861,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1230,100,,213.856,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,1805.76,
0004412 PATCH DURA GUARD,32190049,CDM,278,RC,,,Outpatient,,,1641.28,984.77,,1805.41,110,,84,Percent of Total Billed Charges,110% of Total Billed Charges,738.58,45,,833.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.56,28,,788.568,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,590.86,36,,1013.872,Percent of Total Billed Charges,36% of Total Billed Charges,590.86,36,,1013.872,Percent of Total Billed Charges,36% Total Bille Charges,590.86,36,,1013.872,Percent of Total Billed Charges,36% of Total Billed Charges,902.7,55,,220.504,Percent of Total Billed Charges,55% Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1641.28,100,,3432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,236.67,14.42,,52.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1313.02,80,,172.752,Percent of Total Billed Charges,80% of Total Billed Charges,820.64,50,,173.672,Percent of Total Billed Charges,50% of Total Billed Charges,820.64,50,,291.992,Percent of Total Billed Charges,50% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,820.64,50,,291.992,Percent of Total Billed Charges,50% of Total Billed Charges,820.64,50,,291.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1148.9,70,,532.136,Percent of Total Billed Charges,70% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,229.78,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1641.28,100,,230.336,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,1805.41,
0004414 VASCU-GUARD 8 X 8 CM,32190050,CDM,278,RC,,,Outpatient,,,965.05,579.03,,1061.56,110,,35.136,Percent of Total Billed Charges,110% of Total Billed Charges,434.27,45,,2019.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.21,28,,570.128,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,347.42,36,,733.016,Percent of Total Billed Charges,36% of Total Billed Charges,347.42,36,,733.016,Percent of Total Billed Charges,36% Total Bille Charges,347.42,36,,733.016,Percent of Total Billed Charges,36% of Total Billed Charges,530.78,55,,154.76,Percent of Total Billed Charges,55% Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,965.05,100,,667.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,139.16,14.42,,19.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,772.04,80,,160.392,Percent of Total Billed Charges,80% of Total Billed Charges,482.53,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,482.53,50,,203.104,Percent of Total Billed Charges,50% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.53,50,,203.104,Percent of Total Billed Charges,50% of Total Billed Charges,482.53,50,,203.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675.54,70,,761.04,Percent of Total Billed Charges,70% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,135.11,14,,18.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,965.05,100,,213.856,Percent of Total Billed Charges,100% of Total Billed Charges,44.34,1061.56,
0004796 TUBE EAR REUTER BOBBIN,32190051,CDM,278,RC,,,Outpatient,,,79.94,47.96,,87.93,110,,39799.48,Percent of Total Billed Charges,110% of Total Billed Charges,35.97,45,,2786.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.38,28,,53.584,Percent of Total Billed Charges,28% of Total Billed Charges,44.34,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,36,,68.896,Percent of Total Billed Charges,36% of Total Billed Charges,28.78,36,,68.896,Percent of Total Billed Charges,36% Total Bille Charges,28.78,36,,68.896,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.94,100,,6656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.53,14.42,,12.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.95,80,,172.752,Percent of Total Billed Charges,80% of Total Billed Charges,39.97,50,,291.992,Percent of Total Billed Charges,50% of Total Billed Charges,39.97,50,,210.032,Percent of Total Billed Charges,50% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.97,50,,210.032,Percent of Total Billed Charges,50% of Total Billed Charges,39.97,50,,210.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.96,70,,260.096,Percent of Total Billed Charges,70% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14,,11.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.94,100,,230.336,Percent of Total Billed Charges,100% of Total Billed Charges,11.19,87.93,
5194 REAMER COR CANN 10MM ST,32190053,CDM,272,RC,,,Outpatient,,,998.97,599.38,,599.38,60,,10322.152,Percent of Total Billed Charges,60% of Total Billed Charges,449.54,45,,1178.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.71,28,,71.952,Percent of Total Billed Charges,28% of Total Billed Charges,44.35,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,359.63,36,,92.512,Percent of Total Billed Charges,36% of Total Billed Charges,359.63,36,,92.512,Percent of Total Billed Charges,36% Total Bille Charges,359.63,36,,92.512,Percent of Total Billed Charges,36% of Total Billed Charges,599.38,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,998.97,100,,1852.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,144.05,14.42,,12.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,749.23,75,,1638.256,Percent of Total Billed Charges,75% of Total Billed Charges,499.49,50,,203.104,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.49,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,499.49,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.28,70,,652.768,Percent of Total Billed Charges,70% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,139.86,14,,11.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,998.97,100,,2184.344,Percent of Total Billed Charges,100% of Total Billed Charges,44.35,998.97,
0005214 RELOAD ENDOPATH BLUE,32190054,CDM,272,RC,,,Outpatient,,,511.2,306.72,,306.72,60,,2043.928,Percent of Total Billed Charges,60% of Total Billed Charges,230.04,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.14,28,,23.168,Percent of Total Billed Charges,28% of Total Billed Charges,44.48,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,184.03,36,,29.784,Percent of Total Billed Charges,36% of Total Billed Charges,184.03,36,,29.784,Percent of Total Billed Charges,36% Total Bille Charges,184.03,36,,29.784,Percent of Total Billed Charges,36% of Total Billed Charges,306.72,60,,151.736,Percent of Total Billed Charges,60% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.2,100,,4486.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,73.72,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.4,75,,648.976,Percent of Total Billed Charges,75% of Total Billed Charges,255.6,50,,210.032,Percent of Total Billed Charges,50% of Total Billed Charges,255.6,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.6,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,255.6,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,357.84,70,,43.52,Percent of Total Billed Charges,70% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.2,100,,865.304,Percent of Total Billed Charges,100% of Total Billed Charges,44.48,511.2,
0005216 RELOAD ENDOPATH GREEN,32190055,CDM,272,RC,,,Outpatient,,,692.23,415.34,,415.34,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,311.5,45,,1118.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.82,28,,32.192,Percent of Total Billed Charges,28% of Total Billed Charges,44.51,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,249.2,36,,41.392,Percent of Total Billed Charges,36% of Total Billed Charges,249.2,36,,41.392,Percent of Total Billed Charges,36% Total Bille Charges,249.2,36,,41.392,Percent of Total Billed Charges,36% of Total Billed Charges,415.34,60,,88.696,Percent of Total Billed Charges,60% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.23,100,,6193.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14.42,,12.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.17,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,346.12,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,66.48,Percent of Total Billed Charges,50% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.12,50,,66.48,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,50,,66.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.56,70,,1371.592,Percent of Total Billed Charges,70% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,96.91,14,,11.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,692.23,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,44.51,692.23,
5217 CRTDG STPL RELOAD 55MM,32190056,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,2300.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,22.52,Percent of Total Billed Charges,28% of Total Billed Charges,44.51,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,28.952,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,28.952,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,28.952,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,41.2,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,2618.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,9.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,692.344,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,182.4,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,41.776,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,41.776,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,41.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,606.48,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,9.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,923.128,Percent of Total Billed Charges,100% of Total Billed Charges,41.04,293.15,
0005218 RELOAD ENDOPATH GREEN,32190057,CDM,272,RC,,,Outpatient,,,367.22,220.33,,220.33,60,,25101.496,Percent of Total Billed Charges,60% of Total Billed Charges,165.25,45,,1178.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.82,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,4533.98,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,132.2,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,132.2,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,132.2,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,220.33,60,,54.144,Percent of Total Billed Charges,60% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367.22,100,,1800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,52.95,14.42,,11.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.42,75,,700.28,Percent of Total Billed Charges,75% of Total Billed Charges,183.61,50,,66.48,Percent of Total Billed Charges,50% of Total Billed Charges,183.61,50,,42.176,Percent of Total Billed Charges,50% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.61,50,,42.176,Percent of Total Billed Charges,50% of Total Billed Charges,183.61,50,,42.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.05,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.41,14,,11.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.22,100,,933.704,Percent of Total Billed Charges,100% of Total Billed Charges,51.41,4533.98,
0005219 RELOAD ENDOPATH WHITE,32190058,CDM,272,RC,,,Outpatient,,,511.2,306.72,,306.72,60,,25101.496,Percent of Total Billed Charges,60% of Total Billed Charges,230.04,45,,1862.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.14,28,,102.904,Percent of Total Billed Charges,28% of Total Billed Charges,4595.91,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,184.03,36,,132.304,Percent of Total Billed Charges,36% of Total Billed Charges,184.03,36,,132.304,Percent of Total Billed Charges,36% Total Bille Charges,184.03,36,,132.304,Percent of Total Billed Charges,36% of Total Billed Charges,306.72,60,,222.008,Percent of Total Billed Charges,60% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.2,100,,2485.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,73.72,14.42,,347.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.4,75,,310.576,Percent of Total Billed Charges,75% of Total Billed Charges,255.6,50,,41.776,Percent of Total Billed Charges,50% of Total Billed Charges,255.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,255.6,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,357.84,70,,52.856,Percent of Total Billed Charges,70% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,71.57,14,,337.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.2,100,,414.096,Percent of Total Billed Charges,100% of Total Billed Charges,71.57,4595.91,
0005224 RELOAD PROXIMATE LI,32190059,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,3275.52,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,3536.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,72.216,Percent of Total Billed Charges,28% of Total Billed Charges,4607.36,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,92.856,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,92.856,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,92.856,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,334.48,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,5112.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,16.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,260.504,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,42.176,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,41.736,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,41.736,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,41.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,52.856,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,347.336,Percent of Total Billed Charges,100% of Total Billed Charges,41.04,4607.36,
0005225 RELOAD PROXIMATE BLUE,32190060,CDM,272,RC,,,Outpatient,,,360.16,216.10,,216.1,60,,591.776,Percent of Total Billed Charges,60% of Total Billed Charges,162.07,45,,2798.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.84,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,4709.12,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,129.66,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,129.66,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,129.66,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,216.1,60,,453.024,Percent of Total Billed Charges,60% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.16,100,,2618.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14.42,,74.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.12,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,180.08,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,180.08,50,,32.848,Percent of Total Billed Charges,50% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.08,50,,32.848,Percent of Total Billed Charges,50% of Total Billed Charges,180.08,50,,32.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.11,70,,52.856,Percent of Total Billed Charges,70% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.42,14,,72.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,360.16,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,50.42,4709.12,
0005226 STAPLER RELOAD BLUE,32190061,CDM,272,RC,,,Outpatient,,,267.32,160.39,,160.39,60,,816,Percent of Total Billed Charges,60% of Total Billed Charges,120.29,45,,2798.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.85,28,,65.664,Percent of Total Billed Charges,28% of Total Billed Charges,4709.12,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,96.24,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,96.24,36,,84.424,Percent of Total Billed Charges,36% Total Bille Charges,96.24,36,,84.424,Percent of Total Billed Charges,36% of Total Billed Charges,160.39,60,,58.752,Percent of Total Billed Charges,60% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.32,100,,4139.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,38.55,14.42,,61.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.49,75,,437.992,Percent of Total Billed Charges,75% of Total Billed Charges,133.66,50,,41.736,Percent of Total Billed Charges,50% of Total Billed Charges,133.66,50,,39.464,Percent of Total Billed Charges,50% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.66,50,,39.464,Percent of Total Billed Charges,50% of Total Billed Charges,133.66,50,,39.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.12,70,,164.656,Percent of Total Billed Charges,70% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,60.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.32,100,,583.984,Percent of Total Billed Charges,100% of Total Billed Charges,37.42,4709.12,
0005227 STAPLER RELOAD BLUE,32190062,CDM,272,RC,,,Outpatient,,,287.92,172.75,,172.75,60,,12726.2,Percent of Total Billed Charges,60% of Total Billed Charges,129.56,45,,394.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.62,28,,70.808,Percent of Total Billed Charges,28% of Total Billed Charges,4752.07,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,103.65,36,,91.04,Percent of Total Billed Charges,36% of Total Billed Charges,103.65,36,,91.04,Percent of Total Billed Charges,36% Total Bille Charges,103.65,36,,91.04,Percent of Total Billed Charges,36% of Total Billed Charges,172.75,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.92,100,,7858.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.52,14.42,,16.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.94,75,,304.656,Percent of Total Billed Charges,75% of Total Billed Charges,143.96,50,,32.848,Percent of Total Billed Charges,50% of Total Billed Charges,143.96,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.96,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,143.96,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.54,70,,3521.368,Percent of Total Billed Charges,70% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.92,100,,406.208,Percent of Total Billed Charges,100% of Total Billed Charges,40.31,4752.07,
0005228 STAPLER RELOAD GREEN,32190063,CDM,272,RC,,,Outpatient,,,267.32,160.39,,160.39,60,,11482.816,Percent of Total Billed Charges,60% of Total Billed Charges,120.29,45,,394.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.85,28,,41.392,Percent of Total Billed Charges,28% of Total Billed Charges,4791.63,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,96.24,36,,53.216,Percent of Total Billed Charges,36% of Total Billed Charges,96.24,36,,53.216,Percent of Total Billed Charges,36% Total Bille Charges,96.24,36,,53.216,Percent of Total Billed Charges,36% of Total Billed Charges,160.39,60,,560.224,Percent of Total Billed Charges,60% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.32,100,,6219.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,38.55,14.42,,16.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.49,75,,315.048,Percent of Total Billed Charges,75% of Total Billed Charges,133.66,50,,39.464,Percent of Total Billed Charges,50% of Total Billed Charges,133.66,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.66,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,133.66,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.12,70,,5837.848,Percent of Total Billed Charges,70% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.42,14,,16.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.32,100,,420.064,Percent of Total Billed Charges,100% of Total Billed Charges,37.42,4791.63,
0005229 STAPLER RELOAD GREEN,32190064,CDM,272,RC,,,Outpatient,,,287.92,172.75,,172.75,60,,12941.824,Percent of Total Billed Charges,60% of Total Billed Charges,129.56,45,,1634.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.62,28,,19.224,Percent of Total Billed Charges,28% of Total Billed Charges,4.48,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,103.65,36,,24.72,Percent of Total Billed Charges,36% of Total Billed Charges,103.65,36,,24.72,Percent of Total Billed Charges,36% Total Bille Charges,103.65,36,,24.72,Percent of Total Billed Charges,36% of Total Billed Charges,172.75,60,,148.512,Percent of Total Billed Charges,60% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.92,100,,6219.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,41.52,14.42,,157.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.94,75,,73.8,Percent of Total Billed Charges,75% of Total Billed Charges,143.96,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,143.96,50,,259.992,Percent of Total Billed Charges,50% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.96,50,,259.992,Percent of Total Billed Charges,50% of Total Billed Charges,143.96,50,,259.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.54,70,,5363.896,Percent of Total Billed Charges,70% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.31,14,,153.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.92,100,,98.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.48,287.92,
7121 STPLR INT HERN PROTACK,32190070,CDM,272,RC,,,Outpatient,,,2730.43,1638.26,,1638.26,60,,12941.824,Percent of Total Billed Charges,60% of Total Billed Charges,1228.69,45,,2451.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.52,28,,25.264,Percent of Total Billed Charges,28% of Total Billed Charges,4.5,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,982.95,36,,32.488,Percent of Total Billed Charges,36% of Total Billed Charges,982.95,36,,32.488,Percent of Total Billed Charges,36% Total Bille Charges,982.95,36,,32.488,Percent of Total Billed Charges,36% of Total Billed Charges,1638.26,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2730.43,100,,876,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,393.73,14.42,,13.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2047.82,75,,291.84,Percent of Total Billed Charges,75% of Total Billed Charges,1365.22,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,1365.22,50,,214.304,Percent of Total Billed Charges,50% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365.22,50,,214.304,Percent of Total Billed Charges,50% of Total Billed Charges,1365.22,50,,214.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1911.3,70,,646.744,Percent of Total Billed Charges,70% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,382.26,14,,13.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2730.43,100,,364.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.5,2730.43,
0007125 STPLR INT LIN CUT ARTC,32190072,CDM,272,RC,,,Outpatient,,,1081.63,648.98,,648.98,60,,12941.824,Percent of Total Billed Charges,60% of Total Billed Charges,486.73,45,,1634.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.86,28,,103.608,Percent of Total Billed Charges,28% of Total Billed Charges,4.51,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,389.39,36,,133.208,Percent of Total Billed Charges,36% of Total Billed Charges,389.39,36,,133.208,Percent of Total Billed Charges,36% Total Bille Charges,389.39,36,,133.208,Percent of Total Billed Charges,36% of Total Billed Charges,648.98,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1081.63,100,,876,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,155.97,14.42,,53.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,811.22,75,,99.712,Percent of Total Billed Charges,75% of Total Billed Charges,540.82,50,,259.992,Percent of Total Billed Charges,50% of Total Billed Charges,540.82,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.82,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,540.82,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,757.14,70,,362.88,Percent of Total Billed Charges,70% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,151.43,14,,51.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1081.63,100,,132.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.51,1081.63,
0007134 STPLR INT LIN PROX 90,32190073,CDM,272,RC,,,Outpatient,,,534.6,320.76,,320.76,60,,405.72,Percent of Total Billed Charges,60% of Total Billed Charges,240.57,45,,1529.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,170.28,Percent of Total Billed Charges,28% of Total Billed Charges,4.51,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,218.936,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,218.936,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,218.936,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,242.496,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,3632.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,8.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,62.656,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,214.304,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,270.592,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,83.544,Percent of Total Billed Charges,100% of Total Billed Charges,4.51,534.6,
0007138 STAPLER CURVED 21MM,32190074,CDM,272,RC,,,Outpatient,,,1153.91,692.35,,692.35,60,,286.304,Percent of Total Billed Charges,60% of Total Billed Charges,519.26,45,,1713.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.09,28,,230.632,Percent of Total Billed Charges,28% of Total Billed Charges,4.56,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,415.41,36,,296.528,Percent of Total Billed Charges,36% of Total Billed Charges,415.41,36,,296.528,Percent of Total Billed Charges,36% Total Bille Charges,415.41,36,,296.528,Percent of Total Billed Charges,36% of Total Billed Charges,692.35,60,,394.808,Percent of Total Billed Charges,60% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1153.91,100,,5448.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,166.39,14.42,,223.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,865.43,75,,63.256,Percent of Total Billed Charges,75% of Total Billed Charges,576.96,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,576.96,50,,546.56,Percent of Total Billed Charges,50% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,576.96,50,,546.56,Percent of Total Billed Charges,50% of Total Billed Charges,576.96,50,,546.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,807.74,70,,614.632,Percent of Total Billed Charges,70% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,161.55,14,,216.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1153.91,100,,84.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.56,1153.91,
0007140 STPLR INTNL INTRLUM,32190075,CDM,272,RC,,,Outpatient,,,1167.13,700.28,,700.28,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,525.21,45,,11163.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.8,28,,27.416,Percent of Total Billed Charges,28% of Total Billed Charges,4.58,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,420.17,36,,35.248,Percent of Total Billed Charges,36% of Total Billed Charges,420.17,36,,35.248,Percent of Total Billed Charges,36% Total Bille Charges,420.17,36,,35.248,Percent of Total Billed Charges,36% of Total Billed Charges,700.28,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1167.13,100,,3632.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,168.3,14.42,,21.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.35,75,,77.392,Percent of Total Billed Charges,75% of Total Billed Charges,583.57,50,,57.864,Percent of Total Billed Charges,50% of Total Billed Charges,583.57,50,,47.968,Percent of Total Billed Charges,50% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,583.57,50,,47.968,Percent of Total Billed Charges,50% of Total Billed Charges,583.57,50,,47.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,816.99,70,,2108.504,Percent of Total Billed Charges,70% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,21.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.13,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,4.58,1167.13,
0007141 STPLR INT LIN CUT PROX,32190076,CDM,272,RC,,,Outpatient,,,517.62,310.57,,310.57,60,,2377.432,Percent of Total Billed Charges,60% of Total Billed Charges,232.93,45,,15907.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.93,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,4.62,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,186.34,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,186.34,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,186.34,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,310.57,60,,835.328,Percent of Total Billed Charges,60% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.62,100,,3399,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,74.64,14.42,,15.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.22,75,,62.6,Percent of Total Billed Charges,75% of Total Billed Charges,258.81,50,,546.56,Percent of Total Billed Charges,50% of Total Billed Charges,258.81,50,,184.8,Percent of Total Billed Charges,50% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.81,50,,184.8,Percent of Total Billed Charges,50% of Total Billed Charges,258.81,50,,184.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.33,70,,941.464,Percent of Total Billed Charges,70% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,72.47,14,,15.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.62,100,,83.464,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,517.62,
0007142 STPLR INT LIN CUT PROX,32190077,CDM,272,RC,,,Outpatient,,,434.17,260.50,,260.5,60,,1805.6,Percent of Total Billed Charges,60% of Total Billed Charges,195.38,45,,11163.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.57,28,,46.816,Percent of Total Billed Charges,28% of Total Billed Charges,4.62,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,156.3,36,,60.192,Percent of Total Billed Charges,36% of Total Billed Charges,156.3,36,,60.192,Percent of Total Billed Charges,36% Total Bille Charges,156.3,36,,60.192,Percent of Total Billed Charges,36% of Total Billed Charges,260.5,60,,252.56,Percent of Total Billed Charges,60% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.17,100,,3806.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,62.61,14.42,,122.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.63,75,,49.264,Percent of Total Billed Charges,75% of Total Billed Charges,217.09,50,,47.968,Percent of Total Billed Charges,50% of Total Billed Charges,217.09,50,,29.128,Percent of Total Billed Charges,50% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.09,50,,29.128,Percent of Total Billed Charges,50% of Total Billed Charges,217.09,50,,29.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.92,70,,1170.688,Percent of Total Billed Charges,70% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.78,14,,119.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.17,100,,65.688,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,434.17,
0007145 STPLR INT LIN CUT PRO,32190078,CDM,272,RC,,,Outpatient,,,534.6,320.76,,320.76,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,240.57,45,,101.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,261.44,Percent of Total Billed Charges,28% of Total Billed Charges,4.62,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,336.136,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,336.136,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,336.136,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,342.76,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,24807.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,178.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,59.2,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,184.8,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,774.864,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,774.864,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,774.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,1090.928,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,173.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,78.928,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,534.6,
0007146 STPLR INT LIN CUT,32190079,CDM,272,RC,,,Outpatient,,,729.98,437.99,,437.99,60,,2993.4,Percent of Total Billed Charges,60% of Total Billed Charges,328.49,45,,111.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.39,28,,69.304,Percent of Total Billed Charges,28% of Total Billed Charges,4.65,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,262.79,36,,89.104,Percent of Total Billed Charges,36% of Total Billed Charges,262.79,36,,89.104,Percent of Total Billed Charges,36% Total Bille Charges,262.79,36,,89.104,Percent of Total Billed Charges,36% of Total Billed Charges,437.99,60,,523.92,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.98,100,,35349.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,105.26,14.42,,31.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547.49,75,,1809.6,Percent of Total Billed Charges,75% of Total Billed Charges,364.99,50,,29.128,Percent of Total Billed Charges,50% of Total Billed Charges,364.99,50,,75.528,Percent of Total Billed Charges,50% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.99,50,,75.528,Percent of Total Billed Charges,50% of Total Billed Charges,364.99,50,,75.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.99,70,,886.888,Percent of Total Billed Charges,70% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,102.2,14,,30.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.98,100,,2412.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.65,729.98,
0007148 STPLR INT LIN CUT PROX,32190080,CDM,272,RC,,,Outpatient,,,507.76,304.66,,304.66,60,,3549.192,Percent of Total Billed Charges,60% of Total Billed Charges,228.49,45,,438.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.17,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,4.65,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,182.79,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,182.79,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,182.79,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,304.66,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.76,100,,24807.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,73.22,14.42,,46.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.82,75,,86.792,Percent of Total Billed Charges,75% of Total Billed Charges,253.88,50,,774.864,Percent of Total Billed Charges,50% of Total Billed Charges,253.88,50,,54.24,Percent of Total Billed Charges,50% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.88,50,,54.24,Percent of Total Billed Charges,50% of Total Billed Charges,253.88,50,,54.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.43,70,,1450.4,Percent of Total Billed Charges,70% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,71.09,14,,44.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.76,100,,115.72,Percent of Total Billed Charges,100% of Total Billed Charges,4.65,507.76,
0007149 STPLR INT LIN CUT PROX,32190081,CDM,272,RC,,,Outpatient,,,525.08,315.05,,315.05,60,,1612.624,Percent of Total Billed Charges,60% of Total Billed Charges,236.29,45,,1109.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.02,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,4.68,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,189.03,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,189.03,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,189.03,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,315.05,60,,302.848,Percent of Total Billed Charges,60% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525.08,100,,225.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,75.72,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.81,75,,389.992,Percent of Total Billed Charges,75% of Total Billed Charges,262.54,50,,75.528,Percent of Total Billed Charges,50% of Total Billed Charges,262.54,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.54,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,262.54,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.56,70,,952.384,Percent of Total Billed Charges,70% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,73.51,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525.08,100,,519.984,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,525.08,
7155 STPLR SKN ROT HD PROX 3,32190083,CDM,272,RC,,,Outpatient,,,123,73.80,,73.8,60,,108.288,Percent of Total Billed Charges,60% of Total Billed Charges,55.35,45,,856.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.44,28,,113.168,Percent of Total Billed Charges,28% of Total Billed Charges,4.69,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.28,36,,145.496,Percent of Total Billed Charges,36% of Total Billed Charges,44.28,36,,145.496,Percent of Total Billed Charges,36% Total Bille Charges,44.28,36,,145.496,Percent of Total Billed Charges,36% of Total Billed Charges,73.8,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123,100,,247.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14.42,,15.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.25,75,,321.448,Percent of Total Billed Charges,75% of Total Billed Charges,61.5,50,,54.24,Percent of Total Billed Charges,50% of Total Billed Charges,61.5,50,,620.216,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.5,50,,620.216,Percent of Total Billed Charges,50% of Total Billed Charges,61.5,50,,620.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.1,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,15.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123,100,,428.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.69,123,
7173 STENT URET PRCFLX + 26C,32190086,CDM,278,RC,C2617,HCPCS,Outpatient,,,456,273.60,,695.15,110,,3474.656,Percent of Total Billed Charges,110% of Total Billed Charges,205.2,45,,490.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.68,28,,184.24,Percent of Total Billed Charges,28% of Total Billed Charges,4.72,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,164.16,36,,236.88,Percent of Total Billed Charges,36% of Total Billed Charges,164.16,36,,236.88,Percent of Total Billed Charges,36% Total Bille Charges,164.16,36,,236.88,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,456,100,,974.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,65.76,14.42,,10.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.8,80,,86.792,Percent of Total Billed Charges,80% of Total Billed Charges,228,50,,425.32,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,109.88,Percent of Total Billed Charges,50% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228,50,,109.88,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,109.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.2,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,9.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,456,100,,115.72,Percent of Total Billed Charges,100% of Total Billed Charges,4.72,695.15,
7293 SUT CHRMC 1 18IN TIE MP,32190091,CDM,272,RC,,,Outpatient,,,166.19,99.71,,99.71,60,,1005.032,Percent of Total Billed Charges,60% of Total Billed Charges,74.79,45,,410.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.53,28,,191.52,Percent of Total Billed Charges,28% of Total Billed Charges,4.74,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,59.83,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,59.83,36,,246.24,Percent of Total Billed Charges,36% Total Bille Charges,59.83,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,99.71,60,,90.504,Percent of Total Billed Charges,60% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.19,100,,2465.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.96,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.64,75,,86.792,Percent of Total Billed Charges,75% of Total Billed Charges,83.1,50,,620.216,Percent of Total Billed Charges,50% of Total Billed Charges,83.1,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.1,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,83.1,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.33,70,,504.24,Percent of Total Billed Charges,70% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,23.27,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.19,100,,115.72,Percent of Total Billed Charges,100% of Total Billed Charges,4.74,166.19,
7324 SUT ETHBND EXCL 2 30IN,32190096,CDM,272,RC,,,Outpatient,,,104.43,62.66,,62.66,60,,1336.76,Percent of Total Billed Charges,60% of Total Billed Charges,46.99,45,,470.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.24,28,,425.256,Percent of Total Billed Charges,28% of Total Billed Charges,4.76,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,36,,546.76,Percent of Total Billed Charges,36% of Total Billed Charges,37.59,36,,546.76,Percent of Total Billed Charges,36% Total Bille Charges,37.59,36,,546.76,Percent of Total Billed Charges,36% of Total Billed Charges,62.66,60,,36.576,Percent of Total Billed Charges,60% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.43,100,,1902.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,15.06,14.42,,142.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.32,75,,874.488,Percent of Total Billed Charges,75% of Total Billed Charges,52.22,50,,109.88,Percent of Total Billed Charges,50% of Total Billed Charges,52.22,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.22,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.22,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.1,70,,723.416,Percent of Total Billed Charges,70% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,14.62,14,,138.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.43,100,,1093.112,Percent of Total Billed Charges,100% of Total Billed Charges,4.76,104.43,
7325 SUT ETHBND EXCL 5 30IN,32190097,CDM,272,RC,,,Outpatient,,,105.43,63.26,,63.26,60,,1084.176,Percent of Total Billed Charges,60% of Total Billed Charges,47.44,45,,3104.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.52,28,,128.576,Percent of Total Billed Charges,28% of Total Billed Charges,4.77,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,37.95,36,,165.312,Percent of Total Billed Charges,36% of Total Billed Charges,37.95,36,,165.312,Percent of Total Billed Charges,36% Total Bille Charges,37.95,36,,165.312,Percent of Total Billed Charges,36% of Total Billed Charges,63.26,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.43,100,,1090.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,15.2,14.42,,136.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.07,75,,71.944,Percent of Total Billed Charges,75% of Total Billed Charges,52.72,50,,160.232,Percent of Total Billed Charges,50% of Total Billed Charges,52.72,50,,54.336,Percent of Total Billed Charges,50% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.72,50,,54.336,Percent of Total Billed Charges,50% of Total Billed Charges,52.72,50,,54.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.8,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,132.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.43,100,,95.928,Percent of Total Billed Charges,100% of Total Billed Charges,4.77,105.43,
0007363 SUT FW TAPR NDL 2 38IN,32190100,CDM,272,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,1012.488,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,174.496,Percent of Total Billed Charges,28% of Total Billed Charges,44.8,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,224.352,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,224.352,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,911.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,223.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,277.2,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,35.56,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,35.56,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,35.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,216.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,369.6,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,128.99,
7374 SUT NRLN TF 4-0 18IN N,32190102,CDM,272,RC,,,Outpatient,,,104.33,62.60,,62.6,60,,1012.488,Percent of Total Billed Charges,60% of Total Billed Charges,46.95,45,,491.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.21,28,,266.72,Percent of Total Billed Charges,28% of Total Billed Charges,44.8,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.56,36,,342.928,Percent of Total Billed Charges,36% of Total Billed Charges,37.56,36,,342.928,Percent of Total Billed Charges,36% Total Bille Charges,37.56,36,,342.928,Percent of Total Billed Charges,36% of Total Billed Charges,62.6,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.33,100,,1045.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.04,14.42,,229.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.25,75,,43.688,Percent of Total Billed Charges,75% of Total Billed Charges,52.17,50,,54.336,Percent of Total Billed Charges,50% of Total Billed Charges,52.17,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.17,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,52.17,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.03,70,,2855.16,Percent of Total Billed Charges,70% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,14.61,14,,222.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.33,100,,58.248,Percent of Total Billed Charges,100% of Total Billed Charges,14.61,104.33,
7441 SUT PROL 6-0 24IN BV1 D,32190117,CDM,272,RC,,,Outpatient,,,82.11,49.27,,49.27,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,36.95,45,,1584.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.99,28,,386.4,Percent of Total Billed Charges,28% of Total Billed Charges,44.85,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.56,36,,496.8,Percent of Total Billed Charges,36% of Total Billed Charges,29.56,36,,496.8,Percent of Total Billed Charges,36% Total Bille Charges,29.56,36,,496.8,Percent of Total Billed Charges,36% of Total Billed Charges,49.27,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.11,100,,6898.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.84,14.42,,17.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.58,75,,1162.296,Percent of Total Billed Charges,75% of Total Billed Charges,41.06,50,,35.56,Percent of Total Billed Charges,50% of Total Billed Charges,41.06,50,,493.352,Percent of Total Billed Charges,50% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.06,50,,493.352,Percent of Total Billed Charges,50% of Total Billed Charges,41.06,50,,493.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.48,70,,745.312,Percent of Total Billed Charges,70% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,11.5,14,,17.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.11,100,,1549.728,Percent of Total Billed Charges,100% of Total Billed Charges,11.5,82.11,
7527 SUT VCRL TP-1 2-0 27IN,32190128,CDM,272,RC,,,Outpatient,,,98.66,59.20,,59.2,60,,886.864,Percent of Total Billed Charges,60% of Total Billed Charges,44.4,45,,505.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.62,28,,154.176,Percent of Total Billed Charges,28% of Total Billed Charges,44.89,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,35.52,36,,198.224,Percent of Total Billed Charges,36% of Total Billed Charges,35.52,36,,198.224,Percent of Total Billed Charges,36% Total Bille Charges,35.52,36,,198.224,Percent of Total Billed Charges,36% of Total Billed Charges,59.2,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.66,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,14.23,14.42,,36.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,75,,113.296,Percent of Total Billed Charges,75% of Total Billed Charges,49.33,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,49.33,50,,473.208,Percent of Total Billed Charges,50% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.33,50,,473.208,Percent of Total Billed Charges,50% of Total Billed Charges,49.33,50,,473.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.06,70,,745.312,Percent of Total Billed Charges,70% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,13.81,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.66,100,,151.056,Percent of Total Billed Charges,100% of Total Billed Charges,13.81,98.66,
0007610 SYSTEM NOVASURE IMP,32190137,CDM,272,RC,,,Outpatient,,,3016,1809.60,,1809.6,60,,779.896,Percent of Total Billed Charges,60% of Total Billed Charges,1357.2,45,,499.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.48,28,,386.4,Percent of Total Billed Charges,28% of Total Billed Charges,45.07,32,,38.4,Percent of Total Billed Charges,32% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1085.76,36,,496.8,Percent of Total Billed Charges,36% of Total Billed Charges,1085.76,36,,496.8,Percent of Total Billed Charges,36% Total Bille Charges,1085.76,36,,496.8,Percent of Total Billed Charges,36% of Total Billed Charges,1809.6,60,,379.44,Percent of Total Billed Charges,60% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3016,100,,1091.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,434.91,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2262,75,,81.36,Percent of Total Billed Charges,75% of Total Billed Charges,1508,50,,493.352,Percent of Total Billed Charges,50% of Total Billed Charges,1508,50,,773.52,Percent of Total Billed Charges,50% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1508,50,,773.52,Percent of Total Billed Charges,50% of Total Billed Charges,1508,50,,773.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2111.2,70,,927.816,Percent of Total Billed Charges,70% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,422.24,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3016,100,,108.48,Percent of Total Billed Charges,100% of Total Billed Charges,45.07,3016,
TRACH TUBE CUFFLESS FENESTRATED SHILEY SIZE 4 (4CFN),32190139,CDM,272,RC,,,Outpatient,,,144.65,86.79,,86.79,60,,215.04,Percent of Total Billed Charges,60% of Total Billed Charges,65.09,45,,579.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.5,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,45.12,32,,38.464,Percent of Total Billed Charges,32% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.07,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,52.07,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,52.07,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,86.79,60,,310.496,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.65,100,,3521.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.86,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.49,75,,637.976,Percent of Total Billed Charges,75% of Total Billed Charges,72.33,50,,473.208,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,795.624,Percent of Total Billed Charges,50% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.33,50,,795.624,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,795.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.26,70,,436.624,Percent of Total Billed Charges,70% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.65,100,,850.632,Percent of Total Billed Charges,100% of Total Billed Charges,20.25,144.65,
109118 SUT MCRYL 0 18IN ENDOLP,32190145,CDM,272,RC,,,Outpatient,,,649.98,389.99,,389.99,60,,1987.936,Percent of Total Billed Charges,60% of Total Billed Charges,292.49,45,,428.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.99,28,,42.232,Percent of Total Billed Charges,28% of Total Billed Charges,45.18,32,,38.464,Percent of Total Billed Charges,32% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,233.99,36,,54.304,Percent of Total Billed Charges,36% of Total Billed Charges,233.99,36,,54.304,Percent of Total Billed Charges,36% Total Bille Charges,233.99,36,,54.304,Percent of Total Billed Charges,36% of Total Billed Charges,389.99,60,,310.496,Percent of Total Billed Charges,60% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,649.98,100,,1122.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,93.73,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,487.49,75,,930.328,Percent of Total Billed Charges,75% of Total Billed Charges,324.99,50,,773.52,Percent of Total Billed Charges,50% of Total Billed Charges,324.99,50,,61.912,Percent of Total Billed Charges,50% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.99,50,,61.912,Percent of Total Billed Charges,50% of Total Billed Charges,324.99,50,,61.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,454.99,70,,462.6,Percent of Total Billed Charges,70% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,91,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.98,100,,1240.432,Percent of Total Billed Charges,100% of Total Billed Charges,45.18,649.98,
109327 DISSECTOR BLLN HERN REP,32190146,CDM,272,RC,C1727,HCPCS,Outpatient,,,535.75,321.45,,269.34,100,,7267.408,Fee Schedule,100% of Aetna Fee Schedule,241.09,45,,367.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.01,28,,17.072,Percent of Total Billed Charges,28% of Total Billed Charges,45.36,32,,38.464,Percent of Total Billed Charges,32% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,192.87,36,,21.944,Percent of Total Billed Charges,36% of Total Billed Charges,192.87,36,,21.944,Percent of Total Billed Charges,36% Total Bille Charges,192.87,36,,21.944,Percent of Total Billed Charges,36% of Total Billed Charges,321.45,60,,232.224,Percent of Total Billed Charges,60% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.75,100,,1110.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.26,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.81,75,,164.824,Percent of Total Billed Charges,75% of Total Billed Charges,267.88,50,,795.624,Percent of Total Billed Charges,50% of Total Billed Charges,267.88,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.88,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,267.88,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.03,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,75.01,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,535.75,100,,219.76,Percent of Total Billed Charges,100% of Total Billed Charges,45.36,535.75,
TRACH TUBE CUFFLESS FENESTRATED SHILEY SIZE 6 (6CFN),32190148,CDM,272,RC,,,Outpatient,,,144.65,86.79,,86.79,60,,1622.4,Percent of Total Billed Charges,60% of Total Billed Charges,65.09,45,,535.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.5,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,45.37,32,,38.464,Percent of Total Billed Charges,32% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,86.79,60,,687.792,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.65,100,,1287.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.86,14.42,,9.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.49,75,,240.352,Percent of Total Billed Charges,75% of Total Billed Charges,72.33,50,,61.912,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.33,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.26,70,,6549.088,Percent of Total Billed Charges,70% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,9.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.65,100,,320.464,Percent of Total Billed Charges,100% of Total Billed Charges,20.25,144.65,
TRACH TUBE CUFFLESS FENESTRATED SHILEY SIZE 8 (8CFN),32190150,CDM,272,RC,,,Outpatient,,,144.65,86.79,,86.79,60,,3511.92,Percent of Total Billed Charges,60% of Total Billed Charges,65.09,45,,4927.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.5,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,45.46,32,,38.464,Percent of Total Billed Charges,32% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,52.07,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,86.79,60,,124.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.65,100,,952.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.86,14.42,,39.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.49,75,,1461.904,Percent of Total Billed Charges,75% of Total Billed Charges,72.33,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.33,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,72.33,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.26,70,,947.168,Percent of Total Billed Charges,70% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.25,14,,38.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.65,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.25,144.65,
111001 VASCU-GUARD 2X9 CM,32190151,CDM,278,RC,,,Outpatient,,,1366.39,819.83,,1503.03,110,,59023.296,Percent of Total Billed Charges,110% of Total Billed Charges,614.88,45,,73.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.59,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,45.98,32,,38.544,Percent of Total Billed Charges,32% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,491.9,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,491.9,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,491.9,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,751.51,55,,560.808,Percent of Total Billed Charges,55% Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1366.39,100,,816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,197.03,14.42,,21.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1093.11,80,,81.496,Percent of Total Billed Charges,80% of Total Billed Charges,683.2,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,683.2,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,683.2,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,683.2,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,956.47,70,,345.8,Percent of Total Billed Charges,70% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,191.29,14,,20.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1366.39,100,,108.664,Percent of Total Billed Charges,100% of Total Billed Charges,45.98,1503.03,
111437 SUT PROL 5-0 24IN BV1 D,32190162,CDM,272,RC,,,Outpatient,,,119.91,71.95,,71.95,60,,2880,Percent of Total Billed Charges,60% of Total Billed Charges,53.96,45,,24.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.57,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,45.99,32,,38.608,Percent of Total Billed Charges,32% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,43.17,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,43.17,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,43.17,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,71.95,60,,562.624,Percent of Total Billed Charges,60% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.91,100,,1189.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.93,75,,53.336,Percent of Total Billed Charges,75% of Total Billed Charges,59.96,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.96,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.96,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.96,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.94,70,,133.496,Percent of Total Billed Charges,70% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.91,100,,71.112,Percent of Total Billed Charges,100% of Total Billed Charges,16.79,119.91,
111487 SUT PASSER ARTR THOMASN,32190168,CDM,272,RC,,,Outpatient,,,462,277.20,,277.2,60,,41.136,Percent of Total Billed Charges,60% of Total Billed Charges,207.9,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.36,28,,564.48,Percent of Total Billed Charges,28% of Total Billed Charges,46.16,32,,38.696,Percent of Total Billed Charges,32% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,166.32,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,166.32,36,,725.76,Percent of Total Billed Charges,36% Total Bille Charges,166.32,36,,725.76,Percent of Total Billed Charges,36% of Total Billed Charges,277.2,60,,1072.064,Percent of Total Billed Charges,60% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462,100,,10950.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,66.62,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.5,75,,114.064,Percent of Total Billed Charges,75% of Total Billed Charges,231,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,231,50,,33.096,Percent of Total Billed Charges,50% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231,50,,33.096,Percent of Total Billed Charges,50% of Total Billed Charges,231,50,,33.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.4,70,,260.456,Percent of Total Billed Charges,70% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,64.68,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,46.16,462,
111546 SUT VCRL MO-4 2-0 18IN,32190172,CDM,272,RC,,,Outpatient,,,72.81,43.69,,43.69,60,,6809.096,Percent of Total Billed Charges,60% of Total Billed Charges,32.76,45,,535.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.39,28,,177.072,Percent of Total Billed Charges,28% of Total Billed Charges,46.29,32,,38.76,Percent of Total Billed Charges,32% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,36,,227.664,Percent of Total Billed Charges,36% of Total Billed Charges,26.21,36,,227.664,Percent of Total Billed Charges,36% Total Bille Charges,26.21,36,,227.664,Percent of Total Billed Charges,36% of Total Billed Charges,43.69,60,,251.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.81,100,,164.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.5,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.61,75,,740.032,Percent of Total Billed Charges,75% of Total Billed Charges,36.41,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,36.41,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.41,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,36.41,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.97,70,,621.6,Percent of Total Billed Charges,70% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.81,100,,986.704,Percent of Total Billed Charges,100% of Total Billed Charges,10.19,72.81,
111589 STPLR INT CIR HEMRHOD P,32190174,CDM,272,RC,,,Outpatient,,,1937.16,1162.30,,1162.3,60,,400.712,Percent of Total Billed Charges,60% of Total Billed Charges,871.72,45,,236.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.4,28,,144.896,Percent of Total Billed Charges,28% of Total Billed Charges,46.29,32,,38.768,Percent of Total Billed Charges,32% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,697.38,36,,186.296,Percent of Total Billed Charges,36% of Total Billed Charges,697.38,36,,186.296,Percent of Total Billed Charges,36% Total Bille Charges,697.38,36,,186.296,Percent of Total Billed Charges,36% of Total Billed Charges,1162.3,60,,3800.16,Percent of Total Billed Charges,60% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1937.16,100,,55.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,279.34,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1452.87,75,,757.136,Percent of Total Billed Charges,75% of Total Billed Charges,968.58,50,,33.096,Percent of Total Billed Charges,50% of Total Billed Charges,968.58,50,,74.888,Percent of Total Billed Charges,50% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,968.58,50,,74.888,Percent of Total Billed Charges,50% of Total Billed Charges,968.58,50,,74.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1356.01,70,,39.648,Percent of Total Billed Charges,70% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,271.2,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1937.16,100,,946.416,Percent of Total Billed Charges,100% of Total Billed Charges,46.29,1937.16,
111634 SUT COT II 1MM HC-5 COT,32190175,CDM,272,RC,,,Outpatient,,,188.82,113.29,,113.29,60,,1111.552,Percent of Total Billed Charges,60% of Total Billed Charges,84.97,45,,179.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.87,28,,144.896,Percent of Total Billed Charges,28% of Total Billed Charges,46.29,32,,38.808,Percent of Total Billed Charges,32% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,67.98,36,,186.296,Percent of Total Billed Charges,36% of Total Billed Charges,67.98,36,,186.296,Percent of Total Billed Charges,36% Total Bille Charges,67.98,36,,186.296,Percent of Total Billed Charges,36% of Total Billed Charges,113.29,60,,207.592,Percent of Total Billed Charges,60% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.82,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,27.23,14.42,,21.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.62,75,,1237.632,Percent of Total Billed Charges,75% of Total Billed Charges,94.41,50,,137.008,Percent of Total Billed Charges,50% of Total Billed Charges,94.41,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.41,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,94.41,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.17,70,,72.232,Percent of Total Billed Charges,70% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,26.43,14,,21.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.82,100,,1547.04,Percent of Total Billed Charges,100% of Total Billed Charges,26.43,188.82,
112729 TUBE IRR FRFRM XPS ENT,32190179,CDM,272,RC,,,Outpatient,,,135.6,81.36,,81.36,60,,2692.008,Percent of Total Billed Charges,60% of Total Billed Charges,61.02,45,,29.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.97,28,,30.56,Percent of Total Billed Charges,28% of Total Billed Charges,46.34,32,,38.864,Percent of Total Billed Charges,32% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,48.82,36,,39.288,Percent of Total Billed Charges,36% of Total Billed Charges,48.82,36,,39.288,Percent of Total Billed Charges,36% Total Bille Charges,48.82,36,,39.288,Percent of Total Billed Charges,36% of Total Billed Charges,81.36,60,,3374.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.6,100,,1189.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,19.55,14.42,,21.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.7,75,,1273,Percent of Total Billed Charges,75% of Total Billed Charges,67.8,50,,74.888,Percent of Total Billed Charges,50% of Total Billed Charges,67.8,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.8,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,67.8,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.92,70,,666.8,Percent of Total Billed Charges,70% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,18.98,14,,20.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.6,100,,1591.248,Percent of Total Billed Charges,100% of Total Billed Charges,18.98,135.6,
112920 BASKET STN 3FRX11MMX90C,32190183,CDM,272,RC,,,Outpatient,,,1063.29,637.97,,637.97,60,,3715.872,Percent of Total Billed Charges,60% of Total Billed Charges,478.48,45,,387.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.72,28,,108.368,Percent of Total Billed Charges,28% of Total Billed Charges,46.36,32,,39.032,Percent of Total Billed Charges,32% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.78,36,,139.336,Percent of Total Billed Charges,36% of Total Billed Charges,382.78,36,,139.336,Percent of Total Billed Charges,36% Total Bille Charges,382.78,36,,139.336,Percent of Total Billed Charges,36% of Total Billed Charges,637.97,60,,66.128,Percent of Total Billed Charges,60% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1063.29,100,,526.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,153.33,14.42,,25,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,797.47,75,,92.872,Percent of Total Billed Charges,75% of Total Billed Charges,531.65,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,531.65,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.65,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,531.65,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,744.3,70,,299.376,Percent of Total Billed Charges,70% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,148.86,14,,24.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1063.29,100,,123.824,Percent of Total Billed Charges,100% of Total Billed Charges,46.36,1063.29,
112923 CATH STN BGLY HEL 3W 1.,32190184,CDM,272,RC,,,Outpatient,,,1550.54,930.32,,930.32,60,,1571.232,Percent of Total Billed Charges,60% of Total Billed Charges,697.74,45,,968.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.15,28,,350.144,Percent of Total Billed Charges,28% of Total Billed Charges,46.4,32,,39.048,Percent of Total Billed Charges,32% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,558.19,36,,450.192,Percent of Total Billed Charges,36% of Total Billed Charges,558.19,36,,450.192,Percent of Total Billed Charges,36% Total Bille Charges,558.19,36,,450.192,Percent of Total Billed Charges,36% of Total Billed Charges,930.32,60,,66.128,Percent of Total Billed Charges,60% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1550.54,100,,399.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,223.59,14.42,,10.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1162.91,75,,189.64,Percent of Total Billed Charges,75% of Total Billed Charges,775.27,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,775.27,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,775.27,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,775.27,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1085.38,70,,796.536,Percent of Total Billed Charges,70% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,217.08,14,,9.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1550.54,100,,252.856,Percent of Total Billed Charges,100% of Total Billed Charges,46.4,1550.54,
112952 GW ESCP URET GLDWR 150C,32190186,CDM,272,RC,C1769,HCPCS,Outpatient,,,274.7,164.82,,55.13,100,,1080,Fee Schedule,100% of Aetna Fee Schedule,123.62,45,,1535.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,28,,58.24,Percent of Total Billed Charges,28% of Total Billed Charges,46.52,32,,39.104,Percent of Total Billed Charges,32% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,98.89,36,,74.88,Percent of Total Billed Charges,36% of Total Billed Charges,98.89,36,,74.88,Percent of Total Billed Charges,36% Total Bille Charges,98.89,36,,74.88,Percent of Total Billed Charges,36% of Total Billed Charges,164.82,60,,160.128,Percent of Total Billed Charges,60% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.7,100,,65.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.61,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.03,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,137.35,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,137.35,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.35,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,137.35,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.29,70,,1184.4,Percent of Total Billed Charges,70% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.46,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.7,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,38.46,274.7,
112953 GW ESCP RDRR SNSR 150CM,32190187,CDM,272,RC,C1769,HCPCS,Outpatient,,,400.58,240.35,,55.13,100,,1491.36,Fee Schedule,100% of Aetna Fee Schedule,180.26,45,,894.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.16,28,,261.712,Percent of Total Billed Charges,28% of Total Billed Charges,46.85,32,,39.152,Percent of Total Billed Charges,32% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,144.21,36,,336.488,Percent of Total Billed Charges,36% of Total Billed Charges,144.21,36,,336.488,Percent of Total Billed Charges,36% Total Bille Charges,144.21,36,,336.488,Percent of Total Billed Charges,36% of Total Billed Charges,240.35,60,,376.2,Percent of Total Billed Charges,60% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.58,100,,861.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,57.76,14.42,,5.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.44,75,,77.392,Percent of Total Billed Charges,75% of Total Billed Charges,200.29,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,200.29,50,,73.376,Percent of Total Billed Charges,50% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.29,50,,73.376,Percent of Total Billed Charges,50% of Total Billed Charges,200.29,50,,73.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.41,70,,158.568,Percent of Total Billed Charges,70% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,56.08,14,,5.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.58,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,46.85,400.58,
112961 CATH CSF VENT 3-15CM BA,32190188,CDM,272,RC,C1729,HCPCS,Outpatient,,,2436.5,1461.90,,11.1,100,,1571.232,Fee Schedule,100% of Aetna Fee Schedule,1096.43,45,,894.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,286.424,Percent of Total Billed Charges,28% of Total Billed Charges,46.91,32,,39.168,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,368.264,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,368.264,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,368.264,Percent of Total Billed Charges,36% of Total Billed Charges,1461.9,60,,541.2,Percent of Total Billed Charges,60% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,2151.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,165.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,75,,77.392,Percent of Total Billed Charges,75% of Total Billed Charges,1218.25,50,,76.04,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,86.688,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,86.688,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,86.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,160.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,2436.5,
113392 SUT DEV SURGDAC ENDOSTC,32190191,CDM,272,RC,,,Outpatient,,,135.83,81.50,,81.5,60,,2483.52,Percent of Total Billed Charges,60% of Total Billed Charges,61.12,45,,2372.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.03,28,,545.776,Percent of Total Billed Charges,28% of Total Billed Charges,46.91,32,,39.328,Percent of Total Billed Charges,32% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,48.9,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,48.9,36,,701.712,Percent of Total Billed Charges,36% Total Bille Charges,48.9,36,,701.712,Percent of Total Billed Charges,36% of Total Billed Charges,81.5,60,,709.488,Percent of Total Billed Charges,60% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.83,100,,3411.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.59,14.42,,354.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.87,75,,77.392,Percent of Total Billed Charges,75% of Total Billed Charges,67.92,50,,73.376,Percent of Total Billed Charges,50% of Total Billed Charges,67.92,50,,35.344,Percent of Total Billed Charges,50% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.92,50,,35.344,Percent of Total Billed Charges,50% of Total Billed Charges,67.92,50,,35.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.08,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.02,14,,343.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.83,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,19.02,135.83,
114454 SUTURE PROLENE 7-0,32190194,CDM,272,RC,,,Outpatient,,,88.89,53.33,,53.33,60,,3731.52,Percent of Total Billed Charges,60% of Total Billed Charges,40,45,,2372.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.89,28,,117.352,Percent of Total Billed Charges,28% of Total Billed Charges,47.16,32,,39.328,Percent of Total Billed Charges,32% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,32,36,,150.888,Percent of Total Billed Charges,36% of Total Billed Charges,32,36,,150.888,Percent of Total Billed Charges,36% Total Bille Charges,32,36,,150.888,Percent of Total Billed Charges,36% of Total Billed Charges,53.33,60,,993.608,Percent of Total Billed Charges,60% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.89,100,,1987.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.82,14.42,,95.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.67,75,,49.648,Percent of Total Billed Charges,75% of Total Billed Charges,44.45,50,,86.688,Percent of Total Billed Charges,50% of Total Billed Charges,44.45,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.45,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,44.45,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.22,70,,1971.424,Percent of Total Billed Charges,70% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.44,14,,92.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.89,100,,66.192,Percent of Total Billed Charges,100% of Total Billed Charges,12.44,88.89,
TRACH TUBE CUFFED FENESTRATED 8 SHILEY (8FEN),32190195,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,3731.52,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,4482.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,1773.408,Percent of Total Billed Charges,28% of Total Billed Charges,47.33,32,,39.344,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,2280.096,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,2280.096,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,2280.096,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,555.904,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,1987.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,112.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,205.512,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,35.344,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,20.664,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,20.664,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,20.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,1425.312,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,109.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,274.016,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,190.1,
114664 STAPLER RELOAD CURVED,32190198,CDM,272,RC,,,Outpatient,,,1233.38,740.03,,740.03,60,,525.6,Percent of Total Billed Charges,60% of Total Billed Charges,555.02,45,,156.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.35,28,,96.872,Percent of Total Billed Charges,28% of Total Billed Charges,47.36,32,,39.608,Percent of Total Billed Charges,32% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,444.02,36,,124.552,Percent of Total Billed Charges,36% of Total Billed Charges,444.02,36,,124.552,Percent of Total Billed Charges,36% Total Bille Charges,444.02,36,,124.552,Percent of Total Billed Charges,36% of Total Billed Charges,740.03,60,,740.88,Percent of Total Billed Charges,60% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1233.38,100,,5272.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,177.85,14.42,,8.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,925.04,75,,112.328,Percent of Total Billed Charges,75% of Total Billed Charges,616.69,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,616.69,50,,573.592,Percent of Total Billed Charges,50% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.69,50,,573.592,Percent of Total Billed Charges,50% of Total Billed Charges,616.69,50,,573.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,863.37,70,,133.96,Percent of Total Billed Charges,70% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,172.67,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1233.38,100,,149.768,Percent of Total Billed Charges,100% of Total Billed Charges,47.36,1233.38,
114672 GRAFT PATCH DURA DRGN 1,32190199,CDM,278,RC,,,Outpatient,,,1183.02,709.81,,1301.32,110,,525.6,Percent of Total Billed Charges,110% of Total Billed Charges,532.36,45,,2448.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.25,28,,1718.08,Percent of Total Billed Charges,28% of Total Billed Charges,47.6,32,,39.624,Percent of Total Billed Charges,32% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,425.89,36,,2208.96,Percent of Total Billed Charges,36% of Total Billed Charges,425.89,36,,2208.96,Percent of Total Billed Charges,36% Total Bille Charges,425.89,36,,2208.96,Percent of Total Billed Charges,36% of Total Billed Charges,650.66,55,,50.224,Percent of Total Billed Charges,55% Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.02,100,,5272.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,170.59,14.42,,9.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,946.42,80,,114.064,Percent of Total Billed Charges,80% of Total Billed Charges,591.51,50,,20.664,Percent of Total Billed Charges,50% of Total Billed Charges,591.51,50,,1228.184,Percent of Total Billed Charges,50% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,591.51,50,,1228.184,Percent of Total Billed Charges,50% of Total Billed Charges,591.51,50,,1228.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.11,70,,179.88,Percent of Total Billed Charges,70% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,165.62,14,,9.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1183.02,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,47.6,1301.32,
114673 GRAFT PATCH DURA DRGN 3,32190200,CDM,278,RC,,,Outpatient,,,1933.8,1160.28,,2127.18,110,,2179.496,Percent of Total Billed Charges,110% of Total Billed Charges,870.21,45,,3177.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.46,28,,30.856,Percent of Total Billed Charges,28% of Total Billed Charges,47.6,32,,39.632,Percent of Total Billed Charges,32% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,696.17,36,,39.672,Percent of Total Billed Charges,36% of Total Billed Charges,696.17,36,,39.672,Percent of Total Billed Charges,36% Total Bille Charges,696.17,36,,39.672,Percent of Total Billed Charges,36% of Total Billed Charges,1063.59,55,,89.52,Percent of Total Billed Charges,55% Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1933.8,100,,9960.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,278.85,14.42,,40.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.04,80,,114.064,Percent of Total Billed Charges,80% of Total Billed Charges,966.9,50,,573.592,Percent of Total Billed Charges,50% of Total Billed Charges,966.9,50,,331.152,Percent of Total Billed Charges,50% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,966.9,50,,331.152,Percent of Total Billed Charges,50% of Total Billed Charges,966.9,50,,331.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1353.66,70,,57.912,Percent of Total Billed Charges,70% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,270.73,14,,38.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1933.8,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,47.6,2127.18,
114674 GRAFT PATCH DURA DRGN 2,32190201,CDM,278,RC,,,Outpatient,,,1989.06,1193.44,,2187.97,110,,3269.248,Percent of Total Billed Charges,110% of Total Billed Charges,895.08,45,,307,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.94,28,,30.856,Percent of Total Billed Charges,28% of Total Billed Charges,47.67,32,,39.888,Percent of Total Billed Charges,32% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,716.06,36,,39.672,Percent of Total Billed Charges,36% of Total Billed Charges,716.06,36,,39.672,Percent of Total Billed Charges,36% Total Bille Charges,716.06,36,,39.672,Percent of Total Billed Charges,36% of Total Billed Charges,1093.98,55,,105.36,Percent of Total Billed Charges,55% Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1989.06,100,,347.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,286.82,14.42,,28.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1591.25,80,,114.064,Percent of Total Billed Charges,80% of Total Billed Charges,994.53,50,,1228.184,Percent of Total Billed Charges,50% of Total Billed Charges,994.53,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,994.53,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,994.53,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.34,70,,80.48,Percent of Total Billed Charges,70% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,278.47,14,,27.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1989.06,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,47.67,2187.97,
114888 SUT MERS 5MM 12IN MO4 W,32190207,CDM,272,RC,,,Outpatient,,,154.78,92.87,,92.87,60,,2179.496,Percent of Total Billed Charges,60% of Total Billed Charges,69.65,45,,33.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.34,28,,74.728,Percent of Total Billed Charges,28% of Total Billed Charges,47.67,32,,40.168,Percent of Total Billed Charges,32% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,36,,96.08,Percent of Total Billed Charges,36% of Total Billed Charges,55.72,36,,96.08,Percent of Total Billed Charges,36% Total Bille Charges,55.72,36,,96.08,Percent of Total Billed Charges,36% of Total Billed Charges,92.87,60,,102.12,Percent of Total Billed Charges,60% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.78,100,,5440.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,22.32,14.42,,304.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.09,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,77.39,50,,331.152,Percent of Total Billed Charges,50% of Total Billed Charges,77.39,50,,31.04,Percent of Total Billed Charges,50% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,50,,31.04,Percent of Total Billed Charges,50% of Total Billed Charges,77.39,50,,31.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.35,70,,56.304,Percent of Total Billed Charges,70% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14,,295.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.78,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,21.67,154.78,
114922 TIP MANIP UTER RUMI 6.7,32190209,CDM,272,RC,,,Outpatient,,,316.07,189.64,,189.64,60,,2039.4,Percent of Total Billed Charges,60% of Total Billed Charges,142.23,45,,1090.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.5,28,,191.52,Percent of Total Billed Charges,28% of Total Billed Charges,47.67,32,,40.184,Percent of Total Billed Charges,32% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,113.79,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,113.79,36,,246.24,Percent of Total Billed Charges,36% Total Bille Charges,113.79,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,189.64,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.07,100,,7061.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,45.58,14.42,,36.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.05,75,,114.064,Percent of Total Billed Charges,75% of Total Billed Charges,158.04,50,,389.84,Percent of Total Billed Charges,50% of Total Billed Charges,158.04,50,,33,Percent of Total Billed Charges,50% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.04,50,,33,Percent of Total Billed Charges,50% of Total Billed Charges,158.04,50,,33,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.25,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,35.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.07,100,,152.08,Percent of Total Billed Charges,100% of Total Billed Charges,44.25,316.07,
115042 SLING URETH TRANSOBTR T,32190215,CDM,278,RC,C1771,HCPCS,Outpatient,,,4235,2541.00,,4746.41,110,,2284.128,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,19.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,275.52,Percent of Total Billed Charges,28% of Total Billed Charges,47.84,32,,40.192,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,354.24,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,354.24,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,354.24,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,57.984,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,682.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,13.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,110.064,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,31.04,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,139.096,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,139.096,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,139.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,257.256,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,13.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,146.752,Percent of Total Billed Charges,100% of Total Billed Charges,47.84,4746.41,
115331 BINDER BRST EXPAND-A-BA,32190216,CDM,271,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,31287.992,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,29.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,361.192,Percent of Total Billed Charges,28% of Total Billed Charges,47.99,32,,40.24,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,464.392,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,464.392,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,464.392,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,75.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,178.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,138.696,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,33,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,99.296,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,99.296,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,99.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,180.552,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,173.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,173.368,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,128.99,
115332 BINDER BRST EXPNDABND 3,32190217,CDM,271,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,48554.376,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,505.84,Percent of Total Billed Charges,28% of Total Billed Charges,4800,32,,40.256,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,650.36,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,650.36,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,650.36,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,2422.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,182.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,53.008,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,139.096,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,70.68,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,4800,
115334 BINDER MAM XPD-A-BND BR,32190219,CDM,271,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,31287.992,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,173.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,283.008,Percent of Total Billed Charges,28% of Total Billed Charges,4848,32,,40.256,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,363.864,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,363.864,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,363.864,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,44.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,1132.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,175.888,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,99.296,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,164.168,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,1099.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,4848,
583421 GUIDEWIRE PTFE COATED .,32190224,CDM,272,RC,C1769,HCPCS,Outpatient,,,82.74,49.64,,55.13,100,,1479.032,Fee Schedule,100% of Aetna Fee Schedule,37.23,45,,173.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.17,28,,345.744,Percent of Total Billed Charges,28% of Total Billed Charges,4859.66,32,,40.312,Percent of Total Billed Charges,32% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,36,,444.528,Percent of Total Billed Charges,36% of Total Billed Charges,29.79,36,,444.528,Percent of Total Billed Charges,36% Total Bille Charges,29.79,36,,444.528,Percent of Total Billed Charges,36% of Total Billed Charges,49.64,60,,106.688,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.74,100,,64.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14.42,,472.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.06,75,,31,Percent of Total Billed Charges,75% of Total Billed Charges,41.37,50,,1057.056,Percent of Total Billed Charges,50% of Total Billed Charges,41.37,50,,47.904,Percent of Total Billed Charges,50% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.37,50,,47.904,Percent of Total Billed Charges,50% of Total Billed Charges,41.37,50,,47.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.92,70,,177.024,Percent of Total Billed Charges,70% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.58,14,,458.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.74,100,,41.328,Percent of Total Billed Charges,100% of Total Billed Charges,11.58,4859.66,
116340 GUIDEWIRE ZIPWIRE .038,32190225,CDM,272,RC,C1769,HCPCS,Outpatient,,,342.52,205.51,,55.13,100,,1057.144,Fee Schedule,100% of Aetna Fee Schedule,154.13,45,,30.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.91,28,,23.44,Percent of Total Billed Charges,28% of Total Billed Charges,4859.66,32,,40.32,Percent of Total Billed Charges,32% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,123.31,36,,30.136,Percent of Total Billed Charges,36% of Total Billed Charges,123.31,36,,30.136,Percent of Total Billed Charges,36% Total Bille Charges,123.31,36,,30.136,Percent of Total Billed Charges,36% of Total Billed Charges,205.51,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.52,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.39,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.89,75,,860.384,Percent of Total Billed Charges,75% of Total Billed Charges,171.26,50,,126.432,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,618.112,Percent of Total Billed Charges,50% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.26,50,,618.112,Percent of Total Billed Charges,50% of Total Billed Charges,171.26,50,,618.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.76,70,,103.48,Percent of Total Billed Charges,70% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.52,100,,1147.176,Percent of Total Billed Charges,100% of Total Billed Charges,47.95,4859.66,
116432 SUT PASSER ENDOSCP SHTT,32190228,CDM,272,RC,,,Outpatient,,,187.21,112.33,,112.33,60,,1204.232,Percent of Total Billed Charges,60% of Total Billed Charges,84.24,45,,1584.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.42,28,,41.776,Percent of Total Billed Charges,28% of Total Billed Charges,4859.66,32,,40.352,Percent of Total Billed Charges,32% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.4,36,,53.712,Percent of Total Billed Charges,36% of Total Billed Charges,67.4,36,,53.712,Percent of Total Billed Charges,36% Total Bille Charges,67.4,36,,53.712,Percent of Total Billed Charges,36% of Total Billed Charges,112.33,60,,41.184,Percent of Total Billed Charges,60% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.21,100,,384.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,27,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.41,75,,1842.28,Percent of Total Billed Charges,75% of Total Billed Charges,93.61,50,,47.904,Percent of Total Billed Charges,50% of Total Billed Charges,93.61,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.61,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,93.61,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.05,70,,48.064,Percent of Total Billed Charges,70% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,26.21,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.21,100,,2456.368,Percent of Total Billed Charges,100% of Total Billed Charges,26.21,4859.66,
TRACH TUBE FENESTRATED LPC SIZE 10 (10FEN),32190232,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,7808.808,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,105.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,49.168,Percent of Total Billed Charges,28% of Total Billed Charges,4859.66,32,,40.368,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,63.216,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,63.216,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,63.216,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,384.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,109.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,529.84,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,618.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,3927.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,3927.888,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,3927.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,63.168,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,662.304,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,4859.66,
TRACH TUBE LP  CUFFED FENESTRATED 6 SHILEY   (6FEN),32190237,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,1863.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,47.656,Percent of Total Billed Charges,28% of Total Billed Charges,4859.66,32,,40.384,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,61.272,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,61.272,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,61.272,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,65.808,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,67.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,156.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,584.76,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,1638.104,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,1638.104,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,1638.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,259.008,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,152.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,4859.66,
TRACH TUBE CUFFED LOW PRESSURE 6    (6LPC),32190238,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,1612.624,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,5056,32,,40.448,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,66.008,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,3521.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,53.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,46.552,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,3927.888,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,425.704,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,52.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,62.072,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,5056,
117673 SUT PROL BV PROL 6-0 30,32190239,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,666.544,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,45.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,5056,32,,40.496,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,124.664,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,234.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,134.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,49.496,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,1638.104,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,576.576,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,130.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,65.992,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,5056,
TRACH TUBE CUFFED LOW PRESSURE 8   (8LPC),32190240,CDM,272,RC,,,Outpatient,,,190.1,114.06,,114.06,60,,772.208,Percent of Total Billed Charges,60% of Total Billed Charges,85.55,45,,13.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.23,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,5056,32,,40.544,Percent of Total Billed Charges,32% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,68.44,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,68.44,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,68.44,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,114.06,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.1,100,,4141.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,27.41,14.42,,8.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.58,75,,208.64,Percent of Total Billed Charges,75% of Total Billed Charges,95.05,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.05,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,95.05,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.07,70,,68.544,Percent of Total Billed Charges,70% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,26.61,14,,8.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.1,100,,278.184,Percent of Total Billed Charges,100% of Total Billed Charges,26.61,5056,
117761 SUT PROL MO-6 PROL 1 36,32190243,CDM,272,RC,,,Outpatient,,,183.44,110.06,,110.06,60,,1202.672,Percent of Total Billed Charges,60% of Total Billed Charges,82.55,45,,97.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.36,28,,30.448,Percent of Total Billed Charges,28% of Total Billed Charges,5086.64,32,,40.704,Percent of Total Billed Charges,32% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,66.04,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,66.04,36,,39.144,Percent of Total Billed Charges,36% Total Bille Charges,66.04,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,110.06,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.44,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,26.45,14.42,,282.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.58,75,,148.944,Percent of Total Billed Charges,75% of Total Billed Charges,91.72,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,91.72,50,,543.6,Percent of Total Billed Charges,50% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.72,50,,543.6,Percent of Total Billed Charges,50% of Total Billed Charges,91.72,50,,543.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.41,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,25.68,14,,274.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.44,100,,198.592,Percent of Total Billed Charges,100% of Total Billed Charges,25.68,5086.64,
117840 MESH PROLENE 6X6,32190245,CDM,278,RC,C1781,HCPCS,Outpatient,,,216.71,130.03,,691.14,110,,1719.84,Percent of Total Billed Charges,110% of Total Billed Charges,97.52,45,,72.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.68,28,,46.248,Percent of Total Billed Charges,28% of Total Billed Charges,5086.64,32,,40.768,Percent of Total Billed Charges,32% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,78.02,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,78.02,36,,59.464,Percent of Total Billed Charges,36% Total Bille Charges,78.02,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.71,100,,100.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,14.42,,124.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.37,80,,1691.288,Percent of Total Billed Charges,80% of Total Billed Charges,108.36,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,108.36,50,,185.784,Percent of Total Billed Charges,50% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.36,50,,185.784,Percent of Total Billed Charges,50% of Total Billed Charges,108.36,50,,185.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.7,70,,117.04,Percent of Total Billed Charges,70% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,30.34,14,,121.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.71,100,,2114.112,Percent of Total Billed Charges,100% of Total Billed Charges,30.34,5086.64,
117857 SUT CHRMC 0 18IN MP BRN,32190246,CDM,272,RC,,,Outpatient,,,88.35,53.01,,53.01,60,,1719.84,Percent of Total Billed Charges,60% of Total Billed Charges,39.76,45,,192.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.74,28,,49.784,Percent of Total Billed Charges,28% of Total Billed Charges,4.8,32,,40.832,Percent of Total Billed Charges,32% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.81,36,,64.008,Percent of Total Billed Charges,36% of Total Billed Charges,31.81,36,,64.008,Percent of Total Billed Charges,36% Total Bille Charges,31.81,36,,64.008,Percent of Total Billed Charges,36% of Total Billed Charges,53.01,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.35,100,,30.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.26,75,,189.64,Percent of Total Billed Charges,75% of Total Billed Charges,44.18,50,,543.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,50,,466.264,Percent of Total Billed Charges,50% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.18,50,,466.264,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,50,,466.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.85,70,,653.592,Percent of Total Billed Charges,70% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.35,100,,252.856,Percent of Total Billed Charges,100% of Total Billed Charges,4.8,88.35,
117870 MANIPULATOR INJ UTER 6.,32190247,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,633.048,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,148.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,4.86,32,,40.832,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,215.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,71.856,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,185.784,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,31.088,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,31.088,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,31.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,173.264,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,95.808,Percent of Total Billed Charges,100% of Total Billed Charges,4.86,293.15,
124099 CATH URET POLYVI CL 5FR,32190255,CDM,272,RC,C1757,HCPCS,Outpatient,,,51.66,31.00,,16.33,100,,239.808,Fee Schedule,100% of Aetna Fee Schedule,23.25,45,,148.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.46,28,,19.216,Percent of Total Billed Charges,28% of Total Billed Charges,4.9,32,,40.856,Percent of Total Billed Charges,32% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,36,,24.712,Percent of Total Billed Charges,36% of Total Billed Charges,18.6,36,,24.712,Percent of Total Billed Charges,36% Total Bille Charges,18.6,36,,24.712,Percent of Total Billed Charges,36% of Total Billed Charges,31,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.66,100,,161.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.75,75,,927.168,Percent of Total Billed Charges,75% of Total Billed Charges,25.83,50,,466.264,Percent of Total Billed Charges,50% of Total Billed Charges,25.83,50,,979.712,Percent of Total Billed Charges,50% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.83,50,,979.712,Percent of Total Billed Charges,50% of Total Billed Charges,25.83,50,,979.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.16,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.66,100,,1236.224,Percent of Total Billed Charges,100% of Total Billed Charges,4.9,51.66,
125753 STAPLER 34CM 60MM,32190256,CDM,272,RC,,,Outpatient,,,1433.97,860.38,,860.38,60,,2045.92,Percent of Total Billed Charges,60% of Total Billed Charges,645.29,45,,25.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.51,28,,23.512,Percent of Total Billed Charges,28% of Total Billed Charges,4.91,32,,40.856,Percent of Total Billed Charges,32% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,516.23,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,516.23,36,,30.232,Percent of Total Billed Charges,36% Total Bille Charges,516.23,36,,30.232,Percent of Total Billed Charges,36% of Total Billed Charges,860.38,60,,55.088,Percent of Total Billed Charges,60% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1433.97,100,,427.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,206.78,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1075.48,75,,1013.584,Percent of Total Billed Charges,75% of Total Billed Charges,716.99,50,,31.088,Percent of Total Billed Charges,50% of Total Billed Charges,716.99,50,,433.2,Percent of Total Billed Charges,50% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,716.99,50,,433.2,Percent of Total Billed Charges,50% of Total Billed Charges,716.99,50,,433.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1003.78,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,200.76,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1433.97,100,,1266.984,Percent of Total Billed Charges,100% of Total Billed Charges,4.91,1433.97,
162631 CATH VENT PERI BACTISL,32190272,CDM,272,RC,C1729,HCPCS,Outpatient,,,3070.46,1842.28,,11.1,100,,3511.92,Fee Schedule,100% of Aetna Fee Schedule,1381.71,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.73,28,,30.712,Percent of Total Billed Charges,28% of Total Billed Charges,4.91,32,,4133.184,Percent of Total Billed Charges,32% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,1105.37,36,,39.488,Percent of Total Billed Charges,36% of Total Billed Charges,1105.37,36,,39.488,Percent of Total Billed Charges,36% Total Bille Charges,1105.37,36,,39.488,Percent of Total Billed Charges,36% of Total Billed Charges,1842.28,60,,55.088,Percent of Total Billed Charges,60% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3070.46,100,,329.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,442.76,14.42,,33.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2302.85,75,,6284.616,Percent of Total Billed Charges,75% of Total Billed Charges,1535.23,50,,979.712,Percent of Total Billed Charges,50% of Total Billed Charges,1535.23,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1535.23,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,1535.23,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2149.32,70,,282.912,Percent of Total Billed Charges,70% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,429.86,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.46,100,,7855.768,Percent of Total Billed Charges,100% of Total Billed Charges,4.91,3070.46,
162720 CATH QINTON 62.5CM,32190273,CDM,278,RC,C1750,HCPCS,Outpatient,,,827.88,496.73,,1425.57,110,,2047.184,Percent of Total Billed Charges,110% of Total Billed Charges,372.55,45,,24.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.81,28,,30.808,Percent of Total Billed Charges,28% of Total Billed Charges,4.91,32,,4172.28,Percent of Total Billed Charges,32% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,298.04,36,,39.608,Percent of Total Billed Charges,36% of Total Billed Charges,298.04,36,,39.608,Percent of Total Billed Charges,36% Total Bille Charges,298.04,36,,39.608,Percent of Total Billed Charges,36% of Total Billed Charges,455.33,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,827.88,100,,329.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,119.38,14.42,,725.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.3,80,,2620.96,Percent of Total Billed Charges,80% of Total Billed Charges,413.94,50,,433.2,Percent of Total Billed Charges,50% of Total Billed Charges,413.94,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.94,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,413.94,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.52,70,,460.608,Percent of Total Billed Charges,70% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,115.9,14,,704.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,827.88,100,,3276.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.91,1425.57,
163054 SUT VCRL V130-4 8-0 9IN,32190274,CDM,272,RC,,,Outpatient,,,974.6,584.76,,584.76,60,,3163.232,Percent of Total Billed Charges,60% of Total Billed Charges,438.57,45,,129.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,79.6,Percent of Total Billed Charges,28% of Total Billed Charges,4.94,32,,4215.848,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,102.344,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,102.344,Percent of Total Billed Charges,36% of Total Billed Charges,584.76,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,56.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,1202.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.95,75,,1247.488,Percent of Total Billed Charges,75% of Total Billed Charges,487.3,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,478.8,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,1167.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,4.94,974.6,
177773 CATH URET OPN END 6FRX7,32190288,CDM,272,RC,C1758,HCPCS,Outpatient,,,77.59,46.55,,69,100,,3163.232,Fee Schedule,100% of Aetna Fee Schedule,34.92,45,,97.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.73,28,,70.696,Percent of Total Billed Charges,28% of Total Billed Charges,4.95,32,,4215.848,Percent of Total Billed Charges,32% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,27.93,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,27.93,36,,90.888,Percent of Total Billed Charges,36% Total Bille Charges,27.93,36,,90.888,Percent of Total Billed Charges,36% of Total Billed Charges,46.55,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.59,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14.42,,1104.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.19,75,,175.888,Percent of Total Billed Charges,75% of Total Billed Charges,38.8,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,38.8,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,38.8,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.31,70,,1063.144,Percent of Total Billed Charges,70% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,1072.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.59,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,4.95,77.59,
177823 SUT ETHBND EXCL 0 18IN,32190290,CDM,272,RC,,,Outpatient,,,82.49,49.49,,49.49,60,,5976.368,Percent of Total Billed Charges,60% of Total Billed Charges,37.12,45,,284.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.1,28,,57.44,Percent of Total Billed Charges,28% of Total Billed Charges,4.96,32,,4224,Percent of Total Billed Charges,32% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.7,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,29.7,36,,73.856,Percent of Total Billed Charges,36% Total Bille Charges,29.7,36,,73.856,Percent of Total Billed Charges,36% of Total Billed Charges,49.49,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.49,100,,53.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14.42,,133.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.87,75,,608.152,Percent of Total Billed Charges,75% of Total Billed Charges,41.25,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,41.25,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.25,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,41.25,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.74,70,,321.44,Percent of Total Billed Charges,70% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,11.55,14,,129.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.49,100,,760.192,Percent of Total Billed Charges,100% of Total Billed Charges,4.96,82.49,
178185 CATH KT CHOLGM KARLN 4F,32190292,CDM,272,RC,,,Outpatient,,,347.73,208.64,,208.64,60,,3264.344,Percent of Total Billed Charges,60% of Total Billed Charges,156.48,45,,38.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.36,28,,16.704,Percent of Total Billed Charges,28% of Total Billed Charges,4.97,32,,4233.12,Percent of Total Billed Charges,32% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,125.18,36,,21.472,Percent of Total Billed Charges,36% of Total Billed Charges,125.18,36,,21.472,Percent of Total Billed Charges,36% Total Bille Charges,125.18,36,,21.472,Percent of Total Billed Charges,36% of Total Billed Charges,208.64,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.73,100,,287.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,50.14,14.42,,74.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.8,75,,869.76,Percent of Total Billed Charges,75% of Total Billed Charges,173.87,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,173.87,50,,2515.264,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.87,50,,2515.264,Percent of Total Billed Charges,50% of Total Billed Charges,173.87,50,,2515.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.41,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,48.68,14,,72.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.73,100,,1087.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.97,347.73,
185351 SLEEVE SCD XL KNEE LNGT,32190295,CDM,271,RC,,,Outpatient,,,248.24,148.94,,148.94,60,,4236.96,Percent of Total Billed Charges,60% of Total Billed Charges,111.71,45,,405.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.51,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,5.02,32,,4276.224,Percent of Total Billed Charges,32% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,89.37,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,89.37,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,89.37,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,148.94,60,,280.352,Percent of Total Billed Charges,60% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.24,100,,215.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,35.8,14.42,,55.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.18,75,,278.68,Percent of Total Billed Charges,75% of Total Billed Charges,124.12,50,,117.616,Percent of Total Billed Charges,50% of Total Billed Charges,124.12,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.12,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,124.12,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.77,70,,666.8,Percent of Total Billed Charges,70% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14,,54.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.24,100,,371.568,Percent of Total Billed Charges,100% of Total Billed Charges,5.02,248.24,
191127 GRAFTON PUTTY 5CC,32190296,CDM,278,RC,C1713,HCPCS,Outpatient,,,2642.64,1585.58,,3224.16,110,,45.304,Percent of Total Billed Charges,110% of Total Billed Charges,1189.19,45,,153.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,739.94,28,,25.712,Percent of Total Billed Charges,28% of Total Billed Charges,5.02,32,,4.104,Percent of Total Billed Charges,32% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,951.35,36,,33.056,Percent of Total Billed Charges,36% of Total Billed Charges,951.35,36,,33.056,Percent of Total Billed Charges,36% Total Bille Charges,951.35,36,,33.056,Percent of Total Billed Charges,36% of Total Billed Charges,1453.45,55,,100.208,Percent of Total Billed Charges,55% Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2642.64,100,,631.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,381.07,14.42,,126.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2114.11,80,,699.392,Percent of Total Billed Charges,80% of Total Billed Charges,1321.32,50,,2515.264,Percent of Total Billed Charges,50% of Total Billed Charges,1321.32,50,,3831.352,Percent of Total Billed Charges,50% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1321.32,50,,3831.352,Percent of Total Billed Charges,50% of Total Billed Charges,1321.32,50,,3831.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1849.85,70,,966,Percent of Total Billed Charges,70% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,369.97,14,,122.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2642.64,100,,932.52,Percent of Total Billed Charges,100% of Total Billed Charges,5.02,3224.16,
203742 TIP MANIP UTER RUMI 6.7,32190301,CDM,272,RC,,,Outpatient,,,316.07,189.64,,189.64,60,,2700.536,Percent of Total Billed Charges,60% of Total Billed Charges,142.23,45,,680.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.5,28,,25.712,Percent of Total Billed Charges,28% of Total Billed Charges,5.06,32,,4.104,Percent of Total Billed Charges,32% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,113.79,36,,33.056,Percent of Total Billed Charges,36% of Total Billed Charges,113.79,36,,33.056,Percent of Total Billed Charges,36% Total Bille Charges,113.79,36,,33.056,Percent of Total Billed Charges,36% of Total Billed Charges,189.64,60,,136.192,Percent of Total Billed Charges,60% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.07,100,,85.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,45.58,14.42,,434.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.05,75,,46.632,Percent of Total Billed Charges,75% of Total Billed Charges,158.04,50,,4169.896,Percent of Total Billed Charges,50% of Total Billed Charges,158.04,50,,461.96,Percent of Total Billed Charges,50% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.04,50,,461.96,Percent of Total Billed Charges,50% of Total Billed Charges,158.04,50,,461.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.25,70,,385.44,Percent of Total Billed Charges,70% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,14,,421.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.07,100,,62.176,Percent of Total Billed Charges,100% of Total Billed Charges,5.06,316.07,
217588 PDO 2 24CM 24CM 26MM DI,32190307,CDM,272,RC,,,Outpatient,,,119.76,71.86,,71.86,60,,4592.064,Percent of Total Billed Charges,60% of Total Billed Charges,53.89,45,,680.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.53,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,5.11,32,,4.136,Percent of Total Billed Charges,32% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,43.11,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,43.11,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,43.11,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,71.86,60,,544.792,Percent of Total Billed Charges,60% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.76,100,,901.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,17.27,14.42,,193.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.82,75,,1469.56,Percent of Total Billed Charges,75% of Total Billed Charges,59.88,50,,3831.352,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,50,,259.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,50,,259.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,50,,259.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.83,70,,966,Percent of Total Billed Charges,70% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,16.77,14,,188.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.76,100,,1959.416,Percent of Total Billed Charges,100% of Total Billed Charges,5.11,119.76,
226798 STONE BASKET RETRIEVAL,32190309,CDM,272,RC,,,Outpatient,,,1545.28,927.17,,927.17,60,,177.464,Percent of Total Billed Charges,60% of Total Billed Charges,695.38,45,,680.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.68,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,5.11,32,,4.136,Percent of Total Billed Charges,32% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,556.3,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,556.3,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,556.3,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,927.17,60,,119.64,Percent of Total Billed Charges,60% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1545.28,100,,342.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,222.83,14.42,,241.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1158.96,75,,649.8,Percent of Total Billed Charges,75% of Total Billed Charges,772.64,50,,461.96,Percent of Total Billed Charges,50% of Total Billed Charges,772.64,50,,193.28,Percent of Total Billed Charges,50% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,772.64,50,,193.28,Percent of Total Billed Charges,50% of Total Billed Charges,772.64,50,,193.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1081.7,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,216.34,14,,234.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1545.28,100,,866.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.11,1545.28,
245770 ANCHOR CORKSCREW FT 5.5,32190311,CDM,278,RC,C1713,HCPCS,Outpatient,,,1583.73,950.24,,2059.36,110,,470.448,Percent of Total Billed Charges,110% of Total Billed Charges,712.68,45,,913.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.44,28,,130.832,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.16,Percent of Total Billed Charges,32% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.14,36,,168.208,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,36,,168.208,Percent of Total Billed Charges,36% Total Bille Charges,570.14,36,,168.208,Percent of Total Billed Charges,36% of Total Billed Charges,871.05,55,,330.24,Percent of Total Billed Charges,55% Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.73,100,,1512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,228.37,14.42,,224.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1266.98,80,,51.304,Percent of Total Billed Charges,80% of Total Billed Charges,791.87,50,,259.2,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,439.024,Percent of Total Billed Charges,50% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.87,50,,439.024,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,439.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.61,70,,105.592,Percent of Total Billed Charges,70% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,218.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1583.73,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,48,2059.36,
248615 BAND GAST LAPSCP CRV AD,32190312,CDM,278,RC,,,Outpatient,,,9819.71,5891.83,,10801.68,110,,32.344,Percent of Total Billed Charges,110% of Total Billed Charges,4418.87,45,,680.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2749.52,28,,63.56,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.176,Percent of Total Billed Charges,32% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,3535.1,36,,81.72,Percent of Total Billed Charges,36% of Total Billed Charges,3535.1,36,,81.72,Percent of Total Billed Charges,36% Total Bille Charges,3535.1,36,,81.72,Percent of Total Billed Charges,36% of Total Billed Charges,5400.84,55,,393.24,Percent of Total Billed Charges,55% Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9819.71,100,,1512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1416,14.42,,182.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7855.77,80,,56.632,Percent of Total Billed Charges,80% of Total Billed Charges,4909.86,50,,193.28,Percent of Total Billed Charges,50% of Total Billed Charges,4909.86,50,,1506.072,Percent of Total Billed Charges,50% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4909.86,50,,1506.072,Percent of Total Billed Charges,50% of Total Billed Charges,4909.86,50,,1506.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6873.8,70,,42.672,Percent of Total Billed Charges,70% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,1374.76,14,,177.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9819.71,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,48,10801.68,
276376 PUTTY GRAFTN 10CC JAR D,32190314,CDM,278,RC,C1713,HCPCS,Outpatient,,,4095.25,2457.15,,4822.04,110,,694.848,Percent of Total Billed Charges,110% of Total Billed Charges,1842.86,45,,1044.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1146.67,28,,254.24,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.176,Percent of Total Billed Charges,32% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,1474.29,36,,326.88,Percent of Total Billed Charges,36% of Total Billed Charges,1474.29,36,,326.88,Percent of Total Billed Charges,36% Total Bille Charges,1474.29,36,,326.88,Percent of Total Billed Charges,36% of Total Billed Charges,2252.39,55,,117.24,Percent of Total Billed Charges,55% Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4095.25,100,,1512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,590.54,14.42,,298.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3276.2,80,,56.632,Percent of Total Billed Charges,80% of Total Billed Charges,2047.63,50,,439.024,Percent of Total Billed Charges,50% of Total Billed Charges,2047.63,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2047.63,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,2047.63,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2866.68,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,573.34,14,,290.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4095.25,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,48,4822.04,
279616 PORT INFUS IMP POWERPOR,32190315,CDM,278,RC,C1788,HCPCS,Outpatient,,,1949.2,1169.52,,2752.93,110,,51.528,Percent of Total Billed Charges,110% of Total Billed Charges,877.14,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,55.832,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.176,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,71.784,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,71.784,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,71.784,Percent of Total Billed Charges,36% of Total Billed Charges,1072.06,55,,41.16,Percent of Total Billed Charges,55% Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,2029.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,196.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1559.36,80,,56.632,Percent of Total Billed Charges,80% of Total Billed Charges,974.6,50,,1506.072,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,836.208,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,836.208,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,836.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,190.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,48,2752.93,
284303 SUT FW FIBERLOOP 2 15IN,32190317,CDM,272,RC,,,Outpatient,,,293.15,175.89,,175.89,60,,2808.6,Percent of Total Billed Charges,60% of Total Billed Charges,131.92,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,154.112,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.176,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,198.144,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,198.144,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,198.144,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,79.56,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,1512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,176.416,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,672.48,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,779.232,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,779.232,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,779.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,235.224,Percent of Total Billed Charges,100% of Total Billed Charges,41.04,293.15,
310024 KIT BIO-TENODESIS DISP,32190321,CDM,278,RC,C1713,HCPCS,Outpatient,,,950.24,570.14,,1362.52,110,,2808.6,Percent of Total Billed Charges,110% of Total Billed Charges,427.61,45,,292.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.07,28,,183.512,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.176,Percent of Total Billed Charges,32% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,342.09,36,,235.944,Percent of Total Billed Charges,36% of Total Billed Charges,342.09,36,,235.944,Percent of Total Billed Charges,36% Total Bille Charges,342.09,36,,235.944,Percent of Total Billed Charges,36% of Total Billed Charges,522.63,55,,105.36,Percent of Total Billed Charges,55% Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,950.24,100,,2320.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,137.02,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.19,80,,3772.888,Percent of Total Billed Charges,80% of Total Billed Charges,475.12,50,,836.208,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,475.12,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.17,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,950.24,100,,5030.52,Percent of Total Billed Charges,100% of Total Billed Charges,48,1362.52,
313134 DURAGUARD BAXTER,32190322,CDM,278,RC,C1763,HCPCS,Outpatient,,,1359,815.40,,1903.09,110,,2808.6,Percent of Total Billed Charges,110% of Total Billed Charges,611.55,45,,142.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.52,28,,54.712,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.24,Percent of Total Billed Charges,32% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,489.24,36,,70.344,Percent of Total Billed Charges,36% of Total Billed Charges,489.24,36,,70.344,Percent of Total Billed Charges,36% Total Bille Charges,489.24,36,,70.344,Percent of Total Billed Charges,36% of Total Billed Charges,747.45,55,,179.28,Percent of Total Billed Charges,55% Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1359,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.97,14.42,,103.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1087.2,80,,6671.824,Percent of Total Billed Charges,80% of Total Billed Charges,679.5,50,,779.232,Percent of Total Billed Charges,50% of Total Billed Charges,679.5,50,,1036,Percent of Total Billed Charges,50% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,679.5,50,,1036,Percent of Total Billed Charges,50% of Total Billed Charges,679.5,50,,1036,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,951.3,70,,1411.2,Percent of Total Billed Charges,70% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,190.26,14,,100.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1359,100,,8339.784,Percent of Total Billed Charges,100% of Total Billed Charges,48,1903.09,
313362 INTRO SET COAXIAL 8F,32190323,CDM,272,RC,C1894,HCPCS,Outpatient,,,464.46,278.68,,82.29,100,,2808.6,Fee Schedule,100% of Aetna Fee Schedule,209.01,45,,61.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.05,28,,19.208,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.24,Percent of Total Billed Charges,32% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,167.21,36,,24.696,Percent of Total Billed Charges,36% of Total Billed Charges,167.21,36,,24.696,Percent of Total Billed Charges,36% Total Bille Charges,167.21,36,,24.696,Percent of Total Billed Charges,36% of Total Billed Charges,278.68,60,,179.28,Percent of Total Billed Charges,60% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,464.46,100,,701.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,66.98,14.42,,149.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.35,75,,6130.16,Percent of Total Billed Charges,75% of Total Billed Charges,232.23,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,232.23,50,,680.272,Percent of Total Billed Charges,50% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.23,50,,680.272,Percent of Total Billed Charges,50% of Total Billed Charges,232.23,50,,680.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.12,70,,442.68,Percent of Total Billed Charges,70% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,65.02,14,,144.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,464.46,100,,7662.704,Percent of Total Billed Charges,100% of Total Billed Charges,48,464.46,
FORCEPS ISOCOOL TIP 2.0,32190325,CDM,272,RC,A4649,HCPCS,Outpatient,,,1165.65,699.39,,699.39,60,,3698.264,Percent of Total Billed Charges,60% of Total Billed Charges,524.54,45,,570.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.38,28,,37.128,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.256,Percent of Total Billed Charges,32% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,419.63,36,,47.736,Percent of Total Billed Charges,36% of Total Billed Charges,419.63,36,,47.736,Percent of Total Billed Charges,36% Total Bille Charges,419.63,36,,47.736,Percent of Total Billed Charges,36% of Total Billed Charges,699.39,60,,49.68,Percent of Total Billed Charges,60% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1165.65,100,,651.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,168.09,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,874.24,75,,692.944,Percent of Total Billed Charges,75% of Total Billed Charges,582.83,50,,1036,Percent of Total Billed Charges,50% of Total Billed Charges,582.83,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,582.83,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,582.83,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,815.96,70,,362.24,Percent of Total Billed Charges,70% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,163.19,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1165.65,100,,923.92,Percent of Total Billed Charges,100% of Total Billed Charges,48,1165.65,
324247 SUT VCRL + 1 18IN CT1 M,32190329,CDM,272,RC,,,Outpatient,,,77.72,46.63,,46.63,60,,232.176,Percent of Total Billed Charges,60% of Total Billed Charges,34.97,45,,219.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.76,28,,49.168,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.272,Percent of Total Billed Charges,32% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,27.98,36,,63.216,Percent of Total Billed Charges,36% of Total Billed Charges,27.98,36,,63.216,Percent of Total Billed Charges,36% Total Bille Charges,27.98,36,,63.216,Percent of Total Billed Charges,36% of Total Billed Charges,46.63,60,,126.84,Percent of Total Billed Charges,60% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.72,100,,316.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,11.21,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.29,75,,388.8,Percent of Total Billed Charges,75% of Total Billed Charges,38.86,50,,680.272,Percent of Total Billed Charges,50% of Total Billed Charges,38.86,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.86,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,38.86,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.4,70,,362.24,Percent of Total Billed Charges,70% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,10.88,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.72,100,,518.4,Percent of Total Billed Charges,100% of Total Billed Charges,10.88,77.72,
333786 DEVICE LAP LIGASURE 5MM,32190331,CDM,272,RC,,,Outpatient,,,2449.27,1469.56,,1469.56,60,,863.768,Percent of Total Billed Charges,60% of Total Billed Charges,1102.17,45,,182.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,685.8,28,,83.664,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.344,Percent of Total Billed Charges,32% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,881.74,36,,107.568,Percent of Total Billed Charges,36% of Total Billed Charges,881.74,36,,107.568,Percent of Total Billed Charges,36% Total Bille Charges,881.74,36,,107.568,Percent of Total Billed Charges,36% of Total Billed Charges,1469.56,60,,109.92,Percent of Total Billed Charges,60% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2449.27,100,,136.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,353.18,14.42,,588.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1836.95,75,,289.92,Percent of Total Billed Charges,75% of Total Billed Charges,1224.64,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,1224.64,50,,360.176,Percent of Total Billed Charges,50% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1224.64,50,,360.176,Percent of Total Billed Charges,50% of Total Billed Charges,1224.64,50,,360.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1714.49,70,,76.4,Percent of Total Billed Charges,70% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,342.9,14,,571.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2449.27,100,,386.56,Percent of Total Billed Charges,100% of Total Billed Charges,48,2449.27,
334351 TUBING HYSTEROSCOPY DOL,32190332,CDM,272,RC,,,Outpatient,,,1083,649.80,,649.8,60,,1805.6,Percent of Total Billed Charges,60% of Total Billed Charges,487.35,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.24,28,,83.664,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,4.344,Percent of Total Billed Charges,32% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,389.88,36,,107.568,Percent of Total Billed Charges,36% of Total Billed Charges,389.88,36,,107.568,Percent of Total Billed Charges,36% Total Bille Charges,389.88,36,,107.568,Percent of Total Billed Charges,36% of Total Billed Charges,649.8,60,,191.4,Percent of Total Billed Charges,60% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1083,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,156.17,14.42,,153.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.25,75,,702.432,Percent of Total Billed Charges,75% of Total Billed Charges,541.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,541.5,50,,516.728,Percent of Total Billed Charges,50% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.5,50,,516.728,Percent of Total Billed Charges,50% of Total Billed Charges,541.5,50,,516.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,758.1,70,,270.928,Percent of Total Billed Charges,70% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,151.62,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083,100,,878.04,Percent of Total Billed Charges,100% of Total Billed Charges,48,1083,
334359 ELCTRD LOOP 15X12MM 11C,32190333,CDM,272,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,23.184,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,40.96,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,29.808,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,254.16,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,100,,488.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,153.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,2259.112,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,360.176,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,875.368,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,149.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,3012.144,Percent of Total Billed Charges,100% of Total Billed Charges,11.97,85.5,
334366 ELCTRD LOOP 20X15MM 11C,32190334,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,211.2,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,158.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,59.192,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.024,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,76.104,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,76.104,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,76.104,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,406.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,191.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,1075.96,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,516.728,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,145.6,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,185.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,1344.952,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,94.38,
334369 ELCTRD LOOP 25X22MM 11C,32190335,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,384.96,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,297,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,51.296,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.08,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,65.952,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,65.952,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,65.952,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,171.48,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,89.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,1254.312,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,2039.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,2039.4,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,2039.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,654.28,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,87.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,1672.416,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,94.38,
334370 ELCTRD LOOP 10X10MM 11C,32190336,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,297,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,89.32,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.08,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,114.84,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,114.84,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,114.84,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,298.92,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,95.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,1246.768,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,716.064,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,92.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,1558.464,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,94.38,
345619 HANDLE SIN GUID RELEVA,32190339,CDM,272,RC,,,Outpatient,,,294.03,176.42,,176.42,60,,287.616,Percent of Total Billed Charges,60% of Total Billed Charges,132.31,45,,289.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.33,28,,118.608,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.256,Percent of Total Billed Charges,32% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,105.85,36,,152.496,Percent of Total Billed Charges,36% of Total Billed Charges,105.85,36,,152.496,Percent of Total Billed Charges,36% Total Bille Charges,105.85,36,,152.496,Percent of Total Billed Charges,36% of Total Billed Charges,176.42,60,,360.752,Percent of Total Billed Charges,60% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.03,100,,352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.52,75,,1013.584,Percent of Total Billed Charges,75% of Total Billed Charges,147.02,50,,2039.4,Percent of Total Billed Charges,50% of Total Billed Charges,147.02,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.02,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,147.02,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.82,70,,1364.44,Percent of Total Billed Charges,70% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.03,100,,1266.984,Percent of Total Billed Charges,100% of Total Billed Charges,41.16,294.03,
345697 CATH GD SIN RELVA FLX S,32190340,CDM,272,RC,C1887,HCPCS,Outpatient,,,6288.15,3772.89,,43.86,100,,11484.648,Fee Schedule,100% of Aetna Fee Schedule,2829.67,45,,289.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1760.68,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.32,Percent of Total Billed Charges,32% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,2263.73,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,2263.73,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,2263.73,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,3772.89,60,,1784.176,Percent of Total Billed Charges,60% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6288.15,100,,660,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,906.75,14.42,,1349.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4716.11,75,,1657.6,Percent of Total Billed Charges,75% of Total Billed Charges,3144.08,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,3144.08,50,,662.728,Percent of Total Billed Charges,50% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3144.08,50,,662.728,Percent of Total Billed Charges,50% of Total Billed Charges,3144.08,50,,662.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4401.71,70,,293.392,Percent of Total Billed Charges,70% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,880.34,14,,1309.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6288.15,100,,2072,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,6288.15,
368373 LAP BAND AP STANDARD,32190341,CDM,278,RC,,,Outpatient,,,10424.73,6254.84,,11467.2,110,,287.616,Percent of Total Billed Charges,110% of Total Billed Charges,4691.13,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2918.92,28,,80.024,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.416,Percent of Total Billed Charges,32% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,3752.9,36,,102.888,Percent of Total Billed Charges,36% of Total Billed Charges,3752.9,36,,102.888,Percent of Total Billed Charges,36% Total Bille Charges,3752.9,36,,102.888,Percent of Total Billed Charges,36% of Total Billed Charges,5733.6,55,,41.528,Percent of Total Billed Charges,55% Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10424.73,100,,660,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1503.25,14.42,,195.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8339.78,80,,1020.408,Percent of Total Billed Charges,80% of Total Billed Charges,5212.37,50,,532.368,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,311.872,Percent of Total Billed Charges,50% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5212.37,50,,311.872,Percent of Total Billed Charges,50% of Total Billed Charges,5212.37,50,,311.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7297.31,70,,4433.52,Percent of Total Billed Charges,70% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,1459.46,14,,189.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10424.73,100,,1360.544,Percent of Total Billed Charges,100% of Total Billed Charges,48,11467.2,
368374 LAB BAND LOW PROFILE,32190342,CDM,278,RC,,,Outpatient,,,9578.38,5747.03,,10536.22,110,,287.616,Percent of Total Billed Charges,110% of Total Billed Charges,4310.27,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2681.95,28,,139.496,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.448,Percent of Total Billed Charges,32% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,3448.22,36,,179.352,Percent of Total Billed Charges,36% of Total Billed Charges,3448.22,36,,179.352,Percent of Total Billed Charges,36% Total Bille Charges,3448.22,36,,179.352,Percent of Total Billed Charges,36% of Total Billed Charges,5268.11,55,,329.296,Percent of Total Billed Charges,55% Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9578.38,100,,643.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1381.2,14.42,,71.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7662.7,80,,320.76,Percent of Total Billed Charges,80% of Total Billed Charges,4789.19,50,,662.728,Percent of Total Billed Charges,50% of Total Billed Charges,4789.19,50,,330.432,Percent of Total Billed Charges,50% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4789.19,50,,330.432,Percent of Total Billed Charges,50% of Total Billed Charges,4789.19,50,,330.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6704.87,70,,242.192,Percent of Total Billed Charges,70% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,1340.97,14,,69.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9578.38,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,48,10536.22,
373206 CSF EXT VENT DRAIN SYST,32190346,CDM,272,RC,C1729,HCPCS,Outpatient,,,1154.9,692.94,,11.1,100,,61517.88,Fee Schedule,100% of Aetna Fee Schedule,519.71,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.37,28,,361.32,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.448,Percent of Total Billed Charges,32% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,415.76,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,415.76,36,,464.56,Percent of Total Billed Charges,36% Total Bille Charges,415.76,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,692.94,60,,218.88,Percent of Total Billed Charges,60% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1154.9,100,,643.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,166.54,14.42,,27.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,866.18,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,577.45,50,,311.872,Percent of Total Billed Charges,50% of Total Billed Charges,577.45,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,577.45,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,577.45,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.43,70,,4295.2,Percent of Total Billed Charges,70% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,161.69,14,,26.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1154.9,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,1154.9,
376795 CALIBRATION TUBE FOR LA,32190352,CDM,272,RC,,,Outpatient,,,648,388.80,,388.8,60,,17173.184,Percent of Total Billed Charges,60% of Total Billed Charges,291.6,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.44,28,,168.352,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.776,Percent of Total Billed Charges,32% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,233.28,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,233.28,36,,216.448,Percent of Total Billed Charges,36% Total Bille Charges,233.28,36,,216.448,Percent of Total Billed Charges,36% of Total Billed Charges,388.8,60,,255.36,Percent of Total Billed Charges,60% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,648,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,93.44,14.42,,53.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486,75,,540.256,Percent of Total Billed Charges,75% of Total Billed Charges,324,50,,330.432,Percent of Total Billed Charges,50% of Total Billed Charges,324,50,,4677.92,Percent of Total Billed Charges,50% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324,50,,4677.92,Percent of Total Billed Charges,50% of Total Billed Charges,324,50,,4677.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.6,70,,77.144,Percent of Total Billed Charges,70% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648,100,,720.344,Percent of Total Billed Charges,100% of Total Billed Charges,48,648,
TUBE TRACH HYPERFLEX,32190353,CDM,272,RC,,,Outpatient,,,483.2,289.92,,289.92,60,,2253.224,Percent of Total Billed Charges,60% of Total Billed Charges,217.44,45,,289.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.3,28,,192.04,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.832,Percent of Total Billed Charges,32% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,173.95,36,,246.912,Percent of Total Billed Charges,36% of Total Billed Charges,173.95,36,,246.912,Percent of Total Billed Charges,36% Total Bille Charges,173.95,36,,246.912,Percent of Total Billed Charges,36% of Total Billed Charges,289.92,60,,336.816,Percent of Total Billed Charges,60% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.2,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,69.68,14.42,,128.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.4,75,,826.76,Percent of Total Billed Charges,75% of Total Billed Charges,241.6,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,241.6,50,,676.552,Percent of Total Billed Charges,50% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.6,50,,676.552,Percent of Total Billed Charges,50% of Total Billed Charges,241.6,50,,676.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.24,70,,77.144,Percent of Total Billed Charges,70% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,14,,124.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483.2,100,,1033.448,Percent of Total Billed Charges,100% of Total Billed Charges,48,483.2,
381564 CHIPS MTF CANCELLOUS 15,32190354,CDM,278,RC,C1713,HCPCS,Outpatient,,,1097.55,658.53,,1524.57,110,,2281.784,Percent of Total Billed Charges,110% of Total Billed Charges,493.9,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.31,28,,153.672,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,395.12,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,395.12,36,,197.576,Percent of Total Billed Charges,36% Total Bille Charges,395.12,36,,197.576,Percent of Total Billed Charges,36% of Total Billed Charges,603.65,55,,182.4,Percent of Total Billed Charges,55% Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1097.55,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,158.27,14.42,,8.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,878.04,80,,498.56,Percent of Total Billed Charges,80% of Total Billed Charges,548.78,50,,4677.92,Percent of Total Billed Charges,50% of Total Billed Charges,548.78,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.78,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,548.78,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.29,70,,186.816,Percent of Total Billed Charges,70% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.66,14,,7.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.55,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,48,1524.57,
385106 CATH RELIEVA SINUS GUID,32190355,CDM,272,RC,C1887,HCPCS,Outpatient,,,3765.18,2259.11,,43.86,100,,2281.784,Fee Schedule,100% of Aetna Fee Schedule,1694.33,45,,288.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1054.25,28,,832.616,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,1355.46,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,1355.46,36,,1070.504,Percent of Total Billed Charges,36% Total Bille Charges,1355.46,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,2259.11,60,,400.608,Percent of Total Billed Charges,60% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3765.18,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,542.94,14.42,,14.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2823.89,75,,498.56,Percent of Total Billed Charges,75% of Total Billed Charges,1882.59,50,,676.552,Percent of Total Billed Charges,50% of Total Billed Charges,1882.59,50,,95.36,Percent of Total Billed Charges,50% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1882.59,50,,95.36,Percent of Total Billed Charges,50% of Total Billed Charges,1882.59,50,,95.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2635.63,70,,478.8,Percent of Total Billed Charges,70% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,527.13,14,,14.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3765.18,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,3765.18,
399685 ANCHOR ARTHREX BIOCOMP,32190360,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681.19,1008.71,,2166.57,110,,9193.696,Percent of Total Billed Charges,110% of Total Billed Charges,756.54,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,470.73,28,,697.32,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,605.23,36,,896.56,Percent of Total Billed Charges,36% of Total Billed Charges,605.23,36,,896.56,Percent of Total Billed Charges,36% Total Bille Charges,605.23,36,,896.56,Percent of Total Billed Charges,36% of Total Billed Charges,924.65,55,,319.968,Percent of Total Billed Charges,55% Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1681.19,100,,643.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,242.43,14.42,,137.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344.95,80,,3263.04,Percent of Total Billed Charges,80% of Total Billed Charges,840.6,50,,247,Percent of Total Billed Charges,50% of Total Billed Charges,840.6,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840.6,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,840.6,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.83,70,,688.8,Percent of Total Billed Charges,70% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,235.37,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1681.19,100,,4078.8,Percent of Total Billed Charges,100% of Total Billed Charges,48,2166.57,
411246 SINUS ILLUMINATION SYST,32190369,CDM,272,RC,,,Outpatient,,,2090.52,1254.31,,1254.31,60,,1147.632,Percent of Total Billed Charges,60% of Total Billed Charges,940.73,45,,478.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585.35,28,,102.144,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,752.59,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,752.59,36,,131.328,Percent of Total Billed Charges,36% Total Bille Charges,752.59,36,,131.328,Percent of Total Billed Charges,36% of Total Billed Charges,1254.31,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2090.52,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,301.45,14.42,,61.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1567.89,75,,851.792,Percent of Total Billed Charges,75% of Total Billed Charges,1045.26,50,,95.36,Percent of Total Billed Charges,50% of Total Billed Charges,1045.26,50,,444,Percent of Total Billed Charges,50% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1045.26,50,,444,Percent of Total Billed Charges,50% of Total Billed Charges,1045.26,50,,444,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1463.36,70,,902.984,Percent of Total Billed Charges,70% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,292.67,14,,59.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2090.52,100,,1064.736,Percent of Total Billed Charges,100% of Total Billed Charges,48,2090.52,
411373 COAPTITE INJECTABLE,32190370,CDM,278,RC,L8606,HCPCS,Outpatient,,,1948.08,1168.85,,2257.31,110,,8116.56,Percent of Total Billed Charges,110% of Total Billed Charges,876.64,45,,215.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.46,28,,119.168,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,701.31,36,,153.216,Percent of Total Billed Charges,36% of Total Billed Charges,701.31,36,,153.216,Percent of Total Billed Charges,36% Total Bille Charges,701.31,36,,153.216,Percent of Total Billed Charges,36% of Total Billed Charges,1071.44,55,,139.2,Percent of Total Billed Charges,55% Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1948.08,100,,641.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,280.91,14.42,,164.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1558.46,80,,851.792,Percent of Total Billed Charges,80% of Total Billed Charges,974.04,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,974.04,50,,28.32,Percent of Total Billed Charges,50% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.04,50,,28.32,Percent of Total Billed Charges,50% of Total Billed Charges,974.04,50,,28.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1363.66,70,,1264.592,Percent of Total Billed Charges,70% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,272.73,14,,159.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1948.08,100,,1064.736,Percent of Total Billed Charges,100% of Total Billed Charges,48,2257.31,
411380 ANCHOR SUT 3X14MM FIBER,32190371,CDM,278,RC,C1713,HCPCS,Outpatient,,,1583.73,950.24,,2059.36,110,,132,Percent of Total Billed Charges,110% of Total Billed Charges,712.68,45,,3670.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.44,28,,157.184,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.84,Percent of Total Billed Charges,32% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,570.14,36,,202.088,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,36,,202.088,Percent of Total Billed Charges,36% Total Bille Charges,570.14,36,,202.088,Percent of Total Billed Charges,36% of Total Billed Charges,871.05,55,,75.36,Percent of Total Billed Charges,55% Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.73,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,228.37,14.42,,243.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1266.98,80,,1060.368,Percent of Total Billed Charges,80% of Total Billed Charges,791.87,50,,444,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.87,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.61,70,,707.512,Percent of Total Billed Charges,70% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,236.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1583.73,100,,1325.456,Percent of Total Billed Charges,100% of Total Billed Charges,48,2059.36,
419071 SYS URETHRAL SUPPORT,32190375,CDM,278,RC,C1771,HCPCS,Outpatient,,,2590,1554.00,,2936.91,110,,2151.52,Percent of Total Billed Charges,110% of Total Billed Charges,1165.5,45,,215.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,725.2,28,,85.12,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.872,Percent of Total Billed Charges,32% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,932.4,36,,109.44,Percent of Total Billed Charges,36% of Total Billed Charges,932.4,36,,109.44,Percent of Total Billed Charges,36% Total Bille Charges,932.4,36,,109.44,Percent of Total Billed Charges,36% of Total Billed Charges,1424.5,55,,100.8,Percent of Total Billed Charges,55% Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2590,100,,1062.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,373.48,14.42,,32.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2072,80,,498.992,Percent of Total Billed Charges,80% of Total Billed Charges,1295,50,,28.32,Percent of Total Billed Charges,50% of Total Billed Charges,1295,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1295,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,1295,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1813,70,,864.36,Percent of Total Billed Charges,70% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,362.6,14,,31.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2590,100,,623.744,Percent of Total Billed Charges,100% of Total Billed Charges,48,2936.91,
423564 SPACER GD SNUS RELIEVA,32190380,CDM,272,RC,,,Outpatient,,,1700.68,1020.41,,1020.41,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,765.31,45,,215.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,476.19,28,,186.952,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.936,Percent of Total Billed Charges,32% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,612.24,36,,240.368,Percent of Total Billed Charges,36% of Total Billed Charges,612.24,36,,240.368,Percent of Total Billed Charges,36% Total Bille Charges,612.24,36,,240.368,Percent of Total Billed Charges,36% of Total Billed Charges,1020.41,60,,504.144,Percent of Total Billed Charges,60% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1700.68,100,,479.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,245.24,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1275.51,75,,495.64,Percent of Total Billed Charges,75% of Total Billed Charges,850.34,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,850.34,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,850.34,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,850.34,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1190.48,70,,58.592,Percent of Total Billed Charges,70% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,238.1,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1700.68,100,,660.856,Percent of Total Billed Charges,100% of Total Billed Charges,48,1700.68,
428831 SHEATH URETERAL ACCESS,32190384,CDM,272,RC,C1894,HCPCS,Outpatient,,,534.6,320.76,,82.29,100,,3326.04,Fee Schedule,100% of Aetna Fee Schedule,240.57,45,,23860.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,149.32,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.944,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,191.984,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,191.984,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,191.984,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,8157.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,64.408,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,568.952,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,568.952,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,568.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,104.44,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,85.88,Percent of Total Billed Charges,100% of Total Billed Charges,48,534.6,
428834 SHEATH URET ACCESS 12FR,32190385,CDM,272,RC,C1894,HCPCS,Outpatient,,,534.6,320.76,,82.29,100,,3326.04,Fee Schedule,100% of Aetna Fee Schedule,240.57,45,,5928.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,41.984,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,479.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,406.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,7484.672,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,846,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,846,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,846,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,122.92,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,394.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,9355.84,Percent of Total Billed Charges,100% of Total Billed Charges,48,534.6,
433453 CATHETER DRAIN LUMBAR K,32190389,CDM,272,RC,C1729,HCPCS,Outpatient,,,900.43,540.26,,11.1,100,,3609.4,Fee Schedule,100% of Aetna Fee Schedule,405.19,45,,82.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.12,28,,64.96,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.224,Percent of Total Billed Charges,32% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,324.15,36,,83.52,Percent of Total Billed Charges,36% of Total Billed Charges,324.15,36,,83.52,Percent of Total Billed Charges,36% Total Bille Charges,324.15,36,,83.52,Percent of Total Billed Charges,36% of Total Billed Charges,540.26,60,,237.024,Percent of Total Billed Charges,60% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900.43,100,,479.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,129.84,14.42,,293.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675.32,75,,1014.824,Percent of Total Billed Charges,75% of Total Billed Charges,450.22,50,,568.952,Percent of Total Billed Charges,50% of Total Billed Charges,450.22,50,,113.264,Percent of Total Billed Charges,50% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.22,50,,113.264,Percent of Total Billed Charges,50% of Total Billed Charges,450.22,50,,113.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630.3,70,,119.144,Percent of Total Billed Charges,70% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,126.06,14,,285.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,900.43,100,,1353.096,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,900.43,
435473 MESH COVIDIEN PARIETEX,32190390,CDM,278,RC,C1781,HCPCS,Outpatient,,,1291.81,775.09,,1873.75,110,,2990.76,Percent of Total Billed Charges,110% of Total Billed Charges,581.31,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.71,28,,35.168,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.24,Percent of Total Billed Charges,32% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,465.05,36,,45.216,Percent of Total Billed Charges,36% of Total Billed Charges,465.05,36,,45.216,Percent of Total Billed Charges,36% Total Bille Charges,465.05,36,,45.216,Percent of Total Billed Charges,36% of Total Billed Charges,710.5,55,,120.96,Percent of Total Billed Charges,55% Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1291.81,100,,53024.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,186.28,14.42,,27.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1033.45,80,,370.504,Percent of Total Billed Charges,80% of Total Billed Charges,645.91,50,,846,Percent of Total Billed Charges,50% of Total Billed Charges,645.91,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645.91,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,645.91,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,904.27,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,180.85,14,,26.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1291.81,100,,494,Percent of Total Billed Charges,100% of Total Billed Charges,48,1873.75,
441059 STENT URETERAL 6FX28CM,32190392,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,5607.688,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,47.04,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.304,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,60.48,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,60.48,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,60.48,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,534.664,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,13174.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,37.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,143.032,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,113.264,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,35.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,190.712,Percent of Total Billed Charges,100% of Total Billed Charges,48,1050.45,
454788 STENT POLARIS ULTRA,32190397,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,2658.136,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,1689.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,235.264,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.432,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,302.488,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,302.488,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,201.408,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,183.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,11.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,279.064,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,1408.16,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,1408.16,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,1408.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,11.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,372.08,Percent of Total Billed Charges,100% of Total Billed Charges,48,1050.45,
455262 STIMULAN BONE FILLER,32190398,CDM,278,RC,C1713,HCPCS,Outpatient,,,5098.5,3059.10,,5925.61,110,,2990.76,Percent of Total Billed Charges,110% of Total Billed Charges,2294.33,45,,484.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,28,,246.816,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.48,Percent of Total Billed Charges,32% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,1835.46,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,1835.46,36,,317.336,Percent of Total Billed Charges,36% Total Bille Charges,1835.46,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,2804.18,55,,197.568,Percent of Total Billed Charges,55% Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5098.5,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,735.2,14.42,,16.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4078.8,80,,666,Percent of Total Billed Charges,80% of Total Billed Charges,2549.25,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,2549.25,50,,1018.08,Percent of Total Billed Charges,50% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2549.25,50,,1018.08,Percent of Total Billed Charges,50% of Total Billed Charges,2549.25,50,,1018.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3568.95,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,713.79,14,,16.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5098.5,100,,888,Percent of Total Billed Charges,100% of Total Billed Charges,48,5925.61,
470589 MESH PARIETEX PC W/FLAP,32190400,CDM,278,RC,C1781,HCPCS,Outpatient,,,1330.92,798.55,,1916.77,110,,3688.4,Percent of Total Billed Charges,110% of Total Billed Charges,598.91,45,,484.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.66,28,,147.624,Percent of Total Billed Charges,28% of Total Billed Charges,48,32,,42.496,Percent of Total Billed Charges,32% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,479.13,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,479.13,36,,189.8,Percent of Total Billed Charges,36% Total Bille Charges,479.13,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,732.01,55,,57.408,Percent of Total Billed Charges,55% Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1330.92,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,191.92,14.42,,11.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1064.74,80,,42.48,Percent of Total Billed Charges,80% of Total Billed Charges,665.46,50,,1408.16,Percent of Total Billed Charges,50% of Total Billed Charges,665.46,50,,95.688,Percent of Total Billed Charges,50% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.46,50,,95.688,Percent of Total Billed Charges,50% of Total Billed Charges,665.46,50,,95.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,931.64,70,,115.632,Percent of Total Billed Charges,70% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,11.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1330.92,100,,56.64,Percent of Total Billed Charges,100% of Total Billed Charges,48,1916.77,
476123 MESH PARIETEX PC W/FLAP,32190401,CDM,278,RC,C1781,HCPCS,Outpatient,,,1330.92,798.55,,1916.77,110,,3335.6,Percent of Total Billed Charges,110% of Total Billed Charges,598.91,45,,3670.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.66,28,,35.272,Percent of Total Billed Charges,28% of Total Billed Charges,48.08,32,,42.496,Percent of Total Billed Charges,32% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,479.13,36,,45.352,Percent of Total Billed Charges,36% of Total Billed Charges,479.13,36,,45.352,Percent of Total Billed Charges,36% Total Bille Charges,479.13,36,,45.352,Percent of Total Billed Charges,36% of Total Billed Charges,732.01,55,,147.032,Percent of Total Billed Charges,55% Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1330.92,100,,3755.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,191.92,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1064.74,80,,77.392,Percent of Total Billed Charges,80% of Total Billed Charges,665.46,50,,1018.08,Percent of Total Billed Charges,50% of Total Billed Charges,665.46,50,,128.488,Percent of Total Billed Charges,50% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.46,50,,128.488,Percent of Total Billed Charges,50% of Total Billed Charges,665.46,50,,128.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,931.64,70,,124.464,Percent of Total Billed Charges,70% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,186.33,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1330.92,100,,103.192,Percent of Total Billed Charges,100% of Total Billed Charges,48.08,1916.77,
479370 SUTURE BIOCOMPOSITE 3MM,32190402,CDM,278,RC,C1713,HCPCS,Outpatient,,,1656.82,994.09,,2139.76,110,,2360.016,Percent of Total Billed Charges,110% of Total Billed Charges,745.57,45,,447.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.91,28,,69,Percent of Total Billed Charges,28% of Total Billed Charges,48.08,32,,42.496,Percent of Total Billed Charges,32% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,596.46,36,,88.712,Percent of Total Billed Charges,36% of Total Billed Charges,596.46,36,,88.712,Percent of Total Billed Charges,36% Total Bille Charges,596.46,36,,88.712,Percent of Total Billed Charges,36% of Total Billed Charges,911.25,55,,118.368,Percent of Total Billed Charges,55% Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1656.82,100,,1075.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,238.91,14.42,,52.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1325.46,80,,762.064,Percent of Total Billed Charges,80% of Total Billed Charges,828.41,50,,95.688,Percent of Total Billed Charges,50% of Total Billed Charges,828.41,50,,41.368,Percent of Total Billed Charges,50% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.41,50,,41.368,Percent of Total Billed Charges,50% of Total Billed Charges,828.41,50,,41.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1159.77,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,231.95,14,,51.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1656.82,100,,952.576,Percent of Total Billed Charges,100% of Total Billed Charges,48.08,2139.76,
482119 KIT BIO-SUTURETAK DISP,32190403,CDM,278,RC,C1713,HCPCS,Outpatient,,,779.68,467.81,,1174.91,110,,2134.28,Percent of Total Billed Charges,110% of Total Billed Charges,350.86,45,,3059.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.31,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,48.08,32,,42.544,Percent of Total Billed Charges,32% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,280.68,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,280.68,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,280.68,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,428.82,55,,21.2,Percent of Total Billed Charges,55% Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.68,100,,1075.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,112.43,14.42,,37.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.74,80,,320.76,Percent of Total Billed Charges,80% of Total Billed Charges,389.84,50,,128.488,Percent of Total Billed Charges,50% of Total Billed Charges,389.84,50,,57.488,Percent of Total Billed Charges,50% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.84,50,,57.488,Percent of Total Billed Charges,50% of Total Billed Charges,389.84,50,,57.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,70,,48.048,Percent of Total Billed Charges,70% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,109.16,14,,36.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.68,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,48.08,1174.91,
494644 DRAINAGE CSF EXT SYSTEM,32190404,CDM,272,RC,C1729,HCPCS,Outpatient,,,826.07,495.64,,11.1,100,,5622.52,Fee Schedule,100% of Aetna Fee Schedule,371.73,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.3,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.08,32,,42.624,Percent of Total Billed Charges,32% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,297.39,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,297.39,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,297.39,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,495.64,60,,31.736,Percent of Total Billed Charges,60% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.07,100,,8157.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,119.12,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619.55,75,,853.432,Percent of Total Billed Charges,75% of Total Billed Charges,413.04,50,,41.368,Percent of Total Billed Charges,50% of Total Billed Charges,413.04,50,,40.216,Percent of Total Billed Charges,50% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.04,50,,40.216,Percent of Total Billed Charges,50% of Total Billed Charges,413.04,50,,40.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,578.25,70,,58.776,Percent of Total Billed Charges,70% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,826.07,100,,1137.904,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,826.07,
495362 SKIN ADHESIVE DERMABOND,32190405,CDM,272,RC,,,Outpatient,,,107.35,64.41,,64.41,60,,4514.376,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,835.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.08,32,,42.648,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,64.41,60,,301.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.35,100,,994.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,33.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.51,75,,1353.6,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,57.488,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,76.776,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,32.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.35,100,,1692,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,107.35,
501583 VALVE J&J CERTAS INLINE,32190407,CDM,278,RC,,,Outpatient,,,11694.8,7016.88,,12864.28,110,,6102.056,Percent of Total Billed Charges,110% of Total Billed Charges,5262.66,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3274.54,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.18,32,,42.744,Percent of Total Billed Charges,32% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,4210.13,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,4210.13,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,4210.13,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,6432.14,55,,131.344,Percent of Total Billed Charges,55% Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11694.8,100,,6798,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1686.39,14.42,,36.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9355.84,80,,169.896,Percent of Total Billed Charges,80% of Total Billed Charges,5847.4,50,,40.216,Percent of Total Billed Charges,50% of Total Billed Charges,5847.4,50,,183.752,Percent of Total Billed Charges,50% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5847.4,50,,183.752,Percent of Total Billed Charges,50% of Total Billed Charges,5847.4,50,,183.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8186.36,70,,77.008,Percent of Total Billed Charges,70% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,1637.27,14,,35.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11694.8,100,,226.528,Percent of Total Billed Charges,100% of Total Billed Charges,48.18,12864.28,
507484 LINEAR CUTTER 60 LONG (,32190410,CDM,272,RC,,,Outpatient,,,1691.37,1014.82,,1014.82,60,,6102.056,Percent of Total Billed Charges,60% of Total Billed Charges,761.12,45,,892.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.58,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.26,32,,42.752,Percent of Total Billed Charges,32% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,608.89,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,608.89,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,608.89,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,1014.82,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1691.37,100,,220,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,243.9,14.42,,21.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1268.53,75,,498.56,Percent of Total Billed Charges,75% of Total Billed Charges,845.69,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,845.69,50,,128.968,Percent of Total Billed Charges,50% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,845.69,50,,128.968,Percent of Total Billed Charges,50% of Total Billed Charges,845.69,50,,128.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1183.96,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,236.79,14,,20.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1691.37,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,48.26,1691.37,
508154 RELOAD ECHELON BLACK,32190411,CDM,272,RC,,,Outpatient,,,617.5,370.50,,370.5,60,,2029.912,Percent of Total Billed Charges,60% of Total Billed Charges,277.88,45,,892.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.9,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.37,32,,42.808,Percent of Total Billed Charges,32% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,222.3,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,222.3,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,222.3,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,370.5,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.5,100,,1856.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,89.04,14.42,,9.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.13,75,,498.56,Percent of Total Billed Charges,75% of Total Billed Charges,308.75,50,,183.752,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.75,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,308.75,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.25,70,,199,Percent of Total Billed Charges,70% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,86.45,14,,9.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,617.5,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,48.37,617.5,
508352 SUTURE ETHIBOND 2-0 4-3,32190412,CDM,272,RC,,,Outpatient,,,238.39,143.03,,143.03,60,,2029.912,Percent of Total Billed Charges,60% of Total Billed Charges,107.28,45,,1008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.75,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,48.45,32,,43.032,Percent of Total Billed Charges,32% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,85.82,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,85.82,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,85.82,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,143.03,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.39,100,,180,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,34.38,14.42,,13.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.79,75,,2253.056,Percent of Total Billed Charges,75% of Total Billed Charges,119.2,50,,128.968,Percent of Total Billed Charges,50% of Total Billed Charges,119.2,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.2,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,119.2,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.87,70,,176.728,Percent of Total Billed Charges,70% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.37,14,,12.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.39,100,,2816.32,Percent of Total Billed Charges,100% of Total Billed Charges,33.37,238.39,
511633 CATH EMB ART FGRTY 5.5F,32190414,CDM,272,RC,C1757,HCPCS,Outpatient,,,465.1,279.06,,16.33,100,,1104.28,Fee Schedule,100% of Aetna Fee Schedule,209.3,45,,754.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.23,28,,622.72,Percent of Total Billed Charges,28% of Total Billed Charges,48.46,32,,43.056,Percent of Total Billed Charges,32% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,167.44,36,,800.64,Percent of Total Billed Charges,36% of Total Billed Charges,167.44,36,,800.64,Percent of Total Billed Charges,36% Total Bille Charges,167.44,36,,800.64,Percent of Total Billed Charges,36% of Total Billed Charges,279.06,60,,499.584,Percent of Total Billed Charges,60% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.1,100,,1982.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,67.07,14.42,,53.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.83,75,,1628.928,Percent of Total Billed Charges,75% of Total Billed Charges,232.55,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,232.55,50,,126.448,Percent of Total Billed Charges,50% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.55,50,,126.448,Percent of Total Billed Charges,50% of Total Billed Charges,232.55,50,,126.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.57,70,,143.608,Percent of Total Billed Charges,70% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,51.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465.1,100,,2036.16,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,465.1,
512667 CATH GUIDE SINUS RELIEV,32190415,CDM,272,RC,,,Outpatient,,,1110,666.00,,666,60,,14631.04,Percent of Total Billed Charges,60% of Total Billed Charges,499.5,45,,4205.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,310.8,28,,613.76,Percent of Total Billed Charges,28% of Total Billed Charges,48.51,32,,43.272,Percent of Total Billed Charges,32% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,399.6,36,,789.12,Percent of Total Billed Charges,36% of Total Billed Charges,399.6,36,,789.12,Percent of Total Billed Charges,36% Total Bille Charges,399.6,36,,789.12,Percent of Total Billed Charges,36% of Total Billed Charges,666,60,,69.904,Percent of Total Billed Charges,60% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1110,100,,1982.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,160.06,14.42,,87.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,832.5,75,,143.528,Percent of Total Billed Charges,75% of Total Billed Charges,555,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,555,50,,73.92,Percent of Total Billed Charges,50% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555,50,,73.92,Percent of Total Billed Charges,50% of Total Billed Charges,555,50,,73.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,777,70,,41.752,Percent of Total Billed Charges,70% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.4,14,,85.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1110,100,,191.368,Percent of Total Billed Charges,100% of Total Billed Charges,48.51,1110,
521873 GW U03-02-D0TEFLON GW 0,32190419,CDM,272,RC,C1769,HCPCS,Outpatient,,,70.8,42.48,,55.13,100,,733.44,Fee Schedule,100% of Aetna Fee Schedule,31.86,45,,1993.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.82,28,,370.64,Percent of Total Billed Charges,28% of Total Billed Charges,48.58,32,,43.328,Percent of Total Billed Charges,32% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,36,,476.536,Percent of Total Billed Charges,36% of Total Billed Charges,25.49,36,,476.536,Percent of Total Billed Charges,36% Total Bille Charges,25.49,36,,476.536,Percent of Total Billed Charges,36% of Total Billed Charges,42.48,60,,468.208,Percent of Total Billed Charges,60% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.8,100,,2240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,10.21,14.42,,118.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.1,75,,192.728,Percent of Total Billed Charges,75% of Total Billed Charges,35.4,50,,126.448,Percent of Total Billed Charges,50% of Total Billed Charges,35.4,50,,34.336,Percent of Total Billed Charges,50% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.4,50,,34.336,Percent of Total Billed Charges,50% of Total Billed Charges,35.4,50,,34.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.56,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14,,115.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.8,100,,256.968,Percent of Total Billed Charges,100% of Total Billed Charges,9.91,70.8,
524033 SUT FW 0 38IN TAPR 0.5,32190421,CDM,272,RC,,,Outpatient,,,128.99,77.39,,77.39,60,,2990.76,Percent of Total Billed Charges,60% of Total Billed Charges,58.05,45,,754.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,28,,161.04,Percent of Total Billed Charges,28% of Total Billed Charges,48.79,32,,43.496,Percent of Total Billed Charges,32% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,36,,207.048,Percent of Total Billed Charges,36% of Total Billed Charges,46.44,36,,207.048,Percent of Total Billed Charges,36% Total Bille Charges,46.44,36,,207.048,Percent of Total Billed Charges,36% of Total Billed Charges,77.39,60,,672,Percent of Total Billed Charges,60% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.99,100,,1677.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14.42,,14.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.74,75,,62.056,Percent of Total Billed Charges,75% of Total Billed Charges,64.5,50,,73.92,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,45.12,Percent of Total Billed Charges,50% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.5,50,,45.12,Percent of Total Billed Charges,50% of Total Billed Charges,64.5,50,,45.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.29,70,,64.272,Percent of Total Billed Charges,70% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,14,,13.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.99,100,,82.736,Percent of Total Billed Charges,100% of Total Billed Charges,18.06,128.99,
538769 STENT 5FR X 26CM URETER,32190426,CDM,278,RC,C2617,HCPCS,Outpatient,,,1190.72,714.43,,1503.34,110,,2990.76,Percent of Total Billed Charges,110% of Total Billed Charges,535.82,45,,2766.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.4,28,,64.4,Percent of Total Billed Charges,28% of Total Billed Charges,48.81,32,,4383.232,Percent of Total Billed Charges,32% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,428.66,36,,82.8,Percent of Total Billed Charges,36% of Total Billed Charges,428.66,36,,82.8,Percent of Total Billed Charges,36% Total Bille Charges,428.66,36,,82.8,Percent of Total Billed Charges,36% of Total Billed Charges,654.9,55,,562.368,Percent of Total Billed Charges,55% Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1190.72,100,,9346.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,171.7,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,952.58,80,,86.224,Percent of Total Billed Charges,80% of Total Billed Charges,595.36,50,,34.336,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,185.008,Percent of Total Billed Charges,50% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.36,50,,185.008,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,185.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,833.5,70,,64.272,Percent of Total Billed Charges,70% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1190.72,100,,114.968,Percent of Total Billed Charges,100% of Total Billed Charges,48.81,1503.34,
540574 TOWER MX CEM BNE SMARTM,32190428,CDM,272,RC,,,Outpatient,,,534.6,320.76,,320.76,60,,2990.76,Percent of Total Billed Charges,60% of Total Billed Charges,240.57,45,,2501.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,45.072,Percent of Total Billed Charges,28% of Total Billed Charges,48.88,32,,4407.28,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,57.952,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,4430.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,24.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,60.328,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,45.12,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,304.08,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,304.08,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,304.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,23.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,80.432,Percent of Total Billed Charges,100% of Total Billed Charges,48.88,534.6,
542478 CATH URMX ULT BLN 18FR6,32190429,CDM,272,RC,C1726,HCPCS,Outpatient,,,1422.38,853.43,,396.8,100,,3125.4,Fee Schedule,100% of Aetna Fee Schedule,640.07,45,,1770.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.27,28,,45.072,Percent of Total Billed Charges,28% of Total Billed Charges,48.94,32,,4416.936,Percent of Total Billed Charges,32% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,512.06,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,512.06,36,,57.952,Percent of Total Billed Charges,36% Total Bille Charges,512.06,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,853.43,60,,75.592,Percent of Total Billed Charges,60% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1422.38,100,,1677.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,205.11,14.42,,134.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1066.79,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,711.19,50,,185.008,Percent of Total Billed Charges,50% of Total Billed Charges,711.19,50,,411.84,Percent of Total Billed Charges,50% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711.19,50,,411.84,Percent of Total Billed Charges,50% of Total Billed Charges,711.19,50,,411.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,995.67,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,199.13,14,,130.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1422.38,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,48.94,1422.38,
548113 GRAFT GORE TW 7X70 VT07,32190432,CDM,278,RC,C1768,HCPCS,Outpatient,,,2115,1269.00,,2649.27,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,951.75,45,,1600.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.2,28,,45.072,Percent of Total Billed Charges,28% of Total Billed Charges,48.96,32,,4416.936,Percent of Total Billed Charges,32% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,761.4,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,761.4,36,,57.952,Percent of Total Billed Charges,36% Total Bille Charges,761.4,36,,57.952,Percent of Total Billed Charges,36% of Total Billed Charges,1163.25,55,,147.856,Percent of Total Billed Charges,55% Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2115,100,,6147.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,304.98,14.42,,35.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1692,80,,275.632,Percent of Total Billed Charges,80% of Total Billed Charges,1057.5,50,,304.08,Percent of Total Billed Charges,50% of Total Billed Charges,1057.5,50,,48.96,Percent of Total Billed Charges,50% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1057.5,50,,48.96,Percent of Total Billed Charges,50% of Total Billed Charges,1057.5,50,,48.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1480.5,70,,327.072,Percent of Total Billed Charges,70% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,14,,34.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2115,100,,367.504,Percent of Total Billed Charges,100% of Total Billed Charges,48.96,2649.27,
549046 SUTURE NUROLON 18 BLAC,32190433,CDM,272,RC,,,Outpatient,,,283.16,169.90,,169.9,60,,3125.4,Percent of Total Billed Charges,60% of Total Billed Charges,127.42,45,,4216.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.28,28,,56.792,Percent of Total Billed Charges,28% of Total Billed Charges,49.16,32,,4529.104,Percent of Total Billed Charges,32% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,101.94,36,,73.016,Percent of Total Billed Charges,36% of Total Billed Charges,101.94,36,,73.016,Percent of Total Billed Charges,36% Total Bille Charges,101.94,36,,73.016,Percent of Total Billed Charges,36% of Total Billed Charges,169.9,60,,690.736,Percent of Total Billed Charges,60% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.16,100,,5559.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,40.83,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.37,75,,193.448,Percent of Total Billed Charges,75% of Total Billed Charges,141.58,50,,411.84,Percent of Total Billed Charges,50% of Total Billed Charges,141.58,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.58,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,141.58,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.21,70,,158.896,Percent of Total Billed Charges,70% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,39.64,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.16,100,,257.928,Percent of Total Billed Charges,100% of Total Billed Charges,39.64,283.16,
552262 STENT 5FR X 24CM URETER,32190434,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,3125.4,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,3385.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,414.128,Percent of Total Billed Charges,28% of Total Billed Charges,49.16,32,,4531.2,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,532.456,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,532.456,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,532.456,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,1008,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,3933.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,175.888,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,48.96,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,635.592,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,49.16,1050.45,
554940 STENT BOSTON SCI PERCUF,32190436,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,3125.4,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,4576.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,320.792,Percent of Total Billed Charges,28% of Total Billed Charges,49.18,32,,4531.2,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,412.448,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,412.448,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,412.448,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,32.16,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,3557.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,58.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,175.888,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,139.584,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,56.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,49.18,1050.45,
568634 GRAFT VASC. EPTFE 6 X 7,32190438,CDM,278,RC,C1768,HCPCS,Outpatient,,,3520.4,2112.24,,4195.21,110,,110.4,Percent of Total Billed Charges,110% of Total Billed Charges,1584.18,45,,4576.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,985.71,28,,156.8,Percent of Total Billed Charges,28% of Total Billed Charges,49.51,32,,4.376,Percent of Total Billed Charges,32% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,1267.34,36,,201.6,Percent of Total Billed Charges,36% of Total Billed Charges,1267.34,36,,201.6,Percent of Total Billed Charges,36% Total Bille Charges,1267.34,36,,201.6,Percent of Total Billed Charges,36% of Total Billed Charges,1936.22,55,,57.6,Percent of Total Billed Charges,55% Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3520.4,100,,9370.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,507.64,14.42,,94.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2816.32,80,,189.664,Percent of Total Billed Charges,80% of Total Billed Charges,1760.2,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,1760.2,50,,123.76,Percent of Total Billed Charges,50% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1760.2,50,,123.76,Percent of Total Billed Charges,50% of Total Billed Charges,1760.2,50,,123.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2464.28,70,,385.28,Percent of Total Billed Charges,70% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,492.86,14,,92.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3520.4,100,,252.888,Percent of Total Billed Charges,100% of Total Billed Charges,49.51,4195.21,
568639 ARTEGRAFT COLLAGEN VASC,32190442,CDM,278,RC,,,Outpatient,,,2545.2,1527.12,,2799.72,110,,1102.024,Percent of Total Billed Charges,110% of Total Billed Charges,1145.34,45,,1522.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,712.66,28,,56.792,Percent of Total Billed Charges,28% of Total Billed Charges,49.53,32,,4.384,Percent of Total Billed Charges,32% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,916.27,36,,73.016,Percent of Total Billed Charges,36% of Total Billed Charges,916.27,36,,73.016,Percent of Total Billed Charges,36% Total Bille Charges,916.27,36,,73.016,Percent of Total Billed Charges,36% of Total Billed Charges,1399.86,55,,326,Percent of Total Billed Charges,55% Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2545.2,100,,7523.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,367.02,14.42,,98.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2036.16,80,,110.872,Percent of Total Billed Charges,80% of Total Billed Charges,1272.6,50,,466.856,Percent of Total Billed Charges,50% of Total Billed Charges,1272.6,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1272.6,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1272.6,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1781.64,70,,458.784,Percent of Total Billed Charges,70% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,356.33,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2545.2,100,,147.832,Percent of Total Billed Charges,100% of Total Billed Charges,49.53,2799.72,
568653 SUTURE VICRYL 3-0 36 CT,32190449,CDM,272,RC,,,Outpatient,,,239.21,143.53,,143.53,60,,1208.096,Percent of Total Billed Charges,60% of Total Billed Charges,107.64,45,,1522.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.98,28,,842.104,Percent of Total Billed Charges,28% of Total Billed Charges,49.54,32,,4.384,Percent of Total Billed Charges,32% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,86.12,36,,1082.704,Percent of Total Billed Charges,36% of Total Billed Charges,86.12,36,,1082.704,Percent of Total Billed Charges,36% Total Bille Charges,86.12,36,,1082.704,Percent of Total Billed Charges,36% of Total Billed Charges,143.53,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.21,100,,10170.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,34.49,14.42,,219.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.41,75,,51.496,Percent of Total Billed Charges,75% of Total Billed Charges,119.61,50,,123.76,Percent of Total Billed Charges,50% of Total Billed Charges,119.61,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.61,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,119.61,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.45,70,,136.784,Percent of Total Billed Charges,70% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,33.49,14,,212.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.21,100,,68.664,Percent of Total Billed Charges,100% of Total Billed Charges,33.49,239.21,
568656 SUTURE MONOCRYL 2-0 8-1,32190451,CDM,272,RC,,,Outpatient,,,321.21,192.73,,192.73,60,,2045.76,Percent of Total Billed Charges,60% of Total Billed Charges,144.54,45,,828.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.94,28,,1502.592,Percent of Total Billed Charges,28% of Total Billed Charges,49.86,32,,4.408,Percent of Total Billed Charges,32% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,115.64,36,,1931.904,Percent of Total Billed Charges,36% of Total Billed Charges,115.64,36,,1931.904,Percent of Total Billed Charges,36% Total Bille Charges,115.64,36,,1931.904,Percent of Total Billed Charges,36% of Total Billed Charges,192.73,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.21,100,,10170.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,46.32,14.42,,66.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.91,75,,67.68,Percent of Total Billed Charges,75% of Total Billed Charges,160.61,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,160.61,50,,202.08,Percent of Total Billed Charges,50% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.61,50,,202.08,Percent of Total Billed Charges,50% of Total Billed Charges,160.61,50,,202.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.85,70,,48.024,Percent of Total Billed Charges,70% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,44.97,14,,64.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.21,100,,90.24,Percent of Total Billed Charges,100% of Total Billed Charges,44.97,321.21,
568664 SUTURE PDS II 4-0 PS-1,32190457,CDM,272,RC,,,Outpatient,,,103.42,62.05,,62.05,60,,1318.672,Percent of Total Billed Charges,60% of Total Billed Charges,46.54,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.96,28,,64.504,Percent of Total Billed Charges,28% of Total Billed Charges,50.21,32,,4.416,Percent of Total Billed Charges,32% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.23,36,,82.936,Percent of Total Billed Charges,36% of Total Billed Charges,37.23,36,,82.936,Percent of Total Billed Charges,36% Total Bille Charges,37.23,36,,82.936,Percent of Total Billed Charges,36% of Total Billed Charges,62.05,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.42,100,,3383.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14.42,,89.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.57,75,,277.512,Percent of Total Billed Charges,75% of Total Billed Charges,51.71,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,51.71,50,,329.008,Percent of Total Billed Charges,50% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.71,50,,329.008,Percent of Total Billed Charges,50% of Total Billed Charges,51.71,50,,329.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.39,70,,92.824,Percent of Total Billed Charges,70% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,14.48,14,,87.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.42,100,,370.016,Percent of Total Billed Charges,100% of Total Billed Charges,14.48,103.42,
568667 SUTURE QUILL MONODERM 2,32190458,CDM,272,RC,,,Outpatient,,,143.71,86.23,,86.23,60,,929.096,Percent of Total Billed Charges,60% of Total Billed Charges,64.67,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.24,28,,63.784,Percent of Total Billed Charges,28% of Total Billed Charges,50.23,32,,4.416,Percent of Total Billed Charges,32% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,36,,82.008,Percent of Total Billed Charges,36% of Total Billed Charges,51.74,36,,82.008,Percent of Total Billed Charges,36% Total Bille Charges,51.74,36,,82.008,Percent of Total Billed Charges,36% of Total Billed Charges,86.23,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.71,100,,3383.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14.42,,137.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.78,75,,486.52,Percent of Total Billed Charges,75% of Total Billed Charges,71.86,50,,202.08,Percent of Total Billed Charges,50% of Total Billed Charges,71.86,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.86,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,71.86,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.6,70,,122.92,Percent of Total Billed Charges,70% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,14,,133.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.71,100,,608.152,Percent of Total Billed Charges,100% of Total Billed Charges,20.12,143.71,
568671 SUTURE QUILL 2-0 DIAMON,32190462,CDM,272,RC,,,Outpatient,,,100.54,60.32,,60.32,60,,3128.92,Percent of Total Billed Charges,60% of Total Billed Charges,45.24,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.15,28,,505.912,Percent of Total Billed Charges,28% of Total Billed Charges,50.24,32,,4.448,Percent of Total Billed Charges,32% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.19,36,,650.464,Percent of Total Billed Charges,36% of Total Billed Charges,36.19,36,,650.464,Percent of Total Billed Charges,36% Total Bille Charges,36.19,36,,650.464,Percent of Total Billed Charges,36% of Total Billed Charges,60.32,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.54,100,,1840.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14.42,,199,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.41,75,,658.944,Percent of Total Billed Charges,75% of Total Billed Charges,50.27,50,,329.008,Percent of Total Billed Charges,50% of Total Billed Charges,50.27,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.27,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,50.27,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.38,70,,209.16,Percent of Total Billed Charges,70% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.54,100,,823.68,Percent of Total Billed Charges,100% of Total Billed Charges,14.08,100.54,
ARTERY GRAFT,32190463,CDM,272,RC,33518,HCPCS,Outpatient,,,375,225.00,,362.92,100,,3128.92,Fee Schedule,100% of Aetna Fee Schedule,375,100,,216,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,105,28,,205.96,Percent of Total Billed Charges,28% of Total Billed Charges,50.3,32,,4.448,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,264.8,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,264.8,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,264.8,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,480,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,79.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,281.25,75,,73.44,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,229.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.5,50,,229.6,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,229.6,Percent of Total Billed Charges,50% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,262.5,70,,209.16,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,77.088,Percent of Total Billed Charges,14% of Total Billed Charges,375,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,375,100,,97.92,Percent of Total Billed Charges,100% of Total Billed Charges,50.3,375,
568675 CATH FOGARTY THRU-LUMEN,32190464,CDM,272,RC,C1757,HCPCS,Outpatient,,,459.38,275.63,,16.33,100,,14352.376,Fee Schedule,100% of Aetna Fee Schedule,206.72,45,,550.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.63,28,,453.936,Percent of Total Billed Charges,28% of Total Billed Charges,50.32,32,,4.448,Percent of Total Billed Charges,32% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,165.38,36,,583.632,Percent of Total Billed Charges,36% of Total Billed Charges,165.38,36,,583.632,Percent of Total Billed Charges,36% Total Bille Charges,165.38,36,,583.632,Percent of Total Billed Charges,36% of Total Billed Charges,275.63,60,,25,Percent of Total Billed Charges,60% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.38,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,66.24,14.42,,199,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.54,75,,44.8,Percent of Total Billed Charges,75% of Total Billed Charges,229.69,50,,759.392,Percent of Total Billed Charges,50% of Total Billed Charges,229.69,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.69,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,229.69,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.57,70,,57.96,Percent of Total Billed Charges,70% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,64.31,14,,193.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.38,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,459.38,
568677 SUTURE CHROMIC 3-0 36 G,32190466,CDM,272,RC,,,Outpatient,,,322.41,193.45,,193.45,60,,9829.936,Percent of Total Billed Charges,60% of Total Billed Charges,145.08,45,,754.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.27,28,,381.248,Percent of Total Billed Charges,28% of Total Billed Charges,50.32,32,,4.456,Percent of Total Billed Charges,32% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,116.07,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,116.07,36,,490.176,Percent of Total Billed Charges,36% Total Bille Charges,116.07,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,193.45,60,,38.456,Percent of Total Billed Charges,60% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.41,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.49,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.81,75,,125.4,Percent of Total Billed Charges,75% of Total Billed Charges,161.21,50,,229.6,Percent of Total Billed Charges,50% of Total Billed Charges,161.21,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.21,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,161.21,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.69,70,,147.984,Percent of Total Billed Charges,70% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,45.14,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.41,100,,167.2,Percent of Total Billed Charges,100% of Total Billed Charges,45.14,322.41,
568679 CATH EMBOLECTOMY 3 X 40,32190467,CDM,272,RC,C1757,HCPCS,Outpatient,,,293.15,175.89,,16.33,100,,33429.816,Fee Schedule,100% of Aetna Fee Schedule,131.92,45,,754.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,136.264,Percent of Total Billed Charges,28% of Total Billed Charges,50.39,32,,4.472,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,167.632,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,21.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,700.28,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,128.24,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,21.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,933.704,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,293.15,
568680 CATH EMBOLECTOMY 4 X 40,32190468,CDM,272,RC,C1757,HCPCS,Outpatient,,,293.15,175.89,,16.33,100,,222.72,Fee Schedule,100% of Aetna Fee Schedule,131.92,45,,754.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,136.264,Percent of Total Billed Charges,28% of Total Billed Charges,50.4,32,,4.472,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,175.192,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,56.968,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,1222.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,8.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,185.64,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,476.288,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,275.32,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,275.32,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,275.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,223.304,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,8.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,247.52,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,293.15,
568928 SUTURE ETHIBOND EXCEL 2,32190471,CDM,272,RC,,,Outpatient,,,316.11,189.67,,189.67,60,,6873.544,Percent of Total Billed Charges,60% of Total Billed Charges,142.25,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.51,28,,497.28,Percent of Total Billed Charges,28% of Total Billed Charges,50.44,32,,4.496,Percent of Total Billed Charges,32% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,113.8,36,,639.36,Percent of Total Billed Charges,36% of Total Billed Charges,113.8,36,,639.36,Percent of Total Billed Charges,36% Total Bille Charges,113.8,36,,639.36,Percent of Total Billed Charges,36% of Total Billed Charges,189.67,60,,97.44,Percent of Total Billed Charges,60% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.11,100,,1677.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,45.58,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.08,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,158.06,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,158.06,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.06,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,158.06,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.28,70,,296.52,Percent of Total Billed Charges,70% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,44.26,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.11,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,44.26,316.11,
568929 SUTURE ETHIBOND 2-0 30,32190472,CDM,272,RC,,,Outpatient,,,184.79,110.87,,110.87,60,,7866.536,Percent of Total Billed Charges,60% of Total Billed Charges,83.16,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.74,28,,433.344,Percent of Total Billed Charges,28% of Total Billed Charges,50.46,32,,4.496,Percent of Total Billed Charges,32% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,66.52,36,,557.16,Percent of Total Billed Charges,36% of Total Billed Charges,66.52,36,,557.16,Percent of Total Billed Charges,36% Total Bille Charges,66.52,36,,557.16,Percent of Total Billed Charges,36% of Total Billed Charges,110.87,60,,83.192,Percent of Total Billed Charges,60% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.79,100,,1677.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,26.65,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.59,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,92.4,50,,275.32,Percent of Total Billed Charges,50% of Total Billed Charges,92.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,92.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.35,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,25.87,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.79,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,25.87,184.79,
568934 SUTURE ETHILON 5-0 PC-5,32190475,CDM,272,RC,,,Outpatient,,,85.83,51.50,,51.5,60,,9360.6,Percent of Total Billed Charges,60% of Total Billed Charges,38.62,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.03,28,,137.76,Percent of Total Billed Charges,28% of Total Billed Charges,50.48,32,,4.512,Percent of Total Billed Charges,32% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,30.9,36,,177.12,Percent of Total Billed Charges,36% of Total Billed Charges,30.9,36,,177.12,Percent of Total Billed Charges,36% Total Bille Charges,30.9,36,,177.12,Percent of Total Billed Charges,36% of Total Billed Charges,51.5,60,,207.088,Percent of Total Billed Charges,60% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.83,100,,1677.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.38,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.37,75,,303.12,Percent of Total Billed Charges,75% of Total Billed Charges,42.92,50,,690,Percent of Total Billed Charges,50% of Total Billed Charges,42.92,50,,75.424,Percent of Total Billed Charges,50% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.92,50,,75.424,Percent of Total Billed Charges,50% of Total Billed Charges,42.92,50,,75.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.08,70,,200.064,Percent of Total Billed Charges,70% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.02,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.83,100,,404.16,Percent of Total Billed Charges,100% of Total Billed Charges,12.02,85.83,
568940 SUTURE GORETEX CV-0 TH,32190479,CDM,272,RC,,,Outpatient,,,112.8,67.68,,67.68,60,,2712.24,Percent of Total Billed Charges,60% of Total Billed Charges,50.76,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,28,,2931.296,Percent of Total Billed Charges,28% of Total Billed Charges,50.56,32,,4.512,Percent of Total Billed Charges,32% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,36,,3768.808,Percent of Total Billed Charges,36% of Total Billed Charges,40.61,36,,3768.808,Percent of Total Billed Charges,36% Total Bille Charges,40.61,36,,3768.808,Percent of Total Billed Charges,36% of Total Billed Charges,67.68,60,,153.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.8,100,,1800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,16.27,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.6,75,,493.504,Percent of Total Billed Charges,75% of Total Billed Charges,56.4,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,56.4,50,,30.48,Percent of Total Billed Charges,50% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.4,50,,30.48,Percent of Total Billed Charges,50% of Total Billed Charges,56.4,50,,30.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.96,70,,348.744,Percent of Total Billed Charges,70% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,15.79,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.8,100,,658.008,Percent of Total Billed Charges,100% of Total Billed Charges,15.79,112.8,
568955 SUTURE PROLENE 4-0 BLUE,32190485,CDM,272,RC,,,Outpatient,,,462.52,277.51,,277.51,60,,2860,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.51,28,,491.2,Percent of Total Billed Charges,28% of Total Billed Charges,50.62,32,,4.536,Percent of Total Billed Charges,32% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,166.51,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,166.51,36,,631.544,Percent of Total Billed Charges,36% Total Bille Charges,166.51,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,277.51,60,,158.608,Percent of Total Billed Charges,60% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462.52,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,66.7,14.42,,290.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.89,75,,513,Percent of Total Billed Charges,75% of Total Billed Charges,231.26,50,,75.424,Percent of Total Billed Charges,50% of Total Billed Charges,231.26,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.26,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,231.26,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.76,70,,903.312,Percent of Total Billed Charges,70% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,64.75,14,,282.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462.52,100,,684,Percent of Total Billed Charges,100% of Total Billed Charges,50.62,462.52,
568988 GRAFTON PUTTY,32190491,CDM,278,RC,C1713,HCPCS,Outpatient,,,760.19,456.11,,1153.47,110,,1560,Percent of Total Billed Charges,110% of Total Billed Charges,342.09,45,,82.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.85,28,,491.2,Percent of Total Billed Charges,28% of Total Billed Charges,50.68,32,,4.6,Percent of Total Billed Charges,32% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,273.67,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,273.67,36,,631.544,Percent of Total Billed Charges,36% Total Bille Charges,273.67,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,418.1,55,,1893.12,Percent of Total Billed Charges,55% Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.19,100,,1800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,109.62,14.42,,91.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,608.15,80,,1215.024,Percent of Total Billed Charges,80% of Total Billed Charges,380.1,50,,30.48,Percent of Total Billed Charges,50% of Total Billed Charges,380.1,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.1,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,380.1,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532.13,70,,420.872,Percent of Total Billed Charges,70% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,106.43,14,,88.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.19,100,,1518.776,Percent of Total Billed Charges,100% of Total Billed Charges,50.68,1153.47,
568990 GRAFTON PUTTY,32190492,CDM,278,RC,,,Outpatient,,,1029.6,617.76,,1132.56,110,,1934.4,Percent of Total Billed Charges,110% of Total Billed Charges,463.32,45,,826.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.29,28,,491.2,Percent of Total Billed Charges,28% of Total Billed Charges,50.88,32,,43.528,Percent of Total Billed Charges,32% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,370.66,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,370.66,36,,631.544,Percent of Total Billed Charges,36% Total Bille Charges,370.66,36,,631.544,Percent of Total Billed Charges,36% of Total Billed Charges,566.28,55,,136.528,Percent of Total Billed Charges,55% Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1029.6,100,,1800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,148.47,14.42,,74.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,823.68,80,,367.36,Percent of Total Billed Charges,80% of Total Billed Charges,514.8,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,514.8,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,514.8,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,514.8,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,720.72,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,144.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1029.6,100,,459.2,Percent of Total Billed Charges,100% of Total Billed Charges,50.88,1132.56,
569095 NOZZLE CEMENT 90 DEGREE,32190498,CDM,272,RC,,,Outpatient,,,122.4,73.44,,73.44,60,,332.992,Percent of Total Billed Charges,60% of Total Billed Charges,55.08,45,,3271.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.27,28,,754.208,Percent of Total Billed Charges,28% of Total Billed Charges,50.96,32,,43.528,Percent of Total Billed Charges,32% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,44.06,36,,969.696,Percent of Total Billed Charges,36% of Total Billed Charges,44.06,36,,969.696,Percent of Total Billed Charges,36% Total Bille Charges,44.06,36,,969.696,Percent of Total Billed Charges,36% of Total Billed Charges,73.44,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.4,100,,1800,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.65,14.42,,74.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.8,75,,498.56,Percent of Total Billed Charges,75% of Total Billed Charges,61.2,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.2,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.2,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.2,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.68,70,,48.448,Percent of Total Billed Charges,70% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,17.14,14,,72.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.4,100,,623.2,Percent of Total Billed Charges,100% of Total Billed Charges,17.14,122.4,
571022 TUBE EAR 7MM VENT,32190499,CDM,278,RC,,,Outpatient,,,70,42.00,,77,110,,330,Percent of Total Billed Charges,110% of Total Billed Charges,31.5,45,,906.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,297.92,Percent of Total Billed Charges,28% of Total Billed Charges,51.04,32,,43.528,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,383.04,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,383.04,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,383.04,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,15.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,80,,762.064,Percent of Total Billed Charges,80% of Total Billed Charges,35,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,480.104,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,15.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,952.576,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,77,
571032 KIT DENVER SPLINT,32190505,CDM,271,RC,,,Outpatient,,,209,125.40,,125.4,60,,294.8,Percent of Total Billed Charges,60% of Total Billed Charges,94.05,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.52,28,,287.168,Percent of Total Billed Charges,28% of Total Billed Charges,51.04,32,,43.648,Percent of Total Billed Charges,32% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,75.24,36,,369.216,Percent of Total Billed Charges,36% of Total Billed Charges,75.24,36,,369.216,Percent of Total Billed Charges,36% Total Bille Charges,75.24,36,,369.216,Percent of Total Billed Charges,36% of Total Billed Charges,125.4,60,,19.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209,100,,1836.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14.42,,55.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.75,75,,1035,Percent of Total Billed Charges,75% of Total Billed Charges,104.5,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,104.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,104.5,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.3,70,,384.184,Percent of Total Billed Charges,70% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,29.26,14,,54.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209,100,,1380,Percent of Total Billed Charges,100% of Total Billed Charges,29.26,209,
571034 STAPLER CDH25,32190506,CDM,272,RC,,,Outpatient,,,1167.13,700.28,,700.28,60,,233.2,Percent of Total Billed Charges,60% of Total Billed Charges,525.21,45,,226.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.8,28,,82.88,Percent of Total Billed Charges,28% of Total Billed Charges,51.07,32,,43.648,Percent of Total Billed Charges,32% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,420.17,36,,106.56,Percent of Total Billed Charges,36% of Total Billed Charges,420.17,36,,106.56,Percent of Total Billed Charges,36% Total Bille Charges,420.17,36,,106.56,Percent of Total Billed Charges,36% of Total Billed Charges,700.28,60,,273.464,Percent of Total Billed Charges,60% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1167.13,100,,7269.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,168.3,14.42,,180.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.35,75,,440.504,Percent of Total Billed Charges,75% of Total Billed Charges,583.57,50,,1008,Percent of Total Billed Charges,50% of Total Billed Charges,583.57,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,583.57,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,583.57,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,816.99,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,163.4,14,,175.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.13,100,,550.632,Percent of Total Billed Charges,100% of Total Billed Charges,51.07,1167.13,
571051 CATHETER EPIDURAL BREVI,32190510,CDM,272,RC,,,Outpatient,,,309.4,185.64,,185.64,60,,332.992,Percent of Total Billed Charges,60% of Total Billed Charges,139.23,45,,318.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.63,28,,196.672,Percent of Total Billed Charges,28% of Total Billed Charges,51.07,32,,43.664,Percent of Total Billed Charges,32% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,111.38,36,,252.864,Percent of Total Billed Charges,36% of Total Billed Charges,111.38,36,,252.864,Percent of Total Billed Charges,36% Total Bille Charges,111.38,36,,252.864,Percent of Total Billed Charges,36% of Total Billed Charges,185.64,60,,610.56,Percent of Total Billed Charges,60% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.4,100,,2013.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,44.62,14.42,,29.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.05,75,,1035,Percent of Total Billed Charges,75% of Total Billed Charges,154.7,50,,316.2,Percent of Total Billed Charges,50% of Total Billed Charges,154.7,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.7,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,154.7,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.58,70,,1743.312,Percent of Total Billed Charges,70% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,43.32,14,,29.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,309.4,100,,1380,Percent of Total Billed Charges,100% of Total Billed Charges,43.32,309.4,
571109 SUTURE TEVDEK 2,32190517,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,330,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,201.6,Percent of Total Billed Charges,28% of Total Billed Charges,5166.48,32,,44.032,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,259.2,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,259.2,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,259.2,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,672,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,134.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54.576,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,54.576,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,54.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,255.36,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,130.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,5166.48,
571121 SUTURE ANCHOR CORKSCREW,32190518,CDM,272,RC,,,Outpatient,,,750,450.00,,450,60,,7885.136,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,45,,1534.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,164.64,Percent of Total Billed Charges,28% of Total Billed Charges,5215.35,32,,44.032,Percent of Total Billed Charges,32% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,211.68,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,211.68,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,211.68,Percent of Total Billed Charges,36% of Total Billed Charges,450,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,147.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,113.128,Percent of Total Billed Charges,75% of Total Billed Charges,375,50,,258.744,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,193.52,Percent of Total Billed Charges,50% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,50,,193.52,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,193.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,297.92,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,143.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,150.84,Percent of Total Billed Charges,100% of Total Billed Charges,105,5215.35,
571138 8TA17 TAPER,32190522,CDM,272,RC,,,Outpatient,,,505.2,303.12,,303.12,60,,1252.648,Percent of Total Billed Charges,60% of Total Billed Charges,227.34,45,,136.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.46,28,,137.984,Percent of Total Billed Charges,28% of Total Billed Charges,5269.81,32,,44.032,Percent of Total Billed Charges,32% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,181.87,36,,177.408,Percent of Total Billed Charges,36% of Total Billed Charges,181.87,36,,177.408,Percent of Total Billed Charges,36% Total Bille Charges,181.87,36,,177.408,Percent of Total Billed Charges,36% of Total Billed Charges,303.12,60,,704.68,Percent of Total Billed Charges,60% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.2,100,,708,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,72.85,14.42,,281.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.9,75,,45.72,Percent of Total Billed Charges,75% of Total Billed Charges,252.6,50,,54.576,Percent of Total Billed Charges,50% of Total Billed Charges,252.6,50,,625.264,Percent of Total Billed Charges,50% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.6,50,,625.264,Percent of Total Billed Charges,50% of Total Billed Charges,252.6,50,,625.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.64,70,,392.952,Percent of Total Billed Charges,70% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14,,272.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.2,100,,60.96,Percent of Total Billed Charges,100% of Total Billed Charges,70.73,5269.81,
571143 PERITONEAL CATHETER,32190524,CDM,272,RC,,,Outpatient,,,822.51,493.51,,493.51,60,,3128.92,Percent of Total Billed Charges,60% of Total Billed Charges,370.13,45,,989,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.3,28,,135.968,Percent of Total Billed Charges,28% of Total Billed Charges,5269.81,32,,44.176,Percent of Total Billed Charges,32% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,296.1,36,,174.816,Percent of Total Billed Charges,36% of Total Billed Charges,296.1,36,,174.816,Percent of Total Billed Charges,36% Total Bille Charges,296.1,36,,174.816,Percent of Total Billed Charges,36% of Total Billed Charges,493.51,60,,1117.44,Percent of Total Billed Charges,60% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,822.51,100,,93.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,118.61,14.42,,60.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.88,75,,51.304,Percent of Total Billed Charges,75% of Total Billed Charges,411.26,50,,193.52,Percent of Total Billed Charges,50% of Total Billed Charges,411.26,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,411.26,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,411.26,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,575.76,70,,212.8,Percent of Total Billed Charges,70% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,115.15,14,,58.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,822.51,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,115.15,5269.81,
571144 VENTRICULAR CATHETER,32190525,CDM,272,RC,,,Outpatient,,,855,513.00,,513,60,,27144,Percent of Total Billed Charges,60% of Total Billed Charges,384.75,45,,696.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.4,28,,317.184,Percent of Total Billed Charges,28% of Total Billed Charges,5280,32,,44.232,Percent of Total Billed Charges,32% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,307.8,36,,407.808,Percent of Total Billed Charges,36% of Total Billed Charges,307.8,36,,407.808,Percent of Total Billed Charges,36% Total Bille Charges,307.8,36,,407.808,Percent of Total Billed Charges,36% of Total Billed Charges,513,60,,731.52,Percent of Total Billed Charges,60% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855,100,,3409.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,123.29,14.42,,913.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.25,75,,51.304,Percent of Total Billed Charges,75% of Total Billed Charges,427.5,50,,625.264,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,467.344,Percent of Total Billed Charges,50% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,50,,467.344,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,467.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,70,,467.376,Percent of Total Billed Charges,70% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,886.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,855,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,119.7,5280,
571146 RICKHAM RESERVOIR,32190526,CDM,278,RC,,,Outpatient,,,1898.47,1139.08,,2088.32,110,,26951.04,Percent of Total Billed Charges,110% of Total Billed Charges,854.31,45,,811.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.57,28,,127.68,Percent of Total Billed Charges,28% of Total Billed Charges,5291.4,32,,44.232,Percent of Total Billed Charges,32% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,683.45,36,,164.16,Percent of Total Billed Charges,36% of Total Billed Charges,683.45,36,,164.16,Percent of Total Billed Charges,36% Total Bille Charges,683.45,36,,164.16,Percent of Total Billed Charges,36% of Total Billed Charges,1044.16,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1898.47,100,,304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,273.76,14.42,,49.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1518.78,80,,51.304,Percent of Total Billed Charges,80% of Total Billed Charges,949.24,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,949.24,50,,511.48,Percent of Total Billed Charges,50% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,949.24,50,,511.48,Percent of Total Billed Charges,50% of Total Billed Charges,949.24,50,,511.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1328.93,70,,373.296,Percent of Total Billed Charges,70% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,265.79,14,,48.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1898.47,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,265.79,5291.4,
572379 STENT POLARIS 8FRX22CM,32190530,CDM,278,RC,C2617,HCPCS,Outpatient,,,574,344.40,,824.95,110,,7902.376,Percent of Total Billed Charges,110% of Total Billed Charges,258.3,45,,811.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.72,28,,127.456,Percent of Total Billed Charges,28% of Total Billed Charges,5345.28,32,,44.232,Percent of Total Billed Charges,32% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,206.64,36,,163.872,Percent of Total Billed Charges,36% of Total Billed Charges,206.64,36,,163.872,Percent of Total Billed Charges,36% Total Bille Charges,206.64,36,,163.872,Percent of Total Billed Charges,36% of Total Billed Charges,315.7,55,,962.688,Percent of Total Billed Charges,55% Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574,100,,2197.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14.42,,2467.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.2,80,,51.304,Percent of Total Billed Charges,80% of Total Billed Charges,287,50,,467.344,Percent of Total Billed Charges,50% of Total Billed Charges,287,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,287,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.8,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,80.36,14,,2395.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,574,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,80.36,5345.28,
572384 STENT POLARIS 7FRX24CM,32190533,CDM,278,RC,C2617,HCPCS,Outpatient,,,779,467.40,,1050.45,110,,9896.712,Percent of Total Billed Charges,110% of Total Billed Charges,350.55,45,,4680,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.12,28,,126.112,Percent of Total Billed Charges,28% of Total Billed Charges,5.13,32,,44.272,Percent of Total Billed Charges,32% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,280.44,36,,162.144,Percent of Total Billed Charges,36% of Total Billed Charges,280.44,36,,162.144,Percent of Total Billed Charges,36% Total Bille Charges,280.44,36,,162.144,Percent of Total Billed Charges,36% of Total Billed Charges,428.45,55,,404.352,Percent of Total Billed Charges,55% Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779,100,,1548.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,112.33,14.42,,884.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623.2,80,,1612.8,Percent of Total Billed Charges,80% of Total Billed Charges,389.5,50,,511.48,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,209.568,Percent of Total Billed Charges,50% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.5,50,,209.568,Percent of Total Billed Charges,50% of Total Billed Charges,389.5,50,,209.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.3,70,,162.4,Percent of Total Billed Charges,70% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,109.06,14,,859.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779,100,,2016,Percent of Total Billed Charges,100% of Total Billed Charges,5.13,1050.45,
572388 STENT POLARIS 6FRX22CM,32190535,CDM,278,RC,C2617,HCPCS,Outpatient,,,1190.72,714.43,,1503.34,110,,8864.784,Percent of Total Billed Charges,110% of Total Billed Charges,535.82,45,,3931.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.4,28,,114.464,Percent of Total Billed Charges,28% of Total Billed Charges,5.13,32,,44.28,Percent of Total Billed Charges,32% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,428.66,36,,147.168,Percent of Total Billed Charges,36% of Total Billed Charges,428.66,36,,147.168,Percent of Total Billed Charges,36% Total Bille Charges,428.66,36,,147.168,Percent of Total Billed Charges,36% of Total Billed Charges,654.9,55,,55.048,Percent of Total Billed Charges,55% Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1190.72,100,,1803.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,171.7,14.42,,15.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,952.58,80,,474.304,Percent of Total Billed Charges,80% of Total Billed Charges,595.36,50,,974.6,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,3166.8,Percent of Total Billed Charges,50% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.36,50,,3166.8,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,3166.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,833.5,70,,87.92,Percent of Total Billed Charges,70% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1190.72,100,,632.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.13,1503.34,
572389 GYRUS OPEN FORCEPS,32190536,CDM,272,RC,,,Outpatient,,,1725,1035.00,,1035,60,,6529.416,Percent of Total Billed Charges,60% of Total Billed Charges,776.25,45,,9720,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483,28,,113.12,Percent of Total Billed Charges,28% of Total Billed Charges,5.17,32,,44.28,Percent of Total Billed Charges,32% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,621,36,,145.44,Percent of Total Billed Charges,36% of Total Billed Charges,621,36,,145.44,Percent of Total Billed Charges,36% Total Bille Charges,621,36,,145.44,Percent of Total Billed Charges,36% of Total Billed Charges,1035,60,,211.2,Percent of Total Billed Charges,60% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1725,100,,1803.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,248.75,14.42,,15.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1293.75,75,,388.12,Percent of Total Billed Charges,75% of Total Billed Charges,862.5,50,,209.568,Percent of Total Billed Charges,50% of Total Billed Charges,862.5,50,,172.992,Percent of Total Billed Charges,50% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,862.5,50,,172.992,Percent of Total Billed Charges,50% of Total Billed Charges,862.5,50,,172.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.5,70,,117.6,Percent of Total Billed Charges,70% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,15.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1725,100,,517.488,Percent of Total Billed Charges,100% of Total Billed Charges,5.17,1725,
572392 STENT POLARIS 5FRX22CM,32190537,CDM,278,RC,C2617,HCPCS,Outpatient,,,688.29,412.97,,950.67,110,,816,Percent of Total Billed Charges,110% of Total Billed Charges,309.73,45,,2990.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.72,28,,96.544,Percent of Total Billed Charges,28% of Total Billed Charges,5.17,32,,44.32,Percent of Total Billed Charges,32% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,247.78,36,,124.128,Percent of Total Billed Charges,36% of Total Billed Charges,247.78,36,,124.128,Percent of Total Billed Charges,36% Total Bille Charges,247.78,36,,124.128,Percent of Total Billed Charges,36% of Total Billed Charges,378.56,55,,102.528,Percent of Total Billed Charges,55% Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688.29,100,,10400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,99.25,14.42,,38.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550.63,80,,388.12,Percent of Total Billed Charges,80% of Total Billed Charges,344.15,50,,3166.8,Percent of Total Billed Charges,50% of Total Billed Charges,344.15,50,,3068,Percent of Total Billed Charges,50% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.15,50,,3068,Percent of Total Billed Charges,50% of Total Billed Charges,344.15,50,,6320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.8,70,,588.168,Percent of Total Billed Charges,70% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.36,14,,37.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688.29,100,,517.488,Percent of Total Billed Charges,100% of Total Billed Charges,5.17,950.67,
572393 FORCEP GYRUS CUTTING,32190538,CDM,272,RC,,,Outpatient,,,1725,1035.00,,1035,60,,18238.536,Percent of Total Billed Charges,60% of Total Billed Charges,776.25,45,,563.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483,28,,95.424,Percent of Total Billed Charges,28% of Total Billed Charges,5.2,32,,44.32,Percent of Total Billed Charges,32% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,621,36,,122.688,Percent of Total Billed Charges,36% of Total Billed Charges,621,36,,122.688,Percent of Total Billed Charges,36% Total Bille Charges,621,36,,122.688,Percent of Total Billed Charges,36% of Total Billed Charges,1035,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1725,100,,8736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,248.75,14.42,,98.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1293.75,75,,87.312,Percent of Total Billed Charges,75% of Total Billed Charges,862.5,50,,172.992,Percent of Total Billed Charges,50% of Total Billed Charges,862.5,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,862.5,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,862.5,50,,3068,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.5,70,,617.048,Percent of Total Billed Charges,70% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,241.5,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1725,100,,109.144,Percent of Total Billed Charges,100% of Total Billed Charges,5.2,1725,
572397 CAPTURA GRASPING FORCEP,32190539,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,2860.696,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,167.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,91.84,Percent of Total Billed Charges,28% of Total Billed Charges,5.22,32,,44.392,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,118.08,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,118.08,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,118.08,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,495.744,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,21600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,141.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,290.28,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,3068,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,369.048,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,137.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,387.04,Percent of Total Billed Charges,100% of Total Billed Charges,5.22,600,
572403 GLIDE WIRE .032,32190542,CDM,272,RC,C1769,HCPCS,Outpatient,,,188.55,113.13,,55.13,100,,1149.12,Fee Schedule,100% of Aetna Fee Schedule,84.85,45,,2650.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.79,28,,53.984,Percent of Total Billed Charges,28% of Total Billed Charges,5.22,32,,44.8,Percent of Total Billed Charges,32% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,67.88,36,,69.408,Percent of Total Billed Charges,36% of Total Billed Charges,67.88,36,,69.408,Percent of Total Billed Charges,36% Total Bille Charges,67.88,36,,69.408,Percent of Total Billed Charges,36% of Total Billed Charges,113.13,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.55,100,,6645.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14.42,,186.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.41,75,,1000.424,Percent of Total Billed Charges,75% of Total Billed Charges,94.28,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,94.28,50,,133.44,Percent of Total Billed Charges,50% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.28,50,,133.44,Percent of Total Billed Charges,50% of Total Billed Charges,94.28,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.99,70,,62.992,Percent of Total Billed Charges,70% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,26.4,14,,180.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.55,100,,1250.528,Percent of Total Billed Charges,100% of Total Billed Charges,5.22,188.55,
572405 GUIDE WIRE .035 X 150,32190543,CDM,272,RC,C1769,HCPCS,Outpatient,,,76.2,45.72,,55.13,100,,3927.672,Fee Schedule,100% of Aetna Fee Schedule,34.29,45,,3056.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.34,28,,63.616,Percent of Total Billed Charges,28% of Total Billed Charges,5.22,32,,44.8,Percent of Total Billed Charges,32% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,27.43,36,,81.792,Percent of Total Billed Charges,36% of Total Billed Charges,27.43,36,,81.792,Percent of Total Billed Charges,36% Total Bille Charges,27.43,36,,81.792,Percent of Total Billed Charges,36% of Total Billed Charges,45.72,60,,510.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.2,100,,1252.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14.42,,260.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.15,75,,156,Percent of Total Billed Charges,75% of Total Billed Charges,38.1,50,,55.104,Percent of Total Billed Charges,50% of Total Billed Charges,38.1,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.1,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,38.1,50,,133.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.34,70,,720,Percent of Total Billed Charges,70% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.67,14,,252.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.2,100,,208,Percent of Total Billed Charges,100% of Total Billed Charges,5.22,76.2,
572410 ELECTRODE LOOP 11CM,32190544,CDM,272,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,619.888,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,45,,3668.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,49.728,Percent of Total Billed Charges,28% of Total Billed Charges,5.22,32,,44.8,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,63.936,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,63.936,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,63.936,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,151.68,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,100,,371.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,145.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,701.008,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,133.44,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,222.52,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,141.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,934.68,Percent of Total Billed Charges,100% of Total Billed Charges,5.22,85.5,
572412 ELECTRODE LOOP 10X10MM,32190545,CDM,272,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,439.48,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,45,,226.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,49.28,Percent of Total Billed Charges,28% of Total Billed Charges,5.22,32,,44.8,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,63.36,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,63.36,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,63.36,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,143.408,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,100,,5890.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,178.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,818.36,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,1243.2,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,172.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,1022.952,Percent of Total Billed Charges,100% of Total Billed Charges,5.22,85.5,
572417 ELECTRODE BALL 5MM,32190546,CDM,272,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,2474.752,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,46.144,Percent of Total Billed Charges,28% of Total Billed Charges,5.3,32,,44.824,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,59.328,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,59.328,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,59.328,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,100,,6793.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,12.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,1559.36,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,492,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,903.28,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,903.28,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,1083.368,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,11.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,1949.2,Percent of Total Billed Charges,100% of Total Billed Charges,5.3,85.5,
572419 ELECTRODE BALL 3MM,32190547,CDM,272,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,3986.088,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,45,,937.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,33.152,Percent of Total Billed Charges,28% of Total Billed Charges,5.3,32,,44.824,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,42.624,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,42.624,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,42.624,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,92.16,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,100,,8151.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,21.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,314.344,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,644.992,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,505.368,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,505.368,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,903.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,344.4,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,20.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,419.128,Percent of Total Billed Charges,100% of Total Billed Charges,5.3,85.5,
572422 GRAFT HIATAL HERNIA,32190548,CDM,278,RC,C1763,HCPCS,Outpatient,,,2520,1512.00,,3180.19,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,1134,45,,1170,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.6,28,,31.36,Percent of Total Billed Charges,28% of Total Billed Charges,5.32,32,,44.84,Percent of Total Billed Charges,32% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,907.2,36,,40.32,Percent of Total Billed Charges,36% of Total Billed Charges,907.2,36,,40.32,Percent of Total Billed Charges,36% Total Bille Charges,907.2,36,,40.32,Percent of Total Billed Charges,36% of Total Billed Charges,1386,55,,105.368,Percent of Total Billed Charges,55% Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2520,100,,504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,363.38,14.42,,25.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2016,80,,4750.2,Percent of Total Billed Charges,80% of Total Billed Charges,1260,50,,903.28,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,1260,50,,505.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1764,70,,7328.248,Percent of Total Billed Charges,70% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2520,100,,6333.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.32,3180.19,
572425 STAPLER CDH33,32190549,CDM,272,RC,,,Outpatient,,,790.5,474.30,,474.3,60,,501.08,Percent of Total Billed Charges,60% of Total Billed Charges,355.73,45,,826.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.34,28,,30.464,Percent of Total Billed Charges,28% of Total Billed Charges,5.34,32,,45.112,Percent of Total Billed Charges,32% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,284.58,36,,39.168,Percent of Total Billed Charges,36% of Total Billed Charges,284.58,36,,39.168,Percent of Total Billed Charges,36% Total Bille Charges,284.58,36,,39.168,Percent of Total Billed Charges,36% of Total Billed Charges,474.3,60,,173.44,Percent of Total Billed Charges,60% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.5,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,113.99,14.42,,24.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.88,75,,259.488,Percent of Total Billed Charges,75% of Total Billed Charges,395.25,50,,505.368,Percent of Total Billed Charges,50% of Total Billed Charges,395.25,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.25,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,395.25,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553.35,70,,1228,Percent of Total Billed Charges,70% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,110.67,14,,23.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,790.5,100,,345.984,Percent of Total Billed Charges,100% of Total Billed Charges,5.34,790.5,
572436 3 EHL PROBE,32190552,CDM,272,RC,,,Outpatient,,,646.86,388.12,,388.12,60,,3762.672,Percent of Total Billed Charges,60% of Total Billed Charges,291.09,45,,1170,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.12,28,,29.792,Percent of Total Billed Charges,28% of Total Billed Charges,5.43,32,,45.184,Percent of Total Billed Charges,32% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,232.87,36,,38.304,Percent of Total Billed Charges,36% of Total Billed Charges,232.87,36,,38.304,Percent of Total Billed Charges,36% Total Bille Charges,232.87,36,,38.304,Percent of Total Billed Charges,36% of Total Billed Charges,388.12,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.86,100,,2083.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,93.28,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,485.15,75,,12835.456,Percent of Total Billed Charges,75% of Total Billed Charges,323.43,50,,617.4,Percent of Total Billed Charges,50% of Total Billed Charges,323.43,50,,74.6,Percent of Total Billed Charges,50% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.43,50,,74.6,Percent of Total Billed Charges,50% of Total Billed Charges,323.43,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.8,70,,1228,Percent of Total Billed Charges,70% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.86,100,,17113.944,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,646.86,
572750 PROBE 7 EHL (27080FA),32190560,CDM,272,RC,,,Outpatient,,,646.86,388.12,,388.12,60,,192.032,Percent of Total Billed Charges,60% of Total Billed Charges,291.09,45,,1450.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.12,28,,29.344,Percent of Total Billed Charges,28% of Total Billed Charges,5.43,32,,45.224,Percent of Total Billed Charges,32% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,232.87,36,,37.728,Percent of Total Billed Charges,36% of Total Billed Charges,232.87,36,,37.728,Percent of Total Billed Charges,36% Total Bille Charges,232.87,36,,37.728,Percent of Total Billed Charges,36% of Total Billed Charges,388.12,60,,330.24,Percent of Total Billed Charges,60% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.86,100,,2600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,93.28,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,485.15,75,,4908.8,Percent of Total Billed Charges,75% of Total Billed Charges,323.43,50,,41.856,Percent of Total Billed Charges,50% of Total Billed Charges,323.43,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.43,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,323.43,50,,74.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.8,70,,1228,Percent of Total Billed Charges,70% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.86,100,,6136,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,646.86,
572880 TUBE VNT EAR AMSTRONG,32190562,CDM,278,RC,,,Outpatient,,,136.43,81.86,,150.07,110,,1026.72,Percent of Total Billed Charges,110% of Total Billed Charges,61.39,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.2,28,,28.672,Percent of Total Billed Charges,28% of Total Billed Charges,51.2,32,,45.304,Percent of Total Billed Charges,32% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,49.11,36,,36.864,Percent of Total Billed Charges,36% of Total Billed Charges,49.11,36,,36.864,Percent of Total Billed Charges,36% Total Bille Charges,49.11,36,,36.864,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.43,100,,1836.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.67,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.14,80,,82.656,Percent of Total Billed Charges,80% of Total Billed Charges,68.22,50,,74.6,Percent of Total Billed Charges,50% of Total Billed Charges,68.22,50,,85.104,Percent of Total Billed Charges,50% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.22,50,,85.104,Percent of Total Billed Charges,50% of Total Billed Charges,68.22,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.5,70,,1885.52,Percent of Total Billed Charges,70% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,19.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.43,100,,110.208,Percent of Total Billed Charges,100% of Total Billed Charges,19.1,150.07,
572881 TUBE JEJUNAL 14FR 18.5,32190563,CDM,272,RC,,,Outpatient,,,483.8,290.28,,290.28,60,,3328.68,Percent of Total Billed Charges,60% of Total Billed Charges,217.71,45,,136.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.46,28,,23.744,Percent of Total Billed Charges,28% of Total Billed Charges,51.28,32,,45.304,Percent of Total Billed Charges,32% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,174.17,36,,30.528,Percent of Total Billed Charges,36% of Total Billed Charges,174.17,36,,30.528,Percent of Total Billed Charges,36% Total Bille Charges,174.17,36,,30.528,Percent of Total Billed Charges,36% of Total Billed Charges,290.28,60,,29.88,Percent of Total Billed Charges,60% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.8,100,,2600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,69.76,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.85,75,,82.656,Percent of Total Billed Charges,75% of Total Billed Charges,241.9,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,241.9,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.9,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,241.9,50,,85.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.66,70,,744.8,Percent of Total Billed Charges,70% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,67.73,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,483.8,100,,110.208,Percent of Total Billed Charges,100% of Total Billed Charges,51.28,483.8,
572933 IMP BNE CANCELLOUS 15CC,32190568,CDM,278,RC,C1713,HCPCS,Outpatient,,,1563.16,937.90,,2036.74,110,,5578.888,Percent of Total Billed Charges,110% of Total Billed Charges,703.42,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.68,28,,132.16,Percent of Total Billed Charges,28% of Total Billed Charges,51.35,32,,45.312,Percent of Total Billed Charges,32% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,562.74,36,,169.92,Percent of Total Billed Charges,36% of Total Billed Charges,562.74,36,,169.92,Percent of Total Billed Charges,36% Total Bille Charges,562.74,36,,169.92,Percent of Total Billed Charges,36% of Total Billed Charges,859.74,55,,123.552,Percent of Total Billed Charges,55% Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1563.16,100,,3224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,225.41,14.42,,23.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1250.53,80,,200.16,Percent of Total Billed Charges,80% of Total Billed Charges,781.58,50,,85.104,Percent of Total Billed Charges,50% of Total Billed Charges,781.58,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,781.58,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,781.58,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1094.21,70,,717.92,Percent of Total Billed Charges,70% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,218.84,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1563.16,100,,266.88,Percent of Total Billed Charges,100% of Total Billed Charges,51.35,2036.74,
572993 SUTURE PASSER ROTATOR C,32190570,CDM,272,RC,,,Outpatient,,,260,156.00,,156,60,,6002.168,Percent of Total Billed Charges,60% of Total Billed Charges,117,45,,120.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,28,,134.624,Percent of Total Billed Charges,28% of Total Billed Charges,51.35,32,,45.504,Percent of Total Billed Charges,32% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,93.6,36,,173.088,Percent of Total Billed Charges,36% of Total Billed Charges,93.6,36,,173.088,Percent of Total Billed Charges,36% Total Bille Charges,93.6,36,,173.088,Percent of Total Billed Charges,36% of Total Billed Charges,156,60,,184.56,Percent of Total Billed Charges,60% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,37.49,14.42,,25.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,75,,547.2,Percent of Total Billed Charges,75% of Total Billed Charges,130,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,130,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,130,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182,70,,207.2,Percent of Total Billed Charges,70% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,36.4,14,,24.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260,100,,684,Percent of Total Billed Charges,100% of Total Billed Charges,36.4,260,
572997 ELECTRODE VERSAPOINT BA,32190571,CDM,272,RC,,,Outpatient,,,1168.35,701.01,,701.01,60,,8047.288,Percent of Total Billed Charges,60% of Total Billed Charges,525.76,45,,95.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.14,28,,246.816,Percent of Total Billed Charges,28% of Total Billed Charges,51.57,32,,45.552,Percent of Total Billed Charges,32% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,420.61,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,420.61,36,,317.336,Percent of Total Billed Charges,36% Total Bille Charges,420.61,36,,317.336,Percent of Total Billed Charges,36% of Total Billed Charges,701.01,60,,301.44,Percent of Total Billed Charges,60% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1168.35,100,,302.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,168.48,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,876.26,75,,787.2,Percent of Total Billed Charges,75% of Total Billed Charges,584.18,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,584.18,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.18,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,584.18,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,817.85,70,,491.68,Percent of Total Billed Charges,70% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,163.57,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1168.35,100,,984,Percent of Total Billed Charges,100% of Total Billed Charges,51.57,1168.35,
223068 MESH PATCH PROCEED VTRL,32190581,CDM,278,RC,C1781,HCPCS,Outpatient,,,1278.69,767.21,,1859.32,110,,8897.368,Percent of Total Billed Charges,110% of Total Billed Charges,575.41,45,,322.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,358.03,28,,338.24,Percent of Total Billed Charges,28% of Total Billed Charges,51.65,32,,45.736,Percent of Total Billed Charges,32% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,460.33,36,,434.88,Percent of Total Billed Charges,36% of Total Billed Charges,460.33,36,,434.88,Percent of Total Billed Charges,36% Total Bille Charges,460.33,36,,434.88,Percent of Total Billed Charges,36% of Total Billed Charges,703.28,55,,293.76,Percent of Total Billed Charges,55% Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1278.69,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,184.39,14.42,,9.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1022.95,80,,1031.984,Percent of Total Billed Charges,80% of Total Billed Charges,639.35,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,639.35,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.35,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,639.35,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,895.08,70,,504,Percent of Total Billed Charges,70% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,179.02,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1278.69,100,,1289.976,Percent of Total Billed Charges,100% of Total Billed Charges,51.65,1859.32,
544064 GRAFT DURA DURAFORM 3X3,32190583,CDM,278,RC,,,Outpatient,,,2436.5,1461.90,,2680.15,110,,3987.64,Percent of Total Billed Charges,110% of Total Billed Charges,1096.43,45,,136.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,28,,393.568,Percent of Total Billed Charges,28% of Total Billed Charges,51.77,32,,45.824,Percent of Total Billed Charges,32% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,877.14,36,,506.016,Percent of Total Billed Charges,36% of Total Billed Charges,877.14,36,,506.016,Percent of Total Billed Charges,36% Total Bille Charges,877.14,36,,506.016,Percent of Total Billed Charges,36% of Total Billed Charges,1340.08,55,,67.2,Percent of Total Billed Charges,55% Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2436.5,100,,268,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,351.34,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,80,,1445.248,Percent of Total Billed Charges,80% of Total Billed Charges,1218.25,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,88.904,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,50,,88.904,Percent of Total Billed Charges,50% of Total Billed Charges,1218.25,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,70,,411.6,Percent of Total Billed Charges,70% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,341.11,14,,11.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2436.5,100,,1806.56,Percent of Total Billed Charges,100% of Total Billed Charges,51.77,2680.15,
MED CATH PASSER,32190587,CDM,272,RC,,,Outpatient,,,523.91,314.35,,314.35,60,,141.6,Percent of Total Billed Charges,60% of Total Billed Charges,235.76,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.69,28,,1676.64,Percent of Total Billed Charges,28% of Total Billed Charges,51.81,32,,45.824,Percent of Total Billed Charges,32% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,188.61,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,188.61,36,,2155.68,Percent of Total Billed Charges,36% Total Bille Charges,188.61,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,314.35,60,,622.464,Percent of Total Billed Charges,60% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.91,100,,212,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.55,14.42,,15.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.93,75,,808.592,Percent of Total Billed Charges,75% of Total Billed Charges,261.96,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,261.96,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.96,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,261.96,50,,88.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.74,70,,344.96,Percent of Total Billed Charges,70% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,73.35,14,,15.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.91,100,,1010.736,Percent of Total Billed Charges,100% of Total Billed Charges,51.81,523.91,
ACCESS KIT 10-15,32190605,CDM,272,RC,,,Outpatient,,,7917,4750.20,,4750.2,60,,15983.128,Percent of Total Billed Charges,60% of Total Billed Charges,3562.65,45,,3135.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2216.76,28,,1676.64,Percent of Total Billed Charges,28% of Total Billed Charges,51.81,32,,45.824,Percent of Total Billed Charges,32% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,2850.12,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,2850.12,36,,2155.68,Percent of Total Billed Charges,36% Total Bille Charges,2850.12,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,4750.2,60,,226.56,Percent of Total Billed Charges,60% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7917,100,,717.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1141.63,14.42,,15.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5937.75,75,,926.104,Percent of Total Billed Charges,75% of Total Billed Charges,3958.5,50,,88.904,Percent of Total Billed Charges,50% of Total Billed Charges,3958.5,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3958.5,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,3958.5,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5541.9,70,,339.92,Percent of Total Billed Charges,70% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,1108.38,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7917,100,,1234.8,Percent of Total Billed Charges,100% of Total Billed Charges,51.81,7917,
MICROLINE SURGICAL,32190612,CDM,272,RC,A4649,HCPCS,Outpatient,,,432.48,259.49,,259.49,60,,3125.4,Percent of Total Billed Charges,60% of Total Billed Charges,194.62,45,,313.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.09,28,,1676.64,Percent of Total Billed Charges,28% of Total Billed Charges,52.22,32,,46.08,Percent of Total Billed Charges,32% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,155.69,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,155.69,36,,2155.68,Percent of Total Billed Charges,36% Total Bille Charges,155.69,36,,2155.68,Percent of Total Billed Charges,36% of Total Billed Charges,259.49,60,,230.4,Percent of Total Billed Charges,60% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.48,100,,302.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,62.36,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.36,75,,62.776,Percent of Total Billed Charges,75% of Total Billed Charges,216.24,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,216.24,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.24,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,216.24,50,,34.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.74,70,,792.96,Percent of Total Billed Charges,70% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.48,100,,83.704,Percent of Total Billed Charges,100% of Total Billed Charges,52.22,432.48,
LITHOTRIPSY-KIDNEY STONES,32190613,CDM,790,RC,50590,HCPCS,Outpatient,,,21392.43,12835.46,,12485,100,,3609.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,2995.2,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1676.64,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,52.29,32,,4608,Percent of Total Billed Charges,32% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2155.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2155.68,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2155.68,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,316.8,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,300,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3084.79,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,16044.32,75,,111.904,Percent of Total Billed Charges,75% of Total Billed Charges,7900,100,,34.32,Case Rate,Pays Based on per visit rate,7900,100,,54.84,Case Rate,Pays based on per visit rate,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7900,100,,54.84,Case Rate,Pays based on per visit rate,7900,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,319.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,2994.94,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21392.43,100,,149.2,Percent of Total Billed Charges,100% of Total Billed Charges,52.29,21392.43,
PATELLA TENDON HEMI FF (PS292FF),32190614,CDM,278,RC,C9356,HCPCS,Outpatient,,,7670,4602.00,,8514.38,110,,72,Percent of Total Billed Charges,110% of Total Billed Charges,3451.5,45,,1074.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2147.6,28,,1827.84,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4611.76,Percent of Total Billed Charges,32% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,2761.2,36,,2350.08,Percent of Total Billed Charges,36% of Total Billed Charges,2761.2,36,,2350.08,Percent of Total Billed Charges,36% Total Bille Charges,2761.2,36,,2350.08,Percent of Total Billed Charges,36% of Total Billed Charges,4218.5,55,,864,Percent of Total Billed Charges,55% Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7670,100,,6968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1106.01,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6136,80,,131.704,Percent of Total Billed Charges,80% of Total Billed Charges,3835,50,,41.984,Percent of Total Billed Charges,50% of Total Billed Charges,3835,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3835,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,3835,50,,54.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5369,70,,318.64,Percent of Total Billed Charges,70% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,1073.8,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7670,100,,175.6,Percent of Total Billed Charges,100% of Total Billed Charges,52.3,8514.38,
DRY-DOC CANNULA 7X85MM (C7360),32190615,CDM,272,RC,,,Outpatient,,,137.76,82.66,,82.66,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,61.99,45,,1074.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.57,28,,1827.84,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4633.52,Percent of Total Billed Charges,32% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,36,,2350.08,Percent of Total Billed Charges,36% of Total Billed Charges,49.59,36,,2350.08,Percent of Total Billed Charges,36% Total Bille Charges,49.59,36,,2350.08,Percent of Total Billed Charges,36% of Total Billed Charges,82.66,60,,325.152,Percent of Total Billed Charges,60% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.76,100,,696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.86,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.32,75,,127.648,Percent of Total Billed Charges,75% of Total Billed Charges,68.88,50,,54.84,Percent of Total Billed Charges,50% of Total Billed Charges,68.88,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.88,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,68.88,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.43,70,,315.28,Percent of Total Billed Charges,70% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.76,100,,170.2,Percent of Total Billed Charges,100% of Total Billed Charges,19.29,137.76,
DRY-DOC CANNULA 5X85MM (C7350),32190616,CDM,272,RC,,,Outpatient,,,137.76,82.66,,82.66,60,,31.08,Percent of Total Billed Charges,60% of Total Billed Charges,61.99,45,,1074.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.57,28,,178.08,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4681.632,Percent of Total Billed Charges,32% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,49.59,36,,228.96,Percent of Total Billed Charges,36% Total Bille Charges,49.59,36,,228.96,Percent of Total Billed Charges,36% of Total Billed Charges,82.66,60,,96.784,Percent of Total Billed Charges,60% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.76,100,,6656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.86,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.32,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,68.88,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,68.88,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.88,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,68.88,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.43,70,,286.16,Percent of Total Billed Charges,70% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.76,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,19.29,137.76,
EEA ORVIL STAPLER 21MM (EEAORVIL21A),32190617,CDM,272,RC,,,Outpatient,,,333.6,200.16,,200.16,60,,3762.672,Percent of Total Billed Charges,60% of Total Billed Charges,150.12,45,,975.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.41,28,,75.936,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4704.512,Percent of Total Billed Charges,32% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,120.1,36,,97.632,Percent of Total Billed Charges,36% of Total Billed Charges,120.1,36,,97.632,Percent of Total Billed Charges,36% Total Bille Charges,120.1,36,,97.632,Percent of Total Billed Charges,36% of Total Billed Charges,200.16,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.6,100,,2387.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,48.11,14.42,,136.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.2,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,166.8,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,166.8,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.8,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,166.8,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.52,70,,282.8,Percent of Total Billed Charges,70% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,46.7,14,,132.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.6,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,46.7,333.6,
SUTURE ANCHOR MINI CORKSCREW FT (AR-1319FT),32190618,CDM,278,RC,C1713,HCPCS,Outpatient,,,855,513.00,,1257.76,110,,910.88,Percent of Total Billed Charges,110% of Total Billed Charges,384.75,45,,975.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.4,28,,837.536,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4711.424,Percent of Total Billed Charges,32% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,307.8,36,,1076.832,Percent of Total Billed Charges,36% of Total Billed Charges,307.8,36,,1076.832,Percent of Total Billed Charges,36% Total Bille Charges,307.8,36,,1076.832,Percent of Total Billed Charges,36% of Total Billed Charges,470.25,55,,117.12,Percent of Total Billed Charges,55% Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855,100,,2387.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,123.29,14.42,,40.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,684,80,,64.416,Percent of Total Billed Charges,80% of Total Billed Charges,427.5,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,70,,241.36,Percent of Total Billed Charges,70% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,39.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,855,100,,85.888,Percent of Total Billed Charges,100% of Total Billed Charges,52.3,1257.76,
ANCHOR SUTURE SWIVELOCK TENDOESIS BIOCOMPOSITE 6.25 X 19.1MM (AR-,32190619,CDM,278,RC,C1713,HCPCS,Outpatient,,,1230,738.00,,1670.26,110,,2993.4,Percent of Total Billed Charges,110% of Total Billed Charges,553.5,45,,232.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.4,28,,63.616,Percent of Total Billed Charges,28% of Total Billed Charges,52.3,32,,4770.304,Percent of Total Billed Charges,32% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,442.8,36,,81.792,Percent of Total Billed Charges,36% of Total Billed Charges,442.8,36,,81.792,Percent of Total Billed Charges,36% Total Bille Charges,442.8,36,,81.792,Percent of Total Billed Charges,36% of Total Billed Charges,676.5,55,,59.896,Percent of Total Billed Charges,55% Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1230,100,,2386.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,177.37,14.42,,36.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,984,80,,81.552,Percent of Total Billed Charges,80% of Total Billed Charges,615,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,615,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,615,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,861,70,,238.56,Percent of Total Billed Charges,70% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,172.2,14,,35.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1230,100,,108.736,Percent of Total Billed Charges,100% of Total Billed Charges,52.3,1670.26,
GRAFT VASCULAR HEMASHIELD (M002020851680),32190620,CDM,278,RC,C1768,HCPCS,Outpatient,,,1612.47,967.48,,2096.49,110,,3711.528,Percent of Total Billed Charges,110% of Total Billed Charges,725.61,45,,811.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.49,28,,82.88,Percent of Total Billed Charges,28% of Total Billed Charges,52.34,32,,4817.528,Percent of Total Billed Charges,32% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,580.49,36,,106.56,Percent of Total Billed Charges,36% of Total Billed Charges,580.49,36,,106.56,Percent of Total Billed Charges,36% Total Bille Charges,580.49,36,,106.56,Percent of Total Billed Charges,36% of Total Billed Charges,886.86,55,,113.76,Percent of Total Billed Charges,55% Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1612.47,100,,2168.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,232.52,14.42,,29.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1289.98,80,,123.888,Percent of Total Billed Charges,80% of Total Billed Charges,806.24,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,806.24,50,,474.224,Percent of Total Billed Charges,50% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,806.24,50,,474.224,Percent of Total Billed Charges,50% of Total Billed Charges,806.24,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1128.73,70,,229.6,Percent of Total Billed Charges,70% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,14,,28.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1612.47,100,,165.184,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,2096.49,
VENTRALEX ST HERNIA PATCH 6.4CM (5950008),32190621,CDM,278,RC,C1781,HCPCS,Outpatient,,,2258.2,1354.92,,2936.78,110,,1042.04,Percent of Total Billed Charges,110% of Total Billed Charges,1016.19,45,,9468,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.3,28,,698.88,Percent of Total Billed Charges,28% of Total Billed Charges,52.42,32,,4.616,Percent of Total Billed Charges,32% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,812.95,36,,898.56,Percent of Total Billed Charges,36% of Total Billed Charges,812.95,36,,898.56,Percent of Total Billed Charges,36% Total Bille Charges,812.95,36,,898.56,Percent of Total Billed Charges,36% of Total Billed Charges,1242.01,55,,248.4,Percent of Total Billed Charges,55% Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2258.2,100,,2168.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,325.63,14.42,,8.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1806.56,80,,133.36,Percent of Total Billed Charges,80% of Total Billed Charges,1129.1,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,1129.1,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1129.1,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,1129.1,50,,474.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1580.74,70,,134.96,Percent of Total Billed Charges,70% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,316.15,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2258.2,100,,177.808,Percent of Total Billed Charges,100% of Total Billed Charges,52.42,2936.78,
GRAFT HEMASHIELD PLATINUM (M00202175434PO),32190622,CDM,278,RC,C1768,HCPCS,Outpatient,,,1263.42,758.05,,1712.53,110,,4406.352,Percent of Total Billed Charges,110% of Total Billed Charges,568.54,45,,9720,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.76,28,,2737.28,Percent of Total Billed Charges,28% of Total Billed Charges,52.43,32,,4.624,Percent of Total Billed Charges,32% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,454.83,36,,3519.36,Percent of Total Billed Charges,36% of Total Billed Charges,454.83,36,,3519.36,Percent of Total Billed Charges,36% Total Bille Charges,454.83,36,,3519.36,Percent of Total Billed Charges,36% of Total Billed Charges,694.88,55,,125.344,Percent of Total Billed Charges,55% Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1263.42,100,,516,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,182.19,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1010.74,80,,72.48,Percent of Total Billed Charges,80% of Total Billed Charges,631.71,50,,474.224,Percent of Total Billed Charges,50% of Total Billed Charges,631.71,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.71,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,631.71,50,,142.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,884.39,70,,159.04,Percent of Total Billed Charges,70% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,176.88,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1263.42,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,52.43,1712.53,
RECOVERY RM 0-60 MIN,32200040,CDM,710,RC,,,Outpatient,,,1543.5,926.10,,926.1,60,,10866.08,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,45,,199.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,432.18,28,,7813.264,Percent of Total Billed Charges,28% of Total Billed Charges,52.48,32,,4.704,Percent of Total Billed Charges,32% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,555.66,36,,10045.624,Percent of Total Billed Charges,36% of Total Billed Charges,555.66,36,,10045.624,Percent of Total Billed Charges,36% Total Bille Charges,555.66,36,,10045.624,Percent of Total Billed Charges,36% of Total Billed Charges,926.1,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1543.5,100,,21040,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,222.57,14.42,,13.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1157.63,75,,62.976,Percent of Total Billed Charges,75% of Total Billed Charges,771.75,50,,126.24,Percent of Total Billed Charges,50% of Total Billed Charges,771.75,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.75,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,771.75,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.45,70,,123.2,Percent of Total Billed Charges,70% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,216.09,14,,12.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1543.5,100,,83.968,Percent of Total Billed Charges,100% of Total Billed Charges,52.48,1543.5,
RECOVERY RM EA ADD 30 MIN,32200057,CDM,710,RC,,,Outpatient,,,104.63,62.78,,62.78,60,,2359.64,Percent of Total Billed Charges,60% of Total Billed Charges,47.08,45,,342.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.3,28,,4032,Percent of Total Billed Charges,28% of Total Billed Charges,52.78,32,,4.712,Percent of Total Billed Charges,32% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,36,,5184,Percent of Total Billed Charges,36% of Total Billed Charges,37.67,36,,5184,Percent of Total Billed Charges,36% Total Bille Charges,37.67,36,,5184,Percent of Total Billed Charges,36% of Total Billed Charges,62.78,60,,142.528,Percent of Total Billed Charges,60% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.63,100,,21600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,15.09,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.47,75,,82.264,Percent of Total Billed Charges,75% of Total Billed Charges,52.32,50,,102.576,Percent of Total Billed Charges,50% of Total Billed Charges,52.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.32,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,52.32,50,,29.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.24,70,,115.36,Percent of Total Billed Charges,70% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.65,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.63,100,,109.68,Percent of Total Billed Charges,100% of Total Billed Charges,14.65,104.63,
BG URINE DRN,32221010,CDM,272,RC,,,Outpatient,,,186.5,111.90,,111.9,60,,6485.472,Percent of Total Billed Charges,60% of Total Billed Charges,83.93,45,,26,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.22,28,,1278.368,Percent of Total Billed Charges,28% of Total Billed Charges,52.8,32,,4.792,Percent of Total Billed Charges,32% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,67.14,36,,1643.616,Percent of Total Billed Charges,36% of Total Billed Charges,67.14,36,,1643.616,Percent of Total Billed Charges,36% Total Bille Charges,67.14,36,,1643.616,Percent of Total Billed Charges,36% of Total Billed Charges,111.9,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.5,100,,444.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.89,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.88,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,93.25,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,93.25,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.25,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,93.25,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.55,70,,78.4,Percent of Total Billed Charges,70% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.5,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,26.11,186.5,
TRY CATH FO+BA,32221011,CDM,272,RC,,,Outpatient,,,219.5,131.70,,131.7,60,,9013.896,Percent of Total Billed Charges,60% of Total Billed Charges,98.78,45,,3887.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.46,28,,1744.288,Percent of Total Billed Charges,28% of Total Billed Charges,52.88,32,,4.792,Percent of Total Billed Charges,32% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,79.02,36,,2242.656,Percent of Total Billed Charges,36% of Total Billed Charges,79.02,36,,2242.656,Percent of Total Billed Charges,36% Total Bille Charges,79.02,36,,2242.656,Percent of Total Billed Charges,36% of Total Billed Charges,131.7,60,,25.224,Percent of Total Billed Charges,60% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.5,100,,760.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,31.65,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.63,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,109.75,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,109.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,109.75,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.65,70,,76.16,Percent of Total Billed Charges,70% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.5,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,30.73,219.5,
TRY CATH FO+B+,32221016,CDM,272,RC,,,Outpatient,,,212.75,127.65,,127.65,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,95.74,45,,3465.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.57,28,,4122.496,Percent of Total Billed Charges,28% of Total Billed Charges,53.04,32,,4.8,Percent of Total Billed Charges,32% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,76.59,36,,5300.352,Percent of Total Billed Charges,36% of Total Billed Charges,76.59,36,,5300.352,Percent of Total Billed Charges,36% Total Bille Charges,76.59,36,,5300.352,Percent of Total Billed Charges,36% of Total Billed Charges,127.65,60,,62.592,Percent of Total Billed Charges,60% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.75,100,,857.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.68,14.42,,79.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.56,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,106.38,50,,45.912,Percent of Total Billed Charges,50% of Total Billed Charges,106.38,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.38,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,106.38,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.93,70,,74.48,Percent of Total Billed Charges,70% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,14,,77.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.75,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,29.79,212.75,
0007973 WRAP DURACOLD KNEE LAR,32221018,CDM,271,RC,,,Outpatient,,,150,90.00,,90,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,2202.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,596.96,Percent of Total Billed Charges,28% of Total Billed Charges,53.1,32,,4.816,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,767.52,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,767.52,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,767.52,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,57.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,67.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,73.36,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,65.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
SET INFUSION POWER LOC MAX 20,36000003,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,39589.816,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,1555.008,Percent of Total Billed Charges,28% of Total Billed Charges,53.12,32,,4.84,Percent of Total Billed Charges,32% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,1999.296,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,1999.296,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,1999.296,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,35.864,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,8638.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,71.68,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,120.8,
KIT DRESSING CHANGE POWERGLIDE,36000004,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,26880,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,3032.96,Percent of Total Billed Charges,28% of Total Billed Charges,53.12,32,,46.08,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,3899.52,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,3899.52,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,3899.52,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,100,,7700.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,32.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,711.336,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,59.36,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,31.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,948.448,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,107.36,
TRAY URINE METER SURESTEP 16FR,36000005,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,24135.04,Percent of Total Billed Charges,60% of Total Billed Charges,61.16,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,1103.648,Percent of Total Billed Charges,28% of Total Billed Charges,53.12,32,,46.184,Percent of Total Billed Charges,32% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,1418.976,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,1418.976,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,1418.976,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,50.192,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.92,100,,4894.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,130.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,213.216,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,233.624,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,233.624,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,330.4,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,127.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,284.288,Percent of Total Billed Charges,100% of Total Billed Charges,19.03,135.92,
KIT PORT ACCESS CLEAR SEQUENCE CHANGE CUSTOM,36000006,CDM,271,RC,,,Outpatient,,,206.48,123.89,,123.89,60,,26880,Percent of Total Billed Charges,60% of Total Billed Charges,92.92,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.81,28,,626.528,Percent of Total Billed Charges,28% of Total Billed Charges,53.18,32,,46.6,Percent of Total Billed Charges,32% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,74.33,36,,805.536,Percent of Total Billed Charges,36% of Total Billed Charges,74.33,36,,805.536,Percent of Total Billed Charges,36% Total Bille Charges,74.33,36,,805.536,Percent of Total Billed Charges,36% of Total Billed Charges,123.89,60,,47.792,Percent of Total Billed Charges,60% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.48,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,29.77,14.42,,28.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.86,75,,189.352,Percent of Total Billed Charges,75% of Total Billed Charges,103.24,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.24,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,233.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.54,70,,336.56,Percent of Total Billed Charges,70% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.48,100,,252.472,Percent of Total Billed Charges,100% of Total Billed Charges,28.91,206.48,
TRAY PICC DRSG,36000007,CDM,271,RC,,,Outpatient,,,222.26,133.36,,133.36,60,,8328.24,Percent of Total Billed Charges,60% of Total Billed Charges,100.02,45,,2172.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.23,28,,235.2,Percent of Total Billed Charges,28% of Total Billed Charges,53.28,32,,46.616,Percent of Total Billed Charges,32% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,80.01,36,,302.4,Percent of Total Billed Charges,36% of Total Billed Charges,80.01,36,,302.4,Percent of Total Billed Charges,36% Total Bille Charges,80.01,36,,302.4,Percent of Total Billed Charges,36% of Total Billed Charges,133.36,60,,50.8,Percent of Total Billed Charges,60% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.26,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.05,14.42,,79.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.7,75,,153.864,Percent of Total Billed Charges,75% of Total Billed Charges,111.13,50,,233.624,Percent of Total Billed Charges,50% of Total Billed Charges,111.13,50,,113.496,Percent of Total Billed Charges,50% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.13,50,,113.496,Percent of Total Billed Charges,50% of Total Billed Charges,111.13,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.58,70,,617.048,Percent of Total Billed Charges,70% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,31.12,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.26,100,,205.152,Percent of Total Billed Charges,100% of Total Billed Charges,31.12,222.26,
POWERLOC MAX 20G X 3/4 IN.,36000008,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,2312.624,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,7461.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,120.96,Percent of Total Billed Charges,28% of Total Billed Charges,53.31,32,,46.944,Percent of Total Billed Charges,32% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,155.52,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,155.52,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,93.592,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,94.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,44.736,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,454,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,454,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,113.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,845.6,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,91.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,59.648,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,120.8,
SLEEVE COMPR SCD EXPR KNEE MED,36000009,CDM,271,RC,,,Outpatient,,,85.8,51.48,,51.48,60,,122.88,Percent of Total Billed Charges,60% of Total Billed Charges,38.61,45,,3177.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.02,28,,39.2,Percent of Total Billed Charges,28% of Total Billed Charges,53.43,32,,46.952,Percent of Total Billed Charges,32% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,30.89,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,30.89,36,,50.4,Percent of Total Billed Charges,36% Total Bille Charges,30.89,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,51.48,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.8,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14.42,,28.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.35,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,42.9,50,,113.496,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.9,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,42.9,50,,454,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.06,70,,983.92,Percent of Total Billed Charges,70% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,27.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.8,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,12.01,85.8,
SLEEVE COMPR SCD EXPR KNEE LG,36000010,CDM,271,RC,,,Outpatient,,,104.96,62.98,,62.98,60,,10744.256,Percent of Total Billed Charges,60% of Total Billed Charges,47.23,45,,76.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,28,,1077.44,Percent of Total Billed Charges,28% of Total Billed Charges,53.44,32,,46.96,Percent of Total Billed Charges,32% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,37.79,36,,1385.28,Percent of Total Billed Charges,36% of Total Billed Charges,37.79,36,,1385.28,Percent of Total Billed Charges,36% Total Bille Charges,37.79,36,,1385.28,Percent of Total Billed Charges,36% of Total Billed Charges,62.98,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.96,100,,4828.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,9.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.72,75,,68.864,Percent of Total Billed Charges,75% of Total Billed Charges,52.48,50,,454,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.48,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.48,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.47,70,,4191.6,Percent of Total Billed Charges,70% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.69,14,,9.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.96,100,,91.816,Percent of Total Billed Charges,100% of Total Billed Charges,14.69,104.96,
CUFF FOOT EXPRESS REG SLEEVE,36000011,CDM,271,RC,,,Outpatient,,,137.1,82.26,,82.26,60,,8405.216,Percent of Total Billed Charges,60% of Total Billed Charges,61.7,45,,127.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.39,28,,2912,Percent of Total Billed Charges,28% of Total Billed Charges,53.51,32,,47.04,Percent of Total Billed Charges,32% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,49.36,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,49.36,36,,3744,Percent of Total Billed Charges,36% Total Bille Charges,49.36,36,,3744,Percent of Total Billed Charges,36% of Total Billed Charges,82.26,60,,39.592,Percent of Total Billed Charges,60% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.1,100,,16580.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14.42,,19.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.83,75,,68.864,Percent of Total Billed Charges,75% of Total Billed Charges,68.55,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,68.55,50,,327.704,Percent of Total Billed Charges,50% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.55,50,,327.704,Percent of Total Billed Charges,50% of Total Billed Charges,68.55,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.97,70,,4191.6,Percent of Total Billed Charges,70% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,19.19,14,,18.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.1,100,,91.816,Percent of Total Billed Charges,100% of Total Billed Charges,19.19,137.1,
SLEEVE COMPR SCD EXPR KNEE XL,36000012,CDM,271,RC,,,Outpatient,,,137.52,82.51,,82.51,60,,3113.424,Percent of Total Billed Charges,60% of Total Billed Charges,61.88,45,,438.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.51,28,,3864.816,Percent of Total Billed Charges,28% of Total Billed Charges,53.79,32,,47.232,Percent of Total Billed Charges,32% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,49.51,36,,4969.056,Percent of Total Billed Charges,36% of Total Billed Charges,49.51,36,,4969.056,Percent of Total Billed Charges,36% Total Bille Charges,49.51,36,,4969.056,Percent of Total Billed Charges,36% of Total Billed Charges,82.51,60,,53.592,Percent of Total Billed Charges,60% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.52,100,,7061.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.83,14.42,,25.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.14,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,68.76,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,68.76,50,,97.704,Percent of Total Billed Charges,50% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.76,50,,97.704,Percent of Total Billed Charges,50% of Total Billed Charges,68.76,50,,327.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.26,70,,4191.6,Percent of Total Billed Charges,70% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,24.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.52,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,19.25,137.52,
IV INF THERAPEUTIC CONCURRENT,36000014,CDM,940,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,6067.056,Fee Schedule,100% of Aetna Fee Schedule,116.87,45,,701.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,2589.064,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,47.256,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,3328.8,Fee Schedule,360% of BCBS POS Rate,76.54,360,,3328.8,Fee schedule,360% of BCBS PPO Rate,76.54,360,,3328.8,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.72,100,,170.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,43.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,327.704,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,34.304,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,34.304,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,97.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,4191.6,Case Rate,Pays based on per visit rate,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
IV INF THERAP ADDL SEQUENTIAL,36000015,CDM,940,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,2352.224,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,861.84,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,16.4,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,47.304,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,21.08,Fee Schedule,360% of BCBS POS Rate,114.16,360,,21.08,Fee schedule,360% of BCBS PPO Rate,114.16,360,,21.08,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,284.064,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,43.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,97.704,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,66.304,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,66.304,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,34.304,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,4569.6,Case Rate,Pays based on per visit rate,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IMMUNIZATION INJECT INFLUENZA,36000073,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,2045.92,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,135,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,1569.568,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,47.36,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,2018.016,Fee Schedule,360% of BCBS POS Rate,85.64,360,,2018.016,Fee schedule,360% of BCBS PPO Rate,85.64,360,,2018.016,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,154.624,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,974.6,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,11.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,34.304,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,66.304,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,4569.6,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
IV INFUSION HYDRATION EA HR,36001000,CDM,940,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,37.408,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,839.776,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,2464.864,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,47.744,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,3169.112,Fee Schedule,360% of BCBS POS Rate,49.28,360,,3169.112,Fee schedule,360% of BCBS PPO Rate,49.28,360,,3169.112,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,166.952,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,1915.2,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,26.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,350.44,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,87.8,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,189.84,Case Rate,Pays based on per visit rate,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,25.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,467.248,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION HYDRATION 1ST HR,36001001,CDM,940,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,26397.76,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,777.144,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,420,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,47.832,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,540,Fee Schedule,360% of BCBS POS Rate,138.82,360,,540,Fee schedule,360% of BCBS PPO Rate,138.82,360,,540,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,54.008,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,300,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,46,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,2093.84,Case Rate,Pays based on per visit rate,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
PUNCTURE SHUNT TUBE,36001002,CDM,361,RC,61070,HCPCS,Outpatient,,,1185.56,711.34,,2601,100,,4952.512,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,280.8,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,2271.752,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,53.82,32,,47.832,Percent of Total Billed Charges,32% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,2920.824,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,2920.824,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,2920.824,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,136.856,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,458.304,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,170.96,14.42,,61.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,889.17,75,,170.248,Percent of Total Billed Charges,75% of Total Billed Charges,592.78,50,,149.4,Percent of Total Billed Charges,50% of Total Billed Charges,592.78,50,,105.704,Percent of Total Billed Charges,50% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,592.78,50,,105.704,Percent of Total Billed Charges,50% of Total Billed Charges,592.78,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,159.04,Fee Schedule,100% of ASC Tier Groupings fee schedule,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,165.98,14,,59.304,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1185.56,100,,226.992,Percent of Total Billed Charges,100% of Total Billed Charges,53.82,2601,
INSERT FOLEY CATHETER,36001003,CDM,761,RC,51702,HCPCS,Outpatient,,,355.36,213.22,,24.49,100,,17173.184,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,351,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.5,28,,381.248,Percent of Total Billed Charges,28% of Total Billed Charges,54.09,32,,47.928,Percent of Total Billed Charges,32% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,127.93,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,127.93,36,,490.176,Percent of Total Billed Charges,36% Total Bille Charges,127.93,36,,490.176,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,72,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,1866.16,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,51.24,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,266.52,75,,680.992,Percent of Total Billed Charges,75% of Total Billed Charges,177.68,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.68,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,177.68,50,,105.704,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,248.75,70,,207.2,Percent of Total Billed Charges,70% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,49.75,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,355.36,100,,907.992,Percent of Total Billed Charges,100% of Total Billed Charges,24.49,515,
INSERT STRAIGHT CATHETER,36001004,CDM,761,RC,51701,HCPCS,Outpatient,,,315.59,189.35,,24.67,100,,9829.936,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,131.376,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.37,28,,1528.576,Percent of Total Billed Charges,28% of Total Billed Charges,54.16,32,,48.008,Percent of Total Billed Charges,32% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,113.61,36,,1965.312,Percent of Total Billed Charges,36% of Total Billed Charges,113.61,36,,1965.312,Percent of Total Billed Charges,36% Total Bille Charges,113.61,36,,1965.312,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,84.928,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,1726.992,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,45.51,14.42,,41.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,236.69,75,,149.552,Percent of Total Billed Charges,75% of Total Billed Charges,157.8,50,,105.704,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,157.8,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,157.8,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,70,,1747.2,Percent of Total Billed Charges,70% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,44.18,14,,40.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,315.59,100,,199.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.67,515,
POST VOID RESID BLADDER SCAN,36001005,CDM,761,RC,51798,HCPCS,Outpatient,,,256.44,153.86,,10.26,100,,72,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,131.664,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,71.8,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,54.37,32,,48.008,Percent of Total Billed Charges,32% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,92.32,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,92.32,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,92.32,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,110.792,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,624,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,36.98,14.42,,71.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,192.33,75,,412.8,Percent of Total Billed Charges,75% of Total Billed Charges,128.22,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,211.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,128.22,50,,211.8,Percent of Total Billed Charges,50% of Total Billed Charges,128.22,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,70,,6843.2,Percent of Total Billed Charges,70% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,35.9,14,,69.752,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,256.44,100,,550.4,Percent of Total Billed Charges,100% of Total Billed Charges,10.26,515,
SLEEVE COMPR SCD EXPR KNEE MED,36003020,CDM,271,RC,,,Outpatient,,,74.56,44.74,,44.74,60,,2154.224,Percent of Total Billed Charges,60% of Total Billed Charges,33.55,45,,533.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.88,28,,2523.024,Percent of Total Billed Charges,28% of Total Billed Charges,5479.04,32,,48.024,Percent of Total Billed Charges,32% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,26.84,36,,3243.888,Percent of Total Billed Charges,36% of Total Billed Charges,26.84,36,,3243.888,Percent of Total Billed Charges,36% Total Bille Charges,26.84,36,,3243.888,Percent of Total Billed Charges,36% of Total Billed Charges,44.74,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.56,100,,780,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.75,14.42,,186.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.92,75,,491.552,Percent of Total Billed Charges,75% of Total Billed Charges,37.28,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.28,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,50,,211.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.19,70,,6981.52,Percent of Total Billed Charges,70% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,180.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.56,100,,655.4,Percent of Total Billed Charges,100% of Total Billed Charges,10.44,5479.04,
SLEEVE COMPR SCD EXPR KNEE LG,36003021,CDM,271,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,8202.304,Percent of Total Billed Charges,60% of Total Billed Charges,56.63,45,,1427.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,276.16,Percent of Total Billed Charges,28% of Total Billed Charges,5509.1,32,,48.104,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,355.064,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,355.064,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,355.064,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,291.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,86.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,146.552,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,211.8,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,142.904,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,142.904,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,10080,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,84.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,195.4,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,5509.1,
CUFF FOOT EXPRESS REG SLEEVE,36003024,CDM,271,RC,,,Outpatient,,,114.77,68.86,,68.86,60,,7084.336,Percent of Total Billed Charges,60% of Total Billed Charges,51.65,45,,91.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.14,28,,487.824,Percent of Total Billed Charges,28% of Total Billed Charges,5521.17,32,,48.136,Percent of Total Billed Charges,32% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,36,,627.2,Percent of Total Billed Charges,36% of Total Billed Charges,41.32,36,,627.2,Percent of Total Billed Charges,36% Total Bille Charges,41.32,36,,627.2,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.77,100,,292.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.55,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.08,75,,51.448,Percent of Total Billed Charges,75% of Total Billed Charges,57.39,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,57.39,50,,249.104,Percent of Total Billed Charges,50% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.39,50,,249.104,Percent of Total Billed Charges,50% of Total Billed Charges,57.39,50,,142.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.34,70,,1092,Percent of Total Billed Charges,70% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.77,100,,68.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.07,5521.17,
CUFF FOOT EXPRESS LARGE SLEEVE,36003025,CDM,271,RC,,,Outpatient,,,114.77,68.86,,68.86,60,,9193.696,Percent of Total Billed Charges,60% of Total Billed Charges,51.65,45,,27.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.14,28,,2589.064,Percent of Total Billed Charges,28% of Total Billed Charges,5521.17,32,,48.224,Percent of Total Billed Charges,32% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,41.32,36,,3328.8,Percent of Total Billed Charges,36% of Total Billed Charges,41.32,36,,3328.8,Percent of Total Billed Charges,36% Total Bille Charges,41.32,36,,3328.8,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.77,100,,1185.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.55,14.42,,9.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.08,75,,99.448,Percent of Total Billed Charges,75% of Total Billed Charges,57.39,50,,142.904,Percent of Total Billed Charges,50% of Total Billed Charges,57.39,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.39,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,57.39,50,,249.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.34,70,,3195.92,Percent of Total Billed Charges,70% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,16.07,14,,9.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.77,100,,132.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.07,5521.17,
FEEDING TUBE CORTRAK EAS,36004015,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,4987.824,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,3038.824,Percent of Total Billed Charges,28% of Total Billed Charges,5661.38,32,,48.272,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,3907.064,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,3907.064,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,3907.064,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,3172,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,98.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,131.704,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,249.104,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,4360.72,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,175.6,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,5661.38,
IV INFUSION THERAPEUTIC 1ST HR,36007656,CDM,940,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,17.84,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,40.68,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,3296.384,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,48.336,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,4238.208,Fee Schedule,360% of BCBS POS Rate,262.08,360,,4238.208,Fee schedule,360% of BCBS PPO Rate,262.08,360,,4238.208,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,61.44,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,203.2,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,79.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,224.104,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,1492.4,Case Rate,Pays based on per visit rate,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,76.84,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,298.8,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,36007664,CDM,940,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,17.84,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,302.4,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,3864.816,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,48.384,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,4969.056,Fee Schedule,360% of BCBS POS Rate,79.13,360,,4969.056,Fee schedule,360% of BCBS PPO Rate,79.13,360,,4969.056,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,57.256,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,60.8,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,224.104,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,300.624,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,3887.52,Case Rate,Pays based on per visit rate,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,298.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV PUSH THER INITIAL MED,36007748,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,21.44,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,21.6,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,3296.384,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,48.424,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,4238.208,Fee Schedule,360% of BCBS POS Rate,142.7,360,,4238.208,Fee schedule,360% of BCBS PPO Rate,142.7,360,,4238.208,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,300,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,359.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,62.104,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,7582.4,Case Rate,Pays based on per visit rate,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,348.664,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,82.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
PEG TUBE PLACEMENT,36016195,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,21.44,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,161.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,4712.64,Percent of Total Billed Charges,28% of Total Billed Charges,5664,32,,48.432,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,6059.112,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,6059.112,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,6059.112,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,90.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,52.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,158.552,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,34.608,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,274.416,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,2759.12,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,51.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,211.4,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,5664,
FNA W/O GUIDANCE,36030380,CDM,360,RC,,,Outpatient,,,584.06,350.44,,350.44,60,,94.92,Percent of Total Billed Charges,60% of Total Billed Charges,262.83,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.54,28,,3401.768,Percent of Total Billed Charges,28% of Total Billed Charges,5664,32,,5006.752,Percent of Total Billed Charges,32% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,210.26,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,210.26,36,,4373.696,Percent of Total Billed Charges,36% Total Bille Charges,210.26,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,350.44,60,,375.552,Percent of Total Billed Charges,60% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.06,100,,2529.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,84.22,14.42,,33.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.05,75,,967.832,Percent of Total Billed Charges,75% of Total Billed Charges,292.03,50,,280.68,Percent of Total Billed Charges,50% of Total Billed Charges,292.03,50,,333.84,Percent of Total Billed Charges,50% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.03,50,,333.84,Percent of Total Billed Charges,50% of Total Billed Charges,292.03,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,408.84,70,,40.992,Percent of Total Billed Charges,70% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,81.77,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.06,100,,1290.44,Percent of Total Billed Charges,100% of Total Billed Charges,81.77,5664,
INJECTION SQ OR IM,36030724,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,482.24,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,543.824,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,3401.768,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,5013.792,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,4373.696,Fee Schedule,360% of BCBS POS Rate,217.69,360,,4373.696,Fee schedule,360% of BCBS PPO Rate,217.69,360,,4373.696,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,266.144,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,18.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,450.936,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,266.64,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,266.64,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,333.84,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,3923.92,Case Rate,Pays based on per visit rate,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,17.584,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,601.248,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
ANESTHESIA ADD'L 15 MIN,37000011,CDM,370,RC,,,Outpatient,,,283.74,170.24,,170.24,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,127.68,45,,1469.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.45,28,,3401.768,Percent of Total Billed Charges,28% of Total Billed Charges,5.47,32,,5013.792,Percent of Total Billed Charges,32% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,102.15,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,102.15,36,,4373.696,Percent of Total Billed Charges,36% Total Bille Charges,102.15,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,170.24,60,,92.64,Percent of Total Billed Charges,60% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.74,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,40.92,14.42,,24.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.81,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,141.87,50,,333.84,Percent of Total Billed Charges,50% of Total Billed Charges,141.87,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.87,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,141.87,50,,266.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.62,70,,23296.28,Percent of Total Billed Charges,70% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,39.72,14,,23.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.74,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,5.47,283.74,
ANESTHESIA 0-60 MIN,37000049,CDM,370,RC,,,Outpatient,,,1134.99,680.99,,680.99,60,,95.28,Percent of Total Billed Charges,60% of Total Billed Charges,510.75,45,,81.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.8,28,,3401.768,Percent of Total Billed Charges,28% of Total Billed Charges,5.48,32,,5079.032,Percent of Total Billed Charges,32% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,408.6,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,408.6,36,,4373.696,Percent of Total Billed Charges,36% Total Bille Charges,408.6,36,,4373.696,Percent of Total Billed Charges,36% of Total Billed Charges,680.99,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1134.99,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,163.67,14.42,,121.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.24,75,,51.904,Percent of Total Billed Charges,75% of Total Billed Charges,567.5,50,,266.64,Percent of Total Billed Charges,50% of Total Billed Charges,567.5,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567.5,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,567.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,794.49,70,,6162.16,Percent of Total Billed Charges,70% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,158.9,14,,117.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1134.99,100,,69.208,Percent of Total Billed Charges,100% of Total Billed Charges,5.48,1134.99,
CATH EPIDURAL,37020257,CDM,272,RC,,,Outpatient,,,249.25,149.55,,149.55,60,,96.288,Percent of Total Billed Charges,60% of Total Billed Charges,112.16,45,,107.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.79,28,,5938.896,Percent of Total Billed Charges,28% of Total Billed Charges,5.48,32,,5119.488,Percent of Total Billed Charges,32% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,89.73,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,89.73,36,,7635.72,Percent of Total Billed Charges,36% Total Bille Charges,89.73,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,149.55,60,,105.04,Percent of Total Billed Charges,60% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.25,100,,1208.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,35.94,14.42,,127.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.94,75,,514.4,Percent of Total Billed Charges,75% of Total Billed Charges,124.63,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,124.63,50,,62.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.63,50,,62.8,Percent of Total Billed Charges,50% of Total Billed Charges,124.63,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.48,70,,1050,Percent of Total Billed Charges,70% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,123.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.25,100,,685.864,Percent of Total Billed Charges,100% of Total Billed Charges,5.48,249.25,
CATH CNTRL VEIN,37020258,CDM,272,RC,C1751,HCPCS,Outpatient,,,688,412.80,,67.66,100,,100.776,Fee Schedule,100% of Aetna Fee Schedule,309.6,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.64,28,,5938.896,Percent of Total Billed Charges,28% of Total Billed Charges,5.51,32,,4.912,Percent of Total Billed Charges,32% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,247.68,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,247.68,36,,7635.72,Percent of Total Billed Charges,36% Total Bille Charges,247.68,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,412.8,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688,100,,3265.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,99.21,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516,75,,411.624,Percent of Total Billed Charges,75% of Total Billed Charges,344,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,344,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,344,50,,62.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.6,70,,3821.44,Percent of Total Billed Charges,70% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688,100,,548.832,Percent of Total Billed Charges,100% of Total Billed Charges,5.51,688,
CATH SW-GZ TH/PC,37020259,CDM,272,RC,,,Outpatient,,,819.25,491.55,,491.55,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,368.66,45,,473.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.39,28,,5938.896,Percent of Total Billed Charges,28% of Total Billed Charges,5.52,32,,4.96,Percent of Total Billed Charges,32% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,294.93,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,294.93,36,,7635.72,Percent of Total Billed Charges,36% Total Bille Charges,294.93,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,491.55,60,,71.08,Percent of Total Billed Charges,60% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.25,100,,181.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,118.14,14.42,,29.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.44,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,409.63,50,,62.8,Percent of Total Billed Charges,50% of Total Billed Charges,409.63,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,409.63,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,409.63,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,573.48,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,114.7,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819.25,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,5.52,819.25,
TRY ANS SPINAL,37020261,CDM,272,RC,,,Outpatient,,,244.25,146.55,,146.55,60,,119.64,Percent of Total Billed Charges,60% of Total Billed Charges,109.91,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.39,28,,5938.896,Percent of Total Billed Charges,28% of Total Billed Charges,5.52,32,,4.968,Percent of Total Billed Charges,32% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,87.93,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,87.93,36,,7635.72,Percent of Total Billed Charges,36% Total Bille Charges,87.93,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,146.55,60,,71.08,Percent of Total Billed Charges,60% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.25,100,,239.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,35.22,14.42,,18.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.19,75,,1867.832,Percent of Total Billed Charges,75% of Total Billed Charges,122.13,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,122.13,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.13,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,122.13,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.98,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,14,,17.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.25,100,,2490.44,Percent of Total Billed Charges,100% of Total Billed Charges,5.52,244.25,
TB ENDOTRACH,37020263,CDM,272,RC,,,Outpatient,,,85.75,51.45,,51.45,60,,117.192,Percent of Total Billed Charges,60% of Total Billed Charges,38.59,45,,115.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.01,28,,5938.896,Percent of Total Billed Charges,28% of Total Billed Charges,5.56,32,,5,Percent of Total Billed Charges,32% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,30.87,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,30.87,36,,7635.72,Percent of Total Billed Charges,36% Total Bille Charges,30.87,36,,7635.72,Percent of Total Billed Charges,36% of Total Billed Charges,51.45,60,,35.864,Percent of Total Billed Charges,60% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.75,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.37,14.42,,35.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.31,75,,273.6,Percent of Total Billed Charges,75% of Total Billed Charges,42.88,50,,420.12,Percent of Total Billed Charges,50% of Total Billed Charges,42.88,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.88,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,42.88,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.03,70,,690.4,Percent of Total Billed Charges,70% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,12.01,14,,34.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.75,100,,364.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,85.75,
TB ENDTRACH,37020264,CDM,272,RC,,,Outpatient,,,165.75,99.45,,99.45,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,74.59,45,,160.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.41,28,,5358.648,Percent of Total Billed Charges,28% of Total Billed Charges,5.56,32,,5.008,Percent of Total Billed Charges,32% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,59.67,36,,6889.688,Percent of Total Billed Charges,36% of Total Billed Charges,59.67,36,,6889.688,Percent of Total Billed Charges,36% Total Bille Charges,59.67,36,,6889.688,Percent of Total Billed Charges,36% of Total Billed Charges,99.45,60,,44.152,Percent of Total Billed Charges,60% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.75,100,,1052.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.9,14.42,,242.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.31,75,,319.2,Percent of Total Billed Charges,75% of Total Billed Charges,82.88,50,,440.752,Percent of Total Billed Charges,50% of Total Billed Charges,82.88,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.88,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,82.88,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.03,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,23.21,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.75,100,,425.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,165.75,
TB TRCH OCUF RAE,37020265,CDM,272,RC,,,Outpatient,,,219.5,131.70,,131.7,60,,2745.6,Percent of Total Billed Charges,60% of Total Billed Charges,98.78,45,,1524.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.46,28,,6039.52,Percent of Total Billed Charges,28% of Total Billed Charges,5.56,32,,5.04,Percent of Total Billed Charges,32% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,79.02,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,79.02,36,,7765.096,Percent of Total Billed Charges,36% Total Bille Charges,79.02,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,131.7,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.5,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,31.65,14.42,,13.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.63,75,,421.024,Percent of Total Billed Charges,75% of Total Billed Charges,109.75,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,109.75,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.75,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,109.75,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.65,70,,14847.232,Percent of Total Billed Charges,70% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,30.73,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.5,100,,561.36,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,219.5,
TRNSDU SNGL,37020266,CDM,270,RC,,,Outpatient,,,373.5,224.10,,224.1,60,,727.384,Percent of Total Billed Charges,60% of Total Billed Charges,168.08,45,,47.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,28,,6039.52,Percent of Total Billed Charges,28% of Total Billed Charges,5.57,32,,5.04,Percent of Total Billed Charges,32% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% Total Bille Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,224.1,60,,35.864,Percent of Total Billed Charges,60% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.5,100,,256.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,53.86,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.13,75,,228,Percent of Total Billed Charges,75% of Total Billed Charges,186.75,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,186.75,50,,62.992,Percent of Total Billed Charges,50% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.75,50,,62.992,Percent of Total Billed Charges,50% of Total Billed Charges,186.75,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.45,70,,473.344,Percent of Total Billed Charges,70% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.5,100,,304,Percent of Total Billed Charges,100% of Total Billed Charges,5.57,373.5,
TRNSDU SNGL,37020270,CDM,270,RC,,,Outpatient,,,373.5,224.10,,224.1,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,168.08,45,,60.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,28,,6039.52,Percent of Total Billed Charges,28% of Total Billed Charges,5.59,32,,5.072,Percent of Total Billed Charges,32% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% Total Bille Charges,134.46,36,,7765.096,Percent of Total Billed Charges,36% of Total Billed Charges,224.1,60,,89.28,Percent of Total Billed Charges,60% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.5,100,,356,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,53.86,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.13,75,,500.76,Percent of Total Billed Charges,75% of Total Billed Charges,186.75,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,186.75,50,,123.216,Percent of Total Billed Charges,50% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.75,50,,123.216,Percent of Total Billed Charges,50% of Total Billed Charges,186.75,50,,62.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.45,70,,464.368,Percent of Total Billed Charges,70% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.5,100,,667.68,Percent of Total Billed Charges,100% of Total Billed Charges,5.59,373.5,
NDL SPINAL A/S,37020271,CDM,272,RC,,,Outpatient,,,103.5,62.10,,62.1,60,,637.792,Percent of Total Billed Charges,60% of Total Billed Charges,46.58,45,,135.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.98,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,5.59,32,,5.08,Percent of Total Billed Charges,32% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.26,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,37.26,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,37.26,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,62.1,60,,49.896,Percent of Total Billed Charges,60% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,100,,3388,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.63,75,,399.96,Percent of Total Billed Charges,75% of Total Billed Charges,51.75,50,,62.992,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.75,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,123.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.45,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.5,100,,533.28,Percent of Total Billed Charges,100% of Total Billed Charges,5.59,103.5,
TRAY CSE ANES KI,37020272,CDM,272,RC,,,Outpatient,,,264.25,158.55,,158.55,60,,1498.672,Percent of Total Billed Charges,60% of Total Billed Charges,118.91,45,,382.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.99,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,5.62,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,95.13,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,95.13,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,95.13,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,158.55,60,,104.64,Percent of Total Billed Charges,60% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.25,100,,106.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.1,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.19,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,132.13,50,,123.216,Percent of Total Billed Charges,50% of Total Billed Charges,132.13,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.13,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,132.13,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.98,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,37,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.25,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,5.62,264.25,
NERVE BLOCK TRAY,37020273,CDM,270,RC,,,Outpatient,,,229,137.40,,137.4,60,,1129.68,Percent of Total Billed Charges,60% of Total Billed Charges,103.05,45,,112.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.12,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,5.62,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,82.44,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,82.44,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,82.44,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,137.4,60,,34.04,Percent of Total Billed Charges,60% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229,100,,134.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.02,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.75,75,,174,Percent of Total Billed Charges,75% of Total Billed Charges,114.5,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,114.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,114.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.3,70,,1250.784,Percent of Total Billed Charges,70% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,32.06,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229,100,,232,Percent of Total Billed Charges,100% of Total Billed Charges,5.62,229,
KT ARTERY RADIL,37020274,CDM,272,RC,,,Outpatient,,,398.75,239.25,,239.25,60,,1084.176,Percent of Total Billed Charges,60% of Total Billed Charges,179.44,45,,64.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.65,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,5.64,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.55,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,143.55,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,143.55,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,239.25,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.75,100,,301.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,57.5,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.06,75,,94.2,Percent of Total Billed Charges,75% of Total Billed Charges,199.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,199.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,199.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.13,70,,886.888,Percent of Total Billed Charges,70% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.75,100,,125.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.64,398.75,
CVP MULTILUMEN,37020275,CDM,270,RC,,,Outpatient,,,529.5,317.70,,317.7,60,,371.368,Percent of Total Billed Charges,60% of Total Billed Charges,238.28,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.26,28,,6878.088,Percent of Total Billed Charges,28% of Total Billed Charges,5.64,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,190.62,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,190.62,36,,8843.256,Percent of Total Billed Charges,36% Total Bille Charges,190.62,36,,8843.256,Percent of Total Billed Charges,36% of Total Billed Charges,317.7,60,,36.12,Percent of Total Billed Charges,60% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.5,100,,849.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,76.35,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.13,75,,126,Percent of Total Billed Charges,75% of Total Billed Charges,264.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,264.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,264.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.65,70,,60.48,Percent of Total Billed Charges,70% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,74.13,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.5,100,,168,Percent of Total Billed Charges,100% of Total Billed Charges,5.64,529.5,
TRY ANS EPIDRL,37020276,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,424.808,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,173.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,6835.696,Percent of Total Billed Charges,28% of Total Billed Charges,5.67,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,8788.752,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,8788.752,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,8788.752,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,46,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,249.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,231.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,630.184,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,106.488,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,224.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,840.24,Percent of Total Billed Charges,100% of Total Billed Charges,5.67,150,
TRY ARTRL LIN,37020277,CDM,272,RC,,,Outpatient,,,357.25,214.35,,214.35,60,,424.808,Percent of Total Billed Charges,60% of Total Billed Charges,160.76,45,,2023.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.03,28,,5232.976,Percent of Total Billed Charges,28% of Total Billed Charges,5.75,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,128.61,36,,6728.112,Percent of Total Billed Charges,36% of Total Billed Charges,128.61,36,,6728.112,Percent of Total Billed Charges,36% Total Bille Charges,128.61,36,,6728.112,Percent of Total Billed Charges,36% of Total Billed Charges,214.35,60,,106.32,Percent of Total Billed Charges,60% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,357.25,100,,143.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.52,14.42,,29.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.94,75,,661.12,Percent of Total Billed Charges,75% of Total Billed Charges,178.63,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,178.63,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.63,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,178.63,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.08,70,,21.096,Percent of Total Billed Charges,70% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,50.02,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,357.25,100,,881.496,Percent of Total Billed Charges,100% of Total Billed Charges,5.75,357.25,
KT CATH PERCUTN,37020278,CDM,272,RC,,,Outpatient,,,622.75,373.65,,373.65,60,,637.792,Percent of Total Billed Charges,60% of Total Billed Charges,280.24,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.37,28,,189.336,Percent of Total Billed Charges,28% of Total Billed Charges,54.41,32,,48.664,Percent of Total Billed Charges,32% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,36,,243.432,Percent of Total Billed Charges,36% of Total Billed Charges,224.19,36,,243.432,Percent of Total Billed Charges,36% Total Bille Charges,224.19,36,,243.432,Percent of Total Billed Charges,36% of Total Billed Charges,373.65,60,,68.16,Percent of Total Billed Charges,60% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.75,100,,90.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,89.8,14.42,,122.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,467.06,75,,395.416,Percent of Total Billed Charges,75% of Total Billed Charges,311.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,311.38,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.38,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,311.38,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435.93,70,,1176,Percent of Total Billed Charges,70% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.19,14,,119.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,622.75,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,54.41,622.75,
EPIDURAL BLOOD PATCH,37020281,CDM,761,RC,62273,HCPCS,Outpatient,,,1613.05,967.83,,97.08,100,,633.464,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,1575.944,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,451.65,28,,185.744,Percent of Total Billed Charges,28% of Total Billed Charges,54.41,32,,48.68,Percent of Total Billed Charges,32% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,580.7,36,,238.816,Percent of Total Billed Charges,36% of Total Billed Charges,580.7,36,,238.816,Percent of Total Billed Charges,36% Total Bille Charges,580.7,36,,238.816,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,113.768,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,384.912,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,232.6,14.42,,70.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1209.79,75,,296.28,Percent of Total Billed Charges,75% of Total Billed Charges,806.53,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,806.53,50,,425.6,Percent of Total Billed Charges,50% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,806.53,50,,425.6,Percent of Total Billed Charges,50% of Total Billed Charges,806.53,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.14,70,,327.464,Percent of Total Billed Charges,70% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,68.544,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1613.05,100,,395.04,Percent of Total Billed Charges,100% of Total Billed Charges,54.41,1613.05,
MIDLINE MAX PROVENA 3F,37700000,CDM,271,RC,,,Outpatient,,,751.56,450.94,,450.94,60,,422.312,Percent of Total Billed Charges,60% of Total Billed Charges,338.2,45,,18.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.44,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,54.41,32,,48.768,Percent of Total Billed Charges,32% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,270.56,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,270.56,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,270.56,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,450.94,60,,42.72,Percent of Total Billed Charges,60% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.56,100,,4497.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,108.37,14.42,,79.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.67,75,,151.2,Percent of Total Billed Charges,75% of Total Billed Charges,375.78,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,126.4,Percent of Total Billed Charges,50% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.78,50,,126.4,Percent of Total Billed Charges,50% of Total Billed Charges,375.78,50,,425.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,526.09,70,,627.64,Percent of Total Billed Charges,70% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,105.22,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,751.56,100,,201.6,Percent of Total Billed Charges,100% of Total Billed Charges,54.41,751.56,
INSERT MIDLINE W/IMAGE >5YO,37700002,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,422.312,Fee Schedule,100% of Aetna Fee Schedule,1672.66,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48.96,Other,Not Seperately Reimbusable,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,47.792,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3717.03,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,72.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,668.328,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,425.6,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,126.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,1529.688,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,70.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,891.104,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
CVC STERILE DRESSING,37700013,CDM,272,RC,A6550,HCPCS,Outpatient,,,86.51,51.91,,18.72,100,,1174.24,Fee Schedule,100% of Aetna Fee Schedule,38.93,45,,277.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,280,,180.104,Fee Schedule,280% of BCBS BULE Fee Schedule,87.9,320,,49.344,Fee Schedule,320% of BCBS Blue Essentials Rate,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,98.89,360,,231.568,Fee Schedule,360% of BCBS POS Rate,98.89,360,,231.568,Fee schedule,360% of BCBS PPO Rate,98.89,360,,231.568,Fee Schedule,360% of BCBS Traditional Rate,51.91,60,,38.448,Percent of Total Billed Charges,60% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.51,100,,1984.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.47,14.42,,14.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.88,75,,216,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,43.26,50,,141.68,Percent of Total Billed Charges,50% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.26,50,,141.68,Percent of Total Billed Charges,50% of Total Billed Charges,43.26,50,,195.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.56,70,,245.488,Percent of Total Billed Charges,70% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14,,14.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.51,100,,288,Percent of Total Billed Charges,100% of Total Billed Charges,12.11,98.89,
CVC STERILE DRESSING W/ PRO QR,37700014,CDM,272,RC,A6550,HCPCS,Outpatient,,,,,,18.72,100,,1444.84,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.92,280,,305.632,Fee Schedule,280% of BCBS BULE Fee Schedule,87.9,320,,49.92,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,98.89,360,,392.96,Fee Schedule,360% of BCBS POS Rate,98.89,360,,392.96,Fee schedule,360% of BCBS PPO Rate,98.89,360,,392.96,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.72,98.89,
DECLOT CVAD/CATH THROMBOLYTIC,37700016,CDM,761,RC,36593,HCPCS,Outpatient,,,857.33,514.40,,30.97,100,,4703.448,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,2294.28,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,240.05,28,,769.424,Percent of Total Billed Charges,28% of Total Billed Charges,54.56,32,,50.04,Percent of Total Billed Charges,32% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,308.64,36,,989.256,Percent of Total Billed Charges,36% of Total Billed Charges,308.64,36,,989.256,Percent of Total Billed Charges,36% Total Bille Charges,308.64,36,,989.256,Percent of Total Billed Charges,36% of Total Billed Charges,515,103,,34.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,617.6,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,643,75,,87.384,Percent of Total Billed Charges,75% of Total Billed Charges,428.67,50,,213.512,Percent of Total Billed Charges,50% of Total Billed Charges,428.67,50,,180.112,Percent of Total Billed Charges,50% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,428.67,50,,180.112,Percent of Total Billed Charges,50% of Total Billed Charges,428.67,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,600.13,70,,545.776,Percent of Total Billed Charges,70% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,857.33,100,,116.512,Percent of Total Billed Charges,100% of Total Billed Charges,30.97,857.33,
MIDLINE MAX PROVENA 4F,37700019,CDM,271,RC,,,Outpatient,,,686.04,411.62,,411.62,60,,4001.208,Percent of Total Billed Charges,60% of Total Billed Charges,308.72,45,,1586.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.09,28,,592.904,Percent of Total Billed Charges,28% of Total Billed Charges,54.56,32,,50.4,Percent of Total Billed Charges,32% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,246.97,36,,762.304,Percent of Total Billed Charges,36% of Total Billed Charges,246.97,36,,762.304,Percent of Total Billed Charges,36% Total Bille Charges,246.97,36,,762.304,Percent of Total Billed Charges,36% of Total Billed Charges,411.62,60,,53.624,Percent of Total Billed Charges,60% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,686.04,100,,5098.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,98.93,14.42,,40.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,514.53,75,,702.96,Percent of Total Billed Charges,75% of Total Billed Charges,343.02,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.02,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,343.02,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.23,70,,1034.672,Percent of Total Billed Charges,70% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,96.05,14,,39.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,686.04,100,,937.28,Percent of Total Billed Charges,100% of Total Billed Charges,54.56,686.04,
INSERT PICC CATH W/IMAGE > 5 YO,37700028,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,1859.296,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,1008,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,413.872,Percent of Total Billed Charges,28% of Total Billed Charges,54.58,32,,512.272,Percent of Total Billed Charges,32% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,532.12,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,532.12,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,532.12,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,66.72,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,1800,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,26.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,120,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,140.4,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,94.4,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,94.4,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,4484.504,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,25.784,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,54.58,4892.5,
PICC LINE RPLCMT WO PORT W IMG,37700050,CDM,761,RC,36584,HCPCS,Outpatient,,,3113.05,1867.83,,54.59,100,,2282.272,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,756,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,871.65,28,,409.336,Percent of Total Billed Charges,28% of Total Billed Charges,55.04,32,,534.856,Percent of Total Billed Charges,32% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1120.7,36,,526.288,Percent of Total Billed Charges,36% of Total Billed Charges,1120.7,36,,526.288,Percent of Total Billed Charges,36% Total Bille Charges,1120.7,36,,526.288,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,43.72,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,828.072,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,448.9,14.42,,102.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2334.79,75,,100.368,Percent of Total Billed Charges,75% of Total Billed Charges,1556.53,50,,661.856,Percent of Total Billed Charges,50% of Total Billed Charges,1556.53,50,,115,Percent of Total Billed Charges,50% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1556.53,50,,115,Percent of Total Billed Charges,50% of Total Billed Charges,1556.53,50,,287.568,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2179.14,70,,4335.184,Percent of Total Billed Charges,70% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,435.83,14,,99.904,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3113.05,100,,133.824,Percent of Total Billed Charges,100% of Total Billed Charges,54.59,3113.05,
POWER MIDLINE CATH - FULL KIT,37700061,CDM,272,RC,C1751,HCPCS,Outpatient,,,456,273.60,,67.66,100,,3276.96,Fee Schedule,100% of Aetna Fee Schedule,205.2,45,,3177.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.68,28,,518.72,Percent of Total Billed Charges,28% of Total Billed Charges,55.04,32,,536.832,Percent of Total Billed Charges,32% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,164.16,36,,666.928,Percent of Total Billed Charges,36% of Total Billed Charges,164.16,36,,666.928,Percent of Total Billed Charges,36% Total Bille Charges,164.16,36,,666.928,Percent of Total Billed Charges,36% of Total Billed Charges,273.6,60,,49.6,Percent of Total Billed Charges,60% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,456,100,,1020,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,65.76,14.42,,80.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342,75,,1396.8,Percent of Total Billed Charges,75% of Total Billed Charges,228,50,,101.416,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,572.84,Percent of Total Billed Charges,50% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228,50,,572.84,Percent of Total Billed Charges,50% of Total Billed Charges,228,50,,739.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.2,70,,5500.944,Percent of Total Billed Charges,70% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,63.84,14,,78.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,456,100,,1862.4,Percent of Total Billed Charges,100% of Total Billed Charges,55.04,456,
POWER MIDLINE CATH-MAX BARRIER,37700062,CDM,272,RC,C1751,HCPCS,Outpatient,,,532,319.20,,67.66,100,,1615.832,Fee Schedule,100% of Aetna Fee Schedule,239.4,45,,1334.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.96,28,,1256.272,Percent of Total Billed Charges,28% of Total Billed Charges,55.04,32,,536.832,Percent of Total Billed Charges,32% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,191.52,36,,1615.208,Percent of Total Billed Charges,36% of Total Billed Charges,191.52,36,,1615.208,Percent of Total Billed Charges,36% Total Bille Charges,191.52,36,,1615.208,Percent of Total Billed Charges,36% of Total Billed Charges,319.2,60,,73.92,Percent of Total Billed Charges,60% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532,100,,947.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,76.71,14.42,,29.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399,75,,914.4,Percent of Total Billed Charges,75% of Total Billed Charges,266,50,,739.52,Percent of Total Billed Charges,50% of Total Billed Charges,266,50,,499.728,Percent of Total Billed Charges,50% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,50,,499.728,Percent of Total Billed Charges,50% of Total Billed Charges,266,50,,572.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.4,70,,4353.44,Percent of Total Billed Charges,70% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,74.48,14,,28.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,532,100,,1219.2,Percent of Total Billed Charges,100% of Total Billed Charges,55.04,532,
DOUBLE LUMEN PICC,37700063,CDM,272,RC,C1751,HCPCS,Outpatient,,,701.7,421.02,,67.66,100,,3243.904,Fee Schedule,100% of Aetna Fee Schedule,315.77,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.48,28,,1734.072,Percent of Total Billed Charges,28% of Total Billed Charges,55.22,32,,536.832,Percent of Total Billed Charges,32% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,252.61,36,,2229.52,Percent of Total Billed Charges,36% of Total Billed Charges,252.61,36,,2229.52,Percent of Total Billed Charges,36% Total Bille Charges,252.61,36,,2229.52,Percent of Total Billed Charges,36% of Total Billed Charges,421.02,60,,53.512,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,701.7,100,,4565.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14.42,,433.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,526.28,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,350.85,50,,572.84,Percent of Total Billed Charges,50% of Total Billed Charges,350.85,50,,280,Percent of Total Billed Charges,50% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.85,50,,280,Percent of Total Billed Charges,50% of Total Billed Charges,350.85,50,,499.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.19,70,,4353.44,Percent of Total Billed Charges,70% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,98.24,14,,421.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,701.7,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,55.22,701.7,
POWERGLIDE CATHETER FULL KIT,37700064,CDM,272,RC,C1751,HCPCS,Outpatient,,,380,228.00,,67.66,100,,2898.464,Fee Schedule,100% of Aetna Fee Schedule,171,45,,188.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,28,,733.24,Percent of Total Billed Charges,28% of Total Billed Charges,55.29,32,,536.832,Percent of Total Billed Charges,32% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,136.8,36,,942.736,Percent of Total Billed Charges,36% of Total Billed Charges,136.8,36,,942.736,Percent of Total Billed Charges,36% Total Bille Charges,136.8,36,,942.736,Percent of Total Billed Charges,36% of Total Billed Charges,228,60,,71.816,Percent of Total Billed Charges,60% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380,100,,7061.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.8,14.42,,773.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285,75,,1203.36,Percent of Total Billed Charges,75% of Total Billed Charges,190,50,,499.728,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,101.416,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190,50,,101.416,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,280,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,70,,613.2,Percent of Total Billed Charges,70% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,751.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380,100,,1604.48,Percent of Total Billed Charges,100% of Total Billed Charges,53.2,380,
TRIPLE LUMEN PICC,37700065,CDM,272,RC,C1751,HCPCS,Outpatient,,,834.6,500.76,,67.66,100,,1626.28,Fee Schedule,100% of Aetna Fee Schedule,375.57,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.69,28,,504,Percent of Total Billed Charges,28% of Total Billed Charges,55.29,32,,536.832,Percent of Total Billed Charges,32% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,300.46,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,300.46,36,,648,Percent of Total Billed Charges,36% Total Bille Charges,300.46,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,500.76,60,,101.68,Percent of Total Billed Charges,60% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.6,100,,2964.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.95,75,,505.44,Percent of Total Billed Charges,75% of Total Billed Charges,417.3,50,,280,Percent of Total Billed Charges,50% of Total Billed Charges,417.3,50,,1503.76,Percent of Total Billed Charges,50% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.3,50,,1503.76,Percent of Total Billed Charges,50% of Total Billed Charges,417.3,50,,101.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.22,70,,613.2,Percent of Total Billed Charges,70% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,116.84,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.6,100,,673.92,Percent of Total Billed Charges,100% of Total Billed Charges,55.29,834.6,
SINGLE LUMEN PICC,37700066,CDM,272,RC,C1751,HCPCS,Outpatient,,,666.6,399.96,,67.66,100,,910.552,Fee Schedule,100% of Aetna Fee Schedule,299.97,45,,580.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.65,28,,695.968,Percent of Total Billed Charges,28% of Total Billed Charges,55.29,32,,537.472,Percent of Total Billed Charges,32% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,239.98,36,,894.816,Percent of Total Billed Charges,36% of Total Billed Charges,239.98,36,,894.816,Percent of Total Billed Charges,36% Total Bille Charges,239.98,36,,894.816,Percent of Total Billed Charges,36% of Total Billed Charges,399.96,60,,39.656,Percent of Total Billed Charges,60% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.6,100,,140,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.12,14.42,,458.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.95,75,,68.808,Percent of Total Billed Charges,75% of Total Billed Charges,333.3,50,,101.416,Percent of Total Billed Charges,50% of Total Billed Charges,333.3,50,,2683.2,Percent of Total Billed Charges,50% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.3,50,,2683.2,Percent of Total Billed Charges,50% of Total Billed Charges,333.3,50,,1503.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.62,70,,2542.744,Percent of Total Billed Charges,70% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.32,14,,444.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.6,100,,91.744,Percent of Total Billed Charges,100% of Total Billed Charges,55.29,666.6,
US PROBE COVER W GUIDE,37700067,CDM,272,RC,C1751,HCPCS,Outpatient,,,70,42.00,,67.66,100,,1539.856,Fee Schedule,100% of Aetna Fee Schedule,31.5,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,1431.384,Percent of Total Billed Charges,28% of Total Billed Charges,55.34,32,,537.472,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,1840.352,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,1840.352,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,1840.352,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,419.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,14.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,264,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,1503.76,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,115.184,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,115.184,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,2683.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,3814.12,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,352,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,70,
POWERGLIDE CATHETER BASIC KIT,37700068,CDM,272,RC,C1751,HCPCS,Outpatient,,,290,174.00,,67.66,100,,775.36,Fee Schedule,100% of Aetna Fee Schedule,130.5,45,,783,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,28,,733.24,Percent of Total Billed Charges,28% of Total Billed Charges,55.35,32,,537.6,Percent of Total Billed Charges,32% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,104.4,36,,942.736,Percent of Total Billed Charges,36% of Total Billed Charges,104.4,36,,942.736,Percent of Total Billed Charges,36% Total Bille Charges,104.4,36,,942.736,Percent of Total Billed Charges,36% of Total Billed Charges,174,60,,121.92,Percent of Total Billed Charges,60% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,41.82,14.42,,14.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.5,75,,128.16,Percent of Total Billed Charges,75% of Total Billed Charges,145,50,,2683.2,Percent of Total Billed Charges,50% of Total Billed Charges,145,50,,113.904,Percent of Total Billed Charges,50% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145,50,,113.904,Percent of Total Billed Charges,50% of Total Billed Charges,145,50,,115.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203,70,,2542.744,Percent of Total Billed Charges,70% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,13.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290,100,,170.88,Percent of Total Billed Charges,100% of Total Billed Charges,40.6,290,
EXTRA INTRODUCER KIT,37700069,CDM,272,RC,C1894,HCPCS,Outpatient,,,157,94.20,,82.29,100,,2523.36,Fee Schedule,100% of Aetna Fee Schedule,70.65,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.96,28,,1158.976,Percent of Total Billed Charges,28% of Total Billed Charges,55.35,32,,537.6,Percent of Total Billed Charges,32% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,56.52,36,,1490.112,Percent of Total Billed Charges,36% of Total Billed Charges,56.52,36,,1490.112,Percent of Total Billed Charges,36% Total Bille Charges,56.52,36,,1490.112,Percent of Total Billed Charges,36% of Total Billed Charges,94.2,60,,73.16,Percent of Total Billed Charges,60% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157,100,,1290.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.64,14.42,,367.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.75,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,78.5,50,,115.184,Percent of Total Billed Charges,50% of Total Billed Charges,78.5,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,78.5,50,,113.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.9,70,,2379.304,Percent of Total Billed Charges,70% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.98,14,,356.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,21.98,157,
ACCUCATH W GUIDEWIRE ACCUTIP,37700070,CDM,272,RC,C1769,HCPCS,Outpatient,,,210,126.00,,55.13,100,,910.552,Fee Schedule,100% of Aetna Fee Schedule,94.5,45,,708.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,28,,2200.376,Percent of Total Billed Charges,28% of Total Billed Charges,55.4,32,,538.76,Percent of Total Billed Charges,32% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,36,,2829.056,Percent of Total Billed Charges,36% of Total Billed Charges,75.6,36,,2829.056,Percent of Total Billed Charges,36% Total Bille Charges,75.6,36,,2829.056,Percent of Total Billed Charges,36% of Total Billed Charges,126,60,,111.344,Percent of Total Billed Charges,60% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,100,,1440,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,30.28,14.42,,107.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.5,75,,619.68,Percent of Total Billed Charges,75% of Total Billed Charges,105,50,,113.904,Percent of Total Billed Charges,50% of Total Billed Charges,105,50,,903.424,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,50,,903.424,Percent of Total Billed Charges,50% of Total Billed Charges,105,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147,70,,2664.816,Percent of Total Billed Charges,70% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,104.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,100,,826.24,Percent of Total Billed Charges,100% of Total Billed Charges,29.4,210,
POWERPICC SOLO PROVENA CATH 4F,37700071,CDM,271,RC,,,Outpatient,,,1050.3,630.18,,630.18,60,,1036.44,Percent of Total Billed Charges,60% of Total Billed Charges,472.64,45,,3348.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.08,28,,1741.376,Percent of Total Billed Charges,28% of Total Billed Charges,55.4,32,,539.016,Percent of Total Billed Charges,32% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,378.11,36,,2238.912,Percent of Total Billed Charges,36% of Total Billed Charges,378.11,36,,2238.912,Percent of Total Billed Charges,36% Total Bille Charges,378.11,36,,2238.912,Percent of Total Billed Charges,36% of Total Billed Charges,630.18,60,,44.152,Percent of Total Billed Charges,60% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050.3,100,,1740,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,151.45,14.42,,189.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.73,75,,151.2,Percent of Total Billed Charges,75% of Total Billed Charges,525.15,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,367.784,Percent of Total Billed Charges,50% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525.15,50,,367.784,Percent of Total Billed Charges,50% of Total Billed Charges,525.15,50,,903.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.21,70,,17365.088,Percent of Total Billed Charges,70% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,147.04,14,,184.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.3,100,,201.6,Percent of Total Billed Charges,100% of Total Billed Charges,55.4,1050.3,
POWERPICC SOLO PROVENA CATH 5F,37700072,CDM,271,RC,,,Outpatient,,,1101.87,661.12,,661.12,60,,2606.36,Percent of Total Billed Charges,60% of Total Billed Charges,495.84,45,,516.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.52,28,,1741.376,Percent of Total Billed Charges,28% of Total Billed Charges,55.49,32,,540.864,Percent of Total Billed Charges,32% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,396.67,36,,2238.912,Percent of Total Billed Charges,36% of Total Billed Charges,396.67,36,,2238.912,Percent of Total Billed Charges,36% Total Bille Charges,396.67,36,,2238.912,Percent of Total Billed Charges,36% of Total Billed Charges,661.12,60,,46,Percent of Total Billed Charges,60% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1101.87,100,,1440,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,158.89,14.42,,355.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.4,75,,638.4,Percent of Total Billed Charges,75% of Total Billed Charges,550.94,50,,903.424,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,810.6,Percent of Total Billed Charges,50% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.94,50,,810.6,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,367.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.31,70,,24744.72,Percent of Total Billed Charges,70% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,345.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1101.87,100,,851.2,Percent of Total Billed Charges,100% of Total Billed Charges,55.49,1101.87,
HEMOSTAT SURGICEL 8 IN X 4 IN,38000000,CDM,250,RC,99070,HCPCS,Outpatient,,,659.02,395.41,,16.5,100,,21339.208,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,28,,245.28,Percent of Total Billed Charges,28% of Total Billed Charges,56,32,,540.96,Percent of Total Billed Charges,32% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,237.25,36,,315.36,Percent of Total Billed Charges,36% of Total Billed Charges,237.25,36,,315.36,Percent of Total Billed Charges,36% Total Bille Charges,237.25,36,,315.36,Percent of Total Billed Charges,36% of Total Billed Charges,395.41,60,,437.184,Percent of Total Billed Charges,60% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,95.03,14.42,,196.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.27,75,,189.6,Percent of Total Billed Charges,75% of Total Billed Charges,329.51,50,,367.784,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,1244,Percent of Total Billed Charges,50% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.51,50,,1244,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,810.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.31,70,,17365.088,Percent of Total Billed Charges,70% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,190.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.02,100,,252.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.5,659.02,
INTERLEUKIN 6,41000000,CDM,301,RC,83520,HCPCS,Outpatient,,,493.8,296.28,,20.04,100,,25101.272,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,2620.8,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,245.28,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,541.44,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,315.36,Fee Schedule,360% of BCBS POS Rate,62.17,360,,315.36,Fee schedule,360% of BCBS PPO Rate,62.17,360,,315.36,Fee Schedule,360% of BCBS Traditional Rate,296.28,60,,53.592,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,114.976,Fee Schedule,100% of TX Mediciad 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,,7440.8,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,118.424,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,370.35,75,,179.256,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,810.6,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,1588.376,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,1588.376,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,1244,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,157.592,Fee Schedule,90% of UHC fee schedule,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,114.976,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,493.8,100,,239.008,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,493.8,
NEUTRALIZATION,41000003,CDM,300,RC,86977,HCPCS,Outpatient,,,252,151.20,,43.18,100,,12400.992,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,90,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,1525.648,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,542.656,Fee Schedule,320% of BCBS Blue Essentials Rate,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,1961.544,Fee Schedule,360% of BCBS POS Rate,516.6,360,,1961.544,Fee schedule,360% of BCBS PPO Rate,516.6,360,,1961.544,Fee Schedule,360% of BCBS Traditional Rate,151.2,60,,50.28,Percent of Total Billed Charges,60% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,27200,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14.42,,70.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,189,75,,624,Percent of Total Billed Charges,75% of Total Billed Charges,126,50,,1588.376,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,49.392,Percent of Total Billed Charges,50% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,126,50,,49.392,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,710.128,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,682.224,Fee Schedule,90% of UHC fee schedule,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,68.128,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,252,100,,832,Percent of Total Billed Charges,100% of Total Billed Charges,35.28,516.6,
LUPUS ANTICOAG,41000004,CDM,305,RC,85610,HCPCS,Outpatient,,,1113.88,668.33,,4.98,100,,12400.992,Fee Schedule,100% of Aetna Fee Schedule,6.43,150,,59.4,Fee Schedule ,150% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,280,,1017.096,Fee Schedule,280% of BCBS BULE Fee Schedule,13.73,320,,543.336,Fee Schedule,320% of BCBS Blue Essentials Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,15.44,360,,1307.696,Fee Schedule,360% of BCBS POS Rate,15.44,360,,1307.696,Fee schedule,360% of BCBS PPO Rate,15.44,360,,1307.696,Fee Schedule,360% of BCBS Traditional Rate,668.33,60,,45.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,100,,68.128,Fee Schedule,100% of TX Mediciad 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,,5824,Fee Schedule,100% of CMS OPPS Rate,3.86,90,,,Fee Schedule,90% of CMS OPPS Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,130,,,Fee Schedule,130% of CMS OPPS Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.71,103,,70.176,Fee Schedule,103% of TX Medicaid Rate,4.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4.41,103,,,Fee Schedule,103% of CMS OPPS Rate,835.41,75,,115.2,Percent of Total Billed Charges,75% of Total Billed Charges,7.29,80,,710.128,Fee Schedule,80% of Scott and White EPO fee schedule,7.29,80,,49.392,Fee Schedule,80% of Scott and White HMO fee schedule,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,7.29,170,,49.392,Fee Schedule,170% of Scott and White PPO fee schedule,7.29,170,,49.392,Fee Schedule,170% of Scott and White SWHP fee schedule,6.43,150,,,Fee Schedule,150% of CMS OPPS Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.47,90,,1725.536,Fee Schedule,90% of UHC fee schedule,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,68.128,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.88,100,,153.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.47,1113.88,
INSULIN-LIKE GROWTH FACTOR 11,41000005,CDM,301,RC,83519,HCPCS,Outpatient,,,419.6,251.76,,21.34,100,,5569.608,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,12240,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,951.72,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,543.336,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,1223.64,Fee Schedule,360% of BCBS POS Rate,66.24,360,,1223.64,Fee schedule,360% of BCBS PPO Rate,66.24,360,,1223.64,Fee Schedule,360% of BCBS Traditional Rate,251.76,60,,112.128,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,58.72,Fee Schedule,100% of TX Mediciad 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,,7613.76,Fee Schedule,100% of CMS OPPS Rate,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,60.488,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,314.7,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,49.392,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,1274.4,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,1274.4,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,49.392,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,1331.688,Fee Schedule,90% of UHC fee schedule,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,419.6,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,419.6,
INHIBIN B TUMOR MARKER,41000006,CDM,301,RC,82397,HCPCS,Outpatient,,,411.6,246.96,,16.38,100,,6287.872,Fee Schedule,100% of Aetna Fee Schedule,21.18,150,,9360,Fee Schedule ,150% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,280,,1065.928,Fee Schedule,280% of BCBS BULE Fee Schedule,45.18,320,,550.096,Fee Schedule,320% of BCBS Blue Essentials Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,50.83,360,,1370.48,Fee Schedule,360% of BCBS POS Rate,50.83,360,,1370.48,Fee schedule,360% of BCBS PPO Rate,50.83,360,,1370.48,Fee Schedule,360% of BCBS Traditional Rate,246.96,60,,95.848,Percent of Total Billed Charges,60% of Total Billed Charges,11.86,100,,58.72,Fee Schedule,100% of TX Mediciad 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,,200,Fee Schedule,100% of CMS OPPS Rate,12.7,90,,,Fee Schedule,90% of CMS OPPS Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,18.35,130,,,Fee Schedule,130% of CMS OPPS Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,12.22,103,,60.488,Fee Schedule,103% of TX Medicaid Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,308.7,75,,216.808,Percent of Total Billed Charges,75% of Total Billed Charges,24,80,,49.392,Fee Schedule,80% of Scott and White EPO fee schedule,24,80,,372,Fee Schedule,80% of Scott and White HMO fee schedule,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,24,170,,372,Fee Schedule,170% of Scott and White PPO fee schedule,24,170,,1274.4,Fee Schedule,170% of Scott and White SWHP fee schedule,21.18,150,,,Fee Schedule,150% of CMS OPPS Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.44,90,,763.128,Fee Schedule,90% of UHC fee schedule,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,58.72,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,411.6,100,,289.072,Percent of Total Billed Charges,100% of Total Billed Charges,11.44,411.6,
CYSTATIN C WITH CALCULATED E GFR,41000007,CDM,301,RC,82610,HCPCS,Outpatient,,,119.6,71.76,,21.48,100,,1734.928,Fee Schedule,100% of Aetna Fee Schedule,27.78,150,,8568,Fee Schedule ,150% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,51.86,280,,5161.632,Fee Schedule,280% of BCBS BULE Fee Schedule,59.26,320,,552.448,Fee Schedule,320% of BCBS Blue Essentials Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,66.67,360,,6636.384,Fee Schedule,360% of BCBS POS Rate,66.67,360,,6636.384,Fee schedule,360% of BCBS PPO Rate,66.67,360,,6636.384,Fee Schedule,360% of BCBS Traditional Rate,71.76,60,,29.592,Percent of Total Billed Charges,60% of Total Billed Charges,15.56,100,,138.08,Fee Schedule,100% of TX Mediciad 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,,132,Fee Schedule,100% of CMS OPPS Rate,16.66,90,,,Fee Schedule,90% of CMS OPPS Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,24.07,130,,,Fee Schedule,130% of CMS OPPS Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,16.03,103,,142.224,Fee Schedule,103% of TX Medicaid Rate,19.07,103,,,Fee Schedule,103% of CMS OPPS Rate,19.07,103,,,Fee Schedule,103% of CMS OPPS Rate,89.7,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,31.48,80,,1274.4,Fee Schedule,80% of Scott and White EPO fee schedule,31.48,80,,658.2,Fee Schedule,80% of Scott and White HMO fee schedule,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,31.48,170,,658.2,Fee Schedule,170% of Scott and White PPO fee schedule,31.48,170,,372,Fee Schedule,170% of Scott and White SWHP fee schedule,27.78,150,,,Fee Schedule,150% of CMS OPPS Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15,90,,638.28,Fee Schedule,90% of UHC fee schedule,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,119.6,100,,1280,Percent of Total Billed Charges,100% of Total Billed Charges,15,119.6,
C DIFFICILE TOXIN B RAPID BY PCR,41000008,CDM,306,RC,87493,HCPCS,Outpatient,,,306.32,183.79,,43.24,100,,14504.432,Fee Schedule,100% of Aetna Fee Schedule,55.9,150,,9360,Fee Schedule ,150% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,104.36,280,,6946.032,Fee Schedule,280% of BCBS BULE Fee Schedule,119.26,320,,552.64,Fee Schedule,320% of BCBS Blue Essentials Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,134.17,360,,8930.616,Fee Schedule,360% of BCBS POS Rate,134.17,360,,8930.616,Fee schedule,360% of BCBS PPO Rate,134.17,360,,8930.616,Fee Schedule,360% of BCBS Traditional Rate,183.79,60,,27.72,Percent of Total Billed Charges,60% of Total Billed Charges,31.31,100,,138.08,Fee Schedule,100% of TX Mediciad 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,,27200,Fee Schedule,100% of CMS OPPS Rate,33.54,90,,,Fee Schedule,90% of CMS OPPS Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.45,130,,,Fee Schedule,130% of CMS OPPS Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,32.25,103,,142.224,Fee Schedule,103% of TX Medicaid Rate,38.38,103,,,Fee Schedule,103% of CMS OPPS Rate,38.38,103,,,Fee Schedule,103% of CMS OPPS Rate,229.74,75,,412.8,Percent of Total Billed Charges,75% of Total Billed Charges,63.35,80,,372,Fee Schedule,80% of Scott and White EPO fee schedule,63.35,80,,1232.4,Fee Schedule,80% of Scott and White HMO fee schedule,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,63.35,170,,1232.4,Fee Schedule,170% of Scott and White PPO fee schedule,63.35,170,,658.2,Fee Schedule,170% of Scott and White SWHP fee schedule,55.9,150,,,Fee Schedule,150% of CMS OPPS Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,30.19,90,,731.888,Fee Schedule,90% of UHC fee schedule,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,306.32,100,,550.4,Percent of Total Billed Charges,100% of Total Billed Charges,30.19,306.32,
BODY FLUID HEMATOCRIT,41000009,CDM,305,RC,85013,HCPCS,Outpatient,,,246.6,147.96,,8.12,100,,9669.616,Fee Schedule,100% of Aetna Fee Schedule,10.5,150,,92.16,Fee Schedule ,150% of CMS OPPS Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,280,,9897.888,Fee Schedule,280% of BCBS BULE Fee Schedule,22.4,320,,552.768,Fee Schedule,320% of BCBS Blue Essentials Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,25.2,360,,12725.856,Fee Schedule,360% of BCBS POS Rate,25.2,360,,12725.856,Fee schedule,360% of BCBS PPO Rate,25.2,360,,12725.856,Fee Schedule,360% of BCBS Traditional Rate,147.96,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,5.88,100,,248.64,Fee Schedule,100% of TX Mediciad Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,7,100,,20800,Fee Schedule,100% of CMS OPPS Rate,6.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,9.1,130,,,Fee Schedule,130% of CMS OPPS Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,6.06,103,,256.096,Fee Schedule,103% of TX Medicaid Rate,7.21,103,,,Fee Schedule,103% of CMS OPPS Rate,7.21,103,,,Fee Schedule,103% of CMS OPPS Rate,184.95,75,,77.128,Percent of Total Billed Charges,75% of Total Billed Charges,11.9,80,,658.2,Fee Schedule,80% of Scott and White EPO fee schedule,11.9,80,,920.6,Fee Schedule,80% of Scott and White HMO fee schedule,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.9,170,,920.6,Fee Schedule,170% of Scott and White PPO fee schedule,11.9,170,,1232.4,Fee Schedule,170% of Scott and White SWHP fee schedule,10.5,150,,,Fee Schedule,150% of CMS OPPS Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,90,,4829.024,Fee Schedule,90% of UHC fee schedule,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,248.64,Fee Schedule,100% of TX Medicaid Rate,7,100,,,Fee Schedule,100% of CMS OPPS Rate,246.6,100,,102.84,Percent of Total Billed Charges,100% of Total Billed Charges,5.67,246.6,
BODY FLUID CHOLESTEROL,41000010,CDM,301,RC,82465,HCPCS,Outpatient,,,44.16,26.50,,5.04,100,,9669.616,Fee Schedule,100% of Aetna Fee Schedule,6.52,150,,2982.216,Fee Schedule ,150% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,12.18,280,,6946.032,Fee Schedule,280% of BCBS BULE Fee Schedule,13.92,320,,554.664,Fee Schedule,320% of BCBS Blue Essentials Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,15.66,360,,8930.616,Fee Schedule,360% of BCBS POS Rate,15.66,360,,8930.616,Fee schedule,360% of BCBS PPO Rate,15.66,360,,8930.616,Fee Schedule,360% of BCBS Traditional Rate,26.5,60,,44.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.65,100,,216.672,Fee Schedule,100% of TX Mediciad 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,,19040,Fee Schedule,100% of CMS OPPS Rate,3.91,90,,,Fee Schedule,90% of CMS OPPS Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,5.65,130,,,Fee Schedule,130% of CMS OPPS Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.76,103,,223.176,Fee Schedule,103% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of CMS OPPS Rate,4.48,103,,,Fee Schedule,103% of CMS OPPS Rate,33.12,75,,37.352,Percent of Total Billed Charges,75% of Total Billed Charges,7.39,80,,1232.4,Fee Schedule,80% of Scott and White EPO fee schedule,7.39,80,,680.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,7.39,170,,680.8,Fee Schedule,170% of Scott and White PPO fee schedule,7.39,170,,920.6,Fee Schedule,170% of Scott and White SWHP fee schedule,6.52,150,,,Fee Schedule,150% of CMS OPPS Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,210,Fee Schedule,90% of UHC fee schedule,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,216.672,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,44.16,100,,49.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.53,44.16,
APOLIPOPROTEIN  A1 PLASMA,41000011,CDM,302,RC,82172,HCPCS,Outpatient,,,66.12,39.67,,24.46,100,,943.376,Fee Schedule,100% of Aetna Fee Schedule,31.63,150,,496.8,Fee Schedule ,150% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.05,280,,63.04,Fee Schedule,280% of BCBS BULE Fee Schedule,67.49,320,,554.664,Fee Schedule,320% of BCBS Blue Essentials Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,75.92,360,,81.048,Fee Schedule,360% of BCBS POS Rate,75.92,360,,81.048,Fee schedule,360% of BCBS PPO Rate,75.92,360,,81.048,Fee Schedule,360% of BCBS Traditional Rate,39.67,60,,49.08,Percent of Total Billed Charges,60% of Total Billed Charges,17.72,100,,68.88,Fee Schedule,100% of TX Mediciad 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,,20800,Fee Schedule,100% of CMS OPPS Rate,18.98,90,,,Fee Schedule,90% of CMS OPPS Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.41,130,,,Fee Schedule,130% of CMS OPPS Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,18.25,103,,70.944,Fee Schedule,103% of TX Medicaid Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,49.59,75,,154.44,Percent of Total Billed Charges,75% of Total Billed Charges,35.85,80,,920.6,Fee Schedule,80% of Scott and White EPO fee schedule,35.85,80,,441.944,Fee Schedule,80% of Scott and White HMO fee schedule,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,170,,441.944,Fee Schedule,170% of Scott and White PPO fee schedule,35.85,170,,680.8,Fee Schedule,170% of Scott and White SWHP fee schedule,31.63,150,,,Fee Schedule,150% of CMS OPPS Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.08,90,,764.088,Fee Schedule,90% of UHC fee schedule,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,68.88,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,66.12,100,,205.92,Percent of Total Billed Charges,100% of Total Billed Charges,17.08,75.92,
ANTI-CHYMOPAPAIN IGE,41000012,CDM,301,RC,86003,HCPCS,Outpatient,,,628,376.80,,6.06,100,,1185.408,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,92.16,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,1042.624,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,554.944,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,1340.52,Fee Schedule,360% of BCBS POS Rate,18.79,360,,1340.52,Fee schedule,360% of BCBS PPO Rate,18.79,360,,1340.52,Fee Schedule,360% of BCBS Traditional Rate,376.8,60,,100.472,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,1465.648,Fee Schedule,100% of TX Mediciad 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,,204.8,Fee Schedule,100% of CMS OPPS Rate,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,1509.616,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,471,75,,230.704,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,680.8,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,335.664,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,335.664,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,441.944,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,2464.96,Fee Schedule,90% of UHC fee schedule,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,1465.648,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,628,100,,307.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,628,
ANDROSTENEDIONE,41000013,CDM,301,RC,82157,HCPCS,Outpatient,,,273.64,164.18,,33.96,100,,461.344,Fee Schedule,100% of Aetna Fee Schedule,43.92,150,,4305.24,Fee Schedule ,150% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,280,,69.384,Fee Schedule,280% of BCBS BULE Fee Schedule,93.7,320,,555.52,Fee Schedule,320% of BCBS Blue Essentials Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,105.41,360,,89.208,Fee Schedule,360% of BCBS POS Rate,105.41,360,,89.208,Fee schedule,360% of BCBS PPO Rate,105.41,360,,89.208,Fee Schedule,360% of BCBS Traditional Rate,164.18,60,,82.152,Percent of Total Billed Charges,60% of Total Billed Charges,24.6,100,,245.6,Fee Schedule,100% of TX Mediciad 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,,6627.152,Fee Schedule,100% of CMS OPPS Rate,26.35,90,,,Fee Schedule,90% of CMS OPPS Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,38.06,130,,,Fee Schedule,130% of CMS OPPS Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,25.34,103,,252.968,Fee Schedule,103% of TX Medicaid Rate,30.15,103,,,Fee Schedule,103% of CMS OPPS Rate,30.15,103,,,Fee Schedule,103% of CMS OPPS Rate,205.23,75,,376.8,Percent of Total Billed Charges,75% of Total Billed Charges,49.77,80,,441.944,Fee Schedule,80% of Scott and White EPO fee schedule,49.77,80,,518.616,Fee Schedule,80% of Scott and White HMO fee schedule,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,49.77,170,,518.616,Fee Schedule,170% of Scott and White PPO fee schedule,49.77,170,,335.664,Fee Schedule,170% of Scott and White SWHP fee schedule,43.92,150,,,Fee Schedule,150% of CMS OPPS Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,23.72,90,,785.912,Fee Schedule,90% of UHC fee schedule,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,273.64,100,,502.4,Percent of Total Billed Charges,100% of Total Billed Charges,23.72,273.64,
AMITRPTYLINE,41000014,CDM,301,RC,80335,HCPCS,Outpatient,,,96,57.60,,0.02,100,,461.344,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,555.84,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.6,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,100,,245.6,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.33,103,,252.968,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,75,,367.2,Percent of Total Billed Charges,75% of Total Billed Charges,48,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,48,50,,337.568,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,48,50,,337.568,Percent of Total Billed Charges,50% of Total Billed Charges,48,50,,518.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,96,100,,489.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,96,
AMINO ACIDS QUANT RANDOM URINE,41000015,CDM,301,RC,82139,HCPCS,Outpatient,,,360,216.00,,19.56,100,,1107.704,Fee Schedule,100% of Aetna Fee Schedule,25.3,150,,824.4,Fee Schedule ,150% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,47.24,280,,690.216,Fee Schedule,280% of BCBS BULE Fee Schedule,53.98,320,,555.84,Fee Schedule,320% of BCBS Blue Essentials Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,60.73,360,,887.424,Fee Schedule,360% of BCBS POS Rate,60.73,360,,887.424,Fee schedule,360% of BCBS PPO Rate,60.73,360,,887.424,Fee Schedule,360% of BCBS Traditional Rate,216,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,14.17,100,,245.6,Fee Schedule,100% of TX Mediciad 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,,204.8,Fee Schedule,100% of CMS OPPS Rate,15.18,90,,,Fee Schedule,90% of CMS OPPS Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,130,,,Fee Schedule,130% of CMS OPPS Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.6,103,,252.968,Fee Schedule,103% of TX Medicaid Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,270,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,28.67,80,,518.616,Fee Schedule,80% of Scott and White EPO fee schedule,28.67,80,,337.568,Fee Schedule,80% of Scott and White HMO fee schedule,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.67,170,,337.568,Fee Schedule,170% of Scott and White PPO fee schedule,28.67,170,,337.568,Fee Schedule,170% of Scott and White SWHP fee schedule,25.3,150,,,Fee Schedule,150% of CMS OPPS Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,90,,900.912,Fee Schedule,90% of UHC fee schedule,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,245.6,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,360,100,,112,Percent of Total Billed Charges,100% of Total Billed Charges,13.66,360,
AMINO ACIDS QUANT PLASMA,41000016,CDM,301,RC,82139,HCPCS,Outpatient,,,360,216.00,,19.56,100,,3144,Fee Schedule,100% of Aetna Fee Schedule,25.3,150,,92.16,Fee Schedule ,150% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,47.24,280,,532.68,Fee Schedule,280% of BCBS BULE Fee Schedule,53.98,320,,556.8,Fee Schedule,320% of BCBS Blue Essentials Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,60.73,360,,684.872,Fee Schedule,360% of BCBS POS Rate,60.73,360,,684.872,Fee schedule,360% of BCBS PPO Rate,60.73,360,,684.872,Fee Schedule,360% of BCBS Traditional Rate,216,60,,47.168,Percent of Total Billed Charges,60% of Total Billed Charges,14.17,100,,377.104,Fee Schedule,100% of TX Mediciad 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,,9567.2,Fee Schedule,100% of CMS OPPS Rate,15.18,90,,,Fee Schedule,90% of CMS OPPS Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,130,,,Fee Schedule,130% of CMS OPPS Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.6,103,,388.416,Fee Schedule,103% of TX Medicaid Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,270,75,,778.08,Percent of Total Billed Charges,75% of Total Billed Charges,28.67,80,,337.568,Fee Schedule,80% of Scott and White EPO fee schedule,28.67,80,,321.432,Fee Schedule,80% of Scott and White HMO fee schedule,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.67,170,,321.432,Fee Schedule,170% of Scott and White PPO fee schedule,28.67,170,,337.568,Fee Schedule,170% of Scott and White SWHP fee schedule,25.3,150,,,Fee Schedule,150% of CMS OPPS Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,90,,666.8,Fee Schedule,90% of UHC fee schedule,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,377.104,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,360,100,,1037.44,Percent of Total Billed Charges,100% of Total Billed Charges,13.66,360,
ALUMINUM 24 HOUR URINE,41000017,CDM,301,RC,82108,HCPCS,Outpatient,,,1040.8,624.48,,29.56,100,,3144,Fee Schedule,100% of Aetna Fee Schedule,38.22,150,,108,Fee Schedule ,150% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,71.34,280,,305.248,Fee Schedule,280% of BCBS BULE Fee Schedule,81.54,320,,557.512,Fee Schedule,320% of BCBS Blue Essentials Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,91.73,360,,392.464,Fee Schedule,360% of BCBS POS Rate,91.73,360,,392.464,Fee schedule,360% of BCBS PPO Rate,91.73,360,,392.464,Fee Schedule,360% of BCBS Traditional Rate,624.48,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,21.4,100,,148.96,Fee Schedule,100% of TX Mediciad 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,,7440.8,Fee Schedule,100% of CMS OPPS Rate,22.93,90,,,Fee Schedule,90% of CMS OPPS Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,33.12,130,,,Fee Schedule,130% of CMS OPPS Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,22.04,103,,153.432,Fee Schedule,103% of TX Medicaid Rate,26.24,103,,,Fee Schedule,103% of CMS OPPS Rate,26.24,103,,,Fee Schedule,103% of CMS OPPS Rate,780.6,75,,283.2,Percent of Total Billed Charges,75% of Total Billed Charges,43.31,80,,337.568,Fee Schedule,80% of Scott and White EPO fee schedule,43.31,80,,288.08,Fee Schedule,80% of Scott and White HMO fee schedule,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.31,170,,288.08,Fee Schedule,170% of Scott and White PPO fee schedule,43.31,170,,321.432,Fee Schedule,170% of Scott and White SWHP fee schedule,38.22,150,,,Fee Schedule,150% of CMS OPPS Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.64,90,,571.2,Fee Schedule,90% of UHC fee schedule,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,21.4,100,,148.96,Fee Schedule,100% of TX Medicaid Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.8,100,,377.6,Percent of Total Billed Charges,100% of Total Billed Charges,20.64,1040.8,
INHIBIN A TUMOR MARKER,41000018,CDM,301,RC,86336,HCPCS,Outpatient,,,145.64,87.38,,18.08,100,,6893.864,Fee Schedule,100% of Aetna Fee Schedule,23.38,150,,2391.84,Fee Schedule ,150% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,280,,255.312,Fee Schedule,280% of BCBS BULE Fee Schedule,49.89,320,,558.72,Fee Schedule,320% of BCBS Blue Essentials Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,56.12,360,,328.256,Fee Schedule,360% of BCBS POS Rate,56.12,360,,328.256,Fee schedule,360% of BCBS PPO Rate,56.12,360,,328.256,Fee Schedule,360% of BCBS Traditional Rate,87.38,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,13.1,100,,143.584,Fee Schedule,100% of TX Mediciad 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,,1832,Fee Schedule,100% of CMS OPPS Rate,14.03,90,,,Fee Schedule,90% of CMS OPPS Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,130,,,Fee Schedule,130% of CMS OPPS Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.49,103,,147.888,Fee Schedule,103% of TX Medicaid Rate,16.05,103,,,Fee Schedule,103% of CMS OPPS Rate,16.05,103,,,Fee Schedule,103% of CMS OPPS Rate,109.23,75,,288,Percent of Total Billed Charges,75% of Total Billed Charges,26.5,80,,321.432,Fee Schedule,80% of Scott and White EPO fee schedule,26.5,80,,410.624,Fee Schedule,80% of Scott and White HMO fee schedule,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,170,,410.624,Fee Schedule,170% of Scott and White PPO fee schedule,26.5,170,,288.08,Fee Schedule,170% of Scott and White SWHP fee schedule,23.38,150,,,Fee Schedule,150% of CMS OPPS Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,90,,832.312,Fee Schedule,90% of UHC fee schedule,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,143.584,Fee Schedule,100% of TX Medicaid Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,145.64,100,,384,Percent of Total Billed Charges,100% of Total Billed Charges,12.63,145.64,
HIV-2 DNA/RNA QUAL RT-PCR,41000019,CDM,302,RC,87535,HCPCS,Outpatient,,,975.44,585.26,,40.7,100,,10988.08,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,513,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,292.752,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,561.08,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,376.4,Fee Schedule,360% of BCBS POS Rate,126.32,360,,376.4,Fee schedule,360% of BCBS PPO Rate,126.32,360,,376.4,Fee Schedule,360% of BCBS Traditional Rate,585.26,60,,68.16,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,41.44,Fee Schedule,100% of TX Mediciad 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,,204.8,Fee Schedule,100% of CMS OPPS Rate,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,42.68,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,731.58,75,,396,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,288.08,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,337.2,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,337.2,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,410.624,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,7665.152,Fee Schedule,90% of UHC fee schedule,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,975.44,100,,528,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,975.44,
HEPATIS B VIRUS GENOTYPIN,41000020,CDM,302,RC,87912,HCPCS,Outpatient,,,1400,840.00,,298.64,100,,14101.28,Fee Schedule,100% of Aetna Fee Schedule,386.17,150,,387.696,Fee Schedule ,150% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,720.86,280,,1931.608,Fee Schedule,280% of BCBS BULE Fee Schedule,823.84,320,,561.08,Fee Schedule,320% of BCBS Blue Essentials Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,926.82,360,,2483.496,Fee Schedule,360% of BCBS POS Rate,926.82,360,,2483.496,Fee schedule,360% of BCBS PPO Rate,926.82,360,,2483.496,Fee Schedule,360% of BCBS Traditional Rate,840,60,,62.64,Percent of Total Billed Charges,60% of Total Billed Charges,216.26,100,,98.336,Fee Schedule,100% of TX Mediciad 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,,240,Fee Schedule,100% of CMS OPPS Rate,231.7,90,,,Fee Schedule,90% of CMS OPPS Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,334.68,130,,,Fee Schedule,130% of CMS OPPS Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,222.75,103,,101.288,Fee Schedule,103% of TX Medicaid Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1050,75,,1080,Percent of Total Billed Charges,75% of Total Billed Charges,437.66,80,,410.624,Fee Schedule,80% of Scott and White EPO fee schedule,437.66,80,,1032.416,Fee Schedule,80% of Scott and White HMO fee schedule,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,437.66,170,,1032.416,Fee Schedule,170% of Scott and White PPO fee schedule,437.66,170,,337.2,Fee Schedule,170% of Scott and White SWHP fee schedule,386.17,150,,,Fee Schedule,150% of CMS OPPS Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,208.54,90,,114.92,Fee Schedule,90% of UHC fee schedule,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,98.336,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1400,100,,1440,Percent of Total Billed Charges,100% of Total Billed Charges,208.54,1400,
GALACTOSE QUANTITATIVE,41000021,CDM,301,RC,82760,HCPCS,Outpatient,,,1171.6,702.96,,13,100,,9400.856,Fee Schedule,100% of Aetna Fee Schedule,16.8,150,,3059.104,Fee Schedule ,150% of CMS OPPS Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,31.36,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,35.84,320,,561.368,Fee Schedule,320% of BCBS Blue Essentials Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,40.32,360,,108,Fee Schedule,360% of BCBS POS Rate,40.32,360,,108,Fee schedule,360% of BCBS PPO Rate,40.32,360,,108,Fee Schedule,360% of BCBS Traditional Rate,702.96,60,,79.712,Percent of Total Billed Charges,60% of Total Billed Charges,9.41,100,,100.8,Fee Schedule,100% of TX Mediciad Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,100,,5315.2,Fee Schedule,100% of CMS OPPS Rate,10.07,90,,,Fee Schedule,90% of CMS OPPS Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,14.56,130,,,Fee Schedule,130% of CMS OPPS Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.69,103,,103.824,Fee Schedule,103% of TX Medicaid Rate,11.53,103,,,Fee Schedule,103% of CMS OPPS Rate,11.53,103,,,Fee Schedule,103% of CMS OPPS Rate,878.7,75,,406.44,Percent of Total Billed Charges,75% of Total Billed Charges,19.03,80,,337.2,Fee Schedule,80% of Scott and White EPO fee schedule,19.03,80,,243.328,Fee Schedule,80% of Scott and White HMO fee schedule,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,19.03,170,,243.328,Fee Schedule,170% of Scott and White PPO fee schedule,19.03,170,,1032.416,Fee Schedule,170% of Scott and White SWHP fee schedule,16.8,150,,,Fee Schedule,150% of CMS OPPS Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9.07,90,,38.76,Fee Schedule,90% of UHC fee schedule,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,9.41,100,,100.8,Fee Schedule,100% of TX Medicaid Rate,11.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.6,100,,541.92,Percent of Total Billed Charges,100% of Total Billed Charges,9.07,1171.6,
THYROPEROXIDASE AB,41000022,CDM,302,RC,86376,HCPCS,Outpatient,,,135.92,81.55,,16.88,100,,9400.856,Fee Schedule,100% of Aetna Fee Schedule,21.82,150,,28.056,Fee Schedule ,150% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.74,280,,305.632,Fee Schedule,280% of BCBS BULE Fee Schedule,46.56,320,,561.368,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,52.38,360,,392.96,Fee Schedule,360% of BCBS POS Rate,52.38,360,,392.96,Fee schedule,360% of BCBS PPO Rate,52.38,360,,392.96,Fee Schedule,360% of BCBS Traditional Rate,81.55,60,,65.92,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,100,,82.32,Fee Schedule,100% of TX Mediciad 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,,1140,Fee Schedule,100% of CMS OPPS Rate,13.09,90,,,Fee Schedule,90% of CMS OPPS Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,18.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.59,103,,84.792,Fee Schedule,103% of TX Medicaid Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,101.94,75,,120.984,Percent of Total Billed Charges,75% of Total Billed Charges,24.73,80,,1032.416,Fee Schedule,80% of Scott and White EPO fee schedule,24.73,80,,243.328,Fee Schedule,80% of Scott and White HMO fee schedule,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,170,,243.328,Fee Schedule,170% of Scott and White PPO fee schedule,24.73,170,,243.328,Fee Schedule,170% of Scott and White SWHP fee schedule,21.82,150,,,Fee Schedule,150% of CMS OPPS Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,52.856,Fee Schedule,90% of UHC fee schedule,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,82.32,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,135.92,100,,161.312,Percent of Total Billed Charges,100% of Total Billed Charges,11.79,135.92,
DIHYROTESOSTERONE,41000023,CDM,301,RC,82651,HCPCS,Outpatient,,,157.48,94.49,,94.49,60,,22108.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.09,28,,985.984,Percent of Total Billed Charges,28% of Total Billed Charges,56,32,,561.368,Percent of Total Billed Charges,32% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.69,36,,1267.696,Percent of Total Billed Charges,36% of Total Billed Charges,56.69,36,,1267.696,Percent of Total Billed Charges,36% Total Bille Charges,56.69,36,,1267.696,Percent of Total Billed Charges,36% of Total Billed Charges,94.49,60,,147.936,Percent of Total Billed Charges,60% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.71,14.42,,71.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.11,75,,105.84,Percent of Total Billed Charges,75% of Total Billed Charges,78.74,50,,243.328,Percent of Total Billed Charges,50% of Total Billed Charges,78.74,50,,1244,Percent of Total Billed Charges,50% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.74,50,,1244,Percent of Total Billed Charges,50% of Total Billed Charges,78.74,50,,243.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.74,50,,832.312,Percent of Total Billed Charges,50% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,68.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.48,100,,141.12,Percent of Total Billed Charges,100% of Total Billed Charges,22.05,157.48,
ENDOTOXIN,41000024,CDM,301,RC,87999,HCPCS,Outpatient,,,308.04,184.82,,184.82,60,,14738.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.25,28,,314.368,Percent of Total Billed Charges,28% of Total Billed Charges,56,32,,561.792,Percent of Total Billed Charges,32% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,110.89,36,,404.184,Percent of Total Billed Charges,36% of Total Billed Charges,110.89,36,,404.184,Percent of Total Billed Charges,36% Total Bille Charges,110.89,36,,404.184,Percent of Total Billed Charges,36% of Total Billed Charges,184.82,60,,52.32,Percent of Total Billed Charges,60% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,44.42,14.42,,70.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.03,75,,146.4,Percent of Total Billed Charges,75% of Total Billed Charges,154.02,50,,243.328,Percent of Total Billed Charges,50% of Total Billed Charges,154.02,50,,474.96,Percent of Total Billed Charges,50% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.02,50,,474.96,Percent of Total Billed Charges,50% of Total Billed Charges,154.02,50,,1244,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,43.13,14,,67.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.04,100,,195.2,Percent of Total Billed Charges,100% of Total Billed Charges,43.13,308.04,
T3 TRIIODOTHYR ONLINE REVERSE,41000025,CDM,301,RC,84482,HCPCS,Outpatient,,,1439.04,863.42,,18.28,100,,14738.76,Fee Schedule,100% of Aetna Fee Schedule,23.64,150,,1993.68,Fee Schedule ,150% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,44.13,280,,311.056,Fee Schedule,280% of BCBS BULE Fee Schedule,50.43,320,,568.32,Fee Schedule,320% of BCBS Blue Essentials Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,56.74,360,,399.928,Fee Schedule,360% of BCBS POS Rate,56.74,360,,399.928,Fee schedule,360% of BCBS PPO Rate,56.74,360,,399.928,Fee Schedule,360% of BCBS Traditional Rate,863.42,60,,88.8,Percent of Total Billed Charges,60% of Total Billed Charges,13.24,100,,158.592,Fee Schedule,100% of TX Mediciad 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,,62.352,Fee Schedule,100% of CMS OPPS Rate,14.18,90,,,Fee Schedule,90% of CMS OPPS Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,130,,,Fee Schedule,130% of CMS OPPS Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.64,103,,163.352,Fee Schedule,103% of TX Medicaid Rate,16.23,103,,,Fee Schedule,103% of CMS OPPS Rate,16.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1079.28,75,,74.872,Percent of Total Billed Charges,75% of Total Billed Charges,26.79,80,,1244,Fee Schedule,80% of Scott and White EPO fee schedule,26.79,80,,306.688,Fee Schedule,80% of Scott and White HMO fee schedule,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,170,,306.688,Fee Schedule,170% of Scott and White PPO fee schedule,26.79,170,,474.96,Fee Schedule,170% of Scott and White SWHP fee schedule,23.64,150,,,Fee Schedule,150% of CMS OPPS Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,90,,279.776,Fee Schedule,90% of UHC fee schedule,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,158.592,Fee Schedule,100% of TX Medicaid Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1439.04,100,,99.824,Percent of Total Billed Charges,100% of Total Billed Charges,12.76,1439.04,
HIVVL,41000026,CDM,306,RC,87900,HCPCS,Outpatient,,,,,,151.2,100,,3600,Fee Schedule,100% of Aetna Fee Schedule,195.52,150,,5928.536,Fee Schedule ,150% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,364.98,280,,360.368,Fee Schedule,280% of BCBS BULE Fee Schedule,417.12,320,,571.784,Fee Schedule,320% of BCBS Blue Essentials Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,469.26,360,,463.328,Fee Schedule,360% of BCBS POS Rate,469.26,360,,463.328,Fee schedule,360% of BCBS PPO Rate,469.26,360,,463.328,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,109.49,100,,304.088,Fee Schedule,100% of TX Mediciad 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,,1488,Fee Schedule,100% of CMS OPPS Rate,117.31,90,,,Fee Schedule,90% of CMS OPPS Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,169.45,130,,,Fee Schedule,130% of CMS OPPS Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,112.77,103,,313.208,Fee Schedule,103% of TX Medicaid Rate,134.26,103,,,Fee Schedule,103% of CMS OPPS Rate,134.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,221.59,80,,474.96,Fee Schedule,80% of Scott and White EPO fee schedule,221.59,80,,518.616,Fee Schedule,80% of Scott and White HMO fee schedule,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,221.59,170,,518.616,Fee Schedule,170% of Scott and White PPO fee schedule,221.59,170,,306.688,Fee Schedule,170% of Scott and White SWHP fee schedule,195.52,150,,,Fee Schedule,150% of CMS OPPS Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,105.59,90,,45.808,Fee Schedule,90% of UHC fee schedule,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,109.49,100,,304.088,Fee Schedule,100% of TX Medicaid Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,105.59,469.26,
MYD88,41000027,CDM,310,RC,81305,HCPCS,Outpatient,,,2100,1260.00,,203.46,100,,2400,Fee Schedule,100% of Aetna Fee Schedule,263.1,150,,3931.2,Fee Schedule ,150% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,491.12,280,,266.72,Fee Schedule,280% of BCBS BULE Fee Schedule,561.28,320,,572.16,Fee Schedule,320% of BCBS Blue Essentials Rate,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,631.44,360,,342.928,Fee Schedule,360% of BCBS POS Rate,631.44,360,,342.928,Fee schedule,360% of BCBS PPO Rate,631.44,360,,342.928,Fee Schedule,360% of BCBS Traditional Rate,1260,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,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,,20361.6,Fee Schedule,100% of CMS OPPS Rate,157.86,90,,,Fee Schedule,90% of CMS OPPS Rate,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,228.02,130,,,Fee Schedule,130% of CMS OPPS Rate,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,302.82,14.42,,313.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,1575,75,,310.504,Percent of Total Billed Charges,75% of Total Billed Charges,298.18,80,,306.688,Fee Schedule,80% of Scott and White EPO fee schedule,298.18,80,,337.568,Fee Schedule,80% of Scott and White HMO fee schedule,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,170,,337.568,Fee Schedule,170% of Scott and White PPO fee schedule,298.18,170,,518.616,Fee Schedule,170% of Scott and White SWHP fee schedule,263.1,150,,,Fee Schedule,150% of CMS OPPS Rate,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,142.07,90,,603.08,Fee Schedule,90% of UHC fee schedule,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,304.824,Percent of Total Billed Charges,14% of Total Billed Charges,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,2100,100,,414,Percent of Total Billed Charges,100% of Total Billed Charges,142.07,2100,
MUCOR RACEMOSUS IGE,41000028,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,2400,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,54,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,228.48,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,572.888,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,293.76,Fee Schedule,360% of BCBS POS Rate,18.79,360,,293.76,Fee schedule,360% of BCBS PPO Rate,18.79,360,,293.76,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,44.48,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,63.84,Fee Schedule,100% of TX Mediciad 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,,4430.4,Fee Schedule,100% of CMS OPPS Rate,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,65.752,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,156.68,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,518.616,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,337.568,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,337.568,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,337.568,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,1505.968,Fee Schedule,90% of UHC fee schedule,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,63.84,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,208.904,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
URINE MICROSCOPIC,41000029,CDM,306,RC,81015,HCPCS,Outpatient,,,,,,3.54,100,,2821.792,Fee Schedule,100% of Aetna Fee Schedule,4.57,150,,432,Fee Schedule ,150% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,8.54,280,,332.928,Fee Schedule,280% of BCBS BULE Fee Schedule,9.76,320,,573.248,Fee Schedule,320% of BCBS Blue Essentials Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,10.98,360,,428.048,Fee Schedule,360% of BCBS POS Rate,10.98,360,,428.048,Fee schedule,360% of BCBS PPO Rate,10.98,360,,428.048,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,2.56,100,,63.728,Fee Schedule,100% of TX Mediciad 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,,13174.528,Fee Schedule,100% of CMS OPPS Rate,2.74,90,,,Fee Schedule,90% of CMS OPPS Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,130,,,Fee Schedule,130% of CMS OPPS Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.64,103,,65.64,Fee Schedule,103% of TX Medicaid Rate,3.14,103,,,Fee Schedule,103% of CMS OPPS Rate,3.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,80,,337.568,Fee Schedule,80% of Scott and White EPO fee schedule,5.18,80,,209.728,Fee Schedule,80% of Scott and White HMO fee schedule,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,170,,209.728,Fee Schedule,170% of Scott and White PPO fee schedule,5.18,170,,337.568,Fee Schedule,170% of Scott and White SWHP fee schedule,4.57,150,,,Fee Schedule,150% of CMS OPPS Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2.48,90,,2388.376,Fee Schedule,90% of UHC fee schedule,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,63.728,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.48,10.98,
CVSC RAPID SARS ANTIGEN,41000030,CDM,306,RC,87426,HCPCS,Outpatient,,,120,72.00,,90.46,100,,1881.192,Fee Schedule,100% of Aetna Fee Schedule,52.99,150,,1404,Fee Schedule ,150% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,126.64,280,,3066.064,Fee Schedule,280% of BCBS BULE Fee Schedule,144.74,320,,575.232,Fee Schedule,320% of BCBS Blue Essentials Rate,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,162.83,360,,3942.08,Fee Schedule,360% of BCBS POS Rate,162.83,360,,3942.08,Fee schedule,360% of BCBS PPO Rate,162.83,360,,3942.08,Fee Schedule,360% of BCBS Traditional Rate,72,60,,71.464,Percent of Total Billed Charges,60% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,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,,8736,Fee Schedule,100% of CMS OPPS Rate,31.79,90,,,Fee Schedule,90% of CMS OPPS Rate,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,45.92,130,,,Fee Schedule,130% of CMS OPPS Rate,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.3,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,36.38,103,,,Fee Schedule,103% of CMS OPPS Rate,36.38,103,,,Fee Schedule,103% of CMS OPPS Rate,90,75,,157.8,Percent of Total Billed Charges,75% of Total Billed Charges,60.06,80,,337.568,Fee Schedule,80% of Scott and White EPO fee schedule,60.06,80,,209.728,Fee Schedule,80% of Scott and White HMO fee schedule,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,60.06,170,,209.728,Fee Schedule,170% of Scott and White PPO fee schedule,60.06,170,,209.728,Fee Schedule,170% of Scott and White SWHP fee schedule,52.99,150,,,Fee Schedule,150% of CMS OPPS Rate,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,90,,3690.44,Fee Schedule,90% of UHC fee schedule,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,120,100,,210.4,Percent of Total Billed Charges,100% of Total Billed Charges,16.8,162.83,
CHROMOSOME ANALYSIS 20--25,41000031,CDM,310,RC,88264,HCPCS,Outpatient,,,679.16,407.50,,167.74,100,,1881.192,Fee Schedule,100% of Aetna Fee Schedule,216.91,150,,49.68,Fee Schedule ,150% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,404.91,280,,45.968,Fee Schedule,280% of BCBS BULE Fee Schedule,462.75,320,,575.328,Fee Schedule,320% of BCBS Blue Essentials Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,520.6,360,,59.104,Fee Schedule,360% of BCBS POS Rate,520.6,360,,59.104,Fee schedule,360% of BCBS PPO Rate,520.6,360,,59.104,Fee Schedule,360% of BCBS Traditional Rate,407.5,60,,95.6,Percent of Total Billed Charges,60% of Total Billed Charges,121.47,100,,57.232,Fee Schedule,100% of TX Mediciad 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,,120,Fee Schedule,100% of CMS OPPS Rate,130.14,90,,,Fee Schedule,90% of CMS OPPS Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.99,130,,,Fee Schedule,130% of CMS OPPS Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,125.11,103,,58.952,Fee Schedule,103% of TX Medicaid Rate,148.94,103,,,Fee Schedule,103% of CMS OPPS Rate,148.94,103,,,Fee Schedule,103% of CMS OPPS Rate,509.37,75,,178.168,Percent of Total Billed Charges,75% of Total Billed Charges,245.83,80,,209.728,Fee Schedule,80% of Scott and White EPO fee schedule,245.83,80,,710.128,Fee Schedule,80% of Scott and White HMO fee schedule,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,245.83,170,,710.128,Fee Schedule,170% of Scott and White PPO fee schedule,245.83,170,,209.728,Fee Schedule,170% of Scott and White SWHP fee schedule,216.91,150,,,Fee Schedule,150% of CMS OPPS Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,117.14,90,,3690.44,Fee Schedule,90% of UHC fee schedule,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,121.47,100,,57.232,Fee Schedule,100% of TX Medicaid Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,679.16,100,,237.552,Percent of Total Billed Charges,100% of Total Billed Charges,117.14,679.16,
USPRM,41000032,CDM,307,RC,81015,HCPCS,Outpatient,,,,,,3.54,100,,2830.928,Fee Schedule,100% of Aetna Fee Schedule,4.57,150,,2808,Fee Schedule ,150% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,8.54,280,,15.504,Fee Schedule,280% of BCBS BULE Fee Schedule,9.76,320,,576,Fee Schedule,320% of BCBS Blue Essentials Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,10.98,360,,19.936,Fee Schedule,360% of BCBS POS Rate,10.98,360,,19.936,Fee schedule,360% of BCBS PPO Rate,10.98,360,,19.936,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,2.56,100,,56.56,Fee Schedule,100% of TX Mediciad 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,,960,Fee Schedule,100% of CMS OPPS Rate,2.74,90,,,Fee Schedule,90% of CMS OPPS Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,130,,,Fee Schedule,130% of CMS OPPS Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.64,103,,58.256,Fee Schedule,103% of TX Medicaid Rate,3.14,103,,,Fee Schedule,103% of CMS OPPS Rate,3.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,80,,209.728,Fee Schedule,80% of Scott and White EPO fee schedule,5.18,80,,474.672,Fee Schedule,80% of Scott and White HMO fee schedule,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,170,,474.672,Fee Schedule,170% of Scott and White PPO fee schedule,5.18,170,,710.128,Fee Schedule,170% of Scott and White SWHP fee schedule,4.57,150,,,Fee Schedule,150% of CMS OPPS Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2.48,90,,6972.424,Fee Schedule,90% of UHC fee schedule,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,2.56,100,,56.56,Fee Schedule,100% of TX Medicaid Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.48,10.98,
TC1_E9752  THAWED APHERESIS PLASMA,41000033,CDM,383,RC,P9099,HCPCS,Outpatient,,,200,120.00,,120,60,,2902.592,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,3670.92,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,56,28,,21.144,Percent of Total Billed Charges,28% of Total Billed Charges,56,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,27.184,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,27.184,Percent of Total Billed Charges,36% of Total Billed Charges,120,60,,54.488,Percent of Total Billed Charges,60% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,3120,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,49.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,150,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,100,50,,710.128,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,321.432,Percent of Total Billed Charges,50% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,100,50,,321.432,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,474.672,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,243.328,Case Rate,Pays based on per visit rate,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,48.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,200,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,28,870,
TC_E9762 THAWED CONVALESCENT PLASMA,41000034,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,1786.856,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,1591.2,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,332.928,Percent of Total Billed Charges,28% of Total Billed Charges,56.03,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,428.048,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,428.048,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,75.84,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,110.4,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,49.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,31.528,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,474.672,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,430,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,430,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,321.432,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,3808.4,Case Rate,Pays based on per visit rate,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,47.712,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,42.04,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
TC3_E9763 THAWED CONVALESCENT PLASMA,41000035,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,1191.24,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,135,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,147.36,Percent of Total Billed Charges,28% of Total Billed Charges,56.03,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,189.464,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,75.84,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,6240,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,47.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,78.24,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,321.432,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,288.08,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,288.08,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,430,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,4943.12,Case Rate,Pays based on per visit rate,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,45.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,104.32,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
TC4_E9764 THAWED CONVALESCENT PLASMA,41000036,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,1113.6,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,13.384,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,111.912,Percent of Total Billed Charges,28% of Total Billed Charges,56.05,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,143.888,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,143.888,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,143.888,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,91.064,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,8157.6,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,27.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,430,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,288.08,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,477.56,Case Rate,Pays based on per visit rate,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,101.6,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
TC5_E9765 THAWED CONVALESCENT PLASMA,41000037,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,816,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,13.384,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,18.32,Percent of Total Billed Charges,28% of Total Billed Charges,56.39,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,23.56,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,23.56,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,23.56,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,95.696,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,3536,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,32.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,44.832,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,288.08,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,52.856,Case Rate,Pays based on per visit rate,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,31.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,59.776,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
TC6_E9780 THAWED CONVALESCENT PLASMA,41000038,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,1107.704,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,16.08,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,241.232,Percent of Total Billed Charges,28% of Total Billed Charges,56.48,32,,576,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,310.152,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,310.152,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,104.296,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,300,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,25.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,274.744,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,1695.696,Case Rate,Pays based on per visit rate,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,50.4,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
PROTEINASE 3 ANTIBODY,41000039,CDM,301,RC,86021,HCPCS,Outpatient,,,52.08,31.25,,17.46,100,,428.992,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,16.08,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,602.384,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,576,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,774.496,Fee Schedule,360% of BCBS POS Rate,54.18,360,,774.496,Fee schedule,360% of BCBS PPO Rate,54.18,360,,774.496,Fee Schedule,360% of BCBS Traditional Rate,31.25,60,,96.296,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,24.64,Fee Schedule,100% of TX Mediciad 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,,29.736,Fee Schedule,100% of CMS OPPS Rate,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,25.376,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,39.06,75,,62.744,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,274.744,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,298.56,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,298.56,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,298.56,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,30.968,Fee Schedule,90% of UHC fee schedule,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,24.64,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,52.08,100,,83.656,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,54.18,
HEPATITIS C VIRUS ANTIBODY SCREEN,41000040,CDM,301,RC,86803,HCPCS,Outpatient,,,80.12,48.07,,16.56,100,,7629.952,Fee Schedule,100% of Aetna Fee Schedule,21.4,150,,9360,Fee Schedule ,150% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.96,280,,955.352,Fee Schedule,280% of BCBS BULE Fee Schedule,45.66,320,,576,Fee Schedule,320% of BCBS Blue Essentials Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,51.37,360,,1228.312,Fee Schedule,360% of BCBS POS Rate,51.37,360,,1228.312,Fee schedule,360% of BCBS PPO Rate,51.37,360,,1228.312,Fee Schedule,360% of BCBS Traditional Rate,48.07,60,,64.92,Percent of Total Billed Charges,60% of Total Billed Charges,11.99,100,,23.072,Fee Schedule,100% of TX Mediciad 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,,29.736,Fee Schedule,100% of CMS OPPS Rate,12.84,90,,,Fee Schedule,90% of CMS OPPS Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,18.55,130,,,Fee Schedule,130% of CMS OPPS Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,12.35,103,,23.768,Fee Schedule,103% of TX Medicaid Rate,14.69,103,,,Fee Schedule,103% of CMS OPPS Rate,14.69,103,,,Fee Schedule,103% of CMS OPPS Rate,60.09,75,,59.744,Percent of Total Billed Charges,75% of Total Billed Charges,24.25,80,,298.56,Fee Schedule,80% of Scott and White EPO fee schedule,24.25,80,,493.144,Fee Schedule,80% of Scott and White HMO fee schedule,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,24.25,170,,493.144,Fee Schedule,170% of Scott and White PPO fee schedule,24.25,170,,298.56,Fee Schedule,170% of Scott and White SWHP fee schedule,21.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,11.56,90,,45.384,Fee Schedule,90% of UHC fee schedule,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,23.072,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,80.12,100,,79.656,Percent of Total Billed Charges,100% of Total Billed Charges,11.56,80.12,
HCV RNA VIRAL LOAD BY PCR- HCVQT,41000041,CDM,301,RC,87522,HCPCS,Outpatient,,,349.24,209.54,,49.7,100,,7629.952,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,3276,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,1476.176,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,577.024,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,1897.944,Fee Schedule,360% of BCBS POS Rate,154.22,360,,1897.944,Fee schedule,360% of BCBS PPO Rate,154.22,360,,1897.944,Fee Schedule,360% of BCBS Traditional Rate,209.54,60,,116.64,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,16.576,Fee Schedule,100% of TX Mediciad 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,,35.728,Fee Schedule,100% of CMS OPPS Rate,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,17.072,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,261.93,75,,63.496,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,298.56,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,493.144,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,493.144,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,493.144,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,70.472,Fee Schedule,90% of UHC fee schedule,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,16.576,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,349.24,100,,84.664,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,349.24,
ISLET CELL ANTIBODY SCREEN,41000042,CDM,301,RC,86341,HCPCS,Outpatient,,,118.68,71.21,,27.34,100,,11444.936,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,31.432,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,1476.176,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,577.024,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,1897.944,Fee Schedule,360% of BCBS POS Rate,84.85,360,,1897.944,Fee schedule,360% of BCBS PPO Rate,84.85,360,,1897.944,Fee Schedule,360% of BCBS Traditional Rate,71.21,60,,66.784,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,15.68,Fee Schedule,100% of TX Mediciad 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,,35.728,Fee Schedule,100% of CMS OPPS Rate,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,16.152,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,89.01,75,,116.992,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,493.144,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,888,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,888,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,493.144,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,269.44,Fee Schedule,90% of UHC fee schedule,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,15.68,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,118.68,100,,155.984,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,118.68,
PANEL ELECTROLYTE,41000043,CDM,301,RC,80051,HCPCS,Outpatient,,,203,121.80,,8.14,100,,6177.92,Fee Schedule,100% of Aetna Fee Schedule,10.51,150,,2542.176,Fee Schedule ,150% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,280,,2788.968,Fee Schedule,280% of BCBS BULE Fee Schedule,22.43,320,,577.024,Fee Schedule,320% of BCBS Blue Essentials Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,25.24,360,,3585.816,Fee Schedule,360% of BCBS POS Rate,25.24,360,,3585.816,Fee schedule,360% of BCBS PPO Rate,25.24,360,,3585.816,Fee Schedule,360% of BCBS Traditional Rate,121.8,60,,44.264,Percent of Total Billed Charges,60% of Total Billed Charges,5.89,100,,15.232,Fee Schedule,100% of TX Mediciad 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,,20800,Fee Schedule,100% of CMS OPPS Rate,6.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,130,,,Fee Schedule,130% of CMS OPPS Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,6.07,103,,15.688,Fee Schedule,103% of TX Medicaid Rate,7.22,103,,,Fee Schedule,103% of CMS OPPS Rate,7.22,103,,,Fee Schedule,103% of CMS OPPS Rate,152.25,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,11.91,80,,493.144,Fee Schedule,80% of Scott and White EPO fee schedule,11.91,80,,773.832,Fee Schedule,80% of Scott and White HMO fee schedule,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,170,,773.832,Fee Schedule,170% of Scott and White PPO fee schedule,11.91,170,,888,Fee Schedule,170% of Scott and White SWHP fee schedule,10.51,150,,,Fee Schedule,150% of CMS OPPS Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,90,,269.44,Fee Schedule,90% of UHC fee schedule,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,5.89,100,,15.232,Fee Schedule,100% of TX Medicaid Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,203,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.68,203,
RSV DNA/RNA AMP PROBE,41000044,CDM,306,RC,87634,HCPCS,Outpatient,,,173.32,103.99,,81.44,100,,6177.92,Fee Schedule,100% of Aetna Fee Schedule,105.3,150,,6016.936,Fee Schedule ,150% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,280,,97.336,Fee Schedule,280% of BCBS BULE Fee Schedule,224.64,320,,577.032,Fee Schedule,320% of BCBS Blue Essentials Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,252.72,360,,125.144,Fee Schedule,360% of BCBS POS Rate,252.72,360,,125.144,Fee schedule,360% of BCBS PPO Rate,252.72,360,,125.144,Fee Schedule,360% of BCBS Traditional Rate,103.99,60,,51.504,Percent of Total Billed Charges,60% of Total Billed Charges,58.97,100,,14.896,Fee Schedule,100% of TX Mediciad 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,,7280,Fee Schedule,100% of CMS OPPS Rate,63.18,90,,,Fee Schedule,90% of CMS OPPS Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.26,130,,,Fee Schedule,130% of CMS OPPS Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,60.74,103,,15.344,Fee Schedule,103% of TX Medicaid Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,129.99,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,119.34,80,,888,Fee Schedule,80% of Scott and White EPO fee schedule,119.34,80,,246,Fee Schedule,80% of Scott and White HMO fee schedule,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.34,170,,246,Fee Schedule,170% of Scott and White PPO fee schedule,119.34,170,,773.832,Fee Schedule,170% of Scott and White SWHP fee schedule,105.3,150,,,Fee Schedule,150% of CMS OPPS Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.86,90,,47.568,Fee Schedule,90% of UHC fee schedule,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,14.896,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,173.32,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,56.86,252.72,
CARBON MONOXIDE (CARBOXYHEMOGLOBIN),41000045,CDM,301,RC,82375,HCPCS,Outpatient,,,431.44,258.86,,14.3,100,,9266.88,Fee Schedule,100% of Aetna Fee Schedule,18.48,150,,34.024,Fee Schedule ,150% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.5,280,,1523.36,Fee Schedule,280% of BCBS BULE Fee Schedule,39.42,320,,577.384,Fee Schedule,320% of BCBS Blue Essentials Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,44.35,360,,1958.608,Fee Schedule,360% of BCBS POS Rate,44.35,360,,1958.608,Fee schedule,360% of BCBS PPO Rate,44.35,360,,1958.608,Fee Schedule,360% of BCBS Traditional Rate,258.86,60,,97.544,Percent of Total Billed Charges,60% of Total Billed Charges,10.35,100,,14.672,Fee Schedule,100% of TX Mediciad 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,,69.84,Fee Schedule,100% of CMS OPPS Rate,11.08,90,,,Fee Schedule,90% of CMS OPPS Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,16.01,130,,,Fee Schedule,130% of CMS OPPS Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.66,103,,15.112,Fee Schedule,103% of TX Medicaid Rate,12.68,103,,,Fee Schedule,103% of CMS OPPS Rate,12.68,103,,,Fee Schedule,103% of CMS OPPS Rate,323.58,75,,49.496,Percent of Total Billed Charges,75% of Total Billed Charges,20.94,80,,773.832,Fee Schedule,80% of Scott and White EPO fee schedule,20.94,80,,5234.464,Fee Schedule,80% of Scott and White HMO fee schedule,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.94,170,,5234.464,Fee Schedule,170% of Scott and White PPO fee schedule,20.94,170,,246,Fee Schedule,170% of Scott and White SWHP fee schedule,18.48,150,,,Fee Schedule,150% of CMS OPPS Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,9.98,90,,2464.96,Fee Schedule,90% of UHC fee schedule,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,14.672,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,431.44,100,,65.992,Percent of Total Billed Charges,100% of Total Billed Charges,9.98,431.44,
POTASSIUM- PK,41000046,CDM,301,RC,84132,HCPCS,Outpatient,,,320,192.00,,5.52,100,,14226.136,Fee Schedule,100% of Aetna Fee Schedule,7.14,150,,35.104,Fee Schedule ,150% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,280,,1977.248,Fee Schedule,280% of BCBS BULE Fee Schedule,15.23,320,,578.096,Fee Schedule,320% of BCBS Blue Essentials Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,17.14,360,,2542.176,Fee Schedule,360% of BCBS POS Rate,17.14,360,,2542.176,Fee schedule,360% of BCBS PPO Rate,17.14,360,,2542.176,Fee Schedule,360% of BCBS Traditional Rate,192,60,,64.72,Percent of Total Billed Charges,60% of Total Billed Charges,4,100,,14.336,Fee Schedule,100% of TX Mediciad 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,,5649.28,Fee Schedule,100% of CMS OPPS Rate,4.28,90,,,Fee Schedule,90% of CMS OPPS Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,6.18,130,,,Fee Schedule,130% of CMS OPPS Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.12,103,,14.768,Fee Schedule,103% of TX Medicaid Rate,4.9,103,,,Fee Schedule,103% of CMS OPPS Rate,4.9,103,,,Fee Schedule,103% of CMS OPPS Rate,240,75,,66.992,Percent of Total Billed Charges,75% of Total Billed Charges,8.09,80,,246,Fee Schedule,80% of Scott and White EPO fee schedule,8.09,80,,877.144,Fee Schedule,80% of Scott and White HMO fee schedule,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,170,,877.144,Fee Schedule,170% of Scott and White PPO fee schedule,8.09,170,,5234.464,Fee Schedule,170% of Scott and White SWHP fee schedule,7.14,150,,,Fee Schedule,150% of CMS OPPS Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,164.168,Fee Schedule,90% of UHC fee schedule,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4,100,,14.336,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,320,100,,89.32,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,320,
POC SODIUM,41000047,CDM,301,RC,84295,HCPCS,Outpatient,,,330.44,198.26,,5.58,100,,14226.136,Fee Schedule,100% of Aetna Fee Schedule,7.21,150,,35.104,Fee Schedule ,150% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.47,280,,191.024,Fee Schedule,280% of BCBS BULE Fee Schedule,15.39,320,,578.192,Fee Schedule,320% of BCBS Blue Essentials Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,17.32,360,,245.6,Fee Schedule,360% of BCBS POS Rate,17.32,360,,245.6,Fee schedule,360% of BCBS PPO Rate,17.32,360,,245.6,Fee Schedule,360% of BCBS Traditional Rate,198.26,60,,73.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.04,100,,11.872,Fee Schedule,100% of TX Mediciad 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,,13370.976,Fee Schedule,100% of CMS OPPS Rate,4.32,90,,,Fee Schedule,90% of CMS OPPS Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,130,,,Fee Schedule,130% of CMS OPPS Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.16,103,,12.232,Fee Schedule,103% of TX Medicaid Rate,4.95,103,,,Fee Schedule,103% of CMS OPPS Rate,4.95,103,,,Fee Schedule,103% of CMS OPPS Rate,247.83,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,8.17,80,,5234.464,Fee Schedule,80% of Scott and White EPO fee schedule,8.17,80,,877.144,Fee Schedule,80% of Scott and White HMO fee schedule,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,170,,877.144,Fee Schedule,170% of Scott and White PPO fee schedule,8.17,170,,877.144,Fee Schedule,170% of Scott and White SWHP fee schedule,7.21,150,,,Fee Schedule,150% of CMS OPPS Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.9,90,,2899.392,Fee Schedule,90% of UHC fee schedule,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,11.872,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,330.44,100,,68,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,330.44,
DIABETES MELLITUS T1 EVAL SERUM,41000048,CDM,301,RC,86337,HCPCS,Outpatient,,,3944,2366.40,,24.84,100,,16128.088,Fee Schedule,100% of Aetna Fee Schedule,32.11,150,,35.104,Fee Schedule ,150% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.95,280,,21.144,Fee Schedule,280% of BCBS BULE Fee Schedule,68.51,320,,578.224,Fee Schedule,320% of BCBS Blue Essentials Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,77.08,360,,27.184,Fee Schedule,360% of BCBS POS Rate,77.08,360,,27.184,Fee schedule,360% of BCBS PPO Rate,77.08,360,,27.184,Fee Schedule,360% of BCBS Traditional Rate,2366.4,60,,64.144,Percent of Total Billed Charges,60% of Total Billed Charges,17.98,100,,66.08,Fee Schedule,100% of TX Mediciad 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,,75.6,Fee Schedule,100% of CMS OPPS Rate,19.26,90,,,Fee Schedule,90% of CMS OPPS Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,27.83,130,,,Fee Schedule,130% of CMS OPPS Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,18.52,103,,68.064,Fee Schedule,103% of TX Medicaid Rate,22.05,103,,,Fee Schedule,103% of CMS OPPS Rate,22.05,103,,,Fee Schedule,103% of CMS OPPS Rate,2958,75,,162,Percent of Total Billed Charges,75% of Total Billed Charges,36.39,80,,877.144,Fee Schedule,80% of Scott and White EPO fee schedule,36.39,80,,877.144,Fee Schedule,80% of Scott and White HMO fee schedule,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,36.39,170,,877.144,Fee Schedule,170% of Scott and White PPO fee schedule,36.39,170,,877.144,Fee Schedule,170% of Scott and White SWHP fee schedule,32.11,150,,,Fee Schedule,150% of CMS OPPS Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.34,90,,70.472,Fee Schedule,90% of UHC fee schedule,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,66.08,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3944,100,,216,Percent of Total Billed Charges,100% of Total Billed Charges,17.34,3944,
RF SYNOVIAL FLUID,41000049,CDM,301,RC,86431,HCPCS,Outpatient,,,284.44,170.66,,6.58,100,,16128.088,Fee Schedule,100% of Aetna Fee Schedule,8.5,150,,35.104,Fee Schedule ,150% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,15.88,280,,678.28,Fee Schedule,280% of BCBS BULE Fee Schedule,18.14,320,,578.224,Fee Schedule,320% of BCBS Blue Essentials Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,20.41,360,,872.072,Fee Schedule,360% of BCBS POS Rate,20.41,360,,872.072,Fee schedule,360% of BCBS PPO Rate,20.41,360,,872.072,Fee Schedule,360% of BCBS Traditional Rate,170.66,60,,131.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.76,100,,67.312,Fee Schedule,100% of TX Mediciad 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,,78,Fee Schedule,100% of CMS OPPS Rate,5.1,90,,,Fee Schedule,90% of CMS OPPS Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7.37,130,,,Fee Schedule,130% of CMS OPPS Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.9,103,,69.328,Fee Schedule,103% of TX Medicaid Rate,5.84,103,,,Fee Schedule,103% of CMS OPPS Rate,5.84,103,,,Fee Schedule,103% of CMS OPPS Rate,213.33,75,,193.288,Percent of Total Billed Charges,75% of Total Billed Charges,9.63,80,,877.144,Fee Schedule,80% of Scott and White EPO fee schedule,9.63,80,,1346.8,Fee Schedule,80% of Scott and White HMO fee schedule,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,170,,1346.8,Fee Schedule,170% of Scott and White PPO fee schedule,9.63,170,,877.144,Fee Schedule,170% of Scott and White SWHP fee schedule,8.5,150,,,Fee Schedule,150% of CMS OPPS Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,90,,70.472,Fee Schedule,90% of UHC fee schedule,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,67.312,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,284.44,100,,257.712,Percent of Total Billed Charges,100% of Total Billed Charges,4.59,284.44,
RESPIRATORY VIRUS MINI PANEL,41000050,CDM,306,RC,87631,HCPCS,Outpatient,,,600,360.00,,165.46,100,,25392.136,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,35.104,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,12.384,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,582.4,Fee Schedule,320% of BCBS Blue Essentials Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,513.47,360,,15.928,Fee Schedule,360% of BCBS POS Rate,513.47,360,,15.928,Fee schedule,360% of BCBS PPO Rate,513.47,360,,15.928,Fee Schedule,360% of BCBS Traditional Rate,360,60,,106.984,Percent of Total Billed Charges,60% of Total Billed Charges,119.81,100,,123.408,Fee Schedule,100% of TX Mediciad 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,,78,Fee Schedule,100% of CMS OPPS Rate,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,123.4,103,,127.112,Fee Schedule,103% of TX Medicaid Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,450,75,,105.616,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,877.144,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,532,Fee Schedule,80% of Scott and White HMO fee schedule,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,532,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,1346.8,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.53,90,,21.048,Fee Schedule,90% of UHC fee schedule,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,123.408,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,600,100,,140.816,Percent of Total Billed Charges,100% of Total Billed Charges,115.53,600,
QUANTIFERON TB-GOLD PLUS,41000051,CDM,302,RC,86480,HCPCS,Outpatient,,,167.28,100.37,,71.9,100,,14226.136,Fee Schedule,100% of Aetna Fee Schedule,92.97,150,,56.088,Fee Schedule ,150% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,173.54,280,,18.152,Fee Schedule,280% of BCBS BULE Fee Schedule,198.34,320,,585.056,Fee Schedule,320% of BCBS Blue Essentials Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,223.13,360,,23.336,Fee Schedule,360% of BCBS POS Rate,223.13,360,,23.336,Fee schedule,360% of BCBS PPO Rate,223.13,360,,23.336,Fee Schedule,360% of BCBS Traditional Rate,100.37,60,,133.44,Percent of Total Billed Charges,60% of Total Billed Charges,52.06,100,,169.12,Fee Schedule,100% of TX Mediciad 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,,78,Fee Schedule,100% of CMS OPPS Rate,55.78,90,,,Fee Schedule,90% of CMS OPPS Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,80.57,130,,,Fee Schedule,130% of CMS OPPS Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,53.62,103,,174.192,Fee Schedule,103% of TX Medicaid Rate,63.83,103,,,Fee Schedule,103% of CMS OPPS Rate,63.83,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,75,,208.696,Percent of Total Billed Charges,75% of Total Billed Charges,105.36,80,,1346.8,Fee Schedule,80% of Scott and White EPO fee schedule,105.36,80,,512.8,Fee Schedule,80% of Scott and White HMO fee schedule,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.36,170,,512.8,Fee Schedule,170% of Scott and White PPO fee schedule,105.36,170,,532,Fee Schedule,170% of Scott and White SWHP fee schedule,92.97,150,,,Fee Schedule,150% of CMS OPPS Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,90,,151.032,Fee Schedule,90% of UHC fee schedule,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,169.12,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167.28,100,,278.256,Percent of Total Billed Charges,100% of Total Billed Charges,50.2,223.13,
IFBA,41000052,CDM,301,RC,86340,HCPCS,Outpatient,,,40.36,24.22,,17.5,100,,14226.136,Fee Schedule,100% of Aetna Fee Schedule,22.62,150,,71.192,Fee Schedule ,150% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,280,,28.192,Fee Schedule,280% of BCBS BULE Fee Schedule,48.26,320,,585.44,Fee Schedule,320% of BCBS Blue Essentials Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,54.29,360,,36.24,Fee Schedule,360% of BCBS POS Rate,54.29,360,,36.24,Fee schedule,360% of BCBS PPO Rate,54.29,360,,36.24,Fee Schedule,360% of BCBS Traditional Rate,24.22,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,12.67,100,,196.784,Fee Schedule,100% of TX Mediciad 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,,78,Fee Schedule,100% of CMS OPPS Rate,13.57,90,,,Fee Schedule,90% of CMS OPPS Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,130,,,Fee Schedule,130% of CMS OPPS Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,13.05,103,,202.688,Fee Schedule,103% of TX Medicaid Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,30.27,75,,67.504,Percent of Total Billed Charges,75% of Total Billed Charges,25.63,80,,532,Fee Schedule,80% of Scott and White EPO fee schedule,25.63,80,,148,Fee Schedule,80% of Scott and White HMO fee schedule,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,25.63,170,,148,Fee Schedule,170% of Scott and White PPO fee schedule,25.63,170,,512.8,Fee Schedule,170% of Scott and White SWHP fee schedule,22.62,150,,,Fee Schedule,150% of CMS OPPS Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.21,90,,112.928,Fee Schedule,90% of UHC fee schedule,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,196.784,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.36,100,,90.008,Percent of Total Billed Charges,100% of Total Billed Charges,12.21,54.29,
MTB AND RIF BY PCR,41000053,CDM,306,RC,87556,HCPCS,Outpatient,,,569.72,341.83,,48.34,100,,21339.208,Fee Schedule,100% of Aetna Fee Schedule,62.52,150,,175.136,Fee Schedule ,150% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,116.7,280,,107.776,Fee Schedule,280% of BCBS BULE Fee Schedule,133.38,320,,585.44,Fee Schedule,320% of BCBS Blue Essentials Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,150.05,360,,138.568,Fee Schedule,360% of BCBS POS Rate,150.05,360,,138.568,Fee schedule,360% of BCBS PPO Rate,150.05,360,,138.568,Fee Schedule,360% of BCBS Traditional Rate,341.83,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,35.01,100,,838.32,Fee Schedule,100% of TX Mediciad 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,,78,Fee Schedule,100% of CMS OPPS Rate,37.51,90,,,Fee Schedule,90% of CMS OPPS Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,130,,,Fee Schedule,130% of CMS OPPS Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,36.06,103,,863.472,Fee Schedule,103% of TX Medicaid Rate,42.93,103,,,Fee Schedule,103% of CMS OPPS Rate,42.93,103,,,Fee Schedule,103% of CMS OPPS Rate,427.29,75,,171.072,Percent of Total Billed Charges,75% of Total Billed Charges,70.85,80,,512.8,Fee Schedule,80% of Scott and White EPO fee schedule,70.85,80,,351.2,Fee Schedule,80% of Scott and White HMO fee schedule,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,70.85,170,,351.2,Fee Schedule,170% of Scott and White PPO fee schedule,70.85,170,,148,Fee Schedule,170% of Scott and White SWHP fee schedule,62.52,150,,,Fee Schedule,150% of CMS OPPS Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,33.76,90,,299.376,Fee Schedule,90% of UHC fee schedule,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,569.72,100,,228.096,Percent of Total Billed Charges,100% of Total Billed Charges,33.76,569.72,
HLA TYPE ABC,41000054,CDM,302,RC,81370,HCPCS,Outpatient,,,1272,763.20,,466.46,100,,18528.088,Fee Schedule,100% of Aetna Fee Schedule,603.18,150,,30.112,Fee Schedule ,150% of CMS OPPS Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1125.94,280,,107.776,Fee Schedule,280% of BCBS BULE Fee Schedule,1286.78,320,,585.44,Fee Schedule,320% of BCBS Blue Essentials Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,1447.63,360,,138.568,Fee Schedule,360% of BCBS POS Rate,1447.63,360,,138.568,Fee schedule,360% of BCBS PPO Rate,1447.63,360,,138.568,Fee Schedule,360% of BCBS Traditional Rate,763.2,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,337.78,100,,838.32,Fee Schedule,100% of TX Mediciad Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,402.12,100,,124.64,Fee Schedule,100% of CMS OPPS Rate,361.9,90,,,Fee Schedule,90% of CMS OPPS Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,522.75,130,,,Fee Schedule,130% of CMS OPPS Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,347.91,103,,863.472,Fee Schedule,103% of TX Medicaid Rate,414.18,103,,,Fee Schedule,103% of CMS OPPS Rate,414.18,103,,,Fee Schedule,103% of CMS OPPS Rate,954,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,683.6,80,,148,Fee Schedule,80% of Scott and White EPO fee schedule,683.6,80,,360,Fee Schedule,80% of Scott and White HMO fee schedule,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,683.6,170,,360,Fee Schedule,170% of Scott and White PPO fee schedule,683.6,170,,351.2,Fee Schedule,170% of Scott and White SWHP fee schedule,603.18,150,,,Fee Schedule,150% of CMS OPPS Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,325.72,90,,230.52,Fee Schedule,90% of UHC fee schedule,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,337.78,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,402.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1272,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,325.72,1447.63,
CYTOKINE PANEL 13,41000055,CDM,301,RC,83520,HCPCS,Outpatient,,,1400,840.00,,20.04,100,,18528.088,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,44.28,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,19.024,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,585.44,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,24.464,Fee Schedule,360% of BCBS POS Rate,62.17,360,,24.464,Fee schedule,360% of BCBS PPO Rate,62.17,360,,24.464,Fee Schedule,360% of BCBS Traditional Rate,840,60,,87.12,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,838.32,Fee Schedule,100% of TX Mediciad 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,,158.2,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,863.472,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,1050,75,,106.16,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,351.2,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,294,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,294,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,360,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,230.52,Fee Schedule,90% of UHC fee schedule,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1400,100,,141.544,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,1400,
"INTERLEUKIN-2 RECEPTOR, SOLUABLE",41000056,CDM,301,RC,83520,HCPCS,Outpatient,,,520,312.00,,20.04,100,,27792.136,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,54,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,985.984,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,586.24,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,1267.696,Fee Schedule,360% of BCBS POS Rate,62.17,360,,1267.696,Fee schedule,360% of BCBS PPO Rate,62.17,360,,1267.696,Fee Schedule,360% of BCBS Traditional Rate,312,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,838.32,Fee Schedule,100% of TX Mediciad 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,,389.192,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,863.472,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,390,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,360,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,246.4,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,246.4,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,294,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,39.584,Fee Schedule,90% of UHC fee schedule,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,838.32,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,520,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,520,
BROAD RANGE BACTERIA PCR/SEQUENCING,41000057,CDM,301,RC,87801,HCPCS,Outpatient,,,1468.08,880.85,,81.44,100,,11826.136,Fee Schedule,100% of Aetna Fee Schedule,105.3,150,,54,Fee Schedule ,150% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,280,,65.664,Fee Schedule,280% of BCBS BULE Fee Schedule,224.64,320,,586.32,Fee Schedule,320% of BCBS Blue Essentials Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,252.72,360,,84.424,Fee Schedule,360% of BCBS POS Rate,252.72,360,,84.424,Fee schedule,360% of BCBS PPO Rate,252.72,360,,84.424,Fee Schedule,360% of BCBS Traditional Rate,880.85,60,,110.792,Percent of Total Billed Charges,60% of Total Billed Charges,58.97,100,,913.92,Fee Schedule,100% of TX Mediciad 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,,66.912,Fee Schedule,100% of CMS OPPS Rate,63.18,90,,,Fee Schedule,90% of CMS OPPS Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.26,130,,,Fee Schedule,130% of CMS OPPS Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,60.74,103,,941.336,Fee Schedule,103% of TX Medicaid Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,1101.06,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,119.34,80,,294,Fee Schedule,80% of Scott and White EPO fee schedule,119.34,80,,242.8,Fee Schedule,80% of Scott and White HMO fee schedule,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.34,170,,242.8,Fee Schedule,170% of Scott and White PPO fee schedule,119.34,170,,246.4,Fee Schedule,170% of Scott and White SWHP fee schedule,105.3,150,,,Fee Schedule,150% of CMS OPPS Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.86,90,,210,Fee Schedule,90% of UHC fee schedule,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1468.08,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,56.86,1468.08,
INTERLEUKIN-18,41000058,CDM,301,RC,83520,HCPCS,Outpatient,,,2328,1396.80,,20.04,100,,11826.136,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,71.464,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,1159.76,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,586.32,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,1491.12,Fee Schedule,360% of BCBS POS Rate,62.17,360,,1491.12,Fee schedule,360% of BCBS PPO Rate,62.17,360,,1491.12,Fee Schedule,360% of BCBS Traditional Rate,1396.8,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,913.92,Fee Schedule,100% of TX Mediciad 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,,98.4,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,941.336,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,1746,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,246.4,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,566.4,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,566.4,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,242.8,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,37.736,Fee Schedule,90% of UHC fee schedule,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,913.92,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2328,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,2328,
CXCL9 CHEMOKINE (C-X-C MOTIF) LIGAND 9,41000059,CDM,302,RC,83520,HCPCS,Outpatient,,,1524,914.40,,20.04,100,,18939.208,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,72.216,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,28.192,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,587.552,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,36.24,Fee Schedule,360% of BCBS POS Rate,62.17,360,,36.24,Fee schedule,360% of BCBS PPO Rate,62.17,360,,36.24,Fee Schedule,360% of BCBS Traditional Rate,914.4,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,89.04,Fee Schedule,100% of TX Mediciad 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,,120,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,91.712,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,1143,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,242.8,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,1086.024,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,1086.024,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,566.4,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,201.512,Fee Schedule,90% of UHC fee schedule,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,89.04,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1524,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,1524,
TC20 THAWED APHERESIS CONVAL PLASMA,41000060,CDM,383,RC,P9099,HCPCS,Outpatient,,,150,90.00,,90,60,,2565.408,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,150,,75.584,Fee Schedule ,150% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,42,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,56.53,32,,587.744,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,87.096,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,100,,120,Fee Schedule,100% of CMS OPPS Rate,28.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,39.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,32.17,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,566.4,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1088.656,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,1088.656,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1086.024,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,151.032,Case Rate,Pays based on per visit rate,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,37.968,Percent of Total Billed Charges,14% of Total Billed Charges,31.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,21,870,
CSF MENINGITIS PANEL,41000061,CDM,302,RC,87483,HCPCS,Outpatient,,,2005.6,1203.36,,483.46,100,,12501.176,Fee Schedule,100% of Aetna Fee Schedule,625.16,150,,79.92,Fee Schedule ,150% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.98,280,,8.424,Fee Schedule,280% of BCBS BULE Fee Schedule,1333.7,320,,587.776,Fee Schedule,320% of BCBS Blue Essentials Rate,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,1500.41,360,,10.824,Fee Schedule,360% of BCBS POS Rate,1500.41,360,,10.824,Fee schedule,360% of BCBS PPO Rate,1500.41,360,,10.824,Fee Schedule,360% of BCBS Traditional Rate,1203.36,60,,77,Percent of Total Billed Charges,60% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,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,,158.8,Fee Schedule,100% of CMS OPPS Rate,375.1,90,,,Fee Schedule,90% of CMS OPPS Rate,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,541.81,130,,,Fee Schedule,130% of CMS OPPS Rate,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,289.21,14.42,,431.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1504.2,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,708.52,80,,1086.024,Fee Schedule,80% of Scott and White EPO fee schedule,708.52,80,,228,Fee Schedule,80% of Scott and White HMO fee schedule,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,708.52,170,,228,Fee Schedule,170% of Scott and White PPO fee schedule,708.52,170,,1088.656,Fee Schedule,170% of Scott and White SWHP fee schedule,625.16,150,,,Fee Schedule,150% of CMS OPPS Rate,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,337.59,90,,442.176,Fee Schedule,90% of UHC fee schedule,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,280.78,14,,418.768,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2005.6,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,280.78,2005.6,
NOROVIRUS 1/2 BY RT-PCR,41000062,CDM,306,RC,87798,HCPCS,Outpatient,,,842.4,505.44,,40.7,100,,21338.88,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,98.568,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,60.416,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,587.776,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,77.672,Fee Schedule,360% of BCBS POS Rate,126.32,360,,77.672,Fee schedule,360% of BCBS PPO Rate,126.32,360,,77.672,Fee Schedule,360% of BCBS Traditional Rate,505.44,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,31.808,Fee Schedule,100% of TX Mediciad 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,,160.48,Fee Schedule,100% of CMS OPPS Rate,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,32.76,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,631.8,75,,76.8,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,1088.656,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,227.6,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,227.6,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,228,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,60.12,Fee Schedule,90% of UHC fee schedule,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,31.808,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,842.4,100,,102.4,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,842.4,
C1 ESTERASE INHIBITOR FUNCTIONAL,41000064,CDM,301,RC,86161,HCPCS,Outpatient,,,114.68,68.81,,13.92,100,,21338.88,Fee Schedule,100% of Aetna Fee Schedule,18,150,,89.728,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,45.168,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,588.952,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,58.08,Fee Schedule,360% of BCBS POS Rate,43.2,360,,58.08,Fee schedule,360% of BCBS PPO Rate,43.2,360,,58.08,Fee Schedule,360% of BCBS Traditional Rate,68.81,60,,48.472,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,41.44,Fee Schedule,100% of TX Mediciad 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,,167.96,Fee Schedule,100% of CMS OPPS Rate,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,42.68,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,86.01,75,,71.568,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,228,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,225.2,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,225.2,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,227.6,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,630.888,Fee Schedule,90% of UHC fee schedule,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,41.44,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,114.68,100,,95.424,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,114.68,
VITAMIN B7 (BIOTIN),41000065,CDM,301,RC,84591,HCPCS,Outpatient,,,440,264.00,,19.78,100,,1243.312,Fee Schedule,100% of Aetna Fee Schedule,25.59,150,,17.688,Fee Schedule ,150% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,280,,119.752,Fee Schedule,280% of BCBS BULE Fee Schedule,54.59,320,,588.96,Fee Schedule,320% of BCBS Blue Essentials Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,61.42,360,,153.968,Fee Schedule,360% of BCBS POS Rate,61.42,360,,153.968,Fee schedule,360% of BCBS PPO Rate,61.42,360,,153.968,Fee Schedule,360% of BCBS Traditional Rate,264,60,,57.232,Percent of Total Billed Charges,60% of Total Billed Charges,14.33,100,,349.44,Fee Schedule,100% of TX Mediciad 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,,177.6,Fee Schedule,100% of CMS OPPS Rate,15.35,90,,,Fee Schedule,90% of CMS OPPS Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,130,,,Fee Schedule,130% of CMS OPPS Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.76,103,,359.92,Fee Schedule,103% of TX Medicaid Rate,17.57,103,,,Fee Schedule,103% of CMS OPPS Rate,17.57,103,,,Fee Schedule,103% of CMS OPPS Rate,330,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,29,80,,227.6,Fee Schedule,80% of Scott and White EPO fee schedule,29,80,,204.4,Fee Schedule,80% of Scott and White HMO fee schedule,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29,170,,204.4,Fee Schedule,170% of Scott and White PPO fee schedule,29,170,,225.2,Fee Schedule,170% of Scott and White SWHP fee schedule,25.59,150,,,Fee Schedule,150% of CMS OPPS Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,90,,239.504,Fee Schedule,90% of UHC fee schedule,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,349.44,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,13.82,440,
PORPHOBILINOGEN DEAMINASE,41000066,CDM,301,RC,82657,HCPCS,Outpatient,,,213.6,128.16,,25.72,100,,1243.312,Fee Schedule,100% of Aetna Fee Schedule,33.25,150,,18.904,Fee Schedule ,150% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.08,280,,92.208,Fee Schedule,280% of BCBS BULE Fee Schedule,70.94,320,,590.6,Fee Schedule,320% of BCBS Blue Essentials Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,79.81,360,,118.552,Fee Schedule,360% of BCBS POS Rate,79.81,360,,118.552,Fee schedule,360% of BCBS PPO Rate,79.81,360,,118.552,Fee Schedule,360% of BCBS Traditional Rate,128.16,60,,117.904,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,100,,1546.44,Fee Schedule,100% of TX Mediciad 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,,219.04,Fee Schedule,100% of CMS OPPS Rate,19.95,90,,,Fee Schedule,90% of CMS OPPS Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,28.82,130,,,Fee Schedule,130% of CMS OPPS Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,19.18,103,,1592.832,Fee Schedule,103% of TX Medicaid Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,160.2,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,37.68,80,,225.2,Fee Schedule,80% of Scott and White EPO fee schedule,37.68,80,,202,Fee Schedule,80% of Scott and White HMO fee schedule,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,37.68,170,,202,Fee Schedule,170% of Scott and White PPO fee schedule,37.68,170,,204.4,Fee Schedule,170% of Scott and White SWHP fee schedule,33.25,150,,,Fee Schedule,150% of CMS OPPS Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,90,,1058.4,Fee Schedule,90% of UHC fee schedule,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,1546.44,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.6,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,17.96,213.6,
5 NUCLEOTIDASE,41000067,CDM,301,RC,83915,HCPCS,Outpatient,,,310,186.00,,12.94,100,,1243.312,Fee Schedule,100% of Aetna Fee Schedule,16.72,150,,18.904,Fee Schedule ,150% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,280,,92.208,Fee Schedule,280% of BCBS BULE Fee Schedule,35.68,320,,590.776,Fee Schedule,320% of BCBS Blue Essentials Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,40.14,360,,118.552,Fee Schedule,360% of BCBS POS Rate,40.14,360,,118.552,Fee schedule,360% of BCBS PPO Rate,40.14,360,,118.552,Fee Schedule,360% of BCBS Traditional Rate,186,60,,109.168,Percent of Total Billed Charges,60% of Total Billed Charges,9.37,100,,1396.048,Fee Schedule,100% of TX Mediciad 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,,199.4,Fee Schedule,100% of CMS OPPS Rate,10.03,90,,,Fee Schedule,90% of CMS OPPS Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,14.49,130,,,Fee Schedule,130% of CMS OPPS Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.65,103,,1437.928,Fee Schedule,103% of TX Medicaid Rate,11.48,103,,,Fee Schedule,103% of CMS OPPS Rate,11.48,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,18.95,80,,204.4,Fee Schedule,80% of Scott and White EPO fee schedule,18.95,80,,172.4,Fee Schedule,80% of Scott and White HMO fee schedule,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,18.95,170,,172.4,Fee Schedule,170% of Scott and White PPO fee schedule,18.95,170,,202,Fee Schedule,170% of Scott and White SWHP fee schedule,16.72,150,,,Fee Schedule,150% of CMS OPPS Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,90,,1058.4,Fee Schedule,90% of UHC fee schedule,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,1396.048,Fee Schedule,100% of TX Medicaid Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,9.04,310,
LIPOPROTEIN (A) CHOLESTEROL,41000068,CDM,301,RC,83700,HCPCS,Outpatient,,,1032.8,619.68,,13.06,100,,2004.44,Fee Schedule,100% of Aetna Fee Schedule,16.89,150,,45.304,Fee Schedule ,150% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,31.53,280,,15.832,Fee Schedule,280% of BCBS BULE Fee Schedule,36.03,320,,590.776,Fee Schedule,320% of BCBS Blue Essentials Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,40.54,360,,20.36,Fee Schedule,360% of BCBS POS Rate,40.54,360,,20.36,Fee schedule,360% of BCBS PPO Rate,40.54,360,,20.36,Fee Schedule,360% of BCBS Traditional Rate,619.68,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,9.46,100,,831.368,Fee Schedule,100% of TX Mediciad 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,,39.312,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,Fee Schedule,90% of CMS OPPS Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,130,,,Fee Schedule,130% of CMS OPPS Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.74,103,,856.312,Fee Schedule,103% of TX Medicaid Rate,11.59,103,,,Fee Schedule,103% of CMS OPPS Rate,11.59,103,,,Fee Schedule,103% of CMS OPPS Rate,774.6,75,,42.984,Percent of Total Billed Charges,75% of Total Billed Charges,19.14,80,,202,Fee Schedule,80% of Scott and White EPO fee schedule,19.14,80,,170.4,Fee Schedule,80% of Scott and White HMO fee schedule,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,19.14,170,,170.4,Fee Schedule,170% of Scott and White PPO fee schedule,19.14,170,,172.4,Fee Schedule,170% of Scott and White SWHP fee schedule,16.89,150,,,Fee Schedule,150% of CMS OPPS Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,90,,1058.4,Fee Schedule,90% of UHC fee schedule,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,831.368,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1032.8,100,,57.312,Percent of Total Billed Charges,100% of Total Billed Charges,9.12,1032.8,
IRRADIATION EACH UNIT,41000069,CDM,390,RC,86945,HCPCS,Outpatient,,,252,151.20,,36.12,100,,2004.44,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,87.896,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,592.824,Fee Schedule,320% of BCBS Blue Essentials Rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,108,Fee Schedule,360% of BCBS POS Rate,120.35,360,,108,Fee schedule,360% of BCBS PPO Rate,120.35,360,,108,Fee Schedule,360% of BCBS Traditional Rate,151.2,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,42,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14.42,,3676.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,189,75,,172.784,Percent of Total Billed Charges,75% of Total Billed Charges,126,50,,172.4,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,126,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,1420.592,Case Rate,Pays based on per visit rate,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,3569.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,252,100,,230.376,Percent of Total Billed Charges,100% of Total Billed Charges,33.11,870,
RBC GENOTYPE MOLECULAR TEST,41000070,CDM,390,RC,0084U,HCPCS,Outpatient,,,1064,638.40,,417.6,100,,3006.656,Fee Schedule,100% of Aetna Fee Schedule,1080,150,,135,Fee Schedule ,150% of CMS OPPS Rate,720,100,,,Fee Schedule,100% of CMS OPPS Rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,2016,280,,15.096,Fee Schedule,280% of BCBS BULE Fee Schedule,2304,320,,593.184,Fee Schedule,320% of BCBS Blue Essentials Rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,2592,360,,19.408,Fee Schedule,360% of BCBS POS Rate,2592,360,,19.408,Fee schedule,360% of BCBS PPO Rate,2592,360,,19.408,Fee Schedule,360% of BCBS Traditional Rate,638.4,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,720,100,,,Fee Schedule,100% of CMS OPPS Rate,720,100,,,Fee Schedule,100% of CMS OPPS Rate,720,100,,42,Fee Schedule,100% of CMS OPPS Rate,648,90,,,Fee Schedule,90% of CMS OPPS Rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,936,130,,,Fee Schedule,130% of CMS OPPS Rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,153.43,14.42,,2809.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,741.6,103,,,Fee Schedule,103% of CMS OPPS Rate,741.6,103,,,Fee Schedule,103% of CMS OPPS Rate,798,75,,55.728,Percent of Total Billed Charges,75% of Total Billed Charges,532,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,532,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,532,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,532,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,1080,150,,,Fee Schedule,150% of CMS OPPS Rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,1058.4,Case Rate,Pays based on per visit rate,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.96,14,,2727.792,Percent of Total Billed Charges,14% of Total Billed Charges,720,100,,,Fee Schedule,100% of CMS OPPS Rate,1064,100,,74.304,Percent of Total Billed Charges,100% of Total Billed Charges,148.96,2592,
RH PHENOTYPE,41000071,CDM,390,RC,86906,HCPCS,Outpatient,,,316,189.60,,9,100,,1129.104,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,154.008,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,80.608,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,593.92,Fee Schedule,320% of BCBS Blue Essentials Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,120.35,360,,103.632,Fee Schedule,360% of BCBS POS Rate,120.35,360,,103.632,Fee schedule,360% of BCBS PPO Rate,120.35,360,,103.632,Fee Schedule,360% of BCBS Traditional Rate,189.6,60,,150.72,Percent of Total Billed Charges,60% of Total Billed Charges,6.51,100,,1273.288,Fee Schedule,100% of TX Mediciad Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,100.672,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.71,103,,1311.48,Fee Schedule,103% of TX Medicaid Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,237,75,,128.896,Percent of Total Billed Charges,75% of Total Billed Charges,158,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,158,50,,113.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,158,50,,113.6,Percent of Total Billed Charges,50% of Total Billed Charges,158,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,1624.552,Case Rate,Pays based on per visit rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,1273.288,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,316,100,,171.864,Percent of Total Billed Charges,100% of Total Billed Charges,6.51,870,
BF CELL COUNT DIFF,41000072,CDM,305,RC,89051,HCPCS,Outpatient,,,298.76,179.26,,6.5,100,,1129.104,Fee Schedule,100% of Aetna Fee Schedule,8.4,150,,187.2,Fee Schedule ,150% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,280,,60.416,Fee Schedule,280% of BCBS BULE Fee Schedule,17.92,320,,594.048,Fee Schedule,320% of BCBS Blue Essentials Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,20.16,360,,77.672,Fee Schedule,360% of BCBS POS Rate,20.16,360,,77.672,Fee schedule,360% of BCBS PPO Rate,20.16,360,,77.672,Fee Schedule,360% of BCBS Traditional Rate,179.26,60,,42.72,Percent of Total Billed Charges,60% of Total Billed Charges,4.7,100,,3472.896,Fee Schedule,100% of TX Mediciad 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,,195.32,Fee Schedule,100% of CMS OPPS Rate,5.03,90,,,Fee Schedule,90% of CMS OPPS Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7.28,130,,,Fee Schedule,130% of CMS OPPS Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.84,103,,3577.08,Fee Schedule,103% of TX Medicaid Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,224.07,75,,41.392,Percent of Total Billed Charges,75% of Total Billed Charges,9.51,80,,96.4,Fee Schedule,80% of Scott and White EPO fee schedule,9.51,80,,88.8,Fee Schedule,80% of Scott and White HMO fee schedule,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9.51,170,,88.8,Fee Schedule,170% of Scott and White PPO fee schedule,9.51,170,,113.6,Fee Schedule,170% of Scott and White SWHP fee schedule,8.4,150,,,Fee Schedule,150% of CMS OPPS Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.54,90,,147.752,Fee Schedule,90% of UHC fee schedule,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,3472.896,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,298.76,100,,55.192,Percent of Total Billed Charges,100% of Total Billed Charges,4.54,298.76,
COVID RAPID SCREEN,41000075,CDM,306,RC,87428,HCPCS,Outpatient,,,612,367.20,,146.98,100,,1693.648,Fee Schedule,100% of Aetna Fee Schedule,105.43,150,,1123.2,Fee Schedule ,150% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,86.63,280,,176.872,Fee Schedule,280% of BCBS BULE Fee Schedule,99.01,320,,596.912,Fee Schedule,320% of BCBS Blue Essentials Rate,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,111.38,360,,227.408,Fee Schedule,360% of BCBS POS Rate,111.38,360,,227.408,Fee schedule,360% of BCBS PPO Rate,111.38,360,,227.408,Fee Schedule,360% of BCBS Traditional Rate,367.2,60,,38.448,Percent of Total Billed Charges,60% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,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,,300,Fee Schedule,100% of CMS OPPS Rate,63.26,90,,,Fee Schedule,90% of CMS OPPS Rate,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.37,130,,,Fee Schedule,130% of CMS OPPS Rate,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,88.25,14.42,,1802.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,459,75,,469.44,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.43,150,,,Fee Schedule,150% of CMS OPPS Rate,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,59.59,90,,491.2,Fee Schedule,90% of UHC fee schedule,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.68,14,,1750.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,612,100,,625.92,Percent of Total Billed Charges,100% of Total Billed Charges,59.59,612,
GONADOTROPIN RELEASING HORMONE,41000076,CDM,410,RC,83727,HCPCS,Outpatient,,,1040,624.00,,19.94,100,,624.512,Fee Schedule,100% of Aetna Fee Schedule,25.78,150,,275.424,Fee Schedule ,150% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,48.13,280,,24.048,Fee Schedule,280% of BCBS BULE Fee Schedule,55.01,320,,597.168,Fee Schedule,320% of BCBS Blue Essentials Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,61.88,360,,30.92,Fee Schedule,360% of BCBS POS Rate,61.88,360,,30.92,Fee schedule,360% of BCBS PPO Rate,61.88,360,,30.92,Fee Schedule,360% of BCBS Traditional Rate,194,100,,93.592,Case Rate,Pays based on per visit rate,14.44,100,,334.992,Fee Schedule,100% of TX Mediciad 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,,342.24,Fee Schedule,100% of CMS OPPS Rate,15.47,90,,,Fee Schedule,90% of CMS OPPS Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,130,,,Fee Schedule,130% of CMS OPPS Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.87,103,,345.04,Fee Schedule,103% of TX Medicaid Rate,17.7,103,,,Fee Schedule,103% of CMS OPPS Rate,17.7,103,,,Fee Schedule,103% of CMS OPPS Rate,780,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,520,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,520,50,,82.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,520,50,,82.4,Percent of Total Billed Charges,50% of Total Billed Charges,520,50,,88,Percent of Total Billed Charges,50% of Total Billed Charges,25.78,150,,,Fee Schedule,150% of CMS OPPS Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,455.72,Case Rate,Pays based on per visit rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,14.44,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1040,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,14.44,1040,
COOMBS INDIRECT,41000078,CDM,300,RC,86886,HCPCS,Outpatient,,,192,115.20,,6,100,,624.512,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,97.096,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,252.36,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,597.616,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,516.6,360,,324.456,Fee Schedule,360% of BCBS POS Rate,516.6,360,,324.456,Fee schedule,360% of BCBS PPO Rate,516.6,360,,324.456,Fee Schedule,360% of BCBS Traditional Rate,115.2,60,,330.24,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,334.992,Fee Schedule,100% of TX Mediciad Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,416,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,345.04,Fee Schedule,103% of TX Medicaid Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,144,75,,115.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,88,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,59.2,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,59.2,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,82.4,Fee Schedule,170% of Scott and White SWHP fee schedule,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,221.536,Fee Schedule,90% of UHC fee schedule,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,334.992,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,192,100,,154.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,516.6,
FLUORESCENT ANTIBODY SCRN,41000081,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,1852.2,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,177.056,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,95.8,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,599.08,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,123.168,Fee Schedule,360% of BCBS POS Rate,43.38,360,,123.168,Fee schedule,360% of BCBS PPO Rate,43.38,360,,123.168,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,29.592,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,1368.64,Fee Schedule,100% of TX Mediciad 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,,2496,Fee Schedule,100% of CMS OPPS Rate,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,1409.696,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,82.4,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,56,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,56,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,59.2,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,95.216,Fee Schedule,90% of UHC fee schedule,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,1368.64,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
FLU A RAPID SCREEN,41000082,CDM,306,RC,87428,HCPCS,Outpatient,,,,,,146.98,100,,1852.2,Fee Schedule,100% of Aetna Fee Schedule,105.43,150,,298.224,Fee Schedule ,150% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,86.63,280,,423.36,Fee Schedule,280% of BCBS BULE Fee Schedule,99.01,320,,602.192,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,111.38,360,,544.32,Fee Schedule,360% of BCBS POS Rate,111.38,360,,544.32,Fee schedule,360% of BCBS PPO Rate,111.38,360,,544.32,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,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,,612.048,Fee Schedule,100% of CMS OPPS Rate,63.26,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.37,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.43,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,59.59,90,,886.888,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.59,146.98,
FLU B RAPID SCREEN,41000083,CDM,306,RC,87428,HCPCS,Outpatient,,,,,,146.98,100,,2778.304,Fee Schedule,100% of Aetna Fee Schedule,105.43,150,,109.696,Fee Schedule ,150% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,86.63,280,,423.36,Fee Schedule,280% of BCBS BULE Fee Schedule,99.01,320,,602.192,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,111.38,360,,544.32,Fee Schedule,360% of BCBS POS Rate,111.38,360,,544.32,Fee schedule,360% of BCBS PPO Rate,111.38,360,,544.32,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,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,,215.76,Fee Schedule,100% of CMS OPPS Rate,63.26,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.37,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.43,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,59.59,90,,342.112,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.59,146.98,
TB AG RESPONSE T-CELL SUSP,41000085,CDM,302,RC,86481,HCPCS,Outpatient,,,361.34,216.80,,116,100,,728.592,Fee Schedule,100% of Aetna Fee Schedule,150,150,,28.992,Fee Schedule ,150% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,280,280,,423.36,Fee Schedule,280% of BCBS BULE Fee Schedule,320,320,,602.496,Fee Schedule,320% of BCBS Blue Essentials Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,360,360,,544.32,Fee Schedule,360% of BCBS POS Rate,360,360,,544.32,Fee schedule,360% of BCBS PPO Rate,360,360,,544.32,Fee Schedule,360% of BCBS Traditional Rate,216.8,60,,388.648,Percent of Total Billed Charges,60% of Total Billed Charges,84,100,,513.392,Fee Schedule,100% of TX Mediciad 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,,393.464,Fee Schedule,100% of CMS OPPS Rate,90,90,,,Fee Schedule,90% of CMS OPPS Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,130,130,,,Fee Schedule,130% of CMS OPPS Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,86.52,103,,528.8,Fee Schedule,103% of TX Medicaid Rate,103,103,,,Fee Schedule,103% of CMS OPPS Rate,103,103,,,Fee Schedule,103% of CMS OPPS Rate,271.01,75,,88.856,Percent of Total Billed Charges,75% of Total Billed Charges,170,80,,54.4,Fee Schedule,80% of Scott and White EPO fee schedule,170,80,,52.4,Fee Schedule,80% of Scott and White HMO fee schedule,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,170,170,,52.4,Fee Schedule,170% of Scott and White PPO fee schedule,170,170,,53.2,Fee Schedule,170% of Scott and White SWHP fee schedule,150,150,,,Fee Schedule,150% of CMS OPPS Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,81,90,,284.408,Fee Schedule,90% of UHC fee schedule,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,84,100,,513.392,Fee Schedule,100% of TX Medicaid Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,361.34,100,,118.472,Percent of Total Billed Charges,100% of Total Billed Charges,81,361.34,
PLATELET ABS,41000086,CDM,302,RC,86022,HCPCS,Outpatient,,,1600,960.00,,21.3,100,,1097.704,Fee Schedule,100% of Aetna Fee Schedule,27.55,150,,216,Fee Schedule ,150% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,51.44,280,,568.24,Fee Schedule,280% of BCBS BULE Fee Schedule,58.78,320,,606.144,Fee Schedule,320% of BCBS Blue Essentials Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,66.13,360,,730.592,Fee Schedule,360% of BCBS POS Rate,66.13,360,,730.592,Fee schedule,360% of BCBS PPO Rate,66.13,360,,730.592,Fee Schedule,360% of BCBS Traditional Rate,960,60,,50.112,Percent of Total Billed Charges,60% of Total Billed Charges,15.43,100,,1438.728,Fee Schedule,100% of TX Mediciad 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,,662.728,Fee Schedule,100% of CMS OPPS Rate,16.53,90,,,Fee Schedule,90% of CMS OPPS Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.88,130,,,Fee Schedule,130% of CMS OPPS Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.89,103,,1481.888,Fee Schedule,103% of TX Medicaid Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,1200,75,,88.856,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,80,,53.2,Fee Schedule,80% of Scott and White EPO fee schedule,31.22,80,,51.2,Fee Schedule,80% of Scott and White HMO fee schedule,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,170,,51.2,Fee Schedule,170% of Scott and White PPO fee schedule,31.22,170,,52.4,Fee Schedule,170% of Scott and White SWHP fee schedule,27.55,150,,,Fee Schedule,150% of CMS OPPS Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,90,,210,Fee Schedule,90% of UHC fee schedule,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,118.472,Percent of Total Billed Charges,100% of Total Billed Charges,14.88,1600,
SARS CV19 INHOUSE PCR,41000087,CDM,306,RC,87637,HCPCS,Outpatient,,,688,412.80,,285.26,100,,1097.704,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,135,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,423.36,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,608.776,Fee Schedule,320% of BCBS Blue Essentials Rate,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,513.47,360,,544.32,Fee Schedule,360% of BCBS POS Rate,513.47,360,,544.32,Fee schedule,360% of BCBS PPO Rate,513.47,360,,544.32,Fee Schedule,360% of BCBS Traditional Rate,412.8,60,,45.536,Percent of Total Billed Charges,60% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,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,,243.776,Fee Schedule,100% of CMS OPPS Rate,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,99.21,14.42,,740.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,516,75,,44.832,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,52.4,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,42.4,Fee Schedule,80% of Scott and White HMO fee schedule,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,42.4,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,51.2,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.51,90,,210,Fee Schedule,90% of UHC fee schedule,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,719.408,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,688,100,,59.776,Percent of Total Billed Charges,100% of Total Billed Charges,96.32,688,
LYMPH CHORIOMENINGITIS AB,41000088,CDM,302,RC,86727,HCPCS,Outpatient,,,128.55,77.13,,14.92,100,,539.312,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,351,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,649.816,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,609.016,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,835.48,Fee Schedule,360% of BCBS POS Rate,46.33,360,,835.48,Fee schedule,360% of BCBS PPO Rate,46.33,360,,835.48,Fee Schedule,360% of BCBS Traditional Rate,77.13,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,1389.048,Fee Schedule,100% of TX Mediciad 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,,64.432,Fee Schedule,100% of CMS OPPS Rate,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,1430.72,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,96.41,75,,55.192,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,51.2,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,236,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,236,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,42.4,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,246.4,Fee Schedule,90% of UHC fee schedule,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1389.048,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,128.55,100,,73.584,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,128.55,
GROWTH STIMULATION GENE 2,41000089,CDM,300,RC,83006,HCPCS,Outpatient,,,62.25,37.35,,87.7,100,,59.84,Fee Schedule,100% of Aetna Fee Schedule,113.4,150,,216,Fee Schedule ,150% of CMS OPPS Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,211.68,280,,59.104,Fee Schedule,280% of BCBS BULE Fee Schedule,241.92,320,,609.28,Fee Schedule,320% of BCBS Blue Essentials Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,272.16,360,,75.984,Fee Schedule,360% of BCBS POS Rate,272.16,360,,75.984,Fee schedule,360% of BCBS PPO Rate,272.16,360,,75.984,Fee Schedule,360% of BCBS Traditional Rate,37.35,60,,80.912,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,100,,1438.728,Fee Schedule,100% of TX Mediciad Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,75.59,100,,480,Fee Schedule,100% of CMS OPPS Rate,68.03,90,,,Fee Schedule,90% of CMS OPPS Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,98.28,130,,,Fee Schedule,130% of CMS OPPS Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,65.41,103,,1481.888,Fee Schedule,103% of TX Medicaid Rate,77.86,103,,,Fee Schedule,103% of CMS OPPS Rate,77.86,103,,,Fee Schedule,103% of CMS OPPS Rate,46.69,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,128.51,80,,42.4,Fee Schedule,80% of Scott and White EPO fee schedule,128.51,80,,240.4,Fee Schedule,80% of Scott and White HMO fee schedule,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,128.51,170,,240.4,Fee Schedule,170% of Scott and White PPO fee schedule,128.51,170,,236,Fee Schedule,170% of Scott and White SWHP fee schedule,113.4,150,,,Fee Schedule,150% of CMS OPPS Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,61.24,90,,462,Fee Schedule,90% of UHC fee schedule,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,63.5,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,75.59,100,,,Fee Schedule,100% of CMS OPPS Rate,62.25,100,,50.4,Percent of Total Billed Charges,100% of Total Billed Charges,37.35,272.16,
MOL CYTOGENETIC DNA PROBE,41000091,CDM,310,RC,88271,HCPCS,Outpatient,,,257.4,154.44,,24.84,100,,146.52,Fee Schedule,100% of Aetna Fee Schedule,32.13,150,,326.896,Fee Schedule ,150% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,280,,182.288,Fee Schedule,280% of BCBS BULE Fee Schedule,68.54,320,,612.864,Fee Schedule,320% of BCBS Blue Essentials Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,77.11,360,,234.368,Fee Schedule,360% of BCBS POS Rate,77.11,360,,234.368,Fee schedule,360% of BCBS PPO Rate,77.11,360,,234.368,Fee Schedule,360% of BCBS Traditional Rate,154.44,60,,62.216,Percent of Total Billed Charges,60% of Total Billed Charges,17.99,100,,1438.728,Fee Schedule,100% of TX Mediciad 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,,780,Fee Schedule,100% of CMS OPPS Rate,19.27,90,,,Fee Schedule,90% of CMS OPPS Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,130,,,Fee Schedule,130% of CMS OPPS Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,18.53,103,,1481.888,Fee Schedule,103% of TX Medicaid Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,193.05,75,,111.6,Percent of Total Billed Charges,75% of Total Billed Charges,36.41,80,,240.4,Fee Schedule,80% of Scott and White EPO fee schedule,36.41,80,,604,Fee Schedule,80% of Scott and White HMO fee schedule,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,36.41,170,,604,Fee Schedule,170% of Scott and White PPO fee schedule,36.41,170,,440.752,Fee Schedule,170% of Scott and White SWHP fee schedule,32.13,150,,,Fee Schedule,150% of CMS OPPS Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.35,90,,450.272,Fee Schedule,90% of UHC fee schedule,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,1438.728,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,257.4,100,,148.8,Percent of Total Billed Charges,100% of Total Billed Charges,17.35,257.4,
MOL CYTOGENETIC INSITU 100-300,41000092,CDM,311,RC,88275,HCPCS,Outpatient,,,384.5,230.70,,59.38,100,,57.6,Fee Schedule,100% of Aetna Fee Schedule,76.78,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,143.33,280,,88.616,Fee Schedule,280% of BCBS BULE Fee Schedule,163.81,320,,614.008,Fee Schedule,320% of BCBS Blue Essentials Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,184.28,360,,113.936,Fee Schedule,360% of BCBS POS Rate,184.28,360,,113.936,Fee schedule,360% of BCBS PPO Rate,184.28,360,,113.936,Fee Schedule,360% of BCBS Traditional Rate,230.7,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,43,100,,2016,Fee Schedule,100% of TX Mediciad 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,,480,Fee Schedule,100% of CMS OPPS Rate,46.07,90,,,Fee Schedule,90% of CMS OPPS Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,66.54,130,,,Fee Schedule,130% of CMS OPPS Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,44.29,103,,2076.48,Fee Schedule,103% of TX Medicaid Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,288.38,75,,62.368,Percent of Total Billed Charges,75% of Total Billed Charges,87.02,80,,440.752,Fee Schedule,80% of Scott and White EPO fee schedule,87.02,80,,702.8,Fee Schedule,80% of Scott and White HMO fee schedule,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,87.02,170,,702.8,Fee Schedule,170% of Scott and White PPO fee schedule,87.02,170,,604,Fee Schedule,170% of Scott and White SWHP fee schedule,76.78,150,,,Fee Schedule,150% of CMS OPPS Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,41.46,90,,450.272,Fee Schedule,90% of UHC fee schedule,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,43,100,,2016,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,384.5,100,,83.16,Percent of Total Billed Charges,100% of Total Billed Charges,41.46,384.5,
FLU AB AND COVID COMBO,41000093,CDM,306,RC,87428,HCPCS,Outpatient,,,628,376.80,,146.98,100,,388.8,Fee Schedule,100% of Aetna Fee Schedule,105.43,150,,478.344,Fee Schedule ,150% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,86.63,280,,38.088,Fee Schedule,280% of BCBS BULE Fee Schedule,99.01,320,,614.4,Fee Schedule,320% of BCBS Blue Essentials Rate,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,111.38,360,,48.968,Fee Schedule,360% of BCBS POS Rate,111.38,360,,48.968,Fee schedule,360% of BCBS PPO Rate,111.38,360,,48.968,Fee Schedule,360% of BCBS Traditional Rate,376.8,60,,60.36,Percent of Total Billed Charges,60% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,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,,628.576,Fee Schedule,100% of CMS OPPS Rate,63.26,90,,,Fee Schedule,90% of CMS OPPS Rate,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.37,130,,,Fee Schedule,130% of CMS OPPS Rate,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,90.56,14.42,,224.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,72.39,103,,,Fee Schedule,103% of CMS OPPS Rate,471,75,,130.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.43,150,,,Fee Schedule,150% of CMS OPPS Rate,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,59.59,90,,336,Fee Schedule,90% of UHC fee schedule,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,87.92,14,,218.4,Percent of Total Billed Charges,14% of Total Billed Charges,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,628,100,,174.4,Percent of Total Billed Charges,100% of Total Billed Charges,59.59,628,
RSV SOFIA,41000094,CDM,306,RC,87280,HCPCS,Outpatient,,,612,367.20,,15.56,100,,360,Fee Schedule,100% of Aetna Fee Schedule,20.13,150,,1124,Fee Schedule ,150% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,37.58,280,,354.752,Fee Schedule,280% of BCBS BULE Fee Schedule,42.94,320,,614.888,Fee Schedule,320% of BCBS Blue Essentials Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,48.31,360,,456.112,Fee Schedule,360% of BCBS POS Rate,48.31,360,,456.112,Fee schedule,360% of BCBS PPO Rate,48.31,360,,456.112,Fee Schedule,360% of BCBS Traditional Rate,367.2,60,,90.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.27,100,,639.184,Fee Schedule,100% of TX Mediciad 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,,726.432,Fee Schedule,100% of CMS OPPS Rate,12.07,90,,,Fee Schedule,90% of CMS OPPS Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.44,130,,,Fee Schedule,130% of CMS OPPS Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.61,103,,658.36,Fee Schedule,103% of TX Medicaid Rate,13.82,103,,,Fee Schedule,103% of CMS OPPS Rate,13.82,103,,,Fee Schedule,103% of CMS OPPS Rate,459,75,,42.544,Percent of Total Billed Charges,75% of Total Billed Charges,22.81,80,,702.8,Fee Schedule,80% of Scott and White EPO fee schedule,22.81,80,,2994,Fee Schedule,80% of Scott and White HMO fee schedule,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,22.81,170,,2994,Fee Schedule,170% of Scott and White PPO fee schedule,22.81,170,,2994,Fee Schedule,170% of Scott and White SWHP fee schedule,20.13,150,,,Fee Schedule,150% of CMS OPPS Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,10.87,90,,336,Fee Schedule,90% of UHC fee schedule,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,639.184,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,612,100,,56.728,Percent of Total Billed Charges,100% of Total Billed Charges,10.87,612,
URINE FENTANYL IN-HOUSE,41000095,CDM,301,RC,80305,HCPCS,Outpatient,,,140,84.00,,14.62,100,,192.456,Fee Schedule,100% of Aetna Fee Schedule,18.9,150,,847.264,Fee Schedule ,150% of CMS OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,35.28,280,,136.848,Fee Schedule,280% of BCBS BULE Fee Schedule,40.32,320,,614.888,Fee Schedule,320% of BCBS Blue Essentials Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,45.36,360,,175.944,Fee Schedule,360% of BCBS POS Rate,45.36,360,,175.944,Fee schedule,360% of BCBS PPO Rate,45.36,360,,175.944,Fee Schedule,360% of BCBS Traditional Rate,84,60,,22.024,Percent of Total Billed Charges,60% of Total Billed Charges,10.58,100,,872.144,Fee Schedule,100% of TX Mediciad Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,173.8,Fee Schedule,100% of CMS OPPS Rate,11.34,90,,,Fee Schedule,90% of CMS OPPS Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,130,,,Fee Schedule,130% of CMS OPPS Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.9,103,,898.312,Fee Schedule,103% of TX Medicaid Rate,12.97,103,,,Fee Schedule,103% of CMS OPPS Rate,12.97,103,,,Fee Schedule,103% of CMS OPPS Rate,105,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,21.42,80,,2994,Fee Schedule,80% of Scott and White EPO fee schedule,21.42,80,,2994,Fee Schedule,80% of Scott and White HMO fee schedule,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,170,,2994,Fee Schedule,170% of Scott and White PPO fee schedule,21.42,170,,2994,Fee Schedule,170% of Scott and White SWHP fee schedule,18.9,150,,,Fee Schedule,150% of CMS OPPS Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,10.21,90,,336,Fee Schedule,90% of UHC fee schedule,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,10.58,100,,872.144,Fee Schedule,100% of TX Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,140,100,,68,Percent of Total Billed Charges,100% of Total Billed Charges,10.21,140,
TARGETED GENOMIC SEQ ANALYS,41000097,CDM,310,RC,81450,HCPCS,Outpatient,,,1296.8,778.08,,881.06,100,,171.6,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,813.136,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,113.76,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,618.04,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,146.264,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,146.264,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,146.264,Fee Schedule,360% of BCBS Traditional Rate,778.08,60,,89.28,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,2061.248,Fee Schedule,100% of TX Mediciad 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,,1062.984,Fee Schedule,100% of CMS OPPS Rate,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,2123.088,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,972.6,75,,45.152,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,2994,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,2994,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,2994,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,2994,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,336,Fee Schedule,90% of UHC fee schedule,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,2061.248,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.8,100,,60.2,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
DENGUE VIRUS NS1 AG,41000099,CDM,302,RC,86790,HCPCS,Outpatient,,,472,283.20,,14.94,100,,171.6,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,502.36,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,618.8,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,108,Fee Schedule,360% of BCBS POS Rate,46.37,360,,108,Fee schedule,360% of BCBS PPO Rate,46.37,360,,108,Fee Schedule,360% of BCBS Traditional Rate,283.2,60,,72.208,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,298.48,Fee Schedule,100% of TX Mediciad 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,,2497.784,Fee Schedule,100% of CMS OPPS Rate,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,307.432,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,354,75,,57.496,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,2994,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,3264,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,3264,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,2994,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,450.272,Fee Schedule,90% of UHC fee schedule,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,298.48,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,472,100,,76.664,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,472,
MODIFIED ACID FAST STAIN NOCARDIA,41000100,CDM,306,RC,87206,HCPCS,Outpatient,,,480,288.00,,6.26,100,,182.4,Fee Schedule,100% of Aetna Fee Schedule,8.08,150,,502.36,Fee Schedule ,150% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.09,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,17.25,320,,618.856,Fee Schedule,320% of BCBS Blue Essentials Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,19.4,360,,108,Fee Schedule,360% of BCBS POS Rate,19.4,360,,108,Fee schedule,360% of BCBS PPO Rate,19.4,360,,108,Fee Schedule,360% of BCBS Traditional Rate,288,60,,16.64,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,100,,777.504,Fee Schedule,100% of TX Mediciad 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,,1882.8,Fee Schedule,100% of CMS OPPS Rate,4.85,90,,,Fee Schedule,90% of CMS OPPS Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7,130,,,Fee Schedule,130% of CMS OPPS Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.67,103,,800.832,Fee Schedule,103% of TX Medicaid Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,360,75,,132.904,Percent of Total Billed Charges,75% of Total Billed Charges,9.16,80,,2994,Fee Schedule,80% of Scott and White EPO fee schedule,9.16,80,,3264,Fee Schedule,80% of Scott and White HMO fee schedule,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,170,,3264,Fee Schedule,170% of Scott and White PPO fee schedule,9.16,170,,3264,Fee Schedule,170% of Scott and White SWHP fee schedule,8.08,150,,,Fee Schedule,150% of CMS OPPS Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,336,Fee Schedule,90% of UHC fee schedule,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,777.504,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,480,100,,177.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.37,480,
17 HYDROXYPROGESTERONE,41000101,CDM,306,RC,83498,HCPCS,Outpatient,,,660,396.00,,31.52,100,,35.136,Fee Schedule,100% of Aetna Fee Schedule,40.75,150,,275.76,Fee Schedule ,150% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,76.08,280,,98.56,Fee Schedule,280% of BCBS BULE Fee Schedule,86.94,320,,619.232,Fee Schedule,320% of BCBS Blue Essentials Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,97.81,360,,126.72,Fee Schedule,360% of BCBS POS Rate,97.81,360,,126.72,Fee schedule,360% of BCBS PPO Rate,97.81,360,,126.72,Fee Schedule,360% of BCBS Traditional Rate,396,60,,65.896,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,100,,1516.48,Fee Schedule,100% of TX Mediciad 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,,1806.96,Fee Schedule,100% of CMS OPPS Rate,24.45,90,,,Fee Schedule,90% of CMS OPPS Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,35.32,130,,,Fee Schedule,130% of CMS OPPS Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,23.5,103,,1561.976,Fee Schedule,103% of TX Medicaid Rate,27.98,103,,,Fee Schedule,103% of CMS OPPS Rate,27.98,103,,,Fee Schedule,103% of CMS OPPS Rate,495,75,,85.2,Percent of Total Billed Charges,75% of Total Billed Charges,46.18,80,,3264,Fee Schedule,80% of Scott and White EPO fee schedule,46.18,80,,318,Fee Schedule,80% of Scott and White HMO fee schedule,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.18,170,,318,Fee Schedule,170% of Scott and White PPO fee schedule,46.18,170,,3264,Fee Schedule,170% of Scott and White SWHP fee schedule,40.75,150,,,Fee Schedule,150% of CMS OPPS Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.01,90,,449.12,Fee Schedule,90% of UHC fee schedule,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,22.82,100,,1516.48,Fee Schedule,100% of TX Medicaid Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,660,100,,113.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.01,660,
"NMO/AQP4 FACS, CSF",41000102,CDM,306,RC,86053,HCPCS,Outpatient,,,1800,1080.00,,1080,60,,1399.2,Percent of Total Billed Charges,60% of Total Billed Charges,56.59,150,,275.76,Fee Schedule ,150% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,184.8,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,620,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,237.6,Fee Schedule,360% of BCBS POS Rate,43.38,360,,237.6,Fee schedule,360% of BCBS PPO Rate,43.38,360,,237.6,Fee Schedule,360% of BCBS Traditional Rate,1080,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,551.824,Fee Schedule,100% of TX Mediciad 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,,1116.352,Fee Schedule,100% of CMS OPPS Rate,33.95,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,49.04,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,568.376,Fee Schedule,103% of TX Medicaid Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1350,75,,142.216,Percent of Total Billed Charges,75% of Total Billed Charges,64.14,80,,3264,Fee Schedule,80% of Scott and White EPO fee schedule,64.14,80,,135.6,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.14,170,,135.6,Fee Schedule,170% of Scott and White PPO fee schedule,64.14,170,,318,Fee Schedule,170% of Scott and White SWHP fee schedule,56.59,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,900,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,551.824,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,189.616,Percent of Total Billed Charges,100% of Total Billed Charges,10.12,1800,
CULTURE ACTINOMYCES,41000103,CDM,306,RC,87081,HCPCS,Outpatient,,,677.4,406.44,,7.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,184.8,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,237.6,Fee Schedule,360% of BCBS POS Rate,23.87,360,,237.6,Fee schedule,360% of BCBS PPO Rate,23.87,360,,237.6,Fee Schedule,360% of BCBS Traditional Rate,406.44,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,313.264,Fee Schedule,100% of TX Mediciad 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,,1116.352,Fee Schedule,100% of CMS OPPS Rate,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,322.664,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,508.05,75,,53.4,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,318,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,1495.6,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,1495.6,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,135.6,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,335.552,Fee Schedule,90% of UHC fee schedule,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,313.264,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,677.4,100,,71.2,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,677.4,
SEX HORMONE BINDING GLOBULIN,41000104,CDM,301,RC,84270,HCPCS,Outpatient,,,201.64,120.98,,25.2,100,,182.4,Fee Schedule,100% of Aetna Fee Schedule,32.59,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,60.84,280,,180.104,Fee Schedule,280% of BCBS BULE Fee Schedule,69.54,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,78.23,360,,231.568,Fee Schedule,360% of BCBS POS Rate,78.23,360,,231.568,Fee schedule,360% of BCBS PPO Rate,78.23,360,,231.568,Fee Schedule,360% of BCBS Traditional Rate,120.98,60,,234.128,Percent of Total Billed Charges,60% of Total Billed Charges,18.25,100,,117.6,Fee Schedule,100% of TX Mediciad 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,,612.8,Fee Schedule,100% of CMS OPPS Rate,19.55,90,,,Fee Schedule,90% of CMS OPPS Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.24,130,,,Fee Schedule,130% of CMS OPPS Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.8,103,,121.128,Fee Schedule,103% of TX Medicaid Rate,22.38,103,,,Fee Schedule,103% of CMS OPPS Rate,22.38,103,,,Fee Schedule,103% of CMS OPPS Rate,151.23,75,,59.744,Percent of Total Billed Charges,75% of Total Billed Charges,36.94,80,,135.6,Fee Schedule,80% of Scott and White EPO fee schedule,36.94,80,,113.6,Fee Schedule,80% of Scott and White HMO fee schedule,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,36.94,170,,113.6,Fee Schedule,170% of Scott and White PPO fee schedule,36.94,170,,1495.6,Fee Schedule,170% of Scott and White SWHP fee schedule,32.59,150,,,Fee Schedule,150% of CMS OPPS Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,17.6,90,,5710.32,Fee Schedule,90% of UHC fee schedule,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,18.25,100,,117.6,Fee Schedule,100% of TX Medicaid Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,201.64,100,,79.656,Percent of Total Billed Charges,100% of Total Billed Charges,17.6,201.64,
CULTURE E. COLI 157,41000105,CDM,306,RC,87045,HCPCS,Outpatient,,,176.4,105.84,,10.96,100,,424.808,Fee Schedule,100% of Aetna Fee Schedule,14.16,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,26.43,280,,180.104,Fee Schedule,280% of BCBS BULE Fee Schedule,30.21,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,33.98,360,,231.568,Fee Schedule,360% of BCBS POS Rate,33.98,360,,231.568,Fee schedule,360% of BCBS PPO Rate,33.98,360,,231.568,Fee Schedule,360% of BCBS Traditional Rate,105.84,60,,46.352,Percent of Total Billed Charges,60% of Total Billed Charges,7.93,100,,60.48,Fee Schedule,100% of TX Mediciad 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,,612.8,Fee Schedule,100% of CMS OPPS Rate,8.49,90,,,Fee Schedule,90% of CMS OPPS Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,12.27,130,,,Fee Schedule,130% of CMS OPPS Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,8.17,103,,62.296,Fee Schedule,103% of TX Medicaid Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,132.3,75,,122.336,Percent of Total Billed Charges,75% of Total Billed Charges,16.04,80,,1495.6,Fee Schedule,80% of Scott and White EPO fee schedule,16.04,80,,148,Fee Schedule,80% of Scott and White HMO fee schedule,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,16.04,170,,148,Fee Schedule,170% of Scott and White PPO fee schedule,16.04,170,,113.6,Fee Schedule,170% of Scott and White SWHP fee schedule,14.16,150,,,Fee Schedule,150% of CMS OPPS Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.65,90,,335.552,Fee Schedule,90% of UHC fee schedule,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,60.48,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,176.4,100,,163.112,Percent of Total Billed Charges,100% of Total Billed Charges,7.65,176.4,
VANCOMYCIN,41000316,CDM,301,RC,80202,HCPCS,Outpatient,,,244,146.40,,15.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.3,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,37.91,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,43.33,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,48.74,360,,172.8,Fee Schedule,360% of BCBS POS Rate,48.74,360,,172.8,Fee schedule,360% of BCBS PPO Rate,48.74,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,146.4,60,,88.368,Percent of Total Billed Charges,60% of Total Billed Charges,11.37,100,,19.6,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,12.18,90,,,Fee Schedule,90% of CMS OPPS Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,17.6,130,,,Fee Schedule,130% of CMS OPPS Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.71,103,,20.192,Fee Schedule,103% of TX Medicaid Rate,13.94,103,,,Fee Schedule,103% of CMS OPPS Rate,13.94,103,,,Fee Schedule,103% of CMS OPPS Rate,183,75,,115.504,Percent of Total Billed Charges,75% of Total Billed Charges,23.01,80,,113.6,Fee Schedule,80% of Scott and White EPO fee schedule,23.01,80,,1248,Fee Schedule,80% of Scott and White HMO fee schedule,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,23.01,170,,1248,Fee Schedule,170% of Scott and White PPO fee schedule,23.01,170,,148,Fee Schedule,170% of Scott and White SWHP fee schedule,20.3,150,,,Fee Schedule,150% of CMS OPPS Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,90,,335.552,Fee Schedule,90% of UHC fee schedule,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,244,100,,154,Percent of Total Billed Charges,100% of Total Billed Charges,10.97,244,
CBC WO AUTO DIFF,41000563,CDM,305,RC,85027,HCPCS,Outpatient,,,124.78,74.87,,7.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.7,150,,235.736,Fee Schedule ,150% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.12,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,20.7,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,23.29,360,,172.8,Fee Schedule,360% of BCBS POS Rate,23.29,360,,172.8,Fee schedule,360% of BCBS PPO Rate,23.29,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,74.87,60,,170.008,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,100,,538.72,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,5.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,130,,,Fee Schedule,130% of CMS OPPS Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.59,103,,554.88,Fee Schedule,103% of TX Medicaid Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,93.59,75,,113.4,Percent of Total Billed Charges,75% of Total Billed Charges,10.99,80,,148,Fee Schedule,80% of Scott and White EPO fee schedule,10.99,80,,5522.992,Fee Schedule,80% of Scott and White HMO fee schedule,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,170,,5522.992,Fee Schedule,170% of Scott and White PPO fee schedule,10.99,170,,1248,Fee Schedule,170% of Scott and White SWHP fee schedule,9.7,150,,,Fee Schedule,150% of CMS OPPS Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,90,,37117.08,Fee Schedule,90% of UHC fee schedule,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,538.72,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,124.78,100,,151.2,Percent of Total Billed Charges,100% of Total Billed Charges,5.24,124.78,
PANEL RENAL FUNCTION,41000696,CDM,301,RC,80069,HCPCS,Outpatient,,,237,142.20,,10.06,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,13.02,150,,235.736,Fee Schedule ,150% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,31.25,360,,172.8,Fee Schedule,360% of BCBS POS Rate,31.25,360,,172.8,Fee schedule,360% of BCBS PPO Rate,31.25,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,142.2,60,,159.056,Percent of Total Billed Charges,60% of Total Billed Charges,7.29,100,,1456,Fee Schedule,100% of TX Mediciad 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,,640.032,Fee Schedule,100% of CMS OPPS Rate,7.81,90,,,Fee Schedule,90% of CMS OPPS Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,11.28,130,,,Fee Schedule,130% of CMS OPPS Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.51,103,,1499.68,Fee Schedule,103% of TX Medicaid Rate,8.94,103,,,Fee Schedule,103% of CMS OPPS Rate,8.94,103,,,Fee Schedule,103% of CMS OPPS Rate,177.75,75,,123.6,Percent of Total Billed Charges,75% of Total Billed Charges,14.75,80,,1248,Fee Schedule,80% of Scott and White EPO fee schedule,14.75,80,,4985.888,Fee Schedule,80% of Scott and White HMO fee schedule,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,14.75,170,,4985.888,Fee Schedule,170% of Scott and White PPO fee schedule,14.75,170,,5522.992,Fee Schedule,170% of Scott and White SWHP fee schedule,13.02,150,,,Fee Schedule,150% of CMS OPPS Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,7.03,90,,9222.168,Fee Schedule,90% of UHC fee schedule,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,7.29,100,,1456,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,237,100,,164.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.03,237,
PANEL ACUTE HEPATITIS,41000746,CDM,301,RC,80074,HCPCS,Outpatient,,,517.5,310.50,,55.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,71.44,150,,278.528,Fee Schedule ,150% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,133.36,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,152.42,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,171.47,360,,172.8,Fee Schedule,360% of BCBS POS Rate,171.47,360,,172.8,Fee schedule,360% of BCBS PPO Rate,171.47,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,310.5,60,,256.216,Percent of Total Billed Charges,60% of Total Billed Charges,40.01,100,,1932.408,Fee Schedule,100% of TX Mediciad 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,,640.032,Fee Schedule,100% of CMS OPPS Rate,42.86,90,,,Fee Schedule,90% of CMS OPPS Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,61.91,130,,,Fee Schedule,130% of CMS OPPS Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,41.21,103,,1990.384,Fee Schedule,103% of TX Medicaid Rate,49.05,103,,,Fee Schedule,103% of CMS OPPS Rate,49.05,103,,,Fee Schedule,103% of CMS OPPS Rate,388.13,75,,146.024,Percent of Total Billed Charges,75% of Total Billed Charges,80.97,80,,5522.992,Fee Schedule,80% of Scott and White EPO fee schedule,80.97,80,,2969.168,Fee Schedule,80% of Scott and White HMO fee schedule,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,80.97,170,,2969.168,Fee Schedule,170% of Scott and White PPO fee schedule,80.97,170,,4985.888,Fee Schedule,170% of Scott and White SWHP fee schedule,71.44,150,,,Fee Schedule,150% of CMS OPPS Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,38.58,90,,128.464,Fee Schedule,90% of UHC fee schedule,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,40.01,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,517.5,100,,194.696,Percent of Total Billed Charges,100% of Total Billed Charges,38.58,517.5,
PANEL HEPATIC FUNCTION,41001090,CDM,301,RC,80076,HCPCS,Outpatient,,,261.13,156.68,,9.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.25,150,,318.608,Fee Schedule ,150% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,280,,180.104,Fee Schedule,280% of BCBS BULE Fee Schedule,26.14,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,29.41,360,,231.568,Fee Schedule,360% of BCBS POS Rate,29.41,360,,231.568,Fee schedule,360% of BCBS PPO Rate,29.41,360,,231.568,Fee Schedule,360% of BCBS Traditional Rate,156.68,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,6.86,100,,1294.536,Fee Schedule,100% of TX Mediciad 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,,523.856,Fee Schedule,100% of CMS OPPS Rate,7.35,90,,,Fee Schedule,90% of CMS OPPS Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,130,,,Fee Schedule,130% of CMS OPPS Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.07,103,,1333.368,Fee Schedule,103% of TX Medicaid Rate,8.41,103,,,Fee Schedule,103% of CMS OPPS Rate,8.41,103,,,Fee Schedule,103% of CMS OPPS Rate,195.85,75,,177,Percent of Total Billed Charges,75% of Total Billed Charges,13.88,80,,4985.888,Fee Schedule,80% of Scott and White EPO fee schedule,13.88,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,13.88,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,13.88,170,,2969.168,Fee Schedule,170% of Scott and White SWHP fee schedule,12.25,150,,,Fee Schedule,150% of CMS OPPS Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,6.62,90,,336,Fee Schedule,90% of UHC fee schedule,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,261.13,100,,236,Percent of Total Billed Charges,100% of Total Billed Charges,6.62,261.13,
PANEL COMPREHENSIVE METABOLIC,41001116,CDM,301,RC,80053,HCPCS,Outpatient,,,482.43,289.46,,12.24,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,15.84,150,,318.608,Fee Schedule ,150% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,29.57,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,33.79,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,38.02,360,,172.8,Fee Schedule,360% of BCBS POS Rate,38.02,360,,172.8,Fee schedule,360% of BCBS PPO Rate,38.02,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,289.46,60,,216.136,Percent of Total Billed Charges,60% of Total Billed Charges,8.87,100,,8.2,Fee Schedule,100% of TX Mediciad 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,,523.856,Fee Schedule,100% of CMS OPPS Rate,9.5,90,,,Fee Schedule,90% of CMS OPPS Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,130,,,Fee Schedule,130% of CMS OPPS Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,9.14,103,,8.448,Fee Schedule,103% of TX Medicaid Rate,10.87,103,,,Fee Schedule,103% of CMS OPPS Rate,10.87,103,,,Fee Schedule,103% of CMS OPPS Rate,361.82,75,,120,Percent of Total Billed Charges,75% of Total Billed Charges,17.95,80,,2969.168,Fee Schedule,80% of Scott and White EPO fee schedule,17.95,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,17.95,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,17.95,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,15.84,150,,,Fee Schedule,150% of CMS OPPS Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,90,,210,Fee Schedule,90% of UHC fee schedule,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,8.87,100,,8.2,Fee Schedule,100% of TX Medicaid Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,482.43,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,8.55,482.43,
PANEL LIPID,41001603,CDM,301,RC,80061,HCPCS,Outpatient,,,263,157.80,,15.54,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.08,150,,478.344,Fee Schedule ,150% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,37.49,280,,179.648,Fee Schedule,280% of BCBS BULE Fee Schedule,42.85,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,48.2,360,,230.976,Fee Schedule,360% of BCBS POS Rate,48.2,360,,230.976,Fee schedule,360% of BCBS PPO Rate,48.2,360,,230.976,Fee Schedule,360% of BCBS Traditional Rate,157.8,60,,4416,Percent of Total Billed Charges,60% of Total Billed Charges,11.25,100,,784.784,Fee Schedule,100% of TX Mediciad 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,,618.952,Fee Schedule,100% of CMS OPPS Rate,12.05,90,,,Fee Schedule,90% of CMS OPPS Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,17.4,130,,,Fee Schedule,130% of CMS OPPS Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.59,103,,808.328,Fee Schedule,103% of TX Medicaid Rate,13.79,103,,,Fee Schedule,103% of CMS OPPS Rate,13.79,103,,,Fee Schedule,103% of CMS OPPS Rate,197.25,75,,418.336,Percent of Total Billed Charges,75% of Total Billed Charges,22.76,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,22.76,80,,4547.448,Fee Schedule,80% of Scott and White HMO fee schedule,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,22.76,170,,4547.448,Fee Schedule,170% of Scott and White PPO fee schedule,22.76,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,20.08,150,,,Fee Schedule,150% of CMS OPPS Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.85,90,,2628.76,Fee Schedule,90% of UHC fee schedule,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,11.25,100,,784.784,Fee Schedule,100% of TX Medicaid Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,263,100,,557.776,Percent of Total Billed Charges,100% of Total Billed Charges,10.85,263,
PANEL BASIC METABOLIC,41001660,CDM,301,RC,80048,HCPCS,Outpatient,,,296.94,178.16,,9.82,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.69,150,,388.056,Fee Schedule ,150% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,23.69,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,27.07,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,30.46,360,,108,Fee Schedule,360% of BCBS POS Rate,30.46,360,,108,Fee schedule,360% of BCBS PPO Rate,30.46,360,,108,Fee Schedule,360% of BCBS Traditional Rate,178.16,60,,742.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.11,100,,4659.256,Fee Schedule,100% of TX Mediciad 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,,708.016,Fee Schedule,100% of CMS OPPS Rate,7.61,90,,,Fee Schedule,90% of CMS OPPS Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,130,,,Fee Schedule,130% of CMS OPPS Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.32,103,,4799.032,Fee Schedule,103% of TX Medicaid Rate,8.71,103,,,Fee Schedule,103% of CMS OPPS Rate,8.71,103,,,Fee Schedule,103% of CMS OPPS Rate,222.71,75,,115.2,Percent of Total Billed Charges,75% of Total Billed Charges,14.38,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,14.38,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,14.38,170,,4547.448,Fee Schedule,170% of Scott and White SWHP fee schedule,12.69,150,,,Fee Schedule,150% of CMS OPPS Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.85,90,,753.176,Fee Schedule,90% of UHC fee schedule,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,7.11,100,,4659.256,Fee Schedule,100% of TX Medicaid Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,296.94,100,,153.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.85,296.94,
URINALYSIS AUTOMATED W MICRO,41010018,CDM,307,RC,81001,HCPCS,Outpatient,,,108,64.80,,3.68,100,,1448.448,Fee Schedule,100% of Aetna Fee Schedule,4.75,150,,388.056,Fee Schedule ,150% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.88,280,,3703.976,Fee Schedule,280% of BCBS BULE Fee Schedule,10.14,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,11.41,360,,4762.256,Fee Schedule,360% of BCBS POS Rate,11.41,360,,4762.256,Fee schedule,360% of BCBS PPO Rate,11.41,360,,4762.256,Fee Schedule,360% of BCBS Traditional Rate,64.8,60,,851.888,Percent of Total Billed Charges,60% of Total Billed Charges,2.66,100,,1232.432,Fee Schedule,100% of TX Mediciad 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,,708.016,Fee Schedule,100% of CMS OPPS Rate,2.85,90,,,Fee Schedule,90% of CMS OPPS Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,4.12,130,,,Fee Schedule,130% of CMS OPPS Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.74,103,,1269.408,Fee Schedule,103% of TX Medicaid Rate,3.26,103,,,Fee Schedule,103% of CMS OPPS Rate,3.26,103,,,Fee Schedule,103% of CMS OPPS Rate,81,75,,60.904,Percent of Total Billed Charges,75% of Total Billed Charges,5.38,80,,4547.448,Fee Schedule,80% of Scott and White EPO fee schedule,5.38,80,,6251.2,Fee Schedule,80% of Scott and White HMO fee schedule,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,170,,6251.2,Fee Schedule,170% of Scott and White PPO fee schedule,5.38,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,4.75,150,,,Fee Schedule,150% of CMS OPPS Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.57,90,,753.176,Fee Schedule,90% of UHC fee schedule,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,2.66,100,,1232.432,Fee Schedule,100% of TX Medicaid Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,108,100,,81.2,Percent of Total Billed Charges,100% of Total Billed Charges,2.57,108,
URINALYSIS AUTOMATED WO MICRO,41010042,CDM,307,RC,81003,HCPCS,Outpatient,,,67,40.20,,2.62,100,,1425.4,Fee Schedule,100% of Aetna Fee Schedule,3.37,150,,475.096,Fee Schedule ,150% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,280,,13586.056,Fee Schedule,280% of BCBS BULE Fee Schedule,7.2,320,,623.744,Fee Schedule,320% of BCBS Blue Essentials Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,8.1,360,,17467.784,Fee Schedule,360% of BCBS POS Rate,8.1,360,,17467.784,Fee schedule,360% of BCBS PPO Rate,8.1,360,,17467.784,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,1341.12,Percent of Total Billed Charges,60% of Total Billed Charges,1.89,100,,210,Fee Schedule,100% of TX Mediciad 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,,1062.984,Fee Schedule,100% of CMS OPPS Rate,2.02,90,,,Fee Schedule,90% of CMS OPPS Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.92,130,,,Fee Schedule,130% of CMS OPPS Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.95,103,,216.304,Fee Schedule,103% of TX Medicaid Rate,2.31,103,,,Fee Schedule,103% of CMS OPPS Rate,2.31,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,48.064,Percent of Total Billed Charges,75% of Total Billed Charges,3.82,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,3.82,80,,1196.392,Fee Schedule,80% of Scott and White HMO fee schedule,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.82,170,,1196.392,Fee Schedule,170% of Scott and White PPO fee schedule,3.82,170,,6251.2,Fee Schedule,170% of Scott and White SWHP fee schedule,3.37,150,,,Fee Schedule,150% of CMS OPPS Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1.83,90,,5710.32,Fee Schedule,90% of UHC fee schedule,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,210,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,64.08,Percent of Total Billed Charges,100% of Total Billed Charges,1.83,67,
URINE SNGL ITEM,41010075,CDM,307,RC,81002,HCPCS,Outpatient,,,52.55,31.53,,4.04,100,,63.784,Fee Schedule,100% of Aetna Fee Schedule,5.22,150,,316.728,Fee Schedule ,150% of CMS OPPS Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,9.74,280,,134.224,Fee Schedule,280% of BCBS BULE Fee Schedule,11.14,320,,626.264,Fee Schedule,320% of BCBS Blue Essentials Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,12.53,360,,172.568,Fee Schedule,360% of BCBS POS Rate,12.53,360,,172.568,Fee schedule,360% of BCBS PPO Rate,12.53,360,,172.568,Fee Schedule,360% of BCBS Traditional Rate,31.53,60,,611.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.92,100,,3319.432,Fee Schedule,100% of TX Mediciad Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,862.344,Fee Schedule,100% of CMS OPPS Rate,3.13,90,,,Fee Schedule,90% of CMS OPPS Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.52,130,,,Fee Schedule,130% of CMS OPPS Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.01,103,,3419.016,Fee Schedule,103% of TX Medicaid Rate,3.58,103,,,Fee Schedule,103% of CMS OPPS Rate,3.58,103,,,Fee Schedule,103% of CMS OPPS Rate,39.41,75,,63.496,Percent of Total Billed Charges,75% of Total Billed Charges,5.91,80,,6251.2,Fee Schedule,80% of Scott and White EPO fee schedule,5.91,80,,1196.392,Fee Schedule,80% of Scott and White HMO fee schedule,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.91,170,,1196.392,Fee Schedule,170% of Scott and White PPO fee schedule,5.91,170,,1196.392,Fee Schedule,170% of Scott and White SWHP fee schedule,5.22,150,,,Fee Schedule,150% of CMS OPPS Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2.82,90,,695.864,Fee Schedule,90% of UHC fee schedule,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,2.92,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,52.55,100,,84.664,Percent of Total Billed Charges,100% of Total Billed Charges,2.82,52.55,
URINE PREGNANCY TEST,41010265,CDM,307,RC,81025,HCPCS,Outpatient,,,130.4,78.24,,9.98,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.91,150,,316.728,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,280,,2284.128,Fee Schedule,280% of BCBS BULE Fee Schedule,27.55,320,,626.264,Fee Schedule,320% of BCBS Blue Essentials Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,31,360,,2936.736,Fee Schedule,360% of BCBS POS Rate,31,360,,2936.736,Fee schedule,360% of BCBS PPO Rate,31,360,,2936.736,Fee Schedule,360% of BCBS Traditional Rate,78.24,60,,293.856,Percent of Total Billed Charges,60% of Total Billed Charges,7.23,100,,3319.432,Fee Schedule,100% of TX Mediciad 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,,862.344,Fee Schedule,100% of CMS OPPS Rate,7.74,90,,,Fee Schedule,90% of CMS OPPS Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,130,,,Fee Schedule,130% of CMS OPPS Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.45,103,,3419.016,Fee Schedule,103% of TX Medicaid Rate,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,97.8,75,,122.008,Percent of Total Billed Charges,75% of Total Billed Charges,14.63,80,,1196.392,Fee Schedule,80% of Scott and White EPO fee schedule,14.63,80,,4888,Fee Schedule,80% of Scott and White HMO fee schedule,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,170,,4888,Fee Schedule,170% of Scott and White PPO fee schedule,14.63,170,,1196.392,Fee Schedule,170% of Scott and White SWHP fee schedule,12.91,150,,,Fee Schedule,150% of CMS OPPS Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,4758.6,Fee Schedule,90% of UHC fee schedule,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,130.4,100,,162.68,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,130.4,
CARBAMAZEPINE FREE,41010304,CDM,301,RC,80157,HCPCS,Outpatient,,,127,76.20,,15.38,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,238.808,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,134.224,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,626.264,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,172.568,Fee Schedule,360% of BCBS POS Rate,47.7,360,,172.568,Fee schedule,360% of BCBS PPO Rate,47.7,360,,172.568,Fee Schedule,360% of BCBS Traditional Rate,76.2,60,,139.24,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,4979.152,Fee Schedule,100% of TX Mediciad 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,,1055.768,Fee Schedule,100% of CMS OPPS Rate,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,5128.52,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,95.25,75,,42.752,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,1196.392,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,4986.8,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,4986.8,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,4888,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,154,Fee Schedule,90% of UHC fee schedule,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,4979.152,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,127,100,,57,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,127,
BILIRUBIN TOTAL BF,41010618,CDM,301,RC,82247,HCPCS,Outpatient,,,74.72,44.83,,5.82,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.52,150,,267.6,Fee Schedule ,150% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,14.06,280,,134.224,Fee Schedule,280% of BCBS BULE Fee Schedule,16.06,320,,627.016,Fee Schedule,320% of BCBS Blue Essentials Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,18.07,360,,172.568,Fee Schedule,360% of BCBS POS Rate,18.07,360,,172.568,Fee schedule,360% of BCBS PPO Rate,18.07,360,,172.568,Fee Schedule,360% of BCBS Traditional Rate,44.83,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,4.22,100,,2296,Fee Schedule,100% of TX Mediciad 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,,703.848,Fee Schedule,100% of CMS OPPS Rate,4.51,90,,,Fee Schedule,90% of CMS OPPS Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,130,,,Fee Schedule,130% of CMS OPPS Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.35,103,,2364.88,Fee Schedule,103% of TX Medicaid Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,56.04,75,,60.904,Percent of Total Billed Charges,75% of Total Billed Charges,8.53,80,,4888,Fee Schedule,80% of Scott and White EPO fee schedule,8.53,80,,13952.256,Fee Schedule,80% of Scott and White HMO fee schedule,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,8.53,170,,13952.256,Fee Schedule,170% of Scott and White PPO fee schedule,8.53,170,,4986.8,Fee Schedule,170% of Scott and White SWHP fee schedule,7.52,150,,,Fee Schedule,150% of CMS OPPS Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.07,90,,1299.48,Fee Schedule,90% of UHC fee schedule,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,2296,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.72,100,,81.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,74.72,
OCCULT BLD QL FECES SNGL,41010640,CDM,301,RC,82272,HCPCS,Outpatient,,,63,37.80,,4.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.34,150,,267.6,Fee Schedule ,150% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.84,280,,14846.832,Fee Schedule,280% of BCBS BULE Fee Schedule,13.54,320,,630.944,Fee Schedule,320% of BCBS Blue Essentials Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,15.23,360,,19088.784,Fee Schedule,360% of BCBS POS Rate,15.23,360,,19088.784,Fee schedule,360% of BCBS PPO Rate,15.23,360,,19088.784,Fee Schedule,360% of BCBS Traditional Rate,37.8,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,3.55,100,,3319.432,Fee Schedule,100% of TX Mediciad 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,,703.848,Fee Schedule,100% of CMS OPPS Rate,3.8,90,,,Fee Schedule,90% of CMS OPPS Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,130,,,Fee Schedule,130% of CMS OPPS Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.66,103,,3419.016,Fee Schedule,103% of TX Medicaid Rate,4.35,103,,,Fee Schedule,103% of CMS OPPS Rate,4.35,103,,,Fee Schedule,103% of CMS OPPS Rate,47.25,75,,29.48,Percent of Total Billed Charges,75% of Total Billed Charges,7.19,80,,4986.8,Fee Schedule,80% of Scott and White EPO fee schedule,7.19,80,,1833.552,Fee Schedule,80% of Scott and White HMO fee schedule,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,7.19,170,,1833.552,Fee Schedule,170% of Scott and White PPO fee schedule,7.19,170,,13952.256,Fee Schedule,170% of Scott and White SWHP fee schedule,6.34,150,,,Fee Schedule,150% of CMS OPPS Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.43,90,,126,Fee Schedule,90% of UHC fee schedule,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,3.55,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,63,100,,39.304,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,63,
CHLORIDE BF,41010720,CDM,301,RC,82438,HCPCS,Outpatient,,,104.57,62.74,,5.8,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.5,150,,224.104,Fee Schedule ,150% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,14,280,,3688.864,Fee Schedule,280% of BCBS BULE Fee Schedule,16,320,,632.216,Fee Schedule,320% of BCBS Blue Essentials Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,18,360,,4742.832,Fee Schedule,360% of BCBS POS Rate,18,360,,4742.832,Fee schedule,360% of BCBS PPO Rate,18,360,,4742.832,Fee Schedule,360% of BCBS Traditional Rate,62.74,60,,115.136,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,100,,3319.432,Fee Schedule,100% of TX Mediciad 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,,530.68,Fee Schedule,100% of CMS OPPS Rate,4.5,90,,,Fee Schedule,90% of CMS OPPS Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,130,,,Fee Schedule,130% of CMS OPPS Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.33,103,,3419.016,Fee Schedule,103% of TX Medicaid Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,78.43,75,,67.032,Percent of Total Billed Charges,75% of Total Billed Charges,8.5,80,,13952.256,Fee Schedule,80% of Scott and White EPO fee schedule,8.5,80,,5138.304,Fee Schedule,80% of Scott and White HMO fee schedule,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,170,,5138.304,Fee Schedule,170% of Scott and White PPO fee schedule,8.5,170,,1833.552,Fee Schedule,170% of Scott and White SWHP fee schedule,7.5,150,,,Fee Schedule,150% of CMS OPPS Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.05,90,,1387.68,Fee Schedule,90% of UHC fee schedule,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,3319.432,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.57,100,,89.376,Percent of Total Billed Charges,100% of Total Billed Charges,4.05,104.57,
CREATININE BF,41010842,CDM,301,RC,82570,HCPCS,Outpatient,,,99.57,59.74,,6,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,319.72,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,51.384,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,632.32,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,66.064,Fee Schedule,360% of BCBS POS Rate,18.65,360,,66.064,Fee schedule,360% of BCBS PPO Rate,18.65,360,,66.064,Fee Schedule,360% of BCBS Traditional Rate,59.74,60,,110.496,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,5857.016,Fee Schedule,100% of TX Mediciad 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,,594.672,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,6032.728,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,74.68,75,,89.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,1833.552,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,2569.328,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,2569.328,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,5138.304,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,1387.68,Fee Schedule,90% of UHC fee schedule,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,99.57,100,,119.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,99.57,
GLUCOSE 1HR SCR OB,41010931,CDM,301,RC,82950,HCPCS,Outpatient,,,105.83,63.50,,5.52,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,195.88,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,632.32,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,172.8,Fee Schedule,360% of BCBS POS Rate,17.1,360,,172.8,Fee schedule,360% of BCBS PPO Rate,17.1,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,63.5,60,,91.76,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,5857.016,Fee Schedule,100% of TX Mediciad 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,,594.672,Fee Schedule,100% of CMS OPPS Rate,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,6032.728,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,79.37,75,,144.136,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,5138.304,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,4960.896,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,4960.896,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,2569.328,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,1568,Fee Schedule,90% of UHC fee schedule,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,5857.016,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,105.83,100,,192.176,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,105.83,
LACTIC ACID CSF,41011124,CDM,301,RC,83605,HCPCS,Outpatient,,,194.98,116.99,,13.42,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,17.35,150,,341.32,Fee Schedule ,150% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,37.02,320,,632.808,Fee Schedule,320% of BCBS Blue Essentials Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,41.65,360,,108,Fee Schedule,360% of BCBS POS Rate,41.65,360,,108,Fee schedule,360% of BCBS PPO Rate,41.65,360,,108,Fee Schedule,360% of BCBS Traditional Rate,116.99,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,100,,1135.872,Fee Schedule,100% of TX Mediciad 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,,498,Fee Schedule,100% of CMS OPPS Rate,10.41,90,,,Fee Schedule,90% of CMS OPPS Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,10.01,103,,1169.952,Fee Schedule,103% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,146.24,75,,148.792,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,80,,2569.328,Fee Schedule,80% of Scott and White EPO fee schedule,19.66,80,,5138.304,Fee Schedule,80% of Scott and White HMO fee schedule,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.66,170,,5138.304,Fee Schedule,170% of Scott and White PPO fee schedule,19.66,170,,4960.896,Fee Schedule,170% of Scott and White SWHP fee schedule,17.35,150,,,Fee Schedule,150% of CMS OPPS Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,90,,1174.32,Fee Schedule,90% of UHC fee schedule,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,1135.872,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,194.98,100,,198.392,Percent of Total Billed Charges,100% of Total Billed Charges,9.37,194.98,
MAGNESIUM URINE 24HR,41011179,CDM,301,RC,83735,HCPCS,Outpatient,,,121,72.60,,7.78,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.05,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,280,,1051.504,Fee Schedule,280% of BCBS BULE Fee Schedule,21.44,320,,634.368,Fee Schedule,320% of BCBS Blue Essentials Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,24.12,360,,1351.936,Fee Schedule,360% of BCBS POS Rate,24.12,360,,1351.936,Fee schedule,360% of BCBS PPO Rate,24.12,360,,1351.936,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,100,,190.624,Fee Schedule,100% of TX Mediciad 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,,710.48,Fee Schedule,100% of CMS OPPS Rate,6.03,90,,,Fee Schedule,90% of CMS OPPS Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.8,103,,196.344,Fee Schedule,103% of TX Medicaid Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,11.39,80,,4960.896,Fee Schedule,80% of Scott and White EPO fee schedule,11.39,80,,7707.456,Fee Schedule,80% of Scott and White HMO fee schedule,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,170,,7707.456,Fee Schedule,170% of Scott and White PPO fee schedule,11.39,170,,5138.304,Fee Schedule,170% of Scott and White SWHP fee schedule,10.05,150,,,Fee Schedule,150% of CMS OPPS Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,6542.304,Fee Schedule,90% of UHC fee schedule,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,190.624,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,121,
MAGNESIUM URINE SPOT,41011180,CDM,301,RC,83735,HCPCS,Outpatient,,,121,72.60,,7.78,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.05,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,280,,301.272,Fee Schedule,280% of BCBS BULE Fee Schedule,21.44,320,,634.368,Fee Schedule,320% of BCBS Blue Essentials Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,24.12,360,,387.344,Fee Schedule,360% of BCBS POS Rate,24.12,360,,387.344,Fee schedule,360% of BCBS PPO Rate,24.12,360,,387.344,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,117.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,100,,764.288,Fee Schedule,100% of TX Mediciad 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,,435.296,Fee Schedule,100% of CMS OPPS Rate,6.03,90,,,Fee Schedule,90% of CMS OPPS Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.8,103,,787.216,Fee Schedule,103% of TX Medicaid Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,175.544,Percent of Total Billed Charges,75% of Total Billed Charges,11.39,80,,5138.304,Fee Schedule,80% of Scott and White EPO fee schedule,11.39,80,,5138.304,Fee Schedule,80% of Scott and White HMO fee schedule,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,170,,5138.304,Fee Schedule,170% of Scott and White PPO fee schedule,11.39,170,,7707.456,Fee Schedule,170% of Scott and White SWHP fee schedule,10.05,150,,,Fee Schedule,150% of CMS OPPS Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,3101.16,Fee Schedule,90% of UHC fee schedule,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,764.288,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,234.056,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,121,
SODIUM OTHER SOURCE,41011314,CDM,301,RC,84302,HCPCS,Outpatient,,,82.49,49.49,,5.64,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.29,150,,517.848,Fee Schedule ,150% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,280,,301.272,Fee Schedule,280% of BCBS BULE Fee Schedule,15.55,320,,635.136,Fee Schedule,320% of BCBS Blue Essentials Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,17.5,360,,387.344,Fee Schedule,360% of BCBS POS Rate,17.5,360,,387.344,Fee schedule,360% of BCBS PPO Rate,17.5,360,,387.344,Fee Schedule,360% of BCBS Traditional Rate,49.49,60,,168.48,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,100,,675.928,Fee Schedule,100% of TX Mediciad 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,,758.488,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,,Fee Schedule,90% of CMS OPPS Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,130,,,Fee Schedule,130% of CMS OPPS Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.2,103,,696.208,Fee Schedule,103% of TX Medicaid Rate,5,103,,,Fee Schedule,103% of CMS OPPS Rate,5,103,,,Fee Schedule,103% of CMS OPPS Rate,61.87,75,,113.76,Percent of Total Billed Charges,75% of Total Billed Charges,8.26,80,,7707.456,Fee Schedule,80% of Scott and White EPO fee schedule,8.26,80,,7200,Fee Schedule,80% of Scott and White HMO fee schedule,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8.26,170,,7200,Fee Schedule,170% of Scott and White PPO fee schedule,8.26,170,,5138.304,Fee Schedule,170% of Scott and White SWHP fee schedule,7.29,150,,,Fee Schedule,150% of CMS OPPS Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,90,,1174.32,Fee Schedule,90% of UHC fee schedule,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,675.928,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,82.49,100,,151.68,Percent of Total Billed Charges,100% of Total Billed Charges,3.93,82.49,
TRIGLYCERIDES BF,41011336,CDM,301,RC,84478,HCPCS,Outpatient,,,111.65,66.99,,6.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.61,150,,216.536,Fee Schedule ,150% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,280,,2284.128,Fee Schedule,280% of BCBS BULE Fee Schedule,18.37,320,,635.328,Fee Schedule,320% of BCBS Blue Essentials Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,20.66,360,,2936.736,Fee Schedule,360% of BCBS POS Rate,20.66,360,,2936.736,Fee schedule,360% of BCBS PPO Rate,20.66,360,,2936.736,Fee Schedule,360% of BCBS Traditional Rate,66.99,60,,70.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,5.16,90,,,Fee Schedule,90% of CMS OPPS Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,7.46,130,,,Fee Schedule,130% of CMS OPPS Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.96,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,5.91,103,,,Fee Schedule,103% of CMS OPPS Rate,5.91,103,,,Fee Schedule,103% of CMS OPPS Rate,83.74,75,,154.792,Percent of Total Billed Charges,75% of Total Billed Charges,9.75,80,,5138.304,Fee Schedule,80% of Scott and White EPO fee schedule,9.75,80,,780,Fee Schedule,80% of Scott and White HMO fee schedule,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.75,170,,780,Fee Schedule,170% of Scott and White PPO fee schedule,9.75,170,,7200,Fee Schedule,170% of Scott and White SWHP fee schedule,8.61,150,,,Fee Schedule,150% of CMS OPPS Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,90,,4303.136,Fee Schedule,90% of UHC fee schedule,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,111.65,100,,206.392,Percent of Total Billed Charges,100% of Total Billed Charges,4.65,111.65,
BUN QT BF,41011369,CDM,301,RC,84520,HCPCS,Outpatient,,,85,51.00,,4.58,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.92,150,,3159.432,Fee Schedule ,150% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,280,,278.344,Fee Schedule,280% of BCBS BULE Fee Schedule,12.64,320,,639.656,Fee Schedule,320% of BCBS Blue Essentials Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,14.22,360,,357.872,Fee Schedule,360% of BCBS POS Rate,14.22,360,,357.872,Fee schedule,360% of BCBS PPO Rate,14.22,360,,357.872,Fee Schedule,360% of BCBS Traditional Rate,51,60,,113.28,Percent of Total Billed Charges,60% of Total Billed Charges,3.32,100,,490,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,3.55,90,,,Fee Schedule,90% of CMS OPPS Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.13,130,,,Fee Schedule,130% of CMS OPPS Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.42,103,,504.704,Fee Schedule,103% of TX Medicaid Rate,4.06,103,,,Fee Schedule,103% of CMS OPPS Rate,4.06,103,,,Fee Schedule,103% of CMS OPPS Rate,63.75,75,,88.248,Percent of Total Billed Charges,75% of Total Billed Charges,6.71,80,,7200,Fee Schedule,80% of Scott and White EPO fee schedule,6.71,80,,2282.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.71,170,,2282.8,Fee Schedule,170% of Scott and White PPO fee schedule,6.71,170,,780,Fee Schedule,170% of Scott and White SWHP fee schedule,5.92,150,,,Fee Schedule,150% of CMS OPPS Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,90,,3891.536,Fee Schedule,90% of UHC fee schedule,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,490,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,85,100,,117.664,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,85,
FACTOR II ASSAY,41011404,CDM,305,RC,85210,HCPCS,Outpatient,,,270,162.00,,15.06,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.47,150,,424.624,Fee Schedule ,150% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.34,280,,1903.44,Fee Schedule,280% of BCBS BULE Fee Schedule,41.54,320,,641.536,Fee Schedule,320% of BCBS Blue Essentials Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,46.73,360,,2447.28,Fee Schedule,360% of BCBS POS Rate,46.73,360,,2447.28,Fee schedule,360% of BCBS PPO Rate,46.73,360,,2447.28,Fee Schedule,360% of BCBS Traditional Rate,162,60,,153.784,Percent of Total Billed Charges,60% of Total Billed Charges,10.9,100,,886.424,Fee Schedule,100% of TX Mediciad 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,,1150.776,Fee Schedule,100% of CMS OPPS Rate,11.68,90,,,Fee Schedule,90% of CMS OPPS Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,130,,,Fee Schedule,130% of CMS OPPS Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,11.23,103,,913.016,Fee Schedule,103% of TX Medicaid Rate,13.36,103,,,Fee Schedule,103% of CMS OPPS Rate,13.36,103,,,Fee Schedule,103% of CMS OPPS Rate,202.5,75,,83.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.06,80,,780,Fee Schedule,80% of Scott and White EPO fee schedule,22.06,80,,3114.8,Fee Schedule,80% of Scott and White HMO fee schedule,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.06,170,,3114.8,Fee Schedule,170% of Scott and White PPO fee schedule,22.06,170,,2282.8,Fee Schedule,170% of Scott and White SWHP fee schedule,19.47,150,,,Fee Schedule,150% of CMS OPPS Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.51,90,,2753.352,Fee Schedule,90% of UHC fee schedule,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,10.9,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,270,100,,111.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.51,270,
FACTOR X ASSAY,41011415,CDM,305,RC,85260,HCPCS,Outpatient,,,322.14,193.28,,20.76,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,26.85,150,,424.624,Fee Schedule ,150% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.12,280,,61.6,Fee Schedule,280% of BCBS BULE Fee Schedule,57.28,320,,642.016,Fee Schedule,320% of BCBS Blue Essentials Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,64.44,360,,79.2,Fee Schedule,360% of BCBS POS Rate,64.44,360,,79.2,Fee schedule,360% of BCBS PPO Rate,64.44,360,,79.2,Fee Schedule,360% of BCBS Traditional Rate,193.28,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,15.04,100,,205.48,Fee Schedule,100% of TX Mediciad 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,,481.192,Fee Schedule,100% of CMS OPPS Rate,16.1,90,,,Fee Schedule,90% of CMS OPPS Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,130,,,Fee Schedule,130% of CMS OPPS Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.49,103,,211.648,Fee Schedule,103% of TX Medicaid Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,241.61,75,,179.4,Percent of Total Billed Charges,75% of Total Billed Charges,30.42,80,,2282.8,Fee Schedule,80% of Scott and White EPO fee schedule,30.42,80,,1066,Fee Schedule,80% of Scott and White HMO fee schedule,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,30.42,170,,1066,Fee Schedule,170% of Scott and White PPO fee schedule,30.42,170,,3114.8,Fee Schedule,170% of Scott and White SWHP fee schedule,26.85,150,,,Fee Schedule,150% of CMS OPPS Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,90,,2489.992,Fee Schedule,90% of UHC fee schedule,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,205.48,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,322.14,100,,239.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.5,322.14,
FACTOR XIII SCREEN,41011426,CDM,305,RC,85291,HCPCS,Outpatient,,,176.02,105.61,,10.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,13.66,150,,880.68,Fee Schedule ,150% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,25.51,280,,519.792,Fee Schedule,280% of BCBS BULE Fee Schedule,29.15,320,,642.256,Fee Schedule,320% of BCBS Blue Essentials Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,32.8,360,,668.304,Fee Schedule,360% of BCBS POS Rate,32.8,360,,668.304,Fee schedule,360% of BCBS PPO Rate,32.8,360,,668.304,Fee Schedule,360% of BCBS Traditional Rate,105.61,60,,407.056,Percent of Total Billed Charges,60% of Total Billed Charges,7.65,100,,958,Fee Schedule,100% of TX Mediciad 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,,7020.968,Fee Schedule,100% of CMS OPPS Rate,8.19,90,,,Fee Schedule,90% of CMS OPPS Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,11.84,130,,,Fee Schedule,130% of CMS OPPS Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.88,103,,986.736,Fee Schedule,103% of TX Medicaid Rate,9.38,103,,,Fee Schedule,103% of CMS OPPS Rate,9.38,103,,,Fee Schedule,103% of CMS OPPS Rate,132.02,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,15.48,80,,3114.8,Fee Schedule,80% of Scott and White EPO fee schedule,15.48,80,,2776.8,Fee Schedule,80% of Scott and White HMO fee schedule,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,170,,2776.8,Fee Schedule,170% of Scott and White PPO fee schedule,15.48,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,13.66,150,,,Fee Schedule,150% of CMS OPPS Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.38,90,,6559.608,Fee Schedule,90% of UHC fee schedule,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,7.65,100,,958,Fee Schedule,100% of TX Medicaid Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,176.02,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.38,176.02,
FACTOR VIII INHIBITOR ASSAY,41011458,CDM,305,RC,85335,HCPCS,Outpatient,,,347.82,208.69,,14.92,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,894.408,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,50.4,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,643.384,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,64.8,Fee Schedule,360% of BCBS POS Rate,46.33,360,,64.8,Fee schedule,360% of BCBS PPO Rate,46.33,360,,64.8,Fee Schedule,360% of BCBS Traditional Rate,208.69,60,,578.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,1261.512,Fee Schedule,100% of TX Mediciad 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,,943.608,Fee Schedule,100% of CMS OPPS Rate,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,1299.36,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,75,,73.872,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,1066,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,5416,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,5416,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,1066,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,5266.776,Fee Schedule,90% of UHC fee schedule,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,1261.512,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,347.82,100,,98.496,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,347.82,
ACTIVATED CLOTTING TIME POC,41011469,CDM,305,RC,85347,HCPCS,Outpatient,,,112.51,67.51,,4.96,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.42,150,,894.408,Fee Schedule ,150% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,280,,555.072,Fee Schedule,280% of BCBS BULE Fee Schedule,13.7,320,,643.408,Fee Schedule,320% of BCBS Blue Essentials Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,15.41,360,,713.664,Fee Schedule,360% of BCBS POS Rate,15.41,360,,713.664,Fee schedule,360% of BCBS PPO Rate,15.41,360,,713.664,Fee Schedule,360% of BCBS Traditional Rate,67.51,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,100,,269.688,Fee Schedule,100% of TX Mediciad 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,,943.608,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of CMS OPPS Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,130,,,Fee Schedule,130% of CMS OPPS Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.71,103,,277.784,Fee Schedule,103% of TX Medicaid Rate,4.4,103,,,Fee Schedule,103% of CMS OPPS Rate,4.4,103,,,Fee Schedule,103% of CMS OPPS Rate,84.38,75,,78.6,Percent of Total Billed Charges,75% of Total Billed Charges,7.27,80,,2776.8,Fee Schedule,80% of Scott and White EPO fee schedule,7.27,80,,1970.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,7.27,170,,1970.8,Fee Schedule,170% of Scott and White PPO fee schedule,7.27,170,,2776.8,Fee Schedule,170% of Scott and White SWHP fee schedule,6.42,150,,,Fee Schedule,150% of CMS OPPS Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.47,90,,7119.064,Fee Schedule,90% of UHC fee schedule,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,269.688,Fee Schedule,100% of TX Medicaid Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,112.51,100,,104.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.47,112.51,
FIBRIN SPLIT PRODUCT SEMIQT,41011481,CDM,305,RC,85362,HCPCS,Outpatient,,,285.12,171.07,,8,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.33,150,,1083.632,Fee Schedule ,150% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.29,280,,555.072,Fee Schedule,280% of BCBS BULE Fee Schedule,22.05,320,,643.408,Fee Schedule,320% of BCBS Blue Essentials Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,24.8,360,,713.664,Fee Schedule,360% of BCBS POS Rate,24.8,360,,713.664,Fee schedule,360% of BCBS PPO Rate,24.8,360,,713.664,Fee Schedule,360% of BCBS Traditional Rate,171.07,60,,106.528,Percent of Total Billed Charges,60% of Total Billed Charges,5.79,100,,137.712,Fee Schedule,100% of TX Mediciad 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,,1957.064,Fee Schedule,100% of CMS OPPS Rate,6.2,90,,,Fee Schedule,90% of CMS OPPS Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.95,130,,,Fee Schedule,130% of CMS OPPS Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.96,103,,141.848,Fee Schedule,103% of TX Medicaid Rate,7.09,103,,,Fee Schedule,103% of CMS OPPS Rate,7.09,103,,,Fee Schedule,103% of CMS OPPS Rate,213.84,75,,158.752,Percent of Total Billed Charges,75% of Total Billed Charges,11.71,80,,5416,Fee Schedule,80% of Scott and White EPO fee schedule,11.71,80,,1118.8,Fee Schedule,80% of Scott and White HMO fee schedule,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,11.71,170,,1118.8,Fee Schedule,170% of Scott and White PPO fee schedule,11.71,170,,5416,Fee Schedule,170% of Scott and White SWHP fee schedule,10.33,150,,,Fee Schedule,150% of CMS OPPS Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,5.58,90,,7119.064,Fee Schedule,90% of UHC fee schedule,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,137.712,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,285.12,100,,211.672,Percent of Total Billed Charges,100% of Total Billed Charges,5.58,285.12,
ELECTRONIC CROSSMATCH,41012711,CDM,300,RC,86923,HCPCS,Outpatient,,,150,90.00,,34.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,4751.248,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,627.2,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,643.408,Fee Schedule,320% of BCBS Blue Essentials Rate,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,806.4,Fee Schedule,360% of BCBS POS Rate,516.6,360,,806.4,Fee schedule,360% of BCBS PPO Rate,516.6,360,,806.4,Fee Schedule,360% of BCBS Traditional Rate,90,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1987.568,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,116.992,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,1970.8,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,420,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,420,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1970.8,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,2368.232,Fee Schedule,90% of UHC fee schedule,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,155.984,Percent of Total Billed Charges,100% of Total Billed Charges,21,516.6,
PRETRT RBC INCUBATE W DRUGS EA,41012722,CDM,300,RC,86970,HCPCS,Outpatient,,,176.93,106.16,,36.12,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,9049.888,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,469.728,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,643.408,Fee Schedule,320% of BCBS Blue Essentials Rate,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,603.936,Fee Schedule,360% of BCBS POS Rate,120.35,360,,603.936,Fee schedule,360% of BCBS PPO Rate,120.35,360,,603.936,Fee Schedule,360% of BCBS Traditional Rate,106.16,60,,191.04,Percent of Total Billed Charges,60% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,1987.568,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,25.51,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,132.7,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,88.47,50,,1118.8,Percent of Total Billed Charges,50% of Total Billed Charges,88.47,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,88.47,50,,216,Percent of Total Billed Charges,50% of Total Billed Charges,88.47,50,,1118.8,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,2368.232,Fee Schedule,90% of UHC fee schedule,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,24.77,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,176.93,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,24.77,176.93,
CX BODY FLUID,41012744,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,5580.792,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,2616.92,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,644.32,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,3364.616,Fee Schedule,360% of BCBS POS Rate,31.03,360,,3364.616,Fee schedule,360% of BCBS PPO Rate,31.03,360,,3364.616,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,138.08,Fee Schedule,100% of TX Mediciad 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,,2408.072,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,142.224,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,420,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,70,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,70,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,420,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1288.328,Fee Schedule,90% of UHC fee schedule,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,138.08,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX GENITAL,41012755,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,3527.584,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,1240.464,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,644.608,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,1594.88,Fee Schedule,360% of BCBS POS Rate,31.03,360,,1594.88,Fee schedule,360% of BCBS PPO Rate,31.03,360,,1594.88,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,142.04,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,243.912,Fee Schedule,100% of TX Mediciad 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,,10558.336,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,251.232,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,109.2,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,216,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,1924,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,1924,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,216,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,336,Fee Schedule,90% of UHC fee schedule,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,243.912,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,145.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX OTH SRC AEROBIC PRESUMP ID,41012766,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,575.632,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,469.728,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,645.08,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,603.936,Fee Schedule,360% of BCBS POS Rate,31.03,360,,603.936,Fee schedule,360% of BCBS PPO Rate,31.03,360,,603.936,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,60.36,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,1294.536,Fee Schedule,100% of TX Mediciad 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,,20110.864,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,1333.368,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,77.4,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,70,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,5200,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,5200,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,70,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,378,Fee Schedule,90% of UHC fee schedule,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1294.536,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,103.2,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX RESPIRATORY,41012777,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,2487.68,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,1721.256,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,645.08,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,2213.04,Fee Schedule,360% of BCBS POS Rate,31.03,360,,2213.04,Fee schedule,360% of BCBS PPO Rate,31.03,360,,2213.04,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,1334.4,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,1519.416,Fee Schedule,100% of TX Mediciad 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,,12401.76,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,1564.992,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,1924,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,29.28,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,29.28,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,1924,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1796.496,Fee Schedule,90% of UHC fee schedule,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1519.416,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX THROAT,41012788,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,3000.904,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,1556.616,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,645.12,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,2001.36,Fee Schedule,360% of BCBS POS Rate,31.03,360,,2001.36,Fee schedule,360% of BCBS PPO Rate,31.03,360,,2001.36,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,1315.2,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,1648.192,Fee Schedule,100% of TX Mediciad 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,,7839.08,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,1697.64,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,73.488,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,5200,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,2802.8,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,2802.8,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,5200,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,7280,Fee Schedule,90% of UHC fee schedule,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,97.984,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX TISSUE,41012799,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,2681.424,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,1101.344,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,645.12,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,1416.008,Fee Schedule,360% of BCBS POS Rate,31.03,360,,1416.008,Fee schedule,360% of BCBS PPO Rate,31.03,360,,1416.008,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,428.16,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,1932.408,Fee Schedule,100% of TX Mediciad 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,,1279.176,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,1990.384,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,70.888,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,29.28,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,16640.2,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,16640.2,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1796.496,Fee Schedule,90% of UHC fee schedule,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,1932.408,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,94.512,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX BACT QT URINE W ID EA,41012833,CDM,306,RC,87088,HCPCS,Outpatient,,,128,76.80,,9.38,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.13,150,,1080.576,Fee Schedule ,150% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,22.65,280,,995.992,Fee Schedule,280% of BCBS BULE Fee Schedule,25.89,320,,645.12,Fee Schedule,320% of BCBS Blue Essentials Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,29.12,360,,1280.568,Fee Schedule,360% of BCBS POS Rate,29.12,360,,1280.568,Fee schedule,360% of BCBS PPO Rate,29.12,360,,1280.568,Fee Schedule,360% of BCBS Traditional Rate,76.8,60,,286.864,Percent of Total Billed Charges,60% of Total Billed Charges,6.8,100,,1648.192,Fee Schedule,100% of TX Mediciad 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,,5528.176,Fee Schedule,100% of CMS OPPS Rate,7.28,90,,,Fee Schedule,90% of CMS OPPS Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.51,130,,,Fee Schedule,130% of CMS OPPS Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,7,103,,1697.64,Fee Schedule,103% of TX Medicaid Rate,8.33,103,,,Fee Schedule,103% of CMS OPPS Rate,8.33,103,,,Fee Schedule,103% of CMS OPPS Rate,96,75,,43.952,Percent of Total Billed Charges,75% of Total Billed Charges,13.75,80,,2802.8,Fee Schedule,80% of Scott and White EPO fee schedule,13.75,80,,4401.544,Fee Schedule,80% of Scott and White HMO fee schedule,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,170,,4401.544,Fee Schedule,170% of Scott and White PPO fee schedule,13.75,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,12.13,150,,,Fee Schedule,150% of CMS OPPS Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,6.55,90,,1490.072,Fee Schedule,90% of UHC fee schedule,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,1648.192,Fee Schedule,100% of TX Medicaid Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,128,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.55,128,
SMEAR ACID FAST DIRECT,41012966,CDM,306,RC,87206,HCPCS,Outpatient,,,119.28,71.57,,6.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.08,150,,720.384,Fee Schedule ,150% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.09,280,,2623.84,Fee Schedule,280% of BCBS BULE Fee Schedule,17.25,320,,649.416,Fee Schedule,320% of BCBS Blue Essentials Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,19.4,360,,3373.512,Fee Schedule,360% of BCBS POS Rate,19.4,360,,3373.512,Fee schedule,360% of BCBS PPO Rate,19.4,360,,3373.512,Fee Schedule,360% of BCBS Traditional Rate,71.57,60,,75.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,100,,2356.32,Fee Schedule,100% of TX Mediciad 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,,6668.68,Fee Schedule,100% of CMS OPPS Rate,4.85,90,,,Fee Schedule,90% of CMS OPPS Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7,130,,,Fee Schedule,130% of CMS OPPS Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.67,103,,2427.008,Fee Schedule,103% of TX Medicaid Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,89.46,75,,121.2,Percent of Total Billed Charges,75% of Total Billed Charges,9.16,80,,16640.2,Fee Schedule,80% of Scott and White EPO fee schedule,9.16,80,,750,Fee Schedule,80% of Scott and White HMO fee schedule,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,170,,750,Fee Schedule,170% of Scott and White PPO fee schedule,9.16,170,,29.28,Fee Schedule,170% of Scott and White SWHP fee schedule,8.08,150,,,Fee Schedule,150% of CMS OPPS Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,336,Fee Schedule,90% of UHC fee schedule,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,2356.32,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,119.28,100,,161.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.37,119.28,
MEDICAL DEVICE CULTURE,41013751,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,2620.984,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,2847.624,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,651.568,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,3661.232,Fee Schedule,360% of BCBS POS Rate,31.03,360,,3661.232,Fee schedule,360% of BCBS PPO Rate,31.03,360,,3661.232,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,794.224,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,24.336,Fee Schedule,100% of TX Mediciad 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,,1600.856,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,25.064,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,54.648,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,4401.544,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1174.32,Fee Schedule,90% of UHC fee schedule,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,72.864,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
PROSTHETIC DEVICE CULTURE,41013752,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,2488.096,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,947.296,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,652.024,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,1217.952,Fee Schedule,360% of BCBS POS Rate,31.03,360,,1217.952,Fee schedule,360% of BCBS PPO Rate,31.03,360,,1217.952,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,504.216,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,516.928,Fee Schedule,100% of TX Mediciad 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,,887.752,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,532.44,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,8200,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,8200,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,750,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1174.32,Fee Schedule,90% of UHC fee schedule,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
GROUP A STREP CULTURE,41013753,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,2701.464,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,947.296,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,652.304,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,1217.952,Fee Schedule,360% of BCBS POS Rate,31.03,360,,1217.952,Fee schedule,360% of BCBS PPO Rate,31.03,360,,1217.952,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,345.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,516.928,Fee Schedule,100% of TX Mediciad 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,,7558.168,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,532.44,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,52.2,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,1260,Fee Schedule,90% of UHC fee schedule,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,516.928,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,69.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
MACROSCOPIC EXAM PARASITE,41013754,CDM,306,RC,87169,HCPCS,Outpatient,,,71.64,42.98,,5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.46,150,,1394.472,Fee Schedule ,150% of CMS OPPS Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.07,280,,515.336,Fee Schedule,280% of BCBS BULE Fee Schedule,13.79,320,,661.432,Fee Schedule,320% of BCBS Blue Essentials Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.52,360,,662.568,Fee Schedule,360% of BCBS POS Rate,15.52,360,,662.568,Fee schedule,360% of BCBS PPO Rate,15.52,360,,662.568,Fee Schedule,360% of BCBS Traditional Rate,42.98,60,,138,Percent of Total Billed Charges,60% of Total Billed Charges,3.62,100,,3439.048,Fee Schedule,100% of TX Mediciad Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4.3,100,,5824.4,Fee Schedule,100% of CMS OPPS Rate,3.87,90,,,Fee Schedule,90% of CMS OPPS Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,130,,,Fee Schedule,130% of CMS OPPS Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.73,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,4.43,103,,,Fee Schedule,103% of CMS OPPS Rate,4.43,103,,,Fee Schedule,103% of CMS OPPS Rate,53.73,75,,145.672,Percent of Total Billed Charges,75% of Total Billed Charges,7.32,80,,8200,Fee Schedule,80% of Scott and White EPO fee schedule,7.32,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.32,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,7.32,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,6.46,150,,,Fee Schedule,150% of CMS OPPS Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3.49,90,,84,Fee Schedule,90% of UHC fee schedule,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,3.62,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,,Fee Schedule,100% of CMS OPPS Rate,71.64,100,,194.232,Percent of Total Billed Charges,100% of Total Billed Charges,3.49,71.64,
ACETAMINOPHEN,41020033,CDM,301,RC,80143,HCPCS,Outpatient,,,287.97,172.78,,21.62,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,917.304,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,151.2,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,663.04,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,194.4,Fee Schedule,360% of BCBS POS Rate,67.1,360,,194.4,Fee schedule,360% of BCBS PPO Rate,67.1,360,,194.4,Fee Schedule,360% of BCBS Traditional Rate,172.78,60,,96.584,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,886.424,Fee Schedule,100% of TX Mediciad 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,,6003.256,Fee Schedule,100% of CMS OPPS Rate,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,913.016,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,215.98,75,,66.888,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,8240,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,8240,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,8200,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,1260,Fee Schedule,90% of UHC fee schedule,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,886.424,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,89.184,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,287.97,
ACETONE SERUM,41020090,CDM,300,RC,82009,HCPCS,Outpatient,,,92.88,55.73,,5.24,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.77,150,,1579.32,Fee Schedule ,150% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,12.66,280,,718.6,Fee Schedule,280% of BCBS BULE Fee Schedule,14.46,320,,665.344,Fee Schedule,320% of BCBS Blue Essentials Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,16.27,360,,923.912,Fee Schedule,360% of BCBS POS Rate,16.27,360,,923.912,Fee schedule,360% of BCBS PPO Rate,16.27,360,,923.912,Fee Schedule,360% of BCBS Traditional Rate,55.73,60,,96.584,Percent of Total Billed Charges,60% of Total Billed Charges,3.8,100,,2616.488,Fee Schedule,100% of TX Mediciad 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,,3098.832,Fee Schedule,100% of CMS OPPS Rate,4.06,90,,,Fee Schedule,90% of CMS OPPS Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.87,130,,,Fee Schedule,130% of CMS OPPS Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.91,103,,2694.984,Fee Schedule,103% of TX Medicaid Rate,4.65,103,,,Fee Schedule,103% of CMS OPPS Rate,4.65,103,,,Fee Schedule,103% of CMS OPPS Rate,69.66,75,,42.136,Percent of Total Billed Charges,75% of Total Billed Charges,7.68,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,7.68,80,,4056.696,Fee Schedule,80% of Scott and White HMO fee schedule,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.68,170,,4056.696,Fee Schedule,170% of Scott and White PPO fee schedule,7.68,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,6.77,150,,,Fee Schedule,150% of CMS OPPS Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3.66,90,,1260,Fee Schedule,90% of UHC fee schedule,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,92.88,100,,56.176,Percent of Total Billed Charges,100% of Total Billed Charges,3.66,92.88,
SALICYLATE,41020116,CDM,301,RC,80179,HCPCS,Outpatient,,,214.83,128.90,,21.62,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,672.736,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,2912,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,666.624,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,3744,Fee Schedule,360% of BCBS POS Rate,67.1,360,,3744,Fee schedule,360% of BCBS PPO Rate,67.1,360,,3744,Fee Schedule,360% of BCBS Traditional Rate,128.9,60,,96.584,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,2616.488,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,2694.984,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,161.12,75,,62.008,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,8240,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,680.8,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,680.8,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,128.8,Fee Schedule,90% of UHC fee schedule,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,214.83,100,,82.672,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,214.83,
ALBUMIN,41020405,CDM,301,RC,82040,HCPCS,Outpatient,,,68.99,41.39,,5.74,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.42,150,,1338.584,Fee Schedule ,150% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,13.86,280,,718.6,Fee Schedule,280% of BCBS BULE Fee Schedule,15.84,320,,670.928,Fee Schedule,320% of BCBS Blue Essentials Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,17.82,360,,923.912,Fee Schedule,360% of BCBS POS Rate,17.82,360,,923.912,Fee schedule,360% of BCBS PPO Rate,17.82,360,,923.912,Fee Schedule,360% of BCBS Traditional Rate,41.39,60,,121.696,Percent of Total Billed Charges,60% of Total Billed Charges,4.16,100,,2616.488,Fee Schedule,100% of TX Mediciad 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,,2038.456,Fee Schedule,100% of CMS OPPS Rate,4.45,90,,,Fee Schedule,90% of CMS OPPS Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.43,130,,,Fee Schedule,130% of CMS OPPS Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.28,103,,2694.984,Fee Schedule,103% of TX Medicaid Rate,5.09,103,,,Fee Schedule,103% of CMS OPPS Rate,5.09,103,,,Fee Schedule,103% of CMS OPPS Rate,51.74,75,,92.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.41,80,,4056.696,Fee Schedule,80% of Scott and White EPO fee schedule,8.41,80,,2729.6,Fee Schedule,80% of Scott and White HMO fee schedule,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,170,,2729.6,Fee Schedule,170% of Scott and White PPO fee schedule,8.41,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,7.42,150,,,Fee Schedule,150% of CMS OPPS Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.01,90,,1285.696,Fee Schedule,90% of UHC fee schedule,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.16,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,68.99,100,,123.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,68.99,
ALBUMIN OTHER SOURCE QT EA,41020454,CDM,300,RC,82042,HCPCS,Outpatient,,,782.4,469.44,,9.02,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,11.67,150,,1394.472,Fee Schedule ,150% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,280,,596.032,Fee Schedule,280% of BCBS BULE Fee Schedule,24.9,320,,670.928,Fee Schedule,320% of BCBS Blue Essentials Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,28.01,360,,766.32,Fee Schedule,360% of BCBS POS Rate,28.01,360,,766.32,Fee schedule,360% of BCBS PPO Rate,28.01,360,,766.32,Fee Schedule,360% of BCBS Traditional Rate,469.44,60,,887.424,Percent of Total Billed Charges,60% of Total Billed Charges,6.54,100,,2330.024,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,7,90,,,Fee Schedule,90% of CMS OPPS Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,10.11,130,,,Fee Schedule,130% of CMS OPPS Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.74,103,,2399.928,Fee Schedule,103% of TX Medicaid Rate,8.01,103,,,Fee Schedule,103% of CMS OPPS Rate,8.01,103,,,Fee Schedule,103% of CMS OPPS Rate,586.8,75,,66.888,Percent of Total Billed Charges,75% of Total Billed Charges,13.22,80,,680.8,Fee Schedule,80% of Scott and White EPO fee schedule,13.22,80,,2414.04,Fee Schedule,80% of Scott and White HMO fee schedule,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,170,,2414.04,Fee Schedule,170% of Scott and White PPO fee schedule,13.22,170,,8240,Fee Schedule,170% of Scott and White SWHP fee schedule,11.67,150,,,Fee Schedule,150% of CMS OPPS Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,90,,5088.72,Fee Schedule,90% of UHC fee schedule,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,2330.024,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,782.4,100,,89.184,Percent of Total Billed Charges,100% of Total Billed Charges,6.3,782.4,
ALCOHOL ETHANOL BLD,41020553,CDM,301,RC,82077,HCPCS,Outpatient,,,275.79,165.47,,20.04,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,1338.584,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,675.944,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,172.8,Fee Schedule,360% of BCBS POS Rate,62.17,360,,172.8,Fee schedule,360% of BCBS PPO Rate,62.17,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,687.408,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,1700.88,Fee Schedule,100% of TX Mediciad 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,,1494.96,Fee Schedule,100% of CMS OPPS Rate,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,1751.912,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,89.776,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,2729.6,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,4056.696,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,1409.44,Fee Schedule,90% of UHC fee schedule,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,119.696,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,275.79,
AFP SERUM TUMOR MARKER,41021148,CDM,301,RC,82105,HCPCS,Outpatient,,,193,115.80,,19.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,25.15,150,,1579.32,Fee Schedule ,150% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,280,,342.272,Fee Schedule,280% of BCBS BULE Fee Schedule,53.66,320,,676.352,Fee Schedule,320% of BCBS Blue Essentials Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,60.37,360,,440.064,Fee Schedule,360% of BCBS POS Rate,60.37,360,,440.064,Fee schedule,360% of BCBS PPO Rate,60.37,360,,440.064,Fee Schedule,360% of BCBS Traditional Rate,115.8,60,,599.672,Percent of Total Billed Charges,60% of Total Billed Charges,14.09,100,,1700.88,Fee Schedule,100% of TX Mediciad 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,,2974.624,Fee Schedule,100% of CMS OPPS Rate,15.09,90,,,Fee Schedule,90% of CMS OPPS Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,21.8,130,,,Fee Schedule,130% of CMS OPPS Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.51,103,,1751.912,Fee Schedule,103% of TX Medicaid Rate,17.27,103,,,Fee Schedule,103% of CMS OPPS Rate,17.27,103,,,Fee Schedule,103% of CMS OPPS Rate,144.75,75,,127.096,Percent of Total Billed Charges,75% of Total Billed Charges,28.5,80,,2414.04,Fee Schedule,80% of Scott and White EPO fee schedule,28.5,80,,1573.072,Fee Schedule,80% of Scott and White HMO fee schedule,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,170,,1573.072,Fee Schedule,170% of Scott and White PPO fee schedule,28.5,170,,680.8,Fee Schedule,170% of Scott and White SWHP fee schedule,25.15,150,,,Fee Schedule,150% of CMS OPPS Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.58,90,,336,Fee Schedule,90% of UHC fee schedule,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.09,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,193,100,,169.464,Percent of Total Billed Charges,100% of Total Billed Charges,13.58,193,
AMIKACIN,41021262,CDM,301,RC,80150,HCPCS,Outpatient,,,180,108.00,,17.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,22.62,150,,870.272,Fee Schedule ,150% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,280,,469.728,Fee Schedule,280% of BCBS BULE Fee Schedule,48.26,320,,676.512,Fee Schedule,320% of BCBS Blue Essentials Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,54.29,360,,603.936,Fee Schedule,360% of BCBS POS Rate,54.29,360,,603.936,Fee schedule,360% of BCBS PPO Rate,54.29,360,,603.936,Fee Schedule,360% of BCBS Traditional Rate,108,60,,599.672,Percent of Total Billed Charges,60% of Total Billed Charges,12.67,100,,1700.88,Fee Schedule,100% of TX Mediciad 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,,3098.832,Fee Schedule,100% of CMS OPPS Rate,13.57,90,,,Fee Schedule,90% of CMS OPPS Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,130,,,Fee Schedule,130% of CMS OPPS Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,13.05,103,,1751.912,Fee Schedule,103% of TX Medicaid Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,135,75,,49.568,Percent of Total Billed Charges,75% of Total Billed Charges,25.63,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,25.63,80,,1573.072,Fee Schedule,80% of Scott and White HMO fee schedule,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,25.63,170,,1573.072,Fee Schedule,170% of Scott and White PPO fee schedule,25.63,170,,2729.6,Fee Schedule,170% of Scott and White SWHP fee schedule,22.62,150,,,Fee Schedule,150% of CMS OPPS Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.21,90,,352.8,Fee Schedule,90% of UHC fee schedule,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,180,100,,66.088,Percent of Total Billed Charges,100% of Total Billed Charges,12.21,180,
THEOPHYLLINE,41021379,CDM,301,RC,80198,HCPCS,Outpatient,,,218.84,131.30,,16.4,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.21,150,,3558.64,Fee Schedule ,150% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,39.59,280,,469.728,Fee Schedule,280% of BCBS BULE Fee Schedule,45.25,320,,676.512,Fee Schedule,320% of BCBS Blue Essentials Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,50.9,360,,603.936,Fee Schedule,360% of BCBS POS Rate,50.9,360,,603.936,Fee schedule,360% of BCBS PPO Rate,50.9,360,,603.936,Fee Schedule,360% of BCBS Traditional Rate,131.3,60,,336,Percent of Total Billed Charges,60% of Total Billed Charges,11.88,100,,1700.88,Fee Schedule,100% of TX Mediciad 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,,2974.624,Fee Schedule,100% of CMS OPPS Rate,12.72,90,,,Fee Schedule,90% of CMS OPPS Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.38,130,,,Fee Schedule,130% of CMS OPPS Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,103,,1751.912,Fee Schedule,103% of TX Medicaid Rate,14.56,103,,,Fee Schedule,103% of CMS OPPS Rate,14.56,103,,,Fee Schedule,103% of CMS OPPS Rate,164.13,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,24.03,80,,1573.072,Fee Schedule,80% of Scott and White EPO fee schedule,24.03,80,,1750,Fee Schedule,80% of Scott and White HMO fee schedule,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,24.03,170,,1750,Fee Schedule,170% of Scott and White PPO fee schedule,24.03,170,,2414.04,Fee Schedule,170% of Scott and White SWHP fee schedule,21.21,150,,,Fee Schedule,150% of CMS OPPS Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11.46,90,,495.6,Fee Schedule,90% of UHC fee schedule,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,218.84,100,,75.2,Percent of Total Billed Charges,100% of Total Billed Charges,11.46,218.84,
AMMONIA,41021403,CDM,301,RC,82140,HCPCS,Outpatient,,,195,117.00,,16.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.85,150,,2711.344,Fee Schedule ,150% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.8,280,,469.728,Fee Schedule,280% of BCBS BULE Fee Schedule,46.62,320,,677.192,Fee Schedule,320% of BCBS Blue Essentials Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,52.45,360,,603.936,Fee Schedule,360% of BCBS POS Rate,52.45,360,,603.936,Fee schedule,360% of BCBS PPO Rate,52.45,360,,603.936,Fee Schedule,360% of BCBS Traditional Rate,117,60,,121.696,Percent of Total Billed Charges,60% of Total Billed Charges,12.24,100,,1700.88,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,13.11,90,,,Fee Schedule,90% of CMS OPPS Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.94,130,,,Fee Schedule,130% of CMS OPPS Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.61,103,,1751.912,Fee Schedule,103% of TX Medicaid Rate,15,103,,,Fee Schedule,103% of CMS OPPS Rate,15,103,,,Fee Schedule,103% of CMS OPPS Rate,146.25,75,,152.4,Percent of Total Billed Charges,75% of Total Billed Charges,24.76,80,,1573.072,Fee Schedule,80% of Scott and White EPO fee schedule,24.76,80,,1031.6,Fee Schedule,80% of Scott and White HMO fee schedule,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.76,170,,1031.6,Fee Schedule,170% of Scott and White PPO fee schedule,24.76,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,21.85,150,,,Fee Schedule,150% of CMS OPPS Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.8,90,,65.52,Fee Schedule,90% of UHC fee schedule,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,1700.88,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,195,100,,203.2,Percent of Total Billed Charges,100% of Total Billed Charges,11.8,195,
AMYLASE,41021502,CDM,301,RC,82150,HCPCS,Outpatient,,,148.09,88.85,,7.52,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.72,150,,1394.472,Fee Schedule ,150% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,20.74,320,,677.6,Fee Schedule,320% of BCBS Blue Essentials Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,23.33,360,,648,Fee Schedule,360% of BCBS POS Rate,23.33,360,,648,Fee schedule,360% of BCBS PPO Rate,23.33,360,,648,Fee Schedule,360% of BCBS Traditional Rate,88.85,60,,1804.504,Percent of Total Billed Charges,60% of Total Billed Charges,5.44,100,,1516.704,Fee Schedule,100% of TX Mediciad 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,,1933.936,Fee Schedule,100% of CMS OPPS Rate,5.83,90,,,Fee Schedule,90% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,8.42,130,,,Fee Schedule,130% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.6,103,,1562.208,Fee Schedule,103% of TX Medicaid Rate,6.67,103,,,Fee Schedule,103% of CMS OPPS Rate,6.67,103,,,Fee Schedule,103% of CMS OPPS Rate,111.07,75,,91.456,Percent of Total Billed Charges,75% of Total Billed Charges,11.01,80,,1750,Fee Schedule,80% of Scott and White EPO fee schedule,11.01,80,,1031.6,Fee Schedule,80% of Scott and White HMO fee schedule,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,170,,1031.6,Fee Schedule,170% of Scott and White PPO fee schedule,11.01,170,,1573.072,Fee Schedule,170% of Scott and White SWHP fee schedule,9.72,150,,,Fee Schedule,150% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.25,90,,2386.72,Fee Schedule,90% of UHC fee schedule,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,148.09,100,,121.936,Percent of Total Billed Charges,100% of Total Billed Charges,5.25,148.09,
AMYLASE BF,41021544,CDM,301,RC,82150,HCPCS,Outpatient,,,148.09,88.85,,7.52,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.72,150,,1338.584,Fee Schedule ,150% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,20.74,320,,681.176,Fee Schedule,320% of BCBS Blue Essentials Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,23.33,360,,43.2,Fee Schedule,360% of BCBS POS Rate,23.33,360,,43.2,Fee schedule,360% of BCBS PPO Rate,23.33,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,88.85,60,,3219.84,Percent of Total Billed Charges,60% of Total Billed Charges,5.44,100,,1516.704,Fee Schedule,100% of TX Mediciad 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,,7908.08,Fee Schedule,100% of CMS OPPS Rate,5.83,90,,,Fee Schedule,90% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,8.42,130,,,Fee Schedule,130% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.6,103,,1562.208,Fee Schedule,103% of TX Medicaid Rate,6.67,103,,,Fee Schedule,103% of CMS OPPS Rate,6.67,103,,,Fee Schedule,103% of CMS OPPS Rate,111.07,75,,139.184,Percent of Total Billed Charges,75% of Total Billed Charges,11.01,80,,1031.6,Fee Schedule,80% of Scott and White EPO fee schedule,11.01,80,,3165.792,Fee Schedule,80% of Scott and White HMO fee schedule,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,170,,3165.792,Fee Schedule,170% of Scott and White PPO fee schedule,11.01,170,,1573.072,Fee Schedule,170% of Scott and White SWHP fee schedule,9.72,150,,,Fee Schedule,150% of CMS OPPS Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.25,90,,212.8,Fee Schedule,90% of UHC fee schedule,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.44,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,148.09,100,,185.576,Percent of Total Billed Charges,100% of Total Billed Charges,5.25,148.09,
BILIRUBIN TOTAL,41022500,CDM,301,RC,82247,HCPCS,Outpatient,,,74.72,44.83,,5.82,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.52,150,,1579.32,Fee Schedule ,150% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,14.06,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,16.06,320,,681.176,Fee Schedule,320% of BCBS Blue Essentials Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,18.07,360,,648,Fee Schedule,360% of BCBS POS Rate,18.07,360,,648,Fee schedule,360% of BCBS PPO Rate,18.07,360,,648,Fee Schedule,360% of BCBS Traditional Rate,44.83,60,,190.728,Percent of Total Billed Charges,60% of Total Billed Charges,4.22,100,,1516.704,Fee Schedule,100% of TX Mediciad 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,,6025.208,Fee Schedule,100% of CMS OPPS Rate,4.51,90,,,Fee Schedule,90% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,130,,,Fee Schedule,130% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.35,103,,1562.208,Fee Schedule,103% of TX Medicaid Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,56.04,75,,55.192,Percent of Total Billed Charges,75% of Total Billed Charges,8.53,80,,1031.6,Fee Schedule,80% of Scott and White EPO fee schedule,8.53,80,,733.864,Fee Schedule,80% of Scott and White HMO fee schedule,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,8.53,170,,733.864,Fee Schedule,170% of Scott and White PPO fee schedule,8.53,170,,1750,Fee Schedule,170% of Scott and White SWHP fee schedule,7.52,150,,,Fee Schedule,150% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.07,90,,1538.448,Fee Schedule,90% of UHC fee schedule,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.72,100,,73.584,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,74.72,
BILIRUBIN DIRECT,41022534,CDM,301,RC,82248,HCPCS,Outpatient,,,91.98,55.19,,5.82,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.52,150,,1394.472,Fee Schedule ,150% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,14.06,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,16.06,320,,681.176,Fee Schedule,320% of BCBS Blue Essentials Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,18.07,360,,648,Fee Schedule,360% of BCBS POS Rate,18.07,360,,648,Fee schedule,360% of BCBS PPO Rate,18.07,360,,648,Fee Schedule,360% of BCBS Traditional Rate,55.19,60,,138.224,Percent of Total Billed Charges,60% of Total Billed Charges,4.22,100,,1516.704,Fee Schedule,100% of TX Mediciad 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,,3098.832,Fee Schedule,100% of CMS OPPS Rate,4.51,90,,,Fee Schedule,90% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,130,,,Fee Schedule,130% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.35,103,,1562.208,Fee Schedule,103% of TX Medicaid Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,5.17,103,,,Fee Schedule,103% of CMS OPPS Rate,68.99,75,,57.496,Percent of Total Billed Charges,75% of Total Billed Charges,8.53,80,,3165.792,Fee Schedule,80% of Scott and White EPO fee schedule,8.53,80,,1635.6,Fee Schedule,80% of Scott and White HMO fee schedule,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,8.53,170,,1635.6,Fee Schedule,170% of Scott and White PPO fee schedule,8.53,170,,1031.6,Fee Schedule,170% of Scott and White SWHP fee schedule,7.52,150,,,Fee Schedule,150% of CMS OPPS Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.07,90,,1083.944,Fee Schedule,90% of UHC fee schedule,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,4.22,100,,1516.704,Fee Schedule,100% of TX Medicaid Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,91.98,100,,76.664,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,91.98,
OCCULT BLD QL OTHER SOURCES,41022757,CDM,301,RC,82271,HCPCS,Outpatient,,,63,37.80,,6.18,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.98,150,,1394.472,Fee Schedule ,150% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,17.02,320,,681.176,Fee Schedule,320% of BCBS Blue Essentials Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,19.15,360,,648,Fee Schedule,360% of BCBS POS Rate,19.15,360,,648,Fee schedule,360% of BCBS PPO Rate,19.15,360,,648,Fee Schedule,360% of BCBS Traditional Rate,37.8,60,,136.688,Percent of Total Billed Charges,60% of Total Billed Charges,4.47,100,,2969.448,Fee Schedule,100% of TX Mediciad 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,,2974.624,Fee Schedule,100% of CMS OPPS Rate,4.78,90,,,Fee Schedule,90% of CMS OPPS Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,6.91,130,,,Fee Schedule,130% of CMS OPPS Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.6,103,,3058.528,Fee Schedule,103% of TX Medicaid Rate,5.47,103,,,Fee Schedule,103% of CMS OPPS Rate,5.47,103,,,Fee Schedule,103% of CMS OPPS Rate,47.25,75,,546.48,Percent of Total Billed Charges,75% of Total Billed Charges,9.04,80,,733.864,Fee Schedule,80% of Scott and White EPO fee schedule,9.04,80,,1635.6,Fee Schedule,80% of Scott and White HMO fee schedule,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,170,,1635.6,Fee Schedule,170% of Scott and White PPO fee schedule,9.04,170,,1031.6,Fee Schedule,170% of Scott and White SWHP fee schedule,7.98,150,,,Fee Schedule,150% of CMS OPPS Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4.31,90,,1262.24,Fee Schedule,90% of UHC fee schedule,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.47,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,63,100,,728.64,Percent of Total Billed Charges,100% of Total Billed Charges,4.31,63,
CALCIUM TOTAL,41023102,CDM,301,RC,82310,HCPCS,Outpatient,,,74.72,44.83,,5.98,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.74,150,,1338.584,Fee Schedule ,150% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,280,,51.52,Fee Schedule,280% of BCBS BULE Fee Schedule,16.51,320,,682.104,Fee Schedule,320% of BCBS Blue Essentials Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,18.58,360,,66.24,Fee Schedule,360% of BCBS POS Rate,18.58,360,,66.24,Fee schedule,360% of BCBS PPO Rate,18.58,360,,66.24,Fee Schedule,360% of BCBS Traditional Rate,44.83,60,,79.68,Percent of Total Billed Charges,60% of Total Billed Charges,4.33,100,,2969.448,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,4.64,90,,,Fee Schedule,90% of CMS OPPS Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,130,,,Fee Schedule,130% of CMS OPPS Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.46,103,,3058.528,Fee Schedule,103% of TX Medicaid Rate,5.31,103,,,Fee Schedule,103% of CMS OPPS Rate,5.31,103,,,Fee Schedule,103% of CMS OPPS Rate,56.04,75,,66.992,Percent of Total Billed Charges,75% of Total Billed Charges,8.77,80,,1635.6,Fee Schedule,80% of Scott and White EPO fee schedule,8.77,80,,3421.424,Fee Schedule,80% of Scott and White HMO fee schedule,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,170,,3421.424,Fee Schedule,170% of Scott and White PPO fee schedule,8.77,170,,3165.792,Fee Schedule,170% of Scott and White SWHP fee schedule,7.74,150,,,Fee Schedule,150% of CMS OPPS Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,90,,1262.24,Fee Schedule,90% of UHC fee schedule,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,4.33,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.72,100,,89.32,Percent of Total Billed Charges,100% of Total Billed Charges,4.18,74.72,
CALCIUM IONIZED,41023300,CDM,301,RC,82330,HCPCS,Outpatient,,,186,111.60,,15.86,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.52,150,,1338.584,Fee Schedule ,150% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,38.3,280,,514.28,Fee Schedule,280% of BCBS BULE Fee Schedule,43.78,320,,682.24,Fee Schedule,320% of BCBS Blue Essentials Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,49.25,360,,661.216,Fee Schedule,360% of BCBS POS Rate,49.25,360,,661.216,Fee schedule,360% of BCBS PPO Rate,49.25,360,,661.216,Fee Schedule,360% of BCBS Traditional Rate,111.6,60,,1084.104,Percent of Total Billed Charges,60% of Total Billed Charges,11.49,100,,2969.448,Fee Schedule,100% of TX Mediciad 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,,3098.832,Fee Schedule,100% of CMS OPPS Rate,12.31,90,,,Fee Schedule,90% of CMS OPPS Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,17.78,130,,,Fee Schedule,130% of CMS OPPS Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.83,103,,3058.528,Fee Schedule,103% of TX Medicaid Rate,14.09,103,,,Fee Schedule,103% of CMS OPPS Rate,14.09,103,,,Fee Schedule,103% of CMS OPPS Rate,139.5,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,23.25,80,,1635.6,Fee Schedule,80% of Scott and White EPO fee schedule,23.25,80,,4505.4,Fee Schedule,80% of Scott and White HMO fee schedule,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,23.25,170,,4505.4,Fee Schedule,170% of Scott and White PPO fee schedule,23.25,170,,733.864,Fee Schedule,170% of Scott and White SWHP fee schedule,20.52,150,,,Fee Schedule,150% of CMS OPPS Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,90,,7280,Fee Schedule,90% of UHC fee schedule,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,11.49,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,186,100,,68,Percent of Total Billed Charges,100% of Total Billed Charges,11.08,186,
CALCIUM URINE QT,41023409,CDM,301,RC,82340,HCPCS,Outpatient,,,103.95,62.37,,7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.04,150,,1579.32,Fee Schedule ,150% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.88,280,,2035.488,Fee Schedule,280% of BCBS BULE Fee Schedule,19.3,320,,683.024,Fee Schedule,320% of BCBS Blue Essentials Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,21.71,360,,2617.056,Fee Schedule,360% of BCBS POS Rate,21.71,360,,2617.056,Fee schedule,360% of BCBS PPO Rate,21.71,360,,2617.056,Fee Schedule,360% of BCBS Traditional Rate,62.37,60,,441.336,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,100,,2969.448,Fee Schedule,100% of TX Mediciad 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,,3098.832,Fee Schedule,100% of CMS OPPS Rate,5.42,90,,,Fee Schedule,90% of CMS OPPS Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,7.83,130,,,Fee Schedule,130% of CMS OPPS Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.22,103,,3058.528,Fee Schedule,103% of TX Medicaid Rate,6.21,103,,,Fee Schedule,103% of CMS OPPS Rate,6.21,103,,,Fee Schedule,103% of CMS OPPS Rate,77.96,75,,62.848,Percent of Total Billed Charges,75% of Total Billed Charges,10.25,80,,3421.424,Fee Schedule,80% of Scott and White EPO fee schedule,10.25,80,,963.184,Fee Schedule,80% of Scott and White HMO fee schedule,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.25,170,,963.184,Fee Schedule,170% of Scott and White PPO fee schedule,10.25,170,,1635.6,Fee Schedule,170% of Scott and White SWHP fee schedule,9.04,150,,,Fee Schedule,150% of CMS OPPS Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,4.89,90,,6115.2,Fee Schedule,90% of UHC fee schedule,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,100,,83.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.89,103.95,
TEGRETOL (CARBAM) TOTAL,41023722,CDM,301,RC,80156,HCPCS,Outpatient,,,218,130.80,,16.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.85,150,,1579.32,Fee Schedule ,150% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.8,280,,563.776,Fee Schedule,280% of BCBS BULE Fee Schedule,46.62,320,,683.024,Fee Schedule,320% of BCBS Blue Essentials Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,52.45,360,,724.856,Fee Schedule,360% of BCBS POS Rate,52.45,360,,724.856,Fee schedule,360% of BCBS PPO Rate,52.45,360,,724.856,Fee Schedule,360% of BCBS Traditional Rate,130.8,60,,972.72,Percent of Total Billed Charges,60% of Total Billed Charges,12.24,100,,2969.448,Fee Schedule,100% of TX Mediciad 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,,2974.624,Fee Schedule,100% of CMS OPPS Rate,13.11,90,,,Fee Schedule,90% of CMS OPPS Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.94,130,,,Fee Schedule,130% of CMS OPPS Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.61,103,,3058.528,Fee Schedule,103% of TX Medicaid Rate,15,103,,,Fee Schedule,103% of CMS OPPS Rate,15,103,,,Fee Schedule,103% of CMS OPPS Rate,163.5,75,,56.344,Percent of Total Billed Charges,75% of Total Billed Charges,24.76,80,,4505.4,Fee Schedule,80% of Scott and White EPO fee schedule,24.76,80,,491.84,Fee Schedule,80% of Scott and White HMO fee schedule,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.76,170,,491.84,Fee Schedule,170% of Scott and White PPO fee schedule,24.76,170,,1635.6,Fee Schedule,170% of Scott and White SWHP fee schedule,21.85,150,,,Fee Schedule,150% of CMS OPPS Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.8,90,,15120,Fee Schedule,90% of UHC fee schedule,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,12.24,100,,2969.448,Fee Schedule,100% of TX Medicaid Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,218,100,,75.128,Percent of Total Billed Charges,100% of Total Billed Charges,11.8,218,
CO2 CONTENT,41023748,CDM,301,RC,82374,HCPCS,Outpatient,,,70.91,42.55,,5.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.32,150,,1711.704,Fee Schedule ,150% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,15.62,320,,686.272,Fee Schedule,320% of BCBS Blue Essentials Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,17.57,360,,172.8,Fee Schedule,360% of BCBS POS Rate,17.57,360,,172.8,Fee schedule,360% of BCBS PPO Rate,17.57,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,42.55,60,,1492.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.1,100,,2679.328,Fee Schedule,100% of TX Mediciad 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,,2974.624,Fee Schedule,100% of CMS OPPS Rate,4.39,90,,,Fee Schedule,90% of CMS OPPS Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,6.34,130,,,Fee Schedule,130% of CMS OPPS Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.22,103,,2759.704,Fee Schedule,103% of TX Medicaid Rate,5.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5.02,103,,,Fee Schedule,103% of CMS OPPS Rate,53.18,75,,140.16,Percent of Total Billed Charges,75% of Total Billed Charges,8.29,80,,963.184,Fee Schedule,80% of Scott and White EPO fee schedule,8.29,80,,86.904,Fee Schedule,80% of Scott and White HMO fee schedule,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,8.29,170,,86.904,Fee Schedule,170% of Scott and White PPO fee schedule,8.29,170,,3421.424,Fee Schedule,170% of Scott and White SWHP fee schedule,7.32,150,,,Fee Schedule,150% of CMS OPPS Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,90,,4651.92,Fee Schedule,90% of UHC fee schedule,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.1,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,70.91,100,,186.88,Percent of Total Billed Charges,100% of Total Billed Charges,3.95,70.91,
CHLORIDE URINE,41024365,CDM,301,RC,82436,HCPCS,Outpatient,,,85,51.00,,6.68,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.62,150,,2372.424,Fee Schedule ,150% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,280,,141.12,Fee Schedule,280% of BCBS BULE Fee Schedule,18.4,320,,688.44,Fee Schedule,320% of BCBS Blue Essentials Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,20.7,360,,181.44,Fee Schedule,360% of BCBS POS Rate,20.7,360,,181.44,Fee schedule,360% of BCBS PPO Rate,20.7,360,,181.44,Fee Schedule,360% of BCBS Traditional Rate,51,60,,1906.048,Percent of Total Billed Charges,60% of Total Billed Charges,4.83,100,,2679.328,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,5.17,90,,,Fee Schedule,90% of CMS OPPS Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,130,,,Fee Schedule,130% of CMS OPPS Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.97,103,,2759.704,Fee Schedule,103% of TX Medicaid Rate,5.92,103,,,Fee Schedule,103% of CMS OPPS Rate,5.92,103,,,Fee Schedule,103% of CMS OPPS Rate,63.75,75,,119.808,Percent of Total Billed Charges,75% of Total Billed Charges,9.77,80,,491.84,Fee Schedule,80% of Scott and White EPO fee schedule,9.77,80,,54.8,Fee Schedule,80% of Scott and White HMO fee schedule,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,170,,54.8,Fee Schedule,170% of Scott and White PPO fee schedule,9.77,170,,4505.4,Fee Schedule,170% of Scott and White SWHP fee schedule,8.62,150,,,Fee Schedule,150% of CMS OPPS Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,876.96,Fee Schedule,90% of UHC fee schedule,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.83,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,85,100,,159.744,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,85,
CHLORIDE BLOOD,41024399,CDM,301,RC,82435,HCPCS,Outpatient,,,75.25,45.15,,5.34,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.9,150,,889.2,Fee Schedule ,150% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,280,,198.24,Fee Schedule,280% of BCBS BULE Fee Schedule,14.72,320,,688.44,Fee Schedule,320% of BCBS Blue Essentials Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,16.56,360,,254.88,Fee Schedule,360% of BCBS POS Rate,16.56,360,,254.88,Fee schedule,360% of BCBS PPO Rate,16.56,360,,254.88,Fee Schedule,360% of BCBS Traditional Rate,45.15,60,,852.152,Percent of Total Billed Charges,60% of Total Billed Charges,3.86,100,,2679.328,Fee Schedule,100% of TX Mediciad 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,,3509.6,Fee Schedule,100% of CMS OPPS Rate,4.13,90,,,Fee Schedule,90% of CMS OPPS Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,130,,,Fee Schedule,130% of CMS OPPS Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.98,103,,2759.704,Fee Schedule,103% of TX Medicaid Rate,4.73,103,,,Fee Schedule,103% of CMS OPPS Rate,4.73,103,,,Fee Schedule,103% of CMS OPPS Rate,56.44,75,,36.992,Percent of Total Billed Charges,75% of Total Billed Charges,7.81,80,,86.904,Fee Schedule,80% of Scott and White EPO fee schedule,7.81,80,,493.144,Fee Schedule,80% of Scott and White HMO fee schedule,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,170,,493.144,Fee Schedule,170% of Scott and White PPO fee schedule,7.81,170,,963.184,Fee Schedule,170% of Scott and White SWHP fee schedule,6.9,150,,,Fee Schedule,150% of CMS OPPS Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3.73,90,,259.84,Fee Schedule,90% of UHC fee schedule,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.86,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,75.25,100,,49.32,Percent of Total Billed Charges,100% of Total Billed Charges,3.73,75.25,
CHOLESTEROL TOTAL,41024654,CDM,301,RC,82465,HCPCS,Outpatient,,,95.83,57.50,,5.04,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.52,150,,889.2,Fee Schedule ,150% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,12.18,280,,26.208,Fee Schedule,280% of BCBS BULE Fee Schedule,13.92,320,,688.832,Fee Schedule,320% of BCBS Blue Essentials Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,15.66,360,,33.696,Fee Schedule,360% of BCBS POS Rate,15.66,360,,33.696,Fee schedule,360% of BCBS PPO Rate,15.66,360,,33.696,Fee Schedule,360% of BCBS Traditional Rate,57.5,60,,59.264,Percent of Total Billed Charges,60% of Total Billed Charges,3.65,100,,2679.328,Fee Schedule,100% of TX Mediciad 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,,3803.792,Fee Schedule,100% of CMS OPPS Rate,3.91,90,,,Fee Schedule,90% of CMS OPPS Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,5.65,130,,,Fee Schedule,130% of CMS OPPS Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.76,103,,2759.704,Fee Schedule,103% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of CMS OPPS Rate,4.48,103,,,Fee Schedule,103% of CMS OPPS Rate,71.87,75,,34.648,Percent of Total Billed Charges,75% of Total Billed Charges,7.39,80,,54.8,Fee Schedule,80% of Scott and White EPO fee schedule,7.39,80,,871.112,Fee Schedule,80% of Scott and White HMO fee schedule,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,7.39,170,,871.112,Fee Schedule,170% of Scott and White PPO fee schedule,7.39,170,,491.84,Fee Schedule,170% of Scott and White SWHP fee schedule,6.52,150,,,Fee Schedule,150% of CMS OPPS Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,4123.392,Fee Schedule,90% of UHC fee schedule,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,3.65,100,,2679.328,Fee Schedule,100% of TX Medicaid Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,95.83,100,,46.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.53,95.83,
CORTISOL TOTAL,41025339,CDM,301,RC,82533,HCPCS,Outpatient,,,221.5,132.90,,18.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,24.45,150,,1002.776,Fee Schedule ,150% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,45.64,280,,954.688,Fee Schedule,280% of BCBS BULE Fee Schedule,52.16,320,,691.712,Fee Schedule,320% of BCBS Blue Essentials Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,58.68,360,,1227.456,Fee Schedule,360% of BCBS POS Rate,58.68,360,,1227.456,Fee schedule,360% of BCBS PPO Rate,58.68,360,,1227.456,Fee Schedule,360% of BCBS Traditional Rate,132.9,60,,59.264,Percent of Total Billed Charges,60% of Total Billed Charges,13.69,100,,3019.76,Fee Schedule,100% of TX Mediciad 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,,5272.056,Fee Schedule,100% of CMS OPPS Rate,14.67,90,,,Fee Schedule,90% of CMS OPPS Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.19,130,,,Fee Schedule,130% of CMS OPPS Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,14.1,103,,3110.352,Fee Schedule,103% of TX Medicaid Rate,16.78,103,,,Fee Schedule,103% of CMS OPPS Rate,16.78,103,,,Fee Schedule,103% of CMS OPPS Rate,166.13,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,27.71,80,,493.144,Fee Schedule,80% of Scott and White EPO fee schedule,27.71,80,,10611.192,Fee Schedule,80% of Scott and White HMO fee schedule,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,170,,10611.192,Fee Schedule,170% of Scott and White PPO fee schedule,27.71,170,,86.904,Fee Schedule,170% of Scott and White SWHP fee schedule,24.45,150,,,Fee Schedule,150% of CMS OPPS Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,90,,4755.296,Fee Schedule,90% of UHC fee schedule,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,13.69,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,221.5,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,13.2,221.5,
CREATINE KINASE,41025503,CDM,301,RC,82550,HCPCS,Outpatient,,,142,85.20,,7.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.76,150,,1002.776,Fee Schedule ,150% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,18.23,280,,85.12,Fee Schedule,280% of BCBS BULE Fee Schedule,20.83,320,,693.864,Fee Schedule,320% of BCBS Blue Essentials Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,23.44,360,,109.44,Fee Schedule,360% of BCBS POS Rate,23.44,360,,109.44,Fee schedule,360% of BCBS PPO Rate,23.44,360,,109.44,Fee Schedule,360% of BCBS Traditional Rate,85.2,60,,1529.28,Percent of Total Billed Charges,60% of Total Billed Charges,5.47,100,,3019.76,Fee Schedule,100% of TX Mediciad 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,,1976,Fee Schedule,100% of CMS OPPS Rate,5.85,90,,,Fee Schedule,90% of CMS OPPS Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,130,,,Fee Schedule,130% of CMS OPPS Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.63,103,,3110.352,Fee Schedule,103% of TX Medicaid Rate,6.7,103,,,Fee Schedule,103% of CMS OPPS Rate,6.7,103,,,Fee Schedule,103% of CMS OPPS Rate,106.5,75,,55.2,Percent of Total Billed Charges,75% of Total Billed Charges,11.06,80,,871.112,Fee Schedule,80% of Scott and White EPO fee schedule,11.06,80,,86.904,Fee Schedule,80% of Scott and White HMO fee schedule,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,170,,86.904,Fee Schedule,170% of Scott and White PPO fee schedule,11.06,170,,54.8,Fee Schedule,170% of Scott and White SWHP fee schedule,9.76,150,,,Fee Schedule,150% of CMS OPPS Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,90,,5706.064,Fee Schedule,90% of UHC fee schedule,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,5.47,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,142,100,,73.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.27,142,
CREATINE KINASE MB FRACT ONLY,41025537,CDM,301,RC,82553,HCPCS,Outpatient,,,237.02,142.21,,13.4,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,17.32,150,,308.64,Fee Schedule ,150% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,32.34,280,,615.376,Fee Schedule,280% of BCBS BULE Fee Schedule,36.96,320,,693.864,Fee Schedule,320% of BCBS Blue Essentials Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,41.58,360,,791.2,Fee Schedule,360% of BCBS POS Rate,41.58,360,,791.2,Fee schedule,360% of BCBS PPO Rate,41.58,360,,791.2,Fee Schedule,360% of BCBS Traditional Rate,142.21,60,,446.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.7,100,,3019.76,Fee Schedule,100% of TX Mediciad 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,,1976,Fee Schedule,100% of CMS OPPS Rate,10.39,90,,,Fee Schedule,90% of CMS OPPS Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.01,130,,,Fee Schedule,130% of CMS OPPS Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.99,103,,3110.352,Fee Schedule,103% of TX Medicaid Rate,11.89,103,,,Fee Schedule,103% of CMS OPPS Rate,11.89,103,,,Fee Schedule,103% of CMS OPPS Rate,177.77,75,,61.352,Percent of Total Billed Charges,75% of Total Billed Charges,19.63,80,,10611.192,Fee Schedule,80% of Scott and White EPO fee schedule,19.63,80,,1846.176,Fee Schedule,80% of Scott and White HMO fee schedule,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,170,,1846.176,Fee Schedule,170% of Scott and White PPO fee schedule,19.63,170,,493.144,Fee Schedule,170% of Scott and White SWHP fee schedule,17.32,150,,,Fee Schedule,150% of CMS OPPS Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,90,,352.8,Fee Schedule,90% of UHC fee schedule,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,9.7,100,,3019.76,Fee Schedule,100% of TX Medicaid Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,237.02,100,,81.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.36,237.02,
CREATININE BLOOD,41025651,CDM,301,RC,82565,HCPCS,Outpatient,,,89,53.40,,5.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.68,150,,2457.72,Fee Schedule ,150% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,280,,433.576,Fee Schedule,280% of BCBS BULE Fee Schedule,16.38,320,,694.784,Fee Schedule,320% of BCBS Blue Essentials Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,18.43,360,,557.456,Fee Schedule,360% of BCBS POS Rate,18.43,360,,557.456,Fee schedule,360% of BCBS PPO Rate,18.43,360,,557.456,Fee Schedule,360% of BCBS Traditional Rate,53.4,60,,789.84,Percent of Total Billed Charges,60% of Total Billed Charges,4.3,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,2228.384,Fee Schedule,100% of CMS OPPS Rate,4.6,90,,,Fee Schedule,90% of CMS OPPS Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,6.65,130,,,Fee Schedule,130% of CMS OPPS Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.43,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,5.27,103,,,Fee Schedule,103% of CMS OPPS Rate,5.27,103,,,Fee Schedule,103% of CMS OPPS Rate,66.75,75,,125.592,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,80,,86.904,Fee Schedule,80% of Scott and White EPO fee schedule,8.7,80,,1846.176,Fee Schedule,80% of Scott and White HMO fee schedule,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,170,,1846.176,Fee Schedule,170% of Scott and White PPO fee schedule,8.7,170,,871.112,Fee Schedule,170% of Scott and White SWHP fee schedule,7.68,150,,,Fee Schedule,150% of CMS OPPS Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,90,,84,Fee Schedule,90% of UHC fee schedule,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,89,100,,167.456,Percent of Total Billed Charges,100% of Total Billed Charges,4.15,89,
CREATININE URINE,41025735,CDM,301,RC,82570,HCPCS,Outpatient,,,99.57,59.74,,6,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,1211.872,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,504.896,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,695.376,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,649.152,Fee Schedule,360% of BCBS POS Rate,18.65,360,,649.152,Fee schedule,360% of BCBS PPO Rate,18.65,360,,649.152,Fee Schedule,360% of BCBS Traditional Rate,59.74,60,,1478.88,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,2228.384,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,74.68,75,,102.688,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,1846.176,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,1458.24,Fee Schedule,90% of UHC fee schedule,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,99.57,100,,136.92,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,99.57,
CREATININE CLEARANCE,41025750,CDM,301,RC,82575,HCPCS,Outpatient,,,203.89,122.33,,10.98,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,14.19,150,,2432.928,Fee Schedule ,150% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,26.49,280,,504.896,Fee Schedule,280% of BCBS BULE Fee Schedule,30.27,320,,696.072,Fee Schedule,320% of BCBS Blue Essentials Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,34.06,360,,649.152,Fee Schedule,360% of BCBS POS Rate,34.06,360,,649.152,Fee schedule,360% of BCBS PPO Rate,34.06,360,,649.152,Fee Schedule,360% of BCBS Traditional Rate,122.33,60,,1104.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.95,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,685.864,Fee Schedule,100% of CMS OPPS Rate,8.51,90,,,Fee Schedule,90% of CMS OPPS Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,130,,,Fee Schedule,130% of CMS OPPS Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,8.19,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,9.74,103,,,Fee Schedule,103% of CMS OPPS Rate,9.74,103,,,Fee Schedule,103% of CMS OPPS Rate,152.92,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,16.08,80,,1846.176,Fee Schedule,80% of Scott and White EPO fee schedule,16.08,80,,3165.792,Fee Schedule,80% of Scott and White HMO fee schedule,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.08,170,,3165.792,Fee Schedule,170% of Scott and White PPO fee schedule,16.08,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,14.19,150,,,Fee Schedule,150% of CMS OPPS Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7.66,90,,1820,Fee Schedule,90% of UHC fee schedule,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,203.89,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,7.66,203.89,
CYANOCOBALAMIN VIT B12,41026113,CDM,301,RC,82607,HCPCS,Outpatient,,,192.5,115.50,,17.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,22.62,150,,2173.848,Fee Schedule ,150% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,280,,2912,Fee Schedule,280% of BCBS BULE Fee Schedule,48.26,320,,696.072,Fee Schedule,320% of BCBS Blue Essentials Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,54.29,360,,3744,Fee Schedule,360% of BCBS POS Rate,54.29,360,,3744,Fee schedule,360% of BCBS PPO Rate,54.29,360,,3744,Fee Schedule,360% of BCBS Traditional Rate,115.5,60,,816.96,Percent of Total Billed Charges,60% of Total Billed Charges,12.67,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,5461.6,Fee Schedule,100% of CMS OPPS Rate,13.57,90,,,Fee Schedule,90% of CMS OPPS Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,130,,,Fee Schedule,130% of CMS OPPS Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.05,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,144.38,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,25.63,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,25.63,80,,3165.792,Fee Schedule,80% of Scott and White HMO fee schedule,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,25.63,170,,3165.792,Fee Schedule,170% of Scott and White PPO fee schedule,25.63,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,22.62,150,,,Fee Schedule,150% of CMS OPPS Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.21,90,,1285.76,Fee Schedule,90% of UHC fee schedule,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,192.5,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,12.21,192.5,
DIGOXIN,41026436,CDM,301,RC,80162,HCPCS,Outpatient,,,189,113.40,,15.4,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.92,150,,1219.712,Fee Schedule ,150% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.18,280,,2446.08,Fee Schedule,280% of BCBS BULE Fee Schedule,42.5,320,,698.88,Fee Schedule,320% of BCBS Blue Essentials Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,47.81,360,,3144.96,Fee Schedule,360% of BCBS POS Rate,47.81,360,,3144.96,Fee schedule,360% of BCBS PPO Rate,47.81,360,,3144.96,Fee Schedule,360% of BCBS Traditional Rate,113.4,60,,530.336,Percent of Total Billed Charges,60% of Total Billed Charges,11.16,100,,3439.048,Fee Schedule,100% of TX Mediciad 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,,2693.048,Fee Schedule,100% of CMS OPPS Rate,11.95,90,,,Fee Schedule,90% of CMS OPPS Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,17.26,130,,,Fee Schedule,130% of CMS OPPS Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.49,103,,3542.216,Fee Schedule,103% of TX Medicaid Rate,13.67,103,,,Fee Schedule,103% of CMS OPPS Rate,13.67,103,,,Fee Schedule,103% of CMS OPPS Rate,141.75,75,,58.96,Percent of Total Billed Charges,75% of Total Billed Charges,22.57,80,,3165.792,Fee Schedule,80% of Scott and White EPO fee schedule,22.57,80,,9344.6,Fee Schedule,80% of Scott and White HMO fee schedule,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,22.57,170,,9344.6,Fee Schedule,170% of Scott and White PPO fee schedule,22.57,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,19.92,150,,,Fee Schedule,150% of CMS OPPS Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.76,90,,1820,Fee Schedule,90% of UHC fee schedule,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,3439.048,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,189,100,,78.608,Percent of Total Billed Charges,100% of Total Billed Charges,10.76,189,
PHENYTOIN (DILANTIN) TOTAL,41026550,CDM,301,RC,80185,HCPCS,Outpatient,,,206,123.60,,15.38,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,682.912,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,6048,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,698.992,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,7776,Fee Schedule,360% of BCBS POS Rate,47.7,360,,7776,Fee schedule,360% of BCBS PPO Rate,47.7,360,,7776,Fee Schedule,360% of BCBS Traditional Rate,123.6,60,,402.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,3417.848,Fee Schedule,100% of TX Mediciad 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,,5406.512,Fee Schedule,100% of CMS OPPS Rate,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,3520.384,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,154.5,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,3165.792,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,9344.6,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,9344.6,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,2256.8,Fee Schedule,90% of UHC fee schedule,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,3417.848,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,206,100,,72,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,206,
DRUG SCREEN MULTI DRUG CLASSES,41026626,CDM,301,RC,80307,HCPCS,Outpatient,,,243.37,146.02,,72.08,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,1154.888,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,1860.768,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,699.288,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,2392.416,Fee Schedule,360% of BCBS POS Rate,223.7,360,,2392.416,Fee schedule,360% of BCBS PPO Rate,223.7,360,,2392.416,Fee Schedule,360% of BCBS Traditional Rate,146.02,60,,622.336,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,2616.488,Fee Schedule,100% of TX Mediciad 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,,4830.776,Fee Schedule,100% of CMS OPPS Rate,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,2694.984,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,182.53,75,,73.8,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,9344.6,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,9344.6,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,9344.6,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,420,Fee Schedule,90% of UHC fee schedule,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,2616.488,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,243.37,100,,98.4,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,243.37,
ESTRADIOL,41026709,CDM,301,RC,82670,HCPCS,Outpatient,,,295,177.00,,32.42,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,41.91,150,,581.52,Fee Schedule ,150% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,78.23,280,,350.784,Fee Schedule,280% of BCBS BULE Fee Schedule,89.41,320,,699.288,Fee Schedule,320% of BCBS Blue Essentials Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,100.58,360,,451.008,Fee Schedule,360% of BCBS POS Rate,100.58,360,,451.008,Fee schedule,360% of BCBS PPO Rate,100.58,360,,451.008,Fee Schedule,360% of BCBS Traditional Rate,177,60,,405.08,Percent of Total Billed Charges,60% of Total Billed Charges,23.47,100,,94.672,Fee Schedule,100% of TX Mediciad 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,,2710.464,Fee Schedule,100% of CMS OPPS Rate,25.14,90,,,Fee Schedule,90% of CMS OPPS Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.32,130,,,Fee Schedule,130% of CMS OPPS Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,24.17,103,,97.512,Fee Schedule,103% of TX Medicaid Rate,28.77,103,,,Fee Schedule,103% of CMS OPPS Rate,28.77,103,,,Fee Schedule,103% of CMS OPPS Rate,221.25,75,,85.2,Percent of Total Billed Charges,75% of Total Billed Charges,47.49,80,,9344.6,Fee Schedule,80% of Scott and White EPO fee schedule,47.49,80,,8321.512,Fee Schedule,80% of Scott and White HMO fee schedule,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,47.49,170,,8321.512,Fee Schedule,170% of Scott and White PPO fee schedule,47.49,170,,10611.192,Fee Schedule,170% of Scott and White SWHP fee schedule,41.91,150,,,Fee Schedule,150% of CMS OPPS Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,90,,211.904,Fee Schedule,90% of UHC fee schedule,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,23.47,100,,94.672,Fee Schedule,100% of TX Medicaid Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,295,100,,113.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.64,295,
FERRITIN,41027269,CDM,301,RC,82728,HCPCS,Outpatient,,,200,120.00,,15.82,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.44,150,,1892.52,Fee Schedule ,150% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,38.16,280,,103.936,Fee Schedule,280% of BCBS BULE Fee Schedule,43.62,320,,701.44,Fee Schedule,320% of BCBS Blue Essentials Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,49.07,360,,133.632,Fee Schedule,360% of BCBS POS Rate,49.07,360,,133.632,Fee schedule,360% of BCBS PPO Rate,49.07,360,,133.632,Fee Schedule,360% of BCBS Traditional Rate,120,60,,405.08,Percent of Total Billed Charges,60% of Total Billed Charges,11.45,100,,92.872,Fee Schedule,100% of TX Mediciad 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,,1517.584,Fee Schedule,100% of CMS OPPS Rate,12.26,90,,,Fee Schedule,90% of CMS OPPS Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.71,130,,,Fee Schedule,130% of CMS OPPS Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.79,103,,95.656,Fee Schedule,103% of TX Medicaid Rate,14.03,103,,,Fee Schedule,103% of CMS OPPS Rate,14.03,103,,,Fee Schedule,103% of CMS OPPS Rate,150,75,,78.304,Percent of Total Billed Charges,75% of Total Billed Charges,23.17,80,,9344.6,Fee Schedule,80% of Scott and White EPO fee schedule,23.17,80,,6074.584,Fee Schedule,80% of Scott and White HMO fee schedule,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,23.17,170,,6074.584,Fee Schedule,170% of Scott and White PPO fee schedule,23.17,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,20.44,150,,,Fee Schedule,150% of CMS OPPS Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.04,90,,210,Fee Schedule,90% of UHC fee schedule,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,11.45,100,,92.872,Fee Schedule,100% of TX Medicaid Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,200,100,,104.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.04,200,
FIBRONECTIN FETAL SEMIQT,41027319,CDM,301,RC,82731,HCPCS,Outpatient,,,697.22,418.33,,74.72,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,96.61,150,,682.912,Fee Schedule ,150% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,180.35,280,,1649.36,Fee Schedule,280% of BCBS BULE Fee Schedule,206.11,320,,702.248,Fee Schedule,320% of BCBS Blue Essentials Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,231.88,360,,2120.6,Fee Schedule,360% of BCBS POS Rate,231.88,360,,2120.6,Fee schedule,360% of BCBS PPO Rate,231.88,360,,2120.6,Fee Schedule,360% of BCBS Traditional Rate,418.33,60,,385.712,Percent of Total Billed Charges,60% of Total Billed Charges,54.1,100,,159.6,Fee Schedule,100% of TX Mediciad 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,,2566.424,Fee Schedule,100% of CMS OPPS Rate,57.96,90,,,Fee Schedule,90% of CMS OPPS Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,130,,,Fee Schedule,130% of CMS OPPS Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,55.72,103,,164.392,Fee Schedule,103% of TX Medicaid Rate,66.34,103,,,Fee Schedule,103% of CMS OPPS Rate,66.34,103,,,Fee Schedule,103% of CMS OPPS Rate,522.92,75,,99.64,Percent of Total Billed Charges,75% of Total Billed Charges,109.49,80,,8321.512,Fee Schedule,80% of Scott and White EPO fee schedule,109.49,80,,6074.584,Fee Schedule,80% of Scott and White HMO fee schedule,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,109.49,170,,6074.584,Fee Schedule,170% of Scott and White PPO fee schedule,109.49,170,,86.904,Fee Schedule,170% of Scott and White SWHP fee schedule,96.61,150,,,Fee Schedule,150% of CMS OPPS Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,52.17,90,,187.6,Fee Schedule,90% of UHC fee schedule,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,54.1,100,,159.6,Fee Schedule,100% of TX Medicaid Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,697.22,100,,132.848,Percent of Total Billed Charges,100% of Total Billed Charges,52.17,697.22,
FOLIC ACID SERUM,41027467,CDM,301,RC,82746,HCPCS,Outpatient,,,192,115.20,,17.06,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,22.05,150,,777.328,Fee Schedule ,150% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,41.16,280,,1902.12,Fee Schedule,280% of BCBS BULE Fee Schedule,47.04,320,,702.248,Fee Schedule,320% of BCBS Blue Essentials Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,52.92,360,,2445.584,Fee Schedule,360% of BCBS POS Rate,52.92,360,,2445.584,Fee schedule,360% of BCBS PPO Rate,52.92,360,,2445.584,Fee Schedule,360% of BCBS Traditional Rate,115.2,60,,345.696,Percent of Total Billed Charges,60% of Total Billed Charges,12.35,100,,29.552,Fee Schedule,100% of TX Mediciad 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,,1292.272,Fee Schedule,100% of CMS OPPS Rate,13.23,90,,,Fee Schedule,90% of CMS OPPS Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.11,130,,,Fee Schedule,130% of CMS OPPS Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.72,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,15.14,103,,,Fee Schedule,103% of CMS OPPS Rate,15.14,103,,,Fee Schedule,103% of CMS OPPS Rate,144,75,,82.4,Percent of Total Billed Charges,75% of Total Billed Charges,24.99,80,,6074.584,Fee Schedule,80% of Scott and White EPO fee schedule,24.99,80,,6074.584,Fee Schedule,80% of Scott and White HMO fee schedule,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,24.99,170,,6074.584,Fee Schedule,170% of Scott and White PPO fee schedule,24.99,170,,1846.176,Fee Schedule,170% of Scott and White SWHP fee schedule,22.05,150,,,Fee Schedule,150% of CMS OPPS Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,90,,148.4,Fee Schedule,90% of UHC fee schedule,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,12.35,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,192,100,,109.864,Percent of Total Billed Charges,100% of Total Billed Charges,11.91,192,
GLUCOSE BF,41029455,CDM,301,RC,82945,HCPCS,Outpatient,,,101.5,60.90,,4.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.89,150,,1954.768,Fee Schedule ,150% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11,280,,2282.424,Fee Schedule,280% of BCBS BULE Fee Schedule,12.58,320,,703.288,Fee Schedule,320% of BCBS Blue Essentials Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,14.15,360,,2934.544,Fee Schedule,360% of BCBS POS Rate,14.15,360,,2934.544,Fee schedule,360% of BCBS PPO Rate,14.15,360,,2934.544,Fee Schedule,360% of BCBS Traditional Rate,60.9,60,,492.752,Percent of Total Billed Charges,60% of Total Billed Charges,3.3,100,,42,Fee Schedule,100% of TX Mediciad 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,,4205.6,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,,Fee Schedule,90% of CMS OPPS Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5.1,130,,,Fee Schedule,130% of CMS OPPS Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.4,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,76.13,75,,184.92,Percent of Total Billed Charges,75% of Total Billed Charges,6.68,80,,6074.584,Fee Schedule,80% of Scott and White EPO fee schedule,6.68,80,,6074.584,Fee Schedule,80% of Scott and White HMO fee schedule,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,170,,6074.584,Fee Schedule,170% of Scott and White PPO fee schedule,6.68,170,,1846.176,Fee Schedule,170% of Scott and White SWHP fee schedule,5.89,150,,,Fee Schedule,150% of CMS OPPS Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.19,90,,502.32,Fee Schedule,90% of UHC fee schedule,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,42,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,101.5,100,,246.56,Percent of Total Billed Charges,100% of Total Billed Charges,3.19,101.5,
GLUCOSE QT BLD,41029471,CDM,301,RC,82947,HCPCS,Outpatient,,,80.1,48.06,,4.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.89,150,,16004.408,Fee Schedule ,150% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11,280,,141.12,Fee Schedule,280% of BCBS BULE Fee Schedule,12.58,320,,704.704,Fee Schedule,320% of BCBS Blue Essentials Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,14.15,360,,181.44,Fee Schedule,360% of BCBS POS Rate,14.15,360,,181.44,Fee schedule,360% of BCBS PPO Rate,14.15,360,,181.44,Fee Schedule,360% of BCBS Traditional Rate,48.06,60,,404.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.3,100,,250.16,Fee Schedule,100% of TX Mediciad 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,,1517.584,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,,Fee Schedule,90% of CMS OPPS Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5.1,130,,,Fee Schedule,130% of CMS OPPS Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.4,103,,257.664,Fee Schedule,103% of TX Medicaid Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,60.08,75,,65.4,Percent of Total Billed Charges,75% of Total Billed Charges,6.68,80,,6074.584,Fee Schedule,80% of Scott and White EPO fee schedule,6.68,80,,6074.584,Fee Schedule,80% of Scott and White HMO fee schedule,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,170,,6074.584,Fee Schedule,170% of Scott and White PPO fee schedule,6.68,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,5.89,150,,,Fee Schedule,150% of CMS OPPS Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.19,90,,211.904,Fee Schedule,90% of UHC fee schedule,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,250.16,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,100,,87.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.19,80.1,
GLUCOSE 2HR POST GLUCOSE,41029505,CDM,301,RC,82950,HCPCS,Outpatient,,,105.83,63.50,,5.52,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,18825.952,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,704.928,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,43.2,Fee Schedule,360% of BCBS POS Rate,17.1,360,,43.2,Fee schedule,360% of BCBS PPO Rate,17.1,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,63.5,60,,1238.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,177.376,Fee Schedule,100% of TX Mediciad 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,,1727.4,Fee Schedule,100% of CMS OPPS Rate,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,182.696,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,79.37,75,,111,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,6074.584,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,5416.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,5416.8,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,3165.792,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,210,Fee Schedule,90% of UHC fee schedule,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,105.83,100,,148,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,105.83,
GLUCOSE TOL TEST 3 SPEC,41029513,CDM,301,RC,82951,HCPCS,Outpatient,,,203.35,122.01,,14.92,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,18825.952,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,583.296,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,706.56,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,749.952,Fee Schedule,360% of BCBS POS Rate,46.33,360,,749.952,Fee schedule,360% of BCBS PPO Rate,46.33,360,,749.952,Fee Schedule,360% of BCBS Traditional Rate,122.01,60,,291.992,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,12.096,Fee Schedule,100% of TX Mediciad 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,,4343.928,Fee Schedule,100% of CMS OPPS Rate,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,12.456,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,152.51,75,,91.2,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,6074.584,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,5416.8,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,5416.8,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,3165.792,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,4877.6,Fee Schedule,90% of UHC fee schedule,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,12.096,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,203.35,100,,121.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,203.35,
GLUCOSE TOLERANCE TEST EA ADDL,41029521,CDM,301,RC,82952,HCPCS,Outpatient,,,71.25,42.75,,4.54,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.88,150,,9300.744,Fee Schedule ,150% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,280,,728,Fee Schedule,280% of BCBS BULE Fee Schedule,12.54,320,,709.584,Fee Schedule,320% of BCBS Blue Essentials Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,14.11,360,,936,Fee Schedule,360% of BCBS POS Rate,14.11,360,,936,Fee schedule,360% of BCBS PPO Rate,14.11,360,,936,Fee Schedule,360% of BCBS Traditional Rate,42.75,60,,291.992,Percent of Total Billed Charges,60% of Total Billed Charges,3.29,100,,21.296,Fee Schedule,100% of TX Mediciad 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,,35565.344,Fee Schedule,100% of CMS OPPS Rate,3.52,90,,,Fee Schedule,90% of CMS OPPS Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,130,,,Fee Schedule,130% of CMS OPPS Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.39,103,,21.936,Fee Schedule,103% of TX Medicaid Rate,4.03,103,,,Fee Schedule,103% of CMS OPPS Rate,4.03,103,,,Fee Schedule,103% of CMS OPPS Rate,53.44,75,,52.2,Percent of Total Billed Charges,75% of Total Billed Charges,6.66,80,,5416.8,Fee Schedule,80% of Scott and White EPO fee schedule,6.66,80,,5416.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,6.66,170,,5416.8,Fee Schedule,170% of Scott and White PPO fee schedule,6.66,170,,9344.6,Fee Schedule,170% of Scott and White SWHP fee schedule,5.88,150,,,Fee Schedule,150% of CMS OPPS Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.18,90,,487.2,Fee Schedule,90% of UHC fee schedule,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.29,100,,21.296,Fee Schedule,100% of TX Medicaid Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,71.25,100,,69.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.18,71.25,
GLUCOSE CSF,41029588,CDM,301,RC,82945,HCPCS,Outpatient,,,101.5,60.90,,4.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.89,150,,9300.744,Fee Schedule ,150% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11,280,,514.304,Fee Schedule,280% of BCBS BULE Fee Schedule,12.58,320,,711.68,Fee Schedule,320% of BCBS Blue Essentials Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,14.15,360,,661.248,Fee Schedule,360% of BCBS POS Rate,14.15,360,,661.248,Fee schedule,360% of BCBS PPO Rate,14.15,360,,661.248,Fee Schedule,360% of BCBS Traditional Rate,60.9,60,,1492.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.3,100,,4.216,Fee Schedule,100% of TX Mediciad 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,,41835.456,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,,Fee Schedule,90% of CMS OPPS Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5.1,130,,,Fee Schedule,130% of CMS OPPS Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.4,103,,4.344,Fee Schedule,103% of TX Medicaid Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,76.13,75,,55.6,Percent of Total Billed Charges,75% of Total Billed Charges,6.68,80,,5416.8,Fee Schedule,80% of Scott and White EPO fee schedule,6.68,80,,5416.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,170,,5416.8,Fee Schedule,170% of Scott and White PPO fee schedule,6.68,170,,9344.6,Fee Schedule,170% of Scott and White SWHP fee schedule,5.89,150,,,Fee Schedule,150% of CMS OPPS Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.19,90,,4659.2,Fee Schedule,90% of UHC fee schedule,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,4.216,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,101.5,100,,74.128,Percent of Total Billed Charges,100% of Total Billed Charges,3.19,101.5,
GLUCOSE BY DEVICE POC,41029620,CDM,301,RC,82962,HCPCS,Outpatient,,,49.13,29.48,,3.8,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,4.91,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,9.18,280,,728,Fee Schedule,280% of BCBS BULE Fee Schedule,10.5,320,,712.936,Fee Schedule,320% of BCBS Blue Essentials Rate,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,11.81,360,,936,Fee Schedule,360% of BCBS POS Rate,11.81,360,,936,Fee schedule,360% of BCBS PPO Rate,11.81,360,,936,Fee Schedule,360% of BCBS Traditional Rate,29.48,60,,569.944,Percent of Total Billed Charges,60% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,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,,41835.456,Fee Schedule,100% of CMS OPPS Rate,2.95,90,,,Fee Schedule,90% of CMS OPPS Rate,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,130,,,Fee Schedule,130% of CMS OPPS Rate,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,7.08,14.42,,242.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,3.37,103,,,Fee Schedule,103% of CMS OPPS Rate,3.37,103,,,Fee Schedule,103% of CMS OPPS Rate,36.85,75,,135.24,Percent of Total Billed Charges,75% of Total Billed Charges,5.57,80,,5416.8,Fee Schedule,80% of Scott and White EPO fee schedule,5.57,80,,10605.168,Fee Schedule,80% of Scott and White HMO fee schedule,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,170,,10605.168,Fee Schedule,170% of Scott and White PPO fee schedule,5.57,170,,9344.6,Fee Schedule,170% of Scott and White SWHP fee schedule,4.91,150,,,Fee Schedule,150% of CMS OPPS Rate,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.66,90,,1671.488,Fee Schedule,90% of UHC fee schedule,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,235.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,49.13,100,,180.32,Percent of Total Billed Charges,100% of Total Billed Charges,2.66,49.13,
GLUTAMYLTRANSFERASE GAMMA GGT,41029802,CDM,301,RC,82977,HCPCS,Outpatient,,,111.72,67.03,,8.36,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.8,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,280,,902.72,Fee Schedule,280% of BCBS BULE Fee Schedule,23.04,320,,712.936,Fee Schedule,320% of BCBS Blue Essentials Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,25.92,360,,1160.64,Fee Schedule,360% of BCBS POS Rate,25.92,360,,1160.64,Fee schedule,360% of BCBS PPO Rate,25.92,360,,1160.64,Fee Schedule,360% of BCBS Traditional Rate,67.03,60,,368.024,Percent of Total Billed Charges,60% of Total Billed Charges,6.05,100,,65.496,Fee Schedule,100% of TX Mediciad 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,,20668.32,Fee Schedule,100% of CMS OPPS Rate,6.48,90,,,Fee Schedule,90% of CMS OPPS Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,130,,,Fee Schedule,130% of CMS OPPS Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.23,103,,67.456,Fee Schedule,103% of TX Medicaid Rate,7.41,103,,,Fee Schedule,103% of CMS OPPS Rate,7.41,103,,,Fee Schedule,103% of CMS OPPS Rate,83.79,75,,89.328,Percent of Total Billed Charges,75% of Total Billed Charges,12.24,80,,5416.8,Fee Schedule,80% of Scott and White EPO fee schedule,12.24,80,,10605.168,Fee Schedule,80% of Scott and White HMO fee schedule,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,12.24,170,,10605.168,Fee Schedule,170% of Scott and White PPO fee schedule,12.24,170,,8321.512,Fee Schedule,170% of Scott and White SWHP fee schedule,10.8,150,,,Fee Schedule,150% of CMS OPPS Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,5.83,90,,1671.488,Fee Schedule,90% of UHC fee schedule,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,6.05,100,,65.496,Fee Schedule,100% of TX Medicaid Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,111.72,100,,119.104,Percent of Total Billed Charges,100% of Total Billed Charges,5.83,111.72,
HEMOGLOBIN GLYCOSYLATED A1C,41029943,CDM,301,RC,83036,HCPCS,Outpatient,,,149,89.40,,11.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,14.56,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,27.19,280,,168,Fee Schedule,280% of BCBS BULE Fee Schedule,31.07,320,,713.08,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,34.96,360,,216,Fee Schedule,360% of BCBS POS Rate,34.96,360,,216,Fee schedule,360% of BCBS PPO Rate,34.96,360,,216,Fee Schedule,360% of BCBS Traditional Rate,89.4,60,,622.336,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,100,,125.528,Fee Schedule,100% of TX Mediciad 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,,20668.32,Fee Schedule,100% of CMS OPPS Rate,8.73,90,,,Fee Schedule,90% of CMS OPPS Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,130,,,Fee Schedule,130% of CMS OPPS Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.4,103,,129.296,Fee Schedule,103% of TX Medicaid Rate,10,103,,,Fee Schedule,103% of CMS OPPS Rate,10,103,,,Fee Schedule,103% of CMS OPPS Rate,111.75,75,,119.496,Percent of Total Billed Charges,75% of Total Billed Charges,16.5,80,,10605.168,Fee Schedule,80% of Scott and White EPO fee schedule,16.5,80,,10605.168,Fee Schedule,80% of Scott and White HMO fee schedule,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.5,170,,10605.168,Fee Schedule,170% of Scott and White PPO fee schedule,16.5,170,,6074.584,Fee Schedule,170% of Scott and White SWHP fee schedule,14.56,150,,,Fee Schedule,150% of CMS OPPS Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,90,,1670.76,Fee Schedule,90% of UHC fee schedule,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,125.528,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,149,100,,159.328,Percent of Total Billed Charges,100% of Total Billed Charges,7.87,149,
FSH,41030016,CDM,301,RC,83001,HCPCS,Outpatient,,,240.22,144.13,,21.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,27.86,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,52.02,280,,84.76,Fee Schedule,280% of BCBS BULE Fee Schedule,59.46,320,,713.08,Fee Schedule,320% of BCBS Blue Essentials Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,66.89,360,,108.976,Fee Schedule,360% of BCBS POS Rate,66.89,360,,108.976,Fee schedule,360% of BCBS PPO Rate,66.89,360,,108.976,Fee Schedule,360% of BCBS Traditional Rate,144.13,60,,405.08,Percent of Total Billed Charges,60% of Total Billed Charges,15.61,100,,305.936,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,16.72,90,,,Fee Schedule,90% of CMS OPPS Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,130,,,Fee Schedule,130% of CMS OPPS Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,16.08,103,,315.112,Fee Schedule,103% of TX Medicaid Rate,19.13,103,,,Fee Schedule,103% of CMS OPPS Rate,19.13,103,,,Fee Schedule,103% of CMS OPPS Rate,180.17,75,,137.224,Percent of Total Billed Charges,75% of Total Billed Charges,31.58,80,,10605.168,Fee Schedule,80% of Scott and White EPO fee schedule,31.58,80,,10605.168,Fee Schedule,80% of Scott and White HMO fee schedule,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,170,,10605.168,Fee Schedule,170% of Scott and White PPO fee schedule,31.58,170,,6074.584,Fee Schedule,170% of Scott and White SWHP fee schedule,27.86,150,,,Fee Schedule,150% of CMS OPPS Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,90,,1517.824,Fee Schedule,90% of UHC fee schedule,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,15.61,100,,305.936,Fee Schedule,100% of TX Medicaid Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,240.22,100,,182.96,Percent of Total Billed Charges,100% of Total Billed Charges,15.05,240.22,
LH,41030024,CDM,301,RC,83002,HCPCS,Outpatient,,,247.99,148.79,,21.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,27.78,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,51.86,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,59.26,320,,713.216,Fee Schedule,320% of BCBS Blue Essentials Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,66.67,360,,108,Fee Schedule,360% of BCBS POS Rate,66.67,360,,108,Fee schedule,360% of BCBS PPO Rate,66.67,360,,108,Fee Schedule,360% of BCBS Traditional Rate,148.79,60,,405.08,Percent of Total Billed Charges,60% of Total Billed Charges,15.56,100,,59.872,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,16.66,90,,,Fee Schedule,90% of CMS OPPS Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,24.07,130,,,Fee Schedule,130% of CMS OPPS Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,16.03,103,,61.672,Fee Schedule,103% of TX Medicaid Rate,19.07,103,,,Fee Schedule,103% of CMS OPPS Rate,19.07,103,,,Fee Schedule,103% of CMS OPPS Rate,185.99,75,,68.104,Percent of Total Billed Charges,75% of Total Billed Charges,31.48,80,,10605.168,Fee Schedule,80% of Scott and White EPO fee schedule,31.48,80,,10605.168,Fee Schedule,80% of Scott and White HMO fee schedule,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,31.48,170,,10605.168,Fee Schedule,170% of Scott and White PPO fee schedule,31.48,170,,6074.584,Fee Schedule,170% of Scott and White SWHP fee schedule,27.78,150,,,Fee Schedule,150% of CMS OPPS Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15,90,,1517.824,Fee Schedule,90% of UHC fee schedule,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,15.56,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,247.99,100,,90.808,Percent of Total Billed Charges,100% of Total Billed Charges,15,247.99,
GENTAMICIN,41030040,CDM,301,RC,80170,HCPCS,Outpatient,,,222,133.20,,19,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,24.57,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,45.86,280,,75.04,Fee Schedule,280% of BCBS BULE Fee Schedule,52.42,320,,713.216,Fee Schedule,320% of BCBS Blue Essentials Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,58.97,360,,96.48,Fee Schedule,360% of BCBS POS Rate,58.97,360,,96.48,Fee schedule,360% of BCBS PPO Rate,58.97,360,,96.48,Fee Schedule,360% of BCBS Traditional Rate,133.2,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,13.76,100,,90.056,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,14.74,90,,,Fee Schedule,90% of CMS OPPS Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,130,,,Fee Schedule,130% of CMS OPPS Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,14.17,103,,92.752,Fee Schedule,103% of TX Medicaid Rate,16.87,103,,,Fee Schedule,103% of CMS OPPS Rate,16.87,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,94.8,Percent of Total Billed Charges,75% of Total Billed Charges,27.84,80,,10605.168,Fee Schedule,80% of Scott and White EPO fee schedule,27.84,80,,9569.016,Fee Schedule,80% of Scott and White HMO fee schedule,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,170,,9569.016,Fee Schedule,170% of Scott and White PPO fee schedule,27.84,170,,6074.584,Fee Schedule,170% of Scott and White SWHP fee schedule,24.57,150,,,Fee Schedule,150% of CMS OPPS Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,90,,361.2,Fee Schedule,90% of UHC fee schedule,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,126.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.27,222,
PROCALCITONIN,41030057,CDM,301,RC,84145,HCPCS,Outpatient,,,292.57,175.54,,31.58,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,40.83,150,,183.24,Fee Schedule ,150% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,76.22,280,,59.36,Fee Schedule,280% of BCBS BULE Fee Schedule,87.1,320,,715.544,Fee Schedule,320% of BCBS Blue Essentials Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,97.99,360,,76.32,Fee Schedule,360% of BCBS POS Rate,97.99,360,,76.32,Fee schedule,360% of BCBS PPO Rate,97.99,360,,76.32,Fee Schedule,360% of BCBS Traditional Rate,175.54,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,22.86,100,,152.816,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,24.49,90,,,Fee Schedule,90% of CMS OPPS Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,35.38,130,,,Fee Schedule,130% of CMS OPPS Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,23.55,103,,157.4,Fee Schedule,103% of TX Medicaid Rate,28.03,103,,,Fee Schedule,103% of CMS OPPS Rate,28.03,103,,,Fee Schedule,103% of CMS OPPS Rate,219.43,75,,94.8,Percent of Total Billed Charges,75% of Total Billed Charges,46.27,80,,10605.168,Fee Schedule,80% of Scott and White EPO fee schedule,46.27,80,,9569.016,Fee Schedule,80% of Scott and White HMO fee schedule,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,46.27,170,,9569.016,Fee Schedule,170% of Scott and White PPO fee schedule,46.27,170,,6074.584,Fee Schedule,170% of Scott and White SWHP fee schedule,40.83,150,,,Fee Schedule,150% of CMS OPPS Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,22.05,90,,1262.24,Fee Schedule,90% of UHC fee schedule,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,22.86,100,,152.816,Fee Schedule,100% of TX Medicaid Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,292.57,100,,126.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.05,292.57,
"HCG QL, SERUM PREG",41030131,CDM,301,RC,84703,HCPCS,Outpatient,,,189.6,113.76,,8.72,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,11.28,150,,183.24,Fee Schedule ,150% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,280,,200.928,Fee Schedule,280% of BCBS BULE Fee Schedule,24.06,320,,716.032,Fee Schedule,320% of BCBS Blue Essentials Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,27.07,360,,258.336,Fee Schedule,360% of BCBS POS Rate,27.07,360,,258.336,Fee schedule,360% of BCBS PPO Rate,27.07,360,,258.336,Fee Schedule,360% of BCBS Traditional Rate,113.76,60,,852.152,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,100,,41.912,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,6.76,90,,,Fee Schedule,90% of CMS OPPS Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,130,,,Fee Schedule,130% of CMS OPPS Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.51,103,,43.168,Fee Schedule,103% of TX Medicaid Rate,7.74,103,,,Fee Schedule,103% of CMS OPPS Rate,7.74,103,,,Fee Schedule,103% of CMS OPPS Rate,142.2,75,,113.824,Percent of Total Billed Charges,75% of Total Billed Charges,12.78,80,,9569.016,Fee Schedule,80% of Scott and White EPO fee schedule,12.78,80,,9569.016,Fee Schedule,80% of Scott and White HMO fee schedule,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.78,170,,9569.016,Fee Schedule,170% of Scott and White PPO fee schedule,12.78,170,,5416.8,Fee Schedule,170% of Scott and White SWHP fee schedule,11.28,150,,,Fee Schedule,150% of CMS OPPS Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,90,,14728,Fee Schedule,90% of UHC fee schedule,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,6.32,100,,41.912,Fee Schedule,100% of TX Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,189.6,100,,151.768,Percent of Total Billed Charges,100% of Total Billed Charges,6.09,189.6,
"HCG QUANT, SERUM FEMALE",41030149,CDM,301,RC,84702,HCPCS,Outpatient,,,257.99,154.79,,17.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,4177.208,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,84.76,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,716.8,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,108.976,Fee Schedule,360% of BCBS POS Rate,54.18,360,,108.976,Fee schedule,360% of BCBS PPO Rate,54.18,360,,108.976,Fee Schedule,360% of BCBS Traditional Rate,154.79,60,,569.608,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,384.712,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,396.256,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,193.49,75,,119.616,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,9569.016,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,9569.016,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,9569.016,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,5416.8,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,15120,Fee Schedule,90% of UHC fee schedule,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,384.712,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,257.99,100,,159.488,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,257.99,
AMNISURE ROM TEST,41035007,CDM,301,RC,84112,HCPCS,Outpatient,,,147.08,88.25,,113.8,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,147.16,150,,4715.904,Fee Schedule ,150% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,274.71,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,313.95,320,,716.8,Fee Schedule,320% of BCBS Blue Essentials Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,353.2,360,,108,Fee Schedule,360% of BCBS POS Rate,353.2,360,,108,Fee schedule,360% of BCBS PPO Rate,353.2,360,,108,Fee Schedule,360% of BCBS Traditional Rate,88.25,60,,385.712,Percent of Total Billed Charges,60% of Total Billed Charges,82.41,100,,25.264,Fee Schedule,100% of TX Mediciad 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,,407.2,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,Fee Schedule,90% of CMS OPPS Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,127.54,130,,,Fee Schedule,130% of CMS OPPS Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,84.88,103,,26.024,Fee Schedule,103% of TX Medicaid Rate,101.05,103,,,Fee Schedule,103% of CMS OPPS Rate,101.05,103,,,Fee Schedule,103% of CMS OPPS Rate,110.31,75,,130.368,Percent of Total Billed Charges,75% of Total Billed Charges,166.78,80,,9569.016,Fee Schedule,80% of Scott and White EPO fee schedule,166.78,80,,10784.856,Fee Schedule,80% of Scott and White HMO fee schedule,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,166.78,170,,10784.856,Fee Schedule,170% of Scott and White PPO fee schedule,166.78,170,,5416.8,Fee Schedule,170% of Scott and White SWHP fee schedule,147.16,150,,,Fee Schedule,150% of CMS OPPS Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,79.47,90,,4368,Fee Schedule,90% of UHC fee schedule,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,25.264,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,147.08,100,,173.824,Percent of Total Billed Charges,100% of Total Billed Charges,79.47,353.2,
EIA STREPTOCOCCUS GROUP A,41035262,CDM,306,RC,87430,HCPCS,Outpatient,,,139,83.40,,19.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,25.21,150,,1301.192,Fee Schedule ,150% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,47.07,280,,1951.04,Fee Schedule,280% of BCBS BULE Fee Schedule,53.79,320,,716.8,Fee Schedule,320% of BCBS Blue Essentials Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,60.52,360,,2508.48,Fee Schedule,360% of BCBS POS Rate,60.52,360,,2508.48,Fee schedule,360% of BCBS PPO Rate,60.52,360,,2508.48,Fee Schedule,360% of BCBS Traditional Rate,83.4,60,,516,Percent of Total Billed Charges,60% of Total Billed Charges,14.12,100,,215.584,Fee Schedule,100% of TX Mediciad 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,,407.2,Fee Schedule,100% of CMS OPPS Rate,15.12,90,,,Fee Schedule,90% of CMS OPPS Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,21.85,130,,,Fee Schedule,130% of CMS OPPS Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.54,103,,222.048,Fee Schedule,103% of TX Medicaid Rate,17.31,103,,,Fee Schedule,103% of CMS OPPS Rate,17.31,103,,,Fee Schedule,103% of CMS OPPS Rate,104.25,75,,120.376,Percent of Total Billed Charges,75% of Total Billed Charges,28.57,80,,9569.016,Fee Schedule,80% of Scott and White EPO fee schedule,28.57,80,,10784.856,Fee Schedule,80% of Scott and White HMO fee schedule,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,28.57,170,,10784.856,Fee Schedule,170% of Scott and White PPO fee schedule,28.57,170,,5416.8,Fee Schedule,170% of Scott and White SWHP fee schedule,25.21,150,,,Fee Schedule,150% of CMS OPPS Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,90,,311.088,Fee Schedule,90% of UHC fee schedule,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,215.584,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,139,100,,160.496,Percent of Total Billed Charges,100% of Total Billed Charges,13.62,139,
NATRIURETIC PEPTIDE BNP,41035270,CDM,301,RC,83880,HCPCS,Outpatient,,,299,179.40,,45.54,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,58.89,150,,10878.328,Fee Schedule ,150% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,109.93,280,,194.88,Fee Schedule,280% of BCBS BULE Fee Schedule,125.63,320,,716.8,Fee Schedule,320% of BCBS Blue Essentials Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,141.34,360,,250.56,Fee Schedule,360% of BCBS POS Rate,141.34,360,,250.56,Fee schedule,360% of BCBS PPO Rate,141.34,360,,250.56,Fee Schedule,360% of BCBS Traditional Rate,179.4,60,,345.696,Percent of Total Billed Charges,60% of Total Billed Charges,32.98,100,,296.448,Fee Schedule,100% of TX Mediciad 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,,9282.68,Fee Schedule,100% of CMS OPPS Rate,35.33,90,,,Fee Schedule,90% of CMS OPPS Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,130,,,Fee Schedule,130% of CMS OPPS Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,33.97,103,,305.344,Fee Schedule,103% of TX Medicaid Rate,40.43,103,,,Fee Schedule,103% of CMS OPPS Rate,40.43,103,,,Fee Schedule,103% of CMS OPPS Rate,224.25,75,,81.152,Percent of Total Billed Charges,75% of Total Billed Charges,66.74,80,,10784.856,Fee Schedule,80% of Scott and White EPO fee schedule,66.74,80,,10784.856,Fee Schedule,80% of Scott and White HMO fee schedule,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,170,,10784.856,Fee Schedule,170% of Scott and White PPO fee schedule,66.74,170,,10605.168,Fee Schedule,170% of Scott and White SWHP fee schedule,58.89,150,,,Fee Schedule,150% of CMS OPPS Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,31.8,90,,532.136,Fee Schedule,90% of UHC fee schedule,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,32.98,100,,296.448,Fee Schedule,100% of TX Medicaid Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,299,100,,108.2,Percent of Total Billed Charges,100% of Total Billed Charges,31.8,299,
THYROXINE FREE T4,41035312,CDM,301,RC,84439,HCPCS,Outpatient,,,172,103.20,,10.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,13.53,150,,7252.216,Fee Schedule ,150% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,25.26,280,,1863.68,Fee Schedule,280% of BCBS BULE Fee Schedule,28.86,320,,726.896,Fee Schedule,320% of BCBS Blue Essentials Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,32.47,360,,2396.16,Fee Schedule,360% of BCBS POS Rate,32.47,360,,2396.16,Fee schedule,360% of BCBS PPO Rate,32.47,360,,2396.16,Fee Schedule,360% of BCBS Traditional Rate,103.2,60,,329.688,Percent of Total Billed Charges,60% of Total Billed Charges,7.58,100,,234.504,Fee Schedule,100% of TX Mediciad 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,,10479.792,Fee Schedule,100% of CMS OPPS Rate,8.11,90,,,Fee Schedule,90% of CMS OPPS Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,11.72,130,,,Fee Schedule,130% of CMS OPPS Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.81,103,,241.544,Fee Schedule,103% of TX Medicaid Rate,9.29,103,,,Fee Schedule,103% of CMS OPPS Rate,9.29,103,,,Fee Schedule,103% of CMS OPPS Rate,129,75,,145.8,Percent of Total Billed Charges,75% of Total Billed Charges,15.33,80,,10784.856,Fee Schedule,80% of Scott and White EPO fee schedule,15.33,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,15.33,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,15.33,170,,10605.168,Fee Schedule,170% of Scott and White SWHP fee schedule,13.53,150,,,Fee Schedule,150% of CMS OPPS Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,90,,600.352,Fee Schedule,90% of UHC fee schedule,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,7.58,100,,234.504,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,172,100,,194.4,Percent of Total Billed Charges,100% of Total Billed Charges,7.31,172,
IRON TOTAL,41035403,CDM,301,RC,83540,HCPCS,Outpatient,,,123.12,73.87,,7.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.7,150,,7252.216,Fee Schedule ,150% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.12,280,,668.592,Fee Schedule,280% of BCBS BULE Fee Schedule,20.7,320,,732.16,Fee Schedule,320% of BCBS Blue Essentials Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,23.29,360,,859.624,Fee Schedule,360% of BCBS POS Rate,23.29,360,,859.624,Fee schedule,360% of BCBS PPO Rate,23.29,360,,859.624,Fee Schedule,360% of BCBS Traditional Rate,73.87,60,,329.688,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,100,,142.056,Fee Schedule,100% of TX Mediciad 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,,2891.544,Fee Schedule,100% of CMS OPPS Rate,5.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,130,,,Fee Schedule,130% of CMS OPPS Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.59,103,,146.312,Fee Schedule,103% of TX Medicaid Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,92.34,75,,83.48,Percent of Total Billed Charges,75% of Total Billed Charges,10.99,80,,10784.856,Fee Schedule,80% of Scott and White EPO fee schedule,10.99,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,10.99,170,,10605.168,Fee Schedule,170% of Scott and White SWHP fee schedule,9.7,150,,,Fee Schedule,150% of CMS OPPS Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,90,,40.448,Fee Schedule,90% of UHC fee schedule,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,142.056,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,123.12,100,,111.304,Percent of Total Billed Charges,100% of Total Billed Charges,5.24,123.12,
IRON BINDING CAPACITY,41035502,CDM,301,RC,83550,HCPCS,Outpatient,,,131,78.60,,10.14,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,13.11,150,,673.44,Fee Schedule ,150% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.47,280,,668.592,Fee Schedule,280% of BCBS BULE Fee Schedule,27.97,320,,732.16,Fee Schedule,320% of BCBS Blue Essentials Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,31.46,360,,859.624,Fee Schedule,360% of BCBS POS Rate,31.46,360,,859.624,Fee schedule,360% of BCBS PPO Rate,31.46,360,,859.624,Fee Schedule,360% of BCBS Traditional Rate,78.6,60,,976.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,100,,49.096,Fee Schedule,100% of TX Mediciad 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,,24174.056,Fee Schedule,100% of CMS OPPS Rate,7.86,90,,,Fee Schedule,90% of CMS OPPS Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.36,130,,,Fee Schedule,130% of CMS OPPS Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.56,103,,50.568,Fee Schedule,103% of TX Medicaid Rate,9,103,,,Fee Schedule,103% of CMS OPPS Rate,9,103,,,Fee Schedule,103% of CMS OPPS Rate,98.25,75,,55.336,Percent of Total Billed Charges,75% of Total Billed Charges,14.85,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,14.85,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,14.85,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,14.85,170,,10605.168,Fee Schedule,170% of Scott and White SWHP fee schedule,13.11,150,,,Fee Schedule,150% of CMS OPPS Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,7.08,90,,6047.224,Fee Schedule,90% of UHC fee schedule,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,7.34,100,,49.096,Fee Schedule,100% of TX Medicaid Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,131,100,,73.776,Percent of Total Billed Charges,100% of Total Billed Charges,7.08,131,
T3 FREE,41035544,CDM,301,RC,84481,HCPCS,Outpatient,,,264.59,158.75,,19.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,25.41,150,,448.816,Fee Schedule ,150% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,668.304,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,732.16,Fee Schedule,320% of BCBS Blue Essentials Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,60.98,360,,859.248,Fee Schedule,360% of BCBS POS Rate,60.98,360,,859.248,Fee schedule,360% of BCBS PPO Rate,60.98,360,,859.248,Fee Schedule,360% of BCBS Traditional Rate,158.75,60,,851.216,Percent of Total Billed Charges,60% of Total Billed Charges,14.23,100,,311.912,Fee Schedule,100% of TX Mediciad 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,,16116.032,Fee Schedule,100% of CMS OPPS Rate,15.24,90,,,Fee Schedule,90% of CMS OPPS Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.02,130,,,Fee Schedule,130% of CMS OPPS Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.66,103,,321.272,Fee Schedule,103% of TX Medicaid Rate,17.44,103,,,Fee Schedule,103% of CMS OPPS Rate,17.44,103,,,Fee Schedule,103% of CMS OPPS Rate,198.44,75,,64.384,Percent of Total Billed Charges,75% of Total Billed Charges,28.79,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,28.79,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.79,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,28.79,170,,10605.168,Fee Schedule,170% of Scott and White SWHP fee schedule,25.41,150,,,Fee Schedule,150% of CMS OPPS Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,90,,5390.544,Fee Schedule,90% of UHC fee schedule,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,311.912,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,264.59,100,,85.84,Percent of Total Billed Charges,100% of Total Billed Charges,13.73,264.59,
LACTIC ACID,41036054,CDM,301,RC,83605,HCPCS,Outpatient,,,194.98,116.99,,13.42,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,17.35,150,,707.528,Fee Schedule ,150% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,280,,607.128,Fee Schedule,280% of BCBS BULE Fee Schedule,37.02,320,,735.744,Fee Schedule,320% of BCBS Blue Essentials Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,41.65,360,,780.592,Fee Schedule,360% of BCBS POS Rate,41.65,360,,780.592,Fee schedule,360% of BCBS PPO Rate,41.65,360,,780.592,Fee Schedule,360% of BCBS Traditional Rate,116.99,60,,295.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,100,,252.976,Fee Schedule,100% of TX Mediciad 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,,16116.032,Fee Schedule,100% of CMS OPPS Rate,10.41,90,,,Fee Schedule,90% of CMS OPPS Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,10.01,103,,260.56,Fee Schedule,103% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,146.24,75,,121.928,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,19.66,80,,12282.304,Fee Schedule,80% of Scott and White HMO fee schedule,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.66,170,,12282.304,Fee Schedule,170% of Scott and White PPO fee schedule,19.66,170,,9569.016,Fee Schedule,170% of Scott and White SWHP fee schedule,17.35,150,,,Fee Schedule,150% of CMS OPPS Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,90,,3426.192,Fee Schedule,90% of UHC fee schedule,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,252.976,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,194.98,100,,162.568,Percent of Total Billed Charges,100% of Total Billed Charges,9.37,194.98,
LDH,41036153,CDM,301,RC,83615,HCPCS,Outpatient,,,110,66.00,,7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.06,150,,889.056,Fee Schedule ,150% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,280,,607.128,Fee Schedule,280% of BCBS BULE Fee Schedule,19.33,320,,740.352,Fee Schedule,320% of BCBS Blue Essentials Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,21.74,360,,780.592,Fee Schedule,360% of BCBS POS Rate,21.74,360,,780.592,Fee schedule,360% of BCBS PPO Rate,21.74,360,,780.592,Fee Schedule,360% of BCBS Traditional Rate,66,60,,5757.904,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,100,,109.152,Fee Schedule,100% of TX Mediciad 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,,1496.528,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,,Fee Schedule,90% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,7.85,130,,,Fee Schedule,130% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.22,103,,112.432,Fee Schedule,103% of TX Medicaid Rate,6.22,103,,,Fee Schedule,103% of CMS OPPS Rate,6.22,103,,,Fee Schedule,103% of CMS OPPS Rate,82.5,75,,80.896,Percent of Total Billed Charges,75% of Total Billed Charges,10.26,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,10.26,80,,12206.6,Fee Schedule,80% of Scott and White HMO fee schedule,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,10.26,170,,12206.6,Fee Schedule,170% of Scott and White PPO fee schedule,10.26,170,,9569.016,Fee Schedule,170% of Scott and White SWHP fee schedule,9.06,150,,,Fee Schedule,150% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,90,,11606.344,Fee Schedule,90% of UHC fee schedule,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,110,100,,107.864,Percent of Total Billed Charges,100% of Total Billed Charges,4.9,110,
LDH BF,41036179,CDM,301,RC,83615,HCPCS,Outpatient,,,110,66.00,,7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.06,150,,346.008,Fee Schedule ,150% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,280,,144.48,Fee Schedule,280% of BCBS BULE Fee Schedule,19.33,320,,742.648,Fee Schedule,320% of BCBS Blue Essentials Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,21.74,360,,185.76,Fee Schedule,360% of BCBS POS Rate,21.74,360,,185.76,Fee schedule,360% of BCBS PPO Rate,21.74,360,,185.76,Fee Schedule,360% of BCBS Traditional Rate,66,60,,964.856,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,100,,109.152,Fee Schedule,100% of TX Mediciad 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,,997.36,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,,Fee Schedule,90% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,7.85,130,,,Fee Schedule,130% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.22,103,,112.432,Fee Schedule,103% of TX Medicaid Rate,6.22,103,,,Fee Schedule,103% of CMS OPPS Rate,6.22,103,,,Fee Schedule,103% of CMS OPPS Rate,82.5,75,,91.992,Percent of Total Billed Charges,75% of Total Billed Charges,10.26,80,,12282.304,Fee Schedule,80% of Scott and White EPO fee schedule,10.26,80,,9344.6,Fee Schedule,80% of Scott and White HMO fee schedule,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,10.26,170,,9344.6,Fee Schedule,170% of Scott and White PPO fee schedule,10.26,170,,9569.016,Fee Schedule,170% of Scott and White SWHP fee schedule,9.06,150,,,Fee Schedule,150% of CMS OPPS Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,90,,4943.12,Fee Schedule,90% of UHC fee schedule,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,5.07,100,,109.152,Fee Schedule,100% of TX Medicaid Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,110,100,,122.656,Percent of Total Billed Charges,100% of Total Billed Charges,4.9,110,
LIPASE,41036906,CDM,301,RC,83690,HCPCS,Outpatient,,,182,109.20,,8,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.33,150,,346.008,Fee Schedule ,150% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.29,280,,504.896,Fee Schedule,280% of BCBS BULE Fee Schedule,22.05,320,,744.976,Fee Schedule,320% of BCBS Blue Essentials Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,24.8,360,,649.152,Fee Schedule,360% of BCBS POS Rate,24.8,360,,649.152,Fee schedule,360% of BCBS PPO Rate,24.8,360,,649.152,Fee Schedule,360% of BCBS Traditional Rate,109.2,60,,964.856,Percent of Total Billed Charges,60% of Total Billed Charges,5.79,100,,16.8,Fee Schedule,100% of TX Mediciad 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,,1572.288,Fee Schedule,100% of CMS OPPS Rate,6.2,90,,,Fee Schedule,90% of CMS OPPS Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.95,130,,,Fee Schedule,130% of CMS OPPS Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.96,103,,17.304,Fee Schedule,103% of TX Medicaid Rate,7.09,103,,,Fee Schedule,103% of CMS OPPS Rate,7.09,103,,,Fee Schedule,103% of CMS OPPS Rate,136.5,75,,80.176,Percent of Total Billed Charges,75% of Total Billed Charges,11.71,80,,12206.6,Fee Schedule,80% of Scott and White EPO fee schedule,11.71,80,,338.104,Fee Schedule,80% of Scott and White HMO fee schedule,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,11.71,170,,338.104,Fee Schedule,170% of Scott and White PPO fee schedule,11.71,170,,9569.016,Fee Schedule,170% of Scott and White SWHP fee schedule,10.33,150,,,Fee Schedule,150% of CMS OPPS Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,5.58,90,,119.424,Fee Schedule,90% of UHC fee schedule,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,5.79,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,106.904,Percent of Total Billed Charges,100% of Total Billed Charges,5.58,182,
LITHIUM,41037250,CDM,301,RC,80178,HCPCS,Outpatient,,,129,77.40,,7.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.91,150,,830.776,Fee Schedule ,150% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,18.51,280,,5891.2,Fee Schedule,280% of BCBS BULE Fee Schedule,21.15,320,,745.472,Fee Schedule,320% of BCBS Blue Essentials Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,23.8,360,,7574.4,Fee Schedule,360% of BCBS POS Rate,23.8,360,,7574.4,Fee schedule,360% of BCBS PPO Rate,23.8,360,,7574.4,Fee Schedule,360% of BCBS Traditional Rate,77.4,60,,964.856,Percent of Total Billed Charges,60% of Total Billed Charges,5.55,100,,206.936,Fee Schedule,100% of TX Mediciad 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,,1975.68,Fee Schedule,100% of CMS OPPS Rate,5.94,90,,,Fee Schedule,90% of CMS OPPS Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.59,130,,,Fee Schedule,130% of CMS OPPS Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.72,103,,213.144,Fee Schedule,103% of TX Medicaid Rate,6.8,103,,,Fee Schedule,103% of CMS OPPS Rate,6.8,103,,,Fee Schedule,103% of CMS OPPS Rate,96.75,75,,163.8,Percent of Total Billed Charges,75% of Total Billed Charges,11.23,80,,9344.6,Fee Schedule,80% of Scott and White EPO fee schedule,11.23,80,,331.696,Fee Schedule,80% of Scott and White HMO fee schedule,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,170,,331.696,Fee Schedule,170% of Scott and White PPO fee schedule,11.23,170,,10784.856,Fee Schedule,170% of Scott and White SWHP fee schedule,9.91,150,,,Fee Schedule,150% of CMS OPPS Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,5.36,90,,198.848,Fee Schedule,90% of UHC fee schedule,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,206.936,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,129,100,,218.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.36,129,
MAGNESIUM,41037359,CDM,301,RC,83735,HCPCS,Outpatient,,,121,72.60,,7.78,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.05,150,,1576.024,Fee Schedule ,150% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,280,,6048,Fee Schedule,280% of BCBS BULE Fee Schedule,21.44,320,,757.456,Fee Schedule,320% of BCBS Blue Essentials Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,24.12,360,,7776,Fee Schedule,360% of BCBS POS Rate,24.12,360,,7776,Fee schedule,360% of BCBS PPO Rate,24.12,360,,7776,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,1481.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,100,,29.72,Fee Schedule,100% of TX Mediciad 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,,768.904,Fee Schedule,100% of CMS OPPS Rate,6.03,90,,,Fee Schedule,90% of CMS OPPS Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.8,103,,30.608,Fee Schedule,103% of TX Medicaid Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,133.736,Percent of Total Billed Charges,75% of Total Billed Charges,11.39,80,,338.104,Fee Schedule,80% of Scott and White EPO fee schedule,11.39,80,,570.008,Fee Schedule,80% of Scott and White HMO fee schedule,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,170,,570.008,Fee Schedule,170% of Scott and White PPO fee schedule,11.39,170,,10784.856,Fee Schedule,170% of Scott and White SWHP fee schedule,10.05,150,,,Fee Schedule,150% of CMS OPPS Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,682.224,Fee Schedule,90% of UHC fee schedule,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,178.312,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,121,
OSMOLALITY BLOOD,41039306,CDM,301,RC,83930,HCPCS,Outpatient,,,122.48,73.49,,7.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.91,150,,2068.92,Fee Schedule ,150% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,18.51,280,,1747.2,Fee Schedule,280% of BCBS BULE Fee Schedule,21.15,320,,761.512,Fee Schedule,320% of BCBS Blue Essentials Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,23.8,360,,2246.4,Fee Schedule,360% of BCBS POS Rate,23.8,360,,2246.4,Fee schedule,360% of BCBS PPO Rate,23.8,360,,2246.4,Fee Schedule,360% of BCBS Traditional Rate,73.49,60,,638.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.55,100,,181.976,Fee Schedule,100% of TX Mediciad 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,,768.904,Fee Schedule,100% of CMS OPPS Rate,5.94,90,,,Fee Schedule,90% of CMS OPPS Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.59,130,,,Fee Schedule,130% of CMS OPPS Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.72,103,,187.432,Fee Schedule,103% of TX Medicaid Rate,6.8,103,,,Fee Schedule,103% of CMS OPPS Rate,6.8,103,,,Fee Schedule,103% of CMS OPPS Rate,91.86,75,,166.8,Percent of Total Billed Charges,75% of Total Billed Charges,11.23,80,,331.696,Fee Schedule,80% of Scott and White EPO fee schedule,11.23,80,,105.536,Fee Schedule,80% of Scott and White HMO fee schedule,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,170,,105.536,Fee Schedule,170% of Scott and White PPO fee schedule,11.23,170,,10784.856,Fee Schedule,170% of Scott and White SWHP fee schedule,9.91,150,,,Fee Schedule,150% of CMS OPPS Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,5.36,90,,1091.552,Fee Schedule,90% of UHC fee schedule,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,5.55,100,,181.976,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,122.48,100,,222.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.36,122.48,
OSMOLALITY URINE,41039355,CDM,301,RC,83935,HCPCS,Outpatient,,,118.14,70.88,,7.92,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.23,150,,2358,Fee Schedule ,150% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,19.1,280,,124.44,Fee Schedule,280% of BCBS BULE Fee Schedule,21.82,320,,761.512,Fee Schedule,320% of BCBS Blue Essentials Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,24.55,360,,159.992,Fee Schedule,360% of BCBS POS Rate,24.55,360,,159.992,Fee schedule,360% of BCBS PPO Rate,24.55,360,,159.992,Fee Schedule,360% of BCBS Traditional Rate,70.88,60,,615.36,Percent of Total Billed Charges,60% of Total Billed Charges,5.73,100,,50.176,Fee Schedule,100% of TX Mediciad 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,,1846.176,Fee Schedule,100% of CMS OPPS Rate,6.13,90,,,Fee Schedule,90% of CMS OPPS Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8.86,130,,,Fee Schedule,130% of CMS OPPS Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.9,103,,51.68,Fee Schedule,103% of TX Medicaid Rate,7.02,103,,,Fee Schedule,103% of CMS OPPS Rate,7.02,103,,,Fee Schedule,103% of CMS OPPS Rate,88.61,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,11.59,80,,570.008,Fee Schedule,80% of Scott and White EPO fee schedule,11.59,80,,150,Fee Schedule,80% of Scott and White HMO fee schedule,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.59,170,,150,Fee Schedule,170% of Scott and White PPO fee schedule,11.59,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,10.23,150,,,Fee Schedule,150% of CMS OPPS Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.53,90,,1340.64,Fee Schedule,90% of UHC fee schedule,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,5.73,100,,50.176,Fee Schedule,100% of TX Medicaid Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,118.14,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,5.53,118.14,
PH BODY FLUID EXCEPT BLOOD,41039801,CDM,301,RC,83986,HCPCS,Outpatient,,,73.25,43.95,,4.16,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.37,150,,2358,Fee Schedule ,150% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.02,280,,212.856,Fee Schedule,280% of BCBS BULE Fee Schedule,11.46,320,,763.776,Fee Schedule,320% of BCBS Blue Essentials Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,12.89,360,,273.672,Fee Schedule,360% of BCBS POS Rate,12.89,360,,273.672,Fee schedule,360% of BCBS PPO Rate,12.89,360,,273.672,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,177.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.01,100,,99.12,Fee Schedule,100% of TX Mediciad 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,,3502.272,Fee Schedule,100% of CMS OPPS Rate,3.22,90,,,Fee Schedule,90% of CMS OPPS Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,130,,,Fee Schedule,130% of CMS OPPS Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.1,103,,102.096,Fee Schedule,103% of TX Medicaid Rate,3.68,103,,,Fee Schedule,103% of CMS OPPS Rate,3.68,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,86.184,Percent of Total Billed Charges,75% of Total Billed Charges,6.08,80,,105.536,Fee Schedule,80% of Scott and White EPO fee schedule,6.08,80,,893.416,Fee Schedule,80% of Scott and White HMO fee schedule,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,6.08,170,,893.416,Fee Schedule,170% of Scott and White PPO fee schedule,6.08,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,5.37,150,,,Fee Schedule,150% of CMS OPPS Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2.9,90,,210,Fee Schedule,90% of UHC fee schedule,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,114.912,Percent of Total Billed Charges,100% of Total Billed Charges,2.9,73.25,
PHENOBARBITAL,41040205,CDM,301,RC,80184,HCPCS,Outpatient,,,202,121.20,,17.74,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,22.95,150,,5170.4,Fee Schedule ,150% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,280,,240.144,Fee Schedule,280% of BCBS BULE Fee Schedule,48.96,320,,763.776,Fee Schedule,320% of BCBS Blue Essentials Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,55.08,360,,308.752,Fee Schedule,360% of BCBS POS Rate,55.08,360,,308.752,Fee schedule,360% of BCBS PPO Rate,55.08,360,,308.752,Fee Schedule,360% of BCBS Traditional Rate,121.2,60,,421.44,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,100,,742.344,Fee Schedule,100% of TX Mediciad 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,,4597.6,Fee Schedule,100% of CMS OPPS Rate,13.77,90,,,Fee Schedule,90% of CMS OPPS Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,130,,,Fee Schedule,130% of CMS OPPS Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,13.24,103,,764.608,Fee Schedule,103% of TX Medicaid Rate,15.75,103,,,Fee Schedule,103% of CMS OPPS Rate,15.75,103,,,Fee Schedule,103% of CMS OPPS Rate,151.5,75,,86.184,Percent of Total Billed Charges,75% of Total Billed Charges,26.01,80,,150,Fee Schedule,80% of Scott and White EPO fee schedule,26.01,80,,633.496,Fee Schedule,80% of Scott and White HMO fee schedule,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.01,170,,633.496,Fee Schedule,170% of Scott and White PPO fee schedule,26.01,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,22.95,150,,,Fee Schedule,150% of CMS OPPS Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,90,,320.816,Fee Schedule,90% of UHC fee schedule,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,742.344,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,202,100,,114.912,Percent of Total Billed Charges,100% of Total Billed Charges,12.39,202,
PHOSPHATASE ALKALINE,41040759,CDM,301,RC,84075,HCPCS,Outpatient,,,89.59,53.75,,6,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,8241.056,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,16.176,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,764.112,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,20.8,Fee Schedule,360% of BCBS POS Rate,18.65,360,,20.8,Fee schedule,360% of BCBS PPO Rate,18.65,360,,20.8,Fee Schedule,360% of BCBS Traditional Rate,53.75,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,100.456,Fee Schedule,100% of TX Mediciad 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,,5240,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,103.472,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,67.19,75,,108.904,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,893.416,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,43.2,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,43.2,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,1306.312,Fee Schedule,90% of UHC fee schedule,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,100.456,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,89.59,100,,145.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,89.59,
PHOSPHORUS INORGANIC,41041005,CDM,301,RC,84100,HCPCS,Outpatient,,,84.3,50.58,,5.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.11,150,,10575.96,Fee Schedule ,150% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,280,,2418.888,Fee Schedule,280% of BCBS BULE Fee Schedule,15.17,320,,764.112,Fee Schedule,320% of BCBS Blue Essentials Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,17.06,360,,3110,Fee Schedule,360% of BCBS POS Rate,17.06,360,,3110,Fee schedule,360% of BCBS PPO Rate,17.06,360,,3110,Fee Schedule,360% of BCBS Traditional Rate,50.58,60,,352.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.98,100,,1332.408,Fee Schedule,100% of TX Mediciad 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,,5240,Fee Schedule,100% of CMS OPPS Rate,4.26,90,,,Fee Schedule,90% of CMS OPPS Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6.16,130,,,Fee Schedule,130% of CMS OPPS Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.1,103,,1372.384,Fee Schedule,103% of TX Medicaid Rate,4.88,103,,,Fee Schedule,103% of CMS OPPS Rate,4.88,103,,,Fee Schedule,103% of CMS OPPS Rate,63.23,75,,86.184,Percent of Total Billed Charges,75% of Total Billed Charges,8.05,80,,633.496,Fee Schedule,80% of Scott and White EPO fee schedule,8.05,80,,76.064,Fee Schedule,80% of Scott and White HMO fee schedule,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.05,170,,76.064,Fee Schedule,170% of Scott and White PPO fee schedule,8.05,170,,12282.304,Fee Schedule,170% of Scott and White SWHP fee schedule,7.11,150,,,Fee Schedule,150% of CMS OPPS Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3.84,90,,1208.896,Fee Schedule,90% of UHC fee schedule,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,1332.408,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,84.3,100,,114.912,Percent of Total Billed Charges,100% of Total Billed Charges,3.84,84.3,
PHOSPHORUS URI,41041021,CDM,301,RC,84105,HCPCS,Outpatient,,,91.08,54.65,,6.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.67,150,,7050.64,Fee Schedule ,150% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,280,,2156.216,Fee Schedule,280% of BCBS BULE Fee Schedule,18.5,320,,764.16,Fee Schedule,320% of BCBS Blue Essentials Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,20.81,360,,2772.28,Fee Schedule,360% of BCBS POS Rate,20.81,360,,2772.28,Fee schedule,360% of BCBS PPO Rate,20.81,360,,2772.28,Fee Schedule,360% of BCBS Traditional Rate,54.65,60,,295.68,Percent of Total Billed Charges,60% of Total Billed Charges,4.86,100,,1330.504,Fee Schedule,100% of TX Mediciad 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,,11489.776,Fee Schedule,100% of CMS OPPS Rate,5.2,90,,,Fee Schedule,90% of CMS OPPS Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.51,130,,,Fee Schedule,130% of CMS OPPS Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.01,103,,1370.424,Fee Schedule,103% of TX Medicaid Rate,5.95,103,,,Fee Schedule,103% of CMS OPPS Rate,5.95,103,,,Fee Schedule,103% of CMS OPPS Rate,68.31,75,,138.496,Percent of Total Billed Charges,75% of Total Billed Charges,9.82,80,,43.2,Fee Schedule,80% of Scott and White EPO fee schedule,9.82,80,,15.072,Fee Schedule,80% of Scott and White HMO fee schedule,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,170,,15.072,Fee Schedule,170% of Scott and White PPO fee schedule,9.82,170,,12206.6,Fee Schedule,170% of Scott and White SWHP fee schedule,8.67,150,,,Fee Schedule,150% of CMS OPPS Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4.68,90,,436.8,Fee Schedule,90% of UHC fee schedule,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,1330.504,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,91.08,100,,184.656,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,91.08,
POTASSIUM BLOOD,41041328,CDM,301,RC,84132,HCPCS,Outpatient,,,80,48.00,,5.52,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.14,150,,7050.64,Fee Schedule ,150% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,280,,1370.48,Fee Schedule,280% of BCBS BULE Fee Schedule,15.23,320,,764.336,Fee Schedule,320% of BCBS Blue Essentials Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,17.14,360,,1762.04,Fee Schedule,360% of BCBS POS Rate,17.14,360,,1762.04,Fee schedule,360% of BCBS PPO Rate,17.14,360,,1762.04,Fee Schedule,360% of BCBS Traditional Rate,48,60,,291.36,Percent of Total Billed Charges,60% of Total Billed Charges,4,100,,191.024,Fee Schedule,100% of TX Mediciad 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,,18313.464,Fee Schedule,100% of CMS OPPS Rate,4.28,90,,,Fee Schedule,90% of CMS OPPS Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,6.18,130,,,Fee Schedule,130% of CMS OPPS Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.12,103,,196.752,Fee Schedule,103% of TX Medicaid Rate,4.9,103,,,Fee Schedule,103% of CMS OPPS Rate,4.9,103,,,Fee Schedule,103% of CMS OPPS Rate,60,75,,86.184,Percent of Total Billed Charges,75% of Total Billed Charges,8.09,80,,76.064,Fee Schedule,80% of Scott and White EPO fee schedule,8.09,80,,840,Fee Schedule,80% of Scott and White HMO fee schedule,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,170,,840,Fee Schedule,170% of Scott and White PPO fee schedule,8.09,170,,9344.6,Fee Schedule,170% of Scott and White SWHP fee schedule,7.14,150,,,Fee Schedule,150% of CMS OPPS Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,546,Fee Schedule,90% of UHC fee schedule,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4,100,,191.024,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,80,100,,114.912,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,80,
POTASSIUM URINE,41041336,CDM,301,RC,84133,HCPCS,Outpatient,,,87,52.20,,5.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.09,150,,16581.104,Fee Schedule ,150% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,280,,735.552,Fee Schedule,280% of BCBS BULE Fee Schedule,15.14,320,,765.296,Fee Schedule,320% of BCBS Blue Essentials Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,17.03,360,,945.712,Fee Schedule,360% of BCBS POS Rate,17.03,360,,945.712,Fee schedule,360% of BCBS PPO Rate,17.03,360,,945.712,Fee Schedule,360% of BCBS Traditional Rate,52.2,60,,679.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,100,,896.904,Fee Schedule,100% of TX Mediciad 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,,23502.128,Fee Schedule,100% of CMS OPPS Rate,4.25,90,,,Fee Schedule,90% of CMS OPPS Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,130,,,Fee Schedule,130% of CMS OPPS Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.09,103,,923.808,Fee Schedule,103% of TX Medicaid Rate,4.87,103,,,Fee Schedule,103% of CMS OPPS Rate,4.87,103,,,Fee Schedule,103% of CMS OPPS Rate,65.25,75,,75.6,Percent of Total Billed Charges,75% of Total Billed Charges,8.04,80,,15.072,Fee Schedule,80% of Scott and White EPO fee schedule,8.04,80,,233.904,Fee Schedule,80% of Scott and White HMO fee schedule,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8.04,170,,233.904,Fee Schedule,170% of Scott and White PPO fee schedule,8.04,170,,338.104,Fee Schedule,170% of Scott and White SWHP fee schedule,7.09,150,,,Fee Schedule,150% of CMS OPPS Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,3.83,90,,204.36,Fee Schedule,90% of UHC fee schedule,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,3.97,100,,896.904,Fee Schedule,100% of TX Medicaid Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,87,100,,100.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.83,87,
PROGESTERONE,41041443,CDM,301,RC,84144,HCPCS,Outpatient,,,242.79,145.67,,24.2,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,31.29,150,,11054.072,Fee Schedule ,150% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,58.41,280,,1632.248,Fee Schedule,280% of BCBS BULE Fee Schedule,66.75,320,,765.416,Fee Schedule,320% of BCBS Blue Essentials Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,75.1,360,,2098.608,Fee Schedule,360% of BCBS POS Rate,75.1,360,,2098.608,Fee schedule,360% of BCBS PPO Rate,75.1,360,,2098.608,Fee Schedule,360% of BCBS Traditional Rate,145.67,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,17.52,100,,7.232,Fee Schedule,100% of TX Mediciad 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,,15668.088,Fee Schedule,100% of CMS OPPS Rate,18.77,90,,,Fee Schedule,90% of CMS OPPS Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,130,,,Fee Schedule,130% of CMS OPPS Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,18.05,103,,7.448,Fee Schedule,103% of TX Medicaid Rate,21.48,103,,,Fee Schedule,103% of CMS OPPS Rate,21.48,103,,,Fee Schedule,103% of CMS OPPS Rate,182.09,75,,108.872,Percent of Total Billed Charges,75% of Total Billed Charges,35.46,80,,840,Fee Schedule,80% of Scott and White EPO fee schedule,35.46,80,,448.32,Fee Schedule,80% of Scott and White HMO fee schedule,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,35.46,170,,448.32,Fee Schedule,170% of Scott and White PPO fee schedule,35.46,170,,331.696,Fee Schedule,170% of Scott and White SWHP fee schedule,31.29,150,,,Fee Schedule,150% of CMS OPPS Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,90,,204.808,Fee Schedule,90% of UHC fee schedule,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,17.52,100,,7.232,Fee Schedule,100% of TX Medicaid Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,242.79,100,,145.16,Percent of Total Billed Charges,100% of Total Billed Charges,16.89,242.79,
PROLACTIN,41041468,CDM,301,RC,84146,HCPCS,Outpatient,,,263,157.80,,22.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,29.07,150,,11054.072,Fee Schedule ,150% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,54.26,280,,4642.536,Fee Schedule,280% of BCBS BULE Fee Schedule,62.02,320,,765.44,Fee Schedule,320% of BCBS Blue Essentials Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,69.77,360,,5968.976,Fee Schedule,360% of BCBS POS Rate,69.77,360,,5968.976,Fee schedule,360% of BCBS PPO Rate,69.77,360,,5968.976,Fee Schedule,360% of BCBS Traditional Rate,157.8,60,,273.12,Percent of Total Billed Charges,60% of Total Billed Charges,16.28,100,,378.56,Fee Schedule,100% of TX Mediciad 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,,15668.088,Fee Schedule,100% of CMS OPPS Rate,17.44,90,,,Fee Schedule,90% of CMS OPPS Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,25.19,130,,,Fee Schedule,130% of CMS OPPS Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.77,103,,389.92,Fee Schedule,103% of TX Medicaid Rate,19.96,103,,,Fee Schedule,103% of CMS OPPS Rate,19.96,103,,,Fee Schedule,103% of CMS OPPS Rate,197.25,75,,96.248,Percent of Total Billed Charges,75% of Total Billed Charges,32.94,80,,233.904,Fee Schedule,80% of Scott and White EPO fee schedule,32.94,80,,1092.632,Fee Schedule,80% of Scott and White HMO fee schedule,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,32.94,170,,1092.632,Fee Schedule,170% of Scott and White PPO fee schedule,32.94,170,,570.008,Fee Schedule,170% of Scott and White SWHP fee schedule,29.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,15.7,90,,829.84,Fee Schedule,90% of UHC fee schedule,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,16.28,100,,378.56,Fee Schedule,100% of TX Medicaid Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,263,100,,128.328,Percent of Total Billed Charges,100% of Total Billed Charges,15.7,263,
PROTEIN TOTAL NOT REFR BF,41041542,CDM,301,RC,84157,HCPCS,Outpatient,,,111.48,66.89,,4.64,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6,150,,2700,Fee Schedule ,150% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,280,,1977.248,Fee Schedule,280% of BCBS BULE Fee Schedule,12.8,320,,0.512,Fee Schedule,320% of BCBS Blue Essentials Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,14.4,360,,2542.176,Fee Schedule,360% of BCBS POS Rate,14.4,360,,2542.176,Fee schedule,360% of BCBS PPO Rate,14.4,360,,2542.176,Fee Schedule,360% of BCBS Traditional Rate,66.89,60,,270.24,Percent of Total Billed Charges,60% of Total Billed Charges,3.36,100,,56.88,Fee Schedule,100% of TX Mediciad 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,,36846.904,Fee Schedule,100% of CMS OPPS Rate,3.6,90,,,Fee Schedule,90% of CMS OPPS Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,5.2,130,,,Fee Schedule,130% of CMS OPPS Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.46,103,,58.584,Fee Schedule,103% of TX Medicaid Rate,4.12,103,,,Fee Schedule,103% of CMS OPPS Rate,4.12,103,,,Fee Schedule,103% of CMS OPPS Rate,83.61,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,6.8,80,,448.32,Fee Schedule,80% of Scott and White EPO fee schedule,6.8,80,,213.84,Fee Schedule,80% of Scott and White HMO fee schedule,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,170,,213.84,Fee Schedule,170% of Scott and White PPO fee schedule,6.8,170,,105.536,Fee Schedule,170% of Scott and White SWHP fee schedule,6,150,,,Fee Schedule,150% of CMS OPPS Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.24,90,,2220.4,Fee Schedule,90% of UHC fee schedule,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,111.48,100,,80.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.24,111.48,
TOTAL PROTEIN,41041559,CDM,301,RC,84155,HCPCS,Outpatient,,,70.22,42.13,,4.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.5,150,,1800,Fee Schedule ,150% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.28,280,,47.768,Fee Schedule,280% of BCBS BULE Fee Schedule,11.74,320,,0.52,Fee Schedule,320% of BCBS Blue Essentials Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,13.21,360,,61.416,Fee Schedule,360% of BCBS POS Rate,13.21,360,,61.416,Fee schedule,360% of BCBS PPO Rate,13.21,360,,61.416,Fee Schedule,360% of BCBS Traditional Rate,42.13,60,,245.28,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,100,,59.872,Fee Schedule,100% of TX Mediciad 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,,24564.6,Fee Schedule,100% of CMS OPPS Rate,3.3,90,,,Fee Schedule,90% of CMS OPPS Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.77,130,,,Fee Schedule,130% of CMS OPPS Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.17,103,,61.672,Fee Schedule,103% of TX Medicaid Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,52.67,75,,60.592,Percent of Total Billed Charges,75% of Total Billed Charges,6.23,80,,1092.632,Fee Schedule,80% of Scott and White EPO fee schedule,6.23,80,,321.624,Fee Schedule,80% of Scott and White HMO fee schedule,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,170,,321.624,Fee Schedule,170% of Scott and White PPO fee schedule,6.23,170,,150,Fee Schedule,170% of Scott and White SWHP fee schedule,5.5,150,,,Fee Schedule,150% of CMS OPPS Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,90,,142.24,Fee Schedule,90% of UHC fee schedule,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,70.22,100,,80.784,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,70.22,
PROTEIN TOTAL NOT REFR URINE,41041567,CDM,301,RC,84156,HCPCS,Outpatient,,,103.34,62.00,,4.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.5,150,,1800,Fee Schedule ,150% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.28,280,,79.536,Fee Schedule,280% of BCBS BULE Fee Schedule,11.74,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,13.21,360,,102.264,Fee Schedule,360% of BCBS POS Rate,13.21,360,,102.264,Fee schedule,360% of BCBS PPO Rate,13.21,360,,102.264,Fee Schedule,360% of BCBS Traditional Rate,62,60,,242.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,100,,29.72,Fee Schedule,100% of TX Mediciad 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,,24564.6,Fee Schedule,100% of CMS OPPS Rate,3.3,90,,,Fee Schedule,90% of CMS OPPS Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.77,130,,,Fee Schedule,130% of CMS OPPS Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.17,103,,30.608,Fee Schedule,103% of TX Medicaid Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,77.51,75,,71.536,Percent of Total Billed Charges,75% of Total Billed Charges,6.23,80,,213.84,Fee Schedule,80% of Scott and White EPO fee schedule,6.23,80,,545.776,Fee Schedule,80% of Scott and White HMO fee schedule,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,170,,545.776,Fee Schedule,170% of Scott and White PPO fee schedule,6.23,170,,893.416,Fee Schedule,170% of Scott and White SWHP fee schedule,5.5,150,,,Fee Schedule,150% of CMS OPPS Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,90,,42.56,Fee Schedule,90% of UHC fee schedule,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,103.34,100,,95.384,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,103.34,
PREALBUMIN,41041765,CDM,301,RC,84134,HCPCS,Outpatient,,,154,92.40,,16.92,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.88,150,,2116.344,Fee Schedule ,150% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,40.85,280,,272.888,Fee Schedule,280% of BCBS BULE Fee Schedule,46.69,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,52.52,360,,350.856,Fee Schedule,360% of BCBS POS Rate,52.52,360,,350.856,Fee schedule,360% of BCBS PPO Rate,52.52,360,,350.856,Fee Schedule,360% of BCBS Traditional Rate,92.4,60,,206.88,Percent of Total Billed Charges,60% of Total Billed Charges,12.26,100,,29.72,Fee Schedule,100% of TX Mediciad 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,,6000,Fee Schedule,100% of CMS OPPS Rate,13.13,90,,,Fee Schedule,90% of CMS OPPS Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,130,,,Fee Schedule,130% of CMS OPPS Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.63,103,,30.608,Fee Schedule,103% of TX Medicaid Rate,15.02,103,,,Fee Schedule,103% of CMS OPPS Rate,15.02,103,,,Fee Schedule,103% of CMS OPPS Rate,115.5,75,,147.376,Percent of Total Billed Charges,75% of Total Billed Charges,24.8,80,,321.624,Fee Schedule,80% of Scott and White EPO fee schedule,24.8,80,,149.688,Fee Schedule,80% of Scott and White HMO fee schedule,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,24.8,170,,149.688,Fee Schedule,170% of Scott and White PPO fee schedule,24.8,170,,633.496,Fee Schedule,170% of Scott and White SWHP fee schedule,21.88,150,,,Fee Schedule,150% of CMS OPPS Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,90,,210,Fee Schedule,90% of UHC fee schedule,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,29.72,Fee Schedule,100% of TX Medicaid Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,154,100,,196.504,Percent of Total Billed Charges,100% of Total Billed Charges,11.82,154,
PROTEIN TOTAL NOT REFR CSF,41041955,CDM,301,RC,84157,HCPCS,Outpatient,,,111.48,66.89,,4.64,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6,150,,1410.896,Fee Schedule ,150% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,280,,436.624,Fee Schedule,280% of BCBS BULE Fee Schedule,12.8,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,14.4,360,,561.368,Fee Schedule,360% of BCBS POS Rate,14.4,360,,561.368,Fee schedule,360% of BCBS PPO Rate,14.4,360,,561.368,Fee Schedule,360% of BCBS Traditional Rate,66.89,60,,204.48,Percent of Total Billed Charges,60% of Total Billed Charges,3.36,100,,301.192,Fee Schedule,100% of TX Mediciad 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,,4000,Fee Schedule,100% of CMS OPPS Rate,3.6,90,,,Fee Schedule,90% of CMS OPPS Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,5.2,130,,,Fee Schedule,130% of CMS OPPS Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.46,103,,310.232,Fee Schedule,103% of TX Medicaid Rate,4.12,103,,,Fee Schedule,103% of CMS OPPS Rate,4.12,103,,,Fee Schedule,103% of CMS OPPS Rate,83.61,75,,136.464,Percent of Total Billed Charges,75% of Total Billed Charges,6.8,80,,545.776,Fee Schedule,80% of Scott and White EPO fee schedule,6.8,80,,1373.968,Fee Schedule,80% of Scott and White HMO fee schedule,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,170,,1373.968,Fee Schedule,170% of Scott and White PPO fee schedule,6.8,170,,43.2,Fee Schedule,170% of Scott and White SWHP fee schedule,6,150,,,Fee Schedule,150% of CMS OPPS Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.24,90,,63.28,Fee Schedule,90% of UHC fee schedule,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,3.36,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,111.48,100,,181.952,Percent of Total Billed Charges,100% of Total Billed Charges,3.24,111.48,
QUINIDINE,41042300,CDM,301,RC,80194,HCPCS,Outpatient,,,149.62,89.77,,16.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.9,150,,1410.896,Fee Schedule ,150% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,40.88,280,,536.256,Fee Schedule,280% of BCBS BULE Fee Schedule,46.72,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,52.56,360,,689.472,Fee Schedule,360% of BCBS POS Rate,52.56,360,,689.472,Fee schedule,360% of BCBS PPO Rate,52.56,360,,689.472,Fee Schedule,360% of BCBS Traditional Rate,89.77,60,,196.8,Percent of Total Billed Charges,60% of Total Billed Charges,12.26,100,,6281.352,Fee Schedule,100% of TX Mediciad 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,,4000,Fee Schedule,100% of CMS OPPS Rate,13.14,90,,,Fee Schedule,90% of CMS OPPS Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.98,130,,,Fee Schedule,130% of CMS OPPS Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.63,103,,6469.792,Fee Schedule,103% of TX Medicaid Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,112.22,75,,116.4,Percent of Total Billed Charges,75% of Total Billed Charges,24.82,80,,149.688,Fee Schedule,80% of Scott and White EPO fee schedule,24.82,80,,90.24,Fee Schedule,80% of Scott and White HMO fee schedule,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,24.82,170,,90.24,Fee Schedule,170% of Scott and White PPO fee schedule,24.82,170,,76.064,Fee Schedule,170% of Scott and White SWHP fee schedule,21.9,150,,,Fee Schedule,150% of CMS OPPS Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.83,90,,470.4,Fee Schedule,90% of UHC fee schedule,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,6281.352,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,149.62,100,,155.2,Percent of Total Billed Charges,100% of Total Billed Charges,11.83,149.62,
ROTAVIRUS ANTIGEN,41042524,CDM,306,RC,87425,HCPCS,Outpatient,,,211.83,127.10,,13.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,2123.192,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,108,Fee Schedule,360% of BCBS POS Rate,43.13,360,,108,Fee schedule,360% of BCBS PPO Rate,43.13,360,,108,Fee Schedule,360% of BCBS Traditional Rate,127.1,60,,115.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,204.664,Fee Schedule,100% of TX Mediciad 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,,4702.984,Fee Schedule,100% of CMS OPPS Rate,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,210.808,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,158.87,75,,91.8,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,1373.968,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,769.936,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,769.936,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,15.072,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,33.6,Fee Schedule,90% of UHC fee schedule,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,204.664,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.83,100,,122.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,211.83,
"SODIUM, BLOOD",41042953,CDM,301,RC,84295,HCPCS,Outpatient,,,82.61,49.57,,5.58,100,,1014.304,Fee Schedule,100% of Aetna Fee Schedule,7.21,150,,2176.944,Fee Schedule ,150% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.47,280,,128.328,Fee Schedule,280% of BCBS BULE Fee Schedule,15.39,320,,0.528,Fee Schedule,320% of BCBS Blue Essentials Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,17.32,360,,164.992,Fee Schedule,360% of BCBS POS Rate,17.32,360,,164.992,Fee schedule,360% of BCBS PPO Rate,17.32,360,,164.992,Fee Schedule,360% of BCBS Traditional Rate,49.57,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,4.04,100,,672,Fee Schedule,100% of TX Mediciad 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,,3135.32,Fee Schedule,100% of CMS OPPS Rate,4.32,90,,,Fee Schedule,90% of CMS OPPS Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,130,,,Fee Schedule,130% of CMS OPPS Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.16,103,,692.16,Fee Schedule,103% of TX Medicaid Rate,4.95,103,,,Fee Schedule,103% of CMS OPPS Rate,4.95,103,,,Fee Schedule,103% of CMS OPPS Rate,61.96,75,,116.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.17,80,,90.24,Fee Schedule,80% of Scott and White EPO fee schedule,8.17,80,,1058.752,Fee Schedule,80% of Scott and White HMO fee schedule,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,170,,1058.752,Fee Schedule,170% of Scott and White PPO fee schedule,8.17,170,,840,Fee Schedule,170% of Scott and White SWHP fee schedule,7.21,150,,,Fee Schedule,150% of CMS OPPS Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.9,90,,251.92,Fee Schedule,90% of UHC fee schedule,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.04,100,,672,Fee Schedule,100% of TX Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,82.61,100,,155.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,82.61,
SODIUM URINE,41042961,CDM,301,RC,84300,HCPCS,Outpatient,,,94,56.40,,5.86,100,,1206.344,Fee Schedule,100% of Aetna Fee Schedule,7.58,150,,1340.144,Fee Schedule ,150% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.17,280,,522.528,Fee Schedule,280% of BCBS BULE Fee Schedule,16.19,320,,0.536,Fee Schedule,320% of BCBS Blue Essentials Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,18.22,360,,671.816,Fee Schedule,360% of BCBS POS Rate,18.22,360,,671.816,Fee schedule,360% of BCBS PPO Rate,18.22,360,,671.816,Fee Schedule,360% of BCBS Traditional Rate,56.4,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.25,100,,9.6,Fee Schedule,100% of TX Mediciad 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,,3135.32,Fee Schedule,100% of CMS OPPS Rate,4.55,90,,,Fee Schedule,90% of CMS OPPS Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6.57,130,,,Fee Schedule,130% of CMS OPPS Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.38,103,,9.888,Fee Schedule,103% of TX Medicaid Rate,5.21,103,,,Fee Schedule,103% of CMS OPPS Rate,5.21,103,,,Fee Schedule,103% of CMS OPPS Rate,70.5,75,,188.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.6,80,,769.936,Fee Schedule,80% of Scott and White EPO fee schedule,8.6,80,,837.528,Fee Schedule,80% of Scott and White HMO fee schedule,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,170,,837.528,Fee Schedule,170% of Scott and White PPO fee schedule,8.6,170,,233.904,Fee Schedule,170% of Scott and White SWHP fee schedule,7.58,150,,,Fee Schedule,150% of CMS OPPS Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,4.1,90,,75.04,Fee Schedule,90% of UHC fee schedule,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,4.25,100,,9.6,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,94,100,,251.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.1,94,
TESTOSTERONE TOTAL,41044033,CDM,301,RC,84403,HCPCS,Outpatient,,,254,152.40,,29.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,38.71,150,,893.432,Fee Schedule ,150% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,72.27,280,,483.56,Fee Schedule,280% of BCBS BULE Fee Schedule,82.59,320,,0.536,Fee Schedule,320% of BCBS Blue Essentials Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,92.92,360,,621.72,Fee Schedule,360% of BCBS POS Rate,92.92,360,,621.72,Fee schedule,360% of BCBS PPO Rate,92.92,360,,621.72,Fee Schedule,360% of BCBS Traditional Rate,152.4,60,,105.6,Percent of Total Billed Charges,60% of Total Billed Charges,21.68,100,,856.552,Fee Schedule,100% of TX Mediciad 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,,4718.208,Fee Schedule,100% of CMS OPPS Rate,23.22,90,,,Fee Schedule,90% of CMS OPPS Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,33.55,130,,,Fee Schedule,130% of CMS OPPS Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,22.33,103,,882.248,Fee Schedule,103% of TX Medicaid Rate,26.58,103,,,Fee Schedule,103% of CMS OPPS Rate,26.58,103,,,Fee Schedule,103% of CMS OPPS Rate,190.5,75,,53.4,Percent of Total Billed Charges,75% of Total Billed Charges,43.87,80,,1058.752,Fee Schedule,80% of Scott and White EPO fee schedule,43.87,80,,507.336,Fee Schedule,80% of Scott and White HMO fee schedule,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.87,170,,507.336,Fee Schedule,170% of Scott and White PPO fee schedule,43.87,170,,448.32,Fee Schedule,170% of Scott and White SWHP fee schedule,38.71,150,,,Fee Schedule,150% of CMS OPPS Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.91,90,,142.24,Fee Schedule,90% of UHC fee schedule,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,856.552,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,254,100,,71.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.91,254,
THYROXINE TOTAL T4,41044363,CDM,301,RC,84436,HCPCS,Outpatient,,,152.42,91.45,,7.96,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,10.3,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,19.24,280,,174.72,Fee Schedule,280% of BCBS BULE Fee Schedule,21.98,320,,0.536,Fee Schedule,320% of BCBS Blue Essentials Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,24.73,360,,224.64,Fee Schedule,360% of BCBS POS Rate,24.73,360,,224.64,Fee schedule,360% of BCBS PPO Rate,24.73,360,,224.64,Fee Schedule,360% of BCBS Traditional Rate,91.45,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,5.77,100,,480.48,Fee Schedule,100% of TX Mediciad 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,,4837.648,Fee Schedule,100% of CMS OPPS Rate,6.18,90,,,Fee Schedule,90% of CMS OPPS Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,130,,,Fee Schedule,130% of CMS OPPS Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.94,103,,494.896,Fee Schedule,103% of TX Medicaid Rate,7.07,103,,,Fee Schedule,103% of CMS OPPS Rate,7.07,103,,,Fee Schedule,103% of CMS OPPS Rate,114.32,75,,48.064,Percent of Total Billed Charges,75% of Total Billed Charges,11.67,80,,837.528,Fee Schedule,80% of Scott and White EPO fee schedule,11.67,80,,175.352,Fee Schedule,80% of Scott and White HMO fee schedule,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,170,,175.352,Fee Schedule,170% of Scott and White PPO fee schedule,11.67,170,,1092.632,Fee Schedule,170% of Scott and White SWHP fee schedule,10.3,150,,,Fee Schedule,150% of CMS OPPS Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,90,,196.784,Fee Schedule,90% of UHC fee schedule,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,480.48,Fee Schedule,100% of TX Medicaid Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,152.42,100,,64.08,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,152.42,
THYROID STIMULATING HORMONE,41044439,CDM,301,RC,84443,HCPCS,Outpatient,,,231.97,139.18,,19.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,25.2,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,47.04,280,,218.4,Fee Schedule,280% of BCBS BULE Fee Schedule,53.76,320,,0.536,Fee Schedule,320% of BCBS Blue Essentials Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,60.48,360,,280.8,Fee Schedule,360% of BCBS POS Rate,60.48,360,,280.8,Fee schedule,360% of BCBS PPO Rate,60.48,360,,280.8,Fee Schedule,360% of BCBS Traditional Rate,139.18,60,,71.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.11,100,,93.496,Fee Schedule,100% of TX Mediciad 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,,2978.096,Fee Schedule,100% of CMS OPPS Rate,15.12,90,,,Fee Schedule,90% of CMS OPPS Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,130,,,Fee Schedule,130% of CMS OPPS Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.53,103,,96.304,Fee Schedule,103% of TX Medicaid Rate,17.3,103,,,Fee Schedule,103% of CMS OPPS Rate,17.3,103,,,Fee Schedule,103% of CMS OPPS Rate,173.98,75,,116.992,Percent of Total Billed Charges,75% of Total Billed Charges,28.56,80,,507.336,Fee Schedule,80% of Scott and White EPO fee schedule,28.56,80,,1113.968,Fee Schedule,80% of Scott and White HMO fee schedule,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,28.56,170,,1113.968,Fee Schedule,170% of Scott and White PPO fee schedule,28.56,170,,213.84,Fee Schedule,170% of Scott and White SWHP fee schedule,25.2,150,,,Fee Schedule,150% of CMS OPPS Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,90,,1770.536,Fee Schedule,90% of UHC fee schedule,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,93.496,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,231.97,100,,155.984,Percent of Total Billed Charges,100% of Total Billed Charges,13.61,231.97,
ASPARTATE AMINOTRANSFEREA,41044504,CDM,301,RC,84450,HCPCS,Outpatient,,,91.98,55.19,,6,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,835.2,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,81.744,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,0.536,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,105.096,Fee Schedule,360% of BCBS POS Rate,18.65,360,,105.096,Fee schedule,360% of BCBS PPO Rate,18.65,360,,105.096,Fee Schedule,360% of BCBS Traditional Rate,55.19,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,931.84,Fee Schedule,100% of TX Mediciad 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,,1985.4,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,959.792,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,68.99,75,,412.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,175.352,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,903.48,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,903.48,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,321.624,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,186.304,Fee Schedule,90% of UHC fee schedule,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,931.84,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,91.98,100,,550.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,91.98,
ALANINE AMINOTRANSFERASE,41044603,CDM,301,RC,84460,HCPCS,Outpatient,,,95.83,57.50,,6.14,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.95,150,,884.376,Fee Schedule ,150% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,280,,81.92,Fee Schedule,280% of BCBS BULE Fee Schedule,16.96,320,,0.544,Fee Schedule,320% of BCBS Blue Essentials Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,19.08,360,,105.328,Fee Schedule,360% of BCBS POS Rate,19.08,360,,105.328,Fee schedule,360% of BCBS PPO Rate,19.08,360,,105.328,Fee Schedule,360% of BCBS Traditional Rate,57.5,60,,65.28,Percent of Total Billed Charges,60% of Total Billed Charges,4.45,100,,259.36,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,4.77,90,,,Fee Schedule,90% of CMS OPPS Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,130,,,Fee Schedule,130% of CMS OPPS Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.58,103,,267.144,Fee Schedule,103% of TX Medicaid Rate,5.45,103,,,Fee Schedule,103% of CMS OPPS Rate,5.45,103,,,Fee Schedule,103% of CMS OPPS Rate,71.87,75,,36.992,Percent of Total Billed Charges,75% of Total Billed Charges,9.01,80,,1113.968,Fee Schedule,80% of Scott and White EPO fee schedule,9.01,80,,389.84,Fee Schedule,80% of Scott and White HMO fee schedule,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,170,,389.84,Fee Schedule,170% of Scott and White PPO fee schedule,9.01,170,,545.776,Fee Schedule,170% of Scott and White SWHP fee schedule,7.95,150,,,Fee Schedule,150% of CMS OPPS Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,90,,336,Fee Schedule,90% of UHC fee schedule,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,4.45,100,,259.36,Fee Schedule,100% of TX Medicaid Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,95.83,100,,49.32,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,95.83,
TOBRAMYCIN,41044686,CDM,301,RC,80200,HCPCS,Outpatient,,,910.8,546.48,,18.72,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,24.19,150,,884.376,Fee Schedule ,150% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,45.16,280,,331.936,Fee Schedule,280% of BCBS BULE Fee Schedule,51.62,320,,0.544,Fee Schedule,320% of BCBS Blue Essentials Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,58.07,360,,426.776,Fee Schedule,360% of BCBS POS Rate,58.07,360,,426.776,Fee schedule,360% of BCBS PPO Rate,58.07,360,,426.776,Fee Schedule,360% of BCBS Traditional Rate,546.48,60,,63.84,Percent of Total Billed Charges,60% of Total Billed Charges,13.55,100,,628.136,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,14.51,90,,,Fee Schedule,90% of CMS OPPS Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20.96,130,,,Fee Schedule,130% of CMS OPPS Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.96,103,,646.976,Fee Schedule,103% of TX Medicaid Rate,16.61,103,,,Fee Schedule,103% of CMS OPPS Rate,16.61,103,,,Fee Schedule,103% of CMS OPPS Rate,683.1,75,,80.4,Percent of Total Billed Charges,75% of Total Billed Charges,27.42,80,,903.48,Fee Schedule,80% of Scott and White EPO fee schedule,27.42,80,,389.84,Fee Schedule,80% of Scott and White HMO fee schedule,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,27.42,170,,389.84,Fee Schedule,170% of Scott and White PPO fee schedule,27.42,170,,149.688,Fee Schedule,170% of Scott and White SWHP fee schedule,24.19,150,,,Fee Schedule,150% of CMS OPPS Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,90,,210,Fee Schedule,90% of UHC fee schedule,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,628.136,Fee Schedule,100% of TX Medicaid Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,910.8,100,,107.2,Percent of Total Billed Charges,100% of Total Billed Charges,13.07,910.8,
TRIGLYCERIDES,41044751,CDM,301,RC,84478,HCPCS,Outpatient,,,111.65,66.99,,6.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.61,150,,830.776,Fee Schedule ,150% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,280,,888.16,Fee Schedule,280% of BCBS BULE Fee Schedule,18.37,320,,0.544,Fee Schedule,320% of BCBS Blue Essentials Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,20.66,360,,1141.92,Fee Schedule,360% of BCBS POS Rate,20.66,360,,1141.92,Fee schedule,360% of BCBS PPO Rate,20.66,360,,1141.92,Fee Schedule,360% of BCBS Traditional Rate,66.99,60,,62.88,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,100,,867.04,Fee Schedule,100% of TX Mediciad 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,,1856,Fee Schedule,100% of CMS OPPS Rate,5.16,90,,,Fee Schedule,90% of CMS OPPS Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,7.46,130,,,Fee Schedule,130% of CMS OPPS Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.96,103,,893.048,Fee Schedule,103% of TX Medicaid Rate,5.91,103,,,Fee Schedule,103% of CMS OPPS Rate,5.91,103,,,Fee Schedule,103% of CMS OPPS Rate,83.74,75,,57.904,Percent of Total Billed Charges,75% of Total Billed Charges,9.75,80,,389.84,Fee Schedule,80% of Scott and White EPO fee schedule,9.75,80,,60,Fee Schedule,80% of Scott and White HMO fee schedule,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.75,170,,60,Fee Schedule,170% of Scott and White PPO fee schedule,9.75,170,,1373.968,Fee Schedule,170% of Scott and White SWHP fee schedule,8.61,150,,,Fee Schedule,150% of CMS OPPS Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,90,,845.952,Fee Schedule,90% of UHC fee schedule,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,4.82,100,,867.04,Fee Schedule,100% of TX Medicaid Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,111.65,100,,77.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.65,111.65,
UREA NITROGEN QT,41045204,CDM,301,RC,84520,HCPCS,Outpatient,,,85,51.00,,4.58,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.92,150,,1623.136,Fee Schedule ,150% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,280,,56.896,Fee Schedule,280% of BCBS BULE Fee Schedule,12.64,320,,0.544,Fee Schedule,320% of BCBS Blue Essentials Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,14.22,360,,73.152,Fee Schedule,360% of BCBS POS Rate,14.22,360,,73.152,Fee schedule,360% of BCBS PPO Rate,14.22,360,,73.152,Fee Schedule,360% of BCBS Traditional Rate,51,60,,61.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.32,100,,366.624,Fee Schedule,100% of TX Mediciad 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,,1965.28,Fee Schedule,100% of CMS OPPS Rate,3.55,90,,,Fee Schedule,90% of CMS OPPS Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.13,130,,,Fee Schedule,130% of CMS OPPS Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.42,103,,377.616,Fee Schedule,103% of TX Medicaid Rate,4.06,103,,,Fee Schedule,103% of CMS OPPS Rate,4.06,103,,,Fee Schedule,103% of CMS OPPS Rate,63.75,75,,485.816,Percent of Total Billed Charges,75% of Total Billed Charges,6.71,80,,389.84,Fee Schedule,80% of Scott and White EPO fee schedule,6.71,80,,739.056,Fee Schedule,80% of Scott and White HMO fee schedule,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.71,170,,739.056,Fee Schedule,170% of Scott and White PPO fee schedule,6.71,170,,90.24,Fee Schedule,170% of Scott and White SWHP fee schedule,5.92,150,,,Fee Schedule,150% of CMS OPPS Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,90,,2285.92,Fee Schedule,90% of UHC fee schedule,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.32,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,85,100,,647.752,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,85,
UREA NITROGEN URINE,41045402,CDM,301,RC,84540,HCPCS,Outpatient,,,104.75,62.85,,6.44,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,8.33,150,,1623.136,Fee Schedule ,150% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,280,,17.024,Fee Schedule,280% of BCBS BULE Fee Schedule,17.79,320,,0.552,Fee Schedule,320% of BCBS Blue Essentials Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,20.02,360,,21.888,Fee Schedule,360% of BCBS POS Rate,20.02,360,,21.888,Fee schedule,360% of BCBS PPO Rate,20.02,360,,21.888,Fee Schedule,360% of BCBS Traditional Rate,62.85,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,4.67,100,,252,Fee Schedule,100% of TX Mediciad 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,,1965.28,Fee Schedule,100% of CMS OPPS Rate,5,90,,,Fee Schedule,90% of CMS OPPS Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,130,,,Fee Schedule,130% of CMS OPPS Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.81,103,,259.56,Fee Schedule,103% of TX Medicaid Rate,5.72,103,,,Fee Schedule,103% of CMS OPPS Rate,5.72,103,,,Fee Schedule,103% of CMS OPPS Rate,78.56,75,,62.64,Percent of Total Billed Charges,75% of Total Billed Charges,9.45,80,,60,Fee Schedule,80% of Scott and White EPO fee schedule,9.45,80,,106.144,Fee Schedule,80% of Scott and White HMO fee schedule,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,9.45,170,,106.144,Fee Schedule,170% of Scott and White PPO fee schedule,9.45,170,,769.936,Fee Schedule,170% of Scott and White SWHP fee schedule,8.33,150,,,Fee Schedule,150% of CMS OPPS Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4.5,90,,127.272,Fee Schedule,90% of UHC fee schedule,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,4.67,100,,252,Fee Schedule,100% of TX Medicaid Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,104.75,100,,83.52,Percent of Total Billed Charges,100% of Total Billed Charges,4.5,104.75,
URIC ACID BLOOD,41045501,CDM,301,RC,84550,HCPCS,Outpatient,,,93.91,56.35,,5.24,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.77,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,12.66,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,14.46,320,,0.552,Fee Schedule,320% of BCBS Blue Essentials Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,16.27,360,,108,Fee Schedule,360% of BCBS POS Rate,16.27,360,,108,Fee schedule,360% of BCBS PPO Rate,16.27,360,,108,Fee Schedule,360% of BCBS Traditional Rate,56.35,60,,283.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.8,100,,347.984,Fee Schedule,100% of TX Mediciad 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,,1846.176,Fee Schedule,100% of CMS OPPS Rate,4.06,90,,,Fee Schedule,90% of CMS OPPS Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.87,130,,,Fee Schedule,130% of CMS OPPS Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.91,103,,358.424,Fee Schedule,103% of TX Medicaid Rate,4.65,103,,,Fee Schedule,103% of CMS OPPS Rate,4.65,103,,,Fee Schedule,103% of CMS OPPS Rate,70.43,75,,56.92,Percent of Total Billed Charges,75% of Total Billed Charges,7.68,80,,739.056,Fee Schedule,80% of Scott and White EPO fee schedule,7.68,80,,649.92,Fee Schedule,80% of Scott and White HMO fee schedule,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.68,170,,649.92,Fee Schedule,170% of Scott and White PPO fee schedule,7.68,170,,1058.752,Fee Schedule,170% of Scott and White SWHP fee schedule,6.77,150,,,Fee Schedule,150% of CMS OPPS Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3.66,90,,167.416,Fee Schedule,90% of UHC fee schedule,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,347.984,Fee Schedule,100% of TX Medicaid Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,93.91,100,,75.888,Percent of Total Billed Charges,100% of Total Billed Charges,3.66,93.91,
DEPAKENE VALPROIC ACID,41045840,CDM,301,RC,80164,HCPCS,Outpatient,,,233.6,140.16,,15.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.3,150,,255.368,Fee Schedule ,150% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,37.91,280,,25.312,Fee Schedule,280% of BCBS BULE Fee Schedule,43.33,320,,0.552,Fee Schedule,320% of BCBS Blue Essentials Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,48.74,360,,32.544,Fee Schedule,360% of BCBS POS Rate,48.74,360,,32.544,Fee schedule,360% of BCBS PPO Rate,48.74,360,,32.544,Fee Schedule,360% of BCBS Traditional Rate,140.16,60,,288.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.37,100,,715.696,Fee Schedule,100% of TX Mediciad 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,,3606.96,Fee Schedule,100% of CMS OPPS Rate,12.18,90,,,Fee Schedule,90% of CMS OPPS Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,17.6,130,,,Fee Schedule,130% of CMS OPPS Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.71,103,,737.168,Fee Schedule,103% of TX Medicaid Rate,13.94,103,,,Fee Schedule,103% of CMS OPPS Rate,13.94,103,,,Fee Schedule,103% of CMS OPPS Rate,175.2,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,23.01,80,,106.144,Fee Schedule,80% of Scott and White EPO fee schedule,23.01,80,,179.2,Fee Schedule,80% of Scott and White HMO fee schedule,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,23.01,170,,179.2,Fee Schedule,170% of Scott and White PPO fee schedule,23.01,170,,837.528,Fee Schedule,170% of Scott and White SWHP fee schedule,20.3,150,,,Fee Schedule,150% of CMS OPPS Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,90,,84,Fee Schedule,90% of UHC fee schedule,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,11.37,100,,715.696,Fee Schedule,100% of TX Medicaid Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,233.6,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.97,233.6,
DIFF MANUAL,41050071,CDM,305,RC,85007,HCPCS,Outpatient,,,199.68,119.81,,4.4,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,5.7,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,280,,188.16,Fee Schedule,280% of BCBS BULE Fee Schedule,12.16,320,,0.552,Fee Schedule,320% of BCBS Blue Essentials Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,13.68,360,,241.92,Fee Schedule,360% of BCBS POS Rate,13.68,360,,241.92,Fee schedule,360% of BCBS PPO Rate,13.68,360,,241.92,Fee Schedule,360% of BCBS Traditional Rate,119.81,60,,528.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.19,100,,366.624,Fee Schedule,100% of TX Mediciad 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,,3606.96,Fee Schedule,100% of CMS OPPS Rate,3.42,90,,,Fee Schedule,90% of CMS OPPS Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.94,130,,,Fee Schedule,130% of CMS OPPS Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.29,103,,377.616,Fee Schedule,103% of TX Medicaid Rate,3.91,103,,,Fee Schedule,103% of CMS OPPS Rate,3.91,103,,,Fee Schedule,103% of CMS OPPS Rate,149.76,75,,101.144,Percent of Total Billed Charges,75% of Total Billed Charges,6.46,80,,649.92,Fee Schedule,80% of Scott and White EPO fee schedule,6.46,80,,354,Fee Schedule,80% of Scott and White HMO fee schedule,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,170,,354,Fee Schedule,170% of Scott and White PPO fee schedule,6.46,170,,507.336,Fee Schedule,170% of Scott and White SWHP fee schedule,5.7,150,,,Fee Schedule,150% of CMS OPPS Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,90,,736.8,Fee Schedule,90% of UHC fee schedule,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.19,100,,366.624,Fee Schedule,100% of TX Medicaid Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,199.68,100,,134.856,Percent of Total Billed Charges,100% of Total Billed Charges,3.08,199.68,
HEMATOCRIT,41050147,CDM,305,RC,85014,HCPCS,Outpatient,,,61.65,36.99,,2.74,100,,294.904,Fee Schedule,100% of Aetna Fee Schedule,3.55,150,,336.272,Fee Schedule ,150% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,280,,13.44,Fee Schedule,280% of BCBS BULE Fee Schedule,7.58,320,,0.56,Fee Schedule,320% of BCBS Blue Essentials Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,8.53,360,,17.28,Fee Schedule,360% of BCBS POS Rate,8.53,360,,17.28,Fee schedule,360% of BCBS PPO Rate,8.53,360,,17.28,Fee Schedule,360% of BCBS Traditional Rate,36.99,60,,724.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,100,,579.488,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,2.13,90,,,Fee Schedule,90% of CMS OPPS Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,130,,,Fee Schedule,130% of CMS OPPS Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.05,103,,596.872,Fee Schedule,103% of TX Medicaid Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,46.24,75,,144.672,Percent of Total Billed Charges,75% of Total Billed Charges,4.02,80,,179.2,Fee Schedule,80% of Scott and White EPO fee schedule,4.02,80,,2651.224,Fee Schedule,80% of Scott and White HMO fee schedule,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,170,,2651.224,Fee Schedule,170% of Scott and White PPO fee schedule,4.02,170,,175.352,Fee Schedule,170% of Scott and White SWHP fee schedule,3.55,150,,,Fee Schedule,150% of CMS OPPS Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.92,90,,84,Fee Schedule,90% of UHC fee schedule,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,579.488,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,61.65,100,,192.896,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,61.65,
HEMOGLOBIN,41050188,CDM,305,RC,85018,HCPCS,Outpatient,,,57.75,34.65,,2.74,100,,628.752,Fee Schedule,100% of Aetna Fee Schedule,3.55,150,,575.536,Fee Schedule ,150% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,280,,100.768,Fee Schedule,280% of BCBS BULE Fee Schedule,7.58,320,,0.56,Fee Schedule,320% of BCBS Blue Essentials Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,8.53,360,,129.56,Fee Schedule,360% of BCBS POS Rate,8.53,360,,129.56,Fee schedule,360% of BCBS PPO Rate,8.53,360,,129.56,Fee Schedule,360% of BCBS Traditional Rate,34.65,60,,843.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,100,,1100.192,Fee Schedule,100% of TX Mediciad 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,,567.48,Fee Schedule,100% of CMS OPPS Rate,2.13,90,,,Fee Schedule,90% of CMS OPPS Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,130,,,Fee Schedule,130% of CMS OPPS Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.05,103,,1133.192,Fee Schedule,103% of TX Medicaid Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,43.31,75,,77.768,Percent of Total Billed Charges,75% of Total Billed Charges,4.02,80,,354,Fee Schedule,80% of Scott and White EPO fee schedule,4.02,80,,358.776,Fee Schedule,80% of Scott and White HMO fee schedule,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,170,,358.776,Fee Schedule,170% of Scott and White PPO fee schedule,4.02,170,,1113.968,Fee Schedule,170% of Scott and White SWHP fee schedule,3.55,150,,,Fee Schedule,150% of CMS OPPS Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.92,90,,179.624,Fee Schedule,90% of UHC fee schedule,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,1100.192,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,57.75,100,,103.688,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,57.75,
COMPL BLD CNT (AUTO DIFF),41050287,CDM,305,RC,85025,HCPCS,Outpatient,,,150,90.00,,9.02,100,,1096.976,Fee Schedule,100% of Aetna Fee Schedule,11.65,150,,575.536,Fee Schedule ,150% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,21.76,280,,30.016,Fee Schedule,280% of BCBS BULE Fee Schedule,24.86,320,,0.56,Fee Schedule,320% of BCBS Blue Essentials Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,27.97,360,,38.592,Fee Schedule,360% of BCBS POS Rate,27.97,360,,38.592,Fee schedule,360% of BCBS PPO Rate,27.97,360,,38.592,Fee Schedule,360% of BCBS Traditional Rate,90,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,100,,870.688,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,6.99,90,,,Fee Schedule,90% of CMS OPPS Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,10.1,130,,,Fee Schedule,130% of CMS OPPS Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.73,103,,896.808,Fee Schedule,103% of TX Medicaid Rate,8,103,,,Fee Schedule,103% of CMS OPPS Rate,8,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,129,Percent of Total Billed Charges,75% of Total Billed Charges,13.2,80,,2651.224,Fee Schedule,80% of Scott and White EPO fee schedule,13.2,80,,4758.6,Fee Schedule,80% of Scott and White HMO fee schedule,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,170,,4758.6,Fee Schedule,170% of Scott and White PPO fee schedule,13.2,170,,903.48,Fee Schedule,170% of Scott and White SWHP fee schedule,11.65,150,,,Fee Schedule,150% of CMS OPPS Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.29,90,,249.2,Fee Schedule,90% of UHC fee schedule,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,6.53,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,172,Percent of Total Billed Charges,100% of Total Billed Charges,6.29,150,
RETICULOCYTE COUNT AUTO,41050451,CDM,305,RC,85045,HCPCS,Outpatient,,,92,55.20,,4.62,100,,605.2,Fee Schedule,100% of Aetna Fee Schedule,5.98,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,280,,56.896,Fee Schedule,280% of BCBS BULE Fee Schedule,12.77,320,,0.568,Fee Schedule,320% of BCBS Blue Essentials Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,14.36,360,,73.152,Fee Schedule,360% of BCBS POS Rate,14.36,360,,73.152,Fee schedule,360% of BCBS PPO Rate,14.36,360,,73.152,Fee Schedule,360% of BCBS Traditional Rate,55.2,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.35,100,,870.688,Fee Schedule,100% of TX Mediciad 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,,747.272,Fee Schedule,100% of CMS OPPS Rate,3.59,90,,,Fee Schedule,90% of CMS OPPS Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,130,,,Fee Schedule,130% of CMS OPPS Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.45,103,,896.808,Fee Schedule,103% of TX Medicaid Rate,4.1,103,,,Fee Schedule,103% of CMS OPPS Rate,4.1,103,,,Fee Schedule,103% of CMS OPPS Rate,69,75,,75.448,Percent of Total Billed Charges,75% of Total Billed Charges,6.78,80,,358.776,Fee Schedule,80% of Scott and White EPO fee schedule,6.78,80,,4751.808,Fee Schedule,80% of Scott and White HMO fee schedule,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,170,,4751.808,Fee Schedule,170% of Scott and White PPO fee schedule,6.78,170,,389.84,Fee Schedule,170% of Scott and White SWHP fee schedule,5.98,150,,,Fee Schedule,150% of CMS OPPS Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.23,90,,2371.6,Fee Schedule,90% of UHC fee schedule,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.35,100,,870.688,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,92,100,,100.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.23,92,
WBC STOOL,41050493,CDM,300,RC,89055,HCPCS,Outpatient,,,102.25,61.35,,4.96,100,,1052.024,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,78.712,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,0.568,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,101.2,Fee Schedule,360% of BCBS POS Rate,15.37,360,,101.2,Fee schedule,360% of BCBS PPO Rate,15.37,360,,101.2,Fee Schedule,360% of BCBS Traditional Rate,61.35,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,122.64,Fee Schedule,100% of TX Mediciad 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,,1278.976,Fee Schedule,100% of CMS OPPS Rate,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,126.32,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,76.69,75,,113.4,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,4758.6,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,682.224,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,682.224,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,389.84,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,74.592,Fee Schedule,90% of UHC fee schedule,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.25,100,,151.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,102.25,
D DIMER QUANTITATIVE,41053802,CDM,305,RC,85379,HCPCS,Outpatient,,,209.32,125.59,,11.8,100,,1174.24,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,321.744,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,708.216,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,0.576,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,910.56,Fee Schedule,360% of BCBS POS Rate,36.65,360,,910.56,Fee schedule,360% of BCBS PPO Rate,36.65,360,,910.56,Fee Schedule,360% of BCBS Traditional Rate,125.59,60,,3592.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,122.64,Fee Schedule,100% of TX Mediciad 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,,1278.976,Fee Schedule,100% of CMS OPPS Rate,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,126.32,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,156.99,75,,27.536,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,4751.808,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,3203.216,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,3203.216,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,60,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,94.136,Fee Schedule,90% of UHC fee schedule,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,122.64,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,209.32,100,,36.712,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,209.32,
FIBRINOGEN,41053844,CDM,305,RC,85384,HCPCS,Outpatient,,,171.15,102.69,,11.28,100,,1379.512,Fee Schedule,100% of Aetna Fee Schedule,14.58,150,,5722.464,Fee Schedule ,150% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,280,,74.52,Fee Schedule,280% of BCBS BULE Fee Schedule,31.1,320,,0.576,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,34.99,360,,95.808,Fee Schedule,360% of BCBS POS Rate,34.99,360,,95.808,Fee schedule,360% of BCBS PPO Rate,34.99,360,,95.808,Fee Schedule,360% of BCBS Traditional Rate,102.69,60,,3916.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,100,,508.552,Fee Schedule,100% of TX Mediciad 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,,640.032,Fee Schedule,100% of CMS OPPS Rate,8.74,90,,,Fee Schedule,90% of CMS OPPS Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,130,,,Fee Schedule,130% of CMS OPPS Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.4,103,,523.808,Fee Schedule,103% of TX Medicaid Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,128.36,75,,111.6,Percent of Total Billed Charges,75% of Total Billed Charges,16.52,80,,682.224,Fee Schedule,80% of Scott and White EPO fee schedule,16.52,80,,25.832,Fee Schedule,80% of Scott and White HMO fee schedule,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,16.52,170,,25.832,Fee Schedule,170% of Scott and White PPO fee schedule,16.52,170,,739.056,Fee Schedule,170% of Scott and White SWHP fee schedule,14.58,150,,,Fee Schedule,150% of CMS OPPS Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,7.88,90,,211.176,Fee Schedule,90% of UHC fee schedule,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,100,,148.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.88,171.15,
PFA 2,41055765,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,919.672,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,5722.464,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,0.584,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,172.8,Fee Schedule,360% of BCBS POS Rate,89.68,360,,172.8,Fee schedule,360% of BCBS PPO Rate,89.68,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,141,60,,3916.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,762.824,Fee Schedule,100% of TX Mediciad 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,,640.032,Fee Schedule,100% of CMS OPPS Rate,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,785.712,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,90.256,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,3203.216,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,1352,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,1352,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,106.144,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,594.896,Fee Schedule,90% of UHC fee schedule,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,762.824,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PFA PLATELET FUNCT ASSAY,41055773,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,919.672,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,8583.704,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,0.584,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,108,Fee Schedule,360% of BCBS POS Rate,89.68,360,,108,Fee schedule,360% of BCBS PPO Rate,89.68,360,,108,Fee Schedule,360% of BCBS Traditional Rate,141,60,,381.6,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,508.552,Fee Schedule,100% of TX Mediciad 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,,714.984,Fee Schedule,100% of CMS OPPS Rate,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,523.808,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,20.8,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,25.832,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,203.152,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,203.152,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,649.92,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,174.784,Fee Schedule,90% of UHC fee schedule,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,508.552,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,27.736,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATELET COUNT,41055955,CDM,305,RC,85049,HCPCS,Outpatient,,,98.26,58.96,,5.2,100,,843.368,Fee Schedule,100% of Aetna Fee Schedule,6.72,150,,4633.44,Fee Schedule ,150% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,280,,338.384,Fee Schedule,280% of BCBS BULE Fee Schedule,14.34,320,,0.584,Fee Schedule,320% of BCBS Blue Essentials Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,16.13,360,,435.064,Fee Schedule,360% of BCBS POS Rate,16.13,360,,435.064,Fee schedule,360% of BCBS PPO Rate,16.13,360,,435.064,Fee Schedule,360% of BCBS Traditional Rate,58.96,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,3.76,100,,475.864,Fee Schedule,100% of TX Mediciad 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,,12716.592,Fee Schedule,100% of CMS OPPS Rate,4.03,90,,,Fee Schedule,90% of CMS OPPS Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,130,,,Fee Schedule,130% of CMS OPPS Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.87,103,,490.136,Fee Schedule,103% of TX Medicaid Rate,4.61,103,,,Fee Schedule,103% of CMS OPPS Rate,4.61,103,,,Fee Schedule,103% of CMS OPPS Rate,73.7,75,,82.368,Percent of Total Billed Charges,75% of Total Billed Charges,7.61,80,,1352,Fee Schedule,80% of Scott and White EPO fee schedule,7.61,80,,213.84,Fee Schedule,80% of Scott and White HMO fee schedule,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.61,170,,213.84,Fee Schedule,170% of Scott and White PPO fee schedule,7.61,170,,179.2,Fee Schedule,170% of Scott and White SWHP fee schedule,6.72,150,,,Fee Schedule,150% of CMS OPPS Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.63,90,,100.24,Fee Schedule,90% of UHC fee schedule,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,3.76,100,,475.864,Fee Schedule,100% of TX Medicaid Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,98.26,100,,109.824,Percent of Total Billed Charges,100% of Total Billed Charges,3.63,98.26,
PROTHROMBIN TIME,41056102,CDM,305,RC,85610,HCPCS,Outpatient,,,90,54.00,,4.98,100,,1240.192,Fee Schedule,100% of Aetna Fee Schedule,6.43,150,,4633.44,Fee Schedule ,150% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,280,,914.368,Fee Schedule,280% of BCBS BULE Fee Schedule,13.73,320,,0.584,Fee Schedule,320% of BCBS Blue Essentials Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,15.44,360,,1175.616,Fee Schedule,360% of BCBS POS Rate,15.44,360,,1175.616,Fee schedule,360% of BCBS PPO Rate,15.44,360,,1175.616,Fee Schedule,360% of BCBS Traditional Rate,54,60,,1794.72,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,100,,532.96,Fee Schedule,100% of TX Mediciad 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,,12716.592,Fee Schedule,100% of CMS OPPS Rate,3.86,90,,,Fee Schedule,90% of CMS OPPS Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,130,,,Fee Schedule,130% of CMS OPPS Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.71,103,,548.952,Fee Schedule,103% of TX Medicaid Rate,4.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4.41,103,,,Fee Schedule,103% of CMS OPPS Rate,67.5,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,7.29,80,,203.152,Fee Schedule,80% of Scott and White EPO fee schedule,7.29,80,,106.144,Fee Schedule,80% of Scott and White HMO fee schedule,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,7.29,170,,106.144,Fee Schedule,170% of Scott and White PPO fee schedule,7.29,170,,354,Fee Schedule,170% of Scott and White SWHP fee schedule,6.43,150,,,Fee Schedule,150% of CMS OPPS Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.47,90,,63.28,Fee Schedule,90% of UHC fee schedule,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,3.6,100,,532.96,Fee Schedule,100% of TX Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,90,100,,62.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.47,90,
PTT,41057308,CDM,305,RC,85730,HCPCS,Outpatient,,,123,73.80,,6.98,100,,926.832,Fee Schedule,100% of Aetna Fee Schedule,9.01,150,,6950.16,Fee Schedule ,150% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16.83,280,,50.912,Fee Schedule,280% of BCBS BULE Fee Schedule,19.23,320,,0.584,Fee Schedule,320% of BCBS Blue Essentials Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,21.64,360,,65.456,Fee Schedule,360% of BCBS POS Rate,21.64,360,,65.456,Fee schedule,360% of BCBS PPO Rate,21.64,360,,65.456,Fee Schedule,360% of BCBS Traditional Rate,73.8,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,5.05,100,,2580.816,Fee Schedule,100% of TX Mediciad 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,,19074.896,Fee Schedule,100% of CMS OPPS Rate,5.4,90,,,Fee Schedule,90% of CMS OPPS Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,130,,,Fee Schedule,130% of CMS OPPS Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.2,103,,2658.24,Fee Schedule,103% of TX Medicaid Rate,6.19,103,,,Fee Schedule,103% of CMS OPPS Rate,6.19,103,,,Fee Schedule,103% of CMS OPPS Rate,92.25,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,10.21,80,,213.84,Fee Schedule,80% of Scott and White EPO fee schedule,10.21,80,,106.144,Fee Schedule,80% of Scott and White HMO fee schedule,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.21,170,,106.144,Fee Schedule,170% of Scott and White PPO fee schedule,10.21,170,,2651.224,Fee Schedule,170% of Scott and White SWHP fee schedule,9.01,150,,,Fee Schedule,150% of CMS OPPS Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.87,90,,269.44,Fee Schedule,90% of UHC fee schedule,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,5.05,100,,2580.816,Fee Schedule,100% of TX Medicaid Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,123,100,,62.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.87,123,
INFECTIOUS MONONUCLEOSIS,41060039,CDM,302,RC,86308,HCPCS,Outpatient,,,142,85.20,,6,100,,926.832,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,10669.608,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,66.968,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,0.6,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,86.096,Fee Schedule,360% of BCBS POS Rate,18.65,360,,86.096,Fee schedule,360% of BCBS PPO Rate,18.65,360,,86.096,Fee Schedule,360% of BCBS Traditional Rate,85.2,60,,177.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,3473.016,Fee Schedule,100% of TX Mediciad 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,,10296.536,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,3577.208,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,106.5,75,,292.656,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,106.144,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,1075.696,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,1075.696,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,358.776,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,3148.296,Fee Schedule,90% of UHC fee schedule,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,3473.016,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,142,100,,390.208,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,142,
COLD AGGLUTININ TITER,41060153,CDM,300,RC,86157,HCPCS,Outpatient,,,130.5,78.30,,9.34,100,,1490.632,Fee Schedule,100% of Aetna Fee Schedule,12.09,150,,10669.608,Fee Schedule ,150% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,22.57,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,25.79,320,,0.6,Fee Schedule,320% of BCBS Blue Essentials Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,29.02,360,,43.2,Fee Schedule,360% of BCBS POS Rate,29.02,360,,43.2,Fee schedule,360% of BCBS PPO Rate,29.02,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,78.3,60,,1497.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.77,100,,4948.944,Fee Schedule,100% of TX Mediciad 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,,10296.536,Fee Schedule,100% of CMS OPPS Rate,7.25,90,,,Fee Schedule,90% of CMS OPPS Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,130,,,Fee Schedule,130% of CMS OPPS Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.97,103,,5097.416,Fee Schedule,103% of TX Medicaid Rate,8.3,103,,,Fee Schedule,103% of CMS OPPS Rate,8.3,103,,,Fee Schedule,103% of CMS OPPS Rate,97.88,75,,57.944,Percent of Total Billed Charges,75% of Total Billed Charges,13.7,80,,106.144,Fee Schedule,80% of Scott and White EPO fee schedule,13.7,80,,22433.4,Fee Schedule,80% of Scott and White HMO fee schedule,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,13.7,170,,22433.4,Fee Schedule,170% of Scott and White PPO fee schedule,13.7,170,,4758.6,Fee Schedule,170% of Scott and White SWHP fee schedule,12.09,150,,,Fee Schedule,150% of CMS OPPS Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,90,,336,Fee Schedule,90% of UHC fee schedule,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,4948.944,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,130.5,100,,77.256,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,130.5,
AB SCRN RBC EA SERUM TECHNIQUE,41060161,CDM,302,RC,86850,HCPCS,Outpatient,,,166.06,99.64,,11.34,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,87.888,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,294.72,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,378.928,Fee Schedule,360% of BCBS POS Rate,178.09,360,,378.928,Fee schedule,360% of BCBS PPO Rate,178.09,360,,378.928,Fee Schedule,360% of BCBS Traditional Rate,99.64,60,,6627.584,Percent of Total Billed Charges,60% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,15444.8,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.95,14.42,,3577.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,124.55,75,,110.464,Percent of Total Billed Charges,75% of Total Billed Charges,16.6,80,,1075.696,Fee Schedule,80% of Scott and White EPO fee schedule,16.6,80,,730.952,Fee Schedule,80% of Scott and White HMO fee schedule,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,170,,730.952,Fee Schedule,170% of Scott and White PPO fee schedule,16.6,170,,4751.808,Fee Schedule,170% of Scott and White SWHP fee schedule,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.91,90,,2451.464,Fee Schedule,90% of UHC fee schedule,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,14,,3473.016,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,166.06,100,,147.28,Percent of Total Billed Charges,100% of Total Billed Charges,7.91,178.09,
C REACTIVE PROTEIN,41060211,CDM,302,RC,86140,HCPCS,Outpatient,,,137.33,82.40,,6,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,87.888,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,43.2,Fee Schedule,360% of BCBS POS Rate,18.65,360,,43.2,Fee schedule,360% of BCBS PPO Rate,18.65,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,82.4,60,,5983.064,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,31.52,Fee Schedule,100% of TX Mediciad 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,,23710.232,Fee Schedule,100% of CMS OPPS Rate,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,32.464,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,103,75,,212.512,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,22433.4,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,2400,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,2400,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,682.224,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,29.4,Fee Schedule,90% of UHC fee schedule,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,31.52,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,137.33,100,,283.352,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,137.33,
ANTIBODY IDENTIFICATION,41060245,CDM,300,RC,86870,HCPCS,Outpatient,,,308.2,184.92,,53.16,100,,588.064,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,235.736,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,71.848,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,92.376,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,92.376,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,92.376,Fee Schedule,360% of BCBS Traditional Rate,184.92,60,,3563,Percent of Total Billed Charges,60% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,23710.232,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,44.44,14.42,,536.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,231.15,75,,198.816,Percent of Total Billed Charges,75% of Total Billed Charges,154.1,50,,730.952,Percent of Total Billed Charges,50% of Total Billed Charges,154.1,50,,34.28,Percent of Total Billed Charges,50% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,154.1,50,,34.28,Percent of Total Billed Charges,50% of Total Billed Charges,154.1,50,,3203.216,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,336,Fee Schedule,90% of UHC fee schedule,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.15,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,308.2,100,,265.088,Percent of Total Billed Charges,100% of Total Billed Charges,43.15,1020.28,
DIRECT ANTIGLOB TEST,41060310,CDM,300,RC,86880,HCPCS,Outpatient,,,109,65.40,,6.26,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,111.152,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,99.68,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,120.35,360,,128.16,Fee Schedule,360% of BCBS POS Rate,120.35,360,,128.16,Fee schedule,360% of BCBS PPO Rate,120.35,360,,128.16,Fee Schedule,360% of BCBS Traditional Rate,65.4,60,,5865.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,100,,34.696,Fee Schedule,100% of TX Mediciad Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,195.304,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.67,103,,35.736,Fee Schedule,103% of TX Medicaid Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,81.75,75,,320.272,Percent of Total Billed Charges,75% of Total Billed Charges,9.16,80,,2400,Fee Schedule,80% of Scott and White EPO fee schedule,9.16,80,,3059.104,Fee Schedule,80% of Scott and White HMO fee schedule,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,170,,3059.104,Fee Schedule,170% of Scott and White PPO fee schedule,9.16,170,,25.832,Fee Schedule,170% of Scott and White SWHP fee schedule,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,336,Fee Schedule,90% of UHC fee schedule,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,34.696,Fee Schedule,100% of TX Medicaid Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,109,100,,427.024,Percent of Total Billed Charges,100% of Total Billed Charges,4.37,120.35,
ANTINCL AB TITR,41060419,CDM,302,RC,86039,HCPCS,Outpatient,,,185,111.00,,12.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,16.74,150,,600.208,Fee Schedule ,150% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,31.25,280,,948.64,Fee Schedule,280% of BCBS BULE Fee Schedule,35.71,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,40.18,360,,1219.68,Fee Schedule,360% of BCBS POS Rate,40.18,360,,1219.68,Fee schedule,360% of BCBS PPO Rate,40.18,360,,1219.68,Fee Schedule,360% of BCBS Traditional Rate,111,60,,5984.16,Percent of Total Billed Charges,60% of Total Billed Charges,9.37,100,,136.448,Fee Schedule,100% of TX Mediciad 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,,195.304,Fee Schedule,100% of CMS OPPS Rate,10.04,90,,,Fee Schedule,90% of CMS OPPS Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,130,,,Fee Schedule,130% of CMS OPPS Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.65,103,,140.536,Fee Schedule,103% of TX Medicaid Rate,11.49,103,,,Fee Schedule,103% of CMS OPPS Rate,11.49,103,,,Fee Schedule,103% of CMS OPPS Rate,138.75,75,,338.32,Percent of Total Billed Charges,75% of Total Billed Charges,18.97,80,,34.28,Fee Schedule,80% of Scott and White EPO fee schedule,18.97,80,,1716,Fee Schedule,80% of Scott and White HMO fee schedule,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,170,,1716,Fee Schedule,170% of Scott and White PPO fee schedule,18.97,170,,1352,Fee Schedule,170% of Scott and White SWHP fee schedule,16.74,150,,,Fee Schedule,150% of CMS OPPS Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,90,,1479.52,Fee Schedule,90% of UHC fee schedule,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,9.37,100,,136.448,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,185,100,,451.096,Percent of Total Billed Charges,100% of Total Billed Charges,9.04,185,
ASO TITER,41060609,CDM,302,RC,86060,HCPCS,Outpatient,,,152,91.20,,8.46,100,,430.528,Fee Schedule,100% of Aetna Fee Schedule,10.95,150,,5023.984,Fee Schedule ,150% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,280,,29.84,Fee Schedule,280% of BCBS BULE Fee Schedule,23.36,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,26.28,360,,38.36,Fee Schedule,360% of BCBS POS Rate,26.28,360,,38.36,Fee schedule,360% of BCBS PPO Rate,26.28,360,,38.36,Fee Schedule,360% of BCBS Traditional Rate,91.2,60,,16742.704,Percent of Total Billed Charges,60% of Total Billed Charges,6.13,100,,345.104,Fee Schedule,100% of TX Mediciad 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,,523.856,Fee Schedule,100% of CMS OPPS Rate,6.57,90,,,Fee Schedule,90% of CMS OPPS Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.49,130,,,Fee Schedule,130% of CMS OPPS Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.31,103,,355.464,Fee Schedule,103% of TX Medicaid Rate,7.51,103,,,Fee Schedule,103% of CMS OPPS Rate,7.51,103,,,Fee Schedule,103% of CMS OPPS Rate,114,75,,270.168,Percent of Total Billed Charges,75% of Total Billed Charges,12.41,80,,3059.104,Fee Schedule,80% of Scott and White EPO fee schedule,12.41,80,,333.928,Fee Schedule,80% of Scott and White HMO fee schedule,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,170,,333.928,Fee Schedule,170% of Scott and White PPO fee schedule,12.41,170,,203.152,Fee Schedule,170% of Scott and White SWHP fee schedule,10.95,150,,,Fee Schedule,150% of CMS OPPS Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.91,90,,1706.88,Fee Schedule,90% of UHC fee schedule,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,6.13,100,,345.104,Fee Schedule,100% of TX Medicaid Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,152,100,,360.224,Percent of Total Billed Charges,100% of Total Billed Charges,5.91,152,
ABO GROUP ONLY,41060807,CDM,300,RC,86900,HCPCS,Outpatient,,,87,52.20,,3.46,100,,1336.76,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,475.2,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,37.656,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,0.608,Fee Schedule,320% of BCBS Blue Essentials Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,392.51,360,,48.416,Fee Schedule,360% of BCBS POS Rate,392.51,360,,48.416,Fee schedule,360% of BCBS PPO Rate,392.51,360,,48.416,Fee Schedule,360% of BCBS Traditional Rate,52.2,60,,2200.264,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,100,,266.336,Fee Schedule,100% of TX Mediciad Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,247,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.59,103,,274.328,Fee Schedule,103% of TX Medicaid Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,65.25,75,,5520,Percent of Total Billed Charges,75% of Total Billed Charges,5.08,80,,1716,Fee Schedule,80% of Scott and White EPO fee schedule,5.08,80,,3328,Fee Schedule,80% of Scott and White HMO fee schedule,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,170,,3328,Fee Schedule,170% of Scott and White PPO fee schedule,5.08,170,,213.84,Fee Schedule,170% of Scott and White SWHP fee schedule,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2.42,90,,480.48,Fee Schedule,90% of UHC fee schedule,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,266.336,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,87,100,,7360,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,392.51,
RH TYPE ONLY,41061003,CDM,300,RC,86901,HCPCS,Outpatient,,,92.66,55.60,,3.46,100,,1291.56,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,475.2,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,84.472,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,0.616,Fee Schedule,320% of BCBS Blue Essentials Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,120.35,360,,108.608,Fee Schedule,360% of BCBS POS Rate,120.35,360,,108.608,Fee schedule,360% of BCBS PPO Rate,120.35,360,,108.608,Fee Schedule,360% of BCBS Traditional Rate,55.6,60,,3083.192,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,100,,152.624,Fee Schedule,100% of TX Mediciad Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,1333.8,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.59,103,,157.208,Fee Schedule,103% of TX Medicaid Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,69.5,75,,927.6,Percent of Total Billed Charges,75% of Total Billed Charges,5.08,80,,333.928,Fee Schedule,80% of Scott and White EPO fee schedule,5.08,80,,926.296,Fee Schedule,80% of Scott and White HMO fee schedule,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,170,,926.296,Fee Schedule,170% of Scott and White PPO fee schedule,5.08,170,,106.144,Fee Schedule,170% of Scott and White SWHP fee schedule,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,2.42,90,,224,Fee Schedule,90% of UHC fee schedule,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,152.624,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,92.66,100,,1236.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,120.35,
CARCINOEMBRYONIC ANTIGEN,41061516,CDM,301,RC,82378,HCPCS,Outpatient,,,225.4,135.24,,22,100,,1956.808,Fee Schedule,100% of Aetna Fee Schedule,28.44,150,,475.2,Fee Schedule ,150% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,53.09,280,,237.96,Fee Schedule,280% of BCBS BULE Fee Schedule,60.67,320,,0.616,Fee Schedule,320% of BCBS Blue Essentials Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,68.26,360,,305.944,Fee Schedule,360% of BCBS POS Rate,68.26,360,,305.944,Fee schedule,360% of BCBS PPO Rate,68.26,360,,305.944,Fee Schedule,360% of BCBS Traditional Rate,135.24,60,,8640,Percent of Total Billed Charges,60% of Total Billed Charges,15.93,100,,127.656,Fee Schedule,100% of TX Mediciad 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,,11164.4,Fee Schedule,100% of CMS OPPS Rate,17.06,90,,,Fee Schedule,90% of CMS OPPS Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,24.64,130,,,Fee Schedule,130% of CMS OPPS Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,16.41,103,,131.488,Fee Schedule,103% of TX Medicaid Rate,19.52,103,,,Fee Schedule,103% of CMS OPPS Rate,19.52,103,,,Fee Schedule,103% of CMS OPPS Rate,169.05,75,,1064.856,Percent of Total Billed Charges,75% of Total Billed Charges,32.23,80,,3328,Fee Schedule,80% of Scott and White EPO fee schedule,32.23,80,,2243.344,Fee Schedule,80% of Scott and White HMO fee schedule,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,32.23,170,,2243.344,Fee Schedule,170% of Scott and White PPO fee schedule,32.23,170,,106.144,Fee Schedule,170% of Scott and White SWHP fee schedule,28.44,150,,,Fee Schedule,150% of CMS OPPS Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,15.35,90,,174.72,Fee Schedule,90% of UHC fee schedule,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,127.656,Fee Schedule,100% of TX Medicaid Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,225.4,100,,1419.808,Percent of Total Billed Charges,100% of Total Billed Charges,15.35,225.4,
AB MUMPS IGG,41061805,CDM,302,RC,86735,HCPCS,Outpatient,,,148.88,89.33,,15.14,100,,886.864,Fee Schedule,100% of Aetna Fee Schedule,19.57,150,,1503.328,Fee Schedule ,150% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,36.54,280,,69.912,Fee Schedule,280% of BCBS BULE Fee Schedule,41.76,320,,0.616,Fee Schedule,320% of BCBS Blue Essentials Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,46.98,360,,89.888,Fee Schedule,360% of BCBS POS Rate,46.98,360,,89.888,Fee schedule,360% of BCBS PPO Rate,46.98,360,,89.888,Fee Schedule,360% of BCBS Traditional Rate,89.33,60,,936,Percent of Total Billed Charges,60% of Total Billed Charges,10.96,100,,146.376,Fee Schedule,100% of TX Mediciad 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,,1056,Fee Schedule,100% of CMS OPPS Rate,11.74,90,,,Fee Schedule,90% of CMS OPPS Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.96,130,,,Fee Schedule,130% of CMS OPPS Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,11.29,103,,150.768,Fee Schedule,103% of TX Medicaid Rate,13.44,103,,,Fee Schedule,103% of CMS OPPS Rate,13.44,103,,,Fee Schedule,103% of CMS OPPS Rate,111.66,75,,1676.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.18,80,,926.296,Fee Schedule,80% of Scott and White EPO fee schedule,22.18,80,,3096.56,Fee Schedule,80% of Scott and White HMO fee schedule,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.18,170,,3096.56,Fee Schedule,170% of Scott and White PPO fee schedule,22.18,170,,1075.696,Fee Schedule,170% of Scott and White SWHP fee schedule,19.57,150,,,Fee Schedule,150% of CMS OPPS Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,90,,336,Fee Schedule,90% of UHC fee schedule,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,146.376,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,148.88,100,,2235.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,148.88,
ABBREVIATED CROSSMATCH,41062100,CDM,300,RC,86920,HCPCS,Outpatient,,,199.16,119.50,,43.18,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,1503.328,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,40.096,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,0.616,Fee Schedule,320% of BCBS Blue Essentials Rate,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,51.552,Fee Schedule,360% of BCBS POS Rate,516.6,360,,51.552,Fee schedule,360% of BCBS PPO Rate,516.6,360,,51.552,Fee Schedule,360% of BCBS Traditional Rate,119.5,60,,2739.36,Percent of Total Billed Charges,60% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1056,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,28.72,14.42,,994.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,149.37,75,,763.952,Percent of Total Billed Charges,75% of Total Billed Charges,99.58,50,,2243.344,Percent of Total Billed Charges,50% of Total Billed Charges,99.58,50,,1309.36,Percent of Total Billed Charges,50% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,99.58,50,,1309.36,Percent of Total Billed Charges,50% of Total Billed Charges,99.58,50,,22433.4,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,1389.36,Fee Schedule,90% of UHC fee schedule,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,27.88,14,,965.808,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,199.16,100,,1018.6,Percent of Total Billed Charges,100% of Total Billed Charges,27.88,516.6,
"CROSSMATCH -37,AHG,CC",41062126,CDM,300,RC,86922,HCPCS,Outpatient,,,228.7,137.22,,46.1,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,2254.992,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,25.312,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,0.624,Fee Schedule,320% of BCBS Blue Essentials Rate,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,32.544,Fee Schedule,360% of BCBS POS Rate,516.6,360,,32.544,Fee schedule,360% of BCBS PPO Rate,516.6,360,,32.544,Fee Schedule,360% of BCBS Traditional Rate,137.22,60,,3737.76,Percent of Total Billed Charges,60% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1056,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.98,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,171.53,75,,367.32,Percent of Total Billed Charges,75% of Total Billed Charges,114.35,50,,3096.56,Percent of Total Billed Charges,50% of Total Billed Charges,114.35,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,114.35,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,114.35,50,,730.952,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,432.32,Fee Schedule,90% of UHC fee schedule,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,32.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,228.7,100,,489.76,Percent of Total Billed Charges,100% of Total Billed Charges,32.02,516.6,
THAW FFP EACH UNIT,41062647,CDM,300,RC,86927,HCPCS,Outpatient,,,113.51,68.11,,24.5,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,846.832,Fee Schedule ,150% of CMS OPPS Rate,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,36.32,280,,107.776,Fee Schedule,280% of BCBS BULE Fee Schedule,41.5,320,,0.624,Fee Schedule,320% of BCBS Blue Essentials Rate,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,46.69,360,,138.568,Fee Schedule,360% of BCBS POS Rate,46.69,360,,138.568,Fee schedule,360% of BCBS PPO Rate,46.69,360,,138.568,Fee Schedule,360% of BCBS Traditional Rate,68.11,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,156.69,100,,3340.728,Fee Schedule,100% of CMS OPPS Rate,141.02,90,,,Fee Schedule,90% of CMS OPPS Rate,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,16.37,14.42,,157.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,85.13,75,,174.056,Percent of Total Billed Charges,75% of Total Billed Charges,56.76,50,,1309.36,Percent of Total Billed Charges,50% of Total Billed Charges,56.76,50,,1242.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,56.76,50,,1242.8,Percent of Total Billed Charges,50% of Total Billed Charges,56.76,50,,2400,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,463.912,Fee Schedule,90% of UHC fee schedule,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.89,14,,152.816,Percent of Total Billed Charges,14% of Total Billed Charges,156.69,100,,,Fee Schedule,100% of CMS OPPS Rate,113.51,100,,232.072,Percent of Total Billed Charges,100% of Total Billed Charges,15.89,235.05,
HEP B SURF ANTIGEN,41062878,CDM,306,RC,87340,HCPCS,Outpatient,,,158,94.80,,11.98,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,15.49,150,,846.832,Fee Schedule ,150% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,28.92,280,,1259.32,Fee Schedule,280% of BCBS BULE Fee Schedule,33.06,320,,0.624,Fee Schedule,320% of BCBS Blue Essentials Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,37.19,360,,1619.12,Fee Schedule,360% of BCBS POS Rate,37.19,360,,1619.12,Fee schedule,360% of BCBS PPO Rate,37.19,360,,1619.12,Fee Schedule,360% of BCBS Traditional Rate,94.8,60,,1279.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.68,100,,492.992,Fee Schedule,100% of TX Mediciad 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,,3340.728,Fee Schedule,100% of CMS OPPS Rate,9.29,90,,,Fee Schedule,90% of CMS OPPS Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,130,,,Fee Schedule,130% of CMS OPPS Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.94,103,,507.784,Fee Schedule,103% of TX Medicaid Rate,10.63,103,,,Fee Schedule,103% of CMS OPPS Rate,10.63,103,,,Fee Schedule,103% of CMS OPPS Rate,118.5,75,,200.832,Percent of Total Billed Charges,75% of Total Billed Charges,17.56,80,,900,Fee Schedule,80% of Scott and White EPO fee schedule,17.56,80,,2556.048,Fee Schedule,80% of Scott and White HMO fee schedule,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,17.56,170,,2556.048,Fee Schedule,170% of Scott and White PPO fee schedule,17.56,170,,34.28,Fee Schedule,170% of Scott and White SWHP fee schedule,15.49,150,,,Fee Schedule,150% of CMS OPPS Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,8.37,90,,432.32,Fee Schedule,90% of UHC fee schedule,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,158,100,,267.776,Percent of Total Billed Charges,100% of Total Billed Charges,8.37,158,
AB HEP B SURFACE,41062928,CDM,302,RC,86706,HCPCS,Outpatient,,,158,94.80,,12.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,16.11,150,,1270.24,Fee Schedule ,150% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,30.07,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,34.37,320,,0.632,Fee Schedule,320% of BCBS Blue Essentials Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,38.66,360,,172.8,Fee Schedule,360% of BCBS POS Rate,38.66,360,,172.8,Fee schedule,360% of BCBS PPO Rate,38.66,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,94.8,60,,3332.16,Percent of Total Billed Charges,60% of Total Billed Charges,9.02,100,,157.184,Fee Schedule,100% of TX Mediciad 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,,5011.088,Fee Schedule,100% of CMS OPPS Rate,9.66,90,,,Fee Schedule,90% of CMS OPPS Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.96,130,,,Fee Schedule,130% of CMS OPPS Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.29,103,,161.896,Fee Schedule,103% of TX Medicaid Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,118.5,75,,200.832,Percent of Total Billed Charges,75% of Total Billed Charges,18.25,80,,1242.8,Fee Schedule,80% of Scott and White EPO fee schedule,18.25,80,,1309.36,Fee Schedule,80% of Scott and White HMO fee schedule,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.25,170,,1309.36,Fee Schedule,170% of Scott and White PPO fee schedule,18.25,170,,3059.104,Fee Schedule,170% of Scott and White SWHP fee schedule,16.11,150,,,Fee Schedule,150% of CMS OPPS Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,90,,756.76,Fee Schedule,90% of UHC fee schedule,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,157.184,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,158,100,,267.776,Percent of Total Billed Charges,100% of Total Billed Charges,8.7,158,
AB HEPATITIS B CORE IGM,41062944,CDM,301,RC,86705,HCPCS,Outpatient,,,189.71,113.83,,13.66,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,17.65,150,,468.384,Fee Schedule ,150% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.96,280,,980.584,Fee Schedule,280% of BCBS BULE Fee Schedule,37.66,320,,0.632,Fee Schedule,320% of BCBS Blue Essentials Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,42.37,360,,1260.752,Fee Schedule,360% of BCBS POS Rate,42.37,360,,1260.752,Fee schedule,360% of BCBS PPO Rate,42.37,360,,1260.752,Fee Schedule,360% of BCBS Traditional Rate,113.83,60,,6499.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.89,100,,155.528,Fee Schedule,100% of TX Mediciad 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,,1881.84,Fee Schedule,100% of CMS OPPS Rate,10.59,90,,,Fee Schedule,90% of CMS OPPS Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,130,,,Fee Schedule,130% of CMS OPPS Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,10.19,103,,160.192,Fee Schedule,103% of TX Medicaid Rate,12.12,103,,,Fee Schedule,103% of CMS OPPS Rate,12.12,103,,,Fee Schedule,103% of CMS OPPS Rate,142.28,75,,143.92,Percent of Total Billed Charges,75% of Total Billed Charges,20,80,,2556.048,Fee Schedule,80% of Scott and White EPO fee schedule,20,80,,2069.6,Fee Schedule,80% of Scott and White HMO fee schedule,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,20,170,,2069.6,Fee Schedule,170% of Scott and White PPO fee schedule,20,170,,1716,Fee Schedule,170% of Scott and White SWHP fee schedule,17.65,150,,,Fee Schedule,150% of CMS OPPS Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.53,90,,3299.52,Fee Schedule,90% of UHC fee schedule,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,155.528,Fee Schedule,100% of TX Medicaid Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,189.71,100,,191.896,Percent of Total Billed Charges,100% of Total Billed Charges,9.53,189.71,
HEP A AB IGM,41062977,CDM,301,RC,86709,HCPCS,Outpatient,,,199.36,119.62,,13.06,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,16.89,150,,468.384,Fee Schedule ,150% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,31.53,280,,11.76,Fee Schedule,280% of BCBS BULE Fee Schedule,36.03,320,,0.64,Fee Schedule,320% of BCBS Blue Essentials Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,40.54,360,,15.12,Fee Schedule,360% of BCBS POS Rate,40.54,360,,15.12,Fee schedule,360% of BCBS PPO Rate,40.54,360,,15.12,Fee Schedule,360% of BCBS Traditional Rate,119.62,60,,2364.96,Percent of Total Billed Charges,60% of Total Billed Charges,9.46,100,,180.184,Fee Schedule,100% of TX Mediciad 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,,1881.84,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,Fee Schedule,90% of CMS OPPS Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,130,,,Fee Schedule,130% of CMS OPPS Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.74,103,,185.584,Fee Schedule,103% of TX Medicaid Rate,11.59,103,,,Fee Schedule,103% of CMS OPPS Rate,11.59,103,,,Fee Schedule,103% of CMS OPPS Rate,149.52,75,,138.12,Percent of Total Billed Charges,75% of Total Billed Charges,19.14,80,,1309.36,Fee Schedule,80% of Scott and White EPO fee schedule,19.14,80,,3929.248,Fee Schedule,80% of Scott and White HMO fee schedule,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,19.14,170,,3929.248,Fee Schedule,170% of Scott and White PPO fee schedule,19.14,170,,333.928,Fee Schedule,170% of Scott and White SWHP fee schedule,16.89,150,,,Fee Schedule,150% of CMS OPPS Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,90,,3568.88,Fee Schedule,90% of UHC fee schedule,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,9.46,100,,180.184,Fee Schedule,100% of TX Medicaid Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,199.36,100,,184.16,Percent of Total Billed Charges,100% of Total Billed Charges,9.12,199.36,
AB HEPATITIS C,41063041,CDM,301,RC,86803,HCPCS,Outpatient,,,217.28,130.37,,16.56,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.4,150,,1389.152,Fee Schedule ,150% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.96,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,45.66,320,,0.648,Fee Schedule,320% of BCBS Blue Essentials Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,51.37,360,,172.8,Fee Schedule,360% of BCBS POS Rate,51.37,360,,172.8,Fee schedule,360% of BCBS PPO Rate,51.37,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,130.37,60,,1342.56,Percent of Total Billed Charges,60% of Total Billed Charges,11.99,100,,133.36,Fee Schedule,100% of TX Mediciad 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,,2822.752,Fee Schedule,100% of CMS OPPS Rate,12.84,90,,,Fee Schedule,90% of CMS OPPS Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,18.55,130,,,Fee Schedule,130% of CMS OPPS Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,12.35,103,,137.36,Fee Schedule,103% of TX Medicaid Rate,14.69,103,,,Fee Schedule,103% of CMS OPPS Rate,14.69,103,,,Fee Schedule,103% of CMS OPPS Rate,162.96,75,,114.696,Percent of Total Billed Charges,75% of Total Billed Charges,24.25,80,,2069.6,Fee Schedule,80% of Scott and White EPO fee schedule,24.25,80,,3109.6,Fee Schedule,80% of Scott and White HMO fee schedule,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,24.25,170,,3109.6,Fee Schedule,170% of Scott and White PPO fee schedule,24.25,170,,3328,Fee Schedule,170% of Scott and White SWHP fee schedule,21.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,11.56,90,,4870.32,Fee Schedule,90% of UHC fee schedule,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,11.99,100,,133.36,Fee Schedule,100% of TX Medicaid Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,217.28,100,,152.928,Percent of Total Billed Charges,100% of Total Billed Charges,11.56,217.28,
PSA TOTAL,41063165,CDM,301,RC,84153,HCPCS,Outpatient,,,200.62,120.37,,21.34,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,27.58,150,,1389.152,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.49,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,58.85,320,,0.648,Fee Schedule,320% of BCBS Blue Essentials Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,66.2,360,,172.8,Fee Schedule,360% of BCBS POS Rate,66.2,360,,172.8,Fee schedule,360% of BCBS PPO Rate,66.2,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,120.37,60,,504,Percent of Total Billed Charges,60% of Total Billed Charges,15.45,100,,114.24,Fee Schedule,100% of TX Mediciad 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,,1040.848,Fee Schedule,100% of CMS OPPS Rate,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.9,130,,,Fee Schedule,130% of CMS OPPS Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.91,103,,117.664,Fee Schedule,103% of TX Medicaid Rate,18.94,103,,,Fee Schedule,103% of CMS OPPS Rate,18.94,103,,,Fee Schedule,103% of CMS OPPS Rate,150.47,75,,159.6,Percent of Total Billed Charges,75% of Total Billed Charges,31.26,80,,3929.248,Fee Schedule,80% of Scott and White EPO fee schedule,31.26,80,,3109.6,Fee Schedule,80% of Scott and White HMO fee schedule,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.26,170,,3109.6,Fee Schedule,170% of Scott and White PPO fee schedule,31.26,170,,926.296,Fee Schedule,170% of Scott and White SWHP fee schedule,27.58,150,,,Fee Schedule,150% of CMS OPPS Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,5411.28,Fee Schedule,90% of UHC fee schedule,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,114.24,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,200.62,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,200.62,
"RUBELLA,AB",41063181,CDM,302,RC,86762,HCPCS,Outpatient,,,135.25,81.15,,16.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,2083.728,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,591.808,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,0.664,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,760.896,Fee Schedule,360% of BCBS POS Rate,51.8,360,,760.896,Fee schedule,360% of BCBS PPO Rate,51.8,360,,760.896,Fee Schedule,360% of BCBS Traditional Rate,81.15,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,166.464,Fee Schedule,100% of TX Mediciad 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,,1040.848,Fee Schedule,100% of CMS OPPS Rate,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,171.456,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,101.44,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,3109.6,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,438,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,438,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,2243.344,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,2467.92,Fee Schedule,90% of UHC fee schedule,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,135.25,100,,114.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,135.25,
RESPIRATORY SYNC VIRUS SC,41064148,CDM,306,RC,87420,HCPCS,Outpatient,,,243,145.80,,16.14,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.86,150,,546.448,Fee Schedule ,150% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,38.95,280,,682.752,Fee Schedule,280% of BCBS BULE Fee Schedule,44.51,320,,0.672,Fee Schedule,320% of BCBS Blue Essentials Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,50.08,360,,877.824,Fee Schedule,360% of BCBS POS Rate,50.08,360,,877.824,Fee schedule,360% of BCBS PPO Rate,50.08,360,,877.824,Fee Schedule,360% of BCBS Traditional Rate,145.8,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,11.68,100,,1533.032,Fee Schedule,100% of TX Mediciad 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,,3087,Fee Schedule,100% of CMS OPPS Rate,12.51,90,,,Fee Schedule,90% of CMS OPPS Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,18.08,130,,,Fee Schedule,130% of CMS OPPS Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,12.03,103,,1579.024,Fee Schedule,103% of TX Medicaid Rate,14.32,103,,,Fee Schedule,103% of CMS OPPS Rate,14.32,103,,,Fee Schedule,103% of CMS OPPS Rate,182.25,75,,146.344,Percent of Total Billed Charges,75% of Total Billed Charges,23.64,80,,3109.6,Fee Schedule,80% of Scott and White EPO fee schedule,23.64,80,,438,Fee Schedule,80% of Scott and White HMO fee schedule,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,170,,438,Fee Schedule,170% of Scott and White PPO fee schedule,23.64,170,,3096.56,Fee Schedule,170% of Scott and White SWHP fee schedule,20.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,90,,64.96,Fee Schedule,90% of UHC fee schedule,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,11.68,100,,1533.032,Fee Schedule,100% of TX Medicaid Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,243,100,,195.128,Percent of Total Billed Charges,100% of Total Billed Charges,11.27,243,
RHEUMATOID ARTHRITIS SCRE,41064312,CDM,302,RC,86430,HCPCS,Outpatient,,,139.13,83.48,,7.12,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.21,150,,823.28,Fee Schedule ,150% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,280,,192.192,Fee Schedule,280% of BCBS BULE Fee Schedule,19.65,320,,0.672,Fee Schedule,320% of BCBS Blue Essentials Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,22.1,360,,247.104,Fee Schedule,360% of BCBS POS Rate,22.1,360,,247.104,Fee schedule,360% of BCBS PPO Rate,22.1,360,,247.104,Fee Schedule,360% of BCBS Traditional Rate,83.48,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,100,,22.984,Fee Schedule,100% of TX Mediciad 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,,3087,Fee Schedule,100% of CMS OPPS Rate,5.52,90,,,Fee Schedule,90% of CMS OPPS Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7.98,130,,,Fee Schedule,130% of CMS OPPS Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.31,103,,23.672,Fee Schedule,103% of TX Medicaid Rate,6.32,103,,,Fee Schedule,103% of CMS OPPS Rate,6.32,103,,,Fee Schedule,103% of CMS OPPS Rate,104.35,75,,210.6,Percent of Total Billed Charges,75% of Total Billed Charges,10.43,80,,438,Fee Schedule,80% of Scott and White EPO fee schedule,10.43,80,,1816.248,Fee Schedule,80% of Scott and White HMO fee schedule,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,170,,1816.248,Fee Schedule,170% of Scott and White PPO fee schedule,10.43,170,,1309.36,Fee Schedule,170% of Scott and White SWHP fee schedule,9.21,150,,,Fee Schedule,150% of CMS OPPS Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4.98,90,,165.2,Fee Schedule,90% of UHC fee schedule,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,5.16,100,,22.984,Fee Schedule,100% of TX Medicaid Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,139.13,100,,280.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.98,139.13,
RPR,41065921,CDM,302,RC,86592,HCPCS,Outpatient,,,92.22,55.33,,4.96,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,823.28,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,89.6,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,0.68,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,115.2,Fee Schedule,360% of BCBS POS Rate,15.37,360,,115.2,Fee schedule,360% of BCBS PPO Rate,15.37,360,,115.2,Fee Schedule,360% of BCBS Traditional Rate,55.33,60,,6240,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,7.752,Fee Schedule,100% of TX Mediciad 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,,4630.504,Fee Schedule,100% of CMS OPPS Rate,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,7.984,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,69.17,75,,88.2,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,438,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,2724.376,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,2724.376,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,900,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,230.72,Fee Schedule,90% of UHC fee schedule,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,92.22,100,,117.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,92.22,
SYPHILIS TEST QT VDRL,41065939,CDM,302,RC,86593,HCPCS,Outpatient,,,107.3,64.38,,5.1,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,6.6,150,,546.448,Fee Schedule ,150% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,280,,69.888,Fee Schedule,280% of BCBS BULE Fee Schedule,14.08,320,,0.68,Fee Schedule,320% of BCBS Blue Essentials Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,15.84,360,,89.856,Fee Schedule,360% of BCBS POS Rate,15.84,360,,89.856,Fee schedule,360% of BCBS PPO Rate,15.84,360,,89.856,Fee Schedule,360% of BCBS Traditional Rate,64.38,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,3.7,100,,10.568,Fee Schedule,100% of TX Mediciad 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,,1214.32,Fee Schedule,100% of CMS OPPS Rate,3.96,90,,,Fee Schedule,90% of CMS OPPS Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,5.72,130,,,Fee Schedule,130% of CMS OPPS Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.81,103,,10.888,Fee Schedule,103% of TX Medicaid Rate,4.53,103,,,Fee Schedule,103% of CMS OPPS Rate,4.53,103,,,Fee Schedule,103% of CMS OPPS Rate,80.48,75,,141.6,Percent of Total Billed Charges,75% of Total Billed Charges,7.48,80,,1816.248,Fee Schedule,80% of Scott and White EPO fee schedule,7.48,80,,1816.248,Fee Schedule,80% of Scott and White HMO fee schedule,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,170,,1816.248,Fee Schedule,170% of Scott and White PPO fee schedule,7.48,170,,1242.8,Fee Schedule,170% of Scott and White SWHP fee schedule,6.6,150,,,Fee Schedule,150% of CMS OPPS Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.56,90,,882,Fee Schedule,90% of UHC fee schedule,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,107.3,100,,188.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.56,107.3,
AB HIV 1 & HIV 2 SNGL ASSAY,41067034,CDM,302,RC,86703,HCPCS,Outpatient,,,203.21,121.93,,15.9,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,20.56,150,,381.6,Fee Schedule ,150% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,38.39,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,43.87,320,,0.688,Fee Schedule,320% of BCBS Blue Essentials Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,49.36,360,,172.8,Fee Schedule,360% of BCBS POS Rate,49.36,360,,172.8,Fee schedule,360% of BCBS PPO Rate,49.36,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,121.93,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,11.52,100,,166.464,Fee Schedule,100% of TX Mediciad 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,,1829.504,Fee Schedule,100% of CMS OPPS Rate,12.33,90,,,Fee Schedule,90% of CMS OPPS Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,130,,,Fee Schedule,130% of CMS OPPS Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.87,103,,171.456,Fee Schedule,103% of TX Medicaid Rate,14.12,103,,,Fee Schedule,103% of CMS OPPS Rate,14.12,103,,,Fee Schedule,103% of CMS OPPS Rate,152.41,75,,192.232,Percent of Total Billed Charges,75% of Total Billed Charges,23.3,80,,2724.376,Fee Schedule,80% of Scott and White EPO fee schedule,23.3,80,,1699.504,Fee Schedule,80% of Scott and White HMO fee schedule,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,170,,1699.504,Fee Schedule,170% of Scott and White PPO fee schedule,23.3,170,,2556.048,Fee Schedule,170% of Scott and White SWHP fee schedule,20.56,150,,,Fee Schedule,150% of CMS OPPS Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,11.11,90,,7280,Fee Schedule,90% of UHC fee schedule,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,166.464,Fee Schedule,100% of TX Medicaid Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,203.21,100,,256.312,Percent of Total Billed Charges,100% of Total Billed Charges,11.11,203.21,
"RUBEOLA,AB",41067653,CDM,302,RC,86765,HCPCS,Outpatient,,,134.83,80.90,,14.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,87.888,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,555.744,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,714.528,Fee Schedule,360% of BCBS POS Rate,46.37,360,,714.528,Fee schedule,360% of BCBS PPO Rate,46.37,360,,714.528,Fee Schedule,360% of BCBS Traditional Rate,80.9,60,,35.136,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,73.68,Fee Schedule,100% of TX Mediciad 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,,1829.504,Fee Schedule,100% of CMS OPPS Rate,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,75.888,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,101.12,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,1816.248,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,1903.44,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,1903.44,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,1309.36,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,1260,Fee Schedule,90% of UHC fee schedule,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,134.83,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,134.83,
"VARICEL ZSTR,AB",41067877,CDM,302,RC,86787,HCPCS,Outpatient,,,153.32,91.99,,14.94,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,187.2,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,172.928,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,222.336,Fee Schedule,360% of BCBS POS Rate,46.37,360,,222.336,Fee schedule,360% of BCBS PPO Rate,46.37,360,,222.336,Fee Schedule,360% of BCBS Traditional Rate,91.99,60,,3363.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,55.952,Fee Schedule,100% of TX Mediciad 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,,1214.32,Fee Schedule,100% of CMS OPPS Rate,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,57.632,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,114.99,75,,508.824,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,1699.504,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,12403.632,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,12403.632,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,2069.6,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,4360.72,Fee Schedule,90% of UHC fee schedule,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,55.952,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,153.32,100,,678.432,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,153.32,
AG SC RGN SR EA,41068958,CDM,300,RC,86902,HCPCS,Outpatient,,,133.63,80.18,,7.36,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,185.56,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,1020.28,360,,238.584,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,238.584,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,238.584,Fee Schedule,360% of BCBS Traditional Rate,80.18,60,,18304.224,Percent of Total Billed Charges,60% of Total Billed Charges,5.33,100,,9.16,Fee Schedule,100% of TX Mediciad Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,848,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.49,103,,9.44,Fee Schedule,103% of TX Medicaid Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,100.22,75,,722.952,Percent of Total Billed Charges,75% of Total Billed Charges,10.79,80,,1903.44,Fee Schedule,80% of Scott and White EPO fee schedule,10.79,80,,17674.8,Fee Schedule,80% of Scott and White HMO fee schedule,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,10.79,170,,17674.8,Fee Schedule,170% of Scott and White PPO fee schedule,10.79,170,,3929.248,Fee Schedule,170% of Scott and White SWHP fee schedule,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.15,90,,212.8,Fee Schedule,90% of UHC fee schedule,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,5.33,100,,9.16,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.63,100,,963.936,Percent of Total Billed Charges,100% of Total Billed Charges,5.15,1020.28,
"CULTURE, BLOOD",41070400,CDM,306,RC,87040,HCPCS,Outpatient,,,273,163.80,,11.98,100,,767.504,Fee Schedule,100% of Aetna Fee Schedule,15.48,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,28.9,280,,172.928,Fee Schedule,280% of BCBS BULE Fee Schedule,33.02,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,37.15,360,,222.336,Fee Schedule,360% of BCBS POS Rate,37.15,360,,222.336,Fee schedule,360% of BCBS PPO Rate,37.15,360,,222.336,Fee Schedule,360% of BCBS Traditional Rate,163.8,60,,4841.696,Percent of Total Billed Charges,60% of Total Billed Charges,8.67,100,,120.616,Fee Schedule,100% of TX Mediciad 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,,195.304,Fee Schedule,100% of CMS OPPS Rate,9.28,90,,,Fee Schedule,90% of CMS OPPS Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,13.41,130,,,Fee Schedule,130% of CMS OPPS Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.93,103,,124.232,Fee Schedule,103% of TX Medicaid Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,204.75,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,17.54,80,,12403.632,Fee Schedule,80% of Scott and White EPO fee schedule,17.54,80,,12403.632,Fee Schedule,80% of Scott and White HMO fee schedule,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.54,170,,12403.632,Fee Schedule,170% of Scott and White PPO fee schedule,17.54,170,,3109.6,Fee Schedule,170% of Scott and White SWHP fee schedule,15.48,150,,,Fee Schedule,150% of CMS OPPS Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,90,,1568,Fee Schedule,90% of UHC fee schedule,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,120.616,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,273,100,,94.4,Percent of Total Billed Charges,100% of Total Billed Charges,8.36,273,
"CULTURE, STOOL",41070558,CDM,306,RC,87045,HCPCS,Outpatient,,,222.89,133.73,,10.96,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,14.16,150,,44.88,Fee Schedule ,150% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,26.43,280,,302.704,Fee Schedule,280% of BCBS BULE Fee Schedule,30.21,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,33.98,360,,389.192,Fee Schedule,360% of BCBS POS Rate,33.98,360,,389.192,Fee schedule,360% of BCBS PPO Rate,33.98,360,,389.192,Fee Schedule,360% of BCBS Traditional Rate,133.73,60,,825,Percent of Total Billed Charges,60% of Total Billed Charges,7.93,100,,301.192,Fee Schedule,100% of TX Mediciad 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,,416,Fee Schedule,100% of CMS OPPS Rate,8.49,90,,,Fee Schedule,90% of CMS OPPS Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,12.27,130,,,Fee Schedule,130% of CMS OPPS Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,8.17,103,,310.232,Fee Schedule,103% of TX Medicaid Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,167.17,75,,133.16,Percent of Total Billed Charges,75% of Total Billed Charges,16.04,80,,17674.8,Fee Schedule,80% of Scott and White EPO fee schedule,16.04,80,,112.568,Fee Schedule,80% of Scott and White HMO fee schedule,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,16.04,170,,112.568,Fee Schedule,170% of Scott and White PPO fee schedule,16.04,170,,3109.6,Fee Schedule,170% of Scott and White SWHP fee schedule,14.16,150,,,Fee Schedule,150% of CMS OPPS Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.65,90,,126,Fee Schedule,90% of UHC fee schedule,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,301.192,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,222.89,100,,177.544,Percent of Total Billed Charges,100% of Total Billed Charges,7.65,222.89,
"CULTURE, ANAEROBE",41070756,CDM,306,RC,87075,HCPCS,Outpatient,,,278,166.80,,10.98,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,14.2,150,,184.28,Fee Schedule ,150% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,280,,1319.808,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,0.696,Fee Schedule,320% of BCBS Blue Essentials Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,34.09,360,,1696.896,Fee Schedule,360% of BCBS POS Rate,34.09,360,,1696.896,Fee schedule,360% of BCBS PPO Rate,34.09,360,,1696.896,Fee Schedule,360% of BCBS Traditional Rate,166.8,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,7.95,100,,477.672,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,8.52,90,,,Fee Schedule,90% of CMS OPPS Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.31,130,,,Fee Schedule,130% of CMS OPPS Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,8.19,103,,492.008,Fee Schedule,103% of TX Medicaid Rate,9.75,103,,,Fee Schedule,103% of CMS OPPS Rate,9.75,103,,,Fee Schedule,103% of CMS OPPS Rate,208.5,75,,133.8,Percent of Total Billed Charges,75% of Total Billed Charges,16.09,80,,12403.632,Fee Schedule,80% of Scott and White EPO fee schedule,16.09,80,,1861.832,Fee Schedule,80% of Scott and White HMO fee schedule,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,16.09,170,,1861.832,Fee Schedule,170% of Scott and White PPO fee schedule,16.09,170,,438,Fee Schedule,170% of Scott and White SWHP fee schedule,14.2,150,,,Fee Schedule,150% of CMS OPPS Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.67,90,,81.2,Fee Schedule,90% of UHC fee schedule,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,7.95,100,,477.672,Fee Schedule,100% of TX Medicaid Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,278,100,,178.4,Percent of Total Billed Charges,100% of Total Billed Charges,7.67,278,
CX CSF,41070780,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,109.888,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,1427.552,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,0.704,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,1835.424,Fee Schedule,360% of BCBS POS Rate,31.03,360,,1835.424,Fee schedule,360% of BCBS PPO Rate,31.03,360,,1835.424,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,278.256,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,286.608,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,238.8,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,112.568,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,123.904,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,123.904,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,438,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,239.504,Fee Schedule,90% of UHC fee schedule,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,318.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX MRSA SCREENING,41070806,CDM,306,RC,87081,HCPCS,Outpatient,,,143.64,86.18,,7.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,43.2,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,1948.128,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,0.704,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,2504.736,Fee Schedule,360% of BCBS POS Rate,23.87,360,,2504.736,Fee schedule,360% of BCBS PPO Rate,23.87,360,,2504.736,Fee Schedule,360% of BCBS Traditional Rate,86.18,60,,25101.496,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,278.256,Fee Schedule,100% of TX Mediciad 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,,99.728,Fee Schedule,100% of CMS OPPS Rate,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,286.608,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,107.73,75,,123.6,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,1861.832,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,487.304,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,487.304,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,1816.248,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,882,Fee Schedule,90% of UHC fee schedule,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,278.256,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,143.64,100,,164.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,143.64,
GROUP A STREP SCRN CULT,41070814,CDM,306,RC,87081,HCPCS,Outpatient,,,143.64,86.18,,7.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,291.6,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,2164.512,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,0.704,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,2782.944,Fee Schedule,360% of BCBS POS Rate,23.87,360,,2782.944,Fee schedule,360% of BCBS PPO Rate,23.87,360,,2782.944,Fee Schedule,360% of BCBS Traditional Rate,86.18,60,,25101.496,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,738.088,Fee Schedule,100% of TX Mediciad 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,,409.512,Fee Schedule,100% of CMS OPPS Rate,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,760.232,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,107.73,75,,177.552,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,123.904,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,1232.528,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,1232.528,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,2724.376,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,463.912,Fee Schedule,90% of UHC fee schedule,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,143.64,100,,236.736,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,143.64,
CX URINE,41070863,CDM,306,RC,87086,HCPCS,Outpatient,,,181.5,108.90,,9.36,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.1,150,,270,Fee Schedule ,150% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,22.6,280,,987.168,Fee Schedule,280% of BCBS BULE Fee Schedule,25.82,320,,0.704,Fee Schedule,320% of BCBS Blue Essentials Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,29.05,360,,1269.216,Fee Schedule,360% of BCBS POS Rate,29.05,360,,1269.216,Fee schedule,360% of BCBS PPO Rate,29.05,360,,1269.216,Fee Schedule,360% of BCBS Traditional Rate,108.9,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,6.78,100,,738.088,Fee Schedule,100% of TX Mediciad 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,,244.2,Fee Schedule,100% of CMS OPPS Rate,7.26,90,,,Fee Schedule,90% of CMS OPPS Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,130,,,Fee Schedule,130% of CMS OPPS Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.98,103,,760.232,Fee Schedule,103% of TX Medicaid Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,136.13,75,,75.448,Percent of Total Billed Charges,75% of Total Billed Charges,13.71,80,,487.304,Fee Schedule,80% of Scott and White EPO fee schedule,13.71,80,,951.208,Fee Schedule,80% of Scott and White HMO fee schedule,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,170,,951.208,Fee Schedule,170% of Scott and White PPO fee schedule,13.71,170,,1816.248,Fee Schedule,170% of Scott and White SWHP fee schedule,12.1,150,,,Fee Schedule,150% of CMS OPPS Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,90,,162.4,Fee Schedule,90% of UHC fee schedule,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,738.088,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,181.5,100,,100.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,181.5,
H.PYLORI UREASE FR BIOPSY,41070996,CDM,306,RC,87081,HCPCS,Outpatient,,,143.64,86.18,,7.7,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,144.344,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,25.984,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,0.72,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,33.408,Fee Schedule,360% of BCBS POS Rate,23.87,360,,33.408,Fee schedule,360% of BCBS PPO Rate,23.87,360,,33.408,Fee Schedule,360% of BCBS Traditional Rate,86.18,60,,816.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,1394.488,Fee Schedule,100% of TX Mediciad 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,,96,Fee Schedule,100% of CMS OPPS Rate,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,1436.32,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,107.73,75,,1668,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,1232.528,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,545.096,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,545.096,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,1699.504,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,84,Fee Schedule,90% of UHC fee schedule,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,1394.488,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,143.64,100,,2224,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,143.64,
CX WOUND,41071333,CDM,306,RC,87070,HCPCS,Outpatient,,,230.82,138.49,,10,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,12.92,150,,171.88,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,280,,66.08,Fee Schedule,280% of BCBS BULE Fee Schedule,27.58,320,,0.728,Fee Schedule,320% of BCBS Blue Essentials Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,31.03,360,,84.96,Fee Schedule,360% of BCBS POS Rate,31.03,360,,84.96,Fee schedule,360% of BCBS PPO Rate,31.03,360,,84.96,Fee Schedule,360% of BCBS Traditional Rate,138.49,60,,3275.52,Percent of Total Billed Charges,60% of Total Billed Charges,7.24,100,,48.664,Fee Schedule,100% of TX Mediciad 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,,648,Fee Schedule,100% of CMS OPPS Rate,7.75,90,,,Fee Schedule,90% of CMS OPPS Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,130,,,Fee Schedule,130% of CMS OPPS Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.46,103,,50.128,Fee Schedule,103% of TX Medicaid Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.12,75,,1644,Percent of Total Billed Charges,75% of Total Billed Charges,14.65,80,,951.208,Fee Schedule,80% of Scott and White EPO fee schedule,14.65,80,,455.92,Fee Schedule,80% of Scott and White HMO fee schedule,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,170,,455.92,Fee Schedule,170% of Scott and White PPO fee schedule,14.65,170,,1903.44,Fee Schedule,170% of Scott and White SWHP fee schedule,12.92,150,,,Fee Schedule,150% of CMS OPPS Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,4877.6,Fee Schedule,90% of UHC fee schedule,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,7.24,100,,48.664,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,230.82,100,,2192,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,230.82,
CX GC,41071606,CDM,306,RC,87081,HCPCS,Outpatient,,,143.64,86.18,,7.7,100,,1546.752,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,92.288,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,0.736,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,118.656,Fee Schedule,360% of BCBS POS Rate,23.87,360,,118.656,Fee schedule,360% of BCBS PPO Rate,23.87,360,,118.656,Fee Schedule,360% of BCBS Traditional Rate,86.18,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,761.68,Fee Schedule,100% of TX Mediciad 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,,600,Fee Schedule,100% of CMS OPPS Rate,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,784.528,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,107.73,75,,535.2,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,545.096,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,522.776,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,522.776,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,7600,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,52.856,Fee Schedule,90% of UHC fee schedule,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,761.68,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,143.64,100,,713.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,143.64,
SUSCEP DISK MTHD PER PLATE,41071846,CDM,306,RC,87184,HCPCS,Outpatient,,,126,75.60,,8.68,100,,1546.752,Fee Schedule,100% of Aetna Fee Schedule,11.22,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.94,280,,352.8,Fee Schedule,280% of BCBS BULE Fee Schedule,23.94,320,,0.736,Fee Schedule,320% of BCBS Blue Essentials Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,26.93,360,,453.6,Fee Schedule,360% of BCBS POS Rate,26.93,360,,453.6,Fee schedule,360% of BCBS PPO Rate,26.93,360,,453.6,Fee Schedule,360% of BCBS Traditional Rate,75.6,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,6.28,100,,988.624,Fee Schedule,100% of TX Mediciad 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,,320.76,Fee Schedule,100% of CMS OPPS Rate,6.73,90,,,Fee Schedule,90% of CMS OPPS Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,130,,,Fee Schedule,130% of CMS OPPS Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.47,103,,1018.28,Fee Schedule,103% of TX Medicaid Rate,7.7,103,,,Fee Schedule,103% of CMS OPPS Rate,7.7,103,,,Fee Schedule,103% of CMS OPPS Rate,94.5,75,,358.576,Percent of Total Billed Charges,75% of Total Billed Charges,12.71,80,,455.92,Fee Schedule,80% of Scott and White EPO fee schedule,12.71,80,,3449.304,Fee Schedule,80% of Scott and White HMO fee schedule,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,12.71,170,,3449.304,Fee Schedule,170% of Scott and White PPO fee schedule,12.71,170,,12403.632,Fee Schedule,170% of Scott and White SWHP fee schedule,11.22,150,,,Fee Schedule,150% of CMS OPPS Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.06,90,,260.456,Fee Schedule,90% of UHC fee schedule,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,6.28,100,,988.624,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126,100,,478.104,Percent of Total Billed Charges,100% of Total Billed Charges,6.06,126,
"SENSITIVTY,MIC",41071861,CDM,306,RC,87186,HCPCS,Outpatient,,,181.45,108.87,,10.04,100,,697.8,Fee Schedule,100% of Aetna Fee Schedule,12.97,150,,136.8,Fee Schedule ,150% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,280,,2912,Fee Schedule,280% of BCBS BULE Fee Schedule,27.68,320,,0.736,Fee Schedule,320% of BCBS Blue Essentials Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,31.14,360,,3744,Fee Schedule,360% of BCBS POS Rate,31.14,360,,3744,Fee schedule,360% of BCBS PPO Rate,31.14,360,,3744,Fee Schedule,360% of BCBS Traditional Rate,108.87,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,7.27,100,,95.512,Fee Schedule,100% of TX Mediciad 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,,381.96,Fee Schedule,100% of CMS OPPS Rate,7.78,90,,,Fee Schedule,90% of CMS OPPS Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,11.24,130,,,Fee Schedule,130% of CMS OPPS Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.49,103,,98.376,Fee Schedule,103% of TX Medicaid Rate,8.9,103,,,Fee Schedule,103% of CMS OPPS Rate,8.9,103,,,Fee Schedule,103% of CMS OPPS Rate,136.09,75,,94.504,Percent of Total Billed Charges,75% of Total Billed Charges,14.7,80,,522.776,Fee Schedule,80% of Scott and White EPO fee schedule,14.7,80,,150,Fee Schedule,80% of Scott and White HMO fee schedule,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,170,,150,Fee Schedule,170% of Scott and White PPO fee schedule,14.7,170,,17674.8,Fee Schedule,170% of Scott and White SWHP fee schedule,12.97,150,,,Fee Schedule,150% of CMS OPPS Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,90,,36.264,Fee Schedule,90% of UHC fee schedule,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,7.27,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,181.45,100,,126,Percent of Total Billed Charges,100% of Total Billed Charges,7.01,181.45,
MALARIA SMEAR,41072026,CDM,306,RC,87207,HCPCS,Outpatient,,,160.41,96.25,,6.94,100,,49.68,Fee Schedule,100% of Aetna Fee Schedule,8.98,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,19.17,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,21.56,360,,648,Fee Schedule,360% of BCBS POS Rate,21.56,360,,648,Fee schedule,360% of BCBS PPO Rate,21.56,360,,648,Fee Schedule,360% of BCBS Traditional Rate,96.25,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,5.03,100,,10.568,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,5.39,90,,,Fee Schedule,90% of CMS OPPS Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,130,,,Fee Schedule,130% of CMS OPPS Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.18,103,,10.888,Fee Schedule,103% of TX Medicaid Rate,6.16,103,,,Fee Schedule,103% of CMS OPPS Rate,6.16,103,,,Fee Schedule,103% of CMS OPPS Rate,120.31,75,,56.968,Percent of Total Billed Charges,75% of Total Billed Charges,10.18,80,,3449.304,Fee Schedule,80% of Scott and White EPO fee schedule,10.18,80,,545.776,Fee Schedule,80% of Scott and White HMO fee schedule,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,170,,545.776,Fee Schedule,170% of Scott and White PPO fee schedule,10.18,170,,12403.632,Fee Schedule,170% of Scott and White SWHP fee schedule,8.98,150,,,Fee Schedule,150% of CMS OPPS Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,4.85,90,,204.04,Fee Schedule,90% of UHC fee schedule,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,10.568,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,160.41,100,,75.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.85,160.41,
GRAM STAIN,41072059,CDM,306,RC,87205,HCPCS,Outpatient,,,101,60.60,,4.96,100,,252,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,295.688,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,1744.288,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,2242.656,Fee Schedule,360% of BCBS POS Rate,15.37,360,,2242.656,Fee schedule,360% of BCBS PPO Rate,15.37,360,,2242.656,Fee Schedule,360% of BCBS Traditional Rate,60.6,60,,880.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,339.136,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,349.312,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,75.75,75,,29.904,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,150,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,1760.688,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,1760.688,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,112.568,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,562.8,Fee Schedule,90% of UHC fee schedule,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,339.136,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,101,100,,39.872,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,101,
WET PREP,41072109,CDM,306,RC,87210,HCPCS,Outpatient,,,100.98,60.59,,6.76,100,,374.04,Fee Schedule,100% of Aetna Fee Schedule,8.73,150,,26.352,Fee Schedule ,150% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,280,,85.12,Fee Schedule,280% of BCBS BULE Fee Schedule,18.62,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,20.95,360,,109.44,Fee Schedule,360% of BCBS POS Rate,20.95,360,,109.44,Fee schedule,360% of BCBS PPO Rate,20.95,360,,109.44,Fee Schedule,360% of BCBS Traditional Rate,60.59,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4.89,100,,6.192,Fee Schedule,100% of TX Mediciad 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,,304,Fee Schedule,100% of CMS OPPS Rate,5.23,90,,,Fee Schedule,90% of CMS OPPS Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.56,130,,,Fee Schedule,130% of CMS OPPS Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.04,103,,6.376,Fee Schedule,103% of TX Medicaid Rate,5.99,103,,,Fee Schedule,103% of CMS OPPS Rate,5.99,103,,,Fee Schedule,103% of CMS OPPS Rate,75.74,75,,992.784,Percent of Total Billed Charges,75% of Total Billed Charges,9.89,80,,545.776,Fee Schedule,80% of Scott and White EPO fee schedule,9.89,80,,561.368,Fee Schedule,80% of Scott and White HMO fee schedule,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,170,,561.368,Fee Schedule,170% of Scott and White PPO fee schedule,9.89,170,,1861.832,Fee Schedule,170% of Scott and White SWHP fee schedule,8.73,150,,,Fee Schedule,150% of CMS OPPS Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,90,,2371.6,Fee Schedule,90% of UHC fee schedule,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,4.89,100,,6.192,Fee Schedule,100% of TX Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,100.98,100,,1323.712,Percent of Total Billed Charges,100% of Total Billed Charges,4.72,100.98,
CX ID HELICOBACTER CLOTEST,41072111,CDM,306,RC,87077,HCPCS,Outpatient,,,119.23,71.54,,9.38,100,,232.68,Fee Schedule,100% of Aetna Fee Schedule,12.12,150,,136.8,Fee Schedule ,150% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,22.62,280,,627.2,Fee Schedule,280% of BCBS BULE Fee Schedule,25.86,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,29.09,360,,806.4,Fee Schedule,360% of BCBS POS Rate,29.09,360,,806.4,Fee schedule,360% of BCBS PPO Rate,29.09,360,,806.4,Fee Schedule,360% of BCBS Traditional Rate,71.54,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,6.79,100,,9.08,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,7.27,90,,,Fee Schedule,90% of CMS OPPS Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,130,,,Fee Schedule,130% of CMS OPPS Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.99,103,,9.352,Fee Schedule,103% of TX Medicaid Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,89.42,75,,630.272,Percent of Total Billed Charges,75% of Total Billed Charges,13.73,80,,1760.688,Fee Schedule,80% of Scott and White EPO fee schedule,13.73,80,,555.456,Fee Schedule,80% of Scott and White HMO fee schedule,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,170,,555.456,Fee Schedule,170% of Scott and White PPO fee schedule,13.73,170,,123.904,Fee Schedule,170% of Scott and White SWHP fee schedule,12.12,150,,,Fee Schedule,150% of CMS OPPS Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.54,90,,579.648,Fee Schedule,90% of UHC fee schedule,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,9.08,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,119.23,100,,840.36,Percent of Total Billed Charges,100% of Total Billed Charges,6.54,119.23,
TROPONIN-I,41072356,CDM,301,RC,84484,HCPCS,Outpatient,,,245.63,147.38,,14.46,100,,5550.824,Fee Schedule,100% of Aetna Fee Schedule,18.7,150,,318.608,Fee Schedule ,150% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,34.92,280,,50.4,Fee Schedule,280% of BCBS BULE Fee Schedule,39.9,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,44.89,360,,64.8,Fee Schedule,360% of BCBS POS Rate,44.89,360,,64.8,Fee schedule,360% of BCBS PPO Rate,44.89,360,,64.8,Fee Schedule,360% of BCBS Traditional Rate,147.38,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,10.47,100,,14.096,Fee Schedule,100% of TX Mediciad 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,,657.08,Fee Schedule,100% of CMS OPPS Rate,11.22,90,,,Fee Schedule,90% of CMS OPPS Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,130,,,Fee Schedule,130% of CMS OPPS Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.78,103,,14.52,Fee Schedule,103% of TX Medicaid Rate,12.84,103,,,Fee Schedule,103% of CMS OPPS Rate,12.84,103,,,Fee Schedule,103% of CMS OPPS Rate,184.22,75,,431.352,Percent of Total Billed Charges,75% of Total Billed Charges,21.19,80,,561.368,Fee Schedule,80% of Scott and White EPO fee schedule,21.19,80,,643.512,Fee Schedule,80% of Scott and White HMO fee schedule,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.19,170,,643.512,Fee Schedule,170% of Scott and White PPO fee schedule,21.19,170,,487.304,Fee Schedule,170% of Scott and White SWHP fee schedule,18.7,150,,,Fee Schedule,150% of CMS OPPS Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.1,90,,131.688,Fee Schedule,90% of UHC fee schedule,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.47,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,245.63,100,,575.136,Percent of Total Billed Charges,100% of Total Billed Charges,10.1,245.63,
EIA C DIFFICILE TOXIN,41073248,CDM,306,RC,87324,HCPCS,Outpatient,,,227.44,136.46,,13.9,100,,397.92,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,54,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,32.48,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,0.744,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,41.76,Fee Schedule,360% of BCBS POS Rate,43.13,360,,41.76,Fee schedule,360% of BCBS PPO Rate,43.13,360,,41.76,Fee Schedule,360% of BCBS Traditional Rate,136.46,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,53.888,Fee Schedule,100% of TX Mediciad 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,,58.56,Fee Schedule,100% of CMS OPPS Rate,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,55.504,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,170.58,75,,172.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,555.456,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,476.288,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,476.288,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,1232.528,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,84,Fee Schedule,90% of UHC fee schedule,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,227.44,100,,230,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,227.44,
EIA C DIFF ANTIGEN,41074493,CDM,306,RC,87449,HCPCS,Outpatient,,,194,116.40,,13.9,100,,283.2,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,47.84,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,95.8,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,0.752,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,123.168,Fee Schedule,360% of BCBS POS Rate,43.13,360,,123.168,Fee schedule,360% of BCBS PPO Rate,43.13,360,,123.168,Fee Schedule,360% of BCBS Traditional Rate,116.4,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,53.888,Fee Schedule,100% of TX Mediciad 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,,304,Fee Schedule,100% of CMS OPPS Rate,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,55.504,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,145.5,75,,241.208,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,643.512,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,408,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,408,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,951.208,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,1176,Fee Schedule,90% of UHC fee schedule,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,53.888,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194,100,,321.608,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,194,
RAPID INFLUENZA A,41078049,CDM,306,RC,87804,HCPCS,Outpatient,,,153,91.80,,19.2,100,,275.64,Fee Schedule,100% of Aetna Fee Schedule,24.82,150,,49.32,Fee Schedule ,150% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.34,280,,352.8,Fee Schedule,280% of BCBS BULE Fee Schedule,52.96,320,,0.752,Fee Schedule,320% of BCBS Blue Essentials Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,59.58,360,,453.6,Fee Schedule,360% of BCBS POS Rate,59.58,360,,453.6,Fee schedule,360% of BCBS PPO Rate,59.58,360,,453.6,Fee Schedule,360% of BCBS Traditional Rate,91.8,60,,591.776,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,100,,9.512,Fee Schedule,100% of TX Mediciad 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,,708.016,Fee Schedule,100% of CMS OPPS Rate,14.89,90,,,Fee Schedule,90% of CMS OPPS Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,130,,,Fee Schedule,130% of CMS OPPS Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,14.32,103,,9.8,Fee Schedule,103% of TX Medicaid Rate,17.04,103,,,Fee Schedule,103% of CMS OPPS Rate,17.04,103,,,Fee Schedule,103% of CMS OPPS Rate,114.75,75,,120.728,Percent of Total Billed Charges,75% of Total Billed Charges,28.13,80,,476.288,Fee Schedule,80% of Scott and White EPO fee schedule,28.13,80,,594.512,Fee Schedule,80% of Scott and White HMO fee schedule,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,28.13,170,,594.512,Fee Schedule,170% of Scott and White PPO fee schedule,28.13,170,,545.096,Fee Schedule,170% of Scott and White SWHP fee schedule,24.82,150,,,Fee Schedule,150% of CMS OPPS Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.41,90,,4877.6,Fee Schedule,90% of UHC fee schedule,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,9.512,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153,100,,160.968,Percent of Total Billed Charges,100% of Total Billed Charges,13.41,153,
EIA LEGIONELLA AG URINE,41079120,CDM,306,RC,87449,HCPCS,Outpatient,,,194,116.40,,13.9,100,,98.76,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,185.56,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,0.752,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,238.584,Fee Schedule,360% of BCBS POS Rate,43.13,360,,238.584,Fee schedule,360% of BCBS PPO Rate,43.13,360,,238.584,Fee Schedule,360% of BCBS Traditional Rate,116.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,492.992,Fee Schedule,100% of TX Mediciad 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,,120,Fee Schedule,100% of CMS OPPS Rate,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,507.784,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,145.5,75,,120.728,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,408,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,5475.112,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,5475.112,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,455.92,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,2111.2,Fee Schedule,90% of UHC fee schedule,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,492.992,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194,100,,160.968,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,194,
PANEL BASIC METABOLIC (ION CA),41079138,CDM,301,RC,80047,HCPCS,Outpatient,,,314,188.40,,15.92,100,,267.72,Fee Schedule,100% of Aetna Fee Schedule,20.59,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,38.44,280,,64.96,Fee Schedule,280% of BCBS BULE Fee Schedule,43.94,320,,0.76,Fee Schedule,320% of BCBS Blue Essentials Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,49.43,360,,83.52,Fee Schedule,360% of BCBS POS Rate,49.43,360,,83.52,Fee schedule,360% of BCBS PPO Rate,49.43,360,,83.52,Fee Schedule,360% of BCBS Traditional Rate,188.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,11.53,100,,32.832,Fee Schedule,100% of TX Mediciad 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,,106.304,Fee Schedule,100% of CMS OPPS Rate,12.35,90,,,Fee Schedule,90% of CMS OPPS Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,17.84,130,,,Fee Schedule,130% of CMS OPPS Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.88,103,,33.816,Fee Schedule,103% of TX Medicaid Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,235.5,75,,120.728,Percent of Total Billed Charges,75% of Total Billed Charges,23.34,80,,594.512,Fee Schedule,80% of Scott and White EPO fee schedule,23.34,80,,82.088,Fee Schedule,80% of Scott and White HMO fee schedule,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.34,170,,82.088,Fee Schedule,170% of Scott and White PPO fee schedule,23.34,170,,522.776,Fee Schedule,170% of Scott and White SWHP fee schedule,20.59,150,,,Fee Schedule,150% of CMS OPPS Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,90,,4360.72,Fee Schedule,90% of UHC fee schedule,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,32.832,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,314,100,,160.968,Percent of Total Billed Charges,100% of Total Billed Charges,11.12,314,
CREATININE POC,41079179,CDM,301,RC,82565,HCPCS,Outpatient,,,89,53.40,,5.94,100,,404.04,Fee Schedule,100% of Aetna Fee Schedule,7.68,150,,115.416,Fee Schedule ,150% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,16.38,320,,0.76,Fee Schedule,320% of BCBS Blue Essentials Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,18.43,360,,43.2,Fee Schedule,360% of BCBS POS Rate,18.43,360,,43.2,Fee schedule,360% of BCBS PPO Rate,18.43,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,53.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4.3,100,,579.88,Fee Schedule,100% of TX Mediciad 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,,109.6,Fee Schedule,100% of CMS OPPS Rate,4.6,90,,,Fee Schedule,90% of CMS OPPS Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,6.65,130,,,Fee Schedule,130% of CMS OPPS Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.43,103,,597.272,Fee Schedule,103% of TX Medicaid Rate,5.27,103,,,Fee Schedule,103% of CMS OPPS Rate,5.27,103,,,Fee Schedule,103% of CMS OPPS Rate,66.75,75,,152.12,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,80,,5475.112,Fee Schedule,80% of Scott and White EPO fee schedule,8.7,80,,27.688,Fee Schedule,80% of Scott and White HMO fee schedule,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,170,,27.688,Fee Schedule,170% of Scott and White PPO fee schedule,8.7,170,,3449.304,Fee Schedule,170% of Scott and White SWHP fee schedule,7.68,150,,,Fee Schedule,150% of CMS OPPS Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,90,,714,Fee Schedule,90% of UHC fee schedule,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,4.3,100,,579.88,Fee Schedule,100% of TX Medicaid Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,89,100,,202.824,Percent of Total Billed Charges,100% of Total Billed Charges,4.15,89,
GLUCOSE QT BLD POC,41079195,CDM,301,RC,82947,HCPCS,Outpatient,,,80.1,48.06,,4.56,100,,54.24,Fee Schedule,100% of Aetna Fee Schedule,5.89,150,,115.416,Fee Schedule ,150% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11,280,,1951.04,Fee Schedule,280% of BCBS BULE Fee Schedule,12.58,320,,5142.552,Fee Schedule,320% of BCBS Blue Essentials Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,14.15,360,,2508.48,Fee Schedule,360% of BCBS POS Rate,14.15,360,,2508.48,Fee schedule,360% of BCBS PPO Rate,14.15,360,,2508.48,Fee Schedule,360% of BCBS Traditional Rate,48.06,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,3.3,100,,14.096,Fee Schedule,100% of TX Mediciad 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,,173.8,Fee Schedule,100% of CMS OPPS Rate,3.53,90,,,Fee Schedule,90% of CMS OPPS Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5.1,130,,,Fee Schedule,130% of CMS OPPS Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.4,103,,14.52,Fee Schedule,103% of TX Medicaid Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,4.04,103,,,Fee Schedule,103% of CMS OPPS Rate,60.08,75,,1109.28,Percent of Total Billed Charges,75% of Total Billed Charges,6.68,80,,82.088,Fee Schedule,80% of Scott and White EPO fee schedule,6.68,80,,37.752,Fee Schedule,80% of Scott and White HMO fee schedule,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,170,,37.752,Fee Schedule,170% of Scott and White PPO fee schedule,6.68,170,,150,Fee Schedule,170% of Scott and White SWHP fee schedule,5.89,150,,,Fee Schedule,150% of CMS OPPS Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.19,90,,663.12,Fee Schedule,90% of UHC fee schedule,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.3,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,100,,1479.04,Percent of Total Billed Charges,100% of Total Billed Charges,3.19,80.1,
POC LACTATE,41079203,CDM,301,RC,83605,HCPCS,Outpatient,,,194.98,116.99,,13.42,100,,67.68,Fee Schedule,100% of Aetna Fee Schedule,17.35,150,,575.536,Fee Schedule ,150% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,280,,21.144,Fee Schedule,280% of BCBS BULE Fee Schedule,37.02,320,,5157.128,Fee Schedule,320% of BCBS Blue Essentials Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,41.65,360,,27.184,Fee Schedule,360% of BCBS POS Rate,41.65,360,,27.184,Fee schedule,360% of BCBS PPO Rate,41.65,360,,27.184,Fee Schedule,360% of BCBS Traditional Rate,116.99,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,100,,14.096,Fee Schedule,100% of TX Mediciad 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,,173.8,Fee Schedule,100% of CMS OPPS Rate,10.41,90,,,Fee Schedule,90% of CMS OPPS Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,10.01,103,,14.52,Fee Schedule,103% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,146.24,75,,859.264,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,80,,27.688,Fee Schedule,80% of Scott and White EPO fee schedule,19.66,80,,594.512,Fee Schedule,80% of Scott and White HMO fee schedule,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.66,170,,594.512,Fee Schedule,170% of Scott and White PPO fee schedule,19.66,170,,545.776,Fee Schedule,170% of Scott and White SWHP fee schedule,17.35,150,,,Fee Schedule,150% of CMS OPPS Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,90,,3195.92,Fee Schedule,90% of UHC fee schedule,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,14.096,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,194.98,100,,1145.68,Percent of Total Billed Charges,100% of Total Billed Charges,9.37,194.98,
Step A PCR In-house,41079205,CDM,301,RC,87637,HCPCS,Outpatient,,,688,412.80,,285.26,100,,397.92,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,575.536,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,104.184,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,5157.128,Fee Schedule,320% of BCBS Blue Essentials Rate,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,513.47,360,,133.952,Fee Schedule,360% of BCBS POS Rate,513.47,360,,133.952,Fee schedule,360% of BCBS PPO Rate,513.47,360,,133.952,Fee Schedule,360% of BCBS Traditional Rate,412.8,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,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,,256.48,Fee Schedule,100% of CMS OPPS Rate,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,99.21,14.42,,4.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,516,75,,749.592,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,37.752,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,263.144,Fee Schedule,80% of Scott and White HMO fee schedule,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,263.144,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,1760.688,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.51,90,,4943.12,Fee Schedule,90% of UHC fee schedule,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,688,100,,999.456,Percent of Total Billed Charges,100% of Total Billed Charges,96.32,688,
HEMATOCRIT POC,41079252,CDM,305,RC,85014,HCPCS,Outpatient,,,61.65,36.99,,2.74,100,,239.64,Fee Schedule,100% of Aetna Fee Schedule,3.55,150,,484.888,Fee Schedule ,150% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,280,,14.504,Fee Schedule,280% of BCBS BULE Fee Schedule,7.58,320,,5233.92,Fee Schedule,320% of BCBS Blue Essentials Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,8.53,360,,18.648,Fee Schedule,360% of BCBS POS Rate,8.53,360,,18.648,Fee schedule,360% of BCBS PPO Rate,8.53,360,,18.648,Fee Schedule,360% of BCBS Traditional Rate,36.99,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,100,,30.208,Fee Schedule,100% of TX Mediciad 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,,256.48,Fee Schedule,100% of CMS OPPS Rate,2.13,90,,,Fee Schedule,90% of CMS OPPS Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,130,,,Fee Schedule,130% of CMS OPPS Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.05,103,,31.112,Fee Schedule,103% of TX Medicaid Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,46.24,75,,749.592,Percent of Total Billed Charges,75% of Total Billed Charges,4.02,80,,594.512,Fee Schedule,80% of Scott and White EPO fee schedule,4.02,80,,199.84,Fee Schedule,80% of Scott and White HMO fee schedule,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,170,,199.84,Fee Schedule,170% of Scott and White PPO fee schedule,4.02,170,,561.368,Fee Schedule,170% of Scott and White SWHP fee schedule,3.55,150,,,Fee Schedule,150% of CMS OPPS Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.92,90,,2075.152,Fee Schedule,90% of UHC fee schedule,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,30.208,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,61.65,100,,999.456,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,61.65,
FETAL SCREEN ROSETTE,41083501,CDM,305,RC,85461,HCPCS,Outpatient,,,134,80.40,,10.86,100,,49.68,Fee Schedule,100% of Aetna Fee Schedule,14.04,150,,760.728,Fee Schedule ,150% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,26.21,280,,225.12,Fee Schedule,280% of BCBS BULE Fee Schedule,29.95,320,,5305.76,Fee Schedule,320% of BCBS Blue Essentials Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,33.7,360,,289.44,Fee Schedule,360% of BCBS POS Rate,33.7,360,,289.44,Fee schedule,360% of BCBS PPO Rate,33.7,360,,289.44,Fee Schedule,360% of BCBS Traditional Rate,80.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,7.86,100,,59.872,Fee Schedule,100% of TX Mediciad 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,,1278.976,Fee Schedule,100% of CMS OPPS Rate,8.42,90,,,Fee Schedule,90% of CMS OPPS Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12.16,130,,,Fee Schedule,130% of CMS OPPS Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,8.1,103,,61.672,Fee Schedule,103% of TX Medicaid Rate,9.64,103,,,Fee Schedule,103% of CMS OPPS Rate,9.64,103,,,Fee Schedule,103% of CMS OPPS Rate,100.5,75,,152.12,Percent of Total Billed Charges,75% of Total Billed Charges,15.91,80,,199.84,Fee Schedule,80% of Scott and White EPO fee schedule,15.91,80,,430.776,Fee Schedule,80% of Scott and White HMO fee schedule,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,170,,430.776,Fee Schedule,170% of Scott and White PPO fee schedule,15.91,170,,643.512,Fee Schedule,170% of Scott and White SWHP fee schedule,14.04,150,,,Fee Schedule,150% of CMS OPPS Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,90,,293.832,Fee Schedule,90% of UHC fee schedule,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,7.86,100,,59.872,Fee Schedule,100% of TX Medicaid Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,134,100,,202.824,Percent of Total Billed Charges,100% of Total Billed Charges,7.58,134,
SICKLE CELL SCREEN UNIT,41083503,CDM,305,RC,85660,HCPCS,Outpatient,,,96.5,57.90,,6.4,100,,69.24,Fee Schedule,100% of Aetna Fee Schedule,8.26,150,,904.76,Fee Schedule ,150% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,280,,948.64,Fee Schedule,280% of BCBS BULE Fee Schedule,17.63,320,,5.16,Fee Schedule,320% of BCBS Blue Essentials Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,19.84,360,,1219.68,Fee Schedule,360% of BCBS POS Rate,19.84,360,,1219.68,Fee schedule,360% of BCBS PPO Rate,19.84,360,,1219.68,Fee Schedule,360% of BCBS Traditional Rate,57.9,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,4.63,100,,46.104,Fee Schedule,100% of TX Mediciad 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,,1077.536,Fee Schedule,100% of CMS OPPS Rate,4.95,90,,,Fee Schedule,90% of CMS OPPS Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.16,130,,,Fee Schedule,130% of CMS OPPS Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.77,103,,47.488,Fee Schedule,103% of TX Medicaid Rate,5.67,103,,,Fee Schedule,103% of CMS OPPS Rate,5.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.38,75,,2255.632,Percent of Total Billed Charges,75% of Total Billed Charges,9.36,80,,32.72,Fee Schedule,80% of Scott and White EPO fee schedule,9.36,80,,1075.696,Fee Schedule,80% of Scott and White HMO fee schedule,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,170,,1075.696,Fee Schedule,170% of Scott and White PPO fee schedule,9.36,170,,476.288,Fee Schedule,170% of Scott and White SWHP fee schedule,8.26,150,,,Fee Schedule,150% of CMS OPPS Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.46,90,,336,Fee Schedule,90% of UHC fee schedule,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.5,100,,3007.512,Percent of Total Billed Charges,100% of Total Billed Charges,4.46,96.5,
HLA DONOR MATCH CHARGE,41083504,CDM,309,RC,86813,HCPCS,Outpatient,,,809.69,485.81,,67.28,100,,32.76,Fee Schedule,100% of Aetna Fee Schedule,87,150,,221.176,Fee Schedule ,150% of CMS OPPS Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,162.4,280,,231.864,Fee Schedule,280% of BCBS BULE Fee Schedule,185.6,320,,5.208,Fee Schedule,320% of BCBS Blue Essentials Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,208.8,360,,298.104,Fee Schedule,360% of BCBS POS Rate,208.8,360,,298.104,Fee schedule,360% of BCBS PPO Rate,208.8,360,,298.104,Fee Schedule,360% of BCBS Traditional Rate,485.81,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,48.72,100,,46.104,Fee Schedule,100% of TX Mediciad Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,58,100,,1077.536,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,Fee Schedule,90% of CMS OPPS Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,75.4,130,,,Fee Schedule,130% of CMS OPPS Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,50.18,103,,47.488,Fee Schedule,103% of TX Medicaid Rate,59.74,103,,,Fee Schedule,103% of CMS OPPS Rate,59.74,103,,,Fee Schedule,103% of CMS OPPS Rate,607.27,75,,4024.8,Percent of Total Billed Charges,75% of Total Billed Charges,98.6,80,,430.776,Fee Schedule,80% of Scott and White EPO fee schedule,98.6,80,,1705.984,Fee Schedule,80% of Scott and White HMO fee schedule,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,98.6,170,,1705.984,Fee Schedule,170% of Scott and White PPO fee schedule,98.6,170,,408,Fee Schedule,170% of Scott and White SWHP fee schedule,87,150,,,Fee Schedule,150% of CMS OPPS Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,903.256,Fee Schedule,90% of UHC fee schedule,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,48.72,100,,46.104,Fee Schedule,100% of TX Medicaid Rate,58,100,,,Fee Schedule,100% of CMS OPPS Rate,809.69,100,,5366.4,Percent of Total Billed Charges,100% of Total Billed Charges,46.98,809.69,
BLD TYPING ABO UNIT,41083505,CDM,300,RC,86900,HCPCS,Outpatient,,,104.4,62.64,,3.46,100,,46.944,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,471.568,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,52.672,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,5.208,Fee Schedule,320% of BCBS Blue Essentials Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,392.51,360,,67.72,Fee Schedule,360% of BCBS POS Rate,392.51,360,,67.72,Fee schedule,360% of BCBS PPO Rate,392.51,360,,67.72,Fee Schedule,360% of BCBS Traditional Rate,62.64,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,100,,7.92,Fee Schedule,100% of TX Mediciad Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,1690.512,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.59,103,,8.152,Fee Schedule,103% of TX Medicaid Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,78.3,75,,238.408,Percent of Total Billed Charges,75% of Total Billed Charges,5.08,80,,1075.696,Fee Schedule,80% of Scott and White EPO fee schedule,5.08,80,,993.784,Fee Schedule,80% of Scott and White HMO fee schedule,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,170,,993.784,Fee Schedule,170% of Scott and White PPO fee schedule,5.08,170,,594.512,Fee Schedule,170% of Scott and White SWHP fee schedule,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2.42,90,,1008,Fee Schedule,90% of UHC fee schedule,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.4,100,,317.88,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,392.51,
BLD TYPING RH D UNIT,41083506,CDM,300,RC,86901,HCPCS,Outpatient,,,94.86,56.92,,3.46,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,822.728,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,5.224,Fee Schedule,320% of BCBS Blue Essentials Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,120.35,360,,43.2,Fee Schedule,360% of BCBS POS Rate,120.35,360,,43.2,Fee schedule,360% of BCBS PPO Rate,120.35,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,56.92,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,100,,42,Fee Schedule,100% of TX Mediciad Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,2010.576,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.59,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,71.15,75,,172.776,Percent of Total Billed Charges,75% of Total Billed Charges,5.08,80,,1705.984,Fee Schedule,80% of Scott and White EPO fee schedule,5.08,80,,993.784,Fee Schedule,80% of Scott and White HMO fee schedule,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,170,,993.784,Fee Schedule,170% of Scott and White PPO fee schedule,5.08,170,,5475.112,Fee Schedule,170% of Scott and White SWHP fee schedule,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,2.42,90,,1218,Fee Schedule,90% of UHC fee schedule,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,2.51,100,,42,Fee Schedule,100% of TX Medicaid Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,94.86,100,,230.368,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,120.35,
CELL COUNT MISC BODY FLUID,41090507,CDM,300,RC,89050,HCPCS,Outpatient,,,137,82.20,,5.48,100,,1399.2,Fee Schedule,100% of Aetna Fee Schedule,7.08,150,,453.896,Fee Schedule ,150% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,280,,470.4,Fee Schedule,280% of BCBS BULE Fee Schedule,15.1,320,,5.272,Fee Schedule,320% of BCBS Blue Essentials Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,16.99,360,,604.8,Fee Schedule,360% of BCBS POS Rate,16.99,360,,604.8,Fee schedule,360% of BCBS PPO Rate,16.99,360,,604.8,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,3.96,100,,7.544,Fee Schedule,100% of TX Mediciad 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,,491.504,Fee Schedule,100% of CMS OPPS Rate,4.24,90,,,Fee Schedule,90% of CMS OPPS Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6.13,130,,,Fee Schedule,130% of CMS OPPS Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.08,103,,7.776,Fee Schedule,103% of TX Medicaid Rate,4.86,103,,,Fee Schedule,103% of CMS OPPS Rate,4.86,103,,,Fee Schedule,103% of CMS OPPS Rate,102.75,75,,170.856,Percent of Total Billed Charges,75% of Total Billed Charges,8.02,80,,993.784,Fee Schedule,80% of Scott and White EPO fee schedule,8.02,80,,2636.032,Fee Schedule,80% of Scott and White HMO fee schedule,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,170,,2636.032,Fee Schedule,170% of Scott and White PPO fee schedule,8.02,170,,82.088,Fee Schedule,170% of Scott and White SWHP fee schedule,7.08,150,,,Fee Schedule,150% of CMS OPPS Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,3.83,90,,1008,Fee Schedule,90% of UHC fee schedule,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,3.96,100,,7.544,Fee Schedule,100% of TX Medicaid Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,227.808,Percent of Total Billed Charges,100% of Total Billed Charges,3.83,137,
CELL COUNT W/ DIFF BODY FLUID,41090515,CDM,300,RC,89051,HCPCS,Outpatient,,,168.57,101.14,,6.5,100,,667.12,Fee Schedule,100% of Aetna Fee Schedule,8.4,150,,789.016,Fee Schedule ,150% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,280,,1951.04,Fee Schedule,280% of BCBS BULE Fee Schedule,17.92,320,,5.288,Fee Schedule,320% of BCBS Blue Essentials Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,20.16,360,,2508.48,Fee Schedule,360% of BCBS POS Rate,20.16,360,,2508.48,Fee schedule,360% of BCBS PPO Rate,20.16,360,,2508.48,Fee Schedule,360% of BCBS Traditional Rate,101.14,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4.7,100,,40.304,Fee Schedule,100% of TX Mediciad 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,,1047.92,Fee Schedule,100% of CMS OPPS Rate,5.03,90,,,Fee Schedule,90% of CMS OPPS Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7.28,130,,,Fee Schedule,130% of CMS OPPS Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.84,103,,41.512,Fee Schedule,103% of TX Medicaid Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,126.43,75,,99.6,Percent of Total Billed Charges,75% of Total Billed Charges,9.51,80,,993.784,Fee Schedule,80% of Scott and White EPO fee schedule,9.51,80,,2636.032,Fee Schedule,80% of Scott and White HMO fee schedule,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9.51,170,,2636.032,Fee Schedule,170% of Scott and White PPO fee schedule,9.51,170,,27.688,Fee Schedule,170% of Scott and White SWHP fee schedule,8.4,150,,,Fee Schedule,150% of CMS OPPS Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.54,90,,1102.464,Fee Schedule,90% of UHC fee schedule,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,40.304,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,168.57,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.54,168.57,
SPERM WASH AND SWIM UP,41092602,CDM,300,RC,89260,HCPCS,Outpatient,,,241.12,144.67,,149.64,100,,1152.92,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,880.68,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,844.48,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,5.344,Fee Schedule,320% of BCBS Blue Essentials Rate,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,1085.76,Fee Schedule,360% of BCBS POS Rate,178.09,360,,1085.76,Fee schedule,360% of BCBS PPO Rate,178.09,360,,1085.76,Fee Schedule,360% of BCBS Traditional Rate,144.67,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,1828.288,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,34.77,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,180.84,75,,1355.128,Percent of Total Billed Charges,75% of Total Billed Charges,120.56,50,,2636.032,Percent of Total Billed Charges,50% of Total Billed Charges,120.56,50,,4980.304,Percent of Total Billed Charges,50% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,120.56,50,,4980.304,Percent of Total Billed Charges,50% of Total Billed Charges,120.56,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,5208.56,Fee Schedule,90% of UHC fee schedule,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,33.76,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,241.12,100,,1806.84,Percent of Total Billed Charges,100% of Total Billed Charges,33.76,241.12,
POST VASECTOMY S,41093105,CDM,300,RC,89310,HCPCS,Outpatient,,,129.61,77.77,,9.98,100,,1152.92,Fee Schedule,100% of Aetna Fee Schedule,12.91,150,,1034.64,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,280,,1744.288,Fee Schedule,280% of BCBS BULE Fee Schedule,27.55,320,,5.36,Fee Schedule,320% of BCBS Blue Essentials Rate,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,31,360,,2242.656,Fee Schedule,360% of BCBS POS Rate,31,360,,2242.656,Fee schedule,360% of BCBS PPO Rate,31,360,,2242.656,Fee Schedule,360% of BCBS Traditional Rate,77.77,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,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,,1008.664,Fee Schedule,100% of CMS OPPS Rate,7.74,90,,,Fee Schedule,90% of CMS OPPS Rate,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,130,,,Fee Schedule,130% of CMS OPPS Rate,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.69,14.42,,91.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,97.21,75,,551.672,Percent of Total Billed Charges,75% of Total Billed Charges,14.63,80,,2636.032,Fee Schedule,80% of Scott and White EPO fee schedule,14.63,80,,173.808,Fee Schedule,80% of Scott and White HMO fee schedule,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,170,,173.808,Fee Schedule,170% of Scott and White PPO fee schedule,14.63,170,,594.512,Fee Schedule,170% of Scott and White SWHP fee schedule,12.91,150,,,Fee Schedule,150% of CMS OPPS Rate,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,802.72,Fee Schedule,90% of UHC fee schedule,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14,,88.432,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,129.61,100,,735.56,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,129.61,
SEMEN ANALYSIS COMPLETE,41093204,CDM,300,RC,89320,HCPCS,Outpatient,,,215,129.00,,14.28,100,,527.024,Fee Schedule,100% of Aetna Fee Schedule,18.46,150,,689.76,Fee Schedule ,150% of CMS OPPS Rate,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,34.47,280,,285.6,Fee Schedule,280% of BCBS BULE Fee Schedule,39.39,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,44.32,360,,367.2,Fee Schedule,360% of BCBS POS Rate,44.32,360,,367.2,Fee schedule,360% of BCBS PPO Rate,44.32,360,,367.2,Fee Schedule,360% of BCBS Traditional Rate,129,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12.31,100,,1753.376,Fee Schedule,100% of CMS OPPS Rate,11.07,90,,,Fee Schedule,90% of CMS OPPS Rate,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,16,130,,,Fee Schedule,130% of CMS OPPS Rate,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,31,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,12.67,103,,,Fee Schedule,103% of CMS OPPS Rate,12.67,103,,,Fee Schedule,103% of CMS OPPS Rate,161.25,75,,1215.904,Percent of Total Billed Charges,75% of Total Billed Charges,20.92,80,,4980.304,Fee Schedule,80% of Scott and White EPO fee schedule,20.92,80,,2720.288,Fee Schedule,80% of Scott and White HMO fee schedule,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,170,,2720.288,Fee Schedule,170% of Scott and White PPO fee schedule,20.92,170,,263.144,Fee Schedule,170% of Scott and White SWHP fee schedule,18.46,150,,,Fee Schedule,150% of CMS OPPS Rate,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,9.97,90,,19040,Fee Schedule,90% of UHC fee schedule,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,215,100,,1621.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.97,215,
CRYSTAL ID FLUID NOT URINE,41093634,CDM,300,RC,89060,HCPCS,Outpatient,,,125.75,75.45,,8.5,100,,1829.68,Fee Schedule,100% of Aetna Fee Schedule,10.99,150,,689.76,Fee Schedule ,150% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,280,,265.248,Fee Schedule,280% of BCBS BULE Fee Schedule,23.46,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,26.39,360,,341.032,Fee Schedule,360% of BCBS POS Rate,26.39,360,,341.032,Fee schedule,360% of BCBS PPO Rate,26.39,360,,341.032,Fee Schedule,360% of BCBS Traditional Rate,75.45,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,6.16,100,,126.176,Fee Schedule,100% of TX Mediciad 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,,1957.064,Fee Schedule,100% of CMS OPPS Rate,6.59,90,,,Fee Schedule,90% of CMS OPPS Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.52,130,,,Fee Schedule,130% of CMS OPPS Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.34,103,,129.96,Fee Schedule,103% of TX Medicaid Rate,7.54,103,,,Fee Schedule,103% of CMS OPPS Rate,7.54,103,,,Fee Schedule,103% of CMS OPPS Rate,94.31,75,,1866,Percent of Total Billed Charges,75% of Total Billed Charges,12.46,80,,173.808,Fee Schedule,80% of Scott and White EPO fee schedule,12.46,80,,766.8,Fee Schedule,80% of Scott and White HMO fee schedule,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,170,,766.8,Fee Schedule,170% of Scott and White PPO fee schedule,12.46,170,,199.84,Fee Schedule,170% of Scott and White SWHP fee schedule,10.99,150,,,Fee Schedule,150% of CMS OPPS Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5.94,90,,4076.8,Fee Schedule,90% of UHC fee schedule,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,126.176,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,125.75,100,,2488,Percent of Total Billed Charges,100% of Total Billed Charges,5.94,125.75,
COOMBS INDIRECT,41260324,CDM,300,RC,86886,HCPCS,Outpatient,,,189,113.40,,6,100,,1852.2,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,632.528,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,1278.368,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,516.6,360,,1643.616,Fee Schedule,360% of BCBS POS Rate,516.6,360,,1643.616,Fee schedule,360% of BCBS PPO Rate,516.6,360,,1643.616,Fee Schedule,360% of BCBS Traditional Rate,113.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,47.904,Fee Schedule,100% of TX Mediciad Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,2299.192,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,49.336,Fee Schedule,103% of TX Medicaid Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,141.75,75,,2382.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,2720.288,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,766.8,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,766.8,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,32.72,Fee Schedule,170% of Scott and White SWHP fee schedule,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,5329.632,Fee Schedule,90% of UHC fee schedule,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,47.904,Fee Schedule,100% of TX Medicaid Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,189,100,,3176.752,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,516.6,
SUSCEP ENZYM DETECT PER ENZYME,41270364,CDM,306,RC,87185,HCPCS,Outpatient,,,45.89,27.53,,5.52,100,,2778.304,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,930.144,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,1977.248,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,2542.176,Fee Schedule,360% of BCBS POS Rate,17.1,360,,2542.176,Fee schedule,360% of BCBS PPO Rate,17.1,360,,2542.176,Fee Schedule,360% of BCBS Traditional Rate,27.53,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,211.68,Fee Schedule,100% of TX Mediciad 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,,1532.792,Fee Schedule,100% of CMS OPPS Rate,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,218.032,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,34.42,75,,1065.184,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,766.8,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,3530.8,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,3530.8,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,430.776,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,140,Fee Schedule,90% of UHC fee schedule,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,1420.248,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,45.89,
POOL CRYO EA,42020701,CDM,300,RC,86965,HCPCS,Outpatient,,,186,111.60,,40.28,100,,1174.24,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,695.128,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,830.064,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,1067.224,Fee Schedule,360% of BCBS POS Rate,516.6,360,,1067.224,Fee schedule,360% of BCBS PPO Rate,516.6,360,,1067.224,Fee Schedule,360% of BCBS Traditional Rate,111.6,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1532.792,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.82,14.42,,218.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,139.5,75,,74.08,Percent of Total Billed Charges,75% of Total Billed Charges,93,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,93,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,93,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,93,50,,1075.696,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,92.4,Fee Schedule,90% of UHC fee schedule,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,26.04,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,186,100,,98.776,Percent of Total Billed Charges,100% of Total Billed Charges,26.04,516.6,
SPLITTING BLD PRODUCTS EA UNIT,42069856,CDM,300,RC,86985,HCPCS,Outpatient,,,150.43,90.26,,31.56,100,,1490.632,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,695.128,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,39.2,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,51.2,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,50.4,Fee Schedule,360% of BCBS POS Rate,516.6,360,,50.4,Fee schedule,360% of BCBS PPO Rate,516.6,360,,50.4,Fee Schedule,360% of BCBS Traditional Rate,90.26,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1405.616,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,218.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,74.08,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,1705.984,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,19040,Fee Schedule,90% of UHC fee schedule,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,211.68,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,98.776,Percent of Total Billed Charges,100% of Total Billed Charges,21.06,516.6,
VENIPUNCT *,42090118,CDM,300,RC,36415,HCPCS,Outpatient,,,34.67,20.80,,1.74,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,13.24,150,,1117.976,Fee Schedule ,150% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,51.352,Other,Not Seperately Reimbusable,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,2066.984,Fee Schedule,100% of CMS OPPS Rate,7.94,90,,,Fee Schedule,90% of CMS OPPS Rate,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,130,,,Fee Schedule,130% of CMS OPPS Rate,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,5,14.42,,292.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,9.09,103,,,Fee Schedule,103% of CMS OPPS Rate,9.09,103,,,Fee Schedule,103% of CMS OPPS Rate,26,75,,1911.6,Percent of Total Billed Charges,75% of Total Billed Charges,14.56,80,,341.112,Fee Schedule,80% of Scott and White EPO fee schedule,14.56,80,,1211.216,Fee Schedule,80% of Scott and White HMO fee schedule,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,14.56,170,,1211.216,Fee Schedule,170% of Scott and White PPO fee schedule,14.56,170,,993.784,Fee Schedule,170% of Scott and White SWHP fee schedule,13.24,150,,,Fee Schedule,150% of CMS OPPS Rate,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2.43,90,,14560,Fee Schedule,90% of UHC fee schedule,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,284.12,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,100,,2548.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.74,34.67,
CYTOPATH C/V THIN LAYER REDO,43000010,CDM,311,RC,88143,HCPCS,Outpatient,,,137.28,82.37,,26.72,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,34.56,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,64.51,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,73.73,320,,51.512,Fee Schedule,320% of BCBS Blue Essentials Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,82.94,360,,172.8,Fee Schedule,360% of BCBS POS Rate,82.94,360,,172.8,Fee schedule,360% of BCBS PPO Rate,82.94,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,82.37,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,19.35,100,,211.68,Fee Schedule,100% of TX Mediciad Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,23.04,100,,1544.72,Fee Schedule,100% of CMS OPPS Rate,20.73,90,,,Fee Schedule,90% of CMS OPPS Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,29.95,130,,,Fee Schedule,130% of CMS OPPS Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.93,103,,218.032,Fee Schedule,103% of TX Medicaid Rate,23.73,103,,,Fee Schedule,103% of CMS OPPS Rate,23.73,103,,,Fee Schedule,103% of CMS OPPS Rate,102.96,75,,558,Percent of Total Billed Charges,75% of Total Billed Charges,39.16,80,,37.752,Fee Schedule,80% of Scott and White EPO fee schedule,39.16,80,,22.12,Fee Schedule,80% of Scott and White HMO fee schedule,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.16,170,,22.12,Fee Schedule,170% of Scott and White PPO fee schedule,39.16,170,,993.784,Fee Schedule,170% of Scott and White SWHP fee schedule,34.56,150,,,Fee Schedule,150% of CMS OPPS Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,18.67,90,,13328,Fee Schedule,90% of UHC fee schedule,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,211.68,Fee Schedule,100% of TX Medicaid Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,137.28,100,,744,Percent of Total Billed Charges,100% of Total Billed Charges,18.67,137.28,
CYTOPATH TBS C/V REDO,43000011,CDM,311,RC,88165,HCPCS,Outpatient,,,78,46.80,,48.98,100,,294.904,Fee Schedule,100% of Aetna Fee Schedule,63.33,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,118.22,280,,361.304,Fee Schedule,280% of BCBS BULE Fee Schedule,135.1,320,,51.512,Fee Schedule,320% of BCBS Blue Essentials Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,151.99,360,,464.536,Fee Schedule,360% of BCBS POS Rate,151.99,360,,464.536,Fee schedule,360% of BCBS PPO Rate,151.99,360,,464.536,Fee Schedule,360% of BCBS Traditional Rate,46.8,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,35.46,100,,324.912,Fee Schedule,100% of TX Mediciad Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,100,,1544.72,Fee Schedule,100% of CMS OPPS Rate,37.99,90,,,Fee Schedule,90% of CMS OPPS Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,130,,,Fee Schedule,130% of CMS OPPS Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,36.52,103,,334.656,Fee Schedule,103% of TX Medicaid Rate,43.48,103,,,Fee Schedule,103% of CMS OPPS Rate,43.48,103,,,Fee Schedule,103% of CMS OPPS Rate,58.5,75,,987.304,Percent of Total Billed Charges,75% of Total Billed Charges,71.77,80,,1211.216,Fee Schedule,80% of Scott and White EPO fee schedule,71.77,80,,32.416,Fee Schedule,80% of Scott and White HMO fee schedule,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,71.77,170,,32.416,Fee Schedule,170% of Scott and White PPO fee schedule,71.77,170,,2636.032,Fee Schedule,170% of Scott and White SWHP fee schedule,63.33,150,,,Fee Schedule,150% of CMS OPPS Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,34.2,90,,14560,Fee Schedule,90% of UHC fee schedule,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,35.46,100,,324.912,Fee Schedule,100% of TX Medicaid Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,78,100,,1316.4,Percent of Total Billed Charges,100% of Total Billed Charges,34.2,151.99,
CYTOPATH TBS C/V SELECT,43000013,CDM,311,RC,88167,HCPCS,Outpatient,,,78,46.80,,17.58,100,,229.176,Fee Schedule,100% of Aetna Fee Schedule,26.64,150,,441.048,Fee Schedule ,150% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,280,,403.2,Fee Schedule,280% of BCBS BULE Fee Schedule,48.38,320,,51.512,Fee Schedule,320% of BCBS Blue Essentials Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,54.43,360,,518.4,Fee Schedule,360% of BCBS POS Rate,54.43,360,,518.4,Fee schedule,360% of BCBS PPO Rate,54.43,360,,518.4,Fee Schedule,360% of BCBS Traditional Rate,46.8,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,13.37,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,2484.384,Fee Schedule,100% of CMS OPPS Rate,15.98,90,,,Fee Schedule,90% of CMS OPPS Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.08,130,,,Fee Schedule,130% of CMS OPPS Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.77,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,18.29,103,,,Fee Schedule,103% of CMS OPPS Rate,18.29,103,,,Fee Schedule,103% of CMS OPPS Rate,58.5,75,,1848.6,Percent of Total Billed Charges,75% of Total Billed Charges,29.42,80,,22.12,Fee Schedule,80% of Scott and White EPO fee schedule,29.42,80,,50.336,Fee Schedule,80% of Scott and White HMO fee schedule,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,29.42,170,,50.336,Fee Schedule,170% of Scott and White PPO fee schedule,29.42,170,,2636.032,Fee Schedule,170% of Scott and White SWHP fee schedule,26.64,150,,,Fee Schedule,150% of CMS OPPS Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,90,,143.36,Fee Schedule,90% of UHC fee schedule,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,78,100,,2464.8,Percent of Total Billed Charges,100% of Total Billed Charges,12.25,78,
ANALYSIS TUMOR,43000014,CDM,311,RC,88358,HCPCS,Outpatient,,,487.76,292.66,,107.78,100,,1097.704,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,322.896,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,487.2,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,51.624,Fee Schedule,320% of BCBS Blue Essentials Rate,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,626.4,Fee Schedule,360% of BCBS POS Rate,516.6,360,,626.4,Fee schedule,360% of BCBS PPO Rate,516.6,360,,626.4,Fee Schedule,360% of BCBS Traditional Rate,292.66,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1656.256,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,70.33,14.42,,101.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,365.82,75,,1380.904,Percent of Total Billed Charges,75% of Total Billed Charges,243.88,50,,32.416,Percent of Total Billed Charges,50% of Total Billed Charges,243.88,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,243.88,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,243.88,50,,4980.304,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,4639.008,Fee Schedule,90% of UHC fee schedule,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,14,,98.24,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,487.76,100,,1841.2,Percent of Total Billed Charges,100% of Total Billed Charges,68.29,516.6,
CYTOPATH SLIDE BETHESDA MANUAL,43000015,CDM,311,RC,88164,HCPCS,Outpatient,,,96.57,57.94,,17.58,100,,1097.704,Fee Schedule,100% of Aetna Fee Schedule,26.64,150,,1002.568,Fee Schedule ,150% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,280,,403.2,Fee Schedule,280% of BCBS BULE Fee Schedule,48.38,320,,51.688,Fee Schedule,320% of BCBS Blue Essentials Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,54.43,360,,518.4,Fee Schedule,360% of BCBS POS Rate,54.43,360,,518.4,Fee schedule,360% of BCBS PPO Rate,54.43,360,,518.4,Fee Schedule,360% of BCBS Traditional Rate,57.94,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,13.37,100,,91.144,Fee Schedule,100% of TX Mediciad Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,100,,1656.256,Fee Schedule,100% of CMS OPPS Rate,15.98,90,,,Fee Schedule,90% of CMS OPPS Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.08,130,,,Fee Schedule,130% of CMS OPPS Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.77,103,,93.88,Fee Schedule,103% of TX Medicaid Rate,18.29,103,,,Fee Schedule,103% of CMS OPPS Rate,18.29,103,,,Fee Schedule,103% of CMS OPPS Rate,72.43,75,,1021.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.42,80,,50.336,Fee Schedule,80% of Scott and White EPO fee schedule,29.42,80,,192.456,Fee Schedule,80% of Scott and White HMO fee schedule,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,29.42,170,,192.456,Fee Schedule,170% of Scott and White PPO fee schedule,29.42,170,,173.808,Fee Schedule,170% of Scott and White SWHP fee schedule,26.64,150,,,Fee Schedule,150% of CMS OPPS Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,90,,772.8,Fee Schedule,90% of UHC fee schedule,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,13.37,100,,91.144,Fee Schedule,100% of TX Medicaid Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,96.57,100,,1361.6,Percent of Total Billed Charges,100% of Total Billed Charges,12.25,96.57,
RSV ASSAY W/OPTIC,43000020,CDM,306,RC,87807,HCPCS,Outpatient,,,184.1,110.46,,15.2,100,,1646.552,Fee Schedule,100% of Aetna Fee Schedule,19.65,150,,968.672,Fee Schedule ,150% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36.68,280,,440.984,Fee Schedule,280% of BCBS BULE Fee Schedule,41.92,320,,51.92,Fee Schedule,320% of BCBS Blue Essentials Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,47.16,360,,566.984,Fee Schedule,360% of BCBS POS Rate,47.16,360,,566.984,Fee schedule,360% of BCBS PPO Rate,47.16,360,,566.984,Fee Schedule,360% of BCBS Traditional Rate,110.46,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,11,100,,44.304,Fee Schedule,100% of TX Mediciad Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,980.104,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,,Fee Schedule,90% of CMS OPPS Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,130,,,Fee Schedule,130% of CMS OPPS Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11.33,103,,45.64,Fee Schedule,103% of TX Medicaid Rate,13.49,103,,,Fee Schedule,103% of CMS OPPS Rate,13.49,103,,,Fee Schedule,103% of CMS OPPS Rate,138.08,75,,662.92,Percent of Total Billed Charges,75% of Total Billed Charges,22.27,80,,192.456,Fee Schedule,80% of Scott and White EPO fee schedule,22.27,80,,33.976,Fee Schedule,80% of Scott and White HMO fee schedule,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.27,170,,33.976,Fee Schedule,170% of Scott and White PPO fee schedule,22.27,170,,2720.288,Fee Schedule,170% of Scott and White SWHP fee schedule,19.65,150,,,Fee Schedule,150% of CMS OPPS Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10.61,90,,143.36,Fee Schedule,90% of UHC fee schedule,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,11,100,,44.304,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,184.1,100,,883.888,Percent of Total Billed Charges,100% of Total Billed Charges,10.61,184.1,
BONE MARROW SMEAR INTERP,43000021,CDM,305,RC,85097,HCPCS,Outpatient,,,354.19,212.51,,57.46,100,,659.2,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,1467.608,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,2083.424,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,51.992,Fee Schedule,320% of BCBS Blue Essentials Rate,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,2261.52,360,,2678.688,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,2678.688,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,2678.688,Fee Schedule,360% of BCBS Traditional Rate,212.51,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,717.544,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.07,14.42,,19.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,265.64,75,,503.496,Percent of Total Billed Charges,75% of Total Billed Charges,177.1,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,177.1,50,,1760.688,Percent of Total Billed Charges,50% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,177.1,50,,1760.688,Percent of Total Billed Charges,50% of Total Billed Charges,177.1,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,6697.04,Fee Schedule,90% of UHC fee schedule,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,49.59,14,,19.04,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,354.19,100,,671.328,Percent of Total Billed Charges,100% of Total Billed Charges,49.59,2261.52,
CALR GENE COM VARIANTS,43000022,CDM,310,RC,81219,HCPCS,Outpatient,,,331.36,198.82,,141.1,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,182.44,150,,665.144,Fee Schedule ,150% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,340.56,280,,321.088,Fee Schedule,280% of BCBS BULE Fee Schedule,389.22,320,,52,Fee Schedule,320% of BCBS Blue Essentials Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,437.87,360,,412.824,Fee Schedule,360% of BCBS POS Rate,437.87,360,,412.824,Fee schedule,360% of BCBS PPO Rate,437.87,360,,412.824,Fee Schedule,360% of BCBS Traditional Rate,198.82,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,102.17,100,,177.376,Fee Schedule,100% of TX Mediciad 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,,2227.936,Fee Schedule,100% of CMS OPPS Rate,109.46,90,,,Fee Schedule,90% of CMS OPPS Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,158.11,130,,,Fee Schedule,130% of CMS OPPS Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,105.24,103,,182.696,Fee Schedule,103% of TX Medicaid Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,248.52,75,,777.928,Percent of Total Billed Charges,75% of Total Billed Charges,206.77,80,,33.976,Fee Schedule,80% of Scott and White EPO fee schedule,206.77,80,,117.264,Fee Schedule,80% of Scott and White HMO fee schedule,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,206.77,170,,117.264,Fee Schedule,170% of Scott and White PPO fee schedule,206.77,170,,766.8,Fee Schedule,170% of Scott and White SWHP fee schedule,182.44,150,,,Fee Schedule,150% of CMS OPPS Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.52,90,,5208.56,Fee Schedule,90% of UHC fee schedule,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,331.36,100,,1037.232,Percent of Total Billed Charges,100% of Total Billed Charges,98.52,437.87,
FISH ADDITIONAL PROBE,43000026,CDM,312,RC,88364,HCPCS,Outpatient,,,533.78,320.27,,130.2,100,,1490.632,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.49,280,,7616,Fee Schedule,280% of BCBS BULE Fee Schedule,314.85,320,,52.224,Fee Schedule,320% of BCBS Blue Essentials Rate,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,354.2,360,,9792,Fee Schedule,360% of BCBS POS Rate,354.2,360,,9792,Fee schedule,360% of BCBS PPO Rate,354.2,360,,9792,Fee Schedule,360% of BCBS Traditional Rate,320.27,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,76.97,14.42,,70.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.34,75,,506.344,Percent of Total Billed Charges,75% of Total Billed Charges,266.89,50,,1760.688,Percent of Total Billed Charges,50% of Total Billed Charges,266.89,50,,2071,Percent of Total Billed Charges,50% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.89,50,,2071,Percent of Total Billed Charges,50% of Total Billed Charges,266.89,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.48,90,,1282.4,Fee Schedule,90% of UHC fee schedule,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,74.73,14,,68.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.78,100,,675.128,Percent of Total Billed Charges,100% of Total Billed Charges,74.73,533.78,
FISH INITIAL PROBE,43000027,CDM,312,RC,88365,HCPCS,Outpatient,,,563.87,338.32,,168.64,100,,993.752,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,103.952,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,1630.72,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,52.224,Fee Schedule,320% of BCBS Blue Essentials Rate,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,2096.64,Fee Schedule,360% of BCBS POS Rate,516.6,360,,2096.64,Fee schedule,360% of BCBS PPO Rate,516.6,360,,2096.64,Fee Schedule,360% of BCBS Traditional Rate,338.32,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,3261.344,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,81.31,14.42,,58.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,422.9,75,,506.344,Percent of Total Billed Charges,75% of Total Billed Charges,281.94,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,281.94,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,143.36,Fee Schedule,90% of UHC fee schedule,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,56.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,563.87,100,,675.128,Percent of Total Billed Charges,100% of Total Billed Charges,78.94,563.87,
FISH COMPUTER EA MULTIPROBE,43000028,CDM,312,RC,88374,HCPCS,Outpatient,,,450.28,270.17,,366.92,100,,1151.264,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,103.952,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,2131.856,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,52.4,Fee Schedule,320% of BCBS Blue Essentials Rate,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,2740.952,Fee Schedule,360% of BCBS POS Rate,516.6,360,,2740.952,Fee schedule,360% of BCBS PPO Rate,516.6,360,,2740.952,Fee Schedule,360% of BCBS Traditional Rate,270.17,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1478.104,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,64.93,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,337.71,75,,482.144,Percent of Total Billed Charges,75% of Total Billed Charges,225.14,50,,2071,Percent of Total Billed Charges,50% of Total Billed Charges,225.14,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,225.14,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,225.14,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,168,Fee Schedule,90% of UHC fee schedule,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,450.28,100,,642.856,Percent of Total Billed Charges,100% of Total Billed Charges,63.04,516.6,
TARGET GENOMIC SEQ ANAL,43000029,CDM,312,RC,81450,HCPCS,Outpatient,,,9200,5520.00,,881.06,100,,767.504,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,943.392,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,56,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,52.536,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,72,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,72,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,72,Fee Schedule,360% of BCBS Traditional Rate,5520,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,42,Fee Schedule,100% of TX Mediciad 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,,1279.176,Fee Schedule,100% of CMS OPPS Rate,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,6900,75,,432.12,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,50.336,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,15.04,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,15.04,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,1211.216,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,3720.64,Fee Schedule,90% of UHC fee schedule,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,42,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9200,100,,576.16,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,9200,
IDH1,43000030,CDM,310,RC,81120,HCPCS,Outpatient,,,1546,927.60,,224.18,100,,767.504,Fee Schedule,100% of Aetna Fee Schedule,289.87,150,,943.392,Fee Schedule ,150% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,541.1,280,,36.96,Fee Schedule,280% of BCBS BULE Fee Schedule,618.4,320,,52.536,Fee Schedule,320% of BCBS Blue Essentials Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,695.7,360,,47.52,Fee Schedule,360% of BCBS POS Rate,695.7,360,,47.52,Fee schedule,360% of BCBS PPO Rate,695.7,360,,47.52,Fee Schedule,360% of BCBS Traditional Rate,927.6,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,162.33,100,,49.28,Fee Schedule,100% of TX Mediciad 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,,231,Fee Schedule,100% of CMS OPPS Rate,173.92,90,,,Fee Schedule,90% of CMS OPPS Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,251.22,130,,,Fee Schedule,130% of CMS OPPS Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,167.2,103,,50.76,Fee Schedule,103% of TX Medicaid Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,1159.5,75,,615.936,Percent of Total Billed Charges,75% of Total Billed Charges,328.52,80,,50.336,Fee Schedule,80% of Scott and White EPO fee schedule,328.52,80,,107.88,Fee Schedule,80% of Scott and White HMO fee schedule,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,328.52,170,,107.88,Fee Schedule,170% of Scott and White PPO fee schedule,328.52,170,,22.12,Fee Schedule,170% of Scott and White SWHP fee schedule,289.87,150,,,Fee Schedule,150% of CMS OPPS Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,156.54,90,,798,Fee Schedule,90% of UHC fee schedule,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,49.28,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1546,100,,821.248,Percent of Total Billed Charges,100% of Total Billed Charges,156.54,1546,
IDH2,43000031,CDM,310,RC,81121,HCPCS,Outpatient,,,1774.76,1064.86,,343.12,100,,117.12,Fee Schedule,100% of Aetna Fee Schedule,443.68,150,,523.352,Fee Schedule ,150% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,828.21,280,,7616,Fee Schedule,280% of BCBS BULE Fee Schedule,946.53,320,,52.672,Fee Schedule,320% of BCBS Blue Essentials Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,1064.84,360,,9792,Fee Schedule,360% of BCBS POS Rate,1064.84,360,,9792,Fee schedule,360% of BCBS PPO Rate,1064.84,360,,9792,Fee Schedule,360% of BCBS Traditional Rate,1064.86,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,248.46,100,,92.4,Fee Schedule,100% of TX Mediciad 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,,231,Fee Schedule,100% of CMS OPPS Rate,266.21,90,,,Fee Schedule,90% of CMS OPPS Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,384.52,130,,,Fee Schedule,130% of CMS OPPS Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,255.91,103,,95.176,Fee Schedule,103% of TX Medicaid Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,1331.07,75,,505.8,Percent of Total Billed Charges,75% of Total Billed Charges,502.84,80,,15.04,Fee Schedule,80% of Scott and White EPO fee schedule,502.84,80,,80.664,Fee Schedule,80% of Scott and White HMO fee schedule,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,502.84,170,,80.664,Fee Schedule,170% of Scott and White PPO fee schedule,502.84,170,,32.416,Fee Schedule,170% of Scott and White SWHP fee schedule,443.68,150,,,Fee Schedule,150% of CMS OPPS Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.59,90,,603.08,Fee Schedule,90% of UHC fee schedule,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,92.4,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1774.76,100,,674.4,Percent of Total Billed Charges,100% of Total Billed Charges,239.59,1774.76,
MPL EXON 10 MUTATION DETECTION V,43000032,CDM,310,RC,81339,HCPCS,Outpatient,,,2794,1676.40,,214.84,100,,117.696,Fee Schedule,100% of Aetna Fee Schedule,277.8,150,,37.264,Fee Schedule ,150% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,518.56,280,,5824,Fee Schedule,280% of BCBS BULE Fee Schedule,592.64,320,,52.736,Fee Schedule,320% of BCBS Blue Essentials Rate,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,666.72,360,,7488,Fee Schedule,360% of BCBS POS Rate,666.72,360,,7488,Fee schedule,360% of BCBS PPO Rate,666.72,360,,7488,Fee Schedule,360% of BCBS Traditional Rate,1676.4,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,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,,2096.424,Fee Schedule,100% of CMS OPPS Rate,166.68,90,,,Fee Schedule,90% of CMS OPPS Rate,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,240.76,130,,,Fee Schedule,130% of CMS OPPS Rate,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.89,14.42,,95.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2095.5,75,,1548.624,Percent of Total Billed Charges,75% of Total Billed Charges,314.83,80,,107.88,Fee Schedule,80% of Scott and White EPO fee schedule,314.83,80,,213.84,Fee Schedule,80% of Scott and White HMO fee schedule,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,170,,213.84,Fee Schedule,170% of Scott and White PPO fee schedule,314.83,170,,50.336,Fee Schedule,170% of Scott and White SWHP fee schedule,277.8,150,,,Fee Schedule,150% of CMS OPPS Rate,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,150.01,90,,4758.6,Fee Schedule,90% of UHC fee schedule,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,391.16,14,,92.4,Percent of Total Billed Charges,14% of Total Billed Charges,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2794,100,,2064.832,Percent of Total Billed Charges,100% of Total Billed Charges,150.01,2794,
CHROM ANAL CV 15C 1 KARY,43000260,CDM,310,RC,88267,HCPCS,Outpatient,,,1273.25,763.95,,218.74,100,,79.68,Fee Schedule,100% of Aetna Fee Schedule,282.85,150,,189,Fee Schedule ,150% of CMS OPPS Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,528,280,,5331.2,Fee Schedule,280% of BCBS BULE Fee Schedule,603.42,320,,52.856,Fee Schedule,320% of BCBS Blue Essentials Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,678.85,360,,6854.4,Fee Schedule,360% of BCBS POS Rate,678.85,360,,6854.4,Fee schedule,360% of BCBS PPO Rate,678.85,360,,6854.4,Fee Schedule,360% of BCBS Traditional Rate,763.95,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,100,,90.056,Fee Schedule,100% of TX Mediciad Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,188.57,100,,2096.424,Fee Schedule,100% of CMS OPPS Rate,169.71,90,,,Fee Schedule,90% of CMS OPPS Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,245.14,130,,,Fee Schedule,130% of CMS OPPS Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,163.15,103,,92.752,Fee Schedule,103% of TX Medicaid Rate,194.22,103,,,Fee Schedule,103% of CMS OPPS Rate,194.22,103,,,Fee Schedule,103% of CMS OPPS Rate,954.94,75,,364.984,Percent of Total Billed Charges,75% of Total Billed Charges,320.56,80,,80.664,Fee Schedule,80% of Scott and White EPO fee schedule,320.56,80,,164.656,Fee Schedule,80% of Scott and White HMO fee schedule,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,320.56,170,,164.656,Fee Schedule,170% of Scott and White PPO fee schedule,320.56,170,,192.456,Fee Schedule,170% of Scott and White SWHP fee schedule,282.85,150,,,Fee Schedule,150% of CMS OPPS Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,152.74,90,,43.648,Fee Schedule,90% of UHC fee schedule,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,158.4,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,188.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.25,100,,486.648,Percent of Total Billed Charges,100% of Total Billed Charges,152.74,1273.25,
STONE ANALYSIS,43001200,CDM,312,RC,82365,HCPCS,Outpatient,,,612.2,367.32,,14.96,100,,49.152,Fee Schedule,100% of Aetna Fee Schedule,19.35,150,,280.528,Fee Schedule ,150% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,36.12,280,,5824,Fee Schedule,280% of BCBS BULE Fee Schedule,41.28,320,,52.856,Fee Schedule,320% of BCBS Blue Essentials Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,46.44,360,,7488,Fee Schedule,360% of BCBS POS Rate,46.44,360,,7488,Fee schedule,360% of BCBS PPO Rate,46.44,360,,7488,Fee Schedule,360% of BCBS Traditional Rate,367.32,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,100,,90.056,Fee Schedule,100% of TX Mediciad 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,,1163,Fee Schedule,100% of CMS OPPS Rate,11.61,90,,,Fee Schedule,90% of CMS OPPS Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,130,,,Fee Schedule,130% of CMS OPPS Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,11.17,103,,92.752,Fee Schedule,103% of TX Medicaid Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,459.15,75,,364.984,Percent of Total Billed Charges,75% of Total Billed Charges,21.93,80,,213.84,Fee Schedule,80% of Scott and White EPO fee schedule,21.93,80,,164.656,Fee Schedule,80% of Scott and White HMO fee schedule,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,170,,164.656,Fee Schedule,170% of Scott and White PPO fee schedule,21.93,170,,192.456,Fee Schedule,170% of Scott and White SWHP fee schedule,19.35,150,,,Fee Schedule,150% of CMS OPPS Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.45,90,,1041.6,Fee Schedule,90% of UHC fee schedule,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,90.056,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,612.2,100,,486.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.45,612.2,
IHC ANTIBODY SLIDE ADDL SINGLE,43021720,CDM,312,RC,88341,HCPCS,Outpatient,,,290.09,174.05,,77.66,100,,285.6,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.63,280,,57.344,Fee Schedule,280% of BCBS BULE Fee Schedule,206.43,320,,52.856,Fee Schedule,320% of BCBS Blue Essentials Rate,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,232.24,360,,73.728,Fee Schedule,360% of BCBS POS Rate,232.24,360,,73.728,Fee schedule,360% of BCBS PPO Rate,232.24,360,,73.728,Fee Schedule,360% of BCBS Traditional Rate,174.05,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,41.83,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.57,75,,1866,Percent of Total Billed Charges,75% of Total Billed Charges,145.05,50,,164.656,Percent of Total Billed Charges,50% of Total Billed Charges,145.05,50,,28.28,Percent of Total Billed Charges,50% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.05,50,,28.28,Percent of Total Billed Charges,50% of Total Billed Charges,145.05,50,,33.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.33,90,,14253.12,Fee Schedule,90% of UHC fee schedule,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.09,100,,2488,Percent of Total Billed Charges,100% of Total Billed Charges,40.61,290.09,
IHC ANTIBODY SLIDE SINGLE,43021721,CDM,312,RC,88342,HCPCS,Outpatient,,,334.72,200.83,,84.1,100,,285.6,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,2270.792,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,1855.6,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,52.856,Fee Schedule,320% of BCBS Blue Essentials Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,2385.776,Fee Schedule,360% of BCBS POS Rate,516.6,360,,2385.776,Fee schedule,360% of BCBS PPO Rate,516.6,360,,2385.776,Fee Schedule,360% of BCBS Traditional Rate,200.83,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,420,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,48.27,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,251.04,75,,712.432,Percent of Total Billed Charges,75% of Total Billed Charges,167.36,50,,164.656,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.36,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,1760.688,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,3101.28,Fee Schedule,90% of UHC fee schedule,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334.72,100,,949.912,Percent of Total Billed Charges,100% of Total Billed Charges,46.86,516.6,
IHC ANTIBODY SLIDE MULIPLEX,43021722,CDM,312,RC,88344,HCPCS,Outpatient,,,334.72,200.83,,166.34,100,,51.072,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,143.64,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,309.12,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,52.864,Fee Schedule,320% of BCBS Blue Essentials Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,397.44,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,397.44,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,397.44,Fee Schedule,360% of BCBS Traditional Rate,200.83,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,623.4,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,48.27,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,251.04,75,,460.024,Percent of Total Billed Charges,75% of Total Billed Charges,167.36,50,,28.28,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,26.952,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,167.36,50,,26.952,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,117.264,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,9222.168,Fee Schedule,90% of UHC fee schedule,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,334.72,100,,613.368,Percent of Total Billed Charges,100% of Total Billed Charges,46.86,1020.28,
CYTOPATH FLUID SMEAR W INTERP,43081041,CDM,310,RC,88104,HCPCS,Outpatient,,,239.87,143.92,,47.14,100,,45.6,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,298.44,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,57.344,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,53.408,Fee Schedule,320% of BCBS Blue Essentials Rate,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,73.728,Fee Schedule,360% of BCBS POS Rate,120.35,360,,73.728,Fee schedule,360% of BCBS PPO Rate,120.35,360,,73.728,Fee Schedule,360% of BCBS Traditional Rate,143.92,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,387.8,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,34.59,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,179.9,75,,777.928,Percent of Total Billed Charges,75% of Total Billed Charges,119.94,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,119.94,50,,143.936,Percent of Total Billed Charges,50% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,119.94,50,,143.936,Percent of Total Billed Charges,50% of Total Billed Charges,119.94,50,,2071,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,6115.2,Fee Schedule,90% of UHC fee schedule,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,33.58,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.87,100,,1037.232,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,239.87,
CYTOPATH FLUID FILTER W INTERP,43081066,CDM,310,RC,88106,HCPCS,Outpatient,,,230.2,138.12,,56.28,100,,63.784,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,123.928,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,280,,2678.816,Fee Schedule,280% of BCBS BULE Fee Schedule,73.57,320,,53.408,Fee Schedule,320% of BCBS Blue Essentials Rate,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,82.76,360,,3444.192,Fee Schedule,360% of BCBS POS Rate,82.76,360,,3444.192,Fee schedule,360% of BCBS PPO Rate,82.76,360,,3444.192,Fee Schedule,360% of BCBS Traditional Rate,138.12,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,5046.2,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,33.19,14.42,,92.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,172.65,75,,506.344,Percent of Total Billed Charges,75% of Total Billed Charges,115.1,50,,26.952,Percent of Total Billed Charges,50% of Total Billed Charges,115.1,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,115.1,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,115.1,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,84,Fee Schedule,90% of UHC fee schedule,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.23,14,,90.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,230.2,100,,675.128,Percent of Total Billed Charges,100% of Total Billed Charges,18.62,230.2,
CYTOPATH CONC SMEAR&INTERP,43081082,CDM,311,RC,88108,HCPCS,Outpatient,,,191.16,114.70,,48.8,100,,502.848,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,212.4,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,2083.424,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,53.408,Fee Schedule,320% of BCBS Blue Essentials Rate,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,2678.688,Fee Schedule,360% of BCBS POS Rate,120.35,360,,2678.688,Fee schedule,360% of BCBS PPO Rate,120.35,360,,2678.688,Fee Schedule,360% of BCBS Traditional Rate,114.7,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,319.2,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,27.57,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,143.37,75,,506.344,Percent of Total Billed Charges,75% of Total Billed Charges,95.58,50,,143.936,Percent of Total Billed Charges,50% of Total Billed Charges,95.58,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,95.58,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,95.58,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,672,Fee Schedule,90% of UHC fee schedule,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.76,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,191.16,100,,675.128,Percent of Total Billed Charges,100% of Total Billed Charges,26.76,191.16,
CYTOPATH CELL ENHAN W INTERP,43081124,CDM,311,RC,88112,HCPCS,Outpatient,,,266,159.60,,47.14,100,,502.08,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,206.728,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,512.96,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,53.408,Fee Schedule,320% of BCBS Blue Essentials Rate,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,659.52,Fee Schedule,360% of BCBS POS Rate,178.09,360,,659.52,Fee schedule,360% of BCBS PPO Rate,178.09,360,,659.52,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,405.72,Percent of Total Billed Charges,60% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,663.2,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,38.36,14.42,,92.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,314.592,Percent of Total Billed Charges,75% of Total Billed Charges,133,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,133,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,133,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,133,50,,15.04,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,2184,Fee Schedule,90% of UHC fee schedule,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.24,14,,89.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,419.456,Percent of Total Billed Charges,100% of Total Billed Charges,37.24,266,
CYTOPATH SMEARS SCRN & INTERP,43081611,CDM,311,RC,88161,HCPCS,Outpatient,,,143,85.80,,55.04,100,,88.208,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,74.072,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,280,,57.344,Fee Schedule,280% of BCBS BULE Fee Schedule,73.57,320,,53.424,Fee Schedule,320% of BCBS Blue Essentials Rate,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,82.76,360,,73.728,Fee Schedule,360% of BCBS POS Rate,82.76,360,,73.728,Fee schedule,360% of BCBS PPO Rate,82.76,360,,73.728,Fee Schedule,360% of BCBS Traditional Rate,85.8,60,,398.032,Percent of Total Billed Charges,60% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,275.4,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.62,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,107.25,75,,314.592,Percent of Total Billed Charges,75% of Total Billed Charges,71.5,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,71.5,50,,450.64,Percent of Total Billed Charges,50% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,71.5,50,,450.64,Percent of Total Billed Charges,50% of Total Billed Charges,71.5,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,77.28,Fee Schedule,90% of UHC fee schedule,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143,100,,419.456,Percent of Total Billed Charges,100% of Total Billed Charges,18.62,143,
CYTOPATH FNA EVAL,43081728,CDM,311,RC,88172,HCPCS,Outpatient,,,243.91,146.35,,23.48,100,,180,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,247.68,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,67.2,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,53.504,Fee Schedule,320% of BCBS Blue Essentials Rate,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,86.4,Fee Schedule,360% of BCBS POS Rate,516.6,360,,86.4,Fee schedule,360% of BCBS PPO Rate,516.6,360,,86.4,Fee Schedule,360% of BCBS Traditional Rate,146.35,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,472,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,35.17,14.42,,1907.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,182.93,75,,1065.184,Percent of Total Billed Charges,75% of Total Billed Charges,121.96,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,121.96,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121.96,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,121.96,50,,80.664,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,4368,Fee Schedule,90% of UHC fee schedule,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.15,14,,1851.992,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,243.91,100,,1420.248,Percent of Total Billed Charges,100% of Total Billed Charges,23.48,516.6,
CYTOPATH FNA INTERP & REPORT,43081736,CDM,311,RC,88173,HCPCS,Outpatient,,,351,210.60,,101.36,100,,278.4,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,200.792,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,1488.256,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,53.664,Fee Schedule,320% of BCBS Blue Essentials Rate,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,1913.472,Fee Schedule,360% of BCBS POS Rate,178.09,360,,1913.472,Fee schedule,360% of BCBS PPO Rate,178.09,360,,1913.472,Fee Schedule,360% of BCBS Traditional Rate,210.6,60,,982.76,Percent of Total Billed Charges,60% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,459.4,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,50.61,14.42,,153.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,263.25,75,,712.008,Percent of Total Billed Charges,75% of Total Billed Charges,175.5,50,,450.64,Percent of Total Billed Charges,50% of Total Billed Charges,175.5,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,175.5,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,175.5,50,,213.84,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,5710.32,Fee Schedule,90% of UHC fee schedule,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,351,100,,949.344,Percent of Total Billed Charges,100% of Total Billed Charges,40.07,351,
PATH SURG GROSS ONLY LVL 1,43083005,CDM,312,RC,88300,HCPCS,Outpatient,,,147,88.20,,13.1,100,,324,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,303.032,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,280,,319.2,Fee Schedule,280% of BCBS BULE Fee Schedule,73.57,320,,53.728,Fee Schedule,320% of BCBS Blue Essentials Rate,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,82.76,360,,410.4,Fee Schedule,360% of BCBS POS Rate,82.76,360,,410.4,Fee schedule,360% of BCBS PPO Rate,82.76,360,,410.4,Fee Schedule,360% of BCBS Traditional Rate,88.2,60,,696.84,Percent of Total Billed Charges,60% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,164.6,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14.42,,6996.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,110.25,75,,482.144,Percent of Total Billed Charges,75% of Total Billed Charges,73.5,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,73.5,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,73.5,50,,164.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,2475.2,Fee Schedule,90% of UHC fee schedule,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,20.58,14,,6793.024,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,147,100,,642.856,Percent of Total Billed Charges,100% of Total Billed Charges,13.1,147,
PATH SURG GROSS ONLY LVL 2,43083021,CDM,312,RC,88302,HCPCS,Outpatient,,,236,141.60,,29.7,100,,54.72,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,40.68,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,280,,241.232,Fee Schedule,280% of BCBS BULE Fee Schedule,73.57,320,,53.744,Fee Schedule,320% of BCBS Blue Essentials Rate,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,82.76,360,,310.152,Fee Schedule,360% of BCBS POS Rate,82.76,360,,310.152,Fee schedule,360% of BCBS PPO Rate,82.76,360,,310.152,Fee Schedule,360% of BCBS Traditional Rate,141.6,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,550.4,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.03,14.42,,69.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,177,75,,645,Percent of Total Billed Charges,75% of Total Billed Charges,118,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,118,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,118,50,,164.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,210,Fee Schedule,90% of UHC fee schedule,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,33.04,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,236,100,,860,Percent of Total Billed Charges,100% of Total Billed Charges,18.62,236,
PATH SURG GROSS & MICRO LVL 3,43083047,CDM,312,RC,88304,HCPCS,Outpatient,,,320.39,192.23,,36.36,100,,33.6,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,50.76,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,1903.44,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,5385.872,Fee Schedule,320% of BCBS Blue Essentials Rate,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,2447.28,Fee Schedule,360% of BCBS POS Rate,178.09,360,,2447.28,Fee schedule,360% of BCBS PPO Rate,178.09,360,,2447.28,Fee Schedule,360% of BCBS Traditional Rate,192.23,60,,91.272,Percent of Total Billed Charges,60% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,446.2,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,46.2,14.42,,1176.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,240.29,75,,432.12,Percent of Total Billed Charges,75% of Total Billed Charges,160.2,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,160.2,50,,1014.712,Percent of Total Billed Charges,50% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,50,,1014.712,Percent of Total Billed Charges,50% of Total Billed Charges,160.2,50,,28.28,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,20.816,Fee Schedule,90% of UHC fee schedule,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,44.85,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,320.39,100,,576.16,Percent of Total Billed Charges,100% of Total Billed Charges,36.36,320.39,
PATH SURG GROSS * MICRO LVL 4,43083054,CDM,312,RC,88305,HCPCS,Outpatient,,,150,90.00,,40.08,100,,288,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,298.44,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,17.456,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,5478.4,Fee Schedule,320% of BCBS Blue Essentials Rate,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,22.448,Fee Schedule,360% of BCBS POS Rate,178.09,360,,22.448,Fee schedule,360% of BCBS PPO Rate,178.09,360,,22.448,Fee Schedule,360% of BCBS Traditional Rate,90,60,,18.08,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,673.4,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,69.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,112.5,75,,412.112,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,75,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,20.816,Fee Schedule,90% of UHC fee schedule,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,549.48,Percent of Total Billed Charges,100% of Total Billed Charges,21,178.09,
PATH SURG LEVEL V RP,43083070,CDM,312,RC,88307,HCPCS,Outpatient,,,848.04,508.82,,245.48,100,,54.432,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,137.704,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,416.64,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,5578.416,Fee Schedule,320% of BCBS Blue Essentials Rate,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,535.68,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,535.68,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,535.68,Fee Schedule,360% of BCBS Traditional Rate,508.82,60,,924,Percent of Total Billed Charges,60% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,90.4,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,122.29,14.42,,69.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,636.03,75,,412.112,Percent of Total Billed Charges,75% of Total Billed Charges,424.02,50,,1014.712,Percent of Total Billed Charges,50% of Total Billed Charges,424.02,50,,1160.392,Percent of Total Billed Charges,50% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,424.02,50,,1160.392,Percent of Total Billed Charges,50% of Total Billed Charges,424.02,50,,26.952,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,25.008,Fee Schedule,90% of UHC fee schedule,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,118.73,14,,67.112,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,848.04,100,,549.48,Percent of Total Billed Charges,100% of Total Billed Charges,118.73,1020.28,
PATH SURG GROSS & MICRO LVL 6,43083096,CDM,312,RC,88309,HCPCS,Outpatient,,,1204.92,722.95,,350.14,100,,309.6,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,138.512,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,5701.248,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,5.384,Fee Schedule,320% of BCBS Blue Essentials Rate,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,2261.52,360,,7330.176,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,7330.176,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,7330.176,Fee Schedule,360% of BCBS Traditional Rate,722.95,60,,280.688,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,112.8,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,173.75,14.42,,7646.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,903.69,75,,447.832,Percent of Total Billed Charges,75% of Total Billed Charges,602.46,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,602.46,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,602.46,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,602.46,50,,143.936,Percent of Total Billed Charges,50% of Total Billed Charges,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,25.008,Fee Schedule,90% of UHC fee schedule,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,168.69,14,,7423.416,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1204.92,100,,597.112,Percent of Total Billed Charges,100% of Total Billed Charges,168.69,2261.52,
DECALCIFICATION PROCEDURE,43083112,CDM,312,RC,88311,HCPCS,Outpatient,,,118,70.80,,10.18,100,,108,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.23,280,,1240.512,Fee Schedule,280% of BCBS BULE Fee Schedule,28.83,320,,5.392,Fee Schedule,320% of BCBS Blue Essentials Rate,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,32.44,360,,1594.944,Fee Schedule,360% of BCBS POS Rate,32.44,360,,1594.944,Fee schedule,360% of BCBS PPO Rate,32.44,360,,1594.944,Fee Schedule,360% of BCBS Traditional Rate,70.8,60,,537.976,Percent of Total Billed Charges,60% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,17.02,14.42,,1899.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.5,75,,447.832,Percent of Total Billed Charges,75% of Total Billed Charges,59,50,,1160.392,Percent of Total Billed Charges,50% of Total Billed Charges,59,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,59,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.31,90,,14560,Fee Schedule,90% of UHC fee schedule,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,16.52,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118,100,,597.112,Percent of Total Billed Charges,100% of Total Billed Charges,7.31,118,
SPECIAL STAINS GROUP l EA,43083120,CDM,312,RC,88312,HCPCS,Outpatient,,,221.93,133.16,,102.38,100,,72,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,26.104,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,3688.864,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,5.424,Fee Schedule,320% of BCBS Blue Essentials Rate,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,4742.832,Fee Schedule,360% of BCBS POS Rate,178.09,360,,4742.832,Fee schedule,360% of BCBS PPO Rate,178.09,360,,4742.832,Fee Schedule,360% of BCBS Traditional Rate,133.16,60,,1201.896,Percent of Total Billed Charges,60% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,306,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,32,14.42,,26.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,166.45,75,,739.72,Percent of Total Billed Charges,75% of Total Billed Charges,110.97,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,110.97,50,,325.52,Percent of Total Billed Charges,50% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,110.97,50,,325.52,Percent of Total Billed Charges,50% of Total Billed Charges,110.97,50,,315.84,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,5096,Fee Schedule,90% of UHC fee schedule,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,31.07,14,,25.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,221.93,100,,986.288,Percent of Total Billed Charges,100% of Total Billed Charges,31.07,221.93,
SPECIAL STAINS GROUP ll EA,43083138,CDM,312,RC,88313,HCPCS,Outpatient,,,223,133.80,,82.44,100,,288,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,37.264,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,2446.08,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,5.472,Fee Schedule,320% of BCBS Blue Essentials Rate,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,3144.96,Fee Schedule,360% of BCBS POS Rate,120.35,360,,3144.96,Fee schedule,360% of BCBS PPO Rate,120.35,360,,3144.96,Fee Schedule,360% of BCBS Traditional Rate,133.8,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,307.8,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,32.16,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,167.25,75,,739.72,Percent of Total Billed Charges,75% of Total Billed Charges,111.5,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,111.5,50,,158.24,Percent of Total Billed Charges,50% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,111.5,50,,158.24,Percent of Total Billed Charges,50% of Total Billed Charges,111.5,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,48.888,Fee Schedule,90% of UHC fee schedule,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,223,100,,986.288,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,223,
PATH CONSULT FRZ SECTION 1ST,43083310,CDM,312,RC,88331,HCPCS,Outpatient,,,398,238.80,,50.06,100,,84,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,51.928,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,5.496,Fee Schedule,320% of BCBS Blue Essentials Rate,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,43.2,Fee Schedule,360% of BCBS POS Rate,516.6,360,,43.2,Fee schedule,360% of BCBS PPO Rate,516.6,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,238.8,60,,385.944,Percent of Total Billed Charges,60% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,399.4,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,57.39,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,298.5,75,,1420.8,Percent of Total Billed Charges,75% of Total Billed Charges,199,50,,325.52,Percent of Total Billed Charges,50% of Total Billed Charges,199,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,199,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,199,50,,450.64,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,3954.496,Fee Schedule,90% of UHC fee schedule,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,398,100,,1776,Percent of Total Billed Charges,100% of Total Billed Charges,50.06,516.6,
PATH CONSULT FRZ SECT EA ADDL,43083328,CDM,312,RC,88332,HCPCS,Outpatient,,,206,123.60,,28.46,100,,72,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.54,280,,268.8,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,5.512,Fee Schedule,320% of BCBS Blue Essentials Rate,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,345.6,Fee Schedule,360% of BCBS POS Rate,79.13,360,,345.6,Fee schedule,360% of BCBS PPO Rate,79.13,360,,345.6,Fee Schedule,360% of BCBS Traditional Rate,123.6,60,,600.352,Percent of Total Billed Charges,60% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.71,14.42,,541.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.5,75,,1238.128,Percent of Total Billed Charges,75% of Total Billed Charges,103,50,,158.24,Percent of Total Billed Charges,50% of Total Billed Charges,103,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,103,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.71,90,,52.92,Fee Schedule,90% of UHC fee schedule,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,525.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206,100,,1547.664,Percent of Total Billed Charges,100% of Total Billed Charges,18.71,206,
IMMUNOHISTO ANTIBODY SLIDE,43083344,CDM,312,RC,88334,HCPCS,Outpatient,,,295.92,177.55,,22.84,100,,76.8,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.43,280,,873.6,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,5.528,Fee Schedule,320% of BCBS Blue Essentials Rate,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,1123.2,Fee Schedule,360% of BCBS POS Rate,60.98,360,,1123.2,Fee schedule,360% of BCBS PPO Rate,60.98,360,,1123.2,Fee Schedule,360% of BCBS Traditional Rate,177.55,60,,179.624,Percent of Total Billed Charges,60% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,42.67,14.42,,155.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.94,75,,369,Percent of Total Billed Charges,75% of Total Billed Charges,147.96,50,,68.016,Percent of Total Billed Charges,50% of Total Billed Charges,147.96,50,,244.368,Percent of Total Billed Charges,50% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.96,50,,244.368,Percent of Total Billed Charges,50% of Total Billed Charges,147.96,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.62,90,,54.6,Fee Schedule,90% of UHC fee schedule,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,41.43,14,,150.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.92,100,,492,Percent of Total Billed Charges,100% of Total Billed Charges,14.62,295.92,
CRYSTAL ID FLUID NOT URINE,43093634,CDM,300,RC,89060,HCPCS,Outpatient,,,125.75,75.45,,8.5,100,,96,Fee Schedule,100% of Aetna Fee Schedule,10.99,150,,135,Fee Schedule ,150% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,280,,30.912,Fee Schedule,280% of BCBS BULE Fee Schedule,23.46,320,,5.536,Fee Schedule,320% of BCBS Blue Essentials Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,26.39,360,,39.744,Fee Schedule,360% of BCBS POS Rate,26.39,360,,39.744,Fee schedule,360% of BCBS PPO Rate,26.39,360,,39.744,Fee Schedule,360% of BCBS Traditional Rate,75.45,60,,1648.76,Percent of Total Billed Charges,60% of Total Billed Charges,6.16,100,,150.632,Fee Schedule,100% of TX Mediciad 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,,115.4,Fee Schedule,100% of CMS OPPS Rate,6.59,90,,,Fee Schedule,90% of CMS OPPS Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.52,130,,,Fee Schedule,130% of CMS OPPS Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.34,103,,155.152,Fee Schedule,103% of TX Medicaid Rate,7.54,103,,,Fee Schedule,103% of CMS OPPS Rate,7.54,103,,,Fee Schedule,103% of CMS OPPS Rate,94.31,75,,7851.688,Percent of Total Billed Charges,75% of Total Billed Charges,12.46,80,,633.496,Fee Schedule,80% of Scott and White EPO fee schedule,12.46,80,,203.152,Fee Schedule,80% of Scott and White HMO fee schedule,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,170,,203.152,Fee Schedule,170% of Scott and White PPO fee schedule,12.46,170,,756,Fee Schedule,170% of Scott and White SWHP fee schedule,10.99,150,,,Fee Schedule,150% of CMS OPPS Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5.94,90,,54.6,Fee Schedule,90% of UHC fee schedule,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,6.16,100,,150.632,Fee Schedule,100% of TX Medicaid Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,125.75,100,,10468.92,Percent of Total Billed Charges,100% of Total Billed Charges,5.94,125.75,
PLATELET PHERESIS PATH REDUCTION,45000000,CDM,390,RC,P9035,HCPCS,Outpatient,,,2780,1668.00,,553.76,100,,88.8,Fee Schedule,100% of Aetna Fee Schedule,708.49,150,,500.344,Fee Schedule ,150% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,778.4,28,,1747.2,Percent of Total Billed Charges,28% of Total Billed Charges,56.63,32,,5.536,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1000.8,36,,2246.4,Percent of Total Billed Charges,36% of Total Billed Charges,1000.8,36,,2246.4,Percent of Total Billed Charges,36% Total Bille Charges,1000.8,36,,2246.4,Percent of Total Billed Charges,36% of Total Billed Charges,1668,60,,108.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,54.6,Fee Schedule,100% of CMS OPPS Rate,425.09,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,614.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.49,103,,,Fee Schedule,103% of CMS OPPS Rate,486.49,103,,,Fee Schedule,103% of CMS OPPS Rate,2085,75,,1315.712,Percent of Total Billed Charges,75% of Total Billed Charges,1390,50,,244.368,Percent of Total Billed Charges,50% of Total Billed Charges,1390,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1390,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1390,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,708.49,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,54.6,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2780,100,,1754.28,Percent of Total Billed Charges,100% of Total Billed Charges,56.63,2780,
COLD STORAGE SDP,45000001,CDM,384,RC,P9035,HCPCS,Outpatient,,,2740,1644.00,,553.76,100,,430.56,Fee Schedule,100% of Aetna Fee Schedule,708.49,150,,864.688,Fee Schedule ,150% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,767.2,28,,2284.128,Percent of Total Billed Charges,28% of Total Billed Charges,56.63,32,,5.544,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,986.4,36,,2936.736,Percent of Total Billed Charges,36% of Total Billed Charges,986.4,36,,2936.736,Percent of Total Billed Charges,36% Total Bille Charges,986.4,36,,2936.736,Percent of Total Billed Charges,36% of Total Billed Charges,1644,60,,923.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,100,,78.24,Fee Schedule,100% of CMS OPPS Rate,425.09,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,614.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.49,103,,,Fee Schedule,103% of CMS OPPS Rate,486.49,103,,,Fee Schedule,103% of CMS OPPS Rate,2055,75,,1315.712,Percent of Total Billed Charges,75% of Total Billed Charges,1370,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,1370,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1370,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1370,50,,1014.712,Percent of Total Billed Charges,50% of Total Billed Charges,708.49,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,54.6,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2740,100,,1754.28,Percent of Total Billed Charges,100% of Total Billed Charges,56.63,2740,
FETAL HEMOGLOBIN BY FLOW,45000002,CDM,300,RC,88184,HCPCS,Outpatient,,,892,535.20,,82.66,100,,388.8,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,864.688,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,990.08,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,5.552,Fee Schedule,320% of BCBS Blue Essentials Rate,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,1272.96,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,1272.96,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,1272.96,Fee Schedule,360% of BCBS Traditional Rate,535.2,60,,1164.624,Percent of Total Billed Charges,60% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,300,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,128.63,14.42,,980.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,669,75,,1315.712,Percent of Total Billed Charges,75% of Total Billed Charges,446,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,446,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,446,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,446,50,,756,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,54.6,Fee Schedule,90% of UHC fee schedule,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,124.88,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,892,100,,1754.28,Percent of Total Billed Charges,100% of Total Billed Charges,82.66,1020.28,
HLA CLASS I DNA SNGL LOCUS TYP,45000107,CDM,310,RC,81373,HCPCS,Outpatient,,,597.63,358.58,,147.82,100,,180,Fee Schedule,100% of Aetna Fee Schedule,191.14,150,,395.264,Fee Schedule ,150% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,356.8,280,,8.328,Fee Schedule,280% of BCBS BULE Fee Schedule,407.78,320,,53.76,Fee Schedule,320% of BCBS Blue Essentials Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,458.75,360,,10.704,Fee Schedule,360% of BCBS POS Rate,458.75,360,,10.704,Fee schedule,360% of BCBS PPO Rate,458.75,360,,10.704,Fee Schedule,360% of BCBS Traditional Rate,358.58,60,,1005.032,Percent of Total Billed Charges,60% of Total Billed Charges,107.04,100,,30.8,Fee Schedule,100% of TX Mediciad 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,,1111.872,Fee Schedule,100% of CMS OPPS Rate,114.68,90,,,Fee Schedule,90% of CMS OPPS Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,165.65,130,,,Fee Schedule,130% of CMS OPPS Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,110.25,103,,31.728,Fee Schedule,103% of TX Medicaid Rate,131.25,103,,,Fee Schedule,103% of CMS OPPS Rate,131.25,103,,,Fee Schedule,103% of CMS OPPS Rate,448.22,75,,2154.88,Percent of Total Billed Charges,75% of Total Billed Charges,216.63,80,,150,Fee Schedule,80% of Scott and White EPO fee schedule,216.63,80,,330,Fee Schedule,80% of Scott and White HMO fee schedule,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,216.63,170,,330,Fee Schedule,170% of Scott and White PPO fee schedule,216.63,170,,1160.392,Fee Schedule,170% of Scott and White SWHP fee schedule,191.14,150,,,Fee Schedule,150% of CMS OPPS Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,103.22,90,,87.248,Fee Schedule,90% of UHC fee schedule,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,107.04,100,,30.8,Fee Schedule,100% of TX Medicaid Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,597.63,100,,2693.6,Percent of Total Billed Charges,100% of Total Billed Charges,103.22,597.63,
HEMOLYSINS & AGGLUTINS SCRN EA,45000108,CDM,302,RC,86940,HCPCS,Outpatient,,,157.5,94.50,,10.18,100,,307.008,Fee Schedule,100% of Aetna Fee Schedule,13.15,150,,1372.256,Fee Schedule ,150% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,24.56,280,,8.328,Fee Schedule,280% of BCBS BULE Fee Schedule,28.06,320,,53.784,Fee Schedule,320% of BCBS Blue Essentials Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,31.57,360,,10.704,Fee Schedule,360% of BCBS POS Rate,31.57,360,,10.704,Fee schedule,360% of BCBS PPO Rate,31.57,360,,10.704,Fee Schedule,360% of BCBS Traditional Rate,94.5,60,,608.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.37,100,,259.896,Fee Schedule,100% of TX Mediciad 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,,1921.536,Fee Schedule,100% of CMS OPPS Rate,7.89,90,,,Fee Schedule,90% of CMS OPPS Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.4,130,,,Fee Schedule,130% of CMS OPPS Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.59,103,,267.696,Fee Schedule,103% of TX Medicaid Rate,9.03,103,,,Fee Schedule,103% of CMS OPPS Rate,9.03,103,,,Fee Schedule,103% of CMS OPPS Rate,118.13,75,,798,Percent of Total Billed Charges,75% of Total Billed Charges,14.9,80,,176,Fee Schedule,80% of Scott and White EPO fee schedule,14.9,80,,330,Fee Schedule,80% of Scott and White HMO fee schedule,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,170,,330,Fee Schedule,170% of Scott and White PPO fee schedule,14.9,170,,105.536,Fee Schedule,170% of Scott and White SWHP fee schedule,13.15,150,,,Fee Schedule,150% of CMS OPPS Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.1,90,,110.744,Fee Schedule,90% of UHC fee schedule,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,7.37,100,,259.896,Fee Schedule,100% of TX Medicaid Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,157.5,100,,1064,Percent of Total Billed Charges,100% of Total Billed Charges,7.1,157.5,
REF RBC AB INCUBAT ENZYMES EA,45000109,CDM,300,RC,86971,HCPCS,Outpatient,,,94.94,56.96,,28.66,100,,338.4,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,1389.152,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,10,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,53.904,Fee Schedule,320% of BCBS Blue Essentials Rate,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,12.864,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,12.864,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,12.864,Fee Schedule,360% of BCBS Traditional Rate,56.96,60,,210.416,Percent of Total Billed Charges,60% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,1921.536,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14.42,,25.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,71.21,75,,769.2,Percent of Total Billed Charges,75% of Total Billed Charges,47.47,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,47.47,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,47.47,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,47.47,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,272.432,Fee Schedule,90% of UHC fee schedule,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,94.94,100,,1025.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.29,1020.28,
PATHOGEN TEST FOR PLATELETS,45000113,CDM,305,RC,P9100,HCPCS,Outpatient,,,49.84,29.90,,50.38,100,,288,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,2083.728,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,99.4,280,,10,Fee Schedule,280% of BCBS BULE Fee Schedule,113.6,320,,54.296,Fee Schedule,320% of BCBS Blue Essentials Rate,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,127.8,360,,12.864,Fee Schedule,360% of BCBS POS Rate,127.8,360,,12.864,Fee schedule,360% of BCBS PPO Rate,127.8,360,,12.864,Fee Schedule,360% of BCBS Traditional Rate,29.9,60,,1336.76,Percent of Total Billed Charges,60% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,878.368,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,7.19,14.42,,285.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.79,103,,,Fee Schedule,103% of CMS OPPS Rate,57.79,103,,,Fee Schedule,103% of CMS OPPS Rate,37.38,75,,222,Percent of Total Billed Charges,75% of Total Billed Charges,24.92,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,24.92,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.92,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,24.92,50,,325.52,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,46.84,Fee Schedule,90% of UHC fee schedule,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,6.98,14,,277.536,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,49.84,100,,296,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,127.8,
RBC DEGLY LR IRR FRZ WASHED EA,45000115,CDM,390,RC,P9057,HCPCS,Outpatient,,,1654.64,992.78,,542.08,100,,180,Fee Schedule,100% of Aetna Fee Schedule,739.05,150,,233.552,Fee Schedule ,150% of CMS OPPS Rate,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,463.3,28,,5824,Percent of Total Billed Charges,28% of Total Billed Charges,56.64,32,,54.296,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.67,36,,7488,Percent of Total Billed Charges,36% of Total Billed Charges,595.67,36,,7488,Percent of Total Billed Charges,36% Total Bille Charges,595.67,36,,7488,Percent of Total Billed Charges,36% of Total Billed Charges,992.78,60,,1084.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,492.7,100,,3049.464,Fee Schedule,100% of CMS OPPS Rate,443.43,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,640.51,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.48,103,,,Fee Schedule,103% of CMS OPPS Rate,507.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1240.98,75,,526.8,Percent of Total Billed Charges,75% of Total Billed Charges,827.32,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,827.32,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,827.32,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,827.32,50,,158.24,Percent of Total Billed Charges,50% of Total Billed Charges,739.05,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,68.88,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1654.64,100,,702.4,Percent of Total Billed Charges,100% of Total Billed Charges,56.64,1654.64,
MOPATH PROCEDURE LEVEL 4,45000116,CDM,310,RC,81403,HCPCS,Outpatient,,,1050.45,630.27,,214.84,100,,37.44,Fee Schedule,100% of Aetna Fee Schedule,277.8,150,,233.552,Fee Schedule ,150% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,518.56,280,,2038.4,Fee Schedule,280% of BCBS BULE Fee Schedule,592.64,320,,54.312,Fee Schedule,320% of BCBS Blue Essentials Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,666.72,360,,2620.8,Fee Schedule,360% of BCBS POS Rate,666.72,360,,2620.8,Fee schedule,360% of BCBS PPO Rate,666.72,360,,2620.8,Fee Schedule,360% of BCBS Traditional Rate,630.27,60,,428.824,Percent of Total Billed Charges,60% of Total Billed Charges,155.57,100,,313.6,Fee Schedule,100% of TX Mediciad 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,,3087,Fee Schedule,100% of CMS OPPS Rate,166.68,90,,,Fee Schedule,90% of CMS OPPS Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,240.76,130,,,Fee Schedule,130% of CMS OPPS Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,160.24,103,,323.008,Fee Schedule,103% of TX Medicaid Rate,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,787.84,75,,540,Percent of Total Billed Charges,75% of Total Billed Charges,314.83,80,,321.624,Fee Schedule,80% of Scott and White EPO fee schedule,314.83,80,,240,Fee Schedule,80% of Scott and White HMO fee schedule,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,170,,240,Fee Schedule,170% of Scott and White PPO fee schedule,314.83,170,,68.016,Fee Schedule,170% of Scott and White SWHP fee schedule,277.8,150,,,Fee Schedule,150% of CMS OPPS Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,150.01,90,,84,Fee Schedule,90% of UHC fee schedule,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,313.6,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.45,100,,720,Percent of Total Billed Charges,100% of Total Billed Charges,150.01,1050.45,
RBC LR EA UNIT,45000163,CDM,390,RC,P9016,HCPCS,Outpatient,,,718.92,431.35,,240.18,100,,288,Fee Schedule,100% of Aetna Fee Schedule,271.23,150,,880.68,Fee Schedule ,150% of CMS OPPS Rate,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,201.3,28,,1581.8,Percent of Total Billed Charges,28% of Total Billed Charges,56.88,32,,54.312,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.81,36,,2033.744,Percent of Total Billed Charges,36% of Total Billed Charges,258.81,36,,2033.744,Percent of Total Billed Charges,36% Total Bille Charges,258.81,36,,2033.744,Percent of Total Billed Charges,36% of Total Billed Charges,431.35,60,,428.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,180.82,100,,4630.504,Fee Schedule,100% of CMS OPPS Rate,162.72,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,235.06,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.24,103,,,Fee Schedule,103% of CMS OPPS Rate,186.24,103,,,Fee Schedule,103% of CMS OPPS Rate,539.19,75,,441,Percent of Total Billed Charges,75% of Total Billed Charges,359.46,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,359.46,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,359.46,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,359.46,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,271.23,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,84,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,718.92,100,,588,Percent of Total Billed Charges,100% of Total Billed Charges,56.88,870,
FFP 1 DONOR FRZ W/IN 8HR EA,45000189,CDM,390,RC,P9017,HCPCS,Outpatient,,,287.5,172.50,,64.95,100,,387.016,Fee Schedule,100% of Aetna Fee Schedule,119.93,150,,1117.976,Fee Schedule ,150% of CMS OPPS Rate,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,80.5,28,,1420.504,Percent of Total Billed Charges,28% of Total Billed Charges,56.94,32,,54.312,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.5,36,,1826.36,Percent of Total Billed Charges,36% of Total Billed Charges,103.5,36,,1826.36,Percent of Total Billed Charges,36% Total Bille Charges,103.5,36,,1826.36,Percent of Total Billed Charges,36% of Total Billed Charges,172.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,100,,519,Fee Schedule,100% of CMS OPPS Rate,71.95,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,103.94,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.35,103,,,Fee Schedule,103% of CMS OPPS Rate,82.35,103,,,Fee Schedule,103% of CMS OPPS Rate,215.63,75,,369.6,Percent of Total Billed Charges,75% of Total Billed Charges,143.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,143.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,143.75,50,,244.368,Percent of Total Billed Charges,50% of Total Billed Charges,119.93,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,111.16,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,287.5,100,,492.8,Percent of Total Billed Charges,100% of Total Billed Charges,56.94,870,
THERAPEUTIC PHLEBOTOMY,45000200,CDM,940,RC,99195,HCPCS,Outpatient,,,402.01,241.21,,80.54,100,,352.84,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,4380.904,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,54.312,Fee Schedule,320% of BCBS Blue Essentials Rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,5632.592,Fee Schedule,360% of BCBS POS Rate,392.51,360,,5632.592,Fee schedule,360% of BCBS PPO Rate,392.51,360,,5632.592,Fee Schedule,360% of BCBS Traditional Rate,241.21,60,,886.864,Percent of Total Billed Charges,60% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,519,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,57.97,14.42,,638.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,301.51,75,,364.2,Percent of Total Billed Charges,75% of Total Billed Charges,201.01,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,201.01,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,201.01,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,201.01,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,112.336,Case Rate,Pays based on per visit rate,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,56.28,14,,620.232,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,402.01,100,,485.6,Percent of Total Billed Charges,100% of Total Billed Charges,56.28,402.01,
BLD SPLIT PEDI PLASMA,45000281,CDM,390,RC,P9011,HCPCS,Outpatient,,,201.21,120.73,,38,100,,170.4,Fee Schedule,100% of Aetna Fee Schedule,223.6,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,56.34,28,,4215.336,Percent of Total Billed Charges,28% of Total Billed Charges,57.17,32,,54.312,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.44,36,,5419.72,Percent of Total Billed Charges,36% of Total Billed Charges,72.44,36,,5419.72,Percent of Total Billed Charges,36% Total Bille Charges,72.44,36,,5419.72,Percent of Total Billed Charges,36% of Total Billed Charges,120.73,60,,127.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,1957.064,Fee Schedule,100% of CMS OPPS Rate,134.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,193.79,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,150.91,75,,849.6,Percent of Total Billed Charges,75% of Total Billed Charges,100.61,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,100.61,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,223.6,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,117.576,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,201.21,100,,1132.8,Percent of Total Billed Charges,100% of Total Billed Charges,38,870,
BLD SPLIT PEDI PLATELET LR,45000282,CDM,390,RC,P9011,HCPCS,Outpatient,,,201.21,120.73,,38,100,,627.976,Fee Schedule,100% of Aetna Fee Schedule,223.6,150,,221.176,Fee Schedule ,150% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,56.34,28,,1042.624,Percent of Total Billed Charges,28% of Total Billed Charges,57.28,32,,54.4,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.44,36,,1340.52,Percent of Total Billed Charges,36% of Total Billed Charges,72.44,36,,1340.52,Percent of Total Billed Charges,36% Total Bille Charges,72.44,36,,1340.52,Percent of Total Billed Charges,36% of Total Billed Charges,120.73,60,,779.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,2484.384,Fee Schedule,100% of CMS OPPS Rate,134.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,193.79,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,150.91,75,,1629.04,Percent of Total Billed Charges,75% of Total Billed Charges,100.61,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,100.61,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,223.6,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,124.32,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,201.21,100,,2172.048,Percent of Total Billed Charges,100% of Total Billed Charges,38,870,
BLD SPLIT PEDI RBC LR,45000283,CDM,390,RC,P9011,HCPCS,Outpatient,,,201.21,120.73,,38,100,,72,Fee Schedule,100% of Aetna Fee Schedule,223.6,150,,171.88,Fee Schedule ,150% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,56.34,28,,1061.6,Percent of Total Billed Charges,28% of Total Billed Charges,57.28,32,,54.464,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.44,36,,1364.912,Percent of Total Billed Charges,36% of Total Billed Charges,72.44,36,,1364.912,Percent of Total Billed Charges,36% Total Bille Charges,72.44,36,,1364.912,Percent of Total Billed Charges,36% of Total Billed Charges,120.73,60,,215.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.07,100,,1656.256,Fee Schedule,100% of CMS OPPS Rate,134.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,193.79,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,153.54,103,,,Fee Schedule,103% of CMS OPPS Rate,150.91,75,,1632.976,Percent of Total Billed Charges,75% of Total Billed Charges,100.61,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,100.61,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,100.61,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,223.6,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,153.328,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.07,100,,,Fee Schedule,100% of CMS OPPS Rate,201.21,100,,2177.304,Percent of Total Billed Charges,100% of Total Billed Charges,38,870,
CRYOPRECIPITATE POOLED 5 UNITS,45000284,CDM,390,RC,P9012,HCPCS,Outpatient,,,253.53,152.12,,7.68,100,,249.6,Fee Schedule,100% of Aetna Fee Schedule,89.8,150,,136.472,Fee Schedule ,150% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,28,,5645.144,Percent of Total Billed Charges,28% of Total Billed Charges,57.28,32,,54.544,Percent of Total Billed Charges,32% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,91.27,36,,7258.048,Percent of Total Billed Charges,36% of Total Billed Charges,91.27,36,,7258.048,Percent of Total Billed Charges,36% Total Bille Charges,91.27,36,,7258.048,Percent of Total Billed Charges,36% of Total Billed Charges,152.12,60,,424.8,Percent of Total Billed Charges,60% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,1656.256,Fee Schedule,100% of CMS OPPS Rate,53.88,90,,,Fee Schedule,90% of CMS OPPS Rate,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,77.83,130,,,Fee Schedule,130% of CMS OPPS Rate,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,36.56,14.42,,567.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,61.66,103,,,Fee Schedule,103% of CMS OPPS Rate,61.66,103,,,Fee Schedule,103% of CMS OPPS Rate,190.15,75,,342,Percent of Total Billed Charges,75% of Total Billed Charges,126.77,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,126.77,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,126.77,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,126.77,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,89.8,150,,,Fee Schedule,150% of CMS OPPS Rate,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,139.584,Case Rate,Pays based on per visit rate,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,550.672,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,253.53,100,,456,Percent of Total Billed Charges,100% of Total Billed Charges,7.68,870,
PLT APHER PHER LR CMV NEG EA,45000286,CDM,390,RC,P9055,HCPCS,Outpatient,,,1848.8,1109.28,,183.7,100,,890.848,Fee Schedule,100% of Aetna Fee Schedule,376.21,150,,136.472,Fee Schedule ,150% of CMS OPPS Rate,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,517.66,28,,3354.144,Percent of Total Billed Charges,28% of Total Billed Charges,57.6,32,,54.592,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.57,36,,4312.472,Percent of Total Billed Charges,36% of Total Billed Charges,665.57,36,,4312.472,Percent of Total Billed Charges,36% Total Bille Charges,665.57,36,,4312.472,Percent of Total Billed Charges,36% of Total Billed Charges,1109.28,60,,3181.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,250.81,100,,491.504,Fee Schedule,100% of CMS OPPS Rate,225.72,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,326.05,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.33,103,,,Fee Schedule,103% of CMS OPPS Rate,258.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1386.6,75,,341.4,Percent of Total Billed Charges,75% of Total Billed Charges,924.4,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,924.4,50,,24260.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,924.4,50,,24260.808,Percent of Total Billed Charges,50% of Total Billed Charges,924.4,50,,330,Percent of Total Billed Charges,50% of Total Billed Charges,376.21,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,27.52,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1848.8,100,,455.2,Percent of Total Billed Charges,100% of Total Billed Charges,57.6,1848.8,
TRANSFUSION - BLOOD,45000288,CDM,391,RC,36430,HCPCS,Outpatient,,,1432.1,859.26,,34.88,100,,120.84,Fee Schedule,100% of Aetna Fee Schedule,597.4,150,,177.12,Fee Schedule ,150% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,400.99,28,,8777.544,Percent of Total Billed Charges,28% of Total Billed Charges,5760,32,,54.92,Percent of Total Billed Charges,32% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,515.56,36,,11285.416,Percent of Total Billed Charges,36% of Total Billed Charges,515.56,36,,11285.416,Percent of Total Billed Charges,36% Total Bille Charges,515.56,36,,11285.416,Percent of Total Billed Charges,36% of Total Billed Charges,859.26,60,,430.528,Percent of Total Billed Charges,60% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,381.96,Fee Schedule,100% of CMS OPPS Rate,358.43,90,,,Fee Schedule,90% of CMS OPPS Rate,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,517.75,130,,,Fee Schedule,130% of CMS OPPS Rate,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,206.51,14.42,,1351.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,410.21,103,,,Fee Schedule,103% of CMS OPPS Rate,410.21,103,,,Fee Schedule,103% of CMS OPPS Rate,1074.08,75,,337.8,Percent of Total Billed Charges,75% of Total Billed Charges,716.05,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,716.05,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,716.05,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,716.05,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,597.4,150,,,Fee Schedule,150% of CMS OPPS Rate,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,29.4,Case Rate,Pays based on per visit rate,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,200.49,14,,1311.92,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1432.1,100,,450.4,Percent of Total Billed Charges,100% of Total Billed Charges,34.88,5760,
COLD AGGLUTININ SCREEN,45000289,CDM,302,RC,86156,HCPCS,Outpatient,,,1249.32,749.59,,9.36,100,,377.488,Fee Schedule,100% of Aetna Fee Schedule,12.1,150,,177.12,Fee Schedule ,150% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,22.6,280,,5363.616,Fee Schedule,280% of BCBS BULE Fee Schedule,25.82,320,,55.104,Fee Schedule,320% of BCBS Blue Essentials Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,29.05,360,,6896.08,Fee Schedule,360% of BCBS POS Rate,29.05,360,,6896.08,Fee schedule,360% of BCBS PPO Rate,29.05,360,,6896.08,Fee Schedule,360% of BCBS Traditional Rate,749.59,60,,5710.32,Percent of Total Billed Charges,60% of Total Billed Charges,6.78,100,,1053.352,Fee Schedule,100% of TX Mediciad 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,,303.272,Fee Schedule,100% of CMS OPPS Rate,7.26,90,,,Fee Schedule,90% of CMS OPPS Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,130,,,Fee Schedule,130% of CMS OPPS Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.98,103,,1084.952,Fee Schedule,103% of TX Medicaid Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,936.99,75,,306.6,Percent of Total Billed Charges,75% of Total Billed Charges,13.71,80,,24260.808,Fee Schedule,80% of Scott and White EPO fee schedule,13.71,80,,4078.8,Fee Schedule,80% of Scott and White HMO fee schedule,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,170,,4078.8,Fee Schedule,170% of Scott and White PPO fee schedule,13.71,170,,321.624,Fee Schedule,170% of Scott and White SWHP fee schedule,12.1,150,,,Fee Schedule,150% of CMS OPPS Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,90,,29.4,Fee Schedule,90% of UHC fee schedule,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,1053.352,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1249.32,100,,408.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,1249.32,
PLATELETS PATHOGEN REDUCED EA,45000300,CDM,384,RC,P9073,HCPCS,Outpatient,,,1249.32,749.59,,836.47,100,,377.488,Fee Schedule,100% of Aetna Fee Schedule,826.92,150,,823.28,Fee Schedule ,150% of CMS OPPS Rate,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1713.63,280,,5468.512,Fee Schedule,280% of BCBS BULE Fee Schedule,1958.43,320,,55.296,Fee Schedule,320% of BCBS Blue Essentials Rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,2203.24,360,,7030.944,Fee Schedule,360% of BCBS POS Rate,2203.24,360,,7030.944,Fee schedule,360% of BCBS PPO Rate,2203.24,360,,7030.944,Fee Schedule,360% of BCBS Traditional Rate,749.59,60,,5702.168,Percent of Total Billed Charges,60% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,551.28,100,,303.272,Fee Schedule,100% of CMS OPPS Rate,496.15,90,,,Fee Schedule,90% of CMS OPPS Rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,716.66,130,,,Fee Schedule,130% of CMS OPPS Rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,180.15,14.42,,1466.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,567.79,103,,,Fee Schedule,103% of CMS OPPS Rate,567.79,103,,,Fee Schedule,103% of CMS OPPS Rate,936.99,75,,303,Percent of Total Billed Charges,75% of Total Billed Charges,624.66,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,624.66,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,624.66,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,624.66,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,826.92,150,,,Fee Schedule,150% of CMS OPPS Rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,70.472,Case Rate,Pays based on per visit rate,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,174.9,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,551.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1249.32,100,,404,Percent of Total Billed Charges,100% of Total Billed Charges,174.9,2203.24,
PUSH INFUSION BLOOD PEDIATRIC,45000345,CDM,391,RC,36440,HCPCS,Outpatient,,,700,420.00,,46.55,100,,203.68,Fee Schedule,100% of Aetna Fee Schedule,597.4,150,,823.28,Fee Schedule ,150% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,196,28,,9344.312,Percent of Total Billed Charges,28% of Total Billed Charges,5764.7,32,,55.48,Percent of Total Billed Charges,32% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,252,36,,12014.12,Percent of Total Billed Charges,36% of Total Billed Charges,252,36,,12014.12,Percent of Total Billed Charges,36% Total Bille Charges,252,36,,12014.12,Percent of Total Billed Charges,36% of Total Billed Charges,420,60,,750.44,Percent of Total Billed Charges,60% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,398.27,100,,393.592,Fee Schedule,100% of CMS OPPS Rate,358.43,90,,,Fee Schedule,90% of CMS OPPS Rate,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,517.75,130,,,Fee Schedule,130% of CMS OPPS Rate,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14.42,,1466.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,410.21,103,,,Fee Schedule,103% of CMS OPPS Rate,410.21,103,,,Fee Schedule,103% of CMS OPPS Rate,525,75,,258.6,Percent of Total Billed Charges,75% of Total Billed Charges,350,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,350,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,350,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,350,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,597.4,150,,,Fee Schedule,150% of CMS OPPS Rate,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,136.728,Case Rate,Pays based on per visit rate,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,98,14,,1423.816,Percent of Total Billed Charges,14% of Total Billed Charges,398.27,100,,,Fee Schedule,100% of CMS OPPS Rate,700,100,,344.8,Percent of Total Billed Charges,100% of Total Billed Charges,46.55,5764.7,
CRYOPRECIPITATE EA UNIT,45000395,CDM,390,RC,P9012,HCPCS,Outpatient,,,253.53,152.12,,7.68,100,,9865.592,Fee Schedule,100% of Aetna Fee Schedule,89.8,150,,1234.912,Fee Schedule ,150% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,28,,9344.312,Percent of Total Billed Charges,28% of Total Billed Charges,5791.9,32,,55.712,Percent of Total Billed Charges,32% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,91.27,36,,12014.12,Percent of Total Billed Charges,36% of Total Billed Charges,91.27,36,,12014.12,Percent of Total Billed Charges,36% Total Bille Charges,91.27,36,,12014.12,Percent of Total Billed Charges,36% of Total Billed Charges,152.12,60,,3523.536,Percent of Total Billed Charges,60% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,59.87,100,,393.592,Fee Schedule,100% of CMS OPPS Rate,53.88,90,,,Fee Schedule,90% of CMS OPPS Rate,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,77.83,130,,,Fee Schedule,130% of CMS OPPS Rate,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,36.56,14.42,,487.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,61.66,103,,,Fee Schedule,103% of CMS OPPS Rate,61.66,103,,,Fee Schedule,103% of CMS OPPS Rate,190.15,75,,255.6,Percent of Total Billed Charges,75% of Total Billed Charges,126.77,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,126.77,50,,26512.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,126.77,50,,26512.2,Percent of Total Billed Charges,50% of Total Billed Charges,126.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,89.8,150,,,Fee Schedule,150% of CMS OPPS Rate,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,210,Case Rate,Pays based on per visit rate,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,35.49,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.87,100,,,Fee Schedule,100% of CMS OPPS Rate,253.53,100,,340.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.68,5791.9,
APHERESIS RBC EXCHANGE,45010001,CDM,940,RC,36512,HCPCS,Outpatient,,,3759.39,2255.63,,99.8,100,,288,Fee Schedule,100% of Aetna Fee Schedule,2111.52,150,,494.4,Fee Schedule ,150% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1052.63,28,,8993.264,Percent of Total Billed Charges,28% of Total Billed Charges,5852.04,32,,55.76,Percent of Total Billed Charges,32% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1353.38,36,,11562.768,Percent of Total Billed Charges,36% of Total Billed Charges,1353.38,36,,11562.768,Percent of Total Billed Charges,36% Total Bille Charges,1353.38,36,,11562.768,Percent of Total Billed Charges,36% of Total Billed Charges,2255.63,60,,30.992,Percent of Total Billed Charges,60% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,1829.504,Fee Schedule,100% of CMS OPPS Rate,1266.91,90,,,Fee Schedule,90% of CMS OPPS Rate,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.98,130,,,Fee Schedule,130% of CMS OPPS Rate,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,542.1,14.42,,487.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,2819.54,75,,246,Percent of Total Billed Charges,75% of Total Billed Charges,1879.7,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,1879.7,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1879.7,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,1879.7,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2111.52,150,,,Fee Schedule,150% of CMS OPPS Rate,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,239.568,Case Rate,Pays based on per visit rate,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,526.31,14,,473.648,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,3759.39,100,,328,Percent of Total Billed Charges,100% of Total Billed Charges,99.8,5852.04,
APHERESIS PLASMA EXCHANGE,45010002,CDM,940,RC,36514,HCPCS,Outpatient,,,6708,4024.80,,87.13,100,,100.616,Fee Schedule,100% of Aetna Fee Schedule,2111.52,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1878.24,28,,21.168,Percent of Total Billed Charges,28% of Total Billed Charges,5880.64,32,,55.896,Percent of Total Billed Charges,32% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,2414.88,36,,27.216,Percent of Total Billed Charges,36% of Total Billed Charges,2414.88,36,,27.216,Percent of Total Billed Charges,36% Total Bille Charges,2414.88,36,,27.216,Percent of Total Billed Charges,36% of Total Billed Charges,4024.8,60,,1622.4,Percent of Total Billed Charges,60% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.68,100,,1829.504,Fee Schedule,100% of CMS OPPS Rate,1266.91,90,,,Fee Schedule,90% of CMS OPPS Rate,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.98,130,,,Fee Schedule,130% of CMS OPPS Rate,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,967.29,14.42,,265.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,1449.9,103,,,Fee Schedule,103% of CMS OPPS Rate,5031,75,,144.6,Percent of Total Billed Charges,75% of Total Billed Charges,3354,50,,26512.2,Percent of Total Billed Charges,50% of Total Billed Charges,3354,50,,91.76,Percent of Total Billed Charges,50% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,3354,50,,91.76,Percent of Total Billed Charges,50% of Total Billed Charges,3354,50,,321.624,Percent of Total Billed Charges,50% of Total Billed Charges,2111.52,150,,,Fee Schedule,150% of CMS OPPS Rate,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,291.2,Case Rate,Pays based on per visit rate,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,939.12,14,,257.664,Percent of Total Billed Charges,14% of Total Billed Charges,1407.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6708,100,,192.8,Percent of Total Billed Charges,100% of Total Billed Charges,87.13,6708,
RHOGAM INJ,45061241,CDM,250,RC,J2790,HCPCS,Outpatient,,,397.35,238.41,,79.78,100,,151,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.52,280,,21.84,Fee Schedule,280% of BCBS BULE Fee Schedule,75.52,320,,56.088,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,75.52,360,,28.08,Fee Schedule,360% of BCBS POS Rate,75.52,360,,28.08,Fee schedule,360% of BCBS PPO Rate,75.52,360,,28.08,Fee Schedule,360% of BCBS Traditional Rate,238.41,60,,243.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.01,75,,170.4,Percent of Total Billed Charges,75% of Total Billed Charges,61.46,80,,6587.264,Fee Schedule,80% of Scott and White EPO fee schedule,61.46,80,,240,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.46,80,,240,Fee Schedule,80% of Scott and White PPO fee schedule,61.46,80,,240,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.15,70,,1747.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.35,100,,227.2,Percent of Total Billed Charges,100% of Total Billed Charges,61.46,397.35,
CRYOPRECIPITATE REDUCED PLASMA,45061242,CDM,390,RC,P9044,HCPCS,Outpatient,,,287.96,172.78,,64.05,100,,1666.848,Fee Schedule,100% of Aetna Fee Schedule,103.72,150,,745.312,Fee Schedule ,150% of CMS OPPS Rate,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,28,,21.84,Percent of Total Billed Charges,28% of Total Billed Charges,5889.28,32,,56.088,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.67,36,,28.08,Percent of Total Billed Charges,36% of Total Billed Charges,103.67,36,,28.08,Percent of Total Billed Charges,36% Total Bille Charges,103.67,36,,28.08,Percent of Total Billed Charges,36% of Total Billed Charges,172.78,60,,256.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,69.15,100,,1098.672,Fee Schedule,100% of CMS OPPS Rate,62.23,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,89.89,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.22,103,,,Fee Schedule,103% of CMS OPPS Rate,71.22,103,,,Fee Schedule,103% of CMS OPPS Rate,215.97,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,143.98,50,,91.76,Percent of Total Billed Charges,50% of Total Billed Charges,143.98,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,143.98,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,143.98,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,103.72,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,428.432,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.15,100,,,Fee Schedule,100% of CMS OPPS Rate,287.96,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,62.23,5889.28,
FFP 8-24 HR EA,45061244,CDM,390,RC,P9059,HCPCS,Outpatient,,,284.76,170.86,,55.84,100,,452.992,Fee Schedule,100% of Aetna Fee Schedule,108.85,150,,575.536,Fee Schedule ,150% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,28,,21.84,Percent of Total Billed Charges,28% of Total Billed Charges,5962.88,32,,56.088,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.51,36,,28.08,Percent of Total Billed Charges,36% of Total Billed Charges,102.51,36,,28.08,Percent of Total Billed Charges,36% Total Bille Charges,102.51,36,,28.08,Percent of Total Billed Charges,36% of Total Billed Charges,170.86,60,,127.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,72.56,100,,1656.256,Fee Schedule,100% of CMS OPPS Rate,65.31,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.73,103,,,Fee Schedule,103% of CMS OPPS Rate,74.73,103,,,Fee Schedule,103% of CMS OPPS Rate,213.57,75,,132,Percent of Total Billed Charges,75% of Total Billed Charges,142.38,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,142.38,50,,1877.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,142.38,50,,1877.688,Percent of Total Billed Charges,50% of Total Billed Charges,142.38,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,108.85,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,151.032,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,284.76,100,,176,Percent of Total Billed Charges,100% of Total Billed Charges,55.84,5962.88,
"BLD PROD IRD,EA",45061256,CDM,302,RC,86945,HCPCS,Outpatient,,,166,99.60,,36.12,100,,344.68,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,575.632,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,34.896,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,5632,Fee Schedule,320% of BCBS Blue Essentials Rate,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,44.872,Fee Schedule,360% of BCBS POS Rate,120.35,360,,44.872,Fee schedule,360% of BCBS PPO Rate,120.35,360,,44.872,Fee Schedule,360% of BCBS Traditional Rate,99.6,60,,24676.744,Percent of Total Billed Charges,60% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,1278.976,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14.42,,306.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,124.5,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,83,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,83,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,83,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,83,50,,24260.808,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,170.64,Fee Schedule,90% of UHC fee schedule,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,166,100,,112,Percent of Total Billed Charges,100% of Total Billed Charges,23.24,166,
PLATELET PHERESIS LR IRRAD EA,45090370,CDM,390,RC,P9037,HCPCS,Outpatient,,,2258.55,1355.13,,808.34,100,,344.68,Fee Schedule,100% of Aetna Fee Schedule,1008.72,150,,575.632,Fee Schedule ,150% of CMS OPPS Rate,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,632.39,28,,44.296,Percent of Total Billed Charges,28% of Total Billed Charges,6021.91,32,,5672.704,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,813.08,36,,56.952,Percent of Total Billed Charges,36% of Total Billed Charges,813.08,36,,56.952,Percent of Total Billed Charges,36% Total Bille Charges,813.08,36,,56.952,Percent of Total Billed Charges,36% of Total Billed Charges,1355.13,60,,877.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,672.48,100,,1278.976,Fee Schedule,100% of CMS OPPS Rate,605.23,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,874.22,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.65,103,,,Fee Schedule,103% of CMS OPPS Rate,692.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.91,75,,81.6,Percent of Total Billed Charges,75% of Total Billed Charges,1129.28,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,1129.28,50,,497.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.28,50,,497.048,Percent of Total Billed Charges,50% of Total Billed Charges,1129.28,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,1008.72,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,45.104,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.55,100,,108.8,Percent of Total Billed Charges,100% of Total Billed Charges,605.23,6021.91,
RBC LR IRRAD EA,45090412,CDM,390,RC,P9040,HCPCS,Outpatient,,,919.45,551.67,,270.3,100,,344.68,Fee Schedule,100% of Aetna Fee Schedule,378.72,150,,49.32,Fee Schedule ,150% of CMS OPPS Rate,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,28,,108.976,Percent of Total Billed Charges,28% of Total Billed Charges,5.77,32,,5696,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331,36,,140.112,Percent of Total Billed Charges,36% of Total Billed Charges,331,36,,140.112,Percent of Total Billed Charges,36% Total Bille Charges,331,36,,140.112,Percent of Total Billed Charges,36% of Total Billed Charges,551.67,60,,2880,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,100,,1918.768,Fee Schedule,100% of CMS OPPS Rate,227.23,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,328.22,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.05,103,,,Fee Schedule,103% of CMS OPPS Rate,260.05,103,,,Fee Schedule,103% of CMS OPPS Rate,689.59,75,,79.8,Percent of Total Billed Charges,75% of Total Billed Charges,459.73,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,459.73,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,459.73,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,459.73,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,378.72,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,336,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.48,100,,,Fee Schedule,100% of CMS OPPS Rate,919.45,100,,106.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.77,919.45,
PLATELET PHERESIS LR EA,45096112,CDM,390,RC,P9053,HCPCS,Outpatient,,,2026.5,1215.90,,549.68,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,777.28,150,,78.208,Fee Schedule ,150% of CMS OPPS Rate,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,567.42,28,,18.736,Percent of Total Billed Charges,28% of Total Billed Charges,5.78,32,,5746.304,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.54,36,,24.088,Percent of Total Billed Charges,36% of Total Billed Charges,729.54,36,,24.088,Percent of Total Billed Charges,36% Total Bille Charges,729.54,36,,24.088,Percent of Total Billed Charges,36% of Total Billed Charges,1215.9,60,,41.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,518.19,100,,1279.176,Fee Schedule,100% of CMS OPPS Rate,466.37,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,673.64,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.73,103,,,Fee Schedule,103% of CMS OPPS Rate,533.73,103,,,Fee Schedule,103% of CMS OPPS Rate,1519.88,75,,78.6,Percent of Total Billed Charges,75% of Total Billed Charges,1013.25,50,,497.048,Percent of Total Billed Charges,50% of Total Billed Charges,1013.25,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.25,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,1013.25,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,777.28,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,870,100,,210,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2026.5,100,,104.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.78,2026.5,
TEE WITH CONTRAST,46000001,CDM,483,RC,93312,HCPCS,Outpatient,,,3110,1866.00,,101.05,100,,1158.824,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,87.888,Fee Schedule ,150% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,389.51,280,,27.552,Fee Schedule,280% of BCBS BULE Fee Schedule,445.15,320,,5860.312,Fee Schedule,320% of BCBS Blue Essentials Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,500.8,360,,35.424,Fee Schedule,360% of BCBS POS Rate,500.8,360,,35.424,Fee schedule,360% of BCBS PPO Rate,500.8,360,,35.424,Fee Schedule,360% of BCBS Traditional Rate,1866,60,,3365.008,Percent of Total Billed Charges,60% of Total Billed Charges,241.58,100,,234.864,Fee Schedule,100% of TX Mediciad Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,1279.176,Fee Schedule,100% of CMS OPPS Rate,455.51,90,,,Fee Schedule,90% of CMS OPPS Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,657.97,130,,,Fee Schedule,130% of CMS OPPS Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,248.83,103,,241.912,Fee Schedule,103% of TX Medicaid Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,2332.5,75,,76.8,Percent of Total Billed Charges,75% of Total Billed Charges,1555,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,1555,50,,928.2,Percent of Total Billed Charges,50% of Total Billed Charges,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1555,50,,928.2,Percent of Total Billed Charges,50% of Total Billed Charges,1555,50,,239.68,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,546,Case Rate,Pays based on per visit rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,234.864,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3110,100,,102.4,Percent of Total Billed Charges,100% of Total Billed Charges,101.05,3110,
MYOCRD CONTRAST PRFUJ ECHO,46000005,CDM,483,RC,0439T,HCPCS,Outpatient,,,3970.94,2382.56,,85.77,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.46,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,310.24,320,,5.664,Fee Schedule,320% of BCBS Blue Essentials Rate,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,349.02,360,,43.2,Fee Schedule,360% of BCBS POS Rate,349.02,360,,43.2,Fee schedule,360% of BCBS PPO Rate,349.02,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,2382.56,60,,2059.2,Percent of Total Billed Charges,60% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,572.61,14.42,,241.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2978.21,75,,63.6,Percent of Total Billed Charges,75% of Total Billed Charges,1985.47,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,1985.47,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1985.47,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,1985.47,50,,26512.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800,100,,336,Case Rate,Pays based on per visit rate,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,555.93,14,,234.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3970.94,100,,84.8,Percent of Total Billed Charges,100% of Total Billed Charges,85.77,3970.94,
RENAL ARTERY DUPLEX BIL,46000402,CDM,921,RC,93975,HCPCS,Outpatient,,,1775.31,1065.19,,169.64,100,,2995.864,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,88.272,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,629.66,280,,33.6,Fee Schedule,280% of BCBS BULE Fee Schedule,719.62,320,,5.68,Fee Schedule,320% of BCBS Blue Essentials Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,809.57,360,,43.2,Fee Schedule,360% of BCBS POS Rate,809.57,360,,43.2,Fee schedule,360% of BCBS PPO Rate,809.57,360,,43.2,Fee Schedule,360% of BCBS Traditional Rate,1065.19,60,,400.712,Percent of Total Billed Charges,60% of Total Billed Charges,230.13,100,,252,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,173.8,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,237.03,103,,259.56,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1331.48,75,,354,Percent of Total Billed Charges,75% of Total Billed Charges,887.66,50,,928.2,Percent of Total Billed Charges,50% of Total Billed Charges,887.66,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,887.66,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,887.66,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,440,Case Rate,Pays based on per visit rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,252,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1775.31,100,,472,Percent of Total Billed Charges,100% of Total Billed Charges,169.64,1775.31,
3D ECHO WO INDEP WKSTN,46003503,CDM,402,RC,76376,HCPCS,Outpatient,,,123.47,74.08,,15.12,100,,855.968,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.32,280,,44.464,Fee Schedule,280% of BCBS BULE Fee Schedule,42.66,320,,5.736,Fee Schedule,320% of BCBS Blue Essentials Rate,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,360,,57.168,Fee Schedule,360% of BCBS POS Rate,47.99,360,,57.168,Fee schedule,360% of BCBS PPO Rate,47.99,360,,57.168,Fee Schedule,360% of BCBS Traditional Rate,74.08,60,,3993.6,Percent of Total Billed Charges,60% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.6,75,,360.6,Percent of Total Billed Charges,75% of Total Billed Charges,61.74,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,61.74,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.74,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.74,50,,91.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,121.664,Case Rate,Pays based on per visit rate,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.47,100,,480.8,Percent of Total Billed Charges,100% of Total Billed Charges,15.12,378,
3D ECHO WO INDEP WKSTN,46003503,CDM,402,RC,76376,HCPCS,Outpatient,,,123.47,74.08,,15.12,100,,1305.136,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.32,280,,44.936,Fee Schedule,280% of BCBS BULE Fee Schedule,42.66,320,,5.8,Fee Schedule,320% of BCBS Blue Essentials Rate,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,360,,57.776,Fee Schedule,360% of BCBS POS Rate,47.99,360,,57.776,Fee schedule,360% of BCBS PPO Rate,47.99,360,,57.776,Fee Schedule,360% of BCBS Traditional Rate,74.08,60,,1111.552,Percent of Total Billed Charges,60% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.6,75,,661.12,Percent of Total Billed Charges,75% of Total Billed Charges,61.74,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.74,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.74,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,61.74,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,744.088,Case Rate,Pays based on per visit rate,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,17.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.47,100,,881.496,Percent of Total Billed Charges,100% of Total Billed Charges,15.12,378,
CARDIAC ECHO ECG MD W CONTRAST,46004006,CDM,483,RC,C8930,HCPCS,Outpatient,,,3186,1911.60,,1145.06,100,,225.712,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,214.2,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,47.032,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,5.8,Fee Schedule,320% of BCBS Blue Essentials Rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,2450.95,360,,60.464,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,60.464,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,60.464,Fee Schedule,360% of BCBS Traditional Rate,1911.6,60,,2692.008,Percent of Total Billed Charges,60% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,196.16,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,459.42,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2389.5,75,,906,Percent of Total Billed Charges,75% of Total Billed Charges,1593,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,1593,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1593,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,1593,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,1748.448,Case Rate,Pays based on per visit rate,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,446.04,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3186,100,,1208,Percent of Total Billed Charges,100% of Total Billed Charges,446.04,3186,
MYOCARDIAL STRAIN IMAGING,46004300,CDM,483,RC,93356,HCPCS,Outpatient,,,930,558.00,,8.4,100,,300.992,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.3,280,,49.728,Fee Schedule,280% of BCBS BULE Fee Schedule,39.2,320,,5.856,Fee Schedule,320% of BCBS Blue Essentials Rate,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,360,,63.936,Fee Schedule,360% of BCBS POS Rate,44.1,360,,63.936,Fee schedule,360% of BCBS PPO Rate,44.1,360,,63.936,Fee Schedule,360% of BCBS Traditional Rate,558,60,,3715.872,Percent of Total Billed Charges,60% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,134.11,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,697.5,75,,1054.2,Percent of Total Billed Charges,75% of Total Billed Charges,465,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,465,50,,4673.08,Percent of Total Billed Charges,50% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465,50,,4673.08,Percent of Total Billed Charges,50% of Total Billed Charges,465,50,,1877.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800,100,,1317.96,Case Rate,Pays based on per visit rate,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,130.2,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930,100,,1405.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.4,930,
CARDIAC STRESS TEST,46030177,CDM,482,RC,93017,HCPCS,Outpatient,,,1645.5,987.30,,24.72,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,38.304,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,61.328,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,5.872,Fee Schedule,320% of BCBS Blue Essentials Rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,78.856,Fee Schedule,360% of BCBS POS Rate,911.16,360,,78.856,Fee schedule,360% of BCBS PPO Rate,911.16,360,,78.856,Fee Schedule,360% of BCBS Traditional Rate,987.3,60,,1571.232,Percent of Total Billed Charges,60% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,81.92,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.36,130,,,Fee Schedule,130% of CMS OPPS Rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,237.28,14.42,,26.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1234.13,75,,4491,Percent of Total Billed Charges,75% of Total Billed Charges,822.75,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,822.75,50,,2215.12,Percent of Total Billed Charges,50% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,822.75,50,,2215.12,Percent of Total Billed Charges,50% of Total Billed Charges,822.75,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,970,100,,1264.872,Case Rate,Pays based on per visit rate,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,25.76,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1645.5,100,,5988,Percent of Total Billed Charges,100% of Total Billed Charges,24.72,1645.5,
ECHO COMP W SPECT COL FL DOPPL,46032108,CDM,483,RC,93306,HCPCS,Outpatient,,,3081,1848.60,,96.85,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,34.2,Fee Schedule ,150% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,379.43,280,,55.832,Fee Schedule,280% of BCBS BULE Fee Schedule,433.63,320,,5.872,Fee Schedule,320% of BCBS Blue Essentials Rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,487.84,360,,71.784,Fee Schedule,360% of BCBS POS Rate,487.84,360,,71.784,Fee schedule,360% of BCBS PPO Rate,487.84,360,,71.784,Fee Schedule,360% of BCBS Traditional Rate,1848.6,60,,1080,Percent of Total Billed Charges,60% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,476,Fee Schedule,100% of CMS OPPS Rate,455.51,90,,,Fee Schedule,90% of CMS OPPS Rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,657.97,130,,,Fee Schedule,130% of CMS OPPS Rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,444.28,14.42,,264.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,2310.75,75,,4491,Percent of Total Billed Charges,75% of Total Billed Charges,1540.5,50,,4673.08,Percent of Total Billed Charges,50% of Total Billed Charges,1540.5,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1540.5,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,1540.5,50,,537.984,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,433.264,Case Rate,Pays based on per visit rate,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,431.34,14,,257.136,Percent of Total Billed Charges,14% of Total Billed Charges,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3081,100,,5988,Percent of Total Billed Charges,100% of Total Billed Charges,96.85,3081,
ECHO TRANSTHORACIC CONGENITAL,46032124,CDM,483,RC,93303,HCPCS,Outpatient,,,2301.5,1380.90,,123.77,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,47.84,Fee Schedule ,150% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,488.4,280,,11.008,Fee Schedule,280% of BCBS BULE Fee Schedule,558.18,320,,5.88,Fee Schedule,320% of BCBS Blue Essentials Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,627.95,360,,14.152,Fee Schedule,360% of BCBS POS Rate,627.95,360,,14.152,Fee schedule,360% of BCBS PPO Rate,627.95,360,,14.152,Fee Schedule,360% of BCBS Traditional Rate,1380.9,60,,1491.36,Percent of Total Billed Charges,60% of Total Billed Charges,227.88,100,,1017.744,Fee Schedule,100% of TX Mediciad Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,476,Fee Schedule,100% of CMS OPPS Rate,455.51,90,,,Fee Schedule,90% of CMS OPPS Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,657.97,130,,,Fee Schedule,130% of CMS OPPS Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,234.72,103,,1048.28,Fee Schedule,103% of TX Medicaid Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,1726.13,75,,4491,Percent of Total Billed Charges,75% of Total Billed Charges,1150.75,50,,2215.12,Percent of Total Billed Charges,50% of Total Billed Charges,1150.75,50,,3073.672,Percent of Total Billed Charges,50% of Total Billed Charges,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1150.75,50,,3073.672,Percent of Total Billed Charges,50% of Total Billed Charges,1150.75,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,495.608,Case Rate,Pays based on per visit rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,227.88,100,,1017.744,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2301.5,100,,5988,Percent of Total Billed Charges,100% of Total Billed Charges,123.77,2301.5,
CARDIOVERSION ELECTIVE EXT,46032355,CDM,480,RC,92960,HCPCS,Outpatient,,,1702,1021.20,,76.18,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,377.136,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,476.56,28,,11.76,Percent of Total Billed Charges,28% of Total Billed Charges,5.84,32,,5.88,Percent of Total Billed Charges,32% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,612.72,36,,15.12,Percent of Total Billed Charges,36% of Total Billed Charges,612.72,36,,15.12,Percent of Total Billed Charges,36% Total Bille Charges,612.72,36,,15.12,Percent of Total Billed Charges,36% of Total Billed Charges,1021.2,60,,3067.256,Percent of Total Billed Charges,60% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,85.12,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,245.43,14.42,,290.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,1276.5,75,,4491,Percent of Total Billed Charges,75% of Total Billed Charges,851,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,2779.672,Percent of Total Billed Charges,50% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,851,50,,2779.672,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,497.048,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,495.608,Case Rate,Pays based on per visit rate,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,281.888,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1702,100,,5988,Percent of Total Billed Charges,100% of Total Billed Charges,5.84,1702,
ECHO 2D LIMITED STUDY,46033080,CDM,483,RC,93308,HCPCS,Outpatient,,,1104.86,662.92,,54.72,100,,125.616,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,376.56,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,206.86,280,,11.76,Fee Schedule,280% of BCBS BULE Fee Schedule,236.42,320,,56.32,Fee Schedule,320% of BCBS Blue Essentials Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,265.97,360,,15.12,Fee Schedule,360% of BCBS POS Rate,265.97,360,,15.12,Fee schedule,360% of BCBS PPO Rate,265.97,360,,15.12,Fee Schedule,360% of BCBS Traditional Rate,662.92,60,,1571.232,Percent of Total Billed Charges,60% of Total Billed Charges,98.56,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,76,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,101.52,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,828.65,75,,4896,Percent of Total Billed Charges,75% of Total Billed Charges,552.43,50,,3073.672,Percent of Total Billed Charges,50% of Total Billed Charges,552.43,50,,1966.68,Percent of Total Billed Charges,50% of Total Billed Charges,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,552.43,50,,1966.68,Percent of Total Billed Charges,50% of Total Billed Charges,552.43,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,744.088,Case Rate,Pays based on per visit rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,98.56,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.86,100,,6528,Percent of Total Billed Charges,100% of Total Billed Charges,54.72,1104.86,
LE SEGMENTAL PRESSURE STUDIES,46033082,CDM,921,RC,93923,HCPCS,Outpatient,,,839.16,503.50,,84.43,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,66.152,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,317.86,280,,28.192,Fee Schedule,280% of BCBS BULE Fee Schedule,363.26,320,,56.592,Fee Schedule,320% of BCBS Blue Essentials Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,408.67,360,,36.24,Fee Schedule,360% of BCBS POS Rate,408.67,360,,36.24,Fee schedule,360% of BCBS PPO Rate,408.67,360,,36.24,Fee Schedule,360% of BCBS Traditional Rate,503.5,60,,2483.52,Percent of Total Billed Charges,60% of Total Billed Charges,129.31,100,,70.56,Fee Schedule,100% of TX Mediciad Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,106.304,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,133.19,103,,72.68,Fee Schedule,103% of TX Medicaid Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,629.37,75,,4896,Percent of Total Billed Charges,75% of Total Billed Charges,419.58,50,,2779.672,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,1778.568,Percent of Total Billed Charges,50% of Total Billed Charges,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,419.58,50,,1778.568,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,739.04,Case Rate,Pays based on per visit rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,70.56,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,839.16,100,,6528,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,839.16,
LE VENOUS SCAN BIL,46033083,CDM,921,RC,93970,HCPCS,Outpatient,,,1296.54,777.92,,124.42,100,,218.608,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,135,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,458.14,280,,54.688,Fee Schedule,280% of BCBS BULE Fee Schedule,523.58,320,,56.592,Fee Schedule,320% of BCBS Blue Essentials Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,589.03,360,,70.312,Fee Schedule,360% of BCBS POS Rate,589.03,360,,70.312,Fee schedule,360% of BCBS PPO Rate,589.03,360,,70.312,Fee Schedule,360% of BCBS Traditional Rate,777.92,60,,4715.096,Percent of Total Billed Charges,60% of Total Billed Charges,191.79,100,,99.12,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,838.08,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,197.54,103,,102.096,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,972.41,75,,477,Percent of Total Billed Charges,75% of Total Billed Charges,648.27,50,,1966.68,Percent of Total Billed Charges,50% of Total Billed Charges,648.27,50,,4685.432,Percent of Total Billed Charges,50% of Total Billed Charges,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,648.27,50,,4685.432,Percent of Total Billed Charges,50% of Total Billed Charges,648.27,50,,928.2,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,492.696,Case Rate,Pays based on per visit rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,99.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.54,100,,636,Percent of Total Billed Charges,100% of Total Billed Charges,124.42,1296.54,
LE VENOUS SCAN UNILATERAL,46033085,CDM,921,RC,93971,HCPCS,Outpatient,,,843.91,506.35,,77.76,100,,765.136,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,208.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,280.53,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,320.61,320,,56.704,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,360.68,360,,108,Fee Schedule,360% of BCBS POS Rate,360.68,360,,108,Fee schedule,360% of BCBS PPO Rate,360.68,360,,108,Fee Schedule,360% of BCBS Traditional Rate,506.35,60,,3731.52,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,13.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,836.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,13.496,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,632.93,75,,203.4,Percent of Total Billed Charges,75% of Total Billed Charges,421.96,50,,1778.568,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,3761.984,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,421.96,50,,3761.984,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,492.696,Case Rate,Pays based on per visit rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,843.91,100,,271.2,Percent of Total Billed Charges,100% of Total Billed Charges,77.76,843.91,
LE VENOUS SCAN LT,46033089,CDM,921,RC,93971,HCPCS,Outpatient,,,843.91,506.35,,77.76,100,,1175.44,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,243,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,280.53,280,,95.824,Fee Schedule,280% of BCBS BULE Fee Schedule,320.61,320,,56.832,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,360.68,360,,123.208,Fee Schedule,360% of BCBS POS Rate,360.68,360,,123.208,Fee schedule,360% of BCBS PPO Rate,360.68,360,,123.208,Fee Schedule,360% of BCBS Traditional Rate,506.35,60,,3731.52,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,477.344,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,147.008,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,491.664,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,632.93,75,,2243.4,Percent of Total Billed Charges,75% of Total Billed Charges,421.96,50,,4685.432,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,421.96,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,371.48,Case Rate,Pays based on per visit rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,477.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,843.91,100,,2991.2,Percent of Total Billed Charges,100% of Total Billed Charges,77.76,843.91,
LE ARTRY DUPLEX SCAN LT,46033090,CDM,921,RC,93926,HCPCS,Outpatient,,,803.57,482.14,,81.56,100,,571.96,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,41.04,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,280,,116.48,Fee Schedule,280% of BCBS BULE Fee Schedule,359.81,320,,56.832,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,404.78,360,,149.76,Fee Schedule,360% of BCBS POS Rate,404.78,360,,149.76,Fee schedule,360% of BCBS PPO Rate,404.78,360,,149.76,Fee Schedule,360% of BCBS Traditional Rate,482.14,60,,525.6,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,42.56,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,300,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,43.84,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,602.68,75,,170.4,Percent of Total Billed Charges,75% of Total Billed Charges,401.79,50,,3761.984,Percent of Total Billed Charges,50% of Total Billed Charges,401.79,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,401.79,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,401.79,50,,991.2,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,416.272,Case Rate,Pays based on per visit rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,803.57,100,,227.2,Percent of Total Billed Charges,100% of Total Billed Charges,81.56,803.57,
UE ARTRY DUPLEX LT,46033091,CDM,921,RC,93931,HCPCS,Outpatient,,,720.2,432.12,,80.25,100,,409.336,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,25.2,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,295.65,280,,698.88,Fee Schedule,280% of BCBS BULE Fee Schedule,337.89,320,,56.872,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,380.12,360,,898.56,Fee Schedule,360% of BCBS POS Rate,380.12,360,,898.56,Fee schedule,360% of BCBS PPO Rate,380.12,360,,898.56,Fee Schedule,360% of BCBS Traditional Rate,432.12,60,,525.6,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,307.688,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,464,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,316.92,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,540.15,75,,222,Percent of Total Billed Charges,75% of Total Billed Charges,360.1,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,360.1,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,360.1,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,360.1,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,416.272,Case Rate,Pays based on per visit rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,307.688,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,720.2,100,,296,Percent of Total Billed Charges,100% of Total Billed Charges,80.25,720.2,
ECHO DOPPLER PULSE WAVE,46033254,CDM,483,RC,93320,HCPCS,Outpatient,,,1026.56,615.94,,25.57,100,,60.64,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.9,280,,171.376,Fee Schedule,280% of BCBS BULE Fee Schedule,114.18,320,,56.896,Fee Schedule,320% of BCBS Blue Essentials Rate,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,128.45,360,,220.336,Fee Schedule,360% of BCBS POS Rate,128.45,360,,220.336,Fee schedule,360% of BCBS PPO Rate,128.45,360,,220.336,Fee Schedule,360% of BCBS Traditional Rate,615.94,60,,2179.496,Percent of Total Billed Charges,60% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,148.03,14.42,,223.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,769.92,75,,1872,Percent of Total Billed Charges,75% of Total Billed Charges,513.28,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,513.28,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,513.28,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,513.28,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800,100,,348.6,Case Rate,Pays based on per visit rate,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,143.72,14,,216.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1026.56,100,,2496,Percent of Total Billed Charges,100% of Total Billed Charges,25.57,1026.56,
ECHO DOPPLER COLOR FLOW,46033304,CDM,483,RC,93325,HCPCS,Outpatient,,,843,505.80,,15.81,100,,76.024,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.55,280,,60.416,Fee Schedule,280% of BCBS BULE Fee Schedule,71.49,320,,56.912,Fee Schedule,320% of BCBS Blue Essentials Rate,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,80.42,360,,77.672,Fee Schedule,360% of BCBS POS Rate,80.42,360,,77.672,Fee schedule,360% of BCBS PPO Rate,80.42,360,,77.672,Fee Schedule,360% of BCBS Traditional Rate,505.8,60,,3269.248,Percent of Total Billed Charges,60% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,121.56,14.42,,260.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,632.25,75,,8284.48,Percent of Total Billed Charges,75% of Total Billed Charges,421.5,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,421.5,50,,920.24,Percent of Total Billed Charges,50% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421.5,50,,920.24,Percent of Total Billed Charges,50% of Total Billed Charges,421.5,50,,4673.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800,100,,497.336,Case Rate,Pays based on per visit rate,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,118.02,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,843,100,,11045.976,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,843,
ECHO STRESS DRUG W WO,46033502,CDM,483,RC,93350,HCPCS,Outpatient,,,2581.04,1548.62,,88.94,100,,1101.664,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,40.824,Fee Schedule ,150% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,332,280,,110.168,Fee Schedule,280% of BCBS BULE Fee Schedule,379.42,320,,56.912,Fee Schedule,320% of BCBS Blue Essentials Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,426.85,360,,141.648,Fee Schedule,360% of BCBS POS Rate,426.85,360,,141.648,Fee schedule,360% of BCBS PPO Rate,426.85,360,,141.648,Fee Schedule,360% of BCBS Traditional Rate,1548.62,60,,2179.496,Percent of Total Billed Charges,60% of Total Billed Charges,188.45,100,,252.448,Fee Schedule,100% of TX Mediciad Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,56,Fee Schedule,100% of CMS OPPS Rate,455.51,90,,,Fee Schedule,90% of CMS OPPS Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,657.97,130,,,Fee Schedule,130% of CMS OPPS Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,194.1,103,,260.024,Fee Schedule,103% of TX Medicaid Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,1935.78,75,,7478.824,Percent of Total Billed Charges,75% of Total Billed Charges,1290.52,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,1290.52,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.52,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1290.52,50,,2215.12,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,304.704,Case Rate,Pays based on per visit rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,188.45,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2581.04,100,,9971.768,Percent of Total Billed Charges,100% of Total Billed Charges,88.94,2581.04,
PERIOCARDIOCENTESIS W/US GUIDANCE,46033585,CDM,402,RC,33016,HCPCS,Outpatient,,,608.31,364.99,,209.72,100,,289.416,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,81,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,170.33,28,,68.256,Percent of Total Billed Charges,28% of Total Billed Charges,5.88,32,,56.912,Percent of Total Billed Charges,32% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,218.99,36,,87.76,Percent of Total Billed Charges,36% of Total Billed Charges,218.99,36,,87.76,Percent of Total Billed Charges,36% Total Bille Charges,218.99,36,,87.76,Percent of Total Billed Charges,36% of Total Billed Charges,364.99,60,,2284.128,Percent of Total Billed Charges,60% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,480,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.72,14.42,,1259.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,456.23,75,,19121.008,Percent of Total Billed Charges,75% of Total Billed Charges,304.16,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,304.16,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,304.16,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,304.16,50,,3073.672,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,805.544,Case Rate,Pays based on per visit rate,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,608.31,100,,25494.672,Percent of Total Billed Charges,100% of Total Billed Charges,5.88,2204.01,
PERIOCARDIOCENTESIS W/US GUIDANCE,46033585,CDM,402,RC,33016,HCPCS,Outpatient,,,608.31,364.99,,209.72,100,,110.36,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,54,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,170.33,28,,18.04,Percent of Total Billed Charges,28% of Total Billed Charges,5.89,32,,57.088,Percent of Total Billed Charges,32% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,218.99,36,,23.192,Percent of Total Billed Charges,36% of Total Billed Charges,218.99,36,,23.192,Percent of Total Billed Charges,36% Total Bille Charges,218.99,36,,23.192,Percent of Total Billed Charges,36% of Total Billed Charges,364.99,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,90.72,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,87.72,14.42,,3114.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,456.23,75,,14613.168,Percent of Total Billed Charges,75% of Total Billed Charges,304.16,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,304.16,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,304.16,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,304.16,50,,2779.672,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,336.832,Case Rate,Pays based on per visit rate,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,608.31,100,,19484.224,Percent of Total Billed Charges,100% of Total Billed Charges,5.89,2204.01,
ECHO TRANSESOPH W/WO MODE,46034005,CDM,483,RC,93312,HCPCS,Outpatient,,,3110,1866.00,,101.05,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,216,Fee Schedule ,150% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,389.51,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,445.15,320,,57.112,Fee Schedule,320% of BCBS Blue Essentials Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,500.8,360,,172.8,Fee Schedule,360% of BCBS POS Rate,500.8,360,,172.8,Fee schedule,360% of BCBS PPO Rate,500.8,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,1866,60,,13643.992,Percent of Total Billed Charges,60% of Total Billed Charges,241.58,100,,930.384,Fee Schedule,100% of TX Mediciad Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,516,Fee Schedule,100% of CMS OPPS Rate,455.51,90,,,Fee Schedule,90% of CMS OPPS Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,657.97,130,,,Fee Schedule,130% of CMS OPPS Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,248.83,103,,958.296,Fee Schedule,103% of TX Medicaid Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,521.3,103,,,Fee Schedule,103% of CMS OPPS Rate,2332.5,75,,6821.168,Percent of Total Billed Charges,75% of Total Billed Charges,1555,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,1555,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1555,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,1555,50,,1966.68,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,4914.68,Case Rate,Pays based on per visit rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,241.58,100,,930.384,Fee Schedule,100% of TX Medicaid Rate,506.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3110,100,,9094.888,Percent of Total Billed Charges,100% of Total Billed Charges,101.05,3110,
CAROTID SCAN BIL COMPLETE,46038808,CDM,921,RC,93880,HCPCS,Outpatient,,,1187.39,712.43,,123.37,100,,331.088,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,63,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,460.15,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,525.89,320,,57.328,Fee Schedule,320% of BCBS Blue Essentials Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,591.62,360,,108,Fee Schedule,360% of BCBS POS Rate,591.62,360,,108,Fee schedule,360% of BCBS PPO Rate,591.62,360,,108,Fee Schedule,360% of BCBS Traditional Rate,712.43,60,,19442.28,Percent of Total Billed Charges,60% of Total Billed Charges,195.46,100,,175.392,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,180,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,201.32,103,,180.656,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,890.54,75,,18604.8,Percent of Total Billed Charges,75% of Total Billed Charges,593.7,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,593.7,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,593.7,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,593.7,50,,1778.568,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,1369.944,Case Rate,Pays based on per visit rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,195.46,100,,175.392,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1187.39,100,,24806.4,Percent of Total Billed Charges,100% of Total Billed Charges,123.37,1187.39,
US EXTRACRN DPLX LTD,46038824,CDM,921,RC,93882,HCPCS,Outpatient,,,766.71,460.03,,80.77,100,,285.32,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,54,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,295.65,280,,218.4,Fee Schedule,280% of BCBS BULE Fee Schedule,337.89,320,,57.6,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,380.12,360,,280.8,Fee Schedule,360% of BCBS POS Rate,380.12,360,,280.8,Fee schedule,360% of BCBS PPO Rate,380.12,360,,280.8,Fee Schedule,360% of BCBS Traditional Rate,460.03,60,,13643.992,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,51.968,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,120,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,53.528,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,575.03,75,,9376.8,Percent of Total Billed Charges,75% of Total Billed Charges,383.36,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,383.36,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,383.36,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,383.36,50,,4685.432,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,1685.648,Case Rate,Pays based on per visit rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,51.968,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,766.71,100,,12502.4,Percent of Total Billed Charges,100% of Total Billed Charges,80.77,766.71,
UE VENOUS SCAN BIL,46039657,CDM,921,RC,93970,HCPCS,Outpatient,,,1296.54,777.92,,124.42,100,,855.968,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,57.6,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,458.14,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,523.58,320,,57.6,Fee Schedule,320% of BCBS Blue Essentials Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,589.03,360,,172.8,Fee Schedule,360% of BCBS POS Rate,589.03,360,,172.8,Fee schedule,360% of BCBS PPO Rate,589.03,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,777.92,60,,135.08,Percent of Total Billed Charges,60% of Total Billed Charges,191.79,100,,824.68,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,480,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,197.54,103,,849.416,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,972.41,75,,1794.592,Percent of Total Billed Charges,75% of Total Billed Charges,648.27,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,648.27,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,648.27,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,648.27,50,,3761.984,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,14077.608,Case Rate,Pays based on per visit rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,191.79,100,,824.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.54,100,,2392.784,Percent of Total Billed Charges,100% of Total Billed Charges,124.42,1296.54,
UE VENOUS SCAN UNI,46039715,CDM,921,RC,93971,HCPCS,Outpatient,,,843.91,506.35,,77.76,100,,855.968,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,72,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,280.53,280,,176,Fee Schedule,280% of BCBS BULE Fee Schedule,320.61,320,,57.6,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,360.68,360,,226.288,Fee Schedule,360% of BCBS POS Rate,360.68,360,,226.288,Fee schedule,360% of BCBS PPO Rate,360.68,360,,226.288,Fee Schedule,360% of BCBS Traditional Rate,506.35,60,,2234.2,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,951.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,140,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,979.592,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,632.93,75,,1794.592,Percent of Total Billed Charges,75% of Total Billed Charges,421.96,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,421.96,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,5487.36,Case Rate,Pays based on per visit rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,951.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,843.91,100,,2392.784,Percent of Total Billed Charges,100% of Total Billed Charges,77.76,843.91,
UE VENOUS SCAN LT,46039716,CDM,921,RC,93971,HCPCS,Outpatient,,,843.91,506.35,,77.76,100,,1002.856,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,66.6,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,280.53,280,,297.632,Fee Schedule,280% of BCBS BULE Fee Schedule,320.61,320,,57.6,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,360.68,360,,382.672,Fee Schedule,360% of BCBS POS Rate,360.68,360,,382.672,Fee schedule,360% of BCBS PPO Rate,360.68,360,,382.672,Fee Schedule,360% of BCBS Traditional Rate,506.35,60,,148.68,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,1141.216,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,120,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,1175.448,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,632.93,75,,7332,Percent of Total Billed Charges,75% of Total Billed Charges,421.96,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,421.96,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,421.96,50,,5085.048,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,895.424,Case Rate,Pays based on per visit rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,1141.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,843.91,100,,9776,Percent of Total Billed Charges,100% of Total Billed Charges,77.76,843.91,
UE SEGMENTAL PRESSURE STUDIES,46044020,CDM,921,RC,93922,HCPCS,Outpatient,,,524.32,314.59,,55.54,100,,823.04,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,322.92,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,699.376,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,57.752,Fee Schedule,320% of BCBS Blue Essentials Rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,899.2,Fee Schedule,360% of BCBS POS Rate,392.51,360,,899.2,Fee schedule,360% of BCBS PPO Rate,392.51,360,,899.2,Fee Schedule,360% of BCBS Traditional Rate,314.59,60,,584.76,Percent of Total Billed Charges,60% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,128,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,75.61,14.42,,72.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,393.24,75,,7480.2,Percent of Total Billed Charges,75% of Total Billed Charges,262.16,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,262.16,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,3869.72,Case Rate,Pays based on per visit rate,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,70.56,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,524.32,100,,9973.6,Percent of Total Billed Charges,100% of Total Billed Charges,55.54,650,
UE SEGMENTAL PRESSURE STUDIES,46044228,CDM,921,RC,93922,HCPCS,Outpatient,,,524.32,314.59,,55.54,100,,372.896,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,149.76,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,527.184,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,57.888,Fee Schedule,320% of BCBS Blue Essentials Rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,677.808,Fee Schedule,360% of BCBS POS Rate,392.51,360,,677.808,Fee schedule,360% of BCBS PPO Rate,392.51,360,,677.808,Fee Schedule,360% of BCBS Traditional Rate,314.59,60,,1479.032,Percent of Total Billed Charges,60% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,160,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,75.61,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,393.24,75,,20928.384,Percent of Total Billed Charges,75% of Total Billed Charges,262.16,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,262.16,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,1691.6,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,4668.08,Case Rate,Pays based on per visit rate,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,524.32,100,,27904.512,Percent of Total Billed Charges,100% of Total Billed Charges,55.54,650,
RENAL ARTERY DUPLEX BIL,46044269,CDM,921,RC,93975,HCPCS,Outpatient,,,1775.31,1065.19,,169.64,100,,372.896,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,291.6,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,629.66,280,,505.952,Fee Schedule,280% of BCBS BULE Fee Schedule,719.62,320,,57.952,Fee Schedule,320% of BCBS Blue Essentials Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,809.57,360,,650.504,Fee Schedule,360% of BCBS POS Rate,809.57,360,,650.504,Fee schedule,360% of BCBS PPO Rate,809.57,360,,650.504,Fee Schedule,360% of BCBS Traditional Rate,1065.19,60,,1141.448,Percent of Total Billed Charges,60% of Total Billed Charges,230.13,100,,291.648,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,148,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,237.03,103,,300.4,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1331.48,75,,2750.328,Percent of Total Billed Charges,75% of Total Billed Charges,887.66,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,887.66,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,887.66,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,887.66,50,,920.24,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,4171.104,Case Rate,Pays based on per visit rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,291.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1775.31,100,,3667.104,Percent of Total Billed Charges,100% of Total Billed Charges,169.64,1775.31,
LE ARTRY DUPLEX SCAN BIL,46044301,CDM,921,RC,93925,HCPCS,Outpatient,,,1186.68,712.01,,165.46,100,,1305.136,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,135,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,618.58,280,,173.304,Fee Schedule,280% of BCBS BULE Fee Schedule,706.94,320,,58.072,Fee Schedule,320% of BCBS Blue Essentials Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,795.31,360,,222.824,Fee Schedule,360% of BCBS POS Rate,795.31,360,,222.824,Fee schedule,360% of BCBS PPO Rate,795.31,360,,222.824,Fee Schedule,360% of BCBS Traditional Rate,712.01,60,,654.112,Percent of Total Billed Charges,60% of Total Billed Charges,230.13,100,,364,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,717.6,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,237.03,103,,374.92,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,890.01,75,,7707.448,Percent of Total Billed Charges,75% of Total Billed Charges,593.34,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,593.34,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,593.34,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,593.34,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,1680.896,Case Rate,Pays based on per visit rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.68,100,,10276.6,Percent of Total Billed Charges,100% of Total Billed Charges,165.46,1186.68,
LE ARTRY DUPLEX SCAN UNI,46044327,CDM,921,RC,93926,HCPCS,Outpatient,,,803.57,482.14,,81.56,100,,372.896,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,230.256,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,280,,198.248,Fee Schedule,280% of BCBS BULE Fee Schedule,359.81,320,,58.184,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,404.78,360,,254.888,Fee Schedule,360% of BCBS POS Rate,404.78,360,,254.888,Fee schedule,360% of BCBS PPO Rate,404.78,360,,254.888,Fee Schedule,360% of BCBS Traditional Rate,482.14,60,,501.504,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,257.152,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,332.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,264.864,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,602.68,75,,3853.992,Percent of Total Billed Charges,75% of Total Billed Charges,401.79,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,401.79,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,401.79,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,401.79,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,1120.6,Case Rate,Pays based on per visit rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,257.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,803.57,100,,5138.656,Percent of Total Billed Charges,100% of Total Billed Charges,81.56,803.57,
UE ARTRY DUPLEX BIL,46044400,CDM,921,RC,93930,HCPCS,Outpatient,,,1075,645.00,,127.83,100,,1206.392,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,253.8,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,473.26,280,,198.248,Fee Schedule,280% of BCBS BULE Fee Schedule,540.86,320,,58.312,Fee Schedule,320% of BCBS Blue Essentials Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,608.47,360,,254.888,Fee Schedule,360% of BCBS POS Rate,608.47,360,,254.888,Fee schedule,360% of BCBS PPO Rate,608.47,360,,254.888,Fee Schedule,360% of BCBS Traditional Rate,645,60,,575.056,Percent of Total Billed Charges,60% of Total Billed Charges,202.15,100,,364,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,648,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,208.21,103,,374.92,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,806.25,75,,7441.336,Percent of Total Billed Charges,75% of Total Billed Charges,537.5,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,537.5,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,537.5,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,537.5,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,621.424,Case Rate,Pays based on per visit rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,202.15,100,,364,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1075,100,,9921.784,Percent of Total Billed Charges,100% of Total Billed Charges,127.83,1075,
UE ARTRY DUPLEX UNI,46044426,CDM,921,RC,93931,HCPCS,Outpatient,,,720.2,432.12,,80.25,100,,1002.856,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,216,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,295.65,280,,297.632,Fee Schedule,280% of BCBS BULE Fee Schedule,337.89,320,,58.576,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,380.12,360,,382.672,Fee Schedule,360% of BCBS POS Rate,380.12,360,,382.672,Fee schedule,360% of BCBS PPO Rate,380.12,360,,382.672,Fee Schedule,360% of BCBS Traditional Rate,432.12,60,,3794.232,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,451.36,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,300,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,464.904,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,540.15,75,,7707.448,Percent of Total Billed Charges,75% of Total Billed Charges,360.1,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,360.1,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,360.1,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,360.1,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,5290.72,Case Rate,Pays based on per visit rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,451.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,720.2,100,,10276.6,Percent of Total Billed Charges,100% of Total Billed Charges,80.25,720.2,
DIALYSIS ACCESS SCAN,46050001,CDM,921,RC,93990,HCPCS,Outpatient,,,686.85,412.11,,81.56,100,,344.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,135,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,295.616,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,58.576,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,380.08,Fee Schedule,360% of BCBS POS Rate,403.49,360,,380.08,Fee schedule,360% of BCBS PPO Rate,403.49,360,,380.08,Fee Schedule,360% of BCBS Traditional Rate,412.11,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,84,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,511.68,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,86.52,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,515.14,75,,11561.176,Percent of Total Billed Charges,75% of Total Billed Charges,343.43,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,343.43,50,,918.352,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,343.43,50,,918.352,Percent of Total Billed Charges,50% of Total Billed Charges,343.43,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,4077.08,Case Rate,Pays based on per visit rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,84,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,686.85,100,,15414.904,Percent of Total Billed Charges,100% of Total Billed Charges,81.56,686.85,
US HEMODIALYSIS ACC DPLX,46050019,CDM,921,RC,93990,HCPCS,Outpatient,,,686.85,412.11,,81.56,100,,349.976,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.08,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,197.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,58.624,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,253.384,Fee Schedule,360% of BCBS POS Rate,403.49,360,,253.384,Fee schedule,360% of BCBS PPO Rate,403.49,360,,253.384,Fee Schedule,360% of BCBS Traditional Rate,412.11,60,,600.352,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,42.384,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,564,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,43.656,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,515.14,75,,7707.448,Percent of Total Billed Charges,75% of Total Billed Charges,343.43,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,343.43,50,,3634.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,343.43,50,,3634.8,Percent of Total Billed Charges,50% of Total Billed Charges,343.43,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,3870.368,Case Rate,Pays based on per visit rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,42.384,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,686.85,100,,10276.6,Percent of Total Billed Charges,100% of Total Billed Charges,81.56,686.85,
US ABD LTD,46067062,CDM,402,RC,76705,HCPCS,Outpatient,,,746.39,447.83,,60.78,100,,349.976,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,216,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,197.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,58.728,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,253.384,Fee Schedule,360% of BCBS POS Rate,403.49,360,,253.384,Fee schedule,360% of BCBS PPO Rate,403.49,360,,253.384,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2112.824,Fee Schedule,103% of Cigna fee schedule,88.55,100,,42,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,480,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,559.79,75,,10800,Percent of Total Billed Charges,75% of Total Billed Charges,373.2,50,,918.352,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,1006.744,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,373.2,50,,1006.744,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,4202.28,Case Rate,Pays based on per visit rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,42,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,746.39,100,,14400,Percent of Total Billed Charges,100% of Total Billed Charges,60.78,746.39,
US ABD LTD,46067062,CDM,402,RC,76705,HCPCS,Outpatient,,,746.39,447.83,,60.78,100,,114.896,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,94.984,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,148.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,58.856,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,191.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,191.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,191.048,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,673.64,Fee Schedule,103% of Cigna fee schedule,88.55,100,,37.52,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,300,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,38.648,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,559.79,75,,1170,Percent of Total Billed Charges,75% of Total Billed Charges,373.2,50,,3634.8,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,373.2,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2169.184,Case Rate,Pays based on per visit rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,37.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,746.39,100,,1560,Percent of Total Billed Charges,100% of Total Billed Charges,60.78,746.39,
INJ PSEUDOANEURYSM EXT LT,46067063,CDM,361,RC,36002,HCPCS,Outpatient,,,1232.86,739.72,,2601,100,,1206.392,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,864.52,150,,81,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.09,233,,166.512,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5.96,32,,58.856,Percent of Total Billed Charges,32% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,2030.24,322,,214.08,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2030.24,322,,214.08,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2030.24,322,,214.08,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,666.544,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,62.4,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,177.78,14.42,,30.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,924.65,75,,3424.2,Percent of Total Billed Charges,75% of Total Billed Charges,616.43,50,,1006.744,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,616.43,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,2456.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,29.68,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.86,100,,4565.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.96,2601,
INJ PSEUDOANEURYSM EXT RT,46067064,CDM,361,RC,36002,HCPCS,Outpatient,,,1232.86,739.72,,2601,100,,344.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,864.52,150,,127.8,Fee Schedule ,150% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.09,233,,166.512,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5.99,32,,5899.008,Percent of Total Billed Charges,32% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,2030.24,322,,214.08,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2030.24,322,,214.08,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2030.24,322,,214.08,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,772.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,576.34,100,,480,Fee Schedule,100% of CMS OPPS Rate,518.71,90,,,Fee Schedule,90% of CMS OPPS Rate,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,130,,,Fee Schedule,130% of CMS OPPS Rate,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,177.78,14.42,,103.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,593.64,103,,,Fee Schedule,103% of CMS OPPS Rate,924.65,75,,4672.2,Percent of Total Billed Charges,75% of Total Billed Charges,616.43,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,616.43,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,838.8,Percent of Total Billed Charges,50% of Total Billed Charges,864.52,150,,,Fee Schedule,150% of CMS OPPS Rate,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1426.92,Fee Schedule,100% of ASC Tier Groupings fee schedule,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,100.464,Percent of Total Billed Charges,14% of Total Billed Charges,576.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.86,100,,6229.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.99,2601,
XIENCE SIERRA DES 2.50X08 RX US,46100000,CDM,278,RC,C1874,HCPCS,Outpatient,,,2220,1332.00,,2934.41,110,,344.68,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,621.6,28,,198.936,Percent of Total Billed Charges,28% of Total Billed Charges,5.99,32,,5980.544,Percent of Total Billed Charges,32% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,799.2,36,,255.776,Percent of Total Billed Charges,36% of Total Billed Charges,799.2,36,,255.776,Percent of Total Billed Charges,36% Total Bille Charges,799.2,36,,255.776,Percent of Total Billed Charges,36% of Total Billed Charges,1221,55,,489.6,Percent of Total Billed Charges,55% Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,320.12,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1776,80,,1599,Percent of Total Billed Charges,80% of Total Billed Charges,1110,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,1110,50,,1704.8,Percent of Total Billed Charges,50% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1110,50,,1704.8,Percent of Total Billed Charges,50% of Total Billed Charges,1110,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1554,70,,2082.24,Percent of Total Billed Charges,70% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,310.8,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2220,100,,2132,Percent of Total Billed Charges,100% of Total Billed Charges,5.99,2934.41,
IR COIL INTERLOCK 8-14MM,46100002,CDM,278,RC,,,Outpatient,,,1934.58,1160.75,,2128.04,110,,203.096,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.68,28,,121.88,Percent of Total Billed Charges,28% of Total Billed Charges,6,32,,5980.544,Percent of Total Billed Charges,32% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,696.45,36,,156.704,Percent of Total Billed Charges,36% of Total Billed Charges,696.45,36,,156.704,Percent of Total Billed Charges,36% Total Bille Charges,696.45,36,,156.704,Percent of Total Billed Charges,36% of Total Billed Charges,1064.02,55,,653.96,Percent of Total Billed Charges,55% Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,278.97,14.42,,1004.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1547.66,80,,4165.2,Percent of Total Billed Charges,80% of Total Billed Charges,967.29,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,967.29,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.29,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,967.29,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1354.21,70,,2456.72,Percent of Total Billed Charges,70% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,270.84,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1934.58,100,,5553.6,Percent of Total Billed Charges,100% of Total Billed Charges,6,2128.04,
CATH ANGIO 2XL,46100003,CDM,272,RC,C1725,HCPCS,Outpatient,,,615,369.00,,99.47,100,,110.36,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.2,28,,212.376,Percent of Total Billed Charges,28% of Total Billed Charges,6.02,32,,5980.544,Percent of Total Billed Charges,32% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,221.4,36,,273.056,Percent of Total Billed Charges,36% of Total Billed Charges,221.4,36,,273.056,Percent of Total Billed Charges,36% Total Bille Charges,221.4,36,,273.056,Percent of Total Billed Charges,36% of Total Billed Charges,369,60,,6570.128,Percent of Total Billed Charges,60% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,88.68,14.42,,100.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,461.25,75,,8124,Percent of Total Billed Charges,75% of Total Billed Charges,307.5,50,,1704.8,Percent of Total Billed Charges,50% of Total Billed Charges,307.5,50,,1098.896,Percent of Total Billed Charges,50% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.5,50,,1098.896,Percent of Total Billed Charges,50% of Total Billed Charges,307.5,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.5,70,,1353.752,Percent of Total Billed Charges,70% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,86.1,14,,97.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615,100,,10832,Percent of Total Billed Charges,100% of Total Billed Charges,6.02,615,
ACCOLADE MRI DR L311 PPM,46100007,CDM,275,RC,C1785,HCPCS,Outpatient,,,13086.15,7851.69,,14670.19,110,,331.088,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3664.12,28,,322.216,Percent of Total Billed Charges,28% of Total Billed Charges,6.05,32,,5980.544,Percent of Total Billed Charges,32% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,4711.01,36,,414.28,Percent of Total Billed Charges,36% of Total Billed Charges,4711.01,36,,414.28,Percent of Total Billed Charges,36% Total Bille Charges,4711.01,36,,414.28,Percent of Total Billed Charges,36% of Total Billed Charges,7197.38,55,,98.504,Percent of Total Billed Charges,55% Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1887.02,14.42,,959.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9814.61,75,,2956.2,Percent of Total Billed Charges,75% of Total Billed Charges,6543.08,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,6543.08,50,,774.248,Percent of Total Billed Charges,50% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6543.08,50,,774.248,Percent of Total Billed Charges,50% of Total Billed Charges,6543.08,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9160.31,70,,5535.656,Percent of Total Billed Charges,70% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,1832.06,14,,931.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13086.15,100,,3941.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.05,14670.19,
INGEVITY MRI 7740 LEAD 45CM,46100008,CDM,275,RC,C1898,HCPCS,Outpatient,,,2192.85,1315.71,,3784.92,110,,154.52,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,28,,134.736,Percent of Total Billed Charges,28% of Total Billed Charges,57.6,32,,6016,Percent of Total Billed Charges,32% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,789.43,36,,173.232,Percent of Total Billed Charges,36% of Total Billed Charges,789.43,36,,173.232,Percent of Total Billed Charges,36% Total Bille Charges,789.43,36,,173.232,Percent of Total Billed Charges,36% of Total Billed Charges,1206.07,55,,33.224,Percent of Total Billed Charges,55% Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,316.21,14.42,,344.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1644.64,75,,1678.2,Percent of Total Billed Charges,75% of Total Billed Charges,1096.43,50,,1098.896,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1096.43,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1535,70,,4217.648,Percent of Total Billed Charges,70% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2192.85,100,,2237.6,Percent of Total Billed Charges,100% of Total Billed Charges,57.6,3784.92,
INGEVITY MRI LEAD 7741 52CM,46100009,CDM,275,RC,C1898,HCPCS,Outpatient,,,2192.85,1315.71,,3784.92,110,,331.088,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,28,,1965.872,Percent of Total Billed Charges,28% of Total Billed Charges,57.73,32,,6092.8,Percent of Total Billed Charges,32% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,789.43,36,,2527.552,Percent of Total Billed Charges,36% of Total Billed Charges,789.43,36,,2527.552,Percent of Total Billed Charges,36% Total Bille Charges,789.43,36,,2527.552,Percent of Total Billed Charges,36% of Total Billed Charges,1206.07,55,,45.304,Percent of Total Billed Charges,55% Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,316.21,14.42,,344.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1644.64,75,,630,Percent of Total Billed Charges,75% of Total Billed Charges,1096.43,50,,774.248,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1096.43,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1535,70,,2169.184,Percent of Total Billed Charges,70% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2192.85,100,,840,Percent of Total Billed Charges,100% of Total Billed Charges,57.73,3784.92,
INGEVITY MRI 7742 LEAD 59CM,46100010,CDM,275,RC,C1898,HCPCS,Outpatient,,,2192.85,1315.71,,3784.92,110,,349.976,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,28,,547.976,Percent of Total Billed Charges,28% of Total Billed Charges,58.25,32,,6103.968,Percent of Total Billed Charges,32% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,789.43,36,,704.544,Percent of Total Billed Charges,36% of Total Billed Charges,789.43,36,,704.544,Percent of Total Billed Charges,36% Total Bille Charges,789.43,36,,704.544,Percent of Total Billed Charges,36% of Total Billed Charges,1206.07,55,,653.96,Percent of Total Billed Charges,55% Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,316.21,14.42,,344.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1644.64,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,1096.43,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1096.43,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,1096.43,50,,918.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1535,70,,2082.24,Percent of Total Billed Charges,70% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,307,14,,334.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2192.85,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,58.25,3784.92,
CORMATRIX CANGAROO ENVELOPE,46100011,CDM,278,RC,,,Outpatient,,,3367,2020.20,,3703.7,110,,349.976,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,942.76,28,,596.032,Percent of Total Billed Charges,28% of Total Billed Charges,58.27,32,,6124.168,Percent of Total Billed Charges,32% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,1212.12,36,,766.32,Percent of Total Billed Charges,36% of Total Billed Charges,1212.12,36,,766.32,Percent of Total Billed Charges,36% Total Bille Charges,1212.12,36,,766.32,Percent of Total Billed Charges,36% of Total Billed Charges,1851.85,55,,289.456,Percent of Total Billed Charges,55% Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,485.52,14.42,,312.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2693.6,80,,105,Percent of Total Billed Charges,80% of Total Billed Charges,1683.5,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,1683.5,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1683.5,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,1683.5,50,,3634.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2356.9,70,,2456.72,Percent of Total Billed Charges,70% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,471.38,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3367,100,,140,Percent of Total Billed Charges,100% of Total Billed Charges,58.27,3703.7,
CATHETER ANGIOPLASTY BALLOON 2 LUMEN PERIPHERAL OV,46100012,CDM,271,RC,,,Outpatient,,,1330,798.00,,798,60,,218.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.4,28,,674.264,Percent of Total Billed Charges,28% of Total Billed Charges,58.68,32,,6129.848,Percent of Total Billed Charges,32% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,478.8,36,,866.904,Percent of Total Billed Charges,36% of Total Billed Charges,478.8,36,,866.904,Percent of Total Billed Charges,36% Total Bille Charges,478.8,36,,866.904,Percent of Total Billed Charges,36% of Total Billed Charges,798,60,,239.808,Percent of Total Billed Charges,60% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,191.79,14.42,,312.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,997.5,75,,2886,Percent of Total Billed Charges,75% of Total Billed Charges,665,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,665,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,665,50,,1006.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,931,70,,2169.184,Percent of Total Billed Charges,70% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,186.2,14,,303.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1330,100,,3848,Percent of Total Billed Charges,100% of Total Billed Charges,58.68,1330,
PORT IMPLANTABLE INFUSION LOW PROFILE POWER INJECT,46100013,CDM,271,RC,,,Outpatient,,,1282,769.20,,769.2,60,,218.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,358.96,28,,5631.04,Percent of Total Billed Charges,28% of Total Billed Charges,58.69,32,,5.888,Percent of Total Billed Charges,32% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,461.52,36,,7239.912,Percent of Total Billed Charges,36% of Total Billed Charges,461.52,36,,7239.912,Percent of Total Billed Charges,36% Total Bille Charges,461.52,36,,7239.912,Percent of Total Billed Charges,36% of Total Billed Charges,769.2,60,,39.264,Percent of Total Billed Charges,60% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,184.86,14.42,,74.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.5,75,,7800,Percent of Total Billed Charges,75% of Total Billed Charges,641,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,641,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,641,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,897.4,70,,2169.184,Percent of Total Billed Charges,70% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,179.48,14,,72.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1282,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,58.69,1282,
CATHETER ARTERIAL 7FR L110CM S FEMORAL 4 LUMEN INJ,46100014,CDM,271,RC,,,Outpatient,,,370,222.00,,222,60,,72.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.6,28,,2194.944,Percent of Total Billed Charges,28% of Total Billed Charges,58.7,32,,5.904,Percent of Total Billed Charges,32% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,133.2,36,,2822.072,Percent of Total Billed Charges,36% of Total Billed Charges,133.2,36,,2822.072,Percent of Total Billed Charges,36% Total Bille Charges,133.2,36,,2822.072,Percent of Total Billed Charges,36% of Total Billed Charges,222,60,,473.848,Percent of Total Billed Charges,60% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,53.35,14.42,,260.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.5,75,,10352.2,Percent of Total Billed Charges,75% of Total Billed Charges,185,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,185,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,185,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259,70,,2082.24,Percent of Total Billed Charges,70% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,252.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370,100,,13802.928,Percent of Total Billed Charges,100% of Total Billed Charges,51.8,370,
COIL NESTER EMBOLECT 18-7-10,46100015,CDM,271,RC,,,Outpatient,,,878,526.80,,526.8,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.84,28,,358.168,Percent of Total Billed Charges,28% of Total Billed Charges,58.8,32,,5.976,Percent of Total Billed Charges,32% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,316.08,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,316.08,36,,460.504,Percent of Total Billed Charges,36% Total Bille Charges,316.08,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,526.8,60,,1183.264,Percent of Total Billed Charges,60% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,126.61,14.42,,3033.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,658.5,75,,6935,Percent of Total Billed Charges,75% of Total Billed Charges,439,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,439,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,439,50,,354,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.6,70,,2082.24,Percent of Total Billed Charges,70% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,122.92,14,,2945.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,878,100,,9246.664,Percent of Total Billed Charges,100% of Total Billed Charges,58.8,878,
GUIDEWIRE VASCULAR IMAGING STRAIGHT SPRING COIL TI,46100016,CDM,271,RC,,,Outpatient,,,900,540.00,,540,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,28,,1547.888,Percent of Total Billed Charges,28% of Total Billed Charges,59.04,32,,5.984,Percent of Total Billed Charges,32% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,324,36,,1990.144,Percent of Total Billed Charges,36% of Total Billed Charges,324,36,,1990.144,Percent of Total Billed Charges,36% Total Bille Charges,324,36,,1990.144,Percent of Total Billed Charges,36% of Total Billed Charges,540,60,,2047.184,Percent of Total Billed Charges,60% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,129.78,14.42,,3114.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,75,,43.92,Percent of Total Billed Charges,75% of Total Billed Charges,450,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,450,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,450,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,70,,2456.72,Percent of Total Billed Charges,70% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,3024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,900,100,,58.56,Percent of Total Billed Charges,100% of Total Billed Charges,59.04,900,
KIT DELIVERY ADMIN Y SPIKE 1 WAY STOPCOCK CATHETER,46100017,CDM,271,RC,,,Outpatient,,,735,441.00,,441,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.8,28,,1867.232,Percent of Total Billed Charges,28% of Total Billed Charges,59.07,32,,6.016,Percent of Total Billed Charges,32% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,36,,2400.728,Percent of Total Billed Charges,36% of Total Billed Charges,264.6,36,,2400.728,Percent of Total Billed Charges,36% Total Bille Charges,264.6,36,,2400.728,Percent of Total Billed Charges,36% of Total Billed Charges,441,60,,1192.544,Percent of Total Billed Charges,60% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,105.99,14.42,,199.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,551.25,75,,4204.2,Percent of Total Billed Charges,75% of Total Billed Charges,367.5,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,367.5,50,,3322.8,Percent of Total Billed Charges,50% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.5,50,,3322.8,Percent of Total Billed Charges,50% of Total Billed Charges,367.5,50,,1704.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,514.5,70,,2456.72,Percent of Total Billed Charges,70% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,102.9,14,,194.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735,100,,5605.6,Percent of Total Billed Charges,100% of Total Billed Charges,59.07,735,
COIL VASCULAR STANDARD 8 MM DIAMETER 5 CM LENGTH L,46100018,CDM,271,RC,,,Outpatient,,,616,369.60,,369.6,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.48,28,,1668.44,Percent of Total Billed Charges,28% of Total Billed Charges,59.13,32,,6.048,Percent of Total Billed Charges,32% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,221.76,36,,2145.136,Percent of Total Billed Charges,36% of Total Billed Charges,221.76,36,,2145.136,Percent of Total Billed Charges,36% Total Bille Charges,221.76,36,,2145.136,Percent of Total Billed Charges,36% of Total Billed Charges,369.6,60,,1192.544,Percent of Total Billed Charges,60% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,88.83,14.42,,899.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462,75,,24960.304,Percent of Total Billed Charges,75% of Total Billed Charges,308,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,308,50,,626.4,Percent of Total Billed Charges,50% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308,50,,626.4,Percent of Total Billed Charges,50% of Total Billed Charges,308,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,431.2,70,,2662.656,Percent of Total Billed Charges,70% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616,100,,33280.4,Percent of Total Billed Charges,100% of Total Billed Charges,59.13,616,
COIL VASCULARTANDARD 4 MM DIAMETER 3 CM LENGTH L,46100019,CDM,271,RC,,,Outpatient,,,607,364.20,,364.2,60,,358.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.96,28,,672.36,Percent of Total Billed Charges,28% of Total Billed Charges,59.2,32,,6.072,Percent of Total Billed Charges,32% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,218.52,36,,864.464,Percent of Total Billed Charges,36% of Total Billed Charges,218.52,36,,864.464,Percent of Total Billed Charges,36% Total Bille Charges,218.52,36,,864.464,Percent of Total Billed Charges,36% of Total Billed Charges,364.2,60,,3163.232,Percent of Total Billed Charges,60% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,87.53,14.42,,64.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.25,75,,6602.312,Percent of Total Billed Charges,75% of Total Billed Charges,303.5,50,,3322.8,Percent of Total Billed Charges,50% of Total Billed Charges,303.5,50,,185.6,Percent of Total Billed Charges,50% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.5,50,,185.6,Percent of Total Billed Charges,50% of Total Billed Charges,303.5,50,,1098.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,424.9,70,,3690.44,Percent of Total Billed Charges,70% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,84.98,14,,62.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,607,100,,8803.08,Percent of Total Billed Charges,100% of Total Billed Charges,59.2,607,
KIT STARTER 1000ML PATIENT DISCHARGE BOTTLE PLEURX,46100020,CDM,271,RC,,,Outpatient,,,1416,849.60,,849.6,60,,124.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,396.48,28,,448.24,Percent of Total Billed Charges,28% of Total Billed Charges,59.32,32,,58.88,Percent of Total Billed Charges,32% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,509.76,36,,576.312,Percent of Total Billed Charges,36% of Total Billed Charges,509.76,36,,576.312,Percent of Total Billed Charges,36% Total Bille Charges,509.76,36,,576.312,Percent of Total Billed Charges,36% of Total Billed Charges,849.6,60,,3163.232,Percent of Total Billed Charges,60% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,204.19,14.42,,109.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1062,75,,1200,Percent of Total Billed Charges,75% of Total Billed Charges,708,50,,626.4,Percent of Total Billed Charges,50% of Total Billed Charges,708,50,,2945.28,Percent of Total Billed Charges,50% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,708,50,,2945.28,Percent of Total Billed Charges,50% of Total Billed Charges,708,50,,774.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,991.2,70,,1383.2,Percent of Total Billed Charges,70% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,198.24,14,,106.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1416,100,,1500,Percent of Total Billed Charges,100% of Total Billed Charges,59.32,1416,
CT INJ SUPERIOR HYPOGAST PLEX,46100021,CDM,361,RC,64517,HCPCS,Outpatient,,,2715.06,1629.04,,4162,100,,964.28,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,258.512,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,248.568,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,59.68,32,,59.152,Percent of Total Billed Charges,32% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,319.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,319.592,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,319.592,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,5976.368,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,2010.656,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,391.51,14.42,,123.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2036.3,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,1357.53,50,,185.6,Percent of Total Billed Charges,50% of Total Billed Charges,1357.53,50,,3396.64,Percent of Total Billed Charges,50% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.53,50,,3396.64,Percent of Total Billed Charges,50% of Total Billed Charges,1357.53,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1383.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,380.11,14,,120.072,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2715.06,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,59.68,4162,
IR INJ LUMBOSACRAL STEROID,46100022,CDM,361,RC,62323,HCPCS,Outpatient,,,2721.63,1632.98,,2601,100,,855.968,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,2116.288,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,59.79,32,,59.192,Percent of Total Billed Charges,32% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,2720.944,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,2720.944,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,2720.944,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,208.568,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,574.472,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,392.46,14.42,,8.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,2041.22,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,1360.82,50,,2945.28,Percent of Total Billed Charges,50% of Total Billed Charges,1360.82,50,,4075.76,Percent of Total Billed Charges,50% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.82,50,,4075.76,Percent of Total Billed Charges,50% of Total Billed Charges,1360.82,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1559.872,Fee Schedule,100% of ASC Tier Groupings fee schedule,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,8.088,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2721.63,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,59.79,2721.63,
LUBRICANT INSTRUMENT 100ML FOR ATHERECTOMY VIPERSL,46100023,CDM,271,RC,,,Outpatient,,,570,342.00,,342,60,,823.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,28,,1630.832,Percent of Total Billed Charges,28% of Total Billed Charges,59.79,32,,59.304,Percent of Total Billed Charges,32% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,205.2,36,,2096.784,Percent of Total Billed Charges,36% of Total Billed Charges,205.2,36,,2096.784,Percent of Total Billed Charges,36% Total Bille Charges,205.2,36,,2096.784,Percent of Total Billed Charges,36% of Total Billed Charges,342,60,,3264.344,Percent of Total Billed Charges,60% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,82.19,14.42,,1245.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.5,75,,26674.008,Percent of Total Billed Charges,75% of Total Billed Charges,285,50,,3396.64,Percent of Total Billed Charges,50% of Total Billed Charges,285,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,285,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399,70,,1559.872,Percent of Total Billed Charges,70% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,79.8,14,,1209.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,570,100,,35565.344,Percent of Total Billed Charges,100% of Total Billed Charges,59.79,570,
INTRODUCER VASCULAR SET 7 FR 40 CM LENGTH WITHOUT,46100024,CDM,271,RC,,,Outpatient,,,569,341.40,,341.4,60,,285.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.32,28,,1548.144,Percent of Total Billed Charges,28% of Total Billed Charges,59.91,32,,59.48,Percent of Total Billed Charges,32% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,204.84,36,,1990.472,Percent of Total Billed Charges,36% of Total Billed Charges,204.84,36,,1990.472,Percent of Total Billed Charges,36% Total Bille Charges,204.84,36,,1990.472,Percent of Total Billed Charges,36% of Total Billed Charges,341.4,60,,4236.96,Percent of Total Billed Charges,60% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,82.05,14.42,,1110.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,426.75,75,,12300,Percent of Total Billed Charges,75% of Total Billed Charges,284.5,50,,4075.76,Percent of Total Billed Charges,50% of Total Billed Charges,284.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,284.5,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.3,70,,480.104,Percent of Total Billed Charges,70% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,79.66,14,,1078.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,569,100,,16400,Percent of Total Billed Charges,100% of Total Billed Charges,59.91,569,
MWCE-18-7-4-NESTER-01 0.018 ID PLATINUM MICRO NEST,46100025,CDM,271,RC,,,Outpatient,,,563,337.80,,337.8,60,,811.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.64,28,,1680.912,Percent of Total Billed Charges,28% of Total Billed Charges,60.01,32,,59.784,Percent of Total Billed Charges,32% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,202.68,36,,2161.176,Percent of Total Billed Charges,36% of Total Billed Charges,202.68,36,,2161.176,Percent of Total Billed Charges,36% Total Bille Charges,202.68,36,,2161.176,Percent of Total Billed Charges,36% of Total Billed Charges,337.8,60,,409.336,Percent of Total Billed Charges,60% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,81.18,14.42,,705.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.25,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,281.5,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,281.5,50,,1041.6,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.5,50,,1041.6,Percent of Total Billed Charges,50% of Total Billed Charges,281.5,50,,766.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.1,70,,3823.12,Percent of Total Billed Charges,70% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,685.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,60.01,563,
KIT PERICARDIOCENTESIS 6 FR CATHETER 60 CM LENGTH,46100026,CDM,271,RC,,,Outpatient,,,511,306.60,,306.6,60,,2057.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.08,28,,867.672,Percent of Total Billed Charges,28% of Total Billed Charges,60.01,32,,59.976,Percent of Total Billed Charges,32% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,183.96,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,183.96,36,,1115.576,Percent of Total Billed Charges,36% Total Bille Charges,183.96,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,306.6,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,73.69,14.42,,696.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.25,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,255.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,255.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,255.5,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,357.7,70,,1885.136,Percent of Total Billed Charges,70% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,71.54,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,60.01,511,
KIT CATH CENTRAL VENOUS TRIPLE,46100027,CDM,271,RC,,,Outpatient,,,505,303.00,,303,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.4,28,,982.688,Percent of Total Billed Charges,28% of Total Billed Charges,60.03,32,,60.04,Percent of Total Billed Charges,32% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,181.8,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,181.8,36,,1263.456,Percent of Total Billed Charges,36% Total Bille Charges,181.8,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,303,60,,1332.336,Percent of Total Billed Charges,60% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,72.82,14.42,,378.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.75,75,,31376.872,Percent of Total Billed Charges,75% of Total Billed Charges,252.5,50,,1041.6,Percent of Total Billed Charges,50% of Total Billed Charges,252.5,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.5,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,252.5,50,,1016.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.5,70,,3784.56,Percent of Total Billed Charges,70% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,14,,367.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505,100,,41835.832,Percent of Total Billed Charges,100% of Total Billed Charges,60.03,505,
KIT INFLATION DEVICE 20ML INSERTION TOOL 3 WAY STO,46100028,CDM,271,RC,,,Outpatient,,,431,258.60,,258.6,60,,377.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.68,28,,570.768,Percent of Total Billed Charges,28% of Total Billed Charges,60.13,32,,60.04,Percent of Total Billed Charges,32% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,155.16,36,,733.848,Percent of Total Billed Charges,36% of Total Billed Charges,155.16,36,,733.848,Percent of Total Billed Charges,36% Total Bille Charges,155.16,36,,733.848,Percent of Total Billed Charges,36% of Total Billed Charges,258.6,60,,26.544,Percent of Total Billed Charges,60% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14.42,,840.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.25,75,,31376.872,Percent of Total Billed Charges,75% of Total Billed Charges,215.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,215.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,215.5,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.7,70,,3381.544,Percent of Total Billed Charges,70% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,60.34,14,,816.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,431,100,,41835.832,Percent of Total Billed Charges,100% of Total Billed Charges,60.13,431,
DEVICE FLOW CONTROL ONE WAY HIGH PRESSURE FLOSWITC,46100030,CDM,271,RC,,,Outpatient,,,426,255.60,,255.6,60,,1303.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.28,28,,867.672,Percent of Total Billed Charges,28% of Total Billed Charges,60.17,32,,60.136,Percent of Total Billed Charges,32% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,153.36,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,153.36,36,,1115.576,Percent of Total Billed Charges,36% Total Bille Charges,153.36,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,255.6,60,,38.896,Percent of Total Billed Charges,60% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,61.43,14.42,,696.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.5,75,,6085.048,Percent of Total Billed Charges,75% of Total Billed Charges,213,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,213,50,,1612,Percent of Total Billed Charges,50% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213,50,,1612,Percent of Total Billed Charges,50% of Total Billed Charges,213,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.2,70,,1897.328,Percent of Total Billed Charges,70% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.64,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426,100,,8113.392,Percent of Total Billed Charges,100% of Total Billed Charges,59.64,426,
CATHETER DIAGNOSTIC OD5FR ID0.046IN BERENSTEIN RAD,46100031,CDM,271,RC,,,Outpatient,,,410,246.00,,246,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.8,28,,832.896,Percent of Total Billed Charges,28% of Total Billed Charges,60.28,32,,60.136,Percent of Total Billed Charges,32% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,147.6,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,147.6,36,,1070.864,Percent of Total Billed Charges,36% Total Bille Charges,147.6,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,246,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,59.12,14.42,,696.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.5,75,,1021.2,Percent of Total Billed Charges,75% of Total Billed Charges,205,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,205,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,205,50,,3322.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287,70,,1062.312,Percent of Total Billed Charges,70% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,57.4,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410,100,,1361.6,Percent of Total Billed Charges,100% of Total Billed Charges,57.4,410,
CONTAINER PLEURAL CAVITY DRAINAGE SUCTION CONTROL,46100032,CDM,271,RC,,,Outpatient,,,241,144.60,,144.6,60,,648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.48,28,,982.688,Percent of Total Billed Charges,28% of Total Billed Charges,60.34,32,,60.136,Percent of Total Billed Charges,32% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,86.76,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,86.76,36,,1263.456,Percent of Total Billed Charges,36% Total Bille Charges,86.76,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,144.6,60,,230.944,Percent of Total Billed Charges,60% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14.42,,696.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.75,75,,4094.4,Percent of Total Billed Charges,75% of Total Billed Charges,120.5,50,,1612,Percent of Total Billed Charges,50% of Total Billed Charges,120.5,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.5,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,120.5,50,,626.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.7,70,,1796.496,Percent of Total Billed Charges,70% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241,100,,5459.2,Percent of Total Billed Charges,100% of Total Billed Charges,33.74,241,
PAD DEFIBRILLATION ADULT RADIOTRANSPARENT WITH CAR,46100033,CDM,271,RC,,,Outpatient,,,284,170.40,,170.4,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.52,28,,541.504,Percent of Total Billed Charges,28% of Total Billed Charges,60.42,32,,60.2,Percent of Total Billed Charges,32% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,102.24,36,,696.216,Percent of Total Billed Charges,36% of Total Billed Charges,102.24,36,,696.216,Percent of Total Billed Charges,36% Total Bille Charges,102.24,36,,696.216,Percent of Total Billed Charges,36% of Total Billed Charges,170.4,60,,230.944,Percent of Total Billed Charges,60% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14.42,,696.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,142,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,142,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,142,50,,185.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.8,70,,904.592,Percent of Total Billed Charges,70% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,675.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,39.76,284,
TRAY PICC DRSG,46100034,CDM,271,RC,,,Outpatient,,,222,133.20,,133.2,60,,276.848,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.16,28,,2214.264,Percent of Total Billed Charges,28% of Total Billed Charges,60.48,32,,60.352,Percent of Total Billed Charges,32% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,79.92,36,,2846.912,Percent of Total Billed Charges,36% of Total Billed Charges,79.92,36,,2846.912,Percent of Total Billed Charges,36% Total Bille Charges,79.92,36,,2846.912,Percent of Total Billed Charges,36% of Total Billed Charges,133.2,60,,40.768,Percent of Total Billed Charges,60% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,32.01,14.42,,340.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.5,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,134,Percent of Total Billed Charges,50% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111,50,,134,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,2945.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.4,70,,2943.92,Percent of Total Billed Charges,70% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,31.08,222,
KIT SNARE RETRIEVAL NITINOL DUAL SHEATH KINK RESIS,46100035,CDM,271,RC,,,Outpatient,,,220,132.00,,132,60,,9685.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.6,28,,1687.056,Percent of Total Billed Charges,28% of Total Billed Charges,60.53,32,,60.576,Percent of Total Billed Charges,32% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,79.2,36,,2169.072,Percent of Total Billed Charges,36% of Total Billed Charges,79.2,36,,2169.072,Percent of Total Billed Charges,36% Total Bille Charges,79.2,36,,2169.072,Percent of Total Billed Charges,36% of Total Billed Charges,132,60,,2112.824,Percent of Total Billed Charges,60% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.72,14.42,,340.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,75,,2359.6,Percent of Total Billed Charges,75% of Total Billed Charges,110,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,110,50,,106,Percent of Total Billed Charges,50% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,50,,106,Percent of Total Billed Charges,50% of Total Billed Charges,110,50,,3396.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,70,,1062.312,Percent of Total Billed Charges,70% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.8,14,,330.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220,100,,3146.136,Percent of Total Billed Charges,100% of Total Billed Charges,30.8,220,
INTRODUCER VASCULAR 6 FR 4 CM LENGTH WITHOUT CURVE,46100036,CDM,271,RC,,,Outpatient,,,206,123.60,,123.6,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.68,28,,867.672,Percent of Total Billed Charges,28% of Total Billed Charges,60.54,32,,61.024,Percent of Total Billed Charges,32% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,74.16,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,74.16,36,,1115.576,Percent of Total Billed Charges,36% Total Bille Charges,74.16,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,123.6,60,,140.712,Percent of Total Billed Charges,60% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,29.71,14.42,,2390.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.5,75,,2359.6,Percent of Total Billed Charges,75% of Total Billed Charges,103,50,,134,Percent of Total Billed Charges,50% of Total Billed Charges,103,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,103,50,,4075.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.2,70,,1209.184,Percent of Total Billed Charges,70% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14,,2321.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206,100,,3146.136,Percent of Total Billed Charges,100% of Total Billed Charges,28.84,206,
KIT BASIC MIDLINE CATHETER SINGLE LUMEN 2.7 FR 10,46100037,CDM,271,RC,,,Outpatient,,,148,88.80,,88.8,60,,1222.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.44,28,,832.896,Percent of Total Billed Charges,28% of Total Billed Charges,60.69,32,,61.184,Percent of Total Billed Charges,32% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,53.28,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,53.28,36,,1070.864,Percent of Total Billed Charges,36% Total Bille Charges,53.28,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,88.8,60,,2278.096,Percent of Total Billed Charges,60% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,14.42,,1018.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111,75,,2625,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,106,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.6,70,,3040.752,Percent of Total Billed Charges,70% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,20.72,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148,100,,3500,Percent of Total Billed Charges,100% of Total Billed Charges,20.72,148,
FORCEPS BIOPSY L240CM JAW DIA2.2MM ORANGE STAINLES,46100038,CDM,271,RC,,,Outpatient,,,140,84.00,,84,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.2,28,,982.688,Percent of Total Billed Charges,28% of Total Billed Charges,60.7,32,,61.184,Percent of Total Billed Charges,32% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,50.4,36,,1263.456,Percent of Total Billed Charges,36% Total Bille Charges,50.4,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,84,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,20.19,14.42,,24.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,75,,1547.4,Percent of Total Billed Charges,75% of Total Billed Charges,70,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,70,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,70,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98,70,,24895.744,Percent of Total Billed Charges,70% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,23.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,100,,2063.2,Percent of Total Billed Charges,100% of Total Billed Charges,19.6,140,
TRAY URINE METER SURESTEP 16FR,46100039,CDM,271,RC,,,Outpatient,,,136,81.60,,81.6,60,,510.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.08,28,,867.672,Percent of Total Billed Charges,28% of Total Billed Charges,6080,32,,61.24,Percent of Total Billed Charges,32% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,48.96,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,48.96,36,,1115.576,Percent of Total Billed Charges,36% Total Bille Charges,48.96,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,81.6,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.61,14.42,,40.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102,75,,1547.4,Percent of Total Billed Charges,75% of Total Billed Charges,68,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,68,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,68,50,,1041.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.2,70,,29284.816,Percent of Total Billed Charges,70% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,19.04,14,,39.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136,100,,2063.2,Percent of Total Billed Charges,100% of Total Billed Charges,19.04,6080,
RESUSC MASK ADLT RESVR MED,46100040,CDM,271,RC,,,Outpatient,,,133,79.80,,79.8,60,,5183.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.24,28,,867.672,Percent of Total Billed Charges,28% of Total Billed Charges,6080,32,,61.28,Percent of Total Billed Charges,32% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,47.88,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,47.88,36,,1115.576,Percent of Total Billed Charges,36% Total Bille Charges,47.88,36,,1115.576,Percent of Total Billed Charges,36% of Total Billed Charges,79.8,60,,18.04,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14.42,,140.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.75,75,,4748.688,Percent of Total Billed Charges,75% of Total Billed Charges,66.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,66.5,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.5,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,66.5,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.1,70,,29284.816,Percent of Total Billed Charges,70% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,18.62,14,,136.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133,100,,6331.584,Percent of Total Billed Charges,100% of Total Billed Charges,18.62,6080,
CANNULA NASAL ADULT CO2 AND OXYGEN SAMPLING LINE W,46100041,CDM,271,RC,,,Outpatient,,,131,78.60,,78.6,60,,1568.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.68,28,,832.896,Percent of Total Billed Charges,28% of Total Billed Charges,6177.92,32,,61.352,Percent of Total Billed Charges,32% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,47.16,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,47.16,36,,1070.864,Percent of Total Billed Charges,36% Total Bille Charges,47.16,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,78.6,60,,129.456,Percent of Total Billed Charges,60% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.89,14.42,,224.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.25,75,,1100.8,Percent of Total Billed Charges,75% of Total Billed Charges,65.5,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,65.5,50,,3328,Percent of Total Billed Charges,50% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.5,50,,3328,Percent of Total Billed Charges,50% of Total Billed Charges,65.5,50,,918.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.7,70,,14467.824,Percent of Total Billed Charges,70% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14,,218.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131,100,,1467.728,Percent of Total Billed Charges,100% of Total Billed Charges,18.34,6177.92,
MANIFOLD ASM 1V RH/OFF PERC. PG,46100042,CDM,271,RC,,,Outpatient,,,128,76.80,,76.8,60,,1209.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,28,,832.896,Percent of Total Billed Charges,28% of Total Billed Charges,6240,32,,6144,Percent of Total Billed Charges,32% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,46.08,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,46.08,36,,1070.864,Percent of Total Billed Charges,36% Total Bille Charges,46.08,36,,1070.864,Percent of Total Billed Charges,36% of Total Billed Charges,76.8,60,,235.224,Percent of Total Billed Charges,60% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,18.46,14.42,,276.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,75,,2453.4,Percent of Total Billed Charges,75% of Total Billed Charges,64,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,64,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,64,50,,1300,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.6,70,,14467.824,Percent of Total Billed Charges,70% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,17.92,14,,268.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128,100,,3271.2,Percent of Total Billed Charges,100% of Total Billed Charges,17.92,6240,
BOTTLE DRAIN ACCEL EVC 1000ML,46100043,CDM,271,RC,,,Outpatient,,,106,63.60,,63.6,60,,270.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.68,28,,982.688,Percent of Total Billed Charges,28% of Total Billed Charges,6258.44,32,,6249.728,Percent of Total Billed Charges,32% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,38.16,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,38.16,36,,1263.456,Percent of Total Billed Charges,36% Total Bille Charges,38.16,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,63.6,60,,197.584,Percent of Total Billed Charges,60% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,75,,2453.4,Percent of Total Billed Charges,75% of Total Billed Charges,53,50,,3328,Percent of Total Billed Charges,50% of Total Billed Charges,53,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,53,50,,1612,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.2,70,,6497.88,Percent of Total Billed Charges,70% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,14.84,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106,100,,3271.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.84,6258.44,
CATH SIZING AUROUS,46100044,CDM,271,RC,,,Outpatient,,,590,354.00,,354,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.2,28,,982.688,Percent of Total Billed Charges,28% of Total Billed Charges,6267.24,32,,6272.256,Percent of Total Billed Charges,32% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,212.4,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,212.4,36,,1263.456,Percent of Total Billed Charges,36% Total Bille Charges,212.4,36,,1263.456,Percent of Total Billed Charges,36% of Total Billed Charges,354,60,,197.584,Percent of Total Billed Charges,60% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,85.08,14.42,,66.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.5,75,,5132.128,Percent of Total Billed Charges,75% of Total Billed Charges,295,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,295,50,,1193.4,Percent of Total Billed Charges,50% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295,50,,1193.4,Percent of Total Billed Charges,50% of Total Billed Charges,295,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413,70,,7335.856,Percent of Total Billed Charges,70% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,64.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,590,100,,6842.84,Percent of Total Billed Charges,100% of Total Billed Charges,82.6,6267.24,
MWCE-18-14-10-NESTER-01 0.018 ID PLATINUM MICRO NE,46100045,CDM,271,RC,,,Outpatient,,,601,360.60,,360.6,60,,1081.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.28,28,,1065.064,Percent of Total Billed Charges,28% of Total Billed Charges,6267.24,32,,6.144,Percent of Total Billed Charges,32% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,216.36,36,,1369.368,Percent of Total Billed Charges,36% of Total Billed Charges,216.36,36,,1369.368,Percent of Total Billed Charges,36% Total Bille Charges,216.36,36,,1369.368,Percent of Total Billed Charges,36% of Total Billed Charges,360.6,60,,33.928,Percent of Total Billed Charges,60% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,86.66,14.42,,269.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.75,75,,6758.104,Percent of Total Billed Charges,75% of Total Billed Charges,300.5,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,300.5,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.5,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,300.5,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420.7,70,,2024.08,Percent of Total Billed Charges,70% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,84.14,14,,261.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,601,100,,9010.8,Percent of Total Billed Charges,100% of Total Billed Charges,84.14,6267.24,
POWERPICC SOLO PROVENA CATH 5F,46100046,CDM,271,RC,,,Outpatient,,,1101.87,661.12,,661.12,60,,511.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.52,28,,1476.176,Percent of Total Billed Charges,28% of Total Billed Charges,6348.79,32,,6.144,Percent of Total Billed Charges,32% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,396.67,36,,1897.944,Percent of Total Billed Charges,36% of Total Billed Charges,396.67,36,,1897.944,Percent of Total Billed Charges,36% Total Bille Charges,396.67,36,,1897.944,Percent of Total Billed Charges,36% of Total Billed Charges,661.12,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,158.89,14.42,,249.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.4,75,,1444.776,Percent of Total Billed Charges,75% of Total Billed Charges,550.94,50,,1193.4,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.94,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,550.94,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.31,70,,16921.84,Percent of Total Billed Charges,70% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,154.26,14,,241.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1101.87,100,,1926.368,Percent of Total Billed Charges,100% of Total Billed Charges,154.26,6348.79,
KIT HEMODIALYSIS L40CM L35CM OD15.5FR STRAIGHT SIN,46100047,CDM,271,RC,,,Outpatient,,,1510,906.00,,906,60,,408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.8,28,,553.28,Percent of Total Billed Charges,28% of Total Billed Charges,6399.36,32,,6.144,Percent of Total Billed Charges,32% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,543.6,36,,711.36,Percent of Total Billed Charges,36% of Total Billed Charges,543.6,36,,711.36,Percent of Total Billed Charges,36% Total Bille Charges,543.6,36,,711.36,Percent of Total Billed Charges,36% of Total Billed Charges,906,60,,32.344,Percent of Total Billed Charges,60% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,217.74,14.42,,89.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1132.5,75,,737.76,Percent of Total Billed Charges,75% of Total Billed Charges,755,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,755,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,755,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,755,50,,134,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1057,70,,11281.224,Percent of Total Billed Charges,70% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,211.4,14,,87.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1510,100,,983.68,Percent of Total Billed Charges,100% of Total Billed Charges,211.4,6399.36,
NEEDLE BIOPSY 19GA L60CM SHEATH 7FR SOFT TISSUE TR,46100048,CDM,271,RC,,,Outpatient,,,1757,1054.20,,1054.2,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.96,28,,553.28,Percent of Total Billed Charges,28% of Total Billed Charges,6.14,32,,6.192,Percent of Total Billed Charges,32% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,632.52,36,,711.36,Percent of Total Billed Charges,36% of Total Billed Charges,632.52,36,,711.36,Percent of Total Billed Charges,36% Total Bille Charges,632.52,36,,711.36,Percent of Total Billed Charges,36% of Total Billed Charges,1054.2,60,,172.72,Percent of Total Billed Charges,60% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,253.36,14.42,,112.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1317.75,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,878.5,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,878.5,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,878.5,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,878.5,50,,106,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1229.9,70,,11281.224,Percent of Total Billed Charges,70% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1757,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.14,1757,
CATHETER ANGIOPLASTY L130CM BALLOON L200MM DIA6MM,46100049,CDM,271,RC,,,Outpatient,,,7485,4491.00,,4491,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2095.8,28,,623.944,Percent of Total Billed Charges,28% of Total Billed Charges,6.2,32,,6.192,Percent of Total Billed Charges,32% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% of Total Billed Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% Total Bille Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% of Total Billed Charges,4491,60,,129.456,Percent of Total Billed Charges,60% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1079.34,14.42,,42.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5613.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,3742.5,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,10520,Percent of Total Billed Charges,50% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3742.5,50,,10520,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5239.5,70,,1100.6,Percent of Total Billed Charges,70% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7485,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.2,7485,
CATHETER ANGIOPLASTY L130CM BALLOON L200MM DIA4MM,46100050,CDM,271,RC,,,Outpatient,,,7485,4491.00,,4491,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2095.8,28,,623.944,Percent of Total Billed Charges,28% of Total Billed Charges,6.21,32,,6.2,Percent of Total Billed Charges,32% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% of Total Billed Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% Total Bille Charges,2694.6,36,,802.216,Percent of Total Billed Charges,36% of Total Billed Charges,4491,60,,347.424,Percent of Total Billed Charges,60% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1079.34,14.42,,42.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5613.75,75,,739.72,Percent of Total Billed Charges,75% of Total Billed Charges,3742.5,50,,901.6,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3742.5,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,151.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5239.5,70,,1382.976,Percent of Total Billed Charges,70% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,40.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7485,100,,986.288,Percent of Total Billed Charges,100% of Total Billed Charges,6.21,7485,
BLLN IPA DCB 035 4X200X80,46100051,CDM,271,RC,,,Outpatient,,,7485,4491.00,,4491,60,,61.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2095.8,28,,192.04,Percent of Total Billed Charges,28% of Total Billed Charges,6.25,32,,6.2,Percent of Total Billed Charges,32% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,2694.6,36,,246.912,Percent of Total Billed Charges,36% of Total Billed Charges,2694.6,36,,246.912,Percent of Total Billed Charges,36% Total Bille Charges,2694.6,36,,246.912,Percent of Total Billed Charges,36% of Total Billed Charges,4491,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1079.34,14.42,,170.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5613.75,75,,1306.672,Percent of Total Billed Charges,75% of Total Billed Charges,3742.5,50,,10520,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,693.224,Percent of Total Billed Charges,50% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3742.5,50,,693.224,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5239.5,70,,538.232,Percent of Total Billed Charges,70% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,165.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7485,100,,1742.224,Percent of Total Billed Charges,100% of Total Billed Charges,6.25,7485,
BLLN IPA DCB 035 5X200X130,46100052,CDM,271,RC,,,Outpatient,,,7485,4491.00,,4491,60,,339.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2095.8,28,,1529.248,Percent of Total Billed Charges,28% of Total Billed Charges,6.26,32,,6.216,Percent of Total Billed Charges,32% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,2694.6,36,,1966.176,Percent of Total Billed Charges,36% of Total Billed Charges,2694.6,36,,1966.176,Percent of Total Billed Charges,36% Total Bille Charges,2694.6,36,,1966.176,Percent of Total Billed Charges,36% of Total Billed Charges,4491,60,,540.76,Percent of Total Billed Charges,60% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1079.34,14.42,,457.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5613.75,75,,6935,Percent of Total Billed Charges,75% of Total Billed Charges,3742.5,50,,10800,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3742.5,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,3742.5,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5239.5,70,,538.232,Percent of Total Billed Charges,70% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,1047.9,14,,444.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7485,100,,9246.664,Percent of Total Billed Charges,100% of Total Billed Charges,6.26,7485,
CATHETER ANGIOPLASTY L130CM BALLOON L250MM DIA6MM,46100053,CDM,271,RC,,,Outpatient,,,8160,4896.00,,4896,60,,33.224,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2284.8,28,,754.056,Percent of Total Billed Charges,28% of Total Billed Charges,6.3,32,,6.24,Percent of Total Billed Charges,32% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,2937.6,36,,969.496,Percent of Total Billed Charges,36% of Total Billed Charges,2937.6,36,,969.496,Percent of Total Billed Charges,36% Total Bille Charges,2937.6,36,,969.496,Percent of Total Billed Charges,36% of Total Billed Charges,4896,60,,205.288,Percent of Total Billed Charges,60% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1176.67,14.42,,29.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6120,75,,8139.712,Percent of Total Billed Charges,75% of Total Billed Charges,4080,50,,693.224,Percent of Total Billed Charges,50% of Total Billed Charges,4080,50,,222.208,Percent of Total Billed Charges,50% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4080,50,,222.208,Percent of Total Billed Charges,50% of Total Billed Charges,4080,50,,348,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5712,70,,1292.32,Percent of Total Billed Charges,70% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,28.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8160,100,,10852.952,Percent of Total Billed Charges,100% of Total Billed Charges,6.3,8160,
CATHETER ANGIOPLASTY L130CM BALLOON L250MM DIA4MM,46100054,CDM,271,RC,,,Outpatient,,,8160,4896.00,,4896,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2284.8,28,,1513.824,Percent of Total Billed Charges,28% of Total Billed Charges,6.3,32,,6.256,Percent of Total Billed Charges,32% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,2937.6,36,,1946.344,Percent of Total Billed Charges,36% of Total Billed Charges,2937.6,36,,1946.344,Percent of Total Billed Charges,36% Total Bille Charges,2937.6,36,,1946.344,Percent of Total Billed Charges,36% of Total Billed Charges,4896,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1176.67,14.42,,8.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6120,75,,8829.6,Percent of Total Billed Charges,75% of Total Billed Charges,4080,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,4080,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4080,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,4080,50,,3328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5712,70,,3668,Percent of Total Billed Charges,70% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,1142.4,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8160,100,,11772.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.3,8160,
PACK PROCEDURE CATH LAB,46100055,CDM,271,RC,,,Outpatient,,,795,477.00,,477,60,,387.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.6,28,,1352.616,Percent of Total Billed Charges,28% of Total Billed Charges,6.34,32,,6.28,Percent of Total Billed Charges,32% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,286.2,36,,1739.08,Percent of Total Billed Charges,36% of Total Billed Charges,286.2,36,,1739.08,Percent of Total Billed Charges,36% Total Bille Charges,286.2,36,,1739.08,Percent of Total Billed Charges,36% of Total Billed Charges,477,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,114.64,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,596.25,75,,10352.2,Percent of Total Billed Charges,75% of Total Billed Charges,397.5,50,,222.208,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.5,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,397.5,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.5,70,,3668,Percent of Total Billed Charges,70% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,111.3,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,795,100,,13802.928,Percent of Total Billed Charges,100% of Total Billed Charges,6.34,795,
DRAPE PACEMAKER WITH DUAL POCKET,46100056,CDM,271,RC,,,Outpatient,,,339,203.40,,203.4,60,,387.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.92,28,,758.928,Percent of Total Billed Charges,28% of Total Billed Charges,6.35,32,,6.32,Percent of Total Billed Charges,32% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,122.04,36,,975.768,Percent of Total Billed Charges,36% of Total Billed Charges,122.04,36,,975.768,Percent of Total Billed Charges,36% Total Bille Charges,122.04,36,,975.768,Percent of Total Billed Charges,36% of Total Billed Charges,203.4,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,48.88,14.42,,13.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.25,75,,8829.6,Percent of Total Billed Charges,75% of Total Billed Charges,169.5,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,169.5,50,,28.896,Percent of Total Billed Charges,50% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.5,50,,28.896,Percent of Total Billed Charges,50% of Total Billed Charges,169.5,50,,1193.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.3,70,,8042.84,Percent of Total Billed Charges,70% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.46,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339,100,,11772.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.35,339,
CATHETER INTRAAORTIC BALLOON 8FR 50CC FIBER OPTIC,46100057,CDM,271,RC,,,Outpatient,,,3739,2243.40,,2243.4,60,,192.456,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1046.92,28,,424.92,Percent of Total Billed Charges,28% of Total Billed Charges,60.83,32,,6.328,Percent of Total Billed Charges,32% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,1346.04,36,,546.328,Percent of Total Billed Charges,36% of Total Billed Charges,1346.04,36,,546.328,Percent of Total Billed Charges,36% Total Bille Charges,1346.04,36,,546.328,Percent of Total Billed Charges,36% of Total Billed Charges,2243.4,60,,1217.648,Percent of Total Billed Charges,60% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,539.16,14.42,,96.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2804.25,75,,12623.144,Percent of Total Billed Charges,75% of Total Billed Charges,1869.5,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,1869.5,50,,4319.448,Percent of Total Billed Charges,50% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1869.5,50,,4319.448,Percent of Total Billed Charges,50% of Total Billed Charges,1869.5,50,,1193.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2617.3,70,,12819.424,Percent of Total Billed Charges,70% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,523.46,14,,94.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3739,100,,16830.856,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,3739,
PAD DEFIBRILLATION ADULT RADIOTRANSPARENT WITH CAR,46100058,CDM,271,RC,,,Outpatient,,,284,170.40,,170.4,60,,126.64,Percent of Total Billed Charges,60% of Total Billed Charges,127.8,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.52,28,,718.6,Percent of Total Billed Charges,28% of Total Billed Charges,60.83,32,,6.328,Percent of Total Billed Charges,32% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,102.24,36,,923.912,Percent of Total Billed Charges,36% of Total Billed Charges,102.24,36,,923.912,Percent of Total Billed Charges,36% Total Bille Charges,102.24,36,,923.912,Percent of Total Billed Charges,36% of Total Billed Charges,170.4,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,14.42,,6.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213,75,,15916.792,Percent of Total Billed Charges,75% of Total Billed Charges,142,50,,28.896,Percent of Total Billed Charges,50% of Total Billed Charges,142,50,,3850.392,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142,50,,3850.392,Percent of Total Billed Charges,50% of Total Billed Charges,142,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.8,70,,16451.488,Percent of Total Billed Charges,70% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,39.76,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284,100,,21222.384,Percent of Total Billed Charges,100% of Total Billed Charges,39.76,284,
CATHETER ARTERIAL 7FR L110CM S FEMORAL 4 LUMEN INJ,46100059,CDM,271,RC,,,Outpatient,,,370,222.00,,222,60,,631.544,Percent of Total Billed Charges,60% of Total Billed Charges,166.5,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.6,28,,361.84,Percent of Total Billed Charges,28% of Total Billed Charges,60.83,32,,6.352,Percent of Total Billed Charges,32% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,133.2,36,,465.216,Percent of Total Billed Charges,36% of Total Billed Charges,133.2,36,,465.216,Percent of Total Billed Charges,36% Total Bille Charges,133.2,36,,465.216,Percent of Total Billed Charges,36% of Total Billed Charges,222,60,,1276.432,Percent of Total Billed Charges,60% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,53.35,14.42,,51.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.5,75,,1669.8,Percent of Total Billed Charges,75% of Total Billed Charges,185,50,,4319.448,Percent of Total Billed Charges,50% of Total Billed Charges,185,50,,2447.28,Percent of Total Billed Charges,50% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185,50,,2447.28,Percent of Total Billed Charges,50% of Total Billed Charges,185,50,,1084.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259,70,,10967.664,Percent of Total Billed Charges,70% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,51.8,14,,50.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370,100,,2226.4,Percent of Total Billed Charges,100% of Total Billed Charges,51.8,370,
50-101 INARI SYSTEM,46100078,CDM,272,RC,A4649,HCPCS,Outpatient,,,3120,1872.00,,1872,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,1404,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.6,28,,11713.928,Percent of Total Billed Charges,28% of Total Billed Charges,60.83,32,,62.144,Percent of Total Billed Charges,32% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1123.2,36,,15060.768,Percent of Total Billed Charges,36% of Total Billed Charges,1123.2,36,,15060.768,Percent of Total Billed Charges,36% Total Bille Charges,1123.2,36,,15060.768,Percent of Total Billed Charges,36% of Total Billed Charges,1872,60,,293.24,Percent of Total Billed Charges,60% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3120,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,449.9,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2340,75,,4748.688,Percent of Total Billed Charges,75% of Total Billed Charges,1560,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1560,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2184,70,,2800,Percent of Total Billed Charges,70% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3120,100,,6331.584,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,3120,
DLYS CIRCUIT EMBO OR OCCLUSION,46100080,CDM,361,RC,36909,HCPCS,Outpatient,,,13807.47,8284.48,,2601,100,,648,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,6213.36,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.448,Other,Not Seperately Reimbusable,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8284.48,60,,243.776,Percent of Total Billed Charges,60% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13807.47,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1991.04,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10355.6,75,,14016.904,Percent of Total Billed Charges,75% of Total Billed Charges,6903.74,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,6903.74,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6903.74,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,6903.74,50,,222.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,2800,Fee Schedule,100% of ASC Tier Groupings fee schedule,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,1933.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13807.47,100,,18689.2,Percent of Total Billed Charges,100% of Total Billed Charges,1634,13807.47,
STENT PLMT CTR DIALYSIS SEG,46100081,CDM,361,RC,36908,HCPCS,Outpatient,,,12464.71,7478.83,,2601,100,,180,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5609.12,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.464,Other,Not Seperately Reimbusable,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7478.83,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12464.71,100,,191.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1797.41,14.42,,174.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9348.53,75,,14016.904,Percent of Total Billed Charges,75% of Total Billed Charges,6232.36,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,6232.36,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6232.36,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,6232.36,50,,380.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,3292.088,Fee Schedule,100% of ASC Tier Groupings fee schedule,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,1745.06,14,,169.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12464.71,100,,18689.2,Percent of Total Billed Charges,100% of Total Billed Charges,1634,12464.71,
TRLM BAL ANGP CTR DLYSIS SEG,46100082,CDM,361,RC,36907,HCPCS,Outpatient,,,7422.92,4453.75,,2601,100,,1002.856,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3340.31,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.504,Other,Not Seperately Reimbusable,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4453.75,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7422.92,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1070.39,14.42,,470.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5567.19,75,,14016.904,Percent of Total Billed Charges,75% of Total Billed Charges,3711.46,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,3711.46,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3711.46,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,3711.46,50,,428.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,2194.728,Fee Schedule,100% of ASC Tier Groupings fee schedule,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,1039.21,14,,457.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7422.92,100,,18689.2,Percent of Total Billed Charges,100% of Total Billed Charges,1039.21,7422.92,
IR STENT PLCMT MECH THROM,46100083,CDM,361,RC,36906,HCPCS,Outpatient,,,31868.34,19121.00,,9364,100,,1002.856,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,152.32,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,2599.152,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,60.83,32,,62.528,Percent of Total Billed Charges,32% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,3341.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,3341.768,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,3341.768,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,211.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,574.472,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4595.41,14.42,,26.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,23901.26,75,,12482.272,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,8290.248,Percent of Total Billed Charges,50% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,8290.248,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,28.896,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,28171,100,,2194.728,Fee Schedule,100% of ASC Tier Groupings fee schedule,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,4461.57,14,,25.456,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,31868.34,100,,16643.024,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,51326.7,
IR PTA MECHANICAL THROM,46100084,CDM,361,RC,36905,HCPCS,Outpatient,,,24355.28,14613.17,,9364,100,,180,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,82.768,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2934.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,60.83,32,,62.768,Percent of Total Billed Charges,32% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,3772.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,3772.728,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,3772.728,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,396,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,574.472,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3512.03,14.42,,34.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,18266.46,75,,9111.872,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,4319.448,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,3302.744,Fee Schedule,100% of ASC Tier Groupings fee schedule,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,3409.74,14,,33.48,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,24355.28,100,,12149.16,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,31905.31,
IR MECHANICAL THROM PERC,46100085,CDM,361,RC,36904,HCPCS,Outpatient,,,11368.61,6821.17,,7803,100,,3763.104,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,809.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,60.83,32,,62.928,Percent of Total Billed Charges,32% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,1040.952,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,1040.952,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,1040.952,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,396,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,574.472,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1639.35,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,8526.46,75,,9111.872,Percent of Total Billed Charges,75% of Total Billed Charges,5684.31,50,,8290.248,Percent of Total Billed Charges,50% of Total Billed Charges,5684.31,50,,85.304,Percent of Total Billed Charges,50% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5684.31,50,,85.304,Percent of Total Billed Charges,50% of Total Billed Charges,5684.31,50,,3850.392,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,3386.352,Fee Schedule,100% of ASC Tier Groupings fee schedule,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1591.61,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11368.61,100,,12149.16,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,15951.59,
IR STENT DIALYSIS CIRCUIT,46100086,CDM,361,RC,36903,HCPCS,Outpatient,,,31008,18604.80,,9364,100,,331.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,115.888,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,6768.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,60.85,32,,63,Percent of Total Billed Charges,32% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,8702.664,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,8702.664,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,8702.664,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,385.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,338.496,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4471.35,14.42,,151.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,23256,75,,9111.872,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,142.032,Percent of Total Billed Charges,50% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,142.032,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,2447.28,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,2084.664,Fee Schedule,100% of ASC Tier Groupings fee schedule,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,4341.12,14,,147.36,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,31008,100,,12149.16,Percent of Total Billed Charges,100% of Total Billed Charges,60.85,31905.31,
IR PTA DIALYSIS CIRCUIT,46100088,CDM,361,RC,36902,HCPCS,Outpatient,,,15628,9376.80,,9364,100,,331.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,4512.488,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,60.96,32,,63.04,Percent of Total Billed Charges,32% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,5801.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,5801.768,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,5801.768,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,385.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,183.936,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2253.56,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11721,75,,9111.872,Percent of Total Billed Charges,75% of Total Billed Charges,7814,50,,85.304,Percent of Total Billed Charges,50% of Total Billed Charges,7814,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7814,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,7814,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,1389.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2187.92,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15628,100,,12149.16,Percent of Total Billed Charges,100% of Total Billed Charges,60.96,15951.59,
IR CATH INTRO DIALYSIS CIR,46100089,CDM,361,RC,36901,HCPCS,Outpatient,,,2990.98,1794.59,,2601,100,,331.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,262.48,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.16,233,,4512.488,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.2,32,,63.04,Percent of Total Billed Charges,32% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1846.54,322,,5801.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1846.54,322,,5801.768,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1846.54,322,,5801.768,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,288,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,551.816,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,431.3,14.42,,37,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2243.24,75,,9111.872,Percent of Total Billed Charges,75% of Total Billed Charges,1495.49,50,,142.032,Percent of Total Billed Charges,50% of Total Billed Charges,1495.49,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1495.49,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,1495.49,50,,1313.488,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,700.472,Fee Schedule,100% of ASC Tier Groupings fee schedule,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,35.928,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2990.98,100,,12149.16,Percent of Total Billed Charges,100% of Total Billed Charges,61.2,2990.98,
IR CATH INTRO DIALYSIS CIR,46100090,CDM,361,RC,36901,HCPCS,Outpatient,,,2990.98,1794.59,,2601,100,,331.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,262.48,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.16,233,,440.24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.21,32,,63.04,Percent of Total Billed Charges,32% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1846.54,322,,566.024,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1846.54,322,,566.024,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1846.54,322,,566.024,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,288,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,257.536,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,431.3,14.42,,51.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2243.24,75,,8125.2,Percent of Total Billed Charges,75% of Total Billed Charges,1495.49,50,,487.304,Percent of Total Billed Charges,50% of Total Billed Charges,1495.49,50,,957.6,Percent of Total Billed Charges,50% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1495.49,50,,957.6,Percent of Total Billed Charges,50% of Total Billed Charges,1495.49,50,,2914.736,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1299.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,418.74,14,,49.84,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2990.98,100,,10833.6,Percent of Total Billed Charges,100% of Total Billed Charges,61.21,2990.98,
SHOCKWAVE M5 IVL CATH 5X60MM,46100092,CDM,272,RC,A4649,HCPCS,Outpatient,,,12220,7332.00,,7332,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,5499,45,,163.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3421.6,28,,553.192,Percent of Total Billed Charges,28% of Total Billed Charges,61.21,32,,63.232,Percent of Total Billed Charges,32% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,4399.2,36,,711.248,Percent of Total Billed Charges,36% of Total Billed Charges,4399.2,36,,711.248,Percent of Total Billed Charges,36% Total Bille Charges,4399.2,36,,711.248,Percent of Total Billed Charges,36% of Total Billed Charges,7332,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12220,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1762.12,14.42,,488.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9165,75,,8125.2,Percent of Total Billed Charges,75% of Total Billed Charges,6110,50,,779.68,Percent of Total Billed Charges,50% of Total Billed Charges,6110,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6110,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,6110,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8554,70,,1292.32,Percent of Total Billed Charges,70% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,1710.8,14,,474.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12220,100,,10833.6,Percent of Total Billed Charges,100% of Total Billed Charges,61.21,12220,
40-102 INARI CATH THROMB MECH,46100093,CDM,272,RC,C1757,HCPCS,Outpatient,,,12467,7480.20,,16.33,100,,1828.32,Fee Schedule,100% of Aetna Fee Schedule,5610.15,45,,163.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3490.76,28,,215.296,Percent of Total Billed Charges,28% of Total Billed Charges,61.21,32,,63.352,Percent of Total Billed Charges,32% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,4488.12,36,,276.808,Percent of Total Billed Charges,36% of Total Billed Charges,4488.12,36,,276.808,Percent of Total Billed Charges,36% Total Bille Charges,4488.12,36,,276.808,Percent of Total Billed Charges,36% of Total Billed Charges,7480.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12467,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1797.74,14.42,,15.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9350.25,75,,8125.2,Percent of Total Billed Charges,75% of Total Billed Charges,6233.5,50,,957.6,Percent of Total Billed Charges,50% of Total Billed Charges,6233.5,50,,229.152,Percent of Total Billed Charges,50% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6233.5,50,,229.152,Percent of Total Billed Charges,50% of Total Billed Charges,6233.5,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8726.9,70,,500.488,Percent of Total Billed Charges,70% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,1745.38,14,,14.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12467,100,,10833.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,12467,
PERQ TRNSCATH CLS MITRAL,46100094,CDM,480,RC,93590,HCPCS,Outpatient,,,34880.64,20928.38,,1020,60,,960.68,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,54.648,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,9766.58,28,,215.296,Percent of Total Billed Charges,28% of Total Billed Charges,61.21,32,,63.36,Percent of Total Billed Charges,32% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,12557.03,36,,276.808,Percent of Total Billed Charges,36% of Total Billed Charges,12557.03,36,,276.808,Percent of Total Billed Charges,36% Total Bille Charges,12557.03,36,,276.808,Percent of Total Billed Charges,36% of Total Billed Charges,20928.38,60,,385.944,Percent of Total Billed Charges,60% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,583.288,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,5029.79,14.42,,19.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,26160.48,75,,8125.2,Percent of Total Billed Charges,75% of Total Billed Charges,17440.32,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,17440.32,50,,933.08,Percent of Total Billed Charges,50% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,17440.32,50,,933.08,Percent of Total Billed Charges,50% of Total Billed Charges,17440.32,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,8901.616,Case Rate,Pays based on per visit rate,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,4883.29,14,,18.824,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,34880.64,100,,10833.6,Percent of Total Billed Charges,100% of Total Billed Charges,61.21,34880.64,
TRLUML BAL ANGIOP ADDL VEIN,46100096,CDM,361,RC,37249,HCPCS,Outpatient,,,4583.88,2750.33,,2601,100,,1127.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2062.75,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.512,Other,Not Seperately Reimbusable,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2750.33,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4583.88,100,,364.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,661,14.42,,43.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3437.91,75,,15907.752,Percent of Total Billed Charges,75% of Total Billed Charges,2291.94,50,,229.152,Percent of Total Billed Charges,50% of Total Billed Charges,2291.94,50,,863.496,Percent of Total Billed Charges,50% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2291.94,50,,863.496,Percent of Total Billed Charges,50% of Total Billed Charges,2291.94,50,,2414.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,8901.616,Fee Schedule,100% of ASC Tier Groupings fee schedule,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,641.74,14,,42.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4583.88,100,,21210.336,Percent of Total Billed Charges,100% of Total Billed Charges,641.74,4583.88,
IR PTA ARTERIES INITIAL RT,46100097,CDM,361,RC,37246,HCPCS,Outpatient,,,12845.75,7707.45,,9364,100,,3763.104,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,279.672,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,1467.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.21,32,,63.512,Percent of Total Billed Charges,32% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,1886.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,1886.4,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,1886.4,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,384.96,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,364.344,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1852.36,14.42,,122.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,9634.31,75,,15907.752,Percent of Total Billed Charges,75% of Total Billed Charges,6422.88,50,,933.08,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,312,Percent of Total Billed Charges,50% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6422.88,50,,312,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,13352.424,Fee Schedule,100% of ASC Tier Groupings fee schedule,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,118.976,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12845.75,100,,21210.336,Percent of Total Billed Charges,100% of Total Billed Charges,61.21,15951.59,
TRLUML BAL ANGIOP ADDL ART,46100098,CDM,361,RC,37247,HCPCS,Outpatient,,,6423.32,3853.99,,2601,100,,188.584,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2890.49,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.552,Other,Not Seperately Reimbusable,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3853.99,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6423.32,100,,121.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,926.24,14.42,,36.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4817.49,75,,15907.752,Percent of Total Billed Charges,75% of Total Billed Charges,3211.66,50,,863.496,Percent of Total Billed Charges,50% of Total Billed Charges,3211.66,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3211.66,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,3211.66,50,,1179.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,7207.576,Fee Schedule,100% of ASC Tier Groupings fee schedule,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,899.26,14,,34.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6423.32,100,,21210.336,Percent of Total Billed Charges,100% of Total Billed Charges,899.26,6423.32,
TRLUML BAL ANGIOP 1ST VEIN,46100099,CDM,361,RC,37248,HCPCS,Outpatient,,,12402.23,7441.34,,9364,100,,328.232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,279.672,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,3217.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.21,32,,63.656,Percent of Total Billed Charges,32% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,4136.32,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,4136.32,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,4136.32,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,9064,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,1671.424,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1788.4,14.42,,20.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,9301.67,75,,15907.752,Percent of Total Billed Charges,75% of Total Billed Charges,6201.12,50,,312,Percent of Total Billed Charges,50% of Total Billed Charges,6201.12,50,,145.976,Percent of Total Billed Charges,50% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6201.12,50,,145.976,Percent of Total Billed Charges,50% of Total Billed Charges,6201.12,50,,8290.248,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,7207.576,Fee Schedule,100% of ASC Tier Groupings fee schedule,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,1736.31,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12402.23,100,,21210.336,Percent of Total Billed Charges,100% of Total Billed Charges,61.21,15951.59,
TRLUML BAL ANGIOP 1ST ART,46100100,CDM,361,RC,37246,HCPCS,Outpatient,,,12845.75,7707.45,,9364,100,,327.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,268.912,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,5127.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.28,32,,63.808,Percent of Total Billed Charges,32% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,6592.848,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,6592.848,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,6592.848,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,637.792,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,621.488,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1852.36,14.42,,13.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,9634.31,75,,15907.752,Percent of Total Billed Charges,75% of Total Billed Charges,6422.88,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,146.296,Percent of Total Billed Charges,50% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6422.88,50,,146.296,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,10811.36,Fee Schedule,100% of ASC Tier Groupings fee schedule,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12845.75,100,,21210.336,Percent of Total Billed Charges,100% of Total Billed Charges,61.28,15951.59,
TRLUML BAL ANGIOP BIL,46100101,CDM,361,RC,37246,HCPCS,Outpatient,,,19268.63,11561.18,,9364,100,,33.224,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,93.224,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,6580.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.33,32,,63.808,Percent of Total Billed Charges,32% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,8460.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,8460.768,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,8460.768,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,29112.968,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,621.488,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2778.54,14.42,,55.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,14451.47,75,,14353.528,Percent of Total Billed Charges,75% of Total Billed Charges,9634.32,50,,145.976,Percent of Total Billed Charges,50% of Total Billed Charges,9634.32,50,,592.744,Percent of Total Billed Charges,50% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9634.32,50,,592.744,Percent of Total Billed Charges,50% of Total Billed Charges,9634.32,50,,85.304,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,16597.16,Fee Schedule,100% of ASC Tier Groupings fee schedule,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,2697.61,14,,53.888,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,19268.63,100,,19138.032,Percent of Total Billed Charges,100% of Total Billed Charges,61.33,19268.63,
TRLUML BAL ANGIOP LT,46100102,CDM,361,RC,37246,HCPCS,Outpatient,,,12845.75,7707.45,,9364,100,,56.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,723.208,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,4387.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,61.49,32,,63.984,Percent of Total Billed Charges,32% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,5640.512,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,5640.512,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,5640.512,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,287.616,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,621.488,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1852.36,14.42,,648.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,9634.31,75,,14353.528,Percent of Total Billed Charges,75% of Total Billed Charges,6422.88,50,,146.296,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,1586,Percent of Total Billed Charges,50% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6422.88,50,,1586,Percent of Total Billed Charges,50% of Total Billed Charges,6422.88,50,,142.032,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,16597.16,Fee Schedule,100% of ASC Tier Groupings fee schedule,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,1798.41,14,,629.656,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12845.75,100,,19138.032,Percent of Total Billed Charges,100% of Total Billed Charges,61.49,15951.59,
FT-PPP INARI SYSTEM THROMBECTOMY,46100124,CDM,272,RC,C1757,HCPCS,Outpatient,,,18000,10800.00,,16.33,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,8100,45,,1542.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5040,28,,1680,Percent of Total Billed Charges,28% of Total Billed Charges,61.49,32,,6613.864,Percent of Total Billed Charges,32% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,6480,36,,2160,Percent of Total Billed Charges,36% of Total Billed Charges,6480,36,,2160,Percent of Total Billed Charges,36% Total Bille Charges,6480,36,,2160,Percent of Total Billed Charges,36% of Total Billed Charges,10800,60,,7245.992,Percent of Total Billed Charges,60% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18000,100,,1371.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2595.6,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13500,75,,16177.28,Percent of Total Billed Charges,75% of Total Billed Charges,9000,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,9000,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9000,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,9000,50,,229.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12600,70,,739.2,Percent of Total Billed Charges,70% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2520,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18000,100,,21569.704,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,18000,
DSF-2033 DRYSEAL FLEX 20FR SHEATH,46100125,CDM,272,RC,A4649,HCPCS,Outpatient,,,1950,1170.00,,1170,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,877.5,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546,28,,1120,Percent of Total Billed Charges,28% of Total Billed Charges,61.68,32,,6613.864,Percent of Total Billed Charges,32% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,702,36,,1440,Percent of Total Billed Charges,36% of Total Billed Charges,702,36,,1440,Percent of Total Billed Charges,36% Total Bille Charges,702,36,,1440,Percent of Total Billed Charges,36% of Total Billed Charges,1170,60,,110.112,Percent of Total Billed Charges,60% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1950,100,,475.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,281.19,14.42,,304.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1462.5,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,975,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,975,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,975,50,,933.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365,70,,739.2,Percent of Total Billed Charges,70% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,273,14,,295.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1950,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,61.68,1950,
TACK SYSTEM 1.5-4.5X6MM,46100126,CDM,272,RC,A4649,HCPCS,Outpatient,,,5707,3424.20,,3424.2,60,,417.56,Percent of Total Billed Charges,60% of Total Billed Charges,2568.15,45,,283.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1597.96,28,,1120,Percent of Total Billed Charges,28% of Total Billed Charges,62.4,32,,6.424,Percent of Total Billed Charges,32% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,2054.52,36,,1440,Percent of Total Billed Charges,36% of Total Billed Charges,2054.52,36,,1440,Percent of Total Billed Charges,36% Total Bille Charges,2054.52,36,,1440,Percent of Total Billed Charges,36% of Total Billed Charges,3424.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5707,100,,1352.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,822.95,14.42,,351.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4280.25,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,2853.5,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,2853.5,50,,179.944,Percent of Total Billed Charges,50% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2853.5,50,,179.944,Percent of Total Billed Charges,50% of Total Billed Charges,2853.5,50,,863.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3994.9,70,,2338.512,Percent of Total Billed Charges,70% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,341.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5707,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,62.4,5707,
TACK SYSTEM 4-8X8MM,46100128,CDM,272,RC,A4649,HCPCS,Outpatient,,,7787,4672.20,,4672.2,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,3504.15,45,,977.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2180.36,28,,1316.832,Percent of Total Billed Charges,28% of Total Billed Charges,62.4,32,,6.448,Percent of Total Billed Charges,32% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,2803.32,36,,1693.072,Percent of Total Billed Charges,36% of Total Billed Charges,2803.32,36,,1693.072,Percent of Total Billed Charges,36% Total Bille Charges,2803.32,36,,1693.072,Percent of Total Billed Charges,36% of Total Billed Charges,4672.2,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7787,100,,3428.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1122.89,14.42,,98.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5840.25,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,3893.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3893.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5450.9,70,,2338.512,Percent of Total Billed Charges,70% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,96.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7787,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,62.4,7787,
ANGIO CORS W GRAFTS W LHC,46100130,CDM,481,RC,93459,HCPCS,Outpatient,,,18404,11042.40,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,904.792,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5153.12,28,,877.888,Percent of Total Billed Charges,28% of Total Billed Charges,62.55,32,,6.448,Percent of Total Billed Charges,32% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,6625.44,36,,1128.712,Percent of Total Billed Charges,36% of Total Billed Charges,6625.44,36,,1128.712,Percent of Total Billed Charges,36% Total Bille Charges,6625.44,36,,1128.712,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,2253.224,Percent of Total Billed Charges,60% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,1426.608,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2653.86,14.42,,46.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,13803,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,179.944,Case Rate,Pays Based on per visit rate,9500,100,,101.6,Case Rate,Pays based on per visit rate,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,101.6,Case Rate,Pays based on per visit rate,9500,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,3507.76,Fee Schedule,100% of ASC Tier Groupings fee schedule,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2576.56,14,,44.8,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18404,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,62.55,18404,
RESOLUTE ONYX RX STENT,46100131,CDM,272,RC,C1874,HCPCS,Outpatient,,,2665,1599.00,,492.41,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,1199.25,45,,486,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,746.2,28,,877.888,Percent of Total Billed Charges,28% of Total Billed Charges,62.8,32,,6.448,Percent of Total Billed Charges,32% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,959.4,36,,1128.712,Percent of Total Billed Charges,36% of Total Billed Charges,959.4,36,,1128.712,Percent of Total Billed Charges,36% Total Bille Charges,959.4,36,,1128.712,Percent of Total Billed Charges,36% of Total Billed Charges,1599,60,,591.776,Percent of Total Billed Charges,60% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2665,100,,629.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,384.29,14.42,,35.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.75,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,1332.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,1332.5,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.5,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,1332.5,50,,145.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1865.5,70,,1317.288,Percent of Total Billed Charges,70% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,373.1,14,,34.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2665,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,62.8,2665,
INDIGO CATHETER W/KIT,46100132,CDM,272,RC,C1887,HCPCS,Outpatient,,,6942,4165.20,,43.86,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3123.9,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1943.76,28,,1321.096,Percent of Total Billed Charges,28% of Total Billed Charges,62.84,32,,6.464,Percent of Total Billed Charges,32% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2499.12,36,,1698.552,Percent of Total Billed Charges,36% of Total Billed Charges,2499.12,36,,1698.552,Percent of Total Billed Charges,36% Total Bille Charges,2499.12,36,,1698.552,Percent of Total Billed Charges,36% of Total Billed Charges,4165.2,60,,591.776,Percent of Total Billed Charges,60% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6942,100,,2173.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1001.04,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5206.5,75,,18309.896,Percent of Total Billed Charges,75% of Total Billed Charges,3471,50,,101.6,Percent of Total Billed Charges,50% of Total Billed Charges,3471,50,,1264.672,Percent of Total Billed Charges,50% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3471,50,,1264.672,Percent of Total Billed Charges,50% of Total Billed Charges,3471,50,,146.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4859.4,70,,1317.288,Percent of Total Billed Charges,70% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,971.88,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6942,100,,24413.192,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,6942,
INDIGO CATHETER,46100133,CDM,272,RC,C1887,HCPCS,Outpatient,,,13540,8124.00,,43.86,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,6093,45,,207.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3791.2,28,,1354.544,Percent of Total Billed Charges,28% of Total Billed Charges,63,32,,6.608,Percent of Total Billed Charges,32% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,4874.4,36,,1741.552,Percent of Total Billed Charges,36% of Total Billed Charges,4874.4,36,,1741.552,Percent of Total Billed Charges,36% Total Bille Charges,4874.4,36,,1741.552,Percent of Total Billed Charges,36% of Total Billed Charges,8124,60,,4486.68,Percent of Total Billed Charges,60% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13540,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1952.47,14.42,,286.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10155,75,,14016.904,Percent of Total Billed Charges,75% of Total Billed Charges,6770,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,6770,50,,133.072,Percent of Total Billed Charges,50% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6770,50,,133.072,Percent of Total Billed Charges,50% of Total Billed Charges,6770,50,,592.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9478,70,,1975.928,Percent of Total Billed Charges,70% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,1895.6,14,,277.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13540,100,,18689.2,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,13540,
INDIGO SEPARATOR,46100134,CDM,272,RC,C1757,HCPCS,Outpatient,,,4927,2956.20,,16.33,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2217.15,45,,3801.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1379.56,28,,833.864,Percent of Total Billed Charges,28% of Total Billed Charges,63.25,32,,64,Percent of Total Billed Charges,32% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,1773.72,36,,1072.112,Percent of Total Billed Charges,36% of Total Billed Charges,1773.72,36,,1072.112,Percent of Total Billed Charges,36% Total Bille Charges,1773.72,36,,1072.112,Percent of Total Billed Charges,36% of Total Billed Charges,2956.2,60,,546.752,Percent of Total Billed Charges,60% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4927,100,,1080,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,710.47,14.42,,89.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3695.25,75,,507.152,Percent of Total Billed Charges,75% of Total Billed Charges,2463.5,50,,1264.672,Percent of Total Billed Charges,50% of Total Billed Charges,2463.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2463.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2463.5,50,,1586,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3448.9,70,,728.592,Percent of Total Billed Charges,70% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,689.78,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4927,100,,676.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,4927,
STEERABLE INTRDCR SHEATH 12F X 65MM,46100135,CDM,272,RC,C1893,HCPCS,Outpatient,,,2797,1678.20,,9.31,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,1258.65,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,783.16,28,,555.912,Percent of Total Billed Charges,28% of Total Billed Charges,63.28,32,,64,Percent of Total Billed Charges,32% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1006.92,36,,714.744,Percent of Total Billed Charges,36% of Total Billed Charges,1006.92,36,,714.744,Percent of Total Billed Charges,36% Total Bille Charges,1006.92,36,,714.744,Percent of Total Billed Charges,36% of Total Billed Charges,1678.2,60,,3738.904,Percent of Total Billed Charges,60% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2797,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,403.33,14.42,,95.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097.75,75,,497.536,Percent of Total Billed Charges,75% of Total Billed Charges,1398.5,50,,133.072,Percent of Total Billed Charges,50% of Total Billed Charges,1398.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1398.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1398.5,50,,101.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1957.9,70,,728.592,Percent of Total Billed Charges,70% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,391.58,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2797,100,,663.384,Percent of Total Billed Charges,100% of Total Billed Charges,9.31,2797,
PENUMBRA ENGINE CANISTER IAPS3,46100136,CDM,272,RC,,,Outpatient,,,1050,630.00,,630,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,45,,916.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,28,,280.192,Percent of Total Billed Charges,28% of Total Billed Charges,63.52,32,,64.128,Percent of Total Billed Charges,32% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,378,36,,360.24,Percent of Total Billed Charges,36% of Total Billed Charges,378,36,,360.24,Percent of Total Billed Charges,36% Total Bille Charges,378,36,,360.24,Percent of Total Billed Charges,36% of Total Billed Charges,630,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050,100,,461.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,151.41,14.42,,89.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.5,75,,855.016,Percent of Total Billed Charges,75% of Total Billed Charges,525,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,525,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,525,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735,70,,2160.904,Percent of Total Billed Charges,70% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,147,14,,86.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,100,,1140.016,Percent of Total Billed Charges,100% of Total Billed Charges,63.52,1050,
HI-TORQUE COMMAND GUIDEWIRE,46100138,CDM,272,RC,C1769,HCPCS,Outpatient,,,540,324.00,,55.13,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,243,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.2,28,,519.68,Percent of Total Billed Charges,28% of Total Billed Charges,63.65,32,,64.216,Percent of Total Billed Charges,32% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,194.4,36,,668.16,Percent of Total Billed Charges,36% of Total Billed Charges,194.4,36,,668.16,Percent of Total Billed Charges,36% Total Bille Charges,194.4,36,,668.16,Percent of Total Billed Charges,36% of Total Billed Charges,324,60,,1021.024,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,100,,8447.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,77.87,14.42,,155.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,270,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,1632.8,Percent of Total Billed Charges,50% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,50,,1632.8,Percent of Total Billed Charges,50% of Total Billed Charges,270,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,70,,2160.904,Percent of Total Billed Charges,70% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.6,14,,151.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,540,
RAD PAD,46100139,CDM,272,RC,A4649,HCPCS,Outpatient,,,175,105.00,,105,60,,2411.4,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,45,,208.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,28,,516.928,Percent of Total Billed Charges,28% of Total Billed Charges,63.65,32,,64.448,Percent of Total Billed Charges,32% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,63,36,,664.624,Percent of Total Billed Charges,36% of Total Billed Charges,63,36,,664.624,Percent of Total Billed Charges,36% Total Bille Charges,63,36,,664.624,Percent of Total Billed Charges,36% of Total Billed Charges,105,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,25.24,14.42,,679.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.25,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,87.5,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,90.912,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,50,,90.912,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.5,70,,3241.352,Percent of Total Billed Charges,70% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,659.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,24.5,175,
ABRE VENOUS STENT,46100140,CDM,481,RC,C1876,HCPCS,Outpatient,,,4810,2886.00,,1431.75,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,2164.5,45,,1651.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1346.8,28,,200.192,Percent of Total Billed Charges,28% of Total Billed Charges,63.95,32,,64.512,Percent of Total Billed Charges,32% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,1731.6,36,,257.392,Percent of Total Billed Charges,36% of Total Billed Charges,1731.6,36,,257.392,Percent of Total Billed Charges,36% Total Bille Charges,1731.6,36,,257.392,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1090.32,Percent of Total Billed Charges,60% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4810,100,,2037.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,693.6,14.42,,735.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3607.5,75,,1429.464,Percent of Total Billed Charges,75% of Total Billed Charges,2405,50,,1632.8,Percent of Total Billed Charges,50% of Total Billed Charges,2405,50,,119.584,Percent of Total Billed Charges,50% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2405,50,,119.584,Percent of Total Billed Charges,50% of Total Billed Charges,2405,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3367,70,,850.024,Percent of Total Billed Charges,70% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,673.4,14,,713.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4810,100,,1786.832,Percent of Total Billed Charges,100% of Total Billed Charges,63.95,11330,
QUICKCLEAR THROMB SYSTEM,46100141,CDM,272,RC,C1887,HCPCS,Outpatient,,,13000,7800.00,,43.86,100,,2232.416,Fee Schedule,100% of Aetna Fee Schedule,5850,45,,1176.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,3560.648,Percent of Total Billed Charges,28% of Total Billed Charges,63.99,32,,64.592,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,4577.976,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,4577.976,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,4577.976,Percent of Total Billed Charges,36% of Total Billed Charges,7800,60,,1090.32,Percent of Total Billed Charges,60% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,1003.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9750,75,,1013.584,Percent of Total Billed Charges,75% of Total Billed Charges,6500,50,,90.912,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,1280.656,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,974.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,1266.984,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,13000,
ANGIO CORS W HRT CATH RT,46100142,CDM,481,RC,93456,HCPCS,Outpatient,,,17253.66,10352.20,,9364,100,,2232.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,907.136,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4831.02,28,,3560.648,Percent of Total Billed Charges,28% of Total Billed Charges,640,32,,64.696,Percent of Total Billed Charges,32% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,6211.32,36,,4577.976,Percent of Total Billed Charges,36% of Total Billed Charges,6211.32,36,,4577.976,Percent of Total Billed Charges,36% Total Bille Charges,6211.32,36,,4577.976,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1232,Percent of Total Billed Charges,60% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,464,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2487.98,14.42,,1114.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,12940.25,75,,64.8,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,119.584,Case Rate,Pays Based on per visit rate,9500,100,,526.288,Case Rate,Pays based on per visit rate,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,526.288,Case Rate,Pays based on per visit rate,9500,50,,179.944,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,1280.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,1082.256,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17253.66,100,,86.4,Percent of Total Billed Charges,100% of Total Billed Charges,640,17253.66,
HEART CATH LEFT,46100143,CDM,481,RC,93452,HCPCS,Outpatient,,,11558.33,6935.00,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,202.752,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.33,28,,5340.968,Percent of Total Billed Charges,28% of Total Billed Charges,640.34,32,,64.904,Percent of Total Billed Charges,32% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,4161,36,,6866.96,Percent of Total Billed Charges,36% of Total Billed Charges,4161,36,,6866.96,Percent of Total Billed Charges,36% Total Bille Charges,4161,36,,6866.96,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,922.68,Percent of Total Billed Charges,60% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,3670.92,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1666.71,14.42,,508.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,8668.75,75,,114.088,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,60,Case Rate,Pays Based on per visit rate,9500,100,,60,Case Rate,Pays based on per visit rate,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,60,Case Rate,Pays based on per visit rate,9500,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,291.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,493.584,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11558.33,100,,152.12,Percent of Total Billed Charges,100% of Total Billed Charges,640.34,11558.33,
GEL SPONGE,46100144,CDM,272,RC,,,Outpatient,,,73.2,43.92,,43.92,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,32.94,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.5,28,,2883.032,Percent of Total Billed Charges,28% of Total Billed Charges,642.46,32,,64.904,Percent of Total Billed Charges,32% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,26.35,36,,3706.752,Percent of Total Billed Charges,36% of Total Billed Charges,26.35,36,,3706.752,Percent of Total Billed Charges,36% Total Bille Charges,26.35,36,,3706.752,Percent of Total Billed Charges,36% of Total Billed Charges,43.92,60,,5607.688,Percent of Total Billed Charges,60% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.2,100,,2613.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.56,14.42,,13.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,75,,22.6,Percent of Total Billed Charges,75% of Total Billed Charges,36.6,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.6,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,101.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.24,70,,69.808,Percent of Total Billed Charges,70% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.2,100,,30.136,Percent of Total Billed Charges,100% of Total Billed Charges,10.25,642.46,
CATH EXIMO ATHERECTOMY,46100145,CDM,272,RC,C1885,HCPCS,Outpatient,,,7007,4204.20,,443.13,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3153.15,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1961.96,28,,2883.032,Percent of Total Billed Charges,28% of Total Billed Charges,642.85,32,,64.928,Percent of Total Billed Charges,32% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,2522.52,36,,3706.752,Percent of Total Billed Charges,36% of Total Billed Charges,2522.52,36,,3706.752,Percent of Total Billed Charges,36% Total Bille Charges,2522.52,36,,3706.752,Percent of Total Billed Charges,36% of Total Billed Charges,4204.2,60,,2658.136,Percent of Total Billed Charges,60% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7007,100,,2015.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,1010.41,14.42,,34.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5255.25,75,,1344,Percent of Total Billed Charges,75% of Total Billed Charges,3503.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,3503.5,50,,178,Percent of Total Billed Charges,50% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3503.5,50,,178,Percent of Total Billed Charges,50% of Total Billed Charges,3503.5,50,,140.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4904.9,70,,286.656,Percent of Total Billed Charges,70% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,980.98,14,,33.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7007,100,,1680,Percent of Total Billed Charges,100% of Total Billed Charges,443.13,7007,
ICD BIOTRONIK,46100146,CDM,275,RC,C1722,HCPCS,Outpatient,,,41600.5,24960.30,,49749.35,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,18720.23,45,,49.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11648.14,28,,4324.544,Percent of Total Billed Charges,28% of Total Billed Charges,643.5,32,,65.024,Percent of Total Billed Charges,32% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,14976.18,36,,5560.128,Percent of Total Billed Charges,36% of Total Billed Charges,14976.18,36,,5560.128,Percent of Total Billed Charges,36% Total Bille Charges,14976.18,36,,5560.128,Percent of Total Billed Charges,36% of Total Billed Charges,22880.28,55,,922.68,Percent of Total Billed Charges,55% Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41600.5,100,,450.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5998.79,14.42,,47.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31200.38,75,,350.856,Percent of Total Billed Charges,75% of Total Billed Charges,20800.25,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,20800.25,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20800.25,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,20800.25,50,,1264.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29120.35,70,,170.944,Percent of Total Billed Charges,70% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,5824.07,14,,46.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41600.5,100,,467.808,Percent of Total Billed Charges,100% of Total Billed Charges,643.5,49749.35,
LEAD ICD BIOTRONIK,46100147,CDM,275,RC,C1777,HCPCS,Outpatient,,,11003.85,6602.31,,12902.69,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,4951.73,45,,811.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3081.08,28,,6638.864,Percent of Total Billed Charges,28% of Total Billed Charges,647.04,32,,65.024,Percent of Total Billed Charges,32% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,3961.39,36,,8535.68,Percent of Total Billed Charges,36% of Total Billed Charges,3961.39,36,,8535.68,Percent of Total Billed Charges,36% Total Bille Charges,3961.39,36,,8535.68,Percent of Total Billed Charges,36% of Total Billed Charges,6052.12,55,,3688.4,Percent of Total Billed Charges,55% Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11003.85,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1586.76,14.42,,181.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8252.89,75,,672.472,Percent of Total Billed Charges,75% of Total Billed Charges,5501.93,50,,178,Percent of Total Billed Charges,50% of Total Billed Charges,5501.93,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5501.93,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,5501.93,50,,133.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7702.7,70,,67.2,Percent of Total Billed Charges,70% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,1540.54,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11003.85,100,,896.632,Percent of Total Billed Charges,100% of Total Billed Charges,647.04,12902.69,
ONYX FRONTIER STENT,46100148,CDM,278,RC,C1874,HCPCS,Outpatient,,,1875,1125.00,,2554.91,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,843.75,45,,748.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,28,,6638.864,Percent of Total Billed Charges,28% of Total Billed Charges,648.12,32,,65.384,Percent of Total Billed Charges,32% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,675,36,,8535.68,Percent of Total Billed Charges,36% of Total Billed Charges,675,36,,8535.68,Percent of Total Billed Charges,36% Total Bille Charges,675,36,,8535.68,Percent of Total Billed Charges,36% of Total Billed Charges,1031.25,55,,3335.6,Percent of Total Billed Charges,55% Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1875,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,270.38,14.42,,1499.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1500,80,,1748.208,Percent of Total Billed Charges,80% of Total Billed Charges,937.5,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,937.5,50,,67.24,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,937.5,50,,67.24,Percent of Total Billed Charges,50% of Total Billed Charges,937.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1312.5,70,,453.6,Percent of Total Billed Charges,70% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,262.5,14,,1456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1875,100,,2185.264,Percent of Total Billed Charges,100% of Total Billed Charges,262.5,2554.91,
ATH/PTA ILIAC RIGHT,46100149,CDM,361,RC,0238T,HCPCS,Outpatient,,,29637.79,17782.67,,4738.21,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,24131.69,150,,525.168,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,69.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,648.48,32,,65.536,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,88.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,88.92,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,88.92,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,2360.016,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,109.6,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,150.84,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,150.84,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,420,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,648.48,51326.7,
ATH/PTA ILIAC LEFT,46100150,CDM,361,RC,0238T,HCPCS,Outpatient,,,29637.79,17782.67,,4738.21,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,24131.69,150,,552.856,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,373.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,650.5,32,,65.536,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,480.168,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,480.168,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,480.168,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,2134.28,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1803.216,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,898.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,482.432,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,67.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,424.928,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,424.928,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,224.536,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,643.24,Percent of Total Billed Charges,100% of Total Billed Charges,650.5,51326.7,
ATH/PTA ILIAC BILATERAL,46100151,CDM,361,RC,0238T,HCPCS,Outpatient,,,44456.68,26674.01,,4738.21,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,24131.69,150,,829.288,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,3126.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,655.35,32,,65.536,Percent of Total Billed Charges,32% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,4019.184,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,4019.184,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,4019.184,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,5622.52,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1662.912,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6410.65,14.42,,43.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,33342.51,75,,873.24,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,150.84,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,124.848,Percent of Total Billed Charges,50% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,124.848,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,1632.8,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,212.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,44456.68,100,,1091.552,Percent of Total Billed Charges,100% of Total Billed Charges,655.35,51326.7,
PTA AORTA,46100152,CDM,361,RC,37246,HCPCS,Outpatient,,,20500,12300.00,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7865.86,150,,497.056,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,295.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,662.4,32,,65.536,Percent of Total Billed Charges,32% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,380.16,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,4514.376,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,1167.04,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2956.1,14.42,,323.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,15375,75,,224.536,Percent of Total Billed Charges,75% of Total Billed Charges,10250,50,,424.928,Percent of Total Billed Charges,50% of Total Billed Charges,10250,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10250,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,10250,50,,90.912,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,40.992,Fee Schedule,100% of ASC Tier Groupings fee schedule,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,2870,14,,313.6,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,20500,100,,299.376,Percent of Total Billed Charges,100% of Total Billed Charges,662.4,20500,
IR FEMPOP IVL W ANGPLAS W ATHER LT,46100153,CDM,361,RC,C9766,HCPCS,Outpatient,,,29637.79,17782.67,,17782.67,60,,2358.72,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,745.576,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,295.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,380.16,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,17782.67,60,,6102.056,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1228.568,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,25.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,2060.952,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,124.848,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,119.584,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,212.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,25.2,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,2747.936,Percent of Total Billed Charges,100% of Total Billed Charges,662.5,31905.31,
IR FEMPOP IVL W ANGPLAS W ATHER RT,46100154,CDM,361,RC,C9766,HCPCS,Outpatient,,,29637.79,17782.67,,17782.67,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,508.648,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,295.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,380.16,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,380.16,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,17782.67,60,,6102.056,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1842.856,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,16.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,135.36,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,495.608,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,16.24,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,180.48,Percent of Total Billed Charges,100% of Total Billed Charges,662.5,31905.31,
IR FEMPOP W/STENT AND ATHER/LITHO RT,46100155,CDM,361,RC,C9767,HCPCS,Outpatient,,,52294.79,31376.87,,31376.87,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,762.968,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,935.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,1202.664,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,1202.664,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,1202.664,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,31376.87,60,,2029.912,Percent of Total Billed Charges,60% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1104.56,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7540.91,14.42,,49.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,39221.09,75,,1154.904,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,2248.784,Percent of Total Billed Charges,50% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,2248.784,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,74.416,Fee Schedule,100% of ASC Tier Groupings fee schedule,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,47.904,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,52294.79,100,,1539.872,Percent of Total Billed Charges,100% of Total Billed Charges,662.5,52294.79,
IR FEMPOP W/STENT AND ATHER/LITHO  LT,46100156,CDM,361,RC,C9767,HCPCS,Outpatient,,,52294.79,31376.87,,31376.87,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,486.312,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,935.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,1202.664,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,1202.664,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,1202.664,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,31376.87,60,,2029.912,Percent of Total Billed Charges,60% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1656.832,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7540.91,14.42,,181.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,39221.09,75,,1694,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,76.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,7321.27,14,,176.4,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,52294.79,100,,2117.504,Percent of Total Billed Charges,100% of Total Billed Charges,662.5,52294.79,
PACING WIRE TEMP INSRT,46100319,CDM,481,RC,33210,HCPCS,Outpatient,,,10141.74,6085.04,,6763,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,11691.68,150,,729.472,Fee Schedule ,150% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.69,28,,1403.104,Percent of Total Billed Charges,28% of Total Billed Charges,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,3651.03,36,,1803.992,Percent of Total Billed Charges,36% of Total Billed Charges,3651.03,36,,1803.992,Percent of Total Billed Charges,36% Total Bille Charges,3651.03,36,,1803.992,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1104.28,Percent of Total Billed Charges,60% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,1130.32,Fee Schedule,100% of CMS OPPS Rate,7015,90,,,Fee Schedule,90% of CMS OPPS Rate,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10132.79,130,,,Fee Schedule,130% of CMS OPPS Rate,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1462.44,14.42,,95.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,8028.28,103,,,Fee Schedule,103% of CMS OPPS Rate,8028.28,103,,,Fee Schedule,103% of CMS OPPS Rate,7606.31,75,,1256.288,Percent of Total Billed Charges,75% of Total Billed Charges,5070.87,50,,2248.784,Percent of Total Billed Charges,50% of Total Billed Charges,5070.87,50,,1751.048,Percent of Total Billed Charges,50% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,5070.87,50,,1751.048,Percent of Total Billed Charges,50% of Total Billed Charges,5070.87,50,,128.304,Percent of Total Billed Charges,50% of Total Billed Charges,11691.68,150,,,Fee Schedule,150% of CMS OPPS Rate,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,121.664,Fee Schedule,100% of ASC Tier Groupings fee schedule,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1419.84,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10141.74,100,,1675.048,Percent of Total Billed Charges,100% of Total Billed Charges,662.5,11691.68,
CARDIOVERSION,46100418,CDM,480,RC,92960,HCPCS,Outpatient,,,1702,1021.20,,76.18,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,509.04,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,476.56,28,,526.912,Percent of Total Billed Charges,28% of Total Billed Charges,662.5,32,,65.648,Percent of Total Billed Charges,32% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,612.72,36,,677.464,Percent of Total Billed Charges,36% of Total Billed Charges,612.72,36,,677.464,Percent of Total Billed Charges,36% Total Bille Charges,612.72,36,,677.464,Percent of Total Billed Charges,36% of Total Billed Charges,1021.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,1695.48,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,245.43,14.42,,33.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,1276.5,75,,761.008,Percent of Total Billed Charges,75% of Total Billed Charges,851,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,851,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,851,50,,178,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,121.664,Case Rate,Pays based on per visit rate,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,238.28,14,,32.48,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1702,100,,1014.672,Percent of Total Billed Charges,100% of Total Billed Charges,76.18,1702,
IABP INSRT,46100806,CDM,360,RC,,,Outpatient,,,6824,4094.40,,4094.4,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,3070.8,45,,503.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1910.72,28,,790.368,Percent of Total Billed Charges,28% of Total Billed Charges,664.09,32,,66.296,Percent of Total Billed Charges,32% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,2456.64,36,,1016.192,Percent of Total Billed Charges,36% of Total Billed Charges,2456.64,36,,1016.192,Percent of Total Billed Charges,36% Total Bille Charges,2456.64,36,,1016.192,Percent of Total Billed Charges,36% of Total Billed Charges,4094.4,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6824,100,,1621.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,984.02,14.42,,1004.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5118,75,,1670.952,Percent of Total Billed Charges,75% of Total Billed Charges,3412,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,3412,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3412,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,3412,50,,53.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4776.8,70,,1407.4,Percent of Total Billed Charges,70% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,955.36,14,,975.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6824,100,,2227.936,Percent of Total Billed Charges,100% of Total Billed Charges,664.09,6824,
IVUS CORONARY RC INI,46100814,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,755.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,291.44,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,66.448,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,374.704,Fee Schedule,360% of BCBS POS Rate,361.98,360,,374.704,Fee schedule,360% of BCBS PPO Rate,361.98,360,,374.704,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,1131.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,10.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,1355.224,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,1056.8,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,1056.8,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,67.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,344.056,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,10.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,1806.96,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
ASD CLOSURE,46100822,CDM,481,RC,93580,HCPCS,Outpatient,,,30705.75,18423.45,,10404,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,820.704,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8597.61,28,,291.44,Percent of Total Billed Charges,28% of Total Billed Charges,666.57,32,,6656,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,374.704,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,374.704,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,374.704,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,733.44,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,1696.8,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,53.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,23029.31,75,,623.744,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,1219.2,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15352.88,50,,1219.2,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,150.84,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15648,100,,733.544,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,52.088,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30705.75,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,666.57,30705.75,
IR VENOGRAM IVC W SER SI,46100830,CDM,320,RC,75825,HCPCS,Outpatient,,,3932.67,2359.60,,65.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,1231.056,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,864.36,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,6656,Fee Schedule,320% of BCBS Blue Essentials Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,1111.32,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,1111.32,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,1111.32,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,922.68,Fee Schedule,103% of Cigna fee schedule,114.28,100,,7.256,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,1119.648,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,117.71,103,,7.472,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,2949.5,75,,623.744,Percent of Total Billed Charges,75% of Total Billed Charges,1966.34,50,,1056.8,Percent of Total Billed Charges,50% of Total Billed Charges,1966.34,50,,343.2,Percent of Total Billed Charges,50% of Total Billed Charges,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1966.34,50,,343.2,Percent of Total Billed Charges,50% of Total Billed Charges,1966.34,50,,424.928,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1279.8,Case Rate,Pays based on per visit rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,7.256,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3932.67,100,,779.68,Percent of Total Billed Charges,100% of Total Billed Charges,65.43,9976.61,
IR VENOGRAM IVC W SER SI,46100830,CDM,320,RC,75825,HCPCS,Outpatient,,,3932.67,2359.60,,65.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,695.936,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,864.36,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,6656,Fee Schedule,320% of BCBS Blue Essentials Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,1111.32,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,1111.32,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,1111.32,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,922.68,Fee Schedule,103% of Cigna fee schedule,114.28,100,,40.808,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,1679.472,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,117.71,103,,42.032,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,2949.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,1966.34,50,,1219.2,Percent of Total Billed Charges,50% of Total Billed Charges,1966.34,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1966.34,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,1966.34,50,,124.848,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,706.064,Case Rate,Pays based on per visit rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,114.28,100,,40.808,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3932.67,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,65.43,9976.61,
CORONARY FLOW MEASUREMENT INI,46100897,CDM,481,RC,93571,HCPCS,Outpatient,,,4375,2625.00,,95.02,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,1968.75,45,,1043.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6732.8,Other,Not Seperately Reimbusable,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,922.68,Percent of Total Billed Charges,60% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4375,100,,1823.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,630.88,14.42,,115.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3281.25,75,,1108.576,Percent of Total Billed Charges,75% of Total Billed Charges,2187.5,50,,343.2,Percent of Total Billed Charges,50% of Total Billed Charges,2187.5,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2187.5,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,2187.5,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1227.36,Fee Schedule,100% of ASC Tier Groupings fee schedule,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,612.5,14,,112.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4375,100,,1478.104,Percent of Total Billed Charges,100% of Total Billed Charges,95.02,11330,
IR VENOGRAM SVC W SER SI,46101002,CDM,320,RC,75827,HCPCS,Outpatient,,,2579,1547.40,TC   ,70.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2204.02,150,,135,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.43,280,,340.008,Fee Schedule,280% of BCBS BULE Fee Schedule,2017.63,320,,6787.304,Fee Schedule,320% of BCBS Blue Essentials Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,2269.84,360,,437.152,Fee Schedule,360% of BCBS POS Rate,2269.84,360,,437.152,Fee schedule,360% of BCBS PPO Rate,2269.84,360,,437.152,Fee Schedule,360% of BCBS Traditional Rate,1885.49,103,,990,Fee Schedule,103% of Cigna fee schedule,119.63,100,,474.32,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,2735.68,Fee Schedule,100% of CMS OPPS Rate,1322.41,90,,,Fee Schedule,90% of CMS OPPS Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.15,130,,,Fee Schedule,130% of CMS OPPS Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,123.22,103,,488.552,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1934.25,75,,159.216,Percent of Total Billed Charges,75% of Total Billed Charges,1289.5,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,1289.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1289.5,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,2204.02,150,,,Fee Schedule,150% of CMS OPPS Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1369.944,Case Rate,Pays based on per visit rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,474.32,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2579,100,,212.288,Percent of Total Billed Charges,100% of Total Billed Charges,70.43,2579,
IR VENOGRAM SVC W SER SI,46101002,CDM,320,RC,75827,HCPCS,Outpatient,,,2579,1547.40,TC   ,70.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2204.02,150,,1164.232,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.43,280,,512.264,Fee Schedule,280% of BCBS BULE Fee Schedule,2017.63,320,,6787.304,Fee Schedule,320% of BCBS Blue Essentials Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,2269.84,360,,658.624,Fee Schedule,360% of BCBS POS Rate,2269.84,360,,658.624,Fee schedule,360% of BCBS PPO Rate,2269.84,360,,658.624,Fee Schedule,360% of BCBS Traditional Rate,1885.49,103,,72,Fee Schedule,103% of Cigna fee schedule,119.63,100,,115.928,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,1546.528,Fee Schedule,100% of CMS OPPS Rate,1322.41,90,,,Fee Schedule,90% of CMS OPPS Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.15,130,,,Fee Schedule,130% of CMS OPPS Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,123.22,103,,119.408,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1934.25,75,,974.872,Percent of Total Billed Charges,75% of Total Billed Charges,1289.5,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,1289.5,50,,992.4,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.5,50,,992.4,Percent of Total Billed Charges,50% of Total Billed Charges,1289.5,50,,192.456,Percent of Total Billed Charges,50% of Total Billed Charges,2204.02,150,,,Fee Schedule,150% of CMS OPPS Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1609.432,Case Rate,Pays based on per visit rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,115.928,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2579,100,,1299.832,Percent of Total Billed Charges,100% of Total Billed Charges,70.43,2579,
"CORONARY THROMBECTOMY RCA, INITIAL",46101101,CDM,481,RC,92973,HCPCS,Outpatient,,,7914.48,4748.69,,118.67,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3561.52,45,,144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6787.304,Other,Not Seperately Reimbusable,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,990,Percent of Total Billed Charges,60% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7914.48,100,,2319.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1141.27,14.42,,27.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5935.86,75,,268.8,Percent of Total Billed Charges,75% of Total Billed Charges,3957.24,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3957.24,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,2248.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1072.952,Fee Schedule,100% of ASC Tier Groupings fee schedule,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,26.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7914.48,100,,358.4,Percent of Total Billed Charges,100% of Total Billed Charges,118.67,11330,
INTRO NEEDLE ARTERY EXT,46101218,CDM,361,RC,36140,HCPCS,Outpatient,,,1834.66,1100.80,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,825.6,45,,54.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6787.304,Other,Not Seperately Reimbusable,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100.8,60,,990,Percent of Total Billed Charges,60% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.66,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,264.56,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1376,75,,531,Percent of Total Billed Charges,75% of Total Billed Charges,917.33,50,,992.4,Percent of Total Billed Charges,50% of Total Billed Charges,917.33,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917.33,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,917.33,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1072.952,Fee Schedule,100% of ASC Tier Groupings fee schedule,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,256.85,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1834.66,100,,708,Percent of Total Billed Charges,100% of Total Billed Charges,256.85,2601,
IR VENOGRAM RENAL SEL UNI SI,46101432,CDM,320,RC,75831,HCPCS,Outpatient,,,4089,2453.40,TC   ,71.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,113.4,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,27.92,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,6787.304,Fee Schedule,320% of BCBS Blue Essentials Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,35.904,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,35.904,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,35.904,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,990,Fee Schedule,103% of Cigna fee schedule,120.63,100,,235.2,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,2587.184,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,124.25,103,,242.256,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3066.75,75,,3976.832,Percent of Total Billed Charges,75% of Total Billed Charges,2044.5,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2044.5,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,1751.048,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,983.928,Case Rate,Pays based on per visit rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,235.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4089,100,,5302.44,Percent of Total Billed Charges,100% of Total Billed Charges,71.43,9976.61,
IR VENOGRAM RENAL SEL UNI SI,46101432,CDM,320,RC,75831,HCPCS,Outpatient,,,4089,2453.40,TC   ,71.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,45.36,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,114.664,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,6791.16,Fee Schedule,320% of BCBS Blue Essentials Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,147.424,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,147.424,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,147.424,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,110.4,Fee Schedule,103% of Cigna fee schedule,120.63,100,,975.52,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,320,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,124.25,103,,1004.784,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3066.75,75,,538.16,Percent of Total Billed Charges,75% of Total Billed Charges,2044.5,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,540.544,Percent of Total Billed Charges,50% of Total Billed Charges,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2044.5,50,,540.544,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1446.888,Case Rate,Pays based on per visit rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,975.52,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4089,100,,717.544,Percent of Total Billed Charges,100% of Total Billed Charges,71.43,9976.61,
VEN THROM MECH LYSIS INITIAL,46101556,CDM,361,RC,37187,HCPCS,Outpatient,,,8553.55,5132.13,,12485,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,46.288,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,68.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,668.57,32,,6902.304,Percent of Total Billed Charges,32% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,87.912,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,87.912,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,87.912,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,1102.024,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,120.192,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1233.42,14.42,,434.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,6415.16,75,,7137.904,Percent of Total Billed Charges,75% of Total Billed Charges,4276.78,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,4276.78,50,,2356.8,Percent of Total Billed Charges,50% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4276.78,50,,2356.8,Percent of Total Billed Charges,50% of Total Billed Charges,4276.78,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,1081.304,Fee Schedule,100% of ASC Tier Groupings fee schedule,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,1197.5,14,,422.24,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,8553.55,100,,9517.2,Percent of Total Billed Charges,100% of Total Billed Charges,668.57,15951.59,
THROMBECTOMY FEMORAL ILIAC,46101697,CDM,481,RC,34201,HCPCS,Outpatient,,,11263.5,6758.10,,898.11,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,254.376,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3153.78,28,,26.88,Percent of Total Billed Charges,28% of Total Billed Charges,668.57,32,,6902.304,Percent of Total Billed Charges,32% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,4054.86,36,,34.56,Percent of Total Billed Charges,36% of Total Billed Charges,4054.86,36,,34.56,Percent of Total Billed Charges,36% Total Bille Charges,4054.86,36,,34.56,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,4361.76,Percent of Total Billed Charges,60% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,252,Fee Schedule,100% of CMS OPPS Rate,4537.58,90,,,Fee Schedule,90% of CMS OPPS Rate,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.29,130,,,Fee Schedule,130% of CMS OPPS Rate,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1624.2,14.42,,898.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,5193.01,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.01,103,,,Fee Schedule,103% of CMS OPPS Rate,8447.63,75,,7127.704,Percent of Total Billed Charges,75% of Total Billed Charges,5631.75,50,,540.544,Percent of Total Billed Charges,50% of Total Billed Charges,5631.75,50,,2549.2,Percent of Total Billed Charges,50% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5631.75,50,,2549.2,Percent of Total Billed Charges,50% of Total Billed Charges,5631.75,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,1081.304,Fee Schedule,100% of ASC Tier Groupings fee schedule,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,1576.89,14,,872.144,Percent of Total Billed Charges,14% of Total Billed Charges,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11263.5,100,,9503.608,Percent of Total Billed Charges,100% of Total Billed Charges,668.57,11330,
CATH PULM ART 1ST ORDER RT,46101713,CDM,481,RC,36014,HCPCS,Outpatient,,,2407.96,1444.78,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1083.58,45,,298.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6902.304,Other,Not Seperately Reimbusable,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,1208.096,Percent of Total Billed Charges,60% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2407.96,100,,100.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,347.23,14.42,,147.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1805.97,75,,1091.552,Percent of Total Billed Charges,75% of Total Billed Charges,1203.98,50,,2356.8,Percent of Total Billed Charges,50% of Total Billed Charges,1203.98,50,,3478.8,Percent of Total Billed Charges,50% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1203.98,50,,3478.8,Percent of Total Billed Charges,50% of Total Billed Charges,1203.98,50,,1056.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1739.072,Fee Schedule,100% of ASC Tier Groupings fee schedule,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,337.11,14,,142.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2407.96,100,,1364.44,Percent of Total Billed Charges,100% of Total Billed Charges,337.11,11330,
IR CATH INTRO PULM ART,46101721,CDM,481,RC,36013,HCPCS,Outpatient,,,1229.6,737.76,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,553.32,45,,24.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.688,Other,Not Seperately Reimbusable,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1229.6,100,,102.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,177.31,14.42,,136.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,922.2,75,,4804.824,Percent of Total Billed Charges,75% of Total Billed Charges,614.8,50,,2549.2,Percent of Total Billed Charges,50% of Total Billed Charges,614.8,50,,3865.2,Percent of Total Billed Charges,50% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.8,50,,3865.2,Percent of Total Billed Charges,50% of Total Billed Charges,614.8,50,,1219.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1159.376,Fee Schedule,100% of ASC Tier Groupings fee schedule,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,172.14,14,,132.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1229.6,100,,6406.432,Percent of Total Billed Charges,100% of Total Billed Charges,172.14,11330,
MOD SEDATION INIT 15 MIN 5+ YO,46101757,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,89.816,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,6.696,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,115.472,Fee Schedule,360% of BCBS POS Rate,45.4,360,,115.472,Fee schedule,360% of BCBS PPO Rate,45.4,360,,115.472,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,302.4,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,565.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,658.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,38.744,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,3478.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,1762.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,1762.8,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,343.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,1159.376,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,639.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,51.656,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
MOD SEDATION ADDL 15 MIN,46101760,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,85.12,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,6.704,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,109.44,Fee Schedule,360% of BCBS POS Rate,38.92,360,,109.44,Fee schedule,360% of BCBS PPO Rate,38.92,360,,109.44,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,424.8,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,662.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,1018.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,2028,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,3865.2,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,686.072,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,988.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,2704,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
INJ PSEUDOANEURYSM EXT RT,46101788,CDM,361,RC,,,Outpatient,,,1232.86,739.72,,739.72,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,554.79,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.2,28,,16.4,Percent of Total Billed Charges,28% of Total Billed Charges,668.57,32,,6.72,Percent of Total Billed Charges,32% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,443.83,36,,21.08,Percent of Total Billed Charges,36% of Total Billed Charges,443.83,36,,21.08,Percent of Total Billed Charges,36% Total Bille Charges,443.83,36,,21.08,Percent of Total Billed Charges,36% of Total Billed Charges,739.72,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1232.86,100,,55.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,177.78,14.42,,427.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,924.65,75,,304.72,Percent of Total Billed Charges,75% of Total Billed Charges,616.43,50,,1762.8,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,118,Percent of Total Billed Charges,50% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.43,50,,118,Percent of Total Billed Charges,50% of Total Billed Charges,616.43,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,863,70,,502.28,Percent of Total Billed Charges,70% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,172.6,14,,415.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1232.86,100,,406.296,Percent of Total Billed Charges,100% of Total Billed Charges,172.6,1232.86,
IABP,46102083,CDM,481,RC,33968,HCPCS,Outpatient,,,2177.78,1306.67,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2177.78,100,,236.832,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.78,28,,85.12,Percent of Total Billed Charges,28% of Total Billed Charges,668.57,32,,6.728,Percent of Total Billed Charges,32% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,784,36,,109.44,Percent of Total Billed Charges,36% of Total Billed Charges,784,36,,109.44,Percent of Total Billed Charges,36% Total Bille Charges,784,36,,109.44,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,2045.76,Percent of Total Billed Charges,60% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,57.6,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,314.04,14.42,,20.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1633.34,75,,320.76,Percent of Total Billed Charges,75% of Total Billed Charges,1088.89,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,1088.89,50,,164.8,Percent of Total Billed Charges,50% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1088.89,50,,164.8,Percent of Total Billed Charges,50% of Total Billed Charges,1088.89,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,28171,100,,1559.552,Fee Schedule,100% of ASC Tier Groupings fee schedule,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,304.89,14,,19.6,Percent of Total Billed Charges,14% of Total Billed Charges,2177.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.78,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,304.89,28171,
HRT CATH RT,46102208,CDM,481,RC,93451,HCPCS,Outpatient,,,11558.33,6935.00,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,144.344,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.33,28,,198.248,Percent of Total Billed Charges,28% of Total Billed Charges,668.57,32,,6.752,Percent of Total Billed Charges,32% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,4161,36,,254.888,Percent of Total Billed Charges,36% of Total Billed Charges,4161,36,,254.888,Percent of Total Billed Charges,36% Total Bille Charges,4161,36,,254.888,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,182.4,Percent of Total Billed Charges,60% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,211.072,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1666.71,14.42,,60.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,8668.75,75,,159.216,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,118,Case Rate,Pays Based on per visit rate,9500,100,,630,Case Rate,Pays based on per visit rate,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,630,Case Rate,Pays based on per visit rate,9500,50,,992.4,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,1506.824,Fee Schedule,100% of ASC Tier Groupings fee schedule,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,1618.17,14,,58.768,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11558.33,100,,212.288,Percent of Total Billed Charges,100% of Total Billed Charges,668.57,11558.33,
ANGIO CORS,46102232,CDM,481,RC,93454,HCPCS,Outpatient,,,13566.19,8139.71,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,94.984,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3798.53,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,668.97,32,,6.752,Percent of Total Billed Charges,32% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,4883.83,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,4883.83,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,4883.83,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1318.672,Percent of Total Billed Charges,60% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,211.072,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1956.24,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,10174.64,75,,159.216,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,164.8,Case Rate,Pays Based on per visit rate,9500,100,,5200,Case Rate,Pays based on per visit rate,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,5200,Case Rate,Pays based on per visit rate,9500,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,2282.944,Fee Schedule,100% of ASC Tier Groupings fee schedule,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1899.27,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13566.19,100,,212.288,Percent of Total Billed Charges,100% of Total Billed Charges,668.97,13566.19,
ANGIO CORS W GRAFTS,46102265,CDM,481,RC,93455,HCPCS,Outpatient,,,14716,8829.60,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,473.656,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4120.48,28,,473.344,Percent of Total Billed Charges,28% of Total Billed Charges,670.02,32,,6.752,Percent of Total Billed Charges,32% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,5297.76,36,,608.584,Percent of Total Billed Charges,36% of Total Billed Charges,5297.76,36,,608.584,Percent of Total Billed Charges,36% Total Bille Charges,5297.76,36,,608.584,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,929.096,Percent of Total Billed Charges,60% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,526.288,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2122.05,14.42,,186.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,11037,75,,1721.104,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,630,Case Rate,Pays Based on per visit rate,9500,100,,900,Case Rate,Pays based on per visit rate,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,900,Case Rate,Pays based on per visit rate,9500,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,1034.672,Fee Schedule,100% of ASC Tier Groupings fee schedule,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,180.648,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14716,100,,2151.384,Percent of Total Billed Charges,100% of Total Billed Charges,670.02,14716,
ANGIO CORS W HRT CATH LT,46102273,CDM,481,RC,93458,HCPCS,Outpatient,,,17253.66,10352.20,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,201.6,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4831.02,28,,562.96,Percent of Total Billed Charges,28% of Total Billed Charges,671.04,32,,6.784,Percent of Total Billed Charges,32% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,6211.32,36,,723.808,Percent of Total Billed Charges,36% of Total Billed Charges,6211.32,36,,723.808,Percent of Total Billed Charges,36% Total Bille Charges,6211.32,36,,723.808,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,991.76,Percent of Total Billed Charges,60% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,320.76,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2487.98,14.42,,207.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,12940.25,75,,33650.104,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,5200,Case Rate,Pays Based on per visit rate,9500,100,,3114.8,Case Rate,Pays based on per visit rate,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,3114.8,Case Rate,Pays based on per visit rate,9500,50,,308.8,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,895.424,Fee Schedule,100% of ASC Tier Groupings fee schedule,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2415.51,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17253.66,100,,44866.8,Percent of Total Billed Charges,100% of Total Billed Charges,671.04,17253.66,
ANGIO CORS W GRAFTS,46102281,CDM,481,RC,93455,HCPCS,Outpatient,,,14716,8829.60,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,182.832,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4120.48,28,,137.624,Percent of Total Billed Charges,28% of Total Billed Charges,671.04,32,,6.784,Percent of Total Billed Charges,32% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,5297.76,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,5297.76,36,,176.944,Percent of Total Billed Charges,36% Total Bille Charges,5297.76,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,991.76,Percent of Total Billed Charges,60% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,211.072,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2122.05,14.42,,250.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,11037,75,,1096.432,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,900,Case Rate,Pays Based on per visit rate,9500,100,,152,Case Rate,Pays based on per visit rate,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,152,Case Rate,Pays based on per visit rate,9500,50,,540.544,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,814.104,Fee Schedule,100% of ASC Tier Groupings fee schedule,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2060.24,14,,243.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14716,100,,1461.904,Percent of Total Billed Charges,100% of Total Billed Charges,671.04,14716,
ANGIO CORS HRT CATH RT AND LT,46102299,CDM,481,RC,93460,HCPCS,Outpatient,,,21038.57,12623.14,,9364,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,543.824,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5890.8,28,,293.416,Percent of Total Billed Charges,28% of Total Billed Charges,671.04,32,,6.856,Percent of Total Billed Charges,32% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,7573.89,36,,377.248,Percent of Total Billed Charges,36% of Total Billed Charges,7573.89,36,,377.248,Percent of Total Billed Charges,36% Total Bille Charges,7573.89,36,,377.248,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,5720,Percent of Total Billed Charges,60% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,1052.568,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,3033.76,14.42,,207.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,15778.93,75,,3600,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,3114.8,Case Rate,Pays Based on per visit rate,9500,100,,1120,Case Rate,Pays based on per visit rate,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,1120,Case Rate,Pays based on per visit rate,9500,50,,2356.8,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,57.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2945.4,14,,201.6,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21038.57,100,,4800,Percent of Total Billed Charges,100% of Total Billed Charges,671.04,21038.57,
EMBOLIZATION ARTERIAL NON HEMO,46102622,CDM,481,RC,37242,HCPCS,Outpatient,,,26527.98,15916.79,,4682,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,570.144,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7427.83,28,,511.92,Percent of Total Billed Charges,28% of Total Billed Charges,671.04,32,,6.864,Percent of Total Billed Charges,32% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,9550.07,36,,658.184,Percent of Total Billed Charges,36% of Total Billed Charges,9550.07,36,,658.184,Percent of Total Billed Charges,36% Total Bille Charges,9550.07,36,,658.184,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,4804.8,Percent of Total Billed Charges,60% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,448,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3825.33,14.42,,227.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,19895.99,75,,51.424,Percent of Total Billed Charges,75% of Total Billed Charges,13263.99,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,13263.99,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13263.99,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,13263.99,50,,2549.2,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,294,Fee Schedule,100% of ASC Tier Groupings fee schedule,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,3713.92,14,,220.496,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,26527.98,100,,68.56,Percent of Total Billed Charges,100% of Total Billed Charges,671.04,26527.98,
AORTIC ROOT W CARD CATH,46102703,CDM,481,RC,93567,HCPCS,Outpatient,,,2783,1669.80,,1020,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,1252.35,45,,88.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,66.56,Other,Not Seperately Reimbusable,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,11880,Percent of Total Billed Charges,60% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2783,100,,406.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,401.31,14.42,,1072.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2087.25,75,,4588.648,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,1120,Case Rate,Pays Based on per visit rate,9500,100,,58,Case Rate,Pays based on per visit rate,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9500,100,,58,Case Rate,Pays based on per visit rate,9500,50,,3478.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,436.384,Fee Schedule,100% of ASC Tier Groupings fee schedule,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,389.62,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2783,100,,6118.2,Percent of Total Billed Charges,100% of Total Billed Charges,389.62,11330,
MOD SEDATION INIT 15 MIN,46102754,CDM,370,RC,99151,HCPCS,Outpatient,,,217.25,130.35,,18.43,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,263.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.66,280,,490.944,Fee Schedule,280% of BCBS BULE Fee Schedule,83.04,320,,66.64,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,93.42,360,,631.216,Fee Schedule,360% of BCBS POS Rate,93.42,360,,631.216,Fee schedule,360% of BCBS PPO Rate,93.42,360,,631.216,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,3987.36,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,1208.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,165.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,2574,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,3865.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,271.464,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,160.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,3432,Percent of Total Billed Charges,100% of Total Billed Charges,18.43,217.25,
IVUS CORONARY LC ADD,46102992,CDM,481,RC,92979,HCPCS,Outpatient,,,4615.43,2769.26,,62.23,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2076.94,45,,331.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.03,280,,547.976,Fee Schedule,280% of BCBS BULE Fee Schedule,256.03,320,,66.72,Fee Schedule,320% of BCBS Blue Essentials Rate,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,288.04,360,,704.544,Fee Schedule,360% of BCBS POS Rate,288.04,360,,704.544,Fee schedule,360% of BCBS PPO Rate,288.04,360,,704.544,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,751.68,Percent of Total Billed Charges,60% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4615.43,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,665.55,14.42,,3922.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3461.57,75,,500.888,Percent of Total Billed Charges,75% of Total Billed Charges,2307.72,50,,58,Percent of Total Billed Charges,50% of Total Billed Charges,2307.72,50,,630,Percent of Total Billed Charges,50% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2307.72,50,,630,Percent of Total Billed Charges,50% of Total Billed Charges,2307.72,50,,1762.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,3532.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4615.43,100,,667.848,Percent of Total Billed Charges,100% of Total Billed Charges,62.23,11330,
IVUS CORONARY LD ADD,46103016,CDM,481,RC,92979,HCPCS,Outpatient,,,4615.43,2769.26,,62.23,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2076.94,45,,245.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.03,280,,643.776,Fee Schedule,280% of BCBS BULE Fee Schedule,256.03,320,,66.816,Fee Schedule,320% of BCBS Blue Essentials Rate,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,288.04,360,,827.712,Fee Schedule,360% of BCBS POS Rate,288.04,360,,827.712,Fee schedule,360% of BCBS PPO Rate,288.04,360,,827.712,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,222.72,Percent of Total Billed Charges,60% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4615.43,100,,197,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,665.55,14.42,,839.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3461.57,75,,4992,Percent of Total Billed Charges,75% of Total Billed Charges,2307.72,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,2307.72,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2307.72,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,2307.72,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,223.44,Fee Schedule,100% of ASC Tier Groupings fee schedule,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,646.16,14,,815.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4615.43,100,,6656,Percent of Total Billed Charges,100% of Total Billed Charges,62.23,11330,
ASD CLOSURE,46103040,CDM,481,RC,93580,HCPCS,Outpatient,,,30705.75,18423.45,,10404,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,192.968,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8597.61,28,,429.184,Percent of Total Billed Charges,28% of Total Billed Charges,671.04,32,,66.992,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,551.808,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,551.808,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,551.808,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,3239.808,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,584.76,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,1097.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,23029.31,75,,1389.44,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,630,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15352.88,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,118,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15648,100,,464.24,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1065.928,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30705.75,100,,1852.584,Percent of Total Billed Charges,100% of Total Billed Charges,671.04,30705.75,
"CORONARY THROMBECTOMY LCX, INITIAL",46103156,CDM,481,RC,92973,HCPCS,Outpatient,,,7914.48,4748.69,,118.67,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3561.52,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.072,Other,Not Seperately Reimbusable,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,3736.304,Percent of Total Billed Charges,60% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7914.48,100,,736.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1141.27,14.42,,28.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5935.86,75,,3365.008,Percent of Total Billed Charges,75% of Total Billed Charges,3957.24,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3957.24,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,164.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,192.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7914.48,100,,4486.68,Percent of Total Billed Charges,100% of Total Billed Charges,118.67,11330,
"CORONARY THROMBECTOMY LAD, INITIAL",46103172,CDM,481,RC,92973,HCPCS,Outpatient,,,7914.48,4748.69,,118.67,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3561.52,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.152,Other,Not Seperately Reimbusable,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,4483.336,Percent of Total Billed Charges,60% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7914.48,100,,545.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1141.27,14.42,,19.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5935.86,75,,4644.84,Percent of Total Billed Charges,75% of Total Billed Charges,3957.24,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3957.24,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,3957.24,50,,630,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,330.4,Fee Schedule,100% of ASC Tier Groupings fee schedule,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,1108.03,14,,18.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7914.48,100,,6193.12,Percent of Total Billed Charges,100% of Total Billed Charges,118.67,11330,
STENT BMS INI LC,46103552,CDM,481,RC,92928,HCPCS,Outpatient,,,23361.5,14016.90,,418.82,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,237.104,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6541.22,28,,578.752,Percent of Total Billed Charges,28% of Total Billed Charges,671.84,32,,67.24,Percent of Total Billed Charges,32% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,8410.14,36,,744.112,Percent of Total Billed Charges,36% of Total Billed Charges,8410.14,36,,744.112,Percent of Total Billed Charges,36% Total Bille Charges,8410.14,36,,744.112,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,302.4,Percent of Total Billed Charges,60% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,428.824,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3368.73,14.42,,3922.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,17521.13,75,,1964.04,Percent of Total Billed Charges,75% of Total Billed Charges,11680.75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11680.75,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,5200,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,321.584,Fee Schedule,100% of ASC Tier Groupings fee schedule,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,3808,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23361.5,100,,2618.72,Percent of Total Billed Charges,100% of Total Billed Charges,418.82,23361.5,
STENT BMS INI LD,46103560,CDM,481,RC,92928,HCPCS,Outpatient,,,23361.5,14016.90,,418.82,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6541.22,28,,432.52,Percent of Total Billed Charges,28% of Total Billed Charges,671.84,32,,67.264,Percent of Total Billed Charges,32% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% of Total Billed Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% Total Bille Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,211.072,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3368.73,14.42,,2999.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,17521.13,75,,1350,Percent of Total Billed Charges,75% of Total Billed Charges,11680.75,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11680.75,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,115.224,Fee Schedule,100% of ASC Tier Groupings fee schedule,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23361.5,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,418.82,23361.5,
STENT BMS INI RC,46103578,CDM,481,RC,92928,HCPCS,Outpatient,,,23361.5,14016.90,,418.82,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,288.016,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6541.22,28,,432.52,Percent of Total Billed Charges,28% of Total Billed Charges,672,32,,67.344,Percent of Total Billed Charges,32% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% of Total Billed Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% Total Bille Charges,8410.14,36,,556.096,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1145.76,Percent of Total Billed Charges,60% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,701.712,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3368.73,14.42,,2745.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,17521.13,75,,1864.2,Percent of Total Billed Charges,75% of Total Billed Charges,11680.75,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,25.904,Percent of Total Billed Charges,50% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11680.75,50,,25.904,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,3114.8,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,385.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,2665.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23361.5,100,,2485.6,Percent of Total Billed Charges,100% of Total Billed Charges,418.82,23361.5,
STENT BMS ADD LD,46103693,CDM,481,RC,92929,HCPCS,Outpatient,,,20803.78,12482.27,,352.65,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,9361.7,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.344,Other,Not Seperately Reimbusable,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,1430,Percent of Total Billed Charges,60% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20803.78,100,,526.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2999.91,14.42,,2999.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15602.84,75,,3834.072,Percent of Total Billed Charges,75% of Total Billed Charges,10401.89,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,10401.89,50,,145.744,Percent of Total Billed Charges,50% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10401.89,50,,145.744,Percent of Total Billed Charges,50% of Total Billed Charges,10401.89,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,312.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,2912.53,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20803.78,100,,5112.096,Percent of Total Billed Charges,100% of Total Billed Charges,352.65,20803.78,
PTCA INI LC,46103735,CDM,481,RC,92920,HCPCS,Outpatient,,,15186.45,9111.87,,376.49,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7865.86,150,,258.512,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4252.21,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,672,32,,67.344,Percent of Total Billed Charges,32% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1102.08,Percent of Total Billed Charges,60% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,640.032,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2189.89,14.42,,29.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11389.84,75,,1964.04,Percent of Total Billed Charges,75% of Total Billed Charges,7593.23,50,,25.904,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,402,Percent of Total Billed Charges,50% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7593.23,50,,402,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,1120,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,471.384,Fee Schedule,100% of ASC Tier Groupings fee schedule,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15186.45,100,,2618.72,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,15186.45,
PTCA INI LD,46103743,CDM,481,RC,92920,HCPCS,Outpatient,,,15186.45,9111.87,,376.49,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7865.86,150,,486,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4252.21,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,673.45,32,,67.344,Percent of Total Billed Charges,32% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,5467.12,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1560,Percent of Total Billed Charges,60% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,640.032,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2189.89,14.42,,955.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11389.84,75,,3104.4,Percent of Total Billed Charges,75% of Total Billed Charges,7593.23,50,,145.744,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7593.23,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,63.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,927.8,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15186.45,100,,4139.2,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,15186.45,
PTCA INI RC,46103750,CDM,481,RC,92920,HCPCS,Outpatient,,,15186.45,9111.87,,376.49,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7865.86,150,,135,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4252.21,28,,274.432,Percent of Total Billed Charges,28% of Total Billed Charges,673.77,32,,67.384,Percent of Total Billed Charges,32% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5467.12,36,,352.84,Percent of Total Billed Charges,36% of Total Billed Charges,5467.12,36,,352.84,Percent of Total Billed Charges,36% Total Bille Charges,5467.12,36,,352.84,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1934.4,Percent of Total Billed Charges,60% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,300,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2189.89,14.42,,159.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11389.84,75,,5893.864,Percent of Total Billed Charges,75% of Total Billed Charges,7593.23,50,,402,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,414.04,Percent of Total Billed Charges,50% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7593.23,50,,414.04,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,58,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,78.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,154.56,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15186.45,100,,7858.488,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,15186.45,
PTCA INI LM,46103768,CDM,481,RC,92920,HCPCS,Outpatient,,,15186.45,9111.87,,376.49,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7865.86,150,,752.144,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4252.21,28,,200.912,Percent of Total Billed Charges,28% of Total Billed Charges,676.08,32,,67.488,Percent of Total Billed Charges,32% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5467.12,36,,258.312,Percent of Total Billed Charges,36% of Total Billed Charges,5467.12,36,,258.312,Percent of Total Billed Charges,36% Total Bille Charges,5467.12,36,,258.312,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,574.472,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2189.89,14.42,,29.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11389.84,75,,4664.4,Percent of Total Billed Charges,75% of Total Billed Charges,7593.23,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,94.064,Percent of Total Billed Charges,50% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7593.23,50,,94.064,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,171.072,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,464.24,Fee Schedule,100% of ASC Tier Groupings fee schedule,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15186.45,100,,6219.2,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,15186.45,
PTCA INI RI,46103776,CDM,481,RC,92920,HCPCS,Outpatient,,,15186.45,9111.87,,376.49,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,7865.86,150,,752.144,Fee Schedule ,150% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4252.21,28,,623.824,Percent of Total Billed Charges,28% of Total Billed Charges,676.2,32,,67.544,Percent of Total Billed Charges,32% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5467.12,36,,802.056,Percent of Total Billed Charges,36% of Total Billed Charges,5467.12,36,,802.056,Percent of Total Billed Charges,36% Total Bille Charges,5467.12,36,,802.056,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,430.56,Percent of Total Billed Charges,60% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5243.9,100,,1080,Fee Schedule,100% of CMS OPPS Rate,4719.51,90,,,Fee Schedule,90% of CMS OPPS Rate,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6817.07,130,,,Fee Schedule,130% of CMS OPPS Rate,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2189.89,14.42,,1379.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,5401.22,103,,,Fee Schedule,103% of CMS OPPS Rate,11389.84,75,,4664.4,Percent of Total Billed Charges,75% of Total Billed Charges,7593.23,50,,414.04,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7593.23,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,7593.23,50,,630,Percent of Total Billed Charges,50% of Total Billed Charges,7865.86,150,,,Fee Schedule,150% of CMS OPPS Rate,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,214.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,2126.1,14,,1339.408,Percent of Total Billed Charges,14% of Total Billed Charges,5243.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15186.45,100,,6219.2,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,15186.45,
PTCA ADD LC,46103784,CDM,481,RC,92921,HCPCS,Outpatient,,,13542,8125.20,,300.69,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,6093.9,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.544,Other,Not Seperately Reimbusable,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,3832.4,Percent of Total Billed Charges,60% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13542,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1952.76,14.42,,1072.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10156.5,75,,657,Percent of Total Billed Charges,75% of Total Billed Charges,6771,50,,94.064,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,840,Percent of Total Billed Charges,50% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6771,50,,840,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,215.464,Fee Schedule,100% of ASC Tier Groupings fee schedule,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,1041.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13542,100,,876,Percent of Total Billed Charges,100% of Total Billed Charges,300.69,13542,
PTCA ADD LD,46103792,CDM,481,RC,92921,HCPCS,Outpatient,,,13542,8125.20,,300.69,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,6093.9,45,,1070.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.544,Other,Not Seperately Reimbusable,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,382.8,Percent of Total Billed Charges,60% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13542,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1952.76,14.42,,264.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10156.5,75,,657,Percent of Total Billed Charges,75% of Total Billed Charges,6771,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6771,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,279.584,Fee Schedule,100% of ASC Tier Groupings fee schedule,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,256.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13542,100,,876,Percent of Total Billed Charges,100% of Total Billed Charges,300.69,13542,
PTCA ADD RC,46103800,CDM,481,RC,92921,HCPCS,Outpatient,,,13542,8125.20,,300.69,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,6093.9,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.544,Other,Not Seperately Reimbusable,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,3993.6,Percent of Total Billed Charges,60% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13542,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1952.76,14.42,,29.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10156.5,75,,2724.376,Percent of Total Billed Charges,75% of Total Billed Charges,6771,50,,840,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,1508,Percent of Total Billed Charges,50% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6771,50,,1508,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,40.6,Fee Schedule,100% of ASC Tier Groupings fee schedule,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,28.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13542,100,,3632.496,Percent of Total Billed Charges,100% of Total Billed Charges,300.69,13542,
PTCA ADD RI,46103826,CDM,481,RC,92921,HCPCS,Outpatient,,,13542,8125.20,,300.69,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,6093.9,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.544,Other,Not Seperately Reimbusable,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,1432.704,Percent of Total Billed Charges,60% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13542,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1952.76,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10156.5,75,,4086.56,Percent of Total Billed Charges,75% of Total Billed Charges,6771,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,3114.8,Percent of Total Billed Charges,50% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6771,50,,3114.8,Percent of Total Billed Charges,50% of Total Billed Charges,6771,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,57.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1895.88,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13542,100,,5448.744,Percent of Total Billed Charges,100% of Total Billed Charges,300.69,13542,
STENT DES INI LC,46103933,CDM,481,RC,C9600,HCPCS,Outpatient,,,26512.92,15907.75,,673.3,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7423.62,28,,64.68,Percent of Total Billed Charges,28% of Total Billed Charges,676.8,32,,67.544,Percent of Total Billed Charges,32% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% of Total Billed Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% Total Bille Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1432.704,Percent of Total Billed Charges,60% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,2379.728,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3823.16,14.42,,766.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19884.69,75,,2724.376,Percent of Total Billed Charges,75% of Total Billed Charges,13256.46,50,,1508,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,510,Percent of Total Billed Charges,50% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13256.46,50,,510,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,37.752,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,80.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,744.128,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26512.92,100,,3632.496,Percent of Total Billed Charges,100% of Total Billed Charges,673.3,26512.92,
STENT DES INI LD,46103941,CDM,481,RC,C9600,HCPCS,Outpatient,,,26512.92,15907.75,,673.3,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7423.62,28,,64.68,Percent of Total Billed Charges,28% of Total Billed Charges,678.32,32,,67.544,Percent of Total Billed Charges,32% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% of Total Billed Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% Total Bille Charges,9544.65,36,,83.16,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1432.08,Percent of Total Billed Charges,60% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,551.816,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3823.16,14.42,,164.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19884.69,75,,2549.248,Percent of Total Billed Charges,75% of Total Billed Charges,13256.46,50,,3114.8,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,473.656,Percent of Total Billed Charges,50% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13256.46,50,,473.656,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,186.04,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,38.224,Fee Schedule,100% of ASC Tier Groupings fee schedule,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,159.6,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26512.92,100,,3399,Percent of Total Billed Charges,100% of Total Billed Charges,673.3,26512.92,
STENT DES INI RC,46103958,CDM,481,RC,C9600,HCPCS,Outpatient,,,26512.92,15907.75,,673.3,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,248.32,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7423.62,28,,325.64,Percent of Total Billed Charges,28% of Total Billed Charges,678.32,32,,67.568,Percent of Total Billed Charges,32% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,9544.65,36,,418.68,Percent of Total Billed Charges,36% of Total Billed Charges,9544.65,36,,418.68,Percent of Total Billed Charges,36% Total Bille Charges,9544.65,36,,418.68,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1300.992,Percent of Total Billed Charges,60% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,551.816,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3823.16,14.42,,124.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19884.69,75,,2855.16,Percent of Total Billed Charges,75% of Total Billed Charges,13256.46,50,,510,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,2282.8,Percent of Total Billed Charges,50% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13256.46,50,,2282.8,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,25.904,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,54.768,Fee Schedule,100% of ASC Tier Groupings fee schedule,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,120.616,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26512.92,100,,3806.88,Percent of Total Billed Charges,100% of Total Billed Charges,673.3,26512.92,
STENT DES INI LM,46103966,CDM,481,RC,,,Outpatient,,,26512.92,15907.75,,15907.75,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,11930.81,45,,1371.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7423.62,28,,23.184,Percent of Total Billed Charges,28% of Total Billed Charges,679.17,32,,67.568,Percent of Total Billed Charges,32% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,9544.65,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,9544.65,36,,29.808,Percent of Total Billed Charges,36% Total Bille Charges,9544.65,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1300.992,Percent of Total Billed Charges,60% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26512.92,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3823.16,14.42,,980.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19884.69,75,,13825.8,Percent of Total Billed Charges,75% of Total Billed Charges,13256.46,50,,473.656,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13256.46,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,145.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18559.04,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,951.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26512.92,100,,18434.4,Percent of Total Billed Charges,100% of Total Billed Charges,679.17,26512.92,
STENT DES INI RI,46103974,CDM,481,RC,C9600,HCPCS,Outpatient,,,26512.92,15907.75,,673.3,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,15139.71,150,,263.144,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7423.62,28,,117.6,Percent of Total Billed Charges,28% of Total Billed Charges,679.17,32,,67.568,Percent of Total Billed Charges,32% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,9544.65,36,,151.2,Percent of Total Billed Charges,36% of Total Billed Charges,9544.65,36,,151.2,Percent of Total Billed Charges,36% Total Bille Charges,9544.65,36,,151.2,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,309.6,Percent of Total Billed Charges,60% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,551.816,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3823.16,14.42,,8.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19884.69,75,,18605.448,Percent of Total Billed Charges,75% of Total Billed Charges,13256.46,50,,2282.8,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13256.46,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,13256.46,50,,402,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,778.312,Fee Schedule,100% of ASC Tier Groupings fee schedule,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,3711.81,14,,8.728,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26512.92,100,,24807.264,Percent of Total Billed Charges,100% of Total Billed Charges,673.3,26512.92,
STENT DES ADD LC,46103982,CDM,481,RC,C9601,HCPCS,Outpatient,,,23922.54,14353.52,,627.98,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,10765.14,45,,331.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.648,Other,Not Seperately Reimbusable,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,991.76,Percent of Total Billed Charges,60% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23922.54,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3449.63,14.42,,214.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17941.91,75,,26512.2,Percent of Total Billed Charges,75% of Total Billed Charges,11961.27,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11961.27,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,1694,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1345.072,Fee Schedule,100% of ASC Tier Groupings fee schedule,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,208.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23922.54,100,,35349.6,Percent of Total Billed Charges,100% of Total Billed Charges,627.98,23922.54,
STENT DES ADD LD,46103990,CDM,481,RC,C9601,HCPCS,Outpatient,,,23922.54,14353.52,,627.98,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,10765.14,45,,225.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.84,Other,Not Seperately Reimbusable,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,11572,Percent of Total Billed Charges,60% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23922.54,100,,3047.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3449.63,14.42,,2936.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17941.91,75,,18605.448,Percent of Total Billed Charges,75% of Total Billed Charges,11961.27,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,209.88,Percent of Total Billed Charges,50% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11961.27,50,,209.88,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,414.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1345.072,Fee Schedule,100% of ASC Tier Groupings fee schedule,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,2850.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23922.54,100,,24807.264,Percent of Total Billed Charges,100% of Total Billed Charges,627.98,23922.54,
STENT DES ADD RC,46104006,CDM,481,RC,C9601,HCPCS,Outpatient,,,23922.54,14353.52,,627.98,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,10765.14,45,,559.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.936,Other,Not Seperately Reimbusable,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330,60,,11880,Percent of Total Billed Charges,60% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23922.54,100,,584.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3449.63,14.42,,638.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17941.91,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,11961.27,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11961.27,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,94.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,614.856,Fee Schedule,100% of ASC Tier Groupings fee schedule,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,620.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23922.54,100,,225.136,Percent of Total Billed Charges,100% of Total Billed Charges,627.98,23922.54,
STENT DES ADD LM,46104014,CDM,481,RC,C9604,HCPCS,Outpatient,,,23922.54,14353.52,,14353.52,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,1070.88,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6698.31,28,,89.376,Percent of Total Billed Charges,28% of Total Billed Charges,687.62,32,,67.936,Percent of Total Billed Charges,32% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,8612.11,36,,114.912,Percent of Total Billed Charges,36% of Total Billed Charges,8612.11,36,,114.912,Percent of Total Billed Charges,36% Total Bille Charges,8612.11,36,,114.912,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,3432,Percent of Total Billed Charges,60% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,736.8,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3449.63,14.42,,1899.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,17941.91,75,,2792.752,Percent of Total Billed Charges,75% of Total Billed Charges,11961.27,50,,209.88,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,645.184,Percent of Total Billed Charges,50% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11961.27,50,,645.184,Percent of Total Billed Charges,50% of Total Billed Charges,11961.27,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,2134.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,3349.16,14,,1844.432,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23922.54,100,,3723.664,Percent of Total Billed Charges,100% of Total Billed Charges,687.62,23922.54,
REVASC DES BYPASS GRAFT INI LC,46104139,CDM,481,RC,C9604,HCPCS,Outpatient,,,26962.13,16177.28,,16177.28,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,141.44,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7549.4,28,,185.696,Percent of Total Billed Charges,28% of Total Billed Charges,690.56,32,,67.936,Percent of Total Billed Charges,32% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,9706.37,36,,238.752,Percent of Total Billed Charges,36% of Total Billed Charges,9706.37,36,,238.752,Percent of Total Billed Charges,36% Total Bille Charges,9706.37,36,,238.752,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,266.648,Percent of Total Billed Charges,60% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,500.304,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3887.94,14.42,,1259.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,20221.6,75,,185.848,Percent of Total Billed Charges,75% of Total Billed Charges,13481.07,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13481.07,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,840,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,2160.904,Fee Schedule,100% of ASC Tier Groupings fee schedule,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,1223.04,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26962.13,100,,247.8,Percent of Total Billed Charges,100% of Total Billed Charges,690.56,26962.13,
REVASC DES BYPASS GRAFT INI LD,46104147,CDM,481,RC,C9604,HCPCS,Outpatient,,,26962.13,16177.28,,16177.28,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,246.176,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7549.4,28,,77.112,Percent of Total Billed Charges,28% of Total Billed Charges,690.8,32,,68.328,Percent of Total Billed Charges,32% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,9706.37,36,,99.144,Percent of Total Billed Charges,36% of Total Billed Charges,9706.37,36,,99.144,Percent of Total Billed Charges,36% Total Bille Charges,9706.37,36,,99.144,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,456.112,Percent of Total Billed Charges,60% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,1243.944,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3887.94,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,20221.6,75,,730.952,Percent of Total Billed Charges,75% of Total Billed Charges,13481.07,50,,645.184,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,870,Percent of Total Billed Charges,50% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13481.07,50,,870,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,3484,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,3241.352,Fee Schedule,100% of ASC Tier Groupings fee schedule,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26962.13,100,,974.6,Percent of Total Billed Charges,100% of Total Billed Charges,690.8,26962.13,
REVASC DES BYPASS GRAFT INI RC,46104154,CDM,481,RC,C9604,HCPCS,Outpatient,,,26962.13,16177.28,,16177.28,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,245.44,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7549.4,28,,132.16,Percent of Total Billed Charges,28% of Total Billed Charges,690.96,32,,68.336,Percent of Total Billed Charges,32% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,9706.37,36,,169.92,Percent of Total Billed Charges,36% of Total Billed Charges,9706.37,36,,169.92,Percent of Total Billed Charges,36% Total Bille Charges,9706.37,36,,169.92,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,514.592,Percent of Total Billed Charges,60% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,2379.728,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3887.94,14.42,,138.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,20221.6,75,,1848.792,Percent of Total Billed Charges,75% of Total Billed Charges,13481.07,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13481.07,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,13481.07,50,,1508,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,1369.944,Fee Schedule,100% of ASC Tier Groupings fee schedule,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,3774.7,14,,134.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,26962.13,100,,2465.056,Percent of Total Billed Charges,100% of Total Billed Charges,690.96,26962.13,
REVASCULAR DES AMI INI LC,46104238,CDM,481,RC,C9606,HCPCS,Outpatient,,,30705.75,18423.45,,688,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,30705.75,100,,24.912,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8597.61,28,,128.632,Percent of Total Billed Charges,28% of Total Billed Charges,693.33,32,,68.432,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,165.384,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,165.384,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,165.384,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,34.672,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,314.312,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,449.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23029.31,75,,1426.816,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,870,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,787.48,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15352.88,50,,787.48,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,3114.8,Percent of Total Billed Charges,50% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,1739.072,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,436.8,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,1902.416,Percent of Total Billed Charges,100% of Total Billed Charges,688,30705.75,
REVASCULAR DES AMI INI LC,46104246,CDM,481,RC,C9606,HCPCS,Outpatient,,,30705.75,18423.45,,688,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,30705.75,100,,42.12,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8597.61,28,,46.088,Percent of Total Billed Charges,28% of Total Billed Charges,693.33,32,,68.432,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,59.256,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,59.256,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,59.256,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,4751.392,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,547.056,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,15.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23029.31,75,,817.64,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15352.88,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,510,Percent of Total Billed Charges,50% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,1159.376,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,1090.184,Percent of Total Billed Charges,100% of Total Billed Charges,688,30705.75,
REVASCULAR DES AMI INI LD,46104253,CDM,481,RC,C9606,HCPCS,Outpatient,,,30705.75,18423.45,,688,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,30705.75,100,,75.84,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8597.61,28,,154.112,Percent of Total Billed Charges,28% of Total Billed Charges,693.68,32,,68.504,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,198.144,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,198.144,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,198.144,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,4235.424,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,545.416,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,899.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23029.31,75,,729.464,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,787.48,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,573.376,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15352.88,50,,573.376,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,473.656,Percent of Total Billed Charges,50% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,1159.376,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,873.6,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,911.832,Percent of Total Billed Charges,100% of Total Billed Charges,688,30705.75,
REVASCULAR DES AMI INI LM,46104261,CDM,481,RC,C9606,HCPCS,Outpatient,,,30705.75,18423.45,,688,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,30705.75,100,,165.392,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8597.61,28,,124.936,Percent of Total Billed Charges,28% of Total Billed Charges,694.4,32,,68.608,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,160.632,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,160.632,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,160.632,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,2692.008,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,55.368,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,1176.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23029.31,75,,836.44,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15352.88,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,2282.8,Percent of Total Billed Charges,50% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,344.056,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,1142.064,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,1045.552,Percent of Total Billed Charges,100% of Total Billed Charges,688,30705.75,
REVASCULAR DES AMI INI RI,46104279,CDM,481,RC,C9606,HCPCS,Outpatient,,,30705.75,18423.45,,688,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,30705.75,100,,1099.44,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8597.61,28,,188.552,Percent of Total Billed Charges,28% of Total Billed Charges,694.8,32,,68.824,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,242.424,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,242.424,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,242.424,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,93.6,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,509.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23029.31,75,,5173.96,Percent of Total Billed Charges,75% of Total Billed Charges,15352.88,50,,573.376,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,2912,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15352.88,50,,2912,Percent of Total Billed Charges,50% of Total Billed Charges,15352.88,50,,3530.8,Percent of Total Billed Charges,50% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,267.376,Fee Schedule,100% of ASC Tier Groupings fee schedule,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,495.04,Percent of Total Billed Charges,14% of Total Billed Charges,30705.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30705.75,100,,6898.608,Percent of Total Billed Charges,100% of Total Billed Charges,688,30705.75,
REVASCULAR DES CTO INI RI,46104287,CDM,481,RC,C9607,HCPCS,Outpatient,,,30516.49,18309.89,,912.27,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,24131.69,150,,3400.344,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8544.62,28,,25.312,Percent of Total Billed Charges,28% of Total Billed Charges,694.8,32,,68.928,Percent of Total Billed Charges,32% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,10985.94,36,,32.544,Percent of Total Billed Charges,36% of Total Billed Charges,10985.94,36,,32.544,Percent of Total Billed Charges,36% Total Bille Charges,10985.94,36,,32.544,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,1576.184,Percent of Total Billed Charges,60% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,168.528,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4400.48,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,22887.37,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,15258.25,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,15258.25,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15258.25,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,15258.25,50,,1482.256,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,1280.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,4272.31,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30516.49,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,694.8,30516.49,
REVASCULAR BMS AMI INI LC,46104501,CDM,481,RC,92941,HCPCS,Outpatient,,,23361.5,14016.90,,470.46,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,23361.5,100,,1166.112,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6541.22,28,,31.584,Percent of Total Billed Charges,28% of Total Billed Charges,696,32,,69.04,Percent of Total Billed Charges,32% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,8410.14,36,,40.608,Percent of Total Billed Charges,36% of Total Billed Charges,8410.14,36,,40.608,Percent of Total Billed Charges,36% Total Bille Charges,8410.14,36,,40.608,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,3497.68,Percent of Total Billed Charges,60% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,367.544,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3368.73,14.42,,4.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,17521.13,75,,873.24,Percent of Total Billed Charges,75% of Total Billed Charges,11680.75,50,,2912,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,11680.75,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,11680.75,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7651,100,,1280.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,3270.61,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,23361.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23361.5,100,,1091.552,Percent of Total Billed Charges,100% of Total Billed Charges,470.46,23361.5,
IR TUBE EVAL GI COLIC,46105101,CDM,361,RC,,,Outpatient,,,845.25,507.15,,507.15,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,380.36,45,,65.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.67,28,,185.696,Percent of Total Billed Charges,28% of Total Billed Charges,696.89,32,,69.04,Percent of Total Billed Charges,32% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,304.29,36,,238.752,Percent of Total Billed Charges,36% of Total Billed Charges,304.29,36,,238.752,Percent of Total Billed Charges,36% Total Bille Charges,304.29,36,,238.752,Percent of Total Billed Charges,36% of Total Billed Charges,507.15,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,845.25,100,,2443.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.89,14.42,,4.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,633.94,75,,2641.024,Percent of Total Billed Charges,75% of Total Billed Charges,422.63,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,422.63,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.63,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,422.63,50,,209.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,591.68,70,,1920.976,Percent of Total Billed Charges,70% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,4.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,845.25,100,,3521.368,Percent of Total Billed Charges,100% of Total Billed Charges,118.34,845.25,
BLLN SLEEK <150CM,46105103,CDM,272,RC,C1725,HCPCS,Outpatient,,,829.23,497.54,,99.47,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,373.15,45,,556.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.18,28,,85.68,Percent of Total Billed Charges,28% of Total Billed Charges,698.4,32,,69.04,Percent of Total Billed Charges,32% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,298.52,36,,110.16,Percent of Total Billed Charges,36% of Total Billed Charges,298.52,36,,110.16,Percent of Total Billed Charges,36% Total Bille Charges,298.52,36,,110.16,Percent of Total Billed Charges,36% of Total Billed Charges,497.54,60,,9064,Percent of Total Billed Charges,60% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,829.23,100,,7556.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,119.57,14.42,,5.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.92,75,,842.056,Percent of Total Billed Charges,75% of Total Billed Charges,414.62,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,414.62,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.62,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,414.62,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580.46,70,,769.072,Percent of Total Billed Charges,70% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,116.09,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,829.23,100,,1122.736,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,829.23,
IR TUBE REPL GAST COLON FLUORO,46105109,CDM,361,RC,49450,HCPCS,Outpatient,,,1425.02,855.01,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1247.49,150,,65.88,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1831.19,233,,86.184,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,701.35,32,,6912,Percent of Total Billed Charges,32% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,2530.66,322,,110.808,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2530.66,322,,110.808,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2530.66,322,,110.808,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,9064,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,2591.36,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,205.49,14.42,,5.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1068.77,75,,833.184,Percent of Total Billed Charges,75% of Total Billed Charges,712.51,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,712.51,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,712.51,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,712.51,50,,645.184,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1159.376,Fee Schedule,100% of ASC Tier Groupings fee schedule,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,5,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1425.02,100,,1110.912,Percent of Total Billed Charges,100% of Total Billed Charges,199.5,2601,
POWER GLIDE BASIC KIT,46105110,CDM,278,RC,C1751,HCPCS,Outpatient,,,263.84,158.30,,357.88,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,64.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,111.832,Percent of Total Billed Charges,28% of Total Billed Charges,701.35,32,,6912,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,143.784,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,143.784,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,143.784,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,145.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,2999.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,965.264,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,9520,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,9520,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,1739.072,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,2912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,1287.016,Percent of Total Billed Charges,100% of Total Billed Charges,36.94,701.35,
POWER GLIDE FULL KIT,46105111,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,4608,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,16.24,Percent of Total Billed Charges,28% of Total Billed Charges,701.71,32,,6912,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,20.88,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,20.88,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,20.88,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,9119.272,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1236.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,1049.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,762.064,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,870,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1159.376,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1019.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,952.576,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,701.71,
CATH PALINDROME KIT RUBY 19X36,46105114,CDM,278,RC,C1750,HCPCS,Outpatient,,,2233.54,1340.12,,2971.79,110,,1555.2,Percent of Total Billed Charges,110% of Total Billed Charges,1005.09,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,625.39,28,,23.184,Percent of Total Billed Charges,28% of Total Billed Charges,701.71,32,,7065.6,Percent of Total Billed Charges,32% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,804.07,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,804.07,36,,29.808,Percent of Total Billed Charges,36% Total Bille Charges,804.07,36,,29.808,Percent of Total Billed Charges,36% of Total Billed Charges,1228.45,55,,4236.96,Percent of Total Billed Charges,55% Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2233.54,100,,146.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14.42,,10.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1786.83,80,,612,Percent of Total Billed Charges,80% of Total Billed Charges,1116.77,50,,9520,Percent of Total Billed Charges,50% of Total Billed Charges,1116.77,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1116.77,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,1116.77,50,,720,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1563.48,70,,1343.136,Percent of Total Billed Charges,70% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,312.7,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2233.54,100,,816,Percent of Total Billed Charges,100% of Total Billed Charges,312.7,2971.79,
CATH PEEL AWAY 15.5FR X 32CM,46105117,CDM,278,RC,C1750,HCPCS,Outpatient,,,1583.73,950.24,,2257,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,712.68,45,,88.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.44,28,,32.312,Percent of Total Billed Charges,28% of Total Billed Charges,701.71,32,,6.96,Percent of Total Billed Charges,32% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,570.14,36,,41.544,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,36,,41.544,Percent of Total Billed Charges,36% Total Bille Charges,570.14,36,,41.544,Percent of Total Billed Charges,36% of Total Billed Charges,871.05,55,,102.36,Percent of Total Billed Charges,55% Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.73,100,,142.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,228.37,14.42,,814.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1266.98,80,,951.216,Percent of Total Billed Charges,80% of Total Billed Charges,791.87,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,3313.576,Percent of Total Billed Charges,50% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.87,50,,3313.576,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,787.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.61,70,,895.424,Percent of Total Billed Charges,70% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,790.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1583.73,100,,1189.016,Percent of Total Billed Charges,100% of Total Billed Charges,221.72,2257,
CATH TORCON 5FR MIK 80CM,46105124,CDM,272,RC,,,Outpatient,,,108,64.80,,64.8,60,,2411.4,Percent of Total Billed Charges,60% of Total Billed Charges,48.6,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.24,28,,15.288,Percent of Total Billed Charges,28% of Total Billed Charges,702.24,32,,6.968,Percent of Total Billed Charges,32% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,38.88,36,,19.656,Percent of Total Billed Charges,36% of Total Billed Charges,38.88,36,,19.656,Percent of Total Billed Charges,36% Total Bille Charges,38.88,36,,19.656,Percent of Total Billed Charges,36% of Total Billed Charges,64.8,60,,170.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108,100,,57.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14.42,,731.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81,75,,8212.664,Percent of Total Billed Charges,75% of Total Billed Charges,54,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,54,50,,552,Percent of Total Billed Charges,50% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54,50,,552,Percent of Total Billed Charges,50% of Total Billed Charges,54,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,70,,895.424,Percent of Total Billed Charges,70% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,710.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108,100,,10950.216,Percent of Total Billed Charges,100% of Total Billed Charges,15.12,702.24,
CATH MICKEY AD 20FRX7-10ML LF,46105126,CDM,272,RC,C1781,HCPCS,Outpatient,,,190.15,114.09,,452.76,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,85.57,45,,153.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.24,28,,21.904,Percent of Total Billed Charges,28% of Total Billed Charges,710.4,32,,6.984,Percent of Total Billed Charges,32% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,68.45,36,,28.168,Percent of Total Billed Charges,36% of Total Billed Charges,68.45,36,,28.168,Percent of Total Billed Charges,36% Total Bille Charges,68.45,36,,28.168,Percent of Total Billed Charges,36% of Total Billed Charges,114.09,60,,584.76,Percent of Total Billed Charges,60% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.15,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,27.42,14.42,,2256.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.61,75,,123.128,Percent of Total Billed Charges,75% of Total Billed Charges,95.08,50,,3313.576,Percent of Total Billed Charges,50% of Total Billed Charges,95.08,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.08,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,95.08,50,,573.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.11,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,26.62,14,,2190.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.15,100,,164.168,Percent of Total Billed Charges,100% of Total Billed Charges,26.62,710.4,
CATH NPH FLXM PG REG 10FRX25CM,46105129,CDM,272,RC,C1729,HCPCS,Outpatient,,,37.67,22.60,,11.1,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,16.95,45,,195.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.55,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,714.73,32,,7.008,Percent of Total Billed Charges,32% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,13.56,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,13.56,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,13.56,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,22.6,60,,857.648,Percent of Total Billed Charges,60% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.67,100,,196.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.43,14.42,,1928.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.25,75,,41.528,Percent of Total Billed Charges,75% of Total Billed Charges,18.84,50,,552,Percent of Total Billed Charges,50% of Total Billed Charges,18.84,50,,4783.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.84,50,,4783.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.84,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.37,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,14,,1871.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.67,100,,55.368,Percent of Total Billed Charges,100% of Total Billed Charges,5.27,714.73,
STENT ASSURANT COBALT SYSTEM,46105130,CDM,278,RC,C1876,HCPCS,Outpatient,,,2100,1260.00,,3741.75,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,945,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,588,28,,311.328,Percent of Total Billed Charges,28% of Total Billed Charges,715.2,32,,7.024,Percent of Total Billed Charges,32% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,756,36,,400.272,Percent of Total Billed Charges,36% of Total Billed Charges,756,36,,400.272,Percent of Total Billed Charges,36% Total Bille Charges,756,36,,400.272,Percent of Total Billed Charges,36% of Total Billed Charges,1155,55,,1149.12,Percent of Total Billed Charges,55% Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2100,100,,168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,302.82,14.42,,2170.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1680,80,,56.632,Percent of Total Billed Charges,80% of Total Billed Charges,1050,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,1050,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,1050,50,,2912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1470,70,,136.64,Percent of Total Billed Charges,70% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,2107.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,294,3741.75,
BALLOON AMPHIRION,46105132,CDM,272,RC,C1725,HCPCS,Outpatient,,,584.76,350.86,,99.47,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,263.14,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.73,28,,538.032,Percent of Total Billed Charges,28% of Total Billed Charges,716.11,32,,7.064,Percent of Total Billed Charges,32% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,210.51,36,,691.752,Percent of Total Billed Charges,36% of Total Billed Charges,210.51,36,,691.752,Percent of Total Billed Charges,36% Total Bille Charges,210.51,36,,691.752,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.76,100,,341.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,84.32,14.42,,536.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.57,75,,951.216,Percent of Total Billed Charges,75% of Total Billed Charges,292.38,50,,4783.6,Percent of Total Billed Charges,50% of Total Billed Charges,292.38,50,,916,Percent of Total Billed Charges,50% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.38,50,,916,Percent of Total Billed Charges,50% of Total Billed Charges,292.38,50,,3806.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,409.33,70,,137.312,Percent of Total Billed Charges,70% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,81.87,14,,521.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.76,100,,1189.016,Percent of Total Billed Charges,100% of Total Billed Charges,81.87,716.11,
BALLOON ADMIRAL XTREME OTW PTA,46105134,CDM,272,RC,C1725,HCPCS,Outpatient,,,1120.79,672.47,,99.47,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,504.36,45,,49.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.82,28,,538.032,Percent of Total Billed Charges,28% of Total Billed Charges,716.56,32,,7.064,Percent of Total Billed Charges,32% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,403.48,36,,691.752,Percent of Total Billed Charges,36% of Total Billed Charges,403.48,36,,691.752,Percent of Total Billed Charges,36% Total Bille Charges,403.48,36,,691.752,Percent of Total Billed Charges,36% of Total Billed Charges,672.47,60,,274.984,Percent of Total Billed Charges,60% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1120.79,100,,434,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,161.62,14.42,,546.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,840.59,75,,421.032,Percent of Total Billed Charges,75% of Total Billed Charges,560.4,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,560.4,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560.4,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,560.4,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784.55,70,,92.96,Percent of Total Billed Charges,70% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.91,14,,530.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1120.79,100,,526.288,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,1120.79,
EXPRESS LD 6.0X27X25CM,46105135,CDM,278,RC,C1876,HCPCS,Outpatient,,,2731.58,1638.95,,4436.49,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,1229.21,45,,354.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764.84,28,,245.944,Percent of Total Billed Charges,28% of Total Billed Charges,719.04,32,,7.08,Percent of Total Billed Charges,32% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,983.37,36,,316.216,Percent of Total Billed Charges,36% of Total Billed Charges,983.37,36,,316.216,Percent of Total Billed Charges,36% Total Bille Charges,983.37,36,,316.216,Percent of Total Billed Charges,36% of Total Billed Charges,1502.37,55,,1119.696,Percent of Total Billed Charges,55% Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2731.58,100,,254,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,393.89,14.42,,2907.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2185.26,80,,299.76,Percent of Total Billed Charges,80% of Total Billed Charges,1365.79,50,,916,Percent of Total Billed Charges,50% of Total Billed Charges,1365.79,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365.79,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1365.79,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1912.11,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,382.42,14,,2822.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2731.58,100,,399.68,Percent of Total Billed Charges,100% of Total Billed Charges,382.42,4436.49,
BALLOON NC EUPHORA,46105137,CDM,272,RC,C1725,HCPCS,Outpatient,,,534.6,320.76,,99.47,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,240.57,45,,4599,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,853.848,Percent of Total Billed Charges,28% of Total Billed Charges,719.16,32,,7.08,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,1097.808,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,1097.808,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,1097.808,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,1036.192,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,500,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,1727.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,49.08,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,2657.6,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,2657.6,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,13600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1677.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,65.44,Percent of Total Billed Charges,100% of Total Billed Charges,74.84,719.16,
BALLOON PTA POWERCROSS ALL,46105139,CDM,272,RC,C1725,HCPCS,Outpatient,,,804.05,482.43,,99.47,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,361.82,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.13,28,,864.36,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.08,Percent of Total Billed Charges,32% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,289.46,36,,1111.32,Percent of Total Billed Charges,36% of Total Billed Charges,289.46,36,,1111.32,Percent of Total Billed Charges,36% Total Bille Charges,289.46,36,,1111.32,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,60,,374.4,Percent of Total Billed Charges,60% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,100,,110.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,115.94,14.42,,4520.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.04,75,,646.16,Percent of Total Billed Charges,75% of Total Billed Charges,402.03,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,570,Percent of Total Billed Charges,50% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.03,50,,570,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.84,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,4388.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.05,100,,861.544,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,804.05,
CATH BIOFLO DURAMAX 24CM,46105140,CDM,278,RC,C1750,HCPCS,Outpatient,,,1364.44,818.66,,2015.78,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,614,45,,1166.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.04,28,,1296.544,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.096,Percent of Total Billed Charges,32% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,491.2,36,,1666.984,Percent of Total Billed Charges,36% of Total Billed Charges,491.2,36,,1666.984,Percent of Total Billed Charges,36% Total Bille Charges,491.2,36,,1666.984,Percent of Total Billed Charges,36% of Total Billed Charges,750.44,55,,468,Percent of Total Billed Charges,55% Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1364.44,100,,788,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,196.75,14.42,,2762.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1091.55,80,,1721.104,Percent of Total Billed Charges,80% of Total Billed Charges,682.22,50,,2657.6,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,9520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.11,70,,59.584,Percent of Total Billed Charges,70% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,2681.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,100,,2151.384,Percent of Total Billed Charges,100% of Total Billed Charges,191.02,2015.78,
CATH FLEXIMA DRAIN BILI REG,46105141,CDM,272,RC,C1729,HCPCS,Outpatient,,,374.22,224.53,,11.1,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,168.4,45,,3191.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.78,28,,547.976,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.096,Percent of Total Billed Charges,32% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,134.72,36,,704.544,Percent of Total Billed Charges,36% of Total Billed Charges,134.72,36,,704.544,Percent of Total Billed Charges,36% Total Bille Charges,134.72,36,,704.544,Percent of Total Billed Charges,36% of Total Billed Charges,224.53,60,,175.168,Percent of Total Billed Charges,60% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.22,100,,10220,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,53.96,14.42,,2816.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.67,75,,2558.976,Percent of Total Billed Charges,75% of Total Billed Charges,187.11,50,,570,Percent of Total Billed Charges,50% of Total Billed Charges,187.11,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.11,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,187.11,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.95,70,,53.2,Percent of Total Billed Charges,70% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,52.39,14,,2734.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,100,,3411.968,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,720,
CATH KIT DRN PLEURX PLR,46105144,CDM,272,RC,C1729,HCPCS,Outpatient,,,3434.92,2060.95,,11.1,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,1545.71,45,,1166.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,961.78,28,,695.624,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.104,Percent of Total Billed Charges,32% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,1236.57,36,,894.376,Percent of Total Billed Charges,36% of Total Billed Charges,1236.57,36,,894.376,Percent of Total Billed Charges,36% Total Bille Charges,1236.57,36,,894.376,Percent of Total Billed Charges,36% of Total Billed Charges,2060.95,60,,175.552,Percent of Total Billed Charges,60% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3434.92,100,,67.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,495.32,14.42,,4812.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2576.19,75,,1490.68,Percent of Total Billed Charges,75% of Total Billed Charges,1717.46,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,1717.46,50,,31.176,Percent of Total Billed Charges,50% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1717.46,50,,31.176,Percent of Total Billed Charges,50% of Total Billed Charges,1717.46,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2404.44,70,,74.416,Percent of Total Billed Charges,70% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,480.89,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3434.92,100,,1987.568,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,3434.92,
CATH EP QUAD SUPREME 2-8-2 120,46105146,CDM,272,RC,,,Outpatient,,,225.6,135.36,,135.36,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,101.52,45,,1752.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.17,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.128,Percent of Total Billed Charges,32% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,81.22,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,81.22,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,81.22,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,135.36,60,,711.288,Percent of Total Billed Charges,60% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.6,100,,2591.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,32.53,14.42,,4812.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.2,75,,1490.68,Percent of Total Billed Charges,75% of Total Billed Charges,112.8,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,112.8,50,,744,Percent of Total Billed Charges,50% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.8,50,,744,Percent of Total Billed Charges,50% of Total Billed Charges,112.8,50,,3313.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.92,70,,586.656,Percent of Total Billed Charges,70% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,31.58,14,,4672.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.6,100,,1987.568,Percent of Total Billed Charges,100% of Total Billed Charges,31.58,720,
BALLOON ARMADA 35 PTA,46105147,CDM,272,RC,C1725,HCPCS,Outpatient,,,1924.84,1154.90,,99.47,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,866.18,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.96,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.144,Percent of Total Billed Charges,32% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,692.94,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,692.94,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,692.94,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,1154.9,60,,1903.2,Percent of Total Billed Charges,60% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1924.84,100,,7093.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,277.56,14.42,,4631.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1443.63,75,,3954.04,Percent of Total Billed Charges,75% of Total Billed Charges,962.42,50,,31.176,Percent of Total Billed Charges,50% of Total Billed Charges,962.42,50,,10180.8,Percent of Total Billed Charges,50% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,962.42,50,,10180.8,Percent of Total Billed Charges,50% of Total Billed Charges,962.42,50,,552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1347.39,70,,585.76,Percent of Total Billed Charges,70% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,269.48,14,,4496.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1924.84,100,,5272.056,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,1924.84,
STENT VASC OMNILINK (LOW),46105149,CDM,278,RC,C1876,HCPCS,Outpatient,,,2646.88,1588.13,,4343.32,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1191.1,45,,242.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,741.13,28,,137.624,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,7.16,Percent of Total Billed Charges,32% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,952.88,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,952.88,36,,176.944,Percent of Total Billed Charges,36% Total Bille Charges,952.88,36,,176.944,Percent of Total Billed Charges,36% of Total Billed Charges,1455.78,55,,121.92,Percent of Total Billed Charges,55% Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2646.88,100,,2591.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,381.68,14.42,,10.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2117.5,80,,3954.04,Percent of Total Billed Charges,80% of Total Billed Charges,1323.44,50,,744,Percent of Total Billed Charges,50% of Total Billed Charges,1323.44,50,,2215.2,Percent of Total Billed Charges,50% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323.44,50,,2215.2,Percent of Total Billed Charges,50% of Total Billed Charges,1323.44,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1852.82,70,,102.904,Percent of Total Billed Charges,70% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,370.56,14,,10.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2646.88,100,,5272.056,Percent of Total Billed Charges,100% of Total Billed Charges,370.56,4343.32,
IR CATH PORTAL VEIN PERC,46105151,CDM,361,RC,,,Outpatient,,,2093.81,1256.29,,1256.29,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,942.21,45,,313.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,586.27,28,,106.952,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,69.384,Percent of Total Billed Charges,32% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,753.77,36,,137.504,Percent of Total Billed Charges,36% of Total Billed Charges,753.77,36,,137.504,Percent of Total Billed Charges,36% Total Bille Charges,753.77,36,,137.504,Percent of Total Billed Charges,36% of Total Billed Charges,1256.29,60,,36.48,Percent of Total Billed Charges,60% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2093.81,100,,3893.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,301.93,14.42,,11.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1570.36,75,,7470.456,Percent of Total Billed Charges,75% of Total Billed Charges,1046.91,50,,10180.8,Percent of Total Billed Charges,50% of Total Billed Charges,1046.91,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1046.91,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,1046.91,50,,4783.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1465.67,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,293.13,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2093.81,100,,9960.608,Percent of Total Billed Charges,100% of Total Billed Charges,293.13,2093.81,
SET BIOPSY LIVER ACCESS 7FRX20,46105153,CDM,272,RC,C1887,HCPCS,Outpatient,,,1268.34,761.00,,43.86,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,570.75,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.14,28,,512.264,Percent of Total Billed Charges,28% of Total Billed Charges,720,32,,69.544,Percent of Total Billed Charges,32% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,456.6,36,,658.624,Percent of Total Billed Charges,36% of Total Billed Charges,456.6,36,,658.624,Percent of Total Billed Charges,36% Total Bille Charges,456.6,36,,658.624,Percent of Total Billed Charges,36% of Total Billed Charges,761,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1268.34,100,,254,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,182.89,14.42,,11.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,951.26,75,,260.712,Percent of Total Billed Charges,75% of Total Billed Charges,634.17,50,,2215.2,Percent of Total Billed Charges,50% of Total Billed Charges,634.17,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,634.17,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,634.17,50,,3720.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,887.84,70,,324.8,Percent of Total Billed Charges,70% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,177.57,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1268.34,100,,347.616,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1268.34,
INTRO SHTH CHECK-FLO 12F 30CM,46105154,CDM,272,RC,C1894,HCPCS,Outpatient,,,438.37,263.02,,82.29,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,197.27,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.74,28,,512.264,Percent of Total Billed Charges,28% of Total Billed Charges,721.28,32,,69.992,Percent of Total Billed Charges,32% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,157.81,36,,658.624,Percent of Total Billed Charges,36% of Total Billed Charges,157.81,36,,658.624,Percent of Total Billed Charges,36% Total Bille Charges,157.81,36,,658.624,Percent of Total Billed Charges,36% of Total Billed Charges,263.02,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.37,100,,537.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14.42,,11.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.78,75,,4080.424,Percent of Total Billed Charges,75% of Total Billed Charges,219.19,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,219.19,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.19,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,219.19,50,,916,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.86,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,61.37,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.37,100,,5440.568,Percent of Total Billed Charges,100% of Total Billed Charges,61.37,721.28,
IR DRN ABS CATH EXCH,46105156,CDM,361,RC,,,Outpatient,,,2784.92,1670.95,,1670.95,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,1253.21,45,,1769.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.78,28,,768.392,Percent of Total Billed Charges,28% of Total Billed Charges,721.28,32,,69.992,Percent of Total Billed Charges,32% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,1002.57,36,,987.936,Percent of Total Billed Charges,36% of Total Billed Charges,1002.57,36,,987.936,Percent of Total Billed Charges,36% Total Bille Charges,1002.57,36,,987.936,Percent of Total Billed Charges,36% of Total Billed Charges,1670.95,60,,403.2,Percent of Total Billed Charges,60% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2784.92,100,,695.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,401.59,14.42,,11.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2088.69,75,,1150.2,Percent of Total Billed Charges,75% of Total Billed Charges,1392.46,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,1392.46,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.46,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,1392.46,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.44,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2784.92,100,,1533.6,Percent of Total Billed Charges,100% of Total Billed Charges,389.89,2784.92,
IR INJ MYELOGRAPHY W SI LS,46105157,CDM,361,RC,,,Outpatient,,,2258.7,1355.22,,1355.22,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,1016.42,45,,3456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.44,28,,307.632,Percent of Total Billed Charges,28% of Total Billed Charges,721.28,32,,70.096,Percent of Total Billed Charges,32% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,813.13,36,,395.52,Percent of Total Billed Charges,36% of Total Billed Charges,813.13,36,,395.52,Percent of Total Billed Charges,36% Total Bille Charges,813.13,36,,395.52,Percent of Total Billed Charges,36% of Total Billed Charges,1355.22,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2258.7,100,,132.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,325.7,14.42,,11.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1694.03,75,,1150.2,Percent of Total Billed Charges,75% of Total Billed Charges,1129.35,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1129.35,50,,1560,Percent of Total Billed Charges,50% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1129.35,50,,1560,Percent of Total Billed Charges,50% of Total Billed Charges,1129.35,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1581.09,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,10.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2258.7,100,,1533.6,Percent of Total Billed Charges,100% of Total Billed Charges,316.22,2258.7,
STENT URET FLXM 24CM 8FR PU,46105158,CDM,278,RC,C2617,HCPCS,Outpatient,,,974.6,584.76,,1265.61,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,438.57,45,,1166.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,721.29,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,536.03,55,,215.928,Percent of Total Billed Charges,55% Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,132.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,17.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.68,80,,5296.2,Percent of Total Billed Charges,80% of Total Billed Charges,487.3,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,2657.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,17.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,7061.6,Percent of Total Billed Charges,100% of Total Billed Charges,136.44,1265.61,
STENT URET PGTL 8FRX26CM FLXMA,46105159,CDM,278,RC,C2617,HCPCS,Outpatient,,,974.6,584.76,,1265.61,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,438.57,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,28,,695.624,Percent of Total Billed Charges,28% of Total Billed Charges,721.73,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,350.86,36,,894.376,Percent of Total Billed Charges,36% of Total Billed Charges,350.86,36,,894.376,Percent of Total Billed Charges,36% Total Bille Charges,350.86,36,,894.376,Percent of Total Billed Charges,36% of Total Billed Charges,536.03,55,,64.32,Percent of Total Billed Charges,55% Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,974.6,100,,3931.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,140.54,14.42,,22.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.68,80,,511.672,Percent of Total Billed Charges,80% of Total Billed Charges,487.3,50,,1560,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.3,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,487.3,50,,570,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.44,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,100,,682.224,Percent of Total Billed Charges,100% of Total Billed Charges,136.44,1265.61,
PARACENTESIS THOR 8FRX4.75IN,46105161,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,16.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,463.752,Percent of Total Billed Charges,28% of Total Billed Charges,722.62,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,596.256,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,596.256,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,121.92,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,7680,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,56.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,56.632,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,430.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,63.504,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,54.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,21,722.62,
IR DRN PARACENTESIS W IMG,46105162,CDM,361,RC,,,Outpatient,,,1847.63,1108.58,,1108.58,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,831.43,45,,4.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.34,28,,537.256,Percent of Total Billed Charges,28% of Total Billed Charges,722.74,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,665.15,36,,690.76,Percent of Total Billed Charges,36% of Total Billed Charges,665.15,36,,690.76,Percent of Total Billed Charges,36% Total Bille Charges,665.15,36,,690.76,Percent of Total Billed Charges,36% of Total Billed Charges,1108.58,60,,168.672,Percent of Total Billed Charges,60% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1847.63,100,,2592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,266.43,14.42,,9.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1385.72,75,,1937.936,Percent of Total Billed Charges,75% of Total Billed Charges,923.82,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,1768,Percent of Total Billed Charges,50% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,923.82,50,,1768,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,3399,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1293.34,70,,361.2,Percent of Total Billed Charges,70% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,9.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1847.63,100,,2422.424,Percent of Total Billed Charges,100% of Total Billed Charges,258.67,1847.63,
16FR. PEEL AWAY SHEATH,46105163,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.36,159.22,,82.29,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,119.41,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.3,28,,358.168,Percent of Total Billed Charges,28% of Total Billed Charges,722.78,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.53,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,95.53,36,,460.504,Percent of Total Billed Charges,36% Total Bille Charges,95.53,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,159.22,60,,1391.136,Percent of Total Billed Charges,60% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.36,100,,0.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,38.26,14.42,,14.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.02,75,,33.184,Percent of Total Billed Charges,75% of Total Billed Charges,132.68,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,31.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.75,70,,126,Percent of Total Billed Charges,70% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,13.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.36,100,,44.24,Percent of Total Billed Charges,100% of Total Billed Charges,37.15,722.78,
IR NEPHRO TUBE REMOVAL W FLUOR,46105169,CDM,361,RC,,,Outpatient,,,1624.79,974.87,,974.87,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,731.16,45,,0.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,454.94,28,,358.168,Percent of Total Billed Charges,28% of Total Billed Charges,722.78,32,,70.272,Percent of Total Billed Charges,32% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,584.92,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,584.92,36,,460.504,Percent of Total Billed Charges,36% Total Bille Charges,584.92,36,,460.504,Percent of Total Billed Charges,36% of Total Billed Charges,974.87,60,,159.688,Percent of Total Billed Charges,60% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1624.79,100,,36.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,234.29,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1218.59,75,,48.624,Percent of Total Billed Charges,75% of Total Billed Charges,812.4,50,,1768,Percent of Total Billed Charges,50% of Total Billed Charges,812.4,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,812.4,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,812.4,50,,744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1137.35,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,227.47,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1624.79,100,,64.832,Percent of Total Billed Charges,100% of Total Billed Charges,227.47,1624.79,
PARTICLES PVA FOAM EMBOLIZATIO,46105170,CDM,272,RC,,,Outpatient,,,448,268.80,,268.8,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,201.6,45,,22.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.44,28,,54.656,Percent of Total Billed Charges,28% of Total Billed Charges,728,32,,70.32,Percent of Total Billed Charges,32% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,161.28,36,,70.272,Percent of Total Billed Charges,36% of Total Billed Charges,161.28,36,,70.272,Percent of Total Billed Charges,36% Total Bille Charges,161.28,36,,70.272,Percent of Total Billed Charges,36% of Total Billed Charges,268.8,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,448,100,,9.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,64.6,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,224,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,224,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,224,50,,10180.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.6,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,62.72,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,62.72,728,
CATH USHER SUPPORT,46105171,CDM,272,RC,C1714,HCPCS,Outpatient,,,885,531.00,,389.94,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,398.25,45,,24.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.8,28,,54.928,Percent of Total Billed Charges,28% of Total Billed Charges,731.32,32,,70.4,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,318.6,36,,70.616,Percent of Total Billed Charges,36% of Total Billed Charges,318.6,36,,70.616,Percent of Total Billed Charges,36% Total Bille Charges,318.6,36,,70.616,Percent of Total Billed Charges,36% of Total Billed Charges,531,60,,664.68,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,22.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.75,75,,288.688,Percent of Total Billed Charges,75% of Total Billed Charges,442.5,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.5,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,2215.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.5,70,,98,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,22.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885,100,,384.912,Percent of Total Billed Charges,100% of Total Billed Charges,123.9,885,
CATH CROSSER 56-154CM,46105172,CDM,272,RC,C1714,HCPCS,Outpatient,,,6628.05,3976.83,,389.94,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,2982.62,45,,14.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1855.85,28,,37.184,Percent of Total Billed Charges,28% of Total Billed Charges,731.8,32,,70.4,Percent of Total Billed Charges,32% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,2386.1,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,2386.1,36,,47.808,Percent of Total Billed Charges,36% Total Bille Charges,2386.1,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,3976.83,60,,1796.08,Percent of Total Billed Charges,60% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6628.05,100,,1.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,955.76,14.42,,23.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4971.04,75,,288.688,Percent of Total Billed Charges,75% of Total Billed Charges,3314.03,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,3314.03,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3314.03,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,3314.03,50,,6587.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4639.64,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,927.93,14,,22.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6628.05,100,,384.912,Percent of Total Billed Charges,100% of Total Billed Charges,389.94,6628.05,
IR DRN ABS CATH CHECK,46105173,CDM,361,RC,49424,HCPCS,Outpatient,,,896.93,538.16,,2601,100,,2232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,403.62,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,70.4,Other,Not Seperately Reimbusable,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.16,60,,109.088,Percent of Total Billed Charges,60% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,896.93,100,,50.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,129.34,14.42,,24.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.7,75,,50.968,Percent of Total Billed Charges,75% of Total Billed Charges,448.47,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,448.47,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.47,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,448.47,50,,4368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,89.6,Fee Schedule,100% of ASC Tier Groupings fee schedule,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,23.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,896.93,100,,67.952,Percent of Total Billed Charges,100% of Total Billed Charges,125.57,2601,
CATH ATHER HAWK ONE STAND TIP,46105175,CDM,272,RC,C1714,HCPCS,Outpatient,,,11896.5,7137.90,,389.94,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,5353.43,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3331.02,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,731.8,32,,70.4,Percent of Total Billed Charges,32% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,4282.74,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,4282.74,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,4282.74,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,7137.9,60,,143.496,Percent of Total Billed Charges,60% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11896.5,100,,53.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1715.48,14.42,,25.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8922.38,75,,2641.024,Percent of Total Billed Charges,75% of Total Billed Charges,5948.25,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,5948.25,50,,3640,Percent of Total Billed Charges,50% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5948.25,50,,3640,Percent of Total Billed Charges,50% of Total Billed Charges,5948.25,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8327.55,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,1665.51,14,,24.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11896.5,100,,3521.368,Percent of Total Billed Charges,100% of Total Billed Charges,389.94,11896.5,
CATH ATHER HAWK ONE EXTEND TIP,46105176,CDM,272,RC,C1714,HCPCS,Outpatient,,,11879.51,7127.71,,389.94,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,5345.78,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3326.26,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,731.8,32,,70.816,Percent of Total Billed Charges,32% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,4276.62,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,4276.62,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,4276.62,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,7127.71,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11879.51,100,,31.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1713.03,14.42,,31.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8909.63,75,,175.888,Percent of Total Billed Charges,75% of Total Billed Charges,5939.76,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,5939.76,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5939.76,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,5939.76,50,,480,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8315.66,70,,103.6,Percent of Total Billed Charges,70% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,1663.13,14,,30.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11879.51,100,,234.52,Percent of Total Billed Charges,100% of Total Billed Charges,389.94,11879.51,
8 FR BIOFLO MEDIPORT,46105177,CDM,278,RC,C1788,HCPCS,Outpatient,,,1705.55,1023.33,,2484.92,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,767.5,45,,9.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,28,,23.832,Percent of Total Billed Charges,28% of Total Billed Charges,731.8,32,,70.88,Percent of Total Billed Charges,32% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,614,36,,30.64,Percent of Total Billed Charges,36% of Total Billed Charges,614,36,,30.64,Percent of Total Billed Charges,36% Total Bille Charges,614,36,,30.64,Percent of Total Billed Charges,36% of Total Billed Charges,938.05,55,,631.544,Percent of Total Billed Charges,55% Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1705.55,100,,13.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,245.94,14.42,,28.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1364.44,80,,3313.592,Percent of Total Billed Charges,80% of Total Billed Charges,852.78,50,,3640,Percent of Total Billed Charges,50% of Total Billed Charges,852.78,50,,2824.64,Percent of Total Billed Charges,50% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,50,,2824.64,Percent of Total Billed Charges,50% of Total Billed Charges,852.78,50,,1560,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1193.89,70,,502.32,Percent of Total Billed Charges,70% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,238.78,14,,27.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1705.55,100,,4141.992,Percent of Total Billed Charges,100% of Total Billed Charges,238.78,2484.92,
PACEMAKER ASSURITY PM 2240,46105180,CDM,275,RC,C1785,HCPCS,Outpatient,,,8008.04,4804.82,,9084.26,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,3603.62,45,,3.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2242.25,28,,21.28,Percent of Total Billed Charges,28% of Total Billed Charges,732.8,32,,70.952,Percent of Total Billed Charges,32% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,2882.89,36,,27.36,Percent of Total Billed Charges,36% of Total Billed Charges,2882.89,36,,27.36,Percent of Total Billed Charges,36% Total Bille Charges,2882.89,36,,27.36,Percent of Total Billed Charges,36% of Total Billed Charges,4404.42,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8008.04,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1154.76,14.42,,5.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6006.03,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,4004.02,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,4004.02,50,,2536.608,Percent of Total Billed Charges,50% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4004.02,50,,2536.608,Percent of Total Billed Charges,50% of Total Billed Charges,4004.02,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5605.63,70,,232.96,Percent of Total Billed Charges,70% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,1121.13,14,,5.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8008.04,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,732.8,9084.26,
GW 70CM 3MM J TIP .038,46105181,CDM,272,RC,C1769,HCPCS,Outpatient,,,64.57,38.74,,55.13,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,29.06,45,,0.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.08,28,,29.768,Percent of Total Billed Charges,28% of Total Billed Charges,732.9,32,,70.96,Percent of Total Billed Charges,32% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,23.25,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,23.25,36,,38.272,Percent of Total Billed Charges,36% Total Bille Charges,23.25,36,,38.272,Percent of Total Billed Charges,36% of Total Billed Charges,38.74,60,,153.968,Percent of Total Billed Charges,60% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.57,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.31,14.42,,6.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.43,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,32.29,50,,2824.64,Percent of Total Billed Charges,50% of Total Billed Charges,32.29,50,,7823.048,Percent of Total Billed Charges,50% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.29,50,,7823.048,Percent of Total Billed Charges,50% of Total Billed Charges,32.29,50,,3120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.2,70,,453.6,Percent of Total Billed Charges,70% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,9.04,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.57,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,9.04,732.9,
CATH INNERCOOL 10.7FR,46105182,CDM,272,RC,,,Outpatient,,,3380,2028.00,,2028,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,1521,45,,17.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,946.4,28,,234.664,Percent of Total Billed Charges,28% of Total Billed Charges,732.9,32,,71.16,Percent of Total Billed Charges,32% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,1216.8,36,,301.712,Percent of Total Billed Charges,36% of Total Billed Charges,1216.8,36,,301.712,Percent of Total Billed Charges,36% Total Bille Charges,1216.8,36,,301.712,Percent of Total Billed Charges,36% of Total Billed Charges,2028,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3380,100,,22.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,487.4,14.42,,6.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2535,75,,22.552,Percent of Total Billed Charges,75% of Total Billed Charges,1690,50,,2536.608,Percent of Total Billed Charges,50% of Total Billed Charges,1690,50,,6685.488,Percent of Total Billed Charges,50% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1690,50,,6685.488,Percent of Total Billed Charges,50% of Total Billed Charges,1690,50,,4078.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2366,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,473.2,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3380,100,,30.072,Percent of Total Billed Charges,100% of Total Billed Charges,473.2,3380,
WIRE V-18 300 X .018,46105184,CDM,272,RC,C1769,HCPCS,Outpatient,,,507.87,304.72,,55.13,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,228.54,45,,15.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.2,28,,234.304,Percent of Total Billed Charges,28% of Total Billed Charges,734.44,32,,71.528,Percent of Total Billed Charges,32% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,182.83,36,,301.248,Percent of Total Billed Charges,36% of Total Billed Charges,182.83,36,,301.248,Percent of Total Billed Charges,36% Total Bille Charges,182.83,36,,301.248,Percent of Total Billed Charges,36% of Total Billed Charges,304.72,60,,63.936,Percent of Total Billed Charges,60% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.87,100,,6.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.9,75,,161.824,Percent of Total Billed Charges,75% of Total Billed Charges,253.94,50,,7823.048,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,7527.392,Percent of Total Billed Charges,50% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.94,50,,7527.392,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,1768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.51,70,,358.176,Percent of Total Billed Charges,70% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.87,100,,215.76,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,734.44,
BALLOON EUP 2506X EUPHORA,46105185,CDM,272,RC,C1725,HCPCS,Outpatient,,,534.6,320.76,,99.47,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,240.57,45,,106.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,41.16,Percent of Total Billed Charges,28% of Total Billed Charges,734.68,32,,7.232,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,52.92,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,52.92,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,52.92,Percent of Total Billed Charges,36% of Total Billed Charges,320.76,60,,181.008,Percent of Total Billed Charges,60% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,0.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,28.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,75,,129.064,Percent of Total Billed Charges,75% of Total Billed Charges,267.3,50,,6685.488,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,1861.832,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,1861.832,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,394.8,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,161.328,Percent of Total Billed Charges,100% of Total Billed Charges,74.84,734.68,
PEEL AWAY SHEATH 22FR,46105186,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.36,159.22,,82.29,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,119.41,45,,11.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.3,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,734.72,32,,7.312,Percent of Total Billed Charges,32% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,95.53,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,95.53,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,95.53,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,159.22,60,,467.416,Percent of Total Billed Charges,60% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.36,100,,37.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,38.26,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.02,75,,342.144,Percent of Total Billed Charges,75% of Total Billed Charges,132.68,50,,7527.392,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,1895.72,Percent of Total Billed Charges,50% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.68,50,,1895.72,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.75,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.36,100,,427.68,Percent of Total Billed Charges,100% of Total Billed Charges,37.15,734.72,
PEEL AWAY SHEATH 26FR,46105187,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.36,159.22,,82.29,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,119.41,45,,11.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.3,28,,129.92,Percent of Total Billed Charges,28% of Total Billed Charges,734.72,32,,7.328,Percent of Total Billed Charges,32% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,95.53,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,95.53,36,,167.04,Percent of Total Billed Charges,36% Total Bille Charges,95.53,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,159.22,60,,149.816,Percent of Total Billed Charges,60% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.36,100,,34.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,38.26,14.42,,49.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.02,75,,246.984,Percent of Total Billed Charges,75% of Total Billed Charges,132.68,50,,1861.832,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,10080.624,Percent of Total Billed Charges,50% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.68,50,,10080.624,Percent of Total Billed Charges,50% of Total Billed Charges,132.68,50,,14.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.75,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,37.15,14,,47.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.36,100,,329.312,Percent of Total Billed Charges,100% of Total Billed Charges,37.15,734.72,
EPIC ILIAC STENT,46105188,CDM,278,RC,C1876,HCPCS,Outpatient,,,2689.23,1613.54,,4389.9,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1210.15,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,752.98,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,736.19,32,,7.328,Percent of Total Billed Charges,32% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,968.12,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,968.12,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,968.12,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,1479.08,55,,85.92,Percent of Total Billed Charges,55% Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2689.23,100,,236.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,387.79,14.42,,59.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2151.38,80,,246.984,Percent of Total Billed Charges,80% of Total Billed Charges,1344.62,50,,1895.72,Percent of Total Billed Charges,50% of Total Billed Charges,1344.62,50,,5989.544,Percent of Total Billed Charges,50% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344.62,50,,5989.544,Percent of Total Billed Charges,50% of Total Billed Charges,1344.62,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1882.46,70,,43.68,Percent of Total Billed Charges,70% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2689.23,100,,329.312,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,4389.9,
MEDTRONIC CRT-D VIVA,46105191,CDM,275,RC,C1882,HCPCS,Outpatient,,,56083.5,33650.10,,73779.12,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,25237.58,45,,51.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15703.38,28,,25.536,Percent of Total Billed Charges,28% of Total Billed Charges,736.2,32,,7.328,Percent of Total Billed Charges,32% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,20190.06,36,,32.832,Percent of Total Billed Charges,36% of Total Billed Charges,20190.06,36,,32.832,Percent of Total Billed Charges,36% Total Bille Charges,20190.06,36,,32.832,Percent of Total Billed Charges,36% of Total Billed Charges,30845.93,55,,54.24,Percent of Total Billed Charges,55% Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56083.5,100,,24.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,8087.24,14.42,,359.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42062.63,75,,42.416,Percent of Total Billed Charges,75% of Total Billed Charges,28041.75,50,,10080.624,Percent of Total Billed Charges,50% of Total Billed Charges,28041.75,50,,15674.192,Percent of Total Billed Charges,50% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28041.75,50,,15674.192,Percent of Total Billed Charges,50% of Total Billed Charges,28041.75,50,,17.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39258.45,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,7851.69,14,,349.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56083.5,100,,56.552,Percent of Total Billed Charges,100% of Total Billed Charges,736.2,73779.12,
EP DECAPOLAR CATH,46105192,CDM,272,RC,C1730,HCPCS,Outpatient,,,1827.38,1096.43,,407.16,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,822.32,45,,7.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.67,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,738.25,32,,7.328,Percent of Total Billed Charges,32% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,657.86,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,657.86,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,657.86,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1096.43,60,,230.944,Percent of Total Billed Charges,60% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1827.38,100,,26.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,263.51,14.42,,88.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1370.54,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,913.69,50,,5989.544,Percent of Total Billed Charges,50% of Total Billed Charges,913.69,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,913.69,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,913.69,50,,10400,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1279.17,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,255.83,14,,85.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1827.38,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,255.83,1827.38,
IR CATH INTRAPERITONEAL PERC,46105193,CDM,361,RC,,,Outpatient,,,6000,3600.00,,3600,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,2700,45,,18.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1680,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,738.47,32,,7.336,Percent of Total Billed Charges,32% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,2160,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2160,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,2160,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,3600,60,,2698.536,Percent of Total Billed Charges,60% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6000,100,,57.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,865.2,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4500,75,,40.432,Percent of Total Billed Charges,75% of Total Billed Charges,3000,50,,15674.192,Percent of Total Billed Charges,50% of Total Billed Charges,3000,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3000,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,3000,50,,3640,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4200,70,,126,Percent of Total Billed Charges,70% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,840,14,,30.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6000,100,,53.904,Percent of Total Billed Charges,100% of Total Billed Charges,738.47,6000,
DILATOR 20FR,46105194,CDM,272,RC,,,Outpatient,,,85.7,51.42,,51.42,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,38.57,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,738.47,32,,7.344,Percent of Total Billed Charges,32% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,30.85,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,30.85,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,51.42,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.7,100,,115.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.36,14.42,,56.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.28,75,,215.904,Percent of Total Billed Charges,75% of Total Billed Charges,42.85,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.85,50,,9577.896,Percent of Total Billed Charges,50% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.85,50,,9577.896,Percent of Total Billed Charges,50% of Total Billed Charges,42.85,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.99,70,,198.8,Percent of Total Billed Charges,70% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,12,14,,55.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.7,100,,287.872,Percent of Total Billed Charges,100% of Total Billed Charges,12,738.47,
MEDTRONIC ATTAIN LEAD 429888,46105195,CDM,275,RC,C1900,HCPCS,Outpatient,,,7647.75,4588.65,,8511.37,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,3441.49,45,,49.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2141.37,28,,25.4,Percent of Total Billed Charges,28% of Total Billed Charges,741.03,32,,7.36,Percent of Total Billed Charges,32% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,2753.19,36,,32.656,Percent of Total Billed Charges,36% of Total Billed Charges,2753.19,36,,32.656,Percent of Total Billed Charges,36% Total Bille Charges,2753.19,36,,32.656,Percent of Total Billed Charges,36% of Total Billed Charges,4206.26,55,,2101.256,Percent of Total Billed Charges,55% Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7647.75,100,,16.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1102.81,14.42,,95.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5735.81,75,,161.824,Percent of Total Billed Charges,75% of Total Billed Charges,3823.88,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,3823.88,50,,9765.2,Percent of Total Billed Charges,50% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3823.88,50,,9765.2,Percent of Total Billed Charges,50% of Total Billed Charges,3823.88,50,,2824.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5353.43,70,,284.408,Percent of Total Billed Charges,70% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,1070.69,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7647.75,100,,215.76,Percent of Total Billed Charges,100% of Total Billed Charges,741.03,8511.37,
CATH 5 FR 4 X 100MM,46105199,CDM,272,RC,C1725,HCPCS,Outpatient,,,4290,2574.00,,99.47,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,1930.5,45,,35.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1201.2,28,,144.48,Percent of Total Billed Charges,28% of Total Billed Charges,741.48,32,,7.384,Percent of Total Billed Charges,32% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,1544.4,36,,185.76,Percent of Total Billed Charges,36% of Total Billed Charges,1544.4,36,,185.76,Percent of Total Billed Charges,36% Total Bille Charges,1544.4,36,,185.76,Percent of Total Billed Charges,36% of Total Billed Charges,2574,60,,25.2,Percent of Total Billed Charges,60% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4290,100,,40.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,618.62,14.42,,35.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3217.5,75,,505.344,Percent of Total Billed Charges,75% of Total Billed Charges,2145,50,,9577.896,Percent of Total Billed Charges,50% of Total Billed Charges,2145,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2145,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,2145,50,,2536.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3003,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,600.6,14,,34.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4290,100,,631.68,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,4290,
IR TUNL CATH REM PLEURAL W CUF,46105201,CDM,361,RC,,,Outpatient,,,834.81,500.89,,500.89,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,375.66,45,,5.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.75,28,,50.4,Percent of Total Billed Charges,28% of Total Billed Charges,742.4,32,,7.408,Percent of Total Billed Charges,32% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,300.53,36,,64.8,Percent of Total Billed Charges,36% of Total Billed Charges,300.53,36,,64.8,Percent of Total Billed Charges,36% Total Bille Charges,300.53,36,,64.8,Percent of Total Billed Charges,36% of Total Billed Charges,500.89,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.81,100,,0.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,120.38,14.42,,9.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,626.11,75,,64.408,Percent of Total Billed Charges,75% of Total Billed Charges,417.41,50,,9765.2,Percent of Total Billed Charges,50% of Total Billed Charges,417.41,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.41,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,417.41,50,,7823.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.37,70,,291.2,Percent of Total Billed Charges,70% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,116.87,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.81,100,,85.88,Percent of Total Billed Charges,100% of Total Billed Charges,116.87,834.81,
ATHERECTOMY CATHETER JETSTEAM,46105202,CDM,272,RC,C1724,HCPCS,Outpatient,,,8320,4992.00,,525.82,100,,2232,Fee Schedule,100% of Aetna Fee Schedule,3744,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2329.6,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,742.56,32,,7.408,Percent of Total Billed Charges,32% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2995.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,2995.2,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,2995.2,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,4992,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8320,100,,110.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1199.74,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6240,75,,675.952,Percent of Total Billed Charges,75% of Total Billed Charges,4160,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,4160,50,,16059.408,Percent of Total Billed Charges,50% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4160,50,,16059.408,Percent of Total Billed Charges,50% of Total Billed Charges,4160,50,,6685.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5824,70,,1039.32,Percent of Total Billed Charges,70% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8320,100,,901.272,Percent of Total Billed Charges,100% of Total Billed Charges,525.82,8320,
Y FISTULA CLOSURE,46105204,CDM,360,RC,,,Outpatient,,,2315.73,1389.44,,1389.44,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,1042.08,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.4,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,746.14,32,,7.408,Percent of Total Billed Charges,32% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,833.66,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,833.66,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,833.66,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1389.44,60,,1268.16,Percent of Total Billed Charges,60% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2315.73,100,,79.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,333.93,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1736.8,75,,256.608,Percent of Total Billed Charges,75% of Total Billed Charges,1157.87,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,1157.87,50,,37.8,Percent of Total Billed Charges,50% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1157.87,50,,37.8,Percent of Total Billed Charges,50% of Total Billed Charges,1157.87,50,,7527.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1621.01,70,,140.984,Percent of Total Billed Charges,70% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,324.2,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2315.73,100,,342.144,Percent of Total Billed Charges,100% of Total Billed Charges,324.2,2315.73,
CATH 5 FR 5 X 100MM,46105205,CDM,272,RC,C2623,HCPCS,Outpatient,,,5608.35,3365.01,,3365.01,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,2523.76,45,,3.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1570.34,28,,39.2,Percent of Total Billed Charges,28% of Total Billed Charges,746.46,32,,7.416,Percent of Total Billed Charges,32% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,2019.01,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,2019.01,36,,50.4,Percent of Total Billed Charges,36% Total Bille Charges,2019.01,36,,50.4,Percent of Total Billed Charges,36% of Total Billed Charges,3365.01,60,,1463.04,Percent of Total Billed Charges,60% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5608.35,100,,11.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,808.72,14.42,,112.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4206.26,75,,1209.6,Percent of Total Billed Charges,75% of Total Billed Charges,2804.18,50,,16059.408,Percent of Total Billed Charges,50% of Total Billed Charges,2804.18,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2804.18,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,2804.18,50,,1861.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3925.85,70,,440.408,Percent of Total Billed Charges,70% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,785.17,14,,109.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5608.35,100,,1512,Percent of Total Billed Charges,100% of Total Billed Charges,746.46,5608.35,
SEPARATOR 3,46105207,CDM,272,RC,,,Outpatient,,,7741.4,4644.84,,4644.84,60,,21.68,Percent of Total Billed Charges,60% of Total Billed Charges,3483.63,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2167.59,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,747.02,32,,71.864,Percent of Total Billed Charges,32% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,2786.9,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,2786.9,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,2786.9,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,4644.84,60,,411.84,Percent of Total Billed Charges,60% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7741.4,100,,3.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1116.31,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5806.05,75,,1209.6,Percent of Total Billed Charges,75% of Total Billed Charges,3870.7,50,,37.8,Percent of Total Billed Charges,50% of Total Billed Charges,3870.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3870.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,3870.7,50,,1895.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5418.98,70,,440.408,Percent of Total Billed Charges,70% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1083.8,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7741.4,100,,1512,Percent of Total Billed Charges,100% of Total Billed Charges,747.02,7741.4,
CATH INDIGO 5 STRT TIP 132CM,46105208,CDM,272,RC,,,Outpatient,,,3273.4,1964.04,,1964.04,60,,5.584,Percent of Total Billed Charges,60% of Total Billed Charges,1473.03,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,916.55,28,,35.84,Percent of Total Billed Charges,28% of Total Billed Charges,748.85,32,,71.864,Percent of Total Billed Charges,32% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,1178.42,36,,46.08,Percent of Total Billed Charges,36% of Total Billed Charges,1178.42,36,,46.08,Percent of Total Billed Charges,36% Total Bille Charges,1178.42,36,,46.08,Percent of Total Billed Charges,36% of Total Billed Charges,1964.04,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3273.4,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,472.02,14.42,,90.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2455.05,75,,1209.6,Percent of Total Billed Charges,75% of Total Billed Charges,1636.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1636.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1636.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1636.7,50,,10080.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2291.38,70,,237.624,Percent of Total Billed Charges,70% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3273.4,100,,1512,Percent of Total Billed Charges,100% of Total Billed Charges,458.28,3273.4,
SEPARATOR 5,46105209,CDM,272,RC,,,Outpatient,,,2250,1350.00,,1350,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,45,,37.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,752.74,32,,72.04,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,1350,60,,149.76,Percent of Total Billed Charges,60% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,8.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,180.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1687.5,75,,1522.064,Percent of Total Billed Charges,75% of Total Billed Charges,1125,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,5989.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,5549.216,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,175.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,2029.416,Percent of Total Billed Charges,100% of Total Billed Charges,315,2250,
SEPARATOR 6,46105210,CDM,272,RC,,,Outpatient,,,3107,1864.20,,1864.2,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,1398.15,45,,2.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.96,28,,41.44,Percent of Total Billed Charges,28% of Total Billed Charges,752.74,32,,72.04,Percent of Total Billed Charges,32% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,1118.52,36,,53.28,Percent of Total Billed Charges,36% of Total Billed Charges,1118.52,36,,53.28,Percent of Total Billed Charges,36% Total Bille Charges,1118.52,36,,53.28,Percent of Total Billed Charges,36% of Total Billed Charges,1864.2,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3107,100,,24.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,448.03,14.42,,180.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2330.25,75,,1209.6,Percent of Total Billed Charges,75% of Total Billed Charges,1553.5,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1553.5,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1553.5,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1553.5,50,,15674.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2174.9,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,434.98,14,,174.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3107,100,,1512,Percent of Total Billed Charges,100% of Total Billed Charges,434.98,3107,
SEPARATOR 8,46105211,CDM,272,RC,C1757,HCPCS,Outpatient,,,6390.12,3834.07,,16.33,100,,8.208,Fee Schedule,100% of Aetna Fee Schedule,2875.55,45,,1.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1789.23,28,,200.928,Percent of Total Billed Charges,28% of Total Billed Charges,753.12,32,,72.04,Percent of Total Billed Charges,32% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,2300.44,36,,258.336,Percent of Total Billed Charges,36% of Total Billed Charges,2300.44,36,,258.336,Percent of Total Billed Charges,36% Total Bille Charges,2300.44,36,,258.336,Percent of Total Billed Charges,36% of Total Billed Charges,3834.07,60,,1091.64,Percent of Total Billed Charges,60% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6390.12,100,,24.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,921.46,14.42,,180.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4792.59,75,,1856.624,Percent of Total Billed Charges,75% of Total Billed Charges,3195.06,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,3195.06,50,,62.32,Percent of Total Billed Charges,50% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3195.06,50,,62.32,Percent of Total Billed Charges,50% of Total Billed Charges,3195.06,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4473.08,70,,117.384,Percent of Total Billed Charges,70% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,894.62,14,,175.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6390.12,100,,2320.784,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,6390.12,
CATH INDIGO 3 STRT TIP 150CM,46105212,CDM,272,RC,,,Outpatient,,,3273.4,1964.04,,1964.04,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,1473.03,45,,49.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,916.55,28,,93.184,Percent of Total Billed Charges,28% of Total Billed Charges,757.68,32,,72.096,Percent of Total Billed Charges,32% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,1178.42,36,,119.808,Percent of Total Billed Charges,36% of Total Billed Charges,1178.42,36,,119.808,Percent of Total Billed Charges,36% Total Bille Charges,1178.42,36,,119.808,Percent of Total Billed Charges,36% of Total Billed Charges,1964.04,60,,370.56,Percent of Total Billed Charges,60% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3273.4,100,,84.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,472.02,14.42,,159.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2455.05,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,1636.7,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1636.7,50,,79.104,Percent of Total Billed Charges,50% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1636.7,50,,79.104,Percent of Total Billed Charges,50% of Total Billed Charges,1636.7,50,,626.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2291.38,70,,176.168,Percent of Total Billed Charges,70% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,458.28,14,,154.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3273.4,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,458.28,3273.4,
CATH INDIGO 6 STRT TIP 135CM,46105213,CDM,272,RC,,,Outpatient,,,5174,3104.40,,3104.4,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,2328.3,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1448.72,28,,181.44,Percent of Total Billed Charges,28% of Total Billed Charges,760.97,32,,72.336,Percent of Total Billed Charges,32% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,1862.64,36,,233.28,Percent of Total Billed Charges,36% of Total Billed Charges,1862.64,36,,233.28,Percent of Total Billed Charges,36% Total Bille Charges,1862.64,36,,233.28,Percent of Total Billed Charges,36% of Total Billed Charges,3104.4,60,,397.64,Percent of Total Billed Charges,60% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5174,100,,4.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,746.09,14.42,,104.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3880.5,75,,561.368,Percent of Total Billed Charges,75% of Total Billed Charges,2587,50,,62.32,Percent of Total Billed Charges,50% of Total Billed Charges,2587,50,,194.6,Percent of Total Billed Charges,50% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2587,50,,194.6,Percent of Total Billed Charges,50% of Total Billed Charges,2587,50,,9577.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3621.8,70,,1944.656,Percent of Total Billed Charges,70% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.36,14,,101.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5174,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,724.36,5174,
CATH INDIGO 8 TORQ TIP 85CM,46105214,CDM,272,RC,C1757,HCPCS,Outpatient,,,9823.11,5893.87,,16.33,100,,13.28,Fee Schedule,100% of Aetna Fee Schedule,4420.4,45,,4.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2750.47,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,761.27,32,,72.488,Percent of Total Billed Charges,32% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,3536.32,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,3536.32,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,3536.32,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,5893.87,60,,370.56,Percent of Total Billed Charges,60% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9823.11,100,,2.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1416.49,14.42,,41.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7367.33,75,,488.272,Percent of Total Billed Charges,75% of Total Billed Charges,4911.56,50,,79.104,Percent of Total Billed Charges,50% of Total Billed Charges,4911.56,50,,33.456,Percent of Total Billed Charges,50% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4911.56,50,,33.456,Percent of Total Billed Charges,50% of Total Billed Charges,4911.56,50,,9765.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6876.18,70,,528.488,Percent of Total Billed Charges,70% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,1375.24,14,,40.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9823.11,100,,651.032,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,9823.11,
CATH INDIGO 8 STRT TIP 85CM,46105215,CDM,272,RC,,,Outpatient,,,7774,4664.40,,4664.4,60,,4.16,Percent of Total Billed Charges,60% of Total Billed Charges,3498.3,45,,284.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2176.72,28,,143.272,Percent of Total Billed Charges,28% of Total Billed Charges,761.6,32,,72.64,Percent of Total Billed Charges,32% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,2798.64,36,,184.208,Percent of Total Billed Charges,36% of Total Billed Charges,2798.64,36,,184.208,Percent of Total Billed Charges,36% Total Bille Charges,2798.64,36,,184.208,Percent of Total Billed Charges,36% of Total Billed Charges,4664.4,60,,648.648,Percent of Total Billed Charges,60% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7774,100,,109.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1121.01,14.42,,58.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5830.5,75,,237.36,Percent of Total Billed Charges,75% of Total Billed Charges,3887,50,,194.6,Percent of Total Billed Charges,50% of Total Billed Charges,3887,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3887,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,3887,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5441.8,70,,440.408,Percent of Total Billed Charges,70% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,56.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7774,100,,316.48,Percent of Total Billed Charges,100% of Total Billed Charges,761.6,7774,
CATH INDIGO 8 XTORQ TIP 115CM,46105216,CDM,272,RC,,,Outpatient,,,7774,4664.40,,4664.4,60,,1012.504,Percent of Total Billed Charges,60% of Total Billed Charges,3498.3,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2176.72,28,,157.92,Percent of Total Billed Charges,28% of Total Billed Charges,764.09,32,,72.704,Percent of Total Billed Charges,32% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,2798.64,36,,203.04,Percent of Total Billed Charges,36% of Total Billed Charges,2798.64,36,,203.04,Percent of Total Billed Charges,36% Total Bille Charges,2798.64,36,,203.04,Percent of Total Billed Charges,36% of Total Billed Charges,4664.4,60,,2592.48,Percent of Total Billed Charges,60% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7774,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1121.01,14.42,,215.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5830.5,75,,102.016,Percent of Total Billed Charges,75% of Total Billed Charges,3887,50,,33.456,Percent of Total Billed Charges,50% of Total Billed Charges,3887,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3887,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,3887,50,,16686.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5441.8,70,,1407.456,Percent of Total Billed Charges,70% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1088.36,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7774,100,,136.024,Percent of Total Billed Charges,100% of Total Billed Charges,764.09,7774,
MAX CANISTER W TUB N FILTER,46105217,CDM,272,RC,,,Outpatient,,,1095,657.00,,657,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,492.75,45,,36.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.6,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,766.08,32,,72.704,Percent of Total Billed Charges,32% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,394.2,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,394.2,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,394.2,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,657,60,,2804.12,Percent of Total Billed Charges,60% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1095,100,,10.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,157.9,14.42,,285.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.25,75,,1013.584,Percent of Total Billed Charges,75% of Total Billed Charges,547.5,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,547.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,547.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,547.5,50,,16059.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766.5,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1095,100,,1266.984,Percent of Total Billed Charges,100% of Total Billed Charges,153.3,1095,
MAX ASPIRATION TUBING .88,46105218,CDM,272,RC,,,Outpatient,,,1095,657.00,,657,60,,22.696,Percent of Total Billed Charges,60% of Total Billed Charges,492.75,45,,3.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.6,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,767.51,32,,72.752,Percent of Total Billed Charges,32% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,394.2,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,394.2,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,394.2,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,657,60,,3826.68,Percent of Total Billed Charges,60% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1095,100,,632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,157.9,14.42,,285.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.25,75,,366.552,Percent of Total Billed Charges,75% of Total Billed Charges,547.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,547.5,50,,79.4,Percent of Total Billed Charges,50% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,547.5,50,,79.4,Percent of Total Billed Charges,50% of Total Billed Charges,547.5,50,,37.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766.5,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,153.3,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1095,100,,488.736,Percent of Total Billed Charges,100% of Total Billed Charges,153.3,1095,
IR TUNL CATH INS PLEURAL RT,46105219,CDM,361,RC,,,Outpatient,,,4540.62,2724.37,,2724.37,60,,20.68,Percent of Total Billed Charges,60% of Total Billed Charges,2043.28,45,,1.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1271.37,28,,17.472,Percent of Total Billed Charges,28% of Total Billed Charges,768,32,,72.752,Percent of Total Billed Charges,32% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,1634.62,36,,22.464,Percent of Total Billed Charges,36% of Total Billed Charges,1634.62,36,,22.464,Percent of Total Billed Charges,36% Total Bille Charges,1634.62,36,,22.464,Percent of Total Billed Charges,36% of Total Billed Charges,2724.37,60,,4251.72,Percent of Total Billed Charges,60% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4540.62,100,,0.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,654.76,14.42,,467.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3405.47,75,,304.72,Percent of Total Billed Charges,75% of Total Billed Charges,2270.31,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,2270.31,50,,80.24,Percent of Total Billed Charges,50% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2270.31,50,,80.24,Percent of Total Billed Charges,50% of Total Billed Charges,2270.31,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3178.43,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4540.62,100,,406.296,Percent of Total Billed Charges,100% of Total Billed Charges,635.69,4540.62,
IR TUNL CATH INS PLEURAL BI,46105220,CDM,361,RC,,,Outpatient,,,6810.93,4086.56,,4086.56,60,,142.128,Percent of Total Billed Charges,60% of Total Billed Charges,3064.92,45,,1.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1907.06,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,768.61,32,,72.896,Percent of Total Billed Charges,32% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,2451.93,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,2451.93,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,2451.93,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,4086.56,60,,1939.08,Percent of Total Billed Charges,60% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6810.93,100,,81.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,982.14,14.42,,619.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5108.2,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,3405.47,50,,79.4,Percent of Total Billed Charges,50% of Total Billed Charges,3405.47,50,,83.984,Percent of Total Billed Charges,50% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3405.47,50,,83.984,Percent of Total Billed Charges,50% of Total Billed Charges,3405.47,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4767.65,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,953.53,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6810.93,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,768.61,6810.93,
IR TUNL CATH INS PLEURAL LT,46105221,CDM,361,RC,,,Outpatient,,,4540.62,2724.37,,2724.37,60,,14.744,Percent of Total Billed Charges,60% of Total Billed Charges,2043.28,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1271.37,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,768.61,32,,73.2,Percent of Total Billed Charges,32% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,1634.62,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,1634.62,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,1634.62,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,2724.37,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4540.62,100,,6.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,654.76,14.42,,619.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3405.47,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,2270.31,50,,80.24,Percent of Total Billed Charges,50% of Total Billed Charges,2270.31,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2270.31,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,2270.31,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3178.43,70,,1351.96,Percent of Total Billed Charges,70% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,635.69,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4540.62,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,635.69,4540.62,
BLLN ADMIRAL DCB <100MM,46105222,CDM,272,RC,C2623,HCPCS,Outpatient,,,4248.75,2549.25,,2549.25,60,,15.832,Percent of Total Billed Charges,60% of Total Billed Charges,1911.94,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.65,28,,50.4,Percent of Total Billed Charges,28% of Total Billed Charges,772.55,32,,73.352,Percent of Total Billed Charges,32% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,1529.55,36,,64.8,Percent of Total Billed Charges,36% of Total Billed Charges,1529.55,36,,64.8,Percent of Total Billed Charges,36% Total Bille Charges,1529.55,36,,64.8,Percent of Total Billed Charges,36% of Total Billed Charges,2549.25,60,,141.6,Percent of Total Billed Charges,60% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4248.75,100,,4.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,612.67,14.42,,215.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3186.56,75,,264,Percent of Total Billed Charges,75% of Total Billed Charges,2124.38,50,,83.984,Percent of Total Billed Charges,50% of Total Billed Charges,2124.38,50,,109.52,Percent of Total Billed Charges,50% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2124.38,50,,109.52,Percent of Total Billed Charges,50% of Total Billed Charges,2124.38,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2974.13,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,594.83,14,,209.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4248.75,100,,352,Percent of Total Billed Charges,100% of Total Billed Charges,594.83,4248.75,
BLLN ADMIRAL DCB >100MM,46105223,CDM,272,RC,C2623,HCPCS,Outpatient,,,4758.6,2855.16,,2855.16,60,,9.88,Percent of Total Billed Charges,60% of Total Billed Charges,2141.37,45,,0.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,28,,79.52,Percent of Total Billed Charges,28% of Total Billed Charges,773.5,32,,73.352,Percent of Total Billed Charges,32% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,1713.1,36,,102.24,Percent of Total Billed Charges,36% of Total Billed Charges,1713.1,36,,102.24,Percent of Total Billed Charges,36% Total Bille Charges,1713.1,36,,102.24,Percent of Total Billed Charges,36% of Total Billed Charges,2855.16,60,,197.76,Percent of Total Billed Charges,60% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4758.6,100,,2.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,686.19,14.42,,285.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3568.95,75,,495,Percent of Total Billed Charges,75% of Total Billed Charges,2379.3,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,2379.3,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3331.02,70,,3495.176,Percent of Total Billed Charges,70% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,666.2,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,100,,660,Percent of Total Billed Charges,100% of Total Billed Charges,666.2,4758.6,
ANGIO COR GRFTS HRT CATH RT LT,46105224,CDM,481,RC,93461,HCPCS,Outpatient,,,23043,13825.80,,9364,100,,24.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,0.384,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6452.04,28,,113.76,Percent of Total Billed Charges,28% of Total Billed Charges,773.57,32,,73.352,Percent of Total Billed Charges,32% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,8295.48,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,8295.48,36,,146.264,Percent of Total Billed Charges,36% Total Bille Charges,8295.48,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,756,Percent of Total Billed Charges,60% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,0.184,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3322.8,14.42,,285.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,17282.25,75,,495,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,109.52,Case Rate,Pays Based on per visit rate,9500,100,,19.656,Case Rate,Pays based on per visit rate,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,19.656,Case Rate,Pays based on per visit rate,9500,50,,62.32,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,998.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,3226.02,14,,277.56,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23043,100,,660,Percent of Total Billed Charges,100% of Total Billed Charges,773.57,23043,
INOGEN MINI ICD DR,46105225,CDM,275,RC,C1721,HCPCS,Outpatient,,,31009.08,18605.45,,39109.99,110,,0.104,Percent of Total Billed Charges,110% of Total Billed Charges,13954.09,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8682.54,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,774.04,32,,73.352,Percent of Total Billed Charges,32% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,11163.27,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,11163.27,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,11163.27,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,17054.99,55,,5720,Percent of Total Billed Charges,55% Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31009.08,100,,0.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4471.51,14.42,,467.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23256.81,75,,482.432,Percent of Total Billed Charges,75% of Total Billed Charges,15504.54,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,15504.54,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15504.54,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,15504.54,50,,79.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21706.36,70,,1522.656,Percent of Total Billed Charges,70% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,453.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31009.08,100,,643.24,Percent of Total Billed Charges,100% of Total Billed Charges,774.04,39109.99,
INOGEN CRT-D MODEL G140,46105226,CDM,275,RC,C1882,HCPCS,Outpatient,,,44187,26512.20,,60692.97,110,,66.448,Percent of Total Billed Charges,110% of Total Billed Charges,19884.15,45,,0.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12372.36,28,,116.48,Percent of Total Billed Charges,28% of Total Billed Charges,775,32,,73.6,Percent of Total Billed Charges,32% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,15907.32,36,,149.76,Percent of Total Billed Charges,36% of Total Billed Charges,15907.32,36,,149.76,Percent of Total Billed Charges,36% Total Bille Charges,15907.32,36,,149.76,Percent of Total Billed Charges,36% of Total Billed Charges,24302.85,55,,990,Percent of Total Billed Charges,55% Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44187,100,,0.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6371.77,14.42,,619.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33140.25,75,,482.432,Percent of Total Billed Charges,75% of Total Billed Charges,22093.5,50,,19.656,Percent of Total Billed Charges,50% of Total Billed Charges,22093.5,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22093.5,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,22093.5,50,,194.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30930.9,70,,263.328,Percent of Total Billed Charges,70% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,6186.18,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44187,100,,643.24,Percent of Total Billed Charges,100% of Total Billed Charges,775,60692.97,
INOGEN ICD VR,46105227,CDM,275,RC,C1721,HCPCS,Outpatient,,,31009.08,18605.45,,39109.99,110,,6.928,Percent of Total Billed Charges,110% of Total Billed Charges,13954.09,45,,0.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8682.54,28,,415.728,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.704,Percent of Total Billed Charges,32% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,11163.27,36,,534.504,Percent of Total Billed Charges,36% of Total Billed Charges,11163.27,36,,534.504,Percent of Total Billed Charges,36% Total Bille Charges,11163.27,36,,534.504,Percent of Total Billed Charges,36% of Total Billed Charges,17054.99,55,,3737.76,Percent of Total Billed Charges,55% Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31009.08,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4471.51,14.42,,619.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23256.81,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,15504.54,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,15504.54,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15504.54,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,15504.54,50,,33.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21706.36,70,,351.16,Percent of Total Billed Charges,70% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,4341.27,14,,601.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31009.08,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,779.68,39109.99,
6 FR GLIDESHEATH 25CM,46105228,CDM,272,RC,C1894,HCPCS,Outpatient,,,281.42,168.85,,82.29,100,,2.08,Fee Schedule,100% of Aetna Fee Schedule,126.64,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.8,28,,56.392,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.704,Percent of Total Billed Charges,32% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,101.31,36,,72.504,Percent of Total Billed Charges,36% of Total Billed Charges,101.31,36,,72.504,Percent of Total Billed Charges,36% Total Bille Charges,101.31,36,,72.504,Percent of Total Billed Charges,36% of Total Billed Charges,168.85,60,,182.4,Percent of Total Billed Charges,60% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.42,100,,0.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,40.58,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,140.71,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,97.664,Percent of Total Billed Charges,50% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.71,50,,97.664,Percent of Total Billed Charges,50% of Total Billed Charges,140.71,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.99,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,39.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.42,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,39.4,779.68,
LEAD PM DUAL REMOVAL,46105229,CDM,480,RC,33235,HCPCS,Outpatient,,,4654.58,2792.75,,6763,100,,5.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5404.32,150,,0.408,Fee Schedule ,150% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.28,28,,176.16,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.72,Percent of Total Billed Charges,32% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1675.65,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,1675.65,36,,226.496,Percent of Total Billed Charges,36% Total Bille Charges,1675.65,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,2792.75,60,,1232,Percent of Total Billed Charges,60% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,1.536,Fee Schedule,100% of CMS OPPS Rate,3242.59,90,,,Fee Schedule,90% of CMS OPPS Rate,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4683.74,130,,,Fee Schedule,130% of CMS OPPS Rate,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,671.19,14.42,,153.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,3710.96,103,,,Fee Schedule,103% of CMS OPPS Rate,3710.96,103,,,Fee Schedule,103% of CMS OPPS Rate,3490.94,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,2327.29,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,2327.29,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2327.29,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,2327.29,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,5404.32,150,,,Fee Schedule,150% of CMS OPPS Rate,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,386.272,Case Rate,Pays based on per visit rate,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4654.58,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,370,6763,
COPE NITINOL WIRE,46105230,CDM,272,RC,C1769,HCPCS,Outpatient,,,309.75,185.85,,55.13,100,,14.88,Fee Schedule,100% of Aetna Fee Schedule,139.39,45,,2.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.73,28,,176.16,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.848,Percent of Total Billed Charges,32% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,111.51,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,111.51,36,,226.496,Percent of Total Billed Charges,36% Total Bille Charges,111.51,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,185.85,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.75,100,,0.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,44.67,14.42,,97.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.31,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,154.88,50,,97.664,Percent of Total Billed Charges,50% of Total Billed Charges,154.88,50,,171.12,Percent of Total Billed Charges,50% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.88,50,,171.12,Percent of Total Billed Charges,50% of Total Billed Charges,154.88,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.83,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,94.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,309.75,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,43.37,779.68,
IVC FILTER RETRIEVAL SET,46105232,CDM,272,RC,C1773,HCPCS,Outpatient,,,1218.25,730.95,,70,100,,14.88,Fee Schedule,100% of Aetna Fee Schedule,548.21,45,,3.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,28,,95.048,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.92,Percent of Total Billed Charges,32% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,438.57,36,,122.208,Percent of Total Billed Charges,36% of Total Billed Charges,438.57,36,,122.208,Percent of Total Billed Charges,36% Total Bille Charges,438.57,36,,122.208,Percent of Total Billed Charges,36% of Total Billed Charges,730.95,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1218.25,100,,0.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,175.67,14.42,,360.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,913.69,75,,482.432,Percent of Total Billed Charges,75% of Total Billed Charges,609.13,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609.13,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,79.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,349.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,100,,643.24,Percent of Total Billed Charges,100% of Total Billed Charges,70,1218.25,
Y STENT URETERAL REM REPLACE,46105233,CDM,361,RC,,,Outpatient,,,3081.32,1848.79,,1848.79,60,,50.608,Percent of Total Billed Charges,60% of Total Billed Charges,1386.59,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,862.77,28,,2219.688,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,73.92,Percent of Total Billed Charges,32% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,1109.28,36,,2853.88,Percent of Total Billed Charges,36% of Total Billed Charges,1109.28,36,,2853.88,Percent of Total Billed Charges,36% Total Bille Charges,1109.28,36,,2853.88,Percent of Total Billed Charges,36% of Total Billed Charges,1848.79,60,,205.288,Percent of Total Billed Charges,60% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3081.32,100,,0.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,444.33,14.42,,271.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2310.99,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,1540.66,50,,171.12,Percent of Total Billed Charges,50% of Total Billed Charges,1540.66,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1540.66,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,1540.66,50,,80.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2156.92,70,,146.552,Percent of Total Billed Charges,70% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,431.38,14,,263.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3081.32,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,431.38,3081.32,
CATHETER DIREXION,46105234,CDM,272,RC,C1887,HCPCS,Outpatient,,,2378.02,1426.81,,43.86,100,,165.344,Fee Schedule,100% of Aetna Fee Schedule,1070.11,45,,0.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.85,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7520.68,Percent of Total Billed Charges,32% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,856.09,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,856.09,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,856.09,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,1426.81,60,,756,Percent of Total Billed Charges,60% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2378.02,100,,5.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,342.91,14.42,,260.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.52,75,,481.2,Percent of Total Billed Charges,75% of Total Billed Charges,1189.01,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,1189.01,50,,306.024,Percent of Total Billed Charges,50% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.01,50,,306.024,Percent of Total Billed Charges,50% of Total Billed Charges,1189.01,50,,83.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1664.61,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,332.92,14,,252.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2378.02,100,,641.6,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,2378.02,
FATHOM 16FR WIRE,46105235,CDM,272,RC,C1769,HCPCS,Outpatient,,,1362.73,817.64,,55.13,100,,2.864,Fee Schedule,100% of Aetna Fee Schedule,613.23,45,,19.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,381.56,28,,46.952,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7524.608,Percent of Total Billed Charges,32% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,490.58,36,,60.368,Percent of Total Billed Charges,36% of Total Billed Charges,490.58,36,,60.368,Percent of Total Billed Charges,36% Total Bille Charges,490.58,36,,60.368,Percent of Total Billed Charges,36% of Total Billed Charges,817.64,60,,397.64,Percent of Total Billed Charges,60% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1362.73,100,,7.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,196.51,14.42,,160.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1022.05,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,681.37,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,681.37,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,681.37,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,681.37,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,953.91,70,,255.048,Percent of Total Billed Charges,70% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,190.78,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1362.73,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,1362.73,
PICC CATH 5FR DUAL LUMEN,46105236,CDM,278,RC,C1751,HCPCS,Outpatient,,,1139.79,683.87,,1321.43,110,,1.728,Percent of Total Billed Charges,110% of Total Billed Charges,512.91,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.14,28,,70.464,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7587.272,Percent of Total Billed Charges,32% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,410.32,36,,90.6,Percent of Total Billed Charges,36% of Total Billed Charges,410.32,36,,90.6,Percent of Total Billed Charges,36% Total Bille Charges,410.32,36,,90.6,Percent of Total Billed Charges,36% of Total Billed Charges,626.88,55,,139.2,Percent of Total Billed Charges,55% Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1139.79,100,,1.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,164.36,14.42,,160.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,911.83,80,,9921.368,Percent of Total Billed Charges,80% of Total Billed Charges,569.9,50,,306.024,Percent of Total Billed Charges,50% of Total Billed Charges,569.9,50,,196.736,Percent of Total Billed Charges,50% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,569.9,50,,196.736,Percent of Total Billed Charges,50% of Total Billed Charges,569.9,50,,109.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,797.85,70,,892.656,Percent of Total Billed Charges,70% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,159.57,14,,156.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1139.79,100,,13228.488,Percent of Total Billed Charges,100% of Total Billed Charges,159.57,1321.43,
PICC CATH 5FR TRIPLE LUMEN,46105237,CDM,278,RC,C1751,HCPCS,Outpatient,,,1306.94,784.16,,1505.29,110,,7.824,Percent of Total Billed Charges,110% of Total Billed Charges,588.12,45,,0.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.94,28,,777.864,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7587.272,Percent of Total Billed Charges,32% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,470.5,36,,1000.112,Percent of Total Billed Charges,36% of Total Billed Charges,470.5,36,,1000.112,Percent of Total Billed Charges,36% Total Bille Charges,470.5,36,,1000.112,Percent of Total Billed Charges,36% of Total Billed Charges,718.82,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1306.94,100,,2.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,188.46,14.42,,88.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1045.55,80,,797.24,Percent of Total Billed Charges,80% of Total Billed Charges,653.47,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,653.47,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.47,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,653.47,50,,99.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,914.86,70,,546,Percent of Total Billed Charges,70% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,182.97,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1306.94,100,,1062.984,Percent of Total Billed Charges,100% of Total Billed Charges,182.97,1505.29,
PM ACCOLADE DR,46105238,CDM,275,RC,C1785,HCPCS,Outpatient,,,8623.26,5173.96,,9761.01,110,,6.256,Percent of Total Billed Charges,110% of Total Billed Charges,3880.47,45,,0.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2414.51,28,,211.392,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7.448,Percent of Total Billed Charges,32% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,3104.37,36,,271.792,Percent of Total Billed Charges,36% of Total Billed Charges,3104.37,36,,271.792,Percent of Total Billed Charges,36% Total Bille Charges,3104.37,36,,271.792,Percent of Total Billed Charges,36% of Total Billed Charges,4742.79,55,,4180.8,Percent of Total Billed Charges,55% Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8623.26,100,,43.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1243.47,14.42,,88.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6467.45,75,,36391.216,Percent of Total Billed Charges,75% of Total Billed Charges,4311.63,50,,196.736,Percent of Total Billed Charges,50% of Total Billed Charges,4311.63,50,,121.888,Percent of Total Billed Charges,50% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4311.63,50,,121.888,Percent of Total Billed Charges,50% of Total Billed Charges,4311.63,50,,19.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6036.28,70,,667.288,Percent of Total Billed Charges,70% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,1207.26,14,,85.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8623.26,100,,48521.616,Percent of Total Billed Charges,100% of Total Billed Charges,779.68,9761.01,
CATH BIOFLOW MIDLINE,46105242,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,176.16,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7.472,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,226.496,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,45.304,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,359.52,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,32.216,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,32.216,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,477.56,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,479.36,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,779.68,
CATH DURAFLOW DURAMAX 32CM,46105245,CDM,278,RC,C1750,HCPCS,Outpatient,,,1364.44,818.66,,2015.78,110,,5262.92,Percent of Total Billed Charges,110% of Total Billed Charges,614,45,,0.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.04,28,,562.984,Percent of Total Billed Charges,28% of Total Billed Charges,779.68,32,,7.52,Percent of Total Billed Charges,32% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,491.2,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,491.2,36,,723.84,Percent of Total Billed Charges,36% Total Bille Charges,491.2,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,750.44,55,,223.248,Percent of Total Billed Charges,55% Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1364.44,100,,1.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,196.75,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1091.55,80,,6118.2,Percent of Total Billed Charges,80% of Total Billed Charges,682.22,50,,121.888,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,682.22,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.11,70,,70.752,Percent of Total Billed Charges,70% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,191.02,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,100,,8157.6,Percent of Total Billed Charges,100% of Total Billed Charges,191.02,2015.78,
FILTERWIRE EZ 2.5-3.5X190CM,46105246,CDM,272,RC,C1884,HCPCS,Outpatient,,,4401.71,2641.03,,136.85,100,,162.088,Fee Schedule,100% of Aetna Fee Schedule,1980.77,45,,2.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1232.48,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,782.83,32,,7.552,Percent of Total Billed Charges,32% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1584.62,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,1584.62,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,1584.62,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,2641.03,60,,31.08,Percent of Total Billed Charges,60% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4401.71,100,,0.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,634.73,14.42,,92.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3301.28,75,,359.52,Percent of Total Billed Charges,75% of Total Billed Charges,2200.86,50,,32.216,Percent of Total Billed Charges,50% of Total Billed Charges,2200.86,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2200.86,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,2200.86,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3081.2,70,,88.696,Percent of Total Billed Charges,70% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4401.71,100,,479.36,Percent of Total Billed Charges,100% of Total Billed Charges,136.85,4401.71,
CATH QPLR WEBST 6FR X 92CM 5MM,46105247,CDM,272,RC,C1730,HCPCS,Outpatient,,,1403.42,842.05,,407.16,100,,24,Fee Schedule,100% of Aetna Fee Schedule,631.54,45,,1.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.96,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,782.83,32,,7.656,Percent of Total Billed Charges,32% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,505.23,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,505.23,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,505.23,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,842.05,60,,174.896,Percent of Total Billed Charges,60% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1403.42,100,,2.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,202.37,14.42,,92.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1052.57,75,,359.52,Percent of Total Billed Charges,75% of Total Billed Charges,701.71,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,701.71,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,701.71,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,701.71,50,,97.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,982.39,70,,1285.272,Percent of Total Billed Charges,70% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1403.42,100,,479.36,Percent of Total Billed Charges,100% of Total Billed Charges,196.48,1403.42,
IR TUBE REPL DUOD JEJ W FLUORO,46105248,CDM,361,RC,,,Outpatient,,,1388.64,833.18,,833.18,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,624.89,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.82,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,782.83,32,,74.24,Percent of Total Billed Charges,32% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,499.91,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,499.91,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,499.91,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,833.18,60,,482.4,Percent of Total Billed Charges,60% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1388.64,100,,1.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,200.24,14.42,,75.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1041.48,75,,39768.304,Percent of Total Billed Charges,75% of Total Billed Charges,694.32,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,694.32,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.32,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,694.32,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.05,70,,418.272,Percent of Total Billed Charges,70% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,194.41,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1388.64,100,,53024.4,Percent of Total Billed Charges,100% of Total Billed Charges,194.41,1388.64,
IR TUBE REPL GAST JEJ W FLUORO,46105249,CDM,361,RC,,,Outpatient,,,1608.77,965.26,,965.26,60,,6.032,Percent of Total Billed Charges,60% of Total Billed Charges,723.95,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.46,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,783.77,32,,74.24,Percent of Total Billed Charges,32% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,579.16,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,579.16,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,579.16,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,965.26,60,,1863.4,Percent of Total Billed Charges,60% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1608.77,100,,5.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,231.98,14.42,,75.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1206.58,75,,10539.624,Percent of Total Billed Charges,75% of Total Billed Charges,804.39,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,804.39,50,,314.288,Percent of Total Billed Charges,50% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.39,50,,314.288,Percent of Total Billed Charges,50% of Total Billed Charges,804.39,50,,171.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1126.14,70,,337.656,Percent of Total Billed Charges,70% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,225.23,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1608.77,100,,13174.528,Percent of Total Billed Charges,100% of Total Billed Charges,225.23,1608.77,
STENT URETERAL 5FR X 26CM,46105250,CDM,278,RC,C2617,HCPCS,Outpatient,,,1190.72,714.43,,1503.34,110,,1980,Percent of Total Billed Charges,110% of Total Billed Charges,535.82,45,,0.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.4,28,,540.784,Percent of Total Billed Charges,28% of Total Billed Charges,788.68,32,,74.352,Percent of Total Billed Charges,32% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,428.66,36,,695.296,Percent of Total Billed Charges,36% of Total Billed Charges,428.66,36,,695.296,Percent of Total Billed Charges,36% Total Bille Charges,428.66,36,,695.296,Percent of Total Billed Charges,36% of Total Billed Charges,654.9,55,,455.44,Percent of Total Billed Charges,55% Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1190.72,100,,2.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,171.7,14.42,,89.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,952.58,80,,137.64,Percent of Total Billed Charges,80% of Total Billed Charges,595.36,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,626.456,Percent of Total Billed Charges,50% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.36,50,,626.456,Percent of Total Billed Charges,50% of Total Billed Charges,595.36,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,833.5,70,,113.744,Percent of Total Billed Charges,70% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,166.7,14,,86.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1190.72,100,,183.52,Percent of Total Billed Charges,100% of Total Billed Charges,166.7,1503.34,
CATH BIOFLO DURAMAX 48CM,46105251,CDM,272,RC,C1752,HCPCS,Outpatient,,,1020,612.00,,6,100,,24,Fee Schedule,100% of Aetna Fee Schedule,459,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.6,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,790.27,32,,74.528,Percent of Total Billed Charges,32% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,367.2,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,367.2,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,367.2,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,612,60,,112.872,Percent of Total Billed Charges,60% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020,100,,0.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,147.08,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,510,50,,314.288,Percent of Total Billed Charges,50% of Total Billed Charges,510,50,,624.8,Percent of Total Billed Charges,50% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510,50,,624.8,Percent of Total Billed Charges,50% of Total Billed Charges,510,50,,1248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,714,70,,128.752,Percent of Total Billed Charges,70% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1020,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,6,1020,
CATH BIOFLO DURAMAX 48CM,46105253,CDM,278,RC,C1750,HCPCS,Outpatient,,,1486.27,891.76,,2149.8,110,,135.848,Percent of Total Billed Charges,110% of Total Billed Charges,668.82,45,,11.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.16,28,,1398.072,Percent of Total Billed Charges,28% of Total Billed Charges,790.4,32,,74.88,Percent of Total Billed Charges,32% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,535.06,36,,1797.52,Percent of Total Billed Charges,36% of Total Billed Charges,535.06,36,,1797.52,Percent of Total Billed Charges,36% Total Bille Charges,535.06,36,,1797.52,Percent of Total Billed Charges,36% of Total Billed Charges,817.45,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1486.27,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,214.32,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.02,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,743.14,50,,626.456,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,626.296,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.14,50,,626.296,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,306.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1040.39,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1486.27,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,208.08,2149.8,
CATHETER ANGIOJET ZELANTE DVT,46105254,CDM,272,RC,C1757,HCPCS,Outpatient,,,13687.77,8212.66,,16.33,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,6159.5,45,,0.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3832.58,28,,399.448,Percent of Total Billed Charges,28% of Total Billed Charges,790.4,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,4927.6,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,4927.6,36,,513.576,Percent of Total Billed Charges,36% Total Bille Charges,4927.6,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,8212.66,60,,924,Percent of Total Billed Charges,60% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13687.77,100,,0.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1973.78,14.42,,153.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10265.83,75,,2816.528,Percent of Total Billed Charges,75% of Total Billed Charges,6843.89,50,,624.8,Percent of Total Billed Charges,50% of Total Billed Charges,6843.89,50,,552.464,Percent of Total Billed Charges,50% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6843.89,50,,552.464,Percent of Total Billed Charges,50% of Total Billed Charges,6843.89,50,,107.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9581.44,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,1916.29,14,,148.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13687.77,100,,3755.368,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,13687.77,
CATH 5FR 40CM KMP,46105255,CDM,272,RC,C1887,HCPCS,Outpatient,,,205.21,123.13,,43.86,100,,6113.632,Fee Schedule,100% of Aetna Fee Schedule,92.34,45,,14.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.46,28,,609.064,Percent of Total Billed Charges,28% of Total Billed Charges,791.01,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,73.88,36,,783.08,Percent of Total Billed Charges,36% of Total Billed Charges,73.88,36,,783.08,Percent of Total Billed Charges,36% Total Bille Charges,73.88,36,,783.08,Percent of Total Billed Charges,36% of Total Billed Charges,123.13,60,,4180.8,Percent of Total Billed Charges,60% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.21,100,,0.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,29.59,14.42,,124.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.91,75,,806.968,Percent of Total Billed Charges,75% of Total Billed Charges,102.61,50,,626.296,Percent of Total Billed Charges,50% of Total Billed Charges,102.61,50,,363.216,Percent of Total Billed Charges,50% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.61,50,,363.216,Percent of Total Billed Charges,50% of Total Billed Charges,102.61,50,,196.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.65,70,,332.872,Percent of Total Billed Charges,70% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,28.73,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,100,,1075.96,Percent of Total Billed Charges,100% of Total Billed Charges,28.73,791.01,
CATH 5FR 65CM SHEPARD FLUSH,46105256,CDM,272,RC,C1887,HCPCS,Outpatient,,,69.21,41.53,,43.86,100,,190.64,Fee Schedule,100% of Aetna Fee Schedule,31.14,45,,4.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,28,,105.328,Percent of Total Billed Charges,28% of Total Billed Charges,792.96,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,24.92,36,,135.424,Percent of Total Billed Charges,36% of Total Billed Charges,24.92,36,,135.424,Percent of Total Billed Charges,36% Total Bille Charges,24.92,36,,135.424,Percent of Total Billed Charges,36% of Total Billed Charges,41.53,60,,1658.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.21,100,,26.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,14.42,,124.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.91,75,,806.968,Percent of Total Billed Charges,75% of Total Billed Charges,34.61,50,,552.464,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,144.896,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.61,50,,144.896,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.45,70,,998.624,Percent of Total Billed Charges,70% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,120.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.21,100,,1075.96,Percent of Total Billed Charges,100% of Total Billed Charges,9.69,792.96,
CATH DIAG SOFTVU HOOK1 5FR,46105261,CDM,272,RC,C1887,HCPCS,Outpatient,,,94.38,56.63,,43.86,100,,0.496,Fee Schedule,100% of Aetna Fee Schedule,42.47,45,,2.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,140.464,Percent of Total Billed Charges,28% of Total Billed Charges,792.96,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,180.6,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,180.6,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,180.6,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,3737.76,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,2.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,152.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,6118.2,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,363.216,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,202.456,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,202.456,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,121.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,998.624,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,147.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,8157.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,792.96,
CATH BIOFLOW DURAMAX 40CM,46105262,CDM,278,RC,C1750,HCPCS,Outpatient,,,1486.27,891.76,,2149.8,110,,75.6,Percent of Total Billed Charges,110% of Total Billed Charges,668.82,45,,4.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.16,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,793.92,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,535.06,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,535.06,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,535.06,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,817.45,55,,612,Percent of Total Billed Charges,55% Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1486.27,100,,32.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,214.32,14.42,,101.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.02,80,,795.28,Percent of Total Billed Charges,80% of Total Billed Charges,743.14,50,,144.896,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.14,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,743.14,50,,32.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1040.39,70,,1170,Percent of Total Billed Charges,70% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,208.08,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1486.27,100,,994.096,Percent of Total Billed Charges,100% of Total Billed Charges,208.08,2149.8,
CATH BIOFLO MILDINE MAX BARR,46105263,CDM,278,RC,C1751,HCPCS,Outpatient,,,657.86,394.72,,791.31,110,,0.056,Percent of Total Billed Charges,110% of Total Billed Charges,296.04,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,794.16,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,236.83,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,236.83,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,236.83,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,361.82,55,,521.024,Percent of Total Billed Charges,55% Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,100,,10.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,94.86,14.42,,101.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,526.29,80,,5098.504,Percent of Total Billed Charges,80% of Total Billed Charges,328.93,50,,202.456,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,328.93,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,70,,960.216,Percent of Total Billed Charges,70% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,98.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.86,100,,6798,Percent of Total Billed Charges,100% of Total Billed Charges,92.1,794.16,
CATH JEJU RADPQ 20FR 7-10ML,46105264,CDM,272,RC,,,Outpatient,,,499.6,299.76,,299.76,60,,233.232,Percent of Total Billed Charges,60% of Total Billed Charges,224.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.89,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,799.57,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,179.86,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,179.86,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,179.86,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,299.76,60,,2739.36,Percent of Total Billed Charges,60% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.6,100,,5.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,72.04,14.42,,76.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.7,75,,165,Percent of Total Billed Charges,75% of Total Billed Charges,249.8,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,249.8,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.8,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,249.8,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.72,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.94,14,,74.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.6,100,,220,Percent of Total Billed Charges,100% of Total Billed Charges,69.94,799.57,
CATH 5FRX65CM W SH OMNI FLUSH,46105266,CDM,272,RC,C1887,HCPCS,Outpatient,,,81.8,49.08,,43.86,100,,12.712,Fee Schedule,100% of Aetna Fee Schedule,36.81,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.9,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,801.92,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.45,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,29.45,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,29.45,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,49.08,60,,4236.96,Percent of Total Billed Charges,60% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.8,100,,10.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.8,14.42,,85.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.35,75,,1485.12,Percent of Total Billed Charges,75% of Total Billed Charges,40.9,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,40.9,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.9,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,40.9,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.26,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.8,100,,1856.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.45,801.92,
DEFIB TENDRIL LEAD,46105268,CDM,275,RC,C1898,HCPCS,Outpatient,,,1076.93,646.16,,2557.4,110,,11.92,Percent of Total Billed Charges,110% of Total Billed Charges,484.62,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.54,28,,58.624,Percent of Total Billed Charges,28% of Total Billed Charges,802.52,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,387.69,36,,75.368,Percent of Total Billed Charges,36% of Total Billed Charges,387.69,36,,75.368,Percent of Total Billed Charges,36% Total Bille Charges,387.69,36,,75.368,Percent of Total Billed Charges,36% of Total Billed Charges,592.31,55,,1630.48,Percent of Total Billed Charges,55% Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1076.93,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,155.29,14.42,,85.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,807.7,75,,135,Percent of Total Billed Charges,75% of Total Billed Charges,538.47,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.47,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,753.85,70,,1522.656,Percent of Total Billed Charges,70% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,83.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1076.93,100,,180,Percent of Total Billed Charges,100% of Total Billed Charges,150.77,2557.4,
STENT INNOVA,46105269,CDM,278,RC,C1876,HCPCS,Outpatient,,,2689.23,1613.54,,4389.9,110,,6.512,Percent of Total Billed Charges,110% of Total Billed Charges,1210.15,45,,0.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,752.98,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,802.82,32,,75.048,Percent of Total Billed Charges,32% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,968.12,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,968.12,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,968.12,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,1479.08,55,,84,Percent of Total Billed Charges,55% Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2689.23,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,387.79,14.42,,71.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2151.38,80,,1585.92,Percent of Total Billed Charges,80% of Total Billed Charges,1344.62,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,1344.62,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344.62,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,1344.62,50,,314.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1882.46,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,376.49,14,,69.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2689.23,100,,1982.4,Percent of Total Billed Charges,100% of Total Billed Charges,376.49,4389.9,
IR BX TRNSCATH,46105270,CDM,361,RC,,,Outpatient,,,4264.96,2558.98,,2558.98,60,,38,Percent of Total Billed Charges,60% of Total Billed Charges,1919.23,45,,34.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1194.19,28,,102.016,Percent of Total Billed Charges,28% of Total Billed Charges,804.23,32,,75.272,Percent of Total Billed Charges,32% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,1535.39,36,,131.168,Percent of Total Billed Charges,36% of Total Billed Charges,1535.39,36,,131.168,Percent of Total Billed Charges,36% Total Bille Charges,1535.39,36,,131.168,Percent of Total Billed Charges,36% of Total Billed Charges,2558.98,60,,251.856,Percent of Total Billed Charges,60% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4264.96,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,615.01,14.42,,102.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3198.72,75,,1585.92,Percent of Total Billed Charges,75% of Total Billed Charges,2132.48,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,2132.48,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2132.48,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,2132.48,50,,626.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2985.47,70,,1407.456,Percent of Total Billed Charges,70% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,597.09,14,,99.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4264.96,100,,1982.4,Percent of Total Billed Charges,100% of Total Billed Charges,597.09,4264.96,
IR BX TRNSCATH SI,46105271,CDM,320,RC,75970,HCPCS,Outpatient,,,2484.46,1490.68,,364.85,100,,14.432,Fee Schedule,100% of Aetna Fee Schedule,1118.01,45,,7.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.02,280,,357.064,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,75.272,Fee Schedule,320% of BCBS Blue Essentials Rate,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,459.08,Fee Schedule,360% of BCBS POS Rate,146.59,360,,459.08,Fee schedule,360% of BCBS PPO Rate,146.59,360,,459.08,Fee Schedule,360% of BCBS Traditional Rate,1490.68,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2484.46,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,358.26,14.42,,62.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1863.35,75,,1792,Percent of Total Billed Charges,75% of Total Billed Charges,1242.23,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1242.23,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,624.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1170,Case Rate,Pays based on per visit rate,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,60.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2484.46,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,114.02,2484.46,
IR BX TRNSCATH SI,46105271,CDM,320,RC,75970,HCPCS,Outpatient,,,2484.46,1490.68,,364.85,100,,15.264,Fee Schedule,100% of Aetna Fee Schedule,1118.01,45,,63.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.02,280,,218.4,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,75.496,Fee Schedule,320% of BCBS Blue Essentials Rate,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,280.8,Fee Schedule,360% of BCBS POS Rate,146.59,360,,280.8,Fee schedule,360% of BCBS PPO Rate,146.59,360,,280.8,Fee Schedule,360% of BCBS Traditional Rate,1490.68,60,,774.224,Percent of Total Billed Charges,60% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2484.46,100,,0.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,358.26,14.42,,109.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1863.35,75,,1342.08,Percent of Total Billed Charges,75% of Total Billed Charges,1242.23,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1242.23,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,626.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,402.128,Case Rate,Pays based on per visit rate,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,106.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2484.46,100,,1677.6,Percent of Total Billed Charges,100% of Total Billed Charges,114.02,2484.46,
IR CATH COM CAR INOM EXTCRN RT,46105272,CDM,361,RC,,,Outpatient,,,6590.07,3954.04,,3954.04,60,,77.656,Percent of Total Billed Charges,60% of Total Billed Charges,2965.53,45,,30.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1845.22,28,,266.92,Percent of Total Billed Charges,28% of Total Billed Charges,804.26,32,,75.52,Percent of Total Billed Charges,32% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,2372.43,36,,343.176,Percent of Total Billed Charges,36% of Total Billed Charges,2372.43,36,,343.176,Percent of Total Billed Charges,36% Total Bille Charges,2372.43,36,,343.176,Percent of Total Billed Charges,36% of Total Billed Charges,3954.04,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6590.07,100,,76.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,950.29,14.42,,138.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4942.55,75,,7009.616,Percent of Total Billed Charges,75% of Total Billed Charges,3295.04,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3295.04,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,552.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4613.05,70,,408.304,Percent of Total Billed Charges,70% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,134.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6590.07,100,,9346.152,Percent of Total Billed Charges,100% of Total Billed Charges,804.26,6590.07,
IR CATH COM CAR INOM EXTCRN LT,46105273,CDM,361,RC,,,Outpatient,,,6590.07,3954.04,,3954.04,60,,1.328,Percent of Total Billed Charges,60% of Total Billed Charges,2965.53,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1845.22,28,,191.024,Percent of Total Billed Charges,28% of Total Billed Charges,804.26,32,,75.8,Percent of Total Billed Charges,32% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,2372.43,36,,245.6,Percent of Total Billed Charges,36% of Total Billed Charges,2372.43,36,,245.6,Percent of Total Billed Charges,36% Total Bille Charges,2372.43,36,,245.6,Percent of Total Billed Charges,36% of Total Billed Charges,3954.04,60,,1044,Percent of Total Billed Charges,60% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6590.07,100,,15.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,950.29,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4942.55,75,,3322.672,Percent of Total Billed Charges,75% of Total Billed Charges,3295.04,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3295.04,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,363.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4613.05,70,,408.304,Percent of Total Billed Charges,70% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6590.07,100,,4430.232,Percent of Total Billed Charges,100% of Total Billed Charges,804.26,6590.07,
STENT PLACEMT ANTE CAROTID,46105275,CDM,360,RC,,,Outpatient,,,12450.76,7470.46,,7470.46,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,5602.84,45,,5.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3486.21,28,,28.304,Percent of Total Billed Charges,28% of Total Billed Charges,804.26,32,,76.024,Percent of Total Billed Charges,32% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,4482.27,36,,36.384,Percent of Total Billed Charges,36% of Total Billed Charges,4482.27,36,,36.384,Percent of Total Billed Charges,36% Total Bille Charges,4482.27,36,,36.384,Percent of Total Billed Charges,36% of Total Billed Charges,7470.46,60,,792,Percent of Total Billed Charges,60% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12450.76,100,,140.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1795.4,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9338.07,75,,1342.08,Percent of Total Billed Charges,75% of Total Billed Charges,6225.38,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,6225.38,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6225.38,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,6225.38,50,,144.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8715.53,70,,134.048,Percent of Total Billed Charges,70% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1743.11,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12450.76,100,,1677.6,Percent of Total Billed Charges,100% of Total Billed Charges,804.26,12450.76,
IR ACCESS INTRO NPAS-100-RH,46108000,CDM,272,RC,C1894,HCPCS,Outpatient,,,434.52,260.71,,82.29,100,,623.568,Fee Schedule,100% of Aetna Fee Schedule,195.53,45,,5.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.67,28,,35.48,Percent of Total Billed Charges,28% of Total Billed Charges,804.26,32,,76.264,Percent of Total Billed Charges,32% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,156.43,36,,45.616,Percent of Total Billed Charges,36% of Total Billed Charges,156.43,36,,45.616,Percent of Total Billed Charges,36% Total Bille Charges,156.43,36,,45.616,Percent of Total Billed Charges,36% of Total Billed Charges,260.71,60,,944.968,Percent of Total Billed Charges,60% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.52,100,,67.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,62.66,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.89,75,,4610.504,Percent of Total Billed Charges,75% of Total Billed Charges,217.26,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,217.26,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.26,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,217.26,50,,202.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.16,70,,1407.456,Percent of Total Billed Charges,70% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,60.83,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.52,100,,6147.336,Percent of Total Billed Charges,100% of Total Billed Charges,60.83,804.26,
IR TRNSCATH FB RTVL INTRVS SI,46108005,CDM,361,RC,,,Outpatient,,,6800.71,4080.43,,4080.43,60,,141.552,Percent of Total Billed Charges,60% of Total Billed Charges,3060.32,45,,1.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1904.2,28,,514.112,Percent of Total Billed Charges,28% of Total Billed Charges,805.4,32,,76.368,Percent of Total Billed Charges,32% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,2448.26,36,,661,Percent of Total Billed Charges,36% of Total Billed Charges,2448.26,36,,661,Percent of Total Billed Charges,36% Total Bille Charges,2448.26,36,,661,Percent of Total Billed Charges,36% of Total Billed Charges,4080.43,60,,4092.44,Percent of Total Billed Charges,60% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6800.71,100,,0.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,980.66,14.42,,165.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5100.53,75,,4169.504,Percent of Total Billed Charges,75% of Total Billed Charges,3400.36,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,3400.36,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3400.36,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,3400.36,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4760.5,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,952.1,14,,161.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6800.71,100,,5559.336,Percent of Total Billed Charges,100% of Total Billed Charges,805.4,6800.71,
VENOGRAM EXT BI SI,46108017,CDM,320,RC,75822,HCPCS,Outpatient,,,1917,1150.20,,69.44,100,,6.848,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,99.672,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.02,280,,167.304,Fee Schedule,280% of BCBS BULE Fee Schedule,254.88,320,,76.392,Fee Schedule,320% of BCBS Blue Essentials Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,286.74,360,,215.112,Fee Schedule,360% of BCBS POS Rate,286.74,360,,215.112,Fee schedule,360% of BCBS PPO Rate,286.74,360,,215.112,Fee Schedule,360% of BCBS Traditional Rate,3325.79,103,,630.712,Fee Schedule,103% of Cigna fee schedule,132.99,100,,67.368,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,12.28,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,136.98,103,,69.384,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1437.75,75,,2950.024,Percent of Total Billed Charges,75% of Total Billed Charges,958.5,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,958.5,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,402.128,Case Rate,Pays based on per visit rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,67.368,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1917,100,,3933.36,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,3325.79,
VENOGRAM EXT BI SI,46108017,CDM,320,RC,75822,HCPCS,Outpatient,,,1917,1150.20,,69.44,100,,94.264,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,6.208,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.02,280,,135.064,Fee Schedule,280% of BCBS BULE Fee Schedule,254.88,320,,76.528,Fee Schedule,320% of BCBS Blue Essentials Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,286.74,360,,173.648,Fee Schedule,360% of BCBS POS Rate,286.74,360,,173.648,Fee schedule,360% of BCBS PPO Rate,286.74,360,,173.648,Fee Schedule,360% of BCBS Traditional Rate,3325.79,103,,14960,Fee Schedule,103% of Cigna fee schedule,132.99,100,,982.936,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,12.28,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,136.98,103,,1012.424,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1437.75,75,,2667.848,Percent of Total Billed Charges,75% of Total Billed Charges,958.5,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,958.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,402.128,Case Rate,Pays based on per visit rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,982.936,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1917,100,,3557.128,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,3325.79,
TURBO HAWK ATHRE,46108096,CDM,272,RC,,,Outpatient,,,8827,5296.20,,5296.2,60,,409.608,Percent of Total Billed Charges,60% of Total Billed Charges,3972.15,45,,1.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2471.56,28,,51.504,Percent of Total Billed Charges,28% of Total Billed Charges,805.76,32,,76.752,Percent of Total Billed Charges,32% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,3177.72,36,,66.216,Percent of Total Billed Charges,36% of Total Billed Charges,3177.72,36,,66.216,Percent of Total Billed Charges,36% Total Bille Charges,3177.72,36,,66.216,Percent of Total Billed Charges,36% of Total Billed Charges,5296.2,60,,3203.2,Percent of Total Billed Charges,60% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827,100,,4.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1272.85,14.42,,136.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,75,,7028.152,Percent of Total Billed Charges,75% of Total Billed Charges,4413.5,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4413.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6178.9,70,,236.944,Percent of Total Billed Charges,70% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8827,100,,9370.864,Percent of Total Billed Charges,100% of Total Billed Charges,805.76,8827,
SHEATH RADIAL 5 FR,46108097,CDM,272,RC,C1894,HCPCS,Outpatient,,,852.78,511.67,,82.29,100,,4.592,Fee Schedule,100% of Aetna Fee Schedule,383.75,45,,6.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,806.35,32,,76.752,Percent of Total Billed Charges,32% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,307,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,307,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,307,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,511.67,60,,4187.568,Percent of Total Billed Charges,60% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,852.78,100,,221.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,122.97,14.42,,136.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,639.59,75,,5642.968,Percent of Total Billed Charges,75% of Total Billed Charges,426.39,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,426.39,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.39,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,426.39,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.95,70,,128.752,Percent of Total Billed Charges,70% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,132.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,100,,7523.96,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,852.78,
HEMOSTASIS VALVE,46108098,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,6.096,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,806.35,32,,768,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,13.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,282.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,7627.568,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,10170.088,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,806.35,
FLTR VENA CAVA OPTEASE 55CM,46108125,CDM,278,RC,C1880,HCPCS,Outpatient,,,3028.03,1816.82,,3375.67,110,,124.592,Percent of Total Billed Charges,110% of Total Billed Charges,1362.61,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,847.85,28,,133.152,Percent of Total Billed Charges,28% of Total Billed Charges,806.4,32,,768.408,Percent of Total Billed Charges,32% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,1090.09,36,,171.192,Percent of Total Billed Charges,36% of Total Billed Charges,1090.09,36,,171.192,Percent of Total Billed Charges,36% Total Bille Charges,1090.09,36,,171.192,Percent of Total Billed Charges,36% of Total Billed Charges,1665.42,55,,79.2,Percent of Total Billed Charges,55% Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3028.03,100,,4.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,436.64,14.42,,306.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2422.42,80,,7627.568,Percent of Total Billed Charges,80% of Total Billed Charges,1514.02,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1514.02,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1514.02,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1514.02,50,,747.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2119.62,70,,180.272,Percent of Total Billed Charges,70% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,423.92,14,,298.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3028.03,100,,10170.088,Percent of Total Billed Charges,100% of Total Billed Charges,423.92,3375.67,
GW .035INX260CM J-TIP EMERALD,46108220,CDM,272,RC,C1769,HCPCS,Outpatient,,,55.3,33.18,,55.13,100,,7.824,Fee Schedule,100% of Aetna Fee Schedule,24.89,45,,0.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,28,,399.448,Percent of Total Billed Charges,28% of Total Billed Charges,806.4,32,,770.584,Percent of Total Billed Charges,32% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,19.91,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,19.91,36,,513.576,Percent of Total Billed Charges,36% Total Bille Charges,19.91,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,33.18,60,,14960,Percent of Total Billed Charges,60% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.3,100,,13.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14.42,,286.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.48,75,,2537.392,Percent of Total Billed Charges,75% of Total Billed Charges,27.65,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,27.65,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.65,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,27.65,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.71,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.3,100,,3383.192,Percent of Total Billed Charges,100% of Total Billed Charges,7.74,806.4,
GW .035-145-1.5 THSCF ROSEN SS,46108226,CDM,272,RC,C1769,HCPCS,Outpatient,,,81.04,48.62,,55.13,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,36.47,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.69,28,,399.448,Percent of Total Billed Charges,28% of Total Billed Charges,806.4,32,,772.096,Percent of Total Billed Charges,32% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,29.17,36,,513.576,Percent of Total Billed Charges,36% Total Bille Charges,29.17,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,48.62,60,,11440,Percent of Total Billed Charges,60% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.04,100,,0.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.69,14.42,,286.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.78,75,,2537.392,Percent of Total Billed Charges,75% of Total Billed Charges,40.52,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.52,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.52,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,40.52,50,,991.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.73,70,,408.304,Percent of Total Billed Charges,70% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.35,14,,278.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.04,100,,3383.192,Percent of Total Billed Charges,100% of Total Billed Charges,11.35,806.4,
GW BENTSON .035-260-20 TFE,46108229,CDM,272,RC,C1769,HCPCS,Outpatient,,,125.84,75.50,,55.13,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,56.63,45,,1.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,811.77,32,,775.176,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,10472,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,0.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,438.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,1380.352,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,1619.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,408.304,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,1840.472,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,811.77,
GW VASC HTORQ IRNMN 300CM 3CM,46108237,CDM,272,RC,C1769,HCPCS,Outpatient,,,481.14,288.68,,55.13,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,216.51,45,,36.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.72,28,,384.088,Percent of Total Billed Charges,28% of Total Billed Charges,812.28,32,,780.288,Percent of Total Billed Charges,32% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,173.21,36,,493.824,Percent of Total Billed Charges,36% of Total Billed Charges,173.21,36,,493.824,Percent of Total Billed Charges,36% Total Bille Charges,173.21,36,,493.824,Percent of Total Billed Charges,36% of Total Billed Charges,288.68,60,,11440,Percent of Total Billed Charges,60% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.14,100,,0.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,69.38,14.42,,439.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.86,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,240.57,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.57,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.8,70,,255.04,Percent of Total Billed Charges,70% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.14,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,812.28,
GW VASC HTORQ PLT 50 190CM 3CM,46108238,CDM,272,RC,C1769,HCPCS,Outpatient,,,481.14,288.68,,55.13,100,,126.688,Fee Schedule,100% of Aetna Fee Schedule,216.51,45,,0.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.72,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,813.12,32,,785.096,Percent of Total Billed Charges,32% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,173.21,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,173.21,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,173.21,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,288.68,60,,122.88,Percent of Total Billed Charges,60% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.14,100,,0.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,69.38,14.42,,126.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.86,75,,405,Percent of Total Billed Charges,75% of Total Billed Charges,240.57,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.57,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,2147.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.8,70,,255.04,Percent of Total Billed Charges,70% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,122.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.14,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,813.12,
CATH ANGIO DG OF .035INX5FRX65,46108239,CDM,272,RC,C1887,HCPCS,Outpatient,,,84.94,50.96,,43.86,100,,0.536,Fee Schedule,100% of Aetna Fee Schedule,38.22,45,,0.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.78,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,814.46,32,,786.04,Percent of Total Billed Charges,32% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,30.58,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,30.58,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,30.58,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,50.96,60,,3644.936,Percent of Total Billed Charges,60% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.94,100,,2.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,12.25,14.42,,347.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,75,,1924.816,Percent of Total Billed Charges,75% of Total Billed Charges,42.47,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,42.47,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.47,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,42.47,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.46,70,,85.016,Percent of Total Billed Charges,70% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,337.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.94,100,,2566.424,Percent of Total Billed Charges,100% of Total Billed Charges,11.89,814.46,
PROTECTION EMBL .014INX190CM,46108242,CDM,272,RC,C1884,HCPCS,Outpatient,,,4401.71,2641.03,,136.85,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,1980.77,45,,0.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1232.48,28,,609.064,Percent of Total Billed Charges,28% of Total Billed Charges,815.03,32,,788.816,Percent of Total Billed Charges,32% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,1584.62,36,,783.08,Percent of Total Billed Charges,36% of Total Billed Charges,1584.62,36,,783.08,Percent of Total Billed Charges,36% Total Bille Charges,1584.62,36,,783.08,Percent of Total Billed Charges,36% of Total Billed Charges,2641.03,60,,607.2,Percent of Total Billed Charges,60% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4401.71,100,,80.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,634.73,14.42,,1522.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3301.28,75,,7800,Percent of Total Billed Charges,75% of Total Billed Charges,2200.86,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,2200.86,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2200.86,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,2200.86,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3081.2,70,,1170,Percent of Total Billed Charges,70% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,616.24,14,,1478.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4401.71,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,136.85,4401.71,
INTRO SYS INTRO ACST II 21GA .,46108243,CDM,272,RC,C1894,HCPCS,Outpatient,,,293.15,175.89,,82.29,100,,0.136,Fee Schedule,100% of Aetna Fee Schedule,131.92,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.08,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,815.38,32,,791.44,Percent of Total Billed Charges,32% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,105.53,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,105.53,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,105.53,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,175.89,60,,122.88,Percent of Total Billed Charges,60% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.15,100,,2.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,42.27,14.42,,2541.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.86,75,,1924.816,Percent of Total Billed Charges,75% of Total Billed Charges,146.58,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.58,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,146.58,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.21,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,14,,2467.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.15,100,,2566.424,Percent of Total Billed Charges,100% of Total Billed Charges,41.04,815.38,
FLTR VENA CAVA FEM/JUG 7F 40,46108244,CDM,278,RC,C1880,HCPCS,Outpatient,,,5177.49,3106.49,,5740.08,110,,0.312,Percent of Total Billed Charges,110% of Total Billed Charges,2329.87,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.7,28,,562.984,Percent of Total Billed Charges,28% of Total Billed Charges,826.79,32,,795,Percent of Total Billed Charges,32% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,1863.9,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,1863.9,36,,723.84,Percent of Total Billed Charges,36% Total Bille Charges,1863.9,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,2847.62,55,,5261.96,Percent of Total Billed Charges,55% Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5177.49,100,,1.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,746.59,14.42,,2899.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4141.99,80,,1596.504,Percent of Total Billed Charges,80% of Total Billed Charges,2588.75,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,2588.75,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2588.75,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,2588.75,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3624.24,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,724.85,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5177.49,100,,2128.672,Percent of Total Billed Charges,100% of Total Billed Charges,724.85,5740.08,
SHTH KT INTVENT 6FRX23CM.35,46108245,CDM,272,RC,C1894,HCPCS,Outpatient,,,125.84,75.50,,82.29,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,56.63,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,828.35,32,,795,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,4092.44,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,1.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,2899.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,435.04,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,828.35,
SHTH KT INTVENT 7FRX23CM.35,46108246,CDM,272,RC,C1894,HCPCS,Outpatient,,,125.84,75.50,,82.29,100,,2.704,Fee Schedule,100% of Aetna Fee Schedule,56.63,45,,2.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,828.8,32,,795,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,1007.6,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,1.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,2899.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,916.8,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,418.312,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,1222.4,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,828.8,
GW VASC 175CM 3MM .035IN PTFE,46108252,CDM,272,RC,C1769,HCPCS,Outpatient,,,37.59,22.55,,55.13,100,,1.384,Fee Schedule,100% of Aetna Fee Schedule,16.92,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.53,28,,163.32,Percent of Total Billed Charges,28% of Total Billed Charges,831.68,32,,795.392,Percent of Total Billed Charges,32% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.53,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,13.53,36,,209.984,Percent of Total Billed Charges,36% Total Bille Charges,13.53,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,22.55,60,,122.88,Percent of Total Billed Charges,60% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.59,100,,1.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.42,14.42,,2899.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.19,75,,1342.08,Percent of Total Billed Charges,75% of Total Billed Charges,18.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.31,70,,145.016,Percent of Total Billed Charges,70% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,2815.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.59,100,,1677.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.26,831.68,
CATH GD GLIDE 5FRX100CM N TAPR,46108253,CDM,272,RC,C1887,HCPCS,Outpatient,,,269.7,161.82,,43.86,100,,0.984,Fee Schedule,100% of Aetna Fee Schedule,121.37,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.52,28,,163.32,Percent of Total Billed Charges,28% of Total Billed Charges,833.28,32,,796.944,Percent of Total Billed Charges,32% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,97.09,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,97.09,36,,209.984,Percent of Total Billed Charges,36% Total Bille Charges,97.09,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,161.82,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.7,100,,4.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,38.89,14.42,,1788.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.28,75,,1342.08,Percent of Total Billed Charges,75% of Total Billed Charges,134.85,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.85,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.79,70,,1124.992,Percent of Total Billed Charges,70% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,1736.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.7,100,,1677.6,Percent of Total Billed Charges,100% of Total Billed Charges,37.76,833.28,
COIL EMB A/V HILAL MICROCOILS,46108260,CDM,278,RC,,,Outpatient,,,201.66,121.00,,221.83,110,,0.488,Percent of Total Billed Charges,110% of Total Billed Charges,90.75,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.46,28,,53.616,Percent of Total Billed Charges,28% of Total Billed Charges,838.66,32,,798.72,Percent of Total Billed Charges,32% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,72.6,36,,68.936,Percent of Total Billed Charges,36% of Total Billed Charges,72.6,36,,68.936,Percent of Total Billed Charges,36% Total Bille Charges,72.6,36,,68.936,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.66,100,,4.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,29.08,14.42,,2612.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.33,80,,1342.08,Percent of Total Billed Charges,80% of Total Billed Charges,100.83,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,100.83,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.83,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,100.83,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.16,70,,998.624,Percent of Total Billed Charges,70% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.23,14,,2536.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.66,100,,1677.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.23,838.66,
COIL EMB A/V NST 14CM 4MM,46108261,CDM,278,RC,,,Outpatient,,,534.6,320.76,,588.06,110,,175.744,Percent of Total Billed Charges,110% of Total Billed Charges,240.57,45,,0.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.69,28,,562.984,Percent of Total Billed Charges,28% of Total Billed Charges,838.66,32,,798.72,Percent of Total Billed Charges,32% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,192.46,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,36,,723.84,Percent of Total Billed Charges,36% Total Bille Charges,192.46,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,294.03,55,,627,Percent of Total Billed Charges,55% Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.6,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,77.09,14.42,,1130.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.68,80,,1440,Percent of Total Billed Charges,80% of Total Billed Charges,267.3,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.3,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,267.3,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,374.22,70,,960.216,Percent of Total Billed Charges,70% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,74.84,14,,1097.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,534.6,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,74.84,838.66,
SHTH GUID PINN DESTIN 6FRX45CM,46108267,CDM,272,RC,C1894,HCPCS,Outpatient,,,411.64,246.98,,82.29,100,,1.024,Fee Schedule,100% of Aetna Fee Schedule,185.24,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.26,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,844.93,32,,798.72,Percent of Total Billed Charges,32% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,246.98,60,,473.848,Percent of Total Billed Charges,60% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.64,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,59.36,14.42,,184.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.73,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,205.82,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,205.82,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.82,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,205.82,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.15,70,,332.872,Percent of Total Billed Charges,70% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,411.64,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,57.63,844.93,
SHTH GUID STR XCUT VL 7FRX45CM,46108268,CDM,272,RC,C1894,HCPCS,Outpatient,,,411.64,246.98,,82.29,100,,5.752,Fee Schedule,100% of Aetna Fee Schedule,185.24,45,,0.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.26,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,845.44,32,,799.288,Percent of Total Billed Charges,32% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,148.19,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,246.98,60,,3738.904,Percent of Total Billed Charges,60% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.64,100,,0.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,59.36,14.42,,797.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.73,75,,1440,Percent of Total Billed Charges,75% of Total Billed Charges,205.82,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,205.82,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.82,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,205.82,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.15,70,,947.08,Percent of Total Billed Charges,70% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.63,14,,773.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,411.64,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,57.63,845.44,
GW 035 260 PTFE STRAIGHT,46108270,CDM,272,RC,C1769,HCPCS,Outpatient,,,70.69,42.41,,55.13,100,,0.392,Fee Schedule,100% of Aetna Fee Schedule,31.81,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.79,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,845.64,32,,802.28,Percent of Total Billed Charges,32% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,25.45,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,25.45,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,25.45,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,42.41,60,,37.408,Percent of Total Billed Charges,60% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.69,100,,0.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14.42,,961.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.02,75,,1440,Percent of Total Billed Charges,75% of Total Billed Charges,35.35,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,35.35,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.35,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,35.35,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.48,70,,2400.16,Percent of Total Billed Charges,70% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,933.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.69,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,9.9,845.64,
CATH NEPHSTMY SKTR GW 10FRX35C,46108273,CDM,272,RC,C1729,HCPCS,Outpatient,,,375,225.00,,11.1,100,,10.256,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,94.776,Percent of Total Billed Charges,28% of Total Billed Charges,845.64,32,,803.352,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,121.856,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,121.856,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,121.856,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,892.8,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,859.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1440,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,998.624,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,834.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,845.64,
BMCC KIT LACERATION CSTM,46108275,CDM,272,RC,A4649,HCPCS,Outpatient,,,67.38,40.43,,40.43,60,,0.784,Percent of Total Billed Charges,60% of Total Billed Charges,30.32,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.87,28,,51.504,Percent of Total Billed Charges,28% of Total Billed Charges,846.49,32,,803.712,Percent of Total Billed Charges,32% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,24.26,36,,66.216,Percent of Total Billed Charges,36% of Total Billed Charges,24.26,36,,66.216,Percent of Total Billed Charges,36% Total Bille Charges,24.26,36,,66.216,Percent of Total Billed Charges,36% of Total Billed Charges,40.43,60,,11198.88,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.38,100,,0.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.72,14.42,,775.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.54,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,33.69,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,33.69,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.69,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,33.69,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.17,70,,440.408,Percent of Total Billed Charges,70% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,752.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.38,100,,184,Percent of Total Billed Charges,100% of Total Billed Charges,9.43,846.49,
INTRO SHTH ARROW 7F 35CM,46108279,CDM,272,RC,C1894,HCPCS,Outpatient,,,359.84,215.90,,82.29,100,,0.24,Fee Schedule,100% of Aetna Fee Schedule,161.93,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.76,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,847,32,,803.712,Percent of Total Billed Charges,32% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,129.54,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,129.54,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,129.54,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,215.9,60,,2436.72,Percent of Total Billed Charges,60% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.84,100,,0.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,51.89,14.42,,392.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.88,75,,1377.528,Percent of Total Billed Charges,75% of Total Billed Charges,179.92,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,179.92,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.92,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,179.92,50,,92.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.89,70,,1521.136,Percent of Total Billed Charges,70% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,50.38,14,,380.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.84,100,,1836.704,Percent of Total Billed Charges,100% of Total Billed Charges,50.38,847,
GW STORQ STR,46108283,CDM,272,RC,C1769,HCPCS,Outpatient,,,269.7,161.82,,55.13,100,,0.232,Fee Schedule,100% of Aetna Fee Schedule,121.37,45,,1.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.52,28,,72.112,Percent of Total Billed Charges,28% of Total Billed Charges,851.47,32,,808.992,Percent of Total Billed Charges,32% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,97.09,36,,92.712,Percent of Total Billed Charges,36% of Total Billed Charges,97.09,36,,92.712,Percent of Total Billed Charges,36% Total Bille Charges,97.09,36,,92.712,Percent of Total Billed Charges,36% of Total Billed Charges,161.82,60,,7245.992,Percent of Total Billed Charges,60% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.7,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,38.89,14.42,,398.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.28,75,,5452.2,Percent of Total Billed Charges,75% of Total Billed Charges,134.85,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.85,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.79,70,,1407.456,Percent of Total Billed Charges,70% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,387.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.7,100,,7269.6,Percent of Total Billed Charges,100% of Total Billed Charges,37.76,851.47,
SYRINGES CONTOUR SE,46108286,CDM,278,RC,,,Outpatient,,,789.6,473.76,,868.56,110,,2.104,Percent of Total Billed Charges,110% of Total Billed Charges,355.32,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.09,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,851.47,32,,809.384,Percent of Total Billed Charges,32% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,284.26,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,284.26,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,284.26,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,434.28,55,,4804.8,Percent of Total Billed Charges,55% Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,789.6,100,,0.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,113.86,14.42,,534.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,631.68,80,,1510.12,Percent of Total Billed Charges,80% of Total Billed Charges,394.8,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,394.8,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.8,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,394.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.72,70,,756,Percent of Total Billed Charges,70% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,110.54,14,,518.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,789.6,100,,2013.488,Percent of Total Billed Charges,100% of Total Billed Charges,110.54,868.56,
SKIN ADHESIVE DERMABOND PEN,46108290,CDM,272,RC,,,Outpatient,,,107.35,64.41,,64.41,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,0.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,163.32,Percent of Total Billed Charges,28% of Total Billed Charges,851.47,32,,813.12,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,209.984,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,64.41,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.35,100,,0.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,601.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.51,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,584.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.35,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,851.47,
INTRODUCER LAPAROSCOPIC 20FR,46108294,CDM,272,RC,C1894,HCPCS,Outpatient,,,1126.59,675.95,,82.29,100,,0.416,Fee Schedule,100% of Aetna Fee Schedule,506.97,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.45,28,,163.32,Percent of Total Billed Charges,28% of Total Billed Charges,851.47,32,,821.256,Percent of Total Billed Charges,32% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,405.57,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,405.57,36,,209.984,Percent of Total Billed Charges,36% Total Bille Charges,405.57,36,,209.984,Percent of Total Billed Charges,36% of Total Billed Charges,675.95,60,,528,Percent of Total Billed Charges,60% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1126.59,100,,4.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,162.45,14.42,,606.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.94,75,,378,Percent of Total Billed Charges,75% of Total Billed Charges,563.3,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,563.3,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.3,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,563.3,50,,150.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,788.61,70,,322.984,Percent of Total Billed Charges,70% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,157.72,14,,588.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1126.59,100,,504,Percent of Total Billed Charges,100% of Total Billed Charges,82.29,1126.59,
FLOPPY RUNTHROUGH .014X300CM,46108295,CDM,272,RC,C1769,HCPCS,Outpatient,,,427.68,256.61,,55.13,100,,10.088,Fee Schedule,100% of Aetna Fee Schedule,192.46,45,,0.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.75,28,,102.016,Percent of Total Billed Charges,28% of Total Billed Charges,852.63,32,,821.256,Percent of Total Billed Charges,32% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,153.96,36,,131.16,Percent of Total Billed Charges,36% of Total Billed Charges,153.96,36,,131.16,Percent of Total Billed Charges,36% Total Bille Charges,153.96,36,,131.16,Percent of Total Billed Charges,36% of Total Billed Charges,256.61,60,,1716,Percent of Total Billed Charges,60% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.68,100,,0.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,61.67,14.42,,630.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.76,75,,531,Percent of Total Billed Charges,75% of Total Billed Charges,213.84,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.84,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.38,70,,5913.032,Percent of Total Billed Charges,70% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,612.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.68,100,,708,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,852.63,
STENT PARAMOUNT MINI 6X14 80CM,46108296,CDM,278,RC,C1876,HCPCS,Outpatient,,,1890,1134.00,,3510.75,110,,0.2,Percent of Total Billed Charges,110% of Total Billed Charges,850.5,45,,2.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.2,28,,102.016,Percent of Total Billed Charges,28% of Total Billed Charges,852.8,32,,821.256,Percent of Total Billed Charges,32% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,680.4,36,,131.16,Percent of Total Billed Charges,36% of Total Billed Charges,680.4,36,,131.16,Percent of Total Billed Charges,36% Total Bille Charges,680.4,36,,131.16,Percent of Total Billed Charges,36% of Total Billed Charges,1039.5,55,,66.24,Percent of Total Billed Charges,55% Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1890,100,,1.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,272.54,14.42,,548.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1512,80,,70.2,Percent of Total Billed Charges,80% of Total Billed Charges,945,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,532.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1890,100,,93.6,Percent of Total Billed Charges,100% of Total Billed Charges,264.6,3510.75,
STENT PARAMOUNT MINI 7X18 80CM,46108298,CDM,278,RC,C1876,HCPCS,Outpatient,,,1890,1134.00,,3510.75,110,,0.408,Percent of Total Billed Charges,110% of Total Billed Charges,850.5,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.2,28,,34.008,Percent of Total Billed Charges,28% of Total Billed Charges,853.78,32,,821.256,Percent of Total Billed Charges,32% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,680.4,36,,43.72,Percent of Total Billed Charges,36% of Total Billed Charges,680.4,36,,43.72,Percent of Total Billed Charges,36% Total Bille Charges,680.4,36,,43.72,Percent of Total Billed Charges,36% of Total Billed Charges,1039.5,55,,3432,Percent of Total Billed Charges,55% Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1890,100,,13.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,272.54,14.42,,180.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1512,80,,2557.2,Percent of Total Billed Charges,80% of Total Billed Charges,945,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323,70,,1426.296,Percent of Total Billed Charges,70% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,175.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1890,100,,3409.6,Percent of Total Billed Charges,100% of Total Billed Charges,264.6,3510.75,
STENT PARA MT MINI 5X14 80CM,46108302,CDM,278,RC,C1876,HCPCS,Outpatient,,,1890,1134.00,,3510.75,110,,0.816,Percent of Total Billed Charges,110% of Total Billed Charges,850.5,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.2,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,853.78,32,,827.896,Percent of Total Billed Charges,32% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,680.4,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,680.4,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,680.4,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,1039.5,55,,4486.68,Percent of Total Billed Charges,55% Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1890,100,,0.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,272.54,14.42,,994.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1512,80,,228,Percent of Total Billed Charges,80% of Total Billed Charges,945,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,137.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,965.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1890,100,,304,Percent of Total Billed Charges,100% of Total Billed Charges,264.6,3510.75,
RENEGADE HI-FLO 135X180X20,46108303,CDM,272,RC,C1887,HCPCS,Outpatient,,,2536.77,1522.06,,43.86,100,,39.152,Fee Schedule,100% of Aetna Fee Schedule,1141.55,45,,0.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,710.3,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,857.84,32,,829.44,Percent of Total Billed Charges,32% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,913.24,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,913.24,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,913.24,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,1522.06,60,,1944.8,Percent of Total Billed Charges,60% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2536.77,100,,5.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,365.8,14.42,,984.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1902.58,75,,1648.336,Percent of Total Billed Charges,75% of Total Billed Charges,1268.39,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,1268.39,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1268.39,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,1268.39,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1775.74,70,,324.8,Percent of Total Billed Charges,70% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,355.15,14,,956.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2536.77,100,,2197.784,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,2536.77,
STENT VISI-PRO 35 7 X 57 X 80,46108307,CDM,278,RC,C1876,HCPCS,Outpatient,,,1890,1134.00,,3510.75,110,,0.112,Percent of Total Billed Charges,110% of Total Billed Charges,850.5,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.2,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,860.55,32,,829.784,Percent of Total Billed Charges,32% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,680.4,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,680.4,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,680.4,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,1039.5,55,,180,Percent of Total Billed Charges,55% Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1890,100,,2.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,272.54,14.42,,1180.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1512,80,,1161.368,Percent of Total Billed Charges,80% of Total Billed Charges,945,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,945,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1323,70,,2569.648,Percent of Total Billed Charges,70% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,264.6,14,,1146.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1890,100,,1548.488,Percent of Total Billed Charges,100% of Total Billed Charges,264.6,3510.75,
STENT VISI-PRO 35 8 X 57 X 80,46108308,CDM,278,RC,C1876,HCPCS,Outpatient,,,2900.98,1740.59,,4622.83,110,,5.92,Percent of Total Billed Charges,110% of Total Billed Charges,1305.44,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,812.27,28,,174.016,Percent of Total Billed Charges,28% of Total Billed Charges,860.55,32,,832,Percent of Total Billed Charges,32% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,1044.35,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,1044.35,36,,223.736,Percent of Total Billed Charges,36% Total Bille Charges,1044.35,36,,223.736,Percent of Total Billed Charges,36% of Total Billed Charges,1595.54,55,,17.84,Percent of Total Billed Charges,55% Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2900.98,100,,0.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,418.32,14.42,,821.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2320.78,80,,1442.56,Percent of Total Billed Charges,80% of Total Billed Charges,1450.49,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,1450.49,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1450.49,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,1450.49,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2030.69,70,,1829.72,Percent of Total Billed Charges,70% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,406.14,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2900.98,100,,1803.2,Percent of Total Billed Charges,100% of Total Billed Charges,406.14,4622.83,
COIL MREYE EMBOL .035X5X8X2.0,46108309,CDM,278,RC,,,Outpatient,,,263.84,158.30,,290.22,110,,0.824,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,167.32,Percent of Total Billed Charges,28% of Total Billed Charges,861.04,32,,832,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,215.128,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,215.128,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,215.128,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,0.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,547.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,1442.56,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,166.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,1411.104,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,1803.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.94,861.04,
CLOSURE DEV VASC GRN 6/7FR,46108310,CDM,278,RC,C1760,HCPCS,Outpatient,,,877.14,526.28,,1079.71,110,,1.944,Percent of Total Billed Charges,110% of Total Billed Charges,394.71,45,,0.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,58.008,Percent of Total Billed Charges,28% of Total Billed Charges,864.64,32,,834.304,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,74.584,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,74.584,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,74.584,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,55,,21.44,Percent of Total Billed Charges,55% Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,0.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,547.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,701.71,80,,7800,Percent of Total Billed Charges,80% of Total Billed Charges,438.57,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,315.384,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,122.8,1079.71,
WIRE QUICK CROSS 014,46108312,CDM,272,RC,C1769,HCPCS,Outpatient,,,813.79,488.27,,55.13,100,,0.416,Fee Schedule,100% of Aetna Fee Schedule,366.21,45,,1.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.86,28,,450,Percent of Total Billed Charges,28% of Total Billed Charges,867.33,32,,836.44,Percent of Total Billed Charges,32% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,292.96,36,,578.568,Percent of Total Billed Charges,36% of Total Billed Charges,292.96,36,,578.568,Percent of Total Billed Charges,36% Total Bille Charges,292.96,36,,578.568,Percent of Total Billed Charges,36% of Total Billed Charges,488.27,60,,21.44,Percent of Total Billed Charges,60% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,813.79,100,,13.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,117.35,14.42,,786.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.34,75,,1150.2,Percent of Total Billed Charges,75% of Total Billed Charges,406.9,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,406.9,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.9,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,406.9,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,569.65,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,113.93,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,813.79,100,,1533.6,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,867.33,
GUIDEWIRE ANGLED .018 X 260CM,46108314,CDM,272,RC,C1769,HCPCS,Outpatient,,,395.6,237.36,,55.13,100,,0.488,Fee Schedule,100% of Aetna Fee Schedule,178.02,45,,0.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.77,28,,399.448,Percent of Total Billed Charges,28% of Total Billed Charges,867.33,32,,837.992,Percent of Total Billed Charges,32% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,142.42,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,142.42,36,,513.576,Percent of Total Billed Charges,36% Total Bille Charges,142.42,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,237.36,60,,11440,Percent of Total Billed Charges,60% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.6,100,,13.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,57.05,14.42,,524.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.7,75,,1150.2,Percent of Total Billed Charges,75% of Total Billed Charges,197.8,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,197.8,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.8,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,197.8,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.92,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,55.38,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395.6,100,,1533.6,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,867.33,
GUIDEWIRE ANGLED .035 X 80CM,46108316,CDM,272,RC,C1769,HCPCS,Outpatient,,,170.03,102.02,,55.13,100,,0.136,Fee Schedule,100% of Aetna Fee Schedule,76.51,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.61,28,,384.088,Percent of Total Billed Charges,28% of Total Billed Charges,868.48,32,,837.992,Percent of Total Billed Charges,32% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,36,,493.824,Percent of Total Billed Charges,36% of Total Billed Charges,61.21,36,,493.824,Percent of Total Billed Charges,36% Total Bille Charges,61.21,36,,493.824,Percent of Total Billed Charges,36% of Total Billed Charges,102.02,60,,4004,Percent of Total Billed Charges,60% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.03,100,,1.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14.42,,524.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.52,75,,1525.024,Percent of Total Billed Charges,75% of Total Billed Charges,85.02,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.02,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,85.02,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.02,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,23.8,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.03,100,,2033.368,Percent of Total Billed Charges,100% of Total Billed Charges,23.8,868.48,
CATH PEEL-AWAY 5.5FR X 24CMCEN,46108317,CDM,278,RC,C1750,HCPCS,Outpatient,,,1583.73,950.24,,2257,110,,0.656,Percent of Total Billed Charges,110% of Total Billed Charges,712.68,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.44,28,,133.152,Percent of Total Billed Charges,28% of Total Billed Charges,869.22,32,,839.072,Percent of Total Billed Charges,32% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,570.14,36,,171.192,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,36,,171.192,Percent of Total Billed Charges,36% Total Bille Charges,570.14,36,,171.192,Percent of Total Billed Charges,36% of Total Billed Charges,871.05,55,,41.904,Percent of Total Billed Charges,55% Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.73,100,,3.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,228.37,14.42,,579.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1266.98,80,,1525.024,Percent of Total Billed Charges,80% of Total Billed Charges,791.87,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.87,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.61,70,,1262.248,Percent of Total Billed Charges,70% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1583.73,100,,2033.368,Percent of Total Billed Charges,100% of Total Billed Charges,221.72,2257,
INTRO AMPLATZ RENAL DIL SET 20,46108319,CDM,272,RC,C1726,HCPCS,Outpatient,,,610.92,366.55,,396.8,100,,7.664,Fee Schedule,100% of Aetna Fee Schedule,274.91,45,,0.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.06,28,,378.832,Percent of Total Billed Charges,28% of Total Billed Charges,870.09,32,,839.576,Percent of Total Billed Charges,32% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,219.93,36,,487.072,Percent of Total Billed Charges,36% of Total Billed Charges,219.93,36,,487.072,Percent of Total Billed Charges,36% Total Bille Charges,219.93,36,,487.072,Percent of Total Billed Charges,36% of Total Billed Charges,366.55,60,,3107.104,Percent of Total Billed Charges,60% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.92,100,,1.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,88.09,14.42,,386.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.19,75,,6552,Percent of Total Billed Charges,75% of Total Billed Charges,305.46,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,305.46,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.46,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,305.46,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.64,70,,903.312,Percent of Total Billed Charges,70% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,85.53,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,610.92,100,,8736,Percent of Total Billed Charges,100% of Total Billed Charges,85.53,870.09,
CATH GUIDWR ACUSTIK .014X300CM,46108320,CDM,272,RC,C1769,HCPCS,Outpatient,,,507.87,304.72,,55.13,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,228.54,45,,2.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.2,28,,960.064,Percent of Total Billed Charges,28% of Total Billed Charges,870.09,32,,840.224,Percent of Total Billed Charges,32% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,182.83,36,,1234.368,Percent of Total Billed Charges,36% of Total Billed Charges,182.83,36,,1234.368,Percent of Total Billed Charges,36% Total Bille Charges,182.83,36,,1234.368,Percent of Total Billed Charges,36% of Total Billed Charges,304.72,60,,3043.928,Percent of Total Billed Charges,60% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.87,100,,1.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14.42,,386.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.9,75,,16200,Percent of Total Billed Charges,75% of Total Billed Charges,253.94,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.94,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,201.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.51,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.87,100,,21600,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,870.09,
GUIDE WIRE .035X180,46108322,CDM,272,RC,C1769,HCPCS,Outpatient,,,375,225.00,,55.13,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,1.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,399.448,Percent of Total Billed Charges,28% of Total Billed Charges,873.6,32,,840.632,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,513.576,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,513.576,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,9387.656,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,2.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,923.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,4984.2,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1811.032,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,6645.6,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,873.6,
CATH IMAGER II 5F 100 X 035,46108324,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,0.72,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,176.16,Percent of Total Billed Charges,28% of Total Billed Charges,873.74,32,,846.728,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,226.496,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,226.496,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,8022.584,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,939.6,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,316.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,224,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1252.8,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,873.74,
INTRO KIT INNERCOOL 14FR,46108328,CDM,272,RC,,,Outpatient,,,440,264.00,,264,60,,6.344,Percent of Total Billed Charges,60% of Total Billed Charges,198,45,,0.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.2,28,,608.456,Percent of Total Billed Charges,28% of Total Billed Charges,874.11,32,,847.312,Percent of Total Billed Charges,32% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,158.4,36,,782.296,Percent of Total Billed Charges,36% of Total Billed Charges,158.4,36,,782.296,Percent of Total Billed Charges,36% Total Bille Charges,158.4,36,,782.296,Percent of Total Billed Charges,36% of Total Billed Charges,264,60,,9032.864,Percent of Total Billed Charges,60% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440,100,,4.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.45,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,75,,278.4,Percent of Total Billed Charges,75% of Total Billed Charges,220,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,220,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,220,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308,70,,84.136,Percent of Total Billed Charges,70% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,61.6,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,440,100,,371.2,Percent of Total Billed Charges,100% of Total Billed Charges,61.6,874.11,
BLLN RAPIDCROSS 2.5X210X170CM,46108332,CDM,272,RC,C1725,HCPCS,Outpatient,,,825,495.00,,99.47,100,,1.4,Fee Schedule,100% of Aetna Fee Schedule,371.25,45,,23.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231,28,,562.984,Percent of Total Billed Charges,28% of Total Billed Charges,874.11,32,,848.64,Percent of Total Billed Charges,32% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,297,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,297,36,,723.84,Percent of Total Billed Charges,36% Total Bille Charges,297,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,495,60,,2234.2,Percent of Total Billed Charges,60% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825,100,,3.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,118.97,14.42,,923.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,618.75,75,,4712.448,Percent of Total Billed Charges,75% of Total Billed Charges,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,577.5,70,,176.4,Percent of Total Billed Charges,70% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825,100,,5890.56,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,874.11,
BLLN RAPIDCROSS 4X20X170CM.014,46108333,CDM,272,RC,C1725,HCPCS,Outpatient,,,825,495.00,,99.47,100,,1.4,Fee Schedule,100% of Aetna Fee Schedule,371.25,45,,0.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,876.8,32,,852.152,Percent of Total Billed Charges,32% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,297,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,297,36,,388.8,Percent of Total Billed Charges,36% Total Bille Charges,297,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,495,60,,2274.856,Percent of Total Billed Charges,60% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825,100,,3.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,118.97,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,618.75,75,,5434.624,Percent of Total Billed Charges,75% of Total Billed Charges,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,412.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,412.5,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,577.5,70,,70.56,Percent of Total Billed Charges,70% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825,100,,6793.28,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,876.8,
BLLN 5X40X150CM .018 POWERCROS,46108334,CDM,272,RC,C1725,HCPCS,Outpatient,,,804.05,482.43,,99.47,100,,1.4,Fee Schedule,100% of Aetna Fee Schedule,361.82,45,,0.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.13,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,877.81,32,,854.264,Percent of Total Billed Charges,32% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,289.46,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,289.46,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,289.46,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,60,,12096.744,Percent of Total Billed Charges,60% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,100,,0.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,115.94,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.04,75,,6521.216,Percent of Total Billed Charges,75% of Total Billed Charges,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,1257.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.84,70,,72.008,Percent of Total Billed Charges,70% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.05,100,,8151.52,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,877.81,
BLLN 5X100X150CM .018 POWERCRS,46108335,CDM,272,RC,C1725,HCPCS,Outpatient,,,804.05,482.43,,99.47,100,,1.4,Fee Schedule,100% of Aetna Fee Schedule,361.82,45,,0.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.13,28,,129.192,Percent of Total Billed Charges,28% of Total Billed Charges,877.81,32,,855.568,Percent of Total Billed Charges,32% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,289.46,36,,166.104,Percent of Total Billed Charges,36% of Total Billed Charges,289.46,36,,166.104,Percent of Total Billed Charges,36% Total Bille Charges,289.46,36,,166.104,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,60,,7187.448,Percent of Total Billed Charges,60% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,100,,52.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,115.94,14.42,,919.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.04,75,,378,Percent of Total Billed Charges,75% of Total Billed Charges,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.03,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.84,70,,395.688,Percent of Total Billed Charges,70% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.05,100,,504,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,877.81,
BLLN 5X150X150CM .018 POWERCRS,46108336,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,270,45,,40.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,2365.216,Percent of Total Billed Charges,28% of Total Billed Charges,879.11,32,,856.624,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,3040.992,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,3040.992,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,3040.992,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,18809.024,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,613.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,463.912,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,84,879.11,
BLLN 5X200X150CM .018 POWERCRS,46108337,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,270,45,,3.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,880.88,32,,861.776,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,11493.472,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,613.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,1666.56,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,38.76,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2083.2,Percent of Total Billed Charges,100% of Total Billed Charges,84,880.88,
BLLN 6X100X150CM .018 POWERCRS,46108339,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,19.12,Fee Schedule,100% of Aetna Fee Schedule,270,45,,3,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,570.52,Percent of Total Billed Charges,28% of Total Billed Charges,881.16,32,,861.952,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,733.528,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,733.528,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,733.528,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,11718.24,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,344.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2080,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2600,Percent of Total Billed Charges,100% of Total Billed Charges,84,881.16,
BLLN 6X150X150CM .018 POWERCRO,46108340,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,23.656,Fee Schedule,100% of Aetna Fee Schedule,270,45,,65.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,883.2,32,,865.28,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,20023.528,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,1377.6,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,1836.8,Percent of Total Billed Charges,100% of Total Billed Charges,84,883.2,
BLLN 6X200X150CM .018 POWERCRO,46108341,CDM,272,RC,C1725,HCPCS,Outpatient,,,804.05,482.43,,99.47,100,,24.24,Fee Schedule,100% of Aetna Fee Schedule,361.82,45,,1.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.13,28,,129.92,Percent of Total Billed Charges,28% of Total Billed Charges,886.98,32,,865.28,Percent of Total Billed Charges,32% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,289.46,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,289.46,36,,167.04,Percent of Total Billed Charges,36% Total Bille Charges,289.46,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,482.43,60,,20023.528,Percent of Total Billed Charges,60% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,100,,89.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,115.94,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.04,75,,1950,Percent of Total Billed Charges,75% of Total Billed Charges,402.03,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.03,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,402.03,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.84,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.57,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.05,100,,2600,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,886.98,
STENT POWERCROSS 2X150 150CM,46108342,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,25.528,Fee Schedule,100% of Aetna Fee Schedule,270,45,,8.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,1027.856,Percent of Total Billed Charges,28% of Total Billed Charges,889.6,32,,867.328,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,1321.528,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,19271.288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,7.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,344.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2418,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,368.4,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,3224,Percent of Total Billed Charges,100% of Total Billed Charges,84,889.6,
CATH INTRODUCER GROSHONG 8FR,46108343,CDM,272,RC,,,Outpatient,,,802,481.20,,481.2,60,,20.128,Percent of Total Billed Charges,60% of Total Billed Charges,360.9,45,,0.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.56,28,,731.888,Percent of Total Billed Charges,28% of Total Billed Charges,891.17,32,,867.352,Percent of Total Billed Charges,32% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,288.72,36,,941,Percent of Total Billed Charges,36% of Total Billed Charges,288.72,36,,941,Percent of Total Billed Charges,36% Total Bille Charges,288.72,36,,941,Percent of Total Billed Charges,36% of Total Billed Charges,481.2,60,,45.36,Percent of Total Billed Charges,60% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,802,100,,6.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,115.65,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.5,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,401,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,401,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,401,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,561.4,70,,224.536,Percent of Total Billed Charges,70% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.28,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,802,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,112.28,891.17,
COIL MREYE EMBOLIZATION,46108349,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,50.824,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,564.44,Percent of Total Billed Charges,28% of Total Billed Charges,891.17,32,,874.352,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,725.712,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,145.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,242.176,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,302.72,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,891.17,
HRT CATH WWO VGRAM RT AND LT,46108350,CDM,481,RC,93453,HCPCS,Outpatient,,,16535.61,9921.37,,9364,100,,53.288,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4484.39,150,,0.304,Fee Schedule ,150% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4629.97,28,,126.152,Percent of Total Billed Charges,28% of Total Billed Charges,891.35,32,,877.992,Percent of Total Billed Charges,32% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,5952.82,36,,162.2,Percent of Total Billed Charges,36% of Total Billed Charges,5952.82,36,,162.2,Percent of Total Billed Charges,36% Total Bille Charges,5952.82,36,,162.2,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2989.6,100,,2.952,Fee Schedule,100% of CMS OPPS Rate,2690.63,90,,,Fee Schedule,90% of CMS OPPS Rate,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3886.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2384.43,14.42,,429.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3079.29,103,,,Fee Schedule,103% of CMS OPPS Rate,12401.71,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,9500,100,,200,Case Rate,Pays Based on per visit rate,9500,100,,200,Case Rate,Pays based on per visit rate,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9500,100,,200,Case Rate,Pays based on per visit rate,9500,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,4484.39,150,,,Fee Schedule,150% of CMS OPPS Rate,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6238,100,,736.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2314.99,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,2989.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16535.61,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,891.35,16535.61,
IR INJ MYELOGRAPHY,46108352,CDM,361,RC,62284,HCPCS,Outpatient,,,1328.73,797.24,,2601,100,,0.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,597.93,45,,0.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,878.16,Other,Not Seperately Reimbusable,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,797.24,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1328.73,100,,18.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,191.6,14.42,,286.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,996.55,75,,214.4,Percent of Total Billed Charges,75% of Total Billed Charges,664.37,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,664.37,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,313.6,Fee Schedule,100% of ASC Tier Groupings fee schedule,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1328.73,100,,268,Percent of Total Billed Charges,100% of Total Billed Charges,186.02,2601,
INSERT/REP SUBQ ICD W/ELTRD,46108353,CDM,480,RC,33270,HCPCS,Outpatient,,,60652.02,36391.21,,4682,100,,0.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45275.5,150,,0.744,Fee Schedule ,150% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16982.57,28,,504.904,Percent of Total Billed Charges,28% of Total Billed Charges,891.35,32,,879.336,Percent of Total Billed Charges,32% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,21834.73,36,,649.16,Percent of Total Billed Charges,36% of Total Billed Charges,21834.73,36,,649.16,Percent of Total Billed Charges,36% Total Bille Charges,21834.73,36,,649.16,Percent of Total Billed Charges,36% of Total Billed Charges,36391.21,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,0.376,Fee Schedule,100% of CMS OPPS Rate,27165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39238.76,130,,,Fee Schedule,130% of CMS OPPS Rate,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8746.02,14.42,,286.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,45489.02,75,,169.6,Percent of Total Billed Charges,75% of Total Billed Charges,30326.01,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,30326.01,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30326.01,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,30326.01,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,45275.5,150,,,Fee Schedule,150% of CMS OPPS Rate,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,284.408,Case Rate,Pays based on per visit rate,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,8491.28,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60652.02,100,,212,Percent of Total Billed Charges,100% of Total Billed Charges,370,60652.02,
CATH BIOFLO MIDLINE 5F DUAL,46108354,CDM,272,RC,,,Outpatient,,,599.2,359.52,,359.52,60,,4.264,Percent of Total Billed Charges,60% of Total Billed Charges,269.64,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.78,28,,361.32,Percent of Total Billed Charges,28% of Total Billed Charges,891.52,32,,882.544,Percent of Total Billed Charges,32% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,215.71,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,215.71,36,,464.56,Percent of Total Billed Charges,36% Total Bille Charges,215.71,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,359.52,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.2,100,,3.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,86.4,14.42,,346.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.4,75,,538.2,Percent of Total Billed Charges,75% of Total Billed Charges,299.6,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.6,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,419.44,70,,845.952,Percent of Total Billed Charges,70% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,336.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,599.2,100,,717.6,Percent of Total Billed Charges,100% of Total Billed Charges,83.89,891.52,
EMBLEM S-ICD SUB Q ELECTR 45CM,46108356,CDM,275,RC,C1896,HCPCS,Outpatient,,,10197,6118.20,,14355.81,110,,4.184,Percent of Total Billed Charges,110% of Total Billed Charges,4588.65,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2855.16,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,891.52,32,,888.984,Percent of Total Billed Charges,32% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,3670.92,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,3670.92,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,3670.92,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,5608.35,55,,74.784,Percent of Total Billed Charges,55% Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10197,100,,0.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1470.41,14.42,,230.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7647.75,75,,242.176,Percent of Total Billed Charges,75% of Total Billed Charges,5098.5,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5098.5,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7137.9,70,,886.888,Percent of Total Billed Charges,70% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,224.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10197,100,,302.72,Percent of Total Billed Charges,100% of Total Billed Charges,891.52,14355.81,
CATH BIOFLO MIDLINE 4F SINGLE,46108357,CDM,272,RC,,,Outpatient,,,599.2,359.52,,359.52,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,269.64,45,,0.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.78,28,,724.408,Percent of Total Billed Charges,28% of Total Billed Charges,894.43,32,,891.448,Percent of Total Billed Charges,32% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,215.71,36,,931.384,Percent of Total Billed Charges,36% of Total Billed Charges,215.71,36,,931.384,Percent of Total Billed Charges,36% Total Bille Charges,215.71,36,,931.384,Percent of Total Billed Charges,36% of Total Billed Charges,359.52,60,,94.92,Percent of Total Billed Charges,60% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.2,100,,1.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.4,14.42,,128.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.4,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,299.6,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.6,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,419.44,70,,137.904,Percent of Total Billed Charges,70% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,124.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,599.2,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,83.89,894.43,
CATH BIOFLOW MIDLINE 3F SINGLE,46108358,CDM,272,RC,,,Outpatient,,,599.2,359.52,,359.52,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,269.64,45,,0.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.78,28,,89.6,Percent of Total Billed Charges,28% of Total Billed Charges,895.04,32,,898.56,Percent of Total Billed Charges,32% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,215.71,36,,115.2,Percent of Total Billed Charges,36% of Total Billed Charges,215.71,36,,115.2,Percent of Total Billed Charges,36% Total Bille Charges,215.71,36,,115.2,Percent of Total Billed Charges,36% of Total Billed Charges,359.52,60,,40.144,Percent of Total Billed Charges,60% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.2,100,,1.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,86.4,14.42,,1089.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.4,75,,5226,Percent of Total Billed Charges,75% of Total Billed Charges,299.6,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.6,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,299.6,50,,157.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,419.44,70,,409.336,Percent of Total Billed Charges,70% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,83.89,14,,1058.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,599.2,100,,6968,Percent of Total Billed Charges,100% of Total Billed Charges,83.89,895.04,
EMBLEM MRI S-ICD A219,46108359,CDM,275,RC,C1722,HCPCS,Outpatient,,,66280.5,39768.30,,76897.35,110,,0.464,Percent of Total Billed Charges,110% of Total Billed Charges,29826.23,45,,0.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18558.54,28,,33.656,Percent of Total Billed Charges,28% of Total Billed Charges,896,32,,898.56,Percent of Total Billed Charges,32% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,23860.98,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,23860.98,36,,43.272,Percent of Total Billed Charges,36% Total Bille Charges,23860.98,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,36454.28,55,,59.04,Percent of Total Billed Charges,55% Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66280.5,100,,0.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9557.65,14.42,,839.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49710.38,75,,556.8,Percent of Total Billed Charges,75% of Total Billed Charges,33140.25,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,33140.25,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33140.25,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,33140.25,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46396.35,70,,515.76,Percent of Total Billed Charges,70% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,9279.27,14,,815.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66280.5,100,,696,Percent of Total Billed Charges,100% of Total Billed Charges,896,76897.35,
REVEAL LINQ ICM,46108360,CDM,278,RC,C1764,HCPCS,Outpatient,,,16468.16,9880.90,,21466.48,110,,3.096,Percent of Total Billed Charges,110% of Total Billed Charges,7410.67,45,,8.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4611.08,28,,70.56,Percent of Total Billed Charges,28% of Total Billed Charges,896,32,,901.224,Percent of Total Billed Charges,32% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,5928.54,36,,90.72,Percent of Total Billed Charges,36% of Total Billed Charges,5928.54,36,,90.72,Percent of Total Billed Charges,36% Total Bille Charges,5928.54,36,,90.72,Percent of Total Billed Charges,36% of Total Billed Charges,9057.49,55,,72,Percent of Total Billed Charges,55% Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16468.16,100,,0.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2374.71,14.42,,797.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13174.53,80,,4992,Percent of Total Billed Charges,80% of Total Billed Charges,8234.08,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,8234.08,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8234.08,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,8234.08,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11527.71,70,,382.04,Percent of Total Billed Charges,70% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,774.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16468.16,100,,6656,Percent of Total Billed Charges,100% of Total Billed Charges,896,21466.48,
18FR PEEL AWAY SHEATH,46108362,CDM,272,RC,C1892,HCPCS,Outpatient,,,229.4,137.64,,0.57,100,,0.96,Fee Schedule,100% of Aetna Fee Schedule,103.23,45,,1.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.23,28,,28.224,Percent of Total Billed Charges,28% of Total Billed Charges,896,32,,903.28,Percent of Total Billed Charges,32% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,36,,36.288,Percent of Total Billed Charges,36% of Total Billed Charges,82.58,36,,36.288,Percent of Total Billed Charges,36% Total Bille Charges,82.58,36,,36.288,Percent of Total Billed Charges,36% of Total Billed Charges,137.64,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.4,100,,1.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,33.08,14.42,,865.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.05,75,,1790.88,Percent of Total Billed Charges,75% of Total Billed Charges,114.7,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,114.7,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.7,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,114.7,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.58,70,,300.176,Percent of Total Billed Charges,70% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,32.12,14,,840.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.4,100,,2387.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,896,
CSI VIPERWIRE GW 14,46108364,CDM,272,RC,C1769,HCPCS,Outpatient,,,600,360.00,,55.13,100,,0.856,Fee Schedule,100% of Aetna Fee Schedule,270,45,,1.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,28.8,Percent of Total Billed Charges,28% of Total Billed Charges,896,32,,904.192,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,37.032,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,37.032,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,37.032,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,95.28,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,1.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,446.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,1790.88,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,147.752,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2387.84,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,896,
CATH DRG GW 8-10-12FRX25C,46108365,CDM,272,RC,C1729,HCPCS,Outpatient,,,375,225.00,,11.1,100,,0.544,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,3.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,158.28,Percent of Total Billed Charges,28% of Total Billed Charges,908.62,32,,907.984,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,203.496,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,203.496,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,203.496,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,96.288,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,1.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1790.104,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,491.2,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2386.8,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,908.62,
IR CVD RMV FBRN SHTH SEP ACC,46108366,CDM,361,RC,,,Outpatient,,,4694.21,2816.53,,2816.53,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,2112.39,45,,3.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1314.38,28,,185.56,Percent of Total Billed Charges,28% of Total Billed Charges,915.2,32,,911.136,Percent of Total Billed Charges,32% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,1689.92,36,,238.584,Percent of Total Billed Charges,36% of Total Billed Charges,1689.92,36,,238.584,Percent of Total Billed Charges,36% Total Bille Charges,1689.92,36,,238.584,Percent of Total Billed Charges,36% of Total Billed Charges,2816.53,60,,100.776,Percent of Total Billed Charges,60% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4694.21,100,,18.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,676.91,14.42,,293.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3520.66,75,,1626.24,Percent of Total Billed Charges,75% of Total Billed Charges,2347.11,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,2347.11,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2347.11,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,2347.11,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3285.95,70,,368.832,Percent of Total Billed Charges,70% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,657.19,14,,285.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4694.21,100,,2168.32,Percent of Total Billed Charges,100% of Total Billed Charges,657.19,4694.21,
LEAD TENDRIL MRI LPA1200M 52CM,46108367,CDM,275,RC,C1898,HCPCS,Outpatient,,,1344.95,806.97,,2852.23,110,,1.408,Percent of Total Billed Charges,110% of Total Billed Charges,605.23,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.59,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,915.2,32,,915.2,Percent of Total Billed Charges,32% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,484.18,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,484.18,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,484.18,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,739.72,55,,106.56,Percent of Total Billed Charges,55% Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344.95,100,,3.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,193.94,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1008.71,75,,1626.24,Percent of Total Billed Charges,75% of Total Billed Charges,672.48,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.48,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,941.47,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344.95,100,,2168.32,Percent of Total Billed Charges,100% of Total Billed Charges,188.29,2852.23,
LEAD TENDRIL MRI LPA1200M 58CM,46108368,CDM,275,RC,C1898,HCPCS,Outpatient,,,1344.95,806.97,,2852.23,110,,1.568,Percent of Total Billed Charges,110% of Total Billed Charges,605.23,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.59,28,,16.128,Percent of Total Billed Charges,28% of Total Billed Charges,915.2,32,,915.336,Percent of Total Billed Charges,32% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,484.18,36,,20.736,Percent of Total Billed Charges,36% of Total Billed Charges,484.18,36,,20.736,Percent of Total Billed Charges,36% Total Bille Charges,484.18,36,,20.736,Percent of Total Billed Charges,36% of Total Billed Charges,739.72,55,,131.424,Percent of Total Billed Charges,55% Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344.95,100,,3.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,193.94,14.42,,215.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1008.71,75,,387,Percent of Total Billed Charges,75% of Total Billed Charges,672.48,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.48,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,672.48,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,941.47,70,,402.128,Percent of Total Billed Charges,70% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,188.29,14,,209.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344.95,100,,516,Percent of Total Billed Charges,100% of Total Billed Charges,188.29,2852.23,
PM ASSURITY MRI PM2272,46108369,CDM,275,RC,C1785,HCPCS,Outpatient,,,10197,6118.20,,11492.12,110,,3.208,Percent of Total Billed Charges,110% of Total Billed Charges,4588.65,45,,0.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2855.16,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,919.68,32,,917.2,Percent of Total Billed Charges,32% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,3670.92,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,3670.92,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,3670.92,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,5608.35,55,,119.64,Percent of Total Billed Charges,55% Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10197,100,,7.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1470.41,14.42,,428.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7647.75,75,,1442.56,Percent of Total Billed Charges,75% of Total Billed Charges,5098.5,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5098.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7137.9,70,,756,Percent of Total Billed Charges,70% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10197,100,,1803.2,Percent of Total Billed Charges,100% of Total Billed Charges,919.68,11492.12,
CATH BARD POWER LINE 6F,46108370,CDM,278,RC,C1751,HCPCS,Outpatient,,,1242.62,745.57,,1434.54,110,,1.168,Percent of Total Billed Charges,110% of Total Billed Charges,559.18,45,,6.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.93,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,925.44,32,,919.36,Percent of Total Billed Charges,32% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,447.34,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,447.34,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,447.34,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,683.44,55,,23.584,Percent of Total Billed Charges,55% Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1242.62,100,,8.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,179.19,14.42,,446.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,994.1,80,,15780,Percent of Total Billed Charges,80% of Total Billed Charges,621.31,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,621.31,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,621.31,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,621.31,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.83,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,173.97,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1242.62,100,,21040,Percent of Total Billed Charges,100% of Total Billed Charges,173.97,1434.54,
OPTISURE ICD LEAD 210Q,46108371,CDM,275,RC,C1777,HCPCS,Outpatient,,,8497.5,5098.50,,10145.7,110,,18.088,Percent of Total Billed Charges,110% of Total Billed Charges,3823.88,45,,7.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,28,,147.36,Percent of Total Billed Charges,28% of Total Billed Charges,928.31,32,,925.296,Percent of Total Billed Charges,32% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,3059.1,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,3059.1,36,,189.464,Percent of Total Billed Charges,36% Total Bille Charges,3059.1,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,4673.63,55,,25.2,Percent of Total Billed Charges,55% Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8497.5,100,,1.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1225.34,14.42,,428.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6373.13,75,,16200,Percent of Total Billed Charges,75% of Total Billed Charges,4248.75,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,4248.75,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4248.75,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,4248.75,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5948.25,70,,1170,Percent of Total Billed Charges,70% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8497.5,100,,21600,Percent of Total Billed Charges,100% of Total Billed Charges,928.31,10145.7,
UTERINE ARTERY 5FR 90CM,46108372,CDM,272,RC,,,Outpatient,,,275,165.00,,165,60,,1.048,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,45,,69.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,28,,89.816,Percent of Total Billed Charges,28% of Total Billed Charges,931.22,32,,926.72,Percent of Total Billed Charges,32% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,99,36,,115.472,Percent of Total Billed Charges,36% of Total Billed Charges,99,36,,115.472,Percent of Total Billed Charges,36% Total Bille Charges,99,36,,115.472,Percent of Total Billed Charges,36% of Total Billed Charges,165,60,,25.2,Percent of Total Billed Charges,60% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,39.66,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.25,75,,1039.84,Percent of Total Billed Charges,75% of Total Billed Charges,137.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,137.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,137.5,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.5,70,,1170,Percent of Total Billed Charges,70% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,100,,1386.448,Percent of Total Billed Charges,100% of Total Billed Charges,38.5,931.22,
IR COIL INTERLOCK,46108373,CDM,278,RC,C1884,HCPCS,Outpatient,,,2320.5,1392.30,,2689.4,110,,1.48,Percent of Total Billed Charges,110% of Total Billed Charges,1044.23,45,,22.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.74,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,931.84,32,,928.968,Percent of Total Billed Charges,32% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,835.38,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,835.38,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,835.38,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,1276.28,55,,60.4,Percent of Total Billed Charges,55% Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2320.5,100,,1.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,334.62,14.42,,278.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.4,80,,4680,Percent of Total Billed Charges,80% of Total Billed Charges,1160.25,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1160.25,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1160.25,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1160.25,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1624.35,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,324.87,14,,270.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2320.5,100,,6240,Percent of Total Billed Charges,100% of Total Billed Charges,324.87,2689.4,
CATH GUIDE JR3.5 6F 100CM,46108374,CDM,272,RC,,,Outpatient,,,225,135.00,,135,60,,7.352,Percent of Total Billed Charges,60% of Total Billed Charges,101.25,45,,27.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,28,,294.72,Percent of Total Billed Charges,28% of Total Billed Charges,946.82,32,,931.232,Percent of Total Billed Charges,32% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,81,36,,378.928,Percent of Total Billed Charges,36% of Total Billed Charges,81,36,,378.928,Percent of Total Billed Charges,36% Total Bille Charges,81,36,,378.928,Percent of Total Billed Charges,36% of Total Billed Charges,135,60,,117.192,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,100,,15.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,32.45,14.42,,1140.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.75,75,,333.312,Percent of Total Billed Charges,75% of Total Billed Charges,112.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,70,,1665.808,Percent of Total Billed Charges,70% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,1107.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225,100,,444.416,Percent of Total Billed Charges,100% of Total Billed Charges,31.5,946.82,
EVERFLEX ENTRUST,46108376,CDM,278,RC,C1876,HCPCS,Outpatient,,,2478,1486.80,,4157.55,110,,1.888,Percent of Total Billed Charges,110% of Total Billed Charges,1115.1,45,,0.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,693.84,28,,113.76,Percent of Total Billed Charges,28% of Total Billed Charges,951.89,32,,948.64,Percent of Total Billed Charges,32% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,892.08,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,892.08,36,,146.264,Percent of Total Billed Charges,36% Total Bille Charges,892.08,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,1362.9,55,,205.344,Percent of Total Billed Charges,55% Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2478,100,,155.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,357.33,14.42,,446.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1982.4,80,,643.24,Percent of Total Billed Charges,80% of Total Billed Charges,1239,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1239,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1239,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1734.6,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,100,,857.648,Percent of Total Billed Charges,100% of Total Billed Charges,346.92,4157.55,
STENT EFLEX 5FR.35 6X100X150,46108377,CDM,278,RC,C1876,HCPCS,Outpatient,,,2478,1486.80,,4157.55,110,,0.592,Percent of Total Billed Charges,110% of Total Billed Charges,1115.1,45,,7.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,693.84,28,,338.384,Percent of Total Billed Charges,28% of Total Billed Charges,951.89,32,,948.64,Percent of Total Billed Charges,32% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,892.08,36,,435.064,Percent of Total Billed Charges,36% of Total Billed Charges,892.08,36,,435.064,Percent of Total Billed Charges,36% Total Bille Charges,892.08,36,,435.064,Percent of Total Billed Charges,36% of Total Billed Charges,1362.9,55,,249.6,Percent of Total Billed Charges,55% Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2478,100,,49.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,357.33,14.42,,428.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1982.4,80,,43.336,Percent of Total Billed Charges,80% of Total Billed Charges,1239,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,1239,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1239,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1734.6,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,346.92,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2478,100,,57.784,Percent of Total Billed Charges,100% of Total Billed Charges,346.92,4157.55,
EVERFLEX ENTRUST6X120X150,46108378,CDM,278,RC,C1876,HCPCS,Outpatient,,,2800,1680.00,,4511.75,110,,0.776,Percent of Total Billed Charges,110% of Total Billed Charges,1260,45,,69.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784,28,,354.752,Percent of Total Billed Charges,28% of Total Billed Charges,954.72,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1008,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,1008,36,,456.112,Percent of Total Billed Charges,36% Total Bille Charges,1008,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,1540,55,,1372.8,Percent of Total Billed Charges,55% Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2800,100,,60.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,403.76,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2240,80,,6911.12,Percent of Total Billed Charges,80% of Total Billed Charges,1400,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1960,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2800,100,,8638.896,Percent of Total Billed Charges,100% of Total Billed Charges,392,4511.75,
EVERFLEX ENTRUST 6X80X150,46108379,CDM,278,RC,C1876,HCPCS,Outpatient,,,2097,1258.20,,3738.45,110,,4.408,Percent of Total Billed Charges,110% of Total Billed Charges,943.65,45,,20.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,587.16,28,,55.16,Percent of Total Billed Charges,28% of Total Billed Charges,954.72,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,754.92,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,754.92,36,,70.92,Percent of Total Billed Charges,36% Total Bille Charges,754.92,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,1153.35,55,,336.624,Percent of Total Billed Charges,55% Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097,100,,81.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,302.39,14.42,,446.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1677.6,80,,6160.624,Percent of Total Billed Charges,80% of Total Billed Charges,1048.5,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.5,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.9,70,,386.272,Percent of Total Billed Charges,70% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2097,100,,7700.776,Percent of Total Billed Charges,100% of Total Billed Charges,293.58,3738.45,
IR VERT AUGMENT THOR W IMG,46108380,CDM,361,RC,,,Outpatient,,,11682.69,7009.61,,7009.61,60,,58.248,Percent of Total Billed Charges,60% of Total Billed Charges,5257.21,45,,8.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3271.15,28,,163.736,Percent of Total Billed Charges,28% of Total Billed Charges,955.14,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,4205.77,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,4205.77,36,,210.512,Percent of Total Billed Charges,36% Total Bille Charges,4205.77,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,7009.61,60,,129.456,Percent of Total Billed Charges,60% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11682.69,100,,1.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1684.64,14.42,,446.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8762.02,75,,3915.648,Percent of Total Billed Charges,75% of Total Billed Charges,5841.35,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,5841.35,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5841.35,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,5841.35,50,,290.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8177.88,70,,2133.04,Percent of Total Billed Charges,70% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,1635.58,14,,433.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11682.69,100,,4894.56,Percent of Total Billed Charges,100% of Total Billed Charges,955.14,11682.69,
BIOPSY SOFT TISSUE THIGH/KNEE,46108381,CDM,361,RC,,,Outpatient,,,5537.79,3322.67,,3322.67,60,,13.304,Percent of Total Billed Charges,60% of Total Billed Charges,2492.01,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1550.58,28,,206.304,Percent of Total Billed Charges,28% of Total Billed Charges,955.14,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,1993.6,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,1993.6,36,,265.248,Percent of Total Billed Charges,36% Total Bille Charges,1993.6,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,3322.67,60,,236.08,Percent of Total Billed Charges,60% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5537.79,100,,16.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,798.55,14.42,,428.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4153.34,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,2768.9,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,2768.9,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2768.9,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,2768.9,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3876.45,70,,409.336,Percent of Total Billed Charges,70% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,775.29,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5537.79,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,775.29,5537.79,
EVERFLEX ENTRUST 6X40X150,46108382,CDM,278,RC,C1876,HCPCS,Outpatient,,,2097,1258.20,,3738.45,110,,23.776,Percent of Total Billed Charges,110% of Total Billed Charges,943.65,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,587.16,28,,152.816,Percent of Total Billed Charges,28% of Total Billed Charges,955.2,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,754.92,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,754.92,36,,196.48,Percent of Total Billed Charges,36% Total Bille Charges,754.92,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,1153.35,55,,397.64,Percent of Total Billed Charges,55% Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097,100,,155.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,302.39,14.42,,428.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1677.6,80,,1970.224,Percent of Total Billed Charges,80% of Total Billed Charges,1048.5,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.5,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.9,70,,515.76,Percent of Total Billed Charges,70% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,416.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2097,100,,2626.968,Percent of Total Billed Charges,100% of Total Billed Charges,293.58,3738.45,
EVASC RPR A-AO NDGFT,46108383,CDM,360,RC,,,Outpatient,,,7684.17,4610.50,,4610.5,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,3457.88,45,,4.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2151.57,28,,120.072,Percent of Total Billed Charges,28% of Total Billed Charges,955.42,32,,951.56,Percent of Total Billed Charges,32% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,2766.3,36,,154.376,Percent of Total Billed Charges,36% of Total Billed Charges,2766.3,36,,154.376,Percent of Total Billed Charges,36% Total Bille Charges,2766.3,36,,154.376,Percent of Total Billed Charges,36% of Total Billed Charges,4610.5,60,,146.264,Percent of Total Billed Charges,60% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7684.17,100,,45.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1108.06,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5763.13,75,,4372.096,Percent of Total Billed Charges,75% of Total Billed Charges,3842.09,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,3842.09,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3842.09,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,3842.09,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5378.92,70,,350.216,Percent of Total Billed Charges,70% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1075.78,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7684.17,100,,5829.464,Percent of Total Billed Charges,100% of Total Billed Charges,955.42,7684.17,
EVASC RPR A-AO NDGFT RPT,46108384,CDM,360,RC,,,Outpatient,,,6949.17,4169.50,,4169.5,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,3127.13,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1945.77,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,956.62,32,,951.88,Percent of Total Billed Charges,32% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,2501.7,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,2501.7,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,2501.7,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,4169.5,60,,38.656,Percent of Total Billed Charges,60% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6949.17,100,,19.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,1002.07,14.42,,506.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5211.88,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,3474.59,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,3474.59,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3474.59,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,3474.59,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4864.42,70,,870.76,Percent of Total Billed Charges,70% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,972.88,14,,491.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6949.17,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,956.62,6949.17,
EVASC RPR A-UNILAC NDGFT,46108385,CDM,360,RC,,,Outpatient,,,4916.7,2950.02,,2950.02,60,,90.2,Percent of Total Billed Charges,60% of Total Billed Charges,2212.52,45,,17.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1376.68,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,956.77,32,,951.88,Percent of Total Billed Charges,32% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,1770.01,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,1770.01,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,1770.01,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,2950.02,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4916.7,100,,0.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,708.99,14.42,,548.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3687.53,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,2458.35,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,2458.35,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2458.35,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,2458.35,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3441.69,70,,1665.808,Percent of Total Billed Charges,70% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,688.34,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4916.7,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,688.34,4916.7,
EVASC RPR A-UNILAC NDGFT RPT,46108387,CDM,360,RC,,,Outpatient,,,4446.41,2667.85,,2667.85,60,,87.376,Percent of Total Billed Charges,60% of Total Billed Charges,2000.88,45,,2.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1244.99,28,,147.536,Percent of Total Billed Charges,28% of Total Billed Charges,956.8,32,,951.88,Percent of Total Billed Charges,32% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,1600.71,36,,189.688,Percent of Total Billed Charges,36% of Total Billed Charges,1600.71,36,,189.688,Percent of Total Billed Charges,36% Total Bille Charges,1600.71,36,,189.688,Percent of Total Billed Charges,36% of Total Billed Charges,2667.85,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4446.41,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,641.17,14.42,,548.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3334.81,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,2223.21,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,2223.21,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2223.21,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,2223.21,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3112.49,70,,220.016,Percent of Total Billed Charges,70% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,622.5,14,,532.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4446.41,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,622.5,4446.41,
EVASC RPR A-BI-ILIAC NDGFT,46108388,CDM,360,RC,,,Outpatient,,,11713.58,7028.15,,7028.15,60,,139.408,Percent of Total Billed Charges,60% of Total Billed Charges,5271.11,45,,9.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3279.8,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.64,32,,951.88,Percent of Total Billed Charges,32% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,4216.89,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,4216.89,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,4216.89,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,7028.15,60,,468,Percent of Total Billed Charges,60% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11713.58,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1689.1,14.42,,760.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8785.19,75,,3621.056,Percent of Total Billed Charges,75% of Total Billed Charges,5856.79,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,5856.79,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5856.79,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,5856.79,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8199.51,70,,382.936,Percent of Total Billed Charges,70% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,1639.9,14,,738.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11713.58,100,,4828.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,11713.58,
EVASC RPR A-BI-ILIAC RPT,46108389,CDM,360,RC,,,Outpatient,,,9404.95,5642.97,,5642.97,60,,348.032,Percent of Total Billed Charges,60% of Total Billed Charges,4232.23,45,,159.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2633.39,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,0.65,32,,952.992,Percent of Total Billed Charges,32% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,3385.78,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,3385.78,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,3385.78,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,5642.97,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9404.95,100,,9.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1356.19,14.42,,284.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7053.71,75,,1769.848,Percent of Total Billed Charges,75% of Total Billed Charges,4702.48,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,4702.48,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4702.48,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,4702.48,50,,93.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6583.47,70,,381.792,Percent of Total Billed Charges,70% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1316.69,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9404.95,100,,2359.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,9404.95,
EVASC RPR ILIO-ILIAC NDGFT,46108390,CDM,360,RC,,,Outpatient,,,12712.61,7627.57,,7627.57,60,,0.928,Percent of Total Billed Charges,60% of Total Billed Charges,5720.67,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3559.53,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,954.064,Percent of Total Billed Charges,32% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,4576.54,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,4576.54,36,,388.8,Percent of Total Billed Charges,36% Total Bille Charges,4576.54,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,7627.57,60,,377.144,Percent of Total Billed Charges,60% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12712.61,100,,1.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1833.16,14.42,,284.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9534.46,75,,1769.848,Percent of Total Billed Charges,75% of Total Billed Charges,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,6356.31,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8898.83,70,,38.76,Percent of Total Billed Charges,70% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,276.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12712.61,100,,2359.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,12712.61,
EVASC RPR ILIO-ILIAC RPT,46108391,CDM,360,RC,,,Outpatient,,,12712.61,7627.57,,7627.57,60,,1.392,Percent of Total Billed Charges,60% of Total Billed Charges,5720.67,45,,0.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3559.53,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,957.184,Percent of Total Billed Charges,32% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,4576.54,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,4576.54,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,4576.54,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,7627.57,60,,751.744,Percent of Total Billed Charges,60% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12712.61,100,,39.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1833.16,14.42,,321.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9534.46,75,,12435.368,Percent of Total Billed Charges,75% of Total Billed Charges,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6356.31,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,6356.31,50,,122.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8898.83,70,,65.52,Percent of Total Billed Charges,70% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1779.77,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12712.61,100,,16580.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,12712.61,
PLMT XTN PROSTH EVASC RPR,46108392,CDM,360,RC,,,Outpatient,,,4228.99,2537.39,,2537.39,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,1903.05,45,,139.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1184.12,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,957.184,Percent of Total Billed Charges,32% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,2537.39,60,,749.76,Percent of Total Billed Charges,60% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4228.99,100,,6.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,609.82,14.42,,321.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3171.74,75,,5296.2,Percent of Total Billed Charges,75% of Total Billed Charges,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,2114.5,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2960.29,70,,117.968,Percent of Total Billed Charges,70% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,311.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4228.99,100,,7061.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,4228.99,
DLYD PLMT XTN PROSTH 1ST VSL,46108393,CDM,360,RC,,,Outpatient,,,4228.99,2537.39,,2537.39,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,1903.05,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1184.12,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,962.4,Percent of Total Billed Charges,32% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,1522.44,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,2537.39,60,,751.552,Percent of Total Billed Charges,60% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4228.99,100,,20.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,609.82,14.42,,98.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3171.74,75,,127.952,Percent of Total Billed Charges,75% of Total Billed Charges,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2114.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,2114.5,50,,236.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2960.29,70,,257.28,Percent of Total Billed Charges,70% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,592.06,14,,96.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4228.99,100,,170.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,4228.99,
DLYD PLMT XTN PROSTH EA ADDL,46108394,CDM,360,RC,,,Outpatient,,,2300.59,1380.35,,1380.35,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,1035.27,45,,0.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.17,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,963.888,Percent of Total Billed Charges,32% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,828.21,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,828.21,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,828.21,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,1380.35,60,,662.952,Percent of Total Billed Charges,60% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2300.59,100,,354.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,331.75,14.42,,787.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1725.44,75,,213.048,Percent of Total Billed Charges,75% of Total Billed Charges,1150.3,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1150.3,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1150.3,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,1150.3,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1610.41,70,,1710.248,Percent of Total Billed Charges,70% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,322.08,14,,764.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2300.59,100,,284.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,2300.59,
PACIFIC PLUS PTA 7X40X130CM,46108395,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,270,45,,0.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,666.32,Percent of Total Billed Charges,28% of Total Billed Charges,0.66,32,,965.12,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,856.704,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,435.856,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,388.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,730.952,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,305.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,5289.416,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,377.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,974.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,600,
CATH ANGIO 2XL,46108396,CDM,272,RC,C1725,HCPCS,Outpatient,,,675,405.00,,99.47,100,,3.408,Fee Schedule,100% of Aetna Fee Schedule,303.75,45,,1.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.67,32,,971.68,Percent of Total Billed Charges,32% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,243,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,243,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,243,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,405,60,,173.872,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,0.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,97.34,14.42,,779.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.25,75,,1247.488,Percent of Total Billed Charges,75% of Total Billed Charges,337.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.5,70,,1813.952,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,756.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,1559.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,675,
INSERT MIDLINE CATH >5YO,46108397,CDM,761,RC,36569,HCPCS,Outpatient,,,3208.03,1924.82,,85.23,100,,1.648,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,14.872,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,898.25,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.67,32,,974.176,Percent of Total Billed Charges,32% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,242.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,309.128,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,462.6,14.42,,696.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2406.02,75,,1436.4,Percent of Total Billed Charges,75% of Total Billed Charges,1604.02,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.02,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,384.912,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2245.62,70,,102.08,Percent of Total Billed Charges,70% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,676.312,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3208.03,100,,1915.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,3208.03,
GEN PACER FORTIFY AS SURA VR,46108398,CDM,275,RC,C1722,HCPCS,Outpatient,,,13000,7800.00,,18288.8,110,,1.448,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,1.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.67,32,,975.104,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,896.888,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,0.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,390.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9750,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,6500,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,865.512,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,379.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,18288.8,
IR CVC PIC WO PORT WO G MIN 5Y,46108399,CDM,761,RC,36571,HCPCS,Outpatient,,,3208.03,1924.82,,283.82,100,,0.616,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,0.656,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,898.25,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.67,32,,975.744,Percent of Total Billed Charges,32% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,1154.89,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,3347.5,103,,1189.552,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,0.544,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,462.6,14.42,,218.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,2406.02,75,,343.728,Percent of Total Billed Charges,75% of Total Billed Charges,1604.02,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.02,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2245.62,70,,102.48,Percent of Total Billed Charges,70% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3208.03,100,,458.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,4386.59,
CVC NON TUNLED OVER 5 YEARS,46108400,CDM,761,RC,36556,HCPCS,Outpatient,,,2660.84,1596.50,,76.78,100,,1.072,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,0.376,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,745.04,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,0.67,32,,975.832,Percent of Total Billed Charges,32% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,957.9,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,957.9,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,957.9,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,1189.552,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,1.144,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,383.69,14.42,,626.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1995.63,75,,1399.624,Percent of Total Billed Charges,75% of Total Billed Charges,1330.42,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.42,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.59,70,,99.96,Percent of Total Billed Charges,70% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2660.84,100,,1866.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,4386.59,
PACIFIC PLUS PTA BALLOON,46108401,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.584,Fee Schedule,100% of Aetna Fee Schedule,270,45,,4.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,853.216,Percent of Total Billed Charges,28% of Total Billed Charges,0.68,32,,981.096,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,1096.992,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,1096.992,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,1096.992,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1943.264,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,3.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,370.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,1295.248,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,359.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,1726.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,600,
IR GUIDE DRN FLUID,46108402,CDM,361,RC,,,Outpatient,,,1528,916.80,,916.8,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,687.6,45,,0.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.84,28,,163.736,Percent of Total Billed Charges,28% of Total Billed Charges,0.68,32,,985.648,Percent of Total Billed Charges,32% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,550.08,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,550.08,36,,210.512,Percent of Total Billed Charges,36% Total Bille Charges,550.08,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,916.8,60,,2577.368,Percent of Total Billed Charges,60% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1528,100,,33.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,220.34,14.42,,186.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1146,75,,468,Percent of Total Billed Charges,75% of Total Billed Charges,764,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,764,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,764,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,764,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1069.6,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,180.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1528,100,,624,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,1528,
ENTRUST SELF EXP STENT 8X40X80,46108403,CDM,278,RC,C1876,HCPCS,Outpatient,,,2097,1258.20,,3738.45,110,,0.448,Percent of Total Billed Charges,110% of Total Billed Charges,943.65,45,,0.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,587.16,28,,206.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.68,32,,987.84,Percent of Total Billed Charges,32% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,754.92,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,754.92,36,,265.248,Percent of Total Billed Charges,36% Total Bille Charges,754.92,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,1153.35,55,,2577.368,Percent of Total Billed Charges,55% Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097,100,,2.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,302.39,14.42,,606.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1677.6,80,,585,Percent of Total Billed Charges,80% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.9,70,,137.792,Percent of Total Billed Charges,70% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,588.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2097,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,3738.45,
ENTRUST SELF EXP STENT 8X60X80,46108404,CDM,278,RC,C1876,HCPCS,Outpatient,,,2097,1258.20,,3738.45,110,,0.36,Percent of Total Billed Charges,110% of Total Billed Charges,943.65,45,,2.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,587.16,28,,140.088,Percent of Total Billed Charges,28% of Total Billed Charges,0.68,32,,987.84,Percent of Total Billed Charges,32% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,754.92,36,,180.112,Percent of Total Billed Charges,36% of Total Billed Charges,754.92,36,,180.112,Percent of Total Billed Charges,36% Total Bille Charges,754.92,36,,180.112,Percent of Total Billed Charges,36% of Total Billed Charges,1153.35,55,,896.888,Percent of Total Billed Charges,55% Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097,100,,1.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,302.39,14.42,,218.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1677.6,80,,218.96,Percent of Total Billed Charges,80% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.9,70,,117.6,Percent of Total Billed Charges,70% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,212.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2097,100,,291.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,3738.45,
ENTRUST STENT SELF EXP 8X80X80,46108405,CDM,278,RC,C1876,HCPCS,Outpatient,,,2097,1258.20,,3738.45,110,,1.064,Percent of Total Billed Charges,110% of Total Billed Charges,943.65,45,,0.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,587.16,28,,348.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.69,32,,987.84,Percent of Total Billed Charges,32% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,754.92,36,,447.816,Percent of Total Billed Charges,36% of Total Billed Charges,754.92,36,,447.816,Percent of Total Billed Charges,36% Total Bille Charges,754.92,36,,447.816,Percent of Total Billed Charges,36% of Total Billed Charges,1153.35,55,,1189.552,Percent of Total Billed Charges,55% Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2097,100,,0.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,302.39,14.42,,249.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1677.6,80,,219.44,Percent of Total Billed Charges,80% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1048.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1467.9,70,,238.784,Percent of Total Billed Charges,70% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,293.58,14,,241.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2097,100,,292.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,3738.45,
ENTRUST STENT 6X120X150,46108406,CDM,278,RC,C1876,HCPCS,Outpatient,,,2250,1350.00,,3906.75,110,,3.304,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,666.32,Percent of Total Billed Charges,28% of Total Billed Charges,0.69,32,,991.624,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,856.704,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,1189.552,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,9.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,626.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,889.112,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,303.8,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,608.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,1185.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,3906.75,
TR BAND REGULAR,46108407,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,0.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,88.008,Percent of Total Billed Charges,28% of Total Billed Charges,0.69,32,,991.624,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,113.152,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,113.152,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,113.152,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,1943.264,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,0.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,5128.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,2379,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,177.8,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,3172,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,150,
ENTRUST STENT 6X150X150,46108408,CDM,278,RC,C1876,HCPCS,Outpatient,,,2250,1350.00,,3906.75,110,,0.12,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,4.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,153.176,Percent of Total Billed Charges,28% of Total Billed Charges,0.69,32,,991.624,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,196.944,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,196.944,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,196.944,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,2577.368,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,0.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,6032.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,152.4,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,350,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,203.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,3906.75,
ENTRUST STENT 7X120150,46108409,CDM,278,RC,C1876,HCPCS,Outpatient,,,2250,1350.00,,3906.75,110,,0.112,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,5.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,152.72,Percent of Total Billed Charges,28% of Total Billed Charges,0.7,32,,991.624,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,196.352,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,196.352,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,196.352,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,2577.368,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,6.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,6032.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,45.6,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,77.448,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,5856.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,60.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.7,3906.75,
ENTRUST STENT 7X150X150,46108410,CDM,278,RC,C1876,HCPCS,Outpatient,,,2250,1350.00,,3906.75,110,,0.12,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,9.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,0.7,32,,991.624,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,104.28,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,0.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,2980.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,225,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,551.6,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.7,3906.75,
GLIDECATH 5FR 65CM STRAIGHT,46108411,CDM,272,RC,,,Outpatient,,,230,138.00,,138,60,,48.712,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.4,28,,26.208,Percent of Total Billed Charges,28% of Total Billed Charges,0.7,32,,995.072,Percent of Total Billed Charges,32% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,82.8,36,,33.696,Percent of Total Billed Charges,36% of Total Billed Charges,82.8,36,,33.696,Percent of Total Billed Charges,36% Total Bille Charges,82.8,36,,33.696,Percent of Total Billed Charges,36% of Total Billed Charges,138,60,,637.792,Percent of Total Billed Charges,60% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230,100,,0.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,33.17,14.42,,2980.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.5,75,,67.8,Percent of Total Billed Charges,75% of Total Billed Charges,115,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,115,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,115,50,,146.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161,70,,7154,Percent of Total Billed Charges,70% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,32.2,14,,2893.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230,100,,90.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.7,230,
IR THORCENT W TUBE W IMAGE RT,46108413,CDM,361,RC,,,Outpatient,,,2295.88,1377.53,,1377.53,60,,4.032,Percent of Total Billed Charges,60% of Total Billed Charges,1033.15,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.85,28,,102.912,Percent of Total Billed Charges,28% of Total Billed Charges,0.71,32,,995.072,Percent of Total Billed Charges,32% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,826.52,36,,132.312,Percent of Total Billed Charges,36% of Total Billed Charges,826.52,36,,132.312,Percent of Total Billed Charges,36% Total Bille Charges,826.52,36,,132.312,Percent of Total Billed Charges,36% of Total Billed Charges,1377.53,60,,1498.672,Percent of Total Billed Charges,60% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2295.88,100,,0.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,331.07,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1721.91,75,,504,Percent of Total Billed Charges,75% of Total Billed Charges,1147.94,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,1147.94,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1147.94,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,1147.94,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1607.12,70,,47.04,Percent of Total Billed Charges,70% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,321.42,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2295.88,100,,672,Percent of Total Billed Charges,100% of Total Billed Charges,0.71,2295.88,
6FR HAWKONE ATHERECTOMY CATH,46108414,CDM,272,RC,C1714,HCPCS,Outpatient,,,9087,5452.20,,389.94,100,,2.536,Fee Schedule,100% of Aetna Fee Schedule,4089.15,45,,0.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2544.36,28,,194.864,Percent of Total Billed Charges,28% of Total Billed Charges,0.71,32,,998.4,Percent of Total Billed Charges,32% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,3271.32,36,,250.536,Percent of Total Billed Charges,36% of Total Billed Charges,3271.32,36,,250.536,Percent of Total Billed Charges,36% Total Bille Charges,3271.32,36,,250.536,Percent of Total Billed Charges,36% of Total Billed Charges,5452.2,60,,1129.68,Percent of Total Billed Charges,60% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9087,100,,10.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1310.35,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6815.25,75,,36,Percent of Total Billed Charges,75% of Total Billed Charges,4543.5,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,4543.5,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4543.5,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,4543.5,50,,209.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6360.9,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1272.18,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9087,100,,48,Percent of Total Billed Charges,100% of Total Billed Charges,0.71,9087,
IR URETRL TUBE CHG LT,46108415,CDM,361,RC,,,Outpatient,,,2516.86,1510.12,,1510.12,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,1132.59,45,,4.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,704.72,28,,1100.736,Percent of Total Billed Charges,28% of Total Billed Charges,0.72,32,,999.768,Percent of Total Billed Charges,32% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,906.07,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,906.07,36,,1415.232,Percent of Total Billed Charges,36% Total Bille Charges,906.07,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,1510.12,60,,1084.176,Percent of Total Billed Charges,60% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2516.86,100,,11.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,362.93,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1887.65,75,,269.912,Percent of Total Billed Charges,75% of Total Billed Charges,1258.43,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,1258.43,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1258.43,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,1258.43,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1761.8,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,352.36,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2516.86,100,,359.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,2516.86,
TRAILBLAZER ANGLED 018 150CM,46108416,CDM,272,RC,C1887,HCPCS,Outpatient,,,600,360.00,,43.86,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,270,45,,2.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,2150.4,Percent of Total Billed Charges,28% of Total Billed Charges,0.72,32,,1002.848,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,2764.8,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,2764.8,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,2764.8,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,669.808,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,20.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,80.4,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,1813.952,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,107.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,600,
CATH ANGIO 2XL 18MMX4X75,46108417,CDM,272,RC,C1725,HCPCS,Outpatient,,,630,378.00,,99.47,100,,0.096,Fee Schedule,100% of Aetna Fee Schedule,283.5,45,,12.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.4,28,,725.76,Percent of Total Billed Charges,28% of Total Billed Charges,0.73,32,,1003.304,Percent of Total Billed Charges,32% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,226.8,36,,933.12,Percent of Total Billed Charges,36% of Total Billed Charges,226.8,36,,933.12,Percent of Total Billed Charges,36% Total Bille Charges,226.8,36,,933.12,Percent of Total Billed Charges,36% of Total Billed Charges,378,60,,669.808,Percent of Total Billed Charges,60% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630,100,,3.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,90.85,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.5,75,,152.4,Percent of Total Billed Charges,75% of Total Billed Charges,315,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,315,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,315,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,441,70,,4965.216,Percent of Total Billed Charges,70% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,100,,203.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,630,
MAESTRO MICRO CATH 130CM ANG,46108418,CDM,272,RC,C1887,HCPCS,Outpatient,,,885,531.00,,43.86,100,,0.424,Fee Schedule,100% of Aetna Fee Schedule,398.25,45,,25.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.8,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,0.73,32,,1003.304,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,318.6,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,318.6,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,318.6,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,531,60,,367.68,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885,100,,0.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.75,75,,210.84,Percent of Total Billed Charges,75% of Total Billed Charges,442.5,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.5,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,442.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.5,70,,51.912,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885,100,,281.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,885,
SHEATH 25CM 10FR PINNACLE,46108419,CDM,272,RC,C1894,HCPCS,Outpatient,,,117,70.20,,82.29,100,,0.512,Fee Schedule,100% of Aetna Fee Schedule,52.65,45,,13.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.76,28,,10.112,Percent of Total Billed Charges,28% of Total Billed Charges,0.73,32,,1015.04,Percent of Total Billed Charges,32% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,42.12,36,,13.008,Percent of Total Billed Charges,36% of Total Billed Charges,42.12,36,,13.008,Percent of Total Billed Charges,36% Total Bille Charges,42.12,36,,13.008,Percent of Total Billed Charges,36% of Total Billed Charges,70.2,60,,367.68,Percent of Total Billed Charges,60% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,100,,0.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.87,14.42,,58.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.75,75,,2023.472,Percent of Total Billed Charges,75% of Total Billed Charges,58.5,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.5,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.9,70,,1813.952,Percent of Total Billed Charges,70% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117,100,,2529.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,117,
IR BALLOON DILAT URETERAL ADD,46108420,CDM,361,RC,,,Outpatient,,,4262,2557.20,,2557.2,60,,0.144,Percent of Total Billed Charges,60% of Total Billed Charges,1917.9,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1193.36,28,,2.608,Percent of Total Billed Charges,28% of Total Billed Charges,0.73,32,,1015.824,Percent of Total Billed Charges,32% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,1534.32,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,1534.32,36,,3.352,Percent of Total Billed Charges,36% Total Bille Charges,1534.32,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,2557.2,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4262,100,,9.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,614.58,14.42,,58.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3196.5,75,,199.608,Percent of Total Billed Charges,75% of Total Billed Charges,2131,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,2131,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2131,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,2131,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2983.4,70,,2725.632,Percent of Total Billed Charges,70% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,596.68,14,,57.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4262,100,,266.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,4262,
EVERCROSS BALLOON PTA,46108422,CDM,272,RC,C1725,HCPCS,Outpatient,,,380,228.00,,99.47,100,,0.92,Fee Schedule,100% of Aetna Fee Schedule,171,45,,1.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.73,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,136.8,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,136.8,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,136.8,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,228,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380,100,,5.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,54.8,14.42,,1338.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285,75,,384,Percent of Total Billed Charges,75% of Total Billed Charges,190,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,70,,177.8,Percent of Total Billed Charges,70% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1299.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,380,
IR ENDOLUM BIL TREE BX W GUID,46108423,CDM,361,RC,,,Outpatient,,,2747.23,1648.34,,1648.34,60,,0.368,Percent of Total Billed Charges,60% of Total Billed Charges,1236.25,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,769.22,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,0.75,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,989,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,989,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,989,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1648.34,60,,384.016,Percent of Total Billed Charges,60% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2747.23,100,,28.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,396.15,14.42,,1511.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2060.42,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,1373.62,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,1373.62,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1373.62,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,1373.62,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1923.06,70,,487.152,Percent of Total Billed Charges,70% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,384.61,14,,1467.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2747.23,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,0.75,2747.23,
IR DILATION BILIARY DUCT,46108424,CDM,361,RC,,,Outpatient,,,1935.61,1161.37,,1161.37,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,871.02,45,,25.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.97,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,0.75,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,696.82,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,696.82,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,696.82,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,1161.37,60,,384.016,Percent of Total Billed Charges,60% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1935.61,100,,56.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,279.11,14.42,,416.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1451.71,75,,966.8,Percent of Total Billed Charges,75% of Total Billed Charges,967.81,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,967.81,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.81,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,967.81,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1354.93,70,,2751.84,Percent of Total Billed Charges,70% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,270.99,14,,404.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1935.61,100,,1208.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.75,1935.61,
WALL STENT14X90X75,46108425,CDM,278,RC,C1876,HCPCS,Outpatient,,,2254,1352.40,,3911.15,110,,0.544,Percent of Total Billed Charges,110% of Total Billed Charges,1014.3,45,,1.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.12,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,811.44,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,811.44,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,811.44,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,1239.7,55,,314.312,Percent of Total Billed Charges,55% Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2254,100,,30.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,325.03,14.42,,3485.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1803.2,80,,2612.48,Percent of Total Billed Charges,80% of Total Billed Charges,1127,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1127,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1577.8,70,,5376,Percent of Total Billed Charges,70% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,3384.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254,100,,3265.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,3911.15,
WALLSTENT 14X60X75,46108426,CDM,278,RC,C1876,HCPCS,Outpatient,,,2254,1352.40,,3911.15,110,,3.2,Percent of Total Billed Charges,110% of Total Billed Charges,1014.3,45,,3.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.12,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,811.44,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,811.44,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,811.44,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,1239.7,55,,314.312,Percent of Total Billed Charges,55% Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2254,100,,3.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,325.03,14.42,,2323.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1803.2,80,,136.36,Percent of Total Billed Charges,80% of Total Billed Charges,1127,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1127,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1577.8,70,,1814.4,Percent of Total Billed Charges,70% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254,100,,181.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,3911.15,
QUADRA ALLURE MP RF,46108427,CDM,275,RC,C2621,HCPCS,Outpatient,,,13000,7800.00,,17940.47,110,,4.576,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,6.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.768,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,7.968,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,371.368,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,3.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,2323.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9750,75,,179.368,Percent of Total Billed Charges,75% of Total Billed Charges,6500,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,203.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,2256.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,239.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,17940.47,
IR VENOGRAM EXT BI SI,46108428,CDM,320,RC,75822,HCPCS,Outpatient,,,1917,1150.20,,69.44,100,,1.16,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,6.352,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.02,280,,1.936,Fee Schedule,280% of BCBS BULE Fee Schedule,254.88,320,,0.768,Fee Schedule,320% of BCBS Blue Essentials Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,286.74,360,,2.496,Fee Schedule,360% of BCBS POS Rate,286.74,360,,2.496,Fee schedule,360% of BCBS PPO Rate,286.74,360,,2.496,Fee Schedule,360% of BCBS Traditional Rate,3325.79,103,,424.808,Fee Schedule,103% of Cigna fee schedule,132.99,100,,209.512,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,3.512,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,136.98,103,,215.8,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1437.75,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,958.5,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,958.5,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,25.288,Case Rate,Pays based on per visit rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,209.512,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1917,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,3325.79,
IR VENOGRAM EXT BI SI,46108428,CDM,320,RC,75822,HCPCS,Outpatient,,,1917,1150.20,,69.44,100,,1.312,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,0.424,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,223.02,280,,509.6,Fee Schedule,280% of BCBS BULE Fee Schedule,254.88,320,,0.768,Fee Schedule,320% of BCBS Blue Essentials Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,286.74,360,,655.2,Fee Schedule,360% of BCBS POS Rate,286.74,360,,655.2,Fee schedule,360% of BCBS PPO Rate,286.74,360,,655.2,Fee Schedule,360% of BCBS Traditional Rate,3325.79,103,,424.808,Fee Schedule,103% of Cigna fee schedule,132.99,100,,139.632,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,56.032,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,136.98,103,,143.816,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1437.75,75,,789.424,Percent of Total Billed Charges,75% of Total Billed Charges,958.5,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,958.5,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,958.5,50,,280.2,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.512,Case Rate,Pays based on per visit rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,139.632,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1917,100,,1052.568,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,3325.79,
IR URETRL OR URETHRA DIL SI,46108429,CDM,320,RC,74485,HCPCS,Outpatient,,,2541.71,1525.03,TC   ,78.42,100,,25.816,Fee Schedule,100% of Aetna Fee Schedule,2803.05,150,,0.456,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4960.34,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,5668.96,320,,0.776,Fee Schedule,320% of BCBS Blue Essentials Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,6377.58,360,,0.072,Fee Schedule,360% of BCBS POS Rate,6377.58,360,,0.072,Fee schedule,360% of BCBS PPO Rate,6377.58,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,5290.68,103,,637.792,Fee Schedule,103% of Cigna fee schedule,119.63,100,,220.12,Fee Schedule,100% of TX Mediciad Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,3.832,Fee Schedule,100% of CMS OPPS Rate,1681.83,90,,,Fee Schedule,90% of CMS OPPS Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.31,130,,,Fee Schedule,130% of CMS OPPS Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,123.22,103,,226.72,Fee Schedule,103% of TX Medicaid Rate,1924.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1906.28,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,1270.86,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,1270.86,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.86,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,1270.86,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28,Case Rate,Pays based on per visit rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,220.12,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2541.71,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,78.42,6377.58,
IR URETRL OR URETHRA DIL SI,46108429,CDM,320,RC,74485,HCPCS,Outpatient,,,2541.71,1525.03,TC   ,78.42,100,,0.088,Fee Schedule,100% of Aetna Fee Schedule,2803.05,150,,0.496,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4960.34,280,,10.592,Fee Schedule,280% of BCBS BULE Fee Schedule,5668.96,320,,0.792,Fee Schedule,320% of BCBS Blue Essentials Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,6377.58,360,,13.616,Fee Schedule,360% of BCBS POS Rate,6377.58,360,,13.616,Fee schedule,360% of BCBS PPO Rate,6377.58,360,,13.616,Fee Schedule,360% of BCBS Traditional Rate,5290.68,103,,517.408,Fee Schedule,103% of Cigna fee schedule,119.63,100,,276.592,Fee Schedule,100% of TX Mediciad Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,7.36,Fee Schedule,100% of CMS OPPS Rate,1681.83,90,,,Fee Schedule,90% of CMS OPPS Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.31,130,,,Fee Schedule,130% of CMS OPPS Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,123.22,103,,284.896,Fee Schedule,103% of TX Medicaid Rate,1924.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1906.28,75,,192.456,Percent of Total Billed Charges,75% of Total Billed Charges,1270.86,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,1270.86,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.86,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,1270.86,50,,117.384,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.96,Case Rate,Pays based on per visit rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,119.63,100,,276.592,Fee Schedule,100% of TX Medicaid Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2541.71,100,,256.608,Percent of Total Billed Charges,100% of Total Billed Charges,78.42,6377.58,
AZURE XT DR PPM,46108430,CDM,275,RC,C1785,HCPCS,Outpatient,,,10920,6552.00,,12287.42,110,,0.704,Percent of Total Billed Charges,110% of Total Billed Charges,4914,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3057.6,28,,9.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.792,Percent of Total Billed Charges,32% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3931.2,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,3931.2,36,,12.408,Percent of Total Billed Charges,36% Total Bille Charges,3931.2,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,6006,55,,517.408,Percent of Total Billed Charges,55% Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10920,100,,14.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1574.66,14.42,,110.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8190,75,,284.8,Percent of Total Billed Charges,75% of Total Billed Charges,5460,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,5460,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5460,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,5460,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7644,70,,35.696,Percent of Total Billed Charges,70% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10920,100,,356,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,12287.42,
QUADRA ASSURA MP CRT-D,46108431,CDM,275,RC,C1882,HCPCS,Outpatient,,,27000,16200.00,,41787.27,110,,0.496,Percent of Total Billed Charges,110% of Total Billed Charges,12150,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7560,28,,66.328,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.808,Percent of Total Billed Charges,32% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,9720,36,,85.28,Percent of Total Billed Charges,36% of Total Billed Charges,9720,36,,85.28,Percent of Total Billed Charges,36% Total Bille Charges,9720,36,,85.28,Percent of Total Billed Charges,36% of Total Billed Charges,14850,55,,633.464,Percent of Total Billed Charges,55% Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27000,100,,14.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3893.4,14.42,,110.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20250,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,13500,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,13500,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13500,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,13500,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18900,70,,37.408,Percent of Total Billed Charges,70% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,107.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27000,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,41787.27,
PIONEER PLUS IVUS REENTRY CATH,46108432,CDM,272,RC,C1753,HCPCS,Outpatient,,,8307,4984.20,,85.94,100,,1.664,Fee Schedule,100% of Aetna Fee Schedule,3738.15,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2325.96,28,,6.88,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.808,Percent of Total Billed Charges,32% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,2990.52,36,,8.848,Percent of Total Billed Charges,36% of Total Billed Charges,2990.52,36,,8.848,Percent of Total Billed Charges,36% Total Bille Charges,2990.52,36,,8.848,Percent of Total Billed Charges,36% of Total Billed Charges,4984.2,60,,422.312,Percent of Total Billed Charges,60% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8307,100,,0.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1197.87,14.42,,266.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6230.25,75,,79.92,Percent of Total Billed Charges,75% of Total Billed Charges,4153.5,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,4153.5,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4153.5,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,4153.5,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5814.9,70,,22.256,Percent of Total Billed Charges,70% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,1162.98,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8307,100,,106.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,8307,
TREROTOLA 5FR PTD SET,46108433,CDM,272,RC,C1757,HCPCS,Outpatient,,,1566,939.60,,16.33,100,,0.712,Fee Schedule,100% of Aetna Fee Schedule,704.7,45,,1.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.48,28,,7.392,Percent of Total Billed Charges,28% of Total Billed Charges,0.76,32,,0.808,Percent of Total Billed Charges,32% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,563.76,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,563.76,36,,9.504,Percent of Total Billed Charges,36% Total Bille Charges,563.76,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,939.6,60,,422.312,Percent of Total Billed Charges,60% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566,100,,1.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,225.82,14.42,,505.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1174.5,75,,107.584,Percent of Total Billed Charges,75% of Total Billed Charges,783,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,783,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,783,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,783,50,,230.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1096.2,70,,9.576,Percent of Total Billed Charges,70% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,219.24,14,,490.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1566,100,,134.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,1566,
TREROTOLA ROTATOR DRIVE UNIT,46108434,CDM,272,RC,,,Outpatient,,,464,278.40,,278.4,60,,3.032,Percent of Total Billed Charges,60% of Total Billed Charges,208.8,45,,0.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.92,28,,4.608,Percent of Total Billed Charges,28% of Total Billed Charges,0.77,32,,0.808,Percent of Total Billed Charges,32% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,167.04,36,,5.928,Percent of Total Billed Charges,36% of Total Billed Charges,167.04,36,,5.928,Percent of Total Billed Charges,36% Total Bille Charges,167.04,36,,5.928,Percent of Total Billed Charges,36% of Total Billed Charges,278.4,60,,318.408,Percent of Total Billed Charges,60% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,464,100,,1.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,66.91,14.42,,662.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348,75,,226.264,Percent of Total Billed Charges,75% of Total Billed Charges,232,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,232,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,232,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.8,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,64.96,14,,643.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,464,100,,301.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,464,
VIABAHN VBX 7MM X 59MM X 135CM,46108435,CDM,278,RC,C1874,HCPCS,Outpatient,,,7363.2,4417.92,,8591.93,110,,1.376,Percent of Total Billed Charges,110% of Total Billed Charges,3313.44,45,,2.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2061.7,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,0.77,32,,0.816,Percent of Total Billed Charges,32% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,2650.75,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,2650.75,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,2650.75,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,4049.76,55,,356.8,Percent of Total Billed Charges,55% Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7363.2,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1061.77,14.42,,755.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5890.56,80,,679.88,Percent of Total Billed Charges,80% of Total Billed Charges,3681.6,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,3681.6,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3681.6,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,3681.6,50,,243.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5154.24,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1030.85,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7363.2,100,,849.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,8591.93,
VIABAHN 7MM X 10CM X 120CM,46108436,CDM,278,RC,C1874,HCPCS,Outpatient,,,8491.6,5094.96,,9833.17,110,,0.24,Percent of Total Billed Charges,110% of Total Billed Charges,3821.22,45,,5.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2377.65,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,0.77,32,,0.824,Percent of Total Billed Charges,32% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,3056.98,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,3056.98,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,3056.98,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,4670.38,55,,356.8,Percent of Total Billed Charges,55% Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8491.6,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1224.49,14.42,,755.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6793.28,80,,187.272,Percent of Total Billed Charges,80% of Total Billed Charges,4245.8,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,4245.8,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4245.8,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,4245.8,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5944.12,70,,15.488,Percent of Total Billed Charges,70% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,1188.82,14,,733.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8491.6,100,,249.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,9833.17,
VIABAHN 7MM X 5.0CM X 120CM,46108437,CDM,278,RC,C1874,HCPCS,Outpatient,,,10189.4,6113.64,,11700.75,110,,0.576,Percent of Total Billed Charges,110% of Total Billed Charges,4585.23,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2853.03,28,,31.008,Percent of Total Billed Charges,28% of Total Billed Charges,0.77,32,,0.832,Percent of Total Billed Charges,32% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,3668.18,36,,39.864,Percent of Total Billed Charges,36% of Total Billed Charges,3668.18,36,,39.864,Percent of Total Billed Charges,36% Total Bille Charges,3668.18,36,,39.864,Percent of Total Billed Charges,36% of Total Billed Charges,5604.17,55,,298.8,Percent of Total Billed Charges,55% Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10189.4,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1469.31,14.42,,1656.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8151.52,80,,107.4,Percent of Total Billed Charges,80% of Total Billed Charges,5094.7,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,5094.7,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5094.7,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,5094.7,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7132.58,70,,4.848,Percent of Total Billed Charges,70% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,1426.52,14,,1608.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10189.4,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,11700.75,
XXL BALLOON,46108438,CDM,272,RC,C1725,HCPCS,Outpatient,,,630,378.00,,99.47,100,,0.072,Fee Schedule,100% of Aetna Fee Schedule,283.5,45,,194.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.4,28,,3.232,Percent of Total Billed Charges,28% of Total Billed Charges,0.78,32,,0.832,Percent of Total Billed Charges,32% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,226.8,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,226.8,36,,4.152,Percent of Total Billed Charges,36% Total Bille Charges,226.8,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,378,60,,426.288,Percent of Total Billed Charges,60% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630,100,,3.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,90.85,14.42,,2640.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.5,75,,67.8,Percent of Total Billed Charges,75% of Total Billed Charges,315,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,315,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,315,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,441,70,,1274,Percent of Total Billed Charges,70% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,88.2,14,,2563.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,100,,90.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,630,
MICROPUNCTURE INTRO SET,46108439,CDM,272,RC,C1894,HCPCS,Outpatient,,,150,90.00,,82.29,100,,0.104,Fee Schedule,100% of Aetna Fee Schedule,67.5,45,,48.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,0.78,32,,0.84,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,261.176,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,0.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,3389.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,288.688,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,3290.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,384.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,150,
STENT PALMAZ XL,46108440,CDM,278,RC,C1877,HCPCS,Outpatient,,,2604,1562.40,,3390.3,110,,15.648,Percent of Total Billed Charges,110% of Total Billed Charges,1171.8,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.12,28,,2.464,Percent of Total Billed Charges,28% of Total Billed Charges,0.78,32,,0.84,Percent of Total Billed Charges,32% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,937.44,36,,3.168,Percent of Total Billed Charges,36% of Total Billed Charges,937.44,36,,3.168,Percent of Total Billed Charges,36% Total Bille Charges,937.44,36,,3.168,Percent of Total Billed Charges,36% of Total Billed Charges,1432.2,55,,455.096,Percent of Total Billed Charges,55% Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2604,100,,5.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,375.5,14.42,,2259.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2083.2,80,,3373.168,Percent of Total Billed Charges,80% of Total Billed Charges,1302,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,1302,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,1302,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1822.8,70,,26.48,Percent of Total Billed Charges,70% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,364.56,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2604,100,,4497.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,3390.3,
ADMIRAL IMPACT BALLOON CATH,46108441,CDM,278,RC,C2623,HCPCS,Outpatient,,,3250,1950.00,,3575,110,,1.304,Percent of Total Billed Charges,110% of Total Billed Charges,1462.5,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,28,,6.944,Percent of Total Billed Charges,28% of Total Billed Charges,0.79,32,,0.84,Percent of Total Billed Charges,32% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,1170,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,1170,36,,8.928,Percent of Total Billed Charges,36% Total Bille Charges,1170,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,1787.5,55,,448.36,Percent of Total Billed Charges,55% Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3250,100,,12.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,468.65,14.42,,2259.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2600,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,1625,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,1625,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1625,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,1625,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2275,70,,24.128,Percent of Total Billed Charges,70% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,2193.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3250,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.79,3575,
CHOCOLATE 2.5MM X 120MM X 150C,46108442,CDM,272,RC,C1725,HCPCS,Outpatient,,,2296,1377.60,,99.47,100,,19.456,Fee Schedule,100% of Aetna Fee Schedule,1033.2,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.88,28,,6.944,Percent of Total Billed Charges,28% of Total Billed Charges,0.79,32,,0.856,Percent of Total Billed Charges,32% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,826.56,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,826.56,36,,8.928,Percent of Total Billed Charges,36% Total Bille Charges,826.56,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,1377.6,60,,448.36,Percent of Total Billed Charges,60% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2296,100,,1.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,331.08,14.42,,5313.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1722,75,,2626.576,Percent of Total Billed Charges,75% of Total Billed Charges,1148,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,1148,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1148,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,1148,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1607.2,70,,165.816,Percent of Total Billed Charges,70% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,321.44,14,,5158.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2296,100,,3502.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.79,2296,
BALLOON ADMIRAL IMPACT 130,46108443,CDM,272,RC,C2623,HCPCS,Outpatient,,,3250,1950.00,,1950,60,,6.512,Percent of Total Billed Charges,60% of Total Billed Charges,1462.5,45,,0.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910,28,,23.616,Percent of Total Billed Charges,28% of Total Billed Charges,0.8,32,,0.864,Percent of Total Billed Charges,32% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,1170,36,,30.368,Percent of Total Billed Charges,36% of Total Billed Charges,1170,36,,30.368,Percent of Total Billed Charges,36% Total Bille Charges,1170,36,,30.368,Percent of Total Billed Charges,36% of Total Billed Charges,1950,60,,690.464,Percent of Total Billed Charges,60% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3250,100,,433.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,468.65,14.42,,3542.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2437.5,75,,31.504,Percent of Total Billed Charges,75% of Total Billed Charges,1625,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,1625,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1625,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,1625,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2275,70,,17.2,Percent of Total Billed Charges,70% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,455,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3250,100,,42,Percent of Total Billed Charges,100% of Total Billed Charges,0.8,3250,
BALLOON ADMIRAL IMPACT 150MM,46108446,CDM,272,RC,C2623,HCPCS,Outpatient,,,4030,2418.00,,2418,60,,3.168,Percent of Total Billed Charges,60% of Total Billed Charges,1813.5,45,,10.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1128.4,28,,1.336,Percent of Total Billed Charges,28% of Total Billed Charges,0.81,32,,0.864,Percent of Total Billed Charges,32% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,1450.8,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,1450.8,36,,1.72,Percent of Total Billed Charges,36% Total Bille Charges,1450.8,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,2418,60,,288.712,Percent of Total Billed Charges,60% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4030,100,,107.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,581.13,14.42,,3542.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3022.5,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,2015,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,2015,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2015,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,2015,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2821,70,,18.472,Percent of Total Billed Charges,70% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,564.2,14,,3439.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4030,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.81,4030,
COYOTE ES BALLOON OTW,46108448,CDM,272,RC,C1725,HCPCS,Outpatient,,,750,450.00,,99.47,100,,6.304,Fee Schedule,100% of Aetna Fee Schedule,337.5,45,,9.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,0.808,Percent of Total Billed Charges,28% of Total Billed Charges,0.81,32,,0.864,Percent of Total Billed Charges,32% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,1.04,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,450,60,,298.296,Percent of Total Billed Charges,60% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,0.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,2797.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,375,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,241.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,40.312,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,2716.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.81,750,
VORTX DIAMOND COIL,46108449,CDM,278,RC,,,Outpatient,,,378.4,227.04,,416.24,110,,5.144,Percent of Total Billed Charges,110% of Total Billed Charges,170.28,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.95,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.83,32,,0.864,Percent of Total Billed Charges,32% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,136.22,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,136.22,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,136.22,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.4,100,,0.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,54.57,14.42,,865.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.72,80,,1585.2,Percent of Total Billed Charges,80% of Total Billed Charges,189.2,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,189.2,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.2,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,189.2,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.88,70,,80.608,Percent of Total Billed Charges,70% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,840,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.4,100,,2113.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.83,416.24,
COMPLEX HELICAL COIL,46108450,CDM,278,RC,,,Outpatient,,,375,225.00,,412.5,110,,5.144,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,2.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.84,32,,0.872,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,3.752,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,3.752,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,3.752,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,576.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,1828.8,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,285.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,11.528,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2438.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,412.5,
PUSHABLE COIL 2D HELICAL,46108451,CDM,278,RC,,,Outpatient,,,335,201.00,,368.5,110,,5.144,Percent of Total Billed Charges,110% of Total Billed Charges,150.75,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.8,28,,176.96,Percent of Total Billed Charges,28% of Total Billed Charges,0.84,32,,0.88,Percent of Total Billed Charges,32% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,120.6,36,,227.52,Percent of Total Billed Charges,36% of Total Billed Charges,120.6,36,,227.52,Percent of Total Billed Charges,36% Total Bille Charges,120.6,36,,227.52,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335,100,,0.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,48.31,14.42,,576.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268,80,,514.8,Percent of Total Billed Charges,80% of Total Billed Charges,167.5,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,167.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,167.5,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.5,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,46.9,14,,560,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335,100,,686.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,368.5,
COIL PUSHABLE STRAIGHT,46108452,CDM,278,RC,,,Outpatient,,,265,159.00,,291.5,110,,5.144,Percent of Total Billed Charges,110% of Total Billed Charges,119.25,45,,1.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.2,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,0.85,32,,0.888,Percent of Total Billed Charges,32% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,95.4,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,95.4,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,95.4,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265,100,,22.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,38.21,14.42,,678.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212,80,,240,Percent of Total Billed Charges,80% of Total Billed Charges,132.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,132.5,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.5,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,132.5,50,,201.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.5,70,,0.12,Percent of Total Billed Charges,70% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.1,14,,658.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265,100,,320,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,291.5,
RENEGADE STC MICROCATHETER,46108453,CDM,272,RC,C1887,HCPCS,Outpatient,,,897,538.20,,43.86,100,,0.568,Fee Schedule,100% of Aetna Fee Schedule,403.65,45,,0.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.16,28,,2679.304,Percent of Total Billed Charges,28% of Total Billed Charges,0.85,32,,0.896,Percent of Total Billed Charges,32% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,322.92,36,,3444.816,Percent of Total Billed Charges,36% of Total Billed Charges,322.92,36,,3444.816,Percent of Total Billed Charges,36% Total Bille Charges,322.92,36,,3444.816,Percent of Total Billed Charges,36% of Total Billed Charges,538.2,60,,566.168,Percent of Total Billed Charges,60% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,897,100,,21.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,129.35,14.42,,452.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.75,75,,187.2,Percent of Total Billed Charges,75% of Total Billed Charges,448.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,448.5,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.5,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,448.5,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,627.9,70,,77.52,Percent of Total Billed Charges,70% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,897,100,,249.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,897,
VORTEX DIAMOND COIL,46108454,CDM,278,RC,,,Outpatient,,,378.4,227.04,,416.24,110,,46.016,Percent of Total Billed Charges,110% of Total Billed Charges,170.28,45,,0.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.95,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.86,32,,0.904,Percent of Total Billed Charges,32% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,136.22,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,136.22,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,136.22,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.4,100,,0.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,54.57,14.42,,452.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.72,80,,360,Percent of Total Billed Charges,80% of Total Billed Charges,189.2,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,189.2,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.2,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,189.2,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.88,70,,55.776,Percent of Total Billed Charges,70% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,52.98,14,,438.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.4,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,416.24,
COMPLEX HELICAL COIL,46108455,CDM,278,RC,,,Outpatient,,,375,225.00,,412.5,110,,0.376,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,0.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,0.352,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.92,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,0.456,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,680.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,1587.84,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,8.08,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,660.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1984.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,412.5,
ESSENTIO MRI DR IS-1,46108456,CDM,275,RC,C1785,HCPCS,Outpatient,,,8710,5226.00,,9856.42,110,,7.368,Percent of Total Billed Charges,110% of Total Billed Charges,3919.5,45,,3.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2438.8,28,,2.816,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.928,Percent of Total Billed Charges,32% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,3135.6,36,,3.624,Percent of Total Billed Charges,36% of Total Billed Charges,3135.6,36,,3.624,Percent of Total Billed Charges,36% Total Bille Charges,3135.6,36,,3.624,Percent of Total Billed Charges,36% of Total Billed Charges,4790.5,55,,9064,Percent of Total Billed Charges,55% Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8710,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1255.98,14.42,,697.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6532.5,75,,463.2,Percent of Total Billed Charges,75% of Total Billed Charges,4355,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4355,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,87,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6097,70,,2.432,Percent of Total Billed Charges,70% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,677.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8710,100,,617.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,9856.42,
POWERPORT SLIM SINGLE LUMEN,46108457,CDM,278,RC,C1788,HCPCS,Outpatient,,,870,522.00,,1565.81,110,,7.368,Percent of Total Billed Charges,110% of Total Billed Charges,391.5,45,,0.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.6,28,,1008,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.928,Percent of Total Billed Charges,32% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,313.2,36,,1296,Percent of Total Billed Charges,36% of Total Billed Charges,313.2,36,,1296,Percent of Total Billed Charges,36% Total Bille Charges,313.2,36,,1296,Percent of Total Billed Charges,36% of Total Billed Charges,478.5,55,,1192.544,Percent of Total Billed Charges,55% Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,870,100,,3.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,125.45,14.42,,429.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,696,80,,497.048,Percent of Total Billed Charges,80% of Total Billed Charges,435,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,435,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,435,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,121.8,14,,416.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,870,100,,662.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,1565.81,
JETSTREAM XC CATH,46108458,CDM,272,RC,C1724,HCPCS,Outpatient,,,8320,4992.00,,525.82,100,,2.432,Fee Schedule,100% of Aetna Fee Schedule,3744,45,,0.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2329.6,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.936,Percent of Total Billed Charges,32% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,2995.2,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,2995.2,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,2995.2,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,4992,60,,1192.544,Percent of Total Billed Charges,60% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8320,100,,0.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1199.74,14.42,,286.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6240,75,,463.2,Percent of Total Billed Charges,75% of Total Billed Charges,4160,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,4160,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4160,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,4160,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5824,70,,6.152,Percent of Total Billed Charges,70% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,1164.8,14,,277.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8320,100,,617.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,8320,
ANGIOSCULPT PTA CATH,46108459,CDM,272,RC,C1725,HCPCS,Outpatient,,,2984.8,1790.88,,99.47,100,,132.896,Fee Schedule,100% of Aetna Fee Schedule,1343.16,45,,1.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.74,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.936,Percent of Total Billed Charges,32% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1074.53,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,1074.53,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,1074.53,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,1790.88,60,,1444.84,Percent of Total Billed Charges,60% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2984.8,100,,1.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,430.41,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2238.6,75,,810.808,Percent of Total Billed Charges,75% of Total Billed Charges,1492.4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.36,70,,17.36,Percent of Total Billed Charges,70% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2984.8,100,,1081.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,2984.8,
ANGIOSCULPT PTA CATH,46108460,CDM,272,RC,C1725,HCPCS,Outpatient,,,2984.8,1790.88,,99.47,100,,8.28,Fee Schedule,100% of Aetna Fee Schedule,1343.16,45,,11.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.74,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,0.87,32,,0.936,Percent of Total Billed Charges,32% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,1074.53,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,1074.53,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,1074.53,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,1790.88,60,,6335,Percent of Total Billed Charges,60% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2984.8,100,,0.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,430.41,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2238.6,75,,3770.88,Percent of Total Billed Charges,75% of Total Billed Charges,1492.4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1492.4,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,1492.4,50,,583.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.36,70,,17.36,Percent of Total Billed Charges,70% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,417.87,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2984.8,100,,4713.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,2984.8,
ANGIOSCULPT PTA CATH BLLN,46108461,CDM,272,RC,C1725,HCPCS,Outpatient,,,2983.5,1790.10,,99.47,100,,2.488,Fee Schedule,100% of Aetna Fee Schedule,1342.58,45,,5.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,835.38,28,,35.28,Percent of Total Billed Charges,28% of Total Billed Charges,0.88,32,,0.936,Percent of Total Billed Charges,32% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,1074.06,36,,45.36,Percent of Total Billed Charges,36% of Total Billed Charges,1074.06,36,,45.36,Percent of Total Billed Charges,36% Total Bille Charges,1074.06,36,,45.36,Percent of Total Billed Charges,36% of Total Billed Charges,1790.1,60,,12066.52,Percent of Total Billed Charges,60% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2983.5,100,,6.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,430.22,14.42,,144.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2237.63,75,,4078.72,Percent of Total Billed Charges,75% of Total Billed Charges,1491.75,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,1491.75,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1491.75,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,1491.75,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2088.45,70,,59.048,Percent of Total Billed Charges,70% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,417.69,14,,140.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2983.5,100,,5098.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,2983.5,
ANGIOSCULPT PTA BLLN CATH,46108462,CDM,272,RC,C1725,HCPCS,Outpatient,,,2710.4,1626.24,,99.47,100,,8.272,Fee Schedule,100% of Aetna Fee Schedule,1219.68,45,,3.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,758.91,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,0.88,32,,0.944,Percent of Total Billed Charges,32% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,975.74,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,975.74,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,975.74,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,1626.24,60,,7441.056,Percent of Total Billed Charges,60% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2710.4,100,,0.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,390.84,14.42,,267.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2032.8,75,,5566.08,Percent of Total Billed Charges,75% of Total Billed Charges,1355.2,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,1355.2,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1355.2,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,1355.2,50,,717.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1897.28,70,,164.152,Percent of Total Billed Charges,70% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,259.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2710.4,100,,6957.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,2710.4,
ANGIOSCULPT PTA CATH BALLOON,46108463,CDM,272,RC,C1725,HCPCS,Outpatient,,,2710.4,1626.24,,99.47,100,,0.08,Fee Schedule,100% of Aetna Fee Schedule,1219.68,45,,4.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,758.91,28,,108.84,Percent of Total Billed Charges,28% of Total Billed Charges,0.88,32,,0.944,Percent of Total Billed Charges,32% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,975.74,36,,139.936,Percent of Total Billed Charges,36% of Total Billed Charges,975.74,36,,139.936,Percent of Total Billed Charges,36% Total Bille Charges,975.74,36,,139.936,Percent of Total Billed Charges,36% of Total Billed Charges,1626.24,60,,4703.448,Percent of Total Billed Charges,60% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2710.4,100,,1.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,390.84,14.42,,354.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2032.8,75,,6184.32,Percent of Total Billed Charges,75% of Total Billed Charges,1355.2,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,1355.2,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1355.2,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,1355.2,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1897.28,70,,3.336,Percent of Total Billed Charges,70% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,379.46,14,,344.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2710.4,100,,7730.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,2710.4,
GLIDEWIRE ADVANTGE 300CM,46108464,CDM,272,RC,C1769,HCPCS,Outpatient,,,645,387.00,,55.13,100,,0.152,Fee Schedule,100% of Aetna Fee Schedule,290.25,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.6,28,,5.936,Percent of Total Billed Charges,28% of Total Billed Charges,0.88,32,,0.944,Percent of Total Billed Charges,32% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,232.2,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,232.2,36,,7.632,Percent of Total Billed Charges,36% Total Bille Charges,232.2,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,387,60,,767.504,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,645,100,,3.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,93.01,14.42,,283.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.75,75,,2820.48,Percent of Total Billed Charges,75% of Total Billed Charges,322.5,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,322.5,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.5,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,322.5,50,,847.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.5,70,,2.016,Percent of Total Billed Charges,70% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645,100,,3525.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,645,
WALL STENT,46108465,CDM,278,RC,C1876,HCPCS,Outpatient,,,2254,1352.40,,3911.15,110,,0.272,Percent of Total Billed Charges,110% of Total Billed Charges,1014.3,45,,1.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.12,28,,5.568,Percent of Total Billed Charges,28% of Total Billed Charges,0.9,32,,0.944,Percent of Total Billed Charges,32% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,811.44,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,811.44,36,,7.152,Percent of Total Billed Charges,36% Total Bille Charges,811.44,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,1239.7,55,,3316.904,Percent of Total Billed Charges,55% Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2254,100,,26.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,325.03,14.42,,283.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1803.2,80,,69.6,Percent of Total Billed Charges,80% of Total Billed Charges,1127,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1127,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,1127,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1577.8,70,,76.92,Percent of Total Billed Charges,70% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,275.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,3911.15,
EVERA MRI XT DR SURESCAN ICD,46108466,CDM,275,RC,C1721,HCPCS,Outpatient,,,26300,15780.00,,33930,110,,0.248,Percent of Total Billed Charges,110% of Total Billed Charges,11835,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7364,28,,3.04,Percent of Total Billed Charges,28% of Total Billed Charges,0.91,32,,0.96,Percent of Total Billed Charges,32% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,9468,36,,3.912,Percent of Total Billed Charges,36% of Total Billed Charges,9468,36,,3.912,Percent of Total Billed Charges,36% Total Bille Charges,9468,36,,3.912,Percent of Total Billed Charges,36% of Total Billed Charges,14465,55,,4001.208,Percent of Total Billed Charges,55% Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26300,100,,13.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3792.46,14.42,,266.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19725,75,,177,Percent of Total Billed Charges,75% of Total Billed Charges,13150,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,13150,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13150,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,13150,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18410,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,3682,14,,258.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26300,100,,236,Percent of Total Billed Charges,100% of Total Billed Charges,0.91,33930,
VISIA AF MRI VR SURESCAN ICD,46108467,CDM,275,RC,C1722,HCPCS,Outpatient,,,27000,16200.00,,33688.8,110,,1.352,Percent of Total Billed Charges,110% of Total Billed Charges,12150,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7560,28,,17.728,Percent of Total Billed Charges,28% of Total Billed Charges,0.92,32,,0.96,Percent of Total Billed Charges,32% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,9720,36,,22.8,Percent of Total Billed Charges,36% of Total Billed Charges,9720,36,,22.8,Percent of Total Billed Charges,36% Total Bille Charges,9720,36,,22.8,Percent of Total Billed Charges,36% of Total Billed Charges,14850,55,,3575.232,Percent of Total Billed Charges,55% Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27000,100,,6.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3893.4,14.42,,520.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20250,75,,247.2,Percent of Total Billed Charges,75% of Total Billed Charges,13500,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,13500,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13500,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,13500,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18900,70,,7.296,Percent of Total Billed Charges,70% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,3780,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27000,100,,329.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,33688.8,
IR SCLERATHERAPY FLUID COLL,46108468,CDM,361,RC,49185,HCPCS,Outpatient,,,1733.06,1039.84,,4162,100,,48.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,8.712,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,6.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.92,32,,0.968,Percent of Total Billed Charges,32% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,8.656,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,8.656,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,8.656,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,1440.768,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,11.024,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,249.91,14.42,,520.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1299.8,75,,945,Percent of Total Billed Charges,75% of Total Billed Charges,866.53,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,866.53,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,866.53,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,866.53,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,442.4,Fee Schedule,100% of ASC Tier Groupings fee schedule,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,242.63,14,,504.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1733.06,100,,1260,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,5150,
SPRINT QUATTRO MRI DEFIB LEAD,46108469,CDM,275,RC,C1895,HCPCS,Outpatient,,,7800,4680.00,,9877.97,110,,1.328,Percent of Total Billed Charges,110% of Total Billed Charges,3510,45,,25.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2184,28,,7.12,Percent of Total Billed Charges,28% of Total Billed Charges,0.92,32,,0.968,Percent of Total Billed Charges,32% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,2808,36,,9.16,Percent of Total Billed Charges,36% of Total Billed Charges,2808,36,,9.16,Percent of Total Billed Charges,36% Total Bille Charges,2808,36,,9.16,Percent of Total Billed Charges,36% of Total Billed Charges,4290,55,,960.512,Percent of Total Billed Charges,55% Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7800,100,,6.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1124.76,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5850,75,,8320,Percent of Total Billed Charges,75% of Total Billed Charges,3900,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,3900,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3900,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,3900,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5460,70,,0.072,Percent of Total Billed Charges,70% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7800,100,,10400,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,9877.97,
CHECK-FLO SHEATH,46108470,CDM,272,RC,C1894,HCPCS,Outpatient,,,555.52,333.31,,82.29,100,,1,Fee Schedule,100% of Aetna Fee Schedule,249.98,45,,23.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.55,28,,36.24,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.976,Percent of Total Billed Charges,32% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,199.99,36,,46.592,Percent of Total Billed Charges,36% of Total Billed Charges,199.99,36,,46.592,Percent of Total Billed Charges,36% Total Bille Charges,199.99,36,,46.592,Percent of Total Billed Charges,36% of Total Billed Charges,333.31,60,,532.648,Percent of Total Billed Charges,60% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.52,100,,3.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,80.11,14.42,,81.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.64,75,,1440,Percent of Total Billed Charges,75% of Total Billed Charges,277.76,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,277.76,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.76,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,277.76,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.86,70,,6698.264,Percent of Total Billed Charges,70% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,77.77,14,,79.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.52,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,555.52,
GLIDEWIRE ADVNTAGE,46108471,CDM,272,RC,C1769,HCPCS,Outpatient,,,950.24,570.14,,55.13,100,,0.936,Fee Schedule,100% of Aetna Fee Schedule,427.61,45,,21.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266.07,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.976,Percent of Total Billed Charges,32% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,342.09,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,342.09,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,342.09,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,60,,4534.904,Percent of Total Billed Charges,60% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,950.24,100,,0.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,137.02,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.68,75,,4672.2,Percent of Total Billed Charges,75% of Total Billed Charges,475.12,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,475.12,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,475.12,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.17,70,,164.576,Percent of Total Billed Charges,70% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,133.03,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,950.24,100,,6229.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,950.24,
GLIDEWIRE ADVNTAGE,46108472,CDM,272,RC,C1769,HCPCS,Outpatient,,,1072.06,643.24,,55.13,100,,1.048,Fee Schedule,100% of Aetna Fee Schedule,482.43,45,,17.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.18,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.984,Percent of Total Billed Charges,32% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,385.94,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,385.94,36,,0.304,Percent of Total Billed Charges,36% Total Bille Charges,385.94,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,643.24,60,,3494.64,Percent of Total Billed Charges,60% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1072.06,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,154.59,14.42,,107.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.05,75,,228,Percent of Total Billed Charges,75% of Total Billed Charges,536.03,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,536.03,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.03,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,536.03,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750.44,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,150.09,14,,104.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1072.06,100,,304,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,1072.06,
NEWTON GUIDWIRE,46108473,CDM,272,RC,C1769,HCPCS,Outpatient,,,72.23,43.34,,55.13,100,,1.152,Fee Schedule,100% of Aetna Fee Schedule,32.5,45,,13.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.22,28,,66.056,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.984,Percent of Total Billed Charges,32% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,26,36,,84.928,Percent of Total Billed Charges,36% of Total Billed Charges,26,36,,84.928,Percent of Total Billed Charges,36% Total Bille Charges,26,36,,84.928,Percent of Total Billed Charges,36% of Total Billed Charges,43.34,60,,3317.456,Percent of Total Billed Charges,60% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.23,100,,19.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.17,75,,1792,Percent of Total Billed Charges,75% of Total Billed Charges,36.12,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,36.12,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.12,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,36.12,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.56,70,,0.888,Percent of Total Billed Charges,70% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,10.11,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.23,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,72.23,
VIABAHN VBX,46108474,CDM,278,RC,C1874,HCPCS,Outpatient,,,10798.62,6479.17,,12370.89,110,,2.88,Percent of Total Billed Charges,110% of Total Billed Charges,4859.38,45,,7.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3023.61,28,,3.192,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.984,Percent of Total Billed Charges,32% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,3887.5,36,,4.104,Percent of Total Billed Charges,36% of Total Billed Charges,3887.5,36,,4.104,Percent of Total Billed Charges,36% Total Bille Charges,3887.5,36,,4.104,Percent of Total Billed Charges,36% of Total Billed Charges,5939.24,55,,3601.952,Percent of Total Billed Charges,55% Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10798.62,100,,55.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1557.16,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8638.9,80,,135,Percent of Total Billed Charges,80% of Total Billed Charges,5399.31,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,5399.31,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5399.31,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,5399.31,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7559.03,70,,7.04,Percent of Total Billed Charges,70% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1511.81,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10798.62,100,,180,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,12370.89,
VIABAHN VBX,46108475,CDM,278,RC,C1874,HCPCS,Outpatient,,,9625.97,5775.58,,11080.98,110,,2.936,Percent of Total Billed Charges,110% of Total Billed Charges,4331.69,45,,17.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2695.27,28,,43.992,Percent of Total Billed Charges,28% of Total Billed Charges,0.93,32,,0.992,Percent of Total Billed Charges,32% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,3465.35,36,,56.56,Percent of Total Billed Charges,36% of Total Billed Charges,3465.35,36,,56.56,Percent of Total Billed Charges,36% Total Bille Charges,3465.35,36,,56.56,Percent of Total Billed Charges,36% of Total Billed Charges,5294.28,55,,1859.296,Percent of Total Billed Charges,55% Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9625.97,100,,53.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1388.06,14.42,,92.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7700.78,80,,87,Percent of Total Billed Charges,80% of Total Billed Charges,4812.99,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,4812.99,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4812.99,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,4812.99,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6738.18,70,,81.432,Percent of Total Billed Charges,70% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,1347.64,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9625.97,100,,116,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,11080.98,
STENT VICI VENOUS,46108476,CDM,278,RC,C1876,HCPCS,Outpatient,,,6118.2,3670.92,,8161.77,110,,1.616,Percent of Total Billed Charges,110% of Total Billed Charges,2753.19,45,,0.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1713.1,28,,2.144,Percent of Total Billed Charges,28% of Total Billed Charges,0.94,32,,0.992,Percent of Total Billed Charges,32% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,2202.55,36,,2.76,Percent of Total Billed Charges,36% of Total Billed Charges,2202.55,36,,2.76,Percent of Total Billed Charges,36% Total Bille Charges,2202.55,36,,2.76,Percent of Total Billed Charges,36% of Total Billed Charges,3365.01,55,,2105.76,Percent of Total Billed Charges,55% Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6118.2,100,,47,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,882.24,14.42,,92.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4894.56,80,,256.608,Percent of Total Billed Charges,80% of Total Billed Charges,3059.1,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,3059.1,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3059.1,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,3059.1,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4282.74,70,,2520,Percent of Total Billed Charges,70% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,856.55,14,,89.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6118.2,100,,342.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.94,8161.77,
IVUS CORONARY LD INITIAL,46108477,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,1.616,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,159.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,2.848,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,0.992,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,3.656,Fee Schedule,360% of BCBS POS Rate,361.98,360,,3.656,Fee schedule,360% of BCBS PPO Rate,361.98,360,,3.656,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,1223.072,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,38.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,103.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,945,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,28,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,100.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,1260,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
REMOVAL SUBQ RHYTHM MONITOR,46108478,CDM,480,RC,33286,HCPCS,Outpatient,,,3283.71,1970.23,,2601,100,,0.176,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,20.872,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,919.44,28,,58.144,Percent of Total Billed Charges,28% of Total Billed Charges,0.94,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1182.14,36,,74.752,Percent of Total Billed Charges,36% of Total Billed Charges,1182.14,36,,74.752,Percent of Total Billed Charges,36% Total Bille Charges,1182.14,36,,74.752,Percent of Total Billed Charges,36% of Total Billed Charges,1970.23,60,,2105.76,Percent of Total Billed Charges,60% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,30.672,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,473.51,14.42,,1833.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2462.78,75,,497.048,Percent of Total Billed Charges,75% of Total Billed Charges,1641.86,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,1641.86,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1641.86,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,1641.86,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,132.192,Case Rate,Pays based on per visit rate,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,459.72,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3283.71,100,,662.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.94,3283.71,
INS SUBQ CAR RHYTHM MONITOR,46108479,CDM,480,RC,33285,HCPCS,Outpatient,,,7286.83,4372.10,,2601,100,,0.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,11691.68,150,,178.16,Fee Schedule ,150% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2040.31,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,0.94,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,2623.26,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,2623.26,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,2623.26,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,4372.1,60,,896.976,Percent of Total Billed Charges,60% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7794.46,100,,15.84,Fee Schedule,100% of CMS OPPS Rate,7015,90,,,Fee Schedule,90% of CMS OPPS Rate,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10132.79,130,,,Fee Schedule,130% of CMS OPPS Rate,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1050.76,14.42,,1833.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,8028.28,103,,,Fee Schedule,103% of CMS OPPS Rate,8028.28,103,,,Fee Schedule,103% of CMS OPPS Rate,5465.12,75,,174,Percent of Total Billed Charges,75% of Total Billed Charges,3643.42,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,3643.42,50,,338.104,Percent of Total Billed Charges,50% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,3643.42,50,,338.104,Percent of Total Billed Charges,50% of Total Billed Charges,3643.42,50,,117.432,Percent of Total Billed Charges,50% of Total Billed Charges,11691.68,150,,,Fee Schedule,150% of CMS OPPS Rate,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,1.512,Case Rate,Pays based on per visit rate,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,1020.16,14,,1780.32,Percent of Total Billed Charges,14% of Total Billed Charges,7794.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7286.83,100,,232,Percent of Total Billed Charges,100% of Total Billed Charges,0.94,11691.68,
IVUS CORONARY LC INI,46108480,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,0.376,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,268.792,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,1,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,345.584,Fee Schedule,360% of BCBS POS Rate,361.98,360,,345.584,Fee schedule,360% of BCBS PPO Rate,361.98,360,,345.584,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,1784.776,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,38.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,2750.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,0.776,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2670.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
IVUS CORONARY RC INI,46108481,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,0.4,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,1.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,1,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,0.024,Fee Schedule,360% of BCBS POS Rate,361.98,360,,0.024,Fee schedule,360% of BCBS PPO Rate,361.98,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,1859.296,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,1.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,1484.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,5226,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,338.104,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,0.064,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,6968,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
IVUS CORONARY LM INI,46108482,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,0.592,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,30.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,1,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,0.024,Fee Schedule,360% of BCBS POS Rate,361.98,360,,0.024,Fee schedule,360% of BCBS PPO Rate,361.98,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,1784.776,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,355.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,1484.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,56.632,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1.432,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,1441.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,75.504,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
IVUS CORONARY RI INI,46108483,CDM,481,RC,92978,HCPCS,Outpatient,,,6035.09,3621.05,,123.96,100,,1.616,Fee Schedule,100% of Aetna Fee Schedule,2715.79,45,,0.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.54,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,321.76,320,,1,Fee Schedule,320% of BCBS Blue Essentials Rate,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,361.98,360,,0.024,Fee Schedule,360% of BCBS POS Rate,361.98,360,,0.024,Fee schedule,360% of BCBS PPO Rate,361.98,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,11330,60,,2105.76,Percent of Total Billed Charges,60% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6035.09,100,,46.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,870.26,14.42,,2227.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4526.32,75,,279.064,Percent of Total Billed Charges,75% of Total Billed Charges,3017.55,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3017.55,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,3017.55,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,5069.512,Fee Schedule,100% of ASC Tier Groupings fee schedule,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,844.91,14,,2162.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6035.09,100,,372.08,Percent of Total Billed Charges,100% of Total Billed Charges,123.96,11330,
PERICARDIOCENTESIS W/ IMAGING,46108484,CDM,361,RC,33016,HCPCS,Outpatient,,,2949.74,1769.84,,209.72,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,70.376,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,59.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.95,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,76.016,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,76.016,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,76.016,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,1160.36,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,395.904,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,425.35,14.42,,3419.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2212.31,75,,38.848,Percent of Total Billed Charges,75% of Total Billed Charges,1474.87,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,1474.87,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.87,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1474.87,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,154.568,Fee Schedule,100% of ASC Tier Groupings fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.74,100,,51.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.95,5252.24,
PRCRD DRG 6YR+ W/O CGEN CAR,46108485,CDM,361,RC,33017,HCPCS,Outpatient,,,2949.74,1769.84,,1020,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,2949.74,100,,44.832,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,596.2,233,,0.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.95,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,823.93,322,,0.32,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,823.93,322,,0.32,Fee schedule,Pays based on ASC Tier Groupings fee schedule,823.93,322,,0.32,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,4744.848,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,0.112,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,425.35,14.42,,3419.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2212.31,75,,218.616,Percent of Total Billed Charges,75% of Total Billed Charges,1474.87,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,1474.87,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1474.87,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1474.87,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,27.336,Fee Schedule,100% of ASC Tier Groupings fee schedule,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,412.96,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,2949.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.74,100,,291.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.95,3862.5,
PERCEPTA CRTP MRI SURESCAN,46108486,CDM,275,RC,,,Outpatient,,,20725.61,12435.37,,22798.17,110,,2.52,Percent of Total Billed Charges,110% of Total Billed Charges,9326.52,45,,1.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5803.17,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,6428.19,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,7461.22,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,7461.22,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,7461.22,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,11399.09,55,,3615.128,Percent of Total Billed Charges,55% Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20725.61,100,,4.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2988.63,14.42,,202.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15544.21,75,,603,Percent of Total Billed Charges,75% of Total Billed Charges,10362.81,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,10362.81,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10362.81,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,10362.81,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14507.93,70,,0.584,Percent of Total Billed Charges,70% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,2901.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20725.61,100,,804,Percent of Total Billed Charges,100% of Total Billed Charges,2901.59,22798.17,
DIAMONDBACK 360,46120051,CDM,272,RC,C1724,HCPCS,Outpatient,,,8827,5296.20,,525.82,100,,0.528,Fee Schedule,100% of Aetna Fee Schedule,3972.15,45,,3.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2471.56,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,6446.41,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,3177.72,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,3177.72,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,3177.72,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,5296.2,60,,1859.296,Percent of Total Billed Charges,60% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827,100,,67.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1272.85,14.42,,28.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,75,,2710.4,Percent of Total Billed Charges,75% of Total Billed Charges,4413.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4413.5,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6178.9,70,,88.2,Percent of Total Billed Charges,70% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8827,100,,3388,Percent of Total Billed Charges,100% of Total Billed Charges,525.82,8827,
WIRE GUIDE AMPLA,46120101,CDM,272,RC,C1769,HCPCS,Outpatient,,,213.25,127.95,,55.13,100,,1.04,Fee Schedule,100% of Aetna Fee Schedule,95.96,45,,0.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.71,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,6446.41,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,76.77,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,76.77,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,76.77,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,127.95,60,,1784.776,Percent of Total Billed Charges,60% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.25,100,,1.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,30.75,14.42,,242.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.94,75,,662.456,Percent of Total Billed Charges,75% of Total Billed Charges,106.63,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,106.63,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.63,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,106.63,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.28,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,29.86,14,,235.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.25,100,,828.072,Percent of Total Billed Charges,100% of Total Billed Charges,29.86,6446.41,
WIRE CHOICE PT .,46120200,CDM,272,RC,C1769,HCPCS,Outpatient,,,355.08,213.05,,55.13,100,,8.352,Fee Schedule,100% of Aetna Fee Schedule,159.79,45,,0.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.42,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,6542.4,32,,1,Percent of Total Billed Charges,32% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,127.83,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,127.83,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,127.83,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,213.05,60,,2105.76,Percent of Total Billed Charges,60% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.08,100,,156.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14.42,,28.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.31,75,,141.088,Percent of Total Billed Charges,75% of Total Billed Charges,177.54,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,177.54,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.54,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,177.54,50,,233.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.56,70,,272.104,Percent of Total Billed Charges,70% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.08,100,,188.12,Percent of Total Billed Charges,100% of Total Billed Charges,49.71,6542.4,
BALLOON MUSTANG,46120234,CDM,272,RC,C1725,HCPCS,Outpatient,,,1218.25,730.95,,99.47,100,,0.472,Fee Schedule,100% of Aetna Fee Schedule,548.21,45,,4.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,28,,1.264,Percent of Total Billed Charges,28% of Total Billed Charges,6592.64,32,,1.008,Percent of Total Billed Charges,32% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,438.57,36,,1.624,Percent of Total Billed Charges,36% of Total Billed Charges,438.57,36,,1.624,Percent of Total Billed Charges,36% Total Bille Charges,438.57,36,,1.624,Percent of Total Billed Charges,36% of Total Billed Charges,730.95,60,,1859.296,Percent of Total Billed Charges,60% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1218.25,100,,99.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,175.67,14.42,,389.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,913.69,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,609.13,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609.13,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,609.13,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,70,,40.872,Percent of Total Billed Charges,70% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,170.56,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1218.25,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,6592.64,
STENT VISION RX/,46120259,CDM,278,RC,C1876,HCPCS,Outpatient,,,1949.2,1169.52,,3575.87,110,,3.112,Percent of Total Billed Charges,110% of Total Billed Charges,877.14,45,,1.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.78,28,,0.648,Percent of Total Billed Charges,28% of Total Billed Charges,6632.2,32,,1.008,Percent of Total Billed Charges,32% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,701.71,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,701.71,36,,0.832,Percent of Total Billed Charges,36% Total Bille Charges,701.71,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,1072.06,55,,1859.296,Percent of Total Billed Charges,55% Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1949.2,100,,3.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,281.07,14.42,,453.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1559.36,80,,1344,Percent of Total Billed Charges,80% of Total Billed Charges,974.6,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,974.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,974.6,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1364.44,70,,14.832,Percent of Total Billed Charges,70% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,272.89,14,,440.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.2,100,,1680,Percent of Total Billed Charges,100% of Total Billed Charges,272.89,6632.2,
BALLOON IAB ARRO,46120317,CDM,272,RC,,,Outpatient,,,2394,1436.40,,1436.4,60,,1.512,Percent of Total Billed Charges,60% of Total Billed Charges,1077.3,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,670.32,28,,0.456,Percent of Total Billed Charges,28% of Total Billed Charges,6.45,32,,1.008,Percent of Total Billed Charges,32% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,861.84,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,861.84,36,,0.592,Percent of Total Billed Charges,36% Total Bille Charges,861.84,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,1436.4,60,,1784.776,Percent of Total Billed Charges,60% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2394,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,345.21,14.42,,75.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1795.5,75,,5226,Percent of Total Billed Charges,75% of Total Billed Charges,1197,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,1197,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1197,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,1197,50,,338.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1675.8,70,,13.912,Percent of Total Billed Charges,70% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,335.16,14,,73.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2394,100,,6968,Percent of Total Billed Charges,100% of Total Billed Charges,6.45,2394,
WIRE COR GUIGANT,46120325,CDM,272,RC,C1769,HCPCS,Outpatient,,,375,225.00,,55.13,100,,0.048,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,11.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,0.224,Percent of Total Billed Charges,28% of Total Billed Charges,6.51,32,,1.016,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,0.288,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,1784.776,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,6.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,3876.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,2412.8,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,7.6,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,3016,Percent of Total Billed Charges,100% of Total Billed Charges,6.51,375,
BALLOON POWERFLE,46120341,CDM,272,RC,C1725,HCPCS,Outpatient,,,572.88,343.73,,99.47,100,,0.072,Fee Schedule,100% of Aetna Fee Schedule,257.8,45,,13.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.41,28,,82.016,Percent of Total Billed Charges,28% of Total Billed Charges,6.51,32,,1.016,Percent of Total Billed Charges,32% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,206.24,36,,105.448,Percent of Total Billed Charges,36% of Total Billed Charges,206.24,36,,105.448,Percent of Total Billed Charges,36% Total Bille Charges,206.24,36,,105.448,Percent of Total Billed Charges,36% of Total Billed Charges,343.73,60,,2105.76,Percent of Total Billed Charges,60% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,572.88,100,,1.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,82.61,14.42,,3876.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,429.66,75,,4672.2,Percent of Total Billed Charges,75% of Total Billed Charges,286.44,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,286.44,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,286.44,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,286.44,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.02,70,,44.328,Percent of Total Billed Charges,70% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,80.2,14,,3763.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,572.88,100,,6229.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.51,572.88,
CUTTING BALLOON,46120374,CDM,272,RC,C1725,HCPCS,Outpatient,,,2332.7,1399.62,,99.47,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,1049.72,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,653.16,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,6.53,32,,7735.696,Percent of Total Billed Charges,32% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,839.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,839.77,36,,0.616,Percent of Total Billed Charges,36% Total Bille Charges,839.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,1399.62,60,,2105.76,Percent of Total Billed Charges,60% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2332.7,100,,1.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,336.38,14.42,,6102.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1749.53,75,,765,Percent of Total Billed Charges,75% of Total Billed Charges,1166.35,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,1166.35,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1166.35,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,1166.35,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1632.89,70,,16.832,Percent of Total Billed Charges,70% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,326.58,14,,5924.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2332.7,100,,1020,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,2332.7,
BALLOON CODA COO,46120465,CDM,272,RC,C2628,HCPCS,Outpatient,,,2158.74,1295.24,,560,100,,8.216,Fee Schedule,100% of Aetna Fee Schedule,971.43,45,,2.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,604.45,28,,2.688,Percent of Total Billed Charges,28% of Total Billed Charges,6.59,32,,7812.224,Percent of Total Billed Charges,32% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,777.15,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,777.15,36,,3.456,Percent of Total Billed Charges,36% Total Bille Charges,777.15,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,1295.24,60,,2282.272,Percent of Total Billed Charges,60% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2158.74,100,,9.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,311.29,14.42,,3419.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1619.06,75,,757.848,Percent of Total Billed Charges,75% of Total Billed Charges,1079.37,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,1079.37,50,,1248.896,Percent of Total Billed Charges,50% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1079.37,50,,1248.896,Percent of Total Billed Charges,50% of Total Billed Charges,1079.37,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1511.12,70,,17.808,Percent of Total Billed Charges,70% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,302.22,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2158.74,100,,947.312,Percent of Total Billed Charges,100% of Total Billed Charges,6.59,2158.74,
BALLOON COYOTE 1,46120549,CDM,272,RC,C1725,HCPCS,Outpatient,,,780,468.00,,99.47,100,,8.216,Fee Schedule,100% of Aetna Fee Schedule,351,45,,15.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.4,28,,0.184,Percent of Total Billed Charges,28% of Total Billed Charges,6.61,32,,7831.296,Percent of Total Billed Charges,32% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,280.8,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,280.8,36,,0.232,Percent of Total Billed Charges,36% Total Bille Charges,280.8,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,468,60,,3163.232,Percent of Total Billed Charges,60% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780,100,,4.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,112.48,14.42,,3419.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585,75,,3424.2,Percent of Total Billed Charges,75% of Total Billed Charges,390,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,390,50,,941.4,Percent of Total Billed Charges,50% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390,50,,941.4,Percent of Total Billed Charges,50% of Total Billed Charges,390,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546,70,,90.6,Percent of Total Billed Charges,70% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,109.2,14,,3319.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780,100,,4565.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.61,780,
BALLOON COYOTE >,46120556,CDM,272,RC,C1725,HCPCS,Outpatient,,,975,585.00,,99.47,100,,0.68,Fee Schedule,100% of Aetna Fee Schedule,438.75,45,,51.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,4.784,Percent of Total Billed Charges,28% of Total Billed Charges,6.68,32,,7831.296,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,6.152,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,6.152,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,6.152,Percent of Total Billed Charges,36% of Total Billed Charges,585,60,,1185.6,Percent of Total Billed Charges,60% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,5128.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,731.25,75,,5296.2,Percent of Total Billed Charges,75% of Total Billed Charges,487.5,50,,1248.896,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,903.48,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,903.48,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,1.544,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,4979.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,7061.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.68,975,
CATH SWAN GANZ 7,46120655,CDM,272,RC,C1725,HCPCS,Outpatient,,,364.93,218.96,,99.47,100,,2.136,Fee Schedule,100% of Aetna Fee Schedule,164.22,45,,1.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.18,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,6.7,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,131.37,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,131.37,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,131.37,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,218.96,60,,1185.6,Percent of Total Billed Charges,60% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.93,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.62,14.42,,4452.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.7,75,,2371.6,Percent of Total Billed Charges,75% of Total Billed Charges,182.47,50,,941.4,Percent of Total Billed Charges,50% of Total Billed Charges,182.47,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.47,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,182.47,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.45,70,,0.592,Percent of Total Billed Charges,70% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.09,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.93,100,,2964.504,Percent of Total Billed Charges,100% of Total Billed Charges,6.7,364.93,
SHEATH INTRO 45C,46120671,CDM,272,RC,C1894,HCPCS,Outpatient,,,365.73,219.44,,82.29,100,,0.992,Fee Schedule,100% of Aetna Fee Schedule,164.58,45,,6.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,131.66,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,131.66,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,131.66,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,219.44,60,,1337.032,Percent of Total Billed Charges,60% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,365.73,100,,24.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.74,14.42,,4452.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.3,75,,105,Percent of Total Billed Charges,75% of Total Billed Charges,182.87,50,,903.48,Percent of Total Billed Charges,50% of Total Billed Charges,182.87,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.87,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,182.87,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.01,70,,585.808,Percent of Total Billed Charges,70% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,51.2,14,,4323.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.73,100,,140,Percent of Total Billed Charges,100% of Total Billed Charges,51.2,365.73,
GUARDWIRE EXPORT,46120697,CDM,272,RC,C1757,HCPCS,Outpatient,,,1481.85,889.11,,16.33,100,,1.008,Fee Schedule,100% of Aetna Fee Schedule,666.83,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.92,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,533.47,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,533.47,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,533.47,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,889.11,60,,1337.032,Percent of Total Billed Charges,60% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1481.85,100,,30.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,213.68,14.42,,6679.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1111.39,75,,314.824,Percent of Total Billed Charges,75% of Total Billed Charges,740.93,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,740.93,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,740.93,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,740.93,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.3,70,,367.808,Percent of Total Billed Charges,70% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,207.46,14,,6484.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1481.85,100,,419.76,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,1481.85,
CATH ANGIOJET SO,46120713,CDM,272,RC,C1757,HCPCS,Outpatient,,,3965,2379.00,,16.33,100,,1.52,Fee Schedule,100% of Aetna Fee Schedule,1784.25,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1110.2,28,,0.984,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,1427.4,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,1427.4,36,,1.264,Percent of Total Billed Charges,36% Total Bille Charges,1427.4,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,2379,60,,411.52,Percent of Total Billed Charges,60% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3965,100,,0.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,571.75,14.42,,2842.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2973.75,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,1982.5,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,1982.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1982.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,1982.5,50,,207.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2775.5,70,,45.376,Percent of Total Billed Charges,70% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,555.1,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3965,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,3965,
GUIDE WIRE ANG .,46120754,CDM,272,RC,C1769,HCPCS,Outpatient,,,254,152.40,,55.13,100,,0.808,Fee Schedule,100% of Aetna Fee Schedule,114.3,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.12,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,91.44,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,91.44,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,91.44,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,152.4,60,,3276.96,Percent of Total Billed Charges,60% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254,100,,5.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.63,14.42,,2842.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.5,75,,967.776,Percent of Total Billed Charges,75% of Total Billed Charges,127,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,127,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,127,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.8,70,,165.144,Percent of Total Billed Charges,70% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,2759.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254,100,,1290.368,Percent of Total Billed Charges,100% of Total Billed Charges,35.56,254,
CATH ANGIO VERT,46120788,CDM,272,RC,C1725,HCPCS,Outpatient,,,76,45.60,,99.47,100,,2.8,Fee Schedule,100% of Aetna Fee Schedule,34.2,45,,0.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.28,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.36,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,27.36,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,27.36,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,45.6,60,,1615.832,Percent of Total Billed Charges,60% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76,100,,34.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.96,14.42,,4551.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,75,,1080,Percent of Total Billed Charges,75% of Total Billed Charges,38,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,38,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,38,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,70,,7.984,Percent of Total Billed Charges,70% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,4419.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76,100,,1440,Percent of Total Billed Charges,100% of Total Billed Charges,10.64,99.47,
GUIDE WIRE BMW,46120812,CDM,272,RC,C1769,HCPCS,Outpatient,,,375,225.00,,55.13,100,,1.976,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,4.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,4.712,Percent of Total Billed Charges,28% of Total Billed Charges,64,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,6.056,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,6.056,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,6.056,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,3243.904,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,35.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1305,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,109.976,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,34.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1740,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,375,
CATH SIM2 ANGIOG,46120838,CDM,272,RC,C1725,HCPCS,Outpatient,,,113,67.80,,99.47,100,,2,Fee Schedule,100% of Aetna Fee Schedule,50.85,45,,24.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.64,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,64.19,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,40.68,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,40.68,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,40.68,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,67.8,60,,2898.464,Percent of Total Billed Charges,60% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113,100,,113.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,16.29,14.42,,192.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.75,75,,1152,Percent of Total Billed Charges,75% of Total Billed Charges,56.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.1,70,,287.2,Percent of Total Billed Charges,70% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,186.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113,100,,1440,Percent of Total Billed Charges,100% of Total Billed Charges,15.82,113,
BALLOON SYMMETRY,46120846,CDM,272,RC,C1725,HCPCS,Outpatient,,,840,504.00,,99.47,100,,0.352,Fee Schedule,100% of Aetna Fee Schedule,378,45,,24.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.2,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,64.39,32,,7860.672,Percent of Total Billed Charges,32% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,302.4,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,302.4,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,302.4,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,504,60,,1626.28,Percent of Total Billed Charges,60% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,840,100,,3.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,121.13,14.42,,1609.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630,75,,1181.216,Percent of Total Billed Charges,75% of Total Billed Charges,420,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,420,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,420,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,588,70,,5.36,Percent of Total Billed Charges,70% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,117.6,14,,1563.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,100,,1574.952,Percent of Total Billed Charges,100% of Total Billed Charges,64.39,840,
SHEATH INTRO PIN,46120879,CDM,272,RC,C1894,HCPCS,Outpatient,,,60,36.00,,82.29,100,,31.616,Fee Schedule,100% of Aetna Fee Schedule,27,45,,30.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.8,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,64.39,32,,7.68,Percent of Total Billed Charges,32% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,21.6,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,21.6,36,,0.488,Percent of Total Billed Charges,36% Total Bille Charges,21.6,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,36,60,,910.552,Percent of Total Billed Charges,60% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.65,14.42,,5128.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,75,,5952.64,Percent of Total Billed Charges,75% of Total Billed Charges,30,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,30,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,30,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,70,,7.112,Percent of Total Billed Charges,70% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60,100,,7440.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.4,82.29,
WIRE GUIDE PLAT,46120887,CDM,272,RC,C1769,HCPCS,Outpatient,,,449.85,269.91,,55.13,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,202.43,45,,521.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.96,28,,18.272,Percent of Total Billed Charges,28% of Total Billed Charges,64.39,32,,7.696,Percent of Total Billed Charges,32% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,161.95,36,,23.488,Percent of Total Billed Charges,36% of Total Billed Charges,161.95,36,,23.488,Percent of Total Billed Charges,36% Total Bille Charges,161.95,36,,23.488,Percent of Total Billed Charges,36% of Total Billed Charges,269.91,60,,1539.856,Percent of Total Billed Charges,60% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.85,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,64.87,14.42,,5128.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.39,75,,860.056,Percent of Total Billed Charges,75% of Total Billed Charges,224.93,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,224.93,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.93,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,224.93,50,,1248.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.9,70,,145.352,Percent of Total Billed Charges,70% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,62.98,14,,4979.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,449.85,100,,1146.744,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,449.85,
SHEATH INTRO PIN,46120903,CDM,272,RC,C1894,HCPCS,Outpatient,,,134,80.40,,82.29,100,,0.6,Fee Schedule,100% of Aetna Fee Schedule,60.3,45,,1.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.52,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,64.53,32,,7.728,Percent of Total Billed Charges,32% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,48.24,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,48.24,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,48.24,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,80.4,60,,775.36,Percent of Total Billed Charges,60% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,100,,15.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14.42,,180.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.5,75,,20400,Percent of Total Billed Charges,75% of Total Billed Charges,67,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,67,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,67,50,,941.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.8,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134,100,,27200,Percent of Total Billed Charges,100% of Total Billed Charges,18.76,134,
WIRE GUIDE ANGLE,46120911,CDM,272,RC,C1769,HCPCS,Outpatient,,,254,152.40,,55.13,100,,0.696,Fee Schedule,100% of Aetna Fee Schedule,114.3,45,,0.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.12,28,,2.768,Percent of Total Billed Charges,28% of Total Billed Charges,64.61,32,,7.808,Percent of Total Billed Charges,32% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,91.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,91.44,36,,3.552,Percent of Total Billed Charges,36% Total Bille Charges,91.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,152.4,60,,2523.36,Percent of Total Billed Charges,60% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,36.63,14.42,,180.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.5,75,,4368,Percent of Total Billed Charges,75% of Total Billed Charges,127,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,127,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,127,50,,903.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.8,70,,671.976,Percent of Total Billed Charges,70% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.56,14,,175.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254,100,,5824,Percent of Total Billed Charges,100% of Total Billed Charges,35.56,254,
WIRE GUIDE MAGIC,46120929,CDM,272,RC,C1769,HCPCS,Outpatient,,,351.4,210.84,,55.13,100,,0.704,Fee Schedule,100% of Aetna Fee Schedule,158.13,45,,10.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.39,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,64.9,32,,7.84,Percent of Total Billed Charges,32% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,126.5,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,126.5,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,126.5,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,210.84,60,,910.552,Percent of Total Billed Charges,60% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.4,100,,5.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,50.67,14.42,,187.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.55,75,,5710.32,Percent of Total Billed Charges,75% of Total Billed Charges,175.7,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,175.7,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.7,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175.7,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.98,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.4,100,,7613.76,Percent of Total Billed Charges,100% of Total Billed Charges,49.2,351.4,
STENT SMART CONT,46121026,CDM,278,RC,C1876,HCPCS,Outpatient,,,3161.67,1897.00,,4909.59,110,,53.864,Percent of Total Billed Charges,110% of Total Billed Charges,1422.75,45,,9.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885.27,28,,0.904,Percent of Total Billed Charges,28% of Total Billed Charges,64.99,32,,7.84,Percent of Total Billed Charges,32% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,1138.2,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,1138.2,36,,1.168,Percent of Total Billed Charges,36% Total Bille Charges,1138.2,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,1738.92,55,,1036.44,Percent of Total Billed Charges,55% Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3161.67,100,,0.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,455.91,14.42,,187.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2529.34,80,,150,Percent of Total Billed Charges,80% of Total Billed Charges,1580.84,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,1580.84,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1580.84,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,1580.84,50,,200.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2213.17,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,442.63,14,,181.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3161.67,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,64.99,4909.59,
GUIDE WIRE DOC E,46121067,CDM,272,RC,C1769,HCPCS,Outpatient,,,332.68,199.61,,55.13,100,,4.744,Fee Schedule,100% of Aetna Fee Schedule,149.71,45,,0.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.15,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,65,32,,7.84,Percent of Total Billed Charges,32% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,119.76,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,119.76,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,119.76,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,199.61,60,,2606.36,Percent of Total Billed Charges,60% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.68,100,,1.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,47.97,14.42,,152.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.51,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,166.34,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,166.34,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.34,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,166.34,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.88,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,46.58,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,332.68,100,,132,Percent of Total Billed Charges,100% of Total Billed Charges,46.58,332.68,
DEVICE CLOSURE A,46121109,CDM,278,RC,C1760,HCPCS,Outpatient,,,600,360.00,,774.86,110,,4,Percent of Total Billed Charges,110% of Total Billed Charges,270,45,,95.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,65.28,32,,7.84,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,330,55,,21339.208,Percent of Total Billed Charges,55% Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,8.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,152.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480,80,,20400,Percent of Total Billed Charges,80% of Total Billed Charges,300,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,147.808,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,27200,Percent of Total Billed Charges,100% of Total Billed Charges,65.28,774.86,
COIL NESTER EMBO,46121158,CDM,278,RC,C1884,HCPCS,Outpatient,,,375,225.00,,549.35,110,,87.408,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,1.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,65.28,32,,7.864,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,54.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,152.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,15600,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,0.624,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,147.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,20800,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,549.35,
STENT MINI VISIO,46121240,CDM,278,RC,C1876,HCPCS,Outpatient,,,1510.63,906.38,,3093.44,110,,1.768,Percent of Total Billed Charges,110% of Total Billed Charges,679.78,45,,9.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.98,28,,0.304,Percent of Total Billed Charges,28% of Total Billed Charges,65.5,32,,7.904,Percent of Total Billed Charges,32% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,543.83,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,543.83,36,,0.392,Percent of Total Billed Charges,36% Total Bille Charges,543.83,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,830.85,55,,25101.272,Percent of Total Billed Charges,55% Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1510.63,100,,54.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,217.83,14.42,,481.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1208.5,80,,14280,Percent of Total Billed Charges,80% of Total Billed Charges,755.32,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,755.32,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,755.32,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,755.32,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1057.44,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1510.63,100,,19040,Percent of Total Billed Charges,100% of Total Billed Charges,65.5,3093.44,
STENT RESOLUTE I,46121257,CDM,278,RC,C1874,HCPCS,Outpatient,,,4082,2449.20,,4982.61,110,,11.384,Percent of Total Billed Charges,110% of Total Billed Charges,1836.9,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.96,28,,3.576,Percent of Total Billed Charges,28% of Total Billed Charges,65.67,32,,7.912,Percent of Total Billed Charges,32% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,1469.52,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,1469.52,36,,4.6,Percent of Total Billed Charges,36% Total Bille Charges,1469.52,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,2245.1,55,,12400.992,Percent of Total Billed Charges,55% Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4082,100,,67.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,588.62,14.42,,481.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3265.6,80,,15600,Percent of Total Billed Charges,80% of Total Billed Charges,2041,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,2041,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2041,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,2041,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2857.4,70,,0.16,Percent of Total Billed Charges,70% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,571.48,14,,467.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4082,100,,20800,Percent of Total Billed Charges,100% of Total Billed Charges,65.67,4982.61,
GUIDE CATH LAUNC,46121299,CDM,272,RC,C1887,HCPCS,Outpatient,,,227.27,136.36,,43.86,100,,0.224,Fee Schedule,100% of Aetna Fee Schedule,102.27,45,,4.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.64,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,65.67,32,,7.928,Percent of Total Billed Charges,32% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,81.82,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,81.82,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,81.82,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,136.36,60,,12400.992,Percent of Total Billed Charges,60% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.27,100,,1159.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,32.77,14.42,,722.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.45,75,,153.6,Percent of Total Billed Charges,75% of Total Billed Charges,113.64,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,113.64,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.64,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,113.64,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.09,70,,0.368,Percent of Total Billed Charges,70% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,31.82,14,,701.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.27,100,,204.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.82,227.27,
GUIDE CATH CORDI,46121331,CDM,272,RC,C1887,HCPCS,Outpatient,,,298.95,179.37,,43.86,100,,2.24,Fee Schedule,100% of Aetna Fee Schedule,134.53,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.71,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,65.84,32,,7.928,Percent of Total Billed Charges,32% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,107.62,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,107.62,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,107.62,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,179.37,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.95,100,,3.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,43.11,14.42,,271.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.21,75,,4970.368,Percent of Total Billed Charges,75% of Total Billed Charges,149.48,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,149.48,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.48,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,149.48,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.27,70,,0.04,Percent of Total Billed Charges,70% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,41.85,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.95,100,,6627.152,Percent of Total Billed Charges,100% of Total Billed Charges,41.85,298.95,
CATH DX 6FR MULT,46121349,CDM,272,RC,C1887,HCPCS,Outpatient,,,150,90.00,,43.86,100,,0.408,Fee Schedule,100% of Aetna Fee Schedule,67.5,45,,131.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,65.92,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,0.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,271.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,828,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,3.152,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,263.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,1104,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
SNARE GOOSENECK,46121356,CDM,272,RC,C1773,HCPCS,Outpatient,,,1315.71,789.43,,70,100,,1.032,Fee Schedule,100% of Aetna Fee Schedule,592.07,45,,25.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,368.4,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,66.07,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,473.66,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,473.66,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,473.66,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,789.43,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1315.71,100,,23.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,189.73,14.42,,407.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,986.78,75,,153.6,Percent of Total Billed Charges,75% of Total Billed Charges,657.86,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,657.86,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.86,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,657.86,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,921,70,,1.616,Percent of Total Billed Charges,70% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,395.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1315.71,100,,204.8,Percent of Total Billed Charges,100% of Total Billed Charges,66.07,1315.71,
CATH ANGIO SOS O,46121372,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,78.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,66.07,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,22.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,150.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,7175.4,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,1.152,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,9567.2,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
WIRE SPARTACORE,46121455,CDM,272,RC,C1769,HCPCS,Outpatient,,,320.76,192.46,,55.13,100,,12.72,Fee Schedule,100% of Aetna Fee Schedule,144.34,45,,44.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.81,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,66.07,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,115.47,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,115.47,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,115.47,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,192.46,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.76,100,,2.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,46.25,14.42,,294.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.57,75,,5580.6,Percent of Total Billed Charges,75% of Total Billed Charges,160.38,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,160.38,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.38,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,160.38,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.53,70,,0.568,Percent of Total Billed Charges,70% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.91,14,,285.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.76,100,,7440.8,Percent of Total Billed Charges,100% of Total Billed Charges,44.91,320.76,
COIL MICRO TORNA,46121521,CDM,278,RC,C1884,HCPCS,Outpatient,,,445,267.00,,626.35,110,,12.096,Percent of Total Billed Charges,110% of Total Billed Charges,200.25,45,,33.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.6,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,66.07,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,160.2,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,160.2,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,160.2,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445,100,,211.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,64.17,14.42,,150.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356,80,,1374,Percent of Total Billed Charges,80% of Total Billed Charges,222.5,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,222.5,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.5,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,222.5,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.5,70,,800.8,Percent of Total Billed Charges,70% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.3,14,,145.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,445,100,,1832,Percent of Total Billed Charges,100% of Total Billed Charges,62.3,626.35,
FILTER VENA CAVE,46121554,CDM,278,RC,C1880,HCPCS,Outpatient,,,4235,2541.00,,4703.34,110,,1.272,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,40.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,66.08,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,244.32,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,3.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,445.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,153.6,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,205.04,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,204.8,Percent of Total Billed Charges,100% of Total Billed Charges,66.08,4703.34,
CATH DIAG IMPULS,46121596,CDM,272,RC,C1887,HCPCS,Outpatient,,,133.2,79.92,,43.86,100,,2.928,Fee Schedule,100% of Aetna Fee Schedule,59.94,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.3,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,66.76,32,,76.8,Percent of Total Billed Charges,32% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,47.95,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,47.95,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,47.95,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,79.92,60,,244.32,Percent of Total Billed Charges,60% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.2,100,,21.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,19.21,14.42,,445.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.9,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,66.6,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,66.6,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.6,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,66.6,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.24,70,,1.192,Percent of Total Billed Charges,70% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.65,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.2,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,18.65,133.2,
AMPLATZ ECTRA ST,46121612,CDM,278,RC,C1769,HCPCS,Outpatient,,,168.1,100.86,,240.04,110,,0.84,Percent of Total Billed Charges,110% of Total Billed Charges,75.65,45,,7.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.07,28,,8.928,Percent of Total Billed Charges,28% of Total Billed Charges,66.76,32,,76.808,Percent of Total Billed Charges,32% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,60.52,36,,11.472,Percent of Total Billed Charges,36% of Total Billed Charges,60.52,36,,11.472,Percent of Total Billed Charges,36% Total Bille Charges,60.52,36,,11.472,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.1,100,,2.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,24.24,14.42,,667.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.48,80,,3986.4,Percent of Total Billed Charges,80% of Total Billed Charges,84.05,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,84.05,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.05,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,84.05,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.67,70,,6.712,Percent of Total Billed Charges,70% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.1,100,,5315.2,Percent of Total Billed Charges,100% of Total Billed Charges,23.53,240.04,
WIRE ASAHI MIRAC,46121646,CDM,272,RC,C1769,HCPCS,Outpatient,,,377.1,226.26,,55.13,100,,4.92,Fee Schedule,100% of Aetna Fee Schedule,169.7,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.59,28,,11.04,Percent of Total Billed Charges,28% of Total Billed Charges,66.76,32,,77.152,Percent of Total Billed Charges,32% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,135.76,36,,14.192,Percent of Total Billed Charges,36% of Total Billed Charges,135.76,36,,14.192,Percent of Total Billed Charges,36% Total Bille Charges,135.76,36,,14.192,Percent of Total Billed Charges,36% of Total Billed Charges,226.26,60,,6287.872,Percent of Total Billed Charges,60% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,377.1,100,,9.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,54.38,14.42,,175.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.83,75,,855,Percent of Total Billed Charges,75% of Total Billed Charges,188.55,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,188.55,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.55,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,188.55,50,,177.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.97,70,,0.456,Percent of Total Billed Charges,70% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,52.79,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,377.1,100,,1140,Percent of Total Billed Charges,100% of Total Billed Charges,52.79,377.1,
547867 PROGLIDE CLOSURE SYSTEM,46121653,CDM,278,RC,C1760,HCPCS,Outpatient,,,1062.31,637.39,,1283.4,110,,13.064,Percent of Total Billed Charges,110% of Total Billed Charges,478.04,45,,43.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.45,28,,11.312,Percent of Total Billed Charges,28% of Total Billed Charges,66.76,32,,77.68,Percent of Total Billed Charges,32% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,382.43,36,,14.544,Percent of Total Billed Charges,36% of Total Billed Charges,382.43,36,,14.544,Percent of Total Billed Charges,36% Total Bille Charges,382.43,36,,14.544,Percent of Total Billed Charges,36% of Total Billed Charges,584.27,55,,1734.928,Percent of Total Billed Charges,55% Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1062.31,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,153.19,14.42,,263.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,849.85,80,,646.16,Percent of Total Billed Charges,80% of Total Billed Charges,531.16,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,531.16,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.16,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,531.16,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.62,70,,11.96,Percent of Total Billed Charges,70% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,148.72,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1062.31,100,,861.544,Percent of Total Billed Charges,100% of Total Billed Charges,66.76,1283.4,
WIRE ASAHI SOFT,46121679,CDM,272,RC,C1769,HCPCS,Outpatient,,,312.12,187.27,,55.13,100,,1.216,Fee Schedule,100% of Aetna Fee Schedule,140.45,45,,28.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.39,28,,11.912,Percent of Total Billed Charges,28% of Total Billed Charges,66.78,32,,77.76,Percent of Total Billed Charges,32% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,112.36,36,,15.32,Percent of Total Billed Charges,36% of Total Billed Charges,112.36,36,,15.32,Percent of Total Billed Charges,36% Total Bille Charges,112.36,36,,15.32,Percent of Total Billed Charges,36% of Total Billed Charges,187.27,60,,14504.432,Percent of Total Billed Charges,60% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.12,100,,291.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.01,14.42,,263.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.09,75,,5098.504,Percent of Total Billed Charges,75% of Total Billed Charges,156.06,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,156.06,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.06,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,156.06,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.48,70,,0.92,Percent of Total Billed Charges,70% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.7,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.12,100,,6798,Percent of Total Billed Charges,100% of Total Billed Charges,43.7,312.12,
SHEATH PINNACLE,46121778,CDM,272,RC,C1894,HCPCS,Outpatient,,,179,107.40,,82.29,100,,1.816,Fee Schedule,100% of Aetna Fee Schedule,80.55,45,,12.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.12,28,,9.392,Percent of Total Billed Charges,28% of Total Billed Charges,66.88,32,,78.008,Percent of Total Billed Charges,32% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,36,,12.08,Percent of Total Billed Charges,36% of Total Billed Charges,64.44,36,,12.08,Percent of Total Billed Charges,36% Total Bille Charges,64.44,36,,12.08,Percent of Total Billed Charges,36% of Total Billed Charges,107.4,60,,9669.616,Percent of Total Billed Charges,60% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179,100,,57.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.81,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.25,75,,46.768,Percent of Total Billed Charges,75% of Total Billed Charges,89.5,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.5,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.3,70,,0.28,Percent of Total Billed Charges,70% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179,100,,62.352,Percent of Total Billed Charges,100% of Total Billed Charges,25.06,179,
WIRE BENTSON PTF,46121802,CDM,272,RC,C1769,HCPCS,Outpatient,,,113,67.80,,55.13,100,,0.768,Fee Schedule,100% of Aetna Fee Schedule,50.85,45,,14.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.64,28,,23.72,Percent of Total Billed Charges,28% of Total Billed Charges,67.08,32,,78.048,Percent of Total Billed Charges,32% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,40.68,36,,30.496,Percent of Total Billed Charges,36% of Total Billed Charges,40.68,36,,30.496,Percent of Total Billed Charges,36% Total Bille Charges,40.68,36,,30.496,Percent of Total Billed Charges,36% of Total Billed Charges,67.8,60,,9669.616,Percent of Total Billed Charges,60% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113,100,,173.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,16.29,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.75,75,,1116,Percent of Total Billed Charges,75% of Total Billed Charges,56.5,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.1,70,,0.272,Percent of Total Billed Charges,70% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113,100,,1488,Percent of Total Billed Charges,100% of Total Billed Charges,15.82,113,
GUIDEWIRE WHISPE,46121828,CDM,272,RC,C1769,HCPCS,Outpatient,,,481.14,288.68,,55.13,100,,0.8,Fee Schedule,100% of Aetna Fee Schedule,216.51,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.72,28,,24.864,Percent of Total Billed Charges,28% of Total Billed Charges,67.16,32,,78.056,Percent of Total Billed Charges,32% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,173.21,36,,31.968,Percent of Total Billed Charges,36% of Total Billed Charges,173.21,36,,31.968,Percent of Total Billed Charges,36% Total Bille Charges,173.21,36,,31.968,Percent of Total Billed Charges,36% of Total Billed Charges,288.68,60,,897.92,Percent of Total Billed Charges,60% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.14,100,,99.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,69.38,14.42,,331.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.86,75,,15271.2,Percent of Total Billed Charges,75% of Total Billed Charges,240.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.57,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,240.57,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.8,70,,2.456,Percent of Total Billed Charges,70% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,67.36,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.14,100,,20361.6,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,481.14,
CATH OUTBACK RE-,46121901,CDM,272,RC,C2628,HCPCS,Outpatient,,,5621.95,3373.17,,560,100,,1.304,Fee Schedule,100% of Aetna Fee Schedule,2529.88,45,,124.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1574.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,67.18,32,,78.144,Percent of Total Billed Charges,32% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,2023.9,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,2023.9,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,2023.9,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,3373.17,60,,598.416,Percent of Total Billed Charges,60% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5621.95,100,,75.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,810.69,14.42,,175.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4216.46,75,,3322.8,Percent of Total Billed Charges,75% of Total Billed Charges,2810.98,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,2810.98,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2810.98,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,2810.98,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3935.37,70,,1.176,Percent of Total Billed Charges,70% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,787.07,14,,170.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5621.95,100,,4430.4,Percent of Total Billed Charges,100% of Total Billed Charges,67.18,5621.95,
BALLOON TREK ABB,46121927,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,270,45,,14.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,6732.34,32,,78.336,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,943.376,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,91,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,42.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,10539.624,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,13174.528,Percent of Total Billed Charges,100% of Total Billed Charges,84,6732.34,
EMBOLIC PROTECT,46122024,CDM,272,RC,C1884,HCPCS,Outpatient,,,4377.62,2626.57,,136.85,100,,0.992,Fee Schedule,100% of Aetna Fee Schedule,1969.93,45,,256.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1225.73,28,,1.992,Percent of Total Billed Charges,28% of Total Billed Charges,6848,32,,78.336,Percent of Total Billed Charges,32% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,1575.94,36,,2.56,Percent of Total Billed Charges,36% of Total Billed Charges,1575.94,36,,2.56,Percent of Total Billed Charges,36% Total Bille Charges,1575.94,36,,2.56,Percent of Total Billed Charges,36% of Total Billed Charges,2626.57,60,,1185.408,Percent of Total Billed Charges,60% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4377.62,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,631.25,14.42,,42.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3283.22,75,,6552,Percent of Total Billed Charges,75% of Total Billed Charges,2188.81,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,2188.81,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2188.81,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,2188.81,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3064.33,70,,11.768,Percent of Total Billed Charges,70% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,612.87,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4377.62,100,,8736,Percent of Total Billed Charges,100% of Total Billed Charges,136.85,6848,
CORDIS SHEATH 11,46122065,CDM,272,RC,C1766,HCPCS,Outpatient,,,52.5,31.50,,137.47,100,,0.064,Fee Schedule,100% of Aetna Fee Schedule,23.63,45,,5.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,28,,1.952,Percent of Total Billed Charges,28% of Total Billed Charges,6973.02,32,,78.72,Percent of Total Billed Charges,32% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,36,,2.512,Percent of Total Billed Charges,36% of Total Billed Charges,18.9,36,,2.512,Percent of Total Billed Charges,36% Total Bille Charges,18.9,36,,2.512,Percent of Total Billed Charges,36% of Total Billed Charges,31.5,60,,461.344,Percent of Total Billed Charges,60% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,100,,17.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.57,14.42,,122.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.38,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,26.25,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.75,70,,0.232,Percent of Total Billed Charges,70% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,118.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,6973.02,
SHEATH INTRODUCE,46122115,CDM,272,RC,C1894,HCPCS,Outpatient,,,600,360.00,,82.29,100,,1.424,Fee Schedule,100% of Aetna Fee Schedule,270,45,,26.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,6.73,32,,78.856,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,461.344,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,263.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,720,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,278.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,960,Percent of Total Billed Charges,100% of Total Billed Charges,6.73,600,
CATHETER DUAL LU,46122156,CDM,272,RC,C1894,HCPCS,Outpatient,,,600,360.00,,82.29,100,,1.408,Fee Schedule,100% of Aetna Fee Schedule,270,45,,7.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,6.74,32,,78.864,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.264,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,1107.704,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,97.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,313.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2340,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.952,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,304.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,3120,Percent of Total Billed Charges,100% of Total Billed Charges,6.74,600,
BALLOON ANGIOSCO,46122164,CDM,272,RC,C1725,HCPCS,Outpatient,,,2642,1585.20,,99.47,100,,0.696,Fee Schedule,100% of Aetna Fee Schedule,1188.9,45,,55.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,739.76,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,6.78,32,,79.04,Percent of Total Billed Charges,32% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,951.12,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,951.12,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,951.12,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,1585.2,60,,2101.36,Percent of Total Billed Charges,60% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2642,100,,62.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,380.98,14.42,,469.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1981.5,75,,82.8,Percent of Total Billed Charges,75% of Total Billed Charges,1321,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,1321,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1321,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1321,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1849.4,70,,45.672,Percent of Total Billed Charges,70% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,369.88,14,,456.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2642,100,,110.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.78,2642,
FRONTRUNNER CTO,46122198,CDM,272,RC,C2628,HCPCS,Outpatient,,,3048,1828.80,,560,100,,1.16,Fee Schedule,100% of Aetna Fee Schedule,1371.6,45,,88.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,853.44,28,,1.448,Percent of Total Billed Charges,28% of Total Billed Charges,6.84,32,,79.208,Percent of Total Billed Charges,32% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,1097.28,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,1097.28,36,,1.856,Percent of Total Billed Charges,36% Total Bille Charges,1097.28,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,1828.8,60,,2758.56,Percent of Total Billed Charges,60% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3048,100,,26.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,439.52,14.42,,202.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2286,75,,4680,Percent of Total Billed Charges,75% of Total Billed Charges,1524,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,1524,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1524,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1524,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2133.6,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,426.72,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3048,100,,6240,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,3048,
MICRO GUIDE CATH,46122206,CDM,272,RC,C1887,HCPCS,Outpatient,,,858,514.80,,43.86,100,,2.304,Fee Schedule,100% of Aetna Fee Schedule,386.1,45,,88.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.24,28,,0.448,Percent of Total Billed Charges,28% of Total Billed Charges,6.87,32,,79.296,Percent of Total Billed Charges,32% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,308.88,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,308.88,36,,0.576,Percent of Total Billed Charges,36% Total Bille Charges,308.88,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,514.8,60,,3144,Percent of Total Billed Charges,60% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,858,100,,31.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,123.72,14.42,,28.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,643.5,75,,6118.2,Percent of Total Billed Charges,75% of Total Billed Charges,429,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,429,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,429,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,429,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.6,70,,6.912,Percent of Total Billed Charges,70% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,120.12,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,858,100,,8157.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.87,858,
CRAGG-MCNAMARA I,46122248,CDM,272,RC,C1725,HCPCS,Outpatient,,,400,240.00,,99.47,100,,0.768,Fee Schedule,100% of Aetna Fee Schedule,180,45,,126.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112,28,,0.4,Percent of Total Billed Charges,28% of Total Billed Charges,6.89,32,,79.296,Percent of Total Billed Charges,32% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,144,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,144,36,,0.512,Percent of Total Billed Charges,36% Total Bille Charges,144,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,240,60,,3144,Percent of Total Billed Charges,60% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14.42,,44.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,75,,2652,Percent of Total Billed Charges,75% of Total Billed Charges,200,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,200,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,200,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,70,,0.96,Percent of Total Billed Charges,70% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400,100,,3536,Percent of Total Billed Charges,100% of Total Billed Charges,6.89,400,
"TRAY, PERICARDIO",46122305,CDM,272,RC,C1729,HCPCS,Outpatient,,,312,187.20,,11.1,100,,0.128,Fee Schedule,100% of Aetna Fee Schedule,140.4,45,,55.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.36,28,,0.256,Percent of Total Billed Charges,28% of Total Billed Charges,6.91,32,,7936,Percent of Total Billed Charges,32% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,112.32,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,112.32,36,,0.328,Percent of Total Billed Charges,36% Total Bille Charges,112.32,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,187.2,60,,6893.864,Percent of Total Billed Charges,60% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,100,,276.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,44.99,14.42,,44.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,156,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,156,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,156,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.4,70,,2.272,Percent of Total Billed Charges,70% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14,,43.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,6.91,312,
BALLOON SPRINTER,46122347,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,11.28,Fee Schedule,100% of Aetna Fee Schedule,270,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,6.92,32,,7938.328,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,10988.08,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,32.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,57.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,22.304,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,29.736,Percent of Total Billed Charges,100% of Total Billed Charges,6.92,600,
STENT PROTEGE EV,46122537,CDM,278,RC,C1876,HCPCS,Outpatient,,,2481,1488.60,,4160.85,110,,0.136,Percent of Total Billed Charges,110% of Total Billed Charges,1116.45,45,,168.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.68,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,6.92,32,,7938.328,Percent of Total Billed Charges,32% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,893.16,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,893.16,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,893.16,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1364.55,55,,14101.28,Percent of Total Billed Charges,55% Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2481,100,,570.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,357.76,14.42,,57.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1984.8,80,,22.304,Percent of Total Billed Charges,80% of Total Billed Charges,1240.5,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,1240.5,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1240.5,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,1240.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1736.7,70,,0.568,Percent of Total Billed Charges,70% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,347.34,14,,55.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2481,100,,29.736,Percent of Total Billed Charges,100% of Total Billed Charges,6.92,4160.85,
BALLOON CORDIS A,46122610,CDM,272,RC,C1725,HCPCS,Outpatient,,,772,463.20,,99.47,100,,12.096,Fee Schedule,100% of Aetna Fee Schedule,347.4,45,,153.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.16,28,,0.736,Percent of Total Billed Charges,28% of Total Billed Charges,6.93,32,,7.936,Percent of Total Billed Charges,32% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,277.92,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,277.92,36,,0.944,Percent of Total Billed Charges,36% Total Bille Charges,277.92,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,463.2,60,,9400.856,Percent of Total Billed Charges,60% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,772,100,,12.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,111.32,14.42,,46.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579,75,,26.8,Percent of Total Billed Charges,75% of Total Billed Charges,386,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,386,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,386,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.4,70,,0.16,Percent of Total Billed Charges,70% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,772,100,,35.728,Percent of Total Billed Charges,100% of Total Billed Charges,6.93,772,
WIRE CSI VIPERWI,46122636,CDM,272,RC,C1769,HCPCS,Outpatient,,,828.41,497.05,,55.13,100,,7.952,Fee Schedule,100% of Aetna Fee Schedule,372.78,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,28,,1.496,Percent of Total Billed Charges,28% of Total Billed Charges,6.94,32,,7.936,Percent of Total Billed Charges,32% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,298.23,36,,1.928,Percent of Total Billed Charges,36% of Total Billed Charges,298.23,36,,1.928,Percent of Total Billed Charges,36% Total Bille Charges,298.23,36,,1.928,Percent of Total Billed Charges,36% of Total Billed Charges,497.05,60,,9400.856,Percent of Total Billed Charges,60% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.41,100,,58.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,119.46,14.42,,46.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.31,75,,26.8,Percent of Total Billed Charges,75% of Total Billed Charges,414.21,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.21,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.89,70,,0.768,Percent of Total Billed Charges,70% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.41,100,,35.728,Percent of Total Billed Charges,100% of Total Billed Charges,6.94,828.41,
BALLOON PTA BSC,46122651,CDM,272,RC,C1725,HCPCS,Outpatient,,,772,463.20,,99.47,100,,7.952,Fee Schedule,100% of Aetna Fee Schedule,347.4,45,,8.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.16,28,,0.544,Percent of Total Billed Charges,28% of Total Billed Charges,67.2,32,,7.936,Percent of Total Billed Charges,32% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,277.92,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,277.92,36,,0.704,Percent of Total Billed Charges,36% Total Bille Charges,277.92,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,463.2,60,,22108.144,Percent of Total Billed Charges,60% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,772,100,,16.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,111.32,14.42,,46.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579,75,,15600,Percent of Total Billed Charges,75% of Total Billed Charges,386,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,386,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,386,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.4,70,,8.944,Percent of Total Billed Charges,70% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,108.08,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,772,100,,20800,Percent of Total Billed Charges,100% of Total Billed Charges,67.2,772,
PICC CATH POWERP,46122792,CDM,272,RC,C1751,HCPCS,Outpatient,,,1351.35,810.81,,67.66,100,,0.152,Fee Schedule,100% of Aetna Fee Schedule,608.11,45,,54.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.38,28,,8.44,Percent of Total Billed Charges,28% of Total Billed Charges,67.23,32,,7.944,Percent of Total Billed Charges,32% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,486.49,36,,10.856,Percent of Total Billed Charges,36% of Total Billed Charges,486.49,36,,10.856,Percent of Total Billed Charges,36% Total Bille Charges,486.49,36,,10.856,Percent of Total Billed Charges,36% of Total Billed Charges,810.81,60,,14738.76,Percent of Total Billed Charges,60% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1351.35,100,,123.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,194.86,14.42,,46.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1013.51,75,,5460,Percent of Total Billed Charges,75% of Total Billed Charges,675.68,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,675.68,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675.68,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,675.68,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945.95,70,,0.04,Percent of Total Billed Charges,70% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,189.19,14,,45.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1351.35,100,,7280,Percent of Total Billed Charges,100% of Total Billed Charges,67.23,1351.35,
ATRIUM CAST STEN,46122826,CDM,278,RC,C1874,HCPCS,Outpatient,,,5892,3535.20,,6973.61,110,,0.696,Percent of Total Billed Charges,110% of Total Billed Charges,2651.4,45,,62.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1649.76,28,,0.488,Percent of Total Billed Charges,28% of Total Billed Charges,67.38,32,,8.016,Percent of Total Billed Charges,32% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,2121.12,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,2121.12,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,2121.12,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,3240.6,55,,14738.76,Percent of Total Billed Charges,55% Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5892,100,,197.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,849.63,14.42,,59.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4713.6,80,,52.384,Percent of Total Billed Charges,80% of Total Billed Charges,2946,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,2946,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2946,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,2946,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4124.4,70,,126.064,Percent of Total Billed Charges,70% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,824.88,14,,58.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5892,100,,69.84,Percent of Total Billed Charges,100% of Total Billed Charges,67.38,6973.61,
ATRIUM CAST STEN,46122834,CDM,278,RC,C1874,HCPCS,Outpatient,,,6373,3823.80,,7502.71,110,,18.776,Percent of Total Billed Charges,110% of Total Billed Charges,2867.85,45,,26.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1784.44,28,,0.696,Percent of Total Billed Charges,28% of Total Billed Charges,67.87,32,,8.144,Percent of Total Billed Charges,32% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,2294.28,36,,0.888,Percent of Total Billed Charges,36% of Total Billed Charges,2294.28,36,,0.888,Percent of Total Billed Charges,36% Total Bille Charges,2294.28,36,,0.888,Percent of Total Billed Charges,36% of Total Billed Charges,3505.15,55,,3600,Percent of Total Billed Charges,55% Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6373,100,,197.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,918.99,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5098.4,80,,4236.96,Percent of Total Billed Charges,80% of Total Billed Charges,3186.5,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,3186.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3186.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,3186.5,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4461.1,70,,0.032,Percent of Total Billed Charges,70% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,892.22,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6373,100,,5649.28,Percent of Total Billed Charges,100% of Total Billed Charges,67.87,7502.71,
STENT VIABAHN HE,46122909,CDM,278,RC,C1874,HCPCS,Outpatient,,,8697,5218.20,,10059.11,110,,0.096,Percent of Total Billed Charges,110% of Total Billed Charges,3913.65,45,,153.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2435.16,28,,3.432,Percent of Total Billed Charges,28% of Total Billed Charges,67.87,32,,8.16,Percent of Total Billed Charges,32% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,3130.92,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,3130.92,36,,4.416,Percent of Total Billed Charges,36% Total Bille Charges,3130.92,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,4783.35,55,,2400,Percent of Total Billed Charges,55% Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8697,100,,281.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1254.11,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6957.6,80,,3804.912,Percent of Total Billed Charges,80% of Total Billed Charges,4348.5,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,4348.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4348.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,4348.5,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6087.9,70,,0.84,Percent of Total Billed Charges,70% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1217.58,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8697,100,,5073.216,Percent of Total Billed Charges,100% of Total Billed Charges,67.87,10059.11,
STENT VIABAHN HE,46122917,CDM,278,RC,C1874,HCPCS,Outpatient,,,9663,5797.80,,11121.71,110,,0.096,Percent of Total Billed Charges,110% of Total Billed Charges,4348.35,45,,50.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2705.64,28,,3.432,Percent of Total Billed Charges,28% of Total Billed Charges,67.89,32,,79.872,Percent of Total Billed Charges,32% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,3478.68,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,3478.68,36,,4.416,Percent of Total Billed Charges,36% Total Bille Charges,3478.68,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,5314.65,55,,2400,Percent of Total Billed Charges,55% Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9663,100,,123.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1393.4,14.42,,14.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7730.4,80,,11734.576,Percent of Total Billed Charges,80% of Total Billed Charges,4831.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,4831.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4831.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,4831.5,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6764.1,70,,7.4,Percent of Total Billed Charges,70% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,1352.82,14,,13.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9663,100,,15646.096,Percent of Total Billed Charges,100% of Total Billed Charges,67.89,11121.71,
EMBOLIC PROTECT,46122941,CDM,278,RC,C1884,HCPCS,Outpatient,,,4407,2644.20,,4984.55,110,,0.12,Percent of Total Billed Charges,110% of Total Billed Charges,1983.15,45,,18.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1233.96,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,67.89,32,,79.904,Percent of Total Billed Charges,32% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,1586.52,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1586.52,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1586.52,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2423.85,55,,2821.792,Percent of Total Billed Charges,55% Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4407,100,,240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,635.49,14.42,,59.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3525.6,80,,10028.232,Percent of Total Billed Charges,80% of Total Billed Charges,2203.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,2203.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2203.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,2203.5,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3084.9,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,616.98,14,,57.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4407,100,,13370.976,Percent of Total Billed Charges,100% of Total Billed Charges,67.89,4984.55,
WIRE AMPLATZ SUP,46122958,CDM,272,RC,C1769,HCPCS,Outpatient,,,116,69.60,,55.13,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,52.2,45,,14.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.48,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,67.89,32,,80.128,Percent of Total Billed Charges,32% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,41.76,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,41.76,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,69.6,60,,1881.192,Percent of Total Billed Charges,60% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116,100,,373.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.73,14.42,,35.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87,75,,11291.08,Percent of Total Billed Charges,75% of Total Billed Charges,58,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,58,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,58,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,34.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116,100,,15054.776,Percent of Total Billed Charges,100% of Total Billed Charges,16.24,116,
HEMOSTASIS BAND,46122974,CDM,272,RC,,,Outpatient,,,295,177.00,,177,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,132.75,45,,23.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.6,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,67.89,32,,80.128,Percent of Total Billed Charges,32% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,106.2,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,106.2,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,106.2,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,177,60,,1881.192,Percent of Total Billed Charges,60% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295,100,,340.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,42.54,14.42,,13.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.25,75,,2792.752,Percent of Total Billed Charges,75% of Total Billed Charges,147.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,147.5,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.5,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,147.5,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.5,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,41.3,14,,13.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295,100,,3723.664,Percent of Total Billed Charges,100% of Total Billed Charges,41.3,295,
PACING BALLOON L,46123022,CDM,272,RC,C1769,HCPCS,Outpatient,,,412,247.20,,55.13,100,,0.192,Fee Schedule,100% of Aetna Fee Schedule,185.4,45,,307.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.36,28,,2.056,Percent of Total Billed Charges,28% of Total Billed Charges,67.89,32,,80.128,Percent of Total Billed Charges,32% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,148.32,36,,2.64,Percent of Total Billed Charges,36% of Total Billed Charges,148.32,36,,2.64,Percent of Total Billed Charges,36% Total Bille Charges,148.32,36,,2.64,Percent of Total Billed Charges,36% of Total Billed Charges,247.2,60,,2830.928,Percent of Total Billed Charges,60% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14.42,,93.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,75,,2843.576,Percent of Total Billed Charges,75% of Total Billed Charges,206,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,206,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,206,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.4,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14,,90.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,412,100,,3791.432,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,412,
WIRE VOLCANO SMA,46123071,CDM,272,RC,C1769,HCPCS,Outpatient,,,1575,945.00,,55.13,100,,4.432,Fee Schedule,100% of Aetna Fee Schedule,708.75,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,441,28,,27.184,Percent of Total Billed Charges,28% of Total Billed Charges,68,32,,80.128,Percent of Total Billed Charges,32% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,567,36,,34.952,Percent of Total Billed Charges,36% of Total Billed Charges,567,36,,34.952,Percent of Total Billed Charges,36% Total Bille Charges,567,36,,34.952,Percent of Total Billed Charges,36% of Total Billed Charges,945,60,,2902.592,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1575,100,,18.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,227.12,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1181.25,75,,15120.928,Percent of Total Billed Charges,75% of Total Billed Charges,787.5,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,787.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,787.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,787.5,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1102.5,70,,0.016,Percent of Total Billed Charges,70% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,100,,20161.24,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,1575,
OCCLUDER SEPTAL,46123121,CDM,278,RC,C1817,HCPCS,Outpatient,,,13000,7800.00,,19978.91,110,,0.256,Percent of Total Billed Charges,110% of Total Billed Charges,5850,45,,20.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,28,,6.208,Percent of Total Billed Charges,28% of Total Billed Charges,68.08,32,,80.136,Percent of Total Billed Charges,32% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,4680,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,4680,36,,7.984,Percent of Total Billed Charges,36% Total Bille Charges,4680,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,7150,55,,1786.856,Percent of Total Billed Charges,55% Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000,100,,121.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1874.6,14.42,,46.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10400,80,,8984.312,Percent of Total Billed Charges,80% of Total Billed Charges,6500,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6500,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,6500,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,1820,14,,44.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,100,,11979.08,Percent of Total Billed Charges,100% of Total Billed Charges,68.08,19978.91,
STENT COMPLETE S,46123139,CDM,278,RC,C1876,HCPCS,Outpatient,,,2250,1350.00,,3906.75,110,,0.536,Percent of Total Billed Charges,110% of Total Billed Charges,1012.5,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,11.096,Percent of Total Billed Charges,28% of Total Billed Charges,68.18,32,,80.488,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,14.264,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,14.264,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,14.264,Percent of Total Billed Charges,36% of Total Billed Charges,1237.5,55,,1191.24,Percent of Total Billed Charges,55% Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,100,,138.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,80,,23511.28,Percent of Total Billed Charges,80% of Total Billed Charges,1125,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,22.312,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,31348.376,Percent of Total Billed Charges,100% of Total Billed Charges,68.18,3906.75,
DIAMONDBACK SC 3,46123147,CDM,272,RC,C1724,HCPCS,Outpatient,,,7787,4672.20,,525.82,100,,1.144,Fee Schedule,100% of Aetna Fee Schedule,3504.15,45,,15.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2180.36,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,68.24,32,,80.536,Percent of Total Billed Charges,32% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,2803.32,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,2803.32,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,2803.32,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,4672.2,60,,448.36,Percent of Total Billed Charges,60% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7787,100,,58.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1122.89,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5840.25,75,,940.2,Percent of Total Billed Charges,75% of Total Billed Charges,3893.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3893.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5450.9,70,,27.6,Percent of Total Billed Charges,70% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7787,100,,1253.6,Percent of Total Billed Charges,100% of Total Billed Charges,68.24,7787,
BALLOON EV3 EVER,46123154,CDM,272,RC,C1725,HCPCS,Outpatient,,,380,228.00,,99.47,100,,0.36,Fee Schedule,100% of Aetna Fee Schedule,171,45,,91.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,68.65,32,,80.64,Percent of Total Billed Charges,32% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,136.8,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,136.8,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,136.8,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,228,60,,448.36,Percent of Total Billed Charges,60% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380,100,,342,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.8,14.42,,55.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285,75,,940.2,Percent of Total Billed Charges,75% of Total Billed Charges,190,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,70,,28.28,Percent of Total Billed Charges,70% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380,100,,1253.6,Percent of Total Billed Charges,100% of Total Billed Charges,53.2,380,
WALLSTENT BOS SC,46123162,CDM,278,RC,C1876,HCPCS,Outpatient,,,2800,1680.00,,4511.75,110,,0.36,Percent of Total Billed Charges,110% of Total Billed Charges,1260,45,,27,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784,28,,42.096,Percent of Total Billed Charges,28% of Total Billed Charges,68.88,32,,80.744,Percent of Total Billed Charges,32% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,1008,36,,54.12,Percent of Total Billed Charges,36% of Total Billed Charges,1008,36,,54.12,Percent of Total Billed Charges,36% Total Bille Charges,1008,36,,54.12,Percent of Total Billed Charges,36% of Total Billed Charges,1540,55,,1113.6,Percent of Total Billed Charges,55% Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2800,100,,112.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,403.76,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2240,80,,14366.84,Percent of Total Billed Charges,80% of Total Billed Charges,1400,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,1400,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1960,70,,29.784,Percent of Total Billed Charges,70% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,392,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2800,100,,19155.784,Percent of Total Billed Charges,100% of Total Billed Charges,68.88,4511.75,
WIRE AMPLATZER G,46123188,CDM,272,RC,C1769,HCPCS,Outpatient,,,225,135.00,,55.13,100,,0.728,Fee Schedule,100% of Aetna Fee Schedule,101.25,45,,93.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,28,,40.776,Percent of Total Billed Charges,28% of Total Billed Charges,69.12,32,,80.792,Percent of Total Billed Charges,32% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,81,36,,52.424,Percent of Total Billed Charges,36% of Total Billed Charges,81,36,,52.424,Percent of Total Billed Charges,36% Total Bille Charges,81,36,,52.424,Percent of Total Billed Charges,36% of Total Billed Charges,135,60,,1474.456,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,100,,40.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,32.45,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.75,75,,14647.8,Percent of Total Billed Charges,75% of Total Billed Charges,112.5,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,70,,23.488,Percent of Total Billed Charges,70% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225,100,,19530.4,Percent of Total Billed Charges,100% of Total Billed Charges,31.5,225,
MICROPUNCTURE VA,46123204,CDM,272,RC,C1894,HCPCS,Outpatient,,,145,87.00,,82.29,100,,0.84,Fee Schedule,100% of Aetna Fee Schedule,65.25,45,,54.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,28,,65.056,Percent of Total Billed Charges,28% of Total Billed Charges,69.35,32,,80.792,Percent of Total Billed Charges,32% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,36,,83.64,Percent of Total Billed Charges,36% of Total Billed Charges,52.2,36,,83.64,Percent of Total Billed Charges,36% Total Bille Charges,52.2,36,,83.64,Percent of Total Billed Charges,36% of Total Billed Charges,87,60,,1179.168,Percent of Total Billed Charges,60% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145,100,,32.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.91,14.42,,43.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.75,75,,25029.416,Percent of Total Billed Charges,75% of Total Billed Charges,72.5,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,72.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,72.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.5,70,,59.296,Percent of Total Billed Charges,70% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,20.3,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145,100,,33372.552,Percent of Total Billed Charges,100% of Total Billed Charges,20.3,145,
WIRE RUNTHROUGH,46123212,CDM,272,RC,C1769,HCPCS,Outpatient,,,427.68,256.61,,55.13,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,192.46,45,,5.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.75,28,,162.416,Percent of Total Billed Charges,28% of Total Billed Charges,69.64,32,,80.792,Percent of Total Billed Charges,32% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,153.96,36,,208.824,Percent of Total Billed Charges,36% of Total Billed Charges,153.96,36,,208.824,Percent of Total Billed Charges,36% Total Bille Charges,153.96,36,,208.824,Percent of Total Billed Charges,36% of Total Billed Charges,256.61,60,,1179.168,Percent of Total Billed Charges,60% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.68,100,,51.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,61.67,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.76,75,,25029.416,Percent of Total Billed Charges,75% of Total Billed Charges,213.84,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.84,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,213.84,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.38,70,,62.168,Percent of Total Billed Charges,70% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,59.88,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.68,100,,33372.552,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,427.68,
CATHETER TURBO B,46123220,CDM,272,RC,C1887,HCPCS,Outpatient,,,1575,945.00,,43.86,100,,0.296,Fee Schedule,100% of Aetna Fee Schedule,708.75,45,,7.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,441,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,69.7,32,,80.792,Percent of Total Billed Charges,32% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,567,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,567,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,567,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,945,60,,1107.704,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1575,100,,684,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,227.12,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1181.25,75,,24089.104,Percent of Total Billed Charges,75% of Total Billed Charges,787.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,787.5,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,787.5,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,787.5,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1102.5,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,220.5,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,100,,32118.808,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1575,
BALLOON NANOCROS,46123303,CDM,272,RC,C1725,HCPCS,Outpatient,,,828.41,497.05,,99.47,100,,0.184,Fee Schedule,100% of Aetna Fee Schedule,372.78,45,,15.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,28,,0.648,Percent of Total Billed Charges,28% of Total Billed Charges,69.87,32,,80.792,Percent of Total Billed Charges,32% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,298.23,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,298.23,36,,0.832,Percent of Total Billed Charges,36% Total Bille Charges,298.23,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,497.05,60,,2164.176,Percent of Total Billed Charges,60% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.41,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,119.46,14.42,,8.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.31,75,,56.704,Percent of Total Billed Charges,75% of Total Billed Charges,414.21,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.89,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.41,100,,75.6,Percent of Total Billed Charges,100% of Total Billed Charges,69.87,828.41,
WIRE VSI TRU-TOR,46123360,CDM,272,RC,C1769,HCPCS,Outpatient,,,290,174.00,,55.13,100,,0.272,Fee Schedule,100% of Aetna Fee Schedule,130.5,45,,62.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,70.11,32,,80.912,Percent of Total Billed Charges,32% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,104.4,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,104.4,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,104.4,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,174,60,,2164.176,Percent of Total Billed Charges,60% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290,100,,46.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,41.82,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.5,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,145,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,145,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,145,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203,70,,4.976,Percent of Total Billed Charges,70% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,40.6,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,40.6,290,
HEMOSTASIS BAND,46123378,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,1.68,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,41.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,70.11,32,,80.912,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,43.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,4.88,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,42.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
CATH TURBOHAWK E,46123493,CDM,272,RC,C1714,HCPCS,Outpatient,,,8710,5226.00,,389.94,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,3919.5,45,,25.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2438.8,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,70.11,32,,80.928,Percent of Total Billed Charges,32% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,3135.6,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,3135.6,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,3135.6,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,5226,60,,340.488,Percent of Total Billed Charges,60% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8710,100,,35.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1255.98,14.42,,438.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6532.5,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,4355,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4355,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6097,70,,0.424,Percent of Total Billed Charges,70% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,425.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8710,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,70.11,8710,
HEMOSTASIS VALVE,46123501,CDM,272,RC,,,Outpatient,,,94.38,56.63,,56.63,60,,0.976,Percent of Total Billed Charges,60% of Total Billed Charges,42.47,45,,31,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.43,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,70.24,32,,80.936,Percent of Total Billed Charges,32% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,33.98,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,33.98,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,56.63,60,,448.36,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,100,,204.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,14.42,,439.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.79,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,47.19,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.19,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,47.19,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.07,70,,0.512,Percent of Total Billed Charges,70% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,13.21,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.38,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,13.21,94.38,
CATH EMBOL FOGAR,46123519,CDM,272,RC,C1757,HCPCS,Outpatient,,,465.1,279.06,,16.33,100,,0.44,Fee Schedule,100% of Aetna Fee Schedule,209.3,45,,51.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.23,28,,1.592,Percent of Total Billed Charges,28% of Total Billed Charges,70.24,32,,81.128,Percent of Total Billed Charges,32% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,167.44,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,167.44,36,,2.048,Percent of Total Billed Charges,36% Total Bille Charges,167.44,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,279.06,60,,448.36,Percent of Total Billed Charges,60% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.1,100,,60,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,67.07,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.83,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,232.55,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,232.55,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.55,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,232.55,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.57,70,,0.544,Percent of Total Billed Charges,70% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465.1,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,16.33,465.1,
PERICARDIOCENTES,46123535,CDM,272,RC,,,Outpatient,,,64.75,38.85,,38.85,60,,0.328,Percent of Total Billed Charges,60% of Total Billed Charges,29.14,45,,87.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.13,28,,0.768,Percent of Total Billed Charges,28% of Total Billed Charges,7040,32,,81.48,Percent of Total Billed Charges,32% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,23.31,36,,0.984,Percent of Total Billed Charges,36% Total Bille Charges,23.31,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,38.85,60,,767.384,Percent of Total Billed Charges,60% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.75,100,,207.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.34,14.42,,102.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.56,75,,93.48,Percent of Total Billed Charges,75% of Total Billed Charges,32.38,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,32.38,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.38,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,32.38,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.33,70,,0.912,Percent of Total Billed Charges,70% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,14,,99.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.75,100,,124.64,Percent of Total Billed Charges,100% of Total Billed Charges,9.07,7040,
FLEXIMA NEPHRO C,46123550,CDM,272,RC,C1729,HCPCS,Outpatient,,,364.36,218.62,,11.1,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,163.96,45,,211.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.02,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,7090.88,32,,81.48,Percent of Total Billed Charges,32% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,131.17,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,131.17,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,131.17,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,218.62,60,,767.384,Percent of Total Billed Charges,60% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.36,100,,120.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,52.54,14.42,,316.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.27,75,,118.648,Percent of Total Billed Charges,75% of Total Billed Charges,182.18,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,182.18,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.18,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,182.18,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.05,70,,3.616,Percent of Total Billed Charges,70% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,51.01,14,,307.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.36,100,,158.2,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,7090.88,
BALLOON PTA BARD,46123584,CDM,272,RC,C1725,HCPCS,Outpatient,,,1005,603.00,,99.47,100,,0.376,Fee Schedule,100% of Aetna Fee Schedule,452.25,45,,72.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.4,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,7120,32,,81.744,Percent of Total Billed Charges,32% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,361.8,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,361.8,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,361.8,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,603,60,,384.016,Percent of Total Billed Charges,60% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1005,100,,11.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,144.92,14.42,,226.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,753.75,75,,311.352,Percent of Total Billed Charges,75% of Total Billed Charges,502.5,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,502.5,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.5,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,502.5,50,,124.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.5,70,,1.12,Percent of Total Billed Charges,70% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,140.7,14,,219.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1005,100,,389.192,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,7120,
VENA CAVA FILTER,46123659,CDM,278,RC,C1880,HCPCS,Outpatient,,,4235,2541.00,,4703.34,110,,0.12,Percent of Total Billed Charges,110% of Total Billed Charges,1905.75,45,,33.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1185.8,28,,0.504,Percent of Total Billed Charges,28% of Total Billed Charges,7182.88,32,,81.744,Percent of Total Billed Charges,32% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,1524.6,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,1524.6,36,,0.648,Percent of Total Billed Charges,36% Total Bille Charges,1524.6,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,2329.25,55,,384.016,Percent of Total Billed Charges,55% Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,100,,17.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,610.69,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388,80,,50.184,Percent of Total Billed Charges,80% of Total Billed Charges,2117.5,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2117.5,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,2117.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2964.5,70,,1,Percent of Total Billed Charges,70% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,592.9,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4235,100,,66.912,Percent of Total Billed Charges,100% of Total Billed Charges,592.9,7182.88,
GERSHONG CV CATH,46123691,CDM,278,RC,,,Outpatient,,,1035.09,621.05,,1138.6,110,,0.144,Percent of Total Billed Charges,110% of Total Billed Charges,465.79,45,,11.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.83,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,7325.39,32,,81.744,Percent of Total Billed Charges,32% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,372.63,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,372.63,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,372.63,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,569.3,55,,428.992,Percent of Total Billed Charges,55% Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1035.09,100,,34.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,149.26,14.42,,306.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.07,80,,73.8,Percent of Total Billed Charges,80% of Total Billed Charges,517.55,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,517.55,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.55,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,517.55,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.56,70,,0.632,Percent of Total Billed Charges,70% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,144.91,14,,297.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.09,100,,98.4,Percent of Total Billed Charges,100% of Total Billed Charges,144.91,7325.39,
CATHETER GUIDE L,46123717,CDM,272,RC,C1887,HCPCS,Outpatient,,,235.15,141.09,,43.86,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,105.82,45,,191.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.84,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,7.08,32,,81.744,Percent of Total Billed Charges,32% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,84.65,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,84.65,36,,0.272,Percent of Total Billed Charges,36% Total Bille Charges,84.65,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,141.09,60,,7629.952,Percent of Total Billed Charges,60% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.15,100,,138.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.91,14.42,,15.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.36,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,117.58,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,117.58,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.58,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,117.58,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.61,70,,0.152,Percent of Total Billed Charges,70% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.92,14,,14.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.15,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,7.08,235.15,
CATHETER RADIAL,46123725,CDM,272,RC,C1725,HCPCS,Outpatient,,,150,90.00,,99.47,100,,1.024,Fee Schedule,100% of Aetna Fee Schedule,67.5,45,,18.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,7.1,32,,8256.768,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,0.272,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,7629.952,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,92.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,1.64,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,7.1,150,
STENT INTEGRITY,46123741,CDM,278,RC,C1876,HCPCS,Outpatient,,,2100,1260.00,,3741.75,110,,4.456,Percent of Total Billed Charges,110% of Total Billed Charges,945,45,,757.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,588,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,7.17,32,,8266.368,Percent of Total Billed Charges,32% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,756,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,756,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,756,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,1155,55,,11444.936,Percent of Total Billed Charges,55% Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2100,100,,57.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,302.82,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1680,80,,119.104,Percent of Total Billed Charges,80% of Total Billed Charges,1050,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,1050,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,1050,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1470,70,,1.832,Percent of Total Billed Charges,70% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,294,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,100,,158.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.17,3741.75,
ATHRECTOMY CUTTE,46123766,CDM,272,RC,C1714,HCPCS,Outpatient,,,8710,5226.00,,389.94,100,,6.768,Fee Schedule,100% of Aetna Fee Schedule,3919.5,45,,42.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2438.8,28,,0.496,Percent of Total Billed Charges,28% of Total Billed Charges,7.25,32,,8.192,Percent of Total Billed Charges,32% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,3135.6,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,3135.6,36,,0.64,Percent of Total Billed Charges,36% Total Bille Charges,3135.6,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,5226,60,,6177.92,Percent of Total Billed Charges,60% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8710,100,,68.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1255.98,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6532.5,75,,120.36,Percent of Total Billed Charges,75% of Total Billed Charges,4355,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4355,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,4355,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6097,70,,3.744,Percent of Total Billed Charges,70% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,1219.4,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8710,100,,160.48,Percent of Total Billed Charges,100% of Total Billed Charges,7.25,8710,
STENT XIENCE DES,46123790,CDM,278,RC,C1874,HCPCS,Outpatient,,,3770,2262.00,,4639.41,110,,3.248,Percent of Total Billed Charges,110% of Total Billed Charges,1696.5,45,,16.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1055.6,28,,1.544,Percent of Total Billed Charges,28% of Total Billed Charges,7.25,32,,8.2,Percent of Total Billed Charges,32% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1357.2,36,,1.984,Percent of Total Billed Charges,36% of Total Billed Charges,1357.2,36,,1.984,Percent of Total Billed Charges,36% Total Bille Charges,1357.2,36,,1.984,Percent of Total Billed Charges,36% of Total Billed Charges,2073.5,55,,6177.92,Percent of Total Billed Charges,55% Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3770,100,,115.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,543.63,14.42,,36.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3016,80,,125.968,Percent of Total Billed Charges,80% of Total Billed Charges,1885,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,1885,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1885,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,1885,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2639,70,,1.368,Percent of Total Billed Charges,70% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,527.8,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3770,100,,167.96,Percent of Total Billed Charges,100% of Total Billed Charges,7.25,4639.41,
ATHERECTOMY SYS,46124012,CDM,272,RC,C1724,HCPCS,Outpatient,,,7787,4672.20,,525.82,100,,0.264,Fee Schedule,100% of Aetna Fee Schedule,3504.15,45,,42.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2180.36,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,7.32,32,,8.224,Percent of Total Billed Charges,32% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,2803.32,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,2803.32,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,2803.32,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,4672.2,60,,9266.88,Percent of Total Billed Charges,60% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7787,100,,194.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1122.89,14.42,,36.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5840.25,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,3893.5,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3893.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,3893.5,50,,558.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5450.9,70,,21.104,Percent of Total Billed Charges,70% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,1090.18,14,,35.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7787,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.32,7787,
CATH THROMBECTOM,46124038,CDM,272,RC,C1757,HCPCS,Outpatient,,,1275,765.00,,16.33,100,,0.376,Fee Schedule,100% of Aetna Fee Schedule,573.75,45,,28.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,357,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,7.34,32,,8.32,Percent of Total Billed Charges,32% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,459,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,459,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,459,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,765,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1275,100,,469.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,183.86,14.42,,821.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,956.25,75,,164.28,Percent of Total Billed Charges,75% of Total Billed Charges,637.5,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,637.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,637.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,637.5,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,892.5,70,,1.224,Percent of Total Billed Charges,70% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,178.5,14,,798,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1275,100,,219.04,Percent of Total Billed Charges,100% of Total Billed Charges,7.34,1275,
COIL EMBOSPHERE,46124087,CDM,278,RC,,,Outpatient,,,1184.14,710.48,,1302.55,110,,0.408,Percent of Total Billed Charges,110% of Total Billed Charges,532.86,45,,28.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.56,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,7.34,32,,8.344,Percent of Total Billed Charges,32% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,426.29,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,426.29,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,426.29,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,651.28,55,,14226.136,Percent of Total Billed Charges,55% Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1184.14,100,,162.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,170.75,14.42,,547.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,947.31,80,,149.552,Percent of Total Billed Charges,80% of Total Billed Charges,592.07,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,592.07,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,592.07,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,592.07,50,,257.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.9,70,,1.728,Percent of Total Billed Charges,70% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,165.78,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1184.14,100,,199.4,Percent of Total Billed Charges,100% of Total Billed Charges,7.34,1302.55,
CATHETER CTO CRO,46124095,CDM,272,RC,C1714,HCPCS,Outpatient,,,5707,3424.20,,389.94,100,,0.408,Fee Schedule,100% of Aetna Fee Schedule,2568.15,45,,2.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1597.96,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,7.35,32,,8.352,Percent of Total Billed Charges,32% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,2054.52,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,2054.52,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,2054.52,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,3424.2,60,,117.184,Percent of Total Billed Charges,60% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5707,100,,75.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,822.95,14.42,,547.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4280.25,75,,29.488,Percent of Total Billed Charges,75% of Total Billed Charges,2853.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,2853.5,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2853.5,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,2853.5,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3994.9,70,,8.576,Percent of Total Billed Charges,70% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,798.98,14,,532,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5707,100,,39.312,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,5707,
ATHERECTOMY SYS,46124186,CDM,272,RC,C1724,HCPCS,Outpatient,,,8827,5296.20,,525.82,100,,0.304,Fee Schedule,100% of Aetna Fee Schedule,3972.15,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2471.56,28,,22.728,Percent of Total Billed Charges,28% of Total Billed Charges,7.35,32,,8.368,Percent of Total Billed Charges,32% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,3177.72,36,,29.224,Percent of Total Billed Charges,36% of Total Billed Charges,3177.72,36,,29.224,Percent of Total Billed Charges,36% Total Bille Charges,3177.72,36,,29.224,Percent of Total Billed Charges,36% of Total Billed Charges,5296.2,60,,117.184,Percent of Total Billed Charges,60% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827,100,,25.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1272.85,14.42,,786.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,75,,31.504,Percent of Total Billed Charges,75% of Total Billed Charges,4413.5,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4413.5,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,4413.5,50,,333.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6178.9,70,,8.584,Percent of Total Billed Charges,70% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,1235.78,14,,763.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8827,100,,42,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,8827,
STENT HERCULINK,46124210,CDM,278,RC,C1876,HCPCS,Outpatient,,,3705.63,2223.38,,5507.94,110,,1.04,Percent of Total Billed Charges,110% of Total Billed Charges,1667.53,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1037.58,28,,1.88,Percent of Total Billed Charges,28% of Total Billed Charges,70.4,32,,8.384,Percent of Total Billed Charges,32% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,1334.03,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,1334.03,36,,2.416,Percent of Total Billed Charges,36% Total Bille Charges,1334.03,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,2038.1,55,,314.312,Percent of Total Billed Charges,55% Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3705.63,100,,425.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,534.35,14.42,,524.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2964.5,80,,31.504,Percent of Total Billed Charges,80% of Total Billed Charges,1852.82,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,1852.82,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1852.82,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,1852.82,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2593.94,70,,2.2,Percent of Total Billed Charges,70% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,518.79,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3705.63,100,,42,Percent of Total Billed Charges,100% of Total Billed Charges,70.4,5507.94,
SHEATH GLIDESHEA,46124251,CDM,272,RC,C1894,HCPCS,Outpatient,,,175,105.00,,82.29,100,,1.432,Fee Schedule,100% of Aetna Fee Schedule,78.75,45,,55.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,28,,1.184,Percent of Total Billed Charges,28% of Total Billed Charges,70.74,32,,8.416,Percent of Total Billed Charges,32% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,63,36,,1.52,Percent of Total Billed Charges,36% of Total Billed Charges,63,36,,1.52,Percent of Total Billed Charges,36% Total Bille Charges,63,36,,1.52,Percent of Total Billed Charges,36% of Total Billed Charges,105,60,,16128.088,Percent of Total Billed Charges,60% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,100,,41.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,25.24,14.42,,524.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.25,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,87.5,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,154.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.5,70,,0.688,Percent of Total Billed Charges,70% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,509.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,24.5,175,
HEMODIALYSIS CAT,46124285,CDM,272,RC,C1752,HCPCS,Outpatient,,,524.7,314.82,,6,100,,1.272,Fee Schedule,100% of Aetna Fee Schedule,236.12,45,,207.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.92,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,70.74,32,,8.416,Percent of Total Billed Charges,32% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,188.89,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,188.89,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,188.89,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,314.82,60,,16128.088,Percent of Total Billed Charges,60% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,524.7,100,,1683.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,75.66,14.42,,579.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.53,75,,146.488,Percent of Total Billed Charges,75% of Total Billed Charges,262.35,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,262.35,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.35,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,262.35,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.29,70,,0.904,Percent of Total Billed Charges,70% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,73.46,14,,562.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,524.7,100,,195.32,Percent of Total Billed Charges,100% of Total Billed Charges,6,524.7,
BALLOON FOX SV 2,46124301,CDM,272,RC,C1725,HCPCS,Outpatient,,,600,360.00,,99.47,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,270,45,,18.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,70.88,32,,8.448,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,25392.136,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,94.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,386.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,320,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,5.144,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,70.88,600,
EN SNARE ENDOVAS,46124350,CDM,272,RC,C1773,HCPCS,Outpatient,,,1612.96,967.78,,70,100,,0.096,Fee Schedule,100% of Aetna Fee Schedule,725.83,45,,67.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.63,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,71.04,32,,8.448,Percent of Total Billed Charges,32% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,580.67,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,580.67,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,580.67,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,967.78,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1612.96,100,,36.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,232.59,14.42,,386.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1209.72,75,,256.68,Percent of Total Billed Charges,75% of Total Billed Charges,806.48,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,806.48,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,806.48,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,806.48,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1129.07,70,,67.96,Percent of Total Billed Charges,70% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,225.81,14,,374.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1612.96,100,,342.24,Percent of Total Billed Charges,100% of Total Billed Charges,70,1612.96,
WIRE VOLCANO SMA,46124384,CDM,272,RC,C1769,HCPCS,Outpatient,,,1800,1080.00,,55.13,100,,0.128,Fee Schedule,100% of Aetna Fee Schedule,810,45,,116.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,504,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,71.04,32,,82.112,Percent of Total Billed Charges,32% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,648,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,648,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,648,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,1080,60,,14226.136,Percent of Total Billed Charges,60% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,100,,93.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,259.56,14.42,,923.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1350,75,,312,Percent of Total Billed Charges,75% of Total Billed Charges,900,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,900,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,900,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,900,50,,285.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260,70,,15.52,Percent of Total Billed Charges,70% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,416,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,1800,
VOLCANO IVUS CAT,46124392,CDM,272,RC,C1753,HCPCS,Outpatient,,,2175,1305.00,,85.94,100,,0.104,Fee Schedule,100% of Aetna Fee Schedule,978.75,45,,275.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,609,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,71.09,32,,82.112,Percent of Total Billed Charges,32% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,783,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,783,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,783,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,1305,60,,21339.208,Percent of Total Billed Charges,60% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2175,100,,64.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,313.64,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1631.25,75,,1996.8,Percent of Total Billed Charges,75% of Total Billed Charges,1087.5,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,1087.5,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1087.5,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,1087.5,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1522.5,70,,27.736,Percent of Total Billed Charges,70% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,304.5,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2175,100,,2496,Percent of Total Billed Charges,100% of Total Billed Charges,71.09,2175,
IR COIL INTERLOCK .035 4-10CM,46124405,CDM,278,RC,C1884,HCPCS,Outpatient,,,1800,1080.00,,2116.85,110,,0.536,Percent of Total Billed Charges,110% of Total Billed Charges,810,45,,54.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,504,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,71.12,32,,82.176,Percent of Total Billed Charges,32% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,648,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,648,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,648,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,990,55,,18528.088,Percent of Total Billed Charges,55% Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,100,,64.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,259.56,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440,80,,489.64,Percent of Total Billed Charges,80% of Total Billed Charges,900,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,900,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,900,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,900,50,,337.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260,70,,0.152,Percent of Total Billed Charges,70% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,252,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,612.048,Percent of Total Billed Charges,100% of Total Billed Charges,71.12,2116.85,
MICROCATHETER CANTATA,46124406,CDM,272,RC,C1887,HCPCS,Outpatient,,,1968.69,1181.21,,43.86,100,,81.864,Fee Schedule,100% of Aetna Fee Schedule,885.91,45,,45.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,551.23,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,71.14,32,,82.232,Percent of Total Billed Charges,32% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,708.73,36,,0.552,Percent of Total Billed Charges,36% of Total Billed Charges,708.73,36,,0.552,Percent of Total Billed Charges,36% Total Bille Charges,708.73,36,,0.552,Percent of Total Billed Charges,36% of Total Billed Charges,1181.21,60,,18528.088,Percent of Total Billed Charges,60% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1968.69,100,,6.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,283.89,14.42,,923.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1476.52,75,,161.824,Percent of Total Billed Charges,75% of Total Billed Charges,984.35,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,984.35,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,984.35,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,984.35,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1378.08,70,,0.232,Percent of Total Billed Charges,70% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,275.62,14,,896.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1968.69,100,,215.76,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,1968.69,
EVENT RECORDER 9526 REVEAL PLU,46160004,CDM,278,RC,C1764,HCPCS,Outpatient,,,9301,5580.60,,13582.6,110,,95.992,Percent of Total Billed Charges,110% of Total Billed Charges,4185.45,45,,16.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2604.28,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,71.14,32,,82.336,Percent of Total Billed Charges,32% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,3348.36,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,3348.36,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,3348.36,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,5115.55,55,,27792.136,Percent of Total Billed Charges,55% Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9301,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1341.2,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7440.8,80,,295.096,Percent of Total Billed Charges,80% of Total Billed Charges,4650.5,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,4650.5,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4650.5,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,4650.5,50,,400.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6510.7,70,,105.232,Percent of Total Billed Charges,70% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9301,100,,393.464,Percent of Total Billed Charges,100% of Total Billed Charges,71.14,13582.6,
LEAD MEDTRONIC PACING 5076,46160010,CDM,275,RC,C1898,HCPCS,Outpatient,,,1433.43,860.06,,2949.55,110,,85.752,Percent of Total Billed Charges,110% of Total Billed Charges,645.04,45,,3.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.36,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,71.14,32,,82.408,Percent of Total Billed Charges,32% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,516.03,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,516.03,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,516.03,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,788.39,55,,11826.136,Percent of Total Billed Charges,55% Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1433.43,100,,240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,206.7,14.42,,615.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1075.07,75,,497.048,Percent of Total Billed Charges,75% of Total Billed Charges,716.72,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,716.72,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,716.72,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,716.72,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1003.4,70,,101.936,Percent of Total Billed Charges,70% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,200.68,14,,597.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1433.43,100,,662.728,Percent of Total Billed Charges,100% of Total Billed Charges,71.14,2949.55,
UNIFY QUADRA DF4 ICD,46160014,CDM,275,RC,C1882,HCPCS,Outpatient,,,34000,20400.00,,49487.27,110,,0.872,Percent of Total Billed Charges,110% of Total Billed Charges,15300,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9520,28,,0.256,Percent of Total Billed Charges,28% of Total Billed Charges,71.14,32,,82.448,Percent of Total Billed Charges,32% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,12240,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,12240,36,,0.328,Percent of Total Billed Charges,36% Total Bille Charges,12240,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,18700,55,,11826.136,Percent of Total Billed Charges,55% Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34000,100,,123.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4902.8,14.42,,919.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25500,75,,182.832,Percent of Total Billed Charges,75% of Total Billed Charges,17000,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,17000,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17000,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,17000,50,,306.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23800,70,,162.64,Percent of Total Billed Charges,70% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,892.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34000,100,,243.776,Percent of Total Billed Charges,100% of Total Billed Charges,71.14,49487.27,
QUARTET QUAD LEAD 75/86/92,46160015,CDM,275,RC,C1900,HCPCS,Outpatient,,,7280,4368.00,,8106.84,110,,0.288,Percent of Total Billed Charges,110% of Total Billed Charges,3276,45,,5.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2038.4,28,,1.496,Percent of Total Billed Charges,28% of Total Billed Charges,71.36,32,,82.536,Percent of Total Billed Charges,32% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,2620.8,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,2620.8,36,,1.92,Percent of Total Billed Charges,36% Total Bille Charges,2620.8,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,4004,55,,18939.208,Percent of Total Billed Charges,55% Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7280,100,,461.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1049.78,14.42,,613.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5460,75,,48.328,Percent of Total Billed Charges,75% of Total Billed Charges,3640,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,3640,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,3640,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5096,70,,406.04,Percent of Total Billed Charges,70% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1019.2,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7280,100,,64.432,Percent of Total Billed Charges,100% of Total Billed Charges,71.36,8106.84,
LEAD MEDTRONIC 6935,46160016,CDM,275,RC,C1777,HCPCS,Outpatient,,,9517.2,5710.32,,11267.37,110,,0.344,Percent of Total Billed Charges,110% of Total Billed Charges,4282.74,45,,15.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2664.82,28,,2.136,Percent of Total Billed Charges,28% of Total Billed Charges,71.39,32,,83.104,Percent of Total Billed Charges,32% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,3426.19,36,,2.744,Percent of Total Billed Charges,36% of Total Billed Charges,3426.19,36,,2.744,Percent of Total Billed Charges,36% Total Bille Charges,3426.19,36,,2.744,Percent of Total Billed Charges,36% of Total Billed Charges,5234.46,55,,148.2,Percent of Total Billed Charges,55% Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9517.2,100,,40.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1372.38,14.42,,613.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7137.9,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,4758.6,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,4758.6,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4758.6,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,4758.6,50,,350.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6662.04,70,,1.088,Percent of Total Billed Charges,70% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,1332.41,14,,595.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9517.2,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,71.39,11267.37,
CPS UNIVERSAL SLITTER - SJM,46160017,CDM,272,RC,,,Outpatient,,,250,150.00,,150,60,,0.472,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,71.66,32,,83.104,Percent of Total Billed Charges,32% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,90,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,90,36,,0.696,Percent of Total Billed Charges,36% Total Bille Charges,90,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,150,60,,733.592,Percent of Total Billed Charges,60% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250,100,,149.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,36.05,14.42,,344.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.5,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,70,,1.624,Percent of Total Billed Charges,70% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,35,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,35,250,
PACING CABLES - 4161,46160018,CDM,272,RC,,,Outpatient,,,165,99.00,,99,60,,13.904,Percent of Total Billed Charges,60% of Total Billed Charges,74.25,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.2,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,72,32,,83.104,Percent of Total Billed Charges,32% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,59.4,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,59.4,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,59.4,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,99,60,,6140.424,Percent of Total Billed Charges,60% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,100,,259.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.75,75,,585,Percent of Total Billed Charges,75% of Total Billed Charges,82.5,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,82.5,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.5,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,82.5,50,,449.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.5,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.1,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,23.1,165,
QUADRA CRT-D/DF-4 ICD,46160020,CDM,275,RC,C1882,HCPCS,Outpatient,,,34000,20400.00,,49487.27,110,,1.088,Percent of Total Billed Charges,110% of Total Billed Charges,15300,45,,49.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9520,28,,12.048,Percent of Total Billed Charges,28% of Total Billed Charges,72,32,,83.2,Percent of Total Billed Charges,32% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,12240,36,,15.488,Percent of Total Billed Charges,36% of Total Billed Charges,12240,36,,15.488,Percent of Total Billed Charges,36% Total Bille Charges,12240,36,,15.488,Percent of Total Billed Charges,36% of Total Billed Charges,18700,55,,21338.88,Percent of Total Billed Charges,55% Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34000,100,,612.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4902.8,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25500,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,17000,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,17000,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17000,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,17000,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23800,70,,0.08,Percent of Total Billed Charges,70% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,4760,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34000,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,72,49487.27,
ELLIPSE ICD SJ MED,46160021,CDM,275,RC,C1721,HCPCS,Outpatient,,,26000,15600.00,,33600,110,,0.376,Percent of Total Billed Charges,110% of Total Billed Charges,11700,45,,16.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7280,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,72,32,,83.696,Percent of Total Billed Charges,32% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,9360,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,9360,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,9360,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,14300,55,,21338.88,Percent of Total Billed Charges,55% Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26000,100,,121.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3749.2,14.42,,344.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19500,75,,471.432,Percent of Total Billed Charges,75% of Total Billed Charges,13000,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,165.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18200,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,334.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26000,100,,628.576,Percent of Total Billed Charges,100% of Total Billed Charges,72,33600,
ELLIPSE VR SJ MED,46160022,CDM,275,RC,C1722,HCPCS,Outpatient,,,23800,14280.00,,30168.8,110,,0.728,Percent of Total Billed Charges,110% of Total Billed Charges,10710,45,,29.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6664,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,72,32,,84.392,Percent of Total Billed Charges,32% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,8568,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,8568,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,8568,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,13090,55,,580.8,Percent of Total Billed Charges,55% Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23800,100,,100.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3431.96,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17850,75,,939.68,Percent of Total Billed Charges,75% of Total Billed Charges,11900,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,11900,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11900,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,11900,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16660,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3332,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23800,100,,1252.904,Percent of Total Billed Charges,100% of Total Billed Charges,72,30168.8,
FORTIFY ASSURA ICD SJ MED,46160023,CDM,275,RC,C1721,HCPCS,Outpatient,,,26000,15600.00,,33600,110,,0.736,Percent of Total Billed Charges,110% of Total Billed Charges,11700,45,,64.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7280,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,72.19,32,,8582.176,Percent of Total Billed Charges,32% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,9360,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,9360,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,9360,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,14300,55,,580.8,Percent of Total Billed Charges,55% Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26000,100,,36.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3749.2,14.42,,229.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19500,75,,937.2,Percent of Total Billed Charges,75% of Total Billed Charges,13000,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18200,70,,3.976,Percent of Total Billed Charges,70% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,222.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26000,100,,1249.6,Percent of Total Billed Charges,100% of Total Billed Charges,72.19,33600,
SHEATH PEELAWAY 7FR/8FR/9FR,46160025,CDM,272,RC,C1766,HCPCS,Outpatient,,,256,153.60,,137.47,100,,0.392,Fee Schedule,100% of Aetna Fee Schedule,115.2,45,,88.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,28,,0.776,Percent of Total Billed Charges,28% of Total Billed Charges,72.36,32,,8.456,Percent of Total Billed Charges,32% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,92.16,36,,1,Percent of Total Billed Charges,36% of Total Billed Charges,92.16,36,,1,Percent of Total Billed Charges,36% Total Bille Charges,92.16,36,,1,Percent of Total Billed Charges,36% of Total Billed Charges,153.6,60,,580.8,Percent of Total Billed Charges,60% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256,100,,6.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,36.92,14.42,,176.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192,75,,939.448,Percent of Total Billed Charges,75% of Total Billed Charges,128,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.2,70,,1.92,Percent of Total Billed Charges,70% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,171.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256,100,,1252.592,Percent of Total Billed Charges,100% of Total Billed Charges,35.84,256,
LEAD MEDTRONIC 6947 Q SECURE,46160027,CDM,275,RC,C1895,HCPCS,Outpatient,,,8283.94,4970.36,,10410.3,110,,0.528,Percent of Total Billed Charges,110% of Total Billed Charges,3727.77,45,,2.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2319.5,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,72.44,32,,8.472,Percent of Total Billed Charges,32% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,2982.22,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,2982.22,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,2982.22,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,4556.17,55,,2004.44,Percent of Total Billed Charges,55% Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8283.94,100,,8.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1194.54,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6212.96,75,,828.688,Percent of Total Billed Charges,75% of Total Billed Charges,4141.97,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,4141.97,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4141.97,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,4141.97,50,,374.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5798.76,70,,1.688,Percent of Total Billed Charges,70% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1159.75,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8283.94,100,,1104.92,Percent of Total Billed Charges,100% of Total Billed Charges,72.44,10410.3,
MEDTRN CAPSURE FIX NOVUS 5568,46160032,CDM,275,RC,C1898,HCPCS,Outpatient,,,1380,828.00,,2890.78,110,,0.992,Percent of Total Billed Charges,110% of Total Billed Charges,621,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.4,28,,1.416,Percent of Total Billed Charges,28% of Total Billed Charges,72.59,32,,8.472,Percent of Total Billed Charges,32% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,496.8,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,496.8,36,,1.824,Percent of Total Billed Charges,36% Total Bille Charges,496.8,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,759,55,,2004.44,Percent of Total Billed Charges,55% Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1380,100,,12.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,199,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1035,75,,544.824,Percent of Total Billed Charges,75% of Total Billed Charges,690,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,690,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,690,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,966,70,,0.72,Percent of Total Billed Charges,70% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,193.2,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1380,100,,726.432,Percent of Total Billed Charges,100% of Total Billed Charges,72.59,2890.78,
SAFE SHEATH LONG 25CM,46160036,CDM,272,RC,,,Outpatient,,,256,153.60,,153.6,60,,7.072,Percent of Total Billed Charges,60% of Total Billed Charges,115.2,45,,3.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,28,,0.64,Percent of Total Billed Charges,28% of Total Billed Charges,72.73,32,,8.552,Percent of Total Billed Charges,32% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,92.16,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,92.16,36,,0.824,Percent of Total Billed Charges,36% Total Bille Charges,92.16,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,153.6,60,,3006.656,Percent of Total Billed Charges,60% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256,100,,34.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,36.92,14.42,,155.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192,75,,217.336,Percent of Total Billed Charges,75% of Total Billed Charges,128,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,381.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.2,70,,1.256,Percent of Total Billed Charges,70% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256,100,,289.784,Percent of Total Billed Charges,100% of Total Billed Charges,35.84,256,
MDT ADAPTA DR PPM,46160045,CDM,275,RC,C1785,HCPCS,Outpatient,,,11959,7175.40,,13430.32,110,,31.504,Percent of Total Billed Charges,110% of Total Billed Charges,5381.55,45,,2.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3348.52,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,72.89,32,,8.552,Percent of Total Billed Charges,32% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,4305.24,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,4305.24,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,4305.24,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,6577.45,55,,1129.104,Percent of Total Billed Charges,55% Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11959,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1724.49,14.42,,155.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8969.25,75,,303.688,Percent of Total Billed Charges,75% of Total Billed Charges,5979.5,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,5979.5,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5979.5,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,5979.5,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8371.3,70,,0.68,Percent of Total Billed Charges,70% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,1674.26,14,,150.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11959,100,,404.912,Percent of Total Billed Charges,100% of Total Billed Charges,72.89,13430.32,
MDT VERSA DR PPM,46160046,CDM,275,RC,C1785,HCPCS,Outpatient,,,9301,5580.60,,10506.52,110,,1.312,Percent of Total Billed Charges,110% of Total Billed Charges,4185.45,45,,0.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2604.28,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,73.22,32,,8.552,Percent of Total Billed Charges,32% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,3348.36,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,3348.36,36,,0.344,Percent of Total Billed Charges,36% Total Bille Charges,3348.36,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,5115.55,55,,1129.104,Percent of Total Billed Charges,55% Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9301,100,,98.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1341.2,14.42,,243.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6975.75,75,,1121.112,Percent of Total Billed Charges,75% of Total Billed Charges,4650.5,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,4650.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4650.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,4650.5,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6510.7,70,,0.528,Percent of Total Billed Charges,70% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,1302.14,14,,236.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9301,100,,1494.816,Percent of Total Billed Charges,100% of Total Billed Charges,73.22,10506.52,
ST JUDE PACING LEAD 1788,46160050,CDM,275,RC,C1898,HCPCS,Outpatient,,,2290,1374.00,,3891.78,110,,8.936,Percent of Total Billed Charges,110% of Total Billed Charges,1030.5,45,,3.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,641.2,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,73.22,32,,8.552,Percent of Total Billed Charges,32% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,824.4,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,824.4,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,824.4,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,1259.5,55,,1693.648,Percent of Total Billed Charges,55% Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2290,100,,109.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,330.22,14.42,,289.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1717.5,75,,1486.944,Percent of Total Billed Charges,75% of Total Billed Charges,1145,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,1145,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1145,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,1145,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1603,70,,0.528,Percent of Total Billed Charges,70% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,320.6,14,,281.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2290,100,,1982.592,Percent of Total Billed Charges,100% of Total Billed Charges,73.22,3891.78,
MEDTRONIC TORQR 5FR,46160053,CDM,272,RC,C1730,HCPCS,Outpatient,,,256,153.60,,407.16,100,,4.712,Fee Schedule,100% of Aetna Fee Schedule,115.2,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,73.28,32,,8.568,Percent of Total Billed Charges,32% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.16,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,92.16,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,92.16,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,153.6,60,,624.512,Percent of Total Billed Charges,60% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256,100,,36.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,36.92,14.42,,70.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192,75,,1486.944,Percent of Total Billed Charges,75% of Total Billed Charges,128,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,128,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.2,70,,0.424,Percent of Total Billed Charges,70% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,35.84,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256,100,,1982.592,Percent of Total Billed Charges,100% of Total Billed Charges,35.84,407.16,
WIRE COUGAR XT 0.014,46160056,CDM,272,RC,C1769,HCPCS,Outpatient,,,300,180.00,,55.13,100,,2.848,Fee Schedule,100% of Aetna Fee Schedule,135,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,7.304,Percent of Total Billed Charges,28% of Total Billed Charges,73.41,32,,8.568,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,9.392,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,9.392,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,9.392,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,624.512,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,65.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,151.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,2429.08,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,1.24,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,146.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,3238.768,Percent of Total Billed Charges,100% of Total Billed Charges,42,300,
PACEMAKER SENSIA DUAL CHAMBER,46160059,CDM,275,RC,C1785,HCPCS,Outpatient,,,6644,3986.40,,7583.82,110,,1.304,Percent of Total Billed Charges,110% of Total Billed Charges,2989.8,45,,101.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1860.32,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,73.57,32,,85.168,Percent of Total Billed Charges,32% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,2391.84,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,2391.84,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,2391.84,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,3654.2,55,,1852.2,Percent of Total Billed Charges,55% Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6644,100,,144.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,958.06,14.42,,263.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4983,75,,3221.712,Percent of Total Billed Charges,75% of Total Billed Charges,3322,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3322,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3322,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3322,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4650.8,70,,3.856,Percent of Total Billed Charges,70% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,930.16,14,,255.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6644,100,,4295.616,Percent of Total Billed Charges,100% of Total Billed Charges,73.57,7583.82,
BOS. SCI. PACEMAKER LEAD,46160060,CDM,275,RC,C1898,HCPCS,Outpatient,,,1425,855.00,,2940.28,110,,0.424,Percent of Total Billed Charges,110% of Total Billed Charges,641.25,45,,108.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399,28,,9.08,Percent of Total Billed Charges,28% of Total Billed Charges,73.57,32,,85.208,Percent of Total Billed Charges,32% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,513,36,,11.672,Percent of Total Billed Charges,36% of Total Billed Charges,513,36,,11.672,Percent of Total Billed Charges,36% Total Bille Charges,513,36,,11.672,Percent of Total Billed Charges,36% of Total Billed Charges,783.75,55,,1852.2,Percent of Total Billed Charges,55% Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1425,100,,196.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,205.49,14.42,,145.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1068.75,75,,3221.712,Percent of Total Billed Charges,75% of Total Billed Charges,712.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,712.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,712.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,712.5,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,997.5,70,,0.136,Percent of Total Billed Charges,70% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,199.5,14,,141.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1425,100,,4295.616,Percent of Total Billed Charges,100% of Total Billed Charges,73.57,2940.28,
LEAD TENDRIL ST 1888TC,46160061,CDM,275,RC,C1898,HCPCS,Outpatient,,,1076.93,646.16,,2557.4,110,,0.08,Percent of Total Billed Charges,110% of Total Billed Charges,484.62,45,,345.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.54,28,,3.04,Percent of Total Billed Charges,28% of Total Billed Charges,7373.76,32,,85.4,Percent of Total Billed Charges,32% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,387.69,36,,3.904,Percent of Total Billed Charges,36% of Total Billed Charges,387.69,36,,3.904,Percent of Total Billed Charges,36% Total Bille Charges,387.69,36,,3.904,Percent of Total Billed Charges,36% of Total Billed Charges,592.31,55,,2778.304,Percent of Total Billed Charges,55% Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1076.93,100,,4.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,155.29,14.42,,252.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,807.7,75,,1121.112,Percent of Total Billed Charges,75% of Total Billed Charges,538.47,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.47,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,538.47,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,753.85,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,150.77,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1076.93,100,,1494.816,Percent of Total Billed Charges,100% of Total Billed Charges,150.77,7373.76,
DURATA 7121 LEAD SJM,46160066,CDM,275,RC,C1895,HCPCS,Outpatient,,,8497.5,5098.50,,10645.22,110,,1.016,Percent of Total Billed Charges,110% of Total Billed Charges,3823.88,45,,1.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2379.3,28,,1.48,Percent of Total Billed Charges,28% of Total Billed Charges,7411.2,32,,85.76,Percent of Total Billed Charges,32% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,3059.1,36,,1.904,Percent of Total Billed Charges,36% of Total Billed Charges,3059.1,36,,1.904,Percent of Total Billed Charges,36% Total Bille Charges,3059.1,36,,1.904,Percent of Total Billed Charges,36% of Total Billed Charges,4673.63,55,,728.592,Percent of Total Billed Charges,55% Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8497.5,100,,2.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1225.34,14.42,,282.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6373.13,75,,1486.944,Percent of Total Billed Charges,75% of Total Billed Charges,4248.75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,4248.75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4248.75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,4248.75,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5948.25,70,,0.136,Percent of Total Billed Charges,70% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,1189.65,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8497.5,100,,1982.592,Percent of Total Billed Charges,100% of Total Billed Charges,1189.65,10645.22,
DISPO SURG CABLE REMING 12 FT,46160068,CDM,272,RC,,,Outpatient,,,77.94,46.76,,46.76,60,,15.688,Percent of Total Billed Charges,60% of Total Billed Charges,35.07,45,,8.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.82,28,,2.944,Percent of Total Billed Charges,28% of Total Billed Charges,7475.68,32,,86.064,Percent of Total Billed Charges,32% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,28.06,36,,3.784,Percent of Total Billed Charges,36% of Total Billed Charges,28.06,36,,3.784,Percent of Total Billed Charges,36% Total Bille Charges,28.06,36,,3.784,Percent of Total Billed Charges,36% of Total Billed Charges,46.76,60,,1097.704,Percent of Total Billed Charges,60% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,100,,6.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,11.24,14.42,,261.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.46,75,,1486.944,Percent of Total Billed Charges,75% of Total Billed Charges,38.97,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,38.97,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.97,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,38.97,50,,89.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.56,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,10.91,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.94,100,,1982.592,Percent of Total Billed Charges,100% of Total Billed Charges,10.91,7475.68,
ATTAIN COMMAND 6250C KIT,46160074,CDM,272,RC,C1725,HCPCS,Outpatient,,,1860,1116.00,,99.47,100,,5.896,Fee Schedule,100% of Aetna Fee Schedule,837,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.8,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,7475.68,32,,86.784,Percent of Total Billed Charges,32% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,669.6,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,669.6,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,669.6,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,1116,60,,1097.704,Percent of Total Billed Charges,60% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1860,100,,6.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,268.21,14.42,,261.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1395,75,,2429.08,Percent of Total Billed Charges,75% of Total Billed Charges,930,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,930,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,930,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1302,70,,56.832,Percent of Total Billed Charges,70% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,260.4,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1860,100,,3238.768,Percent of Total Billed Charges,100% of Total Billed Charges,99.47,7475.68,
SECURA DR MEDTRONIC AICD,46160075,CDM,275,RC,C1721,HCPCS,Outpatient,,,25452,15271.20,,32997.2,110,,24.416,Percent of Total Billed Charges,110% of Total Billed Charges,11453.4,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7126.56,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,7475.68,32,,86.928,Percent of Total Billed Charges,32% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,9162.72,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,9162.72,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,9162.72,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,13998.6,55,,728.592,Percent of Total Billed Charges,55% Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25452,100,,0.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3670.18,14.42,,331.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19089,75,,3221.712,Percent of Total Billed Charges,75% of Total Billed Charges,12726,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,12726,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12726,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,12726,50,,159.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17816.4,70,,4.704,Percent of Total Billed Charges,70% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,3563.28,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25452,100,,4295.616,Percent of Total Billed Charges,100% of Total Billed Charges,3563.28,32997.2,
MEDTRONIC AICD LEAD,46160076,CDM,275,RC,C1900,HCPCS,Outpatient,,,5538,3322.80,,6190.64,110,,99.12,Percent of Total Billed Charges,110% of Total Billed Charges,2492.1,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1550.64,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,7475.68,32,,8704,Percent of Total Billed Charges,32% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,1993.68,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,1993.68,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,1993.68,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3045.9,55,,508.8,Percent of Total Billed Charges,55% Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5538,100,,7.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,798.58,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4153.5,75,,3221.712,Percent of Total Billed Charges,75% of Total Billed Charges,2769,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,2769,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2769,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,2769,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3876.6,70,,2.96,Percent of Total Billed Charges,70% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,775.32,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5538,100,,4295.616,Percent of Total Billed Charges,100% of Total Billed Charges,775.32,7475.68,
REVEAL XT ICM MEDTRONIC,46160077,CDM,278,RC,C1764,HCPCS,Outpatient,,,16468.16,9880.90,,21466.48,110,,7.04,Percent of Total Billed Charges,110% of Total Billed Charges,7410.67,45,,0.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4611.08,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,7520,32,,8704,Percent of Total Billed Charges,32% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,5928.54,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,5928.54,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,5928.54,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,9057.49,55,,117.184,Percent of Total Billed Charges,55% Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16468.16,100,,11.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2374.71,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13174.53,80,,209.288,Percent of Total Billed Charges,80% of Total Billed Charges,8234.08,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,8234.08,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8234.08,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,8234.08,50,,180.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11527.71,70,,2.048,Percent of Total Billed Charges,70% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,2305.54,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16468.16,100,,279.048,Percent of Total Billed Charges,100% of Total Billed Charges,2305.54,21466.48,
ACCENT DR RF PACEMAKER-SJM,46160079,CDM,275,RC,C1785,HCPCS,Outpatient,,,10920,6552.00,,12287.42,110,,15.664,Percent of Total Billed Charges,110% of Total Billed Charges,4914,45,,3.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3057.6,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,7616,32,,8832,Percent of Total Billed Charges,32% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,3931.2,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,3931.2,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,3931.2,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,6006,55,,228.8,Percent of Total Billed Charges,55% Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10920,100,,83.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1574.66,14.42,,261.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8190,75,,209.288,Percent of Total Billed Charges,75% of Total Billed Charges,5460,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,5460,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5460,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,5460,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7644,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,1528.8,14,,254.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10920,100,,279.048,Percent of Total Billed Charges,100% of Total Billed Charges,1528.8,12287.42,
MICRO-INTRODUCER KIT 5FR,46160087,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,3.344,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,4.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,21.472,Percent of Total Billed Charges,28% of Total Billed Charges,7629.96,32,,8908.8,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,27.608,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,27.608,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,27.608,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,224.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,202.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,363.408,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,0.112,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,196.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,484.544,Percent of Total Billed Charges,100% of Total Billed Charges,21,7629.96,
LEAD PACING - ST. JUDE,46160094,CDM,275,RC,C1898,HCPCS,Outpatient,,,1200,720.00,,2692.78,110,,3.064,Percent of Total Billed Charges,110% of Total Billed Charges,540,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,7655.21,32,,8929.44,Percent of Total Billed Charges,32% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,432,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,432,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,432,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,660,55,,394.248,Percent of Total Billed Charges,55% Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1200,100,,240.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,173.04,14.42,,298.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,900,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,600,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,600,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840,70,,0.496,Percent of Total Billed Charges,70% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,168,14,,289.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,168,7655.21,
LEAD LV ST. JUDE,46160096,CDM,275,RC,C1899,HCPCS,Outpatient,,,3900,2340.00,,10252.88,110,,0.888,Percent of Total Billed Charges,110% of Total Billed Charges,1755,45,,8.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092,28,,3.44,Percent of Total Billed Charges,28% of Total Billed Charges,7662.31,32,,8.736,Percent of Total Billed Charges,32% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,1404,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,1404,36,,4.424,Percent of Total Billed Charges,36% Total Bille Charges,1404,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,2145,55,,59.84,Percent of Total Billed Charges,55% Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3900,100,,768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,562.38,14.42,,222.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2925,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,1950,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1950,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1950,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1950,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2730,70,,0.6,Percent of Total Billed Charges,70% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,546,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3900,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,546,10252.88,
ST. JUDE 7F FASTCATH SHEATH,46160107,CDM,272,RC,C1894,HCPCS,Outpatient,,,138,82.80,,82.29,100,,0.2,Fee Schedule,100% of Aetna Fee Schedule,62.1,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.64,28,,3.44,Percent of Total Billed Charges,28% of Total Billed Charges,7.36,32,,8.744,Percent of Total Billed Charges,32% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,49.68,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,49.68,36,,4.424,Percent of Total Billed Charges,36% Total Bille Charges,49.68,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,82.8,60,,245.704,Percent of Total Billed Charges,60% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138,100,,3.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.9,14.42,,222.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,69,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,69,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,69,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,70,,0.168,Percent of Total Billed Charges,70% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,216.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,7.36,138,
ACCENT DR PM2110 - ST JUDE,46160110,CDM,275,RC,C1785,HCPCS,Outpatient,,,7800,4680.00,,8855.42,110,,11.528,Percent of Total Billed Charges,110% of Total Billed Charges,3510,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2184,28,,1.136,Percent of Total Billed Charges,28% of Total Billed Charges,7.38,32,,8.752,Percent of Total Billed Charges,32% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,2808,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,2808,36,,1.456,Percent of Total Billed Charges,36% Total Bille Charges,2808,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,4290,55,,146.52,Percent of Total Billed Charges,55% Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7800,100,,18.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1124.76,14.42,,358.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5850,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,3900,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3900,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3900,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,3900,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5460,70,,1.072,Percent of Total Billed Charges,70% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1092,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7800,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.38,8855.42,
SURESCAN REVO MRI PACEMAKER,46160118,CDM,275,RC,C1785,HCPCS,Outpatient,,,10197,6118.20,,11492.12,110,,0.536,Percent of Total Billed Charges,110% of Total Billed Charges,4588.65,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2855.16,28,,62.016,Percent of Total Billed Charges,28% of Total Billed Charges,7.47,32,,8.816,Percent of Total Billed Charges,32% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,3670.92,36,,79.736,Percent of Total Billed Charges,36% of Total Billed Charges,3670.92,36,,79.736,Percent of Total Billed Charges,36% Total Bille Charges,3670.92,36,,79.736,Percent of Total Billed Charges,36% of Total Billed Charges,5608.35,55,,57.6,Percent of Total Billed Charges,55% Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10197,100,,6.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1470.41,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7647.75,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,5098.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5098.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,5098.5,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7137.9,70,,0.432,Percent of Total Billed Charges,70% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1427.58,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10197,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,7.47,11492.12,
LEAD MRI 5086,46160119,CDM,275,RC,C1898,HCPCS,Outpatient,,,4420,2652.00,,6234.78,110,,1.416,Percent of Total Billed Charges,110% of Total Billed Charges,1989,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1237.6,28,,3.864,Percent of Total Billed Charges,28% of Total Billed Charges,7.48,32,,8.84,Percent of Total Billed Charges,32% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,1591.2,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,1591.2,36,,4.968,Percent of Total Billed Charges,36% Total Bille Charges,1591.2,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,2431,55,,388.8,Percent of Total Billed Charges,55% Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4420,100,,3.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,637.36,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3315,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,2210,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,2210,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2210,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,2210,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3094,70,,0.68,Percent of Total Billed Charges,70% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,618.8,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4420,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,7.48,6234.78,
ARISTA-AH 1GM SM0005-USA,46160122,CDM,272,RC,C1765,HCPCS,Outpatient,,,375,225.00,,3.46,100,,0.304,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,4.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.84,Other,Not Seperately Reimbusable,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,0.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,141.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,0.632,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,137.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,375,
DILATOR 6FR,46160127,CDM,272,RC,A4649,HCPCS,Outpatient,,,37.17,22.30,,22.3,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.73,45,,4.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.41,28,,3.856,Percent of Total Billed Charges,28% of Total Billed Charges,7.52,32,,8.864,Percent of Total Billed Charges,32% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,13.38,36,,4.96,Percent of Total Billed Charges,36% of Total Billed Charges,13.38,36,,4.96,Percent of Total Billed Charges,36% Total Bille Charges,13.38,36,,4.96,Percent of Total Billed Charges,36% of Total Billed Charges,22.3,60,,192.456,Percent of Total Billed Charges,60% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.17,100,,0.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.36,14.42,,103.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,18.59,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,18.59,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.59,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,18.59,50,,228.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.02,70,,3.736,Percent of Total Billed Charges,70% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,100.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.17,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,5.2,37.17,
DILATOR 8F,46160128,CDM,272,RC,A4649,HCPCS,Outpatient,,,37.17,22.30,,22.3,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,16.73,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.41,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,7.56,32,,8.896,Percent of Total Billed Charges,32% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,13.38,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,13.38,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,13.38,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,22.3,60,,229.176,Percent of Total Billed Charges,60% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.17,100,,7.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.36,14.42,,321.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,18.59,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,18.59,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.59,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.59,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.02,70,,5.336,Percent of Total Billed Charges,70% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14,,311.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.17,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,5.2,37.17,
DILATOR 10FR,46160129,CDM,272,RC,A4649,HCPCS,Outpatient,,,44.66,26.80,,26.8,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,20.1,45,,2.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.5,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,7.59,32,,8.928,Percent of Total Billed Charges,32% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,16.08,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,16.08,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,26.8,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.66,100,,9.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.44,14.42,,310.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.5,75,,452.424,Percent of Total Billed Charges,75% of Total Billed Charges,22.33,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.33,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.26,70,,1.352,Percent of Total Billed Charges,70% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,301.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.66,100,,603.232,Percent of Total Billed Charges,100% of Total Billed Charges,6.25,44.66,
DILATOR 12FR,46160130,CDM,272,RC,A4649,HCPCS,Outpatient,,,44.66,26.80,,26.8,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,20.1,45,,1.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.5,28,,0.128,Percent of Total Billed Charges,28% of Total Billed Charges,73.6,32,,87.168,Percent of Total Billed Charges,32% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,16.08,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,16.08,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,26.8,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.66,100,,0.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.44,14.42,,470.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.5,75,,452.424,Percent of Total Billed Charges,75% of Total Billed Charges,22.33,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.33,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,22.33,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.26,70,,1.528,Percent of Total Billed Charges,70% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,6.25,14,,456.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.66,100,,603.232,Percent of Total Billed Charges,100% of Total Billed Charges,6.25,73.6,
ENERGEN ICD,46160136,CDM,275,RC,C1882,HCPCS,Outpatient,,,26000,15600.00,,40687.27,110,,0.416,Percent of Total Billed Charges,110% of Total Billed Charges,11700,45,,0.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7280,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,73.94,32,,87.256,Percent of Total Billed Charges,32% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,9360,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,9360,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,9360,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,14300,55,,182.4,Percent of Total Billed Charges,55% Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26000,100,,18.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3749.2,14.42,,213.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19500,75,,138.368,Percent of Total Billed Charges,75% of Total Billed Charges,13000,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13000,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,13000,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18200,70,,30.12,Percent of Total Billed Charges,70% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,3640,14,,206.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26000,100,,184.488,Percent of Total Billed Charges,100% of Total Billed Charges,73.94,40687.27,
ENDOTAK RELIANCE 4-SITE LEAD,46160137,CDM,275,RC,C1895,HCPCS,Outpatient,,,9100,5460.00,,11307.97,110,,1.136,Percent of Total Billed Charges,110% of Total Billed Charges,4095,45,,3.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2548,28,,0.632,Percent of Total Billed Charges,28% of Total Billed Charges,73.99,32,,87.344,Percent of Total Billed Charges,32% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,3276,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,3276,36,,0.816,Percent of Total Billed Charges,36% Total Bille Charges,3276,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,5005,55,,394.248,Percent of Total Billed Charges,55% Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9100,100,,6.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1312.22,14.42,,620.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6825,75,,138.368,Percent of Total Billed Charges,75% of Total Billed Charges,4550,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,4550,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4550,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,4550,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6370,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,1274,14,,602.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9100,100,,184.488,Percent of Total Billed Charges,100% of Total Billed Charges,73.99,11307.97,
DRESSING SILVERLON 4X6 ISLAND,46160142,CDM,272,RC,A6255,HCPCS,Outpatient,,,87.3,52.38,,2.58,100,,0.528,Fee Schedule,100% of Aetna Fee Schedule,39.29,45,,4.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.88,280,,22.6,Fee Schedule,280% of BCBS BULE Fee Schedule,11.3,320,,87.344,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.71,360,,29.056,Fee Schedule,360% of BCBS POS Rate,12.71,360,,29.056,Fee schedule,360% of BCBS PPO Rate,12.71,360,,29.056,Fee Schedule,360% of BCBS Traditional Rate,52.38,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.3,100,,7.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.59,14.42,,389.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.48,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,43.65,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.65,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.11,70,,0.816,Percent of Total Billed Charges,70% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.3,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,2.58,87.3,
PPM INGENIO SR BOSTON SCI,46160148,CDM,275,RC,C1786,HCPCS,Outpatient,,,7061.6,4236.96,,8884.45,110,,0.656,Percent of Total Billed Charges,110% of Total Billed Charges,3177.72,45,,0.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1977.25,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,74.13,32,,87.4,Percent of Total Billed Charges,32% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,2542.18,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,2542.18,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,2542.18,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,3883.88,55,,35.136,Percent of Total Billed Charges,55% Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7061.6,100,,7.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,1018.28,14.42,,184.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5296.2,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,3530.8,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,3530.8,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3530.8,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,3530.8,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4943.12,70,,0.584,Percent of Total Billed Charges,70% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,988.62,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7061.6,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,74.13,8884.45,
LEAD PM ICD RT A V REPOSITION,46160151,CDM,480,RC,33215,HCPCS,Outpatient,,,6341.52,3804.91,,4682,100,,0.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4386.59,150,,24.496,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1775.63,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,74.35,32,,87.688,Percent of Total Billed Charges,32% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2282.95,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,2282.95,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,2282.95,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,3804.91,60,,182.4,Percent of Total Billed Charges,60% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,7.584,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,914.45,14.42,,389.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,4756.14,75,,225.4,Percent of Total Billed Charges,75% of Total Billed Charges,3170.76,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,3170.76,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3170.76,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,3170.76,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,1.944,Case Rate,Pays based on per visit rate,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,887.81,14,,378.448,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,6341.52,100,,300.528,Percent of Total Billed Charges,100% of Total Billed Charges,74.35,6341.52,
PPM SYS DUAL CHMBR UPGRADE,46160155,CDM,480,RC,33214,HCPCS,Outpatient,,,19557.62,11734.57,,9364,100,,0.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14695.35,150,,214.552,Fee Schedule ,150% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5476.13,28,,0.44,Percent of Total Billed Charges,28% of Total Billed Charges,74.73,32,,87.688,Percent of Total Billed Charges,32% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,7040.74,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,7040.74,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,7040.74,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,11734.57,60,,424.808,Percent of Total Billed Charges,60% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,9.392,Fee Schedule,100% of CMS OPPS Rate,8817.2,90,,,Fee Schedule,90% of CMS OPPS Rate,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12735.96,130,,,Fee Schedule,130% of CMS OPPS Rate,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2820.21,14.42,,33.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,14668.22,75,,225.4,Percent of Total Billed Charges,75% of Total Billed Charges,9778.81,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,9778.81,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9778.81,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,9778.81,50,,126.048,Percent of Total Billed Charges,50% of Total Billed Charges,14695.35,150,,,Fee Schedule,150% of CMS OPPS Rate,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,0.832,Case Rate,Pays based on per visit rate,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2738.07,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,19557.62,100,,300.528,Percent of Total Billed Charges,100% of Total Billed Charges,74.73,19557.62,
LEAD LV W PPM ICD GEN INSRT,46160158,CDM,480,RC,33225,HCPCS,Outpatient,,,16713.72,10028.23,,6763,100,,0.536,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7521.17,45,,93.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,87.688,Other,Not Seperately Reimbusable,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10028.23,60,,63.784,Percent of Total Billed Charges,60% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16713.72,100,,10.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2410.12,14.42,,33.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12535.29,75,,124.24,Percent of Total Billed Charges,75% of Total Billed Charges,8356.86,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,8356.86,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8356.86,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,8356.86,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370,100,,3.536,Case Rate,Pays based on per visit rate,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,2339.92,14,,32.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16713.72,100,,165.656,Percent of Total Billed Charges,100% of Total Billed Charges,370,16713.72,
LEAD LV TO EXIS PPM ICD ADD,46160159,CDM,480,RC,33224,HCPCS,Outpatient,,,18818.47,11291.08,,4682,100,,124.944,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14695.35,150,,103.848,Fee Schedule ,150% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5269.17,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,74.97,32,,87.688,Percent of Total Billed Charges,32% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,6774.65,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,6774.65,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,6774.65,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,11291.08,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,130.544,Fee Schedule,100% of CMS OPPS Rate,8817.2,90,,,Fee Schedule,90% of CMS OPPS Rate,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12735.96,130,,,Fee Schedule,130% of CMS OPPS Rate,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2713.62,14.42,,302.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,14113.85,75,,124.24,Percent of Total Billed Charges,75% of Total Billed Charges,9409.24,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,9409.24,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9409.24,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,9409.24,50,,160.992,Percent of Total Billed Charges,50% of Total Billed Charges,14695.35,150,,,Fee Schedule,150% of CMS OPPS Rate,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,1.6,Case Rate,Pays based on per visit rate,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,2634.59,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,18818.47,100,,165.656,Percent of Total Billed Charges,100% of Total Billed Charges,74.97,18818.47,
LEAD PM DUAL REMOVAL,46160161,CDM,480,RC,33235,HCPCS,Outpatient,,,4654.58,2792.75,,6763,100,,0.76,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5404.32,150,,56.488,Fee Schedule ,150% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.28,28,,1.344,Percent of Total Billed Charges,28% of Total Billed Charges,75.05,32,,87.688,Percent of Total Billed Charges,32% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,1675.65,36,,1.728,Percent of Total Billed Charges,36% of Total Billed Charges,1675.65,36,,1.728,Percent of Total Billed Charges,36% Total Bille Charges,1675.65,36,,1.728,Percent of Total Billed Charges,36% of Total Billed Charges,2792.75,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.88,100,,6.112,Fee Schedule,100% of CMS OPPS Rate,3242.59,90,,,Fee Schedule,90% of CMS OPPS Rate,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4683.74,130,,,Fee Schedule,130% of CMS OPPS Rate,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,671.19,14.42,,302.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,3710.96,103,,,Fee Schedule,103% of CMS OPPS Rate,3710.96,103,,,Fee Schedule,103% of CMS OPPS Rate,3490.94,75,,206.272,Percent of Total Billed Charges,75% of Total Billed Charges,2327.29,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2327.29,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2327.29,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2327.29,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,5404.32,150,,,Fee Schedule,150% of CMS OPPS Rate,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,0.28,Case Rate,Pays based on per visit rate,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,651.64,14,,293.496,Percent of Total Billed Charges,14% of Total Billed Charges,3602.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4654.58,100,,275.032,Percent of Total Billed Charges,100% of Total Billed Charges,75.05,6763,
PPM SKIN RELOCATION,46160164,CDM,480,RC,33222,HCPCS,Outpatient,,,4739.29,2843.57,,4162,100,,1,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2509.64,150,,78.344,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1327,28,,1.368,Percent of Total Billed Charges,28% of Total Billed Charges,75.05,32,,87.752,Percent of Total Billed Charges,32% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1706.14,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,1706.14,36,,1.76,Percent of Total Billed Charges,36% Total Bille Charges,1706.14,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,2843.57,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,3.856,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,683.41,14.42,,167.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,3554.47,75,,206.272,Percent of Total Billed Charges,75% of Total Billed Charges,2369.65,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2369.65,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2369.65,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,2369.65,50,,155.104,Percent of Total Billed Charges,50% of Total Billed Charges,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,0.672,Case Rate,Pays based on per visit rate,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,663.5,14,,162.824,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,4739.29,100,,275.032,Percent of Total Billed Charges,100% of Total Billed Charges,75.05,4739.29,
PPM SYSTEM DUAL INSERT,46160173,CDM,480,RC,33208,HCPCS,Outpatient,,,25201.55,15120.93,,9364,100,,0.072,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14695.35,150,,1.168,Fee Schedule ,150% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7056.43,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,75.17,32,,88.048,Percent of Total Billed Charges,32% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9072.56,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,9072.56,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,9072.56,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,15120.93,60,,767.384,Percent of Total Billed Charges,60% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,1.552,Fee Schedule,100% of CMS OPPS Rate,8817.2,90,,,Fee Schedule,90% of CMS OPPS Rate,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12735.96,130,,,Fee Schedule,130% of CMS OPPS Rate,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3634.06,14.42,,11.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18901.16,75,,115.912,Percent of Total Billed Charges,75% of Total Billed Charges,12600.78,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,12600.78,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12600.78,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,12600.78,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,14695.35,150,,,Fee Schedule,150% of CMS OPPS Rate,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,0.088,Case Rate,Pays based on per visit rate,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,3528.22,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,25201.55,100,,154.552,Percent of Total Billed Charges,100% of Total Billed Charges,75.17,25201.55,
PPM SYSTEM VENTRIC INSERT,46160175,CDM,480,RC,33207,HCPCS,Outpatient,,,14973.85,8984.31,,9364,100,,6.928,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14695.35,150,,6.752,Fee Schedule ,150% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4192.68,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,75.17,32,,88.128,Percent of Total Billed Charges,32% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,5390.59,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,5390.59,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,5390.59,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,8984.31,60,,767.384,Percent of Total Billed Charges,60% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,7.264,Fee Schedule,100% of CMS OPPS Rate,8817.2,90,,,Fee Schedule,90% of CMS OPPS Rate,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12735.96,130,,,Fee Schedule,130% of CMS OPPS Rate,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2159.23,14.42,,60.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,11230.39,75,,115.912,Percent of Total Billed Charges,75% of Total Billed Charges,7486.93,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,7486.93,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7486.93,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,7486.93,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,14695.35,150,,,Fee Schedule,150% of CMS OPPS Rate,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,0.12,Case Rate,Pays based on per visit rate,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,2096.34,14,,58.8,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14973.85,100,,154.552,Percent of Total Billed Charges,100% of Total Billed Charges,75.17,14973.85,
ICD W LEAD INSRT REPLACE,46160177,CDM,480,RC,33249,HCPCS,Outpatient,,,39185.47,23511.28,,9364,100,,6.928,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45275.5,150,,3.824,Fee Schedule ,150% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10971.93,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,75.17,32,,88.16,Percent of Total Billed Charges,32% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,14106.77,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,14106.77,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,14106.77,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,23511.28,60,,1014.304,Percent of Total Billed Charges,60% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,9.744,Fee Schedule,100% of CMS OPPS Rate,27165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39238.76,130,,,Fee Schedule,130% of CMS OPPS Rate,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5650.54,14.42,,89.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,29389.1,75,,250.456,Percent of Total Billed Charges,75% of Total Billed Charges,19592.74,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,19592.74,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,19592.74,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,19592.74,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,45275.5,150,,,Fee Schedule,150% of CMS OPPS Rate,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,18.256,Case Rate,Pays based on per visit rate,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,5485.97,14,,87.28,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39185.47,100,,333.944,Percent of Total Billed Charges,100% of Total Billed Charges,75.17,45275.5,
IR VENOGRAM EXT UNI SI,46160180,CDM,320,RC,75820,HCPCS,Outpatient,,,1567,940.20,,65.43,100,,0.08,Fee Schedule,100% of Aetna Fee Schedule,2204.02,150,,14.8,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.43,280,,0.128,Fee Schedule,280% of BCBS BULE Fee Schedule,2017.63,320,,88.44,Fee Schedule,320% of BCBS Blue Essentials Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,2269.84,360,,0.168,Fee Schedule,360% of BCBS POS Rate,2269.84,360,,0.168,Fee schedule,360% of BCBS PPO Rate,2269.84,360,,0.168,Fee Schedule,360% of BCBS Traditional Rate,1885.49,103,,1206.344,Fee Schedule,103% of Cigna fee schedule,109.26,100,,54.296,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,1.888,Fee Schedule,100% of CMS OPPS Rate,1322.41,90,,,Fee Schedule,90% of CMS OPPS Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.15,130,,,Fee Schedule,130% of CMS OPPS Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,112.54,103,,55.92,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1175.25,75,,250.456,Percent of Total Billed Charges,75% of Total Billed Charges,783.5,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,783.5,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,783.5,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,783.5,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,2204.02,150,,,Fee Schedule,150% of CMS OPPS Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.52,Case Rate,Pays based on per visit rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,54.296,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1567,100,,333.944,Percent of Total Billed Charges,100% of Total Billed Charges,65.43,2269.84,
IR VENOGRAM EXT UNI SI,46160180,CDM,320,RC,75820,HCPCS,Outpatient,,,1567,940.20,,65.43,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,2204.02,150,,90.72,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.43,280,,0.176,Fee Schedule,280% of BCBS BULE Fee Schedule,2017.63,320,,88.672,Fee Schedule,320% of BCBS Blue Essentials Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,2269.84,360,,0.224,Fee Schedule,360% of BCBS POS Rate,2269.84,360,,0.224,Fee schedule,360% of BCBS PPO Rate,2269.84,360,,0.224,Fee Schedule,360% of BCBS Traditional Rate,1885.49,103,,294.904,Fee Schedule,103% of Cigna fee schedule,109.26,100,,706.472,Fee Schedule,100% of TX Mediciad Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,54.432,Fee Schedule,100% of CMS OPPS Rate,1322.41,90,,,Fee Schedule,90% of CMS OPPS Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.15,130,,,Fee Schedule,130% of CMS OPPS Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,112.54,103,,727.664,Fee Schedule,103% of TX Medicaid Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1175.25,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,783.5,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,783.5,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,783.5,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,783.5,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,2204.02,150,,,Fee Schedule,150% of CMS OPPS Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,22.696,Case Rate,Pays based on per visit rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,109.26,100,,706.472,Fee Schedule,100% of TX Medicaid Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1567,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,65.43,2269.84,
PPM GEN DUAL LEAD REPLACE,46160183,CDM,480,RC,33228,HCPCS,Outpatient,,,23944.73,14366.84,,4682,100,,0.184,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,14695.35,150,,23.848,Fee Schedule ,150% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6704.52,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,75.25,32,,89.016,Percent of Total Billed Charges,32% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,8620.1,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,8620.1,36,,0.24,Percent of Total Billed Charges,36% Total Bille Charges,8620.1,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,14366.84,60,,628.752,Percent of Total Billed Charges,60% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9796.9,100,,476.784,Fee Schedule,100% of CMS OPPS Rate,8817.2,90,,,Fee Schedule,90% of CMS OPPS Rate,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12735.96,130,,,Fee Schedule,130% of CMS OPPS Rate,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3452.83,14.42,,46.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,10090.79,103,,,Fee Schedule,103% of CMS OPPS Rate,17958.55,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,11972.37,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,11972.37,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11972.37,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,11972.37,50,,103.4,Percent of Total Billed Charges,50% of Total Billed Charges,14695.35,150,,,Fee Schedule,150% of CMS OPPS Rate,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,7.592,Case Rate,Pays based on per visit rate,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,3352.26,14,,44.688,Percent of Total Billed Charges,14% of Total Billed Charges,9796.9,100,,,Fee Schedule,100% of CMS OPPS Rate,23944.73,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,75.25,23944.73,
PPM GEN MULTI LEAD REPLACE,46160184,CDM,480,RC,33229,HCPCS,Outpatient,,,24413,14647.80,,4682,100,,0.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,26815.41,150,,40.144,Fee Schedule ,150% of CMS OPPS Rate,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6835.64,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,75.44,32,,89.304,Percent of Total Billed Charges,32% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,8788.68,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,8788.68,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,8788.68,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,14647.8,60,,1096.976,Percent of Total Billed Charges,60% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17876.93,100,,208.496,Fee Schedule,100% of CMS OPPS Rate,16089.24,90,,,Fee Schedule,90% of CMS OPPS Rate,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23240.02,130,,,Fee Schedule,130% of CMS OPPS Rate,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3520.35,14.42,,95.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,18413.25,103,,,Fee Schedule,103% of CMS OPPS Rate,18413.25,103,,,Fee Schedule,103% of CMS OPPS Rate,18309.75,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,12206.5,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,12206.5,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12206.5,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,12206.5,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,26815.41,150,,,Fee Schedule,150% of CMS OPPS Rate,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,3.696,Case Rate,Pays based on per visit rate,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,3417.82,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,17876.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24413,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,75.44,26815.41,
ICD GEN DUAL INSERT,46160185,CDM,480,RC,33249,HCPCS,Outpatient,,,41715.69,25029.41,,9364,100,,0.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45275.5,150,,55.696,Fee Schedule ,150% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11680.39,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,75.72,32,,89.56,Percent of Total Billed Charges,32% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,15017.65,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,15017.65,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,15017.65,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,25029.41,60,,605.2,Percent of Total Billed Charges,60% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,230.768,Fee Schedule,100% of CMS OPPS Rate,27165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39238.76,130,,,Fee Schedule,130% of CMS OPPS Rate,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,6015.4,14.42,,39.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31286.77,75,,211.896,Percent of Total Billed Charges,75% of Total Billed Charges,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,20857.85,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,45275.5,150,,,Fee Schedule,150% of CMS OPPS Rate,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,7.36,Case Rate,Pays based on per visit rate,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,38.56,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,41715.69,100,,282.528,Percent of Total Billed Charges,100% of Total Billed Charges,75.72,45275.5,
ICD GEN MULTI INSERT,46160186,CDM,480,RC,33249,HCPCS,Outpatient,,,41715.69,25029.41,,9364,100,,8.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45275.5,150,,162.544,Fee Schedule ,150% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11680.39,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,76.28,32,,8960,Percent of Total Billed Charges,32% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,15017.65,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,15017.65,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,15017.65,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,25029.41,60,,1052.024,Percent of Total Billed Charges,60% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,125.536,Fee Schedule,100% of CMS OPPS Rate,27165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39238.76,130,,,Fee Schedule,130% of CMS OPPS Rate,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,6015.4,14.42,,68.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31286.77,75,,211.896,Percent of Total Billed Charges,75% of Total Billed Charges,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20857.85,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,20857.85,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,45275.5,150,,,Fee Schedule,150% of CMS OPPS Rate,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,6,Case Rate,Pays based on per visit rate,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,5840.2,14,,66.08,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,41715.69,100,,282.528,Percent of Total Billed Charges,100% of Total Billed Charges,76.28,45275.5,
ICD GEN MULTI REPLACE,46160189,CDM,480,RC,33249,HCPCS,Outpatient,,,40148.51,24089.11,,9364,100,,0.288,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,45275.5,150,,64.8,Fee Schedule ,150% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11241.58,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,76.48,32,,8.96,Percent of Total Billed Charges,32% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,14453.46,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,14453.46,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,14453.46,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,24089.11,60,,1174.24,Percent of Total Billed Charges,60% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,30183.67,100,,174.096,Fee Schedule,100% of CMS OPPS Rate,27165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39238.76,130,,,Fee Schedule,130% of CMS OPPS Rate,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5789.42,14.42,,66.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,31089.17,103,,,Fee Schedule,103% of CMS OPPS Rate,30111.38,75,,302.848,Percent of Total Billed Charges,75% of Total Billed Charges,20074.26,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,20074.26,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20074.26,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,20074.26,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,45275.5,150,,,Fee Schedule,150% of CMS OPPS Rate,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370,100,,6,Case Rate,Pays based on per visit rate,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,5620.79,14,,64.32,Percent of Total Billed Charges,14% of Total Billed Charges,30183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,40148.51,100,,403.8,Percent of Total Billed Charges,100% of Total Billed Charges,76.48,45275.5,
CATH TEMPO 5FRX65CM UNIV FLSH,46160192,CDM,272,RC,C1887,HCPCS,Outpatient,,,94.5,56.70,,43.86,100,,0.776,Fee Schedule,100% of Aetna Fee Schedule,42.53,45,,1.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.46,28,,1.176,Percent of Total Billed Charges,28% of Total Billed Charges,76.48,32,,8.976,Percent of Total Billed Charges,32% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,34.02,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,34.02,36,,1.512,Percent of Total Billed Charges,36% Total Bille Charges,34.02,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,56.7,60,,1089.784,Percent of Total Billed Charges,60% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,100,,2.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.63,14.42,,23.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.88,75,,302.848,Percent of Total Billed Charges,75% of Total Billed Charges,47.25,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,47.25,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.25,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,47.25,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.15,70,,6,Percent of Total Billed Charges,70% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,13.23,14,,23.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,100,,403.8,Percent of Total Billed Charges,100% of Total Billed Charges,13.23,94.5,
CATH CEREB 5FRX100CM .035IN GW,46160195,CDM,272,RC,C1725,HCPCS,Outpatient,,,97.5,58.50,,99.47,100,,0.264,Fee Schedule,100% of Aetna Fee Schedule,43.88,45,,3.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,76.55,32,,9.008,Percent of Total Billed Charges,32% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.1,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,35.1,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,35.1,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,58.5,60,,1089.784,Percent of Total Billed Charges,60% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,100,,15.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,14.06,14.42,,79.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,474.016,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,70,,6,Percent of Total Billed Charges,70% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,77.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,100,,632.016,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,99.47,
CATH ANGIO PIG 5FR 90CM SIDEH,46160198,CDM,272,RC,C1725,HCPCS,Outpatient,,,97.5,58.50,,99.47,100,,0.32,Fee Schedule,100% of Aetna Fee Schedule,43.88,45,,22.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,76.6,32,,9.08,Percent of Total Billed Charges,32% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,35.1,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,35.1,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,35.1,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,58.5,60,,1379.512,Percent of Total Billed Charges,60% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,100,,8.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.06,14.42,,64.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,474.016,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,70,,0.664,Percent of Total Billed Charges,70% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,62.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,100,,632.016,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,99.47,
CATH ROYFLSH HFLO 5FRX65CM VCF,46160201,CDM,272,RC,,,Outpatient,,,97.5,58.50,,58.5,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,43.88,45,,15.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,28,,3.896,Percent of Total Billed Charges,28% of Total Billed Charges,76.69,32,,9.08,Percent of Total Billed Charges,32% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,35.1,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,35.1,36,,5.008,Percent of Total Billed Charges,36% Total Bille Charges,35.1,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,58.5,60,,919.672,Percent of Total Billed Charges,60% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,100,,32.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,14.06,14.42,,97.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,153.208,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,70,,53.688,Percent of Total Billed Charges,70% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,94.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,100,,204.272,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,97.5,
CATH 5FRX65CM BEAC 0.038IN GW,46160204,CDM,272,RC,,,Outpatient,,,97.5,58.50,,58.5,60,,0.752,Percent of Total Billed Charges,60% of Total Billed Charges,43.88,45,,2.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,7680,32,,9.088,Percent of Total Billed Charges,32% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,35.1,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,35.1,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,35.1,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,58.5,60,,919.672,Percent of Total Billed Charges,60% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,100,,201.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,14.06,14.42,,13.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,153.208,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,70,,11.072,Percent of Total Billed Charges,70% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,12.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,100,,204.272,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,7680,
CATH SIM1 TORB NB ADV 5FRX100C,46160205,CDM,272,RC,C1887,HCPCS,Outpatient,,,97.5,58.50,,43.86,100,,5.936,Fee Schedule,100% of Aetna Fee Schedule,43.88,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.3,28,,1.456,Percent of Total Billed Charges,28% of Total Billed Charges,7812.16,32,,9.128,Percent of Total Billed Charges,32% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,35.1,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,35.1,36,,1.872,Percent of Total Billed Charges,36% Total Bille Charges,35.1,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,58.5,60,,1089.784,Percent of Total Billed Charges,60% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.5,100,,52.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.06,14.42,,16.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,1886.224,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.75,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,70,,98.216,Percent of Total Billed Charges,70% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,13.65,14,,15.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.5,100,,2514.968,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,7812.16,
GW .035 260CM AMPLATZ,46160208,CDM,272,RC,,,Outpatient,,,155.8,93.48,,93.48,60,,12.384,Percent of Total Billed Charges,60% of Total Billed Charges,70.11,45,,902.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.62,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,7840.32,32,,9.128,Percent of Total Billed Charges,32% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,56.09,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,56.09,36,,0.904,Percent of Total Billed Charges,36% Total Bille Charges,56.09,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,93.48,60,,843.368,Percent of Total Billed Charges,60% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.8,100,,89.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,22.47,14.42,,95.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.85,75,,1886.224,Percent of Total Billed Charges,75% of Total Billed Charges,77.9,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,77.9,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.9,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,77.9,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.06,70,,47.296,Percent of Total Billed Charges,70% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.81,14,,92.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.8,100,,2514.968,Percent of Total Billed Charges,100% of Total Billed Charges,21.81,7840.32,
CATH VIS RIM SLIP 5FRX65CM,46160210,CDM,272,RC,,,Outpatient,,,197.75,118.65,,118.65,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,88.99,45,,749.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.37,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,7.68,32,,89.6,Percent of Total Billed Charges,32% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,71.19,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,71.19,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,71.19,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,118.65,60,,1240.192,Percent of Total Billed Charges,60% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.75,100,,123.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,28.52,14.42,,44.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.31,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,98.88,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,98.88,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.88,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,98.88,50,,495.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.43,70,,0.44,Percent of Total Billed Charges,70% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.75,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.68,197.75,
CATH CV PCC SOLO2 5FR W/70 CM,46160240,CDM,278,RC,C1751,HCPCS,Outpatient,,,486.49,291.89,,602.8,110,,0.608,Percent of Total Billed Charges,110% of Total Billed Charges,218.92,45,,60.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.22,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,7.68,32,,89.6,Percent of Total Billed Charges,32% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,175.14,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,175.14,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,175.14,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.49,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,70.15,14.42,,44.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.19,80,,150,Percent of Total Billed Charges,80% of Total Billed Charges,243.25,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,243.25,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.25,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,243.25,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.54,70,,8.6,Percent of Total Billed Charges,70% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,68.11,14,,43.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.49,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.68,602.8,
GW VASC 180CM 1.5MM .035IN SS,46160241,CDM,272,RC,C1769,HCPCS,Outpatient,,,83.64,50.18,,55.13,100,,0.64,Fee Schedule,100% of Aetna Fee Schedule,37.64,45,,89.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.42,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,7.68,32,,89.712,Percent of Total Billed Charges,32% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,30.11,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,30.11,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,30.11,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,50.18,60,,926.832,Percent of Total Billed Charges,60% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.64,100,,361.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.06,14.42,,57.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.73,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,41.82,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.82,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.55,70,,8.6,Percent of Total Billed Charges,70% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14,,55.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.64,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.68,83.64,
GW ESCP AMPTZ RSN 260CM .035IN,46160243,CDM,272,RC,C1769,HCPCS,Outpatient,,,123,73.80,,55.13,100,,0.2,Fee Schedule,100% of Aetna Fee Schedule,55.35,45,,124.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.44,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,7.74,32,,89.712,Percent of Total Billed Charges,32% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,44.28,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,44.28,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,44.28,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,73.8,60,,1490.632,Percent of Total Billed Charges,60% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123,100,,143.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,14.42,,8.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.25,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,61.5,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,61.5,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.5,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,61.5,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.1,70,,2.832,Percent of Total Billed Charges,70% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14,,8.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.74,123,
GW VASC AMPTZ SUP STIFF 75CM,46160244,CDM,272,RC,C1769,HCPCS,Outpatient,,,150,90.00,,55.13,100,,6.976,Fee Schedule,100% of Aetna Fee Schedule,67.5,45,,35.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,7.74,32,,89.712,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,993.752,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,2.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,11.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,330.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,155.04,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,11.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.74,150,
GW VASC AMPTZ XSTIF 180CM,46160246,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,35.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,0.312,Percent of Total Billed Charges,28% of Total Billed Charges,7.75,32,,89.712,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,0.408,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,993.752,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,7.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,16.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,9.664,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.75,150,
GW VASC GLDWR 180CM 3CM .035IN,46160248,CDM,272,RC,,,Outpatient,,,198.5,119.10,,119.1,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,89.33,45,,12.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.58,28,,1,Percent of Total Billed Charges,28% of Total Billed Charges,7.75,32,,89.712,Percent of Total Billed Charges,32% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,71.46,36,,1.28,Percent of Total Billed Charges,36% of Total Billed Charges,71.46,36,,1.28,Percent of Total Billed Charges,36% Total Bille Charges,71.46,36,,1.28,Percent of Total Billed Charges,36% of Total Billed Charges,119.1,60,,588.064,Percent of Total Billed Charges,60% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.5,100,,50.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,28.62,14.42,,7.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.88,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,99.25,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,99.25,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.25,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,99.25,50,,242.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.95,70,,2.904,Percent of Total Billed Charges,70% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14,,7.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.5,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.75,198.5,
GW VASC AMPTZ SUP STIFF 180CM,46160249,CDM,272,RC,,,Outpatient,,,200.6,120.36,,120.36,60,,6.496,Percent of Total Billed Charges,60% of Total Billed Charges,90.27,45,,25.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.17,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,7.77,32,,89.848,Percent of Total Billed Charges,32% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,72.22,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,72.22,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,72.22,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,120.36,60,,430.528,Percent of Total Billed Charges,60% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.6,100,,33.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.93,14.42,,11.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.45,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,100.3,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,100.3,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.3,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,100.3,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.42,70,,9.648,Percent of Total Billed Charges,70% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,14,,10.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.6,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,7.77,200.6,
GW VASC AMPTZ SUP STIFF 260CM,46160250,CDM,272,RC,,,Outpatient,,,209.95,125.97,,125.97,60,,6.112,Percent of Total Billed Charges,60% of Total Billed Charges,94.48,45,,25.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.79,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,7.8,32,,89.896,Percent of Total Billed Charges,32% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,75.58,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,75.58,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,75.58,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,125.97,60,,1336.76,Percent of Total Billed Charges,60% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.95,100,,6.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,30.27,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.46,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,104.98,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,104.98,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.98,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,104.98,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.97,70,,0.096,Percent of Total Billed Charges,70% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,29.39,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.95,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.8,209.95,
GW VASC GLDWR 260CM 3CM .035IN,46160251,CDM,272,RC,,,Outpatient,,,222,133.20,,133.2,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,99.9,45,,2.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.16,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,7.82,32,,89.904,Percent of Total Billed Charges,32% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,79.92,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,79.92,36,,0.912,Percent of Total Billed Charges,36% Total Bille Charges,79.92,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,133.2,60,,1291.56,Percent of Total Billed Charges,60% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222,100,,545.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,32.01,14.42,,70.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.5,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.4,70,,0.176,Percent of Total Billed Charges,70% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.08,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.82,222,
GW VASC GLDWR 180CM 3CM .035IN,46160252,CDM,272,RC,C1769,HCPCS,Outpatient,,,273.8,164.28,,55.13,100,,8.984,Fee Schedule,100% of Aetna Fee Schedule,123.21,45,,53.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.66,28,,0.376,Percent of Total Billed Charges,28% of Total Billed Charges,7.85,32,,89.952,Percent of Total Billed Charges,32% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,98.57,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,98.57,36,,0.488,Percent of Total Billed Charges,36% Total Bille Charges,98.57,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,164.28,60,,1956.808,Percent of Total Billed Charges,60% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.8,100,,2006.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,39.48,14.42,,160.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.35,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,136.9,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,136.9,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.9,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,136.9,50,,161.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.66,70,,0.32,Percent of Total Billed Charges,70% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14,,155.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.8,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.85,273.8,
GW VASC GLDWR 260CM 3CM .035IN,46160253,CDM,272,RC,,,Outpatient,,,249.25,149.55,,149.55,60,,2.912,Percent of Total Billed Charges,60% of Total Billed Charges,112.16,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.79,28,,1.304,Percent of Total Billed Charges,28% of Total Billed Charges,7.9,32,,89.96,Percent of Total Billed Charges,32% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,89.73,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,89.73,36,,1.68,Percent of Total Billed Charges,36% Total Bille Charges,89.73,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,149.55,60,,886.864,Percent of Total Billed Charges,60% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.25,100,,1666.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,35.94,14.42,,277.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.94,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,124.63,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,124.63,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.63,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,124.63,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.48,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.9,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.25,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.9,249.25,
GW .035INX150CM J-TIP EMERALD,46160261,CDM,272,RC,C1769,HCPCS,Outpatient,,,49.14,29.48,,55.13,100,,6.232,Fee Schedule,100% of Aetna Fee Schedule,22.11,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.76,28,,0.92,Percent of Total Billed Charges,28% of Total Billed Charges,7.91,32,,89.992,Percent of Total Billed Charges,32% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,17.69,36,,1.184,Percent of Total Billed Charges,36% Total Bille Charges,17.69,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,29.48,60,,767.504,Percent of Total Billed Charges,60% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.14,100,,133.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.09,14.42,,277.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.86,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,24.57,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.57,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.57,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.57,50,,139.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.4,70,,1.576,Percent of Total Billed Charges,70% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14,,269.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.14,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,6.88,55.13,
INTRO SHTH PNCL 10CM 2.5CM 6FR,46160263,CDM,272,RC,C1894,HCPCS,Outpatient,,,52.5,31.50,,82.29,100,,0.08,Fee Schedule,100% of Aetna Fee Schedule,23.63,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,28,,0.936,Percent of Total Billed Charges,28% of Total Billed Charges,7.91,32,,90,Percent of Total Billed Charges,32% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,36,,1.2,Percent of Total Billed Charges,36% of Total Billed Charges,18.9,36,,1.2,Percent of Total Billed Charges,36% Total Bille Charges,18.9,36,,1.2,Percent of Total Billed Charges,36% of Total Billed Charges,31.5,60,,697.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,100,,199.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.57,14.42,,126.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.38,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,26.25,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.75,70,,56.504,Percent of Total Billed Charges,70% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,122.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,82.29,
INTRO SHTH PNCL 10CM 2.5CM 5FR,46160267,CDM,272,RC,C1894,HCPCS,Outpatient,,,52.5,31.50,,82.29,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,23.63,45,,0.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,7.94,32,,90.328,Percent of Total Billed Charges,32% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,18.9,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,18.9,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,31.5,60,,49.68,Percent of Total Billed Charges,60% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,100,,276.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.57,14.42,,439.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.38,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,26.25,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.75,70,,1.544,Percent of Total Billed Charges,70% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,426.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,82.29,
SHEATH KT BRT TP 7FRX5.5CM.035,46160274,CDM,272,RC,C1894,HCPCS,Outpatient,,,125.84,75.50,,82.29,100,,0.28,Fee Schedule,100% of Aetna Fee Schedule,56.63,45,,0.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,14.752,Percent of Total Billed Charges,28% of Total Billed Charges,7.95,32,,90.368,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,18.968,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,18.968,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,18.968,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,252,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.84,100,,78.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,445.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,236.8,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,1.168,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,432.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,315.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.95,125.84,
CATH ANGI INTVN SLIP 4FRX100,46160283,CDM,272,RC,,,Outpatient,,,244.15,146.49,,146.49,60,,14.864,Percent of Total Billed Charges,60% of Total Billed Charges,109.87,45,,5.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.36,28,,0.28,Percent of Total Billed Charges,28% of Total Billed Charges,76.8,32,,90.368,Percent of Total Billed Charges,32% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,87.89,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,87.89,36,,0.36,Percent of Total Billed Charges,36% Total Bille Charges,87.89,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,146.49,60,,374.04,Percent of Total Billed Charges,60% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.15,100,,78.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,35.21,14.42,,667.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.11,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,122.08,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,122.08,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.08,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,122.08,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.91,70,,1.096,Percent of Total Billed Charges,70% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,648.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.15,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,34.18,244.15,
GW PLATINUM PLUS,46160292,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,14.864,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,94.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,76.86,32,,90.88,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,0.416,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,232.68,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,27.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,74.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,375.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1.224,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,375,
GW .018 THRUWAY WIRE,46160294,CDM,272,RC,C1769,HCPCS,Outpatient,,,427.8,256.68,,55.13,100,,0.424,Fee Schedule,100% of Aetna Fee Schedule,192.51,45,,1.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.78,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,77.12,32,,90.904,Percent of Total Billed Charges,32% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,154.01,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,154.01,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,154.01,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,256.68,60,,2775.408,Percent of Total Billed Charges,60% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.8,100,,56.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,61.69,14.42,,74.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.85,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,213.9,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,213.9,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.9,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,213.9,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.46,70,,1.344,Percent of Total Billed Charges,70% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,59.89,14,,72.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.8,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,427.8,
GW .014 THRUWAY WIRE,46160308,CDM,272,RC,C1769,HCPCS,Outpatient,,,520,312.00,,55.13,100,,0.592,Fee Schedule,100% of Aetna Fee Schedule,234,45,,31.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.6,28,,25.136,Percent of Total Billed Charges,28% of Total Billed Charges,77.24,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,187.2,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,187.2,36,,32.32,Percent of Total Billed Charges,36% Total Bille Charges,187.2,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,312,60,,191.52,Percent of Total Billed Charges,60% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520,100,,56.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,74.98,14.42,,282.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,390,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,260,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,88.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364,70,,3.36,Percent of Total Billed Charges,70% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,273.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,520,
FLTR VENA CAVA OPTEASE 55CM,46160322,CDM,278,RC,,,Outpatient,,,3120,1872.00,,3432,110,,0.792,Percent of Total Billed Charges,110% of Total Billed Charges,1404,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.6,28,,2.216,Percent of Total Billed Charges,28% of Total Billed Charges,77.68,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,1123.2,36,,2.848,Percent of Total Billed Charges,36% of Total Billed Charges,1123.2,36,,2.848,Percent of Total Billed Charges,36% Total Bille Charges,1123.2,36,,2.848,Percent of Total Billed Charges,36% of Total Billed Charges,1716,55,,397.92,Percent of Total Billed Charges,55% Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3120,100,,5.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,449.9,14.42,,358.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2496,80,,300,Percent of Total Billed Charges,80% of Total Billed Charges,1560,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1560,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,1560,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2184,70,,3.424,Percent of Total Billed Charges,70% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,436.8,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3120,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,77.68,3432,
TRAY PICC TRIPLE LUMEN POWER 7,46160326,CDM,278,RC,C1751,HCPCS,Outpatient,,,765.06,459.04,,909.23,110,,0.784,Percent of Total Billed Charges,110% of Total Billed Charges,344.28,45,,15.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.22,28,,1.864,Percent of Total Billed Charges,28% of Total Billed Charges,78.06,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,275.42,36,,2.4,Percent of Total Billed Charges,36% of Total Billed Charges,275.42,36,,2.4,Percent of Total Billed Charges,36% Total Bille Charges,275.42,36,,2.4,Percent of Total Billed Charges,36% of Total Billed Charges,420.78,55,,165.24,Percent of Total Billed Charges,55% Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.06,100,,118.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110.32,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.05,80,,300,Percent of Total Billed Charges,80% of Total Billed Charges,382.53,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,382.53,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.53,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,382.53,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,535.54,70,,1.888,Percent of Total Billed Charges,70% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,107.11,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,765.06,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,78.06,909.23,
CATH GLIDE HYDRPH 5FRX65CM,46160328,CDM,272,RC,C1887,HCPCS,Outpatient,,,269.7,161.82,,43.86,100,,5.856,Fee Schedule,100% of Aetna Fee Schedule,121.37,45,,7.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.52,28,,40.792,Percent of Total Billed Charges,28% of Total Billed Charges,78.08,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,97.09,36,,52.448,Percent of Total Billed Charges,36% of Total Billed Charges,97.09,36,,52.448,Percent of Total Billed Charges,36% Total Bille Charges,97.09,36,,52.448,Percent of Total Billed Charges,36% of Total Billed Charges,161.82,60,,283.2,Percent of Total Billed Charges,60% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.7,100,,3.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,38.89,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.28,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,134.85,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.85,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,134.85,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.79,70,,1.888,Percent of Total Billed Charges,70% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.7,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,37.76,269.7,
SHTH GUID PINN DESTIN 7FRX90CM,46160329,CDM,272,RC,C1894,HCPCS,Outpatient,,,491.83,295.10,,82.29,100,,632.504,Fee Schedule,100% of Aetna Fee Schedule,221.32,45,,16.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.71,28,,0.824,Percent of Total Billed Charges,28% of Total Billed Charges,78.13,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,177.06,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,177.06,36,,1.064,Percent of Total Billed Charges,36% Total Bille Charges,177.06,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,295.1,60,,275.64,Percent of Total Billed Charges,60% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.83,100,,4.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,70.92,14.42,,70.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.87,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,245.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,245.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.92,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,245.92,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.28,70,,0.2,Percent of Total Billed Charges,70% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,14,,68.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.83,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,68.86,491.83,
GW VASC TRNSND 165CM 2CM,46160332,CDM,272,RC,C1769,HCPCS,Outpatient,,,828.41,497.05,,55.13,100,,561.984,Fee Schedule,100% of Aetna Fee Schedule,372.78,45,,4.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,28,,5.312,Percent of Total Billed Charges,28% of Total Billed Charges,78.16,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,298.23,36,,6.832,Percent of Total Billed Charges,36% of Total Billed Charges,298.23,36,,6.832,Percent of Total Billed Charges,36% Total Bille Charges,298.23,36,,6.832,Percent of Total Billed Charges,36% of Total Billed Charges,497.05,60,,98.76,Percent of Total Billed Charges,60% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.41,100,,112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,119.46,14.42,,55.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.31,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,414.21,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.21,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.89,70,,0.32,Percent of Total Billed Charges,70% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,53.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.41,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,828.41,
WIRE VERSA HI TORQUE 145CM,46160334,CDM,272,RC,C1769,HCPCS,Outpatient,,,304.72,182.83,,55.13,100,,20.696,Fee Schedule,100% of Aetna Fee Schedule,137.12,45,,21.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.32,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,78.46,32,,91.24,Percent of Total Billed Charges,32% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,109.7,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,109.7,36,,0.136,Percent of Total Billed Charges,36% Total Bille Charges,109.7,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,182.83,60,,330.24,Percent of Total Billed Charges,60% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.72,100,,1.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,43.94,14.42,,263.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.54,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,152.36,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,152.36,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.36,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,152.36,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.3,70,,0.44,Percent of Total Billed Charges,70% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,42.66,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.72,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,42.66,304.72,
GW SV5 ST 300,46160335,CDM,272,RC,C1769,HCPCS,Outpatient,,,80.54,48.32,,55.13,100,,20.696,Fee Schedule,100% of Aetna Fee Schedule,36.24,45,,6.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.55,28,,1.048,Percent of Total Billed Charges,28% of Total Billed Charges,78.66,32,,91.456,Percent of Total Billed Charges,32% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.99,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,28.99,36,,1.344,Percent of Total Billed Charges,36% Total Bille Charges,28.99,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,48.32,60,,267.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.54,100,,0.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14.42,,263.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.41,75,,333,Percent of Total Billed Charges,75% of Total Billed Charges,40.27,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,40.27,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.27,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,40.27,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.38,70,,0.472,Percent of Total Billed Charges,70% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,256.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.54,100,,444,Percent of Total Billed Charges,100% of Total Billed Charges,11.28,80.54,
GW FATHOM PVS .016/180/35,46160336,CDM,272,RC,C1769,HCPCS,Outpatient,,,600,360.00,,55.13,100,,20.696,Fee Schedule,100% of Aetna Fee Schedule,270,45,,42.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,78.75,32,,91.72,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,404.04,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,11.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,395.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,333,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.688,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,384.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,444,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,600,
GUIDEWIRE STEERABLE,46160337,CDM,272,RC,C1769,HCPCS,Outpatient,,,375,225.00,,55.13,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,52.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,78.8,32,,92.12,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,0.616,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,210.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,158.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,436.432,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,1.888,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,153.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,581.904,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,375,
CATH PEEL AWAY KIT 15.5FX28CM,46160340,CDM,272,RC,C1750,HCPCS,Outpatient,,,975,585.00,,514.9,100,,0.128,Fee Schedule,100% of Aetna Fee Schedule,438.75,45,,5.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,78.8,32,,9381.12,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,0.592,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,585,60,,67.68,Percent of Total Billed Charges,60% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,2.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,731.25,75,,436.432,Percent of Total Billed Charges,75% of Total Billed Charges,487.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,581.904,Percent of Total Billed Charges,100% of Total Billed Charges,78.8,975,
CATH BLN RUBICON 18 135CM,46160342,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,256.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,5.936,Percent of Total Billed Charges,28% of Total Billed Charges,78.8,32,,9.24,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,7.632,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,397.92,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,70.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,358.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,347.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,78.8,600,
DUAL LUMEN PICC SOLO,46160344,CDM,272,RC,C1751,HCPCS,Outpatient,,,785.72,471.43,,67.66,100,,3.584,Fee Schedule,100% of Aetna Fee Schedule,353.57,45,,1.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220,28,,5.648,Percent of Total Billed Charges,28% of Total Billed Charges,79.04,32,,9.264,Percent of Total Billed Charges,32% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,282.86,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,282.86,36,,7.256,Percent of Total Billed Charges,36% Total Bille Charges,282.86,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,471.43,60,,183.6,Percent of Total Billed Charges,60% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.72,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,113.3,14.42,,238.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.29,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,392.86,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,392.86,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.86,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,392.86,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,70,,2.944,Percent of Total Billed Charges,70% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,110,14,,231.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,785.72,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,67.66,785.72,
EEG 41-60 MINUTES,48058119,CDM,740,RC,95812,HCPCS,Outpatient,,,1566.13,939.68,,220.87,100,,6.872,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,2.952,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,760.84,280,,0.592,Fee Schedule,280% of BCBS BULE Fee Schedule,869.54,320,,9.384,Fee Schedule,320% of BCBS Blue Essentials Rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,978.23,360,,0.76,Fee Schedule,360% of BCBS POS Rate,978.23,360,,0.76,Fee schedule,360% of BCBS PPO Rate,978.23,360,,0.76,Fee Schedule,360% of BCBS Traditional Rate,939.68,60,,184.68,Percent of Total Billed Charges,60% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,33.888,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,225.84,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1174.6,75,,333,Percent of Total Billed Charges,75% of Total Billed Charges,783.07,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,783.07,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,783.07,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,783.07,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.616,Case Rate,Pays based on per visit rate,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.26,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.13,100,,444,Percent of Total Billed Charges,100% of Total Billed Charges,219.26,1566.13,
EEG AWAKE/ASLEEP,48058127,CDM,740,RC,95819,HCPCS,Outpatient,,,1562,937.20,,303.19,100,,0.128,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,2.952,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1052.49,280,,1.368,Fee Schedule,280% of BCBS BULE Fee Schedule,1202.85,320,,92.2,Fee Schedule,320% of BCBS Blue Essentials Rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,1353.2,360,,1.76,Fee Schedule,360% of BCBS POS Rate,1353.2,360,,1.76,Fee schedule,360% of BCBS PPO Rate,1353.2,360,,1.76,Fee Schedule,360% of BCBS Traditional Rate,937.2,60,,239.64,Percent of Total Billed Charges,60% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,16.128,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,225.24,14.42,,184.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1171.5,75,,333,Percent of Total Billed Charges,75% of Total Billed Charges,781,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,781,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,781,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,781,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,1.208,Case Rate,Pays based on per visit rate,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,218.68,14,,179.056,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1562,100,,444,Percent of Total Billed Charges,100% of Total Billed Charges,218.68,1562,
EEG BEDSIDE,48058143,CDM,740,RC,95822,HCPCS,Outpatient,,,1565.74,939.44,,272.61,100,,5.584,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,133.344,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,932.4,280,,0.392,Fee Schedule,280% of BCBS BULE Fee Schedule,1065.6,320,,92.824,Fee Schedule,320% of BCBS Blue Essentials Rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,1198.8,360,,0.504,Fee Schedule,360% of BCBS POS Rate,1198.8,360,,0.504,Fee schedule,360% of BCBS PPO Rate,1198.8,360,,0.504,Fee Schedule,360% of BCBS Traditional Rate,939.44,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,37.536,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,225.78,14.42,,276.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1174.31,75,,436.432,Percent of Total Billed Charges,75% of Total Billed Charges,782.87,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,782.87,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,782.87,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,782.87,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,9.744,Case Rate,Pays based on per visit rate,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,219.2,14,,268.624,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.74,100,,581.904,Percent of Total Billed Charges,100% of Total Billed Charges,219.2,1565.74,
EEG AWAKE/DROWSY,48058176,CDM,740,RC,95816,HCPCS,Outpatient,,,1381.15,828.69,,245.7,100,,1.192,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,199.616,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,869.85,280,,2.296,Fee Schedule,280% of BCBS BULE Fee Schedule,994.11,320,,93.048,Fee Schedule,320% of BCBS Blue Essentials Rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,1118.38,360,,2.952,Fee Schedule,360% of BCBS POS Rate,1118.38,360,,2.952,Fee schedule,360% of BCBS PPO Rate,1118.38,360,,2.952,Fee Schedule,360% of BCBS Traditional Rate,828.69,60,,49.68,Percent of Total Billed Charges,60% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,9.664,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,199.16,14.42,,184.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1035.86,75,,436.432,Percent of Total Billed Charges,75% of Total Billed Charges,690.58,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,690.58,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,690.58,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,690.58,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.552,Case Rate,Pays based on per visit rate,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,193.36,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1381.15,100,,581.904,Percent of Total Billed Charges,100% of Total Billed Charges,193.36,1381.15,
EEG DIGITAL ANALYSIS,48058184,CDM,740,RC,95957,HCPCS,Outpatient,,,908.04,544.82,,115.55,100,,0.08,Fee Schedule,100% of Aetna Fee Schedule,408.62,45,,107.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,471.24,280,,6.096,Fee Schedule,280% of BCBS BULE Fee Schedule,538.56,320,,93.28,Fee Schedule,320% of BCBS Blue Essentials Rate,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,605.88,360,,7.84,Fee Schedule,360% of BCBS POS Rate,605.88,360,,7.84,Fee schedule,360% of BCBS PPO Rate,605.88,360,,7.84,Fee Schedule,360% of BCBS Traditional Rate,544.82,60,,69.24,Percent of Total Billed Charges,60% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,908.04,100,,48.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,130.94,14.42,,184.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,681.03,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,454.02,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,454.02,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,454.02,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,454.02,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,3.632,Case Rate,Pays based on per visit rate,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,127.13,14,,179.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,908.04,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,115.55,908.04,
EEG MON 61 - 119 MIN,48060421,CDM,740,RC,95813,HCPCS,Outpatient,,,362.23,217.34,,259.02,100,,0.776,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,2.584,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,902.13,280,,0.568,Fee Schedule,280% of BCBS BULE Fee Schedule,1031.01,320,,93.424,Fee Schedule,320% of BCBS Blue Essentials Rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,1159.88,360,,0.728,Fee Schedule,360% of BCBS POS Rate,1159.88,360,,0.728,Fee schedule,360% of BCBS PPO Rate,1159.88,360,,0.728,Fee Schedule,360% of BCBS Traditional Rate,217.34,60,,32.76,Percent of Total Billed Charges,60% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,14.976,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,52.23,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,271.67,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,181.12,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,181.12,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,181.12,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,181.12,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,1.768,Case Rate,Pays based on per visit rate,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.71,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,362.23,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,50.71,1159.88,
EEG CONT MONT SETUP,48060422,CDM,740,RC,95700,HCPCS,Outpatient,,,506.14,303.68,,187.04,100,,1.32,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,4.576,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.848,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,93.488,Fee Schedule,320% of BCBS Blue Essentials Rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,1.088,Fee Schedule,360% of BCBS POS Rate,911.16,360,,1.088,Fee schedule,360% of BCBS PPO Rate,911.16,360,,1.088,Fee Schedule,360% of BCBS Traditional Rate,303.68,60,,46.944,Percent of Total Billed Charges,60% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,94.336,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,72.99,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,379.61,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,253.07,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,253.07,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,253.07,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,253.07,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.056,Case Rate,Pays based on per visit rate,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,70.86,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,506.14,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,70.86,911.16,
EEG CONT W/O VID 2-12HR UNMT,48060423,CDM,740,RC,95705,HCPCS,Outpatient,,,1868.52,1121.11,,139.86,100,,1.64,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,7.096,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,93.624,Fee Schedule,320% of BCBS Blue Essentials Rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,0.464,Fee Schedule,360% of BCBS POS Rate,911.16,360,,0.464,Fee schedule,360% of BCBS PPO Rate,911.16,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,1121.11,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,117.12,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,269.44,14.42,,202.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1401.39,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,934.26,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,934.26,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,934.26,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,934.26,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.088,Case Rate,Pays based on per visit rate,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,196.976,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.52,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,139.86,1868.52,
EEG CONT W/O VID 2-12HR Q2 MT,48060424,CDM,740,RC,95706,HCPCS,Outpatient,,,2478.24,1486.94,,268.09,100,,1.968,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,2.104,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,93.728,Fee Schedule,320% of BCBS Blue Essentials Rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,0.48,Fee Schedule,360% of BCBS POS Rate,911.16,360,,0.48,Fee schedule,360% of BCBS PPO Rate,911.16,360,,0.48,Fee Schedule,360% of BCBS Traditional Rate,1486.94,60,,667.12,Percent of Total Billed Charges,60% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,12.4,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,357.36,14.42,,28.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1858.68,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,1239.12,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.048,Case Rate,Pays based on per visit rate,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,27.344,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2478.24,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,259.17,2478.24,
EEG CONT W/O VID 2-12HR CNT MT,48060425,CDM,740,RC,95707,HCPCS,Outpatient,,,2478.24,1486.94,,295.27,100,,1.856,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,332.728,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.608,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,93.776,Fee Schedule,320% of BCBS Blue Essentials Rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,0.784,Fee Schedule,360% of BCBS POS Rate,911.16,360,,0.784,Fee schedule,360% of BCBS PPO Rate,911.16,360,,0.784,Fee Schedule,360% of BCBS Traditional Rate,1486.94,60,,1152.92,Percent of Total Billed Charges,60% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,569.232,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,357.36,14.42,,331.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1858.68,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,1239.12,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,9.584,Case Rate,Pays based on per visit rate,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,321.888,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2478.24,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,259.17,2478.24,
EEG CONT W/O VID 12-26 HR UNMT,48060426,CDM,740,RC,95708,HCPCS,Outpatient,,,4048.46,2429.08,,205.74,100,,1.76,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,204.568,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,93.952,Fee Schedule,320% of BCBS Blue Essentials Rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,0.024,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,0.024,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,2429.08,60,,1152.92,Percent of Total Billed Charges,60% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,2.672,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,583.79,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,3036.35,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,2024.23,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2024.23,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.23,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2024.23,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,9.584,Case Rate,Pays based on per visit rate,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4048.46,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,205.74,4048.46,
EEG CONT W/O VID 12-26HR Q2 MT,48060427,CDM,740,RC,95709,HCPCS,Outpatient,,,5369.52,3221.71,,525.19,100,,4.968,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,4.744,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,0.464,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,93.952,Fee Schedule,320% of BCBS Blue Essentials Rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,0.6,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,0.6,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,0.6,Fee Schedule,360% of BCBS Traditional Rate,3221.71,60,,527.024,Percent of Total Billed Charges,60% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,6.56,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,774.28,14.42,,221.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,4027.14,75,,140.528,Percent of Total Billed Charges,75% of Total Billed Charges,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.792,Case Rate,Pays based on per visit rate,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,214.592,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5369.52,100,,187.368,Percent of Total Billed Charges,100% of Total Billed Charges,442.56,5369.52,
EEG CNT W/O VID 12-26HR CNT MT,48060428,CDM,740,RC,95710,HCPCS,Outpatient,,,5369.52,3221.71,,661.25,100,,2.192,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,8.704,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,94.008,Fee Schedule,320% of BCBS Blue Essentials Rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,0.04,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,0.04,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,3221.71,60,,568.096,Percent of Total Billed Charges,60% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,6.56,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,774.28,14.42,,28.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,4027.14,75,,183.4,Percent of Total Billed Charges,75% of Total Billed Charges,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2684.76,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,2.496,Case Rate,Pays based on per visit rate,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,27.328,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5369.52,100,,244.536,Percent of Total Billed Charges,100% of Total Billed Charges,442.56,5369.52,
VEEG CONT 2-12HR UNMT,48060429,CDM,740,RC,95711,HCPCS,Outpatient,,,1868.52,1121.11,,148.87,100,,0.216,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,1.424,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.664,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,94.144,Fee Schedule,320% of BCBS Blue Essentials Rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,0.856,Fee Schedule,360% of BCBS POS Rate,911.16,360,,0.856,Fee schedule,360% of BCBS PPO Rate,911.16,360,,0.856,Fee Schedule,360% of BCBS Traditional Rate,1121.11,60,,1829.68,Percent of Total Billed Charges,60% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,296.32,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.44,14.42,,28.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1401.39,75,,183.4,Percent of Total Billed Charges,75% of Total Billed Charges,934.26,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,934.26,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,934.26,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,934.26,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,1.16,Case Rate,Pays based on per visit rate,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,261.59,14,,27.464,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.52,100,,244.536,Percent of Total Billed Charges,100% of Total Billed Charges,148.87,1868.52,
VEEG CONT 2-12HR QT MT,48060430,CDM,740,RC,95712,HCPCS,Outpatient,,,2478.24,1486.94,,313.05,100,,0.736,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,12.288,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,0.656,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,94.376,Fee Schedule,320% of BCBS Blue Essentials Rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,0.84,Fee Schedule,360% of BCBS POS Rate,911.16,360,,0.84,Fee schedule,360% of BCBS PPO Rate,911.16,360,,0.84,Fee Schedule,360% of BCBS Traditional Rate,1486.94,60,,1852.2,Percent of Total Billed Charges,60% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,443.584,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,357.36,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1858.68,75,,354.992,Percent of Total Billed Charges,75% of Total Billed Charges,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.12,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,1.176,Case Rate,Pays based on per visit rate,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2478.24,100,,473.32,Percent of Total Billed Charges,100% of Total Billed Charges,259.17,2478.24,
VEEG CONT 2-12HR CONT MT,48060431,CDM,740,RC,95713,HCPCS,Outpatient,,,2478.24,1486.94,,408.2,100,,38.984,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,13.496,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,0.328,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,9680.352,Fee Schedule,320% of BCBS Blue Essentials Rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,0.416,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,0.416,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,0.416,Fee Schedule,360% of BCBS Traditional Rate,1486.94,60,,2778.304,Percent of Total Billed Charges,60% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,238.656,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,357.36,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1858.68,75,,354.992,Percent of Total Billed Charges,75% of Total Billed Charges,1239.12,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.12,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,1239.12,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,1.768,Case Rate,Pays based on per visit rate,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,346.95,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2478.24,100,,473.32,Percent of Total Billed Charges,100% of Total Billed Charges,346.95,2478.24,
VEEG CONT 12-26HR UNMT,48060432,CDM,740,RC,95714,HCPCS,Outpatient,,,4048.46,2429.08,,219.33,100,,1.568,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,2.272,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,0.544,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,9.48,Fee Schedule,320% of BCBS Blue Essentials Rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,0.696,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,0.696,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,0.696,Fee Schedule,360% of BCBS Traditional Rate,2429.08,60,,311.4,Percent of Total Billed Charges,60% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,5.744,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,583.79,14.42,,68.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,3036.35,75,,457.848,Percent of Total Billed Charges,75% of Total Billed Charges,2024.23,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,2024.23,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.23,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,2024.23,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,0.944,Case Rate,Pays based on per visit rate,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,566.78,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4048.46,100,,610.464,Percent of Total Billed Charges,100% of Total Billed Charges,219.33,4048.46,
VEEG CONT 12-26HR Q2 MT,48060433,CDM,740,RC,95715,HCPCS,Outpatient,,,5369.52,3221.71,,574.47,100,,1.376,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,0.136,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,280,,1.072,Fee Schedule,280% of BCBS BULE Fee Schedule,1553.95,320,,9.512,Fee Schedule,320% of BCBS Blue Essentials Rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,1748.2,360,,1.384,Fee Schedule,360% of BCBS POS Rate,1748.2,360,,1.384,Fee schedule,360% of BCBS PPO Rate,1748.2,360,,1.384,Fee Schedule,360% of BCBS Traditional Rate,3221.71,60,,311.4,Percent of Total Billed Charges,60% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,10.168,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,774.28,14.42,,68.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,4027.14,75,,457.848,Percent of Total Billed Charges,75% of Total Billed Charges,2684.76,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2684.76,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,3.264,Case Rate,Pays based on per visit rate,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,66.64,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5369.52,100,,610.464,Percent of Total Billed Charges,100% of Total Billed Charges,442.56,5369.52,
VEEG CONT 12-26HR CONT MT,48060434,CDM,740,RC,95716,HCPCS,Outpatient,,,5369.52,3221.71,,824.12,100,,0.944,Fee Schedule,100% of Aetna Fee Schedule,1438.86,150,,1.872,Fee Schedule ,150% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2545.06,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,2908.64,320,,9.512,Fee Schedule,320% of BCBS Blue Essentials Rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,3272.22,360,,0.464,Fee Schedule,360% of BCBS POS Rate,3272.22,360,,0.464,Fee schedule,360% of BCBS PPO Rate,3272.22,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,3221.71,60,,1174.24,Percent of Total Billed Charges,60% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,15.76,Fee Schedule,100% of CMS OPPS Rate,863.31,90,,,Fee Schedule,90% of CMS OPPS Rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.01,130,,,Fee Schedule,130% of CMS OPPS Rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,774.28,14.42,,12.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,4027.14,75,,577.368,Percent of Total Billed Charges,75% of Total Billed Charges,2684.76,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2684.76,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,2684.76,50,,531.496,Percent of Total Billed Charges,50% of Total Billed Charges,1438.86,150,,,Fee Schedule,150% of CMS OPPS Rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,675,100,,2.304,Case Rate,Pays based on per visit rate,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,751.73,14,,11.92,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,5369.52,100,,769.824,Percent of Total Billed Charges,100% of Total Billed Charges,675,5369.52,
DX ARTHROGRAM ANKLE LT SI,49000001,CDM,322,RC,73615,HCPCS,Outpatient,,,348.81,209.29,,106.05,100,,0.464,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,1.808,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,9.6,Fee Schedule,320% of BCBS Blue Essentials Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.072,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.072,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,1490.632,Fee Schedule,103% of Cigna fee schedule,130.31,100,,10.64,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,4.672,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,134.22,103,,10.96,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,261.61,75,,577.368,Percent of Total Billed Charges,75% of Total Billed Charges,174.41,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,174.41,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.336,Case Rate,Pays based on per visit rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,10.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.81,100,,769.824,Percent of Total Billed Charges,100% of Total Billed Charges,106.05,1374.66,
DX ARTHROGRAM ANKLE RT SI,49000002,CDM,322,RC,73615,HCPCS,Outpatient,,,348.81,209.29,,106.05,100,,0.88,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,1.872,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,5.264,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,9.624,Fee Schedule,320% of BCBS Blue Essentials Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,6.768,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,6.768,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,6.768,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,993.752,Fee Schedule,103% of Cigna fee schedule,130.31,100,,14.88,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,739.4,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,134.22,103,,15.328,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,261.61,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,174.41,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,174.41,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,180.416,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.408,Case Rate,Pays based on per visit rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,14.88,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.81,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,106.05,1374.66,
DX ARTHROGRAM ANKLE BI SI,49000003,CDM,322,RC,73615,HCPCS,Outpatient,,,605.68,363.41,,106.05,100,,66.72,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,0.344,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,9.624,Fee Schedule,320% of BCBS Blue Essentials Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.08,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.08,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.08,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,993.752,Fee Schedule,103% of Cigna fee schedule,130.31,100,,117.328,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,454.6,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,134.22,103,,120.848,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,454.26,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,302.84,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,302.84,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,36.888,Case Rate,Pays based on per visit rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,130.31,100,,117.328,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,605.68,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,106.05,1374.66,
DX CHEST 1V STROKE PORT,49000252,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.472,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.648,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,9.64,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,391.632,Fee Schedule,103% of Cigna fee schedule,26.06,100,,117.152,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,10.544,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,120.664,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,117.152,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V STROKE PORT,49000252,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.552,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.712,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,9.648,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.776,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.776,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.776,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,294.904,Fee Schedule,103% of Cigna fee schedule,26.06,100,,20.584,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,19.344,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,21.2,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.704,Case Rate,Pays based on per visit rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,20.584,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V STROKE PORT,49000252,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,22.32,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.712,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,9.696,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.776,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.776,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.776,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,229.176,Fee Schedule,103% of Cigna fee schedule,26.06,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,3.168,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.816,Case Rate,Pays based on per visit rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
CT MOD SED RAD ADULT INI 15 MI,49000400,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,0.072,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,9.696,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,0.088,Fee Schedule,360% of BCBS POS Rate,45.4,360,,0.088,Fee schedule,360% of BCBS PPO Rate,45.4,360,,0.088,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,491.096,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,27.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,66.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,0.816,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,64.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
DX MANDIBLE 1 TO 3V,49001001,CDM,320,RC,70100,HCPCS,Outpatient,,,154.13,92.48,,28.47,100,,0.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,9.448,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.328,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,9.712,Fee Schedule,320% of BCBS Blue Essentials Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,181.96,Fee Schedule,103% of Cigna fee schedule,38.76,100,,75.6,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,29.992,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,39.92,103,,77.872,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,120.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,62.84,Case Rate,Pays based on per visit rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,75.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,300,
DX MANDIBLE 1 TO 3V,49001001,CDM,320,RC,70100,HCPCS,Outpatient,,,154.13,92.48,,28.47,100,,0.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,18.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.76,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,9.712,Fee Schedule,320% of BCBS Blue Essentials Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,11.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,11.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,11.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,181.96,Fee Schedule,103% of Cigna fee schedule,38.76,100,,12.768,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,5.056,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,39.92,103,,13.152,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.536,Case Rate,Pays based on per visit rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,38.76,100,,12.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,300,
DX ABD DECUB RT PORT,49001002,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,5.944,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,5.472,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,94.72,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,236.152,Fee Schedule,103% of Cigna fee schedule,30.08,100,,7.84,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,0.296,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,8.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.664,Case Rate,Pays based on per visit rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,7.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB RT PORT,49001002,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,1.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,18.552,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,94.72,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,236.152,Fee Schedule,103% of Cigna fee schedule,30.08,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,4.16,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,101.976,Case Rate,Pays based on per visit rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB RT PORT,49001002,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,0.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,96.336,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,94.824,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.072,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1097.704,Fee Schedule,103% of Cigna fee schedule,30.08,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,4.016,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.064,Case Rate,Pays based on per visit rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABS FIST SINUS STUDY SI,49001003,CDM,320,RC,76080,HCPCS,Outpatient,,,754.04,452.42,,34.14,100,,1.064,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,8.768,Fee Schedule ,150% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.42,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,1541.06,320,,95.192,Fee Schedule,320% of BCBS Blue Essentials Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,1733.69,360,,0.064,Fee Schedule,360% of BCBS POS Rate,1733.69,360,,0.064,Fee schedule,360% of BCBS PPO Rate,1733.69,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,1512.89,103,,1097.704,Fee Schedule,103% of Cigna fee schedule,60.14,100,,12.704,Fee Schedule,100% of TX Mediciad Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,4.16,Fee Schedule,100% of CMS OPPS Rate,455.52,90,,,Fee Schedule,90% of CMS OPPS Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,657.98,130,,,Fee Schedule,130% of CMS OPPS Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,61.94,103,,13.08,Fee Schedule,103% of TX Medicaid Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,565.53,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,377.02,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,377.02,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.28,Case Rate,Pays based on per visit rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,12.704,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,754.04,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,34.14,1733.69,
DX ABS FIST SINUS STUDY SI,49001003,CDM,320,RC,76080,HCPCS,Outpatient,,,754.04,452.42,,34.14,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,1.872,Fee Schedule ,150% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.42,280,,0.096,Fee Schedule,280% of BCBS BULE Fee Schedule,1541.06,320,,95.616,Fee Schedule,320% of BCBS Blue Essentials Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,1733.69,360,,0.12,Fee Schedule,360% of BCBS POS Rate,1733.69,360,,0.12,Fee schedule,360% of BCBS PPO Rate,1733.69,360,,0.12,Fee Schedule,360% of BCBS Traditional Rate,1512.89,103,,1646.552,Fee Schedule,103% of Cigna fee schedule,60.14,100,,72.24,Fee Schedule,100% of TX Mediciad Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,0.768,Fee Schedule,100% of CMS OPPS Rate,455.52,90,,,Fee Schedule,90% of CMS OPPS Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,657.98,130,,,Fee Schedule,130% of CMS OPPS Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,61.94,103,,74.408,Fee Schedule,103% of TX Medicaid Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,565.53,75,,219.24,Percent of Total Billed Charges,75% of Total Billed Charges,377.02,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,377.02,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,173.728,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.264,Case Rate,Pays based on per visit rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,72.24,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,754.04,100,,292.32,Percent of Total Billed Charges,100% of Total Billed Charges,34.14,1733.69,
DX MANDIBLE MIN 4V,49001100,CDM,320,RC,70110,HCPCS,Outpatient,,,230.61,138.37,TC   ,30.48,100,,4.2,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,83.184,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,95.616,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.112,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.112,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.112,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,659.2,Fee Schedule,103% of Cigna fee schedule,43.44,100,,25.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1.048,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,25.96,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,172.96,75,,219.24,Percent of Total Billed Charges,75% of Total Billed Charges,115.31,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,115.31,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,115.31,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,115.31,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.616,Case Rate,Pays based on per visit rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,230.61,100,,292.32,Percent of Total Billed Charges,100% of Total Billed Charges,30.48,403.49,
DX MANDIBLE MIN 4V,49001100,CDM,320,RC,70110,HCPCS,Outpatient,,,230.61,138.37,TC   ,30.48,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,4.344,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.064,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,95.8,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,993.752,Fee Schedule,103% of Cigna fee schedule,43.44,100,,16.8,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1.232,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,17.304,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,172.96,75,,314.784,Percent of Total Billed Charges,75% of Total Billed Charges,115.31,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,115.31,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,115.31,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,115.31,50,,205.336,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.48,Case Rate,Pays based on per visit rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,230.61,100,,419.712,Percent of Total Billed Charges,100% of Total Billed Charges,30.48,403.49,
DX FACIAL BONES MAX 2V,49001407,CDM,320,RC,70140,HCPCS,Outpatient,,,154.13,92.48,,21.48,100,,1.864,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,1.384,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1490.632,Fee Schedule,103% of Cigna fee schedule,32.41,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,49.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,314.784,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.208,Case Rate,Pays based on per visit rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,419.712,Percent of Total Billed Charges,100% of Total Billed Charges,21.48,300,
DX FACIAL BONES MAX 2V,49001407,CDM,320,RC,70140,HCPCS,Outpatient,,,154.13,92.48,,21.48,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,1.384,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.32,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,993.752,Fee Schedule,103% of Cigna fee schedule,32.41,100,,19.6,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,3.208,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,20.192,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.152,Case Rate,Pays based on per visit rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,19.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,21.48,300,
DX FACIAL BONE MIN 3V,49001506,CDM,320,RC,70150,HCPCS,Outpatient,,,375.66,225.40,TC   ,33.47,100,,0.024,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,1.384,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.536,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.688,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.688,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.688,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,767.384,Fee Schedule,103% of Cigna fee schedule,47.11,100,,16.8,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,20.992,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,17.304,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,281.75,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,187.83,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,187.83,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,187.83,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,187.83,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.84,Case Rate,Pays based on per visit rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,375.66,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,33.47,403.49,
DX FACIAL BONE MIN 3V,49001506,CDM,320,RC,70150,HCPCS,Outpatient,,,375.66,225.40,TC   ,33.47,100,,2.28,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,3.328,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.216,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,767.384,Fee Schedule,103% of Cigna fee schedule,47.11,100,,17.92,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,40.048,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,18.456,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,281.75,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,187.83,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,187.83,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,187.83,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,187.83,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.112,Case Rate,Pays based on per visit rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,17.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,375.66,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,33.47,403.49,
DX ORBITS MIN 4V,49001522,CDM,320,RC,70200,HCPCS,Outpatient,,,207.07,124.24,,33.47,100,,1.296,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,113.184,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.216,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1151.264,Fee Schedule,103% of Cigna fee schedule,48.11,100,,22.4,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,12.16,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,49.55,103,,23.072,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,155.3,75,,315,Percent of Total Billed Charges,75% of Total Billed Charges,103.54,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.54,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.488,Case Rate,Pays based on per visit rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,207.07,100,,420,Percent of Total Billed Charges,100% of Total Billed Charges,33.47,403.49,
DX ORBITS MIN 4V,49001522,CDM,320,RC,70200,HCPCS,Outpatient,,,207.07,124.24,,33.47,100,,1.176,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,15.336,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.44,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.44,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,767.504,Fee Schedule,103% of Cigna fee schedule,48.11,100,,20.72,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,41.232,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,49.55,103,,21.344,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,155.3,75,,315,Percent of Total Billed Charges,75% of Total Billed Charges,103.54,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.54,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,136.896,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.416,Case Rate,Pays based on per visit rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,48.11,100,,20.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,207.07,100,,420,Percent of Total Billed Charges,100% of Total Billed Charges,33.47,403.49,
DX NASAL BONES MIN 3V,49001605,CDM,320,RC,70160,HCPCS,Outpatient,,,343.79,206.27,TC   ,28.47,100,,9.08,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.336,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.392,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.504,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.504,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.504,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,767.504,Fee Schedule,103% of Cigna fee schedule,38.43,100,,100.464,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,214.08,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,39.58,103,,103.48,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,257.84,75,,315,Percent of Total Billed Charges,75% of Total Billed Charges,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.9,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.984,Case Rate,Pays based on per visit rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,100.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,343.79,100,,420,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,343.79,
DX NASAL BONES MIN 3V,49001605,CDM,320,RC,70160,HCPCS,Outpatient,,,343.79,206.27,TC   ,28.47,100,,2.896,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,9.824,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.024,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,65.76,Fee Schedule,103% of Cigna fee schedule,38.43,100,,46.592,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,19.488,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,39.58,103,,47.992,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,257.84,75,,226.24,Percent of Total Billed Charges,75% of Total Billed Charges,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.9,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.9,50,,155.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.744,Case Rate,Pays based on per visit rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,38.43,100,,46.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,343.79,100,,301.648,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,343.79,
DX SINUSES MAX 2V,49002108,CDM,320,RC,70210,HCPCS,Outpatient,,,193.19,115.91,,22.82,100,,3.632,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,5.368,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.136,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,104.28,Fee Schedule,103% of Cigna fee schedule,32.41,100,,90.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,4.16,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,93.44,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,144.89,75,,226.24,Percent of Total Billed Charges,75% of Total Billed Charges,96.6,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,96.6,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.24,Case Rate,Pays based on per visit rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,90.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.19,100,,301.648,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX SINUSES MAX 2V,49002108,CDM,320,RC,70210,HCPCS,Outpatient,,,193.19,115.91,,22.82,100,,24.976,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,237.248,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,117.184,Fee Schedule,103% of Cigna fee schedule,32.41,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,184.848,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,144.89,75,,280.2,Percent of Total Billed Charges,75% of Total Billed Charges,96.6,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,96.6,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,124.168,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.416,Case Rate,Pays based on per visit rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.19,100,,373.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX SINUSES MIN 3V,49002207,CDM,320,RC,70220,HCPCS,Outpatient,,,417.43,250.46,TC   ,26.15,100,,0.392,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,355.296,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.128,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.168,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.168,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.168,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,117.12,Fee Schedule,103% of Cigna fee schedule,37.76,100,,71.632,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,9.648,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,38.89,103,,73.784,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,313.07,75,,280.2,Percent of Total Billed Charges,75% of Total Billed Charges,208.72,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.72,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.72,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,208.72,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.12,Case Rate,Pays based on per visit rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,71.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,417.43,100,,373.6,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,417.43,
DX SINUSES MIN 3V,49002207,CDM,320,RC,70220,HCPCS,Outpatient,,,417.43,250.46,TC   ,26.15,100,,0.856,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,81.496,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.784,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,117.696,Fee Schedule,103% of Cigna fee schedule,37.76,100,,78.96,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,3.072,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,38.89,103,,81.328,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,313.07,75,,304.768,Percent of Total Billed Charges,75% of Total Billed Charges,208.72,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,208.72,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.72,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,208.72,50,,431.176,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.896,Case Rate,Pays based on per visit rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,37.76,100,,78.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,417.43,100,,406.36,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,417.43,
DX CHEST 2V PORT,49002327,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,0.896,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,60.928,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,79.68,Fee Schedule,103% of Cigna fee schedule,33.75,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,3.072,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,304.768,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.928,Case Rate,Pays based on per visit rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,406.36,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V PORT,49002327,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,2.272,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,45.264,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.456,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.584,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.584,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.584,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,49.152,Fee Schedule,103% of Cigna fee schedule,33.75,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,3.072,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,420.304,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.52,Case Rate,Pays based on per visit rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,560.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V PORT,49002327,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,0.504,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,11.56,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.208,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,285.6,Fee Schedule,103% of Cigna fee schedule,33.75,100,,8.736,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,7.392,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,9,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,420.304,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.048,Case Rate,Pays based on per visit rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,8.736,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,560.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX SKULL MAX 3V,49002504,CDM,320,RC,70250,HCPCS,Outpatient,,,353.16,211.90,,25.82,100,,0.488,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,31.36,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.152,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.2,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.2,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.2,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,285.6,Fee Schedule,103% of Cigna fee schedule,36.09,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,251.52,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,37.17,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,264.87,75,,176.08,Percent of Total Billed Charges,75% of Total Billed Charges,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,228.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.16,Case Rate,Pays based on per visit rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,353.16,100,,234.768,Percent of Total Billed Charges,100% of Total Billed Charges,25.82,403.49,
DX SKULL MAX 3V,49002504,CDM,320,RC,70250,HCPCS,Outpatient,,,353.16,211.90,,25.82,100,,14.824,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,491.544,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,51.072,Fee Schedule,103% of Cigna fee schedule,36.09,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,34.072,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.17,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,264.87,75,,176.08,Percent of Total Billed Charges,75% of Total Billed Charges,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,176.58,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.072,Case Rate,Pays based on per visit rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,353.16,100,,234.768,Percent of Total Billed Charges,100% of Total Billed Charges,25.82,403.49,
DX SKULL MIN 4V,49002603,CDM,320,RC,70260,HCPCS,Outpatient,,,504.75,302.85,TC   ,30.14,100,,11.2,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,126.352,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.176,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.224,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.224,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.224,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,45.6,Fee Schedule,103% of Cigna fee schedule,44.78,100,,25.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,0.752,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,46.12,103,,25.96,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,378.56,75,,260.584,Percent of Total Billed Charges,75% of Total Billed Charges,252.38,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,252.38,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,252.38,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,252.38,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.656,Case Rate,Pays based on per visit rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,25.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,504.75,100,,347.448,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,504.75,
DX SKULL MIN 4V,49002603,CDM,320,RC,70260,HCPCS,Outpatient,,,504.75,302.85,TC   ,30.14,100,,6.704,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,45.088,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.072,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.072,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,63.784,Fee Schedule,103% of Cigna fee schedule,44.78,100,,39.76,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,21.824,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,46.12,103,,40.952,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,378.56,75,,260.584,Percent of Total Billed Charges,75% of Total Billed Charges,252.38,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,252.38,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,252.38,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,252.38,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.64,Case Rate,Pays based on per visit rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,44.78,100,,39.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,504.75,100,,347.448,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,504.75,
DX TMJ BI,49003304,CDM,320,RC,70330,HCPCS,Outpatient,,,790.02,474.01,,40.47,100,,1.52,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,2.816,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.088,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.088,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.088,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,502.848,Fee Schedule,103% of Cigna fee schedule,53.13,100,,56.88,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,11.936,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,54.72,103,,58.584,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,592.52,75,,345.896,Percent of Total Billed Charges,75% of Total Billed Charges,395.01,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,395.01,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,395.01,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,395.01,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.816,Case Rate,Pays based on per visit rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,790.02,100,,461.192,Percent of Total Billed Charges,100% of Total Billed Charges,40.47,790.02,
DX TMJ BI,49003304,CDM,320,RC,70330,HCPCS,Outpatient,,,790.02,474.01,,40.47,100,,2.048,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,89.096,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.072,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,502.08,Fee Schedule,103% of Cigna fee schedule,53.13,100,,16.8,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,527.216,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,54.72,103,,17.304,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,592.52,75,,345.896,Percent of Total Billed Charges,75% of Total Billed Charges,395.01,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,395.01,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,395.01,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,395.01,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.352,Case Rate,Pays based on per visit rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,53.13,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,790.02,100,,461.192,Percent of Total Billed Charges,100% of Total Billed Charges,40.47,790.02,
DX NECK SOFT TISSUE,49003601,CDM,320,RC,70360,HCPCS,Outpatient,,,255.34,153.20,,21.83,100,,0.496,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,3.856,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.48,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.616,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.616,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.616,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,88.208,Fee Schedule,103% of Cigna fee schedule,31.74,100,,58.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,789.552,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,59.984,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,191.51,75,,364.672,Percent of Total Billed Charges,75% of Total Billed Charges,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,152.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.688,Case Rate,Pays based on per visit rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,58.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,255.34,100,,486.224,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX NECK SOFT TISSUE,49003601,CDM,320,RC,70360,HCPCS,Outpatient,,,255.34,153.20,,21.83,100,,0.592,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,4.16,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.672,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.672,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.672,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,180,Fee Schedule,103% of Cigna fee schedule,31.74,100,,207.864,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,181.104,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,214.104,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,191.51,75,,364.672,Percent of Total Billed Charges,75% of Total Billed Charges,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,127.67,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.896,Case Rate,Pays based on per visit rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,207.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,255.34,100,,486.224,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX DISKOGRAPHY LUMB SI,49004065,CDM,320,RC,72295,HCPCS,Outpatient,,,3143.71,1886.23,TC   ,69.44,100,,2.68,Fee Schedule,100% of Aetna Fee Schedule,2657.12,150,,9.792,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4814.18,280,,3.16,Fee Schedule,280% of BCBS BULE Fee Schedule,5501.92,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,6189.66,360,,4.064,Fee Schedule,360% of BCBS POS Rate,6189.66,360,,4.064,Fee schedule,360% of BCBS PPO Rate,6189.66,360,,4.064,Fee Schedule,360% of BCBS Traditional Rate,4961.42,103,,278.4,Fee Schedule,103% of Cigna fee schedule,111.26,100,,28.2,Fee Schedule,100% of TX Mediciad Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,135.392,Fee Schedule,100% of CMS OPPS Rate,1594.27,90,,,Fee Schedule,90% of CMS OPPS Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.84,130,,,Fee Schedule,130% of CMS OPPS Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,114.6,103,,29.04,Fee Schedule,103% of TX Medicaid Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2357.78,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,1571.86,50,,166.464,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.144,Case Rate,Pays based on per visit rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,28.2,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3143.71,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,6189.66,
DX DISKOGRAPHY LUMB SI,49004065,CDM,320,RC,72295,HCPCS,Outpatient,,,3143.71,1886.23,TC   ,69.44,100,,0.44,Fee Schedule,100% of Aetna Fee Schedule,2657.12,150,,5.768,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4814.18,280,,1.512,Fee Schedule,280% of BCBS BULE Fee Schedule,5501.92,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,6189.66,360,,1.944,Fee Schedule,360% of BCBS POS Rate,6189.66,360,,1.944,Fee schedule,360% of BCBS PPO Rate,6189.66,360,,1.944,Fee Schedule,360% of BCBS Traditional Rate,4961.42,103,,324,Fee Schedule,103% of Cigna fee schedule,111.26,100,,88.08,Fee Schedule,100% of TX Mediciad Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,100.592,Fee Schedule,100% of CMS OPPS Rate,1594.27,90,,,Fee Schedule,90% of CMS OPPS Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.84,130,,,Fee Schedule,130% of CMS OPPS Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,114.6,103,,90.72,Fee Schedule,103% of TX Medicaid Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2357.78,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.86,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,1571.86,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.16,Case Rate,Pays based on per visit rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,111.26,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3143.71,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,6189.66,
DX HIP WWO PEL 1V LT,49004500,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,35.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,8.64,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.16,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.16,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.16,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,54.72,Fee Schedule,103% of Cigna fee schedule,33.08,100,,88.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,25.696,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,90.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.16,Case Rate,Pays based on per visit rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V LT,49004500,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,191.4,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,8.16,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.176,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.224,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.224,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.224,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,33.6,Fee Schedule,103% of Cigna fee schedule,33.08,100,,47.528,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,69.68,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,48.952,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.112,Case Rate,Pays based on per visit rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,47.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V LT PORT,49004501,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,TC   ,22.16,100,,1.144,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,8.16,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.192,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,288,Fee Schedule,103% of Cigna fee schedule,33.08,100,,40.584,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1092.32,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,41.8,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.28,Case Rate,Pays based on per visit rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,40.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V LT PORT,49004501,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,TC   ,22.16,100,,0.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,58.016,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.192,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,288,Fee Schedule,103% of Cigna fee schedule,33.08,100,,1109.84,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,280.776,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,1143.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.28,Case Rate,Pays based on per visit rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1109.84,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT,49004502,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,5.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.16,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,54.432,Fee Schedule,103% of Cigna fee schedule,33.08,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,100.2,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,270.592,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,110.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.176,Case Rate,Pays based on per visit rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,360.792,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT,49004502,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,0.896,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,2.264,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.488,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.624,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.624,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.624,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,309.6,Fee Schedule,103% of Cigna fee schedule,33.08,100,,23.48,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,6.256,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,24.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,270.592,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.816,Case Rate,Pays based on per visit rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,23.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,360.792,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT PORT,49004503,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,7.112,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.664,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.856,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.856,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.856,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,108,Fee Schedule,103% of Cigna fee schedule,33.08,100,,35.232,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,197.984,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,36.288,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,362.68,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,201.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,21.904,Case Rate,Pays based on per visit rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,35.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,483.576,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT PORT,49004503,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,1.2,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.592,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.76,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.76,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.76,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,72,Fee Schedule,103% of Cigna fee schedule,33.08,100,,388.928,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,8.576,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,400.6,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,362.68,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.112,Case Rate,Pays based on per visit rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,388.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,483.576,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 2-3V RT,49004504,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,TC   ,34.47,100,,1.888,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.024,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,288,Fee Schedule,103% of Cigna fee schedule,47.11,100,,105.696,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,9.248,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,108.872,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,428.656,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.112,Case Rate,Pays based on per visit rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,105.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,571.536,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V RT,49004504,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,TC   ,34.47,100,,3.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.288,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,84,Fee Schedule,103% of Cigna fee schedule,47.11,100,,88.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,21.76,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,90.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,428.656,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.144,Case Rate,Pays based on per visit rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,571.536,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V LT,49004505,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,,34.47,100,,0.936,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.472,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.056,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.072,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.072,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,72,Fee Schedule,103% of Cigna fee schedule,47.11,100,,281.488,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,12.816,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,289.936,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,301.72,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.128,Case Rate,Pays based on per visit rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,402.296,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V LT,49004505,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,,34.47,100,,1.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.312,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,76.8,Fee Schedule,103% of Cigna fee schedule,47.11,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,19.2,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,301.72,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.232,Case Rate,Pays based on per visit rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,402.296,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V RT PORT,49004506,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,TC   ,34.47,100,,1.576,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,1.048,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.32,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,96,Fee Schedule,103% of Cigna fee schedule,47.11,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,18.128,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,206.784,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.224,Case Rate,Pays based on per visit rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,275.712,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V RT PORT,49004506,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,TC   ,34.47,100,,0.712,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,1.088,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,38.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,49.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,49.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,49.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,88.8,Fee Schedule,103% of Cigna fee schedule,47.11,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,18.128,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,206.784,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.168,Case Rate,Pays based on per visit rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,275.712,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V LT PORT,49004507,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,,34.47,100,,56.408,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,0.096,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,44.792,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,57.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,57.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,57.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,430.56,Fee Schedule,103% of Cigna fee schedule,47.11,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,128.928,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,130.504,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,253.592,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.296,Case Rate,Pays based on per visit rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,174,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL 2-3V LT PORT,49004507,CDM,320,RC,73502,HCPCS,Outpatient,,,394.66,236.80,,34.47,100,,1.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,607.456,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,40.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,51.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,51.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,51.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,199.68,Fee Schedule,103% of Cigna fee schedule,47.11,100,,270.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,0.352,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,48.52,103,,278.504,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,296,75,,130.504,Percent of Total Billed Charges,75% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,197.33,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,197.33,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.624,Case Rate,Pays based on per visit rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,47.11,100,,270.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,394.66,100,,174,Percent of Total Billed Charges,100% of Total Billed Charges,34.47,394.66,
DX HIP WWO PEL MIN 4V RT,49004508,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,,43.8,100,,1.072,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,18,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.408,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.528,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.528,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,388.8,Fee Schedule,103% of Cigna fee schedule,59.48,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,5.024,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,232.432,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.336,Case Rate,Pays based on per visit rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,309.912,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V RT,49004508,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,,43.8,100,,19,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,18.152,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.136,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.176,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.176,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.176,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,180,Fee Schedule,103% of Cigna fee schedule,59.48,100,,699.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,26.728,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,720.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,232.432,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.424,Case Rate,Pays based on per visit rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,699.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,309.912,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V LT,49004509,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,TC   ,43.8,100,,0.424,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,115.56,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.208,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.208,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.208,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,307.008,Fee Schedule,103% of Cigna fee schedule,59.48,100,,199.728,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,26.728,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,205.72,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,875.344,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.424,Case Rate,Pays based on per visit rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1167.128,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V LT,49004509,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,TC   ,43.8,100,,0.824,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,1.52,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.28,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.28,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,338.4,Fee Schedule,103% of Cigna fee schedule,59.48,100,,304.528,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,26.728,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,313.664,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,875.344,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.848,Case Rate,Pays based on per visit rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1167.128,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V RT PORT,49004510,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,,43.8,100,,0.656,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,11.536,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.488,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.344,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.344,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.344,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,288,Fee Schedule,103% of Cigna fee schedule,59.48,100,,52.664,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,0.648,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,54.248,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,1075.88,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,169.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.984,Case Rate,Pays based on per visit rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,52.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1434.504,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V RT PORT,49004510,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,,43.8,100,,11.024,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,36.544,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.512,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,180,Fee Schedule,103% of Cigna fee schedule,59.48,100,,70.232,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1.048,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,72.336,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,1075.88,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.04,Case Rate,Pays based on per visit rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,70.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1434.504,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V LT PORT,49004511,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,TC   ,43.8,100,,1.216,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,27.864,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.176,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.224,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.224,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.224,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,37.44,Fee Schedule,103% of Cigna fee schedule,59.48,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,0.696,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,1271.344,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,217.008,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.344,Case Rate,Pays based on per visit rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1695.12,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL MIN 4V LT PORT,49004511,CDM,320,RC,73503,HCPCS,Outpatient,,,500,300.00,TC   ,43.8,100,,0.824,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,27.904,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.336,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.432,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.432,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.432,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,288,Fee Schedule,103% of Cigna fee schedule,59.48,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,2.336,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,61.26,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,1271.344,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.216,Case Rate,Pays based on per visit rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,59.48,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,1695.12,Percent of Total Billed Charges,100% of Total Billed Charges,43.8,500,
DX HIP WWO PEL 2V BI,49004512,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,,29.15,100,,0.304,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,27.864,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.44,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.44,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,170.4,Fee Schedule,103% of Cigna fee schedule,41.44,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,2.416,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,797.24,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.32,Case Rate,Pays based on per visit rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,1062.984,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX HIP WWO PEL 2V BI,49004512,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,,29.15,100,,0.728,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,27.864,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.184,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.232,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.232,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.232,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,223.464,Fee Schedule,103% of Cigna fee schedule,41.44,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,0.216,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.96,Case Rate,Pays based on per visit rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX HIP WWO PEL 3-4V BI,49004513,CDM,320,RC,73522,HCPCS,Outpatient,,,555,333.00,TC   ,37.8,100,,0.992,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,27.864,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.32,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.32,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,72,Fee Schedule,103% of Cigna fee schedule,53.8,100,,29.312,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1349.896,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,55.41,103,,30.192,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,416.25,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,277.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,277.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.024,Case Rate,Pays based on per visit rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,29.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,555,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,555,
DX HIP WWO PEL 3-4V BI,49004513,CDM,320,RC,73522,HCPCS,Outpatient,,,555,333.00,TC   ,37.8,100,,79.96,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,102.312,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.464,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.6,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.6,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,249.6,Fee Schedule,103% of Cigna fee schedule,53.8,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,40,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,55.41,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,416.25,75,,270.616,Percent of Total Billed Charges,75% of Total Billed Charges,277.5,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.144,Case Rate,Pays based on per visit rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,555,100,,360.824,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,555,
DX HIP WWO PEL MIN 5V BI,49004514,CDM,320,RC,73523,HCPCS,Outpatient,,,727.38,436.43,,44.79,100,,1.736,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,54.576,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,120.09,280,,3.304,Fee Schedule,280% of BCBS BULE Fee Schedule,137.25,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,154.4,360,,4.248,Fee Schedule,360% of BCBS POS Rate,154.4,360,,4.248,Fee schedule,360% of BCBS PPO Rate,154.4,360,,4.248,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,890.848,Fee Schedule,103% of Cigna fee schedule,62.15,100,,51.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,40.344,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,52.536,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,545.54,75,,270.616,Percent of Total Billed Charges,75% of Total Billed Charges,363.69,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,144.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.512,Case Rate,Pays based on per visit rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,727.38,100,,360.824,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,727.38,
DX HIP WWO PEL MIN 5V BI,49004514,CDM,320,RC,73523,HCPCS,Outpatient,,,727.38,436.43,,44.79,100,,21.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,180,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,120.09,280,,14.704,Fee Schedule,280% of BCBS BULE Fee Schedule,137.25,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,154.4,360,,18.904,Fee Schedule,360% of BCBS POS Rate,154.4,360,,18.904,Fee schedule,360% of BCBS PPO Rate,154.4,360,,18.904,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,120.84,Fee Schedule,103% of Cigna fee schedule,62.15,100,,178.528,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,256.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,183.888,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,545.54,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.384,Case Rate,Pays based on per visit rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,178.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,727.38,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,727.38,
DX HIP WWO POL 2V BI PORT,49004515,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,TC   ,29.15,100,,24.104,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,36.864,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.608,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.784,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.784,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.784,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,377.488,Fee Schedule,103% of Cigna fee schedule,41.44,100,,109.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,3.384,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,112.48,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,213.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.208,Case Rate,Pays based on per visit rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,109.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX HIP WWO POL 2V BI PORT,49004515,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,TC   ,29.15,100,,23.528,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,88.488,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,4.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,5.36,Fee Schedule,360% of BCBS POS Rate,403.49,360,,5.36,Fee schedule,360% of BCBS PPO Rate,403.49,360,,5.36,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,377.488,Fee Schedule,103% of Cigna fee schedule,41.44,100,,133.456,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,25.632,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,137.464,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.44,Case Rate,Pays based on per visit rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,133.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX HIP WWO PEL 3-4V BI PORT,49004516,CDM,320,RC,73522,HCPCS,Outpatient,,,555,333.00,,37.8,100,,0.856,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,37.296,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.824,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.824,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.824,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,203.68,Fee Schedule,103% of Cigna fee schedule,53.8,100,,95.512,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,81.216,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,55.41,103,,98.376,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,416.25,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.144,Case Rate,Pays based on per visit rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,95.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,555,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,555,
DX HIP WWO PEL 3-4V BI PORT,49004516,CDM,320,RC,73522,HCPCS,Outpatient,,,555,333.00,,37.8,100,,1.856,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,165.712,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.328,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,96,Fee Schedule,320% of BCBS Blue Essentials Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.712,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.712,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.712,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4360.096,Fee Schedule,103% of Cigna fee schedule,53.8,100,,14.152,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,61.92,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,55.41,103,,14.576,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,416.25,75,,343.552,Percent of Total Billed Charges,75% of Total Billed Charges,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,277.5,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,277.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.168,Case Rate,Pays based on per visit rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,53.8,100,,14.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,555,100,,458.072,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,555,
DX HIP WWO PEL MIN 5V BI PORT,49004517,CDM,320,RC,73523,HCPCS,Outpatient,,,727.38,436.43,TC   ,44.79,100,,0.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,99.592,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,120.09,280,,0.608,Fee Schedule,280% of BCBS BULE Fee Schedule,137.25,320,,96.064,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,154.4,360,,0.784,Fee Schedule,360% of BCBS POS Rate,154.4,360,,0.784,Fee schedule,360% of BCBS PPO Rate,154.4,360,,0.784,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,288,Fee Schedule,103% of Cigna fee schedule,62.15,100,,17.736,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,62,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,18.272,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,545.54,75,,343.552,Percent of Total Billed Charges,75% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.136,Case Rate,Pays based on per visit rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,17.736,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,727.38,100,,458.072,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,727.38,
DX HIP WWO PEL MIN 5V BI PORT,49004517,CDM,320,RC,73523,HCPCS,Outpatient,,,727.38,436.43,TC   ,44.79,100,,0.8,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,842.456,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,120.09,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,137.25,320,,96.064,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,154.4,360,,0.256,Fee Schedule,360% of BCBS POS Rate,154.4,360,,0.256,Fee schedule,360% of BCBS PPO Rate,154.4,360,,0.256,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,100.616,Fee Schedule,103% of Cigna fee schedule,62.15,100,,74.28,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,61.92,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,76.512,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,545.54,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,363.69,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,363.69,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.2,Case Rate,Pays based on per visit rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,74.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,727.38,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,727.38,
DX FEMUR 1V RT,49004518,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,0.928,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,76.352,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.064,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,151,Fee Schedule,103% of Cigna fee schedule,29.4,100,,257.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,61.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,264.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.2,Case Rate,Pays based on per visit rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,257.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V RT,49004518,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,11.216,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,43.488,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.064,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1666.848,Fee Schedule,103% of Cigna fee schedule,29.4,100,,83.656,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,61.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,86.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,176.152,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.896,Case Rate,Pays based on per visit rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,83.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,234.864,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V LT,49004519,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,2.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,38.088,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.32,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.416,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,452.992,Fee Schedule,103% of Cigna fee schedule,29.4,100,,67.528,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,227.36,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,69.56,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,176.152,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.784,Case Rate,Pays based on per visit rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,67.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,234.864,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V LT,49004519,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,2.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,45.736,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.752,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.536,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.536,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.536,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.536,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,377.488,Fee Schedule,103% of Cigna fee schedule,29.4,100,,22.752,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,121.28,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,23.432,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,323.504,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,228.216,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.312,Case Rate,Pays based on per visit rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,22.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,431.336,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V RT PORT,49004520,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,4.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,38.648,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.392,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.712,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.648,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.648,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.648,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1206.392,Fee Schedule,103% of Cigna fee schedule,29.4,100,,25.752,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,400,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,26.52,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,323.504,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.44,Case Rate,Pays based on per visit rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,431.336,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V RT PORT,49004520,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,,20.49,100,,4.928,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,48.928,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,46.256,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.768,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,59.472,Fee Schedule,360% of BCBS POS Rate,287.32,360,,59.472,Fee schedule,360% of BCBS PPO Rate,287.32,360,,59.472,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,29.4,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,81.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.48,Case Rate,Pays based on per visit rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V LT PORT,49004521,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,TC   ,20.49,100,,1.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,74.336,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.28,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.872,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.224,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.224,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.224,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,29.4,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,196.64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.48,Case Rate,Pays based on per visit rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX FEMUR 1V LT PORT,49004521,CDM,320,RC,73551,HCPCS,Outpatient,,,234.21,140.53,TC   ,20.49,100,,0.576,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,80.32,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.312,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.872,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,29.4,100,,66.576,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,82.88,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,68.576,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,175.66,75,,308.008,Percent of Total Billed Charges,75% of Total Billed Charges,117.11,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,117.11,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,117.11,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.36,Case Rate,Pays based on per visit rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,234.21,100,,410.672,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,300,
DX SPINE ENTIRE SURVEY 1V,49004522,CDM,320,RC,72081,HCPCS,Outpatient,,,305.67,183.40,,28.47,100,,0.664,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,182.128,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.56,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.984,Fee Schedule,320% of BCBS Blue Essentials Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,42.78,100,,199.728,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,368.24,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.06,103,,205.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,229.25,75,,308.008,Percent of Total Billed Charges,75% of Total Billed Charges,152.84,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,152.84,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.216,Case Rate,Pays based on per visit rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,305.67,100,,410.672,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,305.67,
DX SPINE ENTIRE SURVEY 1V,49004522,CDM,320,RC,72081,HCPCS,Outpatient,,,305.67,183.40,,28.47,100,,9.32,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,58.84,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,96.984,Fee Schedule,320% of BCBS Blue Essentials Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1158.824,Fee Schedule,103% of Cigna fee schedule,42.78,100,,199.728,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,221.312,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.06,103,,205.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,229.25,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,152.84,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,152.84,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.672,Case Rate,Pays based on per visit rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,42.78,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,305.67,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,305.67,
DX SPINE ENTIRE SURVEY 2-3V,49004523,CDM,320,RC,72082,HCPCS,Outpatient,,,591.65,354.99,TC   ,53.12,100,,9.392,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,49.68,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,97.216,Fee Schedule,320% of BCBS Blue Essentials Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,331.088,Fee Schedule,103% of Cigna fee schedule,70.5,100,,234,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1872.12,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,72.62,103,,241.016,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,443.74,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,295.83,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.488,Case Rate,Pays based on per visit rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,234,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,591.65,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,591.65,
DX SPINE ENTIRE SURVEY 2-3V,49004523,CDM,320,RC,72082,HCPCS,Outpatient,,,591.65,354.99,TC   ,53.12,100,,1.096,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,126.416,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,9856,Fee Schedule,320% of BCBS Blue Essentials Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2995.864,Fee Schedule,103% of Cigna fee schedule,70.5,100,,192.04,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,169.664,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,72.62,103,,197.808,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,443.74,75,,350.264,Percent of Total Billed Charges,75% of Total Billed Charges,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,295.83,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,295.83,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.048,Case Rate,Pays based on per visit rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,70.5,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,591.65,100,,467.016,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,591.65,
DX SPINE ENTIRE SURVEY 4-5V,49004524,CDM,320,RC,72083,HCPCS,Outpatient,,,763.08,457.85,,59.78,100,,11.632,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,50.832,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,280,,5.376,Fee Schedule,280% of BCBS BULE Fee Schedule,189.12,320,,9.76,Fee Schedule,320% of BCBS Blue Essentials Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,212.76,360,,6.912,Fee Schedule,360% of BCBS POS Rate,212.76,360,,6.912,Fee schedule,360% of BCBS PPO Rate,212.76,360,,6.912,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,855.968,Fee Schedule,103% of Cigna fee schedule,79.19,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,96.64,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,81.57,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,572.31,75,,350.264,Percent of Total Billed Charges,75% of Total Billed Charges,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,381.54,50,,152.144,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.112,Case Rate,Pays based on per visit rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,763.08,100,,467.016,Percent of Total Billed Charges,100% of Total Billed Charges,59.78,763.08,
DX SPINE ENTIRE SURVEY 4-5V,49004524,CDM,320,RC,72083,HCPCS,Outpatient,,,763.08,457.85,,59.78,100,,0.08,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,53.248,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,189.12,320,,9.816,Fee Schedule,320% of BCBS Blue Essentials Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,212.76,360,,0.32,Fee Schedule,360% of BCBS POS Rate,212.76,360,,0.32,Fee schedule,360% of BCBS PPO Rate,212.76,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1305.136,Fee Schedule,103% of Cigna fee schedule,79.19,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,84.64,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,81.57,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,572.31,75,,233.512,Percent of Total Billed Charges,75% of Total Billed Charges,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,381.54,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,381.54,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.144,Case Rate,Pays based on per visit rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,79.19,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,763.08,100,,311.344,Percent of Total Billed Charges,100% of Total Billed Charges,59.78,763.08,
DX SPINE ENTIRE SURVEY MIN 6V,49004525,CDM,320,RC,72084,HCPCS,Outpatient,,,962.28,577.37,TC   ,75.09,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,394.992,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,193.76,280,,0.664,Fee Schedule,280% of BCBS BULE Fee Schedule,221.44,320,,9.832,Fee Schedule,320% of BCBS Blue Essentials Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,249.12,360,,0.848,Fee Schedule,360% of BCBS POS Rate,249.12,360,,0.848,Fee schedule,360% of BCBS PPO Rate,249.12,360,,0.848,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,225.712,Fee Schedule,103% of Cigna fee schedule,99.58,100,,304.528,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,101.632,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,102.57,103,,313.664,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,721.71,75,,233.512,Percent of Total Billed Charges,75% of Total Billed Charges,481.14,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,481.14,50,,527.888,Percent of Total Billed Charges,50% of Total Billed Charges,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,481.14,50,,527.888,Percent of Total Billed Charges,50% of Total Billed Charges,481.14,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.12,Case Rate,Pays based on per visit rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,304.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,962.28,100,,311.344,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,962.28,
DX SPINE ENTIRE SURVEY MIN 6V,49004525,CDM,320,RC,72084,HCPCS,Outpatient,,,962.28,577.37,TC   ,75.09,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,306.648,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,193.76,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,221.44,320,,9.832,Fee Schedule,320% of BCBS Blue Essentials Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,249.12,360,,0.184,Fee Schedule,360% of BCBS POS Rate,249.12,360,,0.184,Fee schedule,360% of BCBS PPO Rate,249.12,360,,0.184,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,300.992,Fee Schedule,103% of Cigna fee schedule,99.58,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,85.888,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,102.57,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,721.71,75,,507.152,Percent of Total Billed Charges,75% of Total Billed Charges,481.14,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,481.14,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,481.14,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,481.14,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.624,Case Rate,Pays based on per visit rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,99.58,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,962.28,100,,676.2,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,962.28,
DX CHEST 2V NEONATE PORT,49005100,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,5.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,265.68,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.28,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,33.75,100,,281.488,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,108.736,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,289.936,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,325.512,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,527.888,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,95.512,Case Rate,Pays based on per visit rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,434.016,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V NEONATE PORT,49005100,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,1.016,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,324.68,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.264,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.28,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.336,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,33.75,100,,234,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,165.184,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,241.016,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,325.512,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,265.344,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,265.344,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,111.992,Case Rate,Pays based on per visit rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,434.016,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V NEONATE PORT,49005100,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,3.896,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,49.88,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.28,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.28,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.36,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.36,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.36,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,33.75,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,178.48,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,100,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,100.048,Case Rate,Pays based on per visit rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST ABD 1V NEONATE PORT,49005104,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,54.896,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.528,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.28,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.68,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.68,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.68,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,26.06,100,,81.664,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,404.72,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,84.112,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,265.344,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.016,Case Rate,Pays based on per visit rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE PORT,49005104,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,123.976,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.192,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.28,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,125.616,Fee Schedule,103% of Cigna fee schedule,26.06,100,,81.664,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,130.752,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,84.112,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,249,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,249,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,215.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.336,Case Rate,Pays based on per visit rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE PORT,49005104,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,66.008,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.528,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.416,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.68,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.68,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.68,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,26.06,100,,26.808,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,110.4,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,27.616,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,355.24,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,355.24,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.4,Case Rate,Pays based on per visit rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,26.808,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V,49010101,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.328,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,98.424,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.92,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.32,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,218.608,Fee Schedule,103% of Cigna fee schedule,26.06,100,,281.488,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,280.928,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,289.936,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,249,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,217.648,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,217.648,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.552,Case Rate,Pays based on per visit rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V,49010101,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.688,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,98.424,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.304,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,97.92,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.392,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.392,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.392,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,765.136,Fee Schedule,103% of Cigna fee schedule,26.06,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,112.96,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,355.24,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,379.248,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,379.248,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.224,Case Rate,Pays based on per visit rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V,49010101,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,1.976,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,100.584,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,98.304,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.384,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,429,Fee Schedule,103% of Cigna fee schedule,26.06,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,118.32,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,310.624,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,217.648,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.272,Case Rate,Pays based on per visit rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,414.168,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 2V,49010200,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,TC   ,22.16,100,,19.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,122.832,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,98.496,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.384,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,571.96,Fee Schedule,103% of Cigna fee schedule,33.75,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,877.76,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,310.624,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,379.248,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.44,Case Rate,Pays based on per visit rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,414.168,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V,49010200,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,TC   ,22.16,100,,1.696,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,122.832,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,98.96,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.32,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,409.336,Fee Schedule,103% of Cigna fee schedule,33.75,100,,47.392,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,681.44,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,48.808,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,143.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.848,Case Rate,Pays based on per visit rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,47.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V,49010200,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,TC   ,22.16,100,,0.88,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,57.688,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,58.304,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,99.504,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,74.968,Fee Schedule,360% of BCBS POS Rate,287.32,360,,74.968,Fee schedule,360% of BCBS PPO Rate,287.32,360,,74.968,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,60.64,Fee Schedule,103% of Cigna fee schedule,33.75,100,,25.752,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,590.4,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,26.52,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,527.888,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.856,Case Rate,Pays based on per visit rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,25.752,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST 2V W APICAL LORDOTIC,49010218,CDM,324,RC,71047,HCPCS,Outpatient,,,365.4,219.24,,28.14,100,,0.504,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,61.92,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.352,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10031.48,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.456,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.456,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.456,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,76.024,Fee Schedule,103% of Cigna fee schedule,42.44,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,721.504,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,274.05,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.456,Case Rate,Pays based on per visit rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,365.4,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,365.4,
DX CHEST 2V W APICAL LORDOTIC,49010218,CDM,324,RC,71047,HCPCS,Outpatient,,,365.4,219.24,,28.14,100,,5.672,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,61.92,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.464,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10163.28,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.6,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.6,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.6,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1101.664,Fee Schedule,103% of Cigna fee schedule,42.44,100,,36.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,110.848,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,37.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,274.05,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,182.7,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,182.7,50,,351.928,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.616,Case Rate,Pays based on per visit rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,36.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,365.4,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,365.4,
DX CHEST MIN 4V,49010309,CDM,324,RC,71048,HCPCS,Outpatient,,,524.64,314.78,TC   ,29.15,100,,0.136,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,61.92,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.016,Fee Schedule,320% of BCBS Blue Essentials Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.04,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,358.52,Fee Schedule,103% of Cigna fee schedule,46.45,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,121.984,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,47.84,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,393.48,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,262.32,50,,265.344,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.16,Case Rate,Pays based on per visit rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,524.64,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,524.64,
DX CHEST MIN 4V,49010309,CDM,324,RC,71048,HCPCS,Outpatient,,,524.64,314.78,TC   ,29.15,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,48.352,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.232,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.032,Fee Schedule,320% of BCBS Blue Essentials Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.152,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.152,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.152,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,289.416,Fee Schedule,103% of Cigna fee schedule,46.45,100,,81.664,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,275.504,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,47.84,103,,84.112,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,393.48,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,262.32,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,262.32,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.256,Case Rate,Pays based on per visit rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,46.45,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,524.64,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,524.64,
DX CHEST DECUB LT,49010358,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,3.96,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,48.352,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.048,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,97.496,Fee Schedule,103% of Cigna fee schedule,26.06,100,,81.664,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,146.688,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,84.112,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,1873.336,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,297.336,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,36.76,Case Rate,Pays based on per visit rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,81.664,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,2497.784,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB LT,49010358,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.064,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,110.36,Fee Schedule,103% of Cigna fee schedule,26.06,100,,51.008,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,218.72,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,52.536,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,1412.104,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,249,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.528,Case Rate,Pays based on per visit rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,1882.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB LT,49010358,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,0.584,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.128,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,26.06,100,,51.008,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,218.72,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,52.536,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,1355.224,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,355.24,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.424,Case Rate,Pays based on per visit rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,51.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,1806.96,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB BI,49010366,CDM,324,RC,71046,HCPCS,Outpatient,,,525,315.00,TC   ,22.16,100,,0.2,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.136,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,33.75,100,,17,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,223.52,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,17.512,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,393.75,75,,300.6,Percent of Total Billed Charges,75% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,217.648,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.496,Case Rate,Pays based on per visit rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,17,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,525,100,,400.8,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,525,
DX CHEST DECUB BI,49010366,CDM,324,RC,71046,HCPCS,Outpatient,,,525,315.00,TC   ,22.16,100,,6.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.208,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.144,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,285.32,Fee Schedule,103% of Cigna fee schedule,33.75,100,,234,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,272.96,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,241.016,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,393.75,75,,300.6,Percent of Total Billed Charges,75% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,379.248,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.328,Case Rate,Pays based on per visit rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,525,100,,400.8,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,525,
DX CHEST DECUB BI,49010366,CDM,324,RC,71046,HCPCS,Outpatient,,,525,315.00,TC   ,22.16,100,,6.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.392,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.16,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.504,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.504,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.504,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,855.968,Fee Schedule,103% of Cigna fee schedule,33.75,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,272.96,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,393.75,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,262.5,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.52,Case Rate,Pays based on per visit rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,525,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,525,
DX RIBS 2V LT,49011000,CDM,320,RC,71100,HCPCS,Outpatient,,,377.06,226.24,,24.81,100,,12.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,68.864,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.936,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.2,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,855.968,Fee Schedule,103% of Cigna fee schedule,37.09,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,128.192,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,282.8,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,188.53,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,188.53,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,202.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.496,Case Rate,Pays based on per visit rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,377.06,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,377.06,
DX RIBS 2V LT,49011000,CDM,320,RC,71100,HCPCS,Outpatient,,,377.06,226.24,,24.81,100,,1.88,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,89.904,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.136,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.224,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1002.856,Fee Schedule,103% of Cigna fee schedule,37.09,100,,87.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,137.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,89.616,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,282.8,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,188.53,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,188.53,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.096,Case Rate,Pays based on per visit rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,87.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,377.06,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,377.06,
DX RIBS MIN 3V W PA CHEST LT,49011018,CDM,320,RC,71101,HCPCS,Outpatient,,,467,280.20,,28.14,100,,0.24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,400.472,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,100.576,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.464,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.464,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,823.04,Fee Schedule,103% of Cigna fee schedule,42.44,100,,83.664,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,137.6,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,86.168,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,350.25,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.184,Case Rate,Pays based on per visit rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,83.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,467,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,467,
DX RIBS MIN 3V W PA CHEST LT,49011018,CDM,320,RC,71101,HCPCS,Outpatient,,,467,280.20,,28.14,100,,0.312,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,400.472,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,100.664,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.16,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.16,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.16,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,42.44,100,,29,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,137.6,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,29.872,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,350.25,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,18.304,Case Rate,Pays based on per visit rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,29,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,467,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,467,
DX RIBS 3V BI,49011109,CDM,320,RC,71110,HCPCS,Outpatient,,,507.95,304.77,TC   ,28.82,100,,5.712,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,187.792,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,100.88,Fee Schedule,320% of BCBS Blue Essentials Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.192,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.192,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.192,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,44.1,100,,225,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,107.456,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,45.42,103,,231.752,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,380.96,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,253.98,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.88,Case Rate,Pays based on per visit rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,225,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,507.95,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,507.95,
DX RIBS 3V BI,49011109,CDM,320,RC,71110,HCPCS,Outpatient,,,507.95,304.77,TC   ,28.82,100,,3.2,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,117.72,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,101.272,Fee Schedule,320% of BCBS Blue Essentials Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.528,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.528,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1305.136,Fee Schedule,103% of Cigna fee schedule,44.1,100,,199.728,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,107.456,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,45.42,103,,205.72,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,380.96,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,253.98,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,253.98,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28.48,Case Rate,Pays based on per visit rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,44.1,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,507.95,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,507.95,
DX RIBS MIN 4V W PA CHEST BI,49011117,CDM,320,RC,71111,HCPCS,Outpatient,,,700.5,420.30,,35.81,100,,17.032,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,117.72,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.352,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,102.08,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.448,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.448,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.448,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,52.79,100,,192.04,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,197.808,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,525.38,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,350.25,50,,134.752,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,115.64,Case Rate,Pays based on per visit rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,192.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,700.5,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,35.81,700.5,
DX RIBS MIN 4V W PA CHEST BI,49011117,CDM,320,RC,71111,HCPCS,Outpatient,,,700.5,420.30,,35.81,100,,34.168,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,407.272,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.768,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,102.08,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,3.56,Fee Schedule,360% of BCBS POS Rate,403.49,360,,3.56,Fee schedule,360% of BCBS PPO Rate,403.49,360,,3.56,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1206.392,Fee Schedule,103% of Cigna fee schedule,52.79,100,,66.576,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,68.576,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,525.38,75,,249.696,Percent of Total Billed Charges,75% of Total Billed Charges,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,350.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,350.25,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.208,Case Rate,Pays based on per visit rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,66.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,700.5,100,,332.928,Percent of Total Billed Charges,100% of Total Billed Charges,35.81,700.5,
DX STERNUM MIN 2V,49011208,CDM,320,RC,71120,HCPCS,Outpatient,,,293.46,176.08,TC   ,23.15,100,,18.04,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,407.272,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.776,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,102.12,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.432,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.432,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.432,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1002.856,Fee Schedule,103% of Cigna fee schedule,33.75,100,,189.416,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,195.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,220.1,75,,249.696,Percent of Total Billed Charges,75% of Total Billed Charges,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,146.73,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,18.272,Case Rate,Pays based on per visit rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,189.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293.46,100,,332.928,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300,
DX STERNUM MIN 2V,49011208,CDM,320,RC,71120,HCPCS,Outpatient,,,293.46,176.08,TC   ,23.15,100,,2.048,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,36,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,102.144,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,33.75,100,,480.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,494.432,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,220.1,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.73,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,146.73,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.896,Case Rate,Pays based on per visit rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,480.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293.46,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300,
DX CSPINE 2 OR 3V,49020407,CDM,320,RC,72040,HCPCS,Outpatient,,,434.31,260.59,,27.48,100,,1.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,36,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.288,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,102.304,Fee Schedule,320% of BCBS Blue Essentials Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,349.976,Fee Schedule,103% of Cigna fee schedule,39.76,100,,199.728,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,40.95,103,,205.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,325.73,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.576,Case Rate,Pays based on per visit rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,199.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,434.31,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,434.31,
DX CSPINE 2 OR 3V,49020407,CDM,320,RC,72040,HCPCS,Outpatient,,,434.31,260.59,,27.48,100,,2.104,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,33.52,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.304,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1029.952,Fee Schedule,320% of BCBS Blue Essentials Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.384,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.384,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,349.976,Fee Schedule,103% of Cigna fee schedule,39.76,100,,88.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,153.024,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,40.95,103,,90.72,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,325.73,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,217.16,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.04,Case Rate,Pays based on per visit rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,88.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,434.31,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,434.31,
DX CSPINE COMPL,49020506,CDM,320,RC,72050,HCPCS,Outpatient,,,576.49,345.89,TC   ,38.13,100,,33.616,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,32.416,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1029.952,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,114.896,Fee Schedule,103% of Cigna fee schedule,53.46,100,,304.224,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,199.784,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,313.352,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,432.37,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,288.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,288.25,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288.25,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,288.25,50,,237.704,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.232,Case Rate,Pays based on per visit rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,304.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,576.49,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,38.13,576.49,
DX CSPINE COMPL,49020506,CDM,320,RC,72050,HCPCS,Outpatient,,,576.49,345.89,TC   ,38.13,100,,2.296,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,29.016,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.256,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1031.68,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.184,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.184,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.184,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1206.392,Fee Schedule,103% of Cigna fee schedule,53.46,100,,281.488,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,889.936,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,289.936,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,432.37,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,288.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,288.25,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288.25,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,288.25,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.448,Case Rate,Pays based on per visit rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,281.488,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,576.49,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,38.13,576.49,
DX CSPINE COMPL W FLEX EXT,49020522,CDM,320,RC,72052,HCPCS,Outpatient,,,607.78,364.67,,46.13,100,,4.416,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,188.296,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.248,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1039.616,Fee Schedule,320% of BCBS Blue Essentials Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.32,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.32,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.32,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,344.68,Fee Schedule,103% of Cigna fee schedule,62.49,100,,151.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,889.936,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,64.36,103,,155.736,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,455.84,75,,266.576,Percent of Total Billed Charges,75% of Total Billed Charges,303.89,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,303.89,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,303.89,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,303.89,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.624,Case Rate,Pays based on per visit rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,607.78,100,,355.432,Percent of Total Billed Charges,100% of Total Billed Charges,46.13,607.78,
DX CSPINE COMPL W FLEX EXT,49020522,CDM,320,RC,72052,HCPCS,Outpatient,,,607.78,364.67,,46.13,100,,8.464,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,102.936,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.104,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1043.632,Fee Schedule,320% of BCBS Blue Essentials Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.136,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.136,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.136,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,344.68,Fee Schedule,103% of Cigna fee schedule,62.49,100,,67.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,417.312,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,64.36,103,,69.216,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,455.84,75,,343.44,Percent of Total Billed Charges,75% of Total Billed Charges,303.89,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,303.89,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,303.89,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,303.89,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.656,Case Rate,Pays based on per visit rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,62.49,100,,67.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,607.78,100,,457.92,Percent of Total Billed Charges,100% of Total Billed Charges,46.13,607.78,
DX TSPINE 1V,49020696,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,8.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,92.464,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1044.992,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.896,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.896,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.896,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,24.73,100,,64.6,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,261.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,66.536,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,343.44,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.36,Case Rate,Pays based on per visit rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,64.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,457.92,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX TSPINE 1V,49020696,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,0.568,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,86.888,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.848,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1048.384,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.664,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.664,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.664,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,203.096,Fee Schedule,103% of Cigna fee schedule,24.73,100,,1182.608,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,261.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,1218.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.024,Case Rate,Pays based on per visit rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1182.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX TSPINE 2V,49020704,CDM,320,RC,72070,HCPCS,Outpatient,,,398.04,238.82,,21.83,100,,0.608,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,71.888,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.816,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1058.304,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.048,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,110.36,Fee Schedule,103% of Cigna fee schedule,33.08,100,,16.8,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,905.056,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,17.304,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.656,Case Rate,Pays based on per visit rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,16.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,403.49,
DX TSPINE 2V,49020704,CDM,320,RC,72070,HCPCS,Outpatient,,,398.04,238.82,,21.83,100,,0.664,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,61.312,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,4.192,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1062.48,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,5.392,Fee Schedule,360% of BCBS POS Rate,403.49,360,,5.392,Fee schedule,360% of BCBS PPO Rate,403.49,360,,5.392,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,331.088,Fee Schedule,103% of Cigna fee schedule,33.08,100,,285.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,905.056,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,293.816,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,303.184,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.696,Case Rate,Pays based on per visit rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,285.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,404.248,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,403.49,
DX TL SPINE 2V,49020803,CDM,320,RC,72080,HCPCS,Outpatient,,,398.04,238.82,TC   ,23.49,100,,8.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,325.08,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1066.816,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.752,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.752,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.752,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,154.52,Fee Schedule,103% of Cigna fee schedule,34.75,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,80,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,303.184,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.32,Case Rate,Pays based on per visit rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,404.248,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,398.04,
DX TL SPINE 2V,49020803,CDM,320,RC,72080,HCPCS,Outpatient,,,398.04,238.82,TC   ,23.49,100,,8.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,398.112,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.904,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1069.032,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.736,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.736,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.736,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,34.75,100,,64.96,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,80,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,66.912,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.488,Case Rate,Pays based on per visit rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,64.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,398.04,
DX LSPINE 2 OR 3V,49021017,CDM,320,RC,72100,HCPCS,Outpatient,,,450.99,270.59,,27.81,100,,8.344,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,366.92,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1069.032,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,349.976,Fee Schedule,103% of Cigna fee schedule,40.1,100,,513.928,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,74.48,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,529.344,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,338.24,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,225.5,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225.5,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.32,Case Rate,Pays based on per visit rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,513.928,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450.99,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,27.81,450.99,
DX LSPINE 2 OR 3V,49021017,CDM,320,RC,72100,HCPCS,Outpatient,,,450.99,270.59,,27.81,100,,2.208,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,461.672,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1069.864,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.064,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.064,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,349.976,Fee Schedule,103% of Cigna fee schedule,40.1,100,,365.944,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,72.04,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,376.92,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,338.24,75,,417.456,Percent of Total Billed Charges,75% of Total Billed Charges,225.5,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225.5,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.616,Case Rate,Pays based on per visit rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,365.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450.99,100,,556.608,Percent of Total Billed Charges,100% of Total Billed Charges,27.81,450.99,
DX LSPINE MIN 4V,49021108,CDM,320,RC,72110,HCPCS,Outpatient,,,604.47,362.68,TC   ,36.8,100,,0.224,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,49.072,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.128,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1070.288,Fee Schedule,320% of BCBS Blue Essentials Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.168,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.168,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.168,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,218.608,Fee Schedule,103% of Cigna fee schedule,51.45,100,,282.224,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,64.48,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,52.99,103,,290.688,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,453.35,75,,417.456,Percent of Total Billed Charges,75% of Total Billed Charges,302.24,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,302.24,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,302.24,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,302.24,50,,158.472,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.76,Case Rate,Pays based on per visit rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,282.224,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,604.47,100,,556.608,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,604.47,
DX LSPINE MIN 4V,49021108,CDM,320,RC,72110,HCPCS,Outpatient,,,604.47,362.68,TC   ,36.8,100,,3.392,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,39.944,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.936,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1072.56,Fee Schedule,320% of BCBS Blue Essentials Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.92,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.92,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.92,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,218.608,Fee Schedule,103% of Cigna fee schedule,51.45,100,,63.08,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,418.44,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,52.99,103,,64.968,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,453.35,75,,278.304,Percent of Total Billed Charges,75% of Total Billed Charges,302.24,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,302.24,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,302.24,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,302.24,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.736,Case Rate,Pays based on per visit rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,51.45,100,,63.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,604.47,100,,371.072,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,604.47,
DX LSPINE W BEND V,49021140,CDM,320,RC,72114,HCPCS,Outpatient,,,714.42,428.65,,45.8,100,,7.536,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,37.928,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.936,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1082.624,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.92,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.92,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.92,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,72.872,Fee Schedule,103% of Cigna fee schedule,62.15,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,228.752,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,535.82,75,,278.304,Percent of Total Billed Charges,75% of Total Billed Charges,357.21,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,357.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,357.21,50,,185.536,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.736,Case Rate,Pays based on per visit rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,714.42,100,,371.072,Percent of Total Billed Charges,100% of Total Billed Charges,45.8,714.42,
DX LSPINE W BEND V,49021140,CDM,320,RC,72114,HCPCS,Outpatient,,,714.42,428.65,,45.8,100,,1.144,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,37.616,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1082.624,Fee Schedule,320% of BCBS Blue Essentials Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.256,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.256,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.256,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1002.856,Fee Schedule,103% of Cigna fee schedule,62.15,100,,24.336,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,205.472,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,64.01,103,,25.064,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,535.82,75,,343.704,Percent of Total Billed Charges,75% of Total Billed Charges,357.21,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,357.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.21,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,357.21,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.624,Case Rate,Pays based on per visit rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,62.15,100,,24.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,714.42,100,,458.272,Percent of Total Billed Charges,100% of Total Billed Charges,45.8,714.42,
DX LSPINE 2V OR 3V BEND ONLY,49021223,CDM,320,RC,72120,HCPCS,Outpatient,,,502.87,301.72,TC   ,28.82,100,,259.864,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.352,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.352,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.352,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,40.76,100,,15.344,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,193.088,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,15.808,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,75,,343.704,Percent of Total Billed Charges,75% of Total Billed Charges,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,251.44,50,,141.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,145.768,Case Rate,Pays based on per visit rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,15.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,502.87,100,,458.272,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,502.87,
DX LSPINE 2V OR 3V BEND ONLY,49021223,CDM,320,RC,72120,HCPCS,Outpatient,,,502.87,301.72,TC   ,28.82,100,,64.656,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.472,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.472,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.472,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,40.76,100,,252.448,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,159.744,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,260.024,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,251.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,251.44,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.888,Case Rate,Pays based on per visit rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,252.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,502.87,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,502.87,
DX PEL 1 OR 2V,49021751,CDM,320,RC,72170,HCPCS,Outpatient,,,344.64,206.78,,18.5,100,,0.088,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.472,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.472,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.472,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,372.896,Fee Schedule,103% of Cigna fee schedule,28.06,100,,90.608,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,136.256,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.9,103,,93.328,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,258.48,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.168,Case Rate,Pays based on per visit rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,90.608,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,344.64,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,403.49,
DX PEL 1 OR 2V,49021751,CDM,320,RC,72170,HCPCS,Outpatient,,,344.64,206.78,,18.5,100,,0.064,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.736,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,3.512,Fee Schedule,360% of BCBS POS Rate,403.49,360,,3.512,Fee schedule,360% of BCBS PPO Rate,403.49,360,,3.512,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,358.552,Fee Schedule,103% of Cigna fee schedule,28.06,100,,105.344,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,722.4,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.9,103,,108.504,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,258.48,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,172.32,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.088,Case Rate,Pays based on per visit rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,105.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,344.64,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,403.49,
DX SACROILIAC JTS MIN 3V,49022023,CDM,320,RC,72202,HCPCS,Outpatient,,,217.5,130.50,TC   ,27.15,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,295.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,379.504,Fee Schedule,360% of BCBS POS Rate,403.49,360,,379.504,Fee schedule,360% of BCBS PPO Rate,403.49,360,,379.504,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,124.304,Fee Schedule,103% of Cigna fee schedule,39.43,100,,180.664,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,884.696,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,40.61,103,,186.08,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,163.13,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,108.75,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,108.75,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.75,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,108.75,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.08,Case Rate,Pays based on per visit rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,180.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,217.5,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,403.49,
DX SACROILIAC JTS MIN 3V,49022023,CDM,320,RC,72202,HCPCS,Outpatient,,,217.5,130.50,TC   ,27.15,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,262.256,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,337.192,Fee Schedule,360% of BCBS POS Rate,403.49,360,,337.192,Fee schedule,360% of BCBS PPO Rate,403.49,360,,337.192,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,964.28,Fee Schedule,103% of Cigna fee schedule,39.43,100,,232.808,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,815.384,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,40.61,103,,239.792,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,163.13,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,108.75,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,108.75,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.75,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,108.75,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.08,Case Rate,Pays based on per visit rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,232.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,217.5,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,403.49,
DX SACRUM COCCYX MIN 2V,49022239,CDM,320,RC,72220,HCPCS,Outpatient,,,387.39,232.43,,22.82,100,,13.744,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,3.6,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,855.968,Fee Schedule,103% of Cigna fee schedule,32.75,100,,163.384,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1025.936,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,168.288,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.54,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,193.7,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.7,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,180.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.096,Case Rate,Pays based on per visit rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,163.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.39,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,387.39,
DX SACRUM COCCYX MIN 2V,49022239,CDM,320,RC,72220,HCPCS,Outpatient,,,387.39,232.43,,22.82,100,,13.168,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,823.04,Fee Schedule,103% of Cigna fee schedule,32.75,100,,244.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,109.056,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,252.208,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.54,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,193.7,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.7,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,478.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.288,Case Rate,Pays based on per visit rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,244.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.39,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,387.39,
DX MYELOGRAPHY CSPINE SI,49022403,CDM,320,RC,72240,HCPCS,Outpatient,,,1458.91,875.35,TC   ,69.77,100,,0.064,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,9.656,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,12.416,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,12.416,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,12.416,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,285.32,Fee Schedule,103% of Cigna fee schedule,115.28,100,,241.016,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,88.768,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,118.74,103,,248.248,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1094.18,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,729.46,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,729.46,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,729.46,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,729.46,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.216,Case Rate,Pays based on per visit rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,241.016,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.91,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,2450.95,
DX MYELOGRAPHY CSPINE SI,49022403,CDM,320,RC,72240,HCPCS,Outpatient,,,1458.91,875.35,TC   ,69.77,100,,0.088,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,0.152,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,0.152,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,811.784,Fee Schedule,103% of Cigna fee schedule,115.28,100,,1140.2,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,84.288,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,118.74,103,,1174.4,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1094.18,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,729.46,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,729.46,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,729.46,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,729.46,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.52,Case Rate,Pays based on per visit rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,115.28,100,,1140.2,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.91,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,2450.95,
DX MYELOGRAPHY LS SPINE SI,49022502,CDM,320,RC,72265,HCPCS,Outpatient,,,1793.13,1075.88,,66.77,100,,0.512,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,0.08,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,0.08,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,0.08,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,2057.28,Fee Schedule,103% of Cigna fee schedule,109.93,100,,226.544,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,83.584,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,113.23,103,,233.344,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1344.85,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,896.57,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,896.57,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,896.57,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,896.57,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.984,Case Rate,Pays based on per visit rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,226.544,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1793.13,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,66.77,2450.95,
DX MYELOGRAPHY LS SPINE SI,49022502,CDM,320,RC,72265,HCPCS,Outpatient,,,1793.13,1075.88,,66.77,100,,2.32,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,1.472,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,1.896,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,1.896,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,1.896,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,855.968,Fee Schedule,103% of Cigna fee schedule,109.93,100,,166.392,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,64,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,113.23,103,,171.384,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1344.85,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,896.57,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,896.57,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,896.57,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,896.57,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.84,Case Rate,Pays based on per visit rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,109.93,100,,166.392,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1793.13,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,66.77,2450.95,
DX MYELOGRAPHY MIN 2 LVL SI,49022718,CDM,320,RC,72270,HCPCS,Outpatient,,,2118.9,1271.34,,80.75,100,,0.336,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,28.8,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,1.672,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,2.152,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,2.152,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,2.152,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,377.488,Fee Schedule,103% of Cigna fee schedule,165.06,100,,228.744,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,64,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,170.01,103,,235.608,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1589.18,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,1059.45,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,1059.45,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.45,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,1059.45,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.336,Case Rate,Pays based on per visit rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,228.744,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2118.9,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,80.75,2450.95,
DX MYELOGRAPHY MIN 2 LVL SI,49022718,CDM,320,RC,72270,HCPCS,Outpatient,,,2118.9,1271.34,,80.75,100,,0.76,Fee Schedule,100% of Aetna Fee Schedule,1101.88,150,,53.744,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,3.208,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,4.128,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,4.128,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,4.128,Fee Schedule,360% of BCBS Traditional Rate,2103.65,103,,1303.832,Fee Schedule,103% of Cigna fee schedule,165.06,100,,132.768,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,64,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.97,130,,,Fee Schedule,130% of CMS OPPS Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,170.01,103,,136.752,Fee Schedule,103% of TX Medicaid Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,756.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1589.18,75,,302.4,Percent of Total Billed Charges,75% of Total Billed Charges,1059.45,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,1059.45,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.45,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,1059.45,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.904,Case Rate,Pays based on per visit rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,165.06,100,,132.768,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2118.9,100,,403.2,Percent of Total Billed Charges,100% of Total Billed Charges,80.75,2450.95,
DX INJ MYELOGRAPHY,49022767,CDM,361,RC,,,Outpatient,,,1328.73,797.24,,797.24,60,,0.368,Percent of Total Billed Charges,60% of Total Billed Charges,597.93,45,,36.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.04,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,79.19,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,478.34,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,478.34,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,478.34,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,797.24,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1328.73,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,191.6,14.42,,159.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,996.55,75,,302.4,Percent of Total Billed Charges,75% of Total Billed Charges,664.37,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,664.37,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930.11,70,,0.312,Percent of Total Billed Charges,70% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,154.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1328.73,100,,403.2,Percent of Total Billed Charges,100% of Total Billed Charges,79.19,1328.73,
DX CLAVICLE COMPL LT,49030000,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,4.192,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,37.76,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.608,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.352,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.352,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.352,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,648,Fee Schedule,103% of Cigna fee schedule,32.41,100,,151.072,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,155.608,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.368,Case Rate,Pays based on per visit rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,151.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL LT,49030000,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,0.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,114.952,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.552,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.712,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.712,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.712,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,288,Fee Schedule,103% of Cigna fee schedule,32.41,100,,306.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,315.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.032,Case Rate,Pays based on per visit rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,306.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL BI,49030018,CDM,320,RC,73000,HCPCS,Outpatient,,,451.03,270.62,TC   ,23.15,100,,0.776,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,114.952,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,276.848,Fee Schedule,103% of Cigna fee schedule,32.41,100,,459.12,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,472.888,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,338.27,75,,380.384,Percent of Total Billed Charges,75% of Total Billed Charges,225.52,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225.52,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.872,Case Rate,Pays based on per visit rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,459.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,451.03,100,,507.176,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,451.03,
DX CLAVICLE COMPL BI,49030018,CDM,320,RC,73000,HCPCS,Outpatient,,,451.03,270.62,TC   ,23.15,100,,2.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,480.56,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.464,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4645.952,Fee Schedule,103% of Cigna fee schedule,32.41,100,,172,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,177.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,338.27,75,,380.384,Percent of Total Billed Charges,75% of Total Billed Charges,225.52,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225.52,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,137.856,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.928,Case Rate,Pays based on per visit rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,172,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,451.03,100,,507.176,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,451.03,
DX SCAPULA COMPL LT,49030109,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,0.56,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,480.56,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.616,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.792,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.792,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.792,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,72,Fee Schedule,103% of Cigna fee schedule,23.73,100,,258,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,64,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,265.736,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.448,Case Rate,Pays based on per visit rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,258,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL LT,49030109,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,1.096,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,114.952,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.76,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1084.16,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.984,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.984,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.984,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1222.544,Fee Schedule,103% of Cigna fee schedule,23.73,100,,255.8,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,64,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,263.472,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,189.768,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.12,Case Rate,Pays based on per visit rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,255.8,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SHOULDER 1V LT,49030208,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,TC   ,13.5,100,,5.296,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,114.952,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.92,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1084.928,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,21.71,100,,383.696,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,395.208,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.712,Case Rate,Pays based on per visit rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,383.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V LT,49030208,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,TC   ,13.5,100,,0.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,764.064,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1085.952,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,255.2,Fee Schedule,103% of Cigna fee schedule,21.71,100,,154.64,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,159.28,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,150.824,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.752,Case Rate,Pays based on per visit rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,154.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER MIN 2V BI,49030299,CDM,320,RC,73030,HCPCS,Outpatient,,,572.59,343.55,,24.15,100,,0.712,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,764.064,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.824,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1087.68,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2019.008,Fee Schedule,103% of Cigna fee schedule,34.75,100,,231.96,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,64,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,238.912,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.44,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,286.3,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.3,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.232,Case Rate,Pays based on per visit rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,231.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.59,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,572.59,
DX SHOULDER MIN 2V BI,49030299,CDM,320,RC,73030,HCPCS,Outpatient,,,572.59,343.55,,24.15,100,,36.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,38.344,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.32,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1091.072,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.984,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.984,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.984,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1568.328,Fee Schedule,103% of Cigna fee schedule,34.75,100,,271.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,119.424,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,280.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.44,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,286.3,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.3,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.144,Case Rate,Pays based on per visit rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,271.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.59,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,572.59,
DX SHOULDER MIN 2V LT,49030307,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,13.736,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1091.832,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.312,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.312,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.312,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1209.52,Fee Schedule,103% of Cigna fee schedule,34.75,100,,407.776,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,81.216,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,420.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,212.416,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.624,Case Rate,Pays based on per visit rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,407.776,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,283.224,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V LT,49030307,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,22.832,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.104,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1092.464,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.128,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.128,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.128,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,270.328,Fee Schedule,103% of Cigna fee schedule,34.75,100,,158.248,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,83.904,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,162.992,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,212.416,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,82.832,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.272,Case Rate,Pays based on per visit rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,158.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,283.224,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX AC JT W OR WO WEIGHT BI,49030505,CDM,320,RC,73050,HCPCS,Outpatient,,,293.58,176.15,TC   ,18.5,100,,0.584,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,129.6,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1097.216,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.44,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,28.74,100,,237.368,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,255.456,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,244.488,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,220.19,75,,232.648,Percent of Total Billed Charges,75% of Total Billed Charges,146.79,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,146.79,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.79,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,146.79,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.584,Case Rate,Pays based on per visit rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,237.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293.58,100,,310.2,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,300,
DX AC JT W OR WO WEIGHT BI,49030505,CDM,320,RC,73050,HCPCS,Outpatient,,,293.58,176.15,TC   ,18.5,100,,6.752,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,135,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,18.192,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1098.24,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,23.392,Fee Schedule,360% of BCBS POS Rate,287.32,360,,23.392,Fee schedule,360% of BCBS PPO Rate,287.32,360,,23.392,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,104.28,Fee Schedule,103% of Cigna fee schedule,28.74,100,,151.296,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,255.456,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,155.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,220.19,75,,232.648,Percent of Total Billed Charges,75% of Total Billed Charges,146.79,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,146.79,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.79,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,146.79,50,,154.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.128,Case Rate,Pays based on per visit rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,151.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293.58,100,,310.2,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,300,
DX HUMERUS MIN 2V BI,49030596,CDM,320,RC,73060,HCPCS,Outpatient,,,539.17,323.50,,23.15,100,,7.8,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,135,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1104.096,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.944,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.944,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.944,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,65.76,Fee Schedule,103% of Cigna fee schedule,32.41,100,,226.944,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1067.904,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,233.752,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,404.38,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.032,Case Rate,Pays based on per visit rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,226.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,539.17,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,539.17,
DX HUMERUS MIN 2V BI,49030596,CDM,320,RC,73060,HCPCS,Outpatient,,,539.17,323.50,,23.15,100,,4.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,99,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.64,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1112.912,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.824,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.824,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.824,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1081.928,Fee Schedule,103% of Cigna fee schedule,32.41,100,,284.928,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1067.904,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,293.472,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,404.38,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,269.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.48,Case Rate,Pays based on per visit rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,539.17,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,539.17,
DX HUMERUS MIN 2V LT,49030604,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,TC   ,23.15,100,,0.48,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,99,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1116.392,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.568,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.568,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.568,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,997.744,Fee Schedule,103% of Cigna fee schedule,32.41,100,,427.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,255.456,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,440.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.4,Case Rate,Pays based on per visit rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V LT,49030604,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,TC   ,23.15,100,,3.296,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,72,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1120.672,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,700.224,Fee Schedule,103% of Cigna fee schedule,32.41,100,,158.368,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,255.456,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,163.12,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.272,Case Rate,Pays based on per visit rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,158.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX ELBOW 2V BI,49030695,CDM,320,RC,73070,HCPCS,Outpatient,,,513.34,308.00,,20.16,100,,1.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,72,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1123.072,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,737.144,Fee Schedule,103% of Cigna fee schedule,29.4,100,,237.552,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1697.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,244.68,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,385.01,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,256.67,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,256.67,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.088,Case Rate,Pays based on per visit rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,237.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,513.34,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,513.34,
DX ELBOW 2V BI,49030695,CDM,320,RC,73070,HCPCS,Outpatient,,,513.34,308.00,,20.16,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,59.76,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,31.136,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1123.072,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,40.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,40.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,40.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1105.712,Fee Schedule,103% of Cigna fee schedule,29.4,100,,156.752,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,1697.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,161.456,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,385.01,75,,186.688,Percent of Total Billed Charges,75% of Total Billed Charges,256.67,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,256.67,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.128,Case Rate,Pays based on per visit rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,156.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,513.34,100,,248.912,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,513.34,
DX ELBOW 2V LT,49030703,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,0.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,59.76,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1123.072,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,662.736,Fee Schedule,103% of Cigna fee schedule,29.4,100,,235.128,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,85.2,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,242.176,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,186.688,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.328,Case Rate,Pays based on per visit rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,235.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,248.912,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V LT,49030703,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,2.288,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.992,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1123.072,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.024,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,994.096,Fee Schedule,103% of Cigna fee schedule,29.4,100,,111.672,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,30.52,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,115.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,241.488,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.344,Case Rate,Pays based on per visit rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,111.672,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,321.984,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW MIN 3V BI,49030794,CDM,320,RC,73080,HCPCS,Outpatient,,,583.77,350.26,,22.82,100,,7.424,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,57.824,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1123.072,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,678.192,Fee Schedule,103% of Cigna fee schedule,32.75,100,,240.576,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,50.736,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,247.792,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,437.83,75,,241.488,Percent of Total Billed Charges,75% of Total Billed Charges,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,291.89,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.344,Case Rate,Pays based on per visit rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,240.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,583.77,100,,321.984,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,583.77,
DX ELBOW MIN 3V BI,49030794,CDM,320,RC,73080,HCPCS,Outpatient,,,583.77,350.26,,22.82,100,,8.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,57.824,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1126.84,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1017.288,Fee Schedule,103% of Cigna fee schedule,32.75,100,,280.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,288,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,288.8,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,437.83,75,,342.2,Percent of Total Billed Charges,75% of Total Billed Charges,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,291.89,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,291.89,50,,175.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.496,Case Rate,Pays based on per visit rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,280.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,583.77,100,,456.264,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,583.77,
DX ELBOW MIN 3V LT,49030802,CDM,320,RC,73080,HCPCS,Outpatient,,,389.18,233.51,TC   ,22.82,100,,0.736,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,77.224,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1126.84,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.2,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.2,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.2,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,648.416,Fee Schedule,103% of Cigna fee schedule,32.75,100,,294.504,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,300,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,303.344,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,291.89,75,,342.2,Percent of Total Billed Charges,75% of Total Billed Charges,194.59,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,194.59,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.688,Case Rate,Pays based on per visit rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,294.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,389.18,100,,456.264,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,389.18,
DX ELBOW MIN 3V LT,49030802,CDM,320,RC,73080,HCPCS,Outpatient,,,389.18,233.51,TC   ,22.82,100,,6.288,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,77.224,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.776,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1128.192,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.568,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.568,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.568,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,972.632,Fee Schedule,103% of Cigna fee schedule,32.75,100,,396.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,300,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,407.904,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,291.89,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,194.59,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,194.59,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.928,Case Rate,Pays based on per visit rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,396.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,389.18,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,389.18,
DX TUBE EVAL GI COLIC,49030871,CDM,361,RC,49465,HCPCS,Outpatient,,,845.25,507.15,,2601,100,,1.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,337.21,150,,243,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,542.98,233,,0.552,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,79.2,32,,1131.52,Percent of Total Billed Charges,32% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,750.39,322,,0.704,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,750.39,322,,0.704,Fee schedule,Pays based on ASC Tier Groupings fee schedule,750.39,322,,0.704,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,678.72,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,220,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,121.89,14.42,,611.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,633.94,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,422.63,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,422.63,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,422.63,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,422.63,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,0.92,Fee Schedule,100% of ASC Tier Groupings fee schedule,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.34,14,,594.04,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,845.25,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,79.2,2601,
DX FOREARM 2V BI,49030893,CDM,320,RC,73090,HCPCS,Outpatient,,,542.52,325.51,,20.49,100,,11.648,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,243,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1138.28,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.216,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.216,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1018.08,Fee Schedule,103% of Cigna fee schedule,29.4,100,,255.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,220,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,262.992,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,406.89,75,,837.264,Percent of Total Billed Charges,75% of Total Billed Charges,271.26,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,41.208,Case Rate,Pays based on per visit rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,255.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,542.52,100,,1116.352,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,542.52,
DX FOREARM 2V BI,49030893,CDM,320,RC,73090,HCPCS,Outpatient,,,542.52,325.51,,20.49,100,,13.84,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,108.72,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.496,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1150.16,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.64,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.64,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.64,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,671.792,Fee Schedule,103% of Cigna fee schedule,29.4,100,,382.992,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,160,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,394.488,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,406.89,75,,837.264,Percent of Total Billed Charges,75% of Total Billed Charges,271.26,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.832,Case Rate,Pays based on per visit rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,382.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,542.52,100,,1116.352,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,542.52,
DX FOREARM 2V LT,49030919,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,,20.49,100,,10.976,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,108.72,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1152,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1007.68,Fee Schedule,103% of Cigna fee schedule,29.4,100,,284.928,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,160,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,293.472,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,386.168,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,737.92,Case Rate,Pays based on per visit rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,284.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,514.888,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V LT,49030919,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,,20.49,100,,2.968,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,133.56,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.96,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1153.752,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1094.272,Fee Schedule,103% of Cigna fee schedule,29.4,100,,427.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,132.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,440.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,386.168,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,655.648,Case Rate,Pays based on per visit rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,427.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,514.888,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX UPR EXT INF MIN 2V LT,49030927,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,0.232,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,133.56,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1155.84,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1641.408,Fee Schedule,103% of Cigna fee schedule,106.88,100,,216.512,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,132.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,223.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,500.344,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,229.04,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,639.04,Case Rate,Pays based on per visit rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,216.512,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,667.12,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V LT,49030927,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,0.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,82.08,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1158.16,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,927.92,Fee Schedule,103% of Cigna fee schedule,106.88,100,,324.768,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,46.648,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,334.512,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,500.344,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.144,Case Rate,Pays based on per visit rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,324.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,667.12,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX WRIST 2V LT,49031008,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,0.424,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,82.08,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1162.4,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1391.872,Fee Schedule,103% of Cigna fee schedule,34.09,100,,209.92,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,128.496,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,216.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,231.328,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.144,Case Rate,Pays based on per visit rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,209.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,308.432,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V LT,49031008,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,0.56,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,134.224,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1162.4,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1552.312,Fee Schedule,103% of Cigna fee schedule,34.09,100,,440.248,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,128.496,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,453.456,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,231.328,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.144,Case Rate,Pays based on per visit rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,440.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,308.432,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V BI,49031016,CDM,320,RC,73100,HCPCS,Outpatient,,,517.71,310.63,TC   ,24.81,100,,5.552,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,367.208,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1169.032,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,72.112,Fee Schedule,103% of Cigna fee schedule,34.09,100,,281.904,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,171.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,290.36,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,388.28,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,258.86,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.288,Case Rate,Pays based on per visit rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,281.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,517.71,100,,640,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,517.71,
DX WRIST 2V BI,49031016,CDM,320,RC,73100,HCPCS,Outpatient,,,517.71,310.63,TC   ,24.81,100,,1.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,360.168,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.608,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1170.176,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.776,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.776,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.776,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,151.2,Fee Schedule,103% of Cigna fee schedule,34.09,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,171.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,388.28,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.86,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,258.86,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.872,Case Rate,Pays based on per visit rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,517.71,100,,640,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,517.71,
DX WRIST MIN 3V BI,49031099,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,,30.81,100,,6.704,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,803.344,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.552,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1170.176,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.704,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.704,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.704,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,60.48,Fee Schedule,103% of Cigna fee schedule,41.1,100,,91.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,540,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,93.792,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,428.832,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,152.696,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.6,Case Rate,Pays based on per visit rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,91.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,571.776,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V BI,49031099,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,,30.81,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,30.504,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1174.696,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,61.72,Fee Schedule,103% of Cigna fee schedule,41.1,100,,362.208,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,540,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,373.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,428.832,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,33.608,Case Rate,Pays based on per visit rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,362.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,571.776,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V BI,49031099,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,,30.81,100,,0.256,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.856,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.352,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1174.696,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.736,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.736,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.736,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,339.16,Fee Schedule,103% of Cigna fee schedule,41.1,100,,44.8,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,241.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,46.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,506.752,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,77.28,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.152,Case Rate,Pays based on per visit rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,44.8,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,675.672,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V LT,49031107,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,0.352,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,31.272,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.696,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1180.496,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,397.64,Fee Schedule,103% of Cigna fee schedule,41.1,100,,16.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,241.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,17.328,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,506.752,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.68,Case Rate,Pays based on per visit rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,16.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,675.672,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V LT,49031107,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,2.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,30.504,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1191.112,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.984,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.984,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.984,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,33.224,Fee Schedule,103% of Cigna fee schedule,41.1,100,,35.28,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,296.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,36.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,600.096,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,141.264,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.184,Case Rate,Pays based on per visit rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,35.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,800.128,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V LT,49031107,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,0.184,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.856,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.184,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1191.576,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.24,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.24,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.24,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,34.56,Fee Schedule,103% of Cigna fee schedule,41.1,100,,14.112,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,296.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,14.536,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,600.096,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.016,Case Rate,Pays based on per visit rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,14.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,800.128,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX INJ MYELOGRAPHY W SI 2 REGS,49031117,CDM,361,RC,,,Outpatient,,,3122.23,1873.34,,1873.34,60,,0.888,Percent of Total Billed Charges,60% of Total Billed Charges,1405,45,,31.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,874.22,28,,0.4,Percent of Total Billed Charges,28% of Total Billed Charges,79.39,32,,1191.576,Percent of Total Billed Charges,32% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,1124,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,1124,36,,0.512,Percent of Total Billed Charges,36% Total Bille Charges,1124,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,1873.34,60,,315.776,Percent of Total Billed Charges,60% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3122.23,100,,182.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,450.23,14.42,,14.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2341.67,75,,459.6,Percent of Total Billed Charges,75% of Total Billed Charges,1561.12,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1561.12,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1561.12,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1561.12,50,,229.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2185.56,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,437.11,14,,14.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3122.23,100,,612.8,Percent of Total Billed Charges,100% of Total Billed Charges,79.39,3122.23,
DX INJ MYELOGRAPHY W SI CERV,49031118,CDM,361,RC,,,Outpatient,,,2353.5,1412.10,,1412.1,60,,6.976,Percent of Total Billed Charges,60% of Total Billed Charges,1059.08,45,,25.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,658.98,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,79.39,32,,1192.096,Percent of Total Billed Charges,32% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,847.26,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,847.26,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,847.26,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,1412.1,60,,192.456,Percent of Total Billed Charges,60% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2353.5,100,,182.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,339.37,14.42,,81.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1765.13,75,,459.6,Percent of Total Billed Charges,75% of Total Billed Charges,1176.75,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1176.75,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.75,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1176.75,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1647.45,70,,6.512,Percent of Total Billed Charges,70% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,329.49,14,,79.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2353.5,100,,612.8,Percent of Total Billed Charges,100% of Total Billed Charges,79.39,2353.5,
DX INJ MYELOGRAPHY W SI LS,49031119,CDM,361,RC,,,Outpatient,,,2258.7,1355.22,,1355.22,60,,9.024,Percent of Total Billed Charges,60% of Total Billed Charges,1016.42,45,,24.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.44,28,,1.056,Percent of Total Billed Charges,28% of Total Billed Charges,79.44,32,,1192.096,Percent of Total Billed Charges,32% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,813.13,36,,1.36,Percent of Total Billed Charges,36% of Total Billed Charges,813.13,36,,1.36,Percent of Total Billed Charges,36% Total Bille Charges,813.13,36,,1.36,Percent of Total Billed Charges,36% of Total Billed Charges,1355.22,60,,126.64,Percent of Total Billed Charges,60% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2258.7,100,,298.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,325.7,14.42,,95.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1694.03,75,,525.136,Percent of Total Billed Charges,75% of Total Billed Charges,1129.35,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1129.35,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1129.35,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,1129.35,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1581.09,70,,1.392,Percent of Total Billed Charges,70% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,316.22,14,,92.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2258.7,100,,700.176,Percent of Total Billed Charges,100% of Total Billed Charges,79.44,2258.7,
DX HAND 2V BI,49031198,CDM,320,RC,73120,HCPCS,Outpatient,,,501,300.60,,22.16,100,,3.992,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,22.152,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.232,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1192.096,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.304,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.304,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.304,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,631.544,Fee Schedule,103% of Cigna fee schedule,31.41,100,,7.752,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,816.024,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,7.984,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375.75,75,,525.136,Percent of Total Billed Charges,75% of Total Billed Charges,250.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,250.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,250.5,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.096,Case Rate,Pays based on per visit rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,501,100,,700.176,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,501,
DX HAND 2V BI,49031198,CDM,320,RC,73120,HCPCS,Outpatient,,,501,300.60,,22.16,100,,1.04,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,16.704,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.232,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1195.384,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.296,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.296,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.296,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,268.8,Fee Schedule,103% of Cigna fee schedule,31.41,100,,8.064,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,800.368,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,8.304,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375.75,75,,673.896,Percent of Total Billed Charges,75% of Total Billed Charges,250.5,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,250.5,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250.5,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,250.5,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.904,Case Rate,Pays based on per visit rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,501,100,,898.528,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,501,
DX HAND 2V LT,49031206,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,TC   ,22.16,100,,0.624,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,11.744,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.92,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1196.448,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.896,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.896,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.896,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,243.776,Fee Schedule,103% of Cigna fee schedule,31.41,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1785.216,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,673.896,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.544,Case Rate,Pays based on per visit rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,898.528,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V LT,49031206,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,TC   ,22.16,100,,41.04,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,15.776,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.224,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1201.72,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.72,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.72,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.72,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,725.104,Fee Schedule,103% of Cigna fee schedule,31.41,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,67.784,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,248.96,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,152.76,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.912,Case Rate,Pays based on per visit rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,331.944,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND MIN 3V BI,49031297,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,,26.82,100,,5.072,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,37.928,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.128,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1205.816,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.024,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.024,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.024,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,760.192,Fee Schedule,103% of Cigna fee schedule,37.09,100,,73.68,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,28.568,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,75.888,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,248.96,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.296,Case Rate,Pays based on per visit rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,73.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,331.944,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V BI,49031297,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,,26.82,100,,4.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,37.8,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.712,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1213.256,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.912,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.912,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.912,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,118.2,Fee Schedule,103% of Cigna fee schedule,37.09,100,,44.904,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,69.488,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,46.256,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,489.6,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.16,Case Rate,Pays based on per visit rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,44.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,652.8,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V BI,49031297,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,,26.82,100,,0.792,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,21.952,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.952,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1216.552,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.224,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.224,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.224,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,350.856,Fee Schedule,103% of Cigna fee schedule,37.09,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,67.784,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,489.6,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.056,Case Rate,Pays based on per visit rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,652.8,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V LT,49031305,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,0.936,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,9.76,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1217.216,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.296,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.296,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.296,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,442.08,Fee Schedule,103% of Cigna fee schedule,37.09,100,,147.36,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,28.568,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,151.784,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,562.264,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,141.616,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.8,Case Rate,Pays based on per visit rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,147.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,749.68,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V LT,49031305,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,0.744,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.704,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.28,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1218.2,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.36,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.36,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.36,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,327.464,Fee Schedule,103% of Cigna fee schedule,37.09,100,,62.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,69.488,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,64.6,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,562.264,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.552,Case Rate,Pays based on per visit rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,62.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,749.68,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V LT,49031305,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,1.304,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.888,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.256,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1218.2,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,257.296,Fee Schedule,103% of Cigna fee schedule,37.09,100,,56.88,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,56.688,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,58.584,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,572.672,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.256,Case Rate,Pays based on per visit rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,56.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,763.56,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX FINGER 2V BI,49031396,CDM,320,RC,73140,HCPCS,Outpatient,,,416.16,249.70,,29.48,100,,0.792,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,8.064,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1218.2,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,421.024,Fee Schedule,103% of Cigna fee schedule,38.09,100,,169.192,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,53.872,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,174.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,312.12,75,,572.672,Percent of Total Billed Charges,75% of Total Billed Charges,208.08,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.08,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.864,Case Rate,Pays based on per visit rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,169.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,416.16,100,,763.56,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,416.16,
DX FINGER 2V BI,49031396,CDM,320,RC,73140,HCPCS,Outpatient,,,416.16,249.70,,29.48,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,8.088,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,16.544,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1218.2,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,21.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,21.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,21.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,316.144,Fee Schedule,103% of Cigna fee schedule,38.09,100,,177.376,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,49.224,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,182.696,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,312.12,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,208.08,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,575.392,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.08,50,,575.392,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,45.48,Case Rate,Pays based on per visit rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,177.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,416.16,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,416.16,
DX FINGER MIN 2V LT,49031404,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,0.136,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,21.488,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,89.32,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1231.36,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,114.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,114.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,114.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,384.016,Fee Schedule,103% of Cigna fee schedule,38.09,100,,27.584,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,37.128,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,28.408,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,240.6,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,240.6,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.832,Case Rate,Pays based on per visit rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V LT,49031404,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,1.984,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,27.864,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.536,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1251.328,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.688,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.688,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.688,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,384.016,Fee Schedule,103% of Cigna fee schedule,38.09,100,,81.864,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,26.096,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,84.32,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,370.976,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,575.392,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,94.408,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.6,Case Rate,Pays based on per visit rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,494.632,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX HIP WWO PEL 1V LT,49035009,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,11.856,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,25.2,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1257.984,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.208,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.208,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.208,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,180,Fee Schedule,103% of Cigna fee schedule,33.08,100,,103.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,35.056,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,106.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,370.976,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,240.6,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.096,Case Rate,Pays based on per visit rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,494.632,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V LT,49035009,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,5.152,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,14.616,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.496,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1257.984,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.208,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.208,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.208,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,344.68,Fee Schedule,103% of Cigna fee schedule,33.08,100,,76.408,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,84.288,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,78.704,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.536,Case Rate,Pays based on per visit rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,76.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 2V BI,49035207,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,TC   ,29.15,100,,2.216,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,146.152,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1258.672,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,648,Fee Schedule,103% of Cigna fee schedule,41.44,100,,60.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,84,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,61.84,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.024,Case Rate,Pays based on per visit rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,60.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX HIP WWO PEL 2V BI,49035207,CDM,320,RC,73521,HCPCS,Outpatient,,,444.29,266.57,TC   ,29.15,100,,0.024,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,82.368,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.32,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1261.312,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.272,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.272,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.272,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,180,Fee Schedule,103% of Cigna fee schedule,41.44,100,,29.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,48.776,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,30.44,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,333.22,75,,392.896,Percent of Total Billed Charges,75% of Total Billed Charges,222.15,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,222.15,50,,159.216,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,77.84,Case Rate,Pays based on per visit rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,29.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,444.29,100,,523.856,Percent of Total Billed Charges,100% of Total Billed Charges,29.15,444.29,
DX FEMUR MIN 2V BI,49035504,CDM,320,RC,73552,HCPCS,Outpatient,,,572.4,343.44,,25.49,100,,0.048,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,82.368,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.56,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1261.712,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.72,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.72,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.72,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1002.856,Fee Schedule,103% of Cigna fee schedule,35.75,100,,98.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,21.68,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,101.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.3,75,,392.896,Percent of Total Billed Charges,75% of Total Billed Charges,286.2,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.2,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,98.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.4,100,,523.856,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,572.4,
DX FEMUR MIN 2V BI,49035504,CDM,320,RC,73552,HCPCS,Outpatient,,,572.4,343.44,,25.49,100,,1.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,270,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1272.96,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.128,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.128,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.128,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1002.856,Fee Schedule,103% of Cigna fee schedule,35.75,100,,73.768,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,46,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,75.976,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.3,75,,133.648,Percent of Total Billed Charges,75% of Total Billed Charges,286.2,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.2,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,201.536,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.064,Case Rate,Pays based on per visit rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,73.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.4,100,,178.192,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,572.4,
DX FEMUR MIN 2V LT,49035512,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,4.32,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,39.24,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.568,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1273.296,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,180,Fee Schedule,103% of Cigna fee schedule,35.75,100,,89.608,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,46.424,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,92.296,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,133.648,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.04,Case Rate,Pays based on per visit rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,178.192,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V LT,49035512,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,4.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,201.6,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1273.296,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.56,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1308.848,Fee Schedule,103% of Cigna fee schedule,35.75,100,,89.608,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,17.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,92.296,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,238.904,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.064,Case Rate,Pays based on per visit rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,89.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,318.536,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX KNEE 1 OR 2V BI,49035595,CDM,320,RC,73560,HCPCS,Outpatient,,,505.31,303.19,,25.16,100,,0.16,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,39.24,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.856,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1274.376,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.096,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.096,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.096,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,34.41,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,17.976,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378.98,75,,238.904,Percent of Total Billed Charges,75% of Total Billed Charges,252.66,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.66,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.104,Case Rate,Pays based on per visit rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,505.31,100,,318.536,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,505.31,
DX KNEE 1 OR 2V BI,49035595,CDM,320,RC,73560,HCPCS,Outpatient,,,505.31,303.19,,25.16,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,201.6,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.024,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.944,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.944,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.944,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,34.41,100,,196.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,47.744,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,202.76,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378.98,75,,271.208,Percent of Total Billed Charges,75% of Total Billed Charges,252.66,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.66,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.064,Case Rate,Pays based on per visit rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,196.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,505.31,100,,361.608,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,505.31,
DX KNEE 1 OR 2V LT,49035603,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,1.768,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,25.92,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.336,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.024,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.432,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.432,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.432,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,34.41,100,,295.28,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,61.92,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,304.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,271.208,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,575.392,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.48,Case Rate,Pays based on per visit rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,295.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,361.608,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V LT,49035603,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,25.2,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,26.328,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.024,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,33.848,Fee Schedule,360% of BCBS POS Rate,287.32,360,,33.848,Fee schedule,360% of BCBS PPO Rate,287.32,360,,33.848,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,331.088,Fee Schedule,103% of Cigna fee schedule,34.41,100,,80.296,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,56,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,82.712,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,240.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.392,Case Rate,Pays based on per visit rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,80.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE MIN 4V BI,49035694,CDM,320,RC,73564,HCPCS,Outpatient,,,695.76,417.46,TC   ,33.81,100,,10.648,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,16.856,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.496,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.04,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.632,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.632,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.632,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,331.088,Fee Schedule,103% of Cigna fee schedule,46.78,100,,86.656,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,32.48,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,89.256,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,521.82,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,347.88,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.936,Case Rate,Pays based on per visit rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,86.656,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,695.76,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,695.76,
DX KNEE MIN 4V BI,49035694,CDM,320,RC,73564,HCPCS,Outpatient,,,695.76,417.46,TC   ,33.81,100,,0.056,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,7.784,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.504,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.04,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.648,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.648,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.648,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1828.32,Fee Schedule,103% of Cigna fee schedule,46.78,100,,280.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,324.784,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,288.968,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,521.82,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,347.88,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,347.88,50,,396.12,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.376,Case Rate,Pays based on per visit rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,280.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,695.76,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,695.76,
DX KNEE MIN 4V LT,49035702,CDM,320,RC,73564,HCPCS,Outpatient,,,463.84,278.30,,33.81,100,,1.976,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,18.8,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,8.872,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.048,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,11.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,11.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,11.4,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,321.616,Fee Schedule,103% of Cigna fee schedule,46.78,100,,120.448,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,183.04,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,124.064,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,347.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,231.92,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.92,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.424,Case Rate,Pays based on per visit rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,120.448,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,463.84,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,463.84,
DX KNEE MIN 4V LT,49035702,CDM,320,RC,73564,HCPCS,Outpatient,,,463.84,278.30,,33.81,100,,45.112,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,23.872,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.056,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.256,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.256,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.256,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,405.24,Fee Schedule,103% of Cigna fee schedule,46.78,100,,129.976,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,183.04,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,133.88,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,347.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,231.92,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.92,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,92.48,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.24,Case Rate,Pays based on per visit rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,129.976,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,463.84,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,463.84,
DX TIBIA FIBULA 2V BI,49035892,CDM,320,RC,73590,HCPCS,Outpatient,,,572.84,343.70,TC   ,22.82,100,,3.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,11.616,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.384,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.056,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.496,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,300.184,Fee Schedule,103% of Cigna fee schedule,31.74,100,,420.832,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,600,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,433.456,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.63,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,286.42,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.42,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.288,Case Rate,Pays based on per visit rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,420.832,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.84,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,572.84,
DX TIBIA FIBULA 2V BI,49035892,CDM,320,RC,73590,HCPCS,Outpatient,,,572.84,343.70,TC   ,22.82,100,,2.936,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,33.072,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.304,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.056,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.392,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.392,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.392,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,746.368,Fee Schedule,103% of Cigna fee schedule,31.74,100,,284.4,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,87.2,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,292.936,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.63,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,286.42,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.42,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.904,Case Rate,Pays based on per visit rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,284.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.84,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,572.84,
DX TIBIA FIBULA 2V LT,49035900,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,3.104,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.384,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.144,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.056,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.616,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.616,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.616,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1308.848,Fee Schedule,103% of Cigna fee schedule,31.74,100,,304.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,448,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,313.968,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,304.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V LT,49035900,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,3.024,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.816,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.568,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.064,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.728,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.728,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.728,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,188.584,Fee Schedule,103% of Cigna fee schedule,31.74,100,,80.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,87.2,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,82.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,342.2,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.176,Case Rate,Pays based on per visit rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,80.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,456.264,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX LWR EXT INF MIN 2V LT,49035918,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,1.512,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,9.856,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.384,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.08,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.496,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,328.232,Fee Schedule,103% of Cigna fee schedule,80.9,100,,151.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,448,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,155.736,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,342.2,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.024,Case Rate,Pays based on per visit rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,151.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,456.264,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V LT,49035918,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,3.184,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,78.336,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.08,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,327.248,Fee Schedule,103% of Cigna fee schedule,80.9,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,57.6,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,61.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.032,Case Rate,Pays based on per visit rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V BI,49035926,CDM,320,RC,73592,HCPCS,Outpatient,,,231.19,138.71,,22.82,100,,3.824,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,12.776,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.088,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.44,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,33.224,Fee Schedule,103% of Cigna fee schedule,80.9,100,,234,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,56,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,241.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.664,Case Rate,Pays based on per visit rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V BI,49035926,CDM,320,RC,73592,HCPCS,Outpatient,,,231.19,138.71,,22.82,100,,0.32,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,26.2,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.464,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.088,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,56.16,Fee Schedule,103% of Cigna fee schedule,80.9,100,,234,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,37.464,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,241.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.512,Case Rate,Pays based on per visit rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,234,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX ANKLE 2V LT,49036007,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,13.4,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,11.16,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,37.312,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.096,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,47.976,Fee Schedule,360% of BCBS POS Rate,287.32,360,,47.976,Fee schedule,360% of BCBS PPO Rate,287.32,360,,47.976,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,101.12,Fee Schedule,103% of Cigna fee schedule,32.75,100,,42,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,17.304,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,43.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.376,Case Rate,Pays based on per visit rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,42,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V LT,49036007,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,14.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,21.824,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.808,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.112,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,220.528,Fee Schedule,103% of Cigna fee schedule,32.75,100,,333.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,41.776,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,343.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.592,Case Rate,Pays based on per visit rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE MIN 3V BI,49036098,CDM,320,RC,73610,HCPCS,Outpatient,,,450,270.00,TC   ,27.15,100,,11.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,30.136,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.984,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.112,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1465.928,Fee Schedule,103% of Cigna fee schedule,37.09,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,53.04,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.376,Case Rate,Pays based on per visit rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,450,
DX ANKLE MIN 3V BI,49036098,CDM,320,RC,73610,HCPCS,Outpatient,,,450,270.00,TC   ,27.15,100,,4.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,15.072,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.112,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.464,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.464,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.464,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4533.784,Fee Schedule,103% of Cigna fee schedule,37.09,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,25.816,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,138.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.232,Case Rate,Pays based on per visit rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,450,
DX ANKLE MIN 3V LT,49036106,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,,27.15,100,,2.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,21.272,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.984,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.12,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1554.816,Fee Schedule,103% of Cigna fee schedule,37.09,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,73.488,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,29.144,Case Rate,Pays based on per visit rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V LT,49036106,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,,27.15,100,,0.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,9.272,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.4,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.12,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.512,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.512,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.512,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,87.496,Fee Schedule,103% of Cigna fee schedule,37.09,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,45.304,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,189.072,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.456,Case Rate,Pays based on per visit rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,252.096,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX FOOT 2V BI,49036197,CDM,320,RC,73620,HCPCS,Outpatient,,,504,302.40,TC   ,20.16,100,,0.472,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,14.816,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.12,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,741.864,Fee Schedule,103% of Cigna fee schedule,28.4,100,,77.256,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,46.256,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,79.568,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378,75,,241.488,Percent of Total Billed Charges,75% of Total Billed Charges,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1,Case Rate,Pays based on per visit rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,77.256,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,504,100,,321.984,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,504,
DX FOOT 2V BI,49036197,CDM,320,RC,73620,HCPCS,Outpatient,,,504,302.40,TC   ,20.16,100,,6.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,22.36,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.136,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.456,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.456,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.456,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,87.84,Fee Schedule,103% of Cigna fee schedule,28.4,100,,426.608,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,21.896,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,439.408,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378,75,,241.488,Percent of Total Billed Charges,75% of Total Billed Charges,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.04,Case Rate,Pays based on per visit rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,426.608,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,504,100,,321.984,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,504,
DX FOOT 2V LT,49036205,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,0.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,25.2,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.144,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.48,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.48,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.48,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,85.68,Fee Schedule,103% of Cigna fee schedule,28.4,100,,81.864,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,174.08,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,84.32,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,232.648,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.648,Case Rate,Pays based on per visit rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,81.864,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,310.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V LT,49036205,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,1.16,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,252,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.16,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.56,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,34.56,Fee Schedule,103% of Cigna fee schedule,28.4,100,,103.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,28.392,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,106.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,232.648,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.592,Case Rate,Pays based on per visit rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,103.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,310.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT MIN 3V BI,49036296,CDM,320,RC,73630,HCPCS,Outpatient,,,633.97,380.38,TC   ,25.16,100,,10.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,184.864,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.16,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.728,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.728,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.728,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.872,Fee Schedule,103% of Cigna fee schedule,34.41,100,,70.04,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,58.224,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,72.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,475.48,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.568,Case Rate,Pays based on per visit rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,70.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,633.97,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,633.97,
DX FOOT MIN 3V BI,49036296,CDM,320,RC,73630,HCPCS,Outpatient,,,633.97,380.38,TC   ,25.16,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,177.752,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.096,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.168,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.408,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.408,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.408,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,118.112,Fee Schedule,103% of Cigna fee schedule,34.41,100,,174.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,24.808,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,179.376,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,475.48,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,316.99,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.296,Case Rate,Pays based on per visit rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,174.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,633.97,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,633.97,
DX FOOT MIN 3V LT,49036304,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,,25.16,100,,0.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,184.864,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.168,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.344,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.344,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.344,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,100.8,Fee Schedule,103% of Cigna fee schedule,34.41,100,,333.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,48.496,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,343.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,227.672,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.064,Case Rate,Pays based on per visit rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,333.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V LT,49036304,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,,25.16,100,,2.672,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,131.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.176,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.6,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.6,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.6,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,204.672,Fee Schedule,103% of Cigna fee schedule,34.41,100,,44,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,66.96,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,45.32,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.816,Case Rate,Pays based on per visit rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX CALCANEUS MIN 2V BI,49036494,CDM,320,RC,73650,HCPCS,Outpatient,,,222,133.20,TC   ,20.16,100,,0.256,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,252,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.304,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.184,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.96,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.96,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.96,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,260.4,Fee Schedule,103% of Cigna fee schedule,28.74,100,,76.584,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,33.488,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,78.888,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,111,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.776,Case Rate,Pays based on per visit rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V BI,49036494,CDM,320,RC,73650,HCPCS,Outpatient,,,222,133.20,TC   ,20.16,100,,12.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,191.304,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.184,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,152.4,Fee Schedule,103% of Cigna fee schedule,28.74,100,,76.36,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,47.264,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,78.648,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,155.104,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,111,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.384,Case Rate,Pays based on per visit rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,76.36,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,206.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V LT,49036502,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,,20.16,100,,28.752,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,131.024,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.192,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.344,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.344,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.344,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,300,Fee Schedule,103% of Cigna fee schedule,28.74,100,,7.752,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,20.608,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,7.984,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,3510.488,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,3510.488,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.576,Case Rate,Pays based on per visit rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,7.752,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V LT,49036502,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,,20.16,100,,61.384,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,191.304,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.312,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.192,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,66.384,Fee Schedule,103% of Cigna fee schedule,28.74,100,,13.104,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,32.928,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,13.496,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.696,Case Rate,Pays based on per visit rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,13.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX TOES MIN 2V BI,49036577,CDM,320,RC,73660,HCPCS,Outpatient,,,354.03,212.42,,21.83,100,,55.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,270,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.2,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,472.8,Fee Schedule,103% of Cigna fee schedule,29.4,100,,23.592,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,49.68,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,24.304,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.52,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,177.02,50,,3510.488,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.02,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.128,Case Rate,Pays based on per visit rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,23.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.03,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,354.03,
DX TOES MIN 2V BI,49036577,CDM,320,RC,73660,HCPCS,Outpatient,,,354.03,212.42,,21.83,100,,2.648,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,270,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.384,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.2,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.632,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.632,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.632,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6132,Fee Schedule,103% of Cigna fee schedule,29.4,100,,51.456,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,56,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,53,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.52,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,177.02,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.02,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.512,Case Rate,Pays based on per visit rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,51.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.03,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,354.03,
DX ANKLE 2V BI,49036593,CDM,320,RC,73600,HCPCS,Outpatient,,,387.75,232.65,TC   ,23.49,100,,4.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,171.36,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.208,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.656,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,40.32,Fee Schedule,103% of Cigna fee schedule,32.75,100,,342.048,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,560,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,352.312,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.81,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,193.88,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.88,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,41.352,Case Rate,Pays based on per visit rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,342.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.75,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,387.75,
DX ANKLE 2V BI,49036593,CDM,320,RC,73600,HCPCS,Outpatient,,,387.75,232.65,TC   ,23.49,100,,6.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,171.36,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.424,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.216,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.976,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.976,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.976,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,34.56,Fee Schedule,103% of Cigna fee schedule,32.75,100,,1057.88,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,410.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,1089.624,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.81,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,193.88,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.88,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,223.304,Case Rate,Pays based on per visit rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1057.88,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.75,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,387.75,
DX TOES MIN 2V LT,49036601,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,,21.83,100,,4.08,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,151.56,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.216,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,34.56,Fee Schedule,103% of Cigna fee schedule,29.4,100,,362.792,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,395,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,373.672,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.336,Case Rate,Pays based on per visit rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V LT,49036601,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,,21.83,100,,2.096,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,151.56,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.224,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1554.816,Fee Schedule,103% of Cigna fee schedule,29.4,100,,20.416,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,410.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,21.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.4,Case Rate,Pays based on per visit rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,20.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX ABD 1V AP,49040009,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,0.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,112.68,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.744,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.224,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4255.896,Fee Schedule,103% of Cigna fee schedule,30.08,100,,173.104,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,291.16,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,178.296,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,151.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.24,Case Rate,Pays based on per visit rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,173.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V AP,49040009,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,112.68,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.232,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,44.496,Fee Schedule,103% of Cigna fee schedule,30.08,100,,20.496,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,560,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,21.112,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.048,Case Rate,Pays based on per visit rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,20.496,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V AP,49040009,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,11.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,270,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.816,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.232,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.336,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.336,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.336,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1554.816,Fee Schedule,103% of Cigna fee schedule,30.08,100,,19.992,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,425.12,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,20.592,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,743.368,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,248.584,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.296,Case Rate,Pays based on per visit rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,19.992,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,991.152,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD AP OBLIQ CONE V,49040108,CDM,320,RC,74021,HCPCS,Outpatient,,,311.14,186.68,,28.82,100,,33.392,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,270,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.24,Fee Schedule,320% of BCBS Blue Essentials Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,14.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2336.256,Fee Schedule,103% of Cigna fee schedule,43.1,100,,8.064,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,291.16,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,44.39,103,,8.304,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,233.36,75,,743.368,Percent of Total Billed Charges,75% of Total Billed Charges,155.57,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,155.57,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,155.57,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,155.57,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.4,Case Rate,Pays based on per visit rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,311.14,100,,991.152,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,403.49,
DX ABD AP OBLIQ CONE V,49040108,CDM,320,RC,74021,HCPCS,Outpatient,,,311.14,186.68,,28.82,100,,31.88,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,171.36,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.248,Fee Schedule,320% of BCBS Blue Essentials Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.024,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.024,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,100.208,Fee Schedule,103% of Cigna fee schedule,43.1,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,425.12,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,44.39,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,233.36,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,155.57,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,155.57,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,155.57,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,155.57,50,,904.744,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.2,Case Rate,Pays based on per visit rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,311.14,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,28.82,403.49,
DX ABD W DECUB OR ERECT,49040207,CDM,320,RC,74019,HCPCS,Outpatient,,,402.48,241.49,TC   ,24.81,100,,28.2,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,171.36,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.248,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.032,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.032,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.032,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,134.52,Fee Schedule,103% of Cigna fee schedule,37.09,100,,27.56,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,600,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,28.384,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.86,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,201.24,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.24,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,3510.488,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.92,Case Rate,Pays based on per visit rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.48,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,403.49,
DX ABD W DECUB OR ERECT,49040207,CDM,320,RC,74019,HCPCS,Outpatient,,,402.48,241.49,TC   ,24.81,100,,22.888,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,151.56,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.152,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.248,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.192,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.192,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.192,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,152.4,Fee Schedule,103% of Cigna fee schedule,37.09,100,,23.52,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,600,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,24.224,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.86,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,201.24,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.24,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.096,Case Rate,Pays based on per visit rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,23.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.48,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,403.49,
DX ABD ACUTE SERIES,49040223,CDM,320,RC,74022,HCPCS,Outpatient,,,570.33,342.20,,33.14,100,,18.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,112.68,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.32,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.256,Fee Schedule,320% of BCBS Blue Essentials Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.408,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.408,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.408,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1448.104,Fee Schedule,103% of Cigna fee schedule,50.13,100,,47.76,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,380.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,51.63,103,,49.192,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,427.75,75,,495.576,Percent of Total Billed Charges,75% of Total Billed Charges,285.17,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,285.17,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,471.808,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.136,Case Rate,Pays based on per visit rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,47.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,570.33,100,,660.768,Percent of Total Billed Charges,100% of Total Billed Charges,33.14,570.33,
DX ABD ACUTE SERIES,49040223,CDM,320,RC,74022,HCPCS,Outpatient,,,570.33,342.20,,33.14,100,,9.504,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,112.68,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.92,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10278.016,Fee Schedule,320% of BCBS Blue Essentials Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.184,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.184,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.184,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1687.976,Fee Schedule,103% of Cigna fee schedule,50.13,100,,60.76,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,380.8,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,51.63,103,,62.584,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,427.75,75,,363.408,Percent of Total Billed Charges,75% of Total Billed Charges,285.17,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,285.17,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.84,Case Rate,Pays based on per visit rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,60.76,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,570.33,100,,484.544,Percent of Total Billed Charges,100% of Total Billed Charges,33.14,570.33,
DX FB 1V CHILD,49040306,CDM,320,RC,76010,HCPCS,Outpatient,,,154.13,92.48,TC   ,20.16,100,,23.04,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,151.56,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.256,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10441.728,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,11.896,Fee Schedule,360% of BCBS POS Rate,287.32,360,,11.896,Fee schedule,360% of BCBS PPO Rate,287.32,360,,11.896,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2010.76,Fee Schedule,103% of Cigna fee schedule,80.9,100,,35.56,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,336.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,36.624,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,363.408,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,1064.336,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.832,Case Rate,Pays based on per visit rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,35.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,484.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX FB 1V CHILD,49040306,CDM,320,RC,76010,HCPCS,Outpatient,,,154.13,92.48,TC   ,20.16,100,,0.784,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,20.704,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.792,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.312,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2010.76,Fee Schedule,103% of Cigna fee schedule,80.9,100,,70,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,336.8,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,72.104,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,242.272,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,65.808,Case Rate,Pays based on per visit rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,70,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,323.032,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX ERCP BILE PANCREATIC DUCT,49042005,CDM,320,RC,74330,HCPCS,Outpatient,,,1395.44,837.26,,92.37,100,,213.072,Fee Schedule,100% of Aetna Fee Schedule,627.95,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.17,280,,0.408,Fee Schedule,280% of BCBS BULE Fee Schedule,148.77,320,,10.312,Fee Schedule,320% of BCBS Blue Essentials Rate,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,167.36,360,,0.528,Fee Schedule,360% of BCBS POS Rate,167.36,360,,0.528,Fee schedule,360% of BCBS PPO Rate,167.36,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,837.26,60,,322.792,Percent of Total Billed Charges,60% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1395.44,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,201.22,14.42,,15.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1046.58,75,,242.272,Percent of Total Billed Charges,75% of Total Billed Charges,697.72,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,697.72,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,697.72,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,697.72,50,,993.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1.232,Case Rate,Pays based on per visit rate,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,15.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1395.44,100,,323.032,Percent of Total Billed Charges,100% of Total Billed Charges,92.37,1395.44,
DX ERCP BILE PANCREATIC DUCT,49042005,CDM,320,RC,74330,HCPCS,Outpatient,,,1395.44,837.26,,92.37,100,,27.832,Fee Schedule,100% of Aetna Fee Schedule,627.95,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.17,280,,0.232,Fee Schedule,280% of BCBS BULE Fee Schedule,148.77,320,,10.376,Fee Schedule,320% of BCBS Blue Essentials Rate,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,167.36,360,,0.304,Fee Schedule,360% of BCBS POS Rate,167.36,360,,0.304,Fee schedule,360% of BCBS PPO Rate,167.36,360,,0.304,Fee Schedule,360% of BCBS Traditional Rate,837.26,60,,417.56,Percent of Total Billed Charges,60% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1395.44,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,201.22,14.42,,113.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1046.58,75,,242.272,Percent of Total Billed Charges,75% of Total Billed Charges,697.72,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,697.72,50,,1204.04,Percent of Total Billed Charges,50% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,697.72,50,,1204.04,Percent of Total Billed Charges,50% of Total Billed Charges,697.72,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1.256,Case Rate,Pays based on per visit rate,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,195.36,14,,110.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1395.44,100,,323.032,Percent of Total Billed Charges,100% of Total Billed Charges,92.37,1395.44,
DX SWALLOW FNCTN W CINE VIDEO,49042302,CDM,320,RC,74230,HCPCS,Outpatient,,,643.61,386.17,TC   ,104.72,100,,237.544,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,195,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.648,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.4,Fee Schedule,320% of BCBS Blue Essentials Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.408,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.408,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.408,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,789.84,Fee Schedule,103% of Cigna fee schedule,127.64,100,,1430.8,Fee Schedule,100% of TX Mediciad 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,,600,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,131.47,103,,1473.728,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,482.71,75,,242.272,Percent of Total Billed Charges,75% of Total Billed Charges,321.81,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,321.81,50,,5279.168,Percent of Total Billed Charges,50% of Total Billed Charges,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,321.81,50,,5279.168,Percent of Total Billed Charges,50% of Total Billed Charges,321.81,50,,301.616,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,22.168,Case Rate,Pays based on per visit rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,1430.8,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,643.61,100,,323.032,Percent of Total Billed Charges,100% of Total Billed Charges,104.72,655.99,
DX SWALLOW FNCTN W CINE VIDEO,49042302,CDM,320,RC,74230,HCPCS,Outpatient,,,643.61,386.17,TC   ,104.72,100,,0.064,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,195,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.4,Fee Schedule,320% of BCBS Blue Essentials Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.08,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.08,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.08,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2358.72,Fee Schedule,103% of Cigna fee schedule,127.64,100,,9.408,Fee Schedule,100% of TX Mediciad 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,,600,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,131.47,103,,9.688,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,482.71,75,,209.288,Percent of Total Billed Charges,75% of Total Billed Charges,321.81,50,,1204.04,Percent of Total Billed Charges,50% of Total Billed Charges,321.81,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,321.81,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,321.81,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.496,Case Rate,Pays based on per visit rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,127.64,100,,9.408,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,643.61,100,,279.048,Percent of Total Billed Charges,100% of Total Billed Charges,104.72,655.99,
DX UGI WO KUB,49042427,CDM,320,RC,74240,HCPCS,Outpatient,,,833.9,500.34,,84.41,100,,2.6,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,780,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.552,Fee Schedule,320% of BCBS Blue Essentials Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.016,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.016,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.016,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,4608,Fee Schedule,103% of Cigna fee schedule,124.96,100,,8.064,Fee Schedule,100% of TX Mediciad 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,,380.8,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,128.71,103,,8.304,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,625.43,75,,209.288,Percent of Total Billed Charges,75% of Total Billed Charges,416.95,50,,5279.168,Percent of Total Billed Charges,50% of Total Billed Charges,416.95,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,416.95,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,416.95,50,,1635.6,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.96,Case Rate,Pays based on per visit rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,833.9,100,,279.048,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,833.9,
DX UGI WO KUB,49042427,CDM,320,RC,74240,HCPCS,Outpatient,,,833.9,500.34,,84.41,100,,40.752,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,780,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.848,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.552,Fee Schedule,320% of BCBS Blue Essentials Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,2.376,Fee Schedule,360% of BCBS POS Rate,655.99,360,,2.376,Fee schedule,360% of BCBS PPO Rate,655.99,360,,2.376,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,1555.2,Fee Schedule,103% of Cigna fee schedule,124.96,100,,8.064,Fee Schedule,100% of TX Mediciad 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,,380.8,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,128.71,103,,8.304,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,625.43,75,,464.216,Percent of Total Billed Charges,75% of Total Billed Charges,416.95,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,416.95,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,416.95,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,416.95,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.76,Case Rate,Pays based on per visit rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,8.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,833.9,100,,618.952,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,833.9,
DX UGI W KUB,49042435,CDM,320,RC,74240,HCPCS,Outpatient,,,385.54,231.32,TC   ,84.41,100,,0.832,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,55.296,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.64,Fee Schedule,320% of BCBS Blue Essentials Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.208,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.208,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.208,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,0.04,Fee Schedule,103% of Cigna fee schedule,124.96,100,,362.792,Fee Schedule,100% of TX Mediciad 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,,336.8,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,128.71,103,,373.672,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,289.16,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,192.77,50,,1651.72,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.856,Case Rate,Pays based on per visit rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,385.54,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,655.99,
DX UGI W KUB,49042435,CDM,320,RC,74240,HCPCS,Outpatient,,,385.54,231.32,TC   ,84.41,100,,93.832,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,55.296,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,102.64,Fee Schedule,320% of BCBS Blue Essentials Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.352,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.352,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.352,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,21.68,Fee Schedule,103% of Cigna fee schedule,124.96,100,,375.2,Fee Schedule,100% of TX Mediciad 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,,250.4,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,128.71,103,,386.456,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,289.16,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,192.77,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,192.77,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.424,Case Rate,Pays based on per visit rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,124.96,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,385.54,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,655.99,
DX UGI W AIR WO KUB,49042443,CDM,320,RC,74246,HCPCS,Outpatient,,,800,480.00,,98.06,100,,59.776,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,14.112,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,103.136,Fee Schedule,320% of BCBS Blue Essentials Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.12,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.12,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.12,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,5.584,Fee Schedule,103% of Cigna fee schedule,141.68,100,,375.2,Fee Schedule,100% of TX Mediciad 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,,250.4,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,145.93,103,,386.456,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,600,75,,562.624,Percent of Total Billed Charges,75% of Total Billed Charges,400,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,400,50,,6200.88,Percent of Total Billed Charges,50% of Total Billed Charges,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,400,50,,6200.88,Percent of Total Billed Charges,50% of Total Billed Charges,400,50,,2353.576,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.96,Case Rate,Pays based on per visit rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,375.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,750.16,Percent of Total Billed Charges,100% of Total Billed Charges,98.06,800,
DX UGI W AIR WO KUB,49042443,CDM,320,RC,74246,HCPCS,Outpatient,,,800,480.00,,98.06,100,,2.032,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,147,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,3.016,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,103.288,Fee Schedule,320% of BCBS Blue Essentials Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.88,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.88,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.88,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,24,Fee Schedule,103% of Cigna fee schedule,141.68,100,,562.808,Fee Schedule,100% of TX Mediciad 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,,336.8,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,145.93,103,,579.688,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,600,75,,562.624,Percent of Total Billed Charges,75% of Total Billed Charges,400,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,400,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,400,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,400,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.352,Case Rate,Pays based on per visit rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,562.808,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,750.16,Percent of Total Billed Charges,100% of Total Billed Charges,98.06,800,
DX SB SERIES,49042500,CDM,320,RC,74250,HCPCS,Outpatient,,,714.72,428.83,TC   ,84.41,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,147,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,3.112,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,103.288,Fee Schedule,320% of BCBS Blue Essentials Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,4.008,Fee Schedule,360% of BCBS POS Rate,655.99,360,,4.008,Fee schedule,360% of BCBS PPO Rate,655.99,360,,4.008,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.824,Fee Schedule,103% of Cigna fee schedule,124.3,100,,993.04,Fee Schedule,100% of TX Mediciad 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,,46,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,128.03,103,,1022.832,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,536.04,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,357.36,50,,6200.88,Percent of Total Billed Charges,50% of Total Billed Charges,357.36,50,,3919.544,Percent of Total Billed Charges,50% of Total Billed Charges,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,357.36,50,,3919.544,Percent of Total Billed Charges,50% of Total Billed Charges,357.36,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.848,Case Rate,Pays based on per visit rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,993.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,714.72,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,714.72,
DX SB SERIES,49042500,CDM,320,RC,74250,HCPCS,Outpatient,,,714.72,428.83,TC   ,84.41,100,,4.112,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,107.928,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,5.64,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,103.68,Fee Schedule,320% of BCBS Blue Essentials Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,7.248,Fee Schedule,360% of BCBS POS Rate,655.99,360,,7.248,Fee schedule,360% of BCBS PPO Rate,655.99,360,,7.248,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,30.592,Fee Schedule,103% of Cigna fee schedule,124.3,100,,10.384,Fee Schedule,100% of TX Mediciad 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,,540,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,128.03,103,,10.696,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,536.04,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,357.36,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,357.36,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,357.36,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,357.36,50,,438.04,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.152,Case Rate,Pays based on per visit rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,124.3,100,,10.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,714.72,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,84.41,714.72,
DX ENEMA BARIUM,49042708,CDM,320,RC,74270,HCPCS,Outpatient,,,844.59,506.75,,106.38,100,,0.88,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,107.928,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.88,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,103.928,Fee Schedule,320% of BCBS Blue Essentials Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.128,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.128,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.128,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,32.064,Fee Schedule,103% of Cigna fee schedule,156.04,100,,362.792,Fee Schedule,100% of TX Mediciad 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,,540,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,160.72,103,,373.672,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,633.44,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,422.3,50,,3919.544,Percent of Total Billed Charges,50% of Total Billed Charges,422.3,50,,2764.088,Percent of Total Billed Charges,50% of Total Billed Charges,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,422.3,50,,2764.088,Percent of Total Billed Charges,50% of Total Billed Charges,422.3,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,93.288,Case Rate,Pays based on per visit rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,362.792,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,844.59,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,106.38,844.59,
DX ENEMA BARIUM,49042708,CDM,320,RC,74270,HCPCS,Outpatient,,,844.59,506.75,,106.38,100,,0.608,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,15.624,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.112,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,104.184,Fee Schedule,320% of BCBS Blue Essentials Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.144,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.144,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.144,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,19.072,Fee Schedule,103% of Cigna fee schedule,156.04,100,,545.128,Fee Schedule,100% of TX Mediciad 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,,433.336,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,160.72,103,,561.48,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,633.44,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,422.3,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,422.3,50,,3334.344,Percent of Total Billed Charges,50% of Total Billed Charges,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,422.3,50,,3334.344,Percent of Total Billed Charges,50% of Total Billed Charges,422.3,50,,359.096,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.024,Case Rate,Pays based on per visit rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,545.128,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,844.59,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,106.38,844.59,
DX ENEMA BARIUM W AIR,49042807,CDM,320,RC,74280,HCPCS,Outpatient,,,1000.16,600.10,TC   ,165.32,100,,5.6,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,24.544,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,10649.728,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.184,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.184,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.184,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,8.208,Fee Schedule,103% of Cigna fee schedule,180.34,100,,23.384,Fee Schedule,100% of TX Mediciad 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,,433.336,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,24.08,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,750.12,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,500.08,50,,2764.088,Percent of Total Billed Charges,50% of Total Billed Charges,500.08,50,,2979.36,Percent of Total Billed Charges,50% of Total Billed Charges,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,500.08,50,,2979.36,Percent of Total Billed Charges,50% of Total Billed Charges,500.08,50,,1204.04,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.872,Case Rate,Pays based on per visit rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,23.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1000.16,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,151.71,1000.16,
DX ENEMA BARIUM W AIR,49042807,CDM,320,RC,74280,HCPCS,Outpatient,,,1000.16,600.10,TC   ,165.32,100,,2.504,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,410.4,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.664,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,10679.216,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.424,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.424,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.424,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,24,Fee Schedule,103% of Cigna fee schedule,180.34,100,,31.392,Fee Schedule,100% of TX Mediciad 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,,1733.336,Fee Schedule,100% of CMS OPPS Rate,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,32.328,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,750.12,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,500.08,50,,3334.344,Percent of Total Billed Charges,50% of Total Billed Charges,500.08,50,,2687.656,Percent of Total Billed Charges,50% of Total Billed Charges,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,500.08,50,,2687.656,Percent of Total Billed Charges,50% of Total Billed Charges,500.08,50,,5279.168,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,31.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1000.16,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,151.71,1000.16,
DX CHOLANGIOGRAM INTRAOP INI,49043003,CDM,320,RC,74300,HCPCS,Outpatient,,,766,459.60,,24.68,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,344.7,45,,26.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.47,280,,1.488,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,10679.216,Fee Schedule,320% of BCBS Blue Essentials Rate,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,1.92,Fee Schedule,360% of BCBS POS Rate,67.46,360,,1.92,Fee schedule,360% of BCBS PPO Rate,67.46,360,,1.92,Fee Schedule,360% of BCBS Traditional Rate,459.6,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766,100,,1733.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,110.46,14.42,,36.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574.5,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,383,50,,2979.36,Percent of Total Billed Charges,50% of Total Billed Charges,383,50,,1360,Percent of Total Billed Charges,50% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383,50,,1360,Percent of Total Billed Charges,50% of Total Billed Charges,383,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,2.184,Case Rate,Pays based on per visit rate,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,35.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.68,766,
DX CHOLANGIOGRAM INTRAOP INI,49043003,CDM,320,RC,74300,HCPCS,Outpatient,,,766,459.60,,24.68,100,,0.512,Fee Schedule,100% of Aetna Fee Schedule,344.7,45,,26.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.47,280,,7.952,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,10713.6,Fee Schedule,320% of BCBS Blue Essentials Rate,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,10.224,Fee Schedule,360% of BCBS POS Rate,67.46,360,,10.224,Fee schedule,360% of BCBS PPO Rate,67.46,360,,10.224,Fee Schedule,360% of BCBS Traditional Rate,459.6,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766,100,,122.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.46,14.42,,100.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574.5,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,383,50,,2687.656,Percent of Total Billed Charges,50% of Total Billed Charges,383,50,,1382.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383,50,,1382.8,Percent of Total Billed Charges,50% of Total Billed Charges,383,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,2.184,Case Rate,Pays based on per visit rate,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,107.24,14,,97.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.68,766,
DX IVP,49044001,CDM,320,RC,74400,HCPCS,Outpatient,,,875.22,525.13,TC   ,109.71,100,,14.704,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,67.264,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,268.41,280,,15.944,Fee Schedule,280% of BCBS BULE Fee Schedule,306.75,320,,10.528,Fee Schedule,320% of BCBS Blue Essentials Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,345.1,360,,20.504,Fee Schedule,360% of BCBS POS Rate,345.1,360,,20.504,Fee schedule,360% of BCBS PPO Rate,345.1,360,,20.504,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,4.16,Fee Schedule,103% of Cigna fee schedule,137,100,,184.296,Fee Schedule,100% of TX Mediciad 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,,122.888,Fee Schedule,100% of CMS OPPS Rate,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,141.11,103,,189.824,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,656.42,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,437.61,50,,1360,Percent of Total Billed Charges,50% of Total Billed Charges,437.61,50,,1851.768,Percent of Total Billed Charges,50% of Total Billed Charges,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,437.61,50,,1851.768,Percent of Total Billed Charges,50% of Total Billed Charges,437.61,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,137,100,,184.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,875.22,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,109.71,875.22,
DX IVP,49044001,CDM,320,RC,74400,HCPCS,Outpatient,,,875.22,525.13,TC   ,109.71,100,,18.296,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,67.264,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,268.41,280,,8.424,Fee Schedule,280% of BCBS BULE Fee Schedule,306.75,320,,10.576,Fee Schedule,320% of BCBS Blue Essentials Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,345.1,360,,10.824,Fee Schedule,360% of BCBS POS Rate,345.1,360,,10.824,Fee schedule,360% of BCBS PPO Rate,345.1,360,,10.824,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,1001,Fee Schedule,103% of Cigna fee schedule,137,100,,418.264,Fee Schedule,100% of TX Mediciad 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,,31.36,Fee Schedule,100% of CMS OPPS Rate,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,141.11,103,,430.808,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,656.42,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,437.61,50,,1382.8,Percent of Total Billed Charges,50% of Total Billed Charges,437.61,50,,2085.856,Percent of Total Billed Charges,50% of Total Billed Charges,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,437.61,50,,2085.856,Percent of Total Billed Charges,50% of Total Billed Charges,437.61,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,137,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,875.22,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,109.71,875.22,
DX IVP W NEPHROTOMOGRAPHY SI,49044159,CDM,320,RC,74415,HCPCS,Outpatient,,,1123.16,673.90,,132.69,100,,0.04,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,214.2,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,340.06,280,,0.96,Fee Schedule,280% of BCBS BULE Fee Schedule,388.64,320,,10.648,Fee Schedule,320% of BCBS Blue Essentials Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,437.22,360,,1.232,Fee Schedule,360% of BCBS POS Rate,437.22,360,,1.232,Fee schedule,360% of BCBS PPO Rate,437.22,360,,1.232,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,0.128,Fee Schedule,103% of Cigna fee schedule,156.04,100,,418.264,Fee Schedule,100% of TX Mediciad 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,,326.664,Fee Schedule,100% of CMS OPPS Rate,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,160.72,103,,430.808,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,842.37,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,561.58,50,,1851.768,Percent of Total Billed Charges,50% of Total Billed Charges,561.58,50,,2103.224,Percent of Total Billed Charges,50% of Total Billed Charges,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,561.58,50,,2103.224,Percent of Total Billed Charges,50% of Total Billed Charges,561.58,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,418.264,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.16,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,132.69,1123.16,
DX IVP W NEPHROTOMOGRAPHY SI,49044159,CDM,320,RC,74415,HCPCS,Outpatient,,,1123.16,673.90,,132.69,100,,3.152,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,214.2,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,340.06,280,,0.856,Fee Schedule,280% of BCBS BULE Fee Schedule,388.64,320,,10.664,Fee Schedule,320% of BCBS Blue Essentials Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,437.22,360,,1.104,Fee Schedule,360% of BCBS POS Rate,437.22,360,,1.104,Fee schedule,360% of BCBS PPO Rate,437.22,360,,1.104,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,22.696,Fee Schedule,103% of Cigna fee schedule,156.04,100,,18.52,Fee Schedule,100% of TX Mediciad 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,,326.664,Fee Schedule,100% of CMS OPPS Rate,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,160.72,103,,19.08,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,842.37,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,561.58,50,,2085.856,Percent of Total Billed Charges,50% of Total Billed Charges,561.58,50,,2187.808,Percent of Total Billed Charges,50% of Total Billed Charges,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,561.58,50,,2187.808,Percent of Total Billed Charges,50% of Total Billed Charges,561.58,50,,6200.88,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,156.04,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.16,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,132.69,1123.16,
DX CYSTOGRAPHY MIN 3V SI,49044340,CDM,320,RC,74430,HCPCS,Outpatient,,,414.93,248.96,,24.81,100,,20.68,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,186.112,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.984,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,10.696,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,1.264,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,1.264,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,1.264,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,20.68,Fee Schedule,103% of Cigna fee schedule,41.44,100,,18.52,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,239.84,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,19.08,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,311.2,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,207.47,50,,2103.224,Percent of Total Billed Charges,50% of Total Billed Charges,207.47,50,,1902.92,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,207.47,50,,1902.92,Percent of Total Billed Charges,50% of Total Billed Charges,207.47,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.968,Case Rate,Pays based on per visit rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,18.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,414.93,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,1374.66,
DX CYSTOGRAPHY MIN 3V SI,49044340,CDM,320,RC,74430,HCPCS,Outpatient,,,414.93,248.96,,24.81,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,186.112,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,15.688,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,10.696,Fee Schedule,320% of BCBS Blue Essentials Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,20.168,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,20.168,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,20.168,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,142.128,Fee Schedule,103% of Cigna fee schedule,41.44,100,,550.368,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,239.84,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,42.68,103,,566.88,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,311.2,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,207.47,50,,2187.808,Percent of Total Billed Charges,50% of Total Billed Charges,207.47,50,,626.12,Percent of Total Billed Charges,50% of Total Billed Charges,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,207.47,50,,626.12,Percent of Total Billed Charges,50% of Total Billed Charges,207.47,50,,3919.544,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28.12,Case Rate,Pays based on per visit rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,41.44,100,,550.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,414.93,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,1374.66,
DX URETHROCYSTOGRAM RETRO SI,49044506,CDM,320,RC,74450,HCPCS,Outpatient,,,816,489.60,TC   ,219.59,100,,68.048,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,47.136,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,1.072,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,10.696,Fee Schedule,320% of BCBS Blue Essentials Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,1.376,Fee Schedule,360% of BCBS POS Rate,838.94,360,,1.376,Fee schedule,360% of BCBS PPO Rate,838.94,360,,1.376,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,14.744,Fee Schedule,103% of Cigna fee schedule,81.38,100,,1075.2,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,34.72,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,83.82,103,,1107.456,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,612,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,408,50,,1902.92,Percent of Total Billed Charges,50% of Total Billed Charges,408,50,,3447.392,Percent of Total Billed Charges,50% of Total Billed Charges,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,408,50,,3447.392,Percent of Total Billed Charges,50% of Total Billed Charges,408,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,27.448,Case Rate,Pays based on per visit rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,1075.2,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,816,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,81.38,838.94,
DX URETHROCYSTOGRAM RETRO SI,49044506,CDM,320,RC,74450,HCPCS,Outpatient,,,816,489.60,TC   ,219.59,100,,2.36,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,47.136,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,2.064,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,10.736,Fee Schedule,320% of BCBS Blue Essentials Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,2.648,Fee Schedule,360% of BCBS POS Rate,838.94,360,,2.648,Fee schedule,360% of BCBS PPO Rate,838.94,360,,2.648,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,15.832,Fee Schedule,103% of Cigna fee schedule,81.38,100,,362.88,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,54.544,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,83.82,103,,373.768,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,612,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,408,50,,626.12,Percent of Total Billed Charges,50% of Total Billed Charges,408,50,,3414.8,Percent of Total Billed Charges,50% of Total Billed Charges,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,408,50,,3414.8,Percent of Total Billed Charges,50% of Total Billed Charges,408,50,,2764.088,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1,Case Rate,Pays based on per visit rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,81.38,100,,362.88,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,816,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,81.38,838.94,
DX URETHROCYSTOGRAM VOID SI,49044555,CDM,320,RC,74455,HCPCS,Outpatient,,,937.1,562.26,,87.74,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,238.52,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,3.952,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,104.96,Fee Schedule,320% of BCBS Blue Essentials Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,5.08,Fee Schedule,360% of BCBS POS Rate,838.94,360,,5.08,Fee schedule,360% of BCBS PPO Rate,838.94,360,,5.08,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,34.552,Fee Schedule,103% of Cigna fee schedule,105.25,100,,285.496,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,912,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,108.41,103,,294.064,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,702.83,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,468.55,50,,3447.392,Percent of Total Billed Charges,50% of Total Billed Charges,468.55,50,,4094.656,Percent of Total Billed Charges,50% of Total Billed Charges,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,468.55,50,,4094.656,Percent of Total Billed Charges,50% of Total Billed Charges,468.55,50,,3334.344,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.16,Case Rate,Pays based on per visit rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,937.1,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,87.74,937.1,
DX URETHROCYSTOGRAM VOID SI,49044555,CDM,320,RC,74455,HCPCS,Outpatient,,,937.1,562.26,,87.74,100,,0.008,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,356.664,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,3.952,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,105.288,Fee Schedule,320% of BCBS Blue Essentials Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,5.08,Fee Schedule,360% of BCBS POS Rate,838.94,360,,5.08,Fee schedule,360% of BCBS PPO Rate,838.94,360,,5.08,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,69.088,Fee Schedule,103% of Cigna fee schedule,105.25,100,,285.496,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,59.08,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,108.41,103,,294.064,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,702.83,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,468.55,50,,3414.8,Percent of Total Billed Charges,50% of Total Billed Charges,468.55,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,468.55,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,468.55,50,,2979.36,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.888,Case Rate,Pays based on per visit rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,105.25,100,,285.496,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,937.1,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,87.74,937.1,
DX HYSTEROSALPINGOGRAM SI,49047400,CDM,320,RC,74740,HCPCS,Outpatient,,,954.45,572.67,TC   ,77.09,100,,0.576,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,356.664,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,0.264,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,105.376,Fee Schedule,320% of BCBS Blue Essentials Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,0.336,Fee Schedule,360% of BCBS POS Rate,838.94,360,,0.336,Fee schedule,360% of BCBS PPO Rate,838.94,360,,0.336,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,9.88,Fee Schedule,103% of Cigna fee schedule,66.83,100,,353.568,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,59.08,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,68.83,103,,364.176,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,715.84,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,477.23,50,,4094.656,Percent of Total Billed Charges,50% of Total Billed Charges,477.23,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,477.23,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,477.23,50,,2687.656,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.928,Case Rate,Pays based on per visit rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,954.45,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,66.83,954.45,
DX HYSTEROSALPINGOGRAM SI,49047400,CDM,320,RC,74740,HCPCS,Outpatient,,,954.45,572.67,TC   ,77.09,100,,3.28,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,285.864,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,0.28,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,105.376,Fee Schedule,320% of BCBS Blue Essentials Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,0.36,Fee Schedule,360% of BCBS POS Rate,838.94,360,,0.36,Fee schedule,360% of BCBS PPO Rate,838.94,360,,0.36,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,24.208,Fee Schedule,103% of Cigna fee schedule,66.83,100,,353.568,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,149.472,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,68.83,103,,364.176,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,715.84,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,477.23,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,477.23,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,477.23,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,477.23,50,,1360,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.088,Case Rate,Pays based on per visit rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,66.83,100,,353.568,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,954.45,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,66.83,954.45,
IR GUIDE FLUORO CVC CVAD PLCMT,49059975,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,0.112,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,285.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,0.312,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,105.472,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,0.4,Fee Schedule,360% of BCBS POS Rate,262.08,360,,0.4,Fee schedule,360% of BCBS PPO Rate,262.08,360,,0.4,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,149.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,309.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,1382.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,13.08,Case Rate,Pays based on per visit rate,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
IR GUIDE FLUORO CVC CVAD PLCMT,49059975,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,0.776,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,524.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,3.896,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,105.776,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,5.008,Fee Schedule,360% of BCBS POS Rate,262.08,360,,5.008,Fee schedule,360% of BCBS PPO Rate,262.08,360,,5.008,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,66.448,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,476,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,309.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,1851.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,2.736,Case Rate,Pays based on per visit rate,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,300.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
DX FLUORO UP TO 1 HR,49059983,CDM,320,RC,76000,HCPCS,Outpatient,,,618.29,370.97,TC   ,26.48,100,,5.384,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,524.312,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,89.8,280,,3.896,Fee Schedule,280% of BCBS BULE Fee Schedule,102.62,320,,106.272,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,115.45,360,,5.008,Fee Schedule,360% of BCBS POS Rate,115.45,360,,5.008,Fee schedule,360% of BCBS PPO Rate,115.45,360,,5.008,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,47.808,Fee Schedule,103% of Cigna fee schedule,43.44,100,,297.792,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,476,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,306.728,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,463.72,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,309.15,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,309.15,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,2085.856,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.624,Case Rate,Pays based on per visit rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,618.29,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,26.48,701.14,
DX FLUORO UP TO 1 HR,49059983,CDM,320,RC,76000,HCPCS,Outpatient,,,618.29,370.97,TC   ,26.48,100,,32.656,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,136.384,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,89.8,280,,3.896,Fee Schedule,280% of BCBS BULE Fee Schedule,102.62,320,,106.32,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,115.45,360,,5.008,Fee Schedule,360% of BCBS POS Rate,115.45,360,,5.008,Fee schedule,360% of BCBS PPO Rate,115.45,360,,5.008,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,6.928,Fee Schedule,103% of Cigna fee schedule,43.44,100,,297.792,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,413.576,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,306.728,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,463.72,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,309.15,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,309.15,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,2103.224,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.056,Case Rate,Pays based on per visit rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,297.792,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,618.29,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,26.48,701.14,
DX FLUORO GUIDE NDL PLCMT,49060106,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,,86.75,100,,32.656,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,136.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,1.032,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,106.496,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,1.328,Fee Schedule,360% of BCBS POS Rate,268.56,360,,1.328,Fee schedule,360% of BCBS PPO Rate,268.56,360,,1.328,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,413.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,381.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,2187.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,5.752,Case Rate,Pays based on per visit rate,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
DX FLUORO GUIDE NDL PLCMT,49060106,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,,86.75,100,,40.552,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,175.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,0.104,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,106.568,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,0.136,Fee Schedule,360% of BCBS POS Rate,268.56,360,,0.136,Fee schedule,360% of BCBS PPO Rate,268.56,360,,0.136,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,104.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,381.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,1902.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1.176,Case Rate,Pays based on per visit rate,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,370.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
DX FLUORO GUIDE SPINE,49060114,CDM,320,RC,77003,HCPCS,Outpatient,,,654.82,392.89,TC   ,73.76,100,,695.8,Fee Schedule,100% of Aetna Fee Schedule,294.67,45,,175.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.72,280,,1.584,Fee Schedule,280% of BCBS BULE Fee Schedule,220.26,320,,107.224,Fee Schedule,320% of BCBS Blue Essentials Rate,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,247.79,360,,2.032,Fee Schedule,360% of BCBS POS Rate,247.79,360,,2.032,Fee schedule,360% of BCBS PPO Rate,247.79,360,,2.032,Fee Schedule,360% of BCBS Traditional Rate,392.89,60,,5.272,Percent of Total Billed Charges,60% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,654.82,100,,104.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,94.43,14.42,,282.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.12,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,327.41,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.41,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,626.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,0.672,Case Rate,Pays based on per visit rate,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.82,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,73.76,654.82,
DX FLUORO GUIDE SPINE,49060114,CDM,320,RC,77003,HCPCS,Outpatient,,,654.82,392.89,TC   ,73.76,100,,1.904,Fee Schedule,100% of Aetna Fee Schedule,294.67,45,,196.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.72,280,,3.52,Fee Schedule,280% of BCBS BULE Fee Schedule,220.26,320,,107.376,Fee Schedule,320% of BCBS Blue Essentials Rate,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,247.79,360,,4.52,Fee Schedule,360% of BCBS POS Rate,247.79,360,,4.52,Fee schedule,360% of BCBS PPO Rate,247.79,360,,4.52,Fee Schedule,360% of BCBS Traditional Rate,392.89,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,654.82,100,,530.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,94.43,14.42,,282.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.12,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,327.41,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.41,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,3447.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,0.776,Case Rate,Pays based on per visit rate,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,273.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.82,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,73.76,654.82,
DX BONE AGE STUDIES,49060205,CDM,320,RC,77072,HCPCS,Outpatient,,,222.74,133.64,,16.16,100,,0.016,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,171.52,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.536,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10882.304,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.688,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.688,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.688,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,14.88,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,792.584,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,167.06,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,111.37,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,111.37,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,111.37,50,,3414.8,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.872,Case Rate,Pays based on per visit rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.74,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,403.49,
DX BONE AGE STUDIES,49060205,CDM,320,RC,77072,HCPCS,Outpatient,,,222.74,133.64,,16.16,100,,14.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,171.52,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,121.272,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.768,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,155.92,Fee Schedule,360% of BCBS POS Rate,403.49,360,,155.92,Fee schedule,360% of BCBS PPO Rate,403.49,360,,155.92,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,50.608,Fee Schedule,103% of Cigna fee schedule,26.06,100,,5.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,792.584,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,5.208,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,167.06,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,111.37,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,111.37,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,111.37,50,,4094.656,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.952,Case Rate,Pays based on per visit rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,5.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,222.74,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,403.49,
DX BONE LENGTH STUDIES,49060403,CDM,320,RC,77073,HCPCS,Outpatient,,,398.17,238.90,TC   ,30.81,100,,13.304,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,196.928,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,30.176,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.848,Fee Schedule,320% of BCBS Blue Essentials Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,38.792,Fee Schedule,360% of BCBS POS Rate,403.49,360,,38.792,Fee schedule,360% of BCBS PPO Rate,403.49,360,,38.792,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2.864,Fee Schedule,103% of Cigna fee schedule,45.11,100,,1.304,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,635.248,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,46.46,103,,1.344,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.63,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,199.09,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,199.09,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.09,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,199.09,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,108.76,Case Rate,Pays based on per visit rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,1.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.17,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,403.49,
DX BONE LENGTH STUDIES,49060403,CDM,320,RC,77073,HCPCS,Outpatient,,,398.17,238.90,TC   ,30.81,100,,1.264,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,63.952,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.88,Fee Schedule,320% of BCBS Blue Essentials Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.728,Fee Schedule,103% of Cigna fee schedule,45.11,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,635.248,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,46.46,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.63,75,,168,Percent of Total Billed Charges,75% of Total Billed Charges,199.09,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,199.09,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.09,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,199.09,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,34.968,Case Rate,Pays based on per visit rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,45.11,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.17,100,,224,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,403.49,
DX BONE SURVEY LTD,49060601,CDM,320,RC,77074,HCPCS,Outpatient,,,452.01,271.21,,42.47,100,,1.888,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.904,Fee Schedule,320% of BCBS Blue Essentials Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.04,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,65.928,Fee Schedule,103% of Cigna fee schedule,65.15,100,,0.192,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1165.144,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,67.1,103,,0.2,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,339.01,75,,797.24,Percent of Total Billed Charges,75% of Total Billed Charges,226.01,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,226.01,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,226.01,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,226.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,42.52,Case Rate,Pays based on per visit rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,452.01,100,,1062.984,Percent of Total Billed Charges,100% of Total Billed Charges,42.47,452.01,
DX BONE SURVEY LTD,49060601,CDM,320,RC,77074,HCPCS,Outpatient,,,452.01,271.21,,42.47,100,,12.664,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.904,Fee Schedule,320% of BCBS Blue Essentials Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.824,Fee Schedule,103% of Cigna fee schedule,65.15,100,,1.912,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,1165.144,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,67.1,103,,1.976,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,339.01,75,,270.616,Percent of Total Billed Charges,75% of Total Billed Charges,226.01,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,226.01,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,226.01,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,226.01,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,57.12,Case Rate,Pays based on per visit rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,65.15,100,,1.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,452.01,100,,360.824,Percent of Total Billed Charges,100% of Total Billed Charges,42.47,452.01,
DX TOMOGRAPHY WO UROGRAPHY,49061005,CDM,320,RC,76100,HCPCS,Outpatient,,,500,300.00,TC   ,63.11,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.912,Fee Schedule,320% of BCBS Blue Essentials Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,6.256,Fee Schedule,103% of Cigna fee schedule,90.21,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,303.08,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,92.92,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,270.616,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.28,Case Rate,Pays based on per visit rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,360.824,Percent of Total Billed Charges,100% of Total Billed Charges,63.11,500,
DX TOMOGRAPHY WO UROGRAPHY,49061005,CDM,320,RC,76100,HCPCS,Outpatient,,,500,300.00,TC   ,63.11,100,,5.776,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,10.96,Fee Schedule,320% of BCBS Blue Essentials Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.248,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.248,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.248,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,379.2,Fee Schedule,103% of Cigna fee schedule,90.21,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,303.08,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,92.92,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,250,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.48,Case Rate,Pays based on per visit rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,90.21,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,63.11,500,
DX ABD 1V AP PORT,49065000,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,4.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.144,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,10.968,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.896,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.896,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.896,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.064,Fee Schedule,103% of Cigna fee schedule,30.08,100,,3.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,389.04,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,3.192,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,108.76,Case Rate,Pays based on per visit rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V AP PORT,49065000,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,0.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,107.52,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5262.92,Fee Schedule,103% of Cigna fee schedule,30.08,100,,0.968,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,389.04,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,1,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,31.728,Case Rate,Pays based on per visit rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.968,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V AP PORT,49065000,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,13.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,107.52,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,24,Fee Schedule,103% of Cigna fee schedule,30.08,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,437.624,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.568,Case Rate,Pays based on per visit rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V NEONATE PORT,49065001,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,2.656,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,107.776,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.312,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.312,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.312,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.76,Fee Schedule,103% of Cigna fee schedule,30.08,100,,5.296,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,381.152,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,5.456,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.096,Case Rate,Pays based on per visit rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V NEONATE PORT,49065001,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,2.216,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,107.776,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.392,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.392,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.392,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.032,Fee Schedule,103% of Cigna fee schedule,30.08,100,,4.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,381.152,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,4.968,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,180.408,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,4.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,240.544,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD 1V NEONATE PORT,49065001,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,4.664,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,107.776,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.2,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.2,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.2,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,69.8,Fee Schedule,103% of Cigna fee schedule,30.08,100,,33.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,437.624,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,34.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,33.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD ACUTE SERIES PORT,49065002,CDM,320,RC,74022,HCPCS,Outpatient,,,570.33,342.20,,33.14,100,,2.04,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,107.776,Fee Schedule,320% of BCBS Blue Essentials Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.456,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.456,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.456,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1980,Fee Schedule,103% of Cigna fee schedule,50.13,100,,3.44,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,142.112,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,51.63,103,,3.544,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,427.75,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,285.17,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,285.17,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.856,Case Rate,Pays based on per visit rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,570.33,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,33.14,570.33,
DX ABD ACUTE SERIES PORT,49065002,CDM,320,RC,74022,HCPCS,Outpatient,,,570.33,342.20,,33.14,100,,90.8,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,107.984,Fee Schedule,320% of BCBS Blue Essentials Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.216,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.216,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,24,Fee Schedule,103% of Cigna fee schedule,50.13,100,,3.696,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,51.63,103,,3.808,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,427.75,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,285.17,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,285.17,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,285.17,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.184,Case Rate,Pays based on per visit rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,50.13,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,570.33,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,33.14,570.33,
DX ABD DECUB LT,49065003,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,1.096,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.96,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,108.064,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.296,Fee Schedule,103% of Cigna fee schedule,30.08,100,,2.304,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,2.376,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1200.64,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1200.64,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,27.816,Case Rate,Pays based on per visit rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,2.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB LT,49065003,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,9.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,108.32,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.664,Fee Schedule,103% of Cigna fee schedule,30.08,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,260.584,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,800.432,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,800.432,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.544,Case Rate,Pays based on per visit rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,347.448,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB LT,49065003,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,108.632,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.464,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.056,Fee Schedule,103% of Cigna fee schedule,30.08,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,260.584,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,1200.64,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,443.88,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,443.88,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.64,Case Rate,Pays based on per visit rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,347.448,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB LT PORT,49065004,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,15.296,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,108.656,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.352,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.352,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.352,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.224,Fee Schedule,103% of Cigna fee schedule,30.08,100,,15.504,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,15.968,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,308.008,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,800.432,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,3779.088,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,3779.088,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,247.944,Case Rate,Pays based on per visit rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,15.504,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,410.672,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB LT PORT,49065004,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,0.152,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.264,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,108.84,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.336,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3983.192,Fee Schedule,103% of Cigna fee schedule,30.08,100,,11.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,11.488,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,308.008,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,443.88,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2912.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,2912.2,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28,Case Rate,Pays based on per visit rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,11.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,410.672,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB LT PORT,49065004,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,,20.16,100,,6.528,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.024,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.656,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,23.432,Fee Schedule,103% of Cigna fee schedule,30.08,100,,1.616,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,1.664,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,3779.088,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,2764.552,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,2764.552,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.04,Case Rate,Pays based on per visit rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.616,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB RT,49065005,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,1.808,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.056,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.496,Fee Schedule,103% of Cigna fee schedule,30.08,100,,0.488,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,0.504,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,2912.2,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,3001.632,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,3001.632,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,216.392,Case Rate,Pays based on per visit rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB RT,49065005,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,31.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.44,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,75.6,Fee Schedule,103% of Cigna fee schedule,30.08,100,,1.232,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,1.264,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,2764.552,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.064,Case Rate,Pays based on per visit rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,1.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD DECUB RT,49065005,CDM,320,RC,74018,HCPCS,Outpatient,,,315.12,189.07,TC   ,20.16,100,,10.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.328,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.44,Fee Schedule,320% of BCBS Blue Essentials Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.424,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.424,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.424,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.056,Fee Schedule,103% of Cigna fee schedule,30.08,100,,3.472,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.98,103,,3.576,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,236.34,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,157.56,50,,3001.632,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,157.56,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,157.56,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.384,Case Rate,Pays based on per visit rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,30.08,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,315.12,
DX ABD W DECUB OR ERECT PORT,49065007,CDM,320,RC,74019,HCPCS,Outpatient,,,402.48,241.49,,24.81,100,,5.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,17.136,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,109.488,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,22.032,Fee Schedule,360% of BCBS POS Rate,403.49,360,,22.032,Fee schedule,360% of BCBS PPO Rate,403.49,360,,22.032,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,233.232,Fee Schedule,103% of Cigna fee schedule,37.09,100,,3.472,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,3.576,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.86,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,201.24,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,1019.232,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.24,50,,1019.232,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.8,Case Rate,Pays based on per visit rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.48,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,403.49,
DX ABD W DECUB OR ERECT PORT,49065007,CDM,320,RC,74019,HCPCS,Outpatient,,,402.48,241.49,,24.81,100,,0.232,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,109.488,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,35.032,Fee Schedule,103% of Cigna fee schedule,37.09,100,,11.808,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,12.16,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.86,75,,205.336,Percent of Total Billed Charges,75% of Total Billed Charges,201.24,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.24,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,201.24,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.304,Case Rate,Pays based on per visit rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.808,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.48,100,,273.784,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,403.49,
DX ANKLE 2V BI PORT,49065008,CDM,320,RC,73600,HCPCS,Outpatient,,,387.75,232.65,TC   ,23.49,100,,0.568,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.488,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.104,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.104,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,12.712,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.664,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.688,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.81,75,,233.512,Percent of Total Billed Charges,75% of Total Billed Charges,193.88,50,,1019.232,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,747.48,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.88,50,,747.48,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,23.136,Case Rate,Pays based on per visit rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.664,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.75,100,,311.344,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,387.75,
DX ANKLE 2V BI PORT,49065008,CDM,320,RC,73600,HCPCS,Outpatient,,,387.75,232.65,TC   ,23.49,100,,0.064,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.488,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.352,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.352,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.352,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,11.92,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.4,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.416,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.81,75,,233.512,Percent of Total Billed Charges,75% of Total Billed Charges,193.88,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.88,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,193.88,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.984,Case Rate,Pays based on per visit rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.75,100,,311.344,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,387.75,
DX ANKLE 2V LT PORT,49065009,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,0.432,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.152,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.52,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.048,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.048,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.048,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.512,Fee Schedule,103% of Cigna fee schedule,32.75,100,,1.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,1.88,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,186.248,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,747.48,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,1200.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.024,Case Rate,Pays based on per visit rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,248.328,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V LT PORT,49065009,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,6.64,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.64,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.568,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.68,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.68,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.68,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,38,Fee Schedule,103% of Cigna fee schedule,32.75,100,,1.456,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,1.504,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,186.248,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,800.432,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.592,Case Rate,Pays based on per visit rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,248.328,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V RT,49065010,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,TC   ,23.49,100,,5.464,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.184,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.752,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.808,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.808,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.808,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,14.432,Fee Schedule,103% of Cigna fee schedule,32.75,100,,88.48,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,91.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,646.76,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,443.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.616,Case Rate,Pays based on per visit rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,88.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,862.344,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V RT,49065010,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,TC   ,23.49,100,,9.52,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.224,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,109.752,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.288,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.288,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.288,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,15.264,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,646.76,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,966.968,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,966.968,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,3779.088,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.16,Case Rate,Pays based on per visit rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,862.344,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V RT PORT,49065011,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,48.064,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.536,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.008,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.976,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.976,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.976,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,77.656,Fee Schedule,103% of Cigna fee schedule,32.75,100,,1339.656,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,1379.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,372.872,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,3954.04,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,3954.04,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,2912.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.032,Case Rate,Pays based on per visit rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,1339.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,497.16,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE 2V RT PORT,49065011,CDM,320,RC,73600,HCPCS,Outpatient,,,258.5,155.10,,23.49,100,,7.584,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.896,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.032,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.328,Fee Schedule,103% of Cigna fee schedule,32.75,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,193.88,75,,372.872,Percent of Total Billed Charges,75% of Total Billed Charges,129.25,50,,966.968,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,3012.608,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,129.25,50,,3012.608,Percent of Total Billed Charges,50% of Total Billed Charges,129.25,50,,2764.552,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.624,Case Rate,Pays based on per visit rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,100,,497.16,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,300,
DX ANKLE MIN 3V BI PORT,49065012,CDM,320,RC,73610,HCPCS,Outpatient,,,450,270.00,,27.15,100,,0.104,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.032,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.504,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.176,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,343.44,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,3954.04,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,3001.632,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.4,Case Rate,Pays based on per visit rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,457.92,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,450,
DX ANKLE MIN 3V BI PORT,49065012,CDM,320,RC,73610,HCPCS,Outpatient,,,450,270.00,,27.15,100,,20.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.336,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.04,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.432,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.432,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.432,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,460.272,Fee Schedule,103% of Cigna fee schedule,37.09,100,,1.408,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,1.448,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,343.44,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,3012.608,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.68,Case Rate,Pays based on per visit rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,457.92,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,450,
DX ANKLE MIN 3V LT PORT,49065013,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,TC   ,27.15,100,,32.712,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.04,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,315.264,Fee Schedule,103% of Cigna fee schedule,37.09,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.232,Case Rate,Pays based on per visit rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V LT PORT,49065013,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,TC   ,27.15,100,,85.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.464,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.04,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.456,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.456,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.456,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,38.896,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.304,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.312,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1019.232,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.544,Case Rate,Pays based on per visit rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V RT,49065014,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,,27.15,100,,144,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.056,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.808,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.808,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.808,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,141.552,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.792,Case Rate,Pays based on per visit rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V RT,49065014,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,,27.15,100,,2.08,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.112,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.44,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.848,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,747.48,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.104,Case Rate,Pays based on per visit rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V RT PORT,49065015,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,TC   ,27.15,100,,16.824,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.936,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.16,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.776,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.776,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.776,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,94.264,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.288,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.296,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.192,Case Rate,Pays based on per visit rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ANKLE MIN 3V RT PORT,49065015,CDM,320,RC,73610,HCPCS,Outpatient,,,300,180.00,TC   ,27.15,100,,13.136,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.584,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,110.088,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.752,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.752,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.752,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.592,Fee Schedule,103% of Cigna fee schedule,37.09,100,,1013.904,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,1044.32,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,228.96,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.28,Case Rate,Pays based on per visit rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1013.904,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,305.28,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,300,
DX ARTHROGRAM ELBOW LT SI,49065020,CDM,322,RC,73085,HCPCS,Outpatient,,,825.96,495.58,,87.08,100,,10.4,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,5.44,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,110.232,Fee Schedule,320% of BCBS Blue Essentials Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,6.992,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,6.992,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,6.992,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,6.096,Fee Schedule,103% of Cigna fee schedule,112.26,100,,0.12,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,115.63,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,249.696,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.368,Case Rate,Pays based on per visit rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,332.928,Percent of Total Billed Charges,100% of Total Billed Charges,87.08,1374.66,
DX ARTHROGRAM ELBOW LT SI,49065020,CDM,322,RC,73085,HCPCS,Outpatient,,,825.96,495.58,,87.08,100,,27.056,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,6.456,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,110.304,Fee Schedule,320% of BCBS Blue Essentials Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,8.304,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,8.304,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,8.304,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,124.592,Fee Schedule,103% of Cigna fee schedule,112.26,100,,17.64,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,115.63,103,,18.168,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,249.696,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.664,Case Rate,Pays based on per visit rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,17.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,332.928,Percent of Total Billed Charges,100% of Total Billed Charges,87.08,1374.66,
DX ARTHROGRAM HIP BI SI,49065022,CDM,322,RC,73525,HCPCS,Outpatient,,,1238.94,743.36,TC   ,103.05,100,,2.912,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,5.12,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,110.336,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,6.584,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,6.584,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,6.584,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,7.824,Fee Schedule,103% of Cigna fee schedule,131.31,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,929.21,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,619.47,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,619.47,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,619.47,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,619.47,50,,966.968,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.728,Case Rate,Pays based on per visit rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1238.94,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM HIP BI SI,49065022,CDM,322,RC,73525,HCPCS,Outpatient,,,1238.94,743.36,TC   ,103.05,100,,6.568,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,1.384,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,110.712,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,1.784,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,1.784,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,1.784,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,575.976,Fee Schedule,103% of Cigna fee schedule,131.31,100,,2.968,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,3.056,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,929.21,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,619.47,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,619.47,50,,2636.032,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,619.47,50,,2636.032,Percent of Total Billed Charges,50% of Total Billed Charges,619.47,50,,3954.04,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,19.872,Case Rate,Pays based on per visit rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1238.94,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM HIP LT SI,49065023,CDM,322,RC,73525,HCPCS,Outpatient,,,825.96,495.58,,103.05,100,,3.824,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.104,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,111.144,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.136,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.136,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.136,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.04,Fee Schedule,103% of Cigna fee schedule,131.31,100,,2.784,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,2.864,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,3012.608,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,39.864,Case Rate,Pays based on per visit rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,2.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM HIP LT SI,49065023,CDM,322,RC,73525,HCPCS,Outpatient,,,825.96,495.58,,103.05,100,,6.544,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,111.24,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.096,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.096,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.096,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.04,Fee Schedule,103% of Cigna fee schedule,131.31,100,,1.52,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,1.568,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,2636.032,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,21.048,Case Rate,Pays based on per visit rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM HIP RT SI,49065024,CDM,322,RC,73525,HCPCS,Outpatient,,,825.96,495.58,,103.05,100,,8.504,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,111.928,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.256,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.256,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.256,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.04,Fee Schedule,103% of Cigna fee schedule,131.31,100,,8.864,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,9.128,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.392,Case Rate,Pays based on per visit rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,8.864,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM HIP RT SI,49065024,CDM,322,RC,73525,HCPCS,Outpatient,,,825.96,495.58,,103.05,100,,8.144,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.264,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,112.224,Fee Schedule,320% of BCBS Blue Essentials Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.336,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.336,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.336,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,126.688,Fee Schedule,103% of Cigna fee schedule,131.31,100,,3.368,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,135.25,103,,3.464,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,619.47,75,,166.464,Percent of Total Billed Charges,75% of Total Billed Charges,412.98,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.98,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,412.98,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.136,Case Rate,Pays based on per visit rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,131.31,100,,3.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,825.96,100,,221.952,Percent of Total Billed Charges,100% of Total Billed Charges,103.05,1374.66,
DX ARTHROGRAM SHOULDER BI SI,49065028,CDM,322,RC,73040,HCPCS,Outpatient,,,605.68,363.41,TC   ,101.06,100,,51.448,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,2.592,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,112.432,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,3.336,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,3.336,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,3.336,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.536,Fee Schedule,103% of Cigna fee schedule,132.31,100,,3.56,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,3.672,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,454.26,75,,302.4,Percent of Total Billed Charges,75% of Total Billed Charges,302.84,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,302.84,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.456,Case Rate,Pays based on per visit rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,3.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,605.68,100,,403.2,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM SHOULDER BI SI,49065028,CDM,322,RC,73040,HCPCS,Outpatient,,,605.68,363.41,TC   ,101.06,100,,5575.464,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.72,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11311.872,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.928,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.928,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.928,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.056,Fee Schedule,103% of Cigna fee schedule,132.31,100,,18.12,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,18.664,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,454.26,75,,302.4,Percent of Total Billed Charges,75% of Total Billed Charges,302.84,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,2730.8,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,302.84,50,,2730.8,Percent of Total Billed Charges,50% of Total Billed Charges,302.84,50,,1549.416,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,39.224,Case Rate,Pays based on per visit rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,18.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,605.68,100,,403.2,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM SHOULDER LT SI,49065029,CDM,322,RC,73040,HCPCS,Outpatient,,,403.79,242.27,,101.06,100,,37.376,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,3.128,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11380.912,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,4.024,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,4.024,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,4.024,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.136,Fee Schedule,103% of Cigna fee schedule,132.31,100,,0.312,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,0.32,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,302.84,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,201.9,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1346.528,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,201.9,50,,1346.528,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.68,Case Rate,Pays based on per visit rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,403.79,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM SHOULDER LT SI,49065029,CDM,322,RC,73040,HCPCS,Outpatient,,,403.79,242.27,,101.06,100,,30.424,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11.288,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.104,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.104,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.312,Fee Schedule,103% of Cigna fee schedule,132.31,100,,0.12,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,302.84,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,201.9,50,,2730.8,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,2703.256,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,201.9,50,,2703.256,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1487.312,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.152,Case Rate,Pays based on per visit rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,403.79,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM SHOULDER RT SI,49065030,CDM,322,RC,73040,HCPCS,Outpatient,,,403.79,242.27,TC   ,101.06,100,,765.576,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11.32,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.152,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.152,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.032,Fee Schedule,103% of Cigna fee schedule,132.31,100,,117.16,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,120.672,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,302.84,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,201.9,50,,1346.528,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,2415.392,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,201.9,50,,2415.392,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.88,Case Rate,Pays based on per visit rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,117.16,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,403.79,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM SHOULDER RT SI,49065030,CDM,322,RC,73040,HCPCS,Outpatient,,,403.79,242.27,TC   ,101.06,100,,3992.608,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11.32,Fee Schedule,320% of BCBS Blue Essentials Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.208,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.208,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.208,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,2.704,Fee Schedule,103% of Cigna fee schedule,132.31,100,,73.56,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,136.28,103,,75.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,302.84,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,201.9,50,,2703.256,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1355.232,Percent of Total Billed Charges,50% of Total Billed Charges,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,201.9,50,,1355.232,Percent of Total Billed Charges,50% of Total Billed Charges,201.9,50,,1754.8,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.88,Case Rate,Pays based on per visit rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,132.31,100,,73.56,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,403.79,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,101.06,1374.66,
DX ARTHROGRAM WRIST RT SI,49065036,CDM,322,RC,73115,HCPCS,Outpatient,,,348.81,209.29,,106.38,100,,237.624,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,1.144,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11.416,Fee Schedule,320% of BCBS Blue Essentials Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,1.464,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,1.464,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,1.464,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,1.384,Fee Schedule,103% of Cigna fee schedule,136.33,100,,33.032,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,140.42,103,,34.016,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,261.61,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,174.41,50,,2415.392,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,174.41,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.664,Case Rate,Pays based on per visit rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,33.032,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.81,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,106.38,1374.66,
DX ARTHROGRAM WRIST RT SI,49065036,CDM,322,RC,73115,HCPCS,Outpatient,,,348.81,209.29,,106.38,100,,15.36,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,0.088,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,11.432,Fee Schedule,320% of BCBS Blue Essentials Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,0.112,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,0.112,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,0.112,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.984,Fee Schedule,103% of Cigna fee schedule,136.33,100,,1.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,140.42,103,,1.648,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,261.61,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,174.41,50,,1355.232,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,174.41,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,174.41,50,,1901.896,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.704,Case Rate,Pays based on per visit rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,136.33,100,,1.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.81,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,106.38,1374.66,
DX ASP JT INTERMED RT,49065041,CDM,361,RC,,,Outpatient,,,773.69,464.21,,464.21,60,,81.128,Percent of Total Billed Charges,60% of Total Billed Charges,348.16,45,,278.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.63,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,79.57,32,,11.432,Percent of Total Billed Charges,32% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,278.53,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,278.53,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,278.53,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,464.21,60,,0.488,Percent of Total Billed Charges,60% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,773.69,100,,618.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,111.57,14.42,,22.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.27,75,,380.384,Percent of Total Billed Charges,75% of Total Billed Charges,386.85,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,386.85,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.85,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,386.85,50,,2636.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.58,70,,0.776,Percent of Total Billed Charges,70% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,21.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,773.69,100,,507.176,Percent of Total Billed Charges,100% of Total Billed Charges,79.57,773.69,
DX ASP JT MAJOR LT,49065043,CDM,361,RC,,,Outpatient,,,885.02,531.01,,531.01,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,398.26,45,,318.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.81,28,,3.256,Percent of Total Billed Charges,28% of Total Billed Charges,79.76,32,,11.472,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,318.61,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,318.61,36,,4.184,Percent of Total Billed Charges,36% Total Bille Charges,318.61,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,531.01,60,,686.4,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885.02,100,,708.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,1.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.77,75,,380.384,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,646.136,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.51,50,,646.136,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.51,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885.02,100,,507.176,Percent of Total Billed Charges,100% of Total Billed Charges,79.76,885.02,
DX ASP JT MAJOR RT,49065044,CDM,361,RC,,,Outpatient,,,885.02,531.01,,531.01,60,,10.752,Percent of Total Billed Charges,60% of Total Billed Charges,398.26,45,,318.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.81,28,,4.208,Percent of Total Billed Charges,28% of Total Billed Charges,79.76,32,,11.472,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,318.61,36,,5.416,Percent of Total Billed Charges,36% of Total Billed Charges,318.61,36,,5.416,Percent of Total Billed Charges,36% Total Bille Charges,318.61,36,,5.416,Percent of Total Billed Charges,36% of Total Billed Charges,531.01,60,,175.744,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885.02,100,,708.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,1.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.77,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,2102.8,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.51,50,,2102.8,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,988,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.51,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885.02,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,79.76,885.02,
DX BONE SURVEY COMPL,49065048,CDM,320,RC,77075,HCPCS,Outpatient,,,937.7,562.62,TC   ,69.77,100,,14.496,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.864,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,112.64,Fee Schedule,320% of BCBS Blue Essentials Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.392,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.392,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.392,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.024,Fee Schedule,103% of Cigna fee schedule,100.24,100,,29.072,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,103.25,103,,29.944,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,703.28,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,468.85,50,,646.136,Percent of Total Billed Charges,50% of Total Billed Charges,468.85,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,468.85,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,468.85,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.736,Case Rate,Pays based on per visit rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,29.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,937.7,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,937.7,
DX BONE SURVEY COMPL,49065048,CDM,320,RC,77075,HCPCS,Outpatient,,,937.7,562.62,TC   ,69.77,100,,1080,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.48,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,113.64,Fee Schedule,320% of BCBS Blue Essentials Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.624,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.624,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.624,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,5.752,Fee Schedule,103% of Cigna fee schedule,100.24,100,,1.824,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,103.25,103,,1.88,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,703.28,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,468.85,50,,2102.8,Percent of Total Billed Charges,50% of Total Billed Charges,468.85,50,,863.704,Percent of Total Billed Charges,50% of Total Billed Charges,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,468.85,50,,863.704,Percent of Total Billed Charges,50% of Total Billed Charges,468.85,50,,1114.192,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.576,Case Rate,Pays based on per visit rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.24,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,937.7,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,937.7,
DX CALCANEUS MIN 2V BI PORT,49065052,CDM,320,RC,73650,HCPCS,Outpatient,,,222,133.20,,20.16,100,,933.112,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.288,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,113.84,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.376,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.376,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.376,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.392,Fee Schedule,103% of Cigna fee schedule,28.74,100,,134.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,138.424,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,111,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,342.936,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.264,Case Rate,Pays based on per visit rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,134.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V BI PORT,49065052,CDM,320,RC,73650,HCPCS,Outpatient,,,222,133.20,,20.16,100,,18.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,19.152,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,113.92,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,24.624,Fee Schedule,360% of BCBS POS Rate,287.32,360,,24.624,Fee schedule,360% of BCBS PPO Rate,287.32,360,,24.624,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,10.256,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,111,50,,863.704,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,111,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,111,50,,2730.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.952,Case Rate,Pays based on per visit rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V LT PORT,49065053,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,TC   ,20.16,100,,193.384,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.048,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.784,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,253.592,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,1346.528,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.792,Case Rate,Pays based on per visit rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,338.12,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V LT PORT,49065053,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,TC   ,20.16,100,,2.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.28,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.68,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.68,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.68,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.24,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,325.512,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,2703.256,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.336,Case Rate,Pays based on per visit rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,434.016,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V RT,49065054,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,,20.16,100,,181.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.56,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.472,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.232,Fee Schedule,103% of Cigna fee schedule,28.74,100,,29.56,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,30.448,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,325.512,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,2415.392,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,303.176,Case Rate,Pays based on per visit rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,29.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,434.016,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V RT,49065054,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,,20.16,100,,133.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.608,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.56,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.56,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.104,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.128,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.128,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,1355.232,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,75.432,Case Rate,Pays based on per visit rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V RT PORT,49065055,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,TC   ,20.16,100,,52.232,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.688,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.008,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.104,Case Rate,Pays based on per visit rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CALCANEUS MIN 2V RT PORT,49065055,CDM,320,RC,73650,HCPCS,Outpatient,,,148,88.80,TC   ,20.16,100,,30.344,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.608,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,114.888,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.784,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.784,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.784,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.416,Fee Schedule,103% of Cigna fee schedule,28.74,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.6,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,74,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,74,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.08,Case Rate,Pays based on per visit rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.74,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,300,
DX CHEST 1V CAP PORT,49065057,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,40.888,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.16,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.472,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,10.088,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.072,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,1283.216,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.2,Case Rate,Pays based on per visit rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V CAP PORT,49065057,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,12.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.52,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.2,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,646.136,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.208,Case Rate,Pays based on per visit rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V CAP PORT,49065057,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,45.136,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.536,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.08,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.08,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.08,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.408,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.632,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.648,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,217.008,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,2102.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.04,Case Rate,Pays based on per visit rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.632,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,289.344,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V NEONATE PORT,49065059,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,54.6,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.928,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.552,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.192,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.192,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.192,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.816,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.32,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,320.944,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,758.792,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.36,Case Rate,Pays based on per visit rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,427.92,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V NEONATE PORT,49065059,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,7868.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.536,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.56,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,39.152,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,320.944,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,863.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.072,Case Rate,Pays based on per visit rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,427.92,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V NEONATE PORT,49065059,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,7.528,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.4,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.632,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.088,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.088,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.088,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.112,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.112,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,2171.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.104,Case Rate,Pays based on per visit rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V PORT,49065060,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,34.816,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.648,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.328,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.328,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.328,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.92,Fee Schedule,103% of Cigna fee schedule,26.06,100,,160.16,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,164.968,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.6,Case Rate,Pays based on per visit rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,160.16,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V PORT,49065060,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,149.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.656,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.824,Fee Schedule,103% of Cigna fee schedule,26.06,100,,41.008,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,42.24,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.712,Case Rate,Pays based on per visit rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,41.008,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST 1V PORT,49065060,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,149.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.72,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.944,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,4641.344,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,4641.344,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.392,Case Rate,Pays based on per visit rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE,49065062,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,240.84,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.616,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.416,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.792,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.792,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.792,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.416,Fee Schedule,103% of Cigna fee schedule,26.06,100,,1.344,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,1.384,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,5239.896,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,5239.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.888,Case Rate,Pays based on per visit rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,1.344,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE,49065062,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,92.936,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.416,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.488,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,4641.344,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,1445.776,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,1445.776,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.424,Case Rate,Pays based on per visit rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE,49065062,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,184.936,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.416,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.952,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.952,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.952,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.136,Fee Schedule,103% of Cigna fee schedule,26.06,100,,2.392,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,2.464,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,5239.896,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.896,Case Rate,Pays based on per visit rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.392,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE PORT,49065063,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,313.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.584,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.096,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.096,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.096,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.656,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.184,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.192,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,1445.776,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,247.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.544,Case Rate,Pays based on per visit rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE PORT,49065063,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,204.416,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,115.904,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,7.664,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,342.328,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.904,Case Rate,Pays based on per visit rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,456.432,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 1V NEONATE PORT,49065063,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.824,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.048,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.032,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,748.264,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,748.264,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.624,Case Rate,Pays based on per visit rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST ABD 2V NEONATE PORT,49065065,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,11.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.592,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,108.056,Fee Schedule,103% of Cigna fee schedule,33.75,100,,0.488,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,0.504,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,498.68,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,498.68,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,18.416,Case Rate,Pays based on per visit rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST ABD 2V NEONATE PORT,49065065,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,34.816,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.968,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.592,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.384,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.384,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.384,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.032,Fee Schedule,103% of Cigna fee schedule,33.75,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,748.264,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,786.144,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,786.144,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.208,Case Rate,Pays based on per visit rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST ABD 2V NEONATE PORT,49065065,CDM,324,RC,71046,HCPCS,Outpatient,,,350,210.00,,22.16,100,,205.2,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.592,Fee Schedule,320% of BCBS Blue Essentials Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.72,Fee Schedule,103% of Cigna fee schedule,33.75,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,34.76,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,175,50,,498.68,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,987.84,Percent of Total Billed Charges,50% of Total Billed Charges,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,987.84,Percent of Total Billed Charges,50% of Total Billed Charges,175,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.656,Case Rate,Pays based on per visit rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.75,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,350,
DX CHEST DECUB RT,49065069,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,67.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.92,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.736,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.344,Fee Schedule,103% of Cigna fee schedule,26.06,100,,2.352,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,2.424,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,786.144,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.28,Case Rate,Pays based on per visit rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,2.352,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB RT,49065069,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,21.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.736,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,27.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,27.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,27.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.4,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.048,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.048,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,987.84,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.184,Case Rate,Pays based on per visit rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB RT,49065069,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,TC   ,16.16,100,,410.4,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,116.736,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.856,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.856,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.856,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.4,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,203.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.544,Case Rate,Pays based on per visit rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB RT PORT,49065070,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,7.824,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,117.04,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.76,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.76,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.76,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.4,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.192,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.2,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,1751.136,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,1751.136,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,4641.344,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.832,Case Rate,Pays based on per visit rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB RT PORT,49065070,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,27.736,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.448,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,117.504,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.864,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.864,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.864,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.4,Fee Schedule,103% of Cigna fee schedule,26.06,100,,9.136,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,9.408,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,228.216,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,2298.8,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,2298.8,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,5239.896,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,42.848,Case Rate,Pays based on per visit rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,9.136,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,304.288,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CHEST DECUB RT PORT,49065070,CDM,324,RC,71045,HCPCS,Outpatient,,,280,168.00,,16.16,100,,72.56,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,117.6,Fee Schedule,320% of BCBS Blue Essentials Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.816,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.816,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.816,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.016,Fee Schedule,103% of Cigna fee schedule,26.06,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.84,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,210,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,140,50,,1751.136,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,140,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,140,50,,1445.776,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.208,Case Rate,Pays based on per visit rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,26.06,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,280,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,300,
DX CISTERNOGRAM CT OR NM,49065074,CDM,361,RC,,,Outpatient,,,1328.73,797.24,,797.24,60,,10.36,Percent of Total Billed Charges,60% of Total Billed Charges,597.93,45,,478.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.04,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,79.98,32,,117.616,Percent of Total Billed Charges,32% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,478.34,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,478.34,36,,0.904,Percent of Total Billed Charges,36% Total Bille Charges,478.34,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,797.24,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1328.73,100,,1062.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,191.6,14.42,,1.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,996.55,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,664.37,50,,2298.8,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,664.37,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,664.37,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,930.11,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,186.02,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1328.73,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,79.98,1328.73,
DX CLAVICLE COMPL BI PORT,49065075,CDM,320,RC,73000,HCPCS,Outpatient,,,451.03,270.62,TC   ,23.15,100,,20.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.488,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,117.696,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.912,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.912,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.912,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,19.12,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.192,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.2,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,338.27,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,225.52,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,5744.888,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225.52,50,,5744.888,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.68,Case Rate,Pays based on per visit rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,451.03,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,451.03,
DX CLAVICLE COMPL BI PORT,49065075,CDM,320,RC,73000,HCPCS,Outpatient,,,451.03,270.62,TC   ,23.15,100,,116.512,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.784,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11791.008,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.296,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.296,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.296,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,23.656,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.456,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.464,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,338.27,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,225.52,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,225.52,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,225.52,50,,8058.016,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.872,Case Rate,Pays based on per visit rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,451.03,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,451.03,
DX CLAVICLE COMPL LT PORT,49065076,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,25.192,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.936,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.192,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.192,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.192,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,24.24,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,5744.888,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,748.264,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.104,Case Rate,Pays based on per visit rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL LT PORT,49065076,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,1010.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.256,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.936,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,25.528,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.112,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,498.68,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.464,Case Rate,Pays based on per visit rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL RT,49065077,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,TC   ,23.15,100,,21.848,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.704,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,11.968,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.616,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.616,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.616,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,20.128,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,323.504,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,786.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.56,Case Rate,Pays based on per visit rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,431.336,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL RT,49065077,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,TC   ,23.15,100,,38.504,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,50.824,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,323.504,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,987.84,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.84,Case Rate,Pays based on per visit rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,431.336,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL RT PORT,49065078,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,3.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.008,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,53.288,Fee Schedule,103% of Cigna fee schedule,32.41,100,,1.792,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,1.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.24,Case Rate,Pays based on per visit rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CLAVICLE COMPL RT PORT,49065078,CDM,320,RC,73000,HCPCS,Outpatient,,,300.68,180.41,,23.15,100,,7.824,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,117.84,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.304,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.304,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.304,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.248,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,225.51,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.34,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,150.34,50,,384.456,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.024,Case Rate,Pays based on per visit rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300.68,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300.68,
DX CSPINE 1V,49065079,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,144,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.024,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.128,Fee Schedule,103% of Cigna fee schedule,24.73,100,,25.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,25.968,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.848,Case Rate,Pays based on per visit rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,25.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX CSPINE 1V,49065079,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,91.816,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.232,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.264,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,1751.136,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.664,Case Rate,Pays based on per visit rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX CSPINE 1V PORT,49065080,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,383.256,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.136,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.272,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.184,Fee Schedule,103% of Cigna fee schedule,24.73,100,,1.48,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,1.528,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,2298.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.664,Case Rate,Pays based on per visit rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,1.48,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX CSPINE 1V PORT,49065080,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,61.712,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.408,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.208,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.208,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.208,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.36,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,215.672,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.344,Case Rate,Pays based on per visit rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,287.56,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX CSPINE 2 OR 3V PORT,49065081,CDM,320,RC,72040,HCPCS,Outpatient,,,434.31,260.59,,27.48,100,,163.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.544,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.784,Fee Schedule,320% of BCBS Blue Essentials Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.696,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.696,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.696,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.44,Fee Schedule,103% of Cigna fee schedule,39.76,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,40.95,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,325.73,75,,791.824,Percent of Total Billed Charges,75% of Total Billed Charges,217.16,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,2351.496,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,217.16,50,,2351.496,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,2620,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.856,Case Rate,Pays based on per visit rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,434.31,100,,1055.768,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,434.31,
DX CSPINE 2 OR 3V PORT,49065081,CDM,320,RC,72040,HCPCS,Outpatient,,,434.31,260.59,,27.48,100,,23.392,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.824,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,118.904,Fee Schedule,320% of BCBS Blue Essentials Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.2,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.2,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.2,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.464,Fee Schedule,103% of Cigna fee schedule,39.76,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,40.95,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,325.73,75,,527.888,Percent of Total Billed Charges,75% of Total Billed Charges,217.16,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,217.16,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,217.16,50,,5744.888,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.336,Case Rate,Pays based on per visit rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,39.76,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,434.31,100,,703.848,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,434.31,
DX ELBOW 2V BI PORT,49065090,CDM,320,RC,73070,HCPCS,Outpatient,,,513.34,308.00,,20.16,100,,43.672,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.288,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.04,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.784,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,385.01,75,,527.888,Percent of Total Billed Charges,75% of Total Billed Charges,256.67,50,,2351.496,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,256.67,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.456,Case Rate,Pays based on per visit rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,513.34,100,,703.848,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,513.34,
DX ELBOW 2V BI PORT,49065090,CDM,320,RC,73070,HCPCS,Outpatient,,,513.34,308.00,,20.16,100,,176.96,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.04,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.096,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,385.01,75,,398.008,Percent of Total Billed Charges,75% of Total Billed Charges,256.67,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,2359.104,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,256.67,50,,2359.104,Percent of Total Billed Charges,50% of Total Billed Charges,256.67,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.592,Case Rate,Pays based on per visit rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,513.34,100,,530.68,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,513.34,
DX ELBOW 2V LT PORT,49065091,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,16.408,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.064,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.96,Fee Schedule,103% of Cigna fee schedule,29.4,100,,4.464,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,4.592,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,446.008,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,2418.824,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,2418.824,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.144,Case Rate,Pays based on per visit rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,594.672,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V LT PORT,49065091,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,79.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.856,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.064,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.856,Fee Schedule,103% of Cigna fee schedule,29.4,100,,5.52,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,5.688,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,446.008,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,2359.104,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,7834.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.808,Case Rate,Pays based on per visit rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,594.672,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V RT,49065092,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,,20.16,100,,84.72,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,13.416,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.136,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,17.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,17.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,17.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.544,Fee Schedule,103% of Cigna fee schedule,29.4,100,,5.656,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,5.824,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,373.504,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,2418.824,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.464,Case Rate,Pays based on per visit rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,498,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V RT,49065092,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,,20.16,100,,47.6,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,28.648,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.576,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,36.832,Fee Schedule,360% of BCBS POS Rate,287.32,360,,36.832,Fee schedule,360% of BCBS PPO Rate,287.32,360,,36.832,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.128,Fee Schedule,103% of Cigna fee schedule,29.4,100,,5.96,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,6.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,532.864,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.272,Case Rate,Pays based on per visit rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,5.96,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,710.48,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V RT PORT,49065093,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,144,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,25.984,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.808,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,33.408,Fee Schedule,360% of BCBS POS Rate,287.32,360,,33.408,Fee schedule,360% of BCBS PPO Rate,287.32,360,,33.408,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.408,Fee Schedule,103% of Cigna fee schedule,29.4,100,,4.696,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,4.84,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,326.472,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.192,Case Rate,Pays based on per visit rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,435.296,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW 2V RT PORT,49065093,CDM,320,RC,73070,HCPCS,Outpatient,,,342.23,205.34,TC   ,20.16,100,,57.304,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.808,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.584,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.584,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.584,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.568,Fee Schedule,103% of Cigna fee schedule,29.4,100,,11.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,12.216,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,256.67,75,,568.864,Percent of Total Billed Charges,75% of Total Billed Charges,171.12,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,500.336,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,171.12,50,,500.336,Percent of Total Billed Charges,50% of Total Billed Charges,171.12,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.496,Case Rate,Pays based on per visit rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,11.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,342.23,100,,758.488,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,342.23,
DX ELBOW MIN 3V RT,49065094,CDM,320,RC,73080,HCPCS,Outpatient,,,389.18,233.51,,22.82,100,,5.96,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.952,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,119.808,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.504,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.504,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.504,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.208,Fee Schedule,103% of Cigna fee schedule,32.75,100,,12.432,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,12.808,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,291.89,75,,303.184,Percent of Total Billed Charges,75% of Total Billed Charges,194.59,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,928,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,194.59,50,,928,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,3000,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.656,Case Rate,Pays based on per visit rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,12.432,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,389.18,100,,404.248,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,389.18,
DX ELBOW MIN 3V RT,49065094,CDM,320,RC,73080,HCPCS,Outpatient,,,389.18,233.51,,22.82,100,,243.552,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,120.28,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.968,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.968,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.968,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.168,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,291.89,75,,303.184,Percent of Total Billed Charges,75% of Total Billed Charges,194.59,50,,500.336,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,1228.72,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,194.59,50,,1228.72,Percent of Total Billed Charges,50% of Total Billed Charges,194.59,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.48,Case Rate,Pays based on per visit rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,389.18,100,,404.248,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,389.18,
DX ENEMA THERAPEUTIC,49065095,CDM,320,RC,74283,HCPCS,Outpatient,,,310.41,186.25,TC   ,158.99,100,,474.536,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,370.33,280,,1.904,Fee Schedule,280% of BCBS BULE Fee Schedule,423.23,320,,12.104,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,476.14,360,,2.448,Fee Schedule,360% of BCBS POS Rate,476.14,360,,2.448,Fee schedule,360% of BCBS PPO Rate,476.14,360,,2.448,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,18.088,Fee Schedule,103% of Cigna fee schedule,180.34,100,,0.032,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,232.81,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,155.21,50,,928,Percent of Total Billed Charges,50% of Total Billed Charges,155.21,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,155.21,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,155.21,50,,2000,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.8,Case Rate,Pays based on per visit rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.41,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,613.5,
DX ENEMA THERAPEUTIC,49065095,CDM,320,RC,74283,HCPCS,Outpatient,,,310.41,186.25,TC   ,158.99,100,,156.216,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,370.33,280,,0.976,Fee Schedule,280% of BCBS BULE Fee Schedule,423.23,320,,12.16,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,476.14,360,,1.256,Fee Schedule,360% of BCBS POS Rate,476.14,360,,1.256,Fee schedule,360% of BCBS PPO Rate,476.14,360,,1.256,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,1.048,Fee Schedule,103% of Cigna fee schedule,180.34,100,,0.992,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.024,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,232.81,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,155.21,50,,1228.72,Percent of Total Billed Charges,50% of Total Billed Charges,155.21,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,155.21,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,155.21,50,,2351.496,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.816,Case Rate,Pays based on per visit rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.992,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.41,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,613.5,
DX ERCP BILE DUCT,49065097,CDM,320,RC,74328,HCPCS,Outpatient,,,1077.93,646.76,,62.04,100,,191.264,Fee Schedule,100% of Aetna Fee Schedule,485.07,45,,388.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.92,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,116.48,320,,12.208,Fee Schedule,320% of BCBS Blue Essentials Rate,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,131.04,360,,0.056,Fee Schedule,360% of BCBS POS Rate,131.04,360,,0.056,Fee schedule,360% of BCBS PPO Rate,131.04,360,,0.056,Fee Schedule,360% of BCBS Traditional Rate,646.76,60,,1.48,Percent of Total Billed Charges,60% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1077.93,100,,862.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,155.44,14.42,,1.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.45,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,538.97,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,538.97,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.97,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,538.97,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,0.208,Case Rate,Pays based on per visit rate,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1077.93,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,62.04,1077.93,
DX ERCP BILE DUCT,49065097,CDM,320,RC,74328,HCPCS,Outpatient,,,1077.93,646.76,,62.04,100,,165.336,Fee Schedule,100% of Aetna Fee Schedule,485.07,45,,388.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.92,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,116.48,320,,120.376,Fee Schedule,320% of BCBS Blue Essentials Rate,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,131.04,360,,1.12,Fee Schedule,360% of BCBS POS Rate,131.04,360,,1.12,Fee schedule,360% of BCBS PPO Rate,131.04,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,646.76,60,,7.352,Percent of Total Billed Charges,60% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1077.93,100,,862.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,155.44,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.45,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,538.97,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,538.97,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,538.97,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,538.97,50,,1567.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,0.304,Case Rate,Pays based on per visit rate,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,150.91,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1077.93,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,62.04,1077.93,
DX ESOPHAGRAM SINGLE CM,49065098,CDM,320,RC,74220,HCPCS,Outpatient,,,621.45,372.87,TC   ,69.77,100,,207.072,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,5.424,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,121.512,Fee Schedule,320% of BCBS Blue Essentials Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,6.968,Fee Schedule,360% of BCBS POS Rate,655.99,360,,6.968,Fee schedule,360% of BCBS PPO Rate,655.99,360,,6.968,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,7.36,Fee Schedule,103% of Cigna fee schedule,99.9,100,,0.104,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,102.9,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,466.09,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,310.73,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.73,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,2359.104,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.408,Case Rate,Pays based on per visit rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,621.45,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,655.99,
DX ESOPHAGRAM SINGLE CM,49065098,CDM,320,RC,74220,HCPCS,Outpatient,,,621.45,372.87,TC   ,69.77,100,,357.024,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,15.584,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,121.6,Fee Schedule,320% of BCBS Blue Essentials Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,20.032,Fee Schedule,360% of BCBS POS Rate,655.99,360,,20.032,Fee schedule,360% of BCBS PPO Rate,655.99,360,,20.032,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,1.888,Fee Schedule,103% of Cigna fee schedule,99.9,100,,0.112,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,102.9,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,466.09,75,,202.12,Percent of Total Billed Charges,75% of Total Billed Charges,310.73,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.73,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,2418.824,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.848,Case Rate,Pays based on per visit rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,99.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,621.45,100,,269.496,Percent of Total Billed Charges,100% of Total Billed Charges,69.77,655.99,
DX FEMUR MIN 2V BI PORT,49065101,CDM,320,RC,73552,HCPCS,Outpatient,,,572.4,343.44,,25.49,100,,156.216,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,14.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,121.856,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,19.128,Fee Schedule,360% of BCBS POS Rate,287.32,360,,19.128,Fee schedule,360% of BCBS PPO Rate,287.32,360,,19.128,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.592,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.184,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.192,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.3,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,286.2,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.2,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,1489.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.216,Case Rate,Pays based on per visit rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.4,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,572.4,
DX FEMUR MIN 2V BI PORT,49065101,CDM,320,RC,73552,HCPCS,Outpatient,,,572.4,343.44,,25.49,100,,191.264,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,13.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,121.856,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.92,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.92,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.92,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.776,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.744,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.3,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,286.2,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.2,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,286.2,50,,992.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.04,Case Rate,Pays based on per visit rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.4,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,572.4,
DX FEMUR MIN 2V LT PORT,49065102,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,62.816,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.68,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,121.856,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,13.736,Fee Schedule,360% of BCBS POS Rate,287.32,360,,13.736,Fee schedule,360% of BCBS PPO Rate,287.32,360,,13.736,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.408,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.224,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.232,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.136,Case Rate,Pays based on per visit rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V LT PORT,49065102,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,152.112,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.592,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,121.856,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,11.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,11.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,11.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,58.248,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.208,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.528,Case Rate,Pays based on per visit rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V RT,49065103,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,,25.49,100,,181.328,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,122.064,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.704,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.704,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.704,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,13.304,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.128,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.128,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,500.336,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.656,Case Rate,Pays based on per visit rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V RT,49065103,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,,25.49,100,,21.168,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.752,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,122.224,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,13.824,Fee Schedule,360% of BCBS POS Rate,287.32,360,,13.824,Fee schedule,360% of BCBS PPO Rate,287.32,360,,13.824,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,23.776,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,356.56,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,928,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.208,Case Rate,Pays based on per visit rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,475.408,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V RT PORT,49065104,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,230.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.368,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.288,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.472,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.472,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.128,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1228.72,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.728,Case Rate,Pays based on per visit rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FEMUR MIN 2V RT PORT,49065104,CDM,320,RC,73552,HCPCS,Outpatient,,,381.6,228.96,TC   ,25.49,100,,387.2,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,99.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.288,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,127.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,127.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,127.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.2,Fee Schedule,103% of Cigna fee schedule,35.75,100,,0.368,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,36.82,103,,0.376,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.2,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,190.8,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1054.896,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,50,,1054.896,Percent of Total Billed Charges,50% of Total Billed Charges,190.8,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,47.88,Case Rate,Pays based on per visit rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,35.75,100,,0.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,25.49,381.6,
DX FINGER 2V BI PORT,49065105,CDM,320,RC,73140,HCPCS,Outpatient,,,416.16,249.70,,29.48,100,,953.808,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.984,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.48,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.696,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.696,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.696,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,90.2,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.272,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.28,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,312.12,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,208.08,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.08,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.912,Case Rate,Pays based on per visit rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,416.16,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,416.16,
DX FINGER 2V BI PORT,49065105,CDM,320,RC,73140,HCPCS,Outpatient,,,416.16,249.70,,29.48,100,,6.16,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,110.856,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.04,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,142.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,142.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,142.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,87.376,Fee Schedule,103% of Cigna fee schedule,38.09,100,,4.224,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,4.344,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,312.12,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,208.08,50,,1054.896,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,208.08,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,208.08,50,,1725.032,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.208,Case Rate,Pays based on per visit rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,4.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,416.16,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,416.16,
DX FINGER MIN 2V LT PORT,49065106,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,8.768,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.136,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,139.408,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.248,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.928,Case Rate,Pays based on per visit rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V LT PORT,49065106,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,15.88,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.208,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.168,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.56,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.56,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.56,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,348.032,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.344,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.36,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1734.312,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.096,Case Rate,Pays based on per visit rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V RT,49065107,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,,29.48,100,,0.912,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,19.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.168,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,24.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,24.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,24.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.928,Fee Schedule,103% of Cigna fee schedule,38.09,100,,1.712,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,1.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.872,Case Rate,Pays based on per visit rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.712,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V RT,49065107,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,,29.48,100,,11.864,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.384,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.168,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.496,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.496,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.392,Fee Schedule,103% of Cigna fee schedule,38.09,100,,1.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,1.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1676.92,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.52,Case Rate,Pays based on per visit rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V RT PORT,49065108,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,23.752,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,43.784,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.488,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,56.296,Fee Schedule,360% of BCBS POS Rate,287.32,360,,56.296,Fee schedule,360% of BCBS PPO Rate,287.32,360,,56.296,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.456,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.928,Case Rate,Pays based on per visit rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FINGER MIN 2V RT PORT,49065108,CDM,320,RC,73140,HCPCS,Outpatient,,,277.44,166.46,TC   ,29.48,100,,27.28,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,27.896,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.696,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,35.864,Fee Schedule,360% of BCBS POS Rate,287.32,360,,35.864,Fee schedule,360% of BCBS PPO Rate,287.32,360,,35.864,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.064,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,208.08,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,138.72,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,138.72,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,138.72,50,,1923.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.128,Case Rate,Pays based on per visit rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,277.44,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,300,
DX FOOT 2V BI PORT,49065109,CDM,320,RC,73620,HCPCS,Outpatient,,,504,302.40,,20.16,100,,69.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.944,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.832,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.216,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.216,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,28.4,100,,0.184,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,252,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.16,Case Rate,Pays based on per visit rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,504,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,504,
DX FOOT 2V BI PORT,49065109,CDM,320,RC,73620,HCPCS,Outpatient,,,504,302.40,,20.16,100,,45.184,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.92,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,123.856,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.464,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.464,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.464,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.056,Fee Schedule,103% of Cigna fee schedule,28.4,100,,1.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,1.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378,75,,237.712,Percent of Total Billed Charges,75% of Total Billed Charges,252,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,252,50,,2484.328,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.312,Case Rate,Pays based on per visit rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,504,100,,316.944,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,504,
DX FOOT 2V LT PORT,49065110,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,25.424,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.416,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.08,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.408,Fee Schedule,103% of Cigna fee schedule,28.4,100,,13.592,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,14,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,278.304,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.832,Case Rate,Pays based on per visit rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,13.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,371.072,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V LT PORT,49065110,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,57.424,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.288,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.096,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.648,Fee Schedule,103% of Cigna fee schedule,28.4,100,,3.104,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,3.2,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,278.304,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,1563.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.008,Case Rate,Pays based on per visit rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,371.072,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V RT,49065111,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,TC   ,20.16,100,,278.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.616,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.096,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.36,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.36,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.36,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.448,Fee Schedule,103% of Cigna fee schedule,28.4,100,,5.544,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,5.712,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,212.464,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,1054.896,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.584,Case Rate,Pays based on per visit rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,283.28,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V RT,49065111,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,TC   ,20.16,100,,14.888,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.096,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.504,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.504,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.504,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.616,Fee Schedule,103% of Cigna fee schedule,28.4,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,212.464,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,357.496,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,357.496,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.032,Case Rate,Pays based on per visit rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,283.28,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V RT PORT,49065112,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,17.368,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.392,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.312,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.312,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.312,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.072,Fee Schedule,103% of Cigna fee schedule,28.4,100,,0.048,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,0.048,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,982.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.056,Case Rate,Pays based on per visit rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT 2V RT PORT,49065112,CDM,320,RC,73620,HCPCS,Outpatient,,,336,201.60,,20.16,100,,18.488,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.496,Fee Schedule,320% of BCBS Blue Essentials Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.824,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.824,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.824,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.584,Fee Schedule,103% of Cigna fee schedule,28.4,100,,21.048,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,29.25,103,,21.68,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,168,50,,357.496,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,168,50,,923.088,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.536,Case Rate,Pays based on per visit rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,28.4,100,,21.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,20.16,336,
DX FOOT MIN 3V BI PORT,49065113,CDM,320,RC,73630,HCPCS,Outpatient,,,633.97,380.38,,25.16,100,,25.72,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.536,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.496,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,10.976,Fee Schedule,360% of BCBS POS Rate,287.32,360,,10.976,Fee schedule,360% of BCBS PPO Rate,287.32,360,,10.976,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.448,Fee Schedule,103% of Cigna fee schedule,34.41,100,,20.384,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,21,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,475.48,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,316.99,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,316.99,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.04,Case Rate,Pays based on per visit rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,20.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,633.97,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,633.97,
DX FOOT MIN 3V BI PORT,49065113,CDM,320,RC,73630,HCPCS,Outpatient,,,633.97,380.38,,25.16,100,,24.08,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.544,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.024,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.024,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.448,Fee Schedule,103% of Cigna fee schedule,34.41,100,,32.528,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,33.504,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,475.48,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,316.99,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,316.99,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,316.99,50,,1803.48,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.744,Case Rate,Pays based on per visit rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,32.528,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,633.97,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,633.97,
DX FOOT MIN 3V LT PORT,49065114,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,TC   ,25.16,100,,4.984,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.472,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,124.568,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.896,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.896,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.896,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.36,Fee Schedule,103% of Cigna fee schedule,34.41,100,,81.208,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,83.648,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,270.592,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.192,Case Rate,Pays based on per visit rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,81.208,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,360.792,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V LT PORT,49065114,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,TC   ,25.16,100,,9.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.648,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.552,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.408,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.408,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.408,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.064,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.224,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,270.592,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,7722.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,7722.4,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,283.744,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.016,Case Rate,Pays based on per visit rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,360.792,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V RT,49065115,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,,25.16,100,,11.032,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,31.752,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.552,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,40.824,Fee Schedule,360% of BCBS POS Rate,287.32,360,,40.824,Fee schedule,360% of BCBS PPO Rate,287.32,360,,40.824,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.304,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,717.904,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.064,Case Rate,Pays based on per visit rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,957.2,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V RT,49065115,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,,25.16,100,,12.856,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.104,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.576,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.112,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,7722.4,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,373.64,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.024,Case Rate,Pays based on per visit rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V RT PORT,49065116,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,TC   ,25.16,100,,9.296,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.616,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.344,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.344,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.344,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.12,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.424,Case Rate,Pays based on per visit rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOOT MIN 3V RT PORT,49065116,CDM,320,RC,73630,HCPCS,Outpatient,,,422.65,253.59,TC   ,25.16,100,,33,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.528,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.664,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.968,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.968,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.968,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.112,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,211.33,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,211.33,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,211.33,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.064,Case Rate,Pays based on per visit rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,422.65,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,422.65,
DX FOREARM 2V BI PORT,49065117,CDM,320,RC,73090,HCPCS,Outpatient,,,542.52,325.51,,20.49,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.68,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.064,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.12,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,406.89,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,271.26,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,839.576,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,50,,839.576,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.304,Case Rate,Pays based on per visit rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,542.52,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,542.52,
DX FOREARM 2V BI PORT,49065117,CDM,320,RC,73090,HCPCS,Outpatient,,,542.52,325.51,,20.49,100,,5.864,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.688,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.464,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.464,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,48.712,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.792,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.816,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,406.89,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,271.26,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,271.26,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,52.632,Case Rate,Pays based on per visit rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.792,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,542.52,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,542.52,
DX FOREARM 2V LT PORT,49065118,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,TC   ,20.49,100,,226.528,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.704,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.232,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.232,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.232,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.032,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.384,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.392,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,839.576,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,1351.608,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,1351.608,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,357.496,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,595.08,Case Rate,Pays based on per visit rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V LT PORT,49065118,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,TC   ,20.49,100,,362.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,15.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.752,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,19.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,19.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,19.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.536,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.336,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.344,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.608,Case Rate,Pays based on per visit rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V RT,49065119,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,,20.49,100,,367.272,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,15.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,125.912,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,19.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,19.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,19.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.76,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.144,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,1351.608,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,6358.296,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.424,Case Rate,Pays based on per visit rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V RT,49065119,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,,20.49,100,,60.256,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,18.92,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,126.528,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,24.328,Fee Schedule,360% of BCBS POS Rate,287.32,360,,24.328,Fee schedule,360% of BCBS PPO Rate,287.32,360,,24.328,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.112,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.248,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.256,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.616,Case Rate,Pays based on per visit rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V RT PORT,49065120,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,TC   ,20.49,100,,21.624,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,324.712,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,126.688,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,417.48,Fee Schedule,360% of BCBS POS Rate,287.32,360,,417.48,Fee schedule,360% of BCBS PPO Rate,287.32,360,,417.48,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.096,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,206.784,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.528,Case Rate,Pays based on per visit rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,275.712,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX FOREARM 2V RT PORT,49065120,CDM,320,RC,73090,HCPCS,Outpatient,,,361.68,217.01,TC   ,20.49,100,,17.32,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.888,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,126.736,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.144,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.144,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.144,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.424,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.104,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,271.26,75,,206.784,Percent of Total Billed Charges,75% of Total Billed Charges,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.84,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,180.84,50,,5148.272,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.768,Case Rate,Pays based on per visit rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,361.68,100,,275.712,Percent of Total Billed Charges,100% of Total Billed Charges,20.49,361.68,
DX HAND 2V BI PORT,49065124,CDM,320,RC,73120,HCPCS,Outpatient,,,534.9,320.94,,22.16,100,,27.904,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.008,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,127.808,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.008,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.008,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.008,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.512,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,401.18,75,,284.648,Percent of Total Billed Charges,75% of Total Billed Charges,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,267.45,50,,7722.4,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.712,Case Rate,Pays based on per visit rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,534.9,100,,379.528,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,534.9,
DX HAND 2V BI PORT,49065124,CDM,320,RC,73120,HCPCS,Outpatient,,,534.9,320.94,,22.16,100,,120.64,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.608,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,127.896,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.496,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.496,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.496,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.144,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,401.18,75,,284.648,Percent of Total Billed Charges,75% of Total Billed Charges,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,267.45,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.456,Case Rate,Pays based on per visit rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,534.9,100,,379.528,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,534.9,
DX HAND 2V LT PORT,49065125,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,,22.16,100,,66.584,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.208,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,127.968,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,7.984,Fee Schedule,360% of BCBS POS Rate,403.49,360,,7.984,Fee schedule,360% of BCBS PPO Rate,403.49,360,,7.984,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.92,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.248,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.256,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,226.24,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.368,Case Rate,Pays based on per visit rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,301.648,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V LT PORT,49065125,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,,22.16,100,,5.608,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1280,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.76,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.76,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.76,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.368,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.768,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.792,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,226.24,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.632,Case Rate,Pays based on per visit rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,301.648,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V RT,49065126,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,TC   ,22.16,100,,8.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.88,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1280,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.136,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.136,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.136,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.584,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,280.2,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.752,Case Rate,Pays based on per visit rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,373.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V RT,49065126,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,TC   ,22.16,100,,776.616,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.912,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1292.584,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,7.6,Fee Schedule,360% of BCBS POS Rate,403.49,360,,7.6,Fee schedule,360% of BCBS PPO Rate,403.49,360,,7.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.544,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,280.2,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,839.576,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.688,Case Rate,Pays based on per visit rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,373.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V RT PORT,49065127,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,,22.16,100,,33.544,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.672,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1292.64,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.864,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.864,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.864,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,3.2,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,124.24,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.704,Case Rate,Pays based on per visit rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,165.656,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND 2V RT PORT,49065127,CDM,320,RC,73120,HCPCS,Outpatient,,,334,200.40,,22.16,100,,26.432,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.696,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1294.592,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,3.464,Fee Schedule,360% of BCBS POS Rate,403.49,360,,3.464,Fee schedule,360% of BCBS PPO Rate,403.49,360,,3.464,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4.576,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,124.24,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,1351.608,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.544,Case Rate,Pays based on per visit rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,165.656,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,403.49,
DX HAND MIN 3V BI PORT,49065128,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,TC   ,26.82,100,,44.152,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.024,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1297.92,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.16,Fee Schedule,103% of Cigna fee schedule,37.09,100,,11.368,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,11.704,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,232.432,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.032,Case Rate,Pays based on per visit rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,11.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,309.912,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V BI PORT,49065128,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,TC   ,26.82,100,,78.432,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.288,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1300.952,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.312,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.944,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.968,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,232.432,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,123.504,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,123.504,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,261.928,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.552,Case Rate,Pays based on per visit rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,309.912,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V BI PORT,49065128,CDM,320,RC,73130,HCPCS,Outpatient,,,570.54,342.32,TC   ,26.82,100,,205.2,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1305.216,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.016,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,25.816,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.592,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.608,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,427.91,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,666.904,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,285.27,50,,666.904,Percent of Total Billed Charges,50% of Total Billed Charges,285.27,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.848,Case Rate,Pays based on per visit rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,570.54,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,570.54,
DX HAND MIN 3V LT PORT,49065129,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,38.216,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.24,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1308.696,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.592,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.088,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.408,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.424,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,123.504,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,5582.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,5582.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.4,Case Rate,Pays based on per visit rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V LT PORT,49065129,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,56.104,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1324.544,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.328,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.328,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.328,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.704,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,666.904,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.352,Case Rate,Pays based on per visit rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V LT PORT,49065129,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,38.216,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.176,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1325.44,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.8,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.8,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.8,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.496,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,5582.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.064,Case Rate,Pays based on per visit rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT,49065130,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,55.144,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.952,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1331.12,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.224,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.224,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.224,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.664,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT,49065130,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,30.72,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,42.376,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1331.2,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,54.48,Fee Schedule,360% of BCBS POS Rate,287.32,360,,54.48,Fee schedule,360% of BCBS PPO Rate,287.32,360,,54.48,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.712,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.12,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,160.192,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.72,Case Rate,Pays based on per visit rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,213.592,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT,49065130,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,,26.82,100,,14.4,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1331.2,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.656,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.656,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.032,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.12,Case Rate,Pays based on per visit rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT PORT,49065131,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,13.768,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.552,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1337.856,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.856,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.856,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.856,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.376,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.224,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.304,Case Rate,Pays based on per visit rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT PORT,49065131,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,8.672,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1345.792,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.24,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,263.704,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.64,Case Rate,Pays based on per visit rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,351.6,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HAND MIN 3V RT PORT,49065131,CDM,320,RC,73130,HCPCS,Outpatient,,,380.36,228.22,TC   ,26.82,100,,3785.96,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.136,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1363.816,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.576,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.144,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,285.27,75,,263.704,Percent of Total Billed Charges,75% of Total Billed Charges,190.18,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.18,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,190.18,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,33.544,Case Rate,Pays based on per visit rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,380.36,100,,351.6,Percent of Total Billed Charges,100% of Total Billed Charges,26.82,380.36,
DX HIP WWO PEL 1V LT PORT,49065132,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,362.888,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.072,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1363.816,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.096,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.096,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.096,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.072,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.128,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.128,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,71.616,Case Rate,Pays based on per visit rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V LT PORT,49065132,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,36.48,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.048,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1363.816,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.92,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.92,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.92,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.104,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.744,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,64.96,Case Rate,Pays based on per visit rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.744,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT,49065133,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,TC   ,22.16,100,,15.776,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.84,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1366.744,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.08,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.08,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.08,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,15.648,Fee Schedule,103% of Cigna fee schedule,33.08,100,,1.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,1.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,123.504,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.088,Case Rate,Pays based on per visit rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,1.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT,49065133,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,TC   ,22.16,100,,106.632,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,14.784,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1366.744,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,19.008,Fee Schedule,360% of BCBS POS Rate,287.32,360,,19.008,Fee schedule,360% of BCBS PPO Rate,287.32,360,,19.008,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.304,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.272,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.28,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,2505.544,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,2505.544,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,666.904,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.872,Case Rate,Pays based on per visit rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT PORT,49065134,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.808,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1367.144,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,19.456,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.304,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.312,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,5582.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.72,Case Rate,Pays based on per visit rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HIP WWO PEL 1V RT PORT,49065134,CDM,320,RC,73501,HCPCS,Outpatient,,,250,150.00,,22.16,100,,573.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1367.144,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.096,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.096,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.096,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.512,Fee Schedule,103% of Cigna fee schedule,33.08,100,,6.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,6.208,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,175.8,Percent of Total Billed Charges,75% of Total Billed Charges,125,50,,2505.544,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,125,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,125,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.76,Case Rate,Pays based on per visit rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,6.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,234.4,Percent of Total Billed Charges,100% of Total Billed Charges,22.16,300,
DX HUMERUS MIN 2V BI PORT,49065142,CDM,320,RC,73060,HCPCS,Outpatient,,,539.17,323.50,TC   ,23.15,100,,302.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.112,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1367.808,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.144,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.144,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.144,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.168,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,404.38,75,,343.552,Percent of Total Billed Charges,75% of Total Billed Charges,269.59,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,1411.376,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,269.59,50,,1411.376,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,8240,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.44,Case Rate,Pays based on per visit rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,539.17,100,,458.072,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,539.17,
DX HUMERUS MIN 2V BI PORT,49065142,CDM,320,RC,73060,HCPCS,Outpatient,,,539.17,323.50,TC   ,23.15,100,,5052.232,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.264,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1375.4,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.336,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.336,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.304,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,404.38,75,,343.552,Percent of Total Billed Charges,75% of Total Billed Charges,269.59,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,269.59,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,269.59,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.104,Case Rate,Pays based on per visit rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,539.17,100,,458.072,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,539.17,
DX HUMERUS MIN 2V LT PORT,49065143,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,,23.15,100,,41.048,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1380.248,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.04,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.144,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.12,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.12,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,1411.376,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,1021.264,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,1021.264,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,627.096,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V LT PORT,49065143,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,,23.15,100,,34.336,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1381.12,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.144,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.4,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.552,Case Rate,Pays based on per visit rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V RT,49065144,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,TC   ,23.15,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.104,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1390.056,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.984,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.984,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.984,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.144,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.168,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,1021.264,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,649.304,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,38.952,Case Rate,Pays based on per visit rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V RT,49065144,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,TC   ,23.15,100,,3558.168,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.552,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1392.232,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.144,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.704,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.728,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,37.192,Case Rate,Pays based on per visit rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V RT PORT,49065145,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,,23.15,100,,1022.152,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.448,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1416.4,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.712,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.712,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.712,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.568,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.32,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.328,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,32.904,Case Rate,Pays based on per visit rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX HUMERUS MIN 2V RT PORT,49065145,CDM,320,RC,73060,HCPCS,Outpatient,,,359.45,215.67,,23.15,100,,1311.808,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,22.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1417.672,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,28.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,28.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,28.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,46.016,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,269.59,75,,229.04,Percent of Total Billed Charges,75% of Total Billed Charges,179.73,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,179.73,50,,528,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,26.704,Case Rate,Pays based on per visit rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,359.45,100,,305.384,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,359.45,
DX INJ ARTHRO HIP WO ANES BI,49065146,CDM,361,RC,,,Outpatient,,,1319.71,791.83,,791.83,60,,1284.28,Percent of Total Billed Charges,60% of Total Billed Charges,593.87,45,,475.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.52,28,,3.536,Percent of Total Billed Charges,28% of Total Billed Charges,8044.35,32,,1417.728,Percent of Total Billed Charges,32% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,475.1,36,,4.552,Percent of Total Billed Charges,36% of Total Billed Charges,475.1,36,,4.552,Percent of Total Billed Charges,36% Total Bille Charges,475.1,36,,4.552,Percent of Total Billed Charges,36% of Total Billed Charges,791.83,60,,9.488,Percent of Total Billed Charges,60% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1319.71,100,,1055.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,190.3,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,989.78,75,,115.912,Percent of Total Billed Charges,75% of Total Billed Charges,659.86,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,659.86,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.86,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,659.86,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,923.8,70,,21.472,Percent of Total Billed Charges,70% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,184.76,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1319.71,100,,154.552,Percent of Total Billed Charges,100% of Total Billed Charges,184.76,8044.35,
DX INJ ARTHRO HIP WO ANES LT,49065147,CDM,361,RC,,,Outpatient,,,879.81,527.89,,527.89,60,,388.088,Percent of Total Billed Charges,60% of Total Billed Charges,395.91,45,,316.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.35,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,8064.5,32,,1427.712,Percent of Total Billed Charges,32% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,316.73,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,316.73,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,316.73,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,527.89,60,,84.184,Percent of Total Billed Charges,60% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,879.81,100,,703.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,126.87,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.86,75,,115.912,Percent of Total Billed Charges,75% of Total Billed Charges,439.91,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,439.91,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.91,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,439.91,50,,1670.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615.87,70,,11.088,Percent of Total Billed Charges,70% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,879.81,100,,154.552,Percent of Total Billed Charges,100% of Total Billed Charges,123.17,8064.5,
DX INJ ARTHRO HIP WO ANES RT,49065148,CDM,361,RC,,,Outpatient,,,879.81,527.89,,527.89,60,,26.824,Percent of Total Billed Charges,60% of Total Billed Charges,395.91,45,,316.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.35,28,,9.584,Percent of Total Billed Charges,28% of Total Billed Charges,8139.84,32,,1435.736,Percent of Total Billed Charges,32% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,316.73,36,,12.328,Percent of Total Billed Charges,36% of Total Billed Charges,316.73,36,,12.328,Percent of Total Billed Charges,36% Total Bille Charges,316.73,36,,12.328,Percent of Total Billed Charges,36% of Total Billed Charges,527.89,60,,40.536,Percent of Total Billed Charges,60% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,879.81,100,,703.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,126.87,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.86,75,,211.896,Percent of Total Billed Charges,75% of Total Billed Charges,439.91,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,439.91,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.91,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,439.91,50,,2505.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615.87,70,,26.88,Percent of Total Billed Charges,70% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,123.17,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,879.81,100,,282.528,Percent of Total Billed Charges,100% of Total Billed Charges,123.17,8139.84,
DX INJ ARTHROGRAM ELBOW LT,49065153,CDM,361,RC,,,Outpatient,,,663.35,398.01,,398.01,60,,14.832,Percent of Total Billed Charges,60% of Total Billed Charges,298.51,45,,238.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.74,28,,15.264,Percent of Total Billed Charges,28% of Total Billed Charges,8144.64,32,,1435.736,Percent of Total Billed Charges,32% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,238.81,36,,19.624,Percent of Total Billed Charges,36% of Total Billed Charges,238.81,36,,19.624,Percent of Total Billed Charges,36% Total Bille Charges,238.81,36,,19.624,Percent of Total Billed Charges,36% of Total Billed Charges,398.01,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.35,100,,530.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,95.66,14.42,,3.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.51,75,,211.896,Percent of Total Billed Charges,75% of Total Billed Charges,331.68,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,331.68,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.68,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,331.68,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,464.35,70,,0.92,Percent of Total Billed Charges,70% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,92.87,14,,3.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,663.35,100,,282.528,Percent of Total Billed Charges,100% of Total Billed Charges,92.87,8144.64,
DX INJ ARTHROGRAM SHOULDER LT,49065159,CDM,361,RC,,,Outpatient,,,743.34,446.00,,446,60,,31.392,Percent of Total Billed Charges,60% of Total Billed Charges,334.5,45,,267.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.14,28,,40.096,Percent of Total Billed Charges,28% of Total Billed Charges,8267.33,32,,1439.216,Percent of Total Billed Charges,32% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,267.6,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,267.6,36,,51.552,Percent of Total Billed Charges,36% Total Bille Charges,267.6,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,446,60,,7.368,Percent of Total Billed Charges,60% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,743.34,100,,594.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,107.19,14.42,,0.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,557.51,75,,343.704,Percent of Total Billed Charges,75% of Total Billed Charges,371.67,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,371.67,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371.67,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,371.67,50,,940.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.34,70,,248.584,Percent of Total Billed Charges,70% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.34,100,,458.272,Percent of Total Billed Charges,100% of Total Billed Charges,104.07,8267.33,
DX INJ ARTHROGRAM SHOULDER RT,49065160,CDM,361,RC,,,Outpatient,,,743.34,446.00,,446,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,334.5,45,,267.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.14,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,8267.33,32,,1442.816,Percent of Total Billed Charges,32% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,267.6,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,267.6,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,267.6,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,446,60,,7.368,Percent of Total Billed Charges,60% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,743.34,100,,594.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,107.19,14.42,,4.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,557.51,75,,343.704,Percent of Total Billed Charges,75% of Total Billed Charges,371.67,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,371.67,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371.67,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,371.67,50,,1411.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.34,70,,32.472,Percent of Total Billed Charges,70% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,104.07,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,743.34,100,,458.272,Percent of Total Billed Charges,100% of Total Billed Charges,104.07,8267.33,
DX INJ ARTHROGRAM WRIST RT,49065166,CDM,361,RC,,,Outpatient,,,622.5,373.50,,373.5,60,,39.8,Percent of Total Billed Charges,60% of Total Billed Charges,280.13,45,,224.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.3,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,8.03,32,,1451.144,Percent of Total Billed Charges,32% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,224.1,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,224.1,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,373.5,60,,2.432,Percent of Total Billed Charges,60% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.5,100,,498,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,89.76,14.42,,1.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,466.88,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,311.25,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,311.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,311.25,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435.75,70,,277.136,Percent of Total Billed Charges,70% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,87.15,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,622.5,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,8.03,622.5,
DX INJ CYSTOGRAPHY,49065168,CDM,361,RC,,,Outpatient,,,888.1,532.86,,532.86,60,,42.488,Percent of Total Billed Charges,60% of Total Billed Charges,399.65,45,,319.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.67,28,,7.848,Percent of Total Billed Charges,28% of Total Billed Charges,8.06,32,,1460.992,Percent of Total Billed Charges,32% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,319.72,36,,10.096,Percent of Total Billed Charges,36% of Total Billed Charges,319.72,36,,10.096,Percent of Total Billed Charges,36% Total Bille Charges,319.72,36,,10.096,Percent of Total Billed Charges,36% of Total Billed Charges,532.86,60,,132.896,Percent of Total Billed Charges,60% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,888.1,100,,710.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,128.06,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,666.08,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,444.05,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,444.05,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,444.05,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,444.05,50,,1021.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,621.67,70,,0.08,Percent of Total Billed Charges,70% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,124.33,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,888.1,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,8.06,888.1,
DX INJ HYSTEROSALPINGOGRAPHY,49065169,CDM,361,RC,,,Outpatient,,,544.12,326.47,,326.47,60,,37.096,Percent of Total Billed Charges,60% of Total Billed Charges,244.85,45,,195.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.35,28,,6.128,Percent of Total Billed Charges,28% of Total Billed Charges,8.06,32,,1460.992,Percent of Total Billed Charges,32% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,195.88,36,,7.88,Percent of Total Billed Charges,36% of Total Billed Charges,195.88,36,,7.88,Percent of Total Billed Charges,36% Total Bille Charges,195.88,36,,7.88,Percent of Total Billed Charges,36% of Total Billed Charges,326.47,60,,8.28,Percent of Total Billed Charges,60% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,544.12,100,,435.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,78.46,14.42,,1.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.09,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,272.06,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,272.06,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.06,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,272.06,50,,520.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.88,70,,3.032,Percent of Total Billed Charges,70% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,76.18,14,,1.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.12,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,8.06,544.12,
IR INJ URETHROCYSTOGRAPHY,49065170,CDM,361,RC,,,Outpatient,,,948.11,568.87,,568.87,60,,21.512,Percent of Total Billed Charges,60% of Total Billed Charges,426.65,45,,341.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.47,28,,4.856,Percent of Total Billed Charges,28% of Total Billed Charges,8.06,32,,1462.528,Percent of Total Billed Charges,32% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,341.32,36,,6.24,Percent of Total Billed Charges,36% of Total Billed Charges,341.32,36,,6.24,Percent of Total Billed Charges,36% Total Bille Charges,341.32,36,,6.24,Percent of Total Billed Charges,36% of Total Billed Charges,568.87,60,,2.488,Percent of Total Billed Charges,60% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,948.11,100,,758.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.72,14.42,,1.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,711.08,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,474.06,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,474.06,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.06,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,474.06,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,663.68,70,,47.544,Percent of Total Billed Charges,70% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,132.74,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.11,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,8.06,948.11,
DX KNEE 1 OR 2V BI PORT,49065174,CDM,320,RC,73560,HCPCS,Outpatient,,,505.31,303.19,TC   ,25.16,100,,6078.304,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.624,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1463.296,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.232,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.232,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.232,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,8.272,Fee Schedule,103% of Cigna fee schedule,34.41,100,,1.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,1.232,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378.98,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,252.66,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.66,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.968,Case Rate,Pays based on per visit rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,505.31,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,505.31,
DX KNEE 1 OR 2V BI PORT,49065174,CDM,320,RC,73560,HCPCS,Outpatient,,,505.31,303.19,TC   ,25.16,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.36,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1477.504,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.752,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.752,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.752,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.08,Fee Schedule,103% of Cigna fee schedule,34.41,100,,1.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,1.232,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,378.98,75,,229.144,Percent of Total Billed Charges,75% of Total Billed Charges,252.66,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.66,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,252.66,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,109.472,Case Rate,Pays based on per visit rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,505.31,100,,305.52,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,505.31,
DX KNEE 1 OR 2V LT PORT,49065175,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1479.248,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.944,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.944,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.944,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.152,Fee Schedule,103% of Cigna fee schedule,34.41,100,,1.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,1.232,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,69.744,Case Rate,Pays based on per visit rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,1.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V LT PORT,49065175,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,8.424,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.784,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1481.76,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.296,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.296,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.296,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.272,Fee Schedule,103% of Cigna fee schedule,34.41,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,0.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.368,Case Rate,Pays based on per visit rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V RT,49065176,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,TC   ,25.16,100,,5.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.056,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1481.76,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.928,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.928,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.928,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.248,Fee Schedule,103% of Cigna fee schedule,34.41,100,,10.736,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,11.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,212.416,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,424,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,424,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,10.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,283.224,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V RT,49065176,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,TC   ,25.16,100,,183.6,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.968,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1482.224,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.104,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.104,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.104,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.352,Fee Schedule,103% of Cigna fee schedule,34.41,100,,2.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,2.28,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,212.416,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.792,Case Rate,Pays based on per visit rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,283.224,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V RT PORT,49065177,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,5.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.8,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1497.6,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.888,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.888,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.888,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,48.432,Fee Schedule,103% of Cigna fee schedule,34.41,100,,19.64,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,20.232,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,424,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.032,Case Rate,Pays based on per visit rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,19.64,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 1 OR 2V RT PORT,49065177,CDM,320,RC,73560,HCPCS,Outpatient,,,336.87,202.12,,25.16,100,,168.736,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,24.008,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1504.952,Fee Schedule,320% of BCBS Blue Essentials Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,30.864,Fee Schedule,360% of BCBS POS Rate,287.32,360,,30.864,Fee schedule,360% of BCBS PPO Rate,287.32,360,,30.864,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.328,Fee Schedule,103% of Cigna fee schedule,34.41,100,,9.456,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,35.44,103,,9.744,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,252.65,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,168.44,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.44,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,168.44,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.712,Case Rate,Pays based on per visit rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,34.41,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,336.87,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,25.16,336.87,
DX KNEE 3V BI,49065178,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,TC   ,30.14,100,,168.752,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,17.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1508.352,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,22.424,Fee Schedule,360% of BCBS POS Rate,287.32,360,,22.424,Fee schedule,360% of BCBS PPO Rate,287.32,360,,22.424,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,607.16,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.536,Case Rate,Pays based on per visit rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V BI,49065178,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,TC   ,30.14,100,,121.304,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,357.272,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1509.824,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,459.344,Fee Schedule,360% of BCBS POS Rate,287.32,360,,459.344,Fee schedule,360% of BCBS PPO Rate,287.32,360,,459.344,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.936,Fee Schedule,103% of Cigna fee schedule,40.76,100,,1.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,1.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.92,Case Rate,Pays based on per visit rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V BI,49065178,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,TC   ,30.14,100,,114.448,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,36.696,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.288,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,47.184,Fee Schedule,360% of BCBS POS Rate,287.32,360,,47.184,Fee schedule,360% of BCBS PPO Rate,287.32,360,,47.184,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.048,Fee Schedule,103% of Cigna fee schedule,40.76,100,,1.72,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,1.768,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,1086.088,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,1086.088,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.72,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V BI PORT,49065179,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,,30.14,100,,106.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,110.888,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.296,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,142.576,Fee Schedule,360% of BCBS POS Rate,287.32,360,,142.576,Fee schedule,360% of BCBS PPO Rate,287.32,360,,142.576,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.152,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.568,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.584,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,141.616,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,1629,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,1629,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.6,Case Rate,Pays based on per visit rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,188.816,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V BI PORT,49065179,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,,30.14,100,,4321.488,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.296,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.216,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.216,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.88,Fee Schedule,103% of Cigna fee schedule,40.76,100,,31.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,31.936,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,1086.088,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,146.52,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.152,Case Rate,Pays based on per visit rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,31.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V BI PORT,49065179,CDM,320,RC,73562,HCPCS,Outpatient,,,594.26,356.56,,30.14,100,,269.072,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,37.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.304,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,48.68,Fee Schedule,360% of BCBS POS Rate,287.32,360,,48.68,Fee schedule,360% of BCBS PPO Rate,287.32,360,,48.68,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.936,Fee Schedule,103% of Cigna fee schedule,40.76,100,,1.936,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,1.992,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,445.7,75,,206.4,Percent of Total Billed Charges,75% of Total Billed Charges,297.13,50,,1629,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,297.13,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,297.13,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,21.344,Case Rate,Pays based on per visit rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,594.26,100,,275.2,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,594.26,
DX KNEE 3V LT,49065180,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,599.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.416,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.32,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.672,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.672,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.672,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.616,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.584,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.6,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.048,Case Rate,Pays based on per visit rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V LT,49065180,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,23.536,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.328,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.616,Fee Schedule,103% of Cigna fee schedule,40.76,100,,1.928,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,1.984,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,238.824,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.68,Case Rate,Pays based on per visit rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,1.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,318.432,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V LT,49065180,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,328.712,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.768,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.328,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.696,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.696,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.696,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.176,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,302.304,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,58.76,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.128,Case Rate,Pays based on per visit rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,403.072,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V LT PORT,49065181,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,16.888,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,504,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.328,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,648,Fee Schedule,360% of BCBS POS Rate,287.32,360,,648,Fee schedule,360% of BCBS PPO Rate,287.32,360,,648,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.272,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,302.304,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,424,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,403.072,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V LT PORT,49065181,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,40.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,435.456,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.328,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,559.872,Fee Schedule,360% of BCBS POS Rate,287.32,360,,559.872,Fee schedule,360% of BCBS PPO Rate,287.32,360,,559.872,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.376,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.064,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,79.384,Case Rate,Pays based on per visit rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V LT PORT,49065181,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,102.272,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.496,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.336,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,10.928,Fee Schedule,360% of BCBS POS Rate,287.32,360,,10.928,Fee schedule,360% of BCBS PPO Rate,287.32,360,,10.928,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.4,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.752,Case Rate,Pays based on per visit rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT,49065182,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,3.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,90.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.336,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,116.032,Fee Schedule,360% of BCBS POS Rate,287.32,360,,116.032,Fee schedule,360% of BCBS PPO Rate,287.32,360,,116.032,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.592,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.312,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.328,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT,49065182,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,18.432,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.344,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.616,Fee Schedule,103% of Cigna fee schedule,40.76,100,,11.304,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,11.64,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.008,Case Rate,Pays based on per visit rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,11.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT,49065182,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,TC   ,30.14,100,,264,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,317.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.344,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,408.232,Fee Schedule,360% of BCBS POS Rate,287.32,360,,408.232,Fee schedule,360% of BCBS PPO Rate,287.32,360,,408.232,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.312,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.32,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,863.08,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,200.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.536,Case Rate,Pays based on per visit rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.312,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,1150.776,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT PORT,49065183,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,23.816,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,84.672,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.352,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,108.864,Fee Schedule,360% of BCBS POS Rate,287.32,360,,108.864,Fee schedule,360% of BCBS PPO Rate,287.32,360,,108.864,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.056,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,360.896,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,1086.088,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.672,Case Rate,Pays based on per visit rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,481.192,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT PORT,49065183,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,62.096,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.376,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,79.832,Fee Schedule,360% of BCBS POS Rate,287.32,360,,79.832,Fee schedule,360% of BCBS PPO Rate,287.32,360,,79.832,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.52,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.224,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,594.184,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,1629,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.824,Case Rate,Pays based on per visit rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,792.24,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE 3V RT PORT,49065183,CDM,320,RC,73562,HCPCS,Outpatient,,,396.18,237.71,,30.14,100,,16.4,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,24.376,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.384,Fee Schedule,320% of BCBS Blue Essentials Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,31.336,Fee Schedule,360% of BCBS POS Rate,287.32,360,,31.336,Fee schedule,360% of BCBS PPO Rate,287.32,360,,31.336,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.528,Fee Schedule,103% of Cigna fee schedule,40.76,100,,0.248,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,41.98,103,,0.256,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,297.14,75,,594.184,Percent of Total Billed Charges,75% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,198.09,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.128,Case Rate,Pays based on per visit rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,40.76,100,,0.248,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,396.18,100,,792.24,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,396.18,
DX KNEE MIN 4V RT,49065184,CDM,320,RC,73564,HCPCS,Outpatient,,,463.84,278.30,,33.81,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,14.16,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.408,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,18.208,Fee Schedule,360% of BCBS POS Rate,403.49,360,,18.208,Fee schedule,360% of BCBS PPO Rate,403.49,360,,18.208,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.04,Fee Schedule,103% of Cigna fee schedule,46.78,100,,0.272,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,0.28,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,347.88,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,231.92,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.92,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.904,Case Rate,Pays based on per visit rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,463.84,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,463.84,
DX KNEE MIN 4V RT,49065184,CDM,320,RC,73564,HCPCS,Outpatient,,,463.84,278.30,,33.81,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,19.08,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.416,Fee Schedule,320% of BCBS Blue Essentials Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,24.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,24.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,24.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,8.352,Fee Schedule,103% of Cigna fee schedule,46.78,100,,0.672,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,48.18,103,,0.696,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,347.88,75,,138.712,Percent of Total Billed Charges,75% of Total Billed Charges,231.92,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.92,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,231.92,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.28,Case Rate,Pays based on per visit rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,46.78,100,,0.672,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,463.84,100,,184.952,Percent of Total Billed Charges,100% of Total Billed Charges,33.81,463.84,
DX KNEE STANDING AP BI,49065185,CDM,320,RC,73565,HCPCS,Outpatient,,,354.1,212.46,,31.14,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.888,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.416,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.568,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.568,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.568,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.472,Fee Schedule,103% of Cigna fee schedule,40.1,100,,0.688,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,0.704,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.58,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,177.05,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,177.05,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.05,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,177.05,50,,173.872,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,38.104,Case Rate,Pays based on per visit rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.688,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.1,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,31.14,354.1,
DX KNEE STANDING AP BI,49065185,CDM,320,RC,73565,HCPCS,Outpatient,,,354.1,212.46,,31.14,100,,13.808,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,21.064,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.424,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,27.08,Fee Schedule,360% of BCBS POS Rate,287.32,360,,27.08,Fee schedule,360% of BCBS PPO Rate,287.32,360,,27.08,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.112,Fee Schedule,103% of Cigna fee schedule,40.1,100,,0.376,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,0.392,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.58,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,177.05,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,177.05,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.05,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,177.05,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,38.104,Case Rate,Pays based on per visit rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.1,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,31.14,354.1,
DX LSPINE 1V,49065186,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,13.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,25.48,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.432,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,32.76,Fee Schedule,360% of BCBS POS Rate,287.32,360,,32.76,Fee schedule,360% of BCBS PPO Rate,287.32,360,,32.76,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.512,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.376,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.392,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,47.312,Case Rate,Pays based on per visit rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.376,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX LSPINE 1V,49065186,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,TC   ,16.16,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.44,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.048,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,811.768,Case Rate,Pays based on per visit rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX LSPINE 1V PORT,49065187,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,20,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,16.248,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.464,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,20.888,Fee Schedule,360% of BCBS POS Rate,287.32,360,,20.888,Fee schedule,360% of BCBS PPO Rate,287.32,360,,20.888,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.072,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.064,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,153.848,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.216,Case Rate,Pays based on per visit rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX LSPINE 1V PORT,49065187,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,16.616,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,95.392,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.496,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,122.648,Fee Schedule,360% of BCBS POS Rate,287.32,360,,122.648,Fee schedule,360% of BCBS PPO Rate,287.32,360,,122.648,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,92.48,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.024,Case Rate,Pays based on per visit rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,123.304,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX LSPINE 2 OR 3V PORT,49065188,CDM,320,RC,72100,HCPCS,Outpatient,,,450.99,270.59,TC   ,27.81,100,,16.688,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.496,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,8.216,Fee Schedule,103% of Cigna fee schedule,40.1,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,338.24,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,225.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225.5,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,198.2,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.52,Case Rate,Pays based on per visit rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450.99,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,27.81,450.99,
DX LSPINE 2 OR 3V PORT,49065188,CDM,320,RC,72100,HCPCS,Outpatient,,,450.99,270.59,TC   ,27.81,100,,13.24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.136,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.496,Fee Schedule,320% of BCBS Blue Essentials Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.608,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.608,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.608,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,8.216,Fee Schedule,103% of Cigna fee schedule,40.1,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,41.3,103,,0.144,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,338.24,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,225.5,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225.5,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,225.5,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.52,Case Rate,Pays based on per visit rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,40.1,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450.99,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,27.81,450.99,
DX LUMBAR PUNCTURE CHEMO,49065189,CDM,331,RC,96450,HCPCS,Outpatient,,,1196.5,717.90,,44.79,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,466.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.07,280,,16.248,Fee Schedule,280% of BCBS BULE Fee Schedule,261.79,320,,1.52,Fee Schedule,320% of BCBS Blue Essentials Rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,294.52,360,,20.888,Fee Schedule,360% of BCBS POS Rate,294.52,360,,20.888,Fee schedule,360% of BCBS PPO Rate,294.52,360,,20.888,Fee Schedule,360% of BCBS Traditional Rate,674,100,,0.68,Case Rate,Pays based on per visit rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,279.64,90,,,Fee Schedule,90% of CMS OPPS Rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,403.92,130,,,Fee Schedule,130% of CMS OPPS Rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,172.54,14.42,,0.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,320.02,103,,,Fee Schedule,103% of CMS OPPS Rate,897.38,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,598.25,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,598.25,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,598.25,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,466.07,150,,,Fee Schedule,150% of CMS OPPS Rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,1.48,Case Rate,Pays based on per visit rate,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,167.51,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.5,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,44.79,1196.5,
DX LUMBAR PUNCTURE W/FLUOROSCOPIC GUIDANCE,49065190,CDM,361,RC,62328,HCPCS,Outpatient,,,1095.1,657.06,,75.08,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,95.76,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.08,32,,1.528,Percent of Total Billed Charges,32% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,123.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,123.12,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,123.12,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,2.136,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,148.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,8.08,2456,
DX LWR EXT INF MIN 2V BI PORT,49065191,CDM,320,RC,73592,HCPCS,Outpatient,,,231.19,138.71,TC   ,22.82,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,31.424,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,1.528,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,40.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,40.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,40.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.992,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,161.176,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.208,Case Rate,Pays based on per visit rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V BI PORT,49065191,CDM,320,RC,73592,HCPCS,Outpatient,,,231.19,138.71,TC   ,22.82,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12925.184,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.008,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.592,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.608,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,207.088,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.776,Case Rate,Pays based on per visit rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,276.112,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V LT PORT,49065192,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,191.52,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,246.24,Fee Schedule,360% of BCBS POS Rate,287.32,360,,246.24,Fee schedule,360% of BCBS PPO Rate,287.32,360,,246.24,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.52,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.12,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.128,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,175.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.68,Case Rate,Pays based on per visit rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.12,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V LT PORT,49065192,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.648,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,4.696,Fee Schedule,360% of BCBS POS Rate,287.32,360,,4.696,Fee schedule,360% of BCBS PPO Rate,287.32,360,,4.696,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.808,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.744,Case Rate,Pays based on per visit rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V RT,49065193,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,24.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.944,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.64,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.64,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.64,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.8,Fee Schedule,103% of Cigna fee schedule,80.9,100,,1.952,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,2.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.072,Case Rate,Pays based on per visit rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V RT,49065193,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,72.688,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,33.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,43.536,Fee Schedule,360% of BCBS POS Rate,287.32,360,,43.536,Fee schedule,360% of BCBS PPO Rate,287.32,360,,43.536,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.976,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.112,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,49.864,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,49.864,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.72,Case Rate,Pays based on per visit rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V RT PORT,49065194,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.84,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,6.216,Fee Schedule,360% of BCBS POS Rate,287.32,360,,6.216,Fee schedule,360% of BCBS PPO Rate,287.32,360,,6.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.728,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.752,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,204.76,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,204.76,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX LWR EXT INF MIN 2V RT PORT,49065194,CDM,320,RC,73592,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.672,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.44,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.44,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.44,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.352,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.352,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.36,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,49.864,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,122.104,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,122.104,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.592,Case Rate,Pays based on per visit rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX PEL 1 OR 2V PORT,49065197,CDM,320,RC,72170,HCPCS,Outpatient,,,344.64,206.78,,18.5,100,,24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,54.376,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,69.912,Fee Schedule,360% of BCBS POS Rate,403.49,360,,69.912,Fee schedule,360% of BCBS PPO Rate,403.49,360,,69.912,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,31.616,Fee Schedule,103% of Cigna fee schedule,28.06,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.9,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,258.48,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,172.32,50,,204.76,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,172.32,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.104,Case Rate,Pays based on per visit rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,344.64,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,403.49,
DX PEL 1 OR 2V PORT,49065197,CDM,320,RC,72170,HCPCS,Outpatient,,,344.64,206.78,,18.5,100,,24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,11.76,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,15.12,Fee Schedule,360% of BCBS POS Rate,403.49,360,,15.12,Fee schedule,360% of BCBS PPO Rate,403.49,360,,15.12,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.008,Fee Schedule,103% of Cigna fee schedule,28.06,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.9,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,258.48,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,172.32,50,,122.104,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,172.32,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,172.32,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.584,Case Rate,Pays based on per visit rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,28.06,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,344.64,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,18.5,403.49,
DX PEL MIN 3V,49065198,CDM,320,RC,72190,HCPCS,Outpatient,,,474.41,284.65,TC   ,28.47,100,,24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,471.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,606.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,606.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,606.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.6,Fee Schedule,103% of Cigna fee schedule,42.44,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,355.81,75,,341.504,Percent of Total Billed Charges,75% of Total Billed Charges,237.21,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,237.21,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,237.21,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,237.21,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.44,Case Rate,Pays based on per visit rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,474.41,100,,455.336,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,474.41,
DX PEL MIN 3V,49065198,CDM,320,RC,72190,HCPCS,Outpatient,,,474.41,284.65,TC   ,28.47,100,,24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,10.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,13.112,Fee Schedule,360% of BCBS POS Rate,403.49,360,,13.112,Fee schedule,360% of BCBS PPO Rate,403.49,360,,13.112,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.696,Fee Schedule,103% of Cigna fee schedule,42.44,100,,1.92,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,1.976,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,355.81,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,237.21,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,237.21,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,237.21,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,237.21,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.384,Case Rate,Pays based on per visit rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,474.41,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,28.47,474.41,
DX RIBS 2V RT,49065200,CDM,320,RC,71100,HCPCS,Outpatient,,,377.06,226.24,,24.81,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,17.968,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,23.104,Fee Schedule,360% of BCBS POS Rate,287.32,360,,23.104,Fee schedule,360% of BCBS PPO Rate,287.32,360,,23.104,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.704,Fee Schedule,103% of Cigna fee schedule,37.09,100,,1.92,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,1.976,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,282.8,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,188.53,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,188.53,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,105.936,Case Rate,Pays based on per visit rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,1.92,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,377.06,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,377.06,
DX RIBS 2V RT,49065200,CDM,320,RC,71100,HCPCS,Outpatient,,,377.06,226.24,,24.81,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.712,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.208,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.208,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.208,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,53.864,Fee Schedule,103% of Cigna fee schedule,37.09,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,38.2,103,,0.16,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,282.8,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,188.53,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,188.53,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,188.53,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.28,Case Rate,Pays based on per visit rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,37.09,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,377.06,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,377.06,
DX RIBS MIN 3V W PA CHEST RT,49065201,CDM,320,RC,71101,HCPCS,Outpatient,,,467,280.20,TC   ,28.14,100,,9.792,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.648,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.696,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.696,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.696,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4.744,Fee Schedule,103% of Cigna fee schedule,42.44,100,,0.496,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,0.512,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,350.25,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,233.5,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.384,Case Rate,Pays based on per visit rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.496,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,467,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,467,
DX RIBS MIN 3V W PA CHEST RT,49065201,CDM,320,RC,71101,HCPCS,Outpatient,,,467,280.20,TC   ,28.14,100,,10.112,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,67.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,86.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,86.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,86.4,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4,Fee Schedule,103% of Cigna fee schedule,42.44,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,43.71,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,350.25,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,233.5,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,233.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.288,Case Rate,Pays based on per visit rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,42.44,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,467,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,28.14,467,
DX SACROILIAC JTS 2V,49065202,CDM,320,RC,72200,HCPCS,Outpatient,,,207.07,124.24,,23.82,100,,15.032,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,10.92,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,14.04,Fee Schedule,360% of BCBS POS Rate,403.49,360,,14.04,Fee schedule,360% of BCBS PPO Rate,403.49,360,,14.04,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,87.408,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,155.3,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,103.54,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.54,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.84,Case Rate,Pays based on per visit rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,207.07,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,23.82,403.49,
DX SACROILIAC JTS 2V,49065202,CDM,320,RC,72200,HCPCS,Outpatient,,,207.07,124.24,,23.82,100,,24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,20.376,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,26.2,Fee Schedule,360% of BCBS POS Rate,403.49,360,,26.2,Fee schedule,360% of BCBS PPO Rate,403.49,360,,26.2,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.768,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.352,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.368,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,155.3,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,103.54,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.54,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,103.54,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.176,Case Rate,Pays based on per visit rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,207.07,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,23.82,403.49,
DX SACRUM COCCYX MIN 2V PORT,49065203,CDM,320,RC,72220,HCPCS,Outpatient,,,387.39,232.43,,22.82,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,82.576,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,106.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,106.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,106.176,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,11.384,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.192,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.192,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.54,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,49.864,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.616,Case Rate,Pays based on per visit rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.192,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.39,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,387.39,
DX SACRUM COCCYX MIN 2V PORT,49065203,CDM,320,RC,72220,HCPCS,Outpatient,,,387.39,232.43,,22.82,100,,264,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.848,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.848,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.848,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.224,Fee Schedule,103% of Cigna fee schedule,32.75,100,,0.656,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,33.73,103,,0.672,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,290.54,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.7,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,193.7,50,,204.76,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.104,Case Rate,Pays based on per visit rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,32.75,100,,0.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,387.39,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,387.39,
DX SCAPULA COMPL LT PORT,49065205,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,83.24,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,37.296,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,47.952,Fee Schedule,360% of BCBS POS Rate,403.49,360,,47.952,Fee schedule,360% of BCBS PPO Rate,403.49,360,,47.952,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2.24,Fee Schedule,103% of Cigna fee schedule,23.73,100,,0.464,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,0.472,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,122.104,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,36.96,Case Rate,Pays based on per visit rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL LT PORT,49065205,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,52.288,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,39.536,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,50.832,Fee Schedule,360% of BCBS POS Rate,403.49,360,,50.832,Fee schedule,360% of BCBS PPO Rate,403.49,360,,50.832,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.408,Fee Schedule,103% of Cigna fee schedule,23.73,100,,0.464,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,0.48,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.032,Case Rate,Pays based on per visit rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL RT,49065206,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,TC   ,14.16,100,,5.824,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,22.208,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,28.56,Fee Schedule,360% of BCBS POS Rate,403.49,360,,28.56,Fee schedule,360% of BCBS PPO Rate,403.49,360,,28.56,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.032,Fee Schedule,103% of Cigna fee schedule,23.73,100,,0.08,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,227.672,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.024,Case Rate,Pays based on per visit rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,303.56,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL RT,49065206,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,TC   ,14.16,100,,18.176,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,67.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.8,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,86.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,86.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,86.4,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.992,Fee Schedule,103% of Cigna fee schedule,23.73,100,,7.376,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,7.6,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,372.872,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,300,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.272,Case Rate,Pays based on per visit rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,7.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,497.16,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL RT PORT,49065207,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,29.432,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,29.312,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.816,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,37.688,Fee Schedule,360% of BCBS POS Rate,403.49,360,,37.688,Fee schedule,360% of BCBS PPO Rate,403.49,360,,37.688,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,12.72,Fee Schedule,103% of Cigna fee schedule,23.73,100,,0.144,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,0.144,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,372.872,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.072,Case Rate,Pays based on per visit rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,497.16,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SCAPULA COMPL RT PORT,49065207,CDM,320,RC,73010,HCPCS,Outpatient,,,266.99,160.19,,14.16,100,,18.432,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,70.984,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,12.84,Fee Schedule,320% of BCBS Blue Essentials Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,91.264,Fee Schedule,360% of BCBS POS Rate,403.49,360,,91.264,Fee schedule,360% of BCBS PPO Rate,403.49,360,,91.264,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,12.096,Fee Schedule,103% of Cigna fee schedule,23.73,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,24.44,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,200.24,75,,1357.112,Percent of Total Billed Charges,75% of Total Billed Charges,133.5,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,133.5,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,133.5,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.664,Case Rate,Pays based on per visit rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,23.73,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,266.99,100,,1809.48,Percent of Total Billed Charges,100% of Total Billed Charges,14.16,403.49,
DX SELLA TURCICA,49065208,CDM,320,RC,70240,HCPCS,Outpatient,,,154.13,92.48,,23.15,100,,37.624,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,84.624,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.848,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,108.8,Fee Schedule,360% of BCBS POS Rate,287.32,360,,108.8,Fee schedule,360% of BCBS PPO Rate,287.32,360,,108.8,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.272,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,1357.112,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,57.064,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.072,Case Rate,Pays based on per visit rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,1809.48,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300,
DX SELLA TURCICA,49065208,CDM,320,RC,70240,HCPCS,Outpatient,,,154.13,92.48,,23.15,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,9.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.856,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.704,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.704,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.704,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.928,Fee Schedule,103% of Cigna fee schedule,33.08,100,,12.568,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,12.944,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,5265.728,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.504,Case Rate,Pays based on per visit rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,7020.968,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,300,
DX SHOULDER 1V BI PORT,49065209,CDM,320,RC,73020,HCPCS,Outpatient,,,439.5,263.70,TC   ,13.5,100,,3.472,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,180.696,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,232.32,Fee Schedule,360% of BCBS POS Rate,287.32,360,,232.32,Fee schedule,360% of BCBS PPO Rate,287.32,360,,232.32,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.84,Fee Schedule,103% of Cigna fee schedule,21.71,100,,1.104,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,1.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,329.63,75,,707.704,Percent of Total Billed Charges,75% of Total Billed Charges,219.75,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,219.75,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,219.75,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,219.75,50,,80.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,7.752,Case Rate,Pays based on per visit rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,1.104,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,439.5,100,,943.608,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,439.5,
DX SHOULDER 1V BI PORT,49065209,CDM,320,RC,73020,HCPCS,Outpatient,,,439.5,263.70,TC   ,13.5,100,,1.528,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,485.576,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,624.312,Fee Schedule,360% of BCBS POS Rate,287.32,360,,624.312,Fee schedule,360% of BCBS PPO Rate,287.32,360,,624.312,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.92,Fee Schedule,103% of Cigna fee schedule,21.71,100,,0.936,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,0.96,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,329.63,75,,707.704,Percent of Total Billed Charges,75% of Total Billed Charges,219.75,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,219.75,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,219.75,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,219.75,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.376,Case Rate,Pays based on per visit rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.936,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,439.5,100,,943.608,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,439.5,
DX SHOULDER 1V LT PORT,49065210,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,,13.5,100,,2.864,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.696,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.696,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.696,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,13.064,Fee Schedule,103% of Cigna fee schedule,21.71,100,,20.392,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,21.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,1467.8,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.112,Case Rate,Pays based on per visit rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,20.392,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,1957.064,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V LT PORT,49065210,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,,13.5,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.528,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.528,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.528,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.216,Fee Schedule,103% of Cigna fee schedule,21.71,100,,0.416,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,0.424,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,1596.504,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,56.08,Case Rate,Pays based on per visit rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,2128.672,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V RT,49065211,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,TC   ,13.5,100,,1.872,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.424,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.544,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.544,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.544,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.816,Fee Schedule,103% of Cigna fee schedule,21.71,100,,2.656,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,2.736,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,1490.68,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,38.048,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.848,Case Rate,Pays based on per visit rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,2.656,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,1987.568,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V RT,49065211,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,TC   ,13.5,100,,393.552,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,5.536,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.768,Fee Schedule,103% of Cigna fee schedule,21.71,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,1490.68,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,0.12,Case Rate,Pays based on per visit rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,1987.568,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V RT PORT,49065212,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,,13.5,100,,4.064,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.8,Fee Schedule,103% of Cigna fee schedule,21.71,100,,0.52,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,0.536,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,452.424,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,5.048,Case Rate,Pays based on per visit rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,603.232,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER 1V RT PORT,49065212,CDM,320,RC,73020,HCPCS,Outpatient,,,293,175.80,,13.5,100,,5.096,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.304,Fee Schedule,103% of Cigna fee schedule,21.71,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,22.36,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.75,75,,452.424,Percent of Total Billed Charges,75% of Total Billed Charges,146.5,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,146.5,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,23.968,Case Rate,Pays based on per visit rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,21.71,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,293,100,,603.232,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,300,
DX SHOULDER MIN 2V BI PORT,49065213,CDM,320,RC,73030,HCPCS,Outpatient,,,572.59,343.55,TC   ,24.15,100,,20.928,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,32.456,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,41.728,Fee Schedule,360% of BCBS POS Rate,287.32,360,,41.728,Fee schedule,360% of BCBS PPO Rate,287.32,360,,41.728,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.44,75,,2453.4,Percent of Total Billed Charges,75% of Total Billed Charges,286.3,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.3,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,168,Case Rate,Pays based on per visit rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.59,100,,3271.2,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,572.59,
DX SHOULDER MIN 2V BI PORT,49065213,CDM,320,RC,73030,HCPCS,Outpatient,,,572.59,343.55,TC   ,24.15,100,,21.976,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,21.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,27.112,Fee Schedule,360% of BCBS POS Rate,287.32,360,,27.112,Fee schedule,360% of BCBS PPO Rate,287.32,360,,27.112,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.992,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.44,75,,2453.4,Percent of Total Billed Charges,75% of Total Billed Charges,286.3,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.3,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,286.3,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.328,Case Rate,Pays based on per visit rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.59,100,,3271.2,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,572.59,
DX SHOULDER MIN 2V LT PORT,49065214,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,39.256,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.864,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,15.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,15.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,15.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.064,Fee Schedule,103% of Cigna fee schedule,34.75,100,,2.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,2.904,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,2477.584,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.136,Case Rate,Pays based on per visit rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,3303.44,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V LT PORT,49065214,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,86.6,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,26.8,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,34.456,Fee Schedule,360% of BCBS POS Rate,287.32,360,,34.456,Fee schedule,360% of BCBS PPO Rate,287.32,360,,34.456,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.424,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.296,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.304,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,2477.584,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,688.464,Case Rate,Pays based on per visit rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,3303.44,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V RT,49065215,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,TC   ,24.15,100,,118.12,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,129.832,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,166.928,Fee Schedule,360% of BCBS POS Rate,287.32,360,,166.928,Fee schedule,360% of BCBS PPO Rate,287.32,360,,166.928,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.408,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.68,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.704,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,3530.36,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,399.648,Case Rate,Pays based on per visit rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,4707.144,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V RT,49065215,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,TC   ,24.15,100,,2.968,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.952,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.936,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.936,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.936,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.696,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.2,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,3530.36,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,108.632,Case Rate,Pays based on per visit rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,4707.144,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V RT PORT,49065216,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.104,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.912,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,10.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,10.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,10.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.16,Fee Schedule,103% of Cigna fee schedule,34.75,100,,1.152,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,1.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,2282.12,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,148.68,Case Rate,Pays based on per visit rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,3042.824,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SHOULDER MIN 2V RT PORT,49065216,CDM,320,RC,73030,HCPCS,Outpatient,,,381.73,229.04,,24.15,100,,4.072,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,12.928,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,15.432,Fee Schedule,360% of BCBS POS Rate,287.32,360,,15.432,Fee schedule,360% of BCBS PPO Rate,287.32,360,,15.432,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,2.304,Fee Schedule,103% of Cigna fee schedule,34.75,100,,3.048,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,3.136,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.3,75,,2287.096,Percent of Total Billed Charges,75% of Total Billed Charges,190.87,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,190.87,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,597.32,Case Rate,Pays based on per visit rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.73,100,,3049.464,Percent of Total Billed Charges,100% of Total Billed Charges,24.15,381.73,
DX SINUSES MAX 2V PORT,49065217,CDM,320,RC,70210,HCPCS,Outpatient,,,193.19,115.91,TC   ,22.82,100,,3.928,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.232,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.024,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.448,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.448,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.448,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.768,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.28,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.288,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,144.89,75,,657.064,Percent of Total Billed Charges,75% of Total Billed Charges,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,316.904,Case Rate,Pays based on per visit rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.19,100,,876.08,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX SINUSES MAX 2V PORT,49065217,CDM,320,RC,70210,HCPCS,Outpatient,,,193.19,115.91,TC   ,22.82,100,,0.184,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.328,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,128,Fee Schedule,320% of BCBS Blue Essentials Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.992,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.992,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.992,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.128,Fee Schedule,103% of Cigna fee schedule,32.41,100,,0.424,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,33.38,103,,0.44,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,144.89,75,,538.648,Percent of Total Billed Charges,75% of Total Billed Charges,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,96.6,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,96.6,50,,143,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,307.768,Case Rate,Pays based on per visit rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,32.41,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,193.19,100,,718.192,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,300,
DX SKULL MAX 3V PORT,49065219,CDM,320,RC,70250,HCPCS,Outpatient,,,353.16,211.90,,25.82,100,,4.448,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,4.56,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,128,Fee Schedule,320% of BCBS Blue Essentials Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,5.856,Fee Schedule,360% of BCBS POS Rate,403.49,360,,5.856,Fee schedule,360% of BCBS PPO Rate,403.49,360,,5.856,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,11.28,Fee Schedule,103% of Cigna fee schedule,36.09,100,,0.176,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,37.17,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,264.87,75,,538.648,Percent of Total Billed Charges,75% of Total Billed Charges,176.58,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,176.58,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,43.576,Case Rate,Pays based on per visit rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,353.16,100,,718.192,Percent of Total Billed Charges,100% of Total Billed Charges,25.82,403.49,
DX SKULL MAX 3V PORT,49065219,CDM,320,RC,70250,HCPCS,Outpatient,,,353.16,211.90,,25.82,100,,6.712,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.144,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,128,Fee Schedule,320% of BCBS Blue Essentials Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.616,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.616,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.616,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.136,Fee Schedule,103% of Cigna fee schedule,36.09,100,,0.184,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,37.17,103,,0.192,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,264.87,75,,1806.056,Percent of Total Billed Charges,75% of Total Billed Charges,176.58,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,176.58,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,50,,229.32,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,401.392,Case Rate,Pays based on per visit rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,36.09,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,353.16,100,,2408.072,Percent of Total Billed Charges,100% of Total Billed Charges,25.82,403.49,
DX TIBIA FIBULA 2V BI PORT,49065229,CDM,320,RC,73590,HCPCS,Outpatient,,,572.84,343.70,TC   ,22.82,100,,10.84,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.336,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,128,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.576,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.576,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.576,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,7.952,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.63,75,,13220.272,Percent of Total Billed Charges,75% of Total Billed Charges,286.42,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.42,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.352,Case Rate,Pays based on per visit rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.84,100,,17627.024,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,572.84,
DX TIBIA FIBULA 2V BI PORT,49065229,CDM,320,RC,73590,HCPCS,Outpatient,,,572.84,343.70,TC   ,22.82,100,,3.416,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,15.4,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.28,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,19.8,Fee Schedule,360% of BCBS POS Rate,287.32,360,,19.8,Fee schedule,360% of BCBS PPO Rate,287.32,360,,19.8,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,7.952,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.24,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,429.63,75,,15083.152,Percent of Total Billed Charges,75% of Total Billed Charges,286.42,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,286.42,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,286.42,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,38.168,Case Rate,Pays based on per visit rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,572.84,100,,20110.864,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,572.84,
DX TIBIA FIBULA 2V LT PORT,49065230,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,10.184,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.328,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.152,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,15083.152,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,38.2,Case Rate,Pays based on per visit rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,20110.864,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V LT PORT,49065230,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,61.024,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.512,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.696,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.344,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,15083.152,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,152.88,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.736,Case Rate,Pays based on per visit rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,20110.864,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V RT,49065231,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,TC   ,22.82,100,,5.64,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,171.392,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.512,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,220.36,Fee Schedule,360% of BCBS POS Rate,287.32,360,,220.36,Fee schedule,360% of BCBS PPO Rate,287.32,360,,220.36,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,18.776,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,15083.152,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,155.032,Case Rate,Pays based on per visit rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,20110.864,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V RT,49065231,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,TC   ,22.82,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,28.12,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.512,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,36.152,Fee Schedule,360% of BCBS POS Rate,287.32,360,,36.152,Fee schedule,360% of BCBS PPO Rate,287.32,360,,36.152,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.096,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,9301.32,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,212.944,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.72,Case Rate,Pays based on per visit rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,12401.76,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V RT PORT,49065232,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,4.168,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.512,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.976,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.976,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.976,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.096,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.272,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.28,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,13587.208,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,1096.992,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,1096.992,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,155.168,Case Rate,Pays based on per visit rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,18116.28,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TIBIA FIBULA 2V RT PORT,49065232,CDM,320,RC,73590,HCPCS,Outpatient,,,381.9,229.14,,22.82,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,14.208,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.512,Fee Schedule,320% of BCBS Blue Essentials Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,18.264,Fee Schedule,360% of BCBS POS Rate,287.32,360,,18.264,Fee schedule,360% of BCBS PPO Rate,287.32,360,,18.264,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.12,Fee Schedule,103% of Cigna fee schedule,31.74,100,,0.536,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,32.69,103,,0.552,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,286.43,75,,5879.312,Percent of Total Billed Charges,75% of Total Billed Charges,190.95,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,784.52,Percent of Total Billed Charges,50% of Total Billed Charges,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.95,50,,784.52,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.88,Case Rate,Pays based on per visit rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,31.74,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.9,100,,7839.08,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,381.9,
DX TMJ LT,49065234,CDM,320,RC,70328,HCPCS,Outpatient,,,154.13,92.48,TC   ,24.81,100,,3.776,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,24.648,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.928,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,31.688,Fee Schedule,360% of BCBS POS Rate,287.32,360,,31.688,Fee schedule,360% of BCBS PPO Rate,287.32,360,,31.688,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.112,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.176,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,959.384,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,1096.992,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,27.576,Case Rate,Pays based on per visit rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,1279.176,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,300,
DX TMJ LT,49065234,CDM,320,RC,70328,HCPCS,Outpatient,,,154.13,92.48,TC   ,24.81,100,,0.56,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.616,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,129.984,Fee Schedule,320% of BCBS Blue Essentials Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.368,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.368,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.368,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.2,Fee Schedule,103% of Cigna fee schedule,34.75,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.79,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,4146.136,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,784.52,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,141.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,10.856,Case Rate,Pays based on per visit rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.75,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,5528.176,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,300,
DX TOES MIN 2V BI PORT,49065236,CDM,320,RC,73660,HCPCS,Outpatient,,,354.03,212.42,,21.83,100,,3.912,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,4.088,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.016,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.192,Fee Schedule,103% of Cigna fee schedule,29.4,100,,2.632,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,2.712,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.52,75,,5001.512,Percent of Total Billed Charges,75% of Total Billed Charges,177.02,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.02,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,20.976,Case Rate,Pays based on per visit rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.632,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.03,100,,6668.68,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,354.03,
DX TOES MIN 2V BI PORT,49065236,CDM,320,RC,73660,HCPCS,Outpatient,,,354.03,212.42,,21.83,100,,1.44,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,15.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.016,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,20.128,Fee Schedule,360% of BCBS POS Rate,287.32,360,,20.128,Fee schedule,360% of BCBS PPO Rate,287.32,360,,20.128,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.432,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,265.52,75,,4469.04,Percent of Total Billed Charges,75% of Total Billed Charges,177.02,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.02,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,177.02,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,41.016,Case Rate,Pays based on per visit rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.03,100,,5958.72,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,354.03,
DX TOES MIN 2V LT PORT,49065237,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,TC   ,21.83,100,,4.072,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.336,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.016,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,15.864,Fee Schedule,360% of BCBS POS Rate,287.32,360,,15.864,Fee schedule,360% of BCBS PPO Rate,287.32,360,,15.864,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.256,Fee Schedule,103% of Cigna fee schedule,29.4,100,,2.824,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,2.904,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,4031.48,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,48.44,Case Rate,Pays based on per visit rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,2.824,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,5375.304,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V LT PORT,49065237,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,TC   ,21.83,100,,8.648,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,20.608,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.016,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,26.496,Fee Schedule,360% of BCBS POS Rate,287.32,360,,26.496,Fee schedule,360% of BCBS PPO Rate,287.32,360,,26.496,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.536,Fee Schedule,103% of Cigna fee schedule,29.4,100,,1.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,1.912,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,2040,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,39.128,Case Rate,Pays based on per visit rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,2720,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V RT,49065238,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,,21.83,100,,5.312,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,36.6,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.208,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,47.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,47.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,47.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.144,Fee Schedule,103% of Cigna fee schedule,29.4,100,,1.856,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,1.912,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,2074.2,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,22.96,Case Rate,Pays based on per visit rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,1.856,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,2765.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V RT,49065238,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,,21.83,100,,3.352,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,95.76,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.208,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,123.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,123.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,123.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.36,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,2777.656,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1521.416,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,100.24,Case Rate,Pays based on per visit rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,3703.536,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V RT PORT,49065239,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,TC   ,21.83,100,,67.6,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,17.832,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13103.608,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,22.928,Fee Schedule,360% of BCBS POS Rate,287.32,360,,22.928,Fee schedule,360% of BCBS PPO Rate,287.32,360,,22.928,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.36,Fee Schedule,103% of Cigna fee schedule,29.4,100,,0.16,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,0.168,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,3128.784,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,168,Case Rate,Pays based on per visit rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,0.16,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,4171.712,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TOES MIN 2V RT PORT,49065239,CDM,320,RC,73660,HCPCS,Outpatient,,,236.02,141.61,TC   ,21.83,100,,81.56,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,26.184,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.192,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,33.664,Fee Schedule,360% of BCBS POS Rate,287.32,360,,33.664,Fee schedule,360% of BCBS PPO Rate,287.32,360,,33.664,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.728,Fee Schedule,103% of Cigna fee schedule,29.4,100,,4.384,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,30.28,103,,4.512,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,177.02,75,,3154.84,Percent of Total Billed Charges,75% of Total Billed Charges,118.01,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,118.01,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.432,Case Rate,Pays based on per visit rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,29.4,100,,4.384,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,236.02,100,,4206.448,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,300,
DX TSPINE 1V PORT,49065240,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,7.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,17.832,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.224,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,22.928,Fee Schedule,360% of BCBS POS Rate,287.32,360,,22.928,Fee schedule,360% of BCBS PPO Rate,287.32,360,,22.928,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.84,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,3281.712,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,354.008,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,189,Case Rate,Pays based on per visit rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,4375.616,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX TSPINE 1V PORT,49065240,CDM,320,RC,72020,HCPCS,Outpatient,,,344,206.40,,16.16,100,,5.672,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,25.736,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,130.816,Fee Schedule,320% of BCBS Blue Essentials Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,33.088,Fee Schedule,360% of BCBS POS Rate,287.32,360,,33.088,Fee schedule,360% of BCBS PPO Rate,287.32,360,,33.088,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.032,Fee Schedule,103% of Cigna fee schedule,24.73,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,25.47,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258,75,,2854.384,Percent of Total Billed Charges,75% of Total Billed Charges,172,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,172,50,,1096.992,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,66.464,Case Rate,Pays based on per visit rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,24.73,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344,100,,3805.84,Percent of Total Billed Charges,100% of Total Billed Charges,16.16,344,
DX TSPINE 2V PORT,49065241,CDM,320,RC,72070,HCPCS,Outpatient,,,398.04,238.82,TC   ,21.83,100,,4.424,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,14.336,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,130.864,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,18.432,Fee Schedule,360% of BCBS POS Rate,403.49,360,,18.432,Fee schedule,360% of BCBS PPO Rate,403.49,360,,18.432,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.296,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,939.176,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,784.52,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,167.072,Case Rate,Pays based on per visit rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,1252.232,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,403.49,
DX TSPINE 2V PORT,49065241,CDM,320,RC,72070,HCPCS,Outpatient,,,398.04,238.82,TC   ,21.83,100,,1.776,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.72,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,130.864,Fee Schedule,320% of BCBS Blue Essentials Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.64,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.64,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.64,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.184,Fee Schedule,103% of Cigna fee schedule,33.08,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.07,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,298.53,75,,5171.08,Percent of Total Billed Charges,75% of Total Billed Charges,199.02,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,199.02,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,199.02,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,19.632,Case Rate,Pays based on per visit rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,33.08,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,398.04,100,,6894.776,Percent of Total Billed Charges,100% of Total Billed Charges,21.83,403.49,
DX TSPINE 3V,49065242,CDM,320,RC,72072,HCPCS,Outpatient,,,503.84,302.30,,27.15,100,,4.864,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.424,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,131.04,Fee Schedule,320% of BCBS Blue Essentials Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.256,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.256,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.256,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.272,Fee Schedule,103% of Cigna fee schedule,39.43,100,,0.048,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,40.61,103,,0.048,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,377.88,75,,5122.2,Percent of Total Billed Charges,75% of Total Billed Charges,251.92,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,251.92,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,251.92,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,251.92,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,15.328,Case Rate,Pays based on per visit rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,503.84,100,,6829.6,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,503.84,
DX TSPINE 3V,49065242,CDM,320,RC,72072,HCPCS,Outpatient,,,503.84,302.30,,27.15,100,,13.736,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,4.048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,131.12,Fee Schedule,320% of BCBS Blue Essentials Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,5.208,Fee Schedule,360% of BCBS POS Rate,403.49,360,,5.208,Fee schedule,360% of BCBS PPO Rate,403.49,360,,5.208,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.68,Fee Schedule,103% of Cigna fee schedule,39.43,100,,0.048,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,40.61,103,,0.048,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,377.88,75,,6141.984,Percent of Total Billed Charges,75% of Total Billed Charges,251.92,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,251.92,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,251.92,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,251.92,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.136,Case Rate,Pays based on per visit rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,39.43,100,,0.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,503.84,100,,8189.312,Percent of Total Billed Charges,100% of Total Billed Charges,27.15,503.84,
DX TSPINE MIN 4V,49065243,CDM,320,RC,72074,HCPCS,Outpatient,,,550,330.00,TC   ,31.47,100,,38.56,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,169.344,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,131.432,Fee Schedule,320% of BCBS Blue Essentials Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,217.728,Fee Schedule,360% of BCBS POS Rate,403.49,360,,217.728,Fee schedule,360% of BCBS PPO Rate,403.49,360,,217.728,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.016,Fee Schedule,103% of Cigna fee schedule,44.44,100,,1.032,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,45.77,103,,1.064,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,412.5,75,,4275,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,275,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,31.56,Case Rate,Pays based on per visit rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,1.032,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,550,100,,5700,Percent of Total Billed Charges,100% of Total Billed Charges,31.47,550,
DX TSPINE MIN 4V,49065243,CDM,320,RC,72074,HCPCS,Outpatient,,,550,330.00,TC   ,31.47,100,,2.48,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,49.76,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,132.344,Fee Schedule,320% of BCBS Blue Essentials Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,63.976,Fee Schedule,360% of BCBS POS Rate,403.49,360,,63.976,Fee schedule,360% of BCBS PPO Rate,403.49,360,,63.976,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.976,Fee Schedule,103% of Cigna fee schedule,44.44,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,45.77,103,,0.064,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,412.5,75,,2850,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,275,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,2850,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,3.4,Case Rate,Pays based on per visit rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,44.44,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,550,100,,3800,Percent of Total Billed Charges,100% of Total Billed Charges,31.47,550,
DX TUBE CHG PERC WCM SI,49065244,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,,64.44,100,,0.64,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,132.344,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,1.12,Fee Schedule,360% of BCBS POS Rate,246.49,360,,1.12,Fee schedule,360% of BCBS PPO Rate,246.49,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,0.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,2850,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,7.664,Case Rate,Pays based on per visit rate,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,3800,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
DX TUBE CHG PERC WCM SI,49065244,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,,64.44,100,,2.432,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,2572.048,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,132.352,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,3306.912,Fee Schedule,360% of BCBS POS Rate,246.49,360,,3306.912,Fee schedule,360% of BCBS PPO Rate,246.49,360,,3306.912,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,0.328,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,4092.664,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,1900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,4.464,Case Rate,Pays based on per visit rate,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,5456.88,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
DX TUBE GASTRIC FEEDING REPO,49065245,CDM,361,RC,,,Outpatient,,,1438.47,863.08,,863.08,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,647.31,45,,517.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.77,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,8.26,32,,132.384,Percent of Total Billed Charges,32% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,517.85,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,517.85,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,517.85,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,863.08,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1438.47,100,,1150.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,207.43,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1078.85,75,,2728.44,Percent of Total Billed Charges,75% of Total Billed Charges,719.24,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,719.24,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,719.24,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,719.24,50,,2728.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1006.93,70,,7.64,Percent of Total Billed Charges,70% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,201.39,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1438.47,100,,3637.92,Percent of Total Billed Charges,100% of Total Billed Charges,8.26,1438.47,
DX TUBE GI INSERT BY PHYSICIAN,49065247,CDM,361,RC,,,Outpatient,,,601.49,360.89,,360.89,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,270.67,45,,216.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.42,28,,16.024,Percent of Total Billed Charges,28% of Total Billed Charges,80,32,,132.512,Percent of Total Billed Charges,32% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,216.54,36,,20.6,Percent of Total Billed Charges,36% of Total Billed Charges,216.54,36,,20.6,Percent of Total Billed Charges,36% Total Bille Charges,216.54,36,,20.6,Percent of Total Billed Charges,36% of Total Billed Charges,360.89,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.49,100,,481.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,86.73,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.12,75,,2728.44,Percent of Total Billed Charges,75% of Total Billed Charges,300.75,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,300.75,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.75,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,300.75,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421.04,70,,9.92,Percent of Total Billed Charges,70% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,84.21,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,601.49,100,,3637.92,Percent of Total Billed Charges,100% of Total Billed Charges,80,601.49,
DX UGI W AIR W KUB,49065250,CDM,320,RC,74246,HCPCS,Outpatient,,,990.3,594.18,,98.06,100,,144,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,132.608,Fee Schedule,320% of BCBS Blue Essentials Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS POS Rate,655.99,360,,22.608,Fee schedule,360% of BCBS PPO Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,0.12,Fee Schedule,103% of Cigna fee schedule,141.68,100,,0.168,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,145.93,103,,0.176,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,742.73,75,,3011.912,Percent of Total Billed Charges,75% of Total Billed Charges,495.15,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,495.15,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,495.15,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,495.15,50,,1818.96,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.504,Case Rate,Pays based on per visit rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,990.3,100,,4015.88,Percent of Total Billed Charges,100% of Total Billed Charges,98.06,990.3,
DX UGI W AIR W KUB,49065250,CDM,320,RC,74246,HCPCS,Outpatient,,,990.3,594.18,,98.06,100,,25.784,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,4.024,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,13387.344,Fee Schedule,320% of BCBS Blue Essentials Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,5.176,Fee Schedule,360% of BCBS POS Rate,655.99,360,,5.176,Fee schedule,360% of BCBS PPO Rate,655.99,360,,5.176,Fee Schedule,360% of BCBS Traditional Rate,613.5,103,,0.144,Fee Schedule,103% of Cigna fee schedule,141.68,100,,0.2,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,145.93,103,,0.2,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,742.73,75,,2007.944,Percent of Total Billed Charges,75% of Total Billed Charges,495.15,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,495.15,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,495.15,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,495.15,50,,2007.944,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,33.44,Case Rate,Pays based on per visit rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,141.68,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,990.3,100,,2677.256,Percent of Total Billed Charges,100% of Total Billed Charges,98.06,990.3,
DX UPR EXT INF MIN 2V BI PORT,49065252,CDM,320,RC,73092,HCPCS,Outpatient,,,231.19,138.71,,22.82,100,,362.888,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,181.112,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13387.344,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,232.856,Fee Schedule,360% of BCBS POS Rate,403.49,360,,232.856,Fee schedule,360% of BCBS PPO Rate,403.49,360,,232.856,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.112,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,2007.944,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.352,Case Rate,Pays based on per visit rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,2677.256,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V BI PORT,49065252,CDM,320,RC,73092,HCPCS,Outpatient,,,231.19,138.71,,22.82,100,,0.512,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,12.52,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.32,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,16.096,Fee Schedule,360% of BCBS POS Rate,403.49,360,,16.096,Fee schedule,360% of BCBS PPO Rate,403.49,360,,16.096,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.024,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.072,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,173.39,75,,4804.24,Percent of Total Billed Charges,75% of Total Billed Charges,115.6,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,115.6,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,115.6,50,,1338.632,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,20,Case Rate,Pays based on per visit rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,231.19,100,,6405.656,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V LT PORT,49065253,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,0.952,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.92,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.352,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,8.896,Fee Schedule,360% of BCBS POS Rate,403.49,360,,8.896,Fee schedule,360% of BCBS PPO Rate,403.49,360,,8.896,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4.456,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,80.608,Case Rate,Pays based on per visit rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V LT PORT,49065253,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,48.96,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,14.648,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.368,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,18.832,Fee Schedule,360% of BCBS POS Rate,403.49,360,,18.832,Fee schedule,360% of BCBS PPO Rate,403.49,360,,18.832,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,6.768,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.064,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,60.024,Case Rate,Pays based on per visit rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V RT,49065254,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,90.424,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,19.04,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.368,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,24.48,Fee Schedule,360% of BCBS POS Rate,403.49,360,,24.48,Fee schedule,360% of BCBS PPO Rate,403.49,360,,24.48,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,3.248,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.392,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.4,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,4804.24,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4173.856,Case Rate,Pays based on per visit rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.392,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,6405.656,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V RT,49065254,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,,22.82,100,,35.944,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,18.576,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.44,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,23.88,Fee Schedule,360% of BCBS POS Rate,403.49,360,,23.88,Fee schedule,360% of BCBS PPO Rate,403.49,360,,23.88,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.264,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,3202.832,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,31.504,Case Rate,Pays based on per visit rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V RT PORT,49065255,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,43.088,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,19.824,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.44,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,25.488,Fee Schedule,360% of BCBS POS Rate,403.49,360,,25.488,Fee schedule,360% of BCBS PPO Rate,403.49,360,,25.488,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.376,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.232,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.232,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,43.608,Case Rate,Pays based on per visit rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX UPR EXT INF MIN 2V RT PORT,49065255,CDM,320,RC,73092,HCPCS,Outpatient,,,154.13,92.48,TC   ,22.82,100,,42.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,17.312,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,13.44,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,22.256,Fee Schedule,360% of BCBS POS Rate,403.49,360,,22.256,Fee schedule,360% of BCBS PPO Rate,403.49,360,,22.256,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.408,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,115.6,75,,4783.456,Percent of Total Billed Charges,75% of Total Billed Charges,77.07,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,845.256,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,50,,845.256,Percent of Total Billed Charges,50% of Total Billed Charges,77.07,50,,2135.224,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,35.496,Case Rate,Pays based on per visit rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,100,,6377.936,Percent of Total Billed Charges,100% of Total Billed Charges,22.82,403.49,
DX WRIST 2V LT PORT,49065262,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,73.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.44,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,12.912,Fee Schedule,360% of BCBS POS Rate,287.32,360,,12.912,Fee schedule,360% of BCBS PPO Rate,287.32,360,,12.912,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.408,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.08,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,3188.968,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,1005.288,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,1005.288,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,3188.968,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,893.176,Case Rate,Pays based on per visit rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,4251.952,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V LT PORT,49065262,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,77.024,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.496,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.304,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,3188.968,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,845.256,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,69.128,Case Rate,Pays based on per visit rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,4251.952,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V RT,49065263,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,TC   ,24.81,100,,77.024,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.56,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.04,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,1791.28,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,1005.288,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,523.96,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,523.96,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,2125.976,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4747.256,Case Rate,Pays based on per visit rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,2388.376,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V RT,49065263,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,TC   ,24.81,100,,52.08,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,3.928,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,133.12,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,5.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,5.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,5.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.432,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,914.144,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,914.144,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,35.504,Case Rate,Pays based on per visit rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V RT PORT,49065264,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,3.36,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.768,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,133.12,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.552,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.552,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.552,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.272,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,523.96,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.136,Case Rate,Pays based on per visit rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST 2V RT PORT,49065264,CDM,320,RC,73100,HCPCS,Outpatient,,,345.14,207.08,,24.81,100,,3.544,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,85.68,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,133.12,Fee Schedule,320% of BCBS Blue Essentials Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,110.16,Fee Schedule,360% of BCBS POS Rate,287.32,360,,110.16,Fee schedule,360% of BCBS PPO Rate,287.32,360,,110.16,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.04,Fee Schedule,103% of Cigna fee schedule,34.09,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,35.11,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,258.86,75,,1791.28,Percent of Total Billed Charges,75% of Total Billed Charges,172.57,50,,914.144,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,876.688,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.57,50,,876.688,Percent of Total Billed Charges,50% of Total Billed Charges,172.57,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28.736,Case Rate,Pays based on per visit rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,34.09,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,345.14,100,,2388.376,Percent of Total Billed Charges,100% of Total Billed Charges,24.81,345.14,
DX WRIST MIN 3V BI PORT,49065265,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,0.512,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,2.688,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,133.12,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,3.456,Fee Schedule,360% of BCBS POS Rate,287.32,360,,3.456,Fee schedule,360% of BCBS PPO Rate,287.32,360,,3.456,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.096,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,1194.192,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,21.96,Case Rate,Pays based on per visit rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V BI PORT,49065265,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,29.968,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,78.744,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,133.904,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,101.24,Fee Schedule,360% of BCBS POS Rate,287.32,360,,101.24,Fee schedule,360% of BCBS PPO Rate,287.32,360,,101.24,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.128,Fee Schedule,103% of Cigna fee schedule,41.1,100,,1.04,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,1.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,876.688,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,33.48,Case Rate,Pays based on per visit rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V BI PORT,49065265,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,17.768,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,78.752,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,134.12,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,101.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,101.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,101.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.104,Fee Schedule,103% of Cigna fee schedule,41.1,100,,1.576,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,1.624,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,2233.576,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,796.128,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.816,Case Rate,Pays based on per visit rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,1.576,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,2978.096,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V LT PORT,49065266,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,7.696,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,56.608,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,134.32,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,72.784,Fee Schedule,360% of BCBS POS Rate,287.32,360,,72.784,Fee schedule,360% of BCBS PPO Rate,287.32,360,,72.784,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.536,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.064,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,1489.048,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,23.296,Case Rate,Pays based on per visit rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,1985.4,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V LT PORT,49065266,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,44.832,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,49.616,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,134.4,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,63.792,Fee Schedule,360% of BCBS POS Rate,287.32,360,,63.792,Fee schedule,360% of BCBS PPO Rate,287.32,360,,63.792,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,81.864,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,1489.048,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,26.984,Case Rate,Pays based on per visit rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,1985.4,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V LT PORT,49065266,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,55.12,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,10.984,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,134.424,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.12,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.12,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.12,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,95.992,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,1800.96,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,43.96,Case Rate,Pays based on per visit rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,2401.28,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR BI,49065267,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,90.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,153.4,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,134.952,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,197.224,Fee Schedule,360% of BCBS POS Rate,287.32,360,,197.224,Fee schedule,360% of BCBS PPO Rate,287.32,360,,197.224,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,85.752,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,1200.64,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,845.256,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,51.992,Case Rate,Pays based on per visit rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,1600.856,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V NAVICULAR BI,49065267,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,217.592,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.88,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,135.552,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,10.136,Fee Schedule,360% of BCBS POS Rate,287.32,360,,10.136,Fee schedule,360% of BCBS PPO Rate,287.32,360,,10.136,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.872,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.072,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,665.816,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,702.808,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,702.808,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,1005.288,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.912,Case Rate,Pays based on per visit rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,887.752,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V NAVICULAR BI,49065267,CDM,320,RC,73110,HCPCS,Outpatient,,,569.17,341.50,TC   ,30.81,100,,9.92,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,18.92,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.616,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,24.328,Fee Schedule,360% of BCBS POS Rate,287.32,360,,24.328,Fee schedule,360% of BCBS PPO Rate,287.32,360,,24.328,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.288,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,426.88,75,,5668.624,Percent of Total Billed Charges,75% of Total Billed Charges,284.59,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,1033.496,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,284.59,50,,1033.496,Percent of Total Billed Charges,50% of Total Billed Charges,284.59,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,34.416,Case Rate,Pays based on per visit rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,569.17,100,,7558.168,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,569.17,
DX WRIST MIN 3V NAVICULAR LT,49065268,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,345.232,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,47.728,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.624,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,61.36,Fee Schedule,360% of BCBS POS Rate,287.32,360,,61.36,Fee schedule,360% of BCBS PPO Rate,287.32,360,,61.36,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.344,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.336,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.344,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,4368.304,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,702.808,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,523.96,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,6.696,Case Rate,Pays based on per visit rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,5824.4,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR LT,49065268,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,220.32,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.424,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.656,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.832,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.832,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.832,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.472,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.296,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.304,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,4146.824,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1033.496,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,914.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,8.944,Case Rate,Pays based on per visit rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,5529.096,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR LT,49065268,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,164.536,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.6,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.656,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,11.056,Fee Schedule,360% of BCBS POS Rate,287.32,360,,11.056,Fee schedule,360% of BCBS PPO Rate,287.32,360,,11.056,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,13.904,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,4502.44,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,504.336,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.024,Case Rate,Pays based on per visit rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,6003.256,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR RT,49065269,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,8.288,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,123.2,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.656,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,158.4,Fee Schedule,360% of BCBS POS Rate,287.32,360,,158.4,Fee schedule,360% of BCBS PPO Rate,287.32,360,,158.4,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.088,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2324.128,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,876.688,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,21.248,Case Rate,Pays based on per visit rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,3098.832,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR RT,49065269,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,94.88,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.112,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.656,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.288,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.288,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.288,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.376,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,91.736,Case Rate,Pays based on per visit rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V NAVICULAR RT,49065269,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,819.008,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.72,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.728,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,1528.84,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,490.056,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,490.056,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,168,Case Rate,Pays based on per visit rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,2038.456,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT,49065270,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,1080,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.656,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.736,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.84,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.84,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.84,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.736,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.128,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.128,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,358.776,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,358.776,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.888,Case Rate,Pays based on per visit rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.128,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT,49065270,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,29.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.752,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.392,Fee Schedule,103% of Cigna fee schedule,41.1,100,,22.4,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,23.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,1121.224,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,490.056,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1113.968,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,1113.968,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.592,Case Rate,Pays based on per visit rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,22.4,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,1494.96,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT,49065270,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,,30.81,100,,58.496,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,13.768,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,22.608,Fee Schedule,360% of BCBS POS Rate,287.32,360,,22.608,Fee schedule,360% of BCBS PPO Rate,287.32,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.528,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.2,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.208,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2230.968,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,358.776,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1076.304,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,1076.304,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,277.232,Case Rate,Pays based on per visit rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,2974.624,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT PORT,49065271,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,29.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,135.68,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS POS Rate,287.32,360,,14.52,Fee schedule,360% of BCBS PPO Rate,287.32,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.992,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2324.128,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1113.968,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,1630.672,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,1630.672,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,17.92,Case Rate,Pays based on per visit rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,3098.832,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT PORT,49065271,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,135.176,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.44,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,135.84,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,8.28,Fee Schedule,360% of BCBS POS Rate,287.32,360,,8.28,Fee schedule,360% of BCBS PPO Rate,287.32,360,,8.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,7.072,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.08,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.08,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2230.968,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1076.304,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,908.152,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,94.648,Case Rate,Pays based on per visit rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,2974.624,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX WRIST MIN 3V RT PORT,49065271,CDM,320,RC,73110,HCPCS,Outpatient,,,379.45,227.67,TC   ,30.81,100,,19.96,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,6.216,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,136.192,Fee Schedule,320% of BCBS Blue Essentials Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,7.992,Fee Schedule,360% of BCBS POS Rate,287.32,360,,7.992,Fee schedule,360% of BCBS PPO Rate,287.32,360,,7.992,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,31.504,Fee Schedule,103% of Cigna fee schedule,41.1,100,,0.112,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,42.33,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,284.59,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,189.73,50,,1630.672,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,2151.592,Percent of Total Billed Charges,50% of Total Billed Charges,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,189.73,50,,2151.592,Percent of Total Billed Charges,50% of Total Billed Charges,189.73,50,,702.808,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,43.152,Case Rate,Pays based on per visit rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,41.1,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,379.45,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.81,379.45,
DX ESOPHAGRAM DOUBLE CM,49065272,CDM,320,RC,74221,HCPCS,Outpatient,,,621.45,372.87,,77.42,100,,185.552,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,136.272,Fee Schedule,320% of BCBS Blue Essentials Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS POS Rate,655.99,360,,22.608,Fee schedule,360% of BCBS PPO Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,372.87,60,,1.312,Percent of Total Billed Charges,60% of Total Billed Charges,112.26,100,,3.248,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,115.63,103,,3.344,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,466.09,75,,1450.456,Percent of Total Billed Charges,75% of Total Billed Charges,310.73,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.73,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,1033.496,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.032,Case Rate,Pays based on per visit rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,3.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,621.45,100,,1933.936,Percent of Total Billed Charges,100% of Total Billed Charges,77.42,655.99,
DX ESOPHAGRAM DOUBLE CM,49065272,CDM,320,RC,74221,HCPCS,Outpatient,,,621.45,372.87,,77.42,100,,213.448,Fee Schedule,100% of Aetna Fee Schedule,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,9.328,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,12,Fee Schedule,360% of BCBS POS Rate,655.99,360,,12,Fee schedule,360% of BCBS PPO Rate,655.99,360,,12,Fee Schedule,360% of BCBS Traditional Rate,372.87,60,,8.936,Percent of Total Billed Charges,60% of Total Billed Charges,112.26,100,,0.256,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,115.63,103,,0.264,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,466.09,75,,5931.064,Percent of Total Billed Charges,75% of Total Billed Charges,310.73,50,,2151.592,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,310.73,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,310.73,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.544,Case Rate,Pays based on per visit rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,112.26,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,621.45,100,,7908.08,Percent of Total Billed Charges,100% of Total Billed Charges,77.42,655.99,
DX SB SERIES FOLLOW THROUGH,49065273,CDM,320,RC,74248,HCPCS,Outpatient,,,2261.85,1357.11,TC   ,49.94,100,,1.624,Fee Schedule,100% of Aetna Fee Schedule,70.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,7.752,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,172.55,360,,9.968,Fee Schedule,360% of BCBS POS Rate,172.55,360,,9.968,Fee schedule,360% of BCBS PPO Rate,172.55,360,,9.968,Fee Schedule,360% of BCBS Traditional Rate,1357.11,60,,4.712,Percent of Total Billed Charges,60% of Total Billed Charges,83.86,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.17,90,,,Fee Schedule,90% of CMS OPPS Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,60.92,130,,,Fee Schedule,130% of CMS OPPS Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,86.38,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,48.27,103,,,Fee Schedule,103% of CMS OPPS Rate,48.27,103,,,Fee Schedule,103% of CMS OPPS Rate,1696.39,75,,4518.904,Percent of Total Billed Charges,75% of Total Billed Charges,1130.93,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,1130.93,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1130.93,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,1130.93,50,,772.36,Percent of Total Billed Charges,50% of Total Billed Charges,70.29,150,,,Fee Schedule,150% of CMS OPPS Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,16.912,Case Rate,Pays based on per visit rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2261.85,100,,6025.208,Percent of Total Billed Charges,100% of Total Billed Charges,42.17,2261.85,
DX SB SERIES FOLLOW THROUGH,49065273,CDM,320,RC,74248,HCPCS,Outpatient,,,2261.85,1357.11,TC   ,49.94,100,,31.968,Fee Schedule,100% of Aetna Fee Schedule,70.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,134.2,280,,7.784,Fee Schedule,280% of BCBS BULE Fee Schedule,153.38,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,172.55,360,,10.008,Fee Schedule,360% of BCBS POS Rate,172.55,360,,10.008,Fee schedule,360% of BCBS PPO Rate,172.55,360,,10.008,Fee Schedule,360% of BCBS Traditional Rate,1357.11,60,,2.848,Percent of Total Billed Charges,60% of Total Billed Charges,83.86,100,,0.168,Fee Schedule,100% of TX Mediciad Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.17,90,,,Fee Schedule,90% of CMS OPPS Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,60.92,130,,,Fee Schedule,130% of CMS OPPS Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,86.38,103,,0.176,Fee Schedule,103% of TX Medicaid Rate,48.27,103,,,Fee Schedule,103% of CMS OPPS Rate,48.27,103,,,Fee Schedule,103% of CMS OPPS Rate,1696.39,75,,2324.128,Percent of Total Billed Charges,75% of Total Billed Charges,1130.93,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,1130.93,50,,581.504,Percent of Total Billed Charges,50% of Total Billed Charges,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1130.93,50,,581.504,Percent of Total Billed Charges,50% of Total Billed Charges,1130.93,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,70.29,150,,,Fee Schedule,150% of CMS OPPS Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,95.936,Case Rate,Pays based on per visit rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.86,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,46.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2261.85,100,,3098.832,Percent of Total Billed Charges,100% of Total Billed Charges,42.17,2261.85,
IR IVC FILTER RTVL COMP,49100908,CDM,361,RC,,,Outpatient,,,8776.21,5265.73,,5265.73,60,,33.224,Percent of Total Billed Charges,60% of Total Billed Charges,3949.29,45,,3159.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2457.34,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,80,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,3159.44,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,3159.44,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,3159.44,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,5265.73,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8776.21,100,,7020.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1265.53,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6582.16,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,4388.11,50,,581.504,Percent of Total Billed Charges,50% of Total Billed Charges,4388.11,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4388.11,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,4388.11,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6143.35,70,,1088.632,Percent of Total Billed Charges,70% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1228.67,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8776.21,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,80,8776.21,
IR BILE DUCT SCOPE W DIL SI,49100913,CDM,320,RC,74363,HCPCS,Outpatient,,,1179.51,707.71,,74.21,100,,42.512,Fee Schedule,100% of Aetna Fee Schedule,530.78,45,,424.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.12,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,140.7,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,158.29,360,,14.52,Fee Schedule,360% of BCBS POS Rate,158.29,360,,14.52,Fee schedule,360% of BCBS PPO Rate,158.29,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,707.71,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1179.51,100,,943.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,170.09,14.42,,0.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,884.63,75,,2324.128,Percent of Total Billed Charges,75% of Total Billed Charges,589.76,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,589.76,50,,311.704,Percent of Total Billed Charges,50% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,589.76,50,,311.704,Percent of Total Billed Charges,50% of Total Billed Charges,589.76,50,,490.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,268.584,Case Rate,Pays based on per visit rate,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1179.51,100,,3098.832,Percent of Total Billed Charges,100% of Total Billed Charges,74.21,1179.51,
IR BILE DUCT SCOPE W DIL SI,49100913,CDM,320,RC,74363,HCPCS,Outpatient,,,1179.51,707.71,,74.21,100,,8.152,Fee Schedule,100% of Aetna Fee Schedule,530.78,45,,424.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.12,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,140.7,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,158.29,360,,22.608,Fee Schedule,360% of BCBS POS Rate,158.29,360,,22.608,Fee schedule,360% of BCBS PPO Rate,158.29,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,707.71,60,,1.016,Percent of Total Billed Charges,60% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1179.51,100,,943.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,170.09,14.42,,0.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,884.63,75,,2324.128,Percent of Total Billed Charges,75% of Total Billed Charges,589.76,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,589.76,50,,193.904,Percent of Total Billed Charges,50% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,589.76,50,,193.904,Percent of Total Billed Charges,50% of Total Billed Charges,589.76,50,,358.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,21.248,Case Rate,Pays based on per visit rate,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,165.13,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1179.51,100,,3098.832,Percent of Total Billed Charges,100% of Total Billed Charges,74.21,1179.51,
IR BX LIVER PERC,49100916,CDM,361,RC,,,Outpatient,,,2446.33,1467.80,,1467.8,60,,230.704,Percent of Total Billed Charges,60% of Total Billed Charges,1100.85,45,,880.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.97,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,80.16,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,880.68,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,880.68,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,880.68,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,1467.8,60,,15.688,Percent of Total Billed Charges,60% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2446.33,100,,1957.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,352.76,14.42,,0.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.75,75,,2230.968,Percent of Total Billed Charges,75% of Total Billed Charges,1223.17,50,,311.704,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,2523.104,Percent of Total Billed Charges,50% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1223.17,50,,2523.104,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,1113.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1712.43,70,,23.216,Percent of Total Billed Charges,70% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2446.33,100,,2974.624,Percent of Total Billed Charges,100% of Total Billed Charges,80.16,2446.33,
CVC NON TUNLED OVER 5 YEARS,49100922,CDM,481,RC,36556,HCPCS,Outpatient,,,2660.84,1596.50,,2601,100,,72.392,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,745.04,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,80.27,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,957.9,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,957.9,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,957.9,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,11330,60,,5.896,Percent of Total Billed Charges,60% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,383.69,14.42,,2.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1995.63,75,,2230.968,Percent of Total Billed Charges,75% of Total Billed Charges,1330.42,50,,193.904,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.42,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,1330.42,50,,1076.304,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,31.512,Fee Schedule,100% of ASC Tier Groupings fee schedule,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,372.52,14,,2.088,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2660.84,100,,2974.624,Percent of Total Billed Charges,100% of Total Billed Charges,80.27,11330,
IR BX TRNSCATH SI,49100923,CDM,320,RC,75970,HCPCS,Outpatient,,,2484.46,1490.68,,364.85,100,,19.056,Fee Schedule,100% of Aetna Fee Schedule,1118.01,45,,894.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.02,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,14.52,Fee Schedule,360% of BCBS POS Rate,146.59,360,,14.52,Fee schedule,360% of BCBS PPO Rate,146.59,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,1490.68,60,,24.416,Percent of Total Billed Charges,60% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2484.46,100,,1987.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,358.26,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1863.35,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,1242.23,50,,2523.104,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1242.23,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,1630.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,95.232,Case Rate,Pays based on per visit rate,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2484.46,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,114.02,2484.46,
IR BX TRNSCATH SI,49100923,CDM,320,RC,75970,HCPCS,Outpatient,,,2484.46,1490.68,,364.85,100,,19.168,Fee Schedule,100% of Aetna Fee Schedule,1118.01,45,,894.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.02,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,136.856,Fee Schedule,320% of BCBS Blue Essentials Rate,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,14.52,Fee Schedule,360% of BCBS POS Rate,146.59,360,,14.52,Fee schedule,360% of BCBS PPO Rate,146.59,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,1490.68,60,,99.12,Percent of Total Billed Charges,60% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2484.46,100,,1987.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,358.26,14.42,,0.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1863.35,75,,2632.2,Percent of Total Billed Charges,75% of Total Billed Charges,1242.23,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,137.704,Percent of Total Billed Charges,50% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1242.23,50,,137.704,Percent of Total Billed Charges,50% of Total Billed Charges,1242.23,50,,739.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,225.616,Case Rate,Pays based on per visit rate,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,347.82,14,,0.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2484.46,100,,3509.6,Percent of Total Billed Charges,100% of Total Billed Charges,114.02,2484.46,
IR ABS FIST SINUS STUDY SI,49100924,CDM,320,RC,76080,HCPCS,Outpatient,,,754.04,452.42,TC   ,34.14,100,,25.544,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.42,280,,33.92,Fee Schedule,280% of BCBS BULE Fee Schedule,1541.06,320,,137.152,Fee Schedule,320% of BCBS Blue Essentials Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,1733.69,360,,43.616,Fee Schedule,360% of BCBS POS Rate,1733.69,360,,43.616,Fee schedule,360% of BCBS PPO Rate,1733.69,360,,43.616,Fee Schedule,360% of BCBS Traditional Rate,1512.89,103,,7.04,Fee Schedule,103% of Cigna fee schedule,60.14,100,,0.304,Fee Schedule,100% of TX Mediciad Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,455.52,90,,,Fee Schedule,90% of CMS OPPS Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,657.98,130,,,Fee Schedule,130% of CMS OPPS Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,61.94,103,,0.312,Fee Schedule,103% of TX Medicaid Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,565.53,75,,2852.848,Percent of Total Billed Charges,75% of Total Billed Charges,377.02,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,236,Percent of Total Billed Charges,50% of Total Billed Charges,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,377.02,50,,236,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,2151.592,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.728,Case Rate,Pays based on per visit rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,754.04,100,,3803.792,Percent of Total Billed Charges,100% of Total Billed Charges,34.14,1733.69,
IR ABS FIST SINUS STUDY SI,49100924,CDM,320,RC,76080,HCPCS,Outpatient,,,754.04,452.42,TC   ,34.14,100,,248.224,Fee Schedule,100% of Aetna Fee Schedule,759.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.42,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,1541.06,320,,137.224,Fee Schedule,320% of BCBS Blue Essentials Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1733.69,360,,14.4,Fee Schedule,360% of BCBS POS Rate,1733.69,360,,14.4,Fee schedule,360% of BCBS PPO Rate,1733.69,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,1512.89,103,,15.664,Fee Schedule,103% of Cigna fee schedule,60.14,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,455.52,90,,,Fee Schedule,90% of CMS OPPS Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,657.98,130,,,Fee Schedule,130% of CMS OPPS Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,61.94,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,521.32,103,,,Fee Schedule,103% of CMS OPPS Rate,565.53,75,,2852.848,Percent of Total Billed Charges,75% of Total Billed Charges,377.02,50,,137.704,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,229.704,Percent of Total Billed Charges,50% of Total Billed Charges,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,377.02,50,,229.704,Percent of Total Billed Charges,50% of Total Billed Charges,377.02,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,759.2,150,,,Fee Schedule,150% of CMS OPPS Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,302.4,Case Rate,Pays based on per visit rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,60.14,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,506.13,100,,,Fee Schedule,100% of CMS OPPS Rate,754.04,100,,3803.792,Percent of Total Billed Charges,100% of Total Billed Charges,34.14,1733.69,
IR VENOGRAM RENAL SEL BI SI,49100927,CDM,320,RC,75833,HCPCS,Outpatient,,,4089,2453.40,,79.59,100,,274.12,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,137.728,Fee Schedule,320% of BCBS Blue Essentials Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,14.4,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,3.344,Fee Schedule,103% of Cigna fee schedule,147.01,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,151.42,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3066.75,75,,3954.04,Percent of Total Billed Charges,75% of Total Billed Charges,2044.5,50,,236,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,82.304,Percent of Total Billed Charges,50% of Total Billed Charges,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2044.5,50,,82.304,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,793.792,Case Rate,Pays based on per visit rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4089,100,,5272.056,Percent of Total Billed Charges,100% of Total Billed Charges,79.59,9976.61,
IR VENOGRAM RENAL SEL BI SI,49100927,CDM,320,RC,75833,HCPCS,Outpatient,,,4089,2453.40,,79.59,100,,154.592,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,14,Fee Schedule,320% of BCBS Blue Essentials Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,14.4,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,3.064,Fee Schedule,103% of Cigna fee schedule,147.01,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,151.42,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3066.75,75,,1482,Percent of Total Billed Charges,75% of Total Billed Charges,2044.5,50,,229.704,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2044.5,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,2044.5,50,,1351.592,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.016,Case Rate,Pays based on per visit rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,147.01,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4089,100,,1976,Percent of Total Billed Charges,100% of Total Billed Charges,79.59,9976.61,
IR VENOGRAM HEPATIC W HEMO SI,49100932,CDM,320,RC,75889,HCPCS,Outpatient,,,4129.3,2477.58,TC   ,75.75,100,,22.792,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,138.24,Fee Schedule,320% of BCBS Blue Essentials Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,14.4,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,0.888,Fee Schedule,103% of Cigna fee schedule,123.96,100,,3.664,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,127.68,103,,3.768,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3096.98,75,,1482,Percent of Total Billed Charges,75% of Total Billed Charges,2064.65,50,,82.304,Percent of Total Billed Charges,50% of Total Billed Charges,2064.65,50,,223.104,Percent of Total Billed Charges,50% of Total Billed Charges,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2064.65,50,,223.104,Percent of Total Billed Charges,50% of Total Billed Charges,2064.65,50,,581.504,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.064,Case Rate,Pays based on per visit rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,3.664,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4129.3,100,,1976,Percent of Total Billed Charges,100% of Total Billed Charges,75.75,9976.61,
IR VENOGRAM HEPATIC W HEMO SI,49100932,CDM,320,RC,75889,HCPCS,Outpatient,,,4129.3,2477.58,TC   ,75.75,100,,2.24,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,138.24,Fee Schedule,320% of BCBS Blue Essentials Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,14.4,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,0.2,Fee Schedule,103% of Cigna fee schedule,123.96,100,,1.376,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,127.68,103,,1.416,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3096.98,75,,1671.288,Percent of Total Billed Charges,75% of Total Billed Charges,2064.65,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,2064.65,50,,336.704,Percent of Total Billed Charges,50% of Total Billed Charges,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2064.65,50,,336.704,Percent of Total Billed Charges,50% of Total Billed Charges,2064.65,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,4.064,Case Rate,Pays based on per visit rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,123.96,100,,1.376,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4129.3,100,,2228.384,Percent of Total Billed Charges,100% of Total Billed Charges,75.75,9976.61,
IR ART PELVIC SELECTVE SI,49100935,CDM,323,RC,75736,HCPCS,Outpatient,,,5883.93,3530.36,,90.59,100,,11.912,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12869.33,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,14707.81,320,,138.24,Fee Schedule,320% of BCBS Blue Essentials Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,16546.28,360,,14.4,Fee Schedule,360% of BCBS POS Rate,16546.28,360,,14.4,Fee schedule,360% of BCBS PPO Rate,16546.28,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,13309.24,103,,11.528,Fee Schedule,103% of Cigna fee schedule,143.01,100,,5.696,Fee Schedule,100% of TX Mediciad Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4537.59,90,,,Fee Schedule,90% of CMS OPPS Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.3,130,,,Fee Schedule,130% of CMS OPPS Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,147.3,103,,5.864,Fee Schedule,103% of TX Medicaid Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,4412.95,75,,1671.288,Percent of Total Billed Charges,75% of Total Billed Charges,2941.97,50,,223.104,Percent of Total Billed Charges,50% of Total Billed Charges,2941.97,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2941.97,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,2941.97,50,,210,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,211.68,Case Rate,Pays based on per visit rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,5.696,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5883.93,100,,2228.384,Percent of Total Billed Charges,100% of Total Billed Charges,90.59,16546.28,
IR ART PELVIC SELECTVE SI,49100935,CDM,323,RC,75736,HCPCS,Outpatient,,,5883.93,3530.36,,90.59,100,,72.128,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12869.33,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,14707.81,320,,138.24,Fee Schedule,320% of BCBS Blue Essentials Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,16546.28,360,,14.4,Fee Schedule,360% of BCBS POS Rate,16546.28,360,,14.4,Fee schedule,360% of BCBS PPO Rate,16546.28,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,13309.24,103,,0.536,Fee Schedule,103% of Cigna fee schedule,143.01,100,,23.128,Fee Schedule,100% of TX Mediciad Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4537.59,90,,,Fee Schedule,90% of CMS OPPS Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.3,130,,,Fee Schedule,130% of CMS OPPS Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,147.3,103,,23.824,Fee Schedule,103% of TX Medicaid Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,4412.95,75,,514.4,Percent of Total Billed Charges,75% of Total Billed Charges,2941.97,50,,336.704,Percent of Total Billed Charges,50% of Total Billed Charges,2941.97,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2941.97,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,2941.97,50,,311.704,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,155.232,Case Rate,Pays based on per visit rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,143.01,100,,23.128,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5883.93,100,,685.864,Percent of Total Billed Charges,100% of Total Billed Charges,90.59,16546.28,
IR DRN ABS VISCERAL PERC,49100942,CDM,361,RC,49405,HCPCS,Outpatient,,,3803.53,2282.12,,4162,100,,0.408,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,11.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,80.56,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,14.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,14.4,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,14.4,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,1.416,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,548.47,14.42,,1.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2852.65,75,,4096.2,Percent of Total Billed Charges,75% of Total Billed Charges,1901.77,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,1901.77,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1901.77,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,1901.77,50,,193.904,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,60.936,Fee Schedule,100% of ASC Tier Groupings fee schedule,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3803.53,100,,5461.6,Percent of Total Billed Charges,100% of Total Billed Charges,80.56,5665,
IR DRN ABS PERITONEAL PERC,49100943,CDM,361,RC,49406,HCPCS,Outpatient,,,3811.83,2287.10,,4162,100,,81.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,4.568,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,80.64,32,,138.592,Percent of Total Billed Charges,32% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,5.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,5.872,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,5.872,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.304,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,549.67,14.42,,3.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2858.87,75,,2019.784,Percent of Total Billed Charges,75% of Total Billed Charges,1905.92,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1905.92,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,2523.104,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,35.4,Fee Schedule,100% of ASC Tier Groupings fee schedule,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3811.83,100,,2693.048,Percent of Total Billed Charges,100% of Total Billed Charges,80.64,5665,
IR LUMBAR PUNCTURE USING FLUOROSCOPIC GUIDANCE IN DX,49100946,CDM,361,RC,62328,HCPCS,Outpatient,,,1095.1,657.06,,75.08,100,,25.76,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,4.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,80.74,32,,138.664,Percent of Total Billed Charges,32% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,6.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,6.064,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,6.064,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,0.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,157.91,14.42,,0.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,821.33,75,,4054.888,Percent of Total Billed Charges,75% of Total Billed Charges,547.55,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,153.904,Percent of Total Billed Charges,50% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,547.55,50,,153.904,Percent of Total Billed Charges,50% of Total Billed Charges,547.55,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,47.704,Fee Schedule,100% of ASC Tier Groupings fee schedule,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.1,100,,5406.512,Percent of Total Billed Charges,100% of Total Billed Charges,75.08,2456,
PYELOGRAM ANTEGRADE SI,49100949,CDM,320,RC,74425,HCPCS,Outpatient,,,897.74,538.64,,111.72,100,,174.464,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,7.016,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,138.664,Fee Schedule,320% of BCBS Blue Essentials Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,9.024,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,9.024,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,9.024,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.56,Fee Schedule,103% of Cigna fee schedule,137.66,100,,0.712,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,141.79,103,,0.736,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,673.31,75,,3623.08,Percent of Total Billed Charges,75% of Total Billed Charges,448.87,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,448.87,50,,199.704,Percent of Total Billed Charges,50% of Total Billed Charges,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,448.87,50,,199.704,Percent of Total Billed Charges,50% of Total Billed Charges,448.87,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,14.72,Case Rate,Pays based on per visit rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,897.74,100,,4830.776,Percent of Total Billed Charges,100% of Total Billed Charges,111.72,1374.66,
PYELOGRAM ANTEGRADE SI,49100949,CDM,320,RC,74425,HCPCS,Outpatient,,,897.74,538.64,,111.72,100,,233.56,Fee Schedule,100% of Aetna Fee Schedule,529.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,139.296,Fee Schedule,320% of BCBS Blue Essentials Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,14.4,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,14.4,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,1173.48,103,,0.592,Fee Schedule,103% of Cigna fee schedule,137.66,100,,0.208,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.68,130,,,Fee Schedule,130% of CMS OPPS Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,141.79,103,,0.216,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,673.31,75,,2032.848,Percent of Total Billed Charges,75% of Total Billed Charges,448.87,50,,153.904,Percent of Total Billed Charges,50% of Total Billed Charges,448.87,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,448.87,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,448.87,50,,137.704,Percent of Total Billed Charges,50% of Total Billed Charges,529.24,150,,,Fee Schedule,150% of CMS OPPS Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,114.864,Case Rate,Pays based on per visit rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,137.66,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,897.74,100,,2710.464,Percent of Total Billed Charges,100% of Total Billed Charges,111.72,1374.66,
PERC CHOLECYSTM,49100986,CDM,361,RC,,,Outpatient,,,3010.09,1806.05,,1806.05,60,,201.04,Percent of Total Billed Charges,60% of Total Billed Charges,1354.54,45,,1083.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,842.83,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,80.87,32,,139.72,Percent of Total Billed Charges,32% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1083.63,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,1083.63,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,1083.63,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,1806.05,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3010.09,100,,2408.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,434.05,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2257.57,75,,1138.192,Percent of Total Billed Charges,75% of Total Billed Charges,1505.05,50,,199.704,Percent of Total Billed Charges,50% of Total Billed Charges,1505.05,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1505.05,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,1505.05,50,,236,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2107.06,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,421.41,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3010.09,100,,1517.584,Percent of Total Billed Charges,100% of Total Billed Charges,80.87,3010.09,
IR TRNSCATH STNT ART EA ADD,49100988,CDM,361,RC,37237,HCPCS,Outpatient,,,13197.92,7918.75,,2601,100,,4.88,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5939.06,45,,4751.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,139.88,Other,Not Seperately Reimbusable,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7918.75,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13197.92,100,,10558.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1903.14,14.42,,2.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9898.44,75,,3257.944,Percent of Total Billed Charges,75% of Total Billed Charges,6598.96,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,6598.96,50,,57.704,Percent of Total Billed Charges,50% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6598.96,50,,57.704,Percent of Total Billed Charges,50% of Total Billed Charges,6598.96,50,,229.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,204.168,Fee Schedule,100% of ASC Tier Groupings fee schedule,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,1847.71,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13197.92,100,,4343.928,Percent of Total Billed Charges,100% of Total Billed Charges,1847.71,13197.92,
IR TRNSCATH STNT ART INI,49100989,CDM,361,RC,37236,HCPCS,Outpatient,,,22033.78,13220.27,,4682,100,,16.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,38.848,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,81.13,32,,139.88,Percent of Total Billed Charges,32% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,49.944,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,49.944,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,49.944,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,1.136,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3177.27,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,16525.34,75,,1924.816,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,27.304,Percent of Total Billed Charges,50% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,27.304,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,82.304,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,40.048,Fee Schedule,100% of ASC Tier Groupings fee schedule,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,3084.73,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,22033.78,100,,2566.424,Percent of Total Billed Charges,100% of Total Billed Charges,81.13,31905.31,
IR TRNSCATH HEMORRHAGE,49100990,CDM,360,RC,37244,HCPCS,Outpatient,,,25138.58,15083.15,,4682,100,,388.36,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,24.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,81.13,32,,140.008,Percent of Total Billed Charges,32% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,31.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,31.376,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,31.376,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,0.528,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3624.98,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,18853.94,75,,969.208,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,57.704,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,39.12,Percent of Total Billed Charges,50% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,39.12,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,275.2,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,121.68,Fee Schedule,100% of ASC Tier Groupings fee schedule,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,25138.58,100,,1292.272,Percent of Total Billed Charges,100% of Total Billed Charges,81.13,31905.31,
IR TRNSCATH TUMOR INFARCT,49100991,CDM,361,RC,37243,HCPCS,Outpatient,,,25138.58,15083.15,,4682,100,,18.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,81.16,32,,140.04,Percent of Total Billed Charges,32% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,3.496,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,3.496,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,3.496,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,0.656,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3624.98,14.42,,0.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,18853.94,75,,3154.2,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,27.304,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,223.104,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,69.632,Fee Schedule,100% of ASC Tier Groupings fee schedule,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,25138.58,100,,4205.6,Percent of Total Billed Charges,100% of Total Billed Charges,81.16,31905.31,
IR TRNSCATH ART NON HEMORRHAGE,49100992,CDM,361,RC,37242,HCPCS,Outpatient,,,25138.58,15083.15,,4682,100,,5.528,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,8.48,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,81.28,32,,140.04,Percent of Total Billed Charges,32% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,10.904,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,10.904,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,10.904,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,0.632,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3624.98,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,18853.94,75,,1138.192,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,39.12,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,336.704,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,52.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,25138.58,100,,1517.584,Percent of Total Billed Charges,100% of Total Billed Charges,81.28,31905.31,
IR TRNSCATH VEN NON HEMORRHAGE,49100993,CDM,361,RC,,,Outpatient,,,25138.58,15083.15,,15083.15,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,11312.36,45,,9049.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7038.8,28,,13.736,Percent of Total Billed Charges,28% of Total Billed Charges,81.28,32,,140.624,Percent of Total Billed Charges,32% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,9049.89,36,,17.656,Percent of Total Billed Charges,36% of Total Billed Charges,9049.89,36,,17.656,Percent of Total Billed Charges,36% Total Bille Charges,9049.89,36,,17.656,Percent of Total Billed Charges,36% of Total Billed Charges,15083.15,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25138.58,100,,20110.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3624.98,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18853.94,75,,1295.552,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,555.936,Percent of Total Billed Charges,50% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,555.936,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17597.01,70,,63.704,Percent of Total Billed Charges,70% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,3519.4,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25138.58,100,,1727.4,Percent of Total Billed Charges,100% of Total Billed Charges,81.28,25138.58,
IR TRNSCATH STNT VEN EA ADD,49100994,CDM,361,RC,37239,HCPCS,Outpatient,,,15502.2,9301.32,,2601,100,,36.608,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,6975.99,45,,5580.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,140.624,Other,Not Seperately Reimbusable,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9301.32,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15502.2,100,,12401.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2235.42,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11626.65,75,,3257.944,Percent of Total Billed Charges,75% of Total Billed Charges,7751.1,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,7751.1,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7751.1,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,7751.1,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7651,100,,43.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2170.31,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15502.2,100,,4343.928,Percent of Total Billed Charges,100% of Total Billed Charges,2170.31,15502.2,
IR TRNSCATH STNT VEN INI,49100995,CDM,361,RC,37238,HCPCS,Outpatient,,,22645.35,13587.21,,4682,100,,319.904,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,17.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,81.73,32,,140.624,Percent of Total Billed Charges,32% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,22.576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,22.576,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,22.576,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,124.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3265.46,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,16984.01,75,,26674.008,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,555.936,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,331.6,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,12.368,Fee Schedule,100% of ASC Tier Groupings fee schedule,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,3170.35,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,22645.35,100,,35565.344,Percent of Total Billed Charges,100% of Total Billed Charges,81.73,31905.31,
IR IVC FILTER PLCMT COMP,49100998,CDM,361,RC,,,Outpatient,,,9798.85,5879.31,,5879.31,60,,17.6,Percent of Total Billed Charges,60% of Total Billed Charges,4409.48,45,,3527.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2743.68,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,81.92,32,,140.656,Percent of Total Billed Charges,32% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,3527.59,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,3527.59,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,3527.59,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,5879.31,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9798.85,100,,7839.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1412.99,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7349.14,75,,31376.592,Percent of Total Billed Charges,75% of Total Billed Charges,4899.43,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,4899.43,50,,439.184,Percent of Total Billed Charges,50% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4899.43,50,,439.184,Percent of Total Billed Charges,50% of Total Billed Charges,4899.43,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6859.2,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1371.84,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9798.85,100,,41835.456,Percent of Total Billed Charges,100% of Total Billed Charges,81.92,9798.85,
THORACENTESIS W/IMAGING,49101000,CDM,361,RC,,,Outpatient,,,1598.97,959.38,,959.38,60,,10.016,Percent of Total Billed Charges,60% of Total Billed Charges,719.54,45,,575.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.71,28,,1.616,Percent of Total Billed Charges,28% of Total Billed Charges,81.92,32,,14305.168,Percent of Total Billed Charges,32% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,575.63,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,575.63,36,,2.08,Percent of Total Billed Charges,36% Total Bille Charges,575.63,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,959.38,60,,1,Percent of Total Billed Charges,60% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.97,100,,1279.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,230.57,14.42,,0.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.23,75,,31376.592,Percent of Total Billed Charges,75% of Total Billed Charges,799.49,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,473.416,Percent of Total Billed Charges,50% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.49,50,,473.416,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,153.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1119.28,70,,68.272,Percent of Total Billed Charges,70% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.97,100,,41835.456,Percent of Total Billed Charges,100% of Total Billed Charges,81.92,1598.97,
IR CATH RENAL COMP 1ST ORD LT,49101001,CDM,361,RC,,,Outpatient,,,6910.22,4146.13,,4146.13,60,,31.68,Percent of Total Billed Charges,60% of Total Billed Charges,3109.6,45,,2487.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1934.86,28,,0.712,Percent of Total Billed Charges,28% of Total Billed Charges,81.92,32,,14.096,Percent of Total Billed Charges,32% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,2487.68,36,,0.92,Percent of Total Billed Charges,36% of Total Billed Charges,2487.68,36,,0.92,Percent of Total Billed Charges,36% Total Bille Charges,2487.68,36,,0.92,Percent of Total Billed Charges,36% of Total Billed Charges,4146.13,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6910.22,100,,5528.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,996.45,14.42,,0.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5182.67,75,,15501.24,Percent of Total Billed Charges,75% of Total Billed Charges,3455.11,50,,439.184,Percent of Total Billed Charges,50% of Total Billed Charges,3455.11,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3455.11,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,3455.11,50,,199.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4837.15,70,,43.728,Percent of Total Billed Charges,70% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,967.43,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6910.22,100,,20668.32,Percent of Total Billed Charges,100% of Total Billed Charges,81.92,6910.22,
IR CATH RENAL COMP 1ST ORD BI,49101003,CDM,361,RC,,,Outpatient,,,8335.85,5001.51,,5001.51,60,,13.552,Percent of Total Billed Charges,60% of Total Billed Charges,3751.13,45,,3000.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2334.04,28,,1.336,Percent of Total Billed Charges,28% of Total Billed Charges,81.92,32,,14.12,Percent of Total Billed Charges,32% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3000.91,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,3000.91,36,,1.72,Percent of Total Billed Charges,36% Total Bille Charges,3000.91,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,5001.51,60,,6.928,Percent of Total Billed Charges,60% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8335.85,100,,6668.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1202.03,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6251.89,75,,15501.24,Percent of Total Billed Charges,75% of Total Billed Charges,4167.93,50,,473.416,Percent of Total Billed Charges,50% of Total Billed Charges,4167.93,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4167.93,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,4167.93,50,,29,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5835.1,70,,18.784,Percent of Total Billed Charges,70% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1167.02,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8335.85,100,,20668.32,Percent of Total Billed Charges,100% of Total Billed Charges,81.92,8335.85,
IR CATH RENAL COMP SUPRSEL LT,49101004,CDM,361,RC,,,Outpatient,,,7448.4,4469.04,,4469.04,60,,21.664,Percent of Total Billed Charges,60% of Total Billed Charges,3351.78,45,,2681.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2085.55,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,82.06,32,,14.16,Percent of Total Billed Charges,32% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,2681.42,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,2681.42,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,2681.42,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,4469.04,60,,6.928,Percent of Total Billed Charges,60% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7448.4,100,,5958.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1074.06,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5586.3,75,,370.976,Percent of Total Billed Charges,75% of Total Billed Charges,3724.2,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,3724.2,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3724.2,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,3724.2,50,,41.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5213.88,70,,21.96,Percent of Total Billed Charges,70% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1042.78,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7448.4,100,,494.632,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,7448.4,
IR TRNSCTH INTCR NON THROM INI,49101100,CDM,361,RC,61650,HCPCS,Outpatient,,,6719.13,4031.48,,469.23,100,,21.232,Fee Schedule,100% of Aetna Fee Schedule,6719.13,100,,,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1351.94,233,,0.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.06,32,,14.24,Percent of Total Billed Charges,32% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,1868.34,322,,1.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1868.34,322,,1.12,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1868.34,322,,1.12,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,0.08,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,968.9,14.42,,0.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5039.35,75,,370.976,Percent of Total Billed Charges,75% of Total Billed Charges,3359.57,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,3359.57,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3359.57,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,3359.57,50,,57.704,Percent of Total Billed Charges,50% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,43.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,940.68,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,6719.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6719.13,100,,494.632,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,6719.13,
IR TRNSCTH INTCR NON THROM ADD,49101101,CDM,361,RC,61651,HCPCS,Outpatient,,,3400,2040.00,,200.83,100,,21.232,Fee Schedule,100% of Aetna Fee Schedule,3400,100,,,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,588.63,233,,183.656,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.06,32,,14.304,Percent of Total Billed Charges,32% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,813.47,322,,236.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,813.47,322,,236.128,Fee schedule,Pays based on ASC Tier Groupings fee schedule,813.47,322,,236.128,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,0.248,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,490.28,14.42,,30.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2550,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,1700,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,1700,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1700,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,1700,50,,27.304,Percent of Total Billed Charges,50% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,193.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,476,14,,29.152,Percent of Total Billed Charges,14% of Total Billed Charges,3400,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3400,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,3862.5,
IR CHOLANGIOGRAM EXIST W GUIDE,49101102,CDM,361,RC,47531,HCPCS,Outpatient,,,3457,2074.20,,2601,100,,71.992,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,1.896,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.06,32,,14.336,Percent of Total Billed Charges,32% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,2.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,2.44,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,2.44,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,0.184,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.7,90,,,Fee Schedule,90% of CMS OPPS Rate,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,498.5,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2592.75,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,1728.5,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,1728.5,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1728.5,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,1728.5,50,,39.12,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,22.544,Fee Schedule,100% of ASC Tier Groupings fee schedule,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,483.98,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3457,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,10012.07,
IR CHOLANGIOGRAM NEW W GUIDE,49101103,CDM,361,RC,47532,HCPCS,Outpatient,,,4629.42,2777.65,,4162,100,,9.368,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,2.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.06,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,3.056,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,3.056,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,3.056,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.448,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.7,90,,,Fee Schedule,90% of CMS OPPS Rate,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,667.56,14.42,,0.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3472.07,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,2314.71,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,2314.71,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2314.71,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,2314.71,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,5768.648,Fee Schedule,100% of ASC Tier Groupings fee schedule,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,648.12,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4629.42,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,10012.07,
IR DRN BILIARY PLACE EXTERNAL,49101105,CDM,361,RC,47533,HCPCS,Outpatient,,,5214.64,3128.78,,4162,100,,133.424,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,9.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.06,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,12.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,12.56,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,12.56,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.84,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.69,90,,,Fee Schedule,90% of CMS OPPS Rate,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,751.95,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3910.98,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,2607.32,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,2607.32,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2607.32,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,2607.32,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,399.44,Fee Schedule,100% of ASC Tier Groupings fee schedule,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,730.05,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,5214.64,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,82.06,10012.07,
IR DRN BILIARY PLACE INT EXT,49101106,CDM,361,RC,47534,HCPCS,Outpatient,,,5258.06,3154.84,,4162,100,,20.184,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,10.256,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.19,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,13.184,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,13.184,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,13.184,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,8.432,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.69,90,,,Fee Schedule,90% of CMS OPPS Rate,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,758.21,14.42,,1.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3943.55,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,2629.03,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,2629.03,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2629.03,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,2629.03,50,,555.936,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,8.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,736.13,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,5258.06,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,82.19,10012.07,
IR DRN BILIARY CNVERT EXT-INT,49101107,CDM,361,RC,47535,HCPCS,Outpatient,,,5469.52,3281.71,,4162,100,,90.008,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,18.32,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,82.87,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,23.552,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,23.552,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,23.552,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.288,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.69,90,,,Fee Schedule,90% of CMS OPPS Rate,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,788.7,14.42,,1.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,4102.14,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,2734.76,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,2734.76,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2734.76,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,2734.76,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,40.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,765.73,14,,1.616,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,5469.52,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,82.87,10012.07,
IR DRN BILIARY EXCHG OR CNVERT,49101108,CDM,361,RC,47536,HCPCS,Outpatient,,,4757.3,2854.38,,4162,100,,62.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4761.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7244.76,233,,40.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.06,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,10012.07,322,,51.96,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10012.07,322,,51.96,Fee schedule,Pays based on ASC Tier Groupings fee schedule,10012.07,322,,51.96,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.776,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2856.69,90,,,Fee Schedule,90% of CMS OPPS Rate,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4126.34,130,,,Fee Schedule,130% of CMS OPPS Rate,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,686,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3269.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3567.98,75,,305.4,Percent of Total Billed Charges,75% of Total Billed Charges,2378.65,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,2378.65,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2378.65,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,2378.65,50,,960.768,Percent of Total Billed Charges,50% of Total Billed Charges,4761.16,150,,,Fee Schedule,150% of CMS OPPS Rate,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,11.528,Fee Schedule,100% of ASC Tier Groupings fee schedule,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,666.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3174.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4757.3,100,,407.2,Percent of Total Billed Charges,100% of Total Billed Charges,83.06,10012.07,
IR DRN BILIARY REMOVE,49101109,CDM,361,RC,47537,HCPCS,Outpatient,,,1565.29,939.17,,2601,100,,146.36,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1247.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1831.19,233,,55.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8320,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,2530.66,322,,70.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2530.66,322,,70.872,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2530.66,322,,70.872,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,0.264,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.16,130,,,Fee Schedule,130% of CMS OPPS Rate,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,225.71,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.97,75,,305.4,Percent of Total Billed Charges,75% of Total Billed Charges,782.65,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,782.65,50,,326.36,Percent of Total Billed Charges,50% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,782.65,50,,326.36,Percent of Total Billed Charges,50% of Total Billed Charges,782.65,50,,439.184,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,86.592,Fee Schedule,100% of ASC Tier Groupings fee schedule,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.14,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.29,100,,407.2,Percent of Total Billed Charges,100% of Total Billed Charges,219.14,8320,
IR STENT BIL PLCMT EXIST ACC,49101110,CDM,361,RC,47538,HCPCS,Outpatient,,,8618.47,5171.08,,4682,100,,20.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7940.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11262.54,233,,1.384,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8320,32,,141.424,Percent of Total Billed Charges,32% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,15564.55,322,,1.776,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15564.55,322,,1.776,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15564.55,322,,1.776,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.32,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4764.35,90,,,Fee Schedule,90% of CMS OPPS Rate,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6881.85,130,,,Fee Schedule,130% of CMS OPPS Rate,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1242.78,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,6463.85,75,,6962.008,Percent of Total Billed Charges,75% of Total Billed Charges,4309.24,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,4309.24,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4309.24,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4309.24,50,,473.416,Percent of Total Billed Charges,50% of Total Billed Charges,7940.6,150,,,Fee Schedule,150% of CMS OPPS Rate,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,137.928,Fee Schedule,100% of ASC Tier Groupings fee schedule,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,1206.59,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8618.47,100,,9282.68,Percent of Total Billed Charges,100% of Total Billed Charges,1206.59,15564.55,
IR STENT BIL PLCMT NEW ACC,49101111,CDM,361,RC,47539,HCPCS,Outpatient,,,8537,5122.20,,4682,100,,22.496,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7940.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11262.54,233,,0.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8320,32,,141.424,Percent of Total Billed Charges,32% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,15564.55,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15564.55,322,,0.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15564.55,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4764.35,90,,,Fee Schedule,90% of CMS OPPS Rate,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6881.85,130,,,Fee Schedule,130% of CMS OPPS Rate,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1231.04,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,6402.75,75,,7859.848,Percent of Total Billed Charges,75% of Total Billed Charges,4268.5,50,,326.36,Percent of Total Billed Charges,50% of Total Billed Charges,4268.5,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4268.5,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4268.5,50,,1524.736,Percent of Total Billed Charges,50% of Total Billed Charges,7940.6,150,,,Fee Schedule,150% of CMS OPPS Rate,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,137.928,Fee Schedule,100% of ASC Tier Groupings fee schedule,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1195.18,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8537,100,,10479.792,Percent of Total Billed Charges,100% of Total Billed Charges,1195.18,15564.55,
IR STENT BIL NEW W SEP CATH,49101112,CDM,361,RC,47540,HCPCS,Outpatient,,,10236.64,6141.98,,4682,100,,0.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7940.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11262.54,233,,1.904,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8416,32,,141.52,Percent of Total Billed Charges,32% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,15564.55,322,,2.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15564.55,322,,2.448,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15564.55,322,,2.448,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.752,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4764.35,90,,,Fee Schedule,90% of CMS OPPS Rate,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6881.85,130,,,Fee Schedule,130% of CMS OPPS Rate,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1476.12,14.42,,0.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,5452.54,103,,,Fee Schedule,103% of CMS OPPS Rate,7677.48,75,,2168.656,Percent of Total Billed Charges,75% of Total Billed Charges,5118.32,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,5118.32,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5118.32,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,5118.32,50,,1543.504,Percent of Total Billed Charges,50% of Total Billed Charges,7940.6,150,,,Fee Schedule,150% of CMS OPPS Rate,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,197.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1433.13,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,5293.73,100,,,Fee Schedule,100% of CMS OPPS Rate,10236.64,100,,2891.544,Percent of Total Billed Charges,100% of Total Billed Charges,1433.13,15564.55,
IR CATH NEPHRO PLACEMENT BI,49101114,CDM,361,RC,50432,HCPCS,Outpatient,,,7125,4275.00,,4162,100,,6.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,1.832,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8484.13,32,,141.696,Percent of Total Billed Charges,32% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,2.352,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,2.352,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,2.352,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,5.936,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1027.43,14.42,,2.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,5343.75,75,,18130.544,Percent of Total Billed Charges,75% of Total Billed Charges,3562.5,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,3562.5,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3562.5,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,3562.5,50,,2315.256,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,86.592,Fee Schedule,100% of ASC Tier Groupings fee schedule,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7125,100,,24174.056,Percent of Total Billed Charges,100% of Total Billed Charges,997.5,8484.13,
IR CATH NEPHRO PLACEMENT RT,49101115,CDM,361,RC,50432,HCPCS,Outpatient,,,4750,2850.00,,4162,100,,3.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,0.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8484.13,32,,141.824,Percent of Total Billed Charges,32% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,0.112,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,0.112,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,0.112,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,12.384,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,684.95,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3562.5,75,,12087.024,Percent of Total Billed Charges,75% of Total Billed Charges,2375,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2375,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,168,Fee Schedule,100% of ASC Tier Groupings fee schedule,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4750,100,,16116.032,Percent of Total Billed Charges,100% of Total Billed Charges,665,8484.13,
IR CATH NEPHRO PLACEMENT LT,49101116,CDM,361,RC,50432,HCPCS,Outpatient,,,4750,2850.00,,4162,100,,3.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,2.072,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8484.13,32,,141.944,Percent of Total Billed Charges,32% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,2.664,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,2.664,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,2.664,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,0.104,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,684.95,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3562.5,75,,12087.024,Percent of Total Billed Charges,75% of Total Billed Charges,2375,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2375,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,259.504,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,261.696,Fee Schedule,100% of ASC Tier Groupings fee schedule,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4750,100,,16116.032,Percent of Total Billed Charges,100% of Total Billed Charges,665,8484.13,
IR CATH NEPHROURET PLACE BI,49101117,CDM,361,RC,50433,HCPCS,Outpatient,,,6821.1,4092.66,,4162,100,,3.704,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,3.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8484.13,32,,142.048,Percent of Total Billed Charges,32% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,4.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,4.032,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,4.032,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,0.608,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,983.6,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,5115.83,75,,1122.4,Percent of Total Billed Charges,75% of Total Billed Charges,3410.55,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,3410.55,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3410.55,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,3410.55,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,238.48,Fee Schedule,100% of ASC Tier Groupings fee schedule,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6821.1,100,,1496.528,Percent of Total Billed Charges,100% of Total Billed Charges,954.95,9719.7,
IR CATH NEPHROURET PLACE RT,49101118,CDM,361,RC,50433,HCPCS,Outpatient,,,4547.4,2728.44,,4162,100,,3.704,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8484.13,32,,142.216,Percent of Total Billed Charges,32% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.048,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.048,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.048,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,0.64,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,655.74,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3410.55,75,,748.024,Percent of Total Billed Charges,75% of Total Billed Charges,2273.7,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2273.7,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,2.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4547.4,100,,997.36,Percent of Total Billed Charges,100% of Total Billed Charges,636.64,9719.7,
IR CATH NEPHROURET PLACE LT,49101119,CDM,361,RC,50433,HCPCS,Outpatient,,,4547.4,2728.44,,4162,100,,38.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,2.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8488.95,32,,142.784,Percent of Total Billed Charges,32% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,3.384,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,3.384,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,3.384,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,0.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,655.74,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3410.55,75,,1179.216,Percent of Total Billed Charges,75% of Total Billed Charges,2273.7,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2273.7,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,978.536,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,12.848,Fee Schedule,100% of ASC Tier Groupings fee schedule,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4547.4,100,,1572.288,Percent of Total Billed Charges,100% of Total Billed Charges,636.64,9719.7,
IR CATH CNVERT TO NEPHOURET BI,49101120,CDM,361,RC,50434,HCPCS,Outpatient,,,5019.85,3011.91,,2601,100,,31.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,0.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8627.88,32,,14357.376,Percent of Total Billed Charges,32% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,0.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,6.976,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,723.86,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3764.89,75,,1481.76,Percent of Total Billed Charges,75% of Total Billed Charges,2509.93,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,2509.93,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2509.93,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,2509.93,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,84.896,Fee Schedule,100% of ASC Tier Groupings fee schedule,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5019.85,100,,1975.68,Percent of Total Billed Charges,100% of Total Billed Charges,702.78,8627.88,
IR CATH CNVERT TO NEPHOURET RT,49101121,CDM,361,RC,50434,HCPCS,Outpatient,,,3346.57,2007.94,,2601,100,,80.152,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,1.944,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8627.88,32,,14541.312,Percent of Total Billed Charges,32% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,2.496,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,2.496,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,2.496,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.536,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,482.58,14.42,,1.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2509.93,75,,576.68,Percent of Total Billed Charges,75% of Total Billed Charges,1673.29,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.29,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,97.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3346.57,100,,768.904,Percent of Total Billed Charges,100% of Total Billed Charges,468.52,8627.88,
IR CATH CNVERT TO NEPHOURET LT,49101122,CDM,361,RC,50434,HCPCS,Outpatient,,,3346.57,2007.94,,2601,100,,85.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,0.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8627.88,32,,14.432,Percent of Total Billed Charges,32% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,0.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.232,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,482.58,14.42,,2.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2509.93,75,,576.68,Percent of Total Billed Charges,75% of Total Billed Charges,1673.29,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.29,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,40.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3346.57,100,,768.904,Percent of Total Billed Charges,100% of Total Billed Charges,468.52,8627.88,
IR URETRL STENT PLCMT BI,49101124,CDM,361,RC,50693,HCPCS,Outpatient,,,8007.07,4804.24,,4682,100,,25.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.76,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.36,32,,14.552,Percent of Total Billed Charges,32% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.264,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.264,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.264,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,6.496,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1154.62,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6005.3,75,,1384.632,Percent of Total Billed Charges,75% of Total Billed Charges,4003.54,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,409.248,Percent of Total Billed Charges,50% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4003.54,50,,409.248,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,326.36,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,239.4,Fee Schedule,100% of ASC Tier Groupings fee schedule,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.07,100,,1846.176,Percent of Total Billed Charges,100% of Total Billed Charges,8.36,9719.7,
IR URETRL STENT PLCMT LT,49101125,CDM,361,RC,50693,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,90.008,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,0.264,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.37,32,,14.568,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,0.336,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,0.336,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,0.336,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,6.112,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,2626.704,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,78.56,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,3502.272,Percent of Total Billed Charges,100% of Total Billed Charges,8.37,9719.7,
IR URETRL STENT PLCMT RT,49101126,CDM,361,RC,50693,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,98.256,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.824,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.38,32,,14.568,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.344,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.344,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,1.744,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,3448.2,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,409.248,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,28.24,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,4597.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.38,9719.7,
IR URETRL STENT NEW ACCESS BI,49101127,CDM,361,RC,50694,HCPCS,Outpatient,,,8007.07,4804.24,,4682,100,,879.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,0.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.4,32,,14.584,Percent of Total Billed Charges,32% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,0.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,0.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,8.984,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1154.62,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6005.3,75,,3930,Percent of Total Billed Charges,75% of Total Billed Charges,4003.54,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4003.54,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,245.752,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,22.432,Fee Schedule,100% of ASC Tier Groupings fee schedule,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.07,100,,5240,Percent of Total Billed Charges,100% of Total Billed Charges,8.4,9719.7,
IR URETRL STENT NEW ACCESS LT,49101128,CDM,361,RC,50694,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,0.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.896,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.41,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.44,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.44,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,2.912,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,1.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,3930,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,35.848,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,1.632,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,5240,Percent of Total Billed Charges,100% of Total Billed Charges,8.41,9719.7,
IR URETRL STENT NEW ACCESS RT,49101129,CDM,361,RC,50694,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,106.112,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,4.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.44,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,5.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,5.192,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,5.192,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,6.232,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,8617.336,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,286.072,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,478.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,11489.776,Percent of Total Billed Charges,100% of Total Billed Charges,8.44,9719.7,
IR URETRL STENT W SEP CATH BI,49101130,CDM,361,RC,50695,HCPCS,Outpatient,,,7972.42,4783.45,,4682,100,,126.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,2.48,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.44,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,3.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,3.192,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,3.192,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.08,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1149.62,14.42,,1.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,5979.32,75,,13735.096,Percent of Total Billed Charges,75% of Total Billed Charges,3986.21,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,3986.21,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3986.21,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,3986.21,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,9.128,Fee Schedule,100% of ASC Tier Groupings fee schedule,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7972.42,100,,18313.464,Percent of Total Billed Charges,100% of Total Billed Charges,8.44,9719.7,
IR URETRL STENT W SEP CATH LT,49101131,CDM,361,RC,50695,HCPCS,Outpatient,,,5314.94,3188.96,,4682,100,,283.488,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.44,32,,143.464,Percent of Total Billed Charges,32% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.008,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.008,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.008,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.112,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,766.41,14.42,,0.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3986.21,75,,17626.6,Percent of Total Billed Charges,75% of Total Billed Charges,2657.47,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2657.47,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,211.656,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,32.36,Fee Schedule,100% of ASC Tier Groupings fee schedule,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5314.94,100,,23502.128,Percent of Total Billed Charges,100% of Total Billed Charges,8.44,9719.7,
IR URETRL STENT W SEP CATH RT,49101132,CDM,361,RC,50695,HCPCS,Outpatient,,,5314.94,3188.96,,4682,100,,333.496,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,31.544,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.48,32,,143.48,Percent of Total Billed Charges,32% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,40.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,40.56,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,40.56,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.28,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,766.41,14.42,,2.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3986.21,75,,11751.064,Percent of Total Billed Charges,75% of Total Billed Charges,2657.47,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2657.47,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,190.984,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,9.128,Fee Schedule,100% of ASC Tier Groupings fee schedule,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5314.94,100,,15668.088,Percent of Total Billed Charges,100% of Total Billed Charges,8.48,9719.7,
IR INJ NEPH WWO URETR NEW BI,49101133,CDM,361,RC,50430,HCPCS,Outpatient,,,2985.47,1791.28,,2601,100,,6.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,38.056,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.48,32,,144.128,Percent of Total Billed Charges,32% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,48.936,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,48.936,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,48.936,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,14.864,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,430.5,14.42,,0.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.1,75,,11751.064,Percent of Total Billed Charges,75% of Total Billed Charges,1492.74,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1492.74,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,24.568,Fee Schedule,100% of ASC Tier Groupings fee schedule,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.47,100,,15668.088,Percent of Total Billed Charges,100% of Total Billed Charges,8.48,3347.5,
IR INJ NEPH WWO URETR NEW LT,49101134,CDM,361,RC,50430,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,8.384,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,3.624,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.57,32,,144.176,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,4.656,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,4.656,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,4.656,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,14.864,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,1.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,27635.176,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,391,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,143.056,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,36846.904,Percent of Total Billed Charges,100% of Total Billed Charges,8.57,3347.5,
IR INJ NEPH WWO URETR NEW RT,49101135,CDM,361,RC,50430,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,2.576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,2.648,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.58,32,,144.896,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,3.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,3.4,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,3.4,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.424,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,42,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.58,3347.5,
IR INJ NEPH WWO URETR EXIST BI,49101136,CDM,361,RC,50431,HCPCS,Outpatient,,,2985.47,1791.28,,2601,100,,8.384,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,2.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.2,32,,145.32,Percent of Total Billed Charges,32% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,2.656,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,2.656,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,2.656,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.592,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,430.5,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.1,75,,18423.448,Percent of Total Billed Charges,75% of Total Billed Charges,1492.74,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1492.74,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,298.56,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,145.568,Fee Schedule,100% of ASC Tier Groupings fee schedule,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.47,100,,24564.6,Percent of Total Billed Charges,100% of Total Billed Charges,83.2,3347.5,
IR INJ NEPH WWO URETR EXIST LT,49101137,CDM,361,RC,50431,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,23.792,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,0.832,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.3,32,,145.408,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,1.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,1.064,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,1.064,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.792,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,14550.064,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,409.248,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,84.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,19400.08,Percent of Total Billed Charges,100% of Total Billed Charges,83.3,3347.5,
IR INJ NEPH WWO URETR EXIST RT,49101138,CDM,361,RC,50431,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,35.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,2.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.4,32,,145.472,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,2.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,2.92,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,2.92,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.784,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,4500,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,8.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,6000,Percent of Total Billed Charges,100% of Total Billed Charges,83.4,3347.5,
IR TUBE CHG NEPHROSTOMY BI,49101139,CDM,361,RC,50435,HCPCS,Outpatient,,,3722.62,2233.57,,2601,100,,201.6,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,6.408,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.52,32,,145.664,Percent of Total Billed Charges,32% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,8.24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,8.24,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,8.24,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,35.32,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,536.8,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2791.97,75,,3000,Percent of Total Billed Charges,75% of Total Billed Charges,1861.31,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,1861.31,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1861.31,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1861.31,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,12.088,Fee Schedule,100% of ASC Tier Groupings fee schedule,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3722.62,100,,4000,Percent of Total Billed Charges,100% of Total Billed Charges,83.52,5704.39,
IR TUBE CHG NEPHROSTOMY LT,49101140,CDM,361,RC,50435,HCPCS,Outpatient,,,2481.75,1489.05,,2601,100,,30.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,18,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.74,32,,145.88,Percent of Total Billed Charges,32% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,23.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,23.136,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,23.136,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,5.856,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,357.87,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1861.31,75,,3000,Percent of Total Billed Charges,75% of Total Billed Charges,1240.88,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1240.88,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,24.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2481.75,100,,4000,Percent of Total Billed Charges,100% of Total Billed Charges,83.74,5704.39,
IR TUBE CHG NEPHROSTOMY RT,49101141,CDM,361,RC,50435,HCPCS,Outpatient,,,2481.75,1489.05,,2601,100,,30.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,1.16,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.84,32,,14.728,Percent of Total Billed Charges,32% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,1.488,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,1.488,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,1.488,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,632.504,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,357.87,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1861.31,75,,3527.24,Percent of Total Billed Charges,75% of Total Billed Charges,1240.88,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1240.88,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,313.784,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,97.168,Fee Schedule,100% of ASC Tier Groupings fee schedule,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2481.75,100,,4702.984,Percent of Total Billed Charges,100% of Total Billed Charges,83.84,5704.39,
IR ASP RENAL CYST BI,49107349,CDM,361,RC,,,Outpatient,,,3001.6,1800.96,,1800.96,60,,23.904,Percent of Total Billed Charges,60% of Total Billed Charges,1350.72,45,,1080.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,840.45,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,83.94,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1080.58,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,1080.58,36,,0.384,Percent of Total Billed Charges,36% Total Bille Charges,1080.58,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,1800.96,60,,561.984,Percent of Total Billed Charges,60% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3001.6,100,,2401.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,432.83,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2251.2,75,,2351.488,Percent of Total Billed Charges,75% of Total Billed Charges,1500.8,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,1500.8,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1500.8,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,1500.8,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2101.12,70,,64.576,Percent of Total Billed Charges,70% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,420.22,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3001.6,100,,3135.32,Percent of Total Billed Charges,100% of Total Billed Charges,83.94,3001.6,
IR ASP RENAL CYST LT,49107350,CDM,361,RC,,,Outpatient,,,2001.07,1200.64,,1200.64,60,,3.632,Percent of Total Billed Charges,60% of Total Billed Charges,900.48,45,,720.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560.3,28,,1.136,Percent of Total Billed Charges,28% of Total Billed Charges,84.05,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,720.39,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,720.39,36,,1.456,Percent of Total Billed Charges,36% Total Bille Charges,720.39,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,1200.64,60,,547.744,Percent of Total Billed Charges,60% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2001.07,100,,1600.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,288.55,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1500.8,75,,2351.488,Percent of Total Billed Charges,75% of Total Billed Charges,1000.54,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,1000.54,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1000.54,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,1000.54,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400.75,70,,40.144,Percent of Total Billed Charges,70% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,280.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2001.07,100,,3135.32,Percent of Total Billed Charges,100% of Total Billed Charges,84.05,2001.07,
IR ART VEN OCC DEVICE PLCMT,49120300,CDM,361,RC,,,Outpatient,,,1109.69,665.81,,665.81,60,,6.76,Percent of Total Billed Charges,60% of Total Billed Charges,499.36,45,,399.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,310.71,28,,1.6,Percent of Total Billed Charges,28% of Total Billed Charges,84.08,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,399.49,36,,2.056,Percent of Total Billed Charges,36% of Total Billed Charges,399.49,36,,2.056,Percent of Total Billed Charges,36% Total Bille Charges,399.49,36,,2.056,Percent of Total Billed Charges,36% of Total Billed Charges,665.81,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1109.69,100,,887.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,160.02,14.42,,8.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,832.27,75,,3538.656,Percent of Total Billed Charges,75% of Total Billed Charges,554.85,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,554.85,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,554.85,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,554.85,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.78,70,,48.224,Percent of Total Billed Charges,70% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,155.36,14,,8.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1109.69,100,,4718.208,Percent of Total Billed Charges,100% of Total Billed Charges,84.08,1109.69,
IR ART THROM MCH LYSIS INITIAL,49120310,CDM,361,RC,,,Outpatient,,,9447.71,5668.63,,5668.63,60,,15.6,Percent of Total Billed Charges,60% of Total Billed Charges,4251.47,45,,3401.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2645.36,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,84.18,32,,14.792,Percent of Total Billed Charges,32% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,3401.18,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,3401.18,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,3401.18,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,5668.63,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9447.71,100,,7558.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1362.36,14.42,,1.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7085.78,75,,3628.24,Percent of Total Billed Charges,75% of Total Billed Charges,4723.86,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,4723.86,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4723.86,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,4723.86,50,,188.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6613.4,70,,80.856,Percent of Total Billed Charges,70% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1322.68,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9447.71,100,,4837.648,Percent of Total Billed Charges,100% of Total Billed Charges,84.18,9447.71,
IR ART THROM MCH LYSIS SECNDRY,49120311,CDM,361,RC,,,Outpatient,,,7280.5,4368.30,,4368.3,60,,205.784,Percent of Total Billed Charges,60% of Total Billed Charges,3276.23,45,,2620.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2038.54,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,84.18,32,,14.84,Percent of Total Billed Charges,32% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,2620.98,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,2620.98,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,2620.98,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,4368.3,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7280.5,100,,5824.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1049.85,14.42,,152.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5460.38,75,,2233.576,Percent of Total Billed Charges,75% of Total Billed Charges,3640.25,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,3640.25,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3640.25,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,3640.25,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5096.35,70,,135.936,Percent of Total Billed Charges,70% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,1019.27,14,,147.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7280.5,100,,2978.096,Percent of Total Billed Charges,100% of Total Billed Charges,84.18,7280.5,
IR ART THROM MCH LYSIS SUBSQ,49120312,CDM,361,RC,,,Outpatient,,,6911.37,4146.82,,4146.82,60,,206.68,Percent of Total Billed Charges,60% of Total Billed Charges,3110.12,45,,2488.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1935.18,28,,12.032,Percent of Total Billed Charges,28% of Total Billed Charges,84.18,32,,145.92,Percent of Total Billed Charges,32% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,2488.09,36,,15.472,Percent of Total Billed Charges,36% of Total Billed Charges,2488.09,36,,15.472,Percent of Total Billed Charges,36% Total Bille Charges,2488.09,36,,15.472,Percent of Total Billed Charges,36% of Total Billed Charges,4146.82,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6911.37,100,,5529.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,996.62,14.42,,135.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5183.53,75,,1489.048,Percent of Total Billed Charges,75% of Total Billed Charges,3455.69,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,3455.69,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3455.69,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,3455.69,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4837.96,70,,328.72,Percent of Total Billed Charges,70% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,967.59,14,,131.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6911.37,100,,1985.4,Percent of Total Billed Charges,100% of Total Billed Charges,84.18,6911.37,
IR AVS W THROM AND LYSIS,49120316,CDM,361,RC,,,Outpatient,,,7504.07,4502.44,,4502.44,60,,33.304,Percent of Total Billed Charges,60% of Total Billed Charges,3376.83,45,,2701.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2101.14,28,,169.344,Percent of Total Billed Charges,28% of Total Billed Charges,84.18,32,,145.952,Percent of Total Billed Charges,32% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,2701.47,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,2701.47,36,,217.728,Percent of Total Billed Charges,36% Total Bille Charges,2701.47,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,4502.44,60,,3.32,Percent of Total Billed Charges,60% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7504.07,100,,6003.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1082.09,14.42,,131.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5628.05,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,3752.04,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,3752.04,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3752.04,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,3752.04,50,,258.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5252.85,70,,113.448,Percent of Total Billed Charges,70% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,1050.57,14,,127.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7504.07,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,84.18,7504.07,
IR CATH ABD AORTO 1ST ORD,49120320,CDM,361,RC,,,Outpatient,,,3873.54,2324.12,,2324.12,60,,13.968,Percent of Total Billed Charges,60% of Total Billed Charges,1743.09,45,,1394.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1084.59,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,84.23,32,,146.2,Percent of Total Billed Charges,32% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,1394.47,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,1394.47,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,1394.47,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,2324.12,60,,1.376,Percent of Total Billed Charges,60% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3098.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,558.56,14.42,,4.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2905.16,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,1936.77,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1936.77,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2711.48,70,,52.504,Percent of Total Billed Charges,70% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3873.54,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,84.23,3873.54,
IR CATH ABD AORTO 3RD ORD,49120322,CDM,361,RC,,,Outpatient,,,4387,2632.20,,2632.2,60,,78.512,Percent of Total Billed Charges,60% of Total Billed Charges,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.36,28,,0.448,Percent of Total Billed Charges,28% of Total Billed Charges,84.36,32,,146.52,Percent of Total Billed Charges,32% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,1579.32,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,1579.32,36,,0.576,Percent of Total Billed Charges,36% Total Bille Charges,1579.32,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,2632.2,60,,28.808,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,4.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,750.504,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,151.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.9,70,,17.56,Percent of Total Billed Charges,70% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,1000.672,Percent of Total Billed Charges,100% of Total Billed Charges,84.36,4387,
IR CATH AORTO PLCMT,49120323,CDM,361,RC,,,Outpatient,,,2548.07,1528.84,,1528.84,60,,163.44,Percent of Total Billed Charges,60% of Total Billed Charges,1146.63,45,,917.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.46,28,,22.848,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,146.656,Percent of Total Billed Charges,32% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,917.31,36,,29.376,Percent of Total Billed Charges,36% of Total Billed Charges,917.31,36,,29.376,Percent of Total Billed Charges,36% Total Bille Charges,917.31,36,,29.376,Percent of Total Billed Charges,36% of Total Billed Charges,1528.84,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2548.07,100,,2038.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,367.43,14.42,,4.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1911.05,75,,1392,Percent of Total Billed Charges,75% of Total Billed Charges,1274.04,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,1274.04,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1274.04,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,1274.04,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.65,70,,297.816,Percent of Total Billed Charges,70% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,356.73,14,,4.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2548.07,100,,1856,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,2548.07,
IR CATH ART SUBCLAV 3RD ORD RT,49120338,CDM,361,RC,36217,HCPCS,Outpatient,,,4387,2632.20,,4162,100,,7.76,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,146.944,Other,Not Seperately Reimbusable,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2632.2,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,1843.072,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,190.296,Fee Schedule,100% of ASC Tier Groupings fee schedule,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,2457.432,Percent of Total Billed Charges,100% of Total Billed Charges,614.18,4387,
IR CATH ART SUBCLV 1ST ORD LT,49120342,CDM,361,RC,36215,HCPCS,Outpatient,,,1868.7,1121.22,,4162,100,,1.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,840.92,45,,672.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,147.008,Other,Not Seperately Reimbusable,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1121.22,60,,3.584,Percent of Total Billed Charges,60% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1868.7,100,,1494.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,269.47,14.42,,0.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1401.53,75,,2587.552,Percent of Total Billed Charges,75% of Total Billed Charges,934.35,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,934.35,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.35,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,934.35,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,29.392,Fee Schedule,100% of ASC Tier Groupings fee schedule,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,261.62,14,,0.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1868.7,100,,3450.064,Percent of Total Billed Charges,100% of Total Billed Charges,261.62,4162,
IR CATH ART SUBCLAV 2ND ORD RT,49120345,CDM,361,RC,36216,HCPCS,Outpatient,,,3718.28,2230.97,,4162,100,,39.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1673.23,45,,1338.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,147.104,Other,Not Seperately Reimbusable,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.97,60,,6.872,Percent of Total Billed Charges,60% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2974.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,536.18,14.42,,0.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2788.71,75,,2587.552,Percent of Total Billed Charges,75% of Total Billed Charges,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,284.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1178.544,Fee Schedule,100% of ASC Tier Groupings fee schedule,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3718.28,100,,3450.064,Percent of Total Billed Charges,100% of Total Billed Charges,520.56,4162,
IR CATH CELIAC MES 1ST ORD,49120365,CDM,361,RC,,,Outpatient,,,3873.54,2324.12,,2324.12,60,,50.392,Percent of Total Billed Charges,60% of Total Billed Charges,1743.09,45,,1394.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1084.59,28,,19.92,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,147.456,Percent of Total Billed Charges,32% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,1394.47,36,,25.608,Percent of Total Billed Charges,36% of Total Billed Charges,1394.47,36,,25.608,Percent of Total Billed Charges,36% Total Bille Charges,1394.47,36,,25.608,Percent of Total Billed Charges,36% of Total Billed Charges,2324.12,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3098.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,558.56,14.42,,6.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2905.16,75,,2587.552,Percent of Total Billed Charges,75% of Total Billed Charges,1936.77,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1936.77,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2711.48,70,,759.152,Percent of Total Billed Charges,70% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,6.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3450.064,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,3873.54,
IR CATH CELIAC MES 2ND ORD,49120366,CDM,361,RC,,,Outpatient,,,3718.28,2230.97,,2230.97,60,,134.752,Percent of Total Billed Charges,60% of Total Billed Charges,1673.23,45,,1338.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.12,28,,34.168,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,147.648,Percent of Total Billed Charges,32% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1338.58,36,,43.928,Percent of Total Billed Charges,36% of Total Billed Charges,1338.58,36,,43.928,Percent of Total Billed Charges,36% Total Bille Charges,1338.58,36,,43.928,Percent of Total Billed Charges,36% of Total Billed Charges,2230.97,60,,5.584,Percent of Total Billed Charges,60% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2974.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,536.18,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2788.71,75,,2601.464,Percent of Total Billed Charges,75% of Total Billed Charges,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1859.14,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,180,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2602.8,70,,1077.328,Percent of Total Billed Charges,70% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3718.28,100,,3468.616,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,3718.28,
IR CATH CELIAC MES 3RD ORD,49120367,CDM,361,RC,,,Outpatient,,,4387,2632.20,,2632.2,60,,144.008,Percent of Total Billed Charges,60% of Total Billed Charges,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.36,28,,35.944,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,147.968,Percent of Total Billed Charges,32% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,1579.32,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,1579.32,36,,46.216,Percent of Total Billed Charges,36% Total Bille Charges,1579.32,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,2632.2,60,,1.192,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,2601.464,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.9,70,,66.168,Percent of Total Billed Charges,70% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,3468.616,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,4387,
IR CATH CELIAC MES ADD,49120368,CDM,361,RC,,,Outpatient,,,2417.42,1450.45,,1450.45,60,,2.296,Percent of Total Billed Charges,60% of Total Billed Charges,1087.84,45,,870.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,676.88,28,,35.944,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,148.376,Percent of Total Billed Charges,32% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,870.27,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,870.27,36,,46.216,Percent of Total Billed Charges,36% Total Bille Charges,870.27,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,1450.45,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2417.42,100,,1933.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,348.59,14.42,,0.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1813.07,75,,2515.384,Percent of Total Billed Charges,75% of Total Billed Charges,1208.71,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,1208.71,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1208.71,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,1208.71,50,,267.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1692.19,70,,25.488,Percent of Total Billed Charges,70% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,338.44,14,,0.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2417.42,100,,3353.84,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,2417.42,
IR CATH COM CAR INOM EXTCRN BI,49120371,CDM,361,RC,,,Outpatient,,,9885.1,5931.06,,5931.06,60,,11.336,Percent of Total Billed Charges,60% of Total Billed Charges,4448.3,45,,3558.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2767.83,28,,24.304,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,15.04,Percent of Total Billed Charges,32% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,3558.64,36,,31.248,Percent of Total Billed Charges,36% of Total Billed Charges,3558.64,36,,31.248,Percent of Total Billed Charges,36% Total Bille Charges,3558.64,36,,31.248,Percent of Total Billed Charges,36% of Total Billed Charges,5931.06,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9885.1,100,,7908.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1425.43,14.42,,1.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7413.83,75,,2515.384,Percent of Total Billed Charges,75% of Total Billed Charges,4942.55,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,4942.55,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4942.55,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,4942.55,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6919.57,70,,65.36,Percent of Total Billed Charges,70% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,1383.91,14,,1.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9885.1,100,,3353.84,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,9885.1,
IR CATH COM CAR INOM INTCRL LT,49120375,CDM,361,RC,,,Outpatient,,,7531.51,4518.91,,4518.91,60,,4.088,Percent of Total Billed Charges,60% of Total Billed Charges,3389.18,45,,2711.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2108.82,28,,1.568,Percent of Total Billed Charges,28% of Total Billed Charges,84.43,32,,148.48,Percent of Total Billed Charges,32% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,2711.34,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,2711.34,36,,2.016,Percent of Total Billed Charges,36% Total Bille Charges,2711.34,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,4518.91,60,,1.32,Percent of Total Billed Charges,60% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7531.51,100,,6025.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1086.04,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5648.63,75,,2885.4,Percent of Total Billed Charges,75% of Total Billed Charges,3765.76,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,3765.76,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3765.76,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,3765.76,50,,212.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5272.06,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,1054.41,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7531.51,100,,3847.2,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,7531.51,
IR CATH ILIAC FEM 1ST ORD,49120379,CDM,361,RC,,,Outpatient,,,3873.54,2324.12,,2324.12,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,1743.09,45,,1394.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1084.59,28,,1.656,Percent of Total Billed Charges,28% of Total Billed Charges,84.46,32,,148.48,Percent of Total Billed Charges,32% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1394.47,36,,2.128,Percent of Total Billed Charges,36% of Total Billed Charges,1394.47,36,,2.128,Percent of Total Billed Charges,36% Total Bille Charges,1394.47,36,,2.128,Percent of Total Billed Charges,36% of Total Billed Charges,2324.12,60,,1.64,Percent of Total Billed Charges,60% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3098.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,558.56,14.42,,1.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2905.16,75,,2885.4,Percent of Total Billed Charges,75% of Total Billed Charges,1936.77,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1936.77,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2711.48,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3847.2,Percent of Total Billed Charges,100% of Total Billed Charges,84.46,3873.54,
IR CATH ILIAC FEM 2ND ORD,49120380,CDM,361,RC,,,Outpatient,,,3718.28,2230.97,,2230.97,60,,0.152,Percent of Total Billed Charges,60% of Total Billed Charges,1673.23,45,,1338.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.12,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,84.46,32,,149.52,Percent of Total Billed Charges,32% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,1338.58,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,1338.58,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,1338.58,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,2230.97,60,,1.968,Percent of Total Billed Charges,60% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2974.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,536.18,14.42,,0.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2788.71,75,,3726.496,Percent of Total Billed Charges,75% of Total Billed Charges,1859.14,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1859.14,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,211.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2602.8,70,,4.288,Percent of Total Billed Charges,70% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3718.28,100,,4968.656,Percent of Total Billed Charges,100% of Total Billed Charges,84.46,3718.28,
IR CATH ILIAC FEM 3RD ORD,49120381,CDM,361,RC,,,Outpatient,,,4387,2632.20,,2632.2,60,,0.216,Percent of Total Billed Charges,60% of Total Billed Charges,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.36,28,,13.984,Percent of Total Billed Charges,28% of Total Billed Charges,84.46,32,,149.696,Percent of Total Billed Charges,32% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,1579.32,36,,17.984,Percent of Total Billed Charges,36% of Total Billed Charges,1579.32,36,,17.984,Percent of Total Billed Charges,36% Total Bille Charges,1579.32,36,,17.984,Percent of Total Billed Charges,36% of Total Billed Charges,2632.2,60,,1.856,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,3726.496,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,1372.128,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,1372.128,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.9,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,4968.656,Percent of Total Billed Charges,100% of Total Billed Charges,84.46,4387,
IR CATH LWR EXT 1ST ORD LT,49120392,CDM,361,RC,,,Outpatient,,,3873.54,2324.12,,2324.12,60,,4.696,Percent of Total Billed Charges,60% of Total Billed Charges,1743.09,45,,1394.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1084.59,28,,8.296,Percent of Total Billed Charges,28% of Total Billed Charges,84.56,32,,149.912,Percent of Total Billed Charges,32% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1394.47,36,,10.664,Percent of Total Billed Charges,36% of Total Billed Charges,1394.47,36,,10.664,Percent of Total Billed Charges,36% Total Bille Charges,1394.47,36,,10.664,Percent of Total Billed Charges,36% of Total Billed Charges,2324.12,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3098.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,558.56,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2905.16,75,,2344.8,Percent of Total Billed Charges,75% of Total Billed Charges,1936.77,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,549.336,Percent of Total Billed Charges,50% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1936.77,50,,549.336,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,291.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2711.48,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3126.4,Percent of Total Billed Charges,100% of Total Billed Charges,84.56,3873.54,
IR CATH LWR EXT 1ST ORD RT,49120393,CDM,361,RC,,,Outpatient,,,3873.54,2324.12,,2324.12,60,,5.464,Percent of Total Billed Charges,60% of Total Billed Charges,1743.09,45,,1394.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1084.59,28,,3.592,Percent of Total Billed Charges,28% of Total Billed Charges,84.8,32,,151,Percent of Total Billed Charges,32% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,1394.47,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,1394.47,36,,4.616,Percent of Total Billed Charges,36% Total Bille Charges,1394.47,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,2324.12,60,,4.968,Percent of Total Billed Charges,60% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3098.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,558.56,14.42,,0.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2905.16,75,,2344.8,Percent of Total Billed Charges,75% of Total Billed Charges,1936.77,50,,1372.128,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1936.77,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,1936.77,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2711.48,70,,86.368,Percent of Total Billed Charges,70% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,542.3,14,,0.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3873.54,100,,3126.4,Percent of Total Billed Charges,100% of Total Billed Charges,84.8,3873.54,
IR CATH LWR EXT 2ND ORD LT,49120394,CDM,361,RC,,,Outpatient,,,3718.28,2230.97,,2230.97,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,1673.23,45,,1338.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.12,28,,20.92,Percent of Total Billed Charges,28% of Total Billed Charges,84.92,32,,15227.52,Percent of Total Billed Charges,32% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,1338.58,36,,26.896,Percent of Total Billed Charges,36% of Total Billed Charges,1338.58,36,,26.896,Percent of Total Billed Charges,36% Total Bille Charges,1338.58,36,,26.896,Percent of Total Billed Charges,36% of Total Billed Charges,2230.97,60,,2.192,Percent of Total Billed Charges,60% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2974.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,536.18,14.42,,0.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2788.71,75,,1582.336,Percent of Total Billed Charges,75% of Total Billed Charges,1859.14,50,,549.336,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1859.14,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2602.8,70,,323.28,Percent of Total Billed Charges,70% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2109.784,Percent of Total Billed Charges,100% of Total Billed Charges,84.92,3718.28,
IR CATH LWR EXT 2ND ORD RT,49120395,CDM,361,RC,,,Outpatient,,,3718.28,2230.97,,2230.97,60,,11.072,Percent of Total Billed Charges,60% of Total Billed Charges,1673.23,45,,1338.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.12,28,,25.728,Percent of Total Billed Charges,28% of Total Billed Charges,84.92,32,,15304.96,Percent of Total Billed Charges,32% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,1338.58,36,,33.072,Percent of Total Billed Charges,36% of Total Billed Charges,1338.58,36,,33.072,Percent of Total Billed Charges,36% Total Bille Charges,1338.58,36,,33.072,Percent of Total Billed Charges,36% of Total Billed Charges,2230.97,60,,0.216,Percent of Total Billed Charges,60% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3718.28,100,,2974.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,536.18,14.42,,0.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2788.71,75,,1473.96,Percent of Total Billed Charges,75% of Total Billed Charges,1859.14,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1859.14,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,1859.14,50,,253.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2602.8,70,,56.544,Percent of Total Billed Charges,70% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,520.56,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3718.28,100,,1965.28,Percent of Total Billed Charges,100% of Total Billed Charges,84.92,3718.28,
IR CATH LWR EXT 3RD ORD LT,49120396,CDM,361,RC,,,Outpatient,,,4387,2632.20,,2632.2,60,,4.08,Percent of Total Billed Charges,60% of Total Billed Charges,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.36,28,,42.12,Percent of Total Billed Charges,28% of Total Billed Charges,84.92,32,,15.128,Percent of Total Billed Charges,32% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1579.32,36,,54.152,Percent of Total Billed Charges,36% of Total Billed Charges,1579.32,36,,54.152,Percent of Total Billed Charges,36% Total Bille Charges,1579.32,36,,54.152,Percent of Total Billed Charges,36% of Total Billed Charges,2632.2,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,1473.96,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.9,70,,137.904,Percent of Total Billed Charges,70% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,1965.28,Percent of Total Billed Charges,100% of Total Billed Charges,84.92,4387,
IR CATH LWR EXT 3RD ORD RT,49120397,CDM,361,RC,,,Outpatient,,,4387,2632.20,,2632.2,60,,4.552,Percent of Total Billed Charges,60% of Total Billed Charges,1974.15,45,,1579.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.36,28,,101.544,Percent of Total Billed Charges,28% of Total Billed Charges,85.41,32,,15.336,Percent of Total Billed Charges,32% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,1579.32,36,,130.56,Percent of Total Billed Charges,36% of Total Billed Charges,1579.32,36,,130.56,Percent of Total Billed Charges,36% Total Bille Charges,1579.32,36,,130.56,Percent of Total Billed Charges,36% of Total Billed Charges,2632.2,60,,38.984,Percent of Total Billed Charges,60% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4387,100,,3509.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,632.61,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3290.25,75,,1384.632,Percent of Total Billed Charges,75% of Total Billed Charges,2193.5,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2193.5,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,2193.5,50,,196.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3070.9,70,,32.544,Percent of Total Billed Charges,70% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,614.18,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4387,100,,1846.176,Percent of Total Billed Charges,100% of Total Billed Charges,85.41,4387,
IR CATH SUBCLV INNOM VERT LT,49120412,CDM,361,RC,36225,HCPCS,Outpatient,,,4754.74,2852.84,,4162,100,,4.552,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,6457.08,233,,4.624,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,85.42,32,,151.04,Percent of Total Billed Charges,32% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,8923.52,322,,5.952,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8923.52,322,,5.952,Fee schedule,Pays based on ASC Tier Groupings fee schedule,8923.52,322,,5.952,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,1.568,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,685.63,14.42,,1.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3566.06,75,,2705.224,Percent of Total Billed Charges,75% of Total Billed Charges,2377.37,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,2377.37,50,,959.384,Percent of Total Billed Charges,50% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2377.37,50,,959.384,Percent of Total Billed Charges,50% of Total Billed Charges,2377.37,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,39.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4754.74,100,,3606.96,Percent of Total Billed Charges,100% of Total Billed Charges,85.42,8923.52,
IR CATH SUBCLV INNOM VERT RT,49120413,CDM,361,RC,,,Outpatient,,,4754.74,2852.84,,2852.84,60,,4.552,Percent of Total Billed Charges,60% of Total Billed Charges,2139.63,45,,1711.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1331.33,28,,161.112,Percent of Total Billed Charges,28% of Total Billed Charges,85.54,32,,151.04,Percent of Total Billed Charges,32% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,1711.71,36,,207.144,Percent of Total Billed Charges,36% of Total Billed Charges,1711.71,36,,207.144,Percent of Total Billed Charges,36% Total Bille Charges,1711.71,36,,207.144,Percent of Total Billed Charges,36% of Total Billed Charges,2852.84,60,,1.376,Percent of Total Billed Charges,60% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4754.74,100,,3803.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,685.63,14.42,,0.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3566.06,75,,2705.224,Percent of Total Billed Charges,75% of Total Billed Charges,2377.37,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,2377.37,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2377.37,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,2377.37,50,,345.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3328.32,70,,33.368,Percent of Total Billed Charges,70% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,665.66,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4754.74,100,,3606.96,Percent of Total Billed Charges,100% of Total Billed Charges,85.54,4754.74,
IR CATH THOR AORTA NONSEL,49120414,CDM,361,RC,,,Outpatient,,,6590.07,3954.04,,3954.04,60,,5.632,Percent of Total Billed Charges,60% of Total Billed Charges,2965.53,45,,2372.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1845.22,28,,102.816,Percent of Total Billed Charges,28% of Total Billed Charges,85.54,32,,151.192,Percent of Total Billed Charges,32% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,2372.43,36,,132.192,Percent of Total Billed Charges,36% of Total Billed Charges,2372.43,36,,132.192,Percent of Total Billed Charges,36% Total Bille Charges,2372.43,36,,132.192,Percent of Total Billed Charges,36% of Total Billed Charges,3954.04,60,,0.944,Percent of Total Billed Charges,60% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6590.07,100,,5272.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,950.29,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4942.55,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,3295.04,50,,959.384,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3295.04,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,3295.04,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4613.05,70,,224.72,Percent of Total Billed Charges,70% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,922.61,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6590.07,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,85.54,6590.07,
IR CATH VEN 1ST ORDER LT,49120416,CDM,361,RC,,,Outpatient,,,2470,1482.00,,1482,60,,6.2,Percent of Total Billed Charges,60% of Total Billed Charges,1111.5,45,,889.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.6,28,,76.784,Percent of Total Billed Charges,28% of Total Billed Charges,85.63,32,,151.352,Percent of Total Billed Charges,32% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,889.2,36,,98.72,Percent of Total Billed Charges,36% of Total Billed Charges,889.2,36,,98.72,Percent of Total Billed Charges,36% Total Bille Charges,889.2,36,,98.72,Percent of Total Billed Charges,36% of Total Billed Charges,1482,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2470,100,,1976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,356.17,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1852.5,75,,425.608,Percent of Total Billed Charges,75% of Total Billed Charges,1235,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,1235,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1235,50,,269.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1729,70,,27.296,Percent of Total Billed Charges,70% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2470,100,,567.48,Percent of Total Billed Charges,100% of Total Billed Charges,85.63,2470,
IR CATH VEN 1ST ORDER RT,49120417,CDM,361,RC,,,Outpatient,,,2470,1482.00,,1482,60,,78.328,Percent of Total Billed Charges,60% of Total Billed Charges,1111.5,45,,889.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.6,28,,3.864,Percent of Total Billed Charges,28% of Total Billed Charges,85.76,32,,152.168,Percent of Total Billed Charges,32% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,889.2,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,889.2,36,,4.968,Percent of Total Billed Charges,36% Total Bille Charges,889.2,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,1482,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2470,100,,1976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,356.17,14.42,,9.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1852.5,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,1235,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,1235,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1235,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1235,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1729,70,,40.592,Percent of Total Billed Charges,70% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,345.8,14,,9.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2470,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,85.76,2470,
IR CATH VEN 2ND ORDER LT,49120419,CDM,361,RC,,,Outpatient,,,2785.48,1671.29,,1671.29,60,,3.664,Percent of Total Billed Charges,60% of Total Billed Charges,1253.47,45,,1002.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.93,28,,44.272,Percent of Total Billed Charges,28% of Total Billed Charges,86.03,32,,152.168,Percent of Total Billed Charges,32% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1002.77,36,,56.928,Percent of Total Billed Charges,36% of Total Billed Charges,1002.77,36,,56.928,Percent of Total Billed Charges,36% Total Bille Charges,1002.77,36,,56.928,Percent of Total Billed Charges,36% of Total Billed Charges,1671.29,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2785.48,100,,2228.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,401.67,14.42,,0.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.11,75,,560.456,Percent of Total Billed Charges,75% of Total Billed Charges,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1392.74,50,,914.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.84,70,,50.952,Percent of Total Billed Charges,70% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2785.48,100,,747.272,Percent of Total Billed Charges,100% of Total Billed Charges,86.03,2785.48,
IR CATH VEN 2ND ORDER RT,49120420,CDM,361,RC,,,Outpatient,,,2785.48,1671.29,,1671.29,60,,2.312,Percent of Total Billed Charges,60% of Total Billed Charges,1253.47,45,,1002.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.93,28,,382.208,Percent of Total Billed Charges,28% of Total Billed Charges,86.16,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,1002.77,36,,491.408,Percent of Total Billed Charges,36% of Total Billed Charges,1002.77,36,,491.408,Percent of Total Billed Charges,36% Total Bille Charges,1002.77,36,,491.408,Percent of Total Billed Charges,36% of Total Billed Charges,1671.29,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2785.48,100,,2228.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,401.67,14.42,,0.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.11,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.74,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,1392.74,50,,1372.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.84,70,,23.08,Percent of Total Billed Charges,70% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,389.97,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2785.48,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,86.16,2785.48,
IR CVAD DECLOT THROMBOLYTIC,49120431,CDM,361,RC,,,Outpatient,,,857.33,514.40,,514.4,60,,0.928,Percent of Total Billed Charges,60% of Total Billed Charges,385.8,45,,308.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.05,28,,504,Percent of Total Billed Charges,28% of Total Billed Charges,86.3,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,308.64,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,308.64,36,,648,Percent of Total Billed Charges,36% Total Bille Charges,308.64,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,514.4,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,857.33,100,,685.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,123.63,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,643,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,428.67,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,428.67,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.67,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,428.67,50,,549.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.13,70,,20.56,Percent of Total Billed Charges,70% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,120.03,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,857.33,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,86.3,857.33,
IR CVAD TUNL EXCH W PORT,49120435,CDM,361,RC,,,Outpatient,,,6827,4096.20,,4096.2,60,,4.36,Percent of Total Billed Charges,60% of Total Billed Charges,3072.15,45,,2457.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1911.56,28,,13.648,Percent of Total Billed Charges,28% of Total Billed Charges,86.3,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,2457.72,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,2457.72,36,,17.544,Percent of Total Billed Charges,36% Total Bille Charges,2457.72,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,4096.2,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6827,100,,5461.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,984.45,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5120.25,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,3413.5,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,3413.5,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3413.5,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,3413.5,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4778.9,70,,155.24,Percent of Total Billed Charges,70% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,955.78,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6827,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,86.3,6827,
IR CVAD TUNL RMV W PORT,49120439,CDM,361,RC,,,Outpatient,,,3366.31,2019.79,,2019.79,60,,5.848,Percent of Total Billed Charges,60% of Total Billed Charges,1514.84,45,,1211.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,942.57,28,,27.296,Percent of Total Billed Charges,28% of Total Billed Charges,86.3,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1211.87,36,,35.096,Percent of Total Billed Charges,36% of Total Billed Charges,1211.87,36,,35.096,Percent of Total Billed Charges,36% Total Bille Charges,1211.87,36,,35.096,Percent of Total Billed Charges,36% of Total Billed Charges,2019.79,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3366.31,100,,2693.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,485.42,14.42,,0.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2524.73,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,1683.16,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,1683.16,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1683.16,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,1683.16,50,,1242.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2356.42,70,,10.536,Percent of Total Billed Charges,70% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,471.28,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3366.31,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,86.3,3366.31,
IR CVAD TUNL W PORT MIN 5YRS,49120440,CDM,361,RC,,,Outpatient,,,6758.14,4054.88,,4054.88,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,3041.16,45,,2432.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1892.28,28,,13.648,Percent of Total Billed Charges,28% of Total Billed Charges,8640,32,,152.568,Percent of Total Billed Charges,32% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,2432.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,2432.93,36,,17.544,Percent of Total Billed Charges,36% Total Bille Charges,2432.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,4054.88,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6758.14,100,,5406.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,974.52,14.42,,16.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5068.61,75,,536.24,Percent of Total Billed Charges,75% of Total Billed Charges,3379.07,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,3379.07,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3379.07,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,3379.07,50,,828.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4730.7,70,,276.784,Percent of Total Billed Charges,70% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,946.14,14,,15.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6758.14,100,,714.984,Percent of Total Billed Charges,100% of Total Billed Charges,946.14,8640,
IR CVAD W PORT MIN 5YRS,49120442,CDM,361,RC,,,Outpatient,,,6038.47,3623.08,,3623.08,60,,32.656,Percent of Total Billed Charges,60% of Total Billed Charges,2717.31,45,,2173.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1690.77,28,,63.08,Percent of Total Billed Charges,28% of Total Billed Charges,8640,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2173.85,36,,81.104,Percent of Total Billed Charges,36% of Total Billed Charges,2173.85,36,,81.104,Percent of Total Billed Charges,36% Total Bille Charges,2173.85,36,,81.104,Percent of Total Billed Charges,36% of Total Billed Charges,3623.08,60,,1.768,Percent of Total Billed Charges,60% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6038.47,100,,4830.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,870.75,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4528.85,75,,9537.448,Percent of Total Billed Charges,75% of Total Billed Charges,3019.24,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,3019.24,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3019.24,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,3019.24,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4226.93,70,,206.448,Percent of Total Billed Charges,70% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,845.39,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6038.47,100,,12716.592,Percent of Total Billed Charges,100% of Total Billed Charges,845.39,8640,
IR CVC NON TUNL EXCH WO PORT,49120443,CDM,361,RC,,,Outpatient,,,3388.08,2032.85,,2032.85,60,,286.072,Percent of Total Billed Charges,60% of Total Billed Charges,1524.64,45,,1219.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.66,28,,9.312,Percent of Total Billed Charges,28% of Total Billed Charges,8640,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,1219.71,36,,11.976,Percent of Total Billed Charges,36% of Total Billed Charges,1219.71,36,,11.976,Percent of Total Billed Charges,36% Total Bille Charges,1219.71,36,,11.976,Percent of Total Billed Charges,36% of Total Billed Charges,2032.85,60,,14.984,Percent of Total Billed Charges,60% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3388.08,100,,2710.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,488.56,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2541.06,75,,9537.448,Percent of Total Billed Charges,75% of Total Billed Charges,1694.04,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,1694.04,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1694.04,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,1694.04,50,,639.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2371.66,70,,710.344,Percent of Total Billed Charges,70% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,474.33,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3388.08,100,,12716.592,Percent of Total Billed Charges,100% of Total Billed Charges,474.33,8640,
IR CVC NON TUNL REP WO PORT,49120444,CDM,361,RC,,,Outpatient,,,1896.98,1138.19,,1138.19,60,,125.096,Percent of Total Billed Charges,60% of Total Billed Charges,853.64,45,,682.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.15,28,,86.592,Percent of Total Billed Charges,28% of Total Billed Charges,8832,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,682.91,36,,111.328,Percent of Total Billed Charges,36% of Total Billed Charges,682.91,36,,111.328,Percent of Total Billed Charges,36% Total Bille Charges,682.91,36,,111.328,Percent of Total Billed Charges,36% of Total Billed Charges,1138.19,60,,0.336,Percent of Total Billed Charges,60% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1896.98,100,,1517.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,273.54,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1422.74,75,,14306.176,Percent of Total Billed Charges,75% of Total Billed Charges,948.49,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,948.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.49,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,948.49,50,,959.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1327.89,70,,1121.912,Percent of Total Billed Charges,70% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1896.98,100,,19074.896,Percent of Total Billed Charges,100% of Total Billed Charges,265.58,8832,
IR CVC PICC EXCH WO PORT,49120445,CDM,361,RC,36558,HCPCS,Outpatient,,,5429.91,3257.95,,4162,100,,138.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,6457.08,233,,99.608,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8.7,32,,1536,Percent of Total Billed Charges,32% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,8923.52,322,,128.064,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,8923.52,322,,128.064,Fee schedule,Pays based on ASC Tier Groupings fee schedule,8923.52,322,,128.064,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,5.944,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.94,90,,,Fee Schedule,90% of CMS OPPS Rate,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,782.99,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,4072.43,75,,7722.4,Percent of Total Billed Charges,75% of Total Billed Charges,2714.96,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,2714.96,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2714.96,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,2714.96,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,301.848,Fee Schedule,100% of ASC Tier Groupings fee schedule,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5429.91,100,,10296.536,Percent of Total Billed Charges,100% of Total Billed Charges,8.7,8923.52,
IR CVC PIC WO PORT WO G MIN 5Y,49120446,CDM,361,RC,,,Outpatient,,,3208.03,1924.82,,1924.82,60,,75.32,Percent of Total Billed Charges,60% of Total Billed Charges,1443.61,45,,1154.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,898.25,28,,0.76,Percent of Total Billed Charges,28% of Total Billed Charges,8.71,32,,1545.848,Percent of Total Billed Charges,32% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,1154.89,36,,0.976,Percent of Total Billed Charges,36% of Total Billed Charges,1154.89,36,,0.976,Percent of Total Billed Charges,36% Total Bille Charges,1154.89,36,,0.976,Percent of Total Billed Charges,36% of Total Billed Charges,1924.82,60,,1.176,Percent of Total Billed Charges,60% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3208.03,100,,2566.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,462.6,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2406.02,75,,7722.4,Percent of Total Billed Charges,75% of Total Billed Charges,1604.02,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1604.02,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,1604.02,50,,639.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2245.62,70,,458.392,Percent of Total Billed Charges,70% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,449.12,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3208.03,100,,10296.536,Percent of Total Billed Charges,100% of Total Billed Charges,8.71,3208.03,
IR CVC REPOSITION W FLUORO,49120447,CDM,361,RC,,,Outpatient,,,1615.34,969.20,,969.2,60,,104.456,Percent of Total Billed Charges,60% of Total Billed Charges,726.9,45,,581.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.3,28,,14.92,Percent of Total Billed Charges,28% of Total Billed Charges,8.73,32,,1548.048,Percent of Total Billed Charges,32% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,581.52,36,,19.184,Percent of Total Billed Charges,36% of Total Billed Charges,581.52,36,,19.184,Percent of Total Billed Charges,36% Total Bille Charges,581.52,36,,19.184,Percent of Total Billed Charges,36% of Total Billed Charges,969.2,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1615.34,100,,1292.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,232.93,14.42,,3.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1211.51,75,,11583.6,Percent of Total Billed Charges,75% of Total Billed Charges,807.67,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,807.67,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,807.67,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,807.67,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1130.74,70,,16.152,Percent of Total Billed Charges,70% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,226.15,14,,3.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1615.34,100,,15444.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.73,1615.34,
IR CVC TUNL EXCH WO PORT,49120448,CDM,361,RC,,,Outpatient,,,5257,3154.20,,3154.2,60,,1.552,Percent of Total Billed Charges,60% of Total Billed Charges,2365.65,45,,1892.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1471.96,28,,96.032,Percent of Total Billed Charges,28% of Total Billed Charges,8.76,32,,1554.08,Percent of Total Billed Charges,32% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,1892.52,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,1892.52,36,,123.472,Percent of Total Billed Charges,36% Total Bille Charges,1892.52,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,3154.2,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5257,100,,4205.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,758.06,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3942.75,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,2628.5,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,2628.5,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2628.5,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,2628.5,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3679.9,70,,16.16,Percent of Total Billed Charges,70% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,735.98,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5257,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,8.76,5257,
IR CVC TUNL REP WO PORT,49120449,CDM,361,RC,,,Outpatient,,,1896.98,1138.19,,1138.19,60,,9.008,Percent of Total Billed Charges,60% of Total Billed Charges,853.64,45,,682.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,531.15,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,8.78,32,,1557.56,Percent of Total Billed Charges,32% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,682.91,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,682.91,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,682.91,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,1138.19,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1896.98,100,,1517.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,273.54,14.42,,1.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1422.74,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,948.49,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,948.49,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,948.49,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,948.49,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1327.89,70,,14.312,Percent of Total Billed Charges,70% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,265.58,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1896.98,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,8.78,1896.98,
IR CVC TUNL RMV WO PORT,49120450,CDM,361,RC,,,Outpatient,,,2159.25,1295.55,,1295.55,60,,5.096,Percent of Total Billed Charges,60% of Total Billed Charges,971.66,45,,777.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,604.59,28,,19.84,Percent of Total Billed Charges,28% of Total Billed Charges,8.83,32,,1557.64,Percent of Total Billed Charges,32% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,777.33,36,,25.504,Percent of Total Billed Charges,36% of Total Billed Charges,777.33,36,,25.504,Percent of Total Billed Charges,36% Total Bille Charges,777.33,36,,25.504,Percent of Total Billed Charges,36% of Total Billed Charges,1295.55,60,,4.2,Percent of Total Billed Charges,60% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2159.25,100,,1727.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,14.42,,0.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1619.44,75,,1055.248,Percent of Total Billed Charges,75% of Total Billed Charges,1079.63,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,1079.63,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1079.63,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,1079.63,50,,250.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1511.48,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,302.3,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2159.25,100,,1406.992,Percent of Total Billed Charges,100% of Total Billed Charges,8.83,2159.25,
IR CVC TUNL WO PORT MIN 5YRS,49120451,CDM,361,RC,,,Outpatient,,,5429.91,3257.95,,3257.95,60,,19.736,Percent of Total Billed Charges,60% of Total Billed Charges,2443.46,45,,1954.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1520.37,28,,3.8,Percent of Total Billed Charges,28% of Total Billed Charges,8.83,32,,1566.256,Percent of Total Billed Charges,32% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,1954.77,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,1954.77,36,,4.888,Percent of Total Billed Charges,36% Total Bille Charges,1954.77,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,3257.95,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5429.91,100,,4343.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,782.99,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4072.43,75,,146.48,Percent of Total Billed Charges,75% of Total Billed Charges,2714.96,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,2714.96,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2714.96,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,2714.96,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3800.94,70,,1.048,Percent of Total Billed Charges,70% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,760.19,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5429.91,100,,195.304,Percent of Total Billed Charges,100% of Total Billed Charges,8.83,5429.91,
IR FEMPOP W ANGPLAS W ATHER BI,49120453,CDM,361,RC,,,Outpatient,,,44456.68,26674.01,,26674.01,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,20005.51,45,,16004.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12447.87,28,,107.664,Percent of Total Billed Charges,28% of Total Billed Charges,8.85,32,,1596.416,Percent of Total Billed Charges,32% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,16004.4,36,,138.424,Percent of Total Billed Charges,36% of Total Billed Charges,16004.4,36,,138.424,Percent of Total Billed Charges,36% Total Bille Charges,16004.4,36,,138.424,Percent of Total Billed Charges,36% of Total Billed Charges,26674.01,60,,1.864,Percent of Total Billed Charges,60% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44456.68,100,,35565.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6410.65,14.42,,0.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33342.51,75,,1259.36,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,98.08,Percent of Total Billed Charges,50% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,98.08,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,241.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31119.68,70,,19.144,Percent of Total Billed Charges,70% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44456.68,100,,1679.144,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,44456.68,
IR FEMPOP W STENT AND ATHER LT,49120455,CDM,361,RC,,,Outpatient,,,52294.32,31376.59,,31376.59,60,,31.792,Percent of Total Billed Charges,60% of Total Billed Charges,23532.44,45,,18825.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14642.41,28,,33.784,Percent of Total Billed Charges,28% of Total Billed Charges,8.85,32,,1597.44,Percent of Total Billed Charges,32% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,18825.96,36,,43.44,Percent of Total Billed Charges,36% of Total Billed Charges,18825.96,36,,43.44,Percent of Total Billed Charges,36% Total Bille Charges,18825.96,36,,43.44,Percent of Total Billed Charges,36% of Total Billed Charges,31376.59,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52294.32,100,,41835.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7540.84,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39220.74,75,,146.48,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36606.02,70,,93.24,Percent of Total Billed Charges,70% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52294.32,100,,195.304,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,52294.32,
IR FEMPOP W STENT AND ATHER RT,49120456,CDM,361,RC,,,Outpatient,,,52294.32,31376.59,,31376.59,60,,53.528,Percent of Total Billed Charges,60% of Total Billed Charges,23532.44,45,,18825.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14642.41,28,,8.896,Percent of Total Billed Charges,28% of Total Billed Charges,8.85,32,,1597.792,Percent of Total Billed Charges,32% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,18825.96,36,,11.432,Percent of Total Billed Charges,36% of Total Billed Charges,18825.96,36,,11.432,Percent of Total Billed Charges,36% Total Bille Charges,18825.96,36,,11.432,Percent of Total Billed Charges,36% of Total Billed Charges,31376.59,60,,0.024,Percent of Total Billed Charges,60% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52294.32,100,,41835.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7540.84,14.42,,1.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39220.74,75,,2027.416,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,98.08,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36606.02,70,,14.32,Percent of Total Billed Charges,70% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,7321.2,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52294.32,100,,2703.216,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,52294.32,
IR FEMPOP W STENT LT,49120458,CDM,361,RC,,,Outpatient,,,25835.4,15501.24,,15501.24,60,,74.264,Percent of Total Billed Charges,60% of Total Billed Charges,11625.93,45,,9300.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7233.91,28,,8.944,Percent of Total Billed Charges,28% of Total Billed Charges,8.87,32,,1600.112,Percent of Total Billed Charges,32% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,9300.74,36,,11.504,Percent of Total Billed Charges,36% of Total Billed Charges,9300.74,36,,11.504,Percent of Total Billed Charges,36% Total Bille Charges,9300.74,36,,11.504,Percent of Total Billed Charges,36% of Total Billed Charges,15501.24,60,,2.28,Percent of Total Billed Charges,60% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25835.4,100,,20668.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3725.46,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19376.55,75,,2358.48,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18084.78,70,,432.432,Percent of Total Billed Charges,70% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25835.4,100,,3144.64,Percent of Total Billed Charges,100% of Total Billed Charges,8.87,25835.4,
IR FEMPOP W STENT RT,49120459,CDM,361,RC,,,Outpatient,,,25835.4,15501.24,,15501.24,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,11625.93,45,,9300.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7233.91,28,,11.92,Percent of Total Billed Charges,28% of Total Billed Charges,8.87,32,,1603.552,Percent of Total Billed Charges,32% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,9300.74,36,,15.328,Percent of Total Billed Charges,36% of Total Billed Charges,9300.74,36,,15.328,Percent of Total Billed Charges,36% Total Bille Charges,9300.74,36,,15.328,Percent of Total Billed Charges,36% of Total Billed Charges,15501.24,60,,1.296,Percent of Total Billed Charges,60% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25835.4,100,,20668.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3725.46,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19376.55,75,,392.896,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,160.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18084.78,70,,98.84,Percent of Total Billed Charges,70% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,3616.96,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25835.4,100,,523.856,Percent of Total Billed Charges,100% of Total Billed Charges,8.87,25835.4,
IR FLUORO UP TO 1 HR,49120460,CDM,320,RC,76000,HCPCS,Outpatient,,,618.29,370.97,,26.48,100,,216.72,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,89.8,280,,115.84,Fee Schedule,280% of BCBS BULE Fee Schedule,102.62,320,,1609.768,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,115.45,360,,148.936,Fee Schedule,360% of BCBS POS Rate,115.45,360,,148.936,Fee schedule,360% of BCBS PPO Rate,115.45,360,,148.936,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,1.176,Fee Schedule,103% of Cigna fee schedule,43.44,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,463.72,75,,20160.112,Percent of Total Billed Charges,75% of Total Billed Charges,309.15,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,42.56,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,309.15,50,,42.56,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,55.528,Case Rate,Pays based on per visit rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,618.29,100,,26880.152,Percent of Total Billed Charges,100% of Total Billed Charges,26.48,701.14,
IR FLUORO UP TO 1 HR,49120460,CDM,320,RC,76000,HCPCS,Outpatient,,,618.29,370.97,,26.48,100,,86.392,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,89.8,280,,127.92,Fee Schedule,280% of BCBS BULE Fee Schedule,102.62,320,,1614.784,Fee Schedule,320% of BCBS Blue Essentials Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,115.45,360,,164.472,Fee Schedule,360% of BCBS POS Rate,115.45,360,,164.472,Fee schedule,360% of BCBS PPO Rate,115.45,360,,164.472,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,9.08,Fee Schedule,103% of Cigna fee schedule,43.44,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,44.74,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,463.72,75,,20160.112,Percent of Total Billed Charges,75% of Total Billed Charges,309.15,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,309.15,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,309.15,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,168,Case Rate,Pays based on per visit rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,43.44,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,618.29,100,,26880.152,Percent of Total Billed Charges,100% of Total Billed Charges,26.48,701.14,
IR GUIDE FLUORO CVC CVAD EXCH,49120461,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,1.76,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,72.144,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,1623.432,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,92.752,Fee Schedule,360% of BCBS POS Rate,262.08,360,,92.752,Fee schedule,360% of BCBS PPO Rate,262.08,360,,92.752,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,2.896,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,0.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,31740.168,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,42.56,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,703.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,6.28,Case Rate,Pays based on per visit rate,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,42320.224,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
IR GUIDE FLUORO CVC CVAD EXCH,49120461,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,4.648,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,10.64,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,1631.488,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,13.68,Fee Schedule,360% of BCBS POS Rate,262.08,360,,13.68,Fee schedule,360% of BCBS PPO Rate,262.08,360,,13.68,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,3.632,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,0.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,419.04,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,419.04,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,97.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,91.992,Case Rate,Pays based on per visit rate,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
IR GUIDE FLUORO CVC CVAD RMV,49120462,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,30.128,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,1.04,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,1635.872,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,1.344,Fee Schedule,360% of BCBS POS Rate,262.08,360,,1.344,Fee schedule,360% of BCBS PPO Rate,262.08,360,,1.344,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,24.976,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,0.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,17782.672,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,418.4,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,418.4,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,38.808,Case Rate,Pays based on per visit rate,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,23710.232,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
IR GUIDE FLUORO CVC CVAD RMV,49120462,CDM,320,RC,77001,HCPCS,Outpatient,,,709.35,425.61,,82.08,100,,20.056,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.84,280,,5.56,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,1653.272,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,7.152,Fee Schedule,360% of BCBS POS Rate,262.08,360,,7.152,Fee schedule,360% of BCBS PPO Rate,262.08,360,,7.152,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,2.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,26674.008,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,419.04,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,73.504,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,73.504,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,25.168,Case Rate,Pays based on per visit rate,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,2.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,35565.344,Percent of Total Billed Charges,100% of Total Billed Charges,82.08,709.35,
IR GUIDE US NDL PLCMT,49120463,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,TC   ,26.15,100,,3.616,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,33.656,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,1653.272,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,43.272,Fee Schedule,360% of BCBS POS Rate,90.83,360,,43.272,Fee schedule,360% of BCBS PPO Rate,90.83,360,,43.272,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,23160.112,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,418.4,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,766.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,9.128,Case Rate,Pays based on per visit rate,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,30880.152,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
IR GUIDE US NDL PLCMT,49120463,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,TC   ,26.15,100,,327.576,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,0.192,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,1664,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,0.248,Fee Schedule,360% of BCBS POS Rate,90.83,360,,0.248,Fee schedule,360% of BCBS PPO Rate,90.83,360,,0.248,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,0.896,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,23160.112,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,73.504,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,9.128,Case Rate,Pays based on per visit rate,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,30880.152,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
IR GUIDE US VASCULAR ACCESS,49120464,CDM,402,RC,76937,HCPCS,Outpatient,,,509,305.40,,23.97,100,,2206.92,Fee Schedule,100% of Aetna Fee Schedule,229.05,45,,183.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.5,280,,38.192,Fee Schedule,280% of BCBS BULE Fee Schedule,63.42,320,,1664,Fee Schedule,320% of BCBS Blue Essentials Rate,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.35,360,,49.104,Fee Schedule,360% of BCBS POS Rate,71.35,360,,49.104,Fee schedule,360% of BCBS PPO Rate,71.35,360,,49.104,Fee Schedule,360% of BCBS Traditional Rate,305.4,60,,2.272,Percent of Total Billed Charges,60% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509,100,,407.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14.42,,6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,381.75,75,,34740.168,Percent of Total Billed Charges,75% of Total Billed Charges,254.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,254.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,254.5,50,,98.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,43.8,Case Rate,Pays based on per visit rate,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,5.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,509,100,,46320.224,Percent of Total Billed Charges,100% of Total Billed Charges,23.97,509,
IR GUIDE US VASCULAR ACCESS,49120464,CDM,402,RC,76937,HCPCS,Outpatient,,,509,305.40,,23.97,100,,1833.064,Fee Schedule,100% of Aetna Fee Schedule,229.05,45,,183.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.5,280,,12.016,Fee Schedule,280% of BCBS BULE Fee Schedule,63.42,320,,1676.8,Fee Schedule,320% of BCBS Blue Essentials Rate,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.35,360,,15.456,Fee Schedule,360% of BCBS POS Rate,71.35,360,,15.456,Fee schedule,360% of BCBS PPO Rate,71.35,360,,15.456,Fee Schedule,360% of BCBS Traditional Rate,305.4,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509,100,,407.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,381.75,75,,14782.672,Percent of Total Billed Charges,75% of Total Billed Charges,254.5,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,254.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,254.5,50,,66.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,35.064,Case Rate,Pays based on per visit rate,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,71.26,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,509,100,,19710.232,Percent of Total Billed Charges,100% of Total Billed Charges,23.97,509,
IR ILIAC ADD VSL W ANGPLAS,49120465,CDM,361,RC,,,Outpatient,,,11603.35,6962.01,,6962.01,60,,80.264,Percent of Total Billed Charges,60% of Total Billed Charges,5221.51,45,,4177.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3248.94,28,,81.416,Percent of Total Billed Charges,28% of Total Billed Charges,8.88,32,,1676.8,Percent of Total Billed Charges,32% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,4177.21,36,,104.68,Percent of Total Billed Charges,36% of Total Billed Charges,4177.21,36,,104.68,Percent of Total Billed Charges,36% Total Bille Charges,4177.21,36,,104.68,Percent of Total Billed Charges,36% of Total Billed Charges,6962.01,60,,0.488,Percent of Total Billed Charges,60% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11603.35,100,,9282.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1673.2,14.42,,0.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8702.51,75,,14782.672,Percent of Total Billed Charges,75% of Total Billed Charges,5801.68,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,5801.68,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5801.68,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,5801.68,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8122.35,70,,43.4,Percent of Total Billed Charges,70% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,1624.47,14,,0.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11603.35,100,,19710.232,Percent of Total Billed Charges,100% of Total Billed Charges,8.88,11603.35,
IR ILIAC ADD VSL W STENT,49120466,CDM,361,RC,,,Outpatient,,,13099.74,7859.84,,7859.84,60,,119.968,Percent of Total Billed Charges,60% of Total Billed Charges,5894.88,45,,4715.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3667.93,28,,108.992,Percent of Total Billed Charges,28% of Total Billed Charges,8.91,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4715.91,36,,140.136,Percent of Total Billed Charges,36% of Total Billed Charges,4715.91,36,,140.136,Percent of Total Billed Charges,36% Total Bille Charges,4715.91,36,,140.136,Percent of Total Billed Charges,36% of Total Billed Charges,7859.84,60,,14.824,Percent of Total Billed Charges,60% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13099.74,100,,10479.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1888.98,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9824.81,75,,23674.008,Percent of Total Billed Charges,75% of Total Billed Charges,6549.87,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,6549.87,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6549.87,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,6549.87,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9169.82,70,,11.328,Percent of Total Billed Charges,70% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,1833.96,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13099.74,100,,31565.344,Percent of Total Billed Charges,100% of Total Billed Charges,8.91,13099.74,
IR ILIAC REP ANEURYSM,49120467,CDM,361,RC,,,Outpatient,,,3614.43,2168.66,,2168.66,60,,165.832,Percent of Total Billed Charges,60% of Total Billed Charges,1626.49,45,,1301.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1012.04,28,,93.816,Percent of Total Billed Charges,28% of Total Billed Charges,8.93,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,1301.19,36,,120.624,Percent of Total Billed Charges,36% of Total Billed Charges,1301.19,36,,120.624,Percent of Total Billed Charges,36% Total Bille Charges,1301.19,36,,120.624,Percent of Total Billed Charges,36% of Total Billed Charges,2168.66,60,,11.2,Percent of Total Billed Charges,60% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3614.43,100,,2891.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,521.2,14.42,,0.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2710.82,75,,185.248,Percent of Total Billed Charges,75% of Total Billed Charges,1807.22,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1807.22,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1807.22,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1807.22,50,,238,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2530.1,70,,24.416,Percent of Total Billed Charges,70% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,506.02,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3614.43,100,,247,Percent of Total Billed Charges,100% of Total Billed Charges,8.93,3614.43,
IR ILIAC W STENT BI,49120469,CDM,361,RC,,,Outpatient,,,30217.57,18130.54,,18130.54,60,,47.392,Percent of Total Billed Charges,60% of Total Billed Charges,13597.91,45,,10878.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8460.92,28,,2.272,Percent of Total Billed Charges,28% of Total Billed Charges,8.95,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10878.33,36,,2.928,Percent of Total Billed Charges,36% of Total Billed Charges,10878.33,36,,2.928,Percent of Total Billed Charges,36% Total Bille Charges,10878.33,36,,2.928,Percent of Total Billed Charges,36% of Total Billed Charges,18130.54,60,,6.704,Percent of Total Billed Charges,60% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30217.57,100,,24174.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4357.37,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22663.18,75,,1000.352,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,45.36,Percent of Total Billed Charges,50% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,45.36,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,42.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21152.3,70,,29.12,Percent of Total Billed Charges,70% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,4230.46,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30217.57,100,,1333.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.95,30217.57,
IR ILIAC W STENT LT,49120470,CDM,361,RC,,,Outpatient,,,20145.04,12087.02,,12087.02,60,,47.392,Percent of Total Billed Charges,60% of Total Billed Charges,9065.27,45,,7252.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5640.61,28,,7.48,Percent of Total Billed Charges,28% of Total Billed Charges,86.73,32,,1695.872,Percent of Total Billed Charges,32% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,7252.21,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,7252.21,36,,9.624,Percent of Total Billed Charges,36% Total Bille Charges,7252.21,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,12087.02,60,,1.52,Percent of Total Billed Charges,60% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20145.04,100,,16116.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2904.91,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15108.78,75,,8373.304,Percent of Total Billed Charges,75% of Total Billed Charges,10072.52,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10072.52,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10072.52,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,10072.52,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14101.53,70,,31.848,Percent of Total Billed Charges,70% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20145.04,100,,11164.4,Percent of Total Billed Charges,100% of Total Billed Charges,86.73,20145.04,
IR ILIAC W STENT RT,49120471,CDM,361,RC,,,Outpatient,,,20145.04,12087.02,,12087.02,60,,16.736,Percent of Total Billed Charges,60% of Total Billed Charges,9065.27,45,,7252.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5640.61,28,,181.24,Percent of Total Billed Charges,28% of Total Billed Charges,86.93,32,,1696.784,Percent of Total Billed Charges,32% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,7252.21,36,,233.016,Percent of Total Billed Charges,36% of Total Billed Charges,7252.21,36,,233.016,Percent of Total Billed Charges,36% Total Bille Charges,7252.21,36,,233.016,Percent of Total Billed Charges,36% of Total Billed Charges,12087.02,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20145.04,100,,16116.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2904.91,14.42,,3.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15108.78,75,,26673.6,Percent of Total Billed Charges,75% of Total Billed Charges,10072.52,50,,45.36,Percent of Total Billed Charges,50% of Total Billed Charges,10072.52,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10072.52,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,10072.52,50,,53.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14101.53,70,,6.112,Percent of Total Billed Charges,70% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,2820.31,14,,3.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20145.04,100,,35564.8,Percent of Total Billed Charges,100% of Total Billed Charges,86.93,20145.04,
IR INJ VENOGRAM EXT BI,49120472,CDM,361,RC,36005,HCPCS,Outpatient,,,1870.66,1122.40,,2601,100,,33.688,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,841.8,45,,673.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1696.784,Other,Not Seperately Reimbusable,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1122.4,60,,0.496,Percent of Total Billed Charges,60% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1870.66,100,,1496.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,269.75,14.42,,2.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1403,75,,26673.6,Percent of Total Billed Charges,75% of Total Billed Charges,935.33,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,935.33,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,935.33,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,935.33,50,,419.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,136.592,Fee Schedule,100% of ASC Tier Groupings fee schedule,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,261.89,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1870.66,100,,35564.8,Percent of Total Billed Charges,100% of Total Billed Charges,261.89,2601,
IR INJ VENOGRAM EXT LT,49120473,CDM,361,RC,36005,HCPCS,Outpatient,,,1246.7,748.02,,2601,100,,33.688,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,561.02,45,,448.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1700.864,Other,Not Seperately Reimbusable,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,748.02,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1246.7,100,,997.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,179.77,14.42,,1.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,935.03,75,,940.648,Percent of Total Billed Charges,75% of Total Billed Charges,623.35,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,623.35,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,623.35,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,623.35,50,,418.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,430.576,Fee Schedule,100% of ASC Tier Groupings fee schedule,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,174.54,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1246.7,100,,1254.192,Percent of Total Billed Charges,100% of Total Billed Charges,174.54,2601,
IR INJ VENOGRAM EXT RT,49120474,CDM,361,RC,,,Outpatient,,,1965.36,1179.22,,1179.22,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,884.41,45,,707.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.3,28,,1.304,Percent of Total Billed Charges,28% of Total Billed Charges,87.49,32,,1708.464,Percent of Total Billed Charges,32% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,707.53,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,707.53,36,,1.68,Percent of Total Billed Charges,36% Total Bille Charges,707.53,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,1179.22,60,,2.68,Percent of Total Billed Charges,60% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1965.36,100,,1572.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,283.4,14.42,,0.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1474.02,75,,940.648,Percent of Total Billed Charges,75% of Total Billed Charges,982.68,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,982.68,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,982.68,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,982.68,50,,73.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.75,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,275.15,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1965.36,100,,1254.192,Percent of Total Billed Charges,100% of Total Billed Charges,87.49,1965.36,
IR INTRO CATH IVC OR SVC,49120475,CDM,361,RC,,,Outpatient,,,2469.6,1481.76,,1481.76,60,,71.392,Percent of Total Billed Charges,60% of Total Billed Charges,1111.32,45,,889.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,691.49,28,,17.08,Percent of Total Billed Charges,28% of Total Billed Charges,87.49,32,,1708.536,Percent of Total Billed Charges,32% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,889.06,36,,21.96,Percent of Total Billed Charges,36% of Total Billed Charges,889.06,36,,21.96,Percent of Total Billed Charges,36% Total Bille Charges,889.06,36,,21.96,Percent of Total Billed Charges,36% of Total Billed Charges,1481.76,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2469.6,100,,1975.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,356.12,14.42,,0.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1852.2,75,,973.96,Percent of Total Billed Charges,75% of Total Billed Charges,1234.8,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1234.8,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1234.8,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1234.8,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1728.72,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,345.74,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2469.6,100,,1298.608,Percent of Total Billed Charges,100% of Total Billed Charges,87.49,2469.6,
IR INTRO NDL AV SHNT ADD LT,49120476,CDM,361,RC,,,Outpatient,,,961.13,576.68,,576.68,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,432.51,45,,346.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.12,28,,149.288,Percent of Total Billed Charges,28% of Total Billed Charges,87.62,32,,1709.264,Percent of Total Billed Charges,32% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,346.01,36,,191.944,Percent of Total Billed Charges,36% of Total Billed Charges,346.01,36,,191.944,Percent of Total Billed Charges,36% Total Bille Charges,346.01,36,,191.944,Percent of Total Billed Charges,36% of Total Billed Charges,576.68,60,,35.44,Percent of Total Billed Charges,60% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.13,100,,768.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,138.59,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,720.85,75,,973.96,Percent of Total Billed Charges,75% of Total Billed Charges,480.57,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,480.57,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.57,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,480.57,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.79,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,961.13,100,,1298.608,Percent of Total Billed Charges,100% of Total Billed Charges,87.62,961.13,
IR INTRO NDL AV SHNT ADD RT,49120477,CDM,361,RC,,,Outpatient,,,961.13,576.68,,576.68,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,432.51,45,,346.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.12,28,,8.208,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1713.92,Percent of Total Billed Charges,32% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,346.01,36,,10.56,Percent of Total Billed Charges,36% of Total Billed Charges,346.01,36,,10.56,Percent of Total Billed Charges,36% Total Bille Charges,346.01,36,,10.56,Percent of Total Billed Charges,36% of Total Billed Charges,576.68,60,,191.4,Percent of Total Billed Charges,60% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.13,100,,768.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,138.59,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,720.85,75,,844.8,Percent of Total Billed Charges,75% of Total Billed Charges,480.57,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,480.57,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.57,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,480.57,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.79,70,,173.592,Percent of Total Billed Charges,70% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,134.56,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,961.13,100,,1056,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,961.13,
IR INTRO NDL AV SHNT INI RT,49120478,CDM,361,RC,,,Outpatient,,,2307.72,1384.63,,1384.63,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,1038.47,45,,830.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,28,,4.672,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1717.248,Percent of Total Billed Charges,32% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,830.78,36,,6.008,Percent of Total Billed Charges,36% of Total Billed Charges,830.78,36,,6.008,Percent of Total Billed Charges,36% Total Bille Charges,830.78,36,,6.008,Percent of Total Billed Charges,36% of Total Billed Charges,1384.63,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2307.72,100,,1846.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,332.77,14.42,,0.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1730.79,75,,844.8,Percent of Total Billed Charges,75% of Total Billed Charges,1153.86,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,1153.86,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1153.86,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,1153.86,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1615.4,70,,299.336,Percent of Total Billed Charges,70% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2307.72,100,,1056,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,2307.72,
IVUS NON CORONARY EA ADD,49120482,CDM,361,RC,37253,HCPCS,Outpatient,,,4377.84,2626.70,,2601,100,,0.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1970.03,45,,1576.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1730.08,Other,Not Seperately Reimbusable,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2626.7,60,,0.344,Percent of Total Billed Charges,60% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4377.84,100,,3502.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,631.28,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3283.38,75,,844.8,Percent of Total Billed Charges,75% of Total Billed Charges,2188.92,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,2188.92,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2188.92,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,2188.92,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,168,Fee Schedule,100% of ASC Tier Groupings fee schedule,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,612.9,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4377.84,100,,1056,Percent of Total Billed Charges,100% of Total Billed Charges,612.9,4377.84,
IR IVUS NON CORONARY INI,49120483,CDM,361,RC,37252,HCPCS,Outpatient,,,5747,3448.20,,2601,100,,0.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2586.15,45,,2068.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1734.552,Other,Not Seperately Reimbusable,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3448.2,60,,5.344,Percent of Total Billed Charges,60% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5747,100,,4597.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,828.72,14.42,,8.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4310.25,75,,2505.544,Percent of Total Billed Charges,75% of Total Billed Charges,2873.5,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,2873.5,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2873.5,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,2873.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,168,Fee Schedule,100% of ASC Tier Groupings fee schedule,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,804.58,14,,8.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5747,100,,3340.728,Percent of Total Billed Charges,100% of Total Billed Charges,804.58,5747,
IR PTA AV VENOUS SHUNT,49120491,CDM,361,RC,,,Outpatient,,,6550,3930.00,,3930,60,,7.024,Percent of Total Billed Charges,60% of Total Billed Charges,2947.5,45,,2358,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1834,28,,10.112,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1738.2,Percent of Total Billed Charges,32% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,2358,36,,13,Percent of Total Billed Charges,36% of Total Billed Charges,2358,36,,13,Percent of Total Billed Charges,36% Total Bille Charges,2358,36,,13,Percent of Total Billed Charges,36% of Total Billed Charges,3930,60,,0.896,Percent of Total Billed Charges,60% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6550,100,,5240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,944.51,14.42,,46,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4912.5,75,,2505.544,Percent of Total Billed Charges,75% of Total Billed Charges,3275,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,3275,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3275,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,3275,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4585,70,,73.288,Percent of Total Billed Charges,70% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,44.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6550,100,,3340.728,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,6550,
IR PTA VENOUS,49120496,CDM,361,RC,,,Outpatient,,,6550,3930.00,,3930,60,,126.08,Percent of Total Billed Charges,60% of Total Billed Charges,2947.5,45,,2358,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1834,28,,9.904,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1740.288,Percent of Total Billed Charges,32% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2358,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,2358,36,,12.736,Percent of Total Billed Charges,36% Total Bille Charges,2358,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,3930,60,,7.112,Percent of Total Billed Charges,60% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6550,100,,5240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,944.51,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4912.5,75,,3758.32,Percent of Total Billed Charges,75% of Total Billed Charges,3275,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,3275,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3275,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,3275,50,,45.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4585,70,,177.464,Percent of Total Billed Charges,70% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,917,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6550,100,,5011.088,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,6550,
IR TBPRNL ADD VSL W ANGPLAS,49120497,CDM,361,RC,,,Outpatient,,,14362.22,8617.33,,8617.33,60,,1.776,Percent of Total Billed Charges,60% of Total Billed Charges,6463,45,,5170.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4021.42,28,,9.904,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1740.984,Percent of Total Billed Charges,32% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,5170.4,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,5170.4,36,,12.736,Percent of Total Billed Charges,36% Total Bille Charges,5170.4,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,8617.33,60,,1.2,Percent of Total Billed Charges,60% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14362.22,100,,11489.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2071.03,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10771.67,75,,1411.384,Percent of Total Billed Charges,75% of Total Billed Charges,7181.11,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,7181.11,50,,255.84,Percent of Total Billed Charges,50% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7181.11,50,,255.84,Percent of Total Billed Charges,50% of Total Billed Charges,7181.11,50,,258,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10053.55,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,2010.71,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14362.22,100,,1881.84,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,14362.22,
IR TBPRNL ADD VSL W ATHER,49120498,CDM,361,RC,,,Outpatient,,,22891.83,13735.10,,13735.1,60,,42.592,Percent of Total Billed Charges,60% of Total Billed Charges,10301.32,45,,8241.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6409.71,28,,33.592,Percent of Total Billed Charges,28% of Total Billed Charges,87.84,32,,1743.6,Percent of Total Billed Charges,32% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,8241.06,36,,43.192,Percent of Total Billed Charges,36% of Total Billed Charges,8241.06,36,,43.192,Percent of Total Billed Charges,36% Total Bille Charges,8241.06,36,,43.192,Percent of Total Billed Charges,36% of Total Billed Charges,13735.1,60,,1.888,Percent of Total Billed Charges,60% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22891.83,100,,18313.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3301,14.42,,1.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17168.87,75,,1411.384,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16024.28,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,3204.86,14,,1.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22891.83,100,,1881.84,Percent of Total Billed Charges,100% of Total Billed Charges,87.84,22891.83,
IR TBPRNL W ANGPLAS BI,49120499,CDM,361,RC,,,Outpatient,,,29377.66,17626.60,,17626.6,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,13219.95,45,,10575.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8225.74,28,,4.376,Percent of Total Billed Charges,28% of Total Billed Charges,87.9,32,,1746.944,Percent of Total Billed Charges,32% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10575.96,36,,5.624,Percent of Total Billed Charges,36% of Total Billed Charges,10575.96,36,,5.624,Percent of Total Billed Charges,36% Total Bille Charges,10575.96,36,,5.624,Percent of Total Billed Charges,36% of Total Billed Charges,17626.6,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29377.66,100,,23502.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4236.26,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22033.25,75,,2117.064,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,255.84,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20564.36,70,,45.12,Percent of Total Billed Charges,70% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4112.87,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29377.66,100,,2822.752,Percent of Total Billed Charges,100% of Total Billed Charges,87.9,29377.66,
IR TBPRNL W ANGPLAS LT,49120500,CDM,361,RC,,,Outpatient,,,19585.11,11751.07,,11751.07,60,,20.336,Percent of Total Billed Charges,60% of Total Billed Charges,8813.3,45,,7050.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5483.83,28,,62.264,Percent of Total Billed Charges,28% of Total Billed Charges,88,32,,1747.712,Percent of Total Billed Charges,32% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,7050.64,36,,80.056,Percent of Total Billed Charges,36% of Total Billed Charges,7050.64,36,,80.056,Percent of Total Billed Charges,36% Total Bille Charges,7050.64,36,,80.056,Percent of Total Billed Charges,36% of Total Billed Charges,11751.07,60,,0.936,Percent of Total Billed Charges,60% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19585.11,100,,15668.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2824.17,14.42,,1.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14688.83,75,,780.64,Percent of Total Billed Charges,75% of Total Billed Charges,9792.56,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,9792.56,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9792.56,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,9792.56,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13709.58,70,,73.264,Percent of Total Billed Charges,70% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,1.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19585.11,100,,1040.848,Percent of Total Billed Charges,100% of Total Billed Charges,88,19585.11,
IR TBPRNL W ANGPLAS RT,49120501,CDM,361,RC,,,Outpatient,,,19585.11,11751.07,,11751.07,60,,9.68,Percent of Total Billed Charges,60% of Total Billed Charges,8813.3,45,,7050.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5483.83,28,,9.416,Percent of Total Billed Charges,28% of Total Billed Charges,88,32,,1769.016,Percent of Total Billed Charges,32% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,7050.64,36,,12.112,Percent of Total Billed Charges,36% of Total Billed Charges,7050.64,36,,12.112,Percent of Total Billed Charges,36% Total Bille Charges,7050.64,36,,12.112,Percent of Total Billed Charges,36% of Total Billed Charges,11751.07,60,,1.832,Percent of Total Billed Charges,60% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19585.11,100,,15668.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2824.17,14.42,,0.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14688.83,75,,1531.888,Percent of Total Billed Charges,75% of Total Billed Charges,9792.56,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,9792.56,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9792.56,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,9792.56,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13709.58,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,2741.92,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19585.11,100,,2042.52,Percent of Total Billed Charges,100% of Total Billed Charges,88,19585.11,
IR TBPRNL W ANGPLAS W ATHER BI,49120502,CDM,361,RC,,,Outpatient,,,46058.63,27635.18,,27635.18,60,,22.52,Percent of Total Billed Charges,60% of Total Billed Charges,20726.38,45,,16581.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12896.42,28,,42.008,Percent of Total Billed Charges,28% of Total Billed Charges,88,32,,1769.312,Percent of Total Billed Charges,32% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,16581.11,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,16581.11,36,,54.008,Percent of Total Billed Charges,36% Total Bille Charges,16581.11,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,27635.18,60,,1.576,Percent of Total Billed Charges,60% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46058.63,100,,36846.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6641.65,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34543.97,75,,780.64,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32241.04,70,,211.552,Percent of Total Billed Charges,70% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6448.21,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46058.63,100,,1040.848,Percent of Total Billed Charges,100% of Total Billed Charges,88,46058.63,
IR TBPRNL W ANGPLAS W ATHER LT,49120503,CDM,361,RC,,,Outpatient,,,30705.75,18423.45,,18423.45,60,,5.8,Percent of Total Billed Charges,60% of Total Billed Charges,13817.59,45,,11054.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8597.61,28,,29.136,Percent of Total Billed Charges,28% of Total Billed Charges,88,32,,1773.824,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,37.464,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,37.464,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,37.464,Percent of Total Billed Charges,36% of Total Billed Charges,18423.45,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30705.75,100,,24564.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,0.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23029.31,75,,2315.248,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21494.03,70,,235.544,Percent of Total Billed Charges,70% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30705.75,100,,3087,Percent of Total Billed Charges,100% of Total Billed Charges,88,30705.75,
IR TBPRNL W ANGPLAS W ATHER RT,49120504,CDM,361,RC,,,Outpatient,,,30705.75,18423.45,,18423.45,60,,29.216,Percent of Total Billed Charges,60% of Total Billed Charges,13817.59,45,,11054.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8597.61,28,,68.296,Percent of Total Billed Charges,28% of Total Billed Charges,88.52,32,,1777.152,Percent of Total Billed Charges,32% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,11054.07,36,,87.816,Percent of Total Billed Charges,36% of Total Billed Charges,11054.07,36,,87.816,Percent of Total Billed Charges,36% Total Bille Charges,11054.07,36,,87.816,Percent of Total Billed Charges,36% of Total Billed Charges,18423.45,60,,56.408,Percent of Total Billed Charges,60% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30705.75,100,,24564.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4427.77,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23029.31,75,,2315.248,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21494.03,70,,176.112,Percent of Total Billed Charges,70% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,4298.81,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30705.75,100,,3087,Percent of Total Billed Charges,100% of Total Billed Charges,88.52,30705.75,
IR TBPRNL W STENT RT,49120510,CDM,361,RC,37230,HCPCS,Outpatient,,,24250.1,14550.06,,6763,100,,8.984,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37140.13,233,,9.52,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,88.6,32,,1778.984,Percent of Total Billed Charges,32% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,51326.7,322,,12.24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,51326.7,322,,12.24,Fee schedule,Pays based on ASC Tier Groupings fee schedule,51326.7,322,,12.24,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,1.056,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3496.86,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,18187.58,75,,3472.88,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,24.696,Fee Schedule,100% of ASC Tier Groupings fee schedule,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,3395.01,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,24250.1,100,,4630.504,Percent of Total Billed Charges,100% of Total Billed Charges,88.6,51326.7,
IR TRNSCATH LYSIS ART INI BI,49120511,CDM,361,RC,,,Outpatient,,,7500,4500.00,,4500,60,,56.6,Percent of Total Billed Charges,60% of Total Billed Charges,3375,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2100,28,,10.496,Percent of Total Billed Charges,28% of Total Billed Charges,88.69,32,,1788.016,Percent of Total Billed Charges,32% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,2700,36,,13.496,Percent of Total Billed Charges,36% of Total Billed Charges,2700,36,,13.496,Percent of Total Billed Charges,36% Total Bille Charges,2700,36,,13.496,Percent of Total Billed Charges,36% of Total Billed Charges,4500,60,,1.072,Percent of Total Billed Charges,60% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7500,100,,6000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1081.5,14.42,,0.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5625,75,,910.744,Percent of Total Billed Charges,75% of Total Billed Charges,3750,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,3750,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3750,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,3750,50,,358.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5250,70,,253.824,Percent of Total Billed Charges,70% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,1050,14,,0.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7500,100,,1214.32,Percent of Total Billed Charges,100% of Total Billed Charges,88.69,7500,
IR TRNSCATH LYSIS ART INI LT,49120512,CDM,361,RC,,,Outpatient,,,5000,3000.00,,3000,60,,70.272,Percent of Total Billed Charges,60% of Total Billed Charges,2250,45,,1800,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,88.7,32,,1791.128,Percent of Total Billed Charges,32% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,1800,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,1800,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,1800,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,3000,60,,19,Percent of Total Billed Charges,60% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5000,100,,4000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,721,14.42,,0.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3750,75,,1372.128,Percent of Total Billed Charges,75% of Total Billed Charges,2500,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,2500,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2500,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,2500,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3500,70,,207.68,Percent of Total Billed Charges,70% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5000,100,,1829.504,Percent of Total Billed Charges,100% of Total Billed Charges,88.7,5000,
IR TRNSCATH LYSIS ART INI RT,49120513,CDM,361,RC,,,Outpatient,,,5000,3000.00,,3000,60,,7.44,Percent of Total Billed Charges,60% of Total Billed Charges,2250,45,,1800,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,28,,2.856,Percent of Total Billed Charges,28% of Total Billed Charges,88.95,32,,1791.832,Percent of Total Billed Charges,32% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,1800,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,1800,36,,3.672,Percent of Total Billed Charges,36% Total Bille Charges,1800,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,3000,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5000,100,,4000,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,721,14.42,,13.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3750,75,,1372.128,Percent of Total Billed Charges,75% of Total Billed Charges,2500,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,2500,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2500,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,2500,50,,324,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3500,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,700,14,,13.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5000,100,,1829.504,Percent of Total Billed Charges,100% of Total Billed Charges,88.95,5000,
IR TRNSCATH LYSIS VEN INI BI,49120514,CDM,361,RC,,,Outpatient,,,5878.73,3527.24,,3527.24,60,,341.536,Percent of Total Billed Charges,60% of Total Billed Charges,2645.43,45,,2116.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1646.04,28,,1.616,Percent of Total Billed Charges,28% of Total Billed Charges,89.41,32,,1.536,Percent of Total Billed Charges,32% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,2116.34,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,2116.34,36,,2.08,Percent of Total Billed Charges,36% Total Bille Charges,2116.34,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,3527.24,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5878.73,100,,4702.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,847.71,14.42,,0.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4409.05,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,2939.37,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,2939.37,50,,742.376,Percent of Total Billed Charges,50% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2939.37,50,,742.376,Percent of Total Billed Charges,50% of Total Billed Charges,2939.37,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4115.11,70,,222.36,Percent of Total Billed Charges,70% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,823.02,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5878.73,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,89.41,5878.73,
IR TRNSCATH LYSIS VEN INI LT,49120515,CDM,361,RC,,,Outpatient,,,3919.15,2351.49,,2351.49,60,,1.6,Percent of Total Billed Charges,60% of Total Billed Charges,1763.62,45,,1410.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.36,28,,1.744,Percent of Total Billed Charges,28% of Total Billed Charges,9.04,32,,1.544,Percent of Total Billed Charges,32% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,1410.89,36,,2.24,Percent of Total Billed Charges,36% of Total Billed Charges,1410.89,36,,2.24,Percent of Total Billed Charges,36% Total Bille Charges,1410.89,36,,2.24,Percent of Total Billed Charges,36% of Total Billed Charges,2351.49,60,,0.656,Percent of Total Billed Charges,60% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3919.15,100,,3135.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,565.14,14.42,,0.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2939.36,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,1959.58,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,1959.58,50,,100.704,Percent of Total Billed Charges,50% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1959.58,50,,100.704,Percent of Total Billed Charges,50% of Total Billed Charges,1959.58,50,,255.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2743.41,70,,86.008,Percent of Total Billed Charges,70% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,0.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3919.15,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,9.04,3919.15,
IR TRNSCATH LYSIS VEN INI RT,49120516,CDM,361,RC,,,Outpatient,,,3919.15,2351.49,,2351.49,60,,3.936,Percent of Total Billed Charges,60% of Total Billed Charges,1763.62,45,,1410.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.36,28,,1.728,Percent of Total Billed Charges,28% of Total Billed Charges,9.14,32,,1.552,Percent of Total Billed Charges,32% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,1410.89,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,1410.89,36,,2.224,Percent of Total Billed Charges,36% Total Bille Charges,1410.89,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,2351.49,60,,11.024,Percent of Total Billed Charges,60% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3919.15,100,,3135.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,565.14,14.42,,4.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2939.36,75,,1724.392,Percent of Total Billed Charges,75% of Total Billed Charges,1959.58,50,,742.376,Percent of Total Billed Charges,50% of Total Billed Charges,1959.58,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1959.58,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,1959.58,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2743.41,70,,451.736,Percent of Total Billed Charges,70% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,548.68,14,,4.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3919.15,100,,2299.192,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,3919.15,
IR TRNSCATH LYSIS SUBSQ DAY,49120519,CDM,361,RC,,,Outpatient,,,5897.76,3538.66,,3538.66,60,,3.936,Percent of Total Billed Charges,60% of Total Billed Charges,2653.99,45,,2123.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1651.37,28,,1.728,Percent of Total Billed Charges,28% of Total Billed Charges,9.16,32,,1.552,Percent of Total Billed Charges,32% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,2123.19,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,2123.19,36,,2.224,Percent of Total Billed Charges,36% Total Bille Charges,2123.19,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,3538.66,60,,1.216,Percent of Total Billed Charges,60% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5897.76,100,,4718.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,850.46,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4423.32,75,,910.744,Percent of Total Billed Charges,75% of Total Billed Charges,2948.88,50,,100.704,Percent of Total Billed Charges,50% of Total Billed Charges,2948.88,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2948.88,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,2948.88,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4128.43,70,,1213.936,Percent of Total Billed Charges,70% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,825.69,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5897.76,100,,1214.32,Percent of Total Billed Charges,100% of Total Billed Charges,9.16,5897.76,
IR TRNSCATH LYSIS SUBSQ REMOVE,49120520,CDM,361,RC,,,Outpatient,,,6047.06,3628.24,,3628.24,60,,177.792,Percent of Total Billed Charges,60% of Total Billed Charges,2721.18,45,,2176.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1693.18,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,9.16,32,,1.56,Percent of Total Billed Charges,32% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,2176.94,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,2176.94,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,2176.94,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,3628.24,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6047.06,100,,4837.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,871.99,14.42,,0.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4535.3,75,,128.704,Percent of Total Billed Charges,75% of Total Billed Charges,3023.53,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,3023.53,50,,169.736,Percent of Total Billed Charges,50% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3023.53,50,,169.736,Percent of Total Billed Charges,50% of Total Billed Charges,3023.53,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4232.94,70,,720.296,Percent of Total Billed Charges,70% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,846.59,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6047.06,100,,171.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.16,6047.06,
IR TUBE CHG NEPHROSTOMY BI,49120525,CDM,361,RC,,,Outpatient,,,3722.62,2233.57,,2233.57,60,,266.152,Percent of Total Billed Charges,60% of Total Billed Charges,1675.18,45,,1340.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1042.33,28,,14.56,Percent of Total Billed Charges,28% of Total Billed Charges,9.16,32,,1.568,Percent of Total Billed Charges,32% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,1340.14,36,,18.72,Percent of Total Billed Charges,36% of Total Billed Charges,1340.14,36,,18.72,Percent of Total Billed Charges,36% Total Bille Charges,1340.14,36,,18.72,Percent of Total Billed Charges,36% of Total Billed Charges,2233.57,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3722.62,100,,2978.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,536.8,14.42,,0.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2791.97,75,,128.704,Percent of Total Billed Charges,75% of Total Billed Charges,1861.31,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,1861.31,50,,144.936,Percent of Total Billed Charges,50% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1861.31,50,,144.936,Percent of Total Billed Charges,50% of Total Billed Charges,1861.31,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2605.83,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,521.17,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3722.62,100,,171.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.16,3722.62,
IR TUBE CHG NEPHROSTOMY LT,49120526,CDM,361,RC,,,Outpatient,,,2481.75,1489.05,,1489.05,60,,143.192,Percent of Total Billed Charges,60% of Total Billed Charges,1116.79,45,,893.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.89,28,,37.4,Percent of Total Billed Charges,28% of Total Billed Charges,9.16,32,,1.568,Percent of Total Billed Charges,32% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,893.43,36,,48.088,Percent of Total Billed Charges,36% of Total Billed Charges,893.43,36,,48.088,Percent of Total Billed Charges,36% Total Bille Charges,893.43,36,,48.088,Percent of Total Billed Charges,36% of Total Billed Charges,1489.05,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2481.75,100,,1985.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,357.87,14.42,,2.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1861.31,75,,219.784,Percent of Total Billed Charges,75% of Total Billed Charges,1240.88,50,,169.736,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,3963.728,Percent of Total Billed Charges,50% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1240.88,50,,3963.728,Percent of Total Billed Charges,50% of Total Billed Charges,1240.88,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1737.23,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,347.45,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2481.75,100,,293.04,Percent of Total Billed Charges,100% of Total Billed Charges,9.16,2481.75,
IR TUBE CHG PERC WCM SI,49120528,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,TC   ,64.44,100,,3.448,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,39.816,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,1.568,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,51.192,Fee Schedule,360% of BCBS POS Rate,246.49,360,,51.192,Fee schedule,360% of BCBS PPO Rate,246.49,360,,51.192,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,0.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,219.784,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,144.936,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,78.536,Case Rate,Pays based on per visit rate,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,293.04,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
IR TUBE CHG PERC WCM SI,49120528,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,TC   ,64.44,100,,6.104,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,11.696,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,1.584,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,15.04,Fee Schedule,360% of BCBS POS Rate,246.49,360,,15.04,Fee schedule,360% of BCBS PPO Rate,246.49,360,,15.04,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,79.96,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,0.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,3963.728,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,83.848,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,83.848,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,176.96,Case Rate,Pays based on per visit rate,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,100,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
IR TUBE GASTROSTOMY CHG WO IMG,49120531,CDM,761,RC,43762,HCPCS,Outpatient,,,1250.84,750.50,,35.98,100,,9.456,Fee Schedule,100% of Aetna Fee Schedule,340.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,350.24,28,,42.008,Percent of Total Billed Charges,28% of Total Billed Charges,9.17,32,,1.584,Percent of Total Billed Charges,32% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,450.3,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,450.3,36,,54.008,Percent of Total Billed Charges,36% Total Bille Charges,450.3,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,1.736,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,204.07,90,,,Fee Schedule,90% of CMS OPPS Rate,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,294.76,130,,,Fee Schedule,130% of CMS OPPS Rate,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,180.37,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,233.54,103,,,Fee Schedule,103% of CMS OPPS Rate,233.54,103,,,Fee Schedule,103% of CMS OPPS Rate,938.13,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,625.42,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,625.42,50,,125.832,Percent of Total Billed Charges,50% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,625.42,50,,125.832,Percent of Total Billed Charges,50% of Total Billed Charges,625.42,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,340.12,150,,,Fee Schedule,150% of CMS OPPS Rate,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,875.59,70,,7.192,Percent of Total Billed Charges,70% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,175.12,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.84,100,,100,Percent of Total Billed Charges,100% of Total Billed Charges,9.17,1250.84,
IR TUBE GASTROSTOMY PERC,49120532,CDM,361,RC,,,Outpatient,,,2320,1392.00,,1392,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,1044,45,,835.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,649.6,28,,45.856,Percent of Total Billed Charges,28% of Total Billed Charges,9.18,32,,1.608,Percent of Total Billed Charges,32% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,835.2,36,,58.952,Percent of Total Billed Charges,36% of Total Billed Charges,835.2,36,,58.952,Percent of Total Billed Charges,36% Total Bille Charges,835.2,36,,58.952,Percent of Total Billed Charges,36% of Total Billed Charges,1392,60,,13.6,Percent of Total Billed Charges,60% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2320,100,,1856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,334.54,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1740,75,,88.144,Percent of Total Billed Charges,75% of Total Billed Charges,1160,50,,83.848,Percent of Total Billed Charges,50% of Total Billed Charges,1160,50,,1389.04,Percent of Total Billed Charges,50% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1160,50,,1389.04,Percent of Total Billed Charges,50% of Total Billed Charges,1160,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1624,70,,8.504,Percent of Total Billed Charges,70% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,324.8,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2320,100,,117.52,Percent of Total Billed Charges,100% of Total Billed Charges,9.18,2320,
IR CATH INS SWAN GANZ,49120538,CDM,361,RC,93503,HCPCS,Outpatient,,,3071.79,1843.07,,1020,60,,443.64,Percent of Total Billed Charges,60% of Total Billed Charges,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,410.296,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9.2,32,,1.616,Percent of Total Billed Charges,32% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,527.52,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,527.52,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,527.52,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1843.07,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,442.95,14.42,,0.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2303.84,75,,88.144,Percent of Total Billed Charges,75% of Total Billed Charges,1535.9,50,,125.832,Percent of Total Billed Charges,50% of Total Billed Charges,1535.9,50,,377.496,Percent of Total Billed Charges,50% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1535.9,50,,377.496,Percent of Total Billed Charges,50% of Total Billed Charges,1535.9,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,18.528,Fee Schedule,100% of ASC Tier Groupings fee schedule,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,430.05,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3071.79,100,,117.52,Percent of Total Billed Charges,100% of Total Billed Charges,9.2,5252.24,
IR AORTA THOR W SER SI,49120541,CDM,323,RC,75605,HCPCS,Outpatient,,,4312.58,2587.55,,70.76,100,,272.76,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12869.33,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,14707.81,320,,1.616,Fee Schedule,320% of BCBS Blue Essentials Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,16546.28,360,,0.04,Fee Schedule,360% of BCBS POS Rate,16546.28,360,,0.04,Fee schedule,360% of BCBS PPO Rate,16546.28,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,13309.24,103,,1.872,Fee Schedule,103% of Cigna fee schedule,120.63,100,,18.656,Fee Schedule,100% of TX Mediciad Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4537.59,90,,,Fee Schedule,90% of CMS OPPS Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.3,130,,,Fee Schedule,130% of CMS OPPS Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,124.25,103,,19.216,Fee Schedule,103% of TX Medicaid Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,3234.44,75,,636,Percent of Total Billed Charges,75% of Total Billed Charges,2156.29,50,,1389.04,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2156.29,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,20.496,Case Rate,Pays based on per visit rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,120.63,100,,18.656,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4312.58,100,,848,Percent of Total Billed Charges,100% of Total Billed Charges,70.76,16546.28,
IR AORTO ABD W SER SI,49120542,CDM,323,RC,75625,HCPCS,Outpatient,,,4312.58,2587.55,TC   ,64.44,100,,6.328,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,49.52,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.616,Fee Schedule,320% of BCBS Blue Essentials Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,63.664,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,63.664,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,63.664,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,1.872,Fee Schedule,103% of Cigna fee schedule,126.3,100,,0.408,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,130.09,103,,0.416,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3234.44,75,,1372.128,Percent of Total Billed Charges,75% of Total Billed Charges,2156.29,50,,377.496,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2156.29,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,742.376,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,20.496,Case Rate,Pays based on per visit rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4312.58,100,,1829.504,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,9976.61,
IR AORTO ABD W SER SI,49120542,CDM,323,RC,75625,HCPCS,Outpatient,,,4312.58,2587.55,TC   ,64.44,100,,11.608,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,58.96,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.632,Fee Schedule,320% of BCBS Blue Essentials Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,75.808,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,75.808,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,75.808,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,1.872,Fee Schedule,103% of Cigna fee schedule,126.3,100,,3.176,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,130.09,103,,3.272,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3234.44,75,,301.408,Percent of Total Billed Charges,75% of Total Billed Charges,2156.29,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2156.29,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2156.29,50,,100.704,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1.064,Case Rate,Pays based on per visit rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,126.3,100,,3.176,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4312.58,100,,401.88,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,9976.61,
IR AORTO ABD W RUNOFF SI,49120543,CDM,323,RC,75630,HCPCS,Outpatient,,,4335.77,2601.46,,68.43,100,,1.904,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,132.296,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.632,Fee Schedule,320% of BCBS Blue Essentials Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,170.096,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,170.096,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,170.096,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,1.872,Fee Schedule,103% of Cigna fee schedule,156.71,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,161.41,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3251.83,75,,301.408,Percent of Total Billed Charges,75% of Total Billed Charges,2167.89,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,2167.89,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2167.89,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2167.89,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,13.84,Case Rate,Pays based on per visit rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4335.77,100,,401.88,Percent of Total Billed Charges,100% of Total Billed Charges,68.43,9976.61,
IR AORTO ABD W RUNOFF SI,49120543,CDM,323,RC,75630,HCPCS,Outpatient,,,4335.77,2601.46,,68.43,100,,16.384,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,155.632,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.632,Fee Schedule,320% of BCBS Blue Essentials Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,200.096,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,200.096,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,200.096,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,1.872,Fee Schedule,103% of Cigna fee schedule,156.71,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,161.41,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3251.83,75,,301.408,Percent of Total Billed Charges,75% of Total Billed Charges,2167.89,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2167.89,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2167.89,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2167.89,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,27.712,Case Rate,Pays based on per visit rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,156.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4335.77,100,,401.88,Percent of Total Billed Charges,100% of Total Billed Charges,68.43,9976.61,
IR ART EXTREMITY UNI SI,49120545,CDM,323,RC,75710,HCPCS,Outpatient,,,4192.3,2515.38,TC   ,73.1,100,,17.992,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,2.856,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.648,Fee Schedule,320% of BCBS Blue Essentials Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,3.672,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,3.672,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,3.672,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,1.872,Fee Schedule,103% of Cigna fee schedule,150.36,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,154.87,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3144.23,75,,301.408,Percent of Total Billed Charges,75% of Total Billed Charges,2096.15,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2096.15,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2096.15,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2096.15,50,,169.736,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,31.832,Case Rate,Pays based on per visit rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4192.3,100,,401.88,Percent of Total Billed Charges,100% of Total Billed Charges,73.1,9976.61,
IR ART EXTREMITY UNI SI,49120545,CDM,323,RC,75710,HCPCS,Outpatient,,,4192.3,2515.38,TC   ,73.1,100,,3.032,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,3.912,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.648,Fee Schedule,320% of BCBS Blue Essentials Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,5.032,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,5.032,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,5.032,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,21.4,Fee Schedule,103% of Cigna fee schedule,150.36,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,154.87,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3144.23,75,,1629.128,Percent of Total Billed Charges,75% of Total Billed Charges,2096.15,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,2096.15,50,,965.688,Percent of Total Billed Charges,50% of Total Billed Charges,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2096.15,50,,965.688,Percent of Total Billed Charges,50% of Total Billed Charges,2096.15,50,,144.936,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,81.136,Case Rate,Pays based on per visit rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,150.36,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4192.3,100,,2172.168,Percent of Total Billed Charges,100% of Total Billed Charges,73.1,9976.61,
IR ART EXTREMITY BI SI,49120546,CDM,323,RC,75716,HCPCS,Outpatient,,,4809,2885.40,,74.94,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,1.2,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.656,Fee Schedule,320% of BCBS Blue Essentials Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,1.544,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,1.544,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,1.544,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,24.104,Fee Schedule,103% of Cigna fee schedule,162.39,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,167.26,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3606.75,75,,2443.504,Percent of Total Billed Charges,75% of Total Billed Charges,2404.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2404.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2404.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2404.5,50,,3963.728,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,52.72,Case Rate,Pays based on per visit rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4809,100,,3258,Percent of Total Billed Charges,100% of Total Billed Charges,74.94,9976.61,
IR ART EXTREMITY BI SI,49120546,CDM,323,RC,75716,HCPCS,Outpatient,,,4809,2885.40,,74.94,100,,2.496,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,3.912,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.664,Fee Schedule,320% of BCBS Blue Essentials Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,5.032,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,5.032,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,5.032,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,23.528,Fee Schedule,103% of Cigna fee schedule,162.39,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,167.26,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3606.75,75,,260.808,Percent of Total Billed Charges,75% of Total Billed Charges,2404.5,50,,965.688,Percent of Total Billed Charges,50% of Total Billed Charges,2404.5,50,,2496.56,Percent of Total Billed Charges,50% of Total Billed Charges,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2404.5,50,,2496.56,Percent of Total Billed Charges,50% of Total Billed Charges,2404.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,274.68,Case Rate,Pays based on per visit rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.39,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4809,100,,347.744,Percent of Total Billed Charges,100% of Total Billed Charges,74.94,9976.61,
IR ART VISC SELECTVE SI,49120547,CDM,323,RC,75726,HCPCS,Outpatient,,,6210.82,3726.49,,80.93,100,,2.408,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12869.33,280,,11.104,Fee Schedule,280% of BCBS BULE Fee Schedule,14707.81,320,,1.664,Fee Schedule,320% of BCBS Blue Essentials Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,16546.28,360,,14.272,Fee Schedule,360% of BCBS POS Rate,16546.28,360,,14.272,Fee schedule,360% of BCBS PPO Rate,16546.28,360,,14.272,Fee Schedule,360% of BCBS Traditional Rate,13309.24,103,,0.856,Fee Schedule,103% of Cigna fee schedule,171.41,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4537.59,90,,,Fee Schedule,90% of CMS OPPS Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.3,130,,,Fee Schedule,130% of CMS OPPS Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,176.55,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,4658.12,75,,260.808,Percent of Total Billed Charges,75% of Total Billed Charges,3105.41,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,3105.41,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3105.41,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,3105.41,50,,83.848,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,11.648,Case Rate,Pays based on per visit rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6210.82,100,,347.744,Percent of Total Billed Charges,100% of Total Billed Charges,80.93,16546.28,
IR ART VISC SELECTVE SI,49120547,CDM,323,RC,75726,HCPCS,Outpatient,,,6210.82,3726.49,,80.93,100,,2.496,Fee Schedule,100% of Aetna Fee Schedule,7562.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12869.33,280,,16.4,Fee Schedule,280% of BCBS BULE Fee Schedule,14707.81,320,,1.68,Fee Schedule,320% of BCBS Blue Essentials Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,16546.28,360,,21.08,Fee Schedule,360% of BCBS POS Rate,16546.28,360,,21.08,Fee schedule,360% of BCBS PPO Rate,16546.28,360,,21.08,Fee Schedule,360% of BCBS Traditional Rate,13309.24,103,,1.856,Fee Schedule,103% of Cigna fee schedule,171.41,100,,4.992,Fee Schedule,100% of TX Mediciad Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4537.59,90,,,Fee Schedule,90% of CMS OPPS Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6554.3,130,,,Fee Schedule,130% of CMS OPPS Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,176.55,103,,5.144,Fee Schedule,103% of TX Medicaid Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,5193.02,103,,,Fee Schedule,103% of CMS OPPS Rate,4658.12,75,,260.808,Percent of Total Billed Charges,75% of Total Billed Charges,3105.41,50,,2496.56,Percent of Total Billed Charges,50% of Total Billed Charges,3105.41,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3105.41,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,3105.41,50,,125.832,Percent of Total Billed Charges,50% of Total Billed Charges,7562.65,150,,,Fee Schedule,150% of CMS OPPS Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,29.664,Case Rate,Pays based on per visit rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,171.41,100,,4.992,Fee Schedule,100% of TX Medicaid Rate,5041.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6210.82,100,,347.744,Percent of Total Billed Charges,100% of Total Billed Charges,80.93,16546.28,
IR ART PULM SELECTVE UNI SI,49120548,CDM,323,RC,75741,HCPCS,Outpatient,,,3908,2344.80,TC   ,74.43,100,,0.464,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,94.08,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.68,Fee Schedule,320% of BCBS Blue Essentials Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,120.96,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,120.96,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,120.96,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,0.76,Fee Schedule,103% of Cigna fee schedule,130.98,100,,5.624,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,134.91,103,,5.792,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,2931,75,,260.808,Percent of Total Billed Charges,75% of Total Billed Charges,1954,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,1954,50,,188.096,Percent of Total Billed Charges,50% of Total Billed Charges,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1954,50,,188.096,Percent of Total Billed Charges,50% of Total Billed Charges,1954,50,,1389.04,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,67,Case Rate,Pays based on per visit rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.624,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3908,100,,347.744,Percent of Total Billed Charges,100% of Total Billed Charges,74.43,9976.61,
IR ART PULM SELECTVE UNI SI,49120548,CDM,323,RC,75741,HCPCS,Outpatient,,,3908,2344.80,TC   ,74.43,100,,0.632,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,14.152,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.68,Fee Schedule,320% of BCBS Blue Essentials Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,18.192,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,18.192,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,18.192,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,0.8,Fee Schedule,103% of Cigna fee schedule,130.98,100,,5.488,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,134.91,103,,5.656,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,2931,75,,1055.248,Percent of Total Billed Charges,75% of Total Billed Charges,1954,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,1954,50,,250.832,Percent of Total Billed Charges,50% of Total Billed Charges,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1954,50,,250.832,Percent of Total Billed Charges,50% of Total Billed Charges,1954,50,,377.496,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,28.384,Case Rate,Pays based on per visit rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,130.98,100,,5.488,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3908,100,,1406.992,Percent of Total Billed Charges,100% of Total Billed Charges,74.43,9976.61,
IR ART PULM SELECTIVE BI SI,49120549,CDM,323,RC,75743,HCPCS,Outpatient,,,2637.23,1582.34,,75.42,100,,0.736,Fee Schedule,100% of Aetna Fee Schedule,4386.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7759.58,280,,14.152,Fee Schedule,280% of BCBS BULE Fee Schedule,8868.1,320,,1.688,Fee Schedule,320% of BCBS Blue Essentials Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,9976.61,360,,18.192,Fee Schedule,360% of BCBS POS Rate,9976.61,360,,18.192,Fee schedule,360% of BCBS PPO Rate,9976.61,360,,18.192,Fee Schedule,360% of BCBS Traditional Rate,8033,103,,0.928,Fee Schedule,103% of Cigna fee schedule,148.35,100,,0.2,Fee Schedule,100% of TX Mediciad Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.95,90,,,Fee Schedule,90% of CMS OPPS Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3801.71,130,,,Fee Schedule,130% of CMS OPPS Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,152.8,103,,0.208,Fee Schedule,103% of TX Medicaid Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,3012.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1977.92,75,,146.48,Percent of Total Billed Charges,75% of Total Billed Charges,1318.62,50,,188.096,Percent of Total Billed Charges,50% of Total Billed Charges,1318.62,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.62,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1318.62,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,4386.59,150,,,Fee Schedule,150% of CMS OPPS Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,12.664,Case Rate,Pays based on per visit rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,148.35,100,,0.2,Fee Schedule,100% of TX Medicaid Rate,2924.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2637.23,100,,195.304,Percent of Total Billed Charges,100% of Total Billed Charges,75.42,9976.61,
IR ART VESSEL EA ADD SI,49120551,CDM,323,RC,75774,HCPCS,Outpatient,,,2456.6,1473.96,TC   ,55.44,100,,29.76,Fee Schedule,100% of Aetna Fee Schedule,1105.47,45,,884.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.67,280,,11.152,Fee Schedule,280% of BCBS BULE Fee Schedule,212.19,320,,1.696,Fee Schedule,320% of BCBS Blue Essentials Rate,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,238.72,360,,14.344,Fee Schedule,360% of BCBS POS Rate,238.72,360,,14.344,Fee schedule,360% of BCBS PPO Rate,238.72,360,,14.344,Fee Schedule,360% of BCBS Traditional Rate,1473.96,60,,11.216,Percent of Total Billed Charges,60% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2456.6,100,,1965.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,354.24,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.45,75,,230.776,Percent of Total Billed Charges,75% of Total Billed Charges,1228.3,50,,250.832,Percent of Total Billed Charges,50% of Total Billed Charges,1228.3,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.3,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1228.3,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,21.368,Case Rate,Pays based on per visit rate,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2456.6,100,,307.696,Percent of Total Billed Charges,100% of Total Billed Charges,55.44,2456.6,
IR ART VESSEL EA ADD SI,49120551,CDM,323,RC,75774,HCPCS,Outpatient,,,2456.6,1473.96,TC   ,55.44,100,,1.928,Fee Schedule,100% of Aetna Fee Schedule,1105.47,45,,884.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.67,280,,1.696,Fee Schedule,280% of BCBS BULE Fee Schedule,212.19,320,,1.704,Fee Schedule,320% of BCBS Blue Essentials Rate,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,238.72,360,,2.176,Fee Schedule,360% of BCBS POS Rate,238.72,360,,2.176,Fee schedule,360% of BCBS PPO Rate,238.72,360,,2.176,Fee Schedule,360% of BCBS Traditional Rate,1473.96,60,,2.344,Percent of Total Billed Charges,60% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2456.6,100,,1965.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,354.24,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.45,75,,230.776,Percent of Total Billed Charges,75% of Total Billed Charges,1228.3,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1228.3,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1228.3,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1228.3,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,324.576,Case Rate,Pays based on per visit rate,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,343.92,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2456.6,100,,307.696,Percent of Total Billed Charges,100% of Total Billed Charges,55.44,2456.6,
IR INTRO NDL AV SHNT INI LT,49120552,CDM,361,RC,,,Outpatient,,,2307.72,1384.63,,1384.63,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,1038.47,45,,830.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.16,28,,3.152,Percent of Total Billed Charges,28% of Total Billed Charges,9.23,32,,1.704,Percent of Total Billed Charges,32% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,830.78,36,,4.056,Percent of Total Billed Charges,36% of Total Billed Charges,830.78,36,,4.056,Percent of Total Billed Charges,36% Total Bille Charges,830.78,36,,4.056,Percent of Total Billed Charges,36% of Total Billed Charges,1384.63,60,,2.248,Percent of Total Billed Charges,60% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2307.72,100,,1846.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,332.77,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1730.79,75,,297.296,Percent of Total Billed Charges,75% of Total Billed Charges,1153.86,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1153.86,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1153.86,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1153.86,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1615.4,70,,17.368,Percent of Total Billed Charges,70% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,323.08,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2307.72,100,,396.392,Percent of Total Billed Charges,100% of Total Billed Charges,9.23,2307.72,
IR TRNSCATH EMBOLIZATION SI,49120553,CDM,320,RC,75894,HCPCS,Outpatient,,,4508.7,2705.22,,885.75,100,,24.032,Fee Schedule,100% of Aetna Fee Schedule,2028.92,45,,1623.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.87,280,,7.28,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,1.712,Fee Schedule,320% of BCBS Blue Essentials Rate,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,9.36,Fee Schedule,360% of BCBS POS Rate,267.26,360,,9.36,Fee schedule,360% of BCBS PPO Rate,267.26,360,,9.36,Fee Schedule,360% of BCBS Traditional Rate,2705.22,60,,4.336,Percent of Total Billed Charges,60% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4508.7,100,,3606.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,650.15,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3381.53,75,,297.296,Percent of Total Billed Charges,75% of Total Billed Charges,2254.35,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2254.35,50,,104.68,Percent of Total Billed Charges,50% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254.35,50,,104.68,Percent of Total Billed Charges,50% of Total Billed Charges,2254.35,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,20.264,Case Rate,Pays based on per visit rate,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4508.7,100,,396.392,Percent of Total Billed Charges,100% of Total Billed Charges,207.87,4508.7,
IR TRNSCATH EMBOLIZATION SI,49120553,CDM,320,RC,75894,HCPCS,Outpatient,,,4508.7,2705.22,,885.75,100,,7.296,Fee Schedule,100% of Aetna Fee Schedule,2028.92,45,,1623.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.87,280,,96.032,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,1.728,Fee Schedule,320% of BCBS Blue Essentials Rate,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,123.472,Fee Schedule,360% of BCBS POS Rate,267.26,360,,123.472,Fee schedule,360% of BCBS PPO Rate,267.26,360,,123.472,Fee Schedule,360% of BCBS Traditional Rate,2705.22,60,,4.928,Percent of Total Billed Charges,60% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4508.7,100,,3606.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,650.15,14.42,,2.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3381.53,75,,241.76,Percent of Total Billed Charges,75% of Total Billed Charges,2254.35,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2254.35,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254.35,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2254.35,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,21.568,Case Rate,Pays based on per visit rate,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,631.22,14,,2.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4508.7,100,,322.344,Percent of Total Billed Charges,100% of Total Billed Charges,207.87,4508.7,
IR VENGR CVD RMV FBRN SHTH,49120556,CDM,320,RC,75901,HCPCS,Outpatient,,,709.35,425.61,,209.12,100,,24.736,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.49,280,,96.448,Fee Schedule,280% of BCBS BULE Fee Schedule,570.85,320,,1.736,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,642.2,360,,124.008,Fee Schedule,360% of BCBS POS Rate,642.2,360,,124.008,Fee schedule,360% of BCBS PPO Rate,642.2,360,,124.008,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,241.76,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,104.68,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,965.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,30.008,Case Rate,Pays based on per visit rate,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,322.344,Percent of Total Billed Charges,100% of Total Billed Charges,99.31,709.35,
IR VENGR CVD RMV FBRN SHTH,49120556,CDM,320,RC,75901,HCPCS,Outpatient,,,709.35,425.61,,209.12,100,,128.448,Fee Schedule,100% of Aetna Fee Schedule,319.21,45,,255.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.49,280,,15.544,Fee Schedule,280% of BCBS BULE Fee Schedule,570.85,320,,1.752,Fee Schedule,320% of BCBS Blue Essentials Rate,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,642.2,360,,19.984,Fee Schedule,360% of BCBS POS Rate,642.2,360,,19.984,Fee schedule,360% of BCBS PPO Rate,642.2,360,,19.984,Fee Schedule,360% of BCBS Traditional Rate,425.61,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.35,100,,567.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,102.29,14.42,,0.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.01,75,,241.76,Percent of Total Billed Charges,75% of Total Billed Charges,354.68,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,637.616,Percent of Total Billed Charges,50% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.68,50,,637.616,Percent of Total Billed Charges,50% of Total Billed Charges,354.68,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,28.088,Case Rate,Pays based on per visit rate,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,99.31,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,709.35,100,,322.344,Percent of Total Billed Charges,100% of Total Billed Charges,99.31,709.35,
IR CATH CHG PERC WCM SI,49120563,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,TC   ,64.44,100,,11.696,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,6.52,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,1.76,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,8.384,Fee Schedule,360% of BCBS POS Rate,246.49,360,,8.384,Fee schedule,360% of BCBS PPO Rate,246.49,360,,8.384,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,0.664,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,1.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,241.76,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,2496.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,5.816,Case Rate,Pays based on per visit rate,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,322.344,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
IR CATH CHG PERC WCM SI,49120563,CDM,320,RC,75984,HCPCS,Outpatient,,,934.09,560.45,TC   ,64.44,100,,2.496,Fee Schedule,100% of Aetna Fee Schedule,420.34,45,,336.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.72,280,,36.64,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,1.76,Fee Schedule,320% of BCBS Blue Essentials Rate,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,246.49,360,,47.112,Fee Schedule,360% of BCBS POS Rate,246.49,360,,47.112,Fee schedule,360% of BCBS PPO Rate,246.49,360,,47.112,Fee Schedule,360% of BCBS Traditional Rate,560.45,60,,9.32,Percent of Total Billed Charges,60% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.09,100,,747.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,134.7,14.42,,1.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700.57,75,,263.944,Percent of Total Billed Charges,75% of Total Billed Charges,467.05,50,,637.616,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,476.64,Percent of Total Billed Charges,50% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,467.05,50,,476.64,Percent of Total Billed Charges,50% of Total Billed Charges,467.05,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,11.392,Case Rate,Pays based on per visit rate,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,130.77,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,934.09,100,,351.92,Percent of Total Billed Charges,100% of Total Billed Charges,64.44,934.09,
IR GUIDE DRN CATH PLCMT,49120564,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,,74.33,100,,110.912,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,76.272,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,1.784,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,98.064,Fee Schedule,360% of BCBS POS Rate,229.64,360,,98.064,Fee schedule,360% of BCBS PPO Rate,229.64,360,,98.064,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,9.392,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,0.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,263.944,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,12.872,Case Rate,Pays based on per visit rate,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,351.92,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
IR GUIDE DRN CATH PLCMT,49120564,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,,74.33,100,,5.792,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,3.616,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,1.784,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,4.656,Fee Schedule,360% of BCBS POS Rate,229.64,360,,4.656,Fee schedule,360% of BCBS PPO Rate,229.64,360,,4.656,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,93.224,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,332.8,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,476.64,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,50.536,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,50.536,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,188.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,15,Case Rate,Pays based on per visit rate,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,416,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
IR GUIDE FLUORO NDL PLCMT,49120565,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,TC   ,86.75,100,,1.84,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,288.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,0.872,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,15526.92,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,1.12,Fee Schedule,360% of BCBS POS Rate,268.56,360,,1.12,Fee schedule,360% of BCBS PPO Rate,268.56,360,,1.12,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,29.968,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,640.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,0.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,63.36,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,63.36,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,250.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,10.848,Case Rate,Pays based on per visit rate,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
IR GUIDE FLUORO NDL PLCMT,49120565,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,TC   ,86.75,100,,1.84,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,288.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,18.536,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,15532.072,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,23.832,Fee Schedule,360% of BCBS POS Rate,268.56,360,,23.832,Fee schedule,360% of BCBS PPO Rate,268.56,360,,23.832,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,36.448,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,640.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,2.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,50.536,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,265.296,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,265.296,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,38.504,Case Rate,Pays based on per visit rate,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
IR CVAD INJ FLUORO AND IMAGE,49120566,CDM,361,RC,,,Outpatient,,,893.73,536.24,,536.24,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,402.18,45,,321.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250.24,28,,23.52,Percent of Total Billed Charges,28% of Total Billed Charges,9.26,32,,15.36,Percent of Total Billed Charges,32% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,321.74,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,321.74,36,,30.24,Percent of Total Billed Charges,36% Total Bille Charges,321.74,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,536.24,60,,48.96,Percent of Total Billed Charges,60% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,893.73,100,,714.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,128.88,14.42,,2.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,670.3,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,446.87,50,,63.36,Percent of Total Billed Charges,50% of Total Billed Charges,446.87,50,,918.056,Percent of Total Billed Charges,50% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,446.87,50,,918.056,Percent of Total Billed Charges,50% of Total Billed Charges,446.87,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,625.61,70,,3.024,Percent of Total Billed Charges,70% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,125.12,14,,2.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,893.73,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,9.26,893.73,
IR FEMPOP W ANGPLAS LT,49120567,CDM,361,RC,,,Outpatient,,,15895.74,9537.44,,9537.44,60,,4.432,Percent of Total Billed Charges,60% of Total Billed Charges,7153.08,45,,5722.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4450.81,28,,62.88,Percent of Total Billed Charges,28% of Total Billed Charges,9.26,32,,15.544,Percent of Total Billed Charges,32% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,5722.47,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,5722.47,36,,80.848,Percent of Total Billed Charges,36% Total Bille Charges,5722.47,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,9537.44,60,,1.096,Percent of Total Billed Charges,60% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15895.74,100,,12716.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2292.17,14.42,,22.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11921.81,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,7947.87,50,,265.296,Percent of Total Billed Charges,50% of Total Billed Charges,7947.87,50,,298.768,Percent of Total Billed Charges,50% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7947.87,50,,298.768,Percent of Total Billed Charges,50% of Total Billed Charges,7947.87,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11127.02,70,,19.592,Percent of Total Billed Charges,70% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15895.74,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,9.26,15895.74,
IR FEMPOP W ANGPLAS RT,49120568,CDM,361,RC,,,Outpatient,,,15895.74,9537.44,,9537.44,60,,150.912,Percent of Total Billed Charges,60% of Total Billed Charges,7153.08,45,,5722.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4450.81,28,,67.208,Percent of Total Billed Charges,28% of Total Billed Charges,9.26,32,,15.584,Percent of Total Billed Charges,32% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,5722.47,36,,86.408,Percent of Total Billed Charges,36% of Total Billed Charges,5722.47,36,,86.408,Percent of Total Billed Charges,36% Total Bille Charges,5722.47,36,,86.408,Percent of Total Billed Charges,36% of Total Billed Charges,9537.44,60,,9.84,Percent of Total Billed Charges,60% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15895.74,100,,12716.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2292.17,14.42,,7.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11921.81,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,7947.87,50,,918.056,Percent of Total Billed Charges,50% of Total Billed Charges,7947.87,50,,241.184,Percent of Total Billed Charges,50% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7947.87,50,,241.184,Percent of Total Billed Charges,50% of Total Billed Charges,7947.87,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11127.02,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,2225.4,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15895.74,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,9.26,15895.74,
IR FEMPOP W ANGPLAS BI,49120569,CDM,361,RC,,,Outpatient,,,23843.62,14306.17,,14306.17,60,,20.44,Percent of Total Billed Charges,60% of Total Billed Charges,10729.63,45,,8583.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6676.21,28,,1.072,Percent of Total Billed Charges,28% of Total Billed Charges,9.27,32,,15.6,Percent of Total Billed Charges,32% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,8583.7,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,8583.7,36,,1.376,Percent of Total Billed Charges,36% Total Bille Charges,8583.7,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,14306.17,60,,93.224,Percent of Total Billed Charges,60% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23843.62,100,,19074.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3438.25,14.42,,0.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17882.72,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,298.768,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,104.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16690.53,70,,7.088,Percent of Total Billed Charges,70% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,3338.11,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23843.62,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,9.27,23843.62,
IR ILIAC W ANGPLAS RT,49120570,CDM,361,RC,,,Outpatient,,,12870.67,7722.40,,7722.4,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,5791.8,45,,4633.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3603.79,28,,5.288,Percent of Total Billed Charges,28% of Total Billed Charges,89.83,32,,15.6,Percent of Total Billed Charges,32% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,4633.44,36,,6.8,Percent of Total Billed Charges,36% of Total Billed Charges,4633.44,36,,6.8,Percent of Total Billed Charges,36% Total Bille Charges,4633.44,36,,6.8,Percent of Total Billed Charges,36% of Total Billed Charges,7722.4,60,,27.2,Percent of Total Billed Charges,60% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12870.67,100,,10296.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1855.95,14.42,,22.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9653,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,6435.34,50,,241.184,Percent of Total Billed Charges,50% of Total Billed Charges,6435.34,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6435.34,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,6435.34,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9009.47,70,,27.888,Percent of Total Billed Charges,70% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,21.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12870.67,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,89.83,12870.67,
IR ILIAC W ANGPLAS LT,49120571,CDM,361,RC,,,Outpatient,,,12870.67,7722.40,,7722.4,60,,13.096,Percent of Total Billed Charges,60% of Total Billed Charges,5791.8,45,,4633.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3603.79,28,,1.912,Percent of Total Billed Charges,28% of Total Billed Charges,89.83,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,4633.44,36,,2.456,Percent of Total Billed Charges,36% of Total Billed Charges,4633.44,36,,2.456,Percent of Total Billed Charges,36% Total Bille Charges,4633.44,36,,2.456,Percent of Total Billed Charges,36% of Total Billed Charges,7722.4,60,,11.632,Percent of Total Billed Charges,60% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12870.67,100,,10296.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1855.95,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9653,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,6435.34,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,6435.34,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6435.34,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,6435.34,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9009.47,70,,3.76,Percent of Total Billed Charges,70% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,1801.89,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12870.67,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,89.83,12870.67,
IR ILIAC W ANGPLAS BI,49120572,CDM,361,RC,,,Outpatient,,,19306,11583.60,,11583.6,60,,7.16,Percent of Total Billed Charges,60% of Total Billed Charges,8687.7,45,,6950.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5405.68,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,90.05,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,6950.16,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,6950.16,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,6950.16,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,11583.6,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19306,100,,15444.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2783.93,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14479.5,75,,343.984,Percent of Total Billed Charges,75% of Total Billed Charges,9653,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,9653,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9653,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,9653,50,,637.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13514.2,70,,24.296,Percent of Total Billed Charges,70% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2702.84,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19306,100,,458.64,Percent of Total Billed Charges,100% of Total Billed Charges,90.05,19306,
IR FEMPOP W ANGPLAS W ATHER LT,49120573,CDM,361,RC,,,Outpatient,,,29637.79,17782.67,,17782.67,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,13337.01,45,,10669.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8298.58,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,90.05,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10669.6,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,10669.6,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,10669.6,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,17782.67,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29637.79,100,,23710.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22228.34,75,,343.984,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,390,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20746.45,70,,18.816,Percent of Total Billed Charges,70% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29637.79,100,,458.64,Percent of Total Billed Charges,100% of Total Billed Charges,90.05,29637.79,
IR FEMPOP W ANGPLAS W ATHER RT,49120574,CDM,361,RC,,,Outpatient,,,29637.79,17782.67,,17782.67,60,,473.728,Percent of Total Billed Charges,60% of Total Billed Charges,13337.01,45,,10669.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8298.58,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,90.05,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,10669.6,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,10669.6,36,,0.128,Percent of Total Billed Charges,36% Total Bille Charges,10669.6,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,17782.67,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29637.79,100,,23710.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,1.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22228.34,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10300,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,476.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20746.45,70,,20.192,Percent of Total Billed Charges,70% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29637.79,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,90.05,29637.79,
IR ASP FINE NDL W US INIT LESI,49120576,CDM,361,RC,10005,HCPCS,Outpatient,,,1758.74,1055.24,,2601,100,,108.664,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.91,233,,2.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.12,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,241.73,322,,2.816,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,241.73,322,,2.816,Fee schedule,Pays based on ASC Tier Groupings fee schedule,241.73,322,,2.816,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,5.872,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,253.61,14.42,,0.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1319.06,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,879.37,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,879.37,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,341.112,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,48.992,Fee Schedule,100% of ASC Tier Groupings fee schedule,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.74,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,90.12,2601,
IR ASP FINE NDL W US ADD LESIO,49120577,CDM,361,RC,10006,HCPCS,Outpatient,,,244.13,146.48,,2601,100,,81.232,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.86,45,,87.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.6,Other,Not Seperately Reimbusable,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.48,60,,1.016,Percent of Total Billed Charges,60% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.13,100,,195.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,35.2,14.42,,0.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.1,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,122.07,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.07,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,50.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,15.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.13,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,34.18,2601,
IR ASP FINE NDL W CT INIT LESI,49120578,CDM,361,RC,10009,HCPCS,Outpatient,,,2098.93,1259.36,,2601,100,,60.352,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,718.18,233,,0.024,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.42,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,992.5,322,,0.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,992.5,322,,0.032,Fee schedule,Pays based on ASC Tier Groupings fee schedule,992.5,322,,0.032,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,23.84,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,302.67,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1574.2,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,1049.47,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,1049.47,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.47,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,1049.47,50,,63.36,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,6.84,Fee Schedule,100% of ASC Tier Groupings fee schedule,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,293.85,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2098.93,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,90.42,2601,
IR ASP FINE NDL W CT ADD LESIO,49120579,CDM,361,RC,10010,HCPCS,Outpatient,,,244.13,146.48,,2601,100,,15.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.86,45,,87.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.6,Other,Not Seperately Reimbusable,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.48,60,,3.896,Percent of Total Billed Charges,60% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.13,100,,195.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,35.2,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.1,75,,74.8,Percent of Total Billed Charges,75% of Total Billed Charges,122.07,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.07,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,265.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,182.08,Fee Schedule,100% of ASC Tier Groupings fee schedule,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.13,100,,99.728,Percent of Total Billed Charges,100% of Total Billed Charges,34.18,2601,
IR CVC PICC WO PORT W G MIN 5Y,49120580,CDM,361,RC,36573,HCPCS,Outpatient,,,3379.02,2027.41,,2601,100,,41.808,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,1.904,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.61,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,2.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,2.448,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,2.448,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,4892.5,103,,12.544,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,487.25,14.42,,44.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2534.27,75,,307.136,Percent of Total Billed Charges,75% of Total Billed Charges,1689.51,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,1689.51,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1689.51,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,1689.51,50,,918.056,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,246.56,Fee Schedule,100% of ASC Tier Groupings fee schedule,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,43.28,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3379.02,100,,409.512,Percent of Total Billed Charges,100% of Total Billed Charges,90.61,5252.24,
IR SUP HYPOGASTRIC NRV BLK,49120581,CDM,361,RC,64681,HCPCS,Outpatient,,,3930.8,2358.48,,4162,100,,655.392,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,2.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.8,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,2.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,2.728,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,2.728,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,212.52,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,566.82,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2948.1,75,,183.152,Percent of Total Billed Charges,75% of Total Billed Charges,1965.4,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,1965.4,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1965.4,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,1965.4,50,,298.768,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,296.68,Fee Schedule,100% of ASC Tier Groupings fee schedule,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3930.8,100,,244.2,Percent of Total Billed Charges,100% of Total Billed Charges,90.8,4162,
IR GUIDE FLUORO NDL SPINE,49120582,CDM,320,RC,77003,HCPCS,Outpatient,,,654.82,392.89,,73.76,100,,168.464,Fee Schedule,100% of Aetna Fee Schedule,294.67,45,,235.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.72,280,,2.12,Fee Schedule,280% of BCBS BULE Fee Schedule,220.26,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,247.79,360,,2.728,Fee Schedule,360% of BCBS POS Rate,247.79,360,,2.728,Fee schedule,360% of BCBS PPO Rate,247.79,360,,2.728,Fee Schedule,360% of BCBS Traditional Rate,392.89,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,654.82,100,,523.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,94.43,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.12,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,327.41,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.41,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,327.41,50,,241.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,28.664,Case Rate,Pays based on per visit rate,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,91.67,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.82,100,,96,Percent of Total Billed Charges,100% of Total Billed Charges,73.76,654.82,
IR ILIAC IVL W STENT LT,49120583,CDM,361,RC,C9765,HCPCS,Outpatient,,,33600.19,20160.11,,20160.11,60,,3.752,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.12,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.88,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,2.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,2.728,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,2.728,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,20160.11,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4845.15,14.42,,0.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,25200.14,75,,486,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,81.248,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,104.632,Fee Schedule,100% of ASC Tier Groupings fee schedule,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.16,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33600.19,100,,648,Percent of Total Billed Charges,100% of Total Billed Charges,90.88,33600.19,
IR ILIAC IVL W STENT RT,49120584,CDM,361,RC,C9765,HCPCS,Outpatient,,,33600.19,20160.11,,20160.11,60,,118.792,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.88,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,3.384,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,3.384,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,3.384,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,20160.11,60,,185.48,Percent of Total Billed Charges,60% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4845.15,14.42,,0.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,25200.14,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,181.864,Fee Schedule,100% of ASC Tier Groupings fee schedule,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,4704.03,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33600.19,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,90.88,33600.19,
IR ILIAC IVL W STENT BI,49120585,CDM,361,RC,C9765,HCPCS,Outpatient,,,52900.28,31740.17,,31740.17,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.896,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.94,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,3.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,3.72,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,3.72,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,31740.17,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7628.22,14.42,,4.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,39675.21,75,,240.568,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,428.488,Fee Schedule,100% of ASC Tier Groupings fee schedule,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,7406.04,14,,4.624,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,52900.28,100,,320.76,Percent of Total Billed Charges,100% of Total Billed Charges,90.94,52900.28,
IR FEMPOP IVL W ANGIOPLASTY LT,49120586,CDM,361,RC,C9764,HCPCS,Outpatient,,,29637.79,17782.67,,17782.67,60,,5.552,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,36.552,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,90.94,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,46.992,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,46.992,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,46.992,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,17782.67,60,,0.328,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,0.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,85.6,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,84.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.4,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,114.128,Percent of Total Billed Charges,100% of Total Billed Charges,90.94,29637.79,
IR FEMPOP IVL W ANGIOPLASTY RT,49120587,CDM,361,RC,C9764,HCPCS,Outpatient,,,29637.79,17782.67,,17782.67,60,,13.056,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,1.712,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.12,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,2.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,2.2,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,2.2,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,17782.67,60,,0.688,Percent of Total Billed Charges,60% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4273.77,14.42,,0.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,22228.34,75,,85.6,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,70.296,Fee Schedule,100% of ASC Tier Groupings fee schedule,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,4149.29,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,29637.79,100,,114.128,Percent of Total Billed Charges,100% of Total Billed Charges,91.12,29637.79,
IR FEMPOP IVL W ANGIOPLASTY BI,49120588,CDM,361,RC,C9764,HCPCS,Outpatient,,,44456.68,26674.01,,26674.01,60,,7.688,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,1.08,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.5,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,1.392,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,1.392,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,1.392,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,26674.01,60,,1.976,Percent of Total Billed Charges,60% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6410.65,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,33342.51,75,,121.056,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,95.752,Percent of Total Billed Charges,50% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,95.752,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,25.232,Fee Schedule,100% of ASC Tier Groupings fee schedule,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,6223.94,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,44456.68,100,,161.408,Percent of Total Billed Charges,100% of Total Billed Charges,91.5,44456.68,
IR FEMPOP IVL W STENT LT,49120589,CDM,361,RC,C9765,HCPCS,Outpatient,,,38600.19,23160.11,,23160.11,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,0.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.69,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,0.56,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,0.56,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,0.56,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,23160.11,60,,19.832,Percent of Total Billed Charges,60% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5566.15,14.42,,1.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,28950.14,75,,121.056,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,35.512,Fee Schedule,100% of ASC Tier Groupings fee schedule,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38600.19,100,,161.408,Percent of Total Billed Charges,100% of Total Billed Charges,91.69,38600.19,
IT FEMPOP IVL W STENT RT,49120590,CDM,361,RC,C9765,HCPCS,Outpatient,,,38600.19,23160.11,,23160.11,60,,10.88,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.69,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,2.616,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,2.616,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,2.616,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,23160.11,60,,1.696,Percent of Total Billed Charges,60% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5566.15,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,28950.14,75,,57.064,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,95.752,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,61.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,5404.03,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38600.19,100,,76.088,Percent of Total Billed Charges,100% of Total Billed Charges,91.69,38600.19,
IR FEMPOP IVL W STENT BI,49120591,CDM,361,RC,C9765,HCPCS,Outpatient,,,57900.28,34740.17,,34740.17,60,,10.88,Percent of Total Billed Charges,60% of Total Billed Charges,24131.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23086.76,233,,2.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.69,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,31905.31,322,,3.504,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,31905.31,322,,3.504,Fee schedule,Pays based on ASC Tier Groupings fee schedule,31905.31,322,,3.504,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,34740.17,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14479.01,90,,,Fee Schedule,90% of CMS OPPS Rate,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,20914.14,130,,,Fee Schedule,130% of CMS OPPS Rate,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8349.22,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,16570.41,103,,,Fee Schedule,103% of CMS OPPS Rate,43425.21,75,,57.064,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,24131.69,150,,,Fee Schedule,150% of CMS OPPS Rate,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,20.208,Fee Schedule,100% of ASC Tier Groupings fee schedule,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,8106.04,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,16087.8,100,,,Fee Schedule,100% of CMS OPPS Rate,57900.28,100,,76.088,Percent of Total Billed Charges,100% of Total Billed Charges,91.69,57900.28,
IR ILIAC IVL W ANGIOPLASTY LT,49120592,CDM,361,RC,C9764,HCPCS,Outpatient,,,24637.79,14782.67,,14782.67,60,,77.36,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,0.528,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,91.69,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,0.68,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,0.68,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,0.68,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,14782.67,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3552.77,14.42,,0.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,18478.34,75,,57.064,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,32.552,Fee Schedule,100% of ASC Tier Groupings fee schedule,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,24637.79,100,,76.088,Percent of Total Billed Charges,100% of Total Billed Charges,91.69,24637.79,
IR ILIAC IVL W ANGIOPLASTY RT,49120593,CDM,361,RC,C9764,HCPCS,Outpatient,,,24637.79,14782.67,,14782.67,60,,0.208,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,15.24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,92,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,19.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,19.592,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,19.592,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,14782.67,60,,5.672,Percent of Total Billed Charges,60% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3552.77,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,18478.34,75,,57.064,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,169.248,Percent of Total Billed Charges,50% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,169.248,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,140.752,Fee Schedule,100% of ASC Tier Groupings fee schedule,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,3449.29,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,24637.79,100,,76.088,Percent of Total Billed Charges,100% of Total Billed Charges,92,24637.79,
IR ILIAC IVL W ANGIOPLASTY BI,49120594,CDM,361,RC,C9764,HCPCS,Outpatient,,,39456.68,23674.01,,23674.01,60,,3.016,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11542.61,233,,133.496,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,92.13,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,15951.59,322,,171.64,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,15951.59,322,,171.64,Fee schedule,Pays based on ASC Tier Groupings fee schedule,15951.59,322,,171.64,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,23674.01,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5689.65,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,29592.51,75,,667.456,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,1087.616,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,77.68,Fee Schedule,100% of ASC Tier Groupings fee schedule,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,5523.94,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,39456.68,100,,889.936,Percent of Total Billed Charges,100% of Total Billed Charges,92.13,39456.68,
BIOTRONIK SAFE SHEATH,49120595,CDM,272,RC,C1892,HCPCS,Outpatient,,,308.75,185.25,,0.57,100,,16.04,Fee Schedule,100% of Aetna Fee Schedule,138.94,45,,111.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.45,28,,58.376,Percent of Total Billed Charges,28% of Total Billed Charges,92.13,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,111.15,36,,75.056,Percent of Total Billed Charges,36% of Total Billed Charges,111.15,36,,75.056,Percent of Total Billed Charges,36% Total Bille Charges,111.15,36,,75.056,Percent of Total Billed Charges,36% of Total Billed Charges,185.25,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.75,100,,247,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,44.52,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.56,75,,667.456,Percent of Total Billed Charges,75% of Total Billed Charges,154.38,50,,169.248,Percent of Total Billed Charges,50% of Total Billed Charges,154.38,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.38,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,154.38,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.13,70,,4.544,Percent of Total Billed Charges,70% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.75,100,,889.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,308.75,
LEAD PM BIOTRONIK SOLIA,49120596,CDM,275,RC,C1898,HCPCS,Outpatient,,,1667.25,1000.35,,3206.76,110,,16.04,Percent of Total Billed Charges,110% of Total Billed Charges,750.26,45,,600.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.83,28,,64.616,Percent of Total Billed Charges,28% of Total Billed Charges,92.15,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,600.21,36,,83.08,Percent of Total Billed Charges,36% of Total Billed Charges,600.21,36,,83.08,Percent of Total Billed Charges,36% Total Bille Charges,600.21,36,,83.08,Percent of Total Billed Charges,36% of Total Billed Charges,916.99,55,,3.96,Percent of Total Billed Charges,55% Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1667.25,100,,1333.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,240.42,14.42,,1.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1250.44,75,,286.472,Percent of Total Billed Charges,75% of Total Billed Charges,833.63,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,833.63,50,,128.768,Percent of Total Billed Charges,50% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,833.63,50,,128.768,Percent of Total Billed Charges,50% of Total Billed Charges,833.63,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1167.08,70,,6.544,Percent of Total Billed Charges,70% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,233.42,14,,1.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1667.25,100,,381.96,Percent of Total Billed Charges,100% of Total Billed Charges,92.15,3206.76,
PPM BIOTRONIK EDORA 8 DRT,49120597,CDM,275,RC,C1785,HCPCS,Outpatient,,,13955.5,8373.30,,15626.47,110,,16.04,Percent of Total Billed Charges,110% of Total Billed Charges,6279.98,45,,5023.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3907.54,28,,35.152,Percent of Total Billed Charges,28% of Total Billed Charges,92.31,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,5023.98,36,,45.192,Percent of Total Billed Charges,36% of Total Billed Charges,5023.98,36,,45.192,Percent of Total Billed Charges,36% Total Bille Charges,5023.98,36,,45.192,Percent of Total Billed Charges,36% of Total Billed Charges,7675.53,55,,0.344,Percent of Total Billed Charges,55% Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13955.5,100,,11164.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,2012.38,14.42,,1.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10466.63,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,6977.75,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,6977.75,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6977.75,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,6977.75,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9768.85,70,,10.224,Percent of Total Billed Charges,70% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1953.77,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13955.5,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,92.31,15626.47,
IR TIB/PER PTA AND LITHO LT,49120600,CDM,361,RC,C9772,HCPCS,Outpatient,,,44456,26673.60,,26673.6,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23400.05,233,,48.744,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,92.4,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,32338.27,322,,62.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,32338.27,322,,62.672,Fee schedule,Pays based on ASC Tier Groupings fee schedule,32338.27,322,,62.672,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,26673.6,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6410.56,14.42,,2.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,33342,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,128.768,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,51.624,Fee Schedule,100% of ASC Tier Groupings fee schedule,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,2.824,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,44456,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,92.4,44456,
IR TIB/PER PTA AND LITHO RT,49120601,CDM,361,RC,C9772,HCPCS,Outpatient,,,44456,26673.60,,26673.6,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,15139.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23400.05,233,,0.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,92.4,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,32338.27,322,,0.936,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,32338.27,322,,0.936,Fee schedule,Pays based on ASC Tier Groupings fee schedule,32338.27,322,,0.936,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,26673.6,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,9083.82,90,,,Fee Schedule,90% of CMS OPPS Rate,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,13121.08,130,,,Fee Schedule,130% of CMS OPPS Rate,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6410.56,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10395.93,103,,,Fee Schedule,103% of CMS OPPS Rate,33342,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,10300,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,10300,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,15139.71,150,,,Fee Schedule,150% of CMS OPPS Rate,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12037,100,,5.6,Fee Schedule,100% of ASC Tier Groupings fee schedule,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,6223.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,10093.14,100,,,Fee Schedule,100% of CMS OPPS Rate,44456,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,92.4,44456,
DX ASP JT INTERMED W IMG LT,49300271,CDM,361,RC,20606,HCPCS,Outpatient,,,1567.74,940.64,,2601,100,,0.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,108.48,233,,4.2,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9400.85,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,149.92,322,,5.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,149.92,322,,5.4,Fee schedule,Pays based on ASC Tier Groupings fee schedule,149.92,322,,5.4,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,6.464,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,226.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1175.81,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,783.87,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,783.87,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,783.87,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,783.87,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,3.76,Fee Schedule,100% of ASC Tier Groupings fee schedule,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.74,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,108.48,9400.85,
DX ASP JT INTERMED W IMG RT,49300272,CDM,361,RC,20606,HCPCS,Outpatient,,,1567.74,940.64,,2601,100,,1.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,108.48,233,,2.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9405.76,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,149.92,322,,3.056,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,149.92,322,,3.056,Fee schedule,Pays based on ASC Tier Groupings fee schedule,149.92,322,,3.056,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,6.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,226.07,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1175.81,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,783.87,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,783.87,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,783.87,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,783.87,50,,95.752,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,4.36,Fee Schedule,100% of ASC Tier Groupings fee schedule,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,219.48,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.74,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,108.48,9405.76,
DX ASP JT MAJOR W IMG LT,49300274,CDM,361,RC,20611,HCPCS,Outpatient,,,1623.26,973.96,,2601,100,,1.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,121.93,233,,9.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9484.09,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,168.5,322,,11.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,168.5,322,,11.84,Fee schedule,Pays based on ASC Tier Groupings fee schedule,168.5,322,,11.84,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,12.088,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,234.07,14.42,,1.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1217.45,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,811.63,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,811.63,50,,60.728,Percent of Total Billed Charges,50% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,811.63,50,,60.728,Percent of Total Billed Charges,50% of Total Billed Charges,811.63,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,64.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,1.336,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.26,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,121.93,9484.09,
DX ASP JT MAJOR W IMG RT,49300275,CDM,361,RC,20611,HCPCS,Outpatient,,,1623.26,973.96,,2601,100,,0.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,121.93,233,,56.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9484.09,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,168.5,322,,72.576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,168.5,322,,72.576,Fee schedule,Pays based on ASC Tier Groupings fee schedule,168.5,322,,72.576,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,1.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,234.07,14.42,,0.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1217.45,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,811.63,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,811.63,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,811.63,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,811.63,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,936.32,Fee Schedule,100% of ASC Tier Groupings fee schedule,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,227.26,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.26,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,121.93,9484.09,
DELIVERY NDL & REFLECTOR,50100000,CDM,278,RC,A4648,HCPCS,Outpatient,,,1320,792.00,,1554.14,110,,809.936,Percent of Total Billed Charges,110% of Total Billed Charges,594,45,,475.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.6,28,,14.84,Percent of Total Billed Charges,28% of Total Billed Charges,9.31,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,475.2,36,,19.08,Percent of Total Billed Charges,36% of Total Billed Charges,475.2,36,,19.08,Percent of Total Billed Charges,36% Total Bille Charges,475.2,36,,19.08,Percent of Total Billed Charges,36% of Total Billed Charges,726,55,,0.24,Percent of Total Billed Charges,55% Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1320,100,,1056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,190.34,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1056,80,,212.944,Percent of Total Billed Charges,80% of Total Billed Charges,660,50,,60.728,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,924,70,,39.136,Percent of Total Billed Charges,70% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1320,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,9.31,1554.14,
DELIVERY NDL & MINI REFL SINGLE  HAND,50100001,CDM,278,RC,A4648,HCPCS,Outpatient,,,1320,792.00,,1554.14,110,,3179.768,Percent of Total Billed Charges,110% of Total Billed Charges,594,45,,475.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.6,28,,24.984,Percent of Total Billed Charges,28% of Total Billed Charges,9.34,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,475.2,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,475.2,36,,32.12,Percent of Total Billed Charges,36% Total Bille Charges,475.2,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,726,55,,0.312,Percent of Total Billed Charges,55% Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1320,100,,1056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,190.34,14.42,,8.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1056,80,,214.504,Percent of Total Billed Charges,80% of Total Billed Charges,660,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,924,70,,30.84,Percent of Total Billed Charges,70% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,7.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1320,100,,286,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,1554.14,
DELIVERY NDL & REFL SINGLE HAND,50100002,CDM,278,RC,A4648,HCPCS,Outpatient,,,1320,792.00,,1554.14,110,,0.416,Percent of Total Billed Charges,110% of Total Billed Charges,594,45,,475.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.6,28,,34.656,Percent of Total Billed Charges,28% of Total Billed Charges,9.4,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,475.2,36,,44.56,Percent of Total Billed Charges,36% of Total Billed Charges,475.2,36,,44.56,Percent of Total Billed Charges,36% Total Bille Charges,475.2,36,,44.56,Percent of Total Billed Charges,36% of Total Billed Charges,726,55,,5.712,Percent of Total Billed Charges,55% Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1320,100,,1056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,190.34,14.42,,4.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1056,80,,214.504,Percent of Total Billed Charges,80% of Total Billed Charges,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,660,50,,169.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,924,70,,51.512,Percent of Total Billed Charges,70% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,184.8,14,,4.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1320,100,,286,Percent of Total Billed Charges,100% of Total Billed Charges,9.4,1554.14,
MG BX BRST STEREO INI RT,50100200,CDM,361,RC,,,Outpatient,,,4175.91,2505.55,,2505.55,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,1879.16,45,,1503.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1169.25,28,,101.136,Percent of Total Billed Charges,28% of Total Billed Charges,9.44,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,1503.33,36,,130.032,Percent of Total Billed Charges,36% of Total Billed Charges,1503.33,36,,130.032,Percent of Total Billed Charges,36% Total Bille Charges,1503.33,36,,130.032,Percent of Total Billed Charges,36% of Total Billed Charges,2505.55,60,,3.2,Percent of Total Billed Charges,60% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4175.91,100,,3340.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,602.17,14.42,,0.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3131.93,75,,228,Percent of Total Billed Charges,75% of Total Billed Charges,2087.96,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,2087.96,50,,298.792,Percent of Total Billed Charges,50% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2087.96,50,,298.792,Percent of Total Billed Charges,50% of Total Billed Charges,2087.96,50,,91.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2923.14,70,,91.504,Percent of Total Billed Charges,70% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4175.91,100,,304,Percent of Total Billed Charges,100% of Total Billed Charges,9.44,4175.91,
MG BX BRST STEREO INI LT,50100201,CDM,361,RC,,,Outpatient,,,4175.91,2505.55,,2505.55,60,,66.528,Percent of Total Billed Charges,60% of Total Billed Charges,1879.16,45,,1503.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1169.25,28,,40.32,Percent of Total Billed Charges,28% of Total Billed Charges,9.57,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,1503.33,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,1503.33,36,,51.84,Percent of Total Billed Charges,36% Total Bille Charges,1503.33,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,2505.55,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4175.91,100,,3340.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,602.17,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3131.93,75,,343.984,Percent of Total Billed Charges,75% of Total Billed Charges,2087.96,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,2087.96,50,,103.584,Percent of Total Billed Charges,50% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2087.96,50,,103.584,Percent of Total Billed Charges,50% of Total Billed Charges,2087.96,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2923.14,70,,122.528,Percent of Total Billed Charges,70% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,584.63,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4175.91,100,,458.64,Percent of Total Billed Charges,100% of Total Billed Charges,9.57,4175.91,
MG BX BRST STEREO INI BI,50100202,CDM,361,RC,,,Outpatient,,,6263.86,3758.32,,3758.32,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,2818.74,45,,2254.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1753.88,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,92.8,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,2254.99,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,2254.99,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,2254.99,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,3758.32,60,,34.168,Percent of Total Billed Charges,60% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6263.86,100,,5011.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,903.25,14.42,,0.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4697.9,75,,343.984,Percent of Total Billed Charges,75% of Total Billed Charges,3131.93,50,,298.792,Percent of Total Billed Charges,50% of Total Billed Charges,3131.93,50,,803.568,Percent of Total Billed Charges,50% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3131.93,50,,803.568,Percent of Total Billed Charges,50% of Total Billed Charges,3131.93,50,,128.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4384.7,70,,15.208,Percent of Total Billed Charges,70% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,876.94,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6263.86,100,,458.64,Percent of Total Billed Charges,100% of Total Billed Charges,92.8,6263.86,
MG GUIDE NDL MARK PLCMT INI RT,50100204,CDM,361,RC,,,Outpatient,,,2352.3,1411.38,,1411.38,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,1058.54,45,,846.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,658.64,28,,2.168,Percent of Total Billed Charges,28% of Total Billed Charges,92.8,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,846.83,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,846.83,36,,2.784,Percent of Total Billed Charges,36% Total Bille Charges,846.83,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,1411.38,60,,18.04,Percent of Total Billed Charges,60% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2352.3,100,,1881.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,339.2,14.42,,8.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1764.23,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,1176.15,50,,103.584,Percent of Total Billed Charges,50% of Total Billed Charges,1176.15,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.15,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,1176.15,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1646.61,70,,184.8,Percent of Total Billed Charges,70% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,7.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2352.3,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,92.8,2352.3,
MG GUIDE NDL MARK PLCMT INI LT,50100205,CDM,361,RC,,,Outpatient,,,2352.3,1411.38,,1411.38,60,,82.824,Percent of Total Billed Charges,60% of Total Billed Charges,1058.54,45,,846.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,658.64,28,,14.056,Percent of Total Billed Charges,28% of Total Billed Charges,92.94,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,846.83,36,,18.072,Percent of Total Billed Charges,36% of Total Billed Charges,846.83,36,,18.072,Percent of Total Billed Charges,36% Total Bille Charges,846.83,36,,18.072,Percent of Total Billed Charges,36% of Total Billed Charges,1411.38,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2352.3,100,,1881.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,339.2,14.42,,0.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1764.23,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,1176.15,50,,803.568,Percent of Total Billed Charges,50% of Total Billed Charges,1176.15,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1176.15,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,1176.15,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1646.61,70,,64.896,Percent of Total Billed Charges,70% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,329.32,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2352.3,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,92.94,2352.3,
MG GUIDE NDL MARK PLCMT INI BI,50100206,CDM,361,RC,,,Outpatient,,,3528.44,2117.06,,2117.06,60,,18.216,Percent of Total Billed Charges,60% of Total Billed Charges,1587.8,45,,1270.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,987.96,28,,9.36,Percent of Total Billed Charges,28% of Total Billed Charges,93.16,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1270.24,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,1270.24,36,,12.032,Percent of Total Billed Charges,36% Total Bille Charges,1270.24,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,2117.06,60,,1.832,Percent of Total Billed Charges,60% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3528.44,100,,2822.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,508.8,14.42,,1.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2646.33,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,1764.22,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,1764.22,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1764.22,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,1764.22,50,,291.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2469.91,70,,239.4,Percent of Total Billed Charges,70% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,493.98,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3528.44,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,93.16,3528.44,
MG GUIDE NDL MARK PLCMT EA ADD,50100207,CDM,361,RC,,,Outpatient,,,1301.06,780.64,,780.64,60,,12.12,Percent of Total Billed Charges,60% of Total Billed Charges,585.48,45,,468.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.3,28,,1.688,Percent of Total Billed Charges,28% of Total Billed Charges,93.6,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,468.38,36,,2.168,Percent of Total Billed Charges,36% of Total Billed Charges,468.38,36,,2.168,Percent of Total Billed Charges,36% Total Bille Charges,468.38,36,,2.168,Percent of Total Billed Charges,36% of Total Billed Charges,780.64,60,,2.104,Percent of Total Billed Charges,60% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1301.06,100,,1040.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,187.61,14.42,,2.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975.8,75,,229.32,Percent of Total Billed Charges,75% of Total Billed Charges,650.53,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,650.53,50,,676.488,Percent of Total Billed Charges,50% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,650.53,50,,676.488,Percent of Total Billed Charges,50% of Total Billed Charges,650.53,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910.74,70,,44.584,Percent of Total Billed Charges,70% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1301.06,100,,305.76,Percent of Total Billed Charges,100% of Total Billed Charges,93.6,1301.06,
MG STEREO GUIDE NDL PLC INI LT,50100209,CDM,361,RC,19283,HCPCS,Outpatient,,,2553.15,1531.89,,4162,100,,33.952,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,152.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,196.544,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,196.544,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,196.544,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,33.616,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,368.16,14.42,,2.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1914.86,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,1276.58,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,1276.58,50,,1714.4,Percent of Total Billed Charges,50% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1276.58,50,,1714.4,Percent of Total Billed Charges,50% of Total Billed Charges,1276.58,50,,182.176,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,65.456,Fee Schedule,100% of ASC Tier Groupings fee schedule,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,357.44,14,,1.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2553.15,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,4162,
MG STEREO GUIDE NDL PLC EA ADD,50100211,CDM,361,RC,,,Outpatient,,,1301.06,780.64,,780.64,60,,71.392,Percent of Total Billed Charges,60% of Total Billed Charges,585.48,45,,468.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.3,28,,561.76,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,468.38,36,,722.264,Percent of Total Billed Charges,36% of Total Billed Charges,468.38,36,,722.264,Percent of Total Billed Charges,36% Total Bille Charges,468.38,36,,722.264,Percent of Total Billed Charges,36% of Total Billed Charges,780.64,60,,2.296,Percent of Total Billed Charges,60% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1301.06,100,,1040.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,187.61,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975.8,75,,319.408,Percent of Total Billed Charges,75% of Total Billed Charges,650.53,50,,676.488,Percent of Total Billed Charges,50% of Total Billed Charges,650.53,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,650.53,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,650.53,50,,60.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,910.74,70,,44.584,Percent of Total Billed Charges,70% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,182.15,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1301.06,100,,425.88,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,1301.06,
US BX BRST INI RT,50100212,CDM,361,RC,,,Outpatient,,,3858.75,2315.25,,2315.25,60,,6.432,Percent of Total Billed Charges,60% of Total Billed Charges,1736.44,45,,1389.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.45,28,,466.6,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,1389.15,36,,599.912,Percent of Total Billed Charges,36% of Total Billed Charges,1389.15,36,,599.912,Percent of Total Billed Charges,36% Total Bille Charges,1389.15,36,,599.912,Percent of Total Billed Charges,36% of Total Billed Charges,2315.25,60,,4.416,Percent of Total Billed Charges,60% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3858.75,100,,3087,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,556.43,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2894.06,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,1929.38,50,,1714.4,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1929.38,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,835.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2701.13,70,,203.728,Percent of Total Billed Charges,70% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3858.75,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,3858.75,
US BX BRST INI LT,50100213,CDM,361,RC,,,Outpatient,,,3858.75,2315.25,,2315.25,60,,11.768,Percent of Total Billed Charges,60% of Total Billed Charges,1736.44,45,,1389.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.45,28,,37.456,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,1389.15,36,,48.16,Percent of Total Billed Charges,36% of Total Billed Charges,1389.15,36,,48.16,Percent of Total Billed Charges,36% Total Bille Charges,1389.15,36,,48.16,Percent of Total Billed Charges,36% of Total Billed Charges,2315.25,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3858.75,100,,3087,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,556.43,14.42,,0.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2894.06,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,1929.38,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,1086.528,Percent of Total Billed Charges,50% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1929.38,50,,1086.528,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2701.13,70,,64.336,Percent of Total Billed Charges,70% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3858.75,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,3858.75,
US BX BRST INI BI,50100214,CDM,361,RC,,,Outpatient,,,5788.13,3472.88,,3472.88,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,2604.66,45,,2083.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1620.68,28,,55.984,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,2083.73,36,,71.984,Percent of Total Billed Charges,36% of Total Billed Charges,2083.73,36,,71.984,Percent of Total Billed Charges,36% Total Bille Charges,2083.73,36,,71.984,Percent of Total Billed Charges,36% of Total Billed Charges,3472.88,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5788.13,100,,4630.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,834.65,14.42,,2.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4341.1,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,2894.07,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,2894.07,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2894.07,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,2894.07,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4051.69,70,,4.712,Percent of Total Billed Charges,70% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5788.13,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,5788.13,
US BX BRST EA ADD,50100215,CDM,361,RC,,,Outpatient,,,1517.9,910.74,,910.74,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,683.06,45,,546.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.01,28,,77.384,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,546.44,36,,99.496,Percent of Total Billed Charges,36% of Total Billed Charges,546.44,36,,99.496,Percent of Total Billed Charges,36% Total Bille Charges,546.44,36,,99.496,Percent of Total Billed Charges,36% of Total Billed Charges,910.74,60,,0.568,Percent of Total Billed Charges,60% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1517.9,100,,1214.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,218.88,14.42,,2.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1138.43,75,,212.944,Percent of Total Billed Charges,75% of Total Billed Charges,758.95,50,,1086.528,Percent of Total Billed Charges,50% of Total Billed Charges,758.95,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,758.95,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,758.95,50,,310.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1062.53,70,,35.84,Percent of Total Billed Charges,70% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1517.9,100,,283.92,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,1517.9,
US GUIDE NDL MARK PLCMT INI RT,50100216,CDM,361,RC,,,Outpatient,,,2286.88,1372.13,,1372.13,60,,18.832,Percent of Total Billed Charges,60% of Total Billed Charges,1029.1,45,,823.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,640.33,28,,22.12,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% Total Bille Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,1372.13,60,,0.608,Percent of Total Billed Charges,60% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2286.88,100,,1829.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,329.77,14.42,,2.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1715.16,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,1143.44,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1143.44,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,298.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.82,70,,2.36,Percent of Total Billed Charges,70% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,1.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2286.88,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,2286.88,
US GUIDE NDL MARK PLCMT INI LT,50100217,CDM,361,RC,,,Outpatient,,,2286.88,1372.13,,1372.13,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,1029.1,45,,823.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,640.33,28,,22.12,Percent of Total Billed Charges,28% of Total Billed Charges,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% Total Bille Charges,823.28,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,1372.13,60,,0.664,Percent of Total Billed Charges,60% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2286.88,100,,1829.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,329.77,14.42,,0.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1715.16,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,1143.44,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,230.704,Percent of Total Billed Charges,50% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1143.44,50,,230.704,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,103.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.82,70,,5.592,Percent of Total Billed Charges,70% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2286.88,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,2286.88,
US BX LYMPH NODE LT,50100222,CDM,361,RC,38505,HCPCS,Outpatient,,,1915.99,1149.59,,2601,100,,353.264,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,15.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,20.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,20.208,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,20.208,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,8.344,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,0.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.99,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,230.704,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,958,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,77.28,Fee Schedule,100% of ASC Tier Groupings fee schedule,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.99,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,4419.77,
US BX LYMPH NODE RT,50100223,CDM,361,RC,38505,HCPCS,Outpatient,,,1915.99,1149.59,,2601,100,,1.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,15.72,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,93.81,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,20.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,20.208,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,20.208,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,8.344,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,1.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.99,75,,1404.688,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,4223.6,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,1018.784,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,958,50,,1018.784,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,685.872,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,16.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.99,100,,1872.912,Percent of Total Billed Charges,100% of Total Billed Charges,93.81,4419.77,
US BX LYMPH NODE BI,50100224,CDM,361,RC,38505,HCPCS,Outpatient,,,2873.99,1724.39,,2601,100,,139.744,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,1.472,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,94.09,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,1.888,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,1.888,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,1.888,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,2.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,414.43,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2155.49,75,,1404.688,Percent of Total Billed Charges,75% of Total Billed Charges,1437,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,237.768,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,16.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2873.99,100,,1872.912,Percent of Total Billed Charges,100% of Total Billed Charges,94.09,4419.77,
MG BX BRST STEREO EA ADD,50100225,CDM,361,RC,19082,HCPCS,Outpatient,,,1517.9,910.74,,2601,100,,8.816,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,683.06,45,,546.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.6,Other,Not Seperately Reimbusable,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,910.74,60,,0.224,Percent of Total Billed Charges,60% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1517.9,100,,1214.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,218.88,14.42,,62.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1138.43,75,,228,Percent of Total Billed Charges,75% of Total Billed Charges,758.95,50,,1018.784,Percent of Total Billed Charges,50% of Total Billed Charges,758.95,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,758.95,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,758.95,50,,676.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,16.064,Fee Schedule,100% of ASC Tier Groupings fee schedule,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,212.51,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1517.9,100,,304,Percent of Total Billed Charges,100% of Total Billed Charges,212.51,2601,
MG 3D TOMO SCREEN IMPLANT,50106639,CDM,403,RC,77063,HCPCS,Outpatient,,,214.5,128.70,,24.3,100,,1.12,Fee Schedule,100% of Aetna Fee Schedule,33.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,0.848,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,1.088,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.088,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.088,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,3.392,Fee Schedule,103% of Cigna fee schedule,51.79,100,,15.088,Fee Schedule,100% of TX Mediciad Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,20.38,90,,,Fee Schedule,90% of CMS OPPS Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29.43,130,,,Fee Schedule,130% of CMS OPPS Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,53.34,103,,15.536,Fee Schedule,103% of TX Medicaid Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,160.88,75,,2282.12,Percent of Total Billed Charges,75% of Total Billed Charges,107.25,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.25,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,1714.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.96,150,,,Fee Schedule,150% of CMS OPPS Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,10.12,Case Rate,Pays based on per visit rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,15.088,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,214.5,100,,3042.824,Percent of Total Billed Charges,100% of Total Billed Charges,20.38,214.5,
MG 3D TOMO SCREEN IMPLANT,50106639,CDM,403,RC,77063,HCPCS,Outpatient,,,214.5,128.70,,24.3,100,,18733.44,Fee Schedule,100% of Aetna Fee Schedule,33.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,1.24,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,1.592,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.592,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.592,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,7.536,Fee Schedule,103% of Cigna fee schedule,51.79,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,20.38,90,,,Fee Schedule,90% of CMS OPPS Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29.43,130,,,Fee Schedule,130% of CMS OPPS Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,53.34,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,160.88,75,,2287.096,Percent of Total Billed Charges,75% of Total Billed Charges,107.25,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,1306.944,Percent of Total Billed Charges,50% of Total Billed Charges,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.25,50,,1306.944,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,713.304,Percent of Total Billed Charges,50% of Total Billed Charges,33.96,150,,,Fee Schedule,150% of CMS OPPS Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,109.616,Case Rate,Pays based on per visit rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,214.5,100,,3049.464,Percent of Total Billed Charges,100% of Total Billed Charges,20.38,214.5,
MG DIGITAL SCREEN IMPLANT W CAD BI,50106640,CDM,403,RC,77067,HCPCS,Outpatient,,,366.3,219.78,TC   ,92.07,100,,4.76,Fee Schedule,100% of Aetna Fee Schedule,130.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,278.52,280,,31.36,Fee Schedule,280% of BCBS BULE Fee Schedule,318.3,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,358.09,360,,40.32,Fee Schedule,360% of BCBS POS Rate,358.09,360,,40.32,Fee schedule,360% of BCBS PPO Rate,358.09,360,,40.32,Fee Schedule,360% of BCBS Traditional Rate,311.39,103,,1.144,Fee Schedule,103% of Cigna fee schedule,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,78.42,90,,,Fee Schedule,90% of CMS OPPS Rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,113.27,130,,,Fee Schedule,130% of CMS OPPS Rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,52.82,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,274.73,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,183.15,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,183.15,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,183.15,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,183.15,50,,314.576,Percent of Total Billed Charges,50% of Total Billed Charges,130.7,150,,,Fee Schedule,150% of CMS OPPS Rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,4740.296,Case Rate,Pays based on per visit rate,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,366.3,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,51.28,366.3,
MG DIGITAL SCREEN IMPLANT W CAD BI,50106640,CDM,403,RC,77067,HCPCS,Outpatient,,,366.3,219.78,TC   ,92.07,100,,196.424,Fee Schedule,100% of Aetna Fee Schedule,130.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,278.52,280,,0.336,Fee Schedule,280% of BCBS BULE Fee Schedule,318.3,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,358.09,360,,0.432,Fee Schedule,360% of BCBS POS Rate,358.09,360,,0.432,Fee schedule,360% of BCBS PPO Rate,358.09,360,,0.432,Fee Schedule,360% of BCBS Traditional Rate,311.39,103,,259.864,Fee Schedule,103% of Cigna fee schedule,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,78.42,90,,,Fee Schedule,90% of CMS OPPS Rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,113.27,130,,,Fee Schedule,130% of CMS OPPS Rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,52.82,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,274.73,75,,531.016,Percent of Total Billed Charges,75% of Total Billed Charges,183.15,50,,1306.944,Percent of Total Billed Charges,50% of Total Billed Charges,183.15,50,,225.28,Percent of Total Billed Charges,50% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,183.15,50,,225.28,Percent of Total Billed Charges,50% of Total Billed Charges,183.15,50,,1086.528,Percent of Total Billed Charges,50% of Total Billed Charges,130.7,150,,,Fee Schedule,150% of CMS OPPS Rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,237.488,Case Rate,Pays based on per visit rate,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,366.3,100,,708.016,Percent of Total Billed Charges,100% of Total Billed Charges,51.28,366.3,
MG DEXA PERIPH,50106641,CDM,320,RC,77081,HCPCS,Outpatient,,,125,75.00,,20.82,100,,142.208,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,65.6,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,74.98,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,84.35,360,,0.28,Fee Schedule,360% of BCBS POS Rate,84.35,360,,0.28,Fee schedule,360% of BCBS PPO Rate,84.35,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,64.656,Fee Schedule,103% of Cigna fee schedule,31.41,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,93.75,75,,1645.488,Percent of Total Billed Charges,75% of Total Billed Charges,62.5,50,,1007.936,Percent of Total Billed Charges,50% of Total Billed Charges,62.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,62.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,62.5,50,,1005.328,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,399.368,Case Rate,Pays based on per visit rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,125,100,,2193.984,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,300,
MG DEXA PERIPH,50106641,CDM,320,RC,77081,HCPCS,Outpatient,,,125,75.00,,20.82,100,,168.736,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,65.6,280,,3.28,Fee Schedule,280% of BCBS BULE Fee Schedule,74.98,320,,153.6,Fee Schedule,320% of BCBS Blue Essentials Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,84.35,360,,4.216,Fee Schedule,360% of BCBS POS Rate,84.35,360,,4.216,Fee schedule,360% of BCBS PPO Rate,84.35,360,,4.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.088,Fee Schedule,103% of Cigna fee schedule,31.41,100,,3.208,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,32.35,103,,3.304,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,93.75,75,,1176.784,Percent of Total Billed Charges,75% of Total Billed Charges,62.5,50,,225.28,Percent of Total Billed Charges,50% of Total Billed Charges,62.5,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,62.5,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,62.5,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,827.6,Case Rate,Pays based on per visit rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,31.41,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,125,100,,1569.04,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,300,
MG DEXA SPINE ONLY,50106642,CDM,320,RC,77080,HCPCS,Outpatient,,,146.9,88.14,,27.48,100,,362.36,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,85.76,280,,58.832,Fee Schedule,280% of BCBS BULE Fee Schedule,98.02,320,,153.856,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,110.27,360,,75.648,Fee Schedule,360% of BCBS POS Rate,110.27,360,,75.648,Fee schedule,360% of BCBS PPO Rate,110.27,360,,75.648,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.064,Fee Schedule,103% of Cigna fee schedule,38.09,100,,3.072,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,3.168,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,110.18,75,,2745.616,Percent of Total Billed Charges,75% of Total Billed Charges,73.45,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,73.45,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,73.45,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,73.45,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.128,Case Rate,Pays based on per visit rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,3.072,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,146.9,100,,3660.816,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,342.15,
MG DEXA SPINE ONLY,50106642,CDM,320,RC,77080,HCPCS,Outpatient,,,146.9,88.14,,27.48,100,,156.496,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,85.76,280,,0.832,Fee Schedule,280% of BCBS BULE Fee Schedule,98.02,320,,153.984,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,110.27,360,,1.064,Fee Schedule,360% of BCBS POS Rate,110.27,360,,1.064,Fee schedule,360% of BCBS PPO Rate,110.27,360,,1.064,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.176,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,110.18,75,,2745.616,Percent of Total Billed Charges,75% of Total Billed Charges,73.45,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,73.45,50,,901.608,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,73.45,50,,901.608,Percent of Total Billed Charges,50% of Total Billed Charges,73.45,50,,230.704,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,9.128,Case Rate,Pays based on per visit rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,146.9,100,,3660.816,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,342.15,
MG US GUIDE NDL MARK PLCMT EA ADD,50106643,CDM,361,RC,19286,HCPCS,Outpatient,,,1060,636.00,,2601,100,,485.704,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,477,45,,381.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,154.352,Other,Not Seperately Reimbusable,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1060,100,,848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,152.85,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,795,75,,1672.288,Percent of Total Billed Charges,75% of Total Billed Charges,530,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,530,50,,323.6,Percent of Total Billed Charges,50% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,530,50,,323.6,Percent of Total Billed Charges,50% of Total Billed Charges,530,50,,4223.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,43.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,148.4,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1060,100,,2229.712,Percent of Total Billed Charges,100% of Total Billed Charges,148.4,2601,
MG US GUIDE NDL MARK PLCMT INI LT,50106644,CDM,361,RC,19285,HCPCS,Outpatient,,,2286.88,1372.13,,4162,100,,922.048,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,3.648,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,94.09,32,,155.392,Percent of Total Billed Charges,32% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,4.696,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,4.696,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,4.696,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,13.744,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,329.77,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1715.16,75,,1672.288,Percent of Total Billed Charges,75% of Total Billed Charges,1143.44,50,,901.608,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,376.24,Percent of Total Billed Charges,50% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.44,50,,376.24,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,45.336,Fee Schedule,100% of ASC Tier Groupings fee schedule,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2286.88,100,,2229.712,Percent of Total Billed Charges,100% of Total Billed Charges,94.09,4162,
MG DUCTOGRAM MULTI SI RT,50106645,CDM,320,RC,77054,HCPCS,Outpatient,,,502.35,301.41,,48.78,100,,2543.2,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,9.488,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,155.728,Fee Schedule,320% of BCBS Blue Essentials Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,12.2,Fee Schedule,360% of BCBS POS Rate,838.94,360,,12.2,Fee schedule,360% of BCBS PPO Rate,838.94,360,,12.2,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,13.168,Fee Schedule,103% of Cigna fee schedule,69.16,100,,0.544,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,71.23,103,,0.56,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,376.76,75,,1671.64,Percent of Total Billed Charges,75% of Total Billed Charges,251.18,50,,323.6,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,251.18,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,1018.784,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,423.368,Case Rate,Pays based on per visit rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,502.35,100,,2228.856,Percent of Total Billed Charges,100% of Total Billed Charges,48.78,838.94,
MG DUCTOGRAM MULTI SI RT,50106645,CDM,320,RC,77054,HCPCS,Outpatient,,,502.35,301.41,,48.78,100,,487.352,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,4.512,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,155.728,Fee Schedule,320% of BCBS Blue Essentials Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,5.808,Fee Schedule,360% of BCBS POS Rate,838.94,360,,5.808,Fee schedule,360% of BCBS PPO Rate,838.94,360,,5.808,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.064,Fee Schedule,103% of Cigna fee schedule,69.16,100,,0.08,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,71.23,103,,0.08,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,376.76,75,,1671.64,Percent of Total Billed Charges,75% of Total Billed Charges,251.18,50,,376.24,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,831.456,Percent of Total Billed Charges,50% of Total Billed Charges,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,251.18,50,,831.456,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,70.456,Case Rate,Pays based on per visit rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,502.35,100,,2228.856,Percent of Total Billed Charges,100% of Total Billed Charges,48.78,838.94,
MG DUCTOGRAM MULTI SI LT,50106646,CDM,320,RC,77054,HCPCS,Outpatient,,,502.35,301.41,TC   ,48.78,100,,1118.656,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,10.512,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,155.792,Fee Schedule,320% of BCBS Blue Essentials Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,13.512,Fee Schedule,360% of BCBS POS Rate,838.94,360,,13.512,Fee schedule,360% of BCBS PPO Rate,838.94,360,,13.512,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.088,Fee Schedule,103% of Cigna fee schedule,69.16,100,,0.176,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,71.23,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,376.76,75,,2400,Percent of Total Billed Charges,75% of Total Billed Charges,251.18,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,583.52,Percent of Total Billed Charges,50% of Total Billed Charges,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,251.18,50,,583.52,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,168,Case Rate,Pays based on per visit rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,502.35,100,,3200,Percent of Total Billed Charges,100% of Total Billed Charges,48.78,838.94,
MG DUCTOGRAM MULTI SI LT,50106646,CDM,320,RC,77054,HCPCS,Outpatient,,,502.35,301.41,TC   ,48.78,100,,931.008,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,2.704,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,155.936,Fee Schedule,320% of BCBS Blue Essentials Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,3.48,Fee Schedule,360% of BCBS POS Rate,838.94,360,,3.48,Fee schedule,360% of BCBS PPO Rate,838.94,360,,3.48,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.512,Fee Schedule,103% of Cigna fee schedule,69.16,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,71.23,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,376.76,75,,2400,Percent of Total Billed Charges,75% of Total Billed Charges,251.18,50,,831.456,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,874.496,Percent of Total Billed Charges,50% of Total Billed Charges,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,251.18,50,,874.496,Percent of Total Billed Charges,50% of Total Billed Charges,251.18,50,,1835.464,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,1082.136,Case Rate,Pays based on per visit rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,69.16,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,502.35,100,,3200,Percent of Total Billed Charges,100% of Total Billed Charges,48.78,838.94,
MG STEREO GUIDE NDL PLC INI RT,50106647,CDM,361,RC,19283,HCPCS,Outpatient,,,2715.21,1629.13,,4162,100,,252.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,13.632,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,94.37,32,,15662.592,Percent of Total Billed Charges,32% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,17.528,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,17.528,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,17.528,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,2.32,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,391.53,14.42,,1.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2036.41,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,1357.61,50,,583.52,Percent of Total Billed Charges,50% of Total Billed Charges,1357.61,50,,860.784,Percent of Total Billed Charges,50% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.61,50,,860.784,Percent of Total Billed Charges,50% of Total Billed Charges,1357.61,50,,1306.944,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,42.56,Fee Schedule,100% of ASC Tier Groupings fee schedule,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,380.13,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2715.21,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,94.37,4162,
MG STEREO GUIDE NDL PLC INI BI,50106649,CDM,361,RC,19283,HCPCS,Outpatient,,,4072.5,2443.50,,4162,100,,1405.808,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,26.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,94.4,32,,15.696,Percent of Total Billed Charges,32% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,33.96,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,33.96,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,33.96,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,0.76,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,587.25,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,3054.38,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,2036.25,50,,860.784,Percent of Total Billed Charges,50% of Total Billed Charges,2036.25,50,,809.096,Percent of Total Billed Charges,50% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2036.25,50,,809.096,Percent of Total Billed Charges,50% of Total Billed Charges,2036.25,50,,225.28,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,124.408,Fee Schedule,100% of ASC Tier Groupings fee schedule,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,570.15,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4072.5,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,94.4,4162,
MG DUCTOGRAM SNGL SI RT,50106650,CDM,320,RC,77053,HCPCS,Outpatient,,,434.68,260.81,,36.8,100,,753.584,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,32.792,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,15.776,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,42.16,Fee Schedule,360% of BCBS POS Rate,838.94,360,,42.16,Fee schedule,360% of BCBS PPO Rate,838.94,360,,42.16,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.368,Fee Schedule,103% of Cigna fee schedule,53.46,100,,0.528,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,0.544,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,326.01,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,217.34,50,,4072.136,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,594.272,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,217.34,50,,594.272,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,60.976,Case Rate,Pays based on per visit rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.528,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,434.68,100,,280,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,838.94,
MG DUCTOGRAM SNGL SI RT,50106650,CDM,320,RC,77053,HCPCS,Outpatient,,,434.68,260.81,,36.8,100,,407.32,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,3.472,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,15.808,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,4.464,Fee Schedule,360% of BCBS POS Rate,838.94,360,,4.464,Fee schedule,360% of BCBS PPO Rate,838.94,360,,4.464,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,4.192,Fee Schedule,103% of Cigna fee schedule,53.46,100,,3.68,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,3.792,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,326.01,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,217.34,50,,809.096,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,816.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,217.34,50,,816.944,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,165.448,Case Rate,Pays based on per visit rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,3.68,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,434.68,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,838.94,
MG DUCTOGRAM SNGLE SI LT,50106651,CDM,320,RC,77053,HCPCS,Outpatient,,,434.68,260.81,TC   ,36.8,100,,2929.904,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,159.384,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,15.84,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,204.92,Fee Schedule,360% of BCBS POS Rate,838.94,360,,204.92,Fee schedule,360% of BCBS PPO Rate,838.94,360,,204.92,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.464,Fee Schedule,103% of Cigna fee schedule,53.46,100,,1.84,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,1.896,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,326.01,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,217.34,50,,594.272,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,474.176,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,217.34,50,,474.176,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.184,Case Rate,Pays based on per visit rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,1.84,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,434.68,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,838.94,
MG DUCTOGRAM SNGLE SI LT,50106651,CDM,320,RC,77053,HCPCS,Outpatient,,,434.68,260.81,TC   ,36.8,100,,174.184,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,0.752,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,156.392,Fee Schedule,320% of BCBS Blue Essentials Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,0.96,Fee Schedule,360% of BCBS POS Rate,838.94,360,,0.96,Fee schedule,360% of BCBS PPO Rate,838.94,360,,0.96,Fee Schedule,360% of BCBS Traditional Rate,701.14,103,,0.776,Fee Schedule,103% of Cigna fee schedule,53.46,100,,0.256,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.33,90,,,Fee Schedule,90% of CMS OPPS Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,55.06,103,,0.264,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,326.01,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,217.34,50,,816.944,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,552.72,Percent of Total Billed Charges,50% of Total Billed Charges,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,217.34,50,,552.72,Percent of Total Billed Charges,50% of Total Billed Charges,217.34,50,,901.608,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,24.72,Case Rate,Pays based on per visit rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,53.46,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,434.68,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,36.8,838.94,
US ASP FINE NDL INI,50106652,CDM,361,RC,10005,HCPCS,Outpatient,,,1758.74,1055.24,,2601,100,,155.528,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.91,233,,1.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,94.75,32,,156.672,Percent of Total Billed Charges,32% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,241.73,322,,2.36,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,241.73,322,,2.36,Fee schedule,Pays based on ASC Tier Groupings fee schedule,241.73,322,,2.36,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,2.248,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,253.61,14.42,,1.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1319.06,75,,1468.32,Percent of Total Billed Charges,75% of Total Billed Charges,879.37,50,,474.176,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,539.544,Percent of Total Billed Charges,50% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,879.37,50,,539.544,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,323.6,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,20.752,Fee Schedule,100% of ASC Tier Groupings fee schedule,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.74,100,,1957.76,Percent of Total Billed Charges,100% of Total Billed Charges,94.75,2601,
US ASP FINE NDL EA ADD,50106653,CDM,361,RC,10006,HCPCS,Outpatient,,,244.13,146.48,,2601,100,,5243.832,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.86,45,,87.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,156.672,Other,Not Seperately Reimbusable,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.48,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.13,100,,195.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,35.2,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.1,75,,1468.32,Percent of Total Billed Charges,75% of Total Billed Charges,122.07,50,,552.72,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,1093.136,Percent of Total Billed Charges,50% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.07,50,,1093.136,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,376.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,471.248,Fee Schedule,100% of ASC Tier Groupings fee schedule,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.13,100,,1957.76,Percent of Total Billed Charges,100% of Total Billed Charges,34.18,2601,
MG DIGITAL SCREEN W CAD BI,50160515,CDM,403,RC,77067,HCPCS,Outpatient,,,384.62,230.77,,92.07,100,,291.032,Fee Schedule,100% of Aetna Fee Schedule,130.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,278.52,280,,82.968,Fee Schedule,280% of BCBS BULE Fee Schedule,318.3,320,,156.672,Fee Schedule,320% of BCBS Blue Essentials Rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,358.09,360,,106.672,Fee Schedule,360% of BCBS POS Rate,358.09,360,,106.672,Fee schedule,360% of BCBS PPO Rate,358.09,360,,106.672,Fee Schedule,360% of BCBS Traditional Rate,311.39,103,,7.888,Fee Schedule,103% of Cigna fee schedule,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,78.42,90,,,Fee Schedule,90% of CMS OPPS Rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,113.27,130,,,Fee Schedule,130% of CMS OPPS Rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,55.46,14.42,,0.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,288.47,75,,1343.944,Percent of Total Billed Charges,75% of Total Billed Charges,192.31,50,,539.544,Percent of Total Billed Charges,50% of Total Billed Charges,192.31,50,,1639.704,Percent of Total Billed Charges,50% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,192.31,50,,1639.704,Percent of Total Billed Charges,50% of Total Billed Charges,192.31,50,,645.224,Percent of Total Billed Charges,50% of Total Billed Charges,130.7,150,,,Fee Schedule,150% of CMS OPPS Rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,241.536,Case Rate,Pays based on per visit rate,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,384.62,100,,1791.928,Percent of Total Billed Charges,100% of Total Billed Charges,53.85,384.62,
MG DIGITAL SCREEN W CAD BI,50160515,CDM,403,RC,77067,HCPCS,Outpatient,,,384.62,230.77,,92.07,100,,144.912,Fee Schedule,100% of Aetna Fee Schedule,130.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,278.52,280,,124.2,Fee Schedule,280% of BCBS BULE Fee Schedule,318.3,320,,156.944,Fee Schedule,320% of BCBS Blue Essentials Rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,358.09,360,,159.688,Fee Schedule,360% of BCBS POS Rate,358.09,360,,159.688,Fee schedule,360% of BCBS PPO Rate,358.09,360,,159.688,Fee Schedule,360% of BCBS Traditional Rate,311.39,103,,0.56,Fee Schedule,103% of Cigna fee schedule,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,78.42,90,,,Fee Schedule,90% of CMS OPPS Rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,113.27,130,,,Fee Schedule,130% of CMS OPPS Rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,55.46,14.42,,8.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,89.74,103,,,Fee Schedule,103% of CMS OPPS Rate,288.47,75,,1343.944,Percent of Total Billed Charges,75% of Total Billed Charges,192.31,50,,1093.136,Percent of Total Billed Charges,50% of Total Billed Charges,192.31,50,,614.288,Percent of Total Billed Charges,50% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,192.31,50,,614.288,Percent of Total Billed Charges,50% of Total Billed Charges,192.31,50,,831.456,Percent of Total Billed Charges,50% of Total Billed Charges,130.7,150,,,Fee Schedule,150% of CMS OPPS Rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,6430.112,Case Rate,Pays based on per visit rate,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.85,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,87.13,100,,,Fee Schedule,100% of CMS OPPS Rate,384.62,100,,1791.928,Percent of Total Billed Charges,100% of Total Billed Charges,53.85,384.62,
MG DIGITAL DX W CAD BI,50160516,CDM,401,RC,77066,HCPCS,Outpatient,,,495.49,297.29,TC   ,111.38,100,,340.392,Fee Schedule,100% of Aetna Fee Schedule,158.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,337.04,280,,66.824,Fee Schedule,280% of BCBS BULE Fee Schedule,385.18,320,,157.28,Fee Schedule,320% of BCBS Blue Essentials Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,433.33,360,,85.92,Fee Schedule,360% of BCBS POS Rate,433.33,360,,85.92,Fee schedule,360% of BCBS PPO Rate,433.33,360,,85.92,Fee Schedule,360% of BCBS Traditional Rate,376.88,103,,1.096,Fee Schedule,103% of Cigna fee schedule,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,90,,,Fee Schedule,90% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,137.38,130,,,Fee Schedule,130% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,71.45,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,108.85,103,,,Fee Schedule,103% of CMS OPPS Rate,108.85,103,,,Fee Schedule,103% of CMS OPPS Rate,371.62,75,,1702.552,Percent of Total Billed Charges,75% of Total Billed Charges,247.75,50,,1639.704,Percent of Total Billed Charges,50% of Total Billed Charges,247.75,50,,921.432,Percent of Total Billed Charges,50% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,247.75,50,,921.432,Percent of Total Billed Charges,50% of Total Billed Charges,247.75,50,,583.52,Percent of Total Billed Charges,50% of Total Billed Charges,158.52,150,,,Fee Schedule,150% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,47.888,Case Rate,Pays based on per visit rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,495.49,100,,2270.072,Percent of Total Billed Charges,100% of Total Billed Charges,69.37,495.49,
MG DIGITAL DX W CAD BI,50160516,CDM,401,RC,77066,HCPCS,Outpatient,,,495.49,297.29,TC   ,111.38,100,,5305.552,Fee Schedule,100% of Aetna Fee Schedule,158.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,337.04,280,,1.608,Fee Schedule,280% of BCBS BULE Fee Schedule,385.18,320,,157.28,Fee Schedule,320% of BCBS Blue Essentials Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,433.33,360,,2.064,Fee Schedule,360% of BCBS POS Rate,433.33,360,,2.064,Fee schedule,360% of BCBS PPO Rate,433.33,360,,2.064,Fee Schedule,360% of BCBS Traditional Rate,376.88,103,,5.296,Fee Schedule,103% of Cigna fee schedule,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,90,,,Fee Schedule,90% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,137.38,130,,,Fee Schedule,130% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,71.45,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,108.85,103,,,Fee Schedule,103% of CMS OPPS Rate,108.85,103,,,Fee Schedule,103% of CMS OPPS Rate,371.62,75,,1702.552,Percent of Total Billed Charges,75% of Total Billed Charges,247.75,50,,614.288,Percent of Total Billed Charges,50% of Total Billed Charges,247.75,50,,913.568,Percent of Total Billed Charges,50% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,247.75,50,,913.568,Percent of Total Billed Charges,50% of Total Billed Charges,247.75,50,,874.496,Percent of Total Billed Charges,50% of Total Billed Charges,158.52,150,,,Fee Schedule,150% of CMS OPPS Rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,40.064,Case Rate,Pays based on per visit rate,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,69.37,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105.68,100,,,Fee Schedule,100% of CMS OPPS Rate,495.49,100,,2270.072,Percent of Total Billed Charges,100% of Total Billed Charges,69.37,495.49,
MG DIGITAL DX W CAD LT,50160517,CDM,401,RC,77065,HCPCS,Outpatient,,,402.93,241.76,,87.08,100,,1324.648,Fee Schedule,100% of Aetna Fee Schedule,123.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,263.37,280,,2.848,Fee Schedule,280% of BCBS BULE Fee Schedule,300.99,320,,157.28,Fee Schedule,320% of BCBS Blue Essentials Rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,338.62,360,,3.664,Fee Schedule,360% of BCBS POS Rate,338.62,360,,3.664,Fee schedule,360% of BCBS PPO Rate,338.62,360,,3.664,Fee Schedule,360% of BCBS Traditional Rate,294.45,103,,0.464,Fee Schedule,103% of Cigna fee schedule,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,90,,,Fee Schedule,90% of CMS OPPS Rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,130,,,Fee Schedule,130% of CMS OPPS Rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,302.2,75,,192.36,Percent of Total Billed Charges,75% of Total Billed Charges,201.47,50,,921.432,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,1370.344,Percent of Total Billed Charges,50% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,201.47,50,,1370.344,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,860.784,Percent of Total Billed Charges,50% of Total Billed Charges,123.62,150,,,Fee Schedule,150% of CMS OPPS Rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,11.656,Case Rate,Pays based on per visit rate,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,402.93,100,,256.48,Percent of Total Billed Charges,100% of Total Billed Charges,56.41,402.93,
MG DIGITAL DX W CAD LT,50160517,CDM,401,RC,77065,HCPCS,Outpatient,,,402.93,241.76,,87.08,100,,320.584,Fee Schedule,100% of Aetna Fee Schedule,123.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,263.37,280,,4.416,Fee Schedule,280% of BCBS BULE Fee Schedule,300.99,320,,157.44,Fee Schedule,320% of BCBS Blue Essentials Rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,338.62,360,,5.672,Fee Schedule,360% of BCBS POS Rate,338.62,360,,5.672,Fee schedule,360% of BCBS PPO Rate,338.62,360,,5.672,Fee Schedule,360% of BCBS Traditional Rate,294.45,103,,0.712,Fee Schedule,103% of Cigna fee schedule,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,90,,,Fee Schedule,90% of CMS OPPS Rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,130,,,Fee Schedule,130% of CMS OPPS Rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,14.42,,1.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,302.2,75,,192.36,Percent of Total Billed Charges,75% of Total Billed Charges,201.47,50,,913.568,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,552.28,Percent of Total Billed Charges,50% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,201.47,50,,552.28,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,4072.136,Percent of Total Billed Charges,50% of Total Billed Charges,123.62,150,,,Fee Schedule,150% of CMS OPPS Rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,43.96,Case Rate,Pays based on per visit rate,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,402.93,100,,256.48,Percent of Total Billed Charges,100% of Total Billed Charges,56.41,402.93,
MG DIGITAL DX W CAD RT,50160518,CDM,401,RC,77065,HCPCS,Outpatient,,,402.93,241.76,,87.08,100,,774.432,Fee Schedule,100% of Aetna Fee Schedule,123.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,263.37,280,,1.312,Fee Schedule,280% of BCBS BULE Fee Schedule,300.99,320,,157.696,Fee Schedule,320% of BCBS Blue Essentials Rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,338.62,360,,1.68,Fee Schedule,360% of BCBS POS Rate,338.62,360,,1.68,Fee schedule,360% of BCBS PPO Rate,338.62,360,,1.68,Fee Schedule,360% of BCBS Traditional Rate,294.45,103,,36.728,Fee Schedule,103% of Cigna fee schedule,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,90,,,Fee Schedule,90% of CMS OPPS Rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,130,,,Fee Schedule,130% of CMS OPPS Rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,14.42,,1.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,302.2,75,,1156.88,Percent of Total Billed Charges,75% of Total Billed Charges,201.47,50,,1370.344,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,828.416,Percent of Total Billed Charges,50% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,201.47,50,,828.416,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,809.096,Percent of Total Billed Charges,50% of Total Billed Charges,123.62,150,,,Fee Schedule,150% of CMS OPPS Rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,43.96,Case Rate,Pays based on per visit rate,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,402.93,100,,1542.504,Percent of Total Billed Charges,100% of Total Billed Charges,56.41,402.93,
MG DIGITAL DX W CAD RT,50160518,CDM,401,RC,77065,HCPCS,Outpatient,,,402.93,241.76,,87.08,100,,92.24,Fee Schedule,100% of Aetna Fee Schedule,123.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,263.37,280,,207.032,Fee Schedule,280% of BCBS BULE Fee Schedule,300.99,320,,157.808,Fee Schedule,320% of BCBS Blue Essentials Rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,338.62,360,,266.184,Fee Schedule,360% of BCBS POS Rate,338.62,360,,266.184,Fee schedule,360% of BCBS PPO Rate,338.62,360,,266.184,Fee Schedule,360% of BCBS Traditional Rate,294.45,103,,0.176,Fee Schedule,103% of Cigna fee schedule,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,90,,,Fee Schedule,90% of CMS OPPS Rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,130,,,Fee Schedule,130% of CMS OPPS Rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,84.88,103,,,Fee Schedule,103% of CMS OPPS Rate,302.2,75,,1156.88,Percent of Total Billed Charges,75% of Total Billed Charges,201.47,50,,552.28,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,970.904,Percent of Total Billed Charges,50% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,201.47,50,,970.904,Percent of Total Billed Charges,50% of Total Billed Charges,201.47,50,,594.272,Percent of Total Billed Charges,50% of Total Billed Charges,123.62,150,,,Fee Schedule,150% of CMS OPPS Rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,43.96,Case Rate,Pays based on per visit rate,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,56.41,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of CMS OPPS Rate,402.93,100,,1542.504,Percent of Total Billed Charges,100% of Total Billed Charges,56.41,402.93,
DX DEXA HIPS PEL SPINE,50160787,CDM,320,RC,77080,HCPCS,Outpatient,,,439.9,263.94,,27.48,100,,75.488,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,85.76,280,,127.288,Fee Schedule,280% of BCBS BULE Fee Schedule,98.02,320,,158.08,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,110.27,360,,163.656,Fee Schedule,360% of BCBS POS Rate,110.27,360,,163.656,Fee schedule,360% of BCBS PPO Rate,110.27,360,,163.656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.176,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.112,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,329.93,75,,1171.52,Percent of Total Billed Charges,75% of Total Billed Charges,219.95,50,,828.416,Percent of Total Billed Charges,50% of Total Billed Charges,219.95,50,,1456.352,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,219.95,50,,1456.352,Percent of Total Billed Charges,50% of Total Billed Charges,219.95,50,,816.944,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,272.096,Case Rate,Pays based on per visit rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,439.9,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,439.9,
DX DEXA HIPS PEL SPINE,50160787,CDM,320,RC,77080,HCPCS,Outpatient,,,439.9,263.94,,27.48,100,,101.072,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,85.76,280,,2.952,Fee Schedule,280% of BCBS BULE Fee Schedule,98.02,320,,158.08,Fee Schedule,320% of BCBS Blue Essentials Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,110.27,360,,3.792,Fee Schedule,360% of BCBS POS Rate,110.27,360,,3.792,Fee schedule,360% of BCBS PPO Rate,110.27,360,,3.792,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.584,Fee Schedule,103% of Cigna fee schedule,38.09,100,,0.768,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,39.23,103,,0.792,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,329.93,75,,1171.52,Percent of Total Billed Charges,75% of Total Billed Charges,219.95,50,,970.904,Percent of Total Billed Charges,50% of Total Billed Charges,219.95,50,,565.16,Percent of Total Billed Charges,50% of Total Billed Charges,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,219.95,50,,565.16,Percent of Total Billed Charges,50% of Total Billed Charges,219.95,50,,474.176,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,75.832,Case Rate,Pays based on per visit rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,38.09,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,439.9,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,27.48,439.9,
S MG TISSUE MARKER,50161009,CDM,278,RC,A4648,HCPCS,Outpatient,,,520,312.00,,674.14,110,,327.4,Percent of Total Billed Charges,110% of Total Billed Charges,234,45,,187.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.6,28,,5.416,Percent of Total Billed Charges,28% of Total Billed Charges,95.03,32,,158.08,Percent of Total Billed Charges,32% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,187.2,36,,6.96,Percent of Total Billed Charges,36% of Total Billed Charges,187.2,36,,6.96,Percent of Total Billed Charges,36% Total Bille Charges,187.2,36,,6.96,Percent of Total Billed Charges,36% of Total Billed Charges,286,55,,6.752,Percent of Total Billed Charges,55% Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520,100,,416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,74.98,14.42,,0.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416,80,,1171.52,Percent of Total Billed Charges,80% of Total Billed Charges,260,50,,1456.352,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,847.744,Percent of Total Billed Charges,50% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260,50,,847.744,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,552.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364,70,,128.12,Percent of Total Billed Charges,70% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,72.8,674.14,
MG US BRST COMP LT,50166488,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,TC   ,69.44,100,,327.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.888,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,158.08,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.144,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.144,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.144,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.8,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,4275,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,565.16,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,540.352,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,540.352,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,539.544,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,5.408,Case Rate,Pays based on per visit rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,5700,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
MG US BRST COMP LT,50166488,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,TC   ,69.44,100,,66.416,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,7.648,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,15.872,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,9.832,Fee Schedule,360% of BCBS POS Rate,403.49,360,,9.832,Fee schedule,360% of BCBS PPO Rate,403.49,360,,9.832,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,4.68,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.168,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.176,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,2850,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,847.744,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,810.528,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,810.528,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,1093.136,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,33.592,Case Rate,Pays based on per visit rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,3800,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
MG US BRST LIMIT RT,50166489,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,1.488,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,8.4,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,15.984,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,10.8,Fee Schedule,360% of BCBS POS Rate,287.32,360,,10.8,Fee schedule,360% of BCBS PPO Rate,287.32,360,,10.8,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.48,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.536,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.552,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,2850,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,540.352,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1639.704,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,134.592,Case Rate,Pays based on per visit rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.536,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,3800,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
MG US BRST LIMIT RT,50166489,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,203.728,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.416,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16.064,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.824,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.824,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.824,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,3.296,Fee Schedule,103% of Cigna fee schedule,85.54,100,,1.736,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,1.784,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,4092.664,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,810.528,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,614.288,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,62.304,Case Rate,Pays based on per visit rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,5456.88,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
MG US BRST LIMIT BI,50166490,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,TC   ,53.12,100,,12.656,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,159.048,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.104,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.104,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.104,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.92,Fee Schedule,103% of Cigna fee schedule,85.54,100,,1.872,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,1.928,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,2728.44,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,565.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,565.6,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,921.432,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,10.056,Case Rate,Pays based on per visit rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,1.872,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,3637.92,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
MG US BRST LIMIT BI,50166490,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,TC   ,53.12,100,,29.704,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,159.36,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.496,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.496,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.496,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.016,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.168,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.176,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,2728.44,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,913.568,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,4119.008,Case Rate,Pays based on per visit rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.168,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,3637.92,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
MG US BRST COMP RT,50166491,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,,69.44,100,,2.144,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.128,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,159.424,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.448,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.448,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.448,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.728,Fee Schedule,103% of Cigna fee schedule,103.91,100,,1.464,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,1.512,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,3011.912,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,565.6,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,559.824,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,559.824,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,1370.344,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,859.856,Case Rate,Pays based on per visit rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.464,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,4015.88,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
MG US BRST COMP RT,50166491,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,,69.44,100,,720,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,159.6,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.496,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.496,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.496,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2.288,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.288,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.296,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,2007.944,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,839.736,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,839.736,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,552.28,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1260,Case Rate,Pays based on per visit rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,2677.256,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
MG US BRST COMP BI,50166492,CDM,402,RC,76641,HCPCS,Outpatient,,,573.3,343.98,TC   ,69.44,100,,880,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.216,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,159.744,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.28,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.28,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.28,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.424,Fee Schedule,103% of Cigna fee schedule,103.91,100,,2.72,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,2.8,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,429.98,75,,2007.944,Percent of Total Billed Charges,75% of Total Billed Charges,286.65,50,,559.824,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,398.824,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,286.65,50,,398.824,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,828.416,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1303.744,Case Rate,Pays based on per visit rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,2.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,573.3,100,,2677.256,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,573.3,
MG US BRST COMP BI,50166492,CDM,402,RC,76641,HCPCS,Outpatient,,,573.3,343.98,TC   ,69.44,100,,1.552,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.296,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,159.888,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.376,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.376,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.376,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,8.008,Fee Schedule,103% of Cigna fee schedule,103.91,100,,3.232,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,3.328,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,429.98,75,,4804.24,Percent of Total Billed Charges,75% of Total Billed Charges,286.65,50,,839.736,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,859.2,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,286.65,50,,859.2,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,970.904,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,300.72,Case Rate,Pays based on per visit rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,3.232,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,573.3,100,,6405.656,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,573.3,
MG US BRST LIMIT LT,50166493,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,3.792,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.344,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,160.096,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.44,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.44,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.736,Fee Schedule,103% of Cigna fee schedule,85.54,100,,2.56,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,2.64,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,398.824,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1001.392,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,1001.392,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1456.352,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,452.768,Case Rate,Pays based on per visit rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.56,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
MG US BRST LIMIT LT,50166493,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,1.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,13.888,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,160.528,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,17.856,Fee Schedule,360% of BCBS POS Rate,287.32,360,,17.856,Fee schedule,360% of BCBS PPO Rate,287.32,360,,17.856,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,6.288,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.696,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.712,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,859.2,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1051.808,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,1051.808,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,565.16,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,31.296,Case Rate,Pays based on per visit rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US GUIDE NDL PLCMT,50169606,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,0.176,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,0.896,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16358.4,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,1.152,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.152,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.152,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,1.248,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,4804.24,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,1001.392,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,1414.384,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,1414.384,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,847.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,72.944,Case Rate,Pays based on per visit rate,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,6405.656,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
US GUIDE NDL PLCMT,50169606,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,10.616,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,5.88,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.176,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,7.56,Fee Schedule,360% of BCBS POS Rate,90.83,360,,7.56,Fee schedule,360% of BCBS PPO Rate,90.83,360,,7.56,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,1051.808,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,2121.576,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,2121.576,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,540.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,204.928,Case Rate,Pays based on per visit rate,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
S MG BX LOC TRAY,50178052,CDM,272,RC,,,Outpatient,,,124.66,74.80,,74.8,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,56.1,45,,44.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.9,28,,11.216,Percent of Total Billed Charges,28% of Total Billed Charges,95.33,32,,16.176,Percent of Total Billed Charges,32% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,36,,14.416,Percent of Total Billed Charges,36% of Total Billed Charges,44.88,36,,14.416,Percent of Total Billed Charges,36% Total Bille Charges,44.88,36,,14.416,Percent of Total Billed Charges,36% of Total Billed Charges,74.8,60,,13.84,Percent of Total Billed Charges,60% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.66,100,,99.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.98,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.5,75,,3202.832,Percent of Total Billed Charges,75% of Total Billed Charges,62.33,50,,1414.384,Percent of Total Billed Charges,50% of Total Billed Charges,62.33,50,,911.896,Percent of Total Billed Charges,50% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.33,50,,911.896,Percent of Total Billed Charges,50% of Total Billed Charges,62.33,50,,810.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.26,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.45,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.66,100,,4270.44,Percent of Total Billed Charges,100% of Total Billed Charges,17.45,124.66,
S MG STEREO TRAY,50178086,CDM,272,RC,,,Outpatient,,,511.89,307.13,,307.13,60,,283.784,Percent of Total Billed Charges,60% of Total Billed Charges,230.35,45,,184.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.33,28,,3.408,Percent of Total Billed Charges,28% of Total Billed Charges,95.46,32,,16.184,Percent of Total Billed Charges,32% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,184.28,36,,4.376,Percent of Total Billed Charges,36% of Total Billed Charges,184.28,36,,4.376,Percent of Total Billed Charges,36% Total Bille Charges,184.28,36,,4.376,Percent of Total Billed Charges,36% of Total Billed Charges,307.13,60,,10.976,Percent of Total Billed Charges,60% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.89,100,,409.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,73.81,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.92,75,,4783.456,Percent of Total Billed Charges,75% of Total Billed Charges,255.95,50,,2121.576,Percent of Total Billed Charges,50% of Total Billed Charges,255.95,50,,1367.84,Percent of Total Billed Charges,50% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.95,50,,1367.84,Percent of Total Billed Charges,50% of Total Billed Charges,255.95,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,358.32,70,,634.992,Percent of Total Billed Charges,70% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,71.66,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.89,100,,6377.936,Percent of Total Billed Charges,100% of Total Billed Charges,71.66,511.89,
S MG INTRODUCER,50178151,CDM,272,RC,,,Outpatient,,,305.25,183.15,,183.15,60,,126.128,Percent of Total Billed Charges,60% of Total Billed Charges,137.36,45,,109.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.47,28,,11.544,Percent of Total Billed Charges,28% of Total Billed Charges,95.49,32,,16.232,Percent of Total Billed Charges,32% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,109.89,36,,14.84,Percent of Total Billed Charges,36% of Total Billed Charges,109.89,36,,14.84,Percent of Total Billed Charges,36% Total Bille Charges,109.89,36,,14.84,Percent of Total Billed Charges,36% of Total Billed Charges,183.15,60,,2.968,Percent of Total Billed Charges,60% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.25,100,,244.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14.42,,1.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.94,75,,3188.968,Percent of Total Billed Charges,75% of Total Billed Charges,152.63,50,,911.896,Percent of Total Billed Charges,50% of Total Billed Charges,152.63,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.63,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,152.63,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.68,70,,32.528,Percent of Total Billed Charges,70% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,42.74,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.25,100,,4251.952,Percent of Total Billed Charges,100% of Total Billed Charges,42.74,305.25,
S MG NDL & WIRE,50178185,CDM,272,RC,,,Outpatient,,,120,72.00,,72,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,54,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,28,,59.944,Percent of Total Billed Charges,28% of Total Billed Charges,95.66,32,,161.28,Percent of Total Billed Charges,32% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,43.2,36,,77.072,Percent of Total Billed Charges,36% of Total Billed Charges,43.2,36,,77.072,Percent of Total Billed Charges,36% Total Bille Charges,43.2,36,,77.072,Percent of Total Billed Charges,36% of Total Billed Charges,72,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,100,,96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,17.3,14.42,,0.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,75,,3188.968,Percent of Total Billed Charges,75% of Total Billed Charges,60,50,,1367.84,Percent of Total Billed Charges,50% of Total Billed Charges,60,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,60,50,,565.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,70,,17.304,Percent of Total Billed Charges,70% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,16.8,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120,100,,4251.952,Percent of Total Billed Charges,100% of Total Billed Charges,16.8,120,
S MG EVIVA PROBE W VAC,50178219,CDM,272,RC,,,Outpatient,,,810,486.00,,486,60,,46.448,Percent of Total Billed Charges,60% of Total Billed Charges,364.5,45,,291.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.8,28,,5.456,Percent of Total Billed Charges,28% of Total Billed Charges,95.94,32,,161.28,Percent of Total Billed Charges,32% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,291.6,36,,7.016,Percent of Total Billed Charges,36% of Total Billed Charges,291.6,36,,7.016,Percent of Total Billed Charges,36% Total Bille Charges,291.6,36,,7.016,Percent of Total Billed Charges,36% of Total Billed Charges,486,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810,100,,648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,116.8,14.42,,1.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.5,75,,1791.28,Percent of Total Billed Charges,75% of Total Billed Charges,405,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,405,50,,773.264,Percent of Total Billed Charges,50% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405,50,,773.264,Percent of Total Billed Charges,50% of Total Billed Charges,405,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567,70,,36.624,Percent of Total Billed Charges,70% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810,100,,2388.376,Percent of Total Billed Charges,100% of Total Billed Charges,95.94,810,
S MG BARD PROBE NO VAC,50178250,CDM,272,RC,,,Outpatient,,,750,450.00,,450,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,95.94,32,,161.432,Percent of Total Billed Charges,32% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,1.496,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,450,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,375,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,1159.896,Percent of Total Billed Charges,50% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,50,,1159.896,Percent of Total Billed Charges,50% of Total Billed Charges,375,50,,559.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,95.94,750,
SERTERA BIOPSY PROBE,50178251,CDM,272,RC,,,Outpatient,,,400.95,240.57,,240.57,60,,14.104,Percent of Total Billed Charges,60% of Total Billed Charges,180.43,45,,144.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.27,28,,51.76,Percent of Total Billed Charges,28% of Total Billed Charges,960,32,,163.552,Percent of Total Billed Charges,32% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.34,36,,66.544,Percent of Total Billed Charges,36% of Total Billed Charges,144.34,36,,66.544,Percent of Total Billed Charges,36% Total Bille Charges,144.34,36,,66.544,Percent of Total Billed Charges,36% of Total Billed Charges,240.57,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,100,,320.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,57.82,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.71,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,200.48,50,,773.264,Percent of Total Billed Charges,50% of Total Billed Charges,200.48,50,,749.704,Percent of Total Billed Charges,50% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.48,50,,749.704,Percent of Total Billed Charges,50% of Total Billed Charges,200.48,50,,839.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.67,70,,46.432,Percent of Total Billed Charges,70% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.95,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,56.13,960,
MG 3D TOMO DX BI,50182336,CDM,401,RC,G0279,HCPCS,Outpatient,,,142.66,85.60,TC   ,22.21,100,,497.304,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,2.704,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,163.736,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,3.472,Fee Schedule,360% of BCBS POS Rate,90.83,360,,3.472,Fee schedule,360% of BCBS PPO Rate,90.83,360,,3.472,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,5.552,Fee Schedule,103% of Cigna fee schedule,52.79,100,,0.08,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,0.088,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,107,75,,1791.28,Percent of Total Billed Charges,75% of Total Billed Charges,71.33,50,,1159.896,Percent of Total Billed Charges,50% of Total Billed Charges,71.33,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,71.33,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,71.33,50,,398.824,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,49.568,Case Rate,Pays based on per visit rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,142.66,100,,2388.376,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
MG 3D TOMO DX BI,50182336,CDM,401,RC,G0279,HCPCS,Outpatient,,,142.66,85.60,TC   ,22.21,100,,2.336,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,0.864,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16426.752,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.104,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,1.544,Fee Schedule,103% of Cigna fee schedule,52.79,100,,0.568,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,0.584,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,107,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,71.33,50,,749.704,Percent of Total Billed Charges,50% of Total Billed Charges,71.33,50,,1006.8,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,71.33,50,,1006.8,Percent of Total Billed Charges,50% of Total Billed Charges,71.33,50,,859.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,43.28,Case Rate,Pays based on per visit rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.568,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,142.66,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
MG 3D TOMO SCREEN,50182337,CDM,403,RC,77063,HCPCS,Outpatient,,,201.76,121.06,,24.3,100,,0.296,Fee Schedule,100% of Aetna Fee Schedule,33.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,0.864,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16541.44,Fee Schedule,320% of BCBS Blue Essentials Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.104,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,6.704,Fee Schedule,103% of Cigna fee schedule,51.79,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,20.38,90,,,Fee Schedule,90% of CMS OPPS Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29.43,130,,,Fee Schedule,130% of CMS OPPS Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,53.34,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,151.32,75,,1194.184,Percent of Total Billed Charges,75% of Total Billed Charges,100.88,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,100.88,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,100.88,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,100.88,50,,1001.392,Percent of Total Billed Charges,50% of Total Billed Charges,33.96,150,,,Fee Schedule,150% of CMS OPPS Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,25.096,Case Rate,Pays based on per visit rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,201.76,100,,1592.248,Percent of Total Billed Charges,100% of Total Billed Charges,20.38,201.76,
MG 3D TOMO SCREEN,50182337,CDM,403,RC,77063,HCPCS,Outpatient,,,201.76,121.06,,24.3,100,,0.4,Fee Schedule,100% of Aetna Fee Schedule,33.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,0.864,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16541.44,Fee Schedule,320% of BCBS Blue Essentials Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS POS Rate,90.83,360,,1.104,Fee schedule,360% of BCBS PPO Rate,90.83,360,,1.104,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,0.176,Fee Schedule,103% of Cigna fee schedule,51.79,100,,0.208,Fee Schedule,100% of TX Mediciad Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,20.38,90,,,Fee Schedule,90% of CMS OPPS Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29.43,130,,,Fee Schedule,130% of CMS OPPS Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,53.34,103,,0.216,Fee Schedule,103% of TX Medicaid Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,23.32,103,,,Fee Schedule,103% of CMS OPPS Rate,151.32,75,,1378.568,Percent of Total Billed Charges,75% of Total Billed Charges,100.88,50,,1006.8,Percent of Total Billed Charges,50% of Total Billed Charges,100.88,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,100.88,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,100.88,50,,1051.808,Percent of Total Billed Charges,50% of Total Billed Charges,33.96,150,,,Fee Schedule,150% of CMS OPPS Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,1865.52,Case Rate,Pays based on per visit rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,51.79,100,,0.208,Fee Schedule,100% of TX Medicaid Rate,22.64,100,,,Fee Schedule,100% of CMS OPPS Rate,201.76,100,,1838.088,Percent of Total Billed Charges,100% of Total Billed Charges,20.38,201.76,
MG 3D TOMO DX LT,50182338,CDM,401,RC,G0279,HCPCS,Outpatient,,,95.11,57.07,,22.21,100,,19.016,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,2.072,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.384,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,2.664,Fee Schedule,360% of BCBS POS Rate,90.83,360,,2.664,Fee schedule,360% of BCBS PPO Rate,90.83,360,,2.664,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,0.256,Fee Schedule,103% of Cigna fee schedule,52.79,100,,1.624,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,1.68,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,71.33,75,,1378.568,Percent of Total Billed Charges,75% of Total Billed Charges,47.56,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,1293.592,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,50,,1293.592,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,1414.384,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,28,Case Rate,Pays based on per visit rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,1.624,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,100,,1838.088,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
MG 3D TOMO DX LT,50182338,CDM,401,RC,G0279,HCPCS,Outpatient,,,95.11,57.07,,22.21,100,,22.384,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,70.424,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.464,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,90.544,Fee Schedule,360% of BCBS POS Rate,90.83,360,,90.544,Fee schedule,360% of BCBS PPO Rate,90.83,360,,90.544,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,0.352,Fee Schedule,103% of Cigna fee schedule,52.79,100,,2.104,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,2.168,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,71.33,75,,1739.488,Percent of Total Billed Charges,75% of Total Billed Charges,47.56,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,2121.576,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,28,Case Rate,Pays based on per visit rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,2.104,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,100,,2319.312,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
MG 3D TOMO DX RT,50182339,CDM,401,RC,G0279,HCPCS,Outpatient,,,95.11,57.07,TC   ,22.21,100,,3.064,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,9.544,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.464,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,12.264,Fee Schedule,360% of BCBS POS Rate,90.83,360,,12.264,Fee schedule,360% of BCBS PPO Rate,90.83,360,,12.264,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,2.44,Fee Schedule,103% of Cigna fee schedule,52.79,100,,0.928,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,0.96,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,71.33,75,,1739.488,Percent of Total Billed Charges,75% of Total Billed Charges,47.56,50,,1293.592,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,911.896,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,9.832,Case Rate,Pays based on per visit rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.928,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,100,,2319.312,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
MG 3D TOMO DX RT,50182339,CDM,401,RC,G0279,HCPCS,Outpatient,,,95.11,57.07,TC   ,22.21,100,,76.448,Fee Schedule,100% of Aetna Fee Schedule,27.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,70.64,280,,0.208,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.528,Fee Schedule,320% of BCBS Blue Essentials Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,90.83,360,,0.272,Fee Schedule,360% of BCBS POS Rate,90.83,360,,0.272,Fee schedule,360% of BCBS PPO Rate,90.83,360,,0.272,Fee Schedule,360% of BCBS Traditional Rate,79.04,103,,0.184,Fee Schedule,103% of Cigna fee schedule,52.79,100,,0.24,Fee Schedule,100% of TX Mediciad Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,16.42,90,,,Fee Schedule,90% of CMS OPPS Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,23.71,130,,,Fee Schedule,130% of CMS OPPS Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,54.37,103,,0.248,Fee Schedule,103% of TX Medicaid Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,18.79,103,,,Fee Schedule,103% of CMS OPPS Rate,71.33,75,,1633.2,Percent of Total Billed Charges,75% of Total Billed Charges,47.56,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,47.56,50,,1367.84,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,150,,,Fee Schedule,150% of CMS OPPS Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,6.912,Case Rate,Pays based on per visit rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,52.79,100,,0.24,Fee Schedule,100% of TX Medicaid Rate,18.24,100,,,Fee Schedule,100% of CMS OPPS Rate,95.11,100,,2177.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.42,150,
US ASP BRST CYST LT,50182340,CDM,361,RC,19000,HCPCS,Outpatient,,,1112.42,667.45,,2601,100,,109.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,181.62,233,,6.112,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,960.51,32,,16.528,Percent of Total Billed Charges,32% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,251,322,,7.856,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,251,322,,7.856,Fee schedule,Pays based on ASC Tier Groupings fee schedule,251,322,,7.856,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,0.888,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,160.41,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,834.32,75,,1633.2,Percent of Total Billed Charges,75% of Total Billed Charges,556.21,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,556.21,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,1017.6,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,7.264,Fee Schedule,100% of ASC Tier Groupings fee schedule,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.42,100,,2177.6,Percent of Total Billed Charges,100% of Total Billed Charges,155.74,2601,
US ASP BRST CYST RT,50182341,CDM,361,RC,19000,HCPCS,Outpatient,,,1112.42,667.45,,2601,100,,167.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,181.62,233,,3.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,963.23,32,,16.576,Percent of Total Billed Charges,32% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,251,322,,4.296,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,251,322,,4.296,Fee schedule,Pays based on ASC Tier Groupings fee schedule,251,322,,4.296,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,6.976,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,160.41,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,834.32,75,,1219.976,Percent of Total Billed Charges,75% of Total Billed Charges,556.21,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,51.432,Percent of Total Billed Charges,50% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,556.21,50,,51.432,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,1526.4,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,214.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.42,100,,1626.632,Percent of Total Billed Charges,100% of Total Billed Charges,155.74,2601,
US ASP BRST CYST EA ADD,50182342,CDM,361,RC,19001,HCPCS,Outpatient,,,477.45,286.47,,2601,100,,84.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,214.85,45,,171.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,165.12,Other,Not Seperately Reimbusable,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.47,60,,9.024,Percent of Total Billed Charges,60% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,477.45,100,,381.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,68.85,14.42,,1.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,358.09,75,,1219.976,Percent of Total Billed Charges,75% of Total Billed Charges,238.73,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,238.73,50,,282.64,Percent of Total Billed Charges,50% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.73,50,,282.64,Percent of Total Billed Charges,50% of Total Billed Charges,238.73,50,,773.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,6.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.45,100,,1626.632,Percent of Total Billed Charges,100% of Total Billed Charges,66.84,2601,
US GUIDE NDL PLCMT,50182343,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,37.68,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,221.072,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,165.12,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,284.24,Fee Schedule,360% of BCBS POS Rate,90.83,360,,284.24,Fee schedule,360% of BCBS PPO Rate,90.83,360,,284.24,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,3.992,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,1.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,1455.256,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,51.432,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,1159.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,196.864,Case Rate,Pays based on per visit rate,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,1940.344,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
US GUIDE NDL PLCMT,50182343,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,6.016,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,50.712,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,165.6,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,65.2,Fee Schedule,360% of BCBS POS Rate,90.83,360,,65.2,Fee schedule,360% of BCBS PPO Rate,90.83,360,,65.2,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,1.04,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,1455.256,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,282.64,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,749.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,196.88,Case Rate,Pays based on per visit rate,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,1940.344,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
US BRST LTD BIL,50300000,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,,53.12,100,,20.056,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,37.912,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,165.6,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,48.744,Fee Schedule,360% of BCBS POS Rate,287.32,360,,48.744,Fee schedule,360% of BCBS PPO Rate,287.32,360,,48.744,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.624,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.216,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.224,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,1697.4,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,1572.32,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,129.848,Case Rate,Pays based on per visit rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,2263.2,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
US BRST LTD BIL,50300000,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,,53.12,100,,854.64,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,28.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,165.888,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,36.216,Fee Schedule,360% of BCBS POS Rate,287.32,360,,36.216,Fee schedule,360% of BCBS PPO Rate,287.32,360,,36.216,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,41.04,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.176,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.176,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,1697.4,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,1006.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,66.688,Case Rate,Pays based on per visit rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.176,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,2263.2,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
US BRST LTD RT,50300001,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,144.656,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.192,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,166.168,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.248,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.248,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.248,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,5.072,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.304,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.312,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1156.88,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,124.616,Case Rate,Pays based on per visit rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,1542.504,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LTD RT,50300001,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,29.632,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,19.512,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,166.392,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,25.088,Fee Schedule,360% of BCBS POS Rate,287.32,360,,25.088,Fee schedule,360% of BCBS PPO Rate,287.32,360,,25.088,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.464,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.184,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.192,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1156.88,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,75.568,Case Rate,Pays based on per visit rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,1542.504,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LTD LT,50300002,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,305.848,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16.64,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,393.232,Fee Schedule,360% of BCBS POS Rate,287.32,360,,393.232,Fee schedule,360% of BCBS PPO Rate,287.32,360,,393.232,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.792,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1404.688,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,1293.592,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,141.52,Case Rate,Pays based on per visit rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,1872.912,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LTD LT,50300002,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,24,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,78.616,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16.744,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,101.08,Fee Schedule,360% of BCBS POS Rate,287.32,360,,101.08,Fee schedule,360% of BCBS PPO Rate,287.32,360,,101.08,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.936,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1404.688,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,80.168,Case Rate,Pays based on per visit rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,1872.912,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US SOFT TISSUE,50300003,CDM,402,RC,76999,HCPCS,Outpatient,,,357.5,214.50,TC   ,214.5,60,,40.272,Percent of Total Billed Charges,60% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.752,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,2.256,Fee Schedule,360% of BCBS POS Rate,287.32,360,,2.256,Fee schedule,360% of BCBS PPO Rate,287.32,360,,2.256,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.744,Fee Schedule,103% of Cigna fee schedule,80.9,100,,0.464,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.48,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,268.13,75,,1662.656,Percent of Total Billed Charges,75% of Total Billed Charges,178.75,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,178.75,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,178.75,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,178.75,50,,60.096,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1258.4,Case Rate,Pays based on per visit rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,357.5,100,,2216.872,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,378,
US SOFT TISSUE,50300003,CDM,402,RC,76999,HCPCS,Outpatient,,,357.5,214.50,TC   ,214.5,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,55.432,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16.864,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,71.272,Fee Schedule,360% of BCBS POS Rate,287.32,360,,71.272,Fee schedule,360% of BCBS PPO Rate,287.32,360,,71.272,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.304,Fee Schedule,103% of Cigna fee schedule,80.9,100,,2.768,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,2.848,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,268.13,75,,1662.656,Percent of Total Billed Charges,75% of Total Billed Charges,178.75,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,178.75,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,178.75,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,178.75,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,114.032,Case Rate,Pays based on per visit rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,357.5,100,,2216.872,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,378,
CATH DRN MULTI PGTL,50300226,CDM,272,RC,,,Outpatient,,,380,228.00,,228,60,,5.368,Percent of Total Billed Charges,60% of Total Billed Charges,171,45,,136.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,965.12,32,,166.984,Percent of Total Billed Charges,32% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,136.8,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,136.8,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,136.8,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,228,60,,0.792,Percent of Total Billed Charges,60% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380,100,,304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,54.8,14.42,,1.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285,75,,1138.648,Percent of Total Billed Charges,75% of Total Billed Charges,190,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,70,,124.032,Percent of Total Billed Charges,70% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380,100,,1518.2,Percent of Total Billed Charges,100% of Total Billed Charges,53.2,965.12,
US BRST 4 QUADS BI,50300228,CDM,402,RC,76641,HCPCS,Outpatient,,,573.3,343.98,TC   ,69.44,100,,21.512,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.032,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,3.328,Fee Schedule,360% of BCBS POS Rate,403.49,360,,3.328,Fee schedule,360% of BCBS PPO Rate,403.49,360,,3.328,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.112,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.52,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.536,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,429.98,75,,1138.648,Percent of Total Billed Charges,75% of Total Billed Charges,286.65,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,286.65,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,51.432,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,35.848,Case Rate,Pays based on per visit rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,573.3,100,,1518.2,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,573.3,
US BRST 4 QUADS BI,50300228,CDM,402,RC,76641,HCPCS,Outpatient,,,573.3,343.98,TC   ,69.44,100,,398.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,6.096,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.416,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,7.832,Fee Schedule,360% of BCBS POS Rate,403.49,360,,7.832,Fee schedule,360% of BCBS PPO Rate,403.49,360,,7.832,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.136,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,429.98,75,,1422.544,Percent of Total Billed Charges,75% of Total Billed Charges,286.65,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,286.65,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,286.65,50,,282.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,3589.336,Case Rate,Pays based on per visit rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,573.3,100,,1896.72,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,573.3,
US BRST 4 QUADS LT,50300229,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,,69.44,100,,13.744,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.416,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.616,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.616,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.616,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,1.984,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,1422.544,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,331.368,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,348.88,Case Rate,Pays based on per visit rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,1896.72,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
US BRST 4 QUADS LT,50300229,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,,69.44,100,,5.856,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.376,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.416,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.912,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.912,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.912,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,11.856,Fee Schedule,103% of Cigna fee schedule,103.91,100,,0.304,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,0.32,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,1681.8,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,292.384,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,292.384,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,17.032,Case Rate,Pays based on per visit rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,0.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,2242.4,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
US BRST 4 QUADS RT,50300230,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,TC   ,69.44,100,,64.624,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.072,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.608,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.528,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.528,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.528,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,5.152,Fee Schedule,103% of Cigna fee schedule,103.91,100,,1.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,1.04,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,1681.8,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,253.6,Case Rate,Pays based on per visit rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,2242.4,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
US BRST 4 QUADS RT,50300230,CDM,402,RC,76641,HCPCS,Outpatient,,,382.2,229.32,TC   ,69.44,100,,13.712,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.072,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,168.712,Fee Schedule,320% of BCBS Blue Essentials Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.528,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.528,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.528,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,2.216,Fee Schedule,103% of Cigna fee schedule,103.91,100,,1.152,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,107.03,103,,1.184,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,286.65,75,,1854.6,Percent of Total Billed Charges,75% of Total Billed Charges,191.1,50,,292.384,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.1,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,527.328,Case Rate,Pays based on per visit rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,103.91,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,382.2,100,,2472.8,Percent of Total Billed Charges,100% of Total Billed Charges,69.44,403.49,
US BRST LESS 4 QUADS BI,50300231,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,,53.12,100,,104.8,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,36.096,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,168.712,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,46.416,Fee Schedule,360% of BCBS POS Rate,287.32,360,,46.416,Fee schedule,360% of BCBS PPO Rate,287.32,360,,46.416,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.024,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,1854.6,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,214.416,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,214.416,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,40.624,Case Rate,Pays based on per visit rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,2472.8,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
US BRST LESS 4 QUADS BI,50300231,CDM,402,RC,76642,HCPCS,Outpatient,,,532.35,319.41,,53.12,100,,1.088,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.096,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,168.712,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.128,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.128,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.128,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.048,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.416,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.424,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,399.26,75,,1791.424,Percent of Total Billed Charges,75% of Total Billed Charges,266.18,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,266.18,50,,263.144,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,159.632,Case Rate,Pays based on per visit rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.416,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,532.35,100,,2388.56,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,532.35,
US BRST LESS 4 QUADS LT,50300232,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,TC   ,53.12,100,,0.248,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.408,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,168.712,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.808,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.808,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.808,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,1.312,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1791.424,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,214.416,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,160.384,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,27.464,Case Rate,Pays based on per visit rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,2388.56,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LESS 4 QUADS LT,50300232,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,TC   ,53.12,100,,84.072,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.48,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,168.712,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.624,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.32,Fee Schedule,103% of Cigna fee schedule,85.54,100,,2.488,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,2.56,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1672.288,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,263.456,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,263.456,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,67.976,Case Rate,Pays based on per visit rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,2.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,2229.712,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LESS 4 QUADS RT,50300233,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,125.76,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.48,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,168.88,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.624,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,4.92,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1672.288,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,526.288,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,39.016,Case Rate,Pays based on per visit rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,2229.712,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US BRST LESS 4 QUADS RT,50300233,CDM,402,RC,76642,HCPCS,Outpatient,,,354.9,212.94,,53.12,100,,134.752,Fee Schedule,100% of Aetna Fee Schedule,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,7.48,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,16967.808,Fee Schedule,320% of BCBS Blue Essentials Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS POS Rate,287.32,360,,9.624,Fee schedule,360% of BCBS PPO Rate,287.32,360,,9.624,Fee Schedule,360% of BCBS Traditional Rate,189.46,103,,0.16,Fee Schedule,103% of Cigna fee schedule,85.54,100,,0.464,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,88.11,103,,0.472,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,266.18,75,,1671.64,Percent of Total Billed Charges,75% of Total Billed Charges,177.45,50,,263.456,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.45,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,177.45,50,,224,Percent of Total Billed Charges,50% of Total Billed Charges,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,383.496,Case Rate,Pays based on per visit rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,85.54,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,354.9,100,,2228.856,Percent of Total Billed Charges,100% of Total Billed Charges,53.12,378,
US GUIDE NDL PLCMT,50369602,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,17.12,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,0.184,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.896,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,0.232,Fee Schedule,360% of BCBS POS Rate,90.83,360,,0.232,Fee schedule,360% of BCBS PPO Rate,90.83,360,,0.232,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,10.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,1671.64,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,203.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,19.704,Case Rate,Pays based on per visit rate,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,2228.856,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
US GUIDE NDL PLCMT,50369602,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,27.344,Fee Schedule,100% of Aetna Fee Schedule,369.61,45,,295.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,0.296,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,16.896,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,0.376,Fee Schedule,360% of BCBS POS Rate,90.83,360,,0.376,Fee schedule,360% of BCBS PPO Rate,90.83,360,,0.376,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,1.768,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,821.35,100,,657.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,0.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,1668.184,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,604.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,47.296,Case Rate,Pays based on per visit rate,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,2224.248,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
GEL SPONGE,50400000,CDM,272,RC,,,Outpatient,,,73.2,43.92,,43.92,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,32.94,45,,26.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.5,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,968.97,32,,16.96,Percent of Total Billed Charges,32% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,26.35,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,26.35,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,26.35,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,43.92,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.2,100,,58.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.56,14.42,,0.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,75,,1668.184,Percent of Total Billed Charges,75% of Total Billed Charges,36.6,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.6,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,633.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.24,70,,119.312,Percent of Total Billed Charges,70% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.2,100,,2224.248,Percent of Total Billed Charges,100% of Total Billed Charges,10.25,968.97,
CT ASP RENAL CYST W NDL,50400002,CDM,361,RC,50390,HCPCS,Outpatient,,,2070.32,1242.19,,2601,100,,3.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,0.656,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,975.36,32,,17,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,0.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,0.84,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,0.84,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,10.648,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,0.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1552.74,75,,1225.512,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,1367.28,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,703.056,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1035.16,50,,703.056,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,173.928,Fee Schedule,100% of ASC Tier Groupings fee schedule,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2070.32,100,,1634.016,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2601,
CT SINUS W CM,50402007,CDM,351,RC,70487,HCPCS,Outpatient,,,2341.14,1404.68,,1749,110,,53.864,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.68,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.048,Fee Schedule,320% of BCBS Blue Essentials Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.872,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.872,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.872,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.056,Case Rate,Pays based on per visit rate,157.71,100,,0.704,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,162.44,103,,0.728,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1755.86,75,,1225.512,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,150,Case Rate,Pays Based on per visit rate,1334,100,,1054.584,Case Rate,Pays based on per visit rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1054.584,Case Rate,Pays based on per visit rate,1334,100,,292.384,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,51.552,Case Rate,Pays based on per visit rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.704,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2341.14,100,,1634.016,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2341.14,
CT SINUS W CM,50402007,CDM,351,RC,70487,HCPCS,Outpatient,,,2341.14,1404.68,,1749,110,,2.176,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.064,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.104,Fee Schedule,320% of BCBS Blue Essentials Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.08,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.08,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.08,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.976,Case Rate,Pays based on per visit rate,157.71,100,,0.352,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,162.44,103,,0.36,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1755.86,75,,1548.136,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,703.056,Case Rate,Pays Based on per visit rate,1334,100,,286.784,Case Rate,Pays based on per visit rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,286.784,Case Rate,Pays based on per visit rate,1334,100,,368.4,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,24.816,Case Rate,Pays based on per visit rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2341.14,100,,2064.184,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2341.14,
CATH DRN MULTI PGTL,50402069,CDM,272,RC,,,Outpatient,,,380,228.00,,228,60,,0.28,Percent of Total Billed Charges,60% of Total Billed Charges,171,45,,136.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,28,,377.968,Percent of Total Billed Charges,28% of Total Billed Charges,981.37,32,,168.96,Percent of Total Billed Charges,32% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,136.8,36,,485.96,Percent of Total Billed Charges,36% of Total Billed Charges,136.8,36,,485.96,Percent of Total Billed Charges,36% Total Bille Charges,136.8,36,,485.96,Percent of Total Billed Charges,36% of Total Billed Charges,228,60,,45.112,Percent of Total Billed Charges,60% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380,100,,304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,54.8,14.42,,0.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285,75,,1548.136,Percent of Total Billed Charges,75% of Total Billed Charges,190,50,,1054.584,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,190,50,,272.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,266,70,,3.568,Percent of Total Billed Charges,70% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,53.2,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380,100,,2064.184,Percent of Total Billed Charges,100% of Total Billed Charges,53.2,981.37,
CT DRN ABS VISCERAL PERC,50402070,CDM,361,RC,49405,HCPCS,Outpatient,,,3803.53,2282.12,,4162,100,,0.576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,1483.888,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,982.55,32,,168.96,Percent of Total Billed Charges,32% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,1907.856,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,1907.856,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,1907.856,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,510.064,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,548.47,14.42,,0.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2852.65,75,,1792.8,Percent of Total Billed Charges,75% of Total Billed Charges,1901.77,50,,286.784,Percent of Total Billed Charges,50% of Total Billed Charges,1901.77,50,,1001.984,Percent of Total Billed Charges,50% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1901.77,50,,1001.984,Percent of Total Billed Charges,50% of Total Billed Charges,1901.77,50,,214.416,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,21.504,Fee Schedule,100% of ASC Tier Groupings fee schedule,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,532.49,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3803.53,100,,2390.4,Percent of Total Billed Charges,100% of Total Billed Charges,532.49,5665,
CT DRN ABS PERITONEAL PERC,50402071,CDM,361,RC,49406,HCPCS,Outpatient,,,3811.83,2287.10,,4162,100,,2.592,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,0.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,986.02,32,,169.112,Percent of Total Billed Charges,32% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,0.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,0.248,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,0.248,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,3.088,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,549.67,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2858.87,75,,1792.8,Percent of Total Billed Charges,75% of Total Billed Charges,1905.92,50,,309.48,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,430.176,Percent of Total Billed Charges,50% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1905.92,50,,430.176,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,105.536,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,100.88,Fee Schedule,100% of ASC Tier Groupings fee schedule,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3811.83,100,,2390.4,Percent of Total Billed Charges,100% of Total Billed Charges,533.66,5665,
CT ASP JT MAJOR LT,50402076,CDM,361,RC,,,Outpatient,,,885.02,531.01,,531.01,60,,53.392,Percent of Total Billed Charges,60% of Total Billed Charges,398.26,45,,318.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.81,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,989.3,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,318.61,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,318.61,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,318.61,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,531.01,60,,2.936,Percent of Total Billed Charges,60% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,885.02,100,,708.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,3.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,663.77,75,,1385.992,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,1001.984,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,464.208,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.51,50,,464.208,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,350.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,619.51,70,,79.8,Percent of Total Billed Charges,70% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,885.02,100,,1847.992,Percent of Total Billed Charges,100% of Total Billed Charges,123.9,989.3,
CT ASP JT MAJOR RT,50402077,CDM,361,RC,20610,HCPCS,Outpatient,,,885.02,531.01,,2601,100,,12.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,72.32,233,,31.048,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,993.75,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,99.95,322,,39.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,99.95,322,,39.92,Fee schedule,Pays based on ASC Tier Groupings fee schedule,99.95,322,,39.92,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,3.104,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,127.62,14.42,,3.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,663.77,75,,1385.992,Percent of Total Billed Charges,75% of Total Billed Charges,442.51,50,,430.176,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,1502.976,Percent of Total Billed Charges,50% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,442.51,50,,1502.976,Percent of Total Billed Charges,50% of Total Billed Charges,442.51,50,,263.456,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,166.928,Fee Schedule,100% of ASC Tier Groupings fee schedule,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,123.9,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,885.02,100,,1847.992,Percent of Total Billed Charges,100% of Total Billed Charges,72.32,2601,
CT BX AND ASP BONE MARROW,50441610,CDM,361,RC,38222,HCPCS,Outpatient,,,2742.48,1645.49,,2601,100,,7.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3910.43,150,,,Fee Schedule ,150% of CMS OPPS Rate,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5403.01,233,,3.456,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,993.75,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,7466.83,322,,4.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,7466.83,322,,4.448,Fee schedule,Pays based on ASC Tier Groupings fee schedule,7466.83,322,,4.448,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,3.024,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,90,,,Fee Schedule,90% of CMS OPPS Rate,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.04,130,,,Fee Schedule,130% of CMS OPPS Rate,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,395.47,14.42,,2.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,2685.16,103,,,Fee Schedule,103% of CMS OPPS Rate,2685.16,103,,,Fee Schedule,103% of CMS OPPS Rate,2056.86,75,,1569.944,Percent of Total Billed Charges,75% of Total Billed Charges,1371.24,50,,464.208,Percent of Total Billed Charges,50% of Total Billed Charges,1371.24,50,,1015.72,Percent of Total Billed Charges,50% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1371.24,50,,1015.72,Percent of Total Billed Charges,50% of Total Billed Charges,1371.24,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,3910.43,150,,,Fee Schedule,150% of CMS OPPS Rate,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,308,Fee Schedule,100% of ASC Tier Groupings fee schedule,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,383.95,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,2606.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2742.48,100,,2093.256,Percent of Total Billed Charges,100% of Total Billed Charges,383.95,7466.83,
CT  ASP FINE NDL W CT INIT LESION,50500000,CDM,361,RC,10009,HCPCS,Outpatient,,,1961.3,1176.78,,2601,100,,4.8,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,718.18,233,,6.944,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,993.75,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,992.5,322,,8.928,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,992.5,322,,8.928,Fee schedule,Pays based on ASC Tier Groupings fee schedule,992.5,322,,8.928,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,1.512,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,282.82,14.42,,0.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1470.98,75,,1569.944,Percent of Total Billed Charges,75% of Total Billed Charges,980.65,50,,1502.976,Percent of Total Billed Charges,50% of Total Billed Charges,980.65,50,,1088.656,Percent of Total Billed Charges,50% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,980.65,50,,1088.656,Percent of Total Billed Charges,50% of Total Billed Charges,980.65,50,,320.016,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,27.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,274.58,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1961.3,100,,2093.256,Percent of Total Billed Charges,100% of Total Billed Charges,274.58,2601,
CT ANGIO ABD PEL ENTEROGRAPHY,50500001,CDM,352,RC,74174,HCPCS,Outpatient,,,4576.02,2745.61,TC   ,1749,110,,335.936,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,813.34,280,,38.648,Fee Schedule,280% of BCBS BULE Fee Schedule,929.54,320,,169.616,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,1045.73,360,,49.696,Fee Schedule,360% of BCBS POS Rate,1045.73,360,,49.696,Fee schedule,360% of BCBS PPO Rate,1045.73,360,,49.696,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.184,Case Rate,Pays based on per visit rate,368.43,100,,0.512,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.52,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3432.02,75,,1796.312,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1015.72,Case Rate,Pays Based on per visit rate,1334,100,,287.24,Case Rate,Pays based on per visit rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,287.24,Case Rate,Pays based on per visit rate,1334,100,,1367.28,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4576.02,100,,2395.08,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4576.02,
CT ANGIO ABD PEL ENTEROGRAPHY,50500001,CDM,352,RC,74174,HCPCS,Outpatient,,,4576.02,2745.61,TC   ,1749,110,,22.384,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,813.34,280,,8.504,Fee Schedule,280% of BCBS BULE Fee Schedule,929.54,320,,169.616,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,1045.73,360,,10.928,Fee Schedule,360% of BCBS POS Rate,1045.73,360,,10.928,Fee schedule,360% of BCBS PPO Rate,1045.73,360,,10.928,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.824,Case Rate,Pays based on per visit rate,368.43,100,,0.008,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3432.02,75,,1796.312,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1088.656,Case Rate,Pays Based on per visit rate,1334,100,,540,Case Rate,Pays based on per visit rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,540,Case Rate,Pays based on per visit rate,1334,100,,1367.28,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,19.136,Case Rate,Pays based on per visit rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4576.02,100,,2395.08,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4576.02,
CT ANGIO HEAD WWO CM,50500002,CDM,351,RC,70496,HCPCS,Outpatient,,,2787.14,1672.28,,1749,110,,1.36,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,5.656,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,169.816,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,7.272,Fee Schedule,360% of BCBS POS Rate,655.99,360,,7.272,Fee schedule,360% of BCBS PPO Rate,655.99,360,,7.272,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.32,Case Rate,Pays based on per visit rate,180.34,100,,0.112,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.112,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2090.36,75,,1315.6,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,287.24,Case Rate,Pays Based on per visit rate,1334,100,,150,Case Rate,Pays based on per visit rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,150,Case Rate,Pays based on per visit rate,1334,100,,150,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.112,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2787.14,100,,1754.128,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2787.14,
CT ANGIO HEAD WWO CM,50500002,CDM,351,RC,70496,HCPCS,Outpatient,,,2787.14,1672.28,,1749,110,,9.184,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,15.84,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,170.536,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,20.368,Fee Schedule,360% of BCBS POS Rate,655.99,360,,20.368,Fee schedule,360% of BCBS PPO Rate,655.99,360,,20.368,Fee Schedule,360% of BCBS Traditional Rate,916,100,,13.4,Case Rate,Pays based on per visit rate,180.34,100,,1.568,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.616,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2090.36,75,,1315.6,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,540,Case Rate,Pays Based on per visit rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,1334,100,,703.056,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2787.14,100,,1754.128,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2787.14,
CT ANGIO NECK WWO CM,50500003,CDM,351,RC,70498,HCPCS,Outpatient,,,2786.07,1671.64,TC   ,1749,110,,5.816,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,33.32,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,170.616,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,42.84,Fee Schedule,360% of BCBS POS Rate,655.99,360,,42.84,Fee schedule,360% of BCBS PPO Rate,655.99,360,,42.84,Fee Schedule,360% of BCBS Traditional Rate,916,100,,14.36,Case Rate,Pays based on per visit rate,180.34,100,,0.08,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.08,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2089.55,75,,1497.416,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,150,Case Rate,Pays Based on per visit rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,1334,100,,1054.584,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.07,100,,1996.552,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2786.07,
CT ANGIO NECK WWO CM,50500003,CDM,351,RC,70498,HCPCS,Outpatient,,,2786.07,1671.64,TC   ,1749,110,,0.072,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,3,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,170.648,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.856,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.856,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.856,Fee Schedule,360% of BCBS Traditional Rate,916,100,,11.728,Case Rate,Pays based on per visit rate,180.34,100,,0.272,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.28,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2089.55,75,,1497.416,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,835.712,Case Rate,Pays Based on per visit rate,1334,100,,150,Case Rate,Pays based on per visit rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,150,Case Rate,Pays based on per visit rate,1334,100,,286.784,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.07,100,,1996.552,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2786.07,
CT HRT Ct  STRX C GEN HRT DIS W/CM W/3D,50500004,CDM,359,RC,75573,HCPCS,Outpatient,,,4000,2400.00,,1749,110,,9.216,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,565.1,280,,5.496,Fee Schedule,280% of BCBS BULE Fee Schedule,645.82,320,,17.152,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,726.55,360,,7.064,Fee Schedule,360% of BCBS POS Rate,726.55,360,,7.064,Fee schedule,360% of BCBS PPO Rate,726.55,360,,7.064,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.032,Case Rate,Pays based on per visit rate,180.34,100,,2.416,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,2.488,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,3000,75,,1770.688,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,835.712,Case Rate,Pays Based on per visit rate,1334,100,,1189.864,Case Rate,Pays based on per visit rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1189.864,Case Rate,Pays based on per visit rate,1334,100,,309.48,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.416,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4000,100,,2360.912,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,4000,
CT HRT ANGIO CORO W/CM W/3D,50500005,CDM,359,RC,75574,HCPCS,Outpatient,,,4000,2400.00,,1749,110,,9.928,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,565.1,280,,6.192,Fee Schedule,280% of BCBS BULE Fee Schedule,645.82,320,,17.248,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,726.55,360,,7.968,Fee Schedule,360% of BCBS POS Rate,726.55,360,,7.968,Fee schedule,360% of BCBS PPO Rate,726.55,360,,7.968,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.176,Case Rate,Pays based on per visit rate,180.34,100,,0.144,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.152,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,3000,75,,1770.688,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,150,Case Rate,Pays Based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,1334,100,,1001.984,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,16.104,Case Rate,Pays based on per visit rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4000,100,,2360.912,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,4000,
DATA PREPARATION AND TRANSMISSION,50500006,CDM,359,RC,0624T,HCPCS,Outpatient,,,150,90.00,,1810.56,110,,92.512,Percent of Total Billed Charges,110% of Total Billed Charges,67.5,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,387.38,280,,6.192,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,17.272,Fee Schedule,320% of BCBS Blue Essentials Rate,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,7.968,Fee Schedule,360% of BCBS POS Rate,498.06,360,,7.968,Fee schedule,360% of BCBS PPO Rate,498.06,360,,7.968,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.032,Case Rate,Pays based on per visit rate,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,0.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,1335.76,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1189.864,Case Rate,Pays Based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,275.912,Case Rate,Pays based on per visit rate,1334,100,,430.176,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,15.536,Case Rate,Pays based on per visit rate,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,1781.008,Percent of Total Billed Charges,100% of Total Billed Charges,21,1810.56,
COMPUTERIZED ANALYSIS OF CCTA DATA,50500007,CDM,359,RC,0625T,HCPCS,Outpatient,,,2660,1596.00,,1781.75,110,,16.072,Percent of Total Billed Charges,110% of Total Billed Charges,1372.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2661.4,280,,8.792,Fee Schedule,280% of BCBS BULE Fee Schedule,3041.6,320,,17.336,Fee Schedule,320% of BCBS Blue Essentials Rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,3421.8,360,,11.304,Fee Schedule,360% of BCBS POS Rate,3421.8,360,,11.304,Fee schedule,360% of BCBS PPO Rate,3421.8,360,,11.304,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.472,Case Rate,Pays based on per visit rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,823.72,90,,,Fee Schedule,90% of CMS OPPS Rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.83,130,,,Fee Schedule,130% of CMS OPPS Rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,383.57,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,942.7,103,,,Fee Schedule,103% of CMS OPPS Rate,942.7,103,,,Fee Schedule,103% of CMS OPPS Rate,1995,75,,1335.76,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,275.912,Case Rate,Pays Based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,1334,100,,464.208,Case Rate,Pays based on per visit rate,1372.88,150,,,Fee Schedule,150% of CMS OPPS Rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,372.4,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,915.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2660,100,,1781.008,Percent of Total Billed Charges,100% of Total Billed Charges,372.4,3421.8,
RESUSC MASK ADLT RESVR MED,50500008,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,3.496,Percent of Total Billed Charges,60% of Total Billed Charges,59.8,45,,47.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,5.152,Percent of Total Billed Charges,28% of Total Billed Charges,994.24,32,,172.792,Percent of Total Billed Charges,32% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,6.624,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,6.624,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,6.624,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,6.728,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.88,100,,106.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,3.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,1537.2,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,1502.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,23.328,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,2049.6,Percent of Total Billed Charges,100% of Total Billed Charges,18.6,994.24,
CT THORAX LUNG CANCER SCREENING,50500009,CDM,350,RC,71271,HCPCS,Outpatient,,,350,210.00,,1749,110,,1311.808,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,289.6,280,,0.08,Fee Schedule,280% of BCBS BULE Fee Schedule,330.98,320,,172.8,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,372.35,360,,0.096,Fee Schedule,360% of BCBS POS Rate,372.35,360,,0.096,Fee schedule,360% of BCBS PPO Rate,372.35,360,,0.096,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.344,Case Rate,Pays based on per visit rate,106.88,100,,6.712,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,6.912,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,262.5,75,,1537.2,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,275.912,Case Rate,Pays Based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,1334,100,,1015.72,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,19.384,Case Rate,Pays based on per visit rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,350,100,,2049.6,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1800,
CT MOD SED SAME PHY EA ADD 15,50500271,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,3962.104,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,49.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,0.552,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,172.8,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,0.712,Fee Schedule,360% of BCBS POS Rate,38.92,360,,0.712,Fee schedule,360% of BCBS PPO Rate,38.92,360,,0.712,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,1.16,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,109.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,14.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,1805.4,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,1523.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,1523.6,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,1088.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,19.464,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,2407.2,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
CT MOD SED RAD CHILD INI 15 MI,50500273,CDM,370,RC,99151,HCPCS,Outpatient,,,217.25,130.35,,18.43,100,,221.296,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.66,280,,65.216,Fee Schedule,280% of BCBS BULE Fee Schedule,83.04,320,,172.8,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,93.42,360,,83.848,Fee Schedule,360% of BCBS POS Rate,93.42,360,,83.848,Fee schedule,360% of BCBS PPO Rate,93.42,360,,83.848,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,10.336,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,13.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,1805.4,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,275.912,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,292.384,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,292.384,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,287.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,15.448,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,2407.2,Percent of Total Billed Charges,100% of Total Billed Charges,18.43,217.25,
CT MOD SED RAD ADULT INI 15 MI,50500275,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,32.16,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,4.112,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,172.8,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,5.288,Fee Schedule,360% of BCBS POS Rate,45.4,360,,5.288,Fee schedule,360% of BCBS PPO Rate,45.4,360,,5.288,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,0.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,1523.6,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,368.4,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
CT THORACOLUMBAR W CM,50501193,CDM,350,RC,76497,HCPCS,Outpatient,,,2447.2,1468.32,TC   ,1749,110,,19.44,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,0.528,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,172.8,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,0.672,Fee Schedule,360% of BCBS POS Rate,287.32,360,,0.672,Fee schedule,360% of BCBS PPO Rate,287.32,360,,0.672,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.616,Case Rate,Pays based on per visit rate,80.9,100,,0.976,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,1,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1835.4,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,292.384,Case Rate,Pays Based on per visit rate,1334,100,,250.152,Case Rate,Pays based on per visit rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,250.152,Case Rate,Pays based on per visit rate,1334,100,,150,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.976,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2447.2,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2447.2,
CT THORACOLUMBAR W CM,50501193,CDM,350,RC,76497,HCPCS,Outpatient,,,2447.2,1468.32,TC   ,1749,110,,0.304,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,730.016,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,173.36,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,938.592,Fee Schedule,360% of BCBS POS Rate,287.32,360,,938.592,Fee schedule,360% of BCBS PPO Rate,287.32,360,,938.592,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.672,Case Rate,Pays based on per visit rate,80.9,100,,1.544,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,1.592,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1835.4,75,,1510.888,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,368.4,Case Rate,Pays Based on per visit rate,1334,100,,621.976,Case Rate,Pays based on per visit rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,621.976,Case Rate,Pays based on per visit rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.544,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2447.2,100,,2014.512,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2447.2,
CT THORACOLUMBAR WO CM,50501194,CDM,350,RC,76497,HCPCS,Outpatient,,,2239.91,1343.95,,1749,110,,20.56,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1262.464,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.416,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1623.168,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1623.168,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1623.168,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.256,Case Rate,Pays based on per visit rate,80.9,100,,0.952,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.984,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1679.93,75,,1510.888,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,250.152,Case Rate,Pays Based on per visit rate,1334,100,,1189.864,Case Rate,Pays based on per visit rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1189.864,Case Rate,Pays based on per visit rate,1334,100,,835.712,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,43.96,Case Rate,Pays based on per visit rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2239.91,100,,2014.512,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2239.91,
CT THORACOLUMBAR WO CM,50501194,CDM,350,RC,76497,HCPCS,Outpatient,,,2239.91,1343.95,,1749,110,,20.056,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,43.04,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.416,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,55.344,Fee Schedule,360% of BCBS POS Rate,287.32,360,,55.344,Fee schedule,360% of BCBS PPO Rate,287.32,360,,55.344,Fee Schedule,360% of BCBS Traditional Rate,916,100,,12.544,Case Rate,Pays based on per visit rate,80.9,100,,0.488,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.504,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1679.93,75,,1819.792,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,621.976,Case Rate,Pays Based on per visit rate,1334,100,,157.16,Case Rate,Pays based on per visit rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,157.16,Case Rate,Pays based on per visit rate,1334,100,,150,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2239.91,100,,2426.384,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2239.91,
CT THORACOLUMBAR WWO CM,50501195,CDM,350,RC,76497,HCPCS,Outpatient,,,2837.59,1702.55,,1749,110,,39.656,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,35.224,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.416,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,45.288,Fee Schedule,360% of BCBS POS Rate,287.32,360,,45.288,Fee schedule,360% of BCBS PPO Rate,287.32,360,,45.288,Fee Schedule,360% of BCBS Traditional Rate,916,100,,28.752,Case Rate,Pays based on per visit rate,80.9,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.19,75,,1819.792,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1189.864,Case Rate,Pays Based on per visit rate,1334,100,,273.528,Case Rate,Pays based on per visit rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,273.528,Case Rate,Pays based on per visit rate,1334,100,,1189.864,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2837.59,100,,2426.384,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2837.59,
CT THORACOLUMBAR WWO CM,50501195,CDM,350,RC,76497,HCPCS,Outpatient,,,2837.59,1702.55,,1749,110,,12.576,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,47.168,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.448,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,60.64,Fee Schedule,360% of BCBS POS Rate,287.32,360,,60.64,Fee schedule,360% of BCBS PPO Rate,287.32,360,,60.64,Fee Schedule,360% of BCBS Traditional Rate,916,100,,61.384,Case Rate,Pays based on per visit rate,80.9,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.19,75,,1757.208,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,157.16,Case Rate,Pays Based on per visit rate,1334,100,,272.712,Case Rate,Pays based on per visit rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,272.712,Case Rate,Pays based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28.24,Case Rate,Pays based on per visit rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2837.59,100,,2342.944,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2837.59,
CT 3D RENDERING W INDEP WKSTN,50501601,CDM,350,RC,76377,HCPCS,Outpatient,,,320.6,192.36,TC   ,1749,110,,4.064,Percent of Total Billed Charges,110% of Total Billed Charges,144.27,45,,115.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.79,280,,152.784,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,17.472,Fee Schedule,320% of BCBS Blue Essentials Rate,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,196.44,Fee Schedule,360% of BCBS POS Rate,114.16,360,,196.44,Fee schedule,360% of BCBS PPO Rate,114.16,360,,196.44,Fee Schedule,360% of BCBS Traditional Rate,916,100,,55.68,Case Rate,Pays based on per visit rate,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.6,100,,256.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,46.23,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.45,75,,1757.208,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,273.528,Case Rate,Pays Based on per visit rate,1334,100,,27.688,Case Rate,Pays based on per visit rate,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,27.688,Case Rate,Pays based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,84.808,Case Rate,Pays based on per visit rate,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.6,100,,2342.944,Percent of Total Billed Charges,100% of Total Billed Charges,44.88,1800,
CT 3D RENDERING W INDEP WKSTN,50501601,CDM,350,RC,76377,HCPCS,Outpatient,,,320.6,192.36,TC   ,1749,110,,1056,Percent of Total Billed Charges,110% of Total Billed Charges,144.27,45,,115.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.79,280,,152.784,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,17.6,Fee Schedule,320% of BCBS Blue Essentials Rate,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,196.44,Fee Schedule,360% of BCBS POS Rate,114.16,360,,196.44,Fee schedule,360% of BCBS PPO Rate,114.16,360,,196.44,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.648,Case Rate,Pays based on per visit rate,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.6,100,,256.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,46.23,14.42,,8.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.45,75,,1171.472,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,272.712,Case Rate,Pays Based on per visit rate,1334,100,,46.8,Case Rate,Pays based on per visit rate,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,46.8,Case Rate,Pays based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,28,Case Rate,Pays based on per visit rate,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,44.88,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.6,100,,1561.96,Percent of Total Billed Charges,100% of Total Billed Charges,44.88,1800,
CT SINUS WO CM,50502020,CDM,351,RC,70486,HCPCS,Outpatient,,,1928.13,1156.88,,1749,110,,34.08,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,30.992,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,174.536,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,39.848,Fee Schedule,360% of BCBS POS Rate,403.49,360,,39.848,Fee schedule,360% of BCBS PPO Rate,403.49,360,,39.848,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.176,Case Rate,Pays based on per visit rate,106.88,100,,7.44,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,7.664,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.1,75,,1171.472,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,27.688,Case Rate,Pays Based on per visit rate,1334,100,,84.264,Case Rate,Pays based on per visit rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,84.264,Case Rate,Pays based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28,Case Rate,Pays based on per visit rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.44,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1928.13,100,,1561.96,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1928.13,
CT SINUS WO CM,50502020,CDM,351,RC,70486,HCPCS,Outpatient,,,1928.13,1156.88,,1749,110,,4.704,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.696,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,174.616,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.896,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.896,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.896,Fee Schedule,360% of BCBS Traditional Rate,916,100,,6.616,Case Rate,Pays based on per visit rate,106.88,100,,6.584,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,6.776,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.1,75,,1354.264,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,46.8,Case Rate,Pays Based on per visit rate,1334,100,,183.776,Case Rate,Pays based on per visit rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,183.776,Case Rate,Pays based on per visit rate,1334,100,,275.912,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28,Case Rate,Pays based on per visit rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.584,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1928.13,100,,1805.688,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1928.13,
CT HEAD BRAIN WO CM,50504497,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,TC   ,1749,110,,7.984,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,95.072,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,174.616,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,122.24,Fee Schedule,360% of BCBS POS Rate,403.49,360,,122.24,Fee schedule,360% of BCBS PPO Rate,403.49,360,,122.24,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.08,Case Rate,Pays based on per visit rate,106.88,100,,5.344,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.504,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,1354.264,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,84.264,Case Rate,Pays Based on per visit rate,1334,100,,1221.608,Case Rate,Pays based on per visit rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1221.608,Case Rate,Pays based on per visit rate,1334,100,,1523.6,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28,Case Rate,Pays based on per visit rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.344,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,1805.688,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT HEAD BRAIN WO CM,50504497,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,TC   ,1749,110,,10.176,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.904,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,174.648,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,7.592,Fee Schedule,360% of BCBS POS Rate,403.49,360,,7.592,Fee schedule,360% of BCBS PPO Rate,403.49,360,,7.592,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.096,Case Rate,Pays based on per visit rate,106.88,100,,4.296,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,4.424,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,1567.072,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,183.776,Case Rate,Pays Based on per visit rate,1334,100,,3778.16,Case Rate,Pays based on per visit rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,3778.16,Case Rate,Pays based on per visit rate,1334,100,,292.384,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28,Case Rate,Pays based on per visit rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.296,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,2089.424,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT HEAD BRAIN WO CM,50504497,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,TC   ,1749,110,,228.872,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,13.864,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,174.648,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,17.824,Fee Schedule,360% of BCBS POS Rate,403.49,360,,17.824,Fee schedule,360% of BCBS PPO Rate,403.49,360,,17.824,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.088,Case Rate,Pays based on per visit rate,106.88,100,,2.216,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.288,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,1567.072,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1221.608,Case Rate,Pays Based on per visit rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,1334,100,,368.4,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,28,Case Rate,Pays based on per visit rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,2089.424,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT CATH NEPHRO PLACEMENT BI,50504514,CDM,361,RC,50432,HCPCS,Outpatient,,,7125,4275.00,,4162,100,,6072,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,1,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,996.18,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,1.288,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,1.288,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,1.288,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,1.872,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1027.43,14.42,,5.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,5343.75,75,,1432.4,Percent of Total Billed Charges,75% of Total Billed Charges,3562.5,50,,3778.16,Percent of Total Billed Charges,50% of Total Billed Charges,3562.5,50,,72.912,Percent of Total Billed Charges,50% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3562.5,50,,72.912,Percent of Total Billed Charges,50% of Total Billed Charges,3562.5,50,,250.152,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,28,Fee Schedule,100% of ASC Tier Groupings fee schedule,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,997.5,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7125,100,,1909.864,Percent of Total Billed Charges,100% of Total Billed Charges,996.18,7125,
CT CATH NEPHRO PLACEMENT RT,50504515,CDM,361,RC,50432,HCPCS,Outpatient,,,4750,2850.00,,4162,100,,11.52,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,336,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,998.4,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,432,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,432,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,11.616,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,684.95,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3562.5,75,,1432.4,Percent of Total Billed Charges,75% of Total Billed Charges,2375,50,,1295.68,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,618.224,Percent of Total Billed Charges,50% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2375,50,,618.224,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,621.976,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,28,Fee Schedule,100% of ASC Tier Groupings fee schedule,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4750,100,,1909.864,Percent of Total Billed Charges,100% of Total Billed Charges,665,5704.39,
CT CATH NEPHRO PLACEMENT LT,50504516,CDM,361,RC,50432,HCPCS,Outpatient,,,4750,2850.00,,4162,100,,29.584,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,998.4,32,,174.704,Percent of Total Billed Charges,32% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,576,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,576,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,33.392,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,684.95,14.42,,51.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3562.5,75,,2250,Percent of Total Billed Charges,75% of Total Billed Charges,2375,50,,72.912,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2375,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,2375,50,,1189.864,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,11.424,Fee Schedule,100% of ASC Tier Groupings fee schedule,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,665,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4750,100,,3000,Percent of Total Billed Charges,100% of Total Billed Charges,665,5704.39,
CT CATH NEPHROURET PLACE BI,50504517,CDM,361,RC,50433,HCPCS,Outpatient,,,6821.1,4092.66,,4162,100,,20.832,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,0.728,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,998.4,32,,175.056,Percent of Total Billed Charges,32% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,0.936,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,0.936,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,0.936,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,31.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,983.6,14.42,,6.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,5115.83,75,,2250,Percent of Total Billed Charges,75% of Total Billed Charges,3410.55,50,,618.224,Percent of Total Billed Charges,50% of Total Billed Charges,3410.55,50,,71.4,Percent of Total Billed Charges,50% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3410.55,50,,71.4,Percent of Total Billed Charges,50% of Total Billed Charges,3410.55,50,,157.16,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,11.792,Fee Schedule,100% of ASC Tier Groupings fee schedule,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,954.95,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6821.1,100,,3000,Percent of Total Billed Charges,100% of Total Billed Charges,954.95,9719.7,
CT CATH NEPHROURET PLACE RT,50504518,CDM,361,RC,50433,HCPCS,Outpatient,,,4547.4,2728.44,,4162,100,,45.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,999.11,32,,175.312,Percent of Total Billed Charges,32% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,2.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,2.272,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,2.272,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,28.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,655.74,14.42,,57.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3410.55,75,,1779.976,Percent of Total Billed Charges,75% of Total Billed Charges,2273.7,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2273.7,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,273.528,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,17.536,Fee Schedule,100% of ASC Tier Groupings fee schedule,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4547.4,100,,2373.304,Percent of Total Billed Charges,100% of Total Billed Charges,636.64,9719.7,
CT CATH NEPHROURET PLACE LT,50504519,CDM,361,RC,50433,HCPCS,Outpatient,,,4547.4,2728.44,,4162,100,,214.888,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,0.816,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1002.85,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,1.056,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,1.056,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,1.056,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5150,103,,22.888,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,655.74,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3410.55,75,,1779.976,Percent of Total Billed Charges,75% of Total Billed Charges,2273.7,50,,71.4,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2273.7,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,2273.7,50,,272.712,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,28,Fee Schedule,100% of ASC Tier Groupings fee schedule,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,636.64,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4547.4,100,,2373.304,Percent of Total Billed Charges,100% of Total Billed Charges,636.64,9719.7,
CT CATH CNVERT TO NEPHOURET BI,50504520,CDM,361,RC,50434,HCPCS,Outpatient,,,5019.85,3011.91,,2601,100,,24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,0.08,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1004.19,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,0.104,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,0.104,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,0.104,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,18.4,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,723.86,14.42,,0.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,3764.89,75,,1366.328,Percent of Total Billed Charges,75% of Total Billed Charges,2509.93,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,2509.93,50,,98.424,Percent of Total Billed Charges,50% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2509.93,50,,98.424,Percent of Total Billed Charges,50% of Total Billed Charges,2509.93,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,43.96,Fee Schedule,100% of ASC Tier Groupings fee schedule,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,702.78,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5019.85,100,,1821.768,Percent of Total Billed Charges,100% of Total Billed Charges,702.78,5704.39,
CT CATH CNVERT TO NEPHOURET RT,50504521,CDM,361,RC,50434,HCPCS,Outpatient,,,3346.57,2007.94,,2601,100,,24.208,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,4.952,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1004.64,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,6.368,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,6.368,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,6.368,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,9.504,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,482.58,14.42,,9.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2509.93,75,,1366.328,Percent of Total Billed Charges,75% of Total Billed Charges,1673.29,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.29,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,308,Fee Schedule,100% of ASC Tier Groupings fee schedule,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3346.57,100,,1821.768,Percent of Total Billed Charges,100% of Total Billed Charges,468.52,5704.39,
CT CATH CNVERT TO NEPHOURET LT,50504522,CDM,361,RC,50434,HCPCS,Outpatient,,,3346.57,2007.94,,2601,100,,154.08,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2803.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4127.71,233,,0.88,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1004.64,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,5704.39,322,,1.128,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5704.39,322,,1.128,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5704.39,322,,1.128,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,23.04,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.82,90,,,Fee Schedule,90% of CMS OPPS Rate,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.3,130,,,Fee Schedule,130% of CMS OPPS Rate,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,482.58,14.42,,0.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,1924.75,103,,,Fee Schedule,103% of CMS OPPS Rate,2509.93,75,,1496.248,Percent of Total Billed Charges,75% of Total Billed Charges,1673.29,50,,98.424,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,170.56,Percent of Total Billed Charges,50% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.29,50,,170.56,Percent of Total Billed Charges,50% of Total Billed Charges,1673.29,50,,84.264,Percent of Total Billed Charges,50% of Total Billed Charges,2803.05,150,,,Fee Schedule,150% of CMS OPPS Rate,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,55.32,Fee Schedule,100% of ASC Tier Groupings fee schedule,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,468.52,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,1868.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3346.57,100,,1995,Percent of Total Billed Charges,100% of Total Billed Charges,468.52,5704.39,
CT URETRL STENT PLCMT BI,50504523,CDM,361,RC,50693,HCPCS,Outpatient,,,8007.07,4804.24,,4682,100,,2.032,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,132.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1011.24,32,,176.096,Percent of Total Billed Charges,32% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,170.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,170.272,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,170.272,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.784,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1154.62,14.42,,22.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6005.3,75,,1496.248,Percent of Total Billed Charges,75% of Total Billed Charges,4003.54,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,217,Percent of Total Billed Charges,50% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4003.54,50,,217,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,183.776,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,97.112,Fee Schedule,100% of ASC Tier Groupings fee schedule,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.07,100,,1995,Percent of Total Billed Charges,100% of Total Billed Charges,1011.24,9719.7,
CT URETRL STENT PLCMT LT,50504524,CDM,361,RC,50693,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,15.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,58.856,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1011.73,32,,176.128,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,75.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,75.672,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,75.672,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,213.072,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,2049.496,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,170.56,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,127,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,127,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,1221.608,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,61.008,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,2732.656,Percent of Total Billed Charges,100% of Total Billed Charges,747.33,9719.7,
CT URETRL STENT PLCMT RT,50504525,CDM,361,RC,50693,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,124.28,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,43.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1016.4,32,,176.128,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,55.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,55.344,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,55.344,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,27.832,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,2049.496,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,217,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,250,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,250,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,3778.16,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,6.792,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,2732.656,Percent of Total Billed Charges,100% of Total Billed Charges,747.33,9719.7,
CT URETRL STENT NEW ACCESS BI,50504526,CDM,361,RC,50694,HCPCS,Outpatient,,,8007.07,4804.24,,4682,100,,5.976,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,21.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1026.57,32,,176.2,Percent of Total Billed Charges,32% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,27.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,27.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,27.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,237.544,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1154.62,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6005.3,75,,2244.376,Percent of Total Billed Charges,75% of Total Billed Charges,4003.54,50,,127,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,55.32,Percent of Total Billed Charges,50% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4003.54,50,,55.32,Percent of Total Billed Charges,50% of Total Billed Charges,4003.54,50,,1295.68,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,34.984,Fee Schedule,100% of ASC Tier Groupings fee schedule,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1120.99,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.07,100,,2992.504,Percent of Total Billed Charges,100% of Total Billed Charges,1026.57,9719.7,
CT URETRL STENT NEW ACCESS LT,50504527,CDM,361,RC,50694,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,3.576,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1026.57,32,,176.336,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,4.6,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,4.6,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,4.6,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.064,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,2244.376,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,250,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,394,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,394,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,72.912,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,21.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,2992.504,Percent of Total Billed Charges,100% of Total Billed Charges,747.33,9719.7,
CT URETRL STENT NEW ACCESS RT,50504528,CDM,361,RC,50694,HCPCS,Outpatient,,,5338.05,3202.83,,4682,100,,24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,6.584,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1026.57,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,8.464,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,8.464,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,8.464,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,2.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,769.75,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4003.54,75,,1296.688,Percent of Total Billed Charges,75% of Total Billed Charges,2669.03,50,,55.32,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,5110,Percent of Total Billed Charges,50% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2669.03,50,,5110,Percent of Total Billed Charges,50% of Total Billed Charges,2669.03,50,,618.224,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,34.336,Fee Schedule,100% of ASC Tier Groupings fee schedule,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,747.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5338.05,100,,1728.912,Percent of Total Billed Charges,100% of Total Billed Charges,747.33,9719.7,
CT URETRL STENT W SEP CATH BI,50504529,CDM,361,RC,50695,HCPCS,Outpatient,,,7972.42,4783.45,,4682,100,,73.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,251.968,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1026.57,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,323.96,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,323.96,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,323.96,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,40.752,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1149.62,14.42,,1.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,5979.32,75,,1296.688,Percent of Total Billed Charges,75% of Total Billed Charges,3986.21,50,,394,Percent of Total Billed Charges,50% of Total Billed Charges,3986.21,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3986.21,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,3986.21,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,21.504,Fee Schedule,100% of ASC Tier Groupings fee schedule,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1116.14,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7972.42,100,,1728.912,Percent of Total Billed Charges,100% of Total Billed Charges,1026.57,9719.7,
CT URETRL STENT W SEP CATH LT,50504530,CDM,361,RC,50695,HCPCS,Outpatient,,,5314.94,3188.96,,4682,100,,70.368,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,1.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1034.87,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,1.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,1.4,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,1.4,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,0.832,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,766.41,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3986.21,75,,1567.232,Percent of Total Billed Charges,75% of Total Billed Charges,2657.47,50,,5110,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2657.47,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,71.4,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,43.896,Fee Schedule,100% of ASC Tier Groupings fee schedule,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5314.94,100,,2089.64,Percent of Total Billed Charges,100% of Total Billed Charges,744.09,9719.7,
CT URETRL STENT W SEP CATH RT,50504531,CDM,361,RC,50695,HCPCS,Outpatient,,,5314.94,3188.96,,4682,100,,411.168,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4797.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7033.2,233,,0.136,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1036.8,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,9719.7,322,,0.176,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9719.7,322,,0.176,Fee schedule,Pays based on ASC Tier Groupings fee schedule,9719.7,322,,0.176,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,93.832,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2878.57,90,,,Fee Schedule,90% of CMS OPPS Rate,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4157.93,130,,,Fee Schedule,130% of CMS OPPS Rate,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,766.41,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3294.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3986.21,75,,1567.232,Percent of Total Billed Charges,75% of Total Billed Charges,2657.47,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2657.47,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,2657.47,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,4797.62,150,,,Fee Schedule,150% of CMS OPPS Rate,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4951,100,,0.288,Fee Schedule,100% of ASC Tier Groupings fee schedule,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,744.09,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,3198.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5314.94,100,,2089.64,Percent of Total Billed Charges,100% of Total Billed Charges,744.09,9719.7,
CT INJ NEPH WWO URETR NEW BI,50504532,CDM,361,RC,50430,HCPCS,Outpatient,,,2985.47,1791.28,,2601,100,,41.472,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,0.192,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1037.23,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,0.24,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,0.24,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,0.24,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,59.776,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,430.5,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.1,75,,1815.248,Percent of Total Billed Charges,75% of Total Billed Charges,1492.74,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,1295.68,Percent of Total Billed Charges,50% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1492.74,50,,1295.68,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,4.048,Fee Schedule,100% of ASC Tier Groupings fee schedule,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.47,100,,2420.328,Percent of Total Billed Charges,100% of Total Billed Charges,417.97,3347.5,
CT INJ NEPH WWO URETR NEW LT,50504533,CDM,361,RC,50430,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,38.768,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,8.872,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1040,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,11.408,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,11.408,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,11.408,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,2.032,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,4.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,1815.248,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,98.424,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1.784,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,2420.328,Percent of Total Billed Charges,100% of Total Billed Charges,278.64,3347.5,
CT INJ NEPH WWO URETR NEW RT,50504534,CDM,361,RC,50430,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,0.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,10.448,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1040,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,13.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,13.432,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,13.432,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.008,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,2715.352,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,1295.68,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,3.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,3620.472,Percent of Total Billed Charges,100% of Total Billed Charges,278.64,3347.5,
CT INJ NEPH WWO URETR EXIST BI,50504535,CDM,361,RC,50431,HCPCS,Outpatient,,,2985.47,1791.28,,2601,100,,66.008,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,1.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1042.88,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,1.84,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,1.84,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,1.84,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,4.112,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,430.5,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.1,75,,2715.352,Percent of Total Billed Charges,75% of Total Billed Charges,1492.74,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1492.74,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,1492.74,50,,170.56,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1.68,Fee Schedule,100% of ASC Tier Groupings fee schedule,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,417.97,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.47,100,,3620.472,Percent of Total Billed Charges,100% of Total Billed Charges,417.97,3347.5,
CT INJ NEPH WWO URETR EXIST LT,50504536,CDM,361,RC,50431,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,344.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,35.672,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1045.55,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,45.864,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,45.864,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,45.864,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,4.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,2715.352,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,3546.584,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,3546.584,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,217,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,2.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,3620.472,Percent of Total Billed Charges,100% of Total Billed Charges,278.64,3347.5,
CT INJ NEPH WWO URETR EXIST RT,50504537,CDM,361,RC,50431,HCPCS,Outpatient,,,1990.31,1194.19,,2601,100,,1324.8,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,940.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.71,233,,51.024,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1047.49,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,1792.03,322,,65.6,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1792.03,322,,65.6,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1792.03,322,,65.6,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,0.608,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,564.05,90,,,Fee Schedule,90% of CMS OPPS Rate,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,130,,,Fee Schedule,130% of CMS OPPS Rate,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,287,14.42,,16.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,645.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1492.73,75,,3127.896,Percent of Total Billed Charges,75% of Total Billed Charges,995.16,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,995.16,50,,37.08,Percent of Total Billed Charges,50% of Total Billed Charges,995.16,50,,127,Percent of Total Billed Charges,50% of Total Billed Charges,940.08,150,,,Fee Schedule,150% of CMS OPPS Rate,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,459.144,Fee Schedule,100% of ASC Tier Groupings fee schedule,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,278.64,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,626.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.31,100,,4170.528,Percent of Total Billed Charges,100% of Total Billed Charges,278.64,3347.5,
CT HEAD BRAIN W CM,50504604,CDM,351,RC,70460,HCPCS,Outpatient,,,2297.61,1378.57,,1749,110,,9402.144,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,78.136,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,100.464,Fee Schedule,360% of BCBS POS Rate,655.99,360,,100.464,Fee schedule,360% of BCBS PPO Rate,655.99,360,,100.464,Fee Schedule,360% of BCBS Traditional Rate,916,100,,5.6,Case Rate,Pays based on per visit rate,153.36,100,,0.552,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,157.96,103,,0.568,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.21,75,,3127.896,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,3546.584,Case Rate,Pays Based on per visit rate,1334,100,,256.36,Case Rate,Pays based on per visit rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,256.36,Case Rate,Pays based on per visit rate,1334,100,,250,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.736,Case Rate,Pays based on per visit rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2297.61,100,,4170.528,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2297.61,
CT HEAD BRAIN W CM,50504604,CDM,351,RC,70460,HCPCS,Outpatient,,,2297.61,1378.57,,1749,110,,44.672,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,39.472,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,50.752,Fee Schedule,360% of BCBS POS Rate,655.99,360,,50.752,Fee schedule,360% of BCBS PPO Rate,655.99,360,,50.752,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.504,Case Rate,Pays based on per visit rate,153.36,100,,0.136,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,157.96,103,,0.136,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.21,75,,2106.048,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,37.08,Case Rate,Pays Based on per visit rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,1334,100,,55.32,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,5.944,Case Rate,Pays based on per visit rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,153.36,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2297.61,100,,2808.064,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2297.61,
CT ANGIO CHEST WWO CM,50504612,CDM,352,RC,71275,HCPCS,Outpatient,,,2899.14,1739.48,TC   ,1749,110,,1.12,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.808,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.608,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.608,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.608,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.008,Case Rate,Pays based on per visit rate,180.34,100,,0.768,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.784,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2174.36,75,,2106.048,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,256.36,Case Rate,Pays Based on per visit rate,1334,100,,584.304,Case Rate,Pays based on per visit rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,584.304,Case Rate,Pays based on per visit rate,1334,100,,394,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,8.52,Case Rate,Pays based on per visit rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2899.14,100,,2808.064,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2899.14,
CT ANGIO CHEST WWO CM,50504612,CDM,352,RC,71275,HCPCS,Outpatient,,,2899.14,1739.48,TC   ,1749,110,,330.624,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,9.36,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,12.032,Fee Schedule,360% of BCBS POS Rate,655.99,360,,12.032,Fee schedule,360% of BCBS PPO Rate,655.99,360,,12.032,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.512,Case Rate,Pays based on per visit rate,180.34,100,,0.024,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2174.36,75,,916.8,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,820.616,Case Rate,Pays Based on per visit rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,1334,100,,5110,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,24.416,Case Rate,Pays based on per visit rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2899.14,100,,1222.4,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2899.14,
CT HEAD BRAIN WWO CM,50504745,CDM,351,RC,70470,HCPCS,Outpatient,,,2722,1633.20,,1749,110,,4.8,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,398.832,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,512.784,Fee Schedule,360% of BCBS POS Rate,655.99,360,,512.784,Fee schedule,360% of BCBS PPO Rate,655.99,360,,512.784,Fee Schedule,360% of BCBS Traditional Rate,916,100,,14.704,Case Rate,Pays based on per visit rate,180.34,100,,0.184,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.184,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2041.5,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,584.304,Case Rate,Pays Based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,1334,100,,33.6,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.128,Case Rate,Pays based on per visit rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2722,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2722,
CT HEAD BRAIN WWO CM,50504745,CDM,351,RC,70470,HCPCS,Outpatient,,,2722,1633.20,,1749,110,,54.424,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,67.504,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,86.792,Fee Schedule,360% of BCBS POS Rate,655.99,360,,86.792,Fee schedule,360% of BCBS PPO Rate,655.99,360,,86.792,Fee Schedule,360% of BCBS Traditional Rate,916,100,,18.296,Case Rate,Pays based on per visit rate,180.34,100,,1.256,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.296,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2041.5,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,244.712,Case Rate,Pays Based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1140,Case Rate,Pays based on per visit rate,1334,100,,28.8,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,68.88,Case Rate,Pays based on per visit rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2722,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2722,
CT ORBITS OR IAC WO CM,50504802,CDM,351,RC,70480,HCPCS,Outpatient,,,2033.29,1219.97,,1749,110,,84.848,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,13.832,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,17.784,Fee Schedule,360% of BCBS POS Rate,403.49,360,,17.784,Fee schedule,360% of BCBS PPO Rate,403.49,360,,17.784,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.04,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,7.848,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1524.97,75,,808.152,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,836.768,Case Rate,Pays Based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,732,Case Rate,Pays based on per visit rate,1334,100,,28.8,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,76.368,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2033.29,100,,1077.536,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2033.29,
CT ORBITS OR IAC WO CM,50504802,CDM,351,RC,70480,HCPCS,Outpatient,,,2033.29,1219.97,,1749,110,,2130.712,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,176.584,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,14.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.152,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,7.848,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1524.97,75,,808.152,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1140,Case Rate,Pays Based on per visit rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,25.64,Case Rate,Pays based on per visit rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.624,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2033.29,100,,1077.536,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2033.29,
CT ORBITS OR IAC W CM,50504810,CDM,351,RC,70481,HCPCS,Outpatient,,,2425.43,1455.26,TC   ,1749,110,,0.08,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.632,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,14.4,Fee Schedule,360% of BCBS POS Rate,655.99,360,,14.4,Fee schedule,360% of BCBS PPO Rate,655.99,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,20.68,Case Rate,Pays based on per visit rate,180.34,100,,9.464,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,9.744,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1819.07,75,,2745.616,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,732,Case Rate,Pays Based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,1334,100,,1340.016,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,45.8,Case Rate,Pays based on per visit rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,9.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2425.43,100,,3660.816,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2425.43,
CT ORBITS OR IAC W CM,50504810,CDM,351,RC,70481,HCPCS,Outpatient,,,2425.43,1455.26,TC   ,1749,110,,4.648,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,18.792,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.72,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,24.16,Fee Schedule,360% of BCBS POS Rate,655.99,360,,24.16,Fee schedule,360% of BCBS PPO Rate,655.99,360,,24.16,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.008,Case Rate,Pays based on per visit rate,180.34,100,,162.352,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,167.224,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1819.07,75,,2745.616,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1295.68,Case Rate,Pays Based on per visit rate,1334,100,,799.104,Case Rate,Pays based on per visit rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,799.104,Case Rate,Pays based on per visit rate,1334,100,,1340.016,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,101.032,Case Rate,Pays based on per visit rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,162.352,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2425.43,100,,3660.816,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2425.43,
CT ORBITS OR IAC WWO CM,50504828,CDM,351,RC,70482,HCPCS,Outpatient,,,2829,1697.40,,1749,110,,112.456,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.168,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.72,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.504,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.504,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.504,Fee Schedule,360% of BCBS Traditional Rate,916,100,,68.048,Case Rate,Pays based on per visit rate,180.34,100,,0.44,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.456,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2121.75,75,,601.304,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,836.768,Case Rate,Pays Based on per visit rate,1334,100,,636.6,Case Rate,Pays based on per visit rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,636.6,Case Rate,Pays based on per visit rate,1334,100,,2010.016,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,137.808,Case Rate,Pays based on per visit rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2829,100,,801.736,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2829,
CT ORBITS OR IAC WWO CM,50504828,CDM,351,RC,70482,HCPCS,Outpatient,,,2829,1697.40,,1749,110,,1331.2,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.504,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.72,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.216,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.216,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.216,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.36,Case Rate,Pays based on per visit rate,180.34,100,,0.008,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.008,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2121.75,75,,601.304,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,799.104,Case Rate,Pays Based on per visit rate,1334,100,,779.688,Case Rate,Pays based on per visit rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,779.688,Case Rate,Pays based on per visit rate,1334,100,,3546.584,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,3.464,Case Rate,Pays based on per visit rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.008,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2829,100,,801.736,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2829,
CT MAXILLOFACIAL WO CM,50504869,CDM,351,RC,70486,HCPCS,Outpatient,,,1928.13,1156.88,,1749,110,,3062.12,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,10.04,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,17.72,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,12.912,Fee Schedule,360% of BCBS POS Rate,403.49,360,,12.912,Fee schedule,360% of BCBS PPO Rate,403.49,360,,12.912,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.008,Case Rate,Pays based on per visit rate,106.88,100,,3.304,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.4,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.1,75,,1267.888,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,636.6,Case Rate,Pays Based on per visit rate,1334,100,,702.608,Case Rate,Pays based on per visit rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,702.608,Case Rate,Pays based on per visit rate,1334,100,,37.08,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.68,Case Rate,Pays based on per visit rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1928.13,100,,1690.512,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1928.13,
CT MAXILLOFACIAL WO CM,50504869,CDM,351,RC,70486,HCPCS,Outpatient,,,1928.13,1156.88,,1749,110,,1533.56,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,186.008,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,17.76,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,239.16,Fee Schedule,360% of BCBS POS Rate,403.49,360,,239.16,Fee schedule,360% of BCBS PPO Rate,403.49,360,,239.16,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.008,Case Rate,Pays based on per visit rate,106.88,100,,3.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.2,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.1,75,,1507.936,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,779.688,Case Rate,Pays Based on per visit rate,1334,100,,715.872,Case Rate,Pays based on per visit rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,715.872,Case Rate,Pays based on per visit rate,1334,100,,256.36,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.752,Case Rate,Pays based on per visit rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1928.13,100,,2010.576,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1928.13,
CT MAXILLOFACIAL W CM,50504877,CDM,351,RC,70487,HCPCS,Outpatient,,,2341.14,1404.68,TC   ,1749,110,,15.784,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,6.416,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.768,Fee Schedule,320% of BCBS Blue Essentials Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,8.248,Fee Schedule,360% of BCBS POS Rate,655.99,360,,8.248,Fee schedule,360% of BCBS PPO Rate,655.99,360,,8.248,Fee Schedule,360% of BCBS Traditional Rate,916,100,,9.032,Case Rate,Pays based on per visit rate,157.71,100,,0.296,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,162.44,103,,0.304,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1755.86,75,,1723.696,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,702.608,Case Rate,Pays Based on per visit rate,1334,100,,603.376,Case Rate,Pays based on per visit rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,603.376,Case Rate,Pays based on per visit rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.584,Case Rate,Pays based on per visit rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.296,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2341.14,100,,2298.264,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2341.14,
CT MAXILLOFACIAL W CM,50504877,CDM,351,RC,70487,HCPCS,Outpatient,,,2341.14,1404.68,TC   ,1749,110,,15.784,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.736,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.808,Fee Schedule,320% of BCBS Blue Essentials Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.512,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.512,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.512,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.576,Case Rate,Pays based on per visit rate,157.71,100,,0.44,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,162.44,103,,0.456,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1755.86,75,,1723.696,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,715.872,Case Rate,Pays Based on per visit rate,1334,100,,563.928,Case Rate,Pays based on per visit rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,563.928,Case Rate,Pays based on per visit rate,1334,100,,584.304,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.216,Case Rate,Pays based on per visit rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,157.71,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2341.14,100,,2298.264,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2341.14,
CT MAXILLOFACIAL WWO CM,50504885,CDM,351,RC,70488,HCPCS,Outpatient,,,2771.09,1662.65,,1749,110,,15.88,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,30.16,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.888,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,38.776,Fee Schedule,360% of BCBS POS Rate,655.99,360,,38.776,Fee schedule,360% of BCBS PPO Rate,655.99,360,,38.776,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.28,Case Rate,Pays based on per visit rate,180.34,100,,2.952,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.04,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2078.32,75,,1149.136,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,603.376,Case Rate,Pays Based on per visit rate,1334,100,,525.448,Case Rate,Pays based on per visit rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,525.448,Case Rate,Pays based on per visit rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,5.184,Case Rate,Pays based on per visit rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2771.09,100,,1532.176,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2771.09,
CT MAXILLOFACIAL WWO CM,50504885,CDM,351,RC,70488,HCPCS,Outpatient,,,2771.09,1662.65,,1749,110,,338.288,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,6.4,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,176.64,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,8.224,Fee Schedule,360% of BCBS POS Rate,655.99,360,,8.224,Fee schedule,360% of BCBS PPO Rate,655.99,360,,8.224,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.112,Case Rate,Pays based on per visit rate,180.34,100,,0.336,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.344,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2078.32,75,,1149.136,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,563.928,Case Rate,Pays Based on per visit rate,1334,100,,771.352,Case Rate,Pays based on per visit rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,771.352,Case Rate,Pays based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,7.832,Case Rate,Pays based on per visit rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2771.09,100,,1532.176,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2771.09,
CT NECK SOFT TISSUE WO CM,50504901,CDM,350,RC,70490,HCPCS,Outpatient,,,1897.75,1138.65,TC   ,1749,110,,43.2,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,48.912,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,177.208,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,62.88,Fee Schedule,360% of BCBS POS Rate,403.49,360,,62.88,Fee schedule,360% of BCBS PPO Rate,403.49,360,,62.88,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.776,Case Rate,Pays based on per visit rate,106.88,100,,1.352,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,1.392,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1423.31,75,,1149.136,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,525.448,Case Rate,Pays Based on per visit rate,1334,100,,807.792,Case Rate,Pays based on per visit rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,807.792,Case Rate,Pays based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,26.992,Case Rate,Pays based on per visit rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.352,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1897.75,100,,1532.176,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1897.75,
CT NECK SOFT TISSUE WO CM,50504901,CDM,350,RC,70490,HCPCS,Outpatient,,,1897.75,1138.65,TC   ,1749,110,,43.2,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.512,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,177.208,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.656,Fee Schedule,360% of BCBS Traditional Rate,916,100,,5.384,Case Rate,Pays based on per visit rate,106.88,100,,0.144,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.152,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1423.31,75,,1149.136,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,771.352,Case Rate,Pays Based on per visit rate,1334,100,,840.672,Case Rate,Pays based on per visit rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,840.672,Case Rate,Pays based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,12.648,Case Rate,Pays based on per visit rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1897.75,100,,1532.176,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1897.75,
CT NECK SOFT TISSUE W CM,50504919,CDM,350,RC,70491,HCPCS,Outpatient,,,2370.9,1422.54,,1749,110,,144,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.112,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,177.208,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.144,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.144,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.144,Fee Schedule,360% of BCBS Traditional Rate,916,100,,32.656,Case Rate,Pays based on per visit rate,180.34,100,,3.12,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.208,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1778.18,75,,2340,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,807.792,Case Rate,Pays Based on per visit rate,1334,100,,821.8,Case Rate,Pays based on per visit rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,821.8,Case Rate,Pays based on per visit rate,1334,100,,1295.68,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,3.984,Case Rate,Pays based on per visit rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2370.9,100,,3120,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2370.9,
CT NECK SOFT TISSUE W CM,50504919,CDM,350,RC,70491,HCPCS,Outpatient,,,2370.9,1422.54,,1749,110,,352.712,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,39.232,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,177.72,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,50.44,Fee Schedule,360% of BCBS POS Rate,655.99,360,,50.44,Fee schedule,360% of BCBS PPO Rate,655.99,360,,50.44,Fee Schedule,360% of BCBS Traditional Rate,916,100,,32.656,Case Rate,Pays based on per visit rate,180.34,100,,0.624,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.64,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1778.18,75,,2340,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,840.672,Case Rate,Pays Based on per visit rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,11.88,Case Rate,Pays based on per visit rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.624,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2370.9,100,,3120,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2370.9,
CT NECK SOFT TISSUE WWO CM,50504927,CDM,350,RC,70492,HCPCS,Outpatient,,,2803,1681.80,TC   ,1749,110,,37.656,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,58.688,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,177.72,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,75.456,Fee Schedule,360% of BCBS POS Rate,655.99,360,,75.456,Fee schedule,360% of BCBS PPO Rate,655.99,360,,75.456,Fee Schedule,360% of BCBS Traditional Rate,916,100,,40.552,Case Rate,Pays based on per visit rate,180.34,100,,0.52,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.536,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2102.25,75,,1484.704,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,821.8,Case Rate,Pays Based on per visit rate,1334,100,,1200,Case Rate,Pays based on per visit rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1200,Case Rate,Pays based on per visit rate,1334,100,,799.104,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,71.2,Case Rate,Pays based on per visit rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2803,100,,1979.608,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2803,
CT NECK SOFT TISSUE WWO CM,50504927,CDM,350,RC,70492,HCPCS,Outpatient,,,2803,1681.80,TC   ,1749,110,,599.44,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,62.88,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,177.768,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,80.848,Fee Schedule,360% of BCBS POS Rate,655.99,360,,80.848,Fee schedule,360% of BCBS PPO Rate,655.99,360,,80.848,Fee Schedule,360% of BCBS Traditional Rate,916,100,,695.8,Case Rate,Pays based on per visit rate,180.34,100,,1.088,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.12,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2102.25,75,,1484.704,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1774.704,Case Rate,Pays Based on per visit rate,1334,100,,534.536,Case Rate,Pays based on per visit rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,534.536,Case Rate,Pays based on per visit rate,1334,100,,636.6,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,23.352,Case Rate,Pays based on per visit rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.088,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2803,100,,1979.608,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2803,
CT ANGIO ABD AORTA RUNOFF,50504968,CDM,350,RC,75635,HCPCS,Outpatient,,,3091,1854.60,,1749,110,,209.864,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.992,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,177.864,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,10.272,Fee Schedule,360% of BCBS POS Rate,655.99,360,,10.272,Fee schedule,360% of BCBS PPO Rate,655.99,360,,10.272,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.904,Case Rate,Pays based on per visit rate,180.34,100,,0.48,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.488,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2318.25,75,,1484.704,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1200,Case Rate,Pays Based on per visit rate,1334,100,,765.784,Case Rate,Pays based on per visit rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,765.784,Case Rate,Pays based on per visit rate,1334,100,,779.688,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,23.488,Case Rate,Pays based on per visit rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.48,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3091,100,,1979.608,Percent of Total Billed Charges,100% of Total Billed Charges,151.71,3091,
CT ANGIO ABD AORTA RUNOFF,50504968,CDM,350,RC,75635,HCPCS,Outpatient,,,3091,1854.60,,1749,110,,5.696,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,12.76,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,178.328,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,16.408,Fee Schedule,360% of BCBS POS Rate,655.99,360,,16.408,Fee schedule,360% of BCBS PPO Rate,655.99,360,,16.408,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.016,Case Rate,Pays based on per visit rate,180.34,100,,21.184,Fee Schedule,100% of TX Mediciad 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,151.71,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,21.824,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2318.25,75,,1484.704,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,534.536,Case Rate,Pays Based on per visit rate,1334,100,,487.2,Case Rate,Pays based on per visit rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,487.2,Case Rate,Pays based on per visit rate,1334,100,,702.608,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,6.584,Case Rate,Pays based on per visit rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,21.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3091,100,,1979.608,Percent of Total Billed Charges,100% of Total Billed Charges,151.71,3091,
CT ANGIO ABD WWO CM,50504984,CDM,352,RC,74175,HCPCS,Outpatient,,,2985.7,1791.42,TC   ,1749,110,,43.088,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,44.104,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,179.168,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,56.704,Fee Schedule,360% of BCBS POS Rate,655.99,360,,56.704,Fee schedule,360% of BCBS PPO Rate,655.99,360,,56.704,Fee Schedule,360% of BCBS Traditional Rate,916,100,,14.16,Case Rate,Pays based on per visit rate,180.34,100,,0.256,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.264,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.28,75,,368.632,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,765.784,Case Rate,Pays Based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,1334,100,,715.872,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.68,Case Rate,Pays based on per visit rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.7,100,,491.504,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2985.7,
CT ANGIO ABD WWO CM,50504984,CDM,352,RC,74175,HCPCS,Outpatient,,,2985.7,1791.42,TC   ,1749,110,,4.936,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.456,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1793.792,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.872,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.872,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.872,Fee Schedule,360% of BCBS Traditional Rate,916,100,,13.304,Case Rate,Pays based on per visit rate,180.34,100,,2.28,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,2.344,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2239.28,75,,785.944,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,487.2,Case Rate,Pays Based on per visit rate,1334,100,,1946.88,Case Rate,Pays based on per visit rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1946.88,Case Rate,Pays based on per visit rate,1334,100,,603.376,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,2.184,Case Rate,Pays based on per visit rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.7,100,,1047.92,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2985.7,
CT ANGIO HEAD STROKE WWO CM,50505007,CDM,351,RC,70496,HCPCS,Outpatient,,,2787.14,1672.28,,1749,110,,2.52,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,25.136,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1795,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,32.32,Fee Schedule,360% of BCBS POS Rate,655.99,360,,32.32,Fee schedule,360% of BCBS PPO Rate,655.99,360,,32.32,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.264,Case Rate,Pays based on per visit rate,180.34,100,,0.056,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2090.36,75,,1371.216,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,836.768,Case Rate,Pays Based on per visit rate,1334,100,,673.64,Case Rate,Pays based on per visit rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,673.64,Case Rate,Pays based on per visit rate,1334,100,,563.928,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.864,Case Rate,Pays based on per visit rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2787.14,100,,1828.288,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2787.14,
CT ANGIO HEAD STROKE WWO CM,50505007,CDM,351,RC,70496,HCPCS,Outpatient,,,2787.14,1672.28,,1749,110,,5.4,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.016,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1807.768,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.304,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.304,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.304,Fee Schedule,360% of BCBS Traditional Rate,916,100,,127.096,Case Rate,Pays based on per visit rate,180.34,100,,3.568,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.672,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2090.36,75,,756.496,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1946.88,Case Rate,Pays Based on per visit rate,1334,100,,252.416,Case Rate,Pays based on per visit rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,252.416,Case Rate,Pays based on per visit rate,1334,100,,525.448,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.68,Case Rate,Pays based on per visit rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.568,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2787.14,100,,1008.664,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2787.14,
CT ANGIO NECK STROKE WWO CM,50505023,CDM,351,RC,70498,HCPCS,Outpatient,,,2786.07,1671.64,TC   ,1749,110,,1.952,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.136,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1812.216,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.168,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.168,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.168,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.888,Case Rate,Pays based on per visit rate,180.34,100,,0.032,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2089.55,75,,1315.032,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,673.64,Case Rate,Pays Based on per visit rate,1334,100,,83.512,Case Rate,Pays based on per visit rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,83.512,Case Rate,Pays based on per visit rate,1334,100,,771.352,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.4,Case Rate,Pays based on per visit rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.07,100,,1753.376,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2786.07,
CT ANGIO NECK STROKE WWO CM,50505023,CDM,351,RC,70498,HCPCS,Outpatient,,,2786.07,1671.64,TC   ,1749,110,,237.24,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.272,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1815.088,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.344,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.344,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.344,Fee Schedule,360% of BCBS Traditional Rate,916,100,,12.664,Case Rate,Pays based on per visit rate,180.34,100,,1.52,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.568,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2089.55,75,,1467.8,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,252.416,Case Rate,Pays Based on per visit rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,1334,100,,807.792,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.656,Case Rate,Pays based on per visit rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.52,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.07,100,,1957.064,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2786.07,
CT ANGIO PEL WWO CM,50505049,CDM,352,RC,72191,HCPCS,Outpatient,,,2780.31,1668.19,,1749,110,,26.696,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,24.92,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1837.056,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,32.04,Fee Schedule,360% of BCBS POS Rate,655.99,360,,32.04,Fee schedule,360% of BCBS PPO Rate,655.99,360,,32.04,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.44,Case Rate,Pays based on per visit rate,180.34,100,,0.424,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.432,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2085.23,75,,1362.232,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,83.512,Case Rate,Pays Based on per visit rate,1334,100,,735.624,Case Rate,Pays based on per visit rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,735.624,Case Rate,Pays based on per visit rate,1334,100,,840.672,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.568,Case Rate,Pays based on per visit rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2780.31,100,,1816.304,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2780.31,
CT ANGIO PEL WWO CM,50505049,CDM,352,RC,72191,HCPCS,Outpatient,,,2780.31,1668.19,,1749,110,,2.752,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,5.616,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1849.056,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,7.224,Fee Schedule,360% of BCBS POS Rate,655.99,360,,7.224,Fee schedule,360% of BCBS PPO Rate,655.99,360,,7.224,Fee Schedule,360% of BCBS Traditional Rate,916,100,,5.776,Case Rate,Pays based on per visit rate,180.34,100,,7.392,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,7.616,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2085.23,75,,1362.232,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,244.712,Case Rate,Pays Based on per visit rate,1334,100,,937.768,Case Rate,Pays based on per visit rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,937.768,Case Rate,Pays based on per visit rate,1334,100,,821.8,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,32.568,Case Rate,Pays based on per visit rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.392,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2780.31,100,,1816.304,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2780.31,
CT CHEST THORAX WO CM,50512508,CDM,352,RC,71250,HCPCS,Outpatient,,,2042.52,1225.51,TC   ,1749,110,,15.832,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3.48,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1863.68,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,4.472,Fee Schedule,360% of BCBS POS Rate,403.49,360,,4.472,Fee schedule,360% of BCBS PPO Rate,403.49,360,,4.472,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.344,Case Rate,Pays based on per visit rate,106.88,100,,2.408,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.48,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1531.89,75,,1724.392,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,735.624,Case Rate,Pays Based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1140,Case Rate,Pays based on per visit rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,80.16,Case Rate,Pays based on per visit rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.408,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.52,100,,2299.192,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2042.52,
CT CHEST THORAX WO CM,50512508,CDM,352,RC,71250,HCPCS,Outpatient,,,2042.52,1225.51,TC   ,1749,110,,13.744,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.24,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1863.808,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.88,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.88,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.88,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.616,Case Rate,Pays based on per visit rate,106.88,100,,1.208,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,1.24,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1531.89,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,937.768,Case Rate,Pays Based on per visit rate,1334,100,,112.104,Case Rate,Pays based on per visit rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,112.104,Case Rate,Pays based on per visit rate,1334,100,,1200,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.128,Case Rate,Pays based on per visit rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.208,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.52,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2042.52,
CT CHEST THORAX W CM,50512607,CDM,352,RC,71260,HCPCS,Outpatient,,,2580.23,1548.14,,1749,110,,66.04,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,156.768,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1865.28,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,201.56,Fee Schedule,360% of BCBS POS Rate,655.99,360,,201.56,Fee schedule,360% of BCBS PPO Rate,655.99,360,,201.56,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.872,Case Rate,Pays based on per visit rate,173.08,100,,0.056,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1935.17,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1140,Case Rate,Pays Based on per visit rate,1334,100,,601.44,Case Rate,Pays based on per visit rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,601.44,Case Rate,Pays based on per visit rate,1334,100,,534.536,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.68,Case Rate,Pays based on per visit rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2580.23,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2580.23,
CT CHEST THORAX W CM,50512607,CDM,352,RC,71260,HCPCS,Outpatient,,,2580.23,1548.14,,1749,110,,4.896,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,10.448,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1865.432,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,13.432,Fee Schedule,360% of BCBS POS Rate,655.99,360,,13.432,Fee schedule,360% of BCBS PPO Rate,655.99,360,,13.432,Fee Schedule,360% of BCBS Traditional Rate,916,100,,13.36,Case Rate,Pays based on per visit rate,173.08,100,,0.016,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1935.17,75,,1362.232,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,112.104,Case Rate,Pays Based on per visit rate,1334,100,,621.064,Case Rate,Pays based on per visit rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,621.064,Case Rate,Pays based on per visit rate,1334,100,,765.784,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,12.272,Case Rate,Pays based on per visit rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2580.23,100,,1816.304,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2580.23,
CT CHEST THORAX WWO CM,50512706,CDM,352,RC,71270,HCPCS,Outpatient,,,2988,1792.80,TC   ,1749,110,,21.84,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.64,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1867.672,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.816,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.816,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.816,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.656,Case Rate,Pays based on per visit rate,180.34,100,,0.136,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.136,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2241,75,,1054.216,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,601.44,Case Rate,Pays Based on per visit rate,1334,100,,291.32,Case Rate,Pays based on per visit rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,291.32,Case Rate,Pays based on per visit rate,1334,100,,487.2,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.736,Case Rate,Pays based on per visit rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2988,100,,1405.616,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2988,
CT CHEST THORAX WWO CM,50512706,CDM,352,RC,71270,HCPCS,Outpatient,,,2988,1792.80,TC   ,1749,110,,1.8,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.712,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1875.664,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.488,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.488,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.488,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.216,Case Rate,Pays based on per visit rate,180.34,100,,0.016,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2241,75,,1550.24,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,621.064,Case Rate,Pays Based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.736,Case Rate,Pays based on per visit rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2988,100,,2066.984,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2988,
CT CSPINE WO CM,50521251,CDM,352,RC,72125,HCPCS,Outpatient,,,2309.99,1385.99,,1749,110,,2.184,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1884.976,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.04,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.04,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.664,Case Rate,Pays based on per visit rate,106.88,100,,0.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1732.49,75,,1158.544,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,291.32,Case Rate,Pays Based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,1334,100,,1946.88,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.752,Case Rate,Pays based on per visit rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2309.99,100,,1544.72,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2309.99,
CT CSPINE WO CM,50521251,CDM,352,RC,72125,HCPCS,Outpatient,,,2309.99,1385.99,,1749,110,,4.008,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,4.304,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1896.96,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,5.528,Fee Schedule,360% of BCBS POS Rate,403.49,360,,5.528,Fee schedule,360% of BCBS PPO Rate,403.49,360,,5.528,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.04,Case Rate,Pays based on per visit rate,106.88,100,,1.552,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,1.6,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1732.49,75,,1158.544,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,836.768,Case Rate,Pays Based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,732,Case Rate,Pays based on per visit rate,1334,100,,673.64,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,10.088,Case Rate,Pays based on per visit rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.552,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2309.99,100,,1544.72,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2309.99,
CT CSPINE W CM,50521269,CDM,352,RC,72126,HCPCS,Outpatient,,,2616.57,1569.94,TC   ,1749,110,,23.04,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,43.176,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1906.792,Fee Schedule,320% of BCBS Blue Essentials Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,55.512,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,55.512,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,55.512,Fee Schedule,360% of BCBS Traditional Rate,916,100,,90.8,Case Rate,Pays based on per visit rate,175.09,100,,1.272,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,180.34,103,,1.312,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1962.43,75,,1863.288,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,971.816,Case Rate,Pays Based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1140,Case Rate,Pays based on per visit rate,1334,100,,252.416,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,6.2,Case Rate,Pays based on per visit rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,1.272,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2616.57,100,,2484.384,Percent of Total Billed Charges,100% of Total Billed Charges,175.09,2616.57,
CT CSPINE W CM,50521269,CDM,352,RC,72126,HCPCS,Outpatient,,,2616.57,1569.94,TC   ,1749,110,,264,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,7.496,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1916.16,Fee Schedule,320% of BCBS Blue Essentials Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,9.64,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,9.64,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,9.64,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.096,Case Rate,Pays based on per visit rate,175.09,100,,2.224,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,180.34,103,,2.288,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1962.43,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,732,Case Rate,Pays Based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,1334,100,,83.512,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,3.912,Case Rate,Pays based on per visit rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,175.09,100,,2.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2616.57,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,175.09,2616.57,
CT CSPINE WWO CM,50521277,CDM,352,RC,72127,HCPCS,Outpatient,,,2993.85,1796.31,,1749,110,,21.816,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.632,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1916.16,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,2.096,Fee Schedule,360% of BCBS POS Rate,655.99,360,,2.096,Fee schedule,360% of BCBS PPO Rate,655.99,360,,2.096,Fee Schedule,360% of BCBS Traditional Rate,916,100,,9.76,Case Rate,Pays based on per visit rate,180.34,100,,11.216,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,11.552,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2245.39,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1140,Case Rate,Pays Based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,1334,100,,244.712,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,33.832,Case Rate,Pays based on per visit rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,11.216,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2993.85,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2993.85,
CT CSPINE WWO CM,50521277,CDM,352,RC,72127,HCPCS,Outpatient,,,2993.85,1796.31,,1749,110,,17.12,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,103.272,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1916.16,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,132.776,Fee Schedule,360% of BCBS POS Rate,655.99,360,,132.776,Fee schedule,360% of BCBS PPO Rate,655.99,360,,132.776,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.248,Case Rate,Pays based on per visit rate,180.34,100,,1.768,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.824,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2245.39,75,,735.08,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,971.816,Case Rate,Pays Based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,732,Case Rate,Pays based on per visit rate,1334,100,,735.624,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,78.864,Case Rate,Pays based on per visit rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.768,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2993.85,100,,980.104,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2993.85,
CT TSPINE WO CM,50521285,CDM,352,RC,72128,HCPCS,Outpatient,,,2192.66,1315.60,,1749,110,,346.072,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,15.008,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1916.16,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,19.296,Fee Schedule,360% of BCBS POS Rate,403.49,360,,19.296,Fee schedule,360% of BCBS PPO Rate,403.49,360,,19.296,Fee Schedule,360% of BCBS Traditional Rate,916,100,,15.296,Case Rate,Pays based on per visit rate,106.88,100,,0.024,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.024,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1644.5,75,,1739.488,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,836.768,Case Rate,Pays Based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,1334,100,,937.768,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,95.152,Case Rate,Pays based on per visit rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.024,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2192.66,100,,2319.312,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2192.66,
CT TSPINE WO CM,50521285,CDM,352,RC,72128,HCPCS,Outpatient,,,2192.66,1315.60,,1749,110,,59.4,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.144,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1920,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.184,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.184,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.184,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.152,Case Rate,Pays based on per visit rate,106.88,100,,4.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,4.936,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1644.5,75,,1739.488,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,732,Case Rate,Pays Based on per visit rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.056,Case Rate,Pays based on per visit rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2192.66,100,,2319.312,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2192.66,
CT TSPINE W CM,50521293,CDM,352,RC,72129,HCPCS,Outpatient,,,2495.69,1497.41,TC   ,1749,110,,59.4,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,9.6,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1920,Fee Schedule,320% of BCBS Blue Essentials Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,12.336,Fee Schedule,360% of BCBS POS Rate,655.99,360,,12.336,Fee schedule,360% of BCBS PPO Rate,655.99,360,,12.336,Fee Schedule,360% of BCBS Traditional Rate,916,100,,6.528,Case Rate,Pays based on per visit rate,176.43,100,,0.464,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,181.72,103,,0.48,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1871.77,75,,538.16,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,971.816,Case Rate,Pays Based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1140,Case Rate,Pays based on per visit rate,1334,100,,112.104,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,6.616,Case Rate,Pays based on per visit rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,0.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2495.69,100,,717.544,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2495.69,
CT TSPINE W CM,50521293,CDM,352,RC,72129,HCPCS,Outpatient,,,2495.69,1497.41,TC   ,1749,110,,1.88,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,9.36,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1921.04,Fee Schedule,320% of BCBS Blue Essentials Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,12.032,Fee Schedule,360% of BCBS POS Rate,655.99,360,,12.032,Fee schedule,360% of BCBS PPO Rate,655.99,360,,12.032,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1.808,Case Rate,Pays based on per visit rate,176.43,100,,79.928,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,181.72,103,,82.328,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1871.77,75,,1670.952,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1774.704,Case Rate,Pays Based on per visit rate,1334,100,,816.256,Case Rate,Pays based on per visit rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,816.256,Case Rate,Pays based on per visit rate,1334,100,,601.44,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,5.16,Case Rate,Pays based on per visit rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,176.43,100,,79.928,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2495.69,100,,2227.936,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2495.69,
CT TSPINE WWO CM,50521301,CDM,352,RC,72130,HCPCS,Outpatient,,,2951.14,1770.68,,1749,110,,1.928,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,18.504,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1928.064,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,23.792,Fee Schedule,360% of BCBS POS Rate,655.99,360,,23.792,Fee schedule,360% of BCBS PPO Rate,655.99,360,,23.792,Fee Schedule,360% of BCBS Traditional Rate,916,100,,31.68,Case Rate,Pays based on per visit rate,180.34,100,,61.552,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,63.4,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2213.36,75,,1614.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1140,Case Rate,Pays Based on per visit rate,1334,100,,735.224,Case Rate,Pays based on per visit rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,735.224,Case Rate,Pays based on per visit rate,1334,100,,621.064,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,2.072,Case Rate,Pays based on per visit rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,61.552,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2951.14,100,,2152.6,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2951.14,
CT TSPINE WWO CM,50521301,CDM,352,RC,72130,HCPCS,Outpatient,,,2951.14,1770.68,,1749,110,,1.872,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,5.872,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1944.344,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,7.544,Fee Schedule,360% of BCBS POS Rate,655.99,360,,7.544,Fee schedule,360% of BCBS PPO Rate,655.99,360,,7.544,Fee Schedule,360% of BCBS Traditional Rate,916,100,,10.312,Case Rate,Pays based on per visit rate,180.34,100,,7.632,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,7.864,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2213.36,75,,2446.008,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,816.256,Case Rate,Pays Based on per visit rate,1334,100,,127,Case Rate,Pays based on per visit rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,127,Case Rate,Pays based on per visit rate,1334,100,,291.32,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,5.68,Case Rate,Pays based on per visit rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.632,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2951.14,100,,3261.344,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2951.14,
CT LSPINE WO CM,50521319,CDM,352,RC,72131,HCPCS,Outpatient,,,2226.26,1335.76,TC   ,1749,110,,11.632,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.896,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1957.824,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.44,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.44,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.44,Fee Schedule,360% of BCBS Traditional Rate,916,100,,5.16,Case Rate,Pays based on per visit rate,106.88,100,,20.048,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,20.648,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1669.7,75,,1108.576,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,735.224,Case Rate,Pays Based on per visit rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,16.024,Case Rate,Pays based on per visit rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,20.048,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2226.26,100,,1478.104,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2226.26,
CT LSPINE WO CM,50521319,CDM,352,RC,72131,HCPCS,Outpatient,,,2226.26,1335.76,TC   ,1749,110,,27.608,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,537.6,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1963.52,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,691.2,Fee Schedule,360% of BCBS POS Rate,403.49,360,,691.2,Fee schedule,360% of BCBS PPO Rate,403.49,360,,691.2,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.232,Case Rate,Pays based on per visit rate,106.88,100,,33.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,34.608,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1669.7,75,,1171.52,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,127,Case Rate,Pays Based on per visit rate,1334,100,,1206.76,Case Rate,Pays based on per visit rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1206.76,Case Rate,Pays based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,44.992,Case Rate,Pays based on per visit rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2226.26,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2226.26,
CT LSPINE W CM,50521327,CDM,352,RC,72132,HCPCS,Outpatient,,,2562,1537.20,,1749,110,,17.32,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,15.904,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1967.144,Fee Schedule,320% of BCBS Blue Essentials Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,20.448,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,20.448,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,20.448,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.064,Case Rate,Pays based on per visit rate,175.43,100,,0.488,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,180.69,103,,0.504,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1921.5,75,,1171.52,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,820.616,Case Rate,Pays Based on per visit rate,1334,100,,1406.648,Case Rate,Pays based on per visit rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1406.648,Case Rate,Pays based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,94.08,Case Rate,Pays based on per visit rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,0.488,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2562,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,175.43,2562,
CT LSPINE W CM,50521327,CDM,352,RC,72132,HCPCS,Outpatient,,,2562,1537.20,,1749,110,,15.856,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,3.728,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1979.576,Fee Schedule,320% of BCBS Blue Essentials Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,4.792,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,4.792,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,4.792,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.568,Case Rate,Pays based on per visit rate,175.43,100,,3.928,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,180.69,103,,4.04,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1921.5,75,,1171.52,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1206.76,Case Rate,Pays Based on per visit rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,2.896,Case Rate,Pays based on per visit rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,175.43,100,,3.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2562,100,,1562.024,Percent of Total Billed Charges,100% of Total Billed Charges,175.43,2562,
CT LSPINE WWO CM,50521335,CDM,352,RC,72133,HCPCS,Outpatient,,,3009,1805.40,TC   ,1749,110,,7.136,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,4.752,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1981.8,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,6.104,Fee Schedule,360% of BCBS POS Rate,655.99,360,,6.104,Fee schedule,360% of BCBS PPO Rate,655.99,360,,6.104,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.064,Case Rate,Pays based on per visit rate,180.34,100,,3.064,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.16,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2256.75,75,,1200,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1406.648,Case Rate,Pays Based on per visit rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.744,Case Rate,Pays based on per visit rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.064,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3009,100,,1600,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3009,
CT LSPINE WWO CM,50521335,CDM,352,RC,72133,HCPCS,Outpatient,,,3009,1805.40,TC   ,1749,110,,2.944,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,106.808,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1990.144,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,137.328,Fee Schedule,360% of BCBS POS Rate,655.99,360,,137.328,Fee schedule,360% of BCBS PPO Rate,655.99,360,,137.328,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.432,Case Rate,Pays based on per visit rate,180.34,100,,2.424,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,2.496,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2256.75,75,,1200,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1675.64,Case Rate,Pays Based on per visit rate,1334,100,,268.992,Case Rate,Pays based on per visit rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,268.992,Case Rate,Pays based on per visit rate,1334,100,,836.768,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,2.832,Case Rate,Pays based on per visit rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.424,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3009,100,,1600,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3009,
CT PEL WO CM,50521921,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,16.8,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,3091.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1990.144,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,3974.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,3974.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,3974.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,6.64,Case Rate,Pays based on per visit rate,106.88,100,,6.312,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,6.504,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,2400,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1675.64,Case Rate,Pays Based on per visit rate,1334,100,,560.496,Case Rate,Pays based on per visit rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,560.496,Case Rate,Pays based on per visit rate,1334,100,,732,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4,Case Rate,Pays based on per visit rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,6.312,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,3200,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
CT PEL WO CM,50521921,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,12.552,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,5.376,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1991.472,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,6.912,Fee Schedule,360% of BCBS POS Rate,403.49,360,,6.912,Fee schedule,360% of BCBS PPO Rate,403.49,360,,6.912,Fee Schedule,360% of BCBS Traditional Rate,916,100,,5.464,Case Rate,Pays based on per visit rate,106.88,100,,0.68,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.704,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,1366.328,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,268.992,Case Rate,Pays Based on per visit rate,1334,100,,463.76,Case Rate,Pays based on per visit rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,463.76,Case Rate,Pays based on per visit rate,1334,100,,971.816,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.68,Case Rate,Pays based on per visit rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.68,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,1821.768,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
CT PEL W CM,50521939,CDM,352,RC,72193,HCPCS,Outpatient,,,2518.14,1510.88,TC   ,1749,110,,20.448,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,13.808,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1992.648,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,17.752,Fee Schedule,360% of BCBS POS Rate,655.99,360,,17.752,Fee schedule,360% of BCBS PPO Rate,655.99,360,,17.752,Fee Schedule,360% of BCBS Traditional Rate,916,100,,9.52,Case Rate,Pays based on per visit rate,180.34,100,,1.536,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.576,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1888.61,75,,1366.328,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,560.496,Case Rate,Pays Based on per visit rate,1334,100,,347.968,Case Rate,Pays based on per visit rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,347.968,Case Rate,Pays based on per visit rate,1334,100,,1774.704,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,168,Case Rate,Pays based on per visit rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.536,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2518.14,100,,1821.768,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2518.14,
CT PEL W CM,50521939,CDM,352,RC,72193,HCPCS,Outpatient,,,2518.14,1510.88,TC   ,1749,110,,264,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,9.72,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1993.472,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,12.496,Fee Schedule,360% of BCBS POS Rate,655.99,360,,12.496,Fee schedule,360% of BCBS PPO Rate,655.99,360,,12.496,Fee Schedule,360% of BCBS Traditional Rate,916,100,,48.064,Case Rate,Pays based on per visit rate,180.34,100,,0.896,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.92,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1888.61,75,,1186.648,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,463.76,Case Rate,Pays Based on per visit rate,1334,100,,649.52,Case Rate,Pays based on per visit rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,649.52,Case Rate,Pays based on per visit rate,1334,100,,1140,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,30.08,Case Rate,Pays based on per visit rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.896,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2518.14,100,,1582.2,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2518.14,
CT PEL WWO CM,50521947,CDM,352,RC,72194,HCPCS,Outpatient,,,3032.98,1819.79,,1749,110,,24.208,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,21.064,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1993.472,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,27.08,Fee Schedule,360% of BCBS POS Rate,655.99,360,,27.08,Fee schedule,360% of BCBS PPO Rate,655.99,360,,27.08,Fee Schedule,360% of BCBS Traditional Rate,916,100,,7.584,Case Rate,Pays based on per visit rate,180.34,100,,1.528,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.576,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2274.74,75,,1186.648,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,347.968,Case Rate,Pays Based on per visit rate,1334,100,,658.2,Case Rate,Pays based on per visit rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,658.2,Case Rate,Pays based on per visit rate,1334,100,,816.256,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,101.608,Case Rate,Pays based on per visit rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3032.98,100,,1582.2,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3032.98,
CT PEL WWO CM,50521947,CDM,352,RC,72194,HCPCS,Outpatient,,,3032.98,1819.79,,1749,110,,14.648,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,100.28,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1993.472,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,128.936,Fee Schedule,360% of BCBS POS Rate,655.99,360,,128.936,Fee schedule,360% of BCBS PPO Rate,655.99,360,,128.936,Fee Schedule,360% of BCBS Traditional Rate,916,100,,0.104,Case Rate,Pays based on per visit rate,180.34,100,,1.984,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,2.04,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2274.74,75,,1186.648,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,649.52,Case Rate,Pays Based on per visit rate,1334,100,,807.224,Case Rate,Pays based on per visit rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,807.224,Case Rate,Pays based on per visit rate,1334,100,,735.224,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,474.04,Case Rate,Pays based on per visit rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3032.98,100,,1582.2,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3032.98,
CT UPR EXT WO CM BI,50531995,CDM,352,RC,73200,HCPCS,Outpatient,,,2928.68,1757.21,TC   ,1749,110,,13.424,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1996.8,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,14.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.328,Case Rate,Pays based on per visit rate,106.88,100,,1.904,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,1.96,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2196.51,75,,1186.648,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,658.2,Case Rate,Pays Based on per visit rate,1334,100,,1965.6,Case Rate,Pays based on per visit rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1965.6,Case Rate,Pays based on per visit rate,1334,100,,127,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,238.424,Case Rate,Pays based on per visit rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.904,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2928.68,100,,1582.2,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2928.68,
CT UPR EXT WO CM BI,50531995,CDM,352,RC,73200,HCPCS,Outpatient,,,2928.68,1757.21,TC   ,1749,110,,13.24,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1996.8,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,14.52,Fee Schedule,360% of BCBS POS Rate,403.49,360,,14.52,Fee schedule,360% of BCBS PPO Rate,403.49,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,916,100,,20.544,Case Rate,Pays based on per visit rate,106.88,100,,12.008,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,12.368,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2196.51,75,,1496.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,807.224,Case Rate,Pays Based on per visit rate,1334,100,,3840,Case Rate,Pays based on per visit rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,3840,Case Rate,Pays based on per visit rate,1334,100,,820.616,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,45.336,Case Rate,Pays based on per visit rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,12.008,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2928.68,100,,1995,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2928.68,
CT UPR EXT WO CM LT,50532001,CDM,352,RC,73200,HCPCS,Outpatient,,,1952.45,1171.47,,1749,110,,10.048,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,71.904,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1996.8,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,92.448,Fee Schedule,360% of BCBS POS Rate,403.49,360,,92.448,Fee schedule,360% of BCBS PPO Rate,403.49,360,,92.448,Fee Schedule,360% of BCBS Traditional Rate,916,100,,144,Case Rate,Pays based on per visit rate,106.88,100,,834.768,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,859.816,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.34,75,,1496.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1965.6,Case Rate,Pays Based on per visit rate,1334,100,,1296,Case Rate,Pays based on per visit rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1296,Case Rate,Pays based on per visit rate,1334,100,,1206.76,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,423.368,Case Rate,Pays based on per visit rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,834.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.45,100,,1995,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.45,
CT UPR EXT WO CM LT,50532001,CDM,352,RC,73200,HCPCS,Outpatient,,,1952.45,1171.47,,1749,110,,24.208,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.944,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,2019.584,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.216,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.216,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.216,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2,Case Rate,Pays based on per visit rate,106.88,100,,8.72,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,8.984,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.34,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,3840,Case Rate,Pays Based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,1334,100,,1406.648,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,35.76,Case Rate,Pays based on per visit rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.72,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.45,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.45,
CT UPR EXT W CM LT,50532019,CDM,352,RC,73201,HCPCS,Outpatient,,,2257.11,1354.27,TC   ,1749,110,,24.208,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,7.176,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,2026.752,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,9.224,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,9.224,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,9.224,Fee Schedule,360% of BCBS Traditional Rate,916,100,,11.264,Case Rate,Pays based on per visit rate,209.84,100,,7.096,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,7.312,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1692.83,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1296,Case Rate,Pays Based on per visit rate,1334,100,,18.064,Case Rate,Pays based on per visit rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,18.064,Case Rate,Pays based on per visit rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,31.928,Case Rate,Pays based on per visit rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,7.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2257.11,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2257.11,
CT UPR EXT W CM LT,50532019,CDM,352,RC,73201,HCPCS,Outpatient,,,2257.11,1354.27,TC   ,1749,110,,40.984,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,55.16,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1.792,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,70.92,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,70.92,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,70.92,Fee Schedule,360% of BCBS Traditional Rate,916,100,,590.112,Case Rate,Pays based on per visit rate,209.84,100,,178.632,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,183.992,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1692.83,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.032,Case Rate,Pays Based on per visit rate,1334,100,,4.656,Case Rate,Pays based on per visit rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,4.656,Case Rate,Pays based on per visit rate,1334,100,,1675.64,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,55.488,Case Rate,Pays based on per visit rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,178.632,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2257.11,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2257.11,
CT UPR EXT WWO CM LT,50532027,CDM,352,RC,73202,HCPCS,Outpatient,,,2611.78,1567.07,,1749,110,,24.208,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.792,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.792,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.584,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.584,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.584,Fee Schedule,360% of BCBS Traditional Rate,916,100,,342.56,Case Rate,Pays based on per visit rate,180.34,100,,55.448,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,57.112,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1958.84,75,,1235.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,18.064,Case Rate,Pays Based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,20,Case Rate,Pays based on per visit rate,1334,100,,268.992,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.6,Case Rate,Pays based on per visit rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,55.448,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2611.78,100,,1647.264,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2611.78,
CT UPR EXT WWO CM LT,50532027,CDM,352,RC,73202,HCPCS,Outpatient,,,2611.78,1567.07,,1749,110,,24.208,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.808,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,14.4,Fee Schedule,360% of BCBS POS Rate,655.99,360,,14.4,Fee schedule,360% of BCBS PPO Rate,655.99,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,93.112,Case Rate,Pays based on per visit rate,180.34,100,,3.584,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.688,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1958.84,75,,3227.392,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4.656,Case Rate,Pays Based on per visit rate,1334,100,,0.688,Case Rate,Pays based on per visit rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.688,Case Rate,Pays based on per visit rate,1334,100,,560.496,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1.112,Case Rate,Pays based on per visit rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.584,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2611.78,100,,4303.184,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2611.78,
CT UPR EXT W CM BI,50532035,CDM,352,RC,73201,HCPCS,Outpatient,,,2387.33,1432.40,TC   ,1749,110,,6.08,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,11.2,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1.816,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,14.4,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,14.4,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,14.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,127.44,Case Rate,Pays based on per visit rate,209.84,100,,18.928,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,19.496,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1790.5,75,,2027.392,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,20,Case Rate,Pays Based on per visit rate,1334,100,,6.84,Case Rate,Pays based on per visit rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,6.84,Case Rate,Pays based on per visit rate,1334,100,,463.76,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,57.12,Case Rate,Pays based on per visit rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,18.928,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2387.33,100,,2703.184,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2387.33,
CT UPR EXT W CM BI,50532035,CDM,352,RC,73201,HCPCS,Outpatient,,,2387.33,1432.40,TC   ,1749,110,,24,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,34.272,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,1.824,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,44.064,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,44.064,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,44.064,Fee Schedule,360% of BCBS Traditional Rate,916,100,,511.984,Case Rate,Pays based on per visit rate,209.84,100,,2.208,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,2.272,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1790.5,75,,959.384,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.688,Case Rate,Pays Based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,20,Case Rate,Pays based on per visit rate,1334,100,,347.968,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,105.496,Case Rate,Pays based on per visit rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,2.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2387.33,100,,1279.176,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2387.33,
CT UPR EXT WWO CM BI,50532043,CDM,352,RC,73202,HCPCS,Outpatient,,,3750,2250.00,,1749,110,,264,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,32.84,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.824,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,42.224,Fee Schedule,360% of BCBS POS Rate,655.99,360,,42.224,Fee schedule,360% of BCBS PPO Rate,655.99,360,,42.224,Fee Schedule,360% of BCBS Traditional Rate,916,100,,271.632,Case Rate,Pays based on per visit rate,180.34,100,,2.512,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,2.584,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2812.5,75,,2027.392,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,6.84,Case Rate,Pays Based on per visit rate,1334,100,,31.4,Case Rate,Pays based on per visit rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,31.4,Case Rate,Pays based on per visit rate,1334,100,,649.52,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,41.936,Case Rate,Pays based on per visit rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,2.512,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3750,100,,2703.184,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3750,
CT UPR EXT WWO CM BI,50532043,CDM,352,RC,73202,HCPCS,Outpatient,,,3750,2250.00,,1749,110,,84.792,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,19.352,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.84,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,24.88,Fee Schedule,360% of BCBS POS Rate,655.99,360,,24.88,Fee schedule,360% of BCBS PPO Rate,655.99,360,,24.88,Fee Schedule,360% of BCBS Traditional Rate,916,100,,263.8,Case Rate,Pays based on per visit rate,180.34,100,,3.384,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,3.48,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2812.5,75,,1354.264,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,20,Case Rate,Pays Based on per visit rate,1334,100,,11.064,Case Rate,Pays based on per visit rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,11.064,Case Rate,Pays based on per visit rate,1334,100,,658.2,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,50.272,Case Rate,Pays based on per visit rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,3.384,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3750,100,,1805.688,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3750,
CT LWR EXT WO CM BI,50537000,CDM,352,RC,73700,HCPCS,Outpatient,,,2966.63,1779.98,TC   ,1749,110,,114.72,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,18.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.848,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,23.256,Fee Schedule,360% of BCBS POS Rate,403.49,360,,23.256,Fee schedule,360% of BCBS PPO Rate,403.49,360,,23.256,Fee Schedule,360% of BCBS Traditional Rate,916,100,,37.352,Case Rate,Pays based on per visit rate,106.88,100,,252,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,259.56,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2224.97,75,,1354.264,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,31.4,Case Rate,Pays Based on per visit rate,1334,100,,3.464,Case Rate,Pays based on per visit rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,3.464,Case Rate,Pays based on per visit rate,1334,100,,807.224,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,49.792,Case Rate,Pays based on per visit rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,252,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2966.63,100,,1805.688,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2966.63,
CT LWR EXT WO CM BI,50537000,CDM,352,RC,73700,HCPCS,Outpatient,,,2966.63,1779.98,TC   ,1749,110,,18.176,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.12,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.848,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.152,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.152,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.152,Fee Schedule,360% of BCBS Traditional Rate,916,100,,344.048,Case Rate,Pays based on per visit rate,106.88,100,,217.728,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,224.256,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2224.97,75,,1171.472,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,11.064,Case Rate,Pays Based on per visit rate,1334,100,,910,Case Rate,Pays based on per visit rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,910,Case Rate,Pays based on per visit rate,1334,100,,1965.6,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,85.408,Case Rate,Pays based on per visit rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,217.728,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2966.63,100,,1561.96,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2966.63,
CT LWR EXT W CM LT,50537018,CDM,352,RC,73701,HCPCS,Outpatient,,,2277.21,1366.33,,1749,110,,264,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,30.808,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.864,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,39.608,Fee Schedule,360% of BCBS POS Rate,655.99,360,,39.608,Fee schedule,360% of BCBS PPO Rate,655.99,360,,39.608,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1163.424,Case Rate,Pays based on per visit rate,173.08,100,,4.248,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,4.376,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1707.91,75,,1171.472,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,3.464,Case Rate,Pays Based on per visit rate,1334,100,,0.104,Case Rate,Pays based on per visit rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.104,Case Rate,Pays based on per visit rate,1334,100,,3840,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,89.856,Case Rate,Pays based on per visit rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2277.21,100,,1561.96,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2277.21,
CT LWR EXT W CM LT,50537018,CDM,352,RC,73701,HCPCS,Outpatient,,,2277.21,1366.33,,1749,110,,115.296,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,160.88,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.888,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,206.84,Fee Schedule,360% of BCBS POS Rate,655.99,360,,206.84,Fee schedule,360% of BCBS PPO Rate,655.99,360,,206.84,Fee Schedule,360% of BCBS Traditional Rate,916,100,,10.592,Case Rate,Pays based on per visit rate,173.08,100,,45.12,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,46.48,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1707.91,75,,1500,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,910,Case Rate,Pays Based on per visit rate,1334,100,,18.912,Case Rate,Pays based on per visit rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,18.912,Case Rate,Pays based on per visit rate,1334,100,,1296,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,89.856,Case Rate,Pays based on per visit rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,45.12,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2277.21,100,,2000,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2277.21,
CT LWR EXT WWO CM LT,50537026,CDM,352,RC,73702,HCPCS,Outpatient,,,2493.75,1496.25,TC   ,1749,110,,75.344,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,618.24,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.904,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,794.88,Fee Schedule,360% of BCBS POS Rate,655.99,360,,794.88,Fee schedule,360% of BCBS PPO Rate,655.99,360,,794.88,Fee Schedule,360% of BCBS Traditional Rate,916,100,,32.712,Case Rate,Pays based on per visit rate,180.34,100,,0.544,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.56,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.31,75,,1500,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.104,Case Rate,Pays Based on per visit rate,1334,100,,17.232,Case Rate,Pays based on per visit rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,17.232,Case Rate,Pays based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,60.76,Case Rate,Pays based on per visit rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.75,100,,2000,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2493.75,
CT LWR EXT WWO CM LT,50537026,CDM,352,RC,73702,HCPCS,Outpatient,,,2493.75,1496.25,TC   ,1749,110,,37.68,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.528,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.912,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.672,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.672,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.672,Fee Schedule,360% of BCBS Traditional Rate,916,100,,32.744,Case Rate,Pays based on per visit rate,180.34,100,,158.76,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,163.52,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.31,75,,173.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,18.912,Case Rate,Pays Based on per visit rate,1334,100,,118.44,Case Rate,Pays based on per visit rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,118.44,Case Rate,Pays based on per visit rate,1334,100,,18.064,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,3.152,Case Rate,Pays based on per visit rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,158.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.75,100,,231,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2493.75,
CT LWR EXT W CM BI,50537059,CDM,352,RC,73701,HCPCS,Outpatient,,,3415.82,2049.49,,1749,110,,37.68,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,154.288,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.928,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,198.376,Fee Schedule,360% of BCBS POS Rate,655.99,360,,198.376,Fee schedule,360% of BCBS PPO Rate,655.99,360,,198.376,Fee Schedule,360% of BCBS Traditional Rate,916,100,,4.064,Case Rate,Pays based on per visit rate,173.08,100,,42.336,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,43.608,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2561.87,75,,173.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,17.232,Case Rate,Pays Based on per visit rate,1334,100,,12.288,Case Rate,Pays based on per visit rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,12.288,Case Rate,Pays based on per visit rate,1334,100,,4.656,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,7.816,Case Rate,Pays based on per visit rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,42.336,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3415.82,100,,231,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3415.82,
CT LWR EXT W CM BI,50537059,CDM,352,RC,73701,HCPCS,Outpatient,,,3415.82,2049.49,,1749,110,,79.648,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.24,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.936,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,2.88,Fee Schedule,360% of BCBS POS Rate,655.99,360,,2.88,Fee schedule,360% of BCBS PPO Rate,655.99,360,,2.88,Fee Schedule,360% of BCBS Traditional Rate,916,100,,132.88,Case Rate,Pays based on per visit rate,173.08,100,,31.048,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,31.976,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2561.87,75,,1572.32,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,118.44,Case Rate,Pays Based on per visit rate,1334,100,,13.2,Case Rate,Pays based on per visit rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,13.2,Case Rate,Pays based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,3.92,Case Rate,Pays based on per visit rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,31.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3415.82,100,,2096.424,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3415.82,
CT LWR EXT WWO CM BI,50537067,CDM,352,RC,73702,HCPCS,Outpatient,,,3740.63,2244.38,TC   ,1749,110,,52.072,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.032,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.936,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,0.048,Fee Schedule,360% of BCBS POS Rate,655.99,360,,0.048,Fee schedule,360% of BCBS PPO Rate,655.99,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,916,100,,12.616,Case Rate,Pays based on per visit rate,180.34,100,,12.184,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,12.552,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2805.47,75,,1572.32,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,12.288,Case Rate,Pays Based on per visit rate,1334,100,,8.232,Case Rate,Pays based on per visit rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,8.232,Case Rate,Pays based on per visit rate,1334,100,,0.688,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.136,Case Rate,Pays based on per visit rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3740.63,100,,2096.424,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3740.63,
CT LWR EXT WWO CM BI,50537067,CDM,352,RC,73702,HCPCS,Outpatient,,,3740.63,2244.38,TC   ,1749,110,,4.472,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.976,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.952,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,3.824,Fee Schedule,360% of BCBS POS Rate,655.99,360,,3.824,Fee schedule,360% of BCBS PPO Rate,655.99,360,,3.824,Fee Schedule,360% of BCBS Traditional Rate,916,100,,133,Case Rate,Pays based on per visit rate,180.34,100,,7.08,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,7.288,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2805.47,75,,872.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,13.2,Case Rate,Pays Based on per visit rate,1334,100,,20.176,Case Rate,Pays based on per visit rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,20.176,Case Rate,Pays based on per visit rate,1334,100,,6.84,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.6,Case Rate,Pays based on per visit rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,7.08,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3740.63,100,,1163,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3740.63,
CT ABD WO CM,50541507,CDM,352,RC,74150,HCPCS,Outpatient,,,2161.14,1296.68,,1749,110,,3.248,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.168,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.96,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.784,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.784,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.784,Fee Schedule,360% of BCBS Traditional Rate,916,100,,11.04,Case Rate,Pays based on per visit rate,106.88,100,,9.544,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.824,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1620.86,75,,62.104,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,8.232,Case Rate,Pays Based on per visit rate,1334,100,,0.088,Case Rate,Pays based on per visit rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.088,Case Rate,Pays based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,34.968,Case Rate,Pays based on per visit rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2161.14,100,,82.8,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2161.14,
CT ABD WO CM,50541507,CDM,352,RC,74150,HCPCS,Outpatient,,,2161.14,1296.68,,1749,110,,1.264,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,52.48,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,1.976,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,67.472,Fee Schedule,360% of BCBS POS Rate,403.49,360,,67.472,Fee schedule,360% of BCBS PPO Rate,403.49,360,,67.472,Fee Schedule,360% of BCBS Traditional Rate,916,100,,23.632,Case Rate,Pays based on per visit rate,106.88,100,,2.944,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.032,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1620.86,75,,315,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,20.176,Case Rate,Pays Based on per visit rate,1334,100,,55.376,Case Rate,Pays based on per visit rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,55.376,Case Rate,Pays based on per visit rate,1334,100,,31.4,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,20.728,Case Rate,Pays based on per visit rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2161.14,100,,420,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2161.14,
CT ABD W CM,50541606,CDM,352,RC,74160,HCPCS,Outpatient,,,2612.05,1567.23,,1749,110,,16.528,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.368,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.976,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,9.472,Fee Schedule,360% of BCBS POS Rate,655.99,360,,9.472,Fee schedule,360% of BCBS PPO Rate,655.99,360,,9.472,Fee Schedule,360% of BCBS Traditional Rate,916,100,,9.304,Case Rate,Pays based on per visit rate,180.34,100,,10.528,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,10.848,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1959.04,75,,467.552,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.088,Case Rate,Pays Based on per visit rate,1334,100,,5.776,Case Rate,Pays based on per visit rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,5.776,Case Rate,Pays based on per visit rate,1334,100,,11.064,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,8.984,Case Rate,Pays based on per visit rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.528,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2612.05,100,,623.4,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2612.05,
CT ABD W CM,50541606,CDM,352,RC,74160,HCPCS,Outpatient,,,2612.05,1567.23,,1749,110,,215.416,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.368,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,1.992,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,9.472,Fee Schedule,360% of BCBS POS Rate,655.99,360,,9.472,Fee schedule,360% of BCBS PPO Rate,655.99,360,,9.472,Fee Schedule,360% of BCBS Traditional Rate,916,100,,17.984,Case Rate,Pays based on per visit rate,180.34,100,,12.744,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,13.12,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1959.04,75,,290.848,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,55.376,Case Rate,Pays Based on per visit rate,1334,100,,1.736,Case Rate,Pays based on per visit rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1.736,Case Rate,Pays based on per visit rate,1334,100,,3.464,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,52.304,Case Rate,Pays based on per visit rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,12.744,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2612.05,100,,387.8,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2612.05,
CT ABD WWO CM,50541705,CDM,352,RC,74170,HCPCS,Outpatient,,,3025.41,1815.25,TC   ,1749,110,,0.112,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.408,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,2,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,9.528,Fee Schedule,360% of BCBS POS Rate,655.99,360,,9.528,Fee schedule,360% of BCBS PPO Rate,655.99,360,,9.528,Fee Schedule,360% of BCBS Traditional Rate,916,100,,35.152,Case Rate,Pays based on per visit rate,180.34,100,,1153.728,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1188.344,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2269.06,75,,4036.96,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,5.776,Case Rate,Pays Based on per visit rate,1334,100,,4.4,Case Rate,Pays based on per visit rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,4.4,Case Rate,Pays based on per visit rate,1334,100,,910,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,64.312,Case Rate,Pays based on per visit rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1153.728,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3025.41,100,,5046.2,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3025.41,
CT ABD WWO CM,50541705,CDM,352,RC,74170,HCPCS,Outpatient,,,3025.41,1815.25,TC   ,1749,110,,0.088,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,157.872,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,2.016,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,202.976,Fee Schedule,360% of BCBS POS Rate,655.99,360,,202.976,Fee schedule,360% of BCBS PPO Rate,655.99,360,,202.976,Fee Schedule,360% of BCBS Traditional Rate,916,100,,41.52,Case Rate,Pays based on per visit rate,180.34,100,,1.76,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.808,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2269.06,75,,239.4,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.736,Case Rate,Pays Based on per visit rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,1334,100,,0.104,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,105.288,Case Rate,Pays based on per visit rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.76,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3025.41,100,,319.2,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3025.41,
CT ABD PEL W CM,50541770,CDM,352,RC,74177,HCPCS,Outpatient,,,4525.59,2715.35,,1749,110,,3.576,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,20.16,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,2.024,Fee Schedule,320% of BCBS Blue Essentials Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,25.92,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,25.92,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,25.92,Fee Schedule,360% of BCBS Traditional Rate,916,100,,33.536,Case Rate,Pays based on per visit rate,318.09,100,,8.128,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,327.63,103,,8.368,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3394.19,75,,497.4,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4.4,Case Rate,Pays Based on per visit rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,1334,100,,18.912,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,253.856,Case Rate,Pays based on per visit rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,8.128,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4525.59,100,,663.2,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4525.59,
CT ABD PEL W CM,50541770,CDM,352,RC,74177,HCPCS,Outpatient,,,4525.59,2715.35,,1749,110,,100.744,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,20.16,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,2.04,Fee Schedule,320% of BCBS Blue Essentials Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,25.92,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,25.92,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,25.92,Fee Schedule,360% of BCBS Traditional Rate,916,100,,19.68,Case Rate,Pays based on per visit rate,318.09,100,,17.32,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,327.63,103,,17.84,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3394.19,75,,206.552,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,12.4,Case Rate,Pays Based on per visit rate,1334,100,,42.176,Case Rate,Pays based on per visit rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,42.176,Case Rate,Pays based on per visit rate,1334,100,,17.232,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,11.568,Case Rate,Pays based on per visit rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4525.59,100,,275.4,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4525.59,
CT ABD PEL W CM,50541770,CDM,352,RC,74177,HCPCS,Outpatient,,,4525.59,2715.35,,1749,110,,20.312,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,67.2,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,2.04,Fee Schedule,320% of BCBS Blue Essentials Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,86.4,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,86.4,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,86.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,85.92,Case Rate,Pays based on per visit rate,318.09,100,,39.456,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,327.63,103,,40.64,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3394.19,75,,354,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,12.4,Case Rate,Pays Based on per visit rate,1334,100,,147.456,Case Rate,Pays based on per visit rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,147.456,Case Rate,Pays based on per visit rate,1334,100,,118.44,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,402.776,Case Rate,Pays based on per visit rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,318.09,100,,39.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4525.59,100,,472,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4525.59,
CT ABD PEL WWO CM,50541788,CDM,352,RC,74178,HCPCS,Outpatient,,,5213.16,3127.90,,1749,110,,4256.792,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,164.6,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,211.624,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,211.624,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,211.624,Fee Schedule,360% of BCBS Traditional Rate,916,100,,144,Case Rate,Pays based on per visit rate,356.19,100,,17.32,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,366.88,103,,17.84,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3909.87,75,,344.552,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,42.176,Case Rate,Pays Based on per visit rate,1334,100,,2.384,Case Rate,Pays based on per visit rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,2.384,Case Rate,Pays based on per visit rate,1334,100,,12.288,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,257.04,Case Rate,Pays based on per visit rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,17.32,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5213.16,100,,459.4,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5213.16,
CT ABD PEL WWO CM,50541788,CDM,352,RC,74178,HCPCS,Outpatient,,,5213.16,3127.90,,1749,110,,34.128,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,17.576,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,22.592,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,22.592,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,22.592,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.08,Case Rate,Pays based on per visit rate,356.19,100,,33.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,366.88,103,,34.608,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3909.87,75,,123.448,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,147.456,Case Rate,Pays Based on per visit rate,1334,100,,1.44,Case Rate,Pays based on per visit rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1.44,Case Rate,Pays based on per visit rate,1334,100,,13.2,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,191.96,Case Rate,Pays based on per visit rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,356.19,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5213.16,100,,164.6,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5213.16,
CT ABD PEL WO CM,50541796,CDM,352,RC,74176,HCPCS,Outpatient,,,3510.08,2106.05,TC   ,1749,110,,223.2,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,97.936,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,125.92,Fee Schedule,360% of BCBS POS Rate,838.94,360,,125.92,Fee schedule,360% of BCBS PPO Rate,838.94,360,,125.92,Fee Schedule,360% of BCBS Traditional Rate,916,100,,162,Case Rate,Pays based on per visit rate,189.79,100,,47.696,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,195.48,103,,49.128,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2632.56,75,,412.8,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,2.384,Case Rate,Pays Based on per visit rate,1334,100,,6.52,Case Rate,Pays based on per visit rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,6.52,Case Rate,Pays based on per visit rate,1334,100,,8.232,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.664,Case Rate,Pays based on per visit rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,47.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3510.08,100,,550.4,Percent of Total Billed Charges,100% of Total Billed Charges,189.79,3510.08,
CT ABD PEL WO CM,50541796,CDM,352,RC,74176,HCPCS,Outpatient,,,3510.08,2106.05,TC   ,1749,110,,70.736,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,2.656,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,3.416,Fee Schedule,360% of BCBS POS Rate,838.94,360,,3.416,Fee schedule,360% of BCBS PPO Rate,838.94,360,,3.416,Fee Schedule,360% of BCBS Traditional Rate,916,100,,56.968,Case Rate,Pays based on per visit rate,189.79,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,195.48,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2632.56,75,,334.648,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.44,Case Rate,Pays Based on per visit rate,1334,100,,5.216,Case Rate,Pays based on per visit rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,5.216,Case Rate,Pays based on per visit rate,1334,100,,20.176,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,110.688,Case Rate,Pays based on per visit rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,189.79,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3510.08,100,,446.2,Percent of Total Billed Charges,100% of Total Billed Charges,189.79,3510.08,
CT GUIDE DRN FLUID,50544809,CDM,361,RC,10030,HCPCS,Outpatient,,,1528,916.80,,4162,100,,130.088,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,20.104,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1047.49,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,25.848,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,25.848,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,25.848,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,143.2,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,220.34,14.42,,2.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1146,75,,505.048,Percent of Total Billed Charges,75% of Total Billed Charges,764,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,764,50,,316,Percent of Total Billed Charges,50% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,764,50,,316,Percent of Total Billed Charges,50% of Total Billed Charges,764,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,955.512,Fee Schedule,100% of ASC Tier Groupings fee schedule,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,213.92,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1528,100,,673.4,Percent of Total Billed Charges,100% of Total Billed Charges,213.92,4162,
CT GUIDE DRN CATH PLCMT,50559905,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,,74.33,100,,29.144,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,2.304,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,2.96,Fee Schedule,360% of BCBS POS Rate,229.64,360,,2.96,Fee schedule,360% of BCBS PPO Rate,229.64,360,,2.96,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,16.824,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,8.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,67.8,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,5.216,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,55.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1260,Case Rate,Pays based on per visit rate,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,90.4,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
CT GUIDE DRN CATH PLCMT,50559905,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,,74.33,100,,49.984,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,1.176,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,1.512,Fee Schedule,360% of BCBS POS Rate,229.64,360,,1.512,Fee schedule,360% of BCBS PPO Rate,229.64,360,,1.512,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,13.136,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,49.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,84.6,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,316,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,4784.472,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,4784.472,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,34.12,Case Rate,Pays based on per visit rate,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,112.8,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
CT GUIDE NDL PLCMT SI,50563618,CDM,350,RC,77012,HCPCS,Outpatient,,,1346.92,808.15,TC   ,1749,110,,499.2,Percent of Total Billed Charges,110% of Total Billed Charges,606.11,45,,484.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.96,280,,4.12,Fee Schedule,280% of BCBS BULE Fee Schedule,250.24,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,281.52,360,,5.304,Fee Schedule,360% of BCBS POS Rate,281.52,360,,5.304,Fee schedule,360% of BCBS PPO Rate,281.52,360,,5.304,Fee Schedule,360% of BCBS Traditional Rate,916,100,,10.4,Case Rate,Pays based on per visit rate,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1346.92,100,,1077.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,194.23,14.42,,16.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1010.19,75,,497.4,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.056,Case Rate,Pays Based on per visit rate,1334,100,,130.728,Case Rate,Pays based on per visit rate,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,130.728,Case Rate,Pays based on per visit rate,1334,100,,1.736,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,68.24,Case Rate,Pays based on per visit rate,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1346.92,100,,663.2,Percent of Total Billed Charges,100% of Total Billed Charges,188.57,1800,
CT GUIDE NDL PLCMT SI,50563618,CDM,350,RC,77012,HCPCS,Outpatient,,,1346.92,808.15,TC   ,1749,110,,131.76,Percent of Total Billed Charges,110% of Total Billed Charges,606.11,45,,484.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.96,280,,2.52,Fee Schedule,280% of BCBS BULE Fee Schedule,250.24,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,281.52,360,,3.24,Fee Schedule,360% of BCBS POS Rate,281.52,360,,3.24,Fee schedule,360% of BCBS PPO Rate,281.52,360,,3.24,Fee Schedule,360% of BCBS Traditional Rate,916,100,,27.056,Case Rate,Pays based on per visit rate,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1346.92,100,,1077.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.23,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1010.19,75,,229.504,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4784.472,Case Rate,Pays Based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,20,Case Rate,Pays based on per visit rate,1334,100,,4.4,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,34.12,Case Rate,Pays based on per visit rate,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,188.57,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1346.92,100,,306,Percent of Total Billed Charges,100% of Total Billed Charges,188.57,1800,
CT ANGIO ABD PEL WWO CM,50565035,CDM,352,RC,74174,HCPCS,Outpatient,,,4576.02,2745.61,,1749,110,,131.76,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,813.34,280,,0.912,Fee Schedule,280% of BCBS BULE Fee Schedule,929.54,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,1045.73,360,,1.168,Fee Schedule,360% of BCBS POS Rate,1045.73,360,,1.168,Fee schedule,360% of BCBS PPO Rate,1045.73,360,,1.168,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.912,Case Rate,Pays based on per visit rate,368.43,100,,95.76,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,98.632,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3432.02,75,,230.848,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,130.728,Case Rate,Pays Based on per visit rate,1334,100,,0.632,Case Rate,Pays based on per visit rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.632,Case Rate,Pays based on per visit rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,157.704,Case Rate,Pays based on per visit rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,95.76,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4576.02,100,,307.8,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4576.02,
CT ANGIO ABD PEL WWO CM,50565035,CDM,352,RC,74174,HCPCS,Outpatient,,,4576.02,2745.61,,1749,110,,131.76,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,813.34,280,,110.712,Fee Schedule,280% of BCBS BULE Fee Schedule,929.54,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,1045.73,360,,142.344,Fee Schedule,360% of BCBS POS Rate,1045.73,360,,142.344,Fee schedule,360% of BCBS PPO Rate,1045.73,360,,142.344,Fee Schedule,360% of BCBS Traditional Rate,916,100,,6.568,Case Rate,Pays based on per visit rate,368.43,100,,1.824,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,1.88,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3432.02,75,,299.552,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,20,Case Rate,Pays Based on per visit rate,1334,100,,5.032,Case Rate,Pays based on per visit rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,5.032,Case Rate,Pays based on per visit rate,1334,100,,12.4,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,23.288,Case Rate,Pays based on per visit rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4576.02,100,,399.4,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4576.02,
CT LTD OR LOCAL FU STUDY,50565050,CDM,351,RC,76380,HCPCS,Outpatient,,,1002.17,601.30,TC   ,1749,110,,131.76,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,12.456,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,16.016,Fee Schedule,360% of BCBS POS Rate,287.32,360,,16.016,Fee schedule,360% of BCBS PPO Rate,287.32,360,,16.016,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.824,Case Rate,Pays based on per visit rate,86.88,100,,6.472,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,89.49,103,,6.664,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,751.63,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.632,Case Rate,Pays Based on per visit rate,1334,100,,1800,Case Rate,Pays based on per visit rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1800,Case Rate,Pays based on per visit rate,1334,100,,42.176,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,216.472,Case Rate,Pays based on per visit rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.472,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.17,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,1800,
CT LTD OR LOCAL FU STUDY,50565050,CDM,351,RC,76380,HCPCS,Outpatient,,,1002.17,601.30,TC   ,1749,110,,199.064,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,1.28,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,1.648,Fee Schedule,360% of BCBS POS Rate,287.32,360,,1.648,Fee schedule,360% of BCBS PPO Rate,287.32,360,,1.648,Fee Schedule,360% of BCBS Traditional Rate,916,100,,6.544,Case Rate,Pays based on per visit rate,86.88,100,,16.928,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,89.49,103,,17.44,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,751.63,75,,62.104,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,5.032,Case Rate,Pays Based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,20,Case Rate,Pays based on per visit rate,1334,100,,147.456,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,249.024,Case Rate,Pays based on per visit rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.928,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.17,100,,82.8,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,1800,
CT BX BONE DEEP,50575034,CDM,361,RC,,,Outpatient,,,2113.14,1267.88,,1267.88,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,950.91,45,,760.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,591.68,28,,7.392,Percent of Total Billed Charges,28% of Total Billed Charges,1048.84,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,760.73,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,760.73,36,,9.504,Percent of Total Billed Charges,36% Total Bille Charges,760.73,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,1267.88,60,,8.504,Percent of Total Billed Charges,60% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2113.14,100,,1690.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,304.71,14.42,,2.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1584.86,75,,86.552,Percent of Total Billed Charges,75% of Total Billed Charges,1056.57,50,,1800,Percent of Total Billed Charges,50% of Total Billed Charges,1056.57,50,,117.736,Percent of Total Billed Charges,50% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1056.57,50,,117.736,Percent of Total Billed Charges,50% of Total Billed Charges,1056.57,50,,2.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1479.2,70,,1.896,Percent of Total Billed Charges,70% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,295.84,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2113.14,100,,115.4,Percent of Total Billed Charges,100% of Total Billed Charges,295.84,2113.14,
CT DRN ABS PEL TRANSVAG RECTAL,50588235,CDM,361,RC,,,Outpatient,,,2513.22,1507.93,,1507.93,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,1130.95,45,,904.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.7,28,,6.416,Percent of Total Billed Charges,28% of Total Billed Charges,1049.47,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,904.76,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,904.76,36,,8.248,Percent of Total Billed Charges,36% Total Bille Charges,904.76,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,1507.93,60,,8.144,Percent of Total Billed Charges,60% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2513.22,100,,2010.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,362.41,14.42,,4.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1884.92,75,,40.952,Percent of Total Billed Charges,75% of Total Billed Charges,1256.61,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,1256.61,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1256.61,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,1256.61,50,,1.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1759.25,70,,37.296,Percent of Total Billed Charges,70% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,351.85,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.22,100,,54.6,Percent of Total Billed Charges,100% of Total Billed Charges,351.85,2513.22,
CT ANGIO LWR EXT WWO CM BI,50588237,CDM,352,RC,73706,HCPCS,Outpatient,,,2872.83,1723.70,,1749,110,,450.328,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,30.816,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.92,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,39.624,Fee Schedule,360% of BCBS POS Rate,655.99,360,,39.624,Fee schedule,360% of BCBS PPO Rate,655.99,360,,39.624,Fee Schedule,360% of BCBS Traditional Rate,916,100,,28.664,Case Rate,Pays based on per visit rate,180.34,100,,27.184,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,28,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2154.62,75,,58.68,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,117.736,Case Rate,Pays Based on per visit rate,1334,100,,0.552,Case Rate,Pays based on per visit rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.552,Case Rate,Pays based on per visit rate,1334,100,,6.52,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,240.08,Case Rate,Pays based on per visit rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,27.184,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2872.83,100,,78.24,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2872.83,
CT ANGIO LWR EXT WWO CM BI,50588237,CDM,352,RC,73706,HCPCS,Outpatient,,,2872.83,1723.70,,1749,110,,48.728,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,2.288,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.928,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,2.936,Fee Schedule,360% of BCBS POS Rate,655.99,360,,2.936,Fee schedule,360% of BCBS PPO Rate,655.99,360,,2.936,Fee Schedule,360% of BCBS Traditional Rate,916,100,,14.016,Case Rate,Pays based on per visit rate,180.34,100,,5.88,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,6.056,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2154.62,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.08,Case Rate,Pays Based on per visit rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,1334,100,,5.216,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,38.76,Case Rate,Pays based on per visit rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.88,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2872.83,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2872.83,
CT ANGIO LWR EXT WWO CM LT,50588238,CDM,352,RC,73706,HCPCS,Outpatient,,,1915.22,1149.13,TC   ,1749,110,,832,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,10.192,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.968,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,13.104,Fee Schedule,360% of BCBS POS Rate,655.99,360,,13.104,Fee schedule,360% of BCBS PPO Rate,655.99,360,,13.104,Fee Schedule,360% of BCBS Traditional Rate,916,100,,17.144,Case Rate,Pays based on per visit rate,180.34,100,,235.712,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,242.776,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.42,75,,1225.512,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.552,Case Rate,Pays Based on per visit rate,1334,100,,1.024,Case Rate,Pays based on per visit rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1.024,Case Rate,Pays based on per visit rate,1334,100,,316,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,49.592,Case Rate,Pays based on per visit rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,235.712,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.22,100,,1634.016,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,1915.22,
CT ANGIO LWR EXT WWO CM LT,50588238,CDM,352,RC,73706,HCPCS,Outpatient,,,1915.22,1149.13,TC   ,1749,110,,832,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,0.84,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.968,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.08,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.08,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.08,Fee Schedule,360% of BCBS Traditional Rate,916,100,,69.088,Case Rate,Pays based on per visit rate,180.34,100,,215.464,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,221.928,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.42,75,,1225.512,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.048,Case Rate,Pays Based on per visit rate,1334,100,,4950.864,Case Rate,Pays based on per visit rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,4950.864,Case Rate,Pays based on per visit rate,1334,100,,0.056,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,9.512,Case Rate,Pays based on per visit rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,215.464,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.22,100,,1634.016,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,1915.22,
CT ANGIO LWR EXT WWO CM RT,50588239,CDM,352,RC,73706,HCPCS,Outpatient,,,1915.22,1149.13,,1749,110,,832,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,1.016,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,17.992,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,1.312,Fee Schedule,360% of BCBS POS Rate,655.99,360,,1.312,Fee schedule,360% of BCBS PPO Rate,655.99,360,,1.312,Fee Schedule,360% of BCBS Traditional Rate,916,100,,51.448,Case Rate,Pays based on per visit rate,180.34,100,,5.096,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,5.248,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.42,75,,368.632,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.024,Case Rate,Pays Based on per visit rate,1334,100,,162.36,Case Rate,Pays based on per visit rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,162.36,Case Rate,Pays based on per visit rate,1334,100,,4784.472,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,269.16,Case Rate,Pays based on per visit rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.22,100,,491.504,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,1915.22,
CT ANGIO LWR EXT WWO CM RT,50588239,CDM,352,RC,73706,HCPCS,Outpatient,,,1915.22,1149.13,,1749,110,,832,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,10.752,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.096,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,13.824,Fee Schedule,360% of BCBS POS Rate,655.99,360,,13.824,Fee schedule,360% of BCBS PPO Rate,655.99,360,,13.824,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3279.464,Case Rate,Pays based on per visit rate,180.34,100,,8.984,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,9.256,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.42,75,,833.904,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4950.864,Case Rate,Pays Based on per visit rate,1334,100,,0.416,Case Rate,Pays based on per visit rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.416,Case Rate,Pays based on per visit rate,1334,100,,130.728,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,84.456,Case Rate,Pays based on per visit rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,8.984,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.22,100,,1111.872,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,1915.22,
CT ANGIO UPR EXT WWO CM BI,50588240,CDM,352,RC,73206,HCPCS,Outpatient,,,3900,2340.00,,1749,110,,832,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,123.2,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.104,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,158.4,Fee Schedule,360% of BCBS POS Rate,655.99,360,,158.4,Fee schedule,360% of BCBS PPO Rate,655.99,360,,158.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,27,Case Rate,Pays based on per visit rate,180.34,100,,0.856,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,0.88,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2925,75,,1441.152,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,162.36,Case Rate,Pays Based on per visit rate,1334,100,,63,Case Rate,Pays based on per visit rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,63,Case Rate,Pays based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,22.232,Case Rate,Pays based on per visit rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,0.856,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3900,100,,1921.536,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3900,
CT ANGIO UPR EXT WWO CM BI,50588240,CDM,352,RC,73206,HCPCS,Outpatient,,,3900,2340.00,,1749,110,,136.416,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,10.184,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.128,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,13.088,Fee Schedule,360% of BCBS POS Rate,655.99,360,,13.088,Fee schedule,360% of BCBS PPO Rate,655.99,360,,13.088,Fee Schedule,360% of BCBS Traditional Rate,916,100,,37.376,Case Rate,Pays based on per visit rate,180.34,100,,1.824,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,1.88,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2925,75,,1441.152,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.416,Case Rate,Pays Based on per visit rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,1334,100,,0.632,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,22.368,Case Rate,Pays based on per visit rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,1.824,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3900,100,,1921.536,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,3900,
CT ANGIO UPR EXT WWO CM LT,50588241,CDM,352,RC,73206,HCPCS,Outpatient,,,2474.51,1484.71,TC   ,1749,110,,72.768,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.992,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,179.2,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,10.272,Fee Schedule,360% of BCBS POS Rate,655.99,360,,10.272,Fee schedule,360% of BCBS PPO Rate,655.99,360,,10.272,Fee Schedule,360% of BCBS Traditional Rate,916,100,,30.424,Case Rate,Pays based on per visit rate,180.34,100,,33.6,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,34.608,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1855.88,75,,658.776,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,63,Case Rate,Pays Based on per visit rate,1334,100,,194.36,Case Rate,Pays based on per visit rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,194.36,Case Rate,Pays based on per visit rate,1334,100,,5.032,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,29.8,Case Rate,Pays based on per visit rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,33.6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2474.51,100,,878.368,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2474.51,
CT ANGIO UPR EXT WWO CM LT,50588241,CDM,352,RC,73206,HCPCS,Outpatient,,,2474.51,1484.71,TC   ,1749,110,,240,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,161.504,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,179.224,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,207.648,Fee Schedule,360% of BCBS POS Rate,655.99,360,,207.648,Fee schedule,360% of BCBS PPO Rate,655.99,360,,207.648,Fee Schedule,360% of BCBS Traditional Rate,916,100,,765.576,Case Rate,Pays based on per visit rate,180.34,100,,17.272,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,17.792,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1855.88,75,,710.128,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.048,Case Rate,Pays Based on per visit rate,1334,100,,10.6,Case Rate,Pays based on per visit rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,10.6,Case Rate,Pays based on per visit rate,1334,100,,1800,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,289.6,Case Rate,Pays based on per visit rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.272,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2474.51,100,,946.832,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2474.51,
CT ANGIO UPR EXT WWO CM RT,50588242,CDM,352,RC,73206,HCPCS,Outpatient,,,2474.51,1484.71,,1749,110,,49.152,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,27.72,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,179.632,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,35.64,Fee Schedule,360% of BCBS POS Rate,655.99,360,,35.64,Fee schedule,360% of BCBS PPO Rate,655.99,360,,35.64,Fee Schedule,360% of BCBS Traditional Rate,916,100,,59.248,Case Rate,Pays based on per visit rate,180.34,100,,64.656,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,66.592,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1855.88,75,,2287.096,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,194.36,Case Rate,Pays Based on per visit rate,1334,100,,9.936,Case Rate,Pays based on per visit rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,9.936,Case Rate,Pays based on per visit rate,1334,100,,20,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,319.808,Case Rate,Pays based on per visit rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,64.656,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2474.51,100,,3049.464,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2474.51,
CT ANGIO UPR EXT WWO CM RT,50588242,CDM,352,RC,73206,HCPCS,Outpatient,,,2474.51,1484.71,,1749,110,,117.984,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,27.72,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,179.64,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,35.64,Fee Schedule,360% of BCBS POS Rate,655.99,360,,35.64,Fee schedule,360% of BCBS PPO Rate,655.99,360,,35.64,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3729.984,Case Rate,Pays based on per visit rate,180.34,100,,5.456,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,5.624,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1855.88,75,,2315.248,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,10.6,Case Rate,Pays Based on per visit rate,1334,100,,5.432,Case Rate,Pays based on per visit rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,5.432,Case Rate,Pays based on per visit rate,1334,100,,117.736,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,180.352,Case Rate,Pays based on per visit rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.456,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2474.51,100,,3087,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2474.51,
CT ASP,50588243,CDM,361,RC,,,Outpatient,,,614.38,368.63,,368.63,60,,49.728,Percent of Total Billed Charges,60% of Total Billed Charges,276.47,45,,221.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.03,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,1050.28,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,221.18,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,221.18,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,221.18,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,368.63,60,,30.432,Percent of Total Billed Charges,60% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.38,100,,491.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,88.59,14.42,,10.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.79,75,,3472.88,Percent of Total Billed Charges,75% of Total Billed Charges,307.19,50,,9.936,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,31.664,Percent of Total Billed Charges,50% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.19,50,,31.664,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.07,70,,26.592,Percent of Total Billed Charges,70% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.38,100,,4630.504,Percent of Total Billed Charges,100% of Total Billed Charges,86.01,1050.28,
CT BONE MARROW ASPIRATION(S),50588244,CDM,361,RC,,,Outpatient,,,1309.9,785.94,,785.94,60,,220.944,Percent of Total Billed Charges,60% of Total Billed Charges,589.46,45,,471.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.77,28,,0.896,Percent of Total Billed Charges,28% of Total Billed Charges,1050.79,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,471.56,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,471.56,36,,1.152,Percent of Total Billed Charges,36% Total Bille Charges,471.56,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,785.94,60,,9.544,Percent of Total Billed Charges,60% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1309.9,100,,1047.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,188.89,14.42,,42.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,982.43,75,,389.248,Percent of Total Billed Charges,75% of Total Billed Charges,654.95,50,,5.432,Percent of Total Billed Charges,50% of Total Billed Charges,654.95,50,,12.024,Percent of Total Billed Charges,50% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,654.95,50,,12.024,Percent of Total Billed Charges,50% of Total Billed Charges,654.95,50,,0.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,916.93,70,,2.608,Percent of Total Billed Charges,70% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,183.39,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1309.9,100,,519,Percent of Total Billed Charges,100% of Total Billed Charges,183.39,1309.9,
CT BX ABD RETROPERITNL PERC,50588262,CDM,361,RC,,,Outpatient,,,2285.36,1371.22,,1371.22,60,,132.784,Percent of Total Billed Charges,60% of Total Billed Charges,1028.41,45,,822.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.9,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,1058.41,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,822.73,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,822.73,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,822.73,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1371.22,60,,24.632,Percent of Total Billed Charges,60% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2285.36,100,,1828.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,329.55,14.42,,3.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1714.02,75,,389.248,Percent of Total Billed Charges,75% of Total Billed Charges,1142.68,50,,31.664,Percent of Total Billed Charges,50% of Total Billed Charges,1142.68,50,,12.72,Percent of Total Billed Charges,50% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1142.68,50,,12.72,Percent of Total Billed Charges,50% of Total Billed Charges,1142.68,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1599.75,70,,303.888,Percent of Total Billed Charges,70% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,319.95,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2285.36,100,,519,Percent of Total Billed Charges,100% of Total Billed Charges,319.95,2285.36,
CT BONE MARROW BIOPSY(IES),50588263,CDM,361,RC,,,Outpatient,,,1260.83,756.50,,756.5,60,,1123.272,Percent of Total Billed Charges,60% of Total Billed Charges,567.37,45,,453.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.03,28,,5.424,Percent of Total Billed Charges,28% of Total Billed Charges,1059.14,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,453.9,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,453.9,36,,6.976,Percent of Total Billed Charges,36% Total Bille Charges,453.9,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,756.5,60,,18.824,Percent of Total Billed Charges,60% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1260.83,100,,1008.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,181.81,14.42,,19.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,945.62,75,,429.104,Percent of Total Billed Charges,75% of Total Billed Charges,630.42,50,,12.024,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,64.712,Percent of Total Billed Charges,50% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630.42,50,,64.712,Percent of Total Billed Charges,50% of Total Billed Charges,630.42,50,,1.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,882.58,70,,13.896,Percent of Total Billed Charges,70% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,176.52,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1260.83,100,,572.136,Percent of Total Billed Charges,100% of Total Billed Charges,176.52,1260.83,
CT BX BONE SUPERFICIAL,50588264,CDM,361,RC,,,Outpatient,,,2191.72,1315.03,,1315.03,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,986.27,45,,789.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,613.68,28,,12.888,Percent of Total Billed Charges,28% of Total Billed Charges,1060.8,32,,180.424,Percent of Total Billed Charges,32% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,789.02,36,,16.568,Percent of Total Billed Charges,36% of Total Billed Charges,789.02,36,,16.568,Percent of Total Billed Charges,36% Total Bille Charges,789.02,36,,16.568,Percent of Total Billed Charges,36% of Total Billed Charges,1315.03,60,,28.696,Percent of Total Billed Charges,60% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2191.72,100,,1753.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,316.05,14.42,,20.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1643.79,75,,429.104,Percent of Total Billed Charges,75% of Total Billed Charges,1095.86,50,,12.72,Percent of Total Billed Charges,50% of Total Billed Charges,1095.86,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1095.86,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,1095.86,50,,4950.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1534.2,70,,84.144,Percent of Total Billed Charges,70% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2191.72,100,,572.136,Percent of Total Billed Charges,100% of Total Billed Charges,306.84,2191.72,
CT BX LIVER PERC,50588265,CDM,361,RC,,,Outpatient,,,2446.33,1467.80,,1467.8,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,1100.85,45,,880.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.97,28,,8.088,Percent of Total Billed Charges,28% of Total Billed Charges,1065.19,32,,180.48,Percent of Total Billed Charges,32% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,880.68,36,,10.392,Percent of Total Billed Charges,36% of Total Billed Charges,880.68,36,,10.392,Percent of Total Billed Charges,36% Total Bille Charges,880.68,36,,10.392,Percent of Total Billed Charges,36% of Total Billed Charges,1467.8,60,,10.128,Percent of Total Billed Charges,60% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2446.33,100,,1957.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,352.76,14.42,,11.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.75,75,,1467.8,Percent of Total Billed Charges,75% of Total Billed Charges,1223.17,50,,64.712,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1223.17,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,162.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1712.43,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2446.33,100,,1957.064,Percent of Total Billed Charges,100% of Total Billed Charges,342.49,2446.33,
CT BX LUNG MEDIASTINUM LT,50588267,CDM,361,RC,32408,HCPCS,Outpatient,,,2270.38,1362.23,,146.55,100,,50.784,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3278.31,233,,7.4,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1067.83,32,,180.888,Percent of Total Billed Charges,32% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,4530.54,322,,9.512,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4530.54,322,,9.512,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4530.54,322,,9.512,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1362.23,60,,19.968,Percent of Total Billed Charges,60% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,327.39,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1702.79,75,,1863.288,Percent of Total Billed Charges,75% of Total Billed Charges,1135.19,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,508.776,Percent of Total Billed Charges,50% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.19,50,,508.776,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,95.48,Fee Schedule,100% of ASC Tier Groupings fee schedule,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2270.38,100,,2484.384,Percent of Total Billed Charges,100% of Total Billed Charges,146.55,4530.54,
CT BX LUNG MEDIASTINUM RT,50588268,CDM,361,RC,32408,HCPCS,Outpatient,,,2270.38,1362.23,,146.55,100,,60.976,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3278.31,233,,3.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1069.46,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,4530.54,322,,4.28,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4530.54,322,,4.28,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4530.54,322,,4.28,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1362.23,60,,23.128,Percent of Total Billed Charges,60% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,327.39,14.42,,1.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1702.79,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,1135.19,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,117.96,Percent of Total Billed Charges,50% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.19,50,,117.96,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,63,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,30.048,Fee Schedule,100% of ASC Tier Groupings fee schedule,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2270.38,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,146.55,4530.54,
CT BX LYMPH NODE BI,50588269,CDM,361,RC,,,Outpatient,,,2873.99,1724.39,,1724.39,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,1293.3,45,,1034.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,804.72,28,,1.376,Percent of Total Billed Charges,28% of Total Billed Charges,1070.78,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,1034.64,36,,1.768,Percent of Total Billed Charges,36% of Total Billed Charges,1034.64,36,,1.768,Percent of Total Billed Charges,36% Total Bille Charges,1034.64,36,,1.768,Percent of Total Billed Charges,36% of Total Billed Charges,1724.39,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2873.99,100,,2299.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,414.43,14.42,,18.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2155.49,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,1437,50,,508.776,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,5.704,Percent of Total Billed Charges,50% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1437,50,,5.704,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2011.79,70,,203.536,Percent of Total Billed Charges,70% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2873.99,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,402.36,2873.99,
CT BX LYMPH NODE LT,50588270,CDM,361,RC,,,Outpatient,,,1915.99,1149.59,,1149.59,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,862.2,45,,689.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.48,28,,7.84,Percent of Total Billed Charges,28% of Total Billed Charges,1077.22,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,689.76,36,,10.08,Percent of Total Billed Charges,36% of Total Billed Charges,689.76,36,,10.08,Percent of Total Billed Charges,36% Total Bille Charges,689.76,36,,10.08,Percent of Total Billed Charges,36% of Total Billed Charges,1149.59,60,,44.56,Percent of Total Billed Charges,60% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1915.99,100,,1532.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,7.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1436.99,75,,489.544,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,117.96,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,78.552,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,958,50,,78.552,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,194.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1341.19,70,,272.488,Percent of Total Billed Charges,70% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1915.99,100,,652.72,Percent of Total Billed Charges,100% of Total Billed Charges,268.24,1915.99,
CT BX LYMPH NODE RT,50588271,CDM,361,RC,,,Outpatient,,,1915.99,1149.59,,1149.59,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,862.2,45,,689.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.48,28,,5.856,Percent of Total Billed Charges,28% of Total Billed Charges,1077.44,32,,18.176,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,689.76,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,689.76,36,,7.528,Percent of Total Billed Charges,36% Total Bille Charges,689.76,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,1149.59,60,,14.496,Percent of Total Billed Charges,60% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1915.99,100,,1532.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1436.99,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,5.704,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,205.144,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,958,50,,205.144,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,10.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1341.19,70,,234.544,Percent of Total Billed Charges,70% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1915.99,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,268.24,1915.99,
CT BX MEDIASTINUM,50588272,CDM,361,RC,32408,HCPCS,Outpatient,,,2270.38,1362.23,,146.55,100,,107.088,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3278.31,233,,9.544,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1081.6,32,,18.224,Percent of Total Billed Charges,32% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,4530.54,322,,12.272,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4530.54,322,,12.272,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4530.54,322,,12.272,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1362.23,60,,29.504,Percent of Total Billed Charges,60% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,327.39,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1702.79,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,1135.19,50,,78.552,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,3.832,Percent of Total Billed Charges,50% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.19,50,,3.832,Percent of Total Billed Charges,50% of Total Billed Charges,1135.19,50,,9.936,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,5.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,317.85,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2270.38,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,146.55,4530.54,
CT BX MUSCLE PERC,50588273,CDM,361,RC,,,Outpatient,,,1757.02,1054.21,,1054.21,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,790.66,45,,632.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,491.97,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,1081.6,32,,18.312,Percent of Total Billed Charges,32% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,632.53,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,632.53,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,632.53,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,1054.21,60,,5.736,Percent of Total Billed Charges,60% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1757.02,100,,1405.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,253.36,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1317.77,75,,368.632,Percent of Total Billed Charges,75% of Total Billed Charges,878.51,50,,205.144,Percent of Total Billed Charges,50% of Total Billed Charges,878.51,50,,5.08,Percent of Total Billed Charges,50% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,878.51,50,,5.08,Percent of Total Billed Charges,50% of Total Billed Charges,878.51,50,,5.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1229.91,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,245.98,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1757.02,100,,491.504,Percent of Total Billed Charges,100% of Total Billed Charges,245.98,1757.02,
CT BX PANCREAS PERC,50588274,CDM,361,RC,,,Outpatient,,,2583.73,1550.24,,1550.24,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,1162.68,45,,930.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,723.44,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,1084.16,32,,182.136,Percent of Total Billed Charges,32% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,930.14,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,930.14,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,930.14,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,1550.24,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2583.73,100,,2066.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,372.57,14.42,,15.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1937.8,75,,429.104,Percent of Total Billed Charges,75% of Total Billed Charges,1291.87,50,,3.832,Percent of Total Billed Charges,50% of Total Billed Charges,1291.87,50,,103.824,Percent of Total Billed Charges,50% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1291.87,50,,103.824,Percent of Total Billed Charges,50% of Total Billed Charges,1291.87,50,,31.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1808.61,70,,453.088,Percent of Total Billed Charges,70% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,361.72,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2583.73,100,,572.136,Percent of Total Billed Charges,100% of Total Billed Charges,361.72,2583.73,
CT BX PLEURA PERC LT,50588276,CDM,361,RC,,,Outpatient,,,1930.9,1158.54,,1158.54,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,868.91,45,,695.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.65,28,,6.832,Percent of Total Billed Charges,28% of Total Billed Charges,1084.19,32,,182.152,Percent of Total Billed Charges,32% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,695.12,36,,8.784,Percent of Total Billed Charges,36% of Total Billed Charges,695.12,36,,8.784,Percent of Total Billed Charges,36% Total Bille Charges,695.12,36,,8.784,Percent of Total Billed Charges,36% of Total Billed Charges,1158.54,60,,10.304,Percent of Total Billed Charges,60% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1930.9,100,,1544.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,278.44,14.42,,36.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.18,75,,429.104,Percent of Total Billed Charges,75% of Total Billed Charges,965.45,50,,5.08,Percent of Total Billed Charges,50% of Total Billed Charges,965.45,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,965.45,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,965.45,50,,12.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1351.63,70,,22.016,Percent of Total Billed Charges,70% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1930.9,100,,572.136,Percent of Total Billed Charges,100% of Total Billed Charges,270.33,1930.9,
CT BX PLEURA PERC RT,50588277,CDM,361,RC,,,Outpatient,,,1930.9,1158.54,,1158.54,60,,168.56,Percent of Total Billed Charges,60% of Total Billed Charges,868.91,45,,695.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.65,28,,6.264,Percent of Total Billed Charges,28% of Total Billed Charges,1092.94,32,,182.384,Percent of Total Billed Charges,32% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,695.12,36,,8.056,Percent of Total Billed Charges,36% of Total Billed Charges,695.12,36,,8.056,Percent of Total Billed Charges,36% Total Bille Charges,695.12,36,,8.056,Percent of Total Billed Charges,36% of Total Billed Charges,1158.54,60,,18.208,Percent of Total Billed Charges,60% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1930.9,100,,1544.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,278.44,14.42,,43.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.18,75,,317.48,Percent of Total Billed Charges,75% of Total Billed Charges,965.45,50,,103.824,Percent of Total Billed Charges,50% of Total Billed Charges,965.45,50,,479.984,Percent of Total Billed Charges,50% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,965.45,50,,479.984,Percent of Total Billed Charges,50% of Total Billed Charges,965.45,50,,12.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1351.63,70,,6.448,Percent of Total Billed Charges,70% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,270.33,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1930.9,100,,423.304,Percent of Total Billed Charges,100% of Total Billed Charges,270.33,1930.9,
CT BX RENAL PERC BI,50588279,CDM,361,RC,,,Outpatient,,,3105.48,1863.29,,1863.29,60,,67.776,Percent of Total Billed Charges,60% of Total Billed Charges,1397.47,45,,1117.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.53,28,,6.184,Percent of Total Billed Charges,28% of Total Billed Charges,1097.49,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,1117.97,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,1117.97,36,,7.944,Percent of Total Billed Charges,36% Total Bille Charges,1117.97,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,1863.29,60,,78.632,Percent of Total Billed Charges,60% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3105.48,100,,2484.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,447.81,14.42,,5.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2329.11,75,,317.48,Percent of Total Billed Charges,75% of Total Billed Charges,1552.74,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1552.74,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,64.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2173.84,70,,3.264,Percent of Total Billed Charges,70% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3105.48,100,,423.304,Percent of Total Billed Charges,100% of Total Billed Charges,434.77,3105.48,
CT BX RENAL PERC LT,50588280,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,70.992,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,4.688,Percent of Total Billed Charges,28% of Total Billed Charges,1097.7,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,6.032,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,6.032,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,6.032,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,42.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,286.472,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,479.984,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,42.704,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,381.96,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
CT BX RENAL PERC RT,50588281,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,526.656,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,1099.17,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,12.76,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,586.504,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,373.216,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,782,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
CT BX THYROID CORE,50588283,CDM,361,RC,,,Outpatient,,,1225.13,735.08,,735.08,60,,408.864,Percent of Total Billed Charges,60% of Total Billed Charges,551.31,45,,441.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.04,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,1103.18,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,441.05,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,441.05,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,441.05,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,735.08,60,,10.792,Percent of Total Billed Charges,60% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1225.13,100,,980.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,176.66,14.42,,45.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,918.85,75,,586.504,Percent of Total Billed Charges,75% of Total Billed Charges,612.57,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,612.57,50,,105.576,Percent of Total Billed Charges,50% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,612.57,50,,105.576,Percent of Total Billed Charges,50% of Total Billed Charges,612.57,50,,508.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,857.59,70,,20.528,Percent of Total Billed Charges,70% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,171.52,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1225.13,100,,782,Percent of Total Billed Charges,100% of Total Billed Charges,171.52,1225.13,
CT CHEST PE PROTOCOL,50588287,CDM,352,RC,71275,HCPCS,Outpatient,,,2899.14,1739.48,TC   ,1749,110,,354.24,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,19.128,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,183.544,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,24.592,Fee Schedule,360% of BCBS POS Rate,655.99,360,,24.592,Fee schedule,360% of BCBS PPO Rate,655.99,360,,24.592,Fee Schedule,360% of BCBS Traditional Rate,916,100,,237.624,Case Rate,Pays based on per visit rate,180.34,100,,17.2,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,17.72,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2174.36,75,,447.832,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.032,Case Rate,Pays Based on per visit rate,1334,100,,0.448,Case Rate,Pays based on per visit rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.448,Case Rate,Pays based on per visit rate,1334,100,,117.96,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,11.68,Case Rate,Pays based on per visit rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,17.2,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2899.14,100,,597.112,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2899.14,
CT CHEST PE PROTOCOL,50588287,CDM,352,RC,71275,HCPCS,Outpatient,,,2899.14,1739.48,TC   ,1749,110,,432.904,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,11.296,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,183.544,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,14.52,Fee Schedule,360% of BCBS POS Rate,655.99,360,,14.52,Fee schedule,360% of BCBS PPO Rate,655.99,360,,14.52,Fee Schedule,360% of BCBS Traditional Rate,916,100,,15.36,Case Rate,Pays based on per visit rate,180.34,100,,90.344,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,93.056,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2174.36,75,,447.832,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,105.576,Case Rate,Pays Based on per visit rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,1334,100,,5.704,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,36.96,Case Rate,Pays based on per visit rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,90.344,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2899.14,100,,597.112,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2899.14,
CT DRN ABS CATH CHECK,50588290,CDM,361,RC,,,Outpatient,,,896.93,538.16,,538.16,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,403.62,45,,322.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.14,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,1111.23,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,322.89,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,322.89,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,322.89,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,538.16,60,,81.128,Percent of Total Billed Charges,60% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,896.93,100,,717.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,129.34,14.42,,148.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.7,75,,613.872,Percent of Total Billed Charges,75% of Total Billed Charges,448.47,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,448.47,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.47,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,448.47,50,,78.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,627.85,70,,15.816,Percent of Total Billed Charges,70% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,125.57,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,896.93,100,,818.496,Percent of Total Billed Charges,100% of Total Billed Charges,125.57,1111.23,
CT DRN ABS CATH EXCH,50588291,CDM,361,RC,,,Outpatient,,,2784.92,1670.95,,1670.95,60,,73.192,Percent of Total Billed Charges,60% of Total Billed Charges,1253.21,45,,1002.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.78,28,,2.832,Percent of Total Billed Charges,28% of Total Billed Charges,1114.31,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,1002.57,36,,3.648,Percent of Total Billed Charges,36% of Total Billed Charges,1002.57,36,,3.648,Percent of Total Billed Charges,36% Total Bille Charges,1002.57,36,,3.648,Percent of Total Billed Charges,36% of Total Billed Charges,1670.95,60,,36.992,Percent of Total Billed Charges,60% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2784.92,100,,2227.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,401.59,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2088.69,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,1392.46,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,1392.46,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1392.46,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,1392.46,50,,205.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1949.44,70,,25.28,Percent of Total Billed Charges,70% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,389.89,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2784.92,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,389.89,2784.92,
CT DRN ABS TRNSRECT,50588300,CDM,361,RC,,,Outpatient,,,2690.75,1614.45,,1614.45,60,,165.304,Percent of Total Billed Charges,60% of Total Billed Charges,1210.84,45,,968.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,753.41,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,1123.2,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,968.67,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,968.67,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,968.67,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,1614.45,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2690.75,100,,2152.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,388.01,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2018.06,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,1345.38,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,1345.38,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1345.38,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1345.38,50,,3.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1883.53,70,,24.768,Percent of Total Billed Charges,70% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,376.71,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2690.75,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,376.71,2690.75,
CT DRN CHOLECYSTOSTOMY PERC,50588301,CDM,361,RC,,,Outpatient,,,4076.68,2446.01,,2446.01,60,,88.016,Percent of Total Billed Charges,60% of Total Billed Charges,1834.51,45,,1467.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1141.47,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,1123.2,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1467.6,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,1467.6,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,1467.6,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,2446.01,60,,10.752,Percent of Total Billed Charges,60% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4076.68,100,,3261.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,587.86,14.42,,1.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3057.51,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,2038.34,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,2038.34,50,,2.256,Percent of Total Billed Charges,50% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2038.34,50,,2.256,Percent of Total Billed Charges,50% of Total Billed Charges,2038.34,50,,5.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2853.68,70,,24.768,Percent of Total Billed Charges,70% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,570.74,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4076.68,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,570.74,4076.68,
CT DRN PARACENTESIS WO IMG,50588302,CDM,361,RC,,,Outpatient,,,1847.63,1108.58,,1108.58,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,831.43,45,,665.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.34,28,,39.568,Percent of Total Billed Charges,28% of Total Billed Charges,1126.53,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,665.15,36,,50.872,Percent of Total Billed Charges,36% of Total Billed Charges,665.15,36,,50.872,Percent of Total Billed Charges,36% Total Bille Charges,665.15,36,,50.872,Percent of Total Billed Charges,36% of Total Billed Charges,1108.58,60,,14.496,Percent of Total Billed Charges,60% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1847.63,100,,1478.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,266.43,14.42,,3.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1385.72,75,,470.68,Percent of Total Billed Charges,75% of Total Billed Charges,923.82,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,923.82,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,923.82,50,,103.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1293.34,70,,83.992,Percent of Total Billed Charges,70% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,258.67,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1847.63,100,,627.568,Percent of Total Billed Charges,100% of Total Billed Charges,258.67,1847.63,
CT STROKE HEAD BRAIN WO CM,50588307,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,,1749,110,,131.232,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,53.536,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,183.832,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,68.832,Fee Schedule,360% of BCBS POS Rate,403.49,360,,68.832,Fee schedule,360% of BCBS PPO Rate,403.49,360,,68.832,Fee Schedule,360% of BCBS Traditional Rate,916,100,,82.232,Case Rate,Pays based on per visit rate,106.88,100,,0.216,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.216,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,404.728,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,2.256,Case Rate,Pays Based on per visit rate,1334,100,,0.824,Case Rate,Pays based on per visit rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.824,Case Rate,Pays based on per visit rate,1334,100,,6.52,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,168,Case Rate,Pays based on per visit rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.216,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,539.632,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT STROKE HEAD BRAIN WO CM,50588307,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,,1749,110,,134.112,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,8.48,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,183.832,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,10.904,Fee Schedule,360% of BCBS POS Rate,403.49,360,,10.904,Fee schedule,360% of BCBS PPO Rate,403.49,360,,10.904,Fee Schedule,360% of BCBS Traditional Rate,916,100,,1080,Case Rate,Pays based on per visit rate,106.88,100,,2.768,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.848,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,404.728,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.16,Case Rate,Pays Based on per visit rate,1334,100,,0.408,Case Rate,Pays based on per visit rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.408,Case Rate,Pays based on per visit rate,1334,100,,479.984,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,10.928,Case Rate,Pays based on per visit rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.768,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,539.632,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT STROKE HEAD BRAIN WO CM,50588307,CDM,351,RC,70450,HCPCS,Outpatient,,,1952.53,1171.52,,1749,110,,163.776,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,123.2,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,183.832,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,158.4,Fee Schedule,360% of BCBS POS Rate,403.49,360,,158.4,Fee schedule,360% of BCBS PPO Rate,403.49,360,,158.4,Fee Schedule,360% of BCBS Traditional Rate,916,100,,933.112,Case Rate,Pays based on per visit rate,106.88,100,,5.544,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.712,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.4,75,,282.328,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.824,Case Rate,Pays Based on per visit rate,1334,100,,572,Case Rate,Pays based on per visit rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,572,Case Rate,Pays based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,155.664,Case Rate,Pays based on per visit rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.544,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.53,100,,376.44,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.53,
CT HEART CALCIUM SCORING WO CM,50588308,CDM,359,RC,75571,HCPCS,Outpatient,,,2000,1200.00,TC   ,1749,110,,163.776,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,53.808,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,183.832,Fee Schedule,320% of BCBS Blue Essentials Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,69.176,Fee Schedule,360% of BCBS POS Rate,287.32,360,,69.176,Fee schedule,360% of BCBS PPO Rate,287.32,360,,69.176,Fee Schedule,360% of BCBS Traditional Rate,916,100,,230.216,Case Rate,Pays based on per visit rate,86.88,100,,6.368,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,89.49,103,,6.56,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1500,75,,282.328,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.408,Case Rate,Pays Based on per visit rate,1334,100,,146.456,Case Rate,Pays based on per visit rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,146.456,Case Rate,Pays based on per visit rate,1334,100,,0.04,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,23.552,Case Rate,Pays based on per visit rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,6.368,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,376.44,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2000,
CT HEART CALCIUM SCORING WO CM,50588308,CDM,359,RC,75571,HCPCS,Outpatient,,,2000,1200.00,TC   ,1749,110,,76.912,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,280,,35.16,Fee Schedule,280% of BCBS BULE Fee Schedule,255.39,320,,183.856,Fee Schedule,320% of BCBS Blue Essentials Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,287.32,360,,45.208,Fee Schedule,360% of BCBS POS Rate,287.32,360,,45.208,Fee schedule,360% of BCBS PPO Rate,287.32,360,,45.208,Fee Schedule,360% of BCBS Traditional Rate,916,100,,18.208,Case Rate,Pays based on per visit rate,86.88,100,,16.224,Fee Schedule,100% of TX Mediciad Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,108.38,130,,,Fee Schedule,130% of CMS OPPS Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,89.49,103,,16.712,Fee Schedule,103% of TX Medicaid Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,85.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1500,75,,387.976,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,572,Case Rate,Pays Based on per visit rate,1334,100,,0.856,Case Rate,Pays based on per visit rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.856,Case Rate,Pays based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,105.008,Case Rate,Pays based on per visit rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,86.88,100,,16.224,Fee Schedule,100% of TX Medicaid Rate,83.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,517.296,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2000,
CT HEART W/CM W/ 3D,50588309,CDM,359,RC,75572,HCPCS,Outpatient,,,4000,2400.00,,1749,110,,82.56,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,509.6,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,582.4,320,,184.04,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,655.2,360,,22.608,Fee Schedule,360% of BCBS POS Rate,655.2,360,,22.608,Fee schedule,360% of BCBS PPO Rate,655.2,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,916,100,,19.904,Case Rate,Pays based on per visit rate,180.34,100,,10.544,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,10.856,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,3000,75,,387.976,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,146.456,Case Rate,Pays Based on per visit rate,1334,100,,4.8,Case Rate,Pays based on per visit rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,4.8,Case Rate,Pays based on per visit rate,1334,100,,105.576,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,72.848,Case Rate,Pays based on per visit rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,10.544,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4000,100,,517.296,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,4000,
CT LWR EXT W CM RT,50588320,CDM,352,RC,73701,HCPCS,Outpatient,,,2277.21,1366.33,,1749,110,,82.56,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,17.584,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,184.128,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS POS Rate,655.99,360,,22.608,Fee schedule,360% of BCBS PPO Rate,655.99,360,,22.608,Fee Schedule,360% of BCBS Traditional Rate,916,100,,27.008,Case Rate,Pays based on per visit rate,173.08,100,,54.936,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,56.584,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1707.91,75,,387.976,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.856,Case Rate,Pays Based on per visit rate,1334,100,,0.328,Case Rate,Pays based on per visit rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.328,Case Rate,Pays based on per visit rate,1334,100,,0.448,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,170.752,Case Rate,Pays based on per visit rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,54.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2277.21,100,,517.296,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2277.21,
CT LWR EXT W CM RT,50588320,CDM,352,RC,73701,HCPCS,Outpatient,,,2277.21,1366.33,,1749,110,,82.56,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,37.168,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.432,Fee Schedule,320% of BCBS Blue Essentials Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,47.784,Fee Schedule,360% of BCBS POS Rate,655.99,360,,47.784,Fee schedule,360% of BCBS PPO Rate,655.99,360,,47.784,Fee Schedule,360% of BCBS Traditional Rate,916,100,,81.632,Case Rate,Pays based on per visit rate,173.08,100,,5.936,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,178.27,103,,6.112,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1707.91,75,,227.456,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4.8,Case Rate,Pays Based on per visit rate,1334,100,,8.544,Case Rate,Pays based on per visit rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,8.544,Case Rate,Pays based on per visit rate,1334,100,,0.048,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,23.8,Case Rate,Pays based on per visit rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,173.08,100,,5.936,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2277.21,100,,303.272,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2277.21,
CT LWR EXT WO CM LT,50588321,CDM,352,RC,73700,HCPCS,Outpatient,,,1977.75,1186.65,TC   ,1749,110,,64.472,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,24.296,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.488,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,31.24,Fee Schedule,360% of BCBS POS Rate,403.49,360,,31.24,Fee schedule,360% of BCBS PPO Rate,403.49,360,,31.24,Fee Schedule,360% of BCBS Traditional Rate,916,100,,193.384,Case Rate,Pays based on per visit rate,106.88,100,,13.4,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,13.8,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1483.31,75,,227.456,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.328,Case Rate,Pays Based on per visit rate,1334,100,,0.656,Case Rate,Pays based on per visit rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.656,Case Rate,Pays based on per visit rate,1334,100,,0.112,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,26.24,Case Rate,Pays based on per visit rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,13.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1977.75,100,,303.272,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1977.75,
CT LWR EXT WO CM LT,50588321,CDM,352,RC,73700,HCPCS,Outpatient,,,1977.75,1186.65,TC   ,1749,110,,64.472,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.536,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.688,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.688,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.688,Fee Schedule,360% of BCBS Traditional Rate,916,100,,2.336,Case Rate,Pays based on per visit rate,106.88,100,,64.912,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,66.864,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1483.31,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,8.544,Case Rate,Pays Based on per visit rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,1334,100,,0.264,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.656,Case Rate,Pays based on per visit rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,64.912,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1977.75,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1977.75,
CT LWR EXT WO CM RT,50588322,CDM,352,RC,73700,HCPCS,Outpatient,,,1977.75,1186.65,,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.52,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.56,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1.952,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1.952,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1.952,Fee Schedule,360% of BCBS Traditional Rate,916,100,,259.2,Case Rate,Pays based on per visit rate,106.88,100,,3.472,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.576,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1483.31,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.656,Case Rate,Pays Based on per visit rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,7.144,Case Rate,Pays based on per visit rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1977.75,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1977.75,
CT LWR EXT WO CM RT,50588322,CDM,352,RC,73700,HCPCS,Outpatient,,,1977.75,1186.65,,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.56,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.76,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.76,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.76,Fee Schedule,360% of BCBS Traditional Rate,916,100,,680.392,Case Rate,Pays based on per visit rate,106.88,100,,4.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,4.176,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1483.31,75,,426.008,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.2,Case Rate,Pays Based on per visit rate,1334,100,,1.752,Case Rate,Pays based on per visit rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1.752,Case Rate,Pays based on per visit rate,1334,100,,2.256,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.04,Case Rate,Pays based on per visit rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1977.75,100,,568.008,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1977.75,
CT LWR EXT WWO CM RT,50588323,CDM,352,RC,73702,HCPCS,Outpatient,,,2493.75,1496.25,TC   ,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,7.712,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.568,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,9.92,Fee Schedule,360% of BCBS POS Rate,655.99,360,,9.92,Fee schedule,360% of BCBS PPO Rate,655.99,360,,9.92,Fee Schedule,360% of BCBS Traditional Rate,916,100,,7.728,Case Rate,Pays based on per visit rate,180.34,100,,4.312,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,4.44,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.31,75,,426.008,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.2,Case Rate,Pays Based on per visit rate,1334,100,,0.84,Case Rate,Pays based on per visit rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.84,Case Rate,Pays based on per visit rate,1334,100,,1.16,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.36,Case Rate,Pays based on per visit rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.312,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.75,100,,568.008,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2493.75,
CT LWR EXT WWO CM RT,50588323,CDM,352,RC,73702,HCPCS,Outpatient,,,2493.75,1496.25,TC   ,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,100.528,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,18.568,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,129.248,Fee Schedule,360% of BCBS POS Rate,655.99,360,,129.248,Fee schedule,360% of BCBS PPO Rate,655.99,360,,129.248,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.488,Case Rate,Pays based on per visit rate,180.34,100,,6,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,6.184,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.31,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.752,Case Rate,Pays Based on per visit rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,1334,100,,0.824,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.32,Case Rate,Pays based on per visit rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,6,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.75,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2493.75,
CT PEL WO CM BONE,50588324,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.568,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.064,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.064,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.064,Fee Schedule,360% of BCBS Traditional Rate,916,100,,3.488,Case Rate,Pays based on per visit rate,106.88,100,,5.616,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.784,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.84,Case Rate,Pays Based on per visit rate,1334,100,,8.408,Case Rate,Pays based on per visit rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,8.408,Case Rate,Pays based on per visit rate,1334,100,,0.408,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,4.32,Case Rate,Pays based on per visit rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.616,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,360,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
CT PEL WO CM BONE,50588324,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,0.04,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.608,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,0.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,0.048,Fee Schedule,360% of BCBS Traditional Rate,916,100,,181.44,Case Rate,Pays based on per visit rate,106.88,100,,1.16,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,1.2,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,401.632,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.344,Case Rate,Pays Based on per visit rate,1334,100,,0.168,Case Rate,Pays based on per visit rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.168,Case Rate,Pays based on per visit rate,1334,100,,572,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,44.8,Case Rate,Pays based on per visit rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,1.16,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,535.504,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
CT PEL WO CM CYSTOGRAM,50588325,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,262.272,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1.672,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.624,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2.144,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2.144,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2.144,Fee Schedule,360% of BCBS Traditional Rate,916,100,,133.056,Case Rate,Pays based on per visit rate,106.88,100,,2.28,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.344,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,401.632,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,8.408,Case Rate,Pays Based on per visit rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,1334,100,,146.456,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,36.4,Case Rate,Pays based on per visit rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.28,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,535.504,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
CT PEL WO CM CYSTOGRAM,50588325,CDM,352,RC,72192,HCPCS,Outpatient,,,2059.08,1235.45,,1749,110,,262.272,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,47.016,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,18.624,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,60.448,Fee Schedule,360% of BCBS POS Rate,403.49,360,,60.448,Fee schedule,360% of BCBS PPO Rate,403.49,360,,60.448,Fee Schedule,360% of BCBS Traditional Rate,916,100,,52.232,Case Rate,Pays based on per visit rate,106.88,100,,2.576,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.648,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.31,75,,318.112,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.168,Case Rate,Pays Based on per visit rate,1334,100,,0.68,Case Rate,Pays based on per visit rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.68,Case Rate,Pays based on per visit rate,1334,100,,0.856,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,93.512,Case Rate,Pays based on per visit rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2059.08,100,,424.152,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2059.08,
THORACENTESIS W/TUBE W/IMAGE BIL,50588327,CDM,361,RC,32557,HCPCS,Outpatient,,,5378.98,3227.39,,4162,100,,106.104,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,33.008,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1129.1,32,,18.632,Percent of Total Billed Charges,32% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,42.44,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,42.44,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,42.44,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,30.344,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,775.65,14.42,,3.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,4034.24,75,,318.112,Percent of Total Billed Charges,75% of Total Billed Charges,2689.49,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,2689.49,50,,32.624,Percent of Total Billed Charges,50% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.49,50,,32.624,Percent of Total Billed Charges,50% of Total Billed Charges,2689.49,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,99.544,Fee Schedule,100% of ASC Tier Groupings fee schedule,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,753.06,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,5378.98,100,,424.152,Percent of Total Billed Charges,100% of Total Billed Charges,753.06,5378.98,
THORACENTESIS W/TUBE W/IMAGE LT,50588328,CDM,361,RC,32557,HCPCS,Outpatient,,,3378.98,2027.39,,4162,100,,91.992,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,60.712,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1130.24,32,,18.632,Percent of Total Billed Charges,32% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,78.056,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,78.056,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,78.056,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,40.888,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,487.25,14.42,,2.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2534.24,75,,317.52,Percent of Total Billed Charges,75% of Total Billed Charges,1689.49,50,,0.68,Percent of Total Billed Charges,50% of Total Billed Charges,1689.49,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1689.49,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,1689.49,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,29.24,Fee Schedule,100% of ASC Tier Groupings fee schedule,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3378.98,100,,423.36,Percent of Total Billed Charges,100% of Total Billed Charges,473.06,5252.24,
CT THORACENTESIS W IMAGE RT,50588329,CDM,361,RC,,,Outpatient,,,1598.97,959.38,,959.38,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,719.54,45,,575.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.71,28,,13.6,Percent of Total Billed Charges,28% of Total Billed Charges,1134.98,32,,18.64,Percent of Total Billed Charges,32% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,575.63,36,,17.488,Percent of Total Billed Charges,36% of Total Billed Charges,575.63,36,,17.488,Percent of Total Billed Charges,36% Total Bille Charges,575.63,36,,17.488,Percent of Total Billed Charges,36% of Total Billed Charges,959.38,60,,12.616,Percent of Total Billed Charges,60% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.97,100,,1279.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,230.57,14.42,,7.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.23,75,,317.52,Percent of Total Billed Charges,75% of Total Billed Charges,799.49,50,,32.624,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.49,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,8.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1119.28,70,,105.008,Percent of Total Billed Charges,70% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.97,100,,423.36,Percent of Total Billed Charges,100% of Total Billed Charges,223.86,1598.97,
THORACENTESIS W/TUBE W/IMAGE RT,50588330,CDM,361,RC,32557,HCPCS,Outpatient,,,3378.98,2027.39,,4162,100,,265.344,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3800.53,233,,23.328,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1138.92,32,,18.648,Percent of Total Billed Charges,32% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,5252.24,322,,29.992,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5252.24,322,,29.992,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5252.24,322,,29.992,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,98.456,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,487.25,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2534.24,75,,437.36,Percent of Total Billed Charges,75% of Total Billed Charges,1689.49,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,1689.49,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1689.49,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,1689.49,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,114.632,Fee Schedule,100% of ASC Tier Groupings fee schedule,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,473.06,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3378.98,100,,583.144,Percent of Total Billed Charges,100% of Total Billed Charges,473.06,5252.24,
CT UPR EXT W CM RT,50588335,CDM,352,RC,73201,HCPCS,Outpatient,,,2257.11,1354.27,TC   ,1749,110,,148.68,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,232.96,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,18.648,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,299.52,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,299.52,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,299.52,Fee Schedule,360% of BCBS Traditional Rate,916,100,,37.68,Case Rate,Pays based on per visit rate,209.84,100,,1.368,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,1.408,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1692.83,75,,437.36,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,4.936,Case Rate,Pays Based on per visit rate,1334,100,,1.624,Case Rate,Pays based on per visit rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,1.624,Case Rate,Pays based on per visit rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,1025.744,Case Rate,Pays based on per visit rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2257.11,100,,583.144,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2257.11,
CT UPR EXT W CM RT,50588335,CDM,352,RC,73201,HCPCS,Outpatient,,,2257.11,1354.27,TC   ,1749,110,,26.48,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,29.016,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,184.576,Fee Schedule,320% of BCBS Blue Essentials Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,37.304,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,37.304,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,37.304,Fee Schedule,360% of BCBS Traditional Rate,916,100,,175,Case Rate,Pays based on per visit rate,209.84,100,,59.336,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,216.14,103,,61.12,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1692.83,75,,380,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.688,Case Rate,Pays Based on per visit rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,1334,100,,0.2,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.072,Case Rate,Pays based on per visit rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,209.84,100,,59.336,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2257.11,100,,506.664,Percent of Total Billed Charges,100% of Total Billed Charges,209.84,2257.11,
CT UPR EXT WO CM RT,50588336,CDM,352,RC,73200,HCPCS,Outpatient,,,1952.45,1171.47,,1749,110,,288,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,61.488,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,185.024,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,79.056,Fee Schedule,360% of BCBS POS Rate,403.49,360,,79.056,Fee schedule,360% of BCBS PPO Rate,403.49,360,,79.056,Fee Schedule,360% of BCBS Traditional Rate,916,100,,34.328,Case Rate,Pays based on per visit rate,106.88,100,,85.696,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,88.264,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.34,75,,380,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.624,Case Rate,Pays Based on per visit rate,1334,100,,0.408,Case Rate,Pays based on per visit rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.408,Case Rate,Pays based on per visit rate,1334,100,,1.752,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,61.944,Case Rate,Pays based on per visit rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,85.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.45,100,,506.664,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.45,
CT UPR EXT WO CM RT,50588336,CDM,352,RC,73200,HCPCS,Outpatient,,,1952.45,1171.47,,1749,110,,624,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,61.488,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,185.616,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,79.056,Fee Schedule,360% of BCBS POS Rate,403.49,360,,79.056,Fee schedule,360% of BCBS PPO Rate,403.49,360,,79.056,Fee Schedule,360% of BCBS Traditional Rate,916,100,,104.296,Case Rate,Pays based on per visit rate,106.88,100,,14.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,14.48,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1464.34,75,,380,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.344,Case Rate,Pays Based on per visit rate,1334,100,,0.12,Case Rate,Pays based on per visit rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.12,Case Rate,Pays based on per visit rate,1334,100,,0.84,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,123.792,Case Rate,Pays based on per visit rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,14.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1952.45,100,,506.664,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,1952.45,
CT UPR EXT WWO CM RT,50588337,CDM,352,RC,73202,HCPCS,Outpatient,,,2500,1500.00,TC   ,1749,110,,624,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,48.216,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,185.88,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,61.992,Fee Schedule,360% of BCBS POS Rate,655.99,360,,61.992,Fee schedule,360% of BCBS PPO Rate,655.99,360,,61.992,Fee Schedule,360% of BCBS Traditional Rate,916,100,,59.68,Case Rate,Pays based on per visit rate,180.34,100,,5.048,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,5.2,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1875,75,,295.192,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.408,Case Rate,Pays Based on per visit rate,1334,100,,0.552,Case Rate,Pays based on per visit rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.552,Case Rate,Pays based on per visit rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,147.4,Case Rate,Pays based on per visit rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,5.048,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2500,100,,393.592,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2500,
CT UPR EXT WWO CM RT,50588337,CDM,352,RC,73202,HCPCS,Outpatient,,,2500,1500.00,TC   ,1749,110,,1332,Percent of Total Billed Charges,110% of Total Billed Charges,252.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,280,,61.488,Fee Schedule,280% of BCBS BULE Fee Schedule,583.1,320,,185.88,Fee Schedule,320% of BCBS Blue Essentials Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,655.99,360,,79.056,Fee Schedule,360% of BCBS POS Rate,655.99,360,,79.056,Fee schedule,360% of BCBS PPO Rate,655.99,360,,79.056,Fee Schedule,360% of BCBS Traditional Rate,916,100,,45.136,Case Rate,Pays based on per visit rate,180.34,100,,4.04,Fee Schedule,100% of TX Mediciad 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,151.69,90,,,Fee Schedule,90% of CMS OPPS Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,219.13,130,,,Fee Schedule,130% of CMS OPPS Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,185.75,103,,4.16,Fee Schedule,103% of TX Medicaid Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,173.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1875,75,,295.192,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.12,Case Rate,Pays Based on per visit rate,1334,100,,6.392,Case Rate,Pays based on per visit rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,6.392,Case Rate,Pays based on per visit rate,1334,100,,8.408,Case Rate,Pays based on per visit rate,252.85,150,,,Fee Schedule,150% of CMS OPPS Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,330.736,Case Rate,Pays based on per visit rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,180.34,100,,4.04,Fee Schedule,100% of TX Medicaid Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2500,100,,393.592,Percent of Total Billed Charges,100% of Total Billed Charges,151.69,2500,
CT LUNG SCREENING,50588342,CDM,350,RC,G0297,HCPCS,Outpatient,,,288.75,173.25,TC   ,1749,110,,1332,Percent of Total Billed Charges,110% of Total Billed Charges,129.94,45,,103.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.85,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,1144,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,103.95,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,103.95,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,103.95,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,916,100,,54.6,Case Rate,Pays based on per visit rate,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.75,100,,231,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,41.64,14.42,,6.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.56,75,,517.96,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.552,Case Rate,Pays Based on per visit rate,1334,100,,0.032,Case Rate,Pays based on per visit rate,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,0.032,Case Rate,Pays based on per visit rate,1334,100,,0.168,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,389.08,Case Rate,Pays based on per visit rate,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.75,100,,690.608,Percent of Total Billed Charges,100% of Total Billed Charges,40.43,1800,
CT LUNG SCREENING,50588342,CDM,350,RC,G0297,HCPCS,Outpatient,,,288.75,173.25,TC   ,1749,110,,1997.6,Percent of Total Billed Charges,110% of Total Billed Charges,129.94,45,,103.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.85,28,,182.12,Percent of Total Billed Charges,28% of Total Billed Charges,1144.17,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,103.95,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,103.95,36,,234.16,Percent of Total Billed Charges,36% Total Bille Charges,103.95,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,916,100,,37.68,Case Rate,Pays based on per visit rate,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.75,100,,231,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,41.64,14.42,,28.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.56,75,,517.96,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,6.392,Case Rate,Pays Based on per visit rate,1334,100,,0.024,Case Rate,Pays based on per visit rate,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,0.024,Case Rate,Pays based on per visit rate,1334,100,,0.344,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,7.144,Case Rate,Pays based on per visit rate,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,40.43,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.75,100,,690.608,Percent of Total Billed Charges,100% of Total Billed Charges,40.43,1800,
CT PERFUSION HEAD STROKE W CM,50588343,CDM,351,RC,0042T,HCPCS,Outpatient,,,2620.53,1572.32,TC   ,1933.44,110,,2829.6,Percent of Total Billed Charges,110% of Total Billed Charges,1179.24,45,,943.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.4,280,,61.488,Fee Schedule,280% of BCBS BULE Fee Schedule,313.6,320,,185.88,Fee Schedule,320% of BCBS Blue Essentials Rate,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,360,,79.056,Fee Schedule,360% of BCBS POS Rate,352.8,360,,79.056,Fee schedule,360% of BCBS PPO Rate,352.8,360,,79.056,Fee Schedule,360% of BCBS Traditional Rate,916,100,,10.6,Case Rate,Pays based on per visit rate,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2620.53,100,,2096.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,377.88,14.42,,16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1965.4,75,,404.728,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.032,Case Rate,Pays Based on per visit rate,1334,100,,0.6,Case Rate,Pays based on per visit rate,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,0.6,Case Rate,Pays based on per visit rate,1334,100,,0.68,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,9.776,Case Rate,Pays based on per visit rate,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2620.53,100,,539.632,Percent of Total Billed Charges,100% of Total Billed Charges,274.4,2620.53,
CT PERFUSION HEAD STROKE W CM,50588343,CDM,351,RC,0042T,HCPCS,Outpatient,,,2620.53,1572.32,TC   ,1933.44,110,,1997.6,Percent of Total Billed Charges,110% of Total Billed Charges,1179.24,45,,943.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.4,280,,61.488,Fee Schedule,280% of BCBS BULE Fee Schedule,313.6,320,,185.88,Fee Schedule,320% of BCBS Blue Essentials Rate,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,352.8,360,,79.056,Fee Schedule,360% of BCBS POS Rate,352.8,360,,79.056,Fee schedule,360% of BCBS PPO Rate,352.8,360,,79.056,Fee Schedule,360% of BCBS Traditional Rate,916,100,,37.68,Case Rate,Pays based on per visit rate,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2620.53,100,,2096.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,377.88,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1965.4,75,,404.728,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,0.024,Case Rate,Pays Based on per visit rate,1334,100,,5.288,Case Rate,Pays based on per visit rate,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334,100,,5.288,Case Rate,Pays based on per visit rate,1334,100,,32.624,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1800,100,,3,Case Rate,Pays based on per visit rate,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,366.87,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2620.53,100,,539.632,Percent of Total Billed Charges,100% of Total Billed Charges,274.4,2620.53,
INTRODUCER SET,50591000,CDM,272,RC,,,Outpatient,,,1453.75,872.25,,872.25,60,,2829.6,Percent of Total Billed Charges,60% of Total Billed Charges,654.19,45,,523.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,407.05,28,,210.152,Percent of Total Billed Charges,28% of Total Billed Charges,1146.5,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,523.35,36,,270.192,Percent of Total Billed Charges,36% of Total Billed Charges,523.35,36,,270.192,Percent of Total Billed Charges,36% Total Bille Charges,523.35,36,,270.192,Percent of Total Billed Charges,36% of Total Billed Charges,872.25,60,,58.52,Percent of Total Billed Charges,60% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.75,100,,1163,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,209.63,14.42,,2.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1090.31,75,,1372.128,Percent of Total Billed Charges,75% of Total Billed Charges,726.88,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,726.88,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,726.88,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,726.88,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1017.63,70,,9.784,Percent of Total Billed Charges,70% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,203.53,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1453.75,100,,1829.504,Percent of Total Billed Charges,100% of Total Billed Charges,203.53,1453.75,
NDL SPINAL A/S,50591002,CDM,272,RC,,,Outpatient,,,103.5,62.10,,62.1,60,,91.048,Percent of Total Billed Charges,60% of Total Billed Charges,46.58,45,,37.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.98,28,,522.296,Percent of Total Billed Charges,28% of Total Billed Charges,1149.2,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,37.26,36,,671.52,Percent of Total Billed Charges,36% of Total Billed Charges,37.26,36,,671.52,Percent of Total Billed Charges,36% Total Bille Charges,37.26,36,,671.52,Percent of Total Billed Charges,36% of Total Billed Charges,62.1,60,,37.48,Percent of Total Billed Charges,60% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,100,,82.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14.42,,8.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.63,75,,1372.128,Percent of Total Billed Charges,75% of Total Billed Charges,51.75,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.75,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.45,70,,27.752,Percent of Total Billed Charges,70% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.5,100,,1829.504,Percent of Total Billed Charges,100% of Total Billed Charges,14.49,1149.2,
BONE MARROW BIOP,50591003,CDM,272,RC,,,Outpatient,,,525,315.00,,315,60,,223.376,Percent of Total Billed Charges,60% of Total Billed Charges,236.25,45,,189,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147,28,,358.704,Percent of Total Billed Charges,28% of Total Billed Charges,1156.62,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,189,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,189,36,,461.192,Percent of Total Billed Charges,36% Total Bille Charges,189,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,315,60,,16.096,Percent of Total Billed Charges,60% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525,100,,420,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,75.71,14.42,,6.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.75,75,,2058.192,Percent of Total Billed Charges,75% of Total Billed Charges,262.5,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,262.5,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.5,70,,40.992,Percent of Total Billed Charges,70% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,73.5,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,100,,2744.256,Percent of Total Billed Charges,100% of Total Billed Charges,73.5,1156.62,
CATH DIL,50591004,CDM,272,RC,,,Outpatient,,,779.25,467.55,,467.55,60,,346.92,Percent of Total Billed Charges,60% of Total Billed Charges,350.66,45,,280.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.19,28,,291.2,Percent of Total Billed Charges,28% of Total Billed Charges,1158.4,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,280.53,36,,374.4,Percent of Total Billed Charges,36% of Total Billed Charges,280.53,36,,374.4,Percent of Total Billed Charges,36% Total Bille Charges,280.53,36,,374.4,Percent of Total Billed Charges,36% of Total Billed Charges,467.55,60,,18.824,Percent of Total Billed Charges,60% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,779.25,100,,623.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,112.37,14.42,,10.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.44,75,,824.008,Percent of Total Billed Charges,75% of Total Billed Charges,389.63,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,389.63,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.63,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,389.63,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,545.48,70,,235.2,Percent of Total Billed Charges,70% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,109.1,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,779.25,100,,1098.672,Percent of Total Billed Charges,100% of Total Billed Charges,109.1,1158.4,
CATH SUBCLV JUG,50591005,CDM,272,RC,,,Outpatient,,,484.75,290.85,,290.85,60,,588.8,Percent of Total Billed Charges,60% of Total Billed Charges,218.14,45,,174.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.73,28,,582.176,Percent of Total Billed Charges,28% of Total Billed Charges,1161.21,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,174.51,36,,748.512,Percent of Total Billed Charges,36% of Total Billed Charges,174.51,36,,748.512,Percent of Total Billed Charges,36% Total Bille Charges,174.51,36,,748.512,Percent of Total Billed Charges,36% of Total Billed Charges,290.85,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484.75,100,,387.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14.42,,18.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.56,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,242.38,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,242.38,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,242.38,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,242.38,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339.33,70,,35.384,Percent of Total Billed Charges,70% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,484.75,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,67.87,1161.21,
VENA CAVA FILT $,50591006,CDM,278,RC,,,Outpatient,,,6307.75,3784.65,,6938.53,110,,1218.416,Percent of Total Billed Charges,110% of Total Billed Charges,2838.49,45,,2270.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1766.17,28,,936.136,Percent of Total Billed Charges,28% of Total Billed Charges,1164.04,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,2270.79,36,,1203.6,Percent of Total Billed Charges,36% of Total Billed Charges,2270.79,36,,1203.6,Percent of Total Billed Charges,36% Total Bille Charges,2270.79,36,,1203.6,Percent of Total Billed Charges,36% of Total Billed Charges,3469.26,55,,165.72,Percent of Total Billed Charges,55% Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6307.75,100,,5046.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,909.58,14.42,,49.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5046.2,80,,1863.288,Percent of Total Billed Charges,80% of Total Billed Charges,3153.88,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,3153.88,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3153.88,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,3153.88,50,,0.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4415.43,70,,35.384,Percent of Total Billed Charges,70% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,883.09,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6307.75,100,,2484.384,Percent of Total Billed Charges,100% of Total Billed Charges,883.09,6938.53,
GW,50591007,CDM,272,RC,C1769,HCPCS,Outpatient,,,399,239.40,,55.13,100,,3397.904,Fee Schedule,100% of Aetna Fee Schedule,179.55,45,,143.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.72,28,,106.32,Percent of Total Billed Charges,28% of Total Billed Charges,1169.79,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,143.64,36,,136.704,Percent of Total Billed Charges,36% of Total Billed Charges,143.64,36,,136.704,Percent of Total Billed Charges,36% Total Bille Charges,143.64,36,,136.704,Percent of Total Billed Charges,36% of Total Billed Charges,239.4,60,,19.328,Percent of Total Billed Charges,60% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399,100,,319.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,57.54,14.42,,9.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.25,75,,1242.192,Percent of Total Billed Charges,75% of Total Billed Charges,199.5,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,199.5,50,,15.936,Percent of Total Billed Charges,50% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.5,50,,15.936,Percent of Total Billed Charges,50% of Total Billed Charges,199.5,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.3,70,,27.888,Percent of Total Billed Charges,70% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,55.86,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399,100,,1656.256,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,1169.79,
SUT RETRV,50591008,CDM,272,RC,,,Outpatient,,,829,497.40,,497.4,60,,32.072,Percent of Total Billed Charges,60% of Total Billed Charges,373.05,45,,298.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.12,28,,22.744,Percent of Total Billed Charges,28% of Total Billed Charges,1185.8,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,298.44,36,,29.24,Percent of Total Billed Charges,36% of Total Billed Charges,298.44,36,,29.24,Percent of Total Billed Charges,36% Total Bille Charges,298.44,36,,29.24,Percent of Total Billed Charges,36% of Total Billed Charges,497.4,60,,4532.512,Percent of Total Billed Charges,60% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,829,100,,663.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,119.54,14.42,,13.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.75,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,414.5,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,414.5,50,,19.712,Percent of Total Billed Charges,50% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.5,50,,19.712,Percent of Total Billed Charges,50% of Total Billed Charges,414.5,50,,0.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580.3,70,,4.232,Percent of Total Billed Charges,70% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,829,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,116.06,1185.8,
CATH ST,50591012,CDM,272,RC,C1725,HCPCS,Outpatient,,,344.25,206.55,,99.47,100,,47.056,Fee Schedule,100% of Aetna Fee Schedule,154.91,45,,123.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.39,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,1185.8,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,123.93,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,123.93,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,123.93,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,206.55,60,,342.376,Percent of Total Billed Charges,60% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.25,100,,275.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,49.64,14.42,,9.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.19,75,,959.232,Percent of Total Billed Charges,75% of Total Billed Charges,172.13,50,,15.936,Percent of Total Billed Charges,50% of Total Billed Charges,172.13,50,,20.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.13,50,,20.2,Percent of Total Billed Charges,50% of Total Billed Charges,172.13,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.98,70,,7.888,Percent of Total Billed Charges,70% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,48.2,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.25,100,,1278.976,Percent of Total Billed Charges,100% of Total Billed Charges,48.2,1185.8,
CATH FR,50591014,CDM,272,RC,,,Outpatient,,,590,354.00,,354,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,265.5,45,,212.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.2,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,212.4,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,212.4,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,212.4,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,354,60,,7.528,Percent of Total Billed Charges,60% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,590,100,,472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,85.08,14.42,,13.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.5,75,,1439.08,Percent of Total Billed Charges,75% of Total Billed Charges,295,50,,19.712,Percent of Total Billed Charges,50% of Total Billed Charges,295,50,,21.28,Percent of Total Billed Charges,50% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295,50,,21.28,Percent of Total Billed Charges,50% of Total Billed Charges,295,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413,70,,18.2,Percent of Total Billed Charges,70% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,82.6,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,590,100,,1918.768,Percent of Total Billed Charges,100% of Total Billed Charges,82.6,1189.45,
NDL GREEN BIOPSY,50591015,CDM,272,RC,,,Outpatient,,,574.25,344.55,,344.55,60,,91.432,Percent of Total Billed Charges,60% of Total Billed Charges,258.41,45,,206.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.79,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,206.73,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,206.73,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,206.73,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,344.55,60,,34.816,Percent of Total Billed Charges,60% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574.25,100,,459.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,82.81,14.42,,7.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.69,75,,959.384,Percent of Total Billed Charges,75% of Total Billed Charges,287.13,50,,20.2,Percent of Total Billed Charges,50% of Total Billed Charges,287.13,50,,16.776,Percent of Total Billed Charges,50% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.13,50,,16.776,Percent of Total Billed Charges,50% of Total Billed Charges,287.13,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,401.98,70,,240.08,Percent of Total Billed Charges,70% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.4,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,574.25,100,,1279.176,Percent of Total Billed Charges,100% of Total Billed Charges,80.4,1189.45,
CATH TROCAR KIT,50591019,CDM,272,RC,,,Outpatient,,,205.75,123.45,,123.45,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,92.59,45,,74.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.61,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.07,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,74.07,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,74.07,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,123.45,60,,9.88,Percent of Total Billed Charges,60% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.75,100,,164.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,29.67,14.42,,3.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.31,75,,959.384,Percent of Total Billed Charges,75% of Total Billed Charges,102.88,50,,21.28,Percent of Total Billed Charges,50% of Total Billed Charges,102.88,50,,42.352,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.88,50,,42.352,Percent of Total Billed Charges,50% of Total Billed Charges,102.88,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.03,70,,241.128,Percent of Total Billed Charges,70% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,28.81,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.75,100,,1279.176,Percent of Total Billed Charges,100% of Total Billed Charges,28.81,1189.45,
CATH CNTRL VEIN,50591020,CDM,272,RC,C1751,HCPCS,Outpatient,,,688,412.80,,67.66,100,,189.144,Fee Schedule,100% of Aetna Fee Schedule,309.6,45,,247.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.64,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,247.68,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,247.68,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,247.68,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,412.8,60,,74.224,Percent of Total Billed Charges,60% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688,100,,550.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,99.21,14.42,,3.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516,75,,376.44,Percent of Total Billed Charges,75% of Total Billed Charges,344,50,,16.776,Percent of Total Billed Charges,50% of Total Billed Charges,344,50,,44.408,Percent of Total Billed Charges,50% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344,50,,44.408,Percent of Total Billed Charges,50% of Total Billed Charges,344,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,481.6,70,,38.856,Percent of Total Billed Charges,70% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,96.32,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,688,100,,501.92,Percent of Total Billed Charges,100% of Total Billed Charges,67.66,1189.45,
DIL BIL $,50591021,CDM,270,RC,,,Outpatient,,,557.75,334.65,,334.65,60,,38.504,Percent of Total Billed Charges,60% of Total Billed Charges,250.99,45,,200.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.17,28,,63.664,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,200.79,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,200.79,36,,81.848,Percent of Total Billed Charges,36% Total Bille Charges,200.79,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,334.65,60,,204.416,Percent of Total Billed Charges,60% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,557.75,100,,446.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,80.43,14.42,,3.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,418.31,75,,376.44,Percent of Total Billed Charges,75% of Total Billed Charges,278.88,50,,42.352,Percent of Total Billed Charges,50% of Total Billed Charges,278.88,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.88,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,278.88,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,390.43,70,,16.296,Percent of Total Billed Charges,70% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,78.09,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,557.75,100,,501.92,Percent of Total Billed Charges,100% of Total Billed Charges,78.09,1189.45,
TRY ANGIOGRPHIC,50591024,CDM,270,RC,,,Outpatient,,,841.75,505.05,,505.05,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,378.79,45,,303.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.69,28,,33.96,Percent of Total Billed Charges,28% of Total Billed Charges,1189.45,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,303.03,36,,43.664,Percent of Total Billed Charges,36% of Total Billed Charges,303.03,36,,43.664,Percent of Total Billed Charges,36% Total Bille Charges,303.03,36,,43.664,Percent of Total Billed Charges,36% of Total Billed Charges,505.05,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,841.75,100,,673.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,121.38,14.42,,2.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,631.31,75,,376.44,Percent of Total Billed Charges,75% of Total Billed Charges,420.88,50,,44.408,Percent of Total Billed Charges,50% of Total Billed Charges,420.88,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420.88,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,420.88,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,589.23,70,,91.6,Percent of Total Billed Charges,70% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,117.85,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,841.75,100,,501.92,Percent of Total Billed Charges,100% of Total Billed Charges,117.85,1189.45,
DIL VESSEL,50591025,CDM,272,RC,,,Outpatient,,,113,67.80,,67.8,60,,295.888,Percent of Total Billed Charges,60% of Total Billed Charges,50.85,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.64,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,1189.85,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,40.68,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,40.68,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,40.68,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,67.8,60,,11.008,Percent of Total Billed Charges,60% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113,100,,90.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.29,14.42,,87.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.75,75,,376.44,Percent of Total Billed Charges,75% of Total Billed Charges,56.5,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,3.56,Percent of Total Billed Charges,50% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.5,50,,3.56,Percent of Total Billed Charges,50% of Total Billed Charges,56.5,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.1,70,,190.68,Percent of Total Billed Charges,70% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,15.82,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113,100,,501.92,Percent of Total Billed Charges,100% of Total Billed Charges,15.82,1189.85,
ST DILAT URETH,50591026,CDM,270,RC,,,Outpatient,,,141,84.60,,84.6,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,63.45,45,,50.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.48,28,,22.936,Percent of Total Billed Charges,28% of Total Billed Charges,1189.85,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,50.76,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,50.76,36,,29.488,Percent of Total Billed Charges,36% Total Bille Charges,50.76,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,84.6,60,,72.768,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,100,,112.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,20.33,14.42,,8.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.75,75,,362.2,Percent of Total Billed Charges,75% of Total Billed Charges,70.5,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,50,,3.488,Percent of Total Billed Charges,50% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.5,50,,3.488,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.7,70,,9.048,Percent of Total Billed Charges,70% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,19.74,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141,100,,482.928,Percent of Total Billed Charges,100% of Total Billed Charges,19.74,1189.85,
KT ACCESS,50591027,CDM,272,RC,,,Outpatient,,,829,497.40,,497.4,60,,33.736,Percent of Total Billed Charges,60% of Total Billed Charges,373.05,45,,298.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.12,28,,55.056,Percent of Total Billed Charges,28% of Total Billed Charges,1189.85,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,298.44,36,,70.792,Percent of Total Billed Charges,36% of Total Billed Charges,298.44,36,,70.792,Percent of Total Billed Charges,36% Total Bille Charges,298.44,36,,70.792,Percent of Total Billed Charges,36% of Total Billed Charges,497.4,60,,83.384,Percent of Total Billed Charges,60% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,829,100,,663.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,119.54,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.75,75,,362.2,Percent of Total Billed Charges,75% of Total Billed Charges,414.5,50,,3.56,Percent of Total Billed Charges,50% of Total Billed Charges,414.5,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.5,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,414.5,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580.3,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,116.06,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,829,100,,482.928,Percent of Total Billed Charges,100% of Total Billed Charges,116.06,1189.85,
GW STTIP,50591030,CDM,272,RC,C1769,HCPCS,Outpatient,,,382.5,229.50,,55.13,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,172.13,45,,137.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.1,28,,23.208,Percent of Total Billed Charges,28% of Total Billed Charges,1189.85,32,,186.872,Percent of Total Billed Charges,32% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,137.7,36,,29.84,Percent of Total Billed Charges,36% of Total Billed Charges,137.7,36,,29.84,Percent of Total Billed Charges,36% Total Bille Charges,137.7,36,,29.84,Percent of Total Billed Charges,36% of Total Billed Charges,229.5,60,,34.816,Percent of Total Billed Charges,60% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.5,100,,306,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,55.16,14.42,,25.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.88,75,,241.464,Percent of Total Billed Charges,75% of Total Billed Charges,191.25,50,,3.488,Percent of Total Billed Charges,50% of Total Billed Charges,191.25,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.25,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,191.25,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.75,70,,46.344,Percent of Total Billed Charges,70% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.5,100,,321.952,Percent of Total Billed Charges,100% of Total Billed Charges,53.55,1189.85,
CATH HD,50591034,CDM,272,RC,C1725,HCPCS,Outpatient,,,384.75,230.85,,99.47,100,,2411.4,Fee Schedule,100% of Aetna Fee Schedule,173.14,45,,138.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.73,28,,103.104,Percent of Total Billed Charges,28% of Total Billed Charges,1191.24,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,138.51,36,,132.568,Percent of Total Billed Charges,36% of Total Billed Charges,138.51,36,,132.568,Percent of Total Billed Charges,36% Total Bille Charges,138.51,36,,132.568,Percent of Total Billed Charges,36% of Total Billed Charges,230.85,60,,205.2,Percent of Total Billed Charges,60% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.75,100,,307.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,55.48,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.56,75,,241.464,Percent of Total Billed Charges,75% of Total Billed Charges,192.38,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,192.38,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,192.38,50,,15.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,269.33,70,,58.792,Percent of Total Billed Charges,70% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,53.87,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.75,100,,321.952,Percent of Total Billed Charges,100% of Total Billed Charges,53.87,1191.24,
INTRODUCER,50591035,CDM,272,RC,,,Outpatient,,,499.25,299.55,,299.55,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,224.66,45,,179.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.79,28,,61.968,Percent of Total Billed Charges,28% of Total Billed Charges,1192.58,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,179.73,36,,79.672,Percent of Total Billed Charges,36% of Total Billed Charges,179.73,36,,79.672,Percent of Total Billed Charges,36% Total Bille Charges,179.73,36,,79.672,Percent of Total Billed Charges,36% of Total Billed Charges,299.55,60,,67.336,Percent of Total Billed Charges,60% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.25,100,,399.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,71.99,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.44,75,,241.464,Percent of Total Billed Charges,75% of Total Billed Charges,249.63,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,249.63,50,,2.584,Percent of Total Billed Charges,50% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.63,50,,2.584,Percent of Total Billed Charges,50% of Total Billed Charges,249.63,50,,19.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.48,70,,157.208,Percent of Total Billed Charges,70% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.25,100,,321.952,Percent of Total Billed Charges,100% of Total Billed Charges,69.9,1192.58,
SUT CARD VICRYL,50591036,CDM,272,RC,,,Outpatient,,,72.5,43.50,,43.5,60,,2232,Percent of Total Billed Charges,60% of Total Billed Charges,32.63,45,,26.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.3,28,,524.192,Percent of Total Billed Charges,28% of Total Billed Charges,1196.48,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,26.1,36,,673.96,Percent of Total Billed Charges,36% of Total Billed Charges,26.1,36,,673.96,Percent of Total Billed Charges,36% Total Bille Charges,26.1,36,,673.96,Percent of Total Billed Charges,36% of Total Billed Charges,43.5,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.5,100,,58,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.45,14.42,,8.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.38,75,,241.464,Percent of Total Billed Charges,75% of Total Billed Charges,36.25,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,36.25,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.25,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,36.25,50,,20.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.75,70,,168.008,Percent of Total Billed Charges,70% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.15,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.5,100,,321.952,Percent of Total Billed Charges,100% of Total Billed Charges,10.15,1196.48,
NDL SPINAL A/S,50591037,CDM,272,RC,,,Outpatient,,,103.5,62.10,,62.1,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,46.58,45,,37.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.98,28,,47.504,Percent of Total Billed Charges,28% of Total Billed Charges,1196.48,32,,18.904,Percent of Total Billed Charges,32% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,37.26,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,37.26,36,,61.08,Percent of Total Billed Charges,36% Total Bille Charges,37.26,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,62.1,60,,19.232,Percent of Total Billed Charges,60% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,100,,82.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.92,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.63,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,51.75,50,,2.584,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.75,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,51.75,50,,21.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.45,70,,537.6,Percent of Total Billed Charges,70% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,14.49,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.5,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,14.49,1196.48,
SYRINGE MEDRAD,50591039,CDM,272,RC,,,Outpatient,,,144.25,86.55,,86.55,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,64.91,45,,51.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.39,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,1203,32,,187.12,Percent of Total Billed Charges,32% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,51.93,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,51.93,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,51.93,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,86.55,60,,30.728,Percent of Total Billed Charges,60% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.25,100,,115.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.8,14.42,,268.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.19,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,72.13,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,72.13,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.13,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,72.13,50,,16.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.98,70,,2.68,Percent of Total Billed Charges,70% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.25,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.2,1203,
DX MYELOGRAM TRAY,50591040,CDM,272,RC,,,Outpatient,,,68.25,40.95,,40.95,60,,323.168,Percent of Total Billed Charges,60% of Total Billed Charges,30.71,45,,24.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.11,28,,23.696,Percent of Total Billed Charges,28% of Total Billed Charges,1204.86,32,,187.12,Percent of Total Billed Charges,32% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.57,36,,30.472,Percent of Total Billed Charges,36% of Total Billed Charges,24.57,36,,30.472,Percent of Total Billed Charges,36% Total Bille Charges,24.57,36,,30.472,Percent of Total Billed Charges,36% of Total Billed Charges,40.95,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.25,100,,54.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14.42,,93.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.19,75,,1055.248,Percent of Total Billed Charges,75% of Total Billed Charges,34.13,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,34.13,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.13,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,34.13,50,,42.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.78,70,,13.224,Percent of Total Billed Charges,70% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.25,100,,1406.992,Percent of Total Billed Charges,100% of Total Billed Charges,9.56,1204.86,
DX ARTHROGRAM TRAY,50591041,CDM,272,RC,,,Outpatient,,,97.8,58.68,,58.68,60,,323.168,Percent of Total Billed Charges,60% of Total Billed Charges,44.01,45,,35.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.38,28,,28.456,Percent of Total Billed Charges,28% of Total Billed Charges,1206.4,32,,187.664,Percent of Total Billed Charges,32% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,35.21,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,35.21,36,,36.584,Percent of Total Billed Charges,36% Total Bille Charges,35.21,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,58.68,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.8,100,,78.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,14.1,14.42,,6.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.35,75,,146.48,Percent of Total Billed Charges,75% of Total Billed Charges,48.9,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,48.9,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.9,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,48.9,50,,44.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.46,70,,4.768,Percent of Total Billed Charges,70% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,13.69,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.8,100,,195.304,Percent of Total Billed Charges,100% of Total Billed Charges,13.69,1206.4,
APD CATHETER,50592000,CDM,272,RC,C1729,HCPCS,Outpatient,,,375,225.00,,11.1,100,,1005.16,Fee Schedule,100% of Aetna Fee Schedule,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,1214.6,32,,188.112,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,27.736,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,3.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1724.392,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,2.432,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2299.192,Percent of Total Billed Charges,100% of Total Billed Charges,11.1,1214.6,
CT CHEST HIGH RESOLUTION WO CM,50594242,CDM,352,RC,71250,HCPCS,Outpatient,,,2042.52,1225.51,,1749,110,,1005.16,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,30.448,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,188.16,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,39.144,Fee Schedule,360% of BCBS POS Rate,403.49,360,,39.144,Fee schedule,360% of BCBS PPO Rate,403.49,360,,39.144,Fee Schedule,360% of BCBS Traditional Rate,916,100,,7.824,Case Rate,Pays based on per visit rate,106.88,100,,7.328,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,7.544,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1531.89,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.176,Case Rate,Pays Based on per visit rate,1334,100,,2.68,Case Rate,Pays based on per visit rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,2.68,Case Rate,Pays based on per visit rate,1334,100,,0.104,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.176,Case Rate,Pays based on per visit rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,7.328,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.52,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2042.52,
CT CHEST HIGH RESOLUTION WO CM,50594242,CDM,352,RC,71250,HCPCS,Outpatient,,,2042.52,1225.51,,1749,110,,251.064,Percent of Total Billed Charges,110% of Total Billed Charges,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,46.248,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,188.928,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,59.464,Fee Schedule,360% of BCBS POS Rate,403.49,360,,59.464,Fee schedule,360% of BCBS PPO Rate,403.49,360,,59.464,Fee Schedule,360% of BCBS Traditional Rate,916,100,,21.056,Case Rate,Pays based on per visit rate,106.88,100,,9.52,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.808,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1531.89,75,,1149.592,Percent of Total Billed Charges,75% of Total Billed Charges,1334,100,,1.312,Case Rate,Pays Based on per visit rate,1334,100,,0.976,Case Rate,Pays based on per visit rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1334,100,,0.976,Case Rate,Pays based on per visit rate,1334,100,,3.56,Case Rate,Pays based on per visit rate,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,0.256,Case Rate,Pays based on per visit rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,9.52,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.52,100,,1532.792,Percent of Total Billed Charges,100% of Total Billed Charges,90.77,2042.52,
PUNCTURE ASP ABSCESS,50600001,CDM,361,RC,10160,HCPCS,Outpatient,,,614.38,368.63,,2601,100,,137.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,194.25,233,,49.976,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1217.72,32,,19.056,Percent of Total Billed Charges,32% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,268.45,322,,64.256,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,268.45,322,,64.256,Fee schedule,Pays based on ASC Tier Groupings fee schedule,268.45,322,,64.256,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,515,103,,122.616,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,88.59,14.42,,9.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,460.79,75,,146.4,Percent of Total Billed Charges,75% of Total Billed Charges,307.19,50,,2.68,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,15.08,Percent of Total Billed Charges,50% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,307.19,50,,15.08,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,3.488,Percent of Total Billed Charges,50% of Total Billed Charges,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,5.48,Fee Schedule,100% of ASC Tier Groupings fee schedule,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,614.38,100,,195.2,Percent of Total Billed Charges,100% of Total Billed Charges,86.01,2601,
US BX SALIVARY GLAND,50600221,CDM,361,RC,,,Outpatient,,,1389.84,833.90,,833.9,60,,123.28,Percent of Total Billed Charges,60% of Total Billed Charges,625.43,45,,500.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,389.16,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,1218.88,32,,19.088,Percent of Total Billed Charges,32% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,500.34,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,500.34,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,500.34,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,833.9,60,,36,Percent of Total Billed Charges,60% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1389.84,100,,1111.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,200.41,14.42,,10.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1042.38,75,,147.12,Percent of Total Billed Charges,75% of Total Billed Charges,694.92,50,,0.976,Percent of Total Billed Charges,50% of Total Billed Charges,694.92,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.92,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,694.92,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.89,70,,6.376,Percent of Total Billed Charges,70% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,194.58,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1389.84,100,,196.16,Percent of Total Billed Charges,100% of Total Billed Charges,194.58,1389.84,
US DRN PARACENTESIS WO IMG,50611250,CDM,361,RC,,,Outpatient,,,2401.92,1441.15,,1441.15,60,,115.856,Percent of Total Billed Charges,60% of Total Billed Charges,1080.86,45,,864.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.54,28,,36.608,Percent of Total Billed Charges,28% of Total Billed Charges,1219.68,32,,19.088,Percent of Total Billed Charges,32% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,864.69,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,864.69,36,,47.072,Percent of Total Billed Charges,36% Total Bille Charges,864.69,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,1441.15,60,,124.768,Percent of Total Billed Charges,60% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2401.92,100,,1921.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,346.36,14.42,,8.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1801.44,75,,99.6,Percent of Total Billed Charges,75% of Total Billed Charges,1200.96,50,,15.08,Percent of Total Billed Charges,50% of Total Billed Charges,1200.96,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200.96,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,1200.96,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1681.34,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2401.92,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,336.27,2401.92,
US DRN PARACENTESIS W IMG,50611251,CDM,361,RC,,,Outpatient,,,2401.92,1441.15,,1441.15,60,,655.616,Percent of Total Billed Charges,60% of Total Billed Charges,1080.86,45,,864.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672.54,28,,30.912,Percent of Total Billed Charges,28% of Total Billed Charges,1219.79,32,,19.104,Percent of Total Billed Charges,32% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,864.69,36,,39.744,Percent of Total Billed Charges,36% of Total Billed Charges,864.69,36,,39.744,Percent of Total Billed Charges,36% Total Bille Charges,864.69,36,,39.744,Percent of Total Billed Charges,36% of Total Billed Charges,1441.15,60,,72.56,Percent of Total Billed Charges,60% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2401.92,100,,1921.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,346.36,14.42,,5.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1801.44,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,1200.96,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,1200.96,50,,6.128,Percent of Total Billed Charges,50% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200.96,50,,6.128,Percent of Total Billed Charges,50% of Total Billed Charges,1200.96,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1681.34,70,,12.912,Percent of Total Billed Charges,70% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,336.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2401.92,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,336.27,2401.92,
US ASP THYROID CYST,50611607,CDM,361,RC,,,Outpatient,,,1097.96,658.78,,658.78,60,,489.232,Percent of Total Billed Charges,60% of Total Billed Charges,494.08,45,,395.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.43,28,,78.656,Percent of Total Billed Charges,28% of Total Billed Charges,1226.37,32,,19.136,Percent of Total Billed Charges,32% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,395.27,36,,101.136,Percent of Total Billed Charges,36% of Total Billed Charges,395.27,36,,101.136,Percent of Total Billed Charges,36% Total Bille Charges,395.27,36,,101.136,Percent of Total Billed Charges,36% of Total Billed Charges,658.78,60,,7.024,Percent of Total Billed Charges,60% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1097.96,100,,878.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,158.33,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,823.47,75,,357,Percent of Total Billed Charges,75% of Total Billed Charges,548.98,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,548.98,50,,6.136,Percent of Total Billed Charges,50% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.98,50,,6.136,Percent of Total Billed Charges,50% of Total Billed Charges,548.98,50,,2.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.57,70,,4.76,Percent of Total Billed Charges,70% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,153.71,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.96,100,,476,Percent of Total Billed Charges,100% of Total Billed Charges,153.71,1226.37,
US ABD DOPP COMPL,50620152,CDM,921,RC,93975,HCPCS,Outpatient,,,1183.54,710.12,,169.64,100,,1267.392,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,629.66,280,,31.632,Fee Schedule,280% of BCBS BULE Fee Schedule,719.62,320,,19.168,Fee Schedule,320% of BCBS Blue Essentials Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,809.57,360,,40.664,Fee Schedule,360% of BCBS POS Rate,809.57,360,,40.664,Fee schedule,360% of BCBS PPO Rate,809.57,360,,40.664,Fee Schedule,360% of BCBS Traditional Rate,710.12,60,,10.36,Percent of Total Billed Charges,60% of Total Billed Charges,230.13,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,237.03,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,887.66,75,,357,Percent of Total Billed Charges,75% of Total Billed Charges,591.77,50,,6.128,Percent of Total Billed Charges,50% of Total Billed Charges,591.77,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,591.77,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,591.77,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,5.312,Case Rate,Pays based on per visit rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,230.13,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.54,100,,476,Percent of Total Billed Charges,100% of Total Billed Charges,169.64,1183.54,
US DRN ABS PERITONEAL PERC,50620158,CDM,361,RC,,,Outpatient,,,3811.83,2287.10,,2287.1,60,,615.56,Percent of Total Billed Charges,60% of Total Billed Charges,1715.32,45,,1372.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1067.31,28,,33.128,Percent of Total Billed Charges,28% of Total Billed Charges,1232.06,32,,19.184,Percent of Total Billed Charges,32% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,1372.26,36,,42.592,Percent of Total Billed Charges,36% of Total Billed Charges,1372.26,36,,42.592,Percent of Total Billed Charges,36% Total Bille Charges,1372.26,36,,42.592,Percent of Total Billed Charges,36% of Total Billed Charges,2287.1,60,,20.728,Percent of Total Billed Charges,60% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3811.83,100,,3049.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,549.67,14.42,,2.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2858.87,75,,63.84,Percent of Total Billed Charges,75% of Total Billed Charges,1905.92,50,,6.136,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1905.92,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,1905.92,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2668.28,70,,5.312,Percent of Total Billed Charges,70% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,533.66,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3811.83,100,,85.12,Percent of Total Billed Charges,100% of Total Billed Charges,533.66,3811.83,
US BX BRST INI LT,50620159,CDM,361,RC,,,Outpatient,,,3858.75,2315.25,,2315.25,60,,825.6,Percent of Total Billed Charges,60% of Total Billed Charges,1736.44,45,,1389.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1080.45,28,,245.776,Percent of Total Billed Charges,28% of Total Billed Charges,1234.8,32,,190.296,Percent of Total Billed Charges,32% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1389.15,36,,315.992,Percent of Total Billed Charges,36% of Total Billed Charges,1389.15,36,,315.992,Percent of Total Billed Charges,36% Total Bille Charges,1389.15,36,,315.992,Percent of Total Billed Charges,36% of Total Billed Charges,2315.25,60,,83.288,Percent of Total Billed Charges,60% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3858.75,100,,3087,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,556.43,14.42,,1.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2894.06,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,1929.38,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1929.38,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,1929.38,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2701.13,70,,5.312,Percent of Total Billed Charges,70% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,540.23,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3858.75,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,540.23,3858.75,
US BX BRST INI BI,50620160,CDM,361,RC,,,Outpatient,,,5788.13,3472.88,,3472.88,60,,53.264,Percent of Total Billed Charges,60% of Total Billed Charges,2604.66,45,,2083.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1620.68,28,,190.8,Percent of Total Billed Charges,28% of Total Billed Charges,1234.8,32,,190.296,Percent of Total Billed Charges,32% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,2083.73,36,,245.32,Percent of Total Billed Charges,36% of Total Billed Charges,2083.73,36,,245.32,Percent of Total Billed Charges,36% Total Bille Charges,2083.73,36,,245.32,Percent of Total Billed Charges,36% of Total Billed Charges,3472.88,60,,55.352,Percent of Total Billed Charges,60% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5788.13,100,,4630.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,834.65,14.42,,1.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4341.1,75,,79.728,Percent of Total Billed Charges,75% of Total Billed Charges,2894.07,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,2894.07,50,,3.672,Percent of Total Billed Charges,50% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2894.07,50,,3.672,Percent of Total Billed Charges,50% of Total Billed Charges,2894.07,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4051.69,70,,6.576,Percent of Total Billed Charges,70% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,810.34,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5788.13,100,,106.304,Percent of Total Billed Charges,100% of Total Billed Charges,810.34,5788.13,
US GUIDE INTRAOPERATIVE,50620161,CDM,402,RC,76998,HCPCS,Outpatient,,,648.75,389.25,TC   ,56.88,100,,50.576,Fee Schedule,100% of Aetna Fee Schedule,291.94,45,,233.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.64,280,,165.312,Fee Schedule,280% of BCBS BULE Fee Schedule,208.74,320,,191.208,Fee Schedule,320% of BCBS Blue Essentials Rate,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,234.83,360,,212.544,Fee Schedule,360% of BCBS POS Rate,234.83,360,,212.544,Fee schedule,360% of BCBS PPO Rate,234.83,360,,212.544,Fee Schedule,360% of BCBS Traditional Rate,389.25,60,,34.408,Percent of Total Billed Charges,60% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,648.75,100,,519,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,93.55,14.42,,44.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.56,75,,628.56,Percent of Total Billed Charges,75% of Total Billed Charges,324.38,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,324.38,50,,48.544,Percent of Total Billed Charges,50% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.38,50,,48.544,Percent of Total Billed Charges,50% of Total Billed Charges,324.38,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,7.232,Case Rate,Pays based on per visit rate,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.75,100,,838.08,Percent of Total Billed Charges,100% of Total Billed Charges,56.88,648.75,
US GUIDE INTRAOPERATIVE,50620161,CDM,402,RC,76998,HCPCS,Outpatient,,,648.75,389.25,TC   ,56.88,100,,38.4,Fee Schedule,100% of Aetna Fee Schedule,291.94,45,,233.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.64,280,,202.024,Fee Schedule,280% of BCBS BULE Fee Schedule,208.74,320,,191.224,Fee Schedule,320% of BCBS Blue Essentials Rate,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,234.83,360,,259.744,Fee Schedule,360% of BCBS POS Rate,234.83,360,,259.744,Fee schedule,360% of BCBS PPO Rate,234.83,360,,259.744,Fee Schedule,360% of BCBS Traditional Rate,389.25,60,,41.336,Percent of Total Billed Charges,60% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,648.75,100,,519,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,93.55,14.42,,1.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.56,75,,627.6,Percent of Total Billed Charges,75% of Total Billed Charges,324.38,50,,3.672,Percent of Total Billed Charges,50% of Total Billed Charges,324.38,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,324.38,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,324.38,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,91.384,Case Rate,Pays based on per visit rate,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,648.75,100,,836.8,Percent of Total Billed Charges,100% of Total Billed Charges,56.88,648.75,
US THYROID,50620162,CDM,402,RC,76536,HCPCS,Outpatient,,,715.17,429.10,,86.75,100,,38.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,31.04,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,191.232,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,39.904,Fee Schedule,360% of BCBS POS Rate,403.49,360,,39.904,Fee schedule,360% of BCBS PPO Rate,403.49,360,,39.904,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,69.304,Fee Schedule,103% of Cigna fee schedule,106.88,100,,39.376,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,40.552,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,536.38,75,,110.256,Percent of Total Billed Charges,75% of Total Billed Charges,357.59,50,,48.544,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,19.816,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.59,50,,19.816,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,2.68,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,4.28,Case Rate,Pays based on per visit rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,715.17,100,,147.008,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,715.17,
US THYROID,50620162,CDM,402,RC,76536,HCPCS,Outpatient,,,715.17,429.10,,86.75,100,,38.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,34.152,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,43.912,Fee Schedule,360% of BCBS POS Rate,403.49,360,,43.912,Fee schedule,360% of BCBS PPO Rate,403.49,360,,43.912,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,116.512,Fee Schedule,103% of Cigna fee schedule,106.88,100,,39.376,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,40.56,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,536.38,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,357.59,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.59,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,0.976,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2.696,Case Rate,Pays based on per visit rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,39.376,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,715.17,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,715.17,
US BX LIVER PERC,50620163,CDM,361,RC,,,Outpatient,,,2446.33,1467.80,,1467.8,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,1100.85,45,,880.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.97,28,,77.144,Percent of Total Billed Charges,28% of Total Billed Charges,1234.8,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,880.68,36,,99.184,Percent of Total Billed Charges,36% of Total Billed Charges,880.68,36,,99.184,Percent of Total Billed Charges,36% Total Bille Charges,880.68,36,,99.184,Percent of Total Billed Charges,36% of Total Billed Charges,1467.8,60,,281.76,Percent of Total Billed Charges,60% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2446.33,100,,1957.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,352.76,14.42,,29.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.75,75,,348,Percent of Total Billed Charges,75% of Total Billed Charges,1223.17,50,,19.816,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1223.17,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,1223.17,50,,15.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1712.43,70,,1.088,Percent of Total Billed Charges,70% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,342.49,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2446.33,100,,464,Percent of Total Billed Charges,100% of Total Billed Charges,342.49,2446.33,
US BX RENAL PERC BI,50620164,CDM,361,RC,,,Outpatient,,,3105.48,1863.29,,1863.29,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,1397.47,45,,1117.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.53,28,,41.072,Percent of Total Billed Charges,28% of Total Billed Charges,1239.53,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,1117.97,36,,52.808,Percent of Total Billed Charges,36% of Total Billed Charges,1117.97,36,,52.808,Percent of Total Billed Charges,36% Total Bille Charges,1117.97,36,,52.808,Percent of Total Billed Charges,36% of Total Billed Charges,1863.29,60,,97.24,Percent of Total Billed Charges,60% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3105.48,100,,2484.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,447.81,14.42,,25.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2329.11,75,,405,Percent of Total Billed Charges,75% of Total Billed Charges,1552.74,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,75.168,Percent of Total Billed Charges,50% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1552.74,50,,75.168,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2173.84,70,,5.088,Percent of Total Billed Charges,70% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3105.48,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,434.77,3105.48,
US BX RENAL PERC LT,50620165,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,61.24,Percent of Total Billed Charges,28% of Total Billed Charges,1239.53,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,45.008,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,6.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,72.816,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,72.816,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,6.824,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,91.2,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
US BX RENAL PERC RT,50620166,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,61.24,Percent of Total Billed Charges,28% of Total Billed Charges,1239.53,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,15.048,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,5.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,75.168,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,116.176,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,116.176,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,6.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,1.32,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
US ABD DOPP LIMITED,50620180,CDM,921,RC,93976,HCPCS,Outpatient,,,815.9,489.54,,81.56,100,,38.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,280,,62.584,Fee Schedule,280% of BCBS BULE Fee Schedule,359.81,320,,192,Fee Schedule,320% of BCBS Blue Essentials Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,404.78,360,,80.464,Fee Schedule,360% of BCBS POS Rate,404.78,360,,80.464,Fee schedule,360% of BCBS PPO Rate,404.78,360,,80.464,Fee Schedule,360% of BCBS Traditional Rate,489.54,60,,255.272,Percent of Total Billed Charges,60% of Total Billed Charges,108.97,100,,76.696,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,112.24,103,,79,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,611.93,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,407.95,50,,72.816,Percent of Total Billed Charges,50% of Total Billed Charges,407.95,50,,290.032,Percent of Total Billed Charges,50% of Total Billed Charges,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,407.95,50,,290.032,Percent of Total Billed Charges,50% of Total Billed Charges,407.95,50,,6.136,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,38.104,Case Rate,Pays based on per visit rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,108.97,100,,76.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,815.9,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,81.56,815.9,
US AORTA,50620181,CDM,402,RC,76775,HCPCS,Outpatient,,,784.46,470.68,TC   ,29.48,100,,38.4,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,76.432,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192,Fee Schedule,320% of BCBS Blue Essentials Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,98.264,Fee Schedule,360% of BCBS POS Rate,403.49,360,,98.264,Fee schedule,360% of BCBS PPO Rate,403.49,360,,98.264,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,163.112,Fee Schedule,103% of Cigna fee schedule,59.14,100,,3.944,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,60.91,103,,4.056,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,116.176,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,333.752,Case Rate,Pays based on per visit rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,3.944,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,784.46,
US AORTA,50620181,CDM,402,RC,76775,HCPCS,Outpatient,,,784.46,470.68,TC   ,29.48,100,,50.344,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,76.432,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192,Fee Schedule,320% of BCBS Blue Essentials Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,98.264,Fee Schedule,360% of BCBS POS Rate,403.49,360,,98.264,Fee schedule,360% of BCBS PPO Rate,403.49,360,,98.264,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,25.192,Fee Schedule,103% of Cigna fee schedule,59.14,100,,9.456,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,60.91,103,,9.744,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,68.04,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,290.032,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,145.944,Case Rate,Pays based on per visit rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,59.14,100,,9.456,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,90.72,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,784.46,
US ASP,50620182,CDM,361,RC,,,Outpatient,,,614.38,368.63,,368.63,60,,384.064,Percent of Total Billed Charges,60% of Total Billed Charges,276.47,45,,221.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.03,28,,35.896,Percent of Total Billed Charges,28% of Total Billed Charges,1239.53,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,221.18,36,,46.152,Percent of Total Billed Charges,36% of Total Billed Charges,221.18,36,,46.152,Percent of Total Billed Charges,36% Total Bille Charges,221.18,36,,46.152,Percent of Total Billed Charges,36% of Total Billed Charges,368.63,60,,1010.176,Percent of Total Billed Charges,60% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.38,100,,491.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,88.59,14.42,,24.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.79,75,,387,Percent of Total Billed Charges,75% of Total Billed Charges,307.19,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.19,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,307.19,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.07,70,,161.536,Percent of Total Billed Charges,70% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,86.01,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614.38,100,,516,Percent of Total Billed Charges,100% of Total Billed Charges,86.01,1239.53,
US HEAD NECK SOFT TISSUE,50665363,CDM,402,RC,76536,HCPCS,Outpatient,,,715.17,429.10,,86.75,100,,384.064,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,38.528,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192.4,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,49.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,650.704,Fee Schedule,103% of Cigna fee schedule,106.88,100,,0.712,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,0.736,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,536.38,75,,135,Percent of Total Billed Charges,75% of Total Billed Charges,357.59,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.59,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,3.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,87.872,Case Rate,Pays based on per visit rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,715.17,100,,180,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,715.17,
US HEAD NECK SOFT TISSUE,50665363,CDM,402,RC,76536,HCPCS,Outpatient,,,715.17,429.10,,86.75,100,,1277.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,38.528,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192.4,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,49.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,923.424,Fee Schedule,103% of Cigna fee schedule,106.88,100,,4.304,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,4.432,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,536.38,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,357.59,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,357.59,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,357.59,50,,48.544,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,121.864,Case Rate,Pays based on per visit rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,715.17,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,715.17,
US CHEST,50666049,CDM,402,RC,76604,HCPCS,Outpatient,,,529.13,317.48,TC   ,37.8,100,,1277.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,38.528,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192.4,Fee Schedule,320% of BCBS Blue Essentials Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS POS Rate,403.49,360,,49.536,Fee schedule,360% of BCBS PPO Rate,403.49,360,,49.536,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,56.72,Fee Schedule,103% of Cigna fee schedule,56.8,100,,61.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,58.5,103,,63.448,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,396.85,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,264.57,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,264.57,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,264.57,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,264.57,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1.816,Case Rate,Pays based on per visit rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,529.13,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,529.13,
US CHEST,50666049,CDM,402,RC,76604,HCPCS,Outpatient,,,529.13,317.48,TC   ,37.8,100,,384.064,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,30.088,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,192.4,Fee Schedule,320% of BCBS Blue Essentials Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,38.688,Fee Schedule,360% of BCBS POS Rate,403.49,360,,38.688,Fee schedule,360% of BCBS PPO Rate,403.49,360,,38.688,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,21.848,Fee Schedule,103% of Cigna fee schedule,56.8,100,,5.56,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,58.5,103,,5.72,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,396.85,75,,105,Percent of Total Billed Charges,75% of Total Billed Charges,264.57,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,264.57,50,,2.84,Percent of Total Billed Charges,50% of Total Billed Charges,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,264.57,50,,2.84,Percent of Total Billed Charges,50% of Total Billed Charges,264.57,50,,19.816,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,10.504,Case Rate,Pays based on per visit rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,56.8,100,,5.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,529.13,100,,140,Percent of Total Billed Charges,100% of Total Billed Charges,37.8,529.13,
US BREAST CYST ASP ADD LT,50666502,CDM,360,RC,,,Outpatient,,,477.45,286.47,,286.47,60,,384.064,Percent of Total Billed Charges,60% of Total Billed Charges,214.85,45,,171.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.69,28,,30.088,Percent of Total Billed Charges,28% of Total Billed Charges,1239.53,32,,193.072,Percent of Total Billed Charges,32% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,171.88,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,171.88,36,,38.688,Percent of Total Billed Charges,36% Total Bille Charges,171.88,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,286.47,60,,56.024,Percent of Total Billed Charges,60% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,477.45,100,,381.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,68.85,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,358.09,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,238.73,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,238.73,50,,1.376,Percent of Total Billed Charges,50% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.73,50,,1.376,Percent of Total Billed Charges,50% of Total Billed Charges,238.73,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,334.22,70,,5.944,Percent of Total Billed Charges,70% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,66.84,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.45,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,66.84,1239.53,
US ABD COMPL,50667005,CDM,402,RC,76700,HCPCS,Outpatient,,,977.5,586.50,,80.75,100,,1985.656,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,193.312,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.088,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,38.504,Fee Schedule,103% of Cigna fee schedule,106.88,100,,3.824,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.944,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,733.13,75,,96,Percent of Total Billed Charges,75% of Total Billed Charges,488.75,50,,2.84,Percent of Total Billed Charges,50% of Total Billed Charges,488.75,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,488.75,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,488.75,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,23.024,Case Rate,Pays based on per visit rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.824,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,977.5,100,,128,Percent of Total Billed Charges,100% of Total Billed Charges,80.75,977.5,
US ABD COMPL,50667005,CDM,402,RC,76700,HCPCS,Outpatient,,,977.5,586.50,,80.75,100,,1985.656,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,193.536,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.088,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,38.504,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,733.13,75,,120,Percent of Total Billed Charges,75% of Total Billed Charges,488.75,50,,1.376,Percent of Total Billed Charges,50% of Total Billed Charges,488.75,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,488.75,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,488.75,50,,75.168,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,141.12,Case Rate,Pays based on per visit rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,977.5,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,80.75,977.5,
US ABD LTD,50667054,CDM,402,RC,76705,HCPCS,Outpatient,,,746.39,447.83,TC   ,60.78,100,,379.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,193.536,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.088,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,3.68,Fee Schedule,103% of Cigna fee schedule,88.55,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,559.79,75,,111,Percent of Total Billed Charges,75% of Total Billed Charges,373.2,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,373.2,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,72.816,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,37.096,Case Rate,Pays based on per visit rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,746.39,100,,148,Percent of Total Billed Charges,100% of Total Billed Charges,60.78,746.39,
US ABD LTD,50667054,CDM,402,RC,76705,HCPCS,Outpatient,,,746.39,447.83,TC   ,60.78,100,,379.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19646.232,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.088,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.824,Fee Schedule,103% of Cigna fee schedule,88.55,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,559.79,75,,538.2,Percent of Total Billed Charges,75% of Total Billed Charges,373.2,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,373.2,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,373.2,50,,116.176,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,62.448,Case Rate,Pays based on per visit rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,746.39,100,,717.6,Percent of Total Billed Charges,100% of Total Billed Charges,60.78,746.39,
US AORTA ILIAC DPLX COMP,50667055,CDM,921,RC,93978,HCPCS,Outpatient,,,1023.12,613.87,,114.75,100,,291.6,Fee Schedule,100% of Aetna Fee Schedule,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,425.85,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,486.69,320,,19.456,Fee Schedule,320% of BCBS Blue Essentials Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,547.52,360,,55.088,Fee Schedule,360% of BCBS POS Rate,547.52,360,,55.088,Fee schedule,360% of BCBS PPO Rate,547.52,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,613.87,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,184.78,100,,3.224,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,190.32,103,,3.32,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,767.34,75,,249.6,Percent of Total Billed Charges,75% of Total Billed Charges,511.56,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,511.56,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,511.56,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,511.56,50,,290.032,Percent of Total Billed Charges,50% of Total Billed Charges,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,86.64,Case Rate,Pays based on per visit rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,184.78,100,,3.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1023.12,100,,332.8,Percent of Total Billed Charges,100% of Total Billed Charges,114.75,1023.12,
US RETROPERITNL,50667708,CDM,402,RC,76770,HCPCS,Outpatient,,,784.46,470.68,,75.09,100,,291.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.848,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.504,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.088,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.088,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,27.896,Fee Schedule,103% of Cigna fee schedule,106.88,100,,3.104,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.2,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,486,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,0.008,Case Rate,Pays based on per visit rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.104,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,648,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,784.46,
US RETROPERITNL,50667708,CDM,402,RC,76770,HCPCS,Outpatient,,,784.46,470.68,,75.09,100,,225.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,147.624,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.52,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,189.8,Fee Schedule,360% of BCBS POS Rate,403.49,360,,189.8,Fee schedule,360% of BCBS PPO Rate,403.49,360,,189.8,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,34.016,Fee Schedule,103% of Cigna fee schedule,106.88,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,1.16,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,252.84,Case Rate,Pays based on per visit rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,784.46,
US RENAL KIDNEYS COMPL,50667757,CDM,402,RC,76770,HCPCS,Outpatient,,,784.46,470.68,,75.09,100,,225.6,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,122.392,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.584,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,157.36,Fee Schedule,360% of BCBS POS Rate,403.49,360,,157.36,Fee schedule,360% of BCBS PPO Rate,403.49,360,,157.36,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,28.6,Fee Schedule,103% of Cigna fee schedule,106.88,100,,4.664,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,4.808,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,383.76,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,100.792,Case Rate,Pays based on per visit rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,4.664,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,511.68,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,784.46,
US RENAL KIDNEYS COMPL,50667757,CDM,402,RC,76770,HCPCS,Outpatient,,,784.46,470.68,,75.09,100,,195.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,122.392,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,194.608,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,157.36,Fee Schedule,360% of BCBS POS Rate,403.49,360,,157.36,Fee schedule,360% of BCBS PPO Rate,403.49,360,,157.36,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,192.616,Fee Schedule,103% of Cigna fee schedule,106.88,100,,3.88,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.992,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,588.35,75,,423,Percent of Total Billed Charges,75% of Total Billed Charges,392.23,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,2.76,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,392.23,50,,2.76,Percent of Total Billed Charges,50% of Total Billed Charges,392.23,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2.048,Case Rate,Pays based on per visit rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.88,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,784.46,100,,564,Percent of Total Billed Charges,100% of Total Billed Charges,75.09,784.46,
US TESTICULAR,50667823,CDM,402,RC,76870,HCPCS,Outpatient,,,674.54,404.72,TC   ,72.09,100,,195.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,49.512,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,194.712,Fee Schedule,320% of BCBS Blue Essentials Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,63.664,Fee Schedule,360% of BCBS POS Rate,403.49,360,,63.664,Fee schedule,360% of BCBS PPO Rate,403.49,360,,63.664,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,23.392,Fee Schedule,103% of Cigna fee schedule,101.58,100,,3.896,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,104.63,103,,4.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,505.91,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,337.27,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,337.27,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,5.424,Case Rate,Pays based on per visit rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.896,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,674.54,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,72.09,674.54,
US TESTICULAR,50667823,CDM,402,RC,76870,HCPCS,Outpatient,,,674.54,404.72,TC   ,72.09,100,,141.344,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.928,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,195.728,Fee Schedule,320% of BCBS Blue Essentials Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,55.192,Fee Schedule,360% of BCBS POS Rate,403.49,360,,55.192,Fee schedule,360% of BCBS PPO Rate,403.49,360,,55.192,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,34.792,Fee Schedule,103% of Cigna fee schedule,101.58,100,,3.088,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,104.63,103,,3.184,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,505.91,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,337.27,50,,2.76,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,337.27,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,35.144,Case Rate,Pays based on per visit rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,101.58,100,,3.088,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,674.54,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,72.09,674.54,
US SPINAL CANAL,50668003,CDM,402,RC,76800,HCPCS,Outpatient,,,470.55,282.33,,83.42,100,,141.344,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,24.192,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,195.856,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,31.104,Fee Schedule,360% of BCBS POS Rate,403.49,360,,31.104,Fee schedule,360% of BCBS PPO Rate,403.49,360,,31.104,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,43.672,Fee Schedule,103% of Cigna fee schedule,106.88,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,352.91,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,235.28,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,235.28,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,235.28,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,235.28,50,,2.84,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,23.4,Case Rate,Pays based on per visit rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,470.55,100,,62.4,Percent of Total Billed Charges,100% of Total Billed Charges,83.42,470.55,
US SPINAL CANAL,50668003,CDM,402,RC,76800,HCPCS,Outpatient,,,470.55,282.33,,83.42,100,,94.384,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,123.824,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,195.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,159.208,Fee Schedule,360% of BCBS POS Rate,403.49,360,,159.208,Fee schedule,360% of BCBS PPO Rate,403.49,360,,159.208,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,19.784,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,352.91,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,235.28,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,235.28,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,235.28,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,235.28,50,,1.376,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,4.224,Case Rate,Pays based on per visit rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,470.55,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,83.42,470.55,
US OB LESS 14 WKS,50668011,CDM,402,RC,76801,HCPCS,Outpatient,,,646.62,387.97,TC   ,71.76,100,,188.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,205.86,280,,69.384,Fee Schedule,280% of BCBS BULE Fee Schedule,235.26,320,,196.728,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,264.67,360,,89.208,Fee Schedule,360% of BCBS POS Rate,264.67,360,,89.208,Fee schedule,360% of BCBS PPO Rate,264.67,360,,89.208,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,17.624,Fee Schedule,103% of Cigna fee schedule,106.88,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,484.97,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,323.31,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,40.592,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323.31,50,,40.592,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,382.176,Case Rate,Pays based on per visit rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,646.62,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,71.76,646.62,
US OB LESS 14 WKS,50668011,CDM,402,RC,76801,HCPCS,Outpatient,,,646.62,387.97,TC   ,71.76,100,,594,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,205.86,280,,12.352,Fee Schedule,280% of BCBS BULE Fee Schedule,235.26,320,,19.784,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,264.67,360,,15.888,Fee Schedule,360% of BCBS POS Rate,264.67,360,,15.888,Fee schedule,360% of BCBS PPO Rate,264.67,360,,15.888,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,133.064,Fee Schedule,103% of Cigna fee schedule,106.88,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,484.97,75,,144,Percent of Total Billed Charges,75% of Total Billed Charges,323.31,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,3.36,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323.31,50,,3.36,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1404.4,Case Rate,Pays based on per visit rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,646.62,100,,180,Percent of Total Billed Charges,100% of Total Billed Charges,71.76,646.62,
US OB LESS 14 WKS,50668011,CDM,402,RC,76801,HCPCS,Outpatient,,,646.62,387.97,TC   ,71.76,100,,594,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,205.86,280,,832.616,Fee Schedule,280% of BCBS BULE Fee Schedule,235.26,320,,19.816,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,264.67,360,,1070.504,Fee Schedule,360% of BCBS POS Rate,264.67,360,,1070.504,Fee schedule,360% of BCBS PPO Rate,264.67,360,,1070.504,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,9.032,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,484.97,75,,213,Percent of Total Billed Charges,75% of Total Billed Charges,323.31,50,,40.592,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,2.12,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323.31,50,,2.12,Percent of Total Billed Charges,50% of Total Billed Charges,323.31,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,1166.496,Case Rate,Pays based on per visit rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,646.62,100,,284,Percent of Total Billed Charges,100% of Total Billed Charges,71.76,646.62,
US OB LESS 14 WKS EA ADD,50668029,CDM,402,RC,76802,HCPCS,Outpatient,,,379.09,227.45,,21.65,100,,265.76,Fee Schedule,100% of Aetna Fee Schedule,170.59,45,,136.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,61.54,280,,134.4,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,19.864,Fee Schedule,320% of BCBS Blue Essentials Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,79.13,360,,172.8,Fee Schedule,360% of BCBS POS Rate,79.13,360,,172.8,Fee schedule,360% of BCBS PPO Rate,79.13,360,,172.8,Fee Schedule,360% of BCBS Traditional Rate,227.45,60,,237.24,Percent of Total Billed Charges,60% of Total Billed Charges,61.15,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.09,100,,303.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,62.98,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.32,75,,325.04,Percent of Total Billed Charges,75% of Total Billed Charges,189.55,50,,3.36,Percent of Total Billed Charges,50% of Total Billed Charges,189.55,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,189.55,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,189.55,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,378,100,,93.64,Case Rate,Pays based on per visit rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,379.09,100,,406.296,Percent of Total Billed Charges,100% of Total Billed Charges,21.65,379.09,
US OB LESS 14 WKS EA ADD,50668029,CDM,402,RC,76802,HCPCS,Outpatient,,,379.09,227.45,,21.65,100,,265.76,Fee Schedule,100% of Aetna Fee Schedule,170.59,45,,136.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,61.54,280,,324.8,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,19.896,Fee Schedule,320% of BCBS Blue Essentials Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,79.13,360,,416,Fee Schedule,360% of BCBS POS Rate,79.13,360,,416,Fee schedule,360% of BCBS PPO Rate,79.13,360,,416,Fee Schedule,360% of BCBS Traditional Rate,227.45,60,,176.96,Percent of Total Billed Charges,60% of Total Billed Charges,61.15,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.09,100,,303.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,62.98,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.32,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,189.55,50,,2.12,Percent of Total Billed Charges,50% of Total Billed Charges,189.55,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,189.55,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,189.55,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,378,100,,139.968,Case Rate,Pays based on per visit rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,61.15,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,379.09,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21.65,379.09,
US OB LTD,50668102,CDM,402,RC,76815,HCPCS,Outpatient,,,375,225.00,TC   ,51.12,100,,326.48,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,324.8,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.936,Fee Schedule,320% of BCBS Blue Essentials Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,416,Fee Schedule,360% of BCBS POS Rate,403.49,360,,416,Fee schedule,360% of BCBS PPO Rate,403.49,360,,416,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,608.864,Fee Schedule,103% of Cigna fee schedule,81.86,100,,16.96,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,84.32,103,,17.472,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,281.25,75,,312,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,193.472,Case Rate,Pays based on per visit rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,16.96,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,375,100,,416,Percent of Total Billed Charges,100% of Total Billed Charges,51.12,403.49,
US OB LTD,50668102,CDM,402,RC,76815,HCPCS,Outpatient,,,375,225.00,TC   ,51.12,100,,326.48,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.952,Fee Schedule,320% of BCBS Blue Essentials Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,961.64,Fee Schedule,103% of Cigna fee schedule,81.86,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.32,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,281.25,75,,1113.56,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,55.296,Case Rate,Pays based on per visit rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,81.86,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,375,100,,1484.744,Percent of Total Billed Charges,100% of Total Billed Charges,51.12,403.49,
US BIOPHYS W NST PER FETUS,50668185,CDM,402,RC,76818,HCPCS,Outpatient,,,710.01,426.01,,63.95,100,,200.64,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.72,280,,528,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,197.352,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,246.49,360,,681.6,Fee Schedule,360% of BCBS POS Rate,246.49,360,,681.6,Fee schedule,360% of BCBS PPO Rate,246.49,360,,681.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,258.728,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,532.51,75,,151.048,Percent of Total Billed Charges,75% of Total Billed Charges,355.01,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,355.01,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,355.01,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,355.01,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,55.296,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,100,,201.4,Percent of Total Billed Charges,100% of Total Billed Charges,63.95,710.01,
US BIOPHYS W NST PER FETUS,50668185,CDM,402,RC,76818,HCPCS,Outpatient,,,710.01,426.01,,63.95,100,,200.64,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,191.72,280,,528,Fee Schedule,280% of BCBS BULE Fee Schedule,219.1,320,,197.632,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,246.49,360,,681.6,Fee Schedule,360% of BCBS POS Rate,246.49,360,,681.6,Fee schedule,360% of BCBS PPO Rate,246.49,360,,681.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,392.912,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,532.51,75,,471.864,Percent of Total Billed Charges,75% of Total Billed Charges,355.01,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,355.01,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,355.01,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,355.01,50,,2.76,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,19.528,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,100,,629.152,Percent of Total Billed Charges,100% of Total Billed Charges,63.95,710.01,
US BIOPHYS WO NST PER FETUS,50668193,CDM,402,RC,76819,HCPCS,Outpatient,,,450,270.00,TC   ,47.46,100,,99.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,141.26,280,,767.2,Fee Schedule,280% of BCBS BULE Fee Schedule,161.44,320,,197.632,Fee Schedule,320% of BCBS Blue Essentials Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,181.62,360,,985.6,Fee Schedule,360% of BCBS POS Rate,181.62,360,,985.6,Fee schedule,360% of BCBS PPO Rate,181.62,360,,985.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,13.84,Fee Schedule,103% of Cigna fee schedule,84.2,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,86.73,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,471.864,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,0.768,Percent of Total Billed Charges,50% of Total Billed Charges,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,0.768,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,39.304,Case Rate,Pays based on per visit rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,629.152,Percent of Total Billed Charges,100% of Total Billed Charges,47.46,450,
US BIOPHYS WO NST PER FETUS,50668193,CDM,402,RC,76819,HCPCS,Outpatient,,,450,270.00,TC   ,47.46,100,,39.344,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,141.26,280,,767.2,Fee Schedule,280% of BCBS BULE Fee Schedule,161.44,320,,198.064,Fee Schedule,320% of BCBS Blue Essentials Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,181.62,360,,985.6,Fee Schedule,360% of BCBS POS Rate,181.62,360,,985.6,Fee schedule,360% of BCBS PPO Rate,181.62,360,,985.6,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,13.848,Fee Schedule,103% of Cigna fee schedule,84.2,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,86.73,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,337.5,75,,254.6,Percent of Total Billed Charges,75% of Total Billed Charges,225,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,0.312,Percent of Total Billed Charges,50% of Total Billed Charges,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,225,50,,0.312,Percent of Total Billed Charges,50% of Total Billed Charges,225,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,39.304,Case Rate,Pays based on per visit rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,84.2,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,450,100,,339.464,Percent of Total Billed Charges,100% of Total Billed Charges,47.46,450,
US OB OVER 14 WKS,50668250,CDM,402,RC,76805,HCPCS,Outpatient,,,669.38,401.63,,89.75,100,,102.272,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,256.31,280,,1472,Fee Schedule,280% of BCBS BULE Fee Schedule,292.93,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,329.54,360,,1888,Fee Schedule,360% of BCBS POS Rate,329.54,360,,1888,Fee schedule,360% of BCBS PPO Rate,329.54,360,,1888,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,12.264,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,502.04,75,,217.408,Percent of Total Billed Charges,75% of Total Billed Charges,334.69,50,,0.768,Percent of Total Billed Charges,50% of Total Billed Charges,334.69,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334.69,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,334.69,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,3.672,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,669.38,100,,289.872,Percent of Total Billed Charges,100% of Total Billed Charges,89.75,669.38,
US OB OVER 14 WKS,50668250,CDM,402,RC,76805,HCPCS,Outpatient,,,669.38,401.63,,89.75,100,,50.576,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,256.31,280,,2048,Fee Schedule,280% of BCBS BULE Fee Schedule,292.93,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,329.54,360,,2656,Fee Schedule,360% of BCBS POS Rate,329.54,360,,2656,Fee schedule,360% of BCBS PPO Rate,329.54,360,,2656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,13.744,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,502.04,75,,6341.96,Percent of Total Billed Charges,75% of Total Billed Charges,334.69,50,,0.312,Percent of Total Billed Charges,50% of Total Billed Charges,334.69,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,334.69,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,334.69,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,83.296,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,669.38,100,,7927.448,Percent of Total Billed Charges,100% of Total Billed Charges,89.75,669.38,
US OB FU PER FETUS,50668268,CDM,402,RC,76816,HCPCS,Outpatient,,,530.19,318.11,TC   ,70.43,100,,194.872,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,1472,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,1888,Fee Schedule,360% of BCBS POS Rate,403.49,360,,1888,Fee schedule,360% of BCBS PPO Rate,403.49,360,,1888,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,0.896,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,397.64,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,265.1,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,265.1,50,,2.672,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,265.1,50,,2.672,Percent of Total Billed Charges,50% of Total Billed Charges,265.1,50,,40.592,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2.12,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,530.19,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,70.43,530.19,
US OB FU PER FETUS,50668268,CDM,402,RC,76816,HCPCS,Outpatient,,,530.19,318.11,TC   ,70.43,100,,208.992,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,16.408,Fee Schedule,103% of Cigna fee schedule,106.88,100,,2.288,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.352,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,397.64,75,,125.768,Percent of Total Billed Charges,75% of Total Billed Charges,265.1,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,265.1,50,,3.816,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,265.1,50,,3.816,Percent of Total Billed Charges,50% of Total Billed Charges,265.1,50,,3.36,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,3.088,Case Rate,Pays based on per visit rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.288,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,530.19,100,,167.688,Percent of Total Billed Charges,100% of Total Billed Charges,70.43,530.19,
US NEURO NEONATAL,50668284,CDM,402,RC,76506,HCPCS,Outpatient,,,529.2,317.52,,84.08,100,,208.992,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,124.096,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,159.552,Fee Schedule,360% of BCBS POS Rate,403.49,360,,159.552,Fee schedule,360% of BCBS PPO Rate,403.49,360,,159.552,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,79.92,Fee Schedule,103% of Cigna fee schedule,106.88,100,,2.36,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,2.432,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,396.9,75,,188.752,Percent of Total Billed Charges,75% of Total Billed Charges,264.6,50,,2.672,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,50,,2.12,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,78.4,Case Rate,Pays based on per visit rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,2.36,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,529.2,100,,251.664,Percent of Total Billed Charges,100% of Total Billed Charges,84.08,529.2,
US NEURO NEONATAL,50668284,CDM,402,RC,76506,HCPCS,Outpatient,,,529.2,317.52,,84.08,100,,438.32,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,2048,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,198.88,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,2656,Fee Schedule,360% of BCBS POS Rate,403.49,360,,2656,Fee schedule,360% of BCBS PPO Rate,403.49,360,,2656,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,12.272,Fee Schedule,103% of Cigna fee schedule,106.88,100,,3.504,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,3.616,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,396.9,75,,2083.56,Percent of Total Billed Charges,75% of Total Billed Charges,264.6,50,,3.816,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,264.6,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,0.84,Case Rate,Pays based on per visit rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,3.504,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,529.2,100,,2778.08,Percent of Total Billed Charges,100% of Total Billed Charges,84.08,529.2,
US PELVIC TRNSVAG,50668300,CDM,402,RC,76830,HCPCS,Outpatient,,,728.93,437.36,TC   ,88.41,100,,131.328,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,247.24,280,,42.488,Fee Schedule,280% of BCBS BULE Fee Schedule,282.56,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,317.88,360,,54.632,Fee Schedule,360% of BCBS POS Rate,317.88,360,,54.632,Fee schedule,360% of BCBS PPO Rate,317.88,360,,54.632,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,370.656,Fee Schedule,103% of Cigna fee schedule,106.88,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,546.7,75,,566.24,Percent of Total Billed Charges,75% of Total Billed Charges,364.47,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,364.47,50,,21.512,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,364.47,50,,21.512,Percent of Total Billed Charges,50% of Total Billed Charges,364.47,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,0.536,Case Rate,Pays based on per visit rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,728.93,100,,754.984,Percent of Total Billed Charges,100% of Total Billed Charges,88.41,728.93,
US PELVIC TRNSVAG,50668300,CDM,402,RC,76830,HCPCS,Outpatient,,,728.93,437.36,TC   ,88.41,100,,528.208,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,247.24,280,,104.24,Fee Schedule,280% of BCBS BULE Fee Schedule,282.56,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,317.88,360,,134.024,Fee Schedule,360% of BCBS POS Rate,317.88,360,,134.024,Fee schedule,360% of BCBS PPO Rate,317.88,360,,134.024,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,84.72,Fee Schedule,103% of Cigna fee schedule,106.88,100,,8.792,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,110.09,103,,9.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,546.7,75,,471.864,Percent of Total Billed Charges,75% of Total Billed Charges,364.47,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,364.47,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,364.47,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,364.47,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,8.2,Case Rate,Pays based on per visit rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,106.88,100,,8.792,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,728.93,100,,629.152,Percent of Total Billed Charges,100% of Total Billed Charges,88.41,728.93,
US OB TRNSVAG,50668318,CDM,402,RC,76817,HCPCS,Outpatient,,,633.33,380.00,,58.11,100,,131.328,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,161.896,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,208.152,Fee Schedule,360% of BCBS POS Rate,403.49,360,,208.152,Fee schedule,360% of BCBS PPO Rate,403.49,360,,208.152,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,47.6,Fee Schedule,103% of Cigna fee schedule,93.23,100,,61.6,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,96.03,103,,63.448,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,475,75,,1507.992,Percent of Total Billed Charges,75% of Total Billed Charges,316.67,50,,21.512,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,316.67,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,147.088,Case Rate,Pays based on per visit rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,633.33,100,,2010.656,Percent of Total Billed Charges,100% of Total Billed Charges,58.11,633.33,
US OB TRNSVAG,50668318,CDM,402,RC,76817,HCPCS,Outpatient,,,633.33,380.00,,58.11,100,,528.208,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,274.776,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,353.28,Fee Schedule,360% of BCBS POS Rate,403.49,360,,353.28,Fee schedule,360% of BCBS PPO Rate,403.49,360,,353.28,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,144,Fee Schedule,103% of Cigna fee schedule,93.23,100,,19.424,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,96.03,103,,20.008,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,475,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,316.67,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,316.67,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2.072,Case Rate,Pays based on per visit rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,19.424,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,633.33,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,58.11,633.33,
US OB TRNSVAG,50668318,CDM,402,RC,76817,HCPCS,Outpatient,,,633.33,380.00,,58.11,100,,740.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,568.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,731.048,Fee Schedule,360% of BCBS POS Rate,403.49,360,,731.048,Fee schedule,360% of BCBS PPO Rate,403.49,360,,731.048,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,5.384,Fee Schedule,103% of Cigna fee schedule,93.23,100,,12.2,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,96.03,103,,12.568,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,475,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,316.67,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,1.392,Percent of Total Billed Charges,50% of Total Billed Charges,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,316.67,50,,1.392,Percent of Total Billed Charges,50% of Total Billed Charges,316.67,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,49.696,Case Rate,Pays based on per visit rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,93.23,100,,12.2,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,633.33,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,58.11,633.33,
US OB OVER 14 WKS EA ADD,50668433,CDM,402,RC,76810,HCPCS,Outpatient,,,491.99,295.19,TC   ,42.47,100,,576.56,Fee Schedule,100% of Aetna Fee Schedule,221.4,45,,177.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.1,280,,1585.688,Fee Schedule,280% of BCBS BULE Fee Schedule,138.4,320,,199.424,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,155.7,360,,2038.744,Fee Schedule,360% of BCBS POS Rate,155.7,360,,2038.744,Fee schedule,360% of BCBS PPO Rate,155.7,360,,2038.744,Fee Schedule,360% of BCBS Traditional Rate,295.19,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,88.55,100,,1.36,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.99,100,,393.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,1.4,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.99,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,246,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,246,50,,0.592,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,246,50,,0.592,Percent of Total Billed Charges,50% of Total Billed Charges,246,50,,0.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,378,100,,9.128,Case Rate,Pays based on per visit rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,491.99,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,42.47,491.99,
US OB OVER 14 WKS EA ADD,50668433,CDM,402,RC,76810,HCPCS,Outpatient,,,491.99,295.19,TC   ,42.47,100,,559.184,Fee Schedule,100% of Aetna Fee Schedule,221.4,45,,177.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,121.1,280,,14.968,Fee Schedule,280% of BCBS BULE Fee Schedule,138.4,320,,199.488,Fee Schedule,320% of BCBS Blue Essentials Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,155.7,360,,19.248,Fee Schedule,360% of BCBS POS Rate,155.7,360,,19.248,Fee schedule,360% of BCBS PPO Rate,155.7,360,,19.248,Fee Schedule,360% of BCBS Traditional Rate,295.19,60,,21.568,Percent of Total Billed Charges,60% of Total Billed Charges,88.55,100,,4.24,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.99,100,,393.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,91.21,103,,4.368,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.99,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,246,50,,1.392,Percent of Total Billed Charges,50% of Total Billed Charges,246,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,246,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,246,50,,0.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,378,100,,23.72,Case Rate,Pays based on per visit rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,88.55,100,,4.24,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,491.99,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,42.47,491.99,
US PELVIC,50668565,CDM,402,RC,76856,HCPCS,Outpatient,,,863.26,517.96,,74.43,100,,576.56,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,21.96,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,199.6,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,28.232,Fee Schedule,360% of BCBS POS Rate,403.49,360,,28.232,Fee schedule,360% of BCBS PPO Rate,403.49,360,,28.232,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.824,Fee Schedule,103% of Cigna fee schedule,96.28,100,,6.864,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,7.072,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,647.45,75,,1448.528,Percent of Total Billed Charges,75% of Total Billed Charges,431.63,50,,0.592,Percent of Total Billed Charges,50% of Total Billed Charges,431.63,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,431.63,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,431.63,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,11.288,Case Rate,Pays based on per visit rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,6.864,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,863.26,100,,1931.368,Percent of Total Billed Charges,100% of Total Billed Charges,74.43,863.26,
US PELVIC,50668565,CDM,402,RC,76856,HCPCS,Outpatient,,,863.26,517.96,,74.43,100,,444.96,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,28.192,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.968,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,36.24,Fee Schedule,360% of BCBS POS Rate,403.49,360,,36.24,Fee schedule,360% of BCBS PPO Rate,403.49,360,,36.24,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,7.824,Fee Schedule,103% of Cigna fee schedule,96.28,100,,4.304,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,4.432,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,647.45,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,431.63,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,431.63,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,431.63,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,431.63,50,,0.456,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,26.272,Case Rate,Pays based on per visit rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,4.304,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,863.26,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,74.43,863.26,
US PELVIC LTD,50668581,CDM,402,RC,76857,HCPCS,Outpatient,,,674.54,404.72,,23.49,100,,740.68,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,42.672,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,19.976,Fee Schedule,320% of BCBS Blue Essentials Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,54.864,Fee Schedule,360% of BCBS POS Rate,403.49,360,,54.864,Fee schedule,360% of BCBS PPO Rate,403.49,360,,54.864,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,37.544,Fee Schedule,103% of Cigna fee schedule,50.79,100,,8.776,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,52.31,103,,9.04,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,505.91,75,,3744.832,Percent of Total Billed Charges,75% of Total Billed Charges,337.27,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,337.27,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,2.672,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,6.768,Case Rate,Pays based on per visit rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,8.776,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,674.54,100,,4993.112,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,674.54,
US PELVIC LTD,50668581,CDM,402,RC,76857,HCPCS,Outpatient,,,674.54,404.72,,23.49,100,,592.312,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,84,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,20.064,Fee Schedule,320% of BCBS Blue Essentials Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,108,Fee Schedule,360% of BCBS POS Rate,403.49,360,,108,Fee schedule,360% of BCBS PPO Rate,403.49,360,,108,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,30.056,Fee Schedule,103% of Cigna fee schedule,50.79,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,52.31,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,505.91,75,,1069.96,Percent of Total Billed Charges,75% of Total Billed Charges,337.27,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,337.27,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,337.27,50,,3.816,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,34.088,Case Rate,Pays based on per visit rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,50.79,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,674.54,100,,1426.608,Percent of Total Billed Charges,100% of Total Billed Charges,23.49,674.54,
US GUIDE NDL MARK PLCMT INI LT,50669374,CDM,361,RC,,,Outpatient,,,2286.88,1372.13,,1372.13,60,,444.96,Percent of Total Billed Charges,60% of Total Billed Charges,1029.1,45,,823.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,640.33,28,,88.264,Percent of Total Billed Charges,28% of Total Billed Charges,1243.84,32,,20.08,Percent of Total Billed Charges,32% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,823.28,36,,113.488,Percent of Total Billed Charges,36% of Total Billed Charges,823.28,36,,113.488,Percent of Total Billed Charges,36% Total Bille Charges,823.28,36,,113.488,Percent of Total Billed Charges,36% of Total Billed Charges,1372.13,60,,37.2,Percent of Total Billed Charges,60% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2286.88,100,,1829.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,329.77,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1715.16,75,,1631.416,Percent of Total Billed Charges,75% of Total Billed Charges,1143.44,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1143.44,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.82,70,,10.48,Percent of Total Billed Charges,70% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2286.88,100,,2175.224,Percent of Total Billed Charges,100% of Total Billed Charges,320.16,2286.88,
US GUIDE NDL MARK PLCMT INI RT,50669375,CDM,361,RC,,,Outpatient,,,2286.88,1372.13,,1372.13,60,,592.312,Percent of Total Billed Charges,60% of Total Billed Charges,1029.1,45,,823.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,640.33,28,,17.968,Percent of Total Billed Charges,28% of Total Billed Charges,1243.84,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,823.28,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,823.28,36,,23.104,Percent of Total Billed Charges,36% Total Bille Charges,823.28,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,1372.13,60,,9.712,Percent of Total Billed Charges,60% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2286.88,100,,1829.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.77,14.42,,0.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1715.16,75,,282.136,Percent of Total Billed Charges,75% of Total Billed Charges,1143.44,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,13.04,Percent of Total Billed Charges,50% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1143.44,50,,13.04,Percent of Total Billed Charges,50% of Total Billed Charges,1143.44,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1600.82,70,,66.032,Percent of Total Billed Charges,70% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,320.16,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2286.88,100,,376.184,Percent of Total Billed Charges,100% of Total Billed Charges,320.16,2286.88,
US GUIDE NDL MARK PLCMT INI BI,50669376,CDM,361,RC,,,Outpatient,,,3430.32,2058.19,,2058.19,60,,438.32,Percent of Total Billed Charges,60% of Total Billed Charges,1543.64,45,,1234.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,960.49,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,1248,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,1234.92,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,1234.92,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,1234.92,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,2058.19,60,,20.928,Percent of Total Billed Charges,60% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3430.32,100,,2744.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,494.65,14.42,,0.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2572.74,75,,376.24,Percent of Total Billed Charges,75% of Total Billed Charges,1715.16,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,1715.16,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1715.16,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,1715.16,50,,21.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2401.22,70,,81.984,Percent of Total Billed Charges,70% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,480.24,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3430.32,100,,501.656,Percent of Total Billed Charges,100% of Total Billed Charges,480.24,3430.32,
US GUIDE NDL MARK PLCMT EA ADD,50669377,CDM,361,RC,,,Outpatient,,,1373.34,824.00,,824,60,,438.32,Percent of Total Billed Charges,60% of Total Billed Charges,618,45,,494.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.54,28,,138.08,Percent of Total Billed Charges,28% of Total Billed Charges,1249.71,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,494.4,36,,177.528,Percent of Total Billed Charges,36% of Total Billed Charges,494.4,36,,177.528,Percent of Total Billed Charges,36% Total Bille Charges,494.4,36,,177.528,Percent of Total Billed Charges,36% of Total Billed Charges,824,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1373.34,100,,1098.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,198.04,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1030.01,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,686.67,50,,13.04,Percent of Total Billed Charges,50% of Total Billed Charges,686.67,50,,16.216,Percent of Total Billed Charges,50% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,686.67,50,,16.216,Percent of Total Billed Charges,50% of Total Billed Charges,686.67,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,961.34,70,,8.68,Percent of Total Billed Charges,70% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,192.27,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1373.34,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,192.27,1373.34,
US BX RENAL PERC LT,50671339,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,317.76,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,1253.56,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,27.296,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,5.424,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,5.424,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,398.464,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
US BX RENAL PERC BI,50671340,CDM,361,RC,,,Outpatient,,,3105.48,1863.29,,1863.29,60,,317.76,Percent of Total Billed Charges,60% of Total Billed Charges,1397.47,45,,1117.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.53,28,,15.744,Percent of Total Billed Charges,28% of Total Billed Charges,1254.13,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,1117.97,36,,20.24,Percent of Total Billed Charges,36% of Total Billed Charges,1117.97,36,,20.24,Percent of Total Billed Charges,36% Total Bille Charges,1117.97,36,,20.24,Percent of Total Billed Charges,36% of Total Billed Charges,1863.29,60,,62.816,Percent of Total Billed Charges,60% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3105.48,100,,2484.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,447.81,14.42,,94.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2329.11,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1552.74,50,,16.216,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,2.64,Percent of Total Billed Charges,50% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1552.74,50,,2.64,Percent of Total Billed Charges,50% of Total Billed Charges,1552.74,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2173.84,70,,1.872,Percent of Total Billed Charges,70% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,434.77,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3105.48,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,434.77,3105.48,
US BX RENAL PERC RT,50671388,CDM,361,RC,,,Outpatient,,,2070.32,1242.19,,1242.19,60,,595.76,Percent of Total Billed Charges,60% of Total Billed Charges,931.64,45,,745.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.69,28,,249.184,Percent of Total Billed Charges,28% of Total Billed Charges,1254.13,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,745.32,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,745.32,36,,320.376,Percent of Total Billed Charges,36% Total Bille Charges,745.32,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,1242.19,60,,152.112,Percent of Total Billed Charges,60% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070.32,100,,1656.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,298.54,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1552.74,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1035.16,50,,5.424,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,5.256,Percent of Total Billed Charges,50% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.16,50,,5.256,Percent of Total Billed Charges,50% of Total Billed Charges,1035.16,50,,1.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.22,70,,4.592,Percent of Total Billed Charges,70% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,289.84,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2070.32,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,289.84,2070.32,
US GUIDE DRN CATH PLCMT,50676303,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,TC   ,74.33,100,,293.56,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,249.184,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,20.096,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,320.376,Fee Schedule,360% of BCBS POS Rate,229.64,360,,320.376,Fee schedule,360% of BCBS PPO Rate,229.64,360,,320.376,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,1.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,157.024,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,2.64,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,0.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,4.592,Case Rate,Pays based on per visit rate,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,209.36,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
US GUIDE DRN CATH PLCMT,50676303,CDM,320,RC,75989,HCPCS,Outpatient,,,1598.72,959.23,TC   ,74.33,100,,500.72,Fee Schedule,100% of Aetna Fee Schedule,719.42,45,,575.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.61,280,,253.416,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,20.096,Fee Schedule,320% of BCBS Blue Essentials Rate,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,325.824,Fee Schedule,360% of BCBS POS Rate,229.64,360,,325.824,Fee schedule,360% of BCBS PPO Rate,229.64,360,,325.824,Fee Schedule,360% of BCBS Traditional Rate,959.23,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.72,100,,1278.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,230.54,14.42,,5.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.04,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,799.36,50,,5.256,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,799.36,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,207.424,Case Rate,Pays based on per visit rate,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,223.82,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.72,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,74.33,1598.72,
US THORACENTESIS W IMAGE BI,50688234,CDM,361,RC,,,Outpatient,,,2398.46,1439.08,,1439.08,60,,500.72,Percent of Total Billed Charges,60% of Total Billed Charges,1079.31,45,,863.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,671.57,28,,253.416,Percent of Total Billed Charges,28% of Total Billed Charges,1268.8,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,863.45,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,863.45,36,,325.824,Percent of Total Billed Charges,36% Total Bille Charges,863.45,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,1439.08,60,,38.672,Percent of Total Billed Charges,60% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2398.46,100,,1918.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,345.86,14.42,,5.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1798.85,75,,273.264,Percent of Total Billed Charges,75% of Total Billed Charges,1199.23,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,1199.23,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1199.23,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,1199.23,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1678.92,70,,310.512,Percent of Total Billed Charges,70% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,335.78,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2398.46,100,,364.352,Percent of Total Billed Charges,100% of Total Billed Charges,335.78,2398.46,
US THORACENTESIS W IMAGE LT,50688235,CDM,361,RC,,,Outpatient,,,1598.97,959.38,,959.38,60,,885.28,Percent of Total Billed Charges,60% of Total Billed Charges,719.54,45,,575.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.71,28,,20.856,Percent of Total Billed Charges,28% of Total Billed Charges,1269.78,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,575.63,36,,26.816,Percent of Total Billed Charges,36% of Total Billed Charges,575.63,36,,26.816,Percent of Total Billed Charges,36% Total Bille Charges,575.63,36,,26.816,Percent of Total Billed Charges,36% of Total Billed Charges,959.38,60,,62.8,Percent of Total Billed Charges,60% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.97,100,,1279.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,230.57,14.42,,9.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.23,75,,956.416,Percent of Total Billed Charges,75% of Total Billed Charges,799.49,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.49,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1119.28,70,,167.056,Percent of Total Billed Charges,70% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.97,100,,1275.224,Percent of Total Billed Charges,100% of Total Billed Charges,223.86,1598.97,
US THORACENTESIS W IMAGE RT,50688236,CDM,361,RC,,,Outpatient,,,1598.97,959.38,,959.38,60,,885.28,Percent of Total Billed Charges,60% of Total Billed Charges,719.54,45,,575.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.71,28,,18.056,Percent of Total Billed Charges,28% of Total Billed Charges,0.96,32,,199.68,Percent of Total Billed Charges,32% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,575.63,36,,23.216,Percent of Total Billed Charges,36% of Total Billed Charges,575.63,36,,23.216,Percent of Total Billed Charges,36% Total Bille Charges,575.63,36,,23.216,Percent of Total Billed Charges,36% of Total Billed Charges,959.38,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1598.97,100,,1279.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,230.57,14.42,,20.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1199.23,75,,624,Percent of Total Billed Charges,75% of Total Billed Charges,799.49,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,799.49,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,799.49,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1119.28,70,,4.024,Percent of Total Billed Charges,70% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,223.86,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1598.97,100,,780,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,1598.97,
US EXT NONVASCULAR COMPL LT,50694280,CDM,402,RC,76881,HCPCS,Outpatient,,,627.4,376.44,,34.8,100,,644.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,280,,117.16,Fee Schedule,280% of BCBS BULE Fee Schedule,185.66,320,,201.144,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,208.87,360,,150.64,Fee Schedule,360% of BCBS POS Rate,208.87,360,,150.64,Fee schedule,360% of BCBS PPO Rate,208.87,360,,150.64,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,181.328,Fee Schedule,103% of Cigna fee schedule,96.28,100,,27.56,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,28.384,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,470.55,75,,714.952,Percent of Total Billed Charges,75% of Total Billed Charges,313.7,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,38.352,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.7,50,,38.352,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,7.12,Case Rate,Pays based on per visit rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,27.56,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,627.4,100,,953.272,Percent of Total Billed Charges,100% of Total Billed Charges,34.8,627.4,
US EXT NONVASCULAR COMPL LT,50694280,CDM,402,RC,76881,HCPCS,Outpatient,,,627.4,376.44,,34.8,100,,644.16,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,280,,64.048,Fee Schedule,280% of BCBS BULE Fee Schedule,185.66,320,,201.264,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,208.87,360,,82.352,Fee Schedule,360% of BCBS POS Rate,208.87,360,,82.352,Fee schedule,360% of BCBS PPO Rate,208.87,360,,82.352,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,201.896,Fee Schedule,103% of Cigna fee schedule,96.28,100,,0.696,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,0.712,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,470.55,75,,511.672,Percent of Total Billed Charges,75% of Total Billed Charges,313.7,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.7,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,11.032,Case Rate,Pays based on per visit rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.696,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,627.4,100,,682.224,Percent of Total Billed Charges,100% of Total Billed Charges,34.8,627.4,
US EXT NONVASCULAR COMPL RT,50694314,CDM,402,RC,76881,HCPCS,Outpatient,,,627.4,376.44,,34.8,100,,595.76,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,280,,57.536,Fee Schedule,280% of BCBS BULE Fee Schedule,185.66,320,,201.328,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,208.87,360,,73.968,Fee Schedule,360% of BCBS POS Rate,208.87,360,,73.968,Fee schedule,360% of BCBS PPO Rate,208.87,360,,73.968,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,150.952,Fee Schedule,103% of Cigna fee schedule,96.28,100,,0.336,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,0.344,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,470.55,75,,75.808,Percent of Total Billed Charges,75% of Total Billed Charges,313.7,50,,38.352,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.7,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,13.04,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,3.272,Case Rate,Pays based on per visit rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,627.4,100,,101.072,Percent of Total Billed Charges,100% of Total Billed Charges,34.8,627.4,
US EXT NONVASCULAR COMPL RT,50694314,CDM,402,RC,76881,HCPCS,Outpatient,,,627.4,376.44,,34.8,100,,246.04,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,162.46,280,,54.064,Fee Schedule,280% of BCBS BULE Fee Schedule,185.66,320,,201.328,Fee Schedule,320% of BCBS Blue Essentials Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,208.87,360,,69.512,Fee Schedule,360% of BCBS POS Rate,208.87,360,,69.512,Fee schedule,360% of BCBS PPO Rate,208.87,360,,69.512,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,21.168,Fee Schedule,103% of Cigna fee schedule,96.28,100,,0.952,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,99.17,103,,0.976,Fee Schedule,103% of TX Medicaid Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,103.88,103,,,Fee Schedule,103% of CMS OPPS Rate,470.55,75,,95.032,Percent of Total Billed Charges,75% of Total Billed Charges,313.7,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.7,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,313.7,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,517.584,Case Rate,Pays based on per visit rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,96.28,100,,0.952,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,627.4,100,,126.712,Percent of Total Billed Charges,100% of Total Billed Charges,34.8,627.4,
US EXT NONVASCULAR LTD BI,50694330,CDM,402,RC,76882,HCPCS,Outpatient,,,603.66,362.20,TC   ,32.15,100,,246.04,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,501.592,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,201.328,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,644.904,Fee Schedule,360% of BCBS POS Rate,403.49,360,,644.904,Fee schedule,360% of BCBS PPO Rate,403.49,360,,644.904,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,178.008,Fee Schedule,103% of Cigna fee schedule,30.35,100,,0.92,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,0.944,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,452.75,75,,397.944,Percent of Total Billed Charges,75% of Total Billed Charges,301.83,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,301.83,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,301.83,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,301.83,50,,16.216,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,318.224,Case Rate,Pays based on per visit rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.92,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,603.66,100,,530.592,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,603.66,
US EXT NONVASCULAR LTD BI,50694330,CDM,402,RC,76882,HCPCS,Outpatient,,,603.66,362.20,TC   ,32.15,100,,293.56,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,503.416,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,201.328,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,647.248,Fee Schedule,360% of BCBS POS Rate,403.49,360,,647.248,Fee schedule,360% of BCBS PPO Rate,403.49,360,,647.248,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,128.504,Fee Schedule,103% of Cigna fee schedule,30.35,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,0.048,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,452.75,75,,1377.08,Percent of Total Billed Charges,75% of Total Billed Charges,301.83,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,301.83,50,,110.744,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,301.83,50,,110.744,Percent of Total Billed Charges,50% of Total Billed Charges,301.83,50,,5.424,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,7.384,Case Rate,Pays based on per visit rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,603.66,100,,1836.104,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,603.66,
US EXT NONVASCULAR LTD LT,50694355,CDM,402,RC,76882,HCPCS,Outpatient,,,402.44,241.46,,32.15,100,,405.32,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,305.952,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,202.136,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,393.368,Fee Schedule,360% of BCBS POS Rate,403.49,360,,393.368,Fee schedule,360% of BCBS PPO Rate,403.49,360,,393.368,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,190.592,Fee Schedule,103% of Cigna fee schedule,30.35,100,,1.04,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,1.072,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.83,75,,448.144,Percent of Total Billed Charges,75% of Total Billed Charges,201.22,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.22,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,2.64,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,13.544,Case Rate,Pays based on per visit rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.04,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.44,100,,597.528,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,403.49,
US EXT NONVASCULAR LTD LT,50694355,CDM,402,RC,76882,HCPCS,Outpatient,,,402.44,241.46,,32.15,100,,405.32,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,591.448,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,202.136,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,760.432,Fee Schedule,360% of BCBS POS Rate,403.49,360,,760.432,Fee schedule,360% of BCBS PPO Rate,403.49,360,,760.432,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,73.72,Fee Schedule,103% of Cigna fee schedule,30.35,100,,1.568,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,1.616,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.83,75,,361.768,Percent of Total Billed Charges,75% of Total Billed Charges,201.22,50,,110.744,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.22,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,5.256,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,2.216,Case Rate,Pays based on per visit rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,1.568,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.44,100,,482.36,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,403.49,
US EXT NONVASCULAR LTD RT,50694389,CDM,402,RC,76882,HCPCS,Outpatient,,,402.44,241.46,TC   ,32.15,100,,476.672,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,385.28,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,202.2,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,495.36,Fee Schedule,360% of BCBS POS Rate,403.49,360,,495.36,Fee schedule,360% of BCBS PPO Rate,403.49,360,,495.36,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,387.2,Fee Schedule,103% of Cigna fee schedule,30.35,100,,5.4,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,5.56,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.83,75,,121.864,Percent of Total Billed Charges,75% of Total Billed Charges,201.22,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,6.896,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.22,50,,6.896,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,19.12,Case Rate,Pays based on per visit rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,5.4,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.44,100,,162.488,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,403.49,
US EXT NONVASCULAR LTD RT,50694389,CDM,402,RC,76882,HCPCS,Outpatient,,,402.44,241.46,TC   ,32.15,100,,476.672,Fee Schedule,100% of Aetna Fee Schedule,151.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,313.82,280,,24.856,Fee Schedule,280% of BCBS BULE Fee Schedule,358.66,320,,20.264,Fee Schedule,320% of BCBS Blue Essentials Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,403.49,360,,31.96,Fee Schedule,360% of BCBS POS Rate,403.49,360,,31.96,Fee schedule,360% of BCBS PPO Rate,403.49,360,,31.96,Fee Schedule,360% of BCBS Traditional Rate,342.15,103,,953.808,Fee Schedule,103% of Cigna fee schedule,30.35,100,,2.528,Fee Schedule,100% of TX Mediciad Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,90.77,90,,,Fee Schedule,90% of CMS OPPS Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,131.12,130,,,Fee Schedule,130% of CMS OPPS Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,31.26,103,,2.608,Fee Schedule,103% of TX Medicaid Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,103.89,103,,,Fee Schedule,103% of CMS OPPS Rate,301.83,75,,137.952,Percent of Total Billed Charges,75% of Total Billed Charges,201.22,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,201.22,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,201.22,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,151.29,150,,,Fee Schedule,150% of CMS OPPS Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,20.992,Case Rate,Pays based on per visit rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,30.35,100,,2.528,Fee Schedule,100% of TX Medicaid Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,402.44,100,,183.936,Percent of Total Billed Charges,100% of Total Billed Charges,30.35,403.49,
US MOD SED SAME PHY EA ADD 15,50694390,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,1906.672,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,49.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,23.6,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,20.384,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,30.344,Fee Schedule,360% of BCBS POS Rate,38.92,360,,30.344,Fee schedule,360% of BCBS PPO Rate,38.92,360,,30.344,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,617.392,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,109.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,0.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,6.896,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,3.536,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
US MOD SED RAD ADULT INI 15 MI,50694391,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,1906.672,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,17.92,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,20.384,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,23.04,Fee Schedule,360% of BCBS POS Rate,45.4,360,,23.04,Fee schedule,360% of BCBS PPO Rate,45.4,360,,23.04,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,128.504,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
US ASP FINE NDL INIT LESION,50694392,CDM,361,RC,10005,HCPCS,Outpatient,,,1758.74,1055.24,,2601,100,,250.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.91,233,,17.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.96,32,,20.464,Percent of Total Billed Charges,32% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,241.73,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,241.73,322,,23.04,Fee schedule,Pays based on ASC Tier Groupings fee schedule,241.73,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,128.504,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.94,90,,,Fee Schedule,90% of CMS OPPS Rate,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.14,130,,,Fee Schedule,130% of CMS OPPS Rate,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,253.61,14.42,,14.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1319.06,75,,356.656,Percent of Total Billed Charges,75% of Total Billed Charges,879.37,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,879.37,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,879.37,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,2.912,Fee Schedule,100% of ASC Tier Groupings fee schedule,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,246.22,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.74,100,,475.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,2601,
US ASP FINE NDL ADD LESION,50694393,CDM,361,RC,10006,HCPCS,Outpatient,,,244.13,146.48,,2601,100,,250.376,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.86,45,,87.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,202.24,Other,Not Seperately Reimbusable,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.48,60,,67.312,Percent of Total Billed Charges,60% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.13,100,,195.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,35.2,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.1,75,,1069.96,Percent of Total Billed Charges,75% of Total Billed Charges,122.07,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,1.128,Percent of Total Billed Charges,50% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.07,50,,1.128,Percent of Total Billed Charges,50% of Total Billed Charges,122.07,50,,38.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,2.808,Fee Schedule,100% of ASC Tier Groupings fee schedule,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,34.18,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.13,100,,1426.608,Percent of Total Billed Charges,100% of Total Billed Charges,34.18,2601,
US BX LYMPH NODE BI,50694394,CDM,361,RC,38505,HCPCS,Outpatient,,,2873.99,1724.39,,2601,100,,394.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,17.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.96,32,,202.368,Percent of Total Billed Charges,32% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,23.04,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,151.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,414.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2155.49,75,,1069.96,Percent of Total Billed Charges,75% of Total Billed Charges,1437,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,40.36,Percent of Total Billed Charges,50% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,50,,40.36,Percent of Total Billed Charges,50% of Total Billed Charges,1437,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,2.912,Fee Schedule,100% of ASC Tier Groupings fee schedule,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,402.36,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2873.99,100,,1426.608,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,4419.77,
US BX LYMPH NODE RT,50694395,CDM,361,RC,38505,HCPCS,Outpatient,,,1915.99,1149.59,,2601,100,,394.736,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,17.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.96,32,,202.368,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,23.04,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,6.16,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,1,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.99,75,,1253.568,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,1.128,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,958,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,0.536,Fee Schedule,100% of ASC Tier Groupings fee schedule,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.99,100,,1671.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,4419.77,
US BX LYMPH NODE LT,50694396,CDM,361,RC,38505,HCPCS,Outpatient,,,1915.99,1149.59,,2601,100,,192.432,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,17.92,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,0.96,32,,202.512,Percent of Total Billed Charges,32% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,23.04,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,23.04,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,15.88,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,276.29,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1436.99,75,,1028.8,Percent of Total Billed Charges,75% of Total Billed Charges,958,50,,40.36,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,958,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,958,50,,6.144,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,0.736,Fee Schedule,100% of ASC Tier Groupings fee schedule,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,268.24,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.99,100,,1371.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,4419.77,
NEEDLE ENDOSCOPIC VASCULAR 2.3 MM DIA 25 GAUGE 240,50700000,CDM,271,RC,,,Outpatient,,,244,146.40,,146.4,60,,192.432,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,45,,87.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.32,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.96,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,87.84,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,87.84,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,87.84,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,146.4,60,,17.568,Percent of Total Billed Charges,60% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244,100,,195.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,35.18,14.42,,0.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,122,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,122,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,122,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.8,70,,0.864,Percent of Total Billed Charges,70% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.16,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,244,
SYRINGE INFLATION 60ML DISPOSABLE ALLIANCE II,50700001,CDM,271,RC,,,Outpatient,,,245.2,147.12,,147.12,60,,626.664,Percent of Total Billed Charges,60% of Total Billed Charges,110.34,45,,88.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.66,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.96,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,88.27,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,88.27,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,88.27,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,147.12,60,,17.568,Percent of Total Billed Charges,60% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.2,100,,196.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,35.36,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.9,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,122.6,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,122.6,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.6,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,122.6,50,,110.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.64,70,,34.72,Percent of Total Billed Charges,70% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,34.33,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.2,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,245.2,
FORCEP ENDOSCOPIC SPECIMEN RETRIEVAL PULMONARY GR,50700002,CDM,271,RC,,,Outpatient,,,166,99.60,,99.6,60,,626.664,Percent of Total Billed Charges,60% of Total Billed Charges,74.7,45,,59.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.48,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,0.96,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,59.76,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,59.76,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,59.76,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,99.6,60,,0.912,Percent of Total Billed Charges,60% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166,100,,132.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.5,75,,1631.416,Percent of Total Billed Charges,75% of Total Billed Charges,83,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,83,50,,0.96,Percent of Total Billed Charges,50% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83,50,,0.96,Percent of Total Billed Charges,50% of Total Billed Charges,83,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.2,70,,2.248,Percent of Total Billed Charges,70% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166,100,,2175.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,166,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESIV,50700003,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,558,Percent of Total Billed Charges,60% of Total Billed Charges,46.08,45,,36.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,23.496,Percent of Total Billed Charges,28% of Total Billed Charges,0.97,32,,2048.048,Percent of Total Billed Charges,32% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,30.208,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,30.208,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,30.208,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,11.864,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.4,100,,81.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,6.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,14.696,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.97,102.4,
KIT GASTROSTOMY TUBE 20FR BALLOON 5ML STOMA L3CM,50700004,CDM,271,RC,,,Outpatient,,,595,357.00,,357,60,,558,Percent of Total Billed Charges,60% of Total Billed Charges,267.75,45,,214.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.6,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,0.99,32,,2050.056,Percent of Total Billed Charges,32% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,357,60,,23.752,Percent of Total Billed Charges,60% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,476,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,85.8,14.42,,16.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.25,75,,1507.992,Percent of Total Billed Charges,75% of Total Billed Charges,297.5,50,,0.96,Percent of Total Billed Charges,50% of Total Billed Charges,297.5,50,,2.448,Percent of Total Billed Charges,50% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.5,50,,2.448,Percent of Total Billed Charges,50% of Total Billed Charges,297.5,50,,6.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.5,70,,28.032,Percent of Total Billed Charges,70% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595,100,,2010.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.99,595,
KIT GASTROSTOMY 20 FR 3.5 CM LENGTH SILICONE 2 POR,50700005,CDM,271,RC,,,Outpatient,,,595,357.00,,357,60,,143.232,Percent of Total Billed Charges,60% of Total Billed Charges,267.75,45,,214.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.6,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,0.99,32,,2084,Percent of Total Billed Charges,32% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,214.2,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,357,60,,27.28,Percent of Total Billed Charges,60% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,476,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,85.8,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.25,75,,1253.568,Percent of Total Billed Charges,75% of Total Billed Charges,297.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,297.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,297.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.5,70,,8.512,Percent of Total Billed Charges,70% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,83.3,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595,100,,1671.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.99,595,
SYSTEM WATER BOTTLE WITH 4IN CO2 LINE AQUASHIELD,50700006,CDM,271,RC,,,Outpatient,,,106.4,63.84,,63.84,60,,143.232,Percent of Total Billed Charges,60% of Total Billed Charges,47.88,45,,38.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.79,28,,299.016,Percent of Total Billed Charges,28% of Total Billed Charges,1.01,32,,2088.344,Percent of Total Billed Charges,32% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,38.3,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,38.3,36,,384.448,Percent of Total Billed Charges,36% Total Bille Charges,38.3,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,63.84,60,,69.544,Percent of Total Billed Charges,60% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.4,100,,85.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,53.2,50,,2.448,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,53.2,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.48,70,,28.864,Percent of Total Billed Charges,70% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,14.9,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.4,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,106.4,
TUBING IRRIGATION L305CM OLYMPUS ELECTRIC PUMP,50700007,CDM,271,RC,,,Outpatient,,,95,57.00,,57,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,42.75,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.6,28,,299.016,Percent of Total Billed Charges,28% of Total Billed Charges,1.01,32,,2088.96,Percent of Total Billed Charges,32% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,34.2,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,34.2,36,,384.448,Percent of Total Billed Charges,36% Total Bille Charges,34.2,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,57,60,,45.184,Percent of Total Billed Charges,60% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95,100,,76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.7,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.25,75,,437.464,Percent of Total Billed Charges,75% of Total Billed Charges,47.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,47.5,50,,0.144,Percent of Total Billed Charges,50% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.5,50,,0.144,Percent of Total Billed Charges,50% of Total Billed Charges,47.5,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.5,70,,149.856,Percent of Total Billed Charges,70% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,13.3,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95,100,,583.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,95,
RESUSC MASK ADLT RESVR MED,50700008,CDM,271,RC,,,Outpatient,,,132.88,79.73,,79.73,60,,974.904,Percent of Total Billed Charges,60% of Total Billed Charges,59.8,45,,47.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,1.01,32,,2088.96,Percent of Total Billed Charges,32% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,47.84,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,47.84,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,47.84,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,79.73,60,,235.44,Percent of Total Billed Charges,60% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.88,100,,106.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,14.42,,2.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.66,75,,437.464,Percent of Total Billed Charges,75% of Total Billed Charges,66.44,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.44,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,66.44,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,70,,13.64,Percent of Total Billed Charges,70% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,18.6,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.88,100,,583.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,132.88,
DILATOR ENDOSCOPIC BALLOON ESOPHAGEAL PYLORIC COLO,50700009,CDM,271,RC,,,Outpatient,,,1047.6,628.56,,628.56,60,,974.904,Percent of Total Billed Charges,60% of Total Billed Charges,471.42,45,,377.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.33,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,1.01,32,,2110.968,Percent of Total Billed Charges,32% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,377.14,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,377.14,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,377.14,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,628.56,60,,9.984,Percent of Total Billed Charges,60% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1047.6,100,,838.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,151.06,14.42,,1.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.7,75,,143.624,Percent of Total Billed Charges,75% of Total Billed Charges,523.8,50,,0.144,Percent of Total Billed Charges,50% of Total Billed Charges,523.8,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.8,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,523.8,50,,1.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.32,70,,2.912,Percent of Total Billed Charges,70% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,146.66,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1047.6,100,,191.496,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,1047.6,
CLIP LIGATION L235CM RESOLUTION 360,50700010,CDM,271,RC,,,Outpatient,,,1046,627.60,,627.6,60,,788.176,Percent of Total Billed Charges,60% of Total Billed Charges,470.7,45,,376.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.88,28,,475.416,Percent of Total Billed Charges,28% of Total Billed Charges,1.02,32,,2120.688,Percent of Total Billed Charges,32% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,376.56,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,376.56,36,,611.248,Percent of Total Billed Charges,36% Total Bille Charges,376.56,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,627.6,60,,25.424,Percent of Total Billed Charges,60% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1046,100,,836.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,150.83,14.42,,0.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,784.5,75,,1507.992,Percent of Total Billed Charges,75% of Total Billed Charges,523,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,523,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,523,50,,40.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,732.2,70,,129.392,Percent of Total Billed Charges,70% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,146.44,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1046,100,,2010.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.02,1046,
LINE SAMPLING ADULT INTERM LONG TUBING MICRO,50700011,CDM,271,RC,,,Outpatient,,,183.76,110.26,,110.26,60,,788.176,Percent of Total Billed Charges,60% of Total Billed Charges,82.69,45,,66.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.45,28,,475.416,Percent of Total Billed Charges,28% of Total Billed Charges,1.03,32,,2126.592,Percent of Total Billed Charges,32% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,66.15,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,66.15,36,,611.248,Percent of Total Billed Charges,36% Total Bille Charges,66.15,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,110.26,60,,57.424,Percent of Total Billed Charges,60% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.76,100,,147.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,26.5,14.42,,16.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.82,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,91.88,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,91.88,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.88,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,91.88,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.63,70,,6.752,Percent of Total Billed Charges,70% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,25.73,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.76,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.03,183.76,
BIOVAC SUCTION DEVICE,50710002,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,1371.056,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,1.04,32,,2126.984,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,24.328,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,19.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.04,375,
BLLN BILIARY RETRIEVAL,50710003,CDM,270,RC,,,Outpatient,,,580,348.00,,348,60,,1371.056,Percent of Total Billed Charges,60% of Total Billed Charges,261,45,,208.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.4,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,1.04,32,,2129.144,Percent of Total Billed Charges,32% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,208.8,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,208.8,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,208.8,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,348,60,,10.856,Percent of Total Billed Charges,60% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580,100,,464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,83.64,14.42,,1.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,435,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,290,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,290,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,290,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.04,580,
BRAVO PH CAPSULE,50710004,CDM,270,RC,,,Outpatient,,,675,405.00,,405,60,,436.456,Percent of Total Billed Charges,60% of Total Billed Charges,303.75,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,28,,61.6,Percent of Total Billed Charges,28% of Total Billed Charges,1.05,32,,2129.92,Percent of Total Billed Charges,32% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,243,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,243,36,,79.2,Percent of Total Billed Charges,36% Total Bille Charges,243,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,405,60,,18.312,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.34,14.42,,1.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.25,75,,253.872,Percent of Total Billed Charges,75% of Total Billed Charges,337.5,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.5,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.5,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,338.496,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,675,
BRUSH MICRO,50710005,CDM,272,RC,,,Outpatient,,,114,68.40,,68.4,60,,436.456,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,45,,41.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,28,,61.6,Percent of Total Billed Charges,28% of Total Billed Charges,1.05,32,,2129.92,Percent of Total Billed Charges,32% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,41.04,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,41.04,36,,79.2,Percent of Total Billed Charges,36% Total Bille Charges,41.04,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,68.4,60,,278.208,Percent of Total Billed Charges,60% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,100,,91.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,16.44,14.42,,1.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,75,,137.952,Percent of Total Billed Charges,75% of Total Billed Charges,57,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,57,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,57,50,,0.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,70,,5.176,Percent of Total Billed Charges,70% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,15.96,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114,100,,183.936,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,114,
BRUSH PULM CYTOLOGY,50710006,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,455.96,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,1.05,32,,2133.976,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,14.888,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,176.064,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,70,
COLON DECOMPR DEVICE,50710007,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,455.96,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,1.07,32,,2142.208,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,17.368,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,1.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,193.152,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,2.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,23.848,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,257.536,Percent of Total Billed Charges,100% of Total Billed Charges,1.07,600,
CRE DILATION BALLOON,50710008,CDM,272,RC,C1726,HCPCS,Outpatient,,,600,360.00,,396.8,100,,584.448,Fee Schedule,100% of Aetna Fee Schedule,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,37.184,Percent of Total Billed Charges,28% of Total Billed Charges,1.08,32,,2145.232,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,47.808,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,18.488,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,6.96,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,6.96,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,0.528,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,600,
CYTOLOGY BRUSH,50710009,CDM,270,RC,,,Outpatient,,,113.4,68.04,,68.04,60,,508.664,Percent of Total Billed Charges,60% of Total Billed Charges,51.03,45,,40.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.75,28,,37.184,Percent of Total Billed Charges,28% of Total Billed Charges,1.08,32,,2173.848,Percent of Total Billed Charges,32% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,40.82,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,40.82,36,,47.808,Percent of Total Billed Charges,36% Total Bille Charges,40.82,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,68.04,60,,25.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,100,,90.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,16.35,14.42,,9.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.05,75,,437.464,Percent of Total Billed Charges,75% of Total Billed Charges,56.7,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,56.7,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.7,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,56.7,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.38,70,,15.28,Percent of Total Billed Charges,70% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,100,,583.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,113.4,
ENDO GOLD PROBE,50710010,CDM,270,RC,,,Outpatient,,,645,387.00,,387,60,,508.664,Percent of Total Billed Charges,60% of Total Billed Charges,290.25,45,,232.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.6,28,,304.648,Percent of Total Billed Charges,28% of Total Billed Charges,1.08,32,,2175.36,Percent of Total Billed Charges,32% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,232.2,36,,391.688,Percent of Total Billed Charges,36% of Total Billed Charges,232.2,36,,391.688,Percent of Total Billed Charges,36% Total Bille Charges,232.2,36,,391.688,Percent of Total Billed Charges,36% of Total Billed Charges,387,60,,24.08,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,645,100,,516,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,93.01,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483.75,75,,437.464,Percent of Total Billed Charges,75% of Total Billed Charges,322.5,50,,6.96,Percent of Total Billed Charges,50% of Total Billed Charges,322.5,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.5,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,322.5,50,,0.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.5,70,,8.352,Percent of Total Billed Charges,70% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,90.3,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,645,100,,583.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,645,
ERCP CANNULA RX,50710011,CDM,272,RC,,,Outpatient,,,225,135.00,,135,60,,584.448,Percent of Total Billed Charges,60% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,28,,360.472,Percent of Total Billed Charges,28% of Total Billed Charges,1.08,32,,2175.36,Percent of Total Billed Charges,32% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,81,36,,463.464,Percent of Total Billed Charges,36% of Total Billed Charges,81,36,,463.464,Percent of Total Billed Charges,36% Total Bille Charges,81,36,,463.464,Percent of Total Billed Charges,36% of Total Billed Charges,135,60,,4.984,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,100,,180,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,32.45,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.75,75,,273.256,Percent of Total Billed Charges,75% of Total Billed Charges,112.5,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.5,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,70,,369.048,Percent of Total Billed Charges,70% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225,100,,364.344,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,225,
ERCP CANNULA TAPER TIP,50710012,CDM,270,RC,,,Outpatient,,,150,90.00,,90,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,765.064,Percent of Total Billed Charges,28% of Total Billed Charges,1.09,32,,2207.552,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,983.648,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,983.648,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,983.648,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,273.256,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,552.688,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,364.344,Percent of Total Billed Charges,100% of Total Billed Charges,1.09,150,
ERCP EXTRACTION BRACKET,50710013,CDM,272,RC,A4649,HCPCS,Outpatient,,,600,360.00,,360,60,,5605.44,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,158.472,Percent of Total Billed Charges,28% of Total Billed Charges,1.1,32,,2226.432,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,203.752,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,11.032,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,0.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,91.088,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,126.776,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,121.448,Percent of Total Billed Charges,100% of Total Billed Charges,1.1,600,
FORCEPS HOT BX W NEEDLE,50710015,CDM,272,RC,,,Outpatient,,,175,105.00,,105,60,,912,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,28,,812.848,Percent of Total Billed Charges,28% of Total Billed Charges,1.11,32,,2228.872,Percent of Total Billed Charges,32% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,63,36,,1045.088,Percent of Total Billed Charges,36% of Total Billed Charges,63,36,,1045.088,Percent of Total Billed Charges,36% Total Bille Charges,63,36,,1045.088,Percent of Total Billed Charges,36% of Total Billed Charges,105,60,,12.856,Percent of Total Billed Charges,60% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,100,,140,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,25.24,14.42,,0.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.25,75,,1253.568,Percent of Total Billed Charges,75% of Total Billed Charges,87.5,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.5,70,,94.776,Percent of Total Billed Charges,70% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175,100,,1671.424,Percent of Total Billed Charges,100% of Total Billed Charges,1.11,175,
FORCEPS JUMBO,50710016,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,419.384,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,76.056,Percent of Total Billed Charges,28% of Total Billed Charges,1.12,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,97.792,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,97.792,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,97.792,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,9.296,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,70.416,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.12,150,
FORCEPS PEDI,50710018,CDM,272,RC,,,Outpatient,,,160,96.00,,96,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,72,45,,57.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.8,28,,73.232,Percent of Total Billed Charges,28% of Total Billed Charges,1.13,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,57.6,36,,94.152,Percent of Total Billed Charges,36% of Total Billed Charges,57.6,36,,94.152,Percent of Total Billed Charges,36% Total Bille Charges,57.6,36,,94.152,Percent of Total Billed Charges,36% of Total Billed Charges,96,60,,33,Percent of Total Billed Charges,60% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,100,,128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,23.07,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,80,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,80,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,80,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112,70,,17.984,Percent of Total Billed Charges,70% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.4,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.13,160,
FORCEPS PULMONARY,50710019,CDM,272,RC,A4649,HCPCS,Outpatient,,,200,120.00,,120,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,90,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,28,,122.256,Percent of Total Billed Charges,28% of Total Billed Charges,1.15,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,157.184,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,157.184,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,157.184,Percent of Total Billed Charges,36% of Total Billed Charges,120,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,100,,160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,6.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,75,,466.12,Percent of Total Billed Charges,75% of Total Billed Charges,100,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,0.568,Percent of Total Billed Charges,50% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,50,,0.568,Percent of Total Billed Charges,50% of Total Billed Charges,100,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,70,,48.776,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,100,,621.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.15,200,
INJECTION NEEDLE CARR LOCK,50710022,CDM,272,RC,,,Outpatient,,,185,111.00,,111,60,,32.392,Percent of Total Billed Charges,60% of Total Billed Charges,83.25,45,,66.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.8,28,,490.944,Percent of Total Billed Charges,28% of Total Billed Charges,1.16,32,,2241.024,Percent of Total Billed Charges,32% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,66.6,36,,631.216,Percent of Total Billed Charges,36% of Total Billed Charges,66.6,36,,631.216,Percent of Total Billed Charges,36% Total Bille Charges,66.6,36,,631.216,Percent of Total Billed Charges,36% of Total Billed Charges,111,60,,16.792,Percent of Total Billed Charges,60% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185,100,,148,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,26.68,14.42,,87.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.75,75,,448.192,Percent of Total Billed Charges,75% of Total Billed Charges,92.5,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,92.5,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.5,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,92.5,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.5,70,,764.624,Percent of Total Billed Charges,70% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,25.9,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185,100,,597.584,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,185,
JAGTOME RX,50710024,CDM,272,RC,,,Outpatient,,,897,538.20,,538.2,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,403.65,45,,322.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.16,28,,284.488,Percent of Total Billed Charges,28% of Total Billed Charges,1.16,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,322.92,36,,365.776,Percent of Total Billed Charges,36% of Total Billed Charges,322.92,36,,365.776,Percent of Total Billed Charges,36% Total Bille Charges,322.92,36,,365.776,Percent of Total Billed Charges,36% of Total Billed Charges,538.2,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,897,100,,717.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,129.35,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.75,75,,155.376,Percent of Total Billed Charges,75% of Total Billed Charges,448.5,50,,0.568,Percent of Total Billed Charges,50% of Total Billed Charges,448.5,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.5,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,448.5,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,627.9,70,,196.544,Percent of Total Billed Charges,70% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,897,100,,207.168,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,897,
JAGWIRE,50710025,CDM,272,RC,C1769,HCPCS,Outpatient,,,416,249.60,,55.13,100,,127.576,Fee Schedule,100% of Aetna Fee Schedule,187.2,45,,149.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.48,28,,189.664,Percent of Total Billed Charges,28% of Total Billed Charges,1.17,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,149.76,36,,243.848,Percent of Total Billed Charges,36% of Total Billed Charges,149.76,36,,243.848,Percent of Total Billed Charges,36% Total Bille Charges,149.76,36,,243.848,Percent of Total Billed Charges,36% of Total Billed Charges,249.6,60,,6.08,Percent of Total Billed Charges,60% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416,100,,332.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,59.99,14.42,,0.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312,75,,1205.352,Percent of Total Billed Charges,75% of Total Billed Charges,208,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,208,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,208,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.2,70,,70.144,Percent of Total Billed Charges,70% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416,100,,1607.136,Percent of Total Billed Charges,100% of Total Billed Charges,1.17,416,
PEG KIT PUSH PULL,50710026,CDM,272,RC,,,Outpatient,,,810,486.00,,486,60,,79.168,Percent of Total Billed Charges,60% of Total Billed Charges,364.5,45,,291.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.8,28,,82.048,Percent of Total Billed Charges,28% of Total Billed Charges,1.17,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,291.6,36,,105.496,Percent of Total Billed Charges,36% of Total Billed Charges,291.6,36,,105.496,Percent of Total Billed Charges,36% Total Bille Charges,291.6,36,,105.496,Percent of Total Billed Charges,36% of Total Billed Charges,486,60,,23.904,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810,100,,648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,116.8,14.42,,11.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.5,75,,1069.96,Percent of Total Billed Charges,75% of Total Billed Charges,405,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,405,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,405,50,,6.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,567,70,,4.376,Percent of Total Billed Charges,70% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,810,100,,1426.608,Percent of Total Billed Charges,100% of Total Billed Charges,1.17,810,
POLYLOOP LIGATOR,50710028,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,123.08,Percent of Total Billed Charges,28% of Total Billed Charges,1.17,32,,2246.712,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,158.24,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,158.24,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,158.24,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,3.224,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,21.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1028.8,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.68,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,0.68,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,138.592,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1371.736,Percent of Total Billed Charges,100% of Total Billed Charges,1.17,375,
PROBE ERBE SIDEFIRE APC,50710030,CDM,272,RC,,,Outpatient,,,639.6,383.76,,383.76,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,287.82,45,,230.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.09,28,,88.08,Percent of Total Billed Charges,28% of Total Billed Charges,1.17,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,230.26,36,,113.248,Percent of Total Billed Charges,36% of Total Billed Charges,230.26,36,,113.248,Percent of Total Billed Charges,36% Total Bille Charges,230.26,36,,113.248,Percent of Total Billed Charges,36% of Total Billed Charges,383.76,60,,20.824,Percent of Total Billed Charges,60% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,639.6,100,,511.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,92.23,14.42,,8.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,479.7,75,,356.656,Percent of Total Billed Charges,75% of Total Billed Charges,319.8,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,319.8,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.8,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,319.8,50,,2.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.72,70,,6,Percent of Total Billed Charges,70% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,89.54,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,639.6,100,,475.536,Percent of Total Billed Charges,100% of Total Billed Charges,1.17,639.6,
PULMONARY RETRIEVAL BRACKET,50710031,CDM,272,RC,A4649,HCPCS,Outpatient,,,705,423.00,,423,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,317.25,45,,253.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.4,28,,132.128,Percent of Total Billed Charges,28% of Total Billed Charges,1.18,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,253.8,36,,169.88,Percent of Total Billed Charges,36% of Total Billed Charges,253.8,36,,169.88,Percent of Total Billed Charges,36% Total Bille Charges,253.8,36,,169.88,Percent of Total Billed Charges,36% of Total Billed Charges,423,60,,16.128,Percent of Total Billed Charges,60% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,705,100,,564,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,101.66,14.42,,10.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.75,75,,1014.736,Percent of Total Billed Charges,75% of Total Billed Charges,352.5,50,,0.68,Percent of Total Billed Charges,50% of Total Billed Charges,352.5,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.5,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,352.5,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.5,70,,6.472,Percent of Total Billed Charges,70% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.7,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705,100,,1352.976,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,705,
RESOLUTION CLIP,50710032,CDM,270,RC,,,Outpatient,,,600,360.00,,360,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,23.6,Percent of Total Billed Charges,28% of Total Billed Charges,1.18,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,30.344,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,17.304,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,10.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2571.6,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,1.672,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,1.672,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,15.232,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,3428.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,600,
ROTHNET,50710033,CDM,270,RC,,,Outpatient,,,375,225.00,,225,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,90.936,Percent of Total Billed Charges,28% of Total Billed Charges,1.18,32,,2.08,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,116.92,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,116.92,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,116.92,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,41.992,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,17.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1069.96,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.296,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,0.296,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,8.968,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1426.608,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,375,
SNARE JUMBO OVAL,50710035,CDM,272,RC,,,Outpatient,,,78,46.80,,46.8,60,,39.28,Percent of Total Billed Charges,60% of Total Billed Charges,35.1,45,,28.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.84,28,,51.248,Percent of Total Billed Charges,28% of Total Billed Charges,1.18,32,,2.088,Percent of Total Billed Charges,32% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,28.08,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,28.08,36,,65.896,Percent of Total Billed Charges,36% Total Bille Charges,28.08,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,46.8,60,,13.448,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78,100,,62.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14.42,,18.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.5,75,,471.864,Percent of Total Billed Charges,75% of Total Billed Charges,39,50,,1.672,Percent of Total Billed Charges,50% of Total Billed Charges,39,50,,26.352,Percent of Total Billed Charges,50% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39,50,,26.352,Percent of Total Billed Charges,50% of Total Billed Charges,39,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.6,70,,13.44,Percent of Total Billed Charges,70% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,10.92,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78,100,,629.152,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,78,
SPDBND LIGATOR 6 SHTER,50710036,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,47.184,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,51.248,Percent of Total Billed Charges,28% of Total Billed Charges,1.2,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,65.896,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,5.864,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,18.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,1629.784,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,0.296,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,12.688,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2173.048,Percent of Total Billed Charges,100% of Total Billed Charges,1.2,600,
STENT BILIARY PLASTIC,50710039,CDM,278,RC,C2617,HCPCS,Outpatient,,,263.84,158.30,,483.77,110,,64.936,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1.2,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,12.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,1507.992,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,26.352,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,0.504,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,0.504,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,6.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,12.688,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,2010.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.2,483.77,
STENT BILILARY PIGTAIL,50710040,CDM,278,RC,C2617,HCPCS,Outpatient,,,225,135.00,,441.05,110,,80.728,Percent of Total Billed Charges,110% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,28,,1570.624,Percent of Total Billed Charges,28% of Total Billed Charges,1.21,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,81,36,,2019.376,Percent of Total Billed Charges,36% of Total Billed Charges,81,36,,2019.376,Percent of Total Billed Charges,36% Total Bille Charges,81,36,,2019.376,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,100,,180,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,32.45,14.42,,0.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,80,,810,Percent of Total Billed Charges,80% of Total Billed Charges,112.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.5,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,112.5,50,,0.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,70,,90.248,Percent of Total Billed Charges,70% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,31.5,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225,100,,1080,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,441.05,
STENT INTRODUCER,50710041,CDM,272,RC,,,Outpatient,,,355,213.00,,213,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,159.75,45,,127.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.4,28,,874.8,Percent of Total Billed Charges,28% of Total Billed Charges,1.21,32,,2.112,Percent of Total Billed Charges,32% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,127.8,36,,1124.744,Percent of Total Billed Charges,36% of Total Billed Charges,127.8,36,,1124.744,Percent of Total Billed Charges,36% Total Bille Charges,127.8,36,,1124.744,Percent of Total Billed Charges,36% of Total Billed Charges,213,60,,89.68,Percent of Total Billed Charges,60% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355,100,,284,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,51.19,14.42,,0.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.25,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,177.5,50,,0.504,Percent of Total Billed Charges,50% of Total Billed Charges,177.5,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.5,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,177.5,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,248.5,70,,0.248,Percent of Total Billed Charges,70% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,49.7,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,355,
STENT PANCREATIC,50710042,CDM,278,RC,C2625,HCPCS,Outpatient,,,507.87,304.72,,784.97,110,,76.608,Percent of Total Billed Charges,110% of Total Billed Charges,228.54,45,,182.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.2,28,,11.696,Percent of Total Billed Charges,28% of Total Billed Charges,1.22,32,,2.128,Percent of Total Billed Charges,32% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,182.83,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,182.83,36,,15.04,Percent of Total Billed Charges,36% Total Bille Charges,182.83,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,279.33,55,,155.888,Percent of Total Billed Charges,55% Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.87,100,,406.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.3,80,,346.056,Percent of Total Billed Charges,80% of Total Billed Charges,253.94,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.94,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.51,70,,3.52,Percent of Total Billed Charges,70% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.87,100,,461.408,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,784.97,
SYR INFLAT ALLI,50710043,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,16.304,Percent of Total Billed Charges,28% of Total Billed Charges,1.22,32,,2.136,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,20.96,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,367.272,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,7.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,6757.752,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,3.952,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,3.952,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,8447.192,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,150,
TALON GRASPING DEVICE,50710044,CDM,272,RC,,,Outpatient,,,520,312.00,,312,60,,61.056,Percent of Total Billed Charges,60% of Total Billed Charges,234,45,,187.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.6,28,,13.232,Percent of Total Billed Charges,28% of Total Billed Charges,1.23,32,,2.152,Percent of Total Billed Charges,32% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,187.2,36,,17.016,Percent of Total Billed Charges,36% of Total Billed Charges,187.2,36,,17.016,Percent of Total Billed Charges,36% Total Bille Charges,187.2,36,,17.016,Percent of Total Billed Charges,36% of Total Billed Charges,312,60,,72.616,Percent of Total Billed Charges,60% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520,100,,416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,74.98,14.42,,4.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,390,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,260,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,3.336,Percent of Total Billed Charges,50% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260,50,,3.336,Percent of Total Billed Charges,50% of Total Billed Charges,260,50,,1.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,72.8,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,1.23,520,
TRAPEZOID BASKET,50710045,CDM,272,RC,,,Outpatient,,,1855.93,1113.56,,1113.56,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,835.17,45,,668.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,519.66,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1.23,32,,2.152,Percent of Total Billed Charges,32% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,668.13,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,668.13,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,668.13,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,1113.56,60,,60.256,Percent of Total Billed Charges,60% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1855.93,100,,1484.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,267.63,14.42,,1.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1391.95,75,,1528.176,Percent of Total Billed Charges,75% of Total Billed Charges,927.97,50,,3.952,Percent of Total Billed Charges,50% of Total Billed Charges,927.97,50,,72.84,Percent of Total Billed Charges,50% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.97,50,,72.84,Percent of Total Billed Charges,50% of Total Billed Charges,927.97,50,,0.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1299.15,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,259.83,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1855.93,100,,2037.568,Percent of Total Billed Charges,100% of Total Billed Charges,1.23,1855.93,
WANG BRONCHOSCOPY BIOPSY NEEDLE,50710046,CDM,272,RC,A4649,HCPCS,Outpatient,,,251.75,151.05,,151.05,60,,10.416,Percent of Total Billed Charges,60% of Total Billed Charges,113.29,45,,90.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.49,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1.23,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,90.63,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,90.63,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,90.63,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,151.05,60,,21.624,Percent of Total Billed Charges,60% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,251.75,100,,201.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,36.3,14.42,,10.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.81,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,125.88,50,,3.336,Percent of Total Billed Charges,50% of Total Billed Charges,125.88,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.88,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,125.88,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.23,70,,0.456,Percent of Total Billed Charges,70% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,35.25,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.75,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.23,251.75,
BRONCHOSCOPY TRANSBRON BIOPSY,50710047,CDM,750,RC,,,Outpatient,,,786.44,471.86,,471.86,60,,377.488,Percent of Total Billed Charges,60% of Total Billed Charges,353.9,45,,283.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.2,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,1.24,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,471.86,60,,30.44,Percent of Total Billed Charges,60% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.44,100,,629.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14.42,,13.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.83,75,,371.2,Percent of Total Billed Charges,75% of Total Billed Charges,393.22,50,,72.84,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,9.488,Percent of Total Billed Charges,50% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,393.22,50,,9.488,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.51,70,,0.736,Percent of Total Billed Charges,70% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.44,100,,464,Percent of Total Billed Charges,100% of Total Billed Charges,1.24,786.44,
BRONCHOSCOPY TRANS NDL BIOPSY,50710048,CDM,750,RC,,,Outpatient,,,786.44,471.86,,471.86,60,,377.488,Percent of Total Billed Charges,60% of Total Billed Charges,353.9,45,,283.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.2,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,1.24,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,283.12,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,471.86,60,,52.816,Percent of Total Billed Charges,60% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.44,100,,629.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14.42,,21.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.83,75,,2936.736,Percent of Total Billed Charges,75% of Total Billed Charges,393.22,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,393.22,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,1.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.51,70,,0.488,Percent of Total Billed Charges,70% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.44,100,,3670.92,Percent of Total Billed Charges,100% of Total Billed Charges,1.24,786.44,
HEMORRHOID BANDING,50710049,CDM,750,RC,,,Outpatient,,,424.33,254.60,,254.6,60,,203.68,Percent of Total Billed Charges,60% of Total Billed Charges,190.95,45,,152.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.81,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,1.24,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,152.76,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,152.76,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,152.76,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,254.6,60,,17.32,Percent of Total Billed Charges,60% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,424.33,100,,339.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,61.19,14.42,,52.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.25,75,,1960.408,Percent of Total Billed Charges,75% of Total Billed Charges,212.17,50,,9.488,Percent of Total Billed Charges,50% of Total Billed Charges,212.17,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.17,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,212.17,50,,0.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.03,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,59.41,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,424.33,100,,2613.88,Percent of Total Billed Charges,100% of Total Billed Charges,1.24,424.33,
BAND ADJUSTMENT,50710050,CDM,361,RC,43999,HCPCS,Outpatient,,,362.34,217.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1247.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1831.19,233,,94.304,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1.25,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2530.66,322,,121.248,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2530.66,322,,121.248,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2530.66,322,,121.248,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,27.904,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,748.49,90,,,Fee Schedule,90% of CMS OPPS Rate,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.15,130,,,Fee Schedule,130% of CMS OPPS Rate,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.25,14.42,,2.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,856.61,103,,,Fee Schedule,103% of CMS OPPS Rate,271.76,75,,1511.896,Percent of Total Billed Charges,75% of Total Billed Charges,181.17,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,181.17,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,181.17,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,181.17,50,,26.352,Percent of Total Billed Charges,50% of Total Billed Charges,1247.49,150,,,Fee Schedule,150% of CMS OPPS Rate,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,1.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.73,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,831.66,100,,,Fee Schedule,100% of CMS OPPS Rate,362.34,100,,2015.864,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,3862.5,
STENT WALLFLEX 25X90 COLONIC,50710052,CDM,278,RC,C1876,HCPCS,Outpatient,,,9909.31,5945.59,,12331.99,110,,9865.592,Percent of Total Billed Charges,110% of Total Billed Charges,4459.19,45,,3567.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2774.61,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,3567.35,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,3567.35,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,3567.35,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,5450.12,55,,120.64,Percent of Total Billed Charges,55% Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9909.31,100,,7927.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1428.92,14.42,,82.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7927.45,80,,337.912,Percent of Total Billed Charges,80% of Total Billed Charges,4954.66,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,4954.66,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4954.66,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,4954.66,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6936.52,70,,0.152,Percent of Total Billed Charges,70% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,1387.3,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9909.31,100,,450.552,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,12331.99,
NEEDLE EPIDURAL18X16IN WING,50710053,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.184,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,66.584,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,52.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,944.928,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,600,
ANOSCOPY,50710060,CDM,750,RC,,,Outpatient,,,209.61,125.77,,125.77,60,,100.616,Percent of Total Billed Charges,60% of Total Billed Charges,94.32,45,,75.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.69,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.192,Percent of Total Billed Charges,32% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,75.46,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,75.46,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,75.46,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,125.77,60,,3.896,Percent of Total Billed Charges,60% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.61,100,,167.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,30.23,14.42,,39.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.21,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,104.81,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,104.81,50,,10.6,Percent of Total Billed Charges,50% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.81,50,,10.6,Percent of Total Billed Charges,50% of Total Billed Charges,104.81,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.73,70,,3709.728,Percent of Total Billed Charges,70% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,29.35,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.61,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,209.61,
BRONCH BRUSHINGS,50710110,CDM,750,RC,,,Outpatient,,,314.58,188.75,,188.75,60,,151,Percent of Total Billed Charges,60% of Total Billed Charges,141.56,45,,113.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.08,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.216,Percent of Total Billed Charges,32% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,113.25,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,113.25,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,113.25,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,188.75,60,,5.608,Percent of Total Billed Charges,60% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.58,100,,251.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,45.36,14.42,,1.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.94,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,157.29,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,157.29,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.29,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,157.29,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.21,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,44.04,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.58,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,314.58,
BRONCHOSCOPY,50710169,CDM,750,RC,,,Outpatient,,,3472.6,2083.56,,2083.56,60,,1666.848,Percent of Total Billed Charges,60% of Total Billed Charges,1562.67,45,,1250.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972.33,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.224,Percent of Total Billed Charges,32% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,1250.14,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,1250.14,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,1250.14,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,2083.56,60,,8.76,Percent of Total Billed Charges,60% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3472.6,100,,2778.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,500.75,14.42,,22.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2604.45,75,,1352.416,Percent of Total Billed Charges,75% of Total Billed Charges,1736.3,50,,10.6,Percent of Total Billed Charges,50% of Total Billed Charges,1736.3,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1736.3,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,1736.3,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2430.82,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,486.16,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3472.6,100,,1803.216,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,3472.6,
BRONCH BIOPSY,50710177,CDM,750,RC,,,Outpatient,,,943.73,566.24,,566.24,60,,452.992,Percent of Total Billed Charges,60% of Total Billed Charges,424.68,45,,339.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.24,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.224,Percent of Total Billed Charges,32% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,339.74,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,339.74,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,339.74,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,566.24,60,,44.248,Percent of Total Billed Charges,60% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,943.73,100,,754.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,136.09,14.42,,196.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,707.8,75,,485.4,Percent of Total Billed Charges,75% of Total Billed Charges,471.87,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,471.87,50,,2.44,Percent of Total Billed Charges,50% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,471.87,50,,2.44,Percent of Total Billed Charges,50% of Total Billed Charges,471.87,50,,3.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,660.61,70,,77.616,Percent of Total Billed Charges,70% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,132.12,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,943.73,100,,647.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,943.73,
BRONCHOSCOPY NEEDLE ASPRATION,50710193,CDM,750,RC,,,Outpatient,,,786.44,471.86,,471.86,60,,377.488,Percent of Total Billed Charges,60% of Total Billed Charges,353.9,45,,283.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.2,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.232,Percent of Total Billed Charges,32% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,283.12,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,283.12,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,283.12,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,471.86,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.44,100,,629.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.83,75,,564.36,Percent of Total Billed Charges,75% of Total Billed Charges,393.22,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,393.22,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,3.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.51,70,,8.648,Percent of Total Billed Charges,70% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.44,100,,752.48,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,786.44,
COLONOSCOPY,50710276,CDM,750,RC,,,Outpatient,,,2513.32,1507.99,,1507.99,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,1130.99,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.73,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.24,Percent of Total Billed Charges,32% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,904.8,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,904.8,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,904.8,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,1507.99,60,,3.224,Percent of Total Billed Charges,60% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,362.42,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1884.99,75,,967.832,Percent of Total Billed Charges,75% of Total Billed Charges,1256.66,50,,2.44,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,4.104,Percent of Total Billed Charges,50% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1256.66,50,,4.104,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,72.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1759.32,70,,17.36,Percent of Total Billed Charges,70% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.32,100,,1290.44,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,2513.32,
COLONOSCOPY W/BIOPSY,50710292,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.24,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,3.736,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,14.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,1247.184,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,10.888,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,10.888,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,96.632,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,1662.912,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,718.09,
COLONOSCOPY POLYPECTOMY,50710300,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,2.272,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,55.472,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,875.28,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,4.104,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,9.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,21.256,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,1167.04,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,718.09,
COLONOSCOPY CTL BLEEDING,50710391,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,1138.336,Percent of Total Billed Charges,28% of Total Billed Charges,1.25,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,1463.568,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,1463.568,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,1463.568,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,735.68,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,32.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,1311.744,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,10.888,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,14.144,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,1748.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.25,718.09,
EGD CTRL BLEEDING,50710524,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,1.26,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,33.544,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,4.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1291.168,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,39.608,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1721.56,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,689.77,
EGD,50710540,CDM,750,RC,,,Outpatient,,,2414.21,1448.53,,1448.53,60,,1158.824,Percent of Total Billed Charges,60% of Total Billed Charges,1086.39,45,,869.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675.98,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,1.26,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,869.12,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,869.12,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,869.12,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,1448.53,60,,26.432,Percent of Total Billed Charges,60% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2414.21,100,,1931.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,348.13,14.42,,44.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1810.66,75,,6108.2,Percent of Total Billed Charges,75% of Total Billed Charges,1207.11,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,1207.11,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1207.11,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,1207.11,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1689.95,70,,83.296,Percent of Total Billed Charges,70% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,337.99,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2414.21,100,,8144.264,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,2414.21,
EGD BIOPSY,50710557,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,121.336,Percent of Total Billed Charges,28% of Total Billed Charges,1.26,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,156,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,44.152,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,51.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1213.648,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,7.504,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1618.192,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,689.77,
ERCP,50710565,CDM,750,RC,,,Outpatient,,,6241.39,3744.83,,3744.83,60,,2995.864,Percent of Total Billed Charges,60% of Total Billed Charges,2808.63,45,,2246.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1747.59,28,,121.336,Percent of Total Billed Charges,28% of Total Billed Charges,1.27,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,2246.9,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,2246.9,36,,156,Percent of Total Billed Charges,36% Total Bille Charges,2246.9,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,3744.83,60,,78.432,Percent of Total Billed Charges,60% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6241.39,100,,4993.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,900.01,14.42,,0.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4681.04,75,,891.4,Percent of Total Billed Charges,75% of Total Billed Charges,3120.7,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,3120.7,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3120.7,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,3120.7,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4368.97,70,,13.728,Percent of Total Billed Charges,70% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,873.79,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6241.39,100,,1188.536,Percent of Total Billed Charges,100% of Total Billed Charges,1.27,6241.39,
ERCP SPHINCTEROTOMY,50710573,CDM,750,RC,,,Outpatient,,,1783.26,1069.96,,1069.96,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,802.47,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.31,28,,485.336,Percent of Total Billed Charges,28% of Total Billed Charges,1.27,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,641.97,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,641.97,36,,624,Percent of Total Billed Charges,36% Total Bille Charges,641.97,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,1069.96,60,,105.024,Percent of Total Billed Charges,60% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1426.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,257.15,14.42,,7.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.45,75,,1225.416,Percent of Total Billed Charges,75% of Total Billed Charges,891.63,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,891.63,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,10.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1248.28,70,,15.488,Percent of Total Billed Charges,70% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1633.888,Percent of Total Billed Charges,100% of Total Billed Charges,1.27,1783.26,
ENTEROSCOPY,50710599,CDM,750,RC,,,Outpatient,,,2719.03,1631.42,,1631.42,60,,1305.136,Percent of Total Billed Charges,60% of Total Billed Charges,1223.56,45,,978.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,761.33,28,,485.336,Percent of Total Billed Charges,28% of Total Billed Charges,9669.62,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,978.85,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,978.85,36,,624,Percent of Total Billed Charges,36% Total Bille Charges,978.85,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,1631.42,60,,13.04,Percent of Total Billed Charges,60% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2719.03,100,,2175.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,392.08,14.42,,49.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2039.27,75,,711.264,Percent of Total Billed Charges,75% of Total Billed Charges,1359.52,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1359.52,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1359.52,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,1359.52,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1903.32,70,,15.488,Percent of Total Billed Charges,70% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2719.03,100,,948.352,Percent of Total Billed Charges,100% of Total Billed Charges,380.66,9669.62,
EGD ESOPH DILATION/BOUGIE,50710607,CDM,750,RC,,,Outpatient,,,470.23,282.14,,282.14,60,,225.712,Percent of Total Billed Charges,60% of Total Billed Charges,211.6,45,,169.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.66,28,,34.408,Percent of Total Billed Charges,28% of Total Billed Charges,9765.28,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,169.28,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,169.28,36,,44.24,Percent of Total Billed Charges,36% Total Bille Charges,169.28,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,282.14,60,,158.4,Percent of Total Billed Charges,60% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,470.23,100,,376.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,67.81,14.42,,7.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.67,75,,829.072,Percent of Total Billed Charges,75% of Total Billed Charges,235.12,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,235.12,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,235.12,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,235.12,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.16,70,,1142.72,Percent of Total Billed Charges,70% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,65.83,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,470.23,100,,1105.432,Percent of Total Billed Charges,100% of Total Billed Charges,65.83,9765.28,
ESOPH FB REMOVAL,50710649,CDM,750,RC,,,Outpatient,,,627.07,376.24,,376.24,60,,300.992,Percent of Total Billed Charges,60% of Total Billed Charges,282.18,45,,225.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.58,28,,34.408,Percent of Total Billed Charges,28% of Total Billed Charges,9789.12,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,225.75,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,225.75,36,,44.24,Percent of Total Billed Charges,36% Total Bille Charges,225.75,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,376.24,60,,55.624,Percent of Total Billed Charges,60% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,627.07,100,,501.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,90.42,14.42,,10.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,470.3,75,,809.32,Percent of Total Billed Charges,75% of Total Billed Charges,313.54,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,313.54,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.54,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,313.54,50,,2.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.95,70,,21.976,Percent of Total Billed Charges,70% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,87.79,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,627.07,100,,1079.088,Percent of Total Billed Charges,100% of Total Billed Charges,87.79,9789.12,
EGD BAND LIGATION,50710706,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,8.784,Percent of Total Billed Charges,28% of Total Billed Charges,9789.12,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,11.288,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,11.288,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,11.288,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,205.2,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,1.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1639.704,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,12.88,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,2186.272,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,9789.12,
EGD BALLOON DILATION,50710714,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,67.152,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.536,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,38.216,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,55.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,2459.552,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,4.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,0.192,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,3279.4,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,9825.84,
EGD POLYPECTOMY,50710730,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,67.152,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.536,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,56.104,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,17.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,921.424,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,10.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,295.056,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1228.568,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,9825.84,
EGD FB REMOVAL,50710763,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,255.36,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.568,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,328.32,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,328.32,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,328.32,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,38.216,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,4.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1382.144,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.968,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,1.392,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1842.856,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,9825.84,
GASTRIC LAVAGE,50710862,CDM,750,RC,,,Outpatient,,,261.7,157.02,,157.02,60,,125.616,Percent of Total Billed Charges,60% of Total Billed Charges,117.77,45,,94.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.28,28,,41.856,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.616,Percent of Total Billed Charges,32% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,94.21,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,94.21,36,,53.808,Percent of Total Billed Charges,36% Total Bille Charges,94.21,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,157.02,60,,174.624,Percent of Total Billed Charges,60% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.7,100,,209.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,37.74,14.42,,4.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.28,75,,1370.344,Percent of Total Billed Charges,75% of Total Billed Charges,130.85,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,130.85,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.85,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,130.85,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.19,70,,163.04,Percent of Total Billed Charges,70% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.64,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.7,100,,1827.128,Percent of Total Billed Charges,100% of Total Billed Charges,36.64,9825.84,
PEG TUBE PLACEMENT,50710987,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,41.856,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.632,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,53.808,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,55.144,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,6.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,2055.52,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,9.4,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,9.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,10.28,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,2740.688,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,9825.84,
FLEX SIG BIOPSY,50711431,CDM,750,RC,,,Outpatient,,,455.44,273.26,,273.26,60,,218.608,Percent of Total Billed Charges,60% of Total Billed Charges,204.95,45,,163.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.52,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.632,Percent of Total Billed Charges,32% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,163.96,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,163.96,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,163.96,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,273.26,60,,4.04,Percent of Total Billed Charges,60% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.44,100,,364.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,65.67,14.42,,59.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.58,75,,828.424,Percent of Total Billed Charges,75% of Total Billed Charges,227.72,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.72,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.81,70,,207.136,Percent of Total Billed Charges,70% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455.44,100,,1104.56,Percent of Total Billed Charges,100% of Total Billed Charges,63.76,9825.84,
FLEX SIGMOIDOSCOPY,50711456,CDM,750,RC,,,Outpatient,,,1594.03,956.42,,956.42,60,,765.136,Percent of Total Billed Charges,60% of Total Billed Charges,717.31,45,,573.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,446.33,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,20.672,Percent of Total Billed Charges,32% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,573.85,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,573.85,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,573.85,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,956.42,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1594.03,100,,1275.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,229.86,14.42,,65.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1195.52,75,,1242.624,Percent of Total Billed Charges,75% of Total Billed Charges,797.02,50,,9.4,Percent of Total Billed Charges,50% of Total Billed Charges,797.02,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,797.02,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,797.02,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1115.82,70,,276.392,Percent of Total Billed Charges,70% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,223.16,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1594.03,100,,1656.832,Percent of Total Billed Charges,100% of Total Billed Charges,223.16,9825.84,
ACHALASIA BALLOON 30MM,50712298,CDM,278,RC,C1726,HCPCS,Outpatient,,,975,585.00,,1469.3,110,,1175.44,Percent of Total Billed Charges,110% of Total Billed Charges,438.75,45,,351,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273,28,,115.8,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,205.216,Percent of Total Billed Charges,32% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,351,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,351,36,,148.888,Percent of Total Billed Charges,36% Total Bille Charges,351,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,536.25,55,,2.024,Percent of Total Billed Charges,55% Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,975,100,,780,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,140.6,14.42,,37.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780,80,,1456.352,Percent of Total Billed Charges,80% of Total Billed Charges,487.5,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,487.5,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,487.5,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.5,70,,126.76,Percent of Total Billed Charges,70% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,136.5,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,975,100,,1941.8,Percent of Total Billed Charges,100% of Total Billed Charges,136.5,9825.84,
PH MONITOR CAPSULE PLACEMENT,50712314,CDM,750,RC,,,Outpatient,,,1191.59,714.95,,714.95,60,,571.96,Percent of Total Billed Charges,60% of Total Billed Charges,536.22,45,,428.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.65,28,,115.8,Percent of Total Billed Charges,28% of Total Billed Charges,9825.84,32,,205.312,Percent of Total Billed Charges,32% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,428.97,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,428.97,36,,148.888,Percent of Total Billed Charges,36% Total Bille Charges,428.97,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,714.95,60,,4.792,Percent of Total Billed Charges,60% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1191.59,100,,953.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,171.83,14.42,,5.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,893.69,75,,2184.528,Percent of Total Billed Charges,75% of Total Billed Charges,595.8,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,595.8,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.8,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,595.8,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.11,70,,169.008,Percent of Total Billed Charges,70% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,166.82,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1191.59,100,,2912.704,Percent of Total Billed Charges,100% of Total Billed Charges,166.82,9825.84,
GUARDUS OVERTUBE,50712322,CDM,272,RC,,,Outpatient,,,852.78,511.67,,511.67,60,,409.336,Percent of Total Billed Charges,60% of Total Billed Charges,383.75,45,,307,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.78,28,,29.328,Percent of Total Billed Charges,28% of Total Billed Charges,9.6,32,,205.312,Percent of Total Billed Charges,32% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,307,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,307,36,,37.704,Percent of Total Billed Charges,36% Total Bille Charges,307,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,511.67,60,,48.496,Percent of Total Billed Charges,60% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,852.78,100,,682.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,122.97,14.42,,0.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,639.59,75,,847.744,Percent of Total Billed Charges,75% of Total Billed Charges,426.39,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,426.39,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.39,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,426.39,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.95,70,,1.312,Percent of Total Billed Charges,70% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,119.39,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,852.78,100,,1130.32,Percent of Total Billed Charges,100% of Total Billed Charges,9.6,852.78,
RF GROUNDING PAD,50712330,CDM,270,RC,,,Outpatient,,,126.34,75.80,,75.8,60,,60.64,Percent of Total Billed Charges,60% of Total Billed Charges,56.85,45,,45.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.38,28,,29.328,Percent of Total Billed Charges,28% of Total Billed Charges,9.62,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,45.48,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,45.48,36,,37.704,Percent of Total Billed Charges,36% Total Bille Charges,45.48,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,75.8,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.34,100,,101.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,18.22,14.42,,2.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.76,75,,1271.608,Percent of Total Billed Charges,75% of Total Billed Charges,63.17,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,63.17,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.17,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,63.17,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.44,70,,35.536,Percent of Total Billed Charges,70% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,17.69,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.34,100,,1695.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.62,126.34,
CANN CRVD 100MM 20G 10MM,50712348,CDM,272,RC,,,Outpatient,,,158.39,95.03,,95.03,60,,76.024,Percent of Total Billed Charges,60% of Total Billed Charges,71.28,45,,57.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.35,28,,108.584,Percent of Total Billed Charges,28% of Total Billed Charges,9.66,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,57.02,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,57.02,36,,139.608,Percent of Total Billed Charges,36% Total Bille Charges,57.02,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,95.03,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.39,100,,126.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.84,14.42,,17.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.79,75,,810.52,Percent of Total Billed Charges,75% of Total Billed Charges,79.2,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,50,,15.648,Percent of Total Billed Charges,50% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.2,50,,15.648,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,50,,1.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.87,70,,23752.4,Percent of Total Billed Charges,70% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,22.17,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.39,100,,1080.696,Percent of Total Billed Charges,100% of Total Billed Charges,9.66,158.39,
ESOPHAGOSCOPY W/BALLOON DILATION,50712405,CDM,750,RC,43220,HCPCS,Outpatient,,,663.24,397.94,,4162,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2618.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3628.74,233,,148.416,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9.76,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,5014.83,322,,190.816,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5014.83,322,,190.816,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5014.83,322,,190.816,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,14.4,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.18,90,,,Fee Schedule,90% of CMS OPPS Rate,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.48,130,,,Fee Schedule,130% of CMS OPPS Rate,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,95.64,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,1798.12,103,,,Fee Schedule,103% of CMS OPPS Rate,1798.12,103,,,Fee Schedule,103% of CMS OPPS Rate,497.43,75,,1215.784,Percent of Total Billed Charges,75% of Total Billed Charges,331.62,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,331.62,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,331.62,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,331.62,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,2618.64,150,,,Fee Schedule,150% of CMS OPPS Rate,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,41.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,92.85,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,1745.76,100,,,Fee Schedule,100% of CMS OPPS Rate,663.24,100,,1621.048,Percent of Total Billed Charges,100% of Total Billed Charges,9.76,5014.83,
ESOPHAGOSCOPY,50732007,CDM,750,RC,,,Outpatient,,,2295.13,1377.08,,1377.08,60,,1101.664,Percent of Total Billed Charges,60% of Total Billed Charges,1032.81,45,,826.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.64,28,,221.92,Percent of Total Billed Charges,28% of Total Billed Charges,9.8,32,,206.488,Percent of Total Billed Charges,32% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,826.25,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,826.25,36,,285.328,Percent of Total Billed Charges,36% Total Bille Charges,826.25,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,1377.08,60,,8.672,Percent of Total Billed Charges,60% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2295.13,100,,1836.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,330.96,14.42,,6.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1721.35,75,,2289.6,Percent of Total Billed Charges,75% of Total Billed Charges,1147.57,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,1147.57,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1147.57,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,1147.57,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1606.59,70,,663.872,Percent of Total Billed Charges,70% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,321.32,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2295.13,100,,3052.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,2295.13,
REPLACE G TUBE W/WO REVIS TRAC,50732031,CDM,750,RC,,,Outpatient,,,746.91,448.15,,448.15,60,,358.52,Percent of Total Billed Charges,60% of Total Billed Charges,336.11,45,,268.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.13,28,,221.92,Percent of Total Billed Charges,28% of Total Billed Charges,9.8,32,,206.504,Percent of Total Billed Charges,32% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,268.89,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,268.89,36,,285.328,Percent of Total Billed Charges,36% Total Bille Charges,268.89,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,448.15,60,,93.952,Percent of Total Billed Charges,60% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,746.91,100,,597.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,107.7,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.18,75,,848.4,Percent of Total Billed Charges,75% of Total Billed Charges,373.46,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,373.46,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.46,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,373.46,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,522.84,70,,1825.04,Percent of Total Billed Charges,70% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,104.57,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,746.91,100,,1131.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,746.91,
ESOPHAGOSCOPY SUBMUCOSAL INJ,50732049,CDM,750,RC,,,Outpatient,,,602.95,361.77,,361.77,60,,289.416,Percent of Total Billed Charges,60% of Total Billed Charges,271.33,45,,217.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.83,28,,84.864,Percent of Total Billed Charges,28% of Total Billed Charges,9.8,32,,206.984,Percent of Total Billed Charges,32% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,217.06,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,217.06,36,,109.112,Percent of Total Billed Charges,36% Total Bille Charges,217.06,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,361.77,60,,3724.52,Percent of Total Billed Charges,60% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,602.95,100,,482.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,86.95,14.42,,56.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,452.21,75,,1272.6,Percent of Total Billed Charges,75% of Total Billed Charges,301.48,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,301.48,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.48,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,301.48,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.07,70,,7.288,Percent of Total Billed Charges,70% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,84.41,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,602.95,100,,1696.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,602.95,
PEG TUBE REMOVAL,50732056,CDM,750,RC,G0463,HCPCS,Outpatient,,,203.11,121.87,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,84.864,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,207.128,Fee Schedule,320% of BCBS Blue Essentials Rate,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,109.112,Fee Schedule,360% of BCBS POS Rate,417.35,360,,109.112,Fee schedule,360% of BCBS PPO Rate,417.35,360,,109.112,Fee Schedule,360% of BCBS Traditional Rate,121.87,60,,203.56,Percent of Total Billed Charges,60% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,48.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,152.33,75,,839.736,Percent of Total Billed Charges,75% of Total Billed Charges,101.56,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,101.56,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,101.56,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,101.56,50,,9.4,Percent of Total Billed Charges,50% of Total Billed Charges,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,142.18,70,,13.384,Percent of Total Billed Charges,70% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,203.11,100,,1119.648,Percent of Total Billed Charges,100% of Total Billed Charges,28.44,417.35,
EGD SUBMUCOSAL INJ,50732353,CDM,750,RC,,,Outpatient,,,229.92,137.95,,137.95,60,,110.36,Percent of Total Billed Charges,60% of Total Billed Charges,103.46,45,,82.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.38,28,,108.928,Percent of Total Billed Charges,28% of Total Billed Charges,9.8,32,,20.744,Percent of Total Billed Charges,32% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,82.77,36,,140.056,Percent of Total Billed Charges,36% Total Bille Charges,82.77,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,137.95,60,,342.312,Percent of Total Billed Charges,60% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.92,100,,183.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,33.15,14.42,,1.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.44,75,,1259.608,Percent of Total Billed Charges,75% of Total Billed Charges,114.96,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,114.96,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,114.96,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.94,70,,104.792,Percent of Total Billed Charges,70% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.92,100,,1679.472,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,229.92,
EGD SCLEROTHERAPY INJ,50732437,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,108.928,Percent of Total Billed Charges,28% of Total Billed Charges,9.83,32,,20.792,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,140.056,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,709.368,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,598.24,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.216,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.216,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,10.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,19.456,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,797.648,Percent of Total Billed Charges,100% of Total Billed Charges,9.83,689.77,
EGD DIL OF GASTRIC OUTLET,50732452,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,122.536,Percent of Total Billed Charges,28% of Total Billed Charges,9.88,32,,20.88,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,157.544,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,93.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1288.8,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,160.168,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1718.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.88,689.77,
ERCP BRUSHINGS,50732601,CDM,750,RC,,,Outpatient,,,594.42,356.65,,356.65,60,,285.32,Percent of Total Billed Charges,60% of Total Billed Charges,267.49,45,,213.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.44,28,,122.536,Percent of Total Billed Charges,28% of Total Billed Charges,9.89,32,,20.936,Percent of Total Billed Charges,32% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,213.99,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,213.99,36,,157.544,Percent of Total Billed Charges,36% Total Bille Charges,213.99,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,356.65,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,594.42,100,,475.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,85.72,14.42,,4.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.82,75,,1502.08,Percent of Total Billed Charges,75% of Total Billed Charges,297.21,50,,0.216,Percent of Total Billed Charges,50% of Total Billed Charges,297.21,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.21,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,297.21,50,,6.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.09,70,,50.2,Percent of Total Billed Charges,70% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.42,100,,2002.776,Percent of Total Billed Charges,100% of Total Billed Charges,9.89,594.42,
ERCP BALLOON SWEEP,50732643,CDM,750,RC,,,Outpatient,,,1783.26,1069.96,,1069.96,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,802.47,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.31,28,,15.112,Percent of Total Billed Charges,28% of Total Billed Charges,9.91,32,,20.944,Percent of Total Billed Charges,32% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,641.97,36,,19.432,Percent of Total Billed Charges,36% of Total Billed Charges,641.97,36,,19.432,Percent of Total Billed Charges,36% Total Bille Charges,641.97,36,,19.432,Percent of Total Billed Charges,36% of Total Billed Charges,1069.96,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1426.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,257.15,14.42,,1.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.45,75,,1577.704,Percent of Total Billed Charges,75% of Total Billed Charges,891.63,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,891.63,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1248.28,70,,486.528,Percent of Total Billed Charges,70% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.26,100,,2103.608,Percent of Total Billed Charges,100% of Total Billed Charges,9.91,1783.26,
ERCP STONE DESTRUCTION,50732650,CDM,750,RC,,,Outpatient,,,1783.26,1069.96,,1069.96,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,802.47,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.31,28,,22.624,Percent of Total Billed Charges,28% of Total Billed Charges,9.91,32,,20.952,Percent of Total Billed Charges,32% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,641.97,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,641.97,36,,29.088,Percent of Total Billed Charges,36% Total Bille Charges,641.97,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,1069.96,60,,38.856,Percent of Total Billed Charges,60% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1426.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,257.15,14.42,,0.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.45,75,,2121.568,Percent of Total Billed Charges,75% of Total Billed Charges,891.63,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,891.63,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1248.28,70,,43.184,Percent of Total Billed Charges,70% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.26,100,,2828.76,Percent of Total Billed Charges,100% of Total Billed Charges,9.91,1783.26,
ERCP STENT INSERTION,50732684,CDM,750,RC,,,Outpatient,,,2089.28,1253.57,,1253.57,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,940.18,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585,28,,36.944,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,20.968,Percent of Total Billed Charges,32% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,752.14,36,,47.504,Percent of Total Billed Charges,36% of Total Billed Charges,752.14,36,,47.504,Percent of Total Billed Charges,36% Total Bille Charges,752.14,36,,47.504,Percent of Total Billed Charges,36% of Total Billed Charges,1253.57,60,,362.888,Percent of Total Billed Charges,60% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14.42,,8.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566.96,75,,3182.36,Percent of Total Billed Charges,75% of Total Billed Charges,1044.64,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1044.64,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,15.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1462.5,70,,4.904,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.28,100,,4243.144,Percent of Total Billed Charges,100% of Total Billed Charges,96,2089.28,
ERCP DILATION,50732718,CDM,750,RC,,,Outpatient,,,1714.67,1028.80,,1028.8,60,,823.04,Percent of Total Billed Charges,60% of Total Billed Charges,771.6,45,,617.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.11,28,,5.912,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,20.968,Percent of Total Billed Charges,32% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,617.28,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,617.28,36,,7.6,Percent of Total Billed Charges,36% Total Bille Charges,617.28,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,1028.8,60,,60.392,Percent of Total Billed Charges,60% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1714.67,100,,1371.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,247.26,14.42,,76.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1286,75,,1367.84,Percent of Total Billed Charges,75% of Total Billed Charges,857.34,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,857.34,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,857.34,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,857.34,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200.27,70,,99.12,Percent of Total Billed Charges,70% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1714.67,100,,1823.784,Percent of Total Billed Charges,100% of Total Billed Charges,96,1714.67,
ENTEROSCOPY BIOPSY,50743616,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,6.488,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,207.36,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,8.336,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,4.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,2051.76,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,28.2,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,2735.68,Percent of Total Billed Charges,100% of Total Billed Charges,96,776.86,
G TUBE CONV TO PEJ,50743723,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,6.864,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,207.36,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,8.824,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,927.544,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,2.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,1526.4,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,199.032,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,2035.2,Percent of Total Billed Charges,100% of Total Billed Charges,96,776.86,
ILEOSCOPY,50743806,CDM,750,RC,,,Outpatient,,,2719.03,1631.42,,1631.42,60,,1305.136,Percent of Total Billed Charges,60% of Total Billed Charges,1223.56,45,,978.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,761.33,28,,7.944,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,207.432,Percent of Total Billed Charges,32% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,978.85,36,,10.216,Percent of Total Billed Charges,36% of Total Billed Charges,978.85,36,,10.216,Percent of Total Billed Charges,36% Total Bille Charges,978.85,36,,10.216,Percent of Total Billed Charges,36% of Total Billed Charges,1631.42,60,,36.48,Percent of Total Billed Charges,60% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2719.03,100,,2175.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,392.08,14.42,,7.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2039.27,75,,2289.6,Percent of Total Billed Charges,75% of Total Billed Charges,1359.52,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1359.52,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1359.52,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,1359.52,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1903.32,70,,96.688,Percent of Total Billed Charges,70% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,380.66,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2719.03,100,,3052.8,Percent of Total Billed Charges,100% of Total Billed Charges,96,2719.03,
ILEOSCOPY BIOPSY,50743822,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,12.904,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,16.592,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,15.776,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,3.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,1159.896,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,181.888,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,1546.528,Percent of Total Billed Charges,100% of Total Billed Charges,96,776.86,
COLONOSCOPY THRU STOMA,50743889,CDM,750,RC,,,Outpatient,,,2513.32,1507.99,,1507.99,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,1130.99,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.73,28,,18.328,Percent of Total Billed Charges,28% of Total Billed Charges,96,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,904.8,36,,23.568,Percent of Total Billed Charges,36% of Total Billed Charges,904.8,36,,23.568,Percent of Total Billed Charges,36% Total Bille Charges,904.8,36,,23.568,Percent of Total Billed Charges,36% of Total Billed Charges,1507.99,60,,106.632,Percent of Total Billed Charges,60% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,362.42,14.42,,5.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1884.99,75,,1739.84,Percent of Total Billed Charges,75% of Total Billed Charges,1256.66,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,1.4,Percent of Total Billed Charges,50% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1256.66,50,,1.4,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1759.32,70,,52.088,Percent of Total Billed Charges,70% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2319.784,Percent of Total Billed Charges,100% of Total Billed Charges,96,2513.32,
COLONOSCOPY STENT PLACEMENT,50744002,CDM,750,RC,,,Outpatient,,,2089.28,1253.57,,1253.57,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,940.18,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585,28,,22.016,Percent of Total Billed Charges,28% of Total Billed Charges,96.01,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,752.14,36,,28.312,Percent of Total Billed Charges,36% of Total Billed Charges,752.14,36,,28.312,Percent of Total Billed Charges,36% Total Bille Charges,752.14,36,,28.312,Percent of Total Billed Charges,36% of Total Billed Charges,1253.57,60,,52.264,Percent of Total Billed Charges,60% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14.42,,5.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566.96,75,,1124.552,Percent of Total Billed Charges,75% of Total Billed Charges,1044.64,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1044.64,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1462.5,70,,180.208,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1499.4,Percent of Total Billed Charges,100% of Total Billed Charges,96.01,2089.28,
COLONOSCOPY BALLOON DIL,50744010,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,30.304,Percent of Total Billed Charges,28% of Total Billed Charges,96.44,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,38.96,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,38.96,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,38.96,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,141.808,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,5.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,2358.48,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,1.4,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.816,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,0.816,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,128.424,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,3144.64,Percent of Total Billed Charges,100% of Total Billed Charges,96.44,718.09,
FLEX SIG POLYPECTOMY,50753334,CDM,750,RC,,,Outpatient,,,729.11,437.47,,437.47,60,,349.976,Percent of Total Billed Charges,60% of Total Billed Charges,328.1,45,,262.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.15,28,,37.672,Percent of Total Billed Charges,28% of Total Billed Charges,97.1,32,,208.328,Percent of Total Billed Charges,32% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,262.48,36,,48.44,Percent of Total Billed Charges,36% of Total Billed Charges,262.48,36,,48.44,Percent of Total Billed Charges,36% Total Bille Charges,262.48,36,,48.44,Percent of Total Billed Charges,36% of Total Billed Charges,437.47,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.11,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,105.14,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.83,75,,1510.2,Percent of Total Billed Charges,75% of Total Billed Charges,364.56,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.38,70,,135.208,Percent of Total Billed Charges,70% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.11,100,,2013.6,Percent of Total Billed Charges,100% of Total Billed Charges,97.1,729.11,
FLEX SIG BALLOON DILATION,50753342,CDM,750,RC,,,Outpatient,,,729.11,437.47,,437.47,60,,349.976,Percent of Total Billed Charges,60% of Total Billed Charges,328.1,45,,262.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.15,28,,39.224,Percent of Total Billed Charges,28% of Total Billed Charges,97.2,32,,209.728,Percent of Total Billed Charges,32% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,262.48,36,,50.432,Percent of Total Billed Charges,36% of Total Billed Charges,262.48,36,,50.432,Percent of Total Billed Charges,36% Total Bille Charges,262.48,36,,50.432,Percent of Total Billed Charges,36% of Total Billed Charges,437.47,60,,21.184,Percent of Total Billed Charges,60% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.11,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,105.14,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.83,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,364.56,50,,0.816,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.38,70,,840.84,Percent of Total Billed Charges,70% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.11,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,97.2,729.11,
COLONOSCOPY SUBMUCOSAL INJEC,50753888,CDM,750,RC,,,Outpatient,,,239.37,143.62,,143.62,60,,114.896,Percent of Total Billed Charges,60% of Total Billed Charges,107.72,45,,86.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.02,28,,35.752,Percent of Total Billed Charges,28% of Total Billed Charges,97.51,32,,209.896,Percent of Total Billed Charges,32% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,86.17,36,,45.968,Percent of Total Billed Charges,36% of Total Billed Charges,86.17,36,,45.968,Percent of Total Billed Charges,36% Total Bille Charges,86.17,36,,45.968,Percent of Total Billed Charges,36% of Total Billed Charges,143.62,60,,17.792,Percent of Total Billed Charges,60% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.37,100,,191.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,34.52,14.42,,2.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.53,75,,487.832,Percent of Total Billed Charges,75% of Total Billed Charges,119.69,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,119.69,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.69,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,119.69,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.56,70,,75.968,Percent of Total Billed Charges,70% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.51,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.37,100,,650.44,Percent of Total Billed Charges,100% of Total Billed Charges,33.51,239.37,
COLONOSCOPY LIMITED,50753896,CDM,750,RC,,,Outpatient,,,2513.32,1507.99,,1507.99,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,1130.99,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.73,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,97.56,32,,20995.84,Percent of Total Billed Charges,32% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,904.8,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,904.8,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,904.8,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,1507.99,60,,5052.232,Percent of Total Billed Charges,60% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,362.42,14.42,,32.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1884.99,75,,1940.392,Percent of Total Billed Charges,75% of Total Billed Charges,1256.66,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1256.66,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1759.32,70,,209.096,Percent of Total Billed Charges,70% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2587.184,Percent of Total Billed Charges,100% of Total Billed Charges,97.56,2513.32,
COLONOSCOPY ABLATION,50753912,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,28.496,Percent of Total Billed Charges,28% of Total Billed Charges,97.57,32,,20.992,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,36.632,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,36.632,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,36.632,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,41.048,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,4.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,256,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,2.776,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,320,Percent of Total Billed Charges,100% of Total Billed Charges,97.57,718.09,
COLONOSCOPY FB REMOVAL,50753920,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,16.304,Percent of Total Billed Charges,28% of Total Billed Charges,97.68,32,,20.992,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,20.96,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,34.336,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,21.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,90.144,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,155.728,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,120.192,Percent of Total Billed Charges,100% of Total Billed Charges,97.68,718.09,
COLONOSCOPY DECOMPRESSION,50753938,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,97.92,32,,21.024,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,9.992,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,15.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,189,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,138.992,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,252,Percent of Total Billed Charges,100% of Total Billed Charges,97.92,718.09,
COLONOSCOPY BANDING,50753946,CDM,750,RC,,,Outpatient,,,423.12,253.87,,253.87,60,,203.096,Percent of Total Billed Charges,60% of Total Billed Charges,190.4,45,,152.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.47,28,,4.864,Percent of Total Billed Charges,28% of Total Billed Charges,97.92,32,,21.12,Percent of Total Billed Charges,32% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,152.32,36,,6.248,Percent of Total Billed Charges,36% of Total Billed Charges,152.32,36,,6.248,Percent of Total Billed Charges,36% Total Bille Charges,152.32,36,,6.248,Percent of Total Billed Charges,36% of Total Billed Charges,253.87,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,423.12,100,,338.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,61.01,14.42,,35.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.34,75,,75.6,Percent of Total Billed Charges,75% of Total Billed Charges,211.56,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,211.56,50,,0.856,Percent of Total Billed Charges,50% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.56,50,,0.856,Percent of Total Billed Charges,50% of Total Billed Charges,211.56,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.18,70,,397.776,Percent of Total Billed Charges,70% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,59.24,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,423.12,100,,100.8,Percent of Total Billed Charges,100% of Total Billed Charges,59.24,423.12,
EGD BRUSHINGS,50753953,CDM,750,RC,,,Outpatient,,,229.92,137.95,,137.95,60,,110.36,Percent of Total Billed Charges,60% of Total Billed Charges,103.46,45,,82.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.38,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,98.4,32,,21.152,Percent of Total Billed Charges,32% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,82.77,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,82.77,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,137.95,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,229.92,100,,183.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,33.15,14.42,,4.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.44,75,,77.152,Percent of Total Billed Charges,75% of Total Billed Charges,114.96,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,114.96,50,,3.712,Percent of Total Billed Charges,50% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,50,,3.712,Percent of Total Billed Charges,50% of Total Billed Charges,114.96,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.94,70,,34.856,Percent of Total Billed Charges,70% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,32.19,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.92,100,,102.864,Percent of Total Billed Charges,100% of Total Billed Charges,32.19,229.92,
EGD ABLATION,50753961,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,98.57,32,,21.184,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,5.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,423.952,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.856,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,5.64,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,5.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,48.128,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,565.272,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
PLACEMENT N/G TUBE,50753987,CDM,750,RC,,,Outpatient,,,321.92,193.15,,193.15,60,,154.52,Percent of Total Billed Charges,60% of Total Billed Charges,144.86,45,,115.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.14,28,,492.344,Percent of Total Billed Charges,28% of Total Billed Charges,98.58,32,,21.184,Percent of Total Billed Charges,32% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,115.89,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,115.89,36,,633.016,Percent of Total Billed Charges,36% Total Bille Charges,115.89,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,193.15,60,,233.224,Percent of Total Billed Charges,60% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.92,100,,257.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,46.42,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.44,75,,497.048,Percent of Total Billed Charges,75% of Total Billed Charges,160.96,50,,3.712,Percent of Total Billed Charges,50% of Total Billed Charges,160.96,50,,2.704,Percent of Total Billed Charges,50% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.96,50,,2.704,Percent of Total Billed Charges,50% of Total Billed Charges,160.96,50,,1.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.34,70,,55.512,Percent of Total Billed Charges,70% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,45.07,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.92,100,,662.728,Percent of Total Billed Charges,100% of Total Billed Charges,45.07,321.92,
PLACEMENT DUOD FEED TUBE,50753995,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,616.92,Percent of Total Billed Charges,28% of Total Billed Charges,98.8,32,,21.224,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,793.184,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,65,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,1.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,41.528,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,5.64,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,151.192,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,55.368,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
FLEX SIG ABLATION,50754001,CDM,750,RC,,,Outpatient,,,729.11,437.47,,437.47,60,,349.976,Percent of Total Billed Charges,60% of Total Billed Charges,328.1,45,,262.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.15,28,,796.112,Percent of Total Billed Charges,28% of Total Billed Charges,99.01,32,,210.56,Percent of Total Billed Charges,32% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,262.48,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,262.48,36,,1023.576,Percent of Total Billed Charges,36% Total Bille Charges,262.48,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,437.47,60,,109.816,Percent of Total Billed Charges,60% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.11,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,105.14,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.83,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,364.56,50,,2.704,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.38,70,,149.256,Percent of Total Billed Charges,70% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.11,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,99.01,729.11,
FLEX SIG CTRL BLEEDING,50754019,CDM,750,RC,,,Outpatient,,,729.11,437.47,,437.47,60,,349.976,Percent of Total Billed Charges,60% of Total Billed Charges,328.1,45,,262.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.15,28,,177.024,Percent of Total Billed Charges,28% of Total Billed Charges,99.12,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,262.48,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,262.48,36,,227.608,Percent of Total Billed Charges,36% Total Bille Charges,262.48,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,437.47,60,,4.64,Percent of Total Billed Charges,60% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,729.11,100,,583.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,105.14,14.42,,0.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.83,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,364.56,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.56,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,364.56,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,510.38,70,,101.808,Percent of Total Billed Charges,70% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,102.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.11,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,99.12,729.11,
FLEX SIG FB REMOVAL,50754027,CDM,750,RC,,,Outpatient,,,455.43,273.26,,273.26,60,,218.608,Percent of Total Billed Charges,60% of Total Billed Charges,204.94,45,,163.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.52,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,99.12,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,163.95,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,163.95,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,163.95,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,273.26,60,,28.792,Percent of Total Billed Charges,60% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.43,100,,364.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,65.67,14.42,,0.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.57,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,227.72,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.72,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.8,70,,768.6,Percent of Total Billed Charges,70% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455.43,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,63.76,455.43,
FLEX SIG DECOMPRESSION,50754035,CDM,750,RC,,,Outpatient,,,455.43,273.26,,273.26,60,,218.608,Percent of Total Billed Charges,60% of Total Billed Charges,204.94,45,,163.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.52,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,9920,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,163.95,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,163.95,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,163.95,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,273.26,60,,115.36,Percent of Total Billed Charges,60% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.43,100,,364.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,65.67,14.42,,0.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.57,75,,394.72,Percent of Total Billed Charges,75% of Total Billed Charges,227.72,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.72,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,227.72,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.8,70,,145.848,Percent of Total Billed Charges,70% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,63.76,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455.43,100,,526.288,Percent of Total Billed Charges,100% of Total Billed Charges,63.76,9920,
FLEX SIG SUBMUCOSAL INJ,50754043,CDM,750,RC,,,Outpatient,,,151.81,91.09,,91.09,60,,72.872,Percent of Total Billed Charges,60% of Total Billed Charges,68.31,45,,54.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.51,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,9922.91,32,,211.456,Percent of Total Billed Charges,32% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,54.65,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,54.65,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,54.65,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,91.09,60,,53.408,Percent of Total Billed Charges,60% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.81,100,,121.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.89,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.86,75,,240.568,Percent of Total Billed Charges,75% of Total Billed Charges,75.91,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,75.91,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.91,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,75.91,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.27,70,,266.328,Percent of Total Billed Charges,70% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.81,100,,320.76,Percent of Total Billed Charges,100% of Total Billed Charges,21.25,9922.91,
FLEX SIG STENT PLACEMENT,50754050,CDM,750,RC,,,Outpatient,,,2089.28,1253.57,,1253.57,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,940.18,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,9922.91,32,,211.456,Percent of Total Billed Charges,32% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,752.14,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,752.14,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,752.14,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,1253.57,60,,8.624,Percent of Total Billed Charges,60% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14.42,,7.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566.96,75,,158.304,Percent of Total Billed Charges,75% of Total Billed Charges,1044.64,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,1.192,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1044.64,50,,1.192,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1462.5,70,,405.744,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.28,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,292.5,9922.91,
ENTEROSCOPY POLYPECTOMY,50754076,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,9.92,32,,211.472,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,3236.36,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,19.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,789.424,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,4.872,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,1052.568,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,776.86,
ENTEROSCOPY ABLATION,50754084,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,9.92,32,,211.936,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,675.6,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,20.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,336,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,1.192,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,1087.52,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,448,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,776.86,
ENTEROSCOPY CTRL BLEEDING,50754092,CDM,750,RC,,,Outpatient,,,776.86,466.12,,466.12,60,,372.896,Percent of Total Billed Charges,60% of Total Billed Charges,349.59,45,,279.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.52,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,9.92,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,279.67,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,279.67,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,279.67,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,466.12,60,,990,Percent of Total Billed Charges,60% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,776.86,100,,621.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,112.02,14.42,,6.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.65,75,,304.72,Percent of Total Billed Charges,75% of Total Billed Charges,388.43,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.43,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,388.43,50,,0.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.8,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,108.76,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.86,100,,406.296,Percent of Total Billed Charges,100% of Total Billed Charges,9.92,776.86,
ENTEROSCOPY FBODY REMOVAL,50754100,CDM,750,RC,,,Outpatient,,,746.98,448.19,,448.19,60,,358.552,Percent of Total Billed Charges,60% of Total Billed Charges,336.14,45,,268.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.15,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,9.93,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,268.91,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,268.91,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,268.91,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,448.19,60,,1024.368,Percent of Total Billed Charges,60% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,746.98,100,,597.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,107.71,14.42,,21.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.24,75,,906.376,Percent of Total Billed Charges,75% of Total Billed Charges,373.49,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,373.49,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.49,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,373.49,50,,3.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,522.89,70,,2046.248,Percent of Total Billed Charges,70% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,104.58,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,746.98,100,,1208.504,Percent of Total Billed Charges,100% of Total Billed Charges,9.93,746.98,
ENT SUBMUCOSAL INJ,50754118,CDM,750,RC,,,Outpatient,,,258.96,155.38,,155.38,60,,124.304,Percent of Total Billed Charges,60% of Total Billed Charges,116.53,45,,93.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.51,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,10.02,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,93.23,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,93.23,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,93.23,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,155.38,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.96,100,,207.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,37.34,14.42,,23.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.22,75,,950.24,Percent of Total Billed Charges,75% of Total Billed Charges,129.48,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,129.48,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.48,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,129.48,50,,5.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.27,70,,415.888,Percent of Total Billed Charges,70% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,36.25,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.96,100,,1266.984,Percent of Total Billed Charges,100% of Total Billed Charges,10.02,258.96,
ENTEROSCOPY STENT PLACEMENT,50754126,CDM,750,RC,,,Outpatient,,,2008.92,1205.35,,1205.35,60,,964.28,Percent of Total Billed Charges,60% of Total Billed Charges,904.01,45,,723.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.5,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,10.18,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,723.21,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,723.21,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,723.21,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,1205.35,60,,388.088,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2008.92,100,,1607.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,289.69,14.42,,211.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1506.69,75,,147.752,Percent of Total Billed Charges,75% of Total Billed Charges,1004.46,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,1004.46,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1004.46,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,1004.46,50,,2.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1406.24,70,,1263.416,Percent of Total Billed Charges,70% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,281.25,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2008.92,100,,197,Percent of Total Billed Charges,100% of Total Billed Charges,10.18,2008.92,
ERCP BIOPSY,50754134,CDM,750,RC,,,Outpatient,,,1783.26,1069.96,,1069.96,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,802.47,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.31,28,,177.024,Percent of Total Billed Charges,28% of Total Billed Charges,10.2,32,,212.224,Percent of Total Billed Charges,32% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,641.97,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,641.97,36,,227.608,Percent of Total Billed Charges,36% Total Bille Charges,641.97,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,1069.96,60,,26.824,Percent of Total Billed Charges,60% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1426.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,257.15,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.45,75,,438.568,Percent of Total Billed Charges,75% of Total Billed Charges,891.63,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,68.224,Percent of Total Billed Charges,50% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,891.63,50,,68.224,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1248.28,70,,3.8,Percent of Total Billed Charges,70% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.26,100,,584.76,Percent of Total Billed Charges,100% of Total Billed Charges,10.2,1783.26,
ERCP CONTROL BLEED,50754142,CDM,750,RC,,,Outpatient,,,1714.67,1028.80,,1028.8,60,,823.04,Percent of Total Billed Charges,60% of Total Billed Charges,771.6,45,,617.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.11,28,,214.136,Percent of Total Billed Charges,28% of Total Billed Charges,99.84,32,,212.224,Percent of Total Billed Charges,32% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,617.28,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,617.28,36,,275.312,Percent of Total Billed Charges,36% Total Bille Charges,617.28,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,1028.8,60,,62.528,Percent of Total Billed Charges,60% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1714.67,100,,1371.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,247.26,14.42,,12.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1286,75,,552.6,Percent of Total Billed Charges,75% of Total Billed Charges,857.34,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,857.34,50,,79.992,Percent of Total Billed Charges,50% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,857.34,50,,79.992,Percent of Total Billed Charges,50% of Total Billed Charges,857.34,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200.27,70,,34.592,Percent of Total Billed Charges,70% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,240.05,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1714.67,100,,736.8,Percent of Total Billed Charges,100% of Total Billed Charges,99.84,1714.67,
ERCP SUBMUCOSAL INJECTION,50754159,CDM,750,RC,,,Outpatient,,,594.42,356.65,,356.65,60,,285.32,Percent of Total Billed Charges,60% of Total Billed Charges,267.49,45,,213.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.44,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,99.88,32,,212.28,Percent of Total Billed Charges,32% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,213.99,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,213.99,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,213.99,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,356.65,60,,175.648,Percent of Total Billed Charges,60% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,594.42,100,,475.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,85.72,14.42,,25.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.82,75,,409.336,Percent of Total Billed Charges,75% of Total Billed Charges,297.21,50,,68.224,Percent of Total Billed Charges,50% of Total Billed Charges,297.21,50,,71.464,Percent of Total Billed Charges,50% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.21,50,,71.464,Percent of Total Billed Charges,50% of Total Billed Charges,297.21,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.09,70,,978.712,Percent of Total Billed Charges,70% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,83.22,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.42,100,,545.776,Percent of Total Billed Charges,100% of Total Billed Charges,83.22,594.42,
ERCP NASO TUBE INSERTION,50754167,CDM,750,RC,,,Outpatient,,,1691.22,1014.73,,1014.73,60,,811.784,Percent of Total Billed Charges,60% of Total Billed Charges,761.05,45,,608.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,473.54,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,100.16,32,,212.312,Percent of Total Billed Charges,32% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,608.84,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,608.84,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,608.84,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,1014.73,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1691.22,100,,1352.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,243.87,14.42,,30.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1268.42,75,,321.616,Percent of Total Billed Charges,75% of Total Billed Charges,845.61,50,,79.992,Percent of Total Billed Charges,50% of Total Billed Charges,845.61,50,,0.728,Percent of Total Billed Charges,50% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,845.61,50,,0.728,Percent of Total Billed Charges,50% of Total Billed Charges,845.61,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1183.85,70,,193.696,Percent of Total Billed Charges,70% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,236.77,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1691.22,100,,428.824,Percent of Total Billed Charges,100% of Total Billed Charges,100.16,1691.22,
ERCP SPYGLASS,50754175,CDM,750,RC,,,Outpatient,,,4286,2571.60,,2571.6,60,,2057.28,Percent of Total Billed Charges,60% of Total Billed Charges,1928.7,45,,1542.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1200.08,28,,492.344,Percent of Total Billed Charges,28% of Total Billed Charges,100.16,32,,21.408,Percent of Total Billed Charges,32% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,1542.96,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,1542.96,36,,633.016,Percent of Total Billed Charges,36% Total Bille Charges,1542.96,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,2571.6,60,,544.28,Percent of Total Billed Charges,60% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4286,100,,3428.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,618.04,14.42,,68.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3214.5,75,,168.856,Percent of Total Billed Charges,75% of Total Billed Charges,2143,50,,71.464,Percent of Total Billed Charges,50% of Total Billed Charges,2143,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2143,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,2143,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3000.2,70,,280.344,Percent of Total Billed Charges,70% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,600.04,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4286,100,,211.072,Percent of Total Billed Charges,100% of Total Billed Charges,100.16,4286,
ERCP BASKET SWEEP,50754183,CDM,750,RC,,,Outpatient,,,1783.26,1069.96,,1069.96,60,,855.968,Percent of Total Billed Charges,60% of Total Billed Charges,802.47,45,,641.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.31,28,,616.92,Percent of Total Billed Charges,28% of Total Billed Charges,100.16,32,,21.48,Percent of Total Billed Charges,32% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,641.97,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,641.97,36,,793.184,Percent of Total Billed Charges,36% Total Bille Charges,641.97,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,1069.96,60,,27.88,Percent of Total Billed Charges,60% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1783.26,100,,1426.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,257.15,14.42,,80.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.45,75,,526.288,Percent of Total Billed Charges,75% of Total Billed Charges,891.63,50,,0.728,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,891.63,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,891.63,50,,0.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1248.28,70,,306.672,Percent of Total Billed Charges,70% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,249.66,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1783.26,100,,701.712,Percent of Total Billed Charges,100% of Total Billed Charges,100.16,1783.26,
BRONCHOSCOPY FBODY REMOVAL,50754191,CDM,750,RC,,,Outpatient,,,786.44,471.86,,471.86,60,,377.488,Percent of Total Billed Charges,60% of Total Billed Charges,353.9,45,,283.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.2,28,,796.112,Percent of Total Billed Charges,28% of Total Billed Charges,100.16,32,,212.584,Percent of Total Billed Charges,32% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,283.12,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,283.12,36,,1023.576,Percent of Total Billed Charges,36% Total Bille Charges,283.12,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,471.86,60,,14.832,Percent of Total Billed Charges,60% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.44,100,,629.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,14.42,,1.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.83,75,,395.176,Percent of Total Billed Charges,75% of Total Billed Charges,393.22,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,393.22,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,393.22,50,,1.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550.51,70,,21.48,Percent of Total Billed Charges,70% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,110.1,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,786.44,100,,526.904,Percent of Total Billed Charges,100% of Total Billed Charges,100.16,786.44,
CAPSULE ENTEROSCOPY,50755001,CDM,750,RC,,,Outpatient,,,2716.31,1629.79,,1629.79,60,,1303.832,Percent of Total Billed Charges,60% of Total Billed Charges,1222.34,45,,977.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,760.57,28,,214.136,Percent of Total Billed Charges,28% of Total Billed Charges,100.17,32,,212.736,Percent of Total Billed Charges,32% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,977.87,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,977.87,36,,275.312,Percent of Total Billed Charges,36% Total Bille Charges,977.87,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,1629.79,60,,31.392,Percent of Total Billed Charges,60% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2716.31,100,,2173.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,391.69,14.42,,2.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2037.23,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,1358.16,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,1358.16,50,,11.592,Percent of Total Billed Charges,50% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1358.16,50,,11.592,Percent of Total Billed Charges,50% of Total Billed Charges,1358.16,50,,1.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1901.42,70,,110.256,Percent of Total Billed Charges,70% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,380.28,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2716.31,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,100.17,2716.31,
POUCHOSCOPY,50755002,CDM,750,RC,,,Outpatient,,,2513.32,1507.99,,1507.99,60,,1206.392,Percent of Total Billed Charges,60% of Total Billed Charges,1130.99,45,,904.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,703.73,28,,562.984,Percent of Total Billed Charges,28% of Total Billed Charges,100.61,32,,213.656,Percent of Total Billed Charges,32% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,904.8,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,904.8,36,,723.84,Percent of Total Billed Charges,36% Total Bille Charges,904.8,36,,723.84,Percent of Total Billed Charges,36% of Total Billed Charges,1507.99,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2513.32,100,,2010.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,362.42,14.42,,0.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1884.99,75,,480.024,Percent of Total Billed Charges,75% of Total Billed Charges,1256.66,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1256.66,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,1256.66,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1759.32,70,,128.824,Percent of Total Billed Charges,70% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,351.86,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2513.32,100,,640.032,Percent of Total Billed Charges,100% of Total Billed Charges,100.61,2513.32,
SMALL BOWEL ENDO CAPSULE,50755003,CDM,272,RC,,,Outpatient,,,1350,810.00,,810,60,,648,Percent of Total Billed Charges,60% of Total Billed Charges,607.5,45,,486,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,100.67,32,,213.712,Percent of Total Billed Charges,32% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,486,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,486,36,,388.8,Percent of Total Billed Charges,36% Total Bille Charges,486,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,810,60,,39.8,Percent of Total Billed Charges,60% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1350,100,,1080,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,194.67,14.42,,2.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1012.5,75,,2050.912,Percent of Total Billed Charges,75% of Total Billed Charges,675,50,,11.592,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,0.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,70,,1774.552,Percent of Total Billed Charges,70% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1350,100,,2734.552,Percent of Total Billed Charges,100% of Total Billed Charges,100.67,1350,
ADVANCE CAPSULE DELIVER DEVICE,50755004,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,270,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,100.8,32,,21753.6,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,42.488,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,100,,480,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,5.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,2050.912,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,111.832,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,2734.552,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
BLAKEMORE TUBE,50755006,CDM,270,RC,,,Outpatient,,,576.76,346.06,,346.06,60,,276.848,Percent of Total Billed Charges,60% of Total Billed Charges,259.54,45,,207.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.49,28,,129.192,Percent of Total Billed Charges,28% of Total Billed Charges,100.93,32,,21.568,Percent of Total Billed Charges,32% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,207.63,36,,166.104,Percent of Total Billed Charges,36% of Total Billed Charges,207.63,36,,166.104,Percent of Total Billed Charges,36% Total Bille Charges,207.63,36,,166.104,Percent of Total Billed Charges,36% of Total Billed Charges,346.06,60,,37.096,Percent of Total Billed Charges,60% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,576.76,100,,461.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,83.17,14.42,,8.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.57,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,288.38,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,288.38,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.38,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,288.38,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.73,70,,25.64,Percent of Total Billed Charges,70% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,576.76,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,80.75,576.76,
WALLFLEX BILIARY STENT,50755007,CDM,278,RC,C1874,HCPCS,Outpatient,,,10558.99,6335.39,,12107.3,110,,9685.84,Percent of Total Billed Charges,110% of Total Billed Charges,4751.55,45,,3801.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2956.52,28,,2365.216,Percent of Total Billed Charges,28% of Total Billed Charges,100.99,32,,21.624,Percent of Total Billed Charges,32% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,3801.24,36,,3040.992,Percent of Total Billed Charges,36% of Total Billed Charges,3801.24,36,,3040.992,Percent of Total Billed Charges,36% Total Bille Charges,3801.24,36,,3040.992,Percent of Total Billed Charges,36% of Total Billed Charges,5807.44,55,,21.512,Percent of Total Billed Charges,55% Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10558.99,100,,8447.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1522.61,14.42,,48.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8447.19,80,,1054.576,Percent of Total Billed Charges,80% of Total Billed Charges,5279.5,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,5279.5,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5279.5,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,5279.5,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7391.29,70,,793.496,Percent of Total Billed Charges,70% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,1478.26,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10558.99,100,,1406.104,Percent of Total Billed Charges,100% of Total Billed Charges,100.99,12107.3,
PATENCY CAP PILL CAMERA,50755008,CDM,271,RC,,,Outpatient,,,150,90.00,,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,100.99,32,,21.624,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,1465.76,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,7.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,1581.872,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,68.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,316.288,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,2109.16,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
FECAL DISIMPACTION,50755009,CDM,750,RC,,,Outpatient,,,2546.96,1528.18,,1528.18,60,,1222.544,Percent of Total Billed Charges,60% of Total Billed Charges,1146.13,45,,916.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.15,28,,570.52,Percent of Total Billed Charges,28% of Total Billed Charges,100.99,32,,21.736,Percent of Total Billed Charges,32% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,916.91,36,,733.528,Percent of Total Billed Charges,36% of Total Billed Charges,916.91,36,,733.528,Percent of Total Billed Charges,36% Total Bille Charges,916.91,36,,733.528,Percent of Total Billed Charges,36% of Total Billed Charges,1528.18,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2546.96,100,,2037.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,367.27,14.42,,7.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1910.22,75,,430.176,Percent of Total Billed Charges,75% of Total Billed Charges,1273.48,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,1273.48,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1273.48,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,1273.48,50,,79.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1782.87,70,,2866.296,Percent of Total Billed Charges,70% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,356.57,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2546.96,100,,573.568,Percent of Total Billed Charges,100% of Total Billed Charges,100.99,2546.96,
POUCHOSCOPY BIOPSY,50755010,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,100.99,32,,21.744,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,5.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,464.216,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,5.896,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,5.896,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,71.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,20.512,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,618.952,Percent of Total Billed Charges,100% of Total Billed Charges,100.53,718.09,
BUTTON LOW PROFILE GASTROSTOMY,50755011,CDM,278,RC,,,Outpatient,,,580,348.00,,638,110,,510.4,Percent of Total Billed Charges,110% of Total Billed Charges,261,45,,208.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.4,28,,129.92,Percent of Total Billed Charges,28% of Total Billed Charges,100.99,32,,215.04,Percent of Total Billed Charges,32% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,208.8,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,208.8,36,,167.04,Percent of Total Billed Charges,36% Total Bille Charges,208.8,36,,167.04,Percent of Total Billed Charges,36% of Total Billed Charges,319,55,,8.424,Percent of Total Billed Charges,55% Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580,100,,464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,83.64,14.42,,0.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,464,80,,1502.968,Percent of Total Billed Charges,80% of Total Billed Charges,290,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,290,50,,26.256,Percent of Total Billed Charges,50% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290,50,,26.256,Percent of Total Billed Charges,50% of Total Billed Charges,290,50,,0.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406,70,,153.64,Percent of Total Billed Charges,70% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,81.2,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,580,100,,2003.96,Percent of Total Billed Charges,100% of Total Billed Charges,81.2,638,
EVOLUTION BILIARY STENT,50755012,CDM,278,RC,C1876,HCPCS,Outpatient,,,4588.65,2753.19,,6479.27,110,,5183.416,Percent of Total Billed Charges,110% of Total Billed Charges,2064.89,45,,1651.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1284.82,28,,1027.856,Percent of Total Billed Charges,28% of Total Billed Charges,101.14,32,,215.488,Percent of Total Billed Charges,32% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1651.91,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,1651.91,36,,1321.528,Percent of Total Billed Charges,36% Total Bille Charges,1651.91,36,,1321.528,Percent of Total Billed Charges,36% of Total Billed Charges,2523.76,55,,5.92,Percent of Total Billed Charges,55% Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4588.65,100,,3670.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,661.68,14.42,,1.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3670.92,80,,645.256,Percent of Total Billed Charges,80% of Total Billed Charges,2294.33,50,,5.896,Percent of Total Billed Charges,50% of Total Billed Charges,2294.33,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2294.33,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,2294.33,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3212.06,70,,32.64,Percent of Total Billed Charges,70% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,642.41,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4588.65,100,,860.344,Percent of Total Billed Charges,100% of Total Billed Charges,101.14,6479.27,
FECAL TRANSPLANT,50755014,CDM,750,RC,,,Outpatient,,,3267.35,1960.41,,1960.41,60,,1568.328,Percent of Total Billed Charges,60% of Total Billed Charges,1470.31,45,,1176.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,914.86,28,,731.888,Percent of Total Billed Charges,28% of Total Billed Charges,101.14,32,,216.384,Percent of Total Billed Charges,32% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,1176.25,36,,941,Percent of Total Billed Charges,36% of Total Billed Charges,1176.25,36,,941,Percent of Total Billed Charges,36% Total Bille Charges,1176.25,36,,941,Percent of Total Billed Charges,36% of Total Billed Charges,1960.41,60,,6.224,Percent of Total Billed Charges,60% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3267.35,100,,2613.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,471.15,14.42,,3.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2450.51,75,,696.312,Percent of Total Billed Charges,75% of Total Billed Charges,1633.68,50,,26.256,Percent of Total Billed Charges,50% of Total Billed Charges,1633.68,50,,7.448,Percent of Total Billed Charges,50% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1633.68,50,,7.448,Percent of Total Billed Charges,50% of Total Billed Charges,1633.68,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2287.15,70,,73.928,Percent of Total Billed Charges,70% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,457.43,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3267.35,100,,928.416,Percent of Total Billed Charges,100% of Total Billed Charges,101.14,3267.35,
FECAL MICROBIOTA MATERIAL,50755015,CDM,272,RC,,,Outpatient,,,2519.83,1511.90,,1511.9,60,,1209.52,Percent of Total Billed Charges,60% of Total Billed Charges,1133.92,45,,907.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,705.55,28,,564.44,Percent of Total Billed Charges,28% of Total Billed Charges,101.16,32,,216.752,Percent of Total Billed Charges,32% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,907.14,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,907.14,36,,725.712,Percent of Total Billed Charges,36% Total Bille Charges,907.14,36,,725.712,Percent of Total Billed Charges,36% of Total Billed Charges,1511.9,60,,183.6,Percent of Total Billed Charges,60% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2519.83,100,,2015.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,363.36,14.42,,49.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1889.87,75,,2254.456,Percent of Total Billed Charges,75% of Total Billed Charges,1259.92,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,1259.92,50,,3.928,Percent of Total Billed Charges,50% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1259.92,50,,3.928,Percent of Total Billed Charges,50% of Total Billed Charges,1259.92,50,,0.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1763.88,70,,215.872,Percent of Total Billed Charges,70% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,352.78,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2519.83,100,,3005.944,Percent of Total Billed Charges,100% of Total Billed Charges,101.16,2519.83,
PROCTOSIGMOIDOSCOPY,50755016,CDM,750,RC,,,Outpatient,,,563.19,337.91,,337.91,60,,270.328,Percent of Total Billed Charges,60% of Total Billed Charges,253.44,45,,202.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.69,28,,126.152,Percent of Total Billed Charges,28% of Total Billed Charges,101.17,32,,216.92,Percent of Total Billed Charges,32% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,202.75,36,,162.2,Percent of Total Billed Charges,36% of Total Billed Charges,202.75,36,,162.2,Percent of Total Billed Charges,36% Total Bille Charges,202.75,36,,162.2,Percent of Total Billed Charges,36% of Total Billed Charges,337.91,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.19,100,,450.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,81.21,14.42,,49.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.39,75,,1523.584,Percent of Total Billed Charges,75% of Total Billed Charges,281.6,50,,7.448,Percent of Total Billed Charges,50% of Total Billed Charges,281.6,50,,2.376,Percent of Total Billed Charges,50% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.6,50,,2.376,Percent of Total Billed Charges,50% of Total Billed Charges,281.6,50,,11.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.23,70,,162.208,Percent of Total Billed Charges,70% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,563.19,100,,2031.44,Percent of Total Billed Charges,100% of Total Billed Charges,78.85,563.19,
PROCTOSIGMOIDOSCOPY BIOPSY,50755017,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,101.41,32,,217.584,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,168.736,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,8.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1632.976,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,3.928,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,3156.16,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,2177.304,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
MOD SEDATION INIT 15 MIN 5+ YO,50755018,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,97.76,45,,78.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,21.76,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,,Fee Schedule,360% of BCBS POS Rate,45.4,360,,,Fee schedule,360% of BCBS PPO Rate,45.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,168.752,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.25,100,,173.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,3.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,430.856,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,2.376,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,0.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,231.96,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,574.472,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
MOD SEDATION ADDL 15 MIN,50755019,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.65,45,,49.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,21.808,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,,Fee Schedule,360% of BCBS POS Rate,38.92,360,,,Fee schedule,360% of BCBS PPO Rate,38.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,111.296,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,109.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,18.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,810,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,130.656,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,1080,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
BRONCH LAVAGE,50755021,CDM,750,RC,,,Outpatient,,,2254.02,1352.41,,1352.41,60,,1081.928,Percent of Total Billed Charges,60% of Total Billed Charges,1014.31,45,,811.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.13,28,,504.904,Percent of Total Billed Charges,28% of Total Billed Charges,101.85,32,,21.856,Percent of Total Billed Charges,32% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,811.45,36,,649.16,Percent of Total Billed Charges,36% of Total Billed Charges,811.45,36,,649.16,Percent of Total Billed Charges,36% Total Bille Charges,811.45,36,,649.16,Percent of Total Billed Charges,36% of Total Billed Charges,1352.41,60,,57.16,Percent of Total Billed Charges,60% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2254.02,100,,1803.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,325.03,14.42,,39.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1690.52,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,1127.01,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,1127.01,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1127.01,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,1127.01,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1577.81,70,,302.176,Percent of Total Billed Charges,70% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,315.56,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2254.02,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,101.85,2254.02,
TPI SNGL MULTI 1-2 MUSCL,50770007,CDM,361,RC,20552,HCPCS,Outpatient,,,809,485.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,70.65,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,101.85,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,97.63,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,97.63,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,97.63,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,106.816,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,116.66,14.42,,1.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,606.75,75,,1253.568,Percent of Total Billed Charges,75% of Total Billed Charges,404.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,404.5,50,,13.08,Percent of Total Billed Charges,50% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,404.5,50,,13.08,Percent of Total Billed Charges,50% of Total Billed Charges,404.5,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,87.632,Fee Schedule,100% of ASC Tier Groupings fee schedule,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,113.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,809,100,,1671.424,Percent of Total Billed Charges,100% of Total Billed Charges,70.65,2601,
TPI SNGL MULT 3+ MUSCLE,50770023,CDM,361,RC,20553,HCPCS,Outpatient,,,940.6,564.36,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.18,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,113.89,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,113.89,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,113.89,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,64.768,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,135.63,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,705.45,75,,1253.568,Percent of Total Billed Charges,75% of Total Billed Charges,470.3,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,470.3,50,,4.912,Percent of Total Billed Charges,50% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,470.3,50,,4.912,Percent of Total Billed Charges,50% of Total Billed Charges,470.3,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,16.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,131.68,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,940.6,100,,1671.424,Percent of Total Billed Charges,100% of Total Billed Charges,82.41,2601,
EPIDURAL BLOOD PATCH,50770122,CDM,761,RC,62273,HCPCS,Outpatient,,,1613.05,967.83,,97.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,451.65,28,,361.32,Percent of Total Billed Charges,28% of Total Billed Charges,102.18,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,580.7,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,580.7,36,,464.56,Percent of Total Billed Charges,36% Total Bille Charges,580.7,36,,464.56,Percent of Total Billed Charges,36% of Total Billed Charges,1184.5,103,,121.304,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,232.6,14.42,,9.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1209.79,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,806.53,50,,13.08,Percent of Total Billed Charges,50% of Total Billed Charges,806.53,50,,20.344,Percent of Total Billed Charges,50% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,806.53,50,,20.344,Percent of Total Billed Charges,50% of Total Billed Charges,806.53,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.14,70,,6686.744,Percent of Total Billed Charges,70% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,225.83,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1613.05,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,97.08,1613.05,
DISKOGRAPHY LUMBAR EA LEVEL,50770163,CDM,361,RC,62290,HCPCS,Outpatient,,,2078.64,1247.18,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,935.39,45,,748.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.888,Other,Not Seperately Reimbusable,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1247.18,60,,68.72,Percent of Total Billed Charges,60% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2078.64,100,,1662.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,299.74,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1558.98,75,,1903.784,Percent of Total Billed Charges,75% of Total Billed Charges,1039.32,50,,4.912,Percent of Total Billed Charges,50% of Total Billed Charges,1039.32,50,,82.6,Percent of Total Billed Charges,50% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1039.32,50,,82.6,Percent of Total Billed Charges,50% of Total Billed Charges,1039.32,50,,5.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,100.872,Fee Schedule,100% of ASC Tier Groupings fee schedule,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,291.01,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2078.64,100,,2379.728,Percent of Total Billed Charges,100% of Total Billed Charges,291.01,2601,
DISKOGRAPHY CRV/THOR EA LEVEL,50770189,CDM,361,RC,62291,HCPCS,Outpatient,,,1458.8,875.28,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,656.46,45,,525.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.888,Other,Not Seperately Reimbusable,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.28,60,,1078.624,Percent of Total Billed Charges,60% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1458.8,100,,1167.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,210.36,14.42,,32.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1094.1,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,729.4,50,,20.344,Percent of Total Billed Charges,50% of Total Billed Charges,729.4,50,,5.864,Percent of Total Billed Charges,50% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,729.4,50,,5.864,Percent of Total Billed Charges,50% of Total Billed Charges,729.4,50,,26.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1557.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,204.23,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1458.8,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,204.23,2601,
EPIDURAL CRV/THOR,50770205,CDM,360,RC,62320,HCPCS,Outpatient,,,2186.24,1311.74,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.18,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,106.312,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,315.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1639.68,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1093.12,50,,82.6,Percent of Total Billed Charges,50% of Total Billed Charges,1093.12,50,,13.056,Percent of Total Billed Charges,50% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1093.12,50,,13.056,Percent of Total Billed Charges,50% of Total Billed Charges,1093.12,50,,1.096,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,33.968,Fee Schedule,100% of ASC Tier Groupings fee schedule,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,306.07,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2186.24,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,102.18,2601,
EPIDURAL LUMB/SAC/CAU,50770221,CDM,360,RC,62322,HCPCS,Outpatient,,,2151.95,1291.17,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.18,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,30.728,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,310.31,14.42,,110.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1613.96,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1075.98,50,,5.864,Percent of Total Billed Charges,50% of Total Billed Charges,1075.98,50,,2.784,Percent of Total Billed Charges,50% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.98,50,,2.784,Percent of Total Billed Charges,50% of Total Billed Charges,1075.98,50,,7.448,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,273.912,Fee Schedule,100% of ASC Tier Groupings fee schedule,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2151.95,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,102.18,2601,
SCS TRIAL EACH,50770288,CDM,361,RC,63650,HCPCS,Outpatient,,,10180.33,6108.20,,4162,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,9411.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,14416.01,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10320.96,32,,21.936,Percent of Total Billed Charges,32% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,19922.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,19922.56,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,19922.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,5665,103,,2820.192,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,5647.18,90,,,Fee Schedule,90% of CMS OPPS Rate,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8157.04,130,,,Fee Schedule,130% of CMS OPPS Rate,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1468,14.42,,0.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,6462.88,103,,,Fee Schedule,103% of CMS OPPS Rate,6462.88,103,,,Fee Schedule,103% of CMS OPPS Rate,7635.25,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,5090.17,50,,13.056,Percent of Total Billed Charges,50% of Total Billed Charges,5090.17,50,,2.56,Percent of Total Billed Charges,50% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,5090.17,50,,2.56,Percent of Total Billed Charges,50% of Total Billed Charges,5090.17,50,,3.928,Percent of Total Billed Charges,50% of Total Billed Charges,9411.98,150,,,Fee Schedule,150% of CMS OPPS Rate,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,7651,100,,41.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1425.25,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,6274.65,100,,,Fee Schedule,100% of CMS OPPS Rate,10180.33,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,1425.25,19922.56,
OCCIPITAL NERVE BLOCK OR,50770304,CDM,361,RC,64405,HCPCS,Outpatient,,,2022.74,1213.64,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10332.96,32,,21.952,Percent of Total Billed Charges,32% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,106.9,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,106.9,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,106.9,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,299.04,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,291.68,14.42,,2.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1517.06,75,,413.864,Percent of Total Billed Charges,75% of Total Billed Charges,1011.37,50,,2.784,Percent of Total Billed Charges,50% of Total Billed Charges,1011.37,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.37,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,1011.37,50,,2.376,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,4.064,Fee Schedule,100% of ASC Tier Groupings fee schedule,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,283.18,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2022.74,100,,551.816,Percent of Total Billed Charges,100% of Total Billed Charges,77.36,10332.96,
INTERCOSTAL BLK SINGLE,50770320,CDM,361,RC,64420,HCPCS,Outpatient,,,1485.67,891.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.24,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,14.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,214.23,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1114.25,75,,2285.4,Percent of Total Billed Charges,75% of Total Billed Charges,742.84,50,,2.56,Percent of Total Billed Charges,50% of Total Billed Charges,742.84,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,742.84,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,742.84,50,,1.088,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,656.832,Fee Schedule,100% of ASC Tier Groupings fee schedule,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,207.99,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.67,100,,3047.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.24,2601,
INTERCOSTAL BLOCK MULTI,50770346,CDM,361,RC,64421,HCPCS,Outpatient,,,2042.36,1225.42,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.25,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,34.816,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,294.51,14.42,,0.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1531.77,75,,467.808,Percent of Total Billed Charges,75% of Total Billed Charges,1021.18,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,1021.18,50,,9.608,Percent of Total Billed Charges,50% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.18,50,,9.608,Percent of Total Billed Charges,50% of Total Billed Charges,1021.18,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,107.608,Fee Schedule,100% of ASC Tier Groupings fee schedule,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,285.93,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.36,100,,584.76,Percent of Total Billed Charges,100% of Total Billed Charges,10.25,2614.8,
ILIOINGUNAL HYPO/GAST BL,50770361,CDM,361,RC,64425,HCPCS,Outpatient,,,1185.44,711.26,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,174.91,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.28,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,241.73,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,241.73,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,241.73,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,136.832,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,170.94,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,889.08,75,,589.44,Percent of Total Billed Charges,75% of Total Billed Charges,592.72,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,592.72,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,592.72,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,592.72,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,88.064,Fee Schedule,100% of ASC Tier Groupings fee schedule,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,165.96,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1185.44,100,,736.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.28,2601,
SCIATIC NERVE BLK SINGLE,50770387,CDM,361,RC,64445,HCPCS,Outpatient,,,1381.79,829.07,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,208.54,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.4,32,,21.976,Percent of Total Billed Charges,32% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,288.19,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,288.19,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,288.19,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,25.44,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,199.25,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1036.34,75,,375.232,Percent of Total Billed Charges,75% of Total Billed Charges,690.9,50,,9.608,Percent of Total Billed Charges,50% of Total Billed Charges,690.9,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,690.9,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,690.9,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,117.912,Fee Schedule,100% of ASC Tier Groupings fee schedule,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,193.45,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1381.79,100,,500.304,Percent of Total Billed Charges,100% of Total Billed Charges,10.4,2601,
NERVE BLOCK OR,50770403,CDM,361,RC,64450,HCPCS,Outpatient,,,1348.86,809.32,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,112.68,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.43,32,,217.6,Percent of Total Billed Charges,32% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,155.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,155.72,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,155.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,23.536,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,194.51,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1011.65,75,,932.96,Percent of Total Billed Charges,75% of Total Billed Charges,674.43,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,674.43,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,674.43,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,674.43,50,,13.08,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,381.968,Fee Schedule,100% of ASC Tier Groupings fee schedule,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,188.84,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.86,100,,1243.944,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,2601,
SNRB TRANS CRV/THOR SNGL,50770429,CDM,361,RC,64479,HCPCS,Outpatient,,,2732.84,1639.70,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.44,32,,218.064,Percent of Total Billed Charges,32% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,58.264,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,394.08,14.42,,1.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2049.63,75,,1903.784,Percent of Total Billed Charges,75% of Total Billed Charges,1366.42,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,1366.42,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1366.42,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,1366.42,50,,4.912,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,381.968,Fee Schedule,100% of ASC Tier Groupings fee schedule,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,382.6,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2732.84,100,,2379.728,Percent of Total Billed Charges,100% of Total Billed Charges,10.44,2732.84,
SNRB CRV/THOR SNGL LV BI,50770445,CDM,361,RC,64479,HCPCS,Outpatient,,,4099.25,2459.55,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.46,32,,218.312,Percent of Total Billed Charges,32% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,33.44,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,591.11,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3074.44,75,,235.736,Percent of Total Billed Charges,75% of Total Billed Charges,2049.63,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,2049.63,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.63,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,2049.63,50,,20.344,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,77.48,Fee Schedule,100% of ASC Tier Groupings fee schedule,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,573.9,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,4099.25,100,,314.312,Percent of Total Billed Charges,100% of Total Billed Charges,10.46,4099.25,
SNRB CRV/THOR EA ADD LVL,50770460,CDM,361,RC,64480,HCPCS,Outpatient,,,1535.71,921.43,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,691.07,45,,552.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.312,Other,Not Seperately Reimbusable,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921.43,60,,328.712,Percent of Total Billed Charges,60% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1535.71,100,,1228.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,221.45,14.42,,2.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1151.78,75,,410.296,Percent of Total Billed Charges,75% of Total Billed Charges,767.86,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,767.86,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,767.86,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,767.86,50,,82.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1.736,Fee Schedule,100% of ASC Tier Groupings fee schedule,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,215,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1535.71,100,,547.056,Percent of Total Billed Charges,100% of Total Billed Charges,215,2601,
SNRB CRV/THOR EA ADD BI,50770486,CDM,361,RC,64480,HCPCS,Outpatient,,,2303.57,1382.14,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1036.61,45,,829.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.88,Other,Not Seperately Reimbusable,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1382.14,60,,16.888,Percent of Total Billed Charges,60% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2303.57,100,,1842.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,332.17,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1727.68,75,,409.064,Percent of Total Billed Charges,75% of Total Billed Charges,1151.79,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,1151.79,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1151.79,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1151.79,50,,5.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,69.112,Fee Schedule,100% of ASC Tier Groupings fee schedule,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,322.5,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2303.57,100,,545.416,Percent of Total Billed Charges,100% of Total Billed Charges,322.5,2601,
SNRB LUMB/SAC SNGL LVL,50770502,CDM,361,RC,64483,HCPCS,Outpatient,,,2283.91,1370.35,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.48,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,40.544,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,329.34,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1712.93,75,,41.528,Percent of Total Billed Charges,75% of Total Billed Charges,1141.96,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,1141.96,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1141.96,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,1141.96,50,,13.056,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,237.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,319.75,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2283.91,100,,55.368,Percent of Total Billed Charges,100% of Total Billed Charges,10.48,2614.8,
SNRB LUMB/SAC SNGL LV BI,50770528,CDM,361,RC,64483,HCPCS,Outpatient,,,3425.86,2055.52,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.52,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,102.272,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,494.01,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2569.4,75,,70.2,Percent of Total Billed Charges,75% of Total Billed Charges,1712.93,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1712.93,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.93,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1712.93,50,,2.784,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,94.528,Fee Schedule,100% of ASC Tier Groupings fee schedule,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,479.62,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3425.86,100,,93.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.52,3425.86,
SNRB LUMB/SAC EA ADD LVL,50770544,CDM,361,RC,64484,HCPCS,Outpatient,,,1380.7,828.42,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,621.32,45,,497.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.88,Other,Not Seperately Reimbusable,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.42,60,,149.08,Percent of Total Billed Charges,60% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1380.7,100,,1104.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,199.1,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1035.53,75,,126.4,Percent of Total Billed Charges,75% of Total Billed Charges,690.35,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,690.35,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690.35,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,690.35,50,,2.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,14.76,Fee Schedule,100% of ASC Tier Groupings fee schedule,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,193.3,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1380.7,100,,168.528,Percent of Total Billed Charges,100% of Total Billed Charges,193.3,2601,
SNRB LUMB/SAC EA ADD BI,50770569,CDM,361,RC,64484,HCPCS,Outpatient,,,2071.04,1242.62,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,931.97,45,,745.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,219.48,Other,Not Seperately Reimbusable,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1242.62,60,,44.192,Percent of Total Billed Charges,60% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2071.04,100,,1656.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,298.64,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1553.28,75,,275.656,Percent of Total Billed Charges,75% of Total Billed Charges,1035.52,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1035.52,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1035.52,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,1035.52,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,34.656,Fee Schedule,100% of ASC Tier Groupings fee schedule,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,289.95,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2071.04,100,,367.544,Percent of Total Billed Charges,100% of Total Billed Charges,289.95,2601,
FACET CRV/THOR LVL 1,50770585,CDM,361,RC,64490,HCPCS,Outpatient,,,2427.25,1456.35,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.52,32,,219.48,Percent of Total Billed Charges,32% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,21.272,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,350.01,14.42,,1.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1820.44,75,,1832.408,Percent of Total Billed Charges,75% of Total Billed Charges,1213.63,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,1213.63,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.63,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,1213.63,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,2.496,Fee Schedule,100% of ASC Tier Groupings fee schedule,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,339.82,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2427.25,100,,2443.208,Percent of Total Billed Charges,100% of Total Billed Charges,10.52,2614.8,
FACET CRV/THOR LVL 1 BI,50770601,CDM,361,RC,64490,HCPCS,Outpatient,,,3640.88,2184.53,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.56,32,,219.648,Percent of Total Billed Charges,32% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,3.056,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,525.01,14.42,,18.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2730.66,75,,5667.232,Percent of Total Billed Charges,75% of Total Billed Charges,1820.44,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,1820.44,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1820.44,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,1820.44,50,,9.608,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,840,Fee Schedule,100% of ASC Tier Groupings fee schedule,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,509.72,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3640.88,100,,7556.312,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,3640.88,
FACET CRV/THOR LVL 2,50770627,CDM,361,RC,64491,HCPCS,Outpatient,,,1412.9,847.74,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,635.81,45,,508.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.088,Other,Not Seperately Reimbusable,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,847.74,60,,18.432,Percent of Total Billed Charges,60% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1412.9,100,,1130.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,203.74,14.42,,0.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1059.68,75,,1943.52,Percent of Total Billed Charges,75% of Total Billed Charges,706.45,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,706.45,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.45,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,706.45,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1120,Fee Schedule,100% of ASC Tier Groupings fee schedule,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,197.81,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1412.9,100,,2591.36,Percent of Total Billed Charges,100% of Total Billed Charges,197.81,2601,
FACET CRV/THOR LVL 2 BI,50770643,CDM,361,RC,64491,HCPCS,Outpatient,,,2119.35,1271.61,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,953.71,45,,762.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.12,Other,Not Seperately Reimbusable,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1271.61,60,,86.464,Percent of Total Billed Charges,60% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2119.35,100,,1695.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,305.61,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1589.51,75,,109.368,Percent of Total Billed Charges,75% of Total Billed Charges,1059.68,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,1059.68,50,,104.12,Percent of Total Billed Charges,50% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1059.68,50,,104.12,Percent of Total Billed Charges,50% of Total Billed Charges,1059.68,50,,1.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,1.816,Fee Schedule,100% of ASC Tier Groupings fee schedule,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,296.71,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2119.35,100,,145.824,Percent of Total Billed Charges,100% of Total Billed Charges,296.71,2601,
FACET CRV/THOR LVL 3,50770668,CDM,361,RC,64492,HCPCS,Outpatient,,,1350.87,810.52,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,607.89,45,,486.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,221.856,Other,Not Seperately Reimbusable,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,810.52,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1350.87,100,,1080.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,194.8,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1013.15,75,,927.328,Percent of Total Billed Charges,75% of Total Billed Charges,675.44,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,675.44,50,,0.632,Percent of Total Billed Charges,50% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675.44,50,,0.632,Percent of Total Billed Charges,50% of Total Billed Charges,675.44,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,4.424,Fee Schedule,100% of ASC Tier Groupings fee schedule,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,189.12,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1350.87,100,,1236.44,Percent of Total Billed Charges,100% of Total Billed Charges,189.12,2601,
FACET CRV/THOR LVL 3 BI,50770684,CDM,361,RC,64492,HCPCS,Outpatient,,,2026.31,1215.79,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,911.84,45,,729.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,222.696,Other,Not Seperately Reimbusable,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1215.79,60,,143.08,Percent of Total Billed Charges,60% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2026.31,100,,1621.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,292.19,14.42,,1.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1519.73,75,,109.8,Percent of Total Billed Charges,75% of Total Billed Charges,1013.16,50,,104.12,Percent of Total Billed Charges,50% of Total Billed Charges,1013.16,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1013.16,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,1013.16,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,2.048,Fee Schedule,100% of ASC Tier Groupings fee schedule,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,283.68,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2026.31,100,,146.4,Percent of Total Billed Charges,100% of Total Billed Charges,283.68,2601,
FACET LUMB/SAC LVL 1,50770700,CDM,361,RC,64493,HCPCS,Outpatient,,,2544,1526.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,10.56,32,,22.296,Percent of Total Billed Charges,32% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,264,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,366.84,14.42,,1.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1908,75,,107.104,Percent of Total Billed Charges,75% of Total Billed Charges,1272,50,,0.632,Percent of Total Billed Charges,50% of Total Billed Charges,1272,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1272,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,1272,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,0.208,Fee Schedule,100% of ASC Tier Groupings fee schedule,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2544,100,,142.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,2614.8,
FACET LUMB/SAC LVL 1 BI,50770726,CDM,361,RC,64493,HCPCS,Outpatient,,,3816,2289.60,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.64,32,,222.72,Percent of Total Billed Charges,32% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,23.816,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,550.27,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2862,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,1908,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,1908,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,1908,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,12.384,Fee Schedule,100% of ASC Tier Groupings fee schedule,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,102.64,3816,
FACET LUMB/SAC LVL 2,50770742,CDM,361,RC,64494,HCPCS,Outpatient,,,1414,848.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,636.3,45,,509.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,222.72,Other,Not Seperately Reimbusable,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,848.4,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1414,100,,1131.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,203.9,14.42,,7.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1060.5,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,707,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,707,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,707,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,707,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,2.192,Fee Schedule,100% of ASC Tier Groupings fee schedule,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,197.96,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1414,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,197.96,2601,
FACET LUMB/SAC LVL 2 BI,50770767,CDM,361,RC,64494,HCPCS,Outpatient,,,2121,1272.60,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,954.45,45,,763.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,223.672,Other,Not Seperately Reimbusable,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1272.6,60,,16.4,Percent of Total Billed Charges,60% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2121,100,,1696.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,305.85,14.42,,68.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1590.75,75,,147.64,Percent of Total Billed Charges,75% of Total Billed Charges,1060.5,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,1060.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1060.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,1060.5,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,331.08,Fee Schedule,100% of ASC Tier Groupings fee schedule,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,296.94,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2121,100,,196.848,Percent of Total Billed Charges,100% of Total Billed Charges,296.94,2601,
FACET LUMB/SAC LVL 3,50770783,CDM,361,RC,64495,HCPCS,Outpatient,,,1399.56,839.74,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,629.8,45,,503.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,223.672,Other,Not Seperately Reimbusable,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,839.74,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1399.56,100,,1119.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,201.82,14.42,,30.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1049.67,75,,126,Percent of Total Billed Charges,75% of Total Billed Charges,699.78,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,699.78,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.78,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,699.78,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,147.144,Fee Schedule,100% of ASC Tier Groupings fee schedule,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,195.94,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1399.56,100,,168,Percent of Total Billed Charges,100% of Total Billed Charges,195.94,2601,
FACET LUMB/SAC LVL 3 BI,50770809,CDM,361,RC,64495,HCPCS,Outpatient,,,2099.34,1259.60,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,944.7,45,,755.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,224.544,Other,Not Seperately Reimbusable,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1259.6,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2099.34,100,,1679.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,302.72,14.42,,33.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1574.51,75,,255.84,Percent of Total Billed Charges,75% of Total Billed Charges,1049.67,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,1049.67,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1049.67,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,1049.67,50,,0.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,107.608,Fee Schedule,100% of ASC Tier Groupings fee schedule,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,293.91,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2099.34,100,,341.12,Percent of Total Billed Charges,100% of Total Billed Charges,293.91,2601,
SPHENOPALATINE GANG BLK,50770825,CDM,361,RC,64505,HCPCS,Outpatient,,,997.06,598.24,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,166.5,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.64,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,230.1,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,230.1,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,230.1,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,24.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,143.78,14.42,,18.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,747.8,75,,325.504,Percent of Total Billed Charges,75% of Total Billed Charges,498.53,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,498.53,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,498.53,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,498.53,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,54.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,139.59,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,997.06,100,,434,Percent of Total Billed Charges,100% of Total Billed Charges,102.64,2601,
STELALTE GANGLION BLOCK,50770841,CDM,361,RC,64510,HCPCS,Outpatient,,,2148,1288.80,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.72,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,37.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,309.74,14.42,,25.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1611,75,,190.504,Percent of Total Billed Charges,75% of Total Billed Charges,1074,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,1074,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1074,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,1074,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,8.944,Fee Schedule,100% of ASC Tier Groupings fee schedule,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,300.72,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2148,100,,254,Percent of Total Billed Charges,100% of Total Billed Charges,102.72,2614.8,
LUMB SYMPATHETIC BLOCK,50770882,CDM,361,RC,64520,HCPCS,Outpatient,,,2503.47,1502.08,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.79,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,24.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,361,14.42,,0.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1877.6,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,1251.74,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,1251.74,50,,7.032,Percent of Total Billed Charges,50% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1251.74,50,,7.032,Percent of Total Billed Charges,50% of Total Billed Charges,1251.74,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,16.456,Fee Schedule,100% of ASC Tier Groupings fee schedule,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,350.49,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.47,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,102.79,2614.8,
INTERCOSTAL NEUROLYTIC,50770981,CDM,361,RC,64620,HCPCS,Outpatient,,,2629.51,1577.71,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,102.92,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,13.808,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,379.18,14.42,,2.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1972.13,75,,82.984,Percent of Total Billed Charges,75% of Total Billed Charges,1314.76,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,1314.76,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1314.76,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,1314.76,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,629.928,Fee Schedule,100% of ASC Tier Groupings fee schedule,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,368.13,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2629.51,100,,110.64,Percent of Total Billed Charges,100% of Total Billed Charges,102.92,2629.51,
FACET NEURO LUM/SAC SNG,50771005,CDM,360,RC,64635,HCPCS,Outpatient,,,3535.95,2121.57,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4006.09,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.01,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5536.31,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,4635,103,,13.312,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.26,90,,,Fee Schedule,90% of CMS OPPS Rate,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.83,130,,,Fee Schedule,130% of CMS OPPS Rate,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,509.88,14.42,,1.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2651.96,75,,591,Percent of Total Billed Charges,75% of Total Billed Charges,1767.98,50,,7.032,Percent of Total Billed Charges,50% of Total Billed Charges,1767.98,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1767.98,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,1767.98,50,,104.12,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,2.72,Fee Schedule,100% of ASC Tier Groupings fee schedule,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,495.03,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3535.95,100,,788,Percent of Total Billed Charges,100% of Total Billed Charges,103.01,5536.31,
FACET NEURO L/S SNG LVBI,50771021,CDM,360,RC,64635,HCPCS,Outpatient,,,5303.93,3182.36,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4006.09,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.06,32,,224.56,Percent of Total Billed Charges,32% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5536.31,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,4635,103,,37.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.26,90,,,Fee Schedule,90% of CMS OPPS Rate,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.83,130,,,Fee Schedule,130% of CMS OPPS Rate,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,764.83,14.42,,4.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3977.95,75,,7665,Percent of Total Billed Charges,75% of Total Billed Charges,2651.97,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,2651.97,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2651.97,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,2651.97,50,,0.632,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,0.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,742.55,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5303.93,100,,10220,Percent of Total Billed Charges,100% of Total Billed Charges,103.06,5536.31,
FACET NEURO L/S EA ADD,50771047,CDM,360,RC,64636,HCPCS,Outpatient,,,2279.73,1367.84,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1025.88,45,,820.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,224.56,Other,Not Seperately Reimbusable,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1367.84,60,,20,Percent of Total Billed Charges,60% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2279.73,100,,1823.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,328.74,14.42,,29.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1709.8,75,,50.4,Percent of Total Billed Charges,75% of Total Billed Charges,1139.87,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,1139.87,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1139.87,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,1139.87,50,,0.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,0.472,Fee Schedule,100% of ASC Tier Groupings fee schedule,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,319.16,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2279.73,100,,67.2,Percent of Total Billed Charges,100% of Total Billed Charges,319.16,2601,
FACET NEURO L/S ADD LVBI,50771062,CDM,360,RC,64636,HCPCS,Outpatient,,,3419.6,2051.76,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1538.82,45,,1231.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,224.616,Other,Not Seperately Reimbusable,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2051.76,60,,16.616,Percent of Total Billed Charges,60% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3419.6,100,,2735.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,493.11,14.42,,7.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2564.7,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,1709.8,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,1709.8,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1709.8,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,1709.8,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,22.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,478.74,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3419.6,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,478.74,3419.6,
FACET NEURO C/T SNGL LVL,50771088,CDM,361,RC,64633,HCPCS,Outpatient,,,2544,1526.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4006.09,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.17,32,,224.616,Percent of Total Billed Charges,32% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5536.31,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,16.688,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.26,90,,,Fee Schedule,90% of CMS OPPS Rate,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.83,130,,,Fee Schedule,130% of CMS OPPS Rate,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,366.84,14.42,,12.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1908,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,1272,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,1272,50,,0.624,Percent of Total Billed Charges,50% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1272,50,,0.624,Percent of Total Billed Charges,50% of Total Billed Charges,1272,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,26.12,Fee Schedule,100% of ASC Tier Groupings fee schedule,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,356.16,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2544,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,103.17,5536.31,
FACET NEURO C/T SNGL BI,50771104,CDM,361,RC,64633,HCPCS,Outpatient,,,3816,2289.60,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4006.09,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.88,32,,224.768,Percent of Total Billed Charges,32% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,5536.31,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,5536.31,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,13.24,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.26,90,,,Fee Schedule,90% of CMS OPPS Rate,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.83,130,,,Fee Schedule,130% of CMS OPPS Rate,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,550.27,14.42,,17.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2862,75,,1943.52,Percent of Total Billed Charges,75% of Total Billed Charges,1908,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,1908,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,1908,50,,5.776,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3673,100,,3.576,Fee Schedule,100% of ASC Tier Groupings fee schedule,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,534.24,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,100,,2591.36,Percent of Total Billed Charges,100% of Total Billed Charges,103.88,5536.31,
FACET NEURO C/T EA ADDLV,50771120,CDM,361,RC,64634,HCPCS,Outpatient,,,1933.16,1159.90,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,869.92,45,,695.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,225.232,Other,Not Seperately Reimbusable,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1159.9,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1933.16,100,,1546.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,278.76,14.42,,52.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1449.87,75,,1680,Percent of Total Billed Charges,75% of Total Billed Charges,966.58,50,,0.624,Percent of Total Billed Charges,50% of Total Billed Charges,966.58,50,,10.32,Percent of Total Billed Charges,50% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,966.58,50,,10.32,Percent of Total Billed Charges,50% of Total Billed Charges,966.58,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,89.184,Fee Schedule,100% of ASC Tier Groupings fee schedule,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,270.64,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1933.16,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,270.64,2601,
FACET NEURO C/T EA ADDBI,50771146,CDM,361,RC,64634,HCPCS,Outpatient,,,2899.73,1739.84,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1304.88,45,,1043.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,225.232,Other,Not Seperately Reimbusable,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1739.84,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2899.73,100,,2319.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,418.14,14.42,,20.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2174.8,75,,1680,Percent of Total Billed Charges,75% of Total Billed Charges,1449.87,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,1449.87,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.87,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,1449.87,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634,100,,127.552,Fee Schedule,100% of ASC Tier Groupings fee schedule,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,405.96,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2899.73,100,,2240,Percent of Total Billed Charges,100% of Total Billed Charges,405.96,2899.73,
NEUROLY OTHER PERIPHERAL,50771161,CDM,361,RC,64640,HCPCS,Outpatient,,,1874.25,1124.55,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,411.2,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.88,32,,22.616,Percent of Total Billed Charges,32% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,568.27,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,568.27,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,568.27,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,37.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,270.27,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1405.69,75,,1500,Percent of Total Billed Charges,75% of Total Billed Charges,937.13,50,,10.32,Percent of Total Billed Charges,50% of Total Billed Charges,937.13,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,937.13,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,937.13,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,195.344,Fee Schedule,100% of ASC Tier Groupings fee schedule,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,262.4,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1874.25,100,,2000,Percent of Total Billed Charges,100% of Total Billed Charges,103.88,2601,
CELIAC PLEXUS NEUROLYTIC,50771187,CDM,361,RC,64680,HCPCS,Outpatient,,,3930.8,2358.48,,4162,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,103.88,32,,22.656,Percent of Total Billed Charges,32% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,37.68,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,566.82,14.42,,1.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2948.1,75,,1500,Percent of Total Billed Charges,75% of Total Billed Charges,1965.4,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,1965.4,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1965.4,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,1965.4,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,109.24,Fee Schedule,100% of ASC Tier Groupings fee schedule,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,550.31,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3930.8,100,,2000,Percent of Total Billed Charges,100% of Total Billed Charges,103.88,4162,
CELIAC PLEXUS,50771195,CDM,361,RC,64530,HCPCS,Outpatient,,,2517,1510.20,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1254.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.08,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,104,32,,22.672,Percent of Total Billed Charges,32% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2614.8,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2614.8,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,24.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,752.61,90,,,Fee Schedule,90% of CMS OPPS Rate,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.1,130,,,Fee Schedule,130% of CMS OPPS Rate,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,362.95,14.42,,7.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,861.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1887.75,75,,1920,Percent of Total Billed Charges,75% of Total Billed Charges,1258.5,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,1258.5,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1258.5,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,1258.5,50,,0.704,Percent of Total Billed Charges,50% of Total Billed Charges,1254.35,150,,,Fee Schedule,150% of CMS OPPS Rate,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,98.688,Fee Schedule,100% of ASC Tier Groupings fee schedule,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,352.38,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,836.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2517,100,,2560,Percent of Total Billed Charges,100% of Total Billed Charges,104,2614.8,
STENT BIL SYS 10,50771211,CDM,278,RC,C2625,HCPCS,Outpatient,,,375,225.00,,638.81,110,,511.048,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,104.62,32,,22.696,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,4.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,1920,Percent of Total Billed Charges,80% of Total Billed Charges,187.5,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,5.816,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,5.816,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,7.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,2560,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,638.81,
TRACHEOTOMY TUBE CHANGE,50771237,CDM,361,RC,31502,HCPCS,Outpatient,,,813.05,487.83,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,336.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,474.48,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,105.49,32,,22.72,Percent of Total Billed Charges,32% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,655.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,655.72,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,655.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,24.208,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,117.24,14.42,,0.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,609.79,75,,2010.016,Percent of Total Billed Charges,75% of Total Billed Charges,406.53,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,406.53,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,7.016,Fee Schedule,100% of ASC Tier Groupings fee schedule,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,813.05,100,,2680.024,Percent of Total Billed Charges,100% of Total Billed Charges,105.49,2601,
TRIAL LEAD KIT,50771245,CDM,272,RC,C1897,HCPCS,Outpatient,,,3233.98,1940.39,,767.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,1455.29,45,,1164.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,905.51,28,,724.408,Percent of Total Billed Charges,28% of Total Billed Charges,10727.72,32,,22.752,Percent of Total Billed Charges,32% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,1164.23,36,,931.384,Percent of Total Billed Charges,36% of Total Billed Charges,1164.23,36,,931.384,Percent of Total Billed Charges,36% Total Bille Charges,1164.23,36,,931.384,Percent of Total Billed Charges,36% of Total Billed Charges,1940.39,60,,72.688,Percent of Total Billed Charges,60% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3233.98,100,,2587.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,466.34,14.42,,78.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2425.49,75,,2010.016,Percent of Total Billed Charges,75% of Total Billed Charges,1616.99,50,,5.816,Percent of Total Billed Charges,50% of Total Billed Charges,1616.99,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1616.99,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,1616.99,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2263.79,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,452.76,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3233.98,100,,2680.024,Percent of Total Billed Charges,100% of Total Billed Charges,452.76,10727.72,
RAPTOR GRASPING DEVICE,50771252,CDM,278,RC,C1773,HCPCS,Outpatient,,,400,240.00,,510,110,,408,Percent of Total Billed Charges,110% of Total Billed Charges,180,45,,144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112,28,,89.6,Percent of Total Billed Charges,28% of Total Billed Charges,10.57,32,,22.76,Percent of Total Billed Charges,32% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,144,36,,115.2,Percent of Total Billed Charges,36% of Total Billed Charges,144,36,,115.2,Percent of Total Billed Charges,36% Total Bille Charges,144,36,,115.2,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400,100,,320,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,57.68,14.42,,289.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320,80,,3015.024,Percent of Total Billed Charges,80% of Total Billed Charges,200,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,200,50,,5.416,Percent of Total Billed Charges,50% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,50,,5.416,Percent of Total Billed Charges,50% of Total Billed Charges,200,50,,0.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,70,,23.4,Percent of Total Billed Charges,70% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,56,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400,100,,4020.032,Percent of Total Billed Charges,100% of Total Billed Charges,10.57,510,
EPIDURAL TRAY,50771260,CDM,272,RC,,,Outpatient,,,150.24,90.14,,90.14,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,67.61,45,,54.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.07,28,,33.656,Percent of Total Billed Charges,28% of Total Billed Charges,10.59,32,,225.752,Percent of Total Billed Charges,32% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% Total Bille Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,90.14,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.24,100,,120.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14.42,,240.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.68,75,,5319.872,Percent of Total Billed Charges,75% of Total Billed Charges,75.12,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,5.096,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.12,50,,5.096,Percent of Total Billed Charges,50% of Total Billed Charges,75.12,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.17,70,,997.08,Percent of Total Billed Charges,70% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,21.03,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.24,100,,7093.16,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,150.24,
VERSA CATH,50771261,CDM,272,RC,,,Outpatient,,,315,189.00,,189,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,141.75,45,,113.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,28,,70.56,Percent of Total Billed Charges,28% of Total Billed Charges,10.59,32,,226.072,Percent of Total Billed Charges,32% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,113.4,36,,90.72,Percent of Total Billed Charges,36% of Total Billed Charges,113.4,36,,90.72,Percent of Total Billed Charges,36% Total Bille Charges,113.4,36,,90.72,Percent of Total Billed Charges,36% of Total Billed Charges,189,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,100,,252,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,45.42,14.42,,19.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.25,75,,55.624,Percent of Total Billed Charges,75% of Total Billed Charges,157.5,50,,5.416,Percent of Total Billed Charges,50% of Total Billed Charges,157.5,50,,1.456,Percent of Total Billed Charges,50% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,50,,1.456,Percent of Total Billed Charges,50% of Total Billed Charges,157.5,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.5,70,,168.76,Percent of Total Billed Charges,70% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,44.1,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,100,,74.16,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,315,
BRUSH MICRO BRON,50771286,CDM,272,RC,,,Outpatient,,,126,75.60,,75.6,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,45,,45.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.28,28,,28.224,Percent of Total Billed Charges,28% of Total Billed Charges,10.69,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,45.36,36,,36.288,Percent of Total Billed Charges,36% of Total Billed Charges,45.36,36,,36.288,Percent of Total Billed Charges,36% Total Bille Charges,45.36,36,,36.288,Percent of Total Billed Charges,36% of Total Billed Charges,75.6,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,100,,100.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.17,14.42,,28.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,75,,384.544,Percent of Total Billed Charges,75% of Total Billed Charges,63,50,,5.096,Percent of Total Billed Charges,50% of Total Billed Charges,63,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,63,50,,0.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.2,70,,34.576,Percent of Total Billed Charges,70% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,17.64,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126,100,,512.72,Percent of Total Billed Charges,100% of Total Billed Charges,10.69,126,
SNARE EXACTO COL,50771294,CDM,272,RC,,,Outpatient,,,128.58,77.15,,77.15,60,,61.72,Percent of Total Billed Charges,60% of Total Billed Charges,57.86,45,,46.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36,28,,28.8,Percent of Total Billed Charges,28% of Total Billed Charges,10.69,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,46.29,36,,37.032,Percent of Total Billed Charges,36% of Total Billed Charges,46.29,36,,37.032,Percent of Total Billed Charges,36% Total Bille Charges,46.29,36,,37.032,Percent of Total Billed Charges,36% of Total Billed Charges,77.15,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.58,100,,102.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18.54,14.42,,39.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.44,75,,1230.928,Percent of Total Billed Charges,75% of Total Billed Charges,64.29,50,,1.456,Percent of Total Billed Charges,50% of Total Billed Charges,64.29,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.29,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,64.29,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.01,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,18,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.58,100,,1641.232,Percent of Total Billed Charges,100% of Total Billed Charges,10.69,128.58,
6 SHOOTER SAEED MULTI-BAND LIG,50771300,CDM,272,RC,,,Outpatient,,,706.59,423.95,,423.95,60,,339.16,Percent of Total Billed Charges,60% of Total Billed Charges,317.97,45,,254.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.85,28,,158.28,Percent of Total Billed Charges,28% of Total Billed Charges,10.69,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,254.37,36,,203.496,Percent of Total Billed Charges,36% of Total Billed Charges,254.37,36,,203.496,Percent of Total Billed Charges,36% Total Bille Charges,254.37,36,,203.496,Percent of Total Billed Charges,36% of Total Billed Charges,423.95,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,706.59,100,,565.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,101.89,14.42,,11.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.94,75,,876.448,Percent of Total Billed Charges,75% of Total Billed Charges,353.3,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,353.3,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,353.3,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,353.3,50,,10.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.61,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,98.92,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,706.59,100,,1168.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.69,706.59,
ACROBAT CALIBRATED TIP WIRE,50771301,CDM,272,RC,C1769,HCPCS,Outpatient,,,828.41,497.05,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,372.78,45,,298.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.95,28,,185.56,Percent of Total Billed Charges,28% of Total Billed Charges,10.69,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,298.23,36,,238.584,Percent of Total Billed Charges,36% of Total Billed Charges,298.23,36,,238.584,Percent of Total Billed Charges,36% Total Bille Charges,298.23,36,,238.584,Percent of Total Billed Charges,36% of Total Billed Charges,497.05,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,828.41,100,,662.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,119.46,14.42,,11.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,621.31,75,,367.064,Percent of Total Billed Charges,75% of Total Billed Charges,414.21,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,414.21,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,414.21,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.89,70,,42.232,Percent of Total Billed Charges,70% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,115.98,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,828.41,100,,489.416,Percent of Total Billed Charges,100% of Total Billed Charges,10.69,828.41,
BRONCHOSCOPE CYTOLOGY BRUSH,50771303,CDM,272,RC,,,Outpatient,,,69.21,41.53,,41.53,60,,33.224,Percent of Total Billed Charges,60% of Total Billed Charges,31.14,45,,24.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,10.71,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,41.53,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.21,100,,55.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,14.42,,4.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.91,75,,1255.152,Percent of Total Billed Charges,75% of Total Billed Charges,34.61,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.61,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.45,70,,46.984,Percent of Total Billed Charges,70% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.21,100,,1673.536,Percent of Total Billed Charges,100% of Total Billed Charges,9.69,69.21,
CAPTURA SERRATED JUMBO FORCEP,50771308,CDM,272,RC,,,Outpatient,,,72,43.20,,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.16,28,,16.128,Percent of Total Billed Charges,28% of Total Billed Charges,10.71,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,25.92,36,,20.736,Percent of Total Billed Charges,36% of Total Billed Charges,25.92,36,,20.736,Percent of Total Billed Charges,36% Total Bille Charges,25.92,36,,20.736,Percent of Total Billed Charges,36% of Total Billed Charges,43.2,60,,9.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,100,,57.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,14.42,,8.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,75,,1710,Percent of Total Billed Charges,75% of Total Billed Charges,36,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,70,,2.928,Percent of Total Billed Charges,70% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72,100,,2280,Percent of Total Billed Charges,100% of Total Billed Charges,10.08,72,
COTTON-HUIBREGTSE BILIARY STE,50771311,CDM,278,RC,C2617,HCPCS,Outpatient,,,263.84,158.30,,483.77,110,,387.016,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,106.46,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,8.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,1098,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,6.264,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,1464,Percent of Total Billed Charges,100% of Total Billed Charges,36.94,483.77,
COTTON-LEUNG BILIARY STENT,50771312,CDM,278,RC,C2617,HCPCS,Outpatient,,,263.84,158.30,,483.77,110,,387.016,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,106.51,32,,227.352,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,1943.52,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,5.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,25.096,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,2591.36,Percent of Total Billed Charges,100% of Total Billed Charges,36.94,483.77,
ECLIPSE TTC WIRE GUIDED BALLO,50771318,CDM,272,RC,C1726,HCPCS,Outpatient,,,657.86,394.72,,396.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,296.04,45,,236.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,28,,147.36,Percent of Total Billed Charges,28% of Total Billed Charges,106.75,32,,22.976,Percent of Total Billed Charges,32% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,236.83,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,236.83,36,,189.464,Percent of Total Billed Charges,36% Total Bille Charges,236.83,36,,189.464,Percent of Total Billed Charges,36% of Total Billed Charges,394.72,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,100,,526.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,94.86,14.42,,17.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,493.4,75,,1255.152,Percent of Total Billed Charges,75% of Total Billed Charges,328.93,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,328.93,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,328.93,50,,0.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,70,,465.032,Percent of Total Billed Charges,70% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,92.1,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.86,100,,1673.536,Percent of Total Billed Charges,100% of Total Billed Charges,92.1,657.86,
CYTOLOGY BRUSH,50771320,CDM,272,RC,,,Outpatient,,,400.95,240.57,,240.57,60,,192.456,Percent of Total Billed Charges,60% of Total Billed Charges,180.43,45,,144.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.27,28,,89.816,Percent of Total Billed Charges,28% of Total Billed Charges,107.2,32,,22.984,Percent of Total Billed Charges,32% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,144.34,36,,115.472,Percent of Total Billed Charges,36% of Total Billed Charges,144.34,36,,115.472,Percent of Total Billed Charges,36% Total Bille Charges,144.34,36,,115.472,Percent of Total Billed Charges,36% of Total Billed Charges,240.57,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.95,100,,320.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,57.82,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.71,75,,1198.656,Percent of Total Billed Charges,75% of Total Billed Charges,200.48,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,200.48,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.48,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,200.48,50,,0.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.67,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,56.13,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.95,100,,1598.208,Percent of Total Billed Charges,100% of Total Billed Charges,56.13,400.95,
FUSION PUSHING CATHETER,50771322,CDM,272,RC,,,Outpatient,,,263.84,158.30,,158.3,60,,126.64,Percent of Total Billed Charges,60% of Total Billed Charges,118.73,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,107.58,32,,228.792,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,158.3,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,0.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.88,75,,954.904,Percent of Total Billed Charges,75% of Total Billed Charges,131.92,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,5.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,6.832,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,1273.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.94,263.84,
FUSION LITHOTRIPSY EXTRACTION,50771323,CDM,272,RC,,,Outpatient,,,1315.71,789.43,,789.43,60,,631.544,Percent of Total Billed Charges,60% of Total Billed Charges,592.07,45,,473.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,368.4,28,,294.72,Percent of Total Billed Charges,28% of Total Billed Charges,108.48,32,,229.312,Percent of Total Billed Charges,32% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,473.66,36,,378.928,Percent of Total Billed Charges,36% of Total Billed Charges,473.66,36,,378.928,Percent of Total Billed Charges,36% Total Bille Charges,473.66,36,,378.928,Percent of Total Billed Charges,36% of Total Billed Charges,789.43,60,,47.416,Percent of Total Billed Charges,60% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1315.71,100,,1052.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,189.73,14.42,,16.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,986.78,75,,1169.536,Percent of Total Billed Charges,75% of Total Billed Charges,657.86,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,657.86,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,657.86,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,657.86,50,,5.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,921,70,,75.4,Percent of Total Billed Charges,70% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,184.2,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1315.71,100,,1559.376,Percent of Total Billed Charges,100% of Total Billed Charges,108.48,1315.71,
FUSION LOOPTIP WIRE GUIDE,50771326,CDM,272,RC,C1769,HCPCS,Outpatient,,,560,336.00,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,252,45,,201.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.8,28,,125.44,Percent of Total Billed Charges,28% of Total Billed Charges,108.66,32,,229.616,Percent of Total Billed Charges,32% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,201.6,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,201.6,36,,161.28,Percent of Total Billed Charges,36% Total Bille Charges,201.6,36,,161.28,Percent of Total Billed Charges,36% of Total Billed Charges,336,60,,83.24,Percent of Total Billed Charges,60% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,80.75,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420,75,,1053.912,Percent of Total Billed Charges,75% of Total Billed Charges,280,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,280,50,,1.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392,70,,15.992,Percent of Total Billed Charges,70% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,78.4,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560,100,,1405.216,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,560,
FUSION OASIS BILIARY STENT,50771327,CDM,272,RC,C1887,HCPCS,Outpatient,,,507.87,304.72,,43.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,228.54,45,,182.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.2,28,,113.76,Percent of Total Billed Charges,28% of Total Billed Charges,10880,32,,229.632,Percent of Total Billed Charges,32% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,182.83,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,182.83,36,,146.264,Percent of Total Billed Charges,36% Total Bille Charges,182.83,36,,146.264,Percent of Total Billed Charges,36% of Total Billed Charges,304.72,60,,52.288,Percent of Total Billed Charges,60% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,507.87,100,,406.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.9,75,,1073.8,Percent of Total Billed Charges,75% of Total Billed Charges,253.94,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,527.088,Percent of Total Billed Charges,50% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,253.94,50,,527.088,Percent of Total Billed Charges,50% of Total Billed Charges,253.94,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.51,70,,122.272,Percent of Total Billed Charges,70% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,71.1,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.87,100,,1431.736,Percent of Total Billed Charges,100% of Total Billed Charges,43.86,10880,
WIRE SPHINCTERTM PRELOADED,50771329,CDM,272,RC,,,Outpatient,,,1510.63,906.38,,906.38,60,,725.104,Percent of Total Billed Charges,60% of Total Billed Charges,679.78,45,,543.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,422.98,28,,338.384,Percent of Total Billed Charges,28% of Total Billed Charges,10880,32,,229.632,Percent of Total Billed Charges,32% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,543.83,36,,435.064,Percent of Total Billed Charges,36% of Total Billed Charges,543.83,36,,435.064,Percent of Total Billed Charges,36% Total Bille Charges,543.83,36,,435.064,Percent of Total Billed Charges,36% of Total Billed Charges,906.38,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1510.63,100,,1208.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,217.83,14.42,,1.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1132.97,75,,905.064,Percent of Total Billed Charges,75% of Total Billed Charges,755.32,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,755.32,50,,468.32,Percent of Total Billed Charges,50% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,755.32,50,,468.32,Percent of Total Billed Charges,50% of Total Billed Charges,755.32,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1057.44,70,,29.392,Percent of Total Billed Charges,70% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,211.49,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1510.63,100,,1206.752,Percent of Total Billed Charges,100% of Total Billed Charges,211.49,10880,
FUSION PRE-LOADED W ACROBAT GW,50771333,CDM,272,RC,C1769,HCPCS,Outpatient,,,1583.73,950.24,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,712.68,45,,570.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.44,28,,354.752,Percent of Total Billed Charges,28% of Total Billed Charges,11040,32,,2310.664,Percent of Total Billed Charges,32% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,570.14,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,570.14,36,,456.112,Percent of Total Billed Charges,36% Total Bille Charges,570.14,36,,456.112,Percent of Total Billed Charges,36% of Total Billed Charges,950.24,60,,29.984,Percent of Total Billed Charges,60% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.73,100,,1266.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,228.37,14.42,,30.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1187.8,75,,845.888,Percent of Total Billed Charges,75% of Total Billed Charges,791.87,50,,527.088,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.87,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,791.87,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1108.61,70,,1.272,Percent of Total Billed Charges,70% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,221.72,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1583.73,100,,1127.848,Percent of Total Billed Charges,100% of Total Billed Charges,55.13,11040,
GLO-TIP ERCP CATHETER,50771334,CDM,272,RC,,,Outpatient,,,246.25,147.75,,147.75,60,,118.2,Percent of Total Billed Charges,60% of Total Billed Charges,110.81,45,,88.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.95,28,,55.16,Percent of Total Billed Charges,28% of Total Billed Charges,11136,32,,2326.272,Percent of Total Billed Charges,32% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% Total Bille Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,147.75,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,100,,197,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.69,75,,788.176,Percent of Total Billed Charges,75% of Total Billed Charges,123.13,50,,468.32,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.13,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.38,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.25,100,,1050.896,Percent of Total Billed Charges,100% of Total Billed Charges,34.48,11136,
HERCULES 3 STAGE BLLN DILATOR,50771336,CDM,272,RC,C1726,HCPCS,Outpatient,,,730.95,438.57,,396.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,328.93,45,,263.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.67,28,,163.736,Percent of Total Billed Charges,28% of Total Billed Charges,11161.8,32,,2327.64,Percent of Total Billed Charges,32% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% Total Bille Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,438.57,60,,29.432,Percent of Total Billed Charges,60% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.95,100,,584.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,105.4,14.42,,10.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.21,75,,1157.024,Percent of Total Billed Charges,75% of Total Billed Charges,365.48,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,365.48,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.48,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,365.48,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.67,70,,98.088,Percent of Total Billed Charges,70% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,730.95,100,,1542.696,Percent of Total Billed Charges,100% of Total Billed Charges,102.33,11161.8,
HERCULES 3 STAGE WIREGUIDED BA,50771337,CDM,272,RC,C1769,HCPCS,Outpatient,,,921,552.60,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,414.45,45,,331.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.88,28,,206.304,Percent of Total Billed Charges,28% of Total Billed Charges,10.92,32,,2329.6,Percent of Total Billed Charges,32% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% Total Bille Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,552.6,60,,18.432,Percent of Total Billed Charges,60% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921,100,,736.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,132.81,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,690.75,75,,1211.688,Percent of Total Billed Charges,75% of Total Billed Charges,460.5,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,0.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.7,70,,146.72,Percent of Total Billed Charges,70% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,921,100,,1615.584,Percent of Total Billed Charges,100% of Total Billed Charges,10.92,921,
INSTINCT ENDOSCOPIC HEMOCLIP,50771339,CDM,272,RC,,,Outpatient,,,682.22,409.33,,409.33,60,,327.464,Percent of Total Billed Charges,60% of Total Billed Charges,307,45,,245.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.02,28,,152.816,Percent of Total Billed Charges,28% of Total Billed Charges,10.93,32,,2366.792,Percent of Total Billed Charges,32% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,245.6,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,245.6,36,,196.48,Percent of Total Billed Charges,36% Total Bille Charges,245.6,36,,196.48,Percent of Total Billed Charges,36% of Total Billed Charges,409.33,60,,37.624,Percent of Total Billed Charges,60% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.22,100,,545.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.38,14.42,,4.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.67,75,,1261,Percent of Total Billed Charges,75% of Total Billed Charges,341.11,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.11,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,341.11,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.55,70,,111.28,Percent of Total Billed Charges,70% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,95.51,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.22,100,,1681.336,Percent of Total Billed Charges,100% of Total Billed Charges,10.93,682.22,
TRACER METRO DIRECT WIRE GUID,50771348,CDM,272,RC,C1769,HCPCS,Outpatient,,,536.03,321.62,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,241.21,45,,192.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.09,28,,120.072,Percent of Total Billed Charges,28% of Total Billed Charges,10.94,32,,2366.792,Percent of Total Billed Charges,32% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,192.97,36,,154.376,Percent of Total Billed Charges,36% of Total Billed Charges,192.97,36,,154.376,Percent of Total Billed Charges,36% Total Bille Charges,192.97,36,,154.376,Percent of Total Billed Charges,36% of Total Billed Charges,321.62,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.03,100,,428.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,77.3,14.42,,2.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,402.02,75,,1232.704,Percent of Total Billed Charges,75% of Total Billed Charges,268.02,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,268.02,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.02,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,268.02,50,,12.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375.22,70,,157.208,Percent of Total Billed Charges,70% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,75.04,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,536.03,100,,1643.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.94,536.03,
ZIMMON BILIARY STENT,50771352,CDM,278,RC,C2617,HCPCS,Outpatient,,,263.84,158.30,,483.77,110,,387.016,Percent of Total Billed Charges,110% of Total Billed Charges,118.73,45,,94.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.88,28,,59.104,Percent of Total Billed Charges,28% of Total Billed Charges,11.02,32,,2369.536,Percent of Total Billed Charges,32% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% Total Bille Charges,94.98,36,,75.984,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.84,100,,211.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,38.05,14.42,,5.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,80,,2662.056,Percent of Total Billed Charges,80% of Total Billed Charges,131.92,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,2.992,Percent of Total Billed Charges,50% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.92,50,,2.992,Percent of Total Billed Charges,50% of Total Billed Charges,131.92,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.69,70,,58.376,Percent of Total Billed Charges,70% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.94,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.84,100,,3549.408,Percent of Total Billed Charges,100% of Total Billed Charges,11.02,483.77,
FUSION OMNITOME CATH W/ WIRE,50771360,CDM,272,RC,C1769,HCPCS,Outpatient,,,877.14,526.28,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,394.71,45,,315.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.6,28,,196.48,Percent of Total Billed Charges,28% of Total Billed Charges,11.05,32,,2381.056,Percent of Total Billed Charges,32% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,315.77,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,315.77,36,,252.616,Percent of Total Billed Charges,36% Total Bille Charges,315.77,36,,252.616,Percent of Total Billed Charges,36% of Total Billed Charges,526.28,60,,1.528,Percent of Total Billed Charges,60% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,877.14,100,,701.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,126.48,14.42,,1.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,657.86,75,,1800,Percent of Total Billed Charges,75% of Total Billed Charges,438.57,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,5.728,Percent of Total Billed Charges,50% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,438.57,50,,5.728,Percent of Total Billed Charges,50% of Total Billed Charges,438.57,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,614,70,,19.976,Percent of Total Billed Charges,70% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,122.8,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,877.14,100,,2400,Percent of Total Billed Charges,100% of Total Billed Charges,11.05,877.14,
BS WALLSTENT SS GUIDEWIRE,50771361,CDM,272,RC,C1769,HCPCS,Outpatient,,,658.63,395.18,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,296.38,45,,237.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.42,28,,147.536,Percent of Total Billed Charges,28% of Total Billed Charges,11.05,32,,2381.056,Percent of Total Billed Charges,32% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,237.11,36,,189.688,Percent of Total Billed Charges,36% of Total Billed Charges,237.11,36,,189.688,Percent of Total Billed Charges,36% Total Bille Charges,237.11,36,,189.688,Percent of Total Billed Charges,36% of Total Billed Charges,395.18,60,,2.864,Percent of Total Billed Charges,60% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,658.63,100,,526.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,94.97,14.42,,7.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,493.97,75,,801.8,Percent of Total Billed Charges,75% of Total Billed Charges,329.32,50,,2.992,Percent of Total Billed Charges,50% of Total Billed Charges,329.32,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.32,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,329.32,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.04,70,,31.896,Percent of Total Billed Charges,70% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,92.21,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,658.63,100,,1069.064,Percent of Total Billed Charges,100% of Total Billed Charges,11.05,658.63,
DX FLUORO GUIDE NDL PLCMT,50771362,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,,86.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,288.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,2394.808,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,,Fee Schedule,360% of BCBS POS Rate,268.56,360,,,Fee schedule,360% of BCBS PPO Rate,268.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,640.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,2.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,1148.672,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,5.728,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,4.656,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,4.656,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,110.256,Case Rate,Pays based on per visit rate,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,1531.56,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
DX FLUORO GUIDE NDL PLCMT,50771362,CDM,320,RC,77002,HCPCS,Outpatient,,,800.04,480.02,,86.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,360.02,45,,288.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,2396.16,Fee Schedule,320% of BCBS Blue Essentials Rate,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,268.56,360,,,Fee Schedule,360% of BCBS POS Rate,268.56,360,,,Fee schedule,360% of BCBS PPO Rate,268.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,480.02,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.04,100,,640.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,115.37,14.42,,13.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600.03,75,,730.8,Percent of Total Billed Charges,75% of Total Billed Charges,400.02,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,400.02,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,400.02,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,3.648,Case Rate,Pays based on per visit rate,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,112.01,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,800.04,100,,974.4,Percent of Total Billed Charges,100% of Total Billed Charges,86.75,800.04,
DISKOGRAPHY CRV/THOR SI,50771363,CDM,320,RC,72285,HCPCS,Outpatient,,,3418.19,2050.91,TC   ,67.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4814.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5501.92,320,,2407.664,Fee Schedule,320% of BCBS Blue Essentials Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,6189.66,360,,,Fee Schedule,360% of BCBS POS Rate,6189.66,360,,,Fee schedule,360% of BCBS PPO Rate,6189.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,4961.42,103,,393.552,Fee Schedule,103% of Cigna fee schedule,128.98,100,,16.4,Fee Schedule,100% of TX Mediciad Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.27,90,,,Fee Schedule,90% of CMS OPPS Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.84,130,,,Fee Schedule,130% of CMS OPPS Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,132.85,103,,16.888,Fee Schedule,103% of TX Medicaid Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2563.64,75,,1255.152,Percent of Total Billed Charges,75% of Total Billed Charges,1709.1,50,,4.656,Percent of Total Billed Charges,50% of Total Billed Charges,1709.1,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1709.1,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,1709.1,50,,527.088,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,62.84,Case Rate,Pays based on per visit rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,16.4,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3418.19,100,,1673.536,Percent of Total Billed Charges,100% of Total Billed Charges,67.1,6189.66,
DISKOGRAPHY CRV/THOR SI,50771363,CDM,320,RC,72285,HCPCS,Outpatient,,,3418.19,2050.91,TC   ,67.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,2657.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4814.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5501.92,320,,2418.616,Fee Schedule,320% of BCBS Blue Essentials Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,6189.66,360,,,Fee Schedule,360% of BCBS POS Rate,6189.66,360,,,Fee schedule,360% of BCBS PPO Rate,6189.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,4961.42,103,,4.064,Fee Schedule,103% of Cigna fee schedule,128.98,100,,1.736,Fee Schedule,100% of TX Mediciad Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.27,90,,,Fee Schedule,90% of CMS OPPS Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.84,130,,,Fee Schedule,130% of CMS OPPS Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,132.85,103,,1.792,Fee Schedule,103% of TX Medicaid Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1824.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2563.64,75,,2920.32,Percent of Total Billed Charges,75% of Total Billed Charges,1709.1,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,1709.1,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1709.1,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,1709.1,50,,468.32,Percent of Total Billed Charges,50% of Total Billed Charges,2657.12,150,,,Fee Schedule,150% of CMS OPPS Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,2.544,Case Rate,Pays based on per visit rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,128.98,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1771.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3418.19,100,,3893.76,Percent of Total Billed Charges,100% of Total Billed Charges,67.1,6189.66,
LARIAT ISNARE,50771364,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,11.08,32,,2436.4,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,5.096,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,82.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1010.464,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,0.328,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1347.28,Percent of Total Billed Charges,100% of Total Billed Charges,11.08,375,
SACROILIAC JOINT INJECTION,50771365,CDM,361,RC,G0260,HCPCS,Outpatient,,,1757.63,1054.58,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,11.12,32,,2436.4,Percent of Total Billed Charges,32% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,7.304,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,253.45,14.42,,0.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1318.22,75,,378.616,Percent of Total Billed Charges,75% of Total Billed Charges,878.82,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,878.82,50,,1.368,Percent of Total Billed Charges,50% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,878.82,50,,1.368,Percent of Total Billed Charges,50% of Total Billed Charges,878.82,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,0.672,Fee Schedule,100% of ASC Tier Groupings fee schedule,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,246.07,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.63,100,,504.824,Percent of Total Billed Charges,100% of Total Billed Charges,11.12,2601,
SACROILIAC JOINT INJ BI,50771366,CDM,361,RC,G0260,HCPCS,Outpatient,,,2636.45,1581.87,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,11.16,32,,2452.064,Percent of Total Billed Charges,32% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,20.928,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,380.18,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1977.34,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,1318.23,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,1318.23,50,,1.64,Percent of Total Billed Charges,50% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.23,50,,1.64,Percent of Total Billed Charges,50% of Total Billed Charges,1318.23,50,,17.248,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,3.024,Fee Schedule,100% of ASC Tier Groupings fee schedule,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,369.1,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2636.45,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,11.16,2636.45,
BURSA OR JT INJ SMALL,50771367,CDM,361,RC,20600,HCPCS,Outpatient,,,716.96,430.18,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,58.02,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,108.96,32,,2457.6,Percent of Total Billed Charges,32% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,80.18,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,80.18,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,80.18,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,7.824,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,103.39,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,537.72,75,,367.064,Percent of Total Billed Charges,75% of Total Billed Charges,358.48,50,,1.368,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,358.48,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,358.48,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,7.312,Fee Schedule,100% of ASC Tier Groupings fee schedule,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,100.37,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,716.96,100,,489.416,Percent of Total Billed Charges,100% of Total Billed Charges,58.02,2601,
BURSA OR JT INJ INTERMED,50771368,CDM,361,RC,20605,HCPCS,Outpatient,,,773.69,464.21,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,60.53,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.07,32,,2464.248,Percent of Total Billed Charges,32% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,83.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,83.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,59.04,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,111.57,14.42,,42.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,580.27,75,,1103.44,Percent of Total Billed Charges,75% of Total Billed Charges,386.85,50,,1.64,Percent of Total Billed Charges,50% of Total Billed Charges,386.85,50,,1.472,Percent of Total Billed Charges,50% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,386.85,50,,1.472,Percent of Total Billed Charges,50% of Total Billed Charges,386.85,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,22.744,Fee Schedule,100% of ASC Tier Groupings fee schedule,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,108.32,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,773.69,100,,1471.248,Percent of Total Billed Charges,100% of Total Billed Charges,60.53,2601,
BURSA OR JT INJ MAJOR OR,50771369,CDM,361,RC,20610,HCPCS,Outpatient,,,2504.95,1502.97,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,72.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.18,32,,2473.728,Percent of Total Billed Charges,32% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,99.95,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,99.95,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,99.95,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,65.456,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,361.21,14.42,,63.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1878.71,75,,1406.648,Percent of Total Billed Charges,75% of Total Billed Charges,1252.48,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,1252.48,50,,4.144,Percent of Total Billed Charges,50% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1252.48,50,,4.144,Percent of Total Billed Charges,50% of Total Billed Charges,1252.48,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,16.736,Fee Schedule,100% of ASC Tier Groupings fee schedule,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,350.69,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2504.95,100,,1875.528,Percent of Total Billed Charges,100% of Total Billed Charges,72.32,2601,
BURSA OR JT INJ SM WO US BI,50771370,CDM,361,RC,20600,HCPCS,Outpatient,,,1075.43,645.26,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,58.02,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.18,32,,2508.504,Percent of Total Billed Charges,32% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,80.18,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,80.18,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,80.18,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,21.976,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,155.08,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,806.57,75,,1710,Percent of Total Billed Charges,75% of Total Billed Charges,537.72,50,,1.472,Percent of Total Billed Charges,50% of Total Billed Charges,537.72,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,537.72,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,537.72,50,,2.992,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,23.216,Fee Schedule,100% of ASC Tier Groupings fee schedule,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,150.56,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.43,100,,2280,Percent of Total Billed Charges,100% of Total Billed Charges,58.02,2601,
BURSA OR JT INJ INTM WO US BI,50771371,CDM,361,RC,20605,HCPCS,Outpatient,,,1160.52,696.31,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,60.53,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.25,32,,2513.848,Percent of Total Billed Charges,32% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,83.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,83.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,83.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,39.256,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,167.35,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,870.39,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,580.26,50,,4.144,Percent of Total Billed Charges,50% of Total Billed Charges,580.26,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,580.26,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,580.26,50,,5.728,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,52.648,Fee Schedule,100% of ASC Tier Groupings fee schedule,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,162.47,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.52,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,60.53,2601,
BURSA OR JT INJ MAJ OR BI,50771372,CDM,361,RC,20610,HCPCS,Outpatient,,,3757.43,2254.46,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,407.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,72.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.61,32,,2514.64,Percent of Total Billed Charges,32% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,99.95,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,99.95,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,99.95,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,86.6,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244.56,90,,,Fee Schedule,90% of CMS OPPS Rate,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,353.25,130,,,Fee Schedule,130% of CMS OPPS Rate,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,541.82,14.42,,1.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2818.07,75,,902.16,Percent of Total Billed Charges,75% of Total Billed Charges,1878.72,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,1878.72,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1878.72,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,1878.72,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,407.6,150,,,Fee Schedule,150% of CMS OPPS Rate,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,10.192,Fee Schedule,100% of ASC Tier Groupings fee schedule,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,526.04,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,3757.43,100,,1202.88,Percent of Total Billed Charges,100% of Total Billed Charges,72.32,3757.43,
EPIDURAL CRV/THOR W/GUIDANCE,50771373,CDM,361,RC,62321,HCPCS,Outpatient,,,2539.3,1523.58,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.61,32,,2514.72,Percent of Total Billed Charges,32% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,118.12,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,366.17,14.42,,2.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1904.48,75,,931.592,Percent of Total Billed Charges,75% of Total Billed Charges,1269.65,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,1269.65,50,,32.488,Percent of Total Billed Charges,50% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1269.65,50,,32.488,Percent of Total Billed Charges,50% of Total Billed Charges,1269.65,50,,4.656,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,62.296,Fee Schedule,100% of ASC Tier Groupings fee schedule,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,355.5,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2539.3,100,,1242.12,Percent of Total Billed Charges,100% of Total Billed Charges,109.61,2601,
EPIDURAL LUMB/SAC W/GUIDANCE,50771374,CDM,361,RC,62323,HCPCS,Outpatient,,,2721.63,1632.98,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,951.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.37,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,109.61,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2012.66,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,2012.66,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,2.968,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,571.02,90,,,Fee Schedule,90% of CMS OPPS Rate,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,824.8,130,,,Fee Schedule,130% of CMS OPPS Rate,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,392.46,14.42,,0.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,653.49,103,,,Fee Schedule,103% of CMS OPPS Rate,2041.22,75,,436.984,Percent of Total Billed Charges,75% of Total Billed Charges,1360.82,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,1360.82,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.82,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,1360.82,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,951.7,150,,,Fee Schedule,150% of CMS OPPS Rate,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,14.048,Fee Schedule,100% of ASC Tier Groupings fee schedule,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,381.03,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,634.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2721.63,100,,582.64,Percent of Total Billed Charges,100% of Total Billed Charges,109.61,2721.63,
POUCHOSCOPY DILATION,50771375,CDM,750,RC,,,Outpatient,,,718.09,430.85,,430.85,60,,344.68,Percent of Total Billed Charges,60% of Total Billed Charges,323.14,45,,258.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.07,28,,160.856,Percent of Total Billed Charges,28% of Total Billed Charges,109.61,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% Total Bille Charges,258.51,36,,206.808,Percent of Total Billed Charges,36% of Total Billed Charges,430.85,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.09,100,,574.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,103.55,14.42,,106.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.57,75,,1255.152,Percent of Total Billed Charges,75% of Total Billed Charges,359.05,50,,32.488,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.05,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,359.05,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,502.66,70,,8.688,Percent of Total Billed Charges,70% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,100.53,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,718.09,100,,1673.536,Percent of Total Billed Charges,100% of Total Billed Charges,100.53,718.09,
PADLOCK CLIP LOWER,50771376,CDM,272,RC,,,Outpatient,,,1350,810.00,,810,60,,648,Percent of Total Billed Charges,60% of Total Billed Charges,607.5,45,,486,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,109.61,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,486,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,486,36,,388.8,Percent of Total Billed Charges,36% Total Bille Charges,486,36,,388.8,Percent of Total Billed Charges,36% of Total Billed Charges,810,60,,4.072,Percent of Total Billed Charges,60% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1350,100,,1080,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,194.67,14.42,,65.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1012.5,75,,1457.72,Percent of Total Billed Charges,75% of Total Billed Charges,675,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,675,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,945,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,189,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1350,100,,1943.624,Percent of Total Billed Charges,100% of Total Billed Charges,109.61,1350,
MIC-KEY G FEEDING TUBE,50771377,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,109.69,32,,2523.416,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,3.928,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,1.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1098,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,391.92,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1464,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,375,
ERCP STENT OR FB REMOVAL,50771378,CDM,750,RC,,,Outpatient,,,2089.28,1253.57,,1253.57,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,940.18,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,110.06,32,,2528,Percent of Total Billed Charges,32% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,1253.57,60,,0.184,Percent of Total Billed Charges,60% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566.96,75,,1710,Percent of Total Billed Charges,75% of Total Billed Charges,1044.64,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1044.64,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,1.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1462.5,70,,26.12,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.28,100,,2280,Percent of Total Billed Charges,100% of Total Billed Charges,110.06,2089.28,
ERCP STENT REMOVE AND EXCHANGE,50771379,CDM,750,RC,,,Outpatient,,,2089.28,1253.57,,1253.57,60,,1002.856,Percent of Total Billed Charges,60% of Total Billed Charges,940.18,45,,752.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585,28,,468,Percent of Total Billed Charges,28% of Total Billed Charges,110.16,32,,2530.584,Percent of Total Billed Charges,32% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% Total Bille Charges,752.14,36,,601.712,Percent of Total Billed Charges,36% of Total Billed Charges,1253.57,60,,4.448,Percent of Total Billed Charges,60% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1671.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,301.27,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1566.96,75,,1457.72,Percent of Total Billed Charges,75% of Total Billed Charges,1044.64,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1044.64,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,1044.64,50,,1.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1462.5,70,,1.592,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,292.5,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2089.28,100,,1943.624,Percent of Total Billed Charges,100% of Total Billed Charges,110.16,2089.28,
ELEVIEW SOLUTION INJ,50771380,CDM,272,RC,,,Outpatient,,,375,225.00,,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,110.2,32,,2532.608,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,6.712,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,3.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,1255.152,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,10.72,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1673.536,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,375,
EVOLUTION STENT UNCOVERED,50771381,CDM,278,RC,C1876,HCPCS,Outpatient,,,2974.66,1784.80,,4703.88,110,,3763.104,Percent of Total Billed Charges,110% of Total Billed Charges,1338.6,45,,1070.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,832.9,28,,666.32,Percent of Total Billed Charges,28% of Total Billed Charges,110.55,32,,2536.784,Percent of Total Billed Charges,32% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% Total Bille Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,1636.06,55,,23.136,Percent of Total Billed Charges,55% Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2974.66,100,,2379.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,428.95,14.42,,4.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2379.73,80,,1098,Percent of Total Billed Charges,80% of Total Billed Charges,1487.33,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,1487.33,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1487.33,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,1487.33,50,,1.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2082.26,70,,6.784,Percent of Total Billed Charges,70% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2974.66,100,,1464,Percent of Total Billed Charges,100% of Total Billed Charges,110.55,4703.88,
COLON ENDO MUCOSAL RESECTION,50771382,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,110.84,32,,2.304,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,10.84,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,0.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1457.72,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,4.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,0.088,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1943.624,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
EGD ENDO MUCOSAL RESECTION,50771383,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,111.27,32,,2.312,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,3.416,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,2662.056,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,10.752,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,3549.408,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
ESOPHAG ENDO MUCOSAL RESECTION,50771385,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,111.63,32,,2.32,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,10.184,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1710,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,11.584,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,2280,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
FLEX SIG ENDO MUCOSAL RESECTN,50771386,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,111.95,32,,2.328,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,61.024,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,0.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1224.376,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,107.936,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1632.504,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,689.77,
ENTEROSCOPY ENDO MUCO RESEC,50771387,CDM,750,RC,,,Outpatient,,,689.77,413.86,,413.86,60,,331.088,Percent of Total Billed Charges,60% of Total Billed Charges,310.4,45,,248.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.14,28,,154.512,Percent of Total Billed Charges,28% of Total Billed Charges,11200,32,,2.352,Percent of Total Billed Charges,32% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% Total Bille Charges,248.32,36,,198.656,Percent of Total Billed Charges,36% of Total Billed Charges,413.86,60,,20.016,Percent of Total Billed Charges,60% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.77,100,,551.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,99.46,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517.33,75,,1102.84,Percent of Total Billed Charges,75% of Total Billed Charges,344.89,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.89,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,344.89,50,,32.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,482.84,70,,23.528,Percent of Total Billed Charges,70% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,96.57,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.77,100,,1470.448,Percent of Total Billed Charges,100% of Total Billed Charges,96.57,11200,
ENDO HEMOSTAT HEMO SPRAY,50771388,CDM,272,RC,,,Outpatient,,,3809,2285.40,,2285.4,60,,1828.32,Percent of Total Billed Charges,60% of Total Billed Charges,1714.05,45,,1371.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1066.52,28,,853.216,Percent of Total Billed Charges,28% of Total Billed Charges,11.2,32,,2.352,Percent of Total Billed Charges,32% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,1371.24,36,,1096.992,Percent of Total Billed Charges,36% of Total Billed Charges,1371.24,36,,1096.992,Percent of Total Billed Charges,36% Total Bille Charges,1371.24,36,,1096.992,Percent of Total Billed Charges,36% of Total Billed Charges,2285.4,60,,20.128,Percent of Total Billed Charges,60% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3809,100,,3047.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,549.26,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2856.75,75,,190.504,Percent of Total Billed Charges,75% of Total Billed Charges,1904.5,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,1904.5,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1904.5,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,1904.5,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2666.3,70,,18.752,Percent of Total Billed Charges,70% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,533.26,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3809,100,,254,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,3809,
CRE 8-10MM 8CM F/G,50771390,CDM,278,RC,C1726,HCPCS,Outpatient,,,730.95,438.57,,1200.85,110,,960.68,Percent of Total Billed Charges,110% of Total Billed Charges,328.93,45,,263.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.67,28,,163.736,Percent of Total Billed Charges,28% of Total Billed Charges,11.22,32,,2.36,Percent of Total Billed Charges,32% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% Total Bille Charges,263.14,36,,210.512,Percent of Total Billed Charges,36% of Total Billed Charges,402.02,55,,5.64,Percent of Total Billed Charges,55% Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.95,100,,584.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,105.4,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,584.76,80,,1230.928,Percent of Total Billed Charges,80% of Total Billed Charges,365.48,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,365.48,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,365.48,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,365.48,50,,1.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,511.67,70,,4.08,Percent of Total Billed Charges,70% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,102.33,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,730.95,100,,1641.232,Percent of Total Billed Charges,100% of Total Billed Charges,11.22,1200.85,
CRE PRO WG 8-10MM,50771391,CDM,278,RC,C1726,HCPCS,Outpatient,,,921,552.60,,1409.9,110,,1127.92,Percent of Total Billed Charges,110% of Total Billed Charges,414.45,45,,331.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.88,28,,206.304,Percent of Total Billed Charges,28% of Total Billed Charges,11.26,32,,2.36,Percent of Total Billed Charges,32% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% Total Bille Charges,331.56,36,,265.248,Percent of Total Billed Charges,36% of Total Billed Charges,506.55,55,,1.44,Percent of Total Billed Charges,55% Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921,100,,736.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,132.81,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736.8,80,,1810.136,Percent of Total Billed Charges,80% of Total Billed Charges,460.5,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.5,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,460.5,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,644.7,70,,19.968,Percent of Total Billed Charges,70% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,128.94,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,921,100,,2413.512,Percent of Total Billed Charges,100% of Total Billed Charges,11.26,1409.9,
JAG HINI 025.260 ST BX2,50771392,CDM,272,RC,C1769,HCPCS,Outpatient,,,625.38,375.23,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,281.42,45,,225.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.11,28,,140.088,Percent of Total Billed Charges,28% of Total Billed Charges,11.35,32,,2.368,Percent of Total Billed Charges,32% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,225.14,36,,180.112,Percent of Total Billed Charges,36% of Total Billed Charges,225.14,36,,180.112,Percent of Total Billed Charges,36% Total Bille Charges,225.14,36,,180.112,Percent of Total Billed Charges,36% of Total Billed Charges,375.23,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.38,100,,500.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,90.18,14.42,,7.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,469.04,75,,2109.968,Percent of Total Billed Charges,75% of Total Billed Charges,312.69,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,312.69,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.69,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,312.69,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.77,70,,24.88,Percent of Total Billed Charges,70% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,87.55,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,625.38,100,,2813.288,Percent of Total Billed Charges,100% of Total Billed Charges,11.35,625.38,
DREAMTOME 44-20MM,50771393,CDM,272,RC,C1769,HCPCS,Outpatient,,,1554.93,932.96,,55.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,699.72,45,,559.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,435.38,28,,348.304,Percent of Total Billed Charges,28% of Total Billed Charges,11.35,32,,2.368,Percent of Total Billed Charges,32% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,559.77,36,,447.816,Percent of Total Billed Charges,36% of Total Billed Charges,559.77,36,,447.816,Percent of Total Billed Charges,36% Total Bille Charges,559.77,36,,447.816,Percent of Total Billed Charges,36% of Total Billed Charges,932.96,60,,4.168,Percent of Total Billed Charges,60% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1554.93,100,,1243.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,224.22,14.42,,0.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1166.2,75,,2513.456,Percent of Total Billed Charges,75% of Total Billed Charges,777.47,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,777.47,50,,3.504,Percent of Total Billed Charges,50% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,777.47,50,,3.504,Percent of Total Billed Charges,50% of Total Billed Charges,777.47,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1088.45,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1554.93,100,,3351.272,Percent of Total Billed Charges,100% of Total Billed Charges,11.35,1554.93,
WALLFLEX ENTERAL COLONIC,50771394,CDM,278,RC,C1876,HCPCS,Outpatient,,,2974.66,1784.80,,4703.88,110,,3763.104,Percent of Total Billed Charges,110% of Total Billed Charges,1338.6,45,,1070.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,832.9,28,,666.32,Percent of Total Billed Charges,28% of Total Billed Charges,11.36,32,,2.376,Percent of Total Billed Charges,32% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% Total Bille Charges,1070.88,36,,856.704,Percent of Total Billed Charges,36% of Total Billed Charges,1636.06,55,,1.44,Percent of Total Billed Charges,55% Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2974.66,100,,2379.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,428.95,14.42,,3.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2379.73,80,,2513.456,Percent of Total Billed Charges,80% of Total Billed Charges,1487.33,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,1487.33,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1487.33,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1487.33,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2082.26,70,,4633.104,Percent of Total Billed Charges,70% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,416.45,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2974.66,100,,3351.272,Percent of Total Billed Charges,100% of Total Billed Charges,11.36,4703.88,
CYTOLOGY BRUSH WIREGUIDE,50771395,CDM,272,RC,,,Outpatient,,,392.89,235.73,,235.73,60,,188.584,Percent of Total Billed Charges,60% of Total Billed Charges,176.8,45,,141.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.01,28,,88.008,Percent of Total Billed Charges,28% of Total Billed Charges,11.41,32,,2.384,Percent of Total Billed Charges,32% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,141.44,36,,113.152,Percent of Total Billed Charges,36% of Total Billed Charges,141.44,36,,113.152,Percent of Total Billed Charges,36% Total Bille Charges,141.44,36,,113.152,Percent of Total Billed Charges,36% of Total Billed Charges,235.73,60,,3.776,Percent of Total Billed Charges,60% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.89,100,,314.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,56.65,14.42,,5.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.67,75,,403.488,Percent of Total Billed Charges,75% of Total Billed Charges,196.45,50,,3.504,Percent of Total Billed Charges,50% of Total Billed Charges,196.45,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.45,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,196.45,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.02,70,,116.872,Percent of Total Billed Charges,70% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,55,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,392.89,100,,537.984,Percent of Total Billed Charges,100% of Total Billed Charges,11.41,392.89,
SPEEDBAND SUPERVIEW SUPER,50771396,CDM,272,RC,,,Outpatient,,,683.82,410.29,,410.29,60,,328.232,Percent of Total Billed Charges,60% of Total Billed Charges,307.72,45,,246.176,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.47,28,,153.176,Percent of Total Billed Charges,28% of Total Billed Charges,11.41,32,,2.384,Percent of Total Billed Charges,32% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,246.18,36,,196.944,Percent of Total Billed Charges,36% of Total Billed Charges,246.18,36,,196.944,Percent of Total Billed Charges,36% Total Bille Charges,246.18,36,,196.944,Percent of Total Billed Charges,36% of Total Billed Charges,410.29,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,683.82,100,,547.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.61,14.42,,1.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,512.87,75,,840.736,Percent of Total Billed Charges,75% of Total Billed Charges,341.91,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,341.91,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.91,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,341.91,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,478.67,70,,258.176,Percent of Total Billed Charges,70% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,95.73,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,683.82,100,,1120.984,Percent of Total Billed Charges,100% of Total Billed Charges,11.41,683.82,
RESOLUTION 360 CLIP,50771397,CDM,272,RC,,,Outpatient,,,681.77,409.06,,409.06,60,,327.248,Percent of Total Billed Charges,60% of Total Billed Charges,306.8,45,,245.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.9,28,,152.72,Percent of Total Billed Charges,28% of Total Billed Charges,112,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,245.44,36,,196.352,Percent of Total Billed Charges,36% of Total Billed Charges,245.44,36,,196.352,Percent of Total Billed Charges,36% Total Bille Charges,245.44,36,,196.352,Percent of Total Billed Charges,36% of Total Billed Charges,409.06,60,,3.912,Percent of Total Billed Charges,60% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,681.77,100,,545.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,98.31,14.42,,5.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.33,75,,695.64,Percent of Total Billed Charges,75% of Total Billed Charges,340.89,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,340.89,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.89,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,340.89,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.24,70,,90.112,Percent of Total Billed Charges,70% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,95.45,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,681.77,100,,927.52,Percent of Total Billed Charges,100% of Total Billed Charges,95.45,681.77,
CELLEBRITY CYTOL BRSH,50771398,CDM,272,RC,,,Outpatient,,,69.21,41.53,,41.53,60,,33.224,Percent of Total Billed Charges,60% of Total Billed Charges,31.14,45,,24.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,112,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,41.53,60,,27.912,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.21,100,,55.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,14.42,,30.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.91,75,,521.952,Percent of Total Billed Charges,75% of Total Billed Charges,34.61,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,1.904,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.61,50,,1.904,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.45,70,,37.52,Percent of Total Billed Charges,70% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.21,100,,695.936,Percent of Total Billed Charges,100% of Total Billed Charges,9.69,112,
S NM AERSOL VENT KIT,51900010,CDM,272,RC,,,Outpatient,,,117,70.20,,70.2,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,52.65,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.76,28,,26.208,Percent of Total Billed Charges,28% of Total Billed Charges,112.14,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,42.12,36,,33.696,Percent of Total Billed Charges,36% of Total Billed Charges,42.12,36,,33.696,Percent of Total Billed Charges,36% Total Bille Charges,42.12,36,,33.696,Percent of Total Billed Charges,36% of Total Billed Charges,70.2,60,,68.704,Percent of Total Billed Charges,60% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,100,,93.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.87,14.42,,2.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.75,75,,974.272,Percent of Total Billed Charges,75% of Total Billed Charges,58.5,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.5,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.9,70,,7.624,Percent of Total Billed Charges,70% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117,100,,1299.032,Percent of Total Billed Charges,100% of Total Billed Charges,16.38,117,
NM RPH GA67 PER MCI,51914000,CDM,343,RC,A9556,HCPCS,Outpatient,,,210.66,126.40,,115.36,100,,,Case Rate,Pays based on per visit rate,94.8,45,,75.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,119.69,320,,2.44,Fee Schedule,320% of BCBS Blue Essentials Rate,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,119.69,360,,,Fee Schedule,360% of BCBS POS Rate,119.69,360,,,Fee schedule,360% of BCBS PPO Rate,119.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,126.4,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.66,100,,168.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,30.38,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158,75,,987.304,Percent of Total Billed Charges,75% of Total Billed Charges,105.33,50,,1.904,Percent of Total Billed Charges,50% of Total Billed Charges,105.33,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.33,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,105.33,50,,0.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.46,70,,22.68,Percent of Total Billed Charges,70% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.49,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.66,100,,1316.4,Percent of Total Billed Charges,100% of Total Billed Charges,29.49,210.66,
NM RPH TC99M DTPA AEROSOL,51914001,CDM,343,RC,A9567,HCPCS,Outpatient,,,459.43,275.66,,16.46,100,,,Case Rate,Pays based on per visit rate,206.74,45,,165.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.64,28,,102.912,Percent of Total Billed Charges,28% of Total Billed Charges,112.14,32,,2.448,Percent of Total Billed Charges,32% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,165.39,36,,132.312,Percent of Total Billed Charges,36% of Total Billed Charges,165.39,36,,132.312,Percent of Total Billed Charges,36% Total Bille Charges,165.39,36,,132.312,Percent of Total Billed Charges,36% of Total Billed Charges,275.66,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,459.43,100,,367.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14.42,,26.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.57,75,,1210.832,Percent of Total Billed Charges,75% of Total Billed Charges,229.72,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,229.72,50,,7.568,Percent of Total Billed Charges,50% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.72,50,,7.568,Percent of Total Billed Charges,50% of Total Billed Charges,229.72,50,,4.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.6,70,,0.352,Percent of Total Billed Charges,70% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,64.32,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459.43,100,,1614.44,Percent of Total Billed Charges,100% of Total Billed Charges,16.46,459.43,
NM RPH IN111 DTPA,51917243,CDM,343,RC,A9548,HCPCS,Outpatient,,,3054.01,1832.41,,396.66,100,,,Case Rate,Pays based on per visit rate,1374.3,45,,1099.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,411.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,411.54,320,,2.48,Fee Schedule,320% of BCBS Blue Essentials Rate,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,411.54,360,,,Fee Schedule,360% of BCBS POS Rate,411.54,360,,,Fee schedule,360% of BCBS PPO Rate,411.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,1832.41,60,,10.52,Percent of Total Billed Charges,60% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3054.01,100,,2443.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,440.39,14.42,,1.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2290.51,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,1527.01,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,1527.01,50,,2.416,Percent of Total Billed Charges,50% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1527.01,50,,2.416,Percent of Total Billed Charges,50% of Total Billed Charges,1527.01,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2137.81,70,,23.992,Percent of Total Billed Charges,70% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,427.56,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3054.01,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,396.66,3054.01,
NM RPH PROSTASCINT,51917250,CDM,343,RC,A9507,HCPCS,Outpatient,,,9445.39,5667.23,,4220.17,100,,,Case Rate,Pays based on per visit rate,4250.43,45,,3400.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4378.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4378.42,320,,2.48,Fee Schedule,320% of BCBS Blue Essentials Rate,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,4378.42,360,,,Fee Schedule,360% of BCBS POS Rate,4378.42,360,,,Fee schedule,360% of BCBS PPO Rate,4378.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,5667.23,60,,8.344,Percent of Total Billed Charges,60% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9445.39,100,,7556.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1362.03,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7084.04,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,4722.7,50,,7.568,Percent of Total Billed Charges,50% of Total Billed Charges,4722.7,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4722.7,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,4722.7,50,,0.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6611.77,70,,23.4,Percent of Total Billed Charges,70% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1322.35,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9445.39,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,1322.35,9445.39,
NM RPH IN111 WBC,51917292,CDM,343,RC,A9547,HCPCS,Outpatient,,,3239.2,1943.52,,1716.6,100,,,Case Rate,Pays based on per visit rate,1457.64,45,,1166.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1780.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1780.97,320,,2.488,Fee Schedule,320% of BCBS Blue Essentials Rate,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1780.97,360,,,Fee Schedule,360% of BCBS POS Rate,1780.97,360,,,Fee schedule,360% of BCBS PPO Rate,1780.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,1943.52,60,,8.344,Percent of Total Billed Charges,60% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3239.2,100,,2591.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,467.09,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2429.4,75,,1355.096,Percent of Total Billed Charges,75% of Total Billed Charges,1619.6,50,,2.416,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,20.816,Percent of Total Billed Charges,50% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1619.6,50,,20.816,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,0.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2267.44,70,,46.264,Percent of Total Billed Charges,70% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3239.2,100,,1806.792,Percent of Total Billed Charges,100% of Total Billed Charges,453.49,3239.2,
NM RPH TC99M MDP,51940104,CDM,343,RC,A9503,HCPCS,Outpatient,,,182.28,109.37,,12.48,100,,,Case Rate,Pays based on per visit rate,82.03,45,,65.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.95,320,,2.496,Fee Schedule,320% of BCBS Blue Essentials Rate,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,12.95,360,,,Fee Schedule,360% of BCBS POS Rate,12.95,360,,,Fee schedule,360% of BCBS PPO Rate,12.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.37,60,,4.072,Percent of Total Billed Charges,60% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.28,100,,145.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.28,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.71,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,91.14,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,91.14,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.14,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,91.14,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.6,70,,14.672,Percent of Total Billed Charges,70% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.52,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.28,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,12.48,182.28,
NM RPH TC99M CERETEC BRAIN,51940260,CDM,343,RC,A9521,HCPCS,Outpatient,,,1545.55,927.33,,1467.62,100,,,Case Rate,Pays based on per visit rate,695.5,45,,556.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1450.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1450.14,320,,2.504,Fee Schedule,320% of BCBS Blue Essentials Rate,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1450.14,360,,,Fee Schedule,360% of BCBS POS Rate,1450.14,360,,,Fee schedule,360% of BCBS PPO Rate,1450.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,927.33,60,,8.648,Percent of Total Billed Charges,60% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1545.55,100,,1236.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,222.87,14.42,,1.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1159.16,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,772.78,50,,20.816,Percent of Total Billed Charges,50% of Total Billed Charges,772.78,50,,0.712,Percent of Total Billed Charges,50% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,772.78,50,,0.712,Percent of Total Billed Charges,50% of Total Billed Charges,772.78,50,,3.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1081.89,70,,4.736,Percent of Total Billed Charges,70% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,216.38,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1545.55,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,216.38,1545.55,
NM RPH TC99M SESTAMIBI,51941706,CDM,343,RC,A9500,HCPCS,Outpatient,,,183,109.80,,102.48,100,,,Case Rate,Pays based on per visit rate,82.35,45,,65.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,136.13,320,,2.512,Fee Schedule,320% of BCBS Blue Essentials Rate,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,136.13,360,,,Fee Schedule,360% of BCBS POS Rate,136.13,360,,,Fee schedule,360% of BCBS PPO Rate,136.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.8,60,,5.312,Percent of Total Billed Charges,60% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,100,,146.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,26.39,14.42,,36.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.25,75,,1355.096,Percent of Total Billed Charges,75% of Total Billed Charges,91.5,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,91.5,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.5,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,91.5,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.1,70,,1344,Percent of Total Billed Charges,70% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183,100,,1806.792,Percent of Total Billed Charges,100% of Total Billed Charges,25.62,183,
NM RPH TC99M TETROFOSMIN,51941904,CDM,343,RC,A9502,HCPCS,Outpatient,,,178.5,107.10,,93.56,100,,,Case Rate,Pays based on per visit rate,80.33,45,,64.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,97.07,320,,2.528,Fee Schedule,320% of BCBS Blue Essentials Rate,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,97.07,360,,,Fee Schedule,360% of BCBS POS Rate,97.07,360,,,Fee schedule,360% of BCBS PPO Rate,97.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.1,60,,3.352,Percent of Total Billed Charges,60% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.5,100,,142.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14.42,,4.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.88,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,89.25,50,,0.712,Percent of Total Billed Charges,50% of Total Billed Charges,89.25,50,,1.896,Percent of Total Billed Charges,50% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.25,50,,1.896,Percent of Total Billed Charges,50% of Total Billed Charges,89.25,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.95,70,,2.792,Percent of Total Billed Charges,70% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.99,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,178.5,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,24.99,178.5,
NM RPH TL201 PER MCI,51948008,CDM,343,RC,A9505,HCPCS,Outpatient,,,72,43.20,,146.31,100,,,Case Rate,Pays based on per visit rate,32.4,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,151.8,320,,23.04,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,151.8,360,,,Fee Schedule,360% of BCBS POS Rate,151.8,360,,,Fee schedule,360% of BCBS PPO Rate,151.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.2,60,,29,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,100,,57.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,36,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,70,,39.76,Percent of Total Billed Charges,70% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,10.08,151.8,
NM RPH TC99M PER MCI,51995124,CDM,343,RC,A9512,HCPCS,Outpatient,,,3.9,2.34,,1.54,100,,,Case Rate,Pays based on per visit rate,1.76,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.93,320,,23.04,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.93,360,,,Fee Schedule,360% of BCBS POS Rate,3.93,360,,,Fee schedule,360% of BCBS PPO Rate,3.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,67.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,3.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,1355.096,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,1.896,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,0.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,0.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,5.488,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,1806.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,3.93,
NM RPH I123 PER 100UCI,51995165,CDM,343,RC,A9516,HCPCS,Outpatient,,,246.06,147.64,,85.46,100,,,Case Rate,Pays based on per visit rate,110.73,45,,88.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,180.13,320,,23.04,Fee Schedule,320% of BCBS Blue Essentials Rate,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,180.13,360,,,Fee Schedule,360% of BCBS POS Rate,180.13,360,,,Fee schedule,360% of BCBS PPO Rate,180.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.64,60,,81.56,Percent of Total Billed Charges,60% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.06,100,,196.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,35.48,14.42,,1.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.55,75,,2240.696,Percent of Total Billed Charges,75% of Total Billed Charges,123.03,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,123.03,50,,12.352,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.03,50,,12.352,Percent of Total Billed Charges,50% of Total Billed Charges,123.03,50,,1.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.24,70,,9.32,Percent of Total Billed Charges,70% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.06,100,,2987.592,Percent of Total Billed Charges,100% of Total Billed Charges,34.45,246.06,
NM RPH TC99M MEBROFENIN,51995371,CDM,343,RC,A9537,HCPCS,Outpatient,,,210,126.00,,53.1,100,,,Case Rate,Pays based on per visit rate,94.5,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.1,320,,23.12,Fee Schedule,320% of BCBS Blue Essentials Rate,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,55.1,360,,,Fee Schedule,360% of BCBS POS Rate,55.1,360,,,Fee schedule,360% of BCBS PPO Rate,55.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,126,60,,7.76,Percent of Total Billed Charges,60% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,100,,168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,30.28,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.5,75,,2240.696,Percent of Total Billed Charges,75% of Total Billed Charges,105,50,,0.408,Percent of Total Billed Charges,50% of Total Billed Charges,105,50,,9.336,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,50,,9.336,Percent of Total Billed Charges,50% of Total Billed Charges,105,50,,1.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147,70,,11.872,Percent of Total Billed Charges,70% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,29.4,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,100,,2987.592,Percent of Total Billed Charges,100% of Total Billed Charges,29.4,210,
NM RPH TC99M DTPA,51995397,CDM,343,RC,A9539,HCPCS,Outpatient,,,426.4,255.84,,30.08,100,,,Case Rate,Pays based on per visit rate,191.88,45,,153.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.21,320,,23.12,Fee Schedule,320% of BCBS Blue Essentials Rate,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.21,360,,,Fee Schedule,360% of BCBS POS Rate,31.21,360,,,Fee schedule,360% of BCBS PPO Rate,31.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,255.84,60,,5.672,Percent of Total Billed Charges,60% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,426.4,100,,341.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,61.49,14.42,,113.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.8,75,,99.232,Percent of Total Billed Charges,75% of Total Billed Charges,213.2,50,,12.352,Percent of Total Billed Charges,50% of Total Billed Charges,213.2,50,,5.584,Percent of Total Billed Charges,50% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.2,50,,5.584,Percent of Total Billed Charges,50% of Total Billed Charges,213.2,50,,0.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.48,70,,267.016,Percent of Total Billed Charges,70% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.7,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,426.4,100,,132.304,Percent of Total Billed Charges,100% of Total Billed Charges,30.08,426.4,
NM RPH TC99M MAA,51995405,CDM,343,RC,A9540,HCPCS,Outpatient,,,542.5,325.50,,28.8,100,,,Case Rate,Pays based on per visit rate,244.13,45,,195.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.88,320,,23.288,Fee Schedule,320% of BCBS Blue Essentials Rate,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.88,360,,,Fee Schedule,360% of BCBS POS Rate,29.88,360,,,Fee schedule,360% of BCBS PPO Rate,29.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,325.5,60,,4.424,Percent of Total Billed Charges,60% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.5,100,,434,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,78.23,14.42,,26.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.88,75,,99.232,Percent of Total Billed Charges,75% of Total Billed Charges,271.25,50,,9.336,Percent of Total Billed Charges,50% of Total Billed Charges,271.25,50,,1.272,Percent of Total Billed Charges,50% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.25,50,,1.272,Percent of Total Billed Charges,50% of Total Billed Charges,271.25,50,,7.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.75,70,,147.84,Percent of Total Billed Charges,70% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,75.95,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,542.5,100,,132.304,Percent of Total Billed Charges,100% of Total Billed Charges,28.8,542.5,
NM RPH TC99M SULFUR COLLOID,51995413,CDM,343,RC,A9541,HCPCS,Outpatient,,,317.5,190.50,,256.67,100,,,Case Rate,Pays based on per visit rate,142.88,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.26,320,,230.4,Fee Schedule,320% of BCBS Blue Essentials Rate,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,53.26,360,,,Fee Schedule,360% of BCBS POS Rate,53.26,360,,,Fee schedule,360% of BCBS PPO Rate,53.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,190.5,60,,1.776,Percent of Total Billed Charges,60% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.5,100,,254,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,45.78,14.42,,19.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.13,75,,2585.952,Percent of Total Billed Charges,75% of Total Billed Charges,158.75,50,,5.584,Percent of Total Billed Charges,50% of Total Billed Charges,158.75,50,,1.704,Percent of Total Billed Charges,50% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.75,50,,1.704,Percent of Total Billed Charges,50% of Total Billed Charges,158.75,50,,2.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.25,70,,7728,Percent of Total Billed Charges,70% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.5,100,,3447.936,Percent of Total Billed Charges,100% of Total Billed Charges,44.45,317.5,
NM RPH TC99M ULTRATAG RBC,51995603,CDM,343,RC,A9560,HCPCS,Outpatient,,,625,375.00,,89.66,100,,,Case Rate,Pays based on per visit rate,281.25,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.03,320,,230.512,Fee Schedule,320% of BCBS Blue Essentials Rate,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,93.03,360,,,Fee Schedule,360% of BCBS POS Rate,93.03,360,,,Fee schedule,360% of BCBS PPO Rate,93.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,4.864,Percent of Total Billed Charges,60% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625,100,,500,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,90.13,14.42,,14.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468.75,75,,2585.952,Percent of Total Billed Charges,75% of Total Billed Charges,312.5,50,,1.272,Percent of Total Billed Charges,50% of Total Billed Charges,312.5,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.5,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,312.5,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.5,70,,170.8,Percent of Total Billed Charges,70% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,87.5,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,625,100,,3447.936,Percent of Total Billed Charges,100% of Total Billed Charges,87.5,625,
NM RPH TC99M HDP,51995611,CDM,343,RC,A9561,HCPCS,Outpatient,,,138.3,82.98,,42.24,100,,,Case Rate,Pays based on per visit rate,62.24,45,,49.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.82,320,,230.88,Fee Schedule,320% of BCBS Blue Essentials Rate,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,360,,,Fee Schedule,360% of BCBS POS Rate,43.82,360,,,Fee schedule,360% of BCBS PPO Rate,43.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.98,60,,13.736,Percent of Total Billed Charges,60% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.3,100,,110.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.94,14.42,,3.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.73,75,,2617.048,Percent of Total Billed Charges,75% of Total Billed Charges,69.15,50,,1.704,Percent of Total Billed Charges,50% of Total Billed Charges,69.15,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.15,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,69.15,50,,20.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.81,70,,13.44,Percent of Total Billed Charges,70% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.3,100,,3489.392,Percent of Total Billed Charges,100% of Total Billed Charges,19.36,138.3,
NM RPH TC99M MAG3,51995629,CDM,343,RC,A9562,HCPCS,Outpatient,,,985,591.00,,585.41,100,,,Case Rate,Pays based on per visit rate,443.25,45,,354.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,771.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,771.68,320,,231.352,Fee Schedule,320% of BCBS Blue Essentials Rate,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,771.68,360,,,Fee Schedule,360% of BCBS POS Rate,771.68,360,,,Fee schedule,360% of BCBS PPO Rate,771.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,591,60,,38.56,Percent of Total Billed Charges,60% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,985,100,,788,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,142.04,14.42,,10.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738.75,75,,2617.048,Percent of Total Billed Charges,75% of Total Billed Charges,492.5,50,,0.416,Percent of Total Billed Charges,50% of Total Billed Charges,492.5,50,,2.24,Percent of Total Billed Charges,50% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,492.5,50,,2.24,Percent of Total Billed Charges,50% of Total Billed Charges,492.5,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,689.5,70,,34.52,Percent of Total Billed Charges,70% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,137.9,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,985,100,,3489.392,Percent of Total Billed Charges,100% of Total Billed Charges,137.9,985,
NM RPH OCTREOTIDE,51995652,CDM,343,RC,A9572,HCPCS,Outpatient,,,12775,7665.00,,5448.96,100,,,Case Rate,Pays based on per visit rate,5748.75,45,,4599,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5653.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5653.3,320,,231.424,Fee Schedule,320% of BCBS Blue Essentials Rate,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,5653.3,360,,,Fee Schedule,360% of BCBS POS Rate,5653.3,360,,,Fee schedule,360% of BCBS PPO Rate,5653.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,7665,60,,80.64,Percent of Total Billed Charges,60% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12775,100,,10220,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1842.16,14.42,,157.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9581.25,75,,1972.92,Percent of Total Billed Charges,75% of Total Billed Charges,6387.5,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,6387.5,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6387.5,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,6387.5,50,,0.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8942.5,70,,46.416,Percent of Total Billed Charges,70% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,1788.5,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12775,100,,2630.56,Percent of Total Billed Charges,100% of Total Billed Charges,1788.5,12775,
NM RPH I131 CAP DX PER MCI,51996031,CDM,343,RC,A9528,HCPCS,Outpatient,,,84,50.40,,76.31,100,,,Case Rate,Pays based on per visit rate,37.8,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.79,320,,232.128,Fee Schedule,320% of BCBS Blue Essentials Rate,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,46.79,360,,,Fee Schedule,360% of BCBS POS Rate,46.79,360,,,Fee schedule,360% of BCBS PPO Rate,46.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.4,60,,2.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,67.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,12.11,14.42,,40.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63,75,,1972.92,Percent of Total Billed Charges,75% of Total Billed Charges,42,50,,2.24,Percent of Total Billed Charges,50% of Total Billed Charges,42,50,,29.536,Percent of Total Billed Charges,50% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,50,,29.536,Percent of Total Billed Charges,50% of Total Billed Charges,42,50,,0.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,70,,24.304,Percent of Total Billed Charges,70% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,100,,2630.56,Percent of Total Billed Charges,100% of Total Billed Charges,11.76,84,
NM RPH I131CAPTHER 6 TO 300MCI,51996032,CDM,344,RC,A9517,HCPCS,Outpatient,,,72,43.20,,41.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.69,320,,23.424,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,360,,,Fee Schedule,360% of BCBS POS Rate,20.69,360,,,Fee schedule,360% of BCBS PPO Rate,20.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.2,60,,0.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,19.2,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,27.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,14.42,,0.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,21.98,103,,,Fee Schedule,103% of CMS OPPS Rate,21.98,103,,,Fee Schedule,103% of CMS OPPS Rate,54,75,,2557.264,Percent of Total Billed Charges,75% of Total Billed Charges,36,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,36,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,1.896,Percent of Total Billed Charges,50% of Total Billed Charges,32.01,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,70,,52.664,Percent of Total Billed Charges,70% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,72,100,,3409.68,Percent of Total Billed Charges,100% of Total Billed Charges,10.08,72,
NM RPH I131 CAP THER PER MCI,51996033,CDM,344,RC,A9517,HCPCS,Outpatient,,,72,43.20,,41.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.69,320,,23.552,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,360,,,Fee Schedule,360% of BCBS POS Rate,20.69,360,,,Fee schedule,360% of BCBS PPO Rate,20.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.2,60,,2.432,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,19.2,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,27.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,14.42,,28.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,21.98,103,,,Fee Schedule,103% of CMS OPPS Rate,21.98,103,,,Fee Schedule,103% of CMS OPPS Rate,54,75,,2557.264,Percent of Total Billed Charges,75% of Total Billed Charges,36,50,,29.536,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,36,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,32.01,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,70,,250.704,Percent of Total Billed Charges,70% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.34,100,,,Fee Schedule,100% of CMS OPPS Rate,72,100,,3409.68,Percent of Total Billed Charges,100% of Total Billed Charges,10.08,72,
NM RPH IN111 AUTOLO WBC,51996034,CDM,343,RC,A9570,HCPCS,Outpatient,,,3239.2,1943.52,,3433.2,100,,,Case Rate,Pays based on per visit rate,1457.64,45,,1166.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3561.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3561.95,320,,233.952,Fee Schedule,320% of BCBS Blue Essentials Rate,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,3561.95,360,,,Fee Schedule,360% of BCBS POS Rate,3561.95,360,,,Fee schedule,360% of BCBS PPO Rate,3561.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1943.52,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3239.2,100,,2591.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,467.09,14.42,,1.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2429.4,75,,1483.744,Percent of Total Billed Charges,75% of Total Billed Charges,1619.6,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1619.6,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,0.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2267.44,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3239.2,100,,1978.32,Percent of Total Billed Charges,100% of Total Billed Charges,453.49,3561.95,
MR THORACOLUMBAR W CM,52000290,CDM,610,RC,76498,HCPCS,Outpatient,,,2800,1680.00,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.232,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.44,Case Rate,Pays based on per visit rate,80.9,100,,1.296,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,1.336,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2100,75,,1483.744,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.952,Case Rate,Pays Based on per visit rate,1557,100,,4.456,Case Rate,Pays based on per visit rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.456,Case Rate,Pays based on per visit rate,1557,100,,12.352,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.296,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2800,100,,1978.32,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2800,
MR THORACOLUMBAR W CM,52000290,CDM,610,RC,76498,HCPCS,Outpatient,,,2800,1680.00,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.376,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,144,Case Rate,Pays based on per visit rate,80.9,100,,3.048,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,3.136,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2100,75,,2948.4,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.288,Case Rate,Pays Based on per visit rate,1557,100,,0.752,Case Rate,Pays based on per visit rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.752,Case Rate,Pays based on per visit rate,1557,100,,9.336,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,179.76,Case Rate,Pays based on per visit rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,3.048,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2800,100,,3931.2,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2800,
MR THORACOLUMBAR WO CM,52000291,CDM,610,RC,76498,HCPCS,Outpatient,,,2500,1500.00,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.744,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,25.784,Case Rate,Pays based on per visit rate,80.9,100,,1.792,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,1.848,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1875,75,,2233.936,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.456,Case Rate,Pays Based on per visit rate,1557,100,,5.928,Case Rate,Pays based on per visit rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.928,Case Rate,Pays based on per visit rate,1557,100,,5.584,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.368,Case Rate,Pays based on per visit rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2500,100,,2978.576,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2790,
MR THORACOLUMBAR WO CM,52000291,CDM,610,RC,76498,HCPCS,Outpatient,,,2500,1500.00,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.776,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,87.088,Case Rate,Pays based on per visit rate,80.9,100,,2.688,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,2.768,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1875,75,,2233.936,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.752,Case Rate,Pays Based on per visit rate,1557,100,,1,Case Rate,Pays based on per visit rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1,Case Rate,Pays based on per visit rate,1557,100,,1.272,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,17.944,Case Rate,Pays based on per visit rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.688,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2500,100,,2978.576,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,2790,
MR THORACOLUMBAR WWO CM,52000292,CDM,610,RC,76498,HCPCS,Outpatient,,,3200,1920.00,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.776,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,406.32,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,2.616,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2400,75,,1565.68,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.928,Case Rate,Pays Based on per visit rate,1557,100,,1.576,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.576,Case Rate,Pays based on per visit rate,1557,100,,1.704,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,137.904,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3200,100,,2087.576,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,3200,
MR THORACOLUMBAR WWO CM,52000292,CDM,610,RC,76498,HCPCS,Outpatient,,,3200,1920.00,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,125.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.52,320,,235.776,Fee Schedule,320% of BCBS Blue Essentials Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,224.46,360,,,Fee Schedule,360% of BCBS POS Rate,224.46,360,,,Fee schedule,360% of BCBS PPO Rate,224.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,204.36,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Mediciad Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,75.03,90,,,Fee Schedule,90% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,108.37,130,,,Fee Schedule,130% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.33,103,,2.616,Fee Schedule,103% of TX Medicaid Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2400,75,,1565.68,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1,Case Rate,Pays Based on per visit rate,1557,100,,2.8,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.8,Case Rate,Pays based on per visit rate,1557,100,,0.416,Case Rate,Pays based on per visit rate,125.05,150,,,Fee Schedule,150% of CMS OPPS Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,6.976,Case Rate,Pays based on per visit rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,80.9,100,,2.536,Fee Schedule,100% of TX Medicaid Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3200,100,,2087.576,Percent of Total Billed Charges,100% of Total Billed Charges,75.03,3200,
MR GUIDE NDL MARK PLCMT INI RT,52000293,CDM,361,RC,19287,HCPCS,Outpatient,,,3350.03,2010.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,112.14,32,,236.608,Percent of Total Billed Charges,32% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,38.856,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,483.07,14.42,,18.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2512.52,75,,1709.72,Percent of Total Billed Charges,75% of Total Billed Charges,1675.02,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.02,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,0.496,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,28,Fee Schedule,100% of ASC Tier Groupings fee schedule,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3350.03,100,,2279.624,Percent of Total Billed Charges,100% of Total Billed Charges,112.14,4682,
MR GUIDE NDL MARK PLCMT INI LT,52000294,CDM,361,RC,19287,HCPCS,Outpatient,,,3350.03,2010.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,112.14,32,,236.888,Percent of Total Billed Charges,32% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,362.888,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,483.07,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2512.52,75,,1709.72,Percent of Total Billed Charges,75% of Total Billed Charges,1675.02,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,1.528,Percent of Total Billed Charges,50% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.02,50,,1.528,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,2.24,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,592.2,Fee Schedule,100% of ASC Tier Groupings fee schedule,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3350.03,100,,2279.624,Percent of Total Billed Charges,100% of Total Billed Charges,112.14,4682,
MR GUIDE NDL MARK PLCMT INI BI,52000295,CDM,361,RC,19287,HCPCS,Outpatient,,,5025.04,3015.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,112.14,32,,237.024,Percent of Total Billed Charges,32% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,30.648,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,724.61,14.42,,0.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,3768.78,75,,2133.672,Percent of Total Billed Charges,75% of Total Billed Charges,2512.52,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,2512.52,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2512.52,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,2512.52,50,,0.368,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,324.8,Fee Schedule,100% of ASC Tier Groupings fee schedule,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5025.04,100,,2844.896,Percent of Total Billed Charges,100% of Total Billed Charges,112.14,5025.04,
NM RPH I123 MIBG,52010001,CDM,343,RC,A9582,HCPCS,Outpatient,,,8866.45,5319.87,,5668.01,100,,,Fee Schedule,100% of Aetna Fee Schedule,3989.9,45,,3191.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5880.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5880.56,320,,237.12,Fee Schedule,320% of BCBS Blue Essentials Rate,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,5880.56,360,,,Fee Schedule,360% of BCBS POS Rate,5880.56,360,,,Fee schedule,360% of BCBS PPO Rate,5880.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,5319.87,60,,27.368,Percent of Total Billed Charges,60% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8866.45,100,,7093.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1278.54,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6649.84,75,,2133.672,Percent of Total Billed Charges,75% of Total Billed Charges,4433.23,50,,1.528,Percent of Total Billed Charges,50% of Total Billed Charges,4433.23,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4433.23,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,4433.23,50,,29.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6206.52,70,,48.656,Percent of Total Billed Charges,70% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,1241.3,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8866.45,100,,2844.896,Percent of Total Billed Charges,100% of Total Billed Charges,1241.3,8866.45,
NM RPH I131 SOL THER PER MCI,52010002,CDM,344,RC,A9530,HCPCS,Outpatient,,,92.7,55.62,,8.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9.66,320,,237.44,Fee Schedule,320% of BCBS Blue Essentials Rate,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,9.66,360,,,Fee Schedule,360% of BCBS POS Rate,9.66,360,,,Fee schedule,360% of BCBS PPO Rate,9.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.62,60,,47.56,Percent of Total Billed Charges,60% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.35,90,,,Fee Schedule,90% of CMS OPPS Rate,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,130,,,Fee Schedule,130% of CMS OPPS Rate,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,13.37,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,21.01,103,,,Fee Schedule,103% of CMS OPPS Rate,21.01,103,,,Fee Schedule,103% of CMS OPPS Rate,69.53,75,,1817.704,Percent of Total Billed Charges,75% of Total Billed Charges,46.35,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,46.35,50,,47.008,Percent of Total Billed Charges,50% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,50,,47.008,Percent of Total Billed Charges,50% of Total Billed Charges,46.35,50,,159.504,Percent of Total Billed Charges,50% of Total Billed Charges,30.6,150,,,Fee Schedule,150% of CMS OPPS Rate,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,64.89,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,100,,2423.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.89,92.7,
NM THYROID UPTAKE MULT,52080017,CDM,341,RC,78012,HCPCS,Outpatient,,,640.9,384.54,,70.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,208.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,238.72,320,,237.44,Fee Schedule,320% of BCBS Blue Essentials Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,268.56,360,,,Fee Schedule,360% of BCBS POS Rate,268.56,360,,,Fee schedule,360% of BCBS PPO Rate,268.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,0.512,Fee Schedule,103% of Cigna fee schedule,80.86,100,,3.744,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,83.29,103,,3.856,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,480.68,75,,1817.704,Percent of Total Billed Charges,75% of Total Billed Charges,320.45,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,320.45,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,320.45,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,320.45,50,,0.952,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,1213.632,Case Rate,Pays based on per visit rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,80.86,100,,3.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,640.9,100,,2423.6,Percent of Total Billed Charges,100% of Total Billed Charges,70.62,1200,
NM THYROID I131 WHOLE BODY,52080181,CDM,341,RC,78018,HCPCS,Outpatient,,,2051.54,1230.92,,267.57,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,793.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.46,320,,23.824,Fee Schedule,320% of BCBS Blue Essentials Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,1019.77,360,,,Fee Schedule,360% of BCBS POS Rate,1019.77,360,,,Fee schedule,360% of BCBS PPO Rate,1019.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,0.952,Fee Schedule,103% of Cigna fee schedule,308.4,100,,0.088,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,317.65,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1538.66,75,,1689.76,Percent of Total Billed Charges,75% of Total Billed Charges,1025.77,50,,47.008,Percent of Total Billed Charges,50% of Total Billed Charges,1025.77,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.77,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,1025.77,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,85.68,Case Rate,Pays based on per visit rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,0.088,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,2051.54,100,,2253.016,Percent of Total Billed Charges,100% of Total Billed Charges,267.57,2051.54,
NM PARATHRYOID SCAN,52080314,CDM,341,RC,78070,HCPCS,Outpatient,,,1460.75,876.45,,251.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,756.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,864.93,320,,23.832,Fee Schedule,320% of BCBS Blue Essentials Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,973.04,360,,,Fee Schedule,360% of BCBS POS Rate,973.04,360,,,Fee schedule,360% of BCBS PPO Rate,973.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,48.96,Fee Schedule,103% of Cigna fee schedule,290.03,100,,0.144,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,298.73,103,,0.152,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1095.56,75,,1689.76,Percent of Total Billed Charges,75% of Total Billed Charges,730.38,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,730.38,50,,15.84,Percent of Total Billed Charges,50% of Total Billed Charges,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,730.38,50,,15.84,Percent of Total Billed Charges,50% of Total Billed Charges,730.38,50,,4.456,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,780.192,Case Rate,Pays based on per visit rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,290.03,100,,0.144,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.75,100,,2253.016,Percent of Total Billed Charges,100% of Total Billed Charges,251.42,1460.75,
NM BONE MARROW WHOLE BODY,52081049,CDM,341,RC,78104,HCPCS,Outpatient,,,611.77,367.06,,206.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,610.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,697.73,320,,23.912,Fee Schedule,320% of BCBS Blue Essentials Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,784.94,360,,,Fee Schedule,360% of BCBS POS Rate,784.94,360,,,Fee schedule,360% of BCBS PPO Rate,784.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,90.424,Fee Schedule,103% of Cigna fee schedule,244.59,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,251.93,103,,0.104,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,458.83,75,,1805.656,Percent of Total Billed Charges,75% of Total Billed Charges,305.89,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,305.89,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,305.89,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,305.89,50,,0.752,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,82.096,Case Rate,Pays based on per visit rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,244.59,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,611.77,100,,2407.544,Percent of Total Billed Charges,100% of Total Billed Charges,206.46,1200,
NM PROSTASCINT TUMOR SNGL DAY,52081070,CDM,341,RC,78802,HCPCS,Outpatient,,,2091.92,1255.15,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,23.928,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,35.944,Fee Schedule,103% of Cigna fee schedule,307.74,100,,0.328,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,0.336,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1568.94,75,,1805.656,Percent of Total Billed Charges,75% of Total Billed Charges,1045.96,50,,15.84,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.96,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,5.928,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,336,Case Rate,Pays based on per visit rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,0.328,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.92,100,,2407.544,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM PROSTASCINT TUMOR MULT DAY,52081071,CDM,341,RC,78804,HCPCS,Outpatient,,,2850,1710.00,,599.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1718.34,320,,24.056,Fee Schedule,320% of BCBS Blue Essentials Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1933.13,360,,,Fee Schedule,360% of BCBS POS Rate,1933.13,360,,,Fee schedule,360% of BCBS PPO Rate,1933.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,43.088,Fee Schedule,103% of Cigna fee schedule,648.89,100,,0.336,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,668.36,103,,0.352,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.5,75,,1900.808,Percent of Total Billed Charges,75% of Total Billed Charges,1425,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1425,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,1,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,520.128,Case Rate,Pays based on per visit rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,0.336,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2850,100,,2534.408,Percent of Total Billed Charges,100% of Total Billed Charges,599.22,3738.61,
NM CERETEC WBC LIMITED,52081940,CDM,341,RC,78800,HCPCS,Outpatient,,,1830,1098.00,,219.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,468.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,535.1,320,,238.272,Fee Schedule,320% of BCBS Blue Essentials Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,601.99,360,,,Fee Schedule,360% of BCBS POS Rate,601.99,360,,,Fee schedule,360% of BCBS PPO Rate,601.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,42.68,Fee Schedule,103% of Cigna fee schedule,251.6,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,259.15,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1372.5,75,,1900.808,Percent of Total Billed Charges,75% of Total Billed Charges,915,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,9.184,Percent of Total Billed Charges,50% of Total Billed Charges,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,915,50,,9.184,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,48.384,Case Rate,Pays based on per visit rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1830,100,,2534.408,Percent of Total Billed Charges,100% of Total Billed Charges,219.78,1830,
NM RPH TC99M CERETEC WBC,52081965,CDM,343,RC,A9569,HCPCS,Outpatient,,,3239.2,1943.52,,1467.62,100,,,Case Rate,Pays based on per visit rate,1457.64,45,,1166.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1450.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1450.14,320,,240.176,Fee Schedule,320% of BCBS Blue Essentials Rate,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,1450.14,360,,,Fee Schedule,360% of BCBS POS Rate,1450.14,360,,,Fee schedule,360% of BCBS PPO Rate,1450.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,1943.52,60,,73.208,Percent of Total Billed Charges,60% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3239.2,100,,2591.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,467.09,14.42,,194.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2429.4,75,,1738.8,Percent of Total Billed Charges,75% of Total Billed Charges,1619.6,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1619.6,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,1619.6,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2267.44,70,,45.224,Percent of Total Billed Charges,70% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,453.49,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3239.2,100,,2318.4,Percent of Total Billed Charges,100% of Total Billed Charges,453.49,3239.2,
NM LIVER BLOOD POOL W FLW,52082021,CDM,341,RC,78803,HCPCS,Outpatient,,,2091.92,1255.15,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,24.072,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,77.024,Fee Schedule,103% of Cigna fee schedule,380.24,100,,741.944,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,764.2,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1568.94,75,,1738.8,Percent of Total Billed Charges,75% of Total Billed Charges,1045.96,50,,9.184,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.96,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,0.784,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,211.68,Case Rate,Pays based on per visit rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,741.944,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.92,100,,2318.4,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,2091.92,
NM LIVER SPLEEN SPECT,52082054,CDM,341,RC,78803,HCPCS,Outpatient,,,1997.76,1198.66,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,24.072,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,77.024,Fee Schedule,103% of Cigna fee schedule,380.24,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1498.32,75,,1979.464,Percent of Total Billed Charges,75% of Total Billed Charges,998.88,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,998.88,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,998.88,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,998.88,50,,1.528,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,27.44,Case Rate,Pays based on per visit rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1997.76,100,,2639.288,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,1997.76,
NM LIVER SPLEEN SCAN,52082153,CDM,341,RC,78215,HCPCS,Outpatient,,,1591.5,954.90,,168.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,496.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,567.39,320,,24.096,Fee Schedule,320% of BCBS Blue Essentials Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,638.32,360,,,Fee Schedule,360% of BCBS POS Rate,638.32,360,,,Fee schedule,360% of BCBS PPO Rate,638.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,52.08,Fee Schedule,103% of Cigna fee schedule,192.46,100,,0.032,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,198.23,103,,0.032,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1193.63,75,,1979.464,Percent of Total Billed Charges,75% of Total Billed Charges,795.75,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,795.75,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,795.75,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,795.75,50,,1.312,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,14.72,Case Rate,Pays based on per visit rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,192.46,100,,0.032,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1591.5,100,,2639.288,Percent of Total Billed Charges,100% of Total Billed Charges,168.51,1591.5,
NM HEPATOBILIARY W PHARM,52082229,CDM,341,RC,78227,HCPCS,Outpatient,,,1949.22,1169.53,,389.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1337.76,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,1504.98,360,,,Fee Schedule,360% of BCBS POS Rate,1504.98,360,,,Fee schedule,360% of BCBS PPO Rate,1504.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,2.704,Fee Schedule,103% of Cigna fee schedule,433.04,100,,15.52,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,446.03,103,,15.992,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1461.92,75,,2540.464,Percent of Total Billed Charges,75% of Total Billed Charges,974.61,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,974.61,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,974.61,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,974.61,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,28.24,Case Rate,Pays based on per visit rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,433.04,100,,15.52,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1949.22,100,,3387.288,Percent of Total Billed Charges,100% of Total Billed Charges,389.1,1949.22,
NM HEPATOBILIARY,52082237,CDM,341,RC,78226,HCPCS,Outpatient,,,1756.52,1053.91,,285.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,855.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,977.95,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,1100.2,360,,,Fee Schedule,360% of BCBS POS Rate,1100.2,360,,,Fee schedule,360% of BCBS PPO Rate,1100.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,6.704,Fee Schedule,103% of Cigna fee schedule,321.76,100,,1.728,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,331.41,103,,1.784,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1317.39,75,,2540.464,Percent of Total Billed Charges,75% of Total Billed Charges,878.26,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,878.26,50,,66.632,Percent of Total Billed Charges,50% of Total Billed Charges,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,878.26,50,,66.632,Percent of Total Billed Charges,50% of Total Billed Charges,878.26,50,,47.008,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,106.616,Case Rate,Pays based on per visit rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,321.76,100,,1.728,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1756.52,100,,3387.288,Percent of Total Billed Charges,100% of Total Billed Charges,285.56,1756.52,
NM GASTRIC EMPTYING SCAN,52082765,CDM,341,RC,78264,HCPCS,Outpatient,,,1789.67,1073.80,,287.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,862.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,986.02,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,1109.27,360,,,Fee Schedule,360% of BCBS POS Rate,1109.27,360,,,Fee schedule,360% of BCBS PPO Rate,1109.27,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,3.36,Fee Schedule,103% of Cigna fee schedule,326.45,100,,3.472,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,336.24,103,,3.576,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1342.25,75,,1375.416,Percent of Total Billed Charges,75% of Total Billed Charges,894.84,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,894.84,50,,1.448,Percent of Total Billed Charges,50% of Total Billed Charges,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,894.84,50,,1.448,Percent of Total Billed Charges,50% of Total Billed Charges,894.84,50,,0.88,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,136.552,Case Rate,Pays based on per visit rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,326.45,100,,3.472,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1789.67,100,,1833.888,Percent of Total Billed Charges,100% of Total Billed Charges,287.88,1789.67,
NM GI BLEEDING SCAN,52082807,CDM,341,RC,78278,HCPCS,Outpatient,,,1508.44,905.06,,294.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,874.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,999.87,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,1124.86,360,,,Fee Schedule,360% of BCBS POS Rate,1124.86,360,,,Fee schedule,360% of BCBS PPO Rate,1124.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,3.544,Fee Schedule,103% of Cigna fee schedule,342.15,100,,19.328,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,352.41,103,,19.904,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1131.33,75,,1375.416,Percent of Total Billed Charges,75% of Total Billed Charges,754.22,50,,66.632,Percent of Total Billed Charges,50% of Total Billed Charges,754.22,50,,17.832,Percent of Total Billed Charges,50% of Total Billed Charges,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,754.22,50,,17.832,Percent of Total Billed Charges,50% of Total Billed Charges,754.22,50,,0.896,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,119.48,Case Rate,Pays based on per visit rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,342.15,100,,19.328,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1508.44,100,,1833.888,Percent of Total Billed Charges,100% of Total Billed Charges,294.54,1508.44,
NM MECKELS SCAN,52082906,CDM,341,RC,78290,HCPCS,Outpatient,,,1409.81,845.89,,291.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,865.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,989.5,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,1113.19,360,,,Fee Schedule,360% of BCBS POS Rate,1113.19,360,,,Fee schedule,360% of BCBS PPO Rate,1113.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,0.512,Fee Schedule,103% of Cigna fee schedule,324.78,100,,4.248,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,334.52,103,,4.376,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1057.36,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,704.91,50,,1.448,Percent of Total Billed Charges,50% of Total Billed Charges,704.91,50,,20.088,Percent of Total Billed Charges,50% of Total Billed Charges,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,704.91,50,,20.088,Percent of Total Billed Charges,50% of Total Billed Charges,704.91,50,,15.84,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,102.416,Case Rate,Pays based on per visit rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,324.78,100,,4.248,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.81,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,291.21,1409.81,
NM BONE SCAN LTD AREA,52083003,CDM,341,RC,78300,HCPCS,Outpatient,,,1313.62,788.17,,195.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,580.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,663.1,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,745.99,360,,,Fee Schedule,360% of BCBS POS Rate,745.99,360,,,Fee schedule,360% of BCBS PPO Rate,745.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,29.968,Fee Schedule,103% of Cigna fee schedule,225.88,100,,2.832,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,232.66,103,,2.912,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,985.22,75,,2229.544,Percent of Total Billed Charges,75% of Total Billed Charges,656.81,50,,17.832,Percent of Total Billed Charges,50% of Total Billed Charges,656.81,50,,19.608,Percent of Total Billed Charges,50% of Total Billed Charges,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,656.81,50,,19.608,Percent of Total Billed Charges,50% of Total Billed Charges,656.81,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,85.344,Case Rate,Pays based on per visit rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,225.88,100,,2.832,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1313.62,100,,2972.72,Percent of Total Billed Charges,100% of Total Billed Charges,195.15,1313.62,
NM BONE SCAN WHOLE BODY,52083078,CDM,341,RC,78306,HCPCS,Outpatient,,,1928.37,1157.02,,252.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,757.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,866.08,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,974.34,360,,,Fee Schedule,360% of BCBS POS Rate,974.34,360,,,Fee schedule,360% of BCBS PPO Rate,974.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,17.768,Fee Schedule,103% of Cigna fee schedule,294.04,100,,7.92,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,302.86,103,,8.16,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.28,75,,2108.584,Percent of Total Billed Charges,75% of Total Billed Charges,964.19,50,,20.088,Percent of Total Billed Charges,50% of Total Billed Charges,964.19,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,964.19,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,964.19,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,58.52,Case Rate,Pays based on per visit rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,294.04,100,,7.92,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1928.37,100,,2811.44,Percent of Total Billed Charges,100% of Total Billed Charges,252.75,1928.37,
NM BONE SCAN 3 PHASE STUDY,52083151,CDM,341,RC,78315,HCPCS,Outpatient,,,2019.48,1211.69,,291.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,863.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,987.17,320,,24.16,Fee Schedule,320% of BCBS Blue Essentials Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,1110.56,360,,,Fee Schedule,360% of BCBS POS Rate,1110.56,360,,,Fee schedule,360% of BCBS PPO Rate,1110.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,7.696,Fee Schedule,103% of Cigna fee schedule,340.15,100,,16.656,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,350.35,103,,17.16,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1514.61,75,,2108.584,Percent of Total Billed Charges,75% of Total Billed Charges,1009.74,50,,19.608,Percent of Total Billed Charges,50% of Total Billed Charges,1009.74,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.74,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,1009.74,50,,0.544,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,78.04,Case Rate,Pays based on per visit rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,340.15,100,,16.656,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2019.48,100,,2811.44,Percent of Total Billed Charges,100% of Total Billed Charges,291.21,2019.48,
NM BONE SCAN SPECT,52083201,CDM,341,RC,78803,HCPCS,Outpatient,,,2101.67,1261.00,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,24.192,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,44.832,Fee Schedule,103% of Cigna fee schedule,380.24,100,,1.504,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,1.544,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1576.25,75,,1405.72,Percent of Total Billed Charges,75% of Total Billed Charges,1050.84,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,1050.84,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.84,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,1050.84,50,,9.184,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,0.288,Case Rate,Pays based on per visit rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,1.504,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.67,100,,1874.296,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,2101.67,
NM MUGA SCAN,52084035,CDM,341,RC,78472,HCPCS,Outpatient,,,2054.5,1232.70,,177.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,526.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,601.98,320,,241.592,Fee Schedule,320% of BCBS Blue Essentials Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,677.23,360,,,Fee Schedule,360% of BCBS POS Rate,677.23,360,,,Fee schedule,360% of BCBS PPO Rate,677.23,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,55.12,Fee Schedule,103% of Cigna fee schedule,223.86,100,,2.744,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,230.58,103,,2.832,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1540.88,75,,1405.72,Percent of Total Billed Charges,75% of Total Billed Charges,1027.25,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,1027.25,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1027.25,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,1027.25,50,,1.016,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,33.184,Case Rate,Pays based on per visit rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,223.86,100,,2.744,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2054.5,100,,1874.296,Percent of Total Billed Charges,100% of Total Billed Charges,177.5,2054.5,
NM MYOCARD REST REDIST SPECT,52084069,CDM,341,RC,78452,HCPCS,Outpatient,,,4436.76,2662.06,,388.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1310.08,320,,242.384,Fee Schedule,320% of BCBS Blue Essentials Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1473.84,360,,,Fee Schedule,360% of BCBS POS Rate,1473.84,360,,,Fee schedule,360% of BCBS PPO Rate,1473.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,90.248,Fee Schedule,103% of Cigna fee schedule,465.78,100,,3.096,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,479.75,103,,3.192,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,3327.57,75,,1359.16,Percent of Total Billed Charges,75% of Total Billed Charges,2218.38,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,2218.38,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2218.38,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,2218.38,50,,0.688,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,277.624,Case Rate,Pays based on per visit rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4436.76,100,,1812.208,Percent of Total Billed Charges,100% of Total Billed Charges,388.94,4436.76,
NM MYOCARD STR OR REST SPECT,52084654,CDM,341,RC,78451,HCPCS,Outpatient,,,3000,1800.00,,269.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,793.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.46,320,,242.72,Fee Schedule,320% of BCBS Blue Essentials Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1019.77,360,,,Fee Schedule,360% of BCBS POS Rate,1019.77,360,,,Fee schedule,360% of BCBS PPO Rate,1019.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,217.592,Fee Schedule,103% of Cigna fee schedule,334.46,100,,3.096,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,344.49,103,,3.192,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2250,75,,1359.16,Percent of Total Billed Charges,75% of Total Billed Charges,1500,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,1500,50,,9.344,Percent of Total Billed Charges,50% of Total Billed Charges,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1500,50,,9.344,Percent of Total Billed Charges,50% of Total Billed Charges,1500,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,513.24,Case Rate,Pays based on per visit rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,3.096,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,1812.208,Percent of Total Billed Charges,100% of Total Billed Charges,269.24,3738.61,
NM LUNG PERF,52085800,CDM,341,RC,78580,HCPCS,Outpatient,,,1336.33,801.80,,196.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,588.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,672.35,320,,24.32,Fee Schedule,320% of BCBS Blue Essentials Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,756.4,360,,,Fee Schedule,360% of BCBS POS Rate,756.4,360,,,Fee schedule,360% of BCBS PPO Rate,756.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,9.92,Fee Schedule,103% of Cigna fee schedule,232.55,100,,4.392,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,239.53,103,,4.528,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1002.25,75,,2937.048,Percent of Total Billed Charges,75% of Total Billed Charges,668.17,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,668.17,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,668.17,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,668.17,50,,0.608,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,69.656,Case Rate,Pays based on per visit rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,232.55,100,,4.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.33,100,,3916.064,Percent of Total Billed Charges,100% of Total Billed Charges,196.82,1336.33,
NM LUNG VQ VENT AND PERF,52085826,CDM,341,RC,78582,HCPCS,Outpatient,,,1914.45,1148.67,,276.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,821.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,938.75,320,,24.48,Fee Schedule,320% of BCBS Blue Essentials Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,1056.1,360,,,Fee Schedule,360% of BCBS POS Rate,1056.1,360,,,Fee schedule,360% of BCBS PPO Rate,1056.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,345.232,Fee Schedule,103% of Cigna fee schedule,327.11,100,,2.576,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,336.92,103,,2.656,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1435.84,75,,2937.048,Percent of Total Billed Charges,75% of Total Billed Charges,957.23,50,,9.344,Percent of Total Billed Charges,50% of Total Billed Charges,957.23,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,957.23,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,957.23,50,,0.824,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,51.08,Case Rate,Pays based on per visit rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,327.11,100,,2.576,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1914.45,100,,3916.064,Percent of Total Billed Charges,100% of Total Billed Charges,276.23,1914.45,
NM LUNG VENT AEROSOL,52085974,CDM,341,RC,78579,HCPCS,Outpatient,,,1218,730.80,,160.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,472.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,539.71,320,,24.544,Fee Schedule,320% of BCBS Blue Essentials Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,607.18,360,,,Fee Schedule,360% of BCBS POS Rate,607.18,360,,,Fee schedule,360% of BCBS PPO Rate,607.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,220.32,Fee Schedule,103% of Cigna fee schedule,183.78,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,189.29,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,913.5,75,,1958.032,Percent of Total Billed Charges,75% of Total Billed Charges,609,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,609,50,,3.616,Percent of Total Billed Charges,50% of Total Billed Charges,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,609,50,,3.616,Percent of Total Billed Charges,50% of Total Billed Charges,609,50,,66.632,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,48.752,Case Rate,Pays based on per visit rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,183.78,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1218,100,,2610.712,Percent of Total Billed Charges,100% of Total Billed Charges,160.19,1218,
NM BRAIN SCAN SPECT,52086071,CDM,341,RC,78803,HCPCS,Outpatient,,,2091.92,1255.15,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,243.264,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,164.536,Fee Schedule,103% of Cigna fee schedule,380.24,100,,0.28,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,0.288,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1568.94,75,,1958.032,Percent of Total Billed Charges,75% of Total Billed Charges,1045.96,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,4.112,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.96,50,,4.112,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,1.448,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,48.768,Case Rate,Pays based on per visit rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,0.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.92,100,,2610.712,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,2091.92,
NM RPH I123 DATSCAN,52086097,CDM,343,RC,A9584,HCPCS,Outpatient,,,4867.2,2920.32,,2369.28,100,,,Case Rate,Pays based on per visit rate,2190.24,45,,1752.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2458.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2458.13,320,,243.264,Fee Schedule,320% of BCBS Blue Essentials Rate,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,2458.13,360,,,Fee Schedule,360% of BCBS POS Rate,2458.13,360,,,Fee schedule,360% of BCBS PPO Rate,2458.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,2920.32,60,,8.288,Percent of Total Billed Charges,60% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4867.2,100,,3893.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,701.85,14.42,,33.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3650.4,75,,1549.424,Percent of Total Billed Charges,75% of Total Billed Charges,2433.6,50,,3.616,Percent of Total Billed Charges,50% of Total Billed Charges,2433.6,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2433.6,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,2433.6,50,,17.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3407.04,70,,48.976,Percent of Total Billed Charges,70% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,681.41,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4867.2,100,,2065.896,Percent of Total Billed Charges,100% of Total Billed Charges,681.41,4867.2,
NM CISTERNOGRAM,52086303,CDM,341,RC,78630,HCPCS,Outpatient,,,1684.1,1010.46,,298.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,885.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1012.54,320,,243.264,Fee Schedule,320% of BCBS Blue Essentials Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,1139.11,360,,,Fee Schedule,360% of BCBS POS Rate,1139.11,360,,,Fee schedule,360% of BCBS PPO Rate,1139.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,94.88,Fee Schedule,103% of Cigna fee schedule,331.79,100,,2.056,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,341.74,103,,2.12,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.08,75,,1549.424,Percent of Total Billed Charges,75% of Total Billed Charges,842.05,50,,4.112,Percent of Total Billed Charges,50% of Total Billed Charges,842.05,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,842.05,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,842.05,50,,20.088,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,325.816,Case Rate,Pays based on per visit rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,331.79,100,,2.056,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.1,100,,2065.896,Percent of Total Billed Charges,100% of Total Billed Charges,298.2,1684.1,
NM CSF FLOW/LEAKAGE LOC,52086501,CDM,341,RC,78650,HCPCS,Outpatient,,,631.03,378.62,,246.93,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,723.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,826.88,320,,244.224,Fee Schedule,320% of BCBS Blue Essentials Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,930.24,360,,,Fee Schedule,360% of BCBS POS Rate,930.24,360,,,Fee schedule,360% of BCBS PPO Rate,930.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,819.008,Fee Schedule,103% of Cigna fee schedule,272.99,100,,55.28,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,281.18,103,,56.936,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,473.27,75,,2189.392,Percent of Total Billed Charges,75% of Total Billed Charges,315.52,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,315.52,50,,0.56,Percent of Total Billed Charges,50% of Total Billed Charges,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,315.52,50,,0.56,Percent of Total Billed Charges,50% of Total Billed Charges,315.52,50,,19.608,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,66.872,Case Rate,Pays based on per visit rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,272.99,100,,55.28,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,631.03,100,,2919.184,Percent of Total Billed Charges,100% of Total Billed Charges,246.93,3738.61,
NM INJ THYROGEN,52086502,CDM,940,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,244.224,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,,Fee Schedule,360% of BCBS POS Rate,217.69,360,,,Fee schedule,360% of BCBS PPO Rate,217.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,1080,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,26.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,2189.392,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,7.768,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,7.768,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,0.72,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,53.904,Case Rate,Pays based on per visit rate,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,2919.184,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
NM RENAL SCAN W FLOW,52087012,CDM,341,RC,78701,HCPCS,Outpatient,,,611.77,367.06,,192.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,562.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,642.37,320,,244.224,Fee Schedule,320% of BCBS Blue Essentials Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,722.66,360,,,Fee Schedule,360% of BCBS POS Rate,722.66,360,,,Fee schedule,360% of BCBS PPO Rate,722.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,29.248,Fee Schedule,103% of Cigna fee schedule,216.51,100,,33.8,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,223.01,103,,34.816,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,458.83,75,,2086.576,Percent of Total Billed Charges,75% of Total Billed Charges,305.89,50,,0.56,Percent of Total Billed Charges,50% of Total Billed Charges,305.89,50,,7.824,Percent of Total Billed Charges,50% of Total Billed Charges,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,305.89,50,,7.824,Percent of Total Billed Charges,50% of Total Billed Charges,305.89,50,,1.544,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,4.904,Case Rate,Pays based on per visit rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,216.51,100,,33.8,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,611.77,100,,2782.096,Percent of Total Billed Charges,100% of Total Billed Charges,192.48,1200,
NM RENAL SCAN FLW AND FNCTN,52087079,CDM,341,RC,78707,HCPCS,Outpatient,,,1839.06,1103.44,,182.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,541.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,619.3,320,,244.992,Fee Schedule,320% of BCBS Blue Essentials Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,696.71,360,,,Fee Schedule,360% of BCBS POS Rate,696.71,360,,,Fee schedule,360% of BCBS PPO Rate,696.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,58.496,Fee Schedule,103% of Cigna fee schedule,227.21,100,,0.264,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,234.03,103,,0.272,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1379.3,75,,2086.576,Percent of Total Billed Charges,75% of Total Billed Charges,919.53,50,,7.768,Percent of Total Billed Charges,50% of Total Billed Charges,919.53,50,,0.92,Percent of Total Billed Charges,50% of Total Billed Charges,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,919.53,50,,0.92,Percent of Total Billed Charges,50% of Total Billed Charges,919.53,50,,0.64,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,77.008,Case Rate,Pays based on per visit rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,227.21,100,,0.264,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1839.06,100,,2782.096,Percent of Total Billed Charges,100% of Total Billed Charges,182.16,1839.06,
NM TURMOR OR INFECTION SPECT,52088036,CDM,341,RC,78803,HCPCS,Outpatient,,,2344.41,1406.65,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,24.576,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,29.248,Fee Schedule,103% of Cigna fee schedule,380.24,100,,10.04,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,10.344,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1758.31,75,,1826.352,Percent of Total Billed Charges,75% of Total Billed Charges,1172.21,50,,7.824,Percent of Total Billed Charges,50% of Total Billed Charges,1172.21,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.21,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,1172.21,50,,0.664,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,402.192,Case Rate,Pays based on per visit rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,10.04,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2344.41,100,,2435.136,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,2344.41,
NM TUMOR WB MULT DAY,52088044,CDM,341,RC,78804,HCPCS,Outpatient,,,2850,1710.00,,599.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1718.34,320,,24.768,Fee Schedule,320% of BCBS Blue Essentials Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1933.13,360,,,Fee Schedule,360% of BCBS POS Rate,1933.13,360,,,Fee schedule,360% of BCBS PPO Rate,1933.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,135.176,Fee Schedule,103% of Cigna fee schedule,648.89,100,,97.304,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,668.36,103,,100.224,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.5,75,,1826.352,Percent of Total Billed Charges,75% of Total Billed Charges,1425,50,,0.92,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1425,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,1545.6,Case Rate,Pays based on per visit rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,97.304,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2850,100,,2435.136,Percent of Total Billed Charges,100% of Total Billed Charges,599.22,3738.61,
NM INJ NON RADIOPHARM INI,52088051,CDM,940,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,246.048,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,,Fee Schedule,360% of BCBS POS Rate,142.7,360,,,Fee schedule,360% of BCBS PPO Rate,142.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,19.96,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,32.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,2448.664,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,9.344,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,103.104,Case Rate,Pays based on per visit rate,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,3264.888,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
NM I 131 THERAPY,52090057,CDM,342,RC,79005,HCPCS,Outpatient,,,1503.6,902.16,,49.97,100,,,Fee Schedule,100% of Aetna Fee Schedule,342.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,142.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,162.62,320,,246.048,Fee Schedule,320% of BCBS Blue Essentials Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,182.95,360,,,Fee Schedule,360% of BCBS POS Rate,182.95,360,,,Fee schedule,360% of BCBS PPO Rate,182.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,702.15,103,,185.552,Fee Schedule,103% of Cigna fee schedule,132.99,100,,56.072,Fee Schedule,100% of TX Mediciad Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,205.42,90,,,Fee Schedule,90% of CMS OPPS Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,296.72,130,,,Fee Schedule,130% of CMS OPPS Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,136.98,103,,57.752,Fee Schedule,103% of TX Medicaid Rate,235.09,103,,,Fee Schedule,103% of CMS OPPS Rate,235.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1127.7,75,,2448.664,Percent of Total Billed Charges,75% of Total Billed Charges,751.8,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,751.8,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,751.8,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,751.8,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,342.37,150,,,Fee Schedule,150% of CMS OPPS Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,58.232,Case Rate,Pays based on per visit rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,132.99,100,,56.072,Fee Schedule,100% of TX Medicaid Rate,228.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.6,100,,3264.888,Percent of Total Billed Charges,100% of Total Billed Charges,49.97,1503.6,
NM GALLIUM TUMOR WB SNGL DAY,52095080,CDM,341,RC,78802,HCPCS,Outpatient,,,1552.65,931.59,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,247.056,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,213.448,Fee Schedule,103% of Cigna fee schedule,307.74,100,,22.048,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,22.712,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1164.49,75,,2245.096,Percent of Total Billed Charges,75% of Total Billed Charges,776.33,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,776.33,50,,4.896,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,776.33,50,,4.896,Percent of Total Billed Charges,50% of Total Billed Charges,776.33,50,,1.872,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,11876.2,Case Rate,Pays based on per visit rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1552.65,100,,2993.456,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM BONE MARROW LIMITED,52095123,CDM,341,RC,78102,HCPCS,Outpatient,,,728.3,436.98,,143.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,417.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,477.44,320,,247.056,Fee Schedule,320% of BCBS Blue Essentials Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,537.12,360,,,Fee Schedule,360% of BCBS POS Rate,537.12,360,,,Fee schedule,360% of BCBS PPO Rate,537.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,1.624,Fee Schedule,103% of Cigna fee schedule,169.08,100,,158.696,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,174.15,103,,163.456,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,546.23,75,,2245.096,Percent of Total Billed Charges,75% of Total Billed Charges,364.15,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,364.15,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,364.15,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,364.15,50,,3.616,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,52.112,Case Rate,Pays based on per visit rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,169.08,100,,158.696,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,728.3,100,,2993.456,Percent of Total Billed Charges,100% of Total Billed Charges,143.21,1200,
NM BRAIN DATSCAN SPECT,52095124,CDM,341,RC,78803,HCPCS,Outpatient,,,2091.92,1255.15,,329.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,840.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960.67,320,,24.896,Fee Schedule,320% of BCBS Blue Essentials Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1080.76,360,,,Fee Schedule,360% of BCBS POS Rate,1080.76,360,,,Fee schedule,360% of BCBS PPO Rate,1080.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,31.968,Fee Schedule,103% of Cigna fee schedule,380.24,100,,3.36,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,391.65,103,,3.464,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1568.94,75,,1541.64,Percent of Total Billed Charges,75% of Total Billed Charges,1045.96,50,,4.896,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,3.248,Percent of Total Billed Charges,50% of Total Billed Charges,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.96,50,,3.248,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,4.112,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,1.312,Case Rate,Pays based on per visit rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,380.24,100,,3.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.92,100,,2055.52,Percent of Total Billed Charges,100% of Total Billed Charges,329.18,2091.92,
NM CERETEC WHOLE BODY SCAN,52095125,CDM,341,RC,78802,HCPCS,Outpatient,,,2429.53,1457.72,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,24.96,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,205.784,Fee Schedule,103% of Cigna fee schedule,307.74,100,,311.44,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,320.784,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1822.15,75,,1541.64,Percent of Total Billed Charges,75% of Total Billed Charges,1214.77,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,177.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.77,50,,177.104,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,0.84,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,385.728,Case Rate,Pays based on per visit rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,311.44,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.53,100,,2055.52,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM GALLIUM ABSCESS LTD AREA,52095126,CDM,341,RC,78800,HCPCS,Outpatient,,,1830,1098.00,,219.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,468.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,535.1,320,,24.96,Fee Schedule,320% of BCBS Blue Essentials Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,601.99,360,,,Fee Schedule,360% of BCBS POS Rate,601.99,360,,,Fee schedule,360% of BCBS PPO Rate,601.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,33.224,Fee Schedule,103% of Cigna fee schedule,251.6,100,,21.52,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,259.15,103,,22.168,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1372.5,75,,1496.728,Percent of Total Billed Charges,75% of Total Billed Charges,915,50,,3.248,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,915,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,5.6,Case Rate,Pays based on per visit rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,21.52,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1830,100,,1995.64,Percent of Total Billed Charges,100% of Total Billed Charges,219.78,1830,
NM GALLIUM TUMOR WB MULT DAY,52095127,CDM,341,RC,78804,HCPCS,Outpatient,,,2850,1710.00,,599.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1718.34,320,,24.96,Fee Schedule,320% of BCBS Blue Essentials Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1933.13,360,,,Fee Schedule,360% of BCBS POS Rate,1933.13,360,,,Fee schedule,360% of BCBS PPO Rate,1933.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,42.512,Fee Schedule,103% of Cigna fee schedule,648.89,100,,17.616,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,668.36,103,,18.144,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.5,75,,1496.728,Percent of Total Billed Charges,75% of Total Billed Charges,1425,50,,177.104,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1425,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,0.56,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,1137.704,Case Rate,Pays based on per visit rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,17.616,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2850,100,,1995.64,Percent of Total Billed Charges,100% of Total Billed Charges,599.22,3738.61,
NM GALLIUM WHOLE BODY SCAN,52095128,CDM,341,RC,78802,HCPCS,Outpatient,,,2429.53,1457.72,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,24.96,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,8.152,Fee Schedule,103% of Cigna fee schedule,307.74,100,,23.584,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,24.288,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1822.15,75,,2019.888,Percent of Total Billed Charges,75% of Total Billed Charges,1214.77,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.77,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,7.768,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,145.576,Case Rate,Pays based on per visit rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,23.584,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.53,100,,2693.184,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM I123 MIBG TUMOR WB SNGL DAY,52095130,CDM,341,RC,78802,HCPCS,Outpatient,,,2091.92,1255.15,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,24.96,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,230.704,Fee Schedule,103% of Cigna fee schedule,307.74,100,,76.392,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,78.688,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1568.94,75,,2019.888,Percent of Total Billed Charges,75% of Total Billed Charges,1045.96,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,0.272,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.96,50,,0.272,Percent of Total Billed Charges,50% of Total Billed Charges,1045.96,50,,7.824,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,20.832,Case Rate,Pays based on per visit rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.92,100,,2693.184,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM IN111 WBC LIMITED AREA,52095132,CDM,341,RC,78800,HCPCS,Outpatient,,,1830,1098.00,,219.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,468.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,535.1,320,,25.04,Fee Schedule,320% of BCBS Blue Essentials Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,601.99,360,,,Fee Schedule,360% of BCBS POS Rate,601.99,360,,,Fee schedule,360% of BCBS PPO Rate,601.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,72.392,Fee Schedule,103% of Cigna fee schedule,251.6,100,,76.392,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,259.15,103,,78.688,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1372.5,75,,2363.92,Percent of Total Billed Charges,75% of Total Billed Charges,915,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,0.576,Percent of Total Billed Charges,50% of Total Billed Charges,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,915,50,,0.576,Percent of Total Billed Charges,50% of Total Billed Charges,915,50,,0.92,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,10.416,Case Rate,Pays based on per visit rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,251.6,100,,76.392,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1830,100,,3151.888,Percent of Total Billed Charges,100% of Total Billed Charges,219.78,1830,
NM IN111 WHOLE BODY SCAN,52095133,CDM,341,RC,78802,HCPCS,Outpatient,,,2429.53,1457.72,,269.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,818.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,935.3,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1052.21,360,,,Fee Schedule,360% of BCBS POS Rate,1052.21,360,,,Fee schedule,360% of BCBS PPO Rate,1052.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,19.056,Fee Schedule,103% of Cigna fee schedule,307.74,100,,15.496,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,316.97,103,,15.96,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1822.15,75,,2363.92,Percent of Total Billed Charges,75% of Total Billed Charges,1214.77,50,,0.272,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.77,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,1214.77,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,63.496,Case Rate,Pays based on per visit rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,307.74,100,,15.496,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2429.53,100,,3151.888,Percent of Total Billed Charges,100% of Total Billed Charges,269.4,3738.61,
NM MYOCARD STR AND REST SPECT,52095135,CDM,341,RC,78452,HCPCS,Outpatient,,,4436.76,2662.06,,388.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1310.08,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1473.84,360,,,Fee Schedule,360% of BCBS POS Rate,1473.84,360,,,Fee schedule,360% of BCBS PPO Rate,1473.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,19.168,Fee Schedule,103% of Cigna fee schedule,465.78,100,,0.344,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,479.75,103,,0.36,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,3327.57,75,,1355.096,Percent of Total Billed Charges,75% of Total Billed Charges,2218.38,50,,0.576,Percent of Total Billed Charges,50% of Total Billed Charges,2218.38,50,,16.528,Percent of Total Billed Charges,50% of Total Billed Charges,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2218.38,50,,16.528,Percent of Total Billed Charges,50% of Total Billed Charges,2218.38,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,98.984,Case Rate,Pays based on per visit rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,465.78,100,,0.344,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4436.76,100,,1806.792,Percent of Total Billed Charges,100% of Total Billed Charges,388.94,4436.76,
NM OCTREO TUMOR WB MULT DAY,52095136,CDM,341,RC,78804,HCPCS,Outpatient,,,2850,1710.00,,599.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1718.34,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1933.13,360,,,Fee Schedule,360% of BCBS POS Rate,1933.13,360,,,Fee schedule,360% of BCBS PPO Rate,1933.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,3738.61,103,,25.544,Fee Schedule,103% of Cigna fee schedule,648.89,100,,47.536,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,668.36,103,,48.96,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.5,75,,1355.096,Percent of Total Billed Charges,75% of Total Billed Charges,1425,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,1.416,Percent of Total Billed Charges,50% of Total Billed Charges,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1425,50,,1.416,Percent of Total Billed Charges,50% of Total Billed Charges,1425,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,2705.92,Case Rate,Pays based on per visit rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,648.89,100,,47.536,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,2850,100,,1806.792,Percent of Total Billed Charges,100% of Total Billed Charges,599.22,3738.61,
NM PARATHRYOID W SPECT,52095137,CDM,341,RC,78071,HCPCS,Outpatient,,,2040.63,1224.38,,289.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,867.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,991.81,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,1115.78,360,,,Fee Schedule,360% of BCBS POS Rate,1115.78,360,,,Fee schedule,360% of BCBS PPO Rate,1115.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,248.224,Fee Schedule,103% of Cigna fee schedule,346.16,100,,2.952,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,356.54,103,,3.04,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1530.47,75,,1535.032,Percent of Total Billed Charges,75% of Total Billed Charges,1020.32,50,,16.528,Percent of Total Billed Charges,50% of Total Billed Charges,1020.32,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.32,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,1020.32,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,20.496,Case Rate,Pays based on per visit rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,346.16,100,,2.952,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2040.63,100,,2046.704,Percent of Total Billed Charges,100% of Total Billed Charges,289.22,2040.63,
NM RENAL SCAN W DIURETIC,52095138,CDM,341,RC,78708,HCPCS,Outpatient,,,1838.06,1102.84,,116.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,344.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,393.25,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,442.4,360,,,Fee Schedule,360% of BCBS POS Rate,442.4,360,,,Fee schedule,360% of BCBS PPO Rate,442.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,274.12,Fee Schedule,103% of Cigna fee schedule,173.41,100,,6.928,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,178.61,103,,7.136,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1378.55,75,,1535.032,Percent of Total Billed Charges,75% of Total Billed Charges,919.03,50,,1.416,Percent of Total Billed Charges,50% of Total Billed Charges,919.03,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,919.03,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,919.03,50,,4.896,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,0.088,Case Rate,Pays based on per visit rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,173.41,100,,6.928,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.06,100,,2046.704,Percent of Total Billed Charges,100% of Total Billed Charges,116.75,1838.06,
NM RPH TC99M SULFCOL BRST MELA,52095139,CDM,343,RC,A9541,HCPCS,Outpatient,,,317.5,190.50,,256.67,100,,,Case Rate,Pays based on per visit rate,142.88,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.26,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,53.26,360,,,Fee Schedule,360% of BCBS POS Rate,53.26,360,,,Fee schedule,360% of BCBS PPO Rate,53.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,190.5,60,,154.592,Percent of Total Billed Charges,60% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.5,100,,254,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,45.78,14.42,,0.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.13,75,,3419.912,Percent of Total Billed Charges,75% of Total Billed Charges,158.75,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,158.75,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.75,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,158.75,50,,0.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.25,70,,7.44,Percent of Total Billed Charges,70% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.45,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.5,100,,4559.88,Percent of Total Billed Charges,100% of Total Billed Charges,44.45,317.5,
NM THYROID I131 WB POST TX,52095140,CDM,341,RC,78018,HCPCS,Outpatient,,,2051.54,1230.92,,267.57,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,793.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.46,320,,249.496,Fee Schedule,320% of BCBS Blue Essentials Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,1019.77,360,,,Fee Schedule,360% of BCBS POS Rate,1019.77,360,,,Fee schedule,360% of BCBS PPO Rate,1019.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,22.792,Fee Schedule,103% of Cigna fee schedule,308.4,100,,168,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,317.65,103,,173.04,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1538.66,75,,3419.912,Percent of Total Billed Charges,75% of Total Billed Charges,1025.77,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,1025.77,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.77,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,1025.77,50,,3.248,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,5.424,Case Rate,Pays based on per visit rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,308.4,100,,168,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,2051.54,100,,4559.88,Percent of Total Billed Charges,100% of Total Billed Charges,267.57,2051.54,
NM TUMOR INFLAM SPECT CT SINGL,52095144,CDM,341,RC,78830,HCPCS,Outpatient,,,3016.89,1810.13,,413.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1387.36,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1560.78,360,,,Fee Schedule,360% of BCBS POS Rate,1560.78,360,,,Fee schedule,360% of BCBS PPO Rate,1560.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,1810.13,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,447.4,100,,224,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,460.82,103,,230.72,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2262.67,75,,2279.944,Percent of Total Billed Charges,75% of Total Billed Charges,1508.45,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,1508.45,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1508.45,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,1508.45,50,,177.104,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,131.2,Case Rate,Pays based on per visit rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,447.4,100,,224,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3016.89,100,,3039.92,Percent of Total Billed Charges,100% of Total Billed Charges,413.73,3016.89,
NM TUMOR INFLAM SPECT MULTI,52095145,CDM,341,RC,78831,HCPCS,Outpatient,,,3516.61,2109.97,,611.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,1954.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1802.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2059.71,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,2317.18,360,,,Fee Schedule,360% of BCBS POS Rate,2317.18,360,,,Fee schedule,360% of BCBS PPO Rate,2317.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,2109.97,60,,260.472,Percent of Total Billed Charges,60% of Total Billed Charges,660.91,100,,0.36,Fee Schedule,100% of TX Mediciad Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.48,90,,,Fee Schedule,90% of CMS OPPS Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1693.58,130,,,Fee Schedule,130% of CMS OPPS Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,680.74,103,,0.376,Fee Schedule,103% of TX Medicaid Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.83,103,,,Fee Schedule,103% of CMS OPPS Rate,2637.46,75,,2279.944,Percent of Total Billed Charges,75% of Total Billed Charges,1758.31,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,1758.31,50,,3.304,Percent of Total Billed Charges,50% of Total Billed Charges,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.31,50,,3.304,Percent of Total Billed Charges,50% of Total Billed Charges,1758.31,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,1954.14,150,,,Fee Schedule,150% of CMS OPPS Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,1164.8,Case Rate,Pays based on per visit rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,660.91,100,,0.36,Fee Schedule,100% of TX Medicaid Rate,1302.76,100,,,Fee Schedule,100% of CMS OPPS Rate,3516.61,100,,3039.92,Percent of Total Billed Charges,100% of Total Billed Charges,611.88,3516.61,
NM TUMR INFLAM W SPECT CT MULT,52095146,CDM,341,RC,78832,HCPCS,Outpatient,,,4189.09,2513.45,,807.83,100,,,Fee Schedule,100% of Aetna Fee Schedule,2152.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2379.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2719.36,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,3059.28,360,,,Fee Schedule,360% of BCBS POS Rate,3059.28,360,,,Fee schedule,360% of BCBS PPO Rate,3059.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,2513.45,60,,11.912,Percent of Total Billed Charges,60% of Total Billed Charges,846.69,100,,0.888,Fee Schedule,100% of TX Mediciad Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.79,90,,,Fee Schedule,90% of CMS OPPS Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1865.92,130,,,Fee Schedule,130% of CMS OPPS Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,872.09,103,,0.912,Fee Schedule,103% of TX Medicaid Rate,1478.38,103,,,Fee Schedule,103% of CMS OPPS Rate,1478.38,103,,,Fee Schedule,103% of CMS OPPS Rate,3141.82,75,,2554.736,Percent of Total Billed Charges,75% of Total Billed Charges,2094.55,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,2094.55,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2094.55,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,2094.55,50,,0.032,Percent of Total Billed Charges,50% of Total Billed Charges,2152.98,150,,,Fee Schedule,150% of CMS OPPS Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,39.416,Case Rate,Pays based on per visit rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.888,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4189.09,100,,3406.312,Percent of Total Billed Charges,100% of Total Billed Charges,807.83,4189.09,
NM TUMOR INFECT SPECT CT MULTI,52095147,CDM,341,RC,78832,HCPCS,Outpatient,,,4189.09,2513.45,,807.83,100,,,Fee Schedule,100% of Aetna Fee Schedule,2152.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2379.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2719.36,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,3059.28,360,,,Fee Schedule,360% of BCBS POS Rate,3059.28,360,,,Fee schedule,360% of BCBS PPO Rate,3059.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,2513.45,60,,72.128,Percent of Total Billed Charges,60% of Total Billed Charges,846.69,100,,0.408,Fee Schedule,100% of TX Mediciad Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.79,90,,,Fee Schedule,90% of CMS OPPS Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1865.92,130,,,Fee Schedule,130% of CMS OPPS Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,872.09,103,,0.424,Fee Schedule,103% of TX Medicaid Rate,1478.38,103,,,Fee Schedule,103% of CMS OPPS Rate,1478.38,103,,,Fee Schedule,103% of CMS OPPS Rate,3141.82,75,,2554.736,Percent of Total Billed Charges,75% of Total Billed Charges,2094.55,50,,3.304,Percent of Total Billed Charges,50% of Total Billed Charges,2094.55,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2094.55,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,2094.55,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,2152.98,150,,,Fee Schedule,150% of CMS OPPS Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,3890.88,Case Rate,Pays based on per visit rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,846.69,100,,0.408,Fee Schedule,100% of TX Medicaid Rate,1435.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4189.09,100,,3406.312,Percent of Total Billed Charges,100% of Total Billed Charges,807.83,4189.09,
NM QUANT MEASURMNT SINGLE AREA,52095148,CDM,341,RC,78835,HCPCS,Outpatient,,,672.48,403.49,,78.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,302.62,45,,242.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,233.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,266.4,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,299.7,360,,,Fee Schedule,360% of BCBS POS Rate,299.7,360,,,Fee schedule,360% of BCBS PPO Rate,299.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,403.49,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,92.55,100,,0.04,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672.48,100,,537.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,95.33,103,,0.04,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,504.36,75,,2554.736,Percent of Total Billed Charges,75% of Total Billed Charges,336.24,50,,0.288,Percent of Total Billed Charges,50% of Total Billed Charges,336.24,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,336.24,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,336.24,50,,0.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,1200,100,,1945.44,Case Rate,Pays based on per visit rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,92.55,100,,0.04,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,672.48,100,,3406.312,Percent of Total Billed Charges,100% of Total Billed Charges,78.75,1200,
NM MYOCARD INFARCT SCAN,52100000,CDM,341,RC,78466,HCPCS,Outpatient,,,1401.23,840.74,,159.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,472.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,539.71,320,,249.6,Fee Schedule,320% of BCBS Blue Essentials Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,607.18,360,,,Fee Schedule,360% of BCBS POS Rate,607.18,360,,,Fee schedule,360% of BCBS PPO Rate,607.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,81.84,Fee Schedule,103% of Cigna fee schedule,194.46,100,,2.48,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,200.29,103,,2.552,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1050.92,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,700.62,50,,0.488,Percent of Total Billed Charges,50% of Total Billed Charges,700.62,50,,5.392,Percent of Total Billed Charges,50% of Total Billed Charges,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,700.62,50,,5.392,Percent of Total Billed Charges,50% of Total Billed Charges,700.62,50,,0.576,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,18.416,Case Rate,Pays based on per visit rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,194.46,100,,2.48,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1401.23,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,159.86,1401.23,
NM THYROID SCAN W UPTAKE MULT,52180072,CDM,341,RC,78014,HCPCS,Outpatient,,,1159.4,695.64,,210.47,100,,,Fee Schedule,100% of Aetna Fee Schedule,567.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,630.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,720.77,320,,250.056,Fee Schedule,320% of BCBS Blue Essentials Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,810.86,360,,,Fee Schedule,360% of BCBS POS Rate,810.86,360,,,Fee schedule,360% of BCBS PPO Rate,810.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,1074.98,103,,25.76,Fee Schedule,103% of Cigna fee schedule,222.54,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,340.55,90,,,Fee Schedule,90% of CMS OPPS Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,491.91,130,,,Fee Schedule,130% of CMS OPPS Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,229.22,103,,0.456,Fee Schedule,103% of TX Medicaid Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,389.74,103,,,Fee Schedule,103% of CMS OPPS Rate,869.55,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,579.7,50,,0.168,Percent of Total Billed Charges,50% of Total Billed Charges,579.7,50,,5.568,Percent of Total Billed Charges,50% of Total Billed Charges,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,579.7,50,,5.568,Percent of Total Billed Charges,50% of Total Billed Charges,579.7,50,,1.648,Percent of Total Billed Charges,50% of Total Billed Charges,567.59,150,,,Fee Schedule,150% of CMS OPPS Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,18.416,Case Rate,Pays based on per visit rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,222.54,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,378.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1159.4,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,210.47,1200,
NM INJ SENTINAL NODE,52182813,CDM,361,RC,,,Outpatient,,,869.92,521.95,,521.95,60,,417.56,Percent of Total Billed Charges,60% of Total Billed Charges,391.46,45,,313.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.58,28,,194.864,Percent of Total Billed Charges,28% of Total Billed Charges,112.31,32,,250.12,Percent of Total Billed Charges,32% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,313.17,36,,250.536,Percent of Total Billed Charges,36% of Total Billed Charges,313.17,36,,250.536,Percent of Total Billed Charges,36% Total Bille Charges,313.17,36,,250.536,Percent of Total Billed Charges,36% of Total Billed Charges,521.95,60,,174.464,Percent of Total Billed Charges,60% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,869.92,100,,695.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,125.44,14.42,,68.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.44,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,434.96,50,,5.392,Percent of Total Billed Charges,50% of Total Billed Charges,434.96,50,,10.072,Percent of Total Billed Charges,50% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,434.96,50,,10.072,Percent of Total Billed Charges,50% of Total Billed Charges,434.96,50,,16.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,608.94,70,,223.248,Percent of Total Billed Charges,70% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,121.79,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,869.92,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,112.31,869.92,
NM BRAIN SCAN W FLW,52186061,CDM,341,RC,78606,HCPCS,Outpatient,,,1623.79,974.27,,294.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,868.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,992.96,320,,25.096,Fee Schedule,320% of BCBS Blue Essentials Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,1117.08,360,,,Fee Schedule,360% of BCBS POS Rate,1117.08,360,,,Fee schedule,360% of BCBS PPO Rate,1117.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,233.56,Fee Schedule,103% of Cigna fee schedule,326.11,100,,29.432,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,335.89,103,,30.312,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1217.84,75,,2210.264,Percent of Total Billed Charges,75% of Total Billed Charges,811.9,50,,5.568,Percent of Total Billed Charges,50% of Total Billed Charges,811.9,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,811.9,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,811.9,50,,1.416,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,68.272,Case Rate,Pays based on per visit rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,326.11,100,,29.432,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.79,100,,2947.016,Percent of Total Billed Charges,100% of Total Billed Charges,294.21,1623.79,
NM ECG MONITOR W STRESS TEST,52186062,CDM,482,RC,93017,HCPCS,Outpatient,,,1645.5,987.30,,24.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,25.128,Fee Schedule,320% of BCBS Blue Essentials Rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,,Fee Schedule,360% of BCBS POS Rate,911.16,360,,,Fee schedule,360% of BCBS PPO Rate,911.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,987.3,60,,201.04,Percent of Total Billed Charges,60% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.36,130,,,Fee Schedule,130% of CMS OPPS Rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,237.28,14.42,,22.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1234.13,75,,2210.264,Percent of Total Billed Charges,75% of Total Billed Charges,822.75,50,,10.072,Percent of Total Billed Charges,50% of Total Billed Charges,822.75,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,822.75,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,822.75,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,970,100,,51.208,Case Rate,Pays based on per visit rate,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,230.37,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1645.5,100,,2947.016,Percent of Total Billed Charges,100% of Total Billed Charges,24.72,1645.5,
NM LUNG VENT PERF QUANT,52186063,CDM,341,RC,78598,HCPCS,Outpatient,,,2018.05,1210.83,,258.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,743.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,769.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,879.94,320,,25.168,Fee Schedule,320% of BCBS Blue Essentials Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,989.93,360,,,Fee Schedule,360% of BCBS POS Rate,989.93,360,,,Fee schedule,360% of BCBS PPO Rate,989.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,1385.26,103,,4.88,Fee Schedule,103% of Cigna fee schedule,298.71,100,,10.84,Fee Schedule,100% of TX Mediciad Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,90,,,Fee Schedule,90% of CMS OPPS Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,130,,,Fee Schedule,130% of CMS OPPS Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,307.67,103,,11.16,Fee Schedule,103% of TX Medicaid Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,510.76,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.54,75,,1708.656,Percent of Total Billed Charges,75% of Total Billed Charges,1009.03,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,1009.03,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.03,50,,0.264,Percent of Total Billed Charges,50% of Total Billed Charges,1009.03,50,,0.424,Percent of Total Billed Charges,50% of Total Billed Charges,743.83,150,,,Fee Schedule,150% of CMS OPPS Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1200,100,,18.528,Case Rate,Pays based on per visit rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,298.71,100,,10.84,Fee Schedule,100% of TX Medicaid Rate,495.89,100,,,Fee Schedule,100% of CMS OPPS Rate,2018.05,100,,2278.208,Percent of Total Billed Charges,100% of Total Billed Charges,258.41,2018.05,
MR ORBIT/FACE WWO CM,52500000,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.216,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,16.04,Case Rate,Pays based on per visit rate,354.85,100,,1.792,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,1.84,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1708.656,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.2,Case Rate,Pays Based on per visit rate,1557,100,,4.76,Case Rate,Pays based on per visit rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.76,Case Rate,Pays based on per visit rate,1557,100,,4.728,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,394.672,Case Rate,Pays based on per visit rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,1.792,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2278.208,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR ORBIT/FACE WWO CM,52500000,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.216,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,388.36,Case Rate,Pays based on per visit rate,354.85,100,,3.288,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,3.392,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1703.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.264,Case Rate,Pays Based on per visit rate,1557,100,,2.664,Case Rate,Pays based on per visit rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.664,Case Rate,Pays based on per visit rate,1557,100,,0.112,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,50.4,Case Rate,Pays based on per visit rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,3.288,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2271.464,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR ORBIT/FACE WO CM,52500001,CDM,614,RC,70540,HCPCS,Outpatient,,,2258.49,1355.09,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,25.256,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,18.872,Case Rate,Pays based on per visit rate,233.52,100,,125.984,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,129.768,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.87,75,,1703.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.76,Case Rate,Pays Based on per visit rate,1557,100,,14.2,Case Rate,Pays based on per visit rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,14.2,Case Rate,Pays based on per visit rate,1557,100,,0.024,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,50.4,Case Rate,Pays based on per visit rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,125.984,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.49,100,,2271.464,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR SOFT TISSUE NECK WWO CM,52500002,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.28,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,5.528,Case Rate,Pays based on per visit rate,354.85,100,,0.544,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,0.56,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,5760,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.664,Case Rate,Pays Based on per visit rate,1557,100,,28.48,Case Rate,Pays based on per visit rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,28.48,Case Rate,Pays based on per visit rate,1557,100,,3.304,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,168,Case Rate,Pays based on per visit rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.544,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,7680,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR SOFT TISSUE NECK WWO CM,52500002,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.28,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.8,Case Rate,Pays based on per visit rate,354.85,100,,0.072,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1944,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,14.2,Case Rate,Pays Based on per visit rate,1557,100,,15.04,Case Rate,Pays based on per visit rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,15.04,Case Rate,Pays based on per visit rate,1557,100,,0.288,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,411.496,Case Rate,Pays based on per visit rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2592,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR SOFT TISSUE NECK WO CM,52500003,CDM,614,RC,70540,HCPCS,Outpatient,,,2258.49,1355.09,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,252.656,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,36.608,Case Rate,Pays based on per visit rate,233.52,100,,0.096,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.096,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.87,75,,1529.456,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,28.48,Case Rate,Pays Based on per visit rate,1557,100,,1.712,Case Rate,Pays based on per visit rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.712,Case Rate,Pays based on per visit rate,1557,100,,0.488,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,43.936,Case Rate,Pays based on per visit rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.49,100,,2039.272,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR ORBIT WWO CM,52500004,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,252.84,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,319.904,Case Rate,Pays based on per visit rate,354.85,100,,4.44,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,4.568,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1529.456,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,15.04,Case Rate,Pays Based on per visit rate,1557,100,,1.528,Case Rate,Pays based on per visit rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.528,Case Rate,Pays based on per visit rate,1557,100,,0.168,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,478.424,Case Rate,Pays based on per visit rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,4.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2039.272,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR ORBIT WWO CM,52500004,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,253.056,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,17.6,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,5.384,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1894.112,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.712,Case Rate,Pays Based on per visit rate,1557,100,,1.76,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.76,Case Rate,Pays based on per visit rate,1557,100,,5.392,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,244.84,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2525.48,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR ORBIT WO CM,52500005,CDM,614,RC,70540,HCPCS,Outpatient,,,2258.49,1355.09,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,25.384,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,10.016,Case Rate,Pays based on per visit rate,233.52,100,,0.712,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.736,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.87,75,,1894.112,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.528,Case Rate,Pays Based on per visit rate,1557,100,,28.016,Case Rate,Pays based on per visit rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,28.016,Case Rate,Pays based on per visit rate,1557,100,,5.568,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,6.648,Case Rate,Pays based on per visit rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.712,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.49,100,,2525.48,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR BRST WWO CM BI,52500064,CDM,610,RC,C8908,HCPCS,Outpatient,,,3734.49,2240.69,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.52,Fee Schedule,320% of BCBS Blue Essentials Rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,31.68,Case Rate,Pays based on per visit rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,538.51,14.42,,18.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2800.87,75,,1609.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.76,Case Rate,Pays Based on per visit rate,1557,100,,1.92,Case Rate,Pays based on per visit rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.92,Case Rate,Pays based on per visit rate,1557,100,,10.072,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,50.264,Case Rate,Pays based on per visit rate,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3734.49,100,,2146.136,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3734.49,
MR BRST WWO CM BI,52500064,CDM,610,RC,C8908,HCPCS,Outpatient,,,3734.49,2240.69,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,25.536,Fee Schedule,320% of BCBS Blue Essentials Rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,13.552,Case Rate,Pays based on per visit rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,538.51,14.42,,26.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2800.87,75,,1609.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,28.016,Case Rate,Pays Based on per visit rate,1557,100,,3.68,Case Rate,Pays based on per visit rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.68,Case Rate,Pays based on per visit rate,1557,100,,1.568,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,22.264,Case Rate,Pays based on per visit rate,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,522.83,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3734.49,100,,2146.136,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3734.49,
MR BRST CAD,52500073,CDM,610,RC,C8937,HCPCS,Outpatient,,,165.38,99.23,,2790.52,110,,2232.416,Percent of Total Billed Charges,110% of Total Billed Charges,74.42,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,253.624,Fee Schedule,320% of BCBS Blue Essentials Rate,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,,Fee Schedule,360% of BCBS POS Rate,67.46,360,,,Fee schedule,360% of BCBS PPO Rate,67.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,21.232,Case Rate,Pays based on per visit rate,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.38,100,,132.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.85,14.42,,20.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.04,75,,1595.32,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.68,Case Rate,Pays Based on per visit rate,1557,100,,7.056,Case Rate,Pays based on per visit rate,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1557,100,,7.056,Case Rate,Pays based on per visit rate,1557,100,,0.264,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2245,100,,2.944,Case Rate,Pays based on per visit rate,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.38,100,,2127.088,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,2790.52,
MR BRST CAD,52500073,CDM,610,RC,C8937,HCPCS,Outpatient,,,165.38,99.23,,2790.52,110,,2232.416,Percent of Total Billed Charges,110% of Total Billed Charges,74.42,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,254.208,Fee Schedule,320% of BCBS Blue Essentials Rate,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,,Fee Schedule,360% of BCBS POS Rate,67.46,360,,,Fee schedule,360% of BCBS PPO Rate,67.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,21.232,Case Rate,Pays based on per visit rate,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.38,100,,132.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.85,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.04,75,,1984.848,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,7.056,Case Rate,Pays Based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1557,100,,0.472,Case Rate,Pays based on per visit rate,1557,100,,4.76,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2245,100,,10.312,Case Rate,Pays based on per visit rate,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,23.15,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.38,100,,2646.464,Percent of Total Billed Charges,100% of Total Billed Charges,23.15,2790.52,
MR CSPINE WWO CM,52502309,CDM,612,RC,72156,HCPCS,Outpatient,,,4309.92,2585.95,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,255.36,Fee Schedule,320% of BCBS Blue Essentials Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,71.992,Case Rate,Pays based on per visit rate,334.46,100,,1.4,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,344.49,103,,1.448,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3232.44,75,,1984.848,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,7.056,Case Rate,Pays Based on per visit rate,1557,100,,0.504,Case Rate,Pays based on per visit rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.504,Case Rate,Pays based on per visit rate,1557,100,,2.664,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,6.304,Case Rate,Pays based on per visit rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,1.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4309.92,100,,2646.464,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4309.92,
MR CSPINE WWO CM,52502309,CDM,612,RC,72156,HCPCS,Outpatient,,,4309.92,2585.95,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,255.736,Fee Schedule,320% of BCBS Blue Essentials Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,144,Case Rate,Pays based on per visit rate,334.46,100,,4.68,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,344.49,103,,4.816,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3232.44,75,,1467.304,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.472,Case Rate,Pays Based on per visit rate,1557,100,,0.552,Case Rate,Pays based on per visit rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.552,Case Rate,Pays based on per visit rate,1557,100,,14.2,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,428.408,Case Rate,Pays based on per visit rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,334.46,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4309.92,100,,1956.4,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4309.92,
MR TSPINE WWO CM,52502341,CDM,612,RC,72157,HCPCS,Outpatient,,,4361.74,2617.04,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,255.736,Fee Schedule,320% of BCBS Blue Essentials Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,9.368,Case Rate,Pays based on per visit rate,335.14,100,,199.416,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,345.19,103,,205.4,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3271.31,75,,1467.304,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.504,Case Rate,Pays Based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,1557,100,,28.48,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,166.32,Case Rate,Pays based on per visit rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,199.416,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4361.74,100,,1956.4,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4361.74,
MR TSPINE WWO CM,52502341,CDM,612,RC,72157,HCPCS,Outpatient,,,4361.74,2617.04,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,255.736,Fee Schedule,320% of BCBS Blue Essentials Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,133.424,Case Rate,Pays based on per visit rate,335.14,100,,33.752,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,345.19,103,,34.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3271.31,75,,1944.192,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.552,Case Rate,Pays Based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,1557,100,,15.04,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.272,Case Rate,Pays based on per visit rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,335.14,100,,33.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4361.74,100,,2592.256,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4361.74,
MR TSPINE W CM,52502358,CDM,612,RC,72147,HCPCS,Outpatient,,,3288.2,1972.92,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,20.184,Case Rate,Pays based on per visit rate,285.35,100,,6.912,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,293.91,103,,7.12,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2466.15,75,,1944.192,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.96,Case Rate,Pays Based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,1557,100,,1.712,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,276.784,Case Rate,Pays based on per visit rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,6.912,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3288.2,100,,2592.256,Percent of Total Billed Charges,100% of Total Billed Charges,285.35,3288.2,
MR TSPINE W CM,52502358,CDM,612,RC,72147,HCPCS,Outpatient,,,3288.2,1972.92,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,90.008,Case Rate,Pays based on per visit rate,285.35,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,293.91,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2466.15,75,,2019.888,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.96,Case Rate,Pays Based on per visit rate,1557,100,,1.84,Case Rate,Pays based on per visit rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.84,Case Rate,Pays based on per visit rate,1557,100,,1.528,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,31.144,Case Rate,Pays based on per visit rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,285.35,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3288.2,100,,2693.184,Percent of Total Billed Charges,100% of Total Billed Charges,285.35,3288.2,
MR LSPINE WWO CM,52502382,CDM,612,RC,72158,HCPCS,Outpatient,,,4262.1,2557.26,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,62.44,Case Rate,Pays based on per visit rate,333.8,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,343.81,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3196.58,75,,2019.888,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.96,Case Rate,Pays Based on per visit rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,1557,100,,1.76,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3.208,Case Rate,Pays based on per visit rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4262.1,100,,2693.184,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4262.1,
MR LSPINE WWO CM,52502382,CDM,612,RC,72158,HCPCS,Outpatient,,,4262.1,2557.26,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,146.36,Case Rate,Pays based on per visit rate,333.8,100,,9.4,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,343.81,103,,9.68,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3196.58,75,,2562.984,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.84,Case Rate,Pays Based on per visit rate,1557,100,,2.824,Case Rate,Pays based on per visit rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.824,Case Rate,Pays based on per visit rate,1557,100,,28.016,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,18.472,Case Rate,Pays based on per visit rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,333.8,100,,9.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4262.1,100,,3417.312,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4262.1,
MR ANGIO HEAD WO CM,52506011,CDM,615,RC,70544,HCPCS,Outpatient,,,2472.9,1483.74,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,20.4,Case Rate,Pays based on per visit rate,224.54,100,,0.584,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,231.28,103,,0.6,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1854.68,75,,2562.984,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.192,Case Rate,Pays Based on per visit rate,1557,100,,6.28,Case Rate,Pays based on per visit rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.28,Case Rate,Pays based on per visit rate,1557,100,,1.92,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,16.04,Case Rate,Pays based on per visit rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,0.584,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2472.9,100,,3417.312,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR ANGIO HEAD WO CM,52506011,CDM,615,RC,70544,HCPCS,Outpatient,,,2472.9,1483.74,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,22.496,Case Rate,Pays based on per visit rate,224.54,100,,1.256,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,231.28,103,,1.288,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1854.68,75,,1708.656,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.824,Case Rate,Pays Based on per visit rate,1557,100,,0.96,Case Rate,Pays based on per visit rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.96,Case Rate,Pays based on per visit rate,1557,100,,3.68,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,77.048,Case Rate,Pays based on per visit rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.54,100,,1.256,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2472.9,100,,2278.208,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR BX BRST INI RT,52506012,CDM,361,RC,,,Outpatient,,,4914,2948.40,,2948.4,60,,2358.72,Percent of Total Billed Charges,60% of Total Billed Charges,2211.3,45,,1769.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1375.92,28,,1100.736,Percent of Total Billed Charges,28% of Total Billed Charges,112.37,32,,89.896,Percent of Total Billed Charges,32% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,1769.04,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,1769.04,36,,1415.232,Percent of Total Billed Charges,36% Total Bille Charges,1769.04,36,,1415.232,Percent of Total Billed Charges,36% of Total Billed Charges,2948.4,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4914,100,,3931.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,708.6,14.42,,5.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3685.5,75,,1708.656,Percent of Total Billed Charges,75% of Total Billed Charges,2457,50,,6.28,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,216.552,Percent of Total Billed Charges,50% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2457,50,,216.552,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,7.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3439.8,70,,5.712,Percent of Total Billed Charges,70% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4914,100,,2278.208,Percent of Total Billed Charges,100% of Total Billed Charges,112.37,4914,
MR ANGIO HEAD WWO CM,52506037,CDM,615,RC,70546,HCPCS,Outpatient,,,3723.22,2233.93,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,6.128,Case Rate,Pays based on per visit rate,343.83,100,,93.008,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,354.14,103,,95.8,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2792.42,75,,3545.872,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.96,Case Rate,Pays Based on per visit rate,1557,100,,53.88,Case Rate,Pays based on per visit rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,53.88,Case Rate,Pays based on per visit rate,1557,100,,7.056,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,25.48,Case Rate,Pays based on per visit rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,93.008,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3723.22,100,,4727.832,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3723.22,
MR ANGIO HEAD WWO CM,52506037,CDM,615,RC,70546,HCPCS,Outpatient,,,3723.22,2233.93,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.464,Case Rate,Pays based on per visit rate,343.83,100,,3.208,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,354.14,103,,3.304,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2792.42,75,,3545.872,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,216.552,Case Rate,Pays Based on per visit rate,1557,100,,0.072,Case Rate,Pays based on per visit rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.072,Case Rate,Pays based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,117.936,Case Rate,Pays based on per visit rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,343.83,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3723.22,100,,4727.832,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3723.22,
MR ANGIO NECK WO CM,52506060,CDM,615,RC,70547,HCPCS,Outpatient,,,2609.47,1565.68,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.736,Case Rate,Pays based on per visit rate,224.88,100,,1.368,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,231.63,103,,1.408,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1957.1,75,,2363.92,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,53.88,Case Rate,Pays Based on per visit rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,1557,100,,0.504,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,90.864,Case Rate,Pays based on per visit rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,1.368,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2609.47,100,,3151.888,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR ANGIO NECK WO CM,52506060,CDM,615,RC,70547,HCPCS,Outpatient,,,2609.47,1565.68,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.704,Case Rate,Pays based on per visit rate,224.88,100,,15.08,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,231.63,103,,15.536,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1957.1,75,,2363.92,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.072,Case Rate,Pays Based on per visit rate,1557,100,,0.144,Case Rate,Pays based on per visit rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.144,Case Rate,Pays based on per visit rate,1557,100,,0.552,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,34.92,Case Rate,Pays based on per visit rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.88,100,,15.08,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2609.47,100,,3151.888,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR ANGIO NECK W CM,52506078,CDM,615,RC,70548,HCPCS,Outpatient,,,2849.53,1709.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.704,Case Rate,Pays based on per visit rate,256.61,100,,3.2,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,264.31,103,,3.296,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.15,75,,1541.64,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.056,Case Rate,Pays Based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,176.312,Case Rate,Pays based on per visit rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,3.2,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2849.53,100,,2055.52,Percent of Total Billed Charges,100% of Total Billed Charges,256.61,2849.53,
MR ANGIO NECK W CM,52506078,CDM,615,RC,70548,HCPCS,Outpatient,,,2849.53,1709.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,38.4,Case Rate,Pays based on per visit rate,256.61,100,,24.456,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,264.31,103,,25.184,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2137.15,75,,1541.64,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.144,Case Rate,Pays Based on per visit rate,1557,100,,11.456,Case Rate,Pays based on per visit rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,11.456,Case Rate,Pays based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.104,Case Rate,Pays based on per visit rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,256.61,100,,24.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2849.53,100,,2055.52,Percent of Total Billed Charges,100% of Total Billed Charges,256.61,2849.53,
MR ANGIO NECK WWO CM,52506086,CDM,615,RC,70549,HCPCS,Outpatient,,,3556.12,2133.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,31.2,Case Rate,Pays based on per visit rate,360.53,100,,0.256,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,371.35,103,,0.264,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2667.09,75,,1496.728,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.152,Case Rate,Pays Based on per visit rate,1557,100,,10.976,Case Rate,Pays based on per visit rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,10.976,Case Rate,Pays based on per visit rate,1557,100,,6.96,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.552,Case Rate,Pays based on per visit rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3556.12,100,,1995.64,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3556.12,
MR ANGIO NECK WWO CM,52506086,CDM,615,RC,70549,HCPCS,Outpatient,,,3556.12,2133.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,80.152,Case Rate,Pays based on per visit rate,360.53,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,371.35,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2667.09,75,,1496.728,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,11.456,Case Rate,Pays Based on per visit rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,1557,100,,1.84,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,5.104,Case Rate,Pays based on per visit rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,360.53,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3556.12,100,,1995.64,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3556.12,
MR CSPINE WO CM,52506623,CDM,612,RC,72141,HCPCS,Outpatient,,,3029.5,1817.70,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,85.328,Case Rate,Pays based on per visit rate,198.48,100,,19.616,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,204.43,103,,20.208,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2272.13,75,,3315.392,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,10.976,Case Rate,Pays Based on per visit rate,1557,100,,0.08,Case Rate,Pays based on per visit rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.08,Case Rate,Pays based on per visit rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,26.88,Case Rate,Pays based on per visit rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,19.616,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3029.5,100,,4420.52,Percent of Total Billed Charges,100% of Total Billed Charges,198.48,3029.5,
MR CSPINE WO CM,52506623,CDM,612,RC,72141,HCPCS,Outpatient,,,3029.5,1817.70,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,25.064,Case Rate,Pays based on per visit rate,198.48,100,,29.344,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,204.43,103,,30.224,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2272.13,75,,3315.392,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.056,Case Rate,Pays Based on per visit rate,1557,100,,0.432,Case Rate,Pays based on per visit rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.432,Case Rate,Pays based on per visit rate,1557,100,,2.824,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,308,Case Rate,Pays based on per visit rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,29.344,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3029.5,100,,4420.52,Percent of Total Billed Charges,100% of Total Billed Charges,198.48,3029.5,
MR TSPINE WO CM,52506763,CDM,612,RC,72146,HCPCS,Outpatient,,,2816.27,1689.76,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,90.008,Case Rate,Pays based on per visit rate,198.48,100,,31.44,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,204.43,103,,32.384,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2112.2,75,,2210.264,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.08,Case Rate,Pays Based on per visit rate,1557,100,,1.936,Case Rate,Pays based on per visit rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.936,Case Rate,Pays based on per visit rate,1557,100,,6.28,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.44,Case Rate,Pays based on per visit rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,31.44,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2816.27,100,,2947.016,Percent of Total Billed Charges,100% of Total Billed Charges,198.48,2816.27,
MR TSPINE WO CM,52506763,CDM,612,RC,72146,HCPCS,Outpatient,,,2816.27,1689.76,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,98.256,Case Rate,Pays based on per visit rate,198.48,100,,3.992,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,204.43,103,,4.112,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2112.2,75,,2210.264,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.432,Case Rate,Pays Based on per visit rate,1557,100,,0.28,Case Rate,Pays based on per visit rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.28,Case Rate,Pays based on per visit rate,1557,100,,0.96,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,149.92,Case Rate,Pays based on per visit rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,198.48,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2816.27,100,,2947.016,Percent of Total Billed Charges,100% of Total Billed Charges,198.48,2816.27,
MR LSPINE WO CM,52506920,CDM,612,RC,72148,HCPCS,Outpatient,,,3009.43,1805.66,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,879.208,Case Rate,Pays based on per visit rate,199.14,100,,6.376,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,205.11,103,,6.568,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2257.07,75,,1826.352,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.936,Case Rate,Pays Based on per visit rate,1557,100,,0.64,Case Rate,Pays based on per visit rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.64,Case Rate,Pays based on per visit rate,1557,100,,216.552,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,25.456,Case Rate,Pays based on per visit rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,6.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3009.43,100,,2435.136,Percent of Total Billed Charges,100% of Total Billed Charges,199.14,3009.43,
MR LSPINE WO CM,52506920,CDM,612,RC,72148,HCPCS,Outpatient,,,3009.43,1805.66,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.064,Case Rate,Pays based on per visit rate,199.14,100,,22.048,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,205.11,103,,22.712,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2257.07,75,,1826.352,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.28,Case Rate,Pays Based on per visit rate,1557,100,,0.304,Case Rate,Pays based on per visit rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.304,Case Rate,Pays based on per visit rate,1557,100,,53.88,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,19.976,Case Rate,Pays based on per visit rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,199.14,100,,22.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3009.43,100,,2435.136,Percent of Total Billed Charges,100% of Total Billed Charges,199.14,3009.43,
MR LSPINE W CM,52506938,CDM,612,RC,72149,HCPCS,Outpatient,,,3168.01,1900.81,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,53.096,Case Rate,Pays based on per visit rate,282.68,100,,0.728,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,291.16,103,,0.752,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2376.01,75,,1703.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.64,Case Rate,Pays Based on per visit rate,1557,100,,3.496,Case Rate,Pays based on per visit rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.496,Case Rate,Pays based on per visit rate,1557,100,,0.072,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,403.752,Case Rate,Pays based on per visit rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.728,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3168.01,100,,2271.464,Percent of Total Billed Charges,100% of Total Billed Charges,282.68,3168.01,
MR LSPINE W CM,52506938,CDM,612,RC,72149,HCPCS,Outpatient,,,3168.01,1900.81,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,106.112,Case Rate,Pays based on per visit rate,282.68,100,,12.568,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,291.16,103,,12.944,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2376.01,75,,1703.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.304,Case Rate,Pays Based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,69.304,Case Rate,Pays based on per visit rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,12.568,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3168.01,100,,2271.464,Percent of Total Billed Charges,100% of Total Billed Charges,282.68,3168.01,
MR BRAIN WO CM,52508025,CDM,611,RC,70551,HCPCS,Outpatient,,,2898,1738.80,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,126.344,Case Rate,Pays based on per visit rate,204.15,100,,0.512,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,210.27,103,,0.52,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2173.5,75,,2448.664,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.496,Case Rate,Pays Based on per visit rate,1557,100,,0.648,Case Rate,Pays based on per visit rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.648,Case Rate,Pays based on per visit rate,1557,100,,0.144,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,69.304,Case Rate,Pays based on per visit rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2898,100,,3264.888,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2898,
MR BRAIN WO CM,52508025,CDM,611,RC,70551,HCPCS,Outpatient,,,2898,1738.80,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,283.488,Case Rate,Pays based on per visit rate,204.15,100,,0.064,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,210.27,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2173.5,75,,2448.664,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.392,Case Rate,Pays Based on per visit rate,1557,100,,1.88,Case Rate,Pays based on per visit rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.88,Case Rate,Pays based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,357.736,Case Rate,Pays based on per visit rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,204.15,100,,0.064,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2898,100,,3264.888,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2898,
MR BRAIN W CM,52508108,CDM,611,RC,70552,HCPCS,Outpatient,,,3299.11,1979.47,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,333.496,Case Rate,Pays based on per visit rate,282.68,100,,0.136,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,291.16,103,,0.136,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2474.33,75,,1359.16,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.648,Case Rate,Pays Based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,1557,100,,11.456,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.192,Case Rate,Pays based on per visit rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.136,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3299.11,100,,1812.208,Percent of Total Billed Charges,100% of Total Billed Charges,282.68,3299.11,
MR BRAIN W CM,52508108,CDM,611,RC,70552,HCPCS,Outpatient,,,3299.11,1979.47,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,6.12,Case Rate,Pays based on per visit rate,282.68,100,,0.608,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,291.16,103,,0.624,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2474.33,75,,1359.16,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.88,Case Rate,Pays Based on per visit rate,1557,100,,0.92,Case Rate,Pays based on per visit rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.92,Case Rate,Pays based on per visit rate,1557,100,,10.976,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.248,Case Rate,Pays based on per visit rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,282.68,100,,0.608,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3299.11,100,,1812.208,Percent of Total Billed Charges,100% of Total Billed Charges,282.68,3299.11,
MR BRAIN WWO CM,52508165,CDM,611,RC,70553,HCPCS,Outpatient,,,4234.11,2540.47,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,8.384,Case Rate,Pays based on per visit rate,332.8,100,,12.456,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,342.78,103,,12.832,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3175.58,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.472,Case Rate,Pays Based on per visit rate,1557,100,,4.416,Case Rate,Pays based on per visit rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.416,Case Rate,Pays based on per visit rate,1557,100,,0.056,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,2.184,Case Rate,Pays based on per visit rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,12.456,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4234.11,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4234.11,
MR BRAIN WWO CM,52508165,CDM,611,RC,70553,HCPCS,Outpatient,,,4234.11,2540.47,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.576,Case Rate,Pays based on per visit rate,332.8,100,,2.808,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,342.78,103,,2.896,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3175.58,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.92,Case Rate,Pays Based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,1557,100,,0.08,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,209.16,Case Rate,Pays based on per visit rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,332.8,100,,2.808,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4234.11,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4234.11,
MR ORBIT FACE NECK W CM,52508215,CDM,614,RC,70542,HCPCS,Outpatient,,,2292.36,1375.42,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,8.384,Case Rate,Pays based on per visit rate,281,100,,1.736,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,289.43,103,,1.792,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1719.27,75,,1703.152,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.416,Case Rate,Pays Based on per visit rate,1557,100,,0.592,Case Rate,Pays based on per visit rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.592,Case Rate,Pays based on per visit rate,1557,100,,0.432,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,170.872,Case Rate,Pays based on per visit rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.36,100,,2270.872,Percent of Total Billed Charges,100% of Total Billed Charges,281,2790,
MR ORBIT FACE NECK W CM,52508215,CDM,614,RC,70542,HCPCS,Outpatient,,,2292.36,1375.42,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,23.792,Case Rate,Pays based on per visit rate,281,100,,1.12,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,289.43,103,,1.152,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1719.27,75,,1958.032,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.392,Case Rate,Pays Based on per visit rate,1557,100,,30.608,Case Rate,Pays based on per visit rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,30.608,Case Rate,Pays based on per visit rate,1557,100,,1.936,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,291.136,Case Rate,Pays based on per visit rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,281,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.36,100,,2610.712,Percent of Total Billed Charges,100% of Total Billed Charges,281,2790,
MR ORBIT FACE NECK WWO CM,52508223,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,35.136,Case Rate,Pays based on per visit rate,354.85,100,,78.384,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,80.736,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1958.032,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.592,Case Rate,Pays Based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,1557,100,,0.28,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,333.696,Case Rate,Pays based on per visit rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,78.384,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,2610.712,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR ORBIT FACE NECK WWO CM,52508223,CDM,614,RC,70543,HCPCS,Outpatient,,,3715.9,2229.54,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,201.6,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,365.5,103,,5.384,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2786.93,75,,1447.896,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,30.608,Case Rate,Pays Based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,1557,100,,0.64,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,135.072,Case Rate,Pays based on per visit rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,354.85,100,,5.224,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3715.9,100,,1930.528,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3715.9,
MR UPR EXT WO CM BI,52508397,CDM,610,RC,73218,HCPCS,Outpatient,,,3514.3,2108.58,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,30.328,Case Rate,Pays based on per visit rate,233.52,100,,0.32,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.328,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2635.73,75,,1447.896,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.152,Case Rate,Pays Based on per visit rate,1557,100,,0.488,Case Rate,Pays based on per visit rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.488,Case Rate,Pays based on per visit rate,1557,100,,0.304,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,168,Case Rate,Pays based on per visit rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.32,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3514.3,100,,1930.528,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3514.3,
MR UPR EXT WO CM BI,52508397,CDM,610,RC,73218,HCPCS,Outpatient,,,3514.3,2108.58,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,30.328,Case Rate,Pays based on per visit rate,233.52,100,,2.144,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,2.208,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2635.73,75,,1405.72,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.152,Case Rate,Pays Based on per visit rate,1557,100,,5.624,Case Rate,Pays based on per visit rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.624,Case Rate,Pays based on per visit rate,1557,100,,3.496,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,434.648,Case Rate,Pays based on per visit rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,2.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3514.3,100,,1874.296,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3514.3,
MR UPR EXT WO CM LT,52508405,CDM,610,RC,73218,HCPCS,Outpatient,,,2342.87,1405.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,23.904,Case Rate,Pays based on per visit rate,233.52,100,,1.36,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,1.4,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1757.15,75,,1405.72,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.488,Case Rate,Pays Based on per visit rate,1557,100,,6.504,Case Rate,Pays based on per visit rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.504,Case Rate,Pays based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,185.224,Case Rate,Pays based on per visit rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.36,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2342.87,100,,1874.296,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR UPR EXT WO CM LT,52508405,CDM,610,RC,73218,HCPCS,Outpatient,,,2342.87,1405.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.632,Case Rate,Pays based on per visit rate,233.52,100,,0.016,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.016,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1757.15,75,,2279.944,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.624,Case Rate,Pays Based on per visit rate,1557,100,,3.904,Case Rate,Pays based on per visit rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.904,Case Rate,Pays based on per visit rate,1557,100,,0.648,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,164.64,Case Rate,Pays based on per visit rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.016,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2342.87,100,,3039.92,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR UPR EXT JT W CM LT,52508447,CDM,610,RC,73222,HCPCS,Outpatient,,,2265.26,1359.16,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,6.76,Case Rate,Pays based on per visit rate,328.45,100,,2.152,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,338.3,103,,2.216,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1698.95,75,,2279.944,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.504,Case Rate,Pays Based on per visit rate,1557,100,,0.4,Case Rate,Pays based on per visit rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.4,Case Rate,Pays based on per visit rate,1557,100,,1.88,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,168,Case Rate,Pays based on per visit rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.152,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2265.26,100,,3039.92,Percent of Total Billed Charges,100% of Total Billed Charges,328.45,2790,
MR UPR EXT JT W CM LT,52508447,CDM,610,RC,73222,HCPCS,Outpatient,,,2265.26,1359.16,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,15.6,Case Rate,Pays based on per visit rate,328.45,100,,2.32,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,338.3,103,,2.384,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1698.95,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.904,Case Rate,Pays Based on per visit rate,1557,100,,2.744,Case Rate,Pays based on per visit rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.744,Case Rate,Pays based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,254.248,Case Rate,Pays based on per visit rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,2.32,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2265.26,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,328.45,2790,
MR UPR EXT JT WWO CM BI,52508454,CDM,610,RC,73223,HCPCS,Outpatient,,,4895.08,2937.05,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,205.784,Case Rate,Pays based on per visit rate,368.43,100,,21.584,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,22.232,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3671.31,75,,27.096,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.4,Case Rate,Pays Based on per visit rate,1557,100,,1.6,Case Rate,Pays based on per visit rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.6,Case Rate,Pays based on per visit rate,1557,100,,0.92,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,246.344,Case Rate,Pays based on per visit rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,21.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4895.08,100,,36.128,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4895.08,
MR UPR EXT JT WWO CM BI,52508454,CDM,610,RC,73223,HCPCS,Outpatient,,,4895.08,2937.05,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,206.68,Case Rate,Pays based on per visit rate,368.43,100,,3.752,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,3.864,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3671.31,75,,6.976,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.744,Case Rate,Pays Based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,1557,100,,4.416,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,228.792,Case Rate,Pays based on per visit rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.752,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4895.08,100,,9.304,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4895.08,
MR UPR EXT JT WWO CM LT,52508462,CDM,610,RC,73223,HCPCS,Outpatient,,,3263.39,1958.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,33.304,Case Rate,Pays based on per visit rate,368.43,100,,0.816,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.84,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2447.54,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.6,Case Rate,Pays Based on per visit rate,1557,100,,0.608,Case Rate,Pays based on per visit rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.608,Case Rate,Pays based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,155.728,Case Rate,Pays based on per visit rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.816,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3263.39,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3263.39,
MR UPR EXT JT WWO CM LT,52508462,CDM,610,RC,73223,HCPCS,Outpatient,,,3263.39,1958.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,13.968,Case Rate,Pays based on per visit rate,368.43,100,,3.992,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,4.112,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2447.54,75,,1.032,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.016,Case Rate,Pays Based on per visit rate,1557,100,,1.904,Case Rate,Pays based on per visit rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.904,Case Rate,Pays based on per visit rate,1557,100,,0.592,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,154.616,Case Rate,Pays based on per visit rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3263.39,100,,1.376,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3263.39,
MR PEL WO CM,52508504,CDM,610,RC,72195,HCPCS,Outpatient,,,2582.37,1549.42,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,78.512,Case Rate,Pays based on per visit rate,233.52,100,,4.976,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,5.128,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1936.78,75,,38.248,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.608,Case Rate,Pays Based on per visit rate,1557,100,,6.192,Case Rate,Pays based on per visit rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.192,Case Rate,Pays based on per visit rate,1557,100,,30.608,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,150.352,Case Rate,Pays based on per visit rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,4.976,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.37,100,,50.992,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR PEL WO CM,52508504,CDM,610,RC,72195,HCPCS,Outpatient,,,2582.37,1549.42,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,163.44,Case Rate,Pays based on per visit rate,233.52,100,,51.632,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,53.184,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1936.78,75,,40.08,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.904,Case Rate,Pays Based on per visit rate,1557,100,,6.68,Case Rate,Pays based on per visit rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,6.68,Case Rate,Pays based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,43.448,Case Rate,Pays based on per visit rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,51.632,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.37,100,,53.44,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR PEL WWO CM,52508520,CDM,610,RC,72197,HCPCS,Outpatient,,,3648.98,2189.39,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,7.76,Case Rate,Pays based on per visit rate,353.18,100,,7.504,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,363.78,103,,7.728,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2736.74,75,,23.848,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.192,Case Rate,Pays Based on per visit rate,1557,100,,0.616,Case Rate,Pays based on per visit rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.616,Case Rate,Pays based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,190.288,Case Rate,Pays based on per visit rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,7.504,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3648.98,100,,31.792,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3648.98,
MR PEL WWO CM,52508520,CDM,610,RC,72197,HCPCS,Outpatient,,,3648.98,2189.39,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.872,Case Rate,Pays based on per visit rate,353.18,100,,4.536,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,363.78,103,,4.672,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2736.74,75,,10.264,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,6.68,Case Rate,Pays Based on per visit rate,1557,100,,5.24,Case Rate,Pays based on per visit rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.24,Case Rate,Pays based on per visit rate,1557,100,,0.488,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,151.432,Case Rate,Pays based on per visit rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,353.18,100,,4.536,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3648.98,100,,13.68,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3648.98,
MR CHEST WWO CM,52509726,CDM,610,RC,71552,HCPCS,Outpatient,,,3477.62,2086.57,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,39.72,Case Rate,Pays based on per visit rate,368.43,100,,0.072,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.072,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2608.22,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.616,Case Rate,Pays Based on per visit rate,1557,100,,1.04,Case Rate,Pays based on per visit rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.04,Case Rate,Pays based on per visit rate,1557,100,,5.624,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,221.968,Case Rate,Pays based on per visit rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.072,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3477.62,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3477.62,
MR CHEST WWO CM,52509726,CDM,610,RC,71552,HCPCS,Outpatient,,,3477.62,2086.57,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,50.392,Case Rate,Pays based on per visit rate,368.43,100,,4.8,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,4.944,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2608.22,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.24,Case Rate,Pays Based on per visit rate,1557,100,,9.712,Case Rate,Pays based on per visit rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,9.712,Case Rate,Pays based on per visit rate,1557,100,,6.504,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,13.568,Case Rate,Pays based on per visit rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,4.8,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3477.62,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3477.62,
MR ABD W CM,52509742,CDM,610,RC,74182,HCPCS,Outpatient,,,3043.92,1826.35,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,134.752,Case Rate,Pays based on per visit rate,317.43,100,,4.68,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,326.95,103,,4.816,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2282.94,75,,16.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.04,Case Rate,Pays Based on per visit rate,1557,100,,11.536,Case Rate,Pays based on per visit rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,11.536,Case Rate,Pays based on per visit rate,1557,100,,3.904,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,32.208,Case Rate,Pays based on per visit rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,4.68,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.92,100,,22.128,Percent of Total Billed Charges,100% of Total Billed Charges,317.43,3043.92,
MR ABD W CM,52509742,CDM,610,RC,74182,HCPCS,Outpatient,,,3043.92,1826.35,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,144.008,Case Rate,Pays based on per visit rate,317.43,100,,9.256,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,326.95,103,,9.528,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2282.94,75,,5.2,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,9.712,Case Rate,Pays Based on per visit rate,1557,100,,9.152,Case Rate,Pays based on per visit rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,9.152,Case Rate,Pays based on per visit rate,1557,100,,0.4,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,20.208,Case Rate,Pays based on per visit rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,9.256,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.92,100,,6.928,Percent of Total Billed Charges,100% of Total Billed Charges,317.43,3043.92,
MR ABD WWO CM,52510005,CDM,610,RC,74183,HCPCS,Outpatient,,,4081.11,2448.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,460.8,Case Rate,Pays based on per visit rate,354.51,100,,2.936,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,365.15,103,,3.024,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3060.83,75,,1365,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,11.536,Case Rate,Pays Based on per visit rate,1557,100,,2.48,Case Rate,Pays based on per visit rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.48,Case Rate,Pays based on per visit rate,1557,100,,2.744,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,18.496,Case Rate,Pays based on per visit rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,2.936,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4081.11,100,,1820,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4081.11,
MR ABD WWO CM,52510005,CDM,610,RC,74183,HCPCS,Outpatient,,,4081.11,2448.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.296,Case Rate,Pays based on per visit rate,354.51,100,,0.944,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,365.15,103,,0.976,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3060.83,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,9.152,Case Rate,Pays Based on per visit rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,1557,100,,1.6,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,8.328,Case Rate,Pays based on per visit rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,0.944,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4081.11,100,,0.208,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4081.11,
MR LWR EXT WO CM BI,52510021,CDM,610,RC,73718,HCPCS,Outpatient,,,3741.82,2245.09,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,11.336,Case Rate,Pays based on per visit rate,233.52,100,,0.56,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.576,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2806.37,75,,28.368,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.48,Case Rate,Pays Based on per visit rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3.432,Case Rate,Pays based on per visit rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.56,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3741.82,100,,37.824,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3741.82,
MR LWR EXT WO CM BI,52510021,CDM,610,RC,73718,HCPCS,Outpatient,,,3741.82,2245.09,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.088,Case Rate,Pays based on per visit rate,233.52,100,,7.952,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,8.192,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2806.37,75,,25.848,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.192,Case Rate,Pays Based on per visit rate,1557,100,,0.36,Case Rate,Pays based on per visit rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.36,Case Rate,Pays based on per visit rate,1557,100,,0.608,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,19.6,Case Rate,Pays based on per visit rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,7.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3741.82,100,,34.464,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3741.82,
MR LWR EXT W CM LT,52510039,CDM,610,RC,73719,HCPCS,Outpatient,,,2569.4,1541.64,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.08,Case Rate,Pays based on per visit rate,274.65,100,,1.096,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,282.89,103,,1.128,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.05,75,,177.664,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.136,Case Rate,Pays Based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,1557,100,,1.904,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,14.648,Case Rate,Pays based on per visit rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,1.096,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2569.4,100,,236.88,Percent of Total Billed Charges,100% of Total Billed Charges,274.65,2790,
MR LWR EXT W CM LT,52510039,CDM,610,RC,73719,HCPCS,Outpatient,,,2569.4,1541.64,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.152,Case Rate,Pays based on per visit rate,274.65,100,,2.376,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,282.89,103,,2.448,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.05,75,,18.432,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.36,Case Rate,Pays Based on per visit rate,1557,100,,4.632,Case Rate,Pays based on per visit rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.632,Case Rate,Pays based on per visit rate,1557,100,,6.192,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,23.856,Case Rate,Pays based on per visit rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,2.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2569.4,100,,24.576,Percent of Total Billed Charges,100% of Total Billed Charges,274.65,2790,
MR LWR EXT WO CM LT,52510047,CDM,610,RC,73718,HCPCS,Outpatient,,,2494.55,1496.73,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.216,Case Rate,Pays based on per visit rate,233.52,100,,53.4,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,55.008,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.91,75,,19.792,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.472,Case Rate,Pays Based on per visit rate,1557,100,,1.288,Case Rate,Pays based on per visit rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.288,Case Rate,Pays based on per visit rate,1557,100,,6.68,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,254.952,Case Rate,Pays based on per visit rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,53.4,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2494.55,100,,26.392,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR LWR EXT WO CM LT,52510047,CDM,610,RC,73718,HCPCS,Outpatient,,,2494.55,1496.73,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.696,Case Rate,Pays based on per visit rate,233.52,100,,1545.6,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,1591.968,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.91,75,,43.192,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.632,Case Rate,Pays Based on per visit rate,1557,100,,5.584,Case Rate,Pays based on per visit rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.584,Case Rate,Pays based on per visit rate,1557,100,,0.616,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,232.312,Case Rate,Pays based on per visit rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1545.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2494.55,100,,57.592,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR LWR EXT JT W CM LT,52510062,CDM,610,RC,73722,HCPCS,Outpatient,,,3366.48,2019.89,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,5.464,Case Rate,Pays based on per visit rate,328.79,100,,6.904,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,338.65,103,,7.112,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2524.86,75,,86.368,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.288,Case Rate,Pays Based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,1557,100,,5.24,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,245.568,Case Rate,Pays based on per visit rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,6.904,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3366.48,100,,115.152,Percent of Total Billed Charges,100% of Total Billed Charges,328.79,3366.48,
MR LWR EXT JT W CM LT,52510062,CDM,610,RC,73722,HCPCS,Outpatient,,,3366.48,2019.89,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.056,Case Rate,Pays based on per visit rate,328.79,100,,10.536,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,338.65,103,,10.848,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2524.86,75,,12.352,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.584,Case Rate,Pays Based on per visit rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,1557,100,,1.04,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,308,Case Rate,Pays based on per visit rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.536,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3366.48,100,,16.464,Percent of Total Billed Charges,100% of Total Billed Charges,328.79,3366.48,
MR LWR EXT JT WWO CM LT,52510070,CDM,610,RC,73723,HCPCS,Outpatient,,,3939.86,2363.92,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,11.072,Case Rate,Pays based on per visit rate,368.43,100,,50.144,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,51.648,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2954.9,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.152,Case Rate,Pays Based on per visit rate,1557,100,,0.296,Case Rate,Pays based on per visit rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.296,Case Rate,Pays based on per visit rate,1557,100,,9.712,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,50.144,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3939.86,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3939.86,
MR LWR EXT JT WWO CM LT,52510070,CDM,610,RC,73723,HCPCS,Outpatient,,,3939.86,2363.92,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.08,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2954.9,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.216,Case Rate,Pays Based on per visit rate,1557,100,,2.04,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.04,Case Rate,Pays based on per visit rate,1557,100,,11.536,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,17.088,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3939.86,100,,0.176,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3939.86,
MR ORBIT FACE NECK WO CM,52510252,CDM,614,RC,70540,HCPCS,Outpatient,,,2258.49,1355.09,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.552,Case Rate,Pays based on per visit rate,233.52,100,,5.648,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,5.816,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.87,75,,83.056,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.296,Case Rate,Pays Based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,1557,100,,9.152,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,15.656,Case Rate,Pays based on per visit rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.648,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.49,100,,110.744,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR ORBIT FACE NECK WO CM,52510252,CDM,614,RC,70540,HCPCS,Outpatient,,,2258.49,1355.09,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.552,Case Rate,Pays based on per visit rate,233.52,100,,35.952,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,37.032,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1693.87,75,,63.744,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.04,Case Rate,Pays Based on per visit rate,1557,100,,0.744,Case Rate,Pays based on per visit rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.744,Case Rate,Pays based on per visit rate,1557,100,,2.48,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,15.448,Case Rate,Pays based on per visit rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,35.952,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.49,100,,79.68,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR CHEST WO CM,52510401,CDM,610,RC,71550,HCPCS,Outpatient,,,2558.38,1535.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.552,Case Rate,Pays based on per visit rate,233.52,100,,0.472,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,0.488,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1918.79,75,,8.656,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.152,Case Rate,Pays Based on per visit rate,1557,100,,5.816,Case Rate,Pays based on per visit rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.816,Case Rate,Pays based on per visit rate,1557,100,,0.192,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,11.728,Case Rate,Pays based on per visit rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,0.472,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2558.38,100,,11.544,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR CHEST WO CM,52510401,CDM,610,RC,71550,HCPCS,Outpatient,,,2558.38,1535.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,5.632,Case Rate,Pays based on per visit rate,233.52,100,,3.592,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,3.696,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1918.79,75,,2.608,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.744,Case Rate,Pays Based on per visit rate,1557,100,,7.52,Case Rate,Pays based on per visit rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,7.52,Case Rate,Pays based on per visit rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,3.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2558.38,100,,3.472,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR UPR EXT WWO CM BI,52510542,CDM,610,RC,73220,HCPCS,Outpatient,,,5699.85,3419.91,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,6.2,Case Rate,Pays based on per visit rate,368.43,100,,27.584,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,28.408,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4274.89,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.816,Case Rate,Pays Based on per visit rate,1557,100,,3.328,Case Rate,Pays based on per visit rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.328,Case Rate,Pays based on per visit rate,1557,100,,0.36,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.584,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5699.85,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5699.85,
MR UPR EXT WWO CM BI,52510542,CDM,610,RC,73220,HCPCS,Outpatient,,,5699.85,3419.91,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,78.328,Case Rate,Pays based on per visit rate,368.43,100,,1.392,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,1.44,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4274.89,75,,6.592,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,7.52,Case Rate,Pays Based on per visit rate,1557,100,,0.864,Case Rate,Pays based on per visit rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.864,Case Rate,Pays based on per visit rate,1557,100,,0.472,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,1.392,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5699.85,100,,8.792,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5699.85,
MR UPR EXT WWO CM LT,52510559,CDM,610,RC,73220,HCPCS,Outpatient,,,3799.9,2279.94,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.664,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2849.93,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.328,Case Rate,Pays Based on per visit rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,1557,100,,4.632,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,47.816,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3799.9,100,,24.8,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3799.9,
MR UPR EXT WWO CM LT,52510559,CDM,610,RC,73220,HCPCS,Outpatient,,,3799.9,2279.94,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.312,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,5.768,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2849.93,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.864,Case Rate,Pays Based on per visit rate,1557,100,,34.2,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,34.2,Case Rate,Pays based on per visit rate,1557,100,,1.288,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,5.6,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3799.9,100,,24.8,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3799.9,
MR UPR EXT JT WO CM BI,52510591,CDM,610,RC,73221,HCPCS,Outpatient,,,4257.89,2554.73,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.928,Case Rate,Pays based on per visit rate,211.18,100,,17.136,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,17.648,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3193.42,75,,63.264,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.52,Case Rate,Pays Based on per visit rate,1557,100,,4.224,Case Rate,Pays based on per visit rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.224,Case Rate,Pays based on per visit rate,1557,100,,5.584,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28.24,Case Rate,Pays based on per visit rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,17.136,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4257.89,100,,84.352,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,4257.89,
MR UPR EXT JT WO CM BI,52510591,CDM,610,RC,73221,HCPCS,Outpatient,,,4257.89,2554.73,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.36,Case Rate,Pays based on per visit rate,211.18,100,,16.416,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,16.912,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3193.42,75,,175.88,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,34.2,Case Rate,Pays Based on per visit rate,1557,100,,3.72,Case Rate,Pays based on per visit rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.72,Case Rate,Pays based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,7.088,Case Rate,Pays based on per visit rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,16.416,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4257.89,100,,234.504,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,4257.89,
MR UPR EXT JT WO CM BI,52510591,CDM,610,RC,73221,HCPCS,Outpatient,,,4257.89,2554.73,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,5.848,Case Rate,Pays based on per visit rate,211.18,100,,9.048,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,9.32,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3193.42,75,,3.576,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.224,Case Rate,Pays Based on per visit rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,28,Case Rate,Pays based on per visit rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,9.048,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4257.89,100,,4.768,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,4257.89,
MR UPR EXT JT WO CM LT,52510609,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.136,Case Rate,Pays based on per visit rate,211.18,100,,0.056,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,0.056,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,2.16,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.72,Case Rate,Pays Based on per visit rate,1557,100,,0.784,Case Rate,Pays based on per visit rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.784,Case Rate,Pays based on per visit rate,1557,100,,0.296,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,308,Case Rate,Pays based on per visit rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,0.056,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,2.88,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR UPR EXT JT WO CM LT,52510609,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,32.656,Case Rate,Pays based on per visit rate,211.18,100,,13.376,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,13.776,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,82.408,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.664,Case Rate,Pays Based on per visit rate,1557,100,,0.624,Case Rate,Pays based on per visit rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.624,Case Rate,Pays based on per visit rate,1557,100,,2.04,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,98.928,Case Rate,Pays based on per visit rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.376,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,109.88,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR UPR EXT JT WO CM LT,52510609,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,286.072,Case Rate,Pays based on per visit rate,211.18,100,,10.784,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,11.104,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.784,Case Rate,Pays Based on per visit rate,1557,100,,1.088,Case Rate,Pays based on per visit rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.088,Case Rate,Pays based on per visit rate,1557,100,,0.152,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,133.84,Case Rate,Pays based on per visit rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,10.784,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR LWR EXT WWO CM LT,52510658,CDM,610,RC,73720,HCPCS,Outpatient,,,3683.77,2210.26,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,125.096,Case Rate,Pays based on per visit rate,353.51,100,,0.984,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,1.008,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2762.83,75,,7.816,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.624,Case Rate,Pays Based on per visit rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,1557,100,,0.744,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,21.2,Case Rate,Pays based on per visit rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3683.77,100,,10.424,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3683.77,
MR LWR EXT WWO CM LT,52510658,CDM,610,RC,73720,HCPCS,Outpatient,,,3683.77,2210.26,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,138.464,Case Rate,Pays based on per visit rate,353.51,100,,15.4,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,15.864,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2762.83,75,,474,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.088,Case Rate,Pays Based on per visit rate,1557,100,,0.096,Case Rate,Pays based on per visit rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.096,Case Rate,Pays based on per visit rate,1557,100,,5.816,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,308,Case Rate,Pays based on per visit rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,15.4,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3683.77,100,,632,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3683.77,
MR LWR EXT JT WO CM LT,52510708,CDM,610,RC,73721,HCPCS,Outpatient,,,2847.76,1708.66,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,75.32,Case Rate,Pays based on per visit rate,210.84,100,,309.12,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,318.392,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2135.82,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.664,Case Rate,Pays Based on per visit rate,1557,100,,0.112,Case Rate,Pays based on per visit rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.112,Case Rate,Pays based on per visit rate,1557,100,,7.52,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,134.512,Case Rate,Pays based on per visit rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,309.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.76,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2847.76,
MR LWR EXT JT WO CM LT,52510708,CDM,610,RC,73721,HCPCS,Outpatient,,,2847.76,1708.66,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,104.456,Case Rate,Pays based on per visit rate,210.84,100,,10.424,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,10.736,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2135.82,75,,7176.712,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.096,Case Rate,Pays Based on per visit rate,1557,100,,1.656,Case Rate,Pays based on per visit rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.656,Case Rate,Pays based on per visit rate,1557,100,,3.328,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,87.896,Case Rate,Pays based on per visit rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,10.424,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.76,100,,9568.944,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2847.76,
MR ABD WO CM,52510757,CDM,610,RC,74181,HCPCS,Outpatient,,,2839.33,1703.60,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.552,Case Rate,Pays based on per visit rate,204.83,100,,1.12,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,210.97,103,,1.152,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2129.5,75,,176.328,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.112,Case Rate,Pays Based on per visit rate,1557,100,,9.88,Case Rate,Pays based on per visit rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,9.88,Case Rate,Pays based on per visit rate,1557,100,,0.864,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,43.96,Case Rate,Pays based on per visit rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,1.12,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.33,100,,235.104,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2839.33,
MR ABD WO CM,52510757,CDM,610,RC,74181,HCPCS,Outpatient,,,2839.33,1703.60,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,9.008,Case Rate,Pays based on per visit rate,204.83,100,,12.696,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,210.97,103,,13.08,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2129.5,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.656,Case Rate,Pays Based on per visit rate,1557,100,,4.296,Case Rate,Pays based on per visit rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.296,Case Rate,Pays based on per visit rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,43.96,Case Rate,Pays based on per visit rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,12.696,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.33,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2839.33,
PATELLA TENDON HEMI,525748,CDM,272,RC,,,Outpatient,,,9600,5760.00,,5760,60,,4608,Percent of Total Billed Charges,60% of Total Billed Charges,4320,45,,3456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2688,28,,2150.4,Percent of Total Billed Charges,28% of Total Billed Charges,112.38,32,,89.904,Percent of Total Billed Charges,32% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,3456,36,,2764.8,Percent of Total Billed Charges,36% of Total Billed Charges,3456,36,,2764.8,Percent of Total Billed Charges,36% Total Bille Charges,3456,36,,2764.8,Percent of Total Billed Charges,36% of Total Billed Charges,5760,60,,5.096,Percent of Total Billed Charges,60% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9600,100,,7680,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1384.32,14.42,,20.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7200,75,,0.952,Percent of Total Billed Charges,75% of Total Billed Charges,4800,50,,9.88,Percent of Total Billed Charges,50% of Total Billed Charges,4800,50,,1.848,Percent of Total Billed Charges,50% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4800,50,,1.848,Percent of Total Billed Charges,50% of Total Billed Charges,4800,50,,34.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6720,70,,92.92,Percent of Total Billed Charges,70% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,1344,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9600,100,,1.264,Percent of Total Billed Charges,100% of Total Billed Charges,112.38,9600,
GRAFT BONE HUM SHAFT 150X20-25MM ALLOGFT,525749,CDM,272,RC,,,Outpatient,,,3240,1944.00,,1944,60,,1555.2,Percent of Total Billed Charges,60% of Total Billed Charges,1458,45,,1166.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,907.2,28,,725.76,Percent of Total Billed Charges,28% of Total Billed Charges,112.44,32,,89.952,Percent of Total Billed Charges,32% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,1166.4,36,,933.12,Percent of Total Billed Charges,36% of Total Billed Charges,1166.4,36,,933.12,Percent of Total Billed Charges,36% Total Bille Charges,1166.4,36,,933.12,Percent of Total Billed Charges,36% of Total Billed Charges,1944,60,,19.736,Percent of Total Billed Charges,60% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3240,100,,2592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,467.21,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2430,75,,7.544,Percent of Total Billed Charges,75% of Total Billed Charges,1620,50,,4.296,Percent of Total Billed Charges,50% of Total Billed Charges,1620,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1620,50,,0.024,Percent of Total Billed Charges,50% of Total Billed Charges,1620,50,,4.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2268,70,,60.752,Percent of Total Billed Charges,70% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,453.6,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3240,100,,10.056,Percent of Total Billed Charges,100% of Total Billed Charges,112.44,3240,
MR ANGIO ABD WO CM,52589017,CDM,618,RC,C8901,HCPCS,Outpatient,,,2549.09,1529.45,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,120.96,Case Rate,Pays based on per visit rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,367.58,14.42,,1.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1911.82,75,,87.256,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.848,Case Rate,Pays Based on per visit rate,1557,100,,0.04,Case Rate,Pays based on per visit rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.04,Case Rate,Pays based on per visit rate,1557,100,,3.72,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,5.216,Case Rate,Pays based on per visit rate,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2549.09,100,,116.336,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR ANGIO ABD WO CM,52589017,CDM,618,RC,C8901,HCPCS,Outpatient,,,2549.09,1529.45,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,31.792,Case Rate,Pays based on per visit rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,367.58,14.42,,27.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1911.82,75,,2700,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.024,Case Rate,Pays Based on per visit rate,1557,100,,1.096,Case Rate,Pays based on per visit rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.096,Case Rate,Pays based on per visit rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3.792,Case Rate,Pays based on per visit rate,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,356.87,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2549.09,100,,3600,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR ANGIO ABD WWO CM,52589025,CDM,618,RC,C8902,HCPCS,Outpatient,,,3156.85,1894.11,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,53.528,Case Rate,Pays based on per visit rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,455.22,14.42,,239.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2367.64,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.04,Case Rate,Pays Based on per visit rate,1557,100,,3.6,Case Rate,Pays based on per visit rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.6,Case Rate,Pays based on per visit rate,1557,100,,0.784,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,1.48,Case Rate,Pays based on per visit rate,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3156.85,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3156.85,
MR ANGIO ABD WWO CM,52589025,CDM,618,RC,C8902,HCPCS,Outpatient,,,3156.85,1894.11,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,74.264,Case Rate,Pays based on per visit rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,455.22,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2367.64,75,,141.632,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.096,Case Rate,Pays Based on per visit rate,1557,100,,4.104,Case Rate,Pays based on per visit rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,4.104,Case Rate,Pays based on per visit rate,1557,100,,0.624,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,7.384,Case Rate,Pays based on per visit rate,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,441.96,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3156.85,100,,188.84,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3156.85,
MR ANGIO CHEST W CM,52589090,CDM,618,RC,C8909,HCPCS,Outpatient,,,2682.67,1609.60,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.008,Case Rate,Pays based on per visit rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,386.84,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2012,75,,1.624,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.6,Case Rate,Pays Based on per visit rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,1557,100,,1.088,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,19.288,Case Rate,Pays based on per visit rate,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2682.67,100,,2.16,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3014.25,
MR ANGIO CHEST W CM,52589090,CDM,618,RC,C8909,HCPCS,Outpatient,,,2682.67,1609.60,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,216.72,Case Rate,Pays based on per visit rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,386.84,14.42,,45.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2012,75,,0.832,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,4.104,Case Rate,Pays Based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,1557,100,,0.664,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,251.32,Case Rate,Pays based on per visit rate,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,375.57,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2682.67,100,,1.104,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3014.25,
MR ANGIO CHEST WO CM,52589108,CDM,618,RC,C8910,HCPCS,Outpatient,,,2658.86,1595.32,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,86.392,Case Rate,Pays based on per visit rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,383.41,14.42,,3.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1994.15,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.136,Case Rate,Pays Based on per visit rate,1557,100,,1.48,Case Rate,Pays based on per visit rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.48,Case Rate,Pays based on per visit rate,1557,100,,0.096,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,0.128,Case Rate,Pays based on per visit rate,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.86,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR ANGIO CHEST WO CM,52589108,CDM,618,RC,C8910,HCPCS,Outpatient,,,2658.86,1595.32,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.76,Case Rate,Pays based on per visit rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,383.41,14.42,,81.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1994.15,75,,1.528,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.016,Case Rate,Pays Based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,1557,100,,0.112,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,0.104,Case Rate,Pays based on per visit rate,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,372.24,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.86,100,,2.04,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR ANGIO CHEST WWO CM,52589116,CDM,618,RC,C8911,HCPCS,Outpatient,,,3308.08,1984.85,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,4.648,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,477.03,14.42,,10.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2481.06,75,,5431.624,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.48,Case Rate,Pays Based on per visit rate,1557,100,,8.872,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,8.872,Case Rate,Pays based on per visit rate,1557,100,,1.656,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,24.032,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3308.08,100,,7242.16,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3308.08,
MR ANGIO CHEST WWO CM,52589116,CDM,618,RC,C8911,HCPCS,Outpatient,,,3308.08,1984.85,TC   ,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,30.128,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,477.03,14.42,,10.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2481.06,75,,165.608,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.016,Case Rate,Pays Based on per visit rate,1557,100,,0.048,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.048,Case Rate,Pays based on per visit rate,1557,100,,9.88,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,4.176,Case Rate,Pays based on per visit rate,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,463.13,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3308.08,100,,220.808,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3308.08,
MR ANGIO PEL WO CM,52590004,CDM,610,RC,C8919,HCPCS,Outpatient,,,2445.5,1467.30,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,20.056,Case Rate,Pays based on per visit rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,352.64,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1834.13,75,,29.288,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,8.872,Case Rate,Pays Based on per visit rate,1557,100,,1.648,Case Rate,Pays based on per visit rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.648,Case Rate,Pays based on per visit rate,1557,100,,4.296,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,81.432,Case Rate,Pays based on per visit rate,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2445.5,100,,39.048,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR ANGIO PEL WO CM,52590004,CDM,610,RC,C8919,HCPCS,Outpatient,,,2445.5,1467.30,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.616,Case Rate,Pays based on per visit rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,352.64,14.42,,84.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1834.13,75,,0.624,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.048,Case Rate,Pays Based on per visit rate,1557,100,,37.592,Case Rate,Pays based on per visit rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,37.592,Case Rate,Pays based on per visit rate,1557,100,,1.848,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,117.536,Case Rate,Pays based on per visit rate,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,342.37,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2445.5,100,,0.832,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3014.25,
MR CSPINE W CM,52590006,CDM,612,RC,72142,HCPCS,Outpatient,,,3240.32,1944.19,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,327.576,Case Rate,Pays based on per visit rate,287.69,100,,8.784,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,296.32,103,,9.048,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2430.24,75,,94.504,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.648,Case Rate,Pays Based on per visit rate,1557,100,,425.056,Case Rate,Pays based on per visit rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,425.056,Case Rate,Pays based on per visit rate,1557,100,,0.024,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,23.696,Case Rate,Pays based on per visit rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,8.784,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3240.32,100,,126,Percent of Total Billed Charges,100% of Total Billed Charges,287.69,3240.32,
MR CSPINE W CM,52590006,CDM,612,RC,72142,HCPCS,Outpatient,,,3240.32,1944.19,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1103.456,Case Rate,Pays based on per visit rate,287.69,100,,48.968,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,296.32,103,,50.44,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2430.24,75,,0.072,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,37.592,Case Rate,Pays Based on per visit rate,1557,100,,2.576,Case Rate,Pays based on per visit rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.576,Case Rate,Pays based on per visit rate,1557,100,,0.04,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,5411.84,Case Rate,Pays based on per visit rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,287.69,100,,48.968,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3240.32,100,,0.096,Percent of Total Billed Charges,100% of Total Billed Charges,287.69,3240.32,
MR LWR EXT JT W CM RT,52590008,CDM,610,RC,73722,HCPCS,Outpatient,,,3366.48,2019.89,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,916.536,Case Rate,Pays based on per visit rate,328.79,100,,1.328,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,338.65,103,,1.368,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2524.86,75,,291.544,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,425.056,Case Rate,Pays Based on per visit rate,1557,100,,2.448,Case Rate,Pays based on per visit rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.448,Case Rate,Pays based on per visit rate,1557,100,,1.096,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,39.816,Case Rate,Pays based on per visit rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,1.328,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3366.48,100,,388.72,Percent of Total Billed Charges,100% of Total Billed Charges,328.79,3366.48,
MR LWR EXT JT W CM RT,52590008,CDM,610,RC,73722,HCPCS,Outpatient,,,3366.48,2019.89,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,80.264,Case Rate,Pays based on per visit rate,328.79,100,,10.056,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,338.65,103,,10.352,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,2524.86,75,,43.792,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.576,Case Rate,Pays Based on per visit rate,1557,100,,2.584,Case Rate,Pays based on per visit rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.584,Case Rate,Pays based on per visit rate,1557,100,,3.6,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,260.4,Case Rate,Pays based on per visit rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,328.79,100,,10.056,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,3366.48,100,,58.384,Percent of Total Billed Charges,100% of Total Billed Charges,328.79,3366.48,
MR LWR EXT JT WO CM BI,52590009,CDM,610,RC,73721,HCPCS,Outpatient,,,4271.64,2562.98,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,119.968,Case Rate,Pays based on per visit rate,210.84,100,,1.152,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,1.184,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3203.73,75,,16.952,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.448,Case Rate,Pays Based on per visit rate,1557,100,,2.52,Case Rate,Pays based on per visit rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.52,Case Rate,Pays based on per visit rate,1557,100,,4.104,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,5.032,Case Rate,Pays based on per visit rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.152,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4271.64,100,,21.192,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,4271.64,
MR LWR EXT JT WO CM BI,52590009,CDM,610,RC,73721,HCPCS,Outpatient,,,4271.64,2562.98,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,165.832,Case Rate,Pays based on per visit rate,210.84,100,,0.592,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,0.608,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,3203.73,75,,14.904,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.584,Case Rate,Pays Based on per visit rate,1557,100,,1.264,Case Rate,Pays based on per visit rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.264,Case Rate,Pays based on per visit rate,1557,100,,0.136,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,82.52,Case Rate,Pays based on per visit rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.592,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4271.64,100,,19.872,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,4271.64,
MR LWR EXT JT WO CM RT,52590010,CDM,610,RC,73721,HCPCS,Outpatient,,,2847.76,1708.66,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,47.392,Case Rate,Pays based on per visit rate,210.84,100,,1.264,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,1.296,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2135.82,75,,8.144,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.52,Case Rate,Pays Based on per visit rate,1557,100,,2.656,Case Rate,Pays based on per visit rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.656,Case Rate,Pays based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,151.768,Case Rate,Pays based on per visit rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,1.264,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.76,100,,10.856,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2847.76,
MR LWR EXT JT WO CM RT,52590010,CDM,610,RC,73721,HCPCS,Outpatient,,,2847.76,1708.66,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,47.392,Case Rate,Pays based on per visit rate,210.84,100,,0.456,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,217.17,103,,0.472,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2135.82,75,,47.496,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.264,Case Rate,Pays Based on per visit rate,1557,100,,3.184,Case Rate,Pays based on per visit rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.184,Case Rate,Pays based on per visit rate,1557,100,,1.48,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,34,Case Rate,Pays based on per visit rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,210.84,100,,0.456,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.76,100,,63.328,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2847.76,
MR LWR EXT JT WWO CM BI,52590011,CDM,610,RC,73723,HCPCS,Outpatient,,,5909.79,3545.87,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,16.736,Case Rate,Pays based on per visit rate,368.43,100,,55.36,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,57.016,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4432.34,75,,18.04,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.656,Case Rate,Pays Based on per visit rate,1557,100,,0.264,Case Rate,Pays based on per visit rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.264,Case Rate,Pays based on per visit rate,1557,100,,0.016,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,82.12,Case Rate,Pays based on per visit rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,55.36,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5909.79,100,,24.048,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5909.79,
MR LWR EXT JT WWO CM BI,52590011,CDM,610,RC,73723,HCPCS,Outpatient,,,5909.79,3545.87,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,33.688,Case Rate,Pays based on per visit rate,368.43,100,,6.232,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,6.416,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4432.34,75,,19.08,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.184,Case Rate,Pays Based on per visit rate,1557,100,,11.168,Case Rate,Pays based on per visit rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,11.168,Case Rate,Pays based on per visit rate,1557,100,,8.872,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,68.008,Case Rate,Pays based on per visit rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,6.232,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5909.79,100,,25.44,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5909.79,
MR LWR EXT JT WWO CM RT,52590012,CDM,610,RC,73723,HCPCS,Outpatient,,,3939.86,2363.92,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,33.688,Case Rate,Pays based on per visit rate,368.43,100,,0.64,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.664,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2954.9,75,,97.072,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.264,Case Rate,Pays Based on per visit rate,1557,100,,11.968,Case Rate,Pays based on per visit rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,11.968,Case Rate,Pays based on per visit rate,1557,100,,0.048,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,58.32,Case Rate,Pays based on per visit rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.64,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3939.86,100,,129.424,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3939.86,
MR LWR EXT JT WWO CM RT,52590012,CDM,610,RC,73723,HCPCS,Outpatient,,,3939.86,2363.92,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.152,Case Rate,Pays based on per visit rate,368.43,100,,3.696,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,3.808,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2954.9,75,,1.656,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,11.168,Case Rate,Pays Based on per visit rate,1557,100,,9.776,Case Rate,Pays based on per visit rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,9.776,Case Rate,Pays based on per visit rate,1557,100,,1.648,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,582.4,Case Rate,Pays based on per visit rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,3.696,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3939.86,100,,2.208,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3939.86,
MR LWR EXT W CM RT,52590014,CDM,610,RC,73719,HCPCS,Outpatient,,,2569.4,1541.64,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,71.392,Case Rate,Pays based on per visit rate,274.65,100,,3.208,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,282.89,103,,3.304,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.05,75,,0.632,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,11.968,Case Rate,Pays Based on per visit rate,1557,100,,3.36,Case Rate,Pays based on per visit rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.36,Case Rate,Pays based on per visit rate,1557,100,,37.592,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,3.208,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2569.4,100,,0.84,Percent of Total Billed Charges,100% of Total Billed Charges,274.65,2790,
MR LWR EXT W CM RT,52590014,CDM,610,RC,73719,HCPCS,Outpatient,,,2569.4,1541.64,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.816,Case Rate,Pays based on per visit rate,274.65,100,,15.408,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,282.89,103,,15.872,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.05,75,,627.648,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,9.776,Case Rate,Pays Based on per visit rate,1557,100,,1.816,Case Rate,Pays based on per visit rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.816,Case Rate,Pays based on per visit rate,1557,100,,425.056,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,274.65,100,,15.408,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2569.4,100,,836.864,Percent of Total Billed Charges,100% of Total Billed Charges,274.65,2790,
MR LWR EXT WO CM RT,52590015,CDM,610,RC,73718,HCPCS,Outpatient,,,2494.55,1496.73,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,2.648,Case Rate,Pays based on per visit rate,233.52,100,,1.144,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,1.176,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.91,75,,420.352,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.36,Case Rate,Pays Based on per visit rate,1557,100,,0.024,Case Rate,Pays based on per visit rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.024,Case Rate,Pays based on per visit rate,1557,100,,2.576,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,1.144,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2494.55,100,,525.44,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR LWR EXT WO CM RT,52590015,CDM,610,RC,73718,HCPCS,Outpatient,,,2494.55,1496.73,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,67.2,Case Rate,Pays based on per visit rate,233.52,100,,5.096,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,5.248,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1870.91,75,,48.616,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.816,Case Rate,Pays Based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,1557,100,,2.448,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,5.096,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2494.55,100,,64.824,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR LWR EXT WWO CM BI,52590016,CDM,610,RC,73720,HCPCS,Outpatient,,,5525.65,3315.39,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.72,Case Rate,Pays based on per visit rate,353.51,100,,18.176,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,18.72,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4144.24,75,,176.944,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.024,Case Rate,Pays Based on per visit rate,1557,100,,5.608,Case Rate,Pays based on per visit rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.608,Case Rate,Pays based on per visit rate,1557,100,,2.584,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,525.384,Case Rate,Pays based on per visit rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,18.176,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5525.65,100,,235.92,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5525.65,
MR LWR EXT WWO CM BI,52590016,CDM,610,RC,73720,HCPCS,Outpatient,,,5525.65,3315.39,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,0.464,Case Rate,Pays based on per visit rate,353.51,100,,35.264,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,36.32,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,4144.24,75,,8.56,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.392,Case Rate,Pays Based on per visit rate,1557,100,,0.288,Case Rate,Pays based on per visit rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.288,Case Rate,Pays based on per visit rate,1557,100,,2.52,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,35.264,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5525.65,100,,11.408,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,5525.65,
MR LWR EXT WWO CM RT,52590017,CDM,610,RC,73720,HCPCS,Outpatient,,,3683.77,2210.26,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,7.024,Case Rate,Pays based on per visit rate,353.51,100,,0.424,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,0.432,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2762.83,75,,117.832,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.608,Case Rate,Pays Based on per visit rate,1557,100,,0.968,Case Rate,Pays based on per visit rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.968,Case Rate,Pays based on per visit rate,1557,100,,1.264,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,153.72,Case Rate,Pays based on per visit rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.424,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3683.77,100,,157.104,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3683.77,
MR LWR EXT WWO CM RT,52590017,CDM,610,RC,73720,HCPCS,Outpatient,,,3683.77,2210.26,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,126.08,Case Rate,Pays based on per visit rate,353.51,100,,0.512,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,364.12,103,,0.528,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2762.83,75,,307.712,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.288,Case Rate,Pays Based on per visit rate,1557,100,,8.616,Case Rate,Pays based on per visit rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,8.616,Case Rate,Pays based on per visit rate,1557,100,,2.656,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,525.384,Case Rate,Pays based on per visit rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,353.51,100,,0.512,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3683.77,100,,410.28,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3683.77,
MR MRCP W CM,52590018,CDM,610,RC,74182,HCPCS,Outpatient,,,3043.92,1826.35,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.776,Case Rate,Pays based on per visit rate,317.43,100,,1.024,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,326.95,103,,1.048,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2282.94,75,,5.744,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.968,Case Rate,Pays Based on per visit rate,1557,100,,0.008,Case Rate,Pays based on per visit rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.008,Case Rate,Pays based on per visit rate,1557,100,,3.184,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,1305.744,Case Rate,Pays based on per visit rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,1.024,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.92,100,,7.656,Percent of Total Billed Charges,100% of Total Billed Charges,317.43,3043.92,
MR MRCP W CM,52590018,CDM,610,RC,74182,HCPCS,Outpatient,,,3043.92,1826.35,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,42.592,Case Rate,Pays based on per visit rate,317.43,100,,5.376,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,326.95,103,,5.536,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2282.94,75,,7.624,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,8.616,Case Rate,Pays Based on per visit rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,1557,100,,0.264,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,1305.744,Case Rate,Pays based on per visit rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,317.43,100,,5.376,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.92,100,,10.16,Percent of Total Billed Charges,100% of Total Billed Charges,317.43,3043.92,
MR MRCP WO CM,52590019,CDM,610,RC,74181,HCPCS,Outpatient,,,2839.33,1703.60,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,7.824,Case Rate,Pays based on per visit rate,204.83,100,,61.6,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,210.97,103,,63.448,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2129.5,75,,155.736,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.008,Case Rate,Pays Based on per visit rate,1557,100,,2.232,Case Rate,Pays based on per visit rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.232,Case Rate,Pays based on per visit rate,1557,100,,11.168,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,896.76,Case Rate,Pays based on per visit rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,61.6,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.33,100,,207.648,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2839.33,
MR MRCP WO CM,52590019,CDM,610,RC,74181,HCPCS,Outpatient,,,2839.33,1703.60,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,20.336,Case Rate,Pays based on per visit rate,204.83,100,,5.688,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,210.97,103,,5.856,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2129.5,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.52,Case Rate,Pays Based on per visit rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,1557,100,,11.968,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,1455.448,Case Rate,Pays based on per visit rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,204.83,100,,5.688,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.33,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2839.33,
MR MRCP WWO CM,52590020,CDM,610,RC,74183,HCPCS,Outpatient,,,4081.11,2448.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,9.68,Case Rate,Pays based on per visit rate,354.51,100,,29.984,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,365.15,103,,30.888,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3060.83,75,,719.968,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.232,Case Rate,Pays Based on per visit rate,1557,100,,10.456,Case Rate,Pays based on per visit rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,10.456,Case Rate,Pays based on per visit rate,1557,100,,9.776,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,56.848,Case Rate,Pays based on per visit rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,29.984,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4081.11,100,,959.96,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4081.11,
MR MRCP WWO CM,52590020,CDM,610,RC,74183,HCPCS,Outpatient,,,4081.11,2448.67,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,22.52,Case Rate,Pays based on per visit rate,354.51,100,,5.088,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,365.15,103,,5.24,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,3060.83,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.216,Case Rate,Pays Based on per visit rate,1557,100,,23.96,Case Rate,Pays based on per visit rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,23.96,Case Rate,Pays based on per visit rate,1557,100,,3.36,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3520,Case Rate,Pays based on per visit rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,354.51,100,,5.088,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4081.11,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,4081.11,
MR UPR EXT JT W CM RT,52590022,CDM,610,RC,73222,HCPCS,Outpatient,,,2265.26,1359.16,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,5.8,Case Rate,Pays based on per visit rate,328.45,100,,3.992,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,338.3,103,,4.112,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1698.95,75,,0.056,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,10.456,Case Rate,Pays Based on per visit rate,1557,100,,51.152,Case Rate,Pays based on per visit rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,51.152,Case Rate,Pays based on per visit rate,1557,100,,1.816,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3520,Case Rate,Pays based on per visit rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,3.992,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2265.26,100,,0.072,Percent of Total Billed Charges,100% of Total Billed Charges,328.45,2790,
MR UPR EXT JT W CM RT,52590022,CDM,610,RC,73222,HCPCS,Outpatient,,,2265.26,1359.16,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,1101.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2178.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,2450.95,360,,,Fee Schedule,360% of BCBS POS Rate,2450.95,360,,,Fee schedule,360% of BCBS PPO Rate,2450.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,29.216,Case Rate,Pays based on per visit rate,328.45,100,,80.752,Fee Schedule,100% of TX Mediciad Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,661.13,90,,,Fee Schedule,90% of CMS OPPS Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,954.96,130,,,Fee Schedule,130% of CMS OPPS Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,338.3,103,,83.176,Fee Schedule,103% of TX Medicaid Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,756.62,103,,,Fee Schedule,103% of CMS OPPS Rate,1698.95,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,23.96,Case Rate,Pays Based on per visit rate,1557,100,,46.4,Case Rate,Pays based on per visit rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,46.4,Case Rate,Pays based on per visit rate,1557,100,,0.024,Case Rate,Pays based on per visit rate,1101.88,150,,,Fee Schedule,150% of CMS OPPS Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3520,Case Rate,Pays based on per visit rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,328.45,100,,80.752,Fee Schedule,100% of TX Medicaid Rate,734.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2265.26,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,328.45,2790,
MR UPR EXT JT WO CM RT,52590023,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,8.984,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,14.272,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,158.368,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,51.152,Case Rate,Pays Based on per visit rate,1557,100,,2.208,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,2.208,Case Rate,Pays based on per visit rate,1557,100,,0.392,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3520,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,211.152,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR UPR EXT JT WO CM RT,52590023,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,56.6,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,14.272,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,0.672,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,46.4,Case Rate,Pays Based on per visit rate,1557,100,,3.48,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.48,Case Rate,Pays based on per visit rate,1557,100,,5.608,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,3520,Case Rate,Pays based on per visit rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,13.864,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,0.896,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR UPR EXT JT WO CM RT,52590023,CDM,610,RC,73221,HCPCS,Outpatient,,,2838.59,1703.15,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,70.272,Case Rate,Pays based on per visit rate,211.18,100,,71.544,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,217.52,103,,73.696,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2128.94,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,2.208,Case Rate,Pays Based on per visit rate,1557,100,,5.512,Case Rate,Pays based on per visit rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,5.512,Case Rate,Pays based on per visit rate,1557,100,,0.288,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,159.152,Case Rate,Pays based on per visit rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,211.18,100,,71.544,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2838.59,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2838.59,
MR UPR EXT JT WWO CM RT,52590024,CDM,610,RC,73223,HCPCS,Outpatient,,,3263.39,1958.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,7.44,Case Rate,Pays based on per visit rate,368.43,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.456,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2447.54,75,,0.168,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.48,Case Rate,Pays Based on per visit rate,1557,100,,3.4,Case Rate,Pays based on per visit rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,3.4,Case Rate,Pays based on per visit rate,1557,100,,0.968,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,84.896,Case Rate,Pays based on per visit rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3263.39,100,,0.224,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3263.39,
MR UPR EXT JT WWO CM RT,52590024,CDM,610,RC,73223,HCPCS,Outpatient,,,3263.39,1958.03,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,341.536,Case Rate,Pays based on per visit rate,368.43,100,,0.448,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,0.464,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2447.54,75,,0.392,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,5.512,Case Rate,Pays Based on per visit rate,1557,100,,1.744,Case Rate,Pays based on per visit rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.744,Case Rate,Pays based on per visit rate,1557,100,,8.616,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,280,Case Rate,Pays based on per visit rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,0.448,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3263.39,100,,0.52,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3263.39,
MR UPR EXT W CM RT,52590027,CDM,610,RC,73219,HCPCS,Outpatient,,,2413.16,1447.90,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,1.6,Case Rate,Pays based on per visit rate,348.5,100,,0.44,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,358.96,103,,0.448,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1809.87,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,3.4,Case Rate,Pays Based on per visit rate,1557,100,,0.08,Case Rate,Pays based on per visit rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,0.08,Case Rate,Pays based on per visit rate,1557,100,,0.008,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,57.344,Case Rate,Pays based on per visit rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,0.44,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.16,100,,0.056,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,2790,
MR UPR EXT W CM RT,52590027,CDM,610,RC,73219,HCPCS,Outpatient,,,2413.16,1447.90,TC   ,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.936,Case Rate,Pays based on per visit rate,348.5,100,,41.832,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,358.96,103,,43.088,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1809.87,75,,3.376,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.744,Case Rate,Pays Based on per visit rate,1557,100,,1.56,Case Rate,Pays based on per visit rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,1.56,Case Rate,Pays based on per visit rate,1557,100,,0.52,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,137.648,Case Rate,Pays based on per visit rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,348.5,100,,41.832,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.16,100,,4.504,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,2790,
MR UPR EXT WO CM RT,52590028,CDM,610,RC,73218,HCPCS,Outpatient,,,2342.87,1405.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,3.936,Case Rate,Pays based on per visit rate,233.52,100,,34.176,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,35.2,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1757.15,75,,1.736,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,0.08,Case Rate,Pays Based on per visit rate,1557,100,,9.68,Case Rate,Pays based on per visit rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,9.68,Case Rate,Pays based on per visit rate,1557,100,,2.232,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,58.016,Case Rate,Pays based on per visit rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,34.176,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2342.87,100,,2.312,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR UPR EXT WO CM RT,52590028,CDM,610,RC,73218,HCPCS,Outpatient,,,2342.87,1405.72,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,177.792,Case Rate,Pays based on per visit rate,233.52,100,,58.224,Fee Schedule,100% of TX Mediciad Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,240.53,103,,59.976,Fee Schedule,103% of TX Medicaid Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,1757.15,75,,1.232,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,1.56,Case Rate,Pays Based on per visit rate,1557,100,,27.824,Case Rate,Pays based on per visit rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,27.824,Case Rate,Pays based on per visit rate,1557,100,,0.216,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,257.768,Case Rate,Pays based on per visit rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,233.52,100,,58.224,Fee Schedule,100% of TX Medicaid Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2342.87,100,,1.64,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,2790,
MR UPR EXT WWO CM RT,52590029,CDM,610,RC,73220,HCPCS,Outpatient,,,3799.9,2279.94,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,266.152,Case Rate,Pays based on per visit rate,368.43,100,,66.736,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,68.744,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2849.93,75,,0.608,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,9.68,Case Rate,Pays Based on per visit rate,1557,100,,26.568,Case Rate,Pays based on per visit rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,26.568,Case Rate,Pays based on per visit rate,1557,100,,10.456,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,154.92,Case Rate,Pays based on per visit rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,66.736,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3799.9,100,,0.808,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3799.9,
MR UPR EXT WWO CM RT,52590029,CDM,610,RC,73220,HCPCS,Outpatient,,,3799.9,2279.94,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,143.192,Case Rate,Pays based on per visit rate,368.43,100,,27.016,Fee Schedule,100% of TX Mediciad Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,379.48,103,,27.824,Fee Schedule,103% of TX Medicaid Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2849.93,75,,858,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,27.824,Case Rate,Pays Based on per visit rate,1557,100,,23.504,Case Rate,Pays based on per visit rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,23.504,Case Rate,Pays based on per visit rate,1557,100,,23.96,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,1310.488,Case Rate,Pays based on per visit rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,368.43,100,,27.016,Fee Schedule,100% of TX Medicaid Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3799.9,100,,1144,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3799.9,
CALCIUM CARB 1250MG TAB,53000007,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,112.45,32,,89.96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,3.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,100,,0.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,219.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,26.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,19.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,19.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,51.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,118.768,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,292.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,112.45,
MOMETASONE CRM 15GM,53000008,CDM,250,RC,,,Outpatient,,,45.16,27.10,,27.1,60,,21.68,Percent of Total Billed Charges,60% of Total Billed Charges,20.32,45,,16.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.64,28,,10.112,Percent of Total Billed Charges,28% of Total Billed Charges,112.49,32,,89.992,Percent of Total Billed Charges,32% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,16.26,36,,13.008,Percent of Total Billed Charges,36% of Total Billed Charges,16.26,36,,13.008,Percent of Total Billed Charges,36% Total Bille Charges,16.26,36,,13.008,Percent of Total Billed Charges,36% of Total Billed Charges,27.1,60,,6.104,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.16,100,,36.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.51,14.42,,89.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.87,75,,1.28,Percent of Total Billed Charges,75% of Total Billed Charges,22.58,50,,23.504,Percent of Total Billed Charges,50% of Total Billed Charges,22.58,50,,15.336,Percent of Total Billed Charges,50% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.58,50,,15.336,Percent of Total Billed Charges,50% of Total Billed Charges,22.58,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.61,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.16,100,,1.704,Percent of Total Billed Charges,100% of Total Billed Charges,6.32,112.49,
MILNACIPRAN 25 MG TAB,53000009,CDM,250,RC,,,Outpatient,,,11.63,6.98,,6.98,60,,5.584,Percent of Total Billed Charges,60% of Total Billed Charges,5.23,45,,4.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,28,,2.608,Percent of Total Billed Charges,28% of Total Billed Charges,112.5,32,,90,Percent of Total Billed Charges,32% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% Total Bille Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,6.98,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.63,100,,9.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14.42,,38.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.72,75,,7.192,Percent of Total Billed Charges,75% of Total Billed Charges,5.82,50,,19.08,Percent of Total Billed Charges,50% of Total Billed Charges,5.82,50,,7.92,Percent of Total Billed Charges,50% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.82,50,,7.92,Percent of Total Billed Charges,50% of Total Billed Charges,5.82,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.14,70,,59.248,Percent of Total Billed Charges,70% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.63,100,,9.592,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,112.5,
1/4 NS 1000ML,53000010,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,112.91,32,,90.328,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,33.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,0.488,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,15.336,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,3.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,71.144,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,0.648,Percent of Total Billed Charges,100% of Total Billed Charges,7,112.91,
ACYCLOVIR SUSP 40MG/ML 1ML,53000011,CDM,250,RC,,,Outpatient,,,1.72,1.03,,1.03,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,0.77,45,,0.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,112.96,32,,90.368,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,60,,443.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,100,,1.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,75,,12.816,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,50,,7.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,5.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,100,,17.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,112.96,
CEFEPIME 2 GM ADV,53000012,CDM,250,RC,J0692,HCPCS,Outpatient,,,63.74,38.24,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.68,45,,22.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.24,60,,272.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.74,100,,50.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.81,75,,0.984,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,19.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,177.56,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,177.56,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,3.4,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.62,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.74,100,,1.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,63.74,
PIPERACILLIN/TAZOB 3.375GM RTU,53000013,CDM,250,RC,J2543,HCPCS,Outpatient,,,66.8,40.08,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.06,45,,24.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.08,60,,6.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.8,100,,53.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.1,75,,0.304,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,0.656,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,23.192,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,23.192,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,1.744,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.76,70,,115.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.8,100,,0.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,66.8,
CEFEPIME 1GM ADV,53000015,CDM,250,RC,J0692,HCPCS,Outpatient,,,39.74,23.84,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.88,45,,14.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.84,60,,11.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.74,100,,31.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.81,75,,0.296,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,177.56,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,197.952,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,197.952,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,0.08,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.82,70,,124.936,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.74,100,,0.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,39.74,
LIDOCAINE INJ 2% 5ML SDV,53000016,CDM,250,RC,,,Outpatient,,,17.1,10.26,,10.26,60,,8.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.7,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,112.96,32,,90.368,Percent of Total Billed Charges,32% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,10.26,60,,1.904,Percent of Total Billed Charges,60% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.1,100,,13.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14.42,,32.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.83,75,,2.632,Percent of Total Billed Charges,75% of Total Billed Charges,8.55,50,,23.192,Percent of Total Billed Charges,50% of Total Billed Charges,8.55,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.55,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,8.55,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.1,100,,3.504,Percent of Total Billed Charges,100% of Total Billed Charges,2.39,112.96,
1/2 NS 50ML ADV BAG,53000017,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,113.6,32,,90.88,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,16.384,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,31.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,1.264,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,197.952,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,2.168,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,2.168,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,9.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,1.68,Percent of Total Billed Charges,100% of Total Billed Charges,7,113.6,
DIANEAL LO CA DEX2.5% 2L,53000018,CDM,250,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,113.63,32,,90.904,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,17.992,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,30.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,0.52,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,33.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,33.96,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,27.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,77.28,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,0.688,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,113.63,
KETAMINE 20MG/2ML SYRG,53000019,CDM,250,RC,,,Outpatient,,,27.66,16.60,,16.6,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,12.45,45,,9.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,28,,6.192,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% Total Bille Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,16.6,60,,3.032,Percent of Total Billed Charges,60% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.66,100,,22.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.99,14.42,,8.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,75,,12.616,Percent of Total Billed Charges,75% of Total Billed Charges,13.83,50,,2.168,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,0.696,Percent of Total Billed Charges,50% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.83,50,,0.696,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,26.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.36,70,,196.648,Percent of Total Billed Charges,70% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.66,100,,16.816,Percent of Total Billed Charges,100% of Total Billed Charges,3.87,113.72,
PHENYLEPHRINE 1% NSL SPY 15ML,53000020,CDM,250,RC,,,Outpatient,,,8.66,5.20,,5.2,60,,4.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.9,45,,3.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,28,,1.936,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% of Total Billed Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% Total Bille Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% of Total Billed Charges,5.2,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.66,100,,6.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.25,14.42,,39.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,75,,0.256,Percent of Total Billed Charges,75% of Total Billed Charges,4.33,50,,33.96,Percent of Total Billed Charges,50% of Total Billed Charges,4.33,50,,78.192,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.33,50,,78.192,Percent of Total Billed Charges,50% of Total Billed Charges,4.33,50,,23.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.06,70,,79.072,Percent of Total Billed Charges,70% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.66,100,,0.336,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,113.72,
CANGRELOR VL 50MG,53000021,CDM,636,RC,C9460,HCPCS,Outpatient,,,2275,1365.00,,1265.63,110,,1012.504,Percent of Total Billed Charges,110% of Total Billed Charges,28.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,637,28,,509.6,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819,36,,655.2,Percent of Total Billed Charges,36% of Total Billed Charges,819,36,,655.2,Percent of Total Billed Charges,36% Total Bille Charges,819,36,,655.2,Percent of Total Billed Charges,36% of Total Billed Charges,1251.25,55,,2.496,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,103,,,Fee Schedule,103% of CMS OPPS Rate,19.38,103,,,Fee Schedule,103% of CMS OPPS Rate,1706.25,75,,0.512,Percent of Total Billed Charges,75% of Total Billed Charges,1137.5,50,,0.696,Percent of Total Billed Charges,50% of Total Billed Charges,1137.5,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1137.5,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,1137.5,50,,19.08,Percent of Total Billed Charges,50% of Total Billed Charges,28.23,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.5,70,,82.824,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2275,100,,0.68,Percent of Total Billed Charges,100% of Total Billed Charges,16.93,2275,
ALKA SELTZER GOLD 2TAB PK,53000022,CDM,250,RC,,,Outpatient,,,0.26,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,45,,0.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,2.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,100,,0.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,45.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,1.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,78.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,15.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,614.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,100,,1.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,113.72,
LIDOCAINE 1% W/EPI 50ML VL,53000023,CDM,250,RC,,,Outpatient,,,47.28,28.37,,28.37,60,,22.696,Percent of Total Billed Charges,60% of Total Billed Charges,21.28,45,,17.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.24,28,,10.592,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,17.02,36,,13.616,Percent of Total Billed Charges,36% of Total Billed Charges,17.02,36,,13.616,Percent of Total Billed Charges,36% Total Bille Charges,17.02,36,,13.616,Percent of Total Billed Charges,36% of Total Billed Charges,28.37,60,,2.496,Percent of Total Billed Charges,60% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.28,100,,37.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.46,75,,48.936,Percent of Total Billed Charges,75% of Total Billed Charges,23.64,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,23.64,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.64,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,23.64,50,,7.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.1,70,,477.008,Percent of Total Billed Charges,70% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.62,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.28,100,,65.248,Percent of Total Billed Charges,100% of Total Billed Charges,6.62,113.72,
LIDOCAINE TOP 4% SOLN 10ML,53000024,CDM,250,RC,,,Outpatient,,,43.08,25.85,,25.85,60,,20.68,Percent of Total Billed Charges,60% of Total Billed Charges,19.39,45,,15.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.06,28,,9.648,Percent of Total Billed Charges,28% of Total Billed Charges,113.72,32,,90.976,Percent of Total Billed Charges,32% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% Total Bille Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,25.85,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.08,100,,34.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.21,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.31,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,21.54,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,21.54,50,,3.424,Percent of Total Billed Charges,50% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.54,50,,3.424,Percent of Total Billed Charges,50% of Total Billed Charges,21.54,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.16,70,,413.28,Percent of Total Billed Charges,70% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.08,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,6.03,113.72,
DORZOLAMIDE OPHT SOL 10 ML,53000025,CDM,250,RC,,,Outpatient,,,296.1,177.66,,177.66,60,,142.128,Percent of Total Billed Charges,60% of Total Billed Charges,133.25,45,,106.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.91,28,,66.328,Percent of Total Billed Charges,28% of Total Billed Charges,114.05,32,,91.24,Percent of Total Billed Charges,32% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,106.6,36,,85.28,Percent of Total Billed Charges,36% of Total Billed Charges,106.6,36,,85.28,Percent of Total Billed Charges,36% Total Bille Charges,106.6,36,,85.28,Percent of Total Billed Charges,36% of Total Billed Charges,177.66,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.1,100,,236.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,42.7,14.42,,4.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.08,75,,7.408,Percent of Total Billed Charges,75% of Total Billed Charges,148.05,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,148.05,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.05,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,148.05,50,,0.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,207.27,70,,505.056,Percent of Total Billed Charges,70% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,296.1,100,,9.872,Percent of Total Billed Charges,100% of Total Billed Charges,41.45,296.1,
NS 500ML IRR PR,53000026,CDM,250,RC,,,Outpatient,,,30.72,18.43,,18.43,60,,14.744,Percent of Total Billed Charges,60% of Total Billed Charges,13.82,45,,11.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,28,,6.88,Percent of Total Billed Charges,28% of Total Billed Charges,114.32,32,,91.456,Percent of Total Billed Charges,32% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.06,36,,8.848,Percent of Total Billed Charges,36% of Total Billed Charges,11.06,36,,8.848,Percent of Total Billed Charges,36% Total Bille Charges,11.06,36,,8.848,Percent of Total Billed Charges,36% of Total Billed Charges,18.43,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.72,100,,24.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.43,14.42,,3.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.04,75,,1.024,Percent of Total Billed Charges,75% of Total Billed Charges,15.36,50,,3.424,Percent of Total Billed Charges,50% of Total Billed Charges,15.36,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.36,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,15.36,50,,177.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.5,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.3,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.72,100,,1.368,Percent of Total Billed Charges,100% of Total Billed Charges,4.3,114.32,
WATER IRR BOT 1000ML,53000027,CDM,250,RC,,,Outpatient,,,32.99,19.79,,19.79,60,,15.832,Percent of Total Billed Charges,60% of Total Billed Charges,14.85,45,,11.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.24,28,,7.392,Percent of Total Billed Charges,28% of Total Billed Charges,114.65,32,,91.72,Percent of Total Billed Charges,32% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% Total Bille Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,19.79,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.99,100,,26.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.76,14.42,,1.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.74,75,,2.432,Percent of Total Billed Charges,75% of Total Billed Charges,16.5,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,16.5,50,,4.672,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.5,50,,4.672,Percent of Total Billed Charges,50% of Total Billed Charges,16.5,50,,23.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.09,70,,85.392,Percent of Total Billed Charges,70% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.99,100,,3.24,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,114.65,
LEUCOVORIN CALCIUM 50MG INJ,53000028,CDM,250,RC,J0640,HCPCS,Outpatient,,,71.99,43.19,,4.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.4,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.57,360,,,Fee Schedule,360% of BCBS POS Rate,2.57,360,,,Fee schedule,360% of BCBS PPO Rate,2.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.19,60,,1.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.99,100,,57.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.99,75,,0.52,Percent of Total Billed Charges,75% of Total Billed Charges,2.72,80,,0.512,Fee Schedule,80% of Scott and White EPO fee schedule,2.72,80,,2.088,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,80,,2.088,Fee Schedule,80% of Scott and White PPO fee schedule,2.72,80,,197.952,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.39,70,,192.856,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.99,100,,0.688,Percent of Total Billed Charges,100% of Total Billed Charges,2.57,71.99,
LEUCOVORIN CALCIUM 100MG INJ,53000029,CDM,250,RC,J0640,HCPCS,Outpatient,,,143.94,86.36,,4.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.77,45,,51.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.57,360,,,Fee Schedule,360% of BCBS POS Rate,2.57,360,,,Fee schedule,360% of BCBS PPO Rate,2.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.36,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.94,100,,115.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.96,75,,0.616,Percent of Total Billed Charges,75% of Total Billed Charges,2.72,80,,4.672,Fee Schedule,80% of Scott and White EPO fee schedule,2.72,80,,0.008,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,80,,0.008,Fee Schedule,80% of Scott and White PPO fee schedule,2.72,80,,0.056,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.76,70,,102.68,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.94,100,,0.816,Percent of Total Billed Charges,100% of Total Billed Charges,2.57,143.94,
ABACAVIR 300MG CAP,53000030,CDM,250,RC,,,Outpatient,,,20.58,12.35,,12.35,60,,9.88,Percent of Total Billed Charges,60% of Total Billed Charges,9.26,45,,7.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,28,,4.608,Percent of Total Billed Charges,28% of Total Billed Charges,115.15,32,,92.12,Percent of Total Billed Charges,32% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,7.41,36,,5.928,Percent of Total Billed Charges,36% of Total Billed Charges,7.41,36,,5.928,Percent of Total Billed Charges,36% Total Bille Charges,7.41,36,,5.928,Percent of Total Billed Charges,36% of Total Billed Charges,12.35,60,,24.032,Percent of Total Billed Charges,60% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,16.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14.42,,3.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.44,75,,0.176,Percent of Total Billed Charges,75% of Total Billed Charges,10.29,50,,2.088,Percent of Total Billed Charges,50% of Total Billed Charges,10.29,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.29,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,10.29,50,,2.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.41,70,,153.104,Percent of Total Billed Charges,70% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.88,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.58,100,,0.232,Percent of Total Billed Charges,100% of Total Billed Charges,2.88,115.15,
D5 NACL 0.9% INJ 1000ML,53000031,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,22.69,45,,18.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,11726.4,32,,9381.12,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,7.296,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,40.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,4.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,0.824,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,33.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,153.104,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,1.096,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,11726.4,
DEXTROMETH POLYST SUS 1ML,53000032,CDM,250,RC,,,Outpatient,,,0.22,0.13,,0.13,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,11.55,32,,9.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,60,,24.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,100,,0.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,52.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,9.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.11,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,15.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,50,,15.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,0.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,70,,156.464,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,100,,12.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,11.55,
DEFERASIROX 250 MG TAB,53000033,CDM,250,RC,,,Outpatient,,,138.43,83.06,,83.06,60,,66.448,Percent of Total Billed Charges,60% of Total Billed Charges,62.29,45,,49.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.76,28,,31.008,Percent of Total Billed Charges,28% of Total Billed Charges,11.58,32,,9.264,Percent of Total Billed Charges,32% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,49.83,36,,39.864,Percent of Total Billed Charges,36% of Total Billed Charges,49.83,36,,39.864,Percent of Total Billed Charges,36% Total Bille Charges,49.83,36,,39.864,Percent of Total Billed Charges,36% of Total Billed Charges,83.06,60,,128.448,Percent of Total Billed Charges,60% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.43,100,,110.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.96,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.82,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,69.22,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,69.22,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.22,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,69.22,50,,78.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.9,70,,191.072,Percent of Total Billed Charges,70% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,19.38,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.43,100,,0.056,Percent of Total Billed Charges,100% of Total Billed Charges,11.58,138.43,
GADOBUTROL 1MMOL/ML 2ML VL,53000034,CDM,255,RC,A9585,HCPCS,Outpatient,,,99.6,59.76,,0.35,100,,,Case Rate,Pays based on per visit rate,44.82,45,,35.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,59.76,60,,11.696,Percent of Total Billed Charges,60% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.6,100,,79.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,14.36,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.68,80,,135.072,Percent of Total Billed Charges,80% of Total Billed Charges,0.27,80,,15.248,Fee Schedule,80% of Scott and White EPO fee schedule,0.27,80,,2.632,Fee Schedule,80% of Scott and White HMO fee schedule,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,80,,2.632,Fee Schedule,80% of Scott and White PPO fee schedule,0.27,80,,49.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.72,70,,191.072,Percent of Total Billed Charges,70% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,13.94,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.6,100,,180.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,99.6,
SACUBIT/VALSAR TAB 97-103MG,53000035,CDM,250,RC,,,Outpatient,,,14.43,8.66,,8.66,60,,6.928,Percent of Total Billed Charges,60% of Total Billed Charges,6.49,45,,5.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.04,28,,3.232,Percent of Total Billed Charges,28% of Total Billed Charges,11.73,32,,9.384,Percent of Total Billed Charges,32% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% Total Bille Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,8.66,60,,2.496,Percent of Total Billed Charges,60% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.43,100,,11.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14.42,,3.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,7.22,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,17.232,Percent of Total Billed Charges,50% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,50,,17.232,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.1,70,,89.736,Percent of Total Billed Charges,70% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.43,100,,0.048,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,14.43,
RIZATRIPTAN 5 MG TAB,53000036,CDM,250,RC,,,Outpatient,,,4.34,2.60,,2.6,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.95,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,115.25,32,,92.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,2.6,60,,110.912,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,100,,3.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,3.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.26,75,,0.904,Percent of Total Billed Charges,75% of Total Billed Charges,2.17,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,100,,1.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,115.25,
AMPICILLIN 1GM/NS 100ML MBP,53000037,CDM,250,RC,J0290,HCPCS,Outpatient,,,78.5,47.10,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,5.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,7.936,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,17.232,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,56.704,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,56.704,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,3.424,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,10.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,78.5,
THEOPHY ELIX 200MG,53000038,CDM,250,RC,,,Outpatient,,,10.99,6.59,,6.59,60,,5.272,Percent of Total Billed Charges,60% of Total Billed Charges,4.95,45,,3.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.08,28,,2.464,Percent of Total Billed Charges,28% of Total Billed Charges,116.03,32,,92.824,Percent of Total Billed Charges,32% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,3.96,36,,3.168,Percent of Total Billed Charges,36% of Total Billed Charges,3.96,36,,3.168,Percent of Total Billed Charges,36% Total Bille Charges,3.96,36,,3.168,Percent of Total Billed Charges,36% of Total Billed Charges,6.59,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,100,,8.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14.42,,2.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.24,75,,1.752,Percent of Total Billed Charges,75% of Total Billed Charges,5.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,5.5,50,,1.968,Percent of Total Billed Charges,50% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.5,50,,1.968,Percent of Total Billed Charges,50% of Total Billed Charges,5.5,50,,0.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.69,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,100,,2.336,Percent of Total Billed Charges,100% of Total Billed Charges,1.54,116.03,
EMPAGLIFLOZIN TAB 10MG,53000039,CDM,250,RC,,,Outpatient,,,31,18.60,,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,13.95,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,28,,6.944,Percent of Total Billed Charges,28% of Total Billed Charges,116.31,32,,93.048,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% Total Bille Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,18.6,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,100,,24.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.25,75,,1.752,Percent of Total Billed Charges,75% of Total Billed Charges,15.5,50,,56.704,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,0.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.7,70,,75.216,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31,100,,2.336,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,116.31,
EMPAGLIFLOZIN TAB 25MG,53000040,CDM,250,RC,,,Outpatient,,,31,18.60,,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,13.95,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,28,,6.944,Percent of Total Billed Charges,28% of Total Billed Charges,116.6,32,,93.28,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% Total Bille Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,18.6,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,100,,24.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.25,75,,1.752,Percent of Total Billed Charges,75% of Total Billed Charges,15.5,50,,1.968,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.5,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,4.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.7,70,,75.216,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31,100,,2.336,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,116.6,
CICLOPIROX 8% SOLN 6.6ML,53000041,CDM,250,RC,,,Outpatient,,,105.44,63.26,,63.26,60,,50.608,Percent of Total Billed Charges,60% of Total Billed Charges,47.45,45,,37.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.52,28,,23.616,Percent of Total Billed Charges,28% of Total Billed Charges,116.78,32,,93.424,Percent of Total Billed Charges,32% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,37.96,36,,30.368,Percent of Total Billed Charges,36% of Total Billed Charges,37.96,36,,30.368,Percent of Total Billed Charges,36% Total Bille Charges,37.96,36,,30.368,Percent of Total Billed Charges,36% of Total Billed Charges,63.26,60,,4.432,Percent of Total Billed Charges,60% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.44,100,,84.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,15.2,14.42,,9.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.08,75,,1.752,Percent of Total Billed Charges,75% of Total Billed Charges,52.72,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,52.72,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.72,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,52.72,50,,2.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.81,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,14.76,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.44,100,,2.336,Percent of Total Billed Charges,100% of Total Billed Charges,14.76,116.78,
IMMUNE GLOB IV PRIVIGEN 0.5GM,53000042,CDM,636,RC,J1459,HCPCS,Outpatient,,,293.13,175.88,,206.68,110,,165.344,Percent of Total Billed Charges,110% of Total Billed Charges,72.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,47.71,360,,,Fee Schedule,360% of BCBS POS Rate,47.71,360,,,Fee schedule,360% of BCBS PPO Rate,47.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.72,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,63.15,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.03,103,,,Fee Schedule,103% of CMS OPPS Rate,50.03,103,,,Fee Schedule,103% of CMS OPPS Rate,219.85,75,,0.016,Percent of Total Billed Charges,75% of Total Billed Charges,184.32,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,184.32,50,,2.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,184.32,50,,2.736,Percent of Total Billed Charges,50% of Total Billed Charges,184.32,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,72.87,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.19,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.58,100,,,Fee Schedule,100% of CMS OPPS Rate,293.13,100,,0.024,Percent of Total Billed Charges,100% of Total Billed Charges,43.72,293.13,
TRANEXAMIC ACID 5% MTHWASH 1ML,53000043,CDM,250,RC,,,Outpatient,,,5.96,3.58,,3.58,60,,2.864,Percent of Total Billed Charges,60% of Total Billed Charges,2.68,45,,2.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,28,,1.336,Percent of Total Billed Charges,28% of Total Billed Charges,116.86,32,,93.488,Percent of Total Billed Charges,32% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% Total Bille Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,3.58,60,,20.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,4.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.47,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,2.98,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,2.98,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.98,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,2.98,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.17,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.83,116.86,
GUAIFENESIN DM SYR 5ML,53000044,CDM,250,RC,,,Outpatient,,,3.6,2.16,,2.16,60,,1.728,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,45,,1.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,28,,0.808,Percent of Total Billed Charges,28% of Total Billed Charges,117.03,32,,93.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% Total Bille Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,2.16,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,100,,2.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14.42,,1.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,75,,23.904,Percent of Total Billed Charges,75% of Total Billed Charges,1.8,50,,2.736,Percent of Total Billed Charges,50% of Total Billed Charges,1.8,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,1.8,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.52,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,100,,31.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.5,117.03,
VANCOMYCIN ENEMA 500MG/NS100ML,53000045,CDM,250,RC,J3370,HCPCS,Outpatient,,,137.35,82.41,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.81,45,,49.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.41,60,,13.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.35,100,,109.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.01,75,,29.568,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,0.096,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,4.488,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,4.488,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,15.248,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.15,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.35,100,,39.424,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,137.35,
KETAMINE INJ 1MG/ML 10ML,53000046,CDM,250,RC,,,Outpatient,,,16.3,9.78,,9.78,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,117.16,32,,93.728,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,9.78,60,,7.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,30.304,Percent of Total Billed Charges,75% of Total Billed Charges,8.15,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,0.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,40.4,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,117.16,
ASCORBIC ACID 500MG INJ,53000047,CDM,250,RC,,,Outpatient,,,13.03,7.82,,7.82,60,,6.256,Percent of Total Billed Charges,60% of Total Billed Charges,5.86,45,,4.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.65,28,,2.92,Percent of Total Billed Charges,28% of Total Billed Charges,117.22,32,,93.776,Percent of Total Billed Charges,32% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,36,,3.752,Percent of Total Billed Charges,36% of Total Billed Charges,4.69,36,,3.752,Percent of Total Billed Charges,36% Total Bille Charges,4.69,36,,3.752,Percent of Total Billed Charges,36% of Total Billed Charges,7.82,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,100,,10.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14.42,,20.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.77,75,,31.912,Percent of Total Billed Charges,75% of Total Billed Charges,6.52,50,,4.488,Percent of Total Billed Charges,50% of Total Billed Charges,6.52,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.52,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,6.52,50,,2.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.12,70,,369.048,Percent of Total Billed Charges,70% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,100,,42.552,Percent of Total Billed Charges,100% of Total Billed Charges,1.82,117.22,
BUPIVACAINE LIPO VL 1.3% 10ML,53000050,CDM,250,RC,C9290,HCPCS,Outpatient,,,790,474.00,,1.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,355.5,45,,284.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.2,28,,176.96,Percent of Total Billed Charges,28% of Total Billed Charges,117.44,32,,93.952,Percent of Total Billed Charges,32% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,284.4,36,,227.52,Percent of Total Billed Charges,36% of Total Billed Charges,284.4,36,,227.52,Percent of Total Billed Charges,36% Total Bille Charges,284.4,36,,227.52,Percent of Total Billed Charges,36% of Total Billed Charges,474,60,,473.728,Percent of Total Billed Charges,60% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,113.92,14.42,,27.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.5,75,,25.168,Percent of Total Billed Charges,75% of Total Billed Charges,395,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,395,50,,33.792,Percent of Total Billed Charges,50% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,395,50,,33.792,Percent of Total Billed Charges,50% of Total Billed Charges,395,50,,17.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,553,70,,305.984,Percent of Total Billed Charges,70% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,110.6,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,790,100,,33.552,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,790,
RANITIDINE HCL SYR 15MG/ML,53000051,CDM,250,RC,,,Outpatient,,,0.13,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,117.44,32,,93.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,108.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,100,,0.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,4.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,63.528,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,579.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,579.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,305.984,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,84.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,117.44,
ALLOPURINOL 500 MG INJ,53000052,CDM,636,RC,S5000,HCPCS,Outpatient,,,11961.18,7176.71,,6578.65,110,,5262.92,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3349.13,28,,2679.304,Percent of Total Billed Charges,28% of Total Billed Charges,117.51,32,,94.008,Percent of Total Billed Charges,32% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,4306.02,36,,3444.816,Percent of Total Billed Charges,36% of Total Billed Charges,4306.02,36,,3444.816,Percent of Total Billed Charges,36% Total Bille Charges,4306.02,36,,3444.816,Percent of Total Billed Charges,36% of Total Billed Charges,6578.65,55,,81.232,Percent of Total Billed Charges,55% Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1724.8,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8970.89,75,,66.608,Percent of Total Billed Charges,75% of Total Billed Charges,5980.59,50,,33.792,Percent of Total Billed Charges,50% of Total Billed Charges,5980.59,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5980.59,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,5980.59,50,,56.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8372.83,70,,123.792,Percent of Total Billed Charges,70% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,1674.57,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11961.18,100,,88.808,Percent of Total Billed Charges,100% of Total Billed Charges,117.51,11961.18,
INFLIXIMAB-DYYB 10MG,53000053,CDM,636,RC,Q5103,HCPCS,Outpatient,,,293.88,176.33,,202.61,110,,162.088,Percent of Total Billed Charges,110% of Total Billed Charges,20.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,89.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,89.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,89.63,360,,,Fee Schedule,360% of BCBS POS Rate,89.63,360,,,Fee schedule,360% of BCBS PPO Rate,89.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,17.7,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,103,,,Fee Schedule,103% of CMS OPPS Rate,14.02,103,,,Fee Schedule,103% of CMS OPPS Rate,220.41,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,163.41,50,,579.84,Percent of Total Billed Charges,50% of Total Billed Charges,163.41,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,163.41,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,163.41,50,,1.968,Percent of Total Billed Charges,50% of Total Billed Charges,20.42,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,205.72,70,,107.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.62,100,,,Fee Schedule,100% of CMS OPPS Rate,293.88,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,12.25,293.88,
NS (NON-PVC NON-DEHP) 250ML,53000054,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,117.68,32,,94.144,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,15.416,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,18.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,11.8,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,11.8,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,60.48,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,0.208,Percent of Total Billed Charges,100% of Total Billed Charges,7,117.68,
ACARBOSE 50MG TAB,53000055,CDM,250,RC,,,Outpatient,,,1.58,0.95,,0.95,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,28,,0.352,Percent of Total Billed Charges,28% of Total Billed Charges,117.97,32,,94.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% Total Bille Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,75,,5.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.79,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.79,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.79,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,70,,309.568,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,100,,7.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,117.97,
TELMISARTAN 20 MG TABLET,53000056,CDM,250,RC,,,Outpatient,,,12.57,7.54,,7.54,60,,6.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.52,28,,2.816,Percent of Total Billed Charges,28% of Total Billed Charges,12100.44,32,,9680.352,Percent of Total Billed Charges,32% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,4.53,36,,3.624,Percent of Total Billed Charges,36% of Total Billed Charges,4.53,36,,3.624,Percent of Total Billed Charges,36% Total Bille Charges,4.53,36,,3.624,Percent of Total Billed Charges,36% of Total Billed Charges,7.54,60,,655.392,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,75,,5.232,Percent of Total Billed Charges,75% of Total Billed Charges,6.29,50,,11.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.29,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.29,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,6.29,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.8,70,,173.464,Percent of Total Billed Charges,70% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.57,100,,6.976,Percent of Total Billed Charges,100% of Total Billed Charges,1.76,12100.44,
DOPAMINE 800MG/D5 250ML RTU,53000057,CDM,250,RC,J1265,HCPCS,Outpatient,,,145.42,87.25,,0.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.25,360,,,Fee Schedule,360% of BCBS POS Rate,0.25,360,,,Fee schedule,360% of BCBS PPO Rate,0.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,87.25,60,,168.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.07,75,,0.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,80,,11.088,Fee Schedule,80% of Scott and White EPO fee schedule,0.53,80,,1.576,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,80,,1.576,Fee Schedule,80% of Scott and White PPO fee schedule,0.53,80,,2.736,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.79,70,,30.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.42,100,,0.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,145.42,
ANGIOTENSIN II 2.5MG/ML 1ML VL,53000058,CDM,636,RC,J3490,HCPCS,Outpatient,,,4500,2700.00,,2475,110,,1980,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1260,28,,1008,Percent of Total Billed Charges,28% of Total Billed Charges,11.85,32,,9.48,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1620,36,,1296,Percent of Total Billed Charges,36% of Total Billed Charges,1620,36,,1296,Percent of Total Billed Charges,36% Total Bille Charges,1620,36,,1296,Percent of Total Billed Charges,36% of Total Billed Charges,2475,55,,60.12,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3375,75,,0.552,Percent of Total Billed Charges,75% of Total Billed Charges,2250,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,2250,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2250,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,2250,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3150,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4500,100,,0.736,Percent of Total Billed Charges,100% of Total Billed Charges,11.85,4500,
NS 500ML VIS-IV,53000059,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,11.89,32,,9.512,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,3.752,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,1.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,0.584,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,0.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,0.776,Percent of Total Billed Charges,100% of Total Billed Charges,7,50,
INFLIXIMAB-ABDA 10MG,53000060,CDM,636,RC,Q5104,HCPCS,Outpatient,,,236.05,141.63,,169.81,110,,135.848,Percent of Total Billed Charges,110% of Total Billed Charges,40.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,71.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,71.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,71.36,360,,,Fee Schedule,360% of BCBS POS Rate,71.36,360,,,Fee schedule,360% of BCBS PPO Rate,71.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.99,103,,,Fee Schedule,103% of CMS OPPS Rate,27.99,103,,,Fee Schedule,103% of CMS OPPS Rate,177.04,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,147.17,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,147.17,50,,4.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,147.17,50,,4.816,Percent of Total Billed Charges,50% of Total Billed Charges,147.17,50,,4.488,Percent of Total Billed Charges,50% of Total Billed Charges,40.77,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,165.24,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.18,100,,,Fee Schedule,100% of CMS OPPS Rate,236.05,100,,1.304,Percent of Total Billed Charges,100% of Total Billed Charges,24.46,236.05,
INSULIN GLARGINE 5 UNITS,53000061,CDM,250,RC,J1815,HCPCS,Outpatient,,,2.7,1.62,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,1.62,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,0.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.03,75,,3.872,Percent of Total Billed Charges,75% of Total Billed Charges,1.35,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.35,50,,3.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.35,50,,3.624,Percent of Total Billed Charges,50% of Total Billed Charges,1.35,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.7,100,,5.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,2.7,
INSULIN REGULAR 5 UNITS,53000062,CDM,250,RC,J1815,HCPCS,Outpatient,,,1.38,0.83,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,0.83,60,,5.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,3.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,50,,4.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,0.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,50,,0.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,100,,1.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,1.38,
ASPIRIN 81MG CHEW TAB,53000063,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,11.89,32,,9.512,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,13.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,51.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,1.072,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,3.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,11.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,11.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,33.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,1.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,11.89,
INSULIN LISPRO 5 UNITS,53000064,CDM,250,RC,J1815,HCPCS,Outpatient,,,2.55,1.53,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,1.53,60,,7.688,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,75,,0.68,Percent of Total Billed Charges,75% of Total Billed Charges,1.28,50,,0.52,Percent of Total Billed Charges,50% of Total Billed Charges,1.28,50,,2.216,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,50,,2.216,Percent of Total Billed Charges,50% of Total Billed Charges,1.28,50,,579.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.55,100,,0.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,2.55,
CROTALIDAE POLY IMMUNE FAB 1GM,53000065,CDM,636,RC,J0840,HCPCS,Outpatient,,,9052.7,5431.62,,7642.04,110,,6113.632,Percent of Total Billed Charges,110% of Total Billed Charges,2643.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3198,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3198,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,3198,360,,,Fee Schedule,360% of BCBS POS Rate,3198,360,,,Fee schedule,360% of BCBS PPO Rate,3198,360,,,Fee Schedule,360% of BCBS Traditional Rate,4978.99,55,,11.52,Percent of Total Billed Charges,55% Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1586.11,90,,,Fee Schedule,90% of CMS OPPS Rate,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2291.05,130,,,Fee Schedule,130% of CMS OPPS Rate,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1305.4,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,1815.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1815.22,103,,,Fee Schedule,103% of CMS OPPS Rate,6789.53,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,6188.58,50,,11.136,Percent of Total Billed Charges,50% of Total Billed Charges,6188.58,50,,1.848,Percent of Total Billed Charges,50% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6188.58,50,,1.848,Percent of Total Billed Charges,50% of Total Billed Charges,6188.58,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,2643.52,150,,,Fee Schedule,150% of CMS OPPS Rate,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6336.89,70,,520,Percent of Total Billed Charges,70% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1267.38,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9052.7,100,,0.216,Percent of Total Billed Charges,100% of Total Billed Charges,1267.38,9052.7,
RITUXIMAB 10 MG INJ,53000066,CDM,636,RC,J9312,HCPCS,Outpatient,,,276.01,165.61,,238.3,110,,190.64,Percent of Total Billed Charges,110% of Total Billed Charges,115.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,93.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,93.29,360,,,Fee Schedule,360% of BCBS POS Rate,93.29,360,,,Fee schedule,360% of BCBS PPO Rate,93.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,69.56,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,100.5,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.62,103,,,Fee Schedule,103% of CMS OPPS Rate,79.62,103,,,Fee Schedule,103% of CMS OPPS Rate,207.01,75,,1.76,Percent of Total Billed Charges,75% of Total Billed Charges,202.95,50,,2.216,Percent of Total Billed Charges,50% of Total Billed Charges,202.95,50,,3.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,202.95,50,,3.888,Percent of Total Billed Charges,50% of Total Billed Charges,202.95,50,,0.016,Percent of Total Billed Charges,50% of Total Billed Charges,115.96,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,193.21,70,,520,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.31,100,,,Fee Schedule,100% of CMS OPPS Rate,276.01,100,,2.344,Percent of Total Billed Charges,100% of Total Billed Charges,69.56,276.01,
LORAZEPAM 2MG/ML MDV 10ML,53000067,CDM,250,RC,J2060,HCPCS,Outpatient,,,48.81,29.29,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,29.29,60,,10.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.61,75,,1.96,Percent of Total Billed Charges,75% of Total Billed Charges,0.94,80,,1.848,Fee Schedule,80% of Scott and White EPO fee schedule,0.94,80,,1.704,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.94,80,,1.704,Fee Schedule,80% of Scott and White PPO fee schedule,0.94,80,,11.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.17,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.81,100,,2.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,48.81,
METOCLOPRAMIDE 10MG/10ML LIQ,53000068,CDM,250,RC,,,Outpatient,,,1.04,0.62,,0.62,60,,0.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,12,32,,9.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,60,,77.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,4.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,75,,4.016,Percent of Total Billed Charges,75% of Total Billed Charges,0.52,50,,3.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,75.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,50,,75.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,11.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,100,,5.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,12,
DEXMEDETOMIDINE 80MCG/NS 20ML,53000070,CDM,250,RC,,,Outpatient,,,157.5,94.50,,94.5,60,,75.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.1,28,,35.28,Percent of Total Billed Charges,28% of Total Billed Charges,12.03,32,,9.624,Percent of Total Billed Charges,32% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,36,,45.36,Percent of Total Billed Charges,36% of Total Billed Charges,56.7,36,,45.36,Percent of Total Billed Charges,36% Total Bille Charges,56.7,36,,45.36,Percent of Total Billed Charges,36% of Total Billed Charges,94.5,60,,0.208,Percent of Total Billed Charges,60% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.71,14.42,,8.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.13,75,,1.464,Percent of Total Billed Charges,75% of Total Billed Charges,78.75,50,,1.704,Percent of Total Billed Charges,50% of Total Billed Charges,78.75,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.75,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,78.75,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.25,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,22.05,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.5,100,,1.952,Percent of Total Billed Charges,100% of Total Billed Charges,12.03,157.5,
ASPIRIN 325MG TAB,53000071,CDM,250,RC,,,Outpatient,,,0.12,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,12.03,32,,9.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,3.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,75,,22.616,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,75.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,1.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,1440,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,100,,30.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,12.03,
MYCOPHENOLATE MOF 500MG INJ,53000072,CDM,250,RC,J7599,HCPCS,Outpatient,,,485.9,291.54,,291.54,60,,233.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.05,28,,108.84,Percent of Total Billed Charges,28% of Total Billed Charges,12.05,32,,9.64,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.92,36,,139.936,Percent of Total Billed Charges,36% of Total Billed Charges,174.92,36,,139.936,Percent of Total Billed Charges,36% Total Bille Charges,174.92,36,,139.936,Percent of Total Billed Charges,36% of Total Billed Charges,291.54,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.43,75,,1.312,Percent of Total Billed Charges,75% of Total Billed Charges,242.95,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,242.95,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.95,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,242.95,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.13,70,,1440,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,485.9,100,,1.744,Percent of Total Billed Charges,100% of Total Billed Charges,12.05,485.9,
CEFEPIME 1GM/50ML D5W DUPLEX,53000074,CDM,250,RC,J0692,HCPCS,Outpatient,,,72.98,43.79,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.79,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.74,75,,1.856,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,8.136,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,12.744,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,12.744,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,1.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.09,70,,2400,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.98,100,,2.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,72.98,
BARIUM 40% PUDDING 30ML,53000075,CDM,255,RC,,,Outpatient,,,26.49,15.89,,15.89,60,,12.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.42,28,,5.936,Percent of Total Billed Charges,28% of Total Billed Charges,12.06,32,,9.648,Percent of Total Billed Charges,32% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,9.54,36,,7.632,Percent of Total Billed Charges,36% Total Bille Charges,9.54,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,15.89,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14.42,,31.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.19,80,,9.192,Percent of Total Billed Charges,80% of Total Billed Charges,13.25,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,13.25,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.25,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,13.25,50,,4.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.54,70,,2880,Percent of Total Billed Charges,70% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.49,100,,12.256,Percent of Total Billed Charges,100% of Total Billed Charges,3.71,26.49,
CADEXOMER IODINE GEL 0.9% 5GM,53000076,CDM,250,RC,,,Outpatient,,,24.84,14.90,,14.9,60,,11.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.96,28,,5.568,Percent of Total Billed Charges,28% of Total Billed Charges,12.12,32,,9.696,Percent of Total Billed Charges,32% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% Total Bille Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,14.9,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.58,14.42,,7.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.63,75,,9.2,Percent of Total Billed Charges,75% of Total Billed Charges,12.42,50,,12.744,Percent of Total Billed Charges,50% of Total Billed Charges,12.42,50,,5.44,Percent of Total Billed Charges,50% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.42,50,,5.44,Percent of Total Billed Charges,50% of Total Billed Charges,12.42,50,,3.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.39,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.84,100,,12.264,Percent of Total Billed Charges,100% of Total Billed Charges,3.48,24.84,
CLOTRIMAZOL/BETAMETH CR 5GM,53000077,CDM,250,RC,,,Outpatient,,,13.57,8.14,,8.14,60,,6.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,28,,3.04,Percent of Total Billed Charges,28% of Total Billed Charges,12.12,32,,9.696,Percent of Total Billed Charges,32% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,4.89,36,,3.912,Percent of Total Billed Charges,36% of Total Billed Charges,4.89,36,,3.912,Percent of Total Billed Charges,36% Total Bille Charges,4.89,36,,3.912,Percent of Total Billed Charges,36% of Total Billed Charges,8.14,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14.42,,12.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,75,,2.36,Percent of Total Billed Charges,75% of Total Billed Charges,6.79,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,6.79,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.79,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,6.79,50,,0.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.5,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.57,100,,3.144,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,13.57,
COLLAGENASE OINT 250U/GM 5GM,53000078,CDM,250,RC,,,Outpatient,,,79.16,47.50,,47.5,60,,38,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.16,28,,17.728,Percent of Total Billed Charges,28% of Total Billed Charges,12.14,32,,9.712,Percent of Total Billed Charges,32% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,36,,22.8,Percent of Total Billed Charges,36% of Total Billed Charges,28.5,36,,22.8,Percent of Total Billed Charges,36% Total Bille Charges,28.5,36,,22.8,Percent of Total Billed Charges,36% of Total Billed Charges,47.5,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.41,14.42,,119.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.37,75,,0.736,Percent of Total Billed Charges,75% of Total Billed Charges,39.58,50,,5.44,Percent of Total Billed Charges,50% of Total Billed Charges,39.58,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.58,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.58,50,,11.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.41,70,,2400,Percent of Total Billed Charges,70% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,11.08,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.16,100,,0.984,Percent of Total Billed Charges,100% of Total Billed Charges,11.08,79.16,
FLUOCINONIDE CRM 0.05% 5GM,53000079,CDM,250,RC,,,Outpatient,,,30.06,18.04,,18.04,60,,14.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.42,28,,6.736,Percent of Total Billed Charges,28% of Total Billed Charges,12.14,32,,9.712,Percent of Total Billed Charges,32% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,36,,8.656,Percent of Total Billed Charges,36% of Total Billed Charges,10.82,36,,8.656,Percent of Total Billed Charges,36% Total Bille Charges,10.82,36,,8.656,Percent of Total Billed Charges,36% of Total Billed Charges,18.04,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14.42,,23.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.55,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,15.03,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,50,,8.592,Percent of Total Billed Charges,50% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,50,,8.592,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,50,,2.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.04,70,,2880,Percent of Total Billed Charges,70% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,100,,1.296,Percent of Total Billed Charges,100% of Total Billed Charges,4.21,30.06,
GENTAMICIN CRM 0.1% 5GM,53000080,CDM,250,RC,,,Outpatient,,,31.8,19.08,,19.08,60,,15.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.9,28,,7.12,Percent of Total Billed Charges,28% of Total Billed Charges,118.4,32,,94.72,Percent of Total Billed Charges,32% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,36,,9.16,Percent of Total Billed Charges,36% of Total Billed Charges,11.45,36,,9.16,Percent of Total Billed Charges,36% Total Bille Charges,11.45,36,,9.16,Percent of Total Billed Charges,36% of Total Billed Charges,19.08,60,,1.448,Percent of Total Billed Charges,60% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14.42,,157.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.85,75,,5.512,Percent of Total Billed Charges,75% of Total Billed Charges,15.9,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,15.9,50,,4.304,Percent of Total Billed Charges,50% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.9,50,,4.304,Percent of Total Billed Charges,50% of Total Billed Charges,15.9,50,,1.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.26,70,,169.616,Percent of Total Billed Charges,70% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.8,100,,7.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.45,118.4,
MUPIROCIN CRM 2% 5GM,53000081,CDM,250,RC,,,Outpatient,,,161.78,97.07,,97.07,60,,77.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.3,28,,36.24,Percent of Total Billed Charges,28% of Total Billed Charges,118.4,32,,94.72,Percent of Total Billed Charges,32% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,58.24,36,,46.592,Percent of Total Billed Charges,36% of Total Billed Charges,58.24,36,,46.592,Percent of Total Billed Charges,36% Total Bille Charges,58.24,36,,46.592,Percent of Total Billed Charges,36% of Total Billed Charges,97.07,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.33,14.42,,135.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.34,75,,72.808,Percent of Total Billed Charges,75% of Total Billed Charges,80.89,50,,8.592,Percent of Total Billed Charges,50% of Total Billed Charges,80.89,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.89,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,80.89,50,,3.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.25,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,22.65,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.78,100,,97.08,Percent of Total Billed Charges,100% of Total Billed Charges,22.65,161.78,
SILVER SULFADIAZINE CRM 1% 5GM,53000082,CDM,250,RC,,,Outpatient,,,2.76,1.66,,1.66,60,,1.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,118.53,32,,94.824,Percent of Total Billed Charges,32% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,1.66,60,,809.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14.42,,14.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,75,,16.632,Percent of Total Billed Charges,75% of Total Billed Charges,1.38,50,,4.304,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,1.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,70,,310.24,Percent of Total Billed Charges,70% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,100,,22.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,118.53,
ZINC OXIDE OINT 20% 5GM,53000083,CDM,250,RC,,,Outpatient,,,1.05,0.63,,0.63,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,118.99,32,,95.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% Total Bille Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,60,,3179.768,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,75,,29.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,75.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,70,,803.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,100,,39.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,118.99,
PEGFILGRASTIM CBQV INJ 0.5MG,53000084,CDM,636,RC,Q5111,HCPCS,Outpatient,,,1046.08,627.65,,779.46,110,,623.568,Percent of Total Billed Charges,110% of Total Billed Charges,215.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,347.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,347.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,347.92,360,,,Fee Schedule,360% of BCBS POS Rate,347.92,360,,,Fee schedule,360% of BCBS PPO Rate,347.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,575.34,55,,0.416,Percent of Total Billed Charges,55% Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,129.04,90,,,Fee Schedule,90% of CMS OPPS Rate,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,186.39,130,,,Fee Schedule,130% of CMS OPPS Rate,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,150.84,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.68,103,,,Fee Schedule,103% of CMS OPPS Rate,147.68,103,,,Fee Schedule,103% of CMS OPPS Rate,784.56,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,635.97,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,635.97,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,635.97,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,635.97,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,215.07,150,,,Fee Schedule,150% of CMS OPPS Rate,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.26,70,,71.12,Percent of Total Billed Charges,70% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,146.45,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.08,100,,0.216,Percent of Total Billed Charges,100% of Total Billed Charges,129.04,1046.08,
PERFLUTREN LIPID 2ML,53000085,CDM,255,RC,Q5111,HCPCS,Outpatient,,,656.8,394.08,,204.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,215.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,347.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,347.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,347.92,360,,,Fee Schedule,360% of BCBS POS Rate,347.92,360,,,Fee schedule,360% of BCBS PPO Rate,347.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,394.08,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,129.04,90,,,Fee Schedule,90% of CMS OPPS Rate,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,186.39,130,,,Fee Schedule,130% of CMS OPPS Rate,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,94.71,14.42,,19.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.68,103,,,Fee Schedule,103% of CMS OPPS Rate,147.68,103,,,Fee Schedule,103% of CMS OPPS Rate,525.44,80,,0.256,Percent of Total Billed Charges,80% of Total Billed Charges,112.93,80,,0.056,Fee Schedule,80% of Scott and White EPO fee schedule,112.93,80,,5.536,Fee Schedule,80% of Scott and White HMO fee schedule,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,112.93,80,,5.536,Fee Schedule,80% of Scott and White PPO fee schedule,112.93,80,,8.136,Fee Schedule,80% of Scott and White SWHP fee schedule,215.07,150,,,Fee Schedule,150% of CMS OPPS Rate,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,459.76,70,,48.224,Percent of Total Billed Charges,70% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,91.95,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,143.38,100,,,Fee Schedule,100% of CMS OPPS Rate,656.8,100,,0.336,Percent of Total Billed Charges,100% of Total Billed Charges,91.95,656.8,
D20W 500ML,53000086,CDM,258,RC,Q9957,HCPCS,Outpatient,,,81.03,48.62,,46.61,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,95.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,95.34,360,,,Fee Schedule,360% of BCBS POS Rate,95.34,360,,,Fee schedule,360% of BCBS PPO Rate,95.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.62,60,,66.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.77,75,,112.752,Percent of Total Billed Charges,75% of Total Billed Charges,39.24,80,,0.36,Fee Schedule,80% of Scott and White EPO fee schedule,39.24,80,,4.552,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.24,80,,4.552,Fee Schedule,80% of Scott and White PPO fee schedule,39.24,80,,0.208,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.72,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.03,100,,150.336,Percent of Total Billed Charges,100% of Total Billed Charges,39.24,95.34,
FLUCYTOSINE 500MG CAP,53000087,CDM,250,RC,,,Outpatient,,,294.9,176.94,,176.94,60,,141.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.57,28,,66.056,Percent of Total Billed Charges,28% of Total Billed Charges,119.52,32,,95.616,Percent of Total Billed Charges,32% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,106.16,36,,84.928,Percent of Total Billed Charges,36% of Total Billed Charges,106.16,36,,84.928,Percent of Total Billed Charges,36% Total Bille Charges,106.16,36,,84.928,Percent of Total Billed Charges,36% of Total Billed Charges,176.94,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,42.52,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.18,75,,109.216,Percent of Total Billed Charges,75% of Total Billed Charges,147.45,50,,5.536,Percent of Total Billed Charges,50% of Total Billed Charges,147.45,50,,7.936,Percent of Total Billed Charges,50% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.45,50,,7.936,Percent of Total Billed Charges,50% of Total Billed Charges,147.45,50,,12.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.43,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,41.29,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.9,100,,145.624,Percent of Total Billed Charges,100% of Total Billed Charges,41.29,294.9,
PIPERONYL/PYRETHRN SHAMP 60ML,53000088,CDM,250,RC,,,Outpatient,,,14.26,8.56,,8.56,60,,6.848,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.99,28,,3.192,Percent of Total Billed Charges,28% of Total Billed Charges,119.52,32,,95.616,Percent of Total Billed Charges,32% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,36,,4.104,Percent of Total Billed Charges,36% of Total Billed Charges,5.13,36,,4.104,Percent of Total Billed Charges,36% Total Bille Charges,5.13,36,,4.104,Percent of Total Billed Charges,36% of Total Billed Charges,8.56,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2.06,14.42,,44.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.7,75,,174.256,Percent of Total Billed Charges,75% of Total Billed Charges,7.13,50,,4.552,Percent of Total Billed Charges,50% of Total Billed Charges,7.13,50,,40.056,Percent of Total Billed Charges,50% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.13,50,,40.056,Percent of Total Billed Charges,50% of Total Billed Charges,7.13,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.98,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.26,100,,232.344,Percent of Total Billed Charges,100% of Total Billed Charges,2,119.52,
BICTEG/EMTRI/TENO(BIKTARVY)TAB,53000090,CDM,250,RC,,,Outpatient,,,196.38,117.83,,117.83,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.99,28,,43.992,Percent of Total Billed Charges,28% of Total Billed Charges,119.75,32,,95.8,Percent of Total Billed Charges,32% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,70.7,36,,56.56,Percent of Total Billed Charges,36% of Total Billed Charges,70.7,36,,56.56,Percent of Total Billed Charges,36% Total Bille Charges,70.7,36,,56.56,Percent of Total Billed Charges,36% of Total Billed Charges,117.83,60,,82.824,Percent of Total Billed Charges,60% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,28.32,14.42,,24.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.29,75,,435.04,Percent of Total Billed Charges,75% of Total Billed Charges,98.19,50,,7.936,Percent of Total Billed Charges,50% of Total Billed Charges,98.19,50,,6.32,Percent of Total Billed Charges,50% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.19,50,,6.32,Percent of Total Billed Charges,50% of Total Billed Charges,98.19,50,,5.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.47,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,27.49,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.38,100,,580.056,Percent of Total Billed Charges,100% of Total Billed Charges,27.49,196.38,
MENINGOCOCCAL B VAC 4-COMP,53000091,CDM,636,RC,90620,HCPCS,Outpatient,,,512.85,307.71,,512.01,110,,409.608,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,199.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,199.78,360,,,Fee Schedule,360% of BCBS POS Rate,199.78,360,,,Fee schedule,360% of BCBS PPO Rate,199.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.64,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,256.43,50,,40.056,Percent of Total Billed Charges,50% of Total Billed Charges,256.43,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.43,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,256.43,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,512.85,100,,1.552,Percent of Total Billed Charges,100% of Total Billed Charges,199.78,512.85,
LIDO/EPI INJ 1%1:100K MDV20ML,53000092,CDM,250,RC,,,Outpatient,,,9.57,5.74,,5.74,60,,4.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.68,28,,2.144,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,3.45,36,,2.76,Percent of Total Billed Charges,36% of Total Billed Charges,3.45,36,,2.76,Percent of Total Billed Charges,36% Total Bille Charges,3.45,36,,2.76,Percent of Total Billed Charges,36% of Total Billed Charges,5.74,60,,12.12,Percent of Total Billed Charges,60% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14.42,,110.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.18,75,,1.744,Percent of Total Billed Charges,75% of Total Billed Charges,4.79,50,,6.32,Percent of Total Billed Charges,50% of Total Billed Charges,4.79,50,,17.12,Percent of Total Billed Charges,50% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,50,,17.12,Percent of Total Billed Charges,50% of Total Billed Charges,4.79,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.7,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.57,100,,2.32,Percent of Total Billed Charges,100% of Total Billed Charges,1.34,120,
LIDOCAINE JELLY 2% GLYDO 11ML,53000093,CDM,250,RC,,,Outpatient,,,12.7,7.62,,7.62,60,,6.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.56,28,,2.848,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,36,,3.656,Percent of Total Billed Charges,36% of Total Billed Charges,4.57,36,,3.656,Percent of Total Billed Charges,36% Total Bille Charges,4.57,36,,3.656,Percent of Total Billed Charges,36% of Total Billed Charges,7.62,60,,33.952,Percent of Total Billed Charges,60% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14.42,,22.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,6.35,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,6.35,50,,1.664,Percent of Total Billed Charges,50% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.35,50,,1.664,Percent of Total Billed Charges,50% of Total Billed Charges,6.35,50,,8.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.89,70,,37.416,Percent of Total Billed Charges,70% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.7,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,1.78,120,
TRANEXAMIC ACID 1000MG/NS 100M,53000094,CDM,250,RC,,,Outpatient,,,259.56,155.74,,155.74,60,,124.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.68,28,,58.144,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,93.44,36,,74.752,Percent of Total Billed Charges,36% of Total Billed Charges,93.44,36,,74.752,Percent of Total Billed Charges,36% Total Bille Charges,93.44,36,,74.752,Percent of Total Billed Charges,36% of Total Billed Charges,155.74,60,,71.392,Percent of Total Billed Charges,60% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14.42,,27.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.67,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,129.78,50,,17.12,Percent of Total Billed Charges,50% of Total Billed Charges,129.78,50,,219.84,Percent of Total Billed Charges,50% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.78,50,,219.84,Percent of Total Billed Charges,50% of Total Billed Charges,129.78,50,,4.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.69,70,,54.896,Percent of Total Billed Charges,70% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.56,100,,0.112,Percent of Total Billed Charges,100% of Total Billed Charges,36.34,259.56,
LIDOCAINE INJ 2% 20ML MDV,53000095,CDM,250,RC,,,Outpatient,,,16.3,9.78,,9.78,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,9.78,60,,6.432,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,27.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,8.15,50,,1.664,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,27.264,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,50,,27.264,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,0.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,120,
FIBRIN SEALANT (TISSEEL) 4 ML,53000096,CDM,250,RC,C1760,HCPCS,Outpatient,,,1199.95,719.97,,114.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,335.99,28,,268.792,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,431.98,36,,345.584,Percent of Total Billed Charges,36% of Total Billed Charges,431.98,36,,345.584,Percent of Total Billed Charges,36% Total Bille Charges,431.98,36,,345.584,Percent of Total Billed Charges,36% of Total Billed Charges,719.97,60,,11.768,Percent of Total Billed Charges,60% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,173.03,14.42,,22.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,899.96,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,599.98,50,,219.84,Percent of Total Billed Charges,50% of Total Billed Charges,599.98,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,599.98,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,599.98,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,839.97,70,,106.672,Percent of Total Billed Charges,70% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,167.99,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1199.95,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,114.86,1199.95,
SENNA 187MG TAB,53000097,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,4.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,27.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,110.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,110.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,5.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ASPIRIN 81MG EC TAB,53000105,CDM,250,RC,,,Outpatient,,,0.09,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,8.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,75,,2.056,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,0.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,220.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,100,,2.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
SENNA CONC/DOCCUSATE SOD TAB,53000113,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,979.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,11.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,1.808,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,110.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,5.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,2.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ALVIMOPAN 12 MG CAP,53000115,CDM,250,RC,,,Outpatient,,,263.94,158.36,,158.36,60,,126.688,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.9,28,,59.12,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,95.02,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,95.02,36,,76.016,Percent of Total Billed Charges,36% Total Bille Charges,95.02,36,,76.016,Percent of Total Billed Charges,36% of Total Billed Charges,158.36,60,,18.832,Percent of Total Billed Charges,60% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,38.06,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.96,75,,0.768,Percent of Total Billed Charges,75% of Total Billed Charges,131.97,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,131.97,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.97,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,131.97,50,,4.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.76,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,36.95,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.94,100,,1.024,Percent of Total Billed Charges,100% of Total Billed Charges,36.95,263.94,
GUAIFENESIN DM TAB,53000139,CDM,250,RC,,,Outpatient,,,1.12,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,27.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,75,,1.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,7.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,70,,345.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,100,,1.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,120,
ASPIRIN 325MG EC TAB,53000147,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,125.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,0.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,14.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,14.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,40.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,0.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,120,
MAGNESIUM OXIDE 400MG TAB,53000154,CDM,250,RC,,,Outpatient,,,0.28,0.17,,0.17,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,60,,1.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,239.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,75,,0.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,6.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,70,,39.36,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,100,,0.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,120,
MAGNESIUM LAC 84MG ER TAB,53000155,CDM,250,RC,,,Outpatient,,,0.65,0.39,,0.39,60,,0.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,60,,139.744,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,197.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,75,,0.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.33,50,,14.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,8.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,50,,8.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,0.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,70,,334.904,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,100,,0.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,120,
BISACODYL 5MG EC TAB,53000188,CDM,250,RC,,,Outpatient,,,0.07,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,8.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,0.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,22.544,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,22.544,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,17.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,70,,106.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,100,,0.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ACETAZOLAMIDE 250MG TAB,53000980,CDM,250,RC,,,Outpatient,,,5.63,3.38,,3.38,60,,2.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,28,,1.264,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,36,,1.624,Percent of Total Billed Charges,36% of Total Billed Charges,2.03,36,,1.624,Percent of Total Billed Charges,36% Total Bille Charges,2.03,36,,1.624,Percent of Total Billed Charges,36% of Total Billed Charges,3.38,60,,177.544,Percent of Total Billed Charges,60% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.81,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,75,,1.328,Percent of Total Billed Charges,75% of Total Billed Charges,2.82,50,,8.672,Percent of Total Billed Charges,50% of Total Billed Charges,2.82,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.82,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,2.82,50,,1.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.94,70,,335.896,Percent of Total Billed Charges,70% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.63,100,,1.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.79,120,
ACYCLOVIR 200MG CAP,53001608,CDM,250,RC,,,Outpatient,,,2.89,1.73,,1.73,60,,1.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,28,,0.648,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% Total Bille Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,1.73,60,,236.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,75,,4.136,Percent of Total Billed Charges,75% of Total Billed Charges,1.45,50,,22.544,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,50,,5.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,50,,5.48,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,50,,219.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,70,,114.952,Percent of Total Billed Charges,70% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.89,100,,5.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,120,
ACYCLOVIR 800MG TAB,53001616,CDM,250,RC,,,Outpatient,,,2.05,1.23,,1.23,60,,0.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,28,,0.456,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% Total Bille Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,1.23,60,,108.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,24.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.54,75,,0.144,Percent of Total Billed Charges,75% of Total Billed Charges,1.03,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,3.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,50,,3.192,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,27.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,70,,178.168,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,100,,0.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,120,
ACYCLOVIR 400 MG TAB,53001624,CDM,250,RC,,,Outpatient,,,1.01,0.61,,0.61,60,,0.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,28,,0.224,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% Total Bille Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,0.61,60,,144.864,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,24.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,75,,0.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.51,50,,5.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,5.456,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,50,,5.456,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,70,,145.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,100,,0.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,120,
PERAMIVIR 200MG/ 20ML VL,53001625,CDM,250,RC,J2547,HCPCS,Outpatient,,,1430,858.00,,1.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,2.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,360,,,Fee Schedule,360% of BCBS POS Rate,1.58,360,,,Fee schedule,360% of BCBS PPO Rate,1.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,858,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,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,1.45,90,,,Fee Schedule,90% of CMS OPPS Rate,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2.09,130,,,Fee Schedule,130% of CMS OPPS Rate,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,206.21,14.42,,30.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,1.66,103,,,Fee Schedule,103% of CMS OPPS Rate,1.66,103,,,Fee Schedule,103% of CMS OPPS Rate,1072.5,75,,0.144,Percent of Total Billed Charges,75% of Total Billed Charges,715,50,,3.192,Percent of Total Billed Charges,50% of Total Billed Charges,715,50,,7.088,Percent of Total Billed Charges,50% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,715,50,,7.088,Percent of Total Billed Charges,50% of Total Billed Charges,715,50,,110.736,Percent of Total Billed Charges,50% of Total Billed Charges,2.42,150,,,Fee Schedule,150% of CMS OPPS Rate,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1001,70,,116.912,Percent of Total Billed Charges,70% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,200.2,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1430,100,,0.192,Percent of Total Billed Charges,100% of Total Billed Charges,1.45,1430,
ALBENDAZOLE 200MG TAB,53002010,CDM,250,RC,,,Outpatient,,,366.14,219.68,,219.68,60,,175.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.52,28,,82.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,131.81,36,,105.448,Percent of Total Billed Charges,36% of Total Billed Charges,131.81,36,,105.448,Percent of Total Billed Charges,36% Total Bille Charges,131.81,36,,105.448,Percent of Total Billed Charges,36% of Total Billed Charges,219.68,60,,30.464,Percent of Total Billed Charges,60% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,52.8,14.42,,51.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.61,75,,0.152,Percent of Total Billed Charges,75% of Total Billed Charges,183.07,50,,5.456,Percent of Total Billed Charges,50% of Total Billed Charges,183.07,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.07,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,183.07,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.3,70,,156.944,Percent of Total Billed Charges,70% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,51.26,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.14,100,,0.2,Percent of Total Billed Charges,100% of Total Billed Charges,51.26,366.14,
ALENDRONATE 70 MG TAB,53002333,CDM,250,RC,,,Outpatient,,,2.13,1.28,,1.28,60,,1.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% Total Bille Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,1.28,60,,18662.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,97.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,75,,60.888,Percent of Total Billed Charges,75% of Total Billed Charges,1.07,50,,7.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,50,,57.576,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,50,,57.576,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,70,,146.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.13,100,,81.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,120,
ALISKIREN 150 MG TAB,53002424,CDM,250,RC,,,Outpatient,,,11.99,7.19,,7.19,60,,5.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,28,,2.688,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% Total Bille Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,7.19,60,,35.728,Percent of Total Billed Charges,60% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14.42,,100.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.99,75,,5.04,Percent of Total Billed Charges,75% of Total Billed Charges,6,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,6,50,,42.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,50,,42.872,Percent of Total Billed Charges,50% of Total Billed Charges,6,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.39,70,,139.848,Percent of Total Billed Charges,70% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.99,100,,6.72,Percent of Total Billed Charges,100% of Total Billed Charges,1.68,120,
ALLOPURINOL 100MG TAB,53002440,CDM,250,RC,,,Outpatient,,,0.81,0.49,,0.49,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,28,,0.184,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% Total Bille Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,75,,3.176,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,50,,57.576,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,3831.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,50,,3831.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,70,,622.952,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,100,,4.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,120,
FEBUXOSTAT 40 MG TAB,53002445,CDM,250,RC,,,Outpatient,,,21.36,12.82,,12.82,60,,10.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.98,28,,4.784,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.69,36,,6.152,Percent of Total Billed Charges,36% of Total Billed Charges,7.69,36,,6.152,Percent of Total Billed Charges,36% Total Bille Charges,7.69,36,,6.152,Percent of Total Billed Charges,36% of Total Billed Charges,12.82,60,,569.032,Percent of Total Billed Charges,60% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,3.08,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.02,75,,2.2,Percent of Total Billed Charges,75% of Total Billed Charges,10.68,50,,42.872,Percent of Total Billed Charges,50% of Total Billed Charges,10.68,50,,31.152,Percent of Total Billed Charges,50% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.68,50,,31.152,Percent of Total Billed Charges,50% of Total Billed Charges,10.68,50,,14.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.95,70,,622.952,Percent of Total Billed Charges,70% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.36,100,,2.928,Percent of Total Billed Charges,100% of Total Billed Charges,2.99,120,
ALLOPURINOL 300MG TAB,53002481,CDM,250,RC,,,Outpatient,,,1.64,0.98,,0.98,60,,0.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,60,,1564.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,15.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.82,50,,3831.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,637.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,50,,637.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,120,
ALPRAZOLAM 0.25MG TAB,53002945,CDM,250,RC,,,Outpatient,,,0.5,0.30,,0.3,60,,0.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,60,,6.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,59.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,75,,0.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.25,50,,31.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,3603.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,50,,3603.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,8.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,100,,0.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,120,
ALPRAZOLAM 0.5MG TAB,53002986,CDM,250,RC,,,Outpatient,,,0.49,0.29,,0.29,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,60,,11.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,93.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,75,,0.528,Percent of Total Billed Charges,75% of Total Billed Charges,0.25,50,,637.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,8.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,50,,8.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,22.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,70,,633.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,100,,0.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,120,
AMANTADINE 100MG CAP,53004768,CDM,250,RC,,,Outpatient,,,4.38,2.63,,2.63,60,,2.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,28,,0.984,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% Total Bille Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,2.63,60,,89.824,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,27.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.29,75,,0.64,Percent of Total Billed Charges,75% of Total Billed Charges,2.19,50,,3603.264,Percent of Total Billed Charges,50% of Total Billed Charges,2.19,50,,16.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.19,50,,16.64,Percent of Total Billed Charges,50% of Total Billed Charges,2.19,50,,2.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.07,70,,633.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.38,100,,0.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,120,
AMILORIDE 5MG TAB,53005229,CDM,250,RC,,,Outpatient,,,2.1,1.26,,1.26,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,1.26,60,,16.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,47.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,75,,0.184,Percent of Total Billed Charges,75% of Total Billed Charges,1.05,50,,8.44,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,65.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,50,,65.528,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,5.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,100,,0.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,120,
AMIODARONE 200MG TAB,53006250,CDM,250,RC,,,Outpatient,,,0.86,0.52,,0.52,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,60,,137.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,75,,1.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,16.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,198.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,198.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,3.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,100,,1.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,120,
DRONEDARONE 400 MG TAB,53006276,CDM,250,RC,,,Outpatient,,,21.02,12.61,,12.61,60,,10.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.89,28,,4.712,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,7.57,36,,6.056,Percent of Total Billed Charges,36% of Total Billed Charges,7.57,36,,6.056,Percent of Total Billed Charges,36% Total Bille Charges,7.57,36,,6.056,Percent of Total Billed Charges,36% of Total Billed Charges,12.61,60,,43.024,Percent of Total Billed Charges,60% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.77,75,,0.464,Percent of Total Billed Charges,75% of Total Billed Charges,10.51,50,,65.528,Percent of Total Billed Charges,50% of Total Billed Charges,10.51,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.51,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.51,50,,5.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.71,70,,52.136,Percent of Total Billed Charges,70% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.02,100,,0.616,Percent of Total Billed Charges,100% of Total Billed Charges,2.94,120,
AMITRIPTYLINE 10MG TAB,53006342,CDM,250,RC,,,Outpatient,,,0.42,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,417.024,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,42.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,75,,0.736,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,198.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,67.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,67.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,7.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,50.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,100,,0.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,120,
AMITRIPTYLINE 25MG TAB,53006383,CDM,250,RC,,,Outpatient,,,0.85,0.51,,0.51,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,60,,37.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,33.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,75,,0.68,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,45.136,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,100,,0.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,120,
AMITRIPTYLINE 50MG TAB,53006425,CDM,250,RC,,,Outpatient,,,1.7,1.02,,1.02,60,,0.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% Total Bille Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,1.02,60,,84.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,100.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,75,,4,Percent of Total Billed Charges,75% of Total Billed Charges,0.85,50,,67.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,50,,57.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,70,,292.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.7,100,,5.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,120,
LURASIDONE 40MG TAB,53006542,CDM,250,RC,,,Outpatient,,,81.56,48.94,,48.94,60,,39.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.84,28,,18.272,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,29.36,36,,23.488,Percent of Total Billed Charges,36% of Total Billed Charges,29.36,36,,23.488,Percent of Total Billed Charges,36% Total Bille Charges,29.36,36,,23.488,Percent of Total Billed Charges,36% of Total Billed Charges,48.94,60,,24.168,Percent of Total Billed Charges,60% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.76,14.42,,127.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.17,75,,5.72,Percent of Total Billed Charges,75% of Total Billed Charges,40.78,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,40.78,50,,12.08,Percent of Total Billed Charges,50% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.78,50,,12.08,Percent of Total Billed Charges,50% of Total Billed Charges,40.78,50,,42.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.09,70,,160.128,Percent of Total Billed Charges,70% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.42,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.56,100,,7.624,Percent of Total Billed Charges,100% of Total Billed Charges,11.42,120,
AMLODIPINE 5MG TAB,53006615,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,170.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,444.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,1.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,3831.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,143.832,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,1.928,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,120,
AMOX/CLAV 250MG TAB,53007126,CDM,250,RC,,,Outpatient,,,12.34,7.40,,7.4,60,,5.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,28,,2.768,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% Total Bille Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,7.4,60,,82.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14.42,,385.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.26,75,,1.64,Percent of Total Billed Charges,75% of Total Billed Charges,6.17,50,,12.08,Percent of Total Billed Charges,50% of Total Billed Charges,6.17,50,,777.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.17,50,,777.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.17,50,,31.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.64,70,,135.16,Percent of Total Billed Charges,70% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.34,100,,2.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,120,
AMOXICILLIN 875MG TAB,53007134,CDM,250,RC,,,Outpatient,,,1.71,1.03,,1.03,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,60,,155.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,75,,32.272,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,15.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,50,,15.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,637.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,70,,111.824,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,100,,43.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,120,
AMOX/CLAV 500MG TAB,53007159,CDM,250,RC,,,Outpatient,,,4.05,2.43,,2.43,60,,1.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,28,,0.904,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% Total Bille Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,2.43,60,,44.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14.42,,58.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,2.03,50,,777.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.03,50,,161.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.03,50,,161.152,Percent of Total Billed Charges,50% of Total Billed Charges,2.03,50,,3603.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.84,70,,95.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.05,100,,0.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,120,
AMOXICILLIN 250MG CAP,53007233,CDM,250,RC,,,Outpatient,,,0.86,0.52,,0.52,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,60,,110.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,84.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,75,,0.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,15.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,8.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,73.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,100,,1.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,120,
AMOXICILLIN 500MG CAP,53007258,CDM,250,RC,,,Outpatient,,,1.02,0.61,,0.61,60,,0.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.61,60,,720.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,268.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,75,,0.624,Percent of Total Billed Charges,75% of Total Billed Charges,0.51,50,,161.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,566.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,50,,566.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,16.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,70,,80.784,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,100,,0.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,120,
AMPICILLIN 250MG CAP,53007464,CDM,250,RC,,,Outpatient,,,0.29,0.17,,0.17,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,60,,65.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,268.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,75,,2.08,Percent of Total Billed Charges,75% of Total Billed Charges,0.15,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,151.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,50,,151.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,65.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,70,,88.864,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,100,,2.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,120,
AMPICILLIN 500MG CAP,53007506,CDM,250,RC,,,Outpatient,,,1.37,0.82,,0.82,60,,0.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,28,,0.304,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% Total Bille Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,60,,179.224,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,184.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,75,,0.888,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,50,,566.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,110.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,50,,110.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,198.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,70,,97.752,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,100,,1.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,120,
APIXABAN 5 MG TAB,53007510,CDM,250,RC,,,Outpatient,,,15.97,9.58,,9.58,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.47,28,,3.576,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% Total Bille Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,9.58,60,,2.376,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14.42,,149.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,75,,3.792,Percent of Total Billed Charges,75% of Total Billed Charges,7.99,50,,151.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.99,50,,43.528,Percent of Total Billed Charges,50% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.99,50,,43.528,Percent of Total Billed Charges,50% of Total Billed Charges,7.99,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.18,70,,107.536,Percent of Total Billed Charges,70% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.97,100,,5.056,Percent of Total Billed Charges,100% of Total Billed Charges,2.24,120,
ACETAMINOPHEN 500MG TAB,53007560,CDM,250,RC,,,Outpatient,,,0.07,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,119.136,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,299.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,1.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,110.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,25.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,25.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,67.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,70,,1253.984,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,100,,2.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ACETAMINOPHEN 1000MG/100ML VL,53007597,CDM,250,RC,J0131,HCPCS,Outpatient,,,225.12,135.07,,0.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,360,,,Fee Schedule,360% of BCBS POS Rate,0.3,360,,,Fee schedule,360% of BCBS PPO Rate,0.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,135.07,60,,29.872,Percent of Total Billed Charges,60% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,32.46,14.42,,482.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.84,75,,0.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,80,,43.528,Fee Schedule,80% of Scott and White EPO fee schedule,0.07,80,,34.08,Fee Schedule,80% of Scott and White HMO fee schedule,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,80,,34.08,Fee Schedule,80% of Scott and White PPO fee schedule,0.07,80,,7.88,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.58,70,,505.68,Percent of Total Billed Charges,70% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,31.52,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.12,100,,0.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,225.12,
ACETAMINOPHEN 325MG TAB,53007605,CDM,250,RC,,,Outpatient,,,0.06,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,41.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,0.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,50,,25.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,70,,1258.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,100,,0.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ANASTROZOLE 1MG TAB,53007621,CDM,250,RC,J8999,HCPCS,Outpatient,,,1.5,0.90,,0.9,60,,0.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.9,60,,47.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,0.75,50,,34.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,12.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.05,70,,619.288,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,100,,0.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,120,
Cefazolin 3Gm Inj,53007625,CDM,250,RC,J0688,HCPCS,Outpatient,,,13.22,7.93,,7.93,60,,6.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,360,,,Fee Schedule,360% of BCBS POS Rate,1.16,360,,,Fee schedule,360% of BCBS PPO Rate,1.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.93,60,,127.936,Percent of Total Billed Charges,60% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14.42,,16.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.92,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,6.61,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,6.61,50,,45.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.61,50,,45.504,Percent of Total Billed Charges,50% of Total Billed Charges,6.61,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.25,70,,764.88,Percent of Total Billed Charges,70% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.22,100,,0.176,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,13.22,
ARIPIPRAZOLE 15 MG TAB,53007803,CDM,250,RC,,,Outpatient,,,2.92,1.75,,1.75,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,60,,87.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,75,,19.56,Percent of Total Billed Charges,75% of Total Billed Charges,1.46,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,7060.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,50,,7060.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,777.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,70,,570.768,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,100,,26.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,120,
ARIPIPRAZOLE 5 MG TAB,53007837,CDM,250,RC,,,Outpatient,,,2.92,1.75,,1.75,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,60,,658.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,75,,1.632,Percent of Total Billed Charges,75% of Total Billed Charges,1.46,50,,45.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,6.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,50,,6.28,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,15.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,70,,1478.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,100,,2.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,120,
ARIPIPRAZOLE 2 MG TAB,53007840,CDM,250,RC,,,Outpatient,,,2.92,1.75,,1.75,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,60,,125.008,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,75,,24.32,Percent of Total Billed Charges,75% of Total Billed Charges,1.46,50,,7060.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,161.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,70,,718.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,100,,32.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,120,
ARIPIPRAZOLE 10 MG TAB,53007845,CDM,250,RC,,,Outpatient,,,2.92,1.75,,1.75,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,60,,228.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,75,,8.136,Percent of Total Billed Charges,75% of Total Billed Charges,1.46,50,,6.28,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,1.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,70,,963.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,100,,10.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,120,
ANTACID OTC TAB/CAP,53008009,CDM,250,RC,,,Outpatient,,,0.03,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,4.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,75,,3.96,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,566.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,70,,306.232,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,100,,5.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
ASCORBIC ACID 500MG TAB,53010617,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,854.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,7.888,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,151.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,76.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,10.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,120,
RASAGILINE 0.5MG TAB,53010620,CDM,250,RC,,,Outpatient,,,39.84,23.90,,23.9,60,,19.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.16,28,,8.928,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,36,,11.472,Percent of Total Billed Charges,36% of Total Billed Charges,14.34,36,,11.472,Percent of Total Billed Charges,36% Total Bille Charges,14.34,36,,11.472,Percent of Total Billed Charges,36% of Total Billed Charges,23.9,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.74,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.88,75,,6.424,Percent of Total Billed Charges,75% of Total Billed Charges,19.92,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.92,50,,140.912,Percent of Total Billed Charges,50% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.92,50,,140.912,Percent of Total Billed Charges,50% of Total Billed Charges,19.92,50,,110.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.89,70,,62.136,Percent of Total Billed Charges,70% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.84,100,,8.568,Percent of Total Billed Charges,100% of Total Billed Charges,5.58,120,
ATAZANAVIR 150 MG CAP,53011219,CDM,250,RC,,,Outpatient,,,49.28,29.57,,29.57,60,,23.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.8,28,,11.04,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,17.74,36,,14.192,Percent of Total Billed Charges,36% of Total Billed Charges,17.74,36,,14.192,Percent of Total Billed Charges,36% Total Bille Charges,17.74,36,,14.192,Percent of Total Billed Charges,36% of Total Billed Charges,29.57,60,,1607.768,Percent of Total Billed Charges,60% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.96,75,,6.424,Percent of Total Billed Charges,75% of Total Billed Charges,24.64,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.64,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.64,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,24.64,50,,43.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.5,70,,59,Percent of Total Billed Charges,70% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,6.9,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.28,100,,8.568,Percent of Total Billed Charges,100% of Total Billed Charges,6.9,120,
RALTEGRAVIR 400 MG TAB,53011235,CDM,250,RC,,,Outpatient,,,50.5,30.30,,30.3,60,,24.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.14,28,,11.312,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,18.18,36,,14.544,Percent of Total Billed Charges,36% of Total Billed Charges,18.18,36,,14.544,Percent of Total Billed Charges,36% Total Bille Charges,18.18,36,,14.544,Percent of Total Billed Charges,36% of Total Billed Charges,30.3,60,,992.688,Percent of Total Billed Charges,60% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.28,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.88,75,,6.424,Percent of Total Billed Charges,75% of Total Billed Charges,25.25,50,,140.912,Percent of Total Billed Charges,50% of Total Billed Charges,25.25,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.25,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,25.25,50,,25.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.35,70,,58.512,Percent of Total Billed Charges,70% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.5,100,,8.568,Percent of Total Billed Charges,100% of Total Billed Charges,7.07,120,
DARUNAVIR 600 MG TAB,53011243,CDM,250,RC,,,Outpatient,,,53.19,31.91,,31.91,60,,25.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.89,28,,11.912,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.15,36,,15.32,Percent of Total Billed Charges,36% of Total Billed Charges,19.15,36,,15.32,Percent of Total Billed Charges,36% Total Bille Charges,19.15,36,,15.32,Percent of Total Billed Charges,36% of Total Billed Charges,31.91,60,,3.256,Percent of Total Billed Charges,60% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.67,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.89,75,,6.424,Percent of Total Billed Charges,75% of Total Billed Charges,26.6,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,26.6,50,,186.928,Percent of Total Billed Charges,50% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.6,50,,186.928,Percent of Total Billed Charges,50% of Total Billed Charges,26.6,50,,34.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.23,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.19,100,,8.568,Percent of Total Billed Charges,100% of Total Billed Charges,7.45,120,
DARUNAVIR 400MG TAB,53011250,CDM,250,RC,,,Outpatient,,,41.94,25.16,,25.16,60,,20.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.74,28,,9.392,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,15.1,36,,12.08,Percent of Total Billed Charges,36% of Total Billed Charges,15.1,36,,12.08,Percent of Total Billed Charges,36% Total Bille Charges,15.1,36,,12.08,Percent of Total Billed Charges,36% of Total Billed Charges,25.16,60,,29.648,Percent of Total Billed Charges,60% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.46,75,,0.712,Percent of Total Billed Charges,75% of Total Billed Charges,20.97,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,50,,170.344,Percent of Total Billed Charges,50% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.97,50,,170.344,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,50,,10.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.36,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.94,100,,0.944,Percent of Total Billed Charges,100% of Total Billed Charges,5.87,120,
DARUNAVIR 800 MG TAB,53011255,CDM,250,RC,,,Outpatient,,,105.88,63.53,,63.53,60,,50.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.65,28,,23.72,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,38.12,36,,30.496,Percent of Total Billed Charges,36% of Total Billed Charges,38.12,36,,30.496,Percent of Total Billed Charges,36% Total Bille Charges,38.12,36,,30.496,Percent of Total Billed Charges,36% of Total Billed Charges,63.53,60,,768.992,Percent of Total Billed Charges,60% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,15.27,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.41,75,,57.52,Percent of Total Billed Charges,75% of Total Billed Charges,52.94,50,,186.928,Percent of Total Billed Charges,50% of Total Billed Charges,52.94,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.94,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,52.94,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.12,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,14.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.88,100,,76.696,Percent of Total Billed Charges,100% of Total Billed Charges,14.82,120,
DOLUTEGRAVIR 50MG TAB,53011280,CDM,250,RC,,,Outpatient,,,111.01,66.61,,66.61,60,,53.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.08,28,,24.864,Percent of Total Billed Charges,28% of Total Billed Charges,120,32,,96,Percent of Total Billed Charges,32% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,39.96,36,,31.968,Percent of Total Billed Charges,36% of Total Billed Charges,39.96,36,,31.968,Percent of Total Billed Charges,36% Total Bille Charges,39.96,36,,31.968,Percent of Total Billed Charges,36% of Total Billed Charges,66.61,60,,240.296,Percent of Total Billed Charges,60% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,16.01,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.26,75,,11.864,Percent of Total Billed Charges,75% of Total Billed Charges,55.51,50,,170.344,Percent of Total Billed Charges,50% of Total Billed Charges,55.51,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.51,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,55.51,50,,45.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.71,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.54,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.01,100,,15.816,Percent of Total Billed Charges,100% of Total Billed Charges,15.54,120,
ATENOLOL 25MG TAB,53011375,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,120.08,32,,96.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,262.864,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,54.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,105.232,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,7060.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,140.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,120.08,
ATENOLOL 50MG TAB,53011383,CDM,250,RC,,,Outpatient,,,0.26,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,120.08,32,,96.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,18.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,50.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,6.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,100,,67.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,120.08,
NEBIVOLOL 5 MG TAB,53011391,CDM,250,RC,,,Outpatient,,,8.89,5.33,,5.33,60,,4.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.49,28,,1.992,Percent of Total Billed Charges,28% of Total Billed Charges,120.08,32,,96.064,Percent of Total Billed Charges,32% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,36,,2.56,Percent of Total Billed Charges,36% of Total Billed Charges,3.2,36,,2.56,Percent of Total Billed Charges,36% Total Bille Charges,3.2,36,,2.56,Percent of Total Billed Charges,36% of Total Billed Charges,5.33,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,75,,0.472,Percent of Total Billed Charges,75% of Total Billed Charges,4.45,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,4.45,50,,56.112,Percent of Total Billed Charges,50% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.45,50,,56.112,Percent of Total Billed Charges,50% of Total Billed Charges,4.45,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.22,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.24,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.89,100,,0.632,Percent of Total Billed Charges,100% of Total Billed Charges,1.24,120.08,
NEBIVOLOL 20MG TAB,53011417,CDM,250,RC,,,Outpatient,,,8.72,5.23,,5.23,60,,4.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,28,,1.952,Percent of Total Billed Charges,28% of Total Billed Charges,120.08,32,,96.064,Percent of Total Billed Charges,32% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,36,,2.512,Percent of Total Billed Charges,36% of Total Billed Charges,3.14,36,,2.512,Percent of Total Billed Charges,36% Total Bille Charges,3.14,36,,2.512,Percent of Total Billed Charges,36% of Total Billed Charges,5.23,60,,1394.288,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14.42,,53.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.54,75,,9.208,Percent of Total Billed Charges,75% of Total Billed Charges,4.36,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,4.36,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.36,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,4.36,50,,61.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.72,100,,12.28,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,120.08,
ATORVASTATIN 10MG TAB,53011458,CDM,250,RC,,,Outpatient,,,0.75,0.45,,0.45,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,120.52,32,,96.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,60,,95.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,34.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,75,,9.208,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,56.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,100,,12.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,120.52,
ATORVASTATIN 20MG TAB,53011466,CDM,250,RC,,,Outpatient,,,0.92,0.55,,0.55,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,120.67,32,,96.536,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% Total Bille Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,60,,21.976,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,75,,3.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,122.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,100,,4.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,120.67,
ATORVASTATIN 40 MG TAB,53011474,CDM,250,RC,,,Outpatient,,,0.97,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,120.89,32,,96.712,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,623.456,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,75,,166.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,23.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,23.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,140.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,100,,221.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,120.89,
AZATHIOPRINE 50MG TAB,53012159,CDM,250,RC,J7500,HCPCS,Outpatient,,,1.63,0.98,,7.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,360,,,Fee Schedule,360% of BCBS POS Rate,0.61,360,,,Fee schedule,360% of BCBS PPO Rate,0.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,0.98,60,,2252.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,10.352,Percent of Total Billed Charges,75% of Total Billed Charges,11.7,80,,6.52,Fee Schedule,80% of Scott and White EPO fee schedule,11.7,80,,102.184,Fee Schedule,80% of Scott and White HMO fee schedule,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.7,80,,102.184,Fee Schedule,80% of Scott and White PPO fee schedule,11.7,80,,61.856,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,100,,13.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,11.7,
AZITHROMYCIN 250MG TAB,53012209,CDM,250,RC,,,Outpatient,,,6.45,3.87,,3.87,60,,3.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,28,,1.448,Percent of Total Billed Charges,28% of Total Billed Charges,120.96,32,,96.768,Percent of Total Billed Charges,32% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% Total Bille Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,3.87,60,,17.584,Percent of Total Billed Charges,60% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.84,75,,3.112,Percent of Total Billed Charges,75% of Total Billed Charges,3.23,50,,23.112,Percent of Total Billed Charges,50% of Total Billed Charges,3.23,50,,60.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,50,,60.472,Percent of Total Billed Charges,50% of Total Billed Charges,3.23,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.45,100,,4.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,120.96,
BACLOFEN 10MG TAB,53013579,CDM,250,RC,,,Outpatient,,,2,1.20,,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,28,,0.448,Percent of Total Billed Charges,28% of Total Billed Charges,121.09,32,,96.872,Percent of Total Billed Charges,32% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% Total Bille Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,1.2,60,,27.976,Percent of Total Billed Charges,60% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,75,,10.336,Percent of Total Billed Charges,75% of Total Billed Charges,1,50,,102.184,Percent of Total Billed Charges,50% of Total Billed Charges,1,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,1,50,,186.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,70,,83.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,100,,13.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,121.09,
BENAZEPRIL 10MG TAB,53014312,CDM,250,RC,,,Outpatient,,,1.79,1.07,,1.07,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,28,,0.4,Percent of Total Billed Charges,28% of Total Billed Charges,121.09,32,,96.872,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% Total Bille Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,1.07,60,,63.368,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,75,,0.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.9,50,,60.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,50,,8.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,50,,8.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,50,,170.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,70,,56.848,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,100,,0.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,121.09,
BENZONATATE PERLES 100MG CAP,53014999,CDM,250,RC,,,Outpatient,,,1.13,0.68,,0.68,60,,0.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,28,,0.256,Percent of Total Billed Charges,28% of Total Billed Charges,121.23,32,,96.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% Total Bille Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,0.68,60,,185.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,75,,0.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.57,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,50,,17.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,50,,17.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,70,,58.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,100,,0.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,121.23,
BENZTROPINE MES 1MG TAB,53015228,CDM,250,RC,,,Outpatient,,,0.27,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,121.23,32,,96.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,2479.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,0.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,8.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,97.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,97.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,9.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,100,,0.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,121.23,
BETHANECHOL 10MG TAB,53015764,CDM,250,RC,,,Outpatient,,,2.93,1.76,,1.76,60,,1.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,121.52,32,,97.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.76,60,,75.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,1.47,50,,17.28,Percent of Total Billed Charges,50% of Total Billed Charges,1.47,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,1.47,50,,29.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.93,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,121.52,
BETHANECHOL 25MG TAB,53015806,CDM,250,RC,,,Outpatient,,,3.27,1.96,,1.96,60,,1.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,28,,0.736,Percent of Total Billed Charges,28% of Total Billed Charges,12320,32,,9856,Percent of Total Billed Charges,32% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% Total Bille Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.96,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,75,,1.696,Percent of Total Billed Charges,75% of Total Billed Charges,1.64,50,,97.096,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,841.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,50,,841.816,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.29,70,,747.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,100,,2.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,12320,
BICALUTAMIDE 50 MG TAB,53015905,CDM,250,RC,J8999,HCPCS,Outpatient,,,6.69,4.01,,4.01,60,,3.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,28,,1.496,Percent of Total Billed Charges,28% of Total Billed Charges,12.2,32,,9.76,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.41,36,,1.928,Percent of Total Billed Charges,36% of Total Billed Charges,2.41,36,,1.928,Percent of Total Billed Charges,36% Total Bille Charges,2.41,36,,1.928,Percent of Total Billed Charges,36% of Total Billed Charges,4.01,60,,5253.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,75,,60.544,Percent of Total Billed Charges,75% of Total Billed Charges,3.35,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,3.35,50,,18.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,50,,18.208,Percent of Total Billed Charges,50% of Total Billed Charges,3.35,50,,56.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,70,,747.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.69,100,,80.72,Percent of Total Billed Charges,100% of Total Billed Charges,1.87,12.2,
BISOPROLOL 5MG TAB,53016051,CDM,250,RC,,,Outpatient,,,2.44,1.46,,1.46,60,,1.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,28,,0.544,Percent of Total Billed Charges,28% of Total Billed Charges,12.27,32,,9.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% Total Bille Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,1.46,60,,86.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,75,,1.656,Percent of Total Billed Charges,75% of Total Billed Charges,1.22,50,,841.816,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,100,,2.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,12.27,
BUDESONIDE 3 MG EC CAP,53017257,CDM,250,RC,,,Outpatient,,,37.69,22.61,,22.61,60,,18.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.55,28,,8.44,Percent of Total Billed Charges,28% of Total Billed Charges,12.29,32,,9.832,Percent of Total Billed Charges,32% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,13.57,36,,10.856,Percent of Total Billed Charges,36% of Total Billed Charges,13.57,36,,10.856,Percent of Total Billed Charges,36% Total Bille Charges,13.57,36,,10.856,Percent of Total Billed Charges,36% of Total Billed Charges,22.61,60,,1223.52,Percent of Total Billed Charges,60% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.43,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.27,75,,1.248,Percent of Total Billed Charges,75% of Total Billed Charges,18.85,50,,18.208,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,50,,3.064,Percent of Total Billed Charges,50% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.85,50,,3.064,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,50,,342,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.38,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.69,100,,1.664,Percent of Total Billed Charges,100% of Total Billed Charges,5.28,37.69,
BUMETANIDE 1MG TAB,53017422,CDM,250,RC,,,Outpatient,,,2.18,1.31,,1.31,60,,1.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,28,,0.488,Percent of Total Billed Charges,28% of Total Billed Charges,12.29,32,,9.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,1.31,60,,29.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,1.09,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.53,70,,1188.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.18,100,,1.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,12.29,
BUPROPION 75MG TAB,53017455,CDM,250,RC,,,Outpatient,,,3.09,1.85,,1.85,60,,1.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,28,,0.696,Percent of Total Billed Charges,28% of Total Billed Charges,121.6,32,,97.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,36,,0.888,Percent of Total Billed Charges,36% of Total Billed Charges,1.11,36,,0.888,Percent of Total Billed Charges,36% Total Bille Charges,1.11,36,,0.888,Percent of Total Billed Charges,36% of Total Billed Charges,1.85,60,,35.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,75,,1.312,Percent of Total Billed Charges,75% of Total Billed Charges,1.55,50,,3.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,50,,23.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,70,,1188.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.09,100,,1.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.43,121.6,
VARENICLINE 0.5 MG TAB,53017459,CDM,250,RC,,,Outpatient,,,15.32,9.19,,9.19,60,,7.352,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,28,,3.432,Percent of Total Billed Charges,28% of Total Billed Charges,121.6,32,,97.28,Percent of Total Billed Charges,32% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% Total Bille Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,9.19,60,,3.48,Percent of Total Billed Charges,60% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14.42,,61.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.49,75,,1.44,Percent of Total Billed Charges,75% of Total Billed Charges,7.66,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,7.66,50,,61.696,Percent of Total Billed Charges,50% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.66,50,,61.696,Percent of Total Billed Charges,50% of Total Billed Charges,7.66,50,,102.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.72,70,,59.64,Percent of Total Billed Charges,70% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,100,,1.92,Percent of Total Billed Charges,100% of Total Billed Charges,2.14,121.6,
VARENICLINE 1 MG TAB,53017460,CDM,250,RC,,,Outpatient,,,15.33,9.20,,9.2,60,,7.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,28,,3.432,Percent of Total Billed Charges,28% of Total Billed Charges,121.6,32,,97.28,Percent of Total Billed Charges,32% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% Total Bille Charges,5.52,36,,4.416,Percent of Total Billed Charges,36% of Total Billed Charges,9.2,60,,516.088,Percent of Total Billed Charges,60% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,7.67,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,7.67,50,,230.912,Percent of Total Billed Charges,50% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.67,50,,230.912,Percent of Total Billed Charges,50% of Total Billed Charges,7.67,50,,60.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.73,70,,21.368,Percent of Total Billed Charges,70% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.33,100,,4.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.15,121.6,
BUPROPION 100MG TAB,53017463,CDM,250,RC,,,Outpatient,,,3.93,2.36,,2.36,60,,1.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,121.6,32,,97.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.36,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,75,,3.672,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,50,,61.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,54.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,50,,54.152,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.75,70,,35.512,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.93,100,,4.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,121.6,
BUPROPION SR 100MG TAB,53017489,CDM,250,RC,,,Outpatient,,,1.23,0.74,,0.74,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,121.6,32,,97.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,60,,75.488,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,75,,2.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.62,50,,230.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,143.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,50,,143.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,8.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,70,,201.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,100,,2.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,121.6,
BUPROPION 150MG SR TAB ZYBAN,53017497,CDM,250,RC,,,Outpatient,,,1.62,0.97,,0.97,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,121.77,32,,97.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,60,,101.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,2.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.81,50,,54.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,19.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,50,,19.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,17.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,100,,2.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,121.77,
BUPROPION 150MG/24 HOURS ERT,53017498,CDM,250,RC,,,Outpatient,,,9.18,5.51,,5.51,60,,4.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.57,28,,2.056,Percent of Total Billed Charges,28% of Total Billed Charges,122.4,32,,97.92,Percent of Total Billed Charges,32% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.3,36,,2.64,Percent of Total Billed Charges,36% of Total Billed Charges,3.3,36,,2.64,Percent of Total Billed Charges,36% Total Bille Charges,3.3,36,,2.64,Percent of Total Billed Charges,36% of Total Billed Charges,5.51,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.32,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,75,,0.216,Percent of Total Billed Charges,75% of Total Billed Charges,4.59,50,,143.264,Percent of Total Billed Charges,50% of Total Billed Charges,4.59,50,,36.392,Percent of Total Billed Charges,50% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,50,,36.392,Percent of Total Billed Charges,50% of Total Billed Charges,4.59,50,,97.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.43,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.18,100,,0.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,122.4,
BUPRENORPHINE PATCH 5MCG/HR,53017550,CDM,250,RC,,,Outpatient,,,121.35,72.81,,72.81,60,,58.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.98,28,,27.184,Percent of Total Billed Charges,28% of Total Billed Charges,122.4,32,,97.92,Percent of Total Billed Charges,32% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,43.69,36,,34.952,Percent of Total Billed Charges,36% of Total Billed Charges,43.69,36,,34.952,Percent of Total Billed Charges,36% Total Bille Charges,43.69,36,,34.952,Percent of Total Billed Charges,36% of Total Billed Charges,72.81,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,17.5,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.01,75,,0.344,Percent of Total Billed Charges,75% of Total Billed Charges,60.68,50,,19.496,Percent of Total Billed Charges,50% of Total Billed Charges,60.68,50,,147.464,Percent of Total Billed Charges,50% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.68,50,,147.464,Percent of Total Billed Charges,50% of Total Billed Charges,60.68,50,,21,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.95,70,,154,Percent of Total Billed Charges,70% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,16.99,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.35,100,,0.456,Percent of Total Billed Charges,100% of Total Billed Charges,16.99,122.4,
BUPRENORPH-NALOX 2MG/0.5MG TAB,53017562,CDM,250,RC,,,Outpatient,,,27.72,16.63,,16.63,60,,13.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.76,28,,6.208,Percent of Total Billed Charges,28% of Total Billed Charges,122.88,32,,98.304,Percent of Total Billed Charges,32% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% Total Bille Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,16.63,60,,66.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,4,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.79,75,,0.472,Percent of Total Billed Charges,75% of Total Billed Charges,13.86,50,,36.392,Percent of Total Billed Charges,50% of Total Billed Charges,13.86,50,,13.68,Percent of Total Billed Charges,50% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.86,50,,13.68,Percent of Total Billed Charges,50% of Total Billed Charges,13.86,50,,841.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,70,,154,Percent of Total Billed Charges,70% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.72,100,,0.632,Percent of Total Billed Charges,100% of Total Billed Charges,3.88,122.88,
BUPRENORPH-NALOX 8MG/2MG TAB,53017570,CDM,250,RC,,,Outpatient,,,49.53,29.72,,29.72,60,,23.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.87,28,,11.096,Percent of Total Billed Charges,28% of Total Billed Charges,123.12,32,,98.496,Percent of Total Billed Charges,32% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,17.83,36,,14.264,Percent of Total Billed Charges,36% of Total Billed Charges,17.83,36,,14.264,Percent of Total Billed Charges,36% Total Bille Charges,17.83,36,,14.264,Percent of Total Billed Charges,36% of Total Billed Charges,29.72,60,,1.488,Percent of Total Billed Charges,60% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.14,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.15,75,,0.504,Percent of Total Billed Charges,75% of Total Billed Charges,24.77,50,,147.464,Percent of Total Billed Charges,50% of Total Billed Charges,24.77,50,,66.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.77,50,,66.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.77,50,,18.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.67,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.53,100,,0.672,Percent of Total Billed Charges,100% of Total Billed Charges,6.93,123.12,
BUSPIRONE 5MG TAB,53017604,CDM,250,RC,,,Outpatient,,,0.27,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,123.7,32,,98.96,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,59.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,0.736,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,13.68,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,70.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,70.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,100,,0.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,123.7,
BUSPIRONE 10MG TAB,53017612,CDM,250,RC,,,Outpatient,,,0.42,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,124.38,32,,99.504,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,203.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,75,,2.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,66.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,39.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,39.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,3.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,92.96,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,100,,2.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,124.38,
BUPRENORPHINE PATCH 7.5MCG,53017751,CDM,250,RC,,,Outpatient,,,187.92,112.75,,112.75,60,,90.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.62,28,,42.096,Percent of Total Billed Charges,28% of Total Billed Charges,12539.35,32,,10031.48,Percent of Total Billed Charges,32% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,67.65,36,,54.12,Percent of Total Billed Charges,36% of Total Billed Charges,67.65,36,,54.12,Percent of Total Billed Charges,36% Total Bille Charges,67.65,36,,54.12,Percent of Total Billed Charges,36% of Total Billed Charges,112.75,60,,81.024,Percent of Total Billed Charges,60% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.1,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.94,75,,0.056,Percent of Total Billed Charges,75% of Total Billed Charges,93.96,50,,70.6,Percent of Total Billed Charges,50% of Total Billed Charges,93.96,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.96,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,93.96,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.54,70,,92.96,Percent of Total Billed Charges,70% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,26.31,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.92,100,,0.072,Percent of Total Billed Charges,100% of Total Billed Charges,26.31,12539.35,
BUPRENORPHINE 10 MCG/HR PATCH,53017752,CDM,250,RC,,,Outpatient,,,182.03,109.22,,109.22,60,,87.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.97,28,,40.776,Percent of Total Billed Charges,28% of Total Billed Charges,12704.1,32,,10163.28,Percent of Total Billed Charges,32% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,65.53,36,,52.424,Percent of Total Billed Charges,36% of Total Billed Charges,65.53,36,,52.424,Percent of Total Billed Charges,36% Total Bille Charges,65.53,36,,52.424,Percent of Total Billed Charges,36% of Total Billed Charges,109.22,60,,12.656,Percent of Total Billed Charges,60% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.52,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,91.02,50,,39.664,Percent of Total Billed Charges,50% of Total Billed Charges,91.02,50,,27.72,Percent of Total Billed Charges,50% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.02,50,,27.72,Percent of Total Billed Charges,50% of Total Billed Charges,91.02,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.42,70,,32.656,Percent of Total Billed Charges,70% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,25.48,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.03,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,25.48,12704.1,
BUPRENORPHINE PATCH 15MCG,53017753,CDM,250,RC,,,Outpatient,,,290.43,174.26,,174.26,60,,139.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.32,28,,65.056,Percent of Total Billed Charges,28% of Total Billed Charges,12.52,32,,10.016,Percent of Total Billed Charges,32% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,104.55,36,,83.64,Percent of Total Billed Charges,36% of Total Billed Charges,104.55,36,,83.64,Percent of Total Billed Charges,36% Total Bille Charges,104.55,36,,83.64,Percent of Total Billed Charges,36% of Total Billed Charges,174.26,60,,29.704,Percent of Total Billed Charges,60% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,41.88,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.82,75,,3.152,Percent of Total Billed Charges,75% of Total Billed Charges,145.22,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,145.22,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.22,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,145.22,50,,61.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.3,70,,89.944,Percent of Total Billed Charges,70% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,40.66,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.43,100,,4.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.52,290.43,
BUPRENORPHINE PATCH 20MCG/HR,53017754,CDM,250,RC,,,Outpatient,,,725.07,435.04,,435.04,60,,348.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.02,28,,162.416,Percent of Total Billed Charges,28% of Total Billed Charges,12.54,32,,10.032,Percent of Total Billed Charges,32% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,261.03,36,,208.824,Percent of Total Billed Charges,36% of Total Billed Charges,261.03,36,,208.824,Percent of Total Billed Charges,36% Total Bille Charges,261.03,36,,208.824,Percent of Total Billed Charges,36% of Total Billed Charges,435.04,60,,2.144,Percent of Total Billed Charges,60% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,104.56,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,543.8,75,,0.664,Percent of Total Billed Charges,75% of Total Billed Charges,362.54,50,,27.72,Percent of Total Billed Charges,50% of Total Billed Charges,362.54,50,,181.888,Percent of Total Billed Charges,50% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.54,50,,181.888,Percent of Total Billed Charges,50% of Total Billed Charges,362.54,50,,230.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,507.55,70,,89.944,Percent of Total Billed Charges,70% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,725.07,100,,0.88,Percent of Total Billed Charges,100% of Total Billed Charges,12.54,725.07,
CALCITRIOL 0.25MCG CAP,53017919,CDM,250,RC,,,Outpatient,,,1.94,1.16,,1.16,60,,0.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,12.56,32,,10.048,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.16,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,1.296,Percent of Total Billed Charges,75% of Total Billed Charges,0.97,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,391.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,50,,391.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,54.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,70,,120.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.94,100,,1.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,12.56,
CALCIUM ACETATE 667MG TAB,53018107,CDM,250,RC,,,Outpatient,,,2.9,1.74,,1.74,60,,1.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,28,,0.648,Percent of Total Billed Charges,28% of Total Billed Charges,12.58,32,,10.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% Total Bille Charges,1.04,36,,0.832,Percent of Total Billed Charges,36% of Total Billed Charges,1.74,60,,880,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.18,75,,10.44,Percent of Total Billed Charges,75% of Total Billed Charges,1.45,50,,181.888,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,50,,143.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.03,70,,120.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.9,100,,13.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,12.58,
CALCIUM 250MG/ VIT D TAB,53018115,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,12.66,32,,10.128,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,1.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,12.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,0.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,391.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,19.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,0.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,12.66,
CALCIUM CARB 500MG TAB (TUMS),53018156,CDM,250,RC,,,Outpatient,,,0.14,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,12.67,32,,10.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,3.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,3.896,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,36.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,100,,5.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,12.67,
CALCIUM 250MG/ VIT D TAB,53018339,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,12.68,32,,10.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,1.888,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,168.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,168.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,147.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,169.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,2.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,12.68,
CALCIUM 500MG/ VIT D TAB,53018347,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,12.7,32,,10.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,213.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,213.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,13.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,169.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,0.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,12.7,
CANDESARTAN 16MG TAB,53019147,CDM,250,RC,,,Outpatient,,,7.1,4.26,,4.26,60,,3.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,28,,1.592,Percent of Total Billed Charges,28% of Total Billed Charges,12.75,32,,10.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% Total Bille Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,4.26,60,,10.616,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.33,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,3.55,50,,168.856,Percent of Total Billed Charges,50% of Total Billed Charges,3.55,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.55,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,3.55,50,,66.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,70,,207.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.1,100,,0.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.99,12.75,
CAPTOPRIL 12.5MG TAB,53019220,CDM,250,RC,,,Outpatient,,,3.43,2.06,,2.06,60,,1.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,28,,0.768,Percent of Total Billed Charges,28% of Total Billed Charges,12.78,32,,10.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% Total Bille Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,2.06,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,29.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,1.72,50,,213.816,Percent of Total Billed Charges,50% of Total Billed Charges,1.72,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,1.72,50,,70.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,70,,207.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.43,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,12.78,
CAPTOPRIL 25MG TAB,53019238,CDM,250,RC,,,Outpatient,,,3.01,1.81,,1.81,60,,1.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,125.72,32,,100.576,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.81,60,,283.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,75,,10.264,Percent of Total Billed Charges,75% of Total Billed Charges,1.51,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,1.51,50,,52.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,50,,52.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.51,50,,39.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.11,70,,127.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.01,100,,13.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,125.72,
CARBAMAZEPINE 100MG CHW TAB,53019758,CDM,250,RC,,,Outpatient,,,1.28,0.77,,0.77,60,,0.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,125.83,32,,100.664,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,60,,126.128,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,75,,10.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.64,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,126.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,50,,126.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,70,,127.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,100,,13.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,125.83,
CARBAMAZEPINE 200MG TAB,53019816,CDM,250,RC,,,Outpatient,,,2.24,1.34,,1.34,60,,1.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,28,,0.504,Percent of Total Billed Charges,28% of Total Billed Charges,126.1,32,,100.88,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% Total Bille Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,1.34,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,75,,0.848,Percent of Total Billed Charges,75% of Total Billed Charges,1.12,50,,52.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.12,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1.12,50,,27.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,70,,187.744,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,100,,1.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,126.1,
CARBIDOPA/LEVIDOPA 10/100MG T,53020277,CDM,250,RC,,,Outpatient,,,1.21,0.73,,0.73,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,126.59,32,,101.272,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.73,60,,46.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,75,,2.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,50,,126.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,151.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,50,,151.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,5.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,70,,330.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,100,,3.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,126.59,
CARBIDOPA/LEVIDOPA CR 25/100MG,53020319,CDM,250,RC,,,Outpatient,,,0.94,0.56,,0.56,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,127.6,32,,102.08,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% Total Bille Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,75,,1.24,Percent of Total Billed Charges,75% of Total Billed Charges,0.47,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,17.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,50,,17.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,181.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,70,,265.016,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,100,,1.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,127.6,
CARBIDOPA/LEVIDOPA  25/100MG,53020327,CDM,250,RC,,,Outpatient,,,0.94,0.56,,0.56,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,127.6,32,,102.08,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% Total Bille Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,60,,14.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,75,,1.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.47,50,,151.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,203.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,50,,203.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,391.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,70,,265.016,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,100,,1.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,127.6,
CARBIDOPA/LEVIDOPA 25/250MG TA,53020350,CDM,250,RC,,,Outpatient,,,0.75,0.45,,0.45,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,127.65,32,,102.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,60,,494.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,75,,1.896,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,17.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,148.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,148.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,208.792,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,100,,2.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,127.65,
CARBIDOPA/LEVIDOPA CR 50/200MG,53020368,CDM,250,RC,,,Outpatient,,,2.21,1.33,,1.33,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,28,,0.496,Percent of Total Billed Charges,28% of Total Billed Charges,127.68,32,,102.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% Total Bille Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,60,,2.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,36.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,75,,1.016,Percent of Total Billed Charges,75% of Total Billed Charges,1.11,50,,203.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,70,,207.312,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,100,,1.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,127.68,
CARISOPRODOL 350MG TAB,53020582,CDM,250,RC,,,Outpatient,,,6.89,4.13,,4.13,60,,3.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,28,,1.544,Percent of Total Billed Charges,28% of Total Billed Charges,127.88,32,,102.304,Percent of Total Billed Charges,32% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,36,,1.984,Percent of Total Billed Charges,36% of Total Billed Charges,2.48,36,,1.984,Percent of Total Billed Charges,36% Total Bille Charges,2.48,36,,1.984,Percent of Total Billed Charges,36% of Total Billed Charges,4.13,60,,0.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14.42,,39.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.17,75,,3.496,Percent of Total Billed Charges,75% of Total Billed Charges,3.45,50,,148.344,Percent of Total Billed Charges,50% of Total Billed Charges,3.45,50,,158.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.45,50,,158.832,Percent of Total Billed Charges,50% of Total Billed Charges,3.45,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.82,70,,187.744,Percent of Total Billed Charges,70% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.89,100,,4.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,127.88,
CARVEDILOL 3.125MG TAB,53020772,CDM,250,RC,,,Outpatient,,,0.24,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1287.44,32,,1029.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,0.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,75,,2.464,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,61.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,61.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,168.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,70,,330.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,100,,3.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1287.44,
CARVEDILOL 6.25MG TAB,53020780,CDM,250,RC,,,Outpatient,,,0.25,0.15,,0.15,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1287.44,32,,1029.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,60,,19.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,75,,2.504,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,158.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,322.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,322.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,213.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,761.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,100,,3.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1287.44,
CARVEDILOL 12.5 MG TAB,53020798,CDM,250,RC,,,Outpatient,,,0.24,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1289.6,32,,1031.68,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,35.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,75,,0.44,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,61.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,867.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,867.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,139.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,70,,901.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,100,,0.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1289.6,
CARVEDILOL 25 MG TAB,53020806,CDM,250,RC,,,Outpatient,,,0.25,0.15,,0.15,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1299.52,32,,1039.616,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,60,,3.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,40.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,75,,39.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,322.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,514.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,514.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,165.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,1912.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,100,,52.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1299.52,
CEFDINIR 125 MG/5 ML SUS 60 ML,53021010,CDM,250,RC,,,Outpatient,,,101.48,60.89,,60.89,60,,48.712,Percent of Total Billed Charges,60% of Total Billed Charges,45.67,45,,36.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.41,28,,22.728,Percent of Total Billed Charges,28% of Total Billed Charges,1304.54,32,,1043.632,Percent of Total Billed Charges,32% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,36.53,36,,29.224,Percent of Total Billed Charges,36% of Total Billed Charges,36.53,36,,29.224,Percent of Total Billed Charges,36% Total Bille Charges,36.53,36,,29.224,Percent of Total Billed Charges,36% of Total Billed Charges,60.89,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.48,100,,81.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.11,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,50.74,50,,867.096,Percent of Total Billed Charges,50% of Total Billed Charges,50.74,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.74,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,50.74,50,,52.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.04,70,,571.216,Percent of Total Billed Charges,70% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.48,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,14.21,1304.54,
CEFDINIR CAP 300MG,53021011,CDM,250,RC,,,Outpatient,,,8.4,5.04,,5.04,60,,4.032,Percent of Total Billed Charges,60% of Total Billed Charges,3.78,45,,3.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.35,28,,1.88,Percent of Total Billed Charges,28% of Total Billed Charges,1306.24,32,,1044.992,Percent of Total Billed Charges,32% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% Total Bille Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,5.04,60,,109.328,Percent of Total Billed Charges,60% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,100,,6.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.3,75,,0.752,Percent of Total Billed Charges,75% of Total Billed Charges,4.2,50,,514.496,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,50,,126.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.88,70,,560.256,Percent of Total Billed Charges,70% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,100,,1,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,1306.24,
CEFUROXIME AXE 250MG TAB,53021218,CDM,250,RC,,,Outpatient,,,5.29,3.17,,3.17,60,,2.536,Percent of Total Billed Charges,60% of Total Billed Charges,2.38,45,,1.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,28,,1.184,Percent of Total Billed Charges,28% of Total Billed Charges,1310.48,32,,1048.384,Percent of Total Billed Charges,32% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,36,,1.52,Percent of Total Billed Charges,36% of Total Billed Charges,1.9,36,,1.52,Percent of Total Billed Charges,36% Total Bille Charges,1.9,36,,1.52,Percent of Total Billed Charges,36% of Total Billed Charges,3.17,60,,167.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.29,100,,4.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14.42,,8.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,75,,0.872,Percent of Total Billed Charges,75% of Total Billed Charges,2.65,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,2.65,50,,5.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,50,,5.136,Percent of Total Billed Charges,50% of Total Billed Charges,2.65,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.7,70,,1249.648,Percent of Total Billed Charges,70% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.29,100,,1.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.74,1310.48,
CELECOXIB 100MG CAP,53021291,CDM,250,RC,,,Outpatient,,,3.66,2.20,,2.2,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,45,,1.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,1322.88,32,,1058.304,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,60,,93.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,100,,2.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.75,75,,0.88,Percent of Total Billed Charges,75% of Total Billed Charges,1.83,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,6.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,50,,6.072,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,151.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.56,70,,396.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,100,,1.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,1322.88,
CEPACOL LOZENGE EACH,53021614,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1328.1,32,,1062.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,84.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,100,,0.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,67.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,5.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,17.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,2032.112,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,89.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1328.1,
CEPASTAT LOZENGE,53021622,CDM,250,RC,,,Outpatient,,,0.2,0.12,,0.12,60,,0.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1333.52,32,,1066.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,100,,0.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,75,,5.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,6.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,0.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,0.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,203.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,70,,190.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,100,,7.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1333.52,
CEPHALEXIN 250MG CAP,53022042,CDM,250,RC,,,Outpatient,,,0.88,0.53,,0.53,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,45,,0.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,1336.29,32,,1069.032,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,60,,6.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,100,,0.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,61.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,75,,5,Percent of Total Billed Charges,75% of Total Billed Charges,0.44,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,148.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,70,,183.08,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,100,,6.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,1336.29,
CEPHALEXIN 500MG CAP,53022083,CDM,250,RC,,,Outpatient,,,1.07,0.64,,0.64,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.48,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,1336.29,32,,1069.032,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,75,,109.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.54,50,,0.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,19.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,50,,19.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,70,,47.448,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,100,,145.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,1336.29,
CETIRIZINE 10MG TAB,53022463,CDM,250,RC,,,Outpatient,,,0.3,0.18,,0.18,60,,0.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,1337.33,32,,1069.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,100,,0.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,75,,2.216,Percent of Total Billed Charges,75% of Total Billed Charges,0.15,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,22.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,50,,22.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,158.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,70,,20,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,100,,2.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1337.33,
CETIRIZINE/P-EPHED TAB,53022471,CDM,250,RC,,,Outpatient,,,1.92,1.15,,1.15,60,,0.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.86,45,,0.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,1337.86,32,,1070.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,36,,0.552,Percent of Total Billed Charges,36% of Total Billed Charges,0.69,36,,0.552,Percent of Total Billed Charges,36% Total Bille Charges,0.69,36,,0.552,Percent of Total Billed Charges,36% of Total Billed Charges,1.15,60,,854.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,100,,1.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,75,,14.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.96,50,,19.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.96,50,,57.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,50,,57.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.96,50,,61.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,70,,48.64,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,100,,18.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1337.86,
CHLORDIAZEPOXIDE 5MG CAP,53023859,CDM,250,RC,,,Outpatient,,,0.77,0.46,,0.46,60,,0.368,Percent of Total Billed Charges,60% of Total Billed Charges,0.35,45,,0.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,1340.7,32,,1072.56,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,60,,144.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,100,,0.616,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,75,,0.28,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,50,,22.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,50,,37.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,50,,37.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,50,,322.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,70,,47.448,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,100,,0.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,1340.7,
CHLORDIAZEPOXIDE 25MG CAP,53023933,CDM,250,RC,,,Outpatient,,,1.22,0.73,,0.73,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,1353.28,32,,1082.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.73,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,100,,0.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,75,,2.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,50,,57.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,196.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,50,,196.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,867.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,70,,20,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,100,,3.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1353.28,
CHLOROTHIAZIDE TAB 250MG,53024162,CDM,250,RC,,,Outpatient,,,1.13,0.68,,0.68,60,,0.544,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,45,,0.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,28,,0.256,Percent of Total Billed Charges,28% of Total Billed Charges,1353.28,32,,1082.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% Total Bille Charges,0.41,36,,0.328,Percent of Total Billed Charges,36% of Total Billed Charges,0.68,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,100,,0.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,75,,0.512,Percent of Total Billed Charges,75% of Total Billed Charges,0.57,50,,37.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,50,,21.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,50,,21.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,50,,514.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,70,,48.64,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,100,,0.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,1353.28,
CHLORPROMAZINE 10MG TAB,53025904,CDM,250,RC,,,Outpatient,,,6.67,4.00,,4,60,,3.2,Percent of Total Billed Charges,60% of Total Billed Charges,3,45,,2.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.87,28,,1.496,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% Total Bille Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,4,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.67,100,,5.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,75,,1.288,Percent of Total Billed Charges,75% of Total Billed Charges,3.34,50,,196.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.34,50,,47.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.34,50,,47.856,Percent of Total Billed Charges,50% of Total Billed Charges,3.34,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.67,70,,305.64,Percent of Total Billed Charges,70% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.67,100,,1.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,1355.2,
CHLORPROMAZINE 25MG TAB,53025946,CDM,250,RC,,,Outpatient,,,9.53,5.72,,5.72,60,,4.576,Percent of Total Billed Charges,60% of Total Billed Charges,4.29,45,,3.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.67,28,,2.136,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,36,,2.744,Percent of Total Billed Charges,36% of Total Billed Charges,3.43,36,,2.744,Percent of Total Billed Charges,36% Total Bille Charges,3.43,36,,2.744,Percent of Total Billed Charges,36% of Total Billed Charges,5.72,60,,36.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,100,,7.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.15,75,,1.24,Percent of Total Billed Charges,75% of Total Billed Charges,4.77,50,,21.192,Percent of Total Billed Charges,50% of Total Billed Charges,4.77,50,,231.84,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.77,50,,231.84,Percent of Total Billed Charges,50% of Total Billed Charges,4.77,50,,107.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.67,70,,1227.36,Percent of Total Billed Charges,70% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,100,,1.648,Percent of Total Billed Charges,100% of Total Billed Charges,1.33,1355.2,
CHLORTHALIDONE 25MG TAB,53026647,CDM,250,RC,,,Outpatient,,,2.41,1.45,,1.45,60,,1.16,Percent of Total Billed Charges,60% of Total Billed Charges,1.08,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% Total Bille Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,1.45,60,,40.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,100,,1.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.81,75,,15.904,Percent of Total Billed Charges,75% of Total Billed Charges,1.21,50,,47.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,5.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,70,,711.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.41,100,,21.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,1355.2,
CILOSTAZOL 100 MG TAB,53027314,CDM,250,RC,,,Outpatient,,,2.73,1.64,,1.64,60,,1.312,Percent of Total Billed Charges,60% of Total Billed Charges,1.23,45,,0.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.64,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,100,,2.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,75,,15.12,Percent of Total Billed Charges,75% of Total Billed Charges,1.37,50,,231.84,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,14.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,50,,14.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,6.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,70,,474.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,100,,20.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,1355.2,
CINACALCET 30 MG TAB,53027629,CDM,250,RC,,,Outpatient,,,53.78,32.27,,32.27,60,,25.816,Percent of Total Billed Charges,60% of Total Billed Charges,24.2,45,,19.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.06,28,,12.048,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,19.36,36,,15.488,Percent of Total Billed Charges,36% of Total Billed Charges,19.36,36,,15.488,Percent of Total Billed Charges,36% Total Bille Charges,19.36,36,,15.488,Percent of Total Billed Charges,36% of Total Billed Charges,32.27,60,,5.368,Percent of Total Billed Charges,60% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.78,100,,43.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.76,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.34,75,,1.592,Percent of Total Billed Charges,75% of Total Billed Charges,26.89,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,26.89,50,,15.408,Percent of Total Billed Charges,50% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.89,50,,15.408,Percent of Total Billed Charges,50% of Total Billed Charges,26.89,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.65,70,,205.128,Percent of Total Billed Charges,70% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.78,100,,2.12,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,1355.2,
CITALOPRAM 20MG TAB,53027736,CDM,250,RC,,,Outpatient,,,0.18,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,21.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,100,,0.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,3.664,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,14.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,21.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,21.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,0.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,307.696,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,100,,4.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1355.2,
CIPROFLOXACIN 250MG TAB,53027751,CDM,250,RC,,,Outpatient,,,1.46,0.88,,0.88,60,,0.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.66,45,,0.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.88,60,,398.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,100,,1.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,75,,1.048,Percent of Total Billed Charges,75% of Total Billed Charges,0.73,50,,15.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,20.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,50,,20.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,9.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,70,,220.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,100,,1.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1355.2,
CIPROFLOXACIN 500MG TAB,53027769,CDM,250,RC,,,Outpatient,,,1.04,0.62,,0.62,60,,0.496,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,45,,0.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,100,,0.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,75,,6.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.52,50,,21.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,4.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,50,,4.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,19.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,70,,330.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,100,,8.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,1355.2,
CLARITHROMYCIN 250MG TAB,53027801,CDM,250,RC,,,Outpatient,,,3.47,2.08,,2.08,60,,1.664,Percent of Total Billed Charges,60% of Total Billed Charges,1.56,45,,1.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,28,,0.776,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.25,36,,1,Percent of Total Billed Charges,36% of Total Billed Charges,1.25,36,,1,Percent of Total Billed Charges,36% Total Bille Charges,1.25,36,,1,Percent of Total Billed Charges,36% of Total Billed Charges,2.08,60,,5.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,100,,2.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,75,,16.328,Percent of Total Billed Charges,75% of Total Billed Charges,1.74,50,,20.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.74,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.74,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,1.74,50,,22.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,70,,39.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,100,,21.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,1355.2,
CLINDAMYCIN 150MG CAP,53028148,CDM,250,RC,,,Outpatient,,,1.48,0.89,,0.89,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,45,,0.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.89,60,,64.624,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,100,,1.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,75,,1.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,50,,4.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,50,,9.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,50,,9.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,50,,57.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,70,,37.712,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,100,,2.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,1355.2,
CHLORDIAZ/CLINIDIUM CAP,53028411,CDM,250,RC,,,Outpatient,,,6.32,3.79,,3.79,60,,3.032,Percent of Total Billed Charges,60% of Total Billed Charges,2.84,45,,2.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,28,,1.416,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% Total Bille Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,3.79,60,,13.712,Percent of Total Billed Charges,60% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,100,,5.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,75,,2.272,Percent of Total Billed Charges,75% of Total Billed Charges,3.16,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,3.16,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.16,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,3.16,50,,37.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.42,70,,34.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,100,,3.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,1355.2,
CLOTRIMAZOLE TROUCHE 10MG,53028940,CDM,250,RC,,,Outpatient,,,2.86,1.72,,1.72,60,,1.376,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,45,,1.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,28,,0.64,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% Total Bille Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,1.72,60,,104.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,100,,2.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,75,,0.96,Percent of Total Billed Charges,75% of Total Billed Charges,1.43,50,,9.192,Percent of Total Billed Charges,50% of Total Billed Charges,1.43,50,,7.752,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,50,,7.752,Percent of Total Billed Charges,50% of Total Billed Charges,1.43,50,,196.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,70,,25.992,Percent of Total Billed Charges,70% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,100,,1.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,1355.2,
CLONAZEPAM 0.5MG TAB,53029104,CDM,250,RC,,,Outpatient,,,0.5,0.30,,0.3,60,,0.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,60,,25.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,100,,0.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,75,,1,Percent of Total Billed Charges,75% of Total Billed Charges,0.25,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,27.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,50,,27.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,21.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,70,,18.264,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,100,,1.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1355.2,
CLONAZEPAM 1MG TAB,53029146,CDM,250,RC,,,Outpatient,,,1.2,0.72,,0.72,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% Total Bille Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,75,,1.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,50,,7.752,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,47.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,70,,24.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,100,,2.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1355.2,
CLONIDINE 0.1MG TAB,53029419,CDM,250,RC,,,Outpatient,,,0.15,0.09,,0.09,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,45,,0.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,100,,0.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,0.048,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,27.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,4.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,4.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,231.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,59,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,100,,0.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1355.2,
CLONIDINE 0.2MG TAB,53029450,CDM,250,RC,,,Outpatient,,,0.22,0.13,,0.13,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,60,,84.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,100,,0.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,1.24,Percent of Total Billed Charges,75% of Total Billed Charges,0.11,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,130.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,50,,130.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,70,,58.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,100,,1.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1355.2,
PRASUGREL 10 MG TAB,53029641,CDM,250,RC,,,Outpatient,,,32.6,19.56,,19.56,60,,15.648,Percent of Total Billed Charges,60% of Total Billed Charges,14.67,45,,11.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.13,28,,7.304,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,11.74,36,,9.392,Percent of Total Billed Charges,36% of Total Billed Charges,11.74,36,,9.392,Percent of Total Billed Charges,36% Total Bille Charges,11.74,36,,9.392,Percent of Total Billed Charges,36% of Total Billed Charges,19.56,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.6,100,,26.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.7,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.45,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,16.3,50,,4.888,Percent of Total Billed Charges,50% of Total Billed Charges,16.3,50,,176.112,Percent of Total Billed Charges,50% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,50,,176.112,Percent of Total Billed Charges,50% of Total Billed Charges,16.3,50,,14.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.82,70,,34.144,Percent of Total Billed Charges,70% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.6,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,4.56,1355.2,
CLOPIDOGREL 75MG TAB,53029658,CDM,250,RC,,,Outpatient,,,2.72,1.63,,1.63,60,,1.304,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,45,,0.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,60,,95.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,100,,2.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,75,,1.776,Percent of Total Billed Charges,75% of Total Billed Charges,1.36,50,,130.056,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,211.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,50,,211.92,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,15.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,70,,15.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,100,,2.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,1355.2,
CLOPIDOGREL 300 MG TAB,53029708,CDM,250,RC,,,Outpatient,,,40.53,24.32,,24.32,60,,19.456,Percent of Total Billed Charges,60% of Total Billed Charges,18.24,45,,14.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.35,28,,9.08,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,14.59,36,,11.672,Percent of Total Billed Charges,36% of Total Billed Charges,14.59,36,,11.672,Percent of Total Billed Charges,36% Total Bille Charges,14.59,36,,11.672,Percent of Total Billed Charges,36% of Total Billed Charges,24.32,60,,134.752,Percent of Total Billed Charges,60% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.53,100,,32.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.84,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.4,75,,1.76,Percent of Total Billed Charges,75% of Total Billed Charges,20.27,50,,176.112,Percent of Total Billed Charges,50% of Total Billed Charges,20.27,50,,306.064,Percent of Total Billed Charges,50% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.27,50,,306.064,Percent of Total Billed Charges,50% of Total Billed Charges,20.27,50,,21.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.37,70,,32.2,Percent of Total Billed Charges,70% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.53,100,,2.344,Percent of Total Billed Charges,100% of Total Billed Charges,5.67,1355.2,
COLCHICINE 0.6MG TAB,53030425,CDM,250,RC,,,Outpatient,,,13.56,8.14,,8.14,60,,6.512,Percent of Total Billed Charges,60% of Total Billed Charges,6.1,45,,4.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,28,,3.04,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,36,,3.904,Percent of Total Billed Charges,36% of Total Billed Charges,4.88,36,,3.904,Percent of Total Billed Charges,36% Total Bille Charges,4.88,36,,3.904,Percent of Total Billed Charges,36% of Total Billed Charges,8.14,60,,50.032,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.56,100,,10.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14.42,,5.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.17,75,,0.872,Percent of Total Billed Charges,75% of Total Billed Charges,6.78,50,,211.92,Percent of Total Billed Charges,50% of Total Billed Charges,6.78,50,,50.216,Percent of Total Billed Charges,50% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,50,,50.216,Percent of Total Billed Charges,50% of Total Billed Charges,6.78,50,,20.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.49,70,,32.496,Percent of Total Billed Charges,70% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.56,100,,1.16,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,1355.2,
COLESEVELAM 625 MG TAB,53030433,CDM,250,RC,,,Outpatient,,,6.6,3.96,,3.96,60,,3.168,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,45,,2.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,28,,1.48,Percent of Total Billed Charges,28% of Total Billed Charges,1355.2,32,,1084.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,36,,1.904,Percent of Total Billed Charges,36% of Total Billed Charges,2.38,36,,1.904,Percent of Total Billed Charges,36% Total Bille Charges,2.38,36,,1.904,Percent of Total Billed Charges,36% of Total Billed Charges,3.96,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,100,,5.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14.42,,36.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,75,,1.456,Percent of Total Billed Charges,75% of Total Billed Charges,3.3,50,,306.064,Percent of Total Billed Charges,50% of Total Billed Charges,3.3,50,,18.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.3,50,,18.024,Percent of Total Billed Charges,50% of Total Billed Charges,3.3,50,,4.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,70,,12.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,100,,1.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,1355.2,
CONJ EST/MEDROX ACET.625/2.5MG,53030516,CDM,250,RC,,,Outpatient,,,13.14,7.88,,7.88,60,,6.304,Percent of Total Billed Charges,60% of Total Billed Charges,5.91,45,,4.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.68,28,,2.944,Percent of Total Billed Charges,28% of Total Billed Charges,1356.16,32,,1084.928,Percent of Total Billed Charges,32% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.73,36,,3.784,Percent of Total Billed Charges,36% of Total Billed Charges,4.73,36,,3.784,Percent of Total Billed Charges,36% Total Bille Charges,4.73,36,,3.784,Percent of Total Billed Charges,36% of Total Billed Charges,7.88,60,,27.344,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,100,,10.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14.42,,39.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.86,75,,2.88,Percent of Total Billed Charges,75% of Total Billed Charges,6.57,50,,50.216,Percent of Total Billed Charges,50% of Total Billed Charges,6.57,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.57,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,6.57,50,,8.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.2,70,,12.584,Percent of Total Billed Charges,70% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.14,100,,3.84,Percent of Total Billed Charges,100% of Total Billed Charges,1.84,1356.16,
ESTROGEN CONJ 0.3MG TAB,53030656,CDM,250,RC,,,Outpatient,,,10.71,6.43,,6.43,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,1357.44,32,,1085.952,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.43,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,75,,0.96,Percent of Total Billed Charges,75% of Total Billed Charges,5.36,50,,18.024,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,23.256,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,50,,23.256,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,9.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,70,,33.424,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.71,100,,1.28,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,1357.44,
ESTROGEN CONJ 0.625MG TAB,53030698,CDM,250,RC,,,Outpatient,,,10.71,6.43,,6.43,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,1359.6,32,,1087.68,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.43,60,,3.128,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,5.36,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,100.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,50,,100.536,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,10.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,70,,43.344,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.71,100,,0.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,1359.6,
ESTROGEN CONJ 0.9MG TAB,53030706,CDM,250,RC,,,Outpatient,,,10.71,6.43,,6.43,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,1363.84,32,,1091.072,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.43,60,,53.864,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14.42,,35.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,75,,14.104,Percent of Total Billed Charges,75% of Total Billed Charges,5.36,50,,23.256,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,55.488,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,50,,55.488,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,7.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.71,100,,18.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,1363.84,
ESTROGEN CONJ 1.25MG TAB,53030730,CDM,250,RC,,,Outpatient,,,10.71,6.43,,6.43,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,1364.79,32,,1091.832,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.43,60,,2.176,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,100,,8.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,14.42,,40.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.03,75,,0.168,Percent of Total Billed Charges,75% of Total Billed Charges,5.36,50,,100.536,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,4.68,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,50,,4.68,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,27.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,70,,22.736,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.71,100,,0.224,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,1364.79,
CYCLOBENZAPRINE 10MG TAB,53032546,CDM,250,RC,,,Outpatient,,,1.18,0.71,,0.71,60,,0.568,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,45,,0.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,1365.58,32,,1092.464,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.71,60,,0.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,100,,0.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,75,,15.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,55.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,7.304,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,7.304,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,70,,227.352,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,100,,20.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1365.58,
CYCLOPHOSPHAMIDE 25MG CAP,53032780,CDM,250,RC,,,Outpatient,,,95.87,57.52,,57.52,60,,46.016,Percent of Total Billed Charges,60% of Total Billed Charges,43.14,45,,34.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.84,28,,21.472,Percent of Total Billed Charges,28% of Total Billed Charges,1371.52,32,,1097.216,Percent of Total Billed Charges,32% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,34.51,36,,27.608,Percent of Total Billed Charges,36% of Total Billed Charges,34.51,36,,27.608,Percent of Total Billed Charges,36% Total Bille Charges,34.51,36,,27.608,Percent of Total Billed Charges,36% of Total Billed Charges,57.52,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.87,100,,76.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.9,75,,9.944,Percent of Total Billed Charges,75% of Total Billed Charges,47.94,50,,4.68,Percent of Total Billed Charges,50% of Total Billed Charges,47.94,50,,684.176,Percent of Total Billed Charges,50% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.94,50,,684.176,Percent of Total Billed Charges,50% of Total Billed Charges,47.94,50,,4.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.11,70,,128.128,Percent of Total Billed Charges,70% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.87,100,,13.256,Percent of Total Billed Charges,100% of Total Billed Charges,13.42,1371.52,
SANDIMMUNE 25MG,53032868,CDM,250,RC,J7515,HCPCS,Outpatient,,,19.77,11.86,,0.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.9,45,,7.12,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,360,,,Fee Schedule,360% of BCBS POS Rate,0.79,360,,,Fee schedule,360% of BCBS PPO Rate,0.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.86,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.77,100,,15.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.83,75,,9.944,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,80,,7.304,Fee Schedule,80% of Scott and White EPO fee schedule,0.59,80,,27.952,Fee Schedule,80% of Scott and White HMO fee schedule,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,80,,27.952,Fee Schedule,80% of Scott and White PPO fee schedule,0.59,80,,130.056,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.84,70,,128.128,Percent of Total Billed Charges,70% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.77,100,,13.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,19.77,
SIROLIMUS 1 MG TAB,53032870,CDM,250,RC,J7520,HCPCS,Outpatient,,,175.38,105.23,,4.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,78.92,45,,63.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,360,,,Fee Schedule,360% of BCBS POS Rate,9.07,360,,,Fee schedule,360% of BCBS PPO Rate,9.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,105.23,60,,6.264,Percent of Total Billed Charges,60% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.38,100,,140.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,25.29,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.54,75,,0.184,Percent of Total Billed Charges,75% of Total Billed Charges,2.34,80,,684.176,Fee Schedule,80% of Scott and White EPO fee schedule,2.34,80,,22.032,Fee Schedule,80% of Scott and White HMO fee schedule,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,80,,22.032,Fee Schedule,80% of Scott and White PPO fee schedule,2.34,80,,176.112,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.77,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.55,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.38,100,,0.248,Percent of Total Billed Charges,100% of Total Billed Charges,2.34,175.38,
CYCLOSPORINE A 100MG CAP,53032926,CDM,250,RC,J7502,HCPCS,Outpatient,,,84.45,50.67,,2.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,38,45,,30.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,360,,,Fee Schedule,360% of BCBS POS Rate,3.17,360,,,Fee schedule,360% of BCBS PPO Rate,3.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.67,60,,19.496,Percent of Total Billed Charges,60% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.45,100,,67.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,12.18,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.34,75,,0.872,Percent of Total Billed Charges,75% of Total Billed Charges,1.81,80,,27.952,Fee Schedule,80% of Scott and White EPO fee schedule,1.81,80,,36.8,Fee Schedule,80% of Scott and White HMO fee schedule,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,80,,36.8,Fee Schedule,80% of Scott and White PPO fee schedule,1.81,80,,211.92,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.12,70,,3926.568,Percent of Total Billed Charges,70% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.45,100,,1.16,Percent of Total Billed Charges,100% of Total Billed Charges,1.81,84.45,
CYPROHEPTADINE 4MG TAB,53033049,CDM,250,RC,,,Outpatient,,,0.79,0.47,,0.47,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,1372.8,32,,1098.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,60,,14.344,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,100,,0.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,75,,23.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,50,,22.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,65.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,50,,65.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,306.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,70,,2187,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,100,,31.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,1372.8,
DABIGATRAN 75 MG CAP,53033197,CDM,250,RC,,,Outpatient,,,15.35,9.21,,9.21,60,,7.368,Percent of Total Billed Charges,60% of Total Billed Charges,6.91,45,,5.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.3,28,,3.44,Percent of Total Billed Charges,28% of Total Billed Charges,1380.12,32,,1104.096,Percent of Total Billed Charges,32% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% Total Bille Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,9.21,60,,19.904,Percent of Total Billed Charges,60% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,100,,12.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14.42,,18.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.51,75,,0.12,Percent of Total Billed Charges,75% of Total Billed Charges,7.68,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.68,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.68,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,7.68,50,,50.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.75,70,,61.04,Percent of Total Billed Charges,70% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.35,100,,0.16,Percent of Total Billed Charges,100% of Total Billed Charges,2.15,1380.12,
DABIGATRAN 150 MG CAP,53033205,CDM,250,RC,,,Outpatient,,,15.35,9.21,,9.21,60,,7.368,Percent of Total Billed Charges,60% of Total Billed Charges,6.91,45,,5.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.3,28,,3.44,Percent of Total Billed Charges,28% of Total Billed Charges,1391.14,32,,1112.912,Percent of Total Billed Charges,32% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% Total Bille Charges,5.53,36,,4.424,Percent of Total Billed Charges,36% of Total Billed Charges,9.21,60,,45.128,Percent of Total Billed Charges,60% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.35,100,,12.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.51,75,,0.12,Percent of Total Billed Charges,75% of Total Billed Charges,7.68,50,,65.36,Percent of Total Billed Charges,50% of Total Billed Charges,7.68,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.68,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,7.68,50,,18.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.75,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.35,100,,0.16,Percent of Total Billed Charges,100% of Total Billed Charges,2.15,1391.14,
DAPSONE TAB 25MG,53034427,CDM,250,RC,,,Outpatient,,,5.06,3.04,,3.04,60,,2.432,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,45,,1.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.42,28,,1.136,Percent of Total Billed Charges,28% of Total Billed Charges,1395.49,32,,1116.392,Percent of Total Billed Charges,32% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% Total Bille Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,3.04,60,,8.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.06,100,,4.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,75,,0.152,Percent of Total Billed Charges,75% of Total Billed Charges,2.53,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,2.53,50,,46.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,50,,46.76,Percent of Total Billed Charges,50% of Total Billed Charges,2.53,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.54,70,,61.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.06,100,,0.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.71,1395.49,
DEFERASIROX 500MG SUSPENS TAB,53034815,CDM,250,RC,,,Outpatient,,,276.86,166.12,,166.12,60,,132.896,Percent of Total Billed Charges,60% of Total Billed Charges,124.59,45,,99.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.52,28,,62.016,Percent of Total Billed Charges,28% of Total Billed Charges,1400.84,32,,1120.672,Percent of Total Billed Charges,32% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,99.67,36,,79.736,Percent of Total Billed Charges,36% of Total Billed Charges,99.67,36,,79.736,Percent of Total Billed Charges,36% Total Bille Charges,99.67,36,,79.736,Percent of Total Billed Charges,36% of Total Billed Charges,166.12,60,,53.392,Percent of Total Billed Charges,60% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.86,100,,221.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,39.92,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.65,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,138.43,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,138.43,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.43,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,138.43,50,,23.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.8,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,38.76,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.86,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,38.76,1400.84,
DEMECLOCYCLINE 150MG TAB,53035192,CDM,250,RC,,,Outpatient,,,17.25,10.35,,10.35,60,,8.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.76,45,,6.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.83,28,,3.864,Percent of Total Billed Charges,28% of Total Billed Charges,1403.84,32,,1123.072,Percent of Total Billed Charges,32% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% Total Bille Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,10.35,60,,12.04,Percent of Total Billed Charges,60% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.25,100,,13.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.49,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.94,75,,0.256,Percent of Total Billed Charges,75% of Total Billed Charges,8.63,50,,46.76,Percent of Total Billed Charges,50% of Total Billed Charges,8.63,50,,45.96,Percent of Total Billed Charges,50% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.63,50,,45.96,Percent of Total Billed Charges,50% of Total Billed Charges,8.63,50,,100.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.08,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.25,100,,0.336,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,1403.84,
DESIPRAMINE 25MG TAB,53035697,CDM,250,RC,,,Outpatient,,,5.18,3.11,,3.11,60,,2.488,Percent of Total Billed Charges,60% of Total Billed Charges,2.33,45,,1.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,28,,1.16,Percent of Total Billed Charges,28% of Total Billed Charges,1403.84,32,,1123.072,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% of Total Billed Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% Total Bille Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% of Total Billed Charges,3.11,60,,7.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,4.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.89,75,,0.24,Percent of Total Billed Charges,75% of Total Billed Charges,2.59,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,2.59,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.59,50,,55.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.63,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.18,100,,0.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,1403.84,
DESMOPRESSIN ACE 0.2MG TAB,53035861,CDM,250,RC,,,Outpatient,,,17.23,10.34,,10.34,60,,8.272,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,45,,6.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.82,28,,3.856,Percent of Total Billed Charges,28% of Total Billed Charges,1403.84,32,,1123.072,Percent of Total Billed Charges,32% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.2,36,,4.96,Percent of Total Billed Charges,36% of Total Billed Charges,6.2,36,,4.96,Percent of Total Billed Charges,36% Total Bille Charges,6.2,36,,4.96,Percent of Total Billed Charges,36% of Total Billed Charges,10.34,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.23,100,,13.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,75,,5.536,Percent of Total Billed Charges,75% of Total Billed Charges,8.62,50,,45.96,Percent of Total Billed Charges,50% of Total Billed Charges,8.62,50,,3.992,Percent of Total Billed Charges,50% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.62,50,,3.992,Percent of Total Billed Charges,50% of Total Billed Charges,8.62,50,,4.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.06,70,,26.224,Percent of Total Billed Charges,70% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.23,100,,7.384,Percent of Total Billed Charges,100% of Total Billed Charges,2.41,1403.84,
DEXAMETHASONE 0.5MG TAB,53035960,CDM,250,RC,,,Outpatient,,,0.17,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,1403.84,32,,1123.072,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,335.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,100,,0.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,75,,0.32,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,7.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,70,,12.112,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,100,,0.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1403.84,
DEXAMETHASONE 4MG TAB,53036042,CDM,250,RC,,,Outpatient,,,0.31,0.19,,0.19,60,,0.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,1403.84,32,,1123.072,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,100,,0.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,75,,0.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,50,,3.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,684.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,70,,29.24,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,100,,0.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1403.84,
DIAZEPAM 2MG TAB,53037081,CDM,250,RC,,,Outpatient,,,0.57,0.34,,0.34,60,,0.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,45,,0.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,28,,0.128,Percent of Total Billed Charges,28% of Total Billed Charges,1408.55,32,,1126.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,60,,1.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,100,,0.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,75,,1.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.29,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,27.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,70,,37.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,100,,1.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,1408.55,
DIAZEPAM 5MG TAB,53037123,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,1408.55,32,,1126.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,9.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,100,,0.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,16.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,0.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,7.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,7.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,22.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,18.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,0.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1408.55,
DICLOFENAC 25MG+,53037453,CDM,250,RC,,,Outpatient,,,2.82,1.69,,1.69,60,,1.352,Percent of Total Billed Charges,60% of Total Billed Charges,1.27,45,,1.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,28,,0.632,Percent of Total Billed Charges,28% of Total Billed Charges,1410.24,32,,1128.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% Total Bille Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,1.69,60,,5.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,100,,2.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14.42,,8.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.12,75,,0.448,Percent of Total Billed Charges,75% of Total Billed Charges,1.41,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.41,50,,78.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.41,50,,78.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.41,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,70,,51.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.82,100,,0.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,1410.24,
DICLOFENAC SOD 1% GEL 100GM,53037480,CDM,250,RC,,,Outpatient,,,100.9,60.54,,60.54,60,,48.432,Percent of Total Billed Charges,60% of Total Billed Charges,45.41,45,,36.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.25,28,,22.6,Percent of Total Billed Charges,28% of Total Billed Charges,1414.4,32,,1131.52,Percent of Total Billed Charges,32% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,36.32,36,,29.056,Percent of Total Billed Charges,36% of Total Billed Charges,36.32,36,,29.056,Percent of Total Billed Charges,36% Total Bille Charges,36.32,36,,29.056,Percent of Total Billed Charges,36% of Total Billed Charges,60.54,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.9,100,,80.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.55,14.42,,11.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.68,75,,0.912,Percent of Total Billed Charges,75% of Total Billed Charges,50.45,50,,7.232,Percent of Total Billed Charges,50% of Total Billed Charges,50.45,50,,3396.896,Percent of Total Billed Charges,50% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.45,50,,3396.896,Percent of Total Billed Charges,50% of Total Billed Charges,50.45,50,,65.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.63,70,,31.712,Percent of Total Billed Charges,70% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.9,100,,1.216,Percent of Total Billed Charges,100% of Total Billed Charges,14.13,1414.4,
DICLOFENACK50MG+,53037487,CDM,250,RC,,,Outpatient,,,2.76,1.66,,1.66,60,,1.328,Percent of Total Billed Charges,60% of Total Billed Charges,1.24,45,,0.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,1422.85,32,,1138.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,1.66,60,,9.216,Percent of Total Billed Charges,60% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,100,,2.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,75,,1.048,Percent of Total Billed Charges,75% of Total Billed Charges,1.38,50,,78.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,171,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,70,,32.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,100,,1.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,1422.85,
DICLOXACILLIN 250MG CAP,53037669,CDM,250,RC,,,Outpatient,,,2.08,1.25,,1.25,60,,1,Percent of Total Billed Charges,60% of Total Billed Charges,0.94,45,,0.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,1437.7,32,,1150.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,1.25,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,100,,1.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,8.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.56,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,1.04,50,,3396.896,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,70,,15.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.08,100,,0.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1437.7,
DICYCLOMINE 10MG TAB,53038204,CDM,250,RC,,,Outpatient,,,1.95,1.17,,1.17,60,,0.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.88,45,,0.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,28,,0.44,Percent of Total Billed Charges,28% of Total Billed Charges,1440,32,,1152,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.17,60,,92.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,100,,1.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,0.368,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,46.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,70,,121.856,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,100,,0.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1440,
DICYCLOMINE 20MG TAB,53038246,CDM,250,RC,,,Outpatient,,,2.19,1.31,,1.31,60,,1.048,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,28,,0.488,Percent of Total Billed Charges,28% of Total Billed Charges,1442.19,32,,1153.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% Total Bille Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% of Total Billed Charges,1.31,60,,20.168,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,100,,1.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,75,,0.232,Percent of Total Billed Charges,75% of Total Billed Charges,1.1,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.1,50,,88.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,50,,88.864,Percent of Total Billed Charges,50% of Total Billed Charges,1.1,50,,31.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.53,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.19,100,,0.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,1442.19,
PANCREAZE CAP 4200 UNIT,53039004,CDM,250,RC,,,Outpatient,,,2.4,1.44,,1.44,60,,1.152,Percent of Total Billed Charges,60% of Total Billed Charges,1.08,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,1444.8,32,,1155.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,1.44,60,,16.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,100,,1.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,75,,0.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.2,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,1.2,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.2,50,,45.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.68,70,,40.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,100,,0.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,1444.8,
PANCRELIPASE 10500 UNIT DR CAP,53039012,CDM,250,RC,,,Outpatient,,,6,3.60,,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.68,28,,1.344,Percent of Total Billed Charges,28% of Total Billed Charges,1447.7,32,,1158.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,36,,1.728,Percent of Total Billed Charges,36% of Total Billed Charges,2.16,36,,1.728,Percent of Total Billed Charges,36% Total Bille Charges,2.16,36,,1.728,Percent of Total Billed Charges,36% of Total Billed Charges,3.6,60,,3.496,Percent of Total Billed Charges,60% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,100,,4.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14.42,,32.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,75,,2.104,Percent of Total Billed Charges,75% of Total Billed Charges,3,50,,88.864,Percent of Total Billed Charges,50% of Total Billed Charges,3,50,,501.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,50,,501.712,Percent of Total Billed Charges,50% of Total Billed Charges,3,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,70,,17.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,100,,2.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,1447.7,
ZENPEP 10000 UNITS CAP,53039022,CDM,250,RC,,,Outpatient,,,6.12,3.67,,3.67,60,,2.936,Percent of Total Billed Charges,60% of Total Billed Charges,2.75,45,,2.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,28,,1.368,Percent of Total Billed Charges,28% of Total Billed Charges,1453,32,,1162.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% Total Bille Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,3.67,60,,17.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.12,100,,4.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,17.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.59,75,,0.024,Percent of Total Billed Charges,75% of Total Billed Charges,3.06,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,3.06,50,,257.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,50,,257.944,Percent of Total Billed Charges,50% of Total Billed Charges,3.06,50,,3.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,70,,33.944,Percent of Total Billed Charges,70% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,100,,0.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,1453,
DIGOXIN 0.125MG TAB,53039442,CDM,250,RC,,,Outpatient,,,3.37,2.02,,2.02,60,,1.616,Percent of Total Billed Charges,60% of Total Billed Charges,1.52,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,1453,32,,1162.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,2.02,60,,21.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.37,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,75,,1.224,Percent of Total Billed Charges,75% of Total Billed Charges,1.69,50,,501.712,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,4592.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,50,,4592.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,70,,46.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.37,100,,1.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,1453,
DIGOXIN 0.25MG TAB,53039525,CDM,250,RC,,,Outpatient,,,3.37,2.02,,2.02,60,,1.616,Percent of Total Billed Charges,60% of Total Billed Charges,1.52,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,1461.29,32,,1169.032,Percent of Total Billed Charges,32% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,2.02,60,,990,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.37,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,75,,0.552,Percent of Total Billed Charges,75% of Total Billed Charges,1.69,50,,257.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,34.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,50,,34.208,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,70,,23.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.37,100,,0.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,1461.29,
DILTIAZEM 30MG TAB,53040333,CDM,250,RC,,,Outpatient,,,0.36,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,1462.72,32,,1170.176,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,3640.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,100,,0.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,28.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,75,,0.416,Percent of Total Billed Charges,75% of Total Billed Charges,0.18,50,,4592.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,50,,28.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,50,,28.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,50,,11.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,70,,33.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,100,,0.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,1462.72,
DILTIAZEM 60MG TAB,53040374,CDM,250,RC,,,Outpatient,,,0.57,0.34,,0.34,60,,0.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,45,,0.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,28,,0.128,Percent of Total Billed Charges,28% of Total Billed Charges,1462.72,32,,1170.176,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,60,,100.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,100,,0.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,11.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.29,50,,34.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,7.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,70,,14.424,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,1462.72,
DILTIAZEM CD 120MG CAP,53040432,CDM,250,RC,,,Outpatient,,,0.79,0.47,,0.47,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,1468.37,32,,1174.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,60,,221.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,100,,0.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,53.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,75,,0.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,50,,28.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,78.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,70,,23.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,100,,0.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,1468.37,
DILTIAZEM CD 180MG CAP,53040440,CDM,250,RC,,,Outpatient,,,0.84,0.50,,0.5,60,,0.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,45,,0.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,1468.37,32,,1174.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% Total Bille Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.5,60,,77.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,100,,0.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,31.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,75,,0.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.42,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,50,,7.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,50,,7.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,50,,3396.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,70,,34.776,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,100,,0.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,1468.37,
DILTIAZEM CD 240MG CAP,53040457,CDM,250,RC,,,Outpatient,,,1.23,0.74,,0.74,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,1475.62,32,,1180.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,100,,0.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,269.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,75,,0.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.62,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,3157.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,50,,3157.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,100,,0.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1475.62,
DILTIAZEM ER 24 HR 300 MG CAP,53040465,CDM,250,RC,,,Outpatient,,,3.37,2.02,,2.02,60,,1.616,Percent of Total Billed Charges,60% of Total Billed Charges,1.52,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,1488.89,32,,1191.112,Percent of Total Billed Charges,32% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% Total Bille Charges,1.21,36,,0.968,Percent of Total Billed Charges,36% of Total Billed Charges,2.02,60,,6.536,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.37,100,,2.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,24.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,75,,0.144,Percent of Total Billed Charges,75% of Total Billed Charges,1.69,50,,7.184,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,833.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,50,,833.208,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,70,,392,Percent of Total Billed Charges,70% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.37,100,,0.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,1488.89,
DIPHENHYDRAMINE 25MG CAP,53040879,CDM,250,RC,,,Outpatient,,,0.09,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,1489.47,32,,1191.576,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,19.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,100,,0.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,75,,1.288,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,3157.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,287.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,100,,1.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1489.47,
DIPHENHYDRAMINE 50MG CAP,53040911,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,1489.47,32,,1191.576,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,100,,0.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,12.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,5.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,833.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,1150.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,1150.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,88.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,276.504,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,7.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1489.47,
DIPHENOX/ATROP 2.5/.025MG TAB,53040986,CDM,250,RC,,,Outpatient,,,5.25,3.15,,3.15,60,,2.52,Percent of Total Billed Charges,60% of Total Billed Charges,2.36,45,,1.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,28,,1.176,Percent of Total Billed Charges,28% of Total Billed Charges,1490.12,32,,1192.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% Total Bille Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,3.15,60,,20.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,100,,4.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14.42,,14.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,75,,8.464,Percent of Total Billed Charges,75% of Total Billed Charges,2.63,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,50,,323.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,50,,323.408,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.68,70,,287.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.25,100,,11.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.74,1490.12,
DIPYRIDAMOLE 25MG TAB,53041141,CDM,250,RC,,,Outpatient,,,1.1,0.66,,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,1490.12,32,,1192.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,100,,0.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,75,,4.056,Percent of Total Billed Charges,75% of Total Billed Charges,0.55,50,,1150.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,22.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,50,,22.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,501.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,70,,203.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,100,,5.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,1490.12,
DIPYRIDAMOLE 75MG TAB,53041224,CDM,250,RC,,,Outpatient,,,2.16,1.30,,1.3,60,,1.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.97,45,,0.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,1490.12,32,,1192.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,1.3,60,,39.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,100,,1.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,75,,0.328,Percent of Total Billed Charges,75% of Total Billed Charges,1.08,50,,323.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,257.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,70,,392,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,100,,0.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,1490.12,
ASPIRIN/DIPYRID 200/25 MG ER,53041232,CDM,250,RC,,,Outpatient,,,17.4,10.44,,10.44,60,,8.352,Percent of Total Billed Charges,60% of Total Billed Charges,7.83,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,28,,3.896,Percent of Total Billed Charges,28% of Total Billed Charges,1494.23,32,,1195.384,Percent of Total Billed Charges,32% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% Total Bille Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,10.44,60,,12.576,Percent of Total Billed Charges,60% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.4,100,,13.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,14.42,,23.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.05,75,,0.472,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,50,,22.36,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,26.16,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.7,50,,26.16,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,4592.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.18,70,,297.584,Percent of Total Billed Charges,70% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.4,100,,0.632,Percent of Total Billed Charges,100% of Total Billed Charges,2.44,1494.23,
DIVALPROEX SOD 250MG TAB,53041919,CDM,250,RC,,,Outpatient,,,0.98,0.59,,0.59,60,,0.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,45,,0.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,1495.56,32,,1196.448,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,60,,4.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,100,,0.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,25.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,75,,0.512,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,34.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,70,,203.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,100,,0.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,1495.56,
DIVALPROEX SOD XR 500 MG TAB,53041950,CDM,250,RC,,,Outpatient,,,6.49,3.89,,3.89,60,,3.112,Percent of Total Billed Charges,60% of Total Billed Charges,2.92,45,,2.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,28,,1.456,Percent of Total Billed Charges,28% of Total Billed Charges,1502.15,32,,1201.72,Percent of Total Billed Charges,32% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% Total Bille Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,3.89,60,,1056,Percent of Total Billed Charges,60% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.49,100,,5.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.87,75,,0.512,Percent of Total Billed Charges,75% of Total Billed Charges,3.25,50,,26.16,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,50,,33.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.25,50,,33.168,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,50,,28.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.54,70,,297.584,Percent of Total Billed Charges,70% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.49,100,,0.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.91,1502.15,
DIVALPROEX ER 250MG TAB,53041968,CDM,250,RC,,,Outpatient,,,3.15,1.89,,1.89,60,,1.512,Percent of Total Billed Charges,60% of Total Billed Charges,1.42,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,1507.27,32,,1205.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% Total Bille Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,1.89,60,,2.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,100,,2.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,75,,0.384,Percent of Total Billed Charges,75% of Total Billed Charges,1.58,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,35.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,50,,35.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,100,,0.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,1507.27,
OMEGA 3 FATTY ACID CAP,53042008,CDM,250,RC,,,Outpatient,,,0.1,0.06,,0.06,60,,0.048,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,1516.57,32,,1213.256,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,100,,0.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,15.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,1.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,33.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,30.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,30.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,100,,1.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1516.57,
DOCUSATE CAL 240MG CAP,53042032,CDM,250,RC,,,Outpatient,,,0.15,0.09,,0.09,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,45,,0.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,1520.69,32,,1216.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,60,,4.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,100,,0.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,40.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,1.792,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,35.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,7.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,100,,2.384,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1520.69,
DOCUSATE SOD 100MG CAP,53042198,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,1521.52,32,,1217.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,7.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,100,,0.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,16.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,1.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,30.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,4986.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,4986.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,3157.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,2.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1521.52,
DOFETILIDE 125 MCG CAP,53042305,CDM,250,RC,,,Outpatient,,,17.11,10.27,,10.27,60,,8.216,Percent of Total Billed Charges,60% of Total Billed Charges,7.7,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,1522.75,32,,1218.2,Percent of Total Billed Charges,32% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,10.27,60,,10.176,Percent of Total Billed Charges,60% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,13.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14.42,,17.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.83,75,,0.056,Percent of Total Billed Charges,75% of Total Billed Charges,8.56,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,8.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.56,50,,833.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.98,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.11,100,,0.072,Percent of Total Billed Charges,100% of Total Billed Charges,2.4,1522.75,
DOFETILIDE 250 MCG CAP,53042306,CDM,250,RC,,,Outpatient,,,17.11,10.27,,10.27,60,,8.216,Percent of Total Billed Charges,60% of Total Billed Charges,7.7,45,,6.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,28,,3.832,Percent of Total Billed Charges,28% of Total Billed Charges,1522.75,32,,1218.2,Percent of Total Billed Charges,32% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% Total Bille Charges,6.16,36,,4.928,Percent of Total Billed Charges,36% of Total Billed Charges,10.27,60,,228.872,Percent of Total Billed Charges,60% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,13.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14.42,,126.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.83,75,,0.12,Percent of Total Billed Charges,75% of Total Billed Charges,8.56,50,,4986.008,Percent of Total Billed Charges,50% of Total Billed Charges,8.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.56,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.98,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.11,100,,0.16,Percent of Total Billed Charges,100% of Total Billed Charges,2.4,1522.75,
DONEPEZIL 5MG TAB,53042503,CDM,250,RC,,,Outpatient,,,1.41,0.85,,0.85,60,,0.68,Percent of Total Billed Charges,60% of Total Billed Charges,0.63,45,,0.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,28,,0.312,Percent of Total Billed Charges,28% of Total Billed Charges,1522.75,32,,1218.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% Total Bille Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,0.85,60,,126.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,100,,1.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,98.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.71,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.71,50,,7.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,50,,7.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.71,50,,1150.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.99,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.41,100,,0.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1522.75,
DONEPEZIL 23MG TAB,53042505,CDM,250,RC,,,Outpatient,,,4.45,2.67,,2.67,60,,2.136,Percent of Total Billed Charges,60% of Total Billed Charges,2,45,,1.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,28,,1,Percent of Total Billed Charges,28% of Total Billed Charges,1522.75,32,,1218.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,1.6,36,,1.28,Percent of Total Billed Charges,36% of Total Billed Charges,1.6,36,,1.28,Percent of Total Billed Charges,36% Total Bille Charges,1.6,36,,1.28,Percent of Total Billed Charges,36% of Total Billed Charges,2.67,60,,6072,Percent of Total Billed Charges,60% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.45,100,,3.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14.42,,85.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.34,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,2.23,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.23,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.23,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,2.23,50,,323.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.12,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.45,100,,0.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,1522.75,
DOXAZOSIN 1MG TAB,53043352,CDM,250,RC,,,Outpatient,,,2.07,1.24,,1.24,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,45,,0.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,1539.2,32,,1231.36,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,1.24,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,100,,1.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,104.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,75,,0.672,Percent of Total Billed Charges,75% of Total Billed Charges,1.04,50,,7.024,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,22.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,100,,0.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1539.2,
DOXAZOSIN 4MG TAB,53043378,CDM,250,RC,,,Outpatient,,,2.1,1.26,,1.26,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,1564.16,32,,1251.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,1.26,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.1,100,,1.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,75,,102.328,Percent of Total Billed Charges,75% of Total Billed Charges,1.05,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,12.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,100,,136.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1564.16,
DOXEPIN 100MG CAP,53043428,CDM,250,RC,,,Outpatient,,,3.16,1.90,,1.9,60,,1.52,Percent of Total Billed Charges,60% of Total Billed Charges,1.42,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,1572.48,32,,1257.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% Total Bille Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,1.9,60,,29.584,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,100,,2.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14.42,,17.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,75,,119.992,Percent of Total Billed Charges,75% of Total Billed Charges,1.58,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,26.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.16,100,,159.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,1572.48,
DOXEPIN 25MG CAP,53043659,CDM,250,RC,,,Outpatient,,,1.69,1.01,,1.01,60,,0.808,Percent of Total Billed Charges,60% of Total Billed Charges,0.76,45,,0.608,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,28,,0.376,Percent of Total Billed Charges,28% of Total Billed Charges,1572.48,32,,1257.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% Total Bille Charges,0.61,36,,0.488,Percent of Total Billed Charges,36% of Total Billed Charges,1.01,60,,39.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.69,100,,1.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,39.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,75,,107.192,Percent of Total Billed Charges,75% of Total Billed Charges,0.85,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,50,,140.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,50,,140.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,100,,142.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,1572.48,
DOXYCYCLINE 100MG CAP,53043964,CDM,250,RC,,,Outpatient,,,5.83,3.50,,3.5,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.62,45,,2.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,28,,1.304,Percent of Total Billed Charges,28% of Total Billed Charges,1573.34,32,,1258.672,Percent of Total Billed Charges,32% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% Total Bille Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,3.5,60,,20.832,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.83,100,,4.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14.42,,21.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,75,,1.096,Percent of Total Billed Charges,75% of Total Billed Charges,2.92,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,140.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,50,,140.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,33.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.83,100,,1.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.82,1573.34,
DULOXETINE 20 MG CAP,53044103,CDM,250,RC,,,Outpatient,,,4.11,2.47,,2.47,60,,1.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.85,45,,1.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,28,,0.92,Percent of Total Billed Charges,28% of Total Billed Charges,1576.64,32,,1261.312,Percent of Total Billed Charges,32% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% Total Bille Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,2.47,60,,45.136,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,100,,3.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14.42,,31.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,75,,0.36,Percent of Total Billed Charges,75% of Total Billed Charges,2.06,50,,140.616,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,47.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.06,50,,47.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,35.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.11,100,,0.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,1576.64,
DULOXETINE 30 MG CAP,53044111,CDM,250,RC,,,Outpatient,,,4.17,2.50,,2.5,60,,2,Percent of Total Billed Charges,60% of Total Billed Charges,1.88,45,,1.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,28,,0.936,Percent of Total Billed Charges,28% of Total Billed Charges,1577.14,32,,1261.712,Percent of Total Billed Charges,32% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,36,,1.2,Percent of Total Billed Charges,36% of Total Billed Charges,1.5,36,,1.2,Percent of Total Billed Charges,36% Total Bille Charges,1.5,36,,1.2,Percent of Total Billed Charges,36% of Total Billed Charges,2.5,60,,214.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.17,100,,3.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14.42,,31.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,2.09,50,,140.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.09,50,,89.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,50,,89.016,Percent of Total Billed Charges,50% of Total Billed Charges,2.09,50,,30.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.17,100,,0.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,1577.14,
DUTASTERIDE 0.5MG CAP,53044152,CDM,250,RC,,,Outpatient,,,0.73,0.44,,0.44,60,,0.352,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,45,,0.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,1591.2,32,,1272.96,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,100,,0.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,32.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,75,,0.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.37,50,,47.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,50,,101.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,50,,101.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,100,,0.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1591.2,
EFAVIRENZ 600 MG TAB,53044244,CDM,250,RC,,,Outpatient,,,65.87,39.52,,39.52,60,,31.616,Percent of Total Billed Charges,60% of Total Billed Charges,29.64,45,,23.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.44,28,,14.752,Percent of Total Billed Charges,28% of Total Billed Charges,1591.62,32,,1273.296,Percent of Total Billed Charges,32% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,23.71,36,,18.968,Percent of Total Billed Charges,36% of Total Billed Charges,23.71,36,,18.968,Percent of Total Billed Charges,36% Total Bille Charges,23.71,36,,18.968,Percent of Total Billed Charges,36% of Total Billed Charges,39.52,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.87,100,,52.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.5,14.42,,39.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.4,75,,17.384,Percent of Total Billed Charges,75% of Total Billed Charges,32.94,50,,89.016,Percent of Total Billed Charges,50% of Total Billed Charges,32.94,50,,100.176,Percent of Total Billed Charges,50% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.94,50,,100.176,Percent of Total Billed Charges,50% of Total Billed Charges,32.94,50,,4986.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.11,70,,32.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.22,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.87,100,,23.176,Percent of Total Billed Charges,100% of Total Billed Charges,9.22,1591.62,
EFAVIRENZ CAP 100MG,53044293,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,154.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,1.36,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,101.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,88.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,88.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,2845.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,1.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
ENALAPRIL 2.5MG TAB,53044343,CDM,250,RC,,,Outpatient,,,1.25,0.75,,0.75,60,,0.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.56,45,,0.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,28,,0.28,Percent of Total Billed Charges,28% of Total Billed Charges,1591.62,32,,1273.296,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% Total Bille Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,60,,2.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,100,,1,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,18.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.94,75,,0.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,50,,100.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.63,50,,3796.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,50,,3796.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.63,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,100,,0.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,1591.62,
ENALAPRIL 5MG TAB,53044376,CDM,250,RC,,,Outpatient,,,1.45,0.87,,0.87,60,,0.696,Percent of Total Billed Charges,60% of Total Billed Charges,0.65,45,,0.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1592.97,32,,1274.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% Total Bille Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,60,,15.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,100,,1.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,75,,0.904,Percent of Total Billed Charges,75% of Total Billed Charges,0.73,50,,88.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,232.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,50,,232.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,7.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,100,,1.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1592.97,
ENALAPRIL 10MG TAB,53044392,CDM,250,RC,,,Outpatient,,,1.46,0.88,,0.88,60,,0.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.66,45,,0.528,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1.28,32,,1.024,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.88,60,,5.976,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,100,,1.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,75,,0.92,Percent of Total Billed Charges,75% of Total Billed Charges,0.73,50,,3796.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,521.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,50,,521.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,4.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,70,,303.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,100,,1.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1.46,
EMTRICITABINE/TENOFOVIR TAB,53044558,CDM,250,RC,,,Outpatient,,,112.22,67.33,,67.33,60,,53.864,Percent of Total Billed Charges,60% of Total Billed Charges,50.5,45,,40.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.42,28,,25.136,Percent of Total Billed Charges,28% of Total Billed Charges,1.28,32,,1.024,Percent of Total Billed Charges,32% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% Total Bille Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,67.33,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.22,100,,89.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,16.18,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.17,75,,0.488,Percent of Total Billed Charges,75% of Total Billed Charges,56.11,50,,232.496,Percent of Total Billed Charges,50% of Total Billed Charges,56.11,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.11,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.11,50,,5.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.55,70,,303.336,Percent of Total Billed Charges,70% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.22,100,,0.648,Percent of Total Billed Charges,100% of Total Billed Charges,1.28,112.22,
ENTACAPONE 200 MG TAB,53044608,CDM,250,RC,,,Outpatient,,,9.88,5.93,,5.93,60,,4.744,Percent of Total Billed Charges,60% of Total Billed Charges,4.45,45,,3.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,28,,2.216,Percent of Total Billed Charges,28% of Total Billed Charges,1.28,32,,1.024,Percent of Total Billed Charges,32% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,3.56,36,,2.848,Percent of Total Billed Charges,36% of Total Billed Charges,3.56,36,,2.848,Percent of Total Billed Charges,36% Total Bille Charges,3.56,36,,2.848,Percent of Total Billed Charges,36% of Total Billed Charges,5.93,60,,507.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.88,100,,7.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14.42,,15.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,75,,0.664,Percent of Total Billed Charges,75% of Total Billed Charges,4.94,50,,521.432,Percent of Total Billed Charges,50% of Total Billed Charges,4.94,50,,19.616,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.94,50,,19.616,Percent of Total Billed Charges,50% of Total Billed Charges,4.94,50,,153,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.92,70,,1213.336,Percent of Total Billed Charges,70% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.88,100,,0.88,Percent of Total Billed Charges,100% of Total Billed Charges,1.28,9.88,
EPLERENONE 25 MG TAB,53044616,CDM,250,RC,,,Outpatient,,,8.33,5.00,,5,60,,4,Percent of Total Billed Charges,60% of Total Billed Charges,3.75,45,,3,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.33,28,,1.864,Percent of Total Billed Charges,28% of Total Billed Charges,1.3,32,,1.04,Percent of Total Billed Charges,32% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,3,36,,2.4,Percent of Total Billed Charges,36% of Total Billed Charges,3,36,,2.4,Percent of Total Billed Charges,36% Total Bille Charges,3,36,,2.4,Percent of Total Billed Charges,36% of Total Billed Charges,5,60,,278.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.33,100,,6.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14.42,,15.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.25,75,,1.24,Percent of Total Billed Charges,75% of Total Billed Charges,4.17,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.17,50,,273.928,Percent of Total Billed Charges,50% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.17,50,,273.928,Percent of Total Billed Charges,50% of Total Billed Charges,4.17,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.83,70,,1213.336,Percent of Total Billed Charges,70% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.33,100,,1.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.17,8.33,
ATRIPLA 600/200/300 MG TAB,53044673,CDM,250,RC,,,Outpatient,,,182.1,109.26,,109.26,60,,87.408,Percent of Total Billed Charges,60% of Total Billed Charges,81.95,45,,65.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.99,28,,40.792,Percent of Total Billed Charges,28% of Total Billed Charges,1.3,32,,1.04,Percent of Total Billed Charges,32% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,65.56,36,,52.448,Percent of Total Billed Charges,36% of Total Billed Charges,65.56,36,,52.448,Percent of Total Billed Charges,36% Total Bille Charges,65.56,36,,52.448,Percent of Total Billed Charges,36% of Total Billed Charges,109.26,60,,41.704,Percent of Total Billed Charges,60% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.1,100,,145.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.58,75,,8.848,Percent of Total Billed Charges,75% of Total Billed Charges,91.05,50,,19.616,Percent of Total Billed Charges,50% of Total Billed Charges,91.05,50,,14.08,Percent of Total Billed Charges,50% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.05,50,,14.08,Percent of Total Billed Charges,50% of Total Billed Charges,91.05,50,,140.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.47,70,,86.024,Percent of Total Billed Charges,70% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.1,100,,11.792,Percent of Total Billed Charges,100% of Total Billed Charges,1.3,182.1,
ERGOCALCIFEROL 50000U CAP,53044699,CDM,250,RC,,,Outpatient,,,3.69,2.21,,2.21,60,,1.768,Percent of Total Billed Charges,60% of Total Billed Charges,1.66,45,,1.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,28,,0.824,Percent of Total Billed Charges,28% of Total Billed Charges,1.31,32,,1.048,Percent of Total Billed Charges,32% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% Total Bille Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,2.21,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,100,,2.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,75,,39.384,Percent of Total Billed Charges,75% of Total Billed Charges,1.85,50,,273.928,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,33.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,50,,33.784,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,140.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,70,,86.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,100,,52.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,3.69,
ERYTHROMY ERY 250MG TAB,53046470,CDM,250,RC,,,Outpatient,,,23.71,14.23,,14.23,60,,11.384,Percent of Total Billed Charges,60% of Total Billed Charges,10.67,45,,8.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.64,28,,5.312,Percent of Total Billed Charges,28% of Total Billed Charges,1.32,32,,1.056,Percent of Total Billed Charges,32% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,36,,6.832,Percent of Total Billed Charges,36% of Total Billed Charges,8.54,36,,6.832,Percent of Total Billed Charges,36% Total Bille Charges,8.54,36,,6.832,Percent of Total Billed Charges,36% of Total Billed Charges,14.23,60,,1040.256,Percent of Total Billed Charges,60% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.71,100,,18.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.78,75,,1.64,Percent of Total Billed Charges,75% of Total Billed Charges,11.86,50,,14.08,Percent of Total Billed Charges,50% of Total Billed Charges,11.86,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.86,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,11.86,50,,47.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.6,70,,21.952,Percent of Total Billed Charges,70% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.71,100,,2.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.32,23.71,
ESCITALOPRAM 10 MG TAB,53046652,CDM,250,RC,,,Outpatient,,,0.47,0.28,,0.28,60,,0.224,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,45,,0.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,1.32,32,,1.056,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% Total Bille Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,100,,0.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,75,,11.168,Percent of Total Billed Charges,75% of Total Billed Charges,0.24,50,,33.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,89.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,70,,228.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,100,,14.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1.32,
NORETHINDRONE 5MG TAB,53046740,CDM,250,RC,,,Outpatient,,,4.67,2.80,,2.8,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.1,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,28,,1.048,Percent of Total Billed Charges,28% of Total Billed Charges,1.32,32,,1.056,Percent of Total Billed Charges,32% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% Total Bille Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,2.8,60,,668.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.67,100,,3.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,75,,5.888,Percent of Total Billed Charges,75% of Total Billed Charges,2.34,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,2.34,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,2.34,50,,101.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,70,,228.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.67,100,,7.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,4.67,
ESTRADIOL 1MG TAB,53046744,CDM,250,RC,,,Outpatient,,,0.85,0.51,,0.51,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,45,,0.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,1.32,32,,1.056,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,60,,70.368,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,100,,0.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,75,,3.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,100.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,167.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,100,,4.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,1.32,
ESTRADIOL/NORGESTIMATE TAB,53046745,CDM,250,RC,,,Outpatient,,,2.15,1.29,,1.29,60,,1.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.97,45,,0.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,1.33,32,,1.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% Total Bille Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,1.29,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,100,,1.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,75,,1.632,Percent of Total Billed Charges,75% of Total Billed Charges,1.08,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,19.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,50,,19.848,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,88.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,70,,167.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.15,100,,2.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,2.15,
ETHAMBUTOL 400MG TAB,53047742,CDM,250,RC,,,Outpatient,,,2.06,1.24,,1.24,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,45,,0.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,1.35,32,,1.08,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% Total Bille Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,1.24,60,,41.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,100,,1.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,63.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,75,,0.536,Percent of Total Billed Charges,75% of Total Billed Charges,1.03,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,3796.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,70,,24.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.06,100,,0.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,2.06,
EXEMESTANE 25 MG TAB,53048708,CDM,250,RC,J8999,HCPCS,Outpatient,,,26.5,15.90,,15.9,60,,12.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,28,,5.936,Percent of Total Billed Charges,28% of Total Billed Charges,1.35,32,,1.08,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.54,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,9.54,36,,7.632,Percent of Total Billed Charges,36% Total Bille Charges,9.54,36,,7.632,Percent of Total Billed Charges,36% of Total Billed Charges,15.9,60,,38.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.88,75,,0.104,Percent of Total Billed Charges,75% of Total Billed Charges,13.25,50,,19.848,Percent of Total Billed Charges,50% of Total Billed Charges,13.25,50,,13.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,50,,13.672,Percent of Total Billed Charges,50% of Total Billed Charges,13.25,50,,232.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.55,70,,38.184,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,100,,0.136,Percent of Total Billed Charges,100% of Total Billed Charges,1.35,26.5,
EZETIMIBE 10 MG TAB,53048757,CDM,250,RC,,,Outpatient,,,25.2,15.12,,15.12,60,,12.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,28,,5.648,Percent of Total Billed Charges,28% of Total Billed Charges,1.36,32,,1.088,Percent of Total Billed Charges,32% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% Total Bille Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,15.12,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.63,14.42,,25.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,75,,1.272,Percent of Total Billed Charges,75% of Total Billed Charges,12.6,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,50,,521.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,70,,638.4,Percent of Total Billed Charges,70% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,100,,1.696,Percent of Total Billed Charges,100% of Total Billed Charges,1.36,25.2,
ETODOLAC 400 MG TAB,53048856,CDM,250,RC,,,Outpatient,,,2.65,1.59,,1.59,60,,1.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,28,,0.592,Percent of Total Billed Charges,28% of Total Billed Charges,1.36,32,,1.088,Percent of Total Billed Charges,32% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% Total Bille Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,1.59,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14.42,,22.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.99,75,,19.616,Percent of Total Billed Charges,75% of Total Billed Charges,1.33,50,,13.672,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.86,70,,41.36,Percent of Total Billed Charges,70% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,100,,26.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,2.65,
FAMCICLOVIR 500MG TAB,53048989,CDM,250,RC,,,Outpatient,,,6.1,3.66,,3.66,60,,2.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,28,,1.368,Percent of Total Billed Charges,28% of Total Billed Charges,1.37,32,,1.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% Total Bille Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,3.66,60,,12.616,Percent of Total Billed Charges,60% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,12.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.58,75,,7.368,Percent of Total Billed Charges,75% of Total Billed Charges,3.05,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.05,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.05,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,3.05,50,,19.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.27,70,,41.36,Percent of Total Billed Charges,70% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,100,,9.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,6.1,
FAMOTIDINE 20MG TAB,53049003,CDM,250,RC,,,Outpatient,,,1.75,1.05,,1.05,60,,0.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,28,,0.392,Percent of Total Billed Charges,28% of Total Billed Charges,1.39,32,,1.112,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% Total Bille Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,63.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,75,,30.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.88,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,273.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,70,,104.632,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,100,,40.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,1.75,
FE+VITBC+FOLIC +,53049094,CDM,250,RC,,,Outpatient,,,10.25,6.15,,6.15,60,,4.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.87,28,,2.296,Percent of Total Billed Charges,28% of Total Billed Charges,1.39,32,,1.112,Percent of Total Billed Charges,32% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% of Total Billed Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% Total Bille Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% of Total Billed Charges,6.15,60,,91.384,Percent of Total Billed Charges,60% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14.42,,35.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,75,,123.904,Percent of Total Billed Charges,75% of Total Billed Charges,5.13,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,5.13,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.13,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,5.13,50,,14.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.18,70,,104.632,Percent of Total Billed Charges,70% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,100,,165.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.39,10.25,
FELBAMATE 600MG TAB,53049152,CDM,250,RC,,,Outpatient,,,27.21,16.33,,16.33,60,,13.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.62,28,,6.096,Percent of Total Billed Charges,28% of Total Billed Charges,1.39,32,,1.112,Percent of Total Billed Charges,32% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,36,,7.84,Percent of Total Billed Charges,36% of Total Billed Charges,9.8,36,,7.84,Percent of Total Billed Charges,36% Total Bille Charges,9.8,36,,7.84,Percent of Total Billed Charges,36% of Total Billed Charges,16.33,60,,117.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.92,14.42,,6.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.41,75,,8.8,Percent of Total Billed Charges,75% of Total Billed Charges,13.61,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.61,50,,11.504,Percent of Total Billed Charges,50% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.61,50,,11.504,Percent of Total Billed Charges,50% of Total Billed Charges,13.61,50,,33.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.05,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.21,100,,11.728,Percent of Total Billed Charges,100% of Total Billed Charges,1.39,27.21,
FELODIPINE 5MG TAB,53049201,CDM,250,RC,,,Outpatient,,,2.53,1.52,,1.52,60,,1.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,28,,0.568,Percent of Total Billed Charges,28% of Total Billed Charges,1.4,32,,1.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% Total Bille Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% of Total Billed Charges,1.52,60,,102.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,75,,19.576,Percent of Total Billed Charges,75% of Total Billed Charges,1.27,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.27,50,,11.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,50,,11.096,Percent of Total Billed Charges,50% of Total Billed Charges,1.27,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,100,,26.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,2.53,
FENOFIBRATE 48 MG TAB,53049334,CDM,250,RC,,,Outpatient,,,3.78,2.27,,2.27,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,28,,0.848,Percent of Total Billed Charges,28% of Total Billed Charges,1.4,32,,1.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% of Total Billed Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% Total Bille Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% of Total Billed Charges,2.27,60,,87.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.84,75,,4.176,Percent of Total Billed Charges,75% of Total Billed Charges,1.89,50,,11.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,70,,289.504,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.78,100,,5.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,3.78,
FENOFIBRATE 54 MG TAB,53049359,CDM,250,RC,,,Outpatient,,,1.6,0.96,,0.96,60,,0.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,1.4,32,,1.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.96,60,,73.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,75,,3.832,Percent of Total Billed Charges,75% of Total Billed Charges,0.8,50,,11.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,16.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,50,,16.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,70,,289.504,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,100,,5.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,1.6,
FENOFIBRATE 145 MG TAB,53049383,CDM,250,RC,,,Outpatient,,,1.66,1.00,,1,60,,0.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,1.42,32,,1.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% of Total Billed Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% Total Bille Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% of Total Billed Charges,1,60,,50.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,75,,1.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.83,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,13.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,50,,13.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,70,,73.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.66,100,,1.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,1.66,
FERROUS FUMARATE 325 MG TAB,53049920,CDM,250,RC,,,Outpatient,,,2.72,1.63,,1.63,60,,1.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,1.43,32,,1.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,60,,66.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,75,,0.248,Percent of Total Billed Charges,75% of Total Billed Charges,1.36,50,,16.664,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,13.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,50,,13.904,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,19.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,70,,73.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,100,,0.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,2.72,
FERROUS GLUC 325MG TAB,53050175,CDM,250,RC,,,Outpatient,,,0.08,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,1.45,32,,1.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,75,,14.408,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,13.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,271.464,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,100,,19.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1.45,
FERROUS SULF 325MG TAB,53050449,CDM,250,RC,,,Outpatient,,,2.07,1.24,,1.24,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,1.45,32,,1.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,1.24,60,,28.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,75,,0.664,Percent of Total Billed Charges,75% of Total Billed Charges,1.04,50,,13.904,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,13.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,70,,371.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,100,,0.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,2.07,
CA POLYCARBOPHIL 625MG TAB,53050654,CDM,250,RC,,,Outpatient,,,0.13,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,1.46,32,,1.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,237.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,1.768,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,271.464,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,2.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1.46,
FINASTERIDE 5MG TAB,53050662,CDM,250,RC,,,Outpatient,,,2.96,1.78,,1.78,60,,1.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,28,,0.664,Percent of Total Billed Charges,28% of Total Billed Charges,1.46,32,,1.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% of Total Billed Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% Total Bille Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% of Total Billed Charges,1.78,60,,439.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.22,75,,0.384,Percent of Total Billed Charges,75% of Total Billed Charges,1.48,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.48,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.48,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,70,,554.808,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.96,100,,0.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,2.96,
FLAVOXATE 100MG TAB,53050795,CDM,250,RC,,,Outpatient,,,2.93,1.76,,1.76,60,,1.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,1.47,32,,1.176,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.76,60,,59.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,60.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,75,,1.096,Percent of Total Billed Charges,75% of Total Billed Charges,1.47,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.47,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.47,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,70,,554.808,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.93,100,,1.464,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,2.93,
FLECAINIDE 50MG TAB,53050845,CDM,250,RC,,,Outpatient,,,1.45,0.87,,0.87,60,,0.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1.48,32,,1.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% Total Bille Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,60,,43.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,60.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,75,,0.704,Percent of Total Billed Charges,75% of Total Billed Charges,0.73,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,70,,444.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,100,,0.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1.48,
FLECAINDE 100MG TAB,53050852,CDM,250,RC,,,Outpatient,,,2.42,1.45,,1.45,60,,1.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,28,,0.544,Percent of Total Billed Charges,28% of Total Billed Charges,1.48,32,,1.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% Total Bille Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,1.45,60,,41.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,390.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,75,,0.744,Percent of Total Billed Charges,75% of Total Billed Charges,1.21,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,70,,444.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,100,,0.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,2.42,
FLUCONAZOLE 100MG TAB,53050969,CDM,250,RC,,,Outpatient,,,4.8,2.88,,2.88,60,,2.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,28,,1.072,Percent of Total Billed Charges,28% of Total Billed Charges,1.49,32,,1.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,36,,1.384,Percent of Total Billed Charges,36% of Total Billed Charges,1.73,36,,1.384,Percent of Total Billed Charges,36% Total Bille Charges,1.73,36,,1.384,Percent of Total Billed Charges,36% of Total Billed Charges,2.88,60,,41.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14.42,,101.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,75,,1.416,Percent of Total Billed Charges,75% of Total Billed Charges,2.4,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,11.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,70,,815.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,100,,1.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,4.8,
FLUDROCORTISONE 0.1MG TAB,53051298,CDM,250,RC,,,Outpatient,,,1.6,0.96,,0.96,60,,0.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,1.49,32,,1.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.96,60,,41.976,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,101.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,75,,0.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.8,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,60.576,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,50,,60.576,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,11.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,70,,815.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,100,,0.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,1.6,
FLUOXETINE 10MG CAP,53051595,CDM,250,RC,,,Outpatient,,,0.26,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1.5,32,,1.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,279.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,145.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,1.416,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,212.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,100,,1.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1.5,
MIRABEGRON ER 25MG TAB,53051598,CDM,250,RC,,,Outpatient,,,23.5,14.10,,14.1,60,,11.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.58,28,,5.264,Percent of Total Billed Charges,28% of Total Billed Charges,1.5,32,,1.2,Percent of Total Billed Charges,32% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.46,36,,6.768,Percent of Total Billed Charges,36% of Total Billed Charges,8.46,36,,6.768,Percent of Total Billed Charges,36% Total Bille Charges,8.46,36,,6.768,Percent of Total Billed Charges,36% of Total Billed Charges,14.1,60,,57.32,Percent of Total Billed Charges,60% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14.42,,145.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.63,75,,0.664,Percent of Total Billed Charges,75% of Total Billed Charges,11.75,50,,60.576,Percent of Total Billed Charges,50% of Total Billed Charges,11.75,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.75,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,11.75,50,,16.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,70,,212.16,Percent of Total Billed Charges,70% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.29,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.5,100,,0.88,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,23.5,
FLUOXETINE 20MG CAP,53051603,CDM,250,RC,,,Outpatient,,,0.28,0.17,,0.17,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,1.51,32,,1.208,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,60,,46.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,240.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,75,,0.816,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,13.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,70,,272.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,100,,1.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1.51,
VORTIOXETINE TAB 10MG,53051604,CDM,250,RC,,,Outpatient,,,25.2,15.12,,15.12,60,,12.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,28,,5.648,Percent of Total Billed Charges,28% of Total Billed Charges,1.52,32,,1.216,Percent of Total Billed Charges,32% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% Total Bille Charges,9.07,36,,7.256,Percent of Total Billed Charges,36% of Total Billed Charges,15.12,60,,4.208,Percent of Total Billed Charges,60% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.63,14.42,,356.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,75,,0.792,Percent of Total Billed Charges,75% of Total Billed Charges,12.6,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,50,,13.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,70,,272.328,Percent of Total Billed Charges,70% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,100,,1.056,Percent of Total Billed Charges,100% of Total Billed Charges,1.52,25.2,
VILAZODONE HCL 40 MG TAB,53051605,CDM,250,RC,,,Outpatient,,,16.57,9.94,,9.94,60,,7.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.64,28,,3.712,Percent of Total Billed Charges,28% of Total Billed Charges,1.52,32,,1.216,Percent of Total Billed Charges,32% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% of Total Billed Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% Total Bille Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% of Total Billed Charges,9.94,60,,66.008,Percent of Total Billed Charges,60% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.43,75,,0.792,Percent of Total Billed Charges,75% of Total Billed Charges,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.29,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,70,,306.336,Percent of Total Billed Charges,70% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.57,100,,1.056,Percent of Total Billed Charges,100% of Total Billed Charges,1.52,16.57,
VILAZODONE 20 MG TAB,53051610,CDM,250,RC,,,Outpatient,,,16.57,9.94,,9.94,60,,7.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.64,28,,3.712,Percent of Total Billed Charges,28% of Total Billed Charges,1.53,32,,1.224,Percent of Total Billed Charges,32% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% of Total Billed Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% Total Bille Charges,5.97,36,,4.776,Percent of Total Billed Charges,36% of Total Billed Charges,9.94,60,,344.736,Percent of Total Billed Charges,60% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.43,75,,0.672,Percent of Total Billed Charges,75% of Total Billed Charges,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.29,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,8.29,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,70,,266.808,Percent of Total Billed Charges,70% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.57,100,,0.896,Percent of Total Billed Charges,100% of Total Billed Charges,1.53,16.57,
FOLIC ACID 1MG TAB,53052338,CDM,250,RC,,,Outpatient,,,0.31,0.19,,0.19,60,,0.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,1.53,32,,1.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,60,,1324.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,240.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,75,,156.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,70,,266.808,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,100,,208.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1.53,
FLUVOXAMINE 50MG TAB,53052353,CDM,250,RC,,,Outpatient,,,1.45,0.87,,0.87,60,,0.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,1.54,32,,1.232,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% Total Bille Charges,0.52,36,,0.416,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,356.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,75,,0.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.73,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,70,,306.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,100,,1.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1.54,
FOSAMPRENAVIR 700 MG TAB,53052452,CDM,250,RC,,,Outpatient,,,39.12,23.47,,23.47,60,,18.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.95,28,,8.76,Percent of Total Billed Charges,28% of Total Billed Charges,1.54,32,,1.232,Percent of Total Billed Charges,32% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,14.08,36,,11.264,Percent of Total Billed Charges,36% of Total Billed Charges,14.08,36,,11.264,Percent of Total Billed Charges,36% Total Bille Charges,14.08,36,,11.264,Percent of Total Billed Charges,36% of Total Billed Charges,23.47,60,,49.912,Percent of Total Billed Charges,60% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.64,14.42,,34.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.34,75,,1.248,Percent of Total Billed Charges,75% of Total Billed Charges,19.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,19.56,50,,8.16,Percent of Total Billed Charges,50% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.56,50,,8.16,Percent of Total Billed Charges,50% of Total Billed Charges,19.56,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.38,70,,160,Percent of Total Billed Charges,70% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.48,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.12,100,,1.664,Percent of Total Billed Charges,100% of Total Billed Charges,1.54,39.12,
FUROSEMIDE 20MG TAB,53052791,CDM,250,RC,,,Outpatient,,,0.2,0.12,,0.12,60,,0.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1.55,32,,1.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,60,,9331.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,63.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,8.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,8.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,70,,4783.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,100,,0.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1.55,
FUROSEMIDE 40MG TAB,53052833,CDM,250,RC,,,Outpatient,,,0.2,0.12,,0.12,60,,0.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1.56,32,,1.248,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,60,,44.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,165.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,75,,8.656,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,8.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,12.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,12.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,70,,760,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,100,,11.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1.56,
FUROSEMIDE 80MG TAB,53052874,CDM,250,RC,,,Outpatient,,,0.25,0.15,,0.15,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,1.56,32,,1.248,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,21.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,75,,8.656,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,8.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,349.488,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,100,,11.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1.56,
GABAPENTIN 100MG CAP,53052908,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,1.56,32,,1.248,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,330.624,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,53.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,0.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,12.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,60.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,924,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,0.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1.56,
GABAPENTIN 300MG CAP,53052916,CDM,250,RC,,,Outpatient,,,0.42,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,1.57,32,,1.256,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,83.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,43.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,1.57,
GABAPENTIN 400MG CAP,53052924,CDM,250,RC,,,Outpatient,,,0.4,0.24,,0.24,60,,0.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,12847.52,32,,10278.016,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% Total Bille Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.24,60,,975.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,141.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,75,,0.232,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,50,,69.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,50,,69.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,70,,26.992,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,100,,0.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,12847.52,
GALANTAMINE 4 MG TAB,53052999,CDM,250,RC,,,Outpatient,,,9.23,5.54,,5.54,60,,4.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,28,,2.064,Percent of Total Billed Charges,28% of Total Billed Charges,13052.16,32,,10441.728,Percent of Total Billed Charges,32% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% of Total Billed Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% Total Bille Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% of Total Billed Charges,5.54,60,,124.776,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14.42,,292.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.92,75,,0.56,Percent of Total Billed Charges,75% of Total Billed Charges,4.62,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,50,,43.576,Percent of Total Billed Charges,50% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,50,,43.576,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.46,70,,11.888,Percent of Total Billed Charges,70% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.23,100,,0.744,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,13052.16,
GEMFIBROZIL 600MG TAB,53053112,CDM,250,RC,,,Outpatient,,,0.53,0.32,,0.32,60,,0.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,12.89,32,,10.312,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,60,,17.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,816.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,75,,1.048,Percent of Total Billed Charges,75% of Total Billed Charges,0.27,50,,69.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,4.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,50,,4.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,70,,14.776,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,100,,1.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,12.89,
GLIMEPIRIDE 2MG TAB,53053211,CDM,250,RC,,,Outpatient,,,1.12,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,12.89,32,,10.312,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,8.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,7.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,75,,10.544,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,43.576,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,70,,16.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,100,,14.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,12.89,
GLIPIZIDE XL 2.5 MG TAB,53053443,CDM,250,RC,,,Outpatient,,,2.38,1.43,,1.43,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,12.97,32,,10.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,60,,54.424,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,11.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,75,,0.36,Percent of Total Billed Charges,75% of Total Billed Charges,1.19,50,,4.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,24.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,50,,24.528,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,70,,17.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,100,,0.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,12.97,
GLIPIZIDE 5MG TAB,53053450,CDM,250,RC,,,Outpatient,,,0.75,0.45,,0.45,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,128,32,,102.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,60,,84.848,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,100,,1.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,128,
GLIPIZIDE XL 5MG TAB,53053468,CDM,250,RC,,,Outpatient,,,0.75,0.45,,0.45,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,128,32,,102.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,60,,2126.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,21.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,75,,0.328,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,24.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,31.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,31.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,22.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,100,,0.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,128,
GLIPIZIDE 10MG TAB,53053476,CDM,250,RC,,,Outpatient,,,1.52,0.91,,0.91,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,128.19,32,,102.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,60,,17.568,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,75,,0.4,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,8.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,70,,32.264,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.52,100,,0.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,128.19,
GLIPIZIDE XL 10MG TAB,53053484,CDM,250,RC,,,Outpatient,,,1.75,1.05,,1.05,60,,0.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,28,,0.392,Percent of Total Billed Charges,28% of Total Billed Charges,128.19,32,,102.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% Total Bille Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,45.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,75,,1.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.88,50,,31.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,2.896,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,50,,2.896,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,8.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,70,,45.824,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,100,,1.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,128.19,
GLYBURIDE (MICRO) 3MG TAB,53054078,CDM,250,RC,,,Outpatient,,,0.07,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,128.3,32,,102.64,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,6.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,9.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,0.936,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,1.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,1.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,12.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,70,,55.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,100,,1.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,128.3,
GLYBURIDE 2.5MG TAB,53054110,CDM,250,RC,,,Outpatient,,,0.61,0.37,,0.37,60,,0.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,28,,0.136,Percent of Total Billed Charges,28% of Total Billed Charges,128.3,32,,102.64,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% Total Bille Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,60,,4.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,75,,7.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.31,50,,2.896,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,50,,2.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,50,,2.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,70,,75.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,100,,9.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,128.3,
GLUCOSE 4GM TABL,53054128,CDM,250,RC,,,Outpatient,,,0.38,0.23,,0.23,60,,0.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,128.92,32,,103.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% Total Bille Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,60,,112.456,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,71.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,75,,15.48,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,1.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,70,,94.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,100,,20.64,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,128.92,
GLYBURIDE 5MG TAB,53054136,CDM,250,RC,,,Outpatient,,,0.57,0.34,,0.34,60,,0.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,28,,0.128,Percent of Total Billed Charges,28% of Total Billed Charges,129.11,32,,103.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,60,,915.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.29,50,,2.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,70,,98.056,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,100,,0.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,129.11,
GLYCOPYRROLATE 1MG TAB,53054292,CDM,250,RC,,,Outpatient,,,3.5,2.10,,2.1,60,,1.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,28,,0.784,Percent of Total Billed Charges,28% of Total Billed Charges,129.11,32,,103.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,36,,1.008,Percent of Total Billed Charges,36% of Total Billed Charges,1.26,36,,1.008,Percent of Total Billed Charges,36% Total Bille Charges,1.26,36,,1.008,Percent of Total Billed Charges,36% of Total Billed Charges,2.1,60,,33.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14.42,,8.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.63,75,,0.76,Percent of Total Billed Charges,75% of Total Billed Charges,1.75,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.75,50,,327.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,50,,327.96,Percent of Total Billed Charges,50% of Total Billed Charges,1.75,50,,69.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,70,,89.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.5,100,,1.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,129.11,
ROBITUSSIN CF LIQ 1ML,53054799,CDM,250,RC,,,Outpatient,,,0.04,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,129.6,32,,103.68,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,3057.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,75,,0.808,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,43.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,100,,1.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,129.6,
GUAIFENESIN 600MG SR TAB,53054813,CDM,250,RC,,,Outpatient,,,2.04,1.22,,1.22,60,,0.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,28,,0.456,Percent of Total Billed Charges,28% of Total Billed Charges,129.91,32,,103.928,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,36,,0.584,Percent of Total Billed Charges,36% of Total Billed Charges,0.73,36,,0.584,Percent of Total Billed Charges,36% Total Bille Charges,0.73,36,,0.584,Percent of Total Billed Charges,36% of Total Billed Charges,1.22,60,,1528.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.53,75,,0.248,Percent of Total Billed Charges,75% of Total Billed Charges,1.02,50,,327.96,Percent of Total Billed Charges,50% of Total Billed Charges,1.02,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.02,50,,4.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,70,,71.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,100,,0.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,129.91,
GUANFACINE 1MG TAB,53055406,CDM,250,RC,,,Outpatient,,,0.92,0.55,,0.55,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,130.23,32,,104.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% Total Bille Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,75,,8.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,17.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,50,,17.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,70,,78.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,100,,11.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,130.23,
HALOPERIDOL 0.5MG TAB,53056107,CDM,250,RC,,,Outpatient,,,0.69,0.41,,0.41,60,,0.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,28,,0.152,Percent of Total Billed Charges,28% of Total Billed Charges,13312.16,32,,10649.728,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% Total Bille Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.41,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,75,,0.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.35,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,18.32,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,50,,18.32,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,24.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,70,,40.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,100,,0.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,13312.16,
HALOPERIDOL 1MG TAB,53056149,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,13349.02,32,,10679.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,191.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,0.288,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,17.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,32.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,32.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,15.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,0.384,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,13349.02,
HALOPERIDOL 5MG TAB,53056222,CDM,250,RC,,,Outpatient,,,0.79,0.47,,0.47,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,13349.02,32,,10679.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,60,,58.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,75,,8.128,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,50,,18.32,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,72.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,50,,72.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,31.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,70,,48.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,100,,10.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,13349.02,
HYDRALAZINE 10MG TAB,53056727,CDM,250,RC,,,Outpatient,,,0.25,0.15,,0.15,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,13392,32,,10713.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,60,,43.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,75,,7.64,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,32.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,98.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,98.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,12.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,100,,10.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,13392,
HYDRALAZINE 25MG TAB,53056768,CDM,250,RC,,,Outpatient,,,0.3,0.18,,0.18,60,,0.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,13.16,32,,10.528,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,75,,2.176,Percent of Total Billed Charges,75% of Total Billed Charges,0.15,50,,72.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,2.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,50,,2.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,50,,2.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,70,,0.168,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,100,,2.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,13.16,
HYDROCHLOROTHIAZIDE 25MG TAB,53057154,CDM,250,RC,,,Outpatient,,,0.24,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,13.22,32,,10.576,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,338.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,75,,11.232,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,98.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,1.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,70,,0.136,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,100,,14.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,13.22,
HYDROCORT 10MG TAB,53057428,CDM,250,RC,,,Outpatient,,,2.14,1.28,,1.28,60,,1.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,13.31,32,,10.648,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% Total Bille Charges,0.77,36,,0.616,Percent of Total Billed Charges,36% of Total Billed Charges,1.28,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,75,,3.64,Percent of Total Billed Charges,75% of Total Billed Charges,1.07,50,,2.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,50,,2.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,70,,1.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.14,100,,4.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,13.31,
HYDROXYCHLOROQUINE 200MG TAB,53057881,CDM,250,RC,,,Outpatient,,,9.28,5.57,,5.57,60,,4.456,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,28,,2.08,Percent of Total Billed Charges,28% of Total Billed Charges,13.33,32,,10.664,Percent of Total Billed Charges,32% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,3.34,36,,2.672,Percent of Total Billed Charges,36% of Total Billed Charges,3.34,36,,2.672,Percent of Total Billed Charges,36% Total Bille Charges,3.34,36,,2.672,Percent of Total Billed Charges,36% of Total Billed Charges,5.57,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14.42,,383.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.96,75,,7.792,Percent of Total Billed Charges,75% of Total Billed Charges,4.64,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,50,,3.272,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.64,50,,3.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.5,70,,5.2,Percent of Total Billed Charges,70% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.28,100,,10.384,Percent of Total Billed Charges,100% of Total Billed Charges,1.3,13.33,
ATOVAQUO/PROGUAN 250/100 TAB,53057882,CDM,250,RC,,,Outpatient,,,14.1,8.46,,8.46,60,,6.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.95,28,,3.16,Percent of Total Billed Charges,28% of Total Billed Charges,13.37,32,,10.696,Percent of Total Billed Charges,32% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,5.08,36,,4.064,Percent of Total Billed Charges,36% of Total Billed Charges,5.08,36,,4.064,Percent of Total Billed Charges,36% Total Bille Charges,5.08,36,,4.064,Percent of Total Billed Charges,36% of Total Billed Charges,8.46,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14.42,,383.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.58,75,,0.096,Percent of Total Billed Charges,75% of Total Billed Charges,7.05,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.05,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.05,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,7.05,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.87,70,,7.896,Percent of Total Billed Charges,70% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.1,100,,0.128,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,14.1,
HYDROXYUREA 500MG CAP,53058111,CDM,250,RC,J8999,HCPCS,Outpatient,,,6.76,4.06,,4.06,60,,3.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.89,28,,1.512,Percent of Total Billed Charges,28% of Total Billed Charges,13.37,32,,10.696,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,36,,1.944,Percent of Total Billed Charges,36% of Total Billed Charges,2.43,36,,1.944,Percent of Total Billed Charges,36% Total Bille Charges,2.43,36,,1.944,Percent of Total Billed Charges,36% of Total Billed Charges,4.06,60,,352.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,3.38,50,,3.272,Percent of Total Billed Charges,50% of Total Billed Charges,3.38,50,,3.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.38,50,,3.704,Percent of Total Billed Charges,50% of Total Billed Charges,3.38,50,,327.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.73,70,,3.784,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.76,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.89,13.37,
HYDROXYZINE HCL 10MG TAB,53058301,CDM,250,RC,,,Outpatient,,,0.55,0.33,,0.33,60,,0.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,13.37,32,,10.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% of Total Billed Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% Total Bille Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,60,,37.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,349.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,75,,0.352,Percent of Total Billed Charges,75% of Total Billed Charges,0.28,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,70,,0.312,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,100,,0.464,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,13.37,
HYDROXYZINE HCL 25MG TAB,53058319,CDM,250,RC,,,Outpatient,,,0.79,0.47,,0.47,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,13.42,32,,10.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,60,,209.864,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,566.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,75,,18.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,50,,3.704,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,19.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,50,,19.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,70,,0.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,100,,24.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,13.42,
HYDROXYZINE 50 MG TAB,53058320,CDM,250,RC,,,Outpatient,,,0.85,0.51,,0.51,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,131.2,32,,104.96,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,60,,5.696,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,75,,18.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,9.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,9.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,17.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,100,,24.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,131.2,
HYDROXYZINE PAM 25MG CAP,53058343,CDM,250,RC,,,Outpatient,,,0.85,0.51,,0.51,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,131.61,32,,105.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,60,,43.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,75,,0.536,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,19.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,2.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,2.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,18.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,100,,0.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,131.61,
HYDROXYZINE PAM 50MG CAP,53058384,CDM,250,RC,,,Outpatient,,,0.64,0.38,,0.38,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,131.72,32,,105.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,60,,19.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,579.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,75,,0.736,Percent of Total Billed Charges,75% of Total Billed Charges,0.32,50,,9.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,8.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,50,,8.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,32.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,70,,0.36,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,100,,0.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,131.72,
HYOSCYAMINE 0.125MG SL TAB,53058657,CDM,250,RC,,,Outpatient,,,2.17,1.30,,1.3,60,,1.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,28,,0.488,Percent of Total Billed Charges,28% of Total Billed Charges,131.72,32,,105.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,1.3,60,,4.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,386.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,75,,0.992,Percent of Total Billed Charges,75% of Total Billed Charges,1.09,50,,2.848,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,50,,50.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,50,,50.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,50,,72.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.52,70,,1.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,100,,1.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,131.72,
HYOSCYAMINE 0.375MG SA CAP,53058939,CDM,250,RC,,,Outpatient,,,2.98,1.79,,1.79,60,,1.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,28,,0.664,Percent of Total Billed Charges,28% of Total Billed Charges,131.84,32,,105.472,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% of Total Billed Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% Total Bille Charges,1.07,36,,0.856,Percent of Total Billed Charges,36% of Total Billed Charges,1.79,60,,2.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,386.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,75,,0.984,Percent of Total Billed Charges,75% of Total Billed Charges,1.49,50,,8.488,Percent of Total Billed Charges,50% of Total Billed Charges,1.49,50,,4.704,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,50,,4.704,Percent of Total Billed Charges,50% of Total Billed Charges,1.49,50,,98.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,70,,1.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.98,100,,1.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,131.84,
HYOSCYAMINE 0.125MG ORAL TAB,53058945,CDM,250,RC,,,Outpatient,,,2.65,1.59,,1.59,60,,1.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,28,,0.592,Percent of Total Billed Charges,28% of Total Billed Charges,132.22,32,,105.776,Percent of Total Billed Charges,32% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% Total Bille Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,1.59,60,,8.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14.42,,147.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.99,75,,44.152,Percent of Total Billed Charges,75% of Total Billed Charges,1.33,50,,50.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,50,,2.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.86,70,,1.488,Percent of Total Billed Charges,70% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,100,,58.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,132.22,
IBUPROFEN 200MG TAB,53059093,CDM,250,RC,,,Outpatient,,,0.09,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,132.84,32,,106.272,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,5.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,51.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,75,,7.32,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,4.704,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,3.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,3.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,100,,9.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,132.84,
IBUPROFEN 400MG TAB,53059150,CDM,250,RC,,,Outpatient,,,0.2,0.12,,0.12,60,,0.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,132.9,32,,106.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,60,,367.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,97.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,75,,790.624,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,70,,0.112,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,100,,1054.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,132.9,
IBUPROFEN 600MG TAB,53059192,CDM,250,RC,,,Outpatient,,,0.26,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,133.12,32,,106.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,60.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,702.48,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,3.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,3.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,3.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,3.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,100,,936.64,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,133.12,
IBUPROFEN 800MG TAB,53059200,CDM,250,RC,,,Outpatient,,,0.22,0.13,,0.13,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,133.21,32,,106.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,60,,1.952,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,8.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,684.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.11,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,0.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,70,,0.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,100,,912.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,133.21,
IMIPRAMINE 25MG TAB,53059507,CDM,250,RC,,,Outpatient,,,1.12,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,134.03,32,,107.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,237.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,11.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,75,,25.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,3.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,3.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,50,,3.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,3.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,70,,0.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,100,,34.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,134.03,
IMATINIB MESYLATE 100 MG CAP,53059515,CDM,250,RC,J8999,HCPCS,Outpatient,,,170.55,102.33,,102.33,60,,81.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.75,28,,38.2,Percent of Total Billed Charges,28% of Total Billed Charges,134.22,32,,107.376,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.4,36,,49.12,Percent of Total Billed Charges,36% of Total Billed Charges,61.4,36,,49.12,Percent of Total Billed Charges,36% Total Bille Charges,61.4,36,,49.12,Percent of Total Billed Charges,36% of Total Billed Charges,102.33,60,,26.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.91,75,,25.864,Percent of Total Billed Charges,75% of Total Billed Charges,85.28,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,85.28,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.28,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.28,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.39,70,,95.512,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.55,100,,34.488,Percent of Total Billed Charges,100% of Total Billed Charges,47.75,170.55,
IBRUTINIB 140MG CAP,53059516,CDM,250,RC,,,Outpatient,,,199.98,119.99,,119.99,60,,95.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.99,28,,44.792,Percent of Total Billed Charges,28% of Total Billed Charges,13602.88,32,,10882.304,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,71.99,36,,57.592,Percent of Total Billed Charges,36% of Total Billed Charges,71.99,36,,57.592,Percent of Total Billed Charges,36% Total Bille Charges,71.99,36,,57.592,Percent of Total Billed Charges,36% of Total Billed Charges,119.99,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,234.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.99,75,,25.864,Percent of Total Billed Charges,75% of Total Billed Charges,99.99,50,,3.264,Percent of Total Billed Charges,50% of Total Billed Charges,99.99,50,,3.392,Percent of Total Billed Charges,50% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.99,50,,3.392,Percent of Total Billed Charges,50% of Total Billed Charges,99.99,50,,19.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.99,70,,111.992,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.98,100,,34.488,Percent of Total Billed Charges,100% of Total Billed Charges,28,13602.88,
PAZOPANIB 200 MG TAB,53059520,CDM,250,RC,J8999,HCPCS,Outpatient,,,178.65,107.19,,107.19,60,,85.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.02,28,,40.016,Percent of Total Billed Charges,28% of Total Billed Charges,13.46,32,,10.768,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.31,36,,51.448,Percent of Total Billed Charges,36% of Total Billed Charges,64.31,36,,51.448,Percent of Total Billed Charges,36% Total Bille Charges,64.31,36,,51.448,Percent of Total Billed Charges,36% of Total Billed Charges,107.19,60,,15.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.99,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,89.33,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,89.33,50,,7.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.33,50,,7.208,Percent of Total Billed Charges,50% of Total Billed Charges,89.33,50,,9.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.06,70,,100.048,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.65,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,13.46,178.65,
INDAPAMIDE 2.5MG TAB,53059770,CDM,250,RC,,,Outpatient,,,1.82,1.09,,1.09,60,,0.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,28,,0.408,Percent of Total Billed Charges,28% of Total Billed Charges,13.56,32,,10.848,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.09,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,130.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,75,,4.144,Percent of Total Billed Charges,75% of Total Billed Charges,0.91,50,,3.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.91,50,,4.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,50,,4.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.91,50,,2.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,70,,1.016,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,100,,5.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,13.56,
INDOMETHACIN 25MG CAP,53060000,CDM,250,RC,,,Outpatient,,,0.6,0.36,,0.36,60,,0.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,28,,0.136,Percent of Total Billed Charges,28% of Total Billed Charges,13.6,32,,10.88,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% Total Bille Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.36,60,,66.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,130.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,75,,1.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,50,,7.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,2.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,50,,2.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,8.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,70,,0.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,100,,2.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,13.6,
IRBESARTAN 150MG TAB,53060513,CDM,250,RC,,,Outpatient,,,0.71,0.43,,0.43,60,,0.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,13.63,32,,10.904,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,60,,4.896,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,11.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,36.016,Percent of Total Billed Charges,75% of Total Billed Charges,0.36,50,,4.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,56.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,50,,56.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,50.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,70,,0.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,100,,48.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,13.63,
IRBESARTAN 300 MG TAB,53060521,CDM,250,RC,,,Outpatient,,,0.98,0.59,,0.59,60,,0.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,13.63,32,,10.904,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,60,,21.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,11.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,2.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,67.968,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,67.968,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,4.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,70,,0.552,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,100,,0.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,13.63,
IRON POLY SACC 150MG FORTE CAP,53060554,CDM,250,RC,,,Outpatient,,,28.97,17.38,,17.38,60,,13.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.11,28,,6.488,Percent of Total Billed Charges,28% of Total Billed Charges,13.64,32,,10.912,Percent of Total Billed Charges,32% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,10.43,36,,8.344,Percent of Total Billed Charges,36% of Total Billed Charges,10.43,36,,8.344,Percent of Total Billed Charges,36% Total Bille Charges,10.43,36,,8.344,Percent of Total Billed Charges,36% of Total Billed Charges,17.38,60,,101.088,Percent of Total Billed Charges,60% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.18,14.42,,10.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,75,,3.944,Percent of Total Billed Charges,75% of Total Billed Charges,14.49,50,,56.336,Percent of Total Billed Charges,50% of Total Billed Charges,14.49,50,,6.472,Percent of Total Billed Charges,50% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.49,50,,6.472,Percent of Total Billed Charges,50% of Total Billed Charges,14.49,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.28,70,,16.224,Percent of Total Billed Charges,70% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.06,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.97,100,,5.256,Percent of Total Billed Charges,100% of Total Billed Charges,4.06,28.97,
IRON POLYSACC 150 MG CAP,53060562,CDM,250,RC,,,Outpatient,,,2.27,1.36,,1.36,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,28,,0.512,Percent of Total Billed Charges,28% of Total Billed Charges,13.7,32,,10.96,Percent of Total Billed Charges,32% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% Total Bille Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,1.36,60,,77.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14.42,,10.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,75,,4.48,Percent of Total Billed Charges,75% of Total Billed Charges,1.14,50,,67.968,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,3.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,70,,1.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,100,,5.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,13.7,
ISONIAZID 100MG TAB,53060976,CDM,250,RC,,,Outpatient,,,0.79,0.47,,0.47,60,,0.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,28,,0.176,Percent of Total Billed Charges,28% of Total Billed Charges,13.71,32,,10.968,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% Total Bille Charges,0.28,36,,0.224,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,60,,29.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,9.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,75,,8.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,50,,6.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,3.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,50,,3.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,70,,0.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,100,,11.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,13.71,
ISONIAZID 300MG TAB,53061008,CDM,250,RC,,,Outpatient,,,1.51,0.91,,0.91,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,134.4,32,,107.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,60,,151.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,60.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,3.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,70,,0.848,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,100,,0.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,134.4,
ISOSORBIDE DIN 10MG OR TAB,53061776,CDM,250,RC,,,Outpatient,,,1.53,0.92,,0.92,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,134.4,32,,107.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.92,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,32.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,75,,6.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.77,50,,3.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,4.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,50,,4.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,70,,0.856,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.53,100,,9.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,134.4,
ISOSORBIDE MON 20MG TAB,53061826,CDM,250,RC,,,Outpatient,,,0.81,0.49,,0.49,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,28,,0.184,Percent of Total Billed Charges,28% of Total Billed Charges,134.72,32,,107.776,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% Total Bille Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,60,,2.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.81,100,,0.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,29.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,75,,1.488,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,11.448,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,50,,11.448,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,3.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,70,,0.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,100,,1.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,134.72,
ISOSORBIDE MON SR 30MG TAB,53061842,CDM,250,RC,,,Outpatient,,,1.1,0.66,,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,134.72,32,,107.776,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,100,,0.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,27.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,75,,0.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.55,50,,4.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,32.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,50,,32.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,70,,0.616,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,100,,0.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,134.72,
ISOSORBIDE MON SR 60MG TAB,53061867,CDM,250,RC,,,Outpatient,,,2.07,1.24,,1.24,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,45,,0.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,134.72,32,,107.776,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,1.24,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,100,,1.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,23.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,1.04,50,,11.448,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,3.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,70,,1.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,100,,1.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,134.72,
MITOTANE TAB 500MG,53062248,CDM,250,RC,J8999,HCPCS,Outpatient,,,14.74,8.84,,8.84,60,,7.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.13,28,,3.304,Percent of Total Billed Charges,28% of Total Billed Charges,134.72,32,,107.776,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.31,36,,4.248,Percent of Total Billed Charges,36% of Total Billed Charges,5.31,36,,4.248,Percent of Total Billed Charges,36% Total Bille Charges,5.31,36,,4.248,Percent of Total Billed Charges,36% of Total Billed Charges,8.84,60,,24.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,75,,1.648,Percent of Total Billed Charges,75% of Total Billed Charges,7.37,50,,32.136,Percent of Total Billed Charges,50% of Total Billed Charges,7.37,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.37,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,7.37,50,,7.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,70,,8.256,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.74,100,,2.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.13,134.72,
TRETINOIN 10MG CAP,53062250,CDM,250,RC,J8999,HCPCS,Outpatient,,,65.64,39.38,,39.38,60,,31.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.38,28,,14.704,Percent of Total Billed Charges,28% of Total Billed Charges,134.98,32,,107.984,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.63,36,,18.904,Percent of Total Billed Charges,36% of Total Billed Charges,23.63,36,,18.904,Percent of Total Billed Charges,36% Total Bille Charges,23.63,36,,18.904,Percent of Total Billed Charges,36% of Total Billed Charges,39.38,60,,128.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.23,75,,2.048,Percent of Total Billed Charges,75% of Total Billed Charges,32.82,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,32.82,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.82,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,32.82,50,,4.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.95,70,,36.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.64,100,,2.728,Percent of Total Billed Charges,100% of Total Billed Charges,18.38,134.98,
ISRADIPINE 2.5MG CAP,53062550,CDM,250,RC,,,Outpatient,,,2.73,1.64,,1.64,60,,1.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,135.08,32,,108.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.64,60,,21.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,16.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,75,,2.464,Percent of Total Billed Charges,75% of Total Billed Charges,1.37,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,2.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,50,,2.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,2.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,70,,1.528,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,100,,3.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,135.08,
ITRACONAZOLE 100MG CAP,53062576,CDM,250,RC,,,Outpatient,,,18.61,11.17,,11.17,60,,8.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.21,28,,4.168,Percent of Total Billed Charges,28% of Total Billed Charges,135.4,32,,108.32,Percent of Total Billed Charges,32% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,6.7,36,,5.36,Percent of Total Billed Charges,36% of Total Billed Charges,6.7,36,,5.36,Percent of Total Billed Charges,36% Total Bille Charges,6.7,36,,5.36,Percent of Total Billed Charges,36% of Total Billed Charges,11.17,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14.42,,18.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,75,,2.32,Percent of Total Billed Charges,75% of Total Billed Charges,9.31,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,9.31,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.31,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.31,50,,56.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,70,,10.424,Percent of Total Billed Charges,70% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.61,100,,3.088,Percent of Total Billed Charges,100% of Total Billed Charges,2.61,135.4,
IVERMECTIN 3 MG TAB,53062618,CDM,250,RC,,,Outpatient,,,9.81,5.89,,5.89,60,,4.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.75,28,,2.2,Percent of Total Billed Charges,28% of Total Billed Charges,135.79,32,,108.632,Percent of Total Billed Charges,32% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,36,,2.824,Percent of Total Billed Charges,36% of Total Billed Charges,3.53,36,,2.824,Percent of Total Billed Charges,36% Total Bille Charges,3.53,36,,2.824,Percent of Total Billed Charges,36% of Total Billed Charges,5.89,60,,346.072,Percent of Total Billed Charges,60% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.36,75,,2.2,Percent of Total Billed Charges,75% of Total Billed Charges,4.91,50,,2.856,Percent of Total Billed Charges,50% of Total Billed Charges,4.91,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.91,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,4.91,50,,67.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.87,70,,5.496,Percent of Total Billed Charges,70% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.81,100,,2.936,Percent of Total Billed Charges,100% of Total Billed Charges,1.37,135.79,
KETOCONAZOLE 200MG TAB,53062931,CDM,250,RC,,,Outpatient,,,5.94,3.56,,3.56,60,,2.848,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.66,28,,1.328,Percent of Total Billed Charges,28% of Total Billed Charges,135.82,32,,108.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,36,,1.712,Percent of Total Billed Charges,36% of Total Billed Charges,2.14,36,,1.712,Percent of Total Billed Charges,36% Total Bille Charges,2.14,36,,1.712,Percent of Total Billed Charges,36% of Total Billed Charges,3.56,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14.42,,22.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.46,75,,6.208,Percent of Total Billed Charges,75% of Total Billed Charges,2.97,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,50,,21.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,50,,21.488,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,50,,6.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.16,70,,3.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.94,100,,8.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.83,135.82,
KETOROLAC 10MG TAB,53063004,CDM,250,RC,,,Outpatient,,,2.72,1.63,,1.63,60,,1.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,136.05,32,,108.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,258.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,75,,2.736,Percent of Total Billed Charges,75% of Total Billed Charges,1.36,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,4.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,70,,1.52,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,100,,3.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,136.05,
LABETOLOL 100MG TAB,53063202,CDM,250,RC,,,Outpatient,,,0.89,0.53,,0.53,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,136.28,32,,109.024,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,60,,306.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,104.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,75,,0.272,Percent of Total Billed Charges,75% of Total Billed Charges,0.45,50,,21.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,3.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,70,,0.496,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,100,,0.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,136.28,
LACTASE TAB,53063350,CDM,250,RC,,,Outpatient,,,0.17,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,136.32,32,,109.056,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,259.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,75,,0.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,70,,0.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,100,,1.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,136.32,
LACTOBACILLUS CAP,53063384,CDM,250,RC,,,Outpatient,,,2.12,1.27,,1.27,60,,1.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,136.8,32,,109.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,1.27,60,,1.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,127.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,75,,48.736,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,50,,4.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,70,,1.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,100,,64.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,136.8,
LAMIVUDINE 100MG TAB,53063426,CDM,250,RC,,,Outpatient,,,32.69,19.61,,19.61,60,,15.688,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.15,28,,7.32,Percent of Total Billed Charges,28% of Total Billed Charges,136.8,32,,109.44,Percent of Total Billed Charges,32% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,11.77,36,,9.416,Percent of Total Billed Charges,36% of Total Billed Charges,11.77,36,,9.416,Percent of Total Billed Charges,36% Total Bille Charges,11.77,36,,9.416,Percent of Total Billed Charges,36% of Total Billed Charges,19.61,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.71,14.42,,157.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.52,75,,1.96,Percent of Total Billed Charges,75% of Total Billed Charges,16.35,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.35,50,,75.352,Percent of Total Billed Charges,50% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.35,50,,75.352,Percent of Total Billed Charges,50% of Total Billed Charges,16.35,50,,11.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,70,,18.304,Percent of Total Billed Charges,70% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.69,100,,2.616,Percent of Total Billed Charges,100% of Total Billed Charges,4.58,136.8,
LAMIVUDINE 300 MG TAB,53063427,CDM,250,RC,,,Outpatient,,,12.28,7.37,,7.37,60,,5.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.44,28,,2.752,Percent of Total Billed Charges,28% of Total Billed Charges,136.86,32,,109.488,Percent of Total Billed Charges,32% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,4.42,36,,3.536,Percent of Total Billed Charges,36% of Total Billed Charges,4.42,36,,3.536,Percent of Total Billed Charges,36% Total Bille Charges,4.42,36,,3.536,Percent of Total Billed Charges,36% of Total Billed Charges,7.37,60,,179.28,Percent of Total Billed Charges,60% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14.42,,117.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.21,75,,1.72,Percent of Total Billed Charges,75% of Total Billed Charges,6.14,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.14,50,,29.952,Percent of Total Billed Charges,50% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.14,50,,29.952,Percent of Total Billed Charges,50% of Total Billed Charges,6.14,50,,32.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,70,,6.88,Percent of Total Billed Charges,70% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.28,100,,2.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.72,136.86,
MARAVIROC 150 MG TAB,53063428,CDM,250,RC,,,Outpatient,,,50.86,30.52,,30.52,60,,24.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.24,28,,11.392,Percent of Total Billed Charges,28% of Total Billed Charges,136.86,32,,109.488,Percent of Total Billed Charges,32% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,18.31,36,,14.648,Percent of Total Billed Charges,36% of Total Billed Charges,18.31,36,,14.648,Percent of Total Billed Charges,36% Total Bille Charges,18.31,36,,14.648,Percent of Total Billed Charges,36% of Total Billed Charges,30.52,60,,146.464,Percent of Total Billed Charges,60% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.33,14.42,,304.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.15,75,,1.176,Percent of Total Billed Charges,75% of Total Billed Charges,25.43,50,,75.352,Percent of Total Billed Charges,50% of Total Billed Charges,25.43,50,,35.912,Percent of Total Billed Charges,50% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.43,50,,35.912,Percent of Total Billed Charges,50% of Total Billed Charges,25.43,50,,2.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.6,70,,28.48,Percent of Total Billed Charges,70% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,7.12,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.86,100,,1.568,Percent of Total Billed Charges,100% of Total Billed Charges,7.12,136.86,
STRIBILD 150/150/200/300 TAB,53063430,CDM,250,RC,,,Outpatient,,,206.5,123.90,,123.9,60,,99.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.82,28,,46.256,Percent of Total Billed Charges,28% of Total Billed Charges,136.86,32,,109.488,Percent of Total Billed Charges,32% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,74.34,36,,59.472,Percent of Total Billed Charges,36% of Total Billed Charges,74.34,36,,59.472,Percent of Total Billed Charges,36% Total Bille Charges,74.34,36,,59.472,Percent of Total Billed Charges,36% of Total Billed Charges,123.9,60,,249.544,Percent of Total Billed Charges,60% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,29.78,14.42,,147.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.88,75,,0.576,Percent of Total Billed Charges,75% of Total Billed Charges,103.25,50,,29.952,Percent of Total Billed Charges,50% of Total Billed Charges,103.25,50,,35.568,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.25,50,,35.568,Percent of Total Billed Charges,50% of Total Billed Charges,103.25,50,,0.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.55,70,,115.64,Percent of Total Billed Charges,70% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.5,100,,0.768,Percent of Total Billed Charges,100% of Total Billed Charges,28.91,206.5,
COBICISTAT TAB 150MG,53063431,CDM,250,RC,,,Outpatient,,,14.66,8.80,,8.8,60,,7.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.1,28,,3.28,Percent of Total Billed Charges,28% of Total Billed Charges,136.86,32,,109.488,Percent of Total Billed Charges,32% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.28,36,,4.224,Percent of Total Billed Charges,36% of Total Billed Charges,5.28,36,,4.224,Percent of Total Billed Charges,36% Total Bille Charges,5.28,36,,4.224,Percent of Total Billed Charges,36% of Total Billed Charges,8.8,60,,286.024,Percent of Total Billed Charges,60% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.11,14.42,,198.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,75,,1.096,Percent of Total Billed Charges,75% of Total Billed Charges,7.33,50,,35.912,Percent of Total Billed Charges,50% of Total Billed Charges,7.33,50,,61.008,Percent of Total Billed Charges,50% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.33,50,,61.008,Percent of Total Billed Charges,50% of Total Billed Charges,7.33,50,,2.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.26,70,,8.208,Percent of Total Billed Charges,70% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.66,100,,1.464,Percent of Total Billed Charges,100% of Total Billed Charges,2.05,136.86,
ENTECAVIR 0.5 MG TAB,53063440,CDM,250,RC,,,Outpatient,,,32.63,19.58,,19.58,60,,15.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.14,28,,7.312,Percent of Total Billed Charges,28% of Total Billed Charges,136.9,32,,109.52,Percent of Total Billed Charges,32% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,36,,9.4,Percent of Total Billed Charges,36% of Total Billed Charges,11.75,36,,9.4,Percent of Total Billed Charges,36% Total Bille Charges,11.75,36,,9.4,Percent of Total Billed Charges,36% of Total Billed Charges,19.58,60,,115.776,Percent of Total Billed Charges,60% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.71,14.42,,63.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.47,75,,83.4,Percent of Total Billed Charges,75% of Total Billed Charges,16.32,50,,35.568,Percent of Total Billed Charges,50% of Total Billed Charges,16.32,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.32,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,16.32,50,,2.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.84,70,,18.272,Percent of Total Billed Charges,70% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.63,100,,111.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.57,136.9,
LAMIVUDINE 300/ZIDOVU 150 TAB,53063442,CDM,250,RC,,,Outpatient,,,6.96,4.18,,4.18,60,,3.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,28,,1.56,Percent of Total Billed Charges,28% of Total Billed Charges,136.96,32,,109.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% of Total Billed Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% Total Bille Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% of Total Billed Charges,4.18,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,1,14.42,,15.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,3.48,50,,61.008,Percent of Total Billed Charges,50% of Total Billed Charges,3.48,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.48,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,3.48,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,70,,3.896,Percent of Total Billed Charges,70% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.96,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.97,136.96,
LAMIVUDINE 150MG TAB,53063459,CDM,250,RC,,,Outpatient,,,6.39,3.83,,3.83,60,,3.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,28,,1.432,Percent of Total Billed Charges,28% of Total Billed Charges,137.19,32,,109.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% of Total Billed Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% Total Bille Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% of Total Billed Charges,3.83,60,,372.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14.42,,12.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,75,,0.072,Percent of Total Billed Charges,75% of Total Billed Charges,3.2,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,3.2,50,,43.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,50,,43.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.2,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.47,70,,3.576,Percent of Total Billed Charges,70% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.39,100,,0.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.89,137.19,
LAMOTRIGINE 25MG TAB,53063467,CDM,250,RC,,,Outpatient,,,1.85,1.11,,1.11,60,,0.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,137.19,32,,109.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,1.11,60,,158.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,12.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.39,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.93,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,21.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,70,,1.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,100,,0.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,137.19,
LAMOTRIGINE 100MG TAB,53063475,CDM,250,RC,,,Outpatient,,,0.41,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,13.76,32,,11.008,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,12.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,43.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,2.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,2.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,302.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,0.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,13.76,
LANTHANUM CARBONATE 500 MG TAB,53063616,CDM,250,RC,,,Outpatient,,,24.01,14.41,,14.41,60,,11.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.72,28,,5.376,Percent of Total Billed Charges,28% of Total Billed Charges,13.79,32,,11.032,Percent of Total Billed Charges,32% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% Total Bille Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,14.41,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.01,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,12.01,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.01,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,12.01,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.81,70,,13.448,Percent of Total Billed Charges,70% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.01,100,,0.144,Percent of Total Billed Charges,100% of Total Billed Charges,3.36,24.01,
LETROZOLE 2.5MG TAB,53063681,CDM,250,RC,J8999,HCPCS,Outpatient,,,1.11,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,13.79,32,,11.032,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,217.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,75,,2.216,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,2.96,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,24.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,50,,24.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,70,,0.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,100,,2.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,13.79,
LEUCOVORIN CALCIUM 5MG TAB,53063897,CDM,250,RC,,,Outpatient,,,2.95,1.77,,1.77,60,,1.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,28,,0.664,Percent of Total Billed Charges,28% of Total Billed Charges,13.8,32,,11.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,36,,0.848,Percent of Total Billed Charges,36% of Total Billed Charges,1.06,36,,0.848,Percent of Total Billed Charges,36% Total Bille Charges,1.06,36,,0.848,Percent of Total Billed Charges,36% of Total Billed Charges,1.77,60,,211.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,75,,18.736,Percent of Total Billed Charges,75% of Total Billed Charges,1.48,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.48,50,,14.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,50,,14.808,Percent of Total Billed Charges,50% of Total Billed Charges,1.48,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,70,,1.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.95,100,,24.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,13.8,
LEVETIRACETAM 500 MG TAB,53064069,CDM,250,RC,,,Outpatient,,,0.64,0.38,,0.38,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,13.8,32,,11.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,60,,196.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.32,50,,24.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,6.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,50,,6.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,75.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,70,,0.36,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,100,,0.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,13.8,
LEVOFLOXACIN 750 MG TAB,53064283,CDM,250,RC,,,Outpatient,,,1.83,1.10,,1.1,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,28,,0.408,Percent of Total Billed Charges,28% of Total Billed Charges,13.8,32,,11.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.1,60,,133.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,75,,7.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,50,,14.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,37.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,50,,37.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,29.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,70,,1.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,100,,9.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,13.8,
LEVOFLOXACIN 250MG TAB,53064309,CDM,250,RC,,,Outpatient,,,1.17,0.70,,0.7,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,13.82,32,,11.056,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,60,,132.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,75,,1.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,6.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,45.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,45.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,35.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,70,,0.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,100,,1.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,13.82,
LEVOFLOXACIN 500MG TAB,53064317,CDM,250,RC,,,Outpatient,,,1.24,0.74,,0.74,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,28,,0.28,Percent of Total Billed Charges,28% of Total Billed Charges,13.89,32,,11.112,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% Total Bille Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,60,,128.872,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,1.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,75,,0.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.62,50,,37.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,75.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,50,,75.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,35.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,70,,0.696,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.24,100,,0.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,13.89,
LEVOTHYROXINE SOD 0.088MG TAB,53064358,CDM,250,RC,,,Outpatient,,,2.36,1.42,,1.42,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,28,,0.528,Percent of Total Billed Charges,28% of Total Billed Charges,13.95,32,,11.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% Total Bille Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,1.42,60,,37.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,75,,1.336,Percent of Total Billed Charges,75% of Total Billed Charges,1.18,50,,45.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,181.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,50,,181.328,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,61.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,70,,1.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,100,,1.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,13.95,
LEVOTHYROXINE SOD 0.025MG TAB,53064473,CDM,250,RC,,,Outpatient,,,0.87,0.52,,0.52,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,137.61,32,,110.088,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,60,,163.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,0.44,50,,75.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,8.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,50,,8.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,70,,0.488,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,137.61,
LEVOTHYROXINE SOD 0.05MG TAB,53064515,CDM,250,RC,,,Outpatient,,,2.36,1.42,,1.42,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,28,,0.528,Percent of Total Billed Charges,28% of Total Billed Charges,137.79,32,,110.232,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% Total Bille Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,1.42,60,,129.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,75,,5.248,Percent of Total Billed Charges,75% of Total Billed Charges,1.18,50,,181.328,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,287.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,50,,287.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,64.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,70,,1.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,100,,7,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,137.79,
LEVOTHYROXINE SOD 0.075MG TAB,53064549,CDM,250,RC,,,Outpatient,,,1.1,0.66,,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,137.88,32,,110.304,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,60,,190.256,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.83,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.55,50,,8.264,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,183.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,50,,183.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,50,,43.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,70,,0.616,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,137.88,
LEVOTHYROXINE SOD 0.15MG TAB,53064556,CDM,250,RC,,,Outpatient,,,1.36,0.82,,0.82,60,,0.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,28,,0.304,Percent of Total Billed Charges,28% of Total Billed Charges,137.92,32,,110.336,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% Total Bille Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,60,,11.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.02,75,,2.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.68,50,,287.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,50,,137.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,50,,137.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,70,,0.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,100,,3.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,137.92,
LEVOTHYROXINE SOD 0.112MG TAB,53064564,CDM,250,RC,,,Outpatient,,,1.32,0.79,,0.79,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,138.39,32,,110.712,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% Total Bille Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,60,,27.608,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,75,,0.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,50,,183.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,2.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,70,,0.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.32,100,,0.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,138.39,
LEVOTHYROXINE SOD 0.125MG TAB,53064580,CDM,250,RC,,,Outpatient,,,1.32,0.79,,0.79,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,138.93,32,,111.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% Total Bille Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,60,,17.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,17.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,75,,0.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,50,,137.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,79.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,50,,79.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,0.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,70,,0.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.32,100,,0.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,138.93,
LEVOTHYROXINE SOD 0.1MG TAB,53064598,CDM,250,RC,,,Outpatient,,,1.12,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,139.05,32,,111.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,15.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14.42,,11.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,75,,2.848,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,682.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,50,,682.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,24.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,70,,0.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,100,,3.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,139.05,
LINEZOLID 600 MG TAB,53065017,CDM,250,RC,,,Outpatient,,,260.3,156.18,,156.18,60,,124.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.88,28,,58.304,Percent of Total Billed Charges,28% of Total Billed Charges,139.91,32,,111.928,Percent of Total Billed Charges,32% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,93.71,36,,74.968,Percent of Total Billed Charges,36% of Total Billed Charges,93.71,36,,74.968,Percent of Total Billed Charges,36% Total Bille Charges,93.71,36,,74.968,Percent of Total Billed Charges,36% of Total Billed Charges,156.18,60,,7.136,Percent of Total Billed Charges,60% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,37.54,14.42,,12.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.23,75,,1.624,Percent of Total Billed Charges,75% of Total Billed Charges,130.15,50,,79.064,Percent of Total Billed Charges,50% of Total Billed Charges,130.15,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.15,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,130.15,50,,14.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.21,70,,145.768,Percent of Total Billed Charges,70% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.3,100,,2.16,Percent of Total Billed Charges,100% of Total Billed Charges,36.44,260.3,
LIOTHYRONNIE SOD 5MCG TAB,53065132,CDM,250,RC,,,Outpatient,,,1.58,0.95,,0.95,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,28,,0.352,Percent of Total Billed Charges,28% of Total Billed Charges,140.28,32,,112.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% Total Bille Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,60,,2.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,244.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,75,,1.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.79,50,,682.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.79,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.79,50,,6.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,70,,0.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,100,,1.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,140.28,
LIOTHYRONINE SOD 25MCG TAB,53065173,CDM,250,RC,,,Outpatient,,,2.08,1.25,,1.25,60,,1,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,140.54,32,,112.432,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% Total Bille Charges,0.75,36,,0.6,Percent of Total Billed Charges,36% of Total Billed Charges,1.25,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,244.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.56,75,,11.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.04,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,50,,37.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,70,,1.168,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.08,100,,15.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,140.54,
LISINOPRIL 5MG TAB,53066353,CDM,250,RC,,,Outpatient,,,0.15,0.09,,0.09,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,14139.84,32,,11311.872,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,60,,12.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,12.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,3.616,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,45.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,0.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,100,,4.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,14139.84,
SACUBIT/VALSAR TAB 24-26MG,53066355,CDM,250,RC,,,Outpatient,,,14.43,8.66,,8.66,60,,6.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.04,28,,3.232,Percent of Total Billed Charges,28% of Total Billed Charges,14226.14,32,,11380.912,Percent of Total Billed Charges,32% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% Total Bille Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,8.66,60,,20.448,Percent of Total Billed Charges,60% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14.42,,4.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,75,,4.536,Percent of Total Billed Charges,75% of Total Billed Charges,7.22,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,75.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.1,70,,8.08,Percent of Total Billed Charges,70% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.43,100,,6.048,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,14226.14,
SACUBIT/VALSAR TAB 49-51MG,53066356,CDM,250,RC,,,Outpatient,,,14.43,8.66,,8.66,60,,6.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.04,28,,3.232,Percent of Total Billed Charges,28% of Total Billed Charges,14.11,32,,11.288,Percent of Total Billed Charges,32% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% Total Bille Charges,5.19,36,,4.152,Percent of Total Billed Charges,36% of Total Billed Charges,8.66,60,,218.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14.42,,7.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,75,,31.224,Percent of Total Billed Charges,75% of Total Billed Charges,7.22,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,50,,181.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.1,70,,8.08,Percent of Total Billed Charges,70% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.43,100,,41.632,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,14.43,
LISINOPRIL 10MG TAB,53066361,CDM,250,RC,,,Outpatient,,,0.17,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,14.15,32,,11.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,199.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,41.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,75,,0.496,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,8.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,70,,0.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,100,,0.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,14.15,
LITHIUM CARB 300MG TAB,53066528,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,14.15,32,,11.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,210.488,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,1.072,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,287.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,1.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,14.15,
LITHIUM CARB 150MG CAP,53066742,CDM,250,RC,,,Outpatient,,,0.38,0.23,,0.23,60,,0.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,14.27,32,,11.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% Total Bille Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,75,,1.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,183.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,70,,0.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,100,,1.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,14.27,
LITHIUM CARB 450MG CR TAB,53066767,CDM,250,RC,,,Outpatient,,,0.93,0.56,,0.56,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,14.29,32,,11.432,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% Total Bille Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,75,,2.84,Percent of Total Billed Charges,75% of Total Billed Charges,0.47,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,137.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,70,,0.52,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,100,,3.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,14.29,
LOPERAMIDE 2MG CAP,53067294,CDM,250,RC,,,Outpatient,,,1.75,1.05,,1.05,60,,0.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,28,,0.392,Percent of Total Billed Charges,28% of Total Billed Charges,14.29,32,,11.432,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% Total Bille Charges,0.63,36,,0.504,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,60,,14.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,75,,0.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.88,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,50,,6.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,70,,0.984,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,100,,0.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,14.29,
LOPINAVIR/RITONAVIR 200/50 TAB,53067310,CDM,250,RC,,,Outpatient,,,17.57,10.54,,10.54,60,,8.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.92,28,,3.936,Percent of Total Billed Charges,28% of Total Billed Charges,14.34,32,,11.472,Percent of Total Billed Charges,32% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.33,36,,5.064,Percent of Total Billed Charges,36% of Total Billed Charges,6.33,36,,5.064,Percent of Total Billed Charges,36% Total Bille Charges,6.33,36,,5.064,Percent of Total Billed Charges,36% of Total Billed Charges,10.54,60,,13.424,Percent of Total Billed Charges,60% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,75,,0.616,Percent of Total Billed Charges,75% of Total Billed Charges,8.79,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,8.79,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.79,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,8.79,50,,79.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.3,70,,9.84,Percent of Total Billed Charges,70% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.57,100,,0.816,Percent of Total Billed Charges,100% of Total Billed Charges,2.46,17.57,
LORATADINE 10MG TAB,53067401,CDM,250,RC,,,Outpatient,,,0.6,0.36,,0.36,60,,0.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,28,,0.136,Percent of Total Billed Charges,28% of Total Billed Charges,14.34,32,,11.472,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% Total Bille Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.36,60,,13.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,75,,18.528,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,682.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,70,,0.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,100,,24.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,14.34,
LORATAD 5/PSEUDOEPHED 120 TAB,53067419,CDM,250,RC,,,Outpatient,,,1.62,0.97,,0.97,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,140.8,32,,112.64,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,60,,10.048,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,14,Percent of Total Billed Charges,75% of Total Billed Charges,0.81,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,900,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,70,,0.904,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,100,,18.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,140.8,
LORAZEPAM 0.5MG TAB,53067492,CDM,250,RC,,,Outpatient,,,0.55,0.33,,0.33,60,,0.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,142.05,32,,113.64,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% of Total Billed Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% Total Bille Charges,0.2,36,,0.16,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,75,,8.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.28,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,70,,0.312,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,100,,11.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,142.05,
LORAZEPAM 1MG TAB,53067526,CDM,250,RC,,,Outpatient,,,0.66,0.40,,0.4,60,,0.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,142.3,32,,113.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% Total Bille Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,6.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,75,,1.904,Percent of Total Billed Charges,75% of Total Billed Charges,0.33,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,70,,0.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,100,,2.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,142.3,
LOSARTAN 50MG TAB,53067575,CDM,250,RC,,,Outpatient,,,1.84,1.10,,1.1,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,142.4,32,,113.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.1,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,18.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,75,,2.56,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,70,,1.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,100,,3.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,142.4,
LOSARTAN 25MG TAB,53067591,CDM,250,RC,,,Outpatient,,,1.56,0.94,,0.94,60,,0.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,28,,0.352,Percent of Total Billed Charges,28% of Total Billed Charges,142.56,32,,114.048,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% Total Bille Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% of Total Billed Charges,0.94,60,,40.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,18.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,75,,0.616,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,70,,0.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.56,100,,0.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,142.56,
LUBIPROSTONE 8 MCG CAP,53067948,CDM,250,RC,,,Outpatient,,,12.37,7.42,,7.42,60,,5.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,28,,2.768,Percent of Total Billed Charges,28% of Total Billed Charges,142.85,32,,114.28,Percent of Total Billed Charges,32% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,36,,3.56,Percent of Total Billed Charges,36% of Total Billed Charges,4.45,36,,3.56,Percent of Total Billed Charges,36% Total Bille Charges,4.45,36,,3.56,Percent of Total Billed Charges,36% of Total Billed Charges,7.42,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14.42,,24.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.28,75,,0.744,Percent of Total Billed Charges,75% of Total Billed Charges,6.19,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.66,70,,6.928,Percent of Total Billed Charges,70% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.37,100,,0.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,142.85,
LINACLOTIDE 145MCG CAP,53067950,CDM,250,RC,,,Outpatient,,,25.8,15.48,,15.48,60,,12.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,28,,5.776,Percent of Total Billed Charges,28% of Total Billed Charges,143.2,32,,114.56,Percent of Total Billed Charges,32% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,9.29,36,,7.432,Percent of Total Billed Charges,36% of Total Billed Charges,9.29,36,,7.432,Percent of Total Billed Charges,36% Total Bille Charges,9.29,36,,7.432,Percent of Total Billed Charges,36% of Total Billed Charges,15.48,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.72,14.42,,24.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,75,,3.352,Percent of Total Billed Charges,75% of Total Billed Charges,12.9,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,12.9,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.9,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,12.9,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.06,70,,14.448,Percent of Total Billed Charges,70% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.8,100,,4.472,Percent of Total Billed Charges,100% of Total Billed Charges,3.61,143.2,
MAGNESIUM CHLOR SA TAB,53068326,CDM,250,RC,,,Outpatient,,,0.22,0.13,,0.13,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,143.26,32,,114.608,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,60,,6.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,77.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,0.544,Percent of Total Billed Charges,75% of Total Billed Charges,0.11,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,70,,0.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,100,,0.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,143.26,
MECLIZINE 12.5MG TAB,53069688,CDM,250,RC,,,Outpatient,,,1.27,0.76,,0.76,60,,0.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,143.36,32,,114.688,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,77.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,75,,44.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.64,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,70,,0.712,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,100,,59.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,143.36,
MECLIZINE 25MG TAB,53069720,CDM,250,RC,,,Outpatient,,,1.34,0.80,,0.8,60,,0.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,28,,0.304,Percent of Total Billed Charges,28% of Total Billed Charges,143.61,32,,114.888,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% Total Bille Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.8,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,34.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,75,,239.248,Percent of Total Billed Charges,75% of Total Billed Charges,0.67,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,70,,0.752,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,100,,319,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,143.61,
MEDROXYPROGESTRONE 2.5MG TAB,53070223,CDM,250,RC,,,Outpatient,,,0.41,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,143.95,32,,115.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,84.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,34.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,75,,1.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,0.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,100,,1.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,143.95,
MEDROXYPROGESTRONE 10MG TAB,53070264,CDM,250,RC,,,Outpatient,,,14.54,8.72,,8.72,60,,6.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.07,28,,3.256,Percent of Total Billed Charges,28% of Total Billed Charges,14.4,32,,11.52,Percent of Total Billed Charges,32% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% Total Bille Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,8.72,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14.42,,42.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.91,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,7.27,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,7.27,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.27,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,7.27,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.18,70,,8.144,Percent of Total Billed Charges,70% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,2.04,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.54,100,,0.568,Percent of Total Billed Charges,100% of Total Billed Charges,2.04,14.54,
MEGESTROL ACETATE 20MG TAB,53070728,CDM,250,RC,J8999,HCPCS,Outpatient,,,1.12,0.67,,0.67,60,,0.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,28,,0.248,Percent of Total Billed Charges,28% of Total Billed Charges,14.42,32,,11.536,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% Total Bille Charges,0.4,36,,0.32,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,75,,6.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.56,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,70,,0.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.12,100,,8.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,14.42,
MELOXICAM 7.5 MG TAB,53070959,CDM,250,RC,,,Outpatient,,,0.48,0.29,,0.29,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,14.44,32,,11.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% Total Bille Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,26.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,75,,1.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.24,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,70,,0.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,100,,1.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,14.44,
MEMANTINE HCL 10MG TAB,53071114,CDM,250,RC,,,Outpatient,,,13.54,8.12,,8.12,60,,6.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.79,28,,3.032,Percent of Total Billed Charges,28% of Total Billed Charges,14.45,32,,11.56,Percent of Total Billed Charges,32% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,36,,3.896,Percent of Total Billed Charges,36% of Total Billed Charges,4.87,36,,3.896,Percent of Total Billed Charges,36% Total Bille Charges,4.87,36,,3.896,Percent of Total Billed Charges,36% of Total Billed Charges,8.12,60,,115.296,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14.42,,26.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,75,,8.896,Percent of Total Billed Charges,75% of Total Billed Charges,6.77,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,6.77,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.77,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.77,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,70,,7.584,Percent of Total Billed Charges,70% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.54,100,,11.856,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,14.45,
MERCAPTOPURINE 50MG TAB,53072765,CDM,250,RC,J8999,HCPCS,Outpatient,,,12.73,7.64,,7.64,60,,6.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.56,28,,2.848,Percent of Total Billed Charges,28% of Total Billed Charges,14.54,32,,11.632,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.58,36,,3.664,Percent of Total Billed Charges,36% of Total Billed Charges,4.58,36,,3.664,Percent of Total Billed Charges,36% Total Bille Charges,4.58,36,,3.664,Percent of Total Billed Charges,36% of Total Billed Charges,7.64,60,,75.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.55,75,,1.504,Percent of Total Billed Charges,75% of Total Billed Charges,6.37,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,6.37,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,6.37,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.91,70,,7.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.73,100,,2,Percent of Total Billed Charges,100% of Total Billed Charges,3.56,14.54,
MESALAMINE 400MG TAB,53072807,CDM,250,RC,,,Outpatient,,,3.63,2.18,,2.18,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,14.56,32,,11.648,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.31,36,,1.048,Percent of Total Billed Charges,36% of Total Billed Charges,1.31,36,,1.048,Percent of Total Billed Charges,36% Total Bille Charges,1.31,36,,1.048,Percent of Total Billed Charges,36% of Total Billed Charges,2.18,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14.42,,68.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,75,,2.36,Percent of Total Billed Charges,75% of Total Billed Charges,1.82,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.82,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,1.82,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.54,70,,2.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.63,100,,3.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,14.56,
MESALAMINE 1.2GM DR TAB,53072810,CDM,250,RC,,,Outpatient,,,18.72,11.23,,11.23,60,,8.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.24,28,,4.192,Percent of Total Billed Charges,28% of Total Billed Charges,14.57,32,,11.656,Percent of Total Billed Charges,32% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% of Total Billed Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% Total Bille Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% of Total Billed Charges,11.23,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.7,14.42,,54.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.04,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,9.36,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,9.36,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.36,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,9.36,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.1,70,,10.48,Percent of Total Billed Charges,70% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.72,100,,5.6,Percent of Total Billed Charges,100% of Total Billed Charges,2.62,18.72,
MESALAMINE 250MG CR CAP,53072815,CDM,250,RC,,,Outpatient,,,6.07,3.64,,3.64,60,,2.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.7,28,,1.36,Percent of Total Billed Charges,28% of Total Billed Charges,14.65,32,,11.72,Percent of Total Billed Charges,32% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% of Total Billed Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% Total Bille Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% of Total Billed Charges,3.64,60,,79.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,109.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,3.04,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,3.04,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,3.04,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,70,,3.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.07,100,,1.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,14.65,
METAXALONE 800 MG TAB,53073318,CDM,250,RC,,,Outpatient,,,12.98,7.79,,7.79,60,,6.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.63,28,,2.904,Percent of Total Billed Charges,28% of Total Billed Charges,144.27,32,,115.416,Percent of Total Billed Charges,32% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,4.67,36,,3.736,Percent of Total Billed Charges,36% of Total Billed Charges,4.67,36,,3.736,Percent of Total Billed Charges,36% Total Bille Charges,4.67,36,,3.736,Percent of Total Billed Charges,36% of Total Billed Charges,7.79,60,,52.072,Percent of Total Billed Charges,60% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.87,14.42,,54.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.74,75,,2.288,Percent of Total Billed Charges,75% of Total Billed Charges,6.49,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,6.49,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.49,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,6.49,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.09,70,,7.272,Percent of Total Billed Charges,70% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.98,100,,3.048,Percent of Total Billed Charges,100% of Total Billed Charges,1.82,144.27,
METFORMIN 500MG TAB,53073607,CDM,250,RC,,,Outpatient,,,0.16,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,144.27,32,,115.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,4.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,43.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,75,,1.968,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,0.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,100,,2.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,144.27,
METFORMIN 850MG TAB,53073615,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,144.27,32,,115.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,3.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,42.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,0.896,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,1.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,144.27,
METFORMIN XR 500 MG TAB,53073623,CDM,250,RC,,,Outpatient,,,0.58,0.35,,0.35,60,,0.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,28,,0.128,Percent of Total Billed Charges,28% of Total Billed Charges,144.48,32,,115.584,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,60,,1.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,38.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,75,,70.512,Percent of Total Billed Charges,75% of Total Billed Charges,0.29,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,70,,0.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,100,,94.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,144.48,
CANAGLIFLOZIN 100MG TAB,53073625,CDM,250,RC,,,Outpatient,,,30.97,18.58,,18.58,60,,14.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.67,28,,6.936,Percent of Total Billed Charges,28% of Total Billed Charges,144.88,32,,115.904,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% of Total Billed Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% Total Bille Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% of Total Billed Charges,18.58,60,,6.328,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,68.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.23,75,,1.32,Percent of Total Billed Charges,75% of Total Billed Charges,15.49,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,15.49,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.49,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,15.49,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.68,70,,17.344,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.97,100,,1.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,144.88,
CANAGLIFLOZIN 300MG TAB,53073626,CDM,250,RC,,,Outpatient,,,30.97,18.58,,18.58,60,,14.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.67,28,,6.936,Percent of Total Billed Charges,28% of Total Billed Charges,145.06,32,,116.048,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% of Total Billed Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% Total Bille Charges,11.15,36,,8.92,Percent of Total Billed Charges,36% of Total Billed Charges,18.58,60,,16.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,156.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.23,75,,1.344,Percent of Total Billed Charges,75% of Total Billed Charges,15.49,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,15.49,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.49,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,15.49,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.68,70,,17.344,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.97,100,,1.792,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,145.06,
METHIMAZOLE 5MG TAB,53075057,CDM,250,RC,,,Outpatient,,,0.89,0.53,,0.53,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,145.74,32,,116.592,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,60,,215.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,185.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,75,,23.752,Percent of Total Billed Charges,75% of Total Billed Charges,0.45,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,70,,0.496,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,100,,31.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,145.74,
METHIMAZOLE 10MG TAB,53075073,CDM,250,RC,,,Outpatient,,,1.23,0.74,,0.74,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,145.74,32,,116.592,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,394.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,75,,0.536,Percent of Total Billed Charges,75% of Total Billed Charges,0.62,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,70,,0.688,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,100,,0.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,145.74,
METHOCARBAMOL 500MG TAB,53075305,CDM,250,RC,,,Outpatient,,,1.65,0.99,,0.99,60,,0.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,145.74,32,,116.592,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,117.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,75,,1.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.83,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,70,,0.928,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,100,,1.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,145.74,
METHOCARBAMOL 750MG TAB UD,53075347,CDM,250,RC,,,Outpatient,,,1.64,0.98,,0.98,60,,0.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,145.92,32,,116.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,60,,20.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,115.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,75,,0.816,Percent of Total Billed Charges,75% of Total Billed Charges,0.82,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,70,,0.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,100,,1.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,145.92,
METHOTREXATE 2.5MG TAB,53075610,CDM,250,RC,J8610,HCPCS,Outpatient,,,73.58,44.15,,0.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,360,,,Fee Schedule,360% of BCBS POS Rate,2.05,360,,,Fee schedule,360% of BCBS PPO Rate,2.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.15,60,,3.576,Percent of Total Billed Charges,60% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.61,14.42,,257.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.19,75,,13.776,Percent of Total Billed Charges,75% of Total Billed Charges,0.31,80,,14.664,Fee Schedule,80% of Scott and White EPO fee schedule,0.31,80,,26.4,Fee Schedule,80% of Scott and White HMO fee schedule,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,80,,26.4,Fee Schedule,80% of Scott and White PPO fee schedule,0.31,80,,145.384,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.51,70,,41.208,Percent of Total Billed Charges,70% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.58,100,,18.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,73.58,
LEFLUNOMIDE 10 MG TAB,53075612,CDM,250,RC,,,Outpatient,,,12.2,7.32,,7.32,60,,5.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,28,,2.736,Percent of Total Billed Charges,28% of Total Billed Charges,145.92,32,,116.736,Percent of Total Billed Charges,32% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% of Total Billed Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% Total Bille Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% of Total Billed Charges,7.32,60,,69.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14.42,,81.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.15,75,,1.528,Percent of Total Billed Charges,75% of Total Billed Charges,6.1,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.54,70,,6.832,Percent of Total Billed Charges,70% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.2,100,,2.032,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,145.92,
ERLOTINIB 150 MG TAB,53075620,CDM,250,RC,,,Outpatient,,,1317.71,790.63,,790.63,60,,632.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,368.96,28,,295.168,Percent of Total Billed Charges,28% of Total Billed Charges,145.92,32,,116.736,Percent of Total Billed Charges,32% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,474.38,36,,379.504,Percent of Total Billed Charges,36% of Total Billed Charges,474.38,36,,379.504,Percent of Total Billed Charges,36% Total Bille Charges,474.38,36,,379.504,Percent of Total Billed Charges,36% of Total Billed Charges,790.63,60,,100.744,Percent of Total Billed Charges,60% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,190.01,14.42,,418.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,988.28,75,,1.024,Percent of Total Billed Charges,75% of Total Billed Charges,658.86,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,658.86,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,658.86,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,658.86,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,922.4,70,,737.92,Percent of Total Billed Charges,70% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,184.48,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1317.71,100,,1.368,Percent of Total Billed Charges,100% of Total Billed Charges,145.92,1317.71,
ERLOTINIB 100 MG TAB,53075621,CDM,250,RC,,,Outpatient,,,1170.8,702.48,,702.48,60,,561.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.82,28,,262.256,Percent of Total Billed Charges,28% of Total Billed Charges,146.3,32,,117.04,Percent of Total Billed Charges,32% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,421.49,36,,337.192,Percent of Total Billed Charges,36% of Total Billed Charges,421.49,36,,337.192,Percent of Total Billed Charges,36% Total Bille Charges,421.49,36,,337.192,Percent of Total Billed Charges,36% of Total Billed Charges,702.48,60,,20.312,Percent of Total Billed Charges,60% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,168.83,14.42,,39.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,878.1,75,,0.376,Percent of Total Billed Charges,75% of Total Billed Charges,585.4,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,585.4,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,585.4,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,585.4,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819.56,70,,655.648,Percent of Total Billed Charges,70% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,163.91,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1170.8,100,,0.504,Percent of Total Billed Charges,100% of Total Billed Charges,146.3,1170.8,
TEMOZOLOMIDE 100 MG CAP,53075672,CDM,250,RC,J8700,HCPCS,Outpatient,,,1141.14,684.68,,0.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,360,,,Fee Schedule,360% of BCBS POS Rate,4.11,360,,,Fee schedule,360% of BCBS PPO Rate,4.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,684.68,60,,4252.16,Percent of Total Billed Charges,60% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,164.55,14.42,,37.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855.86,75,,0.912,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,80,,18.056,Fee Schedule,80% of Scott and White EPO fee schedule,0.16,80,,17.696,Fee Schedule,80% of Scott and White HMO fee schedule,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,80,,17.696,Fee Schedule,80% of Scott and White PPO fee schedule,0.16,80,,13.368,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798.8,70,,639.04,Percent of Total Billed Charges,70% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,159.76,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1141.14,100,,1.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,1141.14,
ROTIGOTINE PATCH 2MG,53075695,CDM,250,RC,,,Outpatient,,,43.11,25.87,,25.87,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.07,28,,9.656,Percent of Total Billed Charges,28% of Total Billed Charges,146.88,32,,117.504,Percent of Total Billed Charges,32% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% Total Bille Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,25.87,60,,34.128,Percent of Total Billed Charges,60% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14.42,,62.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.33,75,,1.24,Percent of Total Billed Charges,75% of Total Billed Charges,21.56,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.56,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.18,70,,24.144,Percent of Total Billed Charges,70% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.11,100,,1.648,Percent of Total Billed Charges,100% of Total Billed Charges,6.04,146.88,
ROTIGOTINE PATCH 1MG,53075696,CDM,250,RC,,,Outpatient,,,43.11,25.87,,25.87,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.07,28,,9.656,Percent of Total Billed Charges,28% of Total Billed Charges,147,32,,117.6,Percent of Total Billed Charges,32% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% Total Bille Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,25.87,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14.42,,252.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.33,75,,99.952,Percent of Total Billed Charges,75% of Total Billed Charges,21.56,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.56,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.18,70,,24.144,Percent of Total Billed Charges,70% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.11,100,,133.264,Percent of Total Billed Charges,100% of Total Billed Charges,6.04,147,
ROTIGOTINE PATCH 3MG,53075697,CDM,250,RC,,,Outpatient,,,43.11,25.87,,25.87,60,,20.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.07,28,,9.656,Percent of Total Billed Charges,28% of Total Billed Charges,147.02,32,,117.616,Percent of Total Billed Charges,32% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% Total Bille Charges,15.52,36,,12.416,Percent of Total Billed Charges,36% of Total Billed Charges,25.87,60,,4.312,Percent of Total Billed Charges,60% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14.42,,146.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.33,75,,2.176,Percent of Total Billed Charges,75% of Total Billed Charges,21.56,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.56,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,21.56,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.18,70,,24.144,Percent of Total Billed Charges,70% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.11,100,,2.896,Percent of Total Billed Charges,100% of Total Billed Charges,6.04,147.02,
METHYLDOPA 250MG TAB,53075883,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,147.12,32,,117.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,70.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,97.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,17.008,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,22.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,147.12,
METHYLPREDNISOLONE 16MG TAB,53076543,CDM,250,RC,J7509,HCPCS,Outpatient,,,6.91,4.15,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.15,60,,130.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,1,14.42,,42.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.22,80,,111.192,Fee Schedule,80% of Scott and White EPO fee schedule,0.22,80,,75.008,Fee Schedule,80% of Scott and White HMO fee schedule,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,80,,75.008,Fee Schedule,80% of Scott and White PPO fee schedule,0.22,80,,30.504,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.84,70,,3.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.91,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,6.91,
METHYLPREDNISOLONE 4MG TAB UD,53076584,CDM,250,RC,J7509,HCPCS,Outpatient,,,2.86,1.72,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,1.72,60,,29.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14.42,,63.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.22,80,,16.824,Fee Schedule,80% of Scott and White EPO fee schedule,0.22,80,,52.032,Fee Schedule,80% of Scott and White HMO fee schedule,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,80,,52.032,Fee Schedule,80% of Scott and White PPO fee schedule,0.22,80,,266.584,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,70,,1.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,2.86,
METHYLPRED 4MG DOSPK (21 TABS),53076626,CDM,250,RC,J7509,HCPCS,Outpatient,,,60.02,36.01,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.01,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.65,14.42,,45.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.02,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.22,80,,75.008,Fee Schedule,80% of Scott and White EPO fee schedule,0.22,80,,121.968,Fee Schedule,80% of Scott and White HMO fee schedule,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,80,,121.968,Fee Schedule,80% of Scott and White PPO fee schedule,0.22,80,,14.664,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.01,70,,33.608,Percent of Total Billed Charges,70% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.02,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,60.02,
METOCLOPRAMIDE 10MG TAB,53077319,CDM,250,RC,,,Outpatient,,,0.27,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,14738.76,32,,11791.008,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,58.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,68.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,70,,0.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,14738.76,
METOLAZONE 2.5MG TAB,53077584,CDM,250,RC,,,Outpatient,,,6.57,3.94,,3.94,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,28,,1.472,Percent of Total Billed Charges,28% of Total Billed Charges,14.92,32,,11.936,Percent of Total Billed Charges,32% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% of Total Billed Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% Total Bille Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% of Total Billed Charges,3.94,60,,49.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14.42,,60.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.93,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,3.29,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,3.29,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.29,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,3.29,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,70,,3.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.57,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,14.92,
METOLAZONE 5MG TAB,53077624,CDM,250,RC,,,Outpatient,,,7.47,4.48,,4.48,60,,3.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,28,,1.672,Percent of Total Billed Charges,28% of Total Billed Charges,14.92,32,,11.936,Percent of Total Billed Charges,32% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,36,,2.152,Percent of Total Billed Charges,36% of Total Billed Charges,2.69,36,,2.152,Percent of Total Billed Charges,36% Total Bille Charges,2.69,36,,2.152,Percent of Total Billed Charges,36% of Total Billed Charges,4.48,60,,499.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14.42,,60.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,3.74,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,3.74,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.74,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,3.74,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.23,70,,4.184,Percent of Total Billed Charges,70% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.47,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,14.92,
IVABRADINE TAB 5MG,53077840,CDM,250,RC,,,Outpatient,,,14.32,8.59,,8.59,60,,6.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,28,,3.208,Percent of Total Billed Charges,28% of Total Billed Charges,14.96,32,,11.968,Percent of Total Billed Charges,32% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,5.16,36,,4.128,Percent of Total Billed Charges,36% of Total Billed Charges,5.16,36,,4.128,Percent of Total Billed Charges,36% Total Bille Charges,5.16,36,,4.128,Percent of Total Billed Charges,36% of Total Billed Charges,8.59,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.06,14.42,,8.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,7.16,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,7.16,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.16,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,7.16,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.02,70,,8.016,Percent of Total Billed Charges,70% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,2,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.32,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,2,14.96,
METOPROLOL 50MG TAB UD,53077855,CDM,250,RC,,,Outpatient,,,0.26,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,15,32,,12,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,7.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,26.752,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,100,,35.664,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,15,
MILNACIPRAN 50 MG TAB,53077860,CDM,250,RC,,,Outpatient,,,11.63,6.98,,6.98,60,,5.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,28,,2.608,Percent of Total Billed Charges,28% of Total Billed Charges,15.01,32,,12.008,Percent of Total Billed Charges,32% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% Total Bille Charges,4.19,36,,3.352,Percent of Total Billed Charges,36% of Total Billed Charges,6.98,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14.42,,7.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.72,75,,30.136,Percent of Total Billed Charges,75% of Total Billed Charges,5.82,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,5.82,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.82,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,5.82,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.14,70,,6.512,Percent of Total Billed Charges,70% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.63,100,,40.176,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,15.01,
METOPROLOL XL 50MG TAB,53077863,CDM,250,RC,,,Outpatient,,,2.48,1.49,,1.49,60,,1.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,28,,0.552,Percent of Total Billed Charges,28% of Total Billed Charges,147.3,32,,117.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% of Total Billed Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% Total Bille Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% of Total Billed Charges,1.49,60,,186.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14.42,,5.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,75,,29.416,Percent of Total Billed Charges,75% of Total Billed Charges,1.24,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,1.24,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.24,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.24,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.74,70,,1.392,Percent of Total Billed Charges,70% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.48,100,,39.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,147.3,
METOPROLOL 25 MG TAB,53077913,CDM,250,RC,,,Outpatient,,,0.17,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,147.53,32,,118.024,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,83.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,3.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,75,,1.072,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,70,,0.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,100,,1.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,147.53,
METRONIDAZOLE TAB 250MG,53078127,CDM,250,RC,,,Outpatient,,,1.62,0.97,,0.97,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,147.79,32,,118.232,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,60,,62.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,5.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,2.32,Percent of Total Billed Charges,75% of Total Billed Charges,0.81,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,70,,0.904,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,100,,3.088,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,147.79,
METRONIDAZOLE 500MG TAB,53078150,CDM,250,RC,,,Outpatient,,,2.75,1.65,,1.65,60,,1.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,147.84,32,,118.272,Percent of Total Billed Charges,32% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,1.65,60,,51.752,Percent of Total Billed Charges,60% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14.42,,12.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,75,,0.952,Percent of Total Billed Charges,75% of Total Billed Charges,1.38,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,1.38,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,70,,1.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.75,100,,1.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,147.84,
MEXILETINE 150MG CAP,53078366,CDM,250,RC,,,Outpatient,,,3.41,2.05,,2.05,60,,1.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,28,,0.76,Percent of Total Billed Charges,28% of Total Billed Charges,148.01,32,,118.408,Percent of Total Billed Charges,32% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% Total Bille Charges,1.23,36,,0.984,Percent of Total Billed Charges,36% of Total Billed Charges,2.05,60,,27.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,75,,1,Percent of Total Billed Charges,75% of Total Billed Charges,1.71,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.39,70,,1.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.41,100,,1.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.48,148.01,
MEXILETINE 200MG CAP,53078374,CDM,250,RC,,,Outpatient,,,4.1,2.46,,2.46,60,,1.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,28,,0.92,Percent of Total Billed Charges,28% of Total Billed Charges,148.48,32,,118.784,Percent of Total Billed Charges,32% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% Total Bille Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,2.46,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,2.05,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,2.05,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,2.05,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.87,70,,2.296,Percent of Total Billed Charges,70% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.1,100,,1.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,148.48,
MIDODRINE 2.5MG TAB,53078416,CDM,250,RC,,,Outpatient,,,3.86,2.32,,2.32,60,,1.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,28,,0.864,Percent of Total Billed Charges,28% of Total Billed Charges,148.63,32,,118.904,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% of Total Billed Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% Total Bille Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% of Total Billed Charges,2.32,60,,49.008,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,3.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.9,75,,14.016,Percent of Total Billed Charges,75% of Total Billed Charges,1.93,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.93,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,1.93,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.7,70,,2.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,100,,18.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,148.63,
MIDODRINE 5MG TAB,53078424,CDM,250,RC,,,Outpatient,,,3.67,2.20,,2.2,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,28,,0.824,Percent of Total Billed Charges,28% of Total Billed Charges,148.8,32,,119.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,60,,521.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.75,75,,2.928,Percent of Total Billed Charges,75% of Total Billed Charges,1.84,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.84,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,1.84,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.57,70,,2.056,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,100,,3.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,148.8,
MINOCYCLINE 100MG CAP,53078614,CDM,250,RC,,,Outpatient,,,10.35,6.21,,6.21,60,,4.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.9,28,,2.32,Percent of Total Billed Charges,28% of Total Billed Charges,148.8,32,,119.04,Percent of Total Billed Charges,32% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,3.73,36,,2.984,Percent of Total Billed Charges,36% of Total Billed Charges,3.73,36,,2.984,Percent of Total Billed Charges,36% Total Bille Charges,3.73,36,,2.984,Percent of Total Billed Charges,36% of Total Billed Charges,6.21,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14.42,,6.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.76,75,,2.808,Percent of Total Billed Charges,75% of Total Billed Charges,5.18,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,5.18,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.18,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,5.18,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.25,70,,5.8,Percent of Total Billed Charges,70% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.35,100,,3.744,Percent of Total Billed Charges,100% of Total Billed Charges,1.45,148.8,
MIRTAZAPINE ODT 15MG TAB,53078796,CDM,250,RC,,,Outpatient,,,4.56,2.74,,2.74,60,,2.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,28,,1.024,Percent of Total Billed Charges,28% of Total Billed Charges,148.83,32,,119.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% of Total Billed Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% Total Bille Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% of Total Billed Charges,2.74,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14.42,,2.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.42,75,,5.416,Percent of Total Billed Charges,75% of Total Billed Charges,2.28,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,70,,2.552,Percent of Total Billed Charges,70% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,100,,7.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,148.83,
MIRTAZAPINE 15MG TAB,53078804,CDM,250,RC,,,Outpatient,,,0.45,0.27,,0.27,60,,0.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,148.83,32,,119.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% Total Bille Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,2.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,75,,6.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.23,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,70,,0.256,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,100,,8.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,148.83,
MINOXIDIL 2.5MG TAB,53078812,CDM,250,RC,,,Outpatient,,,1.54,0.92,,0.92,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,148.92,32,,119.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.92,60,,128.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,6.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,75,,1.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.77,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,70,,0.864,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,100,,1.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,148.92,
MODAFINIL 100 MG TAB,53078838,CDM,250,RC,,,Outpatient,,,81.22,48.73,,48.73,60,,38.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.74,28,,18.192,Percent of Total Billed Charges,28% of Total Billed Charges,149.47,32,,119.576,Percent of Total Billed Charges,32% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,29.24,36,,23.392,Percent of Total Billed Charges,36% of Total Billed Charges,29.24,36,,23.392,Percent of Total Billed Charges,36% Total Bille Charges,29.24,36,,23.392,Percent of Total Billed Charges,36% of Total Billed Charges,48.73,60,,214.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.71,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.92,75,,0.72,Percent of Total Billed Charges,75% of Total Billed Charges,40.61,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,40.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,40.61,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.85,70,,45.48,Percent of Total Billed Charges,70% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.37,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.22,100,,0.96,Percent of Total Billed Charges,100% of Total Billed Charges,11.37,149.47,
MISOPROSTOL 100MCG TAB,53078903,CDM,250,RC,,,Outpatient,,,3.27,1.96,,1.96,60,,1.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,28,,0.736,Percent of Total Billed Charges,28% of Total Billed Charges,149.76,32,,119.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% Total Bille Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.96,60,,406.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,75,,0.832,Percent of Total Billed Charges,75% of Total Billed Charges,1.64,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.29,70,,1.832,Percent of Total Billed Charges,70% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,100,,1.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,149.76,
MISOPROSTOL 200MCG TAB,53078911,CDM,250,RC,,,Outpatient,,,2.86,1.72,,1.72,60,,1.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,28,,0.64,Percent of Total Billed Charges,28% of Total Billed Charges,149.76,32,,119.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% Total Bille Charges,1.03,36,,0.824,Percent of Total Billed Charges,36% of Total Billed Charges,1.72,60,,64.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14.42,,4.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.15,75,,11.648,Percent of Total Billed Charges,75% of Total Billed Charges,1.43,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,1.43,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,1.43,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,70,,1.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,100,,15.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,149.76,
MISOPROSTOL UNIT DOSE 25 MCG,53078929,CDM,250,RC,,,Outpatient,,,1.96,1.18,,1.18,60,,0.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,28,,0.44,Percent of Total Billed Charges,28% of Total Billed Charges,149.76,32,,119.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,36,,0.568,Percent of Total Billed Charges,36% of Total Billed Charges,0.71,36,,0.568,Percent of Total Billed Charges,36% Total Bille Charges,0.71,36,,0.568,Percent of Total Billed Charges,36% of Total Billed Charges,1.18,60,,246.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,46.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.47,75,,11.736,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,70,,1.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,100,,15.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,149.76,
MONTELUKAST SOD 10MG TAB,53079034,CDM,250,RC,,,Outpatient,,,0.96,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,150.35,32,,120.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,114.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,808.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,75,,124.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.48,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,70,,0.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,100,,155.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,150.35,
MONTELUKAST 5 MG TAB,53079042,CDM,250,RC,,,Outpatient,,,1.83,1.10,,1.1,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,28,,0.408,Percent of Total Billed Charges,28% of Total Billed Charges,15.13,32,,12.104,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.1,60,,199.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,450.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,75,,37.464,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,70,,1.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,100,,49.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,15.13,
MIRACLE MOUTHWASH 120ML,53079109,CDM,250,RC,,,Outpatient,,,139,83.40,,83.4,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.92,28,,31.136,Percent of Total Billed Charges,28% of Total Billed Charges,15.2,32,,12.16,Percent of Total Billed Charges,32% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,50.04,36,,40.032,Percent of Total Billed Charges,36% of Total Billed Charges,50.04,36,,40.032,Percent of Total Billed Charges,36% Total Bille Charges,50.04,36,,40.032,Percent of Total Billed Charges,36% of Total Billed Charges,83.4,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14.42,,8.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.25,75,,45.56,Percent of Total Billed Charges,75% of Total Billed Charges,69.5,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,69.5,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.5,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,69.5,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.3,70,,77.84,Percent of Total Billed Charges,70% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,19.46,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139,100,,60.744,Percent of Total Billed Charges,100% of Total Billed Charges,15.2,139,
MAGIC MOUTHWASH 100ML LI,53079117,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,61.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,81.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
STOMATITIS COCKTAIL 1ML,53079120,CDM,250,RC,,,Outpatient,,,0.12,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,15.26,32,,12.208,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,5.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,75,,1.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,100,,1.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,15.26,
MULTIVITAMIN TAB,53079125,CDM,250,RC,,,Outpatient,,,0.07,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,150.47,32,,120.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,244.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,2.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,12.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,70,,0.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,100,,16.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,150.47,
MULTIVIT THERAP/MIN,53079166,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,151.89,32,,121.512,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,351.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,6.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,124.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,155.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,151.89,
MULTIVITAMIN LIQ 5ML,53079185,CDM,250,RC,,,Outpatient,,,0.18,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,152,32,,121.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,1119.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,7.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,34,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,100,,45.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,152,
MYCOPHENOLATE MOF 250MG CAP,53079562,CDM,250,RC,J7517,HCPCS,Outpatient,,,3.69,2.21,,0.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,360,,,Fee Schedule,360% of BCBS POS Rate,0.57,360,,,Fee schedule,360% of BCBS PPO Rate,0.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.21,60,,1119.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,3.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,75,,15.504,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,80,,25.272,Fee Schedule,80% of Scott and White EPO fee schedule,0.16,80,,19.92,Fee Schedule,80% of Scott and White HMO fee schedule,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,80,,19.92,Fee Schedule,80% of Scott and White PPO fee schedule,0.16,80,,88.424,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,70,,2.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,100,,19.384,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,3.69,
MYCOPHENOLATE SOD 180 MG TAB,53079565,CDM,250,RC,J7518,HCPCS,Outpatient,,,31.22,18.73,,1.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,360,,,Fee Schedule,360% of BCBS POS Rate,1.97,360,,,Fee schedule,360% of BCBS PPO Rate,1.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,18.73,60,,768.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14.42,,10.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.42,75,,0.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.51,80,,25.272,Fee Schedule,80% of Scott and White EPO fee schedule,0.51,80,,3.024,Fee Schedule,80% of Scott and White HMO fee schedule,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,80,,3.024,Fee Schedule,80% of Scott and White PPO fee schedule,0.51,80,,105.288,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.85,70,,17.48,Percent of Total Billed Charges,70% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.22,100,,0.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,31.22,
NABUMETONE 500MG TAB,53079604,CDM,250,RC,,,Outpatient,,,0.7,0.42,,0.42,60,,0.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,152.32,32,,121.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% Total Bille Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,60,,624,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,6.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.35,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,70,,0.392,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,152.32,
NADOLOL 20MG TAB,53079737,CDM,250,RC,,,Outpatient,,,12.38,7.43,,7.43,60,,5.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,28,,2.776,Percent of Total Billed Charges,28% of Total Billed Charges,152.32,32,,121.856,Percent of Total Billed Charges,32% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,36,,3.568,Percent of Total Billed Charges,36% of Total Billed Charges,4.46,36,,3.568,Percent of Total Billed Charges,36% Total Bille Charges,4.46,36,,3.568,Percent of Total Billed Charges,36% of Total Billed Charges,7.43,60,,1247.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14.42,,6.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.29,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,6.19,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.67,70,,6.936,Percent of Total Billed Charges,70% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.38,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,152.32,
NALTREXONE TAB 50MG,53080685,CDM,250,RC,,,Outpatient,,,2.45,1.47,,1.47,60,,1.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,28,,0.552,Percent of Total Billed Charges,28% of Total Billed Charges,152.32,32,,121.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% Total Bille Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,1.47,60,,2006,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,3.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,75,,7.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.23,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,1.23,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,1.23,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,70,,1.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,100,,9.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,152.32,
NAPROXEN 250MG TAB,53080784,CDM,250,RC,,,Outpatient,,,0.75,0.45,,0.45,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,152.32,32,,121.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,25.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,75,,1.272,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,0.424,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,100,,1.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,152.32,
NAPROXEN EC 500MG TAB,53080818,CDM,250,RC,,,Outpatient,,,2.22,1.33,,1.33,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,28,,0.496,Percent of Total Billed Charges,28% of Total Billed Charges,152.58,32,,122.064,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% Total Bille Charges,0.8,36,,0.64,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,60,,136.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.67,75,,29.8,Percent of Total Billed Charges,75% of Total Billed Charges,1.11,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,70,,1.24,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.22,100,,39.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,152.58,
NAPROXEN 500MG TAB,53080883,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,152.78,32,,122.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,72.768,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,4.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,6.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,152.78,
NAPROXEN SOD 550MG TAB,53080891,CDM,250,RC,,,Outpatient,,,8.75,5.25,,5.25,60,,4.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,28,,1.96,Percent of Total Billed Charges,28% of Total Billed Charges,15.36,32,,12.288,Percent of Total Billed Charges,32% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% of Total Billed Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% Total Bille Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% of Total Billed Charges,5.25,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,75,,15.688,Percent of Total Billed Charges,75% of Total Billed Charges,4.38,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,4.38,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.38,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,4.38,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.13,70,,4.904,Percent of Total Billed Charges,70% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.75,100,,20.912,Percent of Total Billed Charges,100% of Total Billed Charges,1.23,15.36,
NATEGLINIDE 60MG TAB,53080925,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,15.36,32,,12.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,6.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,265.648,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,354.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,15.36,
NEOMYCIN SULF 500MG TAB,53081055,CDM,250,RC,,,Outpatient,,,3.89,2.33,,2.33,60,,1.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,15.6,32,,12.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.33,60,,117.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,9.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.92,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,70,,2.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.89,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,15.6,
NIACIN 100MG +,53081972,CDM,250,RC,,,Outpatient,,,0.04,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,153.8,32,,123.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,49.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,4.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,70,,0.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,100,,0.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,153.8,
NIACIN 500MG TAB,53082475,CDM,250,RC,,,Outpatient,,,0.05,0.03,,0.03,60,,0.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,153.92,32,,123.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,60,,220.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,6.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,75,,247.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,70,,0.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,100,,309.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,153.92,
NIFEDIPINE XL 60MG TAB,53083093,CDM,250,RC,,,Outpatient,,,4.75,2.85,,2.85,60,,2.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,28,,1.064,Percent of Total Billed Charges,28% of Total Billed Charges,153.96,32,,123.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% of Total Billed Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% Total Bille Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% of Total Billed Charges,2.85,60,,132.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14.42,,2.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.56,75,,0.072,Percent of Total Billed Charges,75% of Total Billed Charges,2.38,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.33,70,,2.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.75,100,,0.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,153.96,
NIFEDIPINE XL 30MG TAB,53083101,CDM,250,RC,,,Outpatient,,,2.7,1.62,,1.62,60,,1.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,153.96,32,,123.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.97,36,,0.776,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,36,,0.776,Percent of Total Billed Charges,36% Total Bille Charges,0.97,36,,0.776,Percent of Total Billed Charges,36% of Total Billed Charges,1.62,60,,1123.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,4.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.03,75,,0.408,Percent of Total Billed Charges,75% of Total Billed Charges,1.35,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.35,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.35,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.35,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,70,,1.512,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.7,100,,0.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,153.96,
NIFEDIPINE 10MG TAB,53083127,CDM,250,RC,,,Outpatient,,,2.45,1.47,,1.47,60,,1.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,28,,0.552,Percent of Total Billed Charges,28% of Total Billed Charges,153.96,32,,123.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% Total Bille Charges,0.88,36,,0.704,Percent of Total Billed Charges,36% of Total Billed Charges,1.47,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,7.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,75,,0.856,Percent of Total Billed Charges,75% of Total Billed Charges,1.23,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,1.23,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,1.23,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,70,,1.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,100,,1.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,153.96,
NIMODIPINE 30MG CAP,53083200,CDM,250,RC,,,Outpatient,,,18.91,11.35,,11.35,60,,9.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.29,28,,4.232,Percent of Total Billed Charges,28% of Total Billed Charges,154.36,32,,123.488,Percent of Total Billed Charges,32% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.81,36,,5.448,Percent of Total Billed Charges,36% of Total Billed Charges,6.81,36,,5.448,Percent of Total Billed Charges,36% Total Bille Charges,6.81,36,,5.448,Percent of Total Billed Charges,36% of Total Billed Charges,11.35,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,75,,2.472,Percent of Total Billed Charges,75% of Total Billed Charges,9.46,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,9.46,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.46,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,9.46,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.24,70,,10.592,Percent of Total Billed Charges,70% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.91,100,,3.296,Percent of Total Billed Charges,100% of Total Billed Charges,2.65,154.36,
NITROFUR MACR 50MG CAP,53083358,CDM,250,RC,,,Outpatient,,,6.03,3.62,,3.62,60,,2.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,28,,1.352,Percent of Total Billed Charges,28% of Total Billed Charges,154.62,32,,123.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,36,,1.736,Percent of Total Billed Charges,36% of Total Billed Charges,2.17,36,,1.736,Percent of Total Billed Charges,36% Total Bille Charges,2.17,36,,1.736,Percent of Total Billed Charges,36% of Total Billed Charges,3.62,60,,50.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14.42,,48.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,75,,24.784,Percent of Total Billed Charges,75% of Total Billed Charges,3.02,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,3.02,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.02,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,3.02,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.22,70,,3.376,Percent of Total Billed Charges,70% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,100,,33.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,154.62,
NITROFUR MACROBID 100MG CAP,53083374,CDM,250,RC,,,Outpatient,,,7.56,4.54,,4.54,60,,3.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,28,,1.696,Percent of Total Billed Charges,28% of Total Billed Charges,154.79,32,,123.832,Percent of Total Billed Charges,32% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% of Total Billed Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% Total Bille Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% of Total Billed Charges,4.54,60,,60.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14.42,,36.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,75,,2.128,Percent of Total Billed Charges,75% of Total Billed Charges,3.78,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,3.78,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.78,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,3.78,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.29,70,,4.232,Percent of Total Billed Charges,70% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.56,100,,2.832,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,154.79,
NITROGLYCERIN 0.4MG SL TAB 25,53083788,CDM,250,RC,,,Outpatient,,,52.04,31.22,,31.22,60,,24.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.57,28,,11.656,Percent of Total Billed Charges,28% of Total Billed Charges,154.82,32,,123.856,Percent of Total Billed Charges,32% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,18.73,36,,14.984,Percent of Total Billed Charges,36% of Total Billed Charges,18.73,36,,14.984,Percent of Total Billed Charges,36% Total Bille Charges,18.73,36,,14.984,Percent of Total Billed Charges,36% of Total Billed Charges,31.22,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14.42,,36.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.03,75,,1.096,Percent of Total Billed Charges,75% of Total Billed Charges,26.02,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,26.02,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.02,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,26.02,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.43,70,,29.144,Percent of Total Billed Charges,70% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,7.29,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.04,100,,1.464,Percent of Total Billed Charges,100% of Total Billed Charges,7.29,154.82,
NORTRIPTYLINE CAP 10MG,53084281,CDM,250,RC,,,Outpatient,,,0.82,0.49,,0.49,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,28,,0.184,Percent of Total Billed Charges,28% of Total Billed Charges,155.1,32,,124.08,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% Total Bille Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,75,,0.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,70,,0.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,100,,0.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,155.1,
NORTRIPTYLINE 25MG TAB,53084323,CDM,250,RC,,,Outpatient,,,1.78,1.07,,1.07,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,28,,0.4,Percent of Total Billed Charges,28% of Total Billed Charges,155.12,32,,124.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% Total Bille Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,1.07,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,75,,7.096,Percent of Total Billed Charges,75% of Total Billed Charges,0.89,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,0.89,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,0.89,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,70,,1,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,100,,9.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,155.12,
ONDANSETRON ODT 4 MG TAB,53084927,CDM,250,RC,,,Outpatient,,,1.86,1.12,,1.12,60,,0.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,155.12,32,,124.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,1.12,60,,107.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,54.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,75,,0.168,Percent of Total Billed Charges,75% of Total Billed Charges,0.93,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,70,,1.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.86,100,,0.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,155.12,
ONDANSETRON ODT 8 MG TAB,53084935,CDM,250,RC,,,Outpatient,,,4.73,2.84,,2.84,60,,2.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.32,28,,1.056,Percent of Total Billed Charges,28% of Total Billed Charges,155.12,32,,124.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,36,,1.36,Percent of Total Billed Charges,36% of Total Billed Charges,1.7,36,,1.36,Percent of Total Billed Charges,36% Total Bille Charges,1.7,36,,1.36,Percent of Total Billed Charges,36% of Total Billed Charges,2.84,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14.42,,54.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.55,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,2.37,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,2.37,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.37,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,2.37,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.31,70,,2.648,Percent of Total Billed Charges,70% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.73,100,,0.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,155.12,
OLANZAPINE 5MG TAB,53084976,CDM,250,RC,,,Outpatient,,,1.05,0.63,,0.63,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,155.49,32,,124.392,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% Total Bille Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,48.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,75,,4.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,70,,0.592,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,100,,6.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,155.49,
OLANZAPINE 2.5MG TAB,53085007,CDM,250,RC,,,Outpatient,,,1.02,0.61,,0.61,60,,0.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,155.62,32,,124.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.61,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.51,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,70,,0.568,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,100,,0.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,155.62,
OSELTAMIVIR 75MG CAP,53085049,CDM,250,RC,,,Outpatient,,,30.88,18.53,,18.53,60,,14.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.65,28,,6.92,Percent of Total Billed Charges,28% of Total Billed Charges,155.62,32,,124.496,Percent of Total Billed Charges,32% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% of Total Billed Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% Total Bille Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% of Total Billed Charges,18.53,60,,168.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.45,14.42,,586.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.16,75,,0.736,Percent of Total Billed Charges,75% of Total Billed Charges,15.44,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,15.44,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.44,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,15.44,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.62,70,,17.296,Percent of Total Billed Charges,70% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.88,100,,0.976,Percent of Total Billed Charges,100% of Total Billed Charges,4.32,155.62,
OSELTAMIVIR 30MG CAP,53085050,CDM,250,RC,,,Outpatient,,,23.33,14.00,,14,60,,11.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,28,,5.224,Percent of Total Billed Charges,28% of Total Billed Charges,155.68,32,,124.544,Percent of Total Billed Charges,32% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,8.4,36,,6.72,Percent of Total Billed Charges,36% of Total Billed Charges,8.4,36,,6.72,Percent of Total Billed Charges,36% Total Bille Charges,8.4,36,,6.72,Percent of Total Billed Charges,36% of Total Billed Charges,14,60,,67.776,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14.42,,62.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,75,,0.248,Percent of Total Billed Charges,75% of Total Billed Charges,11.67,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,11.67,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.67,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,11.67,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.33,70,,13.064,Percent of Total Billed Charges,70% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.33,100,,0.328,Percent of Total Billed Charges,100% of Total Billed Charges,3.27,155.68,
OLMESARTAN 20 MG TAB,53085205,CDM,250,RC,,,Outpatient,,,13.96,8.38,,8.38,60,,6.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,28,,3.128,Percent of Total Billed Charges,28% of Total Billed Charges,155.71,32,,124.568,Percent of Total Billed Charges,32% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% of Total Billed Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% Total Bille Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% of Total Billed Charges,8.38,60,,70.992,Percent of Total Billed Charges,60% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.01,14.42,,62.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.47,75,,8.08,Percent of Total Billed Charges,75% of Total Billed Charges,6.98,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,6.98,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.98,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,6.98,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.77,70,,7.816,Percent of Total Billed Charges,70% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.96,100,,10.776,Percent of Total Billed Charges,100% of Total Billed Charges,1.95,155.71,
OMEGA-3-ACID ETHYL EST 1GM CAP,53085288,CDM,250,RC,,,Outpatient,,,3.17,1.90,,1.9,60,,1.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,28,,0.712,Percent of Total Billed Charges,28% of Total Billed Charges,15.69,32,,12.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% Total Bille Charges,1.14,36,,0.912,Percent of Total Billed Charges,36% of Total Billed Charges,1.9,60,,526.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14.42,,249.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,75,,8.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.59,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.59,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.59,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.22,70,,1.776,Percent of Total Billed Charges,70% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,100,,11.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,15.69,
ICOSAPENT ETHYL 1GM CAP,53085290,CDM,250,RC,,,Outpatient,,,4.26,2.56,,2.56,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,28,,0.952,Percent of Total Billed Charges,28% of Total Billed Charges,15.69,32,,12.552,Percent of Total Billed Charges,32% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% of Total Billed Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% Total Bille Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% of Total Billed Charges,2.56,60,,408.864,Percent of Total Billed Charges,60% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14.42,,249.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,75,,15.112,Percent of Total Billed Charges,75% of Total Billed Charges,2.13,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,2.13,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.13,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,2.13,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.98,70,,2.384,Percent of Total Billed Charges,70% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.26,100,,20.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,15.69,
OXCARBAZEPINE 300MG TAB,53085718,CDM,250,RC,,,Outpatient,,,1.03,0.62,,0.62,60,,0.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,15.72,32,,12.576,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% Total Bille Charges,0.37,36,,0.296,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,60,,354.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,17.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,75,,2.352,Percent of Total Billed Charges,75% of Total Billed Charges,0.52,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.72,70,,0.576,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,100,,3.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,15.72,
OXYBUTYNIN 5MG TAB,53086401,CDM,250,RC,,,Outpatient,,,1.24,0.74,,0.74,60,,0.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,28,,0.28,Percent of Total Billed Charges,28% of Total Billed Charges,15.77,32,,12.616,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% Total Bille Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,60,,432.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,17.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,75,,0.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.62,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,70,,0.696,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.24,100,,0.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,15.77,
OXYBUTYNIN XL 5 MG TAB,53086419,CDM,250,RC,,,Outpatient,,,5.59,3.35,,3.35,60,,2.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,28,,1.256,Percent of Total Billed Charges,28% of Total Billed Charges,15.83,32,,12.664,Percent of Total Billed Charges,32% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% of Total Billed Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% Total Bille Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% of Total Billed Charges,3.35,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.81,14.42,,4.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.19,75,,0.392,Percent of Total Billed Charges,75% of Total Billed Charges,2.8,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,2.8,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,2.8,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,70,,3.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.59,100,,0.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,15.83,
PANTOPRAZOLE 40 MG TR TAB,53088704,CDM,250,RC,,,Outpatient,,,0.91,0.55,,0.55,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,15.85,32,,12.68,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% Total Bille Charges,0.33,36,,0.264,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,60,,73.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,34.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,75,,7.144,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,70,,0.512,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,100,,9.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,15.85,
PALIPERIDONE ER 3MG TABLET,53088779,CDM,250,RC,,,Outpatient,,,73.84,44.30,,44.3,60,,35.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.68,28,,16.544,Percent of Total Billed Charges,28% of Total Billed Charges,15.86,32,,12.688,Percent of Total Billed Charges,32% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,26.58,36,,21.264,Percent of Total Billed Charges,36% of Total Billed Charges,26.58,36,,21.264,Percent of Total Billed Charges,36% Total Bille Charges,26.58,36,,21.264,Percent of Total Billed Charges,36% of Total Billed Charges,44.3,60,,165.304,Percent of Total Billed Charges,60% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.65,14.42,,34.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.38,75,,4,Percent of Total Billed Charges,75% of Total Billed Charges,36.92,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,36.92,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.92,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,36.92,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.69,70,,41.352,Percent of Total Billed Charges,70% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,10.34,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.84,100,,5.328,Percent of Total Billed Charges,100% of Total Billed Charges,10.34,73.84,
PARLODEL 2.5MG +,53089470,CDM,250,RC,,,Outpatient,,,398.75,239.25,,239.25,60,,191.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.65,28,,89.32,Percent of Total Billed Charges,28% of Total Billed Charges,15.88,32,,12.704,Percent of Total Billed Charges,32% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,143.55,36,,114.84,Percent of Total Billed Charges,36% of Total Billed Charges,143.55,36,,114.84,Percent of Total Billed Charges,36% Total Bille Charges,143.55,36,,114.84,Percent of Total Billed Charges,36% of Total Billed Charges,239.25,60,,88.016,Percent of Total Billed Charges,60% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,57.5,14.42,,5.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.06,75,,21.296,Percent of Total Billed Charges,75% of Total Billed Charges,199.38,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,199.38,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.38,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,199.38,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.13,70,,223.304,Percent of Total Billed Charges,70% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,55.83,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.75,100,,28.392,Percent of Total Billed Charges,100% of Total Billed Charges,15.88,398.75,
PAROXETINE 10MG TAB,53089496,CDM,250,RC,,,Outpatient,,,2.38,1.43,,1.43,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,15.94,32,,12.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,7.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,75,,42.712,Percent of Total Billed Charges,75% of Total Billed Charges,1.19,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,70,,1.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,100,,56.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,15.94,
PAROXETINE 20MG TAB,53089504,CDM,250,RC,,,Outpatient,,,0.71,0.43,,0.43,60,,0.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,157.39,32,,125.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,131.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,22.552,Percent of Total Billed Charges,75% of Total Billed Charges,0.36,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,70,,0.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,100,,30.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,157.39,
PAROXETINE CR 12.5 MG TAB,53089538,CDM,250,RC,,,Outpatient,,,11.14,6.68,,6.68,60,,5.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.12,28,,2.496,Percent of Total Billed Charges,28% of Total Billed Charges,158.16,32,,126.528,Percent of Total Billed Charges,32% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,36,,3.208,Percent of Total Billed Charges,36% of Total Billed Charges,4.01,36,,3.208,Percent of Total Billed Charges,36% Total Bille Charges,4.01,36,,3.208,Percent of Total Billed Charges,36% of Total Billed Charges,6.68,60,,134.112,Percent of Total Billed Charges,60% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14.42,,21.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.36,75,,2.56,Percent of Total Billed Charges,75% of Total Billed Charges,5.57,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,5.57,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.57,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,5.57,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.8,70,,6.24,Percent of Total Billed Charges,70% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.14,100,,3.416,Percent of Total Billed Charges,100% of Total Billed Charges,1.56,158.16,
PENICIL V POT 250MG TAB,53090254,CDM,250,RC,,,Outpatient,,,1.87,1.12,,1.12,60,,0.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,158.36,32,,126.688,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,1.12,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,21.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,75,,2.296,Percent of Total Billed Charges,75% of Total Billed Charges,0.94,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.94,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,0.94,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,70,,1.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.87,100,,3.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,158.36,
PENTAZOCINE/NX 50MGTAB UD,53090635,CDM,250,RC,,,Outpatient,,,14.82,8.89,,8.89,60,,7.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.15,28,,3.32,Percent of Total Billed Charges,28% of Total Billed Charges,158.42,32,,126.736,Percent of Total Billed Charges,32% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,36,,4.272,Percent of Total Billed Charges,36% of Total Billed Charges,5.34,36,,4.272,Percent of Total Billed Charges,36% Total Bille Charges,5.34,36,,4.272,Percent of Total Billed Charges,36% of Total Billed Charges,8.89,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14.42,,15.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.12,75,,2.632,Percent of Total Billed Charges,75% of Total Billed Charges,7.41,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,7.41,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.41,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,7.41,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.37,70,,8.296,Percent of Total Billed Charges,70% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.07,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.82,100,,3.512,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,158.42,
PENTOXIFYLLINE 400MG TAB,53090668,CDM,250,RC,,,Outpatient,,,2.5,1.50,,1.5,60,,1.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,28,,0.56,Percent of Total Billed Charges,28% of Total Billed Charges,159.76,32,,127.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,36,,0.72,Percent of Total Billed Charges,36% of Total Billed Charges,0.9,36,,0.72,Percent of Total Billed Charges,36% Total Bille Charges,0.9,36,,0.72,Percent of Total Billed Charges,36% of Total Billed Charges,1.5,60,,76.912,Percent of Total Billed Charges,60% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14.42,,15.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.88,75,,42.024,Percent of Total Billed Charges,75% of Total Billed Charges,1.25,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,1.25,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.25,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,70,,1.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.5,100,,56.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,159.76,
PERPHENAZINE 2MG TAB,53091062,CDM,250,RC,,,Outpatient,,,3.93,2.36,,2.36,60,,1.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,159.87,32,,127.896,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.36,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,55.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,75,,2.872,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.75,70,,2.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.93,100,,3.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,159.87,
PILOCARPINE 5MG TAB,53091235,CDM,250,RC,,,Outpatient,,,7,4.20,,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,28,,1.568,Percent of Total Billed Charges,28% of Total Billed Charges,159.96,32,,127.968,Percent of Total Billed Charges,32% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% Total Bille Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,4.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14.42,,76.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,75,,5.52,Percent of Total Billed Charges,75% of Total Billed Charges,3.5,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,3.5,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.5,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,3.5,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,70,,3.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,100,,7.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,159.96,
PHENAZOPYRIDINE 100MG TAB,53091450,CDM,250,RC,,,Outpatient,,,1.95,1.17,,1.17,60,,0.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,28,,0.44,Percent of Total Billed Charges,28% of Total Billed Charges,1600,32,,1280,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.17,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,55.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,10.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,70,,1.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,100,,14.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1600,
PHENAZOPYRIDINE 200MG TAB,53091492,CDM,250,RC,,,Outpatient,,,3.81,2.29,,2.29,60,,1.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,28,,0.856,Percent of Total Billed Charges,28% of Total Billed Charges,1600,32,,1280,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,36,,1.096,Percent of Total Billed Charges,36% of Total Billed Charges,1.37,36,,1.096,Percent of Total Billed Charges,36% Total Bille Charges,1.37,36,,1.096,Percent of Total Billed Charges,36% of Total Billed Charges,2.29,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,56.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,75,,10.584,Percent of Total Billed Charges,75% of Total Billed Charges,1.91,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,1.91,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.91,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.67,70,,2.136,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.81,100,,14.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,1600,
PHENYTOIN 50MG TAB,53094348,CDM,250,RC,,,Outpatient,,,3.28,1.97,,1.97,60,,1.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,28,,0.736,Percent of Total Billed Charges,28% of Total Billed Charges,1615.73,32,,1292.584,Percent of Total Billed Charges,32% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% Total Bille Charges,1.18,36,,0.944,Percent of Total Billed Charges,36% of Total Billed Charges,1.97,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14.42,,56.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,75,,0.712,Percent of Total Billed Charges,75% of Total Billed Charges,1.64,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.3,70,,1.84,Percent of Total Billed Charges,70% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.28,100,,0.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,1615.73,
PHENYTOIN 100MG CAP,53094389,CDM,250,RC,,,Outpatient,,,1.49,0.89,,0.89,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,1615.8,32,,1292.64,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.89,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,131.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.12,75,,0.76,Percent of Total Billed Charges,75% of Total Billed Charges,0.75,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,70,,0.832,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,100,,1.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,1615.8,
PHYTONADIONE 5MG TAB,53094611,CDM,250,RC,,,Outpatient,,,117.52,70.51,,70.51,60,,56.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.91,28,,26.328,Percent of Total Billed Charges,28% of Total Billed Charges,1618.24,32,,1294.592,Percent of Total Billed Charges,32% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,42.31,36,,33.848,Percent of Total Billed Charges,36% of Total Billed Charges,42.31,36,,33.848,Percent of Total Billed Charges,36% Total Bille Charges,42.31,36,,33.848,Percent of Total Billed Charges,36% of Total Billed Charges,70.51,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.95,14.42,,698.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.14,75,,0.832,Percent of Total Billed Charges,75% of Total Billed Charges,58.76,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,58.76,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.76,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,58.76,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.26,70,,65.808,Percent of Total Billed Charges,70% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.52,100,,1.104,Percent of Total Billed Charges,100% of Total Billed Charges,16.45,1618.24,
PINDOLOL 5MG TAB,53094843,CDM,250,RC,,,Outpatient,,,2.2,1.32,,1.32,60,,1.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,28,,0.496,Percent of Total Billed Charges,28% of Total Billed Charges,1622.4,32,,1297.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% Total Bille Charges,0.79,36,,0.632,Percent of Total Billed Charges,36% of Total Billed Charges,1.32,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,698.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,75,,10.432,Percent of Total Billed Charges,75% of Total Billed Charges,1.1,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.1,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.1,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,70,,1.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,100,,13.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,1622.4,
PIOGLITAZONE 15 MG TAB,53095006,CDM,250,RC,,,Outpatient,,,2.24,1.34,,1.34,60,,1.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,28,,0.504,Percent of Total Billed Charges,28% of Total Billed Charges,1626.19,32,,1300.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% Total Bille Charges,0.81,36,,0.648,Percent of Total Billed Charges,36% of Total Billed Charges,1.34,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14.42,,95.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,75,,10.432,Percent of Total Billed Charges,75% of Total Billed Charges,1.12,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,1.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.12,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,70,,1.256,Percent of Total Billed Charges,70% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,100,,13.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,1626.19,
PIOGLITAZONE 30 MG TAB,53095022,CDM,250,RC,,,Outpatient,,,39.59,23.75,,23.75,60,,19,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.09,28,,8.872,Percent of Total Billed Charges,28% of Total Billed Charges,1631.52,32,,1305.216,Percent of Total Billed Charges,32% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.25,36,,11.4,Percent of Total Billed Charges,36% of Total Billed Charges,14.25,36,,11.4,Percent of Total Billed Charges,36% Total Bille Charges,14.25,36,,11.4,Percent of Total Billed Charges,36% of Total Billed Charges,23.75,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.71,14.42,,658.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,75,,10.432,Percent of Total Billed Charges,75% of Total Billed Charges,19.8,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.8,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.8,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,19.8,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.71,70,,22.168,Percent of Total Billed Charges,70% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.59,100,,13.912,Percent of Total Billed Charges,100% of Total Billed Charges,5.54,1631.52,
POT PHOS/SOD PHOS 500MG TAB,53096491,CDM,250,RC,,,Outpatient,,,0.89,0.53,,0.53,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,1635.87,32,,1308.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,368.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,75,,2.76,Percent of Total Billed Charges,75% of Total Billed Charges,0.45,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,70,,0.496,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,100,,3.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,1635.87,
POTASSIUM CL 10MEQ,53096574,CDM,258,RC,,,Outpatient,,,1.72,1.03,,1.03,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,1655.68,32,,1324.544,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,161.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,75,,0.28,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,70,,0.96,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,100,,0.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,1655.68,
POT CHL 20MEQ ER TAB,53096582,CDM,250,RC,,,Outpatient,,,1.36,0.82,,0.82,60,,0.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,28,,0.304,Percent of Total Billed Charges,28% of Total Billed Charges,1656.8,32,,1325.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% Total Bille Charges,0.49,36,,0.392,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,163.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.02,75,,4.24,Percent of Total Billed Charges,75% of Total Billed Charges,0.68,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,70,,0.76,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,100,,5.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,1656.8,
POT IODIDE ORAL SOLN 30ML,53096585,CDM,250,RC,,,Outpatient,,,22.96,13.78,,13.78,60,,11.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.43,28,,5.144,Percent of Total Billed Charges,28% of Total Billed Charges,1663.9,32,,1331.12,Percent of Total Billed Charges,32% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% of Total Billed Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% Total Bille Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% of Total Billed Charges,13.78,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14.42,,147.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.22,75,,9.424,Percent of Total Billed Charges,75% of Total Billed Charges,11.48,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,11.48,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.48,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,11.48,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.07,70,,12.856,Percent of Total Billed Charges,70% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.96,100,,12.56,Percent of Total Billed Charges,100% of Total Billed Charges,3.21,1663.9,
POTASSIUM CITR SA 540MG TAB,53096615,CDM,250,RC,,,Outpatient,,,2.54,1.52,,1.52,60,,1.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,28,,0.568,Percent of Total Billed Charges,28% of Total Billed Charges,1664,32,,1331.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% Total Bille Charges,0.91,36,,0.728,Percent of Total Billed Charges,36% of Total Billed Charges,1.52,60,,106.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14.42,,230.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,75,,1.432,Percent of Total Billed Charges,75% of Total Billed Charges,1.27,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.27,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.27,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,70,,1.424,Percent of Total Billed Charges,70% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.54,100,,1.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,1664,
PRAVASTATIN 20MG TAB,53096913,CDM,250,RC,,,Outpatient,,,1.71,1.03,,1.03,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,1664,32,,1331.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.03,60,,91.992,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,1379.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,75,,324.832,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,70,,0.96,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,100,,433.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,1664,
PRAMIPEXOLE 0.25MG TAB,53096921,CDM,250,RC,,,Outpatient,,,0.63,0.38,,0.38,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,1672.32,32,,1337.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,106.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,75,,80.824,Percent of Total Billed Charges,75% of Total Billed Charges,0.32,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,70,,0.352,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,100,,107.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,1672.32,
PRAMIPEXOLE 0.125MG TAB,53096939,CDM,250,RC,,,Outpatient,,,1.52,0.91,,0.91,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,1682.24,32,,1345.792,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,60,,265.344,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,106.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,70,,0.848,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.52,100,,0.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,1682.24,
PRAMIPEXOLE 1MG TAB,53096947,CDM,250,RC,,,Outpatient,,,2.06,1.24,,1.24,60,,0.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,28,,0.464,Percent of Total Billed Charges,28% of Total Billed Charges,1704.77,32,,1363.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% Total Bille Charges,0.74,36,,0.592,Percent of Total Billed Charges,36% of Total Billed Charges,1.24,60,,148.68,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,1347.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,1.03,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,70,,1.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.06,100,,0.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1704.77,
PRAZIQUANTEL 600MG TAB,53097150,CDM,250,RC,,,Outpatient,,,166.58,99.95,,99.95,60,,79.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.64,28,,37.312,Percent of Total Billed Charges,28% of Total Billed Charges,1704.77,32,,1363.816,Percent of Total Billed Charges,32% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,59.97,36,,47.976,Percent of Total Billed Charges,36% of Total Billed Charges,59.97,36,,47.976,Percent of Total Billed Charges,36% Total Bille Charges,59.97,36,,47.976,Percent of Total Billed Charges,36% of Total Billed Charges,99.95,60,,26.48,Percent of Total Billed Charges,60% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,24.02,14.42,,100.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.94,75,,0.216,Percent of Total Billed Charges,75% of Total Billed Charges,83.29,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,83.29,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.29,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,83.29,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.61,70,,93.288,Percent of Total Billed Charges,70% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,23.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.58,100,,0.288,Percent of Total Billed Charges,100% of Total Billed Charges,23.32,1704.77,
PRAZOSIN 1MG CAP,53097234,CDM,250,RC,,,Outpatient,,,3.62,2.17,,2.17,60,,1.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,28,,0.808,Percent of Total Billed Charges,28% of Total Billed Charges,1704.77,32,,1363.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% Total Bille Charges,1.3,36,,1.04,Percent of Total Billed Charges,36% of Total Billed Charges,2.17,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14.42,,55.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,1.81,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,1.81,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,1.81,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,70,,2.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.62,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,1704.77,
PREDNISOLONE 5MG TAB,53097549,CDM,250,RC,J7510,HCPCS,Outpatient,,,28.34,17.00,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,360,,,Fee Schedule,360% of BCBS POS Rate,0.19,360,,,Fee schedule,360% of BCBS PPO Rate,0.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,17,60,,1784.176,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,4.09,14.42,,863.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.26,75,,17.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,80,,272.984,Fee Schedule,80% of Scott and White EPO fee schedule,0.21,80,,833.216,Fee Schedule,80% of Scott and White HMO fee schedule,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,80,,833.216,Fee Schedule,80% of Scott and White PPO fee schedule,0.21,80,,26.496,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.84,70,,15.872,Percent of Total Billed Charges,70% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.34,100,,22.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,28.34,
PREDNISONE 1MG TAB,53097770,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,19.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,16.456,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,1003.144,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,66.888,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,66.888,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,44.608,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,21.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE SOL 5MG/5ML 1ML,53097840,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,12.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,833.216,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,99.976,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,99.976,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,61.888,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE TAB 10MG,53097841,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,51.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,66.888,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,138.192,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,138.192,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,0.008,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,0.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE TAB 20MG,53097842,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,16.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,1199.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,0.64,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,99.976,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,39.496,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,39.496,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,180.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,0.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE TAB 50MG,53097843,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,17.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,2.904,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,138.192,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,39.496,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,39.496,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,72,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE TAB 5MG,53097844,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,198.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,39.496,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,13.952,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,13.952,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,1.464,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,0.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREDNISONE 5MG TAB,53097853,CDM,250,RC,J7512,HCPCS,Outpatient,,,3.9,2.34,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,131.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,0.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,39.496,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,28.072,Fee Schedule,80% of Scott and White HMO fee schedule,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,80,,28.072,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,3.872,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,1.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,3.9,
PREGABALIN 25 MG CAP,53097952,CDM,250,RC,,,Outpatient,,,44.58,26.75,,26.75,60,,21.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.48,28,,9.984,Percent of Total Billed Charges,28% of Total Billed Charges,1708.43,32,,1366.744,Percent of Total Billed Charges,32% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,16.05,36,,12.84,Percent of Total Billed Charges,36% of Total Billed Charges,16.05,36,,12.84,Percent of Total Billed Charges,36% Total Bille Charges,16.05,36,,12.84,Percent of Total Billed Charges,36% of Total Billed Charges,26.75,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.43,14.42,,44.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.44,75,,0.456,Percent of Total Billed Charges,75% of Total Billed Charges,22.29,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,22.29,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.29,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,22.29,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.21,70,,24.968,Percent of Total Billed Charges,70% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,6.24,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.58,100,,0.608,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,1708.43,
PREGABALIN 50 MG CAP,53097960,CDM,250,RC,,,Outpatient,,,50.22,30.13,,30.13,60,,24.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.06,28,,11.248,Percent of Total Billed Charges,28% of Total Billed Charges,1708.43,32,,1366.744,Percent of Total Billed Charges,32% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,18.08,36,,14.464,Percent of Total Billed Charges,36% of Total Billed Charges,18.08,36,,14.464,Percent of Total Billed Charges,36% Total Bille Charges,18.08,36,,14.464,Percent of Total Billed Charges,36% of Total Billed Charges,30.13,60,,145.384,Percent of Total Billed Charges,60% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.24,14.42,,38.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.67,75,,5.248,Percent of Total Billed Charges,75% of Total Billed Charges,25.11,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,25.11,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.11,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,25.11,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.15,70,,28.12,Percent of Total Billed Charges,70% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.22,100,,6.992,Percent of Total Billed Charges,100% of Total Billed Charges,7.03,1708.43,
PREGABALIN 75 MG CAP,53097994,CDM,250,RC,,,Outpatient,,,49.02,29.41,,29.41,60,,23.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.73,28,,10.984,Percent of Total Billed Charges,28% of Total Billed Charges,1708.93,32,,1367.144,Percent of Total Billed Charges,32% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% of Total Billed Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% Total Bille Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% of Total Billed Charges,29.41,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.77,75,,0.584,Percent of Total Billed Charges,75% of Total Billed Charges,24.51,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,24.51,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.51,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,24.51,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.31,70,,27.448,Percent of Total Billed Charges,70% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.86,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.02,100,,0.776,Percent of Total Billed Charges,100% of Total Billed Charges,6.86,1708.93,
VITAMIN PRENATAL TAB,53098000,CDM,250,RC,,,Outpatient,,,1.79,1.07,,1.07,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,28,,0.4,Percent of Total Billed Charges,28% of Total Billed Charges,1708.93,32,,1367.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% Total Bille Charges,0.64,36,,0.512,Percent of Total Billed Charges,36% of Total Billed Charges,1.07,60,,265.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,7.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.9,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,70,,1,Percent of Total Billed Charges,70% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,100,,1.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,1708.93,
PRIMAQUINE PHOS 26.3MG TAB,53098091,CDM,250,RC,,,Outpatient,,,3.86,2.32,,2.32,60,,1.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,28,,0.864,Percent of Total Billed Charges,28% of Total Billed Charges,1709.76,32,,1367.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% of Total Billed Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% Total Bille Charges,1.39,36,,1.112,Percent of Total Billed Charges,36% of Total Billed Charges,2.32,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,457.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.9,75,,2.816,Percent of Total Billed Charges,75% of Total Billed Charges,1.93,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.93,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,1.93,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.7,70,,2.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,100,,3.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,1709.76,
PRIMIDONE 50MG TAB,53098208,CDM,250,RC,,,Outpatient,,,1.59,0.95,,0.95,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,1719.25,32,,1375.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% Total Bille Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,60,,41.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,11.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,75,,19.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.8,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,833.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,70,,0.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,100,,26.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,1719.25,
PROBENECID 500MG TAB,53098471,CDM,250,RC,,,Outpatient,,,1.66,1.00,,1,60,,0.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.75,45,,0.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,1725.31,32,,1380.248,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% of Total Billed Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% Total Bille Charges,0.6,36,,0.48,Percent of Total Billed Charges,36% of Total Billed Charges,1,60,,91.048,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,100,,1.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.25,75,,9.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.83,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,66.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,70,,0.928,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.66,100,,13.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,1725.31,
PROCHLORPERAZINE 10MG TAB,53099834,CDM,250,RC,,,Outpatient,,,1.94,1.16,,1.16,60,,0.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.87,45,,0.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,1726.4,32,,1381.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.16,60,,223.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,100,,1.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,0.704,Percent of Total Billed Charges,75% of Total Billed Charges,0.97,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,99.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,70,,1.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.94,100,,0.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1726.4,
ROFLUMILAST 500 MCG TAB,53100012,CDM,250,RC,,,Outpatient,,,23.36,14.02,,14.02,60,,11.216,Percent of Total Billed Charges,60% of Total Billed Charges,10.51,45,,8.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.54,28,,5.232,Percent of Total Billed Charges,28% of Total Billed Charges,1737.57,32,,1390.056,Percent of Total Billed Charges,32% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,8.41,36,,6.728,Percent of Total Billed Charges,36% of Total Billed Charges,8.41,36,,6.728,Percent of Total Billed Charges,36% Total Bille Charges,8.41,36,,6.728,Percent of Total Billed Charges,36% of Total Billed Charges,14.02,60,,346.92,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.36,100,,18.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.37,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.52,75,,1.376,Percent of Total Billed Charges,75% of Total Billed Charges,11.68,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.68,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.68,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,11.68,50,,138.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.35,70,,13.08,Percent of Total Billed Charges,70% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.36,100,,1.832,Percent of Total Billed Charges,100% of Total Billed Charges,3.27,1737.57,
ACETAMIN 160MG/5ML ELIX 20ML,53100020,CDM,250,RC,,,Outpatient,,,4.88,2.93,,2.93,60,,2.344,Percent of Total Billed Charges,60% of Total Billed Charges,2.2,45,,1.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,28,,1.096,Percent of Total Billed Charges,28% of Total Billed Charges,1740.29,32,,1392.232,Percent of Total Billed Charges,32% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,36,,1.408,Percent of Total Billed Charges,36% of Total Billed Charges,1.76,36,,1.408,Percent of Total Billed Charges,36% Total Bille Charges,1.76,36,,1.408,Percent of Total Billed Charges,36% of Total Billed Charges,2.93,60,,588.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,100,,3.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14.42,,254.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,75,,6.624,Percent of Total Billed Charges,75% of Total Billed Charges,2.44,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,70,,2.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.88,100,,8.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,1740.29,
MILK OF MAGNESIA 30ML,53100061,CDM,250,RC,,,Outpatient,,,4.68,2.81,,2.81,60,,2.248,Percent of Total Billed Charges,60% of Total Billed Charges,2.11,45,,1.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,28,,1.048,Percent of Total Billed Charges,28% of Total Billed Charges,1770.5,32,,1416.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% Total Bille Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,2.81,60,,1218.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,100,,3.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,75,,0.584,Percent of Total Billed Charges,75% of Total Billed Charges,2.34,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,2.34,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,2.34,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.28,70,,2.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,100,,0.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,1770.5,
POTASSIUM CL 10% 20MEQ/15ML PO,53100079,CDM,250,RC,,,Outpatient,,,9.03,5.42,,5.42,60,,4.336,Percent of Total Billed Charges,60% of Total Billed Charges,4.06,45,,3.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,28,,2.024,Percent of Total Billed Charges,28% of Total Billed Charges,1772.09,32,,1417.672,Percent of Total Billed Charges,32% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,3.25,36,,2.6,Percent of Total Billed Charges,36% of Total Billed Charges,3.25,36,,2.6,Percent of Total Billed Charges,36% Total Bille Charges,3.25,36,,2.6,Percent of Total Billed Charges,36% of Total Billed Charges,5.42,60,,3397.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.03,100,,7.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.77,75,,0.888,Percent of Total Billed Charges,75% of Total Billed Charges,4.52,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,4.52,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,4.52,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,70,,5.056,Percent of Total Billed Charges,70% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.03,100,,1.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,1772.09,
POT CHL 10% LIQ 30ML,53100087,CDM,250,RC,,,Outpatient,,,10.27,6.16,,6.16,60,,4.928,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,45,,3.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,28,,2.304,Percent of Total Billed Charges,28% of Total Billed Charges,1772.16,32,,1417.728,Percent of Total Billed Charges,32% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% of Total Billed Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% Total Bille Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% of Total Billed Charges,6.16,60,,32.072,Percent of Total Billed Charges,60% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.27,100,,8.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14.42,,784.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.7,75,,45.904,Percent of Total Billed Charges,75% of Total Billed Charges,5.14,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,5.14,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.14,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,5.14,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.19,70,,5.752,Percent of Total Billed Charges,70% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.27,100,,61.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.44,1772.16,
PROGESTERONE 100 MG CAP,53100301,CDM,250,RC,,,Outpatient,,,2.1,1.26,,1.26,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,1784.64,32,,1427.712,Percent of Total Billed Charges,32% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,1.26,60,,47.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.1,100,,1.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,1.05,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.05,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,70,,1.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.29,1784.64,
PROMETHAZINE 25MG TAB,53100681,CDM,250,RC,,,Outpatient,,,1.2,0.72,,0.72,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,1794.67,32,,1435.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% Total Bille Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,70,,0.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1794.67,
PROPAFENONE 150MG TAB,53100905,CDM,250,RC,,,Outpatient,,,1.39,0.83,,0.83,60,,0.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.63,45,,0.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,28,,0.312,Percent of Total Billed Charges,28% of Total Billed Charges,1794.67,32,,1435.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% of Total Billed Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% Total Bille Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% of Total Billed Charges,0.83,60,,91.432,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.39,100,,1.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,152.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,75,,0.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.7,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.7,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,0.7,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,70,,0.776,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.39,100,,0.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,1794.67,
PROPAFENONE SR 225 MG CAP,53100939,CDM,250,RC,,,Outpatient,,,19.41,11.65,,11.65,60,,9.32,Percent of Total Billed Charges,60% of Total Billed Charges,8.73,45,,6.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.43,28,,4.344,Percent of Total Billed Charges,28% of Total Billed Charges,1799.02,32,,1439.216,Percent of Total Billed Charges,32% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.99,36,,5.592,Percent of Total Billed Charges,36% of Total Billed Charges,6.99,36,,5.592,Percent of Total Billed Charges,36% Total Bille Charges,6.99,36,,5.592,Percent of Total Billed Charges,36% of Total Billed Charges,11.65,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.41,100,,15.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.8,14.42,,153.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.56,75,,8.44,Percent of Total Billed Charges,75% of Total Billed Charges,9.71,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,9.71,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.71,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,9.71,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.59,70,,10.872,Percent of Total Billed Charges,70% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.41,100,,11.248,Percent of Total Billed Charges,100% of Total Billed Charges,2.72,1799.02,
PROPAFENONE SR 325 MG CAP,53100947,CDM,250,RC,,,Outpatient,,,19.56,11.74,,11.74,60,,9.392,Percent of Total Billed Charges,60% of Total Billed Charges,8.8,45,,7.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.48,28,,4.384,Percent of Total Billed Charges,28% of Total Billed Charges,1803.52,32,,1442.816,Percent of Total Billed Charges,32% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.04,36,,5.632,Percent of Total Billed Charges,36% of Total Billed Charges,7.04,36,,5.632,Percent of Total Billed Charges,36% Total Bille Charges,7.04,36,,5.632,Percent of Total Billed Charges,36% of Total Billed Charges,11.74,60,,189.144,Percent of Total Billed Charges,60% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.56,100,,15.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.67,75,,9.752,Percent of Total Billed Charges,75% of Total Billed Charges,9.78,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,9.78,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.78,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,9.78,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,70,,10.952,Percent of Total Billed Charges,70% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,2.74,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.56,100,,13,Percent of Total Billed Charges,100% of Total Billed Charges,2.74,1803.52,
DIATRIZOATE 18% 300 ML,53101380,CDM,255,RC,Q9965,HCPCS,Outpatient,,,194.22,116.53,,0.82,100,,,Case Rate,Pays based on per visit rate,87.4,45,,69.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,360,,,Fee Schedule,360% of BCBS POS Rate,0.67,360,,,Fee schedule,360% of BCBS PPO Rate,0.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.53,60,,38.504,Percent of Total Billed Charges,60% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.22,100,,155.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,28.01,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.38,80,,5.848,Percent of Total Billed Charges,80% of Total Billed Charges,1.23,80,,4.832,Fee Schedule,80% of Scott and White EPO fee schedule,1.23,80,,7.488,Fee Schedule,80% of Scott and White HMO fee schedule,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,80,,7.488,Fee Schedule,80% of Scott and White PPO fee schedule,1.23,80,,56,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.95,70,,108.76,Percent of Total Billed Charges,70% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.22,100,,7.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,194.22,
MYCOPHENOLATE SOD 360MG TAB,53101383,CDM,250,RC,J7518,HCPCS,Outpatient,,,62.44,37.46,,1.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.1,45,,22.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,360,,,Fee Schedule,360% of BCBS POS Rate,1.97,360,,,Fee schedule,360% of BCBS PPO Rate,1.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.46,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.44,100,,49.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,9,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.83,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,0.51,80,,24.352,Fee Schedule,80% of Scott and White EPO fee schedule,0.51,80,,47.168,Fee Schedule,80% of Scott and White HMO fee schedule,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,80,,47.168,Fee Schedule,80% of Scott and White PPO fee schedule,0.51,80,,0.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.71,70,,34.968,Percent of Total Billed Charges,70% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.44,100,,0.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,62.44,
VANCOMYCIN 750MG VIAL,53101384,CDM,250,RC,J3370,HCPCS,Outpatient,,,75.93,45.56,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.17,45,,27.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,45.56,60,,295.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.93,100,,60.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.95,75,,4.12,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,7.488,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,58.56,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,58.56,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,0.384,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.15,70,,42.52,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.93,100,,5.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,75.93,
VANCOMYCIN 1GM/NS 1000ML IRR,53101385,CDM,250,RC,J3370,HCPCS,Outpatient,,,102,61.20,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,45.9,45,,36.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,61.2,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102,100,,81.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,47.168,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,6.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,6.2,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,5.856,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.4,70,,57.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102,100,,3.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,102,
CARBAMAZEPINE SA 100MG TAB UD,53101387,CDM,250,RC,,,Outpatient,,,2.29,1.37,,1.37,60,,1.096,Percent of Total Billed Charges,60% of Total Billed Charges,1.03,45,,0.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,28,,0.512,Percent of Total Billed Charges,28% of Total Billed Charges,1813.93,32,,1451.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% Total Bille Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,1.37,60,,33.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.29,100,,1.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14.42,,30.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,75,,0.024,Percent of Total Billed Charges,75% of Total Billed Charges,1.15,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,70,,1.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.29,100,,0.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,1813.93,
NEO GENTAMICIN 2 MG/ML INJ,53101389,CDM,250,RC,J1580,HCPCS,Outpatient,,,20.5,12.30,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.23,45,,7.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.3,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,100,,16.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.38,75,,0.904,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,6.2,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,1.336,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,1.336,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,1.48,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.35,70,,11.48,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,100,,1.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,20.5,
CYSTOGRAFIN BOTTLE 300ML,53101391,CDM,255,RC,Q9958,HCPCS,Outpatient,,,194.22,116.53,,0.07,100,,,Case Rate,Pays based on per visit rate,87.4,45,,69.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.53,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.22,100,,155.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,28.01,14.42,,42.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.38,80,,2.856,Percent of Total Billed Charges,80% of Total Billed Charges,0.06,80,,284.616,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,3.28,Fee Schedule,80% of Scott and White HMO fee schedule,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,80,,3.28,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,35.496,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.95,70,,108.76,Percent of Total Billed Charges,70% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,27.19,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.22,100,,3.808,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,194.22,
OCTREOTIDE 0.1MG/ML INJ 1ML,53101392,CDM,250,RC,J2354,HCPCS,Outpatient,,,56.66,34.00,,0.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.5,45,,20.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.62,360,,,Fee Schedule,360% of BCBS POS Rate,0.62,360,,,Fee schedule,360% of BCBS PPO Rate,0.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,34,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.66,100,,45.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,75,,9.28,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,80,,1.336,Fee Schedule,80% of Scott and White EPO fee schedule,0.92,80,,3.28,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,80,,3.28,Fee Schedule,80% of Scott and White PPO fee schedule,0.92,80,,6.52,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.66,70,,31.728,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.66,100,,12.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,56.66,
BARIUM 2% READICAT BANAN 450ML,53101394,CDM,255,RC,,,Outpatient,,,24.23,14.54,,14.54,60,,11.632,Percent of Total Billed Charges,60% of Total Billed Charges,10.9,45,,8.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,28,,5.424,Percent of Total Billed Charges,28% of Total Billed Charges,1826.24,32,,1460.992,Percent of Total Billed Charges,32% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% Total Bille Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,14.54,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.23,100,,19.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.49,14.42,,45.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,80,,10.016,Percent of Total Billed Charges,80% of Total Billed Charges,12.12,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,12.12,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.12,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,12.12,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.96,70,,13.568,Percent of Total Billed Charges,70% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.23,100,,13.352,Percent of Total Billed Charges,100% of Total Billed Charges,3.39,1826.24,
MULTIVITAMIN W/FE DROPS 1ML,53101397,CDM,250,RC,,,Outpatient,,,0.17,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,1826.24,32,,1460.992,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,100,,0.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,29.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,75,,0.92,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,70,,0.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,100,,1.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1826.24,
NEO MORPHINE 2MG/ML ORAL SOL,53101398,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,1828.16,32,,1462.528,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,124.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,39.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,7.864,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,10.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,1828.16,
HURRICAINE SPRAY 2OZ,53101399,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,100.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,1.56,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,2.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
LIDOCAINE INJ 1% 2ML SDV,53101400,CDM,250,RC,,,Outpatient,,,12.24,7.34,,7.34,60,,5.872,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,45,,4.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.43,28,,2.744,Percent of Total Billed Charges,28% of Total Billed Charges,1829.12,32,,1463.296,Percent of Total Billed Charges,32% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.41,36,,3.528,Percent of Total Billed Charges,36% of Total Billed Charges,4.41,36,,3.528,Percent of Total Billed Charges,36% Total Bille Charges,4.41,36,,3.528,Percent of Total Billed Charges,36% of Total Billed Charges,7.34,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.24,100,,9.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14.42,,84.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.18,75,,14.56,Percent of Total Billed Charges,75% of Total Billed Charges,6.12,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,6.12,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,6.12,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.57,70,,6.856,Percent of Total Billed Charges,70% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.24,100,,19.416,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,1829.12,
LACTOBACILLUS CAP,53101401,CDM,250,RC,,,Outpatient,,,2.12,1.27,,1.27,60,,1.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,28,,0.472,Percent of Total Billed Charges,28% of Total Billed Charges,1846.88,32,,1477.504,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% Total Bille Charges,0.76,36,,0.608,Percent of Total Billed Charges,36% of Total Billed Charges,1.27,60,,125.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.12,100,,1.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,16.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,75,,17.296,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,70,,1.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,100,,23.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,1846.88,
MIDAZOLAM HCL 50MG/10ML INJ,53101402,CDM,250,RC,J2250,HCPCS,Outpatient,,,49.67,29.80,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.35,45,,17.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,29.8,60,,119.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.67,100,,39.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.25,75,,13.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,5.088,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,2.336,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,2.336,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,47.168,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.77,70,,27.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.67,100,,18.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,49.67,
FENOFIBRATE 160 MG TAB,53101403,CDM,250,RC,,,Outpatient,,,8.11,4.87,,4.87,60,,3.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.65,45,,2.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,28,,1.816,Percent of Total Billed Charges,28% of Total Billed Charges,1849.06,32,,1479.248,Percent of Total Billed Charges,32% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,36,,2.336,Percent of Total Billed Charges,36% of Total Billed Charges,2.92,36,,2.336,Percent of Total Billed Charges,36% Total Bille Charges,2.92,36,,2.336,Percent of Total Billed Charges,36% of Total Billed Charges,4.87,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.11,100,,6.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.08,75,,3.712,Percent of Total Billed Charges,75% of Total Billed Charges,4.06,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,4.06,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.06,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,4.06,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.68,70,,4.544,Percent of Total Billed Charges,70% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.11,100,,4.952,Percent of Total Billed Charges,100% of Total Billed Charges,1.14,1849.06,
NEO AMPICILLIN 100 MG/ML INJ,53101404,CDM,250,RC,J0290,HCPCS,Outpatient,,,26.14,15.68,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.76,45,,9.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.68,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.14,100,,20.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.61,75,,0.288,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,2.336,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,227.304,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,227.304,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,6.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.3,70,,14.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.14,100,,0.384,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,26.14,
NEOSTIGMINE 1MG/ML 10ML VL,53101407,CDM,250,RC,J2710,HCPCS,Outpatient,,,442.75,265.65,,0.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,199.24,45,,159.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.9,360,,,Fee Schedule,360% of BCBS POS Rate,0.9,360,,,Fee schedule,360% of BCBS PPO Rate,0.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,265.65,60,,614.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.75,100,,354.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.06,75,,0.208,Percent of Total Billed Charges,75% of Total Billed Charges,221.38,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,221.38,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.38,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,221.38,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.93,70,,247.944,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.75,100,,0.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,442.75,
NS 500ML INJ,53101408,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,1852.2,32,,1481.76,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,214.48,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,116.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,0.536,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,1.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,0.712,Percent of Total Billed Charges,100% of Total Billed Charges,7,1852.2,
NIACIN ER 500 MG CPL,53101409,CDM,250,RC,,,Outpatient,,,0.07,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,45,,0.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,1852.2,32,,1481.76,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,406.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,100,,0.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,25.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,0.704,Percent of Total Billed Charges,75% of Total Billed Charges,0.04,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,70,,0.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,100,,0.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1852.2,
IOPAMIDOL 61% 15 ML INJ SDV,53101415,CDM,255,RC,Q9967,HCPCS,Outpatient,,,386.41,231.85,,0.12,100,,,Case Rate,Pays based on per visit rate,173.88,45,,139.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,231.85,60,,250.384,Percent of Total Billed Charges,60% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.41,100,,309.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.72,14.42,,19.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.13,80,,6.944,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,9.672,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,13.656,Fee Schedule,80% of Scott and White HMO fee schedule,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,13.656,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,3.28,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.49,70,,216.392,Percent of Total Billed Charges,70% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,54.1,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.41,100,,9.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,386.41,
LIDOCAINE VIS 2% SOL UD 15ML,53101430,CDM,250,RC,,,Outpatient,,,0.12,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,1852.78,32,,1482.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,100,,0.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,42.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,75,,1.936,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,100,,2.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1852.78,
PROPRANOLOL 10MG TAB,53101994,CDM,250,RC,,,Outpatient,,,0.68,0.41,,0.41,60,,0.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.31,45,,0.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,28,,0.152,Percent of Total Billed Charges,28% of Total Billed Charges,1872,32,,1497.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% Total Bille Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.41,60,,49.008,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,100,,0.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,61.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,75,,8.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.34,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,70,,0.384,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,100,,11.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1872,
PROPRANOLOL 40MG TAB,53102034,CDM,250,RC,,,Outpatient,,,1.43,0.86,,0.86,60,,0.688,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,45,,0.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,28,,0.32,Percent of Total Billed Charges,28% of Total Billed Charges,1881.19,32,,1504.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% Total Bille Charges,0.51,36,,0.408,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,60,,292.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,100,,1.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.72,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,0.72,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.72,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.72,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,70,,0.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,1881.19,
PROPRANOLOL LA 60MG CAP,53102083,CDM,250,RC,,,Outpatient,,,4.12,2.47,,2.47,60,,1.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.85,45,,1.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,28,,0.92,Percent of Total Billed Charges,28% of Total Billed Charges,1885.44,32,,1508.352,Percent of Total Billed Charges,32% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% Total Bille Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,2.47,60,,977.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,100,,3.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14.42,,30.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.09,75,,0.328,Percent of Total Billed Charges,75% of Total Billed Charges,2.06,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.06,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,70,,2.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.12,100,,0.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,1885.44,
PROPRANOLOL LA 80MG CAP,53102109,CDM,250,RC,,,Outpatient,,,41.31,24.79,,24.79,60,,19.832,Percent of Total Billed Charges,60% of Total Billed Charges,18.59,45,,14.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.57,28,,9.256,Percent of Total Billed Charges,28% of Total Billed Charges,1887.28,32,,1509.824,Percent of Total Billed Charges,32% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,14.87,36,,11.896,Percent of Total Billed Charges,36% of Total Billed Charges,14.87,36,,11.896,Percent of Total Billed Charges,36% Total Bille Charges,14.87,36,,11.896,Percent of Total Billed Charges,36% of Total Billed Charges,24.79,60,,408.84,Percent of Total Billed Charges,60% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.31,100,,33.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14.42,,20.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.98,75,,0.44,Percent of Total Billed Charges,75% of Total Billed Charges,20.66,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.66,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.92,70,,23.136,Percent of Total Billed Charges,70% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.31,100,,0.584,Percent of Total Billed Charges,100% of Total Billed Charges,5.78,1887.28,
PROPYLTHIOURACIL 50MG TAB,53102166,CDM,250,RC,,,Outpatient,,,3.54,2.12,,2.12,60,,1.696,Percent of Total Billed Charges,60% of Total Billed Charges,1.59,45,,1.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.99,28,,0.792,Percent of Total Billed Charges,28% of Total Billed Charges,1.61,32,,1.288,Percent of Total Billed Charges,32% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,36,,1.016,Percent of Total Billed Charges,36% of Total Billed Charges,1.27,36,,1.016,Percent of Total Billed Charges,36% Total Bille Charges,1.27,36,,1.016,Percent of Total Billed Charges,36% of Total Billed Charges,2.12,60,,497.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,100,,2.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14.42,,28.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,75,,3.056,Percent of Total Billed Charges,75% of Total Billed Charges,1.77,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,1.77,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,1.77,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.48,70,,1.984,Percent of Total Billed Charges,70% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.54,100,,4.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.5,3.54,
PSEUDOEPHEDRINE SA 120MG TAB,53102620,CDM,250,RC,,,Outpatient,,,1.83,1.10,,1.1,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,45,,0.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,28,,0.408,Percent of Total Billed Charges,28% of Total Billed Charges,1.62,32,,1.296,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.1,60,,497.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,100,,1.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14.42,,44.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,75,,0.232,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.28,70,,1.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,100,,0.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,1.83,
PSEUDOEPHEDRINE 30MG TAB,53102661,CDM,250,RC,,,Outpatient,,,1.05,0.63,,0.63,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,45,,0.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,28,,0.232,Percent of Total Billed Charges,28% of Total Billed Charges,1.62,32,,1.296,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% Total Bille Charges,0.38,36,,0.304,Percent of Total Billed Charges,36% of Total Billed Charges,0.63,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.05,100,,0.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.79,75,,1.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,70,,0.592,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,100,,1.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,1.62,
PYRAZINAMIDE TAB 500MG,53102950,CDM,250,RC,,,Outpatient,,,11.82,7.09,,7.09,60,,5.672,Percent of Total Billed Charges,60% of Total Billed Charges,5.32,45,,4.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.31,28,,2.648,Percent of Total Billed Charges,28% of Total Billed Charges,1.63,32,,1.304,Percent of Total Billed Charges,32% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.26,36,,3.408,Percent of Total Billed Charges,36% of Total Billed Charges,4.26,36,,3.408,Percent of Total Billed Charges,36% Total Bille Charges,4.26,36,,3.408,Percent of Total Billed Charges,36% of Total Billed Charges,7.09,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,100,,9.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14.42,,25.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.87,75,,8.72,Percent of Total Billed Charges,75% of Total Billed Charges,5.91,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,5.91,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.91,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,5.91,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.27,70,,6.616,Percent of Total Billed Charges,70% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.82,100,,11.624,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,11.82,
PYRIDOSTIGMINE TAB 60MG,53102976,CDM,250,RC,,,Outpatient,,,0.28,0.17,,0.17,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,45,,0.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,1.65,32,,1.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,60,,44.688,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,100,,0.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,208.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,75,,11.28,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,70,,0.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,100,,15.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,1.65,
PYRIDOXINE 50MG TAB,53103289,CDM,250,RC,,,Outpatient,,,0.06,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,45,,0.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,1.66,32,,1.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,43.224,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,100,,0.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,14.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,4.984,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,70,,0.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,100,,6.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,1.66,
PYRIDOXINE100MG+,53103321,CDM,250,RC,,,Outpatient,,,8.25,4.95,,4.95,60,,3.96,Percent of Total Billed Charges,60% of Total Billed Charges,3.71,45,,2.968,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.31,28,,1.848,Percent of Total Billed Charges,28% of Total Billed Charges,1.66,32,,1.328,Percent of Total Billed Charges,32% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,36,,2.376,Percent of Total Billed Charges,36% of Total Billed Charges,2.97,36,,2.376,Percent of Total Billed Charges,36% Total Bille Charges,2.97,36,,2.376,Percent of Total Billed Charges,36% of Total Billed Charges,4.95,60,,38.688,Percent of Total Billed Charges,60% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.25,100,,6.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14.42,,14.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,75,,1.296,Percent of Total Billed Charges,75% of Total Billed Charges,4.13,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.13,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.13,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,4.13,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.78,70,,4.624,Percent of Total Billed Charges,70% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.25,100,,1.728,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,8.25,
QUETIAPINE 25MG TAB,53103701,CDM,250,RC,,,Outpatient,,,0.71,0.43,,0.43,60,,0.344,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,45,,0.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,1.66,32,,1.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,60,,251.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,100,,0.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,27.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,0.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.36,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,70,,0.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,100,,1.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,1.66,
QUETIAPINE 100MG TAB,53103719,CDM,250,RC,,,Outpatient,,,1.22,0.73,,0.73,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,45,,0.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,1.66,32,,1.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.73,60,,137.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,100,,0.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,27.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,75,,51.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,70,,0.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,100,,68.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,1.66,
QUINAPRIL 10MG TAB,53103982,CDM,250,RC,,,Outpatient,,,0.41,0.25,,0.25,60,,0.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,45,,0.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,1.67,32,,1.336,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% Total Bille Charges,0.15,36,,0.12,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,60,,123.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,100,,0.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,18.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,75,,6.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.29,70,,0.232,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,100,,8.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,1.67,
QUININE SULF 325MG CAP,53104857,CDM,250,RC,,,Outpatient,,,13.47,8.08,,8.08,60,,6.464,Percent of Total Billed Charges,60% of Total Billed Charges,6.06,45,,4.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.77,28,,3.016,Percent of Total Billed Charges,28% of Total Billed Charges,1.67,32,,1.336,Percent of Total Billed Charges,32% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,36,,3.88,Percent of Total Billed Charges,36% of Total Billed Charges,4.85,36,,3.88,Percent of Total Billed Charges,36% Total Bille Charges,4.85,36,,3.88,Percent of Total Billed Charges,36% of Total Billed Charges,8.08,60,,115.856,Percent of Total Billed Charges,60% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.47,100,,10.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14.42,,51.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.1,75,,5.584,Percent of Total Billed Charges,75% of Total Billed Charges,6.74,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,6.74,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.74,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,6.74,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.43,70,,7.544,Percent of Total Billed Charges,70% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.47,100,,7.44,Percent of Total Billed Charges,100% of Total Billed Charges,1.67,13.47,
RALOXIFENE 60MG TAB,53104873,CDM,250,RC,,,Outpatient,,,13.91,8.35,,8.35,60,,6.68,Percent of Total Billed Charges,60% of Total Billed Charges,6.26,45,,5.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.89,28,,3.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.68,32,,1.344,Percent of Total Billed Charges,32% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,5.01,36,,4.008,Percent of Total Billed Charges,36% of Total Billed Charges,5.01,36,,4.008,Percent of Total Billed Charges,36% Total Bille Charges,5.01,36,,4.008,Percent of Total Billed Charges,36% of Total Billed Charges,8.35,60,,95.848,Percent of Total Billed Charges,60% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.91,100,,11.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.01,14.42,,103.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.43,75,,0.992,Percent of Total Billed Charges,75% of Total Billed Charges,6.96,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,6.96,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.96,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,6.96,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.74,70,,7.792,Percent of Total Billed Charges,70% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.91,100,,1.32,Percent of Total Billed Charges,100% of Total Billed Charges,1.68,13.91,
RAMELTEON 8 MG TAB,53104881,CDM,250,RC,,,Outpatient,,,25.18,15.11,,15.11,60,,12.088,Percent of Total Billed Charges,60% of Total Billed Charges,11.33,45,,9.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.05,28,,5.64,Percent of Total Billed Charges,28% of Total Billed Charges,1.68,32,,1.344,Percent of Total Billed Charges,32% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,9.06,36,,7.248,Percent of Total Billed Charges,36% of Total Billed Charges,9.06,36,,7.248,Percent of Total Billed Charges,36% Total Bille Charges,9.06,36,,7.248,Percent of Total Billed Charges,36% of Total Billed Charges,15.11,60,,81.752,Percent of Total Billed Charges,60% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.18,100,,20.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.63,14.42,,38.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.89,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,12.59,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,12.59,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.59,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,12.59,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.63,70,,14.104,Percent of Total Billed Charges,70% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.53,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.18,100,,1.56,Percent of Total Billed Charges,100% of Total Billed Charges,1.68,25.18,
RAMIPRIL 1.25MG CAP,53104899,CDM,250,RC,,,Outpatient,,,3.92,2.35,,2.35,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,1.69,32,,1.352,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.35,60,,65.432,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.92,100,,3.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,33.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,75,,0.928,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,70,,2.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.92,100,,1.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,3.92,
RAMIPRIL 2.5MG CAP,53104907,CDM,250,RC,,,Outpatient,,,0.5,0.30,,0.3,60,,0.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,1.72,32,,1.376,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,60,,53.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,100,,0.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,38.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,75,,1.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.25,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,70,,0.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,100,,2.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,1.72,
RAMIPRIL 5MG CAP,53104915,CDM,250,RC,,,Outpatient,,,0.65,0.39,,0.39,60,,0.312,Percent of Total Billed Charges,60% of Total Billed Charges,0.29,45,,0.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,1.73,32,,1.384,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,100,,0.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,68.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,75,,0.992,Percent of Total Billed Charges,75% of Total Billed Charges,0.33,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,70,,0.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,100,,1.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,1.73,
RANOLAZINE 500 MG TAB,53105201,CDM,250,RC,,,Outpatient,,,11.9,7.14,,7.14,60,,5.712,Percent of Total Billed Charges,60% of Total Billed Charges,5.36,45,,4.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.33,28,,2.664,Percent of Total Billed Charges,28% of Total Billed Charges,1.76,32,,1.408,Percent of Total Billed Charges,32% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,4.28,36,,3.424,Percent of Total Billed Charges,36% of Total Billed Charges,4.28,36,,3.424,Percent of Total Billed Charges,36% Total Bille Charges,4.28,36,,3.424,Percent of Total Billed Charges,36% of Total Billed Charges,7.14,60,,50.152,Percent of Total Billed Charges,60% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,100,,9.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.93,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,5.95,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,5.95,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.95,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,5.95,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.33,70,,6.664,Percent of Total Billed Charges,70% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.9,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.67,11.9,
REPAGLINIDE 0.5MG TAB,53105525,CDM,250,RC,,,Outpatient,,,6.66,4.00,,4,60,,3.2,Percent of Total Billed Charges,60% of Total Billed Charges,3,45,,2.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.86,28,,1.488,Percent of Total Billed Charges,28% of Total Billed Charges,1.77,32,,1.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% Total Bille Charges,2.4,36,,1.92,Percent of Total Billed Charges,36% of Total Billed Charges,4,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.66,100,,5.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14.42,,3.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,75,,0.168,Percent of Total Billed Charges,75% of Total Billed Charges,3.33,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,3.33,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.33,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,3.33,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,70,,3.728,Percent of Total Billed Charges,70% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.66,100,,0.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,6.66,
RIFABUTIN 150MG CAP,53106209,CDM,250,RC,,,Outpatient,,,35.49,21.29,,21.29,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,15.97,45,,12.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.94,28,,7.952,Percent of Total Billed Charges,28% of Total Billed Charges,1.77,32,,1.416,Percent of Total Billed Charges,32% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,12.78,36,,10.224,Percent of Total Billed Charges,36% of Total Billed Charges,12.78,36,,10.224,Percent of Total Billed Charges,36% Total Bille Charges,12.78,36,,10.224,Percent of Total Billed Charges,36% of Total Billed Charges,21.29,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.49,100,,28.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.12,14.42,,3.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.62,75,,2.48,Percent of Total Billed Charges,75% of Total Billed Charges,17.75,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,17.75,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.75,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,17.75,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.84,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.49,100,,3.304,Percent of Total Billed Charges,100% of Total Billed Charges,1.77,35.49,
RIFAXIMIN 550 MG TAB,53106241,CDM,250,RC,,,Outpatient,,,71.19,42.71,,42.71,60,,34.168,Percent of Total Billed Charges,60% of Total Billed Charges,32.04,45,,25.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.93,28,,15.944,Percent of Total Billed Charges,28% of Total Billed Charges,1.78,32,,1.424,Percent of Total Billed Charges,32% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,25.63,36,,20.504,Percent of Total Billed Charges,36% of Total Billed Charges,25.63,36,,20.504,Percent of Total Billed Charges,36% Total Bille Charges,25.63,36,,20.504,Percent of Total Billed Charges,36% of Total Billed Charges,42.71,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.19,100,,56.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,10.27,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.39,75,,14.824,Percent of Total Billed Charges,75% of Total Billed Charges,35.6,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,35.6,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.6,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,35.6,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.83,70,,39.864,Percent of Total Billed Charges,70% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,9.97,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.19,100,,19.76,Percent of Total Billed Charges,100% of Total Billed Charges,1.78,71.19,
RIFAXIMIN 200 MG TAB,53106258,CDM,250,RC,,,Outpatient,,,37.59,22.55,,22.55,60,,18.04,Percent of Total Billed Charges,60% of Total Billed Charges,16.92,45,,13.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.53,28,,8.424,Percent of Total Billed Charges,28% of Total Billed Charges,1.79,32,,1.432,Percent of Total Billed Charges,32% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.53,36,,10.824,Percent of Total Billed Charges,36% of Total Billed Charges,13.53,36,,10.824,Percent of Total Billed Charges,36% Total Bille Charges,13.53,36,,10.824,Percent of Total Billed Charges,36% of Total Billed Charges,22.55,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.59,100,,30.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.42,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.19,75,,6.44,Percent of Total Billed Charges,75% of Total Billed Charges,18.8,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.31,70,,21.048,Percent of Total Billed Charges,70% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.26,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.59,100,,8.584,Percent of Total Billed Charges,100% of Total Billed Charges,1.79,37.59,
RIBAVIRIN 200MG CAP,53106308,CDM,250,RC,,,Outpatient,,,4.27,2.56,,2.56,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,1.92,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,28,,0.96,Percent of Total Billed Charges,28% of Total Billed Charges,1.8,32,,1.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,1.54,36,,1.232,Percent of Total Billed Charges,36% of Total Billed Charges,1.54,36,,1.232,Percent of Total Billed Charges,36% Total Bille Charges,1.54,36,,1.232,Percent of Total Billed Charges,36% of Total Billed Charges,2.56,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,3.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14.42,,4.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,75,,2.776,Percent of Total Billed Charges,75% of Total Billed Charges,2.14,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,2.14,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.14,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,2.14,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.99,70,,2.392,Percent of Total Billed Charges,70% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.27,100,,3.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,4.27,
RIFAMPIN 300MG CAP,53106373,CDM,250,RC,,,Outpatient,,,3.82,2.29,,2.29,60,,1.832,Percent of Total Billed Charges,60% of Total Billed Charges,1.72,45,,1.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,28,,0.856,Percent of Total Billed Charges,28% of Total Billed Charges,1.83,32,,1.464,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% Total Bille Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,2.29,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,100,,3.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,6.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.87,75,,0.032,Percent of Total Billed Charges,75% of Total Billed Charges,1.91,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,1.91,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.91,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.67,70,,2.136,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.82,100,,0.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,3.82,
RIFAMPIN 150MG CAP,53106375,CDM,250,RC,,,Outpatient,,,4.39,2.63,,2.63,60,,2.104,Percent of Total Billed Charges,60% of Total Billed Charges,1.98,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,28,,0.984,Percent of Total Billed Charges,28% of Total Billed Charges,1.87,32,,1.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% Total Bille Charges,1.58,36,,1.264,Percent of Total Billed Charges,36% of Total Billed Charges,2.63,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.39,100,,3.512,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,9.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.29,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,2.2,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,2.2,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,2.2,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.07,70,,2.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.39,100,,0.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,4.39,
RILPIVIRINE 25 MG TAB,53106450,CDM,250,RC,,,Outpatient,,,70.04,42.02,,42.02,60,,33.616,Percent of Total Billed Charges,60% of Total Billed Charges,31.52,45,,25.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.61,28,,15.688,Percent of Total Billed Charges,28% of Total Billed Charges,1.87,32,,1.496,Percent of Total Billed Charges,32% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,25.21,36,,20.168,Percent of Total Billed Charges,36% of Total Billed Charges,25.21,36,,20.168,Percent of Total Billed Charges,36% Total Bille Charges,25.21,36,,20.168,Percent of Total Billed Charges,36% of Total Billed Charges,42.02,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.04,100,,56.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,10.1,14.42,,11.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.53,75,,1.648,Percent of Total Billed Charges,75% of Total Billed Charges,35.02,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,35.02,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.02,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,35.02,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.03,70,,39.224,Percent of Total Billed Charges,70% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.04,100,,2.192,Percent of Total Billed Charges,100% of Total Billed Charges,1.87,70.04,
RISPERIDONE 1MG TAB,53106514,CDM,250,RC,,,Outpatient,,,4.79,2.87,,2.87,60,,2.296,Percent of Total Billed Charges,60% of Total Billed Charges,2.16,45,,1.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,28,,1.072,Percent of Total Billed Charges,28% of Total Billed Charges,1.87,32,,1.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% Total Bille Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,2.87,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,100,,3.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14.42,,15.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.59,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,2.4,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.35,70,,2.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,100,,7.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,4.79,
RIVASTIGMINE 1.5 MG CAP,53106654,CDM,250,RC,,,Outpatient,,,9.2,5.52,,5.52,60,,4.416,Percent of Total Billed Charges,60% of Total Billed Charges,4.14,45,,3.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,28,,2.064,Percent of Total Billed Charges,28% of Total Billed Charges,1.9,32,,1.52,Percent of Total Billed Charges,32% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,36,,2.648,Percent of Total Billed Charges,36% of Total Billed Charges,3.31,36,,2.648,Percent of Total Billed Charges,36% Total Bille Charges,3.31,36,,2.648,Percent of Total Billed Charges,36% of Total Billed Charges,5.52,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,100,,7.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14.42,,19.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.9,75,,6.152,Percent of Total Billed Charges,75% of Total Billed Charges,4.6,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,4.6,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,4.6,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.44,70,,5.152,Percent of Total Billed Charges,70% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.2,100,,8.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,9.2,
RITONAVIR 100MG CAP,53106704,CDM,250,RC,,,Outpatient,,,17.64,10.58,,10.58,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.94,28,,3.952,Percent of Total Billed Charges,28% of Total Billed Charges,1.91,32,,1.528,Percent of Total Billed Charges,32% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% of Total Billed Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% Total Bille Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% of Total Billed Charges,10.58,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,100,,14.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.54,14.42,,20.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,75,,0.208,Percent of Total Billed Charges,75% of Total Billed Charges,8.82,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,8.82,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.82,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,8.82,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.35,70,,9.88,Percent of Total Billed Charges,70% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,100,,0.272,Percent of Total Billed Charges,100% of Total Billed Charges,1.91,17.64,
RITONAVIR 100MG TAB,53106705,CDM,250,RC,,,Outpatient,,,17.64,10.58,,10.58,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.94,28,,3.952,Percent of Total Billed Charges,28% of Total Billed Charges,1.91,32,,1.528,Percent of Total Billed Charges,32% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% of Total Billed Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% Total Bille Charges,6.35,36,,5.08,Percent of Total Billed Charges,36% of Total Billed Charges,10.58,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.64,100,,14.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.54,14.42,,18.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.23,75,,0.016,Percent of Total Billed Charges,75% of Total Billed Charges,8.82,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,8.82,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.82,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,8.82,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.35,70,,9.88,Percent of Total Billed Charges,70% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.64,100,,0.024,Percent of Total Billed Charges,100% of Total Billed Charges,1.91,17.64,
ROPINIROLE 0.5MG,53106761,CDM,250,RC,,,Outpatient,,,1.18,0.71,,0.71,60,,0.568,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,45,,0.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,16156.48,32,,12925.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.71,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,100,,0.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,75,,2.216,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,70,,0.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,100,,2.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,16156.48,
ROPINIROLE ER 2 MG TAB,53106787,CDM,250,RC,,,Outpatient,,,1.26,0.76,,0.76,60,,0.608,Percent of Total Billed Charges,60% of Total Billed Charges,0.57,45,,0.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,28,,0.28,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% Total Bille Charges,0.45,36,,0.36,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,60,,71.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,1.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,14.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,75,,0.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.63,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.63,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,70,,0.704,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,100,,0.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,16,
FLORASTOR 250MG CAPSULE,53106878,CDM,250,RC,,,Outpatient,,,1.38,0.83,,0.83,60,,0.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.62,45,,0.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,28,,0.312,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% of Total Billed Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% Total Bille Charges,0.5,36,,0.4,Percent of Total Billed Charges,36% of Total Billed Charges,0.83,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,100,,1.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,14.42,,16.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,75,,13.312,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,70,,0.776,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,100,,17.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,16,
ROSUVASTATIN 5 MG TAB,53106928,CDM,250,RC,,,Outpatient,,,17.39,10.43,,10.43,60,,8.344,Percent of Total Billed Charges,60% of Total Billed Charges,7.83,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,28,,3.896,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% Total Bille Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,10.43,60,,50.344,Percent of Total Billed Charges,60% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,75,,0.064,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.7,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.17,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.39,100,,0.088,Percent of Total Billed Charges,100% of Total Billed Charges,2.43,17.39,
ROSUVASTATIN 10 MG TAB,53106936,CDM,250,RC,,,Outpatient,,,17.39,10.43,,10.43,60,,8.344,Percent of Total Billed Charges,60% of Total Billed Charges,7.83,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,28,,3.896,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% Total Bille Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,10.43,60,,587.344,Percent of Total Billed Charges,60% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,75,,2.464,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.7,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.17,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.39,100,,3.288,Percent of Total Billed Charges,100% of Total Billed Charges,2.43,17.39,
ROSUVASTATIN 20 MG TAB,53106944,CDM,250,RC,,,Outpatient,,,17.39,10.43,,10.43,60,,8.344,Percent of Total Billed Charges,60% of Total Billed Charges,7.83,45,,6.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,28,,3.896,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% Total Bille Charges,6.26,36,,5.008,Percent of Total Billed Charges,36% of Total Billed Charges,10.43,60,,587.344,Percent of Total Billed Charges,60% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,100,,13.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,14.42,,10.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,75,,56.392,Percent of Total Billed Charges,75% of Total Billed Charges,8.7,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.7,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,8.7,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.17,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,2.43,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.39,100,,75.184,Percent of Total Billed Charges,100% of Total Billed Charges,2.43,17.39,
SELEGILINE 5MG CAP,53107207,CDM,250,RC,,,Outpatient,,,4.6,2.76,,2.76,60,,2.208,Percent of Total Billed Charges,60% of Total Billed Charges,2.07,45,,1.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,28,,1.032,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% Total Bille Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,2.76,60,,933.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,100,,3.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14.42,,2.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,75,,637.584,Percent of Total Billed Charges,75% of Total Billed Charges,2.3,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,2.3,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.3,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,2.3,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.22,70,,2.576,Percent of Total Billed Charges,70% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,100,,850.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,16,
SERTRALINE 50MG TAB,53107603,CDM,250,RC,,,Outpatient,,,0.47,0.28,,0.28,60,,0.224,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,45,,0.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% Total Bille Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.28,60,,933.856,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,100,,0.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,75,,3.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.24,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,70,,0.264,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,100,,5.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,16,
SEVELAMER 400 MG TAB,53107637,CDM,250,RC,,,Outpatient,,,7.06,4.24,,4.24,60,,3.392,Percent of Total Billed Charges,60% of Total Billed Charges,3.18,45,,2.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.98,28,,1.584,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.54,36,,2.032,Percent of Total Billed Charges,36% of Total Billed Charges,2.54,36,,2.032,Percent of Total Billed Charges,36% Total Bille Charges,2.54,36,,2.032,Percent of Total Billed Charges,36% of Total Billed Charges,4.24,60,,51.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,100,,5.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14.42,,0.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,75,,3.672,Percent of Total Billed Charges,75% of Total Billed Charges,3.53,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,3.53,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.53,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,3.53,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.94,70,,3.952,Percent of Total Billed Charges,70% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14,,0.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,100,,4.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.99,16,
SEVELAMER CARB 800MG,53107660,CDM,250,RC,,,Outpatient,,,15.7,9.42,,9.42,60,,7.536,Percent of Total Billed Charges,60% of Total Billed Charges,7.07,45,,5.656,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,28,,3.52,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% of Total Billed Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% Total Bille Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% of Total Billed Charges,9.42,60,,18.312,Percent of Total Billed Charges,60% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.7,100,,12.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14.42,,1.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.78,75,,3.88,Percent of Total Billed Charges,75% of Total Billed Charges,7.85,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,7.85,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.85,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,7.85,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,70,,8.792,Percent of Total Billed Charges,70% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.7,100,,5.168,Percent of Total Billed Charges,100% of Total Billed Charges,2.2,16,
SILDENAFIL 20MG TAB,53107777,CDM,250,RC,,,Outpatient,,,2.39,1.43,,1.43,60,,1.144,Percent of Total Billed Charges,60% of Total Billed Charges,1.08,45,,0.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,28,,0.536,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% Total Bille Charges,0.86,36,,0.688,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,60,,30.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.39,100,,1.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,75,,3.784,Percent of Total Billed Charges,75% of Total Billed Charges,1.2,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,1.2,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.2,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,70,,1.336,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.39,100,,5.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,16,
MACITENTAN 10MG TAB,53107779,CDM,250,RC,,,Outpatient,,,541.38,324.83,,324.83,60,,259.864,Percent of Total Billed Charges,60% of Total Billed Charges,243.62,45,,194.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.59,28,,121.272,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,194.9,36,,155.92,Percent of Total Billed Charges,36% of Total Billed Charges,194.9,36,,155.92,Percent of Total Billed Charges,36% Total Bille Charges,194.9,36,,155.92,Percent of Total Billed Charges,36% of Total Billed Charges,324.83,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,541.38,100,,433.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,78.07,14.42,,62.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.04,75,,1.888,Percent of Total Billed Charges,75% of Total Billed Charges,270.69,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,270.69,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.69,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,270.69,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.97,70,,303.176,Percent of Total Billed Charges,70% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,75.79,14,,60.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.38,100,,2.52,Percent of Total Billed Charges,100% of Total Billed Charges,16,541.38,
SILDENAFIL 25 MG TAB,53107785,CDM,250,RC,,,Outpatient,,,134.7,80.82,,80.82,60,,64.656,Percent of Total Billed Charges,60% of Total Billed Charges,60.62,45,,48.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.72,28,,30.176,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,48.49,36,,38.792,Percent of Total Billed Charges,36% of Total Billed Charges,48.49,36,,38.792,Percent of Total Billed Charges,36% Total Bille Charges,48.49,36,,38.792,Percent of Total Billed Charges,36% of Total Billed Charges,80.82,60,,27.992,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.7,100,,107.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14.42,,15.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.03,75,,3.976,Percent of Total Billed Charges,75% of Total Billed Charges,67.35,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,67.35,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.35,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,67.35,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.29,70,,75.432,Percent of Total Billed Charges,70% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,18.86,14,,15.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.7,100,,5.304,Percent of Total Billed Charges,100% of Total Billed Charges,16,134.7,
SIMETHICONE 80MG TAB,53107835,CDM,250,RC,,,Outpatient,,,0.18,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,45,,0.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,100,,0.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,4.776,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,100,,6.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,16,
SIMETHICONE 125MG CAP,53107843,CDM,250,RC,,,Outpatient,,,0.14,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,100,,0.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,0.4,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,70,,0.08,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,100,,0.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,16,
SIMVASTATIN 10MG TAB,53107918,CDM,250,RC,,,Outpatient,,,0.36,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,454.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,100,,0.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,75,,16.752,Percent of Total Billed Charges,75% of Total Billed Charges,0.18,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,70,,0.2,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,100,,22.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,16,
SIMVASTATIN 40MG TAB,53107934,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,45,,0.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,40.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,100,,0.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,17.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,23.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,16,
SITAGLIPTIN 100 MG TAB,53107967,CDM,250,RC,,,Outpatient,,,28.64,17.18,,17.18,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,12.89,45,,10.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.02,28,,6.416,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% Total Bille Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,17.18,60,,17.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.64,100,,22.912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,75,,14.664,Percent of Total Billed Charges,75% of Total Billed Charges,14.32,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.32,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.05,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.64,100,,19.552,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,28.64,
LINAGLIPTIN TAB 5MG,53107971,CDM,250,RC,,,Outpatient,,,27.43,16.46,,16.46,60,,13.168,Percent of Total Billed Charges,60% of Total Billed Charges,12.34,45,,9.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.68,28,,6.144,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,9.87,36,,7.896,Percent of Total Billed Charges,36% of Total Billed Charges,9.87,36,,7.896,Percent of Total Billed Charges,36% Total Bille Charges,9.87,36,,7.896,Percent of Total Billed Charges,36% of Total Billed Charges,16.46,60,,41.696,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.43,100,,21.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.96,14.42,,3.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.57,75,,5.04,Percent of Total Billed Charges,75% of Total Billed Charges,13.72,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,13.72,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.72,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,13.72,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.2,70,,15.36,Percent of Total Billed Charges,70% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,3.84,14,,3.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.43,100,,6.72,Percent of Total Billed Charges,100% of Total Billed Charges,3.84,27.43,
SOD BICARB 648MG TAB,53108106,CDM,250,RC,,,Outpatient,,,0.13,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,100,,0.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,2.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,0.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,3.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,16,
SOD CHL 1GM TAB,53108338,CDM,250,RC,,,Outpatient,,,0.19,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,402.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,100,,0.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,0.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,100,,0.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,16,
SOD/POT PHOS 1.25G,53108635,CDM,250,RC,,,Outpatient,,,1.07,0.64,,0.64,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.48,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,75,,0.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.54,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,70,,0.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,100,,0.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,16,
SOTALOL 80MG TAB,53108700,CDM,250,RC,,,Outpatient,,,4.84,2.90,,2.9,60,,2.32,Percent of Total Billed Charges,60% of Total Billed Charges,2.18,45,,1.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,28,,1.088,Percent of Total Billed Charges,28% of Total Billed Charges,16,32,,12.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% of Total Billed Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% Total Bille Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% of Total Billed Charges,2.9,60,,402.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.84,100,,3.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.63,75,,8.408,Percent of Total Billed Charges,75% of Total Billed Charges,2.42,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,2.42,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,2.42,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,70,,2.712,Percent of Total Billed Charges,70% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.84,100,,11.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,16,
SPIRONOLACTONE 25MG TAB,53109104,CDM,250,RC,,,Outpatient,,,0.7,0.42,,0.42,60,,0.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,45,,0.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,16.02,32,,12.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% Total Bille Charges,0.25,36,,0.2,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,60,,34.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,100,,0.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,0.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.35,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,70,,0.392,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,100,,0.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,16.02,
SPIRONOLACTONE 50MG TAB,53109146,CDM,250,RC,,,Outpatient,,,1.59,0.95,,0.95,60,,0.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.72,45,,0.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,16.05,32,,12.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% Total Bille Charges,0.57,36,,0.456,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,60,,32.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,100,,1.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,75,,1.456,Percent of Total Billed Charges,75% of Total Billed Charges,0.8,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,70,,0.888,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,100,,1.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,16.05,
SUCRALFATE 1GM TAB,53110060,CDM,250,RC,,,Outpatient,,,0.76,0.46,,0.46,60,,0.368,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,45,,0.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,28,,0.168,Percent of Total Billed Charges,28% of Total Billed Charges,16.06,32,,12.848,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% Total Bille Charges,0.27,36,,0.216,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,60,,29.536,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,100,,0.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,75,,12.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,70,,0.424,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,100,,17.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,16.06,
SULFADIAZINE 500MG TAB,53110524,CDM,250,RC,,,Outpatient,,,8.74,5.24,,5.24,60,,4.192,Percent of Total Billed Charges,60% of Total Billed Charges,3.93,45,,3.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,28,,1.96,Percent of Total Billed Charges,28% of Total Billed Charges,16.07,32,,12.856,Percent of Total Billed Charges,32% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% of Total Billed Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% Total Bille Charges,3.15,36,,2.52,Percent of Total Billed Charges,36% of Total Billed Charges,5.24,60,,22.28,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,100,,6.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14.42,,1.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,4.37,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,4.37,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.37,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,4.37,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,70,,4.896,Percent of Total Billed Charges,70% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.74,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,16.07,
BACTRIM +,53110912,CDM,250,RC,,,Outpatient,,,0.97,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,45,,0.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,15.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,100,,0.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,75,,0.776,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,70,,0.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,100,,1.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,16.14,
SULFASALAZINE 500MG TAB,53111100,CDM,250,RC,,,Outpatient,,,1.62,0.97,,0.97,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,45,,0.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,60,,21.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,100,,1.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,3.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.81,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,70,,0.904,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,100,,4.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,16.14,
SUMATRIPTAN 25MG TAB,53111902,CDM,250,RC,,,Outpatient,,,4.69,2.81,,2.81,60,,2.248,Percent of Total Billed Charges,60% of Total Billed Charges,2.11,45,,1.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,28,,1.048,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,36,,1.352,Percent of Total Billed Charges,36% of Total Billed Charges,1.69,36,,1.352,Percent of Total Billed Charges,36% Total Bille Charges,1.69,36,,1.352,Percent of Total Billed Charges,36% of Total Billed Charges,2.81,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,100,,3.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14.42,,0.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.52,75,,0.328,Percent of Total Billed Charges,75% of Total Billed Charges,2.35,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,2.35,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.35,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,2.35,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.28,70,,2.624,Percent of Total Billed Charges,70% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14,,0.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.69,100,,0.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,16.14,
TACROLIMUS 1MG CAP,53112041,CDM,250,RC,J7507,HCPCS,Outpatient,,,32.88,19.73,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.8,45,,11.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,3.63,360,,,Fee Schedule,360% of BCBS POS Rate,3.63,360,,,Fee schedule,360% of BCBS PPO Rate,3.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,19.73,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.88,100,,26.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.74,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.66,75,,15.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.28,80,,0.104,Fee Schedule,80% of Scott and White EPO fee schedule,0.28,80,,6.176,Fee Schedule,80% of Scott and White HMO fee schedule,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,80,,6.176,Fee Schedule,80% of Scott and White PPO fee schedule,0.28,80,,13.368,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.02,70,,18.416,Percent of Total Billed Charges,70% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.88,100,,20.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,32.88,
TACROLIMUS 0.5 MG CAP,53112042,CDM,250,RC,J7507,HCPCS,Outpatient,,,16.44,9.86,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.4,45,,5.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,3.63,360,,,Fee Schedule,360% of BCBS POS Rate,3.63,360,,,Fee schedule,360% of BCBS PPO Rate,3.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.86,60,,29.264,Percent of Total Billed Charges,60% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.44,100,,13.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.37,14.42,,1.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.33,75,,35.944,Percent of Total Billed Charges,75% of Total Billed Charges,0.28,80,,55.44,Fee Schedule,80% of Scott and White EPO fee schedule,0.28,80,,12.4,Fee Schedule,80% of Scott and White HMO fee schedule,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,80,,12.4,Fee Schedule,80% of Scott and White PPO fee schedule,0.28,80,,13.368,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.51,70,,9.208,Percent of Total Billed Charges,70% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14,,1.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.44,100,,47.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,16.44,
TAMOXIFEN 10MG TAB,53112108,CDM,250,RC,J8999,HCPCS,Outpatient,,,1.17,0.70,,0.7,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,60,,13.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,75,,76.728,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,70,,0.656,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,100,,102.304,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,16.14,
TAMSULOSIN 0.4MG CAP,53112157,CDM,250,RC,,,Outpatient,,,2.29,1.37,,1.37,60,,1.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,28,,0.512,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% Total Bille Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,1.37,60,,27.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14.42,,0.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,1.15,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,70,,1.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.29,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,16.14,
TELMISARTAN 40 MG TAB,53112264,CDM,250,RC,,,Outpatient,,,11.04,6.62,,6.62,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.09,28,,2.472,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,3.97,36,,3.176,Percent of Total Billed Charges,36% of Total Billed Charges,3.97,36,,3.176,Percent of Total Billed Charges,36% Total Bille Charges,3.97,36,,3.176,Percent of Total Billed Charges,36% of Total Billed Charges,6.62,60,,27.856,Percent of Total Billed Charges,60% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14.42,,1.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.28,75,,3.304,Percent of Total Billed Charges,75% of Total Billed Charges,5.52,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,5.52,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.52,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,5.52,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.73,70,,6.184,Percent of Total Billed Charges,70% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.04,100,,4.408,Percent of Total Billed Charges,100% of Total Billed Charges,1.55,16.14,
TEMAZEPAM 15MG CAP,53112330,CDM,250,RC,,,Outpatient,,,0.97,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,10.752,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,75,,5.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,70,,0.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,100,,6.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,16.14,
TEMAZEPAM 30MG CAP,53112371,CDM,250,RC,,,Outpatient,,,1.48,0.89,,0.89,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,28,,0.328,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% Total Bille Charges,0.53,36,,0.424,Percent of Total Billed Charges,36% of Total Billed Charges,0.89,60,,10.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14.42,,0.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,75,,8.272,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,70,,0.832,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,100,,11.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,16.14,
TENOFOVIR DISOROXIL 300MG TAB,53112454,CDM,250,RC,,,Outpatient,,,76.51,45.91,,45.91,60,,36.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.42,28,,17.136,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,27.54,36,,22.032,Percent of Total Billed Charges,36% of Total Billed Charges,27.54,36,,22.032,Percent of Total Billed Charges,36% Total Bille Charges,27.54,36,,22.032,Percent of Total Billed Charges,36% of Total Billed Charges,45.91,60,,28.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,11.03,14.42,,8.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.38,75,,5.104,Percent of Total Billed Charges,75% of Total Billed Charges,38.26,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,38.26,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.26,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,38.26,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,70,,42.848,Percent of Total Billed Charges,70% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,10.71,14,,8.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.51,100,,6.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.71,76.51,
TERAZOSIN 1MG CAP,53112504,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,37.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,2.616,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,3.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,16.14,
TERAZOSIN 5MG CAP,53112520,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,0.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,16.14,
TERBINAFINE 250MG TAB,53112553,CDM,250,RC,,,Outpatient,,,1.21,0.73,,0.73,60,,0.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% Total Bille Charges,0.44,36,,0.352,Percent of Total Billed Charges,36% of Total Billed Charges,0.73,60,,19.488,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,70,,0.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,16.14,
TERBUTALINE 5MG TAB,53112645,CDM,250,RC,,,Outpatient,,,14.06,8.44,,8.44,60,,6.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.94,28,,3.152,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,5.06,36,,4.048,Percent of Total Billed Charges,36% of Total Billed Charges,5.06,36,,4.048,Percent of Total Billed Charges,36% Total Bille Charges,5.06,36,,4.048,Percent of Total Billed Charges,36% of Total Billed Charges,8.44,60,,194.872,Percent of Total Billed Charges,60% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14.42,,1.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.55,75,,14.52,Percent of Total Billed Charges,75% of Total Billed Charges,7.03,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,7.03,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.03,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,7.03,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.84,70,,7.872,Percent of Total Billed Charges,70% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.06,100,,19.36,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,16.14,
TETRACYCLINE 250MG CAP,53113106,CDM,250,RC,,,Outpatient,,,16.25,9.75,,9.75,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.55,28,,3.64,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,36,,4.68,Percent of Total Billed Charges,36% of Total Billed Charges,5.85,36,,4.68,Percent of Total Billed Charges,36% Total Bille Charges,5.85,36,,4.68,Percent of Total Billed Charges,36% of Total Billed Charges,9.75,60,,246.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14.42,,1.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.19,75,,41.736,Percent of Total Billed Charges,75% of Total Billed Charges,8.13,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,8.13,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.13,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.13,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.38,70,,9.104,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.25,100,,55.648,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,16.25,
THEO-DUR 100MG +,53113882,CDM,250,RC,,,Outpatient,,,9.75,5.85,,5.85,60,,4.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,28,,2.184,Percent of Total Billed Charges,28% of Total Billed Charges,16.14,32,,12.912,Percent of Total Billed Charges,32% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,36,,2.808,Percent of Total Billed Charges,36% of Total Billed Charges,3.51,36,,2.808,Percent of Total Billed Charges,36% Total Bille Charges,3.51,36,,2.808,Percent of Total Billed Charges,36% of Total Billed Charges,5.85,60,,246.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,75,,39.856,Percent of Total Billed Charges,75% of Total Billed Charges,4.88,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,4.88,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.88,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,4.88,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.83,70,,5.464,Percent of Total Billed Charges,70% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.75,100,,53.136,Percent of Total Billed Charges,100% of Total Billed Charges,1.37,16.14,
THEOPH ANHYD 34 200MG CAP 12HR,53113924,CDM,250,RC,,,Outpatient,,,1,0.60,,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,28,,0.224,Percent of Total Billed Charges,28% of Total Billed Charges,16.16,32,,12.928,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% Total Bille Charges,0.36,36,,0.288,Percent of Total Billed Charges,36% of Total Billed Charges,0.6,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,75,,35.248,Percent of Total Billed Charges,75% of Total Billed Charges,0.5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.5,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,70,,0.56,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,100,,47,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,16.16,
THEOPHYLLINE 300MG ER TAB 12HR,53113965,CDM,250,RC,,,Outpatient,,,6.86,4.12,,4.12,60,,3.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,28,,1.536,Percent of Total Billed Charges,28% of Total Billed Charges,16.28,32,,13.024,Percent of Total Billed Charges,32% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.47,36,,1.976,Percent of Total Billed Charges,36% of Total Billed Charges,2.47,36,,1.976,Percent of Total Billed Charges,36% Total Bille Charges,2.47,36,,1.976,Percent of Total Billed Charges,36% of Total Billed Charges,4.12,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,14.42,,0.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,75,,28.616,Percent of Total Billed Charges,75% of Total Billed Charges,3.43,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,3.43,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.43,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,3.43,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,70,,3.84,Percent of Total Billed Charges,70% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.86,100,,38.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,16.28,
THEOPH ER CAP 100MG,53114007,CDM,250,RC,,,Outpatient,,,4,2.40,,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,28,,0.896,Percent of Total Billed Charges,28% of Total Billed Charges,160,32,,128,Percent of Total Billed Charges,32% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% Total Bille Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,2.4,60,,22.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14.42,,0.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,75,,23.008,Percent of Total Billed Charges,75% of Total Billed Charges,2,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,2,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,2,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,70,,2.24,Percent of Total Billed Charges,70% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,100,,30.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,160,
THIAMINE 100MG TAB UD,53114716,CDM,250,RC,,,Outpatient,,,0.04,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,160,32,,128,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,10.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,75,,11.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,70,,0.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,100,,15.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,160,
THIORIDAZINE 25MG TAB,53115481,CDM,250,RC,,,Outpatient,,,1.51,0.91,,0.91,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,160,32,,128,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.91,60,,25.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,70,,0.848,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,100,,38.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,160,
THIOTHIXENE 2MG CAP,53115879,CDM,250,RC,,,Outpatient,,,4.76,2.86,,2.86,60,,2.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,28,,1.064,Percent of Total Billed Charges,28% of Total Billed Charges,160,32,,128,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% of Total Billed Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% Total Bille Charges,1.71,36,,1.368,Percent of Total Billed Charges,36% of Total Billed Charges,2.86,60,,31.824,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14.42,,0.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.57,75,,0.984,Percent of Total Billed Charges,75% of Total Billed Charges,2.38,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.33,70,,2.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.76,100,,1.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,160,
TIAGABINE 4 MG TAB,53116307,CDM,250,RC,,,Outpatient,,,15.47,9.28,,9.28,60,,7.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.33,28,,3.464,Percent of Total Billed Charges,28% of Total Billed Charges,160,32,,128,Percent of Total Billed Charges,32% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.57,36,,4.456,Percent of Total Billed Charges,36% of Total Billed Charges,5.57,36,,4.456,Percent of Total Billed Charges,36% Total Bille Charges,5.57,36,,4.456,Percent of Total Billed Charges,36% of Total Billed Charges,9.28,60,,15.488,Percent of Total Billed Charges,60% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.23,14.42,,1.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,75,,266.344,Percent of Total Billed Charges,75% of Total Billed Charges,7.74,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,7.74,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,7.74,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.83,70,,8.664,Percent of Total Billed Charges,70% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.47,100,,355.12,Percent of Total Billed Charges,100% of Total Billed Charges,2.17,160,
Tapentadol 50MG ER Tab,53116394,CDM,250,RC,,,Outpatient,,,16.69,10.01,,10.01,60,,8.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.67,28,,3.736,Percent of Total Billed Charges,28% of Total Billed Charges,161.6,32,,129.28,Percent of Total Billed Charges,32% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,6.01,36,,4.808,Percent of Total Billed Charges,36% of Total Billed Charges,6.01,36,,4.808,Percent of Total Billed Charges,36% Total Bille Charges,6.01,36,,4.808,Percent of Total Billed Charges,36% of Total Billed Charges,10.01,60,,44.096,Percent of Total Billed Charges,60% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.41,14.42,,1.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.52,75,,34.792,Percent of Total Billed Charges,75% of Total Billed Charges,8.35,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,8.35,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.35,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,8.35,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.68,70,,9.344,Percent of Total Billed Charges,70% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,14,,1.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.69,100,,46.384,Percent of Total Billed Charges,100% of Total Billed Charges,2.34,161.6,
THYROID TAB 60MG,53116497,CDM,250,RC,,,Outpatient,,,1.53,0.92,,0.92,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,161.66,32,,129.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.92,60,,27.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,75,,296.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.77,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,70,,0.856,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.53,100,,395.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,161.66,
TICAGRELOR TAB 90MG,53116919,CDM,250,RC,,,Outpatient,,,13.1,7.86,,7.86,60,,6.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,28,,2.936,Percent of Total Billed Charges,28% of Total Billed Charges,161.89,32,,129.512,Percent of Total Billed Charges,32% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.72,36,,3.776,Percent of Total Billed Charges,36% of Total Billed Charges,4.72,36,,3.776,Percent of Total Billed Charges,36% Total Bille Charges,4.72,36,,3.776,Percent of Total Billed Charges,36% of Total Billed Charges,7.86,60,,27.752,Percent of Total Billed Charges,60% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,14.42,,1.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.83,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,6.55,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,6.55,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.55,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,6.55,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.17,70,,7.336,Percent of Total Billed Charges,70% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14,,1.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.1,100,,0.112,Percent of Total Billed Charges,100% of Total Billed Charges,1.83,161.89,
TIZANIDINE 4MG TAB,53116927,CDM,250,RC,,,Outpatient,,,2.6,1.56,,1.56,60,,1.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,28,,0.584,Percent of Total Billed Charges,28% of Total Billed Charges,161.89,32,,129.512,Percent of Total Billed Charges,32% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,36,,0.752,Percent of Total Billed Charges,36% of Total Billed Charges,0.94,36,,0.752,Percent of Total Billed Charges,36% Total Bille Charges,0.94,36,,0.752,Percent of Total Billed Charges,36% of Total Billed Charges,1.56,60,,13.136,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14.42,,0.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,75,,3.248,Percent of Total Billed Charges,75% of Total Billed Charges,1.3,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,70,,1.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14,,0.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,100,,4.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,161.89,
TOLTERODINE LA 2 MG CAP,53117479,CDM,250,RC,,,Outpatient,,,24.27,14.56,,14.56,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.8,28,,5.44,Percent of Total Billed Charges,28% of Total Billed Charges,161.89,32,,129.512,Percent of Total Billed Charges,32% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,36,,6.992,Percent of Total Billed Charges,36% of Total Billed Charges,8.74,36,,6.992,Percent of Total Billed Charges,36% Total Bille Charges,8.74,36,,6.992,Percent of Total Billed Charges,36% of Total Billed Charges,14.56,60,,104.448,Percent of Total Billed Charges,60% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.5,14.42,,2.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,75,,50.944,Percent of Total Billed Charges,75% of Total Billed Charges,12.14,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,12.14,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.14,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,12.14,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.99,70,,13.592,Percent of Total Billed Charges,70% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,3.4,14,,2.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.27,100,,67.92,Percent of Total Billed Charges,100% of Total Billed Charges,3.4,161.89,
TOLTERODINE LA 4 MG CAP,53117487,CDM,250,RC,,,Outpatient,,,28.83,17.30,,17.3,60,,13.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,28,,6.456,Percent of Total Billed Charges,28% of Total Billed Charges,161.89,32,,129.512,Percent of Total Billed Charges,32% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,36,,8.304,Percent of Total Billed Charges,36% of Total Billed Charges,10.38,36,,8.304,Percent of Total Billed Charges,36% Total Bille Charges,10.38,36,,8.304,Percent of Total Billed Charges,36% of Total Billed Charges,17.3,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.16,14.42,,3.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.62,75,,1.04,Percent of Total Billed Charges,75% of Total Billed Charges,14.42,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,14.42,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.42,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,14.42,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.18,70,,16.144,Percent of Total Billed Charges,70% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,14,,3.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.83,100,,1.384,Percent of Total Billed Charges,100% of Total Billed Charges,4.04,161.89,
SOLIFENACIN 5 MG TAB,53117490,CDM,250,RC,,,Outpatient,,,22.87,13.72,,13.72,60,,10.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,28,,5.12,Percent of Total Billed Charges,28% of Total Billed Charges,161.89,32,,129.512,Percent of Total Billed Charges,32% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,36,,6.584,Percent of Total Billed Charges,36% of Total Billed Charges,8.23,36,,6.584,Percent of Total Billed Charges,36% Total Bille Charges,8.23,36,,6.584,Percent of Total Billed Charges,36% of Total Billed Charges,13.72,60,,34.936,Percent of Total Billed Charges,60% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.3,14.42,,2.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.15,75,,117.288,Percent of Total Billed Charges,75% of Total Billed Charges,11.44,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,11.44,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.44,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,11.44,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.01,70,,12.808,Percent of Total Billed Charges,70% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14,,2.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.87,100,,156.384,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,161.89,
TOLTERODINE 2MG TAB,53117529,CDM,250,RC,,,Outpatient,,,6.19,3.71,,3.71,60,,2.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,28,,1.384,Percent of Total Billed Charges,28% of Total Billed Charges,162.41,32,,129.928,Percent of Total Billed Charges,32% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,2.23,36,,1.784,Percent of Total Billed Charges,36% of Total Billed Charges,2.23,36,,1.784,Percent of Total Billed Charges,36% Total Bille Charges,2.23,36,,1.784,Percent of Total Billed Charges,36% of Total Billed Charges,3.71,60,,14.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14.42,,0.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,75,,74.728,Percent of Total Billed Charges,75% of Total Billed Charges,3.1,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,3.1,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.1,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,3.1,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.33,70,,3.464,Percent of Total Billed Charges,70% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,100,,99.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,162.41,
TOPIRAMATE 25MG TAB,53117545,CDM,250,RC,,,Outpatient,,,0.48,0.29,,0.29,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,162.48,32,,129.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% Total Bille Charges,0.17,36,,0.136,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,60,,29.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,75,,2.536,Percent of Total Billed Charges,75% of Total Billed Charges,0.24,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,70,,0.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,100,,3.384,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,162.48,
TOPIRAMATE 100MG TAB,53117552,CDM,250,RC,,,Outpatient,,,0.34,0.20,,0.2,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,162.52,32,,130.016,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% Total Bille Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.2,60,,40.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,0.17,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,70,,0.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,162.52,
TORSEMIDE 10MG TAB,53117610,CDM,250,RC,,,Outpatient,,,0.89,0.53,,0.53,60,,0.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,162.52,32,,130.016,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.53,60,,20.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,75,,5.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.45,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,70,,0.496,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,100,,6.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,162.52,
TORSEMIDE 20MG TAB,53117628,CDM,250,RC,,,Outpatient,,,1.17,0.70,,0.7,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,162.52,32,,130.016,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,60,,28.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,75,,1.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,70,,0.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,100,,1.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,162.52,
TRANEXAMIC ACID 650MG TAB,53117675,CDM,250,RC,,,Outpatient,,,11.57,6.94,,6.94,60,,5.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.24,28,,2.592,Percent of Total Billed Charges,28% of Total Billed Charges,162.52,32,,130.016,Percent of Total Billed Charges,32% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,4.17,36,,3.336,Percent of Total Billed Charges,36% of Total Billed Charges,4.17,36,,3.336,Percent of Total Billed Charges,36% Total Bille Charges,4.17,36,,3.336,Percent of Total Billed Charges,36% of Total Billed Charges,6.94,60,,12.368,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14.42,,1.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.68,75,,0.76,Percent of Total Billed Charges,75% of Total Billed Charges,5.79,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,5.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,5.79,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.1,70,,6.48,Percent of Total Billed Charges,70% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.57,100,,1.016,Percent of Total Billed Charges,100% of Total Billed Charges,1.62,162.52,
TRAMADOL 50MG TAB,53117701,CDM,250,RC,,,Outpatient,,,3.22,1.93,,1.93,60,,1.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,28,,0.72,Percent of Total Billed Charges,28% of Total Billed Charges,162.76,32,,130.208,Percent of Total Billed Charges,32% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,36,,0.928,Percent of Total Billed Charges,36% of Total Billed Charges,1.16,36,,0.928,Percent of Total Billed Charges,36% Total Bille Charges,1.16,36,,0.928,Percent of Total Billed Charges,36% of Total Billed Charges,1.93,60,,19.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14.42,,0.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,75,,7,Percent of Total Billed Charges,75% of Total Billed Charges,1.61,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,1.61,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.61,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.61,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.25,70,,1.8,Percent of Total Billed Charges,70% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.22,100,,9.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,162.76,
TAPENTADOL 50MG TAB,53117727,CDM,250,RC,,,Outpatient,,,13.96,8.38,,8.38,60,,6.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,28,,3.128,Percent of Total Billed Charges,28% of Total Billed Charges,162.76,32,,130.208,Percent of Total Billed Charges,32% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% of Total Billed Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% Total Bille Charges,5.03,36,,4.024,Percent of Total Billed Charges,36% of Total Billed Charges,8.38,60,,29.808,Percent of Total Billed Charges,60% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,2.01,14.42,,1.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.47,75,,3.128,Percent of Total Billed Charges,75% of Total Billed Charges,6.98,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,6.98,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.98,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,6.98,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.77,70,,7.816,Percent of Total Billed Charges,70% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,14,,1.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.96,100,,4.168,Percent of Total Billed Charges,100% of Total Billed Charges,1.95,162.76,
TRAZODONE 50MG TAB,53117917,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,16379.51,32,,13103.608,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,16379.51,
TRAZODONE 100MG TAB,53117958,CDM,250,RC,,,Outpatient,,,0.54,0.32,,0.32,60,,0.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,16.49,32,,13.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,60,,308,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,75,,0.64,Percent of Total Billed Charges,75% of Total Billed Charges,0.27,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,70,,0.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,100,,0.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,16.49,
HCTZ/TRIAMTERENE TAB 25/37.5,53118634,CDM,250,RC,,,Outpatient,,,0.73,0.44,,0.44,60,,0.352,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,16.53,32,,13.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.44,60,,225.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14.42,,0.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,75,,18.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.37,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,70,,0.408,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,100,,24.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,16.53,
TRIFLUOPERAZINE 5MG TAB,53119194,CDM,250,RC,,,Outpatient,,,5.09,3.05,,3.05,60,,2.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,28,,1.144,Percent of Total Billed Charges,28% of Total Billed Charges,163.52,32,,130.816,Percent of Total Billed Charges,32% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,36,,1.464,Percent of Total Billed Charges,36% of Total Billed Charges,1.83,36,,1.464,Percent of Total Billed Charges,36% Total Bille Charges,1.83,36,,1.464,Percent of Total Billed Charges,36% of Total Billed Charges,3.05,60,,225.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14.42,,0.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,75,,22.872,Percent of Total Billed Charges,75% of Total Billed Charges,2.55,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,2.55,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.55,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,2.55,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.56,70,,2.848,Percent of Total Billed Charges,70% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.09,100,,30.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.71,163.52,
TRIHEXYPHENIDYL 2MG TAB,53119426,CDM,250,RC,,,Outpatient,,,0.38,0.23,,0.23,60,,0.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,163.58,32,,130.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% Total Bille Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,60,,308,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,75,,0.056,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,70,,0.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,100,,0.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,163.58,
TRIMETHOPRIM 100MG TAB,53120507,CDM,250,RC,,,Outpatient,,,1.85,1.11,,1.11,60,,0.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,163.58,32,,130.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% Total Bille Charges,0.67,36,,0.536,Percent of Total Billed Charges,36% of Total Billed Charges,1.11,60,,233.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.39,75,,3.944,Percent of Total Billed Charges,75% of Total Billed Charges,0.93,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,70,,1.04,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,100,,5.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,163.58,
URSODIOL 300MG CAP,53122552,CDM,250,RC,,,Outpatient,,,14.53,8.72,,8.72,60,,6.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.07,28,,3.256,Percent of Total Billed Charges,28% of Total Billed Charges,163.8,32,,131.04,Percent of Total Billed Charges,32% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% Total Bille Charges,5.23,36,,4.184,Percent of Total Billed Charges,36% of Total Billed Charges,8.72,60,,233.816,Percent of Total Billed Charges,60% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,14.42,,1.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.9,75,,25.848,Percent of Total Billed Charges,75% of Total Billed Charges,7.27,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,7.27,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.27,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,7.27,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.17,70,,8.136,Percent of Total Billed Charges,70% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14,,1.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.53,100,,34.464,Percent of Total Billed Charges,100% of Total Billed Charges,2.03,163.8,
VALGANCICLOVIR 50MG/1ML OR SOL,53122570,CDM,250,RC,,,Outpatient,,,18.8,11.28,,11.28,60,,9.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.26,28,,4.208,Percent of Total Billed Charges,28% of Total Billed Charges,163.9,32,,131.12,Percent of Total Billed Charges,32% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,6.77,36,,5.416,Percent of Total Billed Charges,36% of Total Billed Charges,6.77,36,,5.416,Percent of Total Billed Charges,36% Total Bille Charges,6.77,36,,5.416,Percent of Total Billed Charges,36% of Total Billed Charges,11.28,60,,330,Percent of Total Billed Charges,60% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14.42,,2.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.1,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,9.4,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,9.4,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.4,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.16,70,,10.528,Percent of Total Billed Charges,70% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,2.63,163.9,
VALACYCLOVIR 500MG CPL,53122586,CDM,250,RC,,,Outpatient,,,8.31,4.99,,4.99,60,,3.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.33,28,,1.864,Percent of Total Billed Charges,28% of Total Billed Charges,164.29,32,,131.432,Percent of Total Billed Charges,32% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,2.99,36,,2.392,Percent of Total Billed Charges,36% of Total Billed Charges,2.99,36,,2.392,Percent of Total Billed Charges,36% Total Bille Charges,2.99,36,,2.392,Percent of Total Billed Charges,36% of Total Billed Charges,4.99,60,,330,Percent of Total Billed Charges,60% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14.42,,0.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.23,75,,85.056,Percent of Total Billed Charges,75% of Total Billed Charges,4.16,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,4.16,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.16,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,4.16,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.82,70,,4.656,Percent of Total Billed Charges,70% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,14,,0.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.31,100,,113.408,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,164.29,
DIVALPROEX SOD 125MG SPK CAP,53122602,CDM,250,RC,,,Outpatient,,,2.16,1.30,,1.3,60,,1.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,28,,0.48,Percent of Total Billed Charges,28% of Total Billed Charges,165.43,32,,132.344,Percent of Total Billed Charges,32% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% Total Bille Charges,0.78,36,,0.624,Percent of Total Billed Charges,36% of Total Billed Charges,1.3,60,,27.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,14.42,,0.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,75,,2.952,Percent of Total Billed Charges,75% of Total Billed Charges,1.08,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,70,,1.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,14,,0.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,100,,3.936,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,165.43,
VALPROIC ACID CAP 250MG,53122610,CDM,250,RC,,,Outpatient,,,1.3,0.78,,0.78,60,,0.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,165.43,32,,132.344,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% Total Bille Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.78,60,,238.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,0.65,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,70,,0.728,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,165.43,
VALGANCICLOVIR 450 MG TAB,53122636,CDM,250,RC,,,Outpatient,,,85.5,51.30,,51.3,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,165.44,32,,132.352,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,51.3,60,,238.336,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,42.75,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.75,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,70,,47.88,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.5,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,11.97,165.44,
VALSARTAN 80MC TAB,53122651,CDM,250,RC,,,Outpatient,,,10.56,6.34,,6.34,60,,5.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.96,28,,2.368,Percent of Total Billed Charges,28% of Total Billed Charges,165.48,32,,132.384,Percent of Total Billed Charges,32% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,3.8,36,,3.04,Percent of Total Billed Charges,36% of Total Billed Charges,3.8,36,,3.04,Percent of Total Billed Charges,36% Total Bille Charges,3.8,36,,3.04,Percent of Total Billed Charges,36% of Total Billed Charges,6.34,60,,953.336,Percent of Total Billed Charges,60% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.52,14.42,,1.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.92,75,,11.296,Percent of Total Billed Charges,75% of Total Billed Charges,5.28,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,5.28,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.28,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,5.28,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.39,70,,5.912,Percent of Total Billed Charges,70% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14,,1.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.56,100,,15.056,Percent of Total Billed Charges,100% of Total Billed Charges,1.48,165.48,
VANCOMYCIN HCL 125MG/2.5ML SOL,53122720,CDM,250,RC,,,Outpatient,,,9.3,5.58,,5.58,60,,4.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,28,,2.08,Percent of Total Billed Charges,28% of Total Billed Charges,165.64,32,,132.512,Percent of Total Billed Charges,32% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,3.35,36,,2.68,Percent of Total Billed Charges,36% of Total Billed Charges,3.35,36,,2.68,Percent of Total Billed Charges,36% Total Bille Charges,3.35,36,,2.68,Percent of Total Billed Charges,36% of Total Billed Charges,5.58,60,,953.336,Percent of Total Billed Charges,60% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14.42,,1.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.98,75,,0.72,Percent of Total Billed Charges,75% of Total Billed Charges,4.65,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,4.65,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.65,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.65,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.51,70,,5.208,Percent of Total Billed Charges,70% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.3,100,,0.96,Percent of Total Billed Charges,100% of Total Billed Charges,1.3,165.64,
VENLAFAXINE XR 37.5MG TAB,53122735,CDM,250,RC,,,Outpatient,,,1.65,0.99,,0.99,60,,0.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,165.76,32,,132.608,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,60,,18.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,75,,4.096,Percent of Total Billed Charges,75% of Total Billed Charges,0.83,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,70,,0.928,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,100,,5.464,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,165.76,
DESVENLAFAXINE TAB 25MG ER,53122742,CDM,250,RC,,,Outpatient,,,1.95,1.17,,1.17,60,,0.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,28,,0.44,Percent of Total Billed Charges,28% of Total Billed Charges,16734.18,32,,13387.344,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.17,60,,143.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,70,,1.096,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,16734.18,
VENLAFAXINE XR 75MG CAP,53122743,CDM,250,RC,,,Outpatient,,,1.55,0.93,,0.93,60,,0.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,16734.18,32,,13387.344,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% Total Bille Charges,0.56,36,,0.448,Percent of Total Billed Charges,36% of Total Billed Charges,0.93,60,,143.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,75,,0.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,70,,0.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,100,,1.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,16734.18,
VENLAFAXINE 25MG TAB,53122750,CDM,250,RC,,,Outpatient,,,2.72,1.63,,1.63,60,,1.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,28,,0.608,Percent of Total Billed Charges,28% of Total Billed Charges,16.65,32,,13.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% Total Bille Charges,0.98,36,,0.784,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,60,,20.832,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,14.42,,0.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.04,75,,6.736,Percent of Total Billed Charges,75% of Total Billed Charges,1.36,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,70,,1.52,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,100,,8.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,16.65,
VENLAFAXINE 37.5MG TAB,53122768,CDM,250,RC,,,Outpatient,,,1.65,0.99,,0.99,60,,0.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,16.69,32,,13.352,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,60,,32.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.24,75,,40.824,Percent of Total Billed Charges,75% of Total Billed Charges,0.83,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.83,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,70,,0.928,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,100,,54.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,16.69,
VERAPAMIL 80MG TAB,53122842,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,16.71,32,,13.368,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,547.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,40.824,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,54.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,16.71,
VERAPAMIL 120MG TAB,53122883,CDM,250,RC,,,Outpatient,,,0.28,0.17,,0.17,60,,0.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,16.71,32,,13.368,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.17,60,,35.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,75,,50.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,70,,0.16,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,100,,67.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,16.71,
VERAPAMIL SR 240MG TAB,53122891,CDM,250,RC,,,Outpatient,,,4.13,2.48,,2.48,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.16,28,,0.928,Percent of Total Billed Charges,28% of Total Billed Charges,16.8,32,,13.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,36,,1.192,Percent of Total Billed Charges,36% of Total Billed Charges,1.49,36,,1.192,Percent of Total Billed Charges,36% Total Bille Charges,1.49,36,,1.192,Percent of Total Billed Charges,36% of Total Billed Charges,2.48,60,,35.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14.42,,0.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.1,75,,869.752,Percent of Total Billed Charges,75% of Total Billed Charges,2.07,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,2.07,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,2.07,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.89,70,,2.312,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.13,100,,1159.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,16.8,
VERAPAMIL SR 180MG TAB,53122909,CDM,250,RC,,,Outpatient,,,24.7,14.82,,14.82,60,,11.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.92,28,,5.536,Percent of Total Billed Charges,28% of Total Billed Charges,16.8,32,,13.44,Percent of Total Billed Charges,32% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,8.89,36,,7.112,Percent of Total Billed Charges,36% of Total Billed Charges,8.89,36,,7.112,Percent of Total Billed Charges,36% Total Bille Charges,8.89,36,,7.112,Percent of Total Billed Charges,36% of Total Billed Charges,14.82,60,,261.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.56,14.42,,2.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.53,75,,2.376,Percent of Total Billed Charges,75% of Total Billed Charges,12.35,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.35,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.29,70,,13.832,Percent of Total Billed Charges,70% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.7,100,,3.168,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,24.7,
VERAPAMIL SR 120MG CAP,53122917,CDM,250,RC,,,Outpatient,,,10.73,6.44,,6.44,60,,5.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,16.8,32,,13.44,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.44,60,,261.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14.42,,1.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,75,,0.024,Percent of Total Billed Charges,75% of Total Billed Charges,5.37,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,5.37,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.37,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,5.37,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.51,70,,6.008,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.73,100,,0.032,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,16.8,
VERAPAMIL ER 120MG TAB,53122920,CDM,250,RC,,,Outpatient,,,4.62,2.77,,2.77,60,,2.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,28,,1.032,Percent of Total Billed Charges,28% of Total Billed Charges,16.8,32,,13.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% Total Bille Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,2.77,60,,227.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14.42,,0.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,75,,17.704,Percent of Total Billed Charges,75% of Total Billed Charges,2.31,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,2.31,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.31,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,2.31,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,70,,2.584,Percent of Total Billed Charges,70% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,100,,23.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,16.8,
VITAMIN A 10000 UNIT CAP,53123352,CDM,250,RC,,,Outpatient,,,0.05,0.03,,0.03,60,,0.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,16.87,32,,13.496,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,60,,227.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,75,,16.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,70,,0.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,100,,22.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,16.87,
VITAMIN B COMP W-C CAP,53123451,CDM,250,RC,,,Outpatient,,,0.1,0.06,,0.06,60,,0.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,16.95,32,,13.56,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,1.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,70,,0.056,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,100,,2.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,16.95,
VIT B12/VIT B6/FOLIC ACID TAB,53123452,CDM,250,RC,,,Outpatient,,,2.74,1.64,,1.64,60,,1.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,28,,0.616,Percent of Total Billed Charges,28% of Total Billed Charges,166.4,32,,133.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% Total Bille Charges,0.99,36,,0.792,Percent of Total Billed Charges,36% of Total Billed Charges,1.64,60,,435.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14.42,,0.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.06,75,,158.872,Percent of Total Billed Charges,75% of Total Billed Charges,1.37,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,70,,1.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14,,0.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,100,,211.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,166.4,
VIT B COMPLEX +,53123576,CDM,250,RC,,,Outpatient,,,9,5.40,,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.52,28,,2.016,Percent of Total Billed Charges,28% of Total Billed Charges,166.4,32,,133.12,Percent of Total Billed Charges,32% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,3.24,36,,2.592,Percent of Total Billed Charges,36% of Total Billed Charges,3.24,36,,2.592,Percent of Total Billed Charges,36% Total Bille Charges,3.24,36,,2.592,Percent of Total Billed Charges,36% of Total Billed Charges,5.4,60,,435.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14.42,,1.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,75,,2.368,Percent of Total Billed Charges,75% of Total Billed Charges,4.5,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.5,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.3,70,,5.04,Percent of Total Billed Charges,70% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,100,,3.152,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,166.4,
VIT B+C IRON +,53123592,CDM,250,RC,,,Outpatient,,,10.25,6.15,,6.15,60,,4.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.87,28,,2.296,Percent of Total Billed Charges,28% of Total Billed Charges,166.4,32,,133.12,Percent of Total Billed Charges,32% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% of Total Billed Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% Total Bille Charges,3.69,36,,2.952,Percent of Total Billed Charges,36% of Total Billed Charges,6.15,60,,349.384,Percent of Total Billed Charges,60% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14.42,,1.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,75,,15.832,Percent of Total Billed Charges,75% of Total Billed Charges,5.13,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,5.13,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.13,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,5.13,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.18,70,,5.744,Percent of Total Billed Charges,70% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,100,,21.104,Percent of Total Billed Charges,100% of Total Billed Charges,1.44,166.4,
CYANOCOBALAMIN 1000MCG TAB,53123642,CDM,250,RC,,,Outpatient,,,0.34,0.20,,0.2,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,166.4,32,,133.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% Total Bille Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.2,60,,349.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.17,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,70,,0.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,166.4,
VITAMIN D 400IU TAB,53123832,CDM,250,RC,,,Outpatient,,,0.03,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,167.38,32,,133.904,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,640.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,75,,7.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,70,,0.016,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,100,,9.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,167.38,
ERGOCALCIFEROL 50000U CAP,53123842,CDM,250,RC,,,Outpatient,,,3.69,2.21,,2.21,60,,1.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,28,,0.824,Percent of Total Billed Charges,28% of Total Billed Charges,167.65,32,,134.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% Total Bille Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,2.21,60,,640.832,Percent of Total Billed Charges,60% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,75,,5.432,Percent of Total Billed Charges,75% of Total Billed Charges,1.85,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,70,,2.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,100,,7.24,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,167.65,
VITAMIN E CAP 100U,53124038,CDM,250,RC,,,Outpatient,,,0.04,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,167.9,32,,134.32,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,240.696,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,75,,0.776,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,70,,0.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,100,,1.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,167.9,
PARICALCITROL 1 MCG CAP,53124050,CDM,250,RC,,,Outpatient,,,22.18,13.31,,13.31,60,,10.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.21,28,,4.968,Percent of Total Billed Charges,28% of Total Billed Charges,168,32,,134.4,Percent of Total Billed Charges,32% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,7.98,36,,6.384,Percent of Total Billed Charges,36% of Total Billed Charges,7.98,36,,6.384,Percent of Total Billed Charges,36% Total Bille Charges,7.98,36,,6.384,Percent of Total Billed Charges,36% of Total Billed Charges,13.31,60,,240.696,Percent of Total Billed Charges,60% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,14.42,,2.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,11.09,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,11.09,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.09,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,11.09,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.53,70,,12.424,Percent of Total Billed Charges,70% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14,,2.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.18,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,3.11,168,
VITAMIN E CAP 400U,53124079,CDM,250,RC,,,Outpatient,,,0.11,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,168.03,32,,134.424,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,548.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,75,,16.704,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,100,,22.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,168.03,
NEPHROCAPS,53124350,CDM,250,RC,,,Outpatient,,,4.11,2.47,,2.47,60,,1.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,28,,0.92,Percent of Total Billed Charges,28% of Total Billed Charges,168.69,32,,134.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% Total Bille Charges,1.48,36,,1.184,Percent of Total Billed Charges,36% of Total Billed Charges,2.47,60,,2907.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14.42,,0.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.08,75,,3.328,Percent of Total Billed Charges,75% of Total Billed Charges,2.06,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.06,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,2.06,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,70,,2.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.11,100,,4.432,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,168.69,
VORICONAZOLE 200 MG TAB,53124517,CDM,250,RC,,,Outpatient,,,93.98,56.39,,56.39,60,,45.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.31,28,,21.048,Percent of Total Billed Charges,28% of Total Billed Charges,169.44,32,,135.552,Percent of Total Billed Charges,32% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,33.83,36,,27.064,Percent of Total Billed Charges,36% of Total Billed Charges,33.83,36,,27.064,Percent of Total Billed Charges,36% Total Bille Charges,33.83,36,,27.064,Percent of Total Billed Charges,36% of Total Billed Charges,56.39,60,,2907.84,Percent of Total Billed Charges,60% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14.42,,10.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.49,75,,2.776,Percent of Total Billed Charges,75% of Total Billed Charges,46.99,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,46.99,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.99,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,46.99,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.79,70,,52.632,Percent of Total Billed Charges,70% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.98,100,,3.696,Percent of Total Billed Charges,100% of Total Billed Charges,13.16,169.44,
ISAVUCONAZONIUM VL 372MG,53124530,CDM,250,RC,J1833,HCPCS,Outpatient,,,1062.64,637.58,,0.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,1.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.85,360,,,Fee Schedule,360% of BCBS POS Rate,0.85,360,,,Fee schedule,360% of BCBS PPO Rate,0.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,637.58,60,,397.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.88,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1.27,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,103,,,Fee Schedule,103% of CMS OPPS Rate,1,103,,,Fee Schedule,103% of CMS OPPS Rate,796.98,75,,5.832,Percent of Total Billed Charges,75% of Total Billed Charges,531.32,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,531.32,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,531.32,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,531.32,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,1.47,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,743.85,70,,595.08,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1062.64,100,,7.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,1062.64,
WARFARIN 2.5MG TAB,53124806,CDM,250,RC,,,Outpatient,,,6.44,3.86,,3.86,60,,3.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,28,,1.44,Percent of Total Billed Charges,28% of Total Billed Charges,17.02,32,,13.616,Percent of Total Billed Charges,32% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% Total Bille Charges,2.32,36,,1.856,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,60,,2740.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14.42,,0.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,75,,2.552,Percent of Total Billed Charges,75% of Total Billed Charges,3.22,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,3.22,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.22,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,3.22,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.51,70,,3.608,Percent of Total Billed Charges,70% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.44,100,,3.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,17.02,
WARFARIN 1MG TAB,53124814,CDM,250,RC,,,Outpatient,,,6.12,3.67,,3.67,60,,2.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,28,,1.368,Percent of Total Billed Charges,28% of Total Billed Charges,17.03,32,,13.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% Total Bille Charges,2.2,36,,1.76,Percent of Total Billed Charges,36% of Total Billed Charges,3.67,60,,1531.624,Percent of Total Billed Charges,60% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,0.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.59,75,,113.504,Percent of Total Billed Charges,75% of Total Billed Charges,3.06,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,3.06,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,3.06,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,70,,3.424,Percent of Total Billed Charges,70% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,100,,151.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,17.03,
WARFARIN 3 MG TAB,53124830,CDM,250,RC,,,Outpatient,,,6.46,3.88,,3.88,60,,3.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,28,,1.448,Percent of Total Billed Charges,28% of Total Billed Charges,17.07,32,,13.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,2.33,36,,1.864,Percent of Total Billed Charges,36% of Total Billed Charges,2.33,36,,1.864,Percent of Total Billed Charges,36% Total Bille Charges,2.33,36,,1.864,Percent of Total Billed Charges,36% of Total Billed Charges,3.88,60,,672,Percent of Total Billed Charges,60% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14.42,,0.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.85,75,,1.368,Percent of Total Billed Charges,75% of Total Billed Charges,3.23,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,3.23,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,3.23,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,70,,3.616,Percent of Total Billed Charges,70% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,0.9,14,,0.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.46,100,,1.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,17.07,
WARFARIN 2MG TAB,53124848,CDM,250,RC,,,Outpatient,,,6.3,3.78,,3.78,60,,3.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.76,28,,1.408,Percent of Total Billed Charges,28% of Total Billed Charges,17.07,32,,13.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.27,36,,1.816,Percent of Total Billed Charges,36% of Total Billed Charges,2.27,36,,1.816,Percent of Total Billed Charges,36% Total Bille Charges,2.27,36,,1.816,Percent of Total Billed Charges,36% of Total Billed Charges,3.78,60,,681.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14.42,,0.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.73,75,,12.2,Percent of Total Billed Charges,75% of Total Billed Charges,3.15,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,3.15,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,3.15,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.41,70,,3.528,Percent of Total Billed Charges,70% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.3,100,,16.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,17.07,
WARFARIN 4 MG TAB,53124855,CDM,250,RC,,,Outpatient,,,3.15,1.89,,1.89,60,,1.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,28,,0.704,Percent of Total Billed Charges,28% of Total Billed Charges,17.07,32,,13.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% Total Bille Charges,1.13,36,,0.904,Percent of Total Billed Charges,36% of Total Billed Charges,1.89,60,,2208,Percent of Total Billed Charges,60% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14.42,,0.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,1.58,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,70,,1.768,Percent of Total Billed Charges,70% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14,,0.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.44,17.07,
WARFARIN 5MG TAB,53124889,CDM,250,RC,,,Outpatient,,,6.63,3.98,,3.98,60,,3.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.86,28,,1.488,Percent of Total Billed Charges,28% of Total Billed Charges,17.07,32,,13.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,2.39,36,,1.912,Percent of Total Billed Charges,36% of Total Billed Charges,2.39,36,,1.912,Percent of Total Billed Charges,36% Total Bille Charges,2.39,36,,1.912,Percent of Total Billed Charges,36% of Total Billed Charges,3.98,60,,131.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14.42,,0.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,75,,19.12,Percent of Total Billed Charges,75% of Total Billed Charges,3.32,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,3.32,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.32,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,3.32,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.64,70,,3.712,Percent of Total Billed Charges,70% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,0.93,14,,0.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.63,100,,25.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,17.07,
WARFARIN 6 MG TAB,53124897,CDM,250,RC,,,Outpatient,,,7.96,4.78,,4.78,60,,3.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.23,28,,1.784,Percent of Total Billed Charges,28% of Total Billed Charges,17.15,32,,13.72,Percent of Total Billed Charges,32% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% of Total Billed Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% Total Bille Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% of Total Billed Charges,4.78,60,,932.928,Percent of Total Billed Charges,60% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14.42,,0.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.97,75,,0.192,Percent of Total Billed Charges,75% of Total Billed Charges,3.98,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,3.98,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.98,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,3.98,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.57,70,,4.456,Percent of Total Billed Charges,70% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.96,100,,0.256,Percent of Total Billed Charges,100% of Total Billed Charges,1.11,17.15,
WARFARIN 7.5MG TAB,53124921,CDM,250,RC,,,Outpatient,,,0.66,0.40,,0.4,60,,0.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,17.17,32,,13.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% Total Bille Charges,0.24,36,,0.192,Percent of Total Billed Charges,36% of Total Billed Charges,0.4,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,75,,8.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.33,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,70,,0.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,100,,10.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,17.17,
RIVAROXABAN 10MG TAB,53124939,CDM,250,RC,,,Outpatient,,,27.92,16.75,,16.75,60,,13.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.82,28,,6.256,Percent of Total Billed Charges,28% of Total Billed Charges,17.19,32,,13.752,Percent of Total Billed Charges,32% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.05,36,,8.04,Percent of Total Billed Charges,36% of Total Billed Charges,10.05,36,,8.04,Percent of Total Billed Charges,36% Total Bille Charges,10.05,36,,8.04,Percent of Total Billed Charges,36% of Total Billed Charges,16.75,60,,681.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14.42,,3.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.94,75,,2.256,Percent of Total Billed Charges,75% of Total Billed Charges,13.96,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,13.96,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.96,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,13.96,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.54,70,,15.632,Percent of Total Billed Charges,70% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.92,100,,3.008,Percent of Total Billed Charges,100% of Total Billed Charges,3.91,27.92,
RIVAROXABAN 15MG TAB,53124940,CDM,250,RC,,,Outpatient,,,29.92,17.95,,17.95,60,,14.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.38,28,,6.704,Percent of Total Billed Charges,28% of Total Billed Charges,17.21,32,,13.768,Percent of Total Billed Charges,32% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.77,36,,8.616,Percent of Total Billed Charges,36% of Total Billed Charges,10.77,36,,8.616,Percent of Total Billed Charges,36% Total Bille Charges,10.77,36,,8.616,Percent of Total Billed Charges,36% of Total Billed Charges,17.95,60,,1397.76,Percent of Total Billed Charges,60% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.31,14.42,,3.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.44,75,,39.6,Percent of Total Billed Charges,75% of Total Billed Charges,14.96,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,14.96,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.96,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,14.96,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.94,70,,16.752,Percent of Total Billed Charges,70% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.19,14,,3.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.92,100,,52.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,29.92,
EDOXABAN TAB 30MG,53124950,CDM,250,RC,,,Outpatient,,,24.44,14.66,,14.66,60,,11.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.84,28,,5.472,Percent of Total Billed Charges,28% of Total Billed Charges,169.6,32,,135.68,Percent of Total Billed Charges,32% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,8.8,36,,7.04,Percent of Total Billed Charges,36% of Total Billed Charges,8.8,36,,7.04,Percent of Total Billed Charges,36% Total Bille Charges,8.8,36,,7.04,Percent of Total Billed Charges,36% of Total Billed Charges,14.66,60,,92.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.52,14.42,,2.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,75,,12.888,Percent of Total Billed Charges,75% of Total Billed Charges,12.22,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.11,70,,13.688,Percent of Total Billed Charges,70% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,3.42,14,,2.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.44,100,,17.184,Percent of Total Billed Charges,100% of Total Billed Charges,3.42,169.6,
WARFARIN 10MG TAB,53124962,CDM,250,RC,,,Outpatient,,,8.4,5.04,,5.04,60,,4.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.35,28,,1.88,Percent of Total Billed Charges,28% of Total Billed Charges,169.8,32,,135.84,Percent of Total Billed Charges,32% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% Total Bille Charges,3.02,36,,2.416,Percent of Total Billed Charges,36% of Total Billed Charges,5.04,60,,835.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.21,14.42,,0.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.3,75,,6.448,Percent of Total Billed Charges,75% of Total Billed Charges,4.2,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.88,70,,4.704,Percent of Total Billed Charges,70% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,100,,8.6,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,169.8,
ZIDOVUDINE 100MG CAP,53125100,CDM,250,RC,,,Outpatient,,,4.54,2.72,,2.72,60,,2.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,28,,1.016,Percent of Total Billed Charges,28% of Total Billed Charges,170.24,32,,136.192,Percent of Total Billed Charges,32% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% Total Bille Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% of Total Billed Charges,2.72,60,,741.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14.42,,0.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.41,75,,0.296,Percent of Total Billed Charges,75% of Total Billed Charges,2.27,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,2.27,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,2.27,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.18,70,,2.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.54,100,,0.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,170.24,
ZINC SULFATE CAP 220MG,53125233,CDM,250,RC,,,Outpatient,,,0.06,0.04,,0.04,60,,0.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,28,,0.016,Percent of Total Billed Charges,28% of Total Billed Charges,170.34,32,,136.272,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% Total Bille Charges,0.02,36,,0.016,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,60,,1009.728,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,70,,0.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,170.34,
ZOLPIDEM 5MG TAB,53125290,CDM,250,RC,,,Outpatient,,,0.98,0.59,,0.59,60,,0.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,60,,25.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,75,,0.712,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.49,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,70,,0.552,Percent of Total Billed Charges,70% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14,,0.112,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,100,,0.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,171.07,
ZIPRASIDONE 20 MG CAP,53125324,CDM,250,RC,,,Outpatient,,,14.01,8.41,,8.41,60,,6.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.92,28,,3.136,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% of Total Billed Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% Total Bille Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% of Total Billed Charges,8.41,60,,614.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14.42,,1.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.51,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,7.01,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,7.01,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.01,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.01,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.81,70,,7.848,Percent of Total Billed Charges,70% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.01,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,171.07,
ZONISAMIDE 50 MG CAP,53125356,CDM,250,RC,,,Outpatient,,,0.71,0.43,,0.43,60,,0.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,28,,0.16,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% Total Bille Charges,0.26,36,,0.208,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,60,,208.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14.42,,0.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,75,,0.544,Percent of Total Billed Charges,75% of Total Billed Charges,0.36,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,0.36,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.5,70,,0.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,14,,0.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,100,,0.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.1,171.07,
ZONISAMIDE 100 MG CAP,53125357,CDM,250,RC,,,Outpatient,,,2.42,1.45,,1.45,60,,1.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,28,,0.544,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% Total Bille Charges,0.87,36,,0.696,Percent of Total Billed Charges,36% of Total Billed Charges,1.45,60,,188.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14.42,,0.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,75,,8.304,Percent of Total Billed Charges,75% of Total Billed Charges,1.21,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.21,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,70,,1.352,Percent of Total Billed Charges,70% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14,,0.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,100,,11.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.34,171.07,
ACTIV CHAR 15GM/75ML,53140323,CDM,250,RC,,,Outpatient,,,21.54,12.92,,12.92,60,,10.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,28,,4.824,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,7.75,36,,6.2,Percent of Total Billed Charges,36% of Total Billed Charges,7.75,36,,6.2,Percent of Total Billed Charges,36% Total Bille Charges,7.75,36,,6.2,Percent of Total Billed Charges,36% of Total Billed Charges,12.92,60,,191.176,Percent of Total Billed Charges,60% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14.42,,2.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.16,75,,6.832,Percent of Total Billed Charges,75% of Total Billed Charges,10.77,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,10.77,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.77,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,10.77,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.08,70,,12.064,Percent of Total Billed Charges,70% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.54,100,,9.104,Percent of Total Billed Charges,100% of Total Billed Charges,3.02,171.07,
MAALOX 30ML +,53140778,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,198.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,11.904,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,15.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
ALUM/MAG/SIME 30ML CUP,53141156,CDM,250,RC,,,Outpatient,,,1.29,0.77,,0.77,60,,0.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,75,,60.088,Percent of Total Billed Charges,75% of Total Billed Charges,0.65,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,70,,0.72,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,100,,80.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,171.07,
ALUM/MAG HYDROX/SIME SUS UD,53141313,CDM,250,RC,,,Outpatient,,,5.57,3.34,,3.34,60,,2.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.56,28,,1.248,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% of Total Billed Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% Total Bille Charges,2.01,36,,1.608,Percent of Total Billed Charges,36% of Total Billed Charges,3.34,60,,5739.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14.42,,0.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,75,,9.48,Percent of Total Billed Charges,75% of Total Billed Charges,2.79,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,2.79,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.79,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,2.79,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,70,,3.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.57,100,,12.64,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,171.07,
ALUMINUM HYDROXIDE 30ML,53141628,CDM,250,RC,,,Outpatient,,,0.54,0.32,,0.32,60,,0.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14.42,,0.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,75,,0.128,Percent of Total Billed Charges,75% of Total Billed Charges,0.27,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.38,70,,0.304,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,100,,0.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,171.07,
AMOX/CLAV 200MG/5ML SUS 50ML,53142303,CDM,250,RC,,,Outpatient,,,26.14,15.68,,15.68,60,,12.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.32,28,,5.856,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% Total Bille Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,15.68,60,,923.424,Percent of Total Billed Charges,60% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.77,14.42,,3.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.61,75,,5.408,Percent of Total Billed Charges,75% of Total Billed Charges,13.07,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,13.07,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.07,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,13.07,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.3,70,,14.64,Percent of Total Billed Charges,70% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.14,100,,7.208,Percent of Total Billed Charges,100% of Total Billed Charges,3.66,171.07,
AMOX/CLAV 600MG/5ML SUS 75ML,53142386,CDM,250,RC,,,Outpatient,,,59.9,35.94,,35.94,60,,28.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.77,28,,13.416,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,21.56,36,,17.248,Percent of Total Billed Charges,36% of Total Billed Charges,21.56,36,,17.248,Percent of Total Billed Charges,36% Total Bille Charges,21.56,36,,17.248,Percent of Total Billed Charges,36% of Total Billed Charges,35.94,60,,121.576,Percent of Total Billed Charges,60% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14.42,,6.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.93,75,,25.68,Percent of Total Billed Charges,75% of Total Billed Charges,29.95,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,29.95,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.95,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,29.95,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.93,70,,33.544,Percent of Total Billed Charges,70% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14,,6.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.9,100,,34.24,Percent of Total Billed Charges,100% of Total Billed Charges,8.39,171.07,
AMOX/CLAV 250MG/5ML SUS 75ML,53142394,CDM,250,RC,,,Outpatient,,,127.88,76.73,,76.73,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.81,28,,28.648,Percent of Total Billed Charges,28% of Total Billed Charges,171.07,32,,136.856,Percent of Total Billed Charges,32% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,46.04,36,,36.832,Percent of Total Billed Charges,36% of Total Billed Charges,46.04,36,,36.832,Percent of Total Billed Charges,36% Total Bille Charges,46.04,36,,36.832,Percent of Total Billed Charges,36% of Total Billed Charges,76.73,60,,442.696,Percent of Total Billed Charges,60% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,18.44,14.42,,14.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.91,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,63.94,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,63.94,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.94,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,63.94,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.52,70,,71.616,Percent of Total Billed Charges,70% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.9,14,,14.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.88,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,17.9,171.07,
AMOXICILLIN PED+,53142451,CDM,250,RC,,,Outpatient,,,116,69.60,,69.6,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.48,28,,25.984,Percent of Total Billed Charges,28% of Total Billed Charges,171.44,32,,137.152,Percent of Total Billed Charges,32% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,36,,33.408,Percent of Total Billed Charges,36% of Total Billed Charges,41.76,36,,33.408,Percent of Total Billed Charges,36% Total Bille Charges,41.76,36,,33.408,Percent of Total Billed Charges,36% of Total Billed Charges,69.6,60,,340.456,Percent of Total Billed Charges,60% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.73,14.42,,13.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87,75,,2.496,Percent of Total Billed Charges,75% of Total Billed Charges,58,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,58,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,58,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,70,,64.96,Percent of Total Billed Charges,70% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,16.24,14,,12.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116,100,,3.328,Percent of Total Billed Charges,100% of Total Billed Charges,16.24,171.44,
AMOXICILLN 50ML+,53142485,CDM,250,RC,,,Outpatient,,,5.51,3.31,,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,28,,1.232,Percent of Total Billed Charges,28% of Total Billed Charges,171.53,32,,137.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,1.98,36,,1.584,Percent of Total Billed Charges,36% of Total Billed Charges,1.98,36,,1.584,Percent of Total Billed Charges,36% Total Bille Charges,1.98,36,,1.584,Percent of Total Billed Charges,36% of Total Billed Charges,3.31,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,14.42,,0.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.13,75,,14.08,Percent of Total Billed Charges,75% of Total Billed Charges,2.76,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,70,,3.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,100,,18.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,171.53,
AMOXICIL 125MG/5ML SUS 150ML,53142493,CDM,250,RC,,,Outpatient,,,8.7,5.22,,5.22,60,,4.176,Percent of Total Billed Charges,60% of Total Billed Charges,3.92,45,,3.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,28,,1.952,Percent of Total Billed Charges,28% of Total Billed Charges,172.16,32,,137.728,Percent of Total Billed Charges,32% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,3.13,36,,2.504,Percent of Total Billed Charges,36% of Total Billed Charges,3.13,36,,2.504,Percent of Total Billed Charges,36% Total Bille Charges,3.13,36,,2.504,Percent of Total Billed Charges,36% of Total Billed Charges,5.22,60,,442.696,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.7,100,,6.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.25,14.42,,1,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,75,,737.64,Percent of Total Billed Charges,75% of Total Billed Charges,4.35,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,4.35,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.35,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,4.35,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.09,70,,4.872,Percent of Total Billed Charges,70% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.7,100,,983.52,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,172.16,
AMOXICIL 250MG/5ML SUS 150ML,53142535,CDM,250,RC,,,Outpatient,,,13.78,8.27,,8.27,60,,6.616,Percent of Total Billed Charges,60% of Total Billed Charges,6.2,45,,4.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,28,,3.088,Percent of Total Billed Charges,28% of Total Billed Charges,17.5,32,,14,Percent of Total Billed Charges,32% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,4.96,36,,3.968,Percent of Total Billed Charges,36% of Total Billed Charges,4.96,36,,3.968,Percent of Total Billed Charges,36% Total Bille Charges,4.96,36,,3.968,Percent of Total Billed Charges,36% of Total Billed Charges,8.27,60,,5605.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.78,100,,11.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.99,14.42,,1.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.34,75,,428.2,Percent of Total Billed Charges,75% of Total Billed Charges,6.89,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,6.89,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.89,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,6.89,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.65,70,,7.72,Percent of Total Billed Charges,70% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14,,1.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.78,100,,570.928,Percent of Total Billed Charges,100% of Total Billed Charges,1.93,17.5,
AMOXICILLIN 400/5 5ML,53142584,CDM,250,RC,,,Outpatient,,,8.5,5.10,,5.1,60,,4.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,28,,1.904,Percent of Total Billed Charges,28% of Total Billed Charges,172.8,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% Total Bille Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,5.1,60,,867.208,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,100,,6.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.38,75,,116.392,Percent of Total Billed Charges,75% of Total Billed Charges,4.25,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.95,70,,4.76,Percent of Total Billed Charges,70% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.5,100,,155.184,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,172.8,
ACETAMIN 160MG/5ML ELIX 10ML,53142873,CDM,250,RC,,,Outpatient,,,4.36,2.62,,2.62,60,,2.096,Percent of Total Billed Charges,60% of Total Billed Charges,1.96,45,,1.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,172.8,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,36,,1.256,Percent of Total Billed Charges,36% of Total Billed Charges,1.57,36,,1.256,Percent of Total Billed Charges,36% Total Bille Charges,1.57,36,,1.256,Percent of Total Billed Charges,36% of Total Billed Charges,2.62,60,,912,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.36,100,,3.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,0.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.27,75,,159.304,Percent of Total Billed Charges,75% of Total Billed Charges,2.18,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,2.18,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.18,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,2.18,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.05,70,,2.44,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.36,100,,212.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,172.8,
TYLENOL100MG 1ML ORAL LI,53142907,CDM,250,RC,,,Outpatient,,,0.19,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,172.8,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% Total Bille Charges,0.07,36,,0.056,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,1689.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,100,,0.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,639.984,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.1,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,100,,853.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,172.8,
NEO ACETAMINOPHEN 32MG/1ML SUS,53142925,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,172.8,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,17.872,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,339.544,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,452.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,172.8,
ATOVAQUONE 750MG/5ML SUS,53142931,CDM,250,RC,,,Outpatient,,,24.2,14.52,,14.52,60,,11.616,Percent of Total Billed Charges,60% of Total Billed Charges,10.89,45,,8.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,28,,5.424,Percent of Total Billed Charges,28% of Total Billed Charges,172.8,32,,138.24,Percent of Total Billed Charges,32% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.71,36,,6.968,Percent of Total Billed Charges,36% of Total Billed Charges,8.71,36,,6.968,Percent of Total Billed Charges,36% Total Bille Charges,8.71,36,,6.968,Percent of Total Billed Charges,36% of Total Billed Charges,14.52,60,,593.392,Percent of Total Billed Charges,60% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.2,100,,19.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.49,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.15,75,,329.752,Percent of Total Billed Charges,75% of Total Billed Charges,12.1,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,12.1,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.1,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.1,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.94,70,,13.552,Percent of Total Billed Charges,70% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.2,100,,439.672,Percent of Total Billed Charges,100% of Total Billed Charges,3.39,172.8,
AZITHROMYCIN 100MG/5ML SU 15ML,53143004,CDM,250,RC,,,Outpatient,,,69.56,41.74,,41.74,60,,33.392,Percent of Total Billed Charges,60% of Total Billed Charges,31.3,45,,25.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.48,28,,15.584,Percent of Total Billed Charges,28% of Total Billed Charges,173.24,32,,138.592,Percent of Total Billed Charges,32% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,25.04,36,,20.032,Percent of Total Billed Charges,36% of Total Billed Charges,25.04,36,,20.032,Percent of Total Billed Charges,36% Total Bille Charges,25.04,36,,20.032,Percent of Total Billed Charges,36% of Total Billed Charges,41.74,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.56,100,,55.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.03,14.42,,8.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.17,75,,46.688,Percent of Total Billed Charges,75% of Total Billed Charges,34.78,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,34.78,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.78,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,34.78,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.69,70,,38.952,Percent of Total Billed Charges,70% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,9.74,14,,7.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.56,100,,62.248,Percent of Total Billed Charges,100% of Total Billed Charges,9.74,173.24,
AZITHROMYCIN SUSP 200MG/5ML PO,53143012,CDM,250,RC,,,Outpatient,,,66.42,39.85,,39.85,60,,31.88,Percent of Total Billed Charges,60% of Total Billed Charges,29.89,45,,23.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.6,28,,14.88,Percent of Total Billed Charges,28% of Total Billed Charges,173.33,32,,138.664,Percent of Total Billed Charges,32% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,23.91,36,,19.128,Percent of Total Billed Charges,36% of Total Billed Charges,23.91,36,,19.128,Percent of Total Billed Charges,36% Total Bille Charges,23.91,36,,19.128,Percent of Total Billed Charges,36% of Total Billed Charges,39.85,60,,69.12,Percent of Total Billed Charges,60% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.42,100,,53.136,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.58,14.42,,7.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.82,75,,430.064,Percent of Total Billed Charges,75% of Total Billed Charges,33.21,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.21,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.21,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,33.21,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.49,70,,37.192,Percent of Total Billed Charges,70% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,9.3,14,,7.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.42,100,,573.416,Percent of Total Billed Charges,100% of Total Billed Charges,9.3,173.33,
AZITHROMYCIN 1GM PDR PKT,53143038,CDM,250,RC,,,Outpatient,,,58.75,35.25,,35.25,60,,28.2,Percent of Total Billed Charges,60% of Total Billed Charges,26.44,45,,21.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,28,,13.16,Percent of Total Billed Charges,28% of Total Billed Charges,173.33,32,,138.664,Percent of Total Billed Charges,32% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,21.15,36,,16.92,Percent of Total Billed Charges,36% of Total Billed Charges,21.15,36,,16.92,Percent of Total Billed Charges,36% Total Bille Charges,21.15,36,,16.92,Percent of Total Billed Charges,36% of Total Billed Charges,35.25,60,,419.384,Percent of Total Billed Charges,60% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.75,100,,47,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.47,14.42,,6.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.06,75,,1454.28,Percent of Total Billed Charges,75% of Total Billed Charges,29.38,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,29.38,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.38,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,29.38,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.13,70,,32.904,Percent of Total Billed Charges,70% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.23,14,,6.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.75,100,,1939.04,Percent of Total Billed Charges,100% of Total Billed Charges,8.23,173.33,
RASAGILINE 1 MG TAB,53143045,CDM,250,RC,,,Outpatient,,,47.69,28.61,,28.61,60,,22.888,Percent of Total Billed Charges,60% of Total Billed Charges,21.46,45,,17.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.35,28,,10.68,Percent of Total Billed Charges,28% of Total Billed Charges,174.12,32,,139.296,Percent of Total Billed Charges,32% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,17.17,36,,13.736,Percent of Total Billed Charges,36% of Total Billed Charges,17.17,36,,13.736,Percent of Total Billed Charges,36% Total Bille Charges,17.17,36,,13.736,Percent of Total Billed Charges,36% of Total Billed Charges,28.61,60,,48.672,Percent of Total Billed Charges,60% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.69,100,,38.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.88,14.42,,5.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.77,75,,13.24,Percent of Total Billed Charges,75% of Total Billed Charges,23.85,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,23.85,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.85,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,23.85,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.38,70,,26.704,Percent of Total Billed Charges,70% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,6.68,14,,5.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.69,100,,17.648,Percent of Total Billed Charges,100% of Total Billed Charges,6.68,174.12,
PEG ELECTROLYTE SOLN 4000ML,53143814,CDM,250,RC,,,Outpatient,,,38.34,23.00,,23,60,,18.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.25,45,,13.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.74,28,,8.592,Percent of Total Billed Charges,28% of Total Billed Charges,174.65,32,,139.72,Percent of Total Billed Charges,32% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,13.8,36,,11.04,Percent of Total Billed Charges,36% of Total Billed Charges,13.8,36,,11.04,Percent of Total Billed Charges,36% Total Bille Charges,13.8,36,,11.04,Percent of Total Billed Charges,36% of Total Billed Charges,23,60,,4250.88,Percent of Total Billed Charges,60% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.34,100,,30.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.53,14.42,,4.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.76,75,,40.888,Percent of Total Billed Charges,75% of Total Billed Charges,19.17,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,19.17,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.17,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,19.17,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.84,70,,21.472,Percent of Total Billed Charges,70% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,14,,4.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.34,100,,54.52,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,174.65,
ELECTROLYTE-148 1000ML,53143882,CDM,250,RC,,,Outpatient,,,19.8,11.88,,11.88,60,,9.504,Percent of Total Billed Charges,60% of Total Billed Charges,8.91,45,,7.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.54,28,,4.432,Percent of Total Billed Charges,28% of Total Billed Charges,174.85,32,,139.88,Percent of Total Billed Charges,32% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,7.13,36,,5.704,Percent of Total Billed Charges,36% of Total Billed Charges,7.13,36,,5.704,Percent of Total Billed Charges,36% Total Bille Charges,7.13,36,,5.704,Percent of Total Billed Charges,36% of Total Billed Charges,11.88,60,,112.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,100,,15.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14.42,,2.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.85,75,,40.936,Percent of Total Billed Charges,75% of Total Billed Charges,9.9,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,9.9,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.9,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,9.9,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.86,70,,11.088,Percent of Total Billed Charges,70% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14,,2.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.8,100,,54.576,Percent of Total Billed Charges,100% of Total Billed Charges,2.77,174.85,
CAFFEINE CIT 20 MG/ML ORAL SOL,53144390,CDM,250,RC,,,Outpatient,,,48,28.80,,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,45,,17.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.44,28,,10.752,Percent of Total Billed Charges,28% of Total Billed Charges,174.85,32,,139.88,Percent of Total Billed Charges,32% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% of Total Billed Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% Total Bille Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,60,,781.936,Percent of Total Billed Charges,60% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,100,,38.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.92,14.42,,5.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,75,,5.08,Percent of Total Billed Charges,75% of Total Billed Charges,24,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,24,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,24,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,70,,26.88,Percent of Total Billed Charges,70% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48,100,,6.768,Percent of Total Billed Charges,100% of Total Billed Charges,6.72,174.85,
CARBAMAZEPINE 200MG/10ML SUS I,53144838,CDM,250,RC,,,Outpatient,,,1.64,0.98,,0.98,60,,0.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.74,45,,0.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.46,28,,0.368,Percent of Total Billed Charges,28% of Total Billed Charges,175.01,32,,140.008,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% Total Bille Charges,0.59,36,,0.472,Percent of Total Billed Charges,36% of Total Billed Charges,0.98,60,,375.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,100,,1.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14.42,,0.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,75,,166.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.82,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,70,,0.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,100,,221.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,175.01,
CEFIXIME 100MG/5ML SUS 50ML,53145462,CDM,250,RC,,,Outpatient,,,443.9,266.34,,266.34,60,,213.072,Percent of Total Billed Charges,60% of Total Billed Charges,199.76,45,,159.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.29,28,,99.432,Percent of Total Billed Charges,28% of Total Billed Charges,175.05,32,,140.04,Percent of Total Billed Charges,32% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,159.8,36,,127.84,Percent of Total Billed Charges,36% of Total Billed Charges,159.8,36,,127.84,Percent of Total Billed Charges,36% Total Bille Charges,159.8,36,,127.84,Percent of Total Billed Charges,36% of Total Billed Charges,266.34,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,443.9,100,,355.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,64.01,14.42,,51.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.93,75,,15.768,Percent of Total Billed Charges,75% of Total Billed Charges,221.95,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,221.95,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.95,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,221.95,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,310.73,70,,248.584,Percent of Total Billed Charges,70% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,62.15,14,,49.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,443.9,100,,21.024,Percent of Total Billed Charges,100% of Total Billed Charges,62.15,443.9,
CEPHALEXIN 250MG/5ML SUS 100ML,53145660,CDM,250,RC,,,Outpatient,,,57.98,34.79,,34.79,60,,27.832,Percent of Total Billed Charges,60% of Total Billed Charges,26.09,45,,20.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.23,28,,12.984,Percent of Total Billed Charges,28% of Total Billed Charges,175.05,32,,140.04,Percent of Total Billed Charges,32% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,20.87,36,,16.696,Percent of Total Billed Charges,36% of Total Billed Charges,20.87,36,,16.696,Percent of Total Billed Charges,36% Total Bille Charges,20.87,36,,16.696,Percent of Total Billed Charges,36% of Total Billed Charges,34.79,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.98,100,,46.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14.42,,6.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.49,75,,166.248,Percent of Total Billed Charges,75% of Total Billed Charges,28.99,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,28.99,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.99,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,28.99,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.59,70,,32.472,Percent of Total Billed Charges,70% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.98,100,,221.664,Percent of Total Billed Charges,100% of Total Billed Charges,8.12,175.05,
CEFUROXIME AXE 250MG/5ML 50ML,53145934,CDM,250,RC,,,Outpatient,,,494.88,296.93,,296.93,60,,237.544,Percent of Total Billed Charges,60% of Total Billed Charges,222.7,45,,178.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.57,28,,110.856,Percent of Total Billed Charges,28% of Total Billed Charges,175.78,32,,140.624,Percent of Total Billed Charges,32% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,178.16,36,,142.528,Percent of Total Billed Charges,36% of Total Billed Charges,178.16,36,,142.528,Percent of Total Billed Charges,36% Total Bille Charges,178.16,36,,142.528,Percent of Total Billed Charges,36% of Total Billed Charges,296.93,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.88,100,,395.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,71.36,14.42,,57.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.16,75,,13.8,Percent of Total Billed Charges,75% of Total Billed Charges,247.44,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,247.44,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.44,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,247.44,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.42,70,,277.136,Percent of Total Billed Charges,70% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,69.28,14,,55.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.88,100,,18.4,Percent of Total Billed Charges,100% of Total Billed Charges,69.28,494.88,
CETIRIZINE 1MG/ML SYRUP 5ML,53145959,CDM,250,RC,,,Outpatient,,,0.14,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,45,,0.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,175.78,32,,140.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,543.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,100,,0.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,29.544,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,70,,0.08,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,100,,39.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,175.78,
CHOLESTYRAMINE LIGHT PWD 4GM,53146791,CDM,250,RC,,,Outpatient,,,5.41,3.25,,3.25,60,,2.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.43,45,,1.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,28,,1.208,Percent of Total Billed Charges,28% of Total Billed Charges,175.78,32,,140.624,Percent of Total Billed Charges,32% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,1.95,36,,1.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.95,36,,1.56,Percent of Total Billed Charges,36% Total Bille Charges,1.95,36,,1.56,Percent of Total Billed Charges,36% of Total Billed Charges,3.25,60,,540.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.41,100,,4.328,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14.42,,0.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.06,75,,11.632,Percent of Total Billed Charges,75% of Total Billed Charges,2.71,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,2.71,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.71,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,2.71,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.79,70,,3.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.41,100,,15.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,175.78,
QUESTRAN/AQUAPHOR/MAALOX,53146809,CDM,250,RC,,,Outpatient,,,84.9,50.94,,50.94,60,,40.752,Percent of Total Billed Charges,60% of Total Billed Charges,38.21,45,,30.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.77,28,,19.016,Percent of Total Billed Charges,28% of Total Billed Charges,175.82,32,,140.656,Percent of Total Billed Charges,32% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,30.56,36,,24.448,Percent of Total Billed Charges,36% of Total Billed Charges,30.56,36,,24.448,Percent of Total Billed Charges,36% Total Bille Charges,30.56,36,,24.448,Percent of Total Billed Charges,36% of Total Billed Charges,50.94,60,,584.64,Percent of Total Billed Charges,60% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.9,100,,67.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,12.24,14.42,,9.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.68,75,,22.48,Percent of Total Billed Charges,75% of Total Billed Charges,42.45,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,42.45,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.45,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,42.45,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.43,70,,47.544,Percent of Total Billed Charges,70% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,14,,9.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.9,100,,29.968,Percent of Total Billed Charges,100% of Total Billed Charges,11.89,175.82,
MAGNESIUM CITRATE SOL 300ML,53147542,CDM,250,RC,,,Outpatient,,,1.73,1.04,,1.04,60,,0.832,Percent of Total Billed Charges,60% of Total Billed Charges,0.78,45,,0.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,28,,0.384,Percent of Total Billed Charges,28% of Total Billed Charges,17881.46,32,,14305.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% Total Bille Charges,0.62,36,,0.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.04,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,100,,1.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.25,14.42,,0.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,75,,43.944,Percent of Total Billed Charges,75% of Total Billed Charges,0.87,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.87,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.87,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.21,70,,0.968,Percent of Total Billed Charges,70% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,0.24,14,,0.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,100,,58.592,Percent of Total Billed Charges,100% of Total Billed Charges,0.24,17881.46,
CLARITHROM 250MG/5ML SUSP 50ML,53147575,CDM,250,RC,,,Outpatient,,,195.48,117.29,,117.29,60,,93.832,Percent of Total Billed Charges,60% of Total Billed Charges,87.97,45,,70.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.73,28,,43.784,Percent of Total Billed Charges,28% of Total Billed Charges,17.62,32,,14.096,Percent of Total Billed Charges,32% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,70.37,36,,56.296,Percent of Total Billed Charges,36% of Total Billed Charges,70.37,36,,56.296,Percent of Total Billed Charges,36% Total Bille Charges,70.37,36,,56.296,Percent of Total Billed Charges,36% of Total Billed Charges,117.29,60,,58.272,Percent of Total Billed Charges,60% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.48,100,,156.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,28.19,14.42,,22.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.61,75,,51.904,Percent of Total Billed Charges,75% of Total Billed Charges,97.74,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,97.74,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.74,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,97.74,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.84,70,,109.472,Percent of Total Billed Charges,70% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,27.37,14,,21.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.48,100,,69.2,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,195.48,
CLINDAMY PED 75MG/5ML SUS 100M,53147690,CDM,250,RC,,,Outpatient,,,124.54,74.72,,74.72,60,,59.776,Percent of Total Billed Charges,60% of Total Billed Charges,56.04,45,,44.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.87,28,,27.896,Percent of Total Billed Charges,28% of Total Billed Charges,17.65,32,,14.12,Percent of Total Billed Charges,32% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.83,36,,35.864,Percent of Total Billed Charges,36% of Total Billed Charges,44.83,36,,35.864,Percent of Total Billed Charges,36% Total Bille Charges,44.83,36,,35.864,Percent of Total Billed Charges,36% of Total Billed Charges,74.72,60,,1337.472,Percent of Total Billed Charges,60% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.54,100,,99.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.96,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.41,75,,41.92,Percent of Total Billed Charges,75% of Total Billed Charges,62.27,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.27,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.18,70,,69.744,Percent of Total Billed Charges,70% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,17.44,14,,13.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.54,100,,55.896,Percent of Total Billed Charges,100% of Total Billed Charges,17.44,124.54,
GUAIFENESIN/COD SYR 10ML,53148185,CDM,250,RC,,,Outpatient,,,4.23,2.54,,2.54,60,,2.032,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,45,,1.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,28,,0.944,Percent of Total Billed Charges,28% of Total Billed Charges,17.7,32,,14.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% of Total Billed Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% Total Bille Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% of Total Billed Charges,2.54,60,,438.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,100,,3.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14.42,,0.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,2.12,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,2.12,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,2.12,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.96,70,,2.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.23,100,,32.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,17.7,
GI COCKTAIL 55ML LIQUID,53148219,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,632.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
SULFAM/TRIM 800/160MG LIQ 20ML,53148557,CDM,250,RC,,,Outpatient,,,8.56,5.14,,5.14,60,,4.112,Percent of Total Billed Charges,60% of Total Billed Charges,3.85,45,,3.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,28,,1.92,Percent of Total Billed Charges,28% of Total Billed Charges,17.8,32,,14.24,Percent of Total Billed Charges,32% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,3.08,36,,2.464,Percent of Total Billed Charges,36% of Total Billed Charges,3.08,36,,2.464,Percent of Total Billed Charges,36% Total Bille Charges,3.08,36,,2.464,Percent of Total Billed Charges,36% of Total Billed Charges,5.14,60,,232.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.56,100,,6.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.42,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,4.28,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,4.28,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,4.28,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.99,70,,4.792,Percent of Total Billed Charges,70% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,14,,0.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.56,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,1.2,17.8,
DEXAMETHASONE .5/5 5ML,53149084,CDM,250,RC,,,Outpatient,,,1.84,1.10,,1.1,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.83,45,,0.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,28,,0.416,Percent of Total Billed Charges,28% of Total Billed Charges,17.88,32,,14.304,Percent of Total Billed Charges,32% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% Total Bille Charges,0.66,36,,0.528,Percent of Total Billed Charges,36% of Total Billed Charges,1.1,60,,72.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.84,100,,1.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,75,,2.608,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,70,,1.032,Percent of Total Billed Charges,70% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,0.26,14,,0.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,100,,3.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.26,17.88,
GUAIFENESIN SYR 10ML,53149240,CDM,250,RC,,,Outpatient,,,1.27,0.76,,0.76,60,,0.608,Percent of Total Billed Charges,60% of Total Billed Charges,0.57,45,,0.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,17.92,32,,14.336,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.76,60,,185.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,100,,1.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14.42,,0.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,75,,202.504,Percent of Total Billed Charges,75% of Total Billed Charges,0.64,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,70,,0.712,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,100,,270,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,17.92,
DIGOXIN 50 MCG/ML ELIXIR 2.5ML,53149662,CDM,250,RC,,,Outpatient,,,11.67,7.00,,7,60,,5.6,Percent of Total Billed Charges,60% of Total Billed Charges,5.25,45,,4.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,28,,2.616,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,36,,3.36,Percent of Total Billed Charges,36% of Total Billed Charges,4.2,36,,3.36,Percent of Total Billed Charges,36% Total Bille Charges,4.2,36,,3.36,Percent of Total Billed Charges,36% of Total Billed Charges,7,60,,3593.624,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.67,100,,9.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14.42,,1.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.75,75,,71.208,Percent of Total Billed Charges,75% of Total Billed Charges,5.84,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,5.84,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.84,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,5.84,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.17,70,,6.536,Percent of Total Billed Charges,70% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,14,,1.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.67,100,,94.944,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,176,
DIPHENHYD 12.5MG/5ML SOL UD,53149985,CDM,250,RC,,,Outpatient,,,5.21,3.13,,3.13,60,,2.504,Percent of Total Billed Charges,60% of Total Billed Charges,2.34,45,,1.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% of Total Billed Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% Total Bille Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% of Total Billed Charges,3.13,60,,79.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.21,100,,4.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,2.61,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,2.61,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.61,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,2.61,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.65,70,,2.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.21,100,,238.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,176,
DIPHENHYDRAMINE+,53150025,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,21.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,28.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
DOCUSATE SOD 100MG/10ML SOL,53150470,CDM,250,RC,,,Outpatient,,,1.07,0.64,,0.64,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.48,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,100,,0.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,75,,16.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.54,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,70,,0.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,100,,21.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,176,
DONNATAL ELIXIR 5 ML (CS) UDL,53150819,CDM,250,RC,,,Outpatient,,,30.63,18.38,,18.38,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,13.78,45,,11.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.58,28,,6.864,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% Total Bille Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,18.38,60,,79.72,Percent of Total Billed Charges,60% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.63,100,,24.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.42,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.97,75,,13,Percent of Total Billed Charges,75% of Total Billed Charges,15.32,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.44,70,,17.152,Percent of Total Billed Charges,70% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.63,100,,17.336,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,176,
ERYTHROMYCIN ES 200MG/5ML UD,53151452,CDM,250,RC,,,Outpatient,,,38.12,22.87,,22.87,60,,18.296,Percent of Total Billed Charges,60% of Total Billed Charges,17.15,45,,13.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.67,28,,8.536,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,36,,10.976,Percent of Total Billed Charges,36% of Total Billed Charges,13.72,36,,10.976,Percent of Total Billed Charges,36% Total Bille Charges,13.72,36,,10.976,Percent of Total Billed Charges,36% of Total Billed Charges,22.87,60,,71.224,Percent of Total Billed Charges,60% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.12,100,,30.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14.42,,4.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.59,75,,33.816,Percent of Total Billed Charges,75% of Total Billed Charges,19.06,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,19.06,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.06,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,19.06,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.68,70,,21.344,Percent of Total Billed Charges,70% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.12,100,,45.088,Percent of Total Billed Charges,100% of Total Billed Charges,5.34,176,
FERROUS SULF 220MG/5ML ELX,53152104,CDM,250,RC,,,Outpatient,,,0.09,0.05,,0.05,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,176,32,,140.8,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% Total Bille Charges,0.03,36,,0.024,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,60,,46.872,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,100,,0.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,75,,3.64,Percent of Total Billed Charges,75% of Total Billed Charges,0.05,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,70,,0.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,100,,4.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,176,
FERROUS SULF 300MG/5ML LIQ UD,53152105,CDM,250,RC,,,Outpatient,,,6.57,3.94,,3.94,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,2.96,45,,2.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,28,,1.472,Percent of Total Billed Charges,28% of Total Billed Charges,176.78,32,,141.424,Percent of Total Billed Charges,32% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% of Total Billed Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% Total Bille Charges,2.37,36,,1.896,Percent of Total Billed Charges,36% of Total Billed Charges,3.94,60,,140.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.57,100,,5.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.93,75,,8.216,Percent of Total Billed Charges,75% of Total Billed Charges,3.29,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,3.29,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.29,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.29,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,70,,3.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.57,100,,10.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,176.78,
FLUCONAZOLE 10MG/ML 5ML,53152203,CDM,250,RC,,,Outpatient,,,43.08,25.85,,25.85,60,,20.68,Percent of Total Billed Charges,60% of Total Billed Charges,19.39,45,,15.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.06,28,,9.648,Percent of Total Billed Charges,28% of Total Billed Charges,176.78,32,,141.424,Percent of Total Billed Charges,32% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% Total Bille Charges,15.51,36,,12.408,Percent of Total Billed Charges,36% of Total Billed Charges,25.85,60,,159.608,Percent of Total Billed Charges,60% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.08,100,,34.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.21,14.42,,4.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.31,75,,4.784,Percent of Total Billed Charges,75% of Total Billed Charges,21.54,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.54,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.54,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,21.54,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.16,70,,24.128,Percent of Total Billed Charges,70% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,6.03,14,,4.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.08,100,,6.376,Percent of Total Billed Charges,100% of Total Billed Charges,6.03,176.78,
FLUCONAZOLE 40MG/ML 5ML UD,53152211,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,8.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,10.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
FLUOXETINE20MG/5ML/120ML,53152278,CDM,250,RC,,,Outpatient,,,141.76,85.06,,85.06,60,,68.048,Percent of Total Billed Charges,60% of Total Billed Charges,63.79,45,,51.032,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.69,28,,31.752,Percent of Total Billed Charges,28% of Total Billed Charges,176.9,32,,141.52,Percent of Total Billed Charges,32% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,51.03,36,,40.824,Percent of Total Billed Charges,36% of Total Billed Charges,51.03,36,,40.824,Percent of Total Billed Charges,36% Total Bille Charges,51.03,36,,40.824,Percent of Total Billed Charges,36% of Total Billed Charges,85.06,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.76,100,,113.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,20.44,14.42,,16.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.32,75,,10.624,Percent of Total Billed Charges,75% of Total Billed Charges,70.88,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,70.88,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.88,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,70.88,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.23,70,,79.384,Percent of Total Billed Charges,70% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.76,100,,14.168,Percent of Total Billed Charges,100% of Total Billed Charges,19.85,176.9,
FUROSEMIDE 40MG/4ML LIQ UD,53152460,CDM,250,RC,,,Outpatient,,,4.92,2.95,,2.95,60,,2.36,Percent of Total Billed Charges,60% of Total Billed Charges,2.21,45,,1.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.38,28,,1.104,Percent of Total Billed Charges,28% of Total Billed Charges,177.12,32,,141.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,36,,1.416,Percent of Total Billed Charges,36% of Total Billed Charges,1.77,36,,1.416,Percent of Total Billed Charges,36% Total Bille Charges,1.77,36,,1.416,Percent of Total Billed Charges,36% of Total Billed Charges,2.95,60,,312,Percent of Total Billed Charges,60% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.92,100,,3.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14.42,,0.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,75,,10.184,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,2.46,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.46,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,2.46,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.44,70,,2.752,Percent of Total Billed Charges,70% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14,,0.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.92,100,,13.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,177.12,
FUROSEMIDE PD +,53152468,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,35.824,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,47.768,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
FUROSEMIDE 10ML+,53152476,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,17.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,23.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
FUROSEMIDE 10MG/ML 4ML INJ,53152480,CDM,250,RC,J1940,HCPCS,Outpatient,,,18.82,11.29,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.47,45,,6.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.45,360,,,Fee Schedule,360% of BCBS POS Rate,1.45,360,,,Fee schedule,360% of BCBS PPO Rate,1.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.29,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,15.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,75,,21.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,80,,10.48,Fee Schedule,80% of Scott and White EPO fee schedule,0.46,80,,960,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,80,,960,Fee Schedule,80% of Scott and White PPO fee schedule,0.46,80,,13.392,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.17,70,,10.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,28.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,18.82,
GUAIFENESIN 100MG/5ML 15,53152856,CDM,250,RC,,,Outpatient,,,1.2,0.72,,0.72,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,177.28,32,,141.824,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% Total Bille Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,100,,0.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,75,,86.368,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,70,,0.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,100,,115.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,177.28,
GUAIFN-PHE-DEXT+,53152930,CDM,250,RC,,,Outpatient,,,6.83,4.10,,4.1,60,,3.28,Percent of Total Billed Charges,60% of Total Billed Charges,3.07,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,28,,1.528,Percent of Total Billed Charges,28% of Total Billed Charges,177.43,32,,141.944,Percent of Total Billed Charges,32% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,36,,1.968,Percent of Total Billed Charges,36% of Total Billed Charges,2.46,36,,1.968,Percent of Total Billed Charges,36% Total Bille Charges,2.46,36,,1.968,Percent of Total Billed Charges,36% of Total Billed Charges,4.1,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.83,100,,5.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14.42,,0.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,75,,64.312,Percent of Total Billed Charges,75% of Total Billed Charges,3.42,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,3.42,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,3.42,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.78,70,,3.824,Percent of Total Billed Charges,70% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,14,,0.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.83,100,,85.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,177.43,
HYDROXYZINE 10MG/5ML SYR 5ML,53153250,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.1,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,177.56,32,,142.048,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,100,,0.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,4471.992,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,5962.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,177.56,
IBUPROFEN 100 MG/5ML SUS 5ML,53153359,CDM,250,RC,,,Outpatient,,,1.62,0.97,,0.97,60,,0.776,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,45,,0.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,28,,0.36,Percent of Total Billed Charges,28% of Total Billed Charges,177.77,32,,142.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% Total Bille Charges,0.58,36,,0.464,Percent of Total Billed Charges,36% of Total Billed Charges,0.97,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,100,,1.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14.42,,0.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,75,,33.752,Percent of Total Billed Charges,75% of Total Billed Charges,0.81,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.81,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.13,70,,0.904,Percent of Total Billed Charges,70% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,14,,0.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,100,,45,Percent of Total Billed Charges,100% of Total Billed Charges,0.23,177.77,
STRONG IODINE SOLUTION 8 ML UD,53153490,CDM,250,RC,,,Outpatient,,,11.22,6.73,,6.73,60,,5.384,Percent of Total Billed Charges,60% of Total Billed Charges,5.05,45,,4.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.14,28,,2.512,Percent of Total Billed Charges,28% of Total Billed Charges,178.48,32,,142.784,Percent of Total Billed Charges,32% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.04,36,,3.232,Percent of Total Billed Charges,36% of Total Billed Charges,4.04,36,,3.232,Percent of Total Billed Charges,36% Total Bille Charges,4.04,36,,3.232,Percent of Total Billed Charges,36% of Total Billed Charges,6.73,60,,52.608,Percent of Total Billed Charges,60% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.22,100,,8.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14.42,,1.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,75,,46.72,Percent of Total Billed Charges,75% of Total Billed Charges,5.61,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,5.61,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,5.61,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.85,70,,6.28,Percent of Total Billed Charges,70% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,100,,62.296,Percent of Total Billed Charges,100% of Total Billed Charges,1.57,178.48,
SOD HYPOCHLORITE 0.5% 480ML,53153492,CDM,250,RC,,,Outpatient,,,68.04,40.82,,40.82,60,,32.656,Percent of Total Billed Charges,60% of Total Billed Charges,30.62,45,,24.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.05,28,,15.24,Percent of Total Billed Charges,28% of Total Billed Charges,17946.72,32,,14357.376,Percent of Total Billed Charges,32% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% Total Bille Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,40.82,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.04,100,,54.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14.42,,7.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.03,75,,38.032,Percent of Total Billed Charges,75% of Total Billed Charges,34.02,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.02,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.63,70,,38.104,Percent of Total Billed Charges,70% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.04,100,,50.704,Percent of Total Billed Charges,100% of Total Billed Charges,9.53,17946.72,
SOD HYPOCHLORITE 0.25% 480ML,53153493,CDM,250,RC,,,Outpatient,,,68.04,40.82,,40.82,60,,32.656,Percent of Total Billed Charges,60% of Total Billed Charges,30.62,45,,24.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.05,28,,15.24,Percent of Total Billed Charges,28% of Total Billed Charges,18176.64,32,,14541.312,Percent of Total Billed Charges,32% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% Total Bille Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,40.82,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.04,100,,54.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14.42,,7.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.03,75,,956.968,Percent of Total Billed Charges,75% of Total Billed Charges,34.02,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.02,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.63,70,,38.104,Percent of Total Billed Charges,70% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.04,100,,1275.96,Percent of Total Billed Charges,100% of Total Billed Charges,9.53,18176.64,
SOD HYPOCHLORITE 0.125% 480ML,53153494,CDM,250,RC,,,Outpatient,,,84.48,50.69,,50.69,60,,40.552,Percent of Total Billed Charges,60% of Total Billed Charges,38.02,45,,30.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.65,28,,18.92,Percent of Total Billed Charges,28% of Total Billed Charges,18.04,32,,14.432,Percent of Total Billed Charges,32% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% of Total Billed Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% Total Bille Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% of Total Billed Charges,50.69,60,,110.44,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.48,100,,67.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,12.18,14.42,,9.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.36,75,,74.064,Percent of Total Billed Charges,75% of Total Billed Charges,42.24,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,42.24,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.24,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,42.24,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.14,70,,47.312,Percent of Total Billed Charges,70% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.83,14,,9.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.48,100,,98.752,Percent of Total Billed Charges,100% of Total Billed Charges,11.83,84.48,
ITRACONAZOLE 10MG/ML SOL 150ML,53153953,CDM,250,RC,,,Outpatient,,,1449.59,869.75,,869.75,60,,695.8,Percent of Total Billed Charges,60% of Total Billed Charges,652.32,45,,521.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.89,28,,324.712,Percent of Total Billed Charges,28% of Total Billed Charges,18.19,32,,14.552,Percent of Total Billed Charges,32% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,521.85,36,,417.48,Percent of Total Billed Charges,36% of Total Billed Charges,521.85,36,,417.48,Percent of Total Billed Charges,36% Total Bille Charges,521.85,36,,417.48,Percent of Total Billed Charges,36% of Total Billed Charges,869.75,60,,105.32,Percent of Total Billed Charges,60% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1449.59,100,,1159.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,209.03,14.42,,167.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1087.19,75,,5086.344,Percent of Total Billed Charges,75% of Total Billed Charges,724.8,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,724.8,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,724.8,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,724.8,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1014.71,70,,811.768,Percent of Total Billed Charges,70% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,202.94,14,,162.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1449.59,100,,6781.792,Percent of Total Billed Charges,100% of Total Billed Charges,18.19,1449.59,
LACTOBACILLUS GRANULES 1GM PKT,53154407,CDM,250,RC,,,Outpatient,,,3.96,2.38,,2.38,60,,1.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.78,45,,1.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,28,,0.888,Percent of Total Billed Charges,28% of Total Billed Charges,18.21,32,,14.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% Total Bille Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% of Total Billed Charges,2.38,60,,82.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.96,100,,3.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,75,,38.04,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,1.98,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.98,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,1.98,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,70,,2.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.96,100,,50.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,18.21,
LACTULOSE 20GM/30ML SYR CUP,53154597,CDM,250,RC,,,Outpatient,,,0.04,0.02,,0.02,60,,0.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,45,,0.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,28,,0.008,Percent of Total Billed Charges,28% of Total Billed Charges,18.21,32,,14.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% Total Bille Charges,0.01,36,,0.008,Percent of Total Billed Charges,36% of Total Billed Charges,0.02,60,,215.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,100,,0.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14.42,,0.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,75,,11.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,70,,0.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,14,,0.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,100,,15.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,18.21,
LACTULOSE ENEMA 200GM 700ML,53154598,CDM,250,RC,,,Outpatient,,,29.5,17.70,,17.7,60,,14.16,Percent of Total Billed Charges,60% of Total Billed Charges,13.28,45,,10.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.26,28,,6.608,Percent of Total Billed Charges,28% of Total Billed Charges,18.23,32,,14.584,Percent of Total Billed Charges,32% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,10.62,36,,8.496,Percent of Total Billed Charges,36% of Total Billed Charges,10.62,36,,8.496,Percent of Total Billed Charges,36% Total Bille Charges,10.62,36,,8.496,Percent of Total Billed Charges,36% of Total Billed Charges,17.7,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,100,,23.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.25,14.42,,3.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.13,75,,30.792,Percent of Total Billed Charges,75% of Total Billed Charges,14.75,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,14.75,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.75,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,14.75,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.65,70,,16.52,Percent of Total Billed Charges,70% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14,,3.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.5,100,,41.056,Percent of Total Billed Charges,100% of Total Billed Charges,4.13,29.5,
LAMIVUDINE 10MG/ML ORL SOL 30M,53154605,CDM,250,RC,,,Outpatient,,,27.72,16.63,,16.63,60,,13.304,Percent of Total Billed Charges,60% of Total Billed Charges,12.47,45,,9.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.76,28,,6.208,Percent of Total Billed Charges,28% of Total Billed Charges,179.2,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% Total Bille Charges,9.98,36,,7.984,Percent of Total Billed Charges,36% of Total Billed Charges,16.63,60,,97.544,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.72,100,,22.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,4,14.42,,3.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.79,75,,23.528,Percent of Total Billed Charges,75% of Total Billed Charges,13.86,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,13.86,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.86,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,13.86,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,70,,15.52,Percent of Total Billed Charges,70% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.72,100,,31.368,Percent of Total Billed Charges,100% of Total Billed Charges,3.88,179.2,
LEVETIRACETM5ML+,53154787,CDM,250,RC,,,Outpatient,,,2.64,1.58,,1.58,60,,1.264,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,45,,0.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,28,,0.592,Percent of Total Billed Charges,28% of Total Billed Charges,179.2,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% Total Bille Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,1.58,60,,101.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.64,100,,2.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14.42,,0.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,75,,35.872,Percent of Total Billed Charges,75% of Total Billed Charges,1.32,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,1.32,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.32,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.32,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,70,,1.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.64,100,,47.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,179.2,
LEVETIRACETAM 1000MG/NS 100ML,53154788,CDM,250,RC,J1953,HCPCS,Outpatient,,,264.79,158.87,,0.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,119.16,45,,95.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.11,360,,,Fee Schedule,360% of BCBS POS Rate,0.11,360,,,Fee schedule,360% of BCBS PPO Rate,0.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,158.87,60,,82.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.79,100,,211.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.59,75,,12.664,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,20.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,1.696,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,1.696,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,3.92,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.35,70,,148.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.79,100,,16.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,264.79,
LIDOCAINE VISC 30ML,53155040,CDM,250,RC,,,Outpatient,,,3.94,2.36,,2.36,60,,1.888,Percent of Total Billed Charges,60% of Total Billed Charges,1.77,45,,1.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,179.2,32,,143.36,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,36,,1.136,Percent of Total Billed Charges,36% of Total Billed Charges,1.42,36,,1.136,Percent of Total Billed Charges,36% Total Bille Charges,1.42,36,,1.136,Percent of Total Billed Charges,36% of Total Billed Charges,2.36,60,,82.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,100,,3.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.96,75,,24.96,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,70,,2.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.94,100,,33.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,179.2,
LIDOCAINE VIS 2% SOL 100ML,53155041,CDM,250,RC,,,Outpatient,,,26.38,15.83,,15.83,60,,12.664,Percent of Total Billed Charges,60% of Total Billed Charges,11.87,45,,9.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.39,28,,5.912,Percent of Total Billed Charges,28% of Total Billed Charges,179.33,32,,143.464,Percent of Total Billed Charges,32% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% Total Bille Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,15.83,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.38,100,,21.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.8,14.42,,3.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,75,,28.912,Percent of Total Billed Charges,75% of Total Billed Charges,13.19,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,13.19,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.19,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,13.19,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.47,70,,14.776,Percent of Total Billed Charges,70% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.38,100,,38.552,Percent of Total Billed Charges,100% of Total Billed Charges,3.69,179.33,
LORAZEPAM INTENSOL 2 MG/ML 1ML,53155305,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.35,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,179.35,32,,143.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,100,,2.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,179.35,
CLARITIN SYR10M+,53155396,CDM,250,RC,,,Outpatient,,,12.04,7.22,,7.22,60,,5.776,Percent of Total Billed Charges,60% of Total Billed Charges,5.42,45,,4.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.37,28,,2.696,Percent of Total Billed Charges,28% of Total Billed Charges,180.16,32,,144.128,Percent of Total Billed Charges,32% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,36,,3.464,Percent of Total Billed Charges,36% of Total Billed Charges,4.33,36,,3.464,Percent of Total Billed Charges,36% Total Bille Charges,4.33,36,,3.464,Percent of Total Billed Charges,36% of Total Billed Charges,7.22,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.04,100,,9.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14.42,,1.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.03,75,,55.704,Percent of Total Billed Charges,75% of Total Billed Charges,6.02,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,6.02,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.02,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,6.02,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.43,70,,6.744,Percent of Total Billed Charges,70% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,100,,74.272,Percent of Total Billed Charges,100% of Total Billed Charges,1.69,180.16,
MEGESTROL 40MG/ML SOL 10ML UD,53155685,CDM,250,RC,J8999,HCPCS,Outpatient,,,9.05,5.43,,5.43,60,,4.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,28,,2.024,Percent of Total Billed Charges,28% of Total Billed Charges,180.22,32,,144.176,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,36,,2.608,Percent of Total Billed Charges,36% of Total Billed Charges,3.26,36,,2.608,Percent of Total Billed Charges,36% Total Bille Charges,3.26,36,,2.608,Percent of Total Billed Charges,36% of Total Billed Charges,5.43,60,,70.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.79,75,,18.12,Percent of Total Billed Charges,75% of Total Billed Charges,4.53,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,4.53,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.53,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,4.53,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.34,70,,5.072,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.05,100,,24.16,Percent of Total Billed Charges,100% of Total Billed Charges,2.53,180.22,
METOCLOPRAMIDE 5MG/5ML SYR 30M,53156691,CDM,250,RC,,,Outpatient,,,1.29,0.77,,0.77,60,,0.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,28,,0.288,Percent of Total Billed Charges,28% of Total Billed Charges,181.12,32,,144.896,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% Total Bille Charges,0.46,36,,0.368,Percent of Total Billed Charges,36% of Total Billed Charges,0.77,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.97,75,,36.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.65,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,70,,0.72,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,100,,49.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,181.12,
MIDAZOLAM 2MG/ML,53157053,CDM,250,RC,J2250,HCPCS,Outpatient,,,3.9,2.34,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,7.168,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,423,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,61.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,61.2,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,17.36,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,9.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,3.9,
MINERAL OIL 10ML,53157111,CDM,250,RC,,,Outpatient,,,27.84,16.70,,16.7,60,,13.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.8,28,,6.24,Percent of Total Billed Charges,28% of Total Billed Charges,181.65,32,,145.32,Percent of Total Billed Charges,32% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,36,,8.016,Percent of Total Billed Charges,36% of Total Billed Charges,10.02,36,,8.016,Percent of Total Billed Charges,36% Total Bille Charges,10.02,36,,8.016,Percent of Total Billed Charges,36% of Total Billed Charges,16.7,60,,347.52,Percent of Total Billed Charges,60% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14.42,,3.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.88,75,,9.584,Percent of Total Billed Charges,75% of Total Billed Charges,13.92,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,13.92,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.92,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,13.92,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.49,70,,15.592,Percent of Total Billed Charges,70% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.9,14,,3.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.84,100,,12.776,Percent of Total Billed Charges,100% of Total Billed Charges,3.9,181.65,
PHENOL ORAL SPY,53157723,CDM,250,RC,,,Outpatient,,,5.54,3.32,,3.32,60,,2.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,28,,1.24,Percent of Total Billed Charges,28% of Total Billed Charges,181.76,32,,145.408,Percent of Total Billed Charges,32% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% of Total Billed Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% Total Bille Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% of Total Billed Charges,3.32,60,,258.136,Percent of Total Billed Charges,60% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14.42,,0.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.16,75,,12.88,Percent of Total Billed Charges,75% of Total Billed Charges,2.77,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,2.77,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,70,,3.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14,,0.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.54,100,,17.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.78,181.76,
POLY-VI-SOL DRP 50ML,53158069,CDM,250,RC,,,Outpatient,,,4.62,2.77,,2.77,60,,2.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,28,,1.032,Percent of Total Billed Charges,28% of Total Billed Charges,181.84,32,,145.472,Percent of Total Billed Charges,32% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% Total Bille Charges,1.66,36,,1.328,Percent of Total Billed Charges,36% of Total Billed Charges,2.77,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14.42,,0.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,75,,22.768,Percent of Total Billed Charges,75% of Total Billed Charges,2.31,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,2.31,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.31,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,2.31,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,70,,2.584,Percent of Total Billed Charges,70% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,100,,30.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,181.84,
MULTIVITAMIN +,53158093,CDM,250,RC,,,Outpatient,,,9.72,5.83,,5.83,60,,4.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.72,28,,2.176,Percent of Total Billed Charges,28% of Total Billed Charges,182.08,32,,145.664,Percent of Total Billed Charges,32% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.5,36,,2.8,Percent of Total Billed Charges,36% of Total Billed Charges,3.5,36,,2.8,Percent of Total Billed Charges,36% Total Bille Charges,3.5,36,,2.8,Percent of Total Billed Charges,36% of Total Billed Charges,5.83,60,,62.656,Percent of Total Billed Charges,60% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14.42,,1.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.29,75,,98.296,Percent of Total Billed Charges,75% of Total Billed Charges,4.86,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4.86,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.86,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,4.86,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.8,70,,5.44,Percent of Total Billed Charges,70% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.72,100,,131.056,Percent of Total Billed Charges,100% of Total Billed Charges,1.36,182.08,
NEVIRAPINE 5ML +,53158424,CDM,250,RC,,,Outpatient,,,4.25,2.55,,2.55,60,,2.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,28,,0.952,Percent of Total Billed Charges,28% of Total Billed Charges,182.35,32,,145.88,Percent of Total Billed Charges,32% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% of Total Billed Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% Total Bille Charges,1.53,36,,1.224,Percent of Total Billed Charges,36% of Total Billed Charges,2.55,60,,107.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14.42,,0.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.19,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,2.13,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,2.13,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.13,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,2.13,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.98,70,,2.384,Percent of Total Billed Charges,70% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14,,0.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,182.35,
NITAZOXANIDE 500 MG TAB,53158630,CDM,250,RC,,,Outpatient,,,189.17,113.50,,113.5,60,,90.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.97,28,,42.376,Percent of Total Billed Charges,28% of Total Billed Charges,18.41,32,,14.728,Percent of Total Billed Charges,32% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,68.1,36,,54.48,Percent of Total Billed Charges,36% of Total Billed Charges,68.1,36,,54.48,Percent of Total Billed Charges,36% Total Bille Charges,68.1,36,,54.48,Percent of Total Billed Charges,36% of Total Billed Charges,113.5,60,,308.536,Percent of Total Billed Charges,60% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,27.28,14.42,,21.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.88,75,,15.952,Percent of Total Billed Charges,75% of Total Billed Charges,94.59,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,94.59,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.59,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,94.59,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.42,70,,105.936,Percent of Total Billed Charges,70% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,26.48,14,,21.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.17,100,,21.272,Percent of Total Billed Charges,100% of Total Billed Charges,18.41,189.17,
NYSTATIN 500000UN/5ML SUS 5ML,53158812,CDM,250,RC,,,Outpatient,,,2.28,1.37,,1.37,60,,1.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,28,,0.512,Percent of Total Billed Charges,28% of Total Billed Charges,18.44,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% Total Bille Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,1.37,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14.42,,0.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,75,,13.496,Percent of Total Billed Charges,75% of Total Billed Charges,1.14,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,70,,1.28,Percent of Total Billed Charges,70% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,100,,17.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,18.44,
NYSTATIN SUS 500000U/5ML 60ML,53158813,CDM,250,RC,,,Outpatient,,,20.33,12.20,,12.2,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.69,28,,4.552,Percent of Total Billed Charges,28% of Total Billed Charges,18.44,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% of Total Billed Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% Total Bille Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% of Total Billed Charges,12.2,60,,4992,Percent of Total Billed Charges,60% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14.42,,2.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,75,,297.032,Percent of Total Billed Charges,75% of Total Billed Charges,10.17,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,10.17,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.17,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,10.17,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.23,70,,11.384,Percent of Total Billed Charges,70% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.33,100,,396.04,Percent of Total Billed Charges,100% of Total Billed Charges,2.85,20.33,
NYSTATIN SUS 100000 UN/ML 1ML,53158815,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,18.44,32,,14.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,854.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,25.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,18.44,
OSELTAMIVIR 60/5 75ML,53158929,CDM,250,RC,,,Outpatient,,,31.86,19.12,,19.12,60,,15.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.92,28,,7.136,Percent of Total Billed Charges,28% of Total Billed Charges,18.49,32,,14.792,Percent of Total Billed Charges,32% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,11.47,36,,9.176,Percent of Total Billed Charges,36% of Total Billed Charges,11.47,36,,9.176,Percent of Total Billed Charges,36% Total Bille Charges,11.47,36,,9.176,Percent of Total Billed Charges,36% of Total Billed Charges,19.12,60,,185.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,14.42,,3.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.9,75,,101.416,Percent of Total Billed Charges,75% of Total Billed Charges,15.93,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,15.93,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.93,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,15.93,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.3,70,,17.84,Percent of Total Billed Charges,70% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14,,3.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.86,100,,135.216,Percent of Total Billed Charges,100% of Total Billed Charges,4.46,31.86,
BISMUTH SUBSALICYL LIQ 15ML,53160073,CDM,250,RC,,,Outpatient,,,0.32,0.19,,0.19,60,,0.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,18.55,32,,14.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% Total Bille Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,60,,283.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.24,75,,46.24,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,70,,0.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,100,,61.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,18.55,
PHENYTOIN 100MG/4ML SUS UD,53160594,CDM,250,RC,,,Outpatient,,,13.6,8.16,,8.16,60,,6.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.81,28,,3.048,Percent of Total Billed Charges,28% of Total Billed Charges,182.4,32,,145.92,Percent of Total Billed Charges,32% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,36,,3.92,Percent of Total Billed Charges,36% of Total Billed Charges,4.9,36,,3.92,Percent of Total Billed Charges,36% Total Bille Charges,4.9,36,,3.92,Percent of Total Billed Charges,36% of Total Billed Charges,8.16,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14.42,,1.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,75,,11.824,Percent of Total Billed Charges,75% of Total Billed Charges,6.8,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,6.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,6.8,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.52,70,,7.616,Percent of Total Billed Charges,70% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14,,1.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.6,100,,15.76,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,182.4,
POLYETHYLENE GLYCOL 17GM PDR,53160727,CDM,250,RC,,,Outpatient,,,3.76,2.26,,2.26,60,,1.808,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,28,,0.84,Percent of Total Billed Charges,28% of Total Billed Charges,182.44,32,,145.952,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% of Total Billed Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% Total Bille Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% of Total Billed Charges,2.26,60,,60.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14.42,,0.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,75,,13.44,Percent of Total Billed Charges,75% of Total Billed Charges,1.88,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,1.88,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.88,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,1.88,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,70,,2.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.76,100,,17.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,182.44,
SOD POLYSTYRENE SULF 60ML,53160743,CDM,250,RC,,,Outpatient,,,66,39.60,,39.6,60,,31.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.48,28,,14.784,Percent of Total Billed Charges,28% of Total Billed Charges,182.75,32,,146.2,Percent of Total Billed Charges,32% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% of Total Billed Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% Total Bille Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% of Total Billed Charges,39.6,60,,72.424,Percent of Total Billed Charges,60% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.52,14.42,,7.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.5,75,,18.12,Percent of Total Billed Charges,75% of Total Billed Charges,33,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,33,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,33,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.2,70,,36.96,Percent of Total Billed Charges,70% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66,100,,24.16,Percent of Total Billed Charges,100% of Total Billed Charges,9.24,182.75,
POTASSIUM CL 20MEQ PKT,53160974,CDM,250,RC,,,Outpatient,,,21.48,12.89,,12.89,60,,10.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.01,28,,4.808,Percent of Total Billed Charges,28% of Total Billed Charges,183.15,32,,146.52,Percent of Total Billed Charges,32% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,7.73,36,,6.184,Percent of Total Billed Charges,36% of Total Billed Charges,7.73,36,,6.184,Percent of Total Billed Charges,36% Total Bille Charges,7.73,36,,6.184,Percent of Total Billed Charges,36% of Total Billed Charges,12.89,60,,70.792,Percent of Total Billed Charges,60% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14.42,,2.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.11,75,,102.792,Percent of Total Billed Charges,75% of Total Billed Charges,10.74,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,10.74,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.74,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,10.74,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.04,70,,12.032,Percent of Total Billed Charges,70% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14,,2.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.48,100,,137.056,Percent of Total Billed Charges,100% of Total Billed Charges,3.01,183.15,
KCL EFF +,53160990,CDM,250,RC,,,Outpatient,,,10.75,6.45,,6.45,60,,5.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.01,28,,2.408,Percent of Total Billed Charges,28% of Total Billed Charges,183.32,32,,146.656,Percent of Total Billed Charges,32% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,36,,3.096,Percent of Total Billed Charges,36% of Total Billed Charges,3.87,36,,3.096,Percent of Total Billed Charges,36% Total Bille Charges,3.87,36,,3.096,Percent of Total Billed Charges,36% of Total Billed Charges,6.45,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14.42,,1.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.06,75,,1350,Percent of Total Billed Charges,75% of Total Billed Charges,5.38,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,5.38,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.38,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5.38,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.53,70,,6.024,Percent of Total Billed Charges,70% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,1.51,14,,1.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.75,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,1.51,183.32,
POTASSIUM LIME 25MEQ EFF TAB,53161097,CDM,250,RC,,,Outpatient,,,0.49,0.29,,0.29,60,,0.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,183.68,32,,146.944,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,60,,62.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,75,,1166.392,Percent of Total Billed Charges,75% of Total Billed Charges,0.25,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.25,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,70,,0.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.49,100,,1555.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,183.68,
PREDNISOLONE 15MG/5ML SOL,53161238,CDM,250,RC,J7510,HCPCS,Outpatient,,,0.13,0.08,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,360,,,Fee Schedule,360% of BCBS POS Rate,0.19,360,,,Fee schedule,360% of BCBS PPO Rate,0.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,0.08,60,,95.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,287.768,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,80,,4,Fee Schedule,80% of Scott and White EPO fee schedule,0.21,80,,0.064,Fee Schedule,80% of Scott and White HMO fee schedule,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,80,,0.064,Fee Schedule,80% of Scott and White PPO fee schedule,0.21,80,,32.304,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,0.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,383.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,0.25,
PROMETHAZINE 6.25MG/5ML SYR 30,53161550,CDM,250,RC,,,Outpatient,,,1.18,0.71,,0.71,60,,0.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,183.76,32,,147.008,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.71,60,,63.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,75,,22.768,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.83,70,,0.664,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,100,,30.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,183.76,
PSEUDOEPHEDRINE 30MG/5ML LIQ,53161840,CDM,250,RC,,,Outpatient,,,0.13,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,183.88,32,,147.104,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,111.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,24.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,0.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,33.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,183.88,
PSYLLIUM SF PDR PKT,53162053,CDM,250,RC,,,Outpatient,,,0.9,0.54,,0.54,60,,0.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,28,,0.2,Percent of Total Billed Charges,28% of Total Billed Charges,184.32,32,,147.456,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% Total Bille Charges,0.32,36,,0.256,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,60,,825.752,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,75,,33.76,Percent of Total Billed Charges,75% of Total Billed Charges,0.45,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,70,,0.504,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.9,100,,45.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,184.32,
RANITIDINE 150MG/10ML SYR UD,53162459,CDM,250,RC,,,Outpatient,,,13.84,8.30,,8.3,60,,6.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,28,,3.104,Percent of Total Billed Charges,28% of Total Billed Charges,184.56,32,,147.648,Percent of Total Billed Charges,32% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,4.98,36,,3.984,Percent of Total Billed Charges,36% of Total Billed Charges,4.98,36,,3.984,Percent of Total Billed Charges,36% Total Bille Charges,4.98,36,,3.984,Percent of Total Billed Charges,36% of Total Billed Charges,8.3,60,,90.24,Percent of Total Billed Charges,60% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,2,14.42,,1.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,75,,102.04,Percent of Total Billed Charges,75% of Total Billed Charges,6.92,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,6.92,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.92,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,6.92,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,70,,7.752,Percent of Total Billed Charges,70% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,1.94,14,,1.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.84,100,,136.048,Percent of Total Billed Charges,100% of Total Billed Charges,1.94,184.56,
SIMETHICONE DROP 30ML,53163333,CDM,250,RC,,,Outpatient,,,11.38,6.83,,6.83,60,,5.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,28,,2.552,Percent of Total Billed Charges,28% of Total Billed Charges,184.96,32,,147.968,Percent of Total Billed Charges,32% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% of Total Billed Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% Total Bille Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% of Total Billed Charges,6.83,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14.42,,1.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.54,75,,241.728,Percent of Total Billed Charges,75% of Total Billed Charges,5.69,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,5.69,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.69,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,5.69,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,70,,6.376,Percent of Total Billed Charges,70% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.38,100,,322.304,Percent of Total Billed Charges,100% of Total Billed Charges,1.59,184.96,
SOD CITR/CITRIC ACID 30ML,53163556,CDM,250,RC,,,Outpatient,,,19.84,11.90,,11.9,60,,9.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.56,28,,4.448,Percent of Total Billed Charges,28% of Total Billed Charges,185.47,32,,148.376,Percent of Total Billed Charges,32% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,7.14,36,,5.712,Percent of Total Billed Charges,36% of Total Billed Charges,7.14,36,,5.712,Percent of Total Billed Charges,36% Total Bille Charges,7.14,36,,5.712,Percent of Total Billed Charges,36% of Total Billed Charges,11.9,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14.42,,2.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.88,75,,2.92,Percent of Total Billed Charges,75% of Total Billed Charges,9.92,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.92,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.89,70,,11.112,Percent of Total Billed Charges,70% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,14,,2.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.84,100,,3.896,Percent of Total Billed Charges,100% of Total Billed Charges,2.78,185.47,
CHARCOAL/SORBITL 25GM/120,53163750,CDM,250,RC,,,Outpatient,,,100.14,60.08,,60.08,60,,48.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.04,28,,22.432,Percent of Total Billed Charges,28% of Total Billed Charges,18.8,32,,15.04,Percent of Total Billed Charges,32% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,36.05,36,,28.84,Percent of Total Billed Charges,36% of Total Billed Charges,36.05,36,,28.84,Percent of Total Billed Charges,36% Total Bille Charges,36.05,36,,28.84,Percent of Total Billed Charges,36% of Total Billed Charges,60.08,60,,548.848,Percent of Total Billed Charges,60% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.44,14.42,,11.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.11,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,50.07,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,50.07,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.07,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,50.07,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.1,70,,56.08,Percent of Total Billed Charges,70% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,14.02,14,,11.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.14,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,14.02,100.14,
SUCRALFATE 1GM/10ML SUS UD,53163903,CDM,250,RC,,,Outpatient,,,15.8,9.48,,9.48,60,,7.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.42,28,,3.536,Percent of Total Billed Charges,28% of Total Billed Charges,185.6,32,,148.48,Percent of Total Billed Charges,32% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.69,36,,4.552,Percent of Total Billed Charges,36% of Total Billed Charges,5.69,36,,4.552,Percent of Total Billed Charges,36% Total Bille Charges,5.69,36,,4.552,Percent of Total Billed Charges,36% of Total Billed Charges,9.48,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14.42,,1.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,75,,850.488,Percent of Total Billed Charges,75% of Total Billed Charges,7.9,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,7.9,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.9,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,7.9,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.06,70,,8.848,Percent of Total Billed Charges,70% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,14,,1.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.8,100,,1133.984,Percent of Total Billed Charges,100% of Total Billed Charges,2.21,185.6,
VALPROIC ACID 250MG/5ML SYR UD,53165825,CDM,250,RC,,,Outpatient,,,0.21,0.13,,0.13,60,,0.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,185.6,32,,148.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,75,,9.664,Percent of Total Billed Charges,75% of Total Billed Charges,0.11,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,70,,0.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,100,,12.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,185.6,
ZIDOVUDINE 10MG INJ,53166610,CDM,250,RC,J3485,HCPCS,Outpatient,,,9.01,5.41,,1.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.41,60,,101.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.76,75,,4.36,Percent of Total Billed Charges,75% of Total Billed Charges,1.21,80,,13.152,Fee Schedule,80% of Scott and White EPO fee schedule,1.21,80,,13.232,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.21,80,,13.232,Fee Schedule,80% of Scott and White PPO fee schedule,1.21,80,,275.52,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.31,70,,5.048,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.01,100,,5.808,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,9.01,
ETRAVIRINE 200 MG TAB,53166620,CDM,250,RC,,,Outpatient,,,42.8,25.68,,25.68,60,,20.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.98,28,,9.584,Percent of Total Billed Charges,28% of Total Billed Charges,186.9,32,,149.52,Percent of Total Billed Charges,32% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,15.41,36,,12.328,Percent of Total Billed Charges,36% of Total Billed Charges,15.41,36,,12.328,Percent of Total Billed Charges,36% Total Bille Charges,15.41,36,,12.328,Percent of Total Billed Charges,36% of Total Billed Charges,25.68,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14.42,,4.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.1,75,,4.36,Percent of Total Billed Charges,75% of Total Billed Charges,21.4,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,21.4,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.4,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,21.4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.96,70,,23.968,Percent of Total Billed Charges,70% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.99,14,,4.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.8,100,,5.808,Percent of Total Billed Charges,100% of Total Billed Charges,5.99,186.9,
ACETAZOLAMIDE 500MG INJ,53180048,CDM,250,RC,J1120,HCPCS,Outpatient,,,300,180.00,,23.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,25.17,360,,,Fee Schedule,360% of BCBS POS Rate,25.17,360,,,Fee schedule,360% of BCBS PPO Rate,25.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,226.8,Percent of Total Billed Charges,75% of Total Billed Charges,23.21,80,,13.232,Fee Schedule,80% of Scott and White EPO fee schedule,23.21,80,,36,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.21,80,,36,Fee Schedule,80% of Scott and White PPO fee schedule,23.21,80,,1936.552,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,302.4,Percent of Total Billed Charges,100% of Total Billed Charges,23.21,300,
ABCIXIMAB 10MG/5ML SDV INJ,53180089,CDM,250,RC,J0130,HCPCS,Outpatient,,,4.16,2.50,,1294.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1348.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1348.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,1348.18,360,,,Fee Schedule,360% of BCBS POS Rate,1348.18,360,,,Fee schedule,360% of BCBS PPO Rate,1348.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.5,60,,107.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.6,14.42,,0.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.12,75,,166.32,Percent of Total Billed Charges,75% of Total Billed Charges,2.08,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,2.08,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.08,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,2.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.91,70,,2.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14,,0.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.16,100,,221.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.58,1348.18,
ACYCLOVIR 500MG INJ,53180113,CDM,250,RC,J0133,HCPCS,Outpatient,,,23.46,14.08,,0.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.12,360,,,Fee Schedule,360% of BCBS POS Rate,0.12,360,,,Fee schedule,360% of BCBS PPO Rate,0.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,14.08,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,75,,65.288,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,80,,36,Fee Schedule,80% of Scott and White EPO fee schedule,0.03,80,,120,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,80,,120,Fee Schedule,80% of Scott and White PPO fee schedule,0.03,80,,5.312,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.42,70,,13.136,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.46,100,,87.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,23.46,
ACETYLCYSTEINE INJ 6000MG/30ML VIAL,53180162,CDM,250,RC,J0132,HCPCS,Outpatient,,,1229.4,737.64,,0.79,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.17,360,,,Fee Schedule,360% of BCBS POS Rate,2.17,360,,,Fee schedule,360% of BCBS PPO Rate,2.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,737.64,60,,1814.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,922.05,75,,37.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,36,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,293.928,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,293.928,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,3.872,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,860.58,70,,688.464,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1229.4,100,,50.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,1229.4,
ADENOSINE 60MG/20ML INJ,53180254,CDM,250,RC,J0153,HCPCS,Outpatient,,,713.66,428.20,,0.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,360,,,Fee Schedule,360% of BCBS POS Rate,1.26,360,,,Fee schedule,360% of BCBS PPO Rate,1.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,428.2,60,,44.872,Percent of Total Billed Charges,60% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,102.91,14.42,,82.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.25,75,,51.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,120,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,31.384,Fee Schedule,80% of Scott and White HMO fee schedule,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,80,,31.384,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,93.72,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,499.56,70,,399.648,Percent of Total Billed Charges,70% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,99.91,14,,79.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.66,100,,68.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,713.66,
ALBUMIN 5% 2.5 GM VL 50 ML,53180311,CDM,250,RC,P9041,HCPCS,Outpatient,,,193.98,116.39,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.92,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.44,360,,,Fee Schedule,360% of BCBS POS Rate,12.44,360,,,Fee schedule,360% of BCBS PPO Rate,12.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.39,60,,106.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,9.55,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.93,103,,,Fee Schedule,103% of CMS OPPS Rate,10.93,103,,,Fee Schedule,103% of CMS OPPS Rate,145.49,75,,15.768,Percent of Total Billed Charges,75% of Total Billed Charges,8.49,80,,293.928,Fee Schedule,80% of Scott and White EPO fee schedule,8.49,80,,526.472,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.49,80,,526.472,Fee Schedule,80% of Scott and White PPO fee schedule,8.49,80,,835.528,Fee Schedule,80% of Scott and White SWHP fee schedule,15.92,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,135.79,70,,108.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,193.98,100,,21.024,Percent of Total Billed Charges,100% of Total Billed Charges,8.49,193.98,
ALBUMIN 5% 12.5 GM VL 250 ML,53180329,CDM,250,RC,P9045,HCPCS,Outpatient,,,265.5,159.30,,55.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,79.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,62.21,360,,,Fee Schedule,360% of BCBS POS Rate,62.21,360,,,Fee schedule,360% of BCBS PPO Rate,62.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.3,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,47.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,199.13,75,,123.072,Percent of Total Billed Charges,75% of Total Billed Charges,42.46,80,,31.384,Fee Schedule,80% of Scott and White EPO fee schedule,42.46,80,,174.888,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.46,80,,174.888,Fee Schedule,80% of Scott and White PPO fee schedule,42.46,80,,28.16,Fee Schedule,80% of Scott and White SWHP fee schedule,79.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,185.85,70,,148.68,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,100,,164.096,Percent of Total Billed Charges,100% of Total Billed Charges,42.46,265.5,
REGADENOSON 0.4MG/5ML SYRG,53180394,CDM,250,RC,J2785,HCPCS,Outpatient,,,1066.64,639.98,,61.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,60.74,360,,,Fee Schedule,360% of BCBS POS Rate,60.74,360,,,Fee schedule,360% of BCBS PPO Rate,60.74,360,,,Fee Schedule,360% of BCBS Traditional Rate,639.98,60,,183.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,799.98,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,49.59,80,,526.472,Fee Schedule,80% of Scott and White EPO fee schedule,49.59,80,,4.752,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.59,80,,4.752,Fee Schedule,80% of Scott and White PPO fee schedule,49.59,80,,2783.24,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,746.65,70,,597.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1066.64,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,49.59,1066.64,
ALBUMIN 25% 12.5 GM VL 50ML,53180634,CDM,250,RC,P9047,HCPCS,Outpatient,,,565.9,339.54,,54,100,,,Fee Schedule,100% of Aetna Fee Schedule,79.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,62.21,360,,,Fee Schedule,360% of BCBS POS Rate,62.21,360,,,Fee schedule,360% of BCBS PPO Rate,62.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,339.54,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,47.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,424.43,75,,218.752,Percent of Total Billed Charges,75% of Total Billed Charges,42.46,80,,174.888,Fee Schedule,80% of Scott and White EPO fee schedule,42.46,80,,35.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.46,80,,35.904,Fee Schedule,80% of Scott and White PPO fee schedule,42.46,80,,1393.64,Fee Schedule,80% of Scott and White SWHP fee schedule,79.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,396.13,70,,316.904,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,565.9,100,,291.672,Percent of Total Billed Charges,100% of Total Billed Charges,42.46,565.9,
ALPROSTADIL 500MCG/ML INJ 1ML,53180832,CDM,250,RC,J0270,HCPCS,Outpatient,,,549.59,329.75,,8.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,360,,,Fee Schedule,360% of BCBS POS Rate,0.19,360,,,Fee schedule,360% of BCBS PPO Rate,0.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,329.75,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,79.25,14.42,,63.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.19,75,,42.912,Percent of Total Billed Charges,75% of Total Billed Charges,274.8,50,,4.752,Percent of Total Billed Charges,50% of Total Billed Charges,274.8,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.8,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,274.8,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,384.71,70,,307.768,Percent of Total Billed Charges,70% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,76.94,14,,61.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,549.59,100,,57.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,549.59,
METHOTREXATE 50MG LPF VL 2ML,53180881,CDM,250,RC,J9260,HCPCS,Outpatient,,,77.81,46.69,,2.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.19,360,,,Fee Schedule,360% of BCBS POS Rate,1.19,360,,,Fee schedule,360% of BCBS PPO Rate,1.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.69,60,,311.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.36,75,,130.368,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,80,,35.904,Fee Schedule,80% of Scott and White EPO fee schedule,1.95,80,,2.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.95,80,,2.104,Fee Schedule,80% of Scott and White PPO fee schedule,1.95,80,,13.152,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.47,70,,43.576,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.81,100,,173.824,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,77.81,
ALTEPLASE 2MG/2ML OCCL CATH,53180964,CDM,250,RC,J2997,HCPCS,Outpatient,,,716.77,430.06,,88.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,137.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,37.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,37.65,360,,,Fee Schedule,360% of BCBS POS Rate,37.65,360,,,Fee schedule,360% of BCBS PPO Rate,37.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,430.06,60,,201.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,82.32,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,118.91,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.21,103,,,Fee Schedule,103% of CMS OPPS Rate,94.21,103,,,Fee Schedule,103% of CMS OPPS Rate,537.58,75,,74.608,Percent of Total Billed Charges,75% of Total Billed Charges,70.05,80,,4.12,Fee Schedule,80% of Scott and White EPO fee schedule,70.05,80,,7.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,70.05,80,,7.368,Fee Schedule,80% of Scott and White PPO fee schedule,70.05,80,,13.232,Fee Schedule,80% of Scott and White SWHP fee schedule,137.19,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,501.74,70,,401.392,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,716.77,100,,99.472,Percent of Total Billed Charges,100% of Total Billed Charges,37.65,716.77,
BIVALIRUDIN 250 MG INJ,53180972,CDM,250,RC,J0583,HCPCS,Outpatient,,,2423.8,1454.28,,0.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,1454.28,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1817.85,75,,56.416,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,80,,2.104,Fee Schedule,80% of Scott and White EPO fee schedule,0.14,80,,4.504,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,80,,4.504,Fee Schedule,80% of Scott and White PPO fee schedule,0.14,80,,281.912,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1696.66,70,,1357.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2423.8,100,,75.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,2423.8,
AMIKACIN INJ 250MG/ML 2ML SDV,53181145,CDM,250,RC,J0278,HCPCS,Outpatient,,,22.06,13.24,,0.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.09,360,,,Fee Schedule,360% of BCBS POS Rate,1.09,360,,,Fee schedule,360% of BCBS PPO Rate,1.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.24,60,,703.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,75,,68.248,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,80,,7.368,Fee Schedule,80% of Scott and White EPO fee schedule,0.76,80,,306.008,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,80,,306.008,Fee Schedule,80% of Scott and White PPO fee schedule,0.76,80,,36,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.44,70,,12.352,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.06,100,,91,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,22.06,
AMINOCAPROIC ACID 5000MG VL,53181517,CDM,250,RC,,,Outpatient,,,68.15,40.89,,40.89,60,,32.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.08,28,,15.264,Percent of Total Billed Charges,28% of Total Billed Charges,187.12,32,,149.696,Percent of Total Billed Charges,32% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,24.53,36,,19.624,Percent of Total Billed Charges,36% of Total Billed Charges,24.53,36,,19.624,Percent of Total Billed Charges,36% Total Bille Charges,24.53,36,,19.624,Percent of Total Billed Charges,36% of Total Billed Charges,40.89,60,,116.72,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14.42,,7.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.11,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,50,,4.504,Percent of Total Billed Charges,50% of Total Billed Charges,34.08,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.08,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.08,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.71,70,,38.168,Percent of Total Billed Charges,70% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,9.54,14,,7.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.15,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.54,187.12,
AMINOPHYLLINE 250MG/10ML INJ,53181772,CDM,250,RC,J0280,HCPCS,Outpatient,,,68.22,40.93,,6.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.68,360,,,Fee Schedule,360% of BCBS POS Rate,0.68,360,,,Fee schedule,360% of BCBS PPO Rate,0.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.93,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.17,75,,13.256,Percent of Total Billed Charges,75% of Total Billed Charges,7.14,80,,306.008,Fee Schedule,80% of Scott and White EPO fee schedule,7.14,80,,1.624,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,80,,1.624,Fee Schedule,80% of Scott and White PPO fee schedule,7.14,80,,120,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.75,70,,38.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.22,100,,17.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,68.22,
AMIODARONE 50MG/ML INJ 3ML,53182002,CDM,250,RC,J0282,HCPCS,Outpatient,,,8.46,5.08,,0.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.08,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.35,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,4.23,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,293.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.92,70,,4.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.46,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,8.46,
AMIODARONE 360MG/200ML BAG,53182025,CDM,250,RC,J0282,HCPCS,Outpatient,,,276.84,166.10,,0.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,166.1,60,,99.808,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.63,75,,73.152,Percent of Total Billed Charges,75% of Total Billed Charges,138.42,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,138.42,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.42,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,138.42,50,,31.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.79,70,,155.032,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.84,100,,97.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,276.84,
AMIODARONE 50MG/ML INJ 9ML,53182028,CDM,250,RC,J0282,HCPCS,Outpatient,,,26.28,15.77,,0.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.77,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.71,75,,46.848,Percent of Total Billed Charges,75% of Total Billed Charges,13.14,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,13.14,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.14,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,13.14,50,,526.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,70,,14.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.28,100,,62.464,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,26.28,
AMPHOTERICIN B (LIPO) INJ 10MG,53182515,CDM,250,RC,J0289,HCPCS,Outpatient,,,277.08,166.25,,29.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.99,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,49.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,49.43,360,,,Fee Schedule,360% of BCBS POS Rate,49.43,360,,,Fee schedule,360% of BCBS PPO Rate,49.43,360,,,Fee Schedule,360% of BCBS Traditional Rate,166.25,60,,32.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,20.99,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,30.32,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.02,103,,,Fee Schedule,103% of CMS OPPS Rate,24.02,103,,,Fee Schedule,103% of CMS OPPS Rate,207.81,75,,20.128,Percent of Total Billed Charges,75% of Total Billed Charges,21.48,80,,22.248,Fee Schedule,80% of Scott and White EPO fee schedule,21.48,80,,13.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,80,,13.2,Fee Schedule,80% of Scott and White PPO fee schedule,21.48,80,,174.888,Fee Schedule,80% of Scott and White SWHP fee schedule,34.99,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,193.96,70,,155.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,277.08,100,,26.832,Percent of Total Billed Charges,100% of Total Billed Charges,20.99,277.08,
AMPICILLIN 500MG VL,53182655,CDM,250,RC,J0290,HCPCS,Outpatient,,,23,13.80,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.8,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.25,75,,23.528,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,2.296,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,11.456,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,11.456,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,4.752,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.1,70,,12.88,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,100,,31.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,23,
AMPICILLIN 1GM VL,53182713,CDM,250,RC,J0290,HCPCS,Outpatient,,,49.24,29.54,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,29.54,60,,313.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.93,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,13.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,55.032,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,55.032,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,35.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.47,70,,27.576,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.24,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,49.24,
AMPICILLIN 250MG VL,53182861,CDM,250,RC,J0290,HCPCS,Outpatient,,,19.39,11.63,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.63,60,,172.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.54,75,,207.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,11.456,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,4.08,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,4.08,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,4.12,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.57,70,,10.856,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.39,100,,276.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,19.39,
AMPICILLIN/SULBAC 1.5GM ADV,53182929,CDM,250,RC,J0295,HCPCS,Outpatient,,,37.46,22.48,,2.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.14,360,,,Fee Schedule,360% of BCBS POS Rate,3.14,360,,,Fee schedule,360% of BCBS PPO Rate,3.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.48,60,,1902.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.1,75,,24.16,Percent of Total Billed Charges,75% of Total Billed Charges,1.73,80,,55.032,Fee Schedule,80% of Scott and White EPO fee schedule,1.73,80,,18.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,80,,18.2,Fee Schedule,80% of Scott and White PPO fee schedule,1.73,80,,2.104,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.22,70,,20.976,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.46,100,,32.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,37.46,
AMPICILLIN/SULBAC 3GM ADV,53182937,CDM,250,RC,J0295,HCPCS,Outpatient,,,73.24,43.94,,2.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.14,360,,,Fee Schedule,360% of BCBS POS Rate,3.14,360,,,Fee schedule,360% of BCBS PPO Rate,3.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.94,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.93,75,,6180.696,Percent of Total Billed Charges,75% of Total Billed Charges,1.73,80,,4.08,Fee Schedule,80% of Scott and White EPO fee schedule,1.73,80,,1.504,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,80,,1.504,Fee Schedule,80% of Scott and White PPO fee schedule,1.73,80,,7.368,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.27,70,,41.016,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.24,100,,8240.928,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,73.24,
ATROPINE 1MG/ML VL 1ML,53183778,CDM,250,RC,J0461,HCPCS,Outpatient,,,86.5,51.90,,0.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.05,360,,,Fee Schedule,360% of BCBS POS Rate,0.05,360,,,Fee schedule,360% of BCBS PPO Rate,0.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,51.9,60,,53.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.88,75,,427.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,80,,18.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.07,80,,1.824,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,80,,1.824,Fee Schedule,80% of Scott and White PPO fee schedule,0.07,80,,4.504,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.55,70,,48.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.5,100,,570.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,86.5,
ATROPINE 0.1 MG/ML SYRG 10 ML,53183851,CDM,250,RC,J0461,HCPCS,Outpatient,,,69.87,41.92,,0.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.05,360,,,Fee Schedule,360% of BCBS POS Rate,0.05,360,,,Fee schedule,360% of BCBS PPO Rate,0.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,41.92,60,,252,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.4,75,,9.416,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,80,,1.504,Fee Schedule,80% of Scott and White EPO fee schedule,0.07,80,,3.648,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,80,,3.648,Fee Schedule,80% of Scott and White PPO fee schedule,0.07,80,,306.008,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.91,70,,39.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.87,100,,12.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,69.87,
AZITHROMYCIN 500MG INJ,53184149,CDM,250,RC,J0456,HCPCS,Outpatient,,,41,24.60,,2.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.15,360,,,Fee Schedule,360% of BCBS POS Rate,4.15,360,,,Fee schedule,360% of BCBS PPO Rate,4.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.6,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.75,75,,43.528,Percent of Total Billed Charges,75% of Total Billed Charges,2.07,80,,1.824,Fee Schedule,80% of Scott and White EPO fee schedule,2.07,80,,19.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,80,,19.2,Fee Schedule,80% of Scott and White PPO fee schedule,2.07,80,,118.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.7,70,,22.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41,100,,58.032,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,41,
AZTREONAM 1GM VL,53184172,CDM,250,RC,,,Outpatient,,,179,107.40,,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.12,28,,40.096,Percent of Total Billed Charges,28% of Total Billed Charges,187.39,32,,149.912,Percent of Total Billed Charges,32% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,64.44,36,,51.552,Percent of Total Billed Charges,36% Total Bille Charges,64.44,36,,51.552,Percent of Total Billed Charges,36% of Total Billed Charges,107.4,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.81,14.42,,20.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.25,75,,12.352,Percent of Total Billed Charges,75% of Total Billed Charges,89.5,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.5,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,89.5,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.3,70,,100.24,Percent of Total Billed Charges,70% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,25.06,14,,20.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179,100,,16.464,Percent of Total Billed Charges,100% of Total Billed Charges,25.06,187.39,
AZTREONAM 2GM VL,53184180,CDM,250,RC,,,Outpatient,,,300,180.00,,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,188.75,32,,151,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,140.464,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,92.776,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,123.704,Percent of Total Billed Charges,100% of Total Billed Charges,42,300,
BACITRACIN 500UN/GM ONT 15GM,53184537,CDM,250,RC,,,Outpatient,,,4.34,2.60,,2.6,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,19034.4,32,,15227.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,2.6,60,,236.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,0.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.26,75,,147.784,Percent of Total Billed Charges,75% of Total Billed Charges,2.17,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,70,,2.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,100,,197.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,19034.4,
BENZTROPINE 1 MG/ML INJ 2 ML,53185377,CDM,250,RC,J0515,HCPCS,Outpatient,,,337.5,202.50,,19.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,17.96,360,,,Fee Schedule,360% of BCBS POS Rate,17.96,360,,,Fee schedule,360% of BCBS PPO Rate,17.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,202.5,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.13,75,,147.784,Percent of Total Billed Charges,75% of Total Billed Charges,12.7,80,,20.312,Fee Schedule,80% of Scott and White EPO fee schedule,12.7,80,,14.272,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.7,80,,14.272,Fee Schedule,80% of Scott and White PPO fee schedule,12.7,80,,2.296,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.25,70,,189,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,337.5,100,,197.04,Percent of Total Billed Charges,100% of Total Billed Charges,12.7,337.5,
BETAMETHASONE 6MG/ML INJ 2ML,53185590,CDM,250,RC,J0702,HCPCS,Outpatient,,,118.68,71.21,,6.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.53,360,,,Fee Schedule,360% of BCBS POS Rate,5.53,360,,,Fee schedule,360% of BCBS PPO Rate,5.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.21,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.01,75,,211.368,Percent of Total Billed Charges,75% of Total Billed Charges,5.12,80,,18.184,Fee Schedule,80% of Scott and White EPO fee schedule,5.12,80,,288.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,80,,288.4,Fee Schedule,80% of Scott and White PPO fee schedule,5.12,80,,13.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.08,70,,66.464,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.68,100,,281.824,Percent of Total Billed Charges,100% of Total Billed Charges,5.12,118.68,
BLEOMYCIN SULF 15UN INJ,53186219,CDM,250,RC,J9040,HCPCS,Outpatient,,,298.34,179.00,,27.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,31.88,360,,,Fee Schedule,360% of BCBS POS Rate,31.88,360,,,Fee schedule,360% of BCBS PPO Rate,31.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,179,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.76,75,,92.776,Percent of Total Billed Charges,75% of Total Billed Charges,19.42,80,,14.272,Fee Schedule,80% of Scott and White EPO fee schedule,19.42,80,,49.504,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.42,80,,49.504,Fee Schedule,80% of Scott and White PPO fee schedule,19.42,80,,11.456,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.84,70,,167.072,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.34,100,,123.704,Percent of Total Billed Charges,100% of Total Billed Charges,19.42,298.34,
BUMETANIDE 2.5MG/10ML INJ,53186839,CDM,250,RC,,,Outpatient,,,35.05,21.03,,21.03,60,,16.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.81,28,,7.848,Percent of Total Billed Charges,28% of Total Billed Charges,19131.2,32,,15304.96,Percent of Total Billed Charges,32% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,12.62,36,,10.096,Percent of Total Billed Charges,36% of Total Billed Charges,12.62,36,,10.096,Percent of Total Billed Charges,36% Total Bille Charges,12.62,36,,10.096,Percent of Total Billed Charges,36% of Total Billed Charges,21.03,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14.42,,4.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.29,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,17.53,50,,288.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.53,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.53,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,17.53,50,,55.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.54,70,,19.632,Percent of Total Billed Charges,70% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,14,,3.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.05,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,4.91,19131.2,
BUMETANIDE 1MG/4ML INJ,53186854,CDM,250,RC,,,Outpatient,,,27.37,16.42,,16.42,60,,13.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.66,28,,6.128,Percent of Total Billed Charges,28% of Total Billed Charges,18.91,32,,15.128,Percent of Total Billed Charges,32% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,9.85,36,,7.88,Percent of Total Billed Charges,36% of Total Billed Charges,9.85,36,,7.88,Percent of Total Billed Charges,36% Total Bille Charges,9.85,36,,7.88,Percent of Total Billed Charges,36% of Total Billed Charges,16.42,60,,205.384,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14.42,,3.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.53,75,,280.392,Percent of Total Billed Charges,75% of Total Billed Charges,13.69,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,13.69,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,13.69,50,,4.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.16,70,,15.328,Percent of Total Billed Charges,70% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.37,100,,373.856,Percent of Total Billed Charges,100% of Total Billed Charges,3.83,27.37,
BUPIVACAINE 0.25% W/EPI INJ 10,53186987,CDM,250,RC,,,Outpatient,,,21.67,13.00,,13,60,,10.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.07,28,,4.856,Percent of Total Billed Charges,28% of Total Billed Charges,19.17,32,,15.336,Percent of Total Billed Charges,32% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,7.8,36,,6.24,Percent of Total Billed Charges,36% of Total Billed Charges,7.8,36,,6.24,Percent of Total Billed Charges,36% Total Bille Charges,7.8,36,,6.24,Percent of Total Billed Charges,36% of Total Billed Charges,13,60,,214.624,Percent of Total Billed Charges,60% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,14.42,,2.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.25,75,,255.52,Percent of Total Billed Charges,75% of Total Billed Charges,10.84,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,50,,18.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.17,70,,12.136,Percent of Total Billed Charges,70% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.67,100,,340.688,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,21.67,
BUPIVACAINE 0.25% W/EPI INJ 30,53187027,CDM,250,RC,,,Outpatient,,,56.36,33.82,,33.82,60,,27.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.78,28,,12.624,Percent of Total Billed Charges,28% of Total Billed Charges,188.8,32,,151.04,Percent of Total Billed Charges,32% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,20.29,36,,16.232,Percent of Total Billed Charges,36% of Total Billed Charges,20.29,36,,16.232,Percent of Total Billed Charges,36% Total Bille Charges,20.29,36,,16.232,Percent of Total Billed Charges,36% of Total Billed Charges,33.82,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,8.13,14.42,,6.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.27,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,28.18,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,28.18,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.18,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,28.18,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.45,70,,31.56,Percent of Total Billed Charges,70% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.89,14,,6.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.36,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,7.89,188.8,
BUPIVACAINE MPF 0.25% INJ 10ML,53187035,CDM,250,RC,,,Outpatient,,,6.07,3.64,,3.64,60,,2.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.7,28,,1.36,Percent of Total Billed Charges,28% of Total Billed Charges,188.8,32,,151.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% of Total Billed Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% Total Bille Charges,2.19,36,,1.752,Percent of Total Billed Charges,36% of Total Billed Charges,3.64,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,0.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,75,,13.768,Percent of Total Billed Charges,75% of Total Billed Charges,3.04,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,3.04,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,3.04,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,70,,3.4,Percent of Total Billed Charges,70% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,14,,0.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.07,100,,18.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,188.8,
BUPIVACAINE MPF 0.5% VL 10ML,53187084,CDM,250,RC,,,Outpatient,,,13.69,8.21,,8.21,60,,6.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.83,28,,3.064,Percent of Total Billed Charges,28% of Total Billed Charges,188.99,32,,151.192,Percent of Total Billed Charges,32% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,36,,3.944,Percent of Total Billed Charges,36% of Total Billed Charges,4.93,36,,3.944,Percent of Total Billed Charges,36% Total Bille Charges,4.93,36,,3.944,Percent of Total Billed Charges,36% of Total Billed Charges,8.21,60,,625.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14.42,,1.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.27,75,,90.96,Percent of Total Billed Charges,75% of Total Billed Charges,6.85,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,6.85,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.85,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,6.85,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.58,70,,7.664,Percent of Total Billed Charges,70% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.92,14,,1.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,100,,121.28,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,188.99,
BUPIVACAINE MPF 0.5% INJ 30ML,53187100,CDM,250,RC,,,Outpatient,,,7.97,4.78,,4.78,60,,3.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.23,28,,1.784,Percent of Total Billed Charges,28% of Total Billed Charges,189.19,32,,151.352,Percent of Total Billed Charges,32% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% of Total Billed Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% Total Bille Charges,2.87,36,,2.296,Percent of Total Billed Charges,36% of Total Billed Charges,4.78,60,,64.384,Percent of Total Billed Charges,60% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14.42,,0.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.98,75,,104.224,Percent of Total Billed Charges,75% of Total Billed Charges,3.99,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,3.99,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.99,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,3.99,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.58,70,,4.464,Percent of Total Billed Charges,70% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14,,0.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,100,,138.968,Percent of Total Billed Charges,100% of Total Billed Charges,1.12,189.19,
BUPIVACAINE MPF 0.75% INJ 10ML,53187134,CDM,250,RC,,,Outpatient,,,13.64,8.18,,8.18,60,,6.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.82,28,,3.056,Percent of Total Billed Charges,28% of Total Billed Charges,190.21,32,,152.168,Percent of Total Billed Charges,32% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,4.91,36,,3.928,Percent of Total Billed Charges,36% of Total Billed Charges,4.91,36,,3.928,Percent of Total Billed Charges,36% Total Bille Charges,4.91,36,,3.928,Percent of Total Billed Charges,36% of Total Billed Charges,8.18,60,,54.424,Percent of Total Billed Charges,60% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14.42,,1.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.23,75,,43.528,Percent of Total Billed Charges,75% of Total Billed Charges,6.82,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,6.82,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.82,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,6.82,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.55,70,,7.64,Percent of Total Billed Charges,70% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,1.91,14,,1.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.64,100,,58.032,Percent of Total Billed Charges,100% of Total Billed Charges,1.91,190.21,
BUPIVACAINE 0.5% W/EPI VL 30ML,53187415,CDM,250,RC,,,Outpatient,,,17.71,10.63,,10.63,60,,8.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.96,28,,3.968,Percent of Total Billed Charges,28% of Total Billed Charges,190.21,32,,152.168,Percent of Total Billed Charges,32% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,36,,5.104,Percent of Total Billed Charges,36% of Total Billed Charges,6.38,36,,5.104,Percent of Total Billed Charges,36% Total Bille Charges,6.38,36,,5.104,Percent of Total Billed Charges,36% of Total Billed Charges,10.63,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.55,14.42,,2.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.28,75,,256.504,Percent of Total Billed Charges,75% of Total Billed Charges,8.86,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,8.86,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.86,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,8.86,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,70,,9.92,Percent of Total Billed Charges,70% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,2.48,14,,1.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.71,100,,342,Percent of Total Billed Charges,100% of Total Billed Charges,2.48,190.21,
BUPIVACAINE/DEXT 0.75% AMP 2ML,53187472,CDM,250,RC,,,Outpatient,,,16.97,10.18,,10.18,60,,8.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.75,28,,3.8,Percent of Total Billed Charges,28% of Total Billed Charges,190.4,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% Total Bille Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,10.18,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14.42,,1.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.73,75,,84.168,Percent of Total Billed Charges,75% of Total Billed Charges,8.49,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,8.49,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,8.49,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.88,70,,9.504,Percent of Total Billed Charges,70% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.97,100,,112.224,Percent of Total Billed Charges,100% of Total Billed Charges,2.38,190.4,
BUPRENORPHINE 0.3MG/ML AMP 1ML,53187506,CDM,250,RC,J0592,HCPCS,Outpatient,,,59.71,35.83,,4.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.94,360,,,Fee Schedule,360% of BCBS POS Rate,2.94,360,,,Fee schedule,360% of BCBS PPO Rate,2.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.83,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.78,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,3.21,80,,5.952,Fee Schedule,80% of Scott and White EPO fee schedule,3.21,80,,14,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,80,,14,Fee Schedule,80% of Scott and White PPO fee schedule,3.21,80,,14.272,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.8,70,,33.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.71,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,2.94,59.71,
BUTORPHANOL TART 1MG/ML VL 1ML,53187522,CDM,250,RC,J0595,HCPCS,Outpatient,,,29.2,17.52,,2.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.91,360,,,Fee Schedule,360% of BCBS POS Rate,0.91,360,,,Fee schedule,360% of BCBS PPO Rate,0.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,17.52,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.9,75,,24.04,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,80,,2.456,Fee Schedule,80% of Scott and White EPO fee schedule,2.7,80,,10.464,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,80,,10.464,Fee Schedule,80% of Scott and White PPO fee schedule,2.7,80,,288.4,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.44,70,,16.352,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.2,100,,32.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.91,29.2,
BUTORPHANOL TART 2MG/ML VL 1ML,53187530,CDM,250,RC,J0595,HCPCS,Outpatient,,,35.72,21.43,,2.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.91,360,,,Fee Schedule,360% of BCBS POS Rate,0.91,360,,,Fee schedule,360% of BCBS PPO Rate,0.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.43,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.79,75,,38.416,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,80,,14,Fee Schedule,80% of Scott and White EPO fee schedule,2.7,80,,17.04,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,80,,17.04,Fee Schedule,80% of Scott and White PPO fee schedule,2.7,80,,49.504,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,70,,20,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.72,100,,51.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.91,35.72,
CAFFEINE CIT 20 MG/ML INJ 3ML,53187605,CDM,250,RC,J0706,HCPCS,Outpatient,,,143.94,86.36,,0.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.36,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.96,75,,513,Percent of Total Billed Charges,75% of Total Billed Charges,71.97,50,,10.464,Percent of Total Billed Charges,50% of Total Billed Charges,71.97,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.97,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,71.97,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.76,70,,80.608,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.94,100,,684,Percent of Total Billed Charges,100% of Total Billed Charges,0.8,143.94,
CAFFEINE NA BENZ 500MG/2ML VL,53187670,CDM,250,RC,,,Outpatient,,,107.18,64.31,,64.31,60,,51.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.01,28,,24.008,Percent of Total Billed Charges,28% of Total Billed Charges,190.4,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,38.58,36,,30.864,Percent of Total Billed Charges,36% of Total Billed Charges,38.58,36,,30.864,Percent of Total Billed Charges,36% Total Bille Charges,38.58,36,,30.864,Percent of Total Billed Charges,36% of Total Billed Charges,64.31,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.46,14.42,,12.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.39,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,53.59,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,53.59,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.59,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,53.59,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.03,70,,60.024,Percent of Total Billed Charges,70% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,15.01,14,,12.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.18,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,15.01,190.4,
CALCITONIN 200UN/ML INJ 2ML,53187886,CDM,636,RC,J0630,HCPCS,Outpatient,,,7453.32,4471.99,,6969.33,110,,5575.464,Percent of Total Billed Charges,110% of Total Billed Charges,1759.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2703.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,2703.07,360,,,Fee Schedule,360% of BCBS POS Rate,2703.07,360,,,Fee schedule,360% of BCBS PPO Rate,2703.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,4099.33,55,,127.68,Percent of Total Billed Charges,55% Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.75,90,,,Fee Schedule,90% of CMS OPPS Rate,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.97,130,,,Fee Schedule,130% of CMS OPPS Rate,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1074.77,14.42,,859.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,1208.25,103,,,Fee Schedule,103% of CMS OPPS Rate,1208.25,103,,,Fee Schedule,103% of CMS OPPS Rate,5589.99,75,,34.672,Percent of Total Billed Charges,75% of Total Billed Charges,4789.05,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,4789.05,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,4789.05,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,4789.05,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,1759.59,150,,,Fee Schedule,150% of CMS OPPS Rate,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,5217.32,70,,4173.856,Percent of Total Billed Charges,70% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1043.46,14,,834.768,Percent of Total Billed Charges,14% of Total Billed Charges,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,7453.32,100,,46.224,Percent of Total Billed Charges,100% of Total Billed Charges,1043.46,7453.32,
CALCITRIOL 1MCG/1ML INJ,53187902,CDM,250,RC,J0636,HCPCS,Outpatient,,,56.25,33.75,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.75,360,,,Fee Schedule,360% of BCBS POS Rate,0.75,360,,,Fee schedule,360% of BCBS PPO Rate,0.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,33.75,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.19,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,20.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,11.184,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,11.184,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,1.56,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.38,70,,31.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.25,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,56.25,
CALCIUM CHL 10% SYG 10ML,53188090,CDM,250,RC,,,Outpatient,,,77.87,46.72,,46.72,60,,37.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.8,28,,17.44,Percent of Total Billed Charges,28% of Total Billed Charges,190.4,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,28.03,36,,22.424,Percent of Total Billed Charges,36% of Total Billed Charges,28.03,36,,22.424,Percent of Total Billed Charges,36% Total Bille Charges,28.03,36,,22.424,Percent of Total Billed Charges,36% of Total Billed Charges,46.72,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14.42,,8.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.4,75,,26.32,Percent of Total Billed Charges,75% of Total Billed Charges,38.94,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,38.94,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.94,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,38.94,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.51,70,,43.608,Percent of Total Billed Charges,70% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,10.9,14,,8.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.87,100,,35.096,Percent of Total Billed Charges,100% of Total Billed Charges,10.9,190.4,
CALCIUM GLU 10ML INJ,53188306,CDM,250,RC,J0612,HCPCS,Outpatient,,,63.38,38.03,,38.03,60,,30.424,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,360,,,Fee Schedule,360% of BCBS POS Rate,0.05,360,,,Fee schedule,360% of BCBS PPO Rate,0.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.03,60,,13.6,Percent of Total Billed Charges,60% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.02,90,,,Fee Schedule,90% of CMS OPPS Rate,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.04,130,,,Fee Schedule,130% of CMS OPPS Rate,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,9.14,14.42,,7.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,0.03,103,,,Fee Schedule,103% of CMS OPPS Rate,0.03,103,,,Fee Schedule,103% of CMS OPPS Rate,47.54,75,,153.272,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,80,,11.184,Fee Schedule,80% of Scott and White EPO fee schedule,0.03,80,,8.376,Fee Schedule,80% of Scott and White HMO fee schedule,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.03,80,,8.376,Fee Schedule,80% of Scott and White PPO fee schedule,0.03,80,,23.008,Fee Schedule,80% of Scott and White SWHP fee schedule,0.05,150,,,Fee Schedule,150% of CMS OPPS Rate,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,44.37,70,,35.496,Percent of Total Billed Charges,70% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14,,7.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,100,,,Fee Schedule,100% of CMS OPPS Rate,63.38,100,,204.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,63.38,
CARBOPROST 250MCG/1ML INJ,53189106,CDM,250,RC,,,Outpatient,,,1594.95,956.97,,956.97,60,,765.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,446.59,28,,357.272,Percent of Total Billed Charges,28% of Total Billed Charges,190.4,32,,152.32,Percent of Total Billed Charges,32% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,574.18,36,,459.344,Percent of Total Billed Charges,36% of Total Billed Charges,574.18,36,,459.344,Percent of Total Billed Charges,36% Total Bille Charges,574.18,36,,459.344,Percent of Total Billed Charges,36% of Total Billed Charges,956.97,60,,7.576,Percent of Total Billed Charges,60% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,229.99,14.42,,183.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1196.21,75,,45,Percent of Total Billed Charges,75% of Total Billed Charges,797.48,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,797.48,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,797.48,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,797.48,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1116.47,70,,893.176,Percent of Total Billed Charges,70% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,223.29,14,,178.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1594.95,100,,60,Percent of Total Billed Charges,100% of Total Billed Charges,190.4,1594.95,
CARBOPLATIN 50MG INJ,53189114,CDM,250,RC,J9045,HCPCS,Outpatient,,,123.44,74.06,,2.63,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.68,360,,,Fee Schedule,360% of BCBS POS Rate,2.68,360,,,Fee schedule,360% of BCBS PPO Rate,2.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.06,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.58,75,,155.968,Percent of Total Billed Charges,75% of Total Billed Charges,1.9,80,,8.376,Fee Schedule,80% of Scott and White EPO fee schedule,1.9,80,,20.176,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,80,,20.176,Fee Schedule,80% of Scott and White PPO fee schedule,1.9,80,,13.216,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.41,70,,69.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.44,100,,207.952,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,123.44,
TRABECTEDIN VL 1MG,53189131,CDM,636,RC,J9352,HCPCS,Outpatient,,,8477.24,5086.34,,4990.76,110,,3992.608,Percent of Total Billed Charges,110% of Total Billed Charges,544.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,306.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,306.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,306.63,360,,,Fee Schedule,360% of BCBS POS Rate,306.63,360,,,Fee schedule,360% of BCBS PPO Rate,306.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,4662.48,55,,420,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,326.52,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,471.66,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.7,103,,,Fee Schedule,103% of CMS OPPS Rate,373.7,103,,,Fee Schedule,103% of CMS OPPS Rate,6357.93,75,,90.704,Percent of Total Billed Charges,75% of Total Billed Charges,4504.08,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,4504.08,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,4504.08,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,4504.08,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,544.23,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5934.07,70,,4747.256,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,362.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8477.24,100,,120.936,Percent of Total Billed Charges,100% of Total Billed Charges,306.63,8477.24,
CEFAZOLIN 500 MG INJ,53189767,CDM,250,RC,J0690,HCPCS,Outpatient,,,63.4,38.04,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.04,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.55,75,,8.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,20.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,20.176,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,20.176,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,2.456,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.38,70,,35.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.4,100,,11.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,63.4,
CEFAZOLIN 1GM ADV,53189817,CDM,250,RC,J0690,HCPCS,Outpatient,,,19.88,11.93,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.93,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.91,75,,12.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,34.152,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,20.176,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,20.176,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,14,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.92,70,,11.136,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.88,100,,17.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,19.88,
CEFAZOLIN 2GM/NS 50ML,53189858,CDM,250,RC,J0690,HCPCS,Outpatient,,,51.32,30.79,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.79,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.49,75,,25.912,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,20.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,5.064,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,5.064,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,10.464,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.92,70,,28.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.32,100,,34.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,51.32,
CEFEPIME 1GM INJ,53189866,CDM,250,RC,J0692,HCPCS,Outpatient,,,39.21,23.53,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.53,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.41,75,,104.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,20.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,20,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,20,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,17.04,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,70,,21.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.21,100,,138.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,39.21,
CEFEPIME 2GM VL,53189874,CDM,250,RC,J0692,HCPCS,Outpatient,,,59.78,35.87,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.87,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.84,75,,69.192,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,5.064,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,220,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,220,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,220,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,70,,33.48,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.78,100,,92.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,59.78,
CEFOTAXIME 1GM INJ,53190237,CDM,250,RC,J0698,HCPCS,Outpatient,,,21.1,12.66,,9.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.07,360,,,Fee Schedule,360% of BCBS POS Rate,2.07,360,,,Fee schedule,360% of BCBS PPO Rate,2.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.66,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.83,75,,43.016,Percent of Total Billed Charges,75% of Total Billed Charges,10.55,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,10.55,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.55,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,10.55,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.77,70,,11.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,100,,57.352,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,21.1,
CEFOTAXIME 2GM INJ,53190286,CDM,250,RC,J0698,HCPCS,Outpatient,,,41.6,24.96,,9.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.07,360,,,Fee Schedule,360% of BCBS POS Rate,2.07,360,,,Fee schedule,360% of BCBS PPO Rate,2.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.96,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.2,75,,51.672,Percent of Total Billed Charges,75% of Total Billed Charges,20.8,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.12,70,,23.296,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.6,100,,68.896,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,41.6,
CEFOXITIN 1GM INJ,53190492,CDM,250,RC,J0694,HCPCS,Outpatient,,,48.19,28.91,,4.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.41,360,,,Fee Schedule,360% of BCBS POS Rate,4.41,360,,,Fee schedule,360% of BCBS PPO Rate,4.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,28.91,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.14,75,,86.632,Percent of Total Billed Charges,75% of Total Billed Charges,4.12,80,,70.664,Fee Schedule,80% of Scott and White EPO fee schedule,4.12,80,,15.144,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,15.144,Fee Schedule,80% of Scott and White PPO fee schedule,4.12,80,,11.184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.73,70,,26.984,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.19,100,,115.504,Percent of Total Billed Charges,100% of Total Billed Charges,4.12,48.19,
CEFOXITIN SOD 1GM IVPB 50ML,53190500,CDM,250,RC,J0694,HCPCS,Outpatient,,,78.5,47.10,,4.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.41,360,,,Fee Schedule,360% of BCBS POS Rate,4.41,360,,,Fee schedule,360% of BCBS PPO Rate,4.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,145.648,Percent of Total Billed Charges,75% of Total Billed Charges,4.12,80,,95.6,Fee Schedule,80% of Scott and White EPO fee schedule,4.12,80,,220,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,220,Fee Schedule,80% of Scott and White PPO fee schedule,4.12,80,,11.04,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,194.192,Percent of Total Billed Charges,100% of Total Billed Charges,4.12,78.5,
CEFOXITIN 2GM INJ,53190542,CDM,250,RC,J0694,HCPCS,Outpatient,,,92.84,55.70,,4.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.41,360,,,Fee Schedule,360% of BCBS POS Rate,4.41,360,,,Fee schedule,360% of BCBS PPO Rate,4.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.7,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.63,75,,352.2,Percent of Total Billed Charges,75% of Total Billed Charges,4.12,80,,15.144,Fee Schedule,80% of Scott and White EPO fee schedule,4.12,80,,96.08,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,96.08,Fee Schedule,80% of Scott and White PPO fee schedule,4.12,80,,8.376,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.99,70,,51.992,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.84,100,,469.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.12,92.84,
CEFTAZIDIME 1GM INJ,53190617,CDM,250,RC,J0713,HCPCS,Outpatient,,,30.2,18.12,,1.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.68,360,,,Fee Schedule,360% of BCBS POS Rate,1.68,360,,,Fee schedule,360% of BCBS PPO Rate,1.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,18.12,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.65,75,,121.552,Percent of Total Billed Charges,75% of Total Billed Charges,1.48,80,,220,Fee Schedule,80% of Scott and White EPO fee schedule,1.48,80,,62.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,80,,62.784,Fee Schedule,80% of Scott and White PPO fee schedule,1.48,80,,20.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.14,70,,16.912,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.2,100,,162.064,Percent of Total Billed Charges,100% of Total Billed Charges,1.48,30.2,
CEFTAZIDIME 2GM INJ,53190625,CDM,250,RC,J0713,HCPCS,Outpatient,,,61.46,36.88,,1.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.68,360,,,Fee Schedule,360% of BCBS POS Rate,1.68,360,,,Fee schedule,360% of BCBS PPO Rate,1.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.88,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.1,75,,56.256,Percent of Total Billed Charges,75% of Total Billed Charges,1.48,80,,96.08,Fee Schedule,80% of Scott and White EPO fee schedule,1.48,80,,31.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,80,,31.4,Fee Schedule,80% of Scott and White PPO fee schedule,1.48,80,,20.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.02,70,,34.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.46,100,,75.008,Percent of Total Billed Charges,100% of Total Billed Charges,1.48,61.46,
CEFTRIAXONE 500MG INJ,53190831,CDM,250,RC,J0696,HCPCS,Outpatient,,,11.95,7.17,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.17,60,,52.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.96,75,,18.808,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,62.784,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,31.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,31.4,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,34.152,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.37,70,,6.696,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,100,,25.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,11.95,
CEFTRIAXONE 1GM INJ,53190849,CDM,250,RC,J0696,HCPCS,Outpatient,,,15.97,9.58,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.58,60,,124.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,75,,319.096,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,31.4,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,66.376,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,66.376,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,20.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.18,70,,8.944,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.97,100,,425.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,15.97,
CEFUROXIME 750MG INJ,53191011,CDM,250,RC,J0697,HCPCS,Outpatient,,,21.47,12.88,,2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.88,60,,35.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.1,75,,203.888,Percent of Total Billed Charges,75% of Total Billed Charges,1.79,80,,31.4,Fee Schedule,80% of Scott and White EPO fee schedule,1.79,80,,43.392,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,80,,43.392,Fee Schedule,80% of Scott and White PPO fee schedule,1.79,80,,20.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,70,,12.024,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.47,100,,271.848,Percent of Total Billed Charges,100% of Total Billed Charges,1.38,21.47,
CEFUROXIME 1.5GM INJ,53191060,CDM,250,RC,J0697,HCPCS,Outpatient,,,37.94,22.76,,2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.76,60,,35.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,75,,31.496,Percent of Total Billed Charges,75% of Total Billed Charges,1.79,80,,66.376,Fee Schedule,80% of Scott and White EPO fee schedule,1.79,80,,3.728,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,80,,3.728,Fee Schedule,80% of Scott and White PPO fee schedule,1.79,80,,5.064,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.56,70,,21.248,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.94,100,,41.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.38,37.94,
CHLOROPROCAINE MPF 3% INJ 20ML,53192415,CDM,250,RC,J2400,HCPCS,Outpatient,,,163.82,98.29,,30.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.87,28,,36.696,Percent of Total Billed Charges,28% of Total Billed Charges,190.71,32,,152.568,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.98,36,,47.184,Percent of Total Billed Charges,36% of Total Billed Charges,58.98,36,,47.184,Percent of Total Billed Charges,36% Total Bille Charges,58.98,36,,47.184,Percent of Total Billed Charges,36% of Total Billed Charges,98.29,60,,43.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.87,75,,1262.728,Percent of Total Billed Charges,75% of Total Billed Charges,81.91,50,,43.392,Percent of Total Billed Charges,50% of Total Billed Charges,81.91,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.91,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,81.91,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.67,70,,91.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.82,100,,1683.632,Percent of Total Billed Charges,100% of Total Billed Charges,30.4,190.71,
CHLOROTHIAZIDE 500MG INJ,53192621,CDM,250,RC,J1205,HCPCS,Outpatient,,,300,180.00,,44.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,143.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,143.71,360,,,Fee Schedule,360% of BCBS POS Rate,143.71,360,,,Fee schedule,360% of BCBS PPO Rate,143.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,813.376,Percent of Total Billed Charges,75% of Total Billed Charges,61.5,80,,3.728,Fee Schedule,80% of Scott and White EPO fee schedule,61.5,80,,1.056,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,80,,1.056,Fee Schedule,80% of Scott and White PPO fee schedule,61.5,80,,220,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,1084.504,Percent of Total Billed Charges,100% of Total Billed Charges,44.35,300,
CIPRO INJ 400MG/D5W 200ML,53193876,CDM,250,RC,J0744,HCPCS,Outpatient,,,26.59,15.95,,0.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.57,360,,,Fee Schedule,360% of BCBS POS Rate,1.57,360,,,Fee schedule,360% of BCBS PPO Rate,1.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.95,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.94,75,,1154.28,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,2.712,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,13.776,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,13.776,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,70.664,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.61,70,,14.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.59,100,,1539.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,26.59,
CIPROFLOXACIN 200MG/D5W 100ML,53193884,CDM,250,RC,J0744,HCPCS,Outpatient,,,22.49,13.49,,0.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.57,360,,,Fee Schedule,360% of BCBS POS Rate,1.57,360,,,Fee schedule,360% of BCBS PPO Rate,1.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.49,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.87,75,,70.896,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,1.056,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,179.52,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,179.52,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,95.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.74,70,,12.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.49,100,,94.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.96,22.49,
CISATRACURIUM 10MG/ML INJ 20ML,53193900,CDM,250,RC,,,Outpatient,,,495.05,297.03,,297.03,60,,237.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.61,28,,110.888,Percent of Total Billed Charges,28% of Total Billed Charges,191.74,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,178.22,36,,142.576,Percent of Total Billed Charges,36% of Total Billed Charges,178.22,36,,142.576,Percent of Total Billed Charges,36% Total Bille Charges,178.22,36,,142.576,Percent of Total Billed Charges,36% of Total Billed Charges,297.03,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,71.39,14.42,,57.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.29,75,,27.312,Percent of Total Billed Charges,75% of Total Billed Charges,247.53,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,247.53,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.53,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,247.53,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,346.54,70,,277.232,Percent of Total Billed Charges,70% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14,,55.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,495.05,100,,36.416,Percent of Total Billed Charges,100% of Total Billed Charges,69.31,495.05,
CISATRACURM 5ML,53193918,CDM,250,RC,,,Outpatient,,,32,19.20,,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.96,28,,7.168,Percent of Total Billed Charges,28% of Total Billed Charges,191.74,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,11.52,36,,9.216,Percent of Total Billed Charges,36% of Total Billed Charges,11.52,36,,9.216,Percent of Total Billed Charges,36% Total Bille Charges,11.52,36,,9.216,Percent of Total Billed Charges,36% of Total Billed Charges,19.2,60,,1058.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.61,14.42,,3.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,75,,70.032,Percent of Total Billed Charges,75% of Total Billed Charges,16,50,,179.52,Percent of Total Billed Charges,50% of Total Billed Charges,16,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,16,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,70,,17.92,Percent of Total Billed Charges,70% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,14,,3.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32,100,,93.376,Percent of Total Billed Charges,100% of Total Billed Charges,4.48,191.74,
CISATRACURIUM 2MG/ML VL 10ML,53193926,CDM,250,RC,,,Outpatient,,,169.02,101.41,,101.41,60,,81.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.33,28,,37.864,Percent of Total Billed Charges,28% of Total Billed Charges,191.74,32,,153.392,Percent of Total Billed Charges,32% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,60.85,36,,48.68,Percent of Total Billed Charges,36% of Total Billed Charges,60.85,36,,48.68,Percent of Total Billed Charges,36% Total Bille Charges,60.85,36,,48.68,Percent of Total Billed Charges,36% of Total Billed Charges,101.41,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,24.37,14.42,,19.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.77,75,,48.136,Percent of Total Billed Charges,75% of Total Billed Charges,84.51,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,84.51,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.51,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,84.51,50,,96.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.31,70,,94.648,Percent of Total Billed Charges,70% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,23.66,14,,18.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.02,100,,64.176,Percent of Total Billed Charges,100% of Total Billed Charges,23.66,191.74,
CISPLATIN PER 10MG INJ,53193983,CDM,250,RC,J9060,HCPCS,Outpatient,,,77.06,46.24,,1.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.45,360,,,Fee Schedule,360% of BCBS POS Rate,2.45,360,,,Fee schedule,360% of BCBS PPO Rate,2.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.24,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.8,75,,48.136,Percent of Total Billed Charges,75% of Total Billed Charges,1.34,80,,0.072,Fee Schedule,80% of Scott and White EPO fee schedule,1.34,80,,58.168,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.34,80,,58.168,Fee Schedule,80% of Scott and White PPO fee schedule,1.34,80,,62.784,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.94,70,,43.152,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.06,100,,64.176,Percent of Total Billed Charges,100% of Total Billed Charges,1.34,77.06,
CLINDAMYCIN 150MG/ML VL 2ML,53194247,CDM,250,RC,,,Outpatient,,,19.7,11.82,,11.82,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.52,28,,4.416,Percent of Total Billed Charges,28% of Total Billed Charges,1920,32,,1536,Percent of Total Billed Charges,32% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% of Total Billed Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% Total Bille Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% of Total Billed Charges,11.82,60,,3264,Percent of Total Billed Charges,60% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.84,14.42,,2.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,75,,4.6,Percent of Total Billed Charges,75% of Total Billed Charges,9.85,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,9.85,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.85,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,9.85,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.79,70,,11.032,Percent of Total Billed Charges,70% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.7,100,,6.128,Percent of Total Billed Charges,100% of Total Billed Charges,2.76,1920,
CLINDAMYCIN 600MG/4ML INJ,53194296,CDM,250,RC,,,Outpatient,,,22.4,13.44,,13.44,60,,10.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.27,28,,5.016,Percent of Total Billed Charges,28% of Total Billed Charges,1932.31,32,,1545.848,Percent of Total Billed Charges,32% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.06,36,,6.448,Percent of Total Billed Charges,36% of Total Billed Charges,8.06,36,,6.448,Percent of Total Billed Charges,36% Total Bille Charges,8.06,36,,6.448,Percent of Total Billed Charges,36% of Total Billed Charges,13.44,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14.42,,2.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,11.2,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.68,70,,12.544,Percent of Total Billed Charges,70% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,3.14,1932.31,
CLINDAMYCIN 900MG/6ML INJ,53194346,CDM,250,RC,,,Outpatient,,,30.2,18.12,,18.12,60,,14.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.46,28,,6.768,Percent of Total Billed Charges,28% of Total Billed Charges,1935.06,32,,1548.048,Percent of Total Billed Charges,32% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.87,36,,8.696,Percent of Total Billed Charges,36% of Total Billed Charges,10.87,36,,8.696,Percent of Total Billed Charges,36% Total Bille Charges,10.87,36,,8.696,Percent of Total Billed Charges,36% of Total Billed Charges,18.12,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.35,14.42,,3.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.65,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,15.1,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,15.1,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.1,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,15.1,50,,66.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.14,70,,16.912,Percent of Total Billed Charges,70% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,14,,3.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.2,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,1935.06,
COLISTIMETHATE 150MG INJ,53194916,CDM,250,RC,J0770,HCPCS,Outpatient,,,171.32,102.79,,14.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,16.13,360,,,Fee Schedule,360% of BCBS POS Rate,16.13,360,,,Fee schedule,360% of BCBS PPO Rate,16.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.79,60,,1955.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.49,75,,92.536,Percent of Total Billed Charges,75% of Total Billed Charges,12.48,80,,16.928,Fee Schedule,80% of Scott and White EPO fee schedule,12.48,80,,28.44,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.48,80,,28.44,Fee Schedule,80% of Scott and White PPO fee schedule,12.48,80,,43.392,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.92,70,,95.936,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.32,100,,123.384,Percent of Total Billed Charges,100% of Total Billed Charges,12.48,171.32,
CONIVAPTAN 20MG/D5W 100ML,53195012,CDM,250,RC,,,Outpatient,,,2250,1350.00,,1350,60,,1080,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,504,Percent of Total Billed Charges,28% of Total Billed Charges,1942.6,32,,1554.08,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,648,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,1350,60,,1955.92,Percent of Total Billed Charges,60% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1687.5,75,,346.368,Percent of Total Billed Charges,75% of Total Billed Charges,1125,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,3.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,461.824,Percent of Total Billed Charges,100% of Total Billed Charges,315,2250,
TOLVAPTAN 15 MG TABLET,53195038,CDM,250,RC,,,Outpatient,,,1943.99,1166.39,,1166.39,60,,933.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,544.32,28,,435.456,Percent of Total Billed Charges,28% of Total Billed Charges,1946.95,32,,1557.56,Percent of Total Billed Charges,32% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,699.84,36,,559.872,Percent of Total Billed Charges,36% of Total Billed Charges,699.84,36,,559.872,Percent of Total Billed Charges,36% Total Bille Charges,699.84,36,,559.872,Percent of Total Billed Charges,36% of Total Billed Charges,1166.39,60,,1239.792,Percent of Total Billed Charges,60% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,280.32,14.42,,224.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1457.99,75,,60.584,Percent of Total Billed Charges,75% of Total Billed Charges,972,50,,28.44,Percent of Total Billed Charges,50% of Total Billed Charges,972,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,972,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,972,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1360.79,70,,1088.632,Percent of Total Billed Charges,70% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,14,,217.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1943.99,100,,80.776,Percent of Total Billed Charges,100% of Total Billed Charges,272.16,1946.95,
COSYNTROPIN 0.25MG INJ,53195905,CDM,250,RC,J0834,HCPCS,Outpatient,,,479.61,287.77,,32.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.95,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,60.95,360,,,Fee Schedule,360% of BCBS POS Rate,60.95,360,,,Fee schedule,360% of BCBS PPO Rate,60.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,287.77,60,,1239.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.71,75,,147.752,Percent of Total Billed Charges,75% of Total Billed Charges,19.82,80,,186,Fee Schedule,80% of Scott and White EPO fee schedule,19.82,80,,58.944,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.82,80,,58.944,Fee Schedule,80% of Scott and White PPO fee schedule,19.82,80,,1.056,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.73,70,,268.584,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,479.61,100,,197,Percent of Total Billed Charges,100% of Total Billed Charges,19.82,479.61,
SMZ/TMP 400/80MG/5ML INJ,53196119,CDM,250,RC,,,Outpatient,,,37.94,22.76,,22.76,60,,18.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.62,28,,8.496,Percent of Total Billed Charges,28% of Total Billed Charges,1947.05,32,,1557.64,Percent of Total Billed Charges,32% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% of Total Billed Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% Total Bille Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% of Total Billed Charges,22.76,60,,1088.304,Percent of Total Billed Charges,60% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.47,14.42,,4.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,75,,34.872,Percent of Total Billed Charges,75% of Total Billed Charges,18.97,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.97,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.97,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,18.97,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.56,70,,21.248,Percent of Total Billed Charges,70% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.94,100,,46.496,Percent of Total Billed Charges,100% of Total Billed Charges,5.31,1947.05,
CYANOCOBALMIN 1MG/ML VL 1ML,53196747,CDM,250,RC,J3420,HCPCS,Outpatient,,,41.46,24.88,,1.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.45,360,,,Fee Schedule,360% of BCBS POS Rate,3.45,360,,,Fee schedule,360% of BCBS PPO Rate,3.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.88,60,,1088.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.1,75,,42.52,Percent of Total Billed Charges,75% of Total Billed Charges,1.28,80,,58.944,Fee Schedule,80% of Scott and White EPO fee schedule,1.28,80,,24.288,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.28,80,,24.288,Fee Schedule,80% of Scott and White PPO fee schedule,1.28,80,,179.52,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.02,70,,23.216,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.46,100,,56.696,Percent of Total Billed Charges,100% of Total Billed Charges,1.28,41.46,
CYTARABINE INJ 100MG,53197265,CDM,250,RC,J9100,HCPCS,Outpatient,,,56.27,33.76,,0.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.66,360,,,Fee Schedule,360% of BCBS POS Rate,0.66,360,,,Fee schedule,360% of BCBS PPO Rate,0.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,33.76,60,,882.456,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.2,75,,35.752,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,108.408,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,41.656,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,41.656,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,0.096,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.39,70,,31.512,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.27,100,,47.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,56.27,
DACARBAZINE 200MG INJ,53197273,CDM,250,RC,J9130,HCPCS,Outpatient,,,170.06,102.04,,3.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.67,360,,,Fee Schedule,360% of BCBS POS Rate,5.67,360,,,Fee schedule,360% of BCBS PPO Rate,5.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.04,60,,1302.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.55,75,,240.776,Percent of Total Billed Charges,75% of Total Billed Charges,3.07,80,,24.288,Fee Schedule,80% of Scott and White EPO fee schedule,3.07,80,,416,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,80,,416,Fee Schedule,80% of Scott and White PPO fee schedule,3.07,80,,0.072,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.04,70,,95.232,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.06,100,,321.032,Percent of Total Billed Charges,100% of Total Billed Charges,3.07,170.06,
DANTROLENE 20MG INJ,53197521,CDM,250,RC,,,Outpatient,,,402.88,241.73,,241.73,60,,193.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.81,28,,90.248,Percent of Total Billed Charges,28% of Total Billed Charges,1957.82,32,,1566.256,Percent of Total Billed Charges,32% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,145.04,36,,116.032,Percent of Total Billed Charges,36% of Total Billed Charges,145.04,36,,116.032,Percent of Total Billed Charges,36% Total Bille Charges,145.04,36,,116.032,Percent of Total Billed Charges,36% of Total Billed Charges,241.73,60,,34.216,Percent of Total Billed Charges,60% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,58.1,14.42,,46.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.16,75,,29.248,Percent of Total Billed Charges,75% of Total Billed Charges,201.44,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,201.44,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.44,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,201.44,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,282.02,70,,225.616,Percent of Total Billed Charges,70% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,56.4,14,,45.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,402.88,100,,38.992,Percent of Total Billed Charges,100% of Total Billed Charges,56.4,1957.82,
DANTROLENE 25MG CAP,53197525,CDM,250,RC,,,Outpatient,,,4.87,2.92,,2.92,60,,2.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,28,,1.088,Percent of Total Billed Charges,28% of Total Billed Charges,1995.52,32,,1596.416,Percent of Total Billed Charges,32% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% Total Bille Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% of Total Billed Charges,2.92,60,,381,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.65,75,,43.496,Percent of Total Billed Charges,75% of Total Billed Charges,2.44,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.41,70,,2.728,Percent of Total Billed Charges,70% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,100,,57.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,1995.52,
DAPTOMYCIN INJ 500MG VIAL,53197596,CDM,250,RC,J0878,HCPCS,Outpatient,,,540,324.00,,0.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.56,360,,,Fee Schedule,360% of BCBS POS Rate,0.56,360,,,Fee schedule,360% of BCBS PPO Rate,0.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,324,60,,153.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,75,,54.592,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,80,,82.24,Fee Schedule,80% of Scott and White EPO fee schedule,0.03,80,,470.464,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,80,,470.464,Fee Schedule,80% of Scott and White PPO fee schedule,0.03,80,,83.952,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378,70,,302.4,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,100,,72.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,540,
BUPIVACAINE LIPO 266MG/20ML,53197692,CDM,250,RC,C9290,HCPCS,Outpatient,,,1417.48,850.49,,1.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,396.89,28,,317.512,Percent of Total Billed Charges,28% of Total Billed Charges,1996.8,32,,1597.44,Percent of Total Billed Charges,32% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,510.29,36,,408.232,Percent of Total Billed Charges,36% of Total Billed Charges,510.29,36,,408.232,Percent of Total Billed Charges,36% Total Bille Charges,510.29,36,,408.232,Percent of Total Billed Charges,36% of Total Billed Charges,850.49,60,,19.864,Percent of Total Billed Charges,60% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,204.4,14.42,,163.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1063.11,75,,24.728,Percent of Total Billed Charges,75% of Total Billed Charges,708.74,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,708.74,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,708.74,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,708.74,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,992.24,70,,793.792,Percent of Total Billed Charges,70% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,198.45,14,,158.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1417.48,100,,32.968,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,1996.8,
DEXAMETH SOD PHOS 4MG/1ML INJ,53198578,CDM,250,RC,J1100,HCPCS,Outpatient,,,16.1,9.66,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.02,360,,,Fee Schedule,360% of BCBS POS Rate,0.02,360,,,Fee schedule,360% of BCBS PPO Rate,0.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.66,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.08,75,,22.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,80,,470.464,Fee Schedule,80% of Scott and White EPO fee schedule,0.1,80,,109.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,80,,109.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.1,80,,3869.352,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.27,70,,9.016,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.1,100,,29.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,16.1,
DEXAMETH SOD PHOS 10MG/1ML INJ,53198594,CDM,250,RC,J1100,HCPCS,Outpatient,,,7.26,4.36,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.02,360,,,Fee Schedule,360% of BCBS POS Rate,0.02,360,,,Fee schedule,360% of BCBS PPO Rate,0.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.36,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.45,75,,166.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,80,,51.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.1,80,,109.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,80,,109.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.1,80,,28.44,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,70,,4.064,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.26,100,,221.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,7.26,
DEXAMETH SOD PHOS 10MG/1ML INJ,53198594,CDM,250,RC,J1100,HCPCS,Outpatient,,,7.26,4.36,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.02,360,,,Fee Schedule,360% of BCBS POS Rate,0.02,360,,,Fee schedule,360% of BCBS PPO Rate,0.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.36,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.45,75,,11.296,Percent of Total Billed Charges,75% of Total Billed Charges,0.1,80,,109.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.1,80,,66.88,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,80,,66.88,Fee Schedule,80% of Scott and White PPO fee schedule,0.1,80,,186,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,70,,4.064,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.26,100,,15.056,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,7.26,
DEXMEDETOMIDINE 400MCG/NS100ML,53198750,CDM,250,RC,,,Outpatient,,,378,226.80,,226.8,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.84,28,,84.672,Percent of Total Billed Charges,28% of Total Billed Charges,1997.24,32,,1597.792,Percent of Total Billed Charges,32% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,136.08,36,,108.864,Percent of Total Billed Charges,36% of Total Billed Charges,136.08,36,,108.864,Percent of Total Billed Charges,36% Total Bille Charges,136.08,36,,108.864,Percent of Total Billed Charges,36% of Total Billed Charges,226.8,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,54.51,14.42,,43.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.5,75,,296.552,Percent of Total Billed Charges,75% of Total Billed Charges,189,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,189,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,189,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.6,70,,211.68,Percent of Total Billed Charges,70% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14,,42.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,395.4,Percent of Total Billed Charges,100% of Total Billed Charges,52.92,1997.24,
DEXMEDETOMIDINE 200MCG/NS 50ML,53198760,CDM,250,RC,,,Outpatient,,,277.2,166.32,,166.32,60,,133.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.62,28,,62.096,Percent of Total Billed Charges,28% of Total Billed Charges,2000.14,32,,1600.112,Percent of Total Billed Charges,32% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,99.79,36,,79.832,Percent of Total Billed Charges,36% of Total Billed Charges,99.79,36,,79.832,Percent of Total Billed Charges,36% Total Bille Charges,99.79,36,,79.832,Percent of Total Billed Charges,36% of Total Billed Charges,166.32,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,39.97,14.42,,31.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.9,75,,221.2,Percent of Total Billed Charges,75% of Total Billed Charges,138.6,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,138.6,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.6,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,138.6,50,,58.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.04,70,,155.232,Percent of Total Billed Charges,70% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,38.81,14,,31.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.2,100,,294.928,Percent of Total Billed Charges,100% of Total Billed Charges,38.81,2000.14,
DEXMEDETOMIDINE 100 MCG/ML 2ML,53198800,CDM,250,RC,,,Outpatient,,,108.81,65.29,,65.29,60,,52.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.47,28,,24.376,Percent of Total Billed Charges,28% of Total Billed Charges,2004.44,32,,1603.552,Percent of Total Billed Charges,32% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,39.17,36,,31.336,Percent of Total Billed Charges,36% of Total Billed Charges,39.17,36,,31.336,Percent of Total Billed Charges,36% Total Bille Charges,39.17,36,,31.336,Percent of Total Billed Charges,36% of Total Billed Charges,65.29,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.69,14.42,,12.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.61,75,,761.08,Percent of Total Billed Charges,75% of Total Billed Charges,54.41,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,54.41,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.41,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,54.41,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.17,70,,60.936,Percent of Total Billed Charges,70% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,15.23,14,,12.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.81,100,,1014.776,Percent of Total Billed Charges,100% of Total Billed Charges,15.23,2004.44,
DEXTROSE 25% SYRG 10ML,53198982,CDM,250,RC,,,Outpatient,,,63.21,37.93,,37.93,60,,30.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.7,28,,14.16,Percent of Total Billed Charges,28% of Total Billed Charges,2012.21,32,,1609.768,Percent of Total Billed Charges,32% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.76,36,,18.208,Percent of Total Billed Charges,36% of Total Billed Charges,22.76,36,,18.208,Percent of Total Billed Charges,36% Total Bille Charges,22.76,36,,18.208,Percent of Total Billed Charges,36% of Total Billed Charges,37.93,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,9.11,14.42,,7.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.41,75,,1202.048,Percent of Total Billed Charges,75% of Total Billed Charges,31.61,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,31.61,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.61,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,31.61,50,,24.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.25,70,,35.4,Percent of Total Billed Charges,70% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.21,100,,1602.728,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,2012.21,
DEXT 50% SYG 50ML,53199139,CDM,250,RC,,,Outpatient,,,85.19,51.11,,51.11,60,,40.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.85,28,,19.08,Percent of Total Billed Charges,28% of Total Billed Charges,2018.48,32,,1614.784,Percent of Total Billed Charges,32% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,30.67,36,,24.536,Percent of Total Billed Charges,36% of Total Billed Charges,30.67,36,,24.536,Percent of Total Billed Charges,36% Total Bille Charges,30.67,36,,24.536,Percent of Total Billed Charges,36% of Total Billed Charges,51.11,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,12.28,14.42,,9.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.89,75,,323.408,Percent of Total Billed Charges,75% of Total Billed Charges,42.6,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,42.6,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.6,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,42.6,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.63,70,,47.704,Percent of Total Billed Charges,70% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14,,9.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.19,100,,431.208,Percent of Total Billed Charges,100% of Total Billed Charges,11.93,2018.48,
D5W 100ML INJ A-V,53199141,CDM,258,RC,,,Outpatient,,,26.28,15.77,,15.77,60,,12.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.36,28,,5.888,Percent of Total Billed Charges,28% of Total Billed Charges,2029.29,32,,1623.432,Percent of Total Billed Charges,32% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,9.46,36,,7.568,Percent of Total Billed Charges,36% of Total Billed Charges,9.46,36,,7.568,Percent of Total Billed Charges,36% Total Bille Charges,9.46,36,,7.568,Percent of Total Billed Charges,36% of Total Billed Charges,15.77,60,,1155.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14.42,,3.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.71,75,,491.136,Percent of Total Billed Charges,75% of Total Billed Charges,13.14,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,13.14,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.14,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.14,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.4,70,,14.72,Percent of Total Billed Charges,70% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.68,14,,2.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.28,100,,654.848,Percent of Total Billed Charges,100% of Total Billed Charges,3.68,2029.29,
DIAZEPAM 5MG/ML SYG 2ML,53199394,CDM,250,RC,J3360,HCPCS,Outpatient,,,205.12,123.07,,7.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.2,360,,,Fee Schedule,360% of BCBS POS Rate,6.2,360,,,Fee schedule,360% of BCBS PPO Rate,6.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.07,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.84,75,,17.304,Percent of Total Billed Charges,75% of Total Billed Charges,5.7,80,,516.624,Fee Schedule,80% of Scott and White EPO fee schedule,5.7,80,,79.128,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.7,80,,79.128,Fee Schedule,80% of Scott and White PPO fee schedule,5.7,80,,82.24,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.58,70,,114.864,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.12,100,,23.072,Percent of Total Billed Charges,100% of Total Billed Charges,5.7,205.12,
CEFAZOLIN 1GM/50 ML IVPB,53199808,CDM,250,RC,J0690,HCPCS,Outpatient,,,78.5,47.10,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,215.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,17.312,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,381.6,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,94.416,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,94.416,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,546.632,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,23.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,78.5,
DICYCLOMINE 10MG/ML VL 2ML,53199816,CDM,250,RC,J0500,HCPCS,Outpatient,,,364.59,218.75,,30.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,164.07,45,,131.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,28.08,360,,,Fee Schedule,360% of BCBS POS Rate,28.08,360,,,Fee schedule,360% of BCBS PPO Rate,28.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,218.75,60,,632.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.59,100,,291.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.44,75,,15.328,Percent of Total Billed Charges,75% of Total Billed Charges,18.22,80,,79.128,Fee Schedule,80% of Scott and White EPO fee schedule,18.22,80,,94.416,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.22,80,,94.416,Fee Schedule,80% of Scott and White PPO fee schedule,18.22,80,,470.464,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.21,70,,204.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.59,100,,20.44,Percent of Total Billed Charges,100% of Total Billed Charges,18.22,364.59,
MEROPENEM IVPB 500MG/NS 50ML,53199824,CDM,250,RC,J2185,HCPCS,Outpatient,,,71.52,42.91,,0.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.18,45,,25.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.21,360,,,Fee Schedule,360% of BCBS POS Rate,2.21,360,,,Fee schedule,360% of BCBS PPO Rate,2.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.91,60,,567.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.52,100,,57.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.64,75,,17.184,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,94.416,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,79.128,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,80,,79.128,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,51.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.06,70,,40.048,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.52,100,,22.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,71.52,
MEROPENEM IVPB 1GM/NS 100ML,53199832,CDM,250,RC,J2185,HCPCS,Outpatient,,,217.28,130.37,,0.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,97.78,45,,78.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.21,360,,,Fee Schedule,360% of BCBS POS Rate,2.21,360,,,Fee schedule,360% of BCBS PPO Rate,2.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.37,60,,159.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.28,100,,173.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.96,75,,1.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,94.416,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,60.176,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,80,,60.176,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,109.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.1,70,,121.68,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.28,100,,1.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,217.28,
CEFOXITIN SOD 2GM DUPLEX 50 ML,53199840,CDM,250,RC,J0694,HCPCS,Outpatient,,,124.34,74.60,,4.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,55.95,45,,44.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.41,360,,,Fee Schedule,360% of BCBS POS Rate,4.41,360,,,Fee schedule,360% of BCBS PPO Rate,4.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.6,60,,422.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.34,100,,99.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.26,75,,20.512,Percent of Total Billed Charges,75% of Total Billed Charges,4.12,80,,79.128,Fee Schedule,80% of Scott and White EPO fee schedule,4.12,80,,29.832,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,80,,29.832,Fee Schedule,80% of Scott and White PPO fee schedule,4.12,80,,109.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.04,70,,69.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.34,100,,27.352,Percent of Total Billed Charges,100% of Total Billed Charges,4.12,124.34,
CLINDAMYCIN 600 MG/50 ML D5W,53199857,CDM,250,RC,,,Outpatient,,,94.03,56.42,,56.42,60,,45.136,Percent of Total Billed Charges,60% of Total Billed Charges,42.31,45,,33.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.33,28,,21.064,Percent of Total Billed Charges,28% of Total Billed Charges,2039.36,32,,1631.488,Percent of Total Billed Charges,32% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% of Total Billed Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% Total Bille Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% of Total Billed Charges,56.42,60,,265.04,Percent of Total Billed Charges,60% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.03,100,,75.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.56,14.42,,10.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.52,75,,99.904,Percent of Total Billed Charges,75% of Total Billed Charges,47.02,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,47.02,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.02,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,47.02,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.82,70,,52.656,Percent of Total Billed Charges,70% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,13.16,14,,10.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.03,100,,133.2,Percent of Total Billed Charges,100% of Total Billed Charges,13.16,2039.36,
CLINDAMYCIN 900 MG/50 ML D5W,53199865,CDM,250,RC,,,Outpatient,,,113.75,68.25,,68.25,60,,54.6,Percent of Total Billed Charges,60% of Total Billed Charges,51.19,45,,40.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.85,28,,25.48,Percent of Total Billed Charges,28% of Total Billed Charges,2044.84,32,,1635.872,Percent of Total Billed Charges,32% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,40.95,36,,32.76,Percent of Total Billed Charges,36% of Total Billed Charges,40.95,36,,32.76,Percent of Total Billed Charges,36% Total Bille Charges,40.95,36,,32.76,Percent of Total Billed Charges,36% of Total Billed Charges,68.25,60,,640.536,Percent of Total Billed Charges,60% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.75,100,,91,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,16.4,14.42,,13.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.31,75,,15.344,Percent of Total Billed Charges,75% of Total Billed Charges,56.88,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,56.88,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.88,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,56.88,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.63,70,,63.704,Percent of Total Billed Charges,70% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.93,14,,12.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.75,100,,20.456,Percent of Total Billed Charges,100% of Total Billed Charges,15.93,2044.84,
CEFTRIAXONE 1 GM/50 ML IVPB,53199873,CDM,250,RC,J0696,HCPCS,Outpatient,,,78.5,47.10,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,80.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,463.32,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,40.84,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,94.096,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,94.096,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,60.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,617.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,78.5,
CEFTRIAXONE 2GM INJ,53199881,CDM,250,RC,J0696,HCPCS,Outpatient,,,22.09,13.25,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.94,45,,7.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.25,60,,102.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,100,,17.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.57,75,,105.904,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,60.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,434.288,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,434.288,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,155.016,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.46,70,,12.368,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.09,100,,141.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,22.09,
VANCOMYCIN 1GM/NS 250 ML,53199895,CDM,250,RC,J3370,HCPCS,Outpatient,,,78.5,47.10,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,59.496,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,94.096,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,829.504,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,829.504,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,86.104,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,79.328,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,78.5,
VANCOMYCIN 1 GM/NS 250 ML,53199899,CDM,250,RC,J3370,HCPCS,Outpatient,,,121.92,73.15,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,54.86,45,,43.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.15,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.92,100,,97.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.44,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,434.288,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,684.184,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,684.184,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,516.624,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.34,70,,68.272,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.92,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,121.92,
PIPERACIL/TAZOBAC 3.375GM ADV,53199907,CDM,250,RC,J2543,HCPCS,Outpatient,,,78.08,46.85,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.14,45,,28.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.85,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.08,100,,62.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.56,75,,6.736,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,829.504,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,109.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,109.8,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,381.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.66,70,,43.728,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.08,100,,8.976,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,78.08,
ZITHROMAX 500MG NS250ML,53199915,CDM,250,RC,J0456,HCPCS,Outpatient,,,33.54,20.12,,2.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.09,45,,12.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.15,360,,,Fee Schedule,360% of BCBS POS Rate,4.15,360,,,Fee schedule,360% of BCBS PPO Rate,4.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,20.12,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.54,100,,26.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,75,,98.56,Percent of Total Billed Charges,75% of Total Billed Charges,2.07,80,,684.184,Fee Schedule,80% of Scott and White EPO fee schedule,2.07,80,,109.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,80,,109.8,Fee Schedule,80% of Scott and White PPO fee schedule,2.07,80,,79.128,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.48,70,,18.784,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.54,100,,131.416,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,33.54,
CEFEPIME 1GM INJ,53199923,CDM,250,RC,J0692,HCPCS,Outpatient,,,39.21,23.53,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.64,45,,14.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.53,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.21,100,,31.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.41,75,,41.584,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,109.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,375.272,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,375.272,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,94.416,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,70,,21.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.21,100,,55.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,39.21,
CEFEPIME 2GM/NS 100ML,53199931,CDM,250,RC,J0692,HCPCS,Outpatient,,,78.5,47.10,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.33,45,,28.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,26.968,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,109.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,84.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,84.672,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,94.416,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,35.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,78.5,
DIGOXIN 100MCG/1ML INJ,53200259,CDM,250,RC,J1160,HCPCS,Outpatient,,,345.25,207.15,,21.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,155.36,45,,124.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.8,360,,,Fee Schedule,360% of BCBS POS Rate,3.8,360,,,Fee schedule,360% of BCBS PPO Rate,3.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,207.15,60,,80.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.25,100,,276.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.94,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,5.89,80,,375.272,Fee Schedule,80% of Scott and White EPO fee schedule,5.89,80,,84.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,80,,84.672,Fee Schedule,80% of Scott and White PPO fee schedule,5.89,80,,79.128,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.68,70,,193.344,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.25,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,3.8,345.25,
DIGOXIN 500MCG/2ML INJ,53200283,CDM,250,RC,J1160,HCPCS,Outpatient,,,40.26,24.16,,21.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.12,45,,14.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.8,360,,,Fee Schedule,360% of BCBS POS Rate,3.8,360,,,Fee schedule,360% of BCBS PPO Rate,3.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.16,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.26,100,,32.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.2,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,5.89,80,,84.672,Fee Schedule,80% of Scott and White EPO fee schedule,5.89,80,,106.944,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,80,,106.944,Fee Schedule,80% of Scott and White PPO fee schedule,5.89,80,,60.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.18,70,,22.544,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.26,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,3.8,40.26,
DIGOXIN IMMUNE FAB 38MG VL,53200317,CDM,636,RC,J1162,HCPCS,Outpatient,,,10301.16,6180.70,,9835.11,110,,7868.088,Percent of Total Billed Charges,110% of Total Billed Charges,7332.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,3821,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3821,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,3821,360,,,Fee Schedule,360% of BCBS POS Rate,3821,360,,,Fee schedule,360% of BCBS PPO Rate,3821,360,,,Fee Schedule,360% of BCBS Traditional Rate,5665.64,55,,90,Percent of Total Billed Charges,55% Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,4399.29,90,,,Fee Schedule,90% of CMS OPPS Rate,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6354.53,130,,,Fee Schedule,130% of CMS OPPS Rate,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1485.43,14.42,,1188.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,5034.74,103,,,Fee Schedule,103% of CMS OPPS Rate,5034.74,103,,,Fee Schedule,103% of CMS OPPS Rate,7725.87,75,,46.936,Percent of Total Billed Charges,75% of Total Billed Charges,8825.44,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,8825.44,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8825.44,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,8825.44,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,7332.15,150,,,Fee Schedule,150% of CMS OPPS Rate,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,7210.81,70,,5768.648,Percent of Total Billed Charges,70% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,1442.16,14,,1153.728,Percent of Total Billed Charges,14% of Total Billed Charges,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10301.16,100,,62.576,Percent of Total Billed Charges,100% of Total Billed Charges,1442.16,10301.16,
DIHYDROERGOTAMINE 1MG/ML AMP,53200499,CDM,250,RC,J1110,HCPCS,Outpatient,,,713.29,427.97,,55.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,320.98,45,,256.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,194.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,194.12,360,,,Fee Schedule,360% of BCBS POS Rate,194.12,360,,,Fee schedule,360% of BCBS PPO Rate,194.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,427.97,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,713.29,100,,570.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.97,75,,37.576,Percent of Total Billed Charges,75% of Total Billed Charges,46.24,80,,106.944,Fee Schedule,80% of Scott and White EPO fee schedule,46.24,80,,338.632,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.24,80,,338.632,Fee Schedule,80% of Scott and White PPO fee schedule,46.24,80,,40.84,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.3,70,,399.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,713.29,100,,50.096,Percent of Total Billed Charges,100% of Total Billed Charges,46.24,713.29,
DILTIAZEM 5MG/ML INJ 5ML,53200606,CDM,250,RC,,,Outpatient,,,15.69,9.41,,9.41,60,,7.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,45,,5.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.39,28,,3.512,Percent of Total Billed Charges,28% of Total Billed Charges,2066.59,32,,1653.272,Percent of Total Billed Charges,32% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% of Total Billed Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% Total Bille Charges,5.65,36,,4.52,Percent of Total Billed Charges,36% of Total Billed Charges,9.41,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.69,100,,12.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14.42,,1.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,75,,46.504,Percent of Total Billed Charges,75% of Total Billed Charges,7.85,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,7.85,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.85,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.85,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.98,70,,8.784,Percent of Total Billed Charges,70% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.2,14,,1.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.69,100,,62,Percent of Total Billed Charges,100% of Total Billed Charges,2.2,2066.59,
DILTIAZEM 100 MG ADV,53200622,CDM,250,RC,,,Outpatient,,,72.54,43.52,,43.52,60,,34.816,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,45,,26.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.31,28,,16.248,Percent of Total Billed Charges,28% of Total Billed Charges,2066.59,32,,1653.272,Percent of Total Billed Charges,32% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% Total Bille Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,43.52,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.54,100,,58.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.46,14.42,,8.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.41,75,,12.136,Percent of Total Billed Charges,75% of Total Billed Charges,36.27,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.27,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,94.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.78,70,,40.624,Percent of Total Billed Charges,70% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.54,100,,16.184,Percent of Total Billed Charges,100% of Total Billed Charges,10.16,2066.59,
DIPHENHYDRAMINE 50MG/1ML INJ,53201174,CDM,250,RC,J1200,HCPCS,Outpatient,,,20.58,12.35,,1.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.26,45,,7.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.69,360,,,Fee Schedule,360% of BCBS POS Rate,0.69,360,,,Fee schedule,360% of BCBS PPO Rate,0.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.35,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,16.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.44,75,,26.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.9,80,,348.6,Fee Schedule,80% of Scott and White EPO fee schedule,0.9,80,,60.176,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,80,,60.176,Fee Schedule,80% of Scott and White PPO fee schedule,0.9,80,,434.288,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,70,,11.528,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.58,100,,34.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,20.58,
DIPHTH/TET/PERTUSS (PEDI),53201463,CDM,250,RC,90700,HCPCS,Outpatient,,,154.63,92.78,,31.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,69.58,45,,55.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.66,360,,,Fee Schedule,360% of BCBS POS Rate,27.66,360,,,Fee schedule,360% of BCBS PPO Rate,27.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,92.78,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.63,100,,123.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14.42,,17.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.97,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,77.32,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,77.32,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.32,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,77.32,50,,829.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.24,70,,86.592,Percent of Total Billed Charges,70% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.63,100,,41.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.65,154.63,
DPT/PERTUS/TET 0.5ML,53201471,CDM,636,RC,90715,HCPCS,Outpatient,,,246.3,147.78,,187.29,110,,149.832,Percent of Total Billed Charges,110% of Total Billed Charges,110.84,45,,88.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,39.52,360,,,Fee Schedule,360% of BCBS POS Rate,39.52,360,,,Fee schedule,360% of BCBS PPO Rate,39.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.3,100,,197.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.73,75,,34.12,Percent of Total Billed Charges,75% of Total Billed Charges,153.25,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,153.25,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.25,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,153.25,50,,684.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.41,70,,137.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.3,100,,45.496,Percent of Total Billed Charges,100% of Total Billed Charges,39.52,246.3,
DIP/TET/ACE PERT VACC >7YR IM,53201472,CDM,636,RC,90715,HCPCS,Outpatient,,,246.3,147.78,,187.29,110,,149.832,Percent of Total Billed Charges,110% of Total Billed Charges,110.84,45,,88.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,39.52,360,,,Fee Schedule,360% of BCBS POS Rate,39.52,360,,,Fee schedule,360% of BCBS PPO Rate,39.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.3,100,,197.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.73,75,,6.552,Percent of Total Billed Charges,75% of Total Billed Charges,153.25,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,153.25,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.25,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,153.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.41,70,,137.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.3,100,,8.736,Percent of Total Billed Charges,100% of Total Billed Charges,39.52,246.3,
DTAP-HEPB-IPV VACC IM DOSE,53201473,CDM,636,RC,90723,HCPCS,Outpatient,,,352.28,211.37,,301.05,110,,240.84,Percent of Total Billed Charges,110% of Total Billed Charges,158.53,45,,126.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,92.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,92.61,360,,,Fee Schedule,360% of BCBS POS Rate,92.61,360,,,Fee schedule,360% of BCBS PPO Rate,92.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,352.28,100,,281.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,50.8,14.42,,40.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.21,75,,146.352,Percent of Total Billed Charges,75% of Total Billed Charges,176.14,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,176.14,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.14,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,176.14,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.6,70,,197.28,Percent of Total Billed Charges,70% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.32,14,,39.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.28,100,,195.136,Percent of Total Billed Charges,100% of Total Billed Charges,49.32,352.28,
DTAP VACC,53201474,CDM,636,RC,90700,HCPCS,Outpatient,,,154.63,92.78,,116.17,110,,92.936,Percent of Total Billed Charges,110% of Total Billed Charges,69.58,45,,55.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,27.66,360,,,Fee Schedule,360% of BCBS POS Rate,27.66,360,,,Fee schedule,360% of BCBS PPO Rate,27.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.63,100,,123.704,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14.42,,17.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.97,75,,461.336,Percent of Total Billed Charges,75% of Total Billed Charges,77.32,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,77.32,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.32,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,77.32,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.24,70,,86.592,Percent of Total Billed Charges,70% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,21.65,14,,17.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.63,100,,615.112,Percent of Total Billed Charges,100% of Total Billed Charges,21.65,154.63,
DTAP-IPV VACC VL 4-6 IM,53201475,CDM,636,RC,90696,HCPCS,Outpatient,,,300,180.00,,231.17,110,,184.936,Percent of Total Billed Charges,110% of Total Billed Charges,135,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,,Fee Schedule,360% of BCBS POS Rate,60.98,360,,,Fee schedule,360% of BCBS PPO Rate,60.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,42,300,
HEPATITIS A&B ADULT VACC IM,53201476,CDM,636,RC,90636,HCPCS,Outpatient,,,467.32,280.39,,391.56,110,,313.248,Percent of Total Billed Charges,110% of Total Billed Charges,210.29,45,,168.232,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,100.35,360,,,Fee Schedule,360% of BCBS POS Rate,100.35,360,,,Fee schedule,360% of BCBS PPO Rate,100.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,467.32,100,,373.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.49,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,233.66,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,233.66,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.66,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,233.66,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.12,70,,261.696,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,467.32,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,100.35,467.32,
POLYMIX1500/BACITR150/NS IRR 3,53201489,CDM,250,RC,,,Outpatient,,,425.86,255.52,,255.52,60,,204.416,Percent of Total Billed Charges,60% of Total Billed Charges,191.64,45,,153.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.24,28,,95.392,Percent of Total Billed Charges,28% of Total Billed Charges,2080,32,,1664,Percent of Total Billed Charges,32% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,153.31,36,,122.648,Percent of Total Billed Charges,36% of Total Billed Charges,153.31,36,,122.648,Percent of Total Billed Charges,36% Total Bille Charges,153.31,36,,122.648,Percent of Total Billed Charges,36% of Total Billed Charges,255.52,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.86,100,,340.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,61.41,14.42,,49.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.4,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,212.93,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,212.93,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.93,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,212.93,50,,106.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.1,70,,238.48,Percent of Total Billed Charges,70% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,59.62,14,,47.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.86,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,59.62,2080,
POLYMIX500 /BACITR50/NS IRR 1L,53201497,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,2080,32,,1664,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,185.992,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,247.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,2080,
NU-LYTELY 4 LITER,53201505,CDM,250,RC,,,Outpatient,,,22.94,13.76,,13.76,60,,11.008,Percent of Total Billed Charges,60% of Total Billed Charges,10.32,45,,8.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.42,28,,5.136,Percent of Total Billed Charges,28% of Total Billed Charges,2096,32,,1676.8,Percent of Total Billed Charges,32% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,8.26,36,,6.608,Percent of Total Billed Charges,36% of Total Billed Charges,8.26,36,,6.608,Percent of Total Billed Charges,36% Total Bille Charges,8.26,36,,6.608,Percent of Total Billed Charges,36% of Total Billed Charges,13.76,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,18.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14.42,,2.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.21,75,,320.72,Percent of Total Billed Charges,75% of Total Billed Charges,11.47,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.47,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.47,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.06,70,,12.848,Percent of Total Billed Charges,70% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,14,,2.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.94,100,,427.624,Percent of Total Billed Charges,100% of Total Billed Charges,3.21,2096,
CHLORPROMAZINE 25MG/ML AMP 1ML,53201513,CDM,250,RC,J3230,HCPCS,Outpatient,,,151.6,90.96,,32.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,68.22,45,,54.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,20.82,360,,,Fee Schedule,360% of BCBS POS Rate,20.82,360,,,Fee schedule,360% of BCBS PPO Rate,20.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,90.96,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.6,100,,121.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.7,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,24.23,80,,116.8,Fee Schedule,80% of Scott and White EPO fee schedule,24.23,80,,442.12,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.23,80,,442.12,Fee Schedule,80% of Scott and White PPO fee schedule,24.23,80,,348.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.12,70,,84.896,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.6,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,151.6,
CHLORPROMAZINE 25MG/ML AMP 2ML,53201521,CDM,250,RC,J3230,HCPCS,Outpatient,,,173.71,104.23,,32.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,78.17,45,,62.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,20.82,360,,,Fee Schedule,360% of BCBS POS Rate,20.82,360,,,Fee schedule,360% of BCBS PPO Rate,20.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,104.23,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.71,100,,138.968,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.28,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,24.23,80,,348.6,Fee Schedule,80% of Scott and White EPO fee schedule,24.23,80,,1540.08,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.23,80,,1540.08,Fee Schedule,80% of Scott and White PPO fee schedule,24.23,80,,60.176,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.6,70,,97.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.71,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,173.71,
DILTIAZEM IVPB 100MG/D5W100,53201588,CDM,250,RC,,,Outpatient,,,72.54,43.52,,43.52,60,,34.816,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,45,,26.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.31,28,,16.248,Percent of Total Billed Charges,28% of Total Billed Charges,2096,32,,1676.8,Percent of Total Billed Charges,32% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% Total Bille Charges,26.11,36,,20.888,Percent of Total Billed Charges,36% of Total Billed Charges,43.52,60,,745.08,Percent of Total Billed Charges,60% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.54,100,,58.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.46,14.42,,8.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.41,75,,78.52,Percent of Total Billed Charges,75% of Total Billed Charges,36.27,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.27,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,36.27,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.78,70,,40.624,Percent of Total Billed Charges,70% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.54,100,,104.696,Percent of Total Billed Charges,100% of Total Billed Charges,10.16,2096,
NICARDIPINE 20 MG/NS 200 ML,53201844,CDM,250,RC,,,Outpatient,,,427.5,256.50,,256.5,60,,205.2,Percent of Total Billed Charges,60% of Total Billed Charges,192.38,45,,153.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,28,,95.76,Percent of Total Billed Charges,28% of Total Billed Charges,2108.82,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% of Total Billed Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% Total Bille Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% of Total Billed Charges,256.5,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.5,100,,342,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,61.65,14.42,,49.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.63,75,,190.144,Percent of Total Billed Charges,75% of Total Billed Charges,213.75,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,213.75,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.75,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,213.75,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.25,70,,239.4,Percent of Total Billed Charges,70% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,100,,253.52,Percent of Total Billed Charges,100% of Total Billed Charges,59.85,2108.82,
NITROGLYCERIN 100MG/D5W 250ML,53201845,CDM,250,RC,,,Outpatient,,,140.28,84.17,,84.17,60,,67.336,Percent of Total Billed Charges,60% of Total Billed Charges,63.13,45,,50.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.28,28,,31.424,Percent of Total Billed Charges,28% of Total Billed Charges,2108.82,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,50.5,36,,40.4,Percent of Total Billed Charges,36% of Total Billed Charges,50.5,36,,40.4,Percent of Total Billed Charges,36% Total Bille Charges,50.5,36,,40.4,Percent of Total Billed Charges,36% of Total Billed Charges,84.17,60,,130.8,Percent of Total Billed Charges,60% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.28,100,,112.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,20.23,14.42,,16.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.21,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,70.14,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,70.14,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.14,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,70.14,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.2,70,,78.56,Percent of Total Billed Charges,70% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,19.64,14,,15.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.28,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,19.64,2108.82,
NITROGLYCERIN 25 MG/D5W 250 ML,53201846,CDM,250,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,22.69,45,,18.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,2108.82,32,,1687.056,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,75,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,40.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,2108.82,
DOBUTAMINE 250MG/20ML VL,53201851,CDM,250,RC,J1250,HCPCS,Outpatient,,,40.06,24.04,,6.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.03,45,,14.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.85,360,,,Fee Schedule,360% of BCBS POS Rate,2.85,360,,,Fee schedule,360% of BCBS PPO Rate,2.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.04,60,,75,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.06,100,,32.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.05,75,,48.344,Percent of Total Billed Charges,75% of Total Billed Charges,5.22,80,,203.344,Fee Schedule,80% of Scott and White EPO fee schedule,5.22,80,,932.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,80,,932.672,Fee Schedule,80% of Scott and White PPO fee schedule,5.22,80,,95.704,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.04,70,,22.432,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.06,100,,64.456,Percent of Total Billed Charges,100% of Total Billed Charges,2.85,40.06,
DOBUTAMINE 250MG/ D5W 250ML,53201869,CDM,250,RC,J1250,HCPCS,Outpatient,,,64.02,38.41,,6.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.81,45,,23.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.85,360,,,Fee Schedule,360% of BCBS POS Rate,2.85,360,,,Fee schedule,360% of BCBS PPO Rate,2.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.41,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.02,100,,51.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.02,75,,78.496,Percent of Total Billed Charges,75% of Total Billed Charges,5.22,80,,292.704,Fee Schedule,80% of Scott and White EPO fee schedule,5.22,80,,932.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,80,,932.672,Fee Schedule,80% of Scott and White PPO fee schedule,5.22,80,,165.888,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,70,,35.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.02,100,,104.664,Percent of Total Billed Charges,100% of Total Billed Charges,2.85,64.02,
NICARDIPINE 40 MG/NS 200 ML,53201877,CDM,250,RC,,,Outpatient,,,855,513.00,,513,60,,410.4,Percent of Total Billed Charges,60% of Total Billed Charges,384.75,45,,307.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.4,28,,191.52,Percent of Total Billed Charges,28% of Total Billed Charges,2119.84,32,,1695.872,Percent of Total Billed Charges,32% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,307.8,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,307.8,36,,246.24,Percent of Total Billed Charges,36% Total Bille Charges,307.8,36,,246.24,Percent of Total Billed Charges,36% of Total Billed Charges,513,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855,100,,684,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,123.29,14.42,,98.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.25,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,427.5,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,427.5,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,598.5,70,,478.8,Percent of Total Billed Charges,70% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,119.7,14,,95.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,855,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,119.7,2119.84,
POTASSIUM PHOS 15MMOL/NS 250ML,53201893,CDM,258,RC,,,Outpatient,,,16.3,9.78,,9.78,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,2120.98,32,,1696.784,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,9.78,60,,1608.96,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,226.664,Percent of Total Billed Charges,75% of Total Billed Charges,8.15,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,302.216,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,2120.98,
SOD BICARB (NEUT) 4% VL 5ML,53201919,CDM,250,RC,,,Outpatient,,,57.78,34.67,,34.67,60,,27.736,Percent of Total Billed Charges,60% of Total Billed Charges,26,45,,20.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.18,28,,12.944,Percent of Total Billed Charges,28% of Total Billed Charges,2120.98,32,,1696.784,Percent of Total Billed Charges,32% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,20.8,36,,16.64,Percent of Total Billed Charges,36% of Total Billed Charges,20.8,36,,16.64,Percent of Total Billed Charges,36% Total Bille Charges,20.8,36,,16.64,Percent of Total Billed Charges,36% of Total Billed Charges,34.67,60,,24.072,Percent of Total Billed Charges,60% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.78,100,,46.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.33,14.42,,6.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.34,75,,252.376,Percent of Total Billed Charges,75% of Total Billed Charges,28.89,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,28.89,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.89,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,28.89,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.45,70,,32.36,Percent of Total Billed Charges,70% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.78,100,,336.496,Percent of Total Billed Charges,100% of Total Billed Charges,8.09,2120.98,
DOPAMINE 200MG/5ML VL,53202065,CDM,250,RC,J1265,HCPCS,Outpatient,,,16.3,9.78,,0.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.25,360,,,Fee Schedule,360% of BCBS POS Rate,0.25,360,,,Fee schedule,360% of BCBS PPO Rate,0.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,794.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,188.688,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,80,,520,Fee Schedule,80% of Scott and White EPO fee schedule,0.53,80,,1671.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,80,,1671.672,Fee Schedule,80% of Scott and White PPO fee schedule,0.53,80,,116.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,251.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,16.3,
DOPAMINE 800 MCG/ML,53202164,CDM,250,RC,J1265,HCPCS,Outpatient,,,43.87,26.32,,0.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.74,45,,15.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.25,360,,,Fee Schedule,360% of BCBS POS Rate,0.25,360,,,Fee schedule,360% of BCBS PPO Rate,0.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.32,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.87,100,,35.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.9,75,,28.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,80,,1039.608,Fee Schedule,80% of Scott and White EPO fee schedule,0.53,80,,58.864,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,80,,58.864,Fee Schedule,80% of Scott and White PPO fee schedule,0.53,80,,348.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.71,70,,24.568,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.87,100,,35.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,43.87,
DORIPENEM 500 MG VL,53202297,CDM,250,RC,J1267,HCPCS,Outpatient,,,255.45,153.27,,0.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,114.95,45,,91.96,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.72,360,,,Fee Schedule,360% of BCBS POS Rate,0.72,360,,,Fee schedule,360% of BCBS PPO Rate,0.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,153.27,60,,246.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.45,100,,204.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.59,75,,271.952,Percent of Total Billed Charges,75% of Total Billed Charges,127.73,50,,1671.672,Percent of Total Billed Charges,50% of Total Billed Charges,127.73,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.73,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,127.73,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.82,70,,143.056,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.45,100,,362.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,255.45,
DOXERCALCIFEROL 4MCG/2ML INJ,53202511,CDM,250,RC,J1270,HCPCS,Outpatient,,,75,45.00,,0.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.75,45,,27,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.69,360,,,Fee Schedule,360% of BCBS POS Rate,0.69,360,,,Fee schedule,360% of BCBS PPO Rate,0.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,45,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,60,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.25,75,,222.512,Percent of Total Billed Charges,75% of Total Billed Charges,0.55,80,,58.864,Fee Schedule,80% of Scott and White EPO fee schedule,0.55,80,,58.024,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,80,,58.024,Fee Schedule,80% of Scott and White PPO fee schedule,0.55,80,,1540.08,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,70,,42,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,296.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,75,
DOXORUBICIN 50MG INJ,53202690,CDM,250,RC,J9000,HCPCS,Outpatient,,,259.94,155.96,,3.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,116.97,45,,93.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.49,360,,,Fee Schedule,360% of BCBS POS Rate,3.49,360,,,Fee schedule,360% of BCBS PPO Rate,3.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,155.96,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.94,100,,207.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.96,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,80,,64.44,Fee Schedule,80% of Scott and White EPO fee schedule,1.97,80,,73.536,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,80,,73.536,Fee Schedule,80% of Scott and White PPO fee schedule,1.97,80,,1336.824,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.96,70,,145.568,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.94,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,259.94,
DOXYCYCLINE 100MG/20ML INJ,53202941,CDM,250,RC,,,Outpatient,,,151.17,90.70,,90.7,60,,72.56,Percent of Total Billed Charges,60% of Total Billed Charges,68.03,45,,54.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.33,28,,33.864,Percent of Total Billed Charges,28% of Total Billed Charges,2126.08,32,,1700.864,Percent of Total Billed Charges,32% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,54.42,36,,43.536,Percent of Total Billed Charges,36% of Total Billed Charges,54.42,36,,43.536,Percent of Total Billed Charges,36% Total Bille Charges,54.42,36,,43.536,Percent of Total Billed Charges,36% of Total Billed Charges,90.7,60,,235.2,Percent of Total Billed Charges,60% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.17,100,,120.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.8,14.42,,17.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.38,75,,238.24,Percent of Total Billed Charges,75% of Total Billed Charges,75.59,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,75.59,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.59,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,75.59,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.82,70,,84.656,Percent of Total Billed Charges,70% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,21.16,14,,16.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.17,100,,317.656,Percent of Total Billed Charges,100% of Total Billed Charges,21.16,2126.08,
DROPERIDOL 2.5MG/ML VL 2ML,53203055,CDM,250,RC,J1790,HCPCS,Outpatient,,,14.64,8.78,,7.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.59,45,,5.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.67,360,,,Fee Schedule,360% of BCBS POS Rate,1.67,360,,,Fee schedule,360% of BCBS PPO Rate,1.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,8.78,60,,82.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.64,100,,11.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.98,75,,92.152,Percent of Total Billed Charges,75% of Total Billed Charges,7.32,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,7.32,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.32,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.32,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,70,,8.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.64,100,,122.864,Percent of Total Billed Charges,100% of Total Billed Charges,1.67,14.64,
ENALAPRILAT INJ 1.25MG/1ML,53203956,CDM,250,RC,,,Outpatient,,,21.59,12.95,,12.95,60,,10.36,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,45,,7.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.05,28,,4.84,Percent of Total Billed Charges,28% of Total Billed Charges,2135.58,32,,1708.464,Percent of Total Billed Charges,32% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,7.77,36,,6.216,Percent of Total Billed Charges,36% of Total Billed Charges,7.77,36,,6.216,Percent of Total Billed Charges,36% Total Bille Charges,7.77,36,,6.216,Percent of Total Billed Charges,36% of Total Billed Charges,12.95,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.59,100,,17.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.11,14.42,,2.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.19,75,,484,Percent of Total Billed Charges,75% of Total Billed Charges,10.8,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,10.8,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.8,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,10.8,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.11,70,,12.088,Percent of Total Billed Charges,70% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14,,2.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.59,100,,645.336,Percent of Total Billed Charges,100% of Total Billed Charges,3.02,2135.58,
ENALAPRILAT 1.25MG/ML INJ 2ML,53203964,CDM,250,RC,,,Outpatient,,,43.19,25.91,,25.91,60,,20.728,Percent of Total Billed Charges,60% of Total Billed Charges,19.44,45,,15.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.09,28,,9.672,Percent of Total Billed Charges,28% of Total Billed Charges,2135.67,32,,1708.536,Percent of Total Billed Charges,32% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,15.55,36,,12.44,Percent of Total Billed Charges,36% of Total Billed Charges,15.55,36,,12.44,Percent of Total Billed Charges,36% Total Bille Charges,15.55,36,,12.44,Percent of Total Billed Charges,36% of Total Billed Charges,25.91,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.19,100,,34.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.23,14.42,,4.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.39,75,,1300.648,Percent of Total Billed Charges,75% of Total Billed Charges,21.6,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.6,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.6,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,21.6,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.23,70,,24.184,Percent of Total Billed Charges,70% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,6.05,14,,4.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.19,100,,1734.192,Percent of Total Billed Charges,100% of Total Billed Charges,6.05,2135.67,
ENOXAPARIN 100MG INJ,53203980,CDM,250,RC,J1650,HCPCS,Outpatient,,,173.52,104.11,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,78.08,45,,62.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,104.11,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.52,100,,138.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.14,75,,771.744,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,69.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,58.864,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,58.864,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,932.672,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.46,70,,97.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.52,100,,1028.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,173.52,
ENOXAPARIN 60MG INJ,53203998,CDM,250,RC,J1650,HCPCS,Outpatient,,,115.32,69.19,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,51.89,45,,41.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.19,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.32,100,,92.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.49,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,74.384,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,73.536,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,73.536,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,640.544,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.72,70,,64.576,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.32,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,115.32,
ENOXAPARIN 30MG INJ,53204004,CDM,250,RC,J1650,HCPCS,Outpatient,,,71.69,43.01,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.26,45,,25.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.01,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,57.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.77,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,58.864,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,66.536,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,66.536,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,520,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.18,70,,40.144,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,71.69,
ENOXAPARIN 40MG INJ,53204012,CDM,250,RC,J1650,HCPCS,Outpatient,,,86.12,51.67,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.75,45,,31,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,51.67,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.12,100,,68.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.59,75,,84.144,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,73.536,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,66.536,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,66.536,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,1039.608,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,70,,48.224,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.12,100,,112.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,86.12,
ENOXAPARIN 80MG INJ,53204020,CDM,250,RC,J1650,HCPCS,Outpatient,,,144.38,86.63,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.97,45,,51.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.63,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.38,100,,115.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.29,75,,189.6,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,66.536,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,54.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,54.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,1671.672,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.07,70,,80.856,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.38,100,,252.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,144.38,
EPHEDRINE 50MG/1ML INJ,53204046,CDM,250,RC,,,Outpatient,,,242.74,145.64,,145.64,60,,116.512,Percent of Total Billed Charges,60% of Total Billed Charges,109.23,45,,87.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.97,28,,54.376,Percent of Total Billed Charges,28% of Total Billed Charges,2136.58,32,,1709.264,Percent of Total Billed Charges,32% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,87.39,36,,69.912,Percent of Total Billed Charges,36% of Total Billed Charges,87.39,36,,69.912,Percent of Total Billed Charges,36% Total Bille Charges,87.39,36,,69.912,Percent of Total Billed Charges,36% of Total Billed Charges,145.64,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.74,100,,194.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,35,14.42,,28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.06,75,,7.704,Percent of Total Billed Charges,75% of Total Billed Charges,121.37,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,121.37,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.37,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,121.37,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.92,70,,135.936,Percent of Total Billed Charges,70% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,33.98,14,,27.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,242.74,100,,10.272,Percent of Total Billed Charges,100% of Total Billed Charges,33.98,2136.58,
ENOXAPARIN 150 MG SYG,53204053,CDM,250,RC,J1650,HCPCS,Outpatient,,,587,352.20,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,264.15,45,,211.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,352.2,60,,65.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,587,100,,469.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440.25,75,,9.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,54.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,69.816,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,69.816,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,64.44,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.9,70,,328.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,587,100,,12.144,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,587,
ENOXAPARIN 120 MG INJ,53204061,CDM,250,RC,J1650,HCPCS,Outpatient,,,202.58,121.55,,0.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,91.16,45,,72.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.22,360,,,Fee Schedule,360% of BCBS POS Rate,1.22,360,,,Fee schedule,360% of BCBS PPO Rate,1.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,121.55,60,,128.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.58,100,,162.064,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.94,75,,19.848,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,67.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,74.384,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,74.384,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,58.024,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.81,70,,113.448,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.58,100,,26.464,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,202.58,
EPINEPHRINE 1:1000 INJ 1ML,53204251,CDM,250,RC,J0171,HCPCS,Outpatient,,,93.76,56.26,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,42.19,45,,33.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,56.26,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.76,100,,75.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.32,75,,21.96,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,80,,69.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.59,80,,189.864,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,80,,189.864,Fee Schedule,80% of Scott and White PPO fee schedule,0.59,80,,73.536,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.63,70,,52.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.76,100,,29.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,93.76,
EPINEPHRINE 1:1000 SYG 10ML,53204350,CDM,250,RC,J0171,HCPCS,Outpatient,,,31.35,18.81,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.11,45,,11.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,18.81,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.35,100,,25.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.51,75,,21.96,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,80,,74.384,Fee Schedule,80% of Scott and White EPO fee schedule,0.59,80,,58.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,80,,58.368,Fee Schedule,80% of Scott and White PPO fee schedule,0.59,80,,66.536,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.95,70,,17.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.35,100,,29.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,31.35,
ERTAPENEM 1GM INJ,53204913,CDM,250,RC,J1335,HCPCS,Outpatient,,,531.82,319.09,,24.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,239.32,45,,191.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,33.72,360,,,Fee Schedule,360% of BCBS POS Rate,33.72,360,,,Fee schedule,360% of BCBS PPO Rate,33.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,319.09,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.82,100,,425.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.87,75,,1.144,Percent of Total Billed Charges,75% of Total Billed Charges,10.26,80,,189.864,Fee Schedule,80% of Scott and White EPO fee schedule,10.26,80,,58.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.26,80,,58.368,Fee Schedule,80% of Scott and White PPO fee schedule,10.26,80,,67.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,372.27,70,,297.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.82,100,,1.52,Percent of Total Billed Charges,100% of Total Billed Charges,10.26,531.82,
ERYTHROMY LAC 500MG VL,53205084,CDM,250,RC,J1364,HCPCS,Outpatient,,,339.81,203.89,,76.01,100,,,Fee Schedule,100% of Aetna Fee Schedule,94.43,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,74.4,360,,,Fee Schedule,360% of BCBS POS Rate,74.4,360,,,Fee schedule,360% of BCBS PPO Rate,74.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,203.89,60,,148.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,56.65,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.83,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.84,103,,,Fee Schedule,103% of CMS OPPS Rate,64.84,103,,,Fee Schedule,103% of CMS OPPS Rate,254.86,75,,14.832,Percent of Total Billed Charges,75% of Total Billed Charges,68.42,80,,58.368,Fee Schedule,80% of Scott and White EPO fee schedule,68.42,80,,184.68,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,80,,184.68,Fee Schedule,80% of Scott and White PPO fee schedule,68.42,80,,69.816,Fee Schedule,80% of Scott and White SWHP fee schedule,94.43,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,237.87,70,,190.296,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.95,100,,,Fee Schedule,100% of CMS OPPS Rate,339.81,100,,19.776,Percent of Total Billed Charges,100% of Total Billed Charges,56.65,339.81,
ESMOLOL 10MG/ML INJ 10ML,53205241,CDM,250,RC,,,Outpatient,,,52.49,31.49,,31.49,60,,25.192,Percent of Total Billed Charges,60% of Total Billed Charges,23.62,45,,18.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,28,,11.76,Percent of Total Billed Charges,28% of Total Billed Charges,2142.4,32,,1713.92,Percent of Total Billed Charges,32% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,18.9,36,,15.12,Percent of Total Billed Charges,36% of Total Billed Charges,18.9,36,,15.12,Percent of Total Billed Charges,36% Total Bille Charges,18.9,36,,15.12,Percent of Total Billed Charges,36% of Total Billed Charges,31.49,60,,40.464,Percent of Total Billed Charges,60% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.49,100,,41.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.57,14.42,,6.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.37,75,,29.688,Percent of Total Billed Charges,75% of Total Billed Charges,26.25,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.74,70,,29.392,Percent of Total Billed Charges,70% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,7.35,14,,5.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.49,100,,39.584,Percent of Total Billed Charges,100% of Total Billed Charges,7.35,2142.4,
ESMOLOL 10MG/ML 250ML NS RTU,53205266,CDM,250,RC,,,Outpatient,,,2104.54,1262.72,,1262.72,60,,1010.176,Percent of Total Billed Charges,60% of Total Billed Charges,947.04,45,,757.632,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,589.27,28,,471.416,Percent of Total Billed Charges,28% of Total Billed Charges,2146.56,32,,1717.248,Percent of Total Billed Charges,32% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,757.63,36,,606.104,Percent of Total Billed Charges,36% of Total Billed Charges,757.63,36,,606.104,Percent of Total Billed Charges,36% Total Bille Charges,757.63,36,,606.104,Percent of Total Billed Charges,36% of Total Billed Charges,1262.72,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2104.54,100,,1683.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,303.47,14.42,,242.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1578.41,75,,34.104,Percent of Total Billed Charges,75% of Total Billed Charges,1052.27,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,1052.27,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1052.27,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,1052.27,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1473.18,70,,1178.544,Percent of Total Billed Charges,70% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,294.64,14,,235.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2104.54,100,,45.472,Percent of Total Billed Charges,100% of Total Billed Charges,294.64,2146.56,
ESTROGEN CONJ 5MG/ML INJ 5ML,53205423,CDM,250,RC,J1410,HCPCS,Outpatient,,,1355.63,813.38,,344.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,574.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,296.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,296.8,360,,,Fee Schedule,360% of BCBS POS Rate,296.8,360,,,Fee schedule,360% of BCBS PPO Rate,296.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,813.38,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,344.51,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,497.62,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,394.27,103,,,Fee Schedule,103% of CMS OPPS Rate,394.27,103,,,Fee Schedule,103% of CMS OPPS Rate,1016.72,75,,86.936,Percent of Total Billed Charges,75% of Total Billed Charges,284.62,80,,118.416,Fee Schedule,80% of Scott and White EPO fee schedule,284.62,80,,158,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,284.62,80,,158,Fee Schedule,80% of Scott and White PPO fee schedule,284.62,80,,73.536,Fee Schedule,80% of Scott and White SWHP fee schedule,574.16,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,948.94,70,,759.152,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.63,100,,115.912,Percent of Total Billed Charges,100% of Total Billed Charges,284.62,1355.63,
ETHANOLAMINE 50MG/ML INJ 2ML,53205753,CDM,250,RC,J1430,HCPCS,Outpatient,,,1923.8,1154.28,,448.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,737.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,427.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,427.51,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,427.51,360,,,Fee Schedule,360% of BCBS POS Rate,427.51,360,,,Fee schedule,360% of BCBS PPO Rate,427.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,1154.28,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,442.51,90,,,Fee Schedule,90% of CMS OPPS Rate,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,639.16,130,,,Fee Schedule,130% of CMS OPPS Rate,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,277.41,14.42,,221.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.43,103,,,Fee Schedule,103% of CMS OPPS Rate,506.43,103,,,Fee Schedule,103% of CMS OPPS Rate,1442.85,75,,56.488,Percent of Total Billed Charges,75% of Total Billed Charges,367.18,80,,158,Fee Schedule,80% of Scott and White EPO fee schedule,367.18,80,,158,Fee Schedule,80% of Scott and White HMO fee schedule,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,367.18,80,,158,Fee Schedule,80% of Scott and White PPO fee schedule,367.18,80,,66.536,Fee Schedule,80% of Scott and White SWHP fee schedule,737.52,150,,,Fee Schedule,150% of CMS OPPS Rate,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1346.66,70,,1077.328,Percent of Total Billed Charges,70% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,269.33,14,,215.464,Percent of Total Billed Charges,14% of Total Billed Charges,491.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1923.8,100,,75.312,Percent of Total Billed Charges,100% of Total Billed Charges,269.33,1923.8,
ETOPOSIDE 20MG/ML INJ 5ML,53206066,CDM,250,RC,J9181,HCPCS,Outpatient,,,118.16,70.90,,0.77,100,,,Fee Schedule,100% of Aetna Fee Schedule,53.17,45,,42.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.65,360,,,Fee Schedule,360% of BCBS POS Rate,0.65,360,,,Fee schedule,360% of BCBS PPO Rate,0.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.9,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.16,100,,94.528,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.62,75,,294.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,80,,158,Fee Schedule,80% of Scott and White EPO fee schedule,0.69,80,,158,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,80,,158,Fee Schedule,80% of Scott and White PPO fee schedule,0.69,80,,66.536,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.71,70,,66.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.16,100,,392.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,118.16,
ETOMIDATE 2 MG/ML INJ 10 ML,53206090,CDM,250,RC,,,Outpatient,,,45.52,27.31,,27.31,60,,21.848,Percent of Total Billed Charges,60% of Total Billed Charges,20.48,45,,16.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.75,28,,10.2,Percent of Total Billed Charges,28% of Total Billed Charges,2162.6,32,,1730.08,Percent of Total Billed Charges,32% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,16.39,36,,13.112,Percent of Total Billed Charges,36% of Total Billed Charges,16.39,36,,13.112,Percent of Total Billed Charges,36% Total Bille Charges,16.39,36,,13.112,Percent of Total Billed Charges,36% of Total Billed Charges,27.31,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.52,100,,36.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14.42,,5.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,75,,12.48,Percent of Total Billed Charges,75% of Total Billed Charges,22.76,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,22.76,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.76,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,22.76,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.86,70,,25.488,Percent of Total Billed Charges,70% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.52,100,,16.64,Percent of Total Billed Charges,100% of Total Billed Charges,6.37,2162.6,
ETOPOSIDE 100MG/5ML VIAL INJ,53206157,CDM,250,RC,J9181,HCPCS,Outpatient,,,116.72,70.03,,0.77,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.52,45,,42.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.65,360,,,Fee Schedule,360% of BCBS POS Rate,0.65,360,,,Fee schedule,360% of BCBS PPO Rate,0.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.03,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.72,100,,93.376,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.54,75,,31.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,80,,158,Fee Schedule,80% of Scott and White EPO fee schedule,0.69,80,,119.344,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,80,,119.344,Fee Schedule,80% of Scott and White PPO fee schedule,0.69,80,,67.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.7,70,,65.36,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.72,100,,42.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,116.72,
FENTANYL/BUPIV 100ML PMX,53206520,CDM,250,RC,J3010,HCPCS,Outpatient,,,80.22,48.13,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.1,45,,28.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.13,60,,176.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.22,100,,64.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.17,75,,71.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,119.344,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,119.344,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,119.344,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,69.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.15,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.22,100,,95.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,80.22,
FENTANYL/BUPIV 250ML PMX,53206538,CDM,250,RC,,,Outpatient,,,80.22,48.13,,48.13,60,,38.504,Percent of Total Billed Charges,60% of Total Billed Charges,36.1,45,,28.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.46,28,,17.968,Percent of Total Billed Charges,28% of Total Billed Charges,2168.19,32,,1734.552,Percent of Total Billed Charges,32% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% Total Bille Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,48.13,60,,1957.072,Percent of Total Billed Charges,60% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.22,100,,64.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14.42,,9.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.17,75,,30.408,Percent of Total Billed Charges,75% of Total Billed Charges,40.11,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,40.11,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.11,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,40.11,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.15,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.22,100,,40.544,Percent of Total Billed Charges,100% of Total Billed Charges,11.23,2168.19,
FAMOTIDINE 10MG/ML INJ 2ML,53206611,CDM,250,RC,,,Outpatient,,,7.66,4.60,,4.6,60,,3.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.45,45,,2.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.14,28,,1.712,Percent of Total Billed Charges,28% of Total Billed Charges,2172.75,32,,1738.2,Percent of Total Billed Charges,32% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,36,,2.208,Percent of Total Billed Charges,36% of Total Billed Charges,2.76,36,,2.208,Percent of Total Billed Charges,36% Total Bille Charges,2.76,36,,2.208,Percent of Total Billed Charges,36% of Total Billed Charges,4.6,60,,107.52,Percent of Total Billed Charges,60% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.66,100,,6.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14.42,,0.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,75,,13.568,Percent of Total Billed Charges,75% of Total Billed Charges,3.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,3.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,3.83,50,,189.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,70,,4.288,Percent of Total Billed Charges,70% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.66,100,,18.088,Percent of Total Billed Charges,100% of Total Billed Charges,1.07,2172.75,
FAMOTIDINE 20MG/2ML INJ,53206620,CDM,250,RC,,,Outpatient,,,16.3,9.78,,9.78,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,2175.36,32,,1740.288,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,9.78,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,22.888,Percent of Total Billed Charges,75% of Total Billed Charges,8.15,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,30.52,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,2175.36,
POSACONAZOLE 100MG DR TAB,53206742,CDM,250,RC,,,Outpatient,,,300,180.00,,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,135,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,2176.23,32,,1740.984,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,159.816,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,240,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,347.76,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,463.68,Percent of Total Billed Charges,100% of Total Billed Charges,42,2176.23,
MENINGOCOCCAL VAC C Y/HIB/PF,53206745,CDM,636,RC,90644,HCPCS,Outpatient,,,154.23,92.54,,114.77,110,,91.816,Percent of Total Billed Charges,110% of Total Billed Charges,69.4,45,,55.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,24.36,360,,,Fee Schedule,360% of BCBS POS Rate,24.36,360,,,Fee schedule,360% of BCBS PPO Rate,24.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.23,100,,123.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,22.24,14.42,,17.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.67,75,,18.616,Percent of Total Billed Charges,75% of Total Billed Charges,77.12,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,77.12,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.12,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,77.12,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.96,70,,86.368,Percent of Total Billed Charges,70% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,21.59,14,,17.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.23,100,,24.816,Percent of Total Billed Charges,100% of Total Billed Charges,21.59,154.23,
MENINGOCOCCAL VACC ACY W-135,53206746,CDM,636,RC,90734,HCPCS,Outpatient,,,577.28,346.37,,479.07,110,,383.256,Percent of Total Billed Charges,110% of Total Billed Charges,259.78,45,,207.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,85.08,360,,,Fee Schedule,360% of BCBS POS Rate,85.08,360,,,Fee schedule,360% of BCBS PPO Rate,85.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,577.28,100,,461.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,83.24,14.42,,66.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.96,75,,21.712,Percent of Total Billed Charges,75% of Total Billed Charges,288.64,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,288.64,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.64,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,288.64,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.1,70,,323.28,Percent of Total Billed Charges,70% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,80.82,14,,64.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,577.28,100,,28.944,Percent of Total Billed Charges,100% of Total Billed Charges,80.82,577.28,
INFLUENZA VAC FLUZONE,53206750,CDM,636,RC,90686,HCPCS,Outpatient,,,100.97,60.58,,77.14,110,,61.712,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,16.82,360,,,Fee Schedule,360% of BCBS POS Rate,16.82,360,,,Fee schedule,360% of BCBS PPO Rate,16.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.73,75,,23.112,Percent of Total Billed Charges,75% of Total Billed Charges,67.69,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,67.69,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.69,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,67.69,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.68,70,,56.544,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.97,100,,30.816,Percent of Total Billed Charges,100% of Total Billed Charges,16.82,100.97,
INFLUENZA VAC FLUZONE HD,53206755,CDM,636,RC,90662,HCPCS,Outpatient,,,246.25,147.75,,204.14,110,,163.312,Percent of Total Billed Charges,110% of Total Billed Charges,125.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,43.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,75.14,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,108.54,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.99,103,,,Fee Schedule,103% of CMS OPPS Rate,85.99,103,,,Fee Schedule,103% of CMS OPPS Rate,184.69,75,,32.152,Percent of Total Billed Charges,75% of Total Billed Charges,179.08,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,179.08,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.08,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,179.08,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,125.24,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,172.38,70,,137.904,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.49,100,,,Fee Schedule,100% of CMS OPPS Rate,246.25,100,,42.864,Percent of Total Billed Charges,100% of Total Billed Charges,43.13,246.25,
FLUCONAZOLE 100MG/NS 50ML,53206769,CDM,250,RC,J1450,HCPCS,Outpatient,,,58.12,34.87,,3.17,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.31,360,,,Fee Schedule,360% of BCBS POS Rate,6.31,360,,,Fee schedule,360% of BCBS PPO Rate,6.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.87,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.59,75,,30.096,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,80,,184,Fee Schedule,80% of Scott and White EPO fee schedule,1.96,80,,213.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,80,,213.368,Fee Schedule,80% of Scott and White PPO fee schedule,1.96,80,,158,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.68,70,,32.544,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.12,100,,40.128,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,58.12,
FLUCONAZOLE 200MG/NS 100ML,53206777,CDM,250,RC,J1450,HCPCS,Outpatient,,,70.87,42.52,,3.17,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.31,360,,,Fee Schedule,360% of BCBS POS Rate,6.31,360,,,Fee schedule,360% of BCBS PPO Rate,6.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.52,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.15,75,,6.232,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,80,,184,Fee Schedule,80% of Scott and White EPO fee schedule,1.96,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,1.96,80,,158,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.61,70,,39.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.87,100,,8.312,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,70.87,
FLUCONAZOLE 400MG/NS 200ML,53206785,CDM,250,RC,J1450,HCPCS,Outpatient,,,59.59,35.75,,3.17,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.31,360,,,Fee Schedule,360% of BCBS POS Rate,6.31,360,,,Fee schedule,360% of BCBS PPO Rate,6.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.75,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.69,75,,12.208,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,80,,213.368,Fee Schedule,80% of Scott and White EPO fee schedule,1.96,80,,213.896,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,80,,213.896,Fee Schedule,80% of Scott and White PPO fee schedule,1.96,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.71,70,,33.368,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.59,100,,16.272,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,59.59,
FLUDARABINE PHOS 50MG INJ,53206801,CDM,250,RC,J9185,HCPCS,Outpatient,,,401.29,240.77,,57.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,201.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,65.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,65.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,65.32,360,,,Fee Schedule,360% of BCBS POS Rate,65.32,360,,,Fee schedule,360% of BCBS PPO Rate,65.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,240.77,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,120.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,174.39,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.16,103,,,Fee Schedule,103% of CMS OPPS Rate,138.16,103,,,Fee Schedule,103% of CMS OPPS Rate,300.97,75,,13.792,Percent of Total Billed Charges,75% of Total Billed Charges,129.39,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,129.39,80,,213.896,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,129.39,80,,213.896,Fee Schedule,80% of Scott and White PPO fee schedule,129.39,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,201.22,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,280.9,70,,224.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.15,100,,,Fee Schedule,100% of CMS OPPS Rate,401.29,100,,18.384,Percent of Total Billed Charges,100% of Total Billed Charges,57.59,401.29,
FLUMAZENIL 0.1MG/ML INJ 5ML,53206819,CDM,250,RC,,,Outpatient,,,48.74,29.24,,29.24,60,,23.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.65,28,,10.92,Percent of Total Billed Charges,28% of Total Billed Charges,2179.5,32,,1743.6,Percent of Total Billed Charges,32% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,17.55,36,,14.04,Percent of Total Billed Charges,36% of Total Billed Charges,17.55,36,,14.04,Percent of Total Billed Charges,36% Total Bille Charges,17.55,36,,14.04,Percent of Total Billed Charges,36% of Total Billed Charges,29.24,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,14.42,,5.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.56,75,,16.072,Percent of Total Billed Charges,75% of Total Billed Charges,24.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,24.37,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.37,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,24.37,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.12,70,,27.296,Percent of Total Billed Charges,70% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,6.82,14,,5.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.74,100,,21.424,Percent of Total Billed Charges,100% of Total Billed Charges,6.82,2179.5,
FLUOROURACIL 500MG INJ,53207080,CDM,250,RC,J9190,HCPCS,Outpatient,,,72.49,43.49,,2.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.16,360,,,Fee Schedule,360% of BCBS POS Rate,2.16,360,,,Fee schedule,360% of BCBS PPO Rate,2.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.49,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.37,75,,11.624,Percent of Total Billed Charges,75% of Total Billed Charges,1.9,80,,213.896,Fee Schedule,80% of Scott and White EPO fee schedule,1.9,80,,213.896,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,80,,213.896,Fee Schedule,80% of Scott and White PPO fee schedule,1.9,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.74,70,,40.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.49,100,,15.496,Percent of Total Billed Charges,100% of Total Billed Charges,1.9,72.49,
FOLIC ACID 5MG/ML INJ 10ML,53207387,CDM,250,RC,,,Outpatient,,,90.98,54.59,,54.59,60,,43.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.47,28,,20.376,Percent of Total Billed Charges,28% of Total Billed Charges,2183.68,32,,1746.944,Percent of Total Billed Charges,32% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,32.75,36,,26.2,Percent of Total Billed Charges,36% of Total Billed Charges,32.75,36,,26.2,Percent of Total Billed Charges,36% Total Bille Charges,32.75,36,,26.2,Percent of Total Billed Charges,36% of Total Billed Charges,54.59,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,13.12,14.42,,10.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.24,75,,41.248,Percent of Total Billed Charges,75% of Total Billed Charges,45.49,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,45.49,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.49,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,45.49,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.69,70,,50.952,Percent of Total Billed Charges,70% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,12.74,14,,10.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.98,100,,55,Percent of Total Billed Charges,100% of Total Billed Charges,12.74,2183.68,
FUROSEMIDE 100MG/10ML INJ,53207593,CDM,250,RC,J1940,HCPCS,Outpatient,,,41.21,24.73,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.45,360,,,Fee Schedule,360% of BCBS POS Rate,1.45,360,,,Fee schedule,360% of BCBS PPO Rate,1.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.73,60,,76.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.91,75,,3.24,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,80,,213.896,Fee Schedule,80% of Scott and White EPO fee schedule,0.46,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,0.46,80,,184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.85,70,,23.08,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.21,100,,4.32,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,41.21,
FUROSEMIDE 20MG/2ML INJ,53207643,CDM,250,RC,J1940,HCPCS,Outpatient,,,36.72,22.03,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.45,360,,,Fee Schedule,360% of BCBS POS Rate,1.45,360,,,Fee schedule,360% of BCBS PPO Rate,1.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.03,60,,85.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.54,75,,20.992,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,0.46,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,0.46,80,,184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.7,70,,20.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.72,100,,27.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,36.72,
FONDAPARINUX 2.5 MG/0.5 ML INJ,53207668,CDM,250,RC,J1652,HCPCS,Outpatient,,,277.22,166.33,,1.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.33,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.33,360,,,Fee Schedule,360% of BCBS POS Rate,2.33,360,,,Fee schedule,360% of BCBS PPO Rate,2.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,166.33,60,,85.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.92,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,0.86,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,0.86,80,,184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.05,70,,155.24,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.22,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,277.22,
FUROSEMIDE 10MG/ML 4ML INJ,53207692,CDM,250,RC,J1940,HCPCS,Outpatient,,,18.82,11.29,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.45,360,,,Fee Schedule,360% of BCBS POS Rate,1.45,360,,,Fee schedule,360% of BCBS PPO Rate,1.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.29,60,,70.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,75,,7.6,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,0.46,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,0.46,80,,184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.17,70,,10.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.82,100,,10.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,18.82,
FONDAPARINUX 10MG/0.8ML INJ,53207734,CDM,250,RC,J1652,HCPCS,Outpatient,,,494.25,296.55,,1.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.33,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.33,360,,,Fee Schedule,360% of BCBS POS Rate,2.33,360,,,Fee schedule,360% of BCBS PPO Rate,2.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,296.55,60,,735.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.69,75,,29.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.86,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,0.86,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,0.86,80,,184,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.98,70,,276.784,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.25,100,,39.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,494.25,
FIDAXOMICIN 200 MG TAB,53207833,CDM,250,RC,,,Outpatient,,,368.66,221.20,,221.2,60,,176.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.22,28,,82.576,Percent of Total Billed Charges,28% of Total Billed Charges,2184.64,32,,1747.712,Percent of Total Billed Charges,32% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,132.72,36,,106.176,Percent of Total Billed Charges,36% of Total Billed Charges,132.72,36,,106.176,Percent of Total Billed Charges,36% Total Bille Charges,132.72,36,,106.176,Percent of Total Billed Charges,36% of Total Billed Charges,221.2,60,,649.808,Percent of Total Billed Charges,60% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,53.16,14.42,,42.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.5,75,,4.032,Percent of Total Billed Charges,75% of Total Billed Charges,184.33,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,184.33,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.33,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,184.33,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.06,70,,206.448,Percent of Total Billed Charges,70% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,51.61,14,,41.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,368.66,100,,5.376,Percent of Total Billed Charges,100% of Total Billed Charges,51.61,2184.64,
FILGRASTIM INJ 300MCG,53207863,CDM,250,RC,J1447,HCPCS,Outpatient,,,1268.47,761.08,,0.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,0.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.82,360,,,Fee Schedule,360% of BCBS POS Rate,0.82,360,,,Fee schedule,360% of BCBS PPO Rate,0.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,761.08,60,,76.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.35,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,951.35,75,,26.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,0.3,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.3,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,0.3,80,,213.368,Fee Schedule,80% of Scott and White SWHP fee schedule,0.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,887.93,70,,710.344,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.47,100,,34.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,1268.47,
FILGRASTIM INJ 480MCG,53207864,CDM,250,RC,J1447,HCPCS,Outpatient,,,2003.41,1202.05,,0.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,0.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.82,360,,,Fee Schedule,360% of BCBS POS Rate,0.82,360,,,Fee schedule,360% of BCBS PPO Rate,0.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,1202.05,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.35,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,1502.56,75,,20.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,80,,225.192,Fee Schedule,80% of Scott and White EPO fee schedule,0.3,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.3,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,0.3,80,,174.784,Fee Schedule,80% of Scott and White SWHP fee schedule,0.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.39,70,,1121.912,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.41,100,,26.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,2003.41,
GANCICLOVIR 500MG INJ,53208302,CDM,250,RC,J1570,HCPCS,Outpatient,,,539.01,323.41,,47.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,41.47,360,,,Fee Schedule,360% of BCBS POS Rate,41.47,360,,,Fee schedule,360% of BCBS PPO Rate,41.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,323.41,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,404.26,75,,21.632,Percent of Total Billed Charges,75% of Total Billed Charges,37.86,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,37.86,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.86,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,37.86,80,,213.896,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,377.31,70,,301.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,539.01,100,,28.84,Percent of Total Billed Charges,100% of Total Billed Charges,37.86,539.01,
GEMCITABINE 1GM VL 50ML,53208401,CDM,250,RC,J9201,HCPCS,Outpatient,,,818.56,491.14,,3.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.1,360,,,Fee Schedule,360% of BCBS POS Rate,5.1,360,,,Fee schedule,360% of BCBS PPO Rate,5.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,491.14,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,613.92,75,,52.488,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,213.896,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,572.99,70,,458.392,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,818.56,100,,69.984,Percent of Total Billed Charges,100% of Total Billed Charges,2.66,818.56,
GENTAMICIN 20MG/2ML INJ,53208427,CDM,250,RC,J1580,HCPCS,Outpatient,,,28.84,17.30,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,17.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,75,,16.816,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,43.696,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,43.696,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,174.784,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.19,70,,16.152,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.84,100,,22.416,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,28.84,
GENTAMICIN 80MG/NS 100ML,53208468,CDM,250,RC,J1580,HCPCS,Outpatient,,,28.85,17.31,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,17.31,60,,77,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.64,75,,7.328,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,181.904,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,213.896,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,70,,16.16,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.85,100,,9.768,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,28.85,
GENTAMICIN 100MG/.9%NACL 100ML,53208484,CDM,250,RC,J1580,HCPCS,Outpatient,,,25.55,15.33,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.33,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.16,75,,195.088,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,43.696,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,174.784,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,70,,14.312,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.55,100,,260.112,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,25.55,
GENTAMICIN 80MG/2ML INJ,53208526,CDM,250,RC,J1580,HCPCS,Outpatient,,,28.64,17.18,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,17.18,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,75,,264.168,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,181.904,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,246.104,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.05,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.64,100,,352.224,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,28.64,
PACLITAXEL 1MG INJ,53208528,CDM,250,RC,J9267,HCPCS,Outpatient,,,1.87,1.12,,0.13,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.18,360,,,Fee Schedule,360% of BCBS POS Rate,0.18,360,,,Fee schedule,360% of BCBS PPO Rate,0.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,1.12,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,75,,317.872,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,80,,181.904,Fee Schedule,80% of Scott and White EPO fee schedule,0.14,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,0.14,80,,246.104,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,70,,1.048,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,100,,423.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,1.87,
PROPOFOL 10MG/ML INJ 20ML,53208530,CDM,250,RC,,,Outpatient,,,34.19,20.51,,20.51,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.57,28,,7.656,Percent of Total Billed Charges,28% of Total Billed Charges,2211.27,32,,1769.016,Percent of Total Billed Charges,32% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,36,,9.848,Percent of Total Billed Charges,36% of Total Billed Charges,12.31,36,,9.848,Percent of Total Billed Charges,36% Total Bille Charges,12.31,36,,9.848,Percent of Total Billed Charges,36% of Total Billed Charges,20.51,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14.42,,3.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.64,75,,30.712,Percent of Total Billed Charges,75% of Total Billed Charges,17.1,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,17.1,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.1,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,17.1,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.93,70,,19.144,Percent of Total Billed Charges,70% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,4.79,14,,3.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.19,100,,40.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.79,2211.27,
PROPOFOL 10MG/ML INJ 100ML,53208532,CDM,250,RC,,,Outpatient,,,166.5,99.90,,99.9,60,,79.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.62,28,,37.296,Percent of Total Billed Charges,28% of Total Billed Charges,2211.64,32,,1769.312,Percent of Total Billed Charges,32% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,59.94,36,,47.952,Percent of Total Billed Charges,36% of Total Billed Charges,59.94,36,,47.952,Percent of Total Billed Charges,36% Total Bille Charges,59.94,36,,47.952,Percent of Total Billed Charges,36% of Total Billed Charges,99.9,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,24.01,14.42,,19.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.88,75,,112.104,Percent of Total Billed Charges,75% of Total Billed Charges,83.25,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,83.25,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.25,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,83.25,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.55,70,,93.24,Percent of Total Billed Charges,70% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,23.31,14,,18.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.5,100,,149.472,Percent of Total Billed Charges,100% of Total Billed Charges,23.31,2211.64,
GENTAMICIN 120MG/NS 100ML,53208542,CDM,250,RC,J1580,HCPCS,Outpatient,,,25.57,15.34,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.65,360,,,Fee Schedule,360% of BCBS POS Rate,1.65,360,,,Fee schedule,360% of BCBS PPO Rate,1.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.34,60,,85.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,75,,194.856,Percent of Total Billed Charges,75% of Total Billed Charges,2.02,80,,103.272,Fee Schedule,80% of Scott and White EPO fee schedule,2.02,80,,285.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.02,80,,285.2,Fee Schedule,80% of Scott and White PPO fee schedule,2.02,80,,174.784,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,70,,14.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.57,100,,259.808,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,25.57,
GLUCAGON 1MG INJ,53208989,CDM,250,RC,J1610,HCPCS,Outpatient,,,772.2,463.32,,168.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,288.45,150,,,Fee Schedule ,150% of CMS OPPS Rate,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,82.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,82.64,360,,,Fee Schedule,360% of BCBS POS Rate,82.64,360,,,Fee schedule,360% of BCBS PPO Rate,82.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,463.32,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,173.07,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,249.99,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.06,103,,,Fee Schedule,103% of CMS OPPS Rate,198.06,103,,,Fee Schedule,103% of CMS OPPS Rate,579.15,75,,459.088,Percent of Total Billed Charges,75% of Total Billed Charges,152.2,80,,285.2,Fee Schedule,80% of Scott and White EPO fee schedule,152.2,80,,285.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,152.2,80,,285.2,Fee Schedule,80% of Scott and White PPO fee schedule,152.2,80,,225.192,Fee Schedule,80% of Scott and White SWHP fee schedule,288.45,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,540.54,70,,432.432,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,772.2,100,,612.12,Percent of Total Billed Charges,100% of Total Billed Charges,82.64,772.2,
GLYCOPYRROLATE 0.2MG/ML 2ML IN,53209193,CDM,250,RC,,,Outpatient,,,176.5,105.90,,105.9,60,,84.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.42,28,,39.536,Percent of Total Billed Charges,28% of Total Billed Charges,2217.28,32,,1773.824,Percent of Total Billed Charges,32% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.54,36,,50.832,Percent of Total Billed Charges,36% of Total Billed Charges,63.54,36,,50.832,Percent of Total Billed Charges,36% Total Bille Charges,63.54,36,,50.832,Percent of Total Billed Charges,36% of Total Billed Charges,105.9,60,,105.432,Percent of Total Billed Charges,60% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,25.45,14.42,,20.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.38,75,,90.768,Percent of Total Billed Charges,75% of Total Billed Charges,88.25,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,88.25,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.25,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,88.25,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.55,70,,98.84,Percent of Total Billed Charges,70% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.71,14,,19.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.5,100,,121.024,Percent of Total Billed Charges,100% of Total Billed Charges,24.71,2217.28,
GLYCOPYRROLATE 0.2MG/1ML INJ,53209201,CDM,250,RC,,,Outpatient,,,99.16,59.50,,59.5,60,,47.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.76,28,,22.208,Percent of Total Billed Charges,28% of Total Billed Charges,2221.44,32,,1777.152,Percent of Total Billed Charges,32% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,35.7,36,,28.56,Percent of Total Billed Charges,36% of Total Billed Charges,35.7,36,,28.56,Percent of Total Billed Charges,36% Total Bille Charges,35.7,36,,28.56,Percent of Total Billed Charges,36% of Total Billed Charges,59.5,60,,89.76,Percent of Total Billed Charges,60% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,14.3,14.42,,11.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.37,75,,75.32,Percent of Total Billed Charges,75% of Total Billed Charges,49.58,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,49.58,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.41,70,,55.528,Percent of Total Billed Charges,70% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14,,11.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.16,100,,100.424,Percent of Total Billed Charges,100% of Total Billed Charges,13.88,2221.44,
GLYCOPYROLATE 0.2MG/ML VL 5ML,53209219,CDM,250,RC,,,Outpatient,,,300,180.00,,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,2223.73,32,,1778.984,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,395.2,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,27.032,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,36.04,Percent of Total Billed Charges,100% of Total Billed Charges,42,2223.73,
ADENOSINE 3MG/ML INJ 2ML,53209708,CDM,250,RC,J0153,HCPCS,Outpatient,,,11.22,6.73,,0.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,360,,,Fee Schedule,360% of BCBS POS Rate,1.26,360,,,Fee schedule,360% of BCBS PPO Rate,1.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,6.73,60,,989.072,Percent of Total Billed Charges,60% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14.42,,1.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,75,,38.056,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,81.264,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,73.728,Fee Schedule,80% of Scott and White HMO fee schedule,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,80,,73.728,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.85,70,,6.28,Percent of Total Billed Charges,70% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,100,,50.736,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,11.22,
ADENOSINE 3MG/ML INJ 4ML,53209709,CDM,250,RC,J0153,HCPCS,Outpatient,,,164.27,98.56,,0.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,360,,,Fee Schedule,360% of BCBS POS Rate,1.26,360,,,Fee schedule,360% of BCBS PPO Rate,1.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.56,60,,349.936,Percent of Total Billed Charges,60% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14.42,,18.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.2,75,,66.024,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,81.264,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,126.136,Fee Schedule,80% of Scott and White HMO fee schedule,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,80,,126.136,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,43.696,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,70,,91.992,Percent of Total Billed Charges,70% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,23,14,,18.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.27,100,,88.032,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,164.27,
HAEMOPHILUS B CONJ VAC M SDV,53209714,CDM,636,RC,90647,HCPCS,Outpatient,,,69.3,41.58,,71.63,110,,57.304,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,29.32,360,,,Fee Schedule,360% of BCBS POS Rate,29.32,360,,,Fee schedule,360% of BCBS PPO Rate,29.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.99,14.42,,7.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.98,75,,21.656,Percent of Total Billed Charges,75% of Total Billed Charges,34.65,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,34.65,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,34.65,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.51,70,,38.808,Percent of Total Billed Charges,70% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,9.7,14,,7.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.3,100,,28.872,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,71.63,
HALOPERIDOL 5MG/1ML INJ,53209722,CDM,250,RC,J1630,HCPCS,Outpatient,,,44.94,26.96,,1.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.97,360,,,Fee Schedule,360% of BCBS POS Rate,3.97,360,,,Fee schedule,360% of BCBS PPO Rate,3.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.96,60,,265.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.71,75,,34.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,80,,126.136,Fee Schedule,80% of Scott and White EPO fee schedule,0.92,80,,145.384,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,80,,145.384,Fee Schedule,80% of Scott and White PPO fee schedule,0.92,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.46,70,,25.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.94,100,,46.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,44.94,
HEPARIN FLUSH 500 UNITS/5ML,53209904,CDM,250,RC,J1642,HCPCS,Outpatient,,,16.3,9.78,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,285.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,150.808,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,135.64,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,49.816,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,49.816,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,201.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,16.3,
NEO HEPARIN 100 UNITS/ML INJ,53209938,CDM,250,RC,J1644,HCPCS,Outpatient,,,16.3,9.78,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,313.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,83.232,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,145.384,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,123.008,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,123.008,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,110.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,16.3,
HEPARIN 25000 UNIT/250ML 1/2NS,53210020,CDM,250,RC,J1644,HCPCS,Outpatient,,,78.22,46.93,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.93,60,,121.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.67,75,,4.872,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,49.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,138.952,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,138.952,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,103.272,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.75,70,,43.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.22,100,,6.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,78.22,
HEPARIN 2000U/1000ML NS,53210043,CDM,250,RC,J1644,HCPCS,Outpatient,,,62.62,37.57,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.57,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.97,75,,7.016,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,123.008,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,145.384,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,145.384,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,285.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.83,70,,35.064,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.62,100,,9.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,62.62,
HEPARIN 25000U/D5W 250ML,53210050,CDM,250,RC,J1644,HCPCS,Outpatient,,,77.5,46.50,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.5,60,,99.808,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.13,75,,10.952,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,138.952,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,107.872,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,107.872,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,285.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.25,70,,43.4,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.5,100,,14.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,77.5,
HEPARIN 100U/ML,53210118,CDM,250,RC,J1642,HCPCS,Outpatient,,,20.23,12.14,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.14,60,,62.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.17,75,,55.312,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,80,,145.384,Fee Schedule,80% of Scott and White EPO fee schedule,0.01,80,,29.04,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,80,,29.04,Fee Schedule,80% of Scott and White PPO fee schedule,0.01,80,,285.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.16,70,,11.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.23,100,,73.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,20.23,
HEPARIN 5000UN VL 1ML,53210167,CDM,250,RC,J1644,HCPCS,Outpatient,,,43.6,26.16,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.16,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,107.872,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,174.784,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,174.784,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,285.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.52,70,,24.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.6,100,,8,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,43.6,
HEPARIN 10000UN/1ML INJ,53210209,CDM,250,RC,J1644,HCPCS,Outpatient,,,52,31.20,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,31.2,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,75,,4.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,29.04,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,73.728,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,73.728,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,81.264,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.4,70,,29.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52,100,,5.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,52,
HEPARIN 1000U/1ML VL,53210639,CDM,250,RC,J1644,HCPCS,Outpatient,,,56.87,34.12,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.12,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.65,75,,4.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,174.784,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,213.896,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,213.896,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,81.264,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.81,70,,31.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.87,100,,6.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,56.87,
HUMATE-P INJ PER 1IU FACTOR Vlll,53210930,CDM,636,RC,J7192,HCPCS,Outpatient,,,10.92,6.55,,7.45,110,,5.96,Percent of Total Billed Charges,110% of Total Billed Charges,2.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.93,360,,,Fee Schedule,360% of BCBS POS Rate,0.93,360,,,Fee schedule,360% of BCBS PPO Rate,0.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1.39,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,103,,,Fee Schedule,103% of CMS OPPS Rate,1.59,103,,,Fee Schedule,103% of CMS OPPS Rate,8.19,75,,69.344,Percent of Total Billed Charges,75% of Total Billed Charges,6.61,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,6.61,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,6.61,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,2.31,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7.64,70,,6.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,100,,92.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.93,10.92,
HEPATITIS B IMMUNE GLOB 0.5ML,53211082,CDM,636,RC,90371,HCPCS,Outpatient,,,243.92,146.35,,304.44,110,,243.552,Percent of Total Billed Charges,110% of Total Billed Charges,209.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,128.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,128.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,128.71,360,,,Fee Schedule,360% of BCBS POS Rate,128.71,360,,,Fee schedule,360% of BCBS PPO Rate,128.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,181.9,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.12,103,,,Fee Schedule,103% of CMS OPPS Rate,144.12,103,,,Fee Schedule,103% of CMS OPPS Rate,182.94,75,,1003.2,Percent of Total Billed Charges,75% of Total Billed Charges,227.36,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,227.36,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,227.36,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,227.36,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,209.89,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,170.74,70,,136.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,243.92,100,,1337.6,Percent of Total Billed Charges,100% of Total Billed Charges,125.93,304.44,
HEPATITIS B IMMUNE GLOB 1 ML,53211132,CDM,636,RC,90371,HCPCS,Outpatient,,,768.89,461.33,,593.17,110,,474.536,Percent of Total Billed Charges,110% of Total Billed Charges,209.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,128.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,128.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,128.71,360,,,Fee Schedule,360% of BCBS POS Rate,128.71,360,,,Fee schedule,360% of BCBS PPO Rate,128.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,181.9,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.12,103,,,Fee Schedule,103% of CMS OPPS Rate,144.12,103,,,Fee Schedule,103% of CMS OPPS Rate,576.67,75,,41.928,Percent of Total Billed Charges,75% of Total Billed Charges,489.85,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,489.85,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,489.85,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,489.85,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,209.89,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,538.22,70,,430.576,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,768.89,100,,55.904,Percent of Total Billed Charges,100% of Total Billed Charges,125.93,768.89,
HEP B 10MCG/0.5ML ENERGIX PEDI,53211140,CDM,636,RC,90744,HCPCS,Outpatient,,,300,180.00,,195.27,110,,156.216,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,22.83,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.83,360,,,Fee Schedule,360% of BCBS POS Rate,22.83,360,,,Fee schedule,360% of BCBS PPO Rate,22.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,33.04,Percent of Total Billed Charges,75% of Total Billed Charges,174.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,174.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.83,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,174.83,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,44.056,Percent of Total Billed Charges,100% of Total Billed Charges,22.83,300,
HEPATITIS B VACC ADULT IM,53211142,CDM,636,RC,90746,HCPCS,Outpatient,,,300,180.00,,239.08,110,,191.264,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,56.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,56.9,360,,,Fee Schedule,360% of BCBS POS Rate,56.9,360,,,Fee schedule,360% of BCBS PPO Rate,56.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,55.192,Percent of Total Billed Charges,75% of Total Billed Charges,206.3,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,206.3,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.3,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,206.3,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,73.592,Percent of Total Billed Charges,100% of Total Billed Charges,56.9,300,
HEPATITIS A VAC PED/ADOL 720U,53211143,CDM,636,RC,90633,HCPCS,Outpatient,,,300,180.00,,206.67,110,,165.336,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,38.21,360,,,Fee Schedule,360% of BCBS POS Rate,38.21,360,,,Fee schedule,360% of BCBS PPO Rate,38.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,98.04,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,130.72,Percent of Total Billed Charges,100% of Total Billed Charges,38.21,300,
HEPATITIS A VACC ADULT 1440U,53211144,CDM,636,RC,90632,HCPCS,Outpatient,,,309.98,185.99,,258.84,110,,207.072,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,67.16,360,,,Fee Schedule,360% of BCBS POS Rate,67.16,360,,,Fee schedule,360% of BCBS PPO Rate,67.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.49,75,,131.28,Percent of Total Billed Charges,75% of Total Billed Charges,211.07,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,211.07,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.07,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,211.07,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.99,70,,173.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309.98,100,,175.04,Percent of Total Billed Charges,100% of Total Billed Charges,67.16,309.98,
ROTAVIRUS VACC ORAL HUMAN,53211145,CDM,636,RC,90681,HCPCS,Outpatient,,,534.53,320.72,,446.28,110,,357.024,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,120.95,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,120.95,360,,,Fee Schedule,360% of BCBS POS Rate,120.95,360,,,Fee schedule,360% of BCBS PPO Rate,120.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.9,75,,16.296,Percent of Total Billed Charges,75% of Total Billed Charges,267.27,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,267.27,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.27,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,267.27,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374.17,70,,299.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.53,100,,21.728,Percent of Total Billed Charges,100% of Total Billed Charges,120.95,534.53,
HEP B 10MCG/0.5ML ENERGIX PEDI,53211157,CDM,636,RC,90744,HCPCS,Outpatient,,,300,180.00,,195.27,110,,156.216,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,22.83,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,22.83,360,,,Fee Schedule,360% of BCBS POS Rate,22.83,360,,,Fee schedule,360% of BCBS PPO Rate,22.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,198,Percent of Total Billed Charges,75% of Total Billed Charges,174.83,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,174.83,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.83,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,174.83,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,264,Percent of Total Billed Charges,100% of Total Billed Charges,22.83,300,
HEPATITIS B VAC REC 10MCG/ML,53211160,CDM,636,RC,90746,HCPCS,Outpatient,,,300,180.00,,239.08,110,,191.264,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,56.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,56.9,360,,,Fee Schedule,360% of BCBS POS Rate,56.9,360,,,Fee schedule,360% of BCBS PPO Rate,56.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,69.528,Percent of Total Billed Charges,75% of Total Billed Charges,206.3,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,206.3,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.3,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,206.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,92.704,Percent of Total Billed Charges,100% of Total Billed Charges,56.9,300,
HETASTARCH 6%/NS 500ML,53211272,CDM,258,RC,,,Outpatient,,,130.87,78.52,,78.52,60,,62.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.64,28,,29.312,Percent of Total Billed Charges,28% of Total Billed Charges,2235.02,32,,1788.016,Percent of Total Billed Charges,32% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,47.11,36,,37.688,Percent of Total Billed Charges,36% of Total Billed Charges,47.11,36,,37.688,Percent of Total Billed Charges,36% Total Bille Charges,47.11,36,,37.688,Percent of Total Billed Charges,36% of Total Billed Charges,78.52,60,,62.808,Percent of Total Billed Charges,60% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.87,14.42,,15.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.15,75,,256.504,Percent of Total Billed Charges,75% of Total Billed Charges,65.44,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,65.44,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.44,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,65.44,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.61,70,,73.288,Percent of Total Billed Charges,70% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14,,14.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.87,100,,342,Percent of Total Billed Charges,100% of Total Billed Charges,18.32,2235.02,
HETASTARCH 6%/ELEC LAC 500ML,53211280,CDM,258,RC,,,Outpatient,,,316.9,190.14,,190.14,60,,152.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.73,28,,70.984,Percent of Total Billed Charges,28% of Total Billed Charges,2238.91,32,,1791.128,Percent of Total Billed Charges,32% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,114.08,36,,91.264,Percent of Total Billed Charges,36% of Total Billed Charges,114.08,36,,91.264,Percent of Total Billed Charges,36% Total Bille Charges,114.08,36,,91.264,Percent of Total Billed Charges,36% of Total Billed Charges,190.14,60,,306.72,Percent of Total Billed Charges,60% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,45.7,14.42,,36.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.68,75,,47.776,Percent of Total Billed Charges,75% of Total Billed Charges,158.45,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,158.45,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.45,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,158.45,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.83,70,,177.464,Percent of Total Billed Charges,70% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,44.37,14,,35.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.9,100,,63.696,Percent of Total Billed Charges,100% of Total Billed Charges,44.37,2238.91,
HYALURONIDASE 150UN INJ,53211819,CDM,250,RC,J3470,HCPCS,Outpatient,,,300,180.00,,53.57,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,55.8,360,,,Fee Schedule,360% of BCBS POS Rate,55.8,360,,,Fee schedule,360% of BCBS PPO Rate,55.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,306.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,70.136,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,93.512,Percent of Total Billed Charges,100% of Total Billed Charges,53.57,300,
HYDRALAZINE 20MG/1ML INJ,53212023,CDM,250,RC,J0360,HCPCS,Outpatient,,,72,43.20,,5.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.48,360,,,Fee Schedule,360% of BCBS POS Rate,6.48,360,,,Fee schedule,360% of BCBS PPO Rate,6.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.2,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,75,,47.776,Percent of Total Billed Charges,75% of Total Billed Charges,4.39,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,4.39,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.39,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,4.39,80,,213.368,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.4,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,100,,63.696,Percent of Total Billed Charges,100% of Total Billed Charges,4.39,72,
HYDROCORT SOD SUC 100MG VL 2ML,53212437,CDM,250,RC,J1720,HCPCS,Outpatient,,,80.57,48.34,,14.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,9.94,360,,,Fee Schedule,360% of BCBS POS Rate,9.94,360,,,Fee schedule,360% of BCBS PPO Rate,9.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.34,60,,68.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.43,75,,218.28,Percent of Total Billed Charges,75% of Total Billed Charges,14.33,80,,66.536,Fee Schedule,80% of Scott and White EPO fee schedule,14.33,80,,246.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.33,80,,246.104,Fee Schedule,80% of Scott and White PPO fee schedule,14.33,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.4,70,,45.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.57,100,,291.04,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,80.57,
HYDROXYZINE 50 MG/ML INJ 1 ML,53213161,CDM,250,RC,J3410,HCPCS,Outpatient,,,130.83,78.50,,8.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.68,360,,,Fee Schedule,360% of BCBS POS Rate,0.68,360,,,Fee schedule,360% of BCBS PPO Rate,0.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.5,60,,118.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.12,75,,68.936,Percent of Total Billed Charges,75% of Total Billed Charges,10.48,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,10.48,80,,225.192,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,80,,225.192,Fee Schedule,80% of Scott and White PPO fee schedule,10.48,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.58,70,,73.264,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.83,100,,91.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,130.83,
HYOSCYAMINE 0.5MG/ML INJ 1ML,53213203,CDM,250,RC,J1980,HCPCS,Outpatient,,,300,180.00,,29.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,29.81,360,,,Fee Schedule,360% of BCBS POS Rate,29.81,360,,,Fee schedule,360% of BCBS PPO Rate,29.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,99.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,5.056,Percent of Total Billed Charges,75% of Total Billed Charges,25.31,80,,246.104,Fee Schedule,80% of Scott and White EPO fee schedule,25.31,80,,225.192,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,80,,225.192,Fee Schedule,80% of Scott and White PPO fee schedule,25.31,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,6.736,Percent of Total Billed Charges,100% of Total Billed Charges,25.31,300,
INDOCYANINE GREEN 25 MG AMP,53213208,CDM,250,RC,,,Outpatient,,,377.77,226.66,,226.66,60,,181.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.78,28,,84.624,Percent of Total Billed Charges,28% of Total Billed Charges,2239.79,32,,1791.832,Percent of Total Billed Charges,32% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,136,36,,108.8,Percent of Total Billed Charges,36% of Total Billed Charges,136,36,,108.8,Percent of Total Billed Charges,36% Total Bille Charges,136,36,,108.8,Percent of Total Billed Charges,36% of Total Billed Charges,226.66,60,,198.296,Percent of Total Billed Charges,60% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,54.47,14.42,,43.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.33,75,,38.4,Percent of Total Billed Charges,75% of Total Billed Charges,188.89,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,188.89,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.89,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,188.89,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.44,70,,211.552,Percent of Total Billed Charges,70% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,52.89,14,,42.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,377.77,100,,51.2,Percent of Total Billed Charges,100% of Total Billed Charges,52.89,2239.79,
IDARUBICIN 5MG INJ,53213211,CDM,250,RC,J9211,HCPCS,Outpatient,,,420.62,252.37,,37.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,39.69,360,,,Fee Schedule,360% of BCBS POS Rate,39.69,360,,,Fee schedule,360% of BCBS PPO Rate,39.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,252.37,60,,123.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.47,75,,2.536,Percent of Total Billed Charges,75% of Total Billed Charges,35.5,80,,225.192,Fee Schedule,80% of Scott and White EPO fee schedule,35.5,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.5,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,35.5,80,,119.344,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.43,70,,235.544,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.62,100,,3.376,Percent of Total Billed Charges,100% of Total Billed Charges,35.5,420.62,
IFOSFAMIDE 1 GM INJ,53213229,CDM,250,RC,J9208,HCPCS,Outpatient,,,314.48,188.69,,26.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.78,360,,,Fee Schedule,360% of BCBS POS Rate,24.78,360,,,Fee schedule,360% of BCBS PPO Rate,24.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,188.69,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.86,75,,5.992,Percent of Total Billed Charges,75% of Total Billed Charges,21.1,80,,181.904,Fee Schedule,80% of Scott and White EPO fee schedule,21.1,80,,181.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.1,80,,181.904,Fee Schedule,80% of Scott and White PPO fee schedule,21.1,80,,158,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.14,70,,176.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.48,100,,7.984,Percent of Total Billed Charges,100% of Total Billed Charges,21.1,314.48,
INDIGO CARMIN 40MG/ML INJ 5ML,53213344,CDM,255,RC,,,Outpatient,,,44.1,26.46,,26.46,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.35,28,,9.88,Percent of Total Billed Charges,28% of Total Billed Charges,1.92,32,,1.536,Percent of Total Billed Charges,32% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,15.88,36,,12.704,Percent of Total Billed Charges,36% of Total Billed Charges,15.88,36,,12.704,Percent of Total Billed Charges,36% Total Bille Charges,15.88,36,,12.704,Percent of Total Billed Charges,36% of Total Billed Charges,26.46,60,,101.336,Percent of Total Billed Charges,60% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14.42,,5.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.28,80,,60.624,Percent of Total Billed Charges,80% of Total Billed Charges,22.05,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,22.05,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.05,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,22.05,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.87,70,,24.696,Percent of Total Billed Charges,70% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.17,14,,4.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.1,100,,80.832,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,44.1,
INFLIXIMAB 10MG INJ,53213567,CDM,636,RC,J1745,HCPCS,Outpatient,,,453.25,271.95,,287.54,110,,230.032,Percent of Total Billed Charges,110% of Total Billed Charges,48.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,108.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,108.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,108.61,360,,,Fee Schedule,360% of BCBS POS Rate,108.61,360,,,Fee schedule,360% of BCBS PPO Rate,108.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,28.99,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,41.88,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.18,103,,,Fee Schedule,103% of CMS OPPS Rate,33.18,103,,,Fee Schedule,103% of CMS OPPS Rate,339.94,75,,82.8,Percent of Total Billed Charges,75% of Total Billed Charges,253.86,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,253.86,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,253.86,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.86,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,48.33,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,317.28,70,,253.824,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,453.25,100,,110.4,Percent of Total Billed Charges,100% of Total Billed Charges,28.99,453.25,
INSULIN LISPRO 100 UNIT/ML 3ML,53213997,CDM,250,RC,J1815,HCPCS,Outpatient,,,370.85,222.51,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,222.51,60,,283.968,Percent of Total Billed Charges,60% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14.42,,42.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.14,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,185.43,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,185.43,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.43,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,185.43,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.6,70,,207.68,Percent of Total Billed Charges,70% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,51.92,14,,41.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.85,100,,24,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,370.85,
INSULIN NPH 100 UNIT/ML 3ML,53214045,CDM,250,RC,J1815,HCPCS,Outpatient,,,267.72,160.63,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.63,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.79,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,133.86,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.86,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.4,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.72,100,,24,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,267.72,
INSULIN HUMALOG MIX 75/25 10ML,53214060,CDM,250,RC,J1815,HCPCS,Outpatient,,,397.07,238.24,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,238.24,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,57.26,14.42,,45.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.8,75,,17.208,Percent of Total Billed Charges,75% of Total Billed Charges,198.54,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,198.54,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.54,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,198.54,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.95,70,,222.36,Percent of Total Billed Charges,70% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,55.59,14,,44.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.07,100,,22.944,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,397.07,
INSULIN GLARGINE 300UN/3ML PEN,53214086,CDM,250,RC,J1815,HCPCS,Outpatient,,,153.58,92.15,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,92.15,60,,70.08,Percent of Total Billed Charges,60% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14.42,,17.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.19,75,,10.84,Percent of Total Billed Charges,75% of Total Billed Charges,76.79,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,76.79,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.79,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,76.79,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.51,70,,86.008,Percent of Total Billed Charges,70% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,21.5,14,,17.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.58,100,,14.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,153.58,
LIRAGLUTIDE INJ 6MG/ML 3ML,53214088,CDM,250,RC,,,Outpatient,,,806.67,484.00,,484,60,,387.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.87,28,,180.696,Percent of Total Billed Charges,28% of Total Billed Charges,1.93,32,,1.544,Percent of Total Billed Charges,32% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,290.4,36,,232.32,Percent of Total Billed Charges,36% of Total Billed Charges,290.4,36,,232.32,Percent of Total Billed Charges,36% Total Bille Charges,290.4,36,,232.32,Percent of Total Billed Charges,36% of Total Billed Charges,484,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,116.32,14.42,,93.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,605,75,,117.448,Percent of Total Billed Charges,75% of Total Billed Charges,403.34,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,403.34,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,403.34,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,403.34,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,564.67,70,,451.736,Percent of Total Billed Charges,70% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,112.93,14,,90.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,806.67,100,,156.592,Percent of Total Billed Charges,100% of Total Billed Charges,1.93,806.67,
EXENATIDE 60DOSE PEN 5MCG/DOSE,53214090,CDM,636,RC,J3490,HCPCS,Outpatient,,,2167.74,1300.64,,1192.26,110,,953.808,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,606.97,28,,485.576,Percent of Total Billed Charges,28% of Total Billed Charges,1.94,32,,1.552,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,780.39,36,,624.312,Percent of Total Billed Charges,36% of Total Billed Charges,780.39,36,,624.312,Percent of Total Billed Charges,36% Total Bille Charges,780.39,36,,624.312,Percent of Total Billed Charges,36% of Total Billed Charges,1192.26,55,,87.6,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1625.81,75,,5078.888,Percent of Total Billed Charges,75% of Total Billed Charges,1083.87,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,1083.87,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1083.87,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,1083.87,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1517.42,70,,1213.936,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2167.74,100,,6771.848,Percent of Total Billed Charges,100% of Total Billed Charges,1.94,2167.74,
INSULIN NOVOLOG MIX 70/30 10ML,53214433,CDM,250,RC,J1815,HCPCS,Outpatient,,,1286.24,771.74,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,771.74,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,185.48,14.42,,148.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,964.68,75,,254.456,Percent of Total Billed Charges,75% of Total Billed Charges,643.12,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,643.12,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,643.12,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,643.12,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,900.37,70,,720.296,Percent of Total Billed Charges,70% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,180.07,14,,144.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1286.24,100,,339.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,1286.24,
INSULIN HUM 70/30 VL 10ML,53214573,CDM,250,RC,J1815,HCPCS,Outpatient,,,267.72,160.63,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.63,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.79,75,,427.888,Percent of Total Billed Charges,75% of Total Billed Charges,133.86,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.86,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.4,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.72,100,,570.52,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,267.72,
INSULIN HUM R 100 UNIT/ML 3ML,53214987,CDM,250,RC,J1815,HCPCS,Outpatient,,,267.72,160.63,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.63,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.79,75,,886.712,Percent of Total Billed Charges,75% of Total Billed Charges,133.86,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.86,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.4,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.72,100,,1182.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,267.72,
IRINOTECAN 20 MG/ML VL 1 ML,53215026,CDM,250,RC,J9206,HCPCS,Outpatient,,,140.24,84.14,,2.47,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.86,360,,,Fee Schedule,360% of BCBS POS Rate,2.86,360,,,Fee schedule,360% of BCBS PPO Rate,2.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,84.14,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.18,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,1.73,80,,145.384,Fee Schedule,80% of Scott and White EPO fee schedule,1.73,80,,123.008,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,80,,123.008,Fee Schedule,80% of Scott and White PPO fee schedule,1.73,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.17,70,,78.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.24,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,140.24,
IRON SUCROSE 100MG/5ML INJ,53215299,CDM,250,RC,J1756,HCPCS,Outpatient,,,316,189.60,,0.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.35,360,,,Fee Schedule,360% of BCBS POS Rate,0.35,360,,,Fee schedule,360% of BCBS PPO Rate,0.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,189.6,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,80,,49.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.16,80,,138.952,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,80,,138.952,Fee Schedule,80% of Scott and White PPO fee schedule,0.16,80,,181.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.2,70,,176.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,316,
FERROUS SULF 15MG/ML IRON 50ML,53215307,CDM,250,RC,,,Outpatient,,,12.84,7.70,,7.7,60,,6.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,28,,2.88,Percent of Total Billed Charges,28% of Total Billed Charges,1.94,32,,1.552,Percent of Total Billed Charges,32% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,36,,3.696,Percent of Total Billed Charges,36% of Total Billed Charges,4.62,36,,3.696,Percent of Total Billed Charges,36% Total Bille Charges,4.62,36,,3.696,Percent of Total Billed Charges,36% of Total Billed Charges,7.7,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14.42,,1.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,6.42,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,6.42,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.42,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,6.42,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.99,70,,7.192,Percent of Total Billed Charges,70% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14,,1.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.84,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.8,12.84,
PROTHROMBIN (KCENTRA) 1 UNIT,53216085,CDM,636,RC,J7168,HCPCS,Outpatient,,,15.18,9.11,,10.96,110,,8.768,Percent of Total Billed Charges,110% of Total Billed Charges,3.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.61,360,,,Fee Schedule,360% of BCBS POS Rate,2.61,360,,,Fee schedule,360% of BCBS PPO Rate,2.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2.91,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.29,103,,,Fee Schedule,103% of CMS OPPS Rate,2.29,103,,,Fee Schedule,103% of CMS OPPS Rate,11.39,75,,48.568,Percent of Total Billed Charges,75% of Total Billed Charges,7.59,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,7.59,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,7.59,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.63,70,,8.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,100,,,Fee Schedule,100% of CMS OPPS Rate,15.18,100,,64.76,Percent of Total Billed Charges,100% of Total Billed Charges,2,15.18,
KETAMINE 50MG/ML VL 10ML,53216305,CDM,250,RC,,,Outpatient,,,33.08,19.85,,19.85,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.26,28,,7.408,Percent of Total Billed Charges,28% of Total Billed Charges,1.95,32,,1.56,Percent of Total Billed Charges,32% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% of Total Billed Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% Total Bille Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% of Total Billed Charges,19.85,60,,65.216,Percent of Total Billed Charges,60% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.77,14.42,,3.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.81,75,,453.608,Percent of Total Billed Charges,75% of Total Billed Charges,16.54,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,16.54,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.54,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,16.54,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.16,70,,18.528,Percent of Total Billed Charges,70% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.08,100,,604.808,Percent of Total Billed Charges,100% of Total Billed Charges,1.95,33.08,
KETOROLAC 30 MG INJ,53216370,CDM,250,RC,J1885,HCPCS,Outpatient,,,36.6,21.96,,0.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.18,360,,,Fee Schedule,360% of BCBS POS Rate,0.18,360,,,Fee schedule,360% of BCBS PPO Rate,0.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.96,60,,126.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,75,,75.496,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,80,,107.872,Fee Schedule,80% of Scott and White EPO fee schedule,0.38,80,,67.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,80,,67.2,Fee Schedule,80% of Scott and White PPO fee schedule,0.38,80,,285.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.62,70,,20.496,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.6,100,,100.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,36.6,
KETOROLAC 30 MG INJ,53216370,CDM,250,RC,J1885,HCPCS,Outpatient,,,36.6,21.96,,0.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.18,360,,,Fee Schedule,360% of BCBS POS Rate,0.18,360,,,Fee schedule,360% of BCBS PPO Rate,0.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.96,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,80,,66.536,Fee Schedule,80% of Scott and White EPO fee schedule,0.38,80,,69.816,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,80,,69.816,Fee Schedule,80% of Scott and White PPO fee schedule,0.38,80,,81.264,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.62,70,,20.496,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.6,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,36.6,
LEVOCARNITINE 330MG TAB,53216397,CDM,250,RC,,,Outpatient,,,1.9,1.14,,1.14,60,,0.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,28,,0.424,Percent of Total Billed Charges,28% of Total Billed Charges,1.96,32,,1.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,36,,0.544,Percent of Total Billed Charges,36% of Total Billed Charges,0.68,36,,0.544,Percent of Total Billed Charges,36% Total Bille Charges,0.68,36,,0.544,Percent of Total Billed Charges,36% of Total Billed Charges,1.14,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14.42,,0.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,75,,1159.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.95,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.95,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.95,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,70,,1.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,100,,1545.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,1.96,
LABETOLOL 5MG/ML VL 20ML,53216412,CDM,250,RC,,,Outpatient,,,24.72,14.83,,14.83,60,,11.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.92,28,,5.536,Percent of Total Billed Charges,28% of Total Billed Charges,1.96,32,,1.568,Percent of Total Billed Charges,32% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,8.9,36,,7.12,Percent of Total Billed Charges,36% of Total Billed Charges,8.9,36,,7.12,Percent of Total Billed Charges,36% Total Bille Charges,8.9,36,,7.12,Percent of Total Billed Charges,36% of Total Billed Charges,14.83,60,,82.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.56,14.42,,2.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,75,,45.6,Percent of Total Billed Charges,75% of Total Billed Charges,12.36,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,12.36,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.36,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,12.36,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.3,70,,13.84,Percent of Total Billed Charges,70% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14,,2.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.72,100,,60.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,24.72,
LABETALOL 5 MG/ML INJ 4 ML,53216420,CDM,250,RC,,,Outpatient,,,49.48,29.69,,29.69,60,,23.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.85,28,,11.08,Percent of Total Billed Charges,28% of Total Billed Charges,1.96,32,,1.568,Percent of Total Billed Charges,32% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,36,,14.248,Percent of Total Billed Charges,36% of Total Billed Charges,17.81,36,,14.248,Percent of Total Billed Charges,36% Total Bille Charges,17.81,36,,14.248,Percent of Total Billed Charges,36% of Total Billed Charges,29.69,60,,65.312,Percent of Total Billed Charges,60% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,7.14,14.42,,5.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.11,75,,19.72,Percent of Total Billed Charges,75% of Total Billed Charges,24.74,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,24.74,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.74,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,24.74,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.64,70,,27.712,Percent of Total Billed Charges,70% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,6.93,14,,5.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.48,100,,26.296,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,49.48,
LACOSAMIDE 50 MG TAB,53216586,CDM,250,RC,,,Outpatient,,,56.84,34.10,,34.1,60,,27.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.92,28,,12.736,Percent of Total Billed Charges,28% of Total Billed Charges,1.98,32,,1.584,Percent of Total Billed Charges,32% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,20.46,36,,16.368,Percent of Total Billed Charges,36% of Total Billed Charges,20.46,36,,16.368,Percent of Total Billed Charges,36% Total Bille Charges,20.46,36,,16.368,Percent of Total Billed Charges,36% of Total Billed Charges,34.1,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,8.2,14.42,,6.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.63,75,,133.288,Percent of Total Billed Charges,75% of Total Billed Charges,28.42,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,28.42,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.42,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,28.42,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.79,70,,31.832,Percent of Total Billed Charges,70% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,14,,6.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.84,100,,177.72,Percent of Total Billed Charges,100% of Total Billed Charges,1.98,56.84,
LACOSAMIDE 200 MG/20 ML VL,53216594,CDM,250,RC,,,Outpatient,,,144.89,86.93,,86.93,60,,69.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.57,28,,32.456,Percent of Total Billed Charges,28% of Total Billed Charges,1.98,32,,1.584,Percent of Total Billed Charges,32% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,52.16,36,,41.728,Percent of Total Billed Charges,36% of Total Billed Charges,52.16,36,,41.728,Percent of Total Billed Charges,36% Total Bille Charges,52.16,36,,41.728,Percent of Total Billed Charges,36% of Total Billed Charges,86.93,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.89,14.42,,16.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.67,75,,65.336,Percent of Total Billed Charges,75% of Total Billed Charges,72.45,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,72.45,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.45,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,72.45,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.42,70,,81.136,Percent of Total Billed Charges,70% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,20.28,14,,16.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.89,100,,87.112,Percent of Total Billed Charges,100% of Total Billed Charges,1.98,144.89,
LACOSAMIDE 200MG TAB,53216636,CDM,250,RC,,,Outpatient,,,94.14,56.48,,56.48,60,,45.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.36,28,,21.088,Percent of Total Billed Charges,28% of Total Billed Charges,2.01,32,,1.608,Percent of Total Billed Charges,32% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,33.89,36,,27.112,Percent of Total Billed Charges,36% of Total Billed Charges,33.89,36,,27.112,Percent of Total Billed Charges,36% Total Bille Charges,33.89,36,,27.112,Percent of Total Billed Charges,36% of Total Billed Charges,56.48,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.57,14.42,,10.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.61,75,,177.264,Percent of Total Billed Charges,75% of Total Billed Charges,47.07,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,47.07,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.07,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.07,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.9,70,,52.72,Percent of Total Billed Charges,70% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,13.18,14,,10.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.14,100,,236.352,Percent of Total Billed Charges,100% of Total Billed Charges,2.01,94.14,
METHYLNALTREXONE 12 MG VL,53216644,CDM,250,RC,J2212,HCPCS,Outpatient,,,490.5,294.30,,1.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,1.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.96,360,,,Fee Schedule,360% of BCBS POS Rate,0.96,360,,,Fee schedule,360% of BCBS PPO Rate,0.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,294.3,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,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,0.84,90,,,Fee Schedule,90% of CMS OPPS Rate,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1.22,130,,,Fee Schedule,130% of CMS OPPS Rate,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,70.73,14.42,,56.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,0.96,103,,,Fee Schedule,103% of CMS OPPS Rate,0.96,103,,,Fee Schedule,103% of CMS OPPS Rate,367.88,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,245.25,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,245.25,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,245.25,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,245.25,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,1.41,150,,,Fee Schedule,150% of CMS OPPS Rate,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,343.35,70,,274.68,Percent of Total Billed Charges,70% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.67,14,,54.936,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,490.5,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,490.5,
LEVETIRACETAM 100 MG/ML VL 5ML,53216958,CDM,250,RC,J1953,HCPCS,Outpatient,,,20.8,12.48,,0.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.11,360,,,Fee Schedule,360% of BCBS POS Rate,0.11,360,,,Fee schedule,360% of BCBS PPO Rate,0.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.48,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,75,,26.488,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,67.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,74.384,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,74.384,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,138.952,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.56,70,,11.648,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,100,,35.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,20.8,
NOREPINEPHRINE 4MG/4ML INJ,53216982,CDM,250,RC,,,Outpatient,,,52.97,31.78,,31.78,60,,25.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.83,28,,11.864,Percent of Total Billed Charges,28% of Total Billed Charges,2.02,32,,1.616,Percent of Total Billed Charges,32% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,19.07,36,,15.256,Percent of Total Billed Charges,36% of Total Billed Charges,19.07,36,,15.256,Percent of Total Billed Charges,36% Total Bille Charges,19.07,36,,15.256,Percent of Total Billed Charges,36% of Total Billed Charges,31.78,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.64,14.42,,6.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.73,75,,22.24,Percent of Total Billed Charges,75% of Total Billed Charges,26.49,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,26.49,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.49,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,26.49,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.08,70,,29.664,Percent of Total Billed Charges,70% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.97,100,,29.648,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,52.97,
NOREPINEPHRINE 4MG/D5W 250ML,53216990,CDM,250,RC,,,Outpatient,,,119.64,71.78,,71.78,60,,57.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.5,28,,26.8,Percent of Total Billed Charges,28% of Total Billed Charges,2.02,32,,1.616,Percent of Total Billed Charges,32% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,43.07,36,,34.456,Percent of Total Billed Charges,36% of Total Billed Charges,43.07,36,,34.456,Percent of Total Billed Charges,36% Total Bille Charges,43.07,36,,34.456,Percent of Total Billed Charges,36% of Total Billed Charges,71.78,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,17.25,14.42,,13.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.73,75,,504.912,Percent of Total Billed Charges,75% of Total Billed Charges,59.82,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,59.82,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.82,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,59.82,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.75,70,,67,Percent of Total Billed Charges,70% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,16.75,14,,13.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.64,100,,673.216,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,119.64,
LEVOFLOXACIN 750MG/D5W 150ML,53217071,CDM,250,RC,J1956,HCPCS,Outpatient,,,50.68,30.41,,0.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.44,360,,,Fee Schedule,360% of BCBS POS Rate,1.44,360,,,Fee schedule,360% of BCBS PPO Rate,1.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.41,60,,54.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.01,75,,258.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,58.368,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,54.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,54.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,66.536,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.48,70,,28.384,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.68,100,,345.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,50.68,
LEVOFLOXACIN 500MG/D5W 100ML,53217113,CDM,250,RC,J1956,HCPCS,Outpatient,,,22.61,13.57,,0.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.44,360,,,Fee Schedule,360% of BCBS POS Rate,1.44,360,,,Fee schedule,360% of BCBS PPO Rate,1.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.57,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.96,75,,6889.408,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,58.368,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,58.024,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,58.024,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,67.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.83,70,,12.664,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.61,100,,9185.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,22.61,
LEVOFLOXACIN 250MG/D5W 50ML,53217121,CDM,250,RC,J1956,HCPCS,Outpatient,,,38.15,22.89,,0.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.44,360,,,Fee Schedule,360% of BCBS POS Rate,1.44,360,,,Fee schedule,360% of BCBS PPO Rate,1.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.89,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.61,75,,51.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,54.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,29.04,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,29.04,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,69.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.71,70,,21.368,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.15,100,,68.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,38.15,
LEVOTHYROXINE 100MCG INJ,53217162,CDM,250,RC,,,Outpatient,,,579.6,347.76,,347.76,60,,278.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.29,28,,129.832,Percent of Total Billed Charges,28% of Total Billed Charges,2.02,32,,1.616,Percent of Total Billed Charges,32% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,208.66,36,,166.928,Percent of Total Billed Charges,36% of Total Billed Charges,208.66,36,,166.928,Percent of Total Billed Charges,36% Total Bille Charges,208.66,36,,166.928,Percent of Total Billed Charges,36% of Total Billed Charges,347.76,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,83.58,14.42,,66.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.7,75,,42.928,Percent of Total Billed Charges,75% of Total Billed Charges,289.8,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,289.8,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,289.8,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,289.8,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.72,70,,324.576,Percent of Total Billed Charges,70% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,81.14,14,,64.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,579.6,100,,57.232,Percent of Total Billed Charges,100% of Total Billed Charges,2.02,579.6,
LIDOCAINE INJ 1% 10ML SDV,53217295,CDM,250,RC,,,Outpatient,,,31.02,18.61,,18.61,60,,14.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.69,28,,6.952,Percent of Total Billed Charges,28% of Total Billed Charges,2.04,32,,1.632,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,11.17,36,,8.936,Percent of Total Billed Charges,36% of Total Billed Charges,11.17,36,,8.936,Percent of Total Billed Charges,36% Total Bille Charges,11.17,36,,8.936,Percent of Total Billed Charges,36% of Total Billed Charges,18.61,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.27,75,,12.496,Percent of Total Billed Charges,75% of Total Billed Charges,15.51,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,15.51,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.51,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,15.51,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.71,70,,17.368,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.02,100,,16.656,Percent of Total Billed Charges,100% of Total Billed Charges,2.04,31.02,
LIDOCAINE INJ 2% 10ML MDV,53217311,CDM,250,RC,,,Outpatient,,,36.18,21.71,,21.71,60,,17.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.13,28,,8.104,Percent of Total Billed Charges,28% of Total Billed Charges,2.04,32,,1.632,Percent of Total Billed Charges,32% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.02,36,,10.416,Percent of Total Billed Charges,36% of Total Billed Charges,13.02,36,,10.416,Percent of Total Billed Charges,36% Total Bille Charges,13.02,36,,10.416,Percent of Total Billed Charges,36% of Total Billed Charges,21.71,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.22,14.42,,4.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.14,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,18.09,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,18.09,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.09,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,18.09,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.33,70,,20.264,Percent of Total Billed Charges,70% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14,,4.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.18,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.04,36.18,
LIDOCAINE 2GM IN D5W 500ML,53217386,CDM,250,RC,J2002,HCPCS,Outpatient,,,38.52,23.11,,23.11,60,,18.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.11,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14.42,,4.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.89,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,19.26,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,19.26,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.26,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,19.26,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.96,70,,21.568,Percent of Total Billed Charges,70% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,5.39,14,,4.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.52,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,38.52,
LIDOCAINE 2% W/EPI 10ML VL,53217485,CDM,250,RC,,,Outpatient,,,53.58,32.15,,32.15,60,,25.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,28,,12,Percent of Total Billed Charges,28% of Total Billed Charges,2.04,32,,1.632,Percent of Total Billed Charges,32% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,19.29,36,,15.432,Percent of Total Billed Charges,36% of Total Billed Charges,19.29,36,,15.432,Percent of Total Billed Charges,36% Total Bille Charges,19.29,36,,15.432,Percent of Total Billed Charges,36% of Total Billed Charges,32.15,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.73,14.42,,6.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.19,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,26.79,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,26.79,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.79,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,26.79,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.51,70,,30.008,Percent of Total Billed Charges,70% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,7.5,14,,6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.58,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.04,53.58,
LIDOCAINE 1% W/EPI 30ML VL,53217600,CDM,250,RC,,,Outpatient,,,50.16,30.10,,30.1,60,,24.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.04,28,,11.232,Percent of Total Billed Charges,28% of Total Billed Charges,2.06,32,,1.648,Percent of Total Billed Charges,32% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,18.06,36,,14.448,Percent of Total Billed Charges,36% of Total Billed Charges,18.06,36,,14.448,Percent of Total Billed Charges,36% Total Bille Charges,18.06,36,,14.448,Percent of Total Billed Charges,36% of Total Billed Charges,30.1,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.23,14.42,,5.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.62,75,,291.536,Percent of Total Billed Charges,75% of Total Billed Charges,25.08,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,25.08,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.08,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,25.08,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.11,70,,28.088,Percent of Total Billed Charges,70% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,7.02,14,,5.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.16,100,,388.712,Percent of Total Billed Charges,100% of Total Billed Charges,2.06,50.16,
LIDOCAINE INJ 1% 20ML MDV,53217717,CDM,250,RC,,,Outpatient,,,10.39,6.23,,6.23,60,,4.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.91,28,,2.328,Percent of Total Billed Charges,28% of Total Billed Charges,2.06,32,,1.648,Percent of Total Billed Charges,32% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.74,36,,2.992,Percent of Total Billed Charges,36% of Total Billed Charges,3.74,36,,2.992,Percent of Total Billed Charges,36% Total Bille Charges,3.74,36,,2.992,Percent of Total Billed Charges,36% of Total Billed Charges,6.23,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14.42,,1.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,75,,81.248,Percent of Total Billed Charges,75% of Total Billed Charges,5.2,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.27,70,,5.816,Percent of Total Billed Charges,70% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,1.45,14,,1.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.39,100,,108.328,Percent of Total Billed Charges,100% of Total Billed Charges,1.45,10.39,
LIDOCAINE INJ 1% 5ML SDV,53217758,CDM,250,RC,,,Outpatient,,,20.34,12.20,,12.2,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.7,28,,4.56,Percent of Total Billed Charges,28% of Total Billed Charges,2.07,32,,1.656,Percent of Total Billed Charges,32% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% of Total Billed Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% Total Bille Charges,7.32,36,,5.856,Percent of Total Billed Charges,36% of Total Billed Charges,12.2,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14.42,,2.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.26,75,,137.272,Percent of Total Billed Charges,75% of Total Billed Charges,10.17,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.17,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.17,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,10.17,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.24,70,,11.392,Percent of Total Billed Charges,70% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,2.85,14,,2.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.34,100,,183.024,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,20.34,
LIDOCAINE 1% BUFF1ML SYRG 3ML,53217770,CDM,250,RC,,,Outpatient,,,22.98,13.79,,13.79,60,,11.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.43,28,,5.144,Percent of Total Billed Charges,28% of Total Billed Charges,2.08,32,,1.664,Percent of Total Billed Charges,32% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% of Total Billed Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% Total Bille Charges,8.27,36,,6.616,Percent of Total Billed Charges,36% of Total Billed Charges,13.79,60,,54.688,Percent of Total Billed Charges,60% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14.42,,2.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.24,75,,5.8,Percent of Total Billed Charges,75% of Total Billed Charges,11.49,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,11.49,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.49,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,11.49,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.09,70,,12.872,Percent of Total Billed Charges,70% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.98,100,,7.728,Percent of Total Billed Charges,100% of Total Billed Charges,2.08,22.98,
LIDOCAINE 2% W/EPI 20ML INJ,53217956,CDM,250,RC,,,Outpatient,,,26.78,16.07,,16.07,60,,12.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,28,,6,Percent of Total Billed Charges,28% of Total Billed Charges,2.08,32,,1.664,Percent of Total Billed Charges,32% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,9.64,36,,7.712,Percent of Total Billed Charges,36% of Total Billed Charges,9.64,36,,7.712,Percent of Total Billed Charges,36% Total Bille Charges,9.64,36,,7.712,Percent of Total Billed Charges,36% of Total Billed Charges,16.07,60,,54.688,Percent of Total Billed Charges,60% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14.42,,3.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.09,75,,35.992,Percent of Total Billed Charges,75% of Total Billed Charges,13.39,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,13.39,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.39,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,13.39,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.75,70,,15,Percent of Total Billed Charges,70% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,3.75,14,,3,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,100,,47.992,Percent of Total Billed Charges,100% of Total Billed Charges,2.08,26.78,
LIDOCAINE 2% SYG 5ML,53218103,CDM,250,RC,,,Outpatient,,,19.37,11.62,,11.62,60,,9.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.42,28,,4.336,Percent of Total Billed Charges,28% of Total Billed Charges,2.1,32,,1.68,Percent of Total Billed Charges,32% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,36,,5.576,Percent of Total Billed Charges,36% of Total Billed Charges,6.97,36,,5.576,Percent of Total Billed Charges,36% Total Bille Charges,6.97,36,,5.576,Percent of Total Billed Charges,36% of Total Billed Charges,11.62,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.79,14.42,,2.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.53,75,,144.208,Percent of Total Billed Charges,75% of Total Billed Charges,9.69,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.56,70,,10.848,Percent of Total Billed Charges,70% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14,,2.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.37,100,,192.272,Percent of Total Billed Charges,100% of Total Billed Charges,2.1,19.37,
LIDO 300MG SYR,53218129,CDM,250,RC,,,Outpatient,,,68.75,41.25,,41.25,60,,33,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.25,28,,15.4,Percent of Total Billed Charges,28% of Total Billed Charges,2.1,32,,1.68,Percent of Total Billed Charges,32% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,36,,19.8,Percent of Total Billed Charges,36% of Total Billed Charges,24.75,36,,19.8,Percent of Total Billed Charges,36% Total Bille Charges,24.75,36,,19.8,Percent of Total Billed Charges,36% of Total Billed Charges,41.25,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.91,14.42,,7.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.56,75,,66.76,Percent of Total Billed Charges,75% of Total Billed Charges,34.38,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,34.38,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.38,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,34.38,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.13,70,,38.504,Percent of Total Billed Charges,70% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,9.63,14,,7.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.75,100,,89.008,Percent of Total Billed Charges,100% of Total Billed Charges,2.1,68.75,
LORAZEPAM 2MG/ML INJ 1ML,53218939,CDM,250,RC,J2060,HCPCS,Outpatient,,,5.4,3.24,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,3.24,60,,56.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,75,,10.776,Percent of Total Billed Charges,75% of Total Billed Charges,0.94,80,,98.32,Fee Schedule,80% of Scott and White EPO fee schedule,0.94,80,,184.12,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.94,80,,184.12,Fee Schedule,80% of Scott and White PPO fee schedule,0.94,80,,29.04,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.78,70,,3.024,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,100,,14.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,5.4,
LORAZEPAM/NS DRIP 100MG 100ML,53218954,CDM,250,RC,J2060,HCPCS,Outpatient,,,34.98,20.99,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.37,360,,,Fee Schedule,360% of BCBS POS Rate,0.37,360,,,Fee schedule,360% of BCBS PPO Rate,0.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,20.99,60,,56.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.24,75,,4413.224,Percent of Total Billed Charges,75% of Total Billed Charges,0.94,80,,41.44,Fee Schedule,80% of Scott and White EPO fee schedule,0.94,80,,110.656,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.94,80,,110.656,Fee Schedule,80% of Scott and White PPO fee schedule,0.94,80,,40.608,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.49,70,,19.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,100,,5884.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,34.98,
MAG SO4 50% 5ML,53219366,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,2.1,32,,1.68,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,84.024,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,921.28,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,1228.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,3.9,
MAG SULF 50% VL 10ML,53219382,CDM,250,RC,J3475,HCPCS,Outpatient,,,12.66,7.60,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.6,60,,84.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,75,,1350,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,110.656,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,84.832,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,84.832,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,31,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,70,,7.088,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.66,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,12.66,
MAGNESIUM SULF 40GM/1000 ML,53219390,CDM,250,RC,J3475,HCPCS,Outpatient,,,49.8,29.88,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,29.88,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.35,75,,1396.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,936.064,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,48.32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,48.32,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,30.96,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.86,70,,27.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.8,100,,1862.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,49.8,
MAG SULF 50% INJ 2ML,53219408,CDM,250,RC,J3475,HCPCS,Outpatient,,,6.72,4.03,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.03,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,75,,322.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,84.832,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,42.32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,42.32,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,30.96,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.7,70,,3.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,100,,429.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,6.72,
MAGNESIUM SULF 4GM/100 ML,53219440,CDM,250,RC,J3475,HCPCS,Outpatient,,,43.38,26.03,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.03,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.54,75,,485.112,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,48.32,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,50.816,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,50.816,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,30.96,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.37,70,,24.296,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.38,100,,646.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,43.38,
MAG SULF 20GM IN WATER 500ML,53219457,CDM,258,RC,J3475,HCPCS,Outpatient,,,33.6,20.16,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,20.16,60,,85.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.2,75,,33.536,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,42.32,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,42.944,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,42.944,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,113.68,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,70,,18.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.6,100,,44.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,33.6,
MAGNESIUM SULF 1 GM/D5W 100 ML,53219507,CDM,250,RC,J3475,HCPCS,Outpatient,,,36.05,21.63,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.63,60,,145.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.04,75,,78.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,50.816,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,54.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,54.368,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,60.64,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.24,70,,20.192,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.05,100,,104.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,36.05,
MAG SULF 2GM/WATER 50ML,53219523,CDM,258,RC,J3475,HCPCS,Outpatient,,,87.48,52.49,,0.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.49,60,,85.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.61,75,,219.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.63,80,,42.944,Fee Schedule,80% of Scott and White EPO fee schedule,0.63,80,,82.592,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,80,,82.592,Fee Schedule,80% of Scott and White PPO fee schedule,0.63,80,,200,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.24,70,,48.992,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.48,100,,292.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,87.48,
MANNITOL 25% VL 50ML,53219614,CDM,250,RC,J2150,HCPCS,Outpatient,,,28.02,16.81,,4.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.07,360,,,Fee Schedule,360% of BCBS POS Rate,3.07,360,,,Fee schedule,360% of BCBS PPO Rate,3.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,16.81,60,,72.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.02,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,2.42,80,,54.368,Fee Schedule,80% of Scott and White EPO fee schedule,2.42,80,,89.24,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,80,,89.24,Fee Schedule,80% of Scott and White PPO fee schedule,2.42,80,,40.96,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.61,70,,15.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.02,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,28.02,
BUPIVACAINE MPF 0.25% VL 30ML,53219650,CDM,250,RC,,,Outpatient,,,12.21,7.33,,7.33,60,,5.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,28,,2.736,Percent of Total Billed Charges,28% of Total Billed Charges,2.11,32,,1.688,Percent of Total Billed Charges,32% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4.4,36,,3.52,Percent of Total Billed Charges,36% of Total Billed Charges,4.4,36,,3.52,Percent of Total Billed Charges,36% Total Bille Charges,4.4,36,,3.52,Percent of Total Billed Charges,36% of Total Billed Charges,7.33,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14.42,,1.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.16,75,,680.344,Percent of Total Billed Charges,75% of Total Billed Charges,6.11,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,6.11,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.11,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,6.11,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.55,70,,6.84,Percent of Total Billed Charges,70% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.21,100,,907.128,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,12.21,
MEAS. MUMPS RUB. VAC S,53219929,CDM,636,RC,90707,HCPCS,Outpatient,,,325.14,195.08,,283.16,110,,226.528,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,70.26,360,,,Fee Schedule,360% of BCBS POS Rate,70.26,360,,,Fee schedule,360% of BCBS PPO Rate,70.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.86,75,,34.848,Percent of Total Billed Charges,75% of Total Billed Charges,162.57,50,,89.24,Percent of Total Billed Charges,50% of Total Billed Charges,162.57,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.57,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,162.57,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.6,70,,182.08,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.14,100,,46.464,Percent of Total Billed Charges,100% of Total Billed Charges,70.26,325.14,
MEDROXYPROGEST 150MG/ML VL 1ML,53220257,CDM,250,RC,J1050,HCPCS,Outpatient,,,440.28,264.17,,0.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.21,360,,,Fee Schedule,360% of BCBS POS Rate,0.21,360,,,Fee schedule,360% of BCBS PPO Rate,0.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,264.17,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.21,75,,18.544,Percent of Total Billed Charges,75% of Total Billed Charges,220.14,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,220.14,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.14,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,220.14,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.2,70,,246.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440.28,100,,24.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,440.28,
MENINGOCOCCAL CONJ VAC 0.5 ML,53220580,CDM,636,RC,90734,HCPCS,Outpatient,,,529.79,317.87,,452.95,110,,362.36,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,85.08,360,,,Fee Schedule,360% of BCBS POS Rate,85.08,360,,,Fee schedule,360% of BCBS PPO Rate,85.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,76.4,14.42,,61.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.34,75,,39.24,Percent of Total Billed Charges,75% of Total Billed Charges,264.9,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,264.9,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,264.9,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,264.9,50,,110.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.85,70,,296.68,Percent of Total Billed Charges,70% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,74.17,14,,59.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.79,100,,52.32,Percent of Total Billed Charges,100% of Total Billed Charges,74.17,529.79,
MEROPENEM 500MG VL,53221149,CDM,250,RC,J2185,HCPCS,Outpatient,,,51.19,30.71,,0.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.04,45,,18.432,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.21,360,,,Fee Schedule,360% of BCBS POS Rate,2.21,360,,,Fee schedule,360% of BCBS PPO Rate,2.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.71,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.19,100,,40.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.39,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,55.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,56.48,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,80,,56.48,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,936.064,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.83,70,,28.664,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.19,100,,68,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,51.19,
MESNA 1GM INJ 10ML,53221225,CDM,250,RC,J9209,HCPCS,Outpatient,,,186.84,112.10,,1.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,84.08,45,,67.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,7.08,360,,,Fee Schedule,360% of BCBS POS Rate,7.08,360,,,Fee schedule,360% of BCBS PPO Rate,7.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.1,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.84,100,,149.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.13,75,,49.752,Percent of Total Billed Charges,75% of Total Billed Charges,1.42,80,,140.464,Fee Schedule,80% of Scott and White EPO fee schedule,1.42,80,,59.16,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,80,,59.16,Fee Schedule,80% of Scott and White PPO fee schedule,1.42,80,,84.832,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.79,70,,104.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.84,100,,66.336,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,186.84,
METHOCARBAMOL 100MG/ML VL 10ML,53221859,CDM,250,RC,J2800,HCPCS,Outpatient,,,324.76,194.86,,6.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,146.14,45,,116.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.59,360,,,Fee Schedule,360% of BCBS POS Rate,12.59,360,,,Fee schedule,360% of BCBS PPO Rate,12.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,194.86,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.76,100,,259.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.57,75,,53.104,Percent of Total Billed Charges,75% of Total Billed Charges,4.24,80,,56.48,Fee Schedule,80% of Scott and White EPO fee schedule,4.24,80,,438.88,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.24,80,,438.88,Fee Schedule,80% of Scott and White PPO fee schedule,4.24,80,,48.32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.33,70,,181.864,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.76,100,,70.808,Percent of Total Billed Charges,100% of Total Billed Charges,4.24,324.76,
METHYLENE BLUE 10MG/ML AMP 10M,53222485,CDM,250,RC,,,Outpatient,,,765.15,459.09,,459.09,60,,367.272,Percent of Total Billed Charges,60% of Total Billed Charges,344.32,45,,275.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.24,28,,171.392,Percent of Total Billed Charges,28% of Total Billed Charges,2.12,32,,1.696,Percent of Total Billed Charges,32% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,275.45,36,,220.36,Percent of Total Billed Charges,36% of Total Billed Charges,275.45,36,,220.36,Percent of Total Billed Charges,36% Total Bille Charges,275.45,36,,220.36,Percent of Total Billed Charges,36% of Total Billed Charges,459.09,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.15,100,,612.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,110.33,14.42,,88.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,573.86,75,,46.376,Percent of Total Billed Charges,75% of Total Billed Charges,382.58,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,382.58,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.58,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,382.58,50,,42.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,535.61,70,,428.488,Percent of Total Billed Charges,70% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,107.12,14,,85.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,765.15,100,,61.832,Percent of Total Billed Charges,100% of Total Billed Charges,2.12,765.15,
METHYLERGONOV 0.2MG/ML INJ 1ML,53222691,CDM,250,RC,J2210,HCPCS,Outpatient,,,151.28,90.77,,19.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,68.08,45,,54.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,13.66,360,,,Fee Schedule,360% of BCBS POS Rate,13.66,360,,,Fee schedule,360% of BCBS PPO Rate,13.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,90.77,60,,76.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.28,100,,121.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.46,75,,26.896,Percent of Total Billed Charges,75% of Total Billed Charges,16.68,80,,438.88,Fee Schedule,80% of Scott and White EPO fee schedule,16.68,80,,295.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.68,80,,295.2,Fee Schedule,80% of Scott and White PPO fee schedule,16.68,80,,50.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.9,70,,84.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.28,100,,35.856,Percent of Total Billed Charges,100% of Total Billed Charges,13.66,151.28,
METHYLERGONOV 0.2MG TAB,53222692,CDM,250,RC,,,Outpatient,,,125.53,75.32,,75.32,60,,60.256,Percent of Total Billed Charges,60% of Total Billed Charges,56.49,45,,45.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.15,28,,28.12,Percent of Total Billed Charges,28% of Total Billed Charges,2.13,32,,1.704,Percent of Total Billed Charges,32% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,45.19,36,,36.152,Percent of Total Billed Charges,36% of Total Billed Charges,45.19,36,,36.152,Percent of Total Billed Charges,36% Total Bille Charges,45.19,36,,36.152,Percent of Total Billed Charges,36% of Total Billed Charges,75.32,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.53,100,,100.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,18.1,14.42,,14.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.15,75,,1998.768,Percent of Total Billed Charges,75% of Total Billed Charges,62.77,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,62.77,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.77,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,62.77,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.87,70,,70.296,Percent of Total Billed Charges,70% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14,,14.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.53,100,,2665.024,Percent of Total Billed Charges,100% of Total Billed Charges,2.13,125.53,
CABERGOLINE 0.5 MG TAB,53222695,CDM,250,RC,,,Outpatient,,,45.05,27.03,,27.03,60,,21.624,Percent of Total Billed Charges,60% of Total Billed Charges,20.27,45,,16.216,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.61,28,,10.088,Percent of Total Billed Charges,28% of Total Billed Charges,2.13,32,,1.704,Percent of Total Billed Charges,32% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,16.22,36,,12.976,Percent of Total Billed Charges,36% of Total Billed Charges,16.22,36,,12.976,Percent of Total Billed Charges,36% Total Bille Charges,16.22,36,,12.976,Percent of Total Billed Charges,36% of Total Billed Charges,27.03,60,,87.752,Percent of Total Billed Charges,60% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.05,100,,36.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14.42,,5.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.79,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,22.53,50,,295.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.53,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.53,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,22.53,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.54,70,,25.232,Percent of Total Billed Charges,70% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.31,14,,5.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.05,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,2.13,45.05,
METHYLPRED ACE 40MG/ML INJ 1ML,53222956,CDM,250,RC,J1030,HCPCS,Outpatient,,,63.42,38.05,,5.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.76,28,,14.208,Percent of Total Billed Charges,28% of Total Billed Charges,2.14,32,,1.712,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.83,36,,18.264,Percent of Total Billed Charges,36% of Total Billed Charges,22.83,36,,18.264,Percent of Total Billed Charges,36% Total Bille Charges,22.83,36,,18.264,Percent of Total Billed Charges,36% of Total Billed Charges,38.05,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.57,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,6.46,80,,360.752,Fee Schedule,80% of Scott and White EPO fee schedule,6.46,80,,60.992,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.46,80,,60.992,Fee Schedule,80% of Scott and White PPO fee schedule,6.46,80,,82.592,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.39,70,,35.512,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.42,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,2.14,63.42,
METHYLPRED ACE 80MG/1ML INJ,53223053,CDM,250,RC,J1040,HCPCS,Outpatient,,,110.04,66.02,,11.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.81,28,,24.648,Percent of Total Billed Charges,28% of Total Billed Charges,2.16,32,,1.728,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.61,36,,31.688,Percent of Total Billed Charges,36% of Total Billed Charges,39.61,36,,31.688,Percent of Total Billed Charges,36% Total Bille Charges,39.61,36,,31.688,Percent of Total Billed Charges,36% of Total Billed Charges,66.02,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.53,75,,10.528,Percent of Total Billed Charges,75% of Total Billed Charges,10.19,80,,55.424,Fee Schedule,80% of Scott and White EPO fee schedule,10.19,80,,137.752,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,80,,137.752,Fee Schedule,80% of Scott and White PPO fee schedule,10.19,80,,89.24,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.03,70,,61.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.04,100,,14.04,Percent of Total Billed Charges,100% of Total Billed Charges,2.16,110.04,
METHYLPRED NA SUC 40MG INJ 1ML,53223152,CDM,250,RC,J2919,HCPCS,Outpatient,,,36.09,21.65,,21.65,60,,17.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,360,,,Fee Schedule,360% of BCBS POS Rate,0.31,360,,,Fee schedule,360% of BCBS PPO Rate,0.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.65,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14.42,,4.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.07,75,,7.408,Percent of Total Billed Charges,75% of Total Billed Charges,18.05,50,,60.992,Percent of Total Billed Charges,50% of Total Billed Charges,18.05,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.05,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,18.05,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.26,70,,20.208,Percent of Total Billed Charges,70% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.09,100,,9.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,36.09,
METHYLPRED NA SUC125MG INJ,53223251,CDM,250,RC,J2919,HCPCS,Outpatient,,,58.13,34.88,,34.88,60,,27.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,360,,,Fee Schedule,360% of BCBS POS Rate,0.31,360,,,Fee schedule,360% of BCBS PPO Rate,0.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.88,60,,64.92,Percent of Total Billed Charges,60% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.38,14.42,,6.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.6,75,,7.784,Percent of Total Billed Charges,75% of Total Billed Charges,29.07,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,29.07,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.07,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,29.07,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.69,70,,32.552,Percent of Total Billed Charges,70% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.13,100,,10.376,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,58.13,
METHYLPRED NA SUC1000MG INJ,53223301,CDM,250,RC,J2919,HCPCS,Outpatient,,,251.34,150.80,,150.8,60,,120.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,360,,,Fee Schedule,360% of BCBS POS Rate,0.31,360,,,Fee schedule,360% of BCBS PPO Rate,0.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,150.8,60,,64.72,Percent of Total Billed Charges,60% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,36.24,14.42,,28.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.51,75,,229.504,Percent of Total Billed Charges,75% of Total Billed Charges,125.67,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,125.67,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.67,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,125.67,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.94,70,,140.752,Percent of Total Billed Charges,70% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,35.19,14,,28.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,251.34,100,,306,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,251.34,
METHYLPRED NA SUC 500MG INJ,53223350,CDM,250,RC,J2919,HCPCS,Outpatient,,,138.72,83.23,,83.23,60,,66.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,360,,,Fee Schedule,360% of BCBS POS Rate,0.31,360,,,Fee schedule,360% of BCBS PPO Rate,0.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.23,60,,73.592,Percent of Total Billed Charges,60% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,20,14.42,,16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.04,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,69.36,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,69.36,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.36,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,69.36,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.1,70,,77.68,Percent of Total Billed Charges,70% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14,,15.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.72,100,,9.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.31,138.72,
METOCLOPRAMIDE 10MG/2ML INJ,53223665,CDM,250,RC,J2765,HCPCS,Outpatient,,,8.12,4.87,,1.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.52,360,,,Fee Schedule,360% of BCBS POS Rate,1.52,360,,,Fee schedule,360% of BCBS PPO Rate,1.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.87,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.09,75,,210.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.85,80,,109.36,Fee Schedule,80% of Scott and White EPO fee schedule,0.85,80,,136.48,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.85,80,,136.48,Fee Schedule,80% of Scott and White PPO fee schedule,0.85,80,,56.48,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.68,70,,4.544,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.12,100,,281.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.85,8.12,
METOPROLOL 1 MG/ML INJ 5 ML,53223822,CDM,250,RC,,,Outpatient,,,11.69,7.01,,7.01,60,,5.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.27,28,,2.616,Percent of Total Billed Charges,28% of Total Billed Charges,2.17,32,,1.736,Percent of Total Billed Charges,32% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,4.21,36,,3.368,Percent of Total Billed Charges,36% of Total Billed Charges,4.21,36,,3.368,Percent of Total Billed Charges,36% Total Bille Charges,4.21,36,,3.368,Percent of Total Billed Charges,36% of Total Billed Charges,7.01,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.77,75,,210.944,Percent of Total Billed Charges,75% of Total Billed Charges,5.85,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.18,70,,6.544,Percent of Total Billed Charges,70% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.69,100,,281.256,Percent of Total Billed Charges,100% of Total Billed Charges,1.64,11.69,
METRONIDAZOLE 500MG/100ML INJ,53223889,CDM,250,RC,,,Outpatient,,,18.25,10.95,,10.95,60,,8.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.11,28,,4.088,Percent of Total Billed Charges,28% of Total Billed Charges,2.19,32,,1.752,Percent of Total Billed Charges,32% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,36,,5.256,Percent of Total Billed Charges,36% of Total Billed Charges,6.57,36,,5.256,Percent of Total Billed Charges,36% Total Bille Charges,6.57,36,,5.256,Percent of Total Billed Charges,36% of Total Billed Charges,10.95,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14.42,,2.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.69,75,,139.12,Percent of Total Billed Charges,75% of Total Billed Charges,9.13,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,9.13,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.13,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,9.13,50,,438.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.78,70,,10.224,Percent of Total Billed Charges,70% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,14,,2.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.25,100,,185.496,Percent of Total Billed Charges,100% of Total Billed Charges,2.19,18.25,
MIDAZOLAM 100 MG/100ML,53224366,CDM,250,RC,J2250,HCPCS,Outpatient,,,92.18,55.31,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.31,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.14,75,,71.448,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,136.48,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,68.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,68.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,340.72,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.53,70,,51.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.18,100,,95.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,92.18,
MIDAZOLAM 1MG/ML INJ 5ML,53224374,CDM,250,RC,J2250,HCPCS,Outpatient,,,10,6.00,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,6,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,75,,133.52,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,64.096,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,68.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,68.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,295.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,100,,178.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,10,
MIDAZOLAM 1 MG/ML INJ 2 ML,53224390,CDM,250,RC,J2250,HCPCS,Outpatient,,,6.72,4.03,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.03,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,75,,80.968,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,68.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,68.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,68.8,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,360.752,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.7,70,,3.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,100,,107.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,6.72,
MIDAZOLAM 5 MG/ML VL 1 ML,53224465,CDM,250,RC,J2250,HCPCS,Outpatient,,,7.79,4.67,,0.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.67,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.84,75,,151.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,68.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,53.728,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,80,,53.728,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,55.424,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.45,70,,4.36,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,100,,202.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,7.79,
MILRINONE LACTATE 20MG/100ML I,53224475,CDM,250,RC,J2260,HCPCS,Outpatient,,,115.57,69.34,,1.63,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.76,360,,,Fee Schedule,360% of BCBS POS Rate,1.76,360,,,Fee schedule,360% of BCBS PPO Rate,1.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.34,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.68,75,,85.896,Percent of Total Billed Charges,75% of Total Billed Charges,1.7,80,,68.8,Fee Schedule,80% of Scott and White EPO fee schedule,1.7,80,,53.728,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,80,,53.728,Fee Schedule,80% of Scott and White PPO fee schedule,1.7,80,,60.992,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.9,70,,64.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.57,100,,114.528,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,115.57,
MITOMYCIN  20MG INJ,53224929,CDM,636,RC,J9280,HCPCS,Outpatient,,,1672,1003.20,,970.77,110,,776.616,Percent of Total Billed Charges,110% of Total Billed Charges,63.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,84.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,84.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,84.94,360,,,Fee Schedule,360% of BCBS POS Rate,84.94,360,,,Fee schedule,360% of BCBS PPO Rate,84.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,919.6,55,,34.8,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.25,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,55.26,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.78,103,,,Fee Schedule,103% of CMS OPPS Rate,43.78,103,,,Fee Schedule,103% of CMS OPPS Rate,1254,75,,1348.288,Percent of Total Billed Charges,75% of Total Billed Charges,855.22,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,855.22,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,855.22,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,855.22,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,63.76,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.4,70,,936.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1672,100,,1797.712,Percent of Total Billed Charges,100% of Total Billed Charges,38.25,1672,
MULTIVITAMIN INJ ADULT 10 ML,53225918,CDM,250,RC,,,Outpatient,,,69.88,41.93,,41.93,60,,33.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.57,28,,15.656,Percent of Total Billed Charges,28% of Total Billed Charges,2.2,32,,1.76,Percent of Total Billed Charges,32% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,25.16,36,,20.128,Percent of Total Billed Charges,36% of Total Billed Charges,25.16,36,,20.128,Percent of Total Billed Charges,36% Total Bille Charges,25.16,36,,20.128,Percent of Total Billed Charges,36% of Total Billed Charges,41.93,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14.42,,8.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.41,75,,122.176,Percent of Total Billed Charges,75% of Total Billed Charges,34.94,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,34.94,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.94,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,34.94,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.92,70,,39.136,Percent of Total Billed Charges,70% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,9.78,14,,7.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.88,100,,162.904,Percent of Total Billed Charges,100% of Total Billed Charges,2.2,69.88,
MULTIVITAMINS 5ML INJ,53226122,CDM,250,RC,,,Outpatient,,,55.07,33.04,,33.04,60,,26.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.42,28,,12.336,Percent of Total Billed Charges,28% of Total Billed Charges,2.2,32,,1.76,Percent of Total Billed Charges,32% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,19.83,36,,15.864,Percent of Total Billed Charges,36% of Total Billed Charges,19.83,36,,15.864,Percent of Total Billed Charges,36% Total Bille Charges,19.83,36,,15.864,Percent of Total Billed Charges,36% of Total Billed Charges,33.04,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.94,14.42,,6.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.3,75,,132.896,Percent of Total Billed Charges,75% of Total Billed Charges,27.54,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,27.54,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.54,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,27.54,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.55,70,,30.84,Percent of Total Billed Charges,70% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,7.71,14,,6.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.07,100,,177.192,Percent of Total Billed Charges,100% of Total Billed Charges,2.2,55.07,
NAFCILLIN 1GM INJ,53226593,CDM,250,RC,,,Outpatient,,,91.99,55.19,,55.19,60,,44.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.76,28,,20.608,Percent of Total Billed Charges,28% of Total Billed Charges,2.23,32,,1.784,Percent of Total Billed Charges,32% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,33.12,36,,26.496,Percent of Total Billed Charges,36% of Total Billed Charges,33.12,36,,26.496,Percent of Total Billed Charges,36% Total Bille Charges,33.12,36,,26.496,Percent of Total Billed Charges,36% of Total Billed Charges,55.19,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,13.26,14.42,,10.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.99,75,,38.408,Percent of Total Billed Charges,75% of Total Billed Charges,46,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,46,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,46,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.39,70,,51.512,Percent of Total Billed Charges,70% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,12.88,14,,10.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.99,100,,51.208,Percent of Total Billed Charges,100% of Total Billed Charges,2.23,91.99,
NAFCILLIN 2GM INJ,53226643,CDM,250,RC,,,Outpatient,,,163.4,98.04,,98.04,60,,78.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.75,28,,36.6,Percent of Total Billed Charges,28% of Total Billed Charges,2.23,32,,1.784,Percent of Total Billed Charges,32% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,58.82,36,,47.056,Percent of Total Billed Charges,36% of Total Billed Charges,58.82,36,,47.056,Percent of Total Billed Charges,36% Total Bille Charges,58.82,36,,47.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.04,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,23.56,14.42,,18.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.55,75,,3845.72,Percent of Total Billed Charges,75% of Total Billed Charges,81.7,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,81.7,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.7,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,81.7,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.38,70,,91.504,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.4,100,,5127.624,Percent of Total Billed Charges,100% of Total Billed Charges,2.23,163.4,
SOD FERRIC GLUC 12.5MG/ML 5ML,53226692,CDM,250,RC,J2916,HCPCS,Outpatient,,,218.8,131.28,,1.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.6,360,,,Fee Schedule,360% of BCBS POS Rate,1.6,360,,,Fee schedule,360% of BCBS PPO Rate,1.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.28,60,,57.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.1,75,,373.8,Percent of Total Billed Charges,75% of Total Billed Charges,1.75,80,,76.512,Fee Schedule,80% of Scott and White EPO fee schedule,1.75,80,,76.512,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.75,80,,76.512,Fee Schedule,80% of Scott and White PPO fee schedule,1.75,80,,136.48,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.16,70,,122.528,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.8,100,,498.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.6,218.8,
NALBUPHINE 10MG/1ML INJ,53226858,CDM,250,RC,J2300,HCPCS,Outpatient,,,27.16,16.30,,3.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.8,360,,,Fee Schedule,360% of BCBS POS Rate,1.8,360,,,Fee schedule,360% of BCBS PPO Rate,1.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,16.3,60,,57.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.37,75,,18.256,Percent of Total Billed Charges,75% of Total Billed Charges,2.28,80,,76.512,Fee Schedule,80% of Scott and White EPO fee schedule,2.28,80,,263.608,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,80,,263.608,Fee Schedule,80% of Scott and White PPO fee schedule,2.28,80,,136.48,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.01,70,,15.208,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.16,100,,24.336,Percent of Total Billed Charges,100% of Total Billed Charges,1.8,27.16,
NALOXONE 1MG/ML INJ 2ML SYR,53227104,CDM,250,RC,J2310,HCPCS,Outpatient,,,330,198.00,,10.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,16.5,360,,,Fee Schedule,360% of BCBS POS Rate,16.5,360,,,Fee schedule,360% of BCBS PPO Rate,16.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,198,60,,71.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.5,75,,271.712,Percent of Total Billed Charges,75% of Total Billed Charges,6.46,80,,76.512,Fee Schedule,80% of Scott and White EPO fee schedule,6.46,80,,218.56,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.46,80,,218.56,Fee Schedule,80% of Scott and White PPO fee schedule,6.46,80,,64.096,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231,70,,184.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,100,,362.28,Percent of Total Billed Charges,100% of Total Billed Charges,6.46,330,
NALOXONE 0.4MG/1ML INJ,53227112,CDM,250,RC,J2310,HCPCS,Outpatient,,,115.88,69.53,,10.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,16.5,360,,,Fee Schedule,360% of BCBS POS Rate,16.5,360,,,Fee schedule,360% of BCBS PPO Rate,16.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.53,60,,62.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.91,75,,564.992,Percent of Total Billed Charges,75% of Total Billed Charges,6.46,80,,263.608,Fee Schedule,80% of Scott and White EPO fee schedule,6.46,80,,218.56,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.46,80,,218.56,Fee Schedule,80% of Scott and White PPO fee schedule,6.46,80,,68.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.12,70,,64.896,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.88,100,,753.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.46,115.88,
SUGAMMADEX VL 100MG/ML 2ML,53228053,CDM,250,RC,,,Outpatient,,,427.5,256.50,,256.5,60,,205.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.7,28,,95.76,Percent of Total Billed Charges,28% of Total Billed Charges,19408.65,32,,15526.92,Percent of Total Billed Charges,32% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% of Total Billed Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% Total Bille Charges,153.9,36,,123.12,Percent of Total Billed Charges,36% of Total Billed Charges,256.5,60,,312.4,Percent of Total Billed Charges,60% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,61.65,14.42,,49.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.63,75,,43.528,Percent of Total Billed Charges,75% of Total Billed Charges,213.75,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,213.75,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.75,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,213.75,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.25,70,,239.4,Percent of Total Billed Charges,70% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,59.85,14,,47.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,427.5,100,,58.032,Percent of Total Billed Charges,100% of Total Billed Charges,59.85,19408.65,
NITROGLYCERIN 5MG/ML INJ 10ML,53228961,CDM,250,RC,,,Outpatient,,,79.62,47.77,,47.77,60,,38.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.29,28,,17.832,Percent of Total Billed Charges,28% of Total Billed Charges,19415.09,32,,15532.072,Percent of Total Billed Charges,32% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% of Total Billed Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% Total Bille Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% of Total Billed Charges,47.77,60,,825.6,Percent of Total Billed Charges,60% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14.42,,9.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.72,75,,171.04,Percent of Total Billed Charges,75% of Total Billed Charges,39.81,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,39.81,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.81,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,39.81,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.73,70,,44.584,Percent of Total Billed Charges,70% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.62,100,,228.048,Percent of Total Billed Charges,100% of Total Billed Charges,11.15,19415.09,
NITROGLYCERIN 25,53228979,CDM,250,RC,,,Outpatient,,,116.89,70.13,,70.13,60,,56.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.73,28,,26.184,Percent of Total Billed Charges,28% of Total Billed Charges,19.2,32,,15.36,Percent of Total Billed Charges,32% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,42.08,36,,33.664,Percent of Total Billed Charges,36% of Total Billed Charges,42.08,36,,33.664,Percent of Total Billed Charges,36% Total Bille Charges,42.08,36,,33.664,Percent of Total Billed Charges,36% of Total Billed Charges,70.13,60,,178.52,Percent of Total Billed Charges,60% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.86,14.42,,13.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.67,75,,31.8,Percent of Total Billed Charges,75% of Total Billed Charges,58.45,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,58.45,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.45,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,58.45,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.82,70,,65.456,Percent of Total Billed Charges,70% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,14,,13.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.89,100,,42.4,Percent of Total Billed Charges,100% of Total Billed Charges,16.36,116.89,
NITROGLYCERIN 5MG/ML INJ 10ML,53228995,CDM,250,RC,,,Outpatient,,,79.62,47.77,,47.77,60,,38.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.29,28,,17.832,Percent of Total Billed Charges,28% of Total Billed Charges,19.43,32,,15.544,Percent of Total Billed Charges,32% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% of Total Billed Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% Total Bille Charges,28.66,36,,22.928,Percent of Total Billed Charges,36% of Total Billed Charges,47.77,60,,191.232,Percent of Total Billed Charges,60% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.48,14.42,,9.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.72,75,,29.424,Percent of Total Billed Charges,75% of Total Billed Charges,39.81,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,39.81,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.81,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,39.81,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.73,70,,44.584,Percent of Total Billed Charges,70% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14,,8.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.62,100,,39.232,Percent of Total Billed Charges,100% of Total Billed Charges,11.15,79.62,
OCTREOTIDE 0.5MG/ML 1,53229209,CDM,250,RC,J2354,HCPCS,Outpatient,,,363.8,218.28,,0.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.62,360,,,Fee Schedule,360% of BCBS POS Rate,0.62,360,,,Fee schedule,360% of BCBS PPO Rate,0.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,218.28,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.85,75,,72.832,Percent of Total Billed Charges,75% of Total Billed Charges,0.92,80,,43.2,Fee Schedule,80% of Scott and White EPO fee schedule,0.92,80,,123.904,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,80,,123.904,Fee Schedule,80% of Scott and White PPO fee schedule,0.92,80,,76.512,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.66,70,,203.728,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.8,100,,97.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,363.8,
NITROPRUSSIDE 25MG/ML 2ML VIAL,53229258,CDM,250,RC,,,Outpatient,,,114.89,68.93,,68.93,60,,55.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.17,28,,25.736,Percent of Total Billed Charges,28% of Total Billed Charges,19.48,32,,15.584,Percent of Total Billed Charges,32% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,41.36,36,,33.088,Percent of Total Billed Charges,36% of Total Billed Charges,41.36,36,,33.088,Percent of Total Billed Charges,36% Total Bille Charges,41.36,36,,33.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.93,60,,92.28,Percent of Total Billed Charges,60% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.57,14.42,,13.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.17,75,,41.8,Percent of Total Billed Charges,75% of Total Billed Charges,57.45,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,57.45,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.45,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,57.45,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.42,70,,64.336,Percent of Total Billed Charges,70% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.89,100,,55.736,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,114.89,
ONDANSETRON 2MG/ML INJ 2ML,53229365,CDM,250,RC,J2405,HCPCS,Outpatient,,,8.42,5.05,,0.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.59,360,,,Fee Schedule,360% of BCBS POS Rate,0.59,360,,,Fee schedule,360% of BCBS PPO Rate,0.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.05,60,,68.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,75,,410.888,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,80,,123.904,Fee Schedule,80% of Scott and White EPO fee schedule,0.07,80,,328.544,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,80,,328.544,Fee Schedule,80% of Scott and White PPO fee schedule,0.07,80,,76.512,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,70,,4.712,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.42,100,,547.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,8.42,
ONDANSETRON 2ML,53229381,CDM,250,RC,,,Outpatient,,,64,38.40,,38.4,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.92,28,,14.336,Percent of Total Billed Charges,28% of Total Billed Charges,19.5,32,,15.6,Percent of Total Billed Charges,32% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,23.04,36,,18.432,Percent of Total Billed Charges,36% of Total Billed Charges,23.04,36,,18.432,Percent of Total Billed Charges,36% Total Bille Charges,23.04,36,,18.432,Percent of Total Billed Charges,36% of Total Billed Charges,38.4,60,,178.52,Percent of Total Billed Charges,60% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,9.23,14.42,,7.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,75,,21.112,Percent of Total Billed Charges,75% of Total Billed Charges,32,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,32,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,32,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.8,70,,35.84,Percent of Total Billed Charges,70% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,8.96,14,,7.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64,100,,28.152,Percent of Total Billed Charges,100% of Total Billed Charges,8.96,64,
OXALIPLATIN PER 0.5MG,53230082,CDM,250,RC,J9263,HCPCS,Outpatient,,,4.22,2.53,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.29,360,,,Fee Schedule,360% of BCBS POS Rate,0.29,360,,,Fee schedule,360% of BCBS PPO Rate,0.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.53,60,,123.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,75,,50.68,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,328.544,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,1486.816,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,1486.816,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,76.512,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,70,,2.36,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,100,,67.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,4.22,
OXYTOCIN 10UN1/ML INJ,53230454,CDM,250,RC,J2590,HCPCS,Outpatient,,,9.98,5.99,,0.83,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.54,360,,,Fee Schedule,360% of BCBS POS Rate,0.54,360,,,Fee schedule,360% of BCBS PPO Rate,0.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.99,60,,184.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.49,75,,127.84,Percent of Total Billed Charges,75% of Total Billed Charges,4.99,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,4.99,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,4.99,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,70,,5.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.98,100,,170.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,9.98,
PAMIDRONATE DISOD 30MG INJ,53230603,CDM,250,RC,J2430,HCPCS,Outpatient,,,101.04,60.62,,10.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,8.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,8.26,360,,,Fee Schedule,360% of BCBS POS Rate,8.26,360,,,Fee schedule,360% of BCBS PPO Rate,8.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,60.62,60,,190.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.78,75,,186.352,Percent of Total Billed Charges,75% of Total Billed Charges,8.46,80,,1486.816,Fee Schedule,80% of Scott and White EPO fee schedule,8.46,80,,54.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.46,80,,54.8,Fee Schedule,80% of Scott and White PPO fee schedule,8.46,80,,263.608,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.73,70,,56.584,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.04,100,,248.464,Percent of Total Billed Charges,100% of Total Billed Charges,8.26,101.04,
PALONOSETRON 0.25MG/5ML INJ,53230645,CDM,250,RC,J2469,HCPCS,Outpatient,,,138,82.80,,0.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.91,360,,,Fee Schedule,360% of BCBS POS Rate,6.91,360,,,Fee schedule,360% of BCBS PPO Rate,6.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.8,60,,122.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,75,,55.24,Percent of Total Billed Charges,75% of Total Billed Charges,1.03,80,,86.904,Fee Schedule,80% of Scott and White EPO fee schedule,1.03,80,,28.392,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,80,,28.392,Fee Schedule,80% of Scott and White PPO fee schedule,1.03,80,,218.56,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.6,70,,77.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138,100,,73.648,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,138,
PROTONIX 40MG/NS 100ML,53230694,CDM,250,RC,C9113,HCPCS,Outpatient,,,30,18.00,,4.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,28,,6.72,Percent of Total Billed Charges,28% of Total Billed Charges,19.5,32,,15.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,10.8,36,,8.64,Percent of Total Billed Charges,36% of Total Billed Charges,10.8,36,,8.64,Percent of Total Billed Charges,36% Total Bille Charges,10.8,36,,8.64,Percent of Total Billed Charges,36% of Total Billed Charges,18,60,,163.68,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14.42,,3.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,75,,26.584,Percent of Total Billed Charges,75% of Total Billed Charges,15,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,15,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,15,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,70,,16.8,Percent of Total Billed Charges,70% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,100,,35.448,Percent of Total Billed Charges,100% of Total Billed Charges,4.2,30,
PANTOPRAZOLE 40 MG INJ,53230702,CDM,250,RC,J2470,HCPCS,Outpatient,,,30,18.00,,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,360,,,Fee Schedule,360% of BCBS POS Rate,4.59,360,,,Fee schedule,360% of BCBS PPO Rate,4.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,18,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14.42,,3.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,75,,3.824,Percent of Total Billed Charges,75% of Total Billed Charges,15,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,15,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,15,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,70,,16.8,Percent of Total Billed Charges,70% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,100,,5.096,Percent of Total Billed Charges,100% of Total Billed Charges,4.2,30,
PANTOPRAZOLE 40MG PKT SUSP,53230710,CDM,250,RC,,,Outpatient,,,28.68,17.21,,17.21,60,,13.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.03,28,,6.424,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,10.32,36,,8.256,Percent of Total Billed Charges,36% of Total Billed Charges,10.32,36,,8.256,Percent of Total Billed Charges,36% Total Bille Charges,10.32,36,,8.256,Percent of Total Billed Charges,36% of Total Billed Charges,17.21,60,,351.936,Percent of Total Billed Charges,60% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.14,14.42,,3.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,75,,23.04,Percent of Total Billed Charges,75% of Total Billed Charges,14.34,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.08,70,,16.064,Percent of Total Billed Charges,70% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,14,,3.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.68,100,,30.72,Percent of Total Billed Charges,100% of Total Billed Charges,4.02,192,
ESOMEPRAZOLE PDR PKT 40MG,53230712,CDM,250,RC,,,Outpatient,,,18.07,10.84,,10.84,60,,8.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.06,28,,4.048,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,6.51,36,,5.208,Percent of Total Billed Charges,36% of Total Billed Charges,6.51,36,,5.208,Percent of Total Billed Charges,36% Total Bille Charges,6.51,36,,5.208,Percent of Total Billed Charges,36% of Total Billed Charges,10.84,60,,68.056,Percent of Total Billed Charges,60% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.61,14.42,,2.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,75,,108.088,Percent of Total Billed Charges,75% of Total Billed Charges,9.04,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,9.04,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.04,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,70,,10.12,Percent of Total Billed Charges,70% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14,,2.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.07,100,,144.112,Percent of Total Billed Charges,100% of Total Billed Charges,2.53,192,
PAPAVERINE 30MG/ML INJ 2ML,53230728,CDM,250,RC,J2440,HCPCS,Outpatient,,,195.74,117.44,,36,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.73,360,,,Fee Schedule,360% of BCBS POS Rate,24.73,360,,,Fee schedule,360% of BCBS PPO Rate,24.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.44,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.81,75,,85.504,Percent of Total Billed Charges,75% of Total Billed Charges,97.87,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,97.87,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.87,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,97.87,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.02,70,,109.616,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.74,100,,114,Percent of Total Billed Charges,100% of Total Billed Charges,24.73,195.74,
PEMETREXED DISODIUM 500 MG VIAL,53230991,CDM,636,RC,J9305,HCPCS,Outpatient,,,8464.81,5078.89,,4732.45,110,,3785.96,Percent of Total Billed Charges,110% of Total Billed Charges,6.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,70.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,70.48,360,,,Fee Schedule,360% of BCBS POS Rate,70.48,360,,,Fee schedule,360% of BCBS PPO Rate,70.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,4655.65,55,,32.16,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,6348.61,75,,178.848,Percent of Total Billed Charges,75% of Total Billed Charges,4246.12,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,4246.12,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4246.12,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,4246.12,50,,123.904,Percent of Total Billed Charges,50% of Total Billed Charges,6.27,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5925.37,70,,4740.296,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8464.81,100,,238.464,Percent of Total Billed Charges,100% of Total Billed Charges,3.76,8464.81,
PENICIL G BENZ(LA) 600000UN,53231098,CDM,250,RC,J0561,HCPCS,Outpatient,,,424.09,254.45,,15.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.6,360,,,Fee Schedule,360% of BCBS POS Rate,12.6,360,,,Fee schedule,360% of BCBS PPO Rate,12.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,254.45,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,318.07,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,14.87,80,,121.16,Fee Schedule,80% of Scott and White EPO fee schedule,14.87,80,,221.6,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.87,80,,221.6,Fee Schedule,80% of Scott and White PPO fee schedule,14.87,80,,22.064,Fee Schedule,80% of Scott and White SWHP fee schedule,36.54,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,296.86,70,,237.488,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,424.09,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,12.6,424.09,
PENICIL G BENZ(LA) 1.2M UNITS,53231189,CDM,250,RC,J0561,HCPCS,Outpatient,,,713.15,427.89,,15.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.6,360,,,Fee Schedule,360% of BCBS POS Rate,12.6,360,,,Fee schedule,360% of BCBS PPO Rate,12.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,427.89,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,534.86,75,,29.768,Percent of Total Billed Charges,75% of Total Billed Charges,14.87,80,,32,Fee Schedule,80% of Scott and White EPO fee schedule,14.87,80,,50.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.87,80,,50.8,Fee Schedule,80% of Scott and White PPO fee schedule,14.87,80,,328.544,Fee Schedule,80% of Scott and White SWHP fee schedule,36.54,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,499.21,70,,399.368,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,713.15,100,,39.688,Percent of Total Billed Charges,100% of Total Billed Charges,12.6,713.15,
PENICIL G BENZ(LA) 2.4M UNITS,53231205,CDM,250,RC,J0561,HCPCS,Outpatient,,,1477.85,886.71,,15.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.6,360,,,Fee Schedule,360% of BCBS POS Rate,12.6,360,,,Fee schedule,360% of BCBS PPO Rate,12.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,886.71,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1108.39,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,14.87,80,,221.6,Fee Schedule,80% of Scott and White EPO fee schedule,14.87,80,,34.448,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.87,80,,34.448,Fee Schedule,80% of Scott and White PPO fee schedule,14.87,80,,1486.816,Fee Schedule,80% of Scott and White SWHP fee schedule,36.54,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1034.5,70,,827.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1477.85,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,12.6,1477.85,
PENICIL G POT 1M UN VL,53231387,CDM,250,RC,J2540,HCPCS,Outpatient,,,16.3,9.78,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.48,360,,,Fee Schedule,360% of BCBS POS Rate,1.48,360,,,Fee schedule,360% of BCBS PPO Rate,1.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,20.504,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,80,,50.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.6,80,,75.88,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,80,,75.88,Fee Schedule,80% of Scott and White PPO fee schedule,0.6,80,,1486.816,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,27.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,16.3,
PENICILLIN G 3 MIL UNITS,53231445,CDM,250,RC,J0558,HCPCS,Outpatient,,,16.3,9.78,,11.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,4.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.6,360,,,Fee Schedule,360% of BCBS POS Rate,4.6,360,,,Fee schedule,360% of BCBS PPO Rate,4.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,25.37,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.1,103,,,Fee Schedule,103% of CMS OPPS Rate,20.1,103,,,Fee Schedule,103% of CMS OPPS Rate,12.23,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,11.53,80,,34.448,Fee Schedule,80% of Scott and White EPO fee schedule,11.53,80,,186.144,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,80,,186.144,Fee Schedule,80% of Scott and White PPO fee schedule,11.53,80,,86.904,Fee Schedule,80% of Scott and White SWHP fee schedule,29.28,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.6,29.28,
PEN G POT 2.5MU/NS 50ML IVPB,53231452,CDM,250,RC,J2540,HCPCS,Outpatient,,,78.5,47.10,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.48,360,,,Fee Schedule,360% of BCBS POS Rate,1.48,360,,,Fee schedule,360% of BCBS PPO Rate,1.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,80,,75.88,Fee Schedule,80% of Scott and White EPO fee schedule,0.6,80,,289.104,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,80,,289.104,Fee Schedule,80% of Scott and White PPO fee schedule,0.6,80,,54.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,78.5,
PENICIL G POT 5M UN VL,53231486,CDM,250,RC,J2540,HCPCS,Outpatient,,,80.95,48.57,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.48,360,,,Fee Schedule,360% of BCBS POS Rate,1.48,360,,,Fee schedule,360% of BCBS PPO Rate,1.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.57,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.71,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,80,,186.144,Fee Schedule,80% of Scott and White EPO fee schedule,0.6,80,,490.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,80,,490.672,Fee Schedule,80% of Scott and White PPO fee schedule,0.6,80,,28.392,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.67,70,,45.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.95,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,80.95,
PENTAMIDINE 300MG VL,53231890,CDM,250,RC,,,Outpatient,,,756.01,453.61,,453.61,60,,362.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.68,28,,169.344,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% Total Bille Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,453.61,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,109.02,14.42,,87.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,567.01,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,378.01,50,,289.104,Percent of Total Billed Charges,50% of Total Billed Charges,378.01,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.01,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,378.01,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.21,70,,423.368,Percent of Total Billed Charges,70% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,756.01,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,105.84,756.01,
PHENOBARBITAL 65MG INJ,53232427,CDM,250,RC,J2560,HCPCS,Outpatient,,,125.82,75.49,,42.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,27.93,360,,,Fee Schedule,360% of BCBS POS Rate,27.93,360,,,Fee schedule,360% of BCBS PPO Rate,27.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,75.49,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.37,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,80,,490.672,Fee Schedule,80% of Scott and White EPO fee schedule,31.22,80,,2831.584,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.22,80,,2831.584,Fee Schedule,80% of Scott and White PPO fee schedule,31.22,80,,240,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.07,70,,70.456,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.82,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,27.93,125.82,
PHENOBARB 130MG/ML VL 1ML,53232468,CDM,250,RC,J2560,HCPCS,Outpatient,,,300,180.00,,42.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,27.93,360,,,Fee Schedule,360% of BCBS POS Rate,27.93,360,,,Fee schedule,360% of BCBS PPO Rate,27.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,17.256,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,80,,1015.344,Fee Schedule,80% of Scott and White EPO fee schedule,31.22,80,,26.728,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.22,80,,26.728,Fee Schedule,80% of Scott and White PPO fee schedule,31.22,80,,168,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,23.008,Percent of Total Billed Charges,100% of Total Billed Charges,27.93,300,
PHENTOLAMINE 5MG INJ,53232674,CDM,250,RC,J2760,HCPCS,Outpatient,,,1932.39,1159.43,,418.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,550.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,299.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,299.16,360,,,Fee Schedule,360% of BCBS POS Rate,299.16,360,,,Fee schedule,360% of BCBS PPO Rate,299.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,1159.43,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,330.4,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,477.25,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.13,103,,,Fee Schedule,103% of CMS OPPS Rate,378.13,103,,,Fee Schedule,103% of CMS OPPS Rate,1449.29,75,,16.648,Percent of Total Billed Charges,75% of Total Billed Charges,361.93,80,,2831.584,Fee Schedule,80% of Scott and White EPO fee schedule,361.93,80,,39.216,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,361.93,80,,39.216,Fee Schedule,80% of Scott and White PPO fee schedule,361.93,80,,168,Fee Schedule,80% of Scott and White SWHP fee schedule,550.66,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.67,70,,1082.136,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,367.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1932.39,100,,22.192,Percent of Total Billed Charges,100% of Total Billed Charges,299.16,1932.39,
PHENYLEPHRINE 10MG/ML INJ 1ML,53232880,CDM,250,RC,J2371,HCPCS,Outpatient,,,76,45.60,,45.6,60,,36.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,45.6,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.96,14.42,,8.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,38,50,,26.728,Percent of Total Billed Charges,50% of Total Billed Charges,38,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,38,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.2,70,,42.56,Percent of Total Billed Charges,70% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,10.64,14,,8.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,76,
PHENYLEPHRINE INJ 10MG/ML 10ML,53232881,CDM,250,RC,J2371,HCPCS,Outpatient,,,32.87,19.72,,19.72,60,,15.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,19.72,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.74,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.65,75,,25,Percent of Total Billed Charges,75% of Total Billed Charges,16.44,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.44,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.01,70,,18.408,Percent of Total Billed Charges,70% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.87,100,,33.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,32.87,
PHYSOSTIGMINE 1MG/ML INJ 2ML,53233458,CDM,250,RC,,,Outpatient,,,222.15,133.29,,133.29,60,,106.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.2,28,,49.76,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,79.97,36,,63.976,Percent of Total Billed Charges,36% of Total Billed Charges,79.97,36,,63.976,Percent of Total Billed Charges,36% Total Bille Charges,79.97,36,,63.976,Percent of Total Billed Charges,36% of Total Billed Charges,133.29,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.03,14.42,,25.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.61,75,,20.776,Percent of Total Billed Charges,75% of Total Billed Charges,111.08,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,111.08,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.08,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,111.08,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.51,70,,124.408,Percent of Total Billed Charges,70% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,31.1,14,,24.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.15,100,,27.696,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,222.15,
PHYTONADIONE 1MG/0.5ML INJ,53233664,CDM,250,RC,J3430,HCPCS,Outpatient,,,108.89,65.33,,3.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.15,360,,,Fee Schedule,360% of BCBS POS Rate,3.15,360,,,Fee schedule,360% of BCBS PPO Rate,3.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,65.33,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.67,75,,20.856,Percent of Total Billed Charges,75% of Total Billed Charges,2.39,80,,76.2,Fee Schedule,80% of Scott and White EPO fee schedule,2.39,80,,157.624,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.39,80,,157.624,Fee Schedule,80% of Scott and White PPO fee schedule,2.39,80,,592,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.22,70,,60.976,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.89,100,,27.808,Percent of Total Billed Charges,100% of Total Billed Charges,2.39,108.89,
PHYTONADIONE 10MG/1ML INJ,53233714,CDM,250,RC,J3430,HCPCS,Outpatient,,,295.44,177.26,,3.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.15,360,,,Fee Schedule,360% of BCBS POS Rate,3.15,360,,,Fee schedule,360% of BCBS PPO Rate,3.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,177.26,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.58,75,,16.552,Percent of Total Billed Charges,75% of Total Billed Charges,2.39,80,,150,Fee Schedule,80% of Scott and White EPO fee schedule,2.39,80,,32.088,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.39,80,,32.088,Fee Schedule,80% of Scott and White PPO fee schedule,2.39,80,,592,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.81,70,,165.448,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.44,100,,22.072,Percent of Total Billed Charges,100% of Total Billed Charges,2.39,295.44,
PIPERACILLIN4GM,53234027,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,192,
PIPERACILLIN/TAZOBAC 2.25GM VL,53234035,CDM,250,RC,J2543,HCPCS,Outpatient,,,44.14,26.48,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.48,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.11,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,32.088,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,246.576,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,246.576,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,1028,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,70,,24.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.14,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,44.14,
PIPERACILLIN/TAZOBAC 4.5GM INJ,53234050,CDM,250,RC,J2543,HCPCS,Outpatient,,,37.06,22.24,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.24,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,42.944,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,28,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,28,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,86.904,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.94,70,,20.752,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.06,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,37.06,
PNEUMOCOCCAL 13-VAL CONJ 0.5ML,53234472,CDM,636,RC,90670,HCPCS,Outpatient,,,841.52,504.91,,716.93,110,,573.544,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,184.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,184.8,360,,,Fee Schedule,360% of BCBS POS Rate,184.8,360,,,Fee schedule,360% of BCBS PPO Rate,184.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,631.14,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,627.14,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,627.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,627.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,627.14,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.06,70,,471.248,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,841.52,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,184.8,841.52,
PNEUMOCCAL VAC 23MCG/0.5ML,53234498,CDM,636,RC,90732,HCPCS,Outpatient,,,431.31,258.79,,377.72,110,,302.176,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,117.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,117.22,360,,,Fee Schedule,360% of BCBS POS Rate,117.22,360,,,Fee schedule,360% of BCBS PPO Rate,117.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,323.48,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,322.43,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,322.43,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.43,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,322.43,50,,752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.92,70,,241.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,431.31,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,117.22,431.31,
CARMUSTINE WAFER 7.7MG,53234555,CDM,636,RC,J9999,HCPCS,Outpatient,,,11482.34,6889.40,,6315.29,110,,5052.232,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3215.06,28,,2572.048,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4133.64,36,,3306.912,Percent of Total Billed Charges,36% of Total Billed Charges,4133.64,36,,3306.912,Percent of Total Billed Charges,36% Total Bille Charges,4133.64,36,,3306.912,Percent of Total Billed Charges,36% of Total Billed Charges,6315.29,55,,32.16,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8611.76,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,5741.17,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,5741.17,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5741.17,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,5741.17,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8037.64,70,,6430.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11482.34,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,192,11482.34,
POLYMIXIN B 500000UN INJ,53234910,CDM,250,RC,,,Outpatient,,,85.51,51.31,,51.31,60,,41.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,28,,19.152,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% Total Bille Charges,30.78,36,,24.624,Percent of Total Billed Charges,36% of Total Billed Charges,51.31,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,12.33,14.42,,9.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.13,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,42.76,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,42.76,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.76,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,42.76,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.86,70,,47.888,Percent of Total Billed Charges,70% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,11.97,14,,9.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.51,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,11.97,192,
BACITRACIN 50000UN INJ,53234950,CDM,250,RC,,,Outpatient,,,71.54,42.92,,42.92,60,,34.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.03,28,,16.024,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,25.75,36,,20.6,Percent of Total Billed Charges,36% of Total Billed Charges,25.75,36,,20.6,Percent of Total Billed Charges,36% Total Bille Charges,25.75,36,,20.6,Percent of Total Billed Charges,36% of Total Billed Charges,42.92,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.32,14.42,,8.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.66,75,,90.864,Percent of Total Billed Charges,75% of Total Billed Charges,35.77,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,35.77,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.77,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,35.77,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.08,70,,40.064,Percent of Total Billed Charges,70% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,10.02,14,,8.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.54,100,,121.152,Percent of Total Billed Charges,100% of Total Billed Charges,10.02,192,
POT CHL 2MEQ/ML VL 20ML,53235438,CDM,258,RC,J3480,HCPCS,Outpatient,,,20.82,12.49,,0.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.49,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.62,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,80,,239.928,Fee Schedule,80% of Scott and White EPO fee schedule,0.09,80,,127.264,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,80,,127.264,Fee Schedule,80% of Scott and White PPO fee schedule,0.09,80,,221.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,70,,11.656,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,20.82,
POTASSIUM CHLOR 10MEQ/100ML PB,53235495,CDM,258,RC,J3480,HCPCS,Outpatient,,,78.5,47.10,,0.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,80,,82.112,Fee Schedule,80% of Scott and White EPO fee schedule,0.09,80,,103.888,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,80,,103.888,Fee Schedule,80% of Scott and White PPO fee schedule,0.09,80,,1028,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,78.5,
POTASSIUM CHLOR 40MEQ/100ML PB,53235503,CDM,258,RC,J3480,HCPCS,Outpatient,,,78.5,47.10,,0.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,80,,127.264,Fee Schedule,80% of Scott and White EPO fee schedule,0.09,80,,83.512,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,80,,83.512,Fee Schedule,80% of Scott and White PPO fee schedule,0.09,80,,50.8,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,78.5,
POTASSIUM CHLOR 20MEQ/100ML PB,53235511,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,43.784,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
PROCAINAMIDE 100MG/ML INJ 10ML,53236758,CDM,250,RC,J2690,HCPCS,Outpatient,,,485.89,291.53,,107.33,100,,,Fee Schedule,100% of Aetna Fee Schedule,819.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,97.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,97.03,360,,,Fee Schedule,360% of BCBS POS Rate,97.03,360,,,Fee schedule,360% of BCBS PPO Rate,97.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,291.53,60,,83.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,491.46,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,709.89,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.45,103,,,Fee Schedule,103% of CMS OPPS Rate,562.45,103,,,Fee Schedule,103% of CMS OPPS Rate,364.42,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,131.5,80,,83.512,Fee Schedule,80% of Scott and White EPO fee schedule,131.5,80,,104.48,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,131.5,80,,104.48,Fee Schedule,80% of Scott and White PPO fee schedule,131.5,80,,75.88,Fee Schedule,80% of Scott and White SWHP fee schedule,819.1,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,340.12,70,,272.096,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,485.89,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,97.03,819.1,
PROCHLORPERAZINE 10MG/2ML INJ,53237251,CDM,250,RC,J0780,HCPCS,Outpatient,,,135.41,81.25,,4.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.44,360,,,Fee Schedule,360% of BCBS POS Rate,12.44,360,,,Fee schedule,360% of BCBS PPO Rate,12.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.25,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.56,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,2.38,80,,112.104,Fee Schedule,80% of Scott and White EPO fee schedule,2.38,80,,99.896,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,80,,99.896,Fee Schedule,80% of Scott and White PPO fee schedule,2.38,80,,186.144,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.79,70,,75.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.41,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,2.38,135.41,
PROGESTERONE 50MG/ML INJ 10ML,53237467,CDM,250,RC,J2675,HCPCS,Outpatient,,,228.78,137.27,,1.17,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.35,360,,,Fee Schedule,360% of BCBS POS Rate,2.35,360,,,Fee schedule,360% of BCBS PPO Rate,2.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,137.27,60,,93.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.59,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,0.76,80,,104.48,Fee Schedule,80% of Scott and White EPO fee schedule,0.76,80,,1965.6,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,80,,1965.6,Fee Schedule,80% of Scott and White PPO fee schedule,0.76,80,,289.104,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.15,70,,128.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.78,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.76,228.78,
PROMETHAZINE 25MG/ML INJ ML,53237939,CDM,250,RC,J2550,HCPCS,Outpatient,,,9.66,5.80,,2.39,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.3,360,,,Fee Schedule,360% of BCBS POS Rate,0.3,360,,,Fee schedule,360% of BCBS PPO Rate,0.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.8,60,,114.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.25,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,2.49,80,,99.896,Fee Schedule,80% of Scott and White EPO fee schedule,2.49,80,,444.968,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.49,80,,444.968,Fee Schedule,80% of Scott and White PPO fee schedule,2.49,80,,490.672,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.76,70,,5.408,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,9.66,
PROPRANOLOL 1MG/ML INJ,53238192,CDM,250,RC,J1800,HCPCS,Outpatient,,,59.99,35.99,,7.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.96,360,,,Fee Schedule,360% of BCBS POS Rate,6.96,360,,,Fee schedule,360% of BCBS PPO Rate,6.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.99,60,,66.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.99,75,,12.24,Percent of Total Billed Charges,75% of Total Billed Charges,30,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,30,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,30,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.99,70,,33.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.99,100,,16.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.96,59.99,
PROTAMINE 10MG/ML INJ 25ML,53238614,CDM,250,RC,J2720,HCPCS,Outpatient,,,240.34,144.20,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.2,360,,,Fee Schedule,360% of BCBS POS Rate,1.2,360,,,Fee schedule,360% of BCBS PPO Rate,1.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,144.2,60,,95.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.26,75,,12.64,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,80,,444.968,Fee Schedule,80% of Scott and White EPO fee schedule,0.69,80,,2010.016,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,80,,2010.016,Fee Schedule,80% of Scott and White PPO fee schedule,0.69,80,,2831.584,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.24,70,,134.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.34,100,,16.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.69,240.34,
PYRIDOXINE 100MG/1ML INJ,53239299,CDM,250,RC,J3415,HCPCS,Outpatient,,,111.26,66.76,,5.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,7.73,360,,,Fee Schedule,360% of BCBS POS Rate,7.73,360,,,Fee schedule,360% of BCBS PPO Rate,7.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,66.76,60,,174.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.45,75,,18.792,Percent of Total Billed Charges,75% of Total Billed Charges,4.5,80,,444.968,Fee Schedule,80% of Scott and White EPO fee schedule,4.5,80,,1340.016,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,80,,1340.016,Fee Schedule,80% of Scott and White PPO fee schedule,4.5,80,,26.728,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.88,70,,62.304,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.26,100,,25.056,Percent of Total Billed Charges,100% of Total Billed Charges,4.5,111.26,
RANITIDINE 25MG/ML INJ 2ML,53239679,CDM,250,RC,J2780,HCPCS,Outpatient,,,17.96,10.78,,6.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.03,28,,4.024,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.47,36,,5.176,Percent of Total Billed Charges,36% of Total Billed Charges,6.47,36,,5.176,Percent of Total Billed Charges,36% Total Bille Charges,6.47,36,,5.176,Percent of Total Billed Charges,36% of Total Billed Charges,10.78,60,,61.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.47,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,8.98,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,8.98,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.98,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,8.98,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,70,,10.056,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.96,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,5.03,192,
RABIES IMM GLOB 150 UN/ML 10ML,53239705,CDM,636,RC,90375,HCPCS,Outpatient,,,7355.37,4413.22,,4447.71,110,,3558.168,Percent of Total Billed Charges,110% of Total Billed Charges,431.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,324.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,324.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,324.12,360,,,Fee Schedule,360% of BCBS POS Rate,324.12,360,,,Fee schedule,360% of BCBS PPO Rate,324.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,4045.45,55,,235.2,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,258.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,374.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5516.53,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,3946.64,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,3946.64,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3946.64,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,3946.64,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,431.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5148.76,70,,4119.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7355.37,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,258.93,7355.37,
RABIES VACCINE 1 ML,53239745,CDM,636,RC,90675,HCPCS,Outpatient,,,1535.46,921.28,,1277.69,110,,1022.152,Percent of Total Billed Charges,110% of Total Billed Charges,525.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,296.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,296.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,296.12,360,,,Fee Schedule,360% of BCBS POS Rate,296.12,360,,,Fee schedule,360% of BCBS PPO Rate,296.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,844.5,55,,246.8,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,315.12,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,455.18,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.64,103,,,Fee Schedule,103% of CMS OPPS Rate,360.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1151.6,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,1041.51,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1041.51,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1041.51,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,1041.51,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,525.21,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1074.82,70,,859.856,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1535.46,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,296.12,1535.46,
RABIES IMM GLOB 150 UN/ML 2ML,53239755,CDM,636,RC,90375,HCPCS,Outpatient,,,2250,1350.00,,1639.76,110,,1311.808,Percent of Total Billed Charges,110% of Total Billed Charges,431.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,324.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,324.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,324.12,360,,,Fee Schedule,360% of BCBS POS Rate,324.12,360,,,Fee schedule,360% of BCBS PPO Rate,324.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,1237.5,55,,192.96,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,258.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,374.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1687.5,75,,59.272,Percent of Total Billed Charges,75% of Total Billed Charges,1393.95,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,1393.95,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1393.95,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,1393.95,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,431.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1575,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2250,100,,79.032,Percent of Total Billed Charges,100% of Total Billed Charges,258.93,2250,
RASBURICASE PER 0.5MG,53239968,CDM,636,RC,J2783,HCPCS,Outpatient,,,2328.11,1396.87,,1605.35,110,,1284.28,Percent of Total Billed Charges,110% of Total Billed Charges,556.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,267.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,267.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,267.87,360,,,Fee Schedule,360% of BCBS POS Rate,267.87,360,,,Fee schedule,360% of BCBS PPO Rate,267.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,1280.46,55,,232.32,Percent of Total Billed Charges,55% Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334.16,90,,,Fee Schedule,90% of CMS OPPS Rate,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,482.67,130,,,Fee Schedule,130% of CMS OPPS Rate,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,335.71,14.42,,268.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,382.42,103,,,Fee Schedule,103% of CMS OPPS Rate,382.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1746.08,75,,104.056,Percent of Total Billed Charges,75% of Total Billed Charges,1438.34,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,1438.34,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1438.34,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,1438.34,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,556.91,150,,,Fee Schedule,150% of CMS OPPS Rate,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1629.68,70,,1303.744,Percent of Total Billed Charges,70% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,325.94,14,,260.752,Percent of Total Billed Charges,14% of Total Billed Charges,371.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2328.11,100,,138.736,Percent of Total Billed Charges,100% of Total Billed Charges,267.87,2328.11,
RHO (D) IMMUNE GLOBULIN 300MCG,53240107,CDM,250,RC,J2790,HCPCS,Outpatient,,,537,322.20,,79.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,75.52,360,,,Fee Schedule,360% of BCBS POS Rate,75.52,360,,,Fee schedule,360% of BCBS PPO Rate,75.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,322.2,60,,218.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,402.75,75,,65.368,Percent of Total Billed Charges,75% of Total Billed Charges,61.46,80,,338.632,Fee Schedule,80% of Scott and White EPO fee schedule,61.46,80,,29.832,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.46,80,,29.832,Fee Schedule,80% of Scott and White PPO fee schedule,61.46,80,,32.088,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.9,70,,300.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,537,100,,87.152,Percent of Total Billed Charges,100% of Total Billed Charges,61.46,537,
RIFAMPIN 600MG VL,53240156,CDM,250,RC,,,Outpatient,,,808.52,485.11,,485.11,60,,388.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.39,28,,181.112,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,291.07,36,,232.856,Percent of Total Billed Charges,36% of Total Billed Charges,291.07,36,,232.856,Percent of Total Billed Charges,36% Total Bille Charges,291.07,36,,232.856,Percent of Total Billed Charges,36% of Total Billed Charges,485.11,60,,221.76,Percent of Total Billed Charges,60% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,116.59,14.42,,93.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,606.39,75,,7.28,Percent of Total Billed Charges,75% of Total Billed Charges,404.26,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,404.26,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.26,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,404.26,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,565.96,70,,452.768,Percent of Total Billed Charges,70% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,113.19,14,,90.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,808.52,100,,9.704,Percent of Total Billed Charges,100% of Total Billed Charges,113.19,808.52,
ROCURONIUM BR 10MG/ML INJ 10ML,53240255,CDM,250,RC,,,Outpatient,,,55.89,33.53,,33.53,60,,26.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.65,28,,12.52,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,20.12,36,,16.096,Percent of Total Billed Charges,36% of Total Billed Charges,20.12,36,,16.096,Percent of Total Billed Charges,36% Total Bille Charges,20.12,36,,16.096,Percent of Total Billed Charges,36% of Total Billed Charges,33.53,60,,279.456,Percent of Total Billed Charges,60% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,8.06,14.42,,6.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.92,75,,37.48,Percent of Total Billed Charges,75% of Total Billed Charges,27.95,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.95,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.12,70,,31.296,Percent of Total Billed Charges,70% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.82,14,,6.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.89,100,,49.976,Percent of Total Billed Charges,100% of Total Billed Charges,7.82,192,
ROPIVACAINE 5MG/ML INJ 30ML,53240412,CDM,250,RC,J2795,HCPCS,Outpatient,,,130.26,78.16,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.16,60,,900.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.7,75,,22.72,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,40.84,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,814.408,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,814.408,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,28,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.18,70,,72.944,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.26,100,,30.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,130.26,
ROPIVACAINE 2MG/ML 200ML,53240453,CDM,250,RC,J2795,HCPCS,Outpatient,,,365.94,219.56,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,219.56,60,,155.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.46,75,,36.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,243.672,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,340.704,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,340.704,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,28.112,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.16,70,,204.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,365.94,100,,49.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,365.94,
ROPIVACAINE 0.2% 400ML ONQ,53240461,CDM,250,RC,J2795,HCPCS,Outpatient,,,16.3,9.78,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,23.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,814.408,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,40,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,40,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,239.216,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,30.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,16.3,
ROPIVACAINE 0.2%/600ML FOR ONQ,53240470,CDM,250,RC,J2795,HCPCS,Outpatient,,,1133.91,680.35,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,680.35,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,850.43,75,,47.032,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,340.704,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,40,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,40,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,76.112,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,793.74,70,,634.992,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1133.91,100,,62.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,1133.91,
ROPIVACAINE AMP 20MG/10ML,53240487,CDM,250,RC,J2795,HCPCS,Outpatient,,,58.08,34.85,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.85,60,,186.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.56,75,,0.304,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,40,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,37.24,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,37.24,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,239.928,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.66,70,,32.528,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.08,100,,0.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,58.08,
SODIUM ACET 2MEQ/ML VL 20ML,53241303,CDM,250,RC,,,Outpatient,,,30.9,18.54,,18.54,60,,14.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.65,28,,6.92,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% of Total Billed Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% Total Bille Charges,11.12,36,,8.896,Percent of Total Billed Charges,36% of Total Billed Charges,18.54,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.46,14.42,,3.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.18,75,,4.336,Percent of Total Billed Charges,75% of Total Billed Charges,15.45,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,15.45,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.45,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,15.45,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.63,70,,17.304,Percent of Total Billed Charges,70% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14,,3.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.9,100,,5.784,Percent of Total Billed Charges,100% of Total Billed Charges,4.33,192,
SOD BICARB 4.2% SYG 10ML,53241410,CDM,250,RC,,,Outpatient,,,65.4,39.24,,39.24,60,,31.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.31,28,,14.648,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,23.54,36,,18.832,Percent of Total Billed Charges,36% of Total Billed Charges,23.54,36,,18.832,Percent of Total Billed Charges,36% Total Bille Charges,23.54,36,,18.832,Percent of Total Billed Charges,36% of Total Billed Charges,39.24,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14.42,,7.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.05,75,,1.912,Percent of Total Billed Charges,75% of Total Billed Charges,32.7,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,32.7,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.7,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,32.7,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.78,70,,36.624,Percent of Total Billed Charges,70% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,9.16,14,,7.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.4,100,,2.552,Percent of Total Billed Charges,100% of Total Billed Charges,9.16,192,
SOD BICARB 8.4% SYG 10ML,53241510,CDM,250,RC,,,Outpatient,,,85,51.00,,51,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,28,,19.04,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.6,36,,24.48,Percent of Total Billed Charges,36% of Total Billed Charges,30.6,36,,24.48,Percent of Total Billed Charges,36% Total Bille Charges,30.6,36,,24.48,Percent of Total Billed Charges,36% of Total Billed Charges,51,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,12.26,14.42,,9.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.75,75,,3.584,Percent of Total Billed Charges,75% of Total Billed Charges,42.5,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,42.5,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.5,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,42.5,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.5,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,11.9,14,,9.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85,100,,4.776,Percent of Total Billed Charges,100% of Total Billed Charges,11.9,192,
SOD BICARB 8.4% VL 50ML,53241519,CDM,250,RC,,,Outpatient,,,82.92,49.75,,49.75,60,,39.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.22,28,,18.576,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,29.85,36,,23.88,Percent of Total Billed Charges,36% of Total Billed Charges,29.85,36,,23.88,Percent of Total Billed Charges,36% Total Bille Charges,29.85,36,,23.88,Percent of Total Billed Charges,36% of Total Billed Charges,49.75,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.96,14.42,,9.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.19,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,41.46,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,41.46,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.46,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,41.46,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.04,70,,46.432,Percent of Total Billed Charges,70% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,11.61,14,,9.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.92,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.61,192,
SOD BICARB 7.5% SYG 50 ML,53241543,CDM,250,RC,,,Outpatient,,,88.51,53.11,,53.11,60,,42.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,28,,19.824,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,31.86,36,,25.488,Percent of Total Billed Charges,36% of Total Billed Charges,31.86,36,,25.488,Percent of Total Billed Charges,36% Total Bille Charges,31.86,36,,25.488,Percent of Total Billed Charges,36% of Total Billed Charges,53.11,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.76,14.42,,10.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.38,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,44.26,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,44.26,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.26,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,44.26,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.96,70,,49.568,Percent of Total Billed Charges,70% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,12.39,14,,9.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.51,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,12.39,192,
SODIUM BICARB 8.4% SYG 50 ML,53241544,CDM,250,RC,,,Outpatient,,,77.29,46.37,,46.37,60,,37.096,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.64,28,,17.312,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,27.82,36,,22.256,Percent of Total Billed Charges,36% of Total Billed Charges,27.82,36,,22.256,Percent of Total Billed Charges,36% Total Bille Charges,27.82,36,,22.256,Percent of Total Billed Charges,36% of Total Billed Charges,46.37,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,11.15,14.42,,8.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.97,75,,491.944,Percent of Total Billed Charges,75% of Total Billed Charges,38.65,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,38.65,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.65,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,38.65,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.1,70,,43.28,Percent of Total Billed Charges,70% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,10.82,14,,8.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.29,100,,655.92,Percent of Total Billed Charges,100% of Total Billed Charges,10.82,192,
SODIUM CHLOR 25%(4MEQ/ML)30ML,53241758,CDM,250,RC,,,Outpatient,,,44.82,26.89,,26.89,60,,21.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.55,28,,10.04,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% of Total Billed Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% Total Bille Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% of Total Billed Charges,26.89,60,,505.224,Percent of Total Billed Charges,60% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.46,14.42,,5.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.62,75,,5.08,Percent of Total Billed Charges,75% of Total Billed Charges,22.41,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,22.41,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.41,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,22.41,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.37,70,,25.096,Percent of Total Billed Charges,70% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.82,100,,6.768,Percent of Total Billed Charges,100% of Total Billed Charges,6.27,192,
CALCIUM DISOD ETDA 200MG/MLINJ,53241760,CDM,636,RC,J0600,HCPCS,Outpatient,,,3331.28,1998.77,,7597.88,110,,6078.304,Percent of Total Billed Charges,110% of Total Billed Charges,9129.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,3722.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3722.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3722.43,360,,,Fee Schedule,360% of BCBS POS Rate,3722.43,360,,,Fee schedule,360% of BCBS PPO Rate,3722.43,360,,,Fee Schedule,360% of BCBS Traditional Rate,1832.2,55,,73.44,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5477.68,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,7912.21,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6268.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6268.9,103,,,Fee Schedule,103% of CMS OPPS Rate,2498.46,75,,6.368,Percent of Total Billed Charges,75% of Total Billed Charges,6232.51,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,6232.51,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,6232.51,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,6232.51,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,9129.48,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2331.9,70,,1865.52,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,3331.28,100,,8.488,Percent of Total Billed Charges,100% of Total Billed Charges,1832.2,9129.48,
NS 100ML INJ A-V,53241761,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,636,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,9.136,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,12.176,Percent of Total Billed Charges,100% of Total Billed Charges,7,192,
NS 250ML INJ A-V,53241762,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,26.16,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,34.88,Percent of Total Billed Charges,100% of Total Billed Charges,7,192,
SOD CHLOR NON BAC 0.9% VL 10ML,53241949,CDM,250,RC,,,Outpatient,,,17.55,10.53,,10.53,60,,8.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.91,28,,3.928,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,36,,5.056,Percent of Total Billed Charges,36% of Total Billed Charges,6.32,36,,5.056,Percent of Total Billed Charges,36% Total Bille Charges,6.32,36,,5.056,Percent of Total Billed Charges,36% of Total Billed Charges,10.53,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.53,14.42,,2.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.16,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,8.78,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,8.78,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.78,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,8.78,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.29,70,,9.832,Percent of Total Billed Charges,70% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,2.46,14,,1.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.55,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,2.46,192,
SODIUM CHL 0.9% 10ML FLUSH SYG,53242004,CDM,250,RC,,,Outpatient,,,12.34,7.40,,7.4,60,,5.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.46,28,,2.768,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% Total Bille Charges,4.44,36,,3.552,Percent of Total Billed Charges,36% of Total Billed Charges,7.4,60,,108.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14.42,,1.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.26,75,,73.8,Percent of Total Billed Charges,75% of Total Billed Charges,6.17,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,6.17,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.17,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,6.17,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.64,70,,6.912,Percent of Total Billed Charges,70% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14,,1.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.34,100,,98.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,192,
SODIUM CL 0.9%-3ML SYRIN,53242012,CDM,250,RC,J7131,HCPCS,Outpatient,,,12.97,7.78,,0.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,360,,,Fee Schedule,360% of BCBS POS Rate,0.05,360,,,Fee schedule,360% of BCBS PPO Rate,0.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.78,60,,114.944,Percent of Total Billed Charges,60% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.87,14.42,,1.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.73,75,,81.824,Percent of Total Billed Charges,75% of Total Billed Charges,6.49,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,6.49,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.49,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,6.49,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.08,70,,7.264,Percent of Total Billed Charges,70% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,14,,1.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.97,100,,109.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,12.97,
SOD THIOSULF 25% 12.5GM/50ML,53242570,CDM,250,RC,,,Outpatient,,,382.5,229.50,,229.5,60,,183.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.1,28,,85.68,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,137.7,36,,110.16,Percent of Total Billed Charges,36% of Total Billed Charges,137.7,36,,110.16,Percent of Total Billed Charges,36% Total Bille Charges,137.7,36,,110.16,Percent of Total Billed Charges,36% of Total Billed Charges,229.5,60,,77.104,Percent of Total Billed Charges,60% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,55.16,14.42,,44.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.88,75,,27.472,Percent of Total Billed Charges,75% of Total Billed Charges,191.25,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,191.25,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.25,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,191.25,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.75,70,,214.2,Percent of Total Billed Charges,70% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,14,,42.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.5,100,,36.632,Percent of Total Billed Charges,100% of Total Billed Charges,53.55,382.5,
SOD PHOS 3MMOL/ML 5ML,53242590,CDM,250,RC,,,Outpatient,,,12,7.20,,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,28,,2.688,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% Total Bille Charges,4.32,36,,3.456,Percent of Total Billed Charges,36% of Total Billed Charges,7.2,60,,119.28,Percent of Total Billed Charges,60% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.73,14.42,,1.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,75,,49.072,Percent of Total Billed Charges,75% of Total Billed Charges,6,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,6,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,6,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,70,,6.72,Percent of Total Billed Charges,70% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,14,,1.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,100,,65.424,Percent of Total Billed Charges,100% of Total Billed Charges,1.68,192,
SODIUM TETRAD SULF 3% AMP 2ML,53242600,CDM,250,RC,,,Outpatient,,,351.54,210.92,,210.92,60,,168.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.43,28,,78.744,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,126.55,36,,101.24,Percent of Total Billed Charges,36% of Total Billed Charges,126.55,36,,101.24,Percent of Total Billed Charges,36% Total Bille Charges,126.55,36,,101.24,Percent of Total Billed Charges,36% of Total Billed Charges,210.92,60,,114.984,Percent of Total Billed Charges,60% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,50.69,14.42,,40.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.66,75,,108.256,Percent of Total Billed Charges,75% of Total Billed Charges,175.77,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,175.77,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.77,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,175.77,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.08,70,,196.864,Percent of Total Billed Charges,70% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.54,100,,144.336,Percent of Total Billed Charges,100% of Total Billed Charges,49.22,351.54,
SOD TETRADECYL SULF 1% INJ 2ML,53242601,CDM,250,RC,,,Outpatient,,,351.57,210.94,,210.94,60,,168.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.44,28,,78.752,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,126.57,36,,101.256,Percent of Total Billed Charges,36% of Total Billed Charges,126.57,36,,101.256,Percent of Total Billed Charges,36% Total Bille Charges,126.57,36,,101.256,Percent of Total Billed Charges,36% of Total Billed Charges,210.94,60,,114.296,Percent of Total Billed Charges,60% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,50.7,14.42,,40.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.68,75,,147.648,Percent of Total Billed Charges,75% of Total Billed Charges,175.79,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.79,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.1,70,,196.88,Percent of Total Billed Charges,70% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,49.22,14,,39.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.57,100,,196.864,Percent of Total Billed Charges,100% of Total Billed Charges,49.22,351.57,
STREPTOMYCIN INJ 1GM S,53243630,CDM,250,RC,J3000,HCPCS,Outpatient,,,231.87,139.12,,33.27,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,75,360,,,Fee Schedule,360% of BCBS POS Rate,75,360,,,Fee schedule,360% of BCBS PPO Rate,75,360,,,Fee Schedule,360% of BCBS Traditional Rate,139.12,60,,163.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.9,75,,3.712,Percent of Total Billed Charges,75% of Total Billed Charges,33.81,80,,32,Fee Schedule,80% of Scott and White EPO fee schedule,33.81,80,,32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.81,80,,32,Fee Schedule,80% of Scott and White PPO fee schedule,33.81,80,,29.832,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.31,70,,129.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.87,100,,4.944,Percent of Total Billed Charges,100% of Total Billed Charges,33.27,231.87,
SUCCINYLCHOLINE 200MG/10ML INJ,53244059,CDM,250,RC,J0330,HCPCS,Outpatient,,,119.08,71.45,,1.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.33,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.33,360,,,Fee Schedule,360% of BCBS POS Rate,1.33,360,,,Fee schedule,360% of BCBS PPO Rate,1.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.45,60,,51.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.31,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,59.54,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,59.54,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.54,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,59.54,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.36,70,,66.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.08,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,119.08,
SUMATRIPTAN 6MG/0.5ML INJ,53244216,CDM,250,RC,J3030,HCPCS,Outpatient,,,222.53,133.52,,35.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.19,360,,,Fee Schedule,360% of BCBS POS Rate,24.19,360,,,Fee schedule,360% of BCBS PPO Rate,24.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.52,60,,25.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.9,75,,5.096,Percent of Total Billed Charges,75% of Total Billed Charges,111.27,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,111.27,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.27,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,111.27,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.77,70,,124.616,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.53,100,,6.792,Percent of Total Billed Charges,100% of Total Billed Charges,24.19,222.53,
TERBUTALINE 1MG/ML AMP 1ML,53244265,CDM,250,RC,J3105,HCPCS,Outpatient,,,134.94,80.96,,1.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.76,360,,,Fee Schedule,360% of BCBS POS Rate,2.76,360,,,Fee schedule,360% of BCBS PPO Rate,2.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.96,60,,499.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.21,75,,4.912,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,4,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,32,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,814.408,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.46,70,,75.568,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.94,100,,6.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,134.94,
TRANEXAMIC ACID 1000MG/10ML,53244325,CDM,250,RC,,,Outpatient,,,252.72,151.63,,151.63,60,,121.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.76,28,,56.608,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,90.98,36,,72.784,Percent of Total Billed Charges,36% of Total Billed Charges,90.98,36,,72.784,Percent of Total Billed Charges,36% Total Bille Charges,90.98,36,,72.784,Percent of Total Billed Charges,36% of Total Billed Charges,151.63,60,,449.856,Percent of Total Billed Charges,60% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,36.44,14.42,,29.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.54,75,,0.232,Percent of Total Billed Charges,75% of Total Billed Charges,126.36,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,126.36,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.36,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,126.36,50,,340.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.9,70,,141.52,Percent of Total Billed Charges,70% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,35.38,14,,28.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.72,100,,0.312,Percent of Total Billed Charges,100% of Total Billed Charges,35.38,252.72,
TESTOSTERONE CY 200MG/1ML VL,53244596,CDM,250,RC,J1071,HCPCS,Outpatient,,,143.16,85.90,,0.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.02,360,,,Fee Schedule,360% of BCBS POS Rate,0.02,360,,,Fee schedule,360% of BCBS PPO Rate,0.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.9,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.37,75,,5.56,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,80,,32,Fee Schedule,80% of Scott and White EPO fee schedule,0.02,80,,32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,80,,32,Fee Schedule,80% of Scott and White PPO fee schedule,0.02,80,,40,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.21,70,,80.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.16,100,,7.408,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,143.16,
TETANUS IMMUNE GLOB 250UN SYG,53244992,CDM,250,RC,J1670,HCPCS,Outpatient,,,2247.14,1348.28,,486.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,872.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,529.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,529.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,529.9,360,,,Fee Schedule,360% of BCBS POS Rate,529.9,360,,,Fee schedule,360% of BCBS PPO Rate,529.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,1348.28,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,523.6,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,756.31,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599.23,103,,,Fee Schedule,103% of CMS OPPS Rate,599.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1685.36,75,,8.392,Percent of Total Billed Charges,75% of Total Billed Charges,436.49,80,,32,Fee Schedule,80% of Scott and White EPO fee schedule,436.49,80,,32,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,436.49,80,,32,Fee Schedule,80% of Scott and White PPO fee schedule,436.49,80,,40,Fee Schedule,80% of Scott and White SWHP fee schedule,872.67,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1573,70,,1258.4,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2247.14,100,,11.192,Percent of Total Billed Charges,100% of Total Billed Charges,436.49,2247.14,
TETANUS DIPHT TOX A 0.5ML SYRG,53245205,CDM,636,RC,90714,HCPCS,Outpatient,,,203.63,122.18,,143.06,110,,114.448,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,18.54,360,,,Fee Schedule,360% of BCBS POS Rate,18.54,360,,,Fee schedule,360% of BCBS PPO Rate,18.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.72,75,,28.92,Percent of Total Billed Charges,75% of Total Billed Charges,125.22,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,125.22,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.22,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,125.22,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.54,70,,114.032,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.63,100,,38.56,Percent of Total Billed Charges,100% of Total Billed Charges,18.54,203.63,
TETRACAINE 1% INJ 2ML,53245619,CDM,250,RC,,,Outpatient,,,221.49,132.89,,132.89,60,,106.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.02,28,,49.616,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,79.74,36,,63.792,Percent of Total Billed Charges,36% of Total Billed Charges,79.74,36,,63.792,Percent of Total Billed Charges,36% Total Bille Charges,79.74,36,,63.792,Percent of Total Billed Charges,36% of Total Billed Charges,132.89,60,,449.856,Percent of Total Billed Charges,60% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.94,14.42,,25.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.12,75,,13.552,Percent of Total Billed Charges,75% of Total Billed Charges,110.75,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,110.75,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.75,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,110.75,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.04,70,,124.032,Percent of Total Billed Charges,70% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,31.01,14,,24.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.49,100,,18.064,Percent of Total Billed Charges,100% of Total Billed Charges,31.01,221.49,
THIAMINE 100 MG/ML INJ 2 ML,53246187,CDM,250,RC,J3411,HCPCS,Outpatient,,,64.01,38.41,,2.85,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.07,360,,,Fee Schedule,360% of BCBS POS Rate,3.07,360,,,Fee schedule,360% of BCBS PPO Rate,3.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.41,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.01,75,,4.272,Percent of Total Billed Charges,75% of Total Billed Charges,1.75,80,,32,Fee Schedule,80% of Scott and White EPO fee schedule,1.75,80,,40.608,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.75,80,,40.608,Fee Schedule,80% of Scott and White PPO fee schedule,1.75,80,,32.24,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.81,70,,35.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,100,,5.696,Percent of Total Billed Charges,100% of Total Billed Charges,1.75,64.01,
THYROTROPIN ALFA 1.1MG INJ,53247037,CDM,636,RC,J3240,HCPCS,Outpatient,,,6409.53,3845.72,,5401.86,110,,4321.488,Percent of Total Billed Charges,110% of Total Billed Charges,3110.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1619,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1619,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1619,360,,,Fee Schedule,360% of BCBS POS Rate,1619,360,,,Fee schedule,360% of BCBS PPO Rate,1619,360,,,Fee Schedule,360% of BCBS Traditional Rate,3525.24,55,,103.392,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1866,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2695.34,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2135.54,103,,,Fee Schedule,103% of CMS OPPS Rate,2135.54,103,,,Fee Schedule,103% of CMS OPPS Rate,4807.15,75,,12.728,Percent of Total Billed Charges,75% of Total Billed Charges,4746.16,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,4746.16,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4746.16,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,4746.16,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,3110.01,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4486.67,70,,3589.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2073.34,100,,,Fee Schedule,100% of CMS OPPS Rate,6409.53,100,,16.968,Percent of Total Billed Charges,100% of Total Billed Charges,1619,6409.53,
TIGECYCLINE 50MG VIAL,53247391,CDM,250,RC,J3243,HCPCS,Outpatient,,,623,373.80,,1.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.87,360,,,Fee Schedule,360% of BCBS POS Rate,1.87,360,,,Fee schedule,360% of BCBS PPO Rate,1.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,373.8,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,467.25,75,,76.288,Percent of Total Billed Charges,75% of Total Billed Charges,0.49,80,,40.608,Fee Schedule,80% of Scott and White EPO fee schedule,0.49,80,,848.96,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.49,80,,848.96,Fee Schedule,80% of Scott and White PPO fee schedule,0.49,80,,114.376,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,436.1,70,,348.88,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,623,100,,101.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.49,623,
TOBRAMYCIN 40MG/ML VL 2ML,53247805,CDM,250,RC,J3260,HCPCS,Outpatient,,,30.42,18.25,,4.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.45,360,,,Fee Schedule,360% of BCBS POS Rate,0.45,360,,,Fee schedule,360% of BCBS PPO Rate,0.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,18.25,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.82,75,,25.024,Percent of Total Billed Charges,75% of Total Billed Charges,1.86,80,,41.952,Fee Schedule,80% of Scott and White EPO fee schedule,1.86,80,,848.96,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,80,,848.96,Fee Schedule,80% of Scott and White PPO fee schedule,1.86,80,,102.736,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.29,70,,17.032,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,100,,33.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,30.42,
TRASTUZUMAB INJ PER 10MG,53248555,CDM,636,RC,J9355,HCPCS,Outpatient,,,452.85,271.71,,336.34,110,,269.072,Percent of Total Billed Charges,110% of Total Billed Charges,116.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,103.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,103.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,103.04,360,,,Fee Schedule,360% of BCBS POS Rate,103.04,360,,,Fee schedule,360% of BCBS PPO Rate,103.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,70.14,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,101.32,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.27,103,,,Fee Schedule,103% of CMS OPPS Rate,80.27,103,,,Fee Schedule,103% of CMS OPPS Rate,339.64,75,,25.168,Percent of Total Billed Charges,75% of Total Billed Charges,290.62,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,290.62,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,290.62,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,290.62,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,116.91,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317,70,,253.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.94,100,,,Fee Schedule,100% of CMS OPPS Rate,452.85,100,,33.552,Percent of Total Billed Charges,100% of Total Billed Charges,70.14,452.85,
ECULIZUMAB 10 MG/ML INJ 1ML,53248560,CDM,636,RC,J1300,HCPCS,Outpatient,,,941.65,564.99,,749.14,110,,599.312,Percent of Total Billed Charges,110% of Total Billed Charges,336.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,214.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,214.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,214.61,360,,,Fee Schedule,360% of BCBS POS Rate,214.61,360,,,Fee schedule,360% of BCBS PPO Rate,214.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,202.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,292.01,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.36,103,,,Fee Schedule,103% of CMS OPPS Rate,231.36,103,,,Fee Schedule,103% of CMS OPPS Rate,706.24,75,,7.048,Percent of Total Billed Charges,75% of Total Billed Charges,651.79,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,651.79,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,651.79,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,651.79,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,336.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,659.16,70,,527.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.63,100,,,Fee Schedule,100% of CMS OPPS Rate,941.65,100,,9.4,Percent of Total Billed Charges,100% of Total Billed Charges,202.16,941.65,
TRIAMCINO ACET 10MG/ML INJ 5ML,53248647,CDM,250,RC,J3301,HCPCS,Outpatient,,,72.54,43.52,,1.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.27,360,,,Fee Schedule,360% of BCBS POS Rate,1.27,360,,,Fee schedule,360% of BCBS PPO Rate,1.27,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.52,60,,145.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.41,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.9,80,,42.6,Fee Schedule,80% of Scott and White EPO fee schedule,0.9,80,,25.368,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,80,,25.368,Fee Schedule,80% of Scott and White PPO fee schedule,0.9,80,,68.128,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.78,70,,40.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.54,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,72.54,
TRIAMCINO ACET 40MG/1ML INJ,53248696,CDM,250,RC,J3301,HCPCS,Outpatient,,,285.06,171.04,,1.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.27,360,,,Fee Schedule,360% of BCBS POS Rate,1.27,360,,,Fee schedule,360% of BCBS PPO Rate,1.27,360,,,Fee Schedule,360% of BCBS Traditional Rate,171.04,60,,120.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.8,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,0.9,80,,15.264,Fee Schedule,80% of Scott and White EPO fee schedule,0.9,80,,144,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,80,,144,Fee Schedule,80% of Scott and White PPO fee schedule,0.9,80,,54.528,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.54,70,,159.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.06,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.9,285.06,
TUBERCULIN PPD 5 TU/0.1 ML TES,53249892,CDM,302,RC,86580,HCPCS,Outpatient,,,53,31.80,,11.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,73.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,82.76,360,,,Fee Schedule,360% of BCBS POS Rate,82.76,360,,,Fee schedule,360% of BCBS PPO Rate,82.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,31.8,60,,214.184,Percent of Total Billed Charges,60% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.64,14.42,,6.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,39.75,75,,5.208,Percent of Total Billed Charges,75% of Total Billed Charges,26.5,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,,Fee Schedule,90% of UHC fee schedule,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,7.42,14,,5.936,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,53,100,,6.944,Percent of Total Billed Charges,100% of Total Billed Charges,7.42,82.76,
VALPROATE SOD 500MG INJ,53250650,CDM,250,RC,,,Outpatient,,,49.04,29.42,,29.42,60,,23.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.73,28,,10.984,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% of Total Billed Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% Total Bille Charges,17.65,36,,14.12,Percent of Total Billed Charges,36% of Total Billed Charges,29.42,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,7.07,14.42,,5.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.78,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,24.52,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,24.52,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.52,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,24.52,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.33,70,,27.464,Percent of Total Billed Charges,70% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,6.87,14,,5.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.04,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.87,192,
VANCOMYCIN 1GM INJ,53250734,CDM,250,RC,J3370,HCPCS,Outpatient,,,121.38,72.83,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.83,60,,68.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.04,75,,4.72,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,23.328,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,64.248,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,64.248,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,41.792,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.97,70,,67.976,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.38,100,,6.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,121.38,
VANCOMYCIN 500MG ADV,53250783,CDM,250,RC,J3370,HCPCS,Outpatient,,,69.67,41.80,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,41.8,60,,120.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.25,75,,0.704,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,64.248,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,85.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,85.8,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.77,70,,39.016,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.67,100,,0.936,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,69.67,
VASOPRESSIN 20UN/1ML INJ,53251005,CDM,250,RC,,,Outpatient,,,684.81,410.89,,410.89,60,,328.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.75,28,,153.4,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,246.53,36,,197.224,Percent of Total Billed Charges,36% of Total Billed Charges,246.53,36,,197.224,Percent of Total Billed Charges,36% Total Bille Charges,246.53,36,,197.224,Percent of Total Billed Charges,36% of Total Billed Charges,410.89,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,98.75,14.42,,79,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,513.61,75,,4.888,Percent of Total Billed Charges,75% of Total Billed Charges,342.41,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,342.41,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.41,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,342.41,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,479.37,70,,383.496,Percent of Total Billed Charges,70% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,95.87,14,,76.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,684.81,100,,6.52,Percent of Total Billed Charges,100% of Total Billed Charges,95.87,684.81,
VECURONIUM 10MG INJ,53251146,CDM,250,RC,,,Outpatient,,,35.19,21.11,,21.11,60,,16.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.85,28,,7.88,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,12.67,36,,10.136,Percent of Total Billed Charges,36% of Total Billed Charges,12.67,36,,10.136,Percent of Total Billed Charges,36% Total Bille Charges,12.67,36,,10.136,Percent of Total Billed Charges,36% of Total Billed Charges,21.11,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,14.42,,4.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.39,75,,34.888,Percent of Total Billed Charges,75% of Total Billed Charges,17.6,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.6,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.6,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,17.6,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.63,70,,19.704,Percent of Total Billed Charges,70% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14,,3.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.19,100,,46.52,Percent of Total Billed Charges,100% of Total Billed Charges,4.93,192,
VECURONIUM BROMID 20MG SDV INJ,53251147,CDM,250,RC,,,Outpatient,,,84.46,50.68,,50.68,60,,40.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.65,28,,18.92,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% of Total Billed Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% Total Bille Charges,30.41,36,,24.328,Percent of Total Billed Charges,36% of Total Billed Charges,50.68,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,12.18,14.42,,9.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.35,75,,85.888,Percent of Total Billed Charges,75% of Total Billed Charges,42.23,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.23,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.23,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,42.23,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.12,70,,47.296,Percent of Total Billed Charges,70% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,11.82,14,,9.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.46,100,,114.512,Percent of Total Billed Charges,100% of Total Billed Charges,11.82,192,
VERAPAMIL 2.5MG/ML INJ 2ML,53251252,CDM,250,RC,,,Outpatient,,,213.06,127.84,,127.84,60,,102.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.66,28,,47.728,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,76.7,36,,61.36,Percent of Total Billed Charges,36% of Total Billed Charges,76.7,36,,61.36,Percent of Total Billed Charges,36% Total Bille Charges,76.7,36,,61.36,Percent of Total Billed Charges,36% of Total Billed Charges,127.84,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,30.72,14.42,,24.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.8,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,106.53,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,106.53,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.53,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,106.53,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.14,70,,119.312,Percent of Total Billed Charges,70% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,29.83,14,,23.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.06,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,29.83,213.06,
VINBLASTINE 10 MG INJ,53251773,CDM,250,RC,J9360,HCPCS,Outpatient,,,310.58,186.35,,3.95,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.98,360,,,Fee Schedule,360% of BCBS POS Rate,2.98,360,,,Fee schedule,360% of BCBS PPO Rate,2.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,186.35,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.94,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,3.18,80,,270,Fee Schedule,80% of Scott and White EPO fee schedule,3.18,80,,120.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.18,80,,120.8,Fee Schedule,80% of Scott and White PPO fee schedule,3.18,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.41,70,,173.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.58,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,2.98,310.58,
VINCRISTINE SULFATE 1MG SYG,53251989,CDM,250,RC,J9370,HCPCS,Outpatient,,,92.06,55.24,,4.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.8,360,,,Fee Schedule,360% of BCBS POS Rate,3.8,360,,,Fee schedule,360% of BCBS PPO Rate,3.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.24,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.05,75,,13.144,Percent of Total Billed Charges,75% of Total Billed Charges,3.87,80,,120.8,Fee Schedule,80% of Scott and White EPO fee schedule,3.87,80,,148.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,80,,148.4,Fee Schedule,80% of Scott and White PPO fee schedule,3.87,80,,4,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.44,70,,51.552,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.06,100,,17.528,Percent of Total Billed Charges,100% of Total Billed Charges,3.8,92.06,
VORICONAZOLE INJ PER 10MG,53252391,CDM,250,RC,J3465,HCPCS,Outpatient,,,44.31,26.59,,1.85,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.39,360,,,Fee Schedule,360% of BCBS POS Rate,4.39,360,,,Fee schedule,360% of BCBS PPO Rate,4.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.59,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.23,75,,10.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.75,80,,120.8,Fee Schedule,80% of Scott and White EPO fee schedule,0.75,80,,148.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,80,,148.4,Fee Schedule,80% of Scott and White PPO fee schedule,0.75,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.02,70,,24.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.31,100,,13.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.75,44.31,
WATER STERILE INJ 10ML,53252508,CDM,250,RC,,,Outpatient,,,6.37,3.82,,3.82,60,,3.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,28,,1.424,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,2.29,36,,1.832,Percent of Total Billed Charges,36% of Total Billed Charges,2.29,36,,1.832,Percent of Total Billed Charges,36% Total Bille Charges,2.29,36,,1.832,Percent of Total Billed Charges,36% of Total Billed Charges,3.82,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14.42,,0.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,75,,10.432,Percent of Total Billed Charges,75% of Total Billed Charges,3.19,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.19,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.19,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.46,70,,3.568,Percent of Total Billed Charges,70% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.37,100,,13.904,Percent of Total Billed Charges,100% of Total Billed Charges,0.89,192,
WATER FOR INJ 1000ML,53252520,CDM,258,RC,,,Outpatient,,,38.4,23.04,,23.04,60,,18.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.75,28,,8.6,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% of Total Billed Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% Total Bille Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% of Total Billed Charges,23.04,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14.42,,4.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.8,75,,5.088,Percent of Total Billed Charges,75% of Total Billed Charges,19.2,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.2,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.2,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,19.2,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.88,70,,21.504,Percent of Total Billed Charges,70% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.4,100,,6.784,Percent of Total Billed Charges,100% of Total Billed Charges,5.38,192,
ZIDOVUDINE 10MG/ML 20ML INJ,53252706,CDM,250,RC,J3485,HCPCS,Outpatient,,,180.14,108.08,,1.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,108.08,60,,44.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.11,75,,10.816,Percent of Total Billed Charges,75% of Total Billed Charges,1.21,80,,91.2,Fee Schedule,80% of Scott and White EPO fee schedule,1.21,80,,378.6,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.21,80,,378.6,Fee Schedule,80% of Scott and White PPO fee schedule,1.21,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.1,70,,100.88,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.14,100,,14.416,Percent of Total Billed Charges,100% of Total Billed Charges,1.21,180.14,
ZOLEDRONIC ACID PER 1MG,53252920,CDM,250,RC,J3489,HCPCS,Outpatient,,,142.5,85.50,,5.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.75,360,,,Fee Schedule,360% of BCBS POS Rate,6.75,360,,,Fee schedule,360% of BCBS PPO Rate,6.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.5,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.88,75,,6.64,Percent of Total Billed Charges,75% of Total Billed Charges,6.47,80,,91.2,Fee Schedule,80% of Scott and White EPO fee schedule,6.47,80,,34.744,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,80,,34.744,Fee Schedule,80% of Scott and White PPO fee schedule,6.47,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.75,70,,79.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.5,100,,8.856,Percent of Total Billed Charges,100% of Total Billed Charges,5.82,142.5,
ZIPRASIDONE PER 10MG INJ,53253019,CDM,250,RC,J3486,HCPCS,Outpatient,,,298.08,178.85,,13.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.84,360,,,Fee Schedule,360% of BCBS POS Rate,24.84,360,,,Fee schedule,360% of BCBS PPO Rate,24.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,178.85,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.56,75,,4.192,Percent of Total Billed Charges,75% of Total Billed Charges,8.09,80,,378.6,Fee Schedule,80% of Scott and White EPO fee schedule,8.09,80,,34.744,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.09,80,,34.744,Fee Schedule,80% of Scott and White PPO fee schedule,8.09,80,,32,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.66,70,,166.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.08,100,,5.584,Percent of Total Billed Charges,100% of Total Billed Charges,8.09,298.08,
CLINIMIX E 5% AA/D20W 1000ML,53253100,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,36.256,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,48.336,Percent of Total Billed Charges,100% of Total Billed Charges,77,550,
D5 LR INJ 500ML,53253150,CDM,258,RC,,,Outpatient,,,49.61,29.77,,29.77,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.89,28,,11.112,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,17.86,36,,14.288,Percent of Total Billed Charges,36% of Total Billed Charges,17.86,36,,14.288,Percent of Total Billed Charges,36% Total Bille Charges,17.86,36,,14.288,Percent of Total Billed Charges,36% of Total Billed Charges,29.77,60,,212.52,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,7.15,14.42,,5.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,75,,84.496,Percent of Total Billed Charges,75% of Total Billed Charges,24.81,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,24.81,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.81,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,24.81,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.73,70,,27.784,Percent of Total Billed Charges,70% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14,,5.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.61,100,,112.664,Percent of Total Billed Charges,100% of Total Billed Charges,6.95,192,
D5 LR INJ 1000ML,53253200,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,101.944,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,135.928,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
D5LR 1000ML KCL 20MEQ,53253250,CDM,258,RC,,,Outpatient,,,34.17,20.50,,20.5,60,,16.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.57,28,,7.656,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,12.3,36,,9.84,Percent of Total Billed Charges,36% of Total Billed Charges,12.3,36,,9.84,Percent of Total Billed Charges,36% Total Bille Charges,12.3,36,,9.84,Percent of Total Billed Charges,36% of Total Billed Charges,20.5,60,,85.264,Percent of Total Billed Charges,60% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.93,14.42,,3.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.63,75,,9.704,Percent of Total Billed Charges,75% of Total Billed Charges,17.09,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,17.09,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.09,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,17.09,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.92,70,,19.136,Percent of Total Billed Charges,70% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.17,100,,12.936,Percent of Total Billed Charges,100% of Total Billed Charges,4.78,192,
OXYTOCIN 30 UNITS/NS 500 ML,53253300,CDM,250,RC,J2590,HCPCS,Outpatient,,,78.5,47.10,,0.83,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.54,360,,,Fee Schedule,360% of BCBS POS Rate,0.54,360,,,Fee schedule,360% of BCBS PPO Rate,0.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,449.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,7.088,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.25,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,9.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,78.5,
OXYTOCIN 20 UNITS/NS 1000 ML,53253350,CDM,250,RC,J2590,HCPCS,Outpatient,,,78.5,47.10,,0.83,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.54,360,,,Fee Schedule,360% of BCBS POS Rate,0.54,360,,,Fee schedule,360% of BCBS PPO Rate,0.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,131.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,5.528,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.25,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,7.368,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,78.5,
D5 NACL 0.225% INJ 1000ML,53253450,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,103.256,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,2.224,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,2.96,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
D5 1/2 NS 500ML,53253500,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,6.088,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,8.112,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
D5 1/2 NS 1000ML,53253550,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,627.84,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,17.176,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,22.896,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
D5 1/2NS 10KCL 1000ML,53253650,CDM,258,RC,,,Outpatient,,,28.76,17.26,,17.26,60,,13.808,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,28,,6.44,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,10.35,36,,8.28,Percent of Total Billed Charges,36% of Total Billed Charges,10.35,36,,8.28,Percent of Total Billed Charges,36% Total Bille Charges,10.35,36,,8.28,Percent of Total Billed Charges,36% of Total Billed Charges,17.26,60,,114.296,Percent of Total Billed Charges,60% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.15,14.42,,3.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.57,75,,48.208,Percent of Total Billed Charges,75% of Total Billed Charges,14.38,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,14.38,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.38,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,14.38,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.13,70,,16.104,Percent of Total Billed Charges,70% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14,,3.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.76,100,,64.272,Percent of Total Billed Charges,100% of Total Billed Charges,4.03,192,
D5 1/2 NS 1000ML W/KCL 20MEQ,53253700,CDM,258,RC,,,Outpatient,,,27.74,16.64,,16.64,60,,13.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.77,28,,6.216,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,9.99,36,,7.992,Percent of Total Billed Charges,36% of Total Billed Charges,9.99,36,,7.992,Percent of Total Billed Charges,36% Total Bille Charges,9.99,36,,7.992,Percent of Total Billed Charges,36% of Total Billed Charges,16.64,60,,58.184,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,4,14.42,,3.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,13.87,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,13.87,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.87,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,13.87,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.42,70,,15.536,Percent of Total Billed Charges,70% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,3.88,14,,3.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.74,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.88,192,
D5 NS 250ML,53253800,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,3.104,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,4.136,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
D5 NS 500ML INJ,53253850,CDM,258,RC,,,Outpatient,,,41.66,25.00,,25,60,,20,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.66,28,,9.328,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,15,36,,12,Percent of Total Billed Charges,36% of Total Billed Charges,15,36,,12,Percent of Total Billed Charges,36% Total Bille Charges,15,36,,12,Percent of Total Billed Charges,36% of Total Billed Charges,25,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,6.01,14.42,,4.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.25,75,,0.8,Percent of Total Billed Charges,75% of Total Billed Charges,20.83,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,20.83,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.83,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,20.83,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.16,70,,23.328,Percent of Total Billed Charges,70% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,14,,4.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.66,100,,1.064,Percent of Total Billed Charges,100% of Total Billed Charges,5.83,192,
D5NS 1000ML KCL 20MEQ,53253900,CDM,258,RC,,,Outpatient,,,34.62,20.77,,20.77,60,,16.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,28,,7.752,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,12.46,36,,9.968,Percent of Total Billed Charges,36% of Total Billed Charges,12.46,36,,9.968,Percent of Total Billed Charges,36% Total Bille Charges,12.46,36,,9.968,Percent of Total Billed Charges,36% of Total Billed Charges,20.77,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14.42,,3.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.97,75,,3.04,Percent of Total Billed Charges,75% of Total Billed Charges,17.31,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,17.31,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.31,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,17.31,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.23,70,,19.384,Percent of Total Billed Charges,70% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.62,100,,4.048,Percent of Total Billed Charges,100% of Total Billed Charges,4.85,192,
D5NS 1000ML KCL 40MEQ,53253950,CDM,258,RC,,,Outpatient,,,34.76,20.86,,20.86,60,,16.688,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.73,28,,7.784,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,12.51,36,,10.008,Percent of Total Billed Charges,36% of Total Billed Charges,12.51,36,,10.008,Percent of Total Billed Charges,36% Total Bille Charges,12.51,36,,10.008,Percent of Total Billed Charges,36% of Total Billed Charges,20.86,60,,138.72,Percent of Total Billed Charges,60% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,5.01,14.42,,4.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,75,,4.288,Percent of Total Billed Charges,75% of Total Billed Charges,17.38,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,17.38,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.38,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,17.38,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.33,70,,19.464,Percent of Total Billed Charges,70% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,4.87,14,,3.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.76,100,,5.712,Percent of Total Billed Charges,100% of Total Billed Charges,4.87,192,
D5W 50ML INJ,53254000,CDM,258,RC,,,Outpatient,,,27.59,16.55,,16.55,60,,13.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.73,28,,6.184,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% Total Bille Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,16.55,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.98,14.42,,3.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,13.8,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.8,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.31,70,,15.448,Percent of Total Billed Charges,70% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.59,100,,2.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.86,192,
D5W 100ML INJ,53254050,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
D5W 250ML INJ,53254100,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,32.232,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,42.976,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
D5W 1000ML KCL 20MEQ,53254250,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,483.384,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,108.864,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,145.152,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
D10W 500ML,53254350,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,507.904,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,677.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,192,
D10W 1000ML,53254400,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,460.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,255.448,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,340.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
LR INJ 500ML,53254450,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,48.568,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,64.76,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
LR INJ 1000ML,53254500,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,453.608,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,378.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,604.808,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,192,
MANNITOL 20% INJ 500ML,53254550,CDM,258,RC,,,Outpatient,,,151.44,90.86,,90.86,60,,72.688,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.4,28,,33.92,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,54.52,36,,43.616,Percent of Total Billed Charges,36% of Total Billed Charges,54.52,36,,43.616,Percent of Total Billed Charges,36% Total Bille Charges,54.52,36,,43.616,Percent of Total Billed Charges,36% of Total Billed Charges,90.86,60,,486.448,Percent of Total Billed Charges,60% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.84,14.42,,17.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.58,75,,38.312,Percent of Total Billed Charges,75% of Total Billed Charges,75.72,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,75.72,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.72,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,75.72,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.01,70,,84.808,Percent of Total Billed Charges,70% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,21.2,14,,16.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.44,100,,51.08,Percent of Total Billed Charges,100% of Total Billed Charges,21.2,192,
1/2 NS 500ML,53254600,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,34.216,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,45.616,Percent of Total Billed Charges,100% of Total Billed Charges,7,192,
1/2 NS 1000ML,53254650,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,59.448,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,79.264,Percent of Total Billed Charges,100% of Total Billed Charges,7,192,
NS 50ML INJ,53254700,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192,32,,153.6,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,0.64,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,0.856,Percent of Total Billed Charges,100% of Total Billed Charges,7,192,
NS 100ML INJ,53254750,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192.32,32,,153.856,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,1.192,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,1.592,Percent of Total Billed Charges,100% of Total Billed Charges,7,192.32,
NS 150ML INJ,53254800,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192.48,32,,153.984,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,1738.312,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,61.2,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,81.6,Percent of Total Billed Charges,100% of Total Billed Charges,7,192.48,
NS 250ML INJ,53254850,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,192.94,32,,154.352,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,291.784,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,113.032,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,150.704,Percent of Total Billed Charges,100% of Total Billed Charges,7,192.94,
NS 500ML INJ,53254900,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,194.24,32,,155.392,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,340.16,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,44.928,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,59.904,Percent of Total Billed Charges,100% of Total Billed Charges,7,194.24,
NS 1000ML INJ,53254950,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,194.66,32,,155.728,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,154.56,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,53.864,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,71.816,Percent of Total Billed Charges,100% of Total Billed Charges,7,194.66,
NS 1000ML/KCL 20MEQ,53255000,CDM,258,RC,,,Outpatient,,,20.4,12.24,,12.24,60,,9.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,28,,4.568,Percent of Total Billed Charges,28% of Total Billed Charges,194.66,32,,155.728,Percent of Total Billed Charges,32% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,7.34,36,,5.872,Percent of Total Billed Charges,36% of Total Billed Charges,7.34,36,,5.872,Percent of Total Billed Charges,36% Total Bille Charges,7.34,36,,5.872,Percent of Total Billed Charges,36% of Total Billed Charges,12.24,60,,50.192,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,14.42,,2.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,75,,53.352,Percent of Total Billed Charges,75% of Total Billed Charges,10.2,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,10.2,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,10.2,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.28,70,,11.424,Percent of Total Billed Charges,70% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,2.86,14,,2.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.4,100,,71.136,Percent of Total Billed Charges,100% of Total Billed Charges,2.86,194.66,
NS 1000ML/KCL 40MEQ,53255050,CDM,258,RC,,,Outpatient,,,21.06,12.64,,12.64,60,,10.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.9,28,,4.72,Percent of Total Billed Charges,28% of Total Billed Charges,194.74,32,,155.792,Percent of Total Billed Charges,32% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,7.58,36,,6.064,Percent of Total Billed Charges,36% of Total Billed Charges,7.58,36,,6.064,Percent of Total Billed Charges,36% Total Bille Charges,7.58,36,,6.064,Percent of Total Billed Charges,36% of Total Billed Charges,12.64,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14.42,,2.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.8,75,,91.512,Percent of Total Billed Charges,75% of Total Billed Charges,10.53,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,10.53,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.53,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,10.53,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.74,70,,11.792,Percent of Total Billed Charges,70% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,14,,2.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.06,100,,122.016,Percent of Total Billed Charges,100% of Total Billed Charges,2.95,194.74,
1/2 NS 1000ML/KCL 20 MEQ,53255100,CDM,258,RC,,,Outpatient,,,31.32,18.79,,18.79,60,,15.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,28,,7.016,Percent of Total Billed Charges,28% of Total Billed Charges,194.92,32,,155.936,Percent of Total Billed Charges,32% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,36,,9.024,Percent of Total Billed Charges,36% of Total Billed Charges,11.28,36,,9.024,Percent of Total Billed Charges,36% Total Bille Charges,11.28,36,,9.024,Percent of Total Billed Charges,36% of Total Billed Charges,18.79,60,,77.816,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14.42,,3.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.49,75,,96.28,Percent of Total Billed Charges,75% of Total Billed Charges,15.66,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,15.66,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.66,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,15.66,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.92,70,,17.536,Percent of Total Billed Charges,70% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,14,,3.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.32,100,,128.368,Percent of Total Billed Charges,100% of Total Billed Charges,4.38,194.92,
NACL 3% INJ 500ML,53255150,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,19578.24,32,,15662.592,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,199.328,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,96.28,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,128.368,Percent of Total Billed Charges,100% of Total Billed Charges,7,19578.24,
WATER FOR INJ 250ML,53255250,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,19578.24,32,,15662.592,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,105.768,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,65.104,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,86.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,19578.24,
TPN ADULT,53255400,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,19.62,32,,15.696,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,96.824,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,3.376,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,4.504,Percent of Total Billed Charges,100% of Total Billed Charges,19.62,550,
DOPAMINE 400 MG/D5W 250 ML,53255500,CDM,250,RC,J1265,HCPCS,Outpatient,,,98.79,59.27,,0.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.25,360,,,Fee Schedule,360% of BCBS POS Rate,0.25,360,,,Fee schedule,360% of BCBS PPO Rate,0.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,59.27,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.09,75,,8.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.53,80,,10.952,Fee Schedule,80% of Scott and White EPO fee schedule,0.53,80,,14.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,80,,14.2,Fee Schedule,80% of Scott and White PPO fee schedule,0.53,80,,10.84,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.15,70,,55.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.79,100,,11.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.25,98.79,
FAT EMULSION 20% 100 ML BAG,53255550,CDM,258,RC,,,Outpatient,,,173.42,104.05,,104.05,60,,83.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.56,28,,38.848,Percent of Total Billed Charges,28% of Total Billed Charges,19.72,32,,15.776,Percent of Total Billed Charges,32% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,62.43,36,,49.944,Percent of Total Billed Charges,36% of Total Billed Charges,62.43,36,,49.944,Percent of Total Billed Charges,36% Total Bille Charges,62.43,36,,49.944,Percent of Total Billed Charges,36% of Total Billed Charges,104.05,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,25.01,14.42,,20.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.07,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,86.71,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,86.71,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.71,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,86.71,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.39,70,,97.112,Percent of Total Billed Charges,70% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,24.28,14,,19.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.42,100,,5.6,Percent of Total Billed Charges,100% of Total Billed Charges,19.72,173.42,
FAT EMULSION 20% 500ML,53255600,CDM,258,RC,,,Outpatient,,,108.94,65.36,,65.36,60,,52.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.5,28,,24.4,Percent of Total Billed Charges,28% of Total Billed Charges,19.76,32,,15.808,Percent of Total Billed Charges,32% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,39.22,36,,31.376,Percent of Total Billed Charges,36% of Total Billed Charges,39.22,36,,31.376,Percent of Total Billed Charges,36% Total Bille Charges,39.22,36,,31.376,Percent of Total Billed Charges,36% of Total Billed Charges,65.36,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14.42,,12.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.71,75,,4.432,Percent of Total Billed Charges,75% of Total Billed Charges,54.47,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.47,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.47,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,54.47,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.26,70,,61.008,Percent of Total Billed Charges,70% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,14,,12.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.94,100,,5.912,Percent of Total Billed Charges,100% of Total Billed Charges,15.25,108.94,
GLYCINE 1.5% IRR 3000ML BAG,53255650,CDM,250,RC,,,Outpatient,,,12.13,7.28,,7.28,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,28,,2.72,Percent of Total Billed Charges,28% of Total Billed Charges,19.8,32,,15.84,Percent of Total Billed Charges,32% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.37,36,,3.496,Percent of Total Billed Charges,36% of Total Billed Charges,4.37,36,,3.496,Percent of Total Billed Charges,36% Total Bille Charges,4.37,36,,3.496,Percent of Total Billed Charges,36% of Total Billed Charges,7.28,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14.42,,1.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,75,,0.64,Percent of Total Billed Charges,75% of Total Billed Charges,6.07,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,6.07,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.07,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,6.07,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,70,,6.792,Percent of Total Billed Charges,70% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.13,100,,0.856,Percent of Total Billed Charges,100% of Total Billed Charges,1.7,19.8,
HEPARIN 1000U/500ML BAG,53255700,CDM,250,RC,J1644,HCPCS,Outpatient,,,62.47,37.48,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.48,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.85,75,,37.464,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,12.408,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,33.48,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,33.48,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,8.992,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.73,70,,34.984,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.47,100,,49.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,62.47,
NS IRRIGATION 1000ML,53255850,CDM,250,RC,,,Outpatient,,,37.86,22.72,,22.72,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,28,,8.48,Percent of Total Billed Charges,28% of Total Billed Charges,195.49,32,,156.392,Percent of Total Billed Charges,32% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% of Total Billed Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% Total Bille Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% of Total Billed Charges,22.72,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.46,14.42,,4.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.4,75,,22.216,Percent of Total Billed Charges,75% of Total Billed Charges,18.93,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,18.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,18.93,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.5,70,,21.2,Percent of Total Billed Charges,70% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.86,100,,29.616,Percent of Total Billed Charges,100% of Total Billed Charges,5.3,195.49,
NS 3000ML IRR SOL,53255900,CDM,258,RC,,,Outpatient,,,61.31,36.79,,36.79,60,,29.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.17,28,,13.736,Percent of Total Billed Charges,28% of Total Billed Charges,195.84,32,,156.672,Percent of Total Billed Charges,32% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,22.07,36,,17.656,Percent of Total Billed Charges,36% of Total Billed Charges,22.07,36,,17.656,Percent of Total Billed Charges,36% Total Bille Charges,22.07,36,,17.656,Percent of Total Billed Charges,36% of Total Billed Charges,36.79,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.84,14.42,,7.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.98,75,,9.624,Percent of Total Billed Charges,75% of Total Billed Charges,30.66,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,30.66,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.66,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,30.66,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.92,70,,34.336,Percent of Total Billed Charges,70% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,8.58,14,,6.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.31,100,,12.832,Percent of Total Billed Charges,100% of Total Billed Charges,8.58,195.84,
WATER STERILE IRRIG 1000ML,53255950,CDM,250,RC,,,Outpatient,,,38.4,23.04,,23.04,60,,18.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.75,28,,8.6,Percent of Total Billed Charges,28% of Total Billed Charges,195.84,32,,156.672,Percent of Total Billed Charges,32% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% of Total Billed Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% Total Bille Charges,13.82,36,,11.056,Percent of Total Billed Charges,36% of Total Billed Charges,23.04,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.54,14.42,,4.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.8,75,,56.04,Percent of Total Billed Charges,75% of Total Billed Charges,19.2,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,19.2,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.2,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,19.2,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.88,70,,21.504,Percent of Total Billed Charges,70% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,5.38,14,,4.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.4,100,,74.72,Percent of Total Billed Charges,100% of Total Billed Charges,5.38,195.84,
WATER FOR IRRIG 3000ML BAG,53256000,CDM,250,RC,,,Outpatient,,,78.38,47.03,,47.03,60,,37.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.95,28,,17.56,Percent of Total Billed Charges,28% of Total Billed Charges,195.84,32,,156.672,Percent of Total Billed Charges,32% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,28.22,36,,22.576,Percent of Total Billed Charges,36% of Total Billed Charges,28.22,36,,22.576,Percent of Total Billed Charges,36% Total Bille Charges,28.22,36,,22.576,Percent of Total Billed Charges,36% of Total Billed Charges,47.03,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,11.3,14.42,,9.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.79,75,,68.904,Percent of Total Billed Charges,75% of Total Billed Charges,39.19,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,39.19,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.19,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,39.19,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.87,70,,43.896,Percent of Total Billed Charges,70% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,10.97,14,,8.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.38,100,,91.872,Percent of Total Billed Charges,100% of Total Billed Charges,10.97,195.84,
TYLENOL W/COD 10ML,53270104,CDM,250,RC,,,Outpatient,,,0.51,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,196.18,32,,156.944,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,75,,112.816,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,100,,150.416,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,196.18,
ACETAMIN/COD #3 TAB,53270195,CDM,250,RC,,,Outpatient,,,7.23,4.34,,4.34,60,,3.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,28,,1.616,Percent of Total Billed Charges,28% of Total Billed Charges,196.6,32,,157.28,Percent of Total Billed Charges,32% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% Total Bille Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,4.34,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,75,,271.992,Percent of Total Billed Charges,75% of Total Billed Charges,3.62,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,3.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,3.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.06,70,,4.048,Percent of Total Billed Charges,70% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.23,100,,362.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,196.6,
FIORICET TAB,53270369,CDM,250,RC,,,Outpatient,,,3.19,1.91,,1.91,60,,1.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,28,,0.712,Percent of Total Billed Charges,28% of Total Billed Charges,196.6,32,,157.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,36,,0.92,Percent of Total Billed Charges,36% of Total Billed Charges,1.15,36,,0.92,Percent of Total Billed Charges,36% Total Bille Charges,1.15,36,,0.92,Percent of Total Billed Charges,36% of Total Billed Charges,1.91,60,,58.608,Percent of Total Billed Charges,60% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.46,14.42,,0.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.39,75,,12.4,Percent of Total Billed Charges,75% of Total Billed Charges,1.6,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,1.6,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,1.6,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.23,70,,1.784,Percent of Total Billed Charges,70% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,100,,16.528,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,196.6,
ACETAM/BUT/CAFF CAP,53270370,CDM,250,RC,,,Outpatient,,,5.97,3.58,,3.58,60,,2.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,28,,1.336,Percent of Total Billed Charges,28% of Total Billed Charges,196.6,32,,157.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% Total Bille Charges,2.15,36,,1.72,Percent of Total Billed Charges,36% of Total Billed Charges,3.58,60,,412.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14.42,,0.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,75,,431.544,Percent of Total Billed Charges,75% of Total Billed Charges,2.99,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,2.99,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.99,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,2.99,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.18,70,,3.344,Percent of Total Billed Charges,70% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14,,0.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.97,100,,575.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.84,196.6,
DEXTROAMPHET. (ADDERALL)10MG,53271102,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,196.8,32,,157.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,275.4,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,367.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,196.8,
APAP/CAFF/BUTALBITAL TAB,53271649,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,197.12,32,,157.696,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,205.672,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,274.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,197.12,
COCAINE TOP SOL 4% 4ML,53273181,CDM,250,RC,,,Outpatient,,,819.9,491.94,,491.94,60,,393.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.57,28,,183.656,Percent of Total Billed Charges,28% of Total Billed Charges,197.26,32,,157.808,Percent of Total Billed Charges,32% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,295.16,36,,236.128,Percent of Total Billed Charges,36% of Total Billed Charges,295.16,36,,236.128,Percent of Total Billed Charges,36% Total Bille Charges,295.16,36,,236.128,Percent of Total Billed Charges,36% of Total Billed Charges,491.94,60,,463.488,Percent of Total Billed Charges,60% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.23,14.42,,94.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.93,75,,10.36,Percent of Total Billed Charges,75% of Total Billed Charges,409.95,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,409.95,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,409.95,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,409.95,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,573.93,70,,459.144,Percent of Total Billed Charges,70% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,114.79,14,,91.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,819.9,100,,13.808,Percent of Total Billed Charges,100% of Total Billed Charges,114.79,819.9,
CODEINE SULF 30MG TAB,53273686,CDM,250,RC,,,Outpatient,,,8.46,5.08,,5.08,60,,4.064,Percent of Total Billed Charges,60% of Total Billed Charges,3.81,45,,3.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.37,28,,1.896,Percent of Total Billed Charges,28% of Total Billed Charges,197.6,32,,158.08,Percent of Total Billed Charges,32% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% Total Bille Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,5.08,60,,497.488,Percent of Total Billed Charges,60% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.46,100,,6.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.35,75,,118.6,Percent of Total Billed Charges,75% of Total Billed Charges,4.23,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.23,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,70,,4.736,Percent of Total Billed Charges,70% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.46,100,,158.128,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,197.6,
DRONABINOL 2.5MG CAP,53274310,CDM,250,RC,,,Outpatient,,,10.61,6.37,,6.37,60,,5.096,Percent of Total Billed Charges,60% of Total Billed Charges,4.77,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,28,,2.376,Percent of Total Billed Charges,28% of Total Billed Charges,197.6,32,,158.08,Percent of Total Billed Charges,32% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% of Total Billed Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% Total Bille Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% of Total Billed Charges,6.37,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.61,100,,8.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.53,14.42,,1.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.96,75,,1023.76,Percent of Total Billed Charges,75% of Total Billed Charges,5.31,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.31,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.43,70,,5.944,Percent of Total Billed Charges,70% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,100,,1365.016,Percent of Total Billed Charges,100% of Total Billed Charges,1.49,197.6,
FENTANYL CIT 50MCG/ML INJ 2ML,53275012,CDM,250,RC,J3010,HCPCS,Outpatient,,,15.22,9.13,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.85,45,,5.48,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.13,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.22,100,,12.176,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.42,75,,1350,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,210.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,253.376,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,253.376,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,26.52,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.65,70,,8.52,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.22,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,15.22,
FENTANYL 12 MCG/HR PATCH,53275046,CDM,250,RC,,,Outpatient,,,43.6,26.16,,26.16,60,,20.928,Percent of Total Billed Charges,60% of Total Billed Charges,19.62,45,,15.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.21,28,,9.768,Percent of Total Billed Charges,28% of Total Billed Charges,197.6,32,,158.08,Percent of Total Billed Charges,32% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,15.7,36,,12.56,Percent of Total Billed Charges,36% of Total Billed Charges,15.7,36,,12.56,Percent of Total Billed Charges,36% Total Bille Charges,15.7,36,,12.56,Percent of Total Billed Charges,36% of Total Billed Charges,26.16,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.6,100,,34.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.29,14.42,,5.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,75,,36.56,Percent of Total Billed Charges,75% of Total Billed Charges,21.8,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.8,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.8,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,21.8,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.52,70,,24.416,Percent of Total Billed Charges,70% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.6,100,,48.744,Percent of Total Billed Charges,100% of Total Billed Charges,6.1,197.6,
FENTANYL CIT 50MCG/ML INJ 5ML,53275053,CDM,250,RC,J3010,HCPCS,Outpatient,,,16.3,9.78,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,80.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,73.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,253.376,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,354.976,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,354.976,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,36.744,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,97.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,16.3,
FENTANYL CIT 10MCG/ML PCA 30ML,53275061,CDM,250,RC,J3010,HCPCS,Outpatient,,,123,73.80,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,55.35,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.8,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123,100,,98.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.25,75,,36.56,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,23,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,354.976,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,354.976,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,22.656,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.1,70,,68.88,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123,100,,48.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,123,
FENTANYL CIT INJ 2500MCG/50ML,53275087,CDM,250,RC,J3010,HCPCS,Outpatient,,,136.37,81.82,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.37,45,,49.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.82,60,,405.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.37,100,,109.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.28,75,,168.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,354.976,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,216.672,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,216.672,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,23.128,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.46,70,,76.368,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.37,100,,225.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,136.37,
FENTANYL 25MCG/HR PATCH,53275103,CDM,250,RC,,,Outpatient,,,45.79,27.47,,27.47,60,,21.976,Percent of Total Billed Charges,60% of Total Billed Charges,20.61,45,,16.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.82,28,,10.256,Percent of Total Billed Charges,28% of Total Billed Charges,197.6,32,,158.08,Percent of Total Billed Charges,32% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,16.48,36,,13.184,Percent of Total Billed Charges,36% of Total Billed Charges,16.48,36,,13.184,Percent of Total Billed Charges,36% Total Bille Charges,16.48,36,,13.184,Percent of Total Billed Charges,36% of Total Billed Charges,27.47,60,,120.08,Percent of Total Billed Charges,60% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.79,100,,36.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.6,14.42,,5.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,75,,24.952,Percent of Total Billed Charges,75% of Total Billed Charges,22.9,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,22.9,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.9,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,22.9,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.05,70,,25.64,Percent of Total Billed Charges,70% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14,,5.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.79,100,,33.264,Percent of Total Billed Charges,100% of Total Billed Charges,6.41,197.6,
FENTANYL 50MCG/HR PATCH,53275111,CDM,250,RC,,,Outpatient,,,81.78,49.07,,49.07,60,,39.256,Percent of Total Billed Charges,60% of Total Billed Charges,36.8,45,,29.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.9,28,,18.32,Percent of Total Billed Charges,28% of Total Billed Charges,19.84,32,,15.872,Percent of Total Billed Charges,32% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,29.44,36,,23.552,Percent of Total Billed Charges,36% of Total Billed Charges,29.44,36,,23.552,Percent of Total Billed Charges,36% Total Bille Charges,29.44,36,,23.552,Percent of Total Billed Charges,36% of Total Billed Charges,49.07,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.78,100,,65.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.79,14.42,,9.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.34,75,,231.936,Percent of Total Billed Charges,75% of Total Billed Charges,40.89,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,40.89,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.89,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,40.89,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.25,70,,45.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,11.45,14,,9.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.78,100,,309.248,Percent of Total Billed Charges,100% of Total Billed Charges,11.45,81.78,
FENTANYL 75MCG/HR PATCH,53275129,CDM,250,RC,,,Outpatient,,,180.42,108.25,,108.25,60,,86.6,Percent of Total Billed Charges,60% of Total Billed Charges,81.19,45,,64.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.52,28,,40.416,Percent of Total Billed Charges,28% of Total Billed Charges,19.98,32,,15.984,Percent of Total Billed Charges,32% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,64.95,36,,51.96,Percent of Total Billed Charges,36% of Total Billed Charges,64.95,36,,51.96,Percent of Total Billed Charges,36% Total Bille Charges,64.95,36,,51.96,Percent of Total Billed Charges,36% of Total Billed Charges,108.25,60,,82.008,Percent of Total Billed Charges,60% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.42,100,,144.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,26.02,14.42,,20.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.32,75,,266.808,Percent of Total Billed Charges,75% of Total Billed Charges,90.21,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,90.21,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.21,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,90.21,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.29,70,,101.032,Percent of Total Billed Charges,70% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14,,20.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.42,100,,355.744,Percent of Total Billed Charges,100% of Total Billed Charges,19.98,180.42,
FENTANYL 100MCG/HR PATCH,53275137,CDM,250,RC,,,Outpatient,,,246.08,147.65,,147.65,60,,118.12,Percent of Total Billed Charges,60% of Total Billed Charges,110.74,45,,88.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.9,28,,55.12,Percent of Total Billed Charges,28% of Total Billed Charges,20.08,32,,16.064,Percent of Total Billed Charges,32% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,88.59,36,,70.872,Percent of Total Billed Charges,36% of Total Billed Charges,88.59,36,,70.872,Percent of Total Billed Charges,36% Total Bille Charges,88.59,36,,70.872,Percent of Total Billed Charges,36% of Total Billed Charges,147.65,60,,126.432,Percent of Total Billed Charges,60% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.08,100,,196.864,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,35.48,14.42,,28.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.56,75,,2.032,Percent of Total Billed Charges,75% of Total Billed Charges,123.04,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,123.04,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.04,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,123.04,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.26,70,,137.808,Percent of Total Billed Charges,70% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,34.45,14,,27.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.08,100,,2.704,Percent of Total Billed Charges,100% of Total Billed Charges,20.08,246.08,
TUSSIONEX SUS 5 ML UD,53275442,CDM,250,RC,,,Outpatient,,,6.18,3.71,,3.71,60,,2.968,Percent of Total Billed Charges,60% of Total Billed Charges,2.78,45,,2.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.73,28,,1.384,Percent of Total Billed Charges,28% of Total Billed Charges,198.81,32,,159.048,Percent of Total Billed Charges,32% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,2.22,36,,1.776,Percent of Total Billed Charges,36% of Total Billed Charges,2.22,36,,1.776,Percent of Total Billed Charges,36% Total Bille Charges,2.22,36,,1.776,Percent of Total Billed Charges,36% of Total Billed Charges,3.71,60,,111.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.18,100,,4.944,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14.42,,0.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,75,,39.96,Percent of Total Billed Charges,75% of Total Billed Charges,3.09,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,3.09,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.09,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,3.09,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.33,70,,3.464,Percent of Total Billed Charges,70% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.87,14,,0.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.18,100,,53.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,198.81,
HYDROCOD/HOM 5/1.5MG/5ML UD,53275517,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.35,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,199.2,32,,159.36,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,100,,2.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,257.232,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,342.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,199.2,
HYDROCODONE/APAP 5/325MG TAB,53275541,CDM,250,RC,,,Outpatient,,,8.49,5.09,,5.09,60,,4.072,Percent of Total Billed Charges,60% of Total Billed Charges,3.82,45,,3.056,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,28,,1.904,Percent of Total Billed Charges,28% of Total Billed Charges,199.28,32,,159.424,Percent of Total Billed Charges,32% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% Total Bille Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,5.09,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.49,100,,6.792,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,75,,41.536,Percent of Total Billed Charges,75% of Total Billed Charges,4.25,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.94,70,,4.752,Percent of Total Billed Charges,70% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,100,,55.376,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,199.28,
HYDROCOD/APAP 10/325MG TAB,53275657,CDM,250,RC,,,Outpatient,,,8.18,4.91,,4.91,60,,3.928,Percent of Total Billed Charges,60% of Total Billed Charges,3.68,45,,2.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.29,28,,1.832,Percent of Total Billed Charges,28% of Total Billed Charges,199.5,32,,159.6,Percent of Total Billed Charges,32% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,2.94,36,,2.352,Percent of Total Billed Charges,36% of Total Billed Charges,2.94,36,,2.352,Percent of Total Billed Charges,36% Total Bille Charges,2.94,36,,2.352,Percent of Total Billed Charges,36% of Total Billed Charges,4.91,60,,34.296,Percent of Total Billed Charges,60% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.18,100,,6.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,75,,53.136,Percent of Total Billed Charges,75% of Total Billed Charges,4.09,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,4.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.09,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.73,70,,4.584,Percent of Total Billed Charges,70% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.18,100,,70.848,Percent of Total Billed Charges,100% of Total Billed Charges,1.15,199.5,
HYDROCOD/APAP 7.5/325MG 15ML,53275660,CDM,250,RC,,,Outpatient,,,0.39,0.23,,0.23,60,,0.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,45,,0.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,28,,0.088,Percent of Total Billed Charges,28% of Total Billed Charges,199.68,32,,159.744,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% Total Bille Charges,0.14,36,,0.112,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,60,,87.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,0.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.29,75,,10.192,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,0.2,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,70,,0.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,100,,13.584,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,199.68,
HYDROCOD/APAP 7.5/325MG TAB,53275673,CDM,250,RC,,,Outpatient,,,9.26,5.56,,5.56,60,,4.448,Percent of Total Billed Charges,60% of Total Billed Charges,4.17,45,,3.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,28,,2.072,Percent of Total Billed Charges,28% of Total Billed Charges,199.86,32,,159.888,Percent of Total Billed Charges,32% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% of Total Billed Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% Total Bille Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% of Total Billed Charges,5.56,60,,135.008,Percent of Total Billed Charges,60% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.26,100,,7.408,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14.42,,1.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.95,75,,288.384,Percent of Total Billed Charges,75% of Total Billed Charges,4.63,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.63,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.63,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,4.63,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.48,70,,5.184,Percent of Total Billed Charges,70% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.26,100,,384.512,Percent of Total Billed Charges,100% of Total Billed Charges,1.3,199.86,
HYDROCOD/IBU 7.5/200MG TAB UD,53275814,CDM,250,RC,,,Outpatient,,,13.99,8.39,,8.39,60,,6.712,Percent of Total Billed Charges,60% of Total Billed Charges,6.3,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.92,28,,3.136,Percent of Total Billed Charges,28% of Total Billed Charges,200.12,32,,160.096,Percent of Total Billed Charges,32% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% of Total Billed Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% Total Bille Charges,5.04,36,,4.032,Percent of Total Billed Charges,36% of Total Billed Charges,8.39,60,,171.848,Percent of Total Billed Charges,60% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.99,100,,11.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,2.02,14.42,,1.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.49,75,,90.496,Percent of Total Billed Charges,75% of Total Billed Charges,7,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,7,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,7,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,70,,7.832,Percent of Total Billed Charges,70% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.96,14,,1.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.99,100,,120.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.96,200.12,
HYDROMORPH 10MG/ML INJ 5ML,53275855,CDM,250,RC,J1171,HCPCS,Outpatient,,,48.2,28.92,,28.92,60,,23.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,28.92,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.95,14.42,,5.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,75,,23.824,Percent of Total Billed Charges,75% of Total Billed Charges,24.1,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.1,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.74,70,,26.992,Percent of Total Billed Charges,70% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14,,5.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.2,100,,31.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,48.2,
HYDROMORPH 2MG/ML CPJ 1ML,53275863,CDM,250,RC,J1171,HCPCS,Outpatient,,,22.58,13.55,,13.55,60,,10.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.55,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.26,14.42,,2.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,75,,23.968,Percent of Total Billed Charges,75% of Total Billed Charges,11.29,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,11.29,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.29,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.29,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.81,70,,12.648,Percent of Total Billed Charges,70% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,3.16,14,,2.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.58,100,,31.952,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,22.58,
HYDROMORPH 2MG TAB UD,53275871,CDM,250,RC,,,Outpatient,,,7.12,4.27,,4.27,60,,3.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,28,,1.592,Percent of Total Billed Charges,28% of Total Billed Charges,200.66,32,,160.528,Percent of Total Billed Charges,32% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% Total Bille Charges,2.56,36,,2.048,Percent of Total Billed Charges,36% of Total Billed Charges,4.27,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14.42,,0.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,75,,31.936,Percent of Total Billed Charges,75% of Total Billed Charges,3.56,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.56,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.56,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,3.56,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.98,70,,3.984,Percent of Total Billed Charges,70% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.12,100,,42.576,Percent of Total Billed Charges,100% of Total Billed Charges,1,200.66,
HYDROMORPH 1MG/ML CPJ,53275889,CDM,250,RC,J1171,HCPCS,Outpatient,,,21.21,12.73,,12.73,60,,10.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.73,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,75,,310.288,Percent of Total Billed Charges,75% of Total Billed Charges,10.61,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.61,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,10.61,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.85,70,,11.88,Percent of Total Billed Charges,70% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.21,100,,413.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,21.21,
HYDROMORPH 1MG/ML PCA 30ML,53276051,CDM,250,RC,J1171,HCPCS,Outpatient,,,127.14,76.28,,76.28,60,,61.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.28,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14.42,,14.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.36,75,,342.648,Percent of Total Billed Charges,75% of Total Billed Charges,63.57,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,63.57,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.57,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,63.57,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89,70,,71.2,Percent of Total Billed Charges,70% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,17.8,14,,14.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.14,100,,456.864,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,127.14,
MEPERIDINE 25MG/1ML INJ,53276259,CDM,250,RC,J2175,HCPCS,Outpatient,,,41.7,25.02,,6.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.82,360,,,Fee Schedule,360% of BCBS POS Rate,1.82,360,,,Fee schedule,360% of BCBS PPO Rate,1.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.02,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.28,75,,193.24,Percent of Total Billed Charges,75% of Total Billed Charges,5.62,80,,2283.832,Fee Schedule,80% of Scott and White EPO fee schedule,5.62,80,,560,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,80,,560,Fee Schedule,80% of Scott and White PPO fee schedule,5.62,80,,275.376,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.19,70,,23.352,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.7,100,,257.648,Percent of Total Billed Charges,100% of Total Billed Charges,1.82,41.7,
MEPERIDINE 100MG/ML INJ 1ML,53276374,CDM,250,RC,J2175,HCPCS,Outpatient,,,41.94,25.16,,6.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.82,360,,,Fee Schedule,360% of BCBS POS Rate,1.82,360,,,Fee schedule,360% of BCBS PPO Rate,1.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.16,60,,159.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.46,75,,28.496,Percent of Total Billed Charges,75% of Total Billed Charges,5.62,80,,1276.36,Fee Schedule,80% of Scott and White EPO fee schedule,5.62,80,,512,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.62,80,,512,Fee Schedule,80% of Scott and White PPO fee schedule,5.62,80,,253.376,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.36,70,,23.488,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.94,100,,37.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.82,41.94,
MEPERIDINE 50MG TAB UD,53276416,CDM,250,RC,,,Outpatient,,,11.75,7.05,,7.05,60,,5.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.29,28,,2.632,Percent of Total Billed Charges,28% of Total Billed Charges,20448,32,,16358.4,Percent of Total Billed Charges,32% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% of Total Billed Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% Total Bille Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% of Total Billed Charges,7.05,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.81,75,,2.8,Percent of Total Billed Charges,75% of Total Billed Charges,5.88,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,5.88,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.88,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,5.88,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.23,70,,6.584,Percent of Total Billed Charges,70% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.75,100,,3.728,Percent of Total Billed Charges,100% of Total Billed Charges,1.65,20448,
METHADONE 5 MG/5ML OR SOL UD,53276614,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,20.22,32,,16.176,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,325.592,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,434.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,20.22,
NICU MORPHINE LIQ0.4MG/M,53276648,CDM,250,RC,J2270,HCPCS,Outpatient,,,3.9,2.34,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.34,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,14.896,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,800,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,368.912,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,368.912,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,253.376,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,100,,19.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,3.9,
METHADONE 5MG TAB,53276747,CDM,250,RC,,,Outpatient,,,8.68,5.21,,5.21,60,,4.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,28,,1.944,Percent of Total Billed Charges,28% of Total Billed Charges,20.22,32,,16.176,Percent of Total Billed Charges,32% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% of Total Billed Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% Total Bille Charges,3.12,36,,2.496,Percent of Total Billed Charges,36% of Total Billed Charges,5.21,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.25,14.42,,1,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.51,75,,90.16,Percent of Total Billed Charges,75% of Total Billed Charges,4.34,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.08,70,,4.864,Percent of Total Billed Charges,70% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14,,0.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,100,,120.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.22,20.22,
METHADONE 40 MG TAB FOR SUS,53276748,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,20.23,32,,16.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,0.544,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,0.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,20.23,
METHADONE 10MG TAB,53276750,CDM,250,RC,,,Outpatient,,,7.86,4.72,,4.72,60,,3.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,28,,1.76,Percent of Total Billed Charges,28% of Total Billed Charges,20.29,32,,16.232,Percent of Total Billed Charges,32% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,2.83,36,,2.264,Percent of Total Billed Charges,36% of Total Billed Charges,2.83,36,,2.264,Percent of Total Billed Charges,36% Total Bille Charges,2.83,36,,2.264,Percent of Total Billed Charges,36% of Total Billed Charges,4.72,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.13,14.42,,0.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.9,75,,102.304,Percent of Total Billed Charges,75% of Total Billed Charges,3.93,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.93,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.93,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,3.93,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.5,70,,4.4,Percent of Total Billed Charges,70% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14,,0.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.86,100,,136.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.1,20.29,
METHYLPHENIDATE 5MG TAB,53276965,CDM,250,RC,,,Outpatient,,,1.17,0.70,,0.7,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,201.6,32,,161.28,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,60,,102.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,75,,32.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,70,,0.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,100,,42.928,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,201.6,
MIDAZOLAM 10MG/5ML SYRUP UD,53277307,CDM,250,RC,,,Outpatient,,,8.15,4.89,,4.89,60,,3.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,28,,1.824,Percent of Total Billed Charges,28% of Total Billed Charges,201.6,32,,161.28,Percent of Total Billed Charges,32% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,36,,2.344,Percent of Total Billed Charges,36% of Total Billed Charges,2.93,36,,2.344,Percent of Total Billed Charges,36% Total Bille Charges,2.93,36,,2.344,Percent of Total Billed Charges,36% of Total Billed Charges,4.89,60,,1173.104,Percent of Total Billed Charges,60% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.11,75,,218.08,Percent of Total Billed Charges,75% of Total Billed Charges,4.08,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,4.08,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,4.08,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,70,,4.568,Percent of Total Billed Charges,70% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14,,0.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,100,,290.768,Percent of Total Billed Charges,100% of Total Billed Charges,1.14,201.6,
MORPHINE PF O.5M/1MG SYG,53277406,CDM,250,RC,J2274,HCPCS,Outpatient,,,58.15,34.89,,14.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,4.66,360,,,Fee Schedule,360% of BCBS POS Rate,4.66,360,,,Fee schedule,360% of BCBS PPO Rate,4.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.89,60,,115.32,Percent of Total Billed Charges,60% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.39,14.42,,6.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.61,75,,291.952,Percent of Total Billed Charges,75% of Total Billed Charges,13.36,80,,2994.688,Fee Schedule,80% of Scott and White EPO fee schedule,13.36,80,,179.512,Fee Schedule,80% of Scott and White HMO fee schedule,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.36,80,,179.512,Fee Schedule,80% of Scott and White PPO fee schedule,13.36,80,,866.672,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.71,70,,32.568,Percent of Total Billed Charges,70% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,8.14,14,,6.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.15,100,,389.264,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,58.15,
MORPHINE PF INJ 0.5MG/ML 10ML,53277414,CDM,250,RC,J2274,HCPCS,Outpatient,,,143.14,85.88,,14.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,4.66,360,,,Fee Schedule,360% of BCBS POS Rate,4.66,360,,,Fee schedule,360% of BCBS PPO Rate,4.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.88,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.64,14.42,,16.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,75,,251.296,Percent of Total Billed Charges,75% of Total Billed Charges,13.36,80,,43.84,Fee Schedule,80% of Scott and White EPO fee schedule,13.36,80,,152.8,Fee Schedule,80% of Scott and White HMO fee schedule,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.36,80,,152.8,Fee Schedule,80% of Scott and White PPO fee schedule,13.36,80,,866.672,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.2,70,,80.16,Percent of Total Billed Charges,70% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,20.04,14,,16.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.14,100,,335.064,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,143.14,
MORPHINE PF 1 MG/ML INJ 10 ML,53277430,CDM,250,RC,J2274,HCPCS,Outpatient,,,16.3,9.78,,14.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.66,360,,,Fee Schedule,360% of BCBS POS Rate,4.66,360,,,Fee schedule,360% of BCBS PPO Rate,4.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.78,60,,94.744,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,6.096,Percent of Total Billed Charges,75% of Total Billed Charges,13.36,80,,179.512,Fee Schedule,80% of Scott and White EPO fee schedule,13.36,80,,133.888,Fee Schedule,80% of Scott and White HMO fee schedule,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.36,80,,133.888,Fee Schedule,80% of Scott and White PPO fee schedule,13.36,80,,61.448,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,8.128,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,16.3,
MORPHINE PO CONC 20MG/1ML,53277554,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,201.79,32,,161.432,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,101.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,20.048,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,26.728,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,201.79,
MORPHINE 2MG/ML CPJ 1 ML,53277570,CDM,250,RC,J2270,HCPCS,Outpatient,,,21.91,13.15,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.15,60,,105.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.43,75,,485.456,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,133.888,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,26.992,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,26.992,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,15.68,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.34,70,,12.272,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.91,100,,647.272,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,21.91,
MORPHINE 4 MG INJ,53277612,CDM,250,RC,J2270,HCPCS,Outpatient,,,17.38,10.43,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,10.43,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,75,,23.592,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,225.552,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,1585.6,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,1585.6,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,17.36,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.17,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.38,100,,31.456,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,17.38,
MORPHINE 10MG/ML INJ 1ML,53277695,CDM,250,RC,J2270,HCPCS,Outpatient,,,17.38,10.43,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,10.43,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,75,,6.912,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,26.992,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,40.4,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,40.4,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,27.272,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.17,70,,9.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.38,100,,9.216,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,17.38,
MORPHINE SULF 15MG IR TAB,53277778,CDM,250,RC,,,Outpatient,,,8.48,5.09,,5.09,60,,4.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.37,28,,1.896,Percent of Total Billed Charges,28% of Total Billed Charges,204.44,32,,163.552,Percent of Total Billed Charges,32% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% Total Bille Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,5.09,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,75,,3.496,Percent of Total Billed Charges,75% of Total Billed Charges,4.24,50,,1585.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.24,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.24,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,4.24,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.94,70,,4.752,Percent of Total Billed Charges,70% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.48,100,,4.664,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,204.44,
OXYMORPHONE ER 5MG TAB,53277790,CDM,250,RC,,,Outpatient,,,18.02,10.81,,10.81,60,,8.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.05,28,,4.04,Percent of Total Billed Charges,28% of Total Billed Charges,204.67,32,,163.736,Percent of Total Billed Charges,32% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.49,36,,5.192,Percent of Total Billed Charges,36% of Total Billed Charges,6.49,36,,5.192,Percent of Total Billed Charges,36% Total Bille Charges,6.49,36,,5.192,Percent of Total Billed Charges,36% of Total Billed Charges,10.81,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.6,14.42,,2.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.52,75,,45.76,Percent of Total Billed Charges,75% of Total Billed Charges,9.01,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.01,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.01,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,9.01,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.61,70,,10.088,Percent of Total Billed Charges,70% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14,,2.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.02,100,,61.008,Percent of Total Billed Charges,100% of Total Billed Charges,2.52,204.67,
MORPHINE SR TAB 15MG,53277802,CDM,250,RC,,,Outpatient,,,11.07,6.64,,6.64,60,,5.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.1,28,,2.48,Percent of Total Billed Charges,28% of Total Billed Charges,20533.44,32,,16426.752,Percent of Total Billed Charges,32% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,3.99,36,,3.192,Percent of Total Billed Charges,36% of Total Billed Charges,3.99,36,,3.192,Percent of Total Billed Charges,36% Total Bille Charges,3.99,36,,3.192,Percent of Total Billed Charges,36% of Total Billed Charges,6.64,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.6,14.42,,1.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.3,75,,399.88,Percent of Total Billed Charges,75% of Total Billed Charges,5.54,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,5.54,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.54,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,5.54,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,70,,6.2,Percent of Total Billed Charges,70% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14,,1.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.07,100,,533.168,Percent of Total Billed Charges,100% of Total Billed Charges,1.55,20533.44,
MORPHINE SR TAB 30MG,53277828,CDM,250,RC,,,Outpatient,,,6.98,4.19,,4.19,60,,3.352,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,28,,1.56,Percent of Total Billed Charges,28% of Total Billed Charges,20676.8,32,,16541.44,Percent of Total Billed Charges,32% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% of Total Billed Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% Total Bille Charges,2.51,36,,2.008,Percent of Total Billed Charges,36% of Total Billed Charges,4.19,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14.42,,0.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.24,75,,22,Percent of Total Billed Charges,75% of Total Billed Charges,3.49,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,3.49,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.49,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,3.49,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.89,70,,3.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.98,100,,29.328,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,20676.8,
MORPHINE SULF 1MG/ML BTL 100ML,53277901,CDM,250,RC,J2270,HCPCS,Outpatient,,,60.42,36.25,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.25,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.32,75,,12.52,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,85.224,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,109,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,109,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,2423.2,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.29,70,,33.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.42,100,,16.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,60.42,
OPIUM BELLADONNA 30MG,53278024,CDM,250,RC,,,Outpatient,,,140.83,84.50,,84.5,60,,67.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.43,28,,31.544,Percent of Total Billed Charges,28% of Total Billed Charges,20676.8,32,,16541.44,Percent of Total Billed Charges,32% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,50.7,36,,40.56,Percent of Total Billed Charges,36% of Total Billed Charges,50.7,36,,40.56,Percent of Total Billed Charges,36% Total Bille Charges,50.7,36,,40.56,Percent of Total Billed Charges,36% of Total Billed Charges,84.5,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14.42,,16.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.62,75,,39.6,Percent of Total Billed Charges,75% of Total Billed Charges,70.42,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,70.42,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.42,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,70.42,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.58,70,,78.864,Percent of Total Billed Charges,70% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,19.72,14,,15.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.83,100,,52.8,Percent of Total Billed Charges,100% of Total Billed Charges,19.72,20676.8,
OPIUM BELLADONNA 60MG,53278065,CDM,250,RC,,,Outpatient,,,169.91,101.95,,101.95,60,,81.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.57,28,,38.056,Percent of Total Billed Charges,28% of Total Billed Charges,20.48,32,,16.384,Percent of Total Billed Charges,32% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,36,,48.936,Percent of Total Billed Charges,36% of Total Billed Charges,61.17,36,,48.936,Percent of Total Billed Charges,36% Total Bille Charges,61.17,36,,48.936,Percent of Total Billed Charges,36% of Total Billed Charges,101.95,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,24.5,14.42,,19.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.43,75,,16.944,Percent of Total Billed Charges,75% of Total Billed Charges,84.96,50,,109,Percent of Total Billed Charges,50% of Total Billed Charges,84.96,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.96,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,84.96,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.94,70,,95.152,Percent of Total Billed Charges,70% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,23.79,14,,19.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.91,100,,22.592,Percent of Total Billed Charges,100% of Total Billed Charges,20.48,169.91,
OXYCODONE/APAP 7.5/325 MG TAB,53278446,CDM,250,RC,,,Outpatient,,,16.17,9.70,,9.7,60,,7.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.53,28,,3.624,Percent of Total Billed Charges,28% of Total Billed Charges,20.58,32,,16.464,Percent of Total Billed Charges,32% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% of Total Billed Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% Total Bille Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% of Total Billed Charges,9.7,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.33,14.42,,1.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.13,75,,27.088,Percent of Total Billed Charges,75% of Total Billed Charges,8.09,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,8.09,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.09,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.32,70,,9.056,Percent of Total Billed Charges,70% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.17,100,,36.112,Percent of Total Billed Charges,100% of Total Billed Charges,2.26,20.58,
OXYCODONE/APAP 10/325 MG TAB,53278461,CDM,250,RC,,,Outpatient,,,11.81,7.09,,7.09,60,,5.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.31,28,,2.648,Percent of Total Billed Charges,28% of Total Billed Charges,20.58,32,,16.464,Percent of Total Billed Charges,32% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,4.25,36,,3.4,Percent of Total Billed Charges,36% of Total Billed Charges,4.25,36,,3.4,Percent of Total Billed Charges,36% Total Bille Charges,4.25,36,,3.4,Percent of Total Billed Charges,36% of Total Billed Charges,7.09,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14.42,,1.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.86,75,,26.536,Percent of Total Billed Charges,75% of Total Billed Charges,5.91,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,5.91,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.91,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.91,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.27,70,,6.616,Percent of Total Billed Charges,70% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.65,14,,1.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.81,100,,35.384,Percent of Total Billed Charges,100% of Total Billed Charges,1.65,20.58,
OXYCODONE/APAP 5/325MG TAB,53278479,CDM,250,RC,,,Outpatient,,,9.21,5.53,,5.53,60,,4.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.58,28,,2.064,Percent of Total Billed Charges,28% of Total Billed Charges,20.66,32,,16.528,Percent of Total Billed Charges,32% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% of Total Billed Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% Total Bille Charges,3.32,36,,2.656,Percent of Total Billed Charges,36% of Total Billed Charges,5.53,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14.42,,1.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.91,75,,26.536,Percent of Total Billed Charges,75% of Total Billed Charges,4.61,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.61,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.61,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.61,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.45,70,,5.16,Percent of Total Billed Charges,70% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.21,100,,35.384,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,20.66,
OXYCODONE 5MG TAB,53278552,CDM,250,RC,,,Outpatient,,,3.7,2.22,,2.22,60,,1.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,28,,0.832,Percent of Total Billed Charges,28% of Total Billed Charges,20.66,32,,16.528,Percent of Total Billed Charges,32% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% Total Bille Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,2.22,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,75,,89.992,Percent of Total Billed Charges,75% of Total Billed Charges,1.85,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,70,,2.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.7,100,,119.984,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,20.66,
OXYCODONE IR TAB 10MG,53278554,CDM,250,RC,,,Outpatient,,,10.14,6.08,,6.08,60,,4.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.84,28,,2.272,Percent of Total Billed Charges,28% of Total Billed Charges,20.72,32,,16.576,Percent of Total Billed Charges,32% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,3.65,36,,2.92,Percent of Total Billed Charges,36% of Total Billed Charges,3.65,36,,2.92,Percent of Total Billed Charges,36% Total Bille Charges,3.65,36,,2.92,Percent of Total Billed Charges,36% of Total Billed Charges,6.08,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.46,14.42,,1.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.61,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,5.07,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.07,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.07,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.07,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.1,70,,5.68,Percent of Total Billed Charges,70% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.14,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,20.72,
OXYCODONE 10MG CR TAB,53278578,CDM,250,RC,,,Outpatient,,,28.62,17.17,,17.17,60,,13.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.01,28,,6.408,Percent of Total Billed Charges,28% of Total Billed Charges,206.4,32,,165.12,Percent of Total Billed Charges,32% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,10.3,36,,8.24,Percent of Total Billed Charges,36% of Total Billed Charges,10.3,36,,8.24,Percent of Total Billed Charges,36% Total Bille Charges,10.3,36,,8.24,Percent of Total Billed Charges,36% of Total Billed Charges,17.17,60,,95.104,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.47,75,,11.712,Percent of Total Billed Charges,75% of Total Billed Charges,14.31,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,14.31,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.31,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.31,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.03,70,,16.024,Percent of Total Billed Charges,70% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.62,100,,15.616,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,206.4,
OXYCODONE 40MG CR TAB,53278594,CDM,250,RC,,,Outpatient,,,80.34,48.20,,48.2,60,,38.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.5,28,,18,Percent of Total Billed Charges,28% of Total Billed Charges,206.4,32,,165.12,Percent of Total Billed Charges,32% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,28.92,36,,23.136,Percent of Total Billed Charges,36% of Total Billed Charges,28.92,36,,23.136,Percent of Total Billed Charges,36% Total Bille Charges,28.92,36,,23.136,Percent of Total Billed Charges,36% of Total Billed Charges,48.2,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14.42,,9.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.26,75,,166.784,Percent of Total Billed Charges,75% of Total Billed Charges,40.17,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.17,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.17,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,40.17,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.24,70,,44.992,Percent of Total Billed Charges,70% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,11.25,14,,9,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.34,100,,222.376,Percent of Total Billed Charges,100% of Total Billed Charges,11.25,206.4,
MORPHINE 1MG/ML PCA 30ML,53278800,CDM,250,RC,J2274,HCPCS,Outpatient,,,168,100.80,,14.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,4.66,360,,,Fee Schedule,360% of BCBS POS Rate,4.66,360,,,Fee schedule,360% of BCBS PPO Rate,4.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,100.8,60,,55.576,Percent of Total Billed Charges,60% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.23,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,75,,25.232,Percent of Total Billed Charges,75% of Total Billed Charges,13.36,80,,133.6,Fee Schedule,80% of Scott and White EPO fee schedule,13.36,80,,56.712,Fee Schedule,80% of Scott and White HMO fee schedule,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.36,80,,56.712,Fee Schedule,80% of Scott and White PPO fee schedule,13.36,80,,494.496,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.6,70,,94.08,Percent of Total Billed Charges,70% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,100,,33.64,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,168,
PHENOBARBITAL 30MG TAB,53279352,CDM,250,RC,,,Outpatient,,,5.17,3.10,,3.1,60,,2.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.45,28,,1.16,Percent of Total Billed Charges,28% of Total Billed Charges,207,32,,165.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% of Total Billed Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% Total Bille Charges,1.86,36,,1.488,Percent of Total Billed Charges,36% of Total Billed Charges,3.1,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.88,75,,112.512,Percent of Total Billed Charges,75% of Total Billed Charges,2.59,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,2.59,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,2.59,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.62,70,,2.896,Percent of Total Billed Charges,70% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14,,0.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.17,100,,150.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,207,
PHENOBARBITAL 60MG TAB,53279394,CDM,250,RC,,,Outpatient,,,1.33,0.80,,0.8,60,,0.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,207,32,,165.6,Percent of Total Billed Charges,32% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% Total Bille Charges,0.48,36,,0.384,Percent of Total Billed Charges,36% of Total Billed Charges,0.8,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,75,,78.048,Percent of Total Billed Charges,75% of Total Billed Charges,0.67,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.93,70,,0.744,Percent of Total Billed Charges,70% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14,,0.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,100,,104.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,207,
PHENOBARBITAL 64.8 MG TAB,53279395,CDM,250,RC,,,Outpatient,,,5.06,3.04,,3.04,60,,2.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.42,28,,1.136,Percent of Total Billed Charges,28% of Total Billed Charges,207.36,32,,165.888,Percent of Total Billed Charges,32% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% Total Bille Charges,1.82,36,,1.456,Percent of Total Billed Charges,36% of Total Billed Charges,3.04,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14.42,,0.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,75,,182.944,Percent of Total Billed Charges,75% of Total Billed Charges,2.53,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,2.53,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.53,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,2.53,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.54,70,,2.832,Percent of Total Billed Charges,70% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,0.71,14,,0.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.06,100,,243.928,Percent of Total Billed Charges,100% of Total Billed Charges,0.71,207.36,
PHENOBARBITAL 100MG TAB,53279436,CDM,250,RC,,,Outpatient,,,7.14,4.28,,4.28,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,28,,1.6,Percent of Total Billed Charges,28% of Total Billed Charges,207.71,32,,166.168,Percent of Total Billed Charges,32% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,36,,2.056,Percent of Total Billed Charges,36% of Total Billed Charges,2.57,36,,2.056,Percent of Total Billed Charges,36% Total Bille Charges,2.57,36,,2.056,Percent of Total Billed Charges,36% of Total Billed Charges,4.28,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14.42,,0.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.36,75,,25.504,Percent of Total Billed Charges,75% of Total Billed Charges,3.57,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,3.57,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.57,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,3.57,50,,179.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,70,,4,Percent of Total Billed Charges,70% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,1,14,,0.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,100,,34,Percent of Total Billed Charges,100% of Total Billed Charges,1,207.71,
PHENOBARBITAL 30MG/7.5ML UD,53279477,CDM,250,RC,,,Outpatient,,,3,1.80,,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,28,,0.672,Percent of Total Billed Charges,28% of Total Billed Charges,207.99,32,,166.392,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% Total Bille Charges,1.08,36,,0.864,Percent of Total Billed Charges,36% of Total Billed Charges,1.8,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14.42,,0.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,75,,28.12,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.1,70,,1.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,100,,37.488,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,207.99,
REMIFENTANIL 1MG/3ML VL 3ML,53279600,CDM,250,RC,,,Outpatient,,,300,180.00,,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,20.8,32,,16.64,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,0.704,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,0.936,Percent of Total Billed Charges,100% of Total Billed Charges,20.8,300,
SUFENTANIL 50MCG/ML AMP 2ML,53279931,CDM,250,RC,,,Outpatient,,,53.72,32.23,,32.23,60,,25.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.04,28,,12.032,Percent of Total Billed Charges,28% of Total Billed Charges,20.93,32,,16.744,Percent of Total Billed Charges,32% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,19.34,36,,15.472,Percent of Total Billed Charges,36% of Total Billed Charges,19.34,36,,15.472,Percent of Total Billed Charges,36% Total Bille Charges,19.34,36,,15.472,Percent of Total Billed Charges,36% of Total Billed Charges,32.23,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.75,14.42,,6.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.29,75,,7.656,Percent of Total Billed Charges,75% of Total Billed Charges,26.86,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,26.86,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.86,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,26.86,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.6,70,,30.08,Percent of Total Billed Charges,70% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,7.52,14,,6.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.72,100,,10.208,Percent of Total Billed Charges,100% of Total Billed Charges,7.52,53.72,
AMPICILLIN 2GM/100ML NS PREMIX,53280038,CDM,250,RC,J0290,HCPCS,Outpatient,,,181.44,108.86,,0.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.4,360,,,Fee Schedule,360% of BCBS POS Rate,2.4,360,,,Fee schedule,360% of BCBS PPO Rate,2.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,108.86,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.08,75,,4.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.74,80,,65.976,Fee Schedule,80% of Scott and White EPO fee schedule,0.74,80,,212,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,80,,212,Fee Schedule,80% of Scott and White PPO fee schedule,0.74,80,,26.992,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.01,70,,101.608,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.44,100,,5.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.72,181.44,
MICAFUNGIN 100 MG VL,53280160,CDM,250,RC,J2248,HCPCS,Outpatient,,,846.5,507.90,,0.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.87,360,,,Fee Schedule,360% of BCBS POS Rate,1.87,360,,,Fee schedule,360% of BCBS PPO Rate,1.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,507.9,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,634.88,75,,4.672,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,147.176,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,186,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,186,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,1585.6,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,592.55,70,,474.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,846.5,100,,6.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,846.5,
MICAFUNGIN 50MG VL,53280178,CDM,250,RC,J2248,HCPCS,Outpatient,,,425.75,255.45,,0.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.87,360,,,Fee Schedule,360% of BCBS POS Rate,1.87,360,,,Fee schedule,360% of BCBS PPO Rate,1.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,255.45,60,,171.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.31,75,,4.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,212,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,106.312,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,106.312,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,40.4,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.03,70,,238.424,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.75,100,,6.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,425.75,
PENICIL G POT 5M UN VL,53280202,CDM,250,RC,J2540,HCPCS,Outpatient,,,80.95,48.57,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.48,360,,,Fee Schedule,360% of BCBS POS Rate,1.48,360,,,Fee schedule,360% of BCBS PPO Rate,1.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.57,60,,171.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.71,75,,4.632,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,80,,186,Fee Schedule,80% of Scott and White EPO fee schedule,0.6,80,,71.056,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,80,,71.056,Fee Schedule,80% of Scott and White PPO fee schedule,0.6,80,,39,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.67,70,,45.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.95,100,,6.176,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,80.95,
PENTAMIDINE 300MG INH SOL 15ML,53280210,CDM,250,RC,,,Outpatient,,,756.01,453.61,,453.61,60,,362.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.68,28,,169.344,Percent of Total Billed Charges,28% of Total Billed Charges,21,32,,16.8,Percent of Total Billed Charges,32% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% Total Bille Charges,272.16,36,,217.728,Percent of Total Billed Charges,36% of Total Billed Charges,453.61,60,,166.784,Percent of Total Billed Charges,60% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,109.02,14.42,,87.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,567.01,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,378.01,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,378.01,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378.01,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,378.01,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,529.21,70,,423.368,Percent of Total Billed Charges,70% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,105.84,14,,84.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,756.01,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,21,756.01,
VANCOMYCIN 500MG VL,53280269,CDM,250,RC,J3370,HCPCS,Outpatient,,,63.85,38.31,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.31,60,,166.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.89,75,,39,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,71.056,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,152.8,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,152.8,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,85.224,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.7,70,,35.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.85,100,,52,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,63.85,
PIPERACIL/TAZOBAC 2.25GM ADV,53280277,CDM,250,RC,J2543,HCPCS,Outpatient,,,57.02,34.21,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.21,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.77,75,,100.192,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,98.112,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,225.552,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,225.552,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,220,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.91,70,,31.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.02,100,,133.584,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,57.02,
PIPERACIL/TAZOBAC 4.5GM ADV,53280285,CDM,250,RC,J2543,HCPCS,Outpatient,,,99.08,59.45,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,59.45,60,,244.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.31,75,,106.656,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,152.8,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,89.2,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,89.2,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,109,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.36,70,,55.488,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.08,100,,142.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,99.08,
NEO FERROUS SUL ORAL15MG/ML1ML,53281051,CDM,250,RC,,,Outpatient,,,1.07,0.64,,0.64,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,21.08,32,,16.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,75,,31.336,Percent of Total Billed Charges,75% of Total Billed Charges,0.54,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,70,,0.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,100,,41.776,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,21.08,
MINERAL OIL 30ML,53300026,CDM,250,RC,,,Outpatient,,,1.99,1.19,,1.19,60,,0.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,28,,0.448,Percent of Total Billed Charges,28% of Total Billed Charges,208.73,32,,166.984,Percent of Total Billed Charges,32% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% Total Bille Charges,0.72,36,,0.576,Percent of Total Billed Charges,36% of Total Billed Charges,1.19,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,14.42,,0.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,75,,112.512,Percent of Total Billed Charges,75% of Total Billed Charges,1,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,1,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,1,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.39,70,,1.112,Percent of Total Billed Charges,70% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14,,0.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,100,,150.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,208.73,
ACETIC ACID 5% TOP SOL 500ML,53300168,CDM,250,RC,,,Outpatient,,,102,61.20,,61.2,60,,48.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.56,28,,22.848,Percent of Total Billed Charges,28% of Total Billed Charges,210.04,32,,168.032,Percent of Total Billed Charges,32% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,36.72,36,,29.376,Percent of Total Billed Charges,36% of Total Billed Charges,36.72,36,,29.376,Percent of Total Billed Charges,36% Total Bille Charges,36.72,36,,29.376,Percent of Total Billed Charges,36% of Total Billed Charges,61.2,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.71,14.42,,11.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,75,,122.824,Percent of Total Billed Charges,75% of Total Billed Charges,51,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,51,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,51,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.4,70,,57.12,Percent of Total Billed Charges,70% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,14.28,14,,11.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102,100,,163.76,Percent of Total Billed Charges,100% of Total Billed Charges,14.28,210.04,
ACETYLCHOLINE 1% OPHT SOL 2ML,53300448,CDM,250,RC,,,Outpatient,,,188.38,113.03,,113.03,60,,90.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.75,28,,42.2,Percent of Total Billed Charges,28% of Total Billed Charges,210.52,32,,168.416,Percent of Total Billed Charges,32% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,67.82,36,,54.256,Percent of Total Billed Charges,36% of Total Billed Charges,67.82,36,,54.256,Percent of Total Billed Charges,36% Total Bille Charges,67.82,36,,54.256,Percent of Total Billed Charges,36% of Total Billed Charges,113.03,60,,1288.84,Percent of Total Billed Charges,60% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,27.16,14.42,,21.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.29,75,,1099.008,Percent of Total Billed Charges,75% of Total Billed Charges,94.19,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,94.19,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.19,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,94.19,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.87,70,,105.496,Percent of Total Billed Charges,70% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,26.37,14,,21.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.38,100,,1465.344,Percent of Total Billed Charges,100% of Total Billed Charges,26.37,210.52,
ACETYLCYSTEINE 10% SOL 4ML,53300653,CDM,250,RC,,,Outpatient,,,74.88,44.93,,44.93,60,,35.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.97,28,,16.776,Percent of Total Billed Charges,28% of Total Billed Charges,210.52,32,,168.416,Percent of Total Billed Charges,32% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,26.96,36,,21.568,Percent of Total Billed Charges,36% of Total Billed Charges,26.96,36,,21.568,Percent of Total Billed Charges,36% Total Bille Charges,26.96,36,,21.568,Percent of Total Billed Charges,36% of Total Billed Charges,44.93,60,,79.168,Percent of Total Billed Charges,60% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.8,14.42,,8.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.16,75,,0.08,Percent of Total Billed Charges,75% of Total Billed Charges,37.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,37.44,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.44,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.44,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.42,70,,41.936,Percent of Total Billed Charges,70% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,14,,8.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.88,100,,0.104,Percent of Total Billed Charges,100% of Total Billed Charges,10.48,210.52,
ACETYLCYSTEINE 20% SOL 4ML,53300794,CDM,250,RC,,,Outpatient,,,89.77,53.86,,53.86,60,,43.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.14,28,,20.112,Percent of Total Billed Charges,28% of Total Billed Charges,210.52,32,,168.416,Percent of Total Billed Charges,32% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.32,36,,25.856,Percent of Total Billed Charges,36% of Total Billed Charges,32.32,36,,25.856,Percent of Total Billed Charges,36% Total Bille Charges,32.32,36,,25.856,Percent of Total Billed Charges,36% of Total Billed Charges,53.86,60,,123.552,Percent of Total Billed Charges,60% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.94,14.42,,10.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.33,75,,66.376,Percent of Total Billed Charges,75% of Total Billed Charges,44.89,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,44.89,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.89,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,44.89,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.84,70,,50.272,Percent of Total Billed Charges,70% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.77,100,,88.496,Percent of Total Billed Charges,100% of Total Billed Charges,12.57,210.52,
ACETYLCYSTEINE 20% SOL 10ML,53300869,CDM,250,RC,,,Outpatient,,,88.92,53.35,,53.35,60,,42.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.9,28,,19.92,Percent of Total Billed Charges,28% of Total Billed Charges,210.76,32,,168.608,Percent of Total Billed Charges,32% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,32.01,36,,25.608,Percent of Total Billed Charges,36% of Total Billed Charges,32.01,36,,25.608,Percent of Total Billed Charges,36% Total Bille Charges,32.01,36,,25.608,Percent of Total Billed Charges,36% of Total Billed Charges,53.35,60,,184.56,Percent of Total Billed Charges,60% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.82,14.42,,10.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.69,75,,132.64,Percent of Total Billed Charges,75% of Total Billed Charges,44.46,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,44.46,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.46,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,44.46,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.24,70,,49.792,Percent of Total Billed Charges,70% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,12.45,14,,9.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.92,100,,176.848,Percent of Total Billed Charges,100% of Total Billed Charges,12.45,210.76,
ACETYLCYSTEINE 20%SOL 30ML,53300935,CDM,250,RC,,,Outpatient,,,152.52,91.51,,91.51,60,,73.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.71,28,,34.168,Percent of Total Billed Charges,28% of Total Billed Charges,210.89,32,,168.712,Percent of Total Billed Charges,32% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,54.91,36,,43.928,Percent of Total Billed Charges,36% of Total Billed Charges,54.91,36,,43.928,Percent of Total Billed Charges,36% Total Bille Charges,54.91,36,,43.928,Percent of Total Billed Charges,36% of Total Billed Charges,91.51,60,,176.608,Percent of Total Billed Charges,60% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.99,14.42,,17.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.39,75,,157.936,Percent of Total Billed Charges,75% of Total Billed Charges,76.26,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,76.26,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.26,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,76.26,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.76,70,,85.408,Percent of Total Billed Charges,70% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.52,100,,210.576,Percent of Total Billed Charges,100% of Total Billed Charges,21.35,210.89,
ALBUTEROL 90 MCG INH 8.5 GM,53301115,CDM,250,RC,,,Outpatient,,,160.46,96.28,,96.28,60,,77.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.93,28,,35.944,Percent of Total Billed Charges,28% of Total Billed Charges,210.89,32,,168.712,Percent of Total Billed Charges,32% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% Total Bille Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,96.28,60,,118.256,Percent of Total Billed Charges,60% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14.42,,18.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.35,75,,354.36,Percent of Total Billed Charges,75% of Total Billed Charges,80.23,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,80.23,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,80.23,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.32,70,,89.856,Percent of Total Billed Charges,70% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.46,100,,472.48,Percent of Total Billed Charges,100% of Total Billed Charges,22.46,210.89,
ALBUTEROL 90 MCG INH 8.5 GM,53301131,CDM,250,RC,,,Outpatient,,,160.46,96.28,,96.28,60,,77.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.93,28,,35.944,Percent of Total Billed Charges,28% of Total Billed Charges,210.89,32,,168.712,Percent of Total Billed Charges,32% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% Total Bille Charges,57.77,36,,46.216,Percent of Total Billed Charges,36% of Total Billed Charges,96.28,60,,93.592,Percent of Total Billed Charges,60% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,23.14,14.42,,18.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.35,75,,416.872,Percent of Total Billed Charges,75% of Total Billed Charges,80.23,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,80.23,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.23,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,80.23,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.32,70,,89.856,Percent of Total Billed Charges,70% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,22.46,14,,17.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.46,100,,555.832,Percent of Total Billed Charges,100% of Total Billed Charges,22.46,210.89,
ALBUTEROL INH 17 GM,53301149,CDM,250,RC,,,Outpatient,,,108.5,65.10,,65.1,60,,52.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.38,28,,24.304,Percent of Total Billed Charges,28% of Total Billed Charges,210.89,32,,168.712,Percent of Total Billed Charges,32% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,39.06,36,,31.248,Percent of Total Billed Charges,36% of Total Billed Charges,39.06,36,,31.248,Percent of Total Billed Charges,36% Total Bille Charges,39.06,36,,31.248,Percent of Total Billed Charges,36% of Total Billed Charges,65.1,60,,66.016,Percent of Total Billed Charges,60% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.65,14.42,,12.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.38,75,,7.648,Percent of Total Billed Charges,75% of Total Billed Charges,54.25,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,54.25,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.25,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,54.25,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.95,70,,60.76,Percent of Total Billed Charges,70% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.5,100,,10.2,Percent of Total Billed Charges,100% of Total Billed Charges,15.19,210.89,
ALBUTEROL 0.083% INH SOLN 3ML,53301164,CDM,250,RC,J7613,HCPCS,Outpatient,,,5.63,3.38,,0.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,3.38,60,,743.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.22,75,,10.48,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,80,,116.04,Fee Schedule,80% of Scott and White EPO fee schedule,0.02,80,,8.496,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,80,,8.496,Fee Schedule,80% of Scott and White PPO fee schedule,0.02,80,,225.552,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,70,,3.152,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.63,100,,13.968,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,5.63,
ALBUTEROL 1.25 MG/3 ML INH SOL,53301165,CDM,250,RC,J7613,HCPCS,Outpatient,,,13.96,8.38,,0.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.08,360,,,Fee Schedule,360% of BCBS POS Rate,0.08,360,,,Fee schedule,360% of BCBS PPO Rate,0.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,8.38,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.47,75,,3.216,Percent of Total Billed Charges,75% of Total Billed Charges,0.02,80,,133.888,Fee Schedule,80% of Scott and White EPO fee schedule,0.02,80,,10.552,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,80,,10.552,Fee Schedule,80% of Scott and White PPO fee schedule,0.02,80,,83.352,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.77,70,,7.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.96,100,,4.288,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,13.96,
ALBUTEROL/IPRATROP INH SOL 3ML,53301230,CDM,250,RC,,,Outpatient,,,7,4.20,,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,28,,1.568,Percent of Total Billed Charges,28% of Total Billed Charges,210.89,32,,168.712,Percent of Total Billed Charges,32% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% Total Bille Charges,2.52,36,,2.016,Percent of Total Billed Charges,36% of Total Billed Charges,4.2,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14.42,,0.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,75,,10.48,Percent of Total Billed Charges,75% of Total Billed Charges,3.5,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,3.5,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.5,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,3.5,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,70,,3.92,Percent of Total Billed Charges,70% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14,,0.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,100,,13.976,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,210.89,
ALBUTEROL 0.5% INH SOL 0.5 ML,53301255,CDM,250,RC,,,Outpatient,,,7.39,4.43,,4.43,60,,3.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.07,28,,1.656,Percent of Total Billed Charges,28% of Total Billed Charges,211.1,32,,168.88,Percent of Total Billed Charges,32% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.66,36,,2.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.66,36,,2.128,Percent of Total Billed Charges,36% Total Bille Charges,2.66,36,,2.128,Percent of Total Billed Charges,36% of Total Billed Charges,4.43,60,,254.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14.42,,0.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.54,75,,29.736,Percent of Total Billed Charges,75% of Total Billed Charges,3.7,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,3.7,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.7,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,3.7,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.17,70,,4.136,Percent of Total Billed Charges,70% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,1.03,14,,0.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.39,100,,39.648,Percent of Total Billed Charges,100% of Total Billed Charges,1.03,211.1,
AMMONIA INH AMPS 0.33ML,53302196,CDM,250,RC,,,Outpatient,,,1.07,0.64,,0.64,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,28,,0.24,Percent of Total Billed Charges,28% of Total Billed Charges,21209.76,32,,16967.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% Total Bille Charges,0.39,36,,0.312,Percent of Total Billed Charges,36% of Total Billed Charges,0.64,60,,189.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14.42,,0.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,75,,43.92,Percent of Total Billed Charges,75% of Total Billed Charges,0.54,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,70,,0.6,Percent of Total Billed Charges,70% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,0.15,14,,0.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,100,,58.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.15,21209.76,
ARTIFICIAL TEARS SOL 15ML,53302428,CDM,250,RC,,,Outpatient,,,62.44,37.46,,37.46,60,,29.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.48,28,,13.984,Percent of Total Billed Charges,28% of Total Billed Charges,21.12,32,,16.896,Percent of Total Billed Charges,32% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.48,36,,17.984,Percent of Total Billed Charges,36% of Total Billed Charges,22.48,36,,17.984,Percent of Total Billed Charges,36% Total Bille Charges,22.48,36,,17.984,Percent of Total Billed Charges,36% of Total Billed Charges,37.46,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,9,14.42,,7.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.83,75,,252,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,31.22,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.22,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,31.22,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.71,70,,34.968,Percent of Total Billed Charges,70% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14,,6.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.44,100,,336,Percent of Total Billed Charges,100% of Total Billed Charges,8.74,62.44,
SOD CHLOR OPHT SOL 2% 15ML,53302430,CDM,250,RC,,,Outpatient,,,37.02,22.21,,22.21,60,,17.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.37,28,,8.296,Percent of Total Billed Charges,28% of Total Billed Charges,21.12,32,,16.896,Percent of Total Billed Charges,32% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,13.33,36,,10.664,Percent of Total Billed Charges,36% of Total Billed Charges,13.33,36,,10.664,Percent of Total Billed Charges,36% Total Bille Charges,13.33,36,,10.664,Percent of Total Billed Charges,36% of Total Billed Charges,22.21,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14.42,,4.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.77,75,,37.912,Percent of Total Billed Charges,75% of Total Billed Charges,18.51,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,18.51,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.51,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,18.51,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.91,70,,20.728,Percent of Total Billed Charges,70% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,5.18,14,,4.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.02,100,,50.544,Percent of Total Billed Charges,100% of Total Billed Charges,5.18,37.02,
HYPOTEARS 1% SOL 15ML,53302444,CDM,250,RC,,,Outpatient,,,16.04,9.62,,9.62,60,,7.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,28,,3.592,Percent of Total Billed Charges,28% of Total Billed Charges,21.2,32,,16.96,Percent of Total Billed Charges,32% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% Total Bille Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,9.62,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.31,14.42,,1.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.03,75,,37.912,Percent of Total Billed Charges,75% of Total Billed Charges,8.02,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,8.02,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.02,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,8.02,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.23,70,,8.984,Percent of Total Billed Charges,70% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,2.25,14,,1.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.04,100,,50.544,Percent of Total Billed Charges,100% of Total Billed Charges,2.25,21.2,
ATROPINE 1% OPHT SOL 5 ML,53302824,CDM,250,RC,,,Outpatient,,,93.4,56.04,,56.04,60,,44.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.15,28,,20.92,Percent of Total Billed Charges,28% of Total Billed Charges,21.25,32,,17,Percent of Total Billed Charges,32% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,33.62,36,,26.896,Percent of Total Billed Charges,36% of Total Billed Charges,33.62,36,,26.896,Percent of Total Billed Charges,36% Total Bille Charges,33.62,36,,26.896,Percent of Total Billed Charges,36% of Total Billed Charges,56.04,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.47,14.42,,10.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.05,75,,29.88,Percent of Total Billed Charges,75% of Total Billed Charges,46.7,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,46.7,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.7,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,46.7,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.38,70,,52.304,Percent of Total Billed Charges,70% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,13.08,14,,10.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.4,100,,39.84,Percent of Total Billed Charges,100% of Total Billed Charges,13.08,93.4,
AZELASTINE NSL SPY 17ML,53303343,CDM,250,RC,,,Outpatient,,,114.84,68.90,,68.9,60,,55.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.16,28,,25.728,Percent of Total Billed Charges,28% of Total Billed Charges,21.31,32,,17.048,Percent of Total Billed Charges,32% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,41.34,36,,33.072,Percent of Total Billed Charges,36% of Total Billed Charges,41.34,36,,33.072,Percent of Total Billed Charges,36% Total Bille Charges,41.34,36,,33.072,Percent of Total Billed Charges,36% of Total Billed Charges,68.9,60,,1248,Percent of Total Billed Charges,60% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.56,14.42,,13.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.13,75,,4.536,Percent of Total Billed Charges,75% of Total Billed Charges,57.42,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,57.42,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.42,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,57.42,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.39,70,,64.312,Percent of Total Billed Charges,70% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14,,12.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.84,100,,6.048,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,114.84,
BACITRACIN OPHT OINT 3.5GM,53303517,CDM,250,RC,,,Outpatient,,,188.02,112.81,,112.81,60,,90.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.65,28,,42.12,Percent of Total Billed Charges,28% of Total Billed Charges,21.38,32,,17.104,Percent of Total Billed Charges,32% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,67.69,36,,54.152,Percent of Total Billed Charges,36% of Total Billed Charges,67.69,36,,54.152,Percent of Total Billed Charges,36% Total Bille Charges,67.69,36,,54.152,Percent of Total Billed Charges,36% of Total Billed Charges,112.81,60,,51.168,Percent of Total Billed Charges,60% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,27.11,14.42,,21.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.02,75,,8.448,Percent of Total Billed Charges,75% of Total Billed Charges,94.01,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,94.01,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.01,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,94.01,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.61,70,,105.288,Percent of Total Billed Charges,70% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,14,,21.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,188.02,100,,11.264,Percent of Total Billed Charges,100% of Total Billed Charges,21.38,188.02,
BECLOMETH 80MCG/INH MDI 8.7GM,53303740,CDM,250,RC,,,Outpatient,,,453.32,271.99,,271.99,60,,217.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.93,28,,101.544,Percent of Total Billed Charges,28% of Total Billed Charges,211.2,32,,168.96,Percent of Total Billed Charges,32% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,163.2,36,,130.56,Percent of Total Billed Charges,36% of Total Billed Charges,163.2,36,,130.56,Percent of Total Billed Charges,36% Total Bille Charges,163.2,36,,130.56,Percent of Total Billed Charges,36% of Total Billed Charges,271.99,60,,54.032,Percent of Total Billed Charges,60% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,65.37,14.42,,52.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339.99,75,,19.504,Percent of Total Billed Charges,75% of Total Billed Charges,226.66,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,226.66,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.66,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,226.66,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.32,70,,253.856,Percent of Total Billed Charges,70% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,63.46,14,,50.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,453.32,100,,26,Percent of Total Billed Charges,100% of Total Billed Charges,63.46,453.32,
BENZOCAINE/ANTIPYRINE OTIC SOL,53304010,CDM,250,RC,,,Outpatient,,,20.66,12.40,,12.4,60,,9.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.78,28,,4.624,Percent of Total Billed Charges,28% of Total Billed Charges,211.2,32,,168.96,Percent of Total Billed Charges,32% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,7.44,36,,5.952,Percent of Total Billed Charges,36% of Total Billed Charges,7.44,36,,5.952,Percent of Total Billed Charges,36% Total Bille Charges,7.44,36,,5.952,Percent of Total Billed Charges,36% of Total Billed Charges,12.4,60,,44.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.98,14.42,,2.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,75,,257.232,Percent of Total Billed Charges,75% of Total Billed Charges,10.33,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,10.33,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.33,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,10.33,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.46,70,,11.568,Percent of Total Billed Charges,70% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,2.89,14,,2.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.66,100,,342.976,Percent of Total Billed Charges,100% of Total Billed Charges,2.89,211.2,
BIMATOPROST 0.01% OP SOL 5ML,53304184,CDM,250,RC,,,Outpatient,,,719.24,431.54,,431.54,60,,345.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.39,28,,161.112,Percent of Total Billed Charges,28% of Total Billed Charges,211.39,32,,169.112,Percent of Total Billed Charges,32% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,258.93,36,,207.144,Percent of Total Billed Charges,36% of Total Billed Charges,258.93,36,,207.144,Percent of Total Billed Charges,36% Total Bille Charges,258.93,36,,207.144,Percent of Total Billed Charges,36% of Total Billed Charges,431.54,60,,87.752,Percent of Total Billed Charges,60% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,103.71,14.42,,82.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,539.43,75,,258.352,Percent of Total Billed Charges,75% of Total Billed Charges,359.62,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,359.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.62,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,359.62,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,503.47,70,,402.776,Percent of Total Billed Charges,70% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,100.69,14,,80.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,719.24,100,,344.464,Percent of Total Billed Charges,100% of Total Billed Charges,100.69,719.24,
BUDESONIDE 180MCG/USE INH,53304275,CDM,250,RC,,,Outpatient,,,459,275.40,,275.4,60,,220.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.52,28,,102.816,Percent of Total Billed Charges,28% of Total Billed Charges,211.93,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,165.24,36,,132.192,Percent of Total Billed Charges,36% of Total Billed Charges,165.24,36,,132.192,Percent of Total Billed Charges,36% Total Bille Charges,165.24,36,,132.192,Percent of Total Billed Charges,36% of Total Billed Charges,275.4,60,,51.856,Percent of Total Billed Charges,60% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,66.19,14.42,,52.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.25,75,,41.632,Percent of Total Billed Charges,75% of Total Billed Charges,229.5,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,229.5,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,229.5,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,229.5,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.3,70,,257.04,Percent of Total Billed Charges,70% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,64.26,14,,51.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,459,100,,55.512,Percent of Total Billed Charges,100% of Total Billed Charges,64.26,459,
BUDESONIDE 90 MCG/USE INH,53304283,CDM,250,RC,,,Outpatient,,,342.78,205.67,,205.67,60,,164.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.98,28,,76.784,Percent of Total Billed Charges,28% of Total Billed Charges,211.93,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,123.4,36,,98.72,Percent of Total Billed Charges,36% of Total Billed Charges,123.4,36,,98.72,Percent of Total Billed Charges,36% Total Bille Charges,123.4,36,,98.72,Percent of Total Billed Charges,36% of Total Billed Charges,205.67,60,,51.504,Percent of Total Billed Charges,60% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,49.43,14.42,,39.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.09,75,,17.464,Percent of Total Billed Charges,75% of Total Billed Charges,171.39,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,171.39,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.39,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,171.39,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239.95,70,,191.96,Percent of Total Billed Charges,70% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,47.99,14,,38.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,342.78,100,,23.28,Percent of Total Billed Charges,100% of Total Billed Charges,47.99,342.78,
BUDESONIDE INH SOL 0.25MG/2ML,53304309,CDM,250,RC,,,Outpatient,,,17.26,10.36,,10.36,60,,8.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.83,28,,3.864,Percent of Total Billed Charges,28% of Total Billed Charges,211.93,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% Total Bille Charges,6.21,36,,4.968,Percent of Total Billed Charges,36% of Total Billed Charges,10.36,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.49,14.42,,1.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,75,,98.144,Percent of Total Billed Charges,75% of Total Billed Charges,8.63,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,8.63,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.63,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,8.63,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.08,70,,9.664,Percent of Total Billed Charges,70% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,2.42,14,,1.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.26,100,,130.856,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,211.93,
CALCITONIN 200IU NSL SPY 2ML,53304457,CDM,250,RC,,,Outpatient,,,197.66,118.60,,118.6,60,,94.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.34,28,,44.272,Percent of Total Billed Charges,28% of Total Billed Charges,211.93,32,,169.544,Percent of Total Billed Charges,32% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,71.16,36,,56.928,Percent of Total Billed Charges,36% of Total Billed Charges,71.16,36,,56.928,Percent of Total Billed Charges,36% Total Bille Charges,71.16,36,,56.928,Percent of Total Billed Charges,36% of Total Billed Charges,118.6,60,,402.624,Percent of Total Billed Charges,60% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,14.42,,22.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.25,75,,204.304,Percent of Total Billed Charges,75% of Total Billed Charges,98.83,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,98.83,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.83,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,98.83,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.36,70,,110.688,Percent of Total Billed Charges,70% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,27.67,14,,22.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.66,100,,272.4,Percent of Total Billed Charges,100% of Total Billed Charges,27.67,211.93,
CALFACTANT INTRATRACH SUS 3 ML,53304465,CDM,250,RC,,,Outpatient,,,1706.27,1023.76,,1023.76,60,,819.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.76,28,,382.208,Percent of Total Billed Charges,28% of Total Billed Charges,212.02,32,,169.616,Percent of Total Billed Charges,32% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,614.26,36,,491.408,Percent of Total Billed Charges,36% of Total Billed Charges,614.26,36,,491.408,Percent of Total Billed Charges,36% Total Bille Charges,614.26,36,,491.408,Percent of Total Billed Charges,36% of Total Billed Charges,1023.76,60,,59.584,Percent of Total Billed Charges,60% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,246.04,14.42,,196.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1279.7,75,,9.696,Percent of Total Billed Charges,75% of Total Billed Charges,853.14,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,853.14,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,853.14,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,853.14,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1194.39,70,,955.512,Percent of Total Billed Charges,70% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,238.88,14,,191.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1706.27,100,,12.928,Percent of Total Billed Charges,100% of Total Billed Charges,212.02,1706.27,
CALFACTANT INTRATRACH SUSP 6ML,53304473,CDM,250,RC,,,Outpatient,,,2250,1350.00,,1350,60,,1080,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,630,28,,504,Percent of Total Billed Charges,28% of Total Billed Charges,212.02,32,,169.616,Percent of Total Billed Charges,32% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,810,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,810,36,,648,Percent of Total Billed Charges,36% Total Bille Charges,810,36,,648,Percent of Total Billed Charges,36% of Total Billed Charges,1350,60,,352.32,Percent of Total Billed Charges,60% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,324.45,14.42,,259.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1687.5,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,1125,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1125,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,1125,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1575,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,315,14,,252,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2250,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,212.02,2250,
BUDESONIDE 0.5MG NEB 2ML,53304481,CDM,250,RC,,,Outpatient,,,60.93,36.56,,36.56,60,,29.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.06,28,,13.648,Percent of Total Billed Charges,28% of Total Billed Charges,212.27,32,,169.816,Percent of Total Billed Charges,32% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% Total Bille Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,36.56,60,,223.592,Percent of Total Billed Charges,60% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.7,75,,49.648,Percent of Total Billed Charges,75% of Total Billed Charges,30.47,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,30.47,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.47,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,30.47,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.65,70,,34.12,Percent of Total Billed Charges,70% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.93,100,,66.2,Percent of Total Billed Charges,100% of Total Billed Charges,8.53,212.27,
BUDESONIDE INH SUS 1MG/2ML,53304482,CDM,250,RC,,,Outpatient,,,121.86,73.12,,73.12,60,,58.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.12,28,,27.296,Percent of Total Billed Charges,28% of Total Billed Charges,213.17,32,,170.536,Percent of Total Billed Charges,32% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,43.87,36,,35.096,Percent of Total Billed Charges,36% of Total Billed Charges,43.87,36,,35.096,Percent of Total Billed Charges,36% Total Bille Charges,43.87,36,,35.096,Percent of Total Billed Charges,36% of Total Billed Charges,73.12,60,,391.256,Percent of Total Billed Charges,60% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.57,14.42,,14.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.4,75,,62.992,Percent of Total Billed Charges,75% of Total Billed Charges,60.93,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,60.93,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.93,50,,48.744,Percent of Total Billed Charges,50% of Total Billed Charges,60.93,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.3,70,,68.24,Percent of Total Billed Charges,70% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,17.06,14,,13.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,121.86,100,,83.992,Percent of Total Billed Charges,100% of Total Billed Charges,17.06,213.17,
BUDESONIDE INH SOL 0.5MG/2ML,53304490,CDM,250,RC,,,Outpatient,,,60.93,36.56,,36.56,60,,29.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.06,28,,13.648,Percent of Total Billed Charges,28% of Total Billed Charges,213.27,32,,170.616,Percent of Total Billed Charges,32% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% Total Bille Charges,21.93,36,,17.544,Percent of Total Billed Charges,36% of Total Billed Charges,36.56,60,,586.24,Percent of Total Billed Charges,60% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.7,75,,168.44,Percent of Total Billed Charges,75% of Total Billed Charges,30.47,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,30.47,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.47,50,,24.376,Percent of Total Billed Charges,50% of Total Billed Charges,30.47,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.65,70,,34.12,Percent of Total Billed Charges,70% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,8.53,14,,6.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.93,100,,224.584,Percent of Total Billed Charges,100% of Total Billed Charges,8.53,213.27,
BRIMONIDINE 0.15% OP SOL 5ML,53304515,CDM,250,RC,,,Outpatient,,,281.62,168.97,,168.97,60,,135.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.85,28,,63.08,Percent of Total Billed Charges,28% of Total Billed Charges,213.31,32,,170.648,Percent of Total Billed Charges,32% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,101.38,36,,81.104,Percent of Total Billed Charges,36% of Total Billed Charges,101.38,36,,81.104,Percent of Total Billed Charges,36% Total Bille Charges,101.38,36,,81.104,Percent of Total Billed Charges,36% of Total Billed Charges,168.97,60,,188.16,Percent of Total Billed Charges,60% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14.42,,32.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.22,75,,180.016,Percent of Total Billed Charges,75% of Total Billed Charges,140.81,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,140.81,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.81,50,,112.648,Percent of Total Billed Charges,50% of Total Billed Charges,140.81,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.13,70,,157.704,Percent of Total Billed Charges,70% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,39.43,14,,31.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,281.62,100,,240.016,Percent of Total Billed Charges,100% of Total Billed Charges,39.43,281.62,
BRIMONIDINE 0.2% OPHT SOL 5ML,53304516,CDM,250,RC,,,Outpatient,,,41.58,24.95,,24.95,60,,19.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.64,28,,9.312,Percent of Total Billed Charges,28% of Total Billed Charges,21.44,32,,17.152,Percent of Total Billed Charges,32% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,14.97,36,,11.976,Percent of Total Billed Charges,36% of Total Billed Charges,14.97,36,,11.976,Percent of Total Billed Charges,36% Total Bille Charges,14.97,36,,11.976,Percent of Total Billed Charges,36% of Total Billed Charges,24.95,60,,95.344,Percent of Total Billed Charges,60% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,6,14.42,,4.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.19,75,,576,Percent of Total Billed Charges,75% of Total Billed Charges,20.79,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,20.79,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.79,50,,16.632,Percent of Total Billed Charges,50% of Total Billed Charges,20.79,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.11,70,,23.288,Percent of Total Billed Charges,70% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,14,,4.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.58,100,,768,Percent of Total Billed Charges,100% of Total Billed Charges,5.82,41.58,
BUDES/FORMO 80/4.5MCG USE INH,53304598,CDM,250,RC,,,Outpatient,,,386.56,231.94,,231.94,60,,185.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.24,28,,86.592,Percent of Total Billed Charges,28% of Total Billed Charges,21.56,32,,17.248,Percent of Total Billed Charges,32% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,139.16,36,,111.328,Percent of Total Billed Charges,36% of Total Billed Charges,139.16,36,,111.328,Percent of Total Billed Charges,36% Total Bille Charges,139.16,36,,111.328,Percent of Total Billed Charges,36% of Total Billed Charges,231.94,60,,65.28,Percent of Total Billed Charges,60% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,55.74,14.42,,44.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.92,75,,2.872,Percent of Total Billed Charges,75% of Total Billed Charges,193.28,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,193.28,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.28,50,,154.624,Percent of Total Billed Charges,50% of Total Billed Charges,193.28,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.59,70,,216.472,Percent of Total Billed Charges,70% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,54.12,14,,43.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.56,100,,3.832,Percent of Total Billed Charges,100% of Total Billed Charges,21.56,386.56,
BUDES/FORMO 160/4.5MCG USE INH,53304606,CDM,250,RC,,,Outpatient,,,444.68,266.81,,266.81,60,,213.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.51,28,,99.608,Percent of Total Billed Charges,28% of Total Billed Charges,21.59,32,,17.272,Percent of Total Billed Charges,32% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,36,,128.064,Percent of Total Billed Charges,36% of Total Billed Charges,160.08,36,,128.064,Percent of Total Billed Charges,36% Total Bille Charges,160.08,36,,128.064,Percent of Total Billed Charges,36% of Total Billed Charges,266.81,60,,117.576,Percent of Total Billed Charges,60% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,64.12,14.42,,51.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.51,75,,14.176,Percent of Total Billed Charges,75% of Total Billed Charges,222.34,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,222.34,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.34,50,,177.872,Percent of Total Billed Charges,50% of Total Billed Charges,222.34,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.28,70,,249.024,Percent of Total Billed Charges,70% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,62.26,14,,49.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,444.68,100,,18.896,Percent of Total Billed Charges,100% of Total Billed Charges,21.59,444.68,
CARBAMIDE PEROX 6.5% OTIC SOL,53304929,CDM,250,RC,,,Outpatient,,,3.38,2.03,,2.03,60,,1.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,28,,0.76,Percent of Total Billed Charges,28% of Total Billed Charges,21.67,32,,17.336,Percent of Total Billed Charges,32% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,36,,0.976,Percent of Total Billed Charges,36% of Total Billed Charges,1.22,36,,0.976,Percent of Total Billed Charges,36% Total Bille Charges,1.22,36,,0.976,Percent of Total Billed Charges,36% of Total Billed Charges,2.03,60,,368.824,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.49,14.42,,0.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.54,75,,5.112,Percent of Total Billed Charges,75% of Total Billed Charges,1.69,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,50,,1.352,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.37,70,,1.896,Percent of Total Billed Charges,70% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.38,100,,6.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,21.67,
CIPROFLOXACIN 0.3%OPH SOL 5ML,53305470,CDM,250,RC,,,Outpatient,,,66.6,39.96,,39.96,60,,31.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.65,28,,14.92,Percent of Total Billed Charges,28% of Total Billed Charges,215.99,32,,172.792,Percent of Total Billed Charges,32% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,23.98,36,,19.184,Percent of Total Billed Charges,36% of Total Billed Charges,23.98,36,,19.184,Percent of Total Billed Charges,36% Total Bille Charges,23.98,36,,19.184,Percent of Total Billed Charges,36% of Total Billed Charges,39.96,60,,189.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.6,14.42,,7.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.95,75,,2.608,Percent of Total Billed Charges,75% of Total Billed Charges,33.3,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,33.3,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.3,50,,26.64,Percent of Total Billed Charges,50% of Total Billed Charges,33.3,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.62,70,,37.296,Percent of Total Billed Charges,70% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,9.32,14,,7.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.6,100,,3.472,Percent of Total Billed Charges,100% of Total Billed Charges,9.32,215.99,
CIPROFLOXACIN OPHT OINT 3.5GM,53305496,CDM,250,RC,,,Outpatient,,,428.72,257.23,,257.23,60,,205.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.04,28,,96.032,Percent of Total Billed Charges,28% of Total Billed Charges,216,32,,172.8,Percent of Total Billed Charges,32% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% Total Bille Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,257.23,60,,506.568,Percent of Total Billed Charges,60% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,61.82,14.42,,49.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.54,75,,0.184,Percent of Total Billed Charges,75% of Total Billed Charges,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,214.36,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.1,70,,240.08,Percent of Total Billed Charges,70% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.72,100,,0.248,Percent of Total Billed Charges,100% of Total Billed Charges,60.02,428.72,
DEFERASIROX 125 MG TAB,53305550,CDM,250,RC,,,Outpatient,,,69.22,41.53,,41.53,60,,33.224,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.38,28,,15.504,Percent of Total Billed Charges,28% of Total Billed Charges,216,32,,172.8,Percent of Total Billed Charges,32% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% Total Bille Charges,24.92,36,,19.936,Percent of Total Billed Charges,36% of Total Billed Charges,41.53,60,,348,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.98,14.42,,7.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.92,75,,0.272,Percent of Total Billed Charges,75% of Total Billed Charges,34.61,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.61,50,,27.688,Percent of Total Billed Charges,50% of Total Billed Charges,34.61,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.45,70,,38.76,Percent of Total Billed Charges,70% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,9.69,14,,7.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.22,100,,0.36,Percent of Total Billed Charges,100% of Total Billed Charges,9.69,216,
CYCLOPENTOLATE 1% OPHT SOL 2ML,53305900,CDM,250,RC,,,Outpatient,,,88.56,53.14,,53.14,60,,42.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.8,28,,19.84,Percent of Total Billed Charges,28% of Total Billed Charges,216,32,,172.8,Percent of Total Billed Charges,32% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,31.88,36,,25.504,Percent of Total Billed Charges,36% of Total Billed Charges,31.88,36,,25.504,Percent of Total Billed Charges,36% Total Bille Charges,31.88,36,,25.504,Percent of Total Billed Charges,36% of Total Billed Charges,53.14,60,,355.304,Percent of Total Billed Charges,60% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.77,14.42,,10.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.42,75,,5.872,Percent of Total Billed Charges,75% of Total Billed Charges,44.28,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,44.28,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.28,50,,35.424,Percent of Total Billed Charges,50% of Total Billed Charges,44.28,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.99,70,,49.592,Percent of Total Billed Charges,70% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,14,,9.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.56,100,,7.824,Percent of Total Billed Charges,100% of Total Billed Charges,12.4,216,
CYCLOSPORINE 0.05% OPHTH 0.4ML,53306106,CDM,250,RC,,,Outpatient,,,16.98,10.19,,10.19,60,,8.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.75,28,,3.8,Percent of Total Billed Charges,28% of Total Billed Charges,216,32,,172.8,Percent of Total Billed Charges,32% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% Total Bille Charges,6.11,36,,4.888,Percent of Total Billed Charges,36% of Total Billed Charges,10.19,60,,62.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14.42,,1.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,75,,6.832,Percent of Total Billed Charges,75% of Total Billed Charges,8.49,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,8.49,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,50,,6.792,Percent of Total Billed Charges,50% of Total Billed Charges,8.49,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.89,70,,9.512,Percent of Total Billed Charges,70% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,2.38,14,,1.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.98,100,,9.112,Percent of Total Billed Charges,100% of Total Billed Charges,2.38,216,
DESMOPRESSIN 0.5MG/5ML NSL SPY,53306399,CDM,250,RC,,,Outpatient,,,480.64,288.38,,288.38,60,,230.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.58,28,,107.664,Percent of Total Billed Charges,28% of Total Billed Charges,216,32,,172.8,Percent of Total Billed Charges,32% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,173.03,36,,138.424,Percent of Total Billed Charges,36% of Total Billed Charges,173.03,36,,138.424,Percent of Total Billed Charges,36% Total Bille Charges,173.03,36,,138.424,Percent of Total Billed Charges,36% of Total Billed Charges,288.38,60,,90.048,Percent of Total Billed Charges,60% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,69.31,14.42,,55.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.48,75,,0.072,Percent of Total Billed Charges,75% of Total Billed Charges,240.32,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,240.32,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.32,50,,192.256,Percent of Total Billed Charges,50% of Total Billed Charges,240.32,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,336.45,70,,269.16,Percent of Total Billed Charges,70% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,67.29,14,,53.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.64,100,,0.096,Percent of Total Billed Charges,100% of Total Billed Charges,67.29,480.64,
DEXAMETHASONE EYE 0.1%5ML,53306957,CDM,250,RC,,,Outpatient,,,150.82,90.49,,90.49,60,,72.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.23,28,,33.784,Percent of Total Billed Charges,28% of Total Billed Charges,216.7,32,,173.36,Percent of Total Billed Charges,32% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,54.3,36,,43.44,Percent of Total Billed Charges,36% of Total Billed Charges,54.3,36,,43.44,Percent of Total Billed Charges,36% Total Bille Charges,54.3,36,,43.44,Percent of Total Billed Charges,36% of Total Billed Charges,90.49,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.75,14.42,,17.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.12,75,,13.84,Percent of Total Billed Charges,75% of Total Billed Charges,75.41,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,75.41,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.41,50,,60.328,Percent of Total Billed Charges,50% of Total Billed Charges,75.41,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.57,70,,84.456,Percent of Total Billed Charges,70% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14,,16.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.82,100,,18.448,Percent of Total Billed Charges,100% of Total Billed Charges,21.11,216.7,
MAXITROL EYE DROP 5ML,53307229,CDM,250,RC,,,Outpatient,,,39.7,23.82,,23.82,60,,19.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.12,28,,8.896,Percent of Total Billed Charges,28% of Total Billed Charges,21.77,32,,17.416,Percent of Total Billed Charges,32% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,36,,11.432,Percent of Total Billed Charges,36% of Total Billed Charges,14.29,36,,11.432,Percent of Total Billed Charges,36% Total Bille Charges,14.29,36,,11.432,Percent of Total Billed Charges,36% of Total Billed Charges,23.82,60,,504.216,Percent of Total Billed Charges,60% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.72,14.42,,4.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.78,75,,5.104,Percent of Total Billed Charges,75% of Total Billed Charges,19.85,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,19.85,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,50,,15.88,Percent of Total Billed Charges,50% of Total Billed Charges,19.85,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.79,70,,22.232,Percent of Total Billed Charges,70% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,14,,4.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.7,100,,6.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,39.7,
NEO/POLY/DEXA OPHT OINT 3.5GM,53307518,CDM,250,RC,,,Outpatient,,,39.94,23.96,,23.96,60,,19.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.18,28,,8.944,Percent of Total Billed Charges,28% of Total Billed Charges,21.77,32,,17.416,Percent of Total Billed Charges,32% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.38,36,,11.504,Percent of Total Billed Charges,36% of Total Billed Charges,14.38,36,,11.504,Percent of Total Billed Charges,36% Total Bille Charges,14.38,36,,11.504,Percent of Total Billed Charges,36% of Total Billed Charges,23.96,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14.42,,4.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.96,75,,5.688,Percent of Total Billed Charges,75% of Total Billed Charges,19.97,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,19.97,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.97,50,,15.976,Percent of Total Billed Charges,50% of Total Billed Charges,19.97,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.96,70,,22.368,Percent of Total Billed Charges,70% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,14,,4.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.94,100,,7.584,Percent of Total Billed Charges,100% of Total Billed Charges,5.59,39.94,
DICLOFENAC OPTH 0.1% 2.5ML,53307617,CDM,250,RC,,,Outpatient,,,53.22,31.93,,31.93,60,,25.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.9,28,,11.92,Percent of Total Billed Charges,28% of Total Billed Charges,21.77,32,,17.416,Percent of Total Billed Charges,32% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,19.16,36,,15.328,Percent of Total Billed Charges,36% of Total Billed Charges,19.16,36,,15.328,Percent of Total Billed Charges,36% Total Bille Charges,19.16,36,,15.328,Percent of Total Billed Charges,36% of Total Billed Charges,31.93,60,,85.264,Percent of Total Billed Charges,60% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.67,14.42,,6.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.92,75,,5.688,Percent of Total Billed Charges,75% of Total Billed Charges,26.61,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.61,50,,21.288,Percent of Total Billed Charges,50% of Total Billed Charges,26.61,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.25,70,,29.8,Percent of Total Billed Charges,70% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,7.45,14,,5.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.22,100,,7.584,Percent of Total Billed Charges,100% of Total Billed Charges,7.45,53.22,
DORNASE ALPHA 2.5ML AMP,53307807,CDM,250,RC,,,Outpatient,,,517.14,310.28,,310.28,60,,248.224,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.8,28,,115.84,Percent of Total Billed Charges,28% of Total Billed Charges,21.81,32,,17.448,Percent of Total Billed Charges,32% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,186.17,36,,148.936,Percent of Total Billed Charges,36% of Total Billed Charges,186.17,36,,148.936,Percent of Total Billed Charges,36% Total Bille Charges,186.17,36,,148.936,Percent of Total Billed Charges,36% of Total Billed Charges,310.28,60,,117.736,Percent of Total Billed Charges,60% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,74.57,14.42,,59.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,387.86,75,,5.688,Percent of Total Billed Charges,75% of Total Billed Charges,258.57,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,258.57,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.57,50,,206.856,Percent of Total Billed Charges,50% of Total Billed Charges,258.57,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,362,70,,289.6,Percent of Total Billed Charges,70% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,72.4,14,,57.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517.14,100,,7.584,Percent of Total Billed Charges,100% of Total Billed Charges,21.81,517.14,
BRINZOLAMIDE 1%OPHT SUS 10ML,53307865,CDM,250,RC,,,Outpatient,,,571.08,342.65,,342.65,60,,274.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.9,28,,127.92,Percent of Total Billed Charges,28% of Total Billed Charges,21.84,32,,17.472,Percent of Total Billed Charges,32% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,205.59,36,,164.472,Percent of Total Billed Charges,36% of Total Billed Charges,205.59,36,,164.472,Percent of Total Billed Charges,36% Total Bille Charges,205.59,36,,164.472,Percent of Total Billed Charges,36% of Total Billed Charges,342.65,60,,183.36,Percent of Total Billed Charges,60% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,82.35,14.42,,65.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,428.31,75,,7.048,Percent of Total Billed Charges,75% of Total Billed Charges,285.54,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,285.54,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.54,50,,228.432,Percent of Total Billed Charges,50% of Total Billed Charges,285.54,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,399.76,70,,319.808,Percent of Total Billed Charges,70% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,79.95,14,,63.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,571.08,100,,9.392,Percent of Total Billed Charges,100% of Total Billed Charges,21.84,571.08,
BRIMONIDINE/TIMOLOL OP SOL 5ML,53307870,CDM,250,RC,,,Outpatient,,,322.06,193.24,,193.24,60,,154.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.18,28,,72.144,Percent of Total Billed Charges,28% of Total Billed Charges,22,32,,17.6,Percent of Total Billed Charges,32% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,115.94,36,,92.752,Percent of Total Billed Charges,36% of Total Billed Charges,115.94,36,,92.752,Percent of Total Billed Charges,36% Total Bille Charges,115.94,36,,92.752,Percent of Total Billed Charges,36% of Total Billed Charges,193.24,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,46.44,14.42,,37.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.55,75,,7.752,Percent of Total Billed Charges,75% of Total Billed Charges,161.03,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,161.03,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.03,50,,128.824,Percent of Total Billed Charges,50% of Total Billed Charges,161.03,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.44,70,,180.352,Percent of Total Billed Charges,70% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,45.09,14,,36.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.06,100,,10.336,Percent of Total Billed Charges,100% of Total Billed Charges,22,322.06,
DORZOLAMIDE/TIMOLOL OP 10ML,53307880,CDM,250,RC,,,Outpatient,,,47.49,28.49,,28.49,60,,22.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.3,28,,10.64,Percent of Total Billed Charges,28% of Total Billed Charges,218.17,32,,174.536,Percent of Total Billed Charges,32% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,17.1,36,,13.68,Percent of Total Billed Charges,36% of Total Billed Charges,17.1,36,,13.68,Percent of Total Billed Charges,36% Total Bille Charges,17.1,36,,13.68,Percent of Total Billed Charges,36% of Total Billed Charges,28.49,60,,107.712,Percent of Total Billed Charges,60% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.85,14.42,,5.48,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.62,75,,97.912,Percent of Total Billed Charges,75% of Total Billed Charges,23.75,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,23.75,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.75,50,,19,Percent of Total Billed Charges,50% of Total Billed Charges,23.75,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.24,70,,26.592,Percent of Total Billed Charges,70% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,6.65,14,,5.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.49,100,,130.544,Percent of Total Billed Charges,100% of Total Billed Charges,6.65,218.17,
RACEPINEPHRINE 2.25% UD,53308342,CDM,250,RC,,,Outpatient,,,4.66,2.80,,2.8,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,28,,1.04,Percent of Total Billed Charges,28% of Total Billed Charges,218.27,32,,174.616,Percent of Total Billed Charges,32% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% Total Bille Charges,1.68,36,,1.344,Percent of Total Billed Charges,36% of Total Billed Charges,2.8,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14.42,,0.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,75,,4.584,Percent of Total Billed Charges,75% of Total Billed Charges,2.33,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,2.33,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.33,50,,1.864,Percent of Total Billed Charges,50% of Total Billed Charges,2.33,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,70,,2.608,Percent of Total Billed Charges,70% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14,,0.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,100,,6.112,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,218.27,
EPINEPH 1:1000 VL 30ML,53308433,CDM,250,RC,J0171,HCPCS,Outpatient,,,542.65,325.59,,0.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,325.59,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.99,75,,2.896,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.59,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.59,80,,34.92,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.86,70,,303.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.65,100,,3.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,542.65,
ERYTHROM OP.ONT 1GM U.D.,53309233,CDM,250,RC,,,Outpatient,,,24.82,14.89,,14.89,60,,11.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.95,28,,5.56,Percent of Total Billed Charges,28% of Total Billed Charges,218.27,32,,174.616,Percent of Total Billed Charges,32% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% Total Bille Charges,8.94,36,,7.152,Percent of Total Billed Charges,36% of Total Billed Charges,14.89,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.58,14.42,,2.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,75,,1.168,Percent of Total Billed Charges,75% of Total Billed Charges,12.41,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,12.41,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.41,50,,9.928,Percent of Total Billed Charges,50% of Total Billed Charges,12.41,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.37,70,,13.896,Percent of Total Billed Charges,70% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,3.47,14,,2.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.82,100,,1.552,Percent of Total Billed Charges,100% of Total Billed Charges,3.47,218.27,
OFLOXACIN 0.3% OTIC SOL 5 ML,53309449,CDM,250,RC,,,Outpatient,,,150.26,90.16,,90.16,60,,72.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.07,28,,33.656,Percent of Total Billed Charges,28% of Total Billed Charges,218.31,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% Total Bille Charges,54.09,36,,43.272,Percent of Total Billed Charges,36% of Total Billed Charges,90.16,60,,87.512,Percent of Total Billed Charges,60% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,14.42,,17.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.7,75,,5.448,Percent of Total Billed Charges,75% of Total Billed Charges,75.13,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,75.13,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.13,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,75.13,50,,60.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.18,70,,84.144,Percent of Total Billed Charges,70% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14,,16.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.26,100,,7.264,Percent of Total Billed Charges,100% of Total Billed Charges,21.04,218.31,
FLUORESCEIN STRIP,53309688,CDM,255,RC,,,Outpatient,,,0.85,0.51,,0.51,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,218.31,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.51,60,,416.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,80,,7.312,Percent of Total Billed Charges,80% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,100,,9.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,218.31,
FLUROMETHALONE 0.1% OPHT SUS 5,53309894,CDM,250,RC,,,Outpatient,,,170.5,102.30,,102.3,60,,81.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.74,28,,38.192,Percent of Total Billed Charges,28% of Total Billed Charges,218.31,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,61.38,36,,49.104,Percent of Total Billed Charges,36% of Total Billed Charges,61.38,36,,49.104,Percent of Total Billed Charges,36% Total Bille Charges,61.38,36,,49.104,Percent of Total Billed Charges,36% of Total Billed Charges,102.3,60,,453.808,Percent of Total Billed Charges,60% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,24.59,14.42,,19.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.88,75,,1.416,Percent of Total Billed Charges,75% of Total Billed Charges,85.25,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.25,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.25,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.25,50,,68.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.35,70,,95.48,Percent of Total Billed Charges,70% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,23.87,14,,19.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.5,100,,1.888,Percent of Total Billed Charges,100% of Total Billed Charges,23.87,218.31,
FLUTICASONE 0.05% NSL SPY 16GM,53309951,CDM,250,RC,,,Outpatient,,,53.66,32.20,,32.2,60,,25.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.02,28,,12.016,Percent of Total Billed Charges,28% of Total Billed Charges,218.31,32,,174.648,Percent of Total Billed Charges,32% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,36,,15.456,Percent of Total Billed Charges,36% of Total Billed Charges,19.32,36,,15.456,Percent of Total Billed Charges,36% Total Bille Charges,19.32,36,,15.456,Percent of Total Billed Charges,36% of Total Billed Charges,32.2,60,,340.16,Percent of Total Billed Charges,60% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.74,14.42,,6.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.25,75,,40.824,Percent of Total Billed Charges,75% of Total Billed Charges,26.83,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,26.83,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.83,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,26.83,50,,21.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.56,70,,30.048,Percent of Total Billed Charges,70% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,14,,6.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.66,100,,54.432,Percent of Total Billed Charges,100% of Total Billed Charges,7.51,218.31,
FLUTICASONE 44MCG INH 60 PUFF,53309977,CDM,250,RC,,,Outpatient,,,363.46,218.08,,218.08,60,,174.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.77,28,,81.416,Percent of Total Billed Charges,28% of Total Billed Charges,218.38,32,,174.704,Percent of Total Billed Charges,32% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,130.85,36,,104.68,Percent of Total Billed Charges,36% of Total Billed Charges,130.85,36,,104.68,Percent of Total Billed Charges,36% Total Bille Charges,130.85,36,,104.68,Percent of Total Billed Charges,36% of Total Billed Charges,218.08,60,,422.192,Percent of Total Billed Charges,60% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,52.41,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,272.6,75,,357.592,Percent of Total Billed Charges,75% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,254.42,70,,203.536,Percent of Total Billed Charges,70% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.46,100,,476.784,Percent of Total Billed Charges,100% of Total Billed Charges,50.88,363.46,
FLUTICASONE 110MCG INH 60 PUFF,53309985,CDM,250,RC,,,Outpatient,,,486.58,291.95,,291.95,60,,233.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.24,28,,108.992,Percent of Total Billed Charges,28% of Total Billed Charges,218.82,32,,175.056,Percent of Total Billed Charges,32% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,175.17,36,,140.136,Percent of Total Billed Charges,36% of Total Billed Charges,175.17,36,,140.136,Percent of Total Billed Charges,36% Total Bille Charges,175.17,36,,140.136,Percent of Total Billed Charges,36% of Total Billed Charges,291.95,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,70.16,14.42,,56.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.94,75,,156.376,Percent of Total Billed Charges,75% of Total Billed Charges,243.29,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,243.29,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.29,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,243.29,50,,194.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.61,70,,272.488,Percent of Total Billed Charges,70% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,68.12,14,,54.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.58,100,,208.496,Percent of Total Billed Charges,100% of Total Billed Charges,68.12,486.58,
FLUTICASONE HFA 220MCG INH 120,53309993,CDM,250,RC,,,Outpatient,,,418.83,251.30,,251.3,60,,201.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.27,28,,93.816,Percent of Total Billed Charges,28% of Total Billed Charges,219.14,32,,175.312,Percent of Total Billed Charges,32% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,150.78,36,,120.624,Percent of Total Billed Charges,36% of Total Billed Charges,150.78,36,,120.624,Percent of Total Billed Charges,36% Total Bille Charges,150.78,36,,120.624,Percent of Total Billed Charges,36% of Total Billed Charges,251.3,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,60.4,14.42,,48.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.12,75,,173.08,Percent of Total Billed Charges,75% of Total Billed Charges,209.42,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,209.42,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.42,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,209.42,50,,167.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,293.18,70,,234.544,Percent of Total Billed Charges,70% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,58.64,14,,46.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,418.83,100,,230.768,Percent of Total Billed Charges,100% of Total Billed Charges,58.64,418.83,
FORMOTEROL 12 MCG CAP,53310082,CDM,250,RC,,,Outpatient,,,10.16,6.10,,6.1,60,,4.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.84,28,,2.272,Percent of Total Billed Charges,28% of Total Billed Charges,219.53,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,36,,2.928,Percent of Total Billed Charges,36% of Total Billed Charges,3.66,36,,2.928,Percent of Total Billed Charges,36% Total Bille Charges,3.66,36,,2.928,Percent of Total Billed Charges,36% of Total Billed Charges,6.1,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.47,14.42,,1.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.62,75,,94.152,Percent of Total Billed Charges,75% of Total Billed Charges,5.08,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,5.08,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.08,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,5.08,50,,4.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.11,70,,5.688,Percent of Total Billed Charges,70% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,1.42,14,,1.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.16,100,,125.536,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,219.53,
FORMOTEROL 20 MCG INH SOL,53310083,CDM,250,RC,,,Outpatient,,,33.41,20.05,,20.05,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.35,28,,7.48,Percent of Total Billed Charges,28% of Total Billed Charges,219.53,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% Total Bille Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,20.05,60,,120.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,75,,130.576,Percent of Total Billed Charges,75% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.39,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.41,100,,174.096,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,219.53,
GELATIN FILM ABSORB OPHT GEL,53310108,CDM,272,RC,,,Outpatient,,,809.09,485.45,,485.45,60,,388.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.55,28,,181.24,Percent of Total Billed Charges,28% of Total Billed Charges,219.53,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,291.27,36,,233.016,Percent of Total Billed Charges,36% of Total Billed Charges,291.27,36,,233.016,Percent of Total Billed Charges,36% Total Bille Charges,291.27,36,,233.016,Percent of Total Billed Charges,36% of Total Billed Charges,485.45,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,116.67,14.42,,93.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,606.82,75,,1.944,Percent of Total Billed Charges,75% of Total Billed Charges,404.55,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,404.55,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,404.55,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,404.55,50,,323.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,566.36,70,,453.088,Percent of Total Billed Charges,70% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,113.27,14,,90.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,809.09,100,,2.592,Percent of Total Billed Charges,100% of Total Billed Charges,113.27,809.09,
GENTAMICIN 0.3% OPHT ONT 3.5GM,53310314,CDM,250,RC,,,Outpatient,,,39.32,23.59,,23.59,60,,18.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.01,28,,8.808,Percent of Total Billed Charges,28% of Total Billed Charges,219.53,32,,175.624,Percent of Total Billed Charges,32% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,14.16,36,,11.328,Percent of Total Billed Charges,36% of Total Billed Charges,14.16,36,,11.328,Percent of Total Billed Charges,36% Total Bille Charges,14.16,36,,11.328,Percent of Total Billed Charges,36% of Total Billed Charges,23.59,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14.42,,4.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.49,75,,11.256,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,19.66,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.66,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,19.66,50,,15.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.52,70,,22.016,Percent of Total Billed Charges,70% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14,,4.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.32,100,,15.008,Percent of Total Billed Charges,100% of Total Billed Charges,5.5,219.53,
GENTAMICIN 0.3% OPHT SOL 5ML,53310389,CDM,250,RC,,,Outpatient,,,11.52,6.91,,6.91,60,,5.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,28,,2.584,Percent of Total Billed Charges,28% of Total Billed Charges,220.12,32,,176.096,Percent of Total Billed Charges,32% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.15,36,,3.32,Percent of Total Billed Charges,36% of Total Billed Charges,4.15,36,,3.32,Percent of Total Billed Charges,36% Total Bille Charges,4.15,36,,3.32,Percent of Total Billed Charges,36% of Total Billed Charges,6.91,60,,866.608,Percent of Total Billed Charges,60% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14.42,,1.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,75,,6.376,Percent of Total Billed Charges,75% of Total Billed Charges,5.76,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,5.76,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,5.76,50,,4.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.06,70,,6.448,Percent of Total Billed Charges,70% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14,,1.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.52,100,,8.496,Percent of Total Billed Charges,100% of Total Billed Charges,1.61,220.12,
IPRATROPIUM 0.02% 2.5ML NEB,53312310,CDM,250,RC,,,Outpatient,,,5.83,3.50,,3.5,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,28,,1.304,Percent of Total Billed Charges,28% of Total Billed Charges,220.16,32,,176.128,Percent of Total Billed Charges,32% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% Total Bille Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,3.5,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14.42,,0.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.37,75,,24.672,Percent of Total Billed Charges,75% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,70,,3.264,Percent of Total Billed Charges,70% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.83,100,,32.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.82,220.16,
IPRATROPIUM 0.06% NSL SPY 15ML,53312336,CDM,250,RC,,,Outpatient,,,76.26,45.76,,45.76,60,,36.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.35,28,,17.08,Percent of Total Billed Charges,28% of Total Billed Charges,220.16,32,,176.128,Percent of Total Billed Charges,32% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,27.45,36,,21.96,Percent of Total Billed Charges,36% of Total Billed Charges,27.45,36,,21.96,Percent of Total Billed Charges,36% Total Bille Charges,27.45,36,,21.96,Percent of Total Billed Charges,36% of Total Billed Charges,45.76,60,,82.384,Percent of Total Billed Charges,60% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,11,14.42,,8.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,75,,151.2,Percent of Total Billed Charges,75% of Total Billed Charges,38.13,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,38.13,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.13,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,38.13,50,,30.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.38,70,,42.704,Percent of Total Billed Charges,70% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,10.68,14,,8.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.26,100,,201.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,220.16,
IPRATROPIUM 17MCG/INH 12.9GM,53312393,CDM,250,RC,,,Outpatient,,,666.46,399.88,,399.88,60,,319.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.61,28,,149.288,Percent of Total Billed Charges,28% of Total Billed Charges,220.25,32,,176.2,Percent of Total Billed Charges,32% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,239.93,36,,191.944,Percent of Total Billed Charges,36% of Total Billed Charges,239.93,36,,191.944,Percent of Total Billed Charges,36% Total Bille Charges,239.93,36,,191.944,Percent of Total Billed Charges,36% of Total Billed Charges,399.88,60,,127.2,Percent of Total Billed Charges,60% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,96.1,14.42,,76.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.85,75,,39.744,Percent of Total Billed Charges,75% of Total Billed Charges,333.23,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.23,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,50,,266.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,466.52,70,,373.216,Percent of Total Billed Charges,70% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,93.3,14,,74.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,666.46,100,,52.992,Percent of Total Billed Charges,100% of Total Billed Charges,93.3,666.46,
KETOROLAC 3ML +,53313540,CDM,250,RC,,,Outpatient,,,36.66,22.00,,22,60,,17.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.26,28,,8.208,Percent of Total Billed Charges,28% of Total Billed Charges,220.42,32,,176.336,Percent of Total Billed Charges,32% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,13.2,36,,10.56,Percent of Total Billed Charges,36% of Total Billed Charges,13.2,36,,10.56,Percent of Total Billed Charges,36% Total Bille Charges,13.2,36,,10.56,Percent of Total Billed Charges,36% of Total Billed Charges,22,60,,76.912,Percent of Total Billed Charges,60% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.29,14.42,,4.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,75,,66.912,Percent of Total Billed Charges,75% of Total Billed Charges,18.33,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,18.33,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.33,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,18.33,50,,14.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.66,70,,20.528,Percent of Total Billed Charges,70% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,5.13,14,,4.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.66,100,,89.216,Percent of Total Billed Charges,100% of Total Billed Charges,5.13,220.42,
KETOTIFEN 0.025% OPH SOL 5ML,53313581,CDM,250,RC,,,Outpatient,,,20.86,12.52,,12.52,60,,10.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.84,28,,4.672,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,7.51,36,,6.008,Percent of Total Billed Charges,36% of Total Billed Charges,7.51,36,,6.008,Percent of Total Billed Charges,36% Total Bille Charges,7.51,36,,6.008,Percent of Total Billed Charges,36% of Total Billed Charges,12.52,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,3.01,14.42,,2.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.65,75,,92.832,Percent of Total Billed Charges,75% of Total Billed Charges,10.43,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,10.43,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.43,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,10.43,50,,8.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,70,,11.68,Percent of Total Billed Charges,70% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,2.92,14,,2.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.86,100,,123.776,Percent of Total Billed Charges,100% of Total Billed Charges,2.92,220.73,
LUBRICANT 3.5G +,53313607,CDM,250,RC,,,Outpatient,,,66,39.60,,39.6,60,,31.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.48,28,,14.784,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% of Total Billed Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% Total Bille Charges,23.76,36,,19.008,Percent of Total Billed Charges,36% of Total Billed Charges,39.6,60,,50.192,Percent of Total Billed Charges,60% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.52,14.42,,7.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.5,75,,0.008,Percent of Total Billed Charges,75% of Total Billed Charges,33,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,33,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,33,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.2,70,,36.96,Percent of Total Billed Charges,70% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,9.24,14,,7.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66,100,,0.008,Percent of Total Billed Charges,100% of Total Billed Charges,9.24,220.73,
LATANOPROST 0.005% OPT SOL 2.5,53313656,CDM,250,RC,,,Outpatient,,,28.24,16.94,,16.94,60,,13.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.91,28,,6.328,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,10.17,36,,8.136,Percent of Total Billed Charges,36% of Total Billed Charges,10.17,36,,8.136,Percent of Total Billed Charges,36% Total Bille Charges,10.17,36,,8.136,Percent of Total Billed Charges,36% of Total Billed Charges,16.94,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14.42,,3.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.18,75,,270.904,Percent of Total Billed Charges,75% of Total Billed Charges,14.12,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,14.12,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,14.12,50,,11.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.77,70,,15.816,Percent of Total Billed Charges,70% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14,,3.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.24,100,,361.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.95,220.73,
LEVOBUNOLOL 0.5% OPHT SOL 5ML,53313706,CDM,250,RC,,,Outpatient,,,45.14,27.08,,27.08,60,,21.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.64,28,,10.112,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,16.25,36,,13,Percent of Total Billed Charges,36% of Total Billed Charges,16.25,36,,13,Percent of Total Billed Charges,36% Total Bille Charges,16.25,36,,13,Percent of Total Billed Charges,36% of Total Billed Charges,27.08,60,,75.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.51,14.42,,5.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,75,,107.992,Percent of Total Billed Charges,75% of Total Billed Charges,22.57,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,22.57,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.57,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,22.57,50,,18.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.6,70,,25.28,Percent of Total Billed Charges,70% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14,,5.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.14,100,,143.992,Percent of Total Billed Charges,100% of Total Billed Charges,6.32,220.73,
LEVALBUTEROL 0.63MG/3ML INH SO,53313755,CDM,250,RC,,,Outpatient,,,44.23,26.54,,26.54,60,,21.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.38,28,,9.904,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% Total Bille Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,26.54,60,,75.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,14.42,,5.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.17,75,,2.2,Percent of Total Billed Charges,75% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,70,,24.768,Percent of Total Billed Charges,70% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.23,100,,2.928,Percent of Total Billed Charges,100% of Total Billed Charges,6.19,220.73,
LEVALBUTEROL 1.25MG/3ML INH,53313763,CDM,250,RC,,,Outpatient,,,44.23,26.54,,26.54,60,,21.232,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.38,28,,9.904,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% Total Bille Charges,15.92,36,,12.736,Percent of Total Billed Charges,36% of Total Billed Charges,26.54,60,,99.928,Percent of Total Billed Charges,60% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,14.42,,5.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.17,75,,5.808,Percent of Total Billed Charges,75% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,22.12,50,,17.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.96,70,,24.768,Percent of Total Billed Charges,70% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.19,14,,4.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.23,100,,7.744,Percent of Total Billed Charges,100% of Total Billed Charges,6.19,220.73,
LEVOFLOXACIN 0.5% OP SOL 5 ML,53313955,CDM,250,RC,,,Outpatient,,,149.98,89.99,,89.99,60,,71.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.99,28,,33.592,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,53.99,36,,43.192,Percent of Total Billed Charges,36% of Total Billed Charges,53.99,36,,43.192,Percent of Total Billed Charges,36% Total Bille Charges,53.99,36,,43.192,Percent of Total Billed Charges,36% of Total Billed Charges,89.99,60,,138.72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.49,75,,37.656,Percent of Total Billed Charges,75% of Total Billed Charges,74.99,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,74.99,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.99,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,74.99,50,,59.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.99,70,,83.992,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.98,100,,50.208,Percent of Total Billed Charges,100% of Total Billed Charges,21,220.73,
METHACHOLINE 100MG 20ML VIAL,53314654,CDM,250,RC,J7674,HCPCS,Outpatient,,,300,180.00,,0.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,360,,,Fee Schedule,360% of BCBS POS Rate,0.75,360,,,Fee schedule,360% of BCBS PPO Rate,0.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,25.072,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,33.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,300,
MUPIROCIN 2% OINT 22 GM,53314886,CDM,250,RC,,,Outpatient,,,19.52,11.71,,11.71,60,,9.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.47,28,,4.376,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,7.03,36,,5.624,Percent of Total Billed Charges,36% of Total Billed Charges,7.03,36,,5.624,Percent of Total Billed Charges,36% Total Bille Charges,7.03,36,,5.624,Percent of Total Billed Charges,36% of Total Billed Charges,11.71,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.81,14.42,,2.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.64,75,,4.528,Percent of Total Billed Charges,75% of Total Billed Charges,9.76,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,9.76,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.76,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,9.76,50,,7.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.66,70,,10.928,Percent of Total Billed Charges,70% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,2.73,14,,2.184,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.52,100,,6.032,Percent of Total Billed Charges,100% of Total Billed Charges,2.73,220.73,
MOMETASONE NSL SPY 17GM,53314894,CDM,250,RC,,,Outpatient,,,277.97,166.78,,166.78,60,,133.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.83,28,,62.264,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,100.07,36,,80.056,Percent of Total Billed Charges,36% of Total Billed Charges,100.07,36,,80.056,Percent of Total Billed Charges,36% Total Bille Charges,100.07,36,,80.056,Percent of Total Billed Charges,36% of Total Billed Charges,166.78,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,40.08,14.42,,32.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.48,75,,409.472,Percent of Total Billed Charges,75% of Total Billed Charges,138.99,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,138.99,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.99,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,138.99,50,,111.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.58,70,,155.664,Percent of Total Billed Charges,70% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,14,,31.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.97,100,,545.96,Percent of Total Billed Charges,100% of Total Billed Charges,38.92,277.97,
MOXIFLOXACIN 0.5% OP SOL 3ML,53314910,CDM,250,RC,,,Outpatient,,,42.05,25.23,,25.23,60,,20.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.77,28,,9.416,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,36,,12.112,Percent of Total Billed Charges,36% of Total Billed Charges,15.14,36,,12.112,Percent of Total Billed Charges,36% Total Bille Charges,15.14,36,,12.112,Percent of Total Billed Charges,36% of Total Billed Charges,25.23,60,,95.976,Percent of Total Billed Charges,60% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,6.06,14.42,,4.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.54,75,,1605.032,Percent of Total Billed Charges,75% of Total Billed Charges,21.03,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.03,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,21.03,50,,16.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.44,70,,23.552,Percent of Total Billed Charges,70% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,5.89,14,,4.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.05,100,,2006.288,Percent of Total Billed Charges,100% of Total Billed Charges,5.89,220.73,
NEO/POLY/HC OTIC SOL 10ML,53315636,CDM,250,RC,,,Outpatient,,,187.52,112.51,,112.51,60,,90.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.51,28,,42.008,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% Total Bille Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,112.51,60,,102.72,Percent of Total Billed Charges,60% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,27.04,14.42,,21.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.64,75,,1333.136,Percent of Total Billed Charges,75% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.26,70,,105.008,Percent of Total Billed Charges,70% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.52,100,,1666.424,Percent of Total Billed Charges,100% of Total Billed Charges,26.25,220.73,
CORTISPORIN EYE OIN 3.5GM,53315842,CDM,250,RC,,,Outpatient,,,130.08,78.05,,78.05,60,,62.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.42,28,,29.136,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,46.83,36,,37.464,Percent of Total Billed Charges,36% of Total Billed Charges,46.83,36,,37.464,Percent of Total Billed Charges,36% Total Bille Charges,46.83,36,,37.464,Percent of Total Billed Charges,36% of Total Billed Charges,78.05,60,,98.784,Percent of Total Billed Charges,60% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.76,14.42,,15.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.56,75,,100.328,Percent of Total Billed Charges,75% of Total Billed Charges,65.04,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,65.04,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.04,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,65.04,50,,52.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.06,70,,72.848,Percent of Total Billed Charges,70% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,18.21,14,,14.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.08,100,,133.768,Percent of Total Billed Charges,100% of Total Billed Charges,18.21,220.73,
NYTROGLYCERIN 4.9G SPRY,53316253,CDM,250,RC,,,Outpatient,,,304.91,182.95,,182.95,60,,146.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.37,28,,68.296,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,109.77,36,,87.816,Percent of Total Billed Charges,36% of Total Billed Charges,109.77,36,,87.816,Percent of Total Billed Charges,36% Total Bille Charges,109.77,36,,87.816,Percent of Total Billed Charges,36% of Total Billed Charges,182.95,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,43.97,14.42,,35.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.68,75,,149.968,Percent of Total Billed Charges,75% of Total Billed Charges,152.46,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,152.46,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.46,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,152.46,50,,121.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.44,70,,170.752,Percent of Total Billed Charges,70% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14,,34.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,304.91,100,,199.952,Percent of Total Billed Charges,100% of Total Billed Charges,42.69,304.91,
OFLOXACIN 0.3% OPHT SOL 5ML,53316402,CDM,250,RC,,,Outpatient,,,42.5,25.50,,25.5,60,,20.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.9,28,,9.52,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,15.3,36,,12.24,Percent of Total Billed Charges,36% of Total Billed Charges,15.3,36,,12.24,Percent of Total Billed Charges,36% Total Bille Charges,15.3,36,,12.24,Percent of Total Billed Charges,36% of Total Billed Charges,25.5,60,,66.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14.42,,4.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.88,75,,207.288,Percent of Total Billed Charges,75% of Total Billed Charges,21.25,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,21.25,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.25,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,21.25,50,,17,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.75,70,,23.8,Percent of Total Billed Charges,70% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,5.95,14,,4.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.5,100,,276.384,Percent of Total Billed Charges,100% of Total Billed Charges,5.95,220.73,
OLOPATADINE 0.1% OPTH SOL 5ML,53316451,CDM,250,RC,,,Outpatient,,,46.86,28.12,,28.12,60,,22.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.12,28,,10.496,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,16.87,36,,13.496,Percent of Total Billed Charges,36% of Total Billed Charges,16.87,36,,13.496,Percent of Total Billed Charges,36% Total Bille Charges,16.87,36,,13.496,Percent of Total Billed Charges,36% of Total Billed Charges,28.12,60,,65.528,Percent of Total Billed Charges,60% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.76,14.42,,5.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.15,75,,59.248,Percent of Total Billed Charges,75% of Total Billed Charges,23.43,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,23.43,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.43,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,23.43,50,,18.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.8,70,,26.24,Percent of Total Billed Charges,70% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.86,100,,78.992,Percent of Total Billed Charges,100% of Total Billed Charges,6.56,220.73,
THYROID 15MG TAB,53316498,CDM,250,RC,,,Outpatient,,,1.17,0.70,,0.7,60,,0.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,28,,0.264,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% Total Bille Charges,0.42,36,,0.336,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,75,,59.248,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,50,,0.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,70,,0.656,Percent of Total Billed Charges,70% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,14,,0.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,100,,78.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,220.73,
OXYMETAZOLINE 0.05% NSL 30ML,53316808,CDM,250,RC,,,Outpatient,,,12.76,7.66,,7.66,60,,6.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.57,28,,2.856,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% Total Bille Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,7.66,60,,86.288,Percent of Total Billed Charges,60% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14.42,,1.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.57,75,,20.92,Percent of Total Billed Charges,75% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.93,70,,7.144,Percent of Total Billed Charges,70% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.76,100,,27.896,Percent of Total Billed Charges,100% of Total Billed Charges,1.79,220.73,
PETROLATUM/MIN OIL OPHTONT 3.5,53317509,CDM,250,RC,,,Outpatient,,,7.22,4.33,,4.33,60,,3.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.02,28,,1.616,Percent of Total Billed Charges,28% of Total Billed Charges,220.73,32,,176.584,Percent of Total Billed Charges,32% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% Total Bille Charges,2.6,36,,2.08,Percent of Total Billed Charges,36% of Total Billed Charges,4.33,60,,46.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,75,,42.112,Percent of Total Billed Charges,75% of Total Billed Charges,3.61,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,3.61,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.61,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,3.61,50,,2.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.05,70,,4.04,Percent of Total Billed Charges,70% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,100,,56.144,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,220.73,
PHENYLEPHRINE 0.125% DROP 15ML,53317806,CDM,250,RC,,,Outpatient,,,7.78,4.67,,4.67,60,,3.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.18,28,,1.744,Percent of Total Billed Charges,28% of Total Billed Charges,220.79,32,,176.632,Percent of Total Billed Charges,32% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.8,36,,2.24,Percent of Total Billed Charges,36% of Total Billed Charges,2.8,36,,2.24,Percent of Total Billed Charges,36% Total Bille Charges,2.8,36,,2.24,Percent of Total Billed Charges,36% of Total Billed Charges,4.67,60,,342.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,14.42,,0.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.84,75,,42.112,Percent of Total Billed Charges,75% of Total Billed Charges,3.89,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,3.89,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.89,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,3.89,50,,3.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.45,70,,4.36,Percent of Total Billed Charges,70% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.78,100,,56.144,Percent of Total Billed Charges,100% of Total Billed Charges,1.09,220.79,
PHENYLEPHRINE 0.25% SPRAY 15ML,53317947,CDM,250,RC,,,Outpatient,,,7.72,4.63,,4.63,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,28,,1.728,Percent of Total Billed Charges,28% of Total Billed Charges,22.15,32,,17.72,Percent of Total Billed Charges,32% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% Total Bille Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,4.63,60,,142.424,Percent of Total Billed Charges,60% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14.42,,0.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.79,75,,3.936,Percent of Total Billed Charges,75% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,70,,4.32,Percent of Total Billed Charges,70% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.72,100,,5.248,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,22.15,
PHENYLEPHRINE 0.5%NSL SPY 15ML,53318085,CDM,250,RC,,,Outpatient,,,7.72,4.63,,4.63,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,28,,1.728,Percent of Total Billed Charges,28% of Total Billed Charges,22.15,32,,17.72,Percent of Total Billed Charges,32% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% Total Bille Charges,2.78,36,,2.224,Percent of Total Billed Charges,36% of Total Billed Charges,4.63,60,,127,Percent of Total Billed Charges,60% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14.42,,0.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.79,75,,89.248,Percent of Total Billed Charges,75% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,50,,3.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,70,,4.32,Percent of Total Billed Charges,70% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,1.08,14,,0.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.72,100,,118.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.08,22.15,
PHENYLEPHRINE 10% OPHT SOLN 5M,53318226,CDM,250,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,22.15,32,,17.72,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,76.416,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,2.272,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,3.024,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,80,
PHENYLEPH OP SOL 2.5% 2ML,53318283,CDM,250,RC,,,Outpatient,,,65,39.00,,39,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.2,28,,14.56,Percent of Total Billed Charges,28% of Total Billed Charges,22.15,32,,17.72,Percent of Total Billed Charges,32% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,23.4,36,,18.72,Percent of Total Billed Charges,36% of Total Billed Charges,23.4,36,,18.72,Percent of Total Billed Charges,36% Total Bille Charges,23.4,36,,18.72,Percent of Total Billed Charges,36% of Total Billed Charges,39,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.37,14.42,,7.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.75,75,,3.312,Percent of Total Billed Charges,75% of Total Billed Charges,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,32.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.5,70,,36.4,Percent of Total Billed Charges,70% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,9.1,14,,7.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65,100,,4.416,Percent of Total Billed Charges,100% of Total Billed Charges,9.1,65,
CYCLOMYDRIL OPHT SOL 2ML,53318424,CDM,250,RC,,,Outpatient,,,166.98,100.19,,100.19,60,,80.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.75,28,,37.4,Percent of Total Billed Charges,28% of Total Billed Charges,22.2,32,,17.76,Percent of Total Billed Charges,32% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,60.11,36,,48.088,Percent of Total Billed Charges,36% of Total Billed Charges,60.11,36,,48.088,Percent of Total Billed Charges,36% Total Bille Charges,60.11,36,,48.088,Percent of Total Billed Charges,36% of Total Billed Charges,100.19,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14.42,,19.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.24,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,83.49,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,83.49,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.49,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,83.49,50,,66.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.89,70,,93.512,Percent of Total Billed Charges,70% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,23.38,14,,18.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.98,100,,112,Percent of Total Billed Charges,100% of Total Billed Charges,22.2,166.98,
PILOCARPINE 2% OPHT SOLN 15ML,53319273,CDM,250,RC,,,Outpatient,,,177.76,106.66,,106.66,60,,85.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.77,28,,39.816,Percent of Total Billed Charges,28% of Total Billed Charges,22.21,32,,17.768,Percent of Total Billed Charges,32% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,63.99,36,,51.192,Percent of Total Billed Charges,36% of Total Billed Charges,63.99,36,,51.192,Percent of Total Billed Charges,36% Total Bille Charges,63.99,36,,51.192,Percent of Total Billed Charges,36% of Total Billed Charges,106.66,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,25.63,14.42,,20.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.32,75,,0.904,Percent of Total Billed Charges,75% of Total Billed Charges,88.88,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,88.88,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.88,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,88.88,50,,71.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.43,70,,99.544,Percent of Total Billed Charges,70% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,24.89,14,,19.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.76,100,,1.2,Percent of Total Billed Charges,100% of Total Billed Charges,22.21,177.76,
BACITRACIN/POLY B OPHT OINT,53320743,CDM,250,RC,,,Outpatient,,,52.22,31.33,,31.33,60,,25.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.62,28,,11.696,Percent of Total Billed Charges,28% of Total Billed Charges,22.26,32,,17.808,Percent of Total Billed Charges,32% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% Total Bille Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,31.33,60,,73.656,Percent of Total Billed Charges,60% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14.42,,6.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.17,75,,0.576,Percent of Total Billed Charges,75% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.55,70,,29.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.22,100,,0.768,Percent of Total Billed Charges,100% of Total Billed Charges,7.31,52.22,
NEO/POLY/HC OTIC SOL 10ML,53320958,CDM,250,RC,,,Outpatient,,,187.52,112.51,,112.51,60,,90.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.51,28,,42.008,Percent of Total Billed Charges,28% of Total Billed Charges,22.36,32,,17.888,Percent of Total Billed Charges,32% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% Total Bille Charges,67.51,36,,54.008,Percent of Total Billed Charges,36% of Total Billed Charges,112.51,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,27.04,14.42,,21.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.64,75,,8.784,Percent of Total Billed Charges,75% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,93.76,50,,75.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.26,70,,105.008,Percent of Total Billed Charges,70% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,26.25,14,,21,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.52,100,,11.712,Percent of Total Billed Charges,100% of Total Billed Charges,22.36,187.52,
POL/NEO/HYDROCORTI SUSP,53321022,CDM,250,RC,,,Outpatient,,,204.7,122.82,,122.82,60,,98.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.32,28,,45.856,Percent of Total Billed Charges,28% of Total Billed Charges,220.8,32,,176.64,Percent of Total Billed Charges,32% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,73.69,36,,58.952,Percent of Total Billed Charges,36% of Total Billed Charges,73.69,36,,58.952,Percent of Total Billed Charges,36% Total Bille Charges,73.69,36,,58.952,Percent of Total Billed Charges,36% of Total Billed Charges,122.82,60,,97.544,Percent of Total Billed Charges,60% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,29.52,14.42,,23.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.53,75,,157.6,Percent of Total Billed Charges,75% of Total Billed Charges,102.35,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,102.35,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.35,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,102.35,50,,81.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,143.29,70,,114.632,Percent of Total Billed Charges,70% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,28.66,14,,22.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,204.7,100,,210.128,Percent of Total Billed Charges,100% of Total Billed Charges,28.66,220.8,
PORACTANT ALFA 120MG/1.5ML SUS,53321402,CDM,250,RC,,,Outpatient,,,1831.68,1099.01,,1099.01,60,,879.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,512.87,28,,410.296,Percent of Total Billed Charges,28% of Total Billed Charges,221.51,32,,177.208,Percent of Total Billed Charges,32% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,659.4,36,,527.52,Percent of Total Billed Charges,36% of Total Billed Charges,659.4,36,,527.52,Percent of Total Billed Charges,36% Total Bille Charges,659.4,36,,527.52,Percent of Total Billed Charges,36% of Total Billed Charges,1099.01,60,,64.688,Percent of Total Billed Charges,60% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,264.13,14.42,,211.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1373.76,75,,2.224,Percent of Total Billed Charges,75% of Total Billed Charges,915.84,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,915.84,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,915.84,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,915.84,50,,732.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1282.18,70,,1025.744,Percent of Total Billed Charges,70% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,256.44,14,,205.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1831.68,100,,2.96,Percent of Total Billed Charges,100% of Total Billed Charges,221.51,1831.68,
PREDNISOLONE-SULF 5ML,53321519,CDM,250,RC,,,Outpatient,,,0.13,0.08,,0.08,60,,0.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,221.51,32,,177.208,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,60,,33.216,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.1,75,,53.248,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,50,,0.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,70,,0.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,100,,70.992,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,221.51,
PREDNISOLONE ACET 1% SUSP 5ML,53321931,CDM,250,RC,J7510,HCPCS,Outpatient,,,110.62,66.37,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,360,,,Fee Schedule,360% of BCBS POS Rate,0.19,360,,,Fee schedule,360% of BCBS PPO Rate,0.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,66.37,60,,78.328,Percent of Total Billed Charges,60% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.95,14.42,,12.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.97,75,,9.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.21,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.21,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.21,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.43,70,,61.944,Percent of Total Billed Charges,70% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,15.49,14,,12.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.62,100,,13.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.19,110.62,
PREDNISOLONE 1% OPHT SUS 10ML,53322004,CDM,250,RC,,,Outpatient,,,221.06,132.64,,132.64,60,,106.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.9,28,,49.52,Percent of Total Billed Charges,28% of Total Billed Charges,221.51,32,,177.208,Percent of Total Billed Charges,32% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% of Total Billed Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% Total Bille Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% of Total Billed Charges,132.64,60,,125.624,Percent of Total Billed Charges,60% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,31.88,14.42,,25.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.8,75,,25.416,Percent of Total Billed Charges,75% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.74,70,,123.792,Percent of Total Billed Charges,70% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.06,100,,33.888,Percent of Total Billed Charges,100% of Total Billed Charges,30.95,221.51,
PROPARACAINE 0.5% OPHT SOL 15M,53322426,CDM,250,RC,,,Outpatient,,,263.22,157.93,,157.93,60,,126.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.7,28,,58.96,Percent of Total Billed Charges,28% of Total Billed Charges,222.15,32,,177.72,Percent of Total Billed Charges,32% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,94.76,36,,75.808,Percent of Total Billed Charges,36% of Total Billed Charges,94.76,36,,75.808,Percent of Total Billed Charges,36% Total Bille Charges,94.76,36,,75.808,Percent of Total Billed Charges,36% of Total Billed Charges,157.93,60,,738.616,Percent of Total Billed Charges,60% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,37.96,14.42,,30.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.42,75,,12.096,Percent of Total Billed Charges,75% of Total Billed Charges,131.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,131.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,131.61,50,,105.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.25,70,,147.4,Percent of Total Billed Charges,70% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,36.85,14,,29.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,263.22,100,,16.128,Percent of Total Billed Charges,100% of Total Billed Charges,36.85,263.22,
SEREVENT INHALR+,53322806,CDM,250,RC,,,Outpatient,,,590.6,354.36,,354.36,60,,283.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.37,28,,132.296,Percent of Total Billed Charges,28% of Total Billed Charges,222.15,32,,177.72,Percent of Total Billed Charges,32% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,212.62,36,,170.096,Percent of Total Billed Charges,36% of Total Billed Charges,212.62,36,,170.096,Percent of Total Billed Charges,36% Total Bille Charges,212.62,36,,170.096,Percent of Total Billed Charges,36% of Total Billed Charges,354.36,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,85.16,14.42,,68.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.95,75,,28.152,Percent of Total Billed Charges,75% of Total Billed Charges,295.3,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,295.3,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.3,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,295.3,50,,236.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.42,70,,330.736,Percent of Total Billed Charges,70% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,82.68,14,,66.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,590.6,100,,37.536,Percent of Total Billed Charges,100% of Total Billed Charges,82.68,590.6,
FLUTICAS/SALOMET 250/50MCG DIS,53322871,CDM,250,RC,,,Outpatient,,,694.79,416.87,,416.87,60,,333.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.54,28,,155.632,Percent of Total Billed Charges,28% of Total Billed Charges,222.21,32,,177.768,Percent of Total Billed Charges,32% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,250.12,36,,200.096,Percent of Total Billed Charges,36% of Total Billed Charges,250.12,36,,200.096,Percent of Total Billed Charges,36% Total Bille Charges,250.12,36,,200.096,Percent of Total Billed Charges,36% of Total Billed Charges,416.87,60,,95.04,Percent of Total Billed Charges,60% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,100.19,14.42,,80.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,521.09,75,,7.248,Percent of Total Billed Charges,75% of Total Billed Charges,347.4,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,347.4,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,347.4,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,347.4,50,,277.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.35,70,,389.08,Percent of Total Billed Charges,70% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,97.27,14,,77.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,694.79,100,,9.664,Percent of Total Billed Charges,100% of Total Billed Charges,97.27,694.79,
SODIUM CHLOR 0.9% INH SOL 3ML,53323911,CDM,250,RC,,,Outpatient,,,12.75,7.65,,7.65,60,,6.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.57,28,,2.856,Percent of Total Billed Charges,28% of Total Billed Charges,222.33,32,,177.864,Percent of Total Billed Charges,32% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% Total Bille Charges,4.59,36,,3.672,Percent of Total Billed Charges,36% of Total Billed Charges,7.65,60,,115.064,Percent of Total Billed Charges,60% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.84,14.42,,1.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.56,75,,36.52,Percent of Total Billed Charges,75% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,6.38,50,,5.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.93,70,,7.144,Percent of Total Billed Charges,70% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.79,14,,1.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.75,100,,48.696,Percent of Total Billed Charges,100% of Total Billed Charges,1.79,222.33,
SODIUM CHLORIDE 0.9% 15 ML NEB,53323912,CDM,250,RC,,,Outpatient,,,17.46,10.48,,10.48,60,,8.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.89,28,,3.912,Percent of Total Billed Charges,28% of Total Billed Charges,222.91,32,,178.328,Percent of Total Billed Charges,32% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% of Total Billed Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% Total Bille Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% of Total Billed Charges,10.48,60,,95.04,Percent of Total Billed Charges,60% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14.42,,2.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,75,,11.232,Percent of Total Billed Charges,75% of Total Billed Charges,8.73,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,8.73,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.73,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,8.73,50,,6.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,70,,9.776,Percent of Total Billed Charges,70% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,14,,1.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.46,100,,14.976,Percent of Total Billed Charges,100% of Total Billed Charges,2.44,222.91,
SODIUM CHLORIDE 45ML,53323960,CDM,250,RC,,,Outpatient,,,5.36,3.22,,3.22,60,,2.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,28,,1.2,Percent of Total Billed Charges,28% of Total Billed Charges,223.96,32,,179.168,Percent of Total Billed Charges,32% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,36,,1.544,Percent of Total Billed Charges,36% of Total Billed Charges,1.93,36,,1.544,Percent of Total Billed Charges,36% Total Bille Charges,1.93,36,,1.544,Percent of Total Billed Charges,36% of Total Billed Charges,3.22,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14.42,,0.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.02,75,,70.752,Percent of Total Billed Charges,75% of Total Billed Charges,2.68,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,2.68,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.68,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,2.68,50,,2.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,70,,3,Percent of Total Billed Charges,70% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14,,0.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,100,,94.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.75,223.96,
SODIUM CHLOR 3% INH SOL 15ML,53324000,CDM,250,RC,,,Outpatient,,,17.47,10.48,,10.48,60,,8.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.89,28,,3.912,Percent of Total Billed Charges,28% of Total Billed Charges,2242.24,32,,1793.792,Percent of Total Billed Charges,32% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% of Total Billed Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% Total Bille Charges,6.29,36,,5.032,Percent of Total Billed Charges,36% of Total Billed Charges,10.48,60,,528.152,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.52,14.42,,2.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,75,,87.84,Percent of Total Billed Charges,75% of Total Billed Charges,8.74,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,8.74,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.74,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,8.74,50,,6.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.23,70,,9.784,Percent of Total Billed Charges,70% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,2.45,14,,1.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.47,100,,117.12,Percent of Total Billed Charges,100% of Total Billed Charges,2.45,2242.24,
BALANCED SALT OPH SOLN 15ML,53324521,CDM,250,RC,,,Outpatient,,,49.56,29.74,,29.74,60,,23.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.88,28,,11.104,Percent of Total Billed Charges,28% of Total Billed Charges,2243.75,32,,1795,Percent of Total Billed Charges,32% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,17.84,36,,14.272,Percent of Total Billed Charges,36% of Total Billed Charges,17.84,36,,14.272,Percent of Total Billed Charges,36% Total Bille Charges,17.84,36,,14.272,Percent of Total Billed Charges,36% of Total Billed Charges,29.74,60,,114.56,Percent of Total Billed Charges,60% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,7.15,14.42,,5.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.17,75,,9.304,Percent of Total Billed Charges,75% of Total Billed Charges,24.78,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.78,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,50,,19.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.69,70,,27.752,Percent of Total Billed Charges,70% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,6.94,14,,5.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.56,100,,12.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.94,2243.75,
SULFACETAMIDE 15% OPHT SOLN 15,53325015,CDM,250,RC,,,Outpatient,,,73.2,43.92,,43.92,60,,35.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.5,28,,16.4,Percent of Total Billed Charges,28% of Total Billed Charges,2259.71,32,,1807.768,Percent of Total Billed Charges,32% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,26.35,36,,21.08,Percent of Total Billed Charges,36% of Total Billed Charges,26.35,36,,21.08,Percent of Total Billed Charges,36% Total Bille Charges,26.35,36,,21.08,Percent of Total Billed Charges,36% of Total Billed Charges,43.92,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.56,14.42,,8.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.9,75,,426.928,Percent of Total Billed Charges,75% of Total Billed Charges,36.6,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.6,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,36.6,50,,29.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.24,70,,40.992,Percent of Total Billed Charges,70% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14,,8.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.2,100,,569.232,Percent of Total Billed Charges,100% of Total Billed Charges,10.25,2259.71,
TALC STERILE 4 GM,53325452,CDM,250,RC,,,Outpatient,,,420,252.00,,252,60,,201.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.6,28,,94.08,Percent of Total Billed Charges,28% of Total Billed Charges,2265.27,32,,1812.216,Percent of Total Billed Charges,32% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,151.2,36,,120.96,Percent of Total Billed Charges,36% of Total Billed Charges,151.2,36,,120.96,Percent of Total Billed Charges,36% Total Bille Charges,151.2,36,,120.96,Percent of Total Billed Charges,36% of Total Billed Charges,252,60,,226.688,Percent of Total Billed Charges,60% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,60.56,14.42,,48.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315,75,,2.008,Percent of Total Billed Charges,75% of Total Billed Charges,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,70,,235.2,Percent of Total Billed Charges,70% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,58.8,14,,47.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,100,,2.672,Percent of Total Billed Charges,100% of Total Billed Charges,58.8,2265.27,
TETRACAINE 0.5% OP SOL 15ML,53325923,CDM,250,RC,,,Outpatient,,,63.18,37.91,,37.91,60,,30.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.69,28,,14.152,Percent of Total Billed Charges,28% of Total Billed Charges,2268.86,32,,1815.088,Percent of Total Billed Charges,32% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% of Total Billed Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% Total Bille Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% of Total Billed Charges,37.91,60,,407.096,Percent of Total Billed Charges,60% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,9.11,14.42,,7.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.39,75,,4.92,Percent of Total Billed Charges,75% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.23,70,,35.384,Percent of Total Billed Charges,70% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.18,100,,6.56,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,2268.86,
TETRACAINE 0.5% OPHT SOL 2ML,53325924,CDM,250,RC,,,Outpatient,,,63.18,37.91,,37.91,60,,30.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.69,28,,14.152,Percent of Total Billed Charges,28% of Total Billed Charges,2296.32,32,,1837.056,Percent of Total Billed Charges,32% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% of Total Billed Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% Total Bille Charges,22.74,36,,18.192,Percent of Total Billed Charges,36% of Total Billed Charges,37.91,60,,56.544,Percent of Total Billed Charges,60% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,9.11,14.42,,7.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.39,75,,4.92,Percent of Total Billed Charges,75% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,31.59,50,,25.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.23,70,,35.384,Percent of Total Billed Charges,70% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,8.85,14,,7.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.18,100,,6.56,Percent of Total Billed Charges,100% of Total Billed Charges,8.85,2296.32,
TETRACAINE OP SOL 0.5% 0.6ML,53325925,CDM,250,RC,,,Outpatient,,,49.8,29.88,,29.88,60,,23.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.94,28,,11.152,Percent of Total Billed Charges,28% of Total Billed Charges,2311.32,32,,1849.056,Percent of Total Billed Charges,32% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,17.93,36,,14.344,Percent of Total Billed Charges,36% of Total Billed Charges,17.93,36,,14.344,Percent of Total Billed Charges,36% Total Bille Charges,17.93,36,,14.344,Percent of Total Billed Charges,36% of Total Billed Charges,29.88,60,,75.416,Percent of Total Billed Charges,60% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,7.18,14.42,,5.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.35,75,,222.24,Percent of Total Billed Charges,75% of Total Billed Charges,24.9,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,24.9,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.9,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,24.9,50,,19.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.86,70,,27.888,Percent of Total Billed Charges,70% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,6.97,14,,5.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.8,100,,296.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.97,2311.32,
TIMOLOL MAL 0.25% OPHT SOL 5ML,53326971,CDM,250,RC,,,Outpatient,,,7.56,4.54,,4.54,60,,3.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,28,,1.696,Percent of Total Billed Charges,28% of Total Billed Charges,2329.6,32,,1863.68,Percent of Total Billed Charges,32% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% of Total Billed Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% Total Bille Charges,2.72,36,,2.176,Percent of Total Billed Charges,36% of Total Billed Charges,4.54,60,,69.12,Percent of Total Billed Charges,60% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14.42,,0.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,75,,332.688,Percent of Total Billed Charges,75% of Total Billed Charges,3.78,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,3.78,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.78,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,3.78,50,,3.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.29,70,,4.232,Percent of Total Billed Charges,70% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.56,100,,443.584,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,2329.6,
TIMOLOL MAL 0.5% OPHT SOL 5ML,53327045,CDM,250,RC,,,Outpatient,,,14.08,8.45,,8.45,60,,6.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.94,28,,3.152,Percent of Total Billed Charges,28% of Total Billed Charges,2329.76,32,,1863.808,Percent of Total Billed Charges,32% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,5.07,36,,4.056,Percent of Total Billed Charges,36% of Total Billed Charges,5.07,36,,4.056,Percent of Total Billed Charges,36% Total Bille Charges,5.07,36,,4.056,Percent of Total Billed Charges,36% of Total Billed Charges,8.45,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,2.03,14.42,,1.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.56,75,,178.992,Percent of Total Billed Charges,75% of Total Billed Charges,7.04,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,7.04,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.04,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,7.04,50,,5.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.86,70,,7.888,Percent of Total Billed Charges,70% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,1.97,14,,1.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.08,100,,238.656,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,2329.76,
TIOTROPIUM 18MCG INH 6,53327110,CDM,250,RC,,,Outpatient,,,32.5,19.50,,19.5,60,,15.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.1,28,,7.28,Percent of Total Billed Charges,28% of Total Billed Charges,2331.6,32,,1865.28,Percent of Total Billed Charges,32% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,11.7,36,,9.36,Percent of Total Billed Charges,36% of Total Billed Charges,11.7,36,,9.36,Percent of Total Billed Charges,36% Total Bille Charges,11.7,36,,9.36,Percent of Total Billed Charges,36% of Total Billed Charges,19.5,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14.42,,3.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.38,75,,4.312,Percent of Total Billed Charges,75% of Total Billed Charges,16.25,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.25,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,50,,13,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.75,70,,18.2,Percent of Total Billed Charges,70% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,4.55,14,,3.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.5,100,,5.744,Percent of Total Billed Charges,100% of Total Billed Charges,4.55,2331.6,
TOBRAMYCIN 0.3% OPHT OINT 3.5G,53327250,CDM,250,RC,,,Outpatient,,,428.72,257.23,,257.23,60,,205.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.04,28,,96.032,Percent of Total Billed Charges,28% of Total Billed Charges,2331.79,32,,1865.432,Percent of Total Billed Charges,32% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% Total Bille Charges,154.34,36,,123.472,Percent of Total Billed Charges,36% of Total Billed Charges,257.23,60,,90.744,Percent of Total Billed Charges,60% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,61.82,14.42,,49.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.54,75,,7.624,Percent of Total Billed Charges,75% of Total Billed Charges,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,214.36,50,,171.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.1,70,,240.08,Percent of Total Billed Charges,70% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,60.02,14,,48.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,428.72,100,,10.168,Percent of Total Billed Charges,100% of Total Billed Charges,60.02,2331.79,
TOBRAMYCIN/DEX OPHTH OINT,53327318,CDM,250,RC,,,Outpatient,,,430.58,258.35,,258.35,60,,206.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.56,28,,96.448,Percent of Total Billed Charges,28% of Total Billed Charges,2334.59,32,,1867.672,Percent of Total Billed Charges,32% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,155.01,36,,124.008,Percent of Total Billed Charges,36% of Total Billed Charges,155.01,36,,124.008,Percent of Total Billed Charges,36% Total Bille Charges,155.01,36,,124.008,Percent of Total Billed Charges,36% of Total Billed Charges,258.35,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,62.09,14.42,,49.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.94,75,,11.824,Percent of Total Billed Charges,75% of Total Billed Charges,215.29,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,215.29,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215.29,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,215.29,50,,172.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.41,70,,241.128,Percent of Total Billed Charges,70% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,60.28,14,,48.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,430.58,100,,15.76,Percent of Total Billed Charges,100% of Total Billed Charges,60.28,2334.59,
TOBRA/DEX 0.3%-0.1 OPH SOL 2.5ML,53327326,CDM,250,RC,,,Outpatient,,,69.39,41.63,,41.63,60,,33.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.43,28,,15.544,Percent of Total Billed Charges,28% of Total Billed Charges,2344.58,32,,1875.664,Percent of Total Billed Charges,32% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,24.98,36,,19.984,Percent of Total Billed Charges,36% of Total Billed Charges,24.98,36,,19.984,Percent of Total Billed Charges,36% Total Bille Charges,24.98,36,,19.984,Percent of Total Billed Charges,36% of Total Billed Charges,41.63,60,,86.056,Percent of Total Billed Charges,60% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,10.01,14.42,,8.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.04,75,,3.504,Percent of Total Billed Charges,75% of Total Billed Charges,34.7,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.7,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.7,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,34.7,50,,27.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.57,70,,38.856,Percent of Total Billed Charges,70% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14,,7.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.39,100,,4.672,Percent of Total Billed Charges,100% of Total Billed Charges,9.71,2344.58,
TOBRAMYCIN 0.3% OPHT SOL 5ML,53327334,CDM,250,RC,,,Outpatient,,,29.1,17.46,,17.46,60,,13.968,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,28,,6.52,Percent of Total Billed Charges,28% of Total Billed Charges,2356.22,32,,1884.976,Percent of Total Billed Charges,32% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,10.48,36,,8.384,Percent of Total Billed Charges,36% of Total Billed Charges,10.48,36,,8.384,Percent of Total Billed Charges,36% Total Bille Charges,10.48,36,,8.384,Percent of Total Billed Charges,36% of Total Billed Charges,17.46,60,,83.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14.42,,3.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.83,75,,554.552,Percent of Total Billed Charges,75% of Total Billed Charges,14.55,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,14.55,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.55,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,14.55,50,,11.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.37,70,,16.296,Percent of Total Billed Charges,70% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.07,14,,3.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.1,100,,739.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.07,2356.22,
TRIAMCINOLONE AQ NSL SPY 16.5G,53327375,CDM,250,RC,,,Outpatient,,,163.57,98.14,,98.14,60,,78.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.8,28,,36.64,Percent of Total Billed Charges,28% of Total Billed Charges,2371.2,32,,1896.96,Percent of Total Billed Charges,32% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,58.89,36,,47.112,Percent of Total Billed Charges,36% of Total Billed Charges,58.89,36,,47.112,Percent of Total Billed Charges,36% Total Bille Charges,58.89,36,,47.112,Percent of Total Billed Charges,36% of Total Billed Charges,98.14,60,,87.544,Percent of Total Billed Charges,60% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,23.59,14.42,,18.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.68,75,,340.952,Percent of Total Billed Charges,75% of Total Billed Charges,81.79,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,81.79,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.79,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,81.79,50,,65.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.5,70,,91.6,Percent of Total Billed Charges,70% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,22.9,14,,18.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.57,100,,454.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.9,2371.2,
TRAVOPROST 0.004% OP SOL 2.5ML,53327458,CDM,250,RC,,,Outpatient,,,340.5,204.30,,204.3,60,,163.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.34,28,,76.272,Percent of Total Billed Charges,28% of Total Billed Charges,2383.49,32,,1906.792,Percent of Total Billed Charges,32% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,122.58,36,,98.064,Percent of Total Billed Charges,36% of Total Billed Charges,122.58,36,,98.064,Percent of Total Billed Charges,36% Total Bille Charges,122.58,36,,98.064,Percent of Total Billed Charges,36% of Total Billed Charges,204.3,60,,177.36,Percent of Total Billed Charges,60% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,49.1,14.42,,39.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.38,75,,7.912,Percent of Total Billed Charges,75% of Total Billed Charges,170.25,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,170.25,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.25,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,170.25,50,,136.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.35,70,,190.68,Percent of Total Billed Charges,70% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,47.67,14,,38.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.5,100,,10.544,Percent of Total Billed Charges,100% of Total Billed Charges,47.67,2383.49,
TROPICAMIDE 1% OPHT SOLN 3ML,53327821,CDM,250,RC,,,Outpatient,,,16.16,9.70,,9.7,60,,7.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,28,,3.616,Percent of Total Billed Charges,28% of Total Billed Charges,2395.2,32,,1916.16,Percent of Total Billed Charges,32% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% of Total Billed Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% Total Bille Charges,5.82,36,,4.656,Percent of Total Billed Charges,36% of Total Billed Charges,9.7,60,,116.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.33,14.42,,1.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.12,75,,14.512,Percent of Total Billed Charges,75% of Total Billed Charges,8.08,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,8.08,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.08,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,8.08,50,,6.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.31,70,,9.048,Percent of Total Billed Charges,70% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,14,,1.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.16,100,,19.344,Percent of Total Billed Charges,100% of Total Billed Charges,2.26,2395.2,
TRYPAN BL 0.06%OPH DYE.5ML,53327904,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,2395.2,32,,1916.16,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,2.376,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,3.168,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,2395.2,
QUESTRAN 20% AUAPHOR,53340006,CDM,250,RC,,,Outpatient,,,82.75,49.65,,49.65,60,,39.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.17,28,,18.536,Percent of Total Billed Charges,28% of Total Billed Charges,2395.2,32,,1916.16,Percent of Total Billed Charges,32% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,29.79,36,,23.832,Percent of Total Billed Charges,36% of Total Billed Charges,29.79,36,,23.832,Percent of Total Billed Charges,36% Total Bille Charges,29.79,36,,23.832,Percent of Total Billed Charges,36% of Total Billed Charges,49.65,60,,145.16,Percent of Total Billed Charges,60% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.93,14.42,,9.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.06,75,,20.488,Percent of Total Billed Charges,75% of Total Billed Charges,41.38,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,41.38,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.38,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,41.38,50,,33.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.93,70,,46.344,Percent of Total Billed Charges,70% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,11.59,14,,9.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.75,100,,27.312,Percent of Total Billed Charges,100% of Total Billed Charges,11.59,2395.2,
ACYCLOVIR 5% OINT 15GM,53340378,CDM,250,RC,,,Outpatient,,,104.99,62.99,,62.99,60,,50.392,Percent of Total Billed Charges,60% of Total Billed Charges,47.25,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,28,,23.52,Percent of Total Billed Charges,28% of Total Billed Charges,2395.2,32,,1916.16,Percent of Total Billed Charges,32% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,37.8,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,37.8,36,,30.24,Percent of Total Billed Charges,36% Total Bille Charges,37.8,36,,30.24,Percent of Total Billed Charges,36% of Total Billed Charges,62.99,60,,111.36,Percent of Total Billed Charges,60% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.99,100,,83.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.74,75,,22.496,Percent of Total Billed Charges,75% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.49,70,,58.792,Percent of Total Billed Charges,70% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.99,100,,29.992,Percent of Total Billed Charges,100% of Total Billed Charges,14.7,2395.2,
ZOVIRAX 5% OINT 3GM,53340386,CDM,250,RC,,,Outpatient,,,280.73,168.44,,168.44,60,,134.752,Percent of Total Billed Charges,60% of Total Billed Charges,126.33,45,,101.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.6,28,,62.88,Percent of Total Billed Charges,28% of Total Billed Charges,2400,32,,1920,Percent of Total Billed Charges,32% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% Total Bille Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,168.44,60,,39.592,Percent of Total Billed Charges,60% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.73,100,,224.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,40.48,14.42,,32.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.55,75,,3.792,Percent of Total Billed Charges,75% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.51,70,,157.208,Percent of Total Billed Charges,70% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.73,100,,5.056,Percent of Total Billed Charges,100% of Total Billed Charges,39.3,2400,
ACYCLOVIR 5% CREAM 5GM,53340395,CDM,250,RC,,,Outpatient,,,300.02,180.01,,180.01,60,,144.008,Percent of Total Billed Charges,60% of Total Billed Charges,135.01,45,,108.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.01,28,,67.208,Percent of Total Billed Charges,28% of Total Billed Charges,2400,32,,1920,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108.01,36,,86.408,Percent of Total Billed Charges,36% of Total Billed Charges,108.01,36,,86.408,Percent of Total Billed Charges,36% Total Bille Charges,108.01,36,,86.408,Percent of Total Billed Charges,36% of Total Billed Charges,180.01,60,,22.656,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.02,100,,240.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.02,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,150.01,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,150.01,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.01,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,150.01,50,,120.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.01,70,,168.008,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300.02,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,42,2400,
INTER ABS 3X4 +,53340451,CDM,250,RC,C1765,HCPCS,Outpatient,,,960,576.00,,3.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,432,45,,345.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,576,60,,38.456,Percent of Total Billed Charges,60% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,960,100,,768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,138.43,14.42,,110.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,720,75,,3.12,Percent of Total Billed Charges,75% of Total Billed Charges,480,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,480,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,480,50,,384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,672,70,,537.6,Percent of Total Billed Charges,70% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,134.4,14,,107.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,960,100,,4.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,960,
ALUMINUM SULF PWD PKT,53341202,CDM,250,RC,,,Outpatient,,,4.79,2.87,,2.87,60,,2.296,Percent of Total Billed Charges,60% of Total Billed Charges,2.16,45,,1.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.34,28,,1.072,Percent of Total Billed Charges,28% of Total Billed Charges,2401.3,32,,1921.04,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% Total Bille Charges,1.72,36,,1.376,Percent of Total Billed Charges,36% of Total Billed Charges,2.87,60,,114.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,100,,3.832,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.69,14.42,,0.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.59,75,,3.016,Percent of Total Billed Charges,75% of Total Billed Charges,2.4,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,2.4,50,,1.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.35,70,,2.68,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.79,100,,4.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,2401.3,
AMMONIUM LACTATE 12% LOT 225GM,53341483,CDM,250,RC,,,Outpatient,,,23.62,14.17,,14.17,60,,11.336,Percent of Total Billed Charges,60% of Total Billed Charges,10.63,45,,8.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.61,28,,5.288,Percent of Total Billed Charges,28% of Total Billed Charges,2410.08,32,,1928.064,Percent of Total Billed Charges,32% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,36,,6.8,Percent of Total Billed Charges,36% of Total Billed Charges,8.5,36,,6.8,Percent of Total Billed Charges,36% Total Bille Charges,8.5,36,,6.8,Percent of Total Billed Charges,36% of Total Billed Charges,14.17,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.62,100,,18.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14.42,,2.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.72,75,,3.12,Percent of Total Billed Charges,75% of Total Billed Charges,11.81,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,11.81,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.81,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,11.81,50,,9.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.53,70,,13.224,Percent of Total Billed Charges,70% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,3.31,14,,2.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.62,100,,4.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.31,2410.08,
AQUAPHOR OINT 1.75OZ,53342101,CDM,250,RC,,,Outpatient,,,8.52,5.11,,5.11,60,,4.088,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.39,28,,1.912,Percent of Total Billed Charges,28% of Total Billed Charges,2430.43,32,,1944.344,Percent of Total Billed Charges,32% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.07,36,,2.456,Percent of Total Billed Charges,36% of Total Billed Charges,3.07,36,,2.456,Percent of Total Billed Charges,36% Total Bille Charges,3.07,36,,2.456,Percent of Total Billed Charges,36% of Total Billed Charges,5.11,60,,90.24,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.52,100,,6.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,75,,0.576,Percent of Total Billed Charges,75% of Total Billed Charges,4.26,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,4.26,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.26,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,4.26,50,,3.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,70,,4.768,Percent of Total Billed Charges,70% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.52,100,,0.768,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,2430.43,
BACITRACIN OINT 15GM,53342911,CDM,250,RC,,,Outpatient,,,4.34,2.60,,2.6,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.95,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,28,,0.976,Percent of Total Billed Charges,28% of Total Billed Charges,2447.28,32,,1957.824,Percent of Total Billed Charges,32% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% Total Bille Charges,1.56,36,,1.248,Percent of Total Billed Charges,36% of Total Billed Charges,2.6,60,,80.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,100,,3.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.63,14.42,,0.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.26,75,,0.784,Percent of Total Billed Charges,75% of Total Billed Charges,2.17,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,50,,1.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,70,,2.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14,,0.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,100,,1.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.61,2447.28,
BACITRACIN OINT 0.9GM PKT,53342945,CDM,250,RC,,,Outpatient,,,0.31,0.19,,0.19,60,,0.152,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,45,,0.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,28,,0.072,Percent of Total Billed Charges,28% of Total Billed Charges,2454.4,32,,1963.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% Total Bille Charges,0.11,36,,0.088,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,60,,76.104,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.31,100,,0.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.23,75,,0.928,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,0.16,50,,0.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,70,,0.176,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,100,,1.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,2454.4,
BACITRACIN/POLY B OINT 0.9GM,53343000,CDM,250,RC,,,Outpatient,,,0.45,0.27,,0.27,60,,0.216,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,45,,0.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,28,,0.104,Percent of Total Billed Charges,28% of Total Billed Charges,2458.93,32,,1967.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% Total Bille Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.27,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,100,,0.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.23,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,0.23,50,,0.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,70,,0.256,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,100,,49.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,2458.93,
BACITRACIN/POLY B OINT 15GM,53343018,CDM,250,RC,,,Outpatient,,,9.78,5.87,,5.87,60,,4.696,Percent of Total Billed Charges,60% of Total Billed Charges,4.4,45,,3.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,28,,2.192,Percent of Total Billed Charges,28% of Total Billed Charges,2474.47,32,,1979.576,Percent of Total Billed Charges,32% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.52,36,,2.816,Percent of Total Billed Charges,36% of Total Billed Charges,3.52,36,,2.816,Percent of Total Billed Charges,36% Total Bille Charges,3.52,36,,2.816,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.78,100,,7.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.34,75,,2.408,Percent of Total Billed Charges,75% of Total Billed Charges,4.89,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,4.89,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.89,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,4.89,50,,3.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.85,70,,5.48,Percent of Total Billed Charges,70% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.78,100,,3.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.37,2474.47,
BACITRACIN/POLYMIX POWDER 10GM,53343042,CDM,250,RC,,,Outpatient,,,11.39,6.83,,6.83,60,,5.464,Percent of Total Billed Charges,60% of Total Billed Charges,5.13,45,,4.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,28,,2.552,Percent of Total Billed Charges,28% of Total Billed Charges,2477.25,32,,1981.8,Percent of Total Billed Charges,32% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% of Total Billed Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% Total Bille Charges,4.1,36,,3.28,Percent of Total Billed Charges,36% of Total Billed Charges,6.83,60,,92.224,Percent of Total Billed Charges,60% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.39,100,,9.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14.42,,1.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.54,75,,15.744,Percent of Total Billed Charges,75% of Total Billed Charges,5.7,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,5.7,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.7,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,5.7,50,,4.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,70,,6.376,Percent of Total Billed Charges,70% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,1.59,14,,1.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.39,100,,20.992,Percent of Total Billed Charges,100% of Total Billed Charges,1.59,2477.25,
WITCH HAZEL PERIANAL PADS,53343711,CDM,250,RC,,,Outpatient,,,0.12,0.07,,0.07,60,,0.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,45,,0.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,28,,0.024,Percent of Total Billed Charges,28% of Total Billed Charges,2487.68,32,,1990.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% Total Bille Charges,0.04,36,,0.032,Percent of Total Billed Charges,36% of Total Billed Charges,0.07,60,,81.328,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,100,,0.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,75,,30.04,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,50,,0.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,70,,0.064,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,100,,40.048,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,2487.68,
BENZOCAINE 20% SPY 0.5ML UD,53344073,CDM,250,RC,,,Outpatient,,,23.06,13.84,,13.84,60,,11.072,Percent of Total Billed Charges,60% of Total Billed Charges,10.38,45,,8.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.46,28,,5.168,Percent of Total Billed Charges,28% of Total Billed Charges,2487.68,32,,1990.144,Percent of Total Billed Charges,32% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,8.3,36,,6.64,Percent of Total Billed Charges,36% of Total Billed Charges,8.3,36,,6.64,Percent of Total Billed Charges,36% Total Bille Charges,8.3,36,,6.64,Percent of Total Billed Charges,36% of Total Billed Charges,13.84,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.06,100,,18.448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.33,14.42,,2.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,75,,9.12,Percent of Total Billed Charges,75% of Total Billed Charges,11.53,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,11.53,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.53,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,11.53,50,,9.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.14,70,,12.912,Percent of Total Billed Charges,70% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14,,2.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.06,100,,12.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.23,2487.68,
BENZOCAINE 10% ORAL JEL 3.5GM,53344149,CDM,250,RC,,,Outpatient,,,8.5,5.10,,5.1,60,,4.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.38,28,,1.904,Percent of Total Billed Charges,28% of Total Billed Charges,2489.34,32,,1991.472,Percent of Total Billed Charges,32% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% Total Bille Charges,3.06,36,,2.448,Percent of Total Billed Charges,36% of Total Billed Charges,5.1,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,100,,6.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14.42,,0.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.38,75,,30.928,Percent of Total Billed Charges,75% of Total Billed Charges,4.25,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.25,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,4.25,50,,3.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.95,70,,4.76,Percent of Total Billed Charges,70% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,1.19,14,,0.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.5,100,,41.232,Percent of Total Billed Charges,100% of Total Billed Charges,1.19,2489.34,
BENZOCAINE 20% SPY 60GM,53344305,CDM,250,RC,,,Outpatient,,,9.48,5.69,,5.69,60,,4.552,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,28,,2.12,Percent of Total Billed Charges,28% of Total Billed Charges,2490.81,32,,1992.648,Percent of Total Billed Charges,32% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% Total Bille Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,5.69,60,,122.688,Percent of Total Billed Charges,60% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,100,,7.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,75,,160.56,Percent of Total Billed Charges,75% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.64,70,,5.312,Percent of Total Billed Charges,70% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,100,,214.08,Percent of Total Billed Charges,100% of Total Billed Charges,1.33,2490.81,
BENZOCAINE 20% SPY 60GM,53344313,CDM,250,RC,,,Outpatient,,,9.48,5.69,,5.69,60,,4.552,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,28,,2.12,Percent of Total Billed Charges,28% of Total Billed Charges,2491.84,32,,1993.472,Percent of Total Billed Charges,32% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% Total Bille Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,5.69,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,100,,7.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,75,,14.616,Percent of Total Billed Charges,75% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.64,70,,5.312,Percent of Total Billed Charges,70% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,100,,19.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.33,2491.84,
BENZOCAINE 20%/BEN CL78GM SPR,53344320,CDM,250,RC,,,Outpatient,,,9.48,5.69,,5.69,60,,4.552,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,45,,3.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,28,,2.12,Percent of Total Billed Charges,28% of Total Billed Charges,2491.84,32,,1993.472,Percent of Total Billed Charges,32% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% Total Bille Charges,3.41,36,,2.728,Percent of Total Billed Charges,36% of Total Billed Charges,5.69,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.48,100,,7.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14.42,,1.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,75,,3.12,Percent of Total Billed Charges,75% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,50,,3.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.64,70,,5.312,Percent of Total Billed Charges,70% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14,,1.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.48,100,,4.16,Percent of Total Billed Charges,100% of Total Billed Charges,1.33,2491.84,
BENZOCAINE/COMB AERO 82.5GM,53344330,CDM,250,RC,,,Outpatient,,,11.74,7.04,,7.04,60,,5.632,Percent of Total Billed Charges,60% of Total Billed Charges,5.28,45,,4.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.29,28,,2.632,Percent of Total Billed Charges,28% of Total Billed Charges,2491.84,32,,1993.472,Percent of Total Billed Charges,32% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% of Total Billed Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% Total Bille Charges,4.23,36,,3.384,Percent of Total Billed Charges,36% of Total Billed Charges,7.04,60,,122.688,Percent of Total Billed Charges,60% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.74,100,,9.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14.42,,1.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.81,75,,138.64,Percent of Total Billed Charges,75% of Total Billed Charges,5.87,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,5.87,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.87,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,5.87,50,,4.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.22,70,,6.576,Percent of Total Billed Charges,70% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,14,,1.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.74,100,,184.848,Percent of Total Billed Charges,100% of Total Billed Charges,1.64,2491.84,
ZINC OXIDE 16% PST 30GM,53344461,CDM,250,RC,,,Outpatient,,,12.92,7.75,,7.75,60,,6.2,Percent of Total Billed Charges,60% of Total Billed Charges,5.81,45,,4.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.62,28,,2.896,Percent of Total Billed Charges,28% of Total Billed Charges,2496,32,,1996.8,Percent of Total Billed Charges,32% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,4.65,36,,3.72,Percent of Total Billed Charges,36% of Total Billed Charges,4.65,36,,3.72,Percent of Total Billed Charges,36% Total Bille Charges,4.65,36,,3.72,Percent of Total Billed Charges,36% of Total Billed Charges,7.75,60,,150.24,Percent of Total Billed Charges,60% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,100,,10.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.86,14.42,,1.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.69,75,,7.24,Percent of Total Billed Charges,75% of Total Billed Charges,6.46,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,6.46,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.46,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,6.46,50,,5.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.04,70,,7.232,Percent of Total Billed Charges,70% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14,,1.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.92,100,,9.648,Percent of Total Billed Charges,100% of Total Billed Charges,1.81,2496,
CADEXOMER IODINE 0.9% GEL 40GM,53346482,CDM,250,RC,,,Outpatient,,,163.18,97.91,,97.91,60,,78.328,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.69,28,,36.552,Percent of Total Billed Charges,28% of Total Billed Charges,2496,32,,1996.8,Percent of Total Billed Charges,32% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,58.74,36,,46.992,Percent of Total Billed Charges,36% of Total Billed Charges,58.74,36,,46.992,Percent of Total Billed Charges,36% Total Bille Charges,58.74,36,,46.992,Percent of Total Billed Charges,36% of Total Billed Charges,97.91,60,,176.64,Percent of Total Billed Charges,60% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.18,100,,130.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,23.53,14.42,,18.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.39,75,,2.304,Percent of Total Billed Charges,75% of Total Billed Charges,81.59,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,81.59,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.59,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,81.59,50,,65.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.23,70,,91.384,Percent of Total Billed Charges,70% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,22.85,14,,18.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.18,100,,3.072,Percent of Total Billed Charges,100% of Total Billed Charges,22.85,2496,
CALAMINE LOT 120 ML,53346599,CDM,250,RC,,,Outpatient,,,7.64,4.58,,4.58,60,,3.664,Percent of Total Billed Charges,60% of Total Billed Charges,3.44,45,,2.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.14,28,,1.712,Percent of Total Billed Charges,28% of Total Billed Charges,2496,32,,1996.8,Percent of Total Billed Charges,32% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,2.75,36,,2.2,Percent of Total Billed Charges,36% of Total Billed Charges,2.75,36,,2.2,Percent of Total Billed Charges,36% Total Bille Charges,2.75,36,,2.2,Percent of Total Billed Charges,36% of Total Billed Charges,4.58,60,,163.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,100,,6.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.1,14.42,,0.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.73,75,,2.304,Percent of Total Billed Charges,75% of Total Billed Charges,3.82,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,3.82,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.82,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,3.82,50,,3.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.35,70,,4.28,Percent of Total Billed Charges,70% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14,,0.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.64,100,,3.072,Percent of Total Billed Charges,100% of Total Billed Charges,1.07,2496,
CALADRYL CLR LTN 180ML,53346607,CDM,250,RC,,,Outpatient,,,4.82,2.89,,2.89,60,,2.312,Percent of Total Billed Charges,60% of Total Billed Charges,2.17,45,,1.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.35,28,,1.08,Percent of Total Billed Charges,28% of Total Billed Charges,2524.48,32,,2019.584,Percent of Total Billed Charges,32% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% of Total Billed Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% Total Bille Charges,1.74,36,,1.392,Percent of Total Billed Charges,36% of Total Billed Charges,2.89,60,,155.2,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,100,,3.856,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.62,75,,2.304,Percent of Total Billed Charges,75% of Total Billed Charges,2.41,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,2.41,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.41,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,2.41,50,,1.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.37,70,,2.696,Percent of Total Billed Charges,70% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,14,,0.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.82,100,,3.072,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,2524.48,
CARMEX,53347365,CDM,250,RC,,,Outpatient,,,1.94,1.16,,1.16,60,,0.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.87,45,,0.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,28,,0.432,Percent of Total Billed Charges,28% of Total Billed Charges,2533.44,32,,2026.752,Percent of Total Billed Charges,32% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% Total Bille Charges,0.7,36,,0.56,Percent of Total Billed Charges,36% of Total Billed Charges,1.16,60,,145.864,Percent of Total Billed Charges,60% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,100,,1.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,14.42,,0.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.46,75,,5.544,Percent of Total Billed Charges,75% of Total Billed Charges,0.97,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.97,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,0.97,50,,0.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,70,,1.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,0.27,14,,0.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.94,100,,7.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,2533.44,
CHLORHEXIDINE TOP SOL 120ML,53347696,CDM,250,RC,,,Outpatient,,,9.08,5.45,,5.45,60,,4.36,Percent of Total Billed Charges,60% of Total Billed Charges,4.09,45,,3.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.54,28,,2.032,Percent of Total Billed Charges,28% of Total Billed Charges,2.24,32,,1.792,Percent of Total Billed Charges,32% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,36,,2.616,Percent of Total Billed Charges,36% of Total Billed Charges,3.27,36,,2.616,Percent of Total Billed Charges,36% Total Bille Charges,3.27,36,,2.616,Percent of Total Billed Charges,36% of Total Billed Charges,5.45,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.08,100,,7.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.31,14.42,,1.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.81,75,,188.64,Percent of Total Billed Charges,75% of Total Billed Charges,4.54,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,4.54,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.54,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,4.54,50,,3.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.36,70,,5.088,Percent of Total Billed Charges,70% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,1.27,14,,1.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.08,100,,251.52,Percent of Total Billed Charges,100% of Total Billed Charges,1.27,9.08,
CHLORHEXIDINE GLU 0.12% 480ML,53347704,CDM,250,RC,,,Outpatient,,,12.18,7.31,,7.31,60,,5.848,Percent of Total Billed Charges,60% of Total Billed Charges,5.48,45,,4.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.41,28,,2.728,Percent of Total Billed Charges,28% of Total Billed Charges,2.24,32,,1.792,Percent of Total Billed Charges,32% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4.38,36,,3.504,Percent of Total Billed Charges,36% of Total Billed Charges,4.38,36,,3.504,Percent of Total Billed Charges,36% Total Bille Charges,4.38,36,,3.504,Percent of Total Billed Charges,36% of Total Billed Charges,7.31,60,,154.032,Percent of Total Billed Charges,60% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.18,100,,9.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14.42,,1.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,75,,25.552,Percent of Total Billed Charges,75% of Total Billed Charges,6.09,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,6.09,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.09,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,6.09,50,,4.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.53,70,,6.824,Percent of Total Billed Charges,70% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.18,100,,34.072,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,12.18,
CHLORHEXIDINE GLU 0.12% 15ML,53347710,CDM,250,RC,,,Outpatient,,,2.36,1.42,,1.42,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,1.06,45,,0.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,28,,0.528,Percent of Total Billed Charges,28% of Total Billed Charges,2.26,32,,1.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% Total Bille Charges,0.85,36,,0.68,Percent of Total Billed Charges,36% of Total Billed Charges,1.42,60,,147.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.36,100,,1.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,75,,0.568,Percent of Total Billed Charges,75% of Total Billed Charges,1.18,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,50,,0.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.65,70,,1.32,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.36,100,,0.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,2.36,
SOD HYPOCHLORITE 0.25% 480ML,53348116,CDM,250,RC,,,Outpatient,,,68.04,40.82,,40.82,60,,32.656,Percent of Total Billed Charges,60% of Total Billed Charges,30.62,45,,24.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.05,28,,15.24,Percent of Total Billed Charges,28% of Total Billed Charges,2.27,32,,1.816,Percent of Total Billed Charges,32% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% Total Bille Charges,24.49,36,,19.592,Percent of Total Billed Charges,36% of Total Billed Charges,40.82,60,,131.096,Percent of Total Billed Charges,60% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.04,100,,54.432,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.81,14.42,,7.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.03,75,,16.368,Percent of Total Billed Charges,75% of Total Billed Charges,34.02,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.02,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,34.02,50,,27.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.63,70,,38.104,Percent of Total Billed Charges,70% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,9.53,14,,7.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.04,100,,21.824,Percent of Total Billed Charges,100% of Total Billed Charges,2.27,68.04,
CIPROFLOXACIN HC OTIC SUS 10ML,53348553,CDM,250,RC,,,Outpatient,,,595.98,357.59,,357.59,60,,286.072,Percent of Total Billed Charges,60% of Total Billed Charges,268.19,45,,214.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166.87,28,,133.496,Percent of Total Billed Charges,28% of Total Billed Charges,2.28,32,,1.824,Percent of Total Billed Charges,32% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,214.55,36,,171.64,Percent of Total Billed Charges,36% of Total Billed Charges,214.55,36,,171.64,Percent of Total Billed Charges,36% Total Bille Charges,214.55,36,,171.64,Percent of Total Billed Charges,36% of Total Billed Charges,357.59,60,,136.304,Percent of Total Billed Charges,60% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595.98,100,,476.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,85.94,14.42,,68.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.99,75,,8.952,Percent of Total Billed Charges,75% of Total Billed Charges,297.99,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,297.99,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.99,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,297.99,50,,238.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.19,70,,333.752,Percent of Total Billed Charges,70% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,83.44,14,,66.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.98,100,,11.936,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,595.98,
CLINDAMYCIN 2% VAG CRM 40GM,53348637,CDM,250,RC,,,Outpatient,,,260.62,156.37,,156.37,60,,125.096,Percent of Total Billed Charges,60% of Total Billed Charges,117.28,45,,93.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.97,28,,58.376,Percent of Total Billed Charges,28% of Total Billed Charges,2.28,32,,1.824,Percent of Total Billed Charges,32% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,93.82,36,,75.056,Percent of Total Billed Charges,36% of Total Billed Charges,93.82,36,,75.056,Percent of Total Billed Charges,36% Total Bille Charges,93.82,36,,75.056,Percent of Total Billed Charges,36% of Total Billed Charges,156.37,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.62,100,,208.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,37.58,14.42,,30.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.47,75,,395.416,Percent of Total Billed Charges,75% of Total Billed Charges,130.31,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,130.31,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.31,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,130.31,50,,104.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,182.43,70,,145.944,Percent of Total Billed Charges,70% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,36.49,14,,29.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.62,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,260.62,
CLINDAMYCIN TOP SOL 60 ML,53348678,CDM,250,RC,,,Outpatient,,,288.46,173.08,,173.08,60,,138.464,Percent of Total Billed Charges,60% of Total Billed Charges,129.81,45,,103.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.77,28,,64.616,Percent of Total Billed Charges,28% of Total Billed Charges,2.3,32,,1.84,Percent of Total Billed Charges,32% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,103.85,36,,83.08,Percent of Total Billed Charges,36% of Total Billed Charges,103.85,36,,83.08,Percent of Total Billed Charges,36% Total Bille Charges,103.85,36,,83.08,Percent of Total Billed Charges,36% of Total Billed Charges,173.08,60,,107.096,Percent of Total Billed Charges,60% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.46,100,,230.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,41.6,14.42,,33.28,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.35,75,,592.168,Percent of Total Billed Charges,75% of Total Billed Charges,144.23,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,144.23,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.23,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,144.23,50,,115.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.92,70,,161.536,Percent of Total Billed Charges,70% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,40.38,14,,32.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,288.46,100,,789.552,Percent of Total Billed Charges,100% of Total Billed Charges,2.3,288.46,
CLOBETASOL 0.05% CRM 15GM,53348686,CDM,250,RC,,,Outpatient,,,156.92,94.15,,94.15,60,,75.32,Percent of Total Billed Charges,60% of Total Billed Charges,70.61,45,,56.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.94,28,,35.152,Percent of Total Billed Charges,28% of Total Billed Charges,2.31,32,,1.848,Percent of Total Billed Charges,32% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.49,36,,45.192,Percent of Total Billed Charges,36% of Total Billed Charges,56.49,36,,45.192,Percent of Total Billed Charges,36% Total Bille Charges,56.49,36,,45.192,Percent of Total Billed Charges,36% of Total Billed Charges,94.15,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.92,100,,125.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,22.63,14.42,,18.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.69,75,,135.832,Percent of Total Billed Charges,75% of Total Billed Charges,78.46,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,78.46,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.46,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,78.46,50,,62.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.84,70,,87.872,Percent of Total Billed Charges,70% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.92,100,,181.104,Percent of Total Billed Charges,100% of Total Billed Charges,2.31,156.92,
CLOBETASOL 0.05% OINT 15 GM,53348690,CDM,250,RC,,,Outpatient,,,217.62,130.57,,130.57,60,,104.456,Percent of Total Billed Charges,60% of Total Billed Charges,97.93,45,,78.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.93,28,,48.744,Percent of Total Billed Charges,28% of Total Billed Charges,2.31,32,,1.848,Percent of Total Billed Charges,32% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,78.34,36,,62.672,Percent of Total Billed Charges,36% of Total Billed Charges,78.34,36,,62.672,Percent of Total Billed Charges,36% Total Bille Charges,78.34,36,,62.672,Percent of Total Billed Charges,36% of Total Billed Charges,130.57,60,,138.92,Percent of Total Billed Charges,60% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.62,100,,174.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,31.38,14.42,,25.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.22,75,,101.544,Percent of Total Billed Charges,75% of Total Billed Charges,108.81,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,108.81,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.81,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,108.81,50,,87.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.33,70,,121.864,Percent of Total Billed Charges,70% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,30.47,14,,24.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.62,100,,135.392,Percent of Total Billed Charges,100% of Total Billed Charges,2.31,217.62,
CLOTRIMAZOLE 1% CRM 15GM,53348710,CDM,250,RC,,,Outpatient,,,3.24,1.94,,1.94,60,,1.552,Percent of Total Billed Charges,60% of Total Billed Charges,1.46,45,,1.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,28,,0.728,Percent of Total Billed Charges,28% of Total Billed Charges,2.33,32,,1.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% of Total Billed Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% Total Bille Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% of Total Billed Charges,1.94,60,,83.04,Percent of Total Billed Charges,60% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.24,100,,2.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14.42,,0.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,75,,75.448,Percent of Total Billed Charges,75% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,70,,1.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.24,100,,100.592,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,3.24,
CLOTRIMAZOLE 2%CRM 21GM 3DAY,53348711,CDM,250,RC,,,Outpatient,,,18.76,11.26,,11.26,60,,9.008,Percent of Total Billed Charges,60% of Total Billed Charges,8.44,45,,6.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.25,28,,4.2,Percent of Total Billed Charges,28% of Total Billed Charges,2.36,32,,1.888,Percent of Total Billed Charges,32% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,36,,5.4,Percent of Total Billed Charges,36% of Total Billed Charges,6.75,36,,5.4,Percent of Total Billed Charges,36% Total Bille Charges,6.75,36,,5.4,Percent of Total Billed Charges,36% of Total Billed Charges,11.26,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.76,100,,15.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,14.42,,2.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.07,75,,19.272,Percent of Total Billed Charges,75% of Total Billed Charges,9.38,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,9.38,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,9.38,50,,7.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.13,70,,10.504,Percent of Total Billed Charges,70% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,2.63,14,,2.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,100,,25.696,Percent of Total Billed Charges,100% of Total Billed Charges,2.36,18.76,
CLOTRIMAZOLE 1% VAG CRM 45GM,53348843,CDM,250,RC,,,Outpatient,,,10.62,6.37,,6.37,60,,5.096,Percent of Total Billed Charges,60% of Total Billed Charges,4.78,45,,3.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,28,,2.376,Percent of Total Billed Charges,28% of Total Billed Charges,2.38,32,,1.904,Percent of Total Billed Charges,32% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% of Total Billed Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% Total Bille Charges,3.82,36,,3.056,Percent of Total Billed Charges,36% of Total Billed Charges,6.37,60,,61.696,Percent of Total Billed Charges,60% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,100,,8.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.53,14.42,,1.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,75,,52.264,Percent of Total Billed Charges,75% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.43,70,,5.944,Percent of Total Billed Charges,70% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,1.49,14,,1.192,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.62,100,,69.68,Percent of Total Billed Charges,100% of Total Billed Charges,1.49,10.62,
CLOTRIMAZOL/BETAMETH CRM 15GM,53348934,CDM,250,RC,,,Outpatient,,,41.12,24.67,,24.67,60,,19.736,Percent of Total Billed Charges,60% of Total Billed Charges,18.5,45,,14.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.51,28,,9.208,Percent of Total Billed Charges,28% of Total Billed Charges,2.39,32,,1.912,Percent of Total Billed Charges,32% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,14.8,36,,11.84,Percent of Total Billed Charges,36% of Total Billed Charges,14.8,36,,11.84,Percent of Total Billed Charges,36% Total Bille Charges,14.8,36,,11.84,Percent of Total Billed Charges,36% of Total Billed Charges,24.67,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.12,100,,32.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14.42,,4.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.84,75,,819.24,Percent of Total Billed Charges,75% of Total Billed Charges,20.56,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,20.56,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.56,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,20.56,50,,16.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.78,70,,23.024,Percent of Total Billed Charges,70% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.12,100,,1092.32,Percent of Total Billed Charges,100% of Total Billed Charges,2.39,41.12,
BETAMETH/CLOTRIMAZOLE CRM 45GM,53348935,CDM,250,RC,,,Outpatient,,,252,151.20,,151.2,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.56,28,,56.448,Percent of Total Billed Charges,28% of Total Billed Charges,2.41,32,,1.928,Percent of Total Billed Charges,32% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,90.72,36,,72.576,Percent of Total Billed Charges,36% of Total Billed Charges,90.72,36,,72.576,Percent of Total Billed Charges,36% Total Bille Charges,90.72,36,,72.576,Percent of Total Billed Charges,36% of Total Billed Charges,151.2,60,,177.84,Percent of Total Billed Charges,60% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252,100,,201.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,36.34,14.42,,29.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,75,,210.584,Percent of Total Billed Charges,75% of Total Billed Charges,126,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,126,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.4,70,,141.12,Percent of Total Billed Charges,70% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,35.28,14,,28.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,100,,280.776,Percent of Total Billed Charges,100% of Total Billed Charges,2.41,252,
CLONIDINE 0.1MG PATCH,53348975,CDM,250,RC,,,Outpatient,,,66.24,39.74,,39.74,60,,31.792,Percent of Total Billed Charges,60% of Total Billed Charges,29.81,45,,23.848,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.55,28,,14.84,Percent of Total Billed Charges,28% of Total Billed Charges,2.42,32,,1.936,Percent of Total Billed Charges,32% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,23.85,36,,19.08,Percent of Total Billed Charges,36% of Total Billed Charges,23.85,36,,19.08,Percent of Total Billed Charges,36% Total Bille Charges,23.85,36,,19.08,Percent of Total Billed Charges,36% of Total Billed Charges,39.74,60,,177.84,Percent of Total Billed Charges,60% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.24,100,,52.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14.42,,7.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.68,75,,75.152,Percent of Total Billed Charges,75% of Total Billed Charges,33.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,33.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,33.12,50,,26.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.37,70,,37.096,Percent of Total Billed Charges,70% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,9.27,14,,7.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.24,100,,100.2,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,66.24,
CLONIDINE 0.2MG PATCH,53348991,CDM,250,RC,,,Outpatient,,,111.52,66.91,,66.91,60,,53.528,Percent of Total Billed Charges,60% of Total Billed Charges,50.18,45,,40.144,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.23,28,,24.984,Percent of Total Billed Charges,28% of Total Billed Charges,2.42,32,,1.936,Percent of Total Billed Charges,32% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.15,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,40.15,36,,32.12,Percent of Total Billed Charges,36% Total Bille Charges,40.15,36,,32.12,Percent of Total Billed Charges,36% of Total Billed Charges,66.91,60,,115.192,Percent of Total Billed Charges,60% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.52,100,,89.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,16.08,14.42,,12.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.64,75,,4.696,Percent of Total Billed Charges,75% of Total Billed Charges,55.76,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,55.76,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.76,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,55.76,50,,44.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.06,70,,62.448,Percent of Total Billed Charges,70% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,15.61,14,,12.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.52,100,,6.256,Percent of Total Billed Charges,100% of Total Billed Charges,2.42,111.52,
CLONIDINE 0.3MG PATCH,53349015,CDM,250,RC,,,Outpatient,,,154.72,92.83,,92.83,60,,74.264,Percent of Total Billed Charges,60% of Total Billed Charges,69.62,45,,55.696,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.32,28,,34.656,Percent of Total Billed Charges,28% of Total Billed Charges,2.44,32,,1.952,Percent of Total Billed Charges,32% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,55.7,36,,44.56,Percent of Total Billed Charges,36% of Total Billed Charges,55.7,36,,44.56,Percent of Total Billed Charges,36% Total Bille Charges,55.7,36,,44.56,Percent of Total Billed Charges,36% of Total Billed Charges,92.83,60,,96.96,Percent of Total Billed Charges,60% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.72,100,,123.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,22.31,14.42,,17.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.04,75,,148.488,Percent of Total Billed Charges,75% of Total Billed Charges,77.36,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,77.36,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.36,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,77.36,50,,61.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.3,70,,86.64,Percent of Total Billed Charges,70% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,21.66,14,,17.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.72,100,,197.984,Percent of Total Billed Charges,100% of Total Billed Charges,2.44,154.72,
PRAMOXINE/ZINC OX CR 28GM,53349361,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,0.008,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,75,,6.432,Percent of Total Billed Charges,75% of Total Billed Charges,0.01,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.01,50,,0.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,70,,0.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,100,,8.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,0.01,
COLLAGENASE 250UN/GM ONT 30GM,53349585,CDM,250,RC,,,Outpatient,,,451.5,270.90,,270.9,60,,216.72,Percent of Total Billed Charges,60% of Total Billed Charges,203.18,45,,162.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.42,28,,101.136,Percent of Total Billed Charges,28% of Total Billed Charges,2.45,32,,1.96,Percent of Total Billed Charges,32% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,162.54,36,,130.032,Percent of Total Billed Charges,36% of Total Billed Charges,162.54,36,,130.032,Percent of Total Billed Charges,36% Total Bille Charges,162.54,36,,130.032,Percent of Total Billed Charges,36% of Total Billed Charges,270.9,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.5,100,,361.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,65.11,14.42,,52.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.63,75,,6.936,Percent of Total Billed Charges,75% of Total Billed Charges,225.75,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,225.75,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.75,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,225.75,50,,180.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.05,70,,252.84,Percent of Total Billed Charges,70% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,63.21,14,,50.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,451.5,100,,9.248,Percent of Total Billed Charges,100% of Total Billed Charges,2.45,451.5,
ESTRADIOL 0.01% VAG CREAM 42.5GM,53349999,CDM,250,RC,,,Outpatient,,,179.99,107.99,,107.99,60,,86.392,Percent of Total Billed Charges,60% of Total Billed Charges,81,45,,64.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,28,,40.32,Percent of Total Billed Charges,28% of Total Billed Charges,2.47,32,,1.976,Percent of Total Billed Charges,32% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,64.8,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,64.8,36,,51.84,Percent of Total Billed Charges,36% Total Bille Charges,64.8,36,,51.84,Percent of Total Billed Charges,36% of Total Billed Charges,107.99,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.99,100,,143.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.95,14.42,,20.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.99,75,,16.32,Percent of Total Billed Charges,75% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.99,70,,100.792,Percent of Total Billed Charges,70% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,14,,20.16,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.99,100,,21.76,Percent of Total Billed Charges,100% of Total Billed Charges,2.47,179.99,
DIPHENHYDRAMINE 2% CR 30GM,53352704,CDM,250,RC,,,Outpatient,,,3.66,2.20,,2.2,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,45,,1.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,2.47,32,,1.976,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,60,,82.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,100,,2.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.75,75,,9.616,Percent of Total Billed Charges,75% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.56,70,,2.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,100,,12.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,3.66,
CALAMINE+DIPHEN LOTION 180ML,53352803,CDM,250,RC,,,Outpatient,,,9.68,5.81,,5.81,60,,4.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.36,45,,3.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.71,28,,2.168,Percent of Total Billed Charges,28% of Total Billed Charges,2.49,32,,1.992,Percent of Total Billed Charges,32% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% Total Bille Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,5.81,60,,115.68,Percent of Total Billed Charges,60% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.68,100,,7.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14.42,,1.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.26,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,70,,5.424,Percent of Total Billed Charges,70% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.68,100,,19.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.36,9.68,
ESTRADIOL 0.05MG/DAY PAT 7 DAY,53353652,CDM,250,RC,,,Outpatient,,,62.76,37.66,,37.66,60,,30.128,Percent of Total Billed Charges,60% of Total Billed Charges,28.24,45,,22.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.57,28,,14.056,Percent of Total Billed Charges,28% of Total Billed Charges,2.5,32,,2,Percent of Total Billed Charges,32% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,22.59,36,,18.072,Percent of Total Billed Charges,36% of Total Billed Charges,22.59,36,,18.072,Percent of Total Billed Charges,36% Total Bille Charges,22.59,36,,18.072,Percent of Total Billed Charges,36% of Total Billed Charges,37.66,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.76,100,,50.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,9.05,14.42,,7.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.07,75,,13.6,Percent of Total Billed Charges,75% of Total Billed Charges,31.38,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,31.38,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.38,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,31.38,50,,25.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.93,70,,35.144,Percent of Total Billed Charges,70% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14,,7.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.76,100,,18.128,Percent of Total Billed Charges,100% of Total Billed Charges,2.5,62.76,
ESTRADIOL 0.1MG/DAY PAT 7 DAY,53353678,CDM,250,RC,,,Outpatient,,,41.78,25.07,,25.07,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,18.8,45,,15.04,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.7,28,,9.36,Percent of Total Billed Charges,28% of Total Billed Charges,2.52,32,,2.016,Percent of Total Billed Charges,32% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% Total Bille Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,25.07,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.78,100,,33.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14.42,,4.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.34,75,,13.6,Percent of Total Billed Charges,75% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.25,70,,23.4,Percent of Total Billed Charges,70% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,100,,18.128,Percent of Total Billed Charges,100% of Total Billed Charges,2.52,41.78,
EYE STREAM OPHT SOL 120ML,53353769,CDM,250,RC,,,Outpatient,,,7.54,4.52,,4.52,60,,3.616,Percent of Total Billed Charges,60% of Total Billed Charges,3.39,45,,2.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.11,28,,1.688,Percent of Total Billed Charges,28% of Total Billed Charges,2.53,32,,2.024,Percent of Total Billed Charges,32% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,2.71,36,,2.168,Percent of Total Billed Charges,36% of Total Billed Charges,2.71,36,,2.168,Percent of Total Billed Charges,36% Total Bille Charges,2.71,36,,2.168,Percent of Total Billed Charges,36% of Total Billed Charges,4.52,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.54,100,,6.032,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14.42,,0.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.66,75,,96.696,Percent of Total Billed Charges,75% of Total Billed Charges,3.77,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,3.77,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.77,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,3.77,50,,3.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.28,70,,4.224,Percent of Total Billed Charges,70% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,1.06,14,,0.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.54,100,,128.928,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,7.54,
FIBRIN SEALANT (HUMAN) 2ML KIT,53353967,CDM,250,RC,,,Outpatient,,,682.45,409.47,,409.47,60,,327.576,Percent of Total Billed Charges,60% of Total Billed Charges,307.1,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.09,28,,152.872,Percent of Total Billed Charges,28% of Total Billed Charges,2.55,32,,2.04,Percent of Total Billed Charges,32% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,245.68,36,,196.544,Percent of Total Billed Charges,36% of Total Billed Charges,245.68,36,,196.544,Percent of Total Billed Charges,36% Total Bille Charges,245.68,36,,196.544,Percent of Total Billed Charges,36% of Total Billed Charges,409.47,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.45,100,,545.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,98.41,14.42,,78.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.84,75,,0.264,Percent of Total Billed Charges,75% of Total Billed Charges,341.23,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,341.23,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.23,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,341.23,50,,272.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.72,70,,382.176,Percent of Total Billed Charges,70% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14,,76.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.45,100,,0.352,Percent of Total Billed Charges,100% of Total Billed Charges,2.55,682.45,
FIBRIN SEALANT (TISSEEL) 10ML,53353975,CDM,278,RC,,,Outpatient,,,2507.86,1504.72,,2758.65,110,,2206.92,Percent of Total Billed Charges,110% of Total Billed Charges,1128.54,45,,902.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,702.2,28,,561.76,Percent of Total Billed Charges,28% of Total Billed Charges,2.55,32,,2.04,Percent of Total Billed Charges,32% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,902.83,36,,722.264,Percent of Total Billed Charges,36% of Total Billed Charges,902.83,36,,722.264,Percent of Total Billed Charges,36% Total Bille Charges,902.83,36,,722.264,Percent of Total Billed Charges,36% of Total Billed Charges,1379.32,55,,76.448,Percent of Total Billed Charges,55% Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2507.86,100,,2006.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,361.63,14.42,,289.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2006.29,80,,3.768,Percent of Total Billed Charges,80% of Total Billed Charges,1253.93,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,1253.93,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1253.93,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,1253.93,50,,1003.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1755.5,70,,1404.4,Percent of Total Billed Charges,70% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,351.1,14,,280.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2507.86,100,,5.024,Percent of Total Billed Charges,100% of Total Billed Charges,2.55,2758.65,
EVICEL KIT 5ML,53354031,CDM,278,RC,,,Outpatient,,,2083.03,1249.82,,2291.33,110,,1833.064,Percent of Total Billed Charges,110% of Total Billed Charges,937.36,45,,749.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,583.25,28,,466.6,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,749.89,36,,599.912,Percent of Total Billed Charges,36% of Total Billed Charges,749.89,36,,599.912,Percent of Total Billed Charges,36% Total Bille Charges,749.89,36,,599.912,Percent of Total Billed Charges,36% of Total Billed Charges,1145.67,55,,76.448,Percent of Total Billed Charges,55% Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2083.03,100,,1666.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,300.37,14.42,,240.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1666.42,80,,20.048,Percent of Total Billed Charges,80% of Total Billed Charges,1041.52,50,,833.216,Percent of Total Billed Charges,50% of Total Billed Charges,1041.52,50,,833.216,Percent of Total Billed Charges,50% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1041.52,50,,833.216,Percent of Total Billed Charges,50% of Total Billed Charges,1041.52,50,,833.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1458.12,70,,1166.496,Percent of Total Billed Charges,70% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,291.62,14,,233.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2083.03,100,,26.728,Percent of Total Billed Charges,100% of Total Billed Charges,22.4,2291.33,
GEL SPONGE #12 (SZ 7MM),53356952,CDM,272,RC,,,Outpatient,,,167.21,100.33,,100.33,60,,80.264,Percent of Total Billed Charges,60% of Total Billed Charges,75.24,45,,60.192,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.82,28,,37.456,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,60.2,36,,48.16,Percent of Total Billed Charges,36% of Total Billed Charges,60.2,36,,48.16,Percent of Total Billed Charges,36% Total Bille Charges,60.2,36,,48.16,Percent of Total Billed Charges,36% of Total Billed Charges,100.33,60,,127.488,Percent of Total Billed Charges,60% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.21,100,,133.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,24.11,14.42,,19.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.41,75,,20.048,Percent of Total Billed Charges,75% of Total Billed Charges,83.61,50,,66.888,Percent of Total Billed Charges,50% of Total Billed Charges,83.61,50,,66.888,Percent of Total Billed Charges,50% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.61,50,,66.888,Percent of Total Billed Charges,50% of Total Billed Charges,83.61,50,,66.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.05,70,,93.64,Percent of Total Billed Charges,70% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.21,100,,26.728,Percent of Total Billed Charges,100% of Total Billed Charges,22.4,167.21,
GELFOAM SIZE 100 SQ CM,53356986,CDM,272,RC,,,Outpatient,,,249.94,149.96,,149.96,60,,119.968,Percent of Total Billed Charges,60% of Total Billed Charges,112.47,45,,89.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.98,28,,55.984,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,89.98,36,,71.984,Percent of Total Billed Charges,36% of Total Billed Charges,89.98,36,,71.984,Percent of Total Billed Charges,36% Total Bille Charges,89.98,36,,71.984,Percent of Total Billed Charges,36% of Total Billed Charges,149.96,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.94,100,,199.952,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,36.04,14.42,,28.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.46,75,,20.048,Percent of Total Billed Charges,75% of Total Billed Charges,124.97,50,,99.976,Percent of Total Billed Charges,50% of Total Billed Charges,124.97,50,,99.976,Percent of Total Billed Charges,50% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.97,50,,99.976,Percent of Total Billed Charges,50% of Total Billed Charges,124.97,50,,99.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.96,70,,139.968,Percent of Total Billed Charges,70% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.99,14,,27.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.94,100,,26.728,Percent of Total Billed Charges,100% of Total Billed Charges,22.4,249.94,
GEL POWDER ABSORB 1GM,53357083,CDM,272,RC,,,Outpatient,,,345.48,207.29,,207.29,60,,165.832,Percent of Total Billed Charges,60% of Total Billed Charges,155.47,45,,124.376,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.73,28,,77.384,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,124.37,36,,99.496,Percent of Total Billed Charges,36% of Total Billed Charges,124.37,36,,99.496,Percent of Total Billed Charges,36% Total Bille Charges,124.37,36,,99.496,Percent of Total Billed Charges,36% of Total Billed Charges,207.29,60,,82.12,Percent of Total Billed Charges,60% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.48,100,,276.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,49.82,14.42,,39.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.11,75,,0.488,Percent of Total Billed Charges,75% of Total Billed Charges,172.74,50,,138.192,Percent of Total Billed Charges,50% of Total Billed Charges,172.74,50,,138.192,Percent of Total Billed Charges,50% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.74,50,,138.192,Percent of Total Billed Charges,50% of Total Billed Charges,172.74,50,,138.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.84,70,,193.472,Percent of Total Billed Charges,70% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,48.37,14,,38.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.48,100,,0.648,Percent of Total Billed Charges,100% of Total Billed Charges,22.4,345.48,
GENTAMICIN CR 0.1% 15GM,53357240,CDM,250,RC,,,Outpatient,,,98.74,59.24,,59.24,60,,47.392,Percent of Total Billed Charges,60% of Total Billed Charges,44.43,45,,35.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.65,28,,22.12,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% Total Bille Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,59.24,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.74,100,,78.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,14.24,14.42,,11.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,75,,0.784,Percent of Total Billed Charges,75% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.12,70,,55.296,Percent of Total Billed Charges,70% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.74,100,,1.048,Percent of Total Billed Charges,100% of Total Billed Charges,13.82,98.74,
GENTAMICIN 0.1% TOP ONT 15GM,53357257,CDM,250,RC,,,Outpatient,,,98.74,59.24,,59.24,60,,47.392,Percent of Total Billed Charges,60% of Total Billed Charges,44.43,45,,35.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.65,28,,22.12,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% Total Bille Charges,35.55,36,,28.44,Percent of Total Billed Charges,36% of Total Billed Charges,59.24,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.74,100,,78.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,14.24,14.42,,11.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,75,,0.52,Percent of Total Billed Charges,75% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,49.37,50,,39.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.12,70,,55.296,Percent of Total Billed Charges,70% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,13.82,14,,11.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.74,100,,0.696,Percent of Total Billed Charges,100% of Total Billed Charges,13.82,98.74,
HYDROACTIVE DRSG 20ML,53358834,CDM,250,RC,,,Outpatient,,,34.87,20.92,,20.92,60,,16.736,Percent of Total Billed Charges,60% of Total Billed Charges,15.69,45,,12.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.76,28,,7.808,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,36,,10.04,Percent of Total Billed Charges,36% of Total Billed Charges,12.55,36,,10.04,Percent of Total Billed Charges,36% Total Bille Charges,12.55,36,,10.04,Percent of Total Billed Charges,36% of Total Billed Charges,20.92,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.87,100,,27.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,5.03,14.42,,4.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.15,75,,1.752,Percent of Total Billed Charges,75% of Total Billed Charges,17.44,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,17.44,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.44,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,17.44,50,,13.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.41,70,,19.528,Percent of Total Billed Charges,70% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,4.88,14,,3.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.87,100,,2.336,Percent of Total Billed Charges,100% of Total Billed Charges,4.88,34.87,
FLUOCINOLONE OINT 0.025% 15GM,53358840,CDM,250,RC,,,Outpatient,,,70.18,42.11,,42.11,60,,33.688,Percent of Total Billed Charges,60% of Total Billed Charges,31.58,45,,25.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.65,28,,15.72,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% of Total Billed Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% Total Bille Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% of Total Billed Charges,42.11,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.18,100,,56.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.12,14.42,,8.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.64,75,,1.816,Percent of Total Billed Charges,75% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.13,70,,39.304,Percent of Total Billed Charges,70% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.18,100,,2.416,Percent of Total Billed Charges,100% of Total Billed Charges,9.83,70.18,
FLUOCINOLONE CR 0.025%15G,53358842,CDM,250,RC,,,Outpatient,,,70.18,42.11,,42.11,60,,33.688,Percent of Total Billed Charges,60% of Total Billed Charges,31.58,45,,25.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.65,28,,15.72,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% of Total Billed Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% Total Bille Charges,25.26,36,,20.208,Percent of Total Billed Charges,36% of Total Billed Charges,42.11,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.18,100,,56.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,10.12,14.42,,8.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.64,75,,0.16,Percent of Total Billed Charges,75% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,35.09,50,,28.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.13,70,,39.304,Percent of Total Billed Charges,70% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14,,7.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.18,100,,0.216,Percent of Total Billed Charges,100% of Total Billed Charges,9.83,70.18,
HYDROCORTISONE 0.5% CRM 30GM,53358867,CDM,250,RC,,,Outpatient,,,6.56,3.94,,3.94,60,,3.152,Percent of Total Billed Charges,60% of Total Billed Charges,2.95,45,,2.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,28,,1.472,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.36,36,,1.888,Percent of Total Billed Charges,36% of Total Billed Charges,2.36,36,,1.888,Percent of Total Billed Charges,36% Total Bille Charges,2.36,36,,1.888,Percent of Total Billed Charges,36% of Total Billed Charges,3.94,60,,62.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,100,,5.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14.42,,0.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.92,75,,1012.424,Percent of Total Billed Charges,75% of Total Billed Charges,3.28,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,3.28,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.28,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,3.28,50,,2.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,70,,3.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14,,0.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.56,100,,1349.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.92,22.4,
PRAMOXINE/HYDROCRT 1%FOAM 10GM,53359063,CDM,250,RC,,,Outpatient,,,148.74,89.24,,89.24,60,,71.392,Percent of Total Billed Charges,60% of Total Billed Charges,66.93,45,,53.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.65,28,,33.32,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% of Total Billed Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% Total Bille Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% of Total Billed Charges,89.24,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.74,100,,118.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,21.45,14.42,,17.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.56,75,,3974.704,Percent of Total Billed Charges,75% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.12,70,,83.296,Percent of Total Billed Charges,70% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.74,100,,5299.608,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,148.74,
HYDROCORTISONE 1% CRM 30GM,53359113,CDM,250,RC,,,Outpatient,,,3.78,2.27,,2.27,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,1.7,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.06,28,,0.848,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% of Total Billed Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% Total Bille Charges,1.36,36,,1.088,Percent of Total Billed Charges,36% of Total Billed Charges,2.27,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.78,100,,3.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.84,75,,0.52,Percent of Total Billed Charges,75% of Total Billed Charges,1.89,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.89,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,50,,1.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,70,,2.12,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.78,100,,0.688,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,22.4,
HYDROCORTISONE 1% OINT 30GM,53359115,CDM,250,RC,,,Outpatient,,,5.52,3.31,,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.48,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,28,,1.24,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% of Total Billed Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% Total Bille Charges,1.99,36,,1.592,Percent of Total Billed Charges,36% of Total Billed Charges,3.31,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.52,100,,4.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14.42,,0.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.14,75,,0.152,Percent of Total Billed Charges,75% of Total Billed Charges,2.76,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,50,,2.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,70,,3.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,0.77,14,,0.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.52,100,,0.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.77,22.4,
HYDROCORTISONE 2.5% CRM 30GM,53359139,CDM,250,RC,,,Outpatient,,,140,84.00,,84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,63,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.2,28,,31.36,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,36,,40.32,Percent of Total Billed Charges,36% of Total Billed Charges,50.4,36,,40.32,Percent of Total Billed Charges,36% Total Bille Charges,50.4,36,,40.32,Percent of Total Billed Charges,36% of Total Billed Charges,84,60,,76.696,Percent of Total Billed Charges,60% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140,100,,112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,20.19,14.42,,16.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,75,,83.16,Percent of Total Billed Charges,75% of Total Billed Charges,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98,70,,78.4,Percent of Total Billed Charges,70% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14,,15.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,100,,110.88,Percent of Total Billed Charges,100% of Total Billed Charges,19.6,140,
HYDROGEN PEROX 3% SOL 120ML,53359378,CDM,250,RC,,,Outpatient,,,1.5,0.90,,0.9,60,,0.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,45,,0.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,28,,0.336,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% Total Bille Charges,0.54,36,,0.432,Percent of Total Billed Charges,36% of Total Billed Charges,0.9,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,100,,1.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.13,75,,9.264,Percent of Total Billed Charges,75% of Total Billed Charges,0.75,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.75,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.75,50,,0.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,70,,0.84,Percent of Total Billed Charges,70% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,14,,0.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,100,,12.352,Percent of Total Billed Charges,100% of Total Billed Charges,0.21,22.4,
HYDROGEN PEROX 3% SOL 240ML,53359380,CDM,250,RC,,,Outpatient,,,0.96,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.43,45,,0.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,22.4,32,,17.92,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,443.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,100,,0.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,70,,0.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,100,,24.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,22.4,
IODINE TINCT 60ML,53359949,CDM,250,RC,,,Outpatient,,,14.64,8.78,,8.78,60,,7.024,Percent of Total Billed Charges,60% of Total Billed Charges,6.59,45,,5.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.1,28,,3.28,Percent of Total Billed Charges,28% of Total Billed Charges,22.41,32,,17.928,Percent of Total Billed Charges,32% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,5.27,36,,4.216,Percent of Total Billed Charges,36% of Total Billed Charges,5.27,36,,4.216,Percent of Total Billed Charges,36% Total Bille Charges,5.27,36,,4.216,Percent of Total Billed Charges,36% of Total Billed Charges,8.78,60,,69.36,Percent of Total Billed Charges,60% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.64,100,,11.712,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.11,14.42,,1.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.98,75,,103.528,Percent of Total Billed Charges,75% of Total Billed Charges,7.32,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,7.32,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.32,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,7.32,50,,5.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.25,70,,8.2,Percent of Total Billed Charges,70% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.05,14,,1.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.64,100,,138.04,Percent of Total Billed Charges,100% of Total Billed Charges,2.05,22.41,
KETOCONAZOLE 2% CRM 15GM,53360848,CDM,250,RC,,,Outpatient,,,262.66,157.60,,157.6,60,,126.08,Percent of Total Billed Charges,60% of Total Billed Charges,118.2,45,,94.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.54,28,,58.832,Percent of Total Billed Charges,28% of Total Billed Charges,22.46,32,,17.968,Percent of Total Billed Charges,32% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,94.56,36,,75.648,Percent of Total Billed Charges,36% of Total Billed Charges,94.56,36,,75.648,Percent of Total Billed Charges,36% Total Bille Charges,94.56,36,,75.648,Percent of Total Billed Charges,36% of Total Billed Charges,157.6,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.66,100,,210.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,37.88,14.42,,30.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197,75,,22.768,Percent of Total Billed Charges,75% of Total Billed Charges,131.33,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,131.33,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.33,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,131.33,50,,105.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.86,70,,147.088,Percent of Total Billed Charges,70% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,36.77,14,,29.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.66,100,,30.36,Percent of Total Billed Charges,100% of Total Billed Charges,22.46,262.66,
LANOLIN MODIFIED CR 7GM,53361192,CDM,250,RC,,,Outpatient,,,3.7,2.22,,2.22,60,,1.776,Percent of Total Billed Charges,60% of Total Billed Charges,1.67,45,,1.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,28,,0.832,Percent of Total Billed Charges,28% of Total Billed Charges,22.46,32,,17.968,Percent of Total Billed Charges,32% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% Total Bille Charges,1.33,36,,1.064,Percent of Total Billed Charges,36% of Total Billed Charges,2.22,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.7,100,,2.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.78,75,,15.152,Percent of Total Billed Charges,75% of Total Billed Charges,1.85,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,50,,1.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,70,,2.072,Percent of Total Billed Charges,70% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,0.52,14,,0.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.7,100,,20.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.52,22.46,
LIDOCAINE 2% JELLY 30GM,53361986,CDM,250,RC,,,Outpatient,,,88.74,53.24,,53.24,60,,42.592,Percent of Total Billed Charges,60% of Total Billed Charges,39.93,45,,31.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.85,28,,19.88,Percent of Total Billed Charges,28% of Total Billed Charges,22.49,32,,17.992,Percent of Total Billed Charges,32% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,31.95,36,,25.56,Percent of Total Billed Charges,36% of Total Billed Charges,31.95,36,,25.56,Percent of Total Billed Charges,36% Total Bille Charges,31.95,36,,25.56,Percent of Total Billed Charges,36% of Total Billed Charges,53.24,60,,63.304,Percent of Total Billed Charges,60% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.74,100,,70.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.8,14.42,,10.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.56,75,,42.44,Percent of Total Billed Charges,75% of Total Billed Charges,44.37,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,44.37,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.37,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,44.37,50,,35.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.12,70,,49.696,Percent of Total Billed Charges,70% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,12.42,14,,9.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.74,100,,56.584,Percent of Total Billed Charges,100% of Total Billed Charges,12.42,88.74,
LIDO EPI TETRA L,53361994,CDM,250,RC,,,Outpatient,,,16.3,9.78,,9.78,60,,7.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,45,,5.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,28,,3.648,Percent of Total Billed Charges,28% of Total Billed Charges,22.62,32,,18.096,Percent of Total Billed Charges,32% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% Total Bille Charges,5.87,36,,4.696,Percent of Total Billed Charges,36% of Total Billed Charges,9.78,60,,80.44,Percent of Total Billed Charges,60% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,13.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.35,14.42,,1.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.23,75,,89.248,Percent of Total Billed Charges,75% of Total Billed Charges,8.15,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.15,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,8.15,50,,6.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.41,70,,9.128,Percent of Total Billed Charges,70% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,14,,1.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.3,100,,118.992,Percent of Total Billed Charges,100% of Total Billed Charges,2.28,22.62,
LIDOCAINE 2% JELLY 5GM,53362026,CDM,250,RC,,,Outpatient,,,42.36,25.42,,25.42,60,,20.336,Percent of Total Billed Charges,60% of Total Billed Charges,19.06,45,,15.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.86,28,,9.488,Percent of Total Billed Charges,28% of Total Billed Charges,22.63,32,,18.104,Percent of Total Billed Charges,32% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.25,36,,12.2,Percent of Total Billed Charges,36% of Total Billed Charges,15.25,36,,12.2,Percent of Total Billed Charges,36% Total Bille Charges,15.25,36,,12.2,Percent of Total Billed Charges,36% of Total Billed Charges,25.42,60,,65.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.36,100,,33.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,6.11,14.42,,4.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.77,75,,8.04,Percent of Total Billed Charges,75% of Total Billed Charges,21.18,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,21.18,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.18,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,21.18,50,,16.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.65,70,,23.72,Percent of Total Billed Charges,70% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,5.93,14,,4.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.36,100,,10.72,Percent of Total Billed Charges,100% of Total Billed Charges,5.93,42.36,
LIDOCAINE/PRILOCAINE CRM 5GM,53362042,CDM,250,RC,,,Outpatient,,,20.16,12.10,,12.1,60,,9.68,Percent of Total Billed Charges,60% of Total Billed Charges,9.07,45,,7.256,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.64,28,,4.512,Percent of Total Billed Charges,28% of Total Billed Charges,22.66,32,,18.128,Percent of Total Billed Charges,32% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,7.26,36,,5.808,Percent of Total Billed Charges,36% of Total Billed Charges,7.26,36,,5.808,Percent of Total Billed Charges,36% Total Bille Charges,7.26,36,,5.808,Percent of Total Billed Charges,36% of Total Billed Charges,12.1,60,,78.776,Percent of Total Billed Charges,60% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.16,100,,16.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.91,14.42,,2.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,75,,14.712,Percent of Total Billed Charges,75% of Total Billed Charges,10.08,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,50,,8.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.11,70,,11.288,Percent of Total Billed Charges,70% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,14,,2.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.16,100,,19.616,Percent of Total Billed Charges,100% of Total Billed Charges,2.82,22.66,
LIDOCAINE JEL 2% UROJET 10ML,53362091,CDM,250,RC,,,Outpatient,,,46.92,28.15,,28.15,60,,22.52,Percent of Total Billed Charges,60% of Total Billed Charges,21.11,45,,16.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.14,28,,10.512,Percent of Total Billed Charges,28% of Total Billed Charges,224,32,,179.2,Percent of Total Billed Charges,32% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,36,,13.512,Percent of Total Billed Charges,36% of Total Billed Charges,16.89,36,,13.512,Percent of Total Billed Charges,36% Total Bille Charges,16.89,36,,13.512,Percent of Total Billed Charges,36% of Total Billed Charges,28.15,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.92,100,,37.536,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.77,14.42,,5.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,75,,16.6,Percent of Total Billed Charges,75% of Total Billed Charges,23.46,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,23.46,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.46,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,23.46,50,,18.768,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.84,70,,26.272,Percent of Total Billed Charges,70% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,6.57,14,,5.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,100,,22.128,Percent of Total Billed Charges,100% of Total Billed Charges,6.57,224,
LIDOCAINE 4% TOP CREAM 5GM,53362117,CDM,250,RC,,,Outpatient,,,12.08,7.25,,7.25,60,,5.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.44,45,,4.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.38,28,,2.704,Percent of Total Billed Charges,28% of Total Billed Charges,224.03,32,,179.224,Percent of Total Billed Charges,32% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.35,36,,3.48,Percent of Total Billed Charges,36% of Total Billed Charges,4.35,36,,3.48,Percent of Total Billed Charges,36% Total Bille Charges,4.35,36,,3.48,Percent of Total Billed Charges,36% of Total Billed Charges,7.25,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.08,100,,9.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14.42,,1.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.06,75,,16.6,Percent of Total Billed Charges,75% of Total Billed Charges,6.04,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.04,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,50,,4.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.46,70,,6.768,Percent of Total Billed Charges,70% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.08,100,,22.128,Percent of Total Billed Charges,100% of Total Billed Charges,1.69,224.03,
LIDOCAINE 5% OINT 35GM,53362125,CDM,250,RC,,,Outpatient,,,60.87,36.52,,36.52,60,,29.216,Percent of Total Billed Charges,60% of Total Billed Charges,27.39,45,,21.912,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.04,28,,13.632,Percent of Total Billed Charges,28% of Total Billed Charges,224.54,32,,179.632,Percent of Total Billed Charges,32% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,21.91,36,,17.528,Percent of Total Billed Charges,36% of Total Billed Charges,21.91,36,,17.528,Percent of Total Billed Charges,36% Total Bille Charges,21.91,36,,17.528,Percent of Total Billed Charges,36% of Total Billed Charges,36.52,60,,128.504,Percent of Total Billed Charges,60% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.87,100,,48.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.78,14.42,,7.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.65,75,,1224.344,Percent of Total Billed Charges,75% of Total Billed Charges,30.44,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,30.44,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.44,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,30.44,50,,24.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.61,70,,34.088,Percent of Total Billed Charges,70% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14,,6.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.87,100,,1632.456,Percent of Total Billed Charges,100% of Total Billed Charges,8.52,224.54,
LIDOCAINE 5% TOPICAL PATCH,53362133,CDM,250,RC,,,Outpatient,,,18.72,11.23,,11.23,60,,8.984,Percent of Total Billed Charges,60% of Total Billed Charges,8.42,45,,6.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.24,28,,4.192,Percent of Total Billed Charges,28% of Total Billed Charges,224.55,32,,179.64,Percent of Total Billed Charges,32% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% of Total Billed Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% Total Bille Charges,6.74,36,,5.392,Percent of Total Billed Charges,36% of Total Billed Charges,11.23,60,,173.872,Percent of Total Billed Charges,60% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.72,100,,14.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.7,14.42,,2.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.04,75,,23.544,Percent of Total Billed Charges,75% of Total Billed Charges,9.36,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,9.36,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.36,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,9.36,50,,7.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.1,70,,10.48,Percent of Total Billed Charges,70% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,14,,2.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.72,100,,31.392,Percent of Total Billed Charges,100% of Total Billed Charges,2.62,224.55,
LIDOCAINE 5% CRM 30 GM,53362158,CDM,250,RC,,,Outpatient,,,117.92,70.75,,70.75,60,,56.6,Percent of Total Billed Charges,60% of Total Billed Charges,53.06,45,,42.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.02,28,,26.416,Percent of Total Billed Charges,28% of Total Billed Charges,225.26,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,42.45,36,,33.96,Percent of Total Billed Charges,36% of Total Billed Charges,42.45,36,,33.96,Percent of Total Billed Charges,36% Total Bille Charges,42.45,36,,33.96,Percent of Total Billed Charges,36% of Total Billed Charges,70.75,60,,111.36,Percent of Total Billed Charges,60% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.92,100,,94.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,17,14.42,,13.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.44,75,,13.8,Percent of Total Billed Charges,75% of Total Billed Charges,58.96,50,,47.168,Percent of Total Billed Charges,50% of Total Billed Charges,58.96,50,,47.168,Percent of Total Billed Charges,50% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.96,50,,47.168,Percent of Total Billed Charges,50% of Total Billed Charges,58.96,50,,47.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.54,70,,66.032,Percent of Total Billed Charges,70% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,16.51,14,,13.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.92,100,,18.4,Percent of Total Billed Charges,100% of Total Billed Charges,16.51,225.26,
LIDOCAINE 4% TOP SOL 4ML KIT,53362800,CDM,250,RC,,,Outpatient,,,146.4,87.84,,87.84,60,,70.272,Percent of Total Billed Charges,60% of Total Billed Charges,65.88,45,,52.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.99,28,,32.792,Percent of Total Billed Charges,28% of Total Billed Charges,225.26,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,52.7,36,,42.16,Percent of Total Billed Charges,36% of Total Billed Charges,52.7,36,,42.16,Percent of Total Billed Charges,36% Total Bille Charges,52.7,36,,42.16,Percent of Total Billed Charges,36% of Total Billed Charges,87.84,60,,300.096,Percent of Total Billed Charges,60% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.4,100,,117.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,21.11,14.42,,16.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.8,75,,0.208,Percent of Total Billed Charges,75% of Total Billed Charges,73.2,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,73.2,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.2,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,73.2,50,,58.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.48,70,,81.984,Percent of Total Billed Charges,70% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,20.5,14,,16.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.4,100,,0.272,Percent of Total Billed Charges,100% of Total Billed Charges,20.5,225.26,
MOISTUREL LOT 8OZ,53362976,CDM,250,RC,,,Outpatient,,,15.5,9.30,,9.3,60,,7.44,Percent of Total Billed Charges,60% of Total Billed Charges,6.98,45,,5.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,28,,3.472,Percent of Total Billed Charges,28% of Total Billed Charges,225.26,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.58,36,,4.464,Percent of Total Billed Charges,36% of Total Billed Charges,5.58,36,,4.464,Percent of Total Billed Charges,36% Total Bille Charges,5.58,36,,4.464,Percent of Total Billed Charges,36% of Total Billed Charges,9.3,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,100,,12.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14.42,,1.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.63,75,,316.128,Percent of Total Billed Charges,75% of Total Billed Charges,7.75,50,,6.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.75,50,,6.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,50,,6.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.75,50,,6.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.85,70,,8.68,Percent of Total Billed Charges,70% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.5,100,,421.504,Percent of Total Billed Charges,100% of Total Billed Charges,2.17,225.26,
PREMARIN VAG CRM 30GM,53362984,CDM,250,RC,,,Outpatient,,,711.54,426.92,,426.92,60,,341.536,Percent of Total Billed Charges,60% of Total Billed Charges,320.19,45,,256.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.23,28,,159.384,Percent of Total Billed Charges,28% of Total Billed Charges,225.26,32,,180.208,Percent of Total Billed Charges,32% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,256.15,36,,204.92,Percent of Total Billed Charges,36% of Total Billed Charges,256.15,36,,204.92,Percent of Total Billed Charges,36% Total Bille Charges,256.15,36,,204.92,Percent of Total Billed Charges,36% of Total Billed Charges,426.92,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,711.54,100,,569.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,102.6,14.42,,82.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.66,75,,1.488,Percent of Total Billed Charges,75% of Total Billed Charges,355.77,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,355.77,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.77,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,355.77,50,,284.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.08,70,,398.464,Percent of Total Billed Charges,70% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,99.62,14,,79.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711.54,100,,1.984,Percent of Total Billed Charges,100% of Total Billed Charges,99.62,711.54,
MENTHLCAMPHR28G+,53363966,CDM,250,RC,,,Outpatient,,,3.34,2.00,,2,60,,1.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,45,,1.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,28,,0.752,Percent of Total Billed Charges,28% of Total Billed Charges,225.53,32,,180.424,Percent of Total Billed Charges,32% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,1.2,36,,0.96,Percent of Total Billed Charges,36% of Total Billed Charges,1.2,36,,0.96,Percent of Total Billed Charges,36% Total Bille Charges,1.2,36,,0.96,Percent of Total Billed Charges,36% of Total Billed Charges,2,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.34,100,,2.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.48,14.42,,0.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.51,75,,174.688,Percent of Total Billed Charges,75% of Total Billed Charges,1.67,50,,1.336,Percent of Total Billed Charges,50% of Total Billed Charges,1.67,50,,1.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.67,50,,1.336,Percent of Total Billed Charges,50% of Total Billed Charges,1.67,50,,1.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,70,,1.872,Percent of Total Billed Charges,70% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14,,0.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.34,100,,232.912,Percent of Total Billed Charges,100% of Total Billed Charges,0.47,225.53,
METHYL SALICYLATE OIL 60ML,53364774,CDM,250,RC,,,Outpatient,,,8.2,4.92,,4.92,60,,3.936,Percent of Total Billed Charges,60% of Total Billed Charges,3.69,45,,2.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.3,28,,1.84,Percent of Total Billed Charges,28% of Total Billed Charges,225.6,32,,180.48,Percent of Total Billed Charges,32% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% of Total Billed Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% Total Bille Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% of Total Billed Charges,4.92,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,100,,6.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.15,75,,11.016,Percent of Total Billed Charges,75% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.74,70,,4.592,Percent of Total Billed Charges,70% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,100,,14.688,Percent of Total Billed Charges,100% of Total Billed Charges,1.15,225.6,
METHYL SALICY/MENTHOL ONT 60GM,53364780,CDM,250,RC,,,Outpatient,,,8.2,4.92,,4.92,60,,3.936,Percent of Total Billed Charges,60% of Total Billed Charges,3.69,45,,2.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.3,28,,1.84,Percent of Total Billed Charges,28% of Total Billed Charges,226.11,32,,180.888,Percent of Total Billed Charges,32% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% of Total Billed Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% Total Bille Charges,2.95,36,,2.36,Percent of Total Billed Charges,36% of Total Billed Charges,4.92,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,100,,6.56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14.42,,0.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.15,75,,221.936,Percent of Total Billed Charges,75% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,4.1,50,,3.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.74,70,,4.592,Percent of Total Billed Charges,70% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,1.15,14,,0.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,100,,295.912,Percent of Total Billed Charges,100% of Total Billed Charges,1.15,226.11,
METRONIDAZOLE 0.75% CREAM 45GM,53365599,CDM,250,RC,,,Outpatient,,,370.4,222.24,,222.24,60,,177.792,Percent of Total Billed Charges,60% of Total Billed Charges,166.68,45,,133.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.71,28,,82.968,Percent of Total Billed Charges,28% of Total Billed Charges,226.39,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,133.34,36,,106.672,Percent of Total Billed Charges,36% of Total Billed Charges,133.34,36,,106.672,Percent of Total Billed Charges,36% Total Bille Charges,133.34,36,,106.672,Percent of Total Billed Charges,36% of Total Billed Charges,222.24,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.4,100,,296.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,53.41,14.42,,42.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.8,75,,315.872,Percent of Total Billed Charges,75% of Total Billed Charges,185.2,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,185.2,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.2,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,185.2,50,,148.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.28,70,,207.424,Percent of Total Billed Charges,70% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,51.86,14,,41.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,370.4,100,,394.84,Percent of Total Billed Charges,100% of Total Billed Charges,51.86,370.4,
METRONIDAZOLE 1% TOP GEL 60GM,53365600,CDM,250,RC,,,Outpatient,,,554.48,332.69,,332.69,60,,266.152,Percent of Total Billed Charges,60% of Total Billed Charges,249.52,45,,199.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.25,28,,124.2,Percent of Total Billed Charges,28% of Total Billed Charges,226.39,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,199.61,36,,159.688,Percent of Total Billed Charges,36% of Total Billed Charges,199.61,36,,159.688,Percent of Total Billed Charges,36% Total Bille Charges,199.61,36,,159.688,Percent of Total Billed Charges,36% of Total Billed Charges,332.69,60,,79.68,Percent of Total Billed Charges,60% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,554.48,100,,443.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,79.96,14.42,,63.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.86,75,,144.864,Percent of Total Billed Charges,75% of Total Billed Charges,277.24,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,277.24,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.24,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,277.24,50,,221.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,388.14,70,,310.512,Percent of Total Billed Charges,70% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,77.63,14,,62.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,554.48,100,,181.08,Percent of Total Billed Charges,100% of Total Billed Charges,77.63,554.48,
METRONIDAZ 0.75% VAG GEL 70GM,53365607,CDM,250,RC,,,Outpatient,,,298.32,178.99,,178.99,60,,143.192,Percent of Total Billed Charges,60% of Total Billed Charges,134.24,45,,107.392,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.53,28,,66.824,Percent of Total Billed Charges,28% of Total Billed Charges,226.39,32,,181.112,Percent of Total Billed Charges,32% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,107.4,36,,85.92,Percent of Total Billed Charges,36% of Total Billed Charges,107.4,36,,85.92,Percent of Total Billed Charges,36% Total Bille Charges,107.4,36,,85.92,Percent of Total Billed Charges,36% of Total Billed Charges,178.99,60,,152.696,Percent of Total Billed Charges,60% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.32,100,,238.656,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.74,75,,193.152,Percent of Total Billed Charges,75% of Total Billed Charges,149.16,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,149.16,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.16,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,149.16,50,,119.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,208.82,70,,167.056,Percent of Total Billed Charges,70% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,41.76,14,,33.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.32,100,,241.44,Percent of Total Billed Charges,100% of Total Billed Charges,41.76,298.32,
MICONAZOLE 100MG VAG SUP (7),53365797,CDM,250,RC,,,Outpatient,,,7.18,4.31,,4.31,60,,3.448,Percent of Total Billed Charges,60% of Total Billed Charges,3.23,45,,2.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.01,28,,1.608,Percent of Total Billed Charges,28% of Total Billed Charges,22.72,32,,18.176,Percent of Total Billed Charges,32% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,2.58,36,,2.064,Percent of Total Billed Charges,36% of Total Billed Charges,2.58,36,,2.064,Percent of Total Billed Charges,36% Total Bille Charges,2.58,36,,2.064,Percent of Total Billed Charges,36% of Total Billed Charges,4.31,60,,146.64,Percent of Total Billed Charges,60% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.18,100,,5.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14.42,,0.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,75,,1.408,Percent of Total Billed Charges,75% of Total Billed Charges,3.59,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,3.59,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.59,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,3.59,50,,2.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.03,70,,4.024,Percent of Total Billed Charges,70% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,1.01,14,,0.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.18,100,,1.872,Percent of Total Billed Charges,100% of Total Billed Charges,1.01,22.72,
MONISTAT 3 4% +,53365821,CDM,250,RC,,,Outpatient,,,12.71,7.63,,7.63,60,,6.104,Percent of Total Billed Charges,60% of Total Billed Charges,5.72,45,,4.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.56,28,,2.848,Percent of Total Billed Charges,28% of Total Billed Charges,22.78,32,,18.224,Percent of Total Billed Charges,32% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,4.58,36,,3.664,Percent of Total Billed Charges,36% of Total Billed Charges,4.58,36,,3.664,Percent of Total Billed Charges,36% Total Bille Charges,4.58,36,,3.664,Percent of Total Billed Charges,36% of Total Billed Charges,7.63,60,,90.296,Percent of Total Billed Charges,60% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.71,100,,10.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14.42,,1.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.53,75,,38.08,Percent of Total Billed Charges,75% of Total Billed Charges,6.36,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,6.36,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.36,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,6.36,50,,5.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.9,70,,7.12,Percent of Total Billed Charges,70% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.78,14,,1.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.71,100,,50.768,Percent of Total Billed Charges,100% of Total Billed Charges,1.78,22.78,
MICONAZOLE 2% VAG CRM 45GM,53365896,CDM,250,RC,,,Outpatient,,,19.7,11.82,,11.82,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,8.87,45,,7.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.52,28,,4.416,Percent of Total Billed Charges,28% of Total Billed Charges,22.89,32,,18.312,Percent of Total Billed Charges,32% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% of Total Billed Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% Total Bille Charges,7.09,36,,5.672,Percent of Total Billed Charges,36% of Total Billed Charges,11.82,60,,65.488,Percent of Total Billed Charges,60% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.7,100,,15.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.84,14.42,,2.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,75,,25449,Percent of Total Billed Charges,75% of Total Billed Charges,9.85,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,9.85,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.85,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,9.85,50,,7.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.79,70,,11.032,Percent of Total Billed Charges,70% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14,,2.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.7,100,,33932,Percent of Total Billed Charges,100% of Total Billed Charges,2.76,22.89,
MICONAZOLE CRM 2% 30GM,53365946,CDM,250,RC,,,Outpatient,,,5.84,3.50,,3.5,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.63,45,,2.104,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,28,,1.312,Percent of Total Billed Charges,28% of Total Billed Charges,227.67,32,,182.136,Percent of Total Billed Charges,32% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% Total Bille Charges,2.1,36,,1.68,Percent of Total Billed Charges,36% of Total Billed Charges,3.5,60,,65.488,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.84,100,,4.672,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,14.42,,0.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,75,,44.664,Percent of Total Billed Charges,75% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,2.92,50,,2.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.09,70,,3.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,14,,0.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.84,100,,59.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.82,227.67,
MICROFIBR COLLAG HEM 1GM PWD,53366100,CDM,272,RC,,,Outpatient,,,924.25,554.55,,554.55,60,,443.64,Percent of Total Billed Charges,60% of Total Billed Charges,415.91,45,,332.728,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.79,28,,207.032,Percent of Total Billed Charges,28% of Total Billed Charges,227.69,32,,182.152,Percent of Total Billed Charges,32% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,332.73,36,,266.184,Percent of Total Billed Charges,36% of Total Billed Charges,332.73,36,,266.184,Percent of Total Billed Charges,36% Total Bille Charges,332.73,36,,266.184,Percent of Total Billed Charges,36% of Total Billed Charges,554.55,60,,71.464,Percent of Total Billed Charges,60% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,924.25,100,,739.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,133.28,14.42,,106.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,693.19,75,,50.272,Percent of Total Billed Charges,75% of Total Billed Charges,462.13,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,462.13,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,462.13,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,462.13,50,,369.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,646.98,70,,517.584,Percent of Total Billed Charges,70% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,129.4,14,,103.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,924.25,100,,67.024,Percent of Total Billed Charges,100% of Total Billed Charges,129.4,924.25,
AVITENE SHEETS,53366126,CDM,250,RC,,,Outpatient,,,568.25,340.95,,340.95,60,,272.76,Percent of Total Billed Charges,60% of Total Billed Charges,255.71,45,,204.568,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.11,28,,127.288,Percent of Total Billed Charges,28% of Total Billed Charges,227.98,32,,182.384,Percent of Total Billed Charges,32% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,204.57,36,,163.656,Percent of Total Billed Charges,36% of Total Billed Charges,204.57,36,,163.656,Percent of Total Billed Charges,36% Total Bille Charges,204.57,36,,163.656,Percent of Total Billed Charges,36% of Total Billed Charges,340.95,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.25,100,,454.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,81.94,14.42,,65.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,426.19,75,,711.296,Percent of Total Billed Charges,75% of Total Billed Charges,284.13,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,284.13,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.13,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,284.13,50,,227.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,397.78,70,,318.224,Percent of Total Billed Charges,70% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,79.56,14,,63.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,568.25,100,,948.392,Percent of Total Billed Charges,100% of Total Billed Charges,79.56,568.25,
EUCERIN CRM 4OZ,53366720,CDM,250,RC,,,Outpatient,,,13.18,7.91,,7.91,60,,6.328,Percent of Total Billed Charges,60% of Total Billed Charges,5.93,45,,4.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,28,,2.952,Percent of Total Billed Charges,28% of Total Billed Charges,229.12,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,4.74,36,,3.792,Percent of Total Billed Charges,36% of Total Billed Charges,4.74,36,,3.792,Percent of Total Billed Charges,36% Total Bille Charges,4.74,36,,3.792,Percent of Total Billed Charges,36% of Total Billed Charges,7.91,60,,124.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,100,,10.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.9,14.42,,1.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,75,,1955.4,Percent of Total Billed Charges,75% of Total Billed Charges,6.59,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,6.59,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.59,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,6.59,50,,5.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.23,70,,7.384,Percent of Total Billed Charges,70% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,1.85,14,,1.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.18,100,,2607.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.85,229.12,
MOMETASONE .1% 45GM,53366811,CDM,250,RC,,,Outpatient,,,24.18,14.51,,14.51,60,,11.608,Percent of Total Billed Charges,60% of Total Billed Charges,10.88,45,,8.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.77,28,,5.416,Percent of Total Billed Charges,28% of Total Billed Charges,229.12,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.7,36,,6.96,Percent of Total Billed Charges,36% of Total Billed Charges,8.7,36,,6.96,Percent of Total Billed Charges,36% Total Bille Charges,8.7,36,,6.96,Percent of Total Billed Charges,36% of Total Billed Charges,14.51,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.18,100,,19.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.49,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.14,75,,7.816,Percent of Total Billed Charges,75% of Total Billed Charges,12.09,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,12.09,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.09,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,12.09,50,,9.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.93,70,,13.544,Percent of Total Billed Charges,70% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.18,100,,10.416,Percent of Total Billed Charges,100% of Total Billed Charges,3.39,229.12,
MONSELS SOL 30CC BTL,53366829,CDM,250,RC,,,Outpatient,,,3.96,2.38,,2.38,60,,1.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.78,45,,1.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,28,,0.888,Percent of Total Billed Charges,28% of Total Billed Charges,229.12,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% of Total Billed Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% Total Bille Charges,1.43,36,,1.144,Percent of Total Billed Charges,36% of Total Billed Charges,2.38,60,,85.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.96,100,,3.168,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,75,,14.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,1.98,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.98,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,1.98,50,,1.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.77,70,,2.216,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.96,100,,19.12,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,229.12,
MUPIROCIN 2% NASAL OINT 1 GM,53366837,CDM,250,RC,,,Outpatient,,,34.14,20.48,,20.48,60,,16.384,Percent of Total Billed Charges,60% of Total Billed Charges,15.36,45,,12.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.56,28,,7.648,Percent of Total Billed Charges,28% of Total Billed Charges,229.12,32,,183.296,Percent of Total Billed Charges,32% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,12.29,36,,9.832,Percent of Total Billed Charges,36% of Total Billed Charges,12.29,36,,9.832,Percent of Total Billed Charges,36% Total Bille Charges,12.29,36,,9.832,Percent of Total Billed Charges,36% of Total Billed Charges,20.48,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.14,100,,27.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.92,14.42,,3.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.61,75,,112.28,Percent of Total Billed Charges,75% of Total Billed Charges,17.07,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,17.07,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.07,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,17.07,50,,13.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.9,70,,19.12,Percent of Total Billed Charges,70% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,4.78,14,,3.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.14,100,,149.704,Percent of Total Billed Charges,100% of Total Billed Charges,4.78,229.12,
MUPIROCIN 2% CRM 15 GM,53366852,CDM,250,RC,,,Outpatient,,,37.49,22.49,,22.49,60,,17.992,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,45,,13.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.5,28,,8.4,Percent of Total Billed Charges,28% of Total Billed Charges,229.43,32,,183.544,Percent of Total Billed Charges,32% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,13.5,36,,10.8,Percent of Total Billed Charges,36% of Total Billed Charges,13.5,36,,10.8,Percent of Total Billed Charges,36% Total Bille Charges,13.5,36,,10.8,Percent of Total Billed Charges,36% of Total Billed Charges,22.49,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.49,100,,29.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.41,14.42,,4.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.12,75,,20.848,Percent of Total Billed Charges,75% of Total Billed Charges,18.75,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,18.75,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.75,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,18.75,50,,15,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.24,70,,20.992,Percent of Total Billed Charges,70% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.25,14,,4.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.49,100,,27.792,Percent of Total Billed Charges,100% of Total Billed Charges,5.25,229.43,
BAC/NEO/POLY ONT 30GM,53367751,CDM,250,RC,,,Outpatient,,,6.32,3.79,,3.79,60,,3.032,Percent of Total Billed Charges,60% of Total Billed Charges,2.84,45,,2.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,28,,1.416,Percent of Total Billed Charges,28% of Total Billed Charges,229.43,32,,183.544,Percent of Total Billed Charges,32% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% Total Bille Charges,2.28,36,,1.824,Percent of Total Billed Charges,36% of Total Billed Charges,3.79,60,,77.496,Percent of Total Billed Charges,60% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.32,100,,5.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14.42,,0.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,75,,171.608,Percent of Total Billed Charges,75% of Total Billed Charges,3.16,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,3.16,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.16,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,3.16,50,,2.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.42,70,,3.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,100,,228.808,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,229.43,
BAC/NEO/POLY ONT 0.9GM,53367819,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,45,,0.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,100,,0.296,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,53.784,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,71.712,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,229.79,
NICOTINE 7MG/24HR PATCH,53368106,CDM,250,RC,,,Outpatient,,,5.2,3.12,,3.12,60,,2.496,Percent of Total Billed Charges,60% of Total Billed Charges,2.34,45,,1.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% Total Bille Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,3.12,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,100,,4.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,75,,521.28,Percent of Total Billed Charges,75% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.64,70,,2.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,100,,695.04,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,229.79,
NICOTINE 14MG/24HR PATCH,53368114,CDM,250,RC,,,Outpatient,,,5.02,3.01,,3.01,60,,2.408,Percent of Total Billed Charges,60% of Total Billed Charges,2.26,45,,1.808,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.41,28,,1.128,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,36,,1.448,Percent of Total Billed Charges,36% of Total Billed Charges,1.81,36,,1.448,Percent of Total Billed Charges,36% Total Bille Charges,1.81,36,,1.448,Percent of Total Billed Charges,36% of Total Billed Charges,3.01,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,4.016,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14.42,,0.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.77,75,,46.272,Percent of Total Billed Charges,75% of Total Billed Charges,2.51,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,2.51,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.51,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,2.51,50,,2.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.51,70,,2.808,Percent of Total Billed Charges,70% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.02,100,,61.696,Percent of Total Billed Charges,100% of Total Billed Charges,0.7,229.79,
NICOTINE 21MG/24HR PATCH,53368122,CDM,250,RC,,,Outpatient,,,5.2,3.12,,3.12,60,,2.496,Percent of Total Billed Charges,60% of Total Billed Charges,2.34,45,,1.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% Total Bille Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,3.12,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,100,,4.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,75,,5.248,Percent of Total Billed Charges,75% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.64,70,,2.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,100,,7,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,229.79,
NITROGLYCERIN PATCH 0.1MG/HR,53368353,CDM,250,RC,,,Outpatient,,,0.96,0.58,,0.58,60,,0.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.43,45,,0.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,28,,0.216,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% Total Bille Charges,0.35,36,,0.28,Percent of Total Billed Charges,36% of Total Billed Charges,0.58,60,,108.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.96,100,,0.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.72,75,,106.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,0.48,50,,0.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,70,,0.536,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.96,100,,141.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,229.79,
NITROGLYCERIN PATCH 0.2MG/HR,53368361,CDM,250,RC,,,Outpatient,,,1.31,0.79,,0.79,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.59,45,,0.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% Total Bille Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,100,,1.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,75,,30.208,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,70,,0.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,100,,40.28,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,229.79,
NITROGLYCERIN PATCH 0.4MG/HR,53368387,CDM,250,RC,,,Outpatient,,,1.54,0.92,,0.92,60,,0.736,Percent of Total Billed Charges,60% of Total Billed Charges,0.69,45,,0.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,28,,0.344,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% Total Bille Charges,0.55,36,,0.44,Percent of Total Billed Charges,36% of Total Billed Charges,0.92,60,,59.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.54,100,,1.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14.42,,0.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.16,75,,213.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.77,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.77,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,0.77,50,,0.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,70,,0.864,Percent of Total Billed Charges,70% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,14,,0.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.54,100,,284.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.22,229.79,
NITROGLYCERIN 2% OINT 30GM,53368684,CDM,250,RC,,,Outpatient,,,62,37.20,,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,45,,22.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.36,28,,13.888,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.32,36,,17.856,Percent of Total Billed Charges,36% of Total Billed Charges,22.32,36,,17.856,Percent of Total Billed Charges,36% Total Bille Charges,22.32,36,,17.856,Percent of Total Billed Charges,36% of Total Billed Charges,37.2,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,100,,49.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.94,14.42,,7.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.5,75,,103.6,Percent of Total Billed Charges,75% of Total Billed Charges,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.4,70,,34.72,Percent of Total Billed Charges,70% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,8.68,14,,6.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62,100,,138.128,Percent of Total Billed Charges,100% of Total Billed Charges,8.68,229.79,
NITROGLYCERIN 2% OINT 1GM,53368882,CDM,250,RC,,,Outpatient,,,4.01,2.41,,2.41,60,,1.928,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,28,,0.896,Percent of Total Billed Charges,28% of Total Billed Charges,229.79,32,,183.832,Percent of Total Billed Charges,32% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% Total Bille Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,2.41,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,100,,3.208,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14.42,,0.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,75,,194.88,Percent of Total Billed Charges,75% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.81,70,,2.248,Percent of Total Billed Charges,70% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,100,,259.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,229.79,
NYSTATIN 100000UN/GM CRM 15GM,53369096,CDM,250,RC,,,Outpatient,,,26.24,15.74,,15.74,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,11.81,45,,9.448,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.35,28,,5.88,Percent of Total Billed Charges,28% of Total Billed Charges,229.82,32,,183.856,Percent of Total Billed Charges,32% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,36,,7.56,Percent of Total Billed Charges,36% of Total Billed Charges,9.45,36,,7.56,Percent of Total Billed Charges,36% Total Bille Charges,9.45,36,,7.56,Percent of Total Billed Charges,36% of Total Billed Charges,15.74,60,,67.088,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.24,100,,20.992,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.78,14.42,,3.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.68,75,,55.808,Percent of Total Billed Charges,75% of Total Billed Charges,13.12,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,13.12,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.12,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,13.12,50,,10.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.37,70,,14.696,Percent of Total Billed Charges,70% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.24,100,,74.408,Percent of Total Billed Charges,100% of Total Billed Charges,3.67,229.82,
NYSTATIN 100000UN/GM PWD 15GM,53369195,CDM,250,RC,,,Outpatient,,,50.06,30.04,,30.04,60,,24.032,Percent of Total Billed Charges,60% of Total Billed Charges,22.53,45,,18.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.02,28,,11.216,Percent of Total Billed Charges,28% of Total Billed Charges,230.05,32,,184.04,Percent of Total Billed Charges,32% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,18.02,36,,14.416,Percent of Total Billed Charges,36% of Total Billed Charges,18.02,36,,14.416,Percent of Total Billed Charges,36% Total Bille Charges,18.02,36,,14.416,Percent of Total Billed Charges,36% of Total Billed Charges,30.04,60,,65.64,Percent of Total Billed Charges,60% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.06,100,,40.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14.42,,5.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.55,75,,193.08,Percent of Total Billed Charges,75% of Total Billed Charges,25.03,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,25.03,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.03,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,25.03,50,,20.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.04,70,,28.032,Percent of Total Billed Charges,70% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,7.01,14,,5.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.06,100,,257.44,Percent of Total Billed Charges,100% of Total Billed Charges,7.01,230.05,
NYSTATIN 100000UN/GM ONT 15GM,53369245,CDM,250,RC,,,Outpatient,,,15.2,9.12,,9.12,60,,7.296,Percent of Total Billed Charges,60% of Total Billed Charges,6.84,45,,5.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.26,28,,3.408,Percent of Total Billed Charges,28% of Total Billed Charges,230.16,32,,184.128,Percent of Total Billed Charges,32% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,5.47,36,,4.376,Percent of Total Billed Charges,36% of Total Billed Charges,5.47,36,,4.376,Percent of Total Billed Charges,36% Total Bille Charges,5.47,36,,4.376,Percent of Total Billed Charges,36% of Total Billed Charges,9.12,60,,125.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.2,100,,12.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.19,14.42,,1.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.4,75,,137.6,Percent of Total Billed Charges,75% of Total Billed Charges,7.6,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,7.6,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,7.6,50,,6.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.64,70,,8.512,Percent of Total Billed Charges,70% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.13,14,,1.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.2,100,,183.464,Percent of Total Billed Charges,100% of Total Billed Charges,2.13,230.16,
CICLOPIROX 0.77% CRM 15 GM,53369850,CDM,250,RC,,,Outpatient,,,51.54,30.92,,30.92,60,,24.736,Percent of Total Billed Charges,60% of Total Billed Charges,23.19,45,,18.552,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.43,28,,11.544,Percent of Total Billed Charges,28% of Total Billed Charges,23.04,32,,18.432,Percent of Total Billed Charges,32% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,18.55,36,,14.84,Percent of Total Billed Charges,36% of Total Billed Charges,18.55,36,,14.84,Percent of Total Billed Charges,36% Total Bille Charges,18.55,36,,14.84,Percent of Total Billed Charges,36% of Total Billed Charges,30.92,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.54,100,,41.232,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.43,14.42,,5.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.66,75,,144.864,Percent of Total Billed Charges,75% of Total Billed Charges,25.77,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,25.77,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.77,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,25.77,50,,20.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.08,70,,28.864,Percent of Total Billed Charges,70% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,7.22,14,,5.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.54,100,,193.152,Percent of Total Billed Charges,100% of Total Billed Charges,7.22,51.54,
UREA CRME 85GM,53369864,CDM,250,RC,,,Outpatient,,,267.6,160.56,,160.56,60,,128.448,Percent of Total Billed Charges,60% of Total Billed Charges,120.42,45,,96.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.93,28,,59.944,Percent of Total Billed Charges,28% of Total Billed Charges,23.11,32,,18.488,Percent of Total Billed Charges,32% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,96.34,36,,77.072,Percent of Total Billed Charges,36% of Total Billed Charges,96.34,36,,77.072,Percent of Total Billed Charges,36% Total Bille Charges,96.34,36,,77.072,Percent of Total Billed Charges,36% of Total Billed Charges,160.56,60,,140.32,Percent of Total Billed Charges,60% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.6,100,,214.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,38.59,14.42,,30.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.7,75,,900.904,Percent of Total Billed Charges,75% of Total Billed Charges,133.8,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,133.8,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.8,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,133.8,50,,107.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.32,70,,149.856,Percent of Total Billed Charges,70% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,37.46,14,,29.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.6,100,,1201.2,Percent of Total Billed Charges,100% of Total Billed Charges,23.11,267.6,
GRANULEX 120ML,53369971,CDM,250,RC,,,Outpatient,,,24.36,14.62,,14.62,60,,11.696,Percent of Total Billed Charges,60% of Total Billed Charges,10.96,45,,8.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.82,28,,5.456,Percent of Total Billed Charges,28% of Total Billed Charges,23.17,32,,18.536,Percent of Total Billed Charges,32% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,8.77,36,,7.016,Percent of Total Billed Charges,36% of Total Billed Charges,8.77,36,,7.016,Percent of Total Billed Charges,36% Total Bille Charges,8.77,36,,7.016,Percent of Total Billed Charges,36% of Total Billed Charges,14.62,60,,209.552,Percent of Total Billed Charges,60% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.36,100,,19.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14.42,,2.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.27,75,,81.392,Percent of Total Billed Charges,75% of Total Billed Charges,12.18,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,12.18,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.18,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,12.18,50,,9.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.05,70,,13.64,Percent of Total Billed Charges,70% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,3.41,14,,2.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.36,100,,108.52,Percent of Total Billed Charges,100% of Total Billed Charges,3.41,24.36,
PETROLATUM ONT 30GM,53370185,CDM,250,RC,,,Outpatient,,,5.2,3.12,,3.12,60,,2.496,Percent of Total Billed Charges,60% of Total Billed Charges,2.34,45,,1.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,23.2,32,,18.56,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% Total Bille Charges,1.87,36,,1.496,Percent of Total Billed Charges,36% of Total Billed Charges,3.12,60,,270.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,100,,4.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.9,75,,224.032,Percent of Total Billed Charges,75% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,50,,2.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.64,70,,2.912,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,100,,298.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,23.2,
CORTISPORIN7.5G+,53370797,CDM,250,RC,,,Outpatient,,,231.06,138.64,,138.64,60,,110.912,Percent of Total Billed Charges,60% of Total Billed Charges,103.98,45,,83.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.7,28,,51.76,Percent of Total Billed Charges,28% of Total Billed Charges,23.2,32,,18.56,Percent of Total Billed Charges,32% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,83.18,36,,66.544,Percent of Total Billed Charges,36% of Total Billed Charges,83.18,36,,66.544,Percent of Total Billed Charges,36% Total Bille Charges,83.18,36,,66.544,Percent of Total Billed Charges,36% of Total Billed Charges,138.64,60,,203.16,Percent of Total Billed Charges,60% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.06,100,,184.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.32,14.42,,26.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.3,75,,2.968,Percent of Total Billed Charges,75% of Total Billed Charges,115.53,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,115.53,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,115.53,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,115.53,50,,92.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.74,70,,129.392,Percent of Total Billed Charges,70% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,32.35,14,,25.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.06,100,,3.96,Percent of Total Billed Charges,100% of Total Billed Charges,23.2,231.06,
NAPHCON-A OPHT SOL 15ML,53370850,CDM,250,RC,,,Outpatient,,,12.06,7.24,,7.24,60,,5.792,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,45,,4.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.38,28,,2.704,Percent of Total Billed Charges,28% of Total Billed Charges,23.21,32,,18.568,Percent of Total Billed Charges,32% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,36,,3.472,Percent of Total Billed Charges,36% of Total Billed Charges,4.34,36,,3.472,Percent of Total Billed Charges,36% Total Bille Charges,4.34,36,,3.472,Percent of Total Billed Charges,36% of Total Billed Charges,7.24,60,,100.576,Percent of Total Billed Charges,60% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.06,100,,9.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14.42,,1.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.05,75,,166.856,Percent of Total Billed Charges,75% of Total Billed Charges,6.03,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,6.03,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.03,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,6.03,50,,4.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.44,70,,6.752,Percent of Total Billed Charges,70% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,1.69,14,,1.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.06,100,,222.472,Percent of Total Billed Charges,100% of Total Billed Charges,1.69,23.21,
POVIDONE-IODINE 10% OINT 30GM,53371076,CDM,250,RC,,,Outpatient,,,3.84,2.30,,2.3,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,28,,0.864,Percent of Total Billed Charges,28% of Total Billed Charges,23.21,32,,18.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% Total Bille Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,2.3,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.84,100,,3.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,75,,148.92,Percent of Total Billed Charges,75% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.69,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.84,100,,198.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,23.21,
POVIDONE-IODINE SOLN 120ML,53371217,CDM,250,RC,,,Outpatient,,,3.84,2.30,,2.3,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,28,,0.864,Percent of Total Billed Charges,28% of Total Billed Charges,23.21,32,,18.568,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% Total Bille Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,2.3,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.84,100,,3.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,75,,426.192,Percent of Total Billed Charges,75% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.69,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.84,100,,568.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,23.21,
POVIDONE-IODINE SOLN 120ML,53371225,CDM,250,RC,,,Outpatient,,,3.84,2.30,,2.3,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.73,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.08,28,,0.864,Percent of Total Billed Charges,28% of Total Billed Charges,23.26,32,,18.608,Percent of Total Billed Charges,32% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% Total Bille Charges,1.38,36,,1.104,Percent of Total Billed Charges,36% of Total Billed Charges,2.3,60,,75.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.84,100,,3.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14.42,,0.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.88,75,,37.344,Percent of Total Billed Charges,75% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,1.92,50,,1.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.69,70,,2.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14,,0.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.84,100,,49.792,Percent of Total Billed Charges,100% of Total Billed Charges,0.54,23.26,
POVIDONE-IODINE,53371233,CDM,250,RC,,,Outpatient,,,9.24,5.54,,5.54,60,,4.432,Percent of Total Billed Charges,60% of Total Billed Charges,4.16,45,,3.328,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.59,28,,2.072,Percent of Total Billed Charges,28% of Total Billed Charges,23.28,32,,18.624,Percent of Total Billed Charges,32% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% of Total Billed Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% Total Bille Charges,3.33,36,,2.664,Percent of Total Billed Charges,36% of Total Billed Charges,5.54,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.24,100,,7.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.33,14.42,,1.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.93,75,,51.568,Percent of Total Billed Charges,75% of Total Billed Charges,4.62,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,50,,3.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.47,70,,5.176,Percent of Total Billed Charges,70% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,1.29,14,,1.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.24,100,,68.752,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,23.28,
PRAMOXINE-HC 2.5% REC CRM 30GM,53371472,CDM,250,RC,,,Outpatient,,,314.4,188.64,,188.64,60,,150.912,Percent of Total Billed Charges,60% of Total Billed Charges,141.48,45,,113.184,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.03,28,,70.424,Percent of Total Billed Charges,28% of Total Billed Charges,23.28,32,,18.624,Percent of Total Billed Charges,32% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,113.18,36,,90.544,Percent of Total Billed Charges,36% of Total Billed Charges,113.18,36,,90.544,Percent of Total Billed Charges,36% Total Bille Charges,113.18,36,,90.544,Percent of Total Billed Charges,36% of Total Billed Charges,188.64,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.4,100,,251.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,45.34,14.42,,36.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.8,75,,59.48,Percent of Total Billed Charges,75% of Total Billed Charges,157.2,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,157.2,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.2,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,157.2,50,,125.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.08,70,,176.064,Percent of Total Billed Charges,70% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,44.02,14,,35.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.4,100,,79.304,Percent of Total Billed Charges,100% of Total Billed Charges,23.28,314.4,
SCOPOLAMINE PATCH 1.5MG,53372538,CDM,250,RC,,,Outpatient,,,42.59,25.55,,25.55,60,,20.44,Percent of Total Billed Charges,60% of Total Billed Charges,19.17,45,,15.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.93,28,,9.544,Percent of Total Billed Charges,28% of Total Billed Charges,23.29,32,,18.632,Percent of Total Billed Charges,32% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.33,36,,12.264,Percent of Total Billed Charges,36% of Total Billed Charges,15.33,36,,12.264,Percent of Total Billed Charges,36% Total Bille Charges,15.33,36,,12.264,Percent of Total Billed Charges,36% of Total Billed Charges,25.55,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.59,100,,34.072,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.14,14.42,,4.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.94,75,,161.992,Percent of Total Billed Charges,75% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.81,70,,23.848,Percent of Total Billed Charges,70% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.59,100,,215.984,Percent of Total Billed Charges,100% of Total Billed Charges,5.96,42.59,
SILVER NITRATE STICK,53372710,CDM,250,RC,,,Outpatient,,,0.94,0.56,,0.56,60,,0.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,45,,0.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,28,,0.208,Percent of Total Billed Charges,28% of Total Billed Charges,23.29,32,,18.632,Percent of Total Billed Charges,32% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% Total Bille Charges,0.34,36,,0.272,Percent of Total Billed Charges,36% of Total Billed Charges,0.56,60,,668.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.94,100,,0.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,14.42,,0.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.71,75,,159.92,Percent of Total Billed Charges,75% of Total Billed Charges,0.47,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.47,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,0.47,50,,0.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,70,,0.528,Percent of Total Billed Charges,70% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14,,0.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.94,100,,213.224,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,23.29,
SILVER SULFADIAZINE 1% CRM 50G,53372728,CDM,250,RC,,,Outpatient,,,27.28,16.37,,16.37,60,,13.096,Percent of Total Billed Charges,60% of Total Billed Charges,12.28,45,,9.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.64,28,,6.112,Percent of Total Billed Charges,28% of Total Billed Charges,23.3,32,,18.64,Percent of Total Billed Charges,32% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,9.82,36,,7.856,Percent of Total Billed Charges,36% of Total Billed Charges,9.82,36,,7.856,Percent of Total Billed Charges,36% Total Bille Charges,9.82,36,,7.856,Percent of Total Billed Charges,36% of Total Billed Charges,16.37,60,,750.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.28,100,,21.824,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.93,14.42,,3.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.46,75,,109.08,Percent of Total Billed Charges,75% of Total Billed Charges,13.64,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,13.64,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.64,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,13.64,50,,10.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.1,70,,15.28,Percent of Total Billed Charges,70% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,3.82,14,,3.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.28,100,,145.44,Percent of Total Billed Charges,100% of Total Billed Charges,3.82,27.28,
SILVER SULFADIAZ 1% TUBE 20G,53372793,CDM,250,RC,,,Outpatient,,,14.92,8.95,,8.95,60,,7.16,Percent of Total Billed Charges,60% of Total Billed Charges,6.71,45,,5.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.18,28,,3.344,Percent of Total Billed Charges,28% of Total Billed Charges,23.31,32,,18.648,Percent of Total Billed Charges,32% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,5.37,36,,4.296,Percent of Total Billed Charges,36% of Total Billed Charges,5.37,36,,4.296,Percent of Total Billed Charges,36% Total Bille Charges,5.37,36,,4.296,Percent of Total Billed Charges,36% of Total Billed Charges,8.95,60,,832.32,Percent of Total Billed Charges,60% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.92,100,,11.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.15,14.42,,1.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.19,75,,823.504,Percent of Total Billed Charges,75% of Total Billed Charges,7.46,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,7.46,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.46,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,7.46,50,,5.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.44,70,,8.352,Percent of Total Billed Charges,70% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,2.09,14,,1.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.92,100,,1098,Percent of Total Billed Charges,100% of Total Billed Charges,2.09,23.31,
SURGICEL 4X8,53373668,CDM,250,RC,,,Outpatient,,,659.02,395.41,,395.41,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,296.56,45,,237.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,28,,147.624,Percent of Total Billed Charges,28% of Total Billed Charges,23.31,32,,18.648,Percent of Total Billed Charges,32% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% Total Bille Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,395.41,60,,212.552,Percent of Total Billed Charges,60% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.02,100,,527.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,95.03,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.27,75,,156.264,Percent of Total Billed Charges,75% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.31,70,,369.048,Percent of Total Billed Charges,70% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.02,100,,208.352,Percent of Total Billed Charges,100% of Total Billed Charges,23.31,659.02,
SURGICEL FIBREL,53373676,CDM,250,RC,,,Outpatient,,,986.94,592.16,,592.16,60,,473.728,Percent of Total Billed Charges,60% of Total Billed Charges,444.12,45,,355.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.34,28,,221.072,Percent of Total Billed Charges,28% of Total Billed Charges,230.72,32,,184.576,Percent of Total Billed Charges,32% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,355.3,36,,284.24,Percent of Total Billed Charges,36% of Total Billed Charges,355.3,36,,284.24,Percent of Total Billed Charges,36% Total Bille Charges,355.3,36,,284.24,Percent of Total Billed Charges,36% of Total Billed Charges,592.16,60,,769.992,Percent of Total Billed Charges,60% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,986.94,100,,789.552,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,142.32,14.42,,113.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,740.21,75,,285.352,Percent of Total Billed Charges,75% of Total Billed Charges,493.47,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,493.47,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.47,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,493.47,50,,394.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,690.86,70,,552.688,Percent of Total Billed Charges,70% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,138.17,14,,110.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,986.94,100,,380.464,Percent of Total Billed Charges,100% of Total Billed Charges,138.17,986.94,
TACROLIMUS 0.1% OINT 30 GM,53373858,CDM,250,RC,,,Outpatient,,,226.38,135.83,,135.83,60,,108.664,Percent of Total Billed Charges,60% of Total Billed Charges,101.87,45,,81.496,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.39,28,,50.712,Percent of Total Billed Charges,28% of Total Billed Charges,231.28,32,,185.024,Percent of Total Billed Charges,32% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,81.5,36,,65.2,Percent of Total Billed Charges,36% of Total Billed Charges,81.5,36,,65.2,Percent of Total Billed Charges,36% Total Bille Charges,81.5,36,,65.2,Percent of Total Billed Charges,36% of Total Billed Charges,135.83,60,,165.952,Percent of Total Billed Charges,60% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.38,100,,181.104,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,32.64,14.42,,26.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.79,75,,434.728,Percent of Total Billed Charges,75% of Total Billed Charges,113.19,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,113.19,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.19,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,113.19,50,,90.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.47,70,,126.776,Percent of Total Billed Charges,70% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.38,100,,579.632,Percent of Total Billed Charges,100% of Total Billed Charges,31.69,231.28,
NYSTATIN/TRIAMCIN ACE CRM 15GM,53373940,CDM,250,RC,,,Outpatient,,,169.24,101.54,,101.54,60,,81.232,Percent of Total Billed Charges,60% of Total Billed Charges,76.16,45,,60.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.39,28,,37.912,Percent of Total Billed Charges,28% of Total Billed Charges,232.02,32,,185.616,Percent of Total Billed Charges,32% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,60.93,36,,48.744,Percent of Total Billed Charges,36% of Total Billed Charges,60.93,36,,48.744,Percent of Total Billed Charges,36% Total Bille Charges,60.93,36,,48.744,Percent of Total Billed Charges,36% of Total Billed Charges,101.54,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.24,100,,135.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,24.4,14.42,,19.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.93,75,,5.224,Percent of Total Billed Charges,75% of Total Billed Charges,84.62,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,84.62,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.62,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,84.62,50,,67.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.47,70,,94.776,Percent of Total Billed Charges,70% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,23.69,14,,18.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,169.24,100,,6.96,Percent of Total Billed Charges,100% of Total Billed Charges,23.69,232.02,
NYSTATIN/TRIAMCIN ACE ONT 15GM,53373999,CDM,250,RC,,,Outpatient,,,125.74,75.44,,75.44,60,,60.352,Percent of Total Billed Charges,60% of Total Billed Charges,56.58,45,,45.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.21,28,,28.168,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,45.27,36,,36.216,Percent of Total Billed Charges,36% of Total Billed Charges,45.27,36,,36.216,Percent of Total Billed Charges,36% Total Bille Charges,45.27,36,,36.216,Percent of Total Billed Charges,36% of Total Billed Charges,75.44,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.74,100,,100.592,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.13,14.42,,14.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.31,75,,1165.2,Percent of Total Billed Charges,75% of Total Billed Charges,62.87,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,62.87,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.87,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,62.87,50,,50.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.02,70,,70.416,Percent of Total Billed Charges,70% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,17.6,14,,14.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.74,100,,1553.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.6,232.35,
TERBINAFINE 1% CRM 30GM,53374294,CDM,250,RC,,,Outpatient,,,32.12,19.27,,19.27,60,,15.416,Percent of Total Billed Charges,60% of Total Billed Charges,14.45,45,,11.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.99,28,,7.192,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,11.56,36,,9.248,Percent of Total Billed Charges,36% of Total Billed Charges,11.56,36,,9.248,Percent of Total Billed Charges,36% Total Bille Charges,11.56,36,,9.248,Percent of Total Billed Charges,36% of Total Billed Charges,19.27,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.12,100,,25.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14.42,,3.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,16.06,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,16.06,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.06,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,16.06,50,,12.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.48,70,,17.984,Percent of Total Billed Charges,70% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,4.5,14,,3.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.12,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,4.5,232.35,
TERCONAZOLE 0.4% VAG CRM,53374310,CDM,250,RC,,,Outpatient,,,87.1,52.26,,52.26,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,39.2,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.39,28,,19.512,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,31.36,36,,25.088,Percent of Total Billed Charges,36% of Total Billed Charges,31.36,36,,25.088,Percent of Total Billed Charges,36% Total Bille Charges,31.36,36,,25.088,Percent of Total Billed Charges,36% of Total Billed Charges,52.26,60,,239.96,Percent of Total Billed Charges,60% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.1,100,,69.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.56,14.42,,10.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.33,75,,2192.416,Percent of Total Billed Charges,75% of Total Billed Charges,43.55,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,43.55,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.55,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,43.55,50,,34.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.97,70,,48.776,Percent of Total Billed Charges,70% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.19,14,,9.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.1,100,,2923.216,Percent of Total Billed Charges,100% of Total Billed Charges,12.19,232.35,
THROMBIN TOP 20000U SPY KIT,53374633,CDM,250,RC,,,Outpatient,,,1365.4,819.24,,819.24,60,,655.392,Percent of Total Billed Charges,60% of Total Billed Charges,614.43,45,,491.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.31,28,,305.848,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,491.54,36,,393.232,Percent of Total Billed Charges,36% of Total Billed Charges,491.54,36,,393.232,Percent of Total Billed Charges,36% Total Bille Charges,491.54,36,,393.232,Percent of Total Billed Charges,36% of Total Billed Charges,819.24,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1365.4,100,,1092.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,196.89,14.42,,157.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1024.05,75,,445.6,Percent of Total Billed Charges,75% of Total Billed Charges,682.7,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,682.7,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.7,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,682.7,50,,546.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,955.78,70,,764.624,Percent of Total Billed Charges,70% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,191.16,14,,152.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1365.4,100,,594.128,Percent of Total Billed Charges,100% of Total Billed Charges,191.16,1365.4,
THROMBIN TOP 5000U,53374674,CDM,250,RC,,,Outpatient,,,350.97,210.58,,210.58,60,,168.464,Percent of Total Billed Charges,60% of Total Billed Charges,157.94,45,,126.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.27,28,,78.616,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,126.35,36,,101.08,Percent of Total Billed Charges,36% of Total Billed Charges,126.35,36,,101.08,Percent of Total Billed Charges,36% Total Bille Charges,126.35,36,,101.08,Percent of Total Billed Charges,36% of Total Billed Charges,210.58,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.97,100,,280.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,50.61,14.42,,40.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.23,75,,1353.664,Percent of Total Billed Charges,75% of Total Billed Charges,175.49,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,175.49,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.49,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,175.49,50,,140.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.68,70,,196.544,Percent of Total Billed Charges,70% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.14,14,,39.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350.97,100,,1804.88,Percent of Total Billed Charges,100% of Total Billed Charges,49.14,350.97,
TOBRAMYCIN 1.2GM VIAL,53374708,CDM,250,RC,J3260,HCPCS,Outpatient,,,125.25,75.15,,4.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,56.36,45,,45.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.45,360,,,Fee Schedule,360% of BCBS POS Rate,0.45,360,,,Fee schedule,360% of BCBS PPO Rate,0.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,75.15,60,,470.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.25,100,,100.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.94,75,,4.072,Percent of Total Billed Charges,75% of Total Billed Charges,1.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.86,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.68,70,,70.144,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.25,100,,5.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,125.25,
TOLNAFATE 1% CRM 15GM,53374930,CDM,250,RC,,,Outpatient,,,7.82,4.69,,4.69,60,,3.752,Percent of Total Billed Charges,60% of Total Billed Charges,3.52,45,,2.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.19,28,,1.752,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,2.82,36,,2.256,Percent of Total Billed Charges,36% of Total Billed Charges,2.82,36,,2.256,Percent of Total Billed Charges,36% Total Bille Charges,2.82,36,,2.256,Percent of Total Billed Charges,36% of Total Billed Charges,4.69,60,,239.96,Percent of Total Billed Charges,60% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.82,100,,6.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.13,14.42,,0.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.87,75,,37.064,Percent of Total Billed Charges,75% of Total Billed Charges,3.91,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,3.91,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,3.91,50,,3.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.47,70,,4.376,Percent of Total Billed Charges,70% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,14,,0.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.82,100,,49.416,Percent of Total Billed Charges,100% of Total Billed Charges,1.09,232.35,
PERMETHRIN 5% CRM 60GM,53375100,CDM,250,RC,,,Outpatient,,,247.48,148.49,,148.49,60,,118.792,Percent of Total Billed Charges,60% of Total Billed Charges,111.37,45,,89.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.29,28,,55.432,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,89.09,36,,71.272,Percent of Total Billed Charges,36% of Total Billed Charges,89.09,36,,71.272,Percent of Total Billed Charges,36% Total Bille Charges,89.09,36,,71.272,Percent of Total Billed Charges,36% of Total Billed Charges,148.49,60,,2400,Percent of Total Billed Charges,60% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.48,100,,197.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,35.69,14.42,,28.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.61,75,,1048.624,Percent of Total Billed Charges,75% of Total Billed Charges,123.74,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,123.74,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.74,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,123.74,50,,98.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.24,70,,138.592,Percent of Total Billed Charges,70% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,34.65,14,,27.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.48,100,,1398.16,Percent of Total Billed Charges,100% of Total Billed Charges,34.65,247.48,
TRIAMCINO ACE 0.1% CRM 15GM,53375705,CDM,250,RC,,,Outpatient,,,10.72,6.43,,6.43,60,,5.144,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,45,,3.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,28,,2.4,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% Total Bille Charges,3.86,36,,3.088,Percent of Total Billed Charges,36% of Total Billed Charges,6.43,60,,61.328,Percent of Total Billed Charges,60% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.72,100,,8.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.55,14.42,,1.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.04,75,,207.528,Percent of Total Billed Charges,75% of Total Billed Charges,5.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,5.36,50,,4.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.5,70,,6,Percent of Total Billed Charges,70% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,1.5,14,,1.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.72,100,,276.704,Percent of Total Billed Charges,100% of Total Billed Charges,1.5,232.35,
TRIAMCINO ACE 0.1% ONT 15GM,53375754,CDM,250,RC,,,Outpatient,,,11.56,6.94,,6.94,60,,5.552,Percent of Total Billed Charges,60% of Total Billed Charges,5.2,45,,4.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.24,28,,2.592,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,4.16,36,,3.328,Percent of Total Billed Charges,36% of Total Billed Charges,4.16,36,,3.328,Percent of Total Billed Charges,36% Total Bille Charges,4.16,36,,3.328,Percent of Total Billed Charges,36% of Total Billed Charges,6.94,60,,214.184,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.56,100,,9.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.67,14.42,,1.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.67,75,,300.368,Percent of Total Billed Charges,75% of Total Billed Charges,5.78,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,5.78,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.78,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,5.78,50,,4.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,70,,6.472,Percent of Total Billed Charges,70% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14,,1.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.56,100,,400.488,Percent of Total Billed Charges,100% of Total Billed Charges,1.62,232.35,
TRIAMCIN .1%60G+,53375796,CDM,250,RC,,,Outpatient,,,27.2,16.32,,16.32,60,,13.056,Percent of Total Billed Charges,60% of Total Billed Charges,12.24,45,,9.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.62,28,,6.096,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,9.79,36,,7.832,Percent of Total Billed Charges,36% of Total Billed Charges,9.79,36,,7.832,Percent of Total Billed Charges,36% Total Bille Charges,9.79,36,,7.832,Percent of Total Billed Charges,36% of Total Billed Charges,16.32,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.2,100,,21.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.92,14.42,,3.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.4,75,,328.576,Percent of Total Billed Charges,75% of Total Billed Charges,13.6,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,13.6,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.6,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,13.6,50,,10.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.04,70,,15.232,Percent of Total Billed Charges,70% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,3.81,14,,3.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.2,100,,438.104,Percent of Total Billed Charges,100% of Total Billed Charges,3.81,232.35,
TRIAMCINO ACE 0.025% CRM 80GM,53375853,CDM,250,RC,,,Outpatient,,,16.02,9.61,,9.61,60,,7.688,Percent of Total Billed Charges,60% of Total Billed Charges,7.21,45,,5.768,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,28,,3.592,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% Total Bille Charges,5.77,36,,4.616,Percent of Total Billed Charges,36% of Total Billed Charges,9.61,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.02,100,,12.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.31,14.42,,1.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.02,75,,23.008,Percent of Total Billed Charges,75% of Total Billed Charges,8.01,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,8.01,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.01,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,8.01,50,,6.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.21,70,,8.968,Percent of Total Billed Charges,70% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.02,100,,30.68,Percent of Total Billed Charges,100% of Total Billed Charges,2.24,232.35,
TRIAMCINO ACE 0.1% ONT 80GM,53375855,CDM,250,RC,,,Outpatient,,,24,14.40,,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.72,28,,5.376,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% Total Bille Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,14.4,60,,622.464,Percent of Total Billed Charges,60% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,100,,19.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.46,14.42,,2.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,75,,118.128,Percent of Total Billed Charges,75% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.8,70,,13.44,Percent of Total Billed Charges,70% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,14,,2.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,100,,157.504,Percent of Total Billed Charges,100% of Total Billed Charges,3.36,232.35,
TRIAMCINO ACE 0.5% CRM 15GM,53375952,CDM,250,RC,,,Outpatient,,,22.66,13.60,,13.6,60,,10.88,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,45,,8.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.34,28,,5.072,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% of Total Billed Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% Total Bille Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% of Total Billed Charges,13.6,60,,159.056,Percent of Total Billed Charges,60% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,100,,18.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14.42,,2.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,75,,138.024,Percent of Total Billed Charges,75% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.86,70,,12.688,Percent of Total Billed Charges,70% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.66,100,,184.032,Percent of Total Billed Charges,100% of Total Billed Charges,3.17,232.35,
TRIAMCINO ACE 0.5% CRM 15GM,53376000,CDM,250,RC,,,Outpatient,,,22.66,13.60,,13.6,60,,10.88,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,45,,8.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.34,28,,5.072,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% of Total Billed Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% Total Bille Charges,8.16,36,,6.528,Percent of Total Billed Charges,36% of Total Billed Charges,13.6,60,,1560.32,Percent of Total Billed Charges,60% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.66,100,,18.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.27,14.42,,2.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,75,,1901.304,Percent of Total Billed Charges,75% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,11.33,50,,9.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.86,70,,12.688,Percent of Total Billed Charges,70% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,14,,2.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.66,100,,2535.072,Percent of Total Billed Charges,100% of Total Billed Charges,3.17,232.35,
TRIAMCINOLONE 0.1% DENT PASTE,53376208,CDM,250,RC,,,Outpatient,,,161.16,96.70,,96.7,60,,77.36,Percent of Total Billed Charges,60% of Total Billed Charges,72.52,45,,58.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.12,28,,36.096,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,58.02,36,,46.416,Percent of Total Billed Charges,36% of Total Billed Charges,58.02,36,,46.416,Percent of Total Billed Charges,36% Total Bille Charges,58.02,36,,46.416,Percent of Total Billed Charges,36% of Total Billed Charges,96.7,60,,301.52,Percent of Total Billed Charges,60% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.16,100,,128.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14.42,,18.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.87,75,,119.824,Percent of Total Billed Charges,75% of Total Billed Charges,80.58,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,80.58,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.58,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,80.58,50,,64.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.81,70,,90.248,Percent of Total Billed Charges,70% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,22.56,14,,18.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,161.16,100,,159.76,Percent of Total Billed Charges,100% of Total Billed Charges,22.56,232.35,
VITAMIN A&D OINT 45GM,53377347,CDM,250,RC,,,Outpatient,,,0.44,0.26,,0.26,60,,0.208,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,45,,0.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,28,,0.096,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% Total Bille Charges,0.16,36,,0.128,Percent of Total Billed Charges,36% of Total Billed Charges,0.26,60,,139.24,Percent of Total Billed Charges,60% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,100,,0.352,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14.42,,0.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,75,,27.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.22,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.22,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,0.22,50,,0.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,70,,0.248,Percent of Total Billed Charges,70% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,14,,0.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,100,,36.624,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,232.35,
ZINC-OXIDE 20% OINT 30GM,53377560,CDM,250,RC,,,Outpatient,,,6.28,3.77,,3.77,60,,3.016,Percent of Total Billed Charges,60% of Total Billed Charges,2.83,45,,2.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.76,28,,1.408,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,2.26,36,,1.808,Percent of Total Billed Charges,36% of Total Billed Charges,2.26,36,,1.808,Percent of Total Billed Charges,36% Total Bille Charges,2.26,36,,1.808,Percent of Total Billed Charges,36% of Total Billed Charges,3.77,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.28,100,,5.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14.42,,0.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.71,75,,850.168,Percent of Total Billed Charges,75% of Total Billed Charges,3.14,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,3.14,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.14,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,3.14,50,,2.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,70,,3.52,Percent of Total Billed Charges,70% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14,,0.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.28,100,,1133.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.88,232.35,
RIVASTIGMINE 4.6 MG PAT,53380093,CDM,250,RC,,,Outpatient,,,33.41,20.05,,20.05,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,45,,12.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.35,28,,7.48,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% Total Bille Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,20.05,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.41,100,,26.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,75,,338.88,Percent of Total Billed Charges,75% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.39,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.41,100,,451.84,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,232.35,
RIVASTIGMINE 9.5 MG PAT,53380101,CDM,250,RC,,,Outpatient,,,33.41,20.05,,20.05,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,45,,12.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.35,28,,7.48,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% Total Bille Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,20.05,60,,102.72,Percent of Total Billed Charges,60% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.41,100,,26.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,75,,3071.032,Percent of Total Billed Charges,75% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.39,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.41,100,,4094.704,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,232.35,
RIVASTIGMINE 13.3 MG PAT,53380103,CDM,250,RC,,,Outpatient,,,33.41,20.05,,20.05,60,,16.04,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,45,,12.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.35,28,,7.48,Percent of Total Billed Charges,28% of Total Billed Charges,232.35,32,,185.88,Percent of Total Billed Charges,32% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% Total Bille Charges,12.03,36,,9.624,Percent of Total Billed Charges,36% of Total Billed Charges,20.05,60,,283.96,Percent of Total Billed Charges,60% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.41,100,,26.728,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14.42,,3.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.06,75,,21.976,Percent of Total Billed Charges,75% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,16.71,50,,13.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.39,70,,18.712,Percent of Total Billed Charges,70% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,4.68,14,,3.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.41,100,,29.304,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,232.35,
ACETAMINOPHEN 120MG SUP,53380168,CDM,250,RC,,,Outpatient,,,0.81,0.49,,0.49,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.36,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,28,,0.184,Percent of Total Billed Charges,28% of Total Billed Charges,233.32,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% Total Bille Charges,0.29,36,,0.232,Percent of Total Billed Charges,36% of Total Billed Charges,0.49,60,,189.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.81,100,,0.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,75,,164.608,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,50,,0.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,70,,0.456,Percent of Total Billed Charges,70% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,0.11,14,,0.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.81,100,,219.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.11,233.32,
ACETAMINOPHEN 325MG SUP,53380200,CDM,250,RC,,,Outpatient,,,1.31,0.79,,0.79,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,0.59,45,,0.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,28,,0.296,Percent of Total Billed Charges,28% of Total Billed Charges,233.32,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% Total Bille Charges,0.47,36,,0.376,Percent of Total Billed Charges,36% of Total Billed Charges,0.79,60,,118.256,Percent of Total Billed Charges,60% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.31,100,,1.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,14.42,,0.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,75,,34.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,0.66,50,,0.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.92,70,,0.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,14,,0.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.31,100,,46.632,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,233.32,
ACETAMINOPHEN 650MG SUP,53380242,CDM,250,RC,,,Outpatient,,,0.87,0.52,,0.52,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.39,45,,0.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,233.32,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,60,,52.416,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.87,100,,0.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,14.42,,0.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,75,,79.216,Percent of Total Billed Charges,75% of Total Billed Charges,0.44,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,0.44,50,,0.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,70,,0.488,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,100,,105.616,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,233.32,
ASPIRIN 300MG SUP,53380952,CDM,250,RC,,,Outpatient,,,2.92,1.75,,1.75,60,,1.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.31,45,,1.048,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,28,,0.656,Percent of Total Billed Charges,28% of Total Billed Charges,233.32,32,,186.656,Percent of Total Billed Charges,32% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% Total Bille Charges,1.05,36,,0.84,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,60,,35.888,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.92,100,,2.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14.42,,0.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.19,75,,231.296,Percent of Total Billed Charges,75% of Total Billed Charges,1.46,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,1.46,50,,1.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,70,,1.632,Percent of Total Billed Charges,70% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14,,0.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.92,100,,308.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,233.32,
ASPIRIN 600MG SUP,53381166,CDM,250,RC,,,Outpatient,,,3.02,1.81,,1.81,60,,1.448,Percent of Total Billed Charges,60% of Total Billed Charges,1.36,45,,1.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.85,28,,0.68,Percent of Total Billed Charges,28% of Total Billed Charges,233.59,32,,186.872,Percent of Total Billed Charges,32% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,1.09,36,,0.872,Percent of Total Billed Charges,36% of Total Billed Charges,1.09,36,,0.872,Percent of Total Billed Charges,36% Total Bille Charges,1.09,36,,0.872,Percent of Total Billed Charges,36% of Total Billed Charges,1.81,60,,88.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,100,,2.416,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.44,14.42,,0.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.27,75,,173.792,Percent of Total Billed Charges,75% of Total Billed Charges,1.51,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,1.51,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.51,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,1.51,50,,1.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.11,70,,1.688,Percent of Total Billed Charges,70% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,0.42,14,,0.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.02,100,,231.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.42,233.59,
BISACODYL 10MG SUP,53381620,CDM,250,RC,,,Outpatient,,,0.27,0.16,,0.16,60,,0.128,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,45,,0.096,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,28,,0.064,Percent of Total Billed Charges,28% of Total Billed Charges,23.42,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% Total Bille Charges,0.1,36,,0.08,Percent of Total Billed Charges,36% of Total Billed Charges,0.16,60,,10.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.27,100,,0.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,75,,3381.6,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,0.14,50,,0.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,70,,0.152,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,100,,4508.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,23.42,
DINOPROSTONE 10MG VAG INS,53383204,CDM,250,RC,,,Outpatient,,,1687.37,1012.42,,1012.42,60,,809.936,Percent of Total Billed Charges,60% of Total Billed Charges,759.32,45,,607.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.46,28,,377.968,Percent of Total Billed Charges,28% of Total Billed Charges,23.42,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,607.45,36,,485.96,Percent of Total Billed Charges,36% of Total Billed Charges,607.45,36,,485.96,Percent of Total Billed Charges,36% Total Bille Charges,607.45,36,,485.96,Percent of Total Billed Charges,36% of Total Billed Charges,1012.42,60,,12.664,Percent of Total Billed Charges,60% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1687.37,100,,1349.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,243.32,14.42,,194.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1265.53,75,,248.536,Percent of Total Billed Charges,75% of Total Billed Charges,843.69,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,843.69,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,843.69,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,843.69,50,,674.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1181.16,70,,944.928,Percent of Total Billed Charges,70% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,236.23,14,,188.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1687.37,100,,331.376,Percent of Total Billed Charges,100% of Total Billed Charges,23.42,1687.37,
DINOPROSTONE 20MG SUP,53383212,CDM,250,RC,S5001,HCPCS,Outpatient,,,6624.51,3974.71,,3974.71,60,,3179.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1854.86,28,,1483.888,Percent of Total Billed Charges,28% of Total Billed Charges,23.42,32,,18.736,Percent of Total Billed Charges,32% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,2384.82,36,,1907.856,Percent of Total Billed Charges,36% of Total Billed Charges,2384.82,36,,1907.856,Percent of Total Billed Charges,36% Total Bille Charges,2384.82,36,,1907.856,Percent of Total Billed Charges,36% of Total Billed Charges,3974.71,60,,13.896,Percent of Total Billed Charges,60% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,955.25,14.42,,764.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4968.38,75,,139.984,Percent of Total Billed Charges,75% of Total Billed Charges,3312.26,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,3312.26,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3312.26,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,3312.26,50,,2649.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4637.16,70,,3709.728,Percent of Total Billed Charges,70% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,927.43,14,,741.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6624.51,100,,186.648,Percent of Total Billed Charges,100% of Total Billed Charges,23.42,6624.51,
GLYCERIN ADULT SUP,53384095,CDM,250,RC,,,Outpatient,,,0.86,0.52,,0.52,60,,0.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,23.63,32,,18.904,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% Total Bille Charges,0.31,36,,0.248,Percent of Total Billed Charges,36% of Total Billed Charges,0.52,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,75,,323.76,Percent of Total Billed Charges,75% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,50,,0.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,70,,0.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,100,,431.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,23.63,
GLYCERIN PEDI SUP,53384137,CDM,250,RC,,,Outpatient,,,0.25,0.15,,0.15,60,,0.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,28,,0.056,Percent of Total Billed Charges,28% of Total Billed Charges,233.9,32,,187.12,Percent of Total Billed Charges,32% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% Total Bille Charges,0.09,36,,0.072,Percent of Total Billed Charges,36% of Total Billed Charges,0.15,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14.42,,0.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.19,75,,93.888,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.13,50,,0.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,70,,0.144,Percent of Total Billed Charges,70% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,0.04,14,,0.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.25,100,,125.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.04,233.9,
HYDROCORT 2.5% REC CRM 30GM,53384855,CDM,250,RC,,,Outpatient,,,138.6,83.16,,83.16,60,,66.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.81,28,,31.048,Percent of Total Billed Charges,28% of Total Billed Charges,233.9,32,,187.12,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.9,36,,39.92,Percent of Total Billed Charges,36% of Total Billed Charges,49.9,36,,39.92,Percent of Total Billed Charges,36% Total Bille Charges,49.9,36,,39.92,Percent of Total Billed Charges,36% of Total Billed Charges,83.16,60,,19.232,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.99,14.42,,15.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.95,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,69.3,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,69.3,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.3,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,69.3,50,,55.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.02,70,,77.616,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.6,100,,24,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,233.9,
HYDROCORTISONE ENEMA 60ML,53384889,CDM,250,RC,,,Outpatient,,,15.44,9.26,,9.26,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.32,28,,3.456,Percent of Total Billed Charges,28% of Total Billed Charges,234.58,32,,187.664,Percent of Total Billed Charges,32% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,5.56,36,,4.448,Percent of Total Billed Charges,36% of Total Billed Charges,5.56,36,,4.448,Percent of Total Billed Charges,36% Total Bille Charges,5.56,36,,4.448,Percent of Total Billed Charges,36% of Total Billed Charges,9.26,60,,27.656,Percent of Total Billed Charges,60% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.23,14.42,,1.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,75,,7164.376,Percent of Total Billed Charges,75% of Total Billed Charges,7.72,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.72,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.72,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.72,50,,6.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,70,,8.648,Percent of Total Billed Charges,70% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.16,14,,1.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.44,100,,9552.496,Percent of Total Billed Charges,100% of Total Billed Charges,2.16,234.58,
HYDROCORTISONE 25MG SUP,53384939,CDM,250,RC,,,Outpatient,,,31,18.60,,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.68,28,,6.944,Percent of Total Billed Charges,28% of Total Billed Charges,235.14,32,,188.112,Percent of Total Billed Charges,32% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% Total Bille Charges,11.16,36,,8.928,Percent of Total Billed Charges,36% of Total Billed Charges,18.6,60,,39.28,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.25,75,,108.08,Percent of Total Billed Charges,75% of Total Billed Charges,15.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.7,70,,17.36,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31,100,,144.104,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,235.14,
INDOMETHACIN 50MG SUP,53384970,CDM,250,RC,,,Outpatient,,,172.55,103.53,,103.53,60,,82.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.31,28,,38.648,Percent of Total Billed Charges,28% of Total Billed Charges,235.2,32,,188.16,Percent of Total Billed Charges,32% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,62.12,36,,49.696,Percent of Total Billed Charges,36% of Total Billed Charges,62.12,36,,49.696,Percent of Total Billed Charges,36% Total Bille Charges,62.12,36,,49.696,Percent of Total Billed Charges,36% of Total Billed Charges,103.53,60,,47.184,Percent of Total Billed Charges,60% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.88,14.42,,19.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.41,75,,1668.432,Percent of Total Billed Charges,75% of Total Billed Charges,86.28,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,86.28,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.28,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,86.28,50,,69.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.79,70,,96.632,Percent of Total Billed Charges,70% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,24.16,14,,19.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.55,100,,2224.576,Percent of Total Billed Charges,100% of Total Billed Charges,24.16,235.2,
MESALAMINE ENEMA 4GM/60ML,53385100,CDM,250,RC,,,Outpatient,,,37.95,22.77,,22.77,60,,18.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.63,28,,8.504,Percent of Total Billed Charges,28% of Total Billed Charges,236.16,32,,188.928,Percent of Total Billed Charges,32% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% of Total Billed Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% Total Bille Charges,13.66,36,,10.928,Percent of Total Billed Charges,36% of Total Billed Charges,22.77,60,,64.936,Percent of Total Billed Charges,60% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.47,14.42,,4.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,75,,36.4,Percent of Total Billed Charges,75% of Total Billed Charges,18.98,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,18.98,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.98,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,18.98,50,,15.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.57,70,,21.256,Percent of Total Billed Charges,70% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,5.31,14,,4.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.95,100,,48.528,Percent of Total Billed Charges,100% of Total Billed Charges,5.31,236.16,
MESALAMINE500MG+,53385118,CDM,250,RC,,,Outpatient,,,25.25,15.15,,15.15,60,,12.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.07,28,,5.656,Percent of Total Billed Charges,28% of Total Billed Charges,23.82,32,,19.056,Percent of Total Billed Charges,32% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,9.09,36,,7.272,Percent of Total Billed Charges,36% of Total Billed Charges,9.09,36,,7.272,Percent of Total Billed Charges,36% Total Bille Charges,9.09,36,,7.272,Percent of Total Billed Charges,36% of Total Billed Charges,15.15,60,,80.728,Percent of Total Billed Charges,60% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.64,14.42,,2.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.94,75,,293.48,Percent of Total Billed Charges,75% of Total Billed Charges,12.63,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,12.63,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.63,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,12.63,50,,10.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.68,70,,14.144,Percent of Total Billed Charges,70% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14,,2.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.25,100,,391.304,Percent of Total Billed Charges,100% of Total Billed Charges,3.54,25.25,
MESALAMINE 1000 MG SUP,53385126,CDM,250,RC,,,Outpatient,,,70.73,42.44,,42.44,60,,33.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.8,28,,15.84,Percent of Total Billed Charges,28% of Total Billed Charges,23.86,32,,19.088,Percent of Total Billed Charges,32% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,25.46,36,,20.368,Percent of Total Billed Charges,36% of Total Billed Charges,25.46,36,,20.368,Percent of Total Billed Charges,36% Total Bille Charges,25.46,36,,20.368,Percent of Total Billed Charges,36% of Total Billed Charges,42.44,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,10.2,14.42,,8.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.05,75,,44.664,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,35.37,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.37,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,35.37,50,,28.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.51,70,,39.608,Percent of Total Billed Charges,70% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,9.9,14,,7.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.73,100,,59.552,Percent of Total Billed Charges,100% of Total Billed Charges,9.9,70.73,
PRAMOXINE/HYDROCRT 1%FOAM 10GM,53385761,CDM,250,RC,,,Outpatient,,,148.74,89.24,,89.24,60,,71.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.65,28,,33.32,Percent of Total Billed Charges,28% of Total Billed Charges,23.86,32,,19.088,Percent of Total Billed Charges,32% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% of Total Billed Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% Total Bille Charges,53.55,36,,42.84,Percent of Total Billed Charges,36% of Total Billed Charges,89.24,60,,76.608,Percent of Total Billed Charges,60% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,21.45,14.42,,17.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.56,75,,4.352,Percent of Total Billed Charges,75% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,74.37,50,,59.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.12,70,,83.296,Percent of Total Billed Charges,70% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,20.82,14,,16.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.74,100,,5.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.82,148.74,
HEMORRHOIDAL OINT 30GM,53385852,CDM,250,RC,,,Outpatient,,,13.4,8.04,,8.04,60,,6.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,28,,3,Percent of Total Billed Charges,28% of Total Billed Charges,23.88,32,,19.104,Percent of Total Billed Charges,32% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,36,,3.856,Percent of Total Billed Charges,36% of Total Billed Charges,4.82,36,,3.856,Percent of Total Billed Charges,36% Total Bille Charges,4.82,36,,3.856,Percent of Total Billed Charges,36% of Total Billed Charges,8.04,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.93,14.42,,1.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.05,75,,703.752,Percent of Total Billed Charges,75% of Total Billed Charges,6.7,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,6.7,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.7,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,6.7,50,,5.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,70,,7.504,Percent of Total Billed Charges,70% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,14,,1.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.4,100,,938.336,Percent of Total Billed Charges,100% of Total Billed Charges,1.88,23.88,
PROCHLORPERAZINE 25MG SUP,53386132,CDM,250,RC,,,Outpatient,,,24.52,14.71,,14.71,60,,11.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.87,28,,5.496,Percent of Total Billed Charges,28% of Total Billed Charges,23.92,32,,19.136,Percent of Total Billed Charges,32% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,36,,7.064,Percent of Total Billed Charges,36% of Total Billed Charges,8.83,36,,7.064,Percent of Total Billed Charges,36% Total Bille Charges,8.83,36,,7.064,Percent of Total Billed Charges,36% of Total Billed Charges,14.71,60,,61.056,Percent of Total Billed Charges,60% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.54,14.42,,2.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,75,,115.296,Percent of Total Billed Charges,75% of Total Billed Charges,12.26,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,12.26,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.26,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,12.26,50,,9.808,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.16,70,,13.728,Percent of Total Billed Charges,70% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,3.43,14,,2.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.52,100,,153.728,Percent of Total Billed Charges,100% of Total Billed Charges,3.43,24.52,
PROMETHAZINE 12.5MG SUP,53386348,CDM,250,RC,,,Outpatient,,,27.66,16.60,,16.6,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,28,,6.192,Percent of Total Billed Charges,28% of Total Billed Charges,23.96,32,,19.168,Percent of Total Billed Charges,32% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% Total Bille Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,16.6,60,,67.136,Percent of Total Billed Charges,60% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.99,14.42,,3.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,75,,94.36,Percent of Total Billed Charges,75% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.36,70,,15.488,Percent of Total Billed Charges,70% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.66,100,,125.808,Percent of Total Billed Charges,100% of Total Billed Charges,3.87,27.66,
PROMETHAZINE 25MG SUP,53386395,CDM,250,RC,,,Outpatient,,,27.66,16.60,,16.6,60,,13.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.74,28,,6.192,Percent of Total Billed Charges,28% of Total Billed Charges,23.98,32,,19.184,Percent of Total Billed Charges,32% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% Total Bille Charges,9.96,36,,7.968,Percent of Total Billed Charges,36% of Total Billed Charges,16.6,60,,34.936,Percent of Total Billed Charges,60% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.99,14.42,,3.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.75,75,,126.336,Percent of Total Billed Charges,75% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,13.83,50,,11.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.36,70,,15.488,Percent of Total Billed Charges,70% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,3.87,14,,3.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.66,100,,168.448,Percent of Total Billed Charges,100% of Total Billed Charges,3.87,27.66,
RISPERIDONE CONSTA 25 MG INJ,53390108,CDM,250,RC,J2794,HCPCS,Outpatient,,,2040.57,1224.34,,11.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,9.37,360,,,Fee Schedule,360% of BCBS POS Rate,9.37,360,,,Fee schedule,360% of BCBS PPO Rate,9.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,1224.34,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.17,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,14.69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.63,103,,,Fee Schedule,103% of CMS OPPS Rate,11.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1530.43,75,,409.248,Percent of Total Billed Charges,75% of Total Billed Charges,9.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,9.26,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,16.95,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1428.4,70,,1142.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2040.57,100,,545.664,Percent of Total Billed Charges,100% of Total Billed Charges,9.26,2040.57,
DILTIAZEM IVPB 125MG/D5W125,53392334,CDM,250,RC,,,Outpatient,,,39.24,23.54,,23.54,60,,18.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,28,,8.792,Percent of Total Billed Charges,28% of Total Billed Charges,237.87,32,,190.296,Percent of Total Billed Charges,32% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,14.13,36,,11.304,Percent of Total Billed Charges,36% of Total Billed Charges,14.13,36,,11.304,Percent of Total Billed Charges,36% Total Bille Charges,14.13,36,,11.304,Percent of Total Billed Charges,36% of Total Billed Charges,23.54,60,,41.904,Percent of Total Billed Charges,60% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.66,14.42,,4.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.43,75,,409.248,Percent of Total Billed Charges,75% of Total Billed Charges,19.62,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,19.62,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.62,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,19.62,50,,15.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.47,70,,21.976,Percent of Total Billed Charges,70% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.24,100,,545.664,Percent of Total Billed Charges,100% of Total Billed Charges,5.49,237.87,
NALOXEGOL TAB 12.5MG,53392335,CDM,250,RC,,,Outpatient,,,23,13.80,,13.8,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.44,28,,5.152,Percent of Total Billed Charges,28% of Total Billed Charges,237.87,32,,190.296,Percent of Total Billed Charges,32% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,8.28,36,,6.624,Percent of Total Billed Charges,36% of Total Billed Charges,8.28,36,,6.624,Percent of Total Billed Charges,36% Total Bille Charges,8.28,36,,6.624,Percent of Total Billed Charges,36% of Total Billed Charges,13.8,60,,10.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.32,14.42,,2.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.25,75,,83.016,Percent of Total Billed Charges,75% of Total Billed Charges,11.5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.1,70,,12.88,Percent of Total Billed Charges,70% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,3.22,14,,2.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23,100,,110.688,Percent of Total Billed Charges,100% of Total Billed Charges,3.22,237.87,
RANITIDINE 150MG TAB UD,53392336,CDM,250,RC,,,Outpatient,,,0.34,0.20,,0.2,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,239.01,32,,191.208,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% Total Bille Charges,0.12,36,,0.096,Percent of Total Billed Charges,36% of Total Billed Charges,0.2,60,,0.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.26,75,,1.864,Percent of Total Billed Charges,75% of Total Billed Charges,0.17,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,50,,0.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,70,,0.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,100,,2.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,239.01,
HEPATITIS B VAC 20MCG/0.5ML,53392337,CDM,636,RC,90739,HCPCS,Outpatient,,,526.88,316.13,,441.58,110,,353.264,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,114.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,114.54,360,,,Fee Schedule,360% of BCBS POS Rate,114.54,360,,,Fee schedule,360% of BCBS PPO Rate,114.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.16,75,,74.048,Percent of Total Billed Charges,75% of Total Billed Charges,385.1,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,385.1,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,385.1,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,385.1,50,,308.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.82,70,,295.056,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,526.88,100,,98.728,Percent of Total Billed Charges,100% of Total Billed Charges,114.54,526.88,
METOPROLOL XL 25 MG TAB,53392338,CDM,250,RC,,,Outpatient,,,2.48,1.49,,1.49,60,,1.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.69,28,,0.552,Percent of Total Billed Charges,28% of Total Billed Charges,239.03,32,,191.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% of Total Billed Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% Total Bille Charges,0.89,36,,0.712,Percent of Total Billed Charges,36% of Total Billed Charges,1.49,60,,1.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.36,14.42,,0.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.86,75,,254.664,Percent of Total Billed Charges,75% of Total Billed Charges,1.24,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,1.24,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.24,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,1.24,50,,0.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.74,70,,1.392,Percent of Total Billed Charges,70% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.35,14,,0.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.48,100,,339.552,Percent of Total Billed Charges,100% of Total Billed Charges,0.35,239.03,
PRAMOXINE HC 1% REC CRM 30GM,53392339,CDM,250,RC,,,Outpatient,,,291.14,174.68,,174.68,60,,139.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.52,28,,65.216,Percent of Total Billed Charges,28% of Total Billed Charges,239.04,32,,191.232,Percent of Total Billed Charges,32% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,104.81,36,,83.848,Percent of Total Billed Charges,36% of Total Billed Charges,104.81,36,,83.848,Percent of Total Billed Charges,36% Total Bille Charges,104.81,36,,83.848,Percent of Total Billed Charges,36% of Total Billed Charges,174.68,60,,139.744,Percent of Total Billed Charges,60% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,41.98,14.42,,33.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.36,75,,101.28,Percent of Total Billed Charges,75% of Total Billed Charges,145.57,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,145.57,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.57,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,145.57,50,,116.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,203.8,70,,163.04,Percent of Total Billed Charges,70% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,40.76,14,,32.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.14,100,,135.04,Percent of Total Billed Charges,100% of Total Billed Charges,40.76,291.14,
WATER ST INJ 100ML,53392340,CDM,250,RC,,,Outpatient,,,18.36,11.02,,11.02,60,,8.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.14,28,,4.112,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,6.61,36,,5.288,Percent of Total Billed Charges,36% of Total Billed Charges,6.61,36,,5.288,Percent of Total Billed Charges,36% Total Bille Charges,6.61,36,,5.288,Percent of Total Billed Charges,36% of Total Billed Charges,11.02,60,,8.816,Percent of Total Billed Charges,60% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.65,14.42,,2.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.77,75,,15.816,Percent of Total Billed Charges,75% of Total Billed Charges,9.18,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,9.18,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.18,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,9.18,50,,7.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,70,,10.28,Percent of Total Billed Charges,70% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,2.57,14,,2.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.36,100,,21.088,Percent of Total Billed Charges,100% of Total Billed Charges,2.57,240,
CEFTAZIDIM/AVIBACT 0.5-0.125GM,53392341,CDM,250,RC,J0714,HCPCS,Outpatient,,,369.89,221.93,,93.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,150.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,89.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,89.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,89.7,360,,,Fee Schedule,360% of BCBS POS Rate,89.7,360,,,Fee schedule,360% of BCBS PPO Rate,89.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.93,60,,177.544,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,90.52,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.75,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.59,103,,,Fee Schedule,103% of CMS OPPS Rate,103.59,103,,,Fee Schedule,103% of CMS OPPS Rate,277.42,75,,37.128,Percent of Total Billed Charges,75% of Total Billed Charges,72.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,72.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,72.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,150.87,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,258.92,70,,207.136,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.58,100,,,Fee Schedule,100% of CMS OPPS Rate,369.89,100,,49.504,Percent of Total Billed Charges,100% of Total Billed Charges,72.66,369.89,
IOHEXOL 300 MG/ML 200 ML,53392342,CDM,255,RC,Q9967,HCPCS,Outpatient,,,493.55,296.13,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,296.13,60,,236.904,Percent of Total Billed Charges,60% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14.42,,56.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,394.84,80,,2.68,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.49,70,,276.392,Percent of Total Billed Charges,70% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,69.1,14,,55.28,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.55,100,,3.568,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,493.55,
GADOTERATE MEG VL 0.5MM/ML15ML,53392344,CDM,255,RC,A9575,HCPCS,Outpatient,,,226.35,135.81,,0.15,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,135.81,60,,108.648,Percent of Total Billed Charges,60% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,32.64,14.42,,26.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.08,80,,900,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.45,70,,126.76,Percent of Total Billed Charges,70% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,31.69,14,,25.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.35,100,,1200,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,226.35,
GADOTERATE MEG VL 0.5MM/ML20ML,53392345,CDM,255,RC,A9575,HCPCS,Outpatient,,,301.8,181.08,,0.15,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,181.08,60,,144.864,Percent of Total Billed Charges,60% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,43.52,14.42,,34.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.44,80,,1200,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.26,70,,169.008,Percent of Total Billed Charges,70% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.25,14,,33.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.8,100,,1600,Percent of Total Billed Charges,100% of Total Billed Charges,0.13,301.8,
FLEET ENEMA #1 +,53392437,CDM,250,RC,,,Outpatient,,,2.34,1.40,,1.4,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.66,28,,0.528,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.84,36,,0.672,Percent of Total Billed Charges,36% of Total Billed Charges,0.84,36,,0.672,Percent of Total Billed Charges,36% Total Bille Charges,0.84,36,,0.672,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.34,14.42,,0.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,75,,1.944,Percent of Total Billed Charges,75% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.64,70,,1.312,Percent of Total Billed Charges,70% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14,,0.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,100,,2.592,Percent of Total Billed Charges,100% of Total Billed Charges,0.33,240,
LINEZOLID PER 200MG,53393000,CDM,250,RC,J2020,HCPCS,Outpatient,,,63.46,38.08,,6.31,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,14.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,14.4,360,,,Fee Schedule,360% of BCBS POS Rate,14.4,360,,,Fee schedule,360% of BCBS PPO Rate,14.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.08,60,,30.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.6,75,,4.744,Percent of Total Billed Charges,75% of Total Billed Charges,2.74,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.74,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.74,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.74,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.42,70,,35.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.46,100,,6.32,Percent of Total Billed Charges,100% of Total Billed Charges,2.74,63.46,
ALTEPLASE 100MG VIAL,53393001,CDM,636,RC,J2997,HCPCS,Outpatient,,,42415,25449.00,,23416.8,110,,18733.44,Percent of Total Billed Charges,110% of Total Billed Charges,3134.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,37.65,360,,,Fee Schedule,360% of BCBS POS Rate,37.65,360,,,Fee schedule,360% of BCBS PPO Rate,37.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,23328.25,55,,18662.6,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3127.79,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3132.37,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.28,103,,,Fee Schedule,103% of CMS OPPS Rate,3129.28,103,,,Fee Schedule,103% of CMS OPPS Rate,31811.25,75,,2.2,Percent of Total Billed Charges,75% of Total Billed Charges,21277.55,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,21277.55,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,21277.55,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,21277.55,50,,17022.04,Percent of Total Billed Charges,50% of Total Billed Charges,3134.65,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,29690.5,70,,23752.4,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3128.94,100,,,Fee Schedule,100% of CMS OPPS Rate,42415,100,,2.928,Percent of Total Billed Charges,100% of Total Billed Charges,37.65,42415,
DARBEPOETIN 1MCG NON ESRD,53393003,CDM,250,RC,J0881,HCPCS,Outpatient,,,74.44,44.66,,3.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.66,60,,35.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,55.83,75,,0.224,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,52.11,70,,41.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,74.44,100,,0.296,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,74.44,
DESMOPRESSIN ACE PER 1MCG,53393004,CDM,250,RC,J2597,HCPCS,Outpatient,,,83.78,50.27,,9.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.16,360,,,Fee Schedule,360% of BCBS POS Rate,2.16,360,,,Fee schedule,360% of BCBS PPO Rate,2.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.27,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,4.87,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.58,103,,,Fee Schedule,103% of CMS OPPS Rate,5.58,103,,,Fee Schedule,103% of CMS OPPS Rate,62.84,75,,13.264,Percent of Total Billed Charges,75% of Total Billed Charges,5.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,5.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,8.13,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,58.65,70,,46.92,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,83.78,100,,17.688,Percent of Total Billed Charges,100% of Total Billed Charges,2.16,83.78,
EPOETIN ALFA 1000 UN NON-ESRD,53393008,CDM,250,RC,J0885,HCPCS,Outpatient,,,1185.49,711.29,,8.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,15.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.96,360,,,Fee Schedule,360% of BCBS POS Rate,15.96,360,,,Fee schedule,360% of BCBS PPO Rate,15.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,711.29,60,,569.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.75,103,,,Fee Schedule,103% of CMS OPPS Rate,7.75,103,,,Fee Schedule,103% of CMS OPPS Rate,889.12,75,,2.352,Percent of Total Billed Charges,75% of Total Billed Charges,6.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.34,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,6.34,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,11.29,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,829.84,70,,663.872,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1185.49,100,,3.136,Percent of Total Billed Charges,100% of Total Billed Charges,6.34,1185.49,
CYCLOPHOSPHAMIDE INJ 1000MG,53393009,CDM,250,RC,J9070,HCPCS,Outpatient,,,3259,1955.40,,27.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,912.52,28,,730.016,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1173.24,36,,938.592,Percent of Total Billed Charges,36% of Total Billed Charges,1173.24,36,,938.592,Percent of Total Billed Charges,36% Total Bille Charges,1173.24,36,,938.592,Percent of Total Billed Charges,36% of Total Billed Charges,1955.4,60,,1564.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2444.25,75,,354.728,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2281.3,70,,1825.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3259,100,,472.968,Percent of Total Billed Charges,100% of Total Billed Charges,17.3,3259,
ANTI-INHIB COAG CMPLX FEIBA 1I,53393010,CDM,250,RC,J7198,HCPCS,Outpatient,,,13.02,7.81,,2.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,3.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.76,360,,,Fee Schedule,360% of BCBS POS Rate,1.76,360,,,Fee schedule,360% of BCBS PPO Rate,1.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.81,60,,6.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2.1,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2.41,103,,,Fee Schedule,103% of CMS OPPS Rate,9.77,75,,157.656,Percent of Total Billed Charges,75% of Total Billed Charges,1.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1.78,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.78,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,3.51,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,70,,7.288,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.02,100,,210.208,Percent of Total Billed Charges,100% of Total Billed Charges,1.76,13.02,
CEFTOLOZANE/TAZOBAC 50MG/25MG,53393011,CDM,250,RC,J0695,HCPCS,Outpatient,,,23.9,14.34,,6.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.34,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.7,360,,,Fee Schedule,360% of BCBS POS Rate,5.7,360,,,Fee schedule,360% of BCBS PPO Rate,5.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,14.34,60,,11.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,10.69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.47,103,,,Fee Schedule,103% of CMS OPPS Rate,8.47,103,,,Fee Schedule,103% of CMS OPPS Rate,17.93,75,,115.296,Percent of Total Billed Charges,75% of Total Billed Charges,5.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,5.37,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,12.34,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,70,,13.384,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.23,100,,,Fee Schedule,100% of CMS OPPS Rate,23.9,100,,153.728,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,23.9,
IRON DEXTRAN PER 50MG,53393012,CDM,250,RC,J1750,HCPCS,Outpatient,,,187.13,112.28,,15.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,13.6,360,,,Fee Schedule,360% of BCBS POS Rate,13.6,360,,,Fee schedule,360% of BCBS PPO Rate,13.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.28,60,,89.824,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,15.9,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,103,,,Fee Schedule,103% of CMS OPPS Rate,18.2,103,,,Fee Schedule,103% of CMS OPPS Rate,140.35,75,,58.056,Percent of Total Billed Charges,75% of Total Billed Charges,13.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.26,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,13.26,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,26.5,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,130.99,70,,104.792,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,187.13,100,,77.408,Percent of Total Billed Charges,100% of Total Billed Charges,13.26,187.13,
ONABOTULINUM TOX PER 1U,53393013,CDM,250,RC,J0585,HCPCS,Outpatient,,,34.74,20.84,,6.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.84,360,,,Fee Schedule,360% of BCBS POS Rate,5.84,360,,,Fee schedule,360% of BCBS PPO Rate,5.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,20.84,60,,16.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.33,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,26.06,75,,9.584,Percent of Total Billed Charges,75% of Total Billed Charges,5.05,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.05,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,5.05,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,9.61,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,70,,19.456,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,34.74,100,,12.776,Percent of Total Billed Charges,100% of Total Billed Charges,5.05,34.74,
BUSULFAN INJ 1MG,53393014,CDM,250,RC,J0594,HCPCS,Outpatient,,,286.01,171.61,,1.47,100,,,Fee Schedule,100% of Aetna Fee Schedule,1.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,8.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,8.41,360,,,Fee Schedule,360% of BCBS POS Rate,8.41,360,,,Fee schedule,360% of BCBS PPO Rate,8.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,171.61,60,,137.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.65,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,103,,,Fee Schedule,103% of CMS OPPS Rate,1.3,103,,,Fee Schedule,103% of CMS OPPS Rate,214.51,75,,17.632,Percent of Total Billed Charges,75% of Total Billed Charges,1.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.5,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,1.9,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,200.21,70,,160.168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.27,100,,,Fee Schedule,100% of CMS OPPS Rate,286.01,100,,23.512,Percent of Total Billed Charges,100% of Total Billed Charges,1.12,286.01,
ISOSULFAN BLUE 1% PER 1MG,53393015,CDM,250,RC,Q9968,HCPCS,Outpatient,,,89.64,53.78,,13.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.16,360,,,Fee Schedule,360% of BCBS POS Rate,1.16,360,,,Fee schedule,360% of BCBS PPO Rate,1.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,53.78,60,,43.024,Percent of Total Billed Charges,60% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.67,90,,,Fee Schedule,90% of CMS OPPS Rate,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,130,,,Fee Schedule,130% of CMS OPPS Rate,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.93,14.42,,10.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,8.77,103,,,Fee Schedule,103% of CMS OPPS Rate,8.77,103,,,Fee Schedule,103% of CMS OPPS Rate,67.23,75,,674.92,Percent of Total Billed Charges,75% of Total Billed Charges,44.82,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,44.82,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,44.82,50,,35.856,Percent of Total Billed Charges,50% of Total Billed Charges,12.79,150,,,Fee Schedule,150% of CMS OPPS Rate,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,62.75,70,,50.2,Percent of Total Billed Charges,70% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.55,14,,10.04,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,89.64,100,,899.896,Percent of Total Billed Charges,100% of Total Billed Charges,1.16,89.64,
CEFTAROLINE 600MG INJ,53393016,CDM,250,RC,J0712,HCPCS,Outpatient,,,868.8,521.28,,3.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,5.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.21,360,,,Fee Schedule,360% of BCBS POS Rate,3.21,360,,,Fee schedule,360% of BCBS PPO Rate,3.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,521.28,60,,417.024,Percent of Total Billed Charges,60% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,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,3.54,90,,,Fee Schedule,90% of CMS OPPS Rate,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,130,,,Fee Schedule,130% of CMS OPPS Rate,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,125.28,14.42,,100.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,4.05,103,,,Fee Schedule,103% of CMS OPPS Rate,4.05,103,,,Fee Schedule,103% of CMS OPPS Rate,651.6,75,,2.92,Percent of Total Billed Charges,75% of Total Billed Charges,3.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,3.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.01,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,3.01,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,5.91,150,,,Fee Schedule,150% of CMS OPPS Rate,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,608.16,70,,486.528,Percent of Total Billed Charges,70% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,121.63,14,,97.304,Percent of Total Billed Charges,14% of Total Billed Charges,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,868.8,100,,3.888,Percent of Total Billed Charges,100% of Total Billed Charges,3.01,868.8,
AZACITIDINE INJ 1MG,53393017,CDM,250,RC,J9025,HCPCS,Outpatient,,,77.12,46.27,,0.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.04,360,,,Fee Schedule,360% of BCBS POS Rate,1.04,360,,,Fee schedule,360% of BCBS PPO Rate,1.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.27,60,,37.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.84,75,,0.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.98,70,,43.184,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.12,100,,0.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,77.12,
HUMATE-P PER INJ 1lU vWF,53393018,CDM,636,RC,J7186,HCPCS,Outpatient,,,8.75,5.25,,5.95,110,,4.76,Percent of Total Billed Charges,110% of Total Billed Charges,1.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,0.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.8,360,,,Fee Schedule,360% of BCBS POS Rate,0.8,360,,,Fee schedule,360% of BCBS PPO Rate,0.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1.1,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1.59,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1.26,103,,,Fee Schedule,103% of CMS OPPS Rate,6.56,75,,0.504,Percent of Total Billed Charges,75% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,5.31,50,,4.248,Percent of Total Billed Charges,50% of Total Billed Charges,1.84,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.13,70,,4.904,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8.75,100,,0.672,Percent of Total Billed Charges,100% of Total Billed Charges,0.8,8.75,
DECITABINE VL 1MG,53393019,CDM,250,RC,J0894,HCPCS,Outpatient,,,177,106.20,,2.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,7.92,360,,,Fee Schedule,360% of BCBS POS Rate,7.92,360,,,Fee schedule,360% of BCBS PPO Rate,7.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.2,60,,84.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.75,75,,23.768,Percent of Total Billed Charges,75% of Total Billed Charges,1.94,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.94,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.94,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.94,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.9,70,,99.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177,100,,31.688,Percent of Total Billed Charges,100% of Total Billed Charges,1.94,177,
SARGRAMOSTIM PER 50MCG,53393020,CDM,250,RC,J2820,HCPCS,Outpatient,,,50.35,30.21,,54.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,90.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,50.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,50.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,50.53,360,,,Fee Schedule,360% of BCBS POS Rate,50.53,360,,,Fee schedule,360% of BCBS PPO Rate,50.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.21,60,,24.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,54.25,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,78.36,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.08,103,,,Fee Schedule,103% of CMS OPPS Rate,62.08,103,,,Fee Schedule,103% of CMS OPPS Rate,37.76,75,,27.984,Percent of Total Billed Charges,75% of Total Billed Charges,45.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,45.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,45.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,90.42,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,35.25,70,,28.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,100,,,Fee Schedule,100% of CMS OPPS Rate,50.35,100,,37.312,Percent of Total Billed Charges,100% of Total Billed Charges,30.21,90.42,
ARSENIC TRIOXIDE INJ 1MG,53393021,CDM,250,RC,J9017,HCPCS,Outpatient,,,355.42,213.25,,12.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,41.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,41.06,360,,,Fee Schedule,360% of BCBS POS Rate,41.06,360,,,Fee schedule,360% of BCBS PPO Rate,41.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,213.25,60,,170.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,6.48,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,103,,,Fee Schedule,103% of CMS OPPS Rate,7.41,103,,,Fee Schedule,103% of CMS OPPS Rate,266.57,75,,3.832,Percent of Total Billed Charges,75% of Total Billed Charges,10.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,10.95,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,10.8,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,248.79,70,,199.032,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,355.42,100,,5.104,Percent of Total Billed Charges,100% of Total Billed Charges,6.48,355.42,
NIVOLUMAB PER 1MG,53393022,CDM,250,RC,J9299,HCPCS,Outpatient,,,172.66,103.60,,29.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,47.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,27.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,27.47,360,,,Fee Schedule,360% of BCBS POS Rate,27.47,360,,,Fee schedule,360% of BCBS PPO Rate,27.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.6,60,,82.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,28.57,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,41.27,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.7,103,,,Fee Schedule,103% of CMS OPPS Rate,32.7,103,,,Fee Schedule,103% of CMS OPPS Rate,129.5,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,23.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,23.93,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,23.93,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,47.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,120.86,70,,96.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.75,100,,,Fee Schedule,100% of CMS OPPS Rate,172.66,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,23.93,172.66,
BORTEZOMIB LYOPH VL 0.1MG,53393023,CDM,250,RC,J9041,HCPCS,Outpatient,,,324.8,194.88,,45.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,2.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,45.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.08,360,,,Fee Schedule,360% of BCBS POS Rate,45.08,360,,,Fee schedule,360% of BCBS PPO Rate,45.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,194.88,60,,155.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1.41,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,2.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.61,103,,,Fee Schedule,103% of CMS OPPS Rate,1.61,103,,,Fee Schedule,103% of CMS OPPS Rate,243.6,75,,136.664,Percent of Total Billed Charges,75% of Total Billed Charges,4.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,4.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,4.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,2.35,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,227.36,70,,181.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,100,,,Fee Schedule,100% of CMS OPPS Rate,324.8,100,,182.216,Percent of Total Billed Charges,100% of Total Billed Charges,1.41,324.8,
DENOSUMAB PER 1MG,53393024,CDM,250,RC,J0897,HCPCS,Outpatient,,,93.01,55.81,,21.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.44,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,18.54,360,,,Fee Schedule,360% of BCBS POS Rate,18.54,360,,,Fee schedule,360% of BCBS PPO Rate,18.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.81,60,,44.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,24.26,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,35.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.76,103,,,Fee Schedule,103% of CMS OPPS Rate,27.76,103,,,Fee Schedule,103% of CMS OPPS Rate,69.76,75,,209.296,Percent of Total Billed Charges,75% of Total Billed Charges,18.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.41,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,18.41,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,40.44,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,65.11,70,,52.088,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,93.01,100,,279.064,Percent of Total Billed Charges,100% of Total Billed Charges,18.41,93.01,
BEVACIZUMAB PER 10MG,53393027,CDM,636,RC,J9035,HCPCS,Outpatient,,,321.8,193.08,,245.53,110,,196.424,Percent of Total Billed Charges,110% of Total Billed Charges,109.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,79.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,79.14,360,,,Fee Schedule,360% of BCBS POS Rate,79.14,360,,,Fee schedule,360% of BCBS PPO Rate,79.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,94.51,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.88,103,,,Fee Schedule,103% of CMS OPPS Rate,74.88,103,,,Fee Schedule,103% of CMS OPPS Rate,241.35,75,,117.04,Percent of Total Billed Charges,75% of Total Billed Charges,217.98,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,217.98,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,217.98,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,217.98,50,,174.384,Percent of Total Billed Charges,50% of Total Billed Charges,109.05,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,70,,180.208,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,321.8,100,,156.056,Percent of Total Billed Charges,100% of Total Billed Charges,65.43,321.8,
IMMUNE GLOB IV GAMUNEX 0.5GM,53393028,CDM,250,RC,J1561,HCPCS,Outpatient,,,229.33,137.60,,46.97,100,,,Fee Schedule,100% of Aetna Fee Schedule,73.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,45.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.35,360,,,Fee Schedule,360% of BCBS POS Rate,45.35,360,,,Fee schedule,360% of BCBS PPO Rate,45.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,137.6,60,,110.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.92,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.27,103,,,Fee Schedule,103% of CMS OPPS Rate,50.27,103,,,Fee Schedule,103% of CMS OPPS Rate,172,75,,105.736,Percent of Total Billed Charges,75% of Total Billed Charges,38.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,38.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,38.16,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,38.16,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,73.2,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,160.53,70,,128.424,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.81,100,,,Fee Schedule,100% of CMS OPPS Rate,229.33,100,,140.984,Percent of Total Billed Charges,100% of Total Billed Charges,38.16,229.33,
ABATACEPT PER 10MG,53393029,CDM,636,RC,J0129,HCPCS,Outpatient,,,241.44,144.86,,177.76,110,,142.208,Percent of Total Billed Charges,110% of Total Billed Charges,65.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,43.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,43.12,360,,,Fee Schedule,360% of BCBS POS Rate,43.12,360,,,Fee schedule,360% of BCBS PPO Rate,43.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,56.47,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.74,103,,,Fee Schedule,103% of CMS OPPS Rate,44.74,103,,,Fee Schedule,103% of CMS OPPS Rate,181.08,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,154.93,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,154.93,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,154.93,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,154.93,50,,123.944,Percent of Total Billed Charges,50% of Total Billed Charges,65.16,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,169.01,70,,135.208,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.44,100,,,Fee Schedule,100% of CMS OPPS Rate,241.44,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,39.09,241.44,
FOSAPREPITANT INJ 150MG,53393030,CDM,250,RC,J1453,HCPCS,Outpatient,,,1501.5,900.90,,0.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.44,360,,,Fee Schedule,360% of BCBS POS Rate,1.44,360,,,Fee schedule,360% of BCBS PPO Rate,1.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,900.9,60,,720.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1126.13,75,,8.016,Percent of Total Billed Charges,75% of Total Billed Charges,0.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.14,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1051.05,70,,840.84,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1501.5,100,,10.024,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,1501.5,
DOCETAXEL PER 1MG,53393031,CDM,250,RC,J9171,HCPCS,Outpatient,,,135.65,81.39,,0.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.42,360,,,Fee Schedule,360% of BCBS POS Rate,2.42,360,,,Fee schedule,360% of BCBS PPO Rate,2.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.39,60,,65.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.74,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.36,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.36,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.96,70,,75.968,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.65,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.36,135.65,
IMMUNE GLOBULIN LYOPH 0.5GM,53393032,CDM,250,RC,J1566,HCPCS,Outpatient,,,373.38,224.03,,70.29,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,29.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,29.36,360,,,Fee Schedule,360% of BCBS POS Rate,29.36,360,,,Fee schedule,360% of BCBS PPO Rate,29.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,224.03,60,,179.224,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,73.97,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,106.84,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.65,103,,,Fee Schedule,103% of CMS OPPS Rate,84.65,103,,,Fee Schedule,103% of CMS OPPS Rate,280.04,75,,25.072,Percent of Total Billed Charges,75% of Total Billed Charges,58.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,58.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,58.54,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,58.54,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,123.28,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,261.37,70,,209.096,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.19,100,,,Fee Schedule,100% of CMS OPPS Rate,373.38,100,,33.424,Percent of Total Billed Charges,100% of Total Billed Charges,29.36,373.38,
FACTOR VIIA (RECOMB) PER 1MCG,53393033,CDM,250,RC,J7189,HCPCS,Outpatient,,,4.95,2.97,,2.33,100,,,Fee Schedule,100% of Aetna Fee Schedule,3.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.63,360,,,Fee Schedule,360% of BCBS POS Rate,1.63,360,,,Fee schedule,360% of BCBS PPO Rate,1.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.97,60,,2.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,3.27,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.59,103,,,Fee Schedule,103% of CMS OPPS Rate,2.59,103,,,Fee Schedule,103% of CMS OPPS Rate,3.71,75,,1068.304,Percent of Total Billed Charges,75% of Total Billed Charges,1.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1.87,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.87,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,3.78,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,3.47,70,,2.776,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.52,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,1424.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,4.95,
C-1 ESTER INHIB BERINERT 10U,53393034,CDM,636,RC,J0597,HCPCS,Outpatient,,,278.09,166.85,,210.92,110,,168.736,Percent of Total Billed Charges,110% of Total Billed Charges,102.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,59.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,59.1,360,,,Fee Schedule,360% of BCBS POS Rate,59.1,360,,,Fee schedule,360% of BCBS PPO Rate,59.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,61.52,90,,,Fee Schedule,90% of CMS OPPS Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,88.86,130,,,Fee Schedule,130% of CMS OPPS Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,40.1,14.42,,32.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.41,103,,,Fee Schedule,103% of CMS OPPS Rate,70.41,103,,,Fee Schedule,103% of CMS OPPS Rate,208.57,75,,180.816,Percent of Total Billed Charges,75% of Total Billed Charges,187.63,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,187.63,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,187.63,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,187.63,50,,150.104,Percent of Total Billed Charges,50% of Total Billed Charges,102.54,150,,,Fee Schedule,150% of CMS OPPS Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,194.66,70,,155.728,Percent of Total Billed Charges,70% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,68.36,100,,,Fee Schedule,100% of CMS OPPS Rate,278.09,100,,241.088,Percent of Total Billed Charges,100% of Total Billed Charges,38.93,278.09,
PALONOSETRON PER 0.025MG,53393035,CDM,250,RC,J2469,HCPCS,Outpatient,,,248.2,148.92,,0.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,6.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,6.91,360,,,Fee Schedule,360% of BCBS POS Rate,6.91,360,,,Fee schedule,360% of BCBS PPO Rate,6.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,148.92,60,,119.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.15,75,,37.048,Percent of Total Billed Charges,75% of Total Billed Charges,1.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.03,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.03,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.74,70,,138.992,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.2,100,,49.392,Percent of Total Billed Charges,100% of Total Billed Charges,0.87,248.2,
CLOFARABINE PER 1MG,53393036,CDM,636,RC,J9027,HCPCS,Outpatient,,,710.32,426.19,,452.95,110,,362.36,Percent of Total Billed Charges,110% of Total Billed Charges,21.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,80.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,80.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,80.24,360,,,Fee Schedule,360% of BCBS POS Rate,80.24,360,,,Fee schedule,360% of BCBS PPO Rate,80.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,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,12.94,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.81,103,,,Fee Schedule,103% of CMS OPPS Rate,14.81,103,,,Fee Schedule,103% of CMS OPPS Rate,532.74,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,380.94,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,380.94,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,380.94,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,380.94,50,,304.752,Percent of Total Billed Charges,50% of Total Billed Charges,21.57,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,497.22,70,,397.776,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,710.32,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,12.94,710.32,
PACLITAXEL PROTEIN BOUND 1MG,53393037,CDM,250,RC,J9264,HCPCS,Outpatient,,,62.24,37.34,,14.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,13.64,360,,,Fee Schedule,360% of BCBS POS Rate,13.64,360,,,Fee schedule,360% of BCBS PPO Rate,13.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.34,60,,29.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,12,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,17.34,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,103,,,Fee Schedule,103% of CMS OPPS Rate,13.74,103,,,Fee Schedule,103% of CMS OPPS Rate,46.68,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,9.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,9.42,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,9.42,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,20.01,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,43.57,70,,34.856,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.34,100,,,Fee Schedule,100% of CMS OPPS Rate,62.24,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,9.42,62.24,
BENDAMUSTINE 1MG INJ,53393038,CDM,250,RC,J9033,HCPCS,Outpatient,,,85.94,51.56,,20.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,30.61,360,,,Fee Schedule,360% of BCBS POS Rate,30.61,360,,,Fee schedule,360% of BCBS PPO Rate,30.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,51.56,60,,41.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,7.05,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.59,103,,,Fee Schedule,103% of CMS OPPS Rate,5.59,103,,,Fee Schedule,103% of CMS OPPS Rate,64.46,75,,45.256,Percent of Total Billed Charges,75% of Total Billed Charges,11.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.5,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,11.5,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,8.14,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60.16,70,,48.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.43,100,,,Fee Schedule,100% of CMS OPPS Rate,85.94,100,,60.336,Percent of Total Billed Charges,100% of Total Billed Charges,4.88,85.94,
CARFILZOMIB VL 1MG,53393039,CDM,250,RC,J9047,HCPCS,Outpatient,,,99.13,59.48,,41.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,74.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,38.73,360,,,Fee Schedule,360% of BCBS POS Rate,38.73,360,,,Fee schedule,360% of BCBS PPO Rate,38.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,59.48,60,,47.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,44.62,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,64.45,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.06,103,,,Fee Schedule,103% of CMS OPPS Rate,51.06,103,,,Fee Schedule,103% of CMS OPPS Rate,74.35,75,,50.344,Percent of Total Billed Charges,75% of Total Billed Charges,35.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.81,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,35.81,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,74.37,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,69.39,70,,55.512,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,99.13,100,,67.12,Percent of Total Billed Charges,100% of Total Billed Charges,35.81,99.13,
IMMUNE GLOB GAMMAGARD 0.5GM,53393040,CDM,636,RC,J1569,HCPCS,Outpatient,,,269.98,161.99,,195.62,110,,156.496,Percent of Total Billed Charges,110% of Total Billed Charges,74.53,150,,,Fee Schedule ,150% of CMS OPPS Rate,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,46.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,46.58,360,,,Fee Schedule,360% of BCBS POS Rate,46.58,360,,,Fee schedule,360% of BCBS PPO Rate,46.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,44.72,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,64.59,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.18,103,,,Fee Schedule,103% of CMS OPPS Rate,51.18,103,,,Fee Schedule,103% of CMS OPPS Rate,202.49,75,,3.136,Percent of Total Billed Charges,75% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,74.53,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,188.99,70,,151.192,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,269.98,100,,4.184,Percent of Total Billed Charges,100% of Total Billed Charges,44.72,269.98,
TREPROSTINIL PER 1MG,53393041,CDM,250,RC,J3285,HCPCS,Outpatient,,,266.53,159.92,,58.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,83.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,41.81,360,,,Fee Schedule,360% of BCBS POS Rate,41.81,360,,,Fee schedule,360% of BCBS PPO Rate,41.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.92,60,,127.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,50.23,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,72.56,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.49,103,,,Fee Schedule,103% of CMS OPPS Rate,57.49,103,,,Fee Schedule,103% of CMS OPPS Rate,199.9,75,,6.712,Percent of Total Billed Charges,75% of Total Billed Charges,44.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,44.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,44.25,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,83.73,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,186.57,70,,149.256,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.82,100,,,Fee Schedule,100% of CMS OPPS Rate,266.53,100,,8.944,Percent of Total Billed Charges,100% of Total Billed Charges,41.81,266.53,
OMALIZUMAB PER 5MG,53393042,CDM,250,RC,J2357,HCPCS,Outpatient,,,181.8,109.08,,37.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,57.43,150,,,Fee Schedule ,150% of CMS OPPS Rate,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,36.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,36.03,360,,,Fee Schedule,360% of BCBS POS Rate,36.03,360,,,Fee schedule,360% of BCBS PPO Rate,36.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.08,60,,87.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,34.46,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,49.77,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.43,103,,,Fee Schedule,103% of CMS OPPS Rate,39.43,103,,,Fee Schedule,103% of CMS OPPS Rate,136.35,75,,26.896,Percent of Total Billed Charges,75% of Total Billed Charges,30.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,30.33,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,57.43,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,127.26,70,,101.808,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,181.8,100,,35.856,Percent of Total Billed Charges,100% of Total Billed Charges,30.33,181.8,
IBANDRONATE PER 1MG,53393043,CDM,250,RC,J1740,HCPCS,Outpatient,,,1372.5,823.50,,29.57,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,11.98,360,,,Fee Schedule,360% of BCBS POS Rate,11.98,360,,,Fee schedule,360% of BCBS PPO Rate,11.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,823.5,60,,658.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1029.38,75,,498.248,Percent of Total Billed Charges,75% of Total Billed Charges,24.67,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.67,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.67,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,960.75,70,,768.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1372.5,100,,664.328,Percent of Total Billed Charges,100% of Total Billed Charges,11.98,1372.5,
PEMETREXED DISOD PER 10MG,53393044,CDM,250,RC,J9305,HCPCS,Outpatient,,,260.44,156.26,,76.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,70.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,70.48,360,,,Fee Schedule,360% of BCBS POS Rate,70.48,360,,,Fee schedule,360% of BCBS PPO Rate,70.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,156.26,60,,125.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,195.33,75,,17.184,Percent of Total Billed Charges,75% of Total Billed Charges,13.71,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.71,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,13.71,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,6.27,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,182.31,70,,145.848,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,260.44,100,,22.912,Percent of Total Billed Charges,100% of Total Billed Charges,3.76,260.44,
FULVESTRANT PER 25MG,53393045,CDM,250,RC,J9395,HCPCS,Outpatient,,,475.58,285.35,,15.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,82.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,82.4,360,,,Fee Schedule,360% of BCBS POS Rate,82.4,360,,,Fee schedule,360% of BCBS PPO Rate,82.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,285.35,60,,228.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.75,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,9.76,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,103,,,Fee Schedule,103% of CMS OPPS Rate,7.73,103,,,Fee Schedule,103% of CMS OPPS Rate,356.69,75,,7.32,Percent of Total Billed Charges,75% of Total Billed Charges,9.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,9.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,9.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,11.26,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,332.91,70,,266.328,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,100,,,Fee Schedule,100% of CMS OPPS Rate,475.58,100,,9.76,Percent of Total Billed Charges,100% of Total Billed Charges,6.75,475.58,
OCTREOTIDE DEPOT PER 1MG,53393047,CDM,636,RC,J2353,HCPCS,Outpatient,,,724.54,434.72,,607.13,110,,485.704,Percent of Total Billed Charges,110% of Total Billed Charges,322.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,208.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,208.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,208.62,360,,,Fee Schedule,360% of BCBS POS Rate,208.62,360,,,Fee schedule,360% of BCBS PPO Rate,208.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,193.39,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,279.33,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.32,103,,,Fee Schedule,103% of CMS OPPS Rate,221.32,103,,,Fee Schedule,103% of CMS OPPS Rate,543.41,75,,80.784,Percent of Total Billed Charges,75% of Total Billed Charges,525.89,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,525.89,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,525.89,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,525.89,50,,420.712,Percent of Total Billed Charges,50% of Total Billed Charges,322.32,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,507.18,70,,405.744,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.88,100,,,Fee Schedule,100% of CMS OPPS Rate,724.54,100,,107.712,Percent of Total Billed Charges,100% of Total Billed Charges,193.39,724.54,
FACTOR IX NON-RECOMB PER IU,53393048,CDM,250,RC,J7193,HCPCS,Outpatient,,,8.7,5.22,,1.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,2.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.83,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.83,360,,,Fee Schedule,360% of BCBS POS Rate,0.83,360,,,Fee schedule,360% of BCBS PPO Rate,0.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.22,60,,4.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1.83,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,103,,,Fee Schedule,103% of CMS OPPS Rate,1.45,103,,,Fee Schedule,103% of CMS OPPS Rate,6.53,75,,17.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,2.11,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,70,,4.872,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,100,,22.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.83,8.7,
ROMIPLOSTIM 125MCG VIAL,53393049,CDM,636,RC,J2796,HCPCS,Outpatient,,,1942,1165.20,,1152.56,110,,922.048,Percent of Total Billed Charges,110% of Total Billed Charges,151.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,71.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,71.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,71.37,360,,,Fee Schedule,360% of BCBS POS Rate,71.37,360,,,Fee schedule,360% of BCBS PPO Rate,71.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,1068.1,55,,854.48,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,90.94,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,131.36,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.08,103,,,Fee Schedule,103% of CMS OPPS Rate,104.08,103,,,Fee Schedule,103% of CMS OPPS Rate,1456.5,75,,131.008,Percent of Total Billed Charges,75% of Total Billed Charges,1043.49,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,1043.49,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.49,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,1043.49,50,,834.792,Percent of Total Billed Charges,50% of Total Billed Charges,151.57,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.4,70,,1087.52,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1942,100,,174.672,Percent of Total Billed Charges,100% of Total Billed Charges,71.37,1942,
CLADRIBINE INJ 1MG,53393050,CDM,250,RC,J9065,HCPCS,Outpatient,,,300,180.00,,15.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,24.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.19,360,,,Fee Schedule,360% of BCBS POS Rate,24.19,360,,,Fee schedule,360% of BCBS PPO Rate,24.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.67,103,,,Fee Schedule,103% of CMS OPPS Rate,14.67,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,31.488,Percent of Total Billed Charges,75% of Total Billed Charges,15.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,15.1,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,21.37,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.25,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,41.984,Percent of Total Billed Charges,100% of Total Billed Charges,12.82,300,
ADALIMUMAB PER 20MG,53393052,CDM,636,RC,J0135,HCPCS,Outpatient,,,3654.02,2192.41,,3179,110,,2543.2,Percent of Total Billed Charges,110% of Total Billed Charges,2751.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1133.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1133.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1133.13,360,,,Fee Schedule,360% of BCBS POS Rate,1133.13,360,,,Fee schedule,360% of BCBS PPO Rate,1133.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,2009.71,55,,1607.768,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,1651.04,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,2384.83,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1889.52,103,,,Fee Schedule,103% of CMS OPPS Rate,1889.52,103,,,Fee Schedule,103% of CMS OPPS Rate,2740.52,75,,1.36,Percent of Total Billed Charges,75% of Total Billed Charges,1827.01,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,1827.01,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1827.01,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,1827.01,50,,1461.608,Percent of Total Billed Charges,50% of Total Billed Charges,2751.73,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,2557.81,70,,2046.248,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,3654.02,100,,1.816,Percent of Total Billed Charges,100% of Total Billed Charges,1133.13,3654.02,
AGALSIDASE BETA PER 1MG,53393053,CDM,636,RC,J0180,HCPCS,Outpatient,,,742.66,445.60,,609.19,110,,487.352,Percent of Total Billed Charges,110% of Total Billed Charges,335.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,166.46,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,166.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,166.46,360,,,Fee Schedule,360% of BCBS POS Rate,166.46,360,,,Fee schedule,360% of BCBS PPO Rate,166.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,201.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,290.57,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230.22,103,,,Fee Schedule,103% of CMS OPPS Rate,230.22,103,,,Fee Schedule,103% of CMS OPPS Rate,557,75,,0.304,Percent of Total Billed Charges,75% of Total Billed Charges,537.86,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,537.86,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,537.86,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,537.86,50,,430.288,Percent of Total Billed Charges,50% of Total Billed Charges,335.28,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,519.86,70,,415.888,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,742.66,100,,0.408,Percent of Total Billed Charges,100% of Total Billed Charges,166.46,742.66,
NELARABINE PER 50MG,53393054,CDM,636,RC,J9261,HCPCS,Outpatient,,,2256.1,1353.66,,1398.32,110,,1118.656,Percent of Total Billed Charges,110% of Total Billed Charges,108.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,146.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,146.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,146.04,360,,,Fee Schedule,360% of BCBS POS Rate,146.04,360,,,Fee schedule,360% of BCBS PPO Rate,146.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,1240.86,55,,992.688,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,65.27,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,94.28,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.7,103,,,Fee Schedule,103% of CMS OPPS Rate,74.7,103,,,Fee Schedule,103% of CMS OPPS Rate,1692.08,75,,105.088,Percent of Total Billed Charges,75% of Total Billed Charges,1231.91,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,1231.91,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.91,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,1231.91,50,,985.528,Percent of Total Billed Charges,50% of Total Billed Charges,108.79,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1579.27,70,,1263.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2256.1,100,,140.12,Percent of Total Billed Charges,100% of Total Billed Charges,65.27,2256.1,
FACTOR IX REC (BENEFIX) 1IU,53393055,CDM,250,RC,J7195,HCPCS,Outpatient,,,6.78,4.07,,1.61,100,,,Fee Schedule,100% of Aetna Fee Schedule,2.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.29,360,,,Fee Schedule,360% of BCBS POS Rate,1.29,360,,,Fee schedule,360% of BCBS PPO Rate,1.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.07,60,,3.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.66,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2.4,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.9,103,,,Fee Schedule,103% of CMS OPPS Rate,1.9,103,,,Fee Schedule,103% of CMS OPPS Rate,5.09,75,,157.2,Percent of Total Billed Charges,75% of Total Billed Charges,1.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1.31,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.31,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,2.77,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,70,,3.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.85,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,209.6,Percent of Total Billed Charges,100% of Total Billed Charges,1.29,6.78,
PERTUZUMAB PER 1MG,53393057,CDM,250,RC,J9306,HCPCS,Outpatient,,,61.77,37.06,,13.69,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,12.28,360,,,Fee Schedule,360% of BCBS POS Rate,12.28,360,,,Fee schedule,360% of BCBS PPO Rate,12.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.06,60,,29.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.6,103,,,Fee Schedule,103% of CMS OPPS Rate,16.6,103,,,Fee Schedule,103% of CMS OPPS Rate,46.33,75,,168.44,Percent of Total Billed Charges,75% of Total Billed Charges,11.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,11.54,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,24.18,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,43.24,70,,34.592,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.12,100,,,Fee Schedule,100% of CMS OPPS Rate,61.77,100,,224.584,Percent of Total Billed Charges,100% of Total Billed Charges,11.54,61.77,
DOXORUBICIN LIPO PER 10MG,53393058,CDM,636,RC,Q2050,HCPCS,Outpatient,,,1747.7,1048.62,,1163.76,110,,931.008,Percent of Total Billed Charges,110% of Total Billed Charges,199.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,334.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,334.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,334.89,360,,,Fee Schedule,360% of BCBS POS Rate,334.89,360,,,Fee schedule,360% of BCBS PPO Rate,334.89,360,,,Fee Schedule,360% of BCBS Traditional Rate,961.24,55,,768.992,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,119.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,173,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.07,103,,,Fee Schedule,103% of CMS OPPS Rate,137.07,103,,,Fee Schedule,103% of CMS OPPS Rate,1310.78,75,,62.544,Percent of Total Billed Charges,75% of Total Billed Charges,936.3,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,936.3,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,936.3,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,936.3,50,,749.04,Percent of Total Billed Charges,50% of Total Billed Charges,199.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1223.39,70,,978.712,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.7,100,,83.392,Percent of Total Billed Charges,100% of Total Billed Charges,119.77,1747.7,
BLINATUMOMAB VL 1MCG,53393059,CDM,636,RC,J9039,HCPCS,Outpatient,,,345.88,207.53,,315.58,110,,252.464,Percent of Total Billed Charges,110% of Total Billed Charges,228.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,112.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,112.49,360,,,Fee Schedule,360% of BCBS POS Rate,112.49,360,,,Fee schedule,360% of BCBS PPO Rate,112.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,136.96,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,197.83,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.74,103,,,Fee Schedule,103% of CMS OPPS Rate,156.74,103,,,Fee Schedule,103% of CMS OPPS Rate,259.41,75,,21.4,Percent of Total Billed Charges,75% of Total Billed Charges,281.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,281.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,281.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,281.79,50,,225.432,Percent of Total Billed Charges,50% of Total Billed Charges,228.27,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,242.12,70,,193.696,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.18,100,,,Fee Schedule,100% of CMS OPPS Rate,345.88,100,,28.536,Percent of Total Billed Charges,100% of Total Billed Charges,112.49,345.88,
SOMATROPIN INJ PER 1MG,53393060,CDM,250,RC,J2941,HCPCS,Outpatient,,,500.61,300.37,,141.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,236.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,54.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,54.62,360,,,Fee Schedule,360% of BCBS POS Rate,54.62,360,,,Fee schedule,360% of BCBS PPO Rate,54.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,300.37,60,,240.296,Percent of Total Billed Charges,60% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,141.72,90,,,Fee Schedule,90% of CMS OPPS Rate,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,204.72,130,,,Fee Schedule,130% of CMS OPPS Rate,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,72.19,14.42,,57.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,162.19,103,,,Fee Schedule,103% of CMS OPPS Rate,162.19,103,,,Fee Schedule,103% of CMS OPPS Rate,375.46,75,,34.176,Percent of Total Billed Charges,75% of Total Billed Charges,250.31,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,250.31,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.31,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,250.31,50,,200.248,Percent of Total Billed Charges,50% of Total Billed Charges,236.22,150,,,Fee Schedule,150% of CMS OPPS Rate,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,350.43,70,,280.344,Percent of Total Billed Charges,70% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,70.09,14,,56.072,Percent of Total Billed Charges,14% of Total Billed Charges,157.47,100,,,Fee Schedule,100% of CMS OPPS Rate,500.61,100,,45.568,Percent of Total Billed Charges,100% of Total Billed Charges,54.62,500.61,
MITOXANTRONE 5MG INJ,53393061,CDM,250,RC,J9293,HCPCS,Outpatient,,,547.63,328.58,,29.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,81.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,37.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,37.41,360,,,Fee Schedule,360% of BCBS POS Rate,37.41,360,,,Fee schedule,360% of BCBS PPO Rate,37.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,328.58,60,,262.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,49.18,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.28,103,,,Fee Schedule,103% of CMS OPPS Rate,56.28,103,,,Fee Schedule,103% of CMS OPPS Rate,410.72,75,,118.128,Percent of Total Billed Charges,75% of Total Billed Charges,39.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,39.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,39.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,81.97,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,383.34,70,,306.672,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.65,100,,,Fee Schedule,100% of CMS OPPS Rate,547.63,100,,157.504,Percent of Total Billed Charges,100% of Total Billed Charges,29.7,547.63,
ZICONOTIDE INJ PER 1MCG,53393063,CDM,250,RC,J2278,HCPCS,Outpatient,,,38.35,23.01,,9.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,5.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.58,360,,,Fee Schedule,360% of BCBS POS Rate,5.58,360,,,Fee schedule,360% of BCBS PPO Rate,5.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.01,60,,18.408,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.93,103,,,Fee Schedule,103% of CMS OPPS Rate,9.93,103,,,Fee Schedule,103% of CMS OPPS Rate,28.76,75,,3.904,Percent of Total Billed Charges,75% of Total Billed Charges,7.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,7.26,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,7.26,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,14.47,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.85,70,,21.48,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.65,100,,,Fee Schedule,100% of CMS OPPS Rate,38.35,100,,5.208,Percent of Total Billed Charges,100% of Total Billed Charges,5.58,38.35,
SECRETIN (HUMAN) PER 1MCG,53393064,CDM,250,RC,J2850,HCPCS,Outpatient,,,196.88,118.13,,31.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,63.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,32.81,360,,,Fee Schedule,360% of BCBS POS Rate,32.81,360,,,Fee schedule,360% of BCBS PPO Rate,32.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.13,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.31,90,,,Fee Schedule,90% of CMS OPPS Rate,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,55.34,130,,,Fee Schedule,130% of CMS OPPS Rate,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14.42,,22.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,43.84,103,,,Fee Schedule,103% of CMS OPPS Rate,43.84,103,,,Fee Schedule,103% of CMS OPPS Rate,147.66,75,,67.336,Percent of Total Billed Charges,75% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,63.85,150,,,Fee Schedule,150% of CMS OPPS Rate,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,137.82,70,,110.256,Percent of Total Billed Charges,70% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,42.57,100,,,Fee Schedule,100% of CMS OPPS Rate,196.88,100,,89.776,Percent of Total Billed Charges,100% of Total Billed Charges,27.56,196.88,
BELINOSTAT INJ PER 10MG,53393065,CDM,636,RC,J9032,HCPCS,Outpatient,,,230.04,138.02,,170.37,110,,136.296,Percent of Total Billed Charges,110% of Total Billed Charges,75.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.08,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,65.11,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.59,103,,,Fee Schedule,103% of CMS OPPS Rate,51.59,103,,,Fee Schedule,103% of CMS OPPS Rate,172.53,75,,2.728,Percent of Total Billed Charges,75% of Total Billed Charges,152.71,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,152.71,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,152.71,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,152.71,50,,122.168,Percent of Total Billed Charges,50% of Total Billed Charges,75.13,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,161.03,70,,128.824,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.04,100,,3.632,Percent of Total Billed Charges,100% of Total Billed Charges,40.61,230.04,
FOMEPIZOLE INJ 1GM/ML 1.5ML SDV,53393066,CDM,636,RC,J1451,HCPCS,Outpatient,,,3168.84,1901.30,,1757.26,110,,1405.808,Percent of Total Billed Charges,110% of Total Billed Charges,9.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,10.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,10.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,10.37,360,,,Fee Schedule,360% of BCBS POS Rate,10.37,360,,,Fee schedule,360% of BCBS PPO Rate,10.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,1742.86,55,,1394.288,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,103,,,Fee Schedule,103% of CMS OPPS Rate,6.63,103,,,Fee Schedule,103% of CMS OPPS Rate,2376.63,75,,0.352,Percent of Total Billed Charges,75% of Total Billed Charges,1584.42,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,1584.42,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1584.42,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,1584.42,50,,1267.536,Percent of Total Billed Charges,50% of Total Billed Charges,9.66,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2218.19,70,,1774.552,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.44,100,,,Fee Schedule,100% of CMS OPPS Rate,3168.84,100,,0.472,Percent of Total Billed Charges,100% of Total Billed Charges,5.79,3168.84,
ADO-TRASTUZUMAB EMTANS PER 1MG,53393067,CDM,250,RC,J9354,HCPCS,Outpatient,,,199.7,119.82,,34.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,60.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,30.41,360,,,Fee Schedule,360% of BCBS POS Rate,30.41,360,,,Fee schedule,360% of BCBS PPO Rate,30.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.82,60,,95.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,36.4,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,52.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.66,103,,,Fee Schedule,103% of CMS OPPS Rate,41.66,103,,,Fee Schedule,103% of CMS OPPS Rate,149.78,75,,0.72,Percent of Total Billed Charges,75% of Total Billed Charges,28.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.99,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,28.99,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,60.67,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,139.79,70,,111.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.45,100,,,Fee Schedule,100% of CMS OPPS Rate,199.7,100,,0.96,Percent of Total Billed Charges,100% of Total Billed Charges,28.99,199.7,
ABOBOTULINUM TOXN A PER 5 UNIT,53393068,CDM,250,RC,J0586,HCPCS,Outpatient,,,45.78,27.47,,8.39,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,8.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,8.46,360,,,Fee Schedule,360% of BCBS POS Rate,8.46,360,,,Fee schedule,360% of BCBS PPO Rate,8.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,27.47,60,,21.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,7.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.21,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.88,103,,,Fee Schedule,103% of CMS OPPS Rate,8.88,103,,,Fee Schedule,103% of CMS OPPS Rate,34.34,75,,3.24,Percent of Total Billed Charges,75% of Total Billed Charges,6.96,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.96,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.96,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,6.96,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,12.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,32.05,70,,25.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,100,,,Fee Schedule,100% of CMS OPPS Rate,45.78,100,,4.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.96,45.78,
ICATIBANT INJ PER 1MG,53393069,CDM,636,RC,J1744,HCPCS,Outpatient,,,1416.95,850.17,,941.98,110,,753.584,Percent of Total Billed Charges,110% of Total Billed Charges,227.45,150,,,Fee Schedule ,150% of CMS OPPS Rate,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,183,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,183,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,183,360,,,Fee Schedule,360% of BCBS POS Rate,183,360,,,Fee schedule,360% of BCBS PPO Rate,183,360,,,Fee Schedule,360% of BCBS Traditional Rate,779.32,55,,623.456,Percent of Total Billed Charges,55% Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,136.47,90,,,Fee Schedule,90% of CMS OPPS Rate,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,197.13,130,,,Fee Schedule,130% of CMS OPPS Rate,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,204.32,14.42,,163.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,156.18,103,,,Fee Schedule,103% of CMS OPPS Rate,156.18,103,,,Fee Schedule,103% of CMS OPPS Rate,1062.71,75,,7.832,Percent of Total Billed Charges,75% of Total Billed Charges,708.48,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,708.48,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,708.48,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,708.48,50,,566.784,Percent of Total Billed Charges,50% of Total Billed Charges,227.45,150,,,Fee Schedule,150% of CMS OPPS Rate,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,991.87,70,,793.496,Percent of Total Billed Charges,70% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,198.37,14,,158.696,Percent of Total Billed Charges,14% of Total Billed Charges,151.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1416.95,100,,10.44,Percent of Total Billed Charges,100% of Total Billed Charges,136.47,1416.95,
BRENTUXIMAB VEDOTIN PER 1MG,53393071,CDM,636,RC,J9042,HCPCS,Outpatient,,,564.8,338.88,,509.15,110,,407.32,Percent of Total Billed Charges,110% of Total Billed Charges,359.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,157.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,157.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,157.61,360,,,Fee Schedule,360% of BCBS POS Rate,157.61,360,,,Fee schedule,360% of BCBS PPO Rate,157.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,215.87,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,311.81,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.05,103,,,Fee Schedule,103% of CMS OPPS Rate,247.05,103,,,Fee Schedule,103% of CMS OPPS Rate,423.6,75,,24.376,Percent of Total Billed Charges,75% of Total Billed Charges,453.43,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,453.43,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,453.43,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,453.43,50,,362.744,Percent of Total Billed Charges,50% of Total Billed Charges,359.79,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,395.36,70,,316.288,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.86,100,,,Fee Schedule,100% of CMS OPPS Rate,564.8,100,,32.496,Percent of Total Billed Charges,100% of Total Billed Charges,157.61,564.8,
DACTINOMYCIN INJ PER 0.5MG,53393072,CDM,636,RC,J9120,HCPCS,Outpatient,,,5118.38,3071.03,,3662.38,110,,2929.904,Percent of Total Billed Charges,110% of Total Billed Charges,423.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1049.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1049.81,360,,,Fee Schedule,360% of BCBS POS Rate,1049.81,360,,,Fee schedule,360% of BCBS PPO Rate,1049.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,2815.11,55,,2252.088,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,253.91,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,366.76,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.58,103,,,Fee Schedule,103% of CMS OPPS Rate,290.58,103,,,Fee Schedule,103% of CMS OPPS Rate,3838.79,75,,17.928,Percent of Total Billed Charges,75% of Total Billed Charges,2996.48,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,2996.48,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2996.48,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,2996.48,50,,2397.184,Percent of Total Billed Charges,50% of Total Billed Charges,423.19,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,3582.87,70,,2866.296,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.13,100,,,Fee Schedule,100% of CMS OPPS Rate,5118.38,100,,23.904,Percent of Total Billed Charges,100% of Total Billed Charges,253.91,5118.38,
DEGARELIX ACETATE PER 1MG,53393073,CDM,250,RC,J9155,HCPCS,Outpatient,,,36.63,21.98,,4.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.93,360,,,Fee Schedule,360% of BCBS POS Rate,5.93,360,,,Fee schedule,360% of BCBS PPO Rate,5.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.98,60,,17.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,4.3,103,,,Fee Schedule,103% of CMS OPPS Rate,27.47,75,,24.88,Percent of Total Billed Charges,75% of Total Billed Charges,3.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,3.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3.25,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,3.25,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,6.27,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,25.64,70,,20.512,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,100,,33.168,Percent of Total Billed Charges,100% of Total Billed Charges,3.25,36.63,
LANREOTIDE 1 MG INJ,53393074,CDM,636,RC,J1930,HCPCS,Outpatient,,,274.35,164.61,,217.73,110,,174.184,Percent of Total Billed Charges,110% of Total Billed Charges,74.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,65.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,65.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,65.85,360,,,Fee Schedule,360% of BCBS POS Rate,65.85,360,,,Fee schedule,360% of BCBS PPO Rate,65.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,44.97,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,64.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.46,103,,,Fee Schedule,103% of CMS OPPS Rate,51.46,103,,,Fee Schedule,103% of CMS OPPS Rate,205.76,75,,56.416,Percent of Total Billed Charges,75% of Total Billed Charges,183.1,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,183.1,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,183.1,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,183.1,50,,146.48,Percent of Total Billed Charges,50% of Total Billed Charges,74.95,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,192.05,70,,153.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.97,100,,,Fee Schedule,100% of CMS OPPS Rate,274.35,100,,75.216,Percent of Total Billed Charges,100% of Total Billed Charges,44.97,274.35,
VERTEPORFIN PER 0.1MG,53393075,CDM,250,RC,J3396,HCPCS,Outpatient,,,58.29,34.97,,11.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,11.29,360,,,Fee Schedule,360% of BCBS POS Rate,11.29,360,,,Fee schedule,360% of BCBS PPO Rate,11.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.97,60,,27.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,43.72,75,,10.92,Percent of Total Billed Charges,75% of Total Billed Charges,9.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.1,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,9.1,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,40.8,70,,32.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,58.29,100,,14.56,Percent of Total Billed Charges,100% of Total Billed Charges,9.1,58.29,
HEMIN INJ PER 1MG,53393076,CDM,250,RC,J1640,HCPCS,Outpatient,,,132.02,79.21,,26.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,48.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,22.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,22.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,22.25,360,,,Fee Schedule,360% of BCBS POS Rate,22.25,360,,,Fee schedule,360% of BCBS PPO Rate,22.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,79.21,60,,63.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,28.98,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,41.86,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.15,103,,,Fee Schedule,103% of CMS OPPS Rate,33.15,103,,,Fee Schedule,103% of CMS OPPS Rate,99.02,75,,66.744,Percent of Total Billed Charges,75% of Total Billed Charges,23.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23.22,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,23.22,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,48.3,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,92.41,70,,73.928,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,100,,,Fee Schedule,100% of CMS OPPS Rate,132.02,100,,88.992,Percent of Total Billed Charges,100% of Total Billed Charges,22.25,132.02,
TBO-FILGRASTIM INJ 300MCG,53393077,CDM,250,RC,J1447,HCPCS,Outpatient,,,385.49,231.29,,0.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,0.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.82,360,,,Fee Schedule,360% of BCBS POS Rate,0.82,360,,,Fee schedule,360% of BCBS PPO Rate,0.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,231.29,60,,185.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.35,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,0.4,103,,,Fee Schedule,103% of CMS OPPS Rate,289.12,75,,15.048,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,0.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,269.84,70,,215.872,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,385.49,100,,20.064,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,385.49,
TEMSIROLIMUS INJ PER 1MG,53393078,CDM,636,RC,J9330,HCPCS,Outpatient,,,289.65,173.79,,194.41,110,,155.528,Percent of Total Billed Charges,110% of Total Billed Charges,48.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,44.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,44.03,360,,,Fee Schedule,360% of BCBS POS Rate,44.03,360,,,Fee schedule,360% of BCBS PPO Rate,44.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,28.98,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,41.87,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.17,103,,,Fee Schedule,103% of CMS OPPS Rate,33.17,103,,,Fee Schedule,103% of CMS OPPS Rate,217.24,75,,9.312,Percent of Total Billed Charges,75% of Total Billed Charges,170.55,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,170.55,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,170.55,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,170.55,50,,136.44,Percent of Total Billed Charges,50% of Total Billed Charges,48.31,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,202.76,70,,162.208,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.21,100,,,Fee Schedule,100% of CMS OPPS Rate,289.65,100,,12.416,Percent of Total Billed Charges,100% of Total Billed Charges,28.98,289.65,
VINCRISTINE LIPO INJ PER 1MG,53393079,CDM,636,RC,J9371,HCPCS,Outpatient,,,5636,3381.60,,6554.79,110,,5243.832,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1578.08,28,,1262.464,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2028.96,36,,1623.168,Percent of Total Billed Charges,36% of Total Billed Charges,2028.96,36,,1623.168,Percent of Total Billed Charges,36% Total Bille Charges,2028.96,36,,1623.168,Percent of Total Billed Charges,36% of Total Billed Charges,3099.8,55,,2479.84,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4227,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,2818,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,2818,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2818,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,2818,50,,2254.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3945.2,70,,3156.16,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5636,100,,8,Percent of Total Billed Charges,100% of Total Billed Charges,240,6554.79,
TENECTEPLASE INJ PER 1MG,53393080,CDM,636,RC,J3101,HCPCS,Outpatient,,,414.22,248.53,,363.79,110,,291.032,Percent of Total Billed Charges,110% of Total Billed Charges,236.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,120.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,120.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,120.75,360,,,Fee Schedule,360% of BCBS POS Rate,120.75,360,,,Fee schedule,360% of BCBS PPO Rate,120.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.94,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,205.03,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.44,103,,,Fee Schedule,103% of CMS OPPS Rate,162.44,103,,,Fee Schedule,103% of CMS OPPS Rate,310.67,75,,419.92,Percent of Total Billed Charges,75% of Total Billed Charges,322.06,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,322.06,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,322.06,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,322.06,50,,257.648,Percent of Total Billed Charges,50% of Total Billed Charges,236.58,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,289.95,70,,231.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,414.22,100,,559.888,Percent of Total Billed Charges,100% of Total Billed Charges,120.75,414.22,
PEMBROLIZUMAB INJ PER 1MG,53393081,CDM,636,RC,J9271,HCPCS,Outpatient,,,233.31,139.99,,181.14,110,,144.912,Percent of Total Billed Charges,110% of Total Billed Charges,87.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,48,360,,,Fee Schedule,360% of BCBS POS Rate,48,360,,,Fee schedule,360% of BCBS PPO Rate,48,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,52.39,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,75.68,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.96,103,,,Fee Schedule,103% of CMS OPPS Rate,59.96,103,,,Fee Schedule,103% of CMS OPPS Rate,174.98,75,,27.984,Percent of Total Billed Charges,75% of Total Billed Charges,160.98,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.98,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,160.98,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.98,50,,128.784,Percent of Total Billed Charges,50% of Total Billed Charges,87.33,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,163.32,70,,130.656,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,233.31,100,,37.312,Percent of Total Billed Charges,100% of Total Billed Charges,48,233.31,
ERIBULIN INJ PER 0.1MG,53393082,CDM,636,RC,J9179,HCPCS,Outpatient,,,539.6,323.76,,425.49,110,,340.392,Percent of Total Billed Charges,110% of Total Billed Charges,203.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,115.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,115.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,115.98,360,,,Fee Schedule,360% of BCBS POS Rate,115.98,360,,,Fee schedule,360% of BCBS PPO Rate,115.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,122.21,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,176.52,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.86,103,,,Fee Schedule,103% of CMS OPPS Rate,139.86,103,,,Fee Schedule,103% of CMS OPPS Rate,404.7,75,,1.704,Percent of Total Billed Charges,75% of Total Billed Charges,371.33,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,371.33,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,371.33,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,371.33,50,,297.064,Percent of Total Billed Charges,50% of Total Billed Charges,203.68,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,377.72,70,,302.176,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.79,100,,,Fee Schedule,100% of CMS OPPS Rate,539.6,100,,2.272,Percent of Total Billed Charges,100% of Total Billed Charges,115.98,539.6,
IMMUNE GLOB RHO(D) 100 U,53393084,CDM,250,RC,J2792,HCPCS,Outpatient,,,156.48,93.89,,31.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,51.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,34.32,360,,,Fee Schedule,360% of BCBS POS Rate,34.32,360,,,Fee schedule,360% of BCBS PPO Rate,34.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.89,60,,75.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,44.64,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.36,103,,,Fee Schedule,103% of CMS OPPS Rate,35.36,103,,,Fee Schedule,103% of CMS OPPS Rate,117.36,75,,11.488,Percent of Total Billed Charges,75% of Total Billed Charges,27.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,27.37,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,27.37,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,51.51,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,109.54,70,,87.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,156.48,100,,15.312,Percent of Total Billed Charges,100% of Total Billed Charges,27.37,156.48,
TELEVANCIN INJ PER 10MG,53393085,CDM,250,RC,J3095,HCPCS,Outpatient,,,30,18.00,,6.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,5.74,360,,,Fee Schedule,360% of BCBS POS Rate,5.74,360,,,Fee schedule,360% of BCBS PPO Rate,5.74,360,,,Fee Schedule,360% of BCBS Traditional Rate,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,90,,,Fee Schedule,90% of CMS OPPS Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,8.27,130,,,Fee Schedule,130% of CMS OPPS Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.33,14.42,,3.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,6.57,103,,,Fee Schedule,103% of CMS OPPS Rate,6.57,103,,,Fee Schedule,103% of CMS OPPS Rate,22.5,75,,7.264,Percent of Total Billed Charges,75% of Total Billed Charges,5.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,5.56,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,9.57,150,,,Fee Schedule,150% of CMS OPPS Rate,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,21,70,,16.8,Percent of Total Billed Charges,70% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.2,14,,3.36,Percent of Total Billed Charges,14% of Total Billed Charges,6.38,100,,,Fee Schedule,100% of CMS OPPS Rate,30,100,,9.688,Percent of Total Billed Charges,100% of Total Billed Charges,4.2,30,
OFATUMUMAB INJ PER 10MG,53393086,CDM,636,RC,J9302,HCPCS,Outpatient,,,11940.62,7164.37,,6631.94,110,,5305.552,Percent of Total Billed Charges,110% of Total Billed Charges,95.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,58.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,58.17,360,,,Fee Schedule,360% of BCBS POS Rate,58.17,360,,,Fee schedule,360% of BCBS PPO Rate,58.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,6567.34,55,,5253.872,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,57.56,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,83.14,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.87,103,,,Fee Schedule,103% of CMS OPPS Rate,65.87,103,,,Fee Schedule,103% of CMS OPPS Rate,8955.47,75,,0.088,Percent of Total Billed Charges,75% of Total Billed Charges,5970.31,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,5970.31,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5970.31,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,5970.31,50,,4776.248,Percent of Total Billed Charges,50% of Total Billed Charges,95.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,8358.43,70,,6686.744,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,11940.62,100,,0.12,Percent of Total Billed Charges,100% of Total Billed Charges,57.56,11940.62,
ORITAVANCIN INJ PER 10MG,53393087,CDM,250,RC,J2407,HCPCS,Outpatient,,,180.13,108.08,,24.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,42.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,24.17,360,,,Fee Schedule,360% of BCBS POS Rate,24.17,360,,,Fee schedule,360% of BCBS PPO Rate,24.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,108.08,60,,86.464,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25.61,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,36.99,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.31,103,,,Fee Schedule,103% of CMS OPPS Rate,29.31,103,,,Fee Schedule,103% of CMS OPPS Rate,135.1,75,,11.52,Percent of Total Billed Charges,75% of Total Billed Charges,21.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,21.33,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,21.33,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,42.69,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,126.09,70,,100.872,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,180.13,100,,15.36,Percent of Total Billed Charges,100% of Total Billed Charges,21.33,180.13,
SILTUXIMAB INJ PER 10MG,53393088,CDM,636,RC,J2860,HCPCS,Outpatient,,,2780.72,1668.43,,1655.81,110,,1324.648,Percent of Total Billed Charges,110% of Total Billed Charges,235.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,107.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,107.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,107.15,360,,,Fee Schedule,360% of BCBS POS Rate,107.15,360,,,Fee schedule,360% of BCBS PPO Rate,107.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,1529.4,55,,1223.52,Percent of Total Billed Charges,55% Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.36,90,,,Fee Schedule,90% of CMS OPPS Rate,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,204.19,130,,,Fee Schedule,130% of CMS OPPS Rate,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,400.98,14.42,,320.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.78,103,,,Fee Schedule,103% of CMS OPPS Rate,2085.54,75,,12.408,Percent of Total Billed Charges,75% of Total Billed Charges,1501.74,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,1501.74,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1501.74,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,1501.74,50,,1201.392,Percent of Total Billed Charges,50% of Total Billed Charges,235.6,150,,,Fee Schedule,150% of CMS OPPS Rate,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.5,70,,1557.2,Percent of Total Billed Charges,70% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,389.3,14,,311.44,Percent of Total Billed Charges,14% of Total Billed Charges,157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2780.72,100,,16.544,Percent of Total Billed Charges,100% of Total Billed Charges,107.15,2780.72,
CERTOLIZUMAB INJ PER 1MG,53393089,CDM,250,RC,J0717,HCPCS,Outpatient,,,60.66,36.40,,6.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,9.48,360,,,Fee Schedule,360% of BCBS POS Rate,9.48,360,,,Fee schedule,360% of BCBS PPO Rate,9.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.4,60,,29.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.78,103,,,Fee Schedule,103% of CMS OPPS Rate,4.78,103,,,Fee Schedule,103% of CMS OPPS Rate,45.5,75,,115.648,Percent of Total Billed Charges,75% of Total Billed Charges,3.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,3.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,3.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,6.97,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,42.46,70,,33.968,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.65,100,,,Fee Schedule,100% of CMS OPPS Rate,60.66,100,,154.192,Percent of Total Billed Charges,100% of Total Billed Charges,3.98,60.66,
PANITUMUMAB INJ PER 10MG,53393090,CDM,636,RC,J9303,HCPCS,Outpatient,,,489.13,293.48,,400.73,110,,320.584,Percent of Total Billed Charges,110% of Total Billed Charges,238.99,150,,,Fee Schedule ,150% of CMS OPPS Rate,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,123.65,360,,,Fee Schedule,360% of BCBS POS Rate,123.65,360,,,Fee schedule,360% of BCBS PPO Rate,123.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,143.38,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,207.12,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.1,103,,,Fee Schedule,103% of CMS OPPS Rate,164.1,103,,,Fee Schedule,103% of CMS OPPS Rate,366.85,75,,25.216,Percent of Total Billed Charges,75% of Total Billed Charges,358.5,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,358.5,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,358.5,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,358.5,50,,286.8,Percent of Total Billed Charges,50% of Total Billed Charges,238.99,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,342.39,70,,273.912,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.33,100,,,Fee Schedule,100% of CMS OPPS Rate,489.13,100,,33.616,Percent of Total Billed Charges,100% of Total Billed Charges,123.65,489.13,
DARBEPOETIN 1MCG ESRD,53393092,CDM,250,RC,J0882,HCPCS,Outpatient,,,74.44,44.66,,3.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.66,60,,35.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,55.83,75,,20.088,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,52.11,70,,41.688,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,74.44,100,,26.784,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,74.44,
FERUMOXYTOL INJ PER 1MG,53393093,CDM,250,RC,Q0138,HCPCS,Outpatient,,,7.25,4.35,,1.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,0.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.97,360,,,Fee Schedule,360% of BCBS POS Rate,1.97,360,,,Fee schedule,360% of BCBS PPO Rate,1.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,4.35,60,,3.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.3,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.44,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.35,103,,,Fee Schedule,103% of CMS OPPS Rate,0.35,103,,,Fee Schedule,103% of CMS OPPS Rate,5.44,75,,4.368,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.38,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.38,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.38,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,0.51,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,70,,4.064,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.34,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,5.824,Percent of Total Billed Charges,100% of Total Billed Charges,0.3,7.25,
PRALATREXATE INJ PER 1MG,53393094,CDM,636,RC,J9307,HCPCS,Outpatient,,,1172.92,703.75,,968.04,110,,774.432,Percent of Total Billed Charges,110% of Total Billed Charges,560.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,287.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,287.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,287.11,360,,,Fee Schedule,360% of BCBS POS Rate,287.11,360,,,Fee schedule,360% of BCBS PPO Rate,287.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,645.11,55,,516.088,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,336.39,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,485.9,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.98,103,,,Fee Schedule,103% of CMS OPPS Rate,384.98,103,,,Fee Schedule,103% of CMS OPPS Rate,879.69,75,,21.392,Percent of Total Billed Charges,75% of Total Billed Charges,868.02,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,868.02,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,868.02,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,868.02,50,,694.416,Percent of Total Billed Charges,50% of Total Billed Charges,560.65,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,821.04,70,,656.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.92,100,,28.52,Percent of Total Billed Charges,100% of Total Billed Charges,287.11,1172.92,
UMECLIDIN/VILANT 62.5/25MCG 30,53393096,CDM,250,RC,,,Outpatient,,,192.16,115.30,,115.3,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.8,28,,43.04,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% of Total Billed Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% Total Bille Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% of Total Billed Charges,115.3,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,27.71,14.42,,22.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.12,75,,26.656,Percent of Total Billed Charges,75% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.51,70,,107.608,Percent of Total Billed Charges,70% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.16,100,,35.544,Percent of Total Billed Charges,100% of Total Billed Charges,26.9,240,
FLUTICASONE 100MCG/INH PDR 14,53393097,CDM,250,RC,,,Outpatient,,,157.26,94.36,,94.36,60,,75.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.03,28,,35.224,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,56.61,36,,45.288,Percent of Total Billed Charges,36% of Total Billed Charges,56.61,36,,45.288,Percent of Total Billed Charges,36% Total Bille Charges,56.61,36,,45.288,Percent of Total Billed Charges,36% of Total Billed Charges,94.36,60,,75.488,Percent of Total Billed Charges,60% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.68,14.42,,18.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.95,75,,1350,Percent of Total Billed Charges,75% of Total Billed Charges,78.63,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,78.63,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.63,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,78.63,50,,62.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.08,70,,88.064,Percent of Total Billed Charges,70% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,22.02,14,,17.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.26,100,,1800,Percent of Total Billed Charges,100% of Total Billed Charges,22.02,240,
FLUTICASONE 200MCG/INH PDR 14,53393098,CDM,250,RC,,,Outpatient,,,210.56,126.34,,126.34,60,,101.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.96,28,,47.168,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,75.8,36,,60.64,Percent of Total Billed Charges,36% of Total Billed Charges,75.8,36,,60.64,Percent of Total Billed Charges,36% Total Bille Charges,75.8,36,,60.64,Percent of Total Billed Charges,36% of Total Billed Charges,126.34,60,,101.072,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,30.36,14.42,,24.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.92,75,,4964.04,Percent of Total Billed Charges,75% of Total Billed Charges,105.28,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,105.28,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.28,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,105.28,50,,84.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.39,70,,117.912,Percent of Total Billed Charges,70% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,29.48,14,,23.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.56,100,,6618.72,Percent of Total Billed Charges,100% of Total Billed Charges,29.48,240,
FLUTICAS/VILANT 100/25MCG 60,53393099,CDM,250,RC,,,Outpatient,,,682.08,409.25,,409.25,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.98,28,,152.784,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% of Total Billed Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% Total Bille Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% of Total Billed Charges,409.25,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,98.36,14.42,,78.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.56,75,,125.224,Percent of Total Billed Charges,75% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.46,70,,381.968,Percent of Total Billed Charges,70% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.08,100,,166.96,Percent of Total Billed Charges,100% of Total Billed Charges,95.49,682.08,
FLUTICAS/VILANT 200/25MCG 60,53393100,CDM,250,RC,,,Outpatient,,,682.08,409.25,,409.25,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.98,28,,152.784,Percent of Total Billed Charges,28% of Total Billed Charges,240,32,,192,Percent of Total Billed Charges,32% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% of Total Billed Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% Total Bille Charges,245.55,36,,196.44,Percent of Total Billed Charges,36% of Total Billed Charges,409.25,60,,327.4,Percent of Total Billed Charges,60% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,98.36,14.42,,78.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.56,75,,276.616,Percent of Total Billed Charges,75% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,341.04,50,,272.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.46,70,,381.968,Percent of Total Billed Charges,70% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,95.49,14,,76.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,682.08,100,,368.824,Percent of Total Billed Charges,100% of Total Billed Charges,95.49,682.08,
UMECLIDINIUM AERO 62.5MCG 7 DS,53393101,CDM,250,RC,,,Outpatient,,,138.36,83.02,,83.02,60,,66.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.74,28,,30.992,Percent of Total Billed Charges,28% of Total Billed Charges,240.5,32,,192.4,Percent of Total Billed Charges,32% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,49.81,36,,39.848,Percent of Total Billed Charges,36% of Total Billed Charges,49.81,36,,39.848,Percent of Total Billed Charges,36% Total Bille Charges,49.81,36,,39.848,Percent of Total Billed Charges,36% of Total Billed Charges,83.02,60,,66.416,Percent of Total Billed Charges,60% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.95,14.42,,15.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.77,75,,96.544,Percent of Total Billed Charges,75% of Total Billed Charges,69.18,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,69.18,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.18,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,69.18,50,,55.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.85,70,,77.48,Percent of Total Billed Charges,70% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14,,15.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.36,100,,128.728,Percent of Total Billed Charges,100% of Total Billed Charges,19.37,240.5,
ZENPEP 5000 UNITS CAP,53393102,CDM,250,RC,,,Outpatient,,,3.1,1.86,,1.86,60,,1.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.87,28,,0.696,Percent of Total Billed Charges,28% of Total Billed Charges,240.5,32,,192.4,Percent of Total Billed Charges,32% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,1.12,36,,0.896,Percent of Total Billed Charges,36% of Total Billed Charges,1.12,36,,0.896,Percent of Total Billed Charges,36% Total Bille Charges,1.12,36,,0.896,Percent of Total Billed Charges,36% of Total Billed Charges,1.86,60,,1.488,Percent of Total Billed Charges,60% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14.42,,0.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.33,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,1.55,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.55,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,1.55,50,,1.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,70,,1.736,Percent of Total Billed Charges,70% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,14,,0.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.1,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.43,240.5,
MORPHINE EPID 100MCG/ML 100ML,53393103,CDM,250,RC,J2270,HCPCS,Outpatient,,,123.41,74.05,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.05,60,,59.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.56,75,,8.176,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.39,70,,69.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.41,100,,10.896,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,123.41,
MORPHINE/ROPIVICAIN EPID 200ML,53393104,CDM,250,RC,,,Outpatient,,,424.44,254.66,,254.66,60,,203.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.84,28,,95.072,Percent of Total Billed Charges,28% of Total Billed Charges,240.5,32,,192.4,Percent of Total Billed Charges,32% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,152.8,36,,122.24,Percent of Total Billed Charges,36% of Total Billed Charges,152.8,36,,122.24,Percent of Total Billed Charges,36% Total Bille Charges,152.8,36,,122.24,Percent of Total Billed Charges,36% of Total Billed Charges,254.66,60,,203.728,Percent of Total Billed Charges,60% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,61.2,14.42,,48.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.33,75,,24.304,Percent of Total Billed Charges,75% of Total Billed Charges,212.22,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,212.22,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.22,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,212.22,50,,169.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.11,70,,237.688,Percent of Total Billed Charges,70% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,59.42,14,,47.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,424.44,100,,32.4,Percent of Total Billed Charges,100% of Total Billed Charges,59.42,424.44,
FENTANYL EPID 5MCG/ML 250ML,53393105,CDM,250,RC,J3010,HCPCS,Outpatient,,,168.8,101.28,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.28,60,,81.024,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.6,75,,0.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.16,70,,94.528,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.8,100,,0.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,168.8,
ATOMOXETINE 25 MG CAP,53393106,CDM,250,RC,,,Outpatient,,,26.36,15.82,,15.82,60,,12.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.38,28,,5.904,Percent of Total Billed Charges,28% of Total Billed Charges,240.5,32,,192.4,Percent of Total Billed Charges,32% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.49,36,,7.592,Percent of Total Billed Charges,36% of Total Billed Charges,9.49,36,,7.592,Percent of Total Billed Charges,36% Total Bille Charges,9.49,36,,7.592,Percent of Total Billed Charges,36% of Total Billed Charges,15.82,60,,12.656,Percent of Total Billed Charges,60% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.8,14.42,,3.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.77,75,,25.704,Percent of Total Billed Charges,75% of Total Billed Charges,13.18,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,13.18,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.18,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,13.18,50,,10.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.45,70,,14.76,Percent of Total Billed Charges,70% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.36,100,,34.272,Percent of Total Billed Charges,100% of Total Billed Charges,3.69,240.5,
TETRACAINE OP SOL 0.5% 4ML,53393110,CDM,250,RC,,,Outpatient,,,61.88,37.13,,37.13,60,,29.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.33,28,,13.864,Percent of Total Billed Charges,28% of Total Billed Charges,241.34,32,,193.072,Percent of Total Billed Charges,32% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,22.28,36,,17.824,Percent of Total Billed Charges,36% of Total Billed Charges,22.28,36,,17.824,Percent of Total Billed Charges,36% Total Bille Charges,22.28,36,,17.824,Percent of Total Billed Charges,36% of Total Billed Charges,37.13,60,,29.704,Percent of Total Billed Charges,60% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.92,14.42,,7.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,75,,25.072,Percent of Total Billed Charges,75% of Total Billed Charges,30.94,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,30.94,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.94,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,30.94,50,,24.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.32,70,,34.656,Percent of Total Billed Charges,70% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,8.66,14,,6.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.88,100,,33.424,Percent of Total Billed Charges,100% of Total Billed Charges,8.66,241.34,
NICARDIPINE 20MG CAP,53393111,CDM,250,RC,,,Outpatient,,,4.46,2.68,,2.68,60,,2.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.25,28,,1,Percent of Total Billed Charges,28% of Total Billed Charges,241.64,32,,193.312,Percent of Total Billed Charges,32% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,36,,1.288,Percent of Total Billed Charges,36% of Total Billed Charges,1.61,36,,1.288,Percent of Total Billed Charges,36% Total Bille Charges,1.61,36,,1.288,Percent of Total Billed Charges,36% of Total Billed Charges,2.68,60,,2.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14.42,,0.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.35,75,,49.576,Percent of Total Billed Charges,75% of Total Billed Charges,2.23,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,2.23,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.23,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,2.23,50,,1.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.12,70,,2.496,Percent of Total Billed Charges,70% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,0.62,14,,0.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.46,100,,66.096,Percent of Total Billed Charges,100% of Total Billed Charges,0.62,241.64,
DACLATASVIR TAB 60MG,53393112,CDM,250,RC,,,Outpatient,,,1500,900.00,,900,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,28,,336,Percent of Total Billed Charges,28% of Total Billed Charges,241.92,32,,193.536,Percent of Total Billed Charges,32% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,540,36,,432,Percent of Total Billed Charges,36% of Total Billed Charges,540,36,,432,Percent of Total Billed Charges,36% Total Bille Charges,540,36,,432,Percent of Total Billed Charges,36% of Total Billed Charges,900,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,216.3,14.42,,173.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1125,75,,15.72,Percent of Total Billed Charges,75% of Total Billed Charges,750,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,750,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,750,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1050,70,,840,Percent of Total Billed Charges,70% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,210,14,,168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1500,100,,20.96,Percent of Total Billed Charges,100% of Total Billed Charges,210,1500,
SOFOSBUVIR TAB 400MG,53393113,CDM,636,RC,J8499,HCPCS,Outpatient,,,2000,1200.00,,1100,110,,880,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,560,28,,448,Percent of Total Billed Charges,28% of Total Billed Charges,241.92,32,,193.536,Percent of Total Billed Charges,32% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,720,36,,576,Percent of Total Billed Charges,36% of Total Billed Charges,720,36,,576,Percent of Total Billed Charges,36% Total Bille Charges,720,36,,576,Percent of Total Billed Charges,36% of Total Billed Charges,1100,55,,880,Percent of Total Billed Charges,55% Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,288.4,14.42,,230.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1500,75,,5.08,Percent of Total Billed Charges,75% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1400,70,,1120,Percent of Total Billed Charges,70% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2000,100,,6.768,Percent of Total Billed Charges,100% of Total Billed Charges,241.92,2000,
ZENPEP 3000 UNITS CAP,53393114,CDM,250,RC,,,Outpatient,,,3.24,1.94,,1.94,60,,1.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,28,,0.728,Percent of Total Billed Charges,28% of Total Billed Charges,24557.79,32,,19646.232,Percent of Total Billed Charges,32% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% of Total Billed Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% Total Bille Charges,1.17,36,,0.936,Percent of Total Billed Charges,36% of Total Billed Charges,1.94,60,,1.552,Percent of Total Billed Charges,60% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.47,14.42,,0.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.43,75,,1440,Percent of Total Billed Charges,75% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,1.62,50,,1.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,70,,1.816,Percent of Total Billed Charges,70% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,0.45,14,,0.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.24,100,,1920,Percent of Total Billed Charges,100% of Total Billed Charges,0.45,24557.79,
GLUCOSE 40% GEL 37.5GM,53393115,CDM,250,RC,,,Outpatient,,,7.9,4.74,,4.74,60,,3.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.21,28,,1.768,Percent of Total Billed Charges,28% of Total Billed Charges,24.32,32,,19.456,Percent of Total Billed Charges,32% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,2.84,36,,2.272,Percent of Total Billed Charges,36% of Total Billed Charges,2.84,36,,2.272,Percent of Total Billed Charges,36% Total Bille Charges,2.84,36,,2.272,Percent of Total Billed Charges,36% of Total Billed Charges,4.74,60,,3.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.14,14.42,,0.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.93,75,,2.992,Percent of Total Billed Charges,75% of Total Billed Charges,3.95,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,3.95,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.95,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,3.95,50,,3.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.53,70,,4.424,Percent of Total Billed Charges,70% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,1.11,14,,0.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.9,100,,3.984,Percent of Total Billed Charges,100% of Total Billed Charges,1.11,24.32,
VERAPAMIL CAP SR 180MG,53393116,CDM,250,RC,,,Outpatient,,,3.66,2.20,,2.2,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,28,,0.816,Percent of Total Billed Charges,28% of Total Billed Charges,24.38,32,,19.504,Percent of Total Billed Charges,32% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% Total Bille Charges,1.32,36,,1.056,Percent of Total Billed Charges,36% of Total Billed Charges,2.2,60,,1.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14.42,,0.424,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.75,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,1.83,50,,1.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.56,70,,2.048,Percent of Total Billed Charges,70% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,0.51,14,,0.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,100,,56.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.51,24.38,
MIRACLE MOUTHWASH 1ML,53393118,CDM,250,RC,,,Outpatient,,,0.37,0.22,,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.1,28,,0.08,Percent of Total Billed Charges,28% of Total Billed Charges,24.4,32,,19.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% Total Bille Charges,0.13,36,,0.104,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14.42,,0.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.28,75,,5.88,Percent of Total Billed Charges,75% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,0.19,50,,0.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,70,,0.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,14,,0.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,100,,7.84,Percent of Total Billed Charges,100% of Total Billed Charges,0.05,24.4,
ESTRADIOL PAT 3D 0.0375MG,53393120,CDM,250,RC,,,Outpatient,,,22.11,13.27,,13.27,60,,10.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.19,28,,4.952,Percent of Total Billed Charges,28% of Total Billed Charges,24.48,32,,19.584,Percent of Total Billed Charges,32% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,7.96,36,,6.368,Percent of Total Billed Charges,36% of Total Billed Charges,7.96,36,,6.368,Percent of Total Billed Charges,36% Total Bille Charges,7.96,36,,6.368,Percent of Total Billed Charges,36% of Total Billed Charges,13.27,60,,10.616,Percent of Total Billed Charges,60% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.19,14.42,,2.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.58,75,,9.984,Percent of Total Billed Charges,75% of Total Billed Charges,11.06,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,11.06,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.06,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,11.06,50,,8.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.48,70,,12.384,Percent of Total Billed Charges,70% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,3.1,14,,2.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.11,100,,13.312,Percent of Total Billed Charges,100% of Total Billed Charges,3.1,24.48,
POT CITRATE TAB ER 10MEQ,53393121,CDM,250,RC,,,Outpatient,,,3.92,2.35,,2.35,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,243.26,32,,194.608,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.35,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,75,,12.72,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,70,,2.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.92,100,,16.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,243.26,
FLUTICAS/VILANT 100/25MCG 14,53393122,CDM,250,RC,,,Outpatient,,,591.21,354.73,,354.73,60,,283.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.54,28,,132.432,Percent of Total Billed Charges,28% of Total Billed Charges,243.39,32,,194.712,Percent of Total Billed Charges,32% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,212.84,36,,170.272,Percent of Total Billed Charges,36% of Total Billed Charges,212.84,36,,170.272,Percent of Total Billed Charges,36% Total Bille Charges,212.84,36,,170.272,Percent of Total Billed Charges,36% of Total Billed Charges,354.73,60,,283.784,Percent of Total Billed Charges,60% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,85.25,14.42,,68.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,443.41,75,,286.096,Percent of Total Billed Charges,75% of Total Billed Charges,295.61,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,295.61,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,295.61,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,295.61,50,,236.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.85,70,,331.08,Percent of Total Billed Charges,70% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,82.77,14,,66.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,591.21,100,,381.456,Percent of Total Billed Charges,100% of Total Billed Charges,82.77,591.21,
FLUTICAS/VILANT 200/25MCG 14,53393123,CDM,250,RC,,,Outpatient,,,262.76,157.66,,157.66,60,,126.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.57,28,,58.856,Percent of Total Billed Charges,28% of Total Billed Charges,244.66,32,,195.728,Percent of Total Billed Charges,32% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,94.59,36,,75.672,Percent of Total Billed Charges,36% of Total Billed Charges,94.59,36,,75.672,Percent of Total Billed Charges,36% Total Bille Charges,94.59,36,,75.672,Percent of Total Billed Charges,36% of Total Billed Charges,157.66,60,,126.128,Percent of Total Billed Charges,60% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,37.89,14.42,,30.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.07,75,,158.4,Percent of Total Billed Charges,75% of Total Billed Charges,131.38,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,131.38,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.38,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,131.38,50,,105.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.93,70,,147.144,Percent of Total Billed Charges,70% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,14,,29.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.76,100,,211.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.79,262.76,
UMECLIDIN/VILANT 62.5/25MCG 14,53393124,CDM,250,RC,,,Outpatient,,,192.16,115.30,,115.3,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.8,28,,43.04,Percent of Total Billed Charges,28% of Total Billed Charges,244.82,32,,195.856,Percent of Total Billed Charges,32% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% of Total Billed Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% Total Bille Charges,69.18,36,,55.344,Percent of Total Billed Charges,36% of Total Billed Charges,115.3,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,27.71,14.42,,22.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.12,75,,8280,Percent of Total Billed Charges,75% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,96.08,50,,76.864,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.51,70,,107.608,Percent of Total Billed Charges,70% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,26.9,14,,21.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.16,100,,11040,Percent of Total Billed Charges,100% of Total Billed Charges,26.9,244.82,
ARFORMOTEROL 15MCG/2ML INH SOL,53393126,CDM,250,RC,,,Outpatient,,,96.76,58.06,,58.06,60,,46.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.09,28,,21.672,Percent of Total Billed Charges,28% of Total Billed Charges,244.85,32,,195.88,Percent of Total Billed Charges,32% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,34.83,36,,27.864,Percent of Total Billed Charges,36% of Total Billed Charges,34.83,36,,27.864,Percent of Total Billed Charges,36% Total Bille Charges,34.83,36,,27.864,Percent of Total Billed Charges,36% of Total Billed Charges,58.06,60,,46.448,Percent of Total Billed Charges,60% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.95,14.42,,11.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.57,75,,183,Percent of Total Billed Charges,75% of Total Billed Charges,48.38,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,48.38,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.38,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,48.38,50,,38.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.73,70,,54.184,Percent of Total Billed Charges,70% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,13.55,14,,10.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.76,100,,244,Percent of Total Billed Charges,100% of Total Billed Charges,13.55,244.85,
APIXABAN 2.5MG TAB,53393127,CDM,250,RC,,,Outpatient,,,15.97,9.58,,9.58,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.47,28,,3.576,Percent of Total Billed Charges,28% of Total Billed Charges,245.91,32,,196.728,Percent of Total Billed Charges,32% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% Total Bille Charges,5.75,36,,4.6,Percent of Total Billed Charges,36% of Total Billed Charges,9.58,60,,7.664,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,14.42,,1.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,7.99,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,7.99,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.99,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,7.99,50,,6.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.18,70,,8.944,Percent of Total Billed Charges,70% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14,,1.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.97,100,,19.2,Percent of Total Billed Charges,100% of Total Billed Charges,2.24,245.91,
LIDO/EPI PF 1.5%/1:200000 5ML,53393128,CDM,250,RC,,,Outpatient,,,29.39,17.63,,17.63,60,,14.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.23,28,,6.584,Percent of Total Billed Charges,28% of Total Billed Charges,24.73,32,,19.784,Percent of Total Billed Charges,32% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,10.58,36,,8.464,Percent of Total Billed Charges,36% of Total Billed Charges,10.58,36,,8.464,Percent of Total Billed Charges,36% Total Bille Charges,10.58,36,,8.464,Percent of Total Billed Charges,36% of Total Billed Charges,17.63,60,,14.104,Percent of Total Billed Charges,60% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.24,14.42,,3.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.04,75,,36.984,Percent of Total Billed Charges,75% of Total Billed Charges,14.7,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,14.7,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,14.7,50,,11.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.57,70,,16.456,Percent of Total Billed Charges,70% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,4.11,14,,3.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.39,100,,49.312,Percent of Total Billed Charges,100% of Total Billed Charges,4.11,29.39,
CLEVIDIPINE 25 MG/50 ML VL,53393129,CDM,636,RC,C9248,HCPCS,Outpatient,,,1124.87,674.92,,621.63,110,,497.304,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.96,28,,251.968,Percent of Total Billed Charges,28% of Total Billed Charges,24.77,32,,19.816,Percent of Total Billed Charges,32% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,404.95,36,,323.96,Percent of Total Billed Charges,36% of Total Billed Charges,404.95,36,,323.96,Percent of Total Billed Charges,36% Total Bille Charges,404.95,36,,323.96,Percent of Total Billed Charges,36% of Total Billed Charges,618.68,55,,494.944,Percent of Total Billed Charges,55% Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,162.21,14.42,,129.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,843.65,75,,49.728,Percent of Total Billed Charges,75% of Total Billed Charges,562.44,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,562.44,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,562.44,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,562.44,50,,449.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,787.41,70,,629.928,Percent of Total Billed Charges,70% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,157.48,14,,125.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1124.87,100,,66.304,Percent of Total Billed Charges,100% of Total Billed Charges,24.77,1124.87,
BUPRENORPHINE TAB 2MG,53393130,CDM,250,RC,,,Outpatient,,,4.86,2.92,,2.92,60,,2.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,28,,1.088,Percent of Total Billed Charges,28% of Total Billed Charges,24.83,32,,19.864,Percent of Total Billed Charges,32% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% of Total Billed Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% Total Bille Charges,1.75,36,,1.4,Percent of Total Billed Charges,36% of Total Billed Charges,2.92,60,,2.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14.42,,0.56,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.65,75,,26.04,Percent of Total Billed Charges,75% of Total Billed Charges,2.43,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,2.43,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.43,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,2.43,50,,1.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,70,,2.72,Percent of Total Billed Charges,70% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,0.68,14,,0.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.86,100,,34.72,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,24.83,
ORA SWEET SF 10ML,53393131,CDM,250,RC,,,Outpatient,,,0.62,0.37,,0.37,60,,0.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,28,,0.136,Percent of Total Billed Charges,28% of Total Billed Charges,24.87,32,,19.896,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% Total Bille Charges,0.22,36,,0.176,Percent of Total Billed Charges,36% of Total Billed Charges,0.37,60,,0.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,75,,56.424,Percent of Total Billed Charges,75% of Total Billed Charges,0.31,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.31,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,0.31,50,,0.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.43,70,,0.344,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.62,100,,75.232,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,24.87,
ORA SWEET 10ML,53393132,CDM,250,RC,,,Outpatient,,,0.84,0.50,,0.5,60,,0.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.24,28,,0.192,Percent of Total Billed Charges,28% of Total Billed Charges,24.92,32,,19.936,Percent of Total Billed Charges,32% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% Total Bille Charges,0.3,36,,0.24,Percent of Total Billed Charges,36% of Total Billed Charges,0.5,60,,0.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14.42,,0.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.63,75,,268.616,Percent of Total Billed Charges,75% of Total Billed Charges,0.42,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.42,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,0.42,50,,0.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,70,,0.472,Percent of Total Billed Charges,70% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.12,14,,0.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,100,,358.152,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,24.92,
TEMAZEPAM 7.5 MG CAP,53393133,CDM,250,RC,,,Outpatient,,,39.61,23.77,,23.77,60,,19.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.09,28,,8.872,Percent of Total Billed Charges,28% of Total Billed Charges,24.94,32,,19.952,Percent of Total Billed Charges,32% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,14.26,36,,11.408,Percent of Total Billed Charges,36% of Total Billed Charges,14.26,36,,11.408,Percent of Total Billed Charges,36% Total Bille Charges,14.26,36,,11.408,Percent of Total Billed Charges,36% of Total Billed Charges,23.77,60,,19.016,Percent of Total Billed Charges,60% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.71,14.42,,4.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.71,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,19.81,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,19.81,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.81,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,19.81,50,,15.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.73,70,,22.184,Percent of Total Billed Charges,70% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,5.55,14,,4.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.61,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,5.55,39.61,
TRIAMCIN ACE CRM 0.1% 454GM,53393134,CDM,250,RC,,,Outpatient,,,46.64,27.98,,27.98,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.06,28,,10.448,Percent of Total Billed Charges,28% of Total Billed Charges,246.69,32,,197.352,Percent of Total Billed Charges,32% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% of Total Billed Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% Total Bille Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% of Total Billed Charges,27.98,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.73,14.42,,5.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.65,70,,26.12,Percent of Total Billed Charges,70% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.64,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,246.69,
NICARPIDINE 30MG CAP,53393135,CDM,250,RC,,,Outpatient,,,6.38,3.83,,3.83,60,,3.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.79,28,,1.432,Percent of Total Billed Charges,28% of Total Billed Charges,247.04,32,,197.632,Percent of Total Billed Charges,32% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% of Total Billed Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% Total Bille Charges,2.3,36,,1.84,Percent of Total Billed Charges,36% of Total Billed Charges,3.83,60,,3.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.92,14.42,,0.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.79,75,,192.6,Percent of Total Billed Charges,75% of Total Billed Charges,3.19,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,3.19,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,3.19,50,,2.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.47,70,,3.576,Percent of Total Billed Charges,70% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,0.89,14,,0.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.38,100,,256.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.89,247.04,
FOSFOMYCIN 3GM PKT,53393136,CDM,250,RC,,,Outpatient,,,159.26,95.56,,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.59,28,,35.672,Percent of Total Billed Charges,28% of Total Billed Charges,247.04,32,,197.632,Percent of Total Billed Charges,32% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,57.33,36,,45.864,Percent of Total Billed Charges,36% of Total Billed Charges,57.33,36,,45.864,Percent of Total Billed Charges,36% Total Bille Charges,57.33,36,,45.864,Percent of Total Billed Charges,36% of Total Billed Charges,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.97,14.42,,18.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.45,75,,2.536,Percent of Total Billed Charges,75% of Total Billed Charges,79.63,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,79.63,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.63,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,79.63,50,,63.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.48,70,,89.184,Percent of Total Billed Charges,70% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,22.3,14,,17.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.26,100,,3.384,Percent of Total Billed Charges,100% of Total Billed Charges,22.3,247.04,
AZTREONAM IVPB 1GM,53393137,CDM,250,RC,,,Outpatient,,,227.77,136.66,,136.66,60,,109.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.78,28,,51.024,Percent of Total Billed Charges,28% of Total Billed Charges,247.58,32,,198.064,Percent of Total Billed Charges,32% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,82,36,,65.6,Percent of Total Billed Charges,36% of Total Billed Charges,82,36,,65.6,Percent of Total Billed Charges,36% Total Bille Charges,82,36,,65.6,Percent of Total Billed Charges,36% of Total Billed Charges,136.66,60,,109.328,Percent of Total Billed Charges,60% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,32.84,14.42,,26.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.83,75,,19.224,Percent of Total Billed Charges,75% of Total Billed Charges,113.89,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,113.89,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.89,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,113.89,50,,91.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.44,70,,127.552,Percent of Total Billed Charges,70% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,31.89,14,,25.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,227.77,100,,25.632,Percent of Total Billed Charges,100% of Total Billed Charges,31.89,247.58,
AZTREONAM IVPB 2GM,53393138,CDM,250,RC,,,Outpatient,,,348.83,209.30,,209.3,60,,167.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.67,28,,78.136,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,125.58,36,,100.464,Percent of Total Billed Charges,36% of Total Billed Charges,125.58,36,,100.464,Percent of Total Billed Charges,36% Total Bille Charges,125.58,36,,100.464,Percent of Total Billed Charges,36% of Total Billed Charges,209.3,60,,167.44,Percent of Total Billed Charges,60% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,50.3,14.42,,40.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.62,75,,147.752,Percent of Total Billed Charges,75% of Total Billed Charges,174.42,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,174.42,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.42,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,174.42,50,,139.536,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.18,70,,195.344,Percent of Total Billed Charges,70% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,48.84,14,,39.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,348.83,100,,197,Percent of Total Billed Charges,100% of Total Billed Charges,48.84,348.83,
PEN G POT IVPB 5000000 UNIT,53393139,CDM,250,RC,J2540,HCPCS,Outpatient,,,195.07,117.04,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.48,360,,,Fee Schedule,360% of BCBS POS Rate,1.48,360,,,Fee schedule,360% of BCBS PPO Rate,1.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.04,60,,93.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.3,75,,7.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.6,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.55,70,,109.24,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.07,100,,9.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.6,195.07,
DOXYCYCLINE IVPB 100MG,53393140,CDM,250,RC,,,Outpatient,,,176.23,105.74,,105.74,60,,84.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.34,28,,39.472,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,63.44,36,,50.752,Percent of Total Billed Charges,36% of Total Billed Charges,63.44,36,,50.752,Percent of Total Billed Charges,36% Total Bille Charges,63.44,36,,50.752,Percent of Total Billed Charges,36% of Total Billed Charges,105.74,60,,84.592,Percent of Total Billed Charges,60% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,25.41,14.42,,20.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.17,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,88.12,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,88.12,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.12,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,88.12,50,,70.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.36,70,,98.688,Percent of Total Billed Charges,70% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,24.67,14,,19.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.23,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,24.67,248.6,
PANTOPRAZOLE IVPB 40MG,53393141,CDM,250,RC,J2470,HCPCS,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,4.59,360,,,Fee Schedule,360% of BCBS POS Rate,4.59,360,,,Fee schedule,360% of BCBS PPO Rate,4.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,634.504,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,846,Percent of Total Billed Charges,100% of Total Billed Charges,4.59,78.5,
BARIUM 98% E-Z HD 340G,53393142,CDM,255,RC,,,Outpatient,,,12.53,7.52,,7.52,60,,6.016,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.51,28,,2.808,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,4.51,36,,3.608,Percent of Total Billed Charges,36% of Total Billed Charges,4.51,36,,3.608,Percent of Total Billed Charges,36% Total Bille Charges,4.51,36,,3.608,Percent of Total Billed Charges,36% of Total Billed Charges,7.52,60,,6.016,Percent of Total Billed Charges,60% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.81,14.42,,1.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.02,80,,348,Percent of Total Billed Charges,80% of Total Billed Charges,6.27,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,6.27,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.27,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,6.27,50,,5.016,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,70,,7.016,Percent of Total Billed Charges,70% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14,,1.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.53,100,,464,Percent of Total Billed Charges,100% of Total Billed Charges,1.75,248.6,
CEFEPIME IVPB 1GM,53393143,CDM,250,RC,J0692,HCPCS,Outpatient,,,78.5,47.10,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,52.128,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,100,,69.504,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,78.5,
ESTRADIOL PAT.0375MG/D 1W,53393145,CDM,250,RC,,,Outpatient,,,41.78,25.07,,25.07,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.7,28,,9.36,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% Total Bille Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,25.07,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14.42,,4.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.34,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.25,70,,23.4,Percent of Total Billed Charges,70% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,5.85,248.6,
SOFOSBU/VELPATAS TAB 400-100MG,53393146,CDM,250,RC,,,Outpatient,,,1780.5,1068.30,,1068.3,60,,854.64,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.54,28,,398.832,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,640.98,36,,512.784,Percent of Total Billed Charges,36% of Total Billed Charges,640.98,36,,512.784,Percent of Total Billed Charges,36% Total Bille Charges,640.98,36,,512.784,Percent of Total Billed Charges,36% of Total Billed Charges,1068.3,60,,854.64,Percent of Total Billed Charges,60% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,256.75,14.42,,205.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1335.38,75,,1300.32,Percent of Total Billed Charges,75% of Total Billed Charges,890.25,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,890.25,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,890.25,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,890.25,50,,712.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1246.35,70,,997.08,Percent of Total Billed Charges,70% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,249.27,14,,199.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1780.5,100,,1733.76,Percent of Total Billed Charges,100% of Total Billed Charges,248.6,1780.5,
BRIMONID/BRINZOL OP 0.2-1% 8ML,53393147,CDM,250,RC,,,Outpatient,,,301.36,180.82,,180.82,60,,144.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.38,28,,67.504,Percent of Total Billed Charges,28% of Total Billed Charges,248.6,32,,198.88,Percent of Total Billed Charges,32% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,108.49,36,,86.792,Percent of Total Billed Charges,36% of Total Billed Charges,108.49,36,,86.792,Percent of Total Billed Charges,36% Total Bille Charges,108.49,36,,86.792,Percent of Total Billed Charges,36% of Total Billed Charges,180.82,60,,144.656,Percent of Total Billed Charges,60% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,43.46,14.42,,34.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.02,75,,91.8,Percent of Total Billed Charges,75% of Total Billed Charges,150.68,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,150.68,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.68,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,150.68,50,,120.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210.95,70,,168.76,Percent of Total Billed Charges,70% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,42.19,14,,33.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.36,100,,122.4,Percent of Total Billed Charges,100% of Total Billed Charges,42.19,301.36,
LIDO/EPI INJ 1%1:200K MPF 30ML,53393148,CDM,250,RC,,,Outpatient,,,61.74,37.04,,37.04,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.29,28,,13.832,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,22.23,36,,17.784,Percent of Total Billed Charges,36% of Total Billed Charges,22.23,36,,17.784,Percent of Total Billed Charges,36% Total Bille Charges,22.23,36,,17.784,Percent of Total Billed Charges,36% of Total Billed Charges,37.04,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.9,14.42,,7.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.31,75,,835.92,Percent of Total Billed Charges,75% of Total Billed Charges,30.87,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,30.87,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.87,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,30.87,50,,24.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.22,70,,34.576,Percent of Total Billed Charges,70% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,8.64,14,,6.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.74,100,,1114.56,Percent of Total Billed Charges,100% of Total Billed Charges,8.64,249.28,
NS 100ML INJ MINIBAG,53393149,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,87.96,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,117.28,Percent of Total Billed Charges,100% of Total Billed Charges,7,249.28,
NS 50ML MINIBAG,53393150,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,7,249.28,
SUCCINYLCHOLINE 100MG/5ML SYRG,53393151,CDM,250,RC,J0330,HCPCS,Outpatient,,,75.42,45.25,,1.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.33,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.33,360,,,Fee Schedule,360% of BCBS POS Rate,1.33,360,,,Fee schedule,360% of BCBS PPO Rate,1.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,45.25,60,,36.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.57,75,,557.28,Percent of Total Billed Charges,75% of Total Billed Charges,37.71,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,37.71,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.71,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,37.71,50,,30.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.79,70,,42.232,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.42,100,,743.04,Percent of Total Billed Charges,100% of Total Billed Charges,1.05,75.42,
IPRATROPIUM 0.03% NSL SPY 30ML,53393153,CDM,250,RC,,,Outpatient,,,83.9,50.34,,50.34,60,,40.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.49,28,,18.792,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,30.2,36,,24.16,Percent of Total Billed Charges,36% of Total Billed Charges,30.2,36,,24.16,Percent of Total Billed Charges,36% Total Bille Charges,30.2,36,,24.16,Percent of Total Billed Charges,36% of Total Billed Charges,50.34,60,,40.272,Percent of Total Billed Charges,60% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,12.1,14.42,,9.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.93,75,,51.84,Percent of Total Billed Charges,75% of Total Billed Charges,41.95,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,41.95,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.95,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,41.95,50,,33.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.73,70,,46.984,Percent of Total Billed Charges,70% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,11.75,14,,9.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.9,100,,69.12,Percent of Total Billed Charges,100% of Total Billed Charges,11.75,249.28,
CLOZAPINE TAB 200MG,53393154,CDM,250,RC,,,Outpatient,,,5.23,3.14,,3.14,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.46,28,,1.168,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% of Total Billed Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% Total Bille Charges,1.88,36,,1.504,Percent of Total Billed Charges,36% of Total Billed Charges,3.14,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.75,14.42,,0.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.92,75,,48.456,Percent of Total Billed Charges,75% of Total Billed Charges,2.62,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,2.62,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.62,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,2.62,50,,2.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,70,,2.928,Percent of Total Billed Charges,70% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,0.73,14,,0.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.23,100,,64.608,Percent of Total Billed Charges,100% of Total Billed Charges,0.73,249.28,
RITONAVIR 80MG/ML SOL 1ML,53393155,CDM,250,RC,,,Outpatient,,,11.18,6.71,,6.71,60,,5.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.13,28,,2.504,Percent of Total Billed Charges,28% of Total Billed Charges,249.28,32,,199.424,Percent of Total Billed Charges,32% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,4.02,36,,3.216,Percent of Total Billed Charges,36% of Total Billed Charges,4.02,36,,3.216,Percent of Total Billed Charges,36% Total Bille Charges,4.02,36,,3.216,Percent of Total Billed Charges,36% of Total Billed Charges,6.71,60,,5.368,Percent of Total Billed Charges,60% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.61,14.42,,1.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.39,75,,226.8,Percent of Total Billed Charges,75% of Total Billed Charges,5.59,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,5.59,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.59,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,5.59,50,,4.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.83,70,,6.264,Percent of Total Billed Charges,70% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,1.57,14,,1.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.18,100,,302.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.57,249.28,
SODIUM CHLOR 25%(4MEQ/ML)30ML,53393156,CDM,250,RC,,,Outpatient,,,44.82,26.89,,26.89,60,,21.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.55,28,,10.04,Percent of Total Billed Charges,28% of Total Billed Charges,249.36,32,,199.488,Percent of Total Billed Charges,32% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% of Total Billed Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% Total Bille Charges,16.14,36,,12.912,Percent of Total Billed Charges,36% of Total Billed Charges,26.89,60,,21.512,Percent of Total Billed Charges,60% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.46,14.42,,5.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.62,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.41,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,22.41,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.41,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,22.41,50,,17.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.37,70,,25.096,Percent of Total Billed Charges,70% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,6.27,14,,5.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.82,100,,39.2,Percent of Total Billed Charges,100% of Total Billed Charges,6.27,249.36,
METHYLENE BLUE 5MG/ML AMP 10ML,53393157,CDM,250,RC,,,Outpatient,,,830.41,498.25,,498.25,60,,398.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.51,28,,186.008,Percent of Total Billed Charges,28% of Total Billed Charges,249.5,32,,199.6,Percent of Total Billed Charges,32% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,298.95,36,,239.16,Percent of Total Billed Charges,36% of Total Billed Charges,298.95,36,,239.16,Percent of Total Billed Charges,36% Total Bille Charges,298.95,36,,239.16,Percent of Total Billed Charges,36% of Total Billed Charges,498.25,60,,398.6,Percent of Total Billed Charges,60% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,119.75,14.42,,95.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.81,75,,15.768,Percent of Total Billed Charges,75% of Total Billed Charges,415.21,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,415.21,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,415.21,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,415.21,50,,332.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,581.29,70,,465.032,Percent of Total Billed Charges,70% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,116.26,14,,93.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,830.41,100,,21.024,Percent of Total Billed Charges,100% of Total Billed Charges,116.26,830.41,
ATOMOXETINE 40 MG CAP,53393158,CDM,250,RC,,,Outpatient,,,28.64,17.18,,17.18,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.02,28,,6.416,Percent of Total Billed Charges,28% of Total Billed Charges,24.96,32,,19.968,Percent of Total Billed Charges,32% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% Total Bille Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,17.18,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.05,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.64,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,28.64,
LEFLUNOMIDE 20 MG TAB,53393159,CDM,250,RC,,,Outpatient,,,12.2,7.32,,7.32,60,,5.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.42,28,,2.736,Percent of Total Billed Charges,28% of Total Billed Charges,24.97,32,,19.976,Percent of Total Billed Charges,32% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% of Total Billed Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% Total Bille Charges,4.39,36,,3.512,Percent of Total Billed Charges,36% of Total Billed Charges,7.32,60,,5.856,Percent of Total Billed Charges,60% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.76,14.42,,1.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.15,75,,114.232,Percent of Total Billed Charges,75% of Total Billed Charges,6.1,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.1,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,50,,4.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.54,70,,6.832,Percent of Total Billed Charges,70% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14,,1.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.2,100,,152.304,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,24.97,
FAT EMULS SMOFLIPID 20% 100ML,53393160,CDM,250,RC,,,Outpatient,,,134.64,80.78,,80.78,60,,64.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.7,28,,30.16,Percent of Total Billed Charges,28% of Total Billed Charges,25.08,32,,20.064,Percent of Total Billed Charges,32% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,48.47,36,,38.776,Percent of Total Billed Charges,36% of Total Billed Charges,48.47,36,,38.776,Percent of Total Billed Charges,36% Total Bille Charges,48.47,36,,38.776,Percent of Total Billed Charges,36% of Total Billed Charges,80.78,60,,64.624,Percent of Total Billed Charges,60% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,19.42,14.42,,15.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.98,75,,146.304,Percent of Total Billed Charges,75% of Total Billed Charges,67.32,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,67.32,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.32,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,67.32,50,,53.856,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.25,70,,75.4,Percent of Total Billed Charges,70% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,18.85,14,,15.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.64,100,,195.072,Percent of Total Billed Charges,100% of Total Billed Charges,18.85,134.64,
DEXTROSE 50% VL 50 ML,53393161,CDM,250,RC,,,Outpatient,,,28.56,17.14,,17.14,60,,13.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,28,,6.4,Percent of Total Billed Charges,28% of Total Billed Charges,25.1,32,,20.08,Percent of Total Billed Charges,32% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,10.28,36,,8.224,Percent of Total Billed Charges,36% of Total Billed Charges,10.28,36,,8.224,Percent of Total Billed Charges,36% Total Bille Charges,10.28,36,,8.224,Percent of Total Billed Charges,36% of Total Billed Charges,17.14,60,,13.712,Percent of Total Billed Charges,60% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4.12,14.42,,3.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,75,,128.016,Percent of Total Billed Charges,75% of Total Billed Charges,14.28,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,14.28,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.28,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,14.28,50,,11.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.99,70,,15.992,Percent of Total Billed Charges,70% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,4,14,,3.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.56,100,,170.688,Percent of Total Billed Charges,100% of Total Billed Charges,4,28.56,
OLANZAPINE 10MG INJ,53393162,CDM,250,RC,,,Outpatient,,,218.34,131.00,,131,60,,104.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.14,28,,48.912,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,78.6,36,,62.88,Percent of Total Billed Charges,36% of Total Billed Charges,78.6,36,,62.88,Percent of Total Billed Charges,36% Total Bille Charges,78.6,36,,62.88,Percent of Total Billed Charges,36% of Total Billed Charges,131,60,,104.8,Percent of Total Billed Charges,60% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,31.48,14.42,,25.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.76,75,,109.728,Percent of Total Billed Charges,75% of Total Billed Charges,109.17,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,109.17,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.17,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,109.17,50,,87.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.84,70,,122.272,Percent of Total Billed Charges,70% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,30.57,14,,24.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.34,100,,146.304,Percent of Total Billed Charges,100% of Total Billed Charges,25.12,218.34,
FENTANYL CIT 50MCG/ML VL 20ML,53393163,CDM,250,RC,J3010,HCPCS,Outpatient,,,52.48,31.49,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,31.49,60,,25.192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.36,75,,91.44,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.74,70,,29.392,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.48,100,,121.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,52.48,
CLONAZEPAM TAB ODT 0.25MG,53393165,CDM,250,RC,,,Outpatient,,,2.27,1.36,,1.36,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,28,,0.512,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% Total Bille Charges,0.82,36,,0.656,Percent of Total Billed Charges,36% of Total Billed Charges,1.36,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.33,14.42,,0.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,75,,62.704,Percent of Total Billed Charges,75% of Total Billed Charges,1.14,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.14,50,,0.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.59,70,,1.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,14,,0.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,100,,83.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.32,25.12,
ZONISAMIDE CAP 25MG,53393166,CDM,250,RC,,,Outpatient,,,0.51,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,28,,0.112,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% Total Bille Charges,0.18,36,,0.144,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,75,,83.608,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.51,100,,111.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,25.12,
ISAVUCONAZONIUM 186MG CAP,53393167,CDM,250,RC,,,Outpatient,,,175.15,105.09,,105.09,60,,84.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.04,28,,39.232,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,63.05,36,,50.44,Percent of Total Billed Charges,36% of Total Billed Charges,63.05,36,,50.44,Percent of Total Billed Charges,36% Total Bille Charges,63.05,36,,50.44,Percent of Total Billed Charges,36% of Total Billed Charges,105.09,60,,84.072,Percent of Total Billed Charges,60% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,25.26,14.42,,20.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.36,75,,0.312,Percent of Total Billed Charges,75% of Total Billed Charges,87.58,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,87.58,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.58,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,87.58,50,,70.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.61,70,,98.088,Percent of Total Billed Charges,70% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,24.52,14,,19.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.15,100,,0.416,Percent of Total Billed Charges,100% of Total Billed Charges,24.52,175.15,
ISOPROTERENOL 0.2MG/ML 5ML INJ,53393168,CDM,250,RC,,,Outpatient,,,262,157.20,,157.2,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.36,28,,58.688,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,94.32,36,,75.456,Percent of Total Billed Charges,36% of Total Billed Charges,94.32,36,,75.456,Percent of Total Billed Charges,36% Total Bille Charges,94.32,36,,75.456,Percent of Total Billed Charges,36% of Total Billed Charges,157.2,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,37.78,14.42,,30.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.5,75,,35.552,Percent of Total Billed Charges,75% of Total Billed Charges,131,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,131,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,131,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.4,70,,146.72,Percent of Total Billed Charges,70% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,36.68,14,,29.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262,100,,47.4,Percent of Total Billed Charges,100% of Total Billed Charges,25.12,262,
LEVOCARNITINE 1GM/5ML INJ,53393174,CDM,250,RC,J1955,HCPCS,Outpatient,,,198.72,119.23,,21.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,33.12,360,,,Fee Schedule,360% of BCBS POS Rate,33.12,360,,,Fee schedule,360% of BCBS PPO Rate,33.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.23,60,,95.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.04,75,,297.448,Percent of Total Billed Charges,75% of Total Billed Charges,27.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.33,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,27.33,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.1,70,,111.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.72,100,,396.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.98,198.72,
ACYCLOVIR 5% OINT 5GM,53393177,CDM,250,RC,,,Outpatient,,,280.73,168.44,,168.44,60,,134.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.6,28,,62.88,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% Total Bille Charges,101.06,36,,80.848,Percent of Total Billed Charges,36% of Total Billed Charges,168.44,60,,134.752,Percent of Total Billed Charges,60% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,40.48,14.42,,32.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.55,75,,549.904,Percent of Total Billed Charges,75% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,140.37,50,,112.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.51,70,,157.208,Percent of Total Billed Charges,70% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,39.3,14,,31.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,280.73,100,,733.2,Percent of Total Billed Charges,100% of Total Billed Charges,25.12,280.73,
VEDOLIZUMAB 1MG INJ,53393178,CDM,250,RC,J3380,HCPCS,Outpatient,,,104.24,62.54,,21.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,21.35,360,,,Fee Schedule,360% of BCBS POS Rate,21.35,360,,,Fee schedule,360% of BCBS PPO Rate,21.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.54,60,,50.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.03,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,28.93,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.92,103,,,Fee Schedule,103% of CMS OPPS Rate,22.92,103,,,Fee Schedule,103% of CMS OPPS Rate,78.18,75,,74.632,Percent of Total Billed Charges,75% of Total Billed Charges,17.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,17.47,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,17.47,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,33.39,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,72.97,70,,58.376,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.26,100,,,Fee Schedule,100% of CMS OPPS Rate,104.24,100,,99.504,Percent of Total Billed Charges,100% of Total Billed Charges,17.47,104.24,
BRIVARACETAM 100MG TAB,53393179,CDM,250,RC,,,Outpatient,,,35.67,21.40,,21.4,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.99,28,,7.992,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% of Total Billed Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% Total Bille Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% of Total Billed Charges,21.4,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,5.14,14.42,,4.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.75,75,,54.728,Percent of Total Billed Charges,75% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,70,,19.976,Percent of Total Billed Charges,70% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.67,100,,72.968,Percent of Total Billed Charges,100% of Total Billed Charges,4.99,35.67,
PROGESTERONE 8% GEL APPL,53393180,CDM,250,RC,,,Outpatient,,,56.96,34.18,,34.18,60,,27.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.95,28,,12.76,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,20.51,36,,16.408,Percent of Total Billed Charges,36% of Total Billed Charges,20.51,36,,16.408,Percent of Total Billed Charges,36% Total Bille Charges,20.51,36,,16.408,Percent of Total Billed Charges,36% of Total Billed Charges,34.18,60,,27.344,Percent of Total Billed Charges,60% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,8.21,14.42,,6.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.72,75,,52.24,Percent of Total Billed Charges,75% of Total Billed Charges,28.48,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.48,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.48,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,28.48,50,,22.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.87,70,,31.896,Percent of Total Billed Charges,70% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.97,14,,6.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.96,100,,69.648,Percent of Total Billed Charges,100% of Total Billed Charges,7.97,56.96,
COB/ELVITEG/EMTR/TENO TAB,53393181,CDM,250,RC,,,Outpatient,,,196.88,118.13,,118.13,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.13,28,,44.104,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,70.88,36,,56.704,Percent of Total Billed Charges,36% of Total Billed Charges,70.88,36,,56.704,Percent of Total Billed Charges,36% Total Bille Charges,70.88,36,,56.704,Percent of Total Billed Charges,36% of Total Billed Charges,118.13,60,,94.504,Percent of Total Billed Charges,60% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,28.39,14.42,,22.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.66,75,,52.256,Percent of Total Billed Charges,75% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,98.44,50,,78.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.82,70,,110.256,Percent of Total Billed Charges,70% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,27.56,14,,22.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.88,100,,69.672,Percent of Total Billed Charges,100% of Total Billed Charges,25.12,196.88,
GI COCKTAIL 45ML,53393183,CDM,250,RC,,,Outpatient,,,6.51,3.91,,3.91,60,,3.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.82,28,,1.456,Percent of Total Billed Charges,28% of Total Billed Charges,25.12,32,,20.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% Total Bille Charges,2.34,36,,1.872,Percent of Total Billed Charges,36% of Total Billed Charges,3.91,60,,3.128,Percent of Total Billed Charges,60% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.94,14.42,,0.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,75,,52.472,Percent of Total Billed Charges,75% of Total Billed Charges,3.26,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,3.26,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,3.26,50,,2.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.56,70,,3.648,Percent of Total Billed Charges,70% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,0.91,14,,0.728,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.51,100,,69.96,Percent of Total Billed Charges,100% of Total Billed Charges,0.91,25.12,
EMTRICITA/TENOF ALA TAB 200-25,53393184,CDM,250,RC,,,Outpatient,,,112.22,67.33,,67.33,60,,53.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.42,28,,25.136,Percent of Total Billed Charges,28% of Total Billed Charges,249.6,32,,199.68,Percent of Total Billed Charges,32% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% Total Bille Charges,40.4,36,,32.32,Percent of Total Billed Charges,36% of Total Billed Charges,67.33,60,,53.864,Percent of Total Billed Charges,60% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,16.18,14.42,,12.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.17,75,,349.096,Percent of Total Billed Charges,75% of Total Billed Charges,56.11,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,56.11,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.11,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,56.11,50,,44.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.55,70,,62.84,Percent of Total Billed Charges,70% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,15.71,14,,12.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.22,100,,465.456,Percent of Total Billed Charges,100% of Total Billed Charges,15.71,249.6,
VERAPAMIL SR 240MG CAP,53393185,CDM,250,RC,,,Outpatient,,,4.54,2.72,,2.72,60,,2.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,28,,1.016,Percent of Total Billed Charges,28% of Total Billed Charges,251.43,32,,201.144,Percent of Total Billed Charges,32% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% of Total Billed Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% Total Bille Charges,1.63,36,,1.304,Percent of Total Billed Charges,36% of Total Billed Charges,2.72,60,,2.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.65,14.42,,0.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.41,75,,71.656,Percent of Total Billed Charges,75% of Total Billed Charges,2.27,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,2.27,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.27,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,2.27,50,,1.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.18,70,,2.544,Percent of Total Billed Charges,70% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.54,100,,95.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,251.43,
MORPHINE TAB 7.5MG,53393187,CDM,250,RC,,,Outpatient,,,0.59,0.35,,0.35,60,,0.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,28,,0.136,Percent of Total Billed Charges,28% of Total Billed Charges,251.58,32,,201.264,Percent of Total Billed Charges,32% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% Total Bille Charges,0.21,36,,0.168,Percent of Total Billed Charges,36% of Total Billed Charges,0.35,60,,0.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.44,75,,57.76,Percent of Total Billed Charges,75% of Total Billed Charges,0.3,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,0.3,50,,0.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,70,,0.328,Percent of Total Billed Charges,70% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,14,,0.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,100,,77.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.08,251.58,
GUAIFENESIN 100MG/5ML SYR 5ML,53393190,CDM,250,RC,,,Outpatient,,,1.2,0.72,,0.72,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.34,28,,0.272,Percent of Total Billed Charges,28% of Total Billed Charges,251.66,32,,201.328,Percent of Total Billed Charges,32% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% Total Bille Charges,0.43,36,,0.344,Percent of Total Billed Charges,36% of Total Billed Charges,0.72,60,,0.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14.42,,0.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.9,75,,5.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.6,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,0.6,50,,0.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,70,,0.672,Percent of Total Billed Charges,70% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,0.17,14,,0.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,100,,7.008,Percent of Total Billed Charges,100% of Total Billed Charges,0.17,251.66,
HYDROMORPHONE 0.5MG/0.5ML SYRG,53393192,CDM,250,RC,J1171,HCPCS,Outpatient,,,5.4,3.24,,3.24,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,3.24,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.78,14.42,,0.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,75,,82.512,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,2.7,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.7,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,2.7,50,,2.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.78,70,,3.024,Percent of Total Billed Charges,70% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14,,0.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,100,,110.016,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,5.4,
CEFAZOLIN INJ 1GM 10ML SYG,53393194,CDM,250,RC,J0690,HCPCS,Outpatient,,,13.05,7.83,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.83,60,,6.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.79,75,,430.92,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.14,70,,7.312,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.05,100,,574.56,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,13.05,
CEFTRIAXONE INJ 1GM 10ML SYG,53393195,CDM,250,RC,J0696,HCPCS,Outpatient,,,40.62,24.37,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.37,60,,19.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.47,75,,1656,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.43,70,,22.744,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.62,100,,2208,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,40.62,
CEFTRIAXONE INJ 2GM 20ML SYG,53393196,CDM,250,RC,J0696,HCPCS,Outpatient,,,29.88,17.93,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,17.93,60,,14.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.41,75,,110.472,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.92,70,,16.736,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.88,100,,147.296,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,29.88,
CEFEPIME INJ 1GM/10ML NS SYG,53393197,CDM,250,RC,J0692,HCPCS,Outpatient,,,41.46,24.88,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.88,60,,19.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.1,75,,62.392,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.02,70,,23.216,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.46,100,,83.184,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,41.46,
CEFEPIME INJ 2GM/12.5ML NS SYG,53393198,CDM,250,RC,J0692,HCPCS,Outpatient,,,94.02,56.41,,1.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.72,360,,,Fee Schedule,360% of BCBS POS Rate,1.72,360,,,Fee schedule,360% of BCBS PPO Rate,1.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,56.41,60,,45.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.52,75,,12724.504,Percent of Total Billed Charges,75% of Total Billed Charges,0.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.81,70,,52.648,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.02,100,,16966,Percent of Total Billed Charges,100% of Total Billed Charges,0.98,94.02,
CEFAZOLIN INJ 2GM 20ML SYG,53393199,CDM,250,RC,J0690,HCPCS,Outpatient,,,18.2,10.92,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,10.92,60,,8.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.65,75,,55.84,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,70,,10.192,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,100,,74.448,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,18.2,
KETAMINE 10MG/ML INJ 20ML,53393200,CDM,250,RC,,,Outpatient,,,111.24,66.74,,66.74,60,,53.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.15,28,,24.92,Percent of Total Billed Charges,28% of Total Billed Charges,251.66,32,,201.328,Percent of Total Billed Charges,32% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,40.05,36,,32.04,Percent of Total Billed Charges,36% of Total Billed Charges,40.05,36,,32.04,Percent of Total Billed Charges,36% Total Bille Charges,40.05,36,,32.04,Percent of Total Billed Charges,36% of Total Billed Charges,66.74,60,,53.392,Percent of Total Billed Charges,60% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,16.04,14.42,,12.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.43,75,,1.408,Percent of Total Billed Charges,75% of Total Billed Charges,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,55.62,50,,44.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.87,70,,62.296,Percent of Total Billed Charges,70% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14,,12.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.24,100,,1.872,Percent of Total Billed Charges,100% of Total Billed Charges,15.57,251.66,
KETAMINE HCL INJ 50 MG/5 ML SY,53393201,CDM,250,RC,,,Outpatient,,,25.08,15.05,,15.05,60,,12.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.02,28,,5.616,Percent of Total Billed Charges,28% of Total Billed Charges,251.66,32,,201.328,Percent of Total Billed Charges,32% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,9.03,36,,7.224,Percent of Total Billed Charges,36% of Total Billed Charges,9.03,36,,7.224,Percent of Total Billed Charges,36% Total Bille Charges,9.03,36,,7.224,Percent of Total Billed Charges,36% of Total Billed Charges,15.05,60,,12.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.62,14.42,,2.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.81,75,,413.28,Percent of Total Billed Charges,75% of Total Billed Charges,12.54,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,12.54,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.54,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,12.54,50,,10.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.56,70,,14.048,Percent of Total Billed Charges,70% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,3.51,14,,2.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.08,100,,551.04,Percent of Total Billed Charges,100% of Total Billed Charges,3.51,251.66,
LIDOCAINE INJ 1% 10ML MDV,53393202,CDM,250,RC,,,Outpatient,,,15.52,9.31,,9.31,60,,7.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.35,28,,3.48,Percent of Total Billed Charges,28% of Total Billed Charges,251.66,32,,201.328,Percent of Total Billed Charges,32% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.59,36,,4.472,Percent of Total Billed Charges,36% of Total Billed Charges,5.59,36,,4.472,Percent of Total Billed Charges,36% Total Bille Charges,5.59,36,,4.472,Percent of Total Billed Charges,36% of Total Billed Charges,9.31,60,,7.448,Percent of Total Billed Charges,60% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.24,14.42,,1.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,7.76,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,7.76,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.76,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,7.76,50,,6.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.86,70,,8.688,Percent of Total Billed Charges,70% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,2.17,14,,1.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.52,100,,8,Percent of Total Billed Charges,100% of Total Billed Charges,2.17,251.66,
DESVENLAFAXINE 50 MG ER TAB,53393203,CDM,250,RC,,,Outpatient,,,10,6.00,,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,28,,2.24,Percent of Total Billed Charges,28% of Total Billed Charges,252.67,32,,202.136,Percent of Total Billed Charges,32% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% of Total Billed Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% Total Bille Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14.42,,1.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,75,,1218.968,Percent of Total Billed Charges,75% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,100,,1625.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.4,252.67,
MINOCYCLINE INJ 100MG,53393204,CDM,250,RC,,,Outpatient,,,699.86,419.92,,419.92,60,,335.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.96,28,,156.768,Percent of Total Billed Charges,28% of Total Billed Charges,252.67,32,,202.136,Percent of Total Billed Charges,32% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,251.95,36,,201.56,Percent of Total Billed Charges,36% of Total Billed Charges,251.95,36,,201.56,Percent of Total Billed Charges,36% Total Bille Charges,251.95,36,,201.56,Percent of Total Billed Charges,36% of Total Billed Charges,419.92,60,,335.936,Percent of Total Billed Charges,60% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,100.92,14.42,,80.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,524.9,75,,155.968,Percent of Total Billed Charges,75% of Total Billed Charges,349.93,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,349.93,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,349.93,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,349.93,50,,279.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,489.9,70,,391.92,Percent of Total Billed Charges,70% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,97.98,14,,78.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,699.86,100,,207.96,Percent of Total Billed Charges,100% of Total Billed Charges,97.98,699.86,
ETOMIDATE 2MG/ML 20ML INJ,53393205,CDM,250,RC,,,Outpatient,,,46.64,27.98,,27.98,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.06,28,,10.448,Percent of Total Billed Charges,28% of Total Billed Charges,252.75,32,,202.2,Percent of Total Billed Charges,32% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% of Total Billed Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% Total Bille Charges,16.79,36,,13.432,Percent of Total Billed Charges,36% of Total Billed Charges,27.98,60,,22.384,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.73,14.42,,5.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,75,,22.32,Percent of Total Billed Charges,75% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,23.32,50,,18.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.65,70,,26.12,Percent of Total Billed Charges,70% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,6.53,14,,5.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.64,100,,29.76,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,252.75,
LIDOCAINE 4% TOPICAL PATCH,53393206,CDM,250,RC,,,Outpatient,,,2.84,1.70,,1.7,60,,1.36,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,28,,0.64,Percent of Total Billed Charges,28% of Total Billed Charges,25.33,32,,20.264,Percent of Total Billed Charges,32% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% Total Bille Charges,1.02,36,,0.816,Percent of Total Billed Charges,36% of Total Billed Charges,1.7,60,,1.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.41,14.42,,0.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.13,75,,11.16,Percent of Total Billed Charges,75% of Total Billed Charges,1.42,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,1.42,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.42,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,1.42,50,,1.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.99,70,,1.592,Percent of Total Billed Charges,70% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.4,14,,0.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.84,100,,14.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.4,25.33,
PHENYLEPHRINE 100MCG/ML 10ML,53393207,CDM,250,RC,J2371,HCPCS,Outpatient,,,19.14,11.48,,11.48,60,,9.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.48,60,,9.184,Percent of Total Billed Charges,60% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.76,14.42,,2.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,75,,68.032,Percent of Total Billed Charges,75% of Total Billed Charges,9.57,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,9.57,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.57,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,9.57,50,,7.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.4,70,,10.72,Percent of Total Billed Charges,70% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,14,,2.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.14,100,,90.704,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,19.14,
AZITHROMYCIN 600MG TAB,53393208,CDM,250,RC,,,Outpatient,,,12.11,7.27,,7.27,60,,5.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,28,,2.712,Percent of Total Billed Charges,28% of Total Billed Charges,25.48,32,,20.384,Percent of Total Billed Charges,32% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,4.36,36,,3.488,Percent of Total Billed Charges,36% of Total Billed Charges,4.36,36,,3.488,Percent of Total Billed Charges,36% Total Bille Charges,4.36,36,,3.488,Percent of Total Billed Charges,36% of Total Billed Charges,7.27,60,,5.816,Percent of Total Billed Charges,60% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.75,14.42,,1.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.08,75,,106.056,Percent of Total Billed Charges,75% of Total Billed Charges,6.06,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,6.06,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.06,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,6.06,50,,4.848,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.48,70,,6.784,Percent of Total Billed Charges,70% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,1.7,14,,1.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.11,100,,141.408,Percent of Total Billed Charges,100% of Total Billed Charges,1.7,25.48,
MELATONIN 3MG TAB,53393209,CDM,250,RC,,,Outpatient,,,0.15,0.09,,0.09,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,25.48,32,,20.384,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% Total Bille Charges,0.05,36,,0.04,Percent of Total Billed Charges,36% of Total Billed Charges,0.09,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,75,,2899.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,0.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,100,,3865.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,25.48,
LOPINAVIR-RITONVIR 80/20MG 1ML,53393210,CDM,250,RC,,,Outpatient,,,19.2,11.52,,11.52,60,,9.216,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.38,28,,4.304,Percent of Total Billed Charges,28% of Total Billed Charges,25.58,32,,20.464,Percent of Total Billed Charges,32% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,6.91,36,,5.528,Percent of Total Billed Charges,36% of Total Billed Charges,6.91,36,,5.528,Percent of Total Billed Charges,36% Total Bille Charges,6.91,36,,5.528,Percent of Total Billed Charges,36% of Total Billed Charges,11.52,60,,9.216,Percent of Total Billed Charges,60% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.77,14.42,,2.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,75,,21.96,Percent of Total Billed Charges,75% of Total Billed Charges,9.6,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,9.6,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,9.6,50,,7.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.44,70,,10.752,Percent of Total Billed Charges,70% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,2.69,14,,2.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.2,100,,29.28,Percent of Total Billed Charges,100% of Total Billed Charges,2.69,25.58,
HYDROMORPH 10MG/ML INJ 1ML,53393211,CDM,250,RC,J1171,HCPCS,Outpatient,,,20.68,12.41,,12.41,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.41,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.98,14.42,,2.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.51,75,,0.096,Percent of Total Billed Charges,75% of Total Billed Charges,10.34,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,10.34,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.34,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,10.34,50,,8.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,70,,11.584,Percent of Total Billed Charges,70% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,2.9,14,,2.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.68,100,,0.128,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,20.68,
GENTAMICIN 0.1% OINT 30GM TUBE,53393212,CDM,250,RC,,,Outpatient,,,192.74,115.64,,115.64,60,,92.512,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.97,28,,43.176,Percent of Total Billed Charges,28% of Total Billed Charges,252.8,32,,202.24,Percent of Total Billed Charges,32% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,69.39,36,,55.512,Percent of Total Billed Charges,36% of Total Billed Charges,69.39,36,,55.512,Percent of Total Billed Charges,36% Total Bille Charges,69.39,36,,55.512,Percent of Total Billed Charges,36% of Total Billed Charges,115.64,60,,92.512,Percent of Total Billed Charges,60% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,27.79,14.42,,22.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.56,75,,7.968,Percent of Total Billed Charges,75% of Total Billed Charges,96.37,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,96.37,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.37,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,96.37,50,,77.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.92,70,,107.936,Percent of Total Billed Charges,70% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,26.98,14,,21.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.74,100,,10.624,Percent of Total Billed Charges,100% of Total Billed Charges,26.98,252.8,
AMINOPHYLLINE 500MG/20ML INJ,53393213,CDM,250,RC,J0280,HCPCS,Outpatient,,,42.02,25.21,,6.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.68,360,,,Fee Schedule,360% of BCBS POS Rate,0.68,360,,,Fee schedule,360% of BCBS PPO Rate,0.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.21,60,,20.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.52,75,,5.808,Percent of Total Billed Charges,75% of Total Billed Charges,7.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.14,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,7.14,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.41,70,,23.528,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.02,100,,7.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.68,42.02,
CIPROFLOXAC 0.3% OP SOL 2.5ML,53393214,CDM,250,RC,,,Outpatient,,,33.48,20.09,,20.09,60,,16.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.37,28,,7.496,Percent of Total Billed Charges,28% of Total Billed Charges,252.96,32,,202.368,Percent of Total Billed Charges,32% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,12.05,36,,9.64,Percent of Total Billed Charges,36% of Total Billed Charges,12.05,36,,9.64,Percent of Total Billed Charges,36% Total Bille Charges,12.05,36,,9.64,Percent of Total Billed Charges,36% of Total Billed Charges,20.09,60,,16.072,Percent of Total Billed Charges,60% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.83,14.42,,3.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.11,75,,140.576,Percent of Total Billed Charges,75% of Total Billed Charges,16.74,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,16.74,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.74,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,16.74,50,,13.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.44,70,,18.752,Percent of Total Billed Charges,70% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,4.69,14,,3.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.48,100,,187.432,Percent of Total Billed Charges,100% of Total Billed Charges,4.69,252.96,
PETROLATUM/MIN OIL OPHTONT 1GM,53393215,CDM,250,RC,,,Outpatient,,,7.28,4.37,,4.37,60,,3.496,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,28,,1.632,Percent of Total Billed Charges,28% of Total Billed Charges,252.96,32,,202.368,Percent of Total Billed Charges,32% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,2.62,36,,2.096,Percent of Total Billed Charges,36% of Total Billed Charges,2.62,36,,2.096,Percent of Total Billed Charges,36% Total Bille Charges,2.62,36,,2.096,Percent of Total Billed Charges,36% of Total Billed Charges,4.37,60,,3.496,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.05,14.42,,0.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.46,75,,1248,Percent of Total Billed Charges,75% of Total Billed Charges,3.64,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,3.64,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.64,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,3.64,50,,2.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,70,,4.08,Percent of Total Billed Charges,70% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,1.02,14,,0.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.28,100,,1664,Percent of Total Billed Charges,100% of Total Billed Charges,1.02,252.96,
CYCLOSPORIN MOD ORAL SOL,53393216,CDM,250,RC,J7502,HCPCS,Outpatient,,,35.65,21.39,,2.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,3.17,360,,,Fee Schedule,360% of BCBS POS Rate,3.17,360,,,Fee schedule,360% of BCBS PPO Rate,3.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.39,60,,17.112,Percent of Total Billed Charges,60% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,5.14,14.42,,4.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.74,75,,42.232,Percent of Total Billed Charges,75% of Total Billed Charges,1.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.81,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.81,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.96,70,,19.968,Percent of Total Billed Charges,70% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.65,100,,56.312,Percent of Total Billed Charges,100% of Total Billed Charges,1.81,35.65,
MYCOPHENOLATE 200MG/ML SUS 1ML,53393217,CDM,250,RC,J7517,HCPCS,Outpatient,,,44.43,26.66,,0.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,360,,,Fee Schedule,360% of BCBS POS Rate,0.57,360,,,Fee schedule,360% of BCBS PPO Rate,0.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.66,60,,21.328,Percent of Total Billed Charges,60% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.41,14.42,,5.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.32,75,,4168.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.16,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.1,70,,24.88,Percent of Total Billed Charges,70% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,6.22,14,,4.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.43,100,,5558.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.16,44.43,
RABIES IMM GLOB 300 UNIT/ML 1ML,53393218,CDM,636,RC,90375,HCPCS,Outpatient,,,2250,1350.00,,1639.76,110,,1311.808,Percent of Total Billed Charges,110% of Total Billed Charges,431.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,324.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,324.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,324.12,360,,,Fee Schedule,360% of BCBS POS Rate,324.12,360,,,Fee schedule,360% of BCBS PPO Rate,324.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,1237.5,55,,990,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,258.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,374.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,1687.5,75,,2084.4,Percent of Total Billed Charges,75% of Total Billed Charges,1393.95,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,1393.95,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1393.95,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,1393.95,50,,1115.16,Percent of Total Billed Charges,50% of Total Billed Charges,431.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1575,70,,1260,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2250,100,,2779.2,Percent of Total Billed Charges,100% of Total Billed Charges,258.93,2250,
RABIES IMM GLOB 300 UNIT/ML 5ML,53393219,CDM,636,RC,90375,HCPCS,Outpatient,,,8273.4,4964.04,,4952.63,110,,3962.104,Percent of Total Billed Charges,110% of Total Billed Charges,431.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,324.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,324.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,324.12,360,,,Fee Schedule,360% of BCBS POS Rate,324.12,360,,,Fee schedule,360% of BCBS PPO Rate,324.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,4550.37,55,,3640.296,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,258.93,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,374.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,296.33,103,,,Fee Schedule,103% of CMS OPPS Rate,6205.05,75,,19.728,Percent of Total Billed Charges,75% of Total Billed Charges,4405.65,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,4405.65,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4405.65,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,4405.65,50,,3524.52,Percent of Total Billed Charges,50% of Total Billed Charges,431.56,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.38,70,,4633.104,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8273.4,100,,26.304,Percent of Total Billed Charges,100% of Total Billed Charges,258.93,8273.4,
DOBUTAMINE 500MG/ D5 250ML RTO,53393221,CDM,250,RC,J1250,HCPCS,Outpatient,,,208.7,125.22,,6.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.85,360,,,Fee Schedule,360% of BCBS POS Rate,2.85,360,,,Fee schedule,360% of BCBS PPO Rate,2.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.22,60,,100.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.53,75,,19.728,Percent of Total Billed Charges,75% of Total Billed Charges,5.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,5.22,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.09,70,,116.872,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.7,100,,26.304,Percent of Total Billed Charges,100% of Total Billed Charges,2.85,208.7,
TOBRAMYCIN 300MG/4ML INH SOL,53393222,CDM,250,RC,,,Outpatient,,,461.03,276.62,,276.62,60,,221.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.09,28,,103.272,Percent of Total Billed Charges,28% of Total Billed Charges,253.14,32,,202.512,Percent of Total Billed Charges,32% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,165.97,36,,132.776,Percent of Total Billed Charges,36% of Total Billed Charges,165.97,36,,132.776,Percent of Total Billed Charges,36% Total Bille Charges,165.97,36,,132.776,Percent of Total Billed Charges,36% of Total Billed Charges,276.62,60,,221.296,Percent of Total Billed Charges,60% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,66.48,14.42,,53.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.77,75,,239.2,Percent of Total Billed Charges,75% of Total Billed Charges,230.52,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,230.52,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.52,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,230.52,50,,184.416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.72,70,,258.176,Percent of Total Billed Charges,70% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.54,14,,51.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.03,100,,318.928,Percent of Total Billed Charges,100% of Total Billed Charges,64.54,461.03,
LEVETIRACETAM 500MG/NS 100ML,53393223,CDM,250,RC,J1953,HCPCS,Outpatient,,,160.91,96.55,,0.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.11,360,,,Fee Schedule,360% of BCBS POS Rate,0.11,360,,,Fee schedule,360% of BCBS PPO Rate,0.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,96.55,60,,77.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.68,75,,73.152,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.64,70,,90.112,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.91,100,,97.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,160.91,
PATIROMER PWD 8.4GM,53393224,CDM,250,RC,,,Outpatient,,,67,40.20,,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.76,28,,15.008,Percent of Total Billed Charges,28% of Total Billed Charges,254.4,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,24.12,36,,19.296,Percent of Total Billed Charges,36% of Total Billed Charges,24.12,36,,19.296,Percent of Total Billed Charges,36% Total Bille Charges,24.12,36,,19.296,Percent of Total Billed Charges,36% of Total Billed Charges,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.66,14.42,,7.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.25,75,,54.864,Percent of Total Billed Charges,75% of Total Billed Charges,33.5,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.5,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.5,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.5,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.9,70,,37.52,Percent of Total Billed Charges,70% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,9.38,14,,7.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67,100,,73.152,Percent of Total Billed Charges,100% of Total Billed Charges,9.38,254.4,
APREPITANT VL PER 1MG,53393225,CDM,250,RC,J0185,HCPCS,Outpatient,,,13.62,8.17,,1.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,2.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.7,360,,,Fee Schedule,360% of BCBS POS Rate,2.7,360,,,Fee schedule,360% of BCBS PPO Rate,2.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,8.17,60,,6.536,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1.59,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.82,103,,,Fee Schedule,103% of CMS OPPS Rate,1.82,103,,,Fee Schedule,103% of CMS OPPS Rate,10.22,75,,19.848,Percent of Total Billed Charges,75% of Total Billed Charges,1.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1.44,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.44,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,2.65,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.53,70,,7.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,26.464,Percent of Total Billed Charges,100% of Total Billed Charges,1.44,13.62,
LIDOCAINE 1GM IN D5W 250 ML,53393226,CDM,250,RC,J2002,HCPCS,Outpatient,,,40.5,24.30,,24.3,60,,19.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.3,60,,19.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.84,14.42,,4.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.38,75,,422.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.25,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.25,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.25,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.25,50,,16.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.35,70,,22.68,Percent of Total Billed Charges,70% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,5.67,14,,4.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.5,100,,563.816,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,40.5,
VANCOMYCIN ORAL SOL 50MG/1ML,53393228,CDM,250,RC,,,Outpatient,,,0.63,0.38,,0.38,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,28,,0.144,Percent of Total Billed Charges,28% of Total Billed Charges,254.4,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% Total Bille Charges,0.23,36,,0.184,Percent of Total Billed Charges,36% of Total Billed Charges,0.38,60,,0.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14.42,,0.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.47,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,0.32,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,0.32,50,,0.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.44,70,,0.352,Percent of Total Billed Charges,70% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,14,,0.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.63,100,,72,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,254.4,
LIDOCAINE 2% JELLY 6ML (GLYDO),53393229,CDM,250,RC,,,Outpatient,,,42.84,25.70,,25.7,60,,20.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,28,,9.6,Percent of Total Billed Charges,28% of Total Billed Charges,254.4,32,,203.52,Percent of Total Billed Charges,32% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,15.42,36,,12.336,Percent of Total Billed Charges,36% of Total Billed Charges,15.42,36,,12.336,Percent of Total Billed Charges,36% Total Bille Charges,15.42,36,,12.336,Percent of Total Billed Charges,36% of Total Billed Charges,25.7,60,,20.56,Percent of Total Billed Charges,60% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6.18,14.42,,4.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.13,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,21.42,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,21.42,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.42,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,21.42,50,,17.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.99,70,,23.992,Percent of Total Billed Charges,70% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,6,14,,4.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,100,,72,Percent of Total Billed Charges,100% of Total Billed Charges,6,254.4,
ESTRADIOL 0.025MG/24HR PATCH,53393230,CDM,250,RC,,,Outpatient,,,41.78,25.07,,25.07,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.7,28,,9.36,Percent of Total Billed Charges,28% of Total Billed Charges,2560.06,32,,2048.048,Percent of Total Billed Charges,32% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% Total Bille Charges,15.04,36,,12.032,Percent of Total Billed Charges,36% of Total Billed Charges,25.07,60,,20.056,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,6.02,14.42,,4.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.34,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.89,50,,16.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.25,70,,23.4,Percent of Total Billed Charges,70% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14,,4.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,5.85,2560.06,
KETOROLAC 0.5% OPHT SOL 5ML,53393231,CDM,250,RC,,,Outpatient,,,82.62,49.57,,49.57,60,,39.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.13,28,,18.504,Percent of Total Billed Charges,28% of Total Billed Charges,2562.57,32,,2050.056,Percent of Total Billed Charges,32% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,29.74,36,,23.792,Percent of Total Billed Charges,36% of Total Billed Charges,29.74,36,,23.792,Percent of Total Billed Charges,36% Total Bille Charges,29.74,36,,23.792,Percent of Total Billed Charges,36% of Total Billed Charges,49.57,60,,39.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.91,14.42,,9.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.97,75,,440.888,Percent of Total Billed Charges,75% of Total Billed Charges,41.31,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,41.31,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.31,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,41.31,50,,33.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.83,70,,46.264,Percent of Total Billed Charges,70% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14,,9.256,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.62,100,,587.848,Percent of Total Billed Charges,100% of Total Billed Charges,11.57,2562.57,
LIDOCAINE MPF 4% 5ML INJ,53393232,CDM,250,RC,,,Outpatient,,,26.2,15.72,,15.72,60,,12.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,28,,5.872,Percent of Total Billed Charges,28% of Total Billed Charges,2605,32,,2084,Percent of Total Billed Charges,32% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,36,,7.544,Percent of Total Billed Charges,36% of Total Billed Charges,9.43,36,,7.544,Percent of Total Billed Charges,36% Total Bille Charges,9.43,36,,7.544,Percent of Total Billed Charges,36% of Total Billed Charges,15.72,60,,12.576,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.78,14.42,,3.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.65,75,,47.072,Percent of Total Billed Charges,75% of Total Billed Charges,13.1,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,13.1,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.1,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,13.1,50,,10.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.34,70,,14.672,Percent of Total Billed Charges,70% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,14,,2.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.2,100,,62.76,Percent of Total Billed Charges,100% of Total Billed Charges,3.67,2605,
METHYL SALICY/MENTHOL CRM 60GM,53393233,CDM,250,RC,,,Outpatient,,,8.46,5.08,,5.08,60,,4.064,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.37,28,,1.896,Percent of Total Billed Charges,28% of Total Billed Charges,2610.43,32,,2088.344,Percent of Total Billed Charges,32% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% Total Bille Charges,3.05,36,,2.44,Percent of Total Billed Charges,36% of Total Billed Charges,5.08,60,,4.064,Percent of Total Billed Charges,60% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.22,14.42,,0.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.35,75,,512.6,Percent of Total Billed Charges,75% of Total Billed Charges,4.23,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.23,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,4.23,50,,3.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,70,,4.736,Percent of Total Billed Charges,70% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,1.18,14,,0.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.46,100,,683.464,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,2610.43,
Revanesse Lips+  2X1 ml kit,53393322,CDM,636,RC,J3490,HCPCS,Outpatient,,,2400,1440.00,,1320,110,,1056,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,672,28,,537.6,Percent of Total Billed Charges,28% of Total Billed Charges,2611.2,32,,2088.96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,864,36,,691.2,Percent of Total Billed Charges,36% of Total Billed Charges,864,36,,691.2,Percent of Total Billed Charges,36% Total Bille Charges,864,36,,691.2,Percent of Total Billed Charges,36% of Total Billed Charges,1320,55,,1056,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1800,75,,262.336,Percent of Total Billed Charges,75% of Total Billed Charges,1200,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,1200,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1200,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,1200,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1680,70,,1344,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2400,100,,349.776,Percent of Total Billed Charges,100% of Total Billed Charges,672,2611.2,
Acetamin-Cod 120mg/12mg  5ml,53500000,CDM,250,RC,J0131,HCPCS,Outpatient,,,4.98,2.99,,0.23,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.3,360,,,Fee Schedule,360% of BCBS POS Rate,0.3,360,,,Fee schedule,360% of BCBS PPO Rate,0.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,2.99,60,,2.392,Percent of Total Billed Charges,60% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.72,14.42,,0.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.74,75,,7.12,Percent of Total Billed Charges,75% of Total Billed Charges,0.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.07,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.49,70,,2.792,Percent of Total Billed Charges,70% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,0.7,14,,0.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.98,100,,9.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,4.98,
Nicardipine 30mg cap,53500001,CDM,250,RC,,,Outpatient,,,71,42.60,,42.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.88,28,,15.904,Percent of Total Billed Charges,28% of Total Billed Charges,2611.2,32,,2088.96,Percent of Total Billed Charges,32% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,25.56,36,,20.448,Percent of Total Billed Charges,36% of Total Billed Charges,25.56,36,,20.448,Percent of Total Billed Charges,36% Total Bille Charges,25.56,36,,20.448,Percent of Total Billed Charges,36% of Total Billed Charges,42.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.25,75,,53.856,Percent of Total Billed Charges,75% of Total Billed Charges,35.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.7,70,,39.76,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71,100,,71.808,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,2611.2,
PHENYLEPHRINE HEMOR OINT 57GM,53500002,CDM,250,RC,J2371,HCPCS,Outpatient,,,9.8,5.88,,5.88,60,,4.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.88,60,,4.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,14.42,,1.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.35,75,,23.856,Percent of Total Billed Charges,75% of Total Billed Charges,4.9,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,4.9,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,4.9,50,,3.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.86,70,,5.488,Percent of Total Billed Charges,70% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,1.37,14,,1.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,100,,31.808,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,9.8,
BENZOCAINE 10% ORAL GEL 9GM,53500003,CDM,250,RC,J3490,HCPCS,Outpatient,,,16.64,9.98,,9.98,60,,7.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.66,28,,3.728,Percent of Total Billed Charges,28% of Total Billed Charges,2638.71,32,,2110.968,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.99,36,,4.792,Percent of Total Billed Charges,36% of Total Billed Charges,5.99,36,,4.792,Percent of Total Billed Charges,36% Total Bille Charges,5.99,36,,4.792,Percent of Total Billed Charges,36% of Total Billed Charges,9.98,60,,7.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.48,75,,6.176,Percent of Total Billed Charges,75% of Total Billed Charges,8.32,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,8.32,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.32,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,8.32,50,,6.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.65,70,,9.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.64,100,,8.232,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,2638.71,
ZINC OXIDE 16% PASTE 113GM,53500004,CDM,250,RC,,,Outpatient,,,21.2,12.72,,12.72,60,,10.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.94,28,,4.752,Percent of Total Billed Charges,28% of Total Billed Charges,2650.86,32,,2120.688,Percent of Total Billed Charges,32% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,7.63,36,,6.104,Percent of Total Billed Charges,36% of Total Billed Charges,7.63,36,,6.104,Percent of Total Billed Charges,36% Total Bille Charges,7.63,36,,6.104,Percent of Total Billed Charges,36% of Total Billed Charges,12.72,60,,10.176,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.9,75,,3.152,Percent of Total Billed Charges,75% of Total Billed Charges,10.6,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,10.6,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,10.6,50,,8.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.84,70,,11.872,Percent of Total Billed Charges,70% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.2,100,,4.2,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,2650.86,
NEO/BACI/POLY/HC 1% OINT 15 G,53500005,CDM,250,RC,,,Outpatient,,,476.82,286.09,,286.09,60,,228.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.51,28,,106.808,Percent of Total Billed Charges,28% of Total Billed Charges,2658.24,32,,2126.592,Percent of Total Billed Charges,32% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,171.66,36,,137.328,Percent of Total Billed Charges,36% of Total Billed Charges,171.66,36,,137.328,Percent of Total Billed Charges,36% Total Bille Charges,171.66,36,,137.328,Percent of Total Billed Charges,36% of Total Billed Charges,286.09,60,,228.872,Percent of Total Billed Charges,60% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,68.76,14.42,,55.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,357.62,75,,11.048,Percent of Total Billed Charges,75% of Total Billed Charges,238.41,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,238.41,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.41,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,238.41,50,,190.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.77,70,,267.016,Percent of Total Billed Charges,70% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,66.75,14,,53.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,476.82,100,,14.728,Percent of Total Billed Charges,100% of Total Billed Charges,66.75,2658.24,
TEMOZOLOMIDE 250MG CAP,53500006,CDM,250,RC,J9328,HCPCS,Outpatient,,,264,158.40,,10.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,10.33,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,10.33,360,,,Fee Schedule,360% of BCBS POS Rate,10.33,360,,,Fee schedule,360% of BCBS PPO Rate,10.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,158.4,60,,126.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.71,103,,,Fee Schedule,103% of CMS OPPS Rate,10.71,103,,,Fee Schedule,103% of CMS OPPS Rate,198,75,,6.752,Percent of Total Billed Charges,75% of Total Billed Charges,8.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,8.33,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,8.33,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,15.6,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,184.8,70,,147.84,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,100,,,Fee Schedule,100% of CMS OPPS Rate,264,100,,9,Percent of Total Billed Charges,100% of Total Billed Charges,8.33,264,
RITUXIMAB 500MG/50ML INJ,53500007,CDM,636,RC,J9310,HCPCS,Outpatient,,,13800,8280.00,,7590,110,,6072,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3864,28,,3091.2,Percent of Total Billed Charges,28% of Total Billed Charges,2658.73,32,,2126.984,Percent of Total Billed Charges,32% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,4968,36,,3974.4,Percent of Total Billed Charges,36% of Total Billed Charges,4968,36,,3974.4,Percent of Total Billed Charges,36% Total Bille Charges,4968,36,,3974.4,Percent of Total Billed Charges,36% of Total Billed Charges,7590,55,,6072,Percent of Total Billed Charges,55% Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1989.96,14.42,,1591.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10350,75,,459.016,Percent of Total Billed Charges,75% of Total Billed Charges,6900,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,6900,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6900,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,6900,50,,5520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9660,70,,7728,Percent of Total Billed Charges,70% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,1932,14,,1545.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13800,100,,612.016,Percent of Total Billed Charges,100% of Total Billed Charges,1932,13800,
ETOPOSIDE PHOSPHATE 100MG INJ,53500008,CDM,250,RC,J9181,HCPCS,Outpatient,,,305,183.00,,0.77,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.65,360,,,Fee Schedule,360% of BCBS POS Rate,0.65,360,,,Fee schedule,360% of BCBS PPO Rate,0.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,183,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.75,75,,178.2,Percent of Total Billed Charges,75% of Total Billed Charges,0.69,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.69,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.69,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.69,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.5,70,,170.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305,100,,237.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.65,305,
Rocuronium 50mg/5ml inj,53500009,CDM,250,RC,J3490,HCPCS,Outpatient,,,24,14.40,,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,28,,5.376,Percent of Total Billed Charges,28% of Total Billed Charges,2661.43,32,,2129.144,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% Total Bille Charges,8.64,36,,6.912,Percent of Total Billed Charges,36% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,75,,2.44,Percent of Total Billed Charges,75% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,70,,13.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,100,,3.248,Percent of Total Billed Charges,100% of Total Billed Charges,6.72,2661.43,
NAFCILLIN 1 GM INJ ADDV,53500010,CDM,250,RC,,,Outpatient,,,61.64,36.98,,36.98,60,,29.584,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.26,28,,13.808,Percent of Total Billed Charges,28% of Total Billed Charges,2662.4,32,,2129.92,Percent of Total Billed Charges,32% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,22.19,36,,17.752,Percent of Total Billed Charges,36% of Total Billed Charges,22.19,36,,17.752,Percent of Total Billed Charges,36% Total Bille Charges,22.19,36,,17.752,Percent of Total Billed Charges,36% of Total Billed Charges,36.98,60,,29.584,Percent of Total Billed Charges,60% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.89,14.42,,7.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.23,75,,296.552,Percent of Total Billed Charges,75% of Total Billed Charges,30.82,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,30.82,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.82,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,30.82,50,,24.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.15,70,,34.52,Percent of Total Billed Charges,70% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,8.63,14,,6.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.64,100,,395.4,Percent of Total Billed Charges,100% of Total Billed Charges,8.63,2662.4,
MEROPENEM 500MG/NS 50ML,53500011,CDM,250,RC,J2185,HCPCS,Outpatient,,,82.88,49.73,,0.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.21,360,,,Fee Schedule,360% of BCBS POS Rate,2.21,360,,,Fee schedule,360% of BCBS PPO Rate,2.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,49.73,60,,39.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.16,75,,33.376,Percent of Total Billed Charges,75% of Total Billed Charges,0.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.39,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.02,70,,46.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.88,100,,44.496,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,82.88,
EXEMESTANE 25 MG TAB,53500012,CDM,250,RC,J8999,HCPCS,Outpatient,,,43.4,26.04,,26.04,60,,20.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.15,28,,9.72,Percent of Total Billed Charges,28% of Total Billed Charges,2662.4,32,,2129.92,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.62,36,,12.496,Percent of Total Billed Charges,36% of Total Billed Charges,15.62,36,,12.496,Percent of Total Billed Charges,36% Total Bille Charges,15.62,36,,12.496,Percent of Total Billed Charges,36% of Total Billed Charges,26.04,60,,20.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.55,75,,3.44,Percent of Total Billed Charges,75% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.38,70,,24.304,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,100,,4.584,Percent of Total Billed Charges,100% of Total Billed Charges,12.15,2662.4,
ROTIGOTINE PATCH 8mg/24hr,53500013,CDM,250,RC,,,Outpatient,,,94.04,56.42,,56.42,60,,45.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.33,28,,21.064,Percent of Total Billed Charges,28% of Total Billed Charges,2667.47,32,,2133.976,Percent of Total Billed Charges,32% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% of Total Billed Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% Total Bille Charges,33.85,36,,27.08,Percent of Total Billed Charges,36% of Total Billed Charges,56.42,60,,45.136,Percent of Total Billed Charges,60% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.56,14.42,,10.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.53,75,,19.792,Percent of Total Billed Charges,75% of Total Billed Charges,47.02,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,47.02,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.02,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,47.02,50,,37.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.83,70,,52.664,Percent of Total Billed Charges,70% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,13.17,14,,10.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.04,100,,26.392,Percent of Total Billed Charges,100% of Total Billed Charges,13.17,2667.47,
VARICELLA VIRUS VACCINE (LIVE),53500014,CDM,250,RC,,,Outpatient,,,447.69,268.61,,268.61,60,,214.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.35,28,,100.28,Percent of Total Billed Charges,28% of Total Billed Charges,2677.76,32,,2142.208,Percent of Total Billed Charges,32% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,161.17,36,,128.936,Percent of Total Billed Charges,36% of Total Billed Charges,161.17,36,,128.936,Percent of Total Billed Charges,36% Total Bille Charges,161.17,36,,128.936,Percent of Total Billed Charges,36% of Total Billed Charges,268.61,60,,214.888,Percent of Total Billed Charges,60% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,64.56,14.42,,51.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.77,75,,17.184,Percent of Total Billed Charges,75% of Total Billed Charges,223.85,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,223.85,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.85,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,223.85,50,,179.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.38,70,,250.704,Percent of Total Billed Charges,70% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,62.68,14,,50.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.69,100,,22.912,Percent of Total Billed Charges,100% of Total Billed Charges,62.68,2677.76,
WATER STERILE IRRIG 2000ML,53500015,CDM,250,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,2681.54,32,,2145.232,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,100,,40,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,82.552,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,110.064,Percent of Total Billed Charges,100% of Total Billed Charges,7,2681.54,
D10W 1/2NS 1000ML,53500016,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,22.69,45,,18.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,2717.31,32,,2173.848,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,40.344,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,6.12,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,8.16,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,2717.31,
BETAXOLOL-S 0.25% OPH SUSP 10ML,53500017,CDM,250,RC,,,Outpatient,,,321,192.60,,192.6,60,,154.08,Percent of Total Billed Charges,60% of Total Billed Charges,144.45,45,,115.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.88,28,,71.904,Percent of Total Billed Charges,28% of Total Billed Charges,2719.2,32,,2175.36,Percent of Total Billed Charges,32% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,115.56,36,,92.448,Percent of Total Billed Charges,36% of Total Billed Charges,115.56,36,,92.448,Percent of Total Billed Charges,36% Total Bille Charges,115.56,36,,92.448,Percent of Total Billed Charges,36% of Total Billed Charges,192.6,60,,154.08,Percent of Total Billed Charges,60% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321,100,,256.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,46.29,14.42,,37.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.75,75,,27.304,Percent of Total Billed Charges,75% of Total Billed Charges,160.5,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,160.5,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.5,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,160.5,50,,128.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.7,70,,179.76,Percent of Total Billed Charges,70% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,44.94,14,,35.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321,100,,36.4,Percent of Total Billed Charges,100% of Total Billed Charges,44.94,2719.2,
DORZOL/TIM 2-0.5% OP GTT  0.2ml,53500018,CDM,250,RC,,,Outpatient,,,4.23,2.54,,2.54,60,,2.032,Percent of Total Billed Charges,60% of Total Billed Charges,1.9,45,,1.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.18,28,,0.944,Percent of Total Billed Charges,28% of Total Billed Charges,2719.2,32,,2175.36,Percent of Total Billed Charges,32% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% of Total Billed Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% Total Bille Charges,1.52,36,,1.216,Percent of Total Billed Charges,36% of Total Billed Charges,2.54,60,,2.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,100,,3.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.61,14.42,,0.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,75,,134.784,Percent of Total Billed Charges,75% of Total Billed Charges,2.12,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,2.12,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.12,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,2.12,50,,1.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.96,70,,2.368,Percent of Total Billed Charges,70% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14,,0.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.23,100,,168.48,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,2719.2,
TIMOLOL 0.5% OPHTH DROPS 10ML,53500019,CDM,250,RC,,,Outpatient,,,32.04,19.22,,19.22,60,,15.376,Percent of Total Billed Charges,60% of Total Billed Charges,14.42,45,,11.536,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.97,28,,7.176,Percent of Total Billed Charges,28% of Total Billed Charges,2759.44,32,,2207.552,Percent of Total Billed Charges,32% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,11.53,36,,9.224,Percent of Total Billed Charges,36% of Total Billed Charges,11.53,36,,9.224,Percent of Total Billed Charges,36% Total Bille Charges,11.53,36,,9.224,Percent of Total Billed Charges,36% of Total Billed Charges,19.22,60,,15.376,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.04,100,,25.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14.42,,3.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.03,75,,103.84,Percent of Total Billed Charges,75% of Total Billed Charges,16.02,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,16.02,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.02,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,16.02,50,,12.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.43,70,,17.944,Percent of Total Billed Charges,70% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,4.49,14,,3.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.04,100,,129.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.49,2759.44,
INFLUENZA VAC FLUBLOK EGG-FREE,53500020,CDM,636,RC,Q2039,HCPCS,Outpatient,,,246.25,147.75,,155.35,110,,124.28,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.95,28,,55.16,Percent of Total Billed Charges,28% of Total Billed Charges,2783.04,32,,2226.432,Percent of Total Billed Charges,32% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% Total Bille Charges,88.65,36,,70.92,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,35.51,14.42,,28.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.69,75,,37.416,Percent of Total Billed Charges,75% of Total Billed Charges,123.13,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.13,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,123.13,50,,98.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.38,70,,137.904,Percent of Total Billed Charges,70% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,34.48,14,,27.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,246.25,100,,49.888,Percent of Total Billed Charges,100% of Total Billed Charges,34.48,2783.04,
OLANZAPINE ODT 5 MG TAB,53500021,CDM,250,RC,,,Outpatient,,,12.45,7.47,,7.47,60,,5.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.49,28,,2.792,Percent of Total Billed Charges,28% of Total Billed Charges,2786.09,32,,2228.872,Percent of Total Billed Charges,32% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,4.48,36,,3.584,Percent of Total Billed Charges,36% of Total Billed Charges,4.48,36,,3.584,Percent of Total Billed Charges,36% Total Bille Charges,4.48,36,,3.584,Percent of Total Billed Charges,36% of Total Billed Charges,7.47,60,,5.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.8,14.42,,1.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.34,75,,188.904,Percent of Total Billed Charges,75% of Total Billed Charges,6.23,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,6.23,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.23,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,6.23,50,,4.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.72,70,,6.976,Percent of Total Billed Charges,70% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,1.74,14,,1.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.45,100,,251.872,Percent of Total Billed Charges,100% of Total Billed Charges,1.74,2786.09,
NS 50ML INJ A-V,53500022,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,2787.2,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,2.248,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,3,Percent of Total Billed Charges,100% of Total Billed Charges,7,2787.2,
EPTIFIBATIDE 0.75MG/ML INJ 100ML,53500024,CDM,250,RC,J1327,HCPCS,Outpatient,,,1057.5,634.50,,21.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.2,360,,,Fee Schedule,360% of BCBS POS Rate,15.2,360,,,Fee schedule,360% of BCBS PPO Rate,15.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,634.5,60,,507.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,3.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.26,103,,,Fee Schedule,103% of CMS OPPS Rate,4.26,103,,,Fee Schedule,103% of CMS OPPS Rate,793.13,75,,2.728,Percent of Total Billed Charges,75% of Total Billed Charges,528.75,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,528.75,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,528.75,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,528.75,50,,423,Percent of Total Billed Charges,50% of Total Billed Charges,6.22,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,740.25,70,,592.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.5,100,,3.64,Percent of Total Billed Charges,100% of Total Billed Charges,3.73,1057.5,
DARBEPOETIN ALPHA 25MCG SYR,53500025,CDM,250,RC,J0882,HCPCS,Outpatient,,,580,348.00,,3.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,348,60,,278.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,435,75,,5.464,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,406,70,,324.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,580,100,,7.288,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,580,
ROPIVIVAINE-PF 5MG/ML (0.5%) 20 ML,53500027,CDM,250,RC,J2795,HCPCS,Outpatient,,,86.88,52.13,,0.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.03,360,,,Fee Schedule,360% of BCBS POS Rate,0.03,360,,,Fee schedule,360% of BCBS PPO Rate,0.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.13,60,,41.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.16,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.82,70,,48.656,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.88,100,,38.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,86.88,
D5 1/2NS 250ML,53500028,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,2787.2,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,7,2787.2,
DARBEPOETIN ALPHA 100MCG SYR,53500029,CDM,250,RC,J0882,HCPCS,Outpatient,,,2167.2,1300.32,,3.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,1300.32,60,,1040.256,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,1625.4,75,,30.472,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1517.04,70,,1213.632,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2167.2,100,,40.624,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,2167.2,
NICARDIPINE 2.5MG/ML INJ 10ML,53500031,CDM,250,RC,,,Outpatient,,,153,91.80,,91.8,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.84,28,,34.272,Percent of Total Billed Charges,28% of Total Billed Charges,2787.2,32,,2229.76,Percent of Total Billed Charges,32% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.08,36,,44.064,Percent of Total Billed Charges,36% of Total Billed Charges,55.08,36,,44.064,Percent of Total Billed Charges,36% Total Bille Charges,55.08,36,,44.064,Percent of Total Billed Charges,36% of Total Billed Charges,91.8,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,22.06,14.42,,17.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.75,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.1,70,,85.68,Percent of Total Billed Charges,70% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,21.42,14,,17.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,21.42,2787.2,
DARBEPOETIN ALPHA 60MCG SYR,53500032,CDM,250,RC,J0882,HCPCS,Outpatient,,,1393.2,835.92,,3.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,835.92,60,,668.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,1044.9,75,,27.272,Percent of Total Billed Charges,75% of Total Billed Charges,2.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,975.24,70,,780.192,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1393.2,100,,36.36,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,1393.2,
CEFROZIL 250MG/5ML ORAL SUSP 5ML,53500033,CDM,250,RC,,,Outpatient,,,146.6,87.96,,87.96,60,,70.368,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.05,28,,32.84,Percent of Total Billed Charges,28% of Total Billed Charges,2801.28,32,,2241.024,Percent of Total Billed Charges,32% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,52.78,36,,42.224,Percent of Total Billed Charges,36% of Total Billed Charges,52.78,36,,42.224,Percent of Total Billed Charges,36% Total Bille Charges,52.78,36,,42.224,Percent of Total Billed Charges,36% of Total Billed Charges,87.96,60,,70.368,Percent of Total Billed Charges,60% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,21.14,14.42,,16.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.95,75,,21.4,Percent of Total Billed Charges,75% of Total Billed Charges,73.3,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,73.3,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.3,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,73.3,50,,58.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.62,70,,82.096,Percent of Total Billed Charges,70% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,20.52,14,,16.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.6,100,,28.536,Percent of Total Billed Charges,100% of Total Billed Charges,20.52,2801.28,
EPTIFIBATIDE 2MG/ML INJ 10ML,53500034,CDM,250,RC,J1327,HCPCS,Outpatient,,,600,360.00,,21.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.2,360,,,Fee Schedule,360% of BCBS POS Rate,15.2,360,,,Fee schedule,360% of BCBS PPO Rate,15.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,3.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.26,103,,,Fee Schedule,103% of CMS OPPS Rate,4.26,103,,,Fee Schedule,103% of CMS OPPS Rate,450,75,,432.592,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,6.22,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,600,100,,576.792,Percent of Total Billed Charges,100% of Total Billed Charges,3.73,600,
DARBEPOETIN ALPHA 40MCG SYR,53500035,CDM,636,RC,J0882,HCPCS,Outpatient,,,928.8,557.28,,513.96,110,,411.168,Percent of Total Billed Charges,110% of Total Billed Charges,4.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.86,360,,,Fee Schedule,360% of BCBS POS Rate,1.86,360,,,Fee schedule,360% of BCBS PPO Rate,1.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,2.73,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3.13,103,,,Fee Schedule,103% of CMS OPPS Rate,696.6,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,466.86,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,466.86,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,466.86,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,466.86,50,,373.488,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,650.16,70,,520.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,928.8,100,,99,Percent of Total Billed Charges,100% of Total Billed Charges,1.86,928.8,
BUPIVACAINE 0.5%/EPI 1:200000 INJ 50ML,53500036,CDM,250,RC,J3490,HCPCS,Outpatient,,,86.4,51.84,,51.84,60,,41.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,28,,19.352,Percent of Total Billed Charges,28% of Total Billed Charges,2803.51,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.1,36,,24.88,Percent of Total Billed Charges,36% of Total Billed Charges,31.1,36,,24.88,Percent of Total Billed Charges,36% Total Bille Charges,31.1,36,,24.88,Percent of Total Billed Charges,36% of Total Billed Charges,51.84,60,,41.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.8,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,43.2,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,43.2,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.2,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,43.2,50,,34.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.48,70,,48.384,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.4,100,,99,Percent of Total Billed Charges,100% of Total Billed Charges,24.19,2803.51,
BUPIVACAINE 0.25%/EPI 1:200000 INJ 50ML,53500038,CDM,250,RC,,,Outpatient,,,80.76,48.46,,48.46,60,,38.768,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.61,28,,18.088,Percent of Total Billed Charges,28% of Total Billed Charges,2803.51,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,29.07,36,,23.256,Percent of Total Billed Charges,36% of Total Billed Charges,29.07,36,,23.256,Percent of Total Billed Charges,36% Total Bille Charges,29.07,36,,23.256,Percent of Total Billed Charges,36% of Total Billed Charges,48.46,60,,38.768,Percent of Total Billed Charges,60% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.65,14.42,,9.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.57,75,,408.848,Percent of Total Billed Charges,75% of Total Billed Charges,40.38,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,40.38,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.38,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,40.38,50,,32.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.53,70,,45.224,Percent of Total Billed Charges,70% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14,,9.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.76,100,,511.056,Percent of Total Billed Charges,100% of Total Billed Charges,11.31,2803.51,
DAPTOMYCIN 350MG VIAL,53500039,CDM,250,RC,J0878,HCPCS,Outpatient,,,378,226.80,,0.05,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.56,360,,,Fee Schedule,360% of BCBS POS Rate,0.56,360,,,Fee schedule,360% of BCBS PPO Rate,0.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,226.8,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.5,75,,2.352,Percent of Total Billed Charges,75% of Total Billed Charges,0.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.03,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,70,,211.68,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378,100,,3.136,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,378,
AZITHROMYCIN 500MG ADDV INJ,53500040,CDM,250,RC,J0456,HCPCS,Outpatient,,,49,29.40,,2.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.15,360,,,Fee Schedule,360% of BCBS POS Rate,4.15,360,,,Fee schedule,360% of BCBS PPO Rate,4.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.75,75,,2.408,Percent of Total Billed Charges,75% of Total Billed Charges,2.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.07,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.3,70,,27.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,3.208,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,49,
D5W 50ml ADDV,53500041,CDM,258,RC,J7070,HCPCS,Outpatient,,,26.28,15.77,,3.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.16,360,,,Fee Schedule,360% of BCBS POS Rate,15.16,360,,,Fee schedule,360% of BCBS PPO Rate,15.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.77,60,,12.616,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.71,75,,2.344,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,70,,14.72,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.28,100,,3.12,Percent of Total Billed Charges,100% of Total Billed Charges,2.7,26.28,
D5W 250ml ADDV,53500042,CDM,258,RC,J7070,HCPCS,Outpatient,,,50.43,30.26,,3.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.16,360,,,Fee Schedule,360% of BCBS POS Rate,15.16,360,,,Fee schedule,360% of BCBS PPO Rate,15.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,239.04,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,298.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.7,50.43,
LINEZOLID 600MG/300ML IVPB,53500043,CDM,250,RC,J2020,HCPCS,Outpatient,,,190.38,114.23,,6.31,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,14.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,14.4,360,,,Fee Schedule,360% of BCBS POS Rate,14.4,360,,,Fee schedule,360% of BCBS PPO Rate,14.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,114.23,60,,91.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.79,75,,195.28,Percent of Total Billed Charges,75% of Total Billed Charges,2.74,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.74,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.74,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.74,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.27,70,,106.616,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.38,100,,244.104,Percent of Total Billed Charges,100% of Total Billed Charges,2.74,190.38,
VANCOMYCIN 2000mg/400ml IVPB,53500044,CDM,250,RC,J3370,HCPCS,Outpatient,,,243.84,146.30,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,146.3,60,,117.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.88,75,,332.728,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.69,70,,136.552,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.84,100,,415.912,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,243.84,
VANCOMYCIN 1750mg/350ml IVPB,53500045,CDM,250,RC,J3370,HCPCS,Outpatient,,,213.36,128.02,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.02,60,,102.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.02,75,,381.368,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.35,70,,119.48,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.36,100,,476.712,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,213.36,
VANCOMYCIN 1500mg/300ml IVPB,53500046,CDM,250,RC,J3370,HCPCS,Outpatient,,,182.88,109.73,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.73,60,,87.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.16,75,,154.368,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.02,70,,102.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.88,100,,192.96,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,182.88,
VANCOMYCIN 1250mg/250ml IVPB,53500047,CDM,250,RC,J3370,HCPCS,Outpatient,,,152.4,91.44,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,91.44,60,,73.152,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.3,75,,192,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.68,70,,85.344,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.4,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,152.4,
VANCOMYCIN 750MG ADDV INJ,53500048,CDM,250,RC,J3370,HCPCS,Outpatient,,,104.5,62.70,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.7,60,,50.16,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.38,75,,496.744,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.15,70,,58.52,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.5,100,,620.928,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,104.5,
VANCOMYCIN 1000MG ADDV INJ,53500049,CDM,250,RC,J3370,HCPCS,Outpatient,,,139.35,83.61,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.61,60,,66.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.51,75,,211.68,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.55,70,,78.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.35,100,,264.6,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,139.35,
VITAMIN D 1000 IU TAB,53500050,CDM,250,RC,,,Outpatient,,,0.52,0.31,,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.15,28,,0.12,Percent of Total Billed Charges,28% of Total Billed Charges,2803.51,32,,2242.808,Percent of Total Billed Charges,32% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% Total Bille Charges,0.19,36,,0.152,Percent of Total Billed Charges,36% of Total Billed Charges,0.31,60,,0.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14.42,,0.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,75,,188.16,Percent of Total Billed Charges,75% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,0.26,50,,0.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.36,70,,0.288,Percent of Total Billed Charges,70% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.07,14,,0.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.52,100,,235.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,2803.51,
AMP/SULBAC 1.5GM/NS 100ML MBP,53500051,CDM,250,RC,J0295,HCPCS,Outpatient,,,59.25,35.55,,2.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.14,360,,,Fee Schedule,360% of BCBS POS Rate,3.14,360,,,Fee schedule,360% of BCBS PPO Rate,3.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.55,60,,28.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.44,75,,192,Percent of Total Billed Charges,75% of Total Billed Charges,1.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.73,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.48,70,,33.184,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.25,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,59.25,
MICAFUNGIN 50 MG/NS 100ML MBP,53500052,CDM,250,RC,J2248,HCPCS,Outpatient,,,495.75,297.45,,0.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.87,360,,,Fee Schedule,360% of BCBS POS Rate,1.87,360,,,Fee schedule,360% of BCBS PPO Rate,1.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,297.45,60,,237.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.81,75,,290.568,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.03,70,,277.624,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,495.75,100,,363.208,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,495.75,
MICAFUNGIN 100MG/NS 100ML MBP,53500053,CDM,250,RC,J2248,HCPCS,Outpatient,,,916.5,549.90,,0.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.87,360,,,Fee Schedule,360% of BCBS POS Rate,1.87,360,,,Fee schedule,360% of BCBS PPO Rate,1.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,549.9,60,,439.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.38,75,,281.536,Percent of Total Billed Charges,75% of Total Billed Charges,0.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.55,70,,513.24,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,916.5,100,,351.92,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,916.5,
CEFTRIAXONE 2GM/NS 100ML ADDV,53500054,CDM,250,RC,J0696,HCPCS,Outpatient,,,124.38,74.63,,0.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.53,360,,,Fee Schedule,360% of BCBS POS Rate,2.53,360,,,Fee schedule,360% of BCBS PPO Rate,2.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.63,60,,59.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.29,75,,261.48,Percent of Total Billed Charges,75% of Total Billed Charges,0.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.41,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.41,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.07,70,,69.656,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.38,100,,326.848,Percent of Total Billed Charges,100% of Total Billed Charges,0.41,124.38,
FUROSEMIDE 100MG/NS 100ML MBP,53500055,CDM,250,RC,J1940,HCPCS,Outpatient,,,91.21,54.73,,0.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.45,360,,,Fee Schedule,360% of BCBS POS Rate,1.45,360,,,Fee schedule,360% of BCBS PPO Rate,1.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.73,60,,43.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.41,75,,177.976,Percent of Total Billed Charges,75% of Total Billed Charges,0.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.85,70,,51.08,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.21,100,,222.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.46,91.21,
PIPERACIL/TAZOBAC 4.5GM/NS 100ML MBP,53500056,CDM,250,RC,J2543,HCPCS,Outpatient,,,87.06,52.24,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.24,60,,41.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.3,75,,176.704,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.94,70,,48.752,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.06,100,,220.88,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,87.06,
PIPERACIL/TAZOBAC 2.25GM/NS 50ML MBP,53500057,CDM,250,RC,J2543,HCPCS,Outpatient,,,87.09,52.25,,1.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2.31,360,,,Fee Schedule,360% of BCBS POS Rate,2.31,360,,,Fee schedule,360% of BCBS PPO Rate,2.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.25,60,,41.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.32,75,,171.824,Percent of Total Billed Charges,75% of Total Billed Charges,1.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.96,70,,48.768,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.09,100,,214.784,Percent of Total Billed Charges,100% of Total Billed Charges,1.06,87.09,
AMP/SULBAC 3 GM/NS 100ML MBP,53500058,CDM,250,RC,J0295,HCPCS,Outpatient,,,87.45,52.47,,2.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.14,360,,,Fee Schedule,360% of BCBS POS Rate,3.14,360,,,Fee schedule,360% of BCBS PPO Rate,3.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.47,60,,41.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.59,75,,49.648,Percent of Total Billed Charges,75% of Total Billed Charges,1.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.73,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.73,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.22,70,,48.976,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.45,100,,62.064,Percent of Total Billed Charges,100% of Total Billed Charges,1.73,87.45,
ERTAPENEM 1 GM/NS 100ML MBP,53500059,CDM,250,RC,J1335,HCPCS,Outpatient,,,581.82,349.09,,24.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,33.72,360,,,Fee Schedule,360% of BCBS POS Rate,33.72,360,,,Fee schedule,360% of BCBS PPO Rate,33.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,349.09,60,,279.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,436.37,75,,217.472,Percent of Total Billed Charges,75% of Total Billed Charges,10.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.26,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,10.26,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.27,70,,325.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.82,100,,271.84,Percent of Total Billed Charges,100% of Total Billed Charges,10.26,581.82,
FOSPHENYTOIN INJ 100MG/2ML,53500063,CDM,250,RC,Q2009,HCPCS,Outpatient,,,119.42,71.65,,4.61,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,360,,,Fee Schedule,360% of BCBS POS Rate,3.28,360,,,Fee schedule,360% of BCBS PPO Rate,3.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.65,60,,57.32,Percent of Total Billed Charges,60% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2.88,90,,,Fee Schedule,90% of CMS OPPS Rate,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,4.16,130,,,Fee Schedule,130% of CMS OPPS Rate,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,17.22,14.42,,13.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,3.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3.29,103,,,Fee Schedule,103% of CMS OPPS Rate,89.57,75,,36.816,Percent of Total Billed Charges,75% of Total Billed Charges,59.71,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,59.71,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,59.71,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,59.71,50,,47.768,Percent of Total Billed Charges,50% of Total Billed Charges,4.8,150,,,Fee Schedule,150% of CMS OPPS Rate,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,83.59,70,,66.872,Percent of Total Billed Charges,70% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,16.72,14,,13.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.42,100,,46.016,Percent of Total Billed Charges,100% of Total Billed Charges,2.88,119.42,
FOSPHENYTOIN INJ 500MG/10ML,53500064,CDM,250,RC,Q2009,HCPCS,Outpatient,,,96.26,57.76,,4.61,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,360,,,Fee Schedule,360% of BCBS POS Rate,3.28,360,,,Fee schedule,360% of BCBS PPO Rate,3.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,57.76,60,,46.208,Percent of Total Billed Charges,60% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2.88,90,,,Fee Schedule,90% of CMS OPPS Rate,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,4.16,130,,,Fee Schedule,130% of CMS OPPS Rate,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.88,14.42,,11.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,3.29,103,,,Fee Schedule,103% of CMS OPPS Rate,3.29,103,,,Fee Schedule,103% of CMS OPPS Rate,72.2,75,,23.096,Percent of Total Billed Charges,75% of Total Billed Charges,48.13,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,48.13,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,48.13,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,48.13,50,,38.504,Percent of Total Billed Charges,50% of Total Billed Charges,4.8,150,,,Fee Schedule,150% of CMS OPPS Rate,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,67.38,70,,53.904,Percent of Total Billed Charges,70% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,13.48,14,,10.784,Percent of Total Billed Charges,14% of Total Billed Charges,3.2,100,,,Fee Schedule,100% of CMS OPPS Rate,96.26,100,,28.872,Percent of Total Billed Charges,100% of Total Billed Charges,2.88,96.26,
CYCLOSPRINE MODIFIED 25MG CAP,53500065,CDM,250,RC,J7515,HCPCS,Outpatient,,,8.76,5.26,,0.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,0.79,360,,,Fee Schedule,360% of BCBS POS Rate,0.79,360,,,Fee schedule,360% of BCBS PPO Rate,0.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.26,60,,4.208,Percent of Total Billed Charges,60% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14.42,,1.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.57,75,,21.136,Percent of Total Billed Charges,75% of Total Billed Charges,0.59,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.59,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.59,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.59,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.13,70,,4.904,Percent of Total Billed Charges,70% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,1.23,14,,0.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.76,100,,26.424,Percent of Total Billed Charges,100% of Total Billed Charges,0.59,8.76,
DEFEROXAMINE MESYLATE INJ 2GM,53500066,CDM,250,RC,,,Outpatient,,,137.52,82.51,,82.51,60,,66.008,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.51,28,,30.808,Percent of Total Billed Charges,28% of Total Billed Charges,2808.39,32,,2246.712,Percent of Total Billed Charges,32% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,49.51,36,,39.608,Percent of Total Billed Charges,36% of Total Billed Charges,49.51,36,,39.608,Percent of Total Billed Charges,36% Total Bille Charges,49.51,36,,39.608,Percent of Total Billed Charges,36% of Total Billed Charges,82.51,60,,66.008,Percent of Total Billed Charges,60% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.83,14.42,,15.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.14,75,,9.52,Percent of Total Billed Charges,75% of Total Billed Charges,68.76,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,68.76,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.76,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,68.76,50,,55.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.26,70,,77.008,Percent of Total Billed Charges,70% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,19.25,14,,15.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.52,100,,11.896,Percent of Total Billed Charges,100% of Total Billed Charges,19.25,2808.39,
CEFIDEROCOL 1GM INJ,53500067,CDM,250,RC,J3490,HCPCS,Outpatient,,,718.2,430.92,,430.92,60,,344.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.1,28,,160.88,Percent of Total Billed Charges,28% of Total Billed Charges,2824.64,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,258.55,36,,206.84,Percent of Total Billed Charges,36% of Total Billed Charges,258.55,36,,206.84,Percent of Total Billed Charges,36% Total Bille Charges,258.55,36,,206.84,Percent of Total Billed Charges,36% of Total Billed Charges,430.92,60,,344.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.65,75,,3.92,Percent of Total Billed Charges,75% of Total Billed Charges,359.1,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,359.1,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.1,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,359.1,50,,287.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,502.74,70,,402.192,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,718.2,100,,4.904,Percent of Total Billed Charges,100% of Total Billed Charges,201.1,2824.64,
RITUXIMAB INJ 100MG/10ML VIAL,53500068,CDM,250,RC,J9310,HCPCS,Outpatient,,,2760,1656.00,,1656,60,,1324.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,772.8,28,,618.24,Percent of Total Billed Charges,28% of Total Billed Charges,2824.64,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,993.6,36,,794.88,Percent of Total Billed Charges,36% of Total Billed Charges,993.6,36,,794.88,Percent of Total Billed Charges,36% Total Bille Charges,993.6,36,,794.88,Percent of Total Billed Charges,36% of Total Billed Charges,1656,60,,1324.8,Percent of Total Billed Charges,60% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,397.99,14.42,,318.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2070,75,,22.4,Percent of Total Billed Charges,75% of Total Billed Charges,1380,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,1380,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1380,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,1380,50,,1104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1932,70,,1545.6,Percent of Total Billed Charges,70% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,386.4,14,,309.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2760,100,,28,Percent of Total Billed Charges,100% of Total Billed Charges,386.4,2824.64,
VINCRISTINE SUL INJ 2MG/2ML,53500069,CDM,250,RC,J9370,HCPCS,Outpatient,,,184.12,110.47,,4.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.8,360,,,Fee Schedule,360% of BCBS POS Rate,3.8,360,,,Fee schedule,360% of BCBS PPO Rate,3.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,110.47,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.09,75,,16.736,Percent of Total Billed Charges,75% of Total Billed Charges,3.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,3.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.87,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,3.87,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.88,70,,103.104,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.12,100,,20.92,Percent of Total Billed Charges,100% of Total Billed Charges,3.8,184.12,
DOXORUBICIN INJ 20MG/10ML,53500070,CDM,250,RC,J9000,HCPCS,Outpatient,,,103.98,62.39,,3.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.49,360,,,Fee Schedule,360% of BCBS POS Rate,3.49,360,,,Fee schedule,360% of BCBS PPO Rate,3.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.39,60,,49.912,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.99,75,,27.264,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.79,70,,58.232,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.98,100,,34.08,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,103.98,
ALTEPLASE 50 MG VIAL,53500071,CDM,636,RC,J2997,HCPCS,Outpatient,,,21207.5,12724.50,,11752.68,110,,9402.144,Percent of Total Billed Charges,110% of Total Billed Charges,137.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,37.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,37.65,360,,,Fee Schedule,360% of BCBS POS Rate,37.65,360,,,Fee schedule,360% of BCBS PPO Rate,37.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,11664.13,55,,9331.304,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,82.32,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,118.91,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.21,103,,,Fee Schedule,103% of CMS OPPS Rate,94.21,103,,,Fee Schedule,103% of CMS OPPS Rate,15905.63,75,,273.16,Percent of Total Billed Charges,75% of Total Billed Charges,10673.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,10673.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10673.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,10673.8,50,,8539.04,Percent of Total Billed Charges,50% of Total Billed Charges,137.19,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14845.25,70,,11876.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21207.5,100,,364.216,Percent of Total Billed Charges,100% of Total Billed Charges,37.65,21207.5,
LIDOCAINE INJ 1% 30ML SDV,53500072,CDM,250,RC,J2003,HCPCS,Outpatient,,,93.06,55.84,,55.84,60,,44.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.84,60,,44.672,Percent of Total Billed Charges,60% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.42,14.42,,10.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.8,75,,248.904,Percent of Total Billed Charges,75% of Total Billed Charges,46.53,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,46.53,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.53,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,46.53,50,,37.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.14,70,,52.112,Percent of Total Billed Charges,70% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.06,100,,331.872,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,93.06,
TAMOXIFEN 20MG TAB,53500073,CDM,250,RC,J8999,HCPCS,Outpatient,,,2.34,1.40,,1.4,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.66,28,,0.528,Percent of Total Billed Charges,28% of Total Billed Charges,2824.64,32,,2259.712,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.84,36,,0.672,Percent of Total Billed Charges,36% of Total Billed Charges,0.84,36,,0.672,Percent of Total Billed Charges,36% Total Bille Charges,0.84,36,,0.672,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.76,75,,263.104,Percent of Total Billed Charges,75% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,1.17,50,,0.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.64,70,,1.312,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.34,100,,350.808,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,2824.64,
RECARBRIO 1.25GM INJ,53500075,CDM,250,RC,J3490,HCPCS,Outpatient,,,688.8,413.28,,413.28,60,,330.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.86,28,,154.288,Percent of Total Billed Charges,28% of Total Billed Charges,2.6,32,,2.08,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.97,36,,198.376,Percent of Total Billed Charges,36% of Total Billed Charges,247.97,36,,198.376,Percent of Total Billed Charges,36% Total Bille Charges,247.97,36,,198.376,Percent of Total Billed Charges,36% of Total Billed Charges,413.28,60,,330.624,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.6,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,344.4,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,344.4,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.4,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,344.4,50,,275.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,482.16,70,,385.728,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,688.8,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,2.6,688.8,
VANCOMYCIN HCL 125MG CAPSULE,53500076,CDM,250,RC,,,Outpatient,,,10,6.00,,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,28,,2.24,Percent of Total Billed Charges,28% of Total Billed Charges,2.61,32,,2.088,Percent of Total Billed Charges,32% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% of Total Billed Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% Total Bille Charges,3.6,36,,2.88,Percent of Total Billed Charges,36% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14.42,,1.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,75,,18.304,Percent of Total Billed Charges,75% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,100,,24.408,Percent of Total Billed Charges,100% of Total Billed Charges,1.4,10,
LEUPROLIDE 22.5MG SYRINGE,53500077,CDM,250,RC,J9218,HCPCS,Outpatient,,,2031.61,1218.97,,15.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,36.64,360,,,Fee Schedule,360% of BCBS POS Rate,36.64,360,,,Fee schedule,360% of BCBS PPO Rate,36.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,1218.97,60,,975.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.27,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.47,103,,,Fee Schedule,103% of CMS OPPS Rate,9.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1523.71,75,,16.776,Percent of Total Billed Charges,75% of Total Billed Charges,6.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,6.41,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,13.8,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.13,70,,1137.704,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2031.61,100,,22.368,Percent of Total Billed Charges,100% of Total Billed Charges,6.41,2031.61,
DOXORUBICIN INJ 50MG/25ML,53500078,CDM,250,RC,J9000,HCPCS,Outpatient,,,259.95,155.97,,3.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,3.49,360,,,Fee Schedule,360% of BCBS POS Rate,3.49,360,,,Fee schedule,360% of BCBS PPO Rate,3.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,155.97,60,,124.776,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.96,75,,16.552,Percent of Total Billed Charges,75% of Total Billed Charges,1.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.97,70,,145.576,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.95,100,,22.072,Percent of Total Billed Charges,100% of Total Billed Charges,1.97,259.95,
VANCOMYCIN HCL 500MG/10ML SOL,53500079,CDM,250,RC,J3370,HCPCS,Outpatient,,,37.2,22.32,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.32,60,,17.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.9,75,,12.568,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.04,70,,20.832,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.2,100,,16.752,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,37.2,
VANCOMYCIN HCL 250MG/5ML SOL,53500080,CDM,250,RC,J3370,HCPCS,Outpatient,,,18.6,11.16,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,11.16,60,,8.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.95,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.02,70,,10.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.6,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,18.6,
CALCIUM GLUCONATE 1000MG/100ML,53500081,CDM,250,RC,J0613,HCPCS,Outpatient,,,113.38,68.03,,68.03,60,,54.424,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,68.03,60,,54.424,Percent of Total Billed Charges,60% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.07,90,,,Fee Schedule,90% of CMS OPPS Rate,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.1,130,,,Fee Schedule,130% of CMS OPPS Rate,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,16.35,14.42,,13.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,0.08,103,,,Fee Schedule,103% of CMS OPPS Rate,0.08,103,,,Fee Schedule,103% of CMS OPPS Rate,85.04,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,0.12,150,,,Fee Schedule,150% of CMS OPPS Rate,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,79.37,70,,63.496,Percent of Total Billed Charges,70% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,15.87,14,,12.696,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,113.38,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,113.38,
CALCIUM GLUCONATE 2000MG/100ML,53500082,CDM,250,RC,J0613,HCPCS,Outpatient,,,176.76,106.06,,106.06,60,,84.848,Percent of Total Billed Charges,60% of Total Billed Charges,0.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.06,60,,84.848,Percent of Total Billed Charges,60% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.07,90,,,Fee Schedule,90% of CMS OPPS Rate,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.1,130,,,Fee Schedule,130% of CMS OPPS Rate,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,25.49,14.42,,20.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,0.08,103,,,Fee Schedule,103% of CMS OPPS Rate,0.08,103,,,Fee Schedule,103% of CMS OPPS Rate,132.57,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.06,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.06,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,0.12,150,,,Fee Schedule,150% of CMS OPPS Rate,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,123.73,70,,98.984,Percent of Total Billed Charges,70% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,24.75,14,,19.8,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,100,,,Fee Schedule,100% of CMS OPPS Rate,176.76,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.06,176.76,
TOCILIZUMAB 200MG/10ML INJ,53500083,CDM,636,RC,J3262,HCPCS,Outpatient,,,4832,2899.20,,2663.39,110,,2130.712,Percent of Total Billed Charges,110% of Total Billed Charges,8.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.17,360,,,Fee Schedule,360% of BCBS POS Rate,5.17,360,,,Fee schedule,360% of BCBS PPO Rate,5.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,2657.6,55,,2126.08,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.36,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7.74,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6.13,103,,,Fee Schedule,103% of CMS OPPS Rate,3624,75,,51.232,Percent of Total Billed Charges,75% of Total Billed Charges,2420.69,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,2420.69,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2420.69,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,2420.69,50,,1936.552,Percent of Total Billed Charges,50% of Total Billed Charges,8.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3382.4,70,,2705.92,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,4832,100,,68.304,Percent of Total Billed Charges,100% of Total Billed Charges,5.17,4832,
KETOROLAC 60MG/2ML INJ,53500084,CDM,250,RC,J1885,HCPCS,Outpatient,,,36.6,21.96,,0.55,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.18,360,,,Fee Schedule,360% of BCBS POS Rate,0.18,360,,,Fee schedule,360% of BCBS PPO Rate,0.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.96,60,,17.568,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.45,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.38,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.38,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.38,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.62,70,,20.496,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.6,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.18,36.6,
"MULTIVITAMINS W/IRON TAB, CHEWABLE",53500085,CDM,250,RC,,,Outpatient,,,0.16,0.10,,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.04,28,,0.032,Percent of Total Billed Charges,28% of Total Billed Charges,2.62,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.1,60,,0.08,Percent of Total Billed Charges,60% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14.42,,0.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.12,75,,30.256,Percent of Total Billed Charges,75% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,0.08,50,,0.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.11,70,,0.088,Percent of Total Billed Charges,70% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.02,14,,0.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,100,,40.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,2.62,
BUPIVACAINE 0.5% INJ 50ML,53500086,CDM,250,RC,S0020,HCPCS,Outpatient,,,13.28,7.97,,2.93,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.72,28,,2.976,Percent of Total Billed Charges,28% of Total Billed Charges,2.62,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.78,36,,3.824,Percent of Total Billed Charges,36% of Total Billed Charges,4.78,36,,3.824,Percent of Total Billed Charges,36% Total Bille Charges,4.78,36,,3.824,Percent of Total Billed Charges,36% of Total Billed Charges,7.97,60,,6.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.96,75,,7.6,Percent of Total Billed Charges,75% of Total Billed Charges,6.64,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,6.64,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.64,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,6.64,50,,5.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,70,,7.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.28,100,,10.128,Percent of Total Billed Charges,100% of Total Billed Charges,2.62,13.28,
THEOPHYLLINE ER 300MG CAP 24HR,53500087,CDM,250,RC,,,Outpatient,,,9.68,5.81,,5.81,60,,4.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.71,28,,2.168,Percent of Total Billed Charges,28% of Total Billed Charges,2.62,32,,2.096,Percent of Total Billed Charges,32% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% Total Bille Charges,3.48,36,,2.784,Percent of Total Billed Charges,36% of Total Billed Charges,5.81,60,,4.648,Percent of Total Billed Charges,60% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14.42,,1.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.26,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,4.84,50,,3.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,70,,5.424,Percent of Total Billed Charges,70% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,1.36,14,,1.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.68,100,,40,Percent of Total Billed Charges,100% of Total Billed Charges,1.36,9.68,
BARICITINIB 2MG TAB,53500088,CDM,250,RC,,,Outpatient,,,234.29,140.57,,140.57,60,,112.456,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.6,28,,52.48,Percent of Total Billed Charges,28% of Total Billed Charges,2.64,32,,2.112,Percent of Total Billed Charges,32% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,84.34,36,,67.472,Percent of Total Billed Charges,36% of Total Billed Charges,84.34,36,,67.472,Percent of Total Billed Charges,36% Total Bille Charges,84.34,36,,67.472,Percent of Total Billed Charges,36% of Total Billed Charges,140.57,60,,112.456,Percent of Total Billed Charges,60% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,33.78,14.42,,27.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.72,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,117.15,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,117.15,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.15,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,117.15,50,,93.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164,70,,131.2,Percent of Total Billed Charges,70% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,32.8,14,,26.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,234.29,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,2.64,234.29,
REMDESIVIR 200MG/250ML IVPB,53500089,CDM,636,RC,J0248,HCPCS,Outpatient,,,2080,1248.00,,1664,110,,1331.2,Percent of Total Billed Charges,110% of Total Billed Charges,9.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,360,,,Fee Schedule,360% of BCBS POS Rate,5.2,360,,,Fee schedule,360% of BCBS PPO Rate,5.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,1144,55,,915.2,Percent of Total Billed Charges,55% Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5.71,90,,,Fee Schedule,90% of CMS OPPS Rate,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,8.25,130,,,Fee Schedule,130% of CMS OPPS Rate,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,299.94,14.42,,239.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,6.54,103,,,Fee Schedule,103% of CMS OPPS Rate,6.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1560,75,,105.992,Percent of Total Billed Charges,75% of Total Billed Charges,1044.41,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,1044.41,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1044.41,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,1044.41,50,,835.528,Percent of Total Billed Charges,50% of Total Billed Charges,9.52,150,,,Fee Schedule,150% of CMS OPPS Rate,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1456,70,,1164.8,Percent of Total Billed Charges,70% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,291.2,14,,232.96,Percent of Total Billed Charges,14% of Total Billed Charges,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2080,100,,141.32,Percent of Total Billed Charges,100% of Total Billed Charges,5.2,2080,
CYCLOSPORINE INJ 50MG/ML 5ML,53500091,CDM,250,RC,J7516,HCPCS,Outpatient,,,70.39,42.23,,62.85,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,27.03,360,,,Fee Schedule,360% of BCBS POS Rate,27.03,360,,,Fee schedule,360% of BCBS PPO Rate,27.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.23,60,,33.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.79,75,,22.72,Percent of Total Billed Charges,75% of Total Billed Charges,35.2,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,35.2,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.2,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,35.2,50,,28.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.27,70,,39.416,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.39,100,,30.288,Percent of Total Billed Charges,100% of Total Billed Charges,27.03,70.39,
ONABOTULINUMTOXINA 200 UNIT VIAL,53500092,CDM,636,RC,J0585,HCPCS,Outpatient,,,6948,4168.80,,3827.65,110,,3062.12,Percent of Total Billed Charges,110% of Total Billed Charges,9.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.84,360,,,Fee Schedule,360% of BCBS POS Rate,5.84,360,,,Fee schedule,360% of BCBS PPO Rate,5.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,3821.4,55,,3057.12,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.33,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,5211,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,3479.05,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,3479.05,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3479.05,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,3479.05,50,,2783.24,Percent of Total Billed Charges,50% of Total Billed Charges,9.61,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4863.6,70,,3890.88,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6948,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,5.76,6948,
ONABOTULINUMTOXINA 100 UNIT VIAL,53500093,CDM,636,RC,J0585,HCPCS,Outpatient,,,3474,2084.40,,1916.95,110,,1533.56,Percent of Total Billed Charges,110% of Total Billed Charges,9.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.84,360,,,Fee Schedule,360% of BCBS POS Rate,5.84,360,,,Fee schedule,360% of BCBS PPO Rate,5.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,1910.7,55,,1528.56,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.76,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.33,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,6.6,103,,,Fee Schedule,103% of CMS OPPS Rate,2605.5,75,,144.12,Percent of Total Billed Charges,75% of Total Billed Charges,1742.05,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,1742.05,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.05,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,1742.05,50,,1393.64,Percent of Total Billed Charges,50% of Total Billed Charges,9.61,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2431.8,70,,1945.44,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3474,100,,192.16,Percent of Total Billed Charges,100% of Total Billed Charges,5.76,3474,
SODIUM ZIRCONIUM CYCLOSILICATE 10G PKT,53500094,CDM,250,RC,,,Outpatient,,,32.88,19.73,,19.73,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.21,28,,7.368,Percent of Total Billed Charges,28% of Total Billed Charges,2.66,32,,2.128,Percent of Total Billed Charges,32% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% of Total Billed Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% Total Bille Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% of Total Billed Charges,19.73,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.74,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.66,75,,94.176,Percent of Total Billed Charges,75% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.02,70,,18.416,Percent of Total Billed Charges,70% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.88,100,,125.568,Percent of Total Billed Charges,100% of Total Billed Charges,2.66,32.88,
SODIUM ZIRCONIUM CYCLOSILICATE 5G PKT,53500095,CDM,250,RC,,,Outpatient,,,32.88,19.73,,19.73,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.21,28,,7.368,Percent of Total Billed Charges,28% of Total Billed Charges,2.67,32,,2.136,Percent of Total Billed Charges,32% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% of Total Billed Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% Total Bille Charges,11.84,36,,9.472,Percent of Total Billed Charges,36% of Total Billed Charges,19.73,60,,15.784,Percent of Total Billed Charges,60% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.74,14.42,,3.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.66,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,16.44,50,,13.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.02,70,,18.416,Percent of Total Billed Charges,70% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,4.6,14,,3.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.88,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,2.67,32.88,
IOPAMIDOL 61% INTRATHECAL 15ML,53500096,CDM,250,RC,Q9967,HCPCS,Outpatient,,,398.66,239.20,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,239.2,60,,191.36,Percent of Total Billed Charges,60% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,57.49,14.42,,45.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299,75,,47.104,Percent of Total Billed Charges,75% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.06,70,,223.248,Percent of Total Billed Charges,70% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,55.81,14,,44.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,398.66,100,,62.8,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,398.66,
VANCOMYCIN 1000MG/200ML IVPB,53500097,CDM,250,RC,J3370,HCPCS,Outpatient,,,121.92,73.15,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.15,60,,58.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.44,75,,99.56,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.34,70,,68.272,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.92,100,,132.744,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,121.92,
VANCOMYCIN 750MG/150ML IVPB,53500098,CDM,250,RC,J3370,HCPCS,Outpatient,,,91.44,54.86,,2.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.42,360,,,Fee Schedule,360% of BCBS POS Rate,1.42,360,,,Fee schedule,360% of BCBS PPO Rate,1.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.86,60,,43.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.58,75,,65.088,Percent of Total Billed Charges,75% of Total Billed Charges,1.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.01,70,,51.208,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.44,100,,86.784,Percent of Total Billed Charges,100% of Total Billed Charges,1.42,91.44,
SOTROVIMAB 500MG INJ,53500099,CDM,250,RC,Q0247,HCPCS,Outpatient,,,,,,0.01,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.01,0.01,
KETAMINE 500MG/5ML INJ VIAL,53500100,CDM,250,RC,,,Outpatient,,,33.08,19.85,,19.85,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.26,28,,7.408,Percent of Total Billed Charges,28% of Total Billed Charges,2.69,32,,2.152,Percent of Total Billed Charges,32% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% of Total Billed Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% Total Bille Charges,11.91,36,,9.528,Percent of Total Billed Charges,36% of Total Billed Charges,19.85,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.77,14.42,,3.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.81,75,,4.064,Percent of Total Billed Charges,75% of Total Billed Charges,16.54,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,16.54,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.54,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,16.54,50,,13.232,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.16,70,,18.528,Percent of Total Billed Charges,70% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,4.63,14,,3.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.08,100,,5.416,Percent of Total Billed Charges,100% of Total Billed Charges,2.69,33.08,
PHENOBARBITAL 20MG/5ML ELIXIR BULK,53500101,CDM,250,RC,,,Outpatient,,,704.77,422.86,,422.86,60,,338.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.34,28,,157.872,Percent of Total Billed Charges,28% of Total Billed Charges,2.69,32,,2.152,Percent of Total Billed Charges,32% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,253.72,36,,202.976,Percent of Total Billed Charges,36% of Total Billed Charges,253.72,36,,202.976,Percent of Total Billed Charges,36% Total Bille Charges,253.72,36,,202.976,Percent of Total Billed Charges,36% of Total Billed Charges,422.86,60,,338.288,Percent of Total Billed Charges,60% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,101.63,14.42,,81.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.58,75,,1.584,Percent of Total Billed Charges,75% of Total Billed Charges,352.39,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,352.39,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,352.39,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,352.39,50,,281.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,493.34,70,,394.672,Percent of Total Billed Charges,70% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,98.67,14,,78.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,704.77,100,,2.112,Percent of Total Billed Charges,100% of Total Billed Charges,2.69,704.77,
LORAZEPAM 2MG/ML 30ML ORAL SOLUTION,53500102,CDM,250,RC,,,Outpatient,,,90,54.00,,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,28,,20.16,Percent of Total Billed Charges,28% of Total Billed Charges,2.71,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% Total Bille Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14.42,,10.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,75,,7.912,Percent of Total Billed Charges,75% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,70,,50.4,Percent of Total Billed Charges,70% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,100,,10.544,Percent of Total Billed Charges,100% of Total Billed Charges,2.71,90,
MORPHINE 20MG/ML 30ML ORAL SOLUTION,53500103,CDM,250,RC,,,Outpatient,,,90,54.00,,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,28,,20.16,Percent of Total Billed Charges,28% of Total Billed Charges,2.71,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% Total Bille Charges,32.4,36,,25.92,Percent of Total Billed Charges,36% of Total Billed Charges,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.98,14.42,,10.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,75,,20.664,Percent of Total Billed Charges,75% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63,70,,50.4,Percent of Total Billed Charges,70% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,14,,10.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,100,,27.552,Percent of Total Billed Charges,100% of Total Billed Charges,2.71,90,
METHADONE 5MG/5ML 500ML ORAL SOLN,53500104,CDM,250,RC,,,Outpatient,,,300,180.00,,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,28,,67.2,Percent of Total Billed Charges,28% of Total Billed Charges,2.71,32,,2.168,Percent of Total Billed Charges,32% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,108,36,,86.4,Percent of Total Billed Charges,36% Total Bille Charges,108,36,,86.4,Percent of Total Billed Charges,36% of Total Billed Charges,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225,75,,269.272,Percent of Total Billed Charges,75% of Total Billed Charges,150,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,150,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,359.032,Percent of Total Billed Charges,100% of Total Billed Charges,2.71,300,
VASOPRESSIN 20U/100ML PREMIX BTL,53500105,CDM,250,RC,,,Outpatient,,,734.81,440.89,,440.89,60,,352.712,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.75,28,,164.6,Percent of Total Billed Charges,28% of Total Billed Charges,2.72,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,264.53,36,,211.624,Percent of Total Billed Charges,36% of Total Billed Charges,264.53,36,,211.624,Percent of Total Billed Charges,36% Total Bille Charges,264.53,36,,211.624,Percent of Total Billed Charges,36% of Total Billed Charges,440.89,60,,352.712,Percent of Total Billed Charges,60% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,105.96,14.42,,84.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,551.11,75,,0.136,Percent of Total Billed Charges,75% of Total Billed Charges,367.41,50,,293.928,Percent of Total Billed Charges,50% of Total Billed Charges,367.41,50,,293.928,Percent of Total Billed Charges,50% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,367.41,50,,293.928,Percent of Total Billed Charges,50% of Total Billed Charges,367.41,50,,293.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,514.37,70,,411.496,Percent of Total Billed Charges,70% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,102.87,14,,82.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,734.81,100,,0.184,Percent of Total Billed Charges,100% of Total Billed Charges,2.72,734.81,
DILTIAZEM 5MG/ML INJ 25ML,53500106,CDM,250,RC,,,Outpatient,,,78.45,47.07,,47.07,60,,37.656,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.97,28,,17.576,Percent of Total Billed Charges,28% of Total Billed Charges,2.72,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,28.24,36,,22.592,Percent of Total Billed Charges,36% of Total Billed Charges,28.24,36,,22.592,Percent of Total Billed Charges,36% Total Bille Charges,28.24,36,,22.592,Percent of Total Billed Charges,36% of Total Billed Charges,47.07,60,,37.656,Percent of Total Billed Charges,60% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,11.31,14.42,,9.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.84,75,,0.112,Percent of Total Billed Charges,75% of Total Billed Charges,39.23,50,,31.384,Percent of Total Billed Charges,50% of Total Billed Charges,39.23,50,,31.384,Percent of Total Billed Charges,50% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.23,50,,31.384,Percent of Total Billed Charges,50% of Total Billed Charges,39.23,50,,31.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.92,70,,43.936,Percent of Total Billed Charges,70% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,14,,8.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.45,100,,0.144,Percent of Total Billed Charges,100% of Total Billed Charges,2.72,78.45,
PNEUMOCOCCAL 20-VAL CONJ. 0.5ML,53500107,CDM,636,RC,90677,HCPCS,Outpatient,,,854.33,512.60,,749.3,110,,599.44,Percent of Total Billed Charges,110% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,247.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,247.88,360,,,Fee Schedule,360% of BCBS POS Rate,247.88,360,,,Fee schedule,360% of BCBS PPO Rate,247.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,640.75,75,,25.752,Percent of Total Billed Charges,75% of Total Billed Charges,658.09,50,,526.472,Percent of Total Billed Charges,50% of Total Billed Charges,658.09,50,,526.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,658.09,50,,526.472,Percent of Total Billed Charges,50% of Total Billed Charges,658.09,50,,526.472,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,598.03,70,,478.424,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,854.33,100,,34.336,Percent of Total Billed Charges,100% of Total Billed Charges,247.88,854.33,
CIPRO/DEX OTIC 0.3/0.1% 7.5ML,53500108,CDM,250,RC,,,Outpatient,,,437.22,262.33,,262.33,60,,209.864,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.42,28,,97.936,Percent of Total Billed Charges,28% of Total Billed Charges,2.72,32,,2.176,Percent of Total Billed Charges,32% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,157.4,36,,125.92,Percent of Total Billed Charges,36% of Total Billed Charges,157.4,36,,125.92,Percent of Total Billed Charges,36% Total Bille Charges,157.4,36,,125.92,Percent of Total Billed Charges,36% of Total Billed Charges,262.33,60,,209.864,Percent of Total Billed Charges,60% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,63.05,14.42,,50.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.92,75,,4.472,Percent of Total Billed Charges,75% of Total Billed Charges,218.61,50,,174.888,Percent of Total Billed Charges,50% of Total Billed Charges,218.61,50,,174.888,Percent of Total Billed Charges,50% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,218.61,50,,174.888,Percent of Total Billed Charges,50% of Total Billed Charges,218.61,50,,174.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.05,70,,244.84,Percent of Total Billed Charges,70% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,61.21,14,,48.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,437.22,100,,5.96,Percent of Total Billed Charges,100% of Total Billed Charges,2.72,437.22,
BENZO/MENTHOL 5/1% THROAT SPRY. 177ML,53500109,CDM,250,RC,,,Outpatient,,,11.87,7.12,,7.12,60,,5.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.32,28,,2.656,Percent of Total Billed Charges,28% of Total Billed Charges,2.73,32,,2.184,Percent of Total Billed Charges,32% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,36,,3.416,Percent of Total Billed Charges,36% of Total Billed Charges,4.27,36,,3.416,Percent of Total Billed Charges,36% Total Bille Charges,4.27,36,,3.416,Percent of Total Billed Charges,36% of Total Billed Charges,7.12,60,,5.696,Percent of Total Billed Charges,60% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.71,14.42,,1.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,75,,87.248,Percent of Total Billed Charges,75% of Total Billed Charges,5.94,50,,4.752,Percent of Total Billed Charges,50% of Total Billed Charges,5.94,50,,4.752,Percent of Total Billed Charges,50% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.94,50,,4.752,Percent of Total Billed Charges,50% of Total Billed Charges,5.94,50,,4.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.31,70,,6.648,Percent of Total Billed Charges,70% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,1.66,14,,1.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.87,100,,116.328,Percent of Total Billed Charges,100% of Total Billed Charges,1.66,11.87,
CEFAZOLIN 2GM/50ML IVPB,53500110,CDM,250,RC,,,Outpatient,,,89.76,53.86,,53.86,60,,43.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.13,28,,20.104,Percent of Total Billed Charges,28% of Total Billed Charges,2.74,32,,2.192,Percent of Total Billed Charges,32% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,32.31,36,,25.848,Percent of Total Billed Charges,36% of Total Billed Charges,32.31,36,,25.848,Percent of Total Billed Charges,36% Total Bille Charges,32.31,36,,25.848,Percent of Total Billed Charges,36% of Total Billed Charges,53.86,60,,43.088,Percent of Total Billed Charges,60% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.94,14.42,,10.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.32,75,,125.928,Percent of Total Billed Charges,75% of Total Billed Charges,44.88,50,,35.904,Percent of Total Billed Charges,50% of Total Billed Charges,44.88,50,,35.904,Percent of Total Billed Charges,50% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.88,50,,35.904,Percent of Total Billed Charges,50% of Total Billed Charges,44.88,50,,35.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.83,70,,50.264,Percent of Total Billed Charges,70% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,12.57,14,,10.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.76,100,,167.904,Percent of Total Billed Charges,100% of Total Billed Charges,2.74,89.76,
CEFAZOLIN 2GM VIAL,53500111,CDM,250,RC,J0690,HCPCS,Outpatient,,,39.76,23.86,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,23.86,60,,19.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.82,75,,25.392,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.83,70,,22.264,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,100,,33.856,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,39.76,
LIDO/EPI INJ 1%/1:200K 10ML SDV,53500112,CDM,250,RC,,,Outpatient,,,10.29,6.17,,6.17,60,,4.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.88,28,,2.304,Percent of Total Billed Charges,28% of Total Billed Charges,2.77,32,,2.216,Percent of Total Billed Charges,32% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% of Total Billed Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% Total Bille Charges,3.7,36,,2.96,Percent of Total Billed Charges,36% of Total Billed Charges,6.17,60,,4.936,Percent of Total Billed Charges,60% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.48,14.42,,1.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.72,75,,5798.4,Percent of Total Billed Charges,75% of Total Billed Charges,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,5.15,50,,4.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,70,,5.76,Percent of Total Billed Charges,70% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14,,1.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.29,100,,7731.2,Percent of Total Billed Charges,100% of Total Billed Charges,1.44,10.29,
UREA 15GM PACKET,53500113,CDM,250,RC,,,Outpatient,,,5.25,3.15,,3.15,60,,2.52,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.47,28,,1.176,Percent of Total Billed Charges,28% of Total Billed Charges,2.78,32,,2.224,Percent of Total Billed Charges,32% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% Total Bille Charges,1.89,36,,1.512,Percent of Total Billed Charges,36% of Total Billed Charges,3.15,60,,2.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.76,14.42,,0.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,75,,42.664,Percent of Total Billed Charges,75% of Total Billed Charges,2.63,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,2.63,50,,2.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.68,70,,2.944,Percent of Total Billed Charges,70% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,0.74,14,,0.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.25,100,,56.88,Percent of Total Billed Charges,100% of Total Billed Charges,0.74,5.25,
BUPIVACAINE INJ 0.25% 50 ML MDV,53500114,CDM,250,RC,S0020,HCPCS,Outpatient,,,18.41,11.05,,2.93,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.15,28,,4.12,Percent of Total Billed Charges,28% of Total Billed Charges,2.78,32,,2.224,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.63,36,,5.304,Percent of Total Billed Charges,36% of Total Billed Charges,6.63,36,,5.304,Percent of Total Billed Charges,36% Total Bille Charges,6.63,36,,5.304,Percent of Total Billed Charges,36% of Total Billed Charges,11.05,60,,8.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.81,75,,279,Percent of Total Billed Charges,75% of Total Billed Charges,9.21,50,,7.368,Percent of Total Billed Charges,50% of Total Billed Charges,9.21,50,,7.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.21,50,,7.368,Percent of Total Billed Charges,50% of Total Billed Charges,9.21,50,,7.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.89,70,,10.312,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.41,100,,372,Percent of Total Billed Charges,100% of Total Billed Charges,2.78,18.41,
ARNICA MONTANA GEL 75G,53500115,CDM,250,RC,,,Outpatient,,,11.25,6.75,,6.75,60,,5.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,28,,2.52,Percent of Total Billed Charges,28% of Total Billed Charges,2.79,32,,2.232,Percent of Total Billed Charges,32% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,36,,3.24,Percent of Total Billed Charges,36% of Total Billed Charges,4.05,36,,3.24,Percent of Total Billed Charges,36% Total Bille Charges,4.05,36,,3.24,Percent of Total Billed Charges,36% of Total Billed Charges,6.75,60,,5.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.62,14.42,,1.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.44,75,,5.392,Percent of Total Billed Charges,75% of Total Billed Charges,5.63,50,,4.504,Percent of Total Billed Charges,50% of Total Billed Charges,5.63,50,,4.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.63,50,,4.504,Percent of Total Billed Charges,50% of Total Billed Charges,5.63,50,,4.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.88,70,,6.304,Percent of Total Billed Charges,70% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,1.58,14,,1.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.25,100,,7.192,Percent of Total Billed Charges,100% of Total Billed Charges,1.58,11.25,
ARGATROBAN INJ 100MG/ML 2.5ML SDV,53500116,CDM,250,RC,J0883,HCPCS,Outpatient,,,765.02,459.01,,3.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,1.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,459.01,60,,367.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.63,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,103,,,Fee Schedule,103% of CMS OPPS Rate,1.29,103,,,Fee Schedule,103% of CMS OPPS Rate,573.77,75,,88.416,Percent of Total Billed Charges,75% of Total Billed Charges,382.51,50,,306.008,Percent of Total Billed Charges,50% of Total Billed Charges,382.51,50,,306.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,382.51,50,,306.008,Percent of Total Billed Charges,50% of Total Billed Charges,382.51,50,,306.008,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,535.51,70,,428.408,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,765.02,100,,117.888,Percent of Total Billed Charges,100% of Total Billed Charges,1.12,765.02,
ARGATROBAN INJ 1MG/ML 50ML SDV,53500117,CDM,250,RC,J0883,HCPCS,Outpatient,,,297,178.20,,3.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,1.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,1.38,360,,,Fee Schedule,360% of BCBS POS Rate,1.38,360,,,Fee schedule,360% of BCBS PPO Rate,1.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,178.2,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1.63,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.29,103,,,Fee Schedule,103% of CMS OPPS Rate,1.29,103,,,Fee Schedule,103% of CMS OPPS Rate,222.75,75,,162.616,Percent of Total Billed Charges,75% of Total Billed Charges,148.5,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,148.5,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,148.5,50,,118.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.89,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,207.9,70,,166.32,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,100,,,Fee Schedule,100% of CMS OPPS Rate,297,100,,216.816,Percent of Total Billed Charges,100% of Total Billed Charges,1.12,297,
NITROGLYCERIN 0.4MG X 1 SL TAB,53500118,CDM,250,RC,,,Outpatient,,,4.06,2.44,,2.44,60,,1.952,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.14,28,,0.912,Percent of Total Billed Charges,28% of Total Billed Charges,2.8,32,,2.24,Percent of Total Billed Charges,32% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% Total Bille Charges,1.46,36,,1.168,Percent of Total Billed Charges,36% of Total Billed Charges,2.44,60,,1.952,Percent of Total Billed Charges,60% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.59,14.42,,0.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.05,75,,36.432,Percent of Total Billed Charges,75% of Total Billed Charges,2.03,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,2.03,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.03,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,2.03,50,,1.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.84,70,,2.272,Percent of Total Billed Charges,70% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14,,0.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.06,100,,48.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.57,4.06,
FONDAPARINUX 7.5MG/0.6ML INJ,53500119,CDM,250,RC,,,Outpatient,,,494.25,296.55,,296.55,60,,237.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.39,28,,110.712,Percent of Total Billed Charges,28% of Total Billed Charges,2.8,32,,2.24,Percent of Total Billed Charges,32% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,177.93,36,,142.344,Percent of Total Billed Charges,36% of Total Billed Charges,177.93,36,,142.344,Percent of Total Billed Charges,36% Total Bille Charges,177.93,36,,142.344,Percent of Total Billed Charges,36% of Total Billed Charges,296.55,60,,237.24,Percent of Total Billed Charges,60% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,71.27,14.42,,57.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.69,75,,87.984,Percent of Total Billed Charges,75% of Total Billed Charges,247.13,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,247.13,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,247.13,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,247.13,50,,197.704,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,345.98,70,,276.784,Percent of Total Billed Charges,70% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,69.2,14,,55.36,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,494.25,100,,117.312,Percent of Total Billed Charges,100% of Total Billed Charges,2.8,494.25,
KETAMINE INJ 100MG/10ML SYRINGE,53500120,CDM,250,RC,,,Outpatient,,,55.62,33.37,,33.37,60,,26.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.57,28,,12.456,Percent of Total Billed Charges,28% of Total Billed Charges,2.84,32,,2.272,Percent of Total Billed Charges,32% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,20.02,36,,16.016,Percent of Total Billed Charges,36% of Total Billed Charges,20.02,36,,16.016,Percent of Total Billed Charges,36% Total Bille Charges,20.02,36,,16.016,Percent of Total Billed Charges,36% of Total Billed Charges,33.37,60,,26.696,Percent of Total Billed Charges,60% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,8.02,14.42,,6.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.72,75,,72.864,Percent of Total Billed Charges,75% of Total Billed Charges,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,27.81,50,,22.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.93,70,,31.144,Percent of Total Billed Charges,70% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,7.79,14,,6.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.62,100,,97.152,Percent of Total Billed Charges,100% of Total Billed Charges,2.84,55.62,
CLOBAZAM SUSP. 2.5MG/ML 5ML,53500121,CDM,250,RC,,,Outpatient,,,5.73,3.44,,3.44,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,28,,1.28,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,2.06,36,,1.648,Percent of Total Billed Charges,36% of Total Billed Charges,2.06,36,,1.648,Percent of Total Billed Charges,36% Total Bille Charges,2.06,36,,1.648,Percent of Total Billed Charges,36% of Total Billed Charges,3.44,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.83,14.42,,0.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.3,75,,62.488,Percent of Total Billed Charges,75% of Total Billed Charges,2.87,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,2.87,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.87,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,2.87,50,,2.296,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,70,,3.208,Percent of Total Billed Charges,70% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,0.8,14,,0.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.73,100,,83.312,Percent of Total Billed Charges,100% of Total Billed Charges,0.8,25.6,
WATER IRR BOT 500ML,53500122,CDM,250,RC,,,Outpatient,,,32.99,19.79,,19.79,60,,15.832,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.24,28,,7.392,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% Total Bille Charges,11.88,36,,9.504,Percent of Total Billed Charges,36% of Total Billed Charges,19.79,60,,15.832,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.76,14.42,,3.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.74,75,,624,Percent of Total Billed Charges,75% of Total Billed Charges,16.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.09,70,,18.472,Percent of Total Billed Charges,70% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.99,100,,832,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,32.99,
SITAGLIPTIN 25MG TABLET,53500123,CDM,250,RC,,,Outpatient,,,28.64,17.18,,17.18,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.02,28,,6.416,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% Total Bille Charges,10.31,36,,8.248,Percent of Total Billed Charges,36% of Total Billed Charges,17.18,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.13,14.42,,3.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,75,,123.36,Percent of Total Billed Charges,75% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,14.32,50,,11.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.05,70,,16.04,Percent of Total Billed Charges,70% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,4.01,14,,3.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.64,100,,164.48,Percent of Total Billed Charges,100% of Total Billed Charges,4.01,28.64,
CLOBAZAM SUSP. 2.5MG/ML 120ML,53500124,CDM,250,RC,,,Outpatient,,,137.58,82.55,,82.55,60,,66.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.52,28,,30.816,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,49.53,36,,39.624,Percent of Total Billed Charges,36% of Total Billed Charges,49.53,36,,39.624,Percent of Total Billed Charges,36% Total Bille Charges,49.53,36,,39.624,Percent of Total Billed Charges,36% of Total Billed Charges,82.55,60,,66.04,Percent of Total Billed Charges,60% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.84,14.42,,15.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.19,75,,819.952,Percent of Total Billed Charges,75% of Total Billed Charges,68.79,50,,55.032,Percent of Total Billed Charges,50% of Total Billed Charges,68.79,50,,55.032,Percent of Total Billed Charges,50% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.79,50,,55.032,Percent of Total Billed Charges,50% of Total Billed Charges,68.79,50,,55.032,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.31,70,,77.048,Percent of Total Billed Charges,70% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,19.26,14,,15.408,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.58,100,,1093.264,Percent of Total Billed Charges,100% of Total Billed Charges,19.26,137.58,
WATER STERILE INJ 2000ML,53500125,CDM,250,RC,,,Outpatient,,,10.2,6.12,,6.12,60,,4.896,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,28,,2.288,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,3.67,36,,2.936,Percent of Total Billed Charges,36% of Total Billed Charges,3.67,36,,2.936,Percent of Total Billed Charges,36% Total Bille Charges,3.67,36,,2.936,Percent of Total Billed Charges,36% of Total Billed Charges,6.12,60,,4.896,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.47,14.42,,1.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.65,75,,705.696,Percent of Total Billed Charges,75% of Total Billed Charges,5.1,50,,4.08,Percent of Total Billed Charges,50% of Total Billed Charges,5.1,50,,4.08,Percent of Total Billed Charges,50% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,50,,4.08,Percent of Total Billed Charges,50% of Total Billed Charges,5.1,50,,4.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,70,,5.712,Percent of Total Billed Charges,70% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,1.43,14,,1.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,100,,940.928,Percent of Total Billed Charges,100% of Total Billed Charges,1.43,25.6,
ABACAVIR/LAMIVUDINE 600/300MG TAB,53500126,CDM,250,RC,,,Outpatient,,,45.5,27.30,,27.3,60,,21.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.74,28,,10.192,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,16.38,36,,13.104,Percent of Total Billed Charges,36% of Total Billed Charges,16.38,36,,13.104,Percent of Total Billed Charges,36% Total Bille Charges,16.38,36,,13.104,Percent of Total Billed Charges,36% of Total Billed Charges,27.3,60,,21.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14.42,,5.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.13,75,,77.728,Percent of Total Billed Charges,75% of Total Billed Charges,22.75,50,,18.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,50,,18.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.75,50,,18.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,50,,18.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.85,70,,25.48,Percent of Total Billed Charges,70% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,6.37,14,,5.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.5,100,,103.632,Percent of Total Billed Charges,100% of Total Billed Charges,6.37,45.5,
PERFLUTREN PROT-A MICROSPHR. 3ML INJ,53500127,CDM,255,RC,Q9956,HCPCS,Outpatient,,,210.6,126.36,,31.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,46.8,360,,,Fee Schedule,360% of BCBS POS Rate,46.8,360,,,Fee schedule,360% of BCBS PPO Rate,46.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,126.36,60,,101.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.48,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,26.21,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.21,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.21,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,26.21,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.42,70,,117.936,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.6,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,26.21,210.6,
IOPAMIDOL 61% 30ML,53500128,CDM,255,RC,Q9967,HCPCS,Outpatient,,,162.25,97.35,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,97.35,60,,77.88,Percent of Total Billed Charges,60% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,23.4,14.42,,18.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.8,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.58,70,,90.864,Percent of Total Billed Charges,70% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,22.72,14,,18.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,162.25,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,162.25,
CEFAZOLIN 3GM/100ML IVPB,53500129,CDM,250,RC,J0690,HCPCS,Outpatient,,,62.36,37.42,,0.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.38,360,,,Fee Schedule,360% of BCBS POS Rate,0.38,360,,,Fee schedule,360% of BCBS PPO Rate,0.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.42,60,,29.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.77,75,,100.32,Percent of Total Billed Charges,75% of Total Billed Charges,0.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.61,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.61,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.65,70,,34.92,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.36,100,,133.76,Percent of Total Billed Charges,100% of Total Billed Charges,0.38,62.36,
MORPHINE INJ 200MG/20ML VIAL,53500130,CDM,250,RC,J2274,HCPCS,Outpatient,,,314.84,188.90,,14.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,4.66,360,,,Fee Schedule,360% of BCBS POS Rate,4.66,360,,,Fee schedule,360% of BCBS PPO Rate,4.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,188.9,60,,151.12,Percent of Total Billed Charges,60% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,14.42,,36.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.13,75,,90.256,Percent of Total Billed Charges,75% of Total Billed Charges,13.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.36,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,13.36,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,220.39,70,,176.312,Percent of Total Billed Charges,70% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,44.08,14,,35.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.84,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.66,314.84,
ARTIFICIAL TEARS SOL 0.9ML,53500131,CDM,250,RC,,,Outpatient,,,3.75,2.25,,2.25,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.05,28,,0.84,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% of Total Billed Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% Total Bille Charges,1.35,36,,1.08,Percent of Total Billed Charges,36% of Total Billed Charges,2.25,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.54,14.42,,0.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.81,75,,90.256,Percent of Total Billed Charges,75% of Total Billed Charges,1.88,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.88,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.88,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,1.88,50,,1.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.63,70,,2.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,0.53,14,,0.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.75,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.53,25.6,
PHENOBARBITAL 32.4MG TABLET,53500132,CDM,250,RC,,,Outpatient,,,4.55,2.73,,2.73,60,,2.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.27,28,,1.016,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% of Total Billed Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% Total Bille Charges,1.64,36,,1.312,Percent of Total Billed Charges,36% of Total Billed Charges,2.73,60,,2.184,Percent of Total Billed Charges,60% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.66,14.42,,0.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.41,75,,226.8,Percent of Total Billed Charges,75% of Total Billed Charges,2.28,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.28,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,2.28,50,,1.824,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.19,70,,2.552,Percent of Total Billed Charges,70% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,0.64,14,,0.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.55,100,,302.4,Percent of Total Billed Charges,100% of Total Billed Charges,0.64,25.6,
PROTHROMBIN CC (BALFAXAR) 1 IU,53500133,CDM,636,RC,J7165,HCPCS,Outpatient,,,9.11,5.47,,5.01,110,,4.008,Percent of Total Billed Charges,110% of Total Billed Charges,3,150,,,Fee Schedule ,150% of CMS OPPS Rate,2,100,,,Fee Schedule,100% of CMS OPPS Rate,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,3.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,3.18,360,,,Fee Schedule,360% of BCBS POS Rate,3.18,360,,,Fee schedule,360% of BCBS PPO Rate,3.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,2,100,,,Fee Schedule,100% of CMS OPPS Rate,2,100,,,Fee Schedule,100% of CMS OPPS Rate,2,100,,,Fee Schedule,100% of CMS OPPS Rate,1.8,90,,,Fee Schedule,90% of CMS OPPS Rate,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,2.6,130,,,Fee Schedule,130% of CMS OPPS Rate,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.31,14.42,,1.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,2.06,103,,,Fee Schedule,103% of CMS OPPS Rate,2.06,103,,,Fee Schedule,103% of CMS OPPS Rate,6.83,75,,232.528,Percent of Total Billed Charges,75% of Total Billed Charges,4.56,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,4.56,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,4.56,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,4.56,50,,3.648,Percent of Total Billed Charges,50% of Total Billed Charges,3,150,,,Fee Schedule,150% of CMS OPPS Rate,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,70,,5.104,Percent of Total Billed Charges,70% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,1.28,14,,1.024,Percent of Total Billed Charges,14% of Total Billed Charges,2,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,310.032,Percent of Total Billed Charges,100% of Total Billed Charges,1.28,9.11,
CALCIUM GLUCONATE 2.5% GEL 25GM,53500134,CDM,250,RC,,,Outpatient,,,48,28.80,,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.44,28,,10.752,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% of Total Billed Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% Total Bille Charges,17.28,36,,13.824,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.92,14.42,,5.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,75,,104.856,Percent of Total Billed Charges,75% of Total Billed Charges,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.6,70,,26.88,Percent of Total Billed Charges,70% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,6.72,14,,5.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48,100,,139.808,Percent of Total Billed Charges,100% of Total Billed Charges,6.72,48,
CLINIMIX 4.25%/D5W 1000ML,53500135,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,25.6,32,,20.48,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,78.6,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,104.8,Percent of Total Billed Charges,100% of Total Billed Charges,25.6,550,
INSULIN REGULAR HUM 100UNIT/NS 100ML,53500136,CDM,250,RC,J1815,HCPCS,Outpatient,,,50.78,30.47,,0.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.47,60,,24.376,Percent of Total Billed Charges,60% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.32,14.42,,5.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.09,75,,64.696,Percent of Total Billed Charges,75% of Total Billed Charges,25.39,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,25.39,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.39,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,25.39,50,,20.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.55,70,,28.44,Percent of Total Billed Charges,70% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,7.11,14,,5.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.78,100,,86.256,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,50.78,
INSULIN HUM R 100 UNIT/ML 10ML,53500137,CDM,250,RC,J1817,HCPCS,Outpatient,,,267.72,160.63,,11.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,4.75,360,,,Fee Schedule,360% of BCBS POS Rate,4.75,360,,,Fee schedule,360% of BCBS PPO Rate,4.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.63,60,,128.504,Percent of Total Billed Charges,60% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,14.42,,30.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.79,75,,34.648,Percent of Total Billed Charges,75% of Total Billed Charges,6.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.98,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,6.98,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.4,70,,149.92,Percent of Total Billed Charges,70% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,37.48,14,,29.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.72,100,,46.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.75,267.72,
NALMEFENE HCL 2MG/2ML INJ,53500138,CDM,250,RC,,,Outpatient,,,45.45,27.27,,27.27,60,,21.816,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.73,28,,10.184,Percent of Total Billed Charges,28% of Total Billed Charges,25.67,32,,20.536,Percent of Total Billed Charges,32% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,16.36,36,,13.088,Percent of Total Billed Charges,36% of Total Billed Charges,16.36,36,,13.088,Percent of Total Billed Charges,36% Total Bille Charges,16.36,36,,13.088,Percent of Total Billed Charges,36% of Total Billed Charges,27.27,60,,21.816,Percent of Total Billed Charges,60% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.55,14.42,,5.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.09,75,,129.16,Percent of Total Billed Charges,75% of Total Billed Charges,22.73,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,22.73,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.73,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,22.73,50,,18.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.82,70,,25.456,Percent of Total Billed Charges,70% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,6.36,14,,5.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.45,100,,172.208,Percent of Total Billed Charges,100% of Total Billed Charges,6.36,45.45,
BRIVARACETAM 50MG TAB,53500139,CDM,250,RC,,,Outpatient,,,35.67,21.40,,21.4,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.99,28,,7.992,Percent of Total Billed Charges,28% of Total Billed Charges,25.67,32,,20.536,Percent of Total Billed Charges,32% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% of Total Billed Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% Total Bille Charges,12.84,36,,10.272,Percent of Total Billed Charges,36% of Total Billed Charges,21.4,60,,17.12,Percent of Total Billed Charges,60% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,5.14,14.42,,4.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.75,75,,774.936,Percent of Total Billed Charges,75% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,17.84,50,,14.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,70,,19.976,Percent of Total Billed Charges,70% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,4.99,14,,3.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.67,100,,1033.248,Percent of Total Billed Charges,100% of Total Billed Charges,4.99,35.67,
DESFLURANE 240ML,53530101,CDM,250,RC,,,Outpatient,,,720.99,432.59,,432.59,60,,346.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,201.88,28,,161.504,Percent of Total Billed Charges,28% of Total Billed Charges,25.71,32,,20.568,Percent of Total Billed Charges,32% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,259.56,36,,207.648,Percent of Total Billed Charges,36% of Total Billed Charges,259.56,36,,207.648,Percent of Total Billed Charges,36% Total Bille Charges,259.56,36,,207.648,Percent of Total Billed Charges,36% of Total Billed Charges,432.59,60,,346.072,Percent of Total Billed Charges,60% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,103.97,14.42,,83.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.74,75,,572.4,Percent of Total Billed Charges,75% of Total Billed Charges,360.5,50,,288.4,Percent of Total Billed Charges,50% of Total Billed Charges,360.5,50,,288.4,Percent of Total Billed Charges,50% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,360.5,50,,288.4,Percent of Total Billed Charges,50% of Total Billed Charges,360.5,50,,288.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,504.69,70,,403.752,Percent of Total Billed Charges,70% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,100.94,14,,80.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,720.99,100,,763.2,Percent of Total Billed Charges,100% of Total Billed Charges,25.71,720.99,
DIATRIZOATE MEG/SOD SOLN 30ML,53554713,CDM,255,RC,,,Outpatient,,,123.75,74.25,,74.25,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,28,,27.72,Percent of Total Billed Charges,28% of Total Billed Charges,25.77,32,,20.616,Percent of Total Billed Charges,32% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% of Total Billed Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% Total Bille Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% of Total Billed Charges,74.25,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.84,14.42,,14.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99,80,,118.688,Percent of Total Billed Charges,80% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.63,70,,69.304,Percent of Total Billed Charges,70% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.75,100,,158.248,Percent of Total Billed Charges,100% of Total Billed Charges,17.33,123.75,
DIATRIZOATE MEG&SOD SOL 30ML,53554715,CDM,255,RC,,,Outpatient,,,123.75,74.25,,74.25,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.65,28,,27.72,Percent of Total Billed Charges,28% of Total Billed Charges,25.79,32,,20.632,Percent of Total Billed Charges,32% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% of Total Billed Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% Total Bille Charges,44.55,36,,35.64,Percent of Total Billed Charges,36% of Total Billed Charges,74.25,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.84,14.42,,14.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99,80,,141.624,Percent of Total Billed Charges,80% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,61.88,50,,49.504,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.63,70,,69.304,Percent of Total Billed Charges,70% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,17.33,14,,13.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.75,100,,188.832,Percent of Total Billed Charges,100% of Total Billed Charges,17.33,123.75,
GADOXETATE 0.25MMOL/ML VL 10ML,53554812,CDM,255,RC,A9581,HCPCS,Outpatient,,,638.82,383.29,,14.89,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,16.45,360,,,Fee Schedule,360% of BCBS POS Rate,16.45,360,,,Fee schedule,360% of BCBS PPO Rate,16.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,383.29,60,,306.632,Percent of Total Billed Charges,60% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,92.12,14.42,,73.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,511.06,80,,141.624,Percent of Total Billed Charges,80% of Total Billed Charges,11.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.77,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,11.77,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,447.17,70,,357.736,Percent of Total Billed Charges,70% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,89.43,14,,71.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,638.82,100,,188.832,Percent of Total Billed Charges,100% of Total Billed Charges,11.77,638.82,
SEVOFLURANE 1ML,53554813,CDM,250,RC,,,Outpatient,,,3.92,2.35,,2.35,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.1,28,,0.88,Percent of Total Billed Charges,28% of Total Billed Charges,25.79,32,,20.632,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% Total Bille Charges,1.41,36,,1.128,Percent of Total Billed Charges,36% of Total Billed Charges,2.35,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.57,14.42,,0.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.94,75,,118.688,Percent of Total Billed Charges,75% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,1.96,50,,1.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.74,70,,2.192,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.92,100,,158.248,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,25.79,
DESFLURANE 1ML,53554814,CDM,250,RC,,,Outpatient,,,4.01,2.41,,2.41,60,,1.928,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.12,28,,0.896,Percent of Total Billed Charges,28% of Total Billed Charges,25.84,32,,20.672,Percent of Total Billed Charges,32% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% Total Bille Charges,1.44,36,,1.152,Percent of Total Billed Charges,36% of Total Billed Charges,2.41,60,,1.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.58,14.42,,0.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.01,75,,90.256,Percent of Total Billed Charges,75% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,2.01,50,,1.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.81,70,,2.248,Percent of Total Billed Charges,70% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14,,0.448,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.01,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.56,25.84,
ISOFLURANE 1ML,53554816,CDM,250,RC,,,Outpatient,,,3.9,2.34,,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.09,28,,0.872,Percent of Total Billed Charges,28% of Total Billed Charges,256.52,32,,205.216,Percent of Total Billed Charges,32% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% Total Bille Charges,1.4,36,,1.12,Percent of Total Billed Charges,36% of Total Billed Charges,2.34,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.56,14.42,,0.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,75,,44.744,Percent of Total Billed Charges,75% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,50,,1.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.73,70,,2.184,Percent of Total Billed Charges,70% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,0.55,14,,0.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.9,100,,59.656,Percent of Total Billed Charges,100% of Total Billed Charges,0.55,256.52,
GADOBUTROL 10 MMOL/10ML VL,53554820,CDM,255,RC,A9585,HCPCS,Outpatient,,,373.5,224.10,,0.35,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,224.1,60,,179.28,Percent of Total Billed Charges,60% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,53.86,14.42,,43.088,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.8,80,,61.264,Percent of Total Billed Charges,80% of Total Billed Charges,0.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.27,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.45,70,,209.16,Percent of Total Billed Charges,70% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,52.29,14,,41.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,373.5,100,,81.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,373.5,
GADOBUTROL 7.5MMOL 7.5ML VL,53554838,CDM,255,RC,A9585,HCPCS,Outpatient,,,305.13,183.08,,0.35,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,183.08,60,,146.464,Percent of Total Billed Charges,60% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,44,14.42,,35.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.1,80,,90.256,Percent of Total Billed Charges,80% of Total Billed Charges,0.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.27,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.27,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,213.59,70,,170.872,Percent of Total Billed Charges,70% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,42.72,14,,34.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,305.13,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.27,305.13,
IOPAMIDOL 76% 125ML,53573420,CDM,255,RC,Q9967,HCPCS,Outpatient,,,519.89,311.93,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,311.93,60,,249.544,Percent of Total Billed Charges,60% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,74.97,14.42,,59.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.91,80,,141.144,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,363.92,70,,291.136,Percent of Total Billed Charges,70% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,72.78,14,,58.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,519.89,100,,188.192,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,519.89,
IOHEXOL 300MG/ML 150ML,53582030,CDM,255,RC,Q9967,HCPCS,Outpatient,,,595.89,357.53,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,357.53,60,,286.024,Percent of Total Billed Charges,60% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,85.93,14.42,,68.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476.71,80,,651.432,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.12,70,,333.696,Percent of Total Billed Charges,70% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,83.42,14,,66.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,595.89,100,,868.576,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,595.89,
IOHEXOL 300MG/ML VL 10ML,53582040,CDM,255,RC,Q9967,HCPCS,Outpatient,,,241.2,144.72,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,144.72,60,,115.776,Percent of Total Billed Charges,60% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,34.78,14.42,,27.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.96,80,,1244.248,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.84,70,,135.072,Percent of Total Billed Charges,70% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,33.77,14,,27.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.2,100,,1659,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,241.2,
IODIXANOL 320MG/ML 50ML,53582041,CDM,255,RC,Q9967,HCPCS,Outpatient,,,300,180.00,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240,80,,1026.272,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,1368.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,300,
IOPAMIDOL 76% 200ML,53582128,CDM,255,RC,Q9967,HCPCS,Outpatient,,,776.16,465.70,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,465.7,60,,372.56,Percent of Total Billed Charges,60% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,111.92,14.42,,89.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,620.93,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,543.31,70,,434.648,Percent of Total Billed Charges,70% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,108.66,14,,86.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,776.16,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,776.16,
IOPAMIDOL 76% 75ML,53582144,CDM,255,RC,Q9967,HCPCS,Outpatient,,,330.75,198.45,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,198.45,60,,158.76,Percent of Total Billed Charges,60% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,47.69,14.42,,38.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,264.6,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,231.53,70,,185.224,Percent of Total Billed Charges,70% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,46.31,14,,37.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330.75,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,330.75,
IOPAMIDOL 76% 50ML,53582145,CDM,255,RC,Q9967,HCPCS,Outpatient,,,294,176.40,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,176.4,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,42.39,14.42,,33.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.2,80,,562.912,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,205.8,70,,164.64,Percent of Total Billed Charges,70% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,41.16,14,,32.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294,100,,750.544,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,294,
IOPAMIDOL 41% INTRATHECAL 10ML,53582151,CDM,255,RC,Q9966,HCPCS,Outpatient,,,300,180.00,,0.35,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,360,,,Fee Schedule,360% of BCBS POS Rate,0.28,360,,,Fee schedule,360% of BCBS PPO Rate,0.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,43.26,14.42,,34.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240,80,,127,Percent of Total Billed Charges,80% of Total Billed Charges,0.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,70,,168,Percent of Total Billed Charges,70% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,42,14,,33.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,100,,169.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,300,
IOHEXOL 350 MG/ML 100 ML,53582169,CDM,255,RC,Q9967,HCPCS,Outpatient,,,454.01,272.41,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,272.41,60,,217.928,Percent of Total Billed Charges,60% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,65.47,14.42,,52.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.21,80,,127,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,317.81,70,,254.248,Percent of Total Billed Charges,70% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,63.56,14,,50.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,454.01,100,,169.336,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,454.01,
IOPAMIDOL 76% 100ML,53582185,CDM,255,RC,Q9967,HCPCS,Outpatient,,,439.9,263.94,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,263.94,60,,211.152,Percent of Total Billed Charges,60% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,63.43,14.42,,50.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.92,80,,160.416,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.93,70,,246.344,Percent of Total Billed Charges,70% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,61.59,14,,49.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,439.9,100,,213.888,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,439.9,
IOHEXOL 300 MG/ML 100 ML,53582193,CDM,255,RC,Q9967,HCPCS,Outpatient,,,408.56,245.14,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,245.14,60,,196.112,Percent of Total Billed Charges,60% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,58.91,14.42,,47.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.85,80,,268.104,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.99,70,,228.792,Percent of Total Billed Charges,70% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,57.2,14,,45.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,408.56,100,,357.472,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,408.56,
IOHEXOL 300 MG/ML 50 ML,53582201,CDM,255,RC,Q9967,HCPCS,Outpatient,,,278.09,166.85,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,166.85,60,,133.48,Percent of Total Billed Charges,60% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,40.1,14.42,,32.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.47,80,,507.952,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,194.66,70,,155.728,Percent of Total Billed Charges,70% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,38.93,14,,31.144,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,278.09,100,,677.264,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,278.09,
IOHEXOL 240 MG/ML 20 ML,53582219,CDM,255,RC,Q9966,HCPCS,Outpatient,,,276.1,165.66,,0.35,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,0.28,360,,,Fee Schedule,360% of BCBS POS Rate,0.28,360,,,Fee schedule,360% of BCBS PPO Rate,0.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.66,60,,132.528,Percent of Total Billed Charges,60% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,39.81,14.42,,31.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.88,80,,522.904,Percent of Total Billed Charges,80% of Total Billed Charges,0.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.4,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.27,70,,154.616,Percent of Total Billed Charges,70% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14,,30.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.1,100,,697.2,Percent of Total Billed Charges,100% of Total Billed Charges,0.28,276.1,
IOHEXOL 180 MG/ML 20 ML,53582227,CDM,255,RC,Q9965,HCPCS,Outpatient,,,268.48,161.09,,0.82,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,0.67,360,,,Fee Schedule,360% of BCBS POS Rate,0.67,360,,,Fee schedule,360% of BCBS PPO Rate,0.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,161.09,60,,128.872,Percent of Total Billed Charges,60% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,38.71,14.42,,30.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.78,80,,90.256,Percent of Total Billed Charges,80% of Total Billed Charges,1.23,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1.23,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.23,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,1.23,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.94,70,,150.352,Percent of Total Billed Charges,70% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,37.59,14,,30.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268.48,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.67,268.48,
IOHEXOL 300 MG/ML 30 ML,53582235,CDM,255,RC,Q9967,HCPCS,Outpatient,,,77.58,46.55,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.55,60,,37.24,Percent of Total Billed Charges,60% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,11.19,14.42,,8.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.06,80,,90.256,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.31,70,,43.448,Percent of Total Billed Charges,70% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,10.86,14,,8.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.58,100,,120.344,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,77.58,
IOHEXOL 350MG/ML 75ML INJ,53582280,CDM,255,RC,Q9967,HCPCS,Outpatient,,,339.8,203.88,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,203.88,60,,163.104,Percent of Total Billed Charges,60% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,49,14.42,,39.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.84,80,,80.312,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,237.86,70,,190.288,Percent of Total Billed Charges,70% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,47.57,14,,38.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,339.8,100,,107.08,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,339.8,
IOPAMIDOL 61% 50 ML VIAL,53582284,CDM,255,RC,Q9967,HCPCS,Outpatient,,,270.42,162.25,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,162.25,60,,129.8,Percent of Total Billed Charges,60% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,38.99,14.42,,31.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.34,80,,307.888,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.29,70,,151.432,Percent of Total Billed Charges,70% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,37.86,14,,30.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.42,100,,410.512,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,270.42,
IOPAMIDOL 61% 100ML,53582292,CDM,255,RC,Q9967,HCPCS,Outpatient,,,396.37,237.82,,0.12,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,0.32,360,,,Fee Schedule,360% of BCBS POS Rate,0.32,360,,,Fee schedule,360% of BCBS PPO Rate,0.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,237.82,60,,190.256,Percent of Total Billed Charges,60% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,57.16,14.42,,45.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,317.1,80,,487.832,Percent of Total Billed Charges,80% of Total Billed Charges,0.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.13,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,277.46,70,,221.968,Percent of Total Billed Charges,70% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,55.49,14,,44.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,396.37,100,,650.44,Percent of Total Billed Charges,100% of Total Billed Charges,0.12,396.37,
BARIUM 2% READICAT BERRY 450ML,53582714,CDM,255,RC,,,Outpatient,,,24.23,14.54,,14.54,60,,11.632,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.78,28,,5.424,Percent of Total Billed Charges,28% of Total Billed Charges,256.64,32,,205.312,Percent of Total Billed Charges,32% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% Total Bille Charges,8.72,36,,6.976,Percent of Total Billed Charges,36% of Total Billed Charges,14.54,60,,11.632,Percent of Total Billed Charges,60% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.49,14.42,,2.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,80,,143.552,Percent of Total Billed Charges,80% of Total Billed Charges,12.12,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,12.12,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.12,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,12.12,50,,9.696,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.96,70,,13.568,Percent of Total Billed Charges,70% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,3.39,14,,2.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.23,100,,191.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.39,256.64,
BARIUM 40% THIN HONEY 120ML,53582722,CDM,255,RC,,,Outpatient,,,57.52,34.51,,34.51,60,,27.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.11,28,,12.888,Percent of Total Billed Charges,28% of Total Billed Charges,256.64,32,,205.312,Percent of Total Billed Charges,32% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,36,,16.568,Percent of Total Billed Charges,36% of Total Billed Charges,20.71,36,,16.568,Percent of Total Billed Charges,36% Total Bille Charges,20.71,36,,16.568,Percent of Total Billed Charges,36% of Total Billed Charges,34.51,60,,27.608,Percent of Total Billed Charges,60% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.29,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.02,80,,248.832,Percent of Total Billed Charges,80% of Total Billed Charges,28.76,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,28.76,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.76,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,28.76,50,,23.008,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.26,70,,32.208,Percent of Total Billed Charges,70% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.52,100,,331.776,Percent of Total Billed Charges,100% of Total Billed Charges,8.05,256.64,
BARIUM 105% POLIBAR SS 750ML,53582730,CDM,255,RC,,,Outpatient,,,36.09,21.65,,21.65,60,,17.32,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.11,28,,8.088,Percent of Total Billed Charges,28% of Total Billed Charges,257.3,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,12.99,36,,10.392,Percent of Total Billed Charges,36% of Total Billed Charges,12.99,36,,10.392,Percent of Total Billed Charges,36% Total Bille Charges,12.99,36,,10.392,Percent of Total Billed Charges,36% of Total Billed Charges,21.65,60,,17.32,Percent of Total Billed Charges,60% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.2,14.42,,4.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.87,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,18.05,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,18.05,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.05,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,18.05,50,,14.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.26,70,,20.208,Percent of Total Billed Charges,70% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14,,4.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.09,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,5.05,257.3,
BARIUM 60% E-Z PAQUE LIQ 355ML,53582748,CDM,255,RC,,,Outpatient,,,33.03,19.82,,19.82,60,,15.856,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.25,28,,7.4,Percent of Total Billed Charges,28% of Total Billed Charges,257.3,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,11.89,36,,9.512,Percent of Total Billed Charges,36% of Total Billed Charges,11.89,36,,9.512,Percent of Total Billed Charges,36% Total Bille Charges,11.89,36,,9.512,Percent of Total Billed Charges,36% of Total Billed Charges,19.82,60,,15.856,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.76,14.42,,3.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.42,80,,164.704,Percent of Total Billed Charges,80% of Total Billed Charges,16.52,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,16.52,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.52,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,16.52,50,,13.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.12,70,,18.496,Percent of Total Billed Charges,70% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,4.62,14,,3.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.03,100,,219.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.62,257.3,
BARIUM 700MG E-Z DISK TABS,53582755,CDM,255,RC,,,Outpatient,,,14.87,8.92,,8.92,60,,7.136,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.16,28,,3.328,Percent of Total Billed Charges,28% of Total Billed Charges,257.3,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,5.35,36,,4.28,Percent of Total Billed Charges,36% of Total Billed Charges,5.35,36,,4.28,Percent of Total Billed Charges,36% Total Bille Charges,5.35,36,,4.28,Percent of Total Billed Charges,36% of Total Billed Charges,8.92,60,,7.136,Percent of Total Billed Charges,60% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.14,14.42,,1.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,80,,220.2,Percent of Total Billed Charges,80% of Total Billed Charges,7.44,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,7.44,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.44,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,7.44,50,,5.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.41,70,,8.328,Percent of Total Billed Charges,70% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,2.08,14,,1.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.87,100,,293.6,Percent of Total Billed Charges,100% of Total Billed Charges,2.08,257.3,
EZ-GAS II GRANULES 4 GM,53582763,CDM,255,RC,,,Outpatient,,,6.13,3.68,,3.68,60,,2.944,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.72,28,,1.376,Percent of Total Billed Charges,28% of Total Billed Charges,257.3,32,,205.84,Percent of Total Billed Charges,32% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,2.21,36,,1.768,Percent of Total Billed Charges,36% of Total Billed Charges,2.21,36,,1.768,Percent of Total Billed Charges,36% Total Bille Charges,2.21,36,,1.768,Percent of Total Billed Charges,36% of Total Billed Charges,3.68,60,,2.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.88,14.42,,0.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.9,80,,175.2,Percent of Total Billed Charges,80% of Total Billed Charges,3.07,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,3.07,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.07,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,3.07,50,,2.456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,70,,3.432,Percent of Total Billed Charges,70% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,0.86,14,,0.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.13,100,,233.6,Percent of Total Billed Charges,100% of Total Billed Charges,0.86,257.3,
BARIUM 81% THIN LIQUID 148G,53582797,CDM,255,RC,,,Outpatient,,,35,21.00,,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,28,,7.84,Percent of Total Billed Charges,28% of Total Billed Charges,258.11,32,,206.488,Percent of Total Billed Charges,32% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,12.6,36,,10.08,Percent of Total Billed Charges,36% of Total Billed Charges,12.6,36,,10.08,Percent of Total Billed Charges,36% Total Bille Charges,12.6,36,,10.08,Percent of Total Billed Charges,36% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,5.05,14.42,,4.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,80,,522.904,Percent of Total Billed Charges,80% of Total Billed Charges,17.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,17.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,17.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.5,70,,19.6,Percent of Total Billed Charges,70% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,4.9,14,,3.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,100,,697.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.9,258.11,
BARIUM 40% NECTAR 120ML,53582805,CDM,255,RC,,,Outpatient,,,26.15,15.69,,15.69,60,,12.552,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.32,28,,5.856,Percent of Total Billed Charges,28% of Total Billed Charges,258.13,32,,206.504,Percent of Total Billed Charges,32% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% Total Bille Charges,9.41,36,,7.528,Percent of Total Billed Charges,36% of Total Billed Charges,15.69,60,,12.552,Percent of Total Billed Charges,60% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.77,14.42,,3.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.92,80,,663.176,Percent of Total Billed Charges,80% of Total Billed Charges,13.08,50,,10.464,Percent of Total Billed Charges,50% of Total Billed Charges,13.08,50,,10.464,Percent of Total Billed Charges,50% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.08,50,,10.464,Percent of Total Billed Charges,50% of Total Billed Charges,13.08,50,,10.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.31,70,,14.648,Percent of Total Billed Charges,70% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,3.66,14,,2.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.15,100,,884.232,Percent of Total Billed Charges,100% of Total Billed Charges,3.66,258.13,
BARIUM 0.1% NEULUMEX 450ML,53582821,CDM,255,RC,,,Outpatient,,,42.6,25.56,,25.56,60,,20.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.93,28,,9.544,Percent of Total Billed Charges,28% of Total Billed Charges,258.73,32,,206.984,Percent of Total Billed Charges,32% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,36,,12.272,Percent of Total Billed Charges,36% of Total Billed Charges,15.34,36,,12.272,Percent of Total Billed Charges,36% Total Bille Charges,15.34,36,,12.272,Percent of Total Billed Charges,36% of Total Billed Charges,25.56,60,,20.448,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,6.14,14.42,,4.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.08,80,,2310.12,Percent of Total Billed Charges,80% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,21.3,50,,17.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.82,70,,23.856,Percent of Total Billed Charges,70% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,5.96,14,,4.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.6,100,,3080.16,Percent of Total Billed Charges,100% of Total Billed Charges,5.96,258.73,
SINCALIDE 5MCG VL,53582904,CDM,250,RC,J2805,HCPCS,Outpatient,,,455.27,273.16,,116.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,101.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,101.17,360,,,Fee Schedule,360% of BCBS POS Rate,101.17,360,,,Fee schedule,360% of BCBS PPO Rate,101.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,273.16,60,,218.528,Percent of Total Billed Charges,60% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,65.65,14.42,,52.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.45,75,,2005.24,Percent of Total Billed Charges,75% of Total Billed Charges,93.02,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,93.02,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.02,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,93.02,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,318.69,70,,254.952,Percent of Total Billed Charges,70% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,63.74,14,,50.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,455.27,100,,2673.648,Percent of Total Billed Charges,100% of Total Billed Charges,63.74,455.27,
ALBUMIN 5% 25 GM VL 500 ML,54100011,CDM,250,RC,P9045,HCPCS,Outpatient,,,414.84,248.90,,55.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,79.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,62.21,360,,,Fee Schedule,360% of BCBS POS Rate,62.21,360,,,Fee schedule,360% of BCBS PPO Rate,62.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,248.9,60,,199.12,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,47.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,311.13,75,,562.912,Percent of Total Billed Charges,75% of Total Billed Charges,42.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,42.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,79.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,290.39,70,,232.312,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,414.84,100,,750.544,Percent of Total Billed Charges,100% of Total Billed Charges,42.46,414.84,
ALBUMIN HUMAN 25% 100 ML BAG,54100029,CDM,250,RC,P9047,HCPCS,Outpatient,,,438.51,263.11,,54,100,,,Fee Schedule,100% of Aetna Fee Schedule,79.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,62.21,360,,,Fee Schedule,360% of BCBS POS Rate,62.21,360,,,Fee schedule,360% of BCBS PPO Rate,62.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,263.11,60,,210.488,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,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,47.77,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,69,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.67,103,,,Fee Schedule,103% of CMS OPPS Rate,328.88,75,,305.016,Percent of Total Billed Charges,75% of Total Billed Charges,42.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.46,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,42.46,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,79.62,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,306.96,70,,245.568,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,438.51,100,,406.688,Percent of Total Billed Charges,100% of Total Billed Charges,42.46,438.51,
CLINIMIX E 4.25%,54110016,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,258.91,32,,207.128,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,439.048,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,585.4,Percent of Total Billed Charges,100% of Total Billed Charges,77,550,
D5 NACL.45 1L,54110043,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,25.93,32,,20.744,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,1399.008,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,1865.344,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,50.43,
D5 1/2NS 30KCL 1000ML,54110047,CDM,258,RC,,,Outpatient,,,30.51,18.31,,18.31,60,,14.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.54,28,,6.832,Percent of Total Billed Charges,28% of Total Billed Charges,25.99,32,,20.792,Percent of Total Billed Charges,32% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,10.98,36,,8.784,Percent of Total Billed Charges,36% of Total Billed Charges,10.98,36,,8.784,Percent of Total Billed Charges,36% Total Bille Charges,10.98,36,,8.784,Percent of Total Billed Charges,36% of Total Billed Charges,18.31,60,,14.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.4,14.42,,3.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,75,,1399.008,Percent of Total Billed Charges,75% of Total Billed Charges,15.26,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,15.26,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.26,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,15.26,50,,12.208,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.36,70,,17.088,Percent of Total Billed Charges,70% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.27,14,,3.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.51,100,,1865.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.27,30.51,
D5 1/2NS 40KCL 1000ML,54110048,CDM,258,RC,,,Outpatient,,,27.96,16.78,,16.78,60,,13.424,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.83,28,,6.264,Percent of Total Billed Charges,28% of Total Billed Charges,26.1,32,,20.88,Percent of Total Billed Charges,32% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.07,36,,8.056,Percent of Total Billed Charges,36% of Total Billed Charges,10.07,36,,8.056,Percent of Total Billed Charges,36% Total Bille Charges,10.07,36,,8.056,Percent of Total Billed Charges,36% of Total Billed Charges,16.78,60,,13.424,Percent of Total Billed Charges,60% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,4.03,14.42,,3.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.97,75,,960.808,Percent of Total Billed Charges,75% of Total Billed Charges,13.98,50,,11.184,Percent of Total Billed Charges,50% of Total Billed Charges,13.98,50,,11.184,Percent of Total Billed Charges,50% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.98,50,,11.184,Percent of Total Billed Charges,50% of Total Billed Charges,13.98,50,,11.184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.57,70,,15.656,Percent of Total Billed Charges,70% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14,,3.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.96,100,,1281.08,Percent of Total Billed Charges,100% of Total Billed Charges,3.91,27.96,
D5W 50ML,54110054,CDM,258,RC,,,Outpatient,,,27.59,16.55,,16.55,60,,13.24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.73,28,,6.184,Percent of Total Billed Charges,28% of Total Billed Charges,26.17,32,,20.936,Percent of Total Billed Charges,32% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% Total Bille Charges,9.93,36,,7.944,Percent of Total Billed Charges,36% of Total Billed Charges,16.55,60,,13.24,Percent of Total Billed Charges,60% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.98,14.42,,3.184,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.69,75,,780,Percent of Total Billed Charges,75% of Total Billed Charges,13.8,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.8,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,50,,11.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.31,70,,15.448,Percent of Total Billed Charges,70% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,3.86,14,,3.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.59,100,,1040,Percent of Total Billed Charges,100% of Total Billed Charges,3.86,27.59,
D5W 100ML,54110055,CDM,258,RC,,,Outpatient,,,20.94,12.56,,12.56,60,,10.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.86,28,,4.688,Percent of Total Billed Charges,28% of Total Billed Charges,26.18,32,,20.944,Percent of Total Billed Charges,32% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.54,36,,6.032,Percent of Total Billed Charges,36% of Total Billed Charges,7.54,36,,6.032,Percent of Total Billed Charges,36% Total Bille Charges,7.54,36,,6.032,Percent of Total Billed Charges,36% of Total Billed Charges,12.56,60,,10.048,Percent of Total Billed Charges,60% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,3.02,14.42,,2.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.71,75,,1559.408,Percent of Total Billed Charges,75% of Total Billed Charges,10.47,50,,8.376,Percent of Total Billed Charges,50% of Total Billed Charges,10.47,50,,8.376,Percent of Total Billed Charges,50% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.47,50,,8.376,Percent of Total Billed Charges,50% of Total Billed Charges,10.47,50,,8.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.66,70,,11.728,Percent of Total Billed Charges,70% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,2.93,14,,2.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.94,100,,2079.208,Percent of Total Billed Charges,100% of Total Billed Charges,2.93,26.18,
D5W 250ML,54110056,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,26.19,32,,20.952,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,2507.504,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,3343.336,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,50.43,
D5W 500ML,54110057,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,26.21,32,,20.968,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,88.296,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,117.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,50.43,
D5W 1000ML,54110058,CDM,258,RC,J7070,HCPCS,Outpatient,,,50.43,30.26,,3.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,15.16,360,,,Fee Schedule,360% of BCBS POS Rate,15.16,360,,,Fee schedule,360% of BCBS PPO Rate,15.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,96.664,Percent of Total Billed Charges,75% of Total Billed Charges,2.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.7,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.7,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,128.88,Percent of Total Billed Charges,100% of Total Billed Charges,2.7,50.43,
D10 NS 1L,54110062,CDM,258,RC,,,Outpatient,,,85.38,51.23,,51.23,60,,40.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.91,28,,19.128,Percent of Total Billed Charges,28% of Total Billed Charges,26.21,32,,20.968,Percent of Total Billed Charges,32% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,30.74,36,,24.592,Percent of Total Billed Charges,36% of Total Billed Charges,30.74,36,,24.592,Percent of Total Billed Charges,36% Total Bille Charges,30.74,36,,24.592,Percent of Total Billed Charges,36% of Total Billed Charges,51.23,60,,40.984,Percent of Total Billed Charges,60% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,12.31,14.42,,9.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.04,75,,87.032,Percent of Total Billed Charges,75% of Total Billed Charges,42.69,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,42.69,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.69,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,42.69,50,,34.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.77,70,,47.816,Percent of Total Billed Charges,70% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,11.95,14,,9.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.38,100,,116.04,Percent of Total Billed Charges,100% of Total Billed Charges,11.95,85.38,
D10W 250ML,54110063,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,259.2,32,,207.36,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,110.296,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,147.064,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,259.2,
D-10 W INJ 500ML,54110064,CDM,258,RC,,,Outpatient,,,50.43,30.26,,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.12,28,,11.296,Percent of Total Billed Charges,28% of Total Billed Charges,259.2,32,,207.36,Percent of Total Billed Charges,32% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% Total Bille Charges,18.15,36,,14.52,Percent of Total Billed Charges,36% of Total Billed Charges,30.26,60,,24.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.27,14.42,,5.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.82,75,,99.808,Percent of Total Billed Charges,75% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,25.22,50,,20.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.3,70,,28.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,7.06,14,,5.648,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.43,100,,133.072,Percent of Total Billed Charges,100% of Total Billed Charges,7.06,259.2,
RINGERS 1L,54110071,CDM,258,RC,,,Outpatient,,,12.66,7.60,,7.6,60,,6.08,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.54,28,,2.832,Percent of Total Billed Charges,28% of Total Billed Charges,259.29,32,,207.432,Percent of Total Billed Charges,32% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,4.56,36,,3.648,Percent of Total Billed Charges,36% of Total Billed Charges,4.56,36,,3.648,Percent of Total Billed Charges,36% Total Bille Charges,4.56,36,,3.648,Percent of Total Billed Charges,36% of Total Billed Charges,7.6,60,,6.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.83,14.42,,1.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,6.33,50,,5.064,Percent of Total Billed Charges,50% of Total Billed Charges,6.33,50,,5.064,Percent of Total Billed Charges,50% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.33,50,,5.064,Percent of Total Billed Charges,50% of Total Billed Charges,6.33,50,,5.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.86,70,,7.088,Percent of Total Billed Charges,70% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,1.77,14,,1.416,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.66,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.77,259.29,
NS 50ML INJ,54110074,CDM,258,RC,,,Outpatient,,,50,30.00,,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,28,,11.2,Percent of Total Billed Charges,28% of Total Billed Charges,260.18,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,18,36,,14.4,Percent of Total Billed Charges,36% Total Bille Charges,18,36,,14.4,Percent of Total Billed Charges,36% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7.21,14.42,,5.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,75,,104.728,Percent of Total Billed Charges,75% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,70,,28,Percent of Total Billed Charges,70% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,7,14,,5.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,100,,139.632,Percent of Total Billed Charges,100% of Total Billed Charges,7,260.18,
TPN NEONATAL 250,54110088,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,260.18,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,111.576,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,148.768,Percent of Total Billed Charges,100% of Total Billed Charges,77,550,
FAT EM 20% 100ML,54110107,CDM,258,RC,,,Outpatient,,,176.65,105.99,,105.99,60,,84.792,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.46,28,,39.568,Percent of Total Billed Charges,28% of Total Billed Charges,260.18,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,63.59,36,,50.872,Percent of Total Billed Charges,36% of Total Billed Charges,63.59,36,,50.872,Percent of Total Billed Charges,36% Total Bille Charges,63.59,36,,50.872,Percent of Total Billed Charges,36% of Total Billed Charges,105.99,60,,84.792,Percent of Total Billed Charges,60% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,25.47,14.42,,20.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.49,75,,88.296,Percent of Total Billed Charges,75% of Total Billed Charges,88.33,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,88.33,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.33,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,88.33,50,,70.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,123.66,70,,98.928,Percent of Total Billed Charges,70% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,24.73,14,,19.784,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,176.65,100,,117.728,Percent of Total Billed Charges,100% of Total Billed Charges,24.73,260.18,
FAT EM 20%500ML,54110108,CDM,258,RC,,,Outpatient,,,239,143.40,,143.4,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.92,28,,53.536,Percent of Total Billed Charges,28% of Total Billed Charges,260.18,32,,208.144,Percent of Total Billed Charges,32% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,86.04,36,,68.832,Percent of Total Billed Charges,36% of Total Billed Charges,86.04,36,,68.832,Percent of Total Billed Charges,36% Total Bille Charges,86.04,36,,68.832,Percent of Total Billed Charges,36% of Total Billed Charges,143.4,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,34.46,14.42,,27.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.25,75,,110.296,Percent of Total Billed Charges,75% of Total Billed Charges,119.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,119.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,119.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,167.3,70,,133.84,Percent of Total Billed Charges,70% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,33.46,14,,26.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,239,100,,147.064,Percent of Total Billed Charges,100% of Total Billed Charges,33.46,260.18,
NS 1000ML IRR,54110116,CDM,258,RC,,,Outpatient,,,37.86,22.72,,22.72,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,28,,8.48,Percent of Total Billed Charges,28% of Total Billed Charges,260.41,32,,208.328,Percent of Total Billed Charges,32% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% of Total Billed Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% Total Bille Charges,13.63,36,,10.904,Percent of Total Billed Charges,36% of Total Billed Charges,22.72,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.46,14.42,,4.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.4,75,,99.808,Percent of Total Billed Charges,75% of Total Billed Charges,18.93,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,18.93,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.93,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,18.93,50,,15.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.5,70,,21.2,Percent of Total Billed Charges,70% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,5.3,14,,4.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.86,100,,133.072,Percent of Total Billed Charges,100% of Total Billed Charges,5.3,260.41,
CLINIMIX E 5/20+LYTES/CA 2L,54110170,CDM,258,RC,,,Outpatient,,,550,330.00,,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154,28,,123.2,Percent of Total Billed Charges,28% of Total Billed Charges,262.16,32,,209.728,Percent of Total Billed Charges,32% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,198,36,,158.4,Percent of Total Billed Charges,36% Total Bille Charges,198,36,,158.4,Percent of Total Billed Charges,36% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,99.808,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,385,70,,308,Percent of Total Billed Charges,70% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,133.072,Percent of Total Billed Charges,100% of Total Billed Charges,77,550,
FAT EMULS. INJ 20% 250ML,54110172,CDM,258,RC,,,Outpatient,,,240.2,144.12,,144.12,60,,115.296,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.26,28,,53.808,Percent of Total Billed Charges,28% of Total Billed Charges,262.37,32,,209.896,Percent of Total Billed Charges,32% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,86.47,36,,69.176,Percent of Total Billed Charges,36% of Total Billed Charges,86.47,36,,69.176,Percent of Total Billed Charges,36% Total Bille Charges,86.47,36,,69.176,Percent of Total Billed Charges,36% of Total Billed Charges,144.12,60,,115.296,Percent of Total Billed Charges,60% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,34.64,14.42,,27.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.15,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,120.1,50,,96.08,Percent of Total Billed Charges,50% of Total Billed Charges,120.1,50,,96.08,Percent of Total Billed Charges,50% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.1,50,,96.08,Percent of Total Billed Charges,50% of Total Billed Charges,120.1,50,,96.08,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.14,70,,134.512,Percent of Total Billed Charges,70% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,33.63,14,,26.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.2,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,33.63,262.37,
TROPHAMINE 10% INJ 500ML,54110200,CDM,258,RC,,,Outpatient,,,156.96,94.18,,94.18,60,,75.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.95,28,,35.16,Percent of Total Billed Charges,28% of Total Billed Charges,26244.8,32,,20995.84,Percent of Total Billed Charges,32% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,56.51,36,,45.208,Percent of Total Billed Charges,36% of Total Billed Charges,56.51,36,,45.208,Percent of Total Billed Charges,36% Total Bille Charges,56.51,36,,45.208,Percent of Total Billed Charges,36% of Total Billed Charges,94.18,60,,75.344,Percent of Total Billed Charges,60% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,22.63,14.42,,18.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.72,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,78.48,50,,62.784,Percent of Total Billed Charges,50% of Total Billed Charges,78.48,50,,62.784,Percent of Total Billed Charges,50% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.48,50,,62.784,Percent of Total Billed Charges,50% of Total Billed Charges,78.48,50,,62.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.87,70,,87.896,Percent of Total Billed Charges,70% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,21.97,14,,17.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.96,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,21.97,26244.8,
D12.5W 250ML,54123709,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,26.24,32,,20.992,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,104.728,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,139.632,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,78.5,
D15W 250ML,54123710,CDM,258,RC,,,Outpatient,,,78.5,47.10,,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.98,28,,17.584,Percent of Total Billed Charges,28% of Total Billed Charges,26.24,32,,20.992,Percent of Total Billed Charges,32% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% Total Bille Charges,28.26,36,,22.608,Percent of Total Billed Charges,36% of Total Billed Charges,47.1,60,,37.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,11.32,14.42,,9.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.88,75,,111.576,Percent of Total Billed Charges,75% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.25,50,,31.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.95,70,,43.96,Percent of Total Billed Charges,70% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,10.99,14,,8.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.5,100,,148.768,Percent of Total Billed Charges,100% of Total Billed Charges,10.99,78.5,
NOREPINEPHRINE 16MG/D5W 250ML,54133460,CDM,250,RC,,,Outpatient,,,165.93,99.56,,99.56,60,,79.648,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.46,28,,37.168,Percent of Total Billed Charges,28% of Total Billed Charges,26.28,32,,21.024,Percent of Total Billed Charges,32% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,59.73,36,,47.784,Percent of Total Billed Charges,36% of Total Billed Charges,59.73,36,,47.784,Percent of Total Billed Charges,36% Total Bille Charges,59.73,36,,47.784,Percent of Total Billed Charges,36% of Total Billed Charges,99.56,60,,79.648,Percent of Total Billed Charges,60% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.93,14.42,,19.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.45,75,,284.8,Percent of Total Billed Charges,75% of Total Billed Charges,82.97,50,,66.376,Percent of Total Billed Charges,50% of Total Billed Charges,82.97,50,,66.376,Percent of Total Billed Charges,50% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.97,50,,66.376,Percent of Total Billed Charges,50% of Total Billed Charges,82.97,50,,66.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.15,70,,92.92,Percent of Total Billed Charges,70% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14,,18.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,165.93,100,,379.728,Percent of Total Billed Charges,100% of Total Billed Charges,23.23,165.93,
LEVOTHYROXINE 400MCG/ NS 100ML,54133461,CDM,250,RC,,,Outpatient,,,108.48,65.09,,65.09,60,,52.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.37,28,,24.296,Percent of Total Billed Charges,28% of Total Billed Charges,26.4,32,,21.12,Percent of Total Billed Charges,32% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,39.05,36,,31.24,Percent of Total Billed Charges,36% of Total Billed Charges,39.05,36,,31.24,Percent of Total Billed Charges,36% Total Bille Charges,39.05,36,,31.24,Percent of Total Billed Charges,36% of Total Billed Charges,65.09,60,,52.072,Percent of Total Billed Charges,60% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.64,14.42,,12.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.36,75,,87.544,Percent of Total Billed Charges,75% of Total Billed Charges,54.24,50,,43.392,Percent of Total Billed Charges,50% of Total Billed Charges,54.24,50,,43.392,Percent of Total Billed Charges,50% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.24,50,,43.392,Percent of Total Billed Charges,50% of Total Billed Charges,54.24,50,,43.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.94,70,,60.752,Percent of Total Billed Charges,70% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14,,12.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.48,100,,116.728,Percent of Total Billed Charges,100% of Total Billed Charges,15.19,108.48,
MUPIROCIN 2% OINT 5 GM,54133463,CDM,250,RC,,,Outpatient,,,9.32,5.59,,5.59,60,,4.472,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.61,28,,2.088,Percent of Total Billed Charges,28% of Total Billed Charges,26.44,32,,21.152,Percent of Total Billed Charges,32% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,3.36,36,,2.688,Percent of Total Billed Charges,36% of Total Billed Charges,3.36,36,,2.688,Percent of Total Billed Charges,36% Total Bille Charges,3.36,36,,2.688,Percent of Total Billed Charges,36% of Total Billed Charges,5.59,60,,4.472,Percent of Total Billed Charges,60% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.34,14.42,,1.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,75,,87.544,Percent of Total Billed Charges,75% of Total Billed Charges,4.66,50,,3.728,Percent of Total Billed Charges,50% of Total Billed Charges,4.66,50,,3.728,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.66,50,,3.728,Percent of Total Billed Charges,50% of Total Billed Charges,4.66,50,,3.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.52,70,,5.216,Percent of Total Billed Charges,70% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14,,1.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.32,100,,116.728,Percent of Total Billed Charges,100% of Total Billed Charges,1.3,26.44,
NYSTATIN TOPICAL PWD 5GM,54133464,CDM,250,RC,,,Outpatient,,,6.77,4.06,,4.06,60,,3.248,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.9,28,,1.52,Percent of Total Billed Charges,28% of Total Billed Charges,26.48,32,,21.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,2.44,36,,1.952,Percent of Total Billed Charges,36% of Total Billed Charges,2.44,36,,1.952,Percent of Total Billed Charges,36% Total Bille Charges,2.44,36,,1.952,Percent of Total Billed Charges,36% of Total Billed Charges,4.06,60,,3.248,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.98,14.42,,0.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,75,,277.024,Percent of Total Billed Charges,75% of Total Billed Charges,3.39,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.39,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,3.39,50,,2.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.74,70,,3.792,Percent of Total Billed Charges,70% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,14,,0.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.77,100,,369.36,Percent of Total Billed Charges,100% of Total Billed Charges,0.95,26.48,
TRIAMCINOLONE 0.1% CRM 5GM,54133465,CDM,250,RC,,,Outpatient,,,2.64,1.58,,1.58,60,,1.264,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.74,28,,0.592,Percent of Total Billed Charges,28% of Total Billed Charges,26.48,32,,21.184,Percent of Total Billed Charges,32% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% Total Bille Charges,0.95,36,,0.76,Percent of Total Billed Charges,36% of Total Billed Charges,1.58,60,,1.264,Percent of Total Billed Charges,60% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.38,14.42,,0.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.98,75,,177.624,Percent of Total Billed Charges,75% of Total Billed Charges,1.32,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,1.32,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.32,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,1.32,50,,1.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.85,70,,1.48,Percent of Total Billed Charges,70% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,0.37,14,,0.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.64,100,,236.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.37,26.48,
HEPARIN 10000 UNITS /10 ML INJ,54133466,CDM,250,RC,J1644,HCPCS,Outpatient,,,13.18,7.91,,0.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.14,360,,,Fee Schedule,360% of BCBS POS Rate,0.14,360,,,Fee schedule,360% of BCBS PPO Rate,0.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,7.91,60,,6.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,0.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.2,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.23,70,,7.384,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.18,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,0.14,13.18,
METRONIDAZOLE 1% TOP GEL 5 GM,54133467,CDM,250,RC,,,Outpatient,,,34.44,20.66,,20.66,60,,16.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.64,28,,7.712,Percent of Total Billed Charges,28% of Total Billed Charges,26.53,32,,21.224,Percent of Total Billed Charges,32% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,12.4,36,,9.92,Percent of Total Billed Charges,36% of Total Billed Charges,12.4,36,,9.92,Percent of Total Billed Charges,36% Total Bille Charges,12.4,36,,9.92,Percent of Total Billed Charges,36% of Total Billed Charges,20.66,60,,16.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14.42,,3.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.83,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,17.22,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.22,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,50,,13.776,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.11,70,,19.288,Percent of Total Billed Charges,70% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,4.82,14,,3.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.44,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,4.82,34.44,
RECK SOLUTION INJ,54133468,CDM,250,RC,,,Outpatient,,,448.79,269.27,,269.27,60,,215.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.66,28,,100.528,Percent of Total Billed Charges,28% of Total Billed Charges,263.2,32,,210.56,Percent of Total Billed Charges,32% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,161.56,36,,129.248,Percent of Total Billed Charges,36% of Total Billed Charges,161.56,36,,129.248,Percent of Total Billed Charges,36% Total Bille Charges,161.56,36,,129.248,Percent of Total Billed Charges,36% of Total Billed Charges,269.27,60,,215.416,Percent of Total Billed Charges,60% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,64.72,14.42,,51.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.59,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,224.4,50,,179.52,Percent of Total Billed Charges,50% of Total Billed Charges,224.4,50,,179.52,Percent of Total Billed Charges,50% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.4,50,,179.52,Percent of Total Billed Charges,50% of Total Billed Charges,224.4,50,,179.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.15,70,,251.32,Percent of Total Billed Charges,70% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.79,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,62.83,448.79,
SIMETHICONE DROPS 1.2ML,54133469,CDM,250,RC,,,Outpatient,,,0.23,0.14,,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.06,28,,0.048,Percent of Total Billed Charges,28% of Total Billed Charges,264,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% Total Bille Charges,0.08,36,,0.064,Percent of Total Billed Charges,36% of Total Billed Charges,0.14,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.17,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,0.12,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.12,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,0.12,50,,0.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.16,70,,0.128,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.23,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,264,
GABAPENTIN 50MG/1ML 1ML SOLN,54133470,CDM,250,RC,,,Outpatient,,,0.18,0.11,,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.05,28,,0.04,Percent of Total Billed Charges,28% of Total Billed Charges,264,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% Total Bille Charges,0.06,36,,0.048,Percent of Total Billed Charges,36% of Total Billed Charges,0.11,60,,0.088,Percent of Total Billed Charges,60% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14.42,,0.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.14,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,0.09,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,0.09,50,,0.072,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.13,70,,0.104,Percent of Total Billed Charges,70% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,0.03,14,,0.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.18,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,264,
AZITHROMYCIN IVPB 500MG/250ML,54133471,CDM,250,RC,J0456,HCPCS,Outpatient,,,42.92,25.75,,2.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,4.15,360,,,Fee Schedule,360% of BCBS POS Rate,4.15,360,,,Fee schedule,360% of BCBS PPO Rate,4.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.75,60,,20.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.19,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,2.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.07,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.07,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.04,70,,24.032,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.92,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,2.07,42.92,
PHENOBARBITAL 20MG/5ML ELX UD,54133473,CDM,250,RC,,,Outpatient,,,7.45,4.47,,4.47,60,,3.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.09,28,,1.672,Percent of Total Billed Charges,28% of Total Billed Charges,264,32,,211.2,Percent of Total Billed Charges,32% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,2.68,36,,2.144,Percent of Total Billed Charges,36% of Total Billed Charges,2.68,36,,2.144,Percent of Total Billed Charges,36% Total Bille Charges,2.68,36,,2.144,Percent of Total Billed Charges,36% of Total Billed Charges,4.47,60,,3.576,Percent of Total Billed Charges,60% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.07,14.42,,0.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.59,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,3.73,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,3.73,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.73,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,3.73,50,,2.984,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.22,70,,4.176,Percent of Total Billed Charges,70% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,1.04,14,,0.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.45,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,1.04,264,
AMIODARONE 150MG/D5W 100ML,54133474,CDM,250,RC,J0282,HCPCS,Outpatient,,,145.41,87.25,,0.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.2,360,,,Fee Schedule,360% of BCBS POS Rate,0.2,360,,,Fee schedule,360% of BCBS PPO Rate,0.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,87.25,60,,69.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.06,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,72.71,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,72.71,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.71,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,72.71,50,,58.168,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.79,70,,81.432,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.41,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,0.2,145.41,
VENETOCLAX TAB 100MG,54133475,CDM,250,RC,,,Outpatient,,,209.88,125.93,,125.93,60,,100.744,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.77,28,,47.016,Percent of Total Billed Charges,28% of Total Billed Charges,264.32,32,,211.456,Percent of Total Billed Charges,32% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,75.56,36,,60.448,Percent of Total Billed Charges,36% of Total Billed Charges,75.56,36,,60.448,Percent of Total Billed Charges,36% Total Bille Charges,75.56,36,,60.448,Percent of Total Billed Charges,36% of Total Billed Charges,125.93,60,,100.744,Percent of Total Billed Charges,60% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,30.26,14.42,,24.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.41,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,104.94,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,104.94,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.94,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,104.94,50,,83.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.92,70,,117.536,Percent of Total Billed Charges,70% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,29.38,14,,23.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.88,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,29.38,264.32,
PHENYLEPH INJ 100MCG/ML 5ML,54133476,CDM,250,RC,J2371,HCPCS,Outpatient,,,42.32,25.39,,25.39,60,,20.312,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,0.01,360,,,Fee Schedule,360% of BCBS POS Rate,0.01,360,,,Fee schedule,360% of BCBS PPO Rate,0.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.39,60,,20.312,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14.42,,4.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.74,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,21.16,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,21.16,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.16,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,21.16,50,,16.928,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.62,70,,23.696,Percent of Total Billed Charges,70% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,5.92,14,,4.736,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.32,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,0.01,42.32,
TOCILIZUMAB (ACTEMRA) 400MG/20ML INJ,54133477,CDM,636,RC,J3262,HCPCS,Outpatient,,,9664,5798.40,,5320.99,110,,4256.792,Percent of Total Billed Charges,110% of Total Billed Charges,8.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,5.17,360,,,Fee Schedule,360% of BCBS POS Rate,5.17,360,,,Fee schedule,360% of BCBS PPO Rate,5.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,5315.2,55,,4252.16,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.36,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7.74,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6.13,103,,,Fee Schedule,103% of CMS OPPS Rate,7248,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,4836.69,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,4836.69,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,4836.69,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,4836.69,50,,3869.352,Percent of Total Billed Charges,50% of Total Billed Charges,8.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,6764.8,70,,5411.84,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.96,100,,,Fee Schedule,100% of CMS OPPS Rate,9664,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,5.17,9664,
HYDROMORPH DRIP 1MG/ML 50ML,54133478,CDM,250,RC,J1171,HCPCS,Outpatient,,,71.1,42.66,,42.66,60,,34.128,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.66,60,,34.128,Percent of Total Billed Charges,60% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,10.25,14.42,,8.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.33,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,35.55,50,,28.44,Percent of Total Billed Charges,50% of Total Billed Charges,35.55,50,,28.44,Percent of Total Billed Charges,50% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.55,50,,28.44,Percent of Total Billed Charges,50% of Total Billed Charges,35.55,50,,28.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.77,70,,39.816,Percent of Total Billed Charges,70% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,9.95,14,,7.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.1,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,71.1,
HYDROMORPH 500MG/ 50ML INJ,54133479,CDM,250,RC,J1171,HCPCS,Outpatient,,,465,279.00,,279,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,0.09,360,,,Fee Schedule,360% of BCBS POS Rate,0.09,360,,,Fee schedule,360% of BCBS PPO Rate,0.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,279,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,67.05,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.75,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,325.5,70,,260.4,Percent of Total Billed Charges,70% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,0.09,465,
AZITHROMYCIN 500MG TAB,54133480,CDM,250,RC,Q0144,HCPCS,Outpatient,,,8.99,5.39,,23.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,16.74,360,,,Fee Schedule,360% of BCBS POS Rate,16.74,360,,,Fee schedule,360% of BCBS PPO Rate,16.74,360,,,Fee Schedule,360% of BCBS Traditional Rate,5.39,60,,4.312,Percent of Total Billed Charges,60% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.3,14.42,,1.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.74,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.29,70,,5.032,Percent of Total Billed Charges,70% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,1.26,14,,1.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.99,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,1.26,23.3,
NICARDIPINE 25MG/NS 250ML,54133481,CDM,250,RC,,,Outpatient,,,147.36,88.42,,88.42,60,,70.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.26,28,,33.008,Percent of Total Billed Charges,28% of Total Billed Charges,264.32,32,,211.456,Percent of Total Billed Charges,32% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,53.05,36,,42.44,Percent of Total Billed Charges,36% of Total Billed Charges,53.05,36,,42.44,Percent of Total Billed Charges,36% Total Bille Charges,53.05,36,,42.44,Percent of Total Billed Charges,36% of Total Billed Charges,88.42,60,,70.736,Percent of Total Billed Charges,60% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,21.25,14.42,,17,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.52,75,,276,Percent of Total Billed Charges,75% of Total Billed Charges,73.68,50,,58.944,Percent of Total Billed Charges,50% of Total Billed Charges,73.68,50,,58.944,Percent of Total Billed Charges,50% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.68,50,,58.944,Percent of Total Billed Charges,50% of Total Billed Charges,73.68,50,,58.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.15,70,,82.52,Percent of Total Billed Charges,70% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,20.63,14,,16.504,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.36,100,,368,Percent of Total Billed Charges,100% of Total Billed Charges,20.63,264.32,
NICARDIPINE 50MG/NS 250ML,54133483,CDM,250,RC,,,Outpatient,,,271.02,162.61,,162.61,60,,130.088,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.89,28,,60.712,Percent of Total Billed Charges,28% of Total Billed Charges,264.34,32,,211.472,Percent of Total Billed Charges,32% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,97.57,36,,78.056,Percent of Total Billed Charges,36% of Total Billed Charges,97.57,36,,78.056,Percent of Total Billed Charges,36% Total Bille Charges,97.57,36,,78.056,Percent of Total Billed Charges,36% of Total Billed Charges,162.61,60,,130.088,Percent of Total Billed Charges,60% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,39.08,14.42,,31.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.27,75,,320.048,Percent of Total Billed Charges,75% of Total Billed Charges,135.51,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,135.51,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.51,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,135.51,50,,108.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.71,70,,151.768,Percent of Total Billed Charges,70% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,37.94,14,,30.352,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.02,100,,426.728,Percent of Total Billed Charges,100% of Total Billed Charges,37.94,271.02,
KETAMINE 250MG/ND 250ML,54133484,CDM,250,RC,,,Outpatient,,,60.72,36.43,,36.43,60,,29.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17,28,,13.6,Percent of Total Billed Charges,28% of Total Billed Charges,264.92,32,,211.936,Percent of Total Billed Charges,32% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.86,36,,17.488,Percent of Total Billed Charges,36% of Total Billed Charges,21.86,36,,17.488,Percent of Total Billed Charges,36% Total Bille Charges,21.86,36,,17.488,Percent of Total Billed Charges,36% of Total Billed Charges,36.43,60,,29.144,Percent of Total Billed Charges,60% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.76,14.42,,7.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.54,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,30.36,50,,24.288,Percent of Total Billed Charges,50% of Total Billed Charges,30.36,50,,24.288,Percent of Total Billed Charges,50% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.36,50,,24.288,Percent of Total Billed Charges,50% of Total Billed Charges,30.36,50,,24.288,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.5,70,,34,Percent of Total Billed Charges,70% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,8.5,14,,6.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.72,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,8.5,264.92,
FENTANYL 2500 MCG/250ML,54133485,CDM,250,RC,J3010,HCPCS,Outpatient,,,146.64,87.98,,0.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.39,360,,,Fee Schedule,360% of BCBS POS Rate,0.39,360,,,Fee schedule,360% of BCBS PPO Rate,0.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,87.98,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.98,75,,320.84,Percent of Total Billed Charges,75% of Total Billed Charges,0.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.78,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,0.78,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.65,70,,82.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.64,100,,427.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.39,146.64,
MORHINE 100MG/NS 100ML,54133486,CDM,250,RC,J2270,HCPCS,Outpatient,,,121.44,72.86,,3.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,0.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,0.07,360,,,Fee Schedule,360% of BCBS POS Rate,0.07,360,,,Fee schedule,360% of BCBS PPO Rate,0.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.86,60,,58.288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.08,75,,320.84,Percent of Total Billed Charges,75% of Total Billed Charges,2.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,2.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,2.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.01,70,,68.008,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.44,100,,427.784,Percent of Total Billed Charges,100% of Total Billed Charges,0.07,121.44,
ALBUTEROL SULF 90MCG HFA 18GM,54133487,CDM,250,RC,,,Outpatient,,,104.14,62.48,,62.48,60,,49.984,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.16,28,,23.328,Percent of Total Billed Charges,28% of Total Billed Charges,265.09,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,37.49,36,,29.992,Percent of Total Billed Charges,36% of Total Billed Charges,37.49,36,,29.992,Percent of Total Billed Charges,36% Total Bille Charges,37.49,36,,29.992,Percent of Total Billed Charges,36% of Total Billed Charges,62.48,60,,49.984,Percent of Total Billed Charges,60% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,15.02,14.42,,12.016,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.11,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,52.07,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,52.07,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.07,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,52.07,50,,41.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.9,70,,58.32,Percent of Total Billed Charges,70% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,14.58,14,,11.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.14,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,14.58,265.09,
REMDESIVIR 100MG,54133490,CDM,250,RC,,,Outpatient,,,1040,624.00,,624,60,,499.2,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,291.2,28,,232.96,Percent of Total Billed Charges,28% of Total Billed Charges,265.09,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,374.4,36,,299.52,Percent of Total Billed Charges,36% of Total Billed Charges,374.4,36,,299.52,Percent of Total Billed Charges,36% Total Bille Charges,374.4,36,,299.52,Percent of Total Billed Charges,36% of Total Billed Charges,624,60,,499.2,Percent of Total Billed Charges,60% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,149.97,14.42,,119.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780,75,,320.84,Percent of Total Billed Charges,75% of Total Billed Charges,520,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,520,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,520,50,,416,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,728,70,,582.4,Percent of Total Billed Charges,70% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,145.6,14,,116.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1040,100,,427.784,Percent of Total Billed Charges,100% of Total Billed Charges,145.6,1040,
SURFACTANT ADMINISTRATION,55000261,CDM,410,RC,94610,HCPCS,Outpatient,,,205.6,123.36,,40.63,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.65,14.42,,23.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,154.2,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,102.8,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,102.8,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,102.8,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,102.8,50,,82.24,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,28.78,14,,23.024,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,205.6,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,28.78,662.26,
BIPAP INITIAL DAY,55000262,CDM,410,RC,94660,HCPCS,Outpatient,,,1366.58,819.95,,27.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.1,90,,,Fee Schedule,90% of CMS OPPS Rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,197.06,14.42,,157.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1024.94,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,683.29,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,683.29,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,683.29,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,683.29,50,,546.632,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,191.32,14,,153.056,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1366.58,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,27.82,1366.58,
BIPAP SUBSEQUENT DAY,55000263,CDM,410,RC,94660,HCPCS,Outpatient,,,1176.16,705.70,,27.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.1,90,,,Fee Schedule,90% of CMS OPPS Rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,169.6,14.42,,135.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,882.12,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,588.08,50,,470.464,Percent of Total Billed Charges,50% of Total Billed Charges,588.08,50,,470.464,Percent of Total Billed Charges,50% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,588.08,50,,470.464,Percent of Total Billed Charges,50% of Total Billed Charges,588.08,50,,470.464,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,164.66,14,,131.728,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.16,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,27.82,1176.16,
ARTERIAL PUNCTURE,55000401,CDM,410,RC,36600,HCPCS,Outpatient,,,129.54,77.72,,14.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,28,,29.016,Percent of Total Billed Charges,28% of Total Billed Charges,265.09,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,46.63,36,,37.304,Percent of Total Billed Charges,36% of Total Billed Charges,46.63,36,,37.304,Percent of Total Billed Charges,36% Total Bille Charges,46.63,36,,37.304,Percent of Total Billed Charges,36% of Total Billed Charges,194,100,,,Case Rate,Pays based on per visit rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.68,14.42,,14.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,97.16,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,64.77,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,64.77,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,64.77,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,64.77,50,,51.816,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,18.14,14,,14.512,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,129.54,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.35,378,
AEROSOL THERAPY CONT INIT DAY,55001002,CDM,271,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,265.09,32,,212.072,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,38.43,274.5,
AEROSOL THERAPY CONT SUB DAY,55001010,CDM,271,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,265.28,32,,212.224,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,38.43,274.5,
INCENTIVE SPIROMETRY,55001162,CDM,410,RC,G0237,HCPCS,Outpatient,,,167.2,100.32,,8.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,35.03,360,,,Fee Schedule,360% of BCBS POS Rate,35.03,360,,,Fee schedule,360% of BCBS PPO Rate,35.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,130,,,Fee Schedule,130% of CMS OPPS Rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,24.11,14.42,,19.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,28.13,103,,,Fee Schedule,103% of CMS OPPS Rate,125.4,75,,337.792,Percent of Total Billed Charges,75% of Total Billed Charges,83.6,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,83.6,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,83.6,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,83.6,50,,66.88,Percent of Total Billed Charges,50% of Total Billed Charges,40.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,23.41,14,,18.728,Percent of Total Billed Charges,14% of Total Billed Charges,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,167.2,100,,450.384,Percent of Total Billed Charges,100% of Total Billed Charges,8.38,378,
NEBULIZED MED INITIAL EA DAY,55001226,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
NEBULIZED MED SUBSEQ SAME DAY,55001234,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
ARTERIAL BLOOD GAS,55001524,CDM,301,RC,82805,HCPCS,Outpatient,,,378,226.80,,91.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,118.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,220.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,252.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,283.57,360,,,Fee Schedule,360% of BCBS POS Rate,283.57,360,,,Fee schedule,360% of BCBS PPO Rate,283.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,226.8,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,66.17,100,,,Fee Schedule,100% of TX Mediciad Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,70.89,90,,,Fee Schedule,90% of CMS OPPS Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,102.4,130,,,Fee Schedule,130% of CMS OPPS Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,68.16,103,,,Fee Schedule,103% of TX Medicaid Rate,81.13,103,,,Fee Schedule,103% of CMS OPPS Rate,81.13,103,,,Fee Schedule,103% of CMS OPPS Rate,283.5,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,133.9,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,133.9,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,133.9,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,133.9,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,118.15,150,,,Fee Schedule,150% of CMS OPPS Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,63.8,90,,,Fee Schedule,90% of UHC fee schedule,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,66.17,100,,,Fee Schedule,100% of TX Medicaid Rate,78.77,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,63.8,378,
EKG 12 LEAD TRACING,55001525,CDM,730,RC,93005,HCPCS,Outpatient,,,387.54,232.52,,4.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,154.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,176.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,198.04,360,,,Fee Schedule,360% of BCBS POS Rate,198.04,360,,,Fee schedule,360% of BCBS PPO Rate,198.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,232.52,60,,186.016,Percent of Total Billed Charges,60% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,55.88,14.42,,44.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,290.66,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,193.77,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,193.77,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,193.77,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,193.77,50,,155.016,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,980,100,,,Case Rate,Pays based on per visit rate,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,54.26,14,,43.408,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,387.54,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.58,980,
CARBOXYHEMOGLOBIN,55001530,CDM,301,RC,82375,HCPCS,Outpatient,,,174.76,104.86,,14.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,44.35,360,,,Fee Schedule,360% of BCBS POS Rate,44.35,360,,,Fee schedule,360% of BCBS PPO Rate,44.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,104.86,60,,83.888,Percent of Total Billed Charges,60% of Total Billed Charges,10.35,100,,,Fee Schedule,100% of TX Mediciad 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,11.08,90,,,Fee Schedule,90% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,16.01,130,,,Fee Schedule,130% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.66,103,,,Fee Schedule,103% of TX Medicaid Rate,12.68,103,,,Fee Schedule,103% of CMS OPPS Rate,12.68,103,,,Fee Schedule,103% of CMS OPPS Rate,131.07,75,,65.544,Percent of Total Billed Charges,75% of Total Billed Charges,20.94,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.94,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.94,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.94,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.48,150,,,Fee Schedule,150% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,9.98,90,,,Fee Schedule,90% of UHC fee schedule,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,10.35,100,,,Fee Schedule,100% of TX Medicaid Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,174.76,100,,87.392,Percent of Total Billed Charges,100% of Total Billed Charges,9.98,174.76,
O2 SATURATION,55001531,CDM,301,RC,82810,HCPCS,Outpatient,,,131,78.60,,11.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,27.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,35.17,360,,,Fee Schedule,360% of BCBS POS Rate,35.17,360,,,Fee schedule,360% of BCBS PPO Rate,35.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.6,60,,62.88,Percent of Total Billed Charges,60% of Total Billed Charges,8.21,100,,,Fee Schedule,100% of TX Mediciad Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.79,90,,,Fee Schedule,90% of CMS OPPS Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,12.7,130,,,Fee Schedule,130% of CMS OPPS Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.46,103,,,Fee Schedule,103% of TX Medicaid Rate,10.06,103,,,Fee Schedule,103% of CMS OPPS Rate,10.06,103,,,Fee Schedule,103% of CMS OPPS Rate,98.25,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,16.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.65,150,,,Fee Schedule,150% of CMS OPPS Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.91,90,,,Fee Schedule,90% of UHC fee schedule,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,8.21,100,,,Fee Schedule,100% of TX Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,131,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,7.91,131,
METHEMOGLOBIN QT,55001532,CDM,301,RC,83050,HCPCS,Outpatient,,,107.82,64.69,,9.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,29.52,360,,,Fee Schedule,360% of BCBS POS Rate,29.52,360,,,Fee schedule,360% of BCBS PPO Rate,29.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.69,60,,51.752,Percent of Total Billed Charges,60% of Total Billed Charges,6.89,100,,,Fee Schedule,100% of TX Mediciad 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,7.37,90,,,Fee Schedule,90% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.66,130,,,Fee Schedule,130% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,7.1,103,,,Fee Schedule,103% of TX Medicaid Rate,8.44,103,,,Fee Schedule,103% of CMS OPPS Rate,8.44,103,,,Fee Schedule,103% of CMS OPPS Rate,80.87,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,13.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.3,150,,,Fee Schedule,150% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,90,,,Fee Schedule,90% of UHC fee schedule,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,107.82,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,6.64,107.82,
HEMOGLOBIN,55001533,CDM,305,RC,85018,HCPCS,Outpatient,,,57.75,34.65,,2.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,3.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,8.53,360,,,Fee Schedule,360% of BCBS POS Rate,8.53,360,,,Fee schedule,360% of BCBS PPO Rate,8.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.65,60,,27.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,100,,,Fee Schedule,100% of TX Mediciad 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,2.13,90,,,Fee Schedule,90% of CMS OPPS Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,130,,,Fee Schedule,130% of CMS OPPS Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.05,103,,,Fee Schedule,103% of TX Medicaid Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,2.44,103,,,Fee Schedule,103% of CMS OPPS Rate,43.31,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,4.02,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,4.02,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,4.02,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,3.55,150,,,Fee Schedule,150% of CMS OPPS Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1.92,90,,,Fee Schedule,90% of UHC fee schedule,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,1.99,100,,,Fee Schedule,100% of TX Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,57.75,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.92,57.75,
NASAL TRACHEAL SUCTION,55001549,CDM,410,RC,31720,HCPCS,Outpatient,,,215.26,129.16,,52.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.27,28,,48.216,Percent of Total Billed Charges,28% of Total Billed Charges,265.28,32,,212.224,Percent of Total Billed Charges,32% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,77.49,36,,61.992,Percent of Total Billed Charges,36% of Total Billed Charges,77.49,36,,61.992,Percent of Total Billed Charges,36% Total Bille Charges,77.49,36,,61.992,Percent of Total Billed Charges,36% of Total Billed Charges,194,100,,,Case Rate,Pays based on per visit rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,31.04,14.42,,24.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,161.45,75,,154.912,Percent of Total Billed Charges,75% of Total Billed Charges,107.63,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,107.63,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,107.63,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,107.63,50,,86.104,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,30.14,14,,24.112,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,215.26,100,,206.544,Percent of Total Billed Charges,100% of Total Billed Charges,30.14,378,
CPR,55001564,CDM,410,RC,92950,HCPCS,Outpatient,,,1291.56,774.94,,127.85,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,539.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,616.99,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,694.12,360,,,Fee Schedule,360% of BCBS POS Rate,694.12,360,,,Fee schedule,360% of BCBS PPO Rate,694.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,186.24,14.42,,148.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,968.67,75,,427.8,Percent of Total Billed Charges,75% of Total Billed Charges,645.78,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,645.78,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,645.78,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,645.78,50,,516.624,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,180.82,14,,144.656,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.56,100,,570.4,Percent of Total Billed Charges,100% of Total Billed Charges,127.85,1291.56,
INTUBATION,55002091,CDM,361,RC,31500,HCPCS,Outpatient,,,954,572.40,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,336.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,474.48,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,265.35,32,,212.28,Percent of Total Billed Charges,32% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,655.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,655.72,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,655.72,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,137.57,14.42,,110.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,715.5,75,,74.72,Percent of Total Billed Charges,75% of Total Billed Charges,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,477,50,,381.6,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1634,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,133.56,14,,106.848,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,954,100,,99.624,Percent of Total Billed Charges,100% of Total Billed Charges,133.56,2601,
PEP THERAPY SUBSEQUENT TRMT,55002109,CDM,410,RC,94668,HCPCS,Outpatient,,,197.81,118.69,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,28.52,14.42,,22.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,148.36,75,,184.512,Percent of Total Billed Charges,75% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,197.81,100,,246.016,Percent of Total Billed Charges,100% of Total Billed Charges,24.84,392.51,
PEP THERAPY INITIAL TREATMENT,55002117,CDM,410,RC,94667,HCPCS,Outpatient,,,236.04,141.62,,16.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,34.04,14.42,,27.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,177.03,75,,208.424,Percent of Total Billed Charges,75% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,236.04,100,,277.896,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,392.51,
CPT INITIAL TREATMENT,55002120,CDM,410,RC,94667,HCPCS,Outpatient,,,236.04,141.62,,16.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,34.04,14.42,,27.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,177.03,75,,218.072,Percent of Total Billed Charges,75% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,118.02,50,,94.416,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,33.05,14,,26.44,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,236.04,100,,290.76,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,392.51,
CPT SUBSEQUENT TREATMENTS,55002133,CDM,410,RC,94668,HCPCS,Outpatient,,,197.81,118.69,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,28.52,14.42,,22.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,148.36,75,,161.8,Percent of Total Billed Charges,75% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,98.91,50,,79.128,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14,,22.152,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,197.81,100,,215.736,Percent of Total Billed Charges,100% of Total Billed Charges,24.84,392.51,
SPUTUM INDUCTION SUBSEQUENT,55002216,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,43.56,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,58.08,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
SMOKING CESSATION 3 TO 10 MIN,55003750,CDM,942,RC,99406,HCPCS,Outpatient,,,74.57,44.74,,9.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,,Fee Schedule,360% of BCBS POS Rate,45.4,360,,,Fee schedule,360% of BCBS PPO Rate,45.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.74,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.68,90,,,Fee Schedule,90% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,130,,,Fee Schedule,130% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.75,14.42,,8.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,55.93,75,,262.176,Percent of Total Billed Charges,75% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,39.47,150,,,Fee Schedule,150% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,45,100,,,Case Rate,Pays based on per visit rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,74.57,100,,349.568,Percent of Total Billed Charges,100% of Total Billed Charges,9.52,74.57,
SMOKING CESSATION > 10 MIN,55003768,CDM,942,RC,99407,HCPCS,Outpatient,,,102.1,61.26,,19.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,73.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,84.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,94.72,360,,,Fee Schedule,360% of BCBS POS Rate,94.72,360,,,Fee schedule,360% of BCBS PPO Rate,94.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,61.26,60,,49.008,Percent of Total Billed Charges,60% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.68,90,,,Fee Schedule,90% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,130,,,Fee Schedule,130% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.72,14.42,,11.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,76.58,75,,110.584,Percent of Total Billed Charges,75% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,39.47,150,,,Fee Schedule,150% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,45,100,,,Case Rate,Pays based on per visit rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,102.1,100,,147.448,Percent of Total Billed Charges,100% of Total Billed Charges,14.29,102.1,
IPPB INITIAL EACH DAY,55005029,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,320.84,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,427.784,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
DEMONSTRATION AND/OR EVAL P/DA,55005045,CDM,410,RC,94664,HCPCS,Outpatient,,,235.24,141.14,,12.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,33.92,14.42,,27.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,176.43,75,,320.048,Percent of Total Billed Charges,75% of Total Billed Charges,117.62,50,,94.096,Percent of Total Billed Charges,50% of Total Billed Charges,117.62,50,,94.096,Percent of Total Billed Charges,50% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,117.62,50,,94.096,Percent of Total Billed Charges,50% of Total Billed Charges,117.62,50,,94.096,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,32.93,14,,26.344,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,235.24,100,,426.728,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,662.26,
NEWBORN RESUSCITATION,55005946,CDM,722,RC,99465,HCPCS,Outpatient,,,1085.72,651.43,,105.11,100,,,Fee Schedule,100% of Aetna Fee Schedule,895.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,416.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,476.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,535.82,360,,,Fee Schedule,360% of BCBS POS Rate,535.82,360,,,Fee schedule,360% of BCBS PPO Rate,535.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,651.43,60,,521.144,Percent of Total Billed Charges,60% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,537.39,90,,,Fee Schedule,90% of CMS OPPS Rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,776.23,130,,,Fee Schedule,130% of CMS OPPS Rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,156.56,14.42,,125.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,615.01,103,,,Fee Schedule,103% of CMS OPPS Rate,814.29,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,542.86,50,,434.288,Percent of Total Billed Charges,50% of Total Billed Charges,542.86,50,,434.288,Percent of Total Billed Charges,50% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,542.86,50,,434.288,Percent of Total Billed Charges,50% of Total Billed Charges,542.86,50,,434.288,Percent of Total Billed Charges,50% of Total Billed Charges,895.66,150,,,Fee Schedule,150% of CMS OPPS Rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,605,100,,,Case Rate,Pays based on per visit rate,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,152,14,,121.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.72,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,105.11,1085.72,
MECHANICAL VENT INITIAL DAY,55006209,CDM,410,RC,94002,HCPCS,Outpatient,,,2073.75,1244.25,,67.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,862.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1486.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,1672.31,360,,,Fee Schedule,360% of BCBS POS Rate,1672.31,360,,,Fee schedule,360% of BCBS PPO Rate,1672.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,517.44,90,,,Fee Schedule,90% of CMS OPPS Rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,747.41,130,,,Fee Schedule,130% of CMS OPPS Rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,299.03,14.42,,239.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,592.17,103,,,Fee Schedule,103% of CMS OPPS Rate,592.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1555.31,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,1036.88,50,,829.504,Percent of Total Billed Charges,50% of Total Billed Charges,1036.88,50,,829.504,Percent of Total Billed Charges,50% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.88,50,,829.504,Percent of Total Billed Charges,50% of Total Billed Charges,1036.88,50,,829.504,Percent of Total Billed Charges,50% of Total Billed Charges,862.41,150,,,Fee Schedule,150% of CMS OPPS Rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,290.33,14,,232.264,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.75,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,67.53,2073.75,
MECHANICAL VENT SUBSEQ DAY,55006266,CDM,410,RC,94003,HCPCS,Outpatient,,,1710.45,1026.27,,48.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,862.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1486.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,1672.31,360,,,Fee Schedule,360% of BCBS POS Rate,1672.31,360,,,Fee schedule,360% of BCBS PPO Rate,1672.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,517.44,90,,,Fee Schedule,90% of CMS OPPS Rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,747.41,130,,,Fee Schedule,130% of CMS OPPS Rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,246.65,14.42,,197.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,592.17,103,,,Fee Schedule,103% of CMS OPPS Rate,592.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1282.84,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,855.23,50,,684.184,Percent of Total Billed Charges,50% of Total Billed Charges,855.23,50,,684.184,Percent of Total Billed Charges,50% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,855.23,50,,684.184,Percent of Total Billed Charges,50% of Total Billed Charges,855.23,50,,684.184,Percent of Total Billed Charges,50% of Total Billed Charges,862.41,150,,,Fee Schedule,150% of CMS OPPS Rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,239.46,14,,191.568,Percent of Total Billed Charges,14% of Total Billed Charges,574.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.45,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,48.21,1710.45,
OXYGEN INITAL DAY,55007025,CDM,270,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,265.39,32,,212.312,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,38.43,274.5,
OXYGEN SUBSEQUENT DAYS,55007033,CDM,270,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,26.76,32,,21.408,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,179.008,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,238.68,Percent of Total Billed Charges,100% of Total Billed Charges,26.76,274.5,
ARTERIAL CANNULATION/CATH,55007034,CDM,761,RC,36620,HCPCS,Outpatient,,,938.18,562.91,,40.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.91,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,135.29,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.64,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,656.73,70,,525.384,Percent of Total Billed Charges,70% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,938.18,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,40.56,938.18,
RT MEDICATION ADMIN INITIAL,55007036,CDM,410,RC,94640,HCPCS,Outpatient,,,211.67,127.00,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,30.52,14.42,,24.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,158.75,75,,88.296,Percent of Total Billed Charges,75% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,211.67,100,,117.728,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
RT MEDICATION ADMIN SUBSEQ,55007037,CDM,410,RC,94640,HCPCS,Outpatient,,,211.67,127.00,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,30.52,14.42,,24.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,158.75,75,,237,Percent of Total Billed Charges,75% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,105.84,50,,84.672,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,29.63,14,,23.704,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,211.67,100,,316,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
OXIMETRY MULT DETERMINATIONS,55011092,CDM,460,RC,94761,HCPCS,Outpatient,,,267.36,160.42,,2.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,15.55,360,,,Fee Schedule,360% of BCBS POS Rate,15.55,360,,,Fee schedule,360% of BCBS PPO Rate,15.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.42,60,,128.336,Percent of Total Billed Charges,60% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,38.55,14.42,,30.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.52,75,,110.296,Percent of Total Billed Charges,75% of Total Billed Charges,133.68,50,,106.944,Percent of Total Billed Charges,50% of Total Billed Charges,133.68,50,,106.944,Percent of Total Billed Charges,50% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.68,50,,106.944,Percent of Total Billed Charges,50% of Total Billed Charges,133.68,50,,106.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766,100,,,Case Rate,Pays based on per visit rate,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,37.43,14,,29.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,267.36,100,,147.064,Percent of Total Billed Charges,100% of Total Billed Charges,2.75,766,
SPIROMETRY W/O BRONCHODILATOR,55012009,CDM,460,RC,94010,HCPCS,Outpatient,,,446.84,268.10,,16.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,387.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,,Fee Schedule,360% of BCBS POS Rate,498.06,360,,,Fee schedule,360% of BCBS PPO Rate,498.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,268.1,60,,214.48,Percent of Total Billed Charges,60% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,90,,,Fee Schedule,90% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,130,,,Fee Schedule,130% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,64.43,14.42,,51.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,335.13,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,446.84,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,766,
SPIROMETRY W/BRONCHODILATOR,55012017,CDM,460,RC,94060,HCPCS,Outpatient,,,846.58,507.95,,27.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,132.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,151.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,169.96,360,,,Fee Schedule,360% of BCBS POS Rate,169.96,360,,,Fee schedule,360% of BCBS PPO Rate,169.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,507.95,60,,406.36,Percent of Total Billed Charges,60% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,122.08,14.42,,97.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,634.94,75,,99.808,Percent of Total Billed Charges,75% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,846.58,100,,133.072,Percent of Total Billed Charges,100% of Total Billed Charges,27.32,846.58,
SIPAP/CPAP INITIAL DAY,55018576,CDM,410,RC,94660,HCPCS,Outpatient,,,871.5,522.90,,27.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.1,90,,,Fee Schedule,90% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,125.67,14.42,,100.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,653.63,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,871.5,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,27.82,871.5,
MDI/DPI INITIAL EACH DAY,55021059,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,369.152,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,492.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
MDI/DPI SUBSEQUENT SAME DAY,55021067,CDM,410,RC,94640,HCPCS,Outpatient,,,150.43,90.26,,10.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,90,,,Fee Schedule,90% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.69,14.42,,17.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,201.55,103,,,Fee Schedule,103% of CMS OPPS Rate,112.82,75,,337.792,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,75.22,50,,60.176,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,21.06,14,,16.848,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,150.43,100,,450.384,Percent of Total Billed Charges,100% of Total Billed Charges,10.59,662.26,
OXIMETRY SPOT CHECK,55022057,CDM,460,RC,94760,HCPCS,Outpatient,,,133.85,80.31,,1.71,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,8.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,9.07,360,,,Fee Schedule,360% of BCBS POS Rate,9.07,360,,,Fee schedule,360% of BCBS PPO Rate,9.07,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.31,60,,64.248,Percent of Total Billed Charges,60% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,19.3,14.42,,15.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.39,75,,337.792,Percent of Total Billed Charges,75% of Total Billed Charges,66.93,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,66.93,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.93,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,66.93,50,,53.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766,100,,,Case Rate,Pays based on per visit rate,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,18.74,14,,14.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.85,100,,450.384,Percent of Total Billed Charges,100% of Total Billed Charges,1.71,766,
OXIMETRY OVERNIGHT STUDY,55030605,CDM,460,RC,94762,HCPCS,Outpatient,,,513.14,307.88,,20.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,387.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,,Fee Schedule,360% of BCBS POS Rate,498.06,360,,,Fee schedule,360% of BCBS PPO Rate,498.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,307.88,60,,246.304,Percent of Total Billed Charges,60% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,73.99,14.42,,59.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,384.86,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,256.57,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,256.57,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,256.57,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,256.57,50,,205.256,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,71.84,14,,57.472,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,513.14,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.52,766,
TRACHEOTOMY TUBE CHANGE,55046114,CDM,410,RC,31502,HCPCS,Outpatient,,,813.05,487.83,,33.19,100,,,Fee Schedule,100% of Aetna Fee Schedule,336.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,227.65,28,,182.12,Percent of Total Billed Charges,28% of Total Billed Charges,26.85,32,,21.48,Percent of Total Billed Charges,32% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,292.7,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,292.7,36,,234.16,Percent of Total Billed Charges,36% Total Bille Charges,292.7,36,,234.16,Percent of Total Billed Charges,36% of Total Billed Charges,194,100,,,Case Rate,Pays based on per visit rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,201.68,90,,,Fee Schedule,90% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,291.32,130,,,Fee Schedule,130% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,117.24,14.42,,93.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,230.82,103,,,Fee Schedule,103% of CMS OPPS Rate,609.79,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,406.53,50,,325.224,Percent of Total Billed Charges,50% of Total Billed Charges,336.14,150,,,Fee Schedule,150% of CMS OPPS Rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,113.83,14,,91.064,Percent of Total Billed Charges,14% of Total Billed Charges,224.1,100,,,Fee Schedule,100% of CMS OPPS Rate,813.05,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,26.85,813.05,
VITAL CAPACITY TOTAL,55046130,CDM,460,RC,94150,HCPCS,Outpatient,,,239.25,143.55,,16.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,387.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,,Fee Schedule,360% of BCBS POS Rate,498.06,360,,,Fee schedule,360% of BCBS PPO Rate,498.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.55,60,,114.84,Percent of Total Billed Charges,60% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,90,,,Fee Schedule,90% of CMS OPPS Rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,130,,,Fee Schedule,130% of CMS OPPS Rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,34.5,14.42,,27.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,179.44,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,119.63,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,119.63,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,119.63,50,,95.704,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,33.5,14,,26.8,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,239.25,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,766,
END TIDAL CO2 CHECK,55046148,CDM,460,RC,94799,HCPCS,Outpatient,,,414.72,248.83,,248.83,60,,199.064,Percent of Total Billed Charges,60% of Total Billed Charges,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,387.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,,Fee Schedule,360% of BCBS POS Rate,498.06,360,,,Fee schedule,360% of BCBS PPO Rate,498.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,248.83,60,,199.064,Percent of Total Billed Charges,60% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,90,,,Fee Schedule,90% of CMS OPPS Rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,130,,,Fee Schedule,130% of CMS OPPS Rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,59.8,14.42,,47.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,311.04,75,,272.848,Percent of Total Billed Charges,75% of Total Billed Charges,207.36,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,207.36,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.36,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,207.36,50,,165.888,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,58.06,14,,46.448,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,414.72,100,,363.8,Percent of Total Billed Charges,100% of Total Billed Charges,58.06,766,
HELIUM OXYGEN SUBSEQUENT DAYS,55046155,CDM,270,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,265.73,32,,212.584,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,427.8,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,570.4,Percent of Total Billed Charges,100% of Total Billed Charges,38.43,274.5,
HELIUM OXYGEN INITIAL DAY,55046163,CDM,270,RC,,,Outpatient,,,274.5,164.70,,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.86,28,,61.488,Percent of Total Billed Charges,28% of Total Billed Charges,265.92,32,,212.736,Percent of Total Billed Charges,32% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% Total Bille Charges,98.82,36,,79.056,Percent of Total Billed Charges,36% of Total Billed Charges,164.7,60,,131.76,Percent of Total Billed Charges,60% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,39.58,14.42,,31.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.88,75,,427.8,Percent of Total Billed Charges,75% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,137.25,50,,109.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.15,70,,153.72,Percent of Total Billed Charges,70% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,38.43,14,,30.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,274.5,100,,570.4,Percent of Total Billed Charges,100% of Total Billed Charges,38.43,274.5,
NEBULIZED MED CONT 1ST HR,55046445,CDM,410,RC,94644,HCPCS,Outpatient,,,367,220.20,,45.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,52.92,14.42,,42.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,275.25,75,,427.8,Percent of Total Billed Charges,75% of Total Billed Charges,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,183.5,50,,146.8,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,51.38,14,,41.104,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,367,100,,570.4,Percent of Total Billed Charges,100% of Total Billed Charges,45.87,392.51,
NEBULIZED MED CONT EA ADDL HR,55046452,CDM,410,RC,94645,HCPCS,Outpatient,,,292,175.20,,12.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,,Fee Schedule,360% of BCBS POS Rate,60.98,360,,,Fee schedule,360% of BCBS PPO Rate,60.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,42.11,14.42,,33.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219,75,,121.888,Percent of Total Billed Charges,75% of Total Billed Charges,146,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,146,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,146,50,,116.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,,Case Rate,Pays based on per visit rate,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,40.88,14,,32.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,292,100,,162.52,Percent of Total Billed Charges,100% of Total Billed Charges,12.42,378,
SIPAP/CPAP SUBSEQUENT DAYS,55046627,CDM,410,RC,94660,HCPCS,Outpatient,,,871.5,522.90,,27.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,293.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,515.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,588.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,662.26,360,,,Fee Schedule,360% of BCBS POS Rate,662.26,360,,,Fee schedule,360% of BCBS PPO Rate,662.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,176.1,90,,,Fee Schedule,90% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,254.38,130,,,Fee Schedule,130% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,125.67,14.42,,100.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,201.54,103,,,Fee Schedule,103% of CMS OPPS Rate,653.63,75,,110.584,Percent of Total Billed Charges,75% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,435.75,50,,348.6,Percent of Total Billed Charges,50% of Total Billed Charges,293.52,150,,,Fee Schedule,150% of CMS OPPS Rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,378,100,,,Case Rate,Pays based on per visit rate,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,122.01,14,,97.608,Percent of Total Billed Charges,14% of Total Billed Charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,871.5,100,,147.448,Percent of Total Billed Charges,100% of Total Billed Charges,27.82,871.5,
BRONCHOSCOPY THERAPY BEDSIDE,55050100,CDM,361,RC,31725,HCPCS,Outpatient,,,1105.29,663.17,,2601,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1105.29,100,,,Fee Schedule ,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,192.29,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,267.07,32,,213.656,Percent of Total Billed Charges,32% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,265.75,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,265.75,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,265.75,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3862.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,159.38,14.42,,127.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,828.97,75,,26.136,Percent of Total Billed Charges,75% of Total Billed Charges,552.65,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,552.65,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,552.65,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,552.65,50,,442.12,Percent of Total Billed Charges,50% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2195,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,154.74,14,,123.792,Percent of Total Billed Charges,14% of Total Billed Charges,1105.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1105.29,100,,34.848,Percent of Total Billed Charges,100% of Total Billed Charges,154.74,3862.5,
BRONCHOSCOPY,55050101,CDM,361,RC,31622,HCPCS,Outpatient,,,3850.2,2310.12,,4162,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2335.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3333.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,267.14,32,,213.712,Percent of Total Billed Charges,32% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,4606.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4606.56,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4606.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1401.45,90,,,Fee Schedule,90% of CMS OPPS Rate,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.32,130,,,Fee Schedule,130% of CMS OPPS Rate,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,555.2,14.42,,444.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2887.65,75,,189.208,Percent of Total Billed Charges,75% of Total Billed Charges,1925.1,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,1925.1,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1925.1,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,1925.1,50,,1540.08,Percent of Total Billed Charges,50% of Total Billed Charges,2335.76,150,,,Fee Schedule,150% of CMS OPPS Rate,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,539.03,14,,431.224,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3850.2,100,,252.272,Percent of Total Billed Charges,100% of Total Billed Charges,267.14,4606.56,
BRONCH LAVAGE,55050104,CDM,361,RC,31624,HCPCS,Outpatient,,,3342.06,2005.24,,4162,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2335.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3333.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,27192,32,,21753.6,Percent of Total Billed Charges,32% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,4606.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4606.56,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4606.56,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,2575,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1401.45,90,,,Fee Schedule,90% of CMS OPPS Rate,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2024.32,130,,,Fee Schedule,130% of CMS OPPS Rate,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,481.93,14.42,,385.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.88,103,,,Fee Schedule,103% of CMS OPPS Rate,2506.55,75,,203.464,Percent of Total Billed Charges,75% of Total Billed Charges,1671.03,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,1671.03,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.03,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,1671.03,50,,1336.824,Percent of Total Billed Charges,50% of Total Billed Charges,2335.76,150,,,Fee Schedule,150% of CMS OPPS Rate,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,467.89,14,,374.312,Percent of Total Billed Charges,14% of Total Billed Charges,1557.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3342.06,100,,271.28,Percent of Total Billed Charges,100% of Total Billed Charges,467.89,27192,
ARTERIAL CANNULATION/CATH,55050111,CDM,361,RC,,,Outpatient,,,938.18,562.91,,562.91,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.69,28,,210.152,Percent of Total Billed Charges,28% of Total Billed Charges,26.96,32,,21.568,Percent of Total Billed Charges,32% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,337.74,36,,270.192,Percent of Total Billed Charges,36% of Total Billed Charges,337.74,36,,270.192,Percent of Total Billed Charges,36% Total Bille Charges,337.74,36,,270.192,Percent of Total Billed Charges,36% of Total Billed Charges,562.91,60,,450.328,Percent of Total Billed Charges,60% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,135.29,14.42,,108.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,703.64,75,,218.072,Percent of Total Billed Charges,75% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,469.09,50,,375.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,656.73,70,,525.384,Percent of Total Billed Charges,70% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,131.35,14,,105.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,938.18,100,,290.76,Percent of Total Billed Charges,100% of Total Billed Charges,26.96,938.18,
RESPIRATORY FLOW VOLUME LOOP,55050125,CDM,460,RC,94375,HCPCS,Outpatient,,,508.36,305.02,,18.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,,Fee Schedule,360% of BCBS POS Rate,911.16,360,,,Fee schedule,360% of BCBS PPO Rate,911.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,305.02,60,,244.016,Percent of Total Billed Charges,60% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.36,130,,,Fee Schedule,130% of CMS OPPS Rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,73.31,14.42,,58.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,381.27,75,,74.72,Percent of Total Billed Charges,75% of Total Billed Charges,254.18,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,254.18,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,254.18,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,254.18,50,,203.344,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,71.17,14,,56.936,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,508.36,100,,99.624,Percent of Total Billed Charges,100% of Total Billed Charges,18.43,911.16,
EXHALED AIR ANALYSIS,55050260,CDM,460,RC,94681,HCPCS,Outpatient,,,731.75,439.05,,31.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,,Fee Schedule,360% of BCBS POS Rate,911.16,360,,,Fee schedule,360% of BCBS PPO Rate,911.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,439.05,60,,351.24,Percent of Total Billed Charges,60% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.36,130,,,Fee Schedule,130% of CMS OPPS Rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,105.52,14.42,,84.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,548.81,75,,184.512,Percent of Total Billed Charges,75% of Total Billed Charges,365.88,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,365.88,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,365.88,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,365.88,50,,292.704,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,102.45,14,,81.96,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,731.75,100,,246.016,Percent of Total Billed Charges,100% of Total Billed Charges,31.24,911.16,
DIALYSIS OP EMERGENT ESRD,56002579,CDM,800,RC,90970,HCPCS,Outpatient,,,2331.68,1399.01,,7.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,652.87,28,,522.296,Percent of Total Billed Charges,28% of Total Billed Charges,27.03,32,,21.624,Percent of Total Billed Charges,32% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,839.4,36,,671.52,Percent of Total Billed Charges,36% of Total Billed Charges,839.4,36,,671.52,Percent of Total Billed Charges,36% Total Bille Charges,839.4,36,,671.52,Percent of Total Billed Charges,36% of Total Billed Charges,1399.01,60,,1119.208,Percent of Total Billed Charges,60% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,336.23,14.42,,268.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1748.76,75,,218.072,Percent of Total Billed Charges,75% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1632.18,70,,1305.744,Percent of Total Billed Charges,70% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2331.68,100,,290.76,Percent of Total Billed Charges,100% of Total Billed Charges,7.18,2331.68,
DIALYSIS OP EMERGENT ESRD,56002579,CDM,800,RC,G0257,HCPCS,Outpatient,,,2331.68,1399.01,,5.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,961.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1792.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2048.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,2304.11,360,,,Fee Schedule,360% of BCBS POS Rate,2304.11,360,,,Fee schedule,360% of BCBS PPO Rate,2304.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,1399.01,60,,1119.208,Percent of Total Billed Charges,60% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,577,90,,,Fee Schedule,90% of CMS OPPS Rate,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,833.45,130,,,Fee Schedule,130% of CMS OPPS Rate,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,336.23,14.42,,268.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,660.35,103,,,Fee Schedule,103% of CMS OPPS Rate,660.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1748.76,75,,161.8,Percent of Total Billed Charges,75% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,1165.84,50,,932.672,Percent of Total Billed Charges,50% of Total Billed Charges,961.67,150,,,Fee Schedule,150% of CMS OPPS Rate,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.18,70,,1305.744,Percent of Total Billed Charges,70% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,326.44,14,,261.152,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,2331.68,100,,215.736,Percent of Total Billed Charges,100% of Total Billed Charges,5.81,2331.68,
PERITONEAL DIALYSIS,56009624,CDM,802,RC,90945,HCPCS,Outpatient,,,1601.35,960.81,,63.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,609.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,448.38,28,,358.704,Percent of Total Billed Charges,28% of Total Billed Charges,27.03,32,,21.624,Percent of Total Billed Charges,32% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,576.49,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,576.49,36,,461.192,Percent of Total Billed Charges,36% Total Bille Charges,576.49,36,,461.192,Percent of Total Billed Charges,36% of Total Billed Charges,960.81,60,,768.648,Percent of Total Billed Charges,60% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,230.91,14.42,,184.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1201.01,75,,99.808,Percent of Total Billed Charges,75% of Total Billed Charges,800.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,800.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,800.68,50,,640.544,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.95,70,,896.76,Percent of Total Billed Charges,70% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,224.19,14,,179.352,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1601.35,100,,133.072,Percent of Total Billed Charges,100% of Total Billed Charges,27.03,1601.35,
PERITONEAL DIALYSIS OP,56009625,CDM,830,RC,90945,HCPCS,Outpatient,,,1300,780.00,,63.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,609.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,364,28,,291.2,Percent of Total Billed Charges,28% of Total Billed Charges,27.17,32,,21.736,Percent of Total Billed Charges,32% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,468,36,,374.4,Percent of Total Billed Charges,36% of Total Billed Charges,468,36,,374.4,Percent of Total Billed Charges,36% Total Bille Charges,468,36,,374.4,Percent of Total Billed Charges,36% of Total Billed Charges,780,60,,624,Percent of Total Billed Charges,60% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,187.46,14.42,,149.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,975,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,650,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,650,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,650,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,650,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,505,100,,,Case Rate,Pays based on per visit rate,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,182,14,,145.6,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1300,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,27.17,1300,
HEMODIALYSIS,56009707,CDM,801,RC,90935,HCPCS,Outpatient,,,2599.01,1559.41,,53.67,100,,,Fee Schedule,100% of Aetna Fee Schedule,961.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,727.72,28,,582.176,Percent of Total Billed Charges,28% of Total Billed Charges,27.18,32,,21.744,Percent of Total Billed Charges,32% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,935.64,36,,748.512,Percent of Total Billed Charges,36% of Total Billed Charges,935.64,36,,748.512,Percent of Total Billed Charges,36% Total Bille Charges,935.64,36,,748.512,Percent of Total Billed Charges,36% of Total Billed Charges,1559.41,60,,1247.528,Percent of Total Billed Charges,60% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,577,90,,,Fee Schedule,90% of CMS OPPS Rate,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,833.45,130,,,Fee Schedule,130% of CMS OPPS Rate,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,374.78,14.42,,299.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,660.35,103,,,Fee Schedule,103% of CMS OPPS Rate,660.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1949.26,75,,104.728,Percent of Total Billed Charges,75% of Total Billed Charges,1299.51,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,1299.51,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1299.51,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,1299.51,50,,1039.608,Percent of Total Billed Charges,50% of Total Billed Charges,961.67,150,,,Fee Schedule,150% of CMS OPPS Rate,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.31,70,,1455.448,Percent of Total Billed Charges,70% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,363.86,14,,291.088,Percent of Total Billed Charges,14% of Total Billed Charges,641.12,100,,,Fee Schedule,100% of CMS OPPS Rate,2599.01,100,,139.632,Percent of Total Billed Charges,100% of Total Billed Charges,27.18,2599.01,
APHERESIS PLASMA,56009772,CDM,940,RC,36516,HCPCS,Outpatient,,,4179.17,2507.50,,76.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,6368.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.17,28,,936.136,Percent of Total Billed Charges,28% of Total Billed Charges,268.8,32,,215.04,Percent of Total Billed Charges,32% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,1504.5,36,,1203.6,Percent of Total Billed Charges,36% of Total Billed Charges,1504.5,36,,1203.6,Percent of Total Billed Charges,36% Total Bille Charges,1504.5,36,,1203.6,Percent of Total Billed Charges,36% of Total Billed Charges,2507.5,60,,2006,Percent of Total Billed Charges,60% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3821.25,90,,,Fee Schedule,90% of CMS OPPS Rate,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,5519.59,130,,,Fee Schedule,130% of CMS OPPS Rate,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,602.64,14.42,,482.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,4373.21,103,,,Fee Schedule,103% of CMS OPPS Rate,4373.21,103,,,Fee Schedule,103% of CMS OPPS Rate,3134.38,75,,111.576,Percent of Total Billed Charges,75% of Total Billed Charges,2089.59,50,,1671.672,Percent of Total Billed Charges,50% of Total Billed Charges,2089.59,50,,1671.672,Percent of Total Billed Charges,50% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2089.59,50,,1671.672,Percent of Total Billed Charges,50% of Total Billed Charges,2089.59,50,,1671.672,Percent of Total Billed Charges,50% of Total Billed Charges,6368.76,150,,,Fee Schedule,150% of CMS OPPS Rate,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,585.08,14,,468.064,Percent of Total Billed Charges,14% of Total Billed Charges,4245.84,100,,,Fee Schedule,100% of CMS OPPS Rate,4179.17,100,,148.768,Percent of Total Billed Charges,100% of Total Billed Charges,76.36,6368.76,
(PT) THERAPEUTIC ACT-EA 15 MIN,57052102,CDM,420,RC,97530,HCPCS,Outpatient,,,147.16,88.30,GP   ,18.03,100,,,Case Rate,Pays based on per visit rate,53.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,114.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,,Fee Schedule,360% of BCBS POS Rate,146.59,360,,,Fee schedule,360% of BCBS PPO Rate,146.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,31.86,90,,,Fee Schedule,90% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,46.02,130,,,Fee Schedule,130% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,110.37,75,,110.296,Percent of Total Billed Charges,75% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,53.1,150,,,Fee Schedule,150% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.16,100,,147.064,Percent of Total Billed Charges,100% of Total Billed Charges,18.03,194,
(PT) GAIT TRAINING-EA 15 MIN,57052573,CDM,420,RC,97116,HCPCS,Outpatient,,,161.1,96.66,GP   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,99.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.56,360,,,Fee Schedule,360% of BCBS POS Rate,111.56,360,,,Fee schedule,360% of BCBS PPO Rate,111.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14.42,,18.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,120.83,75,,104.728,Percent of Total Billed Charges,75% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,161.1,100,,139.632,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
MECHANICAL TRACTION,57052755,CDM,420,RC,97012,HCPCS,Outpatient,,,145.05,87.03,,6.84,100,,,Case Rate,Pays based on per visit rate,20.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,90,,,Fee Schedule,90% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,130,,,Fee Schedule,130% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.92,14.42,,16.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.07,103,,,Fee Schedule,103% of CMS OPPS Rate,14.07,103,,,Fee Schedule,103% of CMS OPPS Rate,108.79,75,,111.576,Percent of Total Billed Charges,75% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.49,150,,,Fee Schedule,150% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,145.05,100,,148.768,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
(PT) MANUAL THERAPY-EA 15 MIN,57052771,CDM,420,RC,97140,HCPCS,Outpatient,,,183.83,110.30,GP   ,12.72,100,,,Case Rate,Pays based on per visit rate,39.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,79.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,91.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,102.49,360,,,Fee Schedule,360% of BCBS POS Rate,102.49,360,,,Fee schedule,360% of BCBS PPO Rate,102.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,90,,,Fee Schedule,90% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,34.14,130,,,Fee Schedule,130% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.51,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,137.87,75,,87.544,Percent of Total Billed Charges,75% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,39.39,150,,,Fee Schedule,150% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,183.83,100,,116.728,Percent of Total Billed Charges,100% of Total Billed Charges,12.72,194,
(PT) ELECTRICAL STIM-EA 15 MIN,57052821,CDM,420,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GP   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
(PT) SELF CARE-EA 15 MIN,57052870,CDM,420,RC,97535,HCPCS,Outpatient,,,168,100.80,GP   ,15.45,100,,,Case Rate,Pays based on per visit rate,47.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,97.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,111.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,125.86,360,,,Fee Schedule,360% of BCBS POS Rate,125.86,360,,,Fee schedule,360% of BCBS PPO Rate,125.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,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,28.48,90,,,Fee Schedule,90% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,130,,,Fee Schedule,130% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.23,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,126,75,,87.032,Percent of Total Billed Charges,75% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.46,150,,,Fee Schedule,150% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,116.04,Percent of Total Billed Charges,100% of Total Billed Charges,15.45,194,
(PT) EXERCISES-EA 15 MIN,57052979,CDM,420,RC,97110,HCPCS,Outpatient,,,174.54,104.72,GP   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,112.86,360,,,Fee Schedule,360% of BCBS POS Rate,112.86,360,,,Fee schedule,360% of BCBS PPO Rate,112.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.17,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,130.91,75,,43.56,Percent of Total Billed Charges,75% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.54,100,,58.08,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
(PT) NEUROMUSC REED-EA 15 MIN,57052995,CDM,420,RC,97112,HCPCS,Outpatient,,,185.96,111.58,GP   ,16.1,100,,,Case Rate,Pays based on per visit rate,49.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,114.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.45,360,,,Fee Schedule,360% of BCBS POS Rate,128.45,360,,,Fee schedule,360% of BCBS PPO Rate,128.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.41,90,,,Fee Schedule,90% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.48,130,,,Fee Schedule,130% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.82,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,139.47,75,,60.912,Percent of Total Billed Charges,75% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,150,,,Fee Schedule,150% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,185.96,100,,81.216,Percent of Total Billed Charges,100% of Total Billed Charges,16.1,194,
(OT) THERAPEUTIC ACT-EA 15 MIN,57053043,CDM,430,RC,97530,HCPCS,Outpatient,,,147.16,88.30,GO   ,18.03,100,,,Case Rate,Pays based on per visit rate,53.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,114.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,,Fee Schedule,360% of BCBS POS Rate,146.59,360,,,Fee schedule,360% of BCBS PPO Rate,146.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,31.86,90,,,Fee Schedule,90% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,46.02,130,,,Fee Schedule,130% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,110.37,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,53.1,150,,,Fee Schedule,150% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.16,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,18.03,194,
(OT) MANUAL THERAPY-EA 15 MIN,57053217,CDM,430,RC,97140,HCPCS,Outpatient,,,183.83,110.30,GO   ,12.72,100,,,Case Rate,Pays based on per visit rate,39.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,79.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,91.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,102.49,360,,,Fee Schedule,360% of BCBS POS Rate,102.49,360,,,Fee schedule,360% of BCBS PPO Rate,102.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,90,,,Fee Schedule,90% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,34.14,130,,,Fee Schedule,130% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.51,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,137.87,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,39.39,150,,,Fee Schedule,150% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,183.83,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,12.72,194,
(OT) ELECTRICAL STIM-EA 15 MIN,57053266,CDM,430,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GO   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
(OT) ELECTRICAL STIM-EA 15 MIN,57053332,CDM,430,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GO   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
ULTRASOUND EA 15 MIN,57053431,CDM,420,RC,97035,HCPCS,Outpatient,,,137,82.20,,6.68,100,,,Case Rate,Pays based on per visit rate,20.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,39.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.99,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.62,360,,,Fee Schedule,360% of BCBS POS Rate,50.62,360,,,Fee schedule,360% of BCBS PPO Rate,50.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,90,,,Fee Schedule,90% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,130,,,Fee Schedule,130% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,102.75,75,,170.52,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.39,150,,,Fee Schedule,150% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,227.36,Percent of Total Billed Charges,100% of Total Billed Charges,6.68,194,
(OT) SELF CARE-EA 15 MIN,57053530,CDM,430,RC,97535,HCPCS,Outpatient,,,168,100.80,GO   ,15.45,100,,,Case Rate,Pays based on per visit rate,47.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,97.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,111.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,125.86,360,,,Fee Schedule,360% of BCBS POS Rate,125.86,360,,,Fee schedule,360% of BCBS PPO Rate,125.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,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,28.48,90,,,Fee Schedule,90% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,130,,,Fee Schedule,130% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.23,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,126,75,,90.96,Percent of Total Billed Charges,75% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.46,150,,,Fee Schedule,150% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,121.28,Percent of Total Billed Charges,100% of Total Billed Charges,15.45,194,
(OT) EXERCISES-EA 15 MIN,57053761,CDM,430,RC,97110,HCPCS,Outpatient,,,174.54,104.72,GO   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,112.86,360,,,Fee Schedule,360% of BCBS POS Rate,112.86,360,,,Fee schedule,360% of BCBS PPO Rate,112.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.17,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,130.91,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.54,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
(OT) NEUROMUSC REED-EA 15 MIN,57053795,CDM,430,RC,97112,HCPCS,Outpatient,,,185.96,111.58,GO   ,16.1,100,,,Case Rate,Pays based on per visit rate,49.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,114.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.45,360,,,Fee Schedule,360% of BCBS POS Rate,128.45,360,,,Fee schedule,360% of BCBS PPO Rate,128.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.41,90,,,Fee Schedule,90% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.48,130,,,Fee Schedule,130% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.82,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,139.47,75,,61.44,Percent of Total Billed Charges,75% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,150,,,Fee Schedule,150% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,185.96,100,,81.92,Percent of Total Billed Charges,100% of Total Billed Charges,16.1,194,
(ST) APHASIA ASSESSMENT EA HR,57054330,CDM,444,RC,96105,HCPCS,Outpatient,,,474.66,284.80,GN   ,74.69,100,,,Fee Schedule,100% of Aetna Fee Schedule,140.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,132.9,28,,106.32,Percent of Total Billed Charges,28% of Total Billed Charges,269.36,32,,215.488,Percent of Total Billed Charges,32% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,170.88,36,,136.704,Percent of Total Billed Charges,36% of Total Billed Charges,170.88,36,,136.704,Percent of Total Billed Charges,36% Total Bille Charges,170.88,36,,136.704,Percent of Total Billed Charges,36% of Total Billed Charges,194,100,,,Case Rate,Pays based on per visit rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,84.39,90,,,Fee Schedule,90% of CMS OPPS Rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,121.9,130,,,Fee Schedule,130% of CMS OPPS Rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,68.45,14.42,,54.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,96.58,103,,,Fee Schedule,103% of CMS OPPS Rate,96.58,103,,,Fee Schedule,103% of CMS OPPS Rate,356,75,,1404.088,Percent of Total Billed Charges,75% of Total Billed Charges,237.33,50,,189.864,Percent of Total Billed Charges,50% of Total Billed Charges,237.33,50,,189.864,Percent of Total Billed Charges,50% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,237.33,50,,189.864,Percent of Total Billed Charges,50% of Total Billed Charges,237.33,50,,189.864,Percent of Total Billed Charges,50% of Total Billed Charges,140.66,150,,,Fee Schedule,150% of CMS OPPS Rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,66.45,14,,53.16,Percent of Total Billed Charges,14% of Total Billed Charges,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,474.66,100,,1872.12,Percent of Total Billed Charges,100% of Total Billed Charges,66.45,474.66,
(ST) COGNITIVE DEVEL-EA 15 MIN,57054454,CDM,430,RC,97129,HCPCS,Outpatient,,,145.91,87.55,GN   ,10.62,100,,,Case Rate,Pays based on per visit rate,32.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,67.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,86.94,360,,,Fee Schedule,360% of BCBS POS Rate,86.94,360,,,Fee schedule,360% of BCBS PPO Rate,86.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,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,19.5,90,,,Fee Schedule,90% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,130,,,Fee Schedule,130% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,109.43,75,,127.248,Percent of Total Billed Charges,75% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,32.51,150,,,Fee Schedule,150% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,145.91,100,,169.664,Percent of Total Billed Charges,100% of Total Billed Charges,10.62,194,
(ST) COG DEVEL-EA ADDL 15 MIN,57054455,CDM,440,RC,97130,HCPCS,Outpatient,,,145.91,87.55,GN   ,10.14,100,,,Case Rate,Pays based on per visit rate,31.04,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,84.35,360,,,Fee Schedule,360% of BCBS POS Rate,84.35,360,,,Fee schedule,360% of BCBS PPO Rate,84.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,,Fee Schedule,90% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.9,130,,,Fee Schedule,130% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,21.31,103,,,Fee Schedule,103% of CMS OPPS Rate,21.31,103,,,Fee Schedule,103% of CMS OPPS Rate,109.43,75,,72.48,Percent of Total Billed Charges,75% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,31.04,150,,,Fee Schedule,150% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,145.91,100,,96.64,Percent of Total Billed Charges,100% of Total Billed Charges,10.14,194,
(ST) STND COGNITIVE TEST EA HR,57054553,CDM,444,RC,96125,HCPCS,Outpatient,,,461.7,277.02,GN   ,79,100,,,Fee Schedule,100% of Aetna Fee Schedule,149.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,359.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,404.78,360,,,Fee Schedule,360% of BCBS POS Rate,404.78,360,,,Fee schedule,360% of BCBS PPO Rate,404.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,89.69,90,,,Fee Schedule,90% of CMS OPPS Rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,129.56,130,,,Fee Schedule,130% of CMS OPPS Rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,66.58,14.42,,53.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,102.65,103,,,Fee Schedule,103% of CMS OPPS Rate,102.65,103,,,Fee Schedule,103% of CMS OPPS Rate,346.28,75,,63.48,Percent of Total Billed Charges,75% of Total Billed Charges,230.85,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,230.85,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,230.85,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,230.85,50,,184.68,Percent of Total Billed Charges,50% of Total Billed Charges,149.49,150,,,Fee Schedule,150% of CMS OPPS Rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,64.64,14,,51.712,Percent of Total Billed Charges,14% of Total Billed Charges,99.66,100,,,Fee Schedule,100% of CMS OPPS Rate,461.7,100,,84.64,Percent of Total Billed Charges,100% of Total Billed Charges,64.64,461.7,
(ST) TREATMENT OF SPEECH-15 MIN,57055100,CDM,440,RC,92507,HCPCS,Outpatient,,,296.04,177.62,,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,42.69,14.42,,34.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,222.03,75,,303.544,Percent of Total Billed Charges,75% of Total Billed Charges,148.02,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,148.02,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,148.02,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,148.02,50,,118.416,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,41.45,14,,33.16,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,296.04,100,,404.72,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,296.04,
(ST) TREATMENT-30 MIN,57055101,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,98.064,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,130.752,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(ST) TREATMENT-45 MIN,57055102,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,82.8,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,110.4,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(ST) TREATMENT-60 MIN,57055103,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,210.696,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,280.928,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(ST) TREATMENT-90 MIN,57055105,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,84.72,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,112.96,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(ST) SWALLOW TREAT-15 MIN,57055116,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,88.744,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,118.32,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-30 MIN,57055117,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,658.32,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,877.76,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-45 MIN,57055118,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,511.08,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,681.44,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-60 MIN,57055119,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,442.8,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,590.4,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-90 MIN,57055121,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,541.128,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,721.504,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) VOICE PROSTHETIC EVAL-15,57055124,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,83.136,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,110.848,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) VOICE PROSTHETIC EVAL-30,57055125,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,91.488,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,121.984,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) VOICE PROSTHETIC EVAL-45,57055126,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,206.632,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,275.504,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) VOICE PROSTHETIC EVAL-60,57055127,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,110.016,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,146.688,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) VOICE PROSTHETIC EVAL-90,57055129,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,164.04,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,218.72,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) VOICE PROSTHETIC EVAL-120,57055131,CDM,440,RC,92597,HCPCS,Outpatient,,,460,276.00,,53.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,90,,,Fee Schedule,90% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,91.72,130,,,Fee Schedule,130% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,66.33,14.42,,53.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.67,103,,,Fee Schedule,103% of CMS OPPS Rate,345,75,,164.04,Percent of Total Billed Charges,75% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,230,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,105.83,150,,,Fee Schedule,150% of CMS OPPS Rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,64.4,14,,51.52,Percent of Total Billed Charges,14% of Total Billed Charges,70.55,100,,,Fee Schedule,100% of CMS OPPS Rate,460,100,,218.72,Percent of Total Billed Charges,100% of Total Billed Charges,53.65,460,
(ST) EVAL SPEECH FLUENCY-30,57055133,CDM,440,RC,92521,HCPCS,Outpatient,,,533.41,320.05,GN   ,69.3,100,,,Case Rate,Pays based on per visit rate,194.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,323.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,416.48,360,,,Fee Schedule,360% of BCBS POS Rate,416.48,360,,,Fee schedule,360% of BCBS PPO Rate,416.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,116.63,90,,,Fee Schedule,90% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,168.47,130,,,Fee Schedule,130% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14.42,,61.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,133.48,103,,,Fee Schedule,103% of CMS OPPS Rate,133.48,103,,,Fee Schedule,103% of CMS OPPS Rate,400.06,75,,167.64,Percent of Total Billed Charges,75% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,194.39,150,,,Fee Schedule,150% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,533.41,100,,223.52,Percent of Total Billed Charges,100% of Total Billed Charges,69.3,533.41,
(ST) EVAL SOUND PRODUCTION-15 MIN,57055174,CDM,440,RC,92522,HCPCS,Outpatient,,,436.96,262.18,,57.77,100,,,Case Rate,Pays based on per visit rate,162.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,262.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,337.32,360,,,Fee Schedule,360% of BCBS POS Rate,337.32,360,,,Fee schedule,360% of BCBS PPO Rate,337.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,97.7,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,141.12,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,204.72,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,162.83,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,272.96,Percent of Total Billed Charges,100% of Total Billed Charges,57.77,436.96,
EVAL SOUND PRODUCTION 30MIN,57055177,CDM,444,RC,92522,HCPCS,Outpatient,,,534.73,320.84,,57.77,100,,,Case Rate,Pays based on per visit rate,162.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,262.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,337.32,360,,,Fee Schedule,360% of BCBS POS Rate,337.32,360,,,Fee schedule,360% of BCBS PPO Rate,337.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,97.7,90,,,Fee Schedule,90% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,141.12,130,,,Fee Schedule,130% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,77.11,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,401.05,75,,204.72,Percent of Total Billed Charges,75% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,162.83,150,,,Fee Schedule,150% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,534.73,100,,272.96,Percent of Total Billed Charges,100% of Total Billed Charges,57.77,534.73,
EVAL SOUND PRODUCTION 45MIN,57055180,CDM,444,RC,92522,HCPCS,Outpatient,,,534.73,320.84,,57.77,100,,,Case Rate,Pays based on per visit rate,162.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,262.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,337.32,360,,,Fee Schedule,360% of BCBS POS Rate,337.32,360,,,Fee schedule,360% of BCBS PPO Rate,337.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,97.7,90,,,Fee Schedule,90% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,141.12,130,,,Fee Schedule,130% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,77.11,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,401.05,75,,96.144,Percent of Total Billed Charges,75% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,162.83,150,,,Fee Schedule,150% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,534.73,100,,128.192,Percent of Total Billed Charges,100% of Total Billed Charges,57.77,534.73,
EVAL SOUND PRODUCTION 60 MIN,57055183,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
(ST) EVAL SOUND PRODUCTION-90,57055189,CDM,440,RC,92522,HCPCS,Outpatient,,,534.73,320.84,GN   ,57.77,100,,,Case Rate,Pays based on per visit rate,162.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,262.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,337.32,360,,,Fee Schedule,360% of BCBS POS Rate,337.32,360,,,Fee schedule,360% of BCBS PPO Rate,337.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,97.7,90,,,Fee Schedule,90% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,141.12,130,,,Fee Schedule,130% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,77.11,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,401.05,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,162.83,150,,,Fee Schedule,150% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,534.73,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,57.77,534.73,
(ST) EVAL LANGUAGE EXPRESS-15 MIN,57055200,CDM,440,RC,92523,HCPCS,Outpatient,,,436.96,262.18,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,61.17,718.78,
EVAL LANGUAGE EXPRESS 30MIN,57055201,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,80.592,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,107.456,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
EVAL LANGUAGE EXPRESS 45MIN,57055202,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,80.592,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,107.456,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
EVAL LANGUAGE EXPRESS 60MIN,57055203,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
EVAL LANGUAGE EXPRESS 90MIN,57055204,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
(ST) EVAL QUAL OF VOICE-15 MIN,57055206,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
EVAL QUAL OF VOICE 30MIN,57055207,CDM,444,RC,92524,HCPCS,Outpatient,,,562.98,337.79,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,81.18,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,422.24,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,562.98,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,562.98,
EVAL QUAL OF VOICE 45 MIN,57055208,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
EVAL QUAL OF VOICE 60 MIN,57055209,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,114.768,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,153.024,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
EVAL QUAL OF VOICE 90 MIN,57055210,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,395.416,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
(ST) BEDSIDE SWALLOW EVAL-120,57055212,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,327.84,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,437.12,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-15 MIN,57055213,CDM,440,RC,92610,HCPCS,Outpatient,,,109.24,65.54,,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.75,14.42,,12.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,81.93,75,,327.84,Percent of Total Billed Charges,75% of Total Billed Charges,54.62,50,,43.696,Percent of Total Billed Charges,50% of Total Billed Charges,54.62,50,,43.696,Percent of Total Billed Charges,50% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,54.62,50,,43.696,Percent of Total Billed Charges,50% of Total Billed Charges,54.62,50,,43.696,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,15.29,14,,12.232,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,109.24,100,,437.12,Percent of Total Billed Charges,100% of Total Billed Charges,15.29,267.26,
(ST) BEDSIDE SWALLOW EVAL-30,57055214,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,132.632,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,176.84,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-45,57055215,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,114.992,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,153.32,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-60,57055216,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,64.8,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,86.4,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-90,57055217,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,331.68,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,442.24,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) DYSPHAGIAGRAM-15 MIN,57055219,CDM,440,RC,92611,HCPCS,Outpatient,,,258.18,154.91,,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,37.23,14.42,,29.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,193.64,75,,185.848,Percent of Total Billed Charges,75% of Total Billed Charges,129.09,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,129.09,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,129.09,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,129.09,50,,103.272,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,36.15,14,,28.92,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,258.18,100,,247.8,Percent of Total Billed Charges,100% of Total Billed Charges,36.15,330.84,
(ST) DYSPHAGIAGRAM-30 MIN,57055220,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,33.096,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,44.128,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(ST) DYSPHAGIAGRAM-45 MIN,57055221,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,492.808,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,657.08,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(ST) DYSPHAGIAGRAM-60 MIN,57055222,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(ST) DYSPHAGIAGRAM-90 MIN,57055223,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,2230.216,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,2973.624,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(PT) GRP THERAPY-30 MIN,57055238,CDM,420,RC,97150,HCPCS,Outpatient,,,203.15,121.89,GP   ,8.29,100,,,Case Rate,Pays based on per visit rate,26.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,,Fee Schedule,360% of BCBS POS Rate,67.46,360,,,Fee schedule,360% of BCBS PPO Rate,67.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,90,,,Fee Schedule,90% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,22.76,130,,,Fee Schedule,130% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,152.36,75,,130.352,Percent of Total Billed Charges,75% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,26.27,150,,,Fee Schedule,150% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,203.15,100,,173.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.29,203.15,
(PT) GRP THERAPY-45 MIN,57055239,CDM,420,RC,97150,HCPCS,Outpatient,,,203.15,121.89,GP   ,8.29,100,,,Case Rate,Pays based on per visit rate,26.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,,Fee Schedule,360% of BCBS POS Rate,67.46,360,,,Fee schedule,360% of BCBS PPO Rate,67.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,90,,,Fee Schedule,90% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,22.76,130,,,Fee Schedule,130% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,152.36,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,26.27,150,,,Fee Schedule,150% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,203.15,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.29,203.15,
(OT) ORTH FIT/TRAIN-EA 15 MIN,57055249,CDM,430,RC,97760,HCPCS,Outpatient,,,184.31,110.59,GO   ,23.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,68.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,155.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,175.14,360,,,Fee Schedule,360% of BCBS POS Rate,175.14,360,,,Fee schedule,360% of BCBS PPO Rate,175.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.3,90,,,Fee Schedule,90% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,130,,,Fee Schedule,130% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,26.58,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,138.23,75,,42.592,Percent of Total Billed Charges,75% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,68.84,150,,,Fee Schedule,150% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,184.31,100,,56.784,Percent of Total Billed Charges,100% of Total Billed Charges,23.02,194,
(PT) EVAL LOW COMPLEXITY,57055273,CDM,420,RC,97161,HCPCS,Outpatient,,,315.34,189.20,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,45.47,14.42,,36.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,236.51,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,315.34,100,,109.6,Percent of Total Billed Charges,100% of Total Billed Charges,44.15,315.34,
(PT) EVAL MOD COMPLEXITY,57055274,CDM,420,RC,97162,HCPCS,Outpatient,,,339.1,203.46,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,48.9,14.42,,39.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,254.33,75,,1248.976,Percent of Total Billed Charges,75% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,339.1,100,,1665.304,Percent of Total Billed Charges,100% of Total Billed Charges,46.59,339.1,
(PT) EVAL HIGH COMPLEXITY,57055275,CDM,420,RC,97163,HCPCS,Outpatient,,,363.45,218.07,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,52.41,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,272.59,75,,1854.72,Percent of Total Billed Charges,75% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,363.45,100,,2472.96,Percent of Total Billed Charges,100% of Total Billed Charges,46.59,363.45,
(PT) RE-EVAL,57055276,CDM,420,RC,97164,HCPCS,Outpatient,,,124.53,74.72,GP   ,31.87,100,,,Case Rate,Pays based on per visit rate,101.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,164.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,187.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,211.46,360,,,Fee Schedule,360% of BCBS POS Rate,211.46,360,,,Fee schedule,360% of BCBS PPO Rate,211.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,60.74,90,,,Fee Schedule,90% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,87.74,130,,,Fee Schedule,130% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.96,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,69.51,103,,,Fee Schedule,103% of CMS OPPS Rate,69.51,103,,,Fee Schedule,103% of CMS OPPS Rate,93.4,75,,181.736,Percent of Total Billed Charges,75% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,101.24,150,,,Fee Schedule,150% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,124.53,100,,242.312,Percent of Total Billed Charges,100% of Total Billed Charges,17.43,211.46,
(OT) EVAL LOW COMPLEXITY,57055277,CDM,430,RC,97165,HCPCS,Outpatient,,,307.52,184.51,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,44.34,14.42,,35.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,230.64,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,307.52,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,43.05,334.73,
(OT) EVAL MOD COMPLEXITY,57055278,CDM,430,RC,97166,HCPCS,Outpatient,,,347.37,208.42,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,50.09,14.42,,40.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,260.53,75,,332.4,Percent of Total Billed Charges,75% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,347.37,100,,443.2,Percent of Total Billed Charges,100% of Total Billed Charges,45.14,347.37,
(OT) EVAL HIGH COMPLEXITY,57055279,CDM,430,RC,97167,HCPCS,Outpatient,,,363.45,218.07,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,52.41,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,272.59,75,,861.288,Percent of Total Billed Charges,75% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,363.45,100,,1148.384,Percent of Total Billed Charges,100% of Total Billed Charges,45.14,363.45,
(OT) RE-EVAL,57055280,CDM,430,RC,97168,HCPCS,Outpatient,,,269.67,161.80,GO   ,30.42,100,,,Case Rate,Pays based on per visit rate,101.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,178.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,,Fee Schedule,360% of BCBS POS Rate,229.64,360,,,Fee schedule,360% of BCBS PPO Rate,229.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,61.02,90,,,Fee Schedule,90% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,88.14,130,,,Fee Schedule,130% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,38.89,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,69.83,103,,,Fee Schedule,103% of CMS OPPS Rate,69.83,103,,,Fee Schedule,103% of CMS OPPS Rate,202.25,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,101.7,150,,,Fee Schedule,150% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,269.67,100,,101.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.42,269.67,
VASOPNEUMATIC  DEVICE,57056103,CDM,420,RC,97016,HCPCS,Outpatient,,,72.6,43.56,,5.55,100,,,Case Rate,Pays based on per visit rate,17,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,36.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,46.69,360,,,Fee Schedule,360% of BCBS POS Rate,46.69,360,,,Fee schedule,360% of BCBS PPO Rate,46.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.2,90,,,Fee Schedule,90% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,14.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14.42,,8.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,11.67,103,,,Fee Schedule,103% of CMS OPPS Rate,11.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.45,75,,113.816,Percent of Total Billed Charges,75% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,17,150,,,Fee Schedule,150% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,72.6,100,,151.752,Percent of Total Billed Charges,100% of Total Billed Charges,5.55,194,
(ST) EVAL QUAL OF VOICE 60MIN,57150054,CDM,440,RC,92524,HCPCS,Outpatient,,,436.96,262.18,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.01,14.42,,50.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,327.72,75,,736,Percent of Total Billed Charges,75% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,218.48,50,,174.784,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,61.17,14,,48.936,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.96,100,,981.336,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,436.96,
(PT) ORTH FIT/TRAIN-EA 15 MIN (OP),57153447,CDM,420,RC,97760,HCPCS,Outpatient,,,184.31,110.59,GP   ,23.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,68.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,155.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,175.14,360,,,Fee Schedule,360% of BCBS POS Rate,175.14,360,,,Fee schedule,360% of BCBS PPO Rate,175.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.3,90,,,Fee Schedule,90% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,130,,,Fee Schedule,130% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,26.58,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,138.23,75,,1523.016,Percent of Total Billed Charges,75% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,68.84,150,,,Fee Schedule,150% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,184.31,100,,2030.688,Percent of Total Billed Charges,100% of Total Billed Charges,23.02,194,
EVAL SOUND PRODUCTION 45MIN (OP),57155008,CDM,444,RC,92522,HCPCS,Outpatient,,,534.73,320.84,,57.77,100,,,Case Rate,Pays based on per visit rate,162.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,262.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,299.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,337.32,360,,,Fee Schedule,360% of BCBS POS Rate,337.32,360,,,Fee schedule,360% of BCBS PPO Rate,337.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,97.7,90,,,Fee Schedule,90% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,141.12,130,,,Fee Schedule,130% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,77.11,14.42,,61.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,111.81,103,,,Fee Schedule,103% of CMS OPPS Rate,401.05,75,,4247.376,Percent of Total Billed Charges,75% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,267.37,50,,213.896,Percent of Total Billed Charges,50% of Total Billed Charges,162.83,150,,,Fee Schedule,150% of CMS OPPS Rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,74.86,14,,59.888,Percent of Total Billed Charges,14% of Total Billed Charges,108.55,100,,,Fee Schedule,100% of CMS OPPS Rate,534.73,100,,5663.168,Percent of Total Billed Charges,100% of Total Billed Charges,57.77,534.73,
EVAL SPEECH FLUENCY 30MIN (OP),57155013,CDM,444,RC,92521,HCPCS,Outpatient,,,533.41,320.05,,69.3,100,,,Case Rate,Pays based on per visit rate,194.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,323.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,416.48,360,,,Fee Schedule,360% of BCBS POS Rate,416.48,360,,,Fee schedule,360% of BCBS PPO Rate,416.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,116.63,90,,,Fee Schedule,90% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,168.47,130,,,Fee Schedule,130% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14.42,,61.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,133.48,103,,,Fee Schedule,103% of CMS OPPS Rate,133.48,103,,,Fee Schedule,103% of CMS OPPS Rate,400.06,75,,40.096,Percent of Total Billed Charges,75% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,266.71,50,,213.368,Percent of Total Billed Charges,50% of Total Billed Charges,194.39,150,,,Fee Schedule,150% of CMS OPPS Rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,74.68,14,,59.744,Percent of Total Billed Charges,14% of Total Billed Charges,129.59,100,,,Fee Schedule,100% of CMS OPPS Rate,533.41,100,,53.456,Percent of Total Billed Charges,100% of Total Billed Charges,69.3,533.41,
(ST) SWALLOW TREAT-15 MIN,57155030,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,58.816,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,78.424,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-30 MIN,57155031,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,75.504,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,100.672,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-45 MIN,57155032,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,114.296,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,152.392,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-60 MIN,57155033,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) SWALLOW TREAT-90 MIN,57155034,CDM,440,RC,92526,HCPCS,Outpatient,,,298.35,179.01,GN   ,64.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,123.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,246.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,281.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,316.58,360,,,Fee Schedule,360% of BCBS POS Rate,316.58,360,,,Fee schedule,360% of BCBS PPO Rate,316.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,90,,,Fee Schedule,90% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,107.04,130,,,Fee Schedule,130% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,43.02,14.42,,34.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,84.81,103,,,Fee Schedule,103% of CMS OPPS Rate,223.76,75,,236.432,Percent of Total Billed Charges,75% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,149.18,50,,119.344,Percent of Total Billed Charges,50% of Total Billed Charges,123.51,150,,,Fee Schedule,150% of CMS OPPS Rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,41.77,14,,33.416,Percent of Total Billed Charges,14% of Total Billed Charges,82.34,100,,,Fee Schedule,100% of CMS OPPS Rate,298.35,100,,315.24,Percent of Total Billed Charges,100% of Total Billed Charges,41.77,316.58,
(ST) TREATMENT-30 MIN,57155037,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,48.128,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,64.168,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(PT) THERAPEUTIC ACT-EA 15 MIN,57155038,CDM,420,RC,97530,HCPCS,Outpatient,,,147.16,88.30,GP   ,18.03,100,,,Case Rate,Pays based on per visit rate,53.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,114.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,,Fee Schedule,360% of BCBS POS Rate,146.59,360,,,Fee schedule,360% of BCBS PPO Rate,146.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,31.86,90,,,Fee Schedule,90% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,46.02,130,,,Fee Schedule,130% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,110.37,75,,64.408,Percent of Total Billed Charges,75% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,53.1,150,,,Fee Schedule,150% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.16,100,,85.88,Percent of Total Billed Charges,100% of Total Billed Charges,18.03,194,
(ST) TREATMENT-45 MIN,57155039,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,369.856,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,493.144,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(ST) TREATMENT-60 MIN,57155040,CDM,440,RC,92507,HCPCS,Outpatient,,,395,237.00,GN   ,39.61,100,,,Case Rate,Pays based on per visit rate,111.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,225.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,257.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,289.33,360,,,Fee Schedule,360% of BCBS POS Rate,289.33,360,,,Fee schedule,360% of BCBS PPO Rate,289.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,66.96,90,,,Fee Schedule,90% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,96.72,130,,,Fee Schedule,130% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,56.96,14.42,,45.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,76.63,103,,,Fee Schedule,103% of CMS OPPS Rate,296.25,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,197.5,50,,158,Percent of Total Billed Charges,50% of Total Billed Charges,111.6,150,,,Fee Schedule,150% of CMS OPPS Rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,14,,44.24,Percent of Total Billed Charges,14% of Total Billed Charges,74.4,100,,,Fee Schedule,100% of CMS OPPS Rate,395,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,39.61,395,
(PT) MANUAL THERAPY-EA 15 MIN,57155152,CDM,420,RC,97140,HCPCS,Outpatient,,,183.83,110.30,GP   ,12.72,100,,,Case Rate,Pays based on per visit rate,39.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,79.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,91.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,102.49,360,,,Fee Schedule,360% of BCBS POS Rate,102.49,360,,,Fee schedule,360% of BCBS PPO Rate,102.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,90,,,Fee Schedule,90% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,34.14,130,,,Fee Schedule,130% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.51,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,137.87,75,,358.824,Percent of Total Billed Charges,75% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,39.39,150,,,Fee Schedule,150% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,183.83,100,,478.432,Percent of Total Billed Charges,100% of Total Billed Charges,12.72,194,
EVAL LANGUAGE EXPRESS 30 MIN,57155201,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,114.168,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,152.224,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
(PT) ELECTRICAL STIM-EA 15 MIN,57155202,CDM,420,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GP   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,359.896,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,479.856,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
EVAL LANGUAGE EXPRESS 60 MIN,57155203,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,123.16,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,164.216,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
EVAL LANGUAGE EXPRESS 90 MIN,57155204,CDM,444,RC,92523,HCPCS,Outpatient,,,615.25,369.15,,119.19,100,,,Case Rate,Pays based on per visit rate,333.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,559.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,638.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,718.78,360,,,Fee Schedule,360% of BCBS POS Rate,718.78,360,,,Fee schedule,360% of BCBS PPO Rate,718.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.94,90,,,Fee Schedule,90% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,288.8,130,,,Fee Schedule,130% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,88.72,14.42,,70.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,228.81,103,,,Fee Schedule,103% of CMS OPPS Rate,461.44,75,,190.888,Percent of Total Billed Charges,75% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,307.63,50,,246.104,Percent of Total Billed Charges,50% of Total Billed Charges,333.23,150,,,Fee Schedule,150% of CMS OPPS Rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,86.14,14,,68.912,Percent of Total Billed Charges,14% of Total Billed Charges,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,615.25,100,,254.52,Percent of Total Billed Charges,100% of Total Billed Charges,86.14,718.78,
EVAL QUAL OF VOICE 30 MIN,57155207,CDM,444,RC,92524,HCPCS,Outpatient,,,562.98,337.79,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,81.18,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,422.24,75,,155.832,Percent of Total Billed Charges,75% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,562.98,100,,207.776,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,562.98,
EVAL QUAL OF VOICE 45 MIN,57155208,CDM,444,RC,92524,HCPCS,Outpatient,,,562.98,337.79,,56.61,100,,,Case Rate,Pays based on per visit rate,160.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,289.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,325.66,360,,,Fee Schedule,360% of BCBS POS Rate,325.66,360,,,Fee schedule,360% of BCBS PPO Rate,325.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,90,,,Fee Schedule,90% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.07,130,,,Fee Schedule,130% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,81.18,14.42,,64.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,110.19,103,,,Fee Schedule,103% of CMS OPPS Rate,422.24,75,,125.264,Percent of Total Billed Charges,75% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,281.49,50,,225.192,Percent of Total Billed Charges,50% of Total Billed Charges,160.47,150,,,Fee Schedule,150% of CMS OPPS Rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,78.82,14,,63.056,Percent of Total Billed Charges,14% of Total Billed Charges,106.98,100,,,Fee Schedule,100% of CMS OPPS Rate,562.98,100,,167.016,Percent of Total Billed Charges,100% of Total Billed Charges,56.61,562.98,
(ST) BEDSIDE SWALLOW EVAL-15,57155213,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,168.152,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,224.2,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-30,57155214,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,156.72,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,208.96,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-45,57155215,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,149.84,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,199.784,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) BEDSIDE SWALLOW EVAL-60,57155216,CDM,444,RC,92610,HCPCS,Outpatient,,,454.75,272.85,GN   ,52.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,102.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.87,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,237.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,267.26,360,,,Fee Schedule,360% of BCBS POS Rate,267.26,360,,,Fee schedule,360% of BCBS PPO Rate,267.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,90,,,Fee Schedule,90% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,88.95,130,,,Fee Schedule,130% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,65.57,14.42,,52.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,70.47,103,,,Fee Schedule,103% of CMS OPPS Rate,341.06,75,,1994.416,Percent of Total Billed Charges,75% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,227.38,50,,181.904,Percent of Total Billed Charges,50% of Total Billed Charges,102.63,150,,,Fee Schedule,150% of CMS OPPS Rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,63.67,14,,50.936,Percent of Total Billed Charges,14% of Total Billed Charges,68.42,100,,,Fee Schedule,100% of CMS OPPS Rate,454.75,100,,2659.224,Percent of Total Billed Charges,100% of Total Billed Charges,52.34,454.75,
(ST) DYSPHAGIAGRAM-30,57155220,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,1994.416,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,2659.224,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(ST) DYSPHAGIAGRAM-45 MIN,57155221,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,1818.912,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,2425.216,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(ST) DYSPHAGIAGRAM-60 MIN,57155222,CDM,440,RC,92611,HCPCS,Outpatient,,,713,427.80,GN   ,69.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,133.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,257.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,294.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,330.84,360,,,Fee Schedule,360% of BCBS POS Rate,330.84,360,,,Fee schedule,360% of BCBS PPO Rate,330.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,80.32,90,,,Fee Schedule,90% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,116.01,130,,,Fee Schedule,130% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,102.81,14.42,,82.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,91.92,103,,,Fee Schedule,103% of CMS OPPS Rate,534.75,75,,1818.912,Percent of Total Billed Charges,75% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,356.5,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,133.86,150,,,Fee Schedule,150% of CMS OPPS Rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,99.82,14,,79.856,Percent of Total Billed Charges,14% of Total Billed Charges,89.24,100,,,Fee Schedule,100% of CMS OPPS Rate,713,100,,2425.216,Percent of Total Billed Charges,100% of Total Billed Charges,69.1,713,
(PT) GRP THERAPY-45 MIN,57155239,CDM,420,RC,97150,HCPCS,Outpatient,,,203.15,121.89,GP   ,8.29,100,,,Case Rate,Pays based on per visit rate,26.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,67.46,360,,,Fee Schedule,360% of BCBS POS Rate,67.46,360,,,Fee schedule,360% of BCBS PPO Rate,67.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,90,,,Fee Schedule,90% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,22.76,130,,,Fee Schedule,130% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.29,14.42,,23.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,18.04,103,,,Fee Schedule,103% of CMS OPPS Rate,152.36,75,,2948.4,Percent of Total Billed Charges,75% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,101.58,50,,81.264,Percent of Total Billed Charges,50% of Total Billed Charges,26.27,150,,,Fee Schedule,150% of CMS OPPS Rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,28.44,14,,22.752,Percent of Total Billed Charges,14% of Total Billed Charges,17.51,100,,,Fee Schedule,100% of CMS OPPS Rate,203.15,100,,3931.2,Percent of Total Billed Charges,100% of Total Billed Charges,8.29,203.15,
(OT) ORTH FIT/TRAIN-EA 15 MIN,57155243,CDM,430,RC,97760,HCPCS,Outpatient,,,184.31,110.59,GO   ,23.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,68.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,155.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,175.14,360,,,Fee Schedule,360% of BCBS POS Rate,175.14,360,,,Fee schedule,360% of BCBS PPO Rate,175.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.3,90,,,Fee Schedule,90% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,130,,,Fee Schedule,130% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,26.58,14.42,,21.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,47.27,103,,,Fee Schedule,103% of CMS OPPS Rate,138.23,75,,667.456,Percent of Total Billed Charges,75% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,92.16,50,,73.728,Percent of Total Billed Charges,50% of Total Billed Charges,68.84,150,,,Fee Schedule,150% of CMS OPPS Rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,25.8,14,,20.64,Percent of Total Billed Charges,14% of Total Billed Charges,45.89,100,,,Fee Schedule,100% of CMS OPPS Rate,184.31,100,,889.936,Percent of Total Billed Charges,100% of Total Billed Charges,23.02,194,
(OT) HEAT/ICE,57155262,CDM,430,RC,97010,HCPCS,Outpatient,,,43.56,26.14,GO   ,2.82,100,,,Case Rate,Pays based on per visit rate,9.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,23.36,360,,,Fee Schedule,360% of BCBS POS Rate,23.36,360,,,Fee schedule,360% of BCBS PPO Rate,23.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.47,90,,,Fee Schedule,90% of CMS OPPS Rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7.9,130,,,Fee Schedule,130% of CMS OPPS Rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.28,14.42,,5.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,6.26,103,,,Fee Schedule,103% of CMS OPPS Rate,6.26,103,,,Fee Schedule,103% of CMS OPPS Rate,32.67,75,,768.432,Percent of Total Billed Charges,75% of Total Billed Charges,21.78,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,21.78,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,21.78,50,,17.424,Percent of Total Billed Charges,50% of Total Billed Charges,9.12,150,,,Fee Schedule,150% of CMS OPPS Rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.1,14,,4.88,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,100,,,Fee Schedule,100% of CMS OPPS Rate,43.56,100,,1024.576,Percent of Total Billed Charges,100% of Total Billed Charges,2.82,194,
(PT) EVAL LOW COMPLEXITY,57155273,CDM,420,RC,97161,HCPCS,Outpatient,,,315.34,189.20,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,45.47,14.42,,36.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,236.51,75,,365.512,Percent of Total Billed Charges,75% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,157.67,50,,126.136,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,44.15,14,,35.32,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,315.34,100,,487.344,Percent of Total Billed Charges,100% of Total Billed Charges,44.15,315.34,
(PT) EVAL MOD COMPLEXITY,57155274,CDM,420,RC,97162,HCPCS,Outpatient,,,339.1,203.46,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,48.9,14.42,,39.12,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,254.33,75,,1221.616,Percent of Total Billed Charges,75% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,169.55,50,,135.64,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,47.47,14,,37.976,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,339.1,100,,1628.816,Percent of Total Billed Charges,100% of Total Billed Charges,46.59,339.1,
(PT) EVAL HIGH COMPLEXITY,57155275,CDM,420,RC,97163,HCPCS,Outpatient,,,363.45,218.07,GP   ,46.59,100,,,Case Rate,Pays based on per visit rate,146.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,242.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,276.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,311.36,360,,,Fee Schedule,360% of BCBS POS Rate,311.36,360,,,Fee schedule,360% of BCBS PPO Rate,311.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,90,,,Fee Schedule,90% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,130,,,Fee Schedule,130% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,52.41,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,100.4,103,,,Fee Schedule,103% of CMS OPPS Rate,272.59,75,,511.048,Percent of Total Billed Charges,75% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,146.22,150,,,Fee Schedule,150% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,97.48,100,,,Fee Schedule,100% of CMS OPPS Rate,363.45,100,,681.4,Percent of Total Billed Charges,100% of Total Billed Charges,46.59,363.45,
(PT) RE-EVAL,57155276,CDM,420,RC,97164,HCPCS,Outpatient,,,124.53,74.72,GP   ,31.87,100,,,Case Rate,Pays based on per visit rate,101.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,164.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,187.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,211.46,360,,,Fee Schedule,360% of BCBS POS Rate,211.46,360,,,Fee schedule,360% of BCBS PPO Rate,211.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,60.74,90,,,Fee Schedule,90% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,87.74,130,,,Fee Schedule,130% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.96,14.42,,14.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,69.51,103,,,Fee Schedule,103% of CMS OPPS Rate,69.51,103,,,Fee Schedule,103% of CMS OPPS Rate,93.4,75,,209.28,Percent of Total Billed Charges,75% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,62.27,50,,49.816,Percent of Total Billed Charges,50% of Total Billed Charges,101.24,150,,,Fee Schedule,150% of CMS OPPS Rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,17.43,14,,13.944,Percent of Total Billed Charges,14% of Total Billed Charges,67.49,100,,,Fee Schedule,100% of CMS OPPS Rate,124.53,100,,261.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.43,211.46,
(OT) EVAL LOW COMPLEXITY,57155277,CDM,430,RC,97165,HCPCS,Outpatient,,,307.52,184.51,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,44.34,14.42,,35.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,230.64,75,,209.28,Percent of Total Billed Charges,75% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,153.76,50,,123.008,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,43.05,14,,34.44,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,307.52,100,,261.6,Percent of Total Billed Charges,100% of Total Billed Charges,43.05,334.73,
(OT) EVAL MOD COMPLEXITY,57155278,CDM,430,RC,97166,HCPCS,Outpatient,,,347.37,208.42,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,50.09,14.42,,40.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,260.53,75,,724.048,Percent of Total Billed Charges,75% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,173.69,50,,138.952,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,48.63,14,,38.904,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,347.37,100,,905.056,Percent of Total Billed Charges,100% of Total Billed Charges,45.14,347.37,
(OT) EVAL HIGH COMPLEXITY,57155279,CDM,430,RC,97167,HCPCS,Outpatient,,,363.45,218.07,GO   ,45.14,100,,,Case Rate,Pays based on per visit rate,147.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,90,,,Fee Schedule,90% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.96,130,,,Fee Schedule,130% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,52.41,14.42,,41.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,101.38,103,,,Fee Schedule,103% of CMS OPPS Rate,272.59,75,,724.048,Percent of Total Billed Charges,75% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,181.73,50,,145.384,Percent of Total Billed Charges,50% of Total Billed Charges,147.65,150,,,Fee Schedule,150% of CMS OPPS Rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,50.88,14,,40.704,Percent of Total Billed Charges,14% of Total Billed Charges,98.43,100,,,Fee Schedule,100% of CMS OPPS Rate,363.45,100,,905.056,Percent of Total Billed Charges,100% of Total Billed Charges,45.14,363.45,
(OT) RE-EVAL,57155280,CDM,430,RC,97168,HCPCS,Outpatient,,,269.67,161.80,GO   ,30.42,100,,,Case Rate,Pays based on per visit rate,101.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,178.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,204.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,229.64,360,,,Fee Schedule,360% of BCBS POS Rate,229.64,360,,,Fee schedule,360% of BCBS PPO Rate,229.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,61.02,90,,,Fee Schedule,90% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,88.14,130,,,Fee Schedule,130% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,38.89,14.42,,31.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,69.83,103,,,Fee Schedule,103% of CMS OPPS Rate,69.83,103,,,Fee Schedule,103% of CMS OPPS Rate,202.25,75,,60,Percent of Total Billed Charges,75% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,134.84,50,,107.872,Percent of Total Billed Charges,50% of Total Billed Charges,101.7,150,,,Fee Schedule,150% of CMS OPPS Rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,37.75,14,,30.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.8,100,,,Fee Schedule,100% of CMS OPPS Rate,269.67,100,,80,Percent of Total Billed Charges,100% of Total Billed Charges,30.42,269.67,
(PT) ELECTRICAL STIM-EA MIN,57155293,CDM,420,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GP   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,60,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,80,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
(PT) SELF CARE-EA 15 MIN,57155533,CDM,420,RC,97535,HCPCS,Outpatient,,,168,100.80,GP   ,15.45,100,,,Case Rate,Pays based on per visit rate,47.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,97.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,111.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,125.86,360,,,Fee Schedule,360% of BCBS POS Rate,125.86,360,,,Fee schedule,360% of BCBS PPO Rate,125.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,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,28.48,90,,,Fee Schedule,90% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,130,,,Fee Schedule,130% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.23,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,126,75,,54.032,Percent of Total Billed Charges,75% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.46,150,,,Fee Schedule,150% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,72.04,Percent of Total Billed Charges,100% of Total Billed Charges,15.45,194,
(PT) EXERCISES-EA 15 MIN,57155699,CDM,420,RC,97110,HCPCS,Outpatient,,,174.54,104.72,GP   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,112.86,360,,,Fee Schedule,360% of BCBS POS Rate,112.86,360,,,Fee schedule,360% of BCBS PPO Rate,112.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.17,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,130.91,75,,48.36,Percent of Total Billed Charges,75% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.54,100,,64.48,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
(PT) NEUROMUSC REED-EA 15 MIN,57155707,CDM,420,RC,97112,HCPCS,Outpatient,,,185.96,111.58,GP   ,16.1,100,,,Case Rate,Pays based on per visit rate,49.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,114.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.45,360,,,Fee Schedule,360% of BCBS POS Rate,128.45,360,,,Fee schedule,360% of BCBS PPO Rate,128.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.41,90,,,Fee Schedule,90% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.48,130,,,Fee Schedule,130% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.82,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,139.47,75,,313.832,Percent of Total Billed Charges,75% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,150,,,Fee Schedule,150% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,185.96,100,,418.44,Percent of Total Billed Charges,100% of Total Billed Charges,16.1,194,
(PT) GAIT TRAINING-EA 15 MIN,57155731,CDM,420,RC,97116,HCPCS,Outpatient,,,161.1,96.66,GP   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,99.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,111.56,360,,,Fee Schedule,360% of BCBS POS Rate,111.56,360,,,Fee schedule,360% of BCBS PPO Rate,111.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,23.23,14.42,,18.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,120.83,75,,171.568,Percent of Total Billed Charges,75% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,80.55,50,,64.44,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,22.55,14,,18.04,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,161.1,100,,228.752,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
(OT) THERAPEUTIC ACT-15 MIN,57156036,CDM,430,RC,97530,HCPCS,Outpatient,,,147.16,88.30,GO   ,18.03,100,,,Case Rate,Pays based on per visit rate,53.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,114.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,146.59,360,,,Fee Schedule,360% of BCBS POS Rate,146.59,360,,,Fee schedule,360% of BCBS PPO Rate,146.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,31.86,90,,,Fee Schedule,90% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,46.02,130,,,Fee Schedule,130% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14.42,,16.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,36.46,103,,,Fee Schedule,103% of CMS OPPS Rate,110.37,75,,104.728,Percent of Total Billed Charges,75% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,73.58,50,,58.864,Percent of Total Billed Charges,50% of Total Billed Charges,53.1,150,,,Fee Schedule,150% of CMS OPPS Rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,20.6,14,,16.48,Percent of Total Billed Charges,14% of Total Billed Charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.16,100,,139.64,Percent of Total Billed Charges,100% of Total Billed Charges,18.03,194,
(OT) MANUAL THERAPY-EA 15 MIN,57156135,CDM,430,RC,97140,HCPCS,Outpatient,,,183.83,110.30,GO   ,12.72,100,,,Case Rate,Pays based on per visit rate,39.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,79.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,91.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,102.49,360,,,Fee Schedule,360% of BCBS POS Rate,102.49,360,,,Fee schedule,360% of BCBS PPO Rate,102.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,90,,,Fee Schedule,90% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,34.14,130,,,Fee Schedule,130% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.51,14.42,,21.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,27.05,103,,,Fee Schedule,103% of CMS OPPS Rate,137.87,75,,1343.56,Percent of Total Billed Charges,75% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,91.92,50,,73.536,Percent of Total Billed Charges,50% of Total Billed Charges,39.39,150,,,Fee Schedule,150% of CMS OPPS Rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,25.74,14,,20.592,Percent of Total Billed Charges,14% of Total Billed Charges,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,183.83,100,,1791.408,Percent of Total Billed Charges,100% of Total Billed Charges,12.72,194,
(OT) ELECTRICAL STIM-EA 15 MIN,57156259,CDM,430,RC,97032,HCPCS,Outpatient,,,166.34,99.80,GO   ,6.84,100,,,Case Rate,Pays based on per visit rate,20.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,90,,,Fee Schedule,90% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.17,130,,,Fee Schedule,130% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.99,14.42,,19.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,14.4,103,,,Fee Schedule,103% of CMS OPPS Rate,124.76,75,,541.8,Percent of Total Billed Charges,75% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,83.17,50,,66.536,Percent of Total Billed Charges,50% of Total Billed Charges,20.97,150,,,Fee Schedule,150% of CMS OPPS Rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,23.29,14,,18.632,Percent of Total Billed Charges,14% of Total Billed Charges,13.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.34,100,,722.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
(OT) SELF CARE-EA 15 MIN,57156432,CDM,430,RC,97535,HCPCS,Outpatient,,,168,100.80,GO   ,15.45,100,,,Case Rate,Pays based on per visit rate,47.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,97.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,111.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,125.86,360,,,Fee Schedule,360% of BCBS POS Rate,125.86,360,,,Fee schedule,360% of BCBS PPO Rate,125.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,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,28.48,90,,,Fee Schedule,90% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,130,,,Fee Schedule,130% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,24.23,14.42,,19.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,32.59,103,,,Fee Schedule,103% of CMS OPPS Rate,126,75,,663.52,Percent of Total Billed Charges,75% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,84,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.46,150,,,Fee Schedule,150% of CMS OPPS Rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,23.52,14,,18.816,Percent of Total Billed Charges,14% of Total Billed Charges,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,884.696,Percent of Total Billed Charges,100% of Total Billed Charges,15.45,194,
(OT) EXERCISES-EA 15 MIN,57156598,CDM,430,RC,97110,HCPCS,Outpatient,,,174.54,104.72,GO   ,13.84,100,,,Case Rate,Pays based on per visit rate,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,112.86,360,,,Fee Schedule,360% of BCBS POS Rate,112.86,360,,,Fee schedule,360% of BCBS PPO Rate,112.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.17,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,29.36,103,,,Fee Schedule,103% of CMS OPPS Rate,130.91,75,,819.52,Percent of Total Billed Charges,75% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,87.27,50,,69.816,Percent of Total Billed Charges,50% of Total Billed Charges,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,174.54,100,,1092.688,Percent of Total Billed Charges,100% of Total Billed Charges,13.84,194,
(OT) NEUROMUSC REED-EA 15 MIN,57156606,CDM,430,RC,97112,HCPCS,Outpatient,,,185.96,111.58,GO   ,16.1,100,,,Case Rate,Pays based on per visit rate,49.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,114.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,128.45,360,,,Fee Schedule,360% of BCBS POS Rate,128.45,360,,,Fee schedule,360% of BCBS PPO Rate,128.45,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.41,90,,,Fee Schedule,90% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.48,130,,,Fee Schedule,130% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.82,14.42,,21.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,33.66,103,,,Fee Schedule,103% of CMS OPPS Rate,139.47,75,,611.536,Percent of Total Billed Charges,75% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,92.98,50,,74.384,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,150,,,Fee Schedule,150% of CMS OPPS Rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,26.03,14,,20.824,Percent of Total Billed Charges,14% of Total Billed Charges,32.68,100,,,Fee Schedule,100% of CMS OPPS Rate,185.96,100,,815.384,Percent of Total Billed Charges,100% of Total Billed Charges,16.1,194,
(ST) COGNITIVE DEVEL-EA 15 MIN,57157497,CDM,440,RC,97129,HCPCS,Outpatient,,,145.91,87.55,GN   ,10.62,100,,,Case Rate,Pays based on per visit rate,32.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,67.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,86.94,360,,,Fee Schedule,360% of BCBS POS Rate,86.94,360,,,Fee schedule,360% of BCBS PPO Rate,86.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,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,19.5,90,,,Fee Schedule,90% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,130,,,Fee Schedule,130% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,109.43,75,,63.216,Percent of Total Billed Charges,75% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,32.51,150,,,Fee Schedule,150% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,145.91,100,,84.288,Percent of Total Billed Charges,100% of Total Billed Charges,10.62,194,
(ST) COG DEVEL-EA ADDL 15 MIN,57157498,CDM,440,RC,97130,HCPCS,Outpatient,,,145.91,87.55,GN   ,10.14,100,,,Case Rate,Pays based on per visit rate,31.04,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,84.35,360,,,Fee Schedule,360% of BCBS POS Rate,84.35,360,,,Fee schedule,360% of BCBS PPO Rate,84.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,90,,,Fee Schedule,90% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.9,130,,,Fee Schedule,130% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,21.04,14.42,,16.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,21.31,103,,,Fee Schedule,103% of CMS OPPS Rate,21.31,103,,,Fee Schedule,103% of CMS OPPS Rate,109.43,75,,62.688,Percent of Total Billed Charges,75% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,72.96,50,,58.368,Percent of Total Billed Charges,50% of Total Billed Charges,31.04,150,,,Fee Schedule,150% of CMS OPPS Rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.43,14,,16.344,Percent of Total Billed Charges,14% of Total Billed Charges,20.69,100,,,Fee Schedule,100% of CMS OPPS Rate,145.91,100,,83.584,Percent of Total Billed Charges,100% of Total Billed Charges,10.14,194,
ULTRASOUND EA 15 MIN,57157837,CDM,430,RC,97035,HCPCS,Outpatient,,,137,82.20,,6.68,100,,,Case Rate,Pays based on per visit rate,20.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,39.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.99,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,50.62,360,,,Fee Schedule,360% of BCBS POS Rate,50.62,360,,,Fee schedule,360% of BCBS PPO Rate,50.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,90,,,Fee Schedule,90% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,130,,,Fee Schedule,130% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,102.75,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.39,150,,,Fee Schedule,150% of CMS OPPS Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,8,Percent of Total Billed Charges,100% of Total Billed Charges,6.68,194,
MECHANICAL TRACTION,57157838,CDM,420,RC,97012,HCPCS,Outpatient,,,145.05,87.03,,6.84,100,,,Case Rate,Pays based on per visit rate,20.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,54.5,360,,,Fee Schedule,360% of BCBS POS Rate,54.5,360,,,Fee schedule,360% of BCBS PPO Rate,54.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,90,,,Fee Schedule,90% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,130,,,Fee Schedule,130% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.92,14.42,,16.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,14.07,103,,,Fee Schedule,103% of CMS OPPS Rate,14.07,103,,,Fee Schedule,103% of CMS OPPS Rate,108.79,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,72.53,50,,58.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.49,150,,,Fee Schedule,150% of CMS OPPS Rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,20.31,14,,16.248,Percent of Total Billed Charges,14% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,145.05,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,194,
VASOPNEUMATIC DEVICE,57157839,CDM,420,RC,97016,HCPCS,Outpatient,,,72.6,43.56,,5.55,100,,,Case Rate,Pays based on per visit rate,17,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,36.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,46.69,360,,,Fee Schedule,360% of BCBS POS Rate,46.69,360,,,Fee schedule,360% of BCBS PPO Rate,46.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,100,,,Case Rate,Pays based on per visit rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.2,90,,,Fee Schedule,90% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,14.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.47,14.42,,8.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,11.67,103,,,Fee Schedule,103% of CMS OPPS Rate,11.67,103,,,Fee Schedule,103% of CMS OPPS Rate,54.45,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,36.3,50,,29.04,Percent of Total Billed Charges,50% of Total Billed Charges,17,150,,,Fee Schedule,150% of CMS OPPS Rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,167,100,,,Case Rate,Pays based on per visit rate,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,10.16,14,,8.128,Percent of Total Billed Charges,14% of Total Billed Charges,11.33,100,,,Fee Schedule,100% of CMS OPPS Rate,72.6,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,5.55,194,
"DRSG Urgo tul 6x8""",59000057,CDM,272,RC,,,Outpatient,,,101.52,60.91,,60.91,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,45.68,45,,36.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.43,28,,22.744,Percent of Total Billed Charges,28% of Total Billed Charges,270.48,32,,216.384,Percent of Total Billed Charges,32% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,36.55,36,,29.24,Percent of Total Billed Charges,36% of Total Billed Charges,36.55,36,,29.24,Percent of Total Billed Charges,36% Total Bille Charges,36.55,36,,29.24,Percent of Total Billed Charges,36% of Total Billed Charges,60.91,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.52,100,,81.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.64,14.42,,11.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.14,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.06,70,,56.848,Percent of Total Billed Charges,70% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.52,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,14.21,270.48,
OBSERVATION-HOURLY,60000106,CDM,762,RC,,,Outpatient,,,77.4,46.44,,1040,60,,832,Percent of Total Billed Charges,60% of Total Billed Charges,34.83,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2324,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,270.94,32,,216.752,Percent of Total Billed Charges,32% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,1545,100,,,Case Rate,Pays based on per visit rate,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4400,70,,3520,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,64,Percent of Total Billed Charges,100% of Total Billed Charges,10.84,4400,
3N OBSERVATION-HOURLY,60010106,CDM,762,RC,,,Outpatient,,,77.5,46.50,,1040,60,,832,Percent of Total Billed Charges,60% of Total Billed Charges,34.88,45,,27.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2324,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,271.15,32,,216.92,Percent of Total Billed Charges,32% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,1545,100,,,Case Rate,Pays based on per visit rate,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.5,100,,62,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,11.18,14.42,,8.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.13,75,,204.368,Percent of Total Billed Charges,75% of Total Billed Charges,38.75,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,38.75,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.75,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,38.75,50,,31,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4400,70,,3520,Percent of Total Billed Charges,70% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,10.85,14,,8.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.5,100,,255.456,Percent of Total Billed Charges,100% of Total Billed Charges,10.85,4400,
5E OBSERVATION-HOURLY,60030106,CDM,762,RC,,,Outpatient,,,77.4,46.44,,1040,60,,832,Percent of Total Billed Charges,60% of Total Billed Charges,34.83,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2324,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,271.98,32,,217.584,Percent of Total Billed Charges,32% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,1545,100,,,Case Rate,Pays based on per visit rate,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,854.32,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4400,70,,3520,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,1067.904,Percent of Total Billed Charges,100% of Total Billed Charges,10.84,4400,
5W OBSERVATION-HOURLY,60040106,CDM,762,RC,,,Outpatient,,,77.4,46.44,,1040,60,,832,Percent of Total Billed Charges,60% of Total Billed Charges,34.83,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2324,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,27.2,32,,21.76,Percent of Total Billed Charges,32% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,1545,100,,,Case Rate,Pays based on per visit rate,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,854.32,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4400,70,,3520,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,1067.904,Percent of Total Billed Charges,100% of Total Billed Charges,10.84,4400,
EHLD OBSERVATION-HOURLY,60060106,CDM,762,RC,,,Outpatient,,,77.4,46.44,,1040,60,,832,Percent of Total Billed Charges,60% of Total Billed Charges,34.83,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2324,28,,1859.2,Percent of Total Billed Charges,28% of Total Billed Charges,27.26,32,,21.808,Percent of Total Billed Charges,32% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% Total Bille Charges,2988,36,,2390.4,Percent of Total Billed Charges,36% of Total Billed Charges,1545,100,,,Case Rate,Pays based on per visit rate,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,204.368,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4400,70,,3520,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,255.456,Percent of Total Billed Charges,100% of Total Billed Charges,10.84,4400,
PAD DEFIBRILLATION ADULT RADIOTRANSPARENT WITH CAR,61000000,CDM,271,RC,,,Outpatient,,,284.2,170.52,,170.52,60,,136.416,Percent of Total Billed Charges,60% of Total Billed Charges,127.89,45,,102.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.58,28,,63.664,Percent of Total Billed Charges,28% of Total Billed Charges,27.32,32,,21.856,Percent of Total Billed Charges,32% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% Total Bille Charges,102.31,36,,81.848,Percent of Total Billed Charges,36% of Total Billed Charges,170.52,60,,136.416,Percent of Total Billed Charges,60% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.2,100,,227.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,40.98,14.42,,32.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.15,75,,204.368,Percent of Total Billed Charges,75% of Total Billed Charges,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,142.1,50,,113.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,198.94,70,,159.152,Percent of Total Billed Charges,70% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,39.79,14,,31.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.2,100,,255.456,Percent of Total Billed Charges,100% of Total Billed Charges,27.32,284.2,
CATH NG ARG SLM SMP 48IN 16FR,61000001,CDM,271,RC,,,Outpatient,,,151.6,90.96,,90.96,60,,72.768,Percent of Total Billed Charges,60% of Total Billed Charges,68.22,45,,54.576,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.45,28,,33.96,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,54.58,36,,43.664,Percent of Total Billed Charges,36% of Total Billed Charges,54.58,36,,43.664,Percent of Total Billed Charges,36% Total Bille Charges,54.58,36,,43.664,Percent of Total Billed Charges,36% of Total Billed Charges,90.96,60,,72.768,Percent of Total Billed Charges,60% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.6,100,,121.28,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.86,14.42,,17.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.7,75,,1358.336,Percent of Total Billed Charges,75% of Total Billed Charges,75.8,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,75.8,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.8,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,75.8,50,,60.64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.12,70,,84.896,Percent of Total Billed Charges,70% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,21.22,14,,16.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.6,100,,1697.92,Percent of Total Billed Charges,100% of Total Billed Charges,21.22,151.6,
DRAIN CHST CHST PLR-EV PED,61000002,CDM,271,RC,,,Outpatient,,,500,300.00,,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,225,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,28,,112,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,180,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,180,36,,144,Percent of Total Billed Charges,36% Total Bille Charges,180,36,,144,Percent of Total Billed Charges,36% of Total Billed Charges,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500,100,,400,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,72.1,14.42,,57.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,75,,1358.336,Percent of Total Billed Charges,75% of Total Billed Charges,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,250,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,350,70,,280,Percent of Total Billed Charges,70% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,70,14,,56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,500,100,,1697.92,Percent of Total Billed Charges,100% of Total Billed Charges,27.36,500,
SENSOR PULSE OXIMETER NEONATAL DISPOSABLE ADHESI,61000003,CDM,271,RC,,,Outpatient,,,102.4,61.44,,61.44,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,46.08,45,,36.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.67,28,,22.936,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% Total Bille Charges,36.86,36,,29.488,Percent of Total Billed Charges,36% of Total Billed Charges,61.44,60,,49.152,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.4,100,,81.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.77,14.42,,11.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.8,75,,63.904,Percent of Total Billed Charges,75% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,51.2,50,,40.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.68,70,,57.344,Percent of Total Billed Charges,70% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,14.34,14,,11.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.4,100,,85.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.34,102.4,
IRRIGATION KT LNS THER IRR,61000004,CDM,271,RC,,,Outpatient,,,245.8,147.48,,147.48,60,,117.984,Percent of Total Billed Charges,60% of Total Billed Charges,110.61,45,,88.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.82,28,,55.056,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,88.49,36,,70.792,Percent of Total Billed Charges,36% of Total Billed Charges,88.49,36,,70.792,Percent of Total Billed Charges,36% Total Bille Charges,88.49,36,,70.792,Percent of Total Billed Charges,36% of Total Billed Charges,147.48,60,,117.984,Percent of Total Billed Charges,60% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.8,100,,196.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,35.44,14.42,,28.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.35,75,,22.888,Percent of Total Billed Charges,75% of Total Billed Charges,122.9,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,122.9,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.9,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,122.9,50,,98.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.06,70,,137.648,Percent of Total Billed Charges,70% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,34.41,14,,27.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.8,100,,30.52,Percent of Total Billed Charges,100% of Total Billed Charges,27.36,245.8,
COVER PROBE ULTRA 6X48 STERILE,61000005,CDM,271,RC,,,Outpatient,,,103.6,62.16,,62.16,60,,49.728,Percent of Total Billed Charges,60% of Total Billed Charges,46.62,45,,37.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.01,28,,23.208,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,37.3,36,,29.84,Percent of Total Billed Charges,36% of Total Billed Charges,37.3,36,,29.84,Percent of Total Billed Charges,36% Total Bille Charges,37.3,36,,29.84,Percent of Total Billed Charges,36% of Total Billed Charges,62.16,60,,49.728,Percent of Total Billed Charges,60% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.6,100,,82.88,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.94,14.42,,11.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.7,75,,38.056,Percent of Total Billed Charges,75% of Total Billed Charges,51.8,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,51.8,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.8,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,51.8,50,,41.44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.52,70,,58.016,Percent of Total Billed Charges,70% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,14.5,14,,11.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.6,100,,50.736,Percent of Total Billed Charges,100% of Total Billed Charges,14.5,103.6,
KIT CHEST TUBE 15.5 FR OPEN TIP STRAIGHT SOFT MULT,61000007,CDM,272,RC,,,Outpatient,,,460.3,276.18,,276.18,60,,220.944,Percent of Total Billed Charges,60% of Total Billed Charges,207.14,45,,165.712,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.88,28,,103.104,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,165.71,36,,132.568,Percent of Total Billed Charges,36% of Total Billed Charges,165.71,36,,132.568,Percent of Total Billed Charges,36% Total Bille Charges,165.71,36,,132.568,Percent of Total Billed Charges,36% of Total Billed Charges,276.18,60,,220.944,Percent of Total Billed Charges,60% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,460.3,100,,368.24,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,66.38,14.42,,53.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.23,75,,216,Percent of Total Billed Charges,75% of Total Billed Charges,230.15,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,230.15,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,230.15,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,230.15,50,,184.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,322.21,70,,257.768,Percent of Total Billed Charges,70% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,64.44,14,,51.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,460.3,100,,288,Percent of Total Billed Charges,100% of Total Billed Charges,27.36,460.3,
VALVE DRN THOR 1 W FILTER,61000008,CDM,271,RC,,,Outpatient,,,276.64,165.98,,165.98,60,,132.784,Percent of Total Billed Charges,60% of Total Billed Charges,124.49,45,,99.592,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.46,28,,61.968,Percent of Total Billed Charges,28% of Total Billed Charges,27.36,32,,21.888,Percent of Total Billed Charges,32% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,99.59,36,,79.672,Percent of Total Billed Charges,36% of Total Billed Charges,99.59,36,,79.672,Percent of Total Billed Charges,36% Total Bille Charges,99.59,36,,79.672,Percent of Total Billed Charges,36% of Total Billed Charges,165.98,60,,132.784,Percent of Total Billed Charges,60% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,276.64,100,,221.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,39.89,14.42,,31.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.48,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,138.32,50,,110.656,Percent of Total Billed Charges,50% of Total Billed Charges,138.32,50,,110.656,Percent of Total Billed Charges,50% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.32,50,,110.656,Percent of Total Billed Charges,50% of Total Billed Charges,138.32,50,,110.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,193.65,70,,154.92,Percent of Total Billed Charges,70% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,38.73,14,,30.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.64,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,27.36,276.64,
CRICOTHYROTOMY TRAY MELKER ER,61000009,CDM,272,RC,,,Outpatient,,,2340.15,1404.09,,1404.09,60,,1123.272,Percent of Total Billed Charges,60% of Total Billed Charges,1053.07,45,,842.456,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,655.24,28,,524.192,Percent of Total Billed Charges,28% of Total Billed Charges,27.42,32,,21.936,Percent of Total Billed Charges,32% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,842.45,36,,673.96,Percent of Total Billed Charges,36% of Total Billed Charges,842.45,36,,673.96,Percent of Total Billed Charges,36% Total Bille Charges,842.45,36,,673.96,Percent of Total Billed Charges,36% of Total Billed Charges,1404.09,60,,1123.272,Percent of Total Billed Charges,60% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2340.15,100,,1872.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,337.45,14.42,,269.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1755.11,75,,240,Percent of Total Billed Charges,75% of Total Billed Charges,1170.08,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,1170.08,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1170.08,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,1170.08,50,,936.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1638.11,70,,1310.488,Percent of Total Billed Charges,70% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,327.62,14,,262.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2340.15,100,,300,Percent of Total Billed Charges,100% of Total Billed Charges,27.42,2340.15,
TRAY LUMBAR PUNCTURE AD 22X3.5,61000010,CDM,272,RC,,,Outpatient,,,212.08,127.25,,127.25,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,95.44,45,,76.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.38,28,,47.504,Percent of Total Billed Charges,28% of Total Billed Charges,27.44,32,,21.952,Percent of Total Billed Charges,32% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% Total Bille Charges,76.35,36,,61.08,Percent of Total Billed Charges,36% of Total Billed Charges,127.25,60,,101.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.08,100,,169.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,30.58,14.42,,24.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.06,75,,176,Percent of Total Billed Charges,75% of Total Billed Charges,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,106.04,50,,84.832,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.46,70,,118.768,Percent of Total Billed Charges,70% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,29.69,14,,23.752,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.08,100,,220,Percent of Total Billed Charges,100% of Total Billed Charges,27.44,212.08,
SET INFUSION POWER LOC MAX 20,61000011,CDM,271,RC,,,Outpatient,,,120.8,72.48,,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,54.36,45,,43.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.82,28,,27.056,Percent of Total Billed Charges,28% of Total Billed Charges,27.46,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% Total Bille Charges,43.49,36,,34.792,Percent of Total Billed Charges,36% of Total Billed Charges,72.48,60,,57.984,Percent of Total Billed Charges,60% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.8,100,,96.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,17.42,14.42,,13.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.6,75,,176,Percent of Total Billed Charges,75% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,60.4,50,,48.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.56,70,,67.648,Percent of Total Billed Charges,70% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,16.91,14,,13.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.8,100,,220,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,120.8,
BOTTLE DRAIN ACCEL EVC 1000ML,61000012,CDM,271,RC,,,Outpatient,,,105.8,63.48,,63.48,60,,50.784,Percent of Total Billed Charges,60% of Total Billed Charges,47.61,45,,38.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.62,28,,23.696,Percent of Total Billed Charges,28% of Total Billed Charges,27.46,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,38.09,36,,30.472,Percent of Total Billed Charges,36% of Total Billed Charges,38.09,36,,30.472,Percent of Total Billed Charges,36% Total Bille Charges,38.09,36,,30.472,Percent of Total Billed Charges,36% of Total Billed Charges,63.48,60,,50.784,Percent of Total Billed Charges,60% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.8,100,,84.64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,15.26,14.42,,12.208,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.35,75,,128,Percent of Total Billed Charges,75% of Total Billed Charges,52.9,50,,42.32,Percent of Total Billed Charges,50% of Total Billed Charges,52.9,50,,42.32,Percent of Total Billed Charges,50% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.9,50,,42.32,Percent of Total Billed Charges,50% of Total Billed Charges,52.9,50,,42.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.06,70,,59.248,Percent of Total Billed Charges,70% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,14.81,14,,11.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.8,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,14.81,105.8,
BLANKET REFLECTIVE FULL BODY,61000013,CDM,271,RC,,,Outpatient,,,127.04,76.22,,76.22,60,,60.976,Percent of Total Billed Charges,60% of Total Billed Charges,57.17,45,,45.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.57,28,,28.456,Percent of Total Billed Charges,28% of Total Billed Charges,27.46,32,,21.968,Percent of Total Billed Charges,32% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% Total Bille Charges,45.73,36,,36.584,Percent of Total Billed Charges,36% of Total Billed Charges,76.22,60,,60.976,Percent of Total Billed Charges,60% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.04,100,,101.632,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,18.32,14.42,,14.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.28,75,,128,Percent of Total Billed Charges,75% of Total Billed Charges,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,63.52,50,,50.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.93,70,,71.144,Percent of Total Billed Charges,70% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,17.79,14,,14.232,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.04,100,,160,Percent of Total Billed Charges,100% of Total Billed Charges,17.79,127.04,
KIT DRESSING CHANGE POWERGLIDE,61000014,CDM,271,RC,,,Outpatient,,,107.36,64.42,,64.42,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,48.31,45,,38.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,27.47,32,,21.976,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,64.42,60,,51.536,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.36,100,,85.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.52,75,,106.24,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.36,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,107.36,
TRAY URINE METER SURESTEP 16FR,61000015,CDM,271,RC,,,Outpatient,,,135.92,81.55,,81.55,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,61.16,45,,48.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.06,28,,30.448,Percent of Total Billed Charges,28% of Total Billed Charges,272,32,,217.6,Percent of Total Billed Charges,32% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% Total Bille Charges,48.93,36,,39.144,Percent of Total Billed Charges,36% of Total Billed Charges,81.55,60,,65.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.92,100,,108.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.6,14.42,,15.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.94,75,,106.24,Percent of Total Billed Charges,75% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,67.96,50,,54.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.14,70,,76.112,Percent of Total Billed Charges,70% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,19.03,14,,15.224,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.92,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,19.03,272,
KIT PORT ACCESS CLEAR SEQUENCE CHANGE CUSTOM,61000016,CDM,271,RC,,,Outpatient,,,206.48,123.89,,123.89,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,92.92,45,,74.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.81,28,,46.248,Percent of Total Billed Charges,28% of Total Billed Charges,272.58,32,,218.064,Percent of Total Billed Charges,32% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% Total Bille Charges,74.33,36,,59.464,Percent of Total Billed Charges,36% of Total Billed Charges,123.89,60,,99.112,Percent of Total Billed Charges,60% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.48,100,,165.184,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,29.77,14.42,,23.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.86,75,,34.984,Percent of Total Billed Charges,75% of Total Billed Charges,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,103.24,50,,82.592,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144.54,70,,115.632,Percent of Total Billed Charges,70% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,28.91,14,,23.128,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.48,100,,46.648,Percent of Total Billed Charges,100% of Total Billed Charges,28.91,272.58,
TRAY PICC DRSG,61000017,CDM,272,RC,,,Outpatient,,,223.1,133.86,,133.86,60,,107.088,Percent of Total Billed Charges,60% of Total Billed Charges,100.4,45,,80.32,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.47,28,,49.976,Percent of Total Billed Charges,28% of Total Billed Charges,272.89,32,,218.312,Percent of Total Billed Charges,32% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,80.32,36,,64.256,Percent of Total Billed Charges,36% of Total Billed Charges,80.32,36,,64.256,Percent of Total Billed Charges,36% Total Bille Charges,80.32,36,,64.256,Percent of Total Billed Charges,36% of Total Billed Charges,133.86,60,,107.088,Percent of Total Billed Charges,60% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.1,100,,178.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,32.17,14.42,,25.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.33,75,,102.8,Percent of Total Billed Charges,75% of Total Billed Charges,111.55,50,,89.24,Percent of Total Billed Charges,50% of Total Billed Charges,111.55,50,,89.24,Percent of Total Billed Charges,50% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.55,50,,89.24,Percent of Total Billed Charges,50% of Total Billed Charges,111.55,50,,89.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,156.17,70,,124.936,Percent of Total Billed Charges,70% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,31.23,14,,24.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,223.1,100,,128.496,Percent of Total Billed Charges,100% of Total Billed Charges,31.23,272.89,
KIT CATH CENTRAL VENOUS TRIPLE,61000018,CDM,272,RC,,,Outpatient,,,505.9,303.54,,303.54,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,227.66,45,,182.128,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.65,28,,113.32,Percent of Total Billed Charges,28% of Total Billed Charges,272.89,32,,218.312,Percent of Total Billed Charges,32% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% Total Bille Charges,182.12,36,,145.696,Percent of Total Billed Charges,36% of Total Billed Charges,303.54,60,,242.832,Percent of Total Billed Charges,60% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,505.9,100,,404.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,72.95,14.42,,58.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,379.43,75,,102.8,Percent of Total Billed Charges,75% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,252.95,50,,202.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,354.13,70,,283.304,Percent of Total Billed Charges,70% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,70.83,14,,56.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,505.9,100,,128.496,Percent of Total Billed Charges,100% of Total Billed Charges,70.83,505.9,
NOVAPLUS SENSOR CHAIR,61000019,CDM,271,RC,,,Outpatient,,,163.44,98.06,,98.06,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,73.55,45,,58.84,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.76,28,,36.608,Percent of Total Billed Charges,28% of Total Billed Charges,273.6,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% Total Bille Charges,58.84,36,,47.072,Percent of Total Billed Charges,36% of Total Billed Charges,98.06,60,,78.448,Percent of Total Billed Charges,60% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.44,100,,130.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,23.57,14.42,,18.856,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.58,75,,128.704,Percent of Total Billed Charges,75% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,81.72,50,,65.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.41,70,,91.528,Percent of Total Billed Charges,70% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14,,18.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.44,100,,171.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.88,273.6,
PUMP BREAST SINGLE SYSTEM WITH 1 CONTAINER MANUAL,61000020,CDM,271,RC,,,Outpatient,,,138,82.80,,82.8,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,62.1,45,,49.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.64,28,,30.912,Percent of Total Billed Charges,28% of Total Billed Charges,273.6,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,49.68,36,,39.744,Percent of Total Billed Charges,36% of Total Billed Charges,49.68,36,,39.744,Percent of Total Billed Charges,36% Total Bille Charges,49.68,36,,39.744,Percent of Total Billed Charges,36% of Total Billed Charges,82.8,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138,100,,110.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.9,14.42,,15.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,75,,137.28,Percent of Total Billed Charges,75% of Total Billed Charges,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.6,70,,77.28,Percent of Total Billed Charges,70% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,19.32,14,,15.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138,100,,171.6,Percent of Total Billed Charges,100% of Total Billed Charges,19.32,273.6,
CHEST TUBE INSERTION TRAY,61000021,CDM,272,RC,,,Outpatient,,,351.16,210.70,,210.7,60,,168.56,Percent of Total Billed Charges,60% of Total Billed Charges,158.02,45,,126.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.32,28,,78.656,Percent of Total Billed Charges,28% of Total Billed Charges,273.6,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,36,,101.136,Percent of Total Billed Charges,36% of Total Billed Charges,126.42,36,,101.136,Percent of Total Billed Charges,36% Total Bille Charges,126.42,36,,101.136,Percent of Total Billed Charges,36% of Total Billed Charges,210.7,60,,168.56,Percent of Total Billed Charges,60% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.16,100,,280.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,50.64,14.42,,40.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.37,75,,432,Percent of Total Billed Charges,75% of Total Billed Charges,175.58,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,175.58,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.58,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,175.58,50,,140.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,245.81,70,,196.648,Percent of Total Billed Charges,70% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,49.16,14,,39.328,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,351.16,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,49.16,351.16,
CABLE EKG SNAP 5 LEADWIRE SET DISPOSABLE MULTILINK,61000022,CDM,271,RC,,,Outpatient,,,141.2,84.72,,84.72,60,,67.776,Percent of Total Billed Charges,60% of Total Billed Charges,63.54,45,,50.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.54,28,,31.632,Percent of Total Billed Charges,28% of Total Billed Charges,273.6,32,,218.88,Percent of Total Billed Charges,32% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,50.83,36,,40.664,Percent of Total Billed Charges,36% of Total Billed Charges,50.83,36,,40.664,Percent of Total Billed Charges,36% Total Bille Charges,50.83,36,,40.664,Percent of Total Billed Charges,36% of Total Billed Charges,84.72,60,,67.776,Percent of Total Billed Charges,60% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.2,100,,112.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,20.36,14.42,,16.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.9,75,,432,Percent of Total Billed Charges,75% of Total Billed Charges,70.6,50,,56.48,Percent of Total Billed Charges,50% of Total Billed Charges,70.6,50,,56.48,Percent of Total Billed Charges,50% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.6,50,,56.48,Percent of Total Billed Charges,50% of Total Billed Charges,70.6,50,,56.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.84,70,,79.072,Percent of Total Billed Charges,70% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,19.77,14,,15.816,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.2,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,19.77,273.6,
MLTIFIRE PREM 35W SKN STPLR,61000023,CDM,271,RC,,,Outpatient,,,147.9,88.74,,88.74,60,,70.992,Percent of Total Billed Charges,60% of Total Billed Charges,66.56,45,,53.248,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.41,28,,33.128,Percent of Total Billed Charges,28% of Total Billed Charges,274.35,32,,219.48,Percent of Total Billed Charges,32% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,53.24,36,,42.592,Percent of Total Billed Charges,36% of Total Billed Charges,53.24,36,,42.592,Percent of Total Billed Charges,36% Total Bille Charges,53.24,36,,42.592,Percent of Total Billed Charges,36% of Total Billed Charges,88.74,60,,70.992,Percent of Total Billed Charges,60% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.9,100,,118.32,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,21.33,14.42,,17.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.93,75,,193.28,Percent of Total Billed Charges,75% of Total Billed Charges,73.95,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,73.95,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.95,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,73.95,50,,59.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.53,70,,82.824,Percent of Total Billed Charges,70% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,20.71,14,,16.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.9,100,,241.6,Percent of Total Billed Charges,100% of Total Billed Charges,20.71,274.35,
TRAY PNEUMOTHORAX 6.3FR,61000024,CDM,272,RC,,,Outpatient,,,1097.2,658.32,,658.32,60,,526.656,Percent of Total Billed Charges,60% of Total Billed Charges,493.74,45,,394.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,307.22,28,,245.776,Percent of Total Billed Charges,28% of Total Billed Charges,274.35,32,,219.48,Percent of Total Billed Charges,32% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,394.99,36,,315.992,Percent of Total Billed Charges,36% of Total Billed Charges,394.99,36,,315.992,Percent of Total Billed Charges,36% Total Bille Charges,394.99,36,,315.992,Percent of Total Billed Charges,36% of Total Billed Charges,658.32,60,,526.656,Percent of Total Billed Charges,60% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1097.2,100,,877.76,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,158.22,14.42,,126.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,822.9,75,,193.28,Percent of Total Billed Charges,75% of Total Billed Charges,548.6,50,,438.88,Percent of Total Billed Charges,50% of Total Billed Charges,548.6,50,,438.88,Percent of Total Billed Charges,50% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,548.6,50,,438.88,Percent of Total Billed Charges,50% of Total Billed Charges,548.6,50,,438.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,768.04,70,,614.432,Percent of Total Billed Charges,70% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,153.61,14,,122.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1097.2,100,,241.6,Percent of Total Billed Charges,100% of Total Billed Charges,153.61,1097.2,
TRAY PNEUMOTHORAX 9FR,61000025,CDM,272,RC,,,Outpatient,,,851.8,511.08,,511.08,60,,408.864,Percent of Total Billed Charges,60% of Total Billed Charges,383.31,45,,306.648,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.5,28,,190.8,Percent of Total Billed Charges,28% of Total Billed Charges,274.56,32,,219.648,Percent of Total Billed Charges,32% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,306.65,36,,245.32,Percent of Total Billed Charges,36% of Total Billed Charges,306.65,36,,245.32,Percent of Total Billed Charges,36% Total Bille Charges,306.65,36,,245.32,Percent of Total Billed Charges,36% of Total Billed Charges,511.08,60,,408.864,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851.8,100,,681.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,122.83,14.42,,98.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,638.85,75,,237.44,Percent of Total Billed Charges,75% of Total Billed Charges,425.9,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,425.9,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.9,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,425.9,50,,340.72,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,596.26,70,,477.008,Percent of Total Billed Charges,70% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,851.8,100,,296.8,Percent of Total Billed Charges,100% of Total Billed Charges,119.25,851.8,
KIT CATH TRIPLE LUMEN CVC,61000026,CDM,272,RC,,,Outpatient,,,738,442.80,,442.8,60,,354.24,Percent of Total Billed Charges,60% of Total Billed Charges,332.1,45,,265.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,206.64,28,,165.312,Percent of Total Billed Charges,28% of Total Billed Charges,27.61,32,,22.088,Percent of Total Billed Charges,32% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,265.68,36,,212.544,Percent of Total Billed Charges,36% of Total Billed Charges,265.68,36,,212.544,Percent of Total Billed Charges,36% Total Bille Charges,265.68,36,,212.544,Percent of Total Billed Charges,36% of Total Billed Charges,442.8,60,,354.24,Percent of Total Billed Charges,60% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738,100,,590.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,106.42,14.42,,85.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,553.5,75,,237.44,Percent of Total Billed Charges,75% of Total Billed Charges,369,50,,295.2,Percent of Total Billed Charges,50% of Total Billed Charges,369,50,,295.2,Percent of Total Billed Charges,50% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369,50,,295.2,Percent of Total Billed Charges,50% of Total Billed Charges,369,50,,295.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,516.6,70,,413.28,Percent of Total Billed Charges,70% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,103.32,14,,82.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,738,100,,296.8,Percent of Total Billed Charges,100% of Total Billed Charges,27.61,738,
KIT CATH TRIPLE LUMEN CVC,61000027,CDM,272,RC,,,Outpatient,,,901.88,541.13,,541.13,60,,432.904,Percent of Total Billed Charges,60% of Total Billed Charges,405.85,45,,324.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.53,28,,202.024,Percent of Total Billed Charges,28% of Total Billed Charges,27.65,32,,22.12,Percent of Total Billed Charges,32% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,324.68,36,,259.744,Percent of Total Billed Charges,36% of Total Billed Charges,324.68,36,,259.744,Percent of Total Billed Charges,36% Total Bille Charges,324.68,36,,259.744,Percent of Total Billed Charges,36% of Total Billed Charges,541.13,60,,432.904,Percent of Total Billed Charges,60% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,901.88,100,,721.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,130.05,14.42,,104.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,676.41,75,,145.92,Percent of Total Billed Charges,75% of Total Billed Charges,450.94,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,450.94,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,450.94,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,450.94,50,,360.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,631.32,70,,505.056,Percent of Total Billed Charges,70% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,126.26,14,,101.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,901.88,100,,182.4,Percent of Total Billed Charges,100% of Total Billed Charges,27.65,901.88,
ABDOMINAL BINDER,61000028,CDM,272,RC,,,Outpatient,,,138.56,83.14,,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,62.35,45,,49.88,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.8,28,,31.04,Percent of Total Billed Charges,28% of Total Billed Charges,277.32,32,,221.856,Percent of Total Billed Charges,32% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% Total Bille Charges,49.88,36,,39.904,Percent of Total Billed Charges,36% of Total Billed Charges,83.14,60,,66.512,Percent of Total Billed Charges,60% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.56,100,,110.848,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.98,14.42,,15.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.92,75,,145.92,Percent of Total Billed Charges,75% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,69.28,50,,55.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.99,70,,77.592,Percent of Total Billed Charges,70% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,19.4,14,,15.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,138.56,100,,182.4,Percent of Total Billed Charges,100% of Total Billed Charges,19.4,277.32,
CURAPLEX OB KITS,61000029,CDM,272,RC,,,Outpatient,,,152.48,91.49,,91.49,60,,73.192,Percent of Total Billed Charges,60% of Total Billed Charges,68.62,45,,54.896,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.69,28,,34.152,Percent of Total Billed Charges,28% of Total Billed Charges,278.37,32,,222.696,Percent of Total Billed Charges,32% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,54.89,36,,43.912,Percent of Total Billed Charges,36% of Total Billed Charges,54.89,36,,43.912,Percent of Total Billed Charges,36% Total Bille Charges,54.89,36,,43.912,Percent of Total Billed Charges,36% of Total Billed Charges,91.49,60,,73.192,Percent of Total Billed Charges,60% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.48,100,,121.984,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.99,14.42,,17.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.36,75,,201.16,Percent of Total Billed Charges,75% of Total Billed Charges,76.24,50,,60.992,Percent of Total Billed Charges,50% of Total Billed Charges,76.24,50,,60.992,Percent of Total Billed Charges,50% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.24,50,,60.992,Percent of Total Billed Charges,50% of Total Billed Charges,76.24,50,,60.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.74,70,,85.392,Percent of Total Billed Charges,70% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,21.35,14,,17.08,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.48,100,,268.208,Percent of Total Billed Charges,100% of Total Billed Charges,21.35,278.37,
UMBILICAL VESSEL CATHETER INSERTION TRAY,61000030,CDM,272,RC,,,Outpatient,,,344.38,206.63,,206.63,60,,165.304,Percent of Total Billed Charges,60% of Total Billed Charges,154.97,45,,123.976,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,96.43,28,,77.144,Percent of Total Billed Charges,28% of Total Billed Charges,27.87,32,,22.296,Percent of Total Billed Charges,32% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,123.98,36,,99.184,Percent of Total Billed Charges,36% of Total Billed Charges,123.98,36,,99.184,Percent of Total Billed Charges,36% Total Bille Charges,123.98,36,,99.184,Percent of Total Billed Charges,36% of Total Billed Charges,206.63,60,,165.304,Percent of Total Billed Charges,60% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.38,100,,275.504,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,49.66,14.42,,39.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.29,75,,353.896,Percent of Total Billed Charges,75% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,172.19,50,,137.752,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.07,70,,192.856,Percent of Total Billed Charges,70% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,48.21,14,,38.568,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,344.38,100,,471.864,Percent of Total Billed Charges,100% of Total Billed Charges,27.87,344.38,
RHINO ROCKET SLIMLINE MED,61000031,CDM,271,RC,,,Outpatient,,,183.36,110.02,,110.02,60,,88.016,Percent of Total Billed Charges,60% of Total Billed Charges,82.51,45,,66.008,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.34,28,,41.072,Percent of Total Billed Charges,28% of Total Billed Charges,278.4,32,,222.72,Percent of Total Billed Charges,32% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,66.01,36,,52.808,Percent of Total Billed Charges,36% of Total Billed Charges,66.01,36,,52.808,Percent of Total Billed Charges,36% Total Bille Charges,66.01,36,,52.808,Percent of Total Billed Charges,36% of Total Billed Charges,110.02,60,,88.016,Percent of Total Billed Charges,60% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.36,100,,146.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,26.44,14.42,,21.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.52,75,,283.944,Percent of Total Billed Charges,75% of Total Billed Charges,91.68,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,91.68,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.68,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,91.68,50,,73.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.35,70,,102.68,Percent of Total Billed Charges,70% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,25.67,14,,20.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.36,100,,378.592,Percent of Total Billed Charges,100% of Total Billed Charges,25.67,278.4,
RAPID RHINO 4.5,61000032,CDM,271,RC,,,Outpatient,,,273.4,164.04,,164.04,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,123.03,45,,98.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.55,28,,61.24,Percent of Total Billed Charges,28% of Total Billed Charges,278.4,32,,222.72,Percent of Total Billed Charges,32% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% Total Bille Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,164.04,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.4,100,,218.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,39.42,14.42,,31.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.05,75,,567.904,Percent of Total Billed Charges,75% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.38,70,,153.104,Percent of Total Billed Charges,70% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.4,100,,757.2,Percent of Total Billed Charges,100% of Total Billed Charges,38.28,278.4,
RAPID RHINO 5.5,61000033,CDM,271,RC,,,Outpatient,,,273.4,164.04,,164.04,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,123.03,45,,98.424,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.55,28,,61.24,Percent of Total Billed Charges,28% of Total Billed Charges,279.59,32,,223.672,Percent of Total Billed Charges,32% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% Total Bille Charges,98.42,36,,78.736,Percent of Total Billed Charges,36% of Total Billed Charges,164.04,60,,131.232,Percent of Total Billed Charges,60% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273.4,100,,218.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,39.42,14.42,,31.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.05,75,,283.944,Percent of Total Billed Charges,75% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,136.7,50,,109.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.38,70,,153.104,Percent of Total Billed Charges,70% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,38.28,14,,30.624,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.4,100,,378.592,Percent of Total Billed Charges,100% of Total Billed Charges,38.28,279.59,
RAPID RHINO 7.5,61000034,CDM,271,RC,,,Outpatient,,,279.4,167.64,,167.64,60,,134.112,Percent of Total Billed Charges,60% of Total Billed Charges,125.73,45,,100.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.23,28,,62.584,Percent of Total Billed Charges,28% of Total Billed Charges,279.59,32,,223.672,Percent of Total Billed Charges,32% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,100.58,36,,80.464,Percent of Total Billed Charges,36% of Total Billed Charges,100.58,36,,80.464,Percent of Total Billed Charges,36% Total Bille Charges,100.58,36,,80.464,Percent of Total Billed Charges,36% of Total Billed Charges,167.64,60,,134.112,Percent of Total Billed Charges,60% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.4,100,,223.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,40.29,14.42,,32.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.55,75,,223.704,Percent of Total Billed Charges,75% of Total Billed Charges,139.7,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,139.7,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.7,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,139.7,50,,111.76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,195.58,70,,156.464,Percent of Total Billed Charges,70% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,39.12,14,,31.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,279.4,100,,298.272,Percent of Total Billed Charges,100% of Total Billed Charges,39.12,279.59,
DENVER SPLINT SMALL,61000035,CDM,271,RC,,,Outpatient,,,341.2,204.72,,204.72,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,153.54,45,,122.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.54,28,,76.432,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% of Total Billed Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% Total Bille Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% of Total Billed Charges,204.72,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.2,100,,272.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14.42,,39.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.9,75,,222.12,Percent of Total Billed Charges,75% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.84,70,,191.072,Percent of Total Billed Charges,70% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.2,100,,296.16,Percent of Total Billed Charges,100% of Total Billed Charges,47.77,341.2,
DENVER SPLINT LARGE,61000036,CDM,271,RC,,,Outpatient,,,341.2,204.72,,204.72,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,153.54,45,,122.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.54,28,,76.432,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% of Total Billed Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% Total Bille Charges,122.83,36,,98.264,Percent of Total Billed Charges,36% of Total Billed Charges,204.72,60,,163.776,Percent of Total Billed Charges,60% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.2,100,,272.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,49.2,14.42,,39.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.9,75,,201.16,Percent of Total Billed Charges,75% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,170.6,50,,136.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,238.84,70,,191.072,Percent of Total Billed Charges,70% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,47.77,14,,38.216,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,341.2,100,,268.208,Percent of Total Billed Charges,100% of Total Billed Charges,47.77,341.2,
BUR OPTHALMIC,61000037,CDM,271,RC,,,Outpatient,,,160.24,96.14,,96.14,60,,76.912,Percent of Total Billed Charges,60% of Total Billed Charges,72.11,45,,57.688,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.87,28,,35.896,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,57.69,36,,46.152,Percent of Total Billed Charges,36% of Total Billed Charges,57.69,36,,46.152,Percent of Total Billed Charges,36% Total Bille Charges,57.69,36,,46.152,Percent of Total Billed Charges,36% of Total Billed Charges,96.14,60,,76.912,Percent of Total Billed Charges,60% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.24,100,,128.192,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,23.11,14.42,,18.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.18,75,,353.896,Percent of Total Billed Charges,75% of Total Billed Charges,80.12,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,80.12,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.12,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,80.12,50,,64.096,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.17,70,,89.736,Percent of Total Billed Charges,70% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,22.43,14,,17.944,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.24,100,,471.864,Percent of Total Billed Charges,100% of Total Billed Charges,22.43,280.68,
GLIDESCOPE S 0,61000038,CDM,271,RC,,,Outpatient,,,172,103.20,,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.16,28,,38.528,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% Total Bille Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172,100,,137.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.8,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,75,,816.024,Percent of Total Billed Charges,75% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.4,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172,100,,1088.032,Percent of Total Billed Charges,100% of Total Billed Charges,24.08,280.68,
GLIDESCOPE S 1.0,61000039,CDM,271,RC,,,Outpatient,,,172,103.20,,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.16,28,,38.528,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% Total Bille Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172,100,,137.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.8,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,75,,965.552,Percent of Total Billed Charges,75% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.4,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172,100,,1287.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.08,280.68,
GLIDESCOPE S 2.0,61000040,CDM,271,RC,,,Outpatient,,,172,103.20,,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.16,28,,38.528,Percent of Total Billed Charges,28% of Total Billed Charges,280.68,32,,224.544,Percent of Total Billed Charges,32% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% Total Bille Charges,61.92,36,,49.536,Percent of Total Billed Charges,36% of Total Billed Charges,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172,100,,137.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.8,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,75,,2049.272,Percent of Total Billed Charges,75% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.4,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172,100,,2732.36,Percent of Total Billed Charges,100% of Total Billed Charges,24.08,280.68,
GLIDESCOPE S 3.0,61000041,CDM,271,RC,,,Outpatient,,,134.32,80.59,,80.59,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,60.44,45,,48.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.61,28,,30.088,Percent of Total Billed Charges,28% of Total Billed Charges,280.7,32,,224.56,Percent of Total Billed Charges,32% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% Total Bille Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,80.59,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.32,100,,107.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14.42,,15.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.74,75,,612.016,Percent of Total Billed Charges,75% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.02,70,,75.216,Percent of Total Billed Charges,70% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.32,100,,816.024,Percent of Total Billed Charges,100% of Total Billed Charges,18.8,280.7,
GLIDESCOPE S 4.0,61000042,CDM,271,RC,,,Outpatient,,,134.32,80.59,,80.59,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,60.44,45,,48.352,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.61,28,,30.088,Percent of Total Billed Charges,28% of Total Billed Charges,280.7,32,,224.56,Percent of Total Billed Charges,32% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% Total Bille Charges,48.36,36,,38.688,Percent of Total Billed Charges,36% of Total Billed Charges,80.59,60,,64.472,Percent of Total Billed Charges,60% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.32,100,,107.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,19.37,14.42,,15.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.74,75,,600.28,Percent of Total Billed Charges,75% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,67.16,50,,53.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.02,70,,75.216,Percent of Total Billed Charges,70% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,14,,15.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.32,100,,800.368,Percent of Total Billed Charges,100% of Total Billed Charges,18.8,280.7,
TUBE GASTROSTOMY 14,61000043,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,280.77,32,,224.616,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,1338.912,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,1785.216,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,280.77,
TUBE GASTROSTOMY 16,61000044,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,280.77,32,,224.616,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,424.48,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,565.968,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,280.77,
TUBE GASTROSTOMY 18,61000045,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,280.96,32,,224.768,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,2177.264,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,2903.016,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,280.96,
TUBE GASTROSTOMY 20,61000046,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,281.54,32,,225.232,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,203.728,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,271.64,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,281.54,
TUBE GASTROSTOMY 22,61000047,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,281.54,32,,225.232,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,196.16,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,261.544,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,281.54,
TUBE GASTROSTOMY 24,61000048,CDM,271,RC,,,Outpatient,,,191.28,114.77,,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,86.08,45,,68.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.56,28,,42.848,Percent of Total Billed Charges,28% of Total Billed Charges,28.27,32,,22.616,Percent of Total Billed Charges,32% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% Total Bille Charges,68.86,36,,55.088,Percent of Total Billed Charges,36% of Total Billed Charges,114.77,60,,91.816,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.28,100,,153.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,27.58,14.42,,22.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.46,75,,50.84,Percent of Total Billed Charges,75% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,95.64,50,,76.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.9,70,,107.12,Percent of Total Billed Charges,70% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,26.78,14,,21.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.28,100,,67.784,Percent of Total Billed Charges,100% of Total Billed Charges,26.78,191.28,
HEMOSTAT SURGICEL 8 IN X 4 IN,61000049,CDM,250,RC,99070,HCPCS,Outpatient,,,659.02,395.41,,16.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,184.53,28,,147.624,Percent of Total Billed Charges,28% of Total Billed Charges,28.32,32,,22.656,Percent of Total Billed Charges,32% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% Total Bille Charges,237.25,36,,189.8,Percent of Total Billed Charges,36% of Total Billed Charges,395.41,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,95.03,14.42,,76.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.27,75,,21.424,Percent of Total Billed Charges,75% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,329.51,50,,263.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,461.31,70,,369.048,Percent of Total Billed Charges,70% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,92.26,14,,73.808,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,659.02,100,,28.568,Percent of Total Billed Charges,100% of Total Billed Charges,16.5,659.02,
NDL INTRAOSSEOUS INFS 15,61000050,CDM,271,RC,,,Outpatient,,,546.4,327.84,,327.84,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.99,28,,122.392,Percent of Total Billed Charges,28% of Total Billed Charges,28.34,32,,22.672,Percent of Total Billed Charges,32% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% of Total Billed Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% Total Bille Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% of Total Billed Charges,327.84,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,78.79,14.42,,63.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.8,75,,52.12,Percent of Total Billed Charges,75% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.48,70,,305.984,Percent of Total Billed Charges,70% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.4,100,,69.488,Percent of Total Billed Charges,100% of Total Billed Charges,28.34,546.4,
NDL INTROSSEOUS INFS,61000051,CDM,271,RC,,,Outpatient,,,546.4,327.84,,327.84,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.99,28,,122.392,Percent of Total Billed Charges,28% of Total Billed Charges,28.37,32,,22.696,Percent of Total Billed Charges,32% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% of Total Billed Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% Total Bille Charges,196.7,36,,157.36,Percent of Total Billed Charges,36% of Total Billed Charges,327.84,60,,262.272,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,78.79,14.42,,63.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.8,75,,54.224,Percent of Total Billed Charges,75% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,273.2,50,,218.56,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,382.48,70,,305.984,Percent of Total Billed Charges,70% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,76.5,14,,61.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.4,100,,67.784,Percent of Total Billed Charges,100% of Total Billed Charges,28.37,546.4,
"QUIKCLOT COMBAT GAUZE 3""X4FT",61000052,CDM,271,RC,,,Outpatient,,,221.05,132.63,,132.63,60,,106.104,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.89,28,,49.512,Percent of Total Billed Charges,28% of Total Billed Charges,28.4,32,,22.72,Percent of Total Billed Charges,32% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% of Total Billed Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% Total Bille Charges,79.58,36,,63.664,Percent of Total Billed Charges,36% of Total Billed Charges,132.63,60,,106.104,Percent of Total Billed Charges,60% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,31.88,14.42,,25.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.79,75,,22.856,Percent of Total Billed Charges,75% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,110.53,50,,88.424,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.74,70,,123.792,Percent of Total Billed Charges,70% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,30.95,14,,24.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.05,100,,28.568,Percent of Total Billed Charges,100% of Total Billed Charges,28.4,221.05,
TOURNIQUET CAT ORANGE,61000053,CDM,271,RC,,,Outpatient,,,191.65,114.99,,114.99,60,,91.992,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.66,28,,42.928,Percent of Total Billed Charges,28% of Total Billed Charges,28.44,32,,22.752,Percent of Total Billed Charges,32% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.99,36,,55.192,Percent of Total Billed Charges,36% of Total Billed Charges,68.99,36,,55.192,Percent of Total Billed Charges,36% Total Bille Charges,68.99,36,,55.192,Percent of Total Billed Charges,36% of Total Billed Charges,114.99,60,,91.992,Percent of Total Billed Charges,60% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,27.64,14.42,,22.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.74,75,,55.592,Percent of Total Billed Charges,75% of Total Billed Charges,95.83,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,95.83,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.83,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,95.83,50,,76.664,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134.16,70,,107.328,Percent of Total Billed Charges,70% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,26.83,14,,21.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.65,100,,69.488,Percent of Total Billed Charges,100% of Total Billed Charges,26.83,191.65,
DRSG VASCULAR ACC INTRAOSSEOUS,61000054,CDM,271,RC,,,Outpatient,,,108,64.80,,64.8,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.24,28,,24.192,Percent of Total Billed Charges,28% of Total Billed Charges,28.45,32,,22.76,Percent of Total Billed Charges,32% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,38.88,36,,31.104,Percent of Total Billed Charges,36% of Total Billed Charges,38.88,36,,31.104,Percent of Total Billed Charges,36% Total Bille Charges,38.88,36,,31.104,Percent of Total Billed Charges,36% of Total Billed Charges,64.8,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.57,14.42,,12.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81,75,,327.472,Percent of Total Billed Charges,75% of Total Billed Charges,54,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,54,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,54,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.6,70,,60.48,Percent of Total Billed Charges,70% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14,,12.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108,100,,436.632,Percent of Total Billed Charges,100% of Total Billed Charges,15.12,108,
SET NDL 15GA L15MM STBLZR KIT,61000055,CDM,271,RC,,,Outpatient,,,552.8,331.68,,331.68,60,,265.344,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.78,28,,123.824,Percent of Total Billed Charges,28% of Total Billed Charges,282.19,32,,225.752,Percent of Total Billed Charges,32% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,199.01,36,,159.208,Percent of Total Billed Charges,36% of Total Billed Charges,199.01,36,,159.208,Percent of Total Billed Charges,36% Total Bille Charges,199.01,36,,159.208,Percent of Total Billed Charges,36% of Total Billed Charges,331.68,60,,265.344,Percent of Total Billed Charges,60% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,79.71,14.42,,63.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.6,75,,1315.032,Percent of Total Billed Charges,75% of Total Billed Charges,276.4,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,276.4,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,276.4,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,276.4,50,,221.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,386.96,70,,309.568,Percent of Total Billed Charges,70% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,77.39,14,,61.912,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,552.8,100,,1753.376,Percent of Total Billed Charges,100% of Total Billed Charges,77.39,552.8,
EXTRACTOR KATZ FOREIGN BODY,61000056,CDM,271,RC,,,Outpatient,,,309.75,185.85,,185.85,60,,148.68,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.73,28,,69.384,Percent of Total Billed Charges,28% of Total Billed Charges,282.59,32,,226.072,Percent of Total Billed Charges,32% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,111.51,36,,89.208,Percent of Total Billed Charges,36% of Total Billed Charges,111.51,36,,89.208,Percent of Total Billed Charges,36% Total Bille Charges,111.51,36,,89.208,Percent of Total Billed Charges,36% of Total Billed Charges,185.85,60,,148.68,Percent of Total Billed Charges,60% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,44.67,14.42,,35.736,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.31,75,,762.032,Percent of Total Billed Charges,75% of Total Billed Charges,154.88,50,,123.904,Percent of Total Billed Charges,50% of Total Billed Charges,154.88,50,,123.904,Percent of Total Billed Charges,50% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.88,50,,123.904,Percent of Total Billed Charges,50% of Total Billed Charges,154.88,50,,123.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.83,70,,173.464,Percent of Total Billed Charges,70% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,43.37,14,,34.696,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,309.75,100,,1016.04,Percent of Total Billed Charges,100% of Total Billed Charges,43.37,309.75,
CAUTERY OPHTH BATTERY,61000057,CDM,271,RC,,,Outpatient,,,55.16,33.10,,33.1,60,,26.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.44,28,,12.352,Percent of Total Billed Charges,28% of Total Billed Charges,283.2,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,19.86,36,,15.888,Percent of Total Billed Charges,36% of Total Billed Charges,19.86,36,,15.888,Percent of Total Billed Charges,36% Total Bille Charges,19.86,36,,15.888,Percent of Total Billed Charges,36% of Total Billed Charges,33.1,60,,26.48,Percent of Total Billed Charges,60% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.95,14.42,,6.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.37,75,,508.024,Percent of Total Billed Charges,75% of Total Billed Charges,27.58,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,27.58,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.58,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,27.58,50,,22.064,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.61,70,,30.888,Percent of Total Billed Charges,70% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,7.72,14,,6.176,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.16,100,,677.36,Percent of Total Billed Charges,100% of Total Billed Charges,7.72,283.2,
GUIDE US NDL PLCMT,61000058,CDM,402,RC,76942,HCPCS,Outpatient,,,821.35,492.81,,26.15,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,80.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,90.83,360,,,Fee Schedule,360% of BCBS POS Rate,90.83,360,,,Fee schedule,360% of BCBS PPO Rate,90.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,492.81,60,,394.248,Percent of Total Billed Charges,60% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,118.44,14.42,,94.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,616.01,75,,219.784,Percent of Total Billed Charges,75% of Total Billed Charges,410.68,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,410.68,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,410.68,50,,328.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,378,100,,,Case Rate,Pays based on per visit rate,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,114.99,14,,91.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,821.35,100,,293.04,Percent of Total Billed Charges,100% of Total Billed Charges,26.15,821.35,
INSERT PICC CATH W/IMAGE >5 YO,61000059,CDM,761,RC,36573,HCPCS,Outpatient,,,3717.03,2230.22,,76.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,2204.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.77,28,,832.616,Percent of Total Billed Charges,28% of Total Billed Charges,283.2,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1338.13,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,1338.13,36,,1070.504,Percent of Total Billed Charges,36% Total Bille Charges,1338.13,36,,1070.504,Percent of Total Billed Charges,36% of Total Billed Charges,4892.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.4,90,,,Fee Schedule,90% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.14,130,,,Fee Schedule,130% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1513.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2787.77,75,,329.672,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,2204.01,150,,,Fee Schedule,150% of CMS OPPS Rate,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,2601.92,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,1469.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3717.03,100,,439.56,Percent of Total Billed Charges,100% of Total Billed Charges,76.76,4892.5,
INSERT MIDLINE W/IMAGE >5 YO,61000060,CDM,761,RC,36410,HCPCS,Outpatient,,,3717.03,2230.22,,8.47,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2230.22,60,,1784.176,Percent of Total Billed Charges,60% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,536,14.42,,428.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2787.77,75,,235.936,Percent of Total Billed Charges,75% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,1858.52,50,,1486.816,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2601.92,70,,2081.536,Percent of Total Billed Charges,70% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,520.38,14,,416.304,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3717.03,100,,314.584,Percent of Total Billed Charges,100% of Total Billed Charges,8.47,3717.03,
MOD SED SEP PHYS INIT 15MIN 5+,61000062,CDM,450,RC,99156,HCPCS,Outpatient,,,217.25,130.35,,55.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,226.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,258.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,290.63,360,,,Fee Schedule,360% of BCBS POS Rate,290.63,360,,,Fee schedule,360% of BCBS PPO Rate,290.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,353.912,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,471.88,Percent of Total Billed Charges,100% of Total Billed Charges,30.42,290.63,
MOD SED SEP PHYS ADDL 15MIN,61000063,CDM,450,RC,99157,HCPCS,Outpatient,,,137,82.20,,46.39,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,183.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,209.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,236.12,360,,,Fee Schedule,360% of BCBS POS Rate,236.12,360,,,Fee schedule,360% of BCBS PPO Rate,236.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,314.592,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,419.456,Percent of Total Billed Charges,100% of Total Billed Charges,19.18,236.12,
IMMUNIZATION INJECT INFLUENZA,61000089,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.98,42.59,,10.31,100,,,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,,Fee Schedule,360% of BCBS POS Rate,85.64,360,,,Fee schedule,360% of BCBS PPO Rate,85.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.59,60,,34.072,Percent of Total Billed Charges,60% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,10.24,14.42,,8.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,53.24,75,,503.496,Percent of Total Billed Charges,75% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,35.49,50,,28.392,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,70,,39.752,Percent of Total Billed Charges,70% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.94,14,,7.952,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,100,,671.328,Percent of Total Billed Charges,100% of Total Billed Charges,9.94,85.64,
BLOOD COLLECTION,61000106,CDM,300,RC,36415,HCPCS,Outpatient,,,34.67,20.80,,1.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,60,,16.64,Percent of Total Billed Charges,60% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,7.94,90,,,Fee Schedule,90% of CMS OPPS Rate,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,130,,,Fee Schedule,130% of CMS OPPS Rate,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,5,14.42,,4,Percent of Total Billed Charges,14.42% of Total Billed Charges,9.09,103,,,Fee Schedule,103% of CMS OPPS Rate,9.09,103,,,Fee Schedule,103% of CMS OPPS Rate,26,75,,314.592,Percent of Total Billed Charges,75% of Total Billed Charges,14.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,14.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.24,150,,,Fee Schedule,150% of CMS OPPS Rate,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2.43,90,,,Fee Schedule,90% of UHC fee schedule,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,4.85,14,,3.88,Percent of Total Billed Charges,14% of Total Billed Charges,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,100,,419.456,Percent of Total Billed Charges,100% of Total Billed Charges,1.74,34.67,
MOD SEDATION INIT 15 MIN,61000107,CDM,370,RC,99151,HCPCS,Outpatient,,,217.25,130.35,,18.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,83.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,93.42,360,,,Fee Schedule,360% of BCBS POS Rate,93.42,360,,,Fee schedule,360% of BCBS PPO Rate,93.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,503.496,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,671.328,Percent of Total Billed Charges,100% of Total Billed Charges,18.43,217.25,
TRAY CHEST TUBE INSERTION,61000108,CDM,272,RC,,,Outpatient,,,600,360.00,,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168,28,,134.4,Percent of Total Billed Charges,28% of Total Billed Charges,283.2,32,,226.56,Percent of Total Billed Charges,32% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,216,36,,172.8,Percent of Total Billed Charges,36% Total Bille Charges,216,36,,172.8,Percent of Total Billed Charges,36% of Total Billed Charges,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,86.52,14.42,,69.216,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,75,,42.52,Percent of Total Billed Charges,75% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,300,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,420,70,,336,Percent of Total Billed Charges,70% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,84,14,,67.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,600,100,,56.688,Percent of Total Billed Charges,100% of Total Billed Charges,84,600,
CLASS I,61005104,CDM,450,RC,99281,HCPCS,Outpatient,,,523.6,314.16,,780,60,,624,Percent of Total Billed Charges,60% of Total Billed Charges,122.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,406,28,,324.8,Percent of Total Billed Charges,28% of Total Billed Charges,283.21,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,520,36,,416,Percent of Total Billed Charges,36% of Total Billed Charges,520,36,,416,Percent of Total Billed Charges,36% Total Bille Charges,520,36,,416,Percent of Total Billed Charges,36% of Total Billed Charges,1030,100,,,Case Rate,Pays based on per visit rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,73.3,90,,,Fee Schedule,90% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.88,130,,,Fee Schedule,130% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,75.5,14.42,,60.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,83.88,103,,,Fee Schedule,103% of CMS OPPS Rate,83.88,103,,,Fee Schedule,103% of CMS OPPS Rate,392.7,75,,36.92,Percent of Total Billed Charges,75% of Total Billed Charges,210,100,,,Case Rate,Pays Based on per visit rate,210,100,,,Case Rate,Pays based on per visit rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,210,100,,,Case Rate,Pays based on per visit rate,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,122.17,150,,,Fee Schedule,150% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,650,70,,520,Percent of Total Billed Charges,70% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,523.6,100,,49.224,Percent of Total Billed Charges,100% of Total Billed Charges,73.3,1030,
CLASS I W/MODIFIER,61005112,CDM,450,RC,99281,HCPCS,Outpatient,,,523.6,314.16,,780,60,,624,Percent of Total Billed Charges,60% of Total Billed Charges,122.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,406,28,,324.8,Percent of Total Billed Charges,28% of Total Billed Charges,283.21,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,520,36,,416,Percent of Total Billed Charges,36% of Total Billed Charges,520,36,,416,Percent of Total Billed Charges,36% Total Bille Charges,520,36,,416,Percent of Total Billed Charges,36% of Total Billed Charges,1030,100,,,Case Rate,Pays based on per visit rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,73.3,90,,,Fee Schedule,90% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.88,130,,,Fee Schedule,130% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,75.5,14.42,,60.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,83.88,103,,,Fee Schedule,103% of CMS OPPS Rate,83.88,103,,,Fee Schedule,103% of CMS OPPS Rate,392.7,75,,27.848,Percent of Total Billed Charges,75% of Total Billed Charges,210,100,,,Case Rate,Pays Based on per visit rate,210,100,,,Case Rate,Pays based on per visit rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,210,100,,,Case Rate,Pays based on per visit rate,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,122.17,150,,,Fee Schedule,150% of CMS OPPS Rate,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,650,70,,520,Percent of Total Billed Charges,70% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,73.3,14,,58.64,Percent of Total Billed Charges,14% of Total Billed Charges,81.45,100,,,Fee Schedule,100% of CMS OPPS Rate,523.6,100,,37.128,Percent of Total Billed Charges,100% of Total Billed Charges,73.3,1030,
CRITICAL CARE INITIAL,61005146,CDM,450,RC,99291,HCPCS,Outpatient,,,3388.89,2033.33,,157.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,1221.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560,28,,2048,Percent of Total Billed Charges,28% of Total Billed Charges,283.21,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% Total Bille Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,2575,100,,,Case Rate,Pays based on per visit rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,732.71,90,,,Fee Schedule,90% of CMS OPPS Rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.35,130,,,Fee Schedule,130% of CMS OPPS Rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,488.68,14.42,,390.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,838.54,103,,,Fee Schedule,103% of CMS OPPS Rate,838.54,103,,,Fee Schedule,103% of CMS OPPS Rate,2541.67,75,,19.576,Percent of Total Billed Charges,75% of Total Billed Charges,1285,100,,,Case Rate,Pays Based on per visit rate,1285,100,,,Case Rate,Pays based on per visit rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1285,100,,,Case Rate,Pays based on per visit rate,1285,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,1221.19,150,,,Fee Schedule,150% of CMS OPPS Rate,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,474.44,14,,379.552,Percent of Total Billed Charges,14% of Total Billed Charges,814.13,100,,,Fee Schedule,100% of CMS OPPS Rate,3388.89,100,,26.096,Percent of Total Billed Charges,100% of Total Billed Charges,157.88,4600,
CLASS II,61005229,CDM,450,RC,99282,HCPCS,Outpatient,,,882.8,529.68,,30.69,100,,,Fee Schedule,100% of Aetna Fee Schedule,225.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,660,28,,528,Percent of Total Billed Charges,28% of Total Billed Charges,283.21,32,,226.568,Percent of Total Billed Charges,32% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,852,36,,681.6,Percent of Total Billed Charges,36% of Total Billed Charges,852,36,,681.6,Percent of Total Billed Charges,36% Total Bille Charges,852,36,,681.6,Percent of Total Billed Charges,36% of Total Billed Charges,1030,100,,,Case Rate,Pays based on per visit rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,135.04,90,,,Fee Schedule,90% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,195.05,130,,,Fee Schedule,130% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,14.42,,101.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,154.54,103,,,Fee Schedule,103% of CMS OPPS Rate,154.54,103,,,Fee Schedule,103% of CMS OPPS Rate,662.1,75,,26.296,Percent of Total Billed Charges,75% of Total Billed Charges,345,100,,,Case Rate,Pays Based on per visit rate,345,100,,,Case Rate,Pays based on per visit rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,345,100,,,Case Rate,Pays based on per visit rate,345,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,225.07,150,,,Fee Schedule,150% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,882.8,100,,35.056,Percent of Total Billed Charges,100% of Total Billed Charges,30.69,1100,
CLASS II W/MODIFIER,61005237,CDM,450,RC,99282,HCPCS,Outpatient,,,882.8,529.68,,30.69,100,,,Fee Schedule,100% of Aetna Fee Schedule,225.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,660,28,,528,Percent of Total Billed Charges,28% of Total Billed Charges,284.19,32,,227.352,Percent of Total Billed Charges,32% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,852,36,,681.6,Percent of Total Billed Charges,36% of Total Billed Charges,852,36,,681.6,Percent of Total Billed Charges,36% Total Bille Charges,852,36,,681.6,Percent of Total Billed Charges,36% of Total Billed Charges,1030,100,,,Case Rate,Pays based on per visit rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,135.04,90,,,Fee Schedule,90% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,195.05,130,,,Fee Schedule,130% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,14.42,,101.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,154.54,103,,,Fee Schedule,103% of CMS OPPS Rate,154.54,103,,,Fee Schedule,103% of CMS OPPS Rate,662.1,75,,63.216,Percent of Total Billed Charges,75% of Total Billed Charges,345,100,,,Case Rate,Pays Based on per visit rate,345,100,,,Case Rate,Pays based on per visit rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,345,100,,,Case Rate,Pays based on per visit rate,345,50,,276,Percent of Total Billed Charges,50% of Total Billed Charges,225.07,150,,,Fee Schedule,150% of CMS OPPS Rate,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,123.59,14,,98.872,Percent of Total Billed Charges,14% of Total Billed Charges,150.05,100,,,Fee Schedule,100% of CMS OPPS Rate,882.8,100,,84.288,Percent of Total Billed Charges,100% of Total Billed Charges,30.69,1100,
CLASS III,61005245,CDM,450,RC,99283,HCPCS,Outpatient,,,1258.89,755.33,,1665,60,,1332,Percent of Total Billed Charges,60% of Total Billed Charges,392.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,959,28,,767.2,Percent of Total Billed Charges,28% of Total Billed Charges,28.72,32,,22.976,Percent of Total Billed Charges,32% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,1232,36,,985.6,Percent of Total Billed Charges,36% of Total Billed Charges,1232,36,,985.6,Percent of Total Billed Charges,36% Total Bille Charges,1232,36,,985.6,Percent of Total Billed Charges,36% of Total Billed Charges,1957,100,,,Case Rate,Pays based on per visit rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,235.58,90,,,Fee Schedule,90% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,340.29,130,,,Fee Schedule,130% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,181.53,14.42,,145.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,269.61,103,,,Fee Schedule,103% of CMS OPPS Rate,269.61,103,,,Fee Schedule,103% of CMS OPPS Rate,944.17,75,,63,Percent of Total Billed Charges,75% of Total Billed Charges,740,100,,,Case Rate,Pays Based on per visit rate,740,100,,,Case Rate,Pays based on per visit rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,740,100,,,Case Rate,Pays based on per visit rate,740,50,,592,Percent of Total Billed Charges,50% of Total Billed Charges,392.65,150,,,Fee Schedule,150% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,70,,1440,Percent of Total Billed Charges,70% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1258.89,100,,84,Percent of Total Billed Charges,100% of Total Billed Charges,28.72,1957,
CLASS III W/MODIFIER,61005252,CDM,450,RC,99283,HCPCS,Outpatient,,,1258.89,755.33,,1665,60,,1332,Percent of Total Billed Charges,60% of Total Billed Charges,392.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,959,28,,767.2,Percent of Total Billed Charges,28% of Total Billed Charges,28.73,32,,22.984,Percent of Total Billed Charges,32% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,1232,36,,985.6,Percent of Total Billed Charges,36% of Total Billed Charges,1232,36,,985.6,Percent of Total Billed Charges,36% Total Bille Charges,1232,36,,985.6,Percent of Total Billed Charges,36% of Total Billed Charges,1957,100,,,Case Rate,Pays based on per visit rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,235.58,90,,,Fee Schedule,90% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,340.29,130,,,Fee Schedule,130% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,181.53,14.42,,145.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,269.61,103,,,Fee Schedule,103% of CMS OPPS Rate,269.61,103,,,Fee Schedule,103% of CMS OPPS Rate,944.17,75,,36.584,Percent of Total Billed Charges,75% of Total Billed Charges,740,100,,,Case Rate,Pays Based on per visit rate,740,100,,,Case Rate,Pays based on per visit rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,740,100,,,Case Rate,Pays based on per visit rate,740,50,,592,Percent of Total Billed Charges,50% of Total Billed Charges,392.65,150,,,Fee Schedule,150% of CMS OPPS Rate,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,70,,1440,Percent of Total Billed Charges,70% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,176.24,14,,140.992,Percent of Total Billed Charges,14% of Total Billed Charges,261.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1258.89,100,,48.776,Percent of Total Billed Charges,100% of Total Billed Charges,28.73,1957,
CLASS IV,61005260,CDM,450,RC,99284,HCPCS,Outpatient,,,2081.63,1248.98,,2497,60,,1997.6,Percent of Total Billed Charges,60% of Total Billed Charges,609.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1840,28,,1472,Percent of Total Billed Charges,28% of Total Billed Charges,285.99,32,,228.792,Percent of Total Billed Charges,32% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,2360,36,,1888,Percent of Total Billed Charges,36% of Total Billed Charges,2360,36,,1888,Percent of Total Billed Charges,36% Total Bille Charges,2360,36,,1888,Percent of Total Billed Charges,36% of Total Billed Charges,2266,100,,,Case Rate,Pays based on per visit rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,300.17,14.42,,240.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1561.22,75,,16.264,Percent of Total Billed Charges,75% of Total Billed Charges,940,100,,,Case Rate,Pays Based on per visit rate,940,100,,,Case Rate,Pays based on per visit rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,940,100,,,Case Rate,Pays based on per visit rate,940,50,,752,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,70,,2400,Percent of Total Billed Charges,70% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.63,100,,21.68,Percent of Total Billed Charges,100% of Total Billed Charges,285.99,3000,
CLASS V,61005278,CDM,450,RC,99285,HCPCS,Outpatient,,,3091.2,1854.72,,3537,60,,2829.6,Percent of Total Billed Charges,60% of Total Billed Charges,883.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2560,28,,2048,Percent of Total Billed Charges,28% of Total Billed Charges,286.64,32,,229.312,Percent of Total Billed Charges,32% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% Total Bille Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,2266,100,,,Case Rate,Pays based on per visit rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,530.36,90,,,Fee Schedule,90% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,766.08,130,,,Fee Schedule,130% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,445.75,14.42,,356.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,606.96,103,,,Fee Schedule,103% of CMS OPPS Rate,606.96,103,,,Fee Schedule,103% of CMS OPPS Rate,2318.4,75,,34.504,Percent of Total Billed Charges,75% of Total Billed Charges,1285,100,,,Case Rate,Pays Based on per visit rate,1285,100,,,Case Rate,Pays based on per visit rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1285,100,,,Case Rate,Pays based on per visit rate,1285,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,883.94,150,,,Fee Schedule,150% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,70,,2880,Percent of Total Billed Charges,70% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3091.2,100,,46,Percent of Total Billed Charges,100% of Total Billed Charges,286.64,3600,
MOD SEDATION INIT 15 MIN 5+ YO,61005280,CDM,370,RC,99152,HCPCS,Outpatient,,,217.25,130.35,,9.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,,Fee Schedule,360% of BCBS POS Rate,45.4,360,,,Fee schedule,360% of BCBS PPO Rate,45.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.35,60,,104.28,Percent of Total Billed Charges,60% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,31.33,14.42,,25.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.94,75,,34.816,Percent of Total Billed Charges,75% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,108.63,50,,86.904,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.08,70,,121.664,Percent of Total Billed Charges,70% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.42,14,,24.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.25,100,,46.424,Percent of Total Billed Charges,100% of Total Billed Charges,9.14,217.25,
MOD SEDATION ADDL 15 MIN,61005281,CDM,370,RC,99153,HCPCS,Outpatient,,,137,82.20,,7.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,38.92,360,,,Fee Schedule,360% of BCBS POS Rate,38.92,360,,,Fee schedule,360% of BCBS PPO Rate,38.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.2,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.76,14.42,,15.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.75,75,,13.44,Percent of Total Billed Charges,75% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.9,70,,76.72,Percent of Total Billed Charges,70% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,19.18,14,,15.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137,100,,17.92,Percent of Total Billed Charges,100% of Total Billed Charges,7.98,137,
CLASS IV W/MODIFIER,61005286,CDM,450,RC,99284,HCPCS,Outpatient,,,2081.63,1248.98,,2497,60,,1997.6,Percent of Total Billed Charges,60% of Total Billed Charges,609.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1840,28,,1472,Percent of Total Billed Charges,28% of Total Billed Charges,287.02,32,,229.616,Percent of Total Billed Charges,32% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,2360,36,,1888,Percent of Total Billed Charges,36% of Total Billed Charges,2360,36,,1888,Percent of Total Billed Charges,36% Total Bille Charges,2360,36,,1888,Percent of Total Billed Charges,36% of Total Billed Charges,2266,100,,,Case Rate,Pays based on per visit rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,365.71,90,,,Fee Schedule,90% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,528.25,130,,,Fee Schedule,130% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,300.17,14.42,,240.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,418.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1561.22,75,,13.48,Percent of Total Billed Charges,75% of Total Billed Charges,940,100,,,Case Rate,Pays Based on per visit rate,940,100,,,Case Rate,Pays based on per visit rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,940,100,,,Case Rate,Pays based on per visit rate,940,50,,752,Percent of Total Billed Charges,50% of Total Billed Charges,609.52,150,,,Fee Schedule,150% of CMS OPPS Rate,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,70,,2400,Percent of Total Billed Charges,70% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,291.43,14,,233.144,Percent of Total Billed Charges,14% of Total Billed Charges,406.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.63,100,,17.976,Percent of Total Billed Charges,100% of Total Billed Charges,287.02,3000,
CLASS V W/MODIFIER,61005294,CDM,450,RC,99285,HCPCS,Outpatient,,,3091.2,1854.72,,3537,60,,2829.6,Percent of Total Billed Charges,60% of Total Billed Charges,883.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2560,28,,2048,Percent of Total Billed Charges,28% of Total Billed Charges,287.04,32,,229.632,Percent of Total Billed Charges,32% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% Total Bille Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,2266,100,,,Case Rate,Pays based on per visit rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,530.36,90,,,Fee Schedule,90% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,766.08,130,,,Fee Schedule,130% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,445.75,14.42,,356.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,606.96,103,,,Fee Schedule,103% of CMS OPPS Rate,606.96,103,,,Fee Schedule,103% of CMS OPPS Rate,2318.4,75,,35.808,Percent of Total Billed Charges,75% of Total Billed Charges,1285,100,,,Case Rate,Pays Based on per visit rate,1285,100,,,Case Rate,Pays based on per visit rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1285,100,,,Case Rate,Pays based on per visit rate,1285,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,883.94,150,,,Fee Schedule,150% of CMS OPPS Rate,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,70,,2880,Percent of Total Billed Charges,70% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,432.77,14,,346.216,Percent of Total Billed Charges,14% of Total Billed Charges,589.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3091.2,100,,47.744,Percent of Total Billed Charges,100% of Total Billed Charges,287.04,3600,
IV HEP LOCK ONLY,61007621,CDM,450,RC,36000,HCPCS,Outpatient,,,302.89,181.73,,8.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.73,60,,145.384,Percent of Total Billed Charges,60% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,43.68,14.42,,34.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227.17,75,,46.44,Percent of Total Billed Charges,75% of Total Billed Charges,151.45,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,151.45,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.45,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,151.45,50,,121.16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212.02,70,,169.616,Percent of Total Billed Charges,70% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,42.4,14,,33.92,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302.89,100,,61.92,Percent of Total Billed Charges,100% of Total Billed Charges,8.3,302.89,
IMMUNIZATION ORAL/NSL INIT VAC,61007696,CDM,771,RC,90473,HCPCS,Outpatient,,,80,48.00,,5,100,,,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,217.69,360,,,Fee Schedule,360% of BCBS POS Rate,217.69,360,,,Fee schedule,360% of BCBS PPO Rate,217.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,60,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,80,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,5,217.69,
INTRAOSSEOUS IV PLACEMENT,61007738,CDM,450,RC,36680,HCPCS,Outpatient,,,554,332.40,,52.89,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,155.12,28,,124.096,Percent of Total Billed Charges,28% of Total Billed Charges,287.04,32,,229.632,Percent of Total Billed Charges,32% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,199.44,36,,159.552,Percent of Total Billed Charges,36% of Total Billed Charges,199.44,36,,159.552,Percent of Total Billed Charges,36% Total Bille Charges,199.44,36,,159.552,Percent of Total Billed Charges,36% of Total Billed Charges,332.4,60,,265.92,Percent of Total Billed Charges,60% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.99,90,,,Fee Schedule,90% of CMS OPPS Rate,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,475.21,130,,,Fee Schedule,130% of CMS OPPS Rate,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,79.89,14.42,,63.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.51,103,,,Fee Schedule,103% of CMS OPPS Rate,376.51,103,,,Fee Schedule,103% of CMS OPPS Rate,415.5,75,,137.28,Percent of Total Billed Charges,75% of Total Billed Charges,277,50,,221.6,Percent of Total Billed Charges,50% of Total Billed Charges,277,50,,221.6,Percent of Total Billed Charges,50% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,277,50,,221.6,Percent of Total Billed Charges,50% of Total Billed Charges,277,50,,221.6,Percent of Total Billed Charges,50% of Total Billed Charges,548.32,150,,,Fee Schedule,150% of CMS OPPS Rate,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,387.8,70,,310.24,Percent of Total Billed Charges,70% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,77.56,14,,62.048,Percent of Total Billed Charges,14% of Total Billed Charges,365.55,100,,,Fee Schedule,100% of CMS OPPS Rate,554,100,,183.04,Percent of Total Billed Charges,100% of Total Billed Charges,52.89,554,
CRITICAL CARE ADDITIONAL 30MIN,61030557,CDM,450,RC,99292,HCPCS,Outpatient,,,1435.48,861.29,,79.27,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2560,28,,2048,Percent of Total Billed Charges,28% of Total Billed Charges,2888.33,32,,2310.664,Percent of Total Billed Charges,32% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,3320,36,,2656,Percent of Total Billed Charges,36% Total Bille Charges,3320,36,,2656,Percent of Total Billed Charges,36% of Total Billed Charges,2575,100,,,Case Rate,Pays based on per visit rate,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,207,14.42,,165.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1076.61,75,,137.28,Percent of Total Billed Charges,75% of Total Billed Charges,1285,100,,,Case Rate,Pays Based on per visit rate,1285,100,,,Case Rate,Pays based on per visit rate,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1285,100,,,Case Rate,Pays based on per visit rate,1285,50,,1028,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1004.84,70,,803.872,Percent of Total Billed Charges,70% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,200.97,14,,160.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1435.48,100,,183.04,Percent of Total Billed Charges,100% of Total Billed Charges,79.27,3320,
IMMUNIZATION IM/SQ INITIAL VAC,61039962,CDM,771,RC,90471,HCPCS,Outpatient,,,127,76.20,,10,100,,,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,217.69,360,,,Fee Schedule,360% of BCBS POS Rate,217.69,360,,,Fee schedule,360% of BCBS PPO Rate,217.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.2,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,95.25,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.9,70,,71.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,127,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,10,217.69,
IMMUNIZATION IM/SQ EA AD VAC,61039988,CDM,771,RC,90472,HCPCS,Outpatient,,,86.12,51.67,,10,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,46.69,360,,,Fee Schedule,360% of BCBS POS Rate,46.69,360,,,Fee schedule,360% of BCBS PPO Rate,46.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,51.67,60,,41.336,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.59,75,,4207.04,Percent of Total Billed Charges,75% of Total Billed Charges,43.06,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,43.06,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.06,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,43.06,50,,34.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.28,70,,48.224,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.12,100,,5609.384,Percent of Total Billed Charges,100% of Total Billed Charges,10,86.12,
LEVEL 1 PROCD/SURG PROCDS,61060034,CDM,450,RC,,,Outpatient,,,189.69,113.81,,113.81,60,,91.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.11,28,,42.488,Percent of Total Billed Charges,28% of Total Billed Charges,2907.84,32,,2326.272,Percent of Total Billed Charges,32% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,68.29,36,,54.632,Percent of Total Billed Charges,36% of Total Billed Charges,68.29,36,,54.632,Percent of Total Billed Charges,36% Total Bille Charges,68.29,36,,54.632,Percent of Total Billed Charges,36% of Total Billed Charges,113.81,60,,91.048,Percent of Total Billed Charges,60% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,27.35,14.42,,21.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.27,75,,2343.208,Percent of Total Billed Charges,75% of Total Billed Charges,94.85,50,,75.88,Percent of Total Billed Charges,50% of Total Billed Charges,94.85,50,,75.88,Percent of Total Billed Charges,50% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.85,50,,75.88,Percent of Total Billed Charges,50% of Total Billed Charges,94.85,50,,75.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,26.56,14,,21.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,189.69,100,,3124.28,Percent of Total Billed Charges,100% of Total Billed Charges,26.56,4600,
LEVEL 2 PROCD/SURG PROCDS,61060042,CDM,450,RC,,,Outpatient,,,465.36,279.22,,279.22,60,,223.376,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.3,28,,104.24,Percent of Total Billed Charges,28% of Total Billed Charges,2909.55,32,,2327.64,Percent of Total Billed Charges,32% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,167.53,36,,134.024,Percent of Total Billed Charges,36% of Total Billed Charges,167.53,36,,134.024,Percent of Total Billed Charges,36% Total Bille Charges,167.53,36,,134.024,Percent of Total Billed Charges,36% of Total Billed Charges,279.22,60,,223.376,Percent of Total Billed Charges,60% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,67.1,14.42,,53.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.02,75,,69.76,Percent of Total Billed Charges,75% of Total Billed Charges,232.68,50,,186.144,Percent of Total Billed Charges,50% of Total Billed Charges,232.68,50,,186.144,Percent of Total Billed Charges,50% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,232.68,50,,186.144,Percent of Total Billed Charges,50% of Total Billed Charges,232.68,50,,186.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,65.15,14,,52.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,465.36,100,,87.2,Percent of Total Billed Charges,100% of Total Billed Charges,65.15,4600,
LEVEL 3 PROCD/SURG PROCDS,61060059,CDM,450,RC,,,Outpatient,,,722.75,433.65,,433.65,60,,346.92,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.37,28,,161.896,Percent of Total Billed Charges,28% of Total Billed Charges,2912,32,,2329.6,Percent of Total Billed Charges,32% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,260.19,36,,208.152,Percent of Total Billed Charges,36% of Total Billed Charges,260.19,36,,208.152,Percent of Total Billed Charges,36% Total Bille Charges,260.19,36,,208.152,Percent of Total Billed Charges,36% of Total Billed Charges,433.65,60,,346.92,Percent of Total Billed Charges,60% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,104.22,14.42,,83.376,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.06,75,,358.4,Percent of Total Billed Charges,75% of Total Billed Charges,361.38,50,,289.104,Percent of Total Billed Charges,50% of Total Billed Charges,361.38,50,,289.104,Percent of Total Billed Charges,50% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.38,50,,289.104,Percent of Total Billed Charges,50% of Total Billed Charges,361.38,50,,289.104,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,101.19,14,,80.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,722.75,100,,448,Percent of Total Billed Charges,100% of Total Billed Charges,101.19,4600,
LEVEL 4 PROCD/SURG PROCDS,61060067,CDM,450,RC,,,Outpatient,,,1226.67,736.00,,736,60,,588.8,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,343.47,28,,274.776,Percent of Total Billed Charges,28% of Total Billed Charges,2958.49,32,,2366.792,Percent of Total Billed Charges,32% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,441.6,36,,353.28,Percent of Total Billed Charges,36% of Total Billed Charges,441.6,36,,353.28,Percent of Total Billed Charges,36% Total Bille Charges,441.6,36,,353.28,Percent of Total Billed Charges,36% of Total Billed Charges,736,60,,588.8,Percent of Total Billed Charges,60% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,176.89,14.42,,141.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,920,75,,69.76,Percent of Total Billed Charges,75% of Total Billed Charges,613.34,50,,490.672,Percent of Total Billed Charges,50% of Total Billed Charges,613.34,50,,490.672,Percent of Total Billed Charges,50% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,613.34,50,,490.672,Percent of Total Billed Charges,50% of Total Billed Charges,613.34,50,,490.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,171.73,14,,137.384,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1226.67,100,,87.2,Percent of Total Billed Charges,100% of Total Billed Charges,171.73,4600,
LEVEL 5 PROCD/SURG PROCDS,61060075,CDM,450,RC,,,Outpatient,,,2538.36,1523.02,,1523.02,60,,1218.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,710.74,28,,568.592,Percent of Total Billed Charges,28% of Total Billed Charges,2958.49,32,,2366.792,Percent of Total Billed Charges,32% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,913.81,36,,731.048,Percent of Total Billed Charges,36% of Total Billed Charges,913.81,36,,731.048,Percent of Total Billed Charges,36% Total Bille Charges,913.81,36,,731.048,Percent of Total Billed Charges,36% of Total Billed Charges,1523.02,60,,1218.416,Percent of Total Billed Charges,60% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,366.03,14.42,,292.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1903.77,75,,358.4,Percent of Total Billed Charges,75% of Total Billed Charges,1269.18,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,1269.18,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1269.18,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,1269.18,50,,1015.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,355.37,14,,284.296,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2538.36,100,,448,Percent of Total Billed Charges,100% of Total Billed Charges,355.37,4600,
LEVEL 6 PROCD/SURG PROCDS,61060083,CDM,450,RC,,,Outpatient,,,7078.96,4247.38,,4247.38,60,,3397.904,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1982.11,28,,1585.688,Percent of Total Billed Charges,28% of Total Billed Charges,2961.92,32,,2369.536,Percent of Total Billed Charges,32% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,2548.43,36,,2038.744,Percent of Total Billed Charges,36% of Total Billed Charges,2548.43,36,,2038.744,Percent of Total Billed Charges,36% Total Bille Charges,2548.43,36,,2038.744,Percent of Total Billed Charges,36% of Total Billed Charges,4247.38,60,,3397.904,Percent of Total Billed Charges,60% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,1020.79,14.42,,816.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5309.22,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,3539.48,50,,2831.584,Percent of Total Billed Charges,50% of Total Billed Charges,3539.48,50,,2831.584,Percent of Total Billed Charges,50% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3539.48,50,,2831.584,Percent of Total Billed Charges,50% of Total Billed Charges,3539.48,50,,2831.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4600,70,,3680,Percent of Total Billed Charges,70% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,991.05,14,,792.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7078.96,100,,57.6,Percent of Total Billed Charges,100% of Total Billed Charges,991.05,7078.96,
IMMB SHLDR FNGR SMALL,61060115,CDM,271,RC,,,Outpatient,,,66.82,40.09,,40.09,60,,32.072,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.71,28,,14.968,Percent of Total Billed Charges,28% of Total Billed Charges,2976.32,32,,2381.056,Percent of Total Billed Charges,32% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,24.06,36,,19.248,Percent of Total Billed Charges,36% of Total Billed Charges,24.06,36,,19.248,Percent of Total Billed Charges,36% Total Bille Charges,24.06,36,,19.248,Percent of Total Billed Charges,36% of Total Billed Charges,40.09,60,,32.072,Percent of Total Billed Charges,60% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.64,14.42,,7.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.12,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,33.41,50,,26.728,Percent of Total Billed Charges,50% of Total Billed Charges,33.41,50,,26.728,Percent of Total Billed Charges,50% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.41,50,,26.728,Percent of Total Billed Charges,50% of Total Billed Charges,33.41,50,,26.728,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.77,70,,37.416,Percent of Total Billed Charges,70% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,9.35,14,,7.48,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.82,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,9.35,2976.32,
IMMB KNEE UNIV 20IN W/,61060116,CDM,271,RC,,,Outpatient,,,98.03,58.82,,58.82,60,,47.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.45,28,,21.96,Percent of Total Billed Charges,28% of Total Billed Charges,2976.32,32,,2381.056,Percent of Total Billed Charges,32% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,35.29,36,,28.232,Percent of Total Billed Charges,36% of Total Billed Charges,35.29,36,,28.232,Percent of Total Billed Charges,36% Total Bille Charges,35.29,36,,28.232,Percent of Total Billed Charges,36% of Total Billed Charges,58.82,60,,47.056,Percent of Total Billed Charges,60% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14.42,,11.312,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.52,75,,28.096,Percent of Total Billed Charges,75% of Total Billed Charges,49.02,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.02,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,49.02,50,,39.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.62,70,,54.896,Percent of Total Billed Charges,70% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,13.72,14,,10.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.03,100,,37.464,Percent of Total Billed Charges,100% of Total Billed Charges,13.72,2976.32,
SLEEVE COMPR SCD EXPR KNEE LG,61060120,CDM,271,RC,,,Outpatient,,,125.84,75.50,,75.5,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.24,28,,28.192,Percent of Total Billed Charges,28% of Total Billed Charges,2993.51,32,,2394.808,Percent of Total Billed Charges,32% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,45.3,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,45.3,36,,36.24,Percent of Total Billed Charges,36% Total Bille Charges,45.3,36,,36.24,Percent of Total Billed Charges,36% of Total Billed Charges,75.5,60,,60.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,18.15,14.42,,14.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.38,75,,12.976,Percent of Total Billed Charges,75% of Total Billed Charges,62.92,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.92,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,62.92,50,,50.336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.09,70,,70.472,Percent of Total Billed Charges,70% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,17.62,14,,14.096,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,125.84,100,,17.304,Percent of Total Billed Charges,100% of Total Billed Charges,17.62,2993.51,
TAPE CAST ORTH 15FTX2IN FBGLS,61060121,CDM,270,RC,,,Outpatient,,,190.49,114.29,,114.29,60,,91.432,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.34,28,,42.672,Percent of Total Billed Charges,28% of Total Billed Charges,2995.2,32,,2396.16,Percent of Total Billed Charges,32% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,68.58,36,,54.864,Percent of Total Billed Charges,36% of Total Billed Charges,68.58,36,,54.864,Percent of Total Billed Charges,36% Total Bille Charges,68.58,36,,54.864,Percent of Total Billed Charges,36% of Total Billed Charges,114.29,60,,91.432,Percent of Total Billed Charges,60% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,27.47,14.42,,21.976,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.87,75,,31.336,Percent of Total Billed Charges,75% of Total Billed Charges,95.25,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,95.25,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.25,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,95.25,50,,76.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.34,70,,106.672,Percent of Total Billed Charges,70% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,26.67,14,,21.336,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.49,100,,41.776,Percent of Total Billed Charges,100% of Total Billed Charges,26.67,2995.2,
TAPE CAST ORTH OTHGL 15FTX4IN,61060125,CDM,271,RC,,,Outpatient,,,375,225.00,,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,3009.58,32,,2407.664,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,225,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.25,75,,39.784,Percent of Total Billed Charges,75% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,187.5,50,,150,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,53.04,Percent of Total Billed Charges,100% of Total Billed Charges,52.5,3009.58,
TAPE CAST ORTH 15FTX5IN FBGLS,61060126,CDM,271,RC,,,Outpatient,,,394.05,236.43,,236.43,60,,189.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.33,28,,88.264,Percent of Total Billed Charges,28% of Total Billed Charges,3023.27,32,,2418.616,Percent of Total Billed Charges,32% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,141.86,36,,113.488,Percent of Total Billed Charges,36% of Total Billed Charges,141.86,36,,113.488,Percent of Total Billed Charges,36% Total Bille Charges,141.86,36,,113.488,Percent of Total Billed Charges,36% of Total Billed Charges,236.43,60,,189.144,Percent of Total Billed Charges,60% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,56.82,14.42,,45.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.54,75,,19.36,Percent of Total Billed Charges,75% of Total Billed Charges,197.03,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,197.03,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,197.03,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,197.03,50,,157.624,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.84,70,,220.672,Percent of Total Billed Charges,70% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,55.17,14,,44.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,394.05,100,,25.816,Percent of Total Billed Charges,100% of Total Billed Charges,55.17,3023.27,
BAG PRESSURE INFUS 1000ML DISP,61060159,CDM,272,RC,,,Outpatient,,,80.21,48.13,,48.13,60,,38.504,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.46,28,,17.968,Percent of Total Billed Charges,28% of Total Billed Charges,3045.5,32,,2436.4,Percent of Total Billed Charges,32% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% Total Bille Charges,28.88,36,,23.104,Percent of Total Billed Charges,36% of Total Billed Charges,48.13,60,,38.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.57,14.42,,9.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.16,75,,55.12,Percent of Total Billed Charges,75% of Total Billed Charges,40.11,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,40.11,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.11,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,40.11,50,,32.088,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.15,70,,44.92,Percent of Total Billed Charges,70% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,11.23,14,,8.984,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.21,100,,73.488,Percent of Total Billed Charges,100% of Total Billed Charges,11.23,3045.5,
SKIN ADHESIVE DERMABOND PEN,61060169,CDM,272,RC,,,Outpatient,,,107.35,64.41,,64.41,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.06,28,,24.048,Percent of Total Billed Charges,28% of Total Billed Charges,3045.5,32,,2436.4,Percent of Total Billed Charges,32% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% Total Bille Charges,38.65,36,,30.92,Percent of Total Billed Charges,36% of Total Billed Charges,64.41,60,,51.528,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.48,14.42,,12.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.51,75,,33.976,Percent of Total Billed Charges,75% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,53.68,50,,42.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.15,70,,60.12,Percent of Total Billed Charges,70% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,15.03,14,,12.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.35,100,,45.304,Percent of Total Billed Charges,100% of Total Billed Charges,15.03,3045.5,
GUN BN INJ AUTO ADULT DISP INT,61060175,CDM,272,RC,,,Outpatient,,,616.43,369.86,,369.86,60,,295.888,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,172.6,28,,138.08,Percent of Total Billed Charges,28% of Total Billed Charges,3065.08,32,,2452.064,Percent of Total Billed Charges,32% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,221.91,36,,177.528,Percent of Total Billed Charges,36% of Total Billed Charges,221.91,36,,177.528,Percent of Total Billed Charges,36% Total Bille Charges,221.91,36,,177.528,Percent of Total Billed Charges,36% of Total Billed Charges,369.86,60,,295.888,Percent of Total Billed Charges,60% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,88.89,14.42,,71.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462.32,75,,34.696,Percent of Total Billed Charges,75% of Total Billed Charges,308.22,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,308.22,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,308.22,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,308.22,50,,246.576,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,431.5,70,,345.2,Percent of Total Billed Charges,70% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,86.3,14,,69.04,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,616.43,100,,46.256,Percent of Total Billed Charges,100% of Total Billed Charges,86.3,3065.08,
RESUS MNL AD W/ 40IN,61060184,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,3072,32,,2457.6,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,16.424,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,21.896,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,3072,
BNDG DRSG TBGZ 5/8INX50YD,61060185,CDM,271,RC,,,Outpatient,,,70.28,42.17,,42.17,60,,33.736,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.68,28,,15.744,Percent of Total Billed Charges,28% of Total Billed Charges,3080.31,32,,2464.248,Percent of Total Billed Charges,32% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,25.3,36,,20.24,Percent of Total Billed Charges,36% of Total Billed Charges,25.3,36,,20.24,Percent of Total Billed Charges,36% Total Bille Charges,25.3,36,,20.24,Percent of Total Billed Charges,36% of Total Billed Charges,42.17,60,,33.736,Percent of Total Billed Charges,60% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,10.13,14.42,,8.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.71,75,,130.56,Percent of Total Billed Charges,75% of Total Billed Charges,35.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,35.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,35.14,50,,28.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.2,70,,39.36,Percent of Total Billed Charges,70% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,9.84,14,,7.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.28,100,,174.08,Percent of Total Billed Charges,100% of Total Billed Charges,9.84,3080.31,
IV INFUSION HYDRATION 1ST HR,61060192,CDM,450,RC,96360,HCPCS,Outpatient,,,598.04,358.82,,26.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,107.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,138.82,360,,,Fee Schedule,360% of BCBS POS Rate,138.82,360,,,Fee schedule,360% of BCBS PPO Rate,138.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,358.82,60,,287.056,Percent of Total Billed Charges,60% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,86.24,14.42,,68.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,448.53,75,,21.296,Percent of Total Billed Charges,75% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,299.02,50,,239.216,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,418.63,70,,334.904,Percent of Total Billed Charges,70% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,83.73,14,,66.984,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,598.04,100,,28.392,Percent of Total Billed Charges,100% of Total Billed Charges,26.92,598.04,
IV INFUSION HYDRATION EA HR,61060193,CDM,450,RC,96361,HCPCS,Outpatient,,,190.28,114.17,,10.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,49.28,360,,,Fee Schedule,360% of BCBS POS Rate,49.28,360,,,Fee schedule,360% of BCBS PPO Rate,49.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,114.17,60,,91.336,Percent of Total Billed Charges,60% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,27.44,14.42,,21.952,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,142.71,75,,43.672,Percent of Total Billed Charges,75% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,95.14,50,,76.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,133.2,70,,106.56,Percent of Total Billed Charges,70% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,26.64,14,,21.312,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,190.28,100,,58.224,Percent of Total Billed Charges,100% of Total Billed Charges,10.32,190.28,
IV INFUSION THERAPEUTIC 1ST HR,61060194,CDM,450,RC,96365,HCPCS,Outpatient,,,599.82,359.89,,54.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,232.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,262.08,360,,,Fee Schedule,360% of BCBS POS Rate,262.08,360,,,Fee schedule,360% of BCBS PPO Rate,262.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,359.89,60,,287.912,Percent of Total Billed Charges,60% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,86.49,14.42,,69.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,449.87,75,,18.608,Percent of Total Billed Charges,75% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,299.91,50,,239.928,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,419.87,70,,335.896,Percent of Total Billed Charges,70% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,83.97,14,,67.176,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,599.82,100,,24.808,Percent of Total Billed Charges,100% of Total Billed Charges,54.64,599.82,
IV INFUSION THERAPEUTIC EA HR,61060195,CDM,450,RC,96366,HCPCS,Outpatient,,,205.27,123.16,,16.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,79.13,360,,,Fee Schedule,360% of BCBS POS Rate,79.13,360,,,Fee schedule,360% of BCBS PPO Rate,79.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.16,60,,98.528,Percent of Total Billed Charges,60% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,29.6,14.42,,23.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,153.95,75,,36.376,Percent of Total Billed Charges,75% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,102.64,50,,82.112,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,143.69,70,,114.952,Percent of Total Billed Charges,70% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,28.74,14,,22.992,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.27,100,,48.496,Percent of Total Billed Charges,100% of Total Billed Charges,16.59,205.27,
IV INF THERAP ADDL SEQUENTIAL,61060196,CDM,450,RC,96367,HCPCS,Outpatient,,,318.15,190.89,,23.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,101.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,114.16,360,,,Fee Schedule,360% of BCBS POS Rate,114.16,360,,,Fee schedule,360% of BCBS PPO Rate,114.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,190.89,60,,152.712,Percent of Total Billed Charges,60% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.01,130,,,Fee Schedule,130% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,45.88,14.42,,36.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,103,,,Fee Schedule,103% of CMS OPPS Rate,238.61,75,,50.224,Percent of Total Billed Charges,75% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,159.08,50,,127.264,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,222.71,70,,178.168,Percent of Total Billed Charges,70% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,44.54,14,,35.632,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,318.15,100,,66.96,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,318.15,
IV INF THERAPEUTIC CONCURRENT,61060197,CDM,450,RC,96368,HCPCS,Outpatient,,,259.72,155.83,,15.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,76.54,360,,,Fee Schedule,360% of BCBS POS Rate,76.54,360,,,Fee schedule,360% of BCBS PPO Rate,76.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,155.83,60,,124.664,Percent of Total Billed Charges,60% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,37.45,14.42,,29.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.79,75,,25.12,Percent of Total Billed Charges,75% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,129.86,50,,103.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,181.8,70,,145.44,Percent of Total Billed Charges,70% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,14,,29.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.72,100,,33.488,Percent of Total Billed Charges,100% of Total Billed Charges,15.81,259.72,
INJECTION SQ OR IM,61060200,CDM,450,RC,96372,HCPCS,Outpatient,,,208.77,125.26,,10.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,96.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,169.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,193.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,217.69,360,,,Fee Schedule,360% of BCBS POS Rate,217.69,360,,,Fee schedule,360% of BCBS PPO Rate,217.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.26,60,,100.208,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,90,,,Fee Schedule,90% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,130,,,Fee Schedule,130% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,30.1,14.42,,24.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,66.57,103,,,Fee Schedule,103% of CMS OPPS Rate,156.58,75,,35.448,Percent of Total Billed Charges,75% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,104.39,50,,83.512,Percent of Total Billed Charges,50% of Total Billed Charges,96.94,150,,,Fee Schedule,150% of CMS OPPS Rate,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,146.14,70,,116.912,Percent of Total Billed Charges,70% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,29.23,14,,23.384,Percent of Total Billed Charges,14% of Total Billed Charges,64.63,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,100,,47.264,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,217.69,
IV PUSH THER INITIAL MED,61060201,CDM,450,RC,96374,HCPCS,Outpatient,,,280.25,168.15,,31.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,294.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,110.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,126.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.7,360,,,Fee Schedule,360% of BCBS POS Rate,142.7,360,,,Fee schedule,360% of BCBS PPO Rate,142.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,168.15,60,,134.52,Percent of Total Billed Charges,60% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,176.97,90,,,Fee Schedule,90% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,255.63,130,,,Fee Schedule,130% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,40.41,14.42,,32.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,202.54,103,,,Fee Schedule,103% of CMS OPPS Rate,210.19,75,,15.456,Percent of Total Billed Charges,75% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,140.13,50,,112.104,Percent of Total Billed Charges,50% of Total Billed Charges,294.97,150,,,Fee Schedule,150% of CMS OPPS Rate,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,196.18,70,,156.944,Percent of Total Billed Charges,70% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,39.24,14,,31.392,Percent of Total Billed Charges,14% of Total Billed Charges,196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,280.25,100,,20.608,Percent of Total Billed Charges,100% of Total Billed Charges,31.1,294.97,
IVP THER EA AD SEQ NEW MED,61060202,CDM,450,RC,96375,HCPCS,Outpatient,,,261.2,156.72,,12.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,65.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,60.98,360,,,Fee Schedule,360% of BCBS POS Rate,60.98,360,,,Fee schedule,360% of BCBS PPO Rate,60.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,156.72,60,,125.376,Percent of Total Billed Charges,60% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,39.22,90,,,Fee Schedule,90% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,130,,,Fee Schedule,130% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,37.67,14.42,,30.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,44.88,103,,,Fee Schedule,103% of CMS OPPS Rate,195.9,75,,24.696,Percent of Total Billed Charges,75% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,130.6,50,,104.48,Percent of Total Billed Charges,50% of Total Billed Charges,65.37,150,,,Fee Schedule,150% of CMS OPPS Rate,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,182.84,70,,146.272,Percent of Total Billed Charges,70% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,36.57,14,,29.256,Percent of Total Billed Charges,14% of Total Billed Charges,43.58,100,,,Fee Schedule,100% of CMS OPPS Rate,261.2,100,,32.928,Percent of Total Billed Charges,100% of Total Billed Charges,12.68,261.2,
IVP THER EA AD SEQ SAME MED,61060203,CDM,450,RC,96376,HCPCS,Outpatient,,,249.73,149.84,,7.71,100,,,Fee Schedule,100% of Aetna Fee Schedule,112.38,45,,89.904,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,76.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,85.64,360,,,Fee Schedule,360% of BCBS POS Rate,85.64,360,,,Fee schedule,360% of BCBS PPO Rate,85.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,149.84,60,,119.872,Percent of Total Billed Charges,60% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.73,100,,199.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,36.01,14.42,,28.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.3,75,,37.264,Percent of Total Billed Charges,75% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,124.87,50,,99.896,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,174.81,70,,139.848,Percent of Total Billed Charges,70% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,34.96,14,,27.968,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,249.73,100,,49.68,Percent of Total Billed Charges,100% of Total Billed Charges,7.71,249.73,
MR BRST W CM BI,68160512,CDM,610,RC,C8906,HCPCS,Outpatient,,,3324.03,1994.42,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,479.33,14.42,,383.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2493.02,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,,Case Rate,Pays Based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,,Case Rate,Pays based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3324.03,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3324.03,
MR BRST W CM BI,68160512,CDM,610,RC,C8906,HCPCS,Outpatient,,,3324.03,1994.42,,3014.25,110,,2411.4,Percent of Total Billed Charges,110% of Total Billed Charges,529.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1221.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,1374.66,360,,,Fee Schedule,360% of BCBS POS Rate,1374.66,360,,,Fee schedule,360% of BCBS PPO Rate,1374.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,317.54,90,,,Fee Schedule,90% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,458.67,130,,,Fee Schedule,130% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,479.33,14.42,,383.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,363.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2493.02,75,,448,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,,Case Rate,Pays Based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,,Case Rate,Pays based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,529.25,150,,,Fee Schedule,150% of CMS OPPS Rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,,Case Rate,Pays based on per visit rate,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,465.36,14,,372.288,Percent of Total Billed Charges,14% of Total Billed Charges,352.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3324.03,100,,560,Percent of Total Billed Charges,100% of Total Billed Charges,317.54,3324.03,
MR BRST WO CM BI,68160513,CDM,610,RC,77047,HCPCS,Outpatient,,,3031.52,1818.91,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,437.15,14.42,,349.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2273.64,75,,328.64,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,,Case Rate,Pays Based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,,Case Rate,Pays based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3031.52,100,,410.8,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3031.52,
MR BRST WO CM BI,68160513,CDM,610,RC,77047,HCPCS,Outpatient,,,3031.52,1818.91,,2790,110,,2232,Percent of Total Billed Charges,110% of Total Billed Charges,337.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,652.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,745.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,838.94,360,,,Fee Schedule,360% of BCBS POS Rate,838.94,360,,,Fee schedule,360% of BCBS PPO Rate,838.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,1424,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,202.32,90,,,Fee Schedule,90% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,292.25,130,,,Fee Schedule,130% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,437.15,14.42,,349.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,231.55,103,,,Fee Schedule,103% of CMS OPPS Rate,2273.64,75,,316,Percent of Total Billed Charges,75% of Total Billed Charges,1557,100,,,Case Rate,Pays Based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1557,100,,,Case Rate,Pays based on per visit rate,1557,100,,,Case Rate,Pays based on per visit rate,337.21,150,,,Fee Schedule,150% of CMS OPPS Rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2245,100,,,Case Rate,Pays based on per visit rate,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,424.41,14,,339.528,Percent of Total Billed Charges,14% of Total Billed Charges,224.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3031.52,100,,395,Percent of Total Billed Charges,100% of Total Billed Charges,202.32,3031.52,
MR BX BRST INI LT,68160514,CDM,361,RC,19085,HCPCS,Outpatient,,,4914,2948.40,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3198.16,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3092.16,32,,2473.728,Percent of Total Billed Charges,32% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,4419.77,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,4419.77,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,4419.77,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,3347.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,708.6,14.42,,566.88,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,3685.5,75,,328.64,Percent of Total Billed Charges,75% of Total Billed Charges,2457,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2457,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,2457,50,,1965.6,Percent of Total Billed Charges,50% of Total Billed Charges,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,687.96,14,,550.368,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,4914,100,,410.8,Percent of Total Billed Charges,100% of Total Billed Charges,687.96,4914,
US ASP BRST CYST LT,68160515,CDM,361,RC,,,Outpatient,,,1112.42,667.45,,667.45,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,500.59,45,,400.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.48,28,,249.184,Percent of Total Billed Charges,28% of Total Billed Charges,3135.63,32,,2508.504,Percent of Total Billed Charges,32% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% Total Bille Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,667.45,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.42,100,,889.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,160.41,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.32,75,,232.928,Percent of Total Billed Charges,75% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,778.69,70,,622.952,Percent of Total Billed Charges,70% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1112.42,100,,291.16,Percent of Total Billed Charges,100% of Total Billed Charges,155.74,3135.63,
US ASP BRST CYST RT,68160516,CDM,361,RC,,,Outpatient,,,1112.42,667.45,,667.45,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,500.59,45,,400.472,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,311.48,28,,249.184,Percent of Total Billed Charges,28% of Total Billed Charges,3142.31,32,,2513.848,Percent of Total Billed Charges,32% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% Total Bille Charges,400.47,36,,320.376,Percent of Total Billed Charges,36% of Total Billed Charges,667.45,60,,533.96,Percent of Total Billed Charges,60% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.42,100,,889.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,160.41,14.42,,128.328,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.32,75,,448,Percent of Total Billed Charges,75% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,556.21,50,,444.968,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,778.69,70,,622.952,Percent of Total Billed Charges,70% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,155.74,14,,124.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1112.42,100,,560,Percent of Total Billed Charges,100% of Total Billed Charges,155.74,3142.31,
MR GUIDE NDL MARK PLCMT INI BI,68160517,CDM,361,RC,19287,HCPCS,Outpatient,,,5025.04,3015.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3143.3,32,,2514.64,Percent of Total Billed Charges,32% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,724.61,14.42,,579.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,3768.78,75,,340.096,Percent of Total Billed Charges,75% of Total Billed Charges,2512.52,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,2512.52,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2512.52,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,2512.52,50,,2010.016,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,703.51,14,,562.808,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5025.04,100,,425.12,Percent of Total Billed Charges,100% of Total Billed Charges,580.95,5025.04,
MR GUIDE NDL MARK PLCMT INI RT,68160518,CDM,361,RC,19287,HCPCS,Outpatient,,,3350.03,2010.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3143.4,32,,2514.72,Percent of Total Billed Charges,32% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,483.07,14.42,,386.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2512.52,75,,232.928,Percent of Total Billed Charges,75% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3350.03,100,,291.16,Percent of Total Billed Charges,100% of Total Billed Charges,469,4682,
MR GUIDE NDL MARK PLCMT INI LT,68160519,CDM,361,RC,19287,HCPCS,Outpatient,,,3350.03,2010.02,,4682,100,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,968.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.32,233,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,3144.48,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings Fee Schedule,1964.23,322,,,Fee schedule,Pays based on ASC Tier Groupings fee schedule,1964.23,322,,,Fee Schedule,Pays based on ASC Tier Groupings fee schedule,1184.5,103,,,Fee Schedule,Pays based on ASC Tier Grouping fee schedule,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,580.95,90,,,Fee Schedule,90% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,839.15,130,,,Fee Schedule,130% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,483.07,14.42,,386.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,664.86,103,,,Fee Schedule,103% of CMS OPPS Rate,2512.52,75,,340.096,Percent of Total Billed Charges,75% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,1675.02,50,,1340.016,Percent of Total Billed Charges,50% of Total Billed Charges,968.25,150,,,Fee Schedule,150% of CMS OPPS Rate,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2456,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,469,14,,375.2,Percent of Total Billed Charges,14% of Total Billed Charges,645.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3350.03,100,,425.12,Percent of Total Billed Charges,100% of Total Billed Charges,469,4682,
BRONCH PROVOCATION W/SPIRO,68411826,CDM,460,RC,94070,HCPCS,Outpatient,,,1280.72,768.43,,25.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,87.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,100.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,112.86,360,,,Fee Schedule,360% of BCBS POS Rate,112.86,360,,,Fee schedule,360% of BCBS PPO Rate,112.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,768.43,60,,614.744,Percent of Total Billed Charges,60% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,184.68,14.42,,147.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,960.54,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,640.36,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,640.36,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,640.36,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,640.36,50,,512.288,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,179.3,14,,143.44,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1280.72,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,25.75,1280.72,
SPIROMETRY W/O BRONCHODILATOR,68412006,CDM,460,RC,94010,HCPCS,Outpatient,,,446.84,268.10,,16.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,387.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,442.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,498.06,360,,,Fee Schedule,360% of BCBS POS Rate,498.06,360,,,Fee schedule,360% of BCBS PPO Rate,498.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,268.1,60,,214.48,Percent of Total Billed Charges,60% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.98,90,,,Fee Schedule,90% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,130,,,Fee Schedule,130% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,64.43,14.42,,51.544,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,147.61,103,,,Fee Schedule,103% of CMS OPPS Rate,335.13,75,,450,Percent of Total Billed Charges,75% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,223.42,50,,178.736,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,62.56,14,,50.048,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,446.84,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,16.08,766,
SPIROMETRY W/BRONCHODILATOR,68412014,CDM,460,RC,94060,HCPCS,Outpatient,,,846.58,507.95,,27.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,132.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,151.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,169.96,360,,,Fee Schedule,360% of BCBS POS Rate,169.96,360,,,Fee schedule,360% of BCBS PPO Rate,169.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,507.95,60,,406.36,Percent of Total Billed Charges,60% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,122.08,14.42,,97.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,634.94,75,,285.6,Percent of Total Billed Charges,75% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,423.29,50,,338.632,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,118.52,14,,94.816,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,846.58,100,,380.8,Percent of Total Billed Charges,100% of Total Billed Charges,27.32,846.58,
CO DIFFUSING CAPACITY,68412089,CDM,460,RC,94729,HCPCS,Outpatient,,,521.64,312.98,,38.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,234.74,45,,187.792,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,149.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,168.66,360,,,Fee Schedule,360% of BCBS POS Rate,168.66,360,,,Fee schedule,360% of BCBS PPO Rate,168.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,312.98,60,,250.384,Percent of Total Billed Charges,60% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,521.64,100,,417.312,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,75.22,14.42,,60.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.23,75,,285.6,Percent of Total Billed Charges,75% of Total Billed Charges,260.82,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,260.82,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.82,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,260.82,50,,208.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,766,100,,,Case Rate,Pays based on per visit rate,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,73.03,14,,58.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,521.64,100,,380.8,Percent of Total Billed Charges,100% of Total Billed Charges,38.3,766,
SMOKE/TOBACCO 3-10,68413047,CDM,942,RC,99406,HCPCS,Outpatient,,,74.57,44.74,,9.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,45.4,360,,,Fee Schedule,360% of BCBS POS Rate,45.4,360,,,Fee schedule,360% of BCBS PPO Rate,45.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.74,60,,35.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.68,90,,,Fee Schedule,90% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,130,,,Fee Schedule,130% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.75,14.42,,8.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,55.93,75,,269.44,Percent of Total Billed Charges,75% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,37.29,50,,29.832,Percent of Total Billed Charges,50% of Total Billed Charges,39.47,150,,,Fee Schedule,150% of CMS OPPS Rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,45,100,,,Case Rate,Pays based on per visit rate,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,10.44,14,,8.352,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,74.57,100,,336.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.52,74.57,
SMOKE/TOBACCO >10,68413048,CDM,942,RC,99407,HCPCS,Outpatient,,,102.1,61.26,,19.59,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,73.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,84.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,94.72,360,,,Fee Schedule,360% of BCBS POS Rate,94.72,360,,,Fee schedule,360% of BCBS PPO Rate,94.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,61.26,60,,49.008,Percent of Total Billed Charges,60% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.68,90,,,Fee Schedule,90% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,130,,,Fee Schedule,130% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.72,14.42,,11.776,Percent of Total Billed Charges,14.42% of Total Billed Charges,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,27.11,103,,,Fee Schedule,103% of CMS OPPS Rate,76.58,75,,252.6,Percent of Total Billed Charges,75% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,51.05,50,,40.84,Percent of Total Billed Charges,50% of Total Billed Charges,39.47,150,,,Fee Schedule,150% of CMS OPPS Rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,45,100,,,Case Rate,Pays based on per visit rate,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,14.29,14,,11.432,Percent of Total Billed Charges,14% of Total Billed Charges,26.32,100,,,Fee Schedule,100% of CMS OPPS Rate,102.1,100,,336.8,Percent of Total Billed Charges,100% of Total Billed Charges,14.29,102.1,
PLETHYSMOGRAPHY LUNG VOLUMES,68437243,CDM,460,RC,94726,HCPCS,Outpatient,,,609.18,365.51,,32.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,708.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,809.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,911.16,360,,,Fee Schedule,360% of BCBS POS Rate,911.16,360,,,Fee schedule,360% of BCBS PPO Rate,911.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,365.51,60,,292.408,Percent of Total Billed Charges,60% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.36,130,,,Fee Schedule,130% of CMS OPPS Rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,87.84,14.42,,70.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,456.89,75,,200.32,Percent of Total Billed Charges,75% of Total Billed Charges,304.59,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,304.59,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,304.59,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,304.59,50,,243.672,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,85.29,14,,68.232,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,609.18,100,,250.4,Percent of Total Billed Charges,100% of Total Billed Charges,32.16,911.16,
CARDIOPULMONARY EXERCISE,68446210,CDM,460,RC,94621,HCPCS,Outpatient,,,2036.02,1221.61,,67.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,431.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,297.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,334.73,360,,,Fee Schedule,360% of BCBS POS Rate,334.73,360,,,Fee schedule,360% of BCBS PPO Rate,334.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,1221.61,60,,977.288,Percent of Total Billed Charges,60% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,259.17,90,,,Fee Schedule,90% of CMS OPPS Rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,130,,,Fee Schedule,130% of CMS OPPS Rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,293.59,14.42,,234.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,296.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1527.02,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,1018.01,50,,814.408,Percent of Total Billed Charges,50% of Total Billed Charges,1018.01,50,,814.408,Percent of Total Billed Charges,50% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.01,50,,814.408,Percent of Total Billed Charges,50% of Total Billed Charges,1018.01,50,,814.408,Percent of Total Billed Charges,50% of Total Billed Charges,431.95,150,,,Fee Schedule,150% of CMS OPPS Rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,766,100,,,Case Rate,Pays based on per visit rate,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,285.04,14,,228.032,Percent of Total Billed Charges,14% of Total Billed Charges,287.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2036.02,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,67.72,2036.02,
BRONCHIAL CHALLENGE,68450709,CDM,924,RC,95070,HCPCS,Outpatient,,,851.75,511.05,,23.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,90.83,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,103.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,116.78,360,,,Fee Schedule,360% of BCBS POS Rate,116.78,360,,,Fee schedule,360% of BCBS PPO Rate,116.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,511.05,60,,408.84,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,122.82,14.42,,98.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,638.81,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,425.88,50,,340.704,Percent of Total Billed Charges,50% of Total Billed Charges,425.88,50,,340.704,Percent of Total Billed Charges,50% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,425.88,50,,340.704,Percent of Total Billed Charges,50% of Total Billed Charges,425.88,50,,340.704,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,,Case Rate,Pays based on per visit rate,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,119.25,14,,95.4,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,851.75,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,23.88,851.75,
THERASKIN 3 SQ CM,69000000,CDM,278,RC,Q4121,HCPCS,Outpatient,,,327,196.20,,403.96,110,,323.168,Percent of Total Billed Charges,110% of Total Billed Charges,147.15,45,,117.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327,100,,261.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.6,80,,304.64,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.9,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327,100,,380.8,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,403.96,
THERASKIN 3 SQ CM WASTE,69000001,CDM,278,RC,Q4121,HCPCS,Outpatient,,,327,196.20,,403.96,110,,323.168,Percent of Total Billed Charges,110% of Total Billed Charges,147.15,45,,117.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327,100,,261.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.6,80,,304.64,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.9,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327,100,,380.8,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,403.96,
MATRIX OASIS ULTRA 3X7CM FEN,69000002,CDM,278,RC,Q4124,HCPCS,Outpatient,,,1131.32,678.79,,1256.45,110,,1005.16,Percent of Total Billed Charges,110% of Total Billed Charges,509.09,45,,407.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.77,28,,253.416,Percent of Total Billed Charges,28% of Total Billed Charges,3144.48,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% Total Bille Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,622.23,55,,497.784,Percent of Total Billed Charges,55% Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1131.32,100,,905.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,163.14,14.42,,130.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,905.06,80,,269.44,Percent of Total Billed Charges,80% of Total Billed Charges,8.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.1,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,8.1,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.92,70,,633.536,Percent of Total Billed Charges,70% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1131.32,100,,336.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.1,3144.48,
MATRIX OASIS ULTRA 3X7CM FEN WASTE,69000003,CDM,278,RC,Q4124,HCPCS,Outpatient,,,1131.32,678.79,,1256.45,110,,1005.16,Percent of Total Billed Charges,110% of Total Billed Charges,509.09,45,,407.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,316.77,28,,253.416,Percent of Total Billed Charges,28% of Total Billed Charges,3144.48,32,,2515.584,Percent of Total Billed Charges,32% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% Total Bille Charges,407.28,36,,325.824,Percent of Total Billed Charges,36% of Total Billed Charges,622.23,55,,497.784,Percent of Total Billed Charges,55% Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1131.32,100,,905.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,163.14,14.42,,130.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,905.06,80,,187.8,Percent of Total Billed Charges,80% of Total Billed Charges,8.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.1,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,8.1,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.92,70,,633.536,Percent of Total Billed Charges,70% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,158.38,14,,126.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1131.32,100,,250.4,Percent of Total Billed Charges,100% of Total Billed Charges,8.1,3144.48,
BANDAGE COFLEX 5.1YD X 4IN TAN,69000004,CDM,272,RC,A6455,HCPCS,Outpatient,,,100,60.00,,1.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,45,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,5.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.83,360,,,Fee Schedule,360% of BCBS POS Rate,5.83,360,,,Fee schedule,360% of BCBS PPO Rate,5.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,60,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,80,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.42,14.42,,11.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,75,,187.8,Percent of Total Billed Charges,75% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,100,,250.4,Percent of Total Billed Charges,100% of Total Billed Charges,1.18,100,
UNNA BOOT CALAMINE 6YD X 4IN,69000005,CDM,272,RC,A6456,HCPCS,Outpatient,,,100,60.00,,1.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,45,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,5.29,360,,,Fee Schedule,360% of BCBS POS Rate,5.29,360,,,Fee schedule,360% of BCBS PPO Rate,5.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,60,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,80,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14.42,14.42,,11.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,75,,252.6,Percent of Total Billed Charges,75% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,50,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,14,14,,11.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,100,,336.8,Percent of Total Billed Charges,100% of Total Billed Charges,1.07,100,
DRSG Mepilex Sacrum 22x25,69000008,CDM,272,RC,A6213,HCPCS,Outpatient,,,93.1,55.86,,11.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,41.9,45,,33.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.07,28,,20.856,Percent of Total Billed Charges,28% of Total Billed Charges,3154.27,32,,2523.416,Percent of Total Billed Charges,32% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,33.52,36,,26.816,Percent of Total Billed Charges,36% of Total Billed Charges,33.52,36,,26.816,Percent of Total Billed Charges,36% Total Bille Charges,33.52,36,,26.816,Percent of Total Billed Charges,36% of Total Billed Charges,55.86,60,,44.688,Percent of Total Billed Charges,60% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.1,100,,74.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.43,14.42,,10.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.83,75,,34.504,Percent of Total Billed Charges,75% of Total Billed Charges,46.55,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,46.55,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.55,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,46.55,50,,37.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,65.17,70,,52.136,Percent of Total Billed Charges,70% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,13.03,14,,10.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,93.1,100,,46,Percent of Total Billed Charges,100% of Total Billed Charges,11.24,3154.27,
DRSG Epiona 2x2,69000009,CDM,272,RC,A6210,HCPCS,Outpatient,,,90.05,54.03,,16.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.52,45,,32.416,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,83.34,360,,,Fee Schedule,360% of BCBS POS Rate,83.34,360,,,Fee schedule,360% of BCBS PPO Rate,83.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.03,60,,43.224,Percent of Total Billed Charges,60% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.05,100,,72.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.99,14.42,,10.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.54,75,,3049.104,Percent of Total Billed Charges,75% of Total Billed Charges,45.03,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,45.03,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.03,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,45.03,50,,36.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.04,70,,50.432,Percent of Total Billed Charges,70% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,12.61,14,,10.088,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.05,100,,4065.472,Percent of Total Billed Charges,100% of Total Billed Charges,12.61,90.05,
"Filler Polymem WIC 0.4x14""",69000010,CDM,272,RC,A6215,HCPCS,Outpatient,,,80.6,48.36,,4.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.27,45,,29.016,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.57,28,,18.056,Percent of Total Billed Charges,28% of Total Billed Charges,3160,32,,2528,Percent of Total Billed Charges,32% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,29.02,36,,23.216,Percent of Total Billed Charges,36% of Total Billed Charges,29.02,36,,23.216,Percent of Total Billed Charges,36% Total Bille Charges,29.02,36,,23.216,Percent of Total Billed Charges,36% of Total Billed Charges,48.36,60,,38.688,Percent of Total Billed Charges,60% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.6,100,,64.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.62,14.42,,9.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.45,75,,405,Percent of Total Billed Charges,75% of Total Billed Charges,40.3,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.3,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,50,,32.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.42,70,,45.136,Percent of Total Billed Charges,70% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,11.28,14,,9.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.6,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,4.04,3160,
KIT CAST COTTON GAUZE DELTA TERRY-NET STOCKINETTE,69000011,CDM,271,RC,,,Outpatient,,,523.05,313.83,,313.83,60,,251.064,Percent of Total Billed Charges,60% of Total Billed Charges,235.37,45,,188.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.45,28,,117.16,Percent of Total Billed Charges,28% of Total Billed Charges,3163.23,32,,2530.584,Percent of Total Billed Charges,32% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,188.3,36,,150.64,Percent of Total Billed Charges,36% of Total Billed Charges,188.3,36,,150.64,Percent of Total Billed Charges,36% Total Bille Charges,188.3,36,,150.64,Percent of Total Billed Charges,36% of Total Billed Charges,313.83,60,,251.064,Percent of Total Billed Charges,60% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,523.05,100,,418.44,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,75.42,14.42,,60.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.29,75,,405,Percent of Total Billed Charges,75% of Total Billed Charges,261.53,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,261.53,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.53,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,261.53,50,,209.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.14,70,,292.912,Percent of Total Billed Charges,70% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,73.23,14,,58.584,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,523.05,100,,540,Percent of Total Billed Charges,100% of Total Billed Charges,73.23,3163.23,
BANDAGE SUPPORT SIZE G L11YD NATURAL VISCOSE/ELAST,69000012,CDM,271,RC,,,Outpatient,,,285.94,171.56,,171.56,60,,137.248,Percent of Total Billed Charges,60% of Total Billed Charges,128.67,45,,102.936,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.06,28,,64.048,Percent of Total Billed Charges,28% of Total Billed Charges,3165.76,32,,2532.608,Percent of Total Billed Charges,32% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,102.94,36,,82.352,Percent of Total Billed Charges,36% of Total Billed Charges,102.94,36,,82.352,Percent of Total Billed Charges,36% Total Bille Charges,102.94,36,,82.352,Percent of Total Billed Charges,36% of Total Billed Charges,171.56,60,,137.248,Percent of Total Billed Charges,60% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.94,100,,228.752,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,41.23,14.42,,32.984,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.46,75,,346.672,Percent of Total Billed Charges,75% of Total Billed Charges,142.97,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,142.97,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.97,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,142.97,50,,114.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200.16,70,,160.128,Percent of Total Billed Charges,70% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,40.03,14,,32.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,285.94,100,,433.336,Percent of Total Billed Charges,100% of Total Billed Charges,40.03,3165.76,
BANDAGE TUBULAR SIZE F L32.81IN LARGE KNEE MEDIUM,69000013,CDM,271,RC,,,Outpatient,,,256.84,154.10,,154.1,60,,123.28,Percent of Total Billed Charges,60% of Total Billed Charges,115.58,45,,92.464,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.92,28,,57.536,Percent of Total Billed Charges,28% of Total Billed Charges,3170.98,32,,2536.784,Percent of Total Billed Charges,32% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,92.46,36,,73.968,Percent of Total Billed Charges,36% of Total Billed Charges,92.46,36,,73.968,Percent of Total Billed Charges,36% Total Bille Charges,92.46,36,,73.968,Percent of Total Billed Charges,36% of Total Billed Charges,154.1,60,,123.28,Percent of Total Billed Charges,60% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.84,100,,205.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.04,14.42,,29.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.63,75,,346.672,Percent of Total Billed Charges,75% of Total Billed Charges,128.42,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,128.42,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.42,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,128.42,50,,102.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.79,70,,143.832,Percent of Total Billed Charges,70% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,35.96,14,,28.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,256.84,100,,433.336,Percent of Total Billed Charges,100% of Total Billed Charges,35.96,3170.98,
TUBIGRIP 10M #E NATURAL,69000014,CDM,271,RC,,,Outpatient,,,241.36,144.82,,144.82,60,,115.856,Percent of Total Billed Charges,60% of Total Billed Charges,108.61,45,,86.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.58,28,,54.064,Percent of Total Billed Charges,28% of Total Billed Charges,2.88,32,,2.304,Percent of Total Billed Charges,32% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,86.89,36,,69.512,Percent of Total Billed Charges,36% of Total Billed Charges,86.89,36,,69.512,Percent of Total Billed Charges,36% Total Bille Charges,86.89,36,,69.512,Percent of Total Billed Charges,36% of Total Billed Charges,144.82,60,,115.856,Percent of Total Billed Charges,60% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.36,100,,193.088,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,34.8,14.42,,27.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.02,75,,1386.672,Percent of Total Billed Charges,75% of Total Billed Charges,120.68,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,120.68,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,120.68,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,120.68,50,,96.544,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.95,70,,135.16,Percent of Total Billed Charges,70% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,33.79,14,,27.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.36,100,,1733.336,Percent of Total Billed Charges,100% of Total Billed Charges,2.88,241.36,
DRSG FM GRNFM VAC 26X15CM LG,69000015,CDM,272,RC,A6550,HCPCS,Outpatient,,,199.68,119.81,,18.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,89.86,45,,71.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,87.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,98.89,360,,,Fee Schedule,360% of BCBS POS Rate,98.89,360,,,Fee schedule,360% of BCBS PPO Rate,98.89,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.81,60,,95.848,Percent of Total Billed Charges,60% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.68,100,,159.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,28.79,14.42,,23.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.76,75,,1386.672,Percent of Total Billed Charges,75% of Total Billed Charges,99.84,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,99.84,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.84,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,99.84,50,,79.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.78,70,,111.824,Percent of Total Billed Charges,70% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,27.96,14,,22.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.68,100,,1733.336,Percent of Total Billed Charges,100% of Total Billed Charges,18.72,199.68,
DRESSING VAC WHITE FOAM SM,69000016,CDM,272,RC,A6550,HCPCS,Outpatient,,,170.32,102.19,,18.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.64,45,,61.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,87.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,98.89,360,,,Fee Schedule,360% of BCBS POS Rate,98.89,360,,,Fee schedule,360% of BCBS PPO Rate,98.89,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.19,60,,81.752,Percent of Total Billed Charges,60% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.32,100,,136.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,24.56,14.42,,19.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.74,75,,98.312,Percent of Total Billed Charges,75% of Total Billed Charges,85.16,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,85.16,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.16,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,85.16,50,,68.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,119.22,70,,95.376,Percent of Total Billed Charges,70% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,23.84,14,,19.072,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,170.32,100,,122.888,Percent of Total Billed Charges,100% of Total Billed Charges,18.72,170.32,
PATIENT LEVEL I,69000017,CDM,510,RC,G0463,HCPCS,Outpatient,,,131.14,78.68,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,,Fee Schedule,360% of BCBS POS Rate,417.35,360,,,Fee schedule,360% of BCBS PPO Rate,417.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.91,14.42,,15.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,98.36,75,,98.312,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,91.8,70,,73.44,Percent of Total Billed Charges,70% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,18.36,14,,14.688,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,131.14,100,,122.888,Percent of Total Billed Charges,100% of Total Billed Charges,18.36,417.35,
PATIENT LEVEL II,69000018,CDM,510,RC,G0463,HCPCS,Outpatient,,,144.25,86.55,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,,Fee Schedule,360% of BCBS POS Rate,417.35,360,,,Fee schedule,360% of BCBS PPO Rate,417.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.8,14.42,,16.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,108.19,75,,23.52,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,100.98,70,,80.784,Percent of Total Billed Charges,70% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,20.2,14,,16.16,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,144.25,100,,31.36,Percent of Total Billed Charges,100% of Total Billed Charges,20.2,417.35,
PATIENT LEVEL III,69000019,CDM,510,RC,G0463,HCPCS,Outpatient,,,158.69,95.21,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,,Fee Schedule,360% of BCBS POS Rate,417.35,360,,,Fee schedule,360% of BCBS PPO Rate,417.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.88,14.42,,18.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,119.02,75,,261.328,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,111.08,70,,88.864,Percent of Total Billed Charges,70% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,22.22,14,,17.776,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,158.69,100,,326.664,Percent of Total Billed Charges,100% of Total Billed Charges,22.22,417.35,
PATIENT LEVEL IV,69000020,CDM,510,RC,G0463,HCPCS,Outpatient,,,174.55,104.73,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,,Fee Schedule,360% of BCBS POS Rate,417.35,360,,,Fee schedule,360% of BCBS PPO Rate,417.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,25.17,14.42,,20.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,130.91,75,,261.328,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,122.19,70,,97.752,Percent of Total Billed Charges,70% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,24.44,14,,19.552,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,174.55,100,,326.664,Percent of Total Billed Charges,100% of Total Billed Charges,24.44,417.35,
PATIENT LEVEL V,69000021,CDM,510,RC,G0463,HCPCS,Outpatient,,,192.03,115.22,,87.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,181.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,324.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,370.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,417.35,360,,,Fee Schedule,360% of BCBS POS Rate,417.35,360,,,Fee schedule,360% of BCBS PPO Rate,417.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,109.14,90,,,Fee Schedule,90% of CMS OPPS Rate,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,157.65,130,,,Fee Schedule,130% of CMS OPPS Rate,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,27.69,14.42,,22.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,124.91,103,,,Fee Schedule,103% of CMS OPPS Rate,144.02,75,,179.88,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,150,,,Fee Schedule,150% of CMS OPPS Rate,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,134.42,70,,107.536,Percent of Total Billed Charges,70% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,26.88,14,,21.504,Percent of Total Billed Charges,14% of Total Billed Charges,121.27,100,,,Fee Schedule,100% of CMS OPPS Rate,192.03,100,,239.84,Percent of Total Billed Charges,100% of Total Billed Charges,26.88,417.35,
APPLY SKN SUB TRNK HI 1ST 25CM,69000022,CDM,510,RC,15271,HCPCS,Outpatient,,,2239.26,1343.56,,62.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,2509.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,626.99,28,,501.592,Percent of Total Billed Charges,28% of Total Billed Charges,2.89,32,,2.312,Percent of Total Billed Charges,32% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,806.13,36,,644.904,Percent of Total Billed Charges,36% of Total Billed Charges,806.13,36,,644.904,Percent of Total Billed Charges,36% Total Bille Charges,806.13,36,,644.904,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,322.9,14.42,,258.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1679.45,75,,179.88,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.48,70,,1253.984,Percent of Total Billed Charges,70% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,313.5,14,,250.8,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2239.26,100,,239.84,Percent of Total Billed Charges,100% of Total Billed Charges,2.89,2509.64,
APPLY SKN SUB TRNK HI ADD 25CM,69000023,CDM,510,RC,15272,HCPCS,Outpatient,,,903,541.80,,12.77,100,,,Fee Schedule,100% of Aetna Fee Schedule,406.35,45,,325.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,903,100,,722.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,130.21,14.42,,104.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,677.25,75,,26.04,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,632.1,70,,505.68,Percent of Total Billed Charges,70% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,126.42,14,,101.136,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,903,100,,34.72,Percent of Total Billed Charges,100% of Total Billed Charges,12.77,903,
APPLY SKN SUB FACE HI 1ST 25CM,69000026,CDM,510,RC,15275,HCPCS,Outpatient,,,2247.39,1348.43,,71.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,2509.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,629.27,28,,503.416,Percent of Total Billed Charges,28% of Total Billed Charges,2.9,32,,2.32,Percent of Total Billed Charges,32% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,809.06,36,,647.248,Percent of Total Billed Charges,36% of Total Billed Charges,809.06,36,,647.248,Percent of Total Billed Charges,36% Total Bille Charges,809.06,36,,647.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,324.07,14.42,,259.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1685.54,75,,40.912,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1573.17,70,,1258.536,Percent of Total Billed Charges,70% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,314.63,14,,251.704,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2247.39,100,,54.544,Percent of Total Billed Charges,100% of Total Billed Charges,2.9,2509.64,
APPLY SKN SUB FACE HI ADD 25CM,69000027,CDM,510,RC,15276,HCPCS,Outpatient,,,1105.87,663.52,,18.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,497.64,45,,398.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1105.87,100,,884.696,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,159.47,14.42,,127.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,829.4,75,,684,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,774.11,70,,619.288,Percent of Total Billed Charges,70% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,154.82,14,,123.856,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1105.87,100,,912,Percent of Total Billed Charges,100% of Total Billed Charges,18.81,1105.87,
APPLY SKN SUB TRNK LW 1ST 25CM,69000030,CDM,510,RC,C5271,HCPCS,Outpatient,,,1365.86,819.52,,819.52,60,,655.616,Percent of Total Billed Charges,60% of Total Billed Charges,864.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,382.44,28,,305.952,Percent of Total Billed Charges,28% of Total Billed Charges,2.91,32,,2.328,Percent of Total Billed Charges,32% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,491.71,36,,393.368,Percent of Total Billed Charges,36% of Total Billed Charges,491.71,36,,393.368,Percent of Total Billed Charges,36% Total Bille Charges,491.71,36,,393.368,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,518.59,90,,,Fee Schedule,90% of CMS OPPS Rate,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,749.07,130,,,Fee Schedule,130% of CMS OPPS Rate,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,196.96,14.42,,157.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1024.4,75,,44.312,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,864.31,150,,,Fee Schedule,150% of CMS OPPS Rate,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,956.1,70,,764.88,Percent of Total Billed Charges,70% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,191.22,14,,152.976,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1365.86,100,,59.08,Percent of Total Billed Charges,100% of Total Billed Charges,2.91,1365.86,
APPLY SKN SUB TRNK LW ADD 25CM,69000031,CDM,510,RC,C5272,HCPCS,Outpatient,,,1019.23,611.54,,611.54,60,,489.232,Percent of Total Billed Charges,60% of Total Billed Charges,458.65,45,,366.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.23,100,,815.384,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,146.97,14.42,,117.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,764.42,75,,44.312,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,713.46,70,,570.768,Percent of Total Billed Charges,70% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,142.69,14,,114.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1019.23,100,,59.08,Percent of Total Billed Charges,100% of Total Billed Charges,142.69,1019.23,
APPLY SKN SUB TRNK LW 1ST100CM,69000032,CDM,510,RC,C5273,HCPCS,Outpatient,,,2640.4,1584.24,,1584.24,60,,1267.392,Percent of Total Billed Charges,60% of Total Billed Charges,2509.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,739.31,28,,591.448,Percent of Total Billed Charges,28% of Total Billed Charges,2.94,32,,2.352,Percent of Total Billed Charges,32% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,950.54,36,,760.432,Percent of Total Billed Charges,36% of Total Billed Charges,950.54,36,,760.432,Percent of Total Billed Charges,36% Total Bille Charges,950.54,36,,760.432,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,380.75,14.42,,304.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1980.3,75,,119.576,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1848.28,70,,1478.624,Percent of Total Billed Charges,70% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,369.66,14,,295.728,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2640.4,100,,149.472,Percent of Total Billed Charges,100% of Total Billed Charges,2.94,2640.4,
APPLY SKN SUB TRNK LW ADD100CM,69000033,CDM,510,RC,C5274,HCPCS,Outpatient,,,1282.42,769.45,,769.45,60,,615.56,Percent of Total Billed Charges,60% of Total Billed Charges,577.09,45,,461.672,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1282.42,100,,1025.936,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,184.92,14.42,,147.936,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.82,75,,119.576,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,897.69,70,,718.152,Percent of Total Billed Charges,70% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,179.54,14,,143.632,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1282.42,100,,149.472,Percent of Total Billed Charges,100% of Total Billed Charges,179.54,1282.42,
APPLY SKN SUB FACE LW 1ST 25CM,69000034,CDM,510,RC,C5275,HCPCS,Outpatient,,,1720,1032.00,,1032,60,,825.6,Percent of Total Billed Charges,60% of Total Billed Charges,864.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,481.6,28,,385.28,Percent of Total Billed Charges,28% of Total Billed Charges,2.94,32,,2.352,Percent of Total Billed Charges,32% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,619.2,36,,495.36,Percent of Total Billed Charges,36% of Total Billed Charges,619.2,36,,495.36,Percent of Total Billed Charges,36% Total Bille Charges,619.2,36,,495.36,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,518.59,90,,,Fee Schedule,90% of CMS OPPS Rate,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,749.07,130,,,Fee Schedule,130% of CMS OPPS Rate,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,248.02,14.42,,198.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1290,75,,380.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,864.31,150,,,Fee Schedule,150% of CMS OPPS Rate,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1204,70,,963.2,Percent of Total Billed Charges,70% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,240.8,14,,192.64,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1720,100,,476,Percent of Total Billed Charges,100% of Total Billed Charges,2.94,1720,
NEG PRE WOUND < 50 SQ CM DISP,69000038,CDM,510,RC,97607,HCPCS,Outpatient,,,546.84,328.10,,16.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,65.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,84.35,360,,,Fee Schedule,360% of BCBS POS Rate,84.35,360,,,Fee schedule,360% of BCBS PPO Rate,84.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,78.85,14.42,,63.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,410.13,75,,380.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,382.79,70,,306.232,Percent of Total Billed Charges,70% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,76.56,14,,61.248,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,546.84,100,,476,Percent of Total Billed Charges,100% of Total Billed Charges,16.38,548.74,
DRSG FM GRNFM VAC 18X12.5IN,69000039,CDM,272,RC,A6550,HCPCS,Outpatient,,,136.32,81.79,,18.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.34,45,,49.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,87.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,98.89,360,,,Fee Schedule,360% of BCBS POS Rate,98.89,360,,,Fee schedule,360% of BCBS PPO Rate,98.89,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.79,60,,65.432,Percent of Total Billed Charges,60% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.32,100,,109.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.66,14.42,,15.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.24,75,,330.864,Percent of Total Billed Charges,75% of Total Billed Charges,68.16,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,68.16,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.16,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,68.16,50,,54.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.42,70,,76.336,Percent of Total Billed Charges,70% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,19.08,14,,15.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.32,100,,413.576,Percent of Total Billed Charges,100% of Total Billed Charges,18.72,136.32,
BANDAGE COFLEX 2 LAYER,69000040,CDM,272,RC,,,Outpatient,,,110.96,66.58,,66.58,60,,53.264,Percent of Total Billed Charges,60% of Total Billed Charges,49.93,45,,39.944,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.07,28,,24.856,Percent of Total Billed Charges,28% of Total Billed Charges,2.95,32,,2.36,Percent of Total Billed Charges,32% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,39.95,36,,31.96,Percent of Total Billed Charges,36% of Total Billed Charges,39.95,36,,31.96,Percent of Total Billed Charges,36% Total Bille Charges,39.95,36,,31.96,Percent of Total Billed Charges,36% of Total Billed Charges,66.58,60,,53.264,Percent of Total Billed Charges,60% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.96,100,,88.768,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,16,14.42,,12.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.22,75,,330.864,Percent of Total Billed Charges,75% of Total Billed Charges,55.48,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,55.48,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.48,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,55.48,50,,44.384,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.67,70,,62.136,Percent of Total Billed Charges,70% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,15.53,14,,12.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.96,100,,413.576,Percent of Total Billed Charges,100% of Total Billed Charges,2.95,110.96,
DRESSING BIOLOGICAL 2 INCH LENGTH 2 INCH WIDTH COL,69000041,CDM,272,RC,,,Outpatient,,,105.36,63.22,,63.22,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,47.41,45,,37.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.5,28,,23.6,Percent of Total Billed Charges,28% of Total Billed Charges,2.95,32,,2.36,Percent of Total Billed Charges,32% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% Total Bille Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,63.22,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.36,100,,84.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14.42,,12.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.02,75,,83.792,Percent of Total Billed Charges,75% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.75,70,,59,Percent of Total Billed Charges,70% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.36,100,,104.744,Percent of Total Billed Charges,100% of Total Billed Charges,2.95,105.36,
BANDAGE COFLEX 7YD X 4IN XL,69000042,CDM,272,RC,A6454,HCPCS,Outpatient,,,104.48,62.69,,0.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,47.02,45,,37.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,3.28,360,,,Fee Schedule,360% of BCBS POS Rate,3.28,360,,,Fee schedule,360% of BCBS PPO Rate,3.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.69,60,,50.152,Percent of Total Billed Charges,60% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.48,100,,83.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,15.07,14.42,,12.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.36,75,,83.792,Percent of Total Billed Charges,75% of Total Billed Charges,52.24,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,52.24,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.24,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,52.24,50,,41.792,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.14,70,,58.512,Percent of Total Billed Charges,70% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,14.63,14,,11.704,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.48,100,,104.744,Percent of Total Billed Charges,100% of Total Billed Charges,0.66,104.48,
SHOE CAST UNISEX LARGE ADULT OPEN TOE CLOSED HEEL,69000043,CDM,271,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,2.96,32,,2.368,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,290.856,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,387.808,Percent of Total Billed Charges,100% of Total Billed Charges,2.96,80,
SHOE CAST UNISEX XLARGE ADULT OPEN TOE CLOSED HEEL,69000044,CDM,271,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,2.96,32,,2.368,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,397.536,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,530.048,Percent of Total Billed Charges,100% of Total Billed Charges,2.96,80,
SHOE CAST UNISEX MEDIUM ADULT OPEN TOE CLOSED HEEL,69000045,CDM,271,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,2.97,32,,2.376,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,290.856,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,387.808,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,80,
SHOE CAST UNISEX SMALL ADULT OPEN TOE CLOSED HEEL,69000046,CDM,271,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,2.98,32,,2.384,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,634.064,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,792.584,Percent of Total Billed Charges,100% of Total Billed Charges,2.98,80,
DRESSING FOAM SACRAL ADHESIVE POLYURETHANE 9.2 I,69000047,CDM,272,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,2.98,32,,2.384,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,634.064,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,792.584,Percent of Total Billed Charges,100% of Total Billed Charges,2.98,80,
DRESSING HUMAN TISSUE W2XL2IN EPIONA COLLAGEN,69000048,CDM,272,RC,A6021,HCPCS,Outpatient,,,80,48.00,,17.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,78.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,87.91,360,,,Fee Schedule,360% of BCBS POS Rate,87.91,360,,,Fee schedule,360% of BCBS PPO Rate,87.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,508.2,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,635.248,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,87.91,
DRESSING GELLING FIBER 10X12CM EXUFIBER,69000049,CDM,272,RC,A6196,HCPCS,Outpatient,,,10,6.00,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.5,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,100,,8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.44,14.42,,1.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,75,,508.2,Percent of Total Billed Charges,75% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,70,,5.6,Percent of Total Billed Charges,70% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,1.4,14,,1.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,100,,635.248,Percent of Total Billed Charges,100% of Total Billed Charges,1.4,30.78,
BANDAGE COFLEX 3.4YD X 4IN TAN,69000050,CDM,272,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,3.03,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,932.112,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,1165.144,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,80,
BANDAGE COFLEX 5.1YD X 4IN TAN,69000051,CDM,272,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,3.03,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,932.112,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,1165.144,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,80,
UNNA BOOT CALAMINE 6YD X 4IN,69000052,CDM,272,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,3.03,32,,2.424,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,242.464,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,303.08,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,80,
PROTECTANT SKIN 2OZ ZINC OXIDE CLEAR SENSI-CARE,69000053,CDM,272,RC,,,Outpatient,,,80,48.00,,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,28,,17.92,Percent of Total Billed Charges,28% of Total Billed Charges,3.05,32,,2.44,Percent of Total Billed Charges,32% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% Total Bille Charges,28.8,36,,23.04,Percent of Total Billed Charges,36% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,242.464,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,303.08,Percent of Total Billed Charges,100% of Total Billed Charges,3.05,80,
DRESSING COMPOSITE 4.34SQIN HEXAGON SILVER,69000054,CDM,272,RC,A6022,HCPCS,Outpatient,,,80,48.00,,17.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,78.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,87.91,360,,,Fee Schedule,360% of BCBS POS Rate,87.91,360,,,Fee schedule,360% of BCBS PPO Rate,87.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,311.232,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,389.04,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,87.91,
DRESSING ALGINATE W0.39XL18IN SILVER,69000055,CDM,272,RC,A6197,HCPCS,Outpatient,,,80,48.00,,13.97,100,,,Fee Schedule,100% of Aetna Fee Schedule,36,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,68.76,360,,,Fee Schedule,360% of BCBS POS Rate,68.76,360,,,Fee schedule,360% of BCBS PPO Rate,68.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,100,,64,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.54,14.42,,9.232,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,75,,311.232,Percent of Total Billed Charges,75% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,11.2,14,,8.96,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80,100,,389.04,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,80,
Gel Normlgel AG 1.5 oz,69000056,CDM,272,RC,A6248,HCPCS,Outpatient,,,149.28,89.57,,13.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,67.18,45,,53.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,67.97,360,,,Fee Schedule,360% of BCBS POS Rate,67.97,360,,,Fee schedule,360% of BCBS PPO Rate,67.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,89.57,60,,71.656,Percent of Total Billed Charges,60% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.28,100,,119.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,21.53,14.42,,17.224,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.96,75,,350.096,Percent of Total Billed Charges,75% of Total Billed Charges,74.64,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,74.64,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.64,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,74.64,50,,59.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.5,70,,83.6,Percent of Total Billed Charges,70% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,20.9,14,,16.72,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,149.28,100,,437.624,Percent of Total Billed Charges,100% of Total Billed Charges,13.81,149.28,
"DRSG Urgo tul 6x8""",69000057,CDM,272,RC,A6207,HCPCS,Outpatient,,,101.52,60.91,,6.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,45.68,45,,36.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,,Fee Schedule,360% of BCBS POS Rate,30.71,360,,,Fee schedule,360% of BCBS PPO Rate,30.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,60.91,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.52,100,,81.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.64,14.42,,11.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.14,75,,304.92,Percent of Total Billed Charges,75% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,50.76,50,,40.608,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.06,70,,56.848,Percent of Total Billed Charges,70% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,14.21,14,,11.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101.52,100,,381.152,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,101.52,
"DRSG  Prisma 4.34""",69000058,CDM,272,RC,,,Outpatient,,,104.88,62.93,,62.93,60,,50.344,Percent of Total Billed Charges,60% of Total Billed Charges,47.2,45,,37.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.37,28,,23.496,Percent of Total Billed Charges,28% of Total Billed Charges,3.06,32,,2.448,Percent of Total Billed Charges,32% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,37.76,36,,30.208,Percent of Total Billed Charges,36% of Total Billed Charges,37.76,36,,30.208,Percent of Total Billed Charges,36% Total Bille Charges,37.76,36,,30.208,Percent of Total Billed Charges,36% of Total Billed Charges,62.93,60,,50.344,Percent of Total Billed Charges,60% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.88,100,,83.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,15.12,14.42,,12.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.66,75,,304.92,Percent of Total Billed Charges,75% of Total Billed Charges,52.44,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,52.44,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.44,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,52.44,50,,41.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.42,70,,58.736,Percent of Total Billed Charges,70% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,14.68,14,,11.744,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104.88,100,,381.152,Percent of Total Billed Charges,100% of Total Billed Charges,3.06,104.88,
AMNIOBAND 3X4,69000060,CDM,278,RC,Q4151,HCPCS,Outpatient,,,319.32,191.59,,480.08,110,,384.064,Percent of Total Billed Charges,110% of Total Billed Charges,143.69,45,,114.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.41,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,3.1,32,,2.48,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,255.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.46,80,,350.096,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,437.624,Percent of Total Billed Charges,100% of Total Billed Charges,3.1,480.08,
AMNIOBAND 3X4 WASTE,69000061,CDM,278,RC,Q4151,HCPCS,Outpatient,,,319.32,191.59,,480.08,110,,384.064,Percent of Total Billed Charges,110% of Total Billed Charges,143.69,45,,114.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.41,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,3.1,32,,2.48,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,255.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.46,80,,686.056,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,914.736,Percent of Total Billed Charges,100% of Total Billed Charges,3.1,480.08,
AMNIOBAND 16MM USAGE,69000062,CDM,278,RC,Q4151,HCPCS,Outpatient,,,1334.88,800.93,,1597.2,110,,1277.76,Percent of Total Billed Charges,110% of Total Billed Charges,600.7,45,,480.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.77,28,,299.016,Percent of Total Billed Charges,28% of Total Billed Charges,3.11,32,,2.488,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.56,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,480.56,36,,384.448,Percent of Total Billed Charges,36% Total Bille Charges,480.56,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,734.18,55,,587.344,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1334.88,100,,1067.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.9,80,,3634.8,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.42,70,,747.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1334.88,100,,4846.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.11,1597.2,
AMNIOBAND 16MM WASTE,69000063,CDM,278,RC,Q4151,HCPCS,Outpatient,,,1334.88,800.93,,1597.2,110,,1277.76,Percent of Total Billed Charges,110% of Total Billed Charges,600.7,45,,480.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,373.77,28,,299.016,Percent of Total Billed Charges,28% of Total Billed Charges,3.12,32,,2.496,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,480.56,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,480.56,36,,384.448,Percent of Total Billed Charges,36% Total Bille Charges,480.56,36,,384.448,Percent of Total Billed Charges,36% of Total Billed Charges,734.18,55,,587.344,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1334.88,100,,1067.904,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.9,80,,3634.8,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.42,70,,747.536,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1334.88,100,,4846.4,Percent of Total Billed Charges,100% of Total Billed Charges,3.12,1597.2,
AMNIOBAND 2X4,69000064,CDM,278,RC,Q4151,HCPCS,Outpatient,,,319.32,191.59,,480.08,110,,384.064,Percent of Total Billed Charges,110% of Total Billed Charges,143.69,45,,114.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.41,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,3.13,32,,2.504,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,255.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.46,80,,497.344,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,663.128,Percent of Total Billed Charges,100% of Total Billed Charges,3.13,480.08,
AMNIOBAND 2X4 WASTE,69000065,CDM,278,RC,Q4151,HCPCS,Outpatient,,,319.32,191.59,,480.08,110,,384.064,Percent of Total Billed Charges,110% of Total Billed Charges,143.69,45,,114.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.41,28,,71.528,Percent of Total Billed Charges,28% of Total Billed Charges,3.14,32,,2.512,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% Total Bille Charges,114.96,36,,91.968,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,255.456,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.46,80,,3425.752,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,70,,178.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,319.32,100,,4567.664,Percent of Total Billed Charges,100% of Total Billed Charges,3.14,480.08,
KERECIS 3X3.5CM USAGE,69000066,CDM,278,RC,Q4158,HCPCS,Outpatient,,,2122.4,1273.44,,2482.07,110,,1985.656,Percent of Total Billed Charges,110% of Total Billed Charges,955.08,45,,764.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.27,28,,475.416,Percent of Total Billed Charges,28% of Total Billed Charges,3.16,32,,2.528,Percent of Total Billed Charges,32% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% Total Bille Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,1167.32,55,,933.856,Percent of Total Billed Charges,55% Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2122.4,100,,1697.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,306.05,14.42,,244.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1697.92,80,,1914.536,Percent of Total Billed Charges,80% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1485.68,70,,1188.544,Percent of Total Billed Charges,70% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2122.4,100,,2552.712,Percent of Total Billed Charges,100% of Total Billed Charges,3.16,2482.07,
KERECIS 3X3.5CM WASTE,69000067,CDM,278,RC,Q4158,HCPCS,Outpatient,,,2122.4,1273.44,,2482.07,110,,1985.656,Percent of Total Billed Charges,110% of Total Billed Charges,955.08,45,,764.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,594.27,28,,475.416,Percent of Total Billed Charges,28% of Total Billed Charges,28.8,32,,23.04,Percent of Total Billed Charges,32% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% Total Bille Charges,764.06,36,,611.248,Percent of Total Billed Charges,36% of Total Billed Charges,1167.32,55,,933.856,Percent of Total Billed Charges,55% Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2122.4,100,,1697.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,306.05,14.42,,244.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1697.92,80,,840,Percent of Total Billed Charges,80% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,1061.2,50,,848.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1485.68,70,,1188.544,Percent of Total Billed Charges,70% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,297.14,14,,237.712,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2122.4,100,,1120,Percent of Total Billed Charges,100% of Total Billed Charges,28.8,2482.07,
IOPLEX 4X5,69000068,CDM,623,RC,A6210,HCPCS,Outpatient,,,106.5,63.90,,16.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,47.93,45,,38.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,83.34,360,,,Fee Schedule,360% of BCBS POS Rate,83.34,360,,,Fee schedule,360% of BCBS PPO Rate,83.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,63.9,60,,51.12,Percent of Total Billed Charges,60% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.5,100,,85.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,15.36,14.42,,12.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.88,75,,852,Percent of Total Billed Charges,75% of Total Billed Charges,53.25,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,53.25,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.25,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,53.25,50,,42.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.55,70,,59.64,Percent of Total Billed Charges,70% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,14.91,14,,11.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.5,100,,1136,Percent of Total Billed Charges,100% of Total Billed Charges,14.91,106.5,
HYDROFERA BLUE OSTOMY RING,69000069,CDM,272,RC,A6209,HCPCS,Outpatient,,,38.15,22.89,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.17,45,,13.736,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.89,60,,18.312,Percent of Total Billed Charges,60% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.15,100,,30.52,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.5,14.42,,4.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.61,75,,2760,Percent of Total Billed Charges,75% of Total Billed Charges,19.08,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,19.08,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.08,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,19.08,50,,15.264,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.71,70,,21.368,Percent of Total Billed Charges,70% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,5.34,14,,4.272,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.15,100,,3680,Percent of Total Billed Charges,100% of Total Billed Charges,5.34,38.15,
TRIPLE HELIX POWDER,69000070,CDM,272,RC,A6010,HCPCS,Outpatient,,,63.42,38.05,,26.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.54,45,,22.832,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,115.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,129.53,360,,,Fee Schedule,360% of BCBS POS Rate,129.53,360,,,Fee schedule,360% of BCBS PPO Rate,129.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.05,60,,30.44,Percent of Total Billed Charges,60% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.42,100,,50.736,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,9.15,14.42,,7.32,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.57,75,,164.736,Percent of Total Billed Charges,75% of Total Billed Charges,31.71,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,31.71,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.71,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,31.71,50,,25.368,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.39,70,,35.512,Percent of Total Billed Charges,70% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,8.88,14,,7.104,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.42,100,,219.648,Percent of Total Billed Charges,100% of Total Billed Charges,8.88,129.53,
PLUROGEL,69000071,CDM,272,RC,A6248,HCPCS,Outpatient,,,360,216.00,,13.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,162,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,67.97,360,,,Fee Schedule,360% of BCBS POS Rate,67.97,360,,,Fee schedule,360% of BCBS PPO Rate,67.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,216,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360,100,,288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,51.91,14.42,,41.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270,75,,1166.16,Percent of Total Billed Charges,75% of Total Billed Charges,180,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,180,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,180,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252,70,,201.6,Percent of Total Billed Charges,70% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,50.4,14,,40.32,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,360,100,,1554.88,Percent of Total Billed Charges,100% of Total Billed Charges,13.81,360,
MIRODERM 2X2,69000072,CDM,278,RC,Q4175,HCPCS,Outpatient,,,375,225.00,,474.5,110,,379.6,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,28.8,32,,23.04,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,240,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,320,Percent of Total Billed Charges,100% of Total Billed Charges,28.8,474.5,
MIRODERM 2X2 WASTE,69000073,CDM,278,RC,Q4175,HCPCS,Outpatient,,,375,225.00,,474.5,110,,379.6,Percent of Total Billed Charges,110% of Total Billed Charges,168.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,28,,84,Percent of Total Billed Charges,28% of Total Billed Charges,28.8,32,,23.04,Percent of Total Billed Charges,32% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,135,36,,108,Percent of Total Billed Charges,36% Total Bille Charges,135,36,,108,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375,100,,300,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,54.08,14.42,,43.264,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,80,,852,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,52.5,14,,42,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,375,100,,1136,Percent of Total Billed Charges,100% of Total Billed Charges,28.8,474.5,
MIRODERM 2X3,69000074,CDM,278,RC,Q4175,HCPCS,Outpatient,,,275,165.00,,364.5,110,,291.6,Percent of Total Billed Charges,110% of Total Billed Charges,123.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,28,,61.6,Percent of Total Billed Charges,28% of Total Billed Charges,28.9,32,,23.12,Percent of Total Billed Charges,32% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,99,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,99,36,,79.2,Percent of Total Billed Charges,36% Total Bille Charges,99,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,100,,220,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,39.66,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220,80,,1747.2,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.5,70,,154,Percent of Total Billed Charges,70% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,100,,2329.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.9,364.5,
MIRODERM 2X3 WASTE,69000075,CDM,278,RC,Q4175,HCPCS,Outpatient,,,275,165.00,,364.5,110,,291.6,Percent of Total Billed Charges,110% of Total Billed Charges,123.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,28,,61.6,Percent of Total Billed Charges,28% of Total Billed Charges,28.9,32,,23.12,Percent of Total Billed Charges,32% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,99,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,99,36,,79.2,Percent of Total Billed Charges,36% Total Bille Charges,99,36,,79.2,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,100,,220,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,39.66,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220,80,,115.2,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.5,70,,154,Percent of Total Billed Charges,70% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,100,,153.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.9,364.5,
MIRODERM 3X3,69000076,CDM,278,RC,Q4175,HCPCS,Outpatient,,,200,120.00,,282,110,,225.6,Percent of Total Billed Charges,110% of Total Billed Charges,90,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,29.11,32,,23.288,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,100,,160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,80,,1044,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,100,,1392,Percent of Total Billed Charges,100% of Total Billed Charges,28,282,
MIRODERM 3X3 WASTE,69000077,CDM,278,RC,Q4175,HCPCS,Outpatient,,,200,120.00,,282,110,,225.6,Percent of Total Billed Charges,110% of Total Billed Charges,90,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56,28,,44.8,Percent of Total Billed Charges,28% of Total Billed Charges,288,32,,230.4,Percent of Total Billed Charges,32% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,72,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,72,36,,57.6,Percent of Total Billed Charges,36% Total Bille Charges,72,36,,57.6,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,100,,160,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28.84,14.42,,23.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,80,,927,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140,70,,112,Percent of Total Billed Charges,70% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,28,14,,22.4,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,200,100,,1236,Percent of Total Billed Charges,100% of Total Billed Charges,28,288,
MIRODERM 4X4,69000078,CDM,278,RC,Q4175,HCPCS,Outpatient,,,166,99.60,,244.6,110,,195.68,Percent of Total Billed Charges,110% of Total Billed Charges,74.7,45,,59.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.48,28,,37.184,Percent of Total Billed Charges,28% of Total Billed Charges,288.14,32,,230.512,Percent of Total Billed Charges,32% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% Total Bille Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166,100,,132.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.8,80,,1262.16,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.2,70,,92.96,Percent of Total Billed Charges,70% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166,100,,1682.88,Percent of Total Billed Charges,100% of Total Billed Charges,23.24,288.14,
MIRODERM 4X4 WASTE,69000079,CDM,278,RC,Q4175,HCPCS,Outpatient,,,166,99.60,,244.6,110,,195.68,Percent of Total Billed Charges,110% of Total Billed Charges,74.7,45,,59.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.48,28,,37.184,Percent of Total Billed Charges,28% of Total Billed Charges,288.6,32,,230.88,Percent of Total Billed Charges,32% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% Total Bille Charges,59.76,36,,47.808,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166,100,,132.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14.42,,19.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.8,80,,31.608,Percent of Total Billed Charges,80% of Total Billed Charges,51.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,51.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,116.2,70,,92.96,Percent of Total Billed Charges,70% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,23.24,14,,18.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,166,100,,42.144,Percent of Total Billed Charges,100% of Total Billed Charges,23.24,288.6,
ALLEVYN SACRUM LARGE 21.6 X 23,69000080,CDM,272,RC,A6214,HCPCS,Outpatient,,,58.31,34.99,,8.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.24,45,,20.992,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,43.06,360,,,Fee Schedule,360% of BCBS POS Rate,43.06,360,,,Fee schedule,360% of BCBS PPO Rate,43.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.99,60,,27.992,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.31,100,,46.648,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.41,14.42,,6.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.73,75,,768,Percent of Total Billed Charges,75% of Total Billed Charges,29.16,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,29.16,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.16,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,29.16,50,,23.328,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.82,70,,32.656,Percent of Total Billed Charges,70% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,8.16,14,,6.528,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.31,100,,1024,Percent of Total Billed Charges,100% of Total Billed Charges,8.16,58.31,
MIRO 3D 2 X2 X2CM,69000081,CDM,278,RC,A2025,HCPCS,Outpatient,,,160.62,96.37,,176.68,110,,141.344,Percent of Total Billed Charges,110% of Total Billed Charges,72.28,45,,57.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,512.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,577.08,360,,,Fee Schedule,360% of BCBS POS Rate,577.08,360,,,Fee schedule,360% of BCBS PPO Rate,577.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.62,100,,128.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,23.16,14.42,,18.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.5,80,,260.4,Percent of Total Billed Charges,80% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.43,70,,89.944,Percent of Total Billed Charges,70% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.62,100,,347.2,Percent of Total Billed Charges,100% of Total Billed Charges,22.49,577.08,
MIRO 3D 2 X 2 X 2CM WASTE,69000082,CDM,278,RC,A2025,HCPCS,Outpatient,,,160.62,96.37,,176.68,110,,141.344,Percent of Total Billed Charges,110% of Total Billed Charges,72.28,45,,57.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,512.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,577.08,360,,,Fee Schedule,360% of BCBS POS Rate,577.08,360,,,Fee schedule,360% of BCBS PPO Rate,577.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.62,100,,128.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,23.16,14.42,,18.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.5,80,,235.368,Percent of Total Billed Charges,80% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,80.31,50,,64.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.43,70,,89.944,Percent of Total Billed Charges,70% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,22.49,14,,17.992,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160.62,100,,313.824,Percent of Total Billed Charges,100% of Total Billed Charges,22.49,577.08,
MIRO 3D 3 X 3 X 2CM,69000083,CDM,636,RC,A2025,HCPCS,Outpatient,,,214.5,128.70,,117.98,110,,94.384,Percent of Total Billed Charges,110% of Total Billed Charges,96.53,45,,77.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,512.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,577.08,360,,,Fee Schedule,360% of BCBS POS Rate,577.08,360,,,Fee schedule,360% of BCBS PPO Rate,577.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.5,100,,171.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.93,14.42,,24.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.88,75,,238.968,Percent of Total Billed Charges,75% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.15,70,,120.12,Percent of Total Billed Charges,70% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.5,100,,318.624,Percent of Total Billed Charges,100% of Total Billed Charges,30.03,577.08,
MIRO 3D 3 X 3 X 2CM WASTE,69000084,CDM,278,RC,A2025,HCPCS,Outpatient,,,214.5,128.70,,235.95,110,,188.76,Percent of Total Billed Charges,110% of Total Billed Charges,96.53,45,,77.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,512.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,577.08,360,,,Fee Schedule,360% of BCBS POS Rate,577.08,360,,,Fee schedule,360% of BCBS PPO Rate,577.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.5,100,,171.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.93,14.42,,24.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.6,80,,248.016,Percent of Total Billed Charges,80% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,50,,85.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.15,70,,120.12,Percent of Total Billed Charges,70% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,30.03,14,,24.024,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.5,100,,330.688,Percent of Total Billed Charges,100% of Total Billed Charges,30.03,577.08,
MIRRAGEN 1.5X1.5,69000085,CDM,278,RC,A2002,HCPCS,Outpatient,,,675,405.00,,742.5,110,,594,Percent of Total Billed Charges,110% of Total Billed Charges,303.75,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,371.25,55,,297,Percent of Total Billed Charges,55% Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,97.34,14.42,,77.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,80,,1200,Percent of Total Billed Charges,80% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.5,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,1600,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,742.5,
MIRRAGEN 1.5X1.5 WASTE,69000086,CDM,278,RC,A2002,HCPCS,Outpatient,,,675,405.00,,742.5,110,,594,Percent of Total Billed Charges,110% of Total Billed Charges,303.75,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,371.25,55,,297,Percent of Total Billed Charges,55% Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,97.34,14.42,,77.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540,80,,7174.8,Percent of Total Billed Charges,80% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,337.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,472.5,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,94.5,14,,75.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,675,100,,9566.4,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,742.5,
MIRRAGEN 3.5X3.5,69000087,CDM,278,RC,A2002,HCPCS,Outpatient,,,302,181.20,,332.2,110,,265.76,Percent of Total Billed Charges,110% of Total Billed Charges,135.9,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302,100,,241.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.55,14.42,,34.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.6,80,,480,Percent of Total Billed Charges,80% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.4,70,,169.12,Percent of Total Billed Charges,70% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302,100,,640,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,332.2,
MIRRAGEN 3.5X3.5 WASTE,69000088,CDM,278,RC,A2002,HCPCS,Outpatient,,,302,181.20,,332.2,110,,265.76,Percent of Total Billed Charges,110% of Total Billed Charges,135.9,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302,100,,241.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,43.55,14.42,,34.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.6,80,,1154.28,Percent of Total Billed Charges,80% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,151,50,,120.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,211.4,70,,169.12,Percent of Total Billed Charges,70% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,42.28,14,,33.824,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,302,100,,1539.04,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,332.2,
MIRRAGEN 2.5X2.5,69000089,CDM,278,RC,A2002,HCPCS,Outpatient,,,371,222.60,,408.1,110,,326.48,Percent of Total Billed Charges,110% of Total Billed Charges,166.95,45,,133.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371,100,,296.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,53.5,14.42,,42.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.8,80,,151.968,Percent of Total Billed Charges,80% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.7,70,,207.76,Percent of Total Billed Charges,70% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371,100,,202.624,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,408.1,
MIRRAGEN 2.5X2.5 WASTE,69000090,CDM,278,RC,A2002,HCPCS,Outpatient,,,371,222.60,,408.1,110,,326.48,Percent of Total Billed Charges,110% of Total Billed Charges,166.95,45,,133.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371,100,,296.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,53.5,14.42,,42.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.8,80,,553.368,Percent of Total Billed Charges,80% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,185.5,50,,148.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,259.7,70,,207.76,Percent of Total Billed Charges,70% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,51.94,14,,41.552,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,371,100,,737.824,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,408.1,
MIRRAGEN 4.5X4.5,69000091,CDM,278,RC,A2002,HCPCS,Outpatient,,,228,136.80,,250.8,110,,200.64,Percent of Total Billed Charges,110% of Total Billed Charges,102.6,45,,82.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228,100,,182.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,32.88,14.42,,26.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.4,80,,425.568,Percent of Total Billed Charges,80% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,70,,127.68,Percent of Total Billed Charges,70% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228,100,,567.424,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,250.8,
MIRRAGEN 4.5X4.5 WASTE,69000092,CDM,278,RC,A2002,HCPCS,Outpatient,,,228,136.80,,250.8,110,,200.64,Percent of Total Billed Charges,110% of Total Billed Charges,102.6,45,,82.08,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,34.09,360,,,Fee Schedule,360% of BCBS POS Rate,34.09,360,,,Fee schedule,360% of BCBS PPO Rate,34.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228,100,,182.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,32.88,14.42,,26.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.4,80,,367.2,Percent of Total Billed Charges,80% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,70,,127.68,Percent of Total Billed Charges,70% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,31.92,14,,25.536,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,228,100,,489.6,Percent of Total Billed Charges,100% of Total Billed Charges,26.52,250.8,
NEG PRESS WOUND TX < 50 CM,69000100,CDM,510,RC,97605,HCPCS,Outpatient,,,335.26,201.16,,18.79,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,489.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,559.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,629.03,360,,,Fee Schedule,360% of BCBS POS Rate,629.03,360,,,Fee schedule,360% of BCBS PPO Rate,629.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,48.34,14.42,,38.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,251.45,75,,553.368,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,234.68,70,,187.744,Percent of Total Billed Charges,70% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,335.26,100,,737.824,Percent of Total Billed Charges,100% of Total Billed Charges,18.79,629.03,
NEG PRESS WOUND TX > 50 CM,69000101,CDM,510,RC,97606,HCPCS,Outpatient,,,589.83,353.90,,20.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,894.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1022.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,1150.24,360,,,Fee Schedule,360% of BCBS POS Rate,1150.24,360,,,Fee schedule,360% of BCBS PPO Rate,1150.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.58,130,,,Fee Schedule,130% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,85.05,14.42,,68.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,442.37,75,,7006.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.88,70,,330.304,Percent of Total Billed Charges,70% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,589.83,100,,9342.4,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,1150.24,
SELECT DEBRIDE 1ST 20 CM,69000105,CDM,510,RC,97597,HCPCS,Outpatient,,,473.24,283.94,,26.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,68.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,78.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,88.24,360,,,Fee Schedule,360% of BCBS POS Rate,88.24,360,,,Fee schedule,360% of BCBS PPO Rate,88.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,68.24,14.42,,54.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,354.93,75,,2112,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,331.27,70,,265.016,Percent of Total Billed Charges,70% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,473.24,100,,2816,Percent of Total Billed Charges,100% of Total Billed Charges,26.51,473.24,
HYPERBARIC OXYGEN 30 MIN SESS.,69010205,CDM,413,RC,G0277,HCPCS,Outpatient,,,946.5,567.90,,144.87,100,,,Fee Schedule,100% of Aetna Fee Schedule,190.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,322.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,368.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,414.22,360,,,Fee Schedule,360% of BCBS POS Rate,414.22,360,,,Fee schedule,360% of BCBS PPO Rate,414.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,567.9,60,,454.32,Percent of Total Billed Charges,60% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,114.56,90,,,Fee Schedule,90% of CMS OPPS Rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,165.49,130,,,Fee Schedule,130% of CMS OPPS Rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,136.49,14.42,,109.192,Percent of Total Billed Charges,14.42% of Total Billed Charges,131.12,103,,,Fee Schedule,103% of CMS OPPS Rate,131.12,103,,,Fee Schedule,103% of CMS OPPS Rate,709.88,75,,22.344,Percent of Total Billed Charges,75% of Total Billed Charges,473.25,50,,378.6,Percent of Total Billed Charges,50% of Total Billed Charges,473.25,50,,378.6,Percent of Total Billed Charges,50% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,473.25,50,,378.6,Percent of Total Billed Charges,50% of Total Billed Charges,473.25,50,,378.6,Percent of Total Billed Charges,50% of Total Billed Charges,190.95,150,,,Fee Schedule,150% of CMS OPPS Rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1035,100,,,Case Rate,Pays based on per visit rate,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,132.51,14,,106.008,Percent of Total Billed Charges,14% of Total Billed Charges,127.3,100,,,Fee Schedule,100% of CMS OPPS Rate,946.5,100,,29.792,Percent of Total Billed Charges,100% of Total Billed Charges,114.56,1035,
SELECT DEBRIDE 1ST 20 CM,69010262,CDM,510,RC,97597,HCPCS,Outpatient,,,473.24,283.94,,26.51,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,68.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,78.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,88.24,360,,,Fee Schedule,360% of BCBS POS Rate,88.24,360,,,Fee schedule,360% of BCBS PPO Rate,88.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,68.24,14.42,,54.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,354.93,75,,741.744,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,331.27,70,,265.016,Percent of Total Billed Charges,70% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,66.25,14,,53,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,473.24,100,,988.992,Percent of Total Billed Charges,100% of Total Billed Charges,26.51,473.24,
SELECT DEBRIDE EA ADD 20 CM,69010270,CDM,510,RC,97598,HCPCS,Outpatient,,,372.84,223.70,,18.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,167.78,45,,134.224,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,372.84,100,,298.272,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,53.76,14.42,,43.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.63,75,,75.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,260.99,70,,208.792,Percent of Total Billed Charges,70% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,52.2,14,,41.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,372.84,100,,100.8,Percent of Total Billed Charges,100% of Total Billed Charges,18.43,372.84,
NON-SELECTIVE DEBRIDEMENT,69010288,CDM,510,RC,97602,HCPCS,Outpatient,,,370.2,222.12,,62.61,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,489.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,559.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,629.03,360,,,Fee Schedule,360% of BCBS POS Rate,629.03,360,,,Fee schedule,360% of BCBS PPO Rate,629.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,53.38,14.42,,42.704,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,277.65,75,,86.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,259.14,70,,207.312,Percent of Total Billed Charges,70% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,51.83,14,,41.464,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,370.2,100,,115.2,Percent of Total Billed Charges,100% of Total Billed Charges,51.83,629.03,
NEG PRESS WOUND TX < 50 CM,69010296,CDM,510,RC,97605,HCPCS,Outpatient,,,335.26,201.16,,18.79,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,489.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,559.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,629.03,360,,,Fee Schedule,360% of BCBS POS Rate,629.03,360,,,Fee schedule,360% of BCBS PPO Rate,629.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,48.34,14.42,,38.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,251.45,75,,524.232,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,234.68,70,,187.744,Percent of Total Billed Charges,70% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,46.94,14,,37.552,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,335.26,100,,698.976,Percent of Total Billed Charges,100% of Total Billed Charges,18.79,629.03,
NEG PRESS WOUND TX > 50 CM,69010304,CDM,510,RC,97606,HCPCS,Outpatient,,,589.83,353.90,,20.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,894.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1022.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,1150.24,360,,,Fee Schedule,360% of BCBS POS Rate,1150.24,360,,,Fee schedule,360% of BCBS PPO Rate,1150.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.58,130,,,Fee Schedule,130% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,85.05,14.42,,68.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,442.37,75,,60.84,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,412.88,70,,330.304,Percent of Total Billed Charges,70% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,589.83,100,,81.12,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,1150.24,
DEBRIDE SUB TIS 1ST 20 SQ CM,69010387,CDM,510,RC,11042,HCPCS,Outpatient,,,1360.04,816.02,,45.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,380.81,28,,304.648,Percent of Total Billed Charges,28% of Total Billed Charges,289.19,32,,231.352,Percent of Total Billed Charges,32% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,489.61,36,,391.688,Percent of Total Billed Charges,36% of Total Billed Charges,489.61,36,,391.688,Percent of Total Billed Charges,36% Total Bille Charges,489.61,36,,391.688,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,196.12,14.42,,156.896,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,1020.03,75,,5313.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,952.03,70,,761.624,Percent of Total Billed Charges,70% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,190.41,14,,152.328,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.04,100,,7084.8,Percent of Total Billed Charges,100% of Total Billed Charges,45.54,1360.04,
DEBRIDE MUSCLE/FASCIA 1ST 20CM,69010395,CDM,510,RC,11043,HCPCS,Outpatient,,,1609.25,965.55,,115.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,864.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,450.59,28,,360.472,Percent of Total Billed Charges,28% of Total Billed Charges,289.28,32,,231.424,Percent of Total Billed Charges,32% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,579.33,36,,463.464,Percent of Total Billed Charges,36% of Total Billed Charges,579.33,36,,463.464,Percent of Total Billed Charges,36% Total Bille Charges,579.33,36,,463.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,518.59,90,,,Fee Schedule,90% of CMS OPPS Rate,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,749.07,130,,,Fee Schedule,130% of CMS OPPS Rate,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,232.05,14.42,,185.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,1206.94,75,,140.808,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,864.31,150,,,Fee Schedule,150% of CMS OPPS Rate,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.48,70,,901.184,Percent of Total Billed Charges,70% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,225.3,14,,180.24,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1609.25,100,,187.744,Percent of Total Billed Charges,100% of Total Billed Charges,115.88,1609.25,
DEBRIDE BONE 1ST 20 CM,69010403,CDM,510,RC,11044,HCPCS,Outpatient,,,3415.45,2049.27,,168.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,956.33,28,,765.064,Percent of Total Billed Charges,28% of Total Billed Charges,290.16,32,,232.128,Percent of Total Billed Charges,32% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1229.56,36,,983.648,Percent of Total Billed Charges,36% of Total Billed Charges,1229.56,36,,983.648,Percent of Total Billed Charges,36% Total Bille Charges,1229.56,36,,983.648,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,492.51,14.42,,394.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2561.59,75,,977.424,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2390.82,70,,1912.656,Percent of Total Billed Charges,70% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,478.16,14,,382.528,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3415.45,100,,1303.232,Percent of Total Billed Charges,100% of Total Billed Charges,168.04,3415.45,
DEBRIDE SUB TIS EA ADD 20SQCM,69010411,CDM,510,RC,11045,HCPCS,Outpatient,,,1020.03,612.02,,19.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,459.01,45,,367.208,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1020.03,100,,816.024,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,147.09,14.42,,117.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.02,75,,469.44,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,714.02,70,,571.216,Percent of Total Billed Charges,70% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,142.8,14,,114.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1020.03,100,,625.92,Percent of Total Billed Charges,100% of Total Billed Charges,19.5,1020.03,
DEBRIDE MUS/FAS EA ADD 20SQCM,69010429,CDM,510,RC,11046,HCPCS,Outpatient,,,1000.46,600.28,,41.17,100,,,Fee Schedule,100% of Aetna Fee Schedule,450.21,45,,360.168,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1000.46,100,,800.368,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,144.27,14.42,,115.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750.35,75,,1386,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,700.32,70,,560.256,Percent of Total Billed Charges,70% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,140.06,14,,112.048,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1000.46,100,,1848,Percent of Total Billed Charges,100% of Total Billed Charges,41.17,1000.46,
DEBRIDE BONE EA ADD 20 CM,69010437,CDM,510,RC,11047,HCPCS,Outpatient,,,2231.52,1338.91,,72.11,100,,,Fee Schedule,100% of Aetna Fee Schedule,1004.18,45,,803.344,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2231.52,100,,1785.216,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,321.79,14.42,,257.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1673.64,75,,324,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1562.06,70,,1249.648,Percent of Total Billed Charges,70% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,312.41,14,,249.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2231.52,100,,432,Percent of Total Billed Charges,100% of Total Billed Charges,72.11,2231.52,
I&D/ABSC/SIMPLE/SING,69010460,CDM,510,RC,10060,HCPCS,Outpatient,,,707.46,424.48,,79.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,198.09,28,,158.472,Percent of Total Billed Charges,28% of Total Billed Charges,29.28,32,,23.424,Percent of Total Billed Charges,32% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,254.69,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,254.69,36,,203.752,Percent of Total Billed Charges,36% Total Bille Charges,254.69,36,,203.752,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.77,130,,,Fee Schedule,130% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,102.02,14.42,,81.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,530.6,75,,312,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.22,70,,396.176,Percent of Total Billed Charges,70% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,99.04,14,,79.232,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,707.46,100,,416,Percent of Total Billed Charges,100% of Total Billed Charges,29.28,707.46,
I&D HEMATOMA SEROMA/FLUID,69010528,CDM,510,RC,10140,HCPCS,Outpatient,,,3628.77,2177.26,,90.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.06,28,,812.848,Percent of Total Billed Charges,28% of Total Billed Charges,29.44,32,,23.552,Percent of Total Billed Charges,32% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1306.36,36,,1045.088,Percent of Total Billed Charges,36% of Total Billed Charges,1306.36,36,,1045.088,Percent of Total Billed Charges,36% Total Bille Charges,1306.36,36,,1045.088,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,523.27,14.42,,418.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,2721.58,75,,679.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2540.14,70,,2032.112,Percent of Total Billed Charges,70% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,508.03,14,,406.424,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3628.77,100,,905.6,Percent of Total Billed Charges,100% of Total Billed Charges,29.44,3628.77,
PAR/CUT CORN/CALLUS SINGLE,69010601,CDM,510,RC,11055,HCPCS,Outpatient,,,339.55,203.73,,12.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,95.07,28,,76.056,Percent of Total Billed Charges,28% of Total Billed Charges,292.44,32,,233.952,Percent of Total Billed Charges,32% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,122.24,36,,97.792,Percent of Total Billed Charges,36% of Total Billed Charges,122.24,36,,97.792,Percent of Total Billed Charges,36% Total Bille Charges,122.24,36,,97.792,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,48.96,14.42,,39.168,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,254.66,75,,675.36,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,237.69,70,,190.152,Percent of Total Billed Charges,70% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,47.54,14,,38.032,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,339.55,100,,900.48,Percent of Total Billed Charges,100% of Total Billed Charges,12.09,339.55,
PAR/CUT CORN/CALLUS 2-4,69010619,CDM,510,RC,11056,HCPCS,Outpatient,,,326.93,196.16,,16.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,91.54,28,,73.232,Percent of Total Billed Charges,28% of Total Billed Charges,294.04,32,,235.232,Percent of Total Billed Charges,32% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,117.69,36,,94.152,Percent of Total Billed Charges,36% of Total Billed Charges,117.69,36,,94.152,Percent of Total Billed Charges,36% Total Bille Charges,117.69,36,,94.152,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,47.14,14.42,,37.712,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,245.2,75,,730.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,228.85,70,,183.08,Percent of Total Billed Charges,70% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,45.77,14,,36.616,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,326.93,100,,974.4,Percent of Total Billed Charges,100% of Total Billed Charges,16.91,326.93,
APLIGRAF 1 SQ CM,69011005,CDM,250,RC,Q4101,HCPCS,Outpatient,,,84.73,50.84,,30.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.13,45,,30.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,34.18,360,,,Fee Schedule,360% of BCBS POS Rate,34.18,360,,,Fee schedule,360% of BCBS PPO Rate,34.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.84,60,,40.672,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.73,100,,67.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.55,75,,64.8,Percent of Total Billed Charges,75% of Total Billed Charges,24.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.34,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.34,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.31,70,,47.448,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.73,100,,86.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.34,84.73,
OASIS WND MATRIX,69011013,CDM,250,RC,Q4102,HCPCS,Outpatient,,,35.71,21.43,,9.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.07,45,,12.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,11.72,360,,,Fee Schedule,360% of BCBS POS Rate,11.72,360,,,Fee schedule,360% of BCBS PPO Rate,11.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.43,60,,17.144,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.71,100,,28.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,75,,72.84,Percent of Total Billed Charges,75% of Total Billed Charges,10.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,10.16,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,70,,20,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.71,100,,97.12,Percent of Total Billed Charges,100% of Total Billed Charges,9.9,35.71,
DERMAGRAFT 1SQCM,69011021,CDM,250,RC,Q4106,HCPCS,Outpatient,,,86.86,52.12,,32.29,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.09,45,,31.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,36.73,360,,,Fee Schedule,360% of BCBS POS Rate,36.73,360,,,Fee schedule,360% of BCBS PPO Rate,36.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.12,60,,41.696,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.86,100,,69.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.15,75,,1671.84,Percent of Total Billed Charges,75% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.8,70,,48.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.86,100,,2229.12,Percent of Total Billed Charges,100% of Total Billed Charges,32.29,86.86,
APLIGRAF PER SQ,69011039,CDM,278,RC,Q4101,HCPCS,Outpatient,,,84.73,50.84,,123.95,110,,99.16,Percent of Total Billed Charges,110% of Total Billed Charges,38.13,45,,30.504,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,34.18,360,,,Fee Schedule,360% of BCBS POS Rate,34.18,360,,,Fee schedule,360% of BCBS PPO Rate,34.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.73,100,,67.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.78,80,,547.68,Percent of Total Billed Charges,80% of Total Billed Charges,24.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.34,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.34,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.31,70,,47.448,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.73,100,,730.24,Percent of Total Billed Charges,100% of Total Billed Charges,24.34,123.95,
OASIS WND MATRIX,69011047,CDM,278,RC,Q4102,HCPCS,Outpatient,,,35.71,21.43,,49.18,110,,39.344,Percent of Total Billed Charges,110% of Total Billed Charges,16.07,45,,12.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,11.72,360,,,Fee Schedule,360% of BCBS POS Rate,11.72,360,,,Fee schedule,360% of BCBS PPO Rate,11.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.71,100,,28.568,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.57,80,,790.824,Percent of Total Billed Charges,80% of Total Billed Charges,10.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,10.16,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,70,,20,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.71,100,,1054.432,Percent of Total Billed Charges,100% of Total Billed Charges,10.16,49.18,
DERMAGRAFT PER S,69011054,CDM,278,RC,Q4106,HCPCS,Outpatient,,,86.86,52.12,,127.84,110,,102.272,Percent of Total Billed Charges,110% of Total Billed Charges,39.09,45,,31.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,36.73,360,,,Fee Schedule,360% of BCBS POS Rate,36.73,360,,,Fee schedule,360% of BCBS PPO Rate,36.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.86,100,,69.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.49,80,,290.4,Percent of Total Billed Charges,80% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,43.43,50,,34.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.8,70,,48.64,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.86,100,,387.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.73,127.84,
CHEMICAL CAUTERIZATION,69011153,CDM,510,RC,17250,HCPCS,Outpatient,,,545.79,327.47,,27.67,100,,,Fee Schedule,100% of Aetna Fee Schedule,275.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,152.82,28,,122.256,Percent of Total Billed Charges,28% of Total Billed Charges,294.22,32,,235.376,Percent of Total Billed Charges,32% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,196.48,36,,157.184,Percent of Total Billed Charges,36% of Total Billed Charges,196.48,36,,157.184,Percent of Total Billed Charges,36% Total Bille Charges,196.48,36,,157.184,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,165.3,90,,,Fee Schedule,90% of CMS OPPS Rate,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,238.78,130,,,Fee Schedule,130% of CMS OPPS Rate,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,78.7,14.42,,62.96,Percent of Total Billed Charges,14.42% of Total Billed Charges,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,189.18,103,,,Fee Schedule,103% of CMS OPPS Rate,409.34,75,,90.096,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.51,150,,,Fee Schedule,150% of CMS OPPS Rate,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,382.05,70,,305.64,Percent of Total Billed Charges,70% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,76.41,14,,61.128,Percent of Total Billed Charges,14% of Total Billed Charges,183.67,100,,,Fee Schedule,100% of CMS OPPS Rate,545.79,100,,120.128,Percent of Total Billed Charges,100% of Total Billed Charges,27.67,545.79,
BONE BX SUPERFICIAL,69011161,CDM,510,RC,20220,HCPCS,Outpatient,,,2191.72,1315.03,,73.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,2231.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,613.68,28,,490.944,Percent of Total Billed Charges,28% of Total Billed Charges,294.68,32,,235.744,Percent of Total Billed Charges,32% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,789.02,36,,631.216,Percent of Total Billed Charges,36% of Total Billed Charges,789.02,36,,631.216,Percent of Total Billed Charges,36% Total Bille Charges,789.02,36,,631.216,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.71,90,,,Fee Schedule,90% of CMS OPPS Rate,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.7,130,,,Fee Schedule,130% of CMS OPPS Rate,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,316.05,14.42,,252.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1532.09,103,,,Fee Schedule,103% of CMS OPPS Rate,1643.79,75,,231.504,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2231.19,150,,,Fee Schedule,150% of CMS OPPS Rate,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1534.2,70,,1227.36,Percent of Total Billed Charges,70% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,306.84,14,,245.472,Percent of Total Billed Charges,14% of Total Billed Charges,1487.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2191.72,100,,308.672,Percent of Total Billed Charges,100% of Total Billed Charges,73.54,2231.19,
APPLY LEG CAST RIGID BILATERAL,69011195,CDM,510,RC,29445,HCPCS,Outpatient,,,1270.05,762.03,,83.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,369.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,355.61,28,,284.488,Percent of Total Billed Charges,28% of Total Billed Charges,294.72,32,,235.776,Percent of Total Billed Charges,32% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,457.22,36,,365.776,Percent of Total Billed Charges,36% of Total Billed Charges,457.22,36,,365.776,Percent of Total Billed Charges,36% Total Bille Charges,457.22,36,,365.776,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,221.75,90,,,Fee Schedule,90% of CMS OPPS Rate,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,320.3,130,,,Fee Schedule,130% of CMS OPPS Rate,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,183.14,14.42,,146.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,253.77,103,,,Fee Schedule,103% of CMS OPPS Rate,253.77,103,,,Fee Schedule,103% of CMS OPPS Rate,952.54,75,,4492.032,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.58,150,,,Fee Schedule,150% of CMS OPPS Rate,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,889.04,70,,711.232,Percent of Total Billed Charges,70% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,177.81,14,,142.248,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.05,100,,5989.376,Percent of Total Billed Charges,100% of Total Billed Charges,83.99,1270.05,
APPLY LEG CAST RIGID,69011211,CDM,510,RC,29445,HCPCS,Outpatient,,,846.7,508.02,,83.99,100,,,Fee Schedule,100% of Aetna Fee Schedule,369.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,237.08,28,,189.664,Percent of Total Billed Charges,28% of Total Billed Charges,294.72,32,,235.776,Percent of Total Billed Charges,32% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,304.81,36,,243.848,Percent of Total Billed Charges,36% of Total Billed Charges,304.81,36,,243.848,Percent of Total Billed Charges,36% Total Bille Charges,304.81,36,,243.848,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,221.75,90,,,Fee Schedule,90% of CMS OPPS Rate,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,320.3,130,,,Fee Schedule,130% of CMS OPPS Rate,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,122.09,14.42,,97.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,253.77,103,,,Fee Schedule,103% of CMS OPPS Rate,253.77,103,,,Fee Schedule,103% of CMS OPPS Rate,635.03,75,,98.992,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.58,150,,,Fee Schedule,150% of CMS OPPS Rate,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,592.69,70,,474.152,Percent of Total Billed Charges,70% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,118.54,14,,94.832,Percent of Total Billed Charges,14% of Total Billed Charges,246.39,100,,,Fee Schedule,100% of CMS OPPS Rate,846.7,100,,131.984,Percent of Total Billed Charges,100% of Total Billed Charges,83.99,846.7,
APPLICATION OF UNNA BOOT,69011237,CDM,510,RC,29580,HCPCS,Outpatient,,,366.3,219.78,,22,100,,,Fee Schedule,100% of Aetna Fee Schedule,216.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,102.56,28,,82.048,Percent of Total Billed Charges,28% of Total Billed Charges,294.72,32,,235.776,Percent of Total Billed Charges,32% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,131.87,36,,105.496,Percent of Total Billed Charges,36% of Total Billed Charges,131.87,36,,105.496,Percent of Total Billed Charges,36% Total Bille Charges,131.87,36,,105.496,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,130.1,90,,,Fee Schedule,90% of CMS OPPS Rate,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,187.92,130,,,Fee Schedule,130% of CMS OPPS Rate,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,52.82,14.42,,42.256,Percent of Total Billed Charges,14.42% of Total Billed Charges,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,274.73,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.84,150,,,Fee Schedule,150% of CMS OPPS Rate,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,256.41,70,,205.128,Percent of Total Billed Charges,70% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,51.28,14,,41.024,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,366.3,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,22,366.3,
APPLICATION OF UNNA BOOT BILAT,69011245,CDM,510,RC,29580,HCPCS,Outpatient,,,549.45,329.67,,22,100,,,Fee Schedule,100% of Aetna Fee Schedule,216.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,153.85,28,,123.08,Percent of Total Billed Charges,28% of Total Billed Charges,295.76,32,,236.608,Percent of Total Billed Charges,32% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,197.8,36,,158.24,Percent of Total Billed Charges,36% of Total Billed Charges,197.8,36,,158.24,Percent of Total Billed Charges,36% Total Bille Charges,197.8,36,,158.24,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,130.1,90,,,Fee Schedule,90% of CMS OPPS Rate,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,187.92,130,,,Fee Schedule,130% of CMS OPPS Rate,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,79.23,14.42,,63.384,Percent of Total Billed Charges,14.42% of Total Billed Charges,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,412.09,75,,395.416,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.84,150,,,Fee Schedule,150% of CMS OPPS Rate,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,384.62,70,,307.696,Percent of Total Billed Charges,70% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,76.92,14,,61.536,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,549.45,100,,527.216,Percent of Total Billed Charges,100% of Total Billed Charges,22,549.45,
MULTILAYER COMPRESSION,69011260,CDM,510,RC,29581,HCPCS,Outpatient,,,393.23,235.94,,23.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,216.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,110.1,28,,88.08,Percent of Total Billed Charges,28% of Total Billed Charges,296.11,32,,236.888,Percent of Total Billed Charges,32% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,141.56,36,,113.248,Percent of Total Billed Charges,36% of Total Billed Charges,141.56,36,,113.248,Percent of Total Billed Charges,36% Total Bille Charges,141.56,36,,113.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,130.1,90,,,Fee Schedule,90% of CMS OPPS Rate,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,187.92,130,,,Fee Schedule,130% of CMS OPPS Rate,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,56.7,14.42,,45.36,Percent of Total Billed Charges,14.42% of Total Billed Charges,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,294.92,75,,99.648,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.84,150,,,Fee Schedule,150% of CMS OPPS Rate,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,275.26,70,,220.208,Percent of Total Billed Charges,70% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,55.05,14,,44.04,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,393.23,100,,132.864,Percent of Total Billed Charges,100% of Total Billed Charges,23.44,393.23,
MULTILAYER COMPRESSION BILAT,69011278,CDM,510,RC,29581,HCPCS,Outpatient,,,589.85,353.91,,23.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,216.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,165.16,28,,132.128,Percent of Total Billed Charges,28% of Total Billed Charges,296.28,32,,237.024,Percent of Total Billed Charges,32% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,212.35,36,,169.88,Percent of Total Billed Charges,36% of Total Billed Charges,212.35,36,,169.88,Percent of Total Billed Charges,36% Total Bille Charges,212.35,36,,169.88,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,130.1,90,,,Fee Schedule,90% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,187.92,130,,,Fee Schedule,130% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,85.06,14.42,,68.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,148.88,103,,,Fee Schedule,103% of CMS OPPS Rate,442.39,75,,89.032,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.84,150,,,Fee Schedule,150% of CMS OPPS Rate,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,412.9,70,,330.32,Percent of Total Billed Charges,70% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,82.58,14,,66.064,Percent of Total Billed Charges,14% of Total Billed Charges,144.56,100,,,Fee Schedule,100% of CMS OPPS Rate,589.85,100,,118.712,Percent of Total Billed Charges,100% of Total Billed Charges,23.44,589.85,
TCPO2 TESTING 1-2 LEVELS UN,69011302,CDM,921,RC,93922,HCPCS,Outpatient,,,524.32,314.59,,55.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,314.59,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,75.61,14.42,,60.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,393.24,75,,58.592,Percent of Total Billed Charges,75% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,,Case Rate,Pays based on per visit rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,524.32,100,,78.12,Percent of Total Billed Charges,100% of Total Billed Charges,55.54,650,
TCP02 TESTING > 3 PROVOCATIVE,69011310,CDM,921,RC,93923,HCPCS,Outpatient,,,839.16,503.50,,84.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,317.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,363.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,408.67,360,,,Fee Schedule,360% of BCBS POS Rate,408.67,360,,,Fee schedule,360% of BCBS PPO Rate,408.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,503.5,60,,402.8,Percent of Total Billed Charges,60% of Total Billed Charges,129.31,100,,,Fee Schedule,100% of TX Mediciad Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,133.19,103,,,Fee Schedule,103% of TX Medicaid Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,629.37,75,,175.152,Percent of Total Billed Charges,75% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,,Case Rate,Pays based on per visit rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,839.16,100,,233.536,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,839.16,
TCP02 TESTING 1-2 LEVELS,69011328,CDM,921,RC,93922,HCPCS,Outpatient,,,524.32,314.59,,55.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,175.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,305.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,348.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,392.51,360,,,Fee Schedule,360% of BCBS POS Rate,392.51,360,,,Fee schedule,360% of BCBS PPO Rate,392.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,314.59,60,,251.672,Percent of Total Billed Charges,60% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,105.47,90,,,Fee Schedule,90% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,152.35,130,,,Fee Schedule,130% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,75.61,14.42,,60.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,120.71,103,,,Fee Schedule,103% of CMS OPPS Rate,393.24,75,,199.504,Percent of Total Billed Charges,75% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,262.16,50,,209.728,Percent of Total Billed Charges,50% of Total Billed Charges,175.79,150,,,Fee Schedule,150% of CMS OPPS Rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,,Case Rate,Pays based on per visit rate,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,73.4,14,,58.72,Percent of Total Billed Charges,14% of Total Billed Charges,117.19,100,,,Fee Schedule,100% of CMS OPPS Rate,524.32,100,,266.008,Percent of Total Billed Charges,100% of Total Billed Charges,55.54,650,
TCP02 TESTING > 3 PROVOCATIVE,69011336,CDM,921,RC,93923,HCPCS,Outpatient,,,839.16,503.50,,84.43,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,317.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,363.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,408.67,360,,,Fee Schedule,360% of BCBS POS Rate,408.67,360,,,Fee schedule,360% of BCBS PPO Rate,408.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,503.5,60,,402.8,Percent of Total Billed Charges,60% of Total Billed Charges,129.31,100,,,Fee Schedule,100% of TX Mediciad Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,133.19,103,,,Fee Schedule,103% of TX Medicaid Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,629.37,75,,309.328,Percent of Total Billed Charges,75% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,419.58,50,,335.664,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,,Case Rate,Pays based on per visit rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,129.31,100,,,Fee Schedule,100% of TX Medicaid Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,839.16,100,,412.44,Percent of Total Billed Charges,100% of Total Billed Charges,84.43,839.16,
DRSG AQUACEL RIBBON,69011468,CDM,272,RC,A6199,HCPCS,Outpatient,,,70.86,42.52,,4.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.89,45,,25.512,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,19.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,22.1,360,,,Fee Schedule,360% of BCBS POS Rate,22.1,360,,,Fee schedule,360% of BCBS PPO Rate,22.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.52,60,,34.016,Percent of Total Billed Charges,60% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.86,100,,56.688,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,10.22,14.42,,8.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.15,75,,309.328,Percent of Total Billed Charges,75% of Total Billed Charges,35.43,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,35.43,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.43,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,35.43,50,,28.344,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.6,70,,39.68,Percent of Total Billed Charges,70% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,9.92,14,,7.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.86,100,,412.44,Percent of Total Billed Charges,100% of Total Billed Charges,4.49,70.86,
DRSG COLLAGEN W SILVER,69011484,CDM,272,RC,A6021,HCPCS,Outpatient,,,67.34,40.40,,17.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.3,45,,24.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,78.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,87.91,360,,,Fee Schedule,360% of BCBS POS Rate,87.91,360,,,Fee schedule,360% of BCBS PPO Rate,87.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.4,60,,32.32,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.34,100,,53.872,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.71,14.42,,7.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.51,75,,390,Percent of Total Billed Charges,75% of Total Billed Charges,33.67,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,33.67,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.67,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,33.67,50,,26.936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.14,70,,37.712,Percent of Total Billed Charges,70% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,9.43,14,,7.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.34,100,,520,Percent of Total Billed Charges,100% of Total Billed Charges,9.43,87.91,
DRSG SILCONE NON ADHER 7.2X4,69011501,CDM,272,RC,A6207,HCPCS,Outpatient,,,61.53,36.92,,6.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.69,45,,22.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,,Fee Schedule,360% of BCBS POS Rate,30.71,360,,,Fee schedule,360% of BCBS PPO Rate,30.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.92,60,,29.536,Percent of Total Billed Charges,60% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.53,100,,49.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.87,14.42,,7.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.15,75,,390,Percent of Total Billed Charges,75% of Total Billed Charges,30.77,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,30.77,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.77,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,30.77,50,,24.616,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.07,70,,34.456,Percent of Total Billed Charges,70% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14,,6.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.53,100,,520,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,61.53,
MULTIDEX POWER,69011502,CDM,272,RC,A6248,HCPCS,Outpatient,,,46.41,27.85,,13.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.88,45,,16.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,67.97,360,,,Fee Schedule,360% of BCBS POS Rate,67.97,360,,,Fee schedule,360% of BCBS PPO Rate,67.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,27.85,60,,22.28,Percent of Total Billed Charges,60% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.41,100,,37.128,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.69,14.42,,5.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.81,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,23.21,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,23.21,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.21,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,23.21,50,,18.568,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.49,70,,25.992,Percent of Total Billed Charges,70% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,6.5,14,,5.2,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.41,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,6.5,67.97,
RESTORE,69011504,CDM,272,RC,A6234,HCPCS,Outpatient,,,32.62,19.57,,5.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.68,45,,11.744,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,27.36,360,,,Fee Schedule,360% of BCBS POS Rate,27.36,360,,,Fee schedule,360% of BCBS PPO Rate,27.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,19.57,60,,15.656,Percent of Total Billed Charges,60% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.62,100,,26.096,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.7,14.42,,3.76,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.47,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,16.31,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,16.31,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.31,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,16.31,50,,13.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.83,70,,18.264,Percent of Total Billed Charges,70% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,4.57,14,,3.656,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.62,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,4.57,32.62,
ALGIDEX AG,69011505,CDM,272,RC,A6209,HCPCS,Outpatient,,,43.82,26.29,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.72,45,,15.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.29,60,,21.032,Percent of Total Billed Charges,60% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,100,,35.056,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.32,14.42,,5.056,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.87,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,21.91,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,21.91,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.91,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,21.91,50,,17.528,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.67,70,,24.536,Percent of Total Billed Charges,70% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,6.13,14,,4.904,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,6.13,43.82,
"DRSG Endoform 2x2""",69011507,CDM,272,RC,a6021,HCPCS,Outpatient,,,105.36,63.22,,63.22,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,47.41,45,,37.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.5,28,,23.6,Percent of Total Billed Charges,28% of Total Billed Charges,296.4,32,,237.12,Percent of Total Billed Charges,32% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% Total Bille Charges,37.93,36,,30.344,Percent of Total Billed Charges,36% of Total Billed Charges,63.22,60,,50.576,Percent of Total Billed Charges,60% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.36,100,,84.288,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,15.19,14.42,,12.152,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.02,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,52.68,50,,42.144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.75,70,,59,Percent of Total Billed Charges,70% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,14.75,14,,11.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105.36,100,,80.8,Percent of Total Billed Charges,100% of Total Billed Charges,14.75,296.4,
SILVASORB GEL 1.5 OZ TUBE,69011509,CDM,272,RC,A6248,HCPCS,Outpatient,,,105,63.00,,13.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,47.25,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,67.97,360,,,Fee Schedule,360% of BCBS POS Rate,67.97,360,,,Fee schedule,360% of BCBS PPO Rate,67.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,63,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,15.14,14.42,,12.112,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.75,75,,102.6,Percent of Total Billed Charges,75% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.5,70,,58.8,Percent of Total Billed Charges,70% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,14.7,14,,11.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,100,,136.8,Percent of Total Billed Charges,100% of Total Billed Charges,13.81,105,
UNNA BOOT,69011511,CDM,272,RC,A6456,HCPCS,Outpatient,,,60.97,36.58,,1.07,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.44,45,,21.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,4.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,5.29,360,,,Fee Schedule,360% of BCBS POS Rate,5.29,360,,,Fee schedule,360% of BCBS PPO Rate,5.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.58,60,,29.264,Percent of Total Billed Charges,60% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.97,100,,48.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.79,14.42,,7.032,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.73,75,,129,Percent of Total Billed Charges,75% of Total Billed Charges,30.49,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,30.49,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.49,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,30.49,50,,24.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.68,70,,34.144,Percent of Total Billed Charges,70% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,8.54,14,,6.832,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.97,100,,172,Percent of Total Billed Charges,100% of Total Billed Charges,1.07,60.97,
ALLEVYN LIFE 12.9 X 12.9CM,69011512,CDM,272,RC,A6212,HCPCS,Outpatient,,,27.1,16.26,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.2,45,,9.76,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,16.26,60,,13.008,Percent of Total Billed Charges,60% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.1,100,,21.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.91,14.42,,3.128,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.33,75,,65.76,Percent of Total Billed Charges,75% of Total Billed Charges,13.55,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,13.55,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.55,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,13.55,50,,10.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.97,70,,15.176,Percent of Total Billed Charges,70% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,3.79,14,,3.032,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.1,100,,87.68,Percent of Total Billed Charges,100% of Total Billed Charges,3.79,40.61,
"DRSG MEPILEX 4X8""",69011513,CDM,272,RC,A6212,HCPCS,Outpatient,,,57.5,34.50,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.88,45,,20.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.5,60,,27.6,Percent of Total Billed Charges,60% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.5,100,,46,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.29,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,75,,109.2,Percent of Total Billed Charges,75% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.25,70,,32.2,Percent of Total Billed Charges,70% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.5,100,,145.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.05,57.5,
DRSG ACTICOAT 4X4,69011514,CDM,272,RC,A6209,HCPCS,Outpatient,,,58.03,34.82,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.11,45,,20.888,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.82,60,,27.856,Percent of Total Billed Charges,60% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.03,100,,46.424,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.37,14.42,,6.696,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.52,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,29.02,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,29.02,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.02,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,29.02,50,,23.216,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.62,70,,32.496,Percent of Total Billed Charges,70% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,8.12,14,,6.496,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.03,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,6.35,58.03,
DRSG SILCONE NON,69011567,CDM,272,RC,A6207,HCPCS,Outpatient,,,22.4,13.44,,6.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.08,45,,8.064,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,,Fee Schedule,360% of BCBS POS Rate,30.71,360,,,Fee schedule,360% of BCBS PPO Rate,30.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.44,60,,10.752,Percent of Total Billed Charges,60% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,100,,17.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.23,14.42,,2.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,75,,138.048,Percent of Total Billed Charges,75% of Total Billed Charges,11.2,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.2,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,50,,8.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.68,70,,12.544,Percent of Total Billed Charges,70% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,3.14,14,,2.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.4,100,,184.064,Percent of Total Billed Charges,100% of Total Billed Charges,3.14,30.71,
DRSG COLLAGEN FI,69011666,CDM,272,RC,A6196,HCPCS,Outpatient,,,22.47,13.48,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.11,45,,8.088,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,13.48,60,,10.784,Percent of Total Billed Charges,60% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.47,100,,17.976,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.24,14.42,,2.592,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,75,,131.648,Percent of Total Billed Charges,75% of Total Billed Charges,11.24,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,11.24,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.24,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,11.24,50,,8.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.73,70,,12.584,Percent of Total Billed Charges,70% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,3.15,14,,2.52,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.47,100,,175.528,Percent of Total Billed Charges,100% of Total Billed Charges,3.15,30.78,
DRSG COLAGN FIBR,69011690,CDM,272,RC,A6196,HCPCS,Outpatient,,,59.68,35.81,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.86,45,,21.488,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,35.81,60,,28.648,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.68,100,,47.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.61,14.42,,6.888,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.76,75,,103.24,Percent of Total Billed Charges,75% of Total Billed Charges,29.84,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,29.84,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.84,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,29.84,50,,23.872,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.78,70,,33.424,Percent of Total Billed Charges,70% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,8.36,14,,6.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.68,100,,137.648,Percent of Total Billed Charges,100% of Total Billed Charges,6.26,59.68,
HYDROFERA BLUE 4,69011864,CDM,272,RC,A6209,HCPCS,Outpatient,,,77.4,46.44,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.83,45,,27.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.44,60,,37.152,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.4,100,,61.92,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,11.16,14.42,,8.928,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,75,,269.272,Percent of Total Billed Charges,75% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,50,,30.96,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,54.18,70,,43.344,Percent of Total Billed Charges,70% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,10.84,14,,8.672,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.4,100,,359.024,Percent of Total Billed Charges,100% of Total Billed Charges,6.35,77.4,
MEDIHONEY HONEYC,69011906,CDM,272,RC,A6234,HCPCS,Outpatient,,,70,42.00,,5.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.5,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,27.36,360,,,Fee Schedule,360% of BCBS POS Rate,27.36,360,,,Fee schedule,360% of BCBS PPO Rate,27.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,137.984,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,183.976,Percent of Total Billed Charges,100% of Total Billed Charges,5.56,70,
GEL MEDIHONEY 0.5 OZ,69011922,CDM,272,RC,A6240,HCPCS,Outpatient,,,40.6,24.36,,10.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.27,45,,14.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,51.23,360,,,Fee Schedule,360% of BCBS POS Rate,51.23,360,,,Fee schedule,360% of BCBS PPO Rate,51.23,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.36,60,,19.488,Percent of Total Billed Charges,60% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.6,100,,32.48,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.85,14.42,,4.68,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.45,75,,121.928,Percent of Total Billed Charges,75% of Total Billed Charges,20.3,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,20.3,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.3,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,20.3,50,,16.24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.42,70,,22.736,Percent of Total Billed Charges,70% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,5.68,14,,4.544,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.6,100,,162.568,Percent of Total Billed Charges,100% of Total Billed Charges,5.68,51.23,
TOTAL CONTACT CA,69011963,CDM,271,RC,,,Outpatient,,,405.98,243.59,,243.59,60,,194.872,Percent of Total Billed Charges,60% of Total Billed Charges,182.69,45,,146.152,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,113.67,28,,90.936,Percent of Total Billed Charges,28% of Total Billed Charges,296.8,32,,237.44,Percent of Total Billed Charges,32% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,146.15,36,,116.92,Percent of Total Billed Charges,36% of Total Billed Charges,146.15,36,,116.92,Percent of Total Billed Charges,36% Total Bille Charges,146.15,36,,116.92,Percent of Total Billed Charges,36% of Total Billed Charges,243.59,60,,194.872,Percent of Total Billed Charges,60% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405.98,100,,324.784,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,58.54,14.42,,46.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.49,75,,126.664,Percent of Total Billed Charges,75% of Total Billed Charges,202.99,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,202.99,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,202.99,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,202.99,50,,162.392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.19,70,,227.352,Percent of Total Billed Charges,70% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,56.84,14,,45.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,405.98,100,,168.888,Percent of Total Billed Charges,100% of Total Billed Charges,56.84,405.98,
GRAFIX PRIME 5X5 PER CM W,69012020,CDM,636,RC,Q4133,HCPCS,Outpatient,,,228.8,137.28,,261.24,110,,208.992,Percent of Total Billed Charges,110% of Total Billed Charges,102.96,45,,82.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.06,28,,51.248,Percent of Total Billed Charges,28% of Total Billed Charges,296.8,32,,237.44,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.37,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,82.37,36,,65.896,Percent of Total Billed Charges,36% Total Bille Charges,82.37,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.8,100,,183.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.6,75,,102.688,Percent of Total Billed Charges,75% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.16,70,,128.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.8,100,,136.92,Percent of Total Billed Charges,100% of Total Billed Charges,64.06,296.8,
GRAFIX PRIME 5X5 PER CM,69012050,CDM,636,RC,Q4133,HCPCS,Outpatient,,,228.8,137.28,,261.24,110,,208.992,Percent of Total Billed Charges,110% of Total Billed Charges,102.96,45,,82.368,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.06,28,,51.248,Percent of Total Billed Charges,28% of Total Billed Charges,29.78,32,,23.824,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.37,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,82.37,36,,65.896,Percent of Total Billed Charges,36% Total Bille Charges,82.37,36,,65.896,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.8,100,,183.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.6,75,,102.688,Percent of Total Billed Charges,75% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,220.62,50,,176.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.16,70,,128.128,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.8,100,,136.92,Percent of Total Billed Charges,100% of Total Billed Charges,29.78,261.24,
GRAFIX PRIME 1.5X2CM,69012073,CDM,636,RC,Q4133,HCPCS,Outpatient,,,750,450.00,,547.9,110,,438.32,Percent of Total Billed Charges,110% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,29.79,32,,23.832,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,29.79,750,
SKN SPLT GRFT FAC/NCK/HF <100,69012112,CDM,510,RC,15120,HCPCS,Outpatient,,,7011.73,4207.04,,520.53,100,,,Fee Schedule,100% of Aetna Fee Schedule,4937.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.28,28,,1570.624,Percent of Total Billed Charges,28% of Total Billed Charges,29.89,32,,23.912,Percent of Total Billed Charges,32% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,2524.22,36,,2019.376,Percent of Total Billed Charges,36% of Total Billed Charges,2524.22,36,,2019.376,Percent of Total Billed Charges,36% Total Bille Charges,2524.22,36,,2019.376,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2962.35,90,,,Fee Schedule,90% of CMS OPPS Rate,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4278.95,130,,,Fee Schedule,130% of CMS OPPS Rate,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,1011.09,14.42,,808.872,Percent of Total Billed Charges,14.42% of Total Billed Charges,3390.24,103,,,Fee Schedule,103% of CMS OPPS Rate,3390.24,103,,,Fee Schedule,103% of CMS OPPS Rate,5258.8,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4937.26,150,,,Fee Schedule,150% of CMS OPPS Rate,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4908.21,70,,3926.568,Percent of Total Billed Charges,70% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,981.64,14,,785.312,Percent of Total Billed Charges,14% of Total Billed Charges,3291.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7011.73,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,29.89,7011.73,
SKN SPLT GRFT TRK/ARM/LEG <100,69012113,CDM,510,RC,15100,HCPCS,Outpatient,,,3905.35,2343.21,,537.85,100,,,Fee Schedule,100% of Aetna Fee Schedule,2509.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1093.5,28,,874.8,Percent of Total Billed Charges,28% of Total Billed Charges,29.91,32,,23.928,Percent of Total Billed Charges,32% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1405.93,36,,1124.744,Percent of Total Billed Charges,36% of Total Billed Charges,1405.93,36,,1124.744,Percent of Total Billed Charges,36% Total Bille Charges,1405.93,36,,1124.744,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,563.15,14.42,,450.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,2929.01,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2733.75,70,,2187,Percent of Total Billed Charges,70% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,546.75,14,,437.4,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,3905.35,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,29.91,3905.35,
THERASKIN PER SQ CM,69012120,CDM,278,RC,Q4121,HCPCS,Outpatient,,,109,65.40,,164.16,110,,131.328,Percent of Total Billed Charges,110% of Total Billed Charges,49.05,45,,39.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109,100,,87.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.2,80,,88.248,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.3,70,,61.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109,100,,117.664,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,164.16,
THERASKIN SM PER SQ CM 101TSS,69012128,CDM,278,RC,Q4121,HCPCS,Outpatient,,,560,336.00,,660.26,110,,528.208,Percent of Total Billed Charges,110% of Total Billed Charges,252,45,,201.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,308,55,,246.4,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,448,80,,187.144,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,660.26,
THERASKIN PER SQ CM WASTE,69012130,CDM,278,RC,Q4121,HCPCS,Outpatient,,,109,65.40,,164.16,110,,131.328,Percent of Total Billed Charges,110% of Total Billed Charges,49.05,45,,39.24,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109,100,,87.2,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.2,80,,119.4,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.3,70,,61.04,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109,100,,159.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,164.16,
THERASKIN SM 101TSS WASTE,69012136,CDM,278,RC,Q4121,HCPCS,Outpatient,,,560,336.00,,660.26,110,,528.208,Percent of Total Billed Charges,110% of Total Billed Charges,252,45,,201.6,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,308,55,,246.4,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,448,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,448,80,,434.4,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392,70,,313.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,100,,579.2,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,660.26,
MESALT SHEET 4X4,69012150,CDM,272,RC,A6222,HCPCS,Outpatient,,,72,43.20,,1.81,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.4,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,8.93,360,,,Fee Schedule,360% of BCBS POS Rate,8.93,360,,,Fee schedule,360% of BCBS PPO Rate,8.93,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,100,,57.6,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.38,14.42,,8.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,75,,322.672,Percent of Total Billed Charges,75% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.4,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,10.08,14,,8.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72,100,,430.224,Percent of Total Billed Charges,100% of Total Billed Charges,1.81,72,
MESALT RIBBON,69012151,CDM,272,RC,A6266,HCPCS,Outpatient,,,70,42.00,,1.63,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.5,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,8.03,360,,,Fee Schedule,360% of BCBS POS Rate,8.03,360,,,Fee schedule,360% of BCBS PPO Rate,8.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,1.63,70,
CONFORM WOUND VEIL,69012152,CDM,272,RC,A6212,HCPCS,Outpatient,,,46.83,28.10,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.07,45,,16.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,28.1,60,,22.48,Percent of Total Billed Charges,60% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.83,100,,37.464,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.75,14.42,,5.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.12,75,,78.32,Percent of Total Billed Charges,75% of Total Billed Charges,23.42,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,23.42,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.42,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,23.42,50,,18.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.78,70,,26.224,Percent of Total Billed Charges,70% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,6.56,14,,5.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.83,100,,104.424,Percent of Total Billed Charges,100% of Total Billed Charges,6.56,46.83,
ALGISITE M,69012153,CDM,272,RC,A6196,HCPCS,Outpatient,,,21.63,12.98,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.73,45,,7.784,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.98,60,,10.384,Percent of Total Billed Charges,60% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.63,100,,17.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.12,14.42,,2.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.22,75,,134.104,Percent of Total Billed Charges,75% of Total Billed Charges,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,10.82,50,,8.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.14,70,,12.112,Percent of Total Billed Charges,70% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,3.03,14,,2.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.63,100,,178.8,Percent of Total Billed Charges,100% of Total Billed Charges,3.03,30.78,
ALGIDEX AG PASTE,69012154,CDM,272,RC,A6261,HCPCS,Outpatient,,,52.22,31.33,,2.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.5,45,,18.8,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.62,28,,11.696,Percent of Total Billed Charges,28% of Total Billed Charges,30.07,32,,24.056,Percent of Total Billed Charges,32% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% Total Bille Charges,18.8,36,,15.04,Percent of Total Billed Charges,36% of Total Billed Charges,31.33,60,,25.064,Percent of Total Billed Charges,60% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.22,100,,41.776,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.53,14.42,,6.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.17,75,,385.672,Percent of Total Billed Charges,75% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,26.11,50,,20.888,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.55,70,,29.24,Percent of Total Billed Charges,70% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,7.31,14,,5.848,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.22,100,,514.224,Percent of Total Billed Charges,100% of Total Billed Charges,2.09,52.22,
DRSG DRAWTEX 4X4,69012155,CDM,272,RC,A6196,HCPCS,Outpatient,,,66.3,39.78,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.84,45,,23.872,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,39.78,60,,31.824,Percent of Total Billed Charges,60% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.3,100,,53.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.56,14.42,,7.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.73,75,,309.328,Percent of Total Billed Charges,75% of Total Billed Charges,33.15,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,33.15,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.15,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,33.15,50,,26.52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.41,70,,37.128,Percent of Total Billed Charges,70% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,9.28,14,,7.424,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.3,100,,412.44,Percent of Total Billed Charges,100% of Total Billed Charges,6.26,66.3,
CUTIMED SORBACT GEL,69012156,CDM,272,RC,A6231,HCPCS,Outpatient,,,32.27,19.36,,3.97,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.52,45,,11.616,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,19.55,360,,,Fee Schedule,360% of BCBS POS Rate,19.55,360,,,Fee schedule,360% of BCBS PPO Rate,19.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,19.36,60,,15.488,Percent of Total Billed Charges,60% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.27,100,,25.816,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.65,14.42,,3.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.2,75,,6240,Percent of Total Billed Charges,75% of Total Billed Charges,16.14,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,16.14,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.14,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,16.14,50,,12.912,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.59,70,,18.072,Percent of Total Billed Charges,70% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,4.52,14,,3.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.27,100,,8320,Percent of Total Billed Charges,100% of Total Billed Charges,3.97,32.27,
SOFSORB 4X6,69012158,CDM,272,RC,A6252,HCPCS,Outpatient,,,91.86,55.12,,2.77,100,,,Fee Schedule,100% of Aetna Fee Schedule,41.34,45,,33.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,13.61,360,,,Fee Schedule,360% of BCBS POS Rate,13.61,360,,,Fee schedule,360% of BCBS PPO Rate,13.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.12,60,,44.096,Percent of Total Billed Charges,60% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.86,100,,73.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,13.25,14.42,,10.6,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.9,75,,1067.92,Percent of Total Billed Charges,75% of Total Billed Charges,45.93,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,45.93,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.93,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,45.93,50,,36.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.3,70,,51.44,Percent of Total Billed Charges,70% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,12.86,14,,10.288,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.86,100,,1423.888,Percent of Total Billed Charges,100% of Total Billed Charges,2.77,91.86,
MEPITEL,69012159,CDM,272,RC,A6207,HCPCS,Outpatient,,,56.63,33.98,,6.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.48,45,,20.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,30.71,360,,,Fee Schedule,360% of BCBS POS Rate,30.71,360,,,Fee schedule,360% of BCBS PPO Rate,30.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,33.98,60,,27.184,Percent of Total Billed Charges,60% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.63,100,,45.304,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,8.17,14.42,,6.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.47,75,,231.904,Percent of Total Billed Charges,75% of Total Billed Charges,28.32,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,28.32,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.32,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,28.32,50,,22.656,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.64,70,,31.712,Percent of Total Billed Charges,70% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,7.93,14,,6.344,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.63,100,,309.2,Percent of Total Billed Charges,100% of Total Billed Charges,6.24,56.63,
ALGIDEX AG SILVER ALGINATE,69012161,CDM,272,RC,A6209,HCPCS,Outpatient,,,57.82,34.69,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.02,45,,20.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.69,60,,27.752,Percent of Total Billed Charges,60% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.82,100,,46.256,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.34,14.42,,6.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.37,75,,354.952,Percent of Total Billed Charges,75% of Total Billed Charges,28.91,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.91,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,28.91,50,,23.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.47,70,,32.376,Percent of Total Billed Charges,70% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,8.09,14,,6.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.82,100,,473.264,Percent of Total Billed Charges,100% of Total Billed Charges,6.35,57.82,
DRESSING ALLEVYN ADH 5X5,69012162,CDM,272,RC,A6212,HCPCS,Outpatient,,,27.37,16.42,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.32,45,,9.856,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,16.42,60,,13.136,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.37,100,,21.896,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.95,14.42,,3.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.53,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,13.69,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,13.69,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.69,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,13.69,50,,10.952,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.16,70,,15.328,Percent of Total Billed Charges,70% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,3.83,14,,3.064,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.37,100,,240,Percent of Total Billed Charges,100% of Total Billed Charges,3.83,40.61,
MEPILEX AG SACRUM,69012163,CDM,272,RC,A6212,HCPCS,Outpatient,,,217.6,130.56,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,97.92,45,,78.336,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.56,60,,104.448,Percent of Total Billed Charges,60% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.6,100,,174.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,31.38,14.42,,25.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.2,75,,76.024,Percent of Total Billed Charges,75% of Total Billed Charges,108.8,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,108.8,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.8,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,108.8,50,,87.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,152.32,70,,121.856,Percent of Total Billed Charges,70% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,30.46,14,,24.368,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,217.6,100,,101.36,Percent of Total Billed Charges,100% of Total Billed Charges,8.25,217.6,
MEPILEX BORDER 10X20,69012165,CDM,272,RC,A6209,HCPCS,Outpatient,,,35.49,21.29,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.97,45,,12.776,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,21.29,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.49,100,,28.392,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.12,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.62,75,,90.528,Percent of Total Billed Charges,75% of Total Billed Charges,17.75,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.75,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.75,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.75,50,,14.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.84,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.49,100,,120.704,Percent of Total Billed Charges,100% of Total Billed Charges,4.97,35.49,
IODOSORB GEL,69012166,CDM,272,RC,A6261,HCPCS,Outpatient,,,72.78,43.67,,2.09,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.75,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.38,28,,16.304,Percent of Total Billed Charges,28% of Total Billed Charges,297.84,32,,238.272,Percent of Total Billed Charges,32% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% Total Bille Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,43.67,60,,34.936,Percent of Total Billed Charges,60% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.78,100,,58.224,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,75,,88.488,Percent of Total Billed Charges,75% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.95,70,,40.76,Percent of Total Billed Charges,70% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.78,100,,117.984,Percent of Total Billed Charges,100% of Total Billed Charges,2.09,297.84,
ALLEVYN THIN 4X4,69012167,CDM,272,RC,A6212,HCPCS,Outpatient,,,31.01,18.61,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,18.61,60,,14.888,Percent of Total Billed Charges,60% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.01,100,,24.808,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.47,14.42,,3.576,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.26,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.51,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,15.51,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.51,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,15.51,50,,12.408,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.71,70,,17.368,Percent of Total Billed Charges,70% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,4.34,14,,3.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.01,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,4.34,40.61,
AQUACEL 4X4,69012168,CDM,272,RC,A6212,HCPCS,Outpatient,,,60.62,36.37,,8.25,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.28,45,,21.824,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,360,,,Fee Schedule,360% of BCBS POS Rate,40.61,360,,,Fee schedule,360% of BCBS PPO Rate,40.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,36.37,60,,29.096,Percent of Total Billed Charges,60% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.62,100,,48.496,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.74,14.42,,6.992,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.47,75,,77.832,Percent of Total Billed Charges,75% of Total Billed Charges,30.31,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,30.31,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.31,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,30.31,50,,24.248,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.43,70,,33.944,Percent of Total Billed Charges,70% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,8.49,14,,6.792,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.62,100,,103.776,Percent of Total Billed Charges,100% of Total Billed Charges,8.25,60.62,
DRSG Aquacel AG ribbon 1x4,69012169,CDM,272,RC,A6199,HCPCS,Outpatient,,,83.7,50.22,,4.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.67,45,,30.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,19.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,22.1,360,,,Fee Schedule,360% of BCBS POS Rate,22.1,360,,,Fee schedule,360% of BCBS PPO Rate,22.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.22,60,,40.176,Percent of Total Billed Charges,60% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.7,100,,66.96,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,12.07,14.42,,9.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.78,75,,119.752,Percent of Total Billed Charges,75% of Total Billed Charges,41.85,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,41.85,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.85,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,41.85,50,,33.48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.59,70,,46.872,Percent of Total Billed Charges,70% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,11.72,14,,9.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.7,100,,159.664,Percent of Total Billed Charges,100% of Total Billed Charges,4.49,83.7,
SILVERCEL 1X12,69012170,CDM,272,RC,A6199,HCPCS,Outpatient,,,41.86,25.12,,4.49,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.84,45,,15.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,19.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,22.1,360,,,Fee Schedule,360% of BCBS POS Rate,22.1,360,,,Fee schedule,360% of BCBS PPO Rate,22.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,25.12,60,,20.096,Percent of Total Billed Charges,60% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.86,100,,33.488,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,6.04,14.42,,4.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.4,75,,78.984,Percent of Total Billed Charges,75% of Total Billed Charges,20.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,20.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,20.93,50,,16.744,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.3,70,,23.44,Percent of Total Billed Charges,70% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,5.86,14,,4.688,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.86,100,,105.312,Percent of Total Billed Charges,100% of Total Billed Charges,4.49,41.86,
MEPITEL ONE 3X4,69012172,CDM,272,RC,A6206,HCPCS,Outpatient,,,59.08,35.45,,2.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.59,45,,21.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.54,28,,13.232,Percent of Total Billed Charges,28% of Total Billed Charges,300.22,32,,240.176,Percent of Total Billed Charges,32% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,21.27,36,,17.016,Percent of Total Billed Charges,36% of Total Billed Charges,21.27,36,,17.016,Percent of Total Billed Charges,36% Total Bille Charges,21.27,36,,17.016,Percent of Total Billed Charges,36% of Total Billed Charges,35.45,60,,28.36,Percent of Total Billed Charges,60% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.08,100,,47.264,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.52,14.42,,6.816,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.31,75,,139.896,Percent of Total Billed Charges,75% of Total Billed Charges,29.54,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,29.54,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.54,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,29.54,50,,23.632,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.36,70,,33.088,Percent of Total Billed Charges,70% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,8.27,14,,6.616,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.08,100,,186.528,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,300.22,
MELGISORB 4X4,69012173,CDM,272,RC,A6196,HCPCS,Outpatient,,,25.76,15.46,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.59,45,,9.272,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,15.46,60,,12.368,Percent of Total Billed Charges,60% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.76,100,,20.608,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.71,14.42,,2.968,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.32,75,,1032.184,Percent of Total Billed Charges,75% of Total Billed Charges,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,12.88,50,,10.304,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.03,70,,14.424,Percent of Total Billed Charges,70% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,3.61,14,,2.888,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.76,100,,1376.248,Percent of Total Billed Charges,100% of Total Billed Charges,3.61,30.78,
MELGISORB AG 4X4,69012174,CDM,272,RC,A6196,HCPCS,Outpatient,,,41.16,24.70,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.52,45,,14.816,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,30.78,360,,,Fee Schedule,360% of BCBS POS Rate,30.78,360,,,Fee schedule,360% of BCBS PPO Rate,30.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.7,60,,19.76,Percent of Total Billed Charges,60% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.16,100,,32.928,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.94,14.42,,4.752,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.87,75,,112.8,Percent of Total Billed Charges,75% of Total Billed Charges,20.58,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,20.58,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.58,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,20.58,50,,16.464,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,70,,23.048,Percent of Total Billed Charges,70% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,5.76,14,,4.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.16,100,,150.4,Percent of Total Billed Charges,100% of Total Billed Charges,5.76,41.16,
"DRSG MEPILEX  6X8""",69012175,CDM,272,RC,A6210,HCPCS,Outpatient,,,62.1,37.26,,16.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.95,45,,22.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,64.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,74.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,83.34,360,,,Fee Schedule,360% of BCBS POS Rate,83.34,360,,,Fee schedule,360% of BCBS PPO Rate,83.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,37.26,60,,29.808,Percent of Total Billed Charges,60% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.1,100,,49.68,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.95,14.42,,7.16,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.58,75,,83.4,Percent of Total Billed Charges,75% of Total Billed Charges,31.05,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,31.05,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.05,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,31.05,50,,24.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.47,70,,34.776,Percent of Total Billed Charges,70% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,8.69,14,,6.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.1,100,,111.2,Percent of Total Billed Charges,100% of Total Billed Charges,8.69,83.34,
STIMULEN,69012176,CDM,272,RC,A6010,HCPCS,Outpatient,,,70,42.00,,26.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.5,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,115.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,129.53,360,,,Fee Schedule,360% of BCBS POS Rate,129.53,360,,,Fee schedule,360% of BCBS PPO Rate,129.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,83.4,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,111.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,129.53,
EPIFIX 2CM X 2CM PER SQ CM WA,69012177,CDM,278,RC,Q4186,HCPCS,Outpatient,,,700,420.00,,925.85,110,,740.68,Percent of Total Billed Charges,110% of Total Billed Charges,315,45,,252,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,385,55,,308,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,100,,560,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,80,,686.064,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,490,70,,392,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,100,,914.752,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,925.85,
EPIFIX 3 CM X 4CM PER SQ CM,69012178,CDM,278,RC,Q4186,HCPCS,Outpatient,,,513.5,308.10,,720.7,110,,576.56,Percent of Total Billed Charges,110% of Total Billed Charges,231.08,45,,184.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,282.43,55,,225.944,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,513.5,100,,410.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.8,80,,540,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.45,70,,287.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,513.5,100,,720,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 2 CM X 3 CM PER SQ CM,69012179,CDM,278,RC,Q4186,HCPCS,Outpatient,,,493.75,296.25,,698.98,110,,559.184,Percent of Total Billed Charges,110% of Total Billed Charges,222.19,45,,177.752,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,493.75,100,,395,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395,80,,129.24,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345.63,70,,276.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,493.75,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 3CM X 4CM PER SQ CM WA,69012180,CDM,278,RC,Q4186,HCPCS,Outpatient,,,513.5,308.10,,720.7,110,,576.56,Percent of Total Billed Charges,110% of Total Billed Charges,231.08,45,,184.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,282.43,55,,225.944,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,513.5,100,,410.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.8,80,,127.096,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.45,70,,287.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,513.5,100,,169.464,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 14 MM DISK PER SQ CM,69012181,CDM,278,RC,Q4186,HCPCS,Outpatient,,,363.95,218.37,,556.2,110,,444.96,Percent of Total Billed Charges,110% of Total Billed Charges,163.78,45,,131.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.95,100,,291.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.16,80,,960,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.77,70,,203.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.95,100,,1280,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 2CM X 2CM PER SQ CM,69012182,CDM,278,RC,Q4186,HCPCS,Outpatient,,,700,420.00,,925.85,110,,740.68,Percent of Total Billed Charges,110% of Total Billed Charges,315,45,,252,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,385,55,,308,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,100,,560,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560,80,,82.128,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,490,70,,392,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,700,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,925.85,
EPIFIX 18 MM DISK PER SQ CM,69012184,CDM,278,RC,Q4186,HCPCS,Outpatient,,,531.4,318.84,,740.39,110,,592.312,Percent of Total Billed Charges,110% of Total Billed Charges,239.13,45,,191.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,292.27,55,,233.816,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.4,100,,425.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.12,80,,134.104,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.98,70,,297.584,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.4,100,,178.8,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 14 MM DISK PER SQ CM WA,69012185,CDM,278,RC,Q4186,HCPCS,Outpatient,,,363.95,218.37,,556.2,110,,444.96,Percent of Total Billed Charges,110% of Total Billed Charges,163.78,45,,131.024,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.95,100,,291.16,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.16,80,,122.296,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.77,70,,203.816,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.95,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
EPIFIX 18 MM DISK PER SQ CM WA,69012186,CDM,278,RC,Q4186,HCPCS,Outpatient,,,531.4,318.84,,740.39,110,,592.312,Percent of Total Billed Charges,110% of Total Billed Charges,239.13,45,,191.304,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,700.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,787.64,360,,,Fee Schedule,360% of BCBS POS Rate,787.64,360,,,Fee schedule,360% of BCBS PPO Rate,787.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,292.27,55,,233.816,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.4,100,,425.12,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.12,80,,2267.84,Percent of Total Billed Charges,80% of Total Billed Charges,120.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.29,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,120.29,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.98,70,,297.584,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,531.4,100,,3023.784,Percent of Total Billed Charges,100% of Total Billed Charges,120.29,787.64,
GRAPHIX PRIME 1.5X2 PER CM,69012187,CDM,636,RC,Q4133,HCPCS,Outpatient,,,750,450.00,,547.9,110,,438.32,Percent of Total Billed Charges,110% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,30.09,32,,24.072,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,56.096,Percent of Total Billed Charges,75% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,74.792,Percent of Total Billed Charges,100% of Total Billed Charges,30.09,750,
GRAPHIX PRIME 1.5X2 PER CM WAS,69012188,CDM,636,RC,Q4133,HCPCS,Outpatient,,,750,450.00,,547.9,110,,438.32,Percent of Total Billed Charges,110% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,30.09,32,,24.072,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.5,75,,133.744,Percent of Total Billed Charges,75% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,481.22,50,,384.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,178.32,Percent of Total Billed Charges,100% of Total Billed Charges,30.09,750,
GRAPHIX PRIME 2X3 PER CM,69012189,CDM,636,RC,Q4133,HCPCS,Outpatient,,,476,285.60,,397.2,110,,317.76,Percent of Total Billed Charges,110% of Total Billed Charges,214.2,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.28,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,30.12,32,,24.096,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,380.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,357,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.2,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,30.12,476,
GRAPHIX PRIME 2X3 PER CM WAS,69012190,CDM,636,RC,Q4133,HCPCS,Outpatient,,,476,285.60,,397.2,110,,317.76,Percent of Total Billed Charges,110% of Total Billed Charges,214.2,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.28,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,380.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,357,75,,229.2,Percent of Total Billed Charges,75% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,344.22,50,,275.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.2,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,305.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,476,
GRAPHIX CORE 3X4 PER CM,69012191,CDM,278,RC,Q4132,HCPCS,Outpatient,,,421,252.60,,744.7,110,,595.76,Percent of Total Billed Charges,110% of Total Billed Charges,189.45,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.88,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,336.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,60.71,14.42,,48.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.8,80,,200.832,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.7,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421,100,,267.776,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,744.7,
GRAPHIX PRIME 3X4 PER CM WAS,69012192,CDM,636,RC,Q4133,HCPCS,Outpatient,,,421,252.60,,366.95,110,,293.56,Percent of Total Billed Charges,110% of Total Billed Charges,189.45,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.88,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,336.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.75,75,,338.32,Percent of Total Billed Charges,75% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.7,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,451.096,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,421,
GRAPHIX CORE 14MM DISC PER CM,69012193,CDM,278,RC,Q4132,HCPCS,Outpatient,,,313,187.80,,625.9,110,,500.72,Percent of Total Billed Charges,110% of Total Billed Charges,140.85,45,,112.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.64,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,45.13,14.42,,36.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.4,80,,389.496,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.1,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313,100,,519.328,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,625.9,
GRAPHIX CORE 14M D PER CM WAS,69012194,CDM,278,RC,Q4132,HCPCS,Outpatient,,,313,187.80,,625.9,110,,500.72,Percent of Total Billed Charges,110% of Total Billed Charges,140.85,45,,112.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.64,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,45.13,14.42,,36.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.4,80,,252,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.1,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,43.82,14,,35.056,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,313,100,,336,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,625.9,
GRAPHIX CORE 1.5X2 PER CM,69012195,CDM,278,RC,Q4132,HCPCS,Outpatient,,,750,450.00,,1106.6,110,,885.28,Percent of Total Billed Charges,110% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,412.5,55,,330,Percent of Total Billed Charges,55% Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,80,,186,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,1106.6,
GRAPHIX CORE 1.5X2 PER CM WAS,69012196,CDM,278,RC,Q4132,HCPCS,Outpatient,,,750,450.00,,1106.6,110,,885.28,Percent of Total Billed Charges,110% of Total Billed Charges,337.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,210,28,,168,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,270,36,,216,Percent of Total Billed Charges,36% Total Bille Charges,270,36,,216,Percent of Total Billed Charges,36% of Total Billed Charges,412.5,55,,330,Percent of Total Billed Charges,55% Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,750,100,,600,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,108.15,14.42,,86.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,600,80,,879.768,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,525,70,,420,Percent of Total Billed Charges,70% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,105,14,,84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,750,100,,1173.024,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,1106.6,
GRAPHIX CORE 2X3 PER CM,69012197,CDM,278,RC,Q4132,HCPCS,Outpatient,,,476,285.60,,805.2,110,,644.16,Percent of Total Billed Charges,110% of Total Billed Charges,214.2,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.28,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,30.2,32,,24.16,Percent of Total Billed Charges,32% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,380.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,68.64,14.42,,54.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.8,80,,145.904,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.2,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,476,100,,194.536,Percent of Total Billed Charges,100% of Total Billed Charges,30.2,805.2,
GRAPHIX CORE 2X3 PER CM WAS,69012198,CDM,278,RC,Q4132,HCPCS,Outpatient,,,476,285.60,,805.2,110,,644.16,Percent of Total Billed Charges,110% of Total Billed Charges,214.2,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,133.28,28,,106.624,Percent of Total Billed Charges,28% of Total Billed Charges,30.24,32,,24.192,Percent of Total Billed Charges,32% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% Total Bille Charges,171.36,36,,137.088,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,100,,380.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,68.64,14.42,,54.912,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.8,80,,57,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,333.2,70,,266.56,Percent of Total Billed Charges,70% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,66.64,14,,53.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,476,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,30.24,805.2,
GRAPHIX CORE 3X4 PER CM WAS,69012199,CDM,278,RC,Q4132,HCPCS,Outpatient,,,421,252.60,,744.7,110,,595.76,Percent of Total Billed Charges,110% of Total Billed Charges,189.45,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.88,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,301.99,32,,241.592,Percent of Total Billed Charges,32% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,336.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,60.71,14.42,,48.568,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.8,80,,60.6,Percent of Total Billed Charges,80% of Total Billed Charges,271.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,271.35,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,271.35,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,294.7,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,58.94,14,,47.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,421,100,,80.8,Percent of Total Billed Charges,100% of Total Billed Charges,58.94,744.7,
GRAPHIX PRIME 14MM DISC PER CM,69012200,CDM,636,RC,Q4133,HCPCS,Outpatient,,,313,187.80,,307.55,110,,246.04,Percent of Total Billed Charges,110% of Total Billed Charges,140.85,45,,112.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.64,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,302.98,32,,242.384,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.75,75,,124.76,Percent of Total Billed Charges,75% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.1,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,166.344,Percent of Total Billed Charges,100% of Total Billed Charges,87.64,313,
GRAPHIX PRIME 14MM D PER CM WA,69012201,CDM,636,RC,Q4133,HCPCS,Outpatient,,,313,187.80,,307.55,110,,246.04,Percent of Total Billed Charges,110% of Total Billed Charges,140.85,45,,112.68,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.64,28,,70.112,Percent of Total Billed Charges,28% of Total Billed Charges,303.4,32,,242.72,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% Total Bille Charges,112.68,36,,90.144,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,250.4,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.75,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,262.72,50,,210.176,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,219.1,70,,175.28,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,87.64,313,
GRAPHIX PRIME 3X4 PER CM,69012202,CDM,636,RC,Q4133,HCPCS,Outpatient,,,421,252.60,,366.95,110,,293.56,Percent of Total Billed Charges,110% of Total Billed Charges,189.45,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.88,28,,94.304,Percent of Total Billed Charges,28% of Total Billed Charges,30.4,32,,24.32,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% Total Bille Charges,151.56,36,,121.248,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,336.8,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.75,75,,40.488,Percent of Total Billed Charges,75% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,316.72,50,,253.376,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.7,70,,235.76,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,100,,53.984,Percent of Total Billed Charges,100% of Total Billed Charges,30.4,421,
TRIAD HYDROPHILIC WND DRSNG,69012206,CDM,272,RC,A6240,HCPCS,Outpatient,,,57.5,34.50,,10.41,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.88,45,,20.704,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,51.23,360,,,Fee Schedule,360% of BCBS POS Rate,51.23,360,,,Fee schedule,360% of BCBS PPO Rate,51.23,360,,,Fee Schedule,360% of BCBS Traditional Rate,34.5,60,,27.6,Percent of Total Billed Charges,60% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.5,100,,46,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.29,14.42,,6.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.13,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,28.75,50,,23,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.25,70,,32.2,Percent of Total Billed Charges,70% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,8.05,14,,6.44,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.5,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,8.05,57.5,
LATE CLOSURE OF WOUND,69012207,CDM,510,RC,13160,HCPCS,Outpatient,,,5081.84,3049.10,,601.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,2509.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.92,28,,1138.336,Percent of Total Billed Charges,28% of Total Billed Charges,30.6,32,,24.48,Percent of Total Billed Charges,32% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1829.46,36,,1463.568,Percent of Total Billed Charges,36% of Total Billed Charges,1829.46,36,,1463.568,Percent of Total Billed Charges,36% Total Bille Charges,1829.46,36,,1463.568,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.78,90,,,Fee Schedule,90% of CMS OPPS Rate,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.02,130,,,Fee Schedule,130% of CMS OPPS Rate,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,732.8,14.42,,586.24,Percent of Total Billed Charges,14.42% of Total Billed Charges,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1723.28,103,,,Fee Schedule,103% of CMS OPPS Rate,3811.38,75,,391.648,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2509.64,150,,,Fee Schedule,150% of CMS OPPS Rate,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,3557.29,70,,2845.832,Percent of Total Billed Charges,70% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,711.46,14,,569.168,Percent of Total Billed Charges,14% of Total Billed Charges,1673.1,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.84,100,,522.2,Percent of Total Billed Charges,100% of Total Billed Charges,30.6,5081.84,
GRAPHIX PRIME 16MM DISC PER CM,69012208,CDM,636,RC,Q4133,HCPCS,Outpatient,,,675,405.00,,506.65,110,,405.32,Percent of Total Billed Charges,110% of Total Billed Charges,303.75,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,30.68,32,,24.544,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,243,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,243,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.25,75,,215.464,Percent of Total Billed Charges,75% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.5,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,287.28,Percent of Total Billed Charges,100% of Total Billed Charges,30.68,675,
GRAPHIX PRIME 16MM PER CM WSTE,69012209,CDM,636,RC,Q4133,HCPCS,Outpatient,,,675,405.00,,506.65,110,,405.32,Percent of Total Billed Charges,110% of Total Billed Charges,303.75,45,,243,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,28,,151.2,Percent of Total Billed Charges,28% of Total Billed Charges,304.08,32,,243.264,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,243,36,,194.4,Percent of Total Billed Charges,36% Total Bille Charges,243,36,,194.4,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,540,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.25,75,,2378.4,Percent of Total Billed Charges,75% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,443.72,50,,354.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.5,70,,378,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675,100,,3171.2,Percent of Total Billed Charges,100% of Total Billed Charges,189,675,
NEOX CORD 8X3 PER SQ CM,69012214,CDM,278,RC,Q4146,HCPCS,Outpatient,,,541.67,325.00,,595.84,110,,476.672,Percent of Total Billed Charges,110% of Total Billed Charges,243.75,45,,195,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.67,28,,121.336,Percent of Total Billed Charges,28% of Total Billed Charges,304.08,32,,243.264,Percent of Total Billed Charges,32% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,195,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,195,36,,156,Percent of Total Billed Charges,36% Total Bille Charges,195,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,297.92,55,,238.336,Percent of Total Billed Charges,55% Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,541.67,100,,433.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.11,14.42,,62.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.34,80,,66.616,Percent of Total Billed Charges,80% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.17,70,,303.336,Percent of Total Billed Charges,70% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.67,100,,88.824,Percent of Total Billed Charges,100% of Total Billed Charges,75.83,595.84,
NEOX CORD 8X3 PER SQ CM WASTE,69012215,CDM,278,RC,Q4146,HCPCS,Outpatient,,,541.67,325.00,,595.84,110,,476.672,Percent of Total Billed Charges,110% of Total Billed Charges,243.75,45,,195,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,151.67,28,,121.336,Percent of Total Billed Charges,28% of Total Billed Charges,304.08,32,,243.264,Percent of Total Billed Charges,32% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,195,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,195,36,,156,Percent of Total Billed Charges,36% Total Bille Charges,195,36,,156,Percent of Total Billed Charges,36% of Total Billed Charges,297.92,55,,238.336,Percent of Total Billed Charges,55% Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,541.67,100,,433.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,78.11,14.42,,62.488,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.34,80,,315,Percent of Total Billed Charges,80% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,270.84,50,,216.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,379.17,70,,303.336,Percent of Total Billed Charges,70% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,75.83,14,,60.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,541.67,100,,420,Percent of Total Billed Charges,100% of Total Billed Charges,75.83,595.84,
NEOX CORD 3X2 PER SQ CM,69012216,CDM,278,RC,Q4146,HCPCS,Outpatient,,,2166.67,1300.00,,2383.34,110,,1906.672,Percent of Total Billed Charges,110% of Total Billed Charges,975,45,,780,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,606.67,28,,485.336,Percent of Total Billed Charges,28% of Total Billed Charges,305.28,32,,244.224,Percent of Total Billed Charges,32% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,780,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,780,36,,624,Percent of Total Billed Charges,36% Total Bille Charges,780,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,1191.67,55,,953.336,Percent of Total Billed Charges,55% Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2166.67,100,,1733.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,312.43,14.42,,249.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1733.34,80,,371.248,Percent of Total Billed Charges,80% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1516.67,70,,1213.336,Percent of Total Billed Charges,70% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2166.67,100,,495,Percent of Total Billed Charges,100% of Total Billed Charges,303.33,2383.34,
NEOX CORD 3X2 PER SQ CM WASTE,69012217,CDM,278,RC,Q4146,HCPCS,Outpatient,,,2166.67,1300.00,,2383.34,110,,1906.672,Percent of Total Billed Charges,110% of Total Billed Charges,975,45,,780,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,606.67,28,,485.336,Percent of Total Billed Charges,28% of Total Billed Charges,305.28,32,,244.224,Percent of Total Billed Charges,32% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,780,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,780,36,,624,Percent of Total Billed Charges,36% Total Bille Charges,780,36,,624,Percent of Total Billed Charges,36% of Total Billed Charges,1191.67,55,,953.336,Percent of Total Billed Charges,55% Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2166.67,100,,1733.336,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,312.43,14.42,,249.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1733.34,80,,371.248,Percent of Total Billed Charges,80% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,1083.34,50,,866.672,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1516.67,70,,1213.336,Percent of Total Billed Charges,70% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,303.33,14,,242.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2166.67,100,,495,Percent of Total Billed Charges,100% of Total Billed Charges,303.33,2383.34,
NEOX THIN 7X7 PER SQ CM,69012219,CDM,278,RC,Q4156,HCPCS,Outpatient,,,153.61,92.17,,312.97,110,,250.376,Percent of Total Billed Charges,110% of Total Billed Charges,69.12,45,,55.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.01,28,,34.408,Percent of Total Billed Charges,28% of Total Billed Charges,305.28,32,,244.224,Percent of Total Billed Charges,32% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% Total Bille Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.61,100,,122.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14.42,,17.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.89,80,,175.584,Percent of Total Billed Charges,80% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.53,70,,86.024,Percent of Total Billed Charges,70% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.61,100,,234.112,Percent of Total Billed Charges,100% of Total Billed Charges,21.51,312.97,
NEOX THIN 7X7 PER SQ CM WASTE,69012220,CDM,278,RC,Q4156,HCPCS,Outpatient,,,153.61,92.17,,312.97,110,,250.376,Percent of Total Billed Charges,110% of Total Billed Charges,69.12,45,,55.296,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.01,28,,34.408,Percent of Total Billed Charges,28% of Total Billed Charges,306.24,32,,244.992,Percent of Total Billed Charges,32% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% Total Bille Charges,55.3,36,,44.24,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.61,100,,122.888,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,22.15,14.42,,17.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.89,80,,295.352,Percent of Total Billed Charges,80% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,76.81,50,,61.448,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,107.53,70,,86.024,Percent of Total Billed Charges,70% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,21.51,14,,17.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,153.61,100,,393.8,Percent of Total Billed Charges,100% of Total Billed Charges,21.51,312.97,
DRESSING ROPE SILVER POLYMEM,69012222,CDM,272,RC,A6215,HCPCS,Outpatient,,,39.2,23.52,,4.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.64,45,,14.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.98,28,,8.784,Percent of Total Billed Charges,28% of Total Billed Charges,30.72,32,,24.576,Percent of Total Billed Charges,32% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,14.11,36,,11.288,Percent of Total Billed Charges,36% of Total Billed Charges,14.11,36,,11.288,Percent of Total Billed Charges,36% Total Bille Charges,14.11,36,,11.288,Percent of Total Billed Charges,36% of Total Billed Charges,23.52,60,,18.816,Percent of Total Billed Charges,60% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.2,100,,31.36,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.65,14.42,,4.52,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,75,,43.952,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,19.6,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,19.6,50,,15.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.44,70,,21.952,Percent of Total Billed Charges,70% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,5.49,14,,4.392,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.2,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.04,39.2,
THERASKIN 100TSXS PER SQ CM,69012223,CDM,278,RC,Q4121,HCPCS,Outpatient,,,408.33,245.00,,493.42,110,,394.736,Percent of Total Billed Charges,110% of Total Billed Charges,183.75,45,,147,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.33,100,,326.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.66,80,,43.952,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.83,70,,228.664,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.33,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,493.42,
THERASKIN 100TSXS CM WASTE,69012224,CDM,278,RC,Q4121,HCPCS,Outpatient,,,408.33,245.00,,493.42,110,,394.736,Percent of Total Billed Charges,110% of Total Billed Charges,183.75,45,,147,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.33,100,,326.664,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.66,80,,43.952,Percent of Total Billed Charges,80% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.83,70,,228.664,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.33,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,36.76,493.42,
ALLOPATCH 1.5X1.5 PER SQ CM,69012225,CDM,250,RC,Q4128,HCPCS,Outpatient,,,299.8,179.88,,35.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,134.91,45,,107.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.94,28,,67.152,Percent of Total Billed Charges,28% of Total Billed Charges,30.96,32,,24.768,Percent of Total Billed Charges,32% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% Total Bille Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,179.88,60,,143.904,Percent of Total Billed Charges,60% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.8,100,,239.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14.42,,34.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.85,75,,43.952,Percent of Total Billed Charges,75% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.86,70,,167.888,Percent of Total Billed Charges,70% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.8,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,299.8,
ALLOPATCH 1.5X1.5 WASTE,69012226,CDM,250,RC,Q4128,HCPCS,Outpatient,,,299.8,179.88,,35.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,134.91,45,,107.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.94,28,,67.152,Percent of Total Billed Charges,28% of Total Billed Charges,307.56,32,,246.048,Percent of Total Billed Charges,32% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% Total Bille Charges,107.93,36,,86.344,Percent of Total Billed Charges,36% of Total Billed Charges,179.88,60,,143.904,Percent of Total Billed Charges,60% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,299.8,100,,239.84,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,43.23,14.42,,34.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.85,75,,256.728,Percent of Total Billed Charges,75% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,209.86,70,,167.888,Percent of Total Billed Charges,70% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,41.97,14,,33.576,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,299.8,100,,342.304,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,307.56,
MEPILEX BORDER SACRUM 18X18,69012227,CDM,272,RC,A6214,HCPCS,Outpatient,,,43.4,26.04,,8.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.53,45,,15.624,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,43.06,360,,,Fee Schedule,360% of BCBS POS Rate,43.06,360,,,Fee schedule,360% of BCBS PPO Rate,43.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,26.04,60,,20.832,Percent of Total Billed Charges,60% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,100,,34.72,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.26,14.42,,5.008,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.55,75,,268.28,Percent of Total Billed Charges,75% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,21.7,50,,17.36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.38,70,,24.304,Percent of Total Billed Charges,70% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,6.08,14,,4.864,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.4,100,,357.704,Percent of Total Billed Charges,100% of Total Billed Charges,6.08,43.4,
MEPILEX BORDER SACRUM 23X23,69012228,CDM,272,RC,A6214,HCPCS,Outpatient,,,68.18,40.91,,8.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.68,45,,24.544,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,43.06,360,,,Fee Schedule,360% of BCBS POS Rate,43.06,360,,,Fee schedule,360% of BCBS PPO Rate,43.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.91,60,,32.728,Percent of Total Billed Charges,60% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.18,100,,54.544,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.83,14.42,,7.864,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.14,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,34.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,34.09,50,,27.272,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.73,70,,38.184,Percent of Total Billed Charges,70% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,9.55,14,,7.64,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.18,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,8.75,68.18,
DRSG CUTIMED SORBION SACHET,69012229,CDM,272,RC,A6198,HCPCS,Outpatient,,,1140,684.00,,20,100,,,Fee Schedule,100% of Aetna Fee Schedule,513,45,,410.4,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,319.2,28,,255.36,Percent of Total Billed Charges,28% of Total Billed Charges,307.56,32,,246.048,Percent of Total Billed Charges,32% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,410.4,36,,328.32,Percent of Total Billed Charges,36% of Total Billed Charges,410.4,36,,328.32,Percent of Total Billed Charges,36% Total Bille Charges,410.4,36,,328.32,Percent of Total Billed Charges,36% of Total Billed Charges,684,60,,547.2,Percent of Total Billed Charges,60% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1140,100,,912,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,164.39,14.42,,131.512,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,855,75,,300,Percent of Total Billed Charges,75% of Total Billed Charges,570,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,570,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,570,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,570,50,,456,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,798,70,,638.4,Percent of Total Billed Charges,70% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.6,14,,127.68,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1140,100,,400,Percent of Total Billed Charges,100% of Total Billed Charges,20,1140,
THERASKIN XL 116 PER SQ CM,69012230,CDM,250,RC,Q4121,HCPCS,Outpatient,,,73.85,44.31,,44.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.23,45,,26.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.31,60,,35.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.85,100,,59.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.39,75,,781.504,Percent of Total Billed Charges,75% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.7,70,,41.36,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.85,100,,1042,Percent of Total Billed Charges,100% of Total Billed Charges,33.23,73.85,
THERASKIN XL 116 SQ CM WASTE,69012231,CDM,250,RC,Q4121,HCPCS,Outpatient,,,73.85,44.31,,44.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.23,45,,26.584,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,45.71,360,,,Fee Schedule,360% of BCBS POS Rate,45.71,360,,,Fee schedule,360% of BCBS PPO Rate,45.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.31,60,,35.448,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.85,100,,59.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.39,75,,80.48,Percent of Total Billed Charges,75% of Total Billed Charges,36.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.76,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,36.76,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.7,70,,41.36,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.85,100,,107.304,Percent of Total Billed Charges,100% of Total Billed Charges,33.23,73.85,
ALLOPATCH 4X4 PER SQ CM,69012232,CDM,278,RC,Q4128,HCPCS,Outpatient,,,186.84,112.10,,240.54,110,,192.432,Percent of Total Billed Charges,110% of Total Billed Charges,84.08,45,,67.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.32,28,,41.856,Percent of Total Billed Charges,28% of Total Billed Charges,308.82,32,,247.056,Percent of Total Billed Charges,32% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% Total Bille Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.84,100,,149.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.94,14.42,,21.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.47,80,,68.032,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.79,70,,104.632,Percent of Total Billed Charges,70% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.84,100,,90.704,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,308.82,
ALLOPATCH 4X4 PER SQ CM WASTE,69012233,CDM,278,RC,Q4128,HCPCS,Outpatient,,,186.84,112.10,,240.54,110,,192.432,Percent of Total Billed Charges,110% of Total Billed Charges,84.08,45,,67.264,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.32,28,,41.856,Percent of Total Billed Charges,28% of Total Billed Charges,308.82,32,,247.056,Percent of Total Billed Charges,32% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% Total Bille Charges,67.26,36,,53.808,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.84,100,,149.472,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.94,14.42,,21.552,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.47,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.79,70,,104.632,Percent of Total Billed Charges,70% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,26.16,14,,20.928,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.84,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,308.82,
AMNIOBAND PER SQ CM 2X2,69012234,CDM,278,RC,Q4151,HCPCS,Outpatient,,,595,357.00,,783.33,110,,626.664,Percent of Total Billed Charges,110% of Total Billed Charges,267.75,45,,214.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.6,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,31.12,32,,24.896,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.2,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,214.2,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,214.2,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,327.25,55,,261.8,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,476,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.5,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.12,783.33,
AMNIOBAND PER SQ CM 2X2 WASTE,69012235,CDM,278,RC,Q4151,HCPCS,Outpatient,,,595,357.00,,783.33,110,,626.664,Percent of Total Billed Charges,110% of Total Billed Charges,267.75,45,,214.2,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.6,28,,133.28,Percent of Total Billed Charges,28% of Total Billed Charges,31.2,32,,24.96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,214.2,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,214.2,36,,171.36,Percent of Total Billed Charges,36% Total Bille Charges,214.2,36,,171.36,Percent of Total Billed Charges,36% of Total Billed Charges,327.25,55,,261.8,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,476,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.5,70,,333.2,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.2,783.33,
AMNIOBAND PER SQ CM 2X3,69012236,CDM,278,RC,Q4151,HCPCS,Outpatient,,,516.97,310.18,,697.5,110,,558,Percent of Total Billed Charges,110% of Total Billed Charges,232.64,45,,186.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.75,28,,115.8,Percent of Total Billed Charges,28% of Total Billed Charges,31.2,32,,24.96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.11,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,186.11,36,,148.888,Percent of Total Billed Charges,36% Total Bille Charges,186.11,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,284.33,55,,227.464,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.97,100,,413.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.58,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.88,70,,289.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.97,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.2,697.5,
AMNIOBAND PER SQ CM 2X3 WASTE,69012237,CDM,278,RC,Q4151,HCPCS,Outpatient,,,516.97,310.18,,697.5,110,,558,Percent of Total Billed Charges,110% of Total Billed Charges,232.64,45,,186.112,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.75,28,,115.8,Percent of Total Billed Charges,28% of Total Billed Charges,31.2,32,,24.96,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.11,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,186.11,36,,148.888,Percent of Total Billed Charges,36% Total Bille Charges,186.11,36,,148.888,Percent of Total Billed Charges,36% of Total Billed Charges,284.33,55,,227.464,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.97,100,,413.576,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.58,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.88,70,,289.504,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.97,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.2,697.5,
ALLOPATCH 4X8 PER SQ CM,69012238,CDM,278,RC,Q4128,HCPCS,Outpatient,,,130.93,78.56,,179.04,110,,143.232,Percent of Total Billed Charges,110% of Total Billed Charges,58.92,45,,47.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.66,28,,29.328,Percent of Total Billed Charges,28% of Total Billed Charges,31.2,32,,24.96,Percent of Total Billed Charges,32% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% Total Bille Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.93,100,,104.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.88,14.42,,15.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.74,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.65,70,,73.32,Percent of Total Billed Charges,70% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.93,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,18.33,179.04,
ALLOPATCH 4X8 PER SQ CM WASTE,69012239,CDM,278,RC,Q4128,HCPCS,Outpatient,,,130.93,78.56,,179.04,110,,143.232,Percent of Total Billed Charges,110% of Total Billed Charges,58.92,45,,47.136,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.66,28,,29.328,Percent of Total Billed Charges,28% of Total Billed Charges,31.2,32,,24.96,Percent of Total Billed Charges,32% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% Total Bille Charges,47.13,36,,37.704,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.93,100,,104.744,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.88,14.42,,15.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.74,80,,159.6,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.65,70,,73.32,Percent of Total Billed Charges,70% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,18.33,14,,14.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,130.93,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,18.33,179.04,
INCISIONAL BIOPSY OF SKIN,69012240,CDM,510,RC,11106,HCPCS,Outpatient,,,484.76,290.86,,43.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,864.31,150,,,Fee Schedule ,150% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,135.73,28,,108.584,Percent of Total Billed Charges,28% of Total Billed Charges,31.3,32,,25.04,Percent of Total Billed Charges,32% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% Total Bille Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,518.59,90,,,Fee Schedule,90% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,749.07,130,,,Fee Schedule,130% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14.42,,55.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,593.49,103,,,Fee Schedule,103% of CMS OPPS Rate,363.57,75,,159.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,864.31,150,,,Fee Schedule,150% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,339.33,70,,271.464,Percent of Total Billed Charges,70% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,576.21,100,,,Fee Schedule,100% of CMS OPPS Rate,484.76,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,31.3,864.31,
PICO 7 2 DRESS KIT,69012242,CDM,272,RC,,,Outpatient,,,662.56,397.54,,397.54,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,298.15,45,,238.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,185.52,28,,148.416,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,238.52,36,,190.816,Percent of Total Billed Charges,36% of Total Billed Charges,238.52,36,,190.816,Percent of Total Billed Charges,36% Total Bille Charges,238.52,36,,190.816,Percent of Total Billed Charges,36% of Total Billed Charges,397.54,60,,318.032,Percent of Total Billed Charges,60% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,662.56,100,,530.048,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,95.54,14.42,,76.432,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,496.92,75,,159.6,Percent of Total Billed Charges,75% of Total Billed Charges,331.28,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,331.28,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,331.28,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,331.28,50,,265.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,463.79,70,,371.032,Percent of Total Billed Charges,70% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,92.76,14,,74.208,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,662.56,100,,212.8,Percent of Total Billed Charges,100% of Total Billed Charges,92.76,662.56,
PUNCH BIOPSY OF SKIN,69012244,CDM,510,RC,11104,HCPCS,Outpatient,,,484.76,290.86,,35.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,548.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,135.73,28,,108.584,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% Total Bille Charges,174.51,36,,139.608,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,329.24,90,,,Fee Schedule,90% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,475.57,130,,,Fee Schedule,130% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,69.9,14.42,,55.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,376.8,103,,,Fee Schedule,103% of CMS OPPS Rate,363.57,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,548.74,150,,,Fee Schedule,150% of CMS OPPS Rate,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,339.33,70,,271.464,Percent of Total Billed Charges,70% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,67.87,14,,54.296,Percent of Total Billed Charges,14% of Total Billed Charges,365.83,100,,,Fee Schedule,100% of CMS OPPS Rate,484.76,100,,80.8,Percent of Total Billed Charges,100% of Total Billed Charges,35.86,548.74,
AMNIOBAND 18MM DISK PER SQ CM,69012245,CDM,278,RC,Q4151,HCPCS,Outpatient,,,990.73,594.44,,1218.63,110,,974.904,Percent of Total Billed Charges,110% of Total Billed Charges,445.83,45,,356.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.4,28,,221.92,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.66,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,356.66,36,,285.328,Percent of Total Billed Charges,36% Total Bille Charges,356.66,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,544.9,55,,435.92,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,990.73,100,,792.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,792.58,80,,17,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,693.51,70,,554.808,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,990.73,100,,22.664,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,1218.63,
AMNIOBAND 18MM PER SQ CM WASTE,69012246,CDM,278,RC,Q4151,HCPCS,Outpatient,,,990.73,594.44,,1218.63,110,,974.904,Percent of Total Billed Charges,110% of Total Billed Charges,445.83,45,,356.664,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.4,28,,221.92,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,356.66,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,356.66,36,,285.328,Percent of Total Billed Charges,36% Total Bille Charges,356.66,36,,285.328,Percent of Total Billed Charges,36% of Total Billed Charges,544.9,55,,435.92,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,990.73,100,,792.584,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,792.58,80,,9.472,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,693.51,70,,554.808,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,990.73,100,,12.624,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,1218.63,
PURAPLY AM 2X2 PER SQ CM,69012247,CDM,278,RC,Q4196,HCPCS,Outpatient,,,794.06,476.44,,985.22,110,,788.176,Percent of Total Billed Charges,110% of Total Billed Charges,357.33,45,,285.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,436.73,55,,349.384,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,794.06,100,,635.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,635.25,80,,46.2,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.84,70,,444.672,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,794.06,100,,61.6,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,985.22,
PURAPLY AM 2X2 PER SQ CM WASTE,69012248,CDM,278,RC,Q4196,HCPCS,Outpatient,,,794.06,476.44,,985.22,110,,788.176,Percent of Total Billed Charges,110% of Total Billed Charges,357.33,45,,285.864,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,436.73,55,,349.384,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,794.06,100,,635.248,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,635.25,80,,525,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.84,70,,444.672,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,794.06,100,,700,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,985.22,
PURAPLY AM 16MM PER SQ CM,69012249,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1456.43,873.86,,1713.82,110,,1371.056,Percent of Total Billed Charges,110% of Total Billed Charges,655.39,45,,524.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,801.04,55,,640.832,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1456.43,100,,1165.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1165.14,80,,450,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.5,70,,815.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1456.43,100,,600,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,1713.82,
PURAPLY AM 16MM PER SQ CM WSTE,69012250,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1456.43,873.86,,1713.82,110,,1371.056,Percent of Total Billed Charges,110% of Total Billed Charges,655.39,45,,524.312,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,801.04,55,,640.832,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1456.43,100,,1165.144,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1165.14,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1019.5,70,,815.6,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1456.43,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,1713.82,
AMNIOBAND 4X6 PER SQ CM,69012251,CDM,278,RC,Q4151,HCPCS,Outpatient,,,378.85,227.31,,545.57,110,,436.456,Percent of Total Billed Charges,110% of Total Billed Charges,170.48,45,,136.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.08,28,,84.864,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.39,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,136.39,36,,109.112,Percent of Total Billed Charges,36% Total Bille Charges,136.39,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.85,100,,303.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.08,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.2,70,,212.16,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.85,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,106.08,545.57,
AMNIOBAND 4X6 PER SQ CM WASTE,69012252,CDM,278,RC,Q4151,HCPCS,Outpatient,,,378.85,227.31,,545.57,110,,436.456,Percent of Total Billed Charges,110% of Total Billed Charges,170.48,45,,136.384,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.08,28,,84.864,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.39,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,136.39,36,,109.112,Percent of Total Billed Charges,36% Total Bille Charges,136.39,36,,109.112,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.85,100,,303.08,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.08,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.2,70,,212.16,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.85,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,106.08,545.57,
ALLOPATCH 2X2 PER SQ CM,69012253,CDM,278,RC,Q4128,HCPCS,Outpatient,,,486.3,291.78,,569.95,110,,455.96,Percent of Total Billed Charges,110% of Total Billed Charges,218.84,45,,175.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.16,28,,108.928,Percent of Total Billed Charges,28% of Total Billed Charges,311.87,32,,249.496,Percent of Total Billed Charges,32% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% Total Bille Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.3,100,,389.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,70.12,14.42,,56.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.04,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.41,70,,272.328,Percent of Total Billed Charges,70% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.3,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,569.95,
ALLOPATCH 2X2 PER SQ CM WASTE,69012254,CDM,278,RC,Q4128,HCPCS,Outpatient,,,486.3,291.78,,569.95,110,,455.96,Percent of Total Billed Charges,110% of Total Billed Charges,218.84,45,,175.072,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.16,28,,108.928,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% Total Bille Charges,175.07,36,,140.056,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.3,100,,389.04,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,70.12,14.42,,56.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.04,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.97,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,340.41,70,,272.328,Percent of Total Billed Charges,70% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,68.08,14,,54.464,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.3,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,24.97,569.95,
AMNIOBAND 4X4 PER SQ CM,69012255,CDM,278,RC,Q4151,HCPCS,Outpatient,,,547.03,328.22,,730.56,110,,584.448,Percent of Total Billed Charges,110% of Total Billed Charges,246.16,45,,196.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.17,28,,122.536,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.93,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,196.93,36,,157.544,Percent of Total Billed Charges,36% Total Bille Charges,196.93,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,300.87,55,,240.696,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547.03,100,,437.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,437.62,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.92,70,,306.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547.03,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,730.56,
PURAPLY AM 2X4 PER SQ CM,69012256,CDM,278,RC,Q4196,HCPCS,Outpatient,,,476.44,285.86,,635.83,110,,508.664,Percent of Total Billed Charges,110% of Total Billed Charges,214.4,45,,171.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476.44,100,,381.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,381.15,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.51,70,,266.808,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476.44,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,635.83,
PURAPLY AM 2X4 PER SQ CM WSTE,69012257,CDM,278,RC,Q4196,HCPCS,Outpatient,,,476.44,285.86,,635.83,110,,508.664,Percent of Total Billed Charges,110% of Total Billed Charges,214.4,45,,171.52,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,430.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,483.84,360,,,Fee Schedule,360% of BCBS POS Rate,483.84,360,,,Fee schedule,360% of BCBS PPO Rate,483.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476.44,100,,381.152,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,381.15,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,86.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.66,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,86.66,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.51,70,,266.808,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,476.44,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,86.66,635.83,
AMNIOBAND 4X4 PER SQ CM WASTE,69012258,CDM,278,RC,Q4151,HCPCS,Outpatient,,,547.03,328.22,,730.56,110,,584.448,Percent of Total Billed Charges,110% of Total Billed Charges,246.16,45,,196.928,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.17,28,,122.536,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.93,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,196.93,36,,157.544,Percent of Total Billed Charges,36% Total Bille Charges,196.93,36,,157.544,Percent of Total Billed Charges,36% of Total Billed Charges,300.87,55,,240.696,Percent of Total Billed Charges,55% Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547.03,100,,437.624,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,437.62,80,,255,Percent of Total Billed Charges,80% of Total Billed Charges,106.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.3,80,,,Fee Schedule,80% of Scott and White PPO fee schedule,106.3,80,,,Fee Schedule,80% of Scott and White SWHP fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.92,70,,306.336,Percent of Total Billed Charges,70% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,547.03,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,106.3,730.56,
SLEEP STUDY UNATT & RESP EFFT,69121010,CDM,920,RC,95806,HCPCS,Outpatient,,,1143.42,686.05,,42.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,251.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,287.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,323.06,360,,,Fee Schedule,360% of BCBS POS Rate,323.06,360,,,Fee schedule,360% of BCBS PPO Rate,323.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,686.05,60,,548.84,Percent of Total Billed Charges,60% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,164.88,14.42,,131.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,857.57,75,,255,Percent of Total Billed Charges,75% of Total Billed Charges,571.71,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,571.71,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,571.71,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,571.71,50,,457.368,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,,Case Rate,Pays based on per visit rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.42,100,,340,Percent of Total Billed Charges,100% of Total Billed Charges,42.62,1143.42,
POLYSOMNGRPHY W/CPAP,69121028,CDM,920,RC,95811,HCPCS,Outpatient,,,6058,3634.80,,395.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,1438.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1684.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,1895.51,360,,,Fee Schedule,360% of BCBS POS Rate,1895.51,360,,,Fee schedule,360% of BCBS PPO Rate,1895.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,3634.8,60,,2907.84,Percent of Total Billed Charges,60% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,863.31,90,,,Fee Schedule,90% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.01,130,,,Fee Schedule,130% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,873.56,14.42,,698.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,4543.5,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,1438.86,150,,,Fee Schedule,150% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,950,100,,,Case Rate,Pays based on per visit rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,6058,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,395.65,6058,
POLYSOMNGRPHY W/CPAP MOD,69121044,CDM,920,RC,95811,HCPCS,Outpatient,,,6058,3634.80,,395.65,100,,,Fee Schedule,100% of Aetna Fee Schedule,1438.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1684.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,1895.51,360,,,Fee Schedule,360% of BCBS POS Rate,1895.51,360,,,Fee schedule,360% of BCBS PPO Rate,1895.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,3634.8,60,,2907.84,Percent of Total Billed Charges,60% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,863.31,90,,,Fee Schedule,90% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.01,130,,,Fee Schedule,130% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,873.56,14.42,,698.848,Percent of Total Billed Charges,14.42% of Total Billed Charges,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,4543.5,75,,65.328,Percent of Total Billed Charges,75% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,3029,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,1438.86,150,,,Fee Schedule,150% of CMS OPPS Rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,950,100,,,Case Rate,Pays based on per visit rate,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,848.12,14,,678.496,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,6058,100,,87.104,Percent of Total Billed Charges,100% of Total Billed Charges,395.65,6058,
POLYSOMNOGRAPHY 4 OR MORE <6YR,69121050,CDM,922,RC,95872,HCPCS,Outpatient,,,828.91,497.35,,40.91,100,,,Fee Schedule,100% of Aetna Fee Schedule,214.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,124.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,141.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,159.59,360,,,Fee Schedule,360% of BCBS POS Rate,159.59,360,,,Fee schedule,360% of BCBS PPO Rate,159.59,360,,,Fee Schedule,360% of BCBS Traditional Rate,497.35,60,,397.88,Percent of Total Billed Charges,60% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.97,90,,,Fee Schedule,90% of CMS OPPS Rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,186.29,130,,,Fee Schedule,130% of CMS OPPS Rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,119.53,14.42,,95.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,147.6,103,,,Fee Schedule,103% of CMS OPPS Rate,621.68,75,,156,Percent of Total Billed Charges,75% of Total Billed Charges,414.46,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,414.46,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,414.46,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,414.46,50,,331.568,Percent of Total Billed Charges,50% of Total Billed Charges,214.96,150,,,Fee Schedule,150% of CMS OPPS Rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,,Case Rate,Pays based on per visit rate,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,116.05,14,,92.84,Percent of Total Billed Charges,14% of Total Billed Charges,143.31,100,,,Fee Schedule,100% of CMS OPPS Rate,828.91,100,,208,Percent of Total Billed Charges,100% of Total Billed Charges,40.91,828.91,
POLYSOMNGRPHY 4 OR MORE,69121051,CDM,920,RC,95810,HCPCS,Outpatient,,,5709.58,3425.75,,378.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,1438.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1603.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,1803.38,360,,,Fee Schedule,360% of BCBS POS Rate,1803.38,360,,,Fee schedule,360% of BCBS PPO Rate,1803.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,3425.75,60,,2740.6,Percent of Total Billed Charges,60% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,863.31,90,,,Fee Schedule,90% of CMS OPPS Rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.01,130,,,Fee Schedule,130% of CMS OPPS Rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,823.32,14.42,,658.656,Percent of Total Billed Charges,14.42% of Total Billed Charges,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,988.01,103,,,Fee Schedule,103% of CMS OPPS Rate,4282.19,75,,44.568,Percent of Total Billed Charges,75% of Total Billed Charges,2854.79,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,2854.79,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2854.79,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,2854.79,50,,2283.832,Percent of Total Billed Charges,50% of Total Billed Charges,1438.86,150,,,Fee Schedule,150% of CMS OPPS Rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,950,100,,,Case Rate,Pays based on per visit rate,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,799.34,14,,639.472,Percent of Total Billed Charges,14% of Total Billed Charges,959.24,100,,,Fee Schedule,100% of CMS OPPS Rate,5709.58,100,,59.424,Percent of Total Billed Charges,100% of Total Billed Charges,378.4,5709.58,
MULTI SLEEP LATENCY TEST,69121150,CDM,920,RC,95805,HCPCS,Outpatient,,,3190.89,1914.53,,276.45,100,,,Fee Schedule,100% of Aetna Fee Schedule,737.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1028.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1175.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,1322.06,360,,,Fee Schedule,360% of BCBS POS Rate,1322.06,360,,,Fee schedule,360% of BCBS PPO Rate,1322.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,1914.53,60,,1531.624,Percent of Total Billed Charges,60% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,442.56,90,,,Fee Schedule,90% of CMS OPPS Rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,639.26,130,,,Fee Schedule,130% of CMS OPPS Rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,460.13,14.42,,368.104,Percent of Total Billed Charges,14.42% of Total Billed Charges,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,506.49,103,,,Fee Schedule,103% of CMS OPPS Rate,2393.17,75,,44.512,Percent of Total Billed Charges,75% of Total Billed Charges,1595.45,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,1595.45,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1595.45,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,1595.45,50,,1276.36,Percent of Total Billed Charges,50% of Total Billed Charges,737.61,150,,,Fee Schedule,150% of CMS OPPS Rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,950,100,,,Case Rate,Pays based on per visit rate,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,446.72,14,,357.376,Percent of Total Billed Charges,14% of Total Billed Charges,491.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3190.89,100,,59.344,Percent of Total Billed Charges,100% of Total Billed Charges,276.45,3190.89,
PNH WITH FLAER,70010000,CDM,302,RC,88184,HCPCS,Outpatient,,,1400,840.00,,82.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,840,60,,672,Percent of Total Billed Charges,60% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,201.88,14.42,,161.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,1050,75,,54.424,Percent of Total Billed Charges,75% of Total Billed Charges,700,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,700,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,700,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,700,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,196,14,,156.8,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1400,100,,72.56,Percent of Total Billed Charges,100% of Total Billed Charges,82.66,1400,
MICRO GEN DX,70010001,CDM,306,RC,0112U,HCPCS,Outpatient,,,1420,852.00,,206.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,534.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,852,60,,681.6,Percent of Total Billed Charges,60% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,320.51,90,,,Fee Schedule,90% of CMS OPPS Rate,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,462.96,130,,,Fee Schedule,130% of CMS OPPS Rate,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,204.76,14.42,,163.808,Percent of Total Billed Charges,14.42% of Total Billed Charges,366.81,103,,,Fee Schedule,103% of CMS OPPS Rate,366.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1065,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,605.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,605.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,605.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,605.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,534.19,150,,,Fee Schedule,150% of CMS OPPS Rate,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,288.47,90,,,Fee Schedule,90% of UHC fee schedule,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,198.8,14,,159.04,Percent of Total Billed Charges,14% of Total Billed Charges,356.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1420,100,,100,Percent of Total Billed Charges,100% of Total Billed Charges,98.25,1420,
PNEUMONIA PANEL PCR,70010002,CDM,302,RC,87798,HCPCS,Outpatient,,,4600,2760.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,2760,60,,2208,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,3450,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,4600,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,4600,
LIDOCAINE,70010003,CDM,302,RC,80176,HCPCS,Outpatient,,,274.56,164.74,,17.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.03,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,52.88,360,,,Fee Schedule,360% of BCBS POS Rate,52.88,360,,,Fee schedule,360% of BCBS PPO Rate,52.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,164.74,60,,131.792,Percent of Total Billed Charges,60% of Total Billed Charges,12.34,100,,,Fee Schedule,100% of TX Mediciad Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,90,,,Fee Schedule,90% of CMS OPPS Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,130,,,Fee Schedule,130% of CMS OPPS Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.71,103,,,Fee Schedule,103% of TX Medicaid Rate,15.13,103,,,Fee Schedule,103% of CMS OPPS Rate,15.13,103,,,Fee Schedule,103% of CMS OPPS Rate,205.92,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,24.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,24.97,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.97,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.03,150,,,Fee Schedule,150% of CMS OPPS Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,11.9,90,,,Fee Schedule,90% of UHC fee schedule,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,12.34,100,,,Fee Schedule,100% of TX Medicaid Rate,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,274.56,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,11.9,274.56,
VIRAL CULTURE NON RESPIRATORY,70010004,CDM,302,RC,87252,HCPCS,Outpatient,,,1943.6,1166.16,,30.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,83.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,93.85,360,,,Fee Schedule,360% of BCBS POS Rate,93.85,360,,,Fee schedule,360% of BCBS PPO Rate,93.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,1166.16,60,,932.928,Percent of Total Billed Charges,60% of Total Billed Charges,21.9,100,,,Fee Schedule,100% of TX Mediciad 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,23.46,90,,,Fee Schedule,90% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.89,130,,,Fee Schedule,130% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,22.56,103,,,Fee Schedule,103% of TX Medicaid Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,1457.7,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,44.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,44.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,44.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,39.1,150,,,Fee Schedule,150% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.11,90,,,Fee Schedule,90% of UHC fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1943.6,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,21.11,1943.6,
"MONKEY POX VIRUS DNA, RT PCR",70010005,CDM,306,RC,87593,HCPCS,Outpatient,,,400,240.00,,240,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,240,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,43.1,100,,,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,44.39,103,,,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,75,,1323,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,200,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,400,100,,1764,Percent of Total Billed Charges,100% of Total Billed Charges,43.1,400,
MICRO GEN DX,70010006,CDM,310,RC,87640,HCPCS,Outpatient,,,1420,852.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,852,60,,681.6,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,1065,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1420,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,1420,
ACUTE PNEUMONIA PANEL RT PCR,70010007,CDM,306,RC,87486,HCPCS,Outpatient,,,2912,1747.20,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1747.2,60,,1397.76,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2184,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2912,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,2912,
HEP B SURFACE AG DIALYSIS,70010008,CDM,306,RC,87340,HCPCS,Outpatient,,,192,115.20,,11.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,28.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,37.19,360,,,Fee Schedule,360% of BCBS POS Rate,37.19,360,,,Fee schedule,360% of BCBS PPO Rate,37.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,115.2,60,,92.16,Percent of Total Billed Charges,60% of Total Billed Charges,8.68,100,,,Fee Schedule,100% of TX Mediciad 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,9.29,90,,,Fee Schedule,90% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,130,,,Fee Schedule,130% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,103,,,Fee Schedule,103% of TX Medicaid Rate,10.63,103,,,Fee Schedule,103% of CMS OPPS Rate,10.63,103,,,Fee Schedule,103% of CMS OPPS Rate,144,75,,4080,Percent of Total Billed Charges,75% of Total Billed Charges,17.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,17.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.49,150,,,Fee Schedule,150% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,8.37,90,,,Fee Schedule,90% of UHC fee schedule,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,8.68,100,,,Fee Schedule,100% of TX Medicaid Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,192,100,,5440,Percent of Total Billed Charges,100% of Total Billed Charges,8.37,192,
"ALPHA DEFENSIN SYNOVIAL FLUID, LFA",70010009,CDM,306,RC,83518,HCPCS,Outpatient,,,1740,1044.00,,11.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,26.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,34.7,360,,,Fee Schedule,360% of BCBS POS Rate,34.7,360,,,Fee schedule,360% of BCBS PPO Rate,34.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,1044,60,,835.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.1,100,,,Fee Schedule,100% of TX Mediciad Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,8.67,90,,,Fee Schedule,90% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,12.53,130,,,Fee Schedule,130% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.34,103,,,Fee Schedule,103% of TX Medicaid Rate,9.92,103,,,Fee Schedule,103% of CMS OPPS Rate,9.92,103,,,Fee Schedule,103% of CMS OPPS Rate,1305,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,16.38,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.38,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.38,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.46,150,,,Fee Schedule,150% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,90,,,Fee Schedule,90% of UHC fee schedule,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of TX Medicaid Rate,9.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1740,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,7.81,1740,
LGl1 ANTIBODY,70010010,CDM,301,RC,86255,HCPCS,Outpatient,,,1545,927.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,927,60,,741.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1158.75,75,,2025,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1545,100,,2700,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,1545,
ARBOVIRUS ANTIBODY PANEL,70010011,CDM,301,RC,86651,HCPCS,Outpatient,,,2103.6,1262.16,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,1262.16,60,,1009.728,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,1577.7,75,,2444.896,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2103.6,100,,3259.864,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,2103.6,
URINE PROTEIN ELECTROPHORESIS,70010012,CDM,301,RC,82570,HCPCS,Outpatient,,,52.68,31.61,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,31.61,60,,25.288,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,39.51,75,,2444.896,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,52.68,100,,3259.864,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,52.68,
PNH WITH FLAER,70010013,CDM,301,RC,88184,HCPCS,Outpatient,,,1280,768.00,,82.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,768,60,,614.4,Percent of Total Billed Charges,60% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,184.58,14.42,,147.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,960,75,,1549.744,Percent of Total Billed Charges,75% of Total Billed Charges,640,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,640,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,640,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,640,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,179.2,14,,143.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,2066.32,Percent of Total Billed Charges,100% of Total Billed Charges,82.66,1280,
GAMMA HYDROXYBUTYRIC ACID,70010014,CDM,301,RC,80307,HCPCS,Outpatient,,,434,260.40,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,260.4,60,,208.32,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,325.5,75,,1549.744,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,434,100,,2066.32,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,434,
KETAMINE AND METABOLITE SCREEN,70010015,CDM,301,RC,80307,HCPCS,Outpatient,,,392.28,235.37,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,235.37,60,,188.296,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,294.21,75,,1360.384,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,392.28,100,,1813.84,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,392.28,
24HR URINE CREATININE,70010016,CDM,301,RC,84156,HCPCS,Outpatient,,,398.28,238.97,,4.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,5.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.21,360,,,Fee Schedule,360% of BCBS POS Rate,13.21,360,,,Fee schedule,360% of BCBS PPO Rate,13.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,238.97,60,,191.176,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,100,,,Fee Schedule,100% of TX Mediciad 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,3.3,90,,,Fee Schedule,90% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.77,130,,,Fee Schedule,130% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.17,103,,,Fee Schedule,103% of TX Medicaid Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,298.71,75,,1360.384,Percent of Total Billed Charges,75% of Total Billed Charges,6.23,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.23,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,6.23,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,5.5,150,,,Fee Schedule,150% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,90,,,Fee Schedule,90% of UHC fee schedule,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,398.28,100,,1813.84,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,398.28,
24HR URINE PROTEIN,70010017,CDM,301,RC,84156,HCPCS,Outpatient,,,413.36,248.02,,4.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,5.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.21,360,,,Fee Schedule,360% of BCBS POS Rate,13.21,360,,,Fee schedule,360% of BCBS PPO Rate,13.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,248.02,60,,198.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,100,,,Fee Schedule,100% of TX Mediciad 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,3.3,90,,,Fee Schedule,90% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.77,130,,,Fee Schedule,130% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.17,103,,,Fee Schedule,103% of TX Medicaid Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,3.78,103,,,Fee Schedule,103% of CMS OPPS Rate,310.02,75,,1103.072,Percent of Total Billed Charges,75% of Total Billed Charges,6.23,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.23,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,6.23,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,5.5,150,,,Fee Schedule,150% of CMS OPPS Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,90,,,Fee Schedule,90% of UHC fee schedule,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.08,100,,,Fee Schedule,100% of TX Medicaid Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,413.36,100,,1470.76,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,413.36,
CARIS,70010018,CDM,306,RC,88360,HCPCS,Outpatient,,,2000,1200.00,,98.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,1200,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,288.4,14.42,,230.72,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,1500,75,,1627.816,Percent of Total Billed Charges,75% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,1000,50,,800,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,280,14,,224,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,2170.424,Percent of Total Billed Charges,100% of Total Billed Charges,98.22,2000,
GH EXACT SCIENCES-ONCOMAP,70010019,CDM,310,RC,0244U,HCPCS,Outpatient,,,11958,7174.80,,1793.73,100,,,Fee Schedule,100% of Aetna Fee Schedule,5250,150,,,Fee Schedule ,150% of CMS OPPS Rate,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,9800,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11200,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,12600,360,,,Fee Schedule,360% of BCBS POS Rate,12600,360,,,Fee schedule,360% of BCBS PPO Rate,12600,360,,,Fee Schedule,360% of BCBS Traditional Rate,7174.8,60,,5739.84,Percent of Total Billed Charges,60% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,3150,90,,,Fee Schedule,90% of CMS OPPS Rate,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,4550,130,,,Fee Schedule,130% of CMS OPPS Rate,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1724.34,14.42,,1379.472,Percent of Total Billed Charges,14.42% of Total Billed Charges,3605,103,,,Fee Schedule,103% of CMS OPPS Rate,3605,103,,,Fee Schedule,103% of CMS OPPS Rate,8968.5,75,,42.768,Percent of Total Billed Charges,75% of Total Billed Charges,5950,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5950,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,5950,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,5950,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,5250,150,,,Fee Schedule,150% of CMS OPPS Rate,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,5979,50,,4783.2,Percent of Total Billed Charges,50% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,1674.12,14,,1339.296,Percent of Total Billed Charges,14% of Total Billed Charges,3500,100,,,Fee Schedule,100% of CMS OPPS Rate,11958,100,,57.024,Percent of Total Billed Charges,100% of Total Billed Charges,1674.12,12600,
M.TB DETECTION AND RIFAMPIN,70010020,CDM,301,RC,87801,HCPCS,Outpatient,,,800,480.00,,81.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,224.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,252.72,360,,,Fee Schedule,360% of BCBS POS Rate,252.72,360,,,Fee schedule,360% of BCBS PPO Rate,252.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,480,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,58.97,100,,,Fee Schedule,100% of TX Mediciad 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,63.18,90,,,Fee Schedule,90% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.26,130,,,Fee Schedule,130% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,60.74,103,,,Fee Schedule,103% of TX Medicaid Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,600,75,,476.248,Percent of Total Billed Charges,75% of Total Billed Charges,119.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,119.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,119.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,105.3,150,,,Fee Schedule,150% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.86,90,,,Fee Schedule,90% of UHC fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,635,Percent of Total Billed Charges,100% of Total Billed Charges,56.86,800,
ISNGS GENERATION SEQUENCING,70010021,CDM,306,RC,87798,HCPCS,Outpatient,,,1923.8,1154.28,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1154.28,60,,923.424,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,1442.85,75,,192,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1923.8,100,,256,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,1923.8,
HSV 1/2 IGM AB,70010022,CDM,301,RC,86695,HCPCS,Outpatient,,,253.28,151.97,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,151.97,60,,121.576,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,189.96,75,,24.832,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,253.28,100,,33.104,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,253.28,
IHC MMR PROTEIN,70010023,CDM,310,RC,88342,HCPCS,Outpatient,,,922.28,553.37,,84.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,553.37,60,,442.696,Percent of Total Billed Charges,60% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,132.99,14.42,,106.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,691.71,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,922.28,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,84.1,922.28,
PERNICIOUS ANEMIA CASCADE,70010024,CDM,301,RC,82607,HCPCS,Outpatient,,,709.28,425.57,,17.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,54.29,360,,,Fee Schedule,360% of BCBS POS Rate,54.29,360,,,Fee schedule,360% of BCBS PPO Rate,54.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,425.57,60,,340.456,Percent of Total Billed Charges,60% of Total Billed Charges,12.67,100,,,Fee Schedule,100% of TX Mediciad 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,13.57,90,,,Fee Schedule,90% of CMS OPPS Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,130,,,Fee Schedule,130% of CMS OPPS Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,103,,,Fee Schedule,103% of TX Medicaid Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,15.53,103,,,Fee Schedule,103% of CMS OPPS Rate,531.96,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,25.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,25.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.62,150,,,Fee Schedule,150% of CMS OPPS Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12.21,90,,,Fee Schedule,90% of UHC fee schedule,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,12.67,100,,,Fee Schedule,100% of TX Medicaid Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,709.28,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,12.21,709.28,
FENTANYL SCREEN RANDOM URINE,70010025,CDM,301,RC,80307,HCPCS,Outpatient,,,612,367.20,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,367.2,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,459,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,612,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,612,
AMYLOID PROTEIN IDENTIFICATION,70010026,CDM,310,RC,88313,HCPCS,Outpatient,,,922.28,553.37,,82.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,,Fee Schedule,360% of BCBS POS Rate,120.35,360,,,Fee schedule,360% of BCBS PPO Rate,120.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,553.37,60,,442.696,Percent of Total Billed Charges,60% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,132.99,14.42,,106.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,691.71,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,461.14,50,,368.912,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,,Fee Schedule,90% of UHC fee schedule,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,129.12,14,,103.296,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,922.28,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,922.28,
TARGETED GENOMIC SEQ ANALYSIS- CARIS,70010027,CDM,310,RC,81479,HCPCS,Outpatient,,,11678,7006.80,,7006.8,60,,5605.44,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,92.34,360,,,Fee Schedule,360% of BCBS POS Rate,92.34,360,,,Fee schedule,360% of BCBS PPO Rate,92.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,7006.8,60,,5605.44,Percent of Total Billed Charges,60% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1683.97,14.42,,1347.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8758.5,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,5839,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,5839,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5839,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,5839,50,,4671.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,1634.92,14,,1307.936,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11678,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,71.82,11678,
MALARIA MOLECULAR DETECTION PCR,70010028,CDM,301,RC,87798,HCPCS,Outpatient,,,1806.68,1084.01,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1084.01,60,,867.208,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,1355.01,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1806.68,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,1806.68,
MDS2  MOVEMENT DISORDER EVALUATION,70010029,CDM,301,RC,86596,HCPCS,Outpatient,,,1900,1140.00,,1140,60,,912,Percent of Total Billed Charges,60% of Total Billed Charges,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,1140,60,,912,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1425,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,950,50,,760,Percent of Total Billed Charges,50% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1900,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,10.84,1900,
NMDA RECEPTOR AB,70010030,CDM,301,RC,86255,HCPCS,Outpatient,,,3520,2112.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,2112,60,,1689.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,2640,75,,38.632,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3520,100,,51.504,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,3520,
RPR WITH REFLEX TO TITER,70010031,CDM,301,RC,86592,HCPCS,Outpatient,,,37.24,22.34,,4.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,,Fee Schedule,360% of BCBS POS Rate,15.37,360,,,Fee schedule,360% of BCBS PPO Rate,15.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,22.34,60,,17.872,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,,Fee Schedule,100% of TX Mediciad 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,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,27.93,75,,1444.504,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,,Fee Schedule,90% of UHC fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,100,,1926,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,37.24,
FENTANYL W/METABOLITE CONFIRMATION,70010032,CDM,301,RC,80354,HCPCS,Outpatient,,,1236.24,741.74,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.74,60,,593.392,Percent of Total Billed Charges,60% of Total Billed Charges,12.81,100,,,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,103,,,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,927.18,75,,58.504,Percent of Total Billed Charges,75% of Total Billed Charges,618.12,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,618.12,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,618.12,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,618.12,50,,494.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.81,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,1236.24,100,,78,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,1236.24,
ARGININE VASOPRESSIN HORMONE,70010033,CDM,301,RC,84588,HCPCS,Outpatient,,,126,75.60,,39.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,50.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,95.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,108.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,122.18,360,,,Fee Schedule,360% of BCBS POS Rate,122.18,360,,,Fee schedule,360% of BCBS PPO Rate,122.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,75.6,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,28.51,100,,,Fee Schedule,100% of TX Mediciad 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,30.54,90,,,Fee Schedule,90% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,44.12,130,,,Fee Schedule,130% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,29.37,103,,,Fee Schedule,103% of TX Medicaid Rate,34.95,103,,,Fee Schedule,103% of CMS OPPS Rate,34.95,103,,,Fee Schedule,103% of CMS OPPS Rate,94.5,75,,268.88,Percent of Total Billed Charges,75% of Total Billed Charges,57.69,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,57.69,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.69,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,57.69,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,50.91,150,,,Fee Schedule,150% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.5,90,,,Fee Schedule,90% of UHC fee schedule,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,28.51,100,,,Fee Schedule,100% of TX Medicaid Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,126,100,,358.504,Percent of Total Billed Charges,100% of Total Billed Charges,27.5,126,
PARANEOPLASTIC EVAL,70010034,CDM,301,RC,86255,HCPCS,Outpatient,,,144,86.40,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.4,60,,69.12,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,108,75,,790.968,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,144,100,,1054.624,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,144,
ANTIMULLERIAN HORMONE SERUM,70010035,CDM,301,RC,82166,HCPCS,Outpatient,,,873.72,524.23,,524.23,60,,419.384,Percent of Total Billed Charges,60% of Total Billed Charges,57.93,150,,,Fee Schedule ,150% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,108.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,139.03,360,,,Fee Schedule,360% of BCBS POS Rate,139.03,360,,,Fee schedule,360% of BCBS PPO Rate,139.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,524.23,60,,419.384,Percent of Total Billed Charges,60% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,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,34.75,90,,,Fee Schedule,90% of CMS OPPS Rate,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,130,,,Fee Schedule,130% of CMS OPPS Rate,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,125.99,14.42,,100.792,Percent of Total Billed Charges,14.42% of Total Billed Charges,39.77,103,,,Fee Schedule,103% of CMS OPPS Rate,39.77,103,,,Fee Schedule,103% of CMS OPPS Rate,655.29,75,,709.888,Percent of Total Billed Charges,75% of Total Billed Charges,436.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,436.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,436.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,57.93,150,,,Fee Schedule,150% of CMS OPPS Rate,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,436.86,50,,349.488,Percent of Total Billed Charges,50% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,122.32,14,,97.856,Percent of Total Billed Charges,14% of Total Billed Charges,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,873.72,100,,946.52,Percent of Total Billed Charges,100% of Total Billed Charges,34.75,873.72,
RSV (ADULT) BY IMMUNOASSAY,70010036,CDM,301,RC,87807,HCPCS,Outpatient,,,101.4,60.84,,15.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,47.16,360,,,Fee Schedule,360% of BCBS POS Rate,47.16,360,,,Fee schedule,360% of BCBS PPO Rate,47.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,60.84,60,,48.672,Percent of Total Billed Charges,60% of Total Billed Charges,11,100,,,Fee Schedule,100% of TX Mediciad Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,,Fee Schedule,90% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,130,,,Fee Schedule,130% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11.33,103,,,Fee Schedule,103% of TX Medicaid Rate,13.49,103,,,Fee Schedule,103% of CMS OPPS Rate,13.49,103,,,Fee Schedule,103% of CMS OPPS Rate,76.05,75,,198.816,Percent of Total Billed Charges,75% of Total Billed Charges,22.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.65,150,,,Fee Schedule,150% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10.61,90,,,Fee Schedule,90% of UHC fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,101.4,100,,265.088,Percent of Total Billed Charges,100% of Total Billed Charges,10.61,101.4,
ENCEPHALOPATHY AUTOIMM PARANEO,70010037,CDM,301,RC,86341,HCPCS,Outpatient,,,8856,5313.60,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,5313.6,60,,4250.88,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,6642,75,,527.736,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8856,100,,703.648,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,8856,
PROTEIN ELECTROPHORESIS 24 HR URINE,70010038,CDM,301,RC,82570,HCPCS,Outpatient,,,234.68,140.81,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,140.81,60,,112.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,176.01,75,,331.304,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,234.68,100,,441.736,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,234.68,
DRUG SCREEN PRESCRIPTION OTC,70010039,CDM,301,RC,80307,HCPCS,Outpatient,,,1629.04,977.42,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,977.42,60,,781.936,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,1221.78,75,,800.672,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1629.04,100,,1067.56,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,1629.04,
"ALBUMIN,CSF",70010040,CDM,301,RC,82042,HCPCS,Outpatient,,,782.4,469.44,,9.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,28.01,360,,,Fee Schedule,360% of BCBS POS Rate,28.01,360,,,Fee schedule,360% of BCBS PPO Rate,28.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,469.44,60,,375.552,Percent of Total Billed Charges,60% of Total Billed Charges,6.54,100,,,Fee Schedule,100% of TX Mediciad 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,7,90,,,Fee Schedule,90% of CMS OPPS Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,10.11,130,,,Fee Schedule,130% of CMS OPPS Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,103,,,Fee Schedule,103% of TX Medicaid Rate,8.01,103,,,Fee Schedule,103% of CMS OPPS Rate,8.01,103,,,Fee Schedule,103% of CMS OPPS Rate,586.8,75,,100.504,Percent of Total Billed Charges,75% of Total Billed Charges,13.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,11.67,150,,,Fee Schedule,150% of CMS OPPS Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,90,,,Fee Schedule,90% of UHC fee schedule,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,6.54,100,,,Fee Schedule,100% of TX Medicaid Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,782.4,100,,134,Percent of Total Billed Charges,100% of Total Billed Charges,6.3,782.4,
"MOGF,SERUM",70010041,CDM,301,RC,86363,HCPCS,Outpatient,,,2310,1386.00,,1386,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,56.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,1386,60,,1108.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,33.95,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,49.04,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,1732.5,75,,127.832,Percent of Total Billed Charges,75% of Total Billed Charges,64.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,64.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,64.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,56.59,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1155,50,,924,Percent of Total Billed Charges,50% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2310,100,,170.44,Percent of Total Billed Charges,100% of Total Billed Charges,10.12,2310,
GANGLIOSIDE AB PANEL,70010042,CDM,301,RC,83516,HCPCS,Outpatient,,,540,324.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,324,60,,259.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,405,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,540,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,540,
"FUNGITELL, BAL",70010043,CDM,301,RC,87449,HCPCS,Outpatient,,,520,312.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,312,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,390,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,520,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,520,
VIRAL RAPID CULTURE W/REFLEX,70010044,CDM,301,RC,87254,HCPCS,Outpatient,,,1132,679.20,,22.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.34,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,54.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,70.42,360,,,Fee Schedule,360% of BCBS POS Rate,70.42,360,,,Fee schedule,360% of BCBS PPO Rate,70.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,679.2,60,,543.36,Percent of Total Billed Charges,60% of Total Billed Charges,16.43,100,,,Fee Schedule,100% of TX Mediciad 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,17.6,90,,,Fee Schedule,90% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,25.42,130,,,Fee Schedule,130% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.92,103,,,Fee Schedule,103% of TX Medicaid Rate,20.14,103,,,Fee Schedule,103% of CMS OPPS Rate,20.14,103,,,Fee Schedule,103% of CMS OPPS Rate,849,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,33.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.34,150,,,Fee Schedule,150% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,90,,,Fee Schedule,90% of UHC fee schedule,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1132,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,15.84,1132,
"PLA2R IMMUNOFLUO, SERUM",70010045,CDM,301,RC,86255,HCPCS,Outpatient,,,1125.6,675.36,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,675.36,60,,540.288,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,844.2,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1125.6,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,1125.6,
"CORTISOL, FREE SERUM",70010046,CDM,301,RC,82530,HCPCS,Outpatient,,,1218,730.80,,19.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.06,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,46.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,60.16,360,,,Fee Schedule,360% of BCBS POS Rate,60.16,360,,,Fee schedule,360% of BCBS PPO Rate,60.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,730.8,60,,584.64,Percent of Total Billed Charges,60% of Total Billed Charges,14.04,100,,,Fee Schedule,100% of TX Mediciad 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,15.03,90,,,Fee Schedule,90% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,21.72,130,,,Fee Schedule,130% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,103,,,Fee Schedule,103% of TX Medicaid Rate,17.21,103,,,Fee Schedule,103% of CMS OPPS Rate,17.21,103,,,Fee Schedule,103% of CMS OPPS Rate,913.5,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,28.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.06,150,,,Fee Schedule,150% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,90,,,Fee Schedule,90% of UHC fee schedule,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1218,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,13.54,1218,
TISSUE TRANSGIT AB,70010047,CDM,301,RC,86364,HCPCS,Outpatient,,,108,64.80,,64.8,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.8,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,81,75,,150,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,54,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,108,100,,200,Percent of Total Billed Charges,100% of Total Billed Charges,9.69,108,
ACTIVATED PROTEIN C RESISTANCE,70010048,CDM,301,RC,85307,HCPCS,Outpatient,,,121.4,72.84,,17.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,42.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,55.15,360,,,Fee Schedule,360% of BCBS POS Rate,55.15,360,,,Fee schedule,360% of BCBS PPO Rate,55.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.84,60,,58.272,Percent of Total Billed Charges,60% of Total Billed Charges,12.87,100,,,Fee Schedule,100% of TX Mediciad 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,13.78,90,,,Fee Schedule,90% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of TX Medicaid Rate,15.77,103,,,Fee Schedule,103% of CMS OPPS Rate,15.77,103,,,Fee Schedule,103% of CMS OPPS Rate,91.05,75,,101.144,Percent of Total Billed Charges,75% of Total Billed Charges,26.04,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.04,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.04,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.98,150,,,Fee Schedule,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,90,,,Fee Schedule,90% of UHC fee schedule,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,121.4,100,,134.856,Percent of Total Billed Charges,100% of Total Billed Charges,12.41,121.4,
LYME DISEASE CSF-PCR,70010049,CDM,301,RC,87798,HCPCS,Outpatient,,,2786.4,1671.84,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1671.84,60,,1337.472,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2089.8,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.4,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,2786.4,
RIBOSOME P ANTIBODIES  IGG SERUM,70010050,CDM,301,RC,83516,HCPCS,Outpatient,,,912.8,547.68,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,547.68,60,,438.144,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,684.6,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,912.8,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,912.8,
PDGFRA GENE,70000001,CDM,310,RC,81314,HCPCS,Outpatient,,,1318.04,790.82,,382.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,922.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1054.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,1186.24,360,,,Fee Schedule,360% of BCBS POS Rate,1186.24,360,,,Fee schedule,360% of BCBS PPO Rate,1186.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,790.82,60,,632.656,Percent of Total Billed Charges,60% of Total Billed Charges,276.79,100,,,Fee Schedule,100% of TX Mediciad 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,296.55,90,,,Fee Schedule,90% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,428.36,130,,,Fee Schedule,130% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,285.09,103,,,Fee Schedule,103% of TX Medicaid Rate,339.39,103,,,Fee Schedule,103% of CMS OPPS Rate,339.39,103,,,Fee Schedule,103% of CMS OPPS Rate,988.53,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,560.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,560.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,560.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,560.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,494.26,150,,,Fee Schedule,150% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,266.9,90,,,Fee Schedule,90% of UHC fee schedule,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.04,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,266.9,1318.04,
INFLUENZA  A & B RT PCR,70000002,CDM,306,RC,87637,HCPCS,Outpatient,,,484,290.40,,285.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,513.47,360,,,Fee Schedule,360% of BCBS POS Rate,513.47,360,,,Fee schedule,360% of BCBS PPO Rate,513.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,290.4,60,,232.32,Percent of Total Billed Charges,60% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,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,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,69.79,14.42,,55.832,Percent of Total Billed Charges,14.42% of Total Billed Charges,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,363,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.51,90,,,Fee Schedule,90% of UHC fee schedule,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,67.76,14,,54.208,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,484,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,67.76,513.47,
THYROGLOBULIN FNA,70000003,CDM,301,RC,84432,HCPCS,Outpatient,,,150.16,90.10,,18.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,44.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,57.82,360,,,Fee Schedule,360% of BCBS POS Rate,57.82,360,,,Fee schedule,360% of BCBS PPO Rate,57.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,90.1,60,,72.08,Percent of Total Billed Charges,60% of Total Billed Charges,13.49,100,,,Fee Schedule,100% of TX Mediciad 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,14.45,90,,,Fee Schedule,90% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.87,130,,,Fee Schedule,130% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.89,103,,,Fee Schedule,103% of TX Medicaid Rate,16.54,103,,,Fee Schedule,103% of CMS OPPS Rate,16.54,103,,,Fee Schedule,103% of CMS OPPS Rate,112.62,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,27.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.09,150,,,Fee Schedule,150% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,150.16,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,150.16,
PARATHYROID INTACT FNA,70000004,CDM,301,RC,83970,HCPCS,Outpatient,,,385.84,231.50,,47.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.92,150,,,Fee Schedule ,150% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,132.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,148.61,360,,,Fee Schedule,360% of BCBS POS Rate,148.61,360,,,Fee schedule,360% of BCBS PPO Rate,148.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,231.5,60,,185.2,Percent of Total Billed Charges,60% of Total Billed Charges,34.68,100,,,Fee Schedule,100% of TX Mediciad 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,37.15,90,,,Fee Schedule,90% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,53.66,130,,,Fee Schedule,130% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.72,103,,,Fee Schedule,103% of TX Medicaid Rate,42.51,103,,,Fee Schedule,103% of CMS OPPS Rate,42.51,103,,,Fee Schedule,103% of CMS OPPS Rate,289.38,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,70.17,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,70.17,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,70.17,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,70.17,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.92,150,,,Fee Schedule,150% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,33.44,90,,,Fee Schedule,90% of UHC fee schedule,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,385.84,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,33.44,385.84,
LEUKEMIA LYMPHOMA PANEL,70000005,CDM,306,RC,88185,HCPCS,Outpatient,,,7486.72,4492.03,,27.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,89.53,360,,,Fee Schedule,360% of BCBS POS Rate,89.53,360,,,Fee schedule,360% of BCBS PPO Rate,89.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,4492.03,60,,3593.624,Percent of Total Billed Charges,60% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1079.59,14.42,,863.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5615.04,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,3743.36,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,3743.36,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3743.36,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,3743.36,50,,2994.688,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.13,90,,,Fee Schedule,90% of UHC fee schedule,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,1048.14,14,,838.512,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7486.72,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,18.13,7486.72,
LAMOTRIGINE (LAMICTAL) LEVEL,70000385,CDM,301,RC,80175,HCPCS,Outpatient,,,164.98,98.99,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.99,60,,79.192,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,123.74,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,164.98,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,164.98,
FLUORESCENT ANTIBODY SCRN,70000386,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
CEBPA GENE FULL SEQUENCE,70000808,CDM,310,RC,81218,HCPCS,Outpatient,,,659.02,395.41,,280.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,362.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,677.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,774.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,870.84,360,,,Fee Schedule,360% of BCBS POS Rate,870.84,360,,,Fee schedule,360% of BCBS PPO Rate,870.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,395.41,60,,316.328,Percent of Total Billed Charges,60% of Total Billed Charges,203.2,100,,,Fee Schedule,100% of TX Mediciad Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.71,90,,,Fee Schedule,90% of CMS OPPS Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,314.47,130,,,Fee Schedule,130% of CMS OPPS Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,209.3,103,,,Fee Schedule,103% of TX Medicaid Rate,249.15,103,,,Fee Schedule,103% of CMS OPPS Rate,249.15,103,,,Fee Schedule,103% of CMS OPPS Rate,494.27,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,411.23,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,411.23,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,411.23,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,411.23,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,362.85,150,,,Fee Schedule,150% of CMS OPPS Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,195.94,90,,,Fee Schedule,90% of UHC fee schedule,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,203.2,100,,,Fee Schedule,100% of TX Medicaid Rate,241.9,100,,,Fee Schedule,100% of CMS OPPS Rate,659.02,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,195.94,870.84,
FLT3 GENE ANALYSIS,70000809,CDM,310,RC,81246,HCPCS,Outpatient,,,166.08,99.65,,96.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,124.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,232.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,265.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,298.8,360,,,Fee Schedule,360% of BCBS POS Rate,298.8,360,,,Fee schedule,360% of BCBS PPO Rate,298.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,99.65,60,,79.72,Percent of Total Billed Charges,60% of Total Billed Charges,69.72,100,,,Fee Schedule,100% of TX Mediciad Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,Fee Schedule,90% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,107.9,130,,,Fee Schedule,130% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,71.81,103,,,Fee Schedule,103% of TX Medicaid Rate,85.49,103,,,Fee Schedule,103% of CMS OPPS Rate,85.49,103,,,Fee Schedule,103% of CMS OPPS Rate,124.56,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,141.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,141.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,141.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,141.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,124.5,150,,,Fee Schedule,150% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,Fee Schedule,90% of UHC fee schedule,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,69.72,100,,,Fee Schedule,100% of TX Medicaid Rate,83,100,,,Fee Schedule,100% of CMS OPPS Rate,166.08,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,67.23,298.8,
SKIN FUNGI CULTURE,70001059,CDM,306,RC,87101,HCPCS,Outpatient,,,148.39,89.03,,8.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,21.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,27.76,360,,,Fee Schedule,360% of BCBS POS Rate,27.76,360,,,Fee schedule,360% of BCBS PPO Rate,27.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,89.03,60,,71.224,Percent of Total Billed Charges,60% of Total Billed Charges,6.48,100,,,Fee Schedule,100% of TX Mediciad 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,6.93,90,,,Fee Schedule,90% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10.02,130,,,Fee Schedule,130% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.67,103,,,Fee Schedule,103% of TX Medicaid Rate,7.94,103,,,Fee Schedule,103% of CMS OPPS Rate,7.94,103,,,Fee Schedule,103% of CMS OPPS Rate,111.29,75,,112.504,Percent of Total Billed Charges,75% of Total Billed Charges,13.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,11.56,150,,,Fee Schedule,150% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,90,,,Fee Schedule,90% of UHC fee schedule,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,6.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,148.39,100,,150,Percent of Total Billed Charges,100% of Total Billed Charges,6.25,148.39,
COLD AGGLUTININ TITER,70001060,CDM,302,RC,86157,HCPCS,Outpatient,,,97.65,58.59,,9.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,22.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,29.02,360,,,Fee Schedule,360% of BCBS POS Rate,29.02,360,,,Fee schedule,360% of BCBS PPO Rate,29.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,58.59,60,,46.872,Percent of Total Billed Charges,60% of Total Billed Charges,6.77,100,,,Fee Schedule,100% of TX Mediciad 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,7.25,90,,,Fee Schedule,90% of CMS OPPS Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,130,,,Fee Schedule,130% of CMS OPPS Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.97,103,,,Fee Schedule,103% of TX Medicaid Rate,8.3,103,,,Fee Schedule,103% of CMS OPPS Rate,8.3,103,,,Fee Schedule,103% of CMS OPPS Rate,73.24,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,13.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,13.7,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.7,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.09,150,,,Fee Schedule,150% of CMS OPPS Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,90,,,Fee Schedule,90% of UHC fee schedule,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,6.77,100,,,Fee Schedule,100% of TX Medicaid Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,97.65,
HIV ANTIGEN W/HIV ANTIBODIES,70001109,CDM,300,RC,87806,HCPCS,Outpatient,,,291.92,175.15,,38.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,49.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,91.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,104.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,117.97,360,,,Fee Schedule,360% of BCBS POS Rate,117.97,360,,,Fee schedule,360% of BCBS PPO Rate,117.97,360,,,Fee Schedule,360% of BCBS Traditional Rate,175.15,60,,140.12,Percent of Total Billed Charges,60% of Total Billed Charges,27.53,100,,,Fee Schedule,100% of TX Mediciad 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,29.49,90,,,Fee Schedule,90% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,42.6,130,,,Fee Schedule,130% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,28.36,103,,,Fee Schedule,103% of TX Medicaid Rate,33.75,103,,,Fee Schedule,103% of CMS OPPS Rate,33.75,103,,,Fee Schedule,103% of CMS OPPS Rate,218.94,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,55.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,55.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,55.7,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,55.7,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,49.15,150,,,Fee Schedule,150% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,26.54,90,,,Fee Schedule,90% of UHC fee schedule,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,27.53,100,,,Fee Schedule,100% of TX Medicaid Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.92,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,26.54,291.92,
DRUG SCREEN MECON MULTI CLASS,70001110,CDM,301,RC,80307,HCPCS,Outpatient,,,332.51,199.51,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,199.51,60,,159.608,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,249.38,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,332.51,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,332.51,
NUC ACID VARICELLA ZOSTER BLD,70001113,CDM,306,RC,87798,HCPCS,Outpatient,,,515.55,309.33,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,309.33,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,386.66,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,515.55,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,515.55,
ADENOVIRUS QUANT BY PCR,70001114,CDM,306,RC,87799,HCPCS,Outpatient,,,515.55,309.33,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,309.33,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,386.66,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,515.55,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,515.55,
HLA CLASS I HIGH DEFIN QUAL,70001115,CDM,302,RC,86832,HCPCS,Outpatient,,,650,390.00,,375.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,485.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,906.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1036,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,1165.5,360,,,Fee Schedule,360% of BCBS POS Rate,1165.5,360,,,Fee schedule,360% of BCBS PPO Rate,1165.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,390,60,,312,Percent of Total Billed Charges,60% of Total Billed Charges,271.95,100,,,Fee Schedule,100% of TX Mediciad Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,291.37,90,,,Fee Schedule,90% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,420.87,130,,,Fee Schedule,130% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,280.11,103,,,Fee Schedule,103% of TX Medicaid Rate,333.46,103,,,Fee Schedule,103% of CMS OPPS Rate,333.46,103,,,Fee Schedule,103% of CMS OPPS Rate,487.5,75,,375,Percent of Total Billed Charges,75% of Total Billed Charges,550.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,550.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,550.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,550.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,485.62,150,,,Fee Schedule,150% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,262.24,90,,,Fee Schedule,90% of UHC fee schedule,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,271.95,100,,,Fee Schedule,100% of TX Medicaid Rate,323.75,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,500,Percent of Total Billed Charges,100% of Total Billed Charges,262.24,1165.5,
HLA CLASS II HIGH DEFIN QUAL,70001116,CDM,302,RC,86833,HCPCS,Outpatient,,,650,390.00,,377.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,488.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,912.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1042.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,1172.88,360,,,Fee Schedule,360% of BCBS POS Rate,1172.88,360,,,Fee schedule,360% of BCBS PPO Rate,1172.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,390,60,,312,Percent of Total Billed Charges,60% of Total Billed Charges,273.67,100,,,Fee Schedule,100% of TX Mediciad Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,293.22,90,,,Fee Schedule,90% of CMS OPPS Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,423.54,130,,,Fee Schedule,130% of CMS OPPS Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,281.88,103,,,Fee Schedule,103% of TX Medicaid Rate,335.57,103,,,Fee Schedule,103% of CMS OPPS Rate,335.57,103,,,Fee Schedule,103% of CMS OPPS Rate,487.5,75,,931.352,Percent of Total Billed Charges,75% of Total Billed Charges,553.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,553.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,553.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,553.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,488.7,150,,,Fee Schedule,150% of CMS OPPS Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,263.9,90,,,Fee Schedule,90% of UHC fee schedule,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,273.67,100,,,Fee Schedule,100% of TX Medicaid Rate,325.8,100,,,Fee Schedule,100% of CMS OPPS Rate,650,100,,1241.8,Percent of Total Billed Charges,100% of Total Billed Charges,263.9,1172.88,
MUMPS BY PCR,70001117,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,440,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NMO/AQP4 FACS TITER CSF,70001118,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,163.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,218,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
NMO/AQP4 FACS TITER S,70001119,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,93.752,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,125,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
SMEAR GRAM/GIEMSA STAIN,70001120,CDM,306,RC,87205,HCPCS,Outpatient,,,101,60.60,,4.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,,Fee Schedule,360% of BCBS POS Rate,15.37,360,,,Fee schedule,360% of BCBS PPO Rate,15.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,60.6,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,,Fee Schedule,100% of TX Mediciad 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,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,75.75,75,,93.752,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,,Fee Schedule,90% of UHC fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,101,100,,125,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,101,
H PYLORI AG IA,70001121,CDM,306,RC,87339,HCPCS,Outpatient,,,171,102.60,,18.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,24,150,,,Fee Schedule ,150% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of CMS OPPS Rate,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,44.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,57.6,360,,,Fee Schedule,360% of BCBS POS Rate,57.6,360,,,Fee schedule,360% of BCBS PPO Rate,57.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.6,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.4,90,,,Fee Schedule,90% of CMS OPPS Rate,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.8,130,,,Fee Schedule,130% of CMS OPPS Rate,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,24.66,14.42,,19.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,16.48,103,,,Fee Schedule,103% of CMS OPPS Rate,16.48,103,,,Fee Schedule,103% of CMS OPPS Rate,128.25,75,,675,Percent of Total Billed Charges,75% of Total Billed Charges,27.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,27.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24,150,,,Fee Schedule,150% of CMS OPPS Rate,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.96,90,,,Fee Schedule,90% of UHC fee schedule,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,23.94,14,,19.152,Percent of Total Billed Charges,14% of Total Billed Charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,171,100,,900,Percent of Total Billed Charges,100% of Total Billed Charges,12.96,171,
PORPHYRINS FRACTIONATED REFLEX,70001123,CDM,301,RC,82542,HCPCS,Outpatient,,,215,129.00,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,129,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,161.25,75,,675,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215,100,,900,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,215,
FISH PER SPEC EA MULTI STAIN,70001124,CDM,311,RC,88366,HCPCS,Outpatient,,,109.6,65.76,,274.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,65.76,60,,52.608,Percent of Total Billed Charges,60% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.8,14.42,,12.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,82.2,75,,2011.2,Percent of Total Billed Charges,75% of Total Billed Charges,54.8,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,54.8,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,54.8,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,54.8,50,,43.84,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,15.34,14,,12.272,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,109.6,100,,2681.6,Percent of Total Billed Charges,100% of Total Billed Charges,15.34,1020.28,
CHEMILUMINESCENT ASSAY,70001125,CDM,301,RC,82397,HCPCS,Outpatient,,,182,109.20,,16.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,50.83,360,,,Fee Schedule,360% of BCBS POS Rate,50.83,360,,,Fee schedule,360% of BCBS PPO Rate,50.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.2,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,11.86,100,,,Fee Schedule,100% of TX Mediciad 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,12.7,90,,,Fee Schedule,90% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,18.35,130,,,Fee Schedule,130% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,103,,,Fee Schedule,103% of TX Medicaid Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,136.5,75,,30.088,Percent of Total Billed Charges,75% of Total Billed Charges,24,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,24,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.18,150,,,Fee Schedule,150% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.44,90,,,Fee Schedule,90% of UHC fee schedule,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,40.12,Percent of Total Billed Charges,100% of Total Billed Charges,11.44,182,
QUANTITATIVE ASSAY DRUG NOS,70001126,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,993,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,1324,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
CARNITINE QT EA SPEC,70001127,CDM,301,RC,82379,HCPCS,Outpatient,,,230.08,138.05,,19.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,47.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,60.73,360,,,Fee Schedule,360% of BCBS POS Rate,60.73,360,,,Fee schedule,360% of BCBS PPO Rate,60.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,138.05,60,,110.44,Percent of Total Billed Charges,60% of Total Billed Charges,14.17,100,,,Fee Schedule,100% of TX Mediciad 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,15.18,90,,,Fee Schedule,90% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,130,,,Fee Schedule,130% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,103,,,Fee Schedule,103% of TX Medicaid Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,172.56,75,,93,Percent of Total Billed Charges,75% of Total Billed Charges,28.67,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.67,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.67,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.67,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.3,150,,,Fee Schedule,150% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,90,,,Fee Schedule,90% of UHC fee schedule,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,230.08,100,,124,Percent of Total Billed Charges,100% of Total Billed Charges,13.66,230.08,
CX CATHETER TIP,70001128,CDM,306,RC,87071,HCPCS,Outpatient,,,219.41,131.65,,11.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,27.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,360,,,Fee Schedule,360% of BCBS POS Rate,35.6,360,,,Fee schedule,360% of BCBS PPO Rate,35.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.65,60,,105.32,Percent of Total Billed Charges,60% of Total Billed Charges,8.31,100,,,Fee Schedule,100% of TX Mediciad 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,8.9,90,,,Fee Schedule,90% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,130,,,Fee Schedule,130% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.56,103,,,Fee Schedule,103% of TX Medicaid Rate,10.18,103,,,Fee Schedule,103% of CMS OPPS Rate,10.18,103,,,Fee Schedule,103% of CMS OPPS Rate,164.56,75,,308.16,Percent of Total Billed Charges,75% of Total Billed Charges,16.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.83,150,,,Fee Schedule,150% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.01,90,,,Fee Schedule,90% of UHC fee schedule,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,219.41,100,,410.88,Percent of Total Billed Charges,100% of Total Billed Charges,8.01,219.41,
AG CRYPTOCOCCAL,70001129,CDM,302,RC,86403,HCPCS,Outpatient,,,172.06,103.24,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,32.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.54,360,,,Fee Schedule,360% of BCBS POS Rate,41.54,360,,,Fee schedule,360% of BCBS PPO Rate,41.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.24,60,,82.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.38,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,15,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.88,103,,,Fee Schedule,103% of CMS OPPS Rate,11.88,103,,,Fee Schedule,103% of CMS OPPS Rate,129.05,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,19.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.61,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.3,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,172.06,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.35,172.06,
MICRODISSECTION MANUAL,70001130,CDM,310,RC,88381,HCPCS,Outpatient,,,448.78,269.27,,213.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,416.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,468.36,360,,,Fee Schedule,360% of BCBS POS Rate,468.36,360,,,Fee schedule,360% of BCBS PPO Rate,468.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,269.27,60,,215.416,Percent of Total Billed Charges,60% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,64.71,14.42,,51.768,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336.59,75,,165,Percent of Total Billed Charges,75% of Total Billed Charges,224.39,50,,179.512,Percent of Total Billed Charges,50% of Total Billed Charges,224.39,50,,179.512,Percent of Total Billed Charges,50% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,224.39,50,,179.512,Percent of Total Billed Charges,50% of Total Billed Charges,224.39,50,,179.512,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.16,90,,,Fee Schedule,90% of UHC fee schedule,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,62.83,14,,50.264,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,448.78,100,,220,Percent of Total Billed Charges,100% of Total Billed Charges,62.83,468.36,
ENZYME CELL ACTIVITY,70001133,CDM,301,RC,82657,HCPCS,Outpatient,,,229.97,137.98,,25.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,79.81,360,,,Fee Schedule,360% of BCBS POS Rate,79.81,360,,,Fee schedule,360% of BCBS PPO Rate,79.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,137.98,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,100,,,Fee Schedule,100% of TX Mediciad 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,19.95,90,,,Fee Schedule,90% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,28.82,130,,,Fee Schedule,130% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,19.18,103,,,Fee Schedule,103% of TX Medicaid Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,172.48,75,,294,Percent of Total Billed Charges,75% of Total Billed Charges,37.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,37.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,33.25,150,,,Fee Schedule,150% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,90,,,Fee Schedule,90% of UHC fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,229.97,100,,392,Percent of Total Billed Charges,100% of Total Billed Charges,17.96,229.97,
GEENIUS HIV 1 & 2 SUPPL ASSAY,70001135,CDM,306,RC,87389,HCPCS,Outpatient,,,203.21,121.93,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,67.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,86.69,360,,,Fee Schedule,360% of BCBS POS Rate,86.69,360,,,Fee schedule,360% of BCBS PPO Rate,86.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,121.93,60,,97.544,Percent of Total Billed Charges,60% of Total Billed Charges,20.23,100,,,Fee Schedule,100% of TX Mediciad 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,21.67,90,,,Fee Schedule,90% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.3,130,,,Fee Schedule,130% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.84,103,,,Fee Schedule,103% of TX Medicaid Rate,24.8,103,,,Fee Schedule,103% of CMS OPPS Rate,24.8,103,,,Fee Schedule,103% of CMS OPPS Rate,152.41,75,,103.408,Percent of Total Billed Charges,75% of Total Billed Charges,40.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.11,150,,,Fee Schedule,150% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,90,,,Fee Schedule,90% of UHC fee schedule,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,203.21,100,,137.88,Percent of Total Billed Charges,100% of Total Billed Charges,19.5,203.21,
FIBRINOLYSINS TEG 1ST CUP,70001136,CDM,305,RC,85390,HCPCS,Outpatient,,,211.11,126.67,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,55.73,360,,,Fee Schedule,360% of BCBS POS Rate,55.73,360,,,Fee schedule,360% of BCBS PPO Rate,55.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,126.67,60,,101.336,Percent of Total Billed Charges,60% of Total Billed Charges,13,100,,,Fee Schedule,100% of TX Mediciad 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,13.93,90,,,Fee Schedule,90% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.12,130,,,Fee Schedule,130% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.39,103,,,Fee Schedule,103% of TX Medicaid Rate,15.94,103,,,Fee Schedule,103% of CMS OPPS Rate,15.94,103,,,Fee Schedule,103% of CMS OPPS Rate,158.33,75,,159.472,Percent of Total Billed Charges,75% of Total Billed Charges,26.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,26.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.22,150,,,Fee Schedule,150% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,90,,,Fee Schedule,90% of UHC fee schedule,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,211.11,100,,212.624,Percent of Total Billed Charges,100% of Total Billed Charges,12.54,211.11,
FIBRINOGEN ACTIVITY TEG PLT MA,70001137,CDM,305,RC,85384,HCPCS,Outpatient,,,171.15,102.69,,11.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,34.99,360,,,Fee Schedule,360% of BCBS POS Rate,34.99,360,,,Fee schedule,360% of BCBS PPO Rate,34.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.69,60,,82.152,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,100,,,Fee Schedule,100% of TX Mediciad 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,8.74,90,,,Fee Schedule,90% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,130,,,Fee Schedule,130% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.4,103,,,Fee Schedule,103% of TX Medicaid Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,128.36,75,,109.2,Percent of Total Billed Charges,75% of Total Billed Charges,16.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,16.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.58,150,,,Fee Schedule,150% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,7.88,90,,,Fee Schedule,90% of UHC fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,100,,145.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.88,171.15,
FIBRINOGEN ACTIVITY TEG 1ST CU,70001138,CDM,305,RC,85384,HCPCS,Outpatient,,,171.15,102.69,,11.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,34.99,360,,,Fee Schedule,360% of BCBS POS Rate,34.99,360,,,Fee schedule,360% of BCBS PPO Rate,34.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.69,60,,82.152,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,100,,,Fee Schedule,100% of TX Mediciad 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,8.74,90,,,Fee Schedule,90% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,130,,,Fee Schedule,130% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.4,103,,,Fee Schedule,103% of TX Medicaid Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,10.01,103,,,Fee Schedule,103% of CMS OPPS Rate,128.36,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,16.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,16.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.58,150,,,Fee Schedule,150% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,7.88,90,,,Fee Schedule,90% of UHC fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,7.88,171.15,
PLATELET AGG MA TEG 1ST CUP,70001139,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
BORDETELLA PERTUSSIS PCR,70001140,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
COMPLEMENT ANTIGEN EACH CMPNT,70001141,CDM,302,RC,86160,HCPCS,Outpatient,,,179,107.40,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,134.25,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,179,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,179,
EVAL AMNIOTIC FLUID PROTEIN,70001142,CDM,301,RC,84112,HCPCS,Outpatient,,,147.08,88.25,,113.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,147.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,274.71,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,313.95,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,353.2,360,,,Fee Schedule,360% of BCBS POS Rate,353.2,360,,,Fee schedule,360% of BCBS PPO Rate,353.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.25,60,,70.6,Percent of Total Billed Charges,60% of Total Billed Charges,82.41,100,,,Fee Schedule,100% of TX Mediciad 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,88.29,90,,,Fee Schedule,90% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,127.54,130,,,Fee Schedule,130% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,84.88,103,,,Fee Schedule,103% of TX Medicaid Rate,101.05,103,,,Fee Schedule,103% of CMS OPPS Rate,101.05,103,,,Fee Schedule,103% of CMS OPPS Rate,110.31,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,166.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,166.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,166.78,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,166.78,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,147.16,150,,,Fee Schedule,150% of CMS OPPS Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,79.47,90,,,Fee Schedule,90% of UHC fee schedule,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,82.41,100,,,Fee Schedule,100% of TX Medicaid Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,147.08,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,79.47,353.2,
RIA NONANTIBODY,70001143,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
ISLET CELL ANTIBODY,70001144,CDM,302,RC,86341,HCPCS,Outpatient,,,199,119.40,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.4,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,149.25,75,,82.4,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,199,100,,109.864,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,199,
DRUG TEST GEN TOX SERUM,70001145,CDM,301,RC,G0483,HCPCS,Outpatient,,,724,434.40,,143.21,100,,,Fee Schedule,100% of Aetna Fee Schedule,370.38,150,,,Fee Schedule ,150% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,691.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,790.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,888.91,360,,,Fee Schedule,360% of BCBS POS Rate,888.91,360,,,Fee schedule,360% of BCBS PPO Rate,888.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,434.4,60,,347.52,Percent of Total Billed Charges,60% of Total Billed Charges,207.41,100,,,Fee Schedule,100% of TX Mediciad 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,222.22,90,,,Fee Schedule,90% of CMS OPPS Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,320.99,130,,,Fee Schedule,130% of CMS OPPS Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,213.63,103,,,Fee Schedule,103% of TX Medicaid Rate,254.32,103,,,Fee Schedule,103% of CMS OPPS Rate,254.32,103,,,Fee Schedule,103% of CMS OPPS Rate,543,75,,160.8,Percent of Total Billed Charges,75% of Total Billed Charges,419.76,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,419.76,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,419.76,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,419.76,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,370.38,150,,,Fee Schedule,150% of CMS OPPS Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,200.01,90,,,Fee Schedule,90% of UHC fee schedule,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,207.41,100,,,Fee Schedule,100% of TX Medicaid Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,724,100,,214.4,Percent of Total Billed Charges,100% of Total Billed Charges,143.21,888.91,
MOPATH PROCEDURE LEVEL 1,70001146,CDM,310,RC,81400,HCPCS,Outpatient,,,537.78,322.67,,74.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,95.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,179.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,204.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,230.26,360,,,Fee Schedule,360% of BCBS POS Rate,230.26,360,,,Fee schedule,360% of BCBS PPO Rate,230.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,322.67,60,,258.136,Percent of Total Billed Charges,60% of Total Billed Charges,53.73,100,,,Fee Schedule,100% of TX Mediciad 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,57.56,90,,,Fee Schedule,90% of CMS OPPS Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,83.14,130,,,Fee Schedule,130% of CMS OPPS Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,55.34,103,,,Fee Schedule,103% of TX Medicaid Rate,65.87,103,,,Fee Schedule,103% of CMS OPPS Rate,65.87,103,,,Fee Schedule,103% of CMS OPPS Rate,403.34,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,108.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,108.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,108.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,108.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,95.94,150,,,Fee Schedule,150% of CMS OPPS Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,51.8,90,,,Fee Schedule,90% of UHC fee schedule,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,53.73,100,,,Fee Schedule,100% of TX Medicaid Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,537.78,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,51.8,537.78,
DRUG TEST DEF 1-7 CLASSES,70001147,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
APOLIPOPROTEIN LEVEL,70001148,CDM,301,RC,82172,HCPCS,Outpatient,,,130.53,78.32,,24.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,75.92,360,,,Fee Schedule,360% of BCBS POS Rate,75.92,360,,,Fee schedule,360% of BCBS PPO Rate,75.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.32,60,,62.656,Percent of Total Billed Charges,60% of Total Billed Charges,17.72,100,,,Fee Schedule,100% of TX Mediciad 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,18.98,90,,,Fee Schedule,90% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.41,130,,,Fee Schedule,130% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,18.25,103,,,Fee Schedule,103% of TX Medicaid Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,97.9,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,35.85,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.85,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.85,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.63,150,,,Fee Schedule,150% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.08,90,,,Fee Schedule,90% of UHC fee schedule,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,130.53,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,17.08,130.53,
IMMUNOASSAY TUMOR AG QT,70001149,CDM,302,RC,86316,HCPCS,Outpatient,,,223.5,134.10,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,134.1,60,,107.28,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,167.63,75,,185.272,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,223.5,100,,247.032,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,223.5,
HLA CLASS II PHENOTYPE QUAL,70001150,CDM,302,RC,86831,HCPCS,Outpatient,,,642.78,385.67,,94.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,122.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,229.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,262.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,294.77,360,,,Fee Schedule,360% of BCBS POS Rate,294.77,360,,,Fee schedule,360% of BCBS PPO Rate,294.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,385.67,60,,308.536,Percent of Total Billed Charges,60% of Total Billed Charges,68.78,100,,,Fee Schedule,100% of TX Mediciad Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,73.69,90,,,Fee Schedule,90% of CMS OPPS Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,106.44,130,,,Fee Schedule,130% of CMS OPPS Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,70.84,103,,,Fee Schedule,103% of TX Medicaid Rate,84.33,103,,,Fee Schedule,103% of CMS OPPS Rate,84.33,103,,,Fee Schedule,103% of CMS OPPS Rate,482.09,75,,50.584,Percent of Total Billed Charges,75% of Total Billed Charges,139.19,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,139.19,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,139.19,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,139.19,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,122.82,150,,,Fee Schedule,150% of CMS OPPS Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,66.32,90,,,Fee Schedule,90% of UHC fee schedule,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,68.78,100,,,Fee Schedule,100% of TX Medicaid Rate,81.88,100,,,Fee Schedule,100% of CMS OPPS Rate,642.78,100,,67.44,Percent of Total Billed Charges,100% of Total Billed Charges,66.32,642.78,
DETECT AGENT NOS DNA QUANT,70001151,CDM,306,RC,87799,HCPCS,Outpatient,,,515.55,309.33,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,309.33,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,386.66,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,515.55,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,515.55,
TARGETED GENOMIC SEQ ANALYSIS-MAYO,70001152,CDM,310,RC,81445,HCPCS,Outpatient,,,10400,6240.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,6240,60,,4992,Percent of Total Billed Charges,60% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1499.68,14.42,,1199.744,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,7800,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,1456,14,,1164.8,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,10400,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,484.31,10400,
HBA1/HBA2 GENE DUP/DEL VRNTS,70001153,CDM,310,RC,81269,HCPCS,Outpatient,,,1779.86,1067.92,,234.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,303.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,566.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,647.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,728.64,360,,,Fee Schedule,360% of BCBS POS Rate,728.64,360,,,Fee schedule,360% of BCBS PPO Rate,728.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,1067.92,60,,854.336,Percent of Total Billed Charges,60% of Total Billed Charges,170.02,100,,,Fee Schedule,100% of TX Mediciad 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,182.16,90,,,Fee Schedule,90% of CMS OPPS Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,263.12,130,,,Fee Schedule,130% of CMS OPPS Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,175.12,103,,,Fee Schedule,103% of TX Medicaid Rate,208.47,103,,,Fee Schedule,103% of CMS OPPS Rate,208.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1334.9,75,,140.248,Percent of Total Billed Charges,75% of Total Billed Charges,344.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,344.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,344.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,344.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,303.6,150,,,Fee Schedule,150% of CMS OPPS Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,90,,,Fee Schedule,90% of UHC fee schedule,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,170.02,100,,,Fee Schedule,100% of TX Medicaid Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1779.86,100,,186.992,Percent of Total Billed Charges,100% of Total Billed Charges,163.94,1779.86,
IDH1 COMMON VARIANTS,70001154,CDM,310,RC,81120,HCPCS,Outpatient,,,386.5,231.90,,224.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,289.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,541.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,618.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,695.7,360,,,Fee Schedule,360% of BCBS POS Rate,695.7,360,,,Fee schedule,360% of BCBS PPO Rate,695.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,231.9,60,,185.52,Percent of Total Billed Charges,60% of Total Billed Charges,162.33,100,,,Fee Schedule,100% of TX Mediciad 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,173.92,90,,,Fee Schedule,90% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,251.22,130,,,Fee Schedule,130% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,167.2,103,,,Fee Schedule,103% of TX Medicaid Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,289.88,75,,344.64,Percent of Total Billed Charges,75% of Total Billed Charges,328.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,328.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,328.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,328.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,289.87,150,,,Fee Schedule,150% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,156.54,90,,,Fee Schedule,90% of UHC fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,386.5,100,,459.52,Percent of Total Billed Charges,100% of Total Billed Charges,156.54,695.7,
IDH2 COMMON VARIANTS,70001155,CDM,310,RC,81121,HCPCS,Outpatient,,,591.58,354.95,,343.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,443.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,828.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,946.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,1064.84,360,,,Fee Schedule,360% of BCBS POS Rate,1064.84,360,,,Fee schedule,360% of BCBS PPO Rate,1064.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,354.95,60,,283.96,Percent of Total Billed Charges,60% of Total Billed Charges,248.46,100,,,Fee Schedule,100% of TX Mediciad 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,266.21,90,,,Fee Schedule,90% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,384.52,130,,,Fee Schedule,130% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,255.91,103,,,Fee Schedule,103% of TX Medicaid Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,443.69,75,,344.64,Percent of Total Billed Charges,75% of Total Billed Charges,502.84,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,502.84,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,502.84,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,502.84,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,443.68,150,,,Fee Schedule,150% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.59,90,,,Fee Schedule,90% of UHC fee schedule,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,591.58,100,,459.52,Percent of Total Billed Charges,100% of Total Billed Charges,239.59,1064.84,
ZIKA VIRUS IGM ANTIBODY,70001156,CDM,302,RC,86794,HCPCS,Outpatient,,,300,180.00,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,225,75,,344.64,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,459.52,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,300,
ZIKA VIRUS DNA/RNA AMP PROBE,70001157,CDM,306,RC,87662,HCPCS,Outpatient,,,126.7,76.02,,59.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,164.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,184.72,360,,,Fee Schedule,360% of BCBS POS Rate,184.72,360,,,Fee schedule,360% of BCBS PPO Rate,184.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.02,60,,60.816,Percent of Total Billed Charges,60% of Total Billed Charges,43.1,100,,,Fee Schedule,100% of TX Mediciad 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,46.17,90,,,Fee Schedule,90% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,66.7,130,,,Fee Schedule,130% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,44.39,103,,,Fee Schedule,103% of TX Medicaid Rate,52.84,103,,,Fee Schedule,103% of CMS OPPS Rate,52.84,103,,,Fee Schedule,103% of CMS OPPS Rate,95.03,75,,220.2,Percent of Total Billed Charges,75% of Total Billed Charges,87.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,87.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,87.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,87.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.96,150,,,Fee Schedule,150% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,41.56,90,,,Fee Schedule,90% of UHC fee schedule,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,126.7,100,,293.6,Percent of Total Billed Charges,100% of Total Billed Charges,41.56,184.72,
IFNL3 GENE ANALYSIS,70001158,CDM,310,RC,81283,HCPCS,Outpatient,,,150.88,90.53,,85.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,110.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,234.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,264.13,360,,,Fee Schedule,360% of BCBS POS Rate,264.13,360,,,Fee schedule,360% of BCBS PPO Rate,264.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,90.53,60,,72.424,Percent of Total Billed Charges,60% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,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,66.03,90,,,Fee Schedule,90% of CMS OPPS Rate,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,95.38,130,,,Fee Schedule,130% of CMS OPPS Rate,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.76,14.42,,17.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,75.57,103,,,Fee Schedule,103% of CMS OPPS Rate,75.57,103,,,Fee Schedule,103% of CMS OPPS Rate,113.16,75,,2446.344,Percent of Total Billed Charges,75% of Total Billed Charges,124.72,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,124.72,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,124.72,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,124.72,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,110.05,150,,,Fee Schedule,150% of CMS OPPS Rate,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.43,90,,,Fee Schedule,90% of UHC fee schedule,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,21.12,14,,16.896,Percent of Total Billed Charges,14% of Total Billed Charges,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,150.88,100,,3261.792,Percent of Total Billed Charges,100% of Total Billed Charges,21.12,264.13,
GAMMAGLOB IGG SUBCLASSES EA,70001159,CDM,301,RC,82787,HCPCS,Outpatient,,,147.48,88.49,,9.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.03,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,22.46,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,28.87,360,,,Fee Schedule,360% of BCBS POS Rate,28.87,360,,,Fee schedule,360% of BCBS PPO Rate,28.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.49,60,,70.792,Percent of Total Billed Charges,60% of Total Billed Charges,6.74,100,,,Fee Schedule,100% of TX Mediciad 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,7.21,90,,,Fee Schedule,90% of CMS OPPS Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,130,,,Fee Schedule,130% of CMS OPPS Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.94,103,,,Fee Schedule,103% of TX Medicaid Rate,8.26,103,,,Fee Schedule,103% of CMS OPPS Rate,8.26,103,,,Fee Schedule,103% of CMS OPPS Rate,110.61,75,,134.4,Percent of Total Billed Charges,75% of Total Billed Charges,13.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.03,150,,,Fee Schedule,150% of CMS OPPS Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,90,,,Fee Schedule,90% of UHC fee schedule,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,6.74,100,,,Fee Schedule,100% of TX Medicaid Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,147.48,100,,179.2,Percent of Total Billed Charges,100% of Total Billed Charges,6.5,147.48,
GAMMAGLOBULIN IGA/D/G/M EACH,70001160,CDM,301,RC,82784,HCPCS,Outpatient,,,147.33,88.40,,10.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,33.48,360,,,Fee Schedule,360% of BCBS POS Rate,33.48,360,,,Fee schedule,360% of BCBS PPO Rate,33.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.4,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of TX Mediciad 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,8.37,90,,,Fee Schedule,90% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,130,,,Fee Schedule,130% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,8.04,103,,,Fee Schedule,103% of TX Medicaid Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.5,75,,149.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.95,150,,,Fee Schedule,150% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,90,,,Fee Schedule,90% of UHC fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,147.33,100,,199.2,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,147.33,
CAMPYLOBACTER ANTIBODY,70001161,CDM,302,RC,86625,HCPCS,Outpatient,,,129.72,77.83,,15.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,36.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,47.23,360,,,Fee Schedule,360% of BCBS POS Rate,47.23,360,,,Fee schedule,360% of BCBS PPO Rate,47.23,360,,,Fee Schedule,360% of BCBS Traditional Rate,77.83,60,,62.264,Percent of Total Billed Charges,60% of Total Billed Charges,11.02,100,,,Fee Schedule,100% of TX Mediciad 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,11.8,90,,,Fee Schedule,90% of CMS OPPS Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,130,,,Fee Schedule,130% of CMS OPPS Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.35,103,,,Fee Schedule,103% of TX Medicaid Rate,13.51,103,,,Fee Schedule,103% of CMS OPPS Rate,13.51,103,,,Fee Schedule,103% of CMS OPPS Rate,97.29,75,,199.768,Percent of Total Billed Charges,75% of Total Billed Charges,22.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.67,150,,,Fee Schedule,150% of CMS OPPS Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.63,90,,,Fee Schedule,90% of UHC fee schedule,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,129.72,100,,266.36,Percent of Total Billed Charges,100% of Total Billed Charges,10.63,129.72,
COLLAGEN CROSSLINKS,70001162,CDM,301,RC,82523,HCPCS,Outpatient,,,199.58,119.75,,21.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,52.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,67.25,360,,,Fee Schedule,360% of BCBS POS Rate,67.25,360,,,Fee schedule,360% of BCBS PPO Rate,67.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.75,60,,95.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.69,100,,,Fee Schedule,100% of TX Mediciad 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,16.81,90,,,Fee Schedule,90% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.28,130,,,Fee Schedule,130% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,16.16,103,,,Fee Schedule,103% of TX Medicaid Rate,19.24,103,,,Fee Schedule,103% of CMS OPPS Rate,19.24,103,,,Fee Schedule,103% of CMS OPPS Rate,149.69,75,,81.576,Percent of Total Billed Charges,75% of Total Billed Charges,31.75,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.75,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.75,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.75,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,28.02,150,,,Fee Schedule,150% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.13,90,,,Fee Schedule,90% of UHC fee schedule,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,15.69,100,,,Fee Schedule,100% of TX Medicaid Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,199.58,100,,108.768,Percent of Total Billed Charges,100% of Total Billed Charges,15.13,199.58,
ASSAY OF INSULIN,70001163,CDM,301,RC,83527,HCPCS,Outpatient,,,131.64,78.98,,15.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,46.62,360,,,Fee Schedule,360% of BCBS POS Rate,46.62,360,,,Fee schedule,360% of BCBS PPO Rate,46.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.98,60,,63.184,Percent of Total Billed Charges,60% of Total Billed Charges,10.88,100,,,Fee Schedule,100% of TX Mediciad 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,11.65,90,,,Fee Schedule,90% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,16.83,130,,,Fee Schedule,130% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.21,103,,,Fee Schedule,103% of TX Medicaid Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,98.73,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,22.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,22.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.42,150,,,Fee Schedule,150% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,90,,,Fee Schedule,90% of UHC fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,131.64,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,10.49,131.64,
ASSAY OF PROCAINAMIDE,70001164,CDM,301,RC,80190,HCPCS,Outpatient,,,233.16,139.90,,69.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,90,150,,,Fee Schedule ,150% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,168,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,192,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,216,360,,,Fee Schedule,360% of BCBS POS Rate,216,360,,,Fee schedule,360% of BCBS PPO Rate,216,360,,,Fee Schedule,360% of BCBS Traditional Rate,139.9,60,,111.92,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,100,,,Fee Schedule,100% of TX Mediciad 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,54,90,,,Fee Schedule,90% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,78,130,,,Fee Schedule,130% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,51.91,103,,,Fee Schedule,103% of TX Medicaid Rate,61.8,103,,,Fee Schedule,103% of CMS OPPS Rate,61.8,103,,,Fee Schedule,103% of CMS OPPS Rate,174.87,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,102,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,102,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,102,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,102,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,90,150,,,Fee Schedule,150% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,Fee Schedule,90% of UHC fee schedule,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,50.4,100,,,Fee Schedule,100% of TX Medicaid Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,233.16,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,48.6,233.16,
AB JOHN CUNNINGHAM VIRUS,70001165,CDM,302,RC,86711,HCPCS,Outpatient,,,1720.31,1032.19,,19.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,47.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,60.8,360,,,Fee Schedule,360% of BCBS POS Rate,60.8,360,,,Fee schedule,360% of BCBS PPO Rate,60.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,1032.19,60,,825.752,Percent of Total Billed Charges,60% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,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,15.2,90,,,Fee Schedule,90% of CMS OPPS Rate,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,21.95,130,,,Fee Schedule,130% of CMS OPPS Rate,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,248.07,14.42,,198.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,17.39,103,,,Fee Schedule,103% of CMS OPPS Rate,17.39,103,,,Fee Schedule,103% of CMS OPPS Rate,1290.23,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,28.71,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.71,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,28.71,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.71,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.33,150,,,Fee Schedule,150% of CMS OPPS Rate,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,90,,,Fee Schedule,90% of UHC fee schedule,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,240.84,14,,192.672,Percent of Total Billed Charges,14% of Total Billed Charges,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1720.31,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,13.68,1720.31,
GAMMAGLOBULIN IGE,70001166,CDM,301,RC,82785,HCPCS,Outpatient,,,188,112.80,,19.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,46.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,52.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,59.26,360,,,Fee Schedule,360% of BCBS POS Rate,59.26,360,,,Fee schedule,360% of BCBS PPO Rate,59.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.8,60,,90.24,Percent of Total Billed Charges,60% of Total Billed Charges,13.83,100,,,Fee Schedule,100% of TX Mediciad 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,14.81,90,,,Fee Schedule,90% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,130,,,Fee Schedule,130% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.24,103,,,Fee Schedule,103% of TX Medicaid Rate,16.95,103,,,Fee Schedule,103% of CMS OPPS Rate,16.95,103,,,Fee Schedule,103% of CMS OPPS Rate,141,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,27.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,27.98,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.98,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.69,150,,,Fee Schedule,150% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,90,,,Fee Schedule,90% of UHC fee schedule,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,13.83,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,188,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,13.33,188,
SACCHAROMYCES CEREVISIAE IGA,70001167,CDM,302,RC,86671,HCPCS,Outpatient,,,139,83.40,,14.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,34.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,44.1,360,,,Fee Schedule,360% of BCBS POS Rate,44.1,360,,,Fee schedule,360% of BCBS PPO Rate,44.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.4,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.29,100,,,Fee Schedule,100% of TX Mediciad 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,11.02,90,,,Fee Schedule,90% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,130,,,Fee Schedule,130% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.6,103,,,Fee Schedule,103% of TX Medicaid Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,104.25,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,20.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.37,150,,,Fee Schedule,150% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,90,,,Fee Schedule,90% of UHC fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,139,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,9.93,139,
SACCHAROMYCES CEREVISIAE IGG,70001168,CDM,302,RC,86671,HCPCS,Outpatient,,,139,83.40,,14.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,34.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,44.1,360,,,Fee Schedule,360% of BCBS POS Rate,44.1,360,,,Fee schedule,360% of BCBS PPO Rate,44.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.4,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.29,100,,,Fee Schedule,100% of TX Mediciad 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,11.02,90,,,Fee Schedule,90% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,130,,,Fee Schedule,130% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.6,103,,,Fee Schedule,103% of TX Medicaid Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,104.25,75,,141,Percent of Total Billed Charges,75% of Total Billed Charges,20.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.37,150,,,Fee Schedule,150% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,90,,,Fee Schedule,90% of UHC fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,139,100,,188,Percent of Total Billed Charges,100% of Total Billed Charges,9.93,139,
CNS DNA AMP PROBE TYPE 12-25,70001169,CDM,306,RC,87483,HCPCS,Outpatient,,,1143.44,686.06,,483.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,625.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1333.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,1500.41,360,,,Fee Schedule,360% of BCBS POS Rate,1500.41,360,,,Fee schedule,360% of BCBS PPO Rate,1500.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,686.06,60,,548.848,Percent of Total Billed Charges,60% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,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,375.1,90,,,Fee Schedule,90% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,541.81,130,,,Fee Schedule,130% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,164.88,14.42,,131.904,Percent of Total Billed Charges,14.42% of Total Billed Charges,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,857.58,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,708.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,708.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,708.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,708.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,625.16,150,,,Fee Schedule,150% of CMS OPPS Rate,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,337.59,90,,,Fee Schedule,90% of UHC fee schedule,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,160.08,14,,128.064,Percent of Total Billed Charges,14% of Total Billed Charges,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.44,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,160.08,1500.41,
KIT GENE ANALYS D816 VARIANT,70001170,CDM,310,RC,81273,HCPCS,Outpatient,,,900,540.00,,144.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,187.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,349.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,399.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,449.53,360,,,Fee Schedule,360% of BCBS POS Rate,449.53,360,,,Fee schedule,360% of BCBS PPO Rate,449.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,540,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,104.89,100,,,Fee Schedule,100% of TX Mediciad 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,112.38,90,,,Fee Schedule,90% of CMS OPPS Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,130,,,Fee Schedule,130% of CMS OPPS Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,108.04,103,,,Fee Schedule,103% of TX Medicaid Rate,128.61,103,,,Fee Schedule,103% of CMS OPPS Rate,128.61,103,,,Fee Schedule,103% of CMS OPPS Rate,675,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,212.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,212.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,212.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,212.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,187.3,150,,,Fee Schedule,150% of CMS OPPS Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,101.14,90,,,Fee Schedule,90% of UHC fee schedule,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,104.89,100,,,Fee Schedule,100% of TX Medicaid Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,101.14,900,
IMMUNOASSAY ANTI GLOM BASE AB,70001171,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
ROTAVIRUS AG IA,70001172,CDM,306,RC,87425,HCPCS,Outpatient,,,211.83,127.10,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,127.1,60,,101.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,158.87,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.83,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,211.83,
GI PATHOGEN PANEL PCR FECES,70001173,CDM,301,RC,87507,HCPCS,Outpatient,,,1600,960.00,,483.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,625.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1333.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,1500.41,360,,,Fee Schedule,360% of BCBS POS Rate,1500.41,360,,,Fee schedule,360% of BCBS PPO Rate,1500.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,350.1,100,,,Fee Schedule,100% of TX Mediciad 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,375.1,90,,,Fee Schedule,90% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,541.81,130,,,Fee Schedule,130% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,360.6,103,,,Fee Schedule,103% of TX Medicaid Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1200,75,,95.464,Percent of Total Billed Charges,75% of Total Billed Charges,708.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,708.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,708.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,708.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,625.16,150,,,Fee Schedule,150% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,337.59,90,,,Fee Schedule,90% of UHC fee schedule,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,127.28,Percent of Total Billed Charges,100% of Total Billed Charges,337.59,1600,
AB ASPERGILLUS NIGER,70001174,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,107.472,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,143.296,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
CHROMOGRANIN A,70001175,CDM,302,RC,86316,HCPCS,Outpatient,,,223.5,134.10,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,134.1,60,,107.28,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,167.63,75,,107.472,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,223.5,100,,143.296,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,223.5,
ETHOSUXIMIDE,70001177,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,87.528,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,116.704,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
NOTCH3 DNA SEQUENCING,70001178,CDM,310,RC,81406,HCPCS,Outpatient,,,3779.73,2267.84,,328.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,424.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,792.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,905.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,1018.37,360,,,Fee Schedule,360% of BCBS POS Rate,1018.37,360,,,Fee schedule,360% of BCBS PPO Rate,1018.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,2267.84,60,,1814.272,Percent of Total Billed Charges,60% of Total Billed Charges,237.62,100,,,Fee Schedule,100% of TX Mediciad Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,254.59,90,,,Fee Schedule,90% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,367.74,130,,,Fee Schedule,130% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,244.75,103,,,Fee Schedule,103% of TX Medicaid Rate,291.36,103,,,Fee Schedule,103% of CMS OPPS Rate,291.36,103,,,Fee Schedule,103% of CMS OPPS Rate,2834.8,75,,919.56,Percent of Total Billed Charges,75% of Total Billed Charges,480.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,480.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,480.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,480.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,424.32,150,,,Fee Schedule,150% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,229.13,90,,,Fee Schedule,90% of UHC fee schedule,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,3779.73,100,,1226.08,Percent of Total Billed Charges,100% of Total Billed Charges,229.13,3779.73,
BACTERIUM ANTIBODY,70001179,CDM,302,RC,86609,HCPCS,Outpatient,,,93.49,56.09,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,56.09,60,,44.872,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,70.12,75,,812.256,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,93.49,100,,1083.008,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,93.49,
FACTOR XIII,70001180,CDM,305,RC,85290,HCPCS,Outpatient,,,222.9,133.74,,18.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,45.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,52.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,58.82,360,,,Fee Schedule,360% of BCBS POS Rate,58.82,360,,,Fee schedule,360% of BCBS PPO Rate,58.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.74,60,,106.992,Percent of Total Billed Charges,60% of Total Billed Charges,13.73,100,,,Fee Schedule,100% of TX Mediciad 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,14.7,90,,,Fee Schedule,90% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,21.24,130,,,Fee Schedule,130% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,103,,,Fee Schedule,103% of TX Medicaid Rate,16.83,103,,,Fee Schedule,103% of CMS OPPS Rate,16.83,103,,,Fee Schedule,103% of CMS OPPS Rate,167.18,75,,95.704,Percent of Total Billed Charges,75% of Total Billed Charges,27.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,27.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.51,150,,,Fee Schedule,150% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,90,,,Fee Schedule,90% of UHC fee schedule,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of TX Medicaid Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,222.9,100,,127.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.24,222.9,
LACOSAMIDE,70001181,CDM,301,RC,80235,HCPCS,Outpatient,,,500,300.00,,31.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,75.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,86.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,97.6,360,,,Fee Schedule,360% of BCBS POS Rate,97.6,360,,,Fee schedule,360% of BCBS PPO Rate,97.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,22.77,100,,,Fee Schedule,100% of TX Mediciad 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,24.39,90,,,Fee Schedule,90% of CMS OPPS Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,35.24,130,,,Fee Schedule,130% of CMS OPPS Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,23.45,103,,,Fee Schedule,103% of TX Medicaid Rate,27.92,103,,,Fee Schedule,103% of CMS OPPS Rate,27.92,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,46.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,46.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,46.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,46.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.66,150,,,Fee Schedule,150% of CMS OPPS Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,90,,,Fee Schedule,90% of UHC fee schedule,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.77,100,,,Fee Schedule,100% of TX Medicaid Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,100,Percent of Total Billed Charges,100% of Total Billed Charges,21.96,500,
PDL1 ANTIBODY,70001182,CDM,312,RC,88360,HCPCS,Outpatient,,,382,229.20,,98.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,229.2,60,,183.36,Percent of Total Billed Charges,60% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,55.08,14.42,,44.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,286.5,75,,162.6,Percent of Total Billed Charges,75% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,382,100,,216.8,Percent of Total Billed Charges,100% of Total Billed Charges,53.48,516.6,
CD68 STAIN,70001183,CDM,312,RC,88342,HCPCS,Outpatient,,,334.72,200.83,,84.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,200.83,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,48.27,14.42,,38.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,251.04,75,,162.6,Percent of Total Billed Charges,75% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334.72,100,,216.8,Percent of Total Billed Charges,100% of Total Billed Charges,46.86,516.6,
IN SITU HYBR JC VIRUS,70001184,CDM,312,RC,88365,HCPCS,Outpatient,,,563.87,338.32,,168.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,338.32,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,81.31,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,422.9,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,563.87,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,78.94,563.87,
HBB FULL GENE SEQUENCE,70001185,CDM,310,RC,81364,HCPCS,Outpatient,,,649.16,389.50,,376.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,486.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,908.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1038.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,1168.49,360,,,Fee Schedule,360% of BCBS POS Rate,1168.49,360,,,Fee schedule,360% of BCBS PPO Rate,1168.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,389.5,60,,311.6,Percent of Total Billed Charges,60% of Total Billed Charges,272.65,100,,,Fee Schedule,100% of TX Mediciad 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,292.12,90,,,Fee Schedule,90% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,421.95,130,,,Fee Schedule,130% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,280.83,103,,,Fee Schedule,103% of TX Medicaid Rate,334.31,103,,,Fee Schedule,103% of CMS OPPS Rate,334.31,103,,,Fee Schedule,103% of CMS OPPS Rate,486.87,75,,96.248,Percent of Total Billed Charges,75% of Total Billed Charges,551.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,551.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,551.78,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,551.78,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,486.87,150,,,Fee Schedule,150% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,262.91,90,,,Fee Schedule,90% of UHC fee schedule,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,649.16,100,,128.328,Percent of Total Billed Charges,100% of Total Billed Charges,262.91,1168.49,
DIURETIC SCREEN URINE,70001186,CDM,301,RC,G0481,HCPCS,Outpatient,,,420,252.00,,90.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,234.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,438.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,501.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,563.72,360,,,Fee Schedule,360% of BCBS POS Rate,563.72,360,,,Fee schedule,360% of BCBS PPO Rate,563.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,252,60,,201.6,Percent of Total Billed Charges,60% of Total Billed Charges,131.54,100,,,Fee Schedule,100% of TX Mediciad 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,140.93,90,,,Fee Schedule,90% of CMS OPPS Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,203.56,130,,,Fee Schedule,130% of CMS OPPS Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,135.49,103,,,Fee Schedule,103% of TX Medicaid Rate,161.28,103,,,Fee Schedule,103% of CMS OPPS Rate,161.28,103,,,Fee Schedule,103% of CMS OPPS Rate,315,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,266.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,266.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,266.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,266.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,234.88,150,,,Fee Schedule,150% of CMS OPPS Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,126.84,90,,,Fee Schedule,90% of UHC fee schedule,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,131.54,100,,,Fee Schedule,100% of TX Medicaid Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,420,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,90.82,563.72,
CENTROMERE ANTIBODIES IGG,70001187,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
ESTROGENS FRACTIONATED,70001188,CDM,301,RC,82671,HCPCS,Outpatient,,,1466.28,879.77,,37.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,48.45,150,,,Fee Schedule ,150% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,90.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,103.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,116.28,360,,,Fee Schedule,360% of BCBS POS Rate,116.28,360,,,Fee schedule,360% of BCBS PPO Rate,116.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,879.77,60,,703.816,Percent of Total Billed Charges,60% of Total Billed Charges,27.13,100,,,Fee Schedule,100% of TX Mediciad 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,29.06,90,,,Fee Schedule,90% of CMS OPPS Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,41.99,130,,,Fee Schedule,130% of CMS OPPS Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.94,103,,,Fee Schedule,103% of TX Medicaid Rate,33.26,103,,,Fee Schedule,103% of CMS OPPS Rate,33.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1099.71,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,54.9,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,54.9,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,54.9,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,48.45,150,,,Fee Schedule,150% of CMS OPPS Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,26.16,90,,,Fee Schedule,90% of UHC fee schedule,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,27.13,100,,,Fee Schedule,100% of TX Medicaid Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1466.28,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,26.16,1466.28,
HYPOGLYCEMIC AGENT SCREEN,70001189,CDM,301,RC,80307,HCPCS,Outpatient,,,243.17,145.90,,72.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,93.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,173.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,223.7,360,,,Fee Schedule,360% of BCBS POS Rate,223.7,360,,,Fee schedule,360% of BCBS PPO Rate,223.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,145.9,60,,116.72,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,100,,,Fee Schedule,100% of TX Mediciad 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,55.92,90,,,Fee Schedule,90% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,130,,,Fee Schedule,130% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,53.77,103,,,Fee Schedule,103% of TX Medicaid Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,64,103,,,Fee Schedule,103% of CMS OPPS Rate,182.38,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,105.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,105.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,93.21,150,,,Fee Schedule,150% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,90,,,Fee Schedule,90% of UHC fee schedule,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,52.2,100,,,Fee Schedule,100% of TX Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,243.17,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,50.34,243.17,
HYPERSENSITIV PNEUMONITIS,70001190,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,143.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,191.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
EOSINOPHILS URINE,70001191,CDM,300,RC,87205,HCPCS,Outpatient,,,101,60.60,,4.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,13.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,15.37,360,,,Fee Schedule,360% of BCBS POS Rate,15.37,360,,,Fee schedule,360% of BCBS PPO Rate,15.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,60.6,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,3.59,100,,,Fee Schedule,100% of TX Mediciad 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,3.84,90,,,Fee Schedule,90% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,5.55,130,,,Fee Schedule,130% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,103,,,Fee Schedule,103% of TX Medicaid Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4.39,103,,,Fee Schedule,103% of CMS OPPS Rate,75.75,75,,106.6,Percent of Total Billed Charges,75% of Total Billed Charges,7.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,7.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,6.4,150,,,Fee Schedule,150% of CMS OPPS Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.46,90,,,Fee Schedule,90% of UHC fee schedule,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,3.59,100,,,Fee Schedule,100% of TX Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,101,100,,142.136,Percent of Total Billed Charges,100% of Total Billed Charges,3.46,101,
ACE ANGIOTENSIN CONV ENZYME,70001192,CDM,301,RC,82164,HCPCS,Outpatient,,,207.93,124.76,,16.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,40.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,52.56,360,,,Fee Schedule,360% of BCBS POS Rate,52.56,360,,,Fee schedule,360% of BCBS PPO Rate,52.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,124.76,60,,99.808,Percent of Total Billed Charges,60% of Total Billed Charges,12.26,100,,,Fee Schedule,100% of TX Mediciad 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,13.14,90,,,Fee Schedule,90% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.98,130,,,Fee Schedule,130% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,103,,,Fee Schedule,103% of TX Medicaid Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,155.95,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,24.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,24.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.9,150,,,Fee Schedule,150% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.83,90,,,Fee Schedule,90% of UHC fee schedule,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,207.93,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,11.83,207.93,
AB ANTI MITOCHONDRIAL,70001193,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,131.792,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,175.72,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
REF STREPTOCOCCUS PNEOMONIA AG,70001194,CDM,306,RC,87450,HCPCS,Outpatient,,,67.48,40.49,,40.49,60,,32.392,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.89,28,,15.112,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,24.29,36,,19.432,Percent of Total Billed Charges,36% of Total Billed Charges,24.29,36,,19.432,Percent of Total Billed Charges,36% Total Bille Charges,24.29,36,,19.432,Percent of Total Billed Charges,36% of Total Billed Charges,40.49,60,,32.392,Percent of Total Billed Charges,60% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.73,14.42,,7.784,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.61,75,,112.2,Percent of Total Billed Charges,75% of Total Billed Charges,33.74,50,,26.992,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,50,,26.992,Percent of Total Billed Charges,50% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.74,50,,26.992,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,50,,26.992,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.74,50,,26.992,Percent of Total Billed Charges,50% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,9.45,14,,7.56,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.48,100,,149.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.45,312,
REF GROWTH DFFRNTN FACTOR 15,70001195,CDM,301,RC,83520,HCPCS,Outpatient,,,500,300.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,494,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,658.664,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,500,
REF FRAGILE X FLLW UP ANLYSIS,70001196,CDM,310,RC,81244,HCPCS,Outpatient,,,652.75,391.65,,52.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,67.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,125.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,143.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,161.6,360,,,Fee Schedule,360% of BCBS POS Rate,161.6,360,,,Fee schedule,360% of BCBS PPO Rate,161.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,391.65,60,,313.32,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,100,,,Fee Schedule,100% of TX Mediciad 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,40.4,90,,,Fee Schedule,90% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,58.35,130,,,Fee Schedule,130% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,38.84,103,,,Fee Schedule,103% of TX Medicaid Rate,46.23,103,,,Fee Schedule,103% of CMS OPPS Rate,46.23,103,,,Fee Schedule,103% of CMS OPPS Rate,489.56,75,,1236.344,Percent of Total Billed Charges,75% of Total Billed Charges,76.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,76.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,76.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,76.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,67.33,150,,,Fee Schedule,150% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,36.36,90,,,Fee Schedule,90% of UHC fee schedule,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,37.71,100,,,Fee Schedule,100% of TX Medicaid Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,652.75,100,,1648.456,Percent of Total Billed Charges,100% of Total Billed Charges,36.36,652.75,
REF CX E COLI 0157,70001197,CDM,306,RC,87081,HCPCS,Outpatient,,,359.1,215.46,,7.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,,Fee Schedule,360% of BCBS POS Rate,23.87,360,,,Fee schedule,360% of BCBS PPO Rate,23.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,215.46,60,,172.368,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of TX Mediciad 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,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,269.33,75,,437.424,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,,Fee Schedule,90% of UHC fee schedule,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,359.1,100,,583.232,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,359.1,
REF BILIARY TRACT MALIG FISH,70001198,CDM,312,RC,88377,HCPCS,Outpatient,,,3964,2378.40,,428.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,2378.4,60,,1902.72,Percent of Total Billed Charges,60% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,571.61,14.42,,457.288,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,2973,75,,346.296,Percent of Total Billed Charges,75% of Total Billed Charges,1982,50,,1585.6,Percent of Total Billed Charges,50% of Total Billed Charges,1982,50,,1585.6,Percent of Total Billed Charges,50% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1982,50,,1585.6,Percent of Total Billed Charges,50% of Total Billed Charges,1982,50,,1585.6,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,554.96,14,,443.968,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3964,100,,461.728,Percent of Total Billed Charges,100% of Total Billed Charges,116.24,3964,
STREP A DNA AMP PROBE,70001199,CDM,300,RC,87651,HCPCS,Outpatient,,,175,105.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,105,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,131.25,75,,331.304,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,175,100,,441.736,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,175,
REF DNA PROBE ID HISTOPLASMA,70001200,CDM,300,RC,87149,HCPCS,Outpatient,,,111.03,66.62,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,66.62,60,,53.296,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,83.27,75,,356.808,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,111.03,100,,475.744,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,111.03,
REF VEDOLIZUMAB QT REFLEX AB,70001201,CDM,301,RC,80299,HCPCS,Outpatient,,,525,315.00,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,315,60,,252,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,393.75,75,,391.336,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,525,100,,521.776,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,525,
REF IDH1 MUT ANLYS EXON 4,70001202,CDM,310,RC,81120,HCPCS,Outpatient,,,618.75,371.25,,224.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,289.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,541.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,618.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,695.7,360,,,Fee Schedule,360% of BCBS POS Rate,695.7,360,,,Fee schedule,360% of BCBS PPO Rate,695.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,371.25,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,162.33,100,,,Fee Schedule,100% of TX Mediciad 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,173.92,90,,,Fee Schedule,90% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,251.22,130,,,Fee Schedule,130% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,167.2,103,,,Fee Schedule,103% of TX Medicaid Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,464.06,75,,151.608,Percent of Total Billed Charges,75% of Total Billed Charges,328.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,328.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,328.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,328.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,289.87,150,,,Fee Schedule,150% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,156.54,90,,,Fee Schedule,90% of UHC fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,618.75,100,,202.144,Percent of Total Billed Charges,100% of Total Billed Charges,156.54,695.7,
REF IDH2 MUT ANLYS EXON 4,70001203,CDM,310,RC,81121,HCPCS,Outpatient,,,618.75,371.25,,343.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,443.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,828.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,946.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,1064.84,360,,,Fee Schedule,360% of BCBS POS Rate,1064.84,360,,,Fee schedule,360% of BCBS PPO Rate,1064.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,371.25,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,248.46,100,,,Fee Schedule,100% of TX Mediciad 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,266.21,90,,,Fee Schedule,90% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,384.52,130,,,Fee Schedule,130% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,255.91,103,,,Fee Schedule,103% of TX Medicaid Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,464.06,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,502.84,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,502.84,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,502.84,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,502.84,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,443.68,150,,,Fee Schedule,150% of CMS OPPS Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.59,90,,,Fee Schedule,90% of UHC fee schedule,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,248.46,100,,,Fee Schedule,100% of TX Medicaid Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,618.75,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,239.59,1064.84,
REF CX HERPES SIMPLEX VIRUS,70001204,CDM,300,RC,87255,HCPCS,Outpatient,,,292.64,175.58,,39.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,50.79,150,,,Fee Schedule ,150% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,94.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,108.35,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,121.9,360,,,Fee Schedule,360% of BCBS POS Rate,121.9,360,,,Fee schedule,360% of BCBS PPO Rate,121.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,175.58,60,,140.464,Percent of Total Billed Charges,60% of Total Billed Charges,28.44,100,,,Fee Schedule,100% of TX Mediciad 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,30.47,90,,,Fee Schedule,90% of CMS OPPS Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,44.01,130,,,Fee Schedule,130% of CMS OPPS Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,29.29,103,,,Fee Schedule,103% of TX Medicaid Rate,34.87,103,,,Fee Schedule,103% of CMS OPPS Rate,34.87,103,,,Fee Schedule,103% of CMS OPPS Rate,219.48,75,,124.76,Percent of Total Billed Charges,75% of Total Billed Charges,57.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,57.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,57.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,57.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,50.79,150,,,Fee Schedule,150% of CMS OPPS Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,27.42,90,,,Fee Schedule,90% of UHC fee schedule,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,28.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,292.64,100,,166.344,Percent of Total Billed Charges,100% of Total Billed Charges,27.42,292.64,
REF DIGOXIN FREE SERUM,70001205,CDM,301,RC,80163,HCPCS,Outpatient,,,492.25,295.35,,15.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.92,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,47.81,360,,,Fee Schedule,360% of BCBS POS Rate,47.81,360,,,Fee schedule,360% of BCBS PPO Rate,47.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,295.35,60,,236.28,Percent of Total Billed Charges,60% of Total Billed Charges,11.16,100,,,Fee Schedule,100% of TX Mediciad 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,11.95,90,,,Fee Schedule,90% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,17.26,130,,,Fee Schedule,130% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.49,103,,,Fee Schedule,103% of TX Medicaid Rate,13.67,103,,,Fee Schedule,103% of CMS OPPS Rate,13.67,103,,,Fee Schedule,103% of CMS OPPS Rate,369.19,75,,78.32,Percent of Total Billed Charges,75% of Total Billed Charges,22.57,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.57,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,22.57,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.57,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.92,150,,,Fee Schedule,150% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.76,90,,,Fee Schedule,90% of UHC fee schedule,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,11.16,100,,,Fee Schedule,100% of TX Medicaid Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,492.25,100,,104.424,Percent of Total Billed Charges,100% of Total Billed Charges,10.76,492.25,
REF ALDOSTERONE IVC SERUM,70001206,CDM,301,RC,82088,HCPCS,Outpatient,,,73.25,43.95,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,149.4,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,199.2,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,146.7,
REF ALDOSTERONE RAV SERUM,70001207,CDM,301,RC,82088,HCPCS,Outpatient,,,73.25,43.95,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,146.7,
REF ALDOSTERONE LAV SERUM,70001208,CDM,301,RC,82088,HCPCS,Outpatient,,,73.25,43.95,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,146.7,
REF ALDOSTERONE SERUM,70001209,CDM,301,RC,82088,HCPCS,Outpatient,,,73.25,43.95,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,72,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,146.7,
REF NECROTIZING MYOPATH EVAL S,70001210,CDM,301,RC,83516,HCPCS,Outpatient,,,427.88,256.73,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,256.73,60,,205.384,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,320.91,75,,64.2,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,427.88,100,,85.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,427.88,
REF NECROTIZING MYOPATH EA AB,70001211,CDM,302,RC,86255,HCPCS,Outpatient,,,447.13,268.28,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,268.28,60,,214.624,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,335.35,75,,651.6,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,447.13,100,,868.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,447.13,
REF NECROTIZING MYOPATH REFLEX,70001212,CDM,301,RC,84182,HCPCS,Outpatient,,,250,150.00,,33.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,43.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,81.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,105.16,360,,,Fee Schedule,360% of BCBS POS Rate,105.16,360,,,Fee schedule,360% of BCBS PPO Rate,105.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,24.54,100,,,Fee Schedule,100% of TX Mediciad 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,26.28,90,,,Fee Schedule,90% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,37.97,130,,,Fee Schedule,130% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,25.28,103,,,Fee Schedule,103% of TX Medicaid Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,75.6,Percent of Total Billed Charges,75% of Total Billed Charges,49.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,43.81,150,,,Fee Schedule,150% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,23.66,90,,,Fee Schedule,90% of UHC fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,100.8,Percent of Total Billed Charges,100% of Total Billed Charges,23.66,250,
REF NECROTIZING MYOPATH REFLEX,70001213,CDM,302,RC,86256,HCPCS,Outpatient,,,500,300.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,300,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,375,75,,115.92,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,500,100,,154.56,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,500,
REF BCR-ABL1 MUT,70001214,CDM,310,RC,81170,HCPCS,Outpatient,,,1302.5,781.50,,348,100,,,Fee Schedule,100% of Aetna Fee Schedule,450,150,,,Fee Schedule ,150% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,840,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,960,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,1080,360,,,Fee Schedule,360% of BCBS POS Rate,1080,360,,,Fee schedule,360% of BCBS PPO Rate,1080,360,,,Fee Schedule,360% of BCBS Traditional Rate,781.5,60,,625.2,Percent of Total Billed Charges,60% of Total Billed Charges,252,100,,,Fee Schedule,100% of TX Mediciad 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,270,90,,,Fee Schedule,90% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,390,130,,,Fee Schedule,130% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,259.56,103,,,Fee Schedule,103% of TX Medicaid Rate,309,103,,,Fee Schedule,103% of CMS OPPS Rate,309,103,,,Fee Schedule,103% of CMS OPPS Rate,976.88,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,510,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,510,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,510,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,510,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,450,150,,,Fee Schedule,150% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,243,90,,,Fee Schedule,90% of UHC fee schedule,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,252,100,,,Fee Schedule,100% of TX Medicaid Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.5,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,243,1302.5,
REF MUCOPLYSSCHRD MSP QN URINE,70001215,CDM,301,RC,83864,HCPCS,Outpatient,,,134.13,80.48,,33.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,42.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,79.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,91.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,102.6,360,,,Fee Schedule,360% of BCBS POS Rate,102.6,360,,,Fee schedule,360% of BCBS PPO Rate,102.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.48,60,,64.384,Percent of Total Billed Charges,60% of Total Billed Charges,23.94,100,,,Fee Schedule,100% of TX Mediciad 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,25.65,90,,,Fee Schedule,90% of CMS OPPS Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,130,,,Fee Schedule,130% of CMS OPPS Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,24.66,103,,,Fee Schedule,103% of TX Medicaid Rate,29.35,103,,,Fee Schedule,103% of CMS OPPS Rate,29.35,103,,,Fee Schedule,103% of CMS OPPS Rate,100.6,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,48.45,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,48.45,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,48.45,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,48.45,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,42.75,150,,,Fee Schedule,150% of CMS OPPS Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,23.09,90,,,Fee Schedule,90% of UHC fee schedule,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,23.94,100,,,Fee Schedule,100% of TX Medicaid Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,134.13,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,23.09,134.13,
REF MUCOPLYSSCHRD MSP QL URINE,70001216,CDM,301,RC,82542,HCPCS,Outpatient,,,113.38,68.03,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,68.03,60,,54.424,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,85.04,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,113.38,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,113.38,
REF PURKINJE CLL CYTOP AB TYTR,70001217,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF CRMP-5-IGG SERUM,70001218,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,73.872,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,98.496,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF ANTI-NEURONAL AB TYPE 3,70001219,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,78.512,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,104.68,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF PURKINJE CELL CYTOP AB TY2,70001220,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,383.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,511.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF ANTI-NEURONAL NUC AB TY 1,70001221,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,383.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,511.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF ANTI-NEURONAL NUC AB TY 2,70001222,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF PURKINJE CELL CYTOP AB TY1,70001223,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,85.256,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,113.672,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF AMPHYIPHYSIN AB SERUM,70001224,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,148.048,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,197.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
REF ANTI-GLIAL NUCLEAR AB TY 1,70001225,CDM,302,RC,86255,HCPCS,Outpatient,,,266,159.60,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.6,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,199.5,75,,124.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,266,100,,166.488,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,266,
EOSINOPHILS URINE,70001226,CDM,305,RC,85999,HCPCS,Outpatient,,,101,60.60,,60.6,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.28,28,,22.624,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,36.36,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,36.36,36,,29.088,Percent of Total Billed Charges,36% Total Bille Charges,36.36,36,,29.088,Percent of Total Billed Charges,36% of Total Billed Charges,60.6,60,,48.48,Percent of Total Billed Charges,60% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.56,14.42,,11.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.75,75,,247.864,Percent of Total Billed Charges,75% of Total Billed Charges,50.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,14.14,14,,11.312,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,101,100,,330.488,Percent of Total Billed Charges,100% of Total Billed Charges,14.14,312,
REF 5 HIAA URINE,70001228,CDM,301,RC,83497,HCPCS,Outpatient,,,28.33,17.00,,14.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,36.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,46.44,360,,,Fee Schedule,360% of BCBS POS Rate,46.44,360,,,Fee schedule,360% of BCBS PPO Rate,46.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,17,60,,13.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,100,,,Fee Schedule,100% of TX Mediciad 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,11.61,90,,,Fee Schedule,90% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,130,,,Fee Schedule,130% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,11.17,103,,,Fee Schedule,103% of TX Medicaid Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,21.25,75,,154.792,Percent of Total Billed Charges,75% of Total Billed Charges,21.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.35,150,,,Fee Schedule,150% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.45,90,,,Fee Schedule,90% of UHC fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.33,100,,206.392,Percent of Total Billed Charges,100% of Total Billed Charges,10.45,46.44,
REF CREATININE RANDOM URINE,70001229,CDM,301,RC,82570,HCPCS,Outpatient,,,15.78,9.47,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,9.47,60,,7.576,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,11.84,75,,176.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15.78,100,,235.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,18.65,
REF DOPAMINE,70001230,CDM,301,RC,82384,HCPCS,Outpatient,,,77,46.20,,29.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,70.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,80.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,90.9,360,,,Fee Schedule,360% of BCBS POS Rate,90.9,360,,,Fee schedule,360% of BCBS PPO Rate,90.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,46.2,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,21.21,100,,,Fee Schedule,100% of TX Mediciad 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,22.72,90,,,Fee Schedule,90% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,32.82,130,,,Fee Schedule,130% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.85,103,,,Fee Schedule,103% of TX Medicaid Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,57.75,75,,126.664,Percent of Total Billed Charges,75% of Total Billed Charges,42.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,42.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.87,150,,,Fee Schedule,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,90,,,Fee Schedule,90% of UHC fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,77,100,,168.888,Percent of Total Billed Charges,100% of Total Billed Charges,20.46,90.9,
CELL FREE DNA QUANT CFDNA,70001231,CDM,310,RC,81267,HCPCS,Outpatient,,,875,525.00,,240.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,311.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,580.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,663.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,746.86,360,,,Fee Schedule,360% of BCBS POS Rate,746.86,360,,,Fee schedule,360% of BCBS PPO Rate,746.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,525,60,,420,Percent of Total Billed Charges,60% of Total Billed Charges,174.27,100,,,Fee Schedule,100% of TX Mediciad Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,186.71,90,,,Fee Schedule,90% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,269.69,130,,,Fee Schedule,130% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,179.5,103,,,Fee Schedule,103% of TX Medicaid Rate,213.68,103,,,Fee Schedule,103% of CMS OPPS Rate,213.68,103,,,Fee Schedule,103% of CMS OPPS Rate,656.25,75,,173.648,Percent of Total Billed Charges,75% of Total Billed Charges,352.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,352.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,352.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,352.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,311.19,150,,,Fee Schedule,150% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,168.04,90,,,Fee Schedule,90% of UHC fee schedule,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,875,100,,231.528,Percent of Total Billed Charges,100% of Total Billed Charges,168.04,875,
DNA QUANT,70001232,CDM,310,RC,81267,HCPCS,Outpatient,,,750,450.00,,240.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,311.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,580.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,663.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,746.86,360,,,Fee Schedule,360% of BCBS POS Rate,746.86,360,,,Fee schedule,360% of BCBS PPO Rate,746.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,450,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,174.27,100,,,Fee Schedule,100% of TX Mediciad Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,186.71,90,,,Fee Schedule,90% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,269.69,130,,,Fee Schedule,130% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,179.5,103,,,Fee Schedule,103% of TX Medicaid Rate,213.68,103,,,Fee Schedule,103% of CMS OPPS Rate,213.68,103,,,Fee Schedule,103% of CMS OPPS Rate,562.5,75,,354.96,Percent of Total Billed Charges,75% of Total Billed Charges,352.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,352.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,352.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,352.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,311.19,150,,,Fee Schedule,150% of CMS OPPS Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,168.04,90,,,Fee Schedule,90% of UHC fee schedule,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,174.27,100,,,Fee Schedule,100% of TX Medicaid Rate,207.46,100,,,Fee Schedule,100% of CMS OPPS Rate,750,100,,473.28,Percent of Total Billed Charges,100% of Total Billed Charges,168.04,750,
DNA QUANT CD3,70001233,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD4,70001234,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD8,70001235,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,87.6,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,116.8,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD14,70001236,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD15,70001237,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD16,70001238,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD19,70001239,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD33,70001240,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD34,70001241,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
DNA QUANT CD56,70001242,CDM,310,RC,81268,HCPCS,Outpatient,,,425,255.00,,302.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,391.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,730.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,834.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,938.84,360,,,Fee Schedule,360% of BCBS POS Rate,938.84,360,,,Fee schedule,360% of BCBS PPO Rate,938.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,255,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,219.06,100,,,Fee Schedule,100% of TX Mediciad Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,234.71,90,,,Fee Schedule,90% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,339.02,130,,,Fee Schedule,130% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,225.63,103,,,Fee Schedule,103% of TX Medicaid Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,268.61,103,,,Fee Schedule,103% of CMS OPPS Rate,318.75,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,443.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,443.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,443.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,443.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,391.18,150,,,Fee Schedule,150% of CMS OPPS Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,211.24,90,,,Fee Schedule,90% of UHC fee schedule,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,219.06,100,,,Fee Schedule,100% of TX Medicaid Rate,260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,425,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,211.24,938.84,
AB ENDOMYSIAL IGA,70001243,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
REF GARDNERELLA VAG QUANT,70001245,CDM,306,RC,87512,HCPCS,Outpatient,,,108.88,65.33,,48.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,62.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,116.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,133.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,150.34,360,,,Fee Schedule,360% of BCBS POS Rate,150.34,360,,,Fee schedule,360% of BCBS PPO Rate,150.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,65.33,60,,52.264,Percent of Total Billed Charges,60% of Total Billed Charges,35.08,100,,,Fee Schedule,100% of TX Mediciad 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,37.58,90,,,Fee Schedule,90% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,54.28,130,,,Fee Schedule,130% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,36.13,103,,,Fee Schedule,103% of TX Medicaid Rate,43.01,103,,,Fee Schedule,103% of CMS OPPS Rate,43.01,103,,,Fee Schedule,103% of CMS OPPS Rate,81.66,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,70.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,70.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,70.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,62.64,150,,,Fee Schedule,150% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,33.82,90,,,Fee Schedule,90% of UHC fee schedule,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,108.88,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,33.82,150.34,
REF CANDIDA ALB GLBRT QUAL PCR,70001246,CDM,306,RC,87481,HCPCS,Outpatient,,,260,156.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,156,60,,124.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,195,75,,81.52,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,260,100,,108.696,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,260,
REF CHLAMYDIA TRACHOMATIS AMP,70001247,CDM,306,RC,87491,HCPCS,Outpatient,,,74.28,44.57,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.57,60,,35.656,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,55.71,75,,158.4,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,74.28,100,,211.2,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,126.32,
REF NEISSERIA GONORRHOEAE AMP,70001248,CDM,306,RC,87591,HCPCS,Outpatient,,,74.18,44.51,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.51,60,,35.608,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,55.64,75,,119.4,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,74.18,100,,159.2,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,126.32,
REF TRICHOMANAS VAGINALIS AMP,70001249,CDM,306,RC,87661,HCPCS,Outpatient,,,90.7,54.42,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.42,60,,43.536,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,68.03,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,90.7,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,126.32,
REF INFECT AGNT AG EA ORGANISM,70001250,CDM,306,RC,87798,HCPCS,Outpatient,,,125,75.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,75,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,93.75,75,,103.24,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,125,100,,137.648,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,126.32,
REF 50SEQ PANEL,70001251,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,81.64,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,108.848,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF 50SEQ WITH FISH,70001252,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF 50SEQ WITH FISH NO PDL1,70001253,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,58.8,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,78.4,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF LUNGSEQ PANEL,70001254,CDM,310,RC,81445,HCPCS,Outpatient,,,2205,1323.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,1323,60,,1058.4,Percent of Total Billed Charges,60% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,317.96,14.42,,254.368,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,1653.75,75,,58.8,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,308.7,14,,246.96,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,2205,100,,78.4,Percent of Total Billed Charges,100% of Total Billed Charges,308.7,2205,
REF LUNGSEQ PNL FISH RUNCONC,70001255,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,58.8,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,78.4,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF LUNGSEQ PNL FISH RUNREFLX,70001256,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,58.8,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,78.4,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF COLONSEQ PANEL,70001257,CDM,310,RC,81445,HCPCS,Outpatient,,,6800,4080.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,4080,60,,3264,Percent of Total Billed Charges,60% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,980.56,14.42,,784.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,5100,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,952,14,,761.6,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,6800,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,484.31,6800,
REF COLONSEQ PLUS PANEL,70001258,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,117.832,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,157.104,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF MELANOMASEQ PLUS PANEL,70001259,CDM,310,RC,81445,HCPCS,Outpatient,,,3375,2025.00,,693.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,896.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1913.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,2152.48,360,,,Fee Schedule,360% of BCBS POS Rate,2152.48,360,,,Fee schedule,360% of BCBS PPO Rate,2152.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,2025,60,,1620,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,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,538.11,90,,,Fee Schedule,90% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,777.28,130,,,Fee Schedule,130% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,486.68,14.42,,389.344,Percent of Total Billed Charges,14.42% of Total Billed Charges,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,615.84,103,,,Fee Schedule,103% of CMS OPPS Rate,2531.25,75,,68.688,Percent of Total Billed Charges,75% of Total Billed Charges,1016.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1016.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1016.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,896.86,150,,,Fee Schedule,150% of CMS OPPS Rate,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.31,90,,,Fee Schedule,90% of UHC fee schedule,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,472.5,14,,378,Percent of Total Billed Charges,14% of Total Billed Charges,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,100,,91.584,Percent of Total Billed Charges,100% of Total Billed Charges,472.5,3375,
REF AML PROFILE,70001260,CDM,310,RC,81450,HCPCS,Outpatient,,,4074.83,2444.90,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,2444.9,60,,1955.92,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,3056.12,75,,71.936,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4074.83,100,,95.912,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,4074.83,
REF AML MUTATION ANALYSIS,70001261,CDM,310,RC,81450,HCPCS,Outpatient,,,4074.83,2444.90,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,2444.9,60,,1955.92,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,3056.12,75,,74.872,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4074.83,100,,99.832,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,4074.83,
REF CLL PROFILE,70001262,CDM,310,RC,81450,HCPCS,Outpatient,,,2582.9,1549.74,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1549.74,60,,1239.792,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1937.18,75,,71.936,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.9,100,,95.912,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF CLL MUTUTATION ANALYSIS,70001263,CDM,310,RC,81450,HCPCS,Outpatient,,,2582.9,1549.74,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1549.74,60,,1239.792,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1937.18,75,,74.872,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.9,100,,99.832,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF DLBCL PROFILE,70001264,CDM,310,RC,81450,HCPCS,Outpatient,,,2267.3,1360.38,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1360.38,60,,1088.304,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1700.48,75,,71.936,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2267.3,100,,95.912,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF DLBCL MUT ANALYS MPN PRFL,70001265,CDM,310,RC,81450,HCPCS,Outpatient,,,2267.3,1360.38,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1360.38,60,,1088.304,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1700.48,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2267.3,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF MPN PROFILE,70001266,CDM,310,RC,81450,HCPCS,Outpatient,,,1838.45,1103.07,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1103.07,60,,882.456,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1378.84,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.45,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF MDS MUTATUION ANALYSIS,70001267,CDM,310,RC,81450,HCPCS,Outpatient,,,2713.03,1627.82,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,1627.82,60,,1302.256,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,2034.77,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2713.03,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
REF DIHYROTESTOSTERONE,70001271,CDM,301,RC,82642,HCPCS,Outpatient,,,71.28,42.77,,33.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,43.92,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,360,,,Fee Schedule,360% of BCBS POS Rate,105.41,360,,,Fee schedule,360% of BCBS PPO Rate,105.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.77,60,,34.216,Percent of Total Billed Charges,60% of Total Billed Charges,24.6,100,,,Fee Schedule,100% of TX Mediciad 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,26.35,90,,,Fee Schedule,90% of CMS OPPS Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,38.06,130,,,Fee Schedule,130% of CMS OPPS Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,25.34,103,,,Fee Schedule,103% of TX Medicaid Rate,30.15,103,,,Fee Schedule,103% of CMS OPPS Rate,30.15,103,,,Fee Schedule,103% of CMS OPPS Rate,53.46,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,49.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,49.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,43.92,150,,,Fee Schedule,150% of CMS OPPS Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,23.72,90,,,Fee Schedule,90% of UHC fee schedule,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.6,100,,,Fee Schedule,100% of TX Medicaid Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,23.72,105.41,
REF SMA CARRIER,70001272,CDM,310,RC,81329,HCPCS,Outpatient,,,793.75,476.25,,158.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,205.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,383.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,438.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,493.2,360,,,Fee Schedule,360% of BCBS POS Rate,493.2,360,,,Fee schedule,360% of BCBS PPO Rate,493.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,476.25,60,,381,Percent of Total Billed Charges,60% of Total Billed Charges,115.08,100,,,Fee Schedule,100% of TX Mediciad 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,123.3,90,,,Fee Schedule,90% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,178.1,130,,,Fee Schedule,130% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,118.53,103,,,Fee Schedule,103% of TX Medicaid Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,595.31,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,232.9,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,232.9,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,232.9,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,232.9,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,205.5,150,,,Fee Schedule,150% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,110.97,90,,,Fee Schedule,90% of UHC fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,793.75,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,110.97,793.75,
REF LYM TCELL SUB PANEL 4 BAL,70001273,CDM,302,RC,86356,HCPCS,Outpatient,,,320,192.00,,31.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,96.41,360,,,Fee Schedule,360% of BCBS POS Rate,96.41,360,,,Fee schedule,360% of BCBS PPO Rate,96.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,192,60,,153.6,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,100,,,Fee Schedule,100% of TX Mediciad 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,24.1,90,,,Fee Schedule,90% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,130,,,Fee Schedule,130% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,23.18,103,,,Fee Schedule,103% of TX Medicaid Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,240,75,,68.36,Percent of Total Billed Charges,75% of Total Billed Charges,45.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.17,150,,,Fee Schedule,150% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.69,90,,,Fee Schedule,90% of UHC fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,320,100,,91.144,Percent of Total Billed Charges,100% of Total Billed Charges,21.69,320,
REF ANTI FIBRILLARIN U3 RNP,70001274,CDM,301,RC,83516,HCPCS,Outpatient,,,41.38,24.83,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.83,60,,19.864,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,31.04,75,,68.36,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,41.38,100,,91.144,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,41.51,
REF ANTI JO1 AB,70001275,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,94.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF ANTI SSA 52 KD AB IGG,70001276,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,94.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF ANTI PM SCL AB,70001277,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,70.6,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,94.136,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF ANTI U1 RNP AB,70001278,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,70.6,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,94.136,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF MDA 5 P140 CADM,70001279,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,105.032,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,140.04,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF NXP 2 P140,70001280,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,105.032,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,140.04,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF TIF1 GAMMA P155 140,70001281,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,118.848,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,158.464,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF ANTI SAE 1 IGG,70001282,CDM,302,RC,86235,HCPCS,Outpatient,,,64.38,38.63,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,38.63,60,,30.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,48.29,75,,118.848,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,64.38,100,,158.464,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,64.55,
REF IGVH MUT ANALYSIS BY SEQ,70001283,CDM,310,RC,81263,HCPCS,Outpatient,,,2407.5,1444.50,,341.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,441.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,824.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,942.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1060.27,360,,,Fee Schedule,360% of BCBS POS Rate,1060.27,360,,,Fee schedule,360% of BCBS PPO Rate,1060.27,360,,,Fee Schedule,360% of BCBS Traditional Rate,1444.5,60,,1155.6,Percent of Total Billed Charges,60% of Total Billed Charges,247.4,100,,,Fee Schedule,100% of TX Mediciad 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,265.06,90,,,Fee Schedule,90% of CMS OPPS Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,382.87,130,,,Fee Schedule,130% of CMS OPPS Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,254.82,103,,,Fee Schedule,103% of TX Medicaid Rate,303.35,103,,,Fee Schedule,103% of CMS OPPS Rate,303.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1805.63,75,,118.848,Percent of Total Billed Charges,75% of Total Billed Charges,500.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,500.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,500.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,500.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,441.78,150,,,Fee Schedule,150% of CMS OPPS Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,90,,,Fee Schedule,90% of UHC fee schedule,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,247.4,100,,,Fee Schedule,100% of TX Medicaid Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.5,100,,158.464,Percent of Total Billed Charges,100% of Total Billed Charges,238.56,2407.5,
REF METHADONE QUANT,70001284,CDM,301,RC,80358,HCPCS,Outpatient,,,97.5,58.50,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.5,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.02,100,,,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.35,103,,,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.13,75,,107.064,Percent of Total Billed Charges,75% of Total Billed Charges,48.75,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,48.75,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,50,,39,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,11.02,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,97.5,100,,142.752,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,97.5,
REF BRAF,70001288,CDM,310,RC,81210,HCPCS,Outpatient,,,448.13,268.88,,203.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,263.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,491.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,561.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,631.44,360,,,Fee Schedule,360% of BCBS POS Rate,631.44,360,,,Fee schedule,360% of BCBS PPO Rate,631.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,268.88,60,,215.104,Percent of Total Billed Charges,60% of Total Billed Charges,147.34,100,,,Fee Schedule,100% of TX Mediciad 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,157.86,90,,,Fee Schedule,90% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,228.02,130,,,Fee Schedule,130% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,151.76,103,,,Fee Schedule,103% of TX Medicaid Rate,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,336.1,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,298.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,298.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,298.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,263.1,150,,,Fee Schedule,150% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,142.07,90,,,Fee Schedule,90% of UHC fee schedule,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,448.13,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,142.07,631.44,
REF KIT,70001289,CDM,310,RC,81311,HCPCS,Outpatient,,,1318.28,790.97,,343.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,443.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,828.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,946.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,1064.84,360,,,Fee Schedule,360% of BCBS POS Rate,1064.84,360,,,Fee schedule,360% of BCBS PPO Rate,1064.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,790.97,60,,632.776,Percent of Total Billed Charges,60% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,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,266.21,90,,,Fee Schedule,90% of CMS OPPS Rate,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,384.52,130,,,Fee Schedule,130% of CMS OPPS Rate,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,190.1,14.42,,152.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,988.71,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,502.84,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,502.84,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,502.84,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,502.84,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,443.68,150,,,Fee Schedule,150% of CMS OPPS Rate,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.59,90,,,Fee Schedule,90% of UHC fee schedule,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,184.56,14,,147.648,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.28,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,184.56,1318.28,
REF NRAS,70001290,CDM,310,RC,81272,HCPCS,Outpatient,,,1183.15,709.89,,382.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,922.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1054.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,1186.24,360,,,Fee Schedule,360% of BCBS POS Rate,1186.24,360,,,Fee schedule,360% of BCBS PPO Rate,1186.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,709.89,60,,567.912,Percent of Total Billed Charges,60% of Total Billed Charges,276.79,100,,,Fee Schedule,100% of TX Mediciad 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,296.55,90,,,Fee Schedule,90% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,428.36,130,,,Fee Schedule,130% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,285.09,103,,,Fee Schedule,103% of TX Medicaid Rate,339.39,103,,,Fee Schedule,103% of CMS OPPS Rate,339.39,103,,,Fee Schedule,103% of CMS OPPS Rate,887.36,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,560.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,560.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,560.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,560.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,494.26,150,,,Fee Schedule,150% of CMS OPPS Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,266.9,90,,,Fee Schedule,90% of UHC fee schedule,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,276.79,100,,,Fee Schedule,100% of TX Medicaid Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.15,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,266.9,1186.24,
CALR GENE COM VARIANTS,70001291,CDM,310,RC,81219,HCPCS,Outpatient,,,331.36,198.82,,141.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,182.44,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,340.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,389.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,437.87,360,,,Fee Schedule,360% of BCBS POS Rate,437.87,360,,,Fee schedule,360% of BCBS PPO Rate,437.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,198.82,60,,159.056,Percent of Total Billed Charges,60% of Total Billed Charges,102.17,100,,,Fee Schedule,100% of TX Mediciad 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,109.46,90,,,Fee Schedule,90% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,158.11,130,,,Fee Schedule,130% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,105.24,103,,,Fee Schedule,103% of TX Medicaid Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,248.52,75,,94.8,Percent of Total Billed Charges,75% of Total Billed Charges,206.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,206.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,206.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,206.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,182.44,150,,,Fee Schedule,150% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.52,90,,,Fee Schedule,90% of UHC fee schedule,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,331.36,100,,126.4,Percent of Total Billed Charges,100% of Total Billed Charges,98.52,437.87,
MOPATH PROCEDURE LEVEL 3,70001292,CDM,310,RC,81402,HCPCS,Outpatient,,,879.56,527.74,,174.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,225.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,420.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,481.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,541.19,360,,,Fee Schedule,360% of BCBS POS Rate,541.19,360,,,Fee schedule,360% of BCBS PPO Rate,541.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,527.74,60,,422.192,Percent of Total Billed Charges,60% of Total Billed Charges,126.28,100,,,Fee Schedule,100% of TX Mediciad 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,135.29,90,,,Fee Schedule,90% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.42,130,,,Fee Schedule,130% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,130.07,103,,,Fee Schedule,103% of TX Medicaid Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,659.67,75,,67.24,Percent of Total Billed Charges,75% of Total Billed Charges,255.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,255.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,255.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,225.49,150,,,Fee Schedule,150% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,121.77,90,,,Fee Schedule,90% of UHC fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,879.56,100,,89.648,Percent of Total Billed Charges,100% of Total Billed Charges,121.77,879.56,
JAK2 V617F MUTATION BY PCR,70001293,CDM,310,RC,81270,HCPCS,Outpatient,,,552.17,331.30,,106.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,137.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,256.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,293.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,329.98,360,,,Fee Schedule,360% of BCBS POS Rate,329.98,360,,,Fee schedule,360% of BCBS PPO Rate,329.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,331.3,60,,265.04,Percent of Total Billed Charges,60% of Total Billed Charges,76.99,100,,,Fee Schedule,100% of TX Mediciad 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,82.49,90,,,Fee Schedule,90% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,119.15,130,,,Fee Schedule,130% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,79.3,103,,,Fee Schedule,103% of TX Medicaid Rate,94.4,103,,,Fee Schedule,103% of CMS OPPS Rate,94.4,103,,,Fee Schedule,103% of CMS OPPS Rate,414.13,75,,67.24,Percent of Total Billed Charges,75% of Total Billed Charges,155.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,155.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,155.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,155.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,137.49,150,,,Fee Schedule,150% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,74.24,90,,,Fee Schedule,90% of UHC fee schedule,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,552.17,100,,89.648,Percent of Total Billed Charges,100% of Total Billed Charges,74.24,552.17,
REF FISH ADDITIONAL PROBE,70001294,CDM,312,RC,88364,HCPCS,Outpatient,,,1334.45,800.67,,130.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,314.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,354.2,360,,,Fee Schedule,360% of BCBS POS Rate,354.2,360,,,Fee schedule,360% of BCBS PPO Rate,354.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,800.67,60,,640.536,Percent of Total Billed Charges,60% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,192.43,14.42,,153.944,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1000.84,75,,67.24,Percent of Total Billed Charges,75% of Total Billed Charges,667.23,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,667.23,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,667.23,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,667.23,50,,533.784,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.48,90,,,Fee Schedule,90% of UHC fee schedule,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,186.82,14,,149.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1334.45,100,,89.648,Percent of Total Billed Charges,100% of Total Billed Charges,84.48,1334.45,
REF BETA LACTAMASE MICROBE SUS,70001295,CDM,306,RC,87185,HCPCS,Outpatient,,,167.5,100.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,100.5,60,,80.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,125.63,75,,97.2,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,167.5,100,,129.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,167.5,
REF MITOTANE LYSODREN,70001296,CDM,301,RC,80375,HCPCS,Outpatient,,,213.05,127.83,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.83,60,,102.264,Percent of Total Billed Charges,60% of Total Billed Charges,18.09,100,,,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.63,103,,,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.79,75,,95.872,Percent of Total Billed Charges,75% of Total Billed Charges,106.53,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,106.53,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,106.53,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,106.53,50,,85.224,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,213.05,100,,127.832,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,213.05,
REF IGG MONOS GM1 TITER SERUM,70001297,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,114.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
REF IGM MONOS GM1 TITER SERUM,70001298,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,109.688,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,146.248,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
REF IGG ASIALO GM1 TITER SERUM,70001299,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,93.72,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,124.96,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
REF IGM ASIALO GM1 TITER SERUM,70001300,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,93.72,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,124.96,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
REF IGG DISIALO GD1B TITER S,70001301,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,93.72,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,124.96,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
REF IGM DISIALO GD1B TITER S,70001302,CDM,301,RC,83520,HCPCS,Outpatient,,,250,150.00,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,150,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,187.5,75,,81.152,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,250,100,,108.2,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,250,
BRONCHIAL LAVAGE WASH DIFF,70001303,CDM,300,RC,89051,HCPCS,Outpatient,,,168.57,101.14,,6.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,20.16,360,,,Fee Schedule,360% of BCBS POS Rate,20.16,360,,,Fee schedule,360% of BCBS PPO Rate,20.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.14,60,,80.912,Percent of Total Billed Charges,60% of Total Billed Charges,4.7,100,,,Fee Schedule,100% of TX Mediciad 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,5.03,90,,,Fee Schedule,90% of CMS OPPS Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7.28,130,,,Fee Schedule,130% of CMS OPPS Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.84,103,,,Fee Schedule,103% of TX Medicaid Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,5.76,103,,,Fee Schedule,103% of CMS OPPS Rate,126.43,75,,80.896,Percent of Total Billed Charges,75% of Total Billed Charges,9.51,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.51,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,9.51,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.51,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.4,150,,,Fee Schedule,150% of CMS OPPS Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.54,90,,,Fee Schedule,90% of UHC fee schedule,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.7,100,,,Fee Schedule,100% of TX Medicaid Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,168.57,100,,107.864,Percent of Total Billed Charges,100% of Total Billed Charges,4.54,168.57,
REF DPPX AB IFA TITER CSF,70001304,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,91.992,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,122.656,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF GFAP IFA TITER CSF,70001305,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF MGLUR1 AB IFA TITER CSF,70001306,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,86.184,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,114.912,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF DPPX AB IFA TITER S,70001307,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,130.984,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,174.64,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF MGLUR1 AB TITER S,70001308,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,123.264,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,164.352,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF GFAP IFA TITER S,70001309,CDM,302,RC,86256,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,123.264,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,164.352,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF DPPX AB IFA CSF,70001310,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,123.264,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,164.352,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF MGLUR1 AB IFA CSF,70001311,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,123.264,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,164.352,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF GFAP IFA CSF,70001312,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF DPPX AB IFA S,70001313,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF MGLUR1 AB IFA S,70001314,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF GFAP IFA S,70001315,CDM,302,RC,86255,HCPCS,Outpatient,,,187.5,112.50,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,140.63,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,187.5,
REF DPPX AB CBA CSF,70001316,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF MGLUR1 AB CBA CSF,70001317,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,43.504,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,58,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF DPPX AB CBA S,70001319,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,71.568,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,95.424,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF MGLUR1 AB CBA S,70001320,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,71.568,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,95.424,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF GFAP CBA S,70001321,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,118.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF GFAP CBA CSF,70001322,CDM,302,RC,86255,HCPCS,Outpatient,,,625,375.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,375,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,468.75,75,,78.64,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,625,100,,104.856,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,625,
REF HLA-B 57:01 GENOTYPE PGX,70001323,CDM,310,RC,81381,HCPCS,Outpatient,,,1552.25,931.35,,197.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,254.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,475.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,543.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,611.64,360,,,Fee Schedule,360% of BCBS POS Rate,611.64,360,,,Fee schedule,360% of BCBS PPO Rate,611.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,931.35,60,,745.08,Percent of Total Billed Charges,60% of Total Billed Charges,142.72,100,,,Fee Schedule,100% of TX Mediciad 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,152.91,90,,,Fee Schedule,90% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,220.87,130,,,Fee Schedule,130% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,147,103,,,Fee Schedule,103% of TX Medicaid Rate,174.99,103,,,Fee Schedule,103% of CMS OPPS Rate,174.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1164.19,75,,390.496,Percent of Total Billed Charges,75% of Total Billed Charges,288.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,288.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,288.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,288.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,254.85,150,,,Fee Schedule,150% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,137.62,90,,,Fee Schedule,90% of UHC fee schedule,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1552.25,100,,520.664,Percent of Total Billed Charges,100% of Total Billed Charges,137.62,1552.25,
GENERAL HEALTH PANEL,70001324,CDM,300,RC,80050,HCPCS,Outpatient,,,550,330.00,,53.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,113.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,127.15,360,,,Fee Schedule,360% of BCBS POS Rate,127.15,360,,,Fee schedule,360% of BCBS PPO Rate,127.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,79.31,14.42,,63.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,412.5,75,,1032,Percent of Total Billed Charges,75% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,275,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.3,90,,,Fee Schedule,90% of UHC fee schedule,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,77,14,,61.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,550,100,,1376,Percent of Total Billed Charges,100% of Total Billed Charges,38.3,550,
REF WARFARIN PLASMA,70001325,CDM,301,RC,80375,HCPCS,Outpatient,,,272.5,163.50,,0.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.5,60,,130.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.09,100,,,Fee Schedule,100% of TX Mediciad Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.63,103,,,Fee Schedule,103% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.38,75,,223.152,Percent of Total Billed Charges,75% of Total Billed Charges,136.25,50,,109,Percent of Total Billed Charges,50% of Total Billed Charges,136.25,50,,109,Percent of Total Billed Charges,50% of Total Billed Charges,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,136.25,50,,109,Percent of Total Billed Charges,50% of Total Billed Charges,136.25,50,,109,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,18.09,100,,,Fee Schedule,100% of TX Medicaid Rate,,,,,Other,Not Seperately Reimbusable,272.5,100,,297.536,Percent of Total Billed Charges,100% of Total Billed Charges,0.02,272.5,
REF FRANCISELLA TULARENSIS IGG,70001327,CDM,302,RC,86668,HCPCS,Outpatient,,,156.25,93.75,,16.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,50.98,360,,,Fee Schedule,360% of BCBS POS Rate,50.98,360,,,Fee schedule,360% of BCBS PPO Rate,50.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.75,60,,75,Percent of Total Billed Charges,60% of Total Billed Charges,11.89,100,,,Fee Schedule,100% of TX Mediciad 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,12.74,90,,,Fee Schedule,90% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,130,,,Fee Schedule,130% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,103,,,Fee Schedule,103% of TX Medicaid Rate,14.58,103,,,Fee Schedule,103% of CMS OPPS Rate,14.58,103,,,Fee Schedule,103% of CMS OPPS Rate,117.19,75,,239.04,Percent of Total Billed Charges,75% of Total Billed Charges,24.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.24,150,,,Fee Schedule,150% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,90,,,Fee Schedule,90% of UHC fee schedule,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,156.25,100,,318.72,Percent of Total Billed Charges,100% of Total Billed Charges,11.47,156.25,
REF FRANCISELLA TULARENSIS IGM,70001328,CDM,302,RC,86668,HCPCS,Outpatient,,,156.25,93.75,,16.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,50.98,360,,,Fee Schedule,360% of BCBS POS Rate,50.98,360,,,Fee schedule,360% of BCBS PPO Rate,50.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.75,60,,75,Percent of Total Billed Charges,60% of Total Billed Charges,11.89,100,,,Fee Schedule,100% of TX Mediciad 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,12.74,90,,,Fee Schedule,90% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,130,,,Fee Schedule,130% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,103,,,Fee Schedule,103% of TX Medicaid Rate,14.58,103,,,Fee Schedule,103% of CMS OPPS Rate,14.58,103,,,Fee Schedule,103% of CMS OPPS Rate,117.19,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,24.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.24,150,,,Fee Schedule,150% of CMS OPPS Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,90,,,Fee Schedule,90% of UHC fee schedule,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,100,,,Fee Schedule,100% of TX Medicaid Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,156.25,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.47,156.25,
REF FLUORESCENT AB SCREEN,70001330,CDM,302,RC,86255,HCPCS,Outpatient,,,1125,675.00,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,675,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,843.75,75,,85.728,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1125,100,,114.304,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,1125,
REF ISLET CELL AB,70001331,CDM,302,RC,86341,HCPCS,Outpatient,,,1125,675.00,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,675,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,843.75,75,,223.152,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1125,100,,297.536,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,1125,
REF MGMT GENE METHYLATION ANAL,70001332,CDM,310,RC,81287,HCPCS,Outpatient,,,3352,2011.20,,144.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,186.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,348.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,398.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,448.7,360,,,Fee Schedule,360% of BCBS POS Rate,448.7,360,,,Fee schedule,360% of BCBS PPO Rate,448.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,2011.2,60,,1608.96,Percent of Total Billed Charges,60% of Total Billed Charges,104.7,100,,,Fee Schedule,100% of TX Mediciad Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,112.17,90,,,Fee Schedule,90% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,162.03,130,,,Fee Schedule,130% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,107.84,103,,,Fee Schedule,103% of TX Medicaid Rate,128.37,103,,,Fee Schedule,103% of CMS OPPS Rate,128.37,103,,,Fee Schedule,103% of CMS OPPS Rate,2514,75,,154.44,Percent of Total Billed Charges,75% of Total Billed Charges,211.88,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,211.88,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,211.88,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,211.88,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,186.96,150,,,Fee Schedule,150% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,100.96,90,,,Fee Schedule,90% of UHC fee schedule,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3352,100,,205.92,Percent of Total Billed Charges,100% of Total Billed Charges,100.96,3352,
REF CAFFEINE SERUM,70001333,CDM,301,RC,80155,HCPCS,Outpatient,,,50.15,30.09,,44.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,57.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,108,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,138.85,360,,,Fee Schedule,360% of BCBS POS Rate,138.85,360,,,Fee schedule,360% of BCBS PPO Rate,138.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,30.09,60,,24.072,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,100,,,Fee Schedule,100% of TX Mediciad 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,34.71,90,,,Fee Schedule,90% of CMS OPPS Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,130,,,Fee Schedule,130% of CMS OPPS Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,33.37,103,,,Fee Schedule,103% of TX Medicaid Rate,39.72,103,,,Fee Schedule,103% of CMS OPPS Rate,39.72,103,,,Fee Schedule,103% of CMS OPPS Rate,37.61,75,,230.704,Percent of Total Billed Charges,75% of Total Billed Charges,65.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,65.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,65.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,65.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,57.85,150,,,Fee Schedule,150% of CMS OPPS Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,31.24,90,,,Fee Schedule,90% of UHC fee schedule,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,32.4,100,,,Fee Schedule,100% of TX Medicaid Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,50.15,100,,307.6,Percent of Total Billed Charges,100% of Total Billed Charges,30.09,138.85,
REF BROAD RANGE BACTI PCR SEQ,70001334,CDM,306,RC,87801,HCPCS,Outpatient,,,1655,993.00,,81.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,224.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,252.72,360,,,Fee Schedule,360% of BCBS POS Rate,252.72,360,,,Fee schedule,360% of BCBS PPO Rate,252.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,993,60,,794.4,Percent of Total Billed Charges,60% of Total Billed Charges,58.97,100,,,Fee Schedule,100% of TX Mediciad 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,63.18,90,,,Fee Schedule,90% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.26,130,,,Fee Schedule,130% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,60.74,103,,,Fee Schedule,103% of TX Medicaid Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,1241.25,75,,238.2,Percent of Total Billed Charges,75% of Total Billed Charges,119.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,119.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,119.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,105.3,150,,,Fee Schedule,150% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.86,90,,,Fee Schedule,90% of UHC fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1655,100,,317.6,Percent of Total Billed Charges,100% of Total Billed Charges,56.86,1655,
NEPHELOMETRY EA ANALYTE,70001335,CDM,301,RC,83883,HCPCS,Outpatient,,,155,93.00,,15.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,48.96,360,,,Fee Schedule,360% of BCBS POS Rate,48.96,360,,,Fee schedule,360% of BCBS PPO Rate,48.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,93,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.42,100,,,Fee Schedule,100% of TX Mediciad 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,12.24,90,,,Fee Schedule,90% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,130,,,Fee Schedule,130% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.76,103,,,Fee Schedule,103% of TX Medicaid Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,116.25,75,,153.2,Percent of Total Billed Charges,75% of Total Billed Charges,23.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.02,90,,,Fee Schedule,90% of UHC fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,155,100,,204.264,Percent of Total Billed Charges,100% of Total Billed Charges,11.02,155,
REF CULT TYP ID NUC ACD YST ID,70001336,CDM,306,RC,87149,HCPCS,Outpatient,,,513.6,308.16,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,308.16,60,,246.528,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,385.2,75,,204.6,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,513.6,100,,272.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,513.6,
COVID 19 PCR,70001342,CDM,306,RC,86769,HCPCS,Outpatient,,,172,103.20,,84.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,63.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,117.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,134.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,151.67,360,,,Fee Schedule,360% of BCBS POS Rate,151.67,360,,,Fee schedule,360% of BCBS PPO Rate,151.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,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,37.91,90,,,Fee Schedule,90% of CMS OPPS Rate,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,54.76,130,,,Fee Schedule,130% of CMS OPPS Rate,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.8,14.42,,19.84,Percent of Total Billed Charges,14.42% of Total Billed Charges,43.39,103,,,Fee Schedule,103% of CMS OPPS Rate,43.39,103,,,Fee Schedule,103% of CMS OPPS Rate,129,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,71.62,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,71.62,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,71.62,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,71.62,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,63.19,150,,,Fee Schedule,150% of CMS OPPS Rate,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,34.13,90,,,Fee Schedule,90% of UHC fee schedule,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,24.08,14,,19.264,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,172,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,24.08,172,
COVID 19 ANITBODY IGG,70001343,CDM,301,RC,86769,HCPCS,Outpatient,,,275,165.00,,84.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,63.19,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,117.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,134.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,151.67,360,,,Fee Schedule,360% of BCBS POS Rate,151.67,360,,,Fee schedule,360% of BCBS PPO Rate,151.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,165,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,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,37.91,90,,,Fee Schedule,90% of CMS OPPS Rate,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,54.76,130,,,Fee Schedule,130% of CMS OPPS Rate,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,39.66,14.42,,31.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,43.39,103,,,Fee Schedule,103% of CMS OPPS Rate,43.39,103,,,Fee Schedule,103% of CMS OPPS Rate,206.25,75,,439.92,Percent of Total Billed Charges,75% of Total Billed Charges,71.62,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,71.62,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,71.62,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,71.62,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,63.19,150,,,Fee Schedule,150% of CMS OPPS Rate,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,34.13,90,,,Fee Schedule,90% of UHC fee schedule,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,38.5,14,,30.8,Percent of Total Billed Charges,14% of Total Billed Charges,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,275,100,,586.56,Percent of Total Billed Charges,100% of Total Billed Charges,34.13,275,
INSITU HYBRIDIZATION AUTO,70002051,CDM,312,RC,88367,HCPCS,Outpatient,,,490,294.00,,97.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,294,60,,235.2,Percent of Total Billed Charges,60% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,70.66,14.42,,56.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,367.5,75,,85.072,Percent of Total Billed Charges,75% of Total Billed Charges,245,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,245,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,245,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,245,50,,196,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,68.6,14,,54.88,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,490,100,,113.424,Percent of Total Billed Charges,100% of Total Billed Charges,68.6,1020.28,
GABAPENTIN,70002506,CDM,301,RC,80171,HCPCS,Outpatient,,,172.35,103.41,,25.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,69.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,78.01,360,,,Fee Schedule,360% of BCBS POS Rate,78.01,360,,,Fee schedule,360% of BCBS PPO Rate,78.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.41,60,,82.728,Percent of Total Billed Charges,60% of Total Billed Charges,18.2,100,,,Fee Schedule,100% of TX Mediciad 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,19.5,90,,,Fee Schedule,90% of CMS OPPS Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,130,,,Fee Schedule,130% of CMS OPPS Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.75,103,,,Fee Schedule,103% of TX Medicaid Rate,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,22.32,103,,,Fee Schedule,103% of CMS OPPS Rate,129.26,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,36.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,36.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.5,150,,,Fee Schedule,150% of CMS OPPS Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,90,,,Fee Schedule,90% of UHC fee schedule,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18.2,100,,,Fee Schedule,100% of TX Medicaid Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,172.35,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.55,172.35,
PROMETHEUS IBD SGI PCR TESTING,70002601,CDM,310,RC,81479,HCPCS,Outpatient,,,265.78,159.47,,159.47,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,92.34,360,,,Fee Schedule,360% of BCBS POS Rate,92.34,360,,,Fee schedule,360% of BCBS PPO Rate,92.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.47,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14.42,,30.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.34,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.78,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,37.21,265.78,
PROMETHEUS IBD SGI CHEMI ASSAY,70002602,CDM,301,RC,82397,HCPCS,Outpatient,,,182,109.20,,16.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,50.83,360,,,Fee Schedule,360% of BCBS POS Rate,50.83,360,,,Fee schedule,360% of BCBS PPO Rate,50.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.2,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,11.86,100,,,Fee Schedule,100% of TX Mediciad 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,12.7,90,,,Fee Schedule,90% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,18.35,130,,,Fee Schedule,130% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,103,,,Fee Schedule,103% of TX Medicaid Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,14.54,103,,,Fee Schedule,103% of CMS OPPS Rate,136.5,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,24,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,24,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.18,150,,,Fee Schedule,150% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.44,90,,,Fee Schedule,90% of UHC fee schedule,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,11.86,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.44,182,
PROMETHEUS IBD ASCA IGA,70002603,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROMETHEUS IBD ASCA IGG,70002604,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROMETHEUS IBD ANCA IGG,70002605,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROMETHEUS IBD ANTI OMPC IGA,70002606,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROMETHEUS IBD ANTI CBIR1,70002607,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROM IBD SGI IMMUNOASSAY ADDL,70002608,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
PROMETHEUS IBD SGI CRP,70002609,CDM,302,RC,86140,HCPCS,Outpatient,,,137.33,82.40,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.4,60,,65.92,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,103,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,137.33,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,137.33,
PROMETHEUS IBD DNASE IGG,70002610,CDM,312,RC,88350,HCPCS,Outpatient,,,268,160.80,,96.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,136.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,155.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,175.14,360,,,Fee Schedule,360% of BCBS POS Rate,175.14,360,,,Fee schedule,360% of BCBS PPO Rate,175.14,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.8,60,,128.64,Percent of Total Billed Charges,60% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,38.65,14.42,,30.92,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,134,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,134,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,134,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,134,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.74,90,,,Fee Schedule,90% of UHC fee schedule,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,37.52,14,,30.016,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,268,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,37.52,268,
PROMETHEUS IBD PANCA IGG,70002611,CDM,312,RC,88346,HCPCS,Outpatient,,,334,200.40,,130.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,200.4,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,48.16,14.42,,38.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,46.76,1020.28,
PROM CROHNS IMMUNOASSAY QT EA,70002612,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
DESYREL (TRAZODONE) LEVEL,70003017,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
FK-506 (TACROLIMUS),70003488,CDM,301,RC,80197,HCPCS,Outpatient,,,308.79,185.27,,15.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,38.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,49.43,360,,,Fee Schedule,360% of BCBS POS Rate,49.43,360,,,Fee schedule,360% of BCBS PPO Rate,49.43,360,,,Fee Schedule,360% of BCBS Traditional Rate,185.27,60,,148.216,Percent of Total Billed Charges,60% of Total Billed Charges,11.53,100,,,Fee Schedule,100% of TX Mediciad 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,12.35,90,,,Fee Schedule,90% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,17.84,130,,,Fee Schedule,130% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,103,,,Fee Schedule,103% of TX Medicaid Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,231.59,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,23.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.59,150,,,Fee Schedule,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,90,,,Fee Schedule,90% of UHC fee schedule,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,308.79,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.12,308.79,
PHOSPHORUS STOOL,70003489,CDM,301,RC,84100,HCPCS,Outpatient,,,84.3,50.58,,5.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.06,360,,,Fee Schedule,360% of BCBS POS Rate,17.06,360,,,Fee schedule,360% of BCBS PPO Rate,17.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,50.58,60,,40.464,Percent of Total Billed Charges,60% of Total Billed Charges,3.98,100,,,Fee Schedule,100% of TX Mediciad 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,4.26,90,,,Fee Schedule,90% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6.16,130,,,Fee Schedule,130% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.1,103,,,Fee Schedule,103% of TX Medicaid Rate,4.88,103,,,Fee Schedule,103% of CMS OPPS Rate,4.88,103,,,Fee Schedule,103% of CMS OPPS Rate,63.23,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,8.05,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.05,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.05,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.05,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.11,150,,,Fee Schedule,150% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3.84,90,,,Fee Schedule,90% of UHC fee schedule,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,3.98,100,,,Fee Schedule,100% of TX Medicaid Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,84.3,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,3.84,84.3,
VIRUS ANTIBODY NOS,70003522,CDM,302,RC,86790,HCPCS,Outpatient,,,158.75,95.25,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.25,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,119.06,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,158.75,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,158.75,
IMMUNOASSAY NONANTIBODY,70003523,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
HLA II TYPING 1 LOCUS LR,70003524,CDM,310,RC,81376,HCPCS,Outpatient,,,233.74,140.24,,141.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,183.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,342.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,391.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,439.99,360,,,Fee Schedule,360% of BCBS POS Rate,439.99,360,,,Fee schedule,360% of BCBS PPO Rate,439.99,360,,,Fee Schedule,360% of BCBS Traditional Rate,140.24,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,102.66,100,,,Fee Schedule,100% of TX Mediciad 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,109.99,90,,,Fee Schedule,90% of CMS OPPS Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,158.88,130,,,Fee Schedule,130% of CMS OPPS Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,105.74,103,,,Fee Schedule,103% of TX Medicaid Rate,125.88,103,,,Fee Schedule,103% of CMS OPPS Rate,125.88,103,,,Fee Schedule,103% of CMS OPPS Rate,175.31,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,207.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,207.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,207.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,207.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,183.33,150,,,Fee Schedule,150% of CMS OPPS Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,99,90,,,Fee Schedule,90% of UHC fee schedule,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,102.66,100,,,Fee Schedule,100% of TX Medicaid Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,233.74,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,99,439.99,
N.GONORRHOEAE RNA TMA,70020000,CDM,306,RC,87591,HCPCS,Outpatient,,,574.4,344.64,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,344.64,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,430.8,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,574.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,574.4,
T.VAGINALIS TNA TMA,70020001,CDM,306,RC,87661,HCPCS,Outpatient,,,574.4,344.64,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,344.64,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,430.8,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,574.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,574.4,
C.TRACHOMATIS RNA TMA,70020002,CDM,306,RC,87497,HCPCS,Outpatient,,,574.4,344.64,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,344.64,60,,275.712,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,430.8,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,574.4,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,574.4,
ACETYLCHOLINE RECEPTOR AB,70020003,CDM,301,RC,84238,HCPCS,Outpatient,,,367,220.20,,42.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,54.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,102.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,117.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,131.65,360,,,Fee Schedule,360% of BCBS POS Rate,131.65,360,,,Fee schedule,360% of BCBS PPO Rate,131.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,220.2,60,,176.16,Percent of Total Billed Charges,60% of Total Billed Charges,30.72,100,,,Fee Schedule,100% of TX Mediciad 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,32.91,90,,,Fee Schedule,90% of CMS OPPS Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,47.54,130,,,Fee Schedule,130% of CMS OPPS Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,31.64,103,,,Fee Schedule,103% of TX Medicaid Rate,37.66,103,,,Fee Schedule,103% of CMS OPPS Rate,37.66,103,,,Fee Schedule,103% of CMS OPPS Rate,275.25,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,62.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,62.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,62.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,54.85,150,,,Fee Schedule,150% of CMS OPPS Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,90,,,Fee Schedule,90% of UHC fee schedule,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,30.72,100,,,Fee Schedule,100% of TX Medicaid Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,367,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,29.62,367,
CHRONIC LYMPHOCYTIC LEUKEMIA PANEL,70020004,CDM,306,RC,88271,HCPCS,Outpatient,,,4077.24,2446.34,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,77.11,360,,,Fee Schedule,360% of BCBS POS Rate,77.11,360,,,Fee schedule,360% of BCBS PPO Rate,77.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,2446.34,60,,1957.072,Percent of Total Billed Charges,60% of Total Billed Charges,17.99,100,,,Fee Schedule,100% of TX Mediciad 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,19.27,90,,,Fee Schedule,90% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,130,,,Fee Schedule,130% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,18.53,103,,,Fee Schedule,103% of TX Medicaid Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,3057.93,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,36.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,36.41,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.41,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.13,150,,,Fee Schedule,150% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.35,90,,,Fee Schedule,90% of UHC fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,4077.24,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.35,4077.24,
MONONUCLEAR CELL AG QN EA,70020186,CDM,302,RC,86356,HCPCS,Outpatient,,,224,134.40,,31.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,96.41,360,,,Fee Schedule,360% of BCBS POS Rate,96.41,360,,,Fee schedule,360% of BCBS PPO Rate,96.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,134.4,60,,107.52,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,100,,,Fee Schedule,100% of TX Mediciad 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,24.1,90,,,Fee Schedule,90% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,130,,,Fee Schedule,130% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,23.18,103,,,Fee Schedule,103% of TX Medicaid Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,168,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,45.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.17,150,,,Fee Schedule,150% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.69,90,,,Fee Schedule,90% of UHC fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,224,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.69,224,
CATECHOLAMINES FRACT,70020201,CDM,301,RC,82384,HCPCS,Outpatient,,,249,149.40,,29.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,70.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,80.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,90.9,360,,,Fee Schedule,360% of BCBS POS Rate,90.9,360,,,Fee schedule,360% of BCBS PPO Rate,90.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,149.4,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,21.21,100,,,Fee Schedule,100% of TX Mediciad 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,22.72,90,,,Fee Schedule,90% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,32.82,130,,,Fee Schedule,130% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.85,103,,,Fee Schedule,103% of TX Medicaid Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,186.75,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,42.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,42.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.87,150,,,Fee Schedule,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,90,,,Fee Schedule,90% of UHC fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,249,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,20.46,249,
ACTH,70020243,CDM,300,RC,82024,HCPCS,Outpatient,,,332.95,199.77,,44.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,57.93,150,,,Fee Schedule ,150% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,108.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,360,,,Fee Schedule,360% of BCBS POS Rate,139.03,360,,,Fee schedule,360% of BCBS PPO Rate,139.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,199.77,60,,159.816,Percent of Total Billed Charges,60% of Total Billed Charges,32.44,100,,,Fee Schedule,100% of TX Mediciad 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,34.75,90,,,Fee Schedule,90% of CMS OPPS Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,130,,,Fee Schedule,130% of CMS OPPS Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,33.41,103,,,Fee Schedule,103% of TX Medicaid Rate,39.77,103,,,Fee Schedule,103% of CMS OPPS Rate,39.77,103,,,Fee Schedule,103% of CMS OPPS Rate,249.71,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,65.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,65.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,65.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,65.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,57.93,150,,,Fee Schedule,150% of CMS OPPS Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,90,,,Fee Schedule,90% of UHC fee schedule,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,32.44,100,,,Fee Schedule,100% of TX Medicaid Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,332.95,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,31.28,332.95,
MICROALBUMIN URINE QT,70020433,CDM,307,RC,82043,HCPCS,Outpatient,,,135.96,81.58,,6.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,360,,,Fee Schedule,360% of BCBS POS Rate,20.81,360,,,Fee schedule,360% of BCBS PPO Rate,20.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.58,60,,65.264,Percent of Total Billed Charges,60% of Total Billed Charges,4.86,100,,,Fee Schedule,100% of TX Mediciad 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,5.2,90,,,Fee Schedule,90% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.51,130,,,Fee Schedule,130% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.01,103,,,Fee Schedule,103% of TX Medicaid Rate,5.95,103,,,Fee Schedule,103% of CMS OPPS Rate,5.95,103,,,Fee Schedule,103% of CMS OPPS Rate,101.97,75,,54.728,Percent of Total Billed Charges,75% of Total Billed Charges,9.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.67,150,,,Fee Schedule,150% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4.68,90,,,Fee Schedule,90% of UHC fee schedule,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,135.96,100,,72.968,Percent of Total Billed Charges,100% of Total Billed Charges,4.68,135.96,
PLATE AGG RISTOCETIN,70020442,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,103.768,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,138.36,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATE AGG ADP,70020443,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,207.032,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,276.04,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATE AGG ARACH ACID,70020444,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,117.288,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,156.384,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATE AGG COLLAGEN,70020445,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,143.728,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,191.632,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATE AGG EPINEPHRINE,70020446,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,83.28,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,111.04,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
PLATE AGG SPONTANEOUS,70020447,CDM,305,RC,85576,HCPCS,Outpatient,,,235,141.00,,28.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,89.68,360,,,Fee Schedule,360% of BCBS POS Rate,89.68,360,,,Fee schedule,360% of BCBS PPO Rate,89.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,141,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,20.92,100,,,Fee Schedule,100% of TX Mediciad 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,22.41,90,,,Fee Schedule,90% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,32.38,130,,,Fee Schedule,130% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,21.55,103,,,Fee Schedule,103% of TX Medicaid Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,25.65,103,,,Fee Schedule,103% of CMS OPPS Rate,176.25,75,,119.128,Percent of Total Billed Charges,75% of Total Billed Charges,42.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.36,150,,,Fee Schedule,150% of CMS OPPS Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.18,90,,,Fee Schedule,90% of UHC fee schedule,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,20.92,100,,,Fee Schedule,100% of TX Medicaid Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,235,100,,158.832,Percent of Total Billed Charges,100% of Total Billed Charges,20.18,235,
GLIADIN ANTIBODY IGG,70020452,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,76.944,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,102.592,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
IMMUNOASSAY TRANSGLUT IGA AB,70020453,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,294,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,392,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
IMMUNOASSAY TRANSGLUT IGG AB,70020454,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,308.504,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,411.336,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
ENDOMYSIAL AB IGA,70020455,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,241.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,321.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
AB EBV NUCLEAR ANTIGEN,70020462,CDM,302,RC,86664,HCPCS,Outpatient,,,159.1,95.46,,17.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.93,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,42.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,55.04,360,,,Fee Schedule,360% of BCBS POS Rate,55.04,360,,,Fee schedule,360% of BCBS PPO Rate,55.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.46,60,,76.368,Percent of Total Billed Charges,60% of Total Billed Charges,12.84,100,,,Fee Schedule,100% of TX Mediciad 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,13.76,90,,,Fee Schedule,90% of CMS OPPS Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,19.87,130,,,Fee Schedule,130% of CMS OPPS Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,13.23,103,,,Fee Schedule,103% of TX Medicaid Rate,15.74,103,,,Fee Schedule,103% of CMS OPPS Rate,15.74,103,,,Fee Schedule,103% of CMS OPPS Rate,119.33,75,,290.4,Percent of Total Billed Charges,75% of Total Billed Charges,25.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.93,150,,,Fee Schedule,150% of CMS OPPS Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,90,,,Fee Schedule,90% of UHC fee schedule,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.84,100,,,Fee Schedule,100% of TX Medicaid Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,159.1,100,,387.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.38,159.1,
AB EBV VIRAL CAPSID IGG,70020463,CDM,302,RC,86665,HCPCS,Outpatient,,,179.12,107.47,,21.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,65.3,360,,,Fee Schedule,360% of BCBS POS Rate,65.3,360,,,Fee schedule,360% of BCBS PPO Rate,65.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.47,60,,85.976,Percent of Total Billed Charges,60% of Total Billed Charges,15.24,100,,,Fee Schedule,100% of TX Mediciad 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,16.32,90,,,Fee Schedule,90% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23.58,130,,,Fee Schedule,130% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.7,103,,,Fee Schedule,103% of TX Medicaid Rate,18.68,103,,,Fee Schedule,103% of CMS OPPS Rate,18.68,103,,,Fee Schedule,103% of CMS OPPS Rate,134.34,75,,273.72,Percent of Total Billed Charges,75% of Total Billed Charges,30.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.21,150,,,Fee Schedule,150% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,90,,,Fee Schedule,90% of UHC fee schedule,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,179.12,100,,364.96,Percent of Total Billed Charges,100% of Total Billed Charges,14.7,179.12,
AB EBV VIRAL CAPSID IGM,70020464,CDM,302,RC,86665,HCPCS,Outpatient,,,179.12,107.47,,21.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,65.3,360,,,Fee Schedule,360% of BCBS POS Rate,65.3,360,,,Fee schedule,360% of BCBS PPO Rate,65.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.47,60,,85.976,Percent of Total Billed Charges,60% of Total Billed Charges,15.24,100,,,Fee Schedule,100% of TX Mediciad 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,16.32,90,,,Fee Schedule,90% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23.58,130,,,Fee Schedule,130% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.7,103,,,Fee Schedule,103% of TX Medicaid Rate,18.68,103,,,Fee Schedule,103% of CMS OPPS Rate,18.68,103,,,Fee Schedule,103% of CMS OPPS Rate,134.34,75,,277.2,Percent of Total Billed Charges,75% of Total Billed Charges,30.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.21,150,,,Fee Schedule,150% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,90,,,Fee Schedule,90% of UHC fee schedule,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,15.24,100,,,Fee Schedule,100% of TX Medicaid Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,179.12,100,,369.6,Percent of Total Billed Charges,100% of Total Billed Charges,14.7,179.12,
CADMIUM,70020472,CDM,301,RC,82300,HCPCS,Outpatient,,,145.88,87.53,,27.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,66.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,360,,,Fee Schedule,360% of BCBS POS Rate,85.1,360,,,Fee schedule,360% of BCBS PPO Rate,85.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,87.53,60,,70.024,Percent of Total Billed Charges,60% of Total Billed Charges,19.86,100,,,Fee Schedule,100% of TX Mediciad 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,21.27,90,,,Fee Schedule,90% of CMS OPPS Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,30.73,130,,,Fee Schedule,130% of CMS OPPS Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,103,,,Fee Schedule,103% of TX Medicaid Rate,24.34,103,,,Fee Schedule,103% of CMS OPPS Rate,24.34,103,,,Fee Schedule,103% of CMS OPPS Rate,109.41,75,,1125.8,Percent of Total Billed Charges,75% of Total Billed Charges,40.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,40.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.46,150,,,Fee Schedule,150% of CMS OPPS Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,19.15,90,,,Fee Schedule,90% of UHC fee schedule,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,19.86,100,,,Fee Schedule,100% of TX Medicaid Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,145.88,100,,1501.064,Percent of Total Billed Charges,100% of Total Billed Charges,19.15,145.88,
BCR/ABL MAJOR BRKPNT,70020482,CDM,310,RC,81206,HCPCS,Outpatient,,,1532.6,919.56,,190.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,245.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,459.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,524.67,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,590.26,360,,,Fee Schedule,360% of BCBS POS Rate,590.26,360,,,Fee schedule,360% of BCBS PPO Rate,590.26,360,,,Fee Schedule,360% of BCBS Traditional Rate,919.56,60,,735.648,Percent of Total Billed Charges,60% of Total Billed Charges,137.73,100,,,Fee Schedule,100% of TX Mediciad 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,147.56,90,,,Fee Schedule,90% of CMS OPPS Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,213.14,130,,,Fee Schedule,130% of CMS OPPS Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,141.86,103,,,Fee Schedule,103% of TX Medicaid Rate,168.87,103,,,Fee Schedule,103% of CMS OPPS Rate,168.87,103,,,Fee Schedule,103% of CMS OPPS Rate,1149.45,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,278.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,278.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,278.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,278.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,245.94,150,,,Fee Schedule,150% of CMS OPPS Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,132.8,90,,,Fee Schedule,90% of UHC fee schedule,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,137.73,100,,,Fee Schedule,100% of TX Medicaid Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1532.6,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,132.8,1532.6,
BCR/ABL MINOR BRKPNT,70020483,CDM,310,RC,81207,HCPCS,Outpatient,,,1353.76,812.26,,168.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,217.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,405.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,463.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,521.42,360,,,Fee Schedule,360% of BCBS POS Rate,521.42,360,,,Fee schedule,360% of BCBS PPO Rate,521.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,812.26,60,,649.808,Percent of Total Billed Charges,60% of Total Billed Charges,121.67,100,,,Fee Schedule,100% of TX Mediciad 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,130.35,90,,,Fee Schedule,90% of CMS OPPS Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,188.29,130,,,Fee Schedule,130% of CMS OPPS Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,125.32,103,,,Fee Schedule,103% of TX Medicaid Rate,149.18,103,,,Fee Schedule,103% of CMS OPPS Rate,149.18,103,,,Fee Schedule,103% of CMS OPPS Rate,1015.32,75,,309.328,Percent of Total Billed Charges,75% of Total Billed Charges,246.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,246.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,246.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,246.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,217.26,150,,,Fee Schedule,150% of CMS OPPS Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,117.32,90,,,Fee Schedule,90% of UHC fee schedule,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,121.67,100,,,Fee Schedule,100% of TX Medicaid Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.76,100,,412.44,Percent of Total Billed Charges,100% of Total Billed Charges,117.32,1353.76,
DRVVT,70020503,CDM,305,RC,85613,HCPCS,Outpatient,,,159.5,95.70,,11.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,34.49,360,,,Fee Schedule,360% of BCBS POS Rate,34.49,360,,,Fee schedule,360% of BCBS PPO Rate,34.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.7,60,,76.56,Percent of Total Billed Charges,60% of Total Billed Charges,8.05,100,,,Fee Schedule,100% of TX Mediciad 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,8.62,90,,,Fee Schedule,90% of CMS OPPS Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.45,130,,,Fee Schedule,130% of CMS OPPS Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.29,103,,,Fee Schedule,103% of TX Medicaid Rate,9.86,103,,,Fee Schedule,103% of CMS OPPS Rate,9.86,103,,,Fee Schedule,103% of CMS OPPS Rate,119.63,75,,233.568,Percent of Total Billed Charges,75% of Total Billed Charges,16.28,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.28,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,16.28,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.28,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.37,150,,,Fee Schedule,150% of CMS OPPS Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7.76,90,,,Fee Schedule,90% of UHC fee schedule,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,8.05,100,,,Fee Schedule,100% of TX Medicaid Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,159.5,100,,311.424,Percent of Total Billed Charges,100% of Total Billed Charges,7.76,159.5,
PTT MIXING OR DILUTING,70020504,CDM,305,RC,85732,HCPCS,Outpatient,,,125,75.00,,7.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,23.29,360,,,Fee Schedule,360% of BCBS POS Rate,23.29,360,,,Fee schedule,360% of BCBS PPO Rate,23.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,75,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,100,,,Fee Schedule,100% of TX Mediciad 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,5.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,130,,,Fee Schedule,130% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.59,103,,,Fee Schedule,103% of TX Medicaid Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,93.75,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,10.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,10.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,9.7,150,,,Fee Schedule,150% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,90,,,Fee Schedule,90% of UHC fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,125,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,5.24,125,
PROM THIOP 6MMPN HPLC,70020512,CDM,301,RC,82542,HCPCS,Outpatient,,,271,162.60,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,162.6,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,203.25,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,271,
PROM THIOPU 6TGN HPLC,70020513,CDM,301,RC,82542,HCPCS,Outpatient,,,271,162.60,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,162.6,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,203.25,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,271,
AMIODARONE LEVEL,70020652,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,125.024,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,166.696,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
SMEAR INC BODIES MICROSPORIDIA,70020662,CDM,306,RC,87207,HCPCS,Outpatient,,,160.41,96.25,,6.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,19.17,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,21.56,360,,,Fee Schedule,360% of BCBS POS Rate,21.56,360,,,Fee schedule,360% of BCBS PPO Rate,21.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,96.25,60,,77,Percent of Total Billed Charges,60% of Total Billed Charges,5.03,100,,,Fee Schedule,100% of TX Mediciad 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,5.39,90,,,Fee Schedule,90% of CMS OPPS Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,130,,,Fee Schedule,130% of CMS OPPS Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,103,,,Fee Schedule,103% of TX Medicaid Rate,6.16,103,,,Fee Schedule,103% of CMS OPPS Rate,6.16,103,,,Fee Schedule,103% of CMS OPPS Rate,120.31,75,,135.992,Percent of Total Billed Charges,75% of Total Billed Charges,10.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,10.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.98,150,,,Fee Schedule,150% of CMS OPPS Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,4.85,90,,,Fee Schedule,90% of UHC fee schedule,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.03,100,,,Fee Schedule,100% of TX Medicaid Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,160.41,100,,181.32,Percent of Total Billed Charges,100% of Total Billed Charges,4.85,160.41,
RSV VIRUS A RT-PCR,70020672,CDM,306,RC,87637,HCPCS,Outpatient,,,369.54,221.72,,285.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,513.47,360,,,Fee Schedule,360% of BCBS POS Rate,513.47,360,,,Fee schedule,360% of BCBS PPO Rate,513.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,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,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,53.29,14.42,,42.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,96.384,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.51,90,,,Fee Schedule,90% of UHC fee schedule,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,128.512,Percent of Total Billed Charges,100% of Total Billed Charges,51.74,513.47,
RSV VIRUS B RT-PCR,70020673,CDM,306,RC,87637,HCPCS,Outpatient,,,369.54,221.72,,285.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,513.47,360,,,Fee Schedule,360% of BCBS POS Rate,513.47,360,,,Fee schedule,360% of BCBS PPO Rate,513.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,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,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,53.29,14.42,,42.632,Percent of Total Billed Charges,14.42% of Total Billed Charges,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,149.104,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.51,90,,,Fee Schedule,90% of UHC fee schedule,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,51.74,14,,41.392,Percent of Total Billed Charges,14% of Total Billed Charges,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,198.8,Percent of Total Billed Charges,100% of Total Billed Charges,51.74,513.47,
DRUG SCREEN NONFORENSIC,70020681,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,143.728,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,191.64,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
BENZODIAZEPINES CLONAZEPAM,70020682,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,142.872,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,190.496,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
SIROLIMUS,70020684,CDM,301,RC,80195,HCPCS,Outpatient,,,239,143.40,,15.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,38.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,49.43,360,,,Fee Schedule,360% of BCBS POS Rate,49.43,360,,,Fee schedule,360% of BCBS PPO Rate,49.43,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.4,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.53,100,,,Fee Schedule,100% of TX Mediciad 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,12.35,90,,,Fee Schedule,90% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,17.84,130,,,Fee Schedule,130% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,103,,,Fee Schedule,103% of TX Medicaid Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,14.14,103,,,Fee Schedule,103% of CMS OPPS Rate,179.25,75,,204.976,Percent of Total Billed Charges,75% of Total Billed Charges,23.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.59,150,,,Fee Schedule,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,90,,,Fee Schedule,90% of UHC fee schedule,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of TX Medicaid Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,239,100,,273.296,Percent of Total Billed Charges,100% of Total Billed Charges,11.12,239,
TOPIRAMATE (TOPAMAX) LEVEL,70020685,CDM,301,RC,80201,HCPCS,Outpatient,,,177.67,106.60,,13.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,42.91,360,,,Fee Schedule,360% of BCBS POS Rate,42.91,360,,,Fee schedule,360% of BCBS PPO Rate,42.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.6,60,,85.28,Percent of Total Billed Charges,60% of Total Billed Charges,10.01,100,,,Fee Schedule,100% of TX Mediciad 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,10.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,130,,,Fee Schedule,130% of CMS OPPS Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.31,103,,,Fee Schedule,103% of TX Medicaid Rate,12.27,103,,,Fee Schedule,103% of CMS OPPS Rate,12.27,103,,,Fee Schedule,103% of CMS OPPS Rate,133.25,75,,64.696,Percent of Total Billed Charges,75% of Total Billed Charges,20.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.88,150,,,Fee Schedule,150% of CMS OPPS Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.66,90,,,Fee Schedule,90% of UHC fee schedule,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,100,,,Fee Schedule,100% of TX Medicaid Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,177.67,100,,86.256,Percent of Total Billed Charges,100% of Total Billed Charges,9.66,177.67,
NORDOXEPINE,70020686,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,32.088,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,42.784,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
OXCARBAZEPINE (TRILEPTAL),70020688,CDM,301,RC,80183,HCPCS,Outpatient,,,219.65,131.79,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.79,60,,105.432,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,164.74,75,,624,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,219.65,100,,832,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,219.65,
LEVETIRACETAM (KEPPRA) LEVEL,70020689,CDM,301,RC,80177,HCPCS,Outpatient,,,187,112.20,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.2,60,,89.76,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,140.25,75,,562.32,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,187,100,,749.76,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,187,
BCL 2/JH GENE REARRANGEMENT,70020690,CDM,301,RC,81402,HCPCS,Outpatient,,,823.33,494.00,,174.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,225.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,420.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,481.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,541.19,360,,,Fee Schedule,360% of BCBS POS Rate,541.19,360,,,Fee schedule,360% of BCBS PPO Rate,541.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,494,60,,395.2,Percent of Total Billed Charges,60% of Total Billed Charges,126.28,100,,,Fee Schedule,100% of TX Mediciad 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,135.29,90,,,Fee Schedule,90% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.42,130,,,Fee Schedule,130% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,130.07,103,,,Fee Schedule,103% of TX Medicaid Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,617.5,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,255.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,255.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,255.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,225.49,150,,,Fee Schedule,150% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,121.77,90,,,Fee Schedule,90% of UHC fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,823.33,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,121.77,823.33,
CFTR GENE MUTATION ANALYSIS,70020692,CDM,310,RC,81220,HCPCS,Outpatient,,,2060.57,1236.34,,645.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,834.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1558.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1781.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,2003.76,360,,,Fee Schedule,360% of BCBS POS Rate,2003.76,360,,,Fee schedule,360% of BCBS PPO Rate,2003.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,1236.34,60,,989.072,Percent of Total Billed Charges,60% of Total Billed Charges,467.54,100,,,Fee Schedule,100% of TX Mediciad 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,500.94,90,,,Fee Schedule,90% of CMS OPPS Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,723.58,130,,,Fee Schedule,130% of CMS OPPS Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,481.57,103,,,Fee Schedule,103% of TX Medicaid Rate,573.29,103,,,Fee Schedule,103% of CMS OPPS Rate,573.29,103,,,Fee Schedule,103% of CMS OPPS Rate,1545.43,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,946.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,946.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,946.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,946.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,834.9,150,,,Fee Schedule,150% of CMS OPPS Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,450.85,90,,,Fee Schedule,90% of UHC fee schedule,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,467.54,100,,,Fee Schedule,100% of TX Medicaid Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.57,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,450.85,2060.57,
FLT3 MUTATION DETECTION BY PCR,70020693,CDM,310,RC,81245,HCPCS,Outpatient,,,729.04,437.42,,192,100,,,Fee Schedule,100% of Aetna Fee Schedule,248.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,463.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,529.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,595.84,360,,,Fee Schedule,360% of BCBS POS Rate,595.84,360,,,Fee schedule,360% of BCBS PPO Rate,595.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,437.42,60,,349.936,Percent of Total Billed Charges,60% of Total Billed Charges,139.03,100,,,Fee Schedule,100% of TX Mediciad Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.95,90,,,Fee Schedule,90% of CMS OPPS Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,215.16,130,,,Fee Schedule,130% of CMS OPPS Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,143.2,103,,,Fee Schedule,103% of TX Medicaid Rate,170.47,103,,,Fee Schedule,103% of CMS OPPS Rate,170.47,103,,,Fee Schedule,103% of CMS OPPS Rate,546.78,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,281.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,281.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,281.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,281.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,248.26,150,,,Fee Schedule,150% of CMS OPPS Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.06,90,,,Fee Schedule,90% of UHC fee schedule,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,139.03,100,,,Fee Schedule,100% of TX Medicaid Rate,165.51,100,,,Fee Schedule,100% of CMS OPPS Rate,729.04,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,134.06,729.04,
HEMOCHROMATOSIS GENE ANALYSIS,70020694,CDM,310,RC,81256,HCPCS,Outpatient,,,577.16,346.30,,75.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,98.04,150,,,Fee Schedule ,150% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,183.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,209.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,235.3,360,,,Fee Schedule,360% of BCBS POS Rate,235.3,360,,,Fee schedule,360% of BCBS PPO Rate,235.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,346.3,60,,277.04,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,100,,,Fee Schedule,100% of TX Mediciad 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,58.82,90,,,Fee Schedule,90% of CMS OPPS Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,84.96,130,,,Fee Schedule,130% of CMS OPPS Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,56.55,103,,,Fee Schedule,103% of TX Medicaid Rate,67.32,103,,,Fee Schedule,103% of CMS OPPS Rate,67.32,103,,,Fee Schedule,103% of CMS OPPS Rate,432.87,75,,562.32,Percent of Total Billed Charges,75% of Total Billed Charges,111.11,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,111.11,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,111.11,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,111.11,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,98.04,150,,,Fee Schedule,150% of CMS OPPS Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,52.94,90,,,Fee Schedule,90% of UHC fee schedule,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,54.9,100,,,Fee Schedule,100% of TX Medicaid Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,577.16,100,,749.76,Percent of Total Billed Charges,100% of Total Billed Charges,52.94,577.16,
JAK2 V617F MUTATION BY PCR,70020696,CDM,310,RC,81270,HCPCS,Outpatient,,,552.17,331.30,,106.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,137.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,256.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,293.31,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,329.98,360,,,Fee Schedule,360% of BCBS POS Rate,329.98,360,,,Fee schedule,360% of BCBS PPO Rate,329.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,331.3,60,,265.04,Percent of Total Billed Charges,60% of Total Billed Charges,76.99,100,,,Fee Schedule,100% of TX Mediciad 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,82.49,90,,,Fee Schedule,90% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,119.15,130,,,Fee Schedule,130% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,79.3,103,,,Fee Schedule,103% of TX Medicaid Rate,94.4,103,,,Fee Schedule,103% of CMS OPPS Rate,94.4,103,,,Fee Schedule,103% of CMS OPPS Rate,414.13,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,155.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,155.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,155.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,155.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,137.49,150,,,Fee Schedule,150% of CMS OPPS Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,74.24,90,,,Fee Schedule,90% of UHC fee schedule,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,76.99,100,,,Fee Schedule,100% of TX Medicaid Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,552.17,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,74.24,552.17,
MTHFR,70020697,CDM,310,RC,81291,HCPCS,Outpatient,,,594.68,356.81,,75.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,98.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,182.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,209.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,235.22,360,,,Fee Schedule,360% of BCBS POS Rate,235.22,360,,,Fee schedule,360% of BCBS PPO Rate,235.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,356.81,60,,285.448,Percent of Total Billed Charges,60% of Total Billed Charges,54.89,100,,,Fee Schedule,100% of TX Mediciad 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,58.8,90,,,Fee Schedule,90% of CMS OPPS Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,84.94,130,,,Fee Schedule,130% of CMS OPPS Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,56.54,103,,,Fee Schedule,103% of TX Medicaid Rate,67.3,103,,,Fee Schedule,103% of CMS OPPS Rate,67.3,103,,,Fee Schedule,103% of CMS OPPS Rate,446.01,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,111.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,111.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,111.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,111.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,98.01,150,,,Fee Schedule,150% of CMS OPPS Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,52.93,90,,,Fee Schedule,90% of UHC fee schedule,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,54.89,100,,,Fee Schedule,100% of TX Medicaid Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,594.68,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,52.93,594.68,
NPM1 GENE MUTATION BY PCR,70020698,CDM,310,RC,81310,HCPCS,Outpatient,,,652.22,391.33,,285.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,369.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,690.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,788.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,887.47,360,,,Fee Schedule,360% of BCBS POS Rate,887.47,360,,,Fee schedule,360% of BCBS PPO Rate,887.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,391.33,60,,313.064,Percent of Total Billed Charges,60% of Total Billed Charges,207.08,100,,,Fee Schedule,100% of TX Mediciad Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,221.86,90,,,Fee Schedule,90% of CMS OPPS Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,320.47,130,,,Fee Schedule,130% of CMS OPPS Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,213.29,103,,,Fee Schedule,103% of TX Medicaid Rate,253.91,103,,,Fee Schedule,103% of CMS OPPS Rate,253.91,103,,,Fee Schedule,103% of CMS OPPS Rate,489.17,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,419.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,419.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,419.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,419.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,369.78,150,,,Fee Schedule,150% of CMS OPPS Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,199.68,90,,,Fee Schedule,90% of UHC fee schedule,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,207.08,100,,,Fee Schedule,100% of TX Medicaid Rate,246.52,100,,,Fee Schedule,100% of CMS OPPS Rate,652.22,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,199.68,887.47,
5 FLUCYTOSINE ANTIMICROBIAL,70020700,CDM,301,RC,82542,HCPCS,Outpatient,,,252.68,151.61,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,151.61,60,,121.288,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,189.51,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252.68,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,252.68,
B-HYDROXYBUTYRATE,70020702,CDM,301,RC,82010,HCPCS,Outpatient,,,121,72.60,,9.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.41,360,,,Fee Schedule,360% of BCBS POS Rate,29.41,360,,,Fee schedule,360% of BCBS PPO Rate,29.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,6.86,100,,,Fee Schedule,100% of TX Mediciad 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,7.35,90,,,Fee Schedule,90% of CMS OPPS Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,130,,,Fee Schedule,130% of CMS OPPS Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,7.07,103,,,Fee Schedule,103% of TX Medicaid Rate,8.41,103,,,Fee Schedule,103% of CMS OPPS Rate,8.41,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,13.88,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.88,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,13.88,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.88,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.25,150,,,Fee Schedule,150% of CMS OPPS Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,6.62,90,,,Fee Schedule,90% of UHC fee schedule,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,6.86,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.62,121,
ANGIOTENSIN I CONV ENZYME CSF,70020703,CDM,301,RC,82164,HCPCS,Outpatient,,,207.93,124.76,,16.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,40.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,52.56,360,,,Fee Schedule,360% of BCBS POS Rate,52.56,360,,,Fee schedule,360% of BCBS PPO Rate,52.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,124.76,60,,99.808,Percent of Total Billed Charges,60% of Total Billed Charges,12.26,100,,,Fee Schedule,100% of TX Mediciad 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,13.14,90,,,Fee Schedule,90% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.98,130,,,Fee Schedule,130% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,103,,,Fee Schedule,103% of TX Medicaid Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,15.03,103,,,Fee Schedule,103% of CMS OPPS Rate,155.95,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,24.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,24.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.9,150,,,Fee Schedule,150% of CMS OPPS Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.83,90,,,Fee Schedule,90% of UHC fee schedule,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,12.26,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,207.93,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,11.83,207.93,
APOLIPOPROTEIN B,70020705,CDM,301,RC,82172,HCPCS,Outpatient,,,130.53,78.32,,24.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,75.92,360,,,Fee Schedule,360% of BCBS POS Rate,75.92,360,,,Fee schedule,360% of BCBS PPO Rate,75.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.32,60,,62.656,Percent of Total Billed Charges,60% of Total Billed Charges,17.72,100,,,Fee Schedule,100% of TX Mediciad 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,18.98,90,,,Fee Schedule,90% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.41,130,,,Fee Schedule,130% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,18.25,103,,,Fee Schedule,103% of TX Medicaid Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,21.72,103,,,Fee Schedule,103% of CMS OPPS Rate,97.9,75,,181.952,Percent of Total Billed Charges,75% of Total Billed Charges,35.85,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.85,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.85,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.63,150,,,Fee Schedule,150% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.08,90,,,Fee Schedule,90% of UHC fee schedule,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,17.72,100,,,Fee Schedule,100% of TX Medicaid Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,130.53,100,,242.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.08,130.53,
CATECHOLAMINES FRACT URINE,70020706,CDM,301,RC,82384,HCPCS,Outpatient,,,249,149.40,,29.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,70.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,80.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,90.9,360,,,Fee Schedule,360% of BCBS POS Rate,90.9,360,,,Fee schedule,360% of BCBS PPO Rate,90.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,149.4,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,21.21,100,,,Fee Schedule,100% of TX Mediciad 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,22.72,90,,,Fee Schedule,90% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,32.82,130,,,Fee Schedule,130% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.85,103,,,Fee Schedule,103% of TX Medicaid Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,26,103,,,Fee Schedule,103% of CMS OPPS Rate,186.75,75,,151.232,Percent of Total Billed Charges,75% of Total Billed Charges,42.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,42.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.87,150,,,Fee Schedule,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,90,,,Fee Schedule,90% of UHC fee schedule,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of TX Medicaid Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,249,100,,201.64,Percent of Total Billed Charges,100% of Total Billed Charges,20.46,249,
PTH RELATED PEPTIDE,70020707,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,267.736,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,356.976,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
IMMUNOASSAY HISTONE AUTOAB,70020710,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,106.136,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,141.512,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
CRYOFIBRINOGEN,70020712,CDM,301,RC,82585,HCPCS,Outpatient,,,90,54.00,,16.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,39.59,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,50.9,360,,,Fee Schedule,360% of BCBS POS Rate,50.9,360,,,Fee schedule,360% of BCBS PPO Rate,50.9,360,,,Fee Schedule,360% of BCBS Traditional Rate,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,11.88,100,,,Fee Schedule,100% of TX Mediciad 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,12.72,90,,,Fee Schedule,90% of CMS OPPS Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.38,130,,,Fee Schedule,130% of CMS OPPS Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.24,103,,,Fee Schedule,103% of TX Medicaid Rate,14.56,103,,,Fee Schedule,103% of CMS OPPS Rate,14.56,103,,,Fee Schedule,103% of CMS OPPS Rate,67.5,75,,86.24,Percent of Total Billed Charges,75% of Total Billed Charges,24.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,24.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.21,150,,,Fee Schedule,150% of CMS OPPS Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11.46,90,,,Fee Schedule,90% of UHC fee schedule,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.88,100,,,Fee Schedule,100% of TX Medicaid Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,90,100,,114.984,Percent of Total Billed Charges,100% of Total Billed Charges,11.46,90,
CRYOGLOBULIN QL,70020713,CDM,301,RC,82595,HCPCS,Outpatient,,,107,64.20,,7.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,23.29,360,,,Fee Schedule,360% of BCBS POS Rate,23.29,360,,,Fee schedule,360% of BCBS PPO Rate,23.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.2,60,,51.36,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,100,,,Fee Schedule,100% of TX Mediciad 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,5.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,130,,,Fee Schedule,130% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.59,103,,,Fee Schedule,103% of TX Medicaid Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,80.25,75,,151.232,Percent of Total Billed Charges,75% of Total Billed Charges,10.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,10.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,9.7,150,,,Fee Schedule,150% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,90,,,Fee Schedule,90% of UHC fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,107,100,,201.64,Percent of Total Billed Charges,100% of Total Billed Charges,5.24,107,
FAT FECES QT,70020716,CDM,301,RC,82710,HCPCS,Outpatient,,,1086,651.60,,19.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,47.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,60.48,360,,,Fee Schedule,360% of BCBS POS Rate,60.48,360,,,Fee schedule,360% of BCBS PPO Rate,60.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,651.6,60,,521.28,Percent of Total Billed Charges,60% of Total Billed Charges,14.11,100,,,Fee Schedule,100% of TX Mediciad 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,15.12,90,,,Fee Schedule,90% of CMS OPPS Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,130,,,Fee Schedule,130% of CMS OPPS Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.53,103,,,Fee Schedule,103% of TX Medicaid Rate,17.3,103,,,Fee Schedule,103% of CMS OPPS Rate,17.3,103,,,Fee Schedule,103% of CMS OPPS Rate,814.5,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,28.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,28.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.2,150,,,Fee Schedule,150% of CMS OPPS Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,90,,,Fee Schedule,90% of UHC fee schedule,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,14.11,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1086,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,13.61,1086,
FRUCTOSAMINE,70020717,CDM,301,RC,82985,HCPCS,Outpatient,,,126,75.60,,19.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,60.34,360,,,Fee Schedule,360% of BCBS POS Rate,60.34,360,,,Fee schedule,360% of BCBS PPO Rate,60.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,75.6,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,14.08,100,,,Fee Schedule,100% of TX Mediciad 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,15.08,90,,,Fee Schedule,90% of CMS OPPS Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,130,,,Fee Schedule,130% of CMS OPPS Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.5,103,,,Fee Schedule,103% of TX Medicaid Rate,17.26,103,,,Fee Schedule,103% of CMS OPPS Rate,17.26,103,,,Fee Schedule,103% of CMS OPPS Rate,94.5,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,28.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,28.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.14,150,,,Fee Schedule,150% of CMS OPPS Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.57,90,,,Fee Schedule,90% of UHC fee schedule,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.08,100,,,Fee Schedule,100% of TX Medicaid Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,126,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,13.57,126,
HEMOGLOBIN CHROMATOGRAPHY,70020719,CDM,301,RC,83021,HCPCS,Outpatient,,,193.2,115.92,,20.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,50.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,65.02,360,,,Fee Schedule,360% of BCBS POS Rate,65.02,360,,,Fee schedule,360% of BCBS PPO Rate,65.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,115.92,60,,92.736,Percent of Total Billed Charges,60% of Total Billed Charges,15.17,100,,,Fee Schedule,100% of TX Mediciad 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,16.25,90,,,Fee Schedule,90% of CMS OPPS Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.47,130,,,Fee Schedule,130% of CMS OPPS Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.63,103,,,Fee Schedule,103% of TX Medicaid Rate,18.6,103,,,Fee Schedule,103% of CMS OPPS Rate,18.6,103,,,Fee Schedule,103% of CMS OPPS Rate,144.9,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,30.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,30.7,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.7,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.09,150,,,Fee Schedule,150% of CMS OPPS Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,90,,,Fee Schedule,90% of UHC fee schedule,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,15.17,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,193.2,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,14.63,193.2,
MAGNESIUM IONIZED,70020720,CDM,301,RC,83735,HCPCS,Outpatient,,,121,72.60,,7.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,24.12,360,,,Fee Schedule,360% of BCBS POS Rate,24.12,360,,,Fee schedule,360% of BCBS PPO Rate,24.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,100,,,Fee Schedule,100% of TX Mediciad 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,6.03,90,,,Fee Schedule,90% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.8,103,,,Fee Schedule,103% of TX Medicaid Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,11.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,11.39,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,10.05,150,,,Fee Schedule,150% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,,Fee Schedule,90% of UHC fee schedule,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,121,
IMMUNOASSAY MYELOPEROXIDASE AB,70020721,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
IMMUNOASSAY PROTEINASE 3 AB,70020722,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
IMMUNOASSAY ANTI STRIATED MUSC,70020724,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IRON LIVER TISSUE,70020726,CDM,301,RC,83540,HCPCS,Outpatient,,,123.12,73.87,,7.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,20.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,23.29,360,,,Fee Schedule,360% of BCBS POS Rate,23.29,360,,,Fee schedule,360% of BCBS PPO Rate,23.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.87,60,,59.096,Percent of Total Billed Charges,60% of Total Billed Charges,5.43,100,,,Fee Schedule,100% of TX Mediciad 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,5.82,90,,,Fee Schedule,90% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,130,,,Fee Schedule,130% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.59,103,,,Fee Schedule,103% of TX Medicaid Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,6.66,103,,,Fee Schedule,103% of CMS OPPS Rate,92.34,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,10.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,10.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,10.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,9.7,150,,,Fee Schedule,150% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,90,,,Fee Schedule,90% of UHC fee schedule,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,5.43,100,,,Fee Schedule,100% of TX Medicaid Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,123.12,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,5.24,123.12,
LDH ISOENZYMES,70020727,CDM,301,RC,83625,HCPCS,Outpatient,,,130.85,78.51,,14.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,35.81,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,46.04,360,,,Fee Schedule,360% of BCBS POS Rate,46.04,360,,,Fee schedule,360% of BCBS PPO Rate,46.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.51,60,,62.808,Percent of Total Billed Charges,60% of Total Billed Charges,10.74,100,,,Fee Schedule,100% of TX Mediciad 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,11.51,90,,,Fee Schedule,90% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16.62,130,,,Fee Schedule,130% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,11.06,103,,,Fee Schedule,103% of TX Medicaid Rate,13.17,103,,,Fee Schedule,103% of CMS OPPS Rate,13.17,103,,,Fee Schedule,103% of CMS OPPS Rate,98.14,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,21.74,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.74,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,21.74,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.74,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,10.36,90,,,Fee Schedule,90% of UHC fee schedule,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,130.85,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,10.36,130.85,
FREE KAPPA LIGHT CHAINS,70020730,CDM,301,RC,83883,HCPCS,Outpatient,,,639,383.40,,15.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,48.96,360,,,Fee Schedule,360% of BCBS POS Rate,48.96,360,,,Fee schedule,360% of BCBS PPO Rate,48.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,383.4,60,,306.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.42,100,,,Fee Schedule,100% of TX Mediciad 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,12.24,90,,,Fee Schedule,90% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,130,,,Fee Schedule,130% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.76,103,,,Fee Schedule,103% of TX Medicaid Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,479.25,75,,56.096,Percent of Total Billed Charges,75% of Total Billed Charges,23.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.02,90,,,Fee Schedule,90% of UHC fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,639,100,,74.792,Percent of Total Billed Charges,100% of Total Billed Charges,11.02,639,
FREE LAMBDA LIGHT CHAINS,70020731,CDM,301,RC,83883,HCPCS,Outpatient,,,639,383.40,,15.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,48.96,360,,,Fee Schedule,360% of BCBS POS Rate,48.96,360,,,Fee schedule,360% of BCBS PPO Rate,48.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,383.4,60,,306.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.42,100,,,Fee Schedule,100% of TX Mediciad 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,12.24,90,,,Fee Schedule,90% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,130,,,Fee Schedule,130% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.76,103,,,Fee Schedule,103% of TX Medicaid Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,479.25,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,23.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.02,90,,,Fee Schedule,90% of UHC fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,639,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,11.02,639,
NICOTINE AND METABOLITES,70020732,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
OXALATE,70020733,CDM,301,RC,83945,HCPCS,Outpatient,,,142.09,85.25,,16.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.46,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,52.02,360,,,Fee Schedule,360% of BCBS POS Rate,52.02,360,,,Fee schedule,360% of BCBS PPO Rate,52.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.25,60,,68.2,Percent of Total Billed Charges,60% of Total Billed Charges,12.14,100,,,Fee Schedule,100% of TX Mediciad 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,13,90,,,Fee Schedule,90% of CMS OPPS Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,18.78,130,,,Fee Schedule,130% of CMS OPPS Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.5,103,,,Fee Schedule,103% of TX Medicaid Rate,14.88,103,,,Fee Schedule,103% of CMS OPPS Rate,14.88,103,,,Fee Schedule,103% of CMS OPPS Rate,106.57,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,24.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,24.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.67,150,,,Fee Schedule,150% of CMS OPPS Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11.71,90,,,Fee Schedule,90% of UHC fee schedule,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,12.14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,142.09,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,11.71,142.09,
PYRIDOXAL PHOSPHATE VITAMIN B6,70020736,CDM,301,RC,84207,HCPCS,Outpatient,,,246.75,148.05,,32.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,42.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,78.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,89.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,101.16,360,,,Fee Schedule,360% of BCBS POS Rate,101.16,360,,,Fee schedule,360% of BCBS PPO Rate,101.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,148.05,60,,118.44,Percent of Total Billed Charges,60% of Total Billed Charges,23.6,100,,,Fee Schedule,100% of TX Mediciad 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,25.29,90,,,Fee Schedule,90% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36.53,130,,,Fee Schedule,130% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,24.31,103,,,Fee Schedule,103% of TX Medicaid Rate,28.94,103,,,Fee Schedule,103% of CMS OPPS Rate,28.94,103,,,Fee Schedule,103% of CMS OPPS Rate,185.06,75,,265.648,Percent of Total Billed Charges,75% of Total Billed Charges,47.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,47.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,47.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,42.15,150,,,Fee Schedule,150% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.76,90,,,Fee Schedule,90% of UHC fee schedule,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.6,100,,,Fee Schedule,100% of TX Medicaid Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,246.75,100,,354.2,Percent of Total Billed Charges,100% of Total Billed Charges,22.76,246.75,
RIBOFLAVIN VITAMIN B2,70020738,CDM,301,RC,84252,HCPCS,Outpatient,,,208.11,124.87,,23.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,56.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,72.86,360,,,Fee Schedule,360% of BCBS POS Rate,72.86,360,,,Fee schedule,360% of BCBS PPO Rate,72.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,124.87,60,,99.896,Percent of Total Billed Charges,60% of Total Billed Charges,17,100,,,Fee Schedule,100% of TX Mediciad 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,18.21,90,,,Fee Schedule,90% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,26.31,130,,,Fee Schedule,130% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17.51,103,,,Fee Schedule,103% of TX Medicaid Rate,20.84,103,,,Fee Schedule,103% of CMS OPPS Rate,20.84,103,,,Fee Schedule,103% of CMS OPPS Rate,156.08,75,,125.024,Percent of Total Billed Charges,75% of Total Billed Charges,34.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,34.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.35,150,,,Fee Schedule,150% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,16.4,90,,,Fee Schedule,90% of UHC fee schedule,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,17,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,208.11,100,,166.696,Percent of Total Billed Charges,100% of Total Billed Charges,16.4,208.11,
THYROID STIMULATING IMMUNOGLOB,70020740,CDM,301,RC,84445,HCPCS,Outpatient,,,413.11,247.87,,59,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,142.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,162.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,183.1,360,,,Fee Schedule,360% of BCBS POS Rate,183.1,360,,,Fee schedule,360% of BCBS PPO Rate,183.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,247.87,60,,198.296,Percent of Total Billed Charges,60% of Total Billed Charges,42.72,100,,,Fee Schedule,100% of TX Mediciad 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,45.77,90,,,Fee Schedule,90% of CMS OPPS Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,66.11,130,,,Fee Schedule,130% of CMS OPPS Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,44,103,,,Fee Schedule,103% of TX Medicaid Rate,52.38,103,,,Fee Schedule,103% of CMS OPPS Rate,52.38,103,,,Fee Schedule,103% of CMS OPPS Rate,309.83,75,,106.584,Percent of Total Billed Charges,75% of Total Billed Charges,86.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,86.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,86.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.29,150,,,Fee Schedule,150% of CMS OPPS Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,41.19,90,,,Fee Schedule,90% of UHC fee schedule,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,42.72,100,,,Fee Schedule,100% of TX Medicaid Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,413.11,100,,142.112,Percent of Total Billed Charges,100% of Total Billed Charges,41.19,413.11,
BHCG TUMOR MARKER,70020742,CDM,301,RC,84702,HCPCS,Outpatient,,,257.99,154.79,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,154.79,60,,123.832,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,193.49,75,,561.728,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,257.99,100,,748.968,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,257.99,
PROTEIN S FUNCTIONAL ASSAY,70020743,CDM,305,RC,85306,HCPCS,Outpatient,,,294,176.40,,17.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,42.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,55.15,360,,,Fee Schedule,360% of BCBS POS Rate,55.15,360,,,Fee schedule,360% of BCBS PPO Rate,55.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,176.4,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,12.87,100,,,Fee Schedule,100% of TX Mediciad 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,13.78,90,,,Fee Schedule,90% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of TX Medicaid Rate,15.77,103,,,Fee Schedule,103% of CMS OPPS Rate,15.77,103,,,Fee Schedule,103% of CMS OPPS Rate,220.5,75,,164.4,Percent of Total Billed Charges,75% of Total Billed Charges,26.04,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.04,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.04,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.98,150,,,Fee Schedule,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,90,,,Fee Schedule,90% of UHC fee schedule,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of TX Medicaid Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,294,100,,219.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.41,294,
FACTOR DEFICIENCY SCREEN,70020744,CDM,305,RC,85390,HCPCS,Outpatient,,,211.11,126.67,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,55.73,360,,,Fee Schedule,360% of BCBS POS Rate,55.73,360,,,Fee schedule,360% of BCBS PPO Rate,55.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,126.67,60,,101.336,Percent of Total Billed Charges,60% of Total Billed Charges,13,100,,,Fee Schedule,100% of TX Mediciad 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,13.93,90,,,Fee Schedule,90% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.12,130,,,Fee Schedule,130% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.39,103,,,Fee Schedule,103% of TX Medicaid Rate,15.94,103,,,Fee Schedule,103% of CMS OPPS Rate,15.94,103,,,Fee Schedule,103% of CMS OPPS Rate,158.33,75,,129.064,Percent of Total Billed Charges,75% of Total Billed Charges,26.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,26.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.22,150,,,Fee Schedule,150% of CMS OPPS Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,90,,,Fee Schedule,90% of UHC fee schedule,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,13,100,,,Fee Schedule,100% of TX Medicaid Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,211.11,100,,172.088,Percent of Total Billed Charges,100% of Total Billed Charges,12.54,211.11,
HEPARIN ASSAY LMW,70020746,CDM,305,RC,85520,HCPCS,Outpatient,,,289.41,173.65,,15.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,36.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,47.12,360,,,Fee Schedule,360% of BCBS POS Rate,47.12,360,,,Fee schedule,360% of BCBS PPO Rate,47.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,173.65,60,,138.92,Percent of Total Billed Charges,60% of Total Billed Charges,11,100,,,Fee Schedule,100% of TX Mediciad 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,11.78,90,,,Fee Schedule,90% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.01,130,,,Fee Schedule,130% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11.33,103,,,Fee Schedule,103% of TX Medicaid Rate,13.48,103,,,Fee Schedule,103% of CMS OPPS Rate,13.48,103,,,Fee Schedule,103% of CMS OPPS Rate,217.06,75,,120.6,Percent of Total Billed Charges,75% of Total Billed Charges,22.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,22.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.63,150,,,Fee Schedule,150% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,90,,,Fee Schedule,90% of UHC fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,289.41,100,,160.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.6,289.41,
ADAMTS13 ACTIVITY,70020750,CDM,305,RC,85397,HCPCS,Outpatient,,,591.6,354.96,,35.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,46.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,86.41,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,98.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,111.1,360,,,Fee Schedule,360% of BCBS POS Rate,111.1,360,,,Fee schedule,360% of BCBS PPO Rate,111.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,354.96,60,,283.968,Percent of Total Billed Charges,60% of Total Billed Charges,25.92,100,,,Fee Schedule,100% of TX Mediciad 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,27.77,90,,,Fee Schedule,90% of CMS OPPS Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,40.11,130,,,Fee Schedule,130% of CMS OPPS Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,26.7,103,,,Fee Schedule,103% of TX Medicaid Rate,31.78,103,,,Fee Schedule,103% of CMS OPPS Rate,31.78,103,,,Fee Schedule,103% of CMS OPPS Rate,443.7,75,,784.8,Percent of Total Billed Charges,75% of Total Billed Charges,52.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,52.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,52.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,52.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,46.29,150,,,Fee Schedule,150% of CMS OPPS Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,24.99,90,,,Fee Schedule,90% of UHC fee schedule,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,25.92,100,,,Fee Schedule,100% of TX Medicaid Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,591.6,100,,1046.4,Percent of Total Billed Charges,100% of Total Billed Charges,24.99,591.6,
COMPLEMENT C1,70020754,CDM,302,RC,86160,HCPCS,Outpatient,,,179,107.40,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,134.25,75,,142.872,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,179,100,,190.496,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,179,
C1 ESTERASE INHIBITOR AG,70020755,CDM,302,RC,86160,HCPCS,Outpatient,,,179,107.40,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,134.25,75,,72.728,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,179,100,,96.968,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,179,
CYCLIC CITRULLINATED PEPTID AB,70020756,CDM,302,RC,86200,HCPCS,Outpatient,,,146,87.60,,15.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,46.62,360,,,Fee Schedule,360% of BCBS POS Rate,46.62,360,,,Fee schedule,360% of BCBS PPO Rate,46.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,87.6,60,,70.08,Percent of Total Billed Charges,60% of Total Billed Charges,10.88,100,,,Fee Schedule,100% of TX Mediciad 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,11.65,90,,,Fee Schedule,90% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,16.83,130,,,Fee Schedule,130% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.21,103,,,Fee Schedule,103% of TX Medicaid Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,109.5,75,,117.832,Percent of Total Billed Charges,75% of Total Billed Charges,22.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,22.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.42,150,,,Fee Schedule,150% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,90,,,Fee Schedule,90% of UHC fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,146,100,,157.104,Percent of Total Billed Charges,100% of Total Billed Charges,10.49,146,
AB AUTOAB TO SSA/RO,70020757,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
AB AUTOAB TO SSB/LA,70020758,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
AB AUTOAB U1RNP,70020759,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,173.4,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,231.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
AB ANTI PARIETAL CELL,70020760,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
ANTI DS DNA TITER,70020761,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI MITOCHONDRIAL TITER,70020762,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI NEUTROPHIL CYTOPLAS TITER,70020764,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,604.232,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,805.64,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI SMOOTH MUSCLE TITER,70020765,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
AB ANTI PARIETAL CELL TITER,70020766,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,575.352,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,767.136,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
GEL DIFFUSION FUNGAL EA,70020767,CDM,302,RC,86331,HCPCS,Outpatient,,,135.87,81.52,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.52,60,,65.216,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,101.9,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,135.87,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,135.87,
IMMUNOFIXATION ELECTROPH URINE,70020768,CDM,302,RC,86335,HCPCS,Outpatient,,,264,158.40,,34.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,44.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,82.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,105.66,360,,,Fee Schedule,360% of BCBS POS Rate,105.66,360,,,Fee schedule,360% of BCBS PPO Rate,105.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,158.4,60,,126.72,Percent of Total Billed Charges,60% of Total Billed Charges,24.65,100,,,Fee Schedule,100% of TX Mediciad 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,26.41,90,,,Fee Schedule,90% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,130,,,Fee Schedule,130% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,25.39,103,,,Fee Schedule,103% of TX Medicaid Rate,30.23,103,,,Fee Schedule,103% of CMS OPPS Rate,30.23,103,,,Fee Schedule,103% of CMS OPPS Rate,198,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,49.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,49.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,44.02,150,,,Fee Schedule,150% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,23.78,90,,,Fee Schedule,90% of UHC fee schedule,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,264,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,264,
GAD65 AB ASSAY,70020770,CDM,302,RC,86341,HCPCS,Outpatient,,,199,119.40,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.4,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,149.25,75,,608.064,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,199,100,,810.752,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,199,
AB ANTI LKM,70020771,CDM,302,RC,86376,HCPCS,Outpatient,,,172,103.20,,16.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,52.38,360,,,Fee Schedule,360% of BCBS POS Rate,52.38,360,,,Fee schedule,360% of BCBS PPO Rate,52.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of TX Mediciad 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,13.09,90,,,Fee Schedule,90% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,18.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,103,,,Fee Schedule,103% of TX Medicaid Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,129,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,24.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.82,150,,,Fee Schedule,150% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,,Fee Schedule,90% of UHC fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,172,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,11.79,172,
AG CRYPTOCOCCAL FL,70020772,CDM,302,RC,86403,HCPCS,Outpatient,,,172.06,103.24,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,32.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.54,360,,,Fee Schedule,360% of BCBS POS Rate,41.54,360,,,Fee schedule,360% of BCBS PPO Rate,41.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.24,60,,82.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.38,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,15,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.88,103,,,Fee Schedule,103% of CMS OPPS Rate,11.88,103,,,Fee Schedule,103% of CMS OPPS Rate,129.05,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,19.61,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.61,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.61,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.3,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,172.06,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,9.35,172.06,
CRYPTOCOCCAL AG TITER,70020773,CDM,302,RC,86406,HCPCS,Outpatient,,,136.06,81.64,,12.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,38.3,360,,,Fee Schedule,360% of BCBS POS Rate,38.3,360,,,Fee schedule,360% of BCBS PPO Rate,38.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.64,60,,65.312,Percent of Total Billed Charges,60% of Total Billed Charges,8.94,100,,,Fee Schedule,100% of TX Mediciad 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,9.57,90,,,Fee Schedule,90% of CMS OPPS Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,13.83,130,,,Fee Schedule,130% of CMS OPPS Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,9.21,103,,,Fee Schedule,103% of TX Medicaid Rate,10.95,103,,,Fee Schedule,103% of CMS OPPS Rate,10.95,103,,,Fee Schedule,103% of CMS OPPS Rate,102.05,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,18.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,18.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.96,150,,,Fee Schedule,150% of CMS OPPS Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,90,,,Fee Schedule,90% of UHC fee schedule,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,8.94,100,,,Fee Schedule,100% of TX Medicaid Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,136.06,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,8.62,136.06,
ASPERGILLUS PRECIPI,70020774,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
AB BARTONELLA HENSE IGG SCREEN,70020775,CDM,302,RC,86611,HCPCS,Outpatient,,,98,58.80,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,58.8,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,73.5,75,,2172.896,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,98,100,,2897.192,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,98,
AB BARTONELLA HENSE IGM SCREEN,70020776,CDM,302,RC,86611,HCPCS,Outpatient,,,98,58.80,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,58.8,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,73.5,75,,364.728,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,98,100,,486.304,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,98,
AB BARTONELLA QUINT IGG SCREEN,70020777,CDM,302,RC,86611,HCPCS,Outpatient,,,98,58.80,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,58.8,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,73.5,75,,425.2,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,98,100,,566.936,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,98,
AB BARTONELLA QUINT IGM SCREEN,70020778,CDM,302,RC,86611,HCPCS,Outpatient,,,98,58.80,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,58.8,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,73.5,75,,193.2,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,98,100,,257.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,98,
AB LYME DISEASE CONF IGM,70020779,CDM,302,RC,86617,HCPCS,Outpatient,,,169,101.40,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,43.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,55.76,360,,,Fee Schedule,360% of BCBS POS Rate,55.76,360,,,Fee schedule,360% of BCBS PPO Rate,55.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.4,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,100,,,Fee Schedule,100% of TX Mediciad 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,13.94,90,,,Fee Schedule,90% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,130,,,Fee Schedule,130% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of TX Medicaid Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,126.75,75,,62.744,Percent of Total Billed Charges,75% of Total Billed Charges,26.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.23,150,,,Fee Schedule,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.55,90,,,Fee Schedule,90% of UHC fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,169,100,,83.656,Percent of Total Billed Charges,100% of Total Billed Charges,12.55,169,
AB LYME DISEASE IGG CSF,70020780,CDM,302,RC,86618,HCPCS,Outpatient,,,196.38,117.83,,19.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,47.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,61.31,360,,,Fee Schedule,360% of BCBS POS Rate,61.31,360,,,Fee schedule,360% of BCBS PPO Rate,61.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.83,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,14.31,100,,,Fee Schedule,100% of TX Mediciad 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,15.32,90,,,Fee Schedule,90% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.13,130,,,Fee Schedule,130% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.74,103,,,Fee Schedule,103% of TX Medicaid Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,147.29,75,,162.6,Percent of Total Billed Charges,75% of Total Billed Charges,28.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,28.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.54,150,,,Fee Schedule,150% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,90,,,Fee Schedule,90% of UHC fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,196.38,100,,216.8,Percent of Total Billed Charges,100% of Total Billed Charges,13.8,196.38,
AB BRUCELLA,70020781,CDM,302,RC,86622,HCPCS,Outpatient,,,114.48,68.69,,10.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,32.15,360,,,Fee Schedule,360% of BCBS POS Rate,32.15,360,,,Fee schedule,360% of BCBS PPO Rate,32.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,68.69,60,,54.952,Percent of Total Billed Charges,60% of Total Billed Charges,7.5,100,,,Fee Schedule,100% of TX Mediciad 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,8.03,90,,,Fee Schedule,90% of CMS OPPS Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.6,130,,,Fee Schedule,130% of CMS OPPS Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,103,,,Fee Schedule,103% of TX Medicaid Rate,9.19,103,,,Fee Schedule,103% of CMS OPPS Rate,9.19,103,,,Fee Schedule,103% of CMS OPPS Rate,85.86,75,,97.264,Percent of Total Billed Charges,75% of Total Billed Charges,15.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.39,150,,,Fee Schedule,150% of CMS OPPS Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,90,,,Fee Schedule,90% of UHC fee schedule,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,7.5,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,114.48,100,,129.688,Percent of Total Billed Charges,100% of Total Billed Charges,7.24,114.48,
AB CHLAMYDIA PNEUMONIAE IGM,70020784,CDM,302,RC,86632,HCPCS,Outpatient,,,119.89,71.93,,14.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,45.65,360,,,Fee Schedule,360% of BCBS POS Rate,45.65,360,,,Fee schedule,360% of BCBS PPO Rate,45.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.93,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,10.65,100,,,Fee Schedule,100% of TX Mediciad 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,11.41,90,,,Fee Schedule,90% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,16.48,130,,,Fee Schedule,130% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.97,103,,,Fee Schedule,103% of TX Medicaid Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,89.92,75,,249.16,Percent of Total Billed Charges,75% of Total Billed Charges,21.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.02,150,,,Fee Schedule,150% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.27,90,,,Fee Schedule,90% of UHC fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,119.89,100,,332.216,Percent of Total Billed Charges,100% of Total Billed Charges,10.27,119.89,
AB CHLAMYDIA PSITTACI IGG,70020785,CDM,302,RC,86631,HCPCS,Outpatient,,,124.79,74.87,,13.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,33.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,42.55,360,,,Fee Schedule,360% of BCBS POS Rate,42.55,360,,,Fee schedule,360% of BCBS PPO Rate,42.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.87,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,100,,,Fee Schedule,100% of TX Mediciad 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,10.63,90,,,Fee Schedule,90% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,130,,,Fee Schedule,130% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.23,103,,,Fee Schedule,103% of TX Medicaid Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,93.59,75,,132.208,Percent of Total Billed Charges,75% of Total Billed Charges,20.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,20.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.73,150,,,Fee Schedule,150% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,90,,,Fee Schedule,90% of UHC fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,124.79,100,,176.28,Percent of Total Billed Charges,100% of Total Billed Charges,9.58,124.79,
AB CHLAMYDIA PSITTACI IGM,70020786,CDM,302,RC,86632,HCPCS,Outpatient,,,119.89,71.93,,14.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,45.65,360,,,Fee Schedule,360% of BCBS POS Rate,45.65,360,,,Fee schedule,360% of BCBS PPO Rate,45.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.93,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,10.65,100,,,Fee Schedule,100% of TX Mediciad 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,11.41,90,,,Fee Schedule,90% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,16.48,130,,,Fee Schedule,130% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.97,103,,,Fee Schedule,103% of TX Medicaid Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,89.92,75,,121.024,Percent of Total Billed Charges,75% of Total Billed Charges,21.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.02,150,,,Fee Schedule,150% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.27,90,,,Fee Schedule,90% of UHC fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,119.89,100,,161.368,Percent of Total Billed Charges,100% of Total Billed Charges,10.27,119.89,
AB CHLAMYDIA TRACHOMATIS IGG,70020787,CDM,302,RC,86631,HCPCS,Outpatient,,,124.79,74.87,,13.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,33.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,42.55,360,,,Fee Schedule,360% of BCBS POS Rate,42.55,360,,,Fee schedule,360% of BCBS PPO Rate,42.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.87,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,100,,,Fee Schedule,100% of TX Mediciad 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,10.63,90,,,Fee Schedule,90% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,130,,,Fee Schedule,130% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.23,103,,,Fee Schedule,103% of TX Medicaid Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,93.59,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,20.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,20.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.73,150,,,Fee Schedule,150% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,90,,,Fee Schedule,90% of UHC fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,124.79,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.58,124.79,
AB CHLAMYDIA TRACHOMATIS IGM,70020788,CDM,302,RC,86632,HCPCS,Outpatient,,,119.89,71.93,,14.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,45.65,360,,,Fee Schedule,360% of BCBS POS Rate,45.65,360,,,Fee schedule,360% of BCBS PPO Rate,45.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.93,60,,57.544,Percent of Total Billed Charges,60% of Total Billed Charges,10.65,100,,,Fee Schedule,100% of TX Mediciad 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,11.41,90,,,Fee Schedule,90% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,16.48,130,,,Fee Schedule,130% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.97,103,,,Fee Schedule,103% of TX Medicaid Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,13.06,103,,,Fee Schedule,103% of CMS OPPS Rate,89.92,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,21.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.02,150,,,Fee Schedule,150% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,10.27,90,,,Fee Schedule,90% of UHC fee schedule,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,10.65,100,,,Fee Schedule,100% of TX Medicaid Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,119.89,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,10.27,119.89,
AB COCCIDIODES CF,70020789,CDM,302,RC,86635,HCPCS,Outpatient,,,121,72.60,,13.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,32.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,41.29,360,,,Fee Schedule,360% of BCBS POS Rate,41.29,360,,,Fee schedule,360% of BCBS PPO Rate,41.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.63,100,,,Fee Schedule,100% of TX Mediciad 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,10.32,90,,,Fee Schedule,90% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.91,130,,,Fee Schedule,130% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.92,103,,,Fee Schedule,103% of TX Medicaid Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,19.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,19.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.2,150,,,Fee Schedule,150% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.29,90,,,Fee Schedule,90% of UHC fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.29,121,
AB COCCIDIODES ID,70020790,CDM,302,RC,86635,HCPCS,Outpatient,,,121,72.60,,13.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,32.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,41.29,360,,,Fee Schedule,360% of BCBS POS Rate,41.29,360,,,Fee schedule,360% of BCBS PPO Rate,41.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.63,100,,,Fee Schedule,100% of TX Mediciad 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,10.32,90,,,Fee Schedule,90% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.91,130,,,Fee Schedule,130% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.92,103,,,Fee Schedule,103% of TX Medicaid Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,19.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,19.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.2,150,,,Fee Schedule,150% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.29,90,,,Fee Schedule,90% of UHC fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.29,121,
AB COCCIDIODES IGM,70020791,CDM,302,RC,86635,HCPCS,Outpatient,,,121,72.60,,13.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,32.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,41.29,360,,,Fee Schedule,360% of BCBS POS Rate,41.29,360,,,Fee schedule,360% of BCBS PPO Rate,41.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.63,100,,,Fee Schedule,100% of TX Mediciad 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,10.32,90,,,Fee Schedule,90% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.91,130,,,Fee Schedule,130% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.92,103,,,Fee Schedule,103% of TX Medicaid Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,19.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,19.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.2,150,,,Fee Schedule,150% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.29,90,,,Fee Schedule,90% of UHC fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.29,121,
AB Q FEVER IGG PHASE I,70020792,CDM,302,RC,86638,HCPCS,Outpatient,,,116,69.60,,14.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,43.63,360,,,Fee Schedule,360% of BCBS POS Rate,43.63,360,,,Fee schedule,360% of BCBS PPO Rate,43.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.6,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.18,100,,,Fee Schedule,100% of TX Mediciad 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,10.9,90,,,Fee Schedule,90% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.75,130,,,Fee Schedule,130% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.49,103,,,Fee Schedule,103% of TX Medicaid Rate,12.48,103,,,Fee Schedule,103% of CMS OPPS Rate,12.48,103,,,Fee Schedule,103% of CMS OPPS Rate,87,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,20.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.17,150,,,Fee Schedule,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,90,,,Fee Schedule,90% of UHC fee schedule,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,116,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.82,116,
AB Q FEVER IGM PHASE I,70020794,CDM,302,RC,86638,HCPCS,Outpatient,,,116,69.60,,14.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,43.63,360,,,Fee Schedule,360% of BCBS POS Rate,43.63,360,,,Fee schedule,360% of BCBS PPO Rate,43.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.6,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.18,100,,,Fee Schedule,100% of TX Mediciad 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,10.9,90,,,Fee Schedule,90% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.75,130,,,Fee Schedule,130% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.49,103,,,Fee Schedule,103% of TX Medicaid Rate,12.48,103,,,Fee Schedule,103% of CMS OPPS Rate,12.48,103,,,Fee Schedule,103% of CMS OPPS Rate,87,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,20.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.17,150,,,Fee Schedule,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,90,,,Fee Schedule,90% of UHC fee schedule,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of TX Medicaid Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,116,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.82,116,
AB ENCEPH EAST EQUINE IGG,70020797,CDM,302,RC,86652,HCPCS,Outpatient,,,113.93,68.36,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,68.36,60,,54.688,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,85.45,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,113.93,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,113.93,
AB ENCEPH EAST EQUINE IGM,70020798,CDM,302,RC,86652,HCPCS,Outpatient,,,113.93,68.36,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,68.36,60,,54.688,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,85.45,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,113.93,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,113.93,
AB ENCEPH ST LOUIS IGG,70020799,CDM,302,RC,86653,HCPCS,Outpatient,,,118,70.80,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.8,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,88.5,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,118,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,118,
AB ENCEPH ST LOUIS IGM,70020800,CDM,302,RC,86653,HCPCS,Outpatient,,,118,70.80,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.8,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,88.5,75,,187.144,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,118,100,,249.528,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,118,
AB ENCEPH WEST EQUINE IGG,70020801,CDM,302,RC,86654,HCPCS,Outpatient,,,117.67,70.60,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.6,60,,56.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,88.25,75,,73.264,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,97.68,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,117.67,
AB ENCEPH WEST EQUINE IGM,70020802,CDM,302,RC,86654,HCPCS,Outpatient,,,117.67,70.60,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.6,60,,56.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,88.25,75,,516.048,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,688.064,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,117.67,
AB EHRLICHIA IGG,70020803,CDM,302,RC,86666,HCPCS,Outpatient,,,175.05,105.03,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,105.03,60,,84.024,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,131.29,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,175.05,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,175.05,
AB ANAPLASMA PHAGOCYTO IGG,70020805,CDM,302,RC,86666,HCPCS,Outpatient,,,175.05,105.03,,11.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,32.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,36.65,360,,,Fee Schedule,360% of BCBS POS Rate,36.65,360,,,Fee schedule,360% of BCBS PPO Rate,36.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,105.03,60,,84.024,Percent of Total Billed Charges,60% of Total Billed Charges,8.55,100,,,Fee Schedule,100% of TX Mediciad 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,9.16,90,,,Fee Schedule,90% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.23,130,,,Fee Schedule,130% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.81,103,,,Fee Schedule,103% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,10.48,103,,,Fee Schedule,103% of CMS OPPS Rate,131.29,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,17.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.27,150,,,Fee Schedule,150% of CMS OPPS Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.24,90,,,Fee Schedule,90% of UHC fee schedule,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,8.55,100,,,Fee Schedule,100% of TX Medicaid Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,175.05,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,8.24,175.05,
AB HELICOBACTER PYLORI IGA,70020807,CDM,302,RC,86677,HCPCS,Outpatient,,,198.08,118.85,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.85,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,148.56,75,,579.36,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,198.08,100,,772.48,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,198.08,
AB HELICOBACTER PYLORI IGG,70020808,CDM,302,RC,86677,HCPCS,Outpatient,,,198.08,118.85,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.85,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,148.56,75,,621.864,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,198.08,100,,829.152,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,198.08,
AB HELICOBACTER PYLORI IGM,70020809,CDM,302,RC,86677,HCPCS,Outpatient,,,198.08,118.85,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.85,60,,95.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,148.56,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,198.08,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,198.08,
AB CYSTERCERCOSIS,70020810,CDM,302,RC,86682,HCPCS,Outpatient,,,178.44,107.06,,15.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,36.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,46.84,360,,,Fee Schedule,360% of BCBS POS Rate,46.84,360,,,Fee schedule,360% of BCBS PPO Rate,46.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.06,60,,85.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.93,100,,,Fee Schedule,100% of TX Mediciad 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,11.7,90,,,Fee Schedule,90% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,130,,,Fee Schedule,130% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.26,103,,,Fee Schedule,103% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,133.83,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,22.11,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.11,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.11,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.11,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.51,150,,,Fee Schedule,150% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,90,,,Fee Schedule,90% of UHC fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,178.44,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,10.54,178.44,
AB ECHINOCOCCUS,70020811,CDM,302,RC,86682,HCPCS,Outpatient,,,302.48,181.49,,15.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,36.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,46.84,360,,,Fee Schedule,360% of BCBS POS Rate,46.84,360,,,Fee schedule,360% of BCBS PPO Rate,46.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,181.49,60,,145.192,Percent of Total Billed Charges,60% of Total Billed Charges,10.93,100,,,Fee Schedule,100% of TX Mediciad 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,11.7,90,,,Fee Schedule,90% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,130,,,Fee Schedule,130% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.26,103,,,Fee Schedule,103% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,226.86,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,22.11,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.11,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.11,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.11,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.51,150,,,Fee Schedule,150% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,90,,,Fee Schedule,90% of UHC fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,302.48,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,10.54,302.48,
STRONGYLOIDES IGG AB,70020812,CDM,302,RC,86682,HCPCS,Outpatient,,,178.44,107.06,,15.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,36.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,46.84,360,,,Fee Schedule,360% of BCBS POS Rate,46.84,360,,,Fee schedule,360% of BCBS PPO Rate,46.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.06,60,,85.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.93,100,,,Fee Schedule,100% of TX Mediciad 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,11.7,90,,,Fee Schedule,90% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,130,,,Fee Schedule,130% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.26,103,,,Fee Schedule,103% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,13.4,103,,,Fee Schedule,103% of CMS OPPS Rate,133.83,75,,100.528,Percent of Total Billed Charges,75% of Total Billed Charges,22.11,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.11,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.11,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.11,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.51,150,,,Fee Schedule,150% of CMS OPPS Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,90,,,Fee Schedule,90% of UHC fee schedule,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.93,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,178.44,100,,134.032,Percent of Total Billed Charges,100% of Total Billed Charges,10.54,178.44,
AB HERPES SIMPLEX NOS IGM,70020814,CDM,302,RC,86694,HCPCS,Outpatient,,,150.56,90.34,,16.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,,Fee Schedule,360% of BCBS POS Rate,51.8,360,,,Fee schedule,360% of BCBS PPO Rate,51.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,90.34,60,,72.272,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of TX Mediciad 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,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,112.92,75,,72.6,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,150.56,100,,96.8,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,150.56,
AB HISTOPLASMA MYCELIAL,70020815,CDM,302,RC,86698,HCPCS,Outpatient,,,121.89,73.13,,16,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,49.64,360,,,Fee Schedule,360% of BCBS POS Rate,49.64,360,,,Fee schedule,360% of BCBS PPO Rate,49.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.13,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,100,,,Fee Schedule,100% of TX Mediciad 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,12.41,90,,,Fee Schedule,90% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,130,,,Fee Schedule,130% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.93,103,,,Fee Schedule,103% of TX Medicaid Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,91.42,75,,507.12,Percent of Total Billed Charges,75% of Total Billed Charges,23.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.68,150,,,Fee Schedule,150% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,90,,,Fee Schedule,90% of UHC fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,121.89,100,,676.16,Percent of Total Billed Charges,100% of Total Billed Charges,11.17,121.89,
AB HISTOPLASMA IMD,70020816,CDM,302,RC,86698,HCPCS,Outpatient,,,121.89,73.13,,16,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,49.64,360,,,Fee Schedule,360% of BCBS POS Rate,49.64,360,,,Fee schedule,360% of BCBS PPO Rate,49.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.13,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,100,,,Fee Schedule,100% of TX Mediciad 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,12.41,90,,,Fee Schedule,90% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,130,,,Fee Schedule,130% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.93,103,,,Fee Schedule,103% of TX Medicaid Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,91.42,75,,150.096,Percent of Total Billed Charges,75% of Total Billed Charges,23.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.68,150,,,Fee Schedule,150% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,90,,,Fee Schedule,90% of UHC fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,121.89,100,,200.128,Percent of Total Billed Charges,100% of Total Billed Charges,11.17,121.89,
AB HISTOPLASMA YEAST,70020817,CDM,302,RC,86698,HCPCS,Outpatient,,,121.89,73.13,,16,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,49.64,360,,,Fee Schedule,360% of BCBS POS Rate,49.64,360,,,Fee schedule,360% of BCBS PPO Rate,49.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.13,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,100,,,Fee Schedule,100% of TX Mediciad 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,12.41,90,,,Fee Schedule,90% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,130,,,Fee Schedule,130% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.93,103,,,Fee Schedule,103% of TX Medicaid Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,91.42,75,,360,Percent of Total Billed Charges,75% of Total Billed Charges,23.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.68,150,,,Fee Schedule,150% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,90,,,Fee Schedule,90% of UHC fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,121.89,100,,480,Percent of Total Billed Charges,100% of Total Billed Charges,11.17,121.89,
AB HEP B SURFACE QT,70020818,CDM,302,RC,86706,HCPCS,Outpatient,,,158,94.80,,12.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,30.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,38.66,360,,,Fee Schedule,360% of BCBS POS Rate,38.66,360,,,Fee schedule,360% of BCBS PPO Rate,38.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,94.8,60,,75.84,Percent of Total Billed Charges,60% of Total Billed Charges,9.02,100,,,Fee Schedule,100% of TX Mediciad 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,9.66,90,,,Fee Schedule,90% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.96,130,,,Fee Schedule,130% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.29,103,,,Fee Schedule,103% of TX Medicaid Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,118.5,75,,102.512,Percent of Total Billed Charges,75% of Total Billed Charges,18.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,18.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,16.11,150,,,Fee Schedule,150% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,90,,,Fee Schedule,90% of UHC fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,158,100,,136.68,Percent of Total Billed Charges,100% of Total Billed Charges,8.7,158,
AB INFLUENZA VIRUS A IGM,70020819,CDM,302,RC,86710,HCPCS,Outpatient,,,112.06,67.24,,15.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,48.78,360,,,Fee Schedule,360% of BCBS POS Rate,48.78,360,,,Fee schedule,360% of BCBS PPO Rate,48.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,67.24,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,11.38,100,,,Fee Schedule,100% of TX Mediciad 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,12.19,90,,,Fee Schedule,90% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.61,130,,,Fee Schedule,130% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.72,103,,,Fee Schedule,103% of TX Medicaid Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,84.05,75,,158.04,Percent of Total Billed Charges,75% of Total Billed Charges,23.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,23.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.32,150,,,Fee Schedule,150% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,90,,,Fee Schedule,90% of UHC fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,112.06,100,,210.72,Percent of Total Billed Charges,100% of Total Billed Charges,10.98,112.06,
AB INFLUENZA VIRUS B IGG,70020820,CDM,302,RC,86710,HCPCS,Outpatient,,,112.06,67.24,,15.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,48.78,360,,,Fee Schedule,360% of BCBS POS Rate,48.78,360,,,Fee schedule,360% of BCBS PPO Rate,48.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,67.24,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,11.38,100,,,Fee Schedule,100% of TX Mediciad 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,12.19,90,,,Fee Schedule,90% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.61,130,,,Fee Schedule,130% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.72,103,,,Fee Schedule,103% of TX Medicaid Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,84.05,75,,139.312,Percent of Total Billed Charges,75% of Total Billed Charges,23.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,23.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.32,150,,,Fee Schedule,150% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,90,,,Fee Schedule,90% of UHC fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,112.06,100,,185.744,Percent of Total Billed Charges,100% of Total Billed Charges,10.98,112.06,
AB INFLUENZA VIRUS B IGM,70020821,CDM,302,RC,86710,HCPCS,Outpatient,,,112.06,67.24,,15.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,48.78,360,,,Fee Schedule,360% of BCBS POS Rate,48.78,360,,,Fee schedule,360% of BCBS PPO Rate,48.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,67.24,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,11.38,100,,,Fee Schedule,100% of TX Mediciad 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,12.19,90,,,Fee Schedule,90% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.61,130,,,Fee Schedule,130% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.72,103,,,Fee Schedule,103% of TX Medicaid Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,84.05,75,,106.136,Percent of Total Billed Charges,75% of Total Billed Charges,23.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,23.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.32,150,,,Fee Schedule,150% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,90,,,Fee Schedule,90% of UHC fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,112.06,100,,141.512,Percent of Total Billed Charges,100% of Total Billed Charges,10.98,112.06,
AB LEPTOSPIRA,70020822,CDM,302,RC,86720,HCPCS,Outpatient,,,162,97.20,,18.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,45.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,58.32,360,,,Fee Schedule,360% of BCBS POS Rate,58.32,360,,,Fee schedule,360% of BCBS PPO Rate,58.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,97.2,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,13.61,100,,,Fee Schedule,100% of TX Mediciad 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,14.58,90,,,Fee Schedule,90% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,130,,,Fee Schedule,130% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,14.02,103,,,Fee Schedule,103% of TX Medicaid Rate,16.68,103,,,Fee Schedule,103% of CMS OPPS Rate,16.68,103,,,Fee Schedule,103% of CMS OPPS Rate,121.5,75,,106.136,Percent of Total Billed Charges,75% of Total Billed Charges,27.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.54,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.3,150,,,Fee Schedule,150% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,90,,,Fee Schedule,90% of UHC fee schedule,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.61,100,,,Fee Schedule,100% of TX Medicaid Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,162,100,,141.512,Percent of Total Billed Charges,100% of Total Billed Charges,13.12,162,
AB PARVOVIRUS B19 IGM,70020823,CDM,302,RC,86747,HCPCS,Outpatient,,,159.79,95.87,,17.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,42.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,54.11,360,,,Fee Schedule,360% of BCBS POS Rate,54.11,360,,,Fee schedule,360% of BCBS PPO Rate,54.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.87,60,,76.696,Percent of Total Billed Charges,60% of Total Billed Charges,12.63,100,,,Fee Schedule,100% of TX Mediciad 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,13.52,90,,,Fee Schedule,90% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,130,,,Fee Schedule,130% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,103,,,Fee Schedule,103% of TX Medicaid Rate,15.48,103,,,Fee Schedule,103% of CMS OPPS Rate,15.48,103,,,Fee Schedule,103% of CMS OPPS Rate,119.84,75,,42.872,Percent of Total Billed Charges,75% of Total Billed Charges,25.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,25.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.54,150,,,Fee Schedule,150% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,12.18,90,,,Fee Schedule,90% of UHC fee schedule,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,159.79,100,,57.16,Percent of Total Billed Charges,100% of Total Billed Charges,12.18,159.79,
AB AMOEBIC (E HISTOLYITICA),70020824,CDM,302,RC,86753,HCPCS,Outpatient,,,143,85.80,,14.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,44.6,360,,,Fee Schedule,360% of BCBS POS Rate,44.6,360,,,Fee schedule,360% of BCBS PPO Rate,44.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.8,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.41,100,,,Fee Schedule,100% of TX Mediciad 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,11.15,90,,,Fee Schedule,90% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,130,,,Fee Schedule,130% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,103,,,Fee Schedule,103% of TX Medicaid Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,107.25,75,,109.544,Percent of Total Billed Charges,75% of Total Billed Charges,21.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.58,150,,,Fee Schedule,150% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.04,90,,,Fee Schedule,90% of UHC fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,143,100,,146.056,Percent of Total Billed Charges,100% of Total Billed Charges,10.04,143,
AB RSV IGM,70020825,CDM,302,RC,86756,HCPCS,Outpatient,,,182.81,109.69,,18.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,50.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,57.2,360,,,Fee Schedule,360% of BCBS POS Rate,57.2,360,,,Fee schedule,360% of BCBS PPO Rate,57.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.69,60,,87.752,Percent of Total Billed Charges,60% of Total Billed Charges,13.35,100,,,Fee Schedule,100% of TX Mediciad Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,90,,,Fee Schedule,90% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,20.65,130,,,Fee Schedule,130% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.75,103,,,Fee Schedule,103% of TX Medicaid Rate,16.36,103,,,Fee Schedule,103% of CMS OPPS Rate,16.36,103,,,Fee Schedule,103% of CMS OPPS Rate,137.11,75,,168.76,Percent of Total Billed Charges,75% of Total Billed Charges,27.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,27.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.83,150,,,Fee Schedule,150% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,90,,,Fee Schedule,90% of UHC fee schedule,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,182.81,100,,225.016,Percent of Total Billed Charges,100% of Total Billed Charges,12.87,182.81,
AB ROCKY MT SPOTTED FEVER IGM,70020826,CDM,302,RC,86757,HCPCS,Outpatient,,,156.2,93.72,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.72,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,117.15,75,,214.816,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.2,100,,286.416,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,156.2,
AB TYPHUS FEVER IGG,70020827,CDM,302,RC,86757,HCPCS,Outpatient,,,156.2,93.72,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.72,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,117.15,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.2,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,156.2,
AB TYPHUS FEVER IGM,70020828,CDM,302,RC,86757,HCPCS,Outpatient,,,156.2,93.72,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.72,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,117.15,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.2,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,156.2,
AB RUBELLA IGM,70020829,CDM,302,RC,86762,HCPCS,Outpatient,,,135.25,81.15,,16.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,,Fee Schedule,360% of BCBS POS Rate,51.8,360,,,Fee schedule,360% of BCBS PPO Rate,51.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.15,60,,64.92,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of TX Mediciad 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,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,101.44,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,135.25,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,135.25,
AB RUBEOLA IGM,70020830,CDM,302,RC,86765,HCPCS,Outpatient,,,134.83,80.90,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.9,60,,64.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,101.12,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,134.83,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,134.83,
AB VARICELLA ZOSTER IGM,70020831,CDM,302,RC,86787,HCPCS,Outpatient,,,153.32,91.99,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,91.99,60,,73.592,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,114.99,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,153.32,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,153.32,
AB HTLV I/II,70020832,CDM,302,RC,86790,HCPCS,Outpatient,,,158.75,95.25,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.25,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,119.06,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,158.75,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,158.75,
CX LEGIONELLA,70020833,CDM,306,RC,87081,HCPCS,Outpatient,,,143.64,86.18,,7.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,9.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,23.87,360,,,Fee Schedule,360% of BCBS POS Rate,23.87,360,,,Fee schedule,360% of BCBS PPO Rate,23.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.18,60,,68.944,Percent of Total Billed Charges,60% of Total Billed Charges,5.57,100,,,Fee Schedule,100% of TX Mediciad 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,5.96,90,,,Fee Schedule,90% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,130,,,Fee Schedule,130% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.74,103,,,Fee Schedule,103% of TX Medicaid Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,6.82,103,,,Fee Schedule,103% of CMS OPPS Rate,107.73,75,,199.104,Percent of Total Billed Charges,75% of Total Billed Charges,11.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,11.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,9.94,150,,,Fee Schedule,150% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.37,90,,,Fee Schedule,90% of UHC fee schedule,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,5.57,100,,,Fee Schedule,100% of TX Medicaid Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,143.64,100,,265.472,Percent of Total Billed Charges,100% of Total Billed Charges,5.37,143.64,
NOCARDIA CULTURE,70020835,CDM,306,RC,87102,HCPCS,Outpatient,,,218.3,130.98,,9.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,23.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,30.28,360,,,Fee Schedule,360% of BCBS POS Rate,30.28,360,,,Fee schedule,360% of BCBS PPO Rate,30.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.98,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,100,,,Fee Schedule,100% of TX Mediciad 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,7.56,90,,,Fee Schedule,90% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.93,130,,,Fee Schedule,130% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.27,103,,,Fee Schedule,103% of TX Medicaid Rate,8.66,103,,,Fee Schedule,103% of CMS OPPS Rate,8.66,103,,,Fee Schedule,103% of CMS OPPS Rate,163.73,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,14.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.61,150,,,Fee Schedule,150% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.81,90,,,Fee Schedule,90% of UHC fee schedule,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,6.81,218.3,
CX TYPE ID M AVIUM,70020836,CDM,306,RC,87149,HCPCS,Outpatient,,,205.44,123.26,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.26,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,154.08,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,205.44,
CX TYPE ID M GORDONI,70020837,CDM,306,RC,87149,HCPCS,Outpatient,,,205.44,123.26,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.26,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,154.08,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,205.44,
CX TYPE ID M KANSASII,70020838,CDM,306,RC,87149,HCPCS,Outpatient,,,205.44,123.26,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.26,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,154.08,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,205.44,
CX TYPE ID M TUBERCULOSIS,70020839,CDM,306,RC,87149,HCPCS,Outpatient,,,205.44,123.26,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.26,60,,98.608,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,154.08,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,205.44,
ETEST AST X1,70020840,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
ETEST AST X2,70020841,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,127.624,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,170.16,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
ETEST AST X3,70020842,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,1466.376,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,1955.168,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
ETEST AST X4,70020843,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,144.152,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,192.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
ETEST AST X5,70020844,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,119.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,159.2,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
ETEST AST X6,70020845,CDM,306,RC,87181,HCPCS,Outpatient,,,72.5,43.50,,5.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.1,360,,,Fee Schedule,360% of BCBS POS Rate,17.1,360,,,Fee schedule,360% of BCBS PPO Rate,17.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.5,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.99,100,,,Fee Schedule,100% of TX Mediciad 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,4.27,90,,,Fee Schedule,90% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6.17,130,,,Fee Schedule,130% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.11,103,,,Fee Schedule,103% of TX Medicaid Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,4.89,103,,,Fee Schedule,103% of CMS OPPS Rate,54.38,75,,118.432,Percent of Total Billed Charges,75% of Total Billed Charges,8.07,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.07,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.07,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.12,150,,,Fee Schedule,150% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3.85,90,,,Fee Schedule,90% of UHC fee schedule,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,3.99,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,100,,157.904,Percent of Total Billed Charges,100% of Total Billed Charges,3.85,72.5,
SMEAR CRYPTOSPORIDIUM,70020846,CDM,306,RC,87206,HCPCS,Outpatient,,,119.28,71.57,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,19.4,360,,,Fee Schedule,360% of BCBS POS Rate,19.4,360,,,Fee schedule,360% of BCBS PPO Rate,19.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.57,60,,57.256,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,100,,,Fee Schedule,100% of TX Mediciad 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,4.85,90,,,Fee Schedule,90% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7,130,,,Fee Schedule,130% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.67,103,,,Fee Schedule,103% of TX Medicaid Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,89.46,75,,126.6,Percent of Total Billed Charges,75% of Total Billed Charges,9.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.08,150,,,Fee Schedule,150% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,,Fee Schedule,90% of UHC fee schedule,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,119.28,100,,168.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.37,119.28,
SMEAR PRIM SOURCE FLUOR/FUNGUS,70020848,CDM,306,RC,87206,HCPCS,Outpatient,,,119.28,71.57,,6.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.09,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.25,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,19.4,360,,,Fee Schedule,360% of BCBS POS Rate,19.4,360,,,Fee schedule,360% of BCBS PPO Rate,19.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,71.57,60,,57.256,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,100,,,Fee Schedule,100% of TX Mediciad 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,4.85,90,,,Fee Schedule,90% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,7,130,,,Fee Schedule,130% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.67,103,,,Fee Schedule,103% of TX Medicaid Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,5.55,103,,,Fee Schedule,103% of CMS OPPS Rate,89.46,75,,131.728,Percent of Total Billed Charges,75% of Total Billed Charges,9.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.08,150,,,Fee Schedule,150% of CMS OPPS Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,90,,,Fee Schedule,90% of UHC fee schedule,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,4.53,100,,,Fee Schedule,100% of TX Medicaid Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,119.28,100,,175.632,Percent of Total Billed Charges,100% of Total Billed Charges,4.37,119.28,
O&P TRICHROME STAIN,70020849,CDM,306,RC,87209,HCPCS,Outpatient,,,148,88.80,,20.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,64.73,360,,,Fee Schedule,360% of BCBS POS Rate,64.73,360,,,Fee schedule,360% of BCBS PPO Rate,64.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.8,60,,71.04,Percent of Total Billed Charges,60% of Total Billed Charges,15.1,100,,,Fee Schedule,100% of TX Mediciad 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,16.18,90,,,Fee Schedule,90% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.37,130,,,Fee Schedule,130% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.55,103,,,Fee Schedule,103% of TX Medicaid Rate,18.51,103,,,Fee Schedule,103% of CMS OPPS Rate,18.51,103,,,Fee Schedule,103% of CMS OPPS Rate,111,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,30.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.97,150,,,Fee Schedule,150% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.56,90,,,Fee Schedule,90% of UHC fee schedule,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,148,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,14.56,148,
ALDOLASE,70020854,CDM,300,RC,82085,HCPCS,Outpatient,,,131.07,78.64,,11.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,27.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,34.96,360,,,Fee Schedule,360% of BCBS POS Rate,34.96,360,,,Fee schedule,360% of BCBS PPO Rate,34.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.64,60,,62.912,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,100,,,Fee Schedule,100% of TX Mediciad 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,8.73,90,,,Fee Schedule,90% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,130,,,Fee Schedule,130% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.4,103,,,Fee Schedule,103% of TX Medicaid Rate,10,103,,,Fee Schedule,103% of CMS OPPS Rate,10,103,,,Fee Schedule,103% of CMS OPPS Rate,98.3,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,16.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.56,150,,,Fee Schedule,150% of CMS OPPS Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,90,,,Fee Schedule,90% of UHC fee schedule,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,8.16,100,,,Fee Schedule,100% of TX Medicaid Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,131.07,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,7.87,131.07,
BRAF MUTATION ANALYSIS,70020860,CDM,310,RC,81210,HCPCS,Outpatient,,,650.83,390.50,,203.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,263.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,491.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,561.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,631.44,360,,,Fee Schedule,360% of BCBS POS Rate,631.44,360,,,Fee schedule,360% of BCBS PPO Rate,631.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,390.5,60,,312.4,Percent of Total Billed Charges,60% of Total Billed Charges,147.34,100,,,Fee Schedule,100% of TX Mediciad 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,157.86,90,,,Fee Schedule,90% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,228.02,130,,,Fee Schedule,130% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,151.76,103,,,Fee Schedule,103% of TX Medicaid Rate,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,180.66,103,,,Fee Schedule,103% of CMS OPPS Rate,488.12,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,298.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,298.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,298.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,263.1,150,,,Fee Schedule,150% of CMS OPPS Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,142.07,90,,,Fee Schedule,90% of UHC fee schedule,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,147.34,100,,,Fee Schedule,100% of TX Medicaid Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,650.83,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,142.07,650.83,
EGFR MUTATION ANALYSIS BY PCR,70020861,CDM,310,RC,81235,HCPCS,Outpatient,,,1720,1032.00,,376.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,486.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,908.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1038.66,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,1168.49,360,,,Fee Schedule,360% of BCBS POS Rate,1168.49,360,,,Fee schedule,360% of BCBS PPO Rate,1168.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,1032,60,,825.6,Percent of Total Billed Charges,60% of Total Billed Charges,272.65,100,,,Fee Schedule,100% of TX Mediciad 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,292.12,90,,,Fee Schedule,90% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,421.95,130,,,Fee Schedule,130% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,280.83,103,,,Fee Schedule,103% of TX Medicaid Rate,334.31,103,,,Fee Schedule,103% of CMS OPPS Rate,334.31,103,,,Fee Schedule,103% of CMS OPPS Rate,1290,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,551.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,551.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,551.78,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,551.78,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,486.87,150,,,Fee Schedule,150% of CMS OPPS Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,262.91,90,,,Fee Schedule,90% of UHC fee schedule,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,272.65,100,,,Fee Schedule,100% of TX Medicaid Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1720,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,262.91,1720,
ALDOSTERONE,70020870,CDM,300,RC,82088,HCPCS,Outpatient,,,371.92,223.15,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,223.15,60,,178.52,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,278.94,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,371.92,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,371.92,
VERIGENE,70020886,CDM,306,RC,87149,HCPCS,Outpatient,,,398.4,239.04,,23.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,72.18,360,,,Fee Schedule,360% of BCBS POS Rate,72.18,360,,,Fee schedule,360% of BCBS PPO Rate,72.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,239.04,60,,191.232,Percent of Total Billed Charges,60% of Total Billed Charges,16.84,100,,,Fee Schedule,100% of TX Mediciad 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,18.04,90,,,Fee Schedule,90% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,130,,,Fee Schedule,130% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of TX Medicaid Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,20.65,103,,,Fee Schedule,103% of CMS OPPS Rate,298.8,75,,82.128,Percent of Total Billed Charges,75% of Total Billed Charges,34.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.07,150,,,Fee Schedule,150% of CMS OPPS Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,90,,,Fee Schedule,90% of UHC fee schedule,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,16.84,100,,,Fee Schedule,100% of TX Medicaid Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,398.4,100,,109.504,Percent of Total Billed Charges,100% of Total Billed Charges,16.25,398.4,
SINGLE URINALYSIS ANALYTE AUTO,70020888,CDM,307,RC,81003,HCPCS,Outpatient,,,67,40.20,,2.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,3.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,7.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,360,,,Fee Schedule,360% of BCBS POS Rate,8.1,360,,,Fee schedule,360% of BCBS PPO Rate,8.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,1.89,100,,,Fee Schedule,100% of TX Mediciad 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,2.02,90,,,Fee Schedule,90% of CMS OPPS Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.92,130,,,Fee Schedule,130% of CMS OPPS Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.95,103,,,Fee Schedule,103% of TX Medicaid Rate,2.31,103,,,Fee Schedule,103% of CMS OPPS Rate,2.31,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,80.928,Percent of Total Billed Charges,75% of Total Billed Charges,3.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,3.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,3.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,3.37,150,,,Fee Schedule,150% of CMS OPPS Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1.83,90,,,Fee Schedule,90% of UHC fee schedule,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,1.89,100,,,Fee Schedule,100% of TX Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,107.904,Percent of Total Billed Charges,100% of Total Billed Charges,1.83,67,
HIV 1 ANTIBODY,70020889,CDM,302,RC,86701,HCPCS,Outpatient,,,192.25,115.35,,10.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.33,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,24.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,32,360,,,Fee Schedule,360% of BCBS POS Rate,32,360,,,Fee schedule,360% of BCBS PPO Rate,32,360,,,Fee Schedule,360% of BCBS Traditional Rate,115.35,60,,92.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,100,,,Fee Schedule,100% of TX Mediciad 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,8,90,,,Fee Schedule,90% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,130,,,Fee Schedule,130% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.69,103,,,Fee Schedule,103% of TX Medicaid Rate,9.15,103,,,Fee Schedule,103% of CMS OPPS Rate,9.15,103,,,Fee Schedule,103% of CMS OPPS Rate,144.19,75,,80.928,Percent of Total Billed Charges,75% of Total Billed Charges,15.11,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.11,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.11,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.33,150,,,Fee Schedule,150% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,90,,,Fee Schedule,90% of UHC fee schedule,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,7.47,100,,,Fee Schedule,100% of TX Medicaid Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,192.25,100,,107.904,Percent of Total Billed Charges,100% of Total Billed Charges,7.2,192.25,
HIV 2 ANTIBODY,70020890,CDM,302,RC,86702,HCPCS,Outpatient,,,142.88,85.73,,15.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,37.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,48.67,360,,,Fee Schedule,360% of BCBS POS Rate,48.67,360,,,Fee schedule,360% of BCBS PPO Rate,48.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.73,60,,68.584,Percent of Total Billed Charges,60% of Total Billed Charges,11.36,100,,,Fee Schedule,100% of TX Mediciad 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,12.16,90,,,Fee Schedule,90% of CMS OPPS Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,17.57,130,,,Fee Schedule,130% of CMS OPPS Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.7,103,,,Fee Schedule,103% of TX Medicaid Rate,13.92,103,,,Fee Schedule,103% of CMS OPPS Rate,13.92,103,,,Fee Schedule,103% of CMS OPPS Rate,107.16,75,,80.928,Percent of Total Billed Charges,75% of Total Billed Charges,22.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.98,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.28,150,,,Fee Schedule,150% of CMS OPPS Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,90,,,Fee Schedule,90% of UHC fee schedule,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,11.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,142.88,100,,107.904,Percent of Total Billed Charges,100% of Total Billed Charges,10.95,142.88,
ALDOSTERONE URINE,70020896,CDM,307,RC,82088,HCPCS,Outpatient,,,371.92,223.15,,47.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,130.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,146.7,360,,,Fee Schedule,360% of BCBS POS Rate,146.7,360,,,Fee schedule,360% of BCBS PPO Rate,146.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,223.15,60,,178.52,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,100,,,Fee Schedule,100% of TX Mediciad 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,36.67,90,,,Fee Schedule,90% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,130,,,Fee Schedule,130% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,35.26,103,,,Fee Schedule,103% of TX Medicaid Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,41.97,103,,,Fee Schedule,103% of CMS OPPS Rate,278.94,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,69.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,69.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,69.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,69.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.12,150,,,Fee Schedule,150% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,90,,,Fee Schedule,90% of UHC fee schedule,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,34.23,100,,,Fee Schedule,100% of TX Medicaid Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,371.92,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,33.01,371.92,
MOL CYTOGENETIC DNA PROBE,70020907,CDM,310,RC,88271,HCPCS,Outpatient,,,257.4,154.44,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,77.11,360,,,Fee Schedule,360% of BCBS POS Rate,77.11,360,,,Fee schedule,360% of BCBS PPO Rate,77.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,154.44,60,,123.552,Percent of Total Billed Charges,60% of Total Billed Charges,17.99,100,,,Fee Schedule,100% of TX Mediciad 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,19.27,90,,,Fee Schedule,90% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,130,,,Fee Schedule,130% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,18.53,103,,,Fee Schedule,103% of TX Medicaid Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,193.05,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,36.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,36.41,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.41,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.13,150,,,Fee Schedule,150% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.35,90,,,Fee Schedule,90% of UHC fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,257.4,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,17.35,257.4,
MOL CYTOGENETIC INSITU 100-300,70020908,CDM,311,RC,88275,HCPCS,Outpatient,,,384.5,230.70,,59.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,143.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,163.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,184.28,360,,,Fee Schedule,360% of BCBS POS Rate,184.28,360,,,Fee schedule,360% of BCBS PPO Rate,184.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,230.7,60,,184.56,Percent of Total Billed Charges,60% of Total Billed Charges,43,100,,,Fee Schedule,100% of TX Mediciad 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,46.07,90,,,Fee Schedule,90% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,66.54,130,,,Fee Schedule,130% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,44.29,103,,,Fee Schedule,103% of TX Medicaid Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,288.38,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,87.02,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,87.02,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,87.02,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,87.02,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.78,150,,,Fee Schedule,150% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,41.46,90,,,Fee Schedule,90% of UHC fee schedule,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,384.5,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,41.46,384.5,
CYTOLOGY CELL BLOCK,70020909,CDM,312,RC,88305,HCPCS,Outpatient,,,397,238.20,,40.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,,Fee Schedule,360% of BCBS POS Rate,178.09,360,,,Fee schedule,360% of BCBS PPO Rate,178.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,238.2,60,,190.56,Percent of Total Billed Charges,60% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,57.25,14.42,,45.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,297.75,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,198.5,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,198.5,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,198.5,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,198.5,50,,158.8,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,,Fee Schedule,90% of UHC fee schedule,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,55.58,14,,44.464,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,397,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,40.07,397,
SPECIAL STAINS HISTOCHEM W FRZ,70020911,CDM,312,RC,88314,HCPCS,Outpatient,,,255.33,153.20,,94.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,196.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,224.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,253.01,360,,,Fee Schedule,360% of BCBS POS Rate,253.01,360,,,Fee schedule,360% of BCBS PPO Rate,253.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,153.2,60,,122.56,Percent of Total Billed Charges,60% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,36.82,14.42,,29.456,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.5,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,127.67,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.67,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,127.67,50,,102.136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.1,90,,,Fee Schedule,90% of UHC fee schedule,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,35.75,14,,28.6,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,255.33,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,35.75,255.33,
HISTO/CYTOCHEMISTRY ID ENZYM,70020912,CDM,312,RC,88319,HCPCS,Outpatient,,,341,204.60,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,204.6,60,,163.68,Percent of Total Billed Charges,60% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,49.17,14.42,,39.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,255.75,75,,118.88,Percent of Total Billed Charges,75% of Total Billed Charges,170.5,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,170.5,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,170.5,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,170.5,50,,136.4,Percent of Total Billed Charges,50% of Total Billed Charges,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,47.74,14,,38.192,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,341,100,,158.504,Percent of Total Billed Charges,100% of Total Billed Charges,47.74,2261.52,
IMMUNOFLUOR ANTB 1ST STAIN,70020914,CDM,312,RC,88346,HCPCS,Outpatient,,,334,200.40,,130.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,200.4,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,48.16,14.42,,38.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,46.76,1020.28,
MICRODISSECTION MANUAL,70020918,CDM,310,RC,88381,HCPCS,Outpatient,,,733.2,439.92,,213.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,416.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,468.36,360,,,Fee Schedule,360% of BCBS POS Rate,468.36,360,,,Fee schedule,360% of BCBS PPO Rate,468.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,439.92,60,,351.936,Percent of Total Billed Charges,60% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,105.73,14.42,,84.584,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,549.9,75,,69.472,Percent of Total Billed Charges,75% of Total Billed Charges,366.6,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,366.6,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.6,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,366.6,50,,293.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.16,90,,,Fee Schedule,90% of UHC fee schedule,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,102.65,14,,82.12,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,733.2,100,,92.624,Percent of Total Billed Charges,100% of Total Billed Charges,102.65,733.2,
MAC EXM TISS NONMICRO EA,70020919,CDM,310,RC,88387,HCPCS,Outpatient,,,141.78,85.07,,9.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,24.66,360,,,Fee Schedule,360% of BCBS POS Rate,24.66,360,,,Fee schedule,360% of BCBS PPO Rate,24.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.07,60,,68.056,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,20.44,14.42,,16.352,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.34,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,70.89,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,70.89,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.89,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,70.89,50,,56.712,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.85,90,,,Fee Schedule,90% of UHC fee schedule,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,19.85,14,,15.88,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,141.78,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,5.85,141.78,
FUNGI MOLD HELMINTHOSPORIUM,70020920,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
ALTERNARIA ALERNATA TENUIS IGE,70020921,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,114.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
ASPERGILLUS FUMIGATUS IGE,70020922,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,114.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
BERMUDA GRASS IGE,70020926,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,54.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,72.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CAT EPITHELIUM DANDER IGE,70020931,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,54.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,72.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CLADOSPORIUM HERBARIUM IGE,70020933,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,54.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,72.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CLAME IGE,70020934,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,54.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,72.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
COCKROACH IGE,70020936,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,54.568,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,72.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CODFISH IGE,70020937,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,213.84,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,285.12,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CORN IGE,70020939,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,213.84,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,285.12,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
COW MILK IGE,70020941,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,208.48,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,277.968,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
CULTIVATED OAT POLLEN IGE,70020943,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,208.48,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,277.968,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
DERMATOPHAGOIDES FARINAE IGE,70020945,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
DERMATOPHAGOIDES PTERONYSSINUS,70020946,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,305.76,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,407.68,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
DOG DANDER IGE,70020947,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,640,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
EGG WHITE IGE,70020948,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
ELM IGE,70020950,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
ENGLISH PLANTAIN RIBWORT IGE,70020951,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,1611.048,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,2148.064,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
MEADOW GRASS KENTUCKY BLUE IGE,70020963,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,98.968,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,131.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
OAK IGE,70020970,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,154.44,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,205.92,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
PEA IGE,70020974,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,230.704,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,307.6,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
PEANUT IGE,70020975,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,220.76,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,294.344,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
SCALLOP IGE,70020989,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,147.816,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,197.088,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
SEASAME IGE,70020990,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,116.992,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,155.984,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
RAGWEED SHORT COMMON IGE,70020992,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,82.52,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,110.024,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
SHRIMP IGE,70020993,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,929.52,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,1239.36,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
SOYBEAN IGE,70020994,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,119.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,159.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
WALNUT IGE,70020999,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
WHEAT IGE,70021000,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,318,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,424,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
SHIGA LIKE TOXIN,70021003,CDM,306,RC,87427,HCPCS,Outpatient,,,91.21,54.73,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.73,60,,43.784,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,68.41,75,,236.704,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,91.21,100,,315.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,91.21,
ALPHA 1 ANTITRYPSIN PHENOTYPE,70021043,CDM,301,RC,82104,HCPCS,Outpatient,,,172.95,103.77,,16.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,40.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,360,,,Fee Schedule,360% of BCBS POS Rate,52.06,360,,,Fee schedule,360% of BCBS PPO Rate,52.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.77,60,,83.016,Percent of Total Billed Charges,60% of Total Billed Charges,12.15,100,,,Fee Schedule,100% of TX Mediciad 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,13.01,90,,,Fee Schedule,90% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,130,,,Fee Schedule,130% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.51,103,,,Fee Schedule,103% of TX Medicaid Rate,14.89,103,,,Fee Schedule,103% of CMS OPPS Rate,14.89,103,,,Fee Schedule,103% of CMS OPPS Rate,129.71,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,24.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.69,150,,,Fee Schedule,150% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,11.71,90,,,Fee Schedule,90% of UHC fee schedule,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,12.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,172.95,100,,101.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.71,172.95,
CX VIRAL CMV,70021150,CDM,306,RC,87252,HCPCS,Outpatient,,,345.05,207.03,,30.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,83.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,93.85,360,,,Fee Schedule,360% of BCBS POS Rate,93.85,360,,,Fee schedule,360% of BCBS PPO Rate,93.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,207.03,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,21.9,100,,,Fee Schedule,100% of TX Mediciad 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,23.46,90,,,Fee Schedule,90% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.89,130,,,Fee Schedule,130% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,22.56,103,,,Fee Schedule,103% of TX Medicaid Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,258.79,75,,40.2,Percent of Total Billed Charges,75% of Total Billed Charges,44.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,44.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,44.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,39.1,150,,,Fee Schedule,150% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.11,90,,,Fee Schedule,90% of UHC fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,345.05,100,,53.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.11,345.05,
SHELL VIAL VIRUS ISOLATION,70021152,CDM,306,RC,87254,HCPCS,Outpatient,,,195.48,117.29,,22.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.34,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,54.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,70.42,360,,,Fee Schedule,360% of BCBS POS Rate,70.42,360,,,Fee schedule,360% of BCBS PPO Rate,70.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.29,60,,93.832,Percent of Total Billed Charges,60% of Total Billed Charges,16.43,100,,,Fee Schedule,100% of TX Mediciad 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,17.6,90,,,Fee Schedule,90% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,25.42,130,,,Fee Schedule,130% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.92,103,,,Fee Schedule,103% of TX Medicaid Rate,20.14,103,,,Fee Schedule,103% of CMS OPPS Rate,20.14,103,,,Fee Schedule,103% of CMS OPPS Rate,146.61,75,,57,Percent of Total Billed Charges,75% of Total Billed Charges,33.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.34,150,,,Fee Schedule,150% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,90,,,Fee Schedule,90% of UHC fee schedule,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,16.43,100,,,Fee Schedule,100% of TX Medicaid Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,195.48,100,,76,Percent of Total Billed Charges,100% of Total Billed Charges,15.84,195.48,
EIA ASPERGILLUS GALACT,70021159,CDM,306,RC,87305,HCPCS,Outpatient,,,239.54,143.72,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.72,60,,114.976,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,179.66,75,,116.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,239.54,100,,155.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,239.54,
EIA CRYPTOSPORIDIUM,70021161,CDM,306,RC,87328,HCPCS,Outpatient,,,138.8,83.28,,16.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,49.75,360,,,Fee Schedule,360% of BCBS POS Rate,49.75,360,,,Fee schedule,360% of BCBS PPO Rate,49.75,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.28,60,,66.624,Percent of Total Billed Charges,60% of Total Billed Charges,11.61,100,,,Fee Schedule,100% of TX Mediciad 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,12.43,90,,,Fee Schedule,90% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,130,,,Fee Schedule,130% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.96,103,,,Fee Schedule,103% of TX Medicaid Rate,14.23,103,,,Fee Schedule,103% of CMS OPPS Rate,14.23,103,,,Fee Schedule,103% of CMS OPPS Rate,104.1,75,,1560,Percent of Total Billed Charges,75% of Total Billed Charges,23.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.73,150,,,Fee Schedule,150% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,90,,,Fee Schedule,90% of UHC fee schedule,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,138.8,100,,2080,Percent of Total Billed Charges,100% of Total Billed Charges,11.2,138.8,
HELICOBACTER ANTIGEN FECES,70021162,CDM,306,RC,87338,HCPCS,Outpatient,,,198.54,119.12,,16.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,40.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,51.77,360,,,Fee Schedule,360% of BCBS POS Rate,51.77,360,,,Fee schedule,360% of BCBS PPO Rate,51.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.12,60,,95.296,Percent of Total Billed Charges,60% of Total Billed Charges,12.08,100,,,Fee Schedule,100% of TX Mediciad 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,12.94,90,,,Fee Schedule,90% of CMS OPPS Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,130,,,Fee Schedule,130% of CMS OPPS Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.44,103,,,Fee Schedule,103% of TX Medicaid Rate,14.81,103,,,Fee Schedule,103% of CMS OPPS Rate,14.81,103,,,Fee Schedule,103% of CMS OPPS Rate,148.91,75,,63.96,Percent of Total Billed Charges,75% of Total Billed Charges,24.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,11.65,90,,,Fee Schedule,90% of UHC fee schedule,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12.08,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,198.54,100,,85.28,Percent of Total Billed Charges,100% of Total Billed Charges,11.65,198.54,
EIA FUNGITELL 1 BETA GLUCAN,70021163,CDM,306,RC,87449,HCPCS,Outpatient,,,363.12,217.87,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,217.87,60,,174.296,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,272.34,75,,67.544,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,363.12,100,,90.056,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,363.12,
EIA S PNEUMONIAE URINE,70021164,CDM,306,RC,87430,HCPCS,Outpatient,,,128.24,76.94,,19.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,47.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,60.52,360,,,Fee Schedule,360% of BCBS POS Rate,60.52,360,,,Fee schedule,360% of BCBS PPO Rate,60.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.94,60,,61.552,Percent of Total Billed Charges,60% of Total Billed Charges,14.12,100,,,Fee Schedule,100% of TX Mediciad 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,15.12,90,,,Fee Schedule,90% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,21.85,130,,,Fee Schedule,130% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.54,103,,,Fee Schedule,103% of TX Medicaid Rate,17.31,103,,,Fee Schedule,103% of CMS OPPS Rate,17.31,103,,,Fee Schedule,103% of CMS OPPS Rate,96.18,75,,55.2,Percent of Total Billed Charges,75% of Total Billed Charges,28.57,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.57,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,28.57,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.57,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.21,150,,,Fee Schedule,150% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,90,,,Fee Schedule,90% of UHC fee schedule,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.12,100,,,Fee Schedule,100% of TX Medicaid Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,128.24,100,,73.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.62,128.24,
NUC ACD LYME DISEASE AMP PROBE,70021165,CDM,306,RC,87476,HCPCS,Outpatient,,,490,294.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,294,60,,235.2,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,367.5,75,,109.688,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,490,100,,146.248,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,490,
NUC ACD CMV QT,70021166,CDM,306,RC,87497,HCPCS,Outpatient,,,514.17,308.50,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,308.5,60,,246.8,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,385.63,75,,64.816,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,514.17,100,,86.424,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,514.17,
INFLUENZA A H1N1 BY RT PCR,70021167,CDM,306,RC,87501,HCPCS,Outpatient,,,402,241.20,,59.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,143.67,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,164.19,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,184.72,360,,,Fee Schedule,360% of BCBS POS Rate,184.72,360,,,Fee schedule,360% of BCBS PPO Rate,184.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,241.2,60,,192.96,Percent of Total Billed Charges,60% of Total Billed Charges,43.1,100,,,Fee Schedule,100% of TX Mediciad 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,46.17,90,,,Fee Schedule,90% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,66.7,130,,,Fee Schedule,130% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,44.39,103,,,Fee Schedule,103% of TX Medicaid Rate,52.84,103,,,Fee Schedule,103% of CMS OPPS Rate,52.84,103,,,Fee Schedule,103% of CMS OPPS Rate,301.5,75,,64.384,Percent of Total Billed Charges,75% of Total Billed Charges,87.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,87.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,87.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,87.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.96,150,,,Fee Schedule,150% of CMS OPPS Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,41.56,90,,,Fee Schedule,90% of UHC fee schedule,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,43.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,402,100,,85.84,Percent of Total Billed Charges,100% of Total Billed Charges,41.56,402,
INFLUENZA A & B RT PCR,70021168,CDM,306,RC,87502,HCPCS,Outpatient,,,484,290.40,,111.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,143.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,268.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,306.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,344.88,360,,,Fee Schedule,360% of BCBS POS Rate,344.88,360,,,Fee schedule,360% of BCBS PPO Rate,344.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,290.4,60,,232.32,Percent of Total Billed Charges,60% of Total Billed Charges,80.47,100,,,Fee Schedule,100% of TX Mediciad 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,86.22,90,,,Fee Schedule,90% of CMS OPPS Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,124.54,130,,,Fee Schedule,130% of CMS OPPS Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,82.88,103,,,Fee Schedule,103% of TX Medicaid Rate,98.67,103,,,Fee Schedule,103% of CMS OPPS Rate,98.67,103,,,Fee Schedule,103% of CMS OPPS Rate,363,75,,43.952,Percent of Total Billed Charges,75% of Total Billed Charges,162.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,162.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,162.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,162.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,143.7,150,,,Fee Schedule,150% of CMS OPPS Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,77.6,90,,,Fee Schedule,90% of UHC fee schedule,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,80.47,100,,,Fee Schedule,100% of TX Medicaid Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,484,100,,58.6,Percent of Total Billed Charges,100% of Total Billed Charges,77.6,484,
NUC ACD HEP B QT,70021169,CDM,306,RC,87517,HCPCS,Outpatient,,,456.2,273.72,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,273.72,60,,218.976,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,342.15,75,,503.28,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,456.2,100,,671.04,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,456.2,
NUC ACD HHV 6 PCR,70021171,CDM,306,RC,87533,HCPCS,Outpatient,,,462,277.20,,48.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,62.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,116.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,133.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,150.34,360,,,Fee Schedule,360% of BCBS POS Rate,150.34,360,,,Fee schedule,360% of BCBS PPO Rate,150.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,277.2,60,,221.76,Percent of Total Billed Charges,60% of Total Billed Charges,35.08,100,,,Fee Schedule,100% of TX Mediciad 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,37.58,90,,,Fee Schedule,90% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,54.28,130,,,Fee Schedule,130% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,36.13,103,,,Fee Schedule,103% of TX Medicaid Rate,43.01,103,,,Fee Schedule,103% of CMS OPPS Rate,43.01,103,,,Fee Schedule,103% of CMS OPPS Rate,346.5,75,,74.488,Percent of Total Billed Charges,75% of Total Billed Charges,70.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,70.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,70.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,62.64,150,,,Fee Schedule,150% of CMS OPPS Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,33.82,90,,,Fee Schedule,90% of UHC fee schedule,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,35.08,100,,,Fee Schedule,100% of TX Medicaid Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,462,100,,99.312,Percent of Total Billed Charges,100% of Total Billed Charges,33.82,462,
RESP VIRUS 3-5 TARGETS,70021172,CDM,306,RC,87631,HCPCS,Outpatient,,,582.2,349.32,,165.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,213.94,150,,,Fee Schedule ,150% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,399.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,456.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,513.47,360,,,Fee Schedule,360% of BCBS POS Rate,513.47,360,,,Fee schedule,360% of BCBS PPO Rate,513.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,349.32,60,,279.456,Percent of Total Billed Charges,60% of Total Billed Charges,119.81,100,,,Fee Schedule,100% of TX Mediciad 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,128.36,90,,,Fee Schedule,90% of CMS OPPS Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,185.41,130,,,Fee Schedule,130% of CMS OPPS Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,123.4,103,,,Fee Schedule,103% of TX Medicaid Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,146.9,103,,,Fee Schedule,103% of CMS OPPS Rate,436.65,75,,440.4,Percent of Total Billed Charges,75% of Total Billed Charges,242.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,242.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,242.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,242.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,213.94,150,,,Fee Schedule,150% of CMS OPPS Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,115.53,90,,,Fee Schedule,90% of UHC fee schedule,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,119.81,100,,,Fee Schedule,100% of TX Medicaid Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,582.2,100,,587.2,Percent of Total Billed Charges,100% of Total Billed Charges,115.53,582.2,
RESPIRATORY VIRUS PANEL BY PCR,70021173,CDM,301,RC,87632,HCPCS,Outpatient,,,1876.33,1125.80,,252.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,327.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,610.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,697.79,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,785.02,360,,,Fee Schedule,360% of BCBS POS Rate,785.02,360,,,Fee schedule,360% of BCBS PPO Rate,785.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,1125.8,60,,900.64,Percent of Total Billed Charges,60% of Total Billed Charges,183.17,100,,,Fee Schedule,100% of TX Mediciad 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,196.25,90,,,Fee Schedule,90% of CMS OPPS Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,283.47,130,,,Fee Schedule,130% of CMS OPPS Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,188.67,103,,,Fee Schedule,103% of TX Medicaid Rate,224.6,103,,,Fee Schedule,103% of CMS OPPS Rate,224.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1407.25,75,,279.496,Percent of Total Billed Charges,75% of Total Billed Charges,370.7,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,370.7,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,370.7,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,370.7,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,327.09,150,,,Fee Schedule,150% of CMS OPPS Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,176.63,90,,,Fee Schedule,90% of UHC fee schedule,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,183.17,100,,,Fee Schedule,100% of TX Medicaid Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1876.33,100,,372.656,Percent of Total Billed Charges,100% of Total Billed Charges,176.63,1876.33,
MRSA AMPLIFIED PROBE TECHNIQUE,70021174,CDM,306,RC,87641,HCPCS,Outpatient,,,323.2,193.92,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,193.92,60,,155.136,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,242.4,75,,489.072,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,323.2,100,,652.096,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,323.2,
NUC ACD ADENOVIRUS AMPL PROBE,70021175,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,732.8,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,977.064,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD BK VIRUS QT,70021176,CDM,306,RC,87799,HCPCS,Outpatient,,,515.55,309.33,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,309.33,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,386.66,75,,235.2,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,515.55,100,,313.6,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,515.55,
NUC ACD ENTEROVIRUS RNA,70021177,CDM,306,RC,87498,HCPCS,Outpatient,,,389.28,233.57,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,233.57,60,,186.856,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,291.96,75,,119.184,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,389.28,100,,158.912,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,389.28,
NUC ACD HHV 8 PCR,70021178,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,81.6,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,108.8,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD JC VIRUS,70021179,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,146.968,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,195.96,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD PARVOVIRUS,70021180,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,461.032,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,614.704,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD VARICELLA ZOSTER,70021181,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,237.248,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,316.328,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD WEST NILE,70021182,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,633.208,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,844.28,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
NUC ACD EBD,70021184,CDM,306,RC,87799,HCPCS,Outpatient,,,515.55,309.33,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,309.33,60,,247.464,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,386.66,75,,435,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,515.55,100,,580,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,515.55,
DETECT AGNT MULT DNA AMPLI,70021185,CDM,306,RC,87801,HCPCS,Outpatient,,,1052.55,631.53,,81.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,105.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,224.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,252.72,360,,,Fee Schedule,360% of BCBS POS Rate,252.72,360,,,Fee schedule,360% of BCBS PPO Rate,252.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,631.53,60,,505.224,Percent of Total Billed Charges,60% of Total Billed Charges,58.97,100,,,Fee Schedule,100% of TX Mediciad 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,63.18,90,,,Fee Schedule,90% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.26,130,,,Fee Schedule,130% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,60.74,103,,,Fee Schedule,103% of TX Medicaid Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,72.3,103,,,Fee Schedule,103% of CMS OPPS Rate,789.41,75,,444.128,Percent of Total Billed Charges,75% of Total Billed Charges,119.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,119.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,119.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,119.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,105.3,150,,,Fee Schedule,150% of CMS OPPS Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.86,90,,,Fee Schedule,90% of UHC fee schedule,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,58.97,100,,,Fee Schedule,100% of TX Medicaid Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1052.55,100,,592.168,Percent of Total Billed Charges,100% of Total Billed Charges,56.86,1052.55,
RAPID INFLUENZA B,70021186,CDM,306,RC,87804,HCPCS,Outpatient,,,153,91.80,,19.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,52.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,59.58,360,,,Fee Schedule,360% of BCBS POS Rate,59.58,360,,,Fee schedule,360% of BCBS PPO Rate,59.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,91.8,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,100,,,Fee Schedule,100% of TX Mediciad 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,14.89,90,,,Fee Schedule,90% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,130,,,Fee Schedule,130% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,103,,,Fee Schedule,103% of TX Medicaid Rate,17.04,103,,,Fee Schedule,103% of CMS OPPS Rate,17.04,103,,,Fee Schedule,103% of CMS OPPS Rate,114.75,75,,78.24,Percent of Total Billed Charges,75% of Total Billed Charges,28.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,28.13,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.13,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.82,150,,,Fee Schedule,150% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.41,90,,,Fee Schedule,90% of UHC fee schedule,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,13.9,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153,100,,104.32,Percent of Total Billed Charges,100% of Total Billed Charges,13.41,153,
HIV 1 GENOTYPE DRUG RESISTANCE,70021187,CDM,306,RC,87901,HCPCS,Outpatient,,,1325,795.00,,298.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,386.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,720.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,823.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,926.82,360,,,Fee Schedule,360% of BCBS POS Rate,926.82,360,,,Fee schedule,360% of BCBS PPO Rate,926.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,795,60,,636,Percent of Total Billed Charges,60% of Total Billed Charges,216.26,100,,,Fee Schedule,100% of TX Mediciad 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,231.7,90,,,Fee Schedule,90% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,334.68,130,,,Fee Schedule,130% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,222.75,103,,,Fee Schedule,103% of TX Medicaid Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,993.75,75,,112.56,Percent of Total Billed Charges,75% of Total Billed Charges,437.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,437.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,437.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,437.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,386.17,150,,,Fee Schedule,150% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,208.54,90,,,Fee Schedule,90% of UHC fee schedule,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1325,100,,150.08,Percent of Total Billed Charges,100% of Total Billed Charges,208.54,1325,
FLOW CYTOMETRY 1ST MARKER,70021189,CDM,311,RC,88184,HCPCS,Outpatient,,,208.37,125.02,,82.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.02,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.05,14.42,,24.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,156.28,75,,279,Percent of Total Billed Charges,75% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,208.37,100,,372,Percent of Total Billed Charges,100% of Total Billed Charges,29.17,1020.28,
BCR/ABL T(9;22) BY FISH,70021190,CDM,312,RC,88365,HCPCS,Outpatient,,,563.87,338.32,,168.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,338.32,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,81.31,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,422.9,75,,630.272,Percent of Total Billed Charges,75% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,563.87,100,,840.36,Percent of Total Billed Charges,100% of Total Billed Charges,78.94,563.87,
MYCOPHENOLIC ACID,70021202,CDM,301,RC,80180,HCPCS,Outpatient,,,226.65,135.99,,20.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,50.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,64.98,360,,,Fee Schedule,360% of BCBS POS Rate,64.98,360,,,Fee schedule,360% of BCBS PPO Rate,64.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,135.99,60,,108.792,Percent of Total Billed Charges,60% of Total Billed Charges,15.16,100,,,Fee Schedule,100% of TX Mediciad 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,16.24,90,,,Fee Schedule,90% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,130,,,Fee Schedule,130% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.61,103,,,Fee Schedule,103% of TX Medicaid Rate,18.59,103,,,Fee Schedule,103% of CMS OPPS Rate,18.59,103,,,Fee Schedule,103% of CMS OPPS Rate,169.99,75,,159.472,Percent of Total Billed Charges,75% of Total Billed Charges,30.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,30.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.07,150,,,Fee Schedule,150% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,90,,,Fee Schedule,90% of UHC fee schedule,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,226.65,100,,212.624,Percent of Total Billed Charges,100% of Total Billed Charges,14.63,226.65,
AMINO ACIDS 2 5 CYSTINE URINE,70021207,CDM,301,RC,82136,HCPCS,Outpatient,,,239.46,143.68,,22.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,54.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,70.6,360,,,Fee Schedule,360% of BCBS POS Rate,70.6,360,,,Fee schedule,360% of BCBS PPO Rate,70.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.68,60,,114.944,Percent of Total Billed Charges,60% of Total Billed Charges,16.47,100,,,Fee Schedule,100% of TX Mediciad 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,17.64,90,,,Fee Schedule,90% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,130,,,Fee Schedule,130% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.96,103,,,Fee Schedule,103% of TX Medicaid Rate,20.19,103,,,Fee Schedule,103% of CMS OPPS Rate,20.19,103,,,Fee Schedule,103% of CMS OPPS Rate,179.6,75,,106.584,Percent of Total Billed Charges,75% of Total Billed Charges,33.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,33.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.41,150,,,Fee Schedule,150% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,90,,,Fee Schedule,90% of UHC fee schedule,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,239.46,100,,142.112,Percent of Total Billed Charges,100% of Total Billed Charges,15.89,239.46,
BILE ACIDS TOTAL,70021210,CDM,301,RC,82239,HCPCS,Outpatient,,,160.64,96.38,,19.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,47.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,360,,,Fee Schedule,360% of BCBS POS Rate,61.63,360,,,Fee schedule,360% of BCBS PPO Rate,61.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,96.38,60,,77.104,Percent of Total Billed Charges,60% of Total Billed Charges,14.38,100,,,Fee Schedule,100% of TX Mediciad 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,15.4,90,,,Fee Schedule,90% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,22.25,130,,,Fee Schedule,130% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,103,,,Fee Schedule,103% of TX Medicaid Rate,17.63,103,,,Fee Schedule,103% of CMS OPPS Rate,17.63,103,,,Fee Schedule,103% of CMS OPPS Rate,120.48,75,,147.168,Percent of Total Billed Charges,75% of Total Billed Charges,29.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,29.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.68,150,,,Fee Schedule,150% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.87,90,,,Fee Schedule,90% of UHC fee schedule,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,14.38,100,,,Fee Schedule,100% of TX Medicaid Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,160.64,100,,196.224,Percent of Total Billed Charges,100% of Total Billed Charges,13.87,160.64,
CITRATE,70021213,CDM,301,RC,82507,HCPCS,Outpatient,,,248.5,149.10,,32.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,41.7,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,77.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,88.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,100.08,360,,,Fee Schedule,360% of BCBS POS Rate,100.08,360,,,Fee schedule,360% of BCBS PPO Rate,100.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,149.1,60,,119.28,Percent of Total Billed Charges,60% of Total Billed Charges,23.35,100,,,Fee Schedule,100% of TX Mediciad 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,25.02,90,,,Fee Schedule,90% of CMS OPPS Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,36.14,130,,,Fee Schedule,130% of CMS OPPS Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,24.05,103,,,Fee Schedule,103% of TX Medicaid Rate,28.63,103,,,Fee Schedule,103% of CMS OPPS Rate,28.63,103,,,Fee Schedule,103% of CMS OPPS Rate,186.38,75,,229.2,Percent of Total Billed Charges,75% of Total Billed Charges,47.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,47.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,47.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,47.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,41.7,150,,,Fee Schedule,150% of CMS OPPS Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,90,,,Fee Schedule,90% of UHC fee schedule,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,23.35,100,,,Fee Schedule,100% of TX Medicaid Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,248.5,100,,305.6,Percent of Total Billed Charges,100% of Total Billed Charges,22.52,248.5,
LACOSAMIDE (VIMPAT) LEVEL,70021215,CDM,301,RC,82542,HCPCS,Outpatient,,,239.55,143.73,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.73,60,,114.984,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,179.66,75,,338.32,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,239.55,100,,451.096,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,239.55,
ELECTROPHORETIC TECHNIQUE NOS,70021220,CDM,301,RC,82664,HCPCS,Outpatient,,,238.12,142.87,,71.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,92.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,172.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,196.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,221.4,360,,,Fee Schedule,360% of BCBS POS Rate,221.4,360,,,Fee schedule,360% of BCBS PPO Rate,221.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,142.87,60,,114.296,Percent of Total Billed Charges,60% of Total Billed Charges,51.66,100,,,Fee Schedule,100% of TX Mediciad 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,55.35,90,,,Fee Schedule,90% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,130,,,Fee Schedule,130% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,53.21,103,,,Fee Schedule,103% of TX Medicaid Rate,63.34,103,,,Fee Schedule,103% of CMS OPPS Rate,63.34,103,,,Fee Schedule,103% of CMS OPPS Rate,178.59,75,,134.64,Percent of Total Billed Charges,75% of Total Billed Charges,104.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,104.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,104.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,92.25,150,,,Fee Schedule,150% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,90,,,Fee Schedule,90% of UHC fee schedule,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,238.12,100,,179.52,Percent of Total Billed Charges,100% of Total Billed Charges,49.82,238.12,
GALACTOKINASE RBC,70021223,CDM,301,RC,82759,HCPCS,Outpatient,,,341.62,204.97,,24.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.22,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,60.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,77.33,360,,,Fee Schedule,360% of BCBS POS Rate,77.33,360,,,Fee schedule,360% of BCBS PPO Rate,77.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,204.97,60,,163.976,Percent of Total Billed Charges,60% of Total Billed Charges,18.04,100,,,Fee Schedule,100% of TX Mediciad Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,19.33,90,,,Fee Schedule,90% of CMS OPPS Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,130,,,Fee Schedule,130% of CMS OPPS Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.58,103,,,Fee Schedule,103% of TX Medicaid Rate,22.12,103,,,Fee Schedule,103% of CMS OPPS Rate,22.12,103,,,Fee Schedule,103% of CMS OPPS Rate,256.22,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,36.51,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.51,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,36.51,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.51,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.22,150,,,Fee Schedule,150% of CMS OPPS Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,17.4,90,,,Fee Schedule,90% of UHC fee schedule,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,18.04,100,,,Fee Schedule,100% of TX Medicaid Rate,21.48,100,,,Fee Schedule,100% of CMS OPPS Rate,341.62,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,17.4,341.62,
METHEMOGLOBIN QT,70021225,CDM,301,RC,83050,HCPCS,Outpatient,,,107.82,64.69,,9.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,29.52,360,,,Fee Schedule,360% of BCBS POS Rate,29.52,360,,,Fee schedule,360% of BCBS PPO Rate,29.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.69,60,,51.752,Percent of Total Billed Charges,60% of Total Billed Charges,6.89,100,,,Fee Schedule,100% of TX Mediciad 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,7.37,90,,,Fee Schedule,90% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.66,130,,,Fee Schedule,130% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,7.1,103,,,Fee Schedule,103% of TX Medicaid Rate,8.44,103,,,Fee Schedule,103% of CMS OPPS Rate,8.44,103,,,Fee Schedule,103% of CMS OPPS Rate,80.87,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,13.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.3,150,,,Fee Schedule,150% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.64,90,,,Fee Schedule,90% of UHC fee schedule,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,6.89,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,107.82,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,6.64,107.82,
SULFHEMOGLOB QT,70021226,CDM,301,RC,83060,HCPCS,Outpatient,,,53.48,32.09,,10.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,24.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,31.68,360,,,Fee Schedule,360% of BCBS POS Rate,31.68,360,,,Fee schedule,360% of BCBS PPO Rate,31.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,32.09,60,,25.672,Percent of Total Billed Charges,60% of Total Billed Charges,7.39,100,,,Fee Schedule,100% of TX Mediciad Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7.92,90,,,Fee Schedule,90% of CMS OPPS Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.44,130,,,Fee Schedule,130% of CMS OPPS Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.61,103,,,Fee Schedule,103% of TX Medicaid Rate,9.06,103,,,Fee Schedule,103% of CMS OPPS Rate,9.06,103,,,Fee Schedule,103% of CMS OPPS Rate,40.11,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,14.96,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.96,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.96,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.96,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.2,150,,,Fee Schedule,150% of CMS OPPS Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,7.13,90,,,Fee Schedule,90% of UHC fee schedule,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,7.39,100,,,Fee Schedule,100% of TX Medicaid Rate,8.8,100,,,Fee Schedule,100% of CMS OPPS Rate,53.48,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,7.13,53.48,
ACH RECEPTOR MODULATING AB,70021227,CDM,301,RC,83519,HCPCS,Outpatient,,,1040,624.00,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,624,60,,499.2,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,780,75,,109.392,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1040,100,,145.856,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,1040,
ACH RECEPTOR MUSCLE BINDING AB,70021228,CDM,301,RC,83519,HCPCS,Outpatient,,,937.2,562.32,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,562.32,60,,449.856,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,702.9,75,,520.2,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,937.2,100,,693.6,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,937.2,
ACHR GANGLIONIC NEURONAL AB,70021229,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,567.264,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,756.352,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
NEURONAL VGKC AUTO AB,70021230,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,425.2,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,566.936,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
N TYPE CALCIUM CHANNEL AB,70021231,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,527.736,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,703.648,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
P/Q TYPE CALCIUM CHANNEL AB,70021232,CDM,301,RC,83519,HCPCS,Outpatient,,,937.2,562.32,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,562.32,60,,449.856,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,702.9,75,,208.8,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,937.2,100,,278.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,937.2,
IMMUNOASSAY MONOSIALO GM1 IGG,70021234,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,208.8,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,278.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IMMUNOASSAY MONOSIALO GM1 IGM,70021235,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,117.832,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,157.104,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IMMUNOASSAY ASIALO GM1 IGG,70021236,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,150.096,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,200.128,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IMMUNOASSAY ASIALO GM1 IGM,70021237,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,132,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IMMUNOASSAY DISIALO GM1 IGG,70021238,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,133.8,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,178.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
IMMUNOASSAY DISIALO GM1 IGM,70021239,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,1083.256,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,1444.344,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
ORGANIC ACID QL EA,70021243,CDM,301,RC,83919,HCPCS,Outpatient,,,303.25,181.95,,19.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,46.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,52.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,59.22,360,,,Fee Schedule,360% of BCBS POS Rate,59.22,360,,,Fee schedule,360% of BCBS PPO Rate,59.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,181.95,60,,145.56,Percent of Total Billed Charges,60% of Total Billed Charges,13.82,100,,,Fee Schedule,100% of TX Mediciad 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,14.8,90,,,Fee Schedule,90% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,130,,,Fee Schedule,130% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,103,,,Fee Schedule,103% of TX Medicaid Rate,16.94,103,,,Fee Schedule,103% of CMS OPPS Rate,16.94,103,,,Fee Schedule,103% of CMS OPPS Rate,227.44,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,27.96,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.96,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,27.96,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.96,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.67,150,,,Fee Schedule,150% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,90,,,Fee Schedule,90% of UHC fee schedule,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,13.82,100,,,Fee Schedule,100% of TX Medicaid Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,303.25,100,,105.6,Percent of Total Billed Charges,100% of Total Billed Charges,13.33,303.25,
ORGANIC ACID QT OROTIC,70021244,CDM,301,RC,83921,HCPCS,Outpatient,,,252.05,151.23,,24.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,59.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,76.36,360,,,Fee Schedule,360% of BCBS POS Rate,76.36,360,,,Fee schedule,360% of BCBS PPO Rate,76.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,151.23,60,,120.984,Percent of Total Billed Charges,60% of Total Billed Charges,17.82,100,,,Fee Schedule,100% of TX Mediciad 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,19.08,90,,,Fee Schedule,90% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,27.57,130,,,Fee Schedule,130% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,18.35,103,,,Fee Schedule,103% of TX Medicaid Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,189.04,75,,102.976,Percent of Total Billed Charges,75% of Total Billed Charges,36.05,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.05,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,36.05,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.05,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.81,150,,,Fee Schedule,150% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.18,90,,,Fee Schedule,90% of UHC fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,252.05,100,,137.304,Percent of Total Billed Charges,100% of Total Billed Charges,17.18,252.05,
CRMP 5 IGG WESTERN BLOT,70021246,CDM,301,RC,84182,HCPCS,Outpatient,,,446.22,267.73,,33.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,43.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,81.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,105.16,360,,,Fee Schedule,360% of BCBS POS Rate,105.16,360,,,Fee schedule,360% of BCBS PPO Rate,105.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,267.73,60,,214.184,Percent of Total Billed Charges,60% of Total Billed Charges,24.54,100,,,Fee Schedule,100% of TX Mediciad 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,26.28,90,,,Fee Schedule,90% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,37.97,130,,,Fee Schedule,130% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,25.28,103,,,Fee Schedule,103% of TX Medicaid Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,334.67,75,,159,Percent of Total Billed Charges,75% of Total Billed Charges,49.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,43.81,150,,,Fee Schedule,150% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,23.66,90,,,Fee Schedule,90% of UHC fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,446.22,100,,212,Percent of Total Billed Charges,100% of Total Billed Charges,23.66,446.22,
SPECTROPHOTOMETRY ANALYTE,70021251,CDM,301,RC,84311,HCPCS,Outpatient,,,176.89,106.13,,9.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,29.16,360,,,Fee Schedule,360% of BCBS POS Rate,29.16,360,,,Fee schedule,360% of BCBS PPO Rate,29.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.13,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,6.8,100,,,Fee Schedule,100% of TX Mediciad 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,7.29,90,,,Fee Schedule,90% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10.53,130,,,Fee Schedule,130% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,7,103,,,Fee Schedule,103% of TX Medicaid Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,132.67,75,,96.136,Percent of Total Billed Charges,75% of Total Billed Charges,13.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.15,150,,,Fee Schedule,150% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.56,90,,,Fee Schedule,90% of UHC fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,176.89,100,,128.184,Percent of Total Billed Charges,100% of Total Billed Charges,6.56,176.89,
AB DEOXYRIBONUCLEASE B TITER,70021255,CDM,302,RC,86215,HCPCS,Outpatient,,,143.73,86.24,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.24,60,,68.992,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,107.8,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,143.73,100,,108,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,143.73,
METHYLMALONIC ACID,70021258,CDM,301,RC,83921,HCPCS,Outpatient,,,252.05,151.23,,24.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,59.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,76.36,360,,,Fee Schedule,360% of BCBS POS Rate,76.36,360,,,Fee schedule,360% of BCBS PPO Rate,76.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,151.23,60,,120.984,Percent of Total Billed Charges,60% of Total Billed Charges,17.82,100,,,Fee Schedule,100% of TX Mediciad 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,19.08,90,,,Fee Schedule,90% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,27.57,130,,,Fee Schedule,130% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,18.35,103,,,Fee Schedule,103% of TX Medicaid Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,189.04,75,,62.744,Percent of Total Billed Charges,75% of Total Billed Charges,36.05,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.05,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,36.05,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.05,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.81,150,,,Fee Schedule,150% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.18,90,,,Fee Schedule,90% of UHC fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,252.05,100,,83.656,Percent of Total Billed Charges,100% of Total Billed Charges,17.18,252.05,
AB AMPHIPHYSIN,70021259,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,63,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,84,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI NEURONAL NUCLEAR AB TYPE1,70021260,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,94.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,125.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI NEURONAL NUCLEAR AB TYPE2,70021261,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,94.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,125.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI NEURONAL NUCLEAR AB TYPE3,70021262,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,124.912,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,166.544,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
AB CRMP 5 IGG,70021263,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,173.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,231.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
PUNKINJE CELL CYTOPLASMIC AB 1,70021264,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,157.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,209.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
PUNKINJE CELL CYTOPLASMIC AB 2,70021265,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,165.472,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,220.632,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
PUNKINJE CELL CYTOPLASMIC AB T,70021266,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,127.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,169.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
ANTI GLIAL NUCLEAR AB TYPE 1,70021267,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,119.968,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,159.96,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
AB LISTERIA,70021268,CDM,302,RC,86609,HCPCS,Outpatient,,,93.49,56.09,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,56.09,60,,44.872,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,70.12,75,,128.4,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,93.49,100,,171.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,93.49,
AB POLIOVIRUS TYPE 1,70021270,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,123.48,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,164.64,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB POLIOVIRUS TYPE 2,70021271,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,117.6,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,156.8,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB POLIOVIRUS TYPE 3,70021272,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,82.792,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,110.384,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
NUC ACD HIV1 AMPL PROBE,70021278,CDM,306,RC,87535,HCPCS,Outpatient,,,442.75,265.65,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,265.65,60,,212.52,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,332.06,75,,81.912,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,442.75,100,,109.216,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,442.75,
FLOW CYTO 1ST MARKER WBC,70021281,CDM,311,RC,88184,HCPCS,Outpatient,,,208.37,125.02,,82.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.02,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,30.05,14.42,,24.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,156.28,75,,109.2,Percent of Total Billed Charges,75% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,104.19,50,,83.352,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,29.17,14,,23.336,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,208.37,100,,145.6,Percent of Total Billed Charges,100% of Total Billed Charges,29.17,1020.28,
FLOW CYTO EA ADDL MARKER WBC,70021283,CDM,311,RC,88185,HCPCS,Outpatient,,,177.64,106.58,,27.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,79.94,45,,63.952,Percent of Total Billed Charges,45% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,89.53,360,,,Fee Schedule,360% of BCBS POS Rate,89.53,360,,,Fee schedule,360% of BCBS PPO Rate,89.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.58,60,,85.264,Percent of Total Billed Charges,60% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.64,100,,142.112,Percent of Total Billed Charges,Pays based on exceed threshold,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14.42,,20.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.23,75,,107.864,Percent of Total Billed Charges,75% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.13,90,,,Fee Schedule,90% of UHC fee schedule,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.64,100,,143.816,Percent of Total Billed Charges,100% of Total Billed Charges,18.13,177.64,
CX TISSUE NON NEOPLAS SKIN,70021285,CDM,310,RC,88233,HCPCS,Outpatient,,,936.21,561.73,,163.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,211.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,394.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,450.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,506.63,360,,,Fee Schedule,360% of BCBS POS Rate,506.63,360,,,Fee schedule,360% of BCBS PPO Rate,506.63,360,,,Fee Schedule,360% of BCBS Traditional Rate,561.73,60,,449.384,Percent of Total Billed Charges,60% of Total Billed Charges,118.21,100,,,Fee Schedule,100% of TX Mediciad 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,126.65,90,,,Fee Schedule,90% of CMS OPPS Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,182.94,130,,,Fee Schedule,130% of CMS OPPS Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,121.76,103,,,Fee Schedule,103% of TX Medicaid Rate,144.95,103,,,Fee Schedule,103% of CMS OPPS Rate,144.95,103,,,Fee Schedule,103% of CMS OPPS Rate,702.16,75,,57.904,Percent of Total Billed Charges,75% of Total Billed Charges,239.24,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,239.24,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,239.24,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,239.24,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,211.09,150,,,Fee Schedule,150% of CMS OPPS Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,113.99,90,,,Fee Schedule,90% of UHC fee schedule,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,118.21,100,,,Fee Schedule,100% of TX Medicaid Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,936.21,100,,77.2,Percent of Total Billed Charges,100% of Total Billed Charges,113.99,936.21,
CHROM ANALY ADDL KARY EACH AFL,70021289,CDM,310,RC,88280,HCPCS,Outpatient,,,274,164.40,,38.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,50.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,93.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,107.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,120.49,360,,,Fee Schedule,360% of BCBS POS Rate,120.49,360,,,Fee schedule,360% of BCBS PPO Rate,120.49,360,,,Fee Schedule,360% of BCBS Traditional Rate,164.4,60,,131.52,Percent of Total Billed Charges,60% of Total Billed Charges,28.11,100,,,Fee Schedule,100% of TX Mediciad 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,30.12,90,,,Fee Schedule,90% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.51,130,,,Fee Schedule,130% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.95,103,,,Fee Schedule,103% of TX Medicaid Rate,34.47,103,,,Fee Schedule,103% of CMS OPPS Rate,34.47,103,,,Fee Schedule,103% of CMS OPPS Rate,205.5,75,,428.4,Percent of Total Billed Charges,75% of Total Billed Charges,56.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,56.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,56.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,56.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,50.2,150,,,Fee Schedule,150% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,90,,,Fee Schedule,90% of UHC fee schedule,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,28.11,100,,,Fee Schedule,100% of TX Medicaid Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,274,100,,571.2,Percent of Total Billed Charges,100% of Total Billed Charges,27.11,274,
CHROM ANALY ADDL CELLS CYTOGEN,70021290,CDM,311,RC,88285,HCPCS,Outpatient,,,215.11,129.07,,31.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,75.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,86.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,96.88,360,,,Fee Schedule,360% of BCBS POS Rate,96.88,360,,,Fee schedule,360% of BCBS PPO Rate,96.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.07,60,,103.256,Percent of Total Billed Charges,60% of Total Billed Charges,22.6,100,,,Fee Schedule,100% of TX Mediciad 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,24.21,90,,,Fee Schedule,90% of CMS OPPS Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,34.98,130,,,Fee Schedule,130% of CMS OPPS Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,23.28,103,,,Fee Schedule,103% of TX Medicaid Rate,27.71,103,,,Fee Schedule,103% of CMS OPPS Rate,27.71,103,,,Fee Schedule,103% of CMS OPPS Rate,161.33,75,,178.024,Percent of Total Billed Charges,75% of Total Billed Charges,45.74,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.74,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,45.74,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.74,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.36,150,,,Fee Schedule,150% of CMS OPPS Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,21.8,90,,,Fee Schedule,90% of UHC fee schedule,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,22.6,100,,,Fee Schedule,100% of TX Medicaid Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,215.11,100,,237.368,Percent of Total Billed Charges,100% of Total Billed Charges,21.8,215.11,
C2 COMPLEMENT SERUM,70021294,CDM,302,RC,86161,HCPCS,Outpatient,,,201,120.60,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,120.6,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,150.75,75,,158.752,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,201,100,,211.672,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,201,
CHROM ANALY 5 CELL 1 KARY,70021297,CDM,311,RC,88261,HCPCS,Outpatient,,,1308,784.80,,306.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,396.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,740.15,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,845.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,951.62,360,,,Fee Schedule,360% of BCBS POS Rate,951.62,360,,,Fee schedule,360% of BCBS PPO Rate,951.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,784.8,60,,627.84,Percent of Total Billed Charges,60% of Total Billed Charges,222.05,100,,,Fee Schedule,100% of TX Mediciad 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,237.9,90,,,Fee Schedule,90% of CMS OPPS Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,343.64,130,,,Fee Schedule,130% of CMS OPPS Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,228.71,103,,,Fee Schedule,103% of TX Medicaid Rate,272.27,103,,,Fee Schedule,103% of CMS OPPS Rate,272.27,103,,,Fee Schedule,103% of CMS OPPS Rate,981,75,,95.52,Percent of Total Billed Charges,75% of Total Billed Charges,449.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,449.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,449.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,449.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,396.5,150,,,Fee Schedule,150% of CMS OPPS Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,214.12,90,,,Fee Schedule,90% of UHC fee schedule,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,222.05,100,,,Fee Schedule,100% of TX Medicaid Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1308,100,,127.36,Percent of Total Billed Charges,100% of Total Billed Charges,214.12,1308,
LIPOPROTEIN METABOLISM PANEL,70021298,CDM,301,RC,82664,HCPCS,Outpatient,,,238.12,142.87,,71.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,92.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,172.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,196.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,221.4,360,,,Fee Schedule,360% of BCBS POS Rate,221.4,360,,,Fee schedule,360% of BCBS PPO Rate,221.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,142.87,60,,114.296,Percent of Total Billed Charges,60% of Total Billed Charges,51.66,100,,,Fee Schedule,100% of TX Mediciad 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,55.35,90,,,Fee Schedule,90% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,130,,,Fee Schedule,130% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,53.21,103,,,Fee Schedule,103% of TX Medicaid Rate,63.34,103,,,Fee Schedule,103% of CMS OPPS Rate,63.34,103,,,Fee Schedule,103% of CMS OPPS Rate,178.59,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,104.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,104.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,104.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,92.25,150,,,Fee Schedule,150% of CMS OPPS Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,90,,,Fee Schedule,90% of UHC fee schedule,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,100,,,Fee Schedule,100% of TX Medicaid Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,238.12,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,49.82,238.12,
ADENOVIRUS ANTIBODY CF,70021304,CDM,302,RC,86603,HCPCS,Outpatient,,,121.21,72.73,,14.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,,Fee Schedule,360% of BCBS POS Rate,46.33,360,,,Fee schedule,360% of BCBS PPO Rate,46.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.73,60,,58.184,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,,Fee Schedule,100% of TX Mediciad 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,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,90.91,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,,Fee Schedule,90% of UHC fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,121.21,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,121.21,
LYME DISEASE SPINAL FLUID,70021305,CDM,302,RC,86618,HCPCS,Outpatient,,,196.38,117.83,,19.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,47.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,61.31,360,,,Fee Schedule,360% of BCBS POS Rate,61.31,360,,,Fee schedule,360% of BCBS PPO Rate,61.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.83,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,14.31,100,,,Fee Schedule,100% of TX Mediciad 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,15.32,90,,,Fee Schedule,90% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.13,130,,,Fee Schedule,130% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.74,103,,,Fee Schedule,103% of TX Medicaid Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,147.29,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,28.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,28.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.54,150,,,Fee Schedule,150% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,90,,,Fee Schedule,90% of UHC fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,196.38,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,13.8,196.38,
LYME DISEASE WESTERN BLOT IGG,70021306,CDM,302,RC,86617,HCPCS,Outpatient,,,169,101.40,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,43.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,55.76,360,,,Fee Schedule,360% of BCBS POS Rate,55.76,360,,,Fee schedule,360% of BCBS PPO Rate,55.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.4,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,100,,,Fee Schedule,100% of TX Mediciad 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,13.94,90,,,Fee Schedule,90% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,130,,,Fee Schedule,130% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of TX Medicaid Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,126.75,75,,92.072,Percent of Total Billed Charges,75% of Total Billed Charges,26.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.23,150,,,Fee Schedule,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.55,90,,,Fee Schedule,90% of UHC fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,169,100,,122.76,Percent of Total Billed Charges,100% of Total Billed Charges,12.55,169,
LYME DISEASE WESTERN BLOT IGM,70021307,CDM,302,RC,86617,HCPCS,Outpatient,,,169,101.40,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,43.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,55.76,360,,,Fee Schedule,360% of BCBS POS Rate,55.76,360,,,Fee schedule,360% of BCBS PPO Rate,55.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.4,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,100,,,Fee Schedule,100% of TX Mediciad 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,13.94,90,,,Fee Schedule,90% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,130,,,Fee Schedule,130% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of TX Medicaid Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,126.75,75,,116.4,Percent of Total Billed Charges,75% of Total Billed Charges,26.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.23,150,,,Fee Schedule,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.55,90,,,Fee Schedule,90% of UHC fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,169,100,,155.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.55,169,
"AMINO ACID, BLOOD",70021308,CDM,301,RC,82131,HCPCS,Outpatient,,,289,173.40,,26.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,64.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,73.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,82.73,360,,,Fee Schedule,360% of BCBS POS Rate,82.73,360,,,Fee schedule,360% of BCBS PPO Rate,82.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,173.4,60,,138.72,Percent of Total Billed Charges,60% of Total Billed Charges,19.3,100,,,Fee Schedule,100% of TX Mediciad 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,20.68,90,,,Fee Schedule,90% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.87,130,,,Fee Schedule,130% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.88,103,,,Fee Schedule,103% of TX Medicaid Rate,23.66,103,,,Fee Schedule,103% of CMS OPPS Rate,23.66,103,,,Fee Schedule,103% of CMS OPPS Rate,216.75,75,,121.928,Percent of Total Billed Charges,75% of Total Billed Charges,39.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,39.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,39.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,34.47,150,,,Fee Schedule,150% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,18.61,90,,,Fee Schedule,90% of UHC fee schedule,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,19.3,100,,,Fee Schedule,100% of TX Medicaid Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,289,100,,162.568,Percent of Total Billed Charges,100% of Total Billed Charges,18.61,289,
AMPHETAMINES URINE CONFIRM,70021310,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,80.864,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,107.816,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
ASSAY OF OPIATES,70021312,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,41.52,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,55.36,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
ANTI ADRENAL CORTEX AB,70021314,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,97.912,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,130.544,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
UROVYSION FOR BLADDER CANCER,70021316,CDM,312,RC,88120,HCPCS,Outpatient,,,1007.05,604.23,,683.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,604.23,60,,483.384,Percent of Total Billed Charges,60% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,145.22,14.42,,116.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,755.29,75,,157.024,Percent of Total Billed Charges,75% of Total Billed Charges,503.53,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,503.53,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,503.53,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,503.53,50,,402.824,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,140.99,14,,112.792,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1007.05,100,,209.368,Percent of Total Billed Charges,100% of Total Billed Charges,116.24,1007.05,
BARBITURATE CONFIRM URINE,70021317,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,923.272,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,1231.024,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
COCAINE CONFIRMATION URINE,70021320,CDM,301,RC,G0480,HCPCS,Outpatient,,,958.92,575.35,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,575.35,60,,460.28,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,719.19,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,958.92,100,,163.064,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,958.92,
METHADONE,70021321,CDM,301,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,118.8,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,158.4,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
VORICONAZOLE QT,70021324,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,143.832,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,191.776,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
ZONISAMIDE,70021325,CDM,301,RC,80203,HCPCS,Outpatient,,,1013.44,608.06,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,608.06,60,,486.448,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,760.08,75,,118.8,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.44,100,,158.4,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,1013.44,
WARFARIN,70021328,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,216,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,288,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
FLECAINIDE SERUM,70021329,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,660.192,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,880.256,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
ITRACONAZOLE SERUM,70021330,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,143.2,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,190.936,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
STREPTOMYCIN HPLC,70021332,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,119.4,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,159.2,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
CHROMOSOMAL MICROARRAY CNGNTL,70021335,CDM,310,RC,81229,HCPCS,Outpatient,,,3621.49,2172.89,,1345.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,1740,150,,,Fee Schedule ,150% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,3248,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,3712,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,4176,360,,,Fee Schedule,360% of BCBS POS Rate,4176,360,,,Fee schedule,360% of BCBS PPO Rate,4176,360,,,Fee Schedule,360% of BCBS Traditional Rate,2172.89,60,,1738.312,Percent of Total Billed Charges,60% of Total Billed Charges,974.4,100,,,Fee Schedule,100% of TX Mediciad 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,1044,90,,,Fee Schedule,90% of CMS OPPS Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1508,130,,,Fee Schedule,130% of CMS OPPS Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1003.63,103,,,Fee Schedule,103% of TX Medicaid Rate,1194.8,103,,,Fee Schedule,103% of CMS OPPS Rate,1194.8,103,,,Fee Schedule,103% of CMS OPPS Rate,2716.12,75,,283.36,Percent of Total Billed Charges,75% of Total Billed Charges,1972,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1972,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1972,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1972,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1740,150,,,Fee Schedule,150% of CMS OPPS Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,939.6,90,,,Fee Schedule,90% of UHC fee schedule,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,974.4,100,,,Fee Schedule,100% of TX Medicaid Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,3621.49,100,,377.816,Percent of Total Billed Charges,100% of Total Billed Charges,939.6,4176,
HLA B5701 GENOTYPE,70021341,CDM,310,RC,81381,HCPCS,Outpatient,,,607.88,364.73,,197.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,254.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,475.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,543.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,611.64,360,,,Fee Schedule,360% of BCBS POS Rate,611.64,360,,,Fee schedule,360% of BCBS PPO Rate,611.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,364.73,60,,291.784,Percent of Total Billed Charges,60% of Total Billed Charges,142.72,100,,,Fee Schedule,100% of TX Mediciad 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,152.91,90,,,Fee Schedule,90% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,220.87,130,,,Fee Schedule,130% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,147,103,,,Fee Schedule,103% of TX Medicaid Rate,174.99,103,,,Fee Schedule,103% of CMS OPPS Rate,174.99,103,,,Fee Schedule,103% of CMS OPPS Rate,455.91,75,,508.872,Percent of Total Billed Charges,75% of Total Billed Charges,288.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,288.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,288.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,288.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,254.85,150,,,Fee Schedule,150% of CMS OPPS Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,137.62,90,,,Fee Schedule,90% of UHC fee schedule,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,142.72,100,,,Fee Schedule,100% of TX Medicaid Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,607.88,100,,678.496,Percent of Total Billed Charges,100% of Total Billed Charges,137.62,611.64,
PROMETHEUS TPMT GENETICS PANEL,70021343,CDM,310,RC,81401,HCPCS,Outpatient,,,708.67,425.20,,158.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,205.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,383.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,438.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,493.2,360,,,Fee Schedule,360% of BCBS POS Rate,493.2,360,,,Fee schedule,360% of BCBS PPO Rate,493.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,425.2,60,,340.16,Percent of Total Billed Charges,60% of Total Billed Charges,115.08,100,,,Fee Schedule,100% of TX Mediciad 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,123.3,90,,,Fee Schedule,90% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,178.1,130,,,Fee Schedule,130% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,118.53,103,,,Fee Schedule,103% of TX Medicaid Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,531.5,75,,70.68,Percent of Total Billed Charges,75% of Total Billed Charges,232.9,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,232.9,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,232.9,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,232.9,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,205.5,150,,,Fee Schedule,150% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,110.97,90,,,Fee Schedule,90% of UHC fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,708.67,100,,94.24,Percent of Total Billed Charges,100% of Total Billed Charges,110.97,708.67,
ACYLCARNITINES QT PLASMA,70021362,CDM,301,RC,82017,HCPCS,Outpatient,,,322,193.20,,19.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,47.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,60.73,360,,,Fee Schedule,360% of BCBS POS Rate,60.73,360,,,Fee schedule,360% of BCBS PPO Rate,60.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,193.2,60,,154.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.17,100,,,Fee Schedule,100% of TX Mediciad 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,15.18,90,,,Fee Schedule,90% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,130,,,Fee Schedule,130% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.6,103,,,Fee Schedule,103% of TX Medicaid Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,17.37,103,,,Fee Schedule,103% of CMS OPPS Rate,241.5,75,,94.264,Percent of Total Billed Charges,75% of Total Billed Charges,28.67,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.67,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.67,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.67,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.3,150,,,Fee Schedule,150% of CMS OPPS Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,90,,,Fee Schedule,90% of UHC fee schedule,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,14.17,100,,,Fee Schedule,100% of TX Medicaid Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,322,100,,125.688,Percent of Total Billed Charges,100% of Total Billed Charges,13.66,322,
CHLORIDE STOOL,70021366,CDM,301,RC,82438,HCPCS,Outpatient,,,104.57,62.74,,5.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18,360,,,Fee Schedule,360% of BCBS POS Rate,18,360,,,Fee schedule,360% of BCBS PPO Rate,18,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.74,60,,50.192,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,100,,,Fee Schedule,100% of TX Mediciad 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,4.5,90,,,Fee Schedule,90% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,130,,,Fee Schedule,130% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.33,103,,,Fee Schedule,103% of TX Medicaid Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,78.43,75,,86.4,Percent of Total Billed Charges,75% of Total Billed Charges,8.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.5,150,,,Fee Schedule,150% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.05,90,,,Fee Schedule,90% of UHC fee schedule,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.57,100,,115.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.05,104.57,
METFORMIN SERUM/PLASMA,70021367,CDM,301,RC,82542,HCPCS,Outpatient,,,271,162.60,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,162.6,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,203.25,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,271,
CHROMIUM SERUM,70021370,CDM,301,RC,82495,HCPCS,Outpatient,,,162.11,97.27,,23.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,56.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,64.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,73.01,360,,,Fee Schedule,360% of BCBS POS Rate,73.01,360,,,Fee schedule,360% of BCBS PPO Rate,73.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,97.27,60,,77.816,Percent of Total Billed Charges,60% of Total Billed Charges,17.04,100,,,Fee Schedule,100% of TX Mediciad 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,18.25,90,,,Fee Schedule,90% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,26.36,130,,,Fee Schedule,130% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.55,103,,,Fee Schedule,103% of TX Medicaid Rate,20.88,103,,,Fee Schedule,103% of CMS OPPS Rate,20.88,103,,,Fee Schedule,103% of CMS OPPS Rate,121.58,75,,70.2,Percent of Total Billed Charges,75% of Total Billed Charges,34.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,34.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.42,150,,,Fee Schedule,150% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,90,,,Fee Schedule,90% of UHC fee schedule,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.04,100,,,Fee Schedule,100% of TX Medicaid Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.11,100,,93.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.43,162.11,
PANCREATIC ELASTASE STOOL,70021375,CDM,301,RC,82656,HCPCS,Outpatient,,,415.27,249.16,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,249.16,60,,199.328,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,311.45,75,,113.432,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,415.27,100,,151.24,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,415.27,
GALECTIN 3,70021380,CDM,301,RC,82777,HCPCS,Outpatient,,,220.35,132.21,,51.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,66.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,123.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,141.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,159.3,360,,,Fee Schedule,360% of BCBS POS Rate,159.3,360,,,Fee schedule,360% of BCBS PPO Rate,159.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,132.21,60,,105.768,Percent of Total Billed Charges,60% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,39.82,90,,,Fee Schedule,90% of CMS OPPS Rate,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,57.52,130,,,Fee Schedule,130% of CMS OPPS Rate,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,31.77,14.42,,25.416,Percent of Total Billed Charges,14.42% of Total Billed Charges,45.57,103,,,Fee Schedule,103% of CMS OPPS Rate,45.57,103,,,Fee Schedule,103% of CMS OPPS Rate,165.26,75,,73.72,Percent of Total Billed Charges,75% of Total Billed Charges,75.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,75.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,75.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,75.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,66.37,150,,,Fee Schedule,150% of CMS OPPS Rate,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,90,,,Fee Schedule,90% of UHC fee schedule,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,30.85,14,,24.68,Percent of Total Billed Charges,14% of Total Billed Charges,44.25,100,,,Fee Schedule,100% of CMS OPPS Rate,220.35,100,,98.296,Percent of Total Billed Charges,100% of Total Billed Charges,30.85,220.35,
HEMOGLOBIN ELECTROPHORESIS,70021382,CDM,301,RC,83020,HCPCS,Outpatient,,,201.71,121.03,,14.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,,Fee Schedule,360% of BCBS POS Rate,46.33,360,,,Fee schedule,360% of BCBS PPO Rate,46.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,121.03,60,,96.824,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,,Fee Schedule,100% of TX Mediciad 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,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,151.28,75,,107.568,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,,Fee Schedule,90% of UHC fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,100,,143.424,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,201.71,
GLIADIN ANTIBODY IGA,70021384,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,104.008,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,138.672,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL MI-2,70021385,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,109.432,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,145.904,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL PL-7,70021386,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,221.704,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,295.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL PL-12,70021387,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,145.752,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,194.336,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL EJ,70021388,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL OJ,70021389,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,181.448,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,241.928,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL SRP,70021390,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,139.2,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,185.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL KU,70021391,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,49.496,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,65.992,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
MYOSITIS AB PANEL U2 SNRNP,70021392,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,28.32,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,37.76,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
PANCREASTATIN,70021397,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,48.072,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,64.096,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
PANCREATIC POLYPEPTIDE PLASMA,70021398,CDM,301,RC,83519,HCPCS,Outpatient,,,311.91,187.15,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.15,60,,149.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,233.93,75,,143.192,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,311.91,100,,190.92,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,311.91,
HAI AMEOBA AB,70021399,CDM,300,RC,86280,HCPCS,Outpatient,,,122.1,73.26,,9.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,360,,,Fee Schedule,360% of BCBS POS Rate,29.48,360,,,Fee schedule,360% of BCBS PPO Rate,29.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.26,60,,58.608,Percent of Total Billed Charges,60% of Total Billed Charges,6.88,100,,,Fee Schedule,100% of TX Mediciad 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,7.37,90,,,Fee Schedule,90% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,130,,,Fee Schedule,130% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,103,,,Fee Schedule,103% of TX Medicaid Rate,8.43,103,,,Fee Schedule,103% of CMS OPPS Rate,8.43,103,,,Fee Schedule,103% of CMS OPPS Rate,91.58,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,13.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.28,150,,,Fee Schedule,150% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,90,,,Fee Schedule,90% of UHC fee schedule,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,122.1,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.63,122.1,
NEURON SPECIFIC ENOLASE CSF,70021403,CDM,301,RC,83520,HCPCS,Outpatient,,,860.08,516.05,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,516.05,60,,412.84,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,645.06,75,,112.8,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,860.08,100,,150.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,860.08,
SACCHAROMYCES CEREVISIAE AB,70021404,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
NEUROMYELITIS OPTICA AUTOAB,70021409,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,95.128,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,126.84,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
RNA POLYMERASE III AB IGG,70021413,CDM,301,RC,83520,HCPCS,Outpatient,,,965.6,579.36,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,579.36,60,,463.488,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,724.2,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,965.6,100,,127.2,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,965.6,
THYROTROPIN RECEPTOR AB SERUM,70021414,CDM,301,RC,83520,HCPCS,Outpatient,,,1036.44,621.86,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,621.86,60,,497.488,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,777.33,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.44,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,1036.44,
TRYPTASE SERUM,70021415,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,115.28,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,153.704,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
CENTROMERE ANTIBODIES IGG,70021416,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,101.664,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,135.552,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
GANGLIOSIDE GQ1B AB,70021417,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,187.504,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,250,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
LACTOFERRIN DETECTION,70021418,CDM,301,RC,83630,HCPCS,Outpatient,,,167.54,100.52,,22.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,55.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,63.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,70.92,360,,,Fee Schedule,360% of BCBS POS Rate,70.92,360,,,Fee schedule,360% of BCBS PPO Rate,70.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,100.52,60,,80.416,Percent of Total Billed Charges,60% of Total Billed Charges,16.55,100,,,Fee Schedule,100% of TX Mediciad 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,17.73,90,,,Fee Schedule,90% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,25.61,130,,,Fee Schedule,130% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,103,,,Fee Schedule,103% of TX Medicaid Rate,20.29,103,,,Fee Schedule,103% of CMS OPPS Rate,20.29,103,,,Fee Schedule,103% of CMS OPPS Rate,125.66,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,33.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,33.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.55,150,,,Fee Schedule,150% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,15.96,90,,,Fee Schedule,90% of UHC fee schedule,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,16.55,100,,,Fee Schedule,100% of TX Medicaid Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.54,100,,112,Percent of Total Billed Charges,100% of Total Billed Charges,15.96,167.54,
MAGNESIUM STOOL,70021422,CDM,301,RC,83735,HCPCS,Outpatient,,,121,72.60,,7.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,24.12,360,,,Fee Schedule,360% of BCBS POS Rate,24.12,360,,,Fee schedule,360% of BCBS PPO Rate,24.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,72.6,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,100,,,Fee Schedule,100% of TX Mediciad 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,6.03,90,,,Fee Schedule,90% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,130,,,Fee Schedule,130% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.8,103,,,Fee Schedule,103% of TX Medicaid Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,6.9,103,,,Fee Schedule,103% of CMS OPPS Rate,90.75,75,,153.36,Percent of Total Billed Charges,75% of Total Billed Charges,11.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,11.39,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,10.05,150,,,Fee Schedule,150% of CMS OPPS Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,90,,,Fee Schedule,90% of UHC fee schedule,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.63,100,,,Fee Schedule,100% of TX Medicaid Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,121,100,,204.48,Percent of Total Billed Charges,100% of Total Billed Charges,5.43,121,
MANGANESE,70021423,CDM,301,RC,83785,HCPCS,Outpatient,,,845.2,507.12,,30.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,74.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,95.94,360,,,Fee Schedule,360% of BCBS POS Rate,95.94,360,,,Fee schedule,360% of BCBS PPO Rate,95.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,507.12,60,,405.696,Percent of Total Billed Charges,60% of Total Billed Charges,22.39,100,,,Fee Schedule,100% of TX Mediciad 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,23.98,90,,,Fee Schedule,90% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,34.64,130,,,Fee Schedule,130% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,23.06,103,,,Fee Schedule,103% of TX Medicaid Rate,27.44,103,,,Fee Schedule,103% of CMS OPPS Rate,27.44,103,,,Fee Schedule,103% of CMS OPPS Rate,633.9,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,45.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,45.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,39.97,150,,,Fee Schedule,150% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,21.59,90,,,Fee Schedule,90% of UHC fee schedule,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.39,100,,,Fee Schedule,100% of TX Medicaid Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,845.2,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,21.59,845.2,
COBALT SERUM,70021424,CDM,301,RC,83789,HCPCS,Outpatient,,,250.16,150.10,,27.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,67.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,86.8,360,,,Fee Schedule,360% of BCBS POS Rate,86.8,360,,,Fee schedule,360% of BCBS PPO Rate,86.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,150.1,60,,120.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,100,,,Fee Schedule,100% of TX Mediciad 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,21.69,90,,,Fee Schedule,90% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,31.34,130,,,Fee Schedule,130% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.86,103,,,Fee Schedule,103% of TX Medicaid Rate,24.83,103,,,Fee Schedule,103% of CMS OPPS Rate,24.83,103,,,Fee Schedule,103% of CMS OPPS Rate,187.62,75,,73.72,Percent of Total Billed Charges,75% of Total Billed Charges,40.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,40.98,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.98,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.16,150,,,Fee Schedule,150% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,90,,,Fee Schedule,90% of UHC fee schedule,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,250.16,100,,98.296,Percent of Total Billed Charges,100% of Total Billed Charges,19.53,250.16,
CALPROTECTIN,70021428,CDM,301,RC,83993,HCPCS,Outpatient,,,600,360.00,,22.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.44,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,70.67,360,,,Fee Schedule,360% of BCBS POS Rate,70.67,360,,,Fee schedule,360% of BCBS PPO Rate,70.67,360,,,Fee Schedule,360% of BCBS Traditional Rate,360,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,16.49,100,,,Fee Schedule,100% of TX Mediciad 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,17.66,90,,,Fee Schedule,90% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,25.51,130,,,Fee Schedule,130% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.98,103,,,Fee Schedule,103% of TX Medicaid Rate,20.21,103,,,Fee Schedule,103% of CMS OPPS Rate,20.21,103,,,Fee Schedule,103% of CMS OPPS Rate,450,75,,153.36,Percent of Total Billed Charges,75% of Total Billed Charges,33.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,33.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.44,150,,,Fee Schedule,150% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15.9,90,,,Fee Schedule,90% of UHC fee schedule,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.49,100,,,Fee Schedule,100% of TX Medicaid Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,600,100,,204.48,Percent of Total Billed Charges,100% of Total Billed Charges,15.9,600,
PREGNENOLONE SERUM,70021430,CDM,301,RC,84140,HCPCS,Outpatient,,,170.85,102.51,,23.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,31,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,57.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,74.41,360,,,Fee Schedule,360% of BCBS POS Rate,74.41,360,,,Fee schedule,360% of BCBS PPO Rate,74.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.51,60,,82.008,Percent of Total Billed Charges,60% of Total Billed Charges,17.36,100,,,Fee Schedule,100% of TX Mediciad 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,18.6,90,,,Fee Schedule,90% of CMS OPPS Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,26.87,130,,,Fee Schedule,130% of CMS OPPS Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.88,103,,,Fee Schedule,103% of TX Medicaid Rate,21.29,103,,,Fee Schedule,103% of CMS OPPS Rate,21.29,103,,,Fee Schedule,103% of CMS OPPS Rate,128.14,75,,187.8,Percent of Total Billed Charges,75% of Total Billed Charges,35.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,35.13,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.13,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31,150,,,Fee Schedule,150% of CMS OPPS Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,90,,,Fee Schedule,90% of UHC fee schedule,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,17.36,100,,,Fee Schedule,100% of TX Medicaid Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,170.85,100,,250.4,Percent of Total Billed Charges,100% of Total Billed Charges,16.74,170.85,
MYELIN ASSOC GLYCOPROTEIN AB,70021431,CDM,301,RC,84181,HCPCS,Outpatient,,,263.4,158.04,,19.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,47.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,61.31,360,,,Fee Schedule,360% of BCBS POS Rate,61.31,360,,,Fee schedule,360% of BCBS PPO Rate,61.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,158.04,60,,126.432,Percent of Total Billed Charges,60% of Total Billed Charges,14.31,100,,,Fee Schedule,100% of TX Mediciad 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,15.32,90,,,Fee Schedule,90% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.13,130,,,Fee Schedule,130% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.74,103,,,Fee Schedule,103% of TX Medicaid Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,197.55,75,,220.8,Percent of Total Billed Charges,75% of Total Billed Charges,28.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,28.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.54,150,,,Fee Schedule,150% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,90,,,Fee Schedule,90% of UHC fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,263.4,100,,294.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.8,263.4,
PROINSULIN PLASMA,70021432,CDM,301,RC,84206,HCPCS,Outpatient,,,232.18,139.31,,30.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.03,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,74.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,96.08,360,,,Fee Schedule,360% of BCBS POS Rate,96.08,360,,,Fee schedule,360% of BCBS PPO Rate,96.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,139.31,60,,111.448,Percent of Total Billed Charges,60% of Total Billed Charges,22.42,100,,,Fee Schedule,100% of TX Mediciad 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,24.02,90,,,Fee Schedule,90% of CMS OPPS Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,34.69,130,,,Fee Schedule,130% of CMS OPPS Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,23.09,103,,,Fee Schedule,103% of TX Medicaid Rate,27.49,103,,,Fee Schedule,103% of CMS OPPS Rate,27.49,103,,,Fee Schedule,103% of CMS OPPS Rate,174.14,75,,204.152,Percent of Total Billed Charges,75% of Total Billed Charges,45.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,45.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.03,150,,,Fee Schedule,150% of CMS OPPS Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,21.62,90,,,Fee Schedule,90% of UHC fee schedule,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,22.42,100,,,Fee Schedule,100% of TX Medicaid Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,232.18,100,,272.2,Percent of Total Billed Charges,100% of Total Billed Charges,21.62,232.18,
ADENOSINE DEAMINASE FLUID,70021434,CDM,301,RC,84311,HCPCS,Outpatient,,,176.89,106.13,,9.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,29.16,360,,,Fee Schedule,360% of BCBS POS Rate,29.16,360,,,Fee schedule,360% of BCBS PPO Rate,29.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.13,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,6.8,100,,,Fee Schedule,100% of TX Mediciad 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,7.29,90,,,Fee Schedule,90% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10.53,130,,,Fee Schedule,130% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,7,103,,,Fee Schedule,103% of TX Medicaid Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,132.67,75,,194,Percent of Total Billed Charges,75% of Total Billed Charges,13.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.15,150,,,Fee Schedule,150% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.56,90,,,Fee Schedule,90% of UHC fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,176.89,100,,258.664,Percent of Total Billed Charges,100% of Total Billed Charges,6.56,176.89,
PORPHYRINS TOTAL PLASMA,70021436,CDM,301,RC,84311,HCPCS,Outpatient,,,176.89,106.13,,9.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.15,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,29.16,360,,,Fee Schedule,360% of BCBS POS Rate,29.16,360,,,Fee schedule,360% of BCBS PPO Rate,29.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.13,60,,84.904,Percent of Total Billed Charges,60% of Total Billed Charges,6.8,100,,,Fee Schedule,100% of TX Mediciad 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,7.29,90,,,Fee Schedule,90% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,10.53,130,,,Fee Schedule,130% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,7,103,,,Fee Schedule,103% of TX Medicaid Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,8.34,103,,,Fee Schedule,103% of CMS OPPS Rate,132.67,75,,182.336,Percent of Total Billed Charges,75% of Total Billed Charges,13.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.15,150,,,Fee Schedule,150% of CMS OPPS Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,6.56,90,,,Fee Schedule,90% of UHC fee schedule,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,6.8,100,,,Fee Schedule,100% of TX Medicaid Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,176.89,100,,243.112,Percent of Total Billed Charges,100% of Total Billed Charges,6.56,176.89,
SULFATE URINE,70021437,CDM,301,RC,84392,HCPCS,Outpatient,,,71.45,42.87,,6.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,19.76,360,,,Fee Schedule,360% of BCBS POS Rate,19.76,360,,,Fee schedule,360% of BCBS PPO Rate,19.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,42.87,60,,34.296,Percent of Total Billed Charges,60% of Total Billed Charges,4.61,100,,,Fee Schedule,100% of TX Mediciad 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,4.94,90,,,Fee Schedule,90% of CMS OPPS Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.13,130,,,Fee Schedule,130% of CMS OPPS Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.75,103,,,Fee Schedule,103% of TX Medicaid Rate,5.65,103,,,Fee Schedule,103% of CMS OPPS Rate,5.65,103,,,Fee Schedule,103% of CMS OPPS Rate,53.59,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,9.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,9.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.23,150,,,Fee Schedule,150% of CMS OPPS Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,4.45,90,,,Fee Schedule,90% of UHC fee schedule,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,4.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,71.45,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.45,71.45,
NIACIN (VITAMIN B3),70021439,CDM,301,RC,84591,HCPCS,Outpatient,,,182.57,109.54,,19.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,61.42,360,,,Fee Schedule,360% of BCBS POS Rate,61.42,360,,,Fee schedule,360% of BCBS PPO Rate,61.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.54,60,,87.632,Percent of Total Billed Charges,60% of Total Billed Charges,14.33,100,,,Fee Schedule,100% of TX Mediciad 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,15.35,90,,,Fee Schedule,90% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,130,,,Fee Schedule,130% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.76,103,,,Fee Schedule,103% of TX Medicaid Rate,17.57,103,,,Fee Schedule,103% of CMS OPPS Rate,17.57,103,,,Fee Schedule,103% of CMS OPPS Rate,136.93,75,,192.544,Percent of Total Billed Charges,75% of Total Billed Charges,29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.59,150,,,Fee Schedule,150% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,90,,,Fee Schedule,90% of UHC fee schedule,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,14.33,100,,,Fee Schedule,100% of TX Medicaid Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,182.57,100,,256.72,Percent of Total Billed Charges,100% of Total Billed Charges,13.82,182.57,
VITAMIN K1,70021440,CDM,301,RC,84597,HCPCS,Outpatient,,,281.27,168.76,,15.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,38.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,49.39,360,,,Fee Schedule,360% of BCBS POS Rate,49.39,360,,,Fee schedule,360% of BCBS PPO Rate,49.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,168.76,60,,135.008,Percent of Total Billed Charges,60% of Total Billed Charges,11.52,100,,,Fee Schedule,100% of TX Mediciad 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,12.34,90,,,Fee Schedule,90% of CMS OPPS Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.83,130,,,Fee Schedule,130% of CMS OPPS Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of TX Medicaid Rate,14.13,103,,,Fee Schedule,103% of CMS OPPS Rate,14.13,103,,,Fee Schedule,103% of CMS OPPS Rate,210.95,75,,183.808,Percent of Total Billed Charges,75% of Total Billed Charges,23.32,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.32,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,23.32,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.32,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.58,150,,,Fee Schedule,150% of CMS OPPS Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,90,,,Fee Schedule,90% of UHC fee schedule,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,11.52,100,,,Fee Schedule,100% of TX Medicaid Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,281.27,100,,245.072,Percent of Total Billed Charges,100% of Total Billed Charges,11.12,281.27,
VON WILLEBRAND FACTOR MULTIMER,70021442,CDM,305,RC,85247,HCPCS,Outpatient,,,358.02,214.81,,26.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,64.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,73.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,82.58,360,,,Fee Schedule,360% of BCBS POS Rate,82.58,360,,,Fee schedule,360% of BCBS PPO Rate,82.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,214.81,60,,171.848,Percent of Total Billed Charges,60% of Total Billed Charges,19.27,100,,,Fee Schedule,100% of TX Mediciad 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,20.64,90,,,Fee Schedule,90% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,130,,,Fee Schedule,130% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.85,103,,,Fee Schedule,103% of TX Medicaid Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,268.52,75,,163.864,Percent of Total Billed Charges,75% of Total Billed Charges,38.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,38.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,38.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,34.41,150,,,Fee Schedule,150% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.59,90,,,Fee Schedule,90% of UHC fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,358.02,100,,218.488,Percent of Total Billed Charges,100% of Total Billed Charges,18.59,358.02,
ASCARIS IGE,70021445,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,170.384,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,227.176,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
ANIMAL FEATHER MIX IGE,70021447,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,208.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,278.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
FOOD BEEF IGE,70021448,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,133.872,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,178.496,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
FUNGI MOLD PHOMA BETAE IGE,70021450,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,133.8,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,178.4,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
RNP ANTIBODIES IGG SERUM,70021453,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,173.648,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,231.528,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
CENTROMERE ANTIBODIES,70021454,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,103.8,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,138.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
HUMAN EPIDIDYMIS PROTEIN 4,70021455,CDM,302,RC,86305,HCPCS,Outpatient,,,331.84,199.10,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,199.1,60,,159.28,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,248.88,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,331.84,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,331.84,
PIGEON SERUM AB,70021457,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,77.128,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,102.832,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
MICROPOLYSPORA FAENI AB,70021458,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
THERMOACTINOMYCES VULGARIS AB,70021459,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,222.304,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,296.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
SACCHAROMONOSPORA VIRIDIS AB,70021460,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,222.304,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,296.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
THERMOACTINOMYCES CANDIDUS AB,70021461,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,143.992,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,191.984,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
THERMOACTINOMYCES SACCHARI AB,70021462,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,121.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,161.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
C1Q BINDING ASSAY,70021463,CDM,302,RC,86332,HCPCS,Outpatient,,,212.7,127.62,,28.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,68.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,87.73,360,,,Fee Schedule,360% of BCBS POS Rate,87.73,360,,,Fee schedule,360% of BCBS PPO Rate,87.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,127.62,60,,102.096,Percent of Total Billed Charges,60% of Total Billed Charges,20.47,100,,,Fee Schedule,100% of TX Mediciad Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,90,,,Fee Schedule,90% of CMS OPPS Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,130,,,Fee Schedule,130% of CMS OPPS Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.08,103,,,Fee Schedule,103% of TX Medicaid Rate,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,25.1,103,,,Fee Schedule,103% of CMS OPPS Rate,159.53,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,41.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,41.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,41.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,41.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.55,150,,,Fee Schedule,150% of CMS OPPS Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,19.74,90,,,Fee Schedule,90% of UHC fee schedule,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,20.47,100,,,Fee Schedule,100% of TX Medicaid Rate,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,212.7,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,19.74,212.7,
BETA-2 TRANSFERRIN,70021464,CDM,302,RC,86335,HCPCS,Outpatient,,,2443.96,1466.38,,34.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,44.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,82.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,105.66,360,,,Fee Schedule,360% of BCBS POS Rate,105.66,360,,,Fee schedule,360% of BCBS PPO Rate,105.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,1466.38,60,,1173.104,Percent of Total Billed Charges,60% of Total Billed Charges,24.65,100,,,Fee Schedule,100% of TX Mediciad 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,26.41,90,,,Fee Schedule,90% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,130,,,Fee Schedule,130% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,25.39,103,,,Fee Schedule,103% of TX Medicaid Rate,30.23,103,,,Fee Schedule,103% of CMS OPPS Rate,30.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1832.97,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,49.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,49.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,44.02,150,,,Fee Schedule,150% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,23.78,90,,,Fee Schedule,90% of UHC fee schedule,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,24.65,100,,,Fee Schedule,100% of TX Medicaid Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2443.96,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,23.78,2443.96,
AB INSULIN,70021465,CDM,302,RC,86337,HCPCS,Outpatient,,,240.25,144.15,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.51,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,77.08,360,,,Fee Schedule,360% of BCBS POS Rate,77.08,360,,,Fee schedule,360% of BCBS PPO Rate,77.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,144.15,60,,115.32,Percent of Total Billed Charges,60% of Total Billed Charges,17.98,100,,,Fee Schedule,100% of TX Mediciad 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,19.26,90,,,Fee Schedule,90% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,27.83,130,,,Fee Schedule,130% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,18.52,103,,,Fee Schedule,103% of TX Medicaid Rate,22.05,103,,,Fee Schedule,103% of CMS OPPS Rate,22.05,103,,,Fee Schedule,103% of CMS OPPS Rate,180.19,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,36.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,36.39,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.39,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.11,150,,,Fee Schedule,150% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.34,90,,,Fee Schedule,90% of UHC fee schedule,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of TX Medicaid Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.25,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,17.34,240.25,
ISLET ANTIGEN 2 ANTIBODY,70021466,CDM,302,RC,86341,HCPCS,Outpatient,,,199,119.40,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.4,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,149.25,75,,103.168,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,199,100,,137.552,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,199,
B CELLS TOTAL COUNT,70021470,CDM,302,RC,86355,HCPCS,Outpatient,,,197.38,118.43,,43.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,56.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,105.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,120.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,135.83,360,,,Fee Schedule,360% of BCBS POS Rate,135.83,360,,,Fee schedule,360% of BCBS PPO Rate,135.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.43,60,,94.744,Percent of Total Billed Charges,60% of Total Billed Charges,31.69,100,,,Fee Schedule,100% of TX Mediciad 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,33.95,90,,,Fee Schedule,90% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,49.04,130,,,Fee Schedule,130% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,32.64,103,,,Fee Schedule,103% of TX Medicaid Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,148.04,75,,144.6,Percent of Total Billed Charges,75% of Total Billed Charges,64.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,64.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,64.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,56.59,150,,,Fee Schedule,150% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,30.56,90,,,Fee Schedule,90% of UHC fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,197.38,100,,192.8,Percent of Total Billed Charges,100% of Total Billed Charges,30.56,197.38,
NK CELLS TOTAL COUNT,70021471,CDM,302,RC,86357,HCPCS,Outpatient,,,211,126.60,,43.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,56.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,105.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,120.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,135.83,360,,,Fee Schedule,360% of BCBS POS Rate,135.83,360,,,Fee schedule,360% of BCBS PPO Rate,135.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,126.6,60,,101.28,Percent of Total Billed Charges,60% of Total Billed Charges,31.69,100,,,Fee Schedule,100% of TX Mediciad 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,33.95,90,,,Fee Schedule,90% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,49.04,130,,,Fee Schedule,130% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,32.64,103,,,Fee Schedule,103% of TX Medicaid Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,158.25,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,64.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,64.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,64.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,56.59,150,,,Fee Schedule,150% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,30.56,90,,,Fee Schedule,90% of UHC fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,211,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,30.56,211,
T CELLS TOTAL COUNT,70021472,CDM,302,RC,86359,HCPCS,Outpatient,,,219.54,131.72,,43.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,56.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,105.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,120.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,135.83,360,,,Fee Schedule,360% of BCBS POS Rate,135.83,360,,,Fee schedule,360% of BCBS PPO Rate,135.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.72,60,,105.376,Percent of Total Billed Charges,60% of Total Billed Charges,31.69,100,,,Fee Schedule,100% of TX Mediciad 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,33.95,90,,,Fee Schedule,90% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,49.04,130,,,Fee Schedule,130% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,32.64,103,,,Fee Schedule,103% of TX Medicaid Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,38.86,103,,,Fee Schedule,103% of CMS OPPS Rate,164.66,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,64.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,64.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,64.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,56.59,150,,,Fee Schedule,150% of CMS OPPS Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,30.56,90,,,Fee Schedule,90% of UHC fee schedule,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,31.69,100,,,Fee Schedule,100% of TX Medicaid Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,219.54,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,30.56,219.54,
AB ASPERGILLUS FLAVUS,70021476,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
ASPERGILLUS FUMIGATUS 1 AB,70021477,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
ASPERGILLUS FUMIGATUS 6 AB,70021478,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
ASPERGILLUS FUMIGATUS 2 AB,70021479,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
ASPERGILLUS FUMIGATUS 3 AB,70021480,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,159.36,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,212.48,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
AB ASPERGILLUS FUMIGATUS,70021481,CDM,302,RC,86606,HCPCS,Outpatient,,,136.88,82.13,,17.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,54.18,360,,,Fee Schedule,360% of BCBS POS Rate,54.18,360,,,Fee schedule,360% of BCBS PPO Rate,54.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.13,60,,65.704,Percent of Total Billed Charges,60% of Total Billed Charges,12.64,100,,,Fee Schedule,100% of TX Mediciad 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,13.54,90,,,Fee Schedule,90% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,19.56,130,,,Fee Schedule,130% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,103,,,Fee Schedule,103% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,15.5,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,25.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.57,150,,,Fee Schedule,150% of CMS OPPS Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.2,90,,,Fee Schedule,90% of UHC fee schedule,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,12.64,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.88,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,12.2,136.88,
B PERTUSSIS AB IGA,70021482,CDM,302,RC,86615,HCPCS,Outpatient,,,134.88,80.93,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.93,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,101.16,75,,102.648,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,134.88,100,,136.864,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,134.88,
B PERTUSSIS AB IGG,70021483,CDM,302,RC,86615,HCPCS,Outpatient,,,134.88,80.93,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.93,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,101.16,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,134.88,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,134.88,
B PERTUSSIS AB IGM,70021484,CDM,302,RC,86615,HCPCS,Outpatient,,,134.88,80.93,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.93,60,,64.744,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,101.16,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,134.88,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,134.88,
AB ECHOVIRUS 11,70021486,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB ECHOVIRUS 30,70021487,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB ECHOVIRUS 4,70021488,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,67.24,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,89.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
ECHO VIRUS 7 AB,70021489,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,78.152,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,104.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB ECHOVIRUS 9,70021490,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
HAEMOPHILUS INFLUENZAE TYPE B,70021492,CDM,302,RC,86684,HCPCS,Outpatient,,,198.13,118.88,,18.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,44.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,50.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,57.02,360,,,Fee Schedule,360% of BCBS POS Rate,57.02,360,,,Fee schedule,360% of BCBS PPO Rate,57.02,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.88,60,,95.104,Percent of Total Billed Charges,60% of Total Billed Charges,13.31,100,,,Fee Schedule,100% of TX Mediciad 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,14.25,90,,,Fee Schedule,90% of CMS OPPS Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,20.59,130,,,Fee Schedule,130% of CMS OPPS Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.71,103,,,Fee Schedule,103% of TX Medicaid Rate,16.31,103,,,Fee Schedule,103% of CMS OPPS Rate,16.31,103,,,Fee Schedule,103% of CMS OPPS Rate,148.6,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,26.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.76,150,,,Fee Schedule,150% of CMS OPPS Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,12.83,90,,,Fee Schedule,90% of UHC fee schedule,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,13.31,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,198.13,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,12.83,198.13,
HISTOPLASMA MYCELIAL CSF,70021493,CDM,302,RC,86698,HCPCS,Outpatient,,,121.89,73.13,,16,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,49.64,360,,,Fee Schedule,360% of BCBS POS Rate,49.64,360,,,Fee schedule,360% of BCBS PPO Rate,49.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.13,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,100,,,Fee Schedule,100% of TX Mediciad 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,12.41,90,,,Fee Schedule,90% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,130,,,Fee Schedule,130% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.93,103,,,Fee Schedule,103% of TX Medicaid Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,91.42,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,23.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.68,150,,,Fee Schedule,150% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,90,,,Fee Schedule,90% of UHC fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,121.89,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,11.17,121.89,
LEISHMANIASIS (VISCERAL) AB,70021494,CDM,302,RC,86717,HCPCS,Outpatient,,,115.78,69.47,,14.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,34.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,44.1,360,,,Fee Schedule,360% of BCBS POS Rate,44.1,360,,,Fee schedule,360% of BCBS PPO Rate,44.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.47,60,,55.576,Percent of Total Billed Charges,60% of Total Billed Charges,10.29,100,,,Fee Schedule,100% of TX Mediciad 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,11.02,90,,,Fee Schedule,90% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,130,,,Fee Schedule,130% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.6,103,,,Fee Schedule,103% of TX Medicaid Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,12.61,103,,,Fee Schedule,103% of CMS OPPS Rate,86.84,75,,95.872,Percent of Total Billed Charges,75% of Total Billed Charges,20.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.37,150,,,Fee Schedule,150% of CMS OPPS Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,90,,,Fee Schedule,90% of UHC fee schedule,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,10.29,100,,,Fee Schedule,100% of TX Medicaid Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,115.78,100,,127.832,Percent of Total Billed Charges,100% of Total Billed Charges,9.93,115.78,
AB MYCOPLASMA IGG,70021495,CDM,302,RC,86738,HCPCS,Outpatient,,,164,98.40,,15.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,47.66,360,,,Fee Schedule,360% of BCBS POS Rate,47.66,360,,,Fee schedule,360% of BCBS PPO Rate,47.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.12,100,,,Fee Schedule,100% of TX Mediciad 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,11.91,90,,,Fee Schedule,90% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,130,,,Fee Schedule,130% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.45,103,,,Fee Schedule,103% of TX Medicaid Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,123,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.73,90,,,Fee Schedule,90% of UHC fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,164,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.73,164,
MYCOPLASMA PNEUMONIAE AB,70021496,CDM,302,RC,86738,HCPCS,Outpatient,,,164,98.40,,15.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,47.66,360,,,Fee Schedule,360% of BCBS POS Rate,47.66,360,,,Fee schedule,360% of BCBS PPO Rate,47.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.12,100,,,Fee Schedule,100% of TX Mediciad 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,11.91,90,,,Fee Schedule,90% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,130,,,Fee Schedule,130% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.45,103,,,Fee Schedule,103% of TX Medicaid Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,123,75,,554.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.73,90,,,Fee Schedule,90% of UHC fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,164,100,,739.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.73,164,
BABESIA MICROTI AB IGG,70021497,CDM,302,RC,86753,HCPCS,Outpatient,,,143,85.80,,14.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,44.6,360,,,Fee Schedule,360% of BCBS POS Rate,44.6,360,,,Fee schedule,360% of BCBS PPO Rate,44.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.8,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.41,100,,,Fee Schedule,100% of TX Mediciad 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,11.15,90,,,Fee Schedule,90% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,130,,,Fee Schedule,130% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,103,,,Fee Schedule,103% of TX Medicaid Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,107.25,75,,86.704,Percent of Total Billed Charges,75% of Total Billed Charges,21.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.58,150,,,Fee Schedule,150% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.04,90,,,Fee Schedule,90% of UHC fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,143,100,,115.6,Percent of Total Billed Charges,100% of Total Billed Charges,10.04,143,
TRYPANOSOMA CRUZI AB,70021498,CDM,302,RC,86753,HCPCS,Outpatient,,,143,85.80,,14.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,44.6,360,,,Fee Schedule,360% of BCBS POS Rate,44.6,360,,,Fee schedule,360% of BCBS PPO Rate,44.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,85.8,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.41,100,,,Fee Schedule,100% of TX Mediciad 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,11.15,90,,,Fee Schedule,90% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,130,,,Fee Schedule,130% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,103,,,Fee Schedule,103% of TX Medicaid Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,107.25,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,21.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.58,150,,,Fee Schedule,150% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.04,90,,,Fee Schedule,90% of UHC fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,143,100,,136,Percent of Total Billed Charges,100% of Total Billed Charges,10.04,143,
SALMONELLA H TYPE A,70021499,CDM,302,RC,86768,HCPCS,Outpatient,,,90.95,54.57,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.57,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,68.21,75,,87,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,116,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,90.95,
SALMONELLA H TYPE B,70021500,CDM,302,RC,86768,HCPCS,Outpatient,,,90.95,54.57,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.57,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,68.21,75,,79.136,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,105.512,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,90.95,
SALMONELLA H TYPE D,70021501,CDM,302,RC,86768,HCPCS,Outpatient,,,90.95,54.57,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.57,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,68.21,75,,100.552,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,134.072,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,90.95,
SALMONELLA O TYPE VI,70021502,CDM,302,RC,86768,HCPCS,Outpatient,,,90.95,54.57,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.57,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,68.21,75,,81.808,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,109.072,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,90.95,
SALMONELLA O TYPE D,70021503,CDM,302,RC,86768,HCPCS,Outpatient,,,90.95,54.57,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,54.57,60,,43.656,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,68.21,75,,98.472,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,131.296,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,90.95,
DENGUE FEVER IGG,70021505,CDM,302,RC,86790,HCPCS,Outpatient,,,356.4,213.84,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,213.84,60,,171.072,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,267.3,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,356.4,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,356.4,
DENGUE FEVER IGM,70021506,CDM,302,RC,86790,HCPCS,Outpatient,,,356.4,213.84,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,213.84,60,,171.072,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,267.3,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,356.4,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,356.4,
HANTAVIRUS IGG,70021507,CDM,302,RC,86790,HCPCS,Outpatient,,,347.46,208.48,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,208.48,60,,166.784,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,260.6,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,347.46,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,347.46,
HANTAVIRUS IGM,70021508,CDM,302,RC,86790,HCPCS,Outpatient,,,347.46,208.48,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,208.48,60,,166.784,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,260.6,75,,217.336,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,347.46,100,,289.784,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,347.46,
SCHISTOSOMA EXAM URINE,70021511,CDM,306,RC,87177,HCPCS,Outpatient,,,164,98.40,,10.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,24.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,32.04,360,,,Fee Schedule,360% of BCBS POS Rate,32.04,360,,,Fee schedule,360% of BCBS PPO Rate,32.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.48,100,,,Fee Schedule,100% of TX Mediciad 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,8.01,90,,,Fee Schedule,90% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,130,,,Fee Schedule,130% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.7,103,,,Fee Schedule,103% of TX Medicaid Rate,9.16,103,,,Fee Schedule,103% of CMS OPPS Rate,9.16,103,,,Fee Schedule,103% of CMS OPPS Rate,123,75,,139.2,Percent of Total Billed Charges,75% of Total Billed Charges,15.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15.13,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.13,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.35,150,,,Fee Schedule,150% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.21,90,,,Fee Schedule,90% of UHC fee schedule,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,164,100,,185.6,Percent of Total Billed Charges,100% of Total Billed Charges,7.21,164,
COCCIDIOIDES ANTIGEN EIA,70021515,CDM,306,RC,87449,HCPCS,Outpatient,,,509.6,305.76,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,305.76,60,,244.608,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,382.2,75,,375.12,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,509.6,100,,500.16,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,509.6,
MYCOPLASMA PNEUMONIAE DNA,70021516,CDM,306,RC,87581,HCPCS,Outpatient,,,800,480.00,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,480,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,600,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,800,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,800,
TROPHERYMA WHIPPLEI,70021517,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
TOXOPLASMA GONDII MOLEC DETECT,70021518,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
PNEUMOCYSTIS JIROVECI PCR,70021519,CDM,306,RC,87798,HCPCS,Outpatient,,,2685.08,1611.05,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,1611.05,60,,1288.84,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2013.81,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2685.08,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,2685.08,
TROFILE CO-RECEPTOR TROPISM,70021524,CDM,306,RC,87999,HCPCS,Outpatient,,,164.94,98.96,,98.96,60,,79.168,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.18,28,,36.944,Percent of Total Billed Charges,28% of Total Billed Charges,312,32,,249.6,Percent of Total Billed Charges,32% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,59.38,36,,47.504,Percent of Total Billed Charges,36% of Total Billed Charges,59.38,36,,47.504,Percent of Total Billed Charges,36% Total Bille Charges,59.38,36,,47.504,Percent of Total Billed Charges,36% of Total Billed Charges,98.96,60,,79.168,Percent of Total Billed Charges,60% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.78,14.42,,19.024,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.71,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,82.47,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,82.47,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.47,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,82.47,50,,65.976,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,23.09,14,,18.472,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,164.94,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,23.09,312,
CYTOGEN DNA PROBE FISH,70021529,CDM,310,RC,88271,HCPCS,Outpatient,,,257.4,154.44,,24.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,77.11,360,,,Fee Schedule,360% of BCBS POS Rate,77.11,360,,,Fee schedule,360% of BCBS PPO Rate,77.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,154.44,60,,123.552,Percent of Total Billed Charges,60% of Total Billed Charges,17.99,100,,,Fee Schedule,100% of TX Mediciad 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,19.27,90,,,Fee Schedule,90% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,130,,,Fee Schedule,130% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,18.53,103,,,Fee Schedule,103% of TX Medicaid Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,22.06,103,,,Fee Schedule,103% of CMS OPPS Rate,193.05,75,,93.72,Percent of Total Billed Charges,75% of Total Billed Charges,36.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,36.41,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.41,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.13,150,,,Fee Schedule,150% of CMS OPPS Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.35,90,,,Fee Schedule,90% of UHC fee schedule,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,17.99,100,,,Fee Schedule,100% of TX Medicaid Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,257.4,100,,124.96,Percent of Total Billed Charges,100% of Total Billed Charges,17.35,257.4,
INTERPHASE IN SITU HYBRID,70021532,CDM,311,RC,88275,HCPCS,Outpatient,,,384.5,230.70,,59.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,143.33,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,163.81,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,184.28,360,,,Fee Schedule,360% of BCBS POS Rate,184.28,360,,,Fee schedule,360% of BCBS PPO Rate,184.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,230.7,60,,184.56,Percent of Total Billed Charges,60% of Total Billed Charges,43,100,,,Fee Schedule,100% of TX Mediciad 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,46.07,90,,,Fee Schedule,90% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,66.54,130,,,Fee Schedule,130% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,44.29,103,,,Fee Schedule,103% of TX Medicaid Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,52.72,103,,,Fee Schedule,103% of CMS OPPS Rate,288.38,75,,99.6,Percent of Total Billed Charges,75% of Total Billed Charges,87.02,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,87.02,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,87.02,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,87.02,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.78,150,,,Fee Schedule,150% of CMS OPPS Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,41.46,90,,,Fee Schedule,90% of UHC fee schedule,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,43,100,,,Fee Schedule,100% of TX Medicaid Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,384.5,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,41.46,384.5,
CONSULT RPT REF SLIDES W PREP,70021533,CDM,310,RC,88323,HCPCS,Outpatient,,,367.93,220.76,,32.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,74.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,138.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,158.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,178.09,360,,,Fee Schedule,360% of BCBS POS Rate,178.09,360,,,Fee schedule,360% of BCBS PPO Rate,178.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,220.76,60,,176.608,Percent of Total Billed Charges,60% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,90,,,Fee Schedule,90% of CMS OPPS Rate,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,130,,,Fee Schedule,130% of CMS OPPS Rate,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,53.06,14.42,,42.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,51.2,103,,,Fee Schedule,103% of CMS OPPS Rate,275.95,75,,190.872,Percent of Total Billed Charges,75% of Total Billed Charges,183.97,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,183.97,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,183.97,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,183.97,50,,147.176,Percent of Total Billed Charges,50% of Total Billed Charges,74.57,150,,,Fee Schedule,150% of CMS OPPS Rate,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,90,,,Fee Schedule,90% of UHC fee schedule,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,51.51,14,,41.208,Percent of Total Billed Charges,14% of Total Billed Charges,49.71,100,,,Fee Schedule,100% of CMS OPPS Rate,367.93,100,,254.496,Percent of Total Billed Charges,100% of Total Billed Charges,32.2,367.93,
CONFIRMATION MARIJUANA QN,70021567,CDM,301,RC,82542,HCPCS,Outpatient,,,246.36,147.82,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.82,60,,118.256,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,184.77,75,,81.856,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,246.36,100,,109.144,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,246.36,
D LACTATE,70021576,CDM,301,RC,83605,HCPCS,Outpatient,,,194.98,116.99,,13.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,41.65,360,,,Fee Schedule,360% of BCBS POS Rate,41.65,360,,,Fee schedule,360% of BCBS PPO Rate,41.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.99,60,,93.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,100,,,Fee Schedule,100% of TX Mediciad 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,10.41,90,,,Fee Schedule,90% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,103,,,Fee Schedule,103% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,146.24,75,,81.856,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.35,150,,,Fee Schedule,150% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,90,,,Fee Schedule,90% of UHC fee schedule,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,194.98,100,,109.144,Percent of Total Billed Charges,100% of Total Billed Charges,9.37,194.98,
PROTOPORPHYRIN FRACTION REFLEX,70021578,CDM,301,RC,84202,HCPCS,Outpatient,,,137.53,82.52,,16.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,40.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,51.66,360,,,Fee Schedule,360% of BCBS POS Rate,51.66,360,,,Fee schedule,360% of BCBS PPO Rate,51.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.52,60,,66.016,Percent of Total Billed Charges,60% of Total Billed Charges,12.05,100,,,Fee Schedule,100% of TX Mediciad 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,12.91,90,,,Fee Schedule,90% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,18.65,130,,,Fee Schedule,130% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of TX Medicaid Rate,14.78,103,,,Fee Schedule,103% of CMS OPPS Rate,14.78,103,,,Fee Schedule,103% of CMS OPPS Rate,103.15,75,,89.328,Percent of Total Billed Charges,75% of Total Billed Charges,24.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,24.39,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.39,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.52,150,,,Fee Schedule,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,11.63,90,,,Fee Schedule,90% of UHC fee schedule,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of TX Medicaid Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,137.53,100,,119.104,Percent of Total Billed Charges,100% of Total Billed Charges,11.63,137.53,
STREPTOCOCCUS PNEUMO SEROTYPES,70021579,CDM,302,RC,86317,HCPCS,Outpatient,,,1549.2,929.52,,17.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,41.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,53.96,360,,,Fee Schedule,360% of BCBS POS Rate,53.96,360,,,Fee schedule,360% of BCBS PPO Rate,53.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,929.52,60,,743.616,Percent of Total Billed Charges,60% of Total Billed Charges,12.59,100,,,Fee Schedule,100% of TX Mediciad 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,13.49,90,,,Fee Schedule,90% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,19.48,130,,,Fee Schedule,130% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.97,103,,,Fee Schedule,103% of TX Medicaid Rate,15.43,103,,,Fee Schedule,103% of CMS OPPS Rate,15.43,103,,,Fee Schedule,103% of CMS OPPS Rate,1161.9,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,25.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.48,150,,,Fee Schedule,150% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,12.14,90,,,Fee Schedule,90% of UHC fee schedule,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.2,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,12.14,1549.2,
ISLET CELL CYTOPLASMIC AB,70021580,CDM,302,RC,86341,HCPCS,Outpatient,,,199,119.40,,27.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,35.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,75.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,84.85,360,,,Fee Schedule,360% of BCBS POS Rate,84.85,360,,,Fee schedule,360% of BCBS PPO Rate,84.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.4,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,100,,,Fee Schedule,100% of TX Mediciad 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,21.21,90,,,Fee Schedule,90% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,30.64,130,,,Fee Schedule,130% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,20.39,103,,,Fee Schedule,103% of TX Medicaid Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,24.27,103,,,Fee Schedule,103% of CMS OPPS Rate,149.25,75,,155.4,Percent of Total Billed Charges,75% of Total Billed Charges,40.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,35.35,150,,,Fee Schedule,150% of CMS OPPS Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,90,,,Fee Schedule,90% of UHC fee schedule,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,100,,,Fee Schedule,100% of TX Medicaid Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,199,100,,207.2,Percent of Total Billed Charges,100% of Total Billed Charges,19.09,199,
EHRLICHIA ANAPLASMA PCR,70021582,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
MORPHO ANLYS ISH EA PROBE,70021584,CDM,312,RC,88368,HCPCS,Outpatient,,,530,318.00,,113.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,318,60,,254.4,Percent of Total Billed Charges,60% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,76.43,14.42,,61.144,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,397.5,75,,106.624,Percent of Total Billed Charges,75% of Total Billed Charges,265,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,265,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,265,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,265,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,74.2,14,,59.36,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,530,100,,142.168,Percent of Total Billed Charges,100% of Total Billed Charges,74.2,1020.28,
CYTOGEN CHROM IN SITU 25-99,70021594,CDM,310,RC,88274,HCPCS,Outpatient,,,394.5,236.70,,49.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,63.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,118.66,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,135.62,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,152.57,360,,,Fee Schedule,360% of BCBS POS Rate,152.57,360,,,Fee schedule,360% of BCBS PPO Rate,152.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,236.7,60,,189.36,Percent of Total Billed Charges,60% of Total Billed Charges,35.6,100,,,Fee Schedule,100% of TX Mediciad 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,38.14,90,,,Fee Schedule,90% of CMS OPPS Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,55.09,130,,,Fee Schedule,130% of CMS OPPS Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,36.67,103,,,Fee Schedule,103% of TX Medicaid Rate,43.65,103,,,Fee Schedule,103% of CMS OPPS Rate,43.65,103,,,Fee Schedule,103% of CMS OPPS Rate,295.88,75,,74.872,Percent of Total Billed Charges,75% of Total Billed Charges,72.04,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.04,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,72.04,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.04,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,63.57,150,,,Fee Schedule,150% of CMS OPPS Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,34.33,90,,,Fee Schedule,90% of UHC fee schedule,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,100,,,Fee Schedule,100% of TX Medicaid Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,394.5,100,,99.832,Percent of Total Billed Charges,100% of Total Billed Charges,34.33,394.5,
IMMUNOASSAY OPTICAL ORGANISM,70021595,CDM,306,RC,87899,HCPCS,Outpatient,,,127,76.20,,18.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,57.85,360,,,Fee Schedule,360% of BCBS POS Rate,57.85,360,,,Fee schedule,360% of BCBS PPO Rate,57.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.2,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,100,,,Fee Schedule,100% of TX Mediciad 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,14.46,90,,,Fee Schedule,90% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,20.89,130,,,Fee Schedule,130% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.91,103,,,Fee Schedule,103% of TX Medicaid Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,95.25,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,27.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.1,150,,,Fee Schedule,150% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,127,100,,136,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,127,
FOOD PORK IGE,70021604,CDM,302,RC,86003,HCPCS,Outpatient,,,67,40.20,,6.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,360,,,Fee Schedule,360% of BCBS POS Rate,18.79,360,,,Fee schedule,360% of BCBS PPO Rate,18.79,360,,,Fee Schedule,360% of BCBS Traditional Rate,40.2,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.38,100,,,Fee Schedule,100% of TX Mediciad 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,4.69,90,,,Fee Schedule,90% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,130,,,Fee Schedule,130% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.51,103,,,Fee Schedule,103% of TX Medicaid Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,5.37,103,,,Fee Schedule,103% of CMS OPPS Rate,50.25,75,,96.872,Percent of Total Billed Charges,75% of Total Billed Charges,8.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.83,150,,,Fee Schedule,150% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,90,,,Fee Schedule,90% of UHC fee schedule,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,4.38,100,,,Fee Schedule,100% of TX Medicaid Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67,100,,129.16,Percent of Total Billed Charges,100% of Total Billed Charges,4.23,67,
AUREOBASIDIUM PULLULANS AB,70021605,CDM,302,RC,86331,HCPCS,Outpatient,,,95,57.00,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,57,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,71.25,75,,207.032,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,95,100,,276.04,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,95,
NOROVIRUS EIA STOOL,70021606,CDM,306,RC,87449,HCPCS,Outpatient,,,194,116.40,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.4,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,145.5,75,,130.984,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194,100,,174.64,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,194,
MUSK AB TITER QN,70021608,CDM,301,RC,83519,HCPCS,Outpatient,,,2600,1560.00,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.88,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,66.24,360,,,Fee Schedule,360% of BCBS POS Rate,66.24,360,,,Fee schedule,360% of BCBS PPO Rate,66.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,1560,60,,1248,Percent of Total Billed Charges,60% of Total Billed Charges,15.46,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,130,,,Fee Schedule,130% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.92,103,,,Fee Schedule,103% of TX Medicaid Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,18.95,103,,,Fee Schedule,103% of CMS OPPS Rate,1950,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,31.27,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.27,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.27,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.27,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.6,150,,,Fee Schedule,150% of CMS OPPS Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,15.46,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2600,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,2600,
CONCENTRATED MYCOBACTERIA CX,70021609,CDM,306,RC,87015,HCPCS,Outpatient,,,106.6,63.96,,7.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,10.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,21.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,24.05,360,,,Fee Schedule,360% of BCBS POS Rate,24.05,360,,,Fee schedule,360% of BCBS PPO Rate,24.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,63.96,60,,51.168,Percent of Total Billed Charges,60% of Total Billed Charges,5.61,100,,,Fee Schedule,100% of TX Mediciad 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,6.01,90,,,Fee Schedule,90% of CMS OPPS Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,130,,,Fee Schedule,130% of CMS OPPS Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.78,103,,,Fee Schedule,103% of TX Medicaid Rate,6.88,103,,,Fee Schedule,103% of CMS OPPS Rate,6.88,103,,,Fee Schedule,103% of CMS OPPS Rate,79.95,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,11.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,11.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,11.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,11.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,10.02,150,,,Fee Schedule,150% of CMS OPPS Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,90,,,Fee Schedule,90% of UHC fee schedule,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,5.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,106.6,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,5.41,106.6,
HEXAGNAL PHOSPH PLTLT NEUTRL,70021611,CDM,305,RC,85598,HCPCS,Outpatient,,,112.57,67.54,,20.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,50.34,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,64.73,360,,,Fee Schedule,360% of BCBS POS Rate,64.73,360,,,Fee schedule,360% of BCBS PPO Rate,64.73,360,,,Fee Schedule,360% of BCBS Traditional Rate,67.54,60,,54.032,Percent of Total Billed Charges,60% of Total Billed Charges,15.1,100,,,Fee Schedule,100% of TX Mediciad 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,16.18,90,,,Fee Schedule,90% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.37,130,,,Fee Schedule,130% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.55,103,,,Fee Schedule,103% of TX Medicaid Rate,18.51,103,,,Fee Schedule,103% of CMS OPPS Rate,18.51,103,,,Fee Schedule,103% of CMS OPPS Rate,84.43,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,30.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.97,150,,,Fee Schedule,150% of CMS OPPS Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.56,90,,,Fee Schedule,90% of UHC fee schedule,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.1,100,,,Fee Schedule,100% of TX Medicaid Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.56,112.57,
SED RATE AUTO,70021612,CDM,305,RC,85652,HCPCS,Outpatient,,,92,55.20,,3.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,8.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,360,,,Fee Schedule,360% of BCBS POS Rate,9.72,360,,,Fee schedule,360% of BCBS PPO Rate,9.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,55.2,60,,44.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.27,100,,,Fee Schedule,100% of TX Mediciad 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,2.43,90,,,Fee Schedule,90% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3.51,130,,,Fee Schedule,130% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.34,103,,,Fee Schedule,103% of TX Medicaid Rate,2.78,103,,,Fee Schedule,103% of CMS OPPS Rate,2.78,103,,,Fee Schedule,103% of CMS OPPS Rate,69,75,,74.472,Percent of Total Billed Charges,75% of Total Billed Charges,4.59,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,4.59,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,4.59,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,4.05,150,,,Fee Schedule,150% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.19,90,,,Fee Schedule,90% of UHC fee schedule,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.27,100,,,Fee Schedule,100% of TX Medicaid Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,92,100,,99.296,Percent of Total Billed Charges,100% of Total Billed Charges,2.19,92,
AB RSV IGG,70021613,CDM,302,RC,86756,HCPCS,Outpatient,,,182.81,109.69,,18.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,50.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,57.2,360,,,Fee Schedule,360% of BCBS POS Rate,57.2,360,,,Fee schedule,360% of BCBS PPO Rate,57.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.69,60,,87.752,Percent of Total Billed Charges,60% of Total Billed Charges,13.35,100,,,Fee Schedule,100% of TX Mediciad Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,90,,,Fee Schedule,90% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,20.65,130,,,Fee Schedule,130% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.75,103,,,Fee Schedule,103% of TX Medicaid Rate,16.36,103,,,Fee Schedule,103% of CMS OPPS Rate,16.36,103,,,Fee Schedule,103% of CMS OPPS Rate,137.11,75,,207.032,Percent of Total Billed Charges,75% of Total Billed Charges,27.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,27.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.83,150,,,Fee Schedule,150% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,90,,,Fee Schedule,90% of UHC fee schedule,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,13.35,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,100,,,Fee Schedule,100% of CMS OPPS Rate,182.81,100,,276.04,Percent of Total Billed Charges,100% of Total Billed Charges,12.87,182.81,
CX STOOL ADDL PATH EACH PLATE,70021614,CDM,306,RC,87046,HCPCS,Outpatient,,,108.03,64.82,,10.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,26.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,30.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,33.98,360,,,Fee Schedule,360% of BCBS POS Rate,33.98,360,,,Fee schedule,360% of BCBS PPO Rate,33.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.82,60,,51.856,Percent of Total Billed Charges,60% of Total Billed Charges,7.93,100,,,Fee Schedule,100% of TX Mediciad 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,8.49,90,,,Fee Schedule,90% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,12.27,130,,,Fee Schedule,130% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,8.17,103,,,Fee Schedule,103% of TX Medicaid Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,9.72,103,,,Fee Schedule,103% of CMS OPPS Rate,81.02,75,,115.296,Percent of Total Billed Charges,75% of Total Billed Charges,16.04,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.04,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,16.04,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.04,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.16,150,,,Fee Schedule,150% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.65,90,,,Fee Schedule,90% of UHC fee schedule,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,7.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,108.03,100,,153.728,Percent of Total Billed Charges,100% of Total Billed Charges,7.65,108.03,
SYPHILIS TEST QT RPR,70021616,CDM,302,RC,86593,HCPCS,Outpatient,,,107.3,64.38,,5.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,6.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,14.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,15.84,360,,,Fee Schedule,360% of BCBS POS Rate,15.84,360,,,Fee schedule,360% of BCBS PPO Rate,15.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,64.38,60,,51.504,Percent of Total Billed Charges,60% of Total Billed Charges,3.7,100,,,Fee Schedule,100% of TX Mediciad 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,3.96,90,,,Fee Schedule,90% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,5.72,130,,,Fee Schedule,130% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.81,103,,,Fee Schedule,103% of TX Medicaid Rate,4.53,103,,,Fee Schedule,103% of CMS OPPS Rate,4.53,103,,,Fee Schedule,103% of CMS OPPS Rate,80.48,75,,83.864,Percent of Total Billed Charges,75% of Total Billed Charges,7.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,7.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,7.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,6.6,150,,,Fee Schedule,150% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,3.56,90,,,Fee Schedule,90% of UHC fee schedule,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,3.7,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,107.3,100,,111.816,Percent of Total Billed Charges,100% of Total Billed Charges,3.56,107.3,
POC PH BODY FLUID,70021617,CDM,301,RC,83986,HCPCS,Outpatient,,,73.25,43.95,,4.16,100,,,Fee Schedule,100% of Aetna Fee Schedule,5.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.02,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,12.89,360,,,Fee Schedule,360% of BCBS POS Rate,12.89,360,,,Fee schedule,360% of BCBS PPO Rate,12.89,360,,,Fee Schedule,360% of BCBS Traditional Rate,43.95,60,,35.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.01,100,,,Fee Schedule,100% of TX Mediciad 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,3.22,90,,,Fee Schedule,90% of CMS OPPS Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4.65,130,,,Fee Schedule,130% of CMS OPPS Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.1,103,,,Fee Schedule,103% of TX Medicaid Rate,3.68,103,,,Fee Schedule,103% of CMS OPPS Rate,3.68,103,,,Fee Schedule,103% of CMS OPPS Rate,54.94,75,,82.048,Percent of Total Billed Charges,75% of Total Billed Charges,6.08,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.08,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,6.08,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,6.08,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,5.37,150,,,Fee Schedule,150% of CMS OPPS Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2.9,90,,,Fee Schedule,90% of UHC fee schedule,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.01,100,,,Fee Schedule,100% of TX Medicaid Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,73.25,100,,109.4,Percent of Total Billed Charges,100% of Total Billed Charges,2.9,73.25,
PROCAINAMIDE NAPA LEVEL,70021618,CDM,301,RC,80192,HCPCS,Outpatient,,,838.8,503.28,,19.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,60.3,360,,,Fee Schedule,360% of BCBS POS Rate,60.3,360,,,Fee schedule,360% of BCBS PPO Rate,60.3,360,,,Fee Schedule,360% of BCBS Traditional Rate,503.28,60,,402.624,Percent of Total Billed Charges,60% of Total Billed Charges,14.07,100,,,Fee Schedule,100% of TX Mediciad Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,15.07,90,,,Fee Schedule,90% of CMS OPPS Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,21.77,130,,,Fee Schedule,130% of CMS OPPS Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.49,103,,,Fee Schedule,103% of TX Medicaid Rate,17.25,103,,,Fee Schedule,103% of CMS OPPS Rate,17.25,103,,,Fee Schedule,103% of CMS OPPS Rate,629.1,75,,156.4,Percent of Total Billed Charges,75% of Total Billed Charges,28.47,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.47,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,28.47,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.47,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.12,150,,,Fee Schedule,150% of CMS OPPS Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.57,90,,,Fee Schedule,90% of UHC fee schedule,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,100,,,Fee Schedule,100% of TX Medicaid Rate,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,838.8,100,,208.536,Percent of Total Billed Charges,100% of Total Billed Charges,13.57,838.8,
CHOLESTEROL HDL,70021620,CDM,301,RC,83718,HCPCS,Outpatient,,,124.14,74.48,,9.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.28,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,360,,,Fee Schedule,360% of BCBS POS Rate,29.48,360,,,Fee schedule,360% of BCBS PPO Rate,29.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.48,60,,59.584,Percent of Total Billed Charges,60% of Total Billed Charges,6.88,100,,,Fee Schedule,100% of TX Mediciad 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,7.37,90,,,Fee Schedule,90% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,130,,,Fee Schedule,130% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,103,,,Fee Schedule,103% of TX Medicaid Rate,8.43,103,,,Fee Schedule,103% of CMS OPPS Rate,8.43,103,,,Fee Schedule,103% of CMS OPPS Rate,93.11,75,,127.2,Percent of Total Billed Charges,75% of Total Billed Charges,13.92,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.92,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.92,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.92,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.28,150,,,Fee Schedule,150% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,90,,,Fee Schedule,90% of UHC fee schedule,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,6.88,100,,,Fee Schedule,100% of TX Medicaid Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,124.14,100,,169.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.63,124.14,
IG HEAVY CHAIN GENE REARRANGE,70021630,CDM,310,RC,81261,HCPCS,Outpatient,,,734,440.40,,229.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,296.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,554.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,633.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,712.76,360,,,Fee Schedule,360% of BCBS POS Rate,712.76,360,,,Fee schedule,360% of BCBS PPO Rate,712.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,440.4,60,,352.32,Percent of Total Billed Charges,60% of Total Billed Charges,166.31,100,,,Fee Schedule,100% of TX Mediciad 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,178.19,90,,,Fee Schedule,90% of CMS OPPS Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,257.38,130,,,Fee Schedule,130% of CMS OPPS Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,171.3,103,,,Fee Schedule,103% of TX Medicaid Rate,203.92,103,,,Fee Schedule,103% of CMS OPPS Rate,203.92,103,,,Fee Schedule,103% of CMS OPPS Rate,550.5,75,,175.4,Percent of Total Billed Charges,75% of Total Billed Charges,336.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,336.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,336.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,336.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,296.98,150,,,Fee Schedule,150% of CMS OPPS Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,160.37,90,,,Fee Schedule,90% of UHC fee schedule,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,166.31,100,,,Fee Schedule,100% of TX Medicaid Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,734,100,,233.864,Percent of Total Billed Charges,100% of Total Billed Charges,160.37,734,
K RAS VARIANTS CODONS,70021631,CDM,310,RC,81275,HCPCS,Outpatient,,,465.82,279.49,,224.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,289.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,541.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,618.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,695.7,360,,,Fee Schedule,360% of BCBS POS Rate,695.7,360,,,Fee schedule,360% of BCBS PPO Rate,695.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,279.49,60,,223.592,Percent of Total Billed Charges,60% of Total Billed Charges,162.33,100,,,Fee Schedule,100% of TX Mediciad 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,173.92,90,,,Fee Schedule,90% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,251.22,130,,,Fee Schedule,130% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,167.2,103,,,Fee Schedule,103% of TX Medicaid Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,349.37,75,,261.944,Percent of Total Billed Charges,75% of Total Billed Charges,328.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,328.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,328.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,328.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,289.87,150,,,Fee Schedule,150% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,156.54,90,,,Fee Schedule,90% of UHC fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,465.82,100,,349.256,Percent of Total Billed Charges,100% of Total Billed Charges,156.54,695.7,
MICROSATELLITE INSTABILITY,70021636,CDM,310,RC,81301,HCPCS,Outpatient,,,815.12,489.07,,404.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,522.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,975.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1115.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,1254.82,360,,,Fee Schedule,360% of BCBS POS Rate,1254.82,360,,,Fee schedule,360% of BCBS PPO Rate,1254.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,489.07,60,,391.256,Percent of Total Billed Charges,60% of Total Billed Charges,292.79,100,,,Fee Schedule,100% of TX Mediciad 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,313.7,90,,,Fee Schedule,90% of CMS OPPS Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,453.12,130,,,Fee Schedule,130% of CMS OPPS Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,301.57,103,,,Fee Schedule,103% of TX Medicaid Rate,359.01,103,,,Fee Schedule,103% of CMS OPPS Rate,359.01,103,,,Fee Schedule,103% of CMS OPPS Rate,611.34,75,,338.296,Percent of Total Billed Charges,75% of Total Billed Charges,592.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,592.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,592.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,592.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,522.84,150,,,Fee Schedule,150% of CMS OPPS Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,282.33,90,,,Fee Schedule,90% of UHC fee schedule,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,292.79,100,,,Fee Schedule,100% of TX Medicaid Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,815.12,100,,451.064,Percent of Total Billed Charges,100% of Total Billed Charges,282.33,1254.82,
MOPATH PROCEDURE LEVEL 5,70021638,CDM,310,RC,81404,HCPCS,Outpatient,,,1221.33,732.80,,318.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,412.24,150,,,Fee Schedule ,150% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,769.52,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,879.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,989.39,360,,,Fee Schedule,360% of BCBS POS Rate,989.39,360,,,Fee schedule,360% of BCBS PPO Rate,989.39,360,,,Fee Schedule,360% of BCBS Traditional Rate,732.8,60,,586.24,Percent of Total Billed Charges,60% of Total Billed Charges,230.86,100,,,Fee Schedule,100% of TX Mediciad 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,247.34,90,,,Fee Schedule,90% of CMS OPPS Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,357.27,130,,,Fee Schedule,130% of CMS OPPS Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,237.79,103,,,Fee Schedule,103% of TX Medicaid Rate,283.07,103,,,Fee Schedule,103% of CMS OPPS Rate,283.07,103,,,Fee Schedule,103% of CMS OPPS Rate,916,75,,253.952,Percent of Total Billed Charges,75% of Total Billed Charges,467.21,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,467.21,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,467.21,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,467.21,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,412.24,150,,,Fee Schedule,150% of CMS OPPS Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,222.62,90,,,Fee Schedule,90% of UHC fee schedule,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,230.86,100,,,Fee Schedule,100% of TX Medicaid Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1221.33,100,,338.6,Percent of Total Billed Charges,100% of Total Billed Charges,222.62,1221.33,
DIHYDROXYVITAMIN D 1 25,70021639,CDM,301,RC,82652,HCPCS,Outpatient,,,392,235.20,,44.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,57.75,150,,,Fee Schedule ,150% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,107.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,123.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,138.6,360,,,Fee Schedule,360% of BCBS POS Rate,138.6,360,,,Fee schedule,360% of BCBS PPO Rate,138.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,235.2,60,,188.16,Percent of Total Billed Charges,60% of Total Billed Charges,32.34,100,,,Fee Schedule,100% of TX Mediciad 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,34.65,90,,,Fee Schedule,90% of CMS OPPS Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,50.05,130,,,Fee Schedule,130% of CMS OPPS Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,33.31,103,,,Fee Schedule,103% of TX Medicaid Rate,39.65,103,,,Fee Schedule,103% of CMS OPPS Rate,39.65,103,,,Fee Schedule,103% of CMS OPPS Rate,294,75,,125.728,Percent of Total Billed Charges,75% of Total Billed Charges,65.45,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,65.45,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,65.45,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,65.45,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,57.75,150,,,Fee Schedule,150% of CMS OPPS Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,90,,,Fee Schedule,90% of UHC fee schedule,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,32.34,100,,,Fee Schedule,100% of TX Medicaid Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,392,100,,167.632,Percent of Total Billed Charges,100% of Total Billed Charges,31.19,392,
CX FUNGI DEFINITIVE ID YEAST,70021642,CDM,306,RC,87106,HCPCS,Outpatient,,,198.64,119.18,,11.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,28.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,37.15,360,,,Fee Schedule,360% of BCBS POS Rate,37.15,360,,,Fee schedule,360% of BCBS PPO Rate,37.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.18,60,,95.344,Percent of Total Billed Charges,60% of Total Billed Charges,8.67,100,,,Fee Schedule,100% of TX Mediciad 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,9.28,90,,,Fee Schedule,90% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,13.41,130,,,Fee Schedule,130% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,103,,,Fee Schedule,103% of TX Medicaid Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,148.98,75,,162.6,Percent of Total Billed Charges,75% of Total Billed Charges,17.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.54,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.54,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.48,150,,,Fee Schedule,150% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,90,,,Fee Schedule,90% of UHC fee schedule,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,198.64,100,,216.8,Percent of Total Billed Charges,100% of Total Billed Charges,8.36,198.64,
CX FUNGI DEFINITIVE ID MOLD,70021643,CDM,306,RC,87107,HCPCS,Outpatient,,,136,81.60,,11.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,15.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,28.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,33.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,37.15,360,,,Fee Schedule,360% of BCBS POS Rate,37.15,360,,,Fee schedule,360% of BCBS PPO Rate,37.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.6,60,,65.28,Percent of Total Billed Charges,60% of Total Billed Charges,8.67,100,,,Fee Schedule,100% of TX Mediciad 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,9.28,90,,,Fee Schedule,90% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,13.41,130,,,Fee Schedule,130% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.93,103,,,Fee Schedule,103% of TX Medicaid Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10.62,103,,,Fee Schedule,103% of CMS OPPS Rate,102,75,,137.984,Percent of Total Billed Charges,75% of Total Billed Charges,17.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,17.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.54,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,17.54,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,15.48,150,,,Fee Schedule,150% of CMS OPPS Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,90,,,Fee Schedule,90% of UHC fee schedule,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,8.67,100,,,Fee Schedule,100% of TX Medicaid Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,136,100,,183.976,Percent of Total Billed Charges,100% of Total Billed Charges,8.36,136,
ETA QLE HYSTOLYTICA ANTIGEN,70021646,CDM,306,RC,87337,HCPCS,Outpatient,,,244.95,146.97,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,146.97,60,,117.576,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,183.71,75,,94.296,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,244.95,100,,125.728,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,244.95,
TCR GAMMA GENE REARRANGEMENT,70021651,CDM,310,RC,81342,HCPCS,Outpatient,,,768.38,461.03,,233.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,302.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,564.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,644.8,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,725.4,360,,,Fee Schedule,360% of BCBS POS Rate,725.4,360,,,Fee schedule,360% of BCBS PPO Rate,725.4,360,,,Fee Schedule,360% of BCBS Traditional Rate,461.03,60,,368.824,Percent of Total Billed Charges,60% of Total Billed Charges,169.26,100,,,Fee Schedule,100% of TX Mediciad 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,181.35,90,,,Fee Schedule,90% of CMS OPPS Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,261.95,130,,,Fee Schedule,130% of CMS OPPS Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,174.34,103,,,Fee Schedule,103% of TX Medicaid Rate,207.54,103,,,Fee Schedule,103% of CMS OPPS Rate,207.54,103,,,Fee Schedule,103% of CMS OPPS Rate,576.29,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,342.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,342.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,342.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,342.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,302.25,150,,,Fee Schedule,150% of CMS OPPS Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,Fee Schedule,90% of UHC fee schedule,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,169.26,100,,,Fee Schedule,100% of TX Medicaid Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,163.22,768.38,
NUCLEIC ACID AMP CMV,70021658,CDM,306,RC,87496,HCPCS,Outpatient,,,395.41,237.25,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,237.25,60,,189.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,296.56,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,395.41,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,395.41,
CHROM ANALY TISSUE 15-20 CELLS,70021663,CDM,310,RC,88262,HCPCS,Outpatient,,,1055.35,633.21,,145.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,188.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,351.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,401.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,451.76,360,,,Fee Schedule,360% of BCBS POS Rate,451.76,360,,,Fee schedule,360% of BCBS PPO Rate,451.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,633.21,60,,506.568,Percent of Total Billed Charges,60% of Total Billed Charges,105.41,100,,,Fee Schedule,100% of TX Mediciad 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,112.94,90,,,Fee Schedule,90% of CMS OPPS Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,163.13,130,,,Fee Schedule,130% of CMS OPPS Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,108.57,103,,,Fee Schedule,103% of TX Medicaid Rate,129.25,103,,,Fee Schedule,103% of CMS OPPS Rate,129.25,103,,,Fee Schedule,103% of CMS OPPS Rate,791.51,75,,835.336,Percent of Total Billed Charges,75% of Total Billed Charges,213.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,213.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,213.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,213.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,188.23,150,,,Fee Schedule,150% of CMS OPPS Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,101.65,90,,,Fee Schedule,90% of UHC fee schedule,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,105.41,100,,,Fee Schedule,100% of TX Medicaid Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.35,100,,1113.776,Percent of Total Billed Charges,100% of Total Billed Charges,101.65,1055.35,
CX TISSUE NON NEOPLAS LYMPHO,70021675,CDM,310,RC,88230,HCPCS,Outpatient,,,725,435.00,,135.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,174.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,326.17,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,372.77,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,419.36,360,,,Fee Schedule,360% of BCBS POS Rate,419.36,360,,,Fee schedule,360% of BCBS PPO Rate,419.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,435,60,,348,Percent of Total Billed Charges,60% of Total Billed Charges,97.85,100,,,Fee Schedule,100% of TX Mediciad 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,104.84,90,,,Fee Schedule,90% of CMS OPPS Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,151.43,130,,,Fee Schedule,130% of CMS OPPS Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,100.79,103,,,Fee Schedule,103% of TX Medicaid Rate,119.98,103,,,Fee Schedule,103% of CMS OPPS Rate,119.98,103,,,Fee Schedule,103% of CMS OPPS Rate,543.75,75,,937.864,Percent of Total Billed Charges,75% of Total Billed Charges,198.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,198.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,198.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,198.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,174.73,150,,,Fee Schedule,150% of CMS OPPS Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,94.36,90,,,Fee Schedule,90% of UHC fee schedule,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,97.85,100,,,Fee Schedule,100% of TX Medicaid Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,725,100,,1250.488,Percent of Total Billed Charges,100% of Total Billed Charges,94.36,725,
CX TISSUE NEOPLASM BLD/BM,70021676,CDM,310,RC,88237,HCPCS,Outpatient,,,740.21,444.13,,166.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,215.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,402.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,460,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,517.5,360,,,Fee Schedule,360% of BCBS POS Rate,517.5,360,,,Fee schedule,360% of BCBS PPO Rate,517.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,444.13,60,,355.304,Percent of Total Billed Charges,60% of Total Billed Charges,120.75,100,,,Fee Schedule,100% of TX Mediciad 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,129.37,90,,,Fee Schedule,90% of CMS OPPS Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,186.87,130,,,Fee Schedule,130% of CMS OPPS Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,124.37,103,,,Fee Schedule,103% of TX Medicaid Rate,148.06,103,,,Fee Schedule,103% of CMS OPPS Rate,148.06,103,,,Fee Schedule,103% of CMS OPPS Rate,555.16,75,,1040.4,Percent of Total Billed Charges,75% of Total Billed Charges,244.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,244.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,244.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,244.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,215.62,150,,,Fee Schedule,150% of CMS OPPS Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,116.44,90,,,Fee Schedule,90% of UHC fee schedule,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,120.75,100,,,Fee Schedule,100% of TX Medicaid Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,740.21,100,,1387.2,Percent of Total Billed Charges,100% of Total Billed Charges,116.44,740.21,
POC URINE PREGNANCY TEST,70021683,CDM,307,RC,81025,HCPCS,Outpatient,,,130.4,78.24,,9.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.55,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,31,360,,,Fee Schedule,360% of BCBS POS Rate,31,360,,,Fee schedule,360% of BCBS PPO Rate,31,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.24,60,,62.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.23,100,,,Fee Schedule,100% of TX Mediciad 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,7.74,90,,,Fee Schedule,90% of CMS OPPS Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,130,,,Fee Schedule,130% of CMS OPPS Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.45,103,,,Fee Schedule,103% of TX Medicaid Rate,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,8.86,103,,,Fee Schedule,103% of CMS OPPS Rate,97.8,75,,265.696,Percent of Total Billed Charges,75% of Total Billed Charges,14.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.91,150,,,Fee Schedule,150% of CMS OPPS Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,90,,,Fee Schedule,90% of UHC fee schedule,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,7.23,100,,,Fee Schedule,100% of TX Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,130.4,100,,354.256,Percent of Total Billed Charges,100% of Total Billed Charges,6.98,130.4,
CX DEFINITIVE ID AEROBIC,70021688,CDM,306,RC,87077,HCPCS,Outpatient,,,187.6,112.56,,9.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,22.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,29.09,360,,,Fee Schedule,360% of BCBS POS Rate,29.09,360,,,Fee schedule,360% of BCBS PPO Rate,29.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.56,60,,90.048,Percent of Total Billed Charges,60% of Total Billed Charges,6.79,100,,,Fee Schedule,100% of TX Mediciad 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,7.27,90,,,Fee Schedule,90% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,130,,,Fee Schedule,130% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.99,103,,,Fee Schedule,103% of TX Medicaid Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,140.7,75,,962.488,Percent of Total Billed Charges,75% of Total Billed Charges,13.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.12,150,,,Fee Schedule,150% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.54,90,,,Fee Schedule,90% of UHC fee schedule,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,187.6,100,,1283.32,Percent of Total Billed Charges,100% of Total Billed Charges,6.54,187.6,
IHC CAT HER-2 ER/PR QUANT,70021689,CDM,312,RC,88361,HCPCS,Outpatient,,,465,279.00,,95.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,279,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,67.05,14.42,,53.64,Percent of Total Billed Charges,14.42% of Total Billed Charges,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,348.75,75,,207.44,Percent of Total Billed Charges,75% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,232.5,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,65.1,14,,52.08,Percent of Total Billed Charges,14% of Total Billed Charges,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,465,100,,276.584,Percent of Total Billed Charges,100% of Total Billed Charges,65.1,1020.28,
MOPATH PROCEDURE LEVEL 4,70021690,CDM,310,RC,81403,HCPCS,Outpatient,,,1050.45,630.27,,214.84,100,,,Fee Schedule,100% of Aetna Fee Schedule,277.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,518.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,592.64,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,666.72,360,,,Fee Schedule,360% of BCBS POS Rate,666.72,360,,,Fee schedule,360% of BCBS PPO Rate,666.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,630.27,60,,504.216,Percent of Total Billed Charges,60% of Total Billed Charges,155.57,100,,,Fee Schedule,100% of TX Mediciad 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,166.68,90,,,Fee Schedule,90% of CMS OPPS Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,240.76,130,,,Fee Schedule,130% of CMS OPPS Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,160.24,103,,,Fee Schedule,103% of TX Medicaid Rate,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,190.75,103,,,Fee Schedule,103% of CMS OPPS Rate,787.84,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,314.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,314.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,314.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,314.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,277.8,150,,,Fee Schedule,150% of CMS OPPS Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,150.01,90,,,Fee Schedule,90% of UHC fee schedule,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,155.57,100,,,Fee Schedule,100% of TX Medicaid Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.45,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,150.01,1050.45,
UNLISTED MOLECULAR PATH PROC,70021691,CDM,310,RC,81479,HCPCS,Outpatient,,,265.78,159.47,,159.47,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.08,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,92.34,360,,,Fee Schedule,360% of BCBS POS Rate,92.34,360,,,Fee schedule,360% of BCBS PPO Rate,92.34,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.47,60,,127.576,Percent of Total Billed Charges,60% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,38.33,14.42,,30.664,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.34,75,,540,Percent of Total Billed Charges,75% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,132.89,50,,106.312,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,37.21,14,,29.768,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,265.78,100,,720,Percent of Total Billed Charges,100% of Total Billed Charges,37.21,265.78,
FLOW CYTOMETRY EA ADDL MARKER,70021693,CDM,311,RC,88185,HCPCS,Outpatient,,,177.64,106.58,,27.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,89.53,360,,,Fee Schedule,360% of BCBS POS Rate,89.53,360,,,Fee schedule,360% of BCBS PPO Rate,89.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.58,60,,85.264,Percent of Total Billed Charges,60% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,25.62,14.42,,20.496,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.23,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,88.82,50,,71.056,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.13,90,,,Fee Schedule,90% of UHC fee schedule,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,24.87,14,,19.896,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.64,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,18.13,177.64,
CONSULT RPT REF SLIDES WO PREP,70021694,CDM,310,RC,88321,HCPCS,Outpatient,,,245.28,147.17,,98.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,55.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,,Fee Schedule,360% of BCBS POS Rate,120.35,360,,,Fee schedule,360% of BCBS PPO Rate,120.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.17,60,,117.736,Percent of Total Billed Charges,60% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,33.11,90,,,Fee Schedule,90% of CMS OPPS Rate,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,47.83,130,,,Fee Schedule,130% of CMS OPPS Rate,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,35.37,14.42,,28.296,Percent of Total Billed Charges,14.42% of Total Billed Charges,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,37.89,103,,,Fee Schedule,103% of CMS OPPS Rate,183.96,75,,299.944,Percent of Total Billed Charges,75% of Total Billed Charges,122.64,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,122.64,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,122.64,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,122.64,50,,98.112,Percent of Total Billed Charges,50% of Total Billed Charges,55.18,150,,,Fee Schedule,150% of CMS OPPS Rate,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,,Fee Schedule,90% of UHC fee schedule,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,34.34,14,,27.472,Percent of Total Billed Charges,14% of Total Billed Charges,36.79,100,,,Fee Schedule,100% of CMS OPPS Rate,245.28,100,,399.928,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,245.28,
IHC MANUAL HER/2 ER/PR QUANT,70021696,CDM,312,RC,88360,HCPCS,Outpatient,,,382,229.20,,98.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,229.2,60,,183.36,Percent of Total Billed Charges,60% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,55.08,14.42,,44.064,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,286.5,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,191,50,,152.8,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,53.48,14,,42.784,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,382,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,53.48,516.6,
IN SITU HYBRIDIZATION FISH,70021697,CDM,312,RC,88365,HCPCS,Outpatient,,,563.87,338.32,,168.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,338.32,60,,270.656,Percent of Total Billed Charges,60% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,81.31,14.42,,65.048,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,422.9,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,281.94,50,,225.552,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,78.94,14,,63.152,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,563.87,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,78.94,563.87,
CX TYPE IMMUNOLOGIC MTHD EA,70021698,CDM,306,RC,87147,HCPCS,Outpatient,,,224.4,134.64,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,134.64,60,,107.712,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,168.3,75,,587.968,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,224.4,100,,783.952,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,224.4,
PHOSPHATIDYLGLYCEROL IGG,70021699,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,299.944,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,399.928,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
PHOSPHATIDYLGLYCEROL IGM,70021700,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,3000,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,4000,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
PHOSPHATIDYLGLYCEROL IGA,70021701,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,76.656,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,102.208,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
CX ANAEROBIC ISOLATE EA ISOLAT,70021704,CDM,306,RC,87076,HCPCS,Outpatient,,,182.32,109.39,,9.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.12,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,22.62,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.86,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,29.09,360,,,Fee Schedule,360% of BCBS POS Rate,29.09,360,,,Fee schedule,360% of BCBS PPO Rate,29.09,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.39,60,,87.512,Percent of Total Billed Charges,60% of Total Billed Charges,6.79,100,,,Fee Schedule,100% of TX Mediciad 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,7.27,90,,,Fee Schedule,90% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,130,,,Fee Schedule,130% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.99,103,,,Fee Schedule,103% of TX Medicaid Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,8.32,103,,,Fee Schedule,103% of CMS OPPS Rate,136.74,75,,267.736,Percent of Total Billed Charges,75% of Total Billed Charges,13.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.12,150,,,Fee Schedule,150% of CMS OPPS Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.54,90,,,Fee Schedule,90% of UHC fee schedule,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,6.79,100,,,Fee Schedule,100% of TX Medicaid Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,182.32,100,,356.976,Percent of Total Billed Charges,100% of Total Billed Charges,6.54,182.32,
IGK REARRANGE ABN CLONAL POP,70021708,CDM,310,RC,81264,HCPCS,Outpatient,,,867,520.20,,200.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,259.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,483.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,552.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,621.83,360,,,Fee Schedule,360% of BCBS POS Rate,621.83,360,,,Fee schedule,360% of BCBS PPO Rate,621.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,520.2,60,,416.16,Percent of Total Billed Charges,60% of Total Billed Charges,145.09,100,,,Fee Schedule,100% of TX Mediciad 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,155.45,90,,,Fee Schedule,90% of CMS OPPS Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,224.54,130,,,Fee Schedule,130% of CMS OPPS Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,149.44,103,,,Fee Schedule,103% of TX Medicaid Rate,177.91,103,,,Fee Schedule,103% of CMS OPPS Rate,177.91,103,,,Fee Schedule,103% of CMS OPPS Rate,650.25,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,293.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,293.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,293.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,293.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,259.09,150,,,Fee Schedule,150% of CMS OPPS Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,139.91,90,,,Fee Schedule,90% of UHC fee schedule,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,145.09,100,,,Fee Schedule,100% of TX Medicaid Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,867,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,139.91,867,
TRB GENE REARRANGE AMPLIFY,70021709,CDM,310,RC,81340,HCPCS,Outpatient,,,945.44,567.26,,242.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,313.37,150,,,Fee Schedule ,150% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,584.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,668.54,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,752.11,360,,,Fee Schedule,360% of BCBS POS Rate,752.11,360,,,Fee schedule,360% of BCBS PPO Rate,752.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,567.26,60,,453.808,Percent of Total Billed Charges,60% of Total Billed Charges,175.49,100,,,Fee Schedule,100% of TX Mediciad 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,188.02,90,,,Fee Schedule,90% of CMS OPPS Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,271.59,130,,,Fee Schedule,130% of CMS OPPS Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,180.75,103,,,Fee Schedule,103% of TX Medicaid Rate,215.18,103,,,Fee Schedule,103% of CMS OPPS Rate,215.18,103,,,Fee Schedule,103% of CMS OPPS Rate,709.08,75,,137.984,Percent of Total Billed Charges,75% of Total Billed Charges,355.16,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,355.16,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,355.16,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,355.16,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,313.37,150,,,Fee Schedule,150% of CMS OPPS Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,169.23,90,,,Fee Schedule,90% of UHC fee schedule,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,175.49,100,,,Fee Schedule,100% of TX Medicaid Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,945.44,100,,183.976,Percent of Total Billed Charges,100% of Total Billed Charges,169.23,945.44,
MOPATH PROCEDURE LEVEL 2,70021710,CDM,310,RC,81401,HCPCS,Outpatient,,,708.67,425.20,,158.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,205.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,383.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,438.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,493.2,360,,,Fee Schedule,360% of BCBS POS Rate,493.2,360,,,Fee schedule,360% of BCBS PPO Rate,493.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,425.2,60,,340.16,Percent of Total Billed Charges,60% of Total Billed Charges,115.08,100,,,Fee Schedule,100% of TX Mediciad 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,123.3,90,,,Fee Schedule,90% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,178.1,130,,,Fee Schedule,130% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,118.53,103,,,Fee Schedule,103% of TX Medicaid Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,141.11,103,,,Fee Schedule,103% of CMS OPPS Rate,531.5,75,,778.08,Percent of Total Billed Charges,75% of Total Billed Charges,232.9,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,232.9,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,232.9,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,232.9,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,205.5,150,,,Fee Schedule,150% of CMS OPPS Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,110.97,90,,,Fee Schedule,90% of UHC fee schedule,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,115.08,100,,,Fee Schedule,100% of TX Medicaid Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,708.67,100,,1037.44,Percent of Total Billed Charges,100% of Total Billed Charges,110.97,708.67,
MOPATH PROCEDURE LEVEL 3,70021711,CDM,310,RC,81402,HCPCS,Outpatient,,,879.56,527.74,,174.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,225.49,150,,,Fee Schedule ,150% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,420.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,481.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,541.19,360,,,Fee Schedule,360% of BCBS POS Rate,541.19,360,,,Fee schedule,360% of BCBS PPO Rate,541.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,527.74,60,,422.192,Percent of Total Billed Charges,60% of Total Billed Charges,126.28,100,,,Fee Schedule,100% of TX Mediciad 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,135.29,90,,,Fee Schedule,90% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.42,130,,,Fee Schedule,130% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,130.07,103,,,Fee Schedule,103% of TX Medicaid Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,154.83,103,,,Fee Schedule,103% of CMS OPPS Rate,659.67,75,,198.816,Percent of Total Billed Charges,75% of Total Billed Charges,255.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,255.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,255.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,225.49,150,,,Fee Schedule,150% of CMS OPPS Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,121.77,90,,,Fee Schedule,90% of UHC fee schedule,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,126.28,100,,,Fee Schedule,100% of TX Medicaid Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,879.56,100,,265.088,Percent of Total Billed Charges,100% of Total Billed Charges,121.77,879.56,
HERPES SIMPLEX VIRUS 1 QL PCR,70021714,CDM,306,RC,87529,HCPCS,Outpatient,,,348,208.80,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,208.8,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,261,75,,1950.4,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,348,100,,2600.536,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,348,
HERPES SIMPLEX VIRUS 2 QL PCR,70021715,CDM,306,RC,87529,HCPCS,Outpatient,,,348,208.80,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,208.8,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,261,75,,376.896,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,348,100,,502.528,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,348,
LYME DISEASE ANTIBODY,70021722,CDM,302,RC,86618,HCPCS,Outpatient,,,196.38,117.83,,19.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,47.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,61.31,360,,,Fee Schedule,360% of BCBS POS Rate,61.31,360,,,Fee schedule,360% of BCBS PPO Rate,61.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.83,60,,94.264,Percent of Total Billed Charges,60% of Total Billed Charges,14.31,100,,,Fee Schedule,100% of TX Mediciad 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,15.32,90,,,Fee Schedule,90% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.13,130,,,Fee Schedule,130% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.74,103,,,Fee Schedule,103% of TX Medicaid Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,17.54,103,,,Fee Schedule,103% of CMS OPPS Rate,147.29,75,,174.056,Percent of Total Billed Charges,75% of Total Billed Charges,28.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,28.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.54,150,,,Fee Schedule,150% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,90,,,Fee Schedule,90% of UHC fee schedule,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.31,100,,,Fee Schedule,100% of TX Medicaid Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,196.38,100,,232.072,Percent of Total Billed Charges,100% of Total Billed Charges,13.8,196.38,
TPMT ERYTHROCYTES,70021723,CDM,301,RC,83789,HCPCS,Outpatient,,,250.16,150.10,,27.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,67.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,86.8,360,,,Fee Schedule,360% of BCBS POS Rate,86.8,360,,,Fee schedule,360% of BCBS PPO Rate,86.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,150.1,60,,120.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,100,,,Fee Schedule,100% of TX Mediciad 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,21.69,90,,,Fee Schedule,90% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,31.34,130,,,Fee Schedule,130% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.86,103,,,Fee Schedule,103% of TX Medicaid Rate,24.83,103,,,Fee Schedule,103% of CMS OPPS Rate,24.83,103,,,Fee Schedule,103% of CMS OPPS Rate,187.62,75,,200.832,Percent of Total Billed Charges,75% of Total Billed Charges,40.98,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.98,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,40.98,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.98,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.16,150,,,Fee Schedule,150% of CMS OPPS Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,90,,,Fee Schedule,90% of UHC fee schedule,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,20.25,100,,,Fee Schedule,100% of TX Medicaid Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,250.16,100,,267.776,Percent of Total Billed Charges,100% of Total Billed Charges,19.53,250.16,
ARSENIC,70021753,CDM,301,RC,82175,HCPCS,Outpatient,,,165,99.00,,22,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.45,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,53.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,68.29,360,,,Fee Schedule,360% of BCBS POS Rate,68.29,360,,,Fee schedule,360% of BCBS PPO Rate,68.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,99,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,15.93,100,,,Fee Schedule,100% of TX Mediciad 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,17.07,90,,,Fee Schedule,90% of CMS OPPS Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,24.66,130,,,Fee Schedule,130% of CMS OPPS Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,16.41,103,,,Fee Schedule,103% of TX Medicaid Rate,19.53,103,,,Fee Schedule,103% of CMS OPPS Rate,19.53,103,,,Fee Schedule,103% of CMS OPPS Rate,123.75,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,32.24,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.24,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,32.24,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.24,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,28.45,150,,,Fee Schedule,150% of CMS OPPS Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,90,,,Fee Schedule,90% of UHC fee schedule,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,15.93,100,,,Fee Schedule,100% of TX Medicaid Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,165,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,15.36,165,
SPECIAL STAINS GROUP II EA,70021754,CDM,312,RC,88313,HCPCS,Outpatient,,,223,133.80,,82.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,,Fee Schedule,360% of BCBS POS Rate,120.35,360,,,Fee schedule,360% of BCBS PPO Rate,120.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.8,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,32.16,14.42,,25.728,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,167.25,75,,128.4,Percent of Total Billed Charges,75% of Total Billed Charges,111.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,111.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,111.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,111.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,,Fee Schedule,90% of UHC fee schedule,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,31.22,14,,24.976,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,223,100,,171.2,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,223,
ELECTRON MICROSCOPY DX,70021755,CDM,312,RC,88348,HCPCS,Outpatient,,,1805.43,1083.26,,420.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,1083.26,60,,866.608,Percent of Total Billed Charges,60% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,260.34,14.42,,208.272,Percent of Total Billed Charges,14.42% of Total Billed Charges,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1354.07,75,,354.952,Percent of Total Billed Charges,75% of Total Billed Charges,902.72,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,902.72,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,902.72,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,902.72,50,,722.176,Percent of Total Billed Charges,50% of Total Billed Charges,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,252.76,14,,202.208,Percent of Total Billed Charges,14% of Total Billed Charges,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1805.43,100,,473.264,Percent of Total Billed Charges,100% of Total Billed Charges,252.76,2261.52,
ASCORBIC ACID VITAMIN C BLOOD,70021803,CDM,301,RC,82180,HCPCS,Outpatient,,,132,79.20,,11.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,27.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,35.6,360,,,Fee Schedule,360% of BCBS POS Rate,35.6,360,,,Fee schedule,360% of BCBS PPO Rate,35.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,79.2,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,8.31,100,,,Fee Schedule,100% of TX Mediciad 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,8.9,90,,,Fee Schedule,90% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,130,,,Fee Schedule,130% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.56,103,,,Fee Schedule,103% of TX Medicaid Rate,10.18,103,,,Fee Schedule,103% of CMS OPPS Rate,10.18,103,,,Fee Schedule,103% of CMS OPPS Rate,99,75,,236.632,Percent of Total Billed Charges,75% of Total Billed Charges,16.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.83,150,,,Fee Schedule,150% of CMS OPPS Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.01,90,,,Fee Schedule,90% of UHC fee schedule,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,8.31,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,132,100,,315.504,Percent of Total Billed Charges,100% of Total Billed Charges,8.01,132,
BETA 2 MICROGLOBULIN,70022322,CDM,301,RC,82232,HCPCS,Outpatient,,,171.63,102.98,,18.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,58.25,360,,,Fee Schedule,360% of BCBS POS Rate,58.25,360,,,Fee schedule,360% of BCBS PPO Rate,58.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.98,60,,82.384,Percent of Total Billed Charges,60% of Total Billed Charges,13.59,100,,,Fee Schedule,100% of TX Mediciad 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,14.56,90,,,Fee Schedule,90% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,21.03,130,,,Fee Schedule,130% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14,103,,,Fee Schedule,103% of TX Medicaid Rate,16.66,103,,,Fee Schedule,103% of CMS OPPS Rate,16.66,103,,,Fee Schedule,103% of CMS OPPS Rate,128.72,75,,147.816,Percent of Total Billed Charges,75% of Total Billed Charges,27.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.27,150,,,Fee Schedule,150% of CMS OPPS Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,90,,,Fee Schedule,90% of UHC fee schedule,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,13.59,100,,,Fee Schedule,100% of TX Medicaid Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,171.63,100,,197.088,Percent of Total Billed Charges,100% of Total Billed Charges,13.1,171.63,
CALCITONIN,70023080,CDM,301,RC,82308,HCPCS,Outpatient,,,265,159.00,,31.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,75.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,96.44,360,,,Fee Schedule,360% of BCBS POS Rate,96.44,360,,,Fee schedule,360% of BCBS PPO Rate,96.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,159,60,,127.2,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,100,,,Fee Schedule,100% of TX Mediciad 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,24.11,90,,,Fee Schedule,90% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,34.82,130,,,Fee Schedule,130% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,23.18,103,,,Fee Schedule,103% of TX Medicaid Rate,27.59,103,,,Fee Schedule,103% of CMS OPPS Rate,27.59,103,,,Fee Schedule,103% of CMS OPPS Rate,198.75,75,,65.52,Percent of Total Billed Charges,75% of Total Billed Charges,45.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.54,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.18,150,,,Fee Schedule,150% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,90,,,Fee Schedule,90% of UHC fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,265,100,,87.36,Percent of Total Billed Charges,100% of Total Billed Charges,21.7,265,
CALCULUS QUANT CHEMICAL,70023601,CDM,300,RC,82360,HCPCS,Outpatient,,,160.23,96.14,,14.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.3,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,46.33,360,,,Fee Schedule,360% of BCBS POS Rate,46.33,360,,,Fee schedule,360% of BCBS PPO Rate,46.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,96.14,60,,76.912,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,100,,,Fee Schedule,100% of TX Mediciad 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,11.58,90,,,Fee Schedule,90% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,130,,,Fee Schedule,130% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,103,,,Fee Schedule,103% of TX Medicaid Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,13.25,103,,,Fee Schedule,103% of CMS OPPS Rate,120.17,75,,44.864,Percent of Total Billed Charges,75% of Total Billed Charges,21.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.3,150,,,Fee Schedule,150% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,90,,,Fee Schedule,90% of UHC fee schedule,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,10.81,100,,,Fee Schedule,100% of TX Medicaid Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,160.23,100,,59.816,Percent of Total Billed Charges,100% of Total Billed Charges,10.42,160.23,
CERULOPLASMIN,70023908,CDM,301,RC,82390,HCPCS,Outpatient,,,135,81.00,,12.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,30.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,38.66,360,,,Fee Schedule,360% of BCBS POS Rate,38.66,360,,,Fee schedule,360% of BCBS PPO Rate,38.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,81,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.02,100,,,Fee Schedule,100% of TX Mediciad 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,9.66,90,,,Fee Schedule,90% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.96,130,,,Fee Schedule,130% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.29,103,,,Fee Schedule,103% of TX Medicaid Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,101.25,75,,110.4,Percent of Total Billed Charges,75% of Total Billed Charges,18.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,18.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,16.11,150,,,Fee Schedule,150% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,90,,,Fee Schedule,90% of UHC fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,135,100,,147.2,Percent of Total Billed Charges,100% of Total Billed Charges,8.7,135,
CHLORIDE CSF,70024385,CDM,301,RC,82438,HCPCS,Outpatient,,,104.57,62.74,,5.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,14,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,18,360,,,Fee Schedule,360% of BCBS POS Rate,18,360,,,Fee schedule,360% of BCBS PPO Rate,18,360,,,Fee Schedule,360% of BCBS Traditional Rate,62.74,60,,50.192,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,100,,,Fee Schedule,100% of TX Mediciad 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,4.5,90,,,Fee Schedule,90% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,130,,,Fee Schedule,130% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.33,103,,,Fee Schedule,103% of TX Medicaid Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,5.15,103,,,Fee Schedule,103% of CMS OPPS Rate,78.43,75,,12.736,Percent of Total Billed Charges,75% of Total Billed Charges,8.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.5,150,,,Fee Schedule,150% of CMS OPPS Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.05,90,,,Fee Schedule,90% of UHC fee schedule,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,100,,,Fee Schedule,100% of TX Medicaid Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.57,100,,16.984,Percent of Total Billed Charges,100% of Total Billed Charges,4.05,104.57,
"CHOLINESTERASE, PSUEDO",70024807,CDM,300,RC,82480,HCPCS,Outpatient,,,105,63.00,,9.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,22.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,28.33,360,,,Fee Schedule,360% of BCBS POS Rate,28.33,360,,,Fee schedule,360% of BCBS PPO Rate,28.33,360,,,Fee Schedule,360% of BCBS Traditional Rate,63,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.61,100,,,Fee Schedule,100% of TX Mediciad 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,7.08,90,,,Fee Schedule,90% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.23,130,,,Fee Schedule,130% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.81,103,,,Fee Schedule,103% of TX Medicaid Rate,8.1,103,,,Fee Schedule,103% of CMS OPPS Rate,8.1,103,,,Fee Schedule,103% of CMS OPPS Rate,78.75,75,,15.832,Percent of Total Billed Charges,75% of Total Billed Charges,13.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,13.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,11.8,150,,,Fee Schedule,150% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.37,90,,,Fee Schedule,90% of UHC fee schedule,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,6.61,100,,,Fee Schedule,100% of TX Medicaid Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,21.104,Percent of Total Billed Charges,100% of Total Billed Charges,6.37,105,
COPPER,70025259,CDM,301,RC,82525,HCPCS,Outpatient,,,157,94.20,,14.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,44.68,360,,,Fee Schedule,360% of BCBS POS Rate,44.68,360,,,Fee schedule,360% of BCBS PPO Rate,44.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,94.2,60,,75.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.42,100,,,Fee Schedule,100% of TX Mediciad 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,11.16,90,,,Fee Schedule,90% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,130,,,Fee Schedule,130% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.73,103,,,Fee Schedule,103% of TX Medicaid Rate,12.78,103,,,Fee Schedule,103% of CMS OPPS Rate,12.78,103,,,Fee Schedule,103% of CMS OPPS Rate,117.75,75,,17.368,Percent of Total Billed Charges,75% of Total Billed Charges,21.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.61,150,,,Fee Schedule,150% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.05,90,,,Fee Schedule,90% of UHC fee schedule,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,157,100,,23.16,Percent of Total Billed Charges,100% of Total Billed Charges,10.05,157,
COPPER URINE,70025267,CDM,301,RC,82525,HCPCS,Outpatient,,,157,94.20,,14.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,34.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.71,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,44.68,360,,,Fee Schedule,360% of BCBS POS Rate,44.68,360,,,Fee schedule,360% of BCBS PPO Rate,44.68,360,,,Fee Schedule,360% of BCBS Traditional Rate,94.2,60,,75.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.42,100,,,Fee Schedule,100% of TX Mediciad 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,11.16,90,,,Fee Schedule,90% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,130,,,Fee Schedule,130% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.73,103,,,Fee Schedule,103% of TX Medicaid Rate,12.78,103,,,Fee Schedule,103% of CMS OPPS Rate,12.78,103,,,Fee Schedule,103% of CMS OPPS Rate,117.75,75,,18.384,Percent of Total Billed Charges,75% of Total Billed Charges,21.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.61,150,,,Fee Schedule,150% of CMS OPPS Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.05,90,,,Fee Schedule,90% of UHC fee schedule,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,157,100,,24.512,Percent of Total Billed Charges,100% of Total Billed Charges,10.05,157,
CORTISOL FREE URINE,70025358,CDM,301,RC,82530,HCPCS,Outpatient,,,208.18,124.91,,19.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.06,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,46.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,60.16,360,,,Fee Schedule,360% of BCBS POS Rate,60.16,360,,,Fee schedule,360% of BCBS PPO Rate,60.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,124.91,60,,99.928,Percent of Total Billed Charges,60% of Total Billed Charges,14.04,100,,,Fee Schedule,100% of TX Mediciad 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,15.03,90,,,Fee Schedule,90% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,21.72,130,,,Fee Schedule,130% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.46,103,,,Fee Schedule,103% of TX Medicaid Rate,17.21,103,,,Fee Schedule,103% of CMS OPPS Rate,17.21,103,,,Fee Schedule,103% of CMS OPPS Rate,156.14,75,,21.288,Percent of Total Billed Charges,75% of Total Billed Charges,28.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,28.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.06,150,,,Fee Schedule,150% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,90,,,Fee Schedule,90% of UHC fee schedule,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,14.04,100,,,Fee Schedule,100% of TX Medicaid Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,208.18,100,,28.384,Percent of Total Billed Charges,100% of Total Billed Charges,13.54,208.18,
CYCLOSPORINE,70026133,CDM,301,RC,80158,HCPCS,Outpatient,,,289,173.40,,20.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,50.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,64.98,360,,,Fee Schedule,360% of BCBS POS Rate,64.98,360,,,Fee schedule,360% of BCBS PPO Rate,64.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,173.4,60,,138.72,Percent of Total Billed Charges,60% of Total Billed Charges,15.16,100,,,Fee Schedule,100% of TX Mediciad 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,16.24,90,,,Fee Schedule,90% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,130,,,Fee Schedule,130% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.61,103,,,Fee Schedule,103% of TX Medicaid Rate,18.59,103,,,Fee Schedule,103% of CMS OPPS Rate,18.59,103,,,Fee Schedule,103% of CMS OPPS Rate,216.75,75,,24.04,Percent of Total Billed Charges,75% of Total Billed Charges,30.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,30.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.07,150,,,Fee Schedule,150% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,90,,,Fee Schedule,90% of UHC fee schedule,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,15.16,100,,,Fee Schedule,100% of TX Medicaid Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,289,100,,32.048,Percent of Total Billed Charges,100% of Total Billed Charges,14.63,289,
DHEA SULFATE,70026315,CDM,301,RC,82627,HCPCS,Outpatient,,,262,157.20,,25.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.34,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,62.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,71.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,80.03,360,,,Fee Schedule,360% of BCBS POS Rate,80.03,360,,,Fee schedule,360% of BCBS PPO Rate,80.03,360,,,Fee Schedule,360% of BCBS Traditional Rate,157.2,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,18.67,100,,,Fee Schedule,100% of TX Mediciad 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,20,90,,,Fee Schedule,90% of CMS OPPS Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,28.89,130,,,Fee Schedule,130% of CMS OPPS Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,19.23,103,,,Fee Schedule,103% of TX Medicaid Rate,22.89,103,,,Fee Schedule,103% of CMS OPPS Rate,22.89,103,,,Fee Schedule,103% of CMS OPPS Rate,196.5,75,,34.576,Percent of Total Billed Charges,75% of Total Billed Charges,37.79,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.79,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,37.79,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.79,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,33.34,150,,,Fee Schedule,150% of CMS OPPS Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.01,90,,,Fee Schedule,90% of UHC fee schedule,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,18.67,100,,,Fee Schedule,100% of TX Medicaid Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,262,100,,46.096,Percent of Total Billed Charges,100% of Total Billed Charges,18.01,262,
DOXEPIN LEVEL,70026570,CDM,300,RC,G0480,HCPCS,Outpatient,,,275.79,165.47,,66.37,100,,,Fee Schedule,100% of Aetna Fee Schedule,171.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,366.18,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,411.95,360,,,Fee Schedule,360% of BCBS POS Rate,411.95,360,,,Fee schedule,360% of BCBS PPO Rate,411.95,360,,,Fee Schedule,360% of BCBS Traditional Rate,165.47,60,,132.376,Percent of Total Billed Charges,60% of Total Billed Charges,96.12,100,,,Fee Schedule,100% of TX Mediciad 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,102.98,90,,,Fee Schedule,90% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,148.75,130,,,Fee Schedule,130% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,99,103,,,Fee Schedule,103% of TX Medicaid Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,117.86,103,,,Fee Schedule,103% of CMS OPPS Rate,206.84,75,,49.096,Percent of Total Billed Charges,75% of Total Billed Charges,194.53,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,194.53,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,194.53,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,194.53,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,171.64,150,,,Fee Schedule,150% of CMS OPPS Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,92.69,90,,,Fee Schedule,90% of UHC fee schedule,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,96.12,100,,,Fee Schedule,100% of TX Medicaid Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,275.79,100,,65.464,Percent of Total Billed Charges,100% of Total Billed Charges,66.37,411.95,
ERYTHROPOIETIN,70026687,CDM,301,RC,82668,HCPCS,Outpatient,,,212,127.20,,21.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.18,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,52.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,67.64,360,,,Fee Schedule,360% of BCBS POS Rate,67.64,360,,,Fee schedule,360% of BCBS PPO Rate,67.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,127.2,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,15.78,100,,,Fee Schedule,100% of TX Mediciad 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,16.91,90,,,Fee Schedule,90% of CMS OPPS Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,24.42,130,,,Fee Schedule,130% of CMS OPPS Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,103,,,Fee Schedule,103% of TX Medicaid Rate,19.35,103,,,Fee Schedule,103% of CMS OPPS Rate,19.35,103,,,Fee Schedule,103% of CMS OPPS Rate,159,75,,58.984,Percent of Total Billed Charges,75% of Total Billed Charges,31.94,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.94,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,31.94,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.94,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,28.18,150,,,Fee Schedule,150% of CMS OPPS Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,15.22,90,,,Fee Schedule,90% of UHC fee schedule,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,15.78,100,,,Fee Schedule,100% of TX Medicaid Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,212,100,,78.64,Percent of Total Billed Charges,100% of Total Billed Charges,15.22,212,
ESTRONE,70026794,CDM,301,RC,82679,HCPCS,Outpatient,,,199.95,119.97,,28.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,37.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,69.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,79.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,89.82,360,,,Fee Schedule,360% of BCBS POS Rate,89.82,360,,,Fee schedule,360% of BCBS PPO Rate,89.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.97,60,,95.976,Percent of Total Billed Charges,60% of Total Billed Charges,20.96,100,,,Fee Schedule,100% of TX Mediciad 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,22.45,90,,,Fee Schedule,90% of CMS OPPS Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,32.43,130,,,Fee Schedule,130% of CMS OPPS Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,21.59,103,,,Fee Schedule,103% of TX Medicaid Rate,25.69,103,,,Fee Schedule,103% of CMS OPPS Rate,25.69,103,,,Fee Schedule,103% of CMS OPPS Rate,149.96,75,,81.176,Percent of Total Billed Charges,75% of Total Billed Charges,42.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,42.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,42.41,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,42.41,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,37.42,150,,,Fee Schedule,150% of CMS OPPS Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,20.21,90,,,Fee Schedule,90% of UHC fee schedule,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,20.96,100,,,Fee Schedule,100% of TX Medicaid Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,199.95,100,,108.232,Percent of Total Billed Charges,100% of Total Billed Charges,20.21,199.95,
ETHYLENE GLYCOL,70026919,CDM,301,RC,82693,HCPCS,Outpatient,,,214,128.40,,17.28,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.72,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.68,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,53.64,360,,,Fee Schedule,360% of BCBS POS Rate,53.64,360,,,Fee schedule,360% of BCBS PPO Rate,53.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.4,60,,102.72,Percent of Total Billed Charges,60% of Total Billed Charges,12.52,100,,,Fee Schedule,100% of TX Mediciad 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,13.41,90,,,Fee Schedule,90% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,19.37,130,,,Fee Schedule,130% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,103,,,Fee Schedule,103% of TX Medicaid Rate,15.34,103,,,Fee Schedule,103% of CMS OPPS Rate,15.34,103,,,Fee Schedule,103% of CMS OPPS Rate,160.5,75,,100.912,Percent of Total Billed Charges,75% of Total Billed Charges,25.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,25.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.35,150,,,Fee Schedule,150% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.07,90,,,Fee Schedule,90% of UHC fee schedule,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,12.52,100,,,Fee Schedule,100% of TX Medicaid Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,214,100,,134.552,Percent of Total Billed Charges,100% of Total Billed Charges,12.07,214,
FOLIC ACID RBC,70027479,CDM,301,RC,82747,HCPCS,Outpatient,,,205.8,123.48,,20.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,56.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,63.54,360,,,Fee Schedule,360% of BCBS POS Rate,63.54,360,,,Fee schedule,360% of BCBS PPO Rate,63.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,123.48,60,,98.784,Percent of Total Billed Charges,60% of Total Billed Charges,14.83,100,,,Fee Schedule,100% of TX Mediciad 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,15.88,90,,,Fee Schedule,90% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,130,,,Fee Schedule,130% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,15.27,103,,,Fee Schedule,103% of TX Medicaid Rate,18.17,103,,,Fee Schedule,103% of CMS OPPS Rate,18.17,103,,,Fee Schedule,103% of CMS OPPS Rate,154.35,75,,105.064,Percent of Total Billed Charges,75% of Total Billed Charges,30,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,30,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.47,150,,,Fee Schedule,150% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,90,,,Fee Schedule,90% of UHC fee schedule,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,205.8,100,,140.08,Percent of Total Billed Charges,100% of Total Billed Charges,14.3,205.8,
GASTRIN,70029418,CDM,301,RC,82941,HCPCS,Outpatient,,,196,117.60,,20.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.44,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,49.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,56.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,63.47,360,,,Fee Schedule,360% of BCBS POS Rate,63.47,360,,,Fee schedule,360% of BCBS PPO Rate,63.47,360,,,Fee Schedule,360% of BCBS Traditional Rate,117.6,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.81,100,,,Fee Schedule,100% of TX Mediciad 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,15.86,90,,,Fee Schedule,90% of CMS OPPS Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,22.91,130,,,Fee Schedule,130% of CMS OPPS Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,15.25,103,,,Fee Schedule,103% of TX Medicaid Rate,18.15,103,,,Fee Schedule,103% of CMS OPPS Rate,18.15,103,,,Fee Schedule,103% of CMS OPPS Rate,147,75,,95.76,Percent of Total Billed Charges,75% of Total Billed Charges,29.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,29.97,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.97,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.44,150,,,Fee Schedule,150% of CMS OPPS Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,14.28,90,,,Fee Schedule,90% of UHC fee schedule,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,14.81,100,,,Fee Schedule,100% of TX Medicaid Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,196,100,,127.68,Percent of Total Billed Charges,100% of Total Billed Charges,14.28,196,
GLUCAGON,70029434,CDM,301,RC,82943,HCPCS,Outpatient,,,137.98,82.79,,16.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.43,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,51.44,360,,,Fee Schedule,360% of BCBS POS Rate,51.44,360,,,Fee schedule,360% of BCBS PPO Rate,51.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.79,60,,66.232,Percent of Total Billed Charges,60% of Total Billed Charges,12,100,,,Fee Schedule,100% of TX Mediciad 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,12.86,90,,,Fee Schedule,90% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,130,,,Fee Schedule,130% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of TX Medicaid Rate,14.71,103,,,Fee Schedule,103% of CMS OPPS Rate,14.71,103,,,Fee Schedule,103% of CMS OPPS Rate,103.49,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,24.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,24.29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.43,150,,,Fee Schedule,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,90,,,Fee Schedule,90% of UHC fee schedule,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of TX Medicaid Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,137.98,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,11.57,137.98,
G6PD QUANTITATIVE,70029558,CDM,301,RC,82955,HCPCS,Outpatient,,,136.52,81.91,,11.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,14.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,31.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,34.92,360,,,Fee Schedule,360% of BCBS POS Rate,34.92,360,,,Fee schedule,360% of BCBS PPO Rate,34.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.91,60,,65.528,Percent of Total Billed Charges,60% of Total Billed Charges,8.15,100,,,Fee Schedule,100% of TX Mediciad 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,8.72,90,,,Fee Schedule,90% of CMS OPPS Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,12.61,130,,,Fee Schedule,130% of CMS OPPS Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.39,103,,,Fee Schedule,103% of TX Medicaid Rate,9.99,103,,,Fee Schedule,103% of CMS OPPS Rate,9.99,103,,,Fee Schedule,103% of CMS OPPS Rate,102.39,75,,76.32,Percent of Total Billed Charges,75% of Total Billed Charges,16.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,16.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,16.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,16.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,14.55,150,,,Fee Schedule,150% of CMS OPPS Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,7.86,90,,,Fee Schedule,90% of UHC fee schedule,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,8.15,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,136.52,100,,101.76,Percent of Total Billed Charges,100% of Total Billed Charges,7.86,136.52,
HUMAN GROWTH HORMONE HGH,70030036,CDM,301,RC,83003,HCPCS,Outpatient,,,182,109.20,,19.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,25,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,46.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,60.01,360,,,Fee Schedule,360% of BCBS POS Rate,60.01,360,,,Fee schedule,360% of BCBS PPO Rate,60.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.2,60,,87.36,Percent of Total Billed Charges,60% of Total Billed Charges,14,100,,,Fee Schedule,100% of TX Mediciad 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,15,90,,,Fee Schedule,90% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,130,,,Fee Schedule,130% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14.42,103,,,Fee Schedule,103% of TX Medicaid Rate,17.17,103,,,Fee Schedule,103% of CMS OPPS Rate,17.17,103,,,Fee Schedule,103% of CMS OPPS Rate,136.5,75,,83.92,Percent of Total Billed Charges,75% of Total Billed Charges,28.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,28.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25,150,,,Fee Schedule,150% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,90,,,Fee Schedule,90% of UHC fee schedule,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,14,100,,,Fee Schedule,100% of TX Medicaid Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,111.888,Percent of Total Billed Charges,100% of Total Billed Charges,13.5,182,
HAPTOGLOBIN QUANTITATIVE,70030101,CDM,301,RC,83010,HCPCS,Outpatient,,,179.77,107.86,,14.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,45.29,360,,,Fee Schedule,360% of BCBS POS Rate,45.29,360,,,Fee schedule,360% of BCBS PPO Rate,45.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.86,60,,86.288,Percent of Total Billed Charges,60% of Total Billed Charges,10.57,100,,,Fee Schedule,100% of TX Mediciad 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,11.32,90,,,Fee Schedule,90% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,16.35,130,,,Fee Schedule,130% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.89,103,,,Fee Schedule,103% of TX Medicaid Rate,12.95,103,,,Fee Schedule,103% of CMS OPPS Rate,12.95,103,,,Fee Schedule,103% of CMS OPPS Rate,134.83,75,,43.672,Percent of Total Billed Charges,75% of Total Billed Charges,21.38,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.38,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.38,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.87,150,,,Fee Schedule,150% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.19,90,,,Fee Schedule,90% of UHC fee schedule,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,10.57,100,,,Fee Schedule,100% of TX Medicaid Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,179.77,100,,58.224,Percent of Total Billed Charges,100% of Total Billed Charges,10.19,179.77,
SICKLE CELL TEST,70030523,CDM,305,RC,85660,HCPCS,Outpatient,,,96.5,57.90,,6.4,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.63,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,19.84,360,,,Fee Schedule,360% of BCBS POS Rate,19.84,360,,,Fee schedule,360% of BCBS PPO Rate,19.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,57.9,60,,46.32,Percent of Total Billed Charges,60% of Total Billed Charges,4.63,100,,,Fee Schedule,100% of TX Mediciad 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,4.95,90,,,Fee Schedule,90% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.16,130,,,Fee Schedule,130% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.77,103,,,Fee Schedule,103% of TX Medicaid Rate,5.67,103,,,Fee Schedule,103% of CMS OPPS Rate,5.67,103,,,Fee Schedule,103% of CMS OPPS Rate,72.38,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,9.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.26,150,,,Fee Schedule,150% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.46,90,,,Fee Schedule,90% of UHC fee schedule,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,4.63,100,,,Fee Schedule,100% of TX Medicaid Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.5,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,4.46,96.5,
NUC ACD HIV1 QT,70030846,CDM,306,RC,87536,HCPCS,Outpatient,,,714,428.40,,98.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,127.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,238.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,272.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,306.36,360,,,Fee Schedule,360% of BCBS POS Rate,306.36,360,,,Fee schedule,360% of BCBS PPO Rate,306.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,428.4,60,,342.72,Percent of Total Billed Charges,60% of Total Billed Charges,71.48,100,,,Fee Schedule,100% of TX Mediciad 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,76.58,90,,,Fee Schedule,90% of CMS OPPS Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,110.63,130,,,Fee Schedule,130% of CMS OPPS Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,73.62,103,,,Fee Schedule,103% of TX Medicaid Rate,87.65,103,,,Fee Schedule,103% of CMS OPPS Rate,87.65,103,,,Fee Schedule,103% of CMS OPPS Rate,535.5,75,,52.384,Percent of Total Billed Charges,75% of Total Billed Charges,144.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,144.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,144.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,144.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,127.65,150,,,Fee Schedule,150% of CMS OPPS Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,68.93,90,,,Fee Schedule,90% of UHC fee schedule,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,71.48,100,,,Fee Schedule,100% of TX Medicaid Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,714,100,,69.84,Percent of Total Billed Charges,100% of Total Billed Charges,68.93,714,
HISTAMINE,70030887,CDM,301,RC,83088,HCPCS,Outpatient,,,296.71,178.03,,34.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,44.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,82.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,94.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,106.31,360,,,Fee Schedule,360% of BCBS POS Rate,106.31,360,,,Fee schedule,360% of BCBS PPO Rate,106.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,178.03,60,,142.424,Percent of Total Billed Charges,60% of Total Billed Charges,24.81,100,,,Fee Schedule,100% of TX Mediciad 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,26.57,90,,,Fee Schedule,90% of CMS OPPS Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,38.38,130,,,Fee Schedule,130% of CMS OPPS Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,25.55,103,,,Fee Schedule,103% of TX Medicaid Rate,30.41,103,,,Fee Schedule,103% of CMS OPPS Rate,30.41,103,,,Fee Schedule,103% of CMS OPPS Rate,222.53,75,,13.024,Percent of Total Billed Charges,75% of Total Billed Charges,50.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,50.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,50.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,44.29,150,,,Fee Schedule,150% of CMS OPPS Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,90,,,Fee Schedule,90% of UHC fee schedule,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,24.81,100,,,Fee Schedule,100% of TX Medicaid Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,296.71,100,,17.36,Percent of Total Billed Charges,100% of Total Billed Charges,23.92,296.71,
HOMOCYSTEINE,70030895,CDM,301,RC,83090,HCPCS,Outpatient,,,264.59,158.75,,20.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.88,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,50.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,64.51,360,,,Fee Schedule,360% of BCBS POS Rate,64.51,360,,,Fee schedule,360% of BCBS PPO Rate,64.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,158.75,60,,127,Percent of Total Billed Charges,60% of Total Billed Charges,15.05,100,,,Fee Schedule,100% of TX Mediciad 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,16.12,90,,,Fee Schedule,90% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,130,,,Fee Schedule,130% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,103,,,Fee Schedule,103% of TX Medicaid Rate,18.45,103,,,Fee Schedule,103% of CMS OPPS Rate,18.45,103,,,Fee Schedule,103% of CMS OPPS Rate,198.44,75,,158.752,Percent of Total Billed Charges,75% of Total Billed Charges,30.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,30.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.88,150,,,Fee Schedule,150% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14.52,90,,,Fee Schedule,90% of UHC fee schedule,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,15.05,100,,,Fee Schedule,100% of TX Medicaid Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,264.59,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,14.52,264.59,
5 - HIAA,70034970,CDM,301,RC,83497,HCPCS,Outpatient,,,159.2,95.52,,14.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,36.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,46.44,360,,,Fee Schedule,360% of BCBS POS Rate,46.44,360,,,Fee schedule,360% of BCBS PPO Rate,46.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.52,60,,76.416,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,100,,,Fee Schedule,100% of TX Mediciad 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,11.61,90,,,Fee Schedule,90% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,130,,,Fee Schedule,130% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,11.17,103,,,Fee Schedule,103% of TX Medicaid Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,119.4,75,,95.52,Percent of Total Billed Charges,75% of Total Billed Charges,21.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.35,150,,,Fee Schedule,150% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.45,90,,,Fee Schedule,90% of UHC fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,159.2,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.45,159.2,
FOLIC ACID RBC,70035126,CDM,301,RC,82784,HCPCS,Outpatient,,,147.33,88.40,,10.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,33.48,360,,,Fee Schedule,360% of BCBS POS Rate,33.48,360,,,Fee schedule,360% of BCBS PPO Rate,33.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.4,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of TX Mediciad 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,8.37,90,,,Fee Schedule,90% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,130,,,Fee Schedule,130% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,8.04,103,,,Fee Schedule,103% of TX Medicaid Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.5,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.95,150,,,Fee Schedule,150% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,90,,,Fee Schedule,90% of UHC fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,147.33,100,,1758.376,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,147.33,
FOLIC ACID RBC,70035142,CDM,301,RC,82784,HCPCS,Outpatient,,,147.33,88.40,,10.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,33.48,360,,,Fee Schedule,360% of BCBS POS Rate,33.48,360,,,Fee schedule,360% of BCBS PPO Rate,33.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.4,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of TX Mediciad 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,8.37,90,,,Fee Schedule,90% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,130,,,Fee Schedule,130% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,8.04,103,,,Fee Schedule,103% of TX Medicaid Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.5,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.95,150,,,Fee Schedule,150% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,90,,,Fee Schedule,90% of UHC fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,147.33,100,,2203.288,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,147.33,
FOLIC ACID RBC,70035159,CDM,301,RC,82784,HCPCS,Outpatient,,,147.33,88.40,,10.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,33.48,360,,,Fee Schedule,360% of BCBS POS Rate,33.48,360,,,Fee schedule,360% of BCBS PPO Rate,33.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.4,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of TX Mediciad 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,8.37,90,,,Fee Schedule,90% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,130,,,Fee Schedule,130% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,8.04,103,,,Fee Schedule,103% of TX Medicaid Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.5,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.95,150,,,Fee Schedule,150% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,90,,,Fee Schedule,90% of UHC fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,147.33,100,,2843.256,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,147.33,
INSULIN TOTAL,70035258,CDM,301,RC,83525,HCPCS,Outpatient,,,153.45,92.07,,13.26,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,41.15,360,,,Fee Schedule,360% of BCBS POS Rate,41.15,360,,,Fee schedule,360% of BCBS PPO Rate,41.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,92.07,60,,73.656,Percent of Total Billed Charges,60% of Total Billed Charges,9.6,100,,,Fee Schedule,100% of TX Mediciad 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,10.28,90,,,Fee Schedule,90% of CMS OPPS Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,14.85,130,,,Fee Schedule,130% of CMS OPPS Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.89,103,,,Fee Schedule,103% of TX Medicaid Rate,11.77,103,,,Fee Schedule,103% of CMS OPPS Rate,11.77,103,,,Fee Schedule,103% of CMS OPPS Rate,115.09,75,,92.072,Percent of Total Billed Charges,75% of Total Billed Charges,19.43,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.43,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,19.43,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.43,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.14,150,,,Fee Schedule,150% of CMS OPPS Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,90,,,Fee Schedule,90% of UHC fee schedule,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,9.6,100,,,Fee Schedule,100% of TX Medicaid Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,100,,632.24,Percent of Total Billed Charges,100% of Total Billed Charges,9.26,153.45,
T3 BY RIA,70035399,CDM,301,RC,84480,HCPCS,Outpatient,,,194,116.40,,16.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,51.05,360,,,Fee Schedule,360% of BCBS POS Rate,51.05,360,,,Fee schedule,360% of BCBS PPO Rate,51.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,116.4,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,100,,,Fee Schedule,100% of TX Mediciad 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,12.76,90,,,Fee Schedule,90% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,130,,,Fee Schedule,130% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,12.27,103,,,Fee Schedule,103% of TX Medicaid Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,145.5,75,,116.4,Percent of Total Billed Charges,75% of Total Billed Charges,24.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.27,150,,,Fee Schedule,150% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,90,,,Fee Schedule,90% of UHC fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,194,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,11.48,194,
EIA QL HIV1 & HIV2 ANTIBODY,70036174,CDM,306,RC,87389,HCPCS,Outpatient,,,203.21,121.93,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,67.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,86.69,360,,,Fee Schedule,360% of BCBS POS Rate,86.69,360,,,Fee schedule,360% of BCBS PPO Rate,86.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,121.93,60,,97.544,Percent of Total Billed Charges,60% of Total Billed Charges,20.23,100,,,Fee Schedule,100% of TX Mediciad 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,21.67,90,,,Fee Schedule,90% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.3,130,,,Fee Schedule,130% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.84,103,,,Fee Schedule,103% of TX Medicaid Rate,24.8,103,,,Fee Schedule,103% of CMS OPPS Rate,24.8,103,,,Fee Schedule,103% of CMS OPPS Rate,152.41,75,,121.928,Percent of Total Billed Charges,75% of Total Billed Charges,40.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.11,150,,,Fee Schedule,150% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,90,,,Fee Schedule,90% of UHC fee schedule,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,20.23,100,,,Fee Schedule,100% of TX Medicaid Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,203.21,100,,1485.208,Percent of Total Billed Charges,100% of Total Billed Charges,19.5,203.21,
LEAD LEVEL BLOOD,70036553,CDM,301,RC,83655,HCPCS,Outpatient,,,134.77,80.86,,14.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,33.91,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.75,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,43.6,360,,,Fee Schedule,360% of BCBS POS Rate,43.6,360,,,Fee schedule,360% of BCBS PPO Rate,43.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,80.86,60,,64.688,Percent of Total Billed Charges,60% of Total Billed Charges,10.17,100,,,Fee Schedule,100% of TX Mediciad 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,10.89,90,,,Fee Schedule,90% of CMS OPPS Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.48,103,,,Fee Schedule,103% of TX Medicaid Rate,12.47,103,,,Fee Schedule,103% of CMS OPPS Rate,12.47,103,,,Fee Schedule,103% of CMS OPPS Rate,101.08,75,,80.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.58,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.58,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.58,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.58,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.16,150,,,Fee Schedule,150% of CMS OPPS Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.81,90,,,Fee Schedule,90% of UHC fee schedule,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,10.17,100,,,Fee Schedule,100% of TX Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,134.77,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,9.81,134.77,
LIPOPROTEIN (A),70037163,CDM,300,RC,83695,HCPCS,Outpatient,,,69.2,41.52,,16.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,51.55,360,,,Fee Schedule,360% of BCBS POS Rate,51.55,360,,,Fee schedule,360% of BCBS PPO Rate,51.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,41.52,60,,33.216,Percent of Total Billed Charges,60% of Total Billed Charges,12.03,100,,,Fee Schedule,100% of TX Mediciad 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,12.88,90,,,Fee Schedule,90% of CMS OPPS Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,18.61,130,,,Fee Schedule,130% of CMS OPPS Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,103,,,Fee Schedule,103% of TX Medicaid Rate,14.74,103,,,Fee Schedule,103% of CMS OPPS Rate,14.74,103,,,Fee Schedule,103% of CMS OPPS Rate,51.9,75,,41.52,Percent of Total Billed Charges,75% of Total Billed Charges,24.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.48,150,,,Fee Schedule,150% of CMS OPPS Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,11.6,90,,,Fee Schedule,90% of UHC fee schedule,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,12.03,100,,,Fee Schedule,100% of TX Medicaid Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,69.2,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,11.6,69.2,
MERCURY,70038252,CDM,301,RC,83825,HCPCS,Outpatient,,,163.18,97.91,,18.86,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.39,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,45.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,52.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,58.54,360,,,Fee Schedule,360% of BCBS POS Rate,58.54,360,,,Fee schedule,360% of BCBS PPO Rate,58.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,97.91,60,,78.328,Percent of Total Billed Charges,60% of Total Billed Charges,13.66,100,,,Fee Schedule,100% of TX Mediciad 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,14.63,90,,,Fee Schedule,90% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.13,130,,,Fee Schedule,130% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,14.07,103,,,Fee Schedule,103% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of CMS OPPS Rate,16.74,103,,,Fee Schedule,103% of CMS OPPS Rate,122.39,75,,97.912,Percent of Total Billed Charges,75% of Total Billed Charges,27.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,27.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.39,150,,,Fee Schedule,150% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13.17,90,,,Fee Schedule,90% of UHC fee schedule,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,13.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,163.18,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,13.17,163.18,
METANEPHRINES,70038351,CDM,301,RC,83835,HCPCS,Outpatient,,,261.71,157.03,,19.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,47.43,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,60.98,360,,,Fee Schedule,360% of BCBS POS Rate,60.98,360,,,Fee schedule,360% of BCBS PPO Rate,60.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,157.03,60,,125.624,Percent of Total Billed Charges,60% of Total Billed Charges,14.23,100,,,Fee Schedule,100% of TX Mediciad 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,15.24,90,,,Fee Schedule,90% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.02,130,,,Fee Schedule,130% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.66,103,,,Fee Schedule,103% of TX Medicaid Rate,17.44,103,,,Fee Schedule,103% of CMS OPPS Rate,17.44,103,,,Fee Schedule,103% of CMS OPPS Rate,196.28,75,,157.024,Percent of Total Billed Charges,75% of Total Billed Charges,28.79,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.79,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.79,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.79,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.41,150,,,Fee Schedule,150% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,90,,,Fee Schedule,90% of UHC fee schedule,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,14.23,100,,,Fee Schedule,100% of TX Medicaid Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,13.73,261.71,
METHYLMALONIC ACID,70038542,CDM,301,RC,83921,HCPCS,Outpatient,,,1538.78,923.27,,24.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,59.39,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.87,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,76.36,360,,,Fee Schedule,360% of BCBS POS Rate,76.36,360,,,Fee schedule,360% of BCBS PPO Rate,76.36,360,,,Fee Schedule,360% of BCBS Traditional Rate,923.27,60,,738.616,Percent of Total Billed Charges,60% of Total Billed Charges,17.82,100,,,Fee Schedule,100% of TX Mediciad 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,19.08,90,,,Fee Schedule,90% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,27.57,130,,,Fee Schedule,130% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,18.35,103,,,Fee Schedule,103% of TX Medicaid Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,21.84,103,,,Fee Schedule,103% of CMS OPPS Rate,1154.09,75,,923.272,Percent of Total Billed Charges,75% of Total Billed Charges,36.05,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.05,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,36.05,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.05,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.81,150,,,Fee Schedule,150% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,17.18,90,,,Fee Schedule,90% of UHC fee schedule,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of TX Medicaid Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.78,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,17.18,1538.78,
METHOTREXATE LEVEL,70038609,CDM,301,RC,80299,HCPCS,Outpatient,,,203.83,122.30,,21.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,59.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,67.1,360,,,Fee Schedule,360% of BCBS POS Rate,67.1,360,,,Fee schedule,360% of BCBS PPO Rate,67.1,360,,,Fee Schedule,360% of BCBS Traditional Rate,122.3,60,,97.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.66,100,,,Fee Schedule,100% of TX Mediciad 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,16.77,90,,,Fee Schedule,90% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.23,130,,,Fee Schedule,130% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,16.13,103,,,Fee Schedule,103% of TX Medicaid Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,19.19,103,,,Fee Schedule,103% of CMS OPPS Rate,152.87,75,,122.296,Percent of Total Billed Charges,75% of Total Billed Charges,31.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.96,150,,,Fee Schedule,150% of CMS OPPS Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,90,,,Fee Schedule,90% of UHC fee schedule,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,15.66,100,,,Fee Schedule,100% of TX Medicaid Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,203.83,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,15.1,203.83,
MYOGLOBIN,70038732,CDM,301,RC,83874,HCPCS,Outpatient,,,198,118.80,,14.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.38,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,36.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,46.51,360,,,Fee Schedule,360% of BCBS POS Rate,46.51,360,,,Fee schedule,360% of BCBS PPO Rate,46.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.8,60,,95.04,Percent of Total Billed Charges,60% of Total Billed Charges,10.85,100,,,Fee Schedule,100% of TX Mediciad 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,11.62,90,,,Fee Schedule,90% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,16.79,130,,,Fee Schedule,130% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,11.18,103,,,Fee Schedule,103% of TX Medicaid Rate,13.3,103,,,Fee Schedule,103% of CMS OPPS Rate,13.3,103,,,Fee Schedule,103% of CMS OPPS Rate,148.5,75,,118.8,Percent of Total Billed Charges,75% of Total Billed Charges,21.96,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.96,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.96,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.38,150,,,Fee Schedule,150% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,90,,,Fee Schedule,90% of UHC fee schedule,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,198,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.47,198,
MYELIN BASIC PROTEIN CSF,70038740,CDM,301,RC,83873,HCPCS,Outpatient,,,239.72,143.83,,19.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.8,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.04,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,61.92,360,,,Fee Schedule,360% of BCBS POS Rate,61.92,360,,,Fee schedule,360% of BCBS PPO Rate,61.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.83,60,,115.064,Percent of Total Billed Charges,60% of Total Billed Charges,14.45,100,,,Fee Schedule,100% of TX Mediciad 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,15.48,90,,,Fee Schedule,90% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,22.36,130,,,Fee Schedule,130% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.88,103,,,Fee Schedule,103% of TX Medicaid Rate,17.71,103,,,Fee Schedule,103% of CMS OPPS Rate,17.71,103,,,Fee Schedule,103% of CMS OPPS Rate,179.79,75,,143.832,Percent of Total Billed Charges,75% of Total Billed Charges,29.24,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.24,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,29.24,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.24,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.8,150,,,Fee Schedule,150% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,90,,,Fee Schedule,90% of UHC fee schedule,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,14.45,100,,,Fee Schedule,100% of TX Medicaid Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,239.72,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,13.93,239.72,
MYOGLOBIN URINE,70038757,CDM,301,RC,83874,HCPCS,Outpatient,,,198,118.80,,14.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.38,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,36.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,46.51,360,,,Fee Schedule,360% of BCBS POS Rate,46.51,360,,,Fee schedule,360% of BCBS PPO Rate,46.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,118.8,60,,95.04,Percent of Total Billed Charges,60% of Total Billed Charges,10.85,100,,,Fee Schedule,100% of TX Mediciad 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,11.62,90,,,Fee Schedule,90% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,16.79,130,,,Fee Schedule,130% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,11.18,103,,,Fee Schedule,103% of TX Medicaid Rate,13.3,103,,,Fee Schedule,103% of CMS OPPS Rate,13.3,103,,,Fee Schedule,103% of CMS OPPS Rate,148.5,75,,118.8,Percent of Total Billed Charges,75% of Total Billed Charges,21.96,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.96,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.96,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.38,150,,,Fee Schedule,150% of CMS OPPS Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,90,,,Fee Schedule,90% of UHC fee schedule,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,10.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,198,100,,632.24,Percent of Total Billed Charges,100% of Total Billed Charges,10.47,198,
PARATHYROID HORMONE,70039029,CDM,301,RC,83970,HCPCS,Outpatient,,,360,216.00,,47.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,61.92,150,,,Fee Schedule ,150% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,132.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,148.61,360,,,Fee Schedule,360% of BCBS POS Rate,148.61,360,,,Fee schedule,360% of BCBS PPO Rate,148.61,360,,,Fee Schedule,360% of BCBS Traditional Rate,216,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,34.68,100,,,Fee Schedule,100% of TX Mediciad 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,37.15,90,,,Fee Schedule,90% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,53.66,130,,,Fee Schedule,130% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.72,103,,,Fee Schedule,103% of TX Medicaid Rate,42.51,103,,,Fee Schedule,103% of CMS OPPS Rate,42.51,103,,,Fee Schedule,103% of CMS OPPS Rate,270,75,,216,Percent of Total Billed Charges,75% of Total Billed Charges,70.17,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,70.17,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,70.17,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,70.17,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,61.92,150,,,Fee Schedule,150% of CMS OPPS Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,33.44,90,,,Fee Schedule,90% of UHC fee schedule,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,34.68,100,,,Fee Schedule,100% of TX Medicaid Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,360,100,,764.76,Percent of Total Billed Charges,100% of Total Billed Charges,33.44,360,
NUC ACD HEP C GENOTYPE,70039177,CDM,306,RC,87902,HCPCS,Outpatient,,,1100.32,660.19,,298.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,386.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,720.86,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,823.84,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,926.82,360,,,Fee Schedule,360% of BCBS POS Rate,926.82,360,,,Fee schedule,360% of BCBS PPO Rate,926.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,660.19,60,,528.152,Percent of Total Billed Charges,60% of Total Billed Charges,216.26,100,,,Fee Schedule,100% of TX Mediciad 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,231.7,90,,,Fee Schedule,90% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,334.68,130,,,Fee Schedule,130% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,222.75,103,,,Fee Schedule,103% of TX Medicaid Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,265.17,103,,,Fee Schedule,103% of CMS OPPS Rate,825.24,75,,660.192,Percent of Total Billed Charges,75% of Total Billed Charges,437.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,437.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,437.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,437.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,386.17,150,,,Fee Schedule,150% of CMS OPPS Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,208.54,90,,,Fee Schedule,90% of UHC fee schedule,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,216.26,100,,,Fee Schedule,100% of TX Medicaid Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1100.32,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,208.54,1100.32,
OLIGOCLONAL BANDS,70039250,CDM,301,RC,83916,HCPCS,Outpatient,,,238.67,143.20,,31.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,41.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,76.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,87.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,98.6,360,,,Fee Schedule,360% of BCBS POS Rate,98.6,360,,,Fee schedule,360% of BCBS PPO Rate,98.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.2,60,,114.56,Percent of Total Billed Charges,60% of Total Billed Charges,23.01,100,,,Fee Schedule,100% of TX Mediciad 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,24.65,90,,,Fee Schedule,90% of CMS OPPS Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,130,,,Fee Schedule,130% of CMS OPPS Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.7,103,,,Fee Schedule,103% of TX Medicaid Rate,28.21,103,,,Fee Schedule,103% of CMS OPPS Rate,28.21,103,,,Fee Schedule,103% of CMS OPPS Rate,179,75,,143.2,Percent of Total Billed Charges,75% of Total Billed Charges,46.56,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,46.56,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.56,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,46.56,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,41.08,150,,,Fee Schedule,150% of CMS OPPS Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,22.19,90,,,Fee Schedule,90% of UHC fee schedule,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,23.01,100,,,Fee Schedule,100% of TX Medicaid Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,238.67,100,,1485.208,Percent of Total Billed Charges,100% of Total Billed Charges,22.19,238.67,
C PEPTIDE,70039763,CDM,301,RC,84681,HCPCS,Outpatient,,,199,119.40,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,119.4,60,,95.52,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,149.25,75,,119.4,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,199,100,,1758.376,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,199,
FACTOR V LEIDEN MUTATION,70039912,CDM,310,RC,81241,HCPCS,Outpatient,,,472.27,283.36,,85.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,110.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,234.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,264.13,360,,,Fee Schedule,360% of BCBS POS Rate,264.13,360,,,Fee schedule,360% of BCBS PPO Rate,264.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,283.36,60,,226.688,Percent of Total Billed Charges,60% of Total Billed Charges,61.63,100,,,Fee Schedule,100% of TX Mediciad 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,66.03,90,,,Fee Schedule,90% of CMS OPPS Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,95.38,130,,,Fee Schedule,130% of CMS OPPS Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,63.48,103,,,Fee Schedule,103% of TX Medicaid Rate,75.57,103,,,Fee Schedule,103% of CMS OPPS Rate,75.57,103,,,Fee Schedule,103% of CMS OPPS Rate,354.2,75,,283.36,Percent of Total Billed Charges,75% of Total Billed Charges,124.72,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,124.72,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,124.72,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,124.72,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,110.05,150,,,Fee Schedule,150% of CMS OPPS Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.43,90,,,Fee Schedule,90% of UHC fee schedule,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,61.63,100,,,Fee Schedule,100% of TX Medicaid Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,472.27,100,,2203.288,Percent of Total Billed Charges,100% of Total Billed Charges,59.43,472.27,
PROTHROMBIN G20210A MUTATION,70039920,CDM,310,RC,81240,HCPCS,Outpatient,,,848.12,508.87,,76.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,98.53,150,,,Fee Schedule ,150% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,183.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,210.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,236.48,360,,,Fee Schedule,360% of BCBS POS Rate,236.48,360,,,Fee schedule,360% of BCBS PPO Rate,236.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,508.87,60,,407.096,Percent of Total Billed Charges,60% of Total Billed Charges,55.18,100,,,Fee Schedule,100% of TX Mediciad 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,59.12,90,,,Fee Schedule,90% of CMS OPPS Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,85.39,130,,,Fee Schedule,130% of CMS OPPS Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,56.84,103,,,Fee Schedule,103% of TX Medicaid Rate,67.66,103,,,Fee Schedule,103% of CMS OPPS Rate,67.66,103,,,Fee Schedule,103% of CMS OPPS Rate,636.09,75,,508.872,Percent of Total Billed Charges,75% of Total Billed Charges,111.67,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,111.67,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,111.67,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,111.67,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,98.53,150,,,Fee Schedule,150% of CMS OPPS Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,53.21,90,,,Fee Schedule,90% of UHC fee schedule,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,55.18,100,,,Fee Schedule,100% of TX Medicaid Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,848.12,100,,2843.256,Percent of Total Billed Charges,100% of Total Billed Charges,53.21,848.12,
NEONATAL SCREEN,70040308,CDM,301,RC,84030,HCPCS,Outpatient,,,117.8,70.68,,6.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,360,,,Fee Schedule,360% of BCBS POS Rate,19.8,360,,,Fee schedule,360% of BCBS PPO Rate,19.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.68,60,,56.544,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,100,,,Fee Schedule,100% of TX Mediciad 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,4.95,90,,,Fee Schedule,90% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,130,,,Fee Schedule,130% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,103,,,Fee Schedule,103% of TX Medicaid Rate,5.66,103,,,Fee Schedule,103% of CMS OPPS Rate,5.66,103,,,Fee Schedule,103% of CMS OPPS Rate,88.35,75,,70.68,Percent of Total Billed Charges,75% of Total Billed Charges,9.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.25,150,,,Fee Schedule,150% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.46,90,,,Fee Schedule,90% of UHC fee schedule,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,117.8,100,,764.76,Percent of Total Billed Charges,100% of Total Billed Charges,4.46,117.8,
PHENYTOIN (DILANTIN) FREE,70040456,CDM,301,RC,80186,HCPCS,Outpatient,,,157.11,94.27,,15.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.64,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,49.54,360,,,Fee Schedule,360% of BCBS POS Rate,49.54,360,,,Fee schedule,360% of BCBS PPO Rate,49.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,94.27,60,,75.416,Percent of Total Billed Charges,60% of Total Billed Charges,11.56,100,,,Fee Schedule,100% of TX Mediciad 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,12.38,90,,,Fee Schedule,90% of CMS OPPS Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.88,130,,,Fee Schedule,130% of CMS OPPS Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of TX Medicaid Rate,14.17,103,,,Fee Schedule,103% of CMS OPPS Rate,14.17,103,,,Fee Schedule,103% of CMS OPPS Rate,117.83,75,,94.264,Percent of Total Billed Charges,75% of Total Billed Charges,23.39,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.39,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.39,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.39,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.64,150,,,Fee Schedule,150% of CMS OPPS Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,11.14,90,,,Fee Schedule,90% of UHC fee schedule,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,11.56,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,157.11,100,,125.688,Percent of Total Billed Charges,100% of Total Billed Charges,11.14,157.11,
PHOSPHATASE ALKALINE ISOENZYME,70040803,CDM,301,RC,84080,HCPCS,Outpatient,,,144,86.40,,17.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,41.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,53.21,360,,,Fee Schedule,360% of BCBS POS Rate,53.21,360,,,Fee schedule,360% of BCBS PPO Rate,53.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.4,60,,69.12,Percent of Total Billed Charges,60% of Total Billed Charges,12.42,100,,,Fee Schedule,100% of TX Mediciad 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,13.3,90,,,Fee Schedule,90% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,19.21,130,,,Fee Schedule,130% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,103,,,Fee Schedule,103% of TX Medicaid Rate,15.22,103,,,Fee Schedule,103% of CMS OPPS Rate,15.22,103,,,Fee Schedule,103% of CMS OPPS Rate,108,75,,86.4,Percent of Total Billed Charges,75% of Total Billed Charges,25.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.17,150,,,Fee Schedule,150% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,11.97,90,,,Fee Schedule,90% of UHC fee schedule,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,144,100,,115.2,Percent of Total Billed Charges,100% of Total Billed Charges,11.97,144,
URIC ACID BODY FLUID,70041026,CDM,301,RC,84560,HCPCS,Outpatient,,,110,66.00,,5.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,14.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,18.29,360,,,Fee Schedule,360% of BCBS POS Rate,18.29,360,,,Fee schedule,360% of BCBS PPO Rate,18.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,66,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,100,,,Fee Schedule,100% of TX Mediciad 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,4.57,90,,,Fee Schedule,90% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.6,130,,,Fee Schedule,130% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,103,,,Fee Schedule,103% of TX Medicaid Rate,5.23,103,,,Fee Schedule,103% of CMS OPPS Rate,5.23,103,,,Fee Schedule,103% of CMS OPPS Rate,82.5,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,8.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.62,150,,,Fee Schedule,150% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,4.11,90,,,Fee Schedule,90% of UHC fee schedule,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,110,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,4.11,110,
"PORPHOBILN,UR,QN",70041108,CDM,301,RC,84110,HCPCS,Outpatient,,,117,70.20,,9.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.66,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,30.38,360,,,Fee Schedule,360% of BCBS POS Rate,30.38,360,,,Fee schedule,360% of BCBS PPO Rate,30.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,70.2,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,7.09,100,,,Fee Schedule,100% of TX Mediciad 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,7.59,90,,,Fee Schedule,90% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,130,,,Fee Schedule,130% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.3,103,,,Fee Schedule,103% of TX Medicaid Rate,8.69,103,,,Fee Schedule,103% of CMS OPPS Rate,8.69,103,,,Fee Schedule,103% of CMS OPPS Rate,87.75,75,,70.2,Percent of Total Billed Charges,75% of Total Billed Charges,14.34,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.34,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.34,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.66,150,,,Fee Schedule,150% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,6.84,90,,,Fee Schedule,90% of UHC fee schedule,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,7.09,100,,,Fee Schedule,100% of TX Medicaid Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,117,100,,93.6,Percent of Total Billed Charges,100% of Total Billed Charges,6.84,117,
"PORPHYRINS, URINE QUANT/F",70041207,CDM,301,RC,84120,HCPCS,Outpatient,,,189.05,113.43,,17.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.06,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41.19,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.07,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,52.96,360,,,Fee Schedule,360% of BCBS POS Rate,52.96,360,,,Fee schedule,360% of BCBS PPO Rate,52.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,113.43,60,,90.744,Percent of Total Billed Charges,60% of Total Billed Charges,12.36,100,,,Fee Schedule,100% of TX Mediciad 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,13.23,90,,,Fee Schedule,90% of CMS OPPS Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,19.12,130,,,Fee Schedule,130% of CMS OPPS Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.73,103,,,Fee Schedule,103% of TX Medicaid Rate,15.15,103,,,Fee Schedule,103% of CMS OPPS Rate,15.15,103,,,Fee Schedule,103% of CMS OPPS Rate,141.79,75,,113.432,Percent of Total Billed Charges,75% of Total Billed Charges,25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.06,150,,,Fee Schedule,150% of CMS OPPS Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,90,,,Fee Schedule,90% of UHC fee schedule,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,12.36,100,,,Fee Schedule,100% of TX Medicaid Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,189.05,100,,151.24,Percent of Total Billed Charges,100% of Total Billed Charges,11.92,189.05,
POTASSIUM STOOL,70041355,CDM,301,RC,84999,HCPCS,Outpatient,,,122.87,73.72,,73.72,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.72,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.72,14.42,,14.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.15,75,,73.72,Percent of Total Billed Charges,75% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.87,100,,98.296,Percent of Total Billed Charges,100% of Total Billed Charges,17.2,122.87,
SERUM PROTEIN ELECTROPHOR,70041652,CDM,301,RC,84165,HCPCS,Outpatient,,,179.28,107.57,,12.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.11,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,30.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,38.66,360,,,Fee Schedule,360% of BCBS POS Rate,38.66,360,,,Fee schedule,360% of BCBS PPO Rate,38.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.57,60,,86.056,Percent of Total Billed Charges,60% of Total Billed Charges,9.02,100,,,Fee Schedule,100% of TX Mediciad 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,9.66,90,,,Fee Schedule,90% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.96,130,,,Fee Schedule,130% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.29,103,,,Fee Schedule,103% of TX Medicaid Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,11.06,103,,,Fee Schedule,103% of CMS OPPS Rate,134.46,75,,107.568,Percent of Total Billed Charges,75% of Total Billed Charges,18.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,18.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,16.11,150,,,Fee Schedule,150% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.7,90,,,Fee Schedule,90% of UHC fee schedule,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,9.02,100,,,Fee Schedule,100% of TX Medicaid Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,179.28,100,,143.424,Percent of Total Billed Charges,100% of Total Billed Charges,8.7,179.28,
PROTEIN ELECTROPH FRACT OTH FL,70041918,CDM,301,RC,84166,HCPCS,Outpatient,,,173.34,104.00,,20.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,49.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,64.19,360,,,Fee Schedule,360% of BCBS POS Rate,64.19,360,,,Fee schedule,360% of BCBS PPO Rate,64.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,104,60,,83.2,Percent of Total Billed Charges,60% of Total Billed Charges,14.98,100,,,Fee Schedule,100% of TX Mediciad 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,16.04,90,,,Fee Schedule,90% of CMS OPPS Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.17,130,,,Fee Schedule,130% of CMS OPPS Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,103,,,Fee Schedule,103% of TX Medicaid Rate,18.36,103,,,Fee Schedule,103% of CMS OPPS Rate,18.36,103,,,Fee Schedule,103% of CMS OPPS Rate,130.01,75,,104.008,Percent of Total Billed Charges,75% of Total Billed Charges,30.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.74,150,,,Fee Schedule,150% of CMS OPPS Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,90,,,Fee Schedule,90% of UHC fee schedule,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,14.98,100,,,Fee Schedule,100% of TX Medicaid Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,173.34,100,,138.672,Percent of Total Billed Charges,100% of Total Billed Charges,14.45,173.34,
PSA FREE,70042007,CDM,301,RC,84154,HCPCS,Outpatient,,,182.38,109.43,,21.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,51.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,66.2,360,,,Fee Schedule,360% of BCBS POS Rate,66.2,360,,,Fee schedule,360% of BCBS PPO Rate,66.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.43,60,,87.544,Percent of Total Billed Charges,60% of Total Billed Charges,15.45,100,,,Fee Schedule,100% of TX Mediciad 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,16.55,90,,,Fee Schedule,90% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,23.9,130,,,Fee Schedule,130% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,103,,,Fee Schedule,103% of TX Medicaid Rate,18.94,103,,,Fee Schedule,103% of CMS OPPS Rate,18.94,103,,,Fee Schedule,103% of CMS OPPS Rate,136.79,75,,109.432,Percent of Total Billed Charges,75% of Total Billed Charges,31.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.58,150,,,Fee Schedule,150% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,90,,,Fee Schedule,90% of UHC fee schedule,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,15.45,100,,,Fee Schedule,100% of TX Medicaid Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,182.38,100,,145.904,Percent of Total Billed Charges,100% of Total Billed Charges,14.9,182.38,
VASOACTIVE INTESTINAL POL,70042387,CDM,301,RC,84586,HCPCS,Outpatient,,,369.5,221.70,,40.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.99,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,98.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,113.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,127.19,360,,,Fee Schedule,360% of BCBS POS Rate,127.19,360,,,Fee schedule,360% of BCBS PPO Rate,127.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.7,60,,177.36,Percent of Total Billed Charges,60% of Total Billed Charges,29.68,100,,,Fee Schedule,100% of TX Mediciad 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,31.79,90,,,Fee Schedule,90% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,45.92,130,,,Fee Schedule,130% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,30.57,103,,,Fee Schedule,103% of TX Medicaid Rate,36.38,103,,,Fee Schedule,103% of CMS OPPS Rate,36.38,103,,,Fee Schedule,103% of CMS OPPS Rate,277.13,75,,221.704,Percent of Total Billed Charges,75% of Total Billed Charges,60.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,60.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,60.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,60.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.99,150,,,Fee Schedule,150% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,90,,,Fee Schedule,90% of UHC fee schedule,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,29.68,100,,,Fee Schedule,100% of TX Medicaid Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,369.5,100,,295.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.62,369.5,
"RENIN, PLASMA",70042445,CDM,301,RC,84244,HCPCS,Outpatient,,,242.92,145.75,,25.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,32.98,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,61.57,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,79.16,360,,,Fee Schedule,360% of BCBS POS Rate,79.16,360,,,Fee schedule,360% of BCBS PPO Rate,79.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,145.75,60,,116.6,Percent of Total Billed Charges,60% of Total Billed Charges,18.47,100,,,Fee Schedule,100% of TX Mediciad 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,19.79,90,,,Fee Schedule,90% of CMS OPPS Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,28.58,130,,,Fee Schedule,130% of CMS OPPS Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,19.02,103,,,Fee Schedule,103% of TX Medicaid Rate,22.64,103,,,Fee Schedule,103% of CMS OPPS Rate,22.64,103,,,Fee Schedule,103% of CMS OPPS Rate,182.19,75,,145.752,Percent of Total Billed Charges,75% of Total Billed Charges,37.38,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.38,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,37.38,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.38,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,32.98,150,,,Fee Schedule,150% of CMS OPPS Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,17.81,90,,,Fee Schedule,90% of UHC fee schedule,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,18.47,100,,,Fee Schedule,100% of TX Medicaid Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,242.92,100,,194.336,Percent of Total Billed Charges,100% of Total Billed Charges,17.81,242.92,
SCLERODERMA AB,70042585,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
SEROTONIN,70042601,CDM,301,RC,84260,HCPCS,Outpatient,,,302.41,181.45,,35.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,46.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,86.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,99.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,111.53,360,,,Fee Schedule,360% of BCBS POS Rate,111.53,360,,,Fee schedule,360% of BCBS PPO Rate,111.53,360,,,Fee Schedule,360% of BCBS Traditional Rate,181.45,60,,145.16,Percent of Total Billed Charges,60% of Total Billed Charges,26.02,100,,,Fee Schedule,100% of TX Mediciad 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,27.88,90,,,Fee Schedule,90% of CMS OPPS Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,40.27,130,,,Fee Schedule,130% of CMS OPPS Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.8,103,,,Fee Schedule,103% of TX Medicaid Rate,31.9,103,,,Fee Schedule,103% of CMS OPPS Rate,31.9,103,,,Fee Schedule,103% of CMS OPPS Rate,226.81,75,,181.448,Percent of Total Billed Charges,75% of Total Billed Charges,52.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,52.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,52.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,46.47,150,,,Fee Schedule,150% of CMS OPPS Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,25.09,90,,,Fee Schedule,90% of UHC fee schedule,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,26.02,100,,,Fee Schedule,100% of TX Medicaid Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,302.41,100,,241.928,Percent of Total Billed Charges,100% of Total Billed Charges,25.09,302.41,
SOMATOMEDIN -C,70043005,CDM,301,RC,84305,HCPCS,Outpatient,,,232,139.20,,24.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,59.53,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,68.03,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,76.54,360,,,Fee Schedule,360% of BCBS POS Rate,76.54,360,,,Fee schedule,360% of BCBS PPO Rate,76.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,139.2,60,,111.36,Percent of Total Billed Charges,60% of Total Billed Charges,17.86,100,,,Fee Schedule,100% of TX Mediciad 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,19.13,90,,,Fee Schedule,90% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,27.63,130,,,Fee Schedule,130% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,18.4,103,,,Fee Schedule,103% of TX Medicaid Rate,21.89,103,,,Fee Schedule,103% of CMS OPPS Rate,21.89,103,,,Fee Schedule,103% of CMS OPPS Rate,174,75,,139.2,Percent of Total Billed Charges,75% of Total Billed Charges,36.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,36.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.89,150,,,Fee Schedule,150% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,90,,,Fee Schedule,90% of UHC fee schedule,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,17.86,100,,,Fee Schedule,100% of TX Medicaid Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,232,100,,185.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.22,232,
SODIUM STOOL,70043021,CDM,301,RC,84302,HCPCS,Outpatient,,,82.49,49.49,,5.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,15.55,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,17.5,360,,,Fee Schedule,360% of BCBS POS Rate,17.5,360,,,Fee schedule,360% of BCBS PPO Rate,17.5,360,,,Fee Schedule,360% of BCBS Traditional Rate,49.49,60,,39.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,100,,,Fee Schedule,100% of TX Mediciad 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,4.37,90,,,Fee Schedule,90% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,130,,,Fee Schedule,130% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.2,103,,,Fee Schedule,103% of TX Medicaid Rate,5,103,,,Fee Schedule,103% of CMS OPPS Rate,5,103,,,Fee Schedule,103% of CMS OPPS Rate,61.87,75,,49.496,Percent of Total Billed Charges,75% of Total Billed Charges,8.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.29,150,,,Fee Schedule,150% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,90,,,Fee Schedule,90% of UHC fee schedule,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.08,100,,,Fee Schedule,100% of TX Medicaid Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,82.49,100,,65.992,Percent of Total Billed Charges,100% of Total Billed Charges,3.93,82.49,
"BODY FLUID,SPEC GRAVITY",70043153,CDM,301,RC,84315,HCPCS,Outpatient,,,47.2,28.32,,3.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,4.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,9.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,10.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,11.81,360,,,Fee Schedule,360% of BCBS POS Rate,11.81,360,,,Fee schedule,360% of BCBS PPO Rate,11.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,28.32,60,,22.656,Percent of Total Billed Charges,60% of Total Billed Charges,2.76,100,,,Fee Schedule,100% of TX Mediciad 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,2.95,90,,,Fee Schedule,90% of CMS OPPS Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,130,,,Fee Schedule,130% of CMS OPPS Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.84,103,,,Fee Schedule,103% of TX Medicaid Rate,3.37,103,,,Fee Schedule,103% of CMS OPPS Rate,3.37,103,,,Fee Schedule,103% of CMS OPPS Rate,35.4,75,,28.32,Percent of Total Billed Charges,75% of Total Billed Charges,5.57,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,5.57,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,5.57,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,4.91,150,,,Fee Schedule,150% of CMS OPPS Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.66,90,,,Fee Schedule,90% of UHC fee schedule,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,2.76,100,,,Fee Schedule,100% of TX Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,47.2,100,,37.76,Percent of Total Billed Charges,100% of Total Billed Charges,2.66,47.2,
REDUCING SUBSTANCES STOOL,70043773,CDM,301,RC,84376,HCPCS,Outpatient,,,80.12,48.07,,6.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,17.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,19.8,360,,,Fee Schedule,360% of BCBS POS Rate,19.8,360,,,Fee schedule,360% of BCBS PPO Rate,19.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,48.07,60,,38.456,Percent of Total Billed Charges,60% of Total Billed Charges,4.62,100,,,Fee Schedule,100% of TX Mediciad 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,4.95,90,,,Fee Schedule,90% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,130,,,Fee Schedule,130% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,103,,,Fee Schedule,103% of TX Medicaid Rate,5.66,103,,,Fee Schedule,103% of CMS OPPS Rate,5.66,103,,,Fee Schedule,103% of CMS OPPS Rate,60.09,75,,48.072,Percent of Total Billed Charges,75% of Total Billed Charges,9.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.25,150,,,Fee Schedule,150% of CMS OPPS Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4.46,90,,,Fee Schedule,90% of UHC fee schedule,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,4.62,100,,,Fee Schedule,100% of TX Medicaid Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,80.12,100,,64.096,Percent of Total Billed Charges,100% of Total Billed Charges,4.46,80.12,
TESTOSTERONE FREE,70044078,CDM,301,RC,84402,HCPCS,Outpatient,,,238.65,143.19,,29.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,71.32,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,91.69,360,,,Fee Schedule,360% of BCBS POS Rate,91.69,360,,,Fee schedule,360% of BCBS PPO Rate,91.69,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.19,60,,114.552,Percent of Total Billed Charges,60% of Total Billed Charges,21.39,100,,,Fee Schedule,100% of TX Mediciad 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,22.92,90,,,Fee Schedule,90% of CMS OPPS Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.11,130,,,Fee Schedule,130% of CMS OPPS Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,22.03,103,,,Fee Schedule,103% of TX Medicaid Rate,26.23,103,,,Fee Schedule,103% of CMS OPPS Rate,26.23,103,,,Fee Schedule,103% of CMS OPPS Rate,178.99,75,,143.192,Percent of Total Billed Charges,75% of Total Billed Charges,43.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.2,150,,,Fee Schedule,150% of CMS OPPS Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,20.63,90,,,Fee Schedule,90% of UHC fee schedule,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,21.39,100,,,Fee Schedule,100% of TX Medicaid Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,238.65,100,,190.92,Percent of Total Billed Charges,100% of Total Billed Charges,20.63,238.65,
VIT B1 WHLE BLD,70044292,CDM,301,RC,84425,HCPCS,Outpatient,,,222,133.20,,24.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.84,150,,,Fee Schedule ,150% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,59.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,67.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,76.43,360,,,Fee Schedule,360% of BCBS POS Rate,76.43,360,,,Fee schedule,360% of BCBS PPO Rate,76.43,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.2,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,17.83,100,,,Fee Schedule,100% of TX Mediciad 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,19.1,90,,,Fee Schedule,90% of CMS OPPS Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,27.59,130,,,Fee Schedule,130% of CMS OPPS Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,18.36,103,,,Fee Schedule,103% of TX Medicaid Rate,21.86,103,,,Fee Schedule,103% of CMS OPPS Rate,21.86,103,,,Fee Schedule,103% of CMS OPPS Rate,166.5,75,,133.2,Percent of Total Billed Charges,75% of Total Billed Charges,36.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,36.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,36.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,36.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.84,150,,,Fee Schedule,150% of CMS OPPS Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,90,,,Fee Schedule,90% of UHC fee schedule,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.83,100,,,Fee Schedule,100% of TX Medicaid Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,222,100,,177.6,Percent of Total Billed Charges,100% of Total Billed Charges,17.2,222,
THYROGLOBULIN QUANT (RIA),70044326,CDM,301,RC,84432,HCPCS,Outpatient,,,188,112.80,,18.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.09,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,44.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.39,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,57.82,360,,,Fee Schedule,360% of BCBS POS Rate,57.82,360,,,Fee schedule,360% of BCBS PPO Rate,57.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.8,60,,90.24,Percent of Total Billed Charges,60% of Total Billed Charges,13.49,100,,,Fee Schedule,100% of TX Mediciad 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,14.45,90,,,Fee Schedule,90% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.87,130,,,Fee Schedule,130% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.89,103,,,Fee Schedule,103% of TX Medicaid Rate,16.54,103,,,Fee Schedule,103% of CMS OPPS Rate,16.54,103,,,Fee Schedule,103% of CMS OPPS Rate,141,75,,112.8,Percent of Total Billed Charges,75% of Total Billed Charges,27.3,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.3,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.3,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.09,150,,,Fee Schedule,150% of CMS OPPS Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,100,,,Fee Schedule,100% of TX Medicaid Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,188,100,,150.4,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,188,
THYROXINE BINDING GLOBULIN TBG,70044425,CDM,301,RC,84442,HCPCS,Outpatient,,,168,100.80,,17.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,41.38,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,53.21,360,,,Fee Schedule,360% of BCBS POS Rate,53.21,360,,,Fee schedule,360% of BCBS PPO Rate,53.21,360,,,Fee Schedule,360% of BCBS Traditional Rate,100.8,60,,80.64,Percent of Total Billed Charges,60% of Total Billed Charges,12.42,100,,,Fee Schedule,100% of TX Mediciad 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,13.3,90,,,Fee Schedule,90% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,19.21,130,,,Fee Schedule,130% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.79,103,,,Fee Schedule,103% of TX Medicaid Rate,15.22,103,,,Fee Schedule,103% of CMS OPPS Rate,15.22,103,,,Fee Schedule,103% of CMS OPPS Rate,126,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,25.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.17,150,,,Fee Schedule,150% of CMS OPPS Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,11.97,90,,,Fee Schedule,90% of UHC fee schedule,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,12.42,100,,,Fee Schedule,100% of TX Medicaid Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,134.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.97,168,
VITAMIN E,70044466,CDM,301,RC,84446,HCPCS,Outpatient,,,158.55,95.13,,16.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,51.05,360,,,Fee Schedule,360% of BCBS POS Rate,51.05,360,,,Fee schedule,360% of BCBS PPO Rate,51.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.13,60,,76.104,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,100,,,Fee Schedule,100% of TX Mediciad 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,12.76,90,,,Fee Schedule,90% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,130,,,Fee Schedule,130% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,12.27,103,,,Fee Schedule,103% of TX Medicaid Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,118.91,75,,95.128,Percent of Total Billed Charges,75% of Total Billed Charges,24.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.27,150,,,Fee Schedule,150% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,90,,,Fee Schedule,90% of UHC fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,158.55,100,,126.84,Percent of Total Billed Charges,100% of Total Billed Charges,11.48,158.55,
TRANSFERRIN,70044623,CDM,301,RC,84466,HCPCS,Outpatient,,,159,95.40,,14.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.14,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,35.73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,40.83,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,45.94,360,,,Fee Schedule,360% of BCBS POS Rate,45.94,360,,,Fee schedule,360% of BCBS PPO Rate,45.94,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.4,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,10.72,100,,,Fee Schedule,100% of TX Mediciad 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,11.48,90,,,Fee Schedule,90% of CMS OPPS Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.58,130,,,Fee Schedule,130% of CMS OPPS Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.04,103,,,Fee Schedule,103% of TX Medicaid Rate,13.14,103,,,Fee Schedule,103% of CMS OPPS Rate,13.14,103,,,Fee Schedule,103% of CMS OPPS Rate,119.25,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,21.69,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.69,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,21.69,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.69,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.14,150,,,Fee Schedule,150% of CMS OPPS Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,90,,,Fee Schedule,90% of UHC fee schedule,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,100,,,Fee Schedule,100% of TX Medicaid Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,159,100,,127.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.33,159,
"URIC ACD,OTH SR",70045570,CDM,301,RC,84560,HCPCS,Outpatient,,,110,66.00,,5.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.62,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,14.22,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,18.29,360,,,Fee Schedule,360% of BCBS POS Rate,18.29,360,,,Fee schedule,360% of BCBS PPO Rate,18.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,66,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.27,100,,,Fee Schedule,100% of TX Mediciad 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,4.57,90,,,Fee Schedule,90% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6.6,130,,,Fee Schedule,130% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.4,103,,,Fee Schedule,103% of TX Medicaid Rate,5.23,103,,,Fee Schedule,103% of CMS OPPS Rate,5.23,103,,,Fee Schedule,103% of CMS OPPS Rate,82.5,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,8.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.62,150,,,Fee Schedule,150% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,4.11,90,,,Fee Schedule,90% of UHC fee schedule,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,4.27,100,,,Fee Schedule,100% of TX Medicaid Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,110,100,,88,Percent of Total Billed Charges,100% of Total Billed Charges,4.11,110,
VANILLYMANDELIC ACID,70045869,CDM,301,RC,84585,HCPCS,Outpatient,,,192.13,115.28,,17.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,43.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.6,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,55.8,360,,,Fee Schedule,360% of BCBS POS Rate,55.8,360,,,Fee schedule,360% of BCBS PPO Rate,55.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,115.28,60,,92.224,Percent of Total Billed Charges,60% of Total Billed Charges,13.02,100,,,Fee Schedule,100% of TX Mediciad 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,13.95,90,,,Fee Schedule,90% of CMS OPPS Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,20.15,130,,,Fee Schedule,130% of CMS OPPS Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.41,103,,,Fee Schedule,103% of TX Medicaid Rate,15.96,103,,,Fee Schedule,103% of CMS OPPS Rate,15.96,103,,,Fee Schedule,103% of CMS OPPS Rate,144.1,75,,115.28,Percent of Total Billed Charges,75% of Total Billed Charges,26.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,26.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.25,150,,,Fee Schedule,150% of CMS OPPS Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,12.56,90,,,Fee Schedule,90% of UHC fee schedule,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,13.02,100,,,Fee Schedule,100% of TX Medicaid Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,192.13,100,,153.704,Percent of Total Billed Charges,100% of Total Billed Charges,12.56,192.13,
VIT A,70045901,CDM,301,RC,84446,HCPCS,Outpatient,,,169.44,101.66,,16.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,45.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,51.05,360,,,Fee Schedule,360% of BCBS POS Rate,51.05,360,,,Fee schedule,360% of BCBS PPO Rate,51.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.66,60,,81.328,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,100,,,Fee Schedule,100% of TX Mediciad 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,12.76,90,,,Fee Schedule,90% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,130,,,Fee Schedule,130% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,12.27,103,,,Fee Schedule,103% of TX Medicaid Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,14.6,103,,,Fee Schedule,103% of CMS OPPS Rate,127.08,75,,101.664,Percent of Total Billed Charges,75% of Total Billed Charges,24.1,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.1,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.1,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.1,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.27,150,,,Fee Schedule,150% of CMS OPPS Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,90,,,Fee Schedule,90% of UHC fee schedule,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,11.91,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,169.44,100,,135.552,Percent of Total Billed Charges,100% of Total Billed Charges,11.48,169.44,
VITAMIN D25 HYDROXY,70045950,CDM,301,RC,82306,HCPCS,Outpatient,,,312.5,187.50,,34.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,44.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,82.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,94.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,106.56,360,,,Fee Schedule,360% of BCBS POS Rate,106.56,360,,,Fee schedule,360% of BCBS PPO Rate,106.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,24.86,100,,,Fee Schedule,100% of TX Mediciad 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,26.64,90,,,Fee Schedule,90% of CMS OPPS Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.48,130,,,Fee Schedule,130% of CMS OPPS Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,25.61,103,,,Fee Schedule,103% of TX Medicaid Rate,30.48,103,,,Fee Schedule,103% of CMS OPPS Rate,30.48,103,,,Fee Schedule,103% of CMS OPPS Rate,234.38,75,,187.504,Percent of Total Billed Charges,75% of Total Billed Charges,50.32,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,50.32,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,50.32,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,50.32,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,44.4,150,,,Fee Schedule,150% of CMS OPPS Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.98,90,,,Fee Schedule,90% of UHC fee schedule,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,24.86,100,,,Fee Schedule,100% of TX Medicaid Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,312.5,100,,250,Percent of Total Billed Charges,100% of Total Billed Charges,23.98,312.5,
ZINC (PLASMA),70046305,CDM,301,RC,84630,HCPCS,Outpatient,,,140,84.00,,13.22,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.08,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,31.89,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.45,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,41,360,,,Fee Schedule,360% of BCBS POS Rate,41,360,,,Fee schedule,360% of BCBS PPO Rate,41,360,,,Fee Schedule,360% of BCBS Traditional Rate,84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.57,100,,,Fee Schedule,100% of TX Mediciad 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,10.25,90,,,Fee Schedule,90% of CMS OPPS Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,130,,,Fee Schedule,130% of CMS OPPS Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.86,103,,,Fee Schedule,103% of TX Medicaid Rate,11.73,103,,,Fee Schedule,103% of CMS OPPS Rate,11.73,103,,,Fee Schedule,103% of CMS OPPS Rate,105,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,19.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.08,150,,,Fee Schedule,150% of CMS OPPS Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.23,90,,,Fee Schedule,90% of UHC fee schedule,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,9.57,100,,,Fee Schedule,100% of TX Medicaid Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,140,100,,112,Percent of Total Billed Charges,100% of Total Billed Charges,9.23,140,
CA 27-29,70048988,CDM,302,RC,86300,HCPCS,Outpatient,,,255.6,153.36,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,153.36,60,,122.688,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,191.7,75,,153.36,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,255.6,100,,204.48,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,255.6,
CARBOHYDRATE ANTIGEN 19-9,70049002,CDM,302,RC,86301,HCPCS,Outpatient,,,246,147.60,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.6,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,184.5,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,246,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,246,
OSMOLALITY STOOL,70049036,CDM,301,RC,84999,HCPCS,Outpatient,,,122.87,73.72,,73.72,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.72,60,,58.976,Percent of Total Billed Charges,60% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.72,14.42,,14.176,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.15,75,,73.72,Percent of Total Billed Charges,75% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,61.44,50,,49.152,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,17.2,14,,13.76,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.87,100,,98.296,Percent of Total Billed Charges,100% of Total Billed Charges,17.2,122.87,
IA TUMOR AG CA 15 3 QT,70049986,CDM,302,RC,86300,HCPCS,Outpatient,,,255.6,153.36,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,153.36,60,,122.688,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,191.7,75,,153.36,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,255.6,100,,204.48,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,255.6,
FACTOR V ACTIVITY,70052204,CDM,305,RC,85220,HCPCS,Outpatient,,,313,187.80,,20.48,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.47,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,56.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,63.54,360,,,Fee Schedule,360% of BCBS POS Rate,63.54,360,,,Fee schedule,360% of BCBS PPO Rate,63.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,187.8,60,,150.24,Percent of Total Billed Charges,60% of Total Billed Charges,14.83,100,,,Fee Schedule,100% of TX Mediciad 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,15.88,90,,,Fee Schedule,90% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,130,,,Fee Schedule,130% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,15.27,103,,,Fee Schedule,103% of TX Medicaid Rate,18.17,103,,,Fee Schedule,103% of CMS OPPS Rate,18.17,103,,,Fee Schedule,103% of CMS OPPS Rate,234.75,75,,187.8,Percent of Total Billed Charges,75% of Total Billed Charges,30,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,30,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.47,150,,,Fee Schedule,150% of CMS OPPS Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,90,,,Fee Schedule,90% of UHC fee schedule,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,14.83,100,,,Fee Schedule,100% of TX Medicaid Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,250.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.3,313,
FAACTOR VII ASSAY,70052303,CDM,305,RC,85230,HCPCS,Outpatient,,,368,220.80,,20.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,64.44,360,,,Fee Schedule,360% of BCBS POS Rate,64.44,360,,,Fee schedule,360% of BCBS PPO Rate,64.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,220.8,60,,176.64,Percent of Total Billed Charges,60% of Total Billed Charges,15.04,100,,,Fee Schedule,100% of TX Mediciad 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,16.1,90,,,Fee Schedule,90% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,130,,,Fee Schedule,130% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,103,,,Fee Schedule,103% of TX Medicaid Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,276,75,,220.8,Percent of Total Billed Charges,75% of Total Billed Charges,30.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,30.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.85,150,,,Fee Schedule,150% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,90,,,Fee Schedule,90% of UHC fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,368,100,,294.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.5,368,
FACTOR VIII ASSAY,70052402,CDM,305,RC,85240,HCPCS,Outpatient,,,340.25,204.15,,20.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,64.44,360,,,Fee Schedule,360% of BCBS POS Rate,64.44,360,,,Fee schedule,360% of BCBS PPO Rate,64.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,204.15,60,,163.32,Percent of Total Billed Charges,60% of Total Billed Charges,15.04,100,,,Fee Schedule,100% of TX Mediciad 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,16.1,90,,,Fee Schedule,90% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,130,,,Fee Schedule,130% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,103,,,Fee Schedule,103% of TX Medicaid Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,255.19,75,,204.152,Percent of Total Billed Charges,75% of Total Billed Charges,30.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,30.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.85,150,,,Fee Schedule,150% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,90,,,Fee Schedule,90% of UHC fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,340.25,100,,272.2,Percent of Total Billed Charges,100% of Total Billed Charges,14.5,340.25,
RISTOCETIN COFACTOR-FACT8,70052451,CDM,305,RC,85245,HCPCS,Outpatient,,,323.33,194.00,,26.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,64.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,73.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,82.58,360,,,Fee Schedule,360% of BCBS POS Rate,82.58,360,,,Fee schedule,360% of BCBS PPO Rate,82.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,194,60,,155.2,Percent of Total Billed Charges,60% of Total Billed Charges,19.27,100,,,Fee Schedule,100% of TX Mediciad 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,20.64,90,,,Fee Schedule,90% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,130,,,Fee Schedule,130% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.85,103,,,Fee Schedule,103% of TX Medicaid Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,242.5,75,,194,Percent of Total Billed Charges,75% of Total Billed Charges,38.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,38.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,38.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,34.41,150,,,Fee Schedule,150% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.59,90,,,Fee Schedule,90% of UHC fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,323.33,100,,258.664,Percent of Total Billed Charges,100% of Total Billed Charges,18.59,323.33,
VW FACTOR AG,70052469,CDM,305,RC,85246,HCPCS,Outpatient,,,303.89,182.33,,26.62,100,,,Fee Schedule,100% of Aetna Fee Schedule,34.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,64.23,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,73.41,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,82.58,360,,,Fee Schedule,360% of BCBS POS Rate,82.58,360,,,Fee schedule,360% of BCBS PPO Rate,82.58,360,,,Fee Schedule,360% of BCBS Traditional Rate,182.33,60,,145.864,Percent of Total Billed Charges,60% of Total Billed Charges,19.27,100,,,Fee Schedule,100% of TX Mediciad 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,20.64,90,,,Fee Schedule,90% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,130,,,Fee Schedule,130% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.85,103,,,Fee Schedule,103% of TX Medicaid Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,23.62,103,,,Fee Schedule,103% of CMS OPPS Rate,227.92,75,,182.336,Percent of Total Billed Charges,75% of Total Billed Charges,38.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,38.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,38.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,34.41,150,,,Fee Schedule,150% of CMS OPPS Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.59,90,,,Fee Schedule,90% of UHC fee schedule,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,19.27,100,,,Fee Schedule,100% of TX Medicaid Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,303.89,100,,243.112,Percent of Total Billed Charges,100% of Total Billed Charges,18.59,303.89,
FACTOR IX ACTIVITY,70052501,CDM,305,RC,85250,HCPCS,Outpatient,,,336,201.60,,22.08,100,,,Fee Schedule,100% of Aetna Fee Schedule,28.56,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,53.31,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,60.93,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,68.54,360,,,Fee Schedule,360% of BCBS POS Rate,68.54,360,,,Fee schedule,360% of BCBS PPO Rate,68.54,360,,,Fee Schedule,360% of BCBS Traditional Rate,201.6,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,15.99,100,,,Fee Schedule,100% of TX Mediciad 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,17.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,24.75,130,,,Fee Schedule,130% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,16.47,103,,,Fee Schedule,103% of TX Medicaid Rate,19.61,103,,,Fee Schedule,103% of CMS OPPS Rate,19.61,103,,,Fee Schedule,103% of CMS OPPS Rate,252,75,,201.6,Percent of Total Billed Charges,75% of Total Billed Charges,32.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,32.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,28.56,150,,,Fee Schedule,150% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,90,,,Fee Schedule,90% of UHC fee schedule,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,15.99,100,,,Fee Schedule,100% of TX Medicaid Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,336,100,,268.8,Percent of Total Billed Charges,100% of Total Billed Charges,15.43,336,
CLOT FACTOR XI,70052709,CDM,305,RC,85270,HCPCS,Outpatient,,,320.9,192.54,,20.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.85,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,64.44,360,,,Fee Schedule,360% of BCBS POS Rate,64.44,360,,,Fee schedule,360% of BCBS PPO Rate,64.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,192.54,60,,154.032,Percent of Total Billed Charges,60% of Total Billed Charges,15.04,100,,,Fee Schedule,100% of TX Mediciad 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,16.1,90,,,Fee Schedule,90% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,130,,,Fee Schedule,130% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,103,,,Fee Schedule,103% of TX Medicaid Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,18.43,103,,,Fee Schedule,103% of CMS OPPS Rate,240.68,75,,192.544,Percent of Total Billed Charges,75% of Total Billed Charges,30.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,30.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.85,150,,,Fee Schedule,150% of CMS OPPS Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,90,,,Fee Schedule,90% of UHC fee schedule,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,15.04,100,,,Fee Schedule,100% of TX Medicaid Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,320.9,100,,256.72,Percent of Total Billed Charges,100% of Total Billed Charges,14.5,320.9,
FACTOR XII (HAGEMANN),70052808,CDM,305,RC,85280,HCPCS,Outpatient,,,306.34,183.80,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,183.8,60,,147.04,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,229.76,75,,183.808,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,306.34,100,,245.072,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,306.34,
ANTI THROMBIN III ACTIVITY,70053004,CDM,305,RC,85300,HCPCS,Outpatient,,,273.11,163.87,,13.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,33.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,42.66,360,,,Fee Schedule,360% of BCBS POS Rate,42.66,360,,,Fee schedule,360% of BCBS PPO Rate,42.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,163.87,60,,131.096,Percent of Total Billed Charges,60% of Total Billed Charges,9.95,100,,,Fee Schedule,100% of TX Mediciad 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,10.66,90,,,Fee Schedule,90% of CMS OPPS Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,130,,,Fee Schedule,130% of CMS OPPS Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.25,103,,,Fee Schedule,103% of TX Medicaid Rate,12.2,103,,,Fee Schedule,103% of CMS OPPS Rate,12.2,103,,,Fee Schedule,103% of CMS OPPS Rate,204.83,75,,163.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.77,150,,,Fee Schedule,150% of CMS OPPS Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,9.6,90,,,Fee Schedule,90% of UHC fee schedule,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,9.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,273.11,100,,218.488,Percent of Total Billed Charges,100% of Total Billed Charges,9.6,273.11,
PROTEIN C ACTIVITY,70053020,CDM,305,RC,85302,HCPCS,Outpatient,,,283.97,170.38,,13.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.01,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,43.24,360,,,Fee Schedule,360% of BCBS POS Rate,43.24,360,,,Fee schedule,360% of BCBS PPO Rate,43.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,170.38,60,,136.304,Percent of Total Billed Charges,60% of Total Billed Charges,10.09,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15.61,130,,,Fee Schedule,130% of CMS OPPS Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.39,103,,,Fee Schedule,103% of TX Medicaid Rate,12.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12.37,103,,,Fee Schedule,103% of CMS OPPS Rate,212.98,75,,170.384,Percent of Total Billed Charges,75% of Total Billed Charges,20.41,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.41,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,20.41,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.41,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.01,150,,,Fee Schedule,150% of CMS OPPS Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,9.73,90,,,Fee Schedule,90% of UHC fee schedule,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,283.97,100,,227.176,Percent of Total Billed Charges,100% of Total Billed Charges,9.73,283.97,
APC RESISTANCE,70053038,CDM,305,RC,85303,HCPCS,Outpatient,,,348,208.80,,16.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.76,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,49.82,360,,,Fee Schedule,360% of BCBS POS Rate,49.82,360,,,Fee schedule,360% of BCBS PPO Rate,49.82,360,,,Fee Schedule,360% of BCBS Traditional Rate,208.8,60,,167.04,Percent of Total Billed Charges,60% of Total Billed Charges,11.63,100,,,Fee Schedule,100% of TX Mediciad 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,12.45,90,,,Fee Schedule,90% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17.99,130,,,Fee Schedule,130% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,103,,,Fee Schedule,103% of TX Medicaid Rate,14.25,103,,,Fee Schedule,103% of CMS OPPS Rate,14.25,103,,,Fee Schedule,103% of CMS OPPS Rate,261,75,,208.8,Percent of Total Billed Charges,75% of Total Billed Charges,23.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,23.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.76,150,,,Fee Schedule,150% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,11.21,90,,,Fee Schedule,90% of UHC fee schedule,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,348,100,,278.4,Percent of Total Billed Charges,100% of Total Billed Charges,11.21,348,
"PROTEIN S,TOTAL",70053053,CDM,305,RC,85305,HCPCS,Outpatient,,,223.12,133.87,,13.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.41,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.51,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.15,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,41.8,360,,,Fee Schedule,360% of BCBS POS Rate,41.8,360,,,Fee schedule,360% of BCBS PPO Rate,41.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.87,60,,107.096,Percent of Total Billed Charges,60% of Total Billed Charges,9.75,100,,,Fee Schedule,100% of TX Mediciad 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,10.44,90,,,Fee Schedule,90% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.09,130,,,Fee Schedule,130% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,10.04,103,,,Fee Schedule,103% of TX Medicaid Rate,11.95,103,,,Fee Schedule,103% of CMS OPPS Rate,11.95,103,,,Fee Schedule,103% of CMS OPPS Rate,167.34,75,,133.872,Percent of Total Billed Charges,75% of Total Billed Charges,19.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.41,150,,,Fee Schedule,150% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.41,90,,,Fee Schedule,90% of UHC fee schedule,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,9.75,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,223.12,100,,178.496,Percent of Total Billed Charges,100% of Total Billed Charges,9.41,223.12,
"HEMOGLB,FETAL",70054606,CDM,305,RC,85460,HCPCS,Outpatient,,,223,133.80,,8.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,11.59,150,,,Fee Schedule ,150% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.64,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,24.74,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,27.83,360,,,Fee Schedule,360% of BCBS POS Rate,27.83,360,,,Fee schedule,360% of BCBS PPO Rate,27.83,360,,,Fee Schedule,360% of BCBS Traditional Rate,133.8,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,6.49,100,,,Fee Schedule,100% of TX Mediciad 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,6.95,90,,,Fee Schedule,90% of CMS OPPS Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,10.04,130,,,Fee Schedule,130% of CMS OPPS Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.68,103,,,Fee Schedule,103% of TX Medicaid Rate,7.96,103,,,Fee Schedule,103% of CMS OPPS Rate,7.96,103,,,Fee Schedule,103% of CMS OPPS Rate,167.25,75,,133.8,Percent of Total Billed Charges,75% of Total Billed Charges,13.14,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.14,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.14,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.14,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,11.59,150,,,Fee Schedule,150% of CMS OPPS Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.26,90,,,Fee Schedule,90% of UHC fee schedule,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,6.49,100,,,Fee Schedule,100% of TX Medicaid Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,223,100,,178.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.26,223,
HEPARIN ASSAY,70055207,CDM,305,RC,85520,HCPCS,Outpatient,,,289.41,173.65,,15.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,36.65,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.89,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,47.12,360,,,Fee Schedule,360% of BCBS POS Rate,47.12,360,,,Fee schedule,360% of BCBS PPO Rate,47.12,360,,,Fee Schedule,360% of BCBS Traditional Rate,173.65,60,,138.92,Percent of Total Billed Charges,60% of Total Billed Charges,11,100,,,Fee Schedule,100% of TX Mediciad 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,11.78,90,,,Fee Schedule,90% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.01,130,,,Fee Schedule,130% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11.33,103,,,Fee Schedule,103% of TX Medicaid Rate,13.48,103,,,Fee Schedule,103% of CMS OPPS Rate,13.48,103,,,Fee Schedule,103% of CMS OPPS Rate,217.06,75,,173.648,Percent of Total Billed Charges,75% of Total Billed Charges,22.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,22.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.63,150,,,Fee Schedule,150% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,90,,,Fee Schedule,90% of UHC fee schedule,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,11,100,,,Fee Schedule,100% of TX Medicaid Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,289.41,100,,231.528,Percent of Total Billed Charges,100% of Total Billed Charges,10.6,289.41,
LEUKOCYTE ALKALINE PHOSPH,70055405,CDM,305,RC,85540,HCPCS,Outpatient,,,173,103.80,,9.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,30.96,360,,,Fee Schedule,360% of BCBS POS Rate,30.96,360,,,Fee schedule,360% of BCBS PPO Rate,30.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.8,60,,83.04,Percent of Total Billed Charges,60% of Total Billed Charges,7.22,100,,,Fee Schedule,100% of TX Mediciad Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7.74,90,,,Fee Schedule,90% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.18,130,,,Fee Schedule,130% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.44,103,,,Fee Schedule,103% of TX Medicaid Rate,8.85,103,,,Fee Schedule,103% of CMS OPPS Rate,8.85,103,,,Fee Schedule,103% of CMS OPPS Rate,129.75,75,,103.8,Percent of Total Billed Charges,75% of Total Billed Charges,14.62,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.62,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.62,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.62,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.9,150,,,Fee Schedule,150% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6.97,90,,,Fee Schedule,90% of UHC fee schedule,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,7.22,100,,,Fee Schedule,100% of TX Medicaid Rate,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,173,100,,138.4,Percent of Total Billed Charges,100% of Total Billed Charges,6.97,173,
AB THYROIPEROXIDASE,70055595,CDM,302,RC,86376,HCPCS,Outpatient,,,172,103.20,,16.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,52.38,360,,,Fee Schedule,360% of BCBS POS Rate,52.38,360,,,Fee schedule,360% of BCBS PPO Rate,52.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of TX Mediciad 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,13.09,90,,,Fee Schedule,90% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,18.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,103,,,Fee Schedule,103% of TX Medicaid Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,129,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,24.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.82,150,,,Fee Schedule,150% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,,Fee Schedule,90% of UHC fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,172,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.79,172,
PT SUB PLS FRCT,70056114,CDM,305,RC,85611,HCPCS,Outpatient,,,128.54,77.12,,4.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,5.91,150,,,Fee Schedule ,150% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.03,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,12.61,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,14.18,360,,,Fee Schedule,360% of BCBS POS Rate,14.18,360,,,Fee schedule,360% of BCBS PPO Rate,14.18,360,,,Fee Schedule,360% of BCBS Traditional Rate,77.12,60,,61.696,Percent of Total Billed Charges,60% of Total Billed Charges,3.31,100,,,Fee Schedule,100% of TX Mediciad 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,3.54,90,,,Fee Schedule,90% of CMS OPPS Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,130,,,Fee Schedule,130% of CMS OPPS Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.41,103,,,Fee Schedule,103% of TX Medicaid Rate,4.05,103,,,Fee Schedule,103% of CMS OPPS Rate,4.05,103,,,Fee Schedule,103% of CMS OPPS Rate,96.41,75,,77.128,Percent of Total Billed Charges,75% of Total Billed Charges,6.69,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.69,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,6.69,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,6.69,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,5.91,150,,,Fee Schedule,150% of CMS OPPS Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,90,,,Fee Schedule,90% of UHC fee schedule,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.31,100,,,Fee Schedule,100% of TX Medicaid Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,128.54,100,,102.832,Percent of Total Billed Charges,100% of Total Billed Charges,3.2,128.54,
"THROMBIN,PLASMA",70056700,CDM,305,RC,85670,HCPCS,Outpatient,,,116,69.60,,6.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.65,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.46,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,20.77,360,,,Fee Schedule,360% of BCBS POS Rate,20.77,360,,,Fee schedule,360% of BCBS PPO Rate,20.77,360,,,Fee Schedule,360% of BCBS Traditional Rate,69.6,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,4.85,100,,,Fee Schedule,100% of TX Mediciad 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,5.19,90,,,Fee Schedule,90% of CMS OPPS Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.5,130,,,Fee Schedule,130% of CMS OPPS Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5,103,,,Fee Schedule,103% of TX Medicaid Rate,5.94,103,,,Fee Schedule,103% of CMS OPPS Rate,5.94,103,,,Fee Schedule,103% of CMS OPPS Rate,87,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,9.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.65,150,,,Fee Schedule,150% of CMS OPPS Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4.67,90,,,Fee Schedule,90% of UHC fee schedule,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,4.85,100,,,Fee Schedule,100% of TX Medicaid Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,116,100,,92.8,Percent of Total Billed Charges,100% of Total Billed Charges,4.67,116,
PLATELET ANTIBODY PANEL,70060140,CDM,302,RC,86022,HCPCS,Outpatient,,,370.5,222.30,,21.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,51.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,66.13,360,,,Fee Schedule,360% of BCBS POS Rate,66.13,360,,,Fee schedule,360% of BCBS PPO Rate,66.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,222.3,60,,177.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.43,100,,,Fee Schedule,100% of TX Mediciad 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,16.53,90,,,Fee Schedule,90% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.88,130,,,Fee Schedule,130% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,103,,,Fee Schedule,103% of TX Medicaid Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,277.88,75,,222.304,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.55,150,,,Fee Schedule,150% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,90,,,Fee Schedule,90% of UHC fee schedule,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,370.5,100,,296.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.88,370.5,
HEPARIN INDUCED PLATELET AB,70060173,CDM,302,RC,86022,HCPCS,Outpatient,,,370.5,222.30,,21.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,27.55,150,,,Fee Schedule ,150% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,51.44,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,58.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,66.13,360,,,Fee Schedule,360% of BCBS POS Rate,66.13,360,,,Fee schedule,360% of BCBS PPO Rate,66.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,222.3,60,,177.84,Percent of Total Billed Charges,60% of Total Billed Charges,15.43,100,,,Fee Schedule,100% of TX Mediciad 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,16.53,90,,,Fee Schedule,90% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.88,130,,,Fee Schedule,130% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.89,103,,,Fee Schedule,103% of TX Medicaid Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,18.92,103,,,Fee Schedule,103% of CMS OPPS Rate,277.88,75,,222.304,Percent of Total Billed Charges,75% of Total Billed Charges,31.22,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,31.22,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,31.22,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,27.55,150,,,Fee Schedule,150% of CMS OPPS Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,90,,,Fee Schedule,90% of UHC fee schedule,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,15.43,100,,,Fee Schedule,100% of TX Medicaid Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,370.5,100,,296.4,Percent of Total Billed Charges,100% of Total Billed Charges,14.88,370.5,
AB ELUTION RBC EA ELUTION,70060199,CDM,302,RC,86860,HCPCS,Outpatient,,,239.98,143.99,,39.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,143.99,60,,115.192,Percent of Total Billed Charges,60% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,34.61,14.42,,27.688,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,179.99,75,,143.992,Percent of Total Billed Charges,75% of Total Billed Charges,119.99,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,119.99,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,119.99,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,119.99,50,,95.992,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,33.6,14,,26.88,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,239.98,100,,191.984,Percent of Total Billed Charges,100% of Total Billed Charges,33.6,516.6,
ANTINUCLEAR ANTIBODY,70060439,CDM,302,RC,86038,HCPCS,Outpatient,,,202,121.20,,14.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.69,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,43.52,360,,,Fee Schedule,360% of BCBS POS Rate,43.52,360,,,Fee schedule,360% of BCBS PPO Rate,43.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,121.2,60,,96.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.16,100,,,Fee Schedule,100% of TX Mediciad 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,10.88,90,,,Fee Schedule,90% of CMS OPPS Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,15.71,130,,,Fee Schedule,130% of CMS OPPS Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.46,103,,,Fee Schedule,103% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of CMS OPPS Rate,12.45,103,,,Fee Schedule,103% of CMS OPPS Rate,151.5,75,,121.2,Percent of Total Billed Charges,75% of Total Billed Charges,20.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.13,150,,,Fee Schedule,150% of CMS OPPS Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.79,90,,,Fee Schedule,90% of UHC fee schedule,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,10.16,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,202,100,,161.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.79,202,
COLD AGGLUTININ SCREEN,70060504,CDM,302,RC,86156,HCPCS,Outpatient,,,159.26,95.56,,9.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,22.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,25.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,29.05,360,,,Fee Schedule,360% of BCBS POS Rate,29.05,360,,,Fee schedule,360% of BCBS PPO Rate,29.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,6.78,100,,,Fee Schedule,100% of TX Mediciad 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,7.26,90,,,Fee Schedule,90% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,130,,,Fee Schedule,130% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.98,103,,,Fee Schedule,103% of TX Medicaid Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8.31,103,,,Fee Schedule,103% of CMS OPPS Rate,119.45,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,13.71,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,13.71,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,13.71,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.1,150,,,Fee Schedule,150% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,90,,,Fee Schedule,90% of UHC fee schedule,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,6.78,100,,,Fee Schedule,100% of TX Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.26,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,6.53,159.26,
AB ANTI NEUTROPHIL CYTOPLASMIC,70060595,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
ALPHA 1 ANTITRYPSIN,70060678,CDM,301,RC,82103,HCPCS,Outpatient,,,169,101.40,,15.6,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,37.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.01,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,48.38,360,,,Fee Schedule,360% of BCBS POS Rate,48.38,360,,,Fee schedule,360% of BCBS PPO Rate,48.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.4,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,11.29,100,,,Fee Schedule,100% of TX Mediciad 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,12.09,90,,,Fee Schedule,90% of CMS OPPS Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,17.47,130,,,Fee Schedule,130% of CMS OPPS Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.63,103,,,Fee Schedule,103% of TX Medicaid Rate,13.84,103,,,Fee Schedule,103% of CMS OPPS Rate,13.84,103,,,Fee Schedule,103% of CMS OPPS Rate,126.75,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.84,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.84,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,22.84,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.84,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.16,150,,,Fee Schedule,150% of CMS OPPS Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,10.89,90,,,Fee Schedule,90% of UHC fee schedule,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,100,,,Fee Schedule,100% of TX Medicaid Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,169,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.89,169,
RBC AG ROOM TEMP,70060900,CDM,300,RC,86905,HCPCS,Outpatient,,,171.94,103.16,,4.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,494.67,150,,,Fee Schedule ,150% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.16,60,,82.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.22,100,,,Fee Schedule,100% of TX Mediciad Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,296.8,90,,,Fee Schedule,90% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,428.71,130,,,Fee Schedule,130% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.32,103,,,Fee Schedule,103% of TX Medicaid Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,339.67,103,,,Fee Schedule,103% of CMS OPPS Rate,128.96,75,,103.168,Percent of Total Billed Charges,75% of Total Billed Charges,6.51,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,6.51,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,6.51,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,494.67,150,,,Fee Schedule,150% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,90,,,Fee Schedule,90% of UHC fee schedule,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,3.22,100,,,Fee Schedule,100% of TX Medicaid Rate,329.78,100,,,Fee Schedule,100% of CMS OPPS Rate,171.94,100,,137.552,Percent of Total Billed Charges,100% of Total Billed Charges,3.11,1020.28,
ABSORPTION FEE EA ABSORPTION,70061072,CDM,300,RC,86978,HCPCS,Outpatient,,,241,144.60,,43.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,84.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,106.98,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,120.35,360,,,Fee Schedule,360% of BCBS POS Rate,120.35,360,,,Fee schedule,360% of BCBS PPO Rate,120.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,144.6,60,,115.68,Percent of Total Billed Charges,60% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,90,,,Fee Schedule,90% of CMS OPPS Rate,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,72.95,130,,,Fee Schedule,130% of CMS OPPS Rate,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,34.75,14.42,,27.8,Percent of Total Billed Charges,14.42% of Total Billed Charges,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,57.8,103,,,Fee Schedule,103% of CMS OPPS Rate,180.75,75,,144.6,Percent of Total Billed Charges,75% of Total Billed Charges,120.5,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,120.5,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,120.5,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,120.5,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,84.17,150,,,Fee Schedule,150% of CMS OPPS Rate,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.08,90,,,Fee Schedule,90% of UHC fee schedule,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,33.74,14,,26.992,Percent of Total Billed Charges,14% of Total Billed Charges,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,241,100,,192.8,Percent of Total Billed Charges,100% of Total Billed Charges,27.08,241,
BETA 2 GLYCOPROT,70061155,CDM,302,RC,86146,HCPCS,Outpatient,,,156,93.60,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.6,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,117,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,156,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,156,
BETA 2 GLYCOPROT,70061163,CDM,302,RC,86146,HCPCS,Outpatient,,,156,93.60,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.6,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,117,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,156,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,156,
BETA 2 GLYCOPROT,70061171,CDM,302,RC,86146,HCPCS,Outpatient,,,156,93.60,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.6,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,117,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,156,100,,124.8,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,156,
PHOSPHATIDYLSERN,70061379,CDM,302,RC,86148,HCPCS,Outpatient,,,159.26,95.56,,18.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,57.85,360,,,Fee Schedule,360% of BCBS POS Rate,57.85,360,,,Fee schedule,360% of BCBS PPO Rate,57.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,100,,,Fee Schedule,100% of TX Mediciad 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,14.46,90,,,Fee Schedule,90% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,20.89,130,,,Fee Schedule,130% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.91,103,,,Fee Schedule,103% of TX Medicaid Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,119.45,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,27.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.1,150,,,Fee Schedule,150% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.26,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,159.26,
PHOSPHATIDYLSERN,70061387,CDM,302,RC,86148,HCPCS,Outpatient,,,159.26,95.56,,18.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,57.85,360,,,Fee Schedule,360% of BCBS POS Rate,57.85,360,,,Fee schedule,360% of BCBS PPO Rate,57.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,100,,,Fee Schedule,100% of TX Mediciad 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,14.46,90,,,Fee Schedule,90% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,20.89,130,,,Fee Schedule,130% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.91,103,,,Fee Schedule,103% of TX Medicaid Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,119.45,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,27.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.1,150,,,Fee Schedule,150% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.26,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,159.26,
PHOSPHATIDLYSEN,70061395,CDM,302,RC,86148,HCPCS,Outpatient,,,159.26,95.56,,18.64,100,,,Fee Schedule,100% of Aetna Fee Schedule,24.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,51.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,57.85,360,,,Fee Schedule,360% of BCBS POS Rate,57.85,360,,,Fee schedule,360% of BCBS PPO Rate,57.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.56,60,,76.448,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,100,,,Fee Schedule,100% of TX Mediciad 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,14.46,90,,,Fee Schedule,90% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,20.89,130,,,Fee Schedule,130% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.91,103,,,Fee Schedule,103% of TX Medicaid Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,16.55,103,,,Fee Schedule,103% of CMS OPPS Rate,119.45,75,,95.56,Percent of Total Billed Charges,75% of Total Billed Charges,27.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,24.1,150,,,Fee Schedule,150% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,90,,,Fee Schedule,90% of UHC fee schedule,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,13.5,100,,,Fee Schedule,100% of TX Medicaid Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.26,100,,127.408,Percent of Total Billed Charges,100% of Total Billed Charges,13.01,159.26,
COMPLEMENT TOTAL CH50,70061627,CDM,302,RC,86162,HCPCS,Outpatient,,,265.6,159.36,,23.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,56.9,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,65.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,73.15,360,,,Fee Schedule,360% of BCBS POS Rate,73.15,360,,,Fee schedule,360% of BCBS PPO Rate,73.15,360,,,Fee Schedule,360% of BCBS Traditional Rate,159.36,60,,127.488,Percent of Total Billed Charges,60% of Total Billed Charges,17.07,100,,,Fee Schedule,100% of TX Mediciad 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,18.28,90,,,Fee Schedule,90% of CMS OPPS Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,26.41,130,,,Fee Schedule,130% of CMS OPPS Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.58,103,,,Fee Schedule,103% of TX Medicaid Rate,20.92,103,,,Fee Schedule,103% of CMS OPPS Rate,20.92,103,,,Fee Schedule,103% of CMS OPPS Rate,199.2,75,,159.36,Percent of Total Billed Charges,75% of Total Billed Charges,34.54,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.54,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,34.54,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.54,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.48,150,,,Fee Schedule,150% of CMS OPPS Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,90,,,Fee Schedule,90% of UHC fee schedule,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,17.07,100,,,Fee Schedule,100% of TX Medicaid Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,265.6,100,,212.48,Percent of Total Billed Charges,100% of Total Billed Charges,16.46,265.6,
COCCIDIOMYCOSIS ANTIBODIE,70061726,CDM,302,RC,86635,HCPCS,Outpatient,,,180,108.00,,13.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,32.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,41.29,360,,,Fee Schedule,360% of BCBS POS Rate,41.29,360,,,Fee schedule,360% of BCBS PPO Rate,41.29,360,,,Fee Schedule,360% of BCBS Traditional Rate,108,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.63,100,,,Fee Schedule,100% of TX Mediciad 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,10.32,90,,,Fee Schedule,90% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.91,130,,,Fee Schedule,130% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.92,103,,,Fee Schedule,103% of TX Medicaid Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,11.81,103,,,Fee Schedule,103% of CMS OPPS Rate,135,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,19.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,19.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.2,150,,,Fee Schedule,150% of CMS OPPS Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.29,90,,,Fee Schedule,90% of UHC fee schedule,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,9.63,100,,,Fee Schedule,100% of TX Medicaid Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,180,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,9.29,180,
ANTI-THYROGLOBULIN ANTIBO,70061759,CDM,302,RC,86800,HCPCS,Outpatient,,,171.08,102.65,,18.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,50.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,57.28,360,,,Fee Schedule,360% of BCBS POS Rate,57.28,360,,,Fee schedule,360% of BCBS PPO Rate,57.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,102.65,60,,82.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.36,100,,,Fee Schedule,100% of TX Mediciad 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,14.31,90,,,Fee Schedule,90% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,20.68,130,,,Fee Schedule,130% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.76,103,,,Fee Schedule,103% of TX Medicaid Rate,16.38,103,,,Fee Schedule,103% of CMS OPPS Rate,16.38,103,,,Fee Schedule,103% of CMS OPPS Rate,128.31,75,,102.648,Percent of Total Billed Charges,75% of Total Billed Charges,27.04,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,27.04,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.04,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,27.04,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.86,150,,,Fee Schedule,150% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,12.89,90,,,Fee Schedule,90% of UHC fee schedule,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,13.36,100,,,Fee Schedule,100% of TX Medicaid Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,171.08,100,,136.864,Percent of Total Billed Charges,100% of Total Billed Charges,12.89,171.08,
HISTOPLASMOSIS ANTIBODIES,70061767,CDM,302,RC,86698,HCPCS,Outpatient,,,121.89,73.13,,16,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,44.13,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,49.64,360,,,Fee Schedule,360% of BCBS POS Rate,49.64,360,,,Fee schedule,360% of BCBS PPO Rate,49.64,360,,,Fee Schedule,360% of BCBS Traditional Rate,73.13,60,,58.504,Percent of Total Billed Charges,60% of Total Billed Charges,11.58,100,,,Fee Schedule,100% of TX Mediciad 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,12.41,90,,,Fee Schedule,90% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,130,,,Fee Schedule,130% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.93,103,,,Fee Schedule,103% of TX Medicaid Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,14.2,103,,,Fee Schedule,103% of CMS OPPS Rate,91.42,75,,73.136,Percent of Total Billed Charges,75% of Total Billed Charges,23.44,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.44,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.44,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.68,150,,,Fee Schedule,150% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,90,,,Fee Schedule,90% of UHC fee schedule,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,11.58,100,,,Fee Schedule,100% of TX Medicaid Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,121.89,100,,97.512,Percent of Total Billed Charges,100% of Total Billed Charges,11.17,121.89,
MYCOPLASMA,70061817,CDM,302,RC,86738,HCPCS,Outpatient,,,164,98.40,,15.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,47.66,360,,,Fee Schedule,360% of BCBS POS Rate,47.66,360,,,Fee schedule,360% of BCBS PPO Rate,47.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,11.12,100,,,Fee Schedule,100% of TX Mediciad 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,11.91,90,,,Fee Schedule,90% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,130,,,Fee Schedule,130% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.45,103,,,Fee Schedule,103% of TX Medicaid Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,123,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.73,90,,,Fee Schedule,90% of UHC fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,164,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.73,164,
AB COXSACKIE A,70061866,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
AB COXSACKIE B,70061867,CDM,302,RC,86658,HCPCS,Outpatient,,,124.56,74.74,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.74,60,,59.792,Percent of Total Billed Charges,60% of Total Billed Charges,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,93.42,75,,74.736,Percent of Total Billed Charges,75% of Total Billed Charges,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,100,,99.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.56,124.56,
INFLUENZA A&B ANTIBODIES,70061973,CDM,302,RC,86710,HCPCS,Outpatient,,,112.06,67.24,,15.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.36,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,48.78,360,,,Fee Schedule,360% of BCBS POS Rate,48.78,360,,,Fee schedule,360% of BCBS PPO Rate,48.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,67.24,60,,53.792,Percent of Total Billed Charges,60% of Total Billed Charges,11.38,100,,,Fee Schedule,100% of TX Mediciad 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,12.19,90,,,Fee Schedule,90% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.61,130,,,Fee Schedule,130% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.72,103,,,Fee Schedule,103% of TX Medicaid Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,13.95,103,,,Fee Schedule,103% of CMS OPPS Rate,84.05,75,,67.24,Percent of Total Billed Charges,75% of Total Billed Charges,23.03,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.03,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,23.03,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.03,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.32,150,,,Fee Schedule,150% of CMS OPPS Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,90,,,Fee Schedule,90% of UHC fee schedule,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,11.38,100,,,Fee Schedule,100% of TX Medicaid Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,112.06,100,,89.648,Percent of Total Billed Charges,100% of Total Billed Charges,10.98,112.06,
"BLASTOMYCES,AB",70061981,CDM,302,RC,86612,HCPCS,Outpatient,,,130.25,78.15,,14.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,36.12,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.28,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,46.44,360,,,Fee Schedule,360% of BCBS POS Rate,46.44,360,,,Fee schedule,360% of BCBS PPO Rate,46.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,78.15,60,,62.52,Percent of Total Billed Charges,60% of Total Billed Charges,10.84,100,,,Fee Schedule,100% of TX Mediciad 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,11.61,90,,,Fee Schedule,90% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,130,,,Fee Schedule,130% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,11.17,103,,,Fee Schedule,103% of TX Medicaid Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,13.28,103,,,Fee Schedule,103% of CMS OPPS Rate,97.69,75,,78.152,Percent of Total Billed Charges,75% of Total Billed Charges,21.93,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.93,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.93,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.35,150,,,Fee Schedule,150% of CMS OPPS Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.45,90,,,Fee Schedule,90% of UHC fee schedule,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,10.84,100,,,Fee Schedule,100% of TX Medicaid Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,130.25,100,,104.2,Percent of Total Billed Charges,100% of Total Billed Charges,10.45,130.25,
AB ANTI DS DNA,70062203,CDM,302,RC,86225,HCPCS,Outpatient,,,219.52,131.71,,15.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,49.46,360,,,Fee Schedule,360% of BCBS POS Rate,49.46,360,,,Fee schedule,360% of BCBS PPO Rate,49.46,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,11.54,100,,,Fee Schedule,100% of TX Mediciad 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,12.36,90,,,Fee Schedule,90% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,17.86,130,,,Fee Schedule,130% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.89,103,,,Fee Schedule,103% of TX Medicaid Rate,14.15,103,,,Fee Schedule,103% of CMS OPPS Rate,14.15,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,23.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.61,150,,,Fee Schedule,150% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,90,,,Fee Schedule,90% of UHC fee schedule,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,11.54,100,,,Fee Schedule,100% of TX Medicaid Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,11.13,219.52,
AB AUTOAB TO SM,70062229,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
AB AUTOAB TO JO 1,70062393,CDM,302,RC,86235,HCPCS,Outpatient,,,182.5,109.50,,20.8,100,,,Fee Schedule,100% of Aetna Fee Schedule,26.89,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,57.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,64.55,360,,,Fee Schedule,360% of BCBS POS Rate,64.55,360,,,Fee schedule,360% of BCBS PPO Rate,64.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,109.5,60,,87.6,Percent of Total Billed Charges,60% of Total Billed Charges,15.06,100,,,Fee Schedule,100% of TX Mediciad 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,16.13,90,,,Fee Schedule,90% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,130,,,Fee Schedule,130% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.51,103,,,Fee Schedule,103% of TX Medicaid Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,18.46,103,,,Fee Schedule,103% of CMS OPPS Rate,136.88,75,,109.504,Percent of Total Billed Charges,75% of Total Billed Charges,30.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,30.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,30.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,26.89,150,,,Fee Schedule,150% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,90,,,Fee Schedule,90% of UHC fee schedule,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,15.06,100,,,Fee Schedule,100% of TX Medicaid Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,182.5,100,,146,Percent of Total Billed Charges,100% of Total Billed Charges,14.53,182.5,
AB PARVOVIRUS B19 IGG,70062468,CDM,302,RC,86747,HCPCS,Outpatient,,,159.79,95.87,,17.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,42.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.1,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,54.11,360,,,Fee Schedule,360% of BCBS POS Rate,54.11,360,,,Fee schedule,360% of BCBS PPO Rate,54.11,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.87,60,,76.696,Percent of Total Billed Charges,60% of Total Billed Charges,12.63,100,,,Fee Schedule,100% of TX Mediciad 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,13.52,90,,,Fee Schedule,90% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,130,,,Fee Schedule,130% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,103,,,Fee Schedule,103% of TX Medicaid Rate,15.48,103,,,Fee Schedule,103% of CMS OPPS Rate,15.48,103,,,Fee Schedule,103% of CMS OPPS Rate,119.84,75,,95.872,Percent of Total Billed Charges,75% of Total Billed Charges,25.55,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.55,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,25.55,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.55,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.54,150,,,Fee Schedule,150% of CMS OPPS Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,12.18,90,,,Fee Schedule,90% of UHC fee schedule,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,12.63,100,,,Fee Schedule,100% of TX Medicaid Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,159.79,100,,127.832,Percent of Total Billed Charges,100% of Total Billed Charges,12.18,159.79,
"LYME DISEASE AB (IGG,IGM)",70062575,CDM,302,RC,86617,HCPCS,Outpatient,,,169,101.40,,17.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.23,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,43.37,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.57,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,55.76,360,,,Fee Schedule,360% of BCBS POS Rate,55.76,360,,,Fee schedule,360% of BCBS PPO Rate,55.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,101.4,60,,81.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,100,,,Fee Schedule,100% of TX Mediciad 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,13.94,90,,,Fee Schedule,90% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,130,,,Fee Schedule,130% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.4,103,,,Fee Schedule,103% of TX Medicaid Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,15.95,103,,,Fee Schedule,103% of CMS OPPS Rate,126.75,75,,101.4,Percent of Total Billed Charges,75% of Total Billed Charges,26.33,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.33,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.33,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.23,150,,,Fee Schedule,150% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.55,90,,,Fee Schedule,90% of UHC fee schedule,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,13.01,100,,,Fee Schedule,100% of TX Medicaid Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,169,100,,135.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.55,169,
AB LEGIONELLA,70062583,CDM,302,RC,86713,HCPCS,Outpatient,,,924,554.40,,17.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,48.96,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,55.08,360,,,Fee Schedule,360% of BCBS POS Rate,55.08,360,,,Fee schedule,360% of BCBS PPO Rate,55.08,360,,,Fee Schedule,360% of BCBS Traditional Rate,554.4,60,,443.52,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,100,,,Fee Schedule,100% of TX Mediciad 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,13.77,90,,,Fee Schedule,90% of CMS OPPS Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,130,,,Fee Schedule,130% of CMS OPPS Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,103,,,Fee Schedule,103% of TX Medicaid Rate,15.75,103,,,Fee Schedule,103% of CMS OPPS Rate,15.75,103,,,Fee Schedule,103% of CMS OPPS Rate,693,75,,554.4,Percent of Total Billed Charges,75% of Total Billed Charges,26.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.95,150,,,Fee Schedule,150% of CMS OPPS Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,90,,,Fee Schedule,90% of UHC fee schedule,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,12.85,100,,,Fee Schedule,100% of TX Medicaid Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,924,100,,739.2,Percent of Total Billed Charges,100% of Total Billed Charges,12.39,924,
AB HEP B CORE TOTAL,70062898,CDM,302,RC,86704,HCPCS,Outpatient,,,144.5,86.70,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,86.7,60,,69.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,108.38,75,,86.704,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,144.5,100,,115.6,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,144.5,
"HEPATITIS A AB,TOTAL IGG/",70062914,CDM,302,RC,86708,HCPCS,Outpatient,,,170,102.00,,14.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.69,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,39.65,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,44.6,360,,,Fee Schedule,360% of BCBS POS Rate,44.6,360,,,Fee schedule,360% of BCBS PPO Rate,44.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,102,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.41,100,,,Fee Schedule,100% of TX Mediciad 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,11.15,90,,,Fee Schedule,90% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,130,,,Fee Schedule,130% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.72,103,,,Fee Schedule,103% of TX Medicaid Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,12.76,103,,,Fee Schedule,103% of CMS OPPS Rate,127.5,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,21.06,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.06,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.06,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.58,150,,,Fee Schedule,150% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.04,90,,,Fee Schedule,90% of UHC fee schedule,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,10.41,100,,,Fee Schedule,100% of TX Medicaid Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,170,100,,136,Percent of Total Billed Charges,100% of Total Billed Charges,10.04,170,
HEP BE ANTIGEN,70062930,CDM,306,RC,87350,HCPCS,Outpatient,,,145,87.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,87,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,108.75,75,,87,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,145,100,,116,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,145,
AB HEPATITS BE,70062963,CDM,302,RC,86707,HCPCS,Outpatient,,,131.89,79.13,,13.42,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.02,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,41.65,360,,,Fee Schedule,360% of BCBS POS Rate,41.65,360,,,Fee schedule,360% of BCBS PPO Rate,41.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,79.13,60,,63.304,Percent of Total Billed Charges,60% of Total Billed Charges,9.72,100,,,Fee Schedule,100% of TX Mediciad 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,10.41,90,,,Fee Schedule,90% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,10.01,103,,,Fee Schedule,103% of TX Medicaid Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,11.91,103,,,Fee Schedule,103% of CMS OPPS Rate,98.92,75,,79.136,Percent of Total Billed Charges,75% of Total Billed Charges,19.66,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.66,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.66,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.66,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.35,150,,,Fee Schedule,150% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,9.37,90,,,Fee Schedule,90% of UHC fee schedule,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,9.72,100,,,Fee Schedule,100% of TX Medicaid Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,131.89,100,,105.512,Percent of Total Billed Charges,100% of Total Billed Charges,9.37,131.89,
AB HEPATITIS DELTA AGENT,70062971,CDM,302,RC,86692,HCPCS,Outpatient,,,167.59,100.55,,19.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.74,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.05,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,54.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,61.78,360,,,Fee Schedule,360% of BCBS POS Rate,61.78,360,,,Fee schedule,360% of BCBS PPO Rate,61.78,360,,,Fee Schedule,360% of BCBS Traditional Rate,100.55,60,,80.44,Percent of Total Billed Charges,60% of Total Billed Charges,14.41,100,,,Fee Schedule,100% of TX Mediciad 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,15.44,90,,,Fee Schedule,90% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,130,,,Fee Schedule,130% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.84,103,,,Fee Schedule,103% of TX Medicaid Rate,17.67,103,,,Fee Schedule,103% of CMS OPPS Rate,17.67,103,,,Fee Schedule,103% of CMS OPPS Rate,125.69,75,,100.552,Percent of Total Billed Charges,75% of Total Billed Charges,29.17,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.17,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.17,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.17,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.74,150,,,Fee Schedule,150% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,90,,,Fee Schedule,90% of UHC fee schedule,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of TX Medicaid Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,167.59,100,,134.072,Percent of Total Billed Charges,100% of Total Billed Charges,13.9,167.59,
AB HERPES SIMPLEX TYPE 1,70062989,CDM,302,RC,86695,HCPCS,Outpatient,,,136.34,81.80,,15.3,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.78,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.21,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,47.48,360,,,Fee Schedule,360% of BCBS POS Rate,47.48,360,,,Fee schedule,360% of BCBS PPO Rate,47.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.8,60,,65.44,Percent of Total Billed Charges,60% of Total Billed Charges,11.08,100,,,Fee Schedule,100% of TX Mediciad 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,11.87,90,,,Fee Schedule,90% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,130,,,Fee Schedule,130% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.41,103,,,Fee Schedule,103% of TX Medicaid Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,13.58,103,,,Fee Schedule,103% of CMS OPPS Rate,102.26,75,,81.808,Percent of Total Billed Charges,75% of Total Billed Charges,22.42,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.42,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,22.42,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.42,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.78,150,,,Fee Schedule,150% of CMS OPPS Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.68,90,,,Fee Schedule,90% of UHC fee schedule,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,11.08,100,,,Fee Schedule,100% of TX Medicaid Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,136.34,100,,109.072,Percent of Total Billed Charges,100% of Total Billed Charges,10.68,136.34,
HERPES SIMPLEX TYPE 2 TEST,70062997,CDM,302,RC,86696,HCPCS,Outpatient,,,164.12,98.47,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.47,60,,78.776,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,123.09,75,,98.472,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,164.12,100,,131.296,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,164.12,
COMPLEMENT C3,70063326,CDM,302,RC,86160,HCPCS,Outpatient,,,179,107.40,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,134.25,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,179,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,179,
COMPLEMENT C4,70063334,CDM,302,RC,86160,HCPCS,Outpatient,,,179,107.40,,13.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,18,150,,,Fee Schedule ,150% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,43.2,360,,,Fee Schedule,360% of BCBS POS Rate,43.2,360,,,Fee schedule,360% of BCBS PPO Rate,43.2,360,,,Fee Schedule,360% of BCBS Traditional Rate,107.4,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,10.08,100,,,Fee Schedule,100% of TX Mediciad 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,10.8,90,,,Fee Schedule,90% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,130,,,Fee Schedule,130% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.38,103,,,Fee Schedule,103% of TX Medicaid Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,12.36,103,,,Fee Schedule,103% of CMS OPPS Rate,134.25,75,,107.4,Percent of Total Billed Charges,75% of Total Billed Charges,20.4,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.4,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,20.4,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.4,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18,150,,,Fee Schedule,150% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,90,,,Fee Schedule,90% of UHC fee schedule,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,10.08,100,,,Fee Schedule,100% of TX Medicaid Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,179,100,,143.2,Percent of Total Billed Charges,100% of Total Billed Charges,9.72,179,
IMMUNOFIXATION ELECTROPH SERUM,70063409,CDM,302,RC,86334,HCPCS,Outpatient,,,267.72,160.63,,25.92,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.51,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,71.49,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,80.42,360,,,Fee Schedule,360% of BCBS POS Rate,80.42,360,,,Fee schedule,360% of BCBS PPO Rate,80.42,360,,,Fee Schedule,360% of BCBS Traditional Rate,160.63,60,,128.504,Percent of Total Billed Charges,60% of Total Billed Charges,18.77,100,,,Fee Schedule,100% of TX Mediciad 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,20.1,90,,,Fee Schedule,90% of CMS OPPS Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,29.04,130,,,Fee Schedule,130% of CMS OPPS Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,19.33,103,,,Fee Schedule,103% of TX Medicaid Rate,23.01,103,,,Fee Schedule,103% of CMS OPPS Rate,23.01,103,,,Fee Schedule,103% of CMS OPPS Rate,200.79,75,,160.632,Percent of Total Billed Charges,75% of Total Billed Charges,37.97,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.97,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,37.97,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.97,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,33.51,150,,,Fee Schedule,150% of CMS OPPS Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,18.1,90,,,Fee Schedule,90% of UHC fee schedule,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,18.77,100,,,Fee Schedule,100% of TX Medicaid Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,267.72,100,,214.176,Percent of Total Billed Charges,100% of Total Billed Charges,18.1,267.72,
T CELLS;T4/T8,70063607,CDM,302,RC,86360,HCPCS,Outpatient,,,362.23,217.34,,54.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,70.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,150.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,169.13,360,,,Fee Schedule,360% of BCBS POS Rate,169.13,360,,,Fee schedule,360% of BCBS PPO Rate,169.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,217.34,60,,173.872,Percent of Total Billed Charges,60% of Total Billed Charges,39.46,100,,,Fee Schedule,100% of TX Mediciad 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,42.28,90,,,Fee Schedule,90% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.07,130,,,Fee Schedule,130% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,40.64,103,,,Fee Schedule,103% of TX Medicaid Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,271.67,75,,217.336,Percent of Total Billed Charges,75% of Total Billed Charges,79.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,79.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,79.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,79.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,70.46,150,,,Fee Schedule,150% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.05,90,,,Fee Schedule,90% of UHC fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,362.23,100,,289.784,Percent of Total Billed Charges,100% of Total Billed Charges,38.05,362.23,
T HELPER/INDUCER PANEL,70063615,CDM,302,RC,86361,HCPCS,Outpatient,,,232,139.20,,31.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,40.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,85.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,96.41,360,,,Fee Schedule,360% of BCBS POS Rate,96.41,360,,,Fee schedule,360% of BCBS PPO Rate,96.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,139.2,60,,111.36,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,100,,,Fee Schedule,100% of TX Mediciad 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,24.1,90,,,Fee Schedule,90% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,130,,,Fee Schedule,130% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,23.18,103,,,Fee Schedule,103% of TX Medicaid Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,27.58,103,,,Fee Schedule,103% of CMS OPPS Rate,174,75,,139.2,Percent of Total Billed Charges,75% of Total Billed Charges,45.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,45.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,45.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,40.17,150,,,Fee Schedule,150% of CMS OPPS Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.69,90,,,Fee Schedule,90% of UHC fee schedule,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,22.5,100,,,Fee Schedule,100% of TX Medicaid Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,232,100,,185.6,Percent of Total Billed Charges,100% of Total Billed Charges,21.69,232,
CRP HIGH SENSITIVITY,70063631,CDM,302,RC,86141,HCPCS,Outpatient,,,625.2,375.12,,15.02,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.42,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,46.62,360,,,Fee Schedule,360% of BCBS POS Rate,46.62,360,,,Fee schedule,360% of BCBS PPO Rate,46.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,375.12,60,,300.096,Percent of Total Billed Charges,60% of Total Billed Charges,10.88,100,,,Fee Schedule,100% of TX Mediciad 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,11.65,90,,,Fee Schedule,90% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,16.83,130,,,Fee Schedule,130% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,11.21,103,,,Fee Schedule,103% of TX Medicaid Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,13.33,103,,,Fee Schedule,103% of CMS OPPS Rate,468.9,75,,375.12,Percent of Total Billed Charges,75% of Total Billed Charges,22.01,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.01,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,22.01,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.01,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.42,150,,,Fee Schedule,150% of CMS OPPS Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,90,,,Fee Schedule,90% of UHC fee schedule,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,10.88,100,,,Fee Schedule,100% of TX Medicaid Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,625.2,100,,500.16,Percent of Total Billed Charges,100% of Total Billed Charges,10.49,625.2,
ANTI-MICROSOMAL ANTIBODY,70063771,CDM,302,RC,86376,HCPCS,Outpatient,,,172,103.20,,16.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,52.38,360,,,Fee Schedule,360% of BCBS POS Rate,52.38,360,,,Fee schedule,360% of BCBS PPO Rate,52.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,100,,,Fee Schedule,100% of TX Mediciad 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,13.09,90,,,Fee Schedule,90% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,18.91,130,,,Fee Schedule,130% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,103,,,Fee Schedule,103% of TX Medicaid Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,14.98,103,,,Fee Schedule,103% of CMS OPPS Rate,129,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,24.73,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.73,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,24.73,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.73,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.82,150,,,Fee Schedule,150% of CMS OPPS Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,90,,,Fee Schedule,90% of UHC fee schedule,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,12.22,100,,,Fee Schedule,100% of TX Medicaid Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,172,100,,137.6,Percent of Total Billed Charges,100% of Total Billed Charges,11.79,172,
AB ANTI SMOOTH MUSCLE,70063797,CDM,302,RC,86255,HCPCS,Outpatient,,,219.52,131.71,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,131.71,60,,105.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,164.64,75,,131.712,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.52,100,,175.616,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,219.52,
CARDIOLIPIN IGG ANTIBODY,70063821,CDM,302,RC,86147,HCPCS,Outpatient,,,214.93,128.96,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.96,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,161.2,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,214.93,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,214.93,
AB ANTI CARDIOLIPIN IGA,70063854,CDM,302,RC,86147,HCPCS,Outpatient,,,214.93,128.96,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.96,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,161.2,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,214.93,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,214.93,
AB ANTI CARDIOLIPIN IGM,70063862,CDM,302,RC,86147,HCPCS,Outpatient,,,214.93,128.96,,29.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.17,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,81.44,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,91.62,360,,,Fee Schedule,360% of BCBS POS Rate,91.62,360,,,Fee schedule,360% of BCBS PPO Rate,91.62,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.96,60,,103.168,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,100,,,Fee Schedule,100% of TX Mediciad 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,22.9,90,,,Fee Schedule,90% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,130,,,Fee Schedule,130% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,22.02,103,,,Fee Schedule,103% of TX Medicaid Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,26.21,103,,,Fee Schedule,103% of CMS OPPS Rate,161.2,75,,128.96,Percent of Total Billed Charges,75% of Total Billed Charges,43.26,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.26,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.26,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.17,150,,,Fee Schedule,150% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,90,,,Fee Schedule,90% of UHC fee schedule,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,21.38,100,,,Fee Schedule,100% of TX Medicaid Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,214.93,100,,171.944,Percent of Total Billed Charges,100% of Total Billed Charges,20.62,214.93,
ROCKY MT SPOTTED FEVER IG,70064373,CDM,302,RC,86757,HCPCS,Outpatient,,,156.2,93.72,,22.44,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,69.66,360,,,Fee Schedule,360% of BCBS POS Rate,69.66,360,,,Fee schedule,360% of BCBS PPO Rate,69.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,93.72,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,16.25,100,,,Fee Schedule,100% of TX Mediciad 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,17.41,90,,,Fee Schedule,90% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,130,,,Fee Schedule,130% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.74,103,,,Fee Schedule,103% of TX Medicaid Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,19.93,103,,,Fee Schedule,103% of CMS OPPS Rate,117.15,75,,93.72,Percent of Total Billed Charges,75% of Total Billed Charges,32.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,32.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,32.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.02,150,,,Fee Schedule,150% of CMS OPPS Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,90,,,Fee Schedule,90% of UHC fee schedule,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,16.25,100,,,Fee Schedule,100% of TX Medicaid Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.2,100,,124.96,Percent of Total Billed Charges,100% of Total Billed Charges,15.68,156.2,
AB WEST NILE IGG,70064720,CDM,302,RC,86789,HCPCS,Outpatient,,,166,99.60,,16.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,,Fee Schedule,360% of BCBS POS Rate,51.8,360,,,Fee schedule,360% of BCBS PPO Rate,51.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,99.6,60,,79.68,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of TX Mediciad 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,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,124.5,75,,99.6,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,166,100,,132.8,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,166,
TUBERCULOSIS AG,70064928,CDM,302,RC,86480,HCPCS,Outpatient,,,318.12,190.87,,71.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,92.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,173.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,198.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,223.13,360,,,Fee Schedule,360% of BCBS POS Rate,223.13,360,,,Fee schedule,360% of BCBS PPO Rate,223.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,190.87,60,,152.696,Percent of Total Billed Charges,60% of Total Billed Charges,52.06,100,,,Fee Schedule,100% of TX Mediciad 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,55.78,90,,,Fee Schedule,90% of CMS OPPS Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,80.57,130,,,Fee Schedule,130% of CMS OPPS Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,53.62,103,,,Fee Schedule,103% of TX Medicaid Rate,63.83,103,,,Fee Schedule,103% of CMS OPPS Rate,63.83,103,,,Fee Schedule,103% of CMS OPPS Rate,238.59,75,,190.872,Percent of Total Billed Charges,75% of Total Billed Charges,105.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,105.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,105.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,92.97,150,,,Fee Schedule,150% of CMS OPPS Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,50.2,90,,,Fee Schedule,90% of UHC fee schedule,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,52.06,100,,,Fee Schedule,100% of TX Medicaid Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,318.12,100,,254.496,Percent of Total Billed Charges,100% of Total Billed Charges,50.2,318.12,
HUMAN LEUKOCYTO AG B-27,70065982,CDM,302,RC,86812,HCPCS,Outpatient,,,305.5,183.30,,29.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,38.71,150,,,Fee Schedule ,150% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,72.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,82.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,92.92,360,,,Fee Schedule,360% of BCBS POS Rate,92.92,360,,,Fee schedule,360% of BCBS PPO Rate,92.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,183.3,60,,146.64,Percent of Total Billed Charges,60% of Total Billed Charges,21.68,100,,,Fee Schedule,100% of TX Mediciad 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,23.22,90,,,Fee Schedule,90% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,33.55,130,,,Fee Schedule,130% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,22.33,103,,,Fee Schedule,103% of TX Medicaid Rate,26.58,103,,,Fee Schedule,103% of CMS OPPS Rate,26.58,103,,,Fee Schedule,103% of CMS OPPS Rate,229.13,75,,183.304,Percent of Total Billed Charges,75% of Total Billed Charges,43.87,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,43.87,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,43.87,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,43.87,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,38.71,150,,,Fee Schedule,150% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.91,90,,,Fee Schedule,90% of UHC fee schedule,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,21.68,100,,,Fee Schedule,100% of TX Medicaid Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,305.5,100,,244.4,Percent of Total Billed Charges,100% of Total Billed Charges,20.91,305.5,
CMV ANTIBODY IGM,70066451,CDM,302,RC,86645,HCPCS,Outpatient,,,188.11,112.87,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,112.87,60,,90.296,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,141.08,75,,112.864,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,188.11,100,,150.488,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,188.11,
TREPONEMAL AB (MHA-TP),70066501,CDM,302,RC,86780,HCPCS,Outpatient,,,136.43,81.86,,15.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,47.66,360,,,Fee Schedule,360% of BCBS POS Rate,47.66,360,,,Fee schedule,360% of BCBS PPO Rate,47.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.86,60,,65.488,Percent of Total Billed Charges,60% of Total Billed Charges,11.12,100,,,Fee Schedule,100% of TX Mediciad 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,11.91,90,,,Fee Schedule,90% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,130,,,Fee Schedule,130% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.45,103,,,Fee Schedule,103% of TX Medicaid Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,102.32,75,,81.856,Percent of Total Billed Charges,75% of Total Billed Charges,22.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.73,90,,,Fee Schedule,90% of UHC fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,136.43,100,,109.144,Percent of Total Billed Charges,100% of Total Billed Charges,10.73,136.43,
AB T PALLIDUM CONFIRM IGG,70066502,CDM,302,RC,86780,HCPCS,Outpatient,,,136.43,81.86,,15.36,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.86,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.37,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,47.66,360,,,Fee Schedule,360% of BCBS POS Rate,47.66,360,,,Fee schedule,360% of BCBS PPO Rate,47.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,81.86,60,,65.488,Percent of Total Billed Charges,60% of Total Billed Charges,11.12,100,,,Fee Schedule,100% of TX Mediciad 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,11.91,90,,,Fee Schedule,90% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,130,,,Fee Schedule,130% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.45,103,,,Fee Schedule,103% of TX Medicaid Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,13.63,103,,,Fee Schedule,103% of CMS OPPS Rate,102.32,75,,81.856,Percent of Total Billed Charges,75% of Total Billed Charges,22.5,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.5,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.5,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.86,150,,,Fee Schedule,150% of CMS OPPS Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,10.73,90,,,Fee Schedule,90% of UHC fee schedule,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,11.12,100,,,Fee Schedule,100% of TX Medicaid Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,136.43,100,,109.144,Percent of Total Billed Charges,100% of Total Billed Charges,10.73,136.43,
AB MUMPS IGM,70067129,CDM,302,RC,86735,HCPCS,Outpatient,,,148.88,89.33,,15.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.57,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,36.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,360,,,Fee Schedule,360% of BCBS POS Rate,46.98,360,,,Fee schedule,360% of BCBS PPO Rate,46.98,360,,,Fee Schedule,360% of BCBS Traditional Rate,89.33,60,,71.464,Percent of Total Billed Charges,60% of Total Billed Charges,10.96,100,,,Fee Schedule,100% of TX Mediciad 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,11.74,90,,,Fee Schedule,90% of CMS OPPS Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.96,130,,,Fee Schedule,130% of CMS OPPS Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,11.29,103,,,Fee Schedule,103% of TX Medicaid Rate,13.44,103,,,Fee Schedule,103% of CMS OPPS Rate,13.44,103,,,Fee Schedule,103% of CMS OPPS Rate,111.66,75,,89.328,Percent of Total Billed Charges,75% of Total Billed Charges,22.18,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.18,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.18,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.18,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.57,150,,,Fee Schedule,150% of CMS OPPS Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,90,,,Fee Schedule,90% of UHC fee schedule,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,10.96,100,,,Fee Schedule,100% of TX Medicaid Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,148.88,100,,119.104,Percent of Total Billed Charges,100% of Total Billed Charges,10.58,148.88,
AB WEST NILE IGM,70067962,CDM,302,RC,86788,HCPCS,Outpatient,,,158.75,95.25,,19.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.27,150,,,Fee Schedule ,150% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,53.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,60.66,360,,,Fee Schedule,360% of BCBS POS Rate,60.66,360,,,Fee schedule,360% of BCBS PPO Rate,60.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.25,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,14.15,100,,,Fee Schedule,100% of TX Mediciad 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,15.16,90,,,Fee Schedule,90% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,130,,,Fee Schedule,130% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.57,103,,,Fee Schedule,103% of TX Medicaid Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,17.35,103,,,Fee Schedule,103% of CMS OPPS Rate,119.06,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,28.64,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,28.64,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28.64,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,28.64,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.27,150,,,Fee Schedule,150% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.65,90,,,Fee Schedule,90% of UHC fee schedule,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,14.15,100,,,Fee Schedule,100% of TX Medicaid Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,158.75,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,13.65,158.75,
IA TUMOR AG CA 125 QT,70069000,CDM,302,RC,86304,HCPCS,Outpatient,,,259,155.40,,24.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,31.21,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,66.59,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,74.92,360,,,Fee Schedule,360% of BCBS POS Rate,74.92,360,,,Fee schedule,360% of BCBS PPO Rate,74.92,360,,,Fee Schedule,360% of BCBS Traditional Rate,155.4,60,,124.32,Percent of Total Billed Charges,60% of Total Billed Charges,17.48,100,,,Fee Schedule,100% of TX Mediciad 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,18.72,90,,,Fee Schedule,90% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.05,130,,,Fee Schedule,130% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,18,103,,,Fee Schedule,103% of TX Medicaid Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,21.43,103,,,Fee Schedule,103% of CMS OPPS Rate,194.25,75,,155.4,Percent of Total Billed Charges,75% of Total Billed Charges,35.37,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,35.37,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,35.37,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,31.21,150,,,Fee Schedule,150% of CMS OPPS Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,16.86,90,,,Fee Schedule,90% of UHC fee schedule,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,17.48,100,,,Fee Schedule,100% of TX Medicaid Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,259,100,,207.2,Percent of Total Billed Charges,100% of Total Billed Charges,16.86,259,
TOXOPLASMA IGM ANTIBODY,70069091,CDM,302,RC,86778,HCPCS,Outpatient,,,180,108.00,,16.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,40.35,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.11,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,51.88,360,,,Fee Schedule,360% of BCBS POS Rate,51.88,360,,,Fee schedule,360% of BCBS PPO Rate,51.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,108,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,12.1,100,,,Fee Schedule,100% of TX Mediciad 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,12.96,90,,,Fee Schedule,90% of CMS OPPS Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,18.73,130,,,Fee Schedule,130% of CMS OPPS Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.46,103,,,Fee Schedule,103% of TX Medicaid Rate,14.84,103,,,Fee Schedule,103% of CMS OPPS Rate,14.84,103,,,Fee Schedule,103% of CMS OPPS Rate,135,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,24.49,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.49,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,24.49,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.49,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.61,150,,,Fee Schedule,150% of CMS OPPS Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,90,,,Fee Schedule,90% of UHC fee schedule,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,12.1,100,,,Fee Schedule,100% of TX Medicaid Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,180,100,,144,Percent of Total Billed Charges,100% of Total Billed Charges,11.67,180,
CMV ANTIBODY,70069109,CDM,302,RC,86644,HCPCS,Outpatient,,,177.71,106.63,,16.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,,Fee Schedule,360% of BCBS POS Rate,51.8,360,,,Fee schedule,360% of BCBS PPO Rate,51.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,106.63,60,,85.304,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of TX Mediciad 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,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,133.28,75,,106.624,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,177.71,100,,142.168,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,177.71,
"CHLAMYD,PNEU,IGG",70069182,CDM,302,RC,86631,HCPCS,Outpatient,,,124.79,74.87,,13.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.73,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,33.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,42.55,360,,,Fee Schedule,360% of BCBS POS Rate,42.55,360,,,Fee schedule,360% of BCBS PPO Rate,42.55,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.87,60,,59.896,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,100,,,Fee Schedule,100% of TX Mediciad 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,10.63,90,,,Fee Schedule,90% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,130,,,Fee Schedule,130% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,10.23,103,,,Fee Schedule,103% of TX Medicaid Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,12.17,103,,,Fee Schedule,103% of CMS OPPS Rate,93.59,75,,74.872,Percent of Total Billed Charges,75% of Total Billed Charges,20.09,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.09,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,20.09,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.09,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.73,150,,,Fee Schedule,150% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,90,,,Fee Schedule,90% of UHC fee schedule,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,9.93,100,,,Fee Schedule,100% of TX Medicaid Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,124.79,100,,99.832,Percent of Total Billed Charges,100% of Total Billed Charges,9.58,124.79,
TOXOPLASMA IGG ANTIBODY,70069208,CDM,302,RC,86777,HCPCS,Outpatient,,,170,102.00,,16.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,21.58,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,46.05,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,51.8,360,,,Fee Schedule,360% of BCBS POS Rate,51.8,360,,,Fee schedule,360% of BCBS PPO Rate,51.8,360,,,Fee Schedule,360% of BCBS Traditional Rate,102,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,12.09,100,,,Fee Schedule,100% of TX Mediciad 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,12.95,90,,,Fee Schedule,90% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.7,130,,,Fee Schedule,130% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.45,103,,,Fee Schedule,103% of TX Medicaid Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,14.82,103,,,Fee Schedule,103% of CMS OPPS Rate,127.5,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,24.46,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,24.46,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.46,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,24.46,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,21.58,150,,,Fee Schedule,150% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,12.09,100,,,Fee Schedule,100% of TX Medicaid Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,170,100,,136,Percent of Total Billed Charges,100% of Total Billed Charges,11.66,170,
NEOCYTE HARVEST,70069729,CDM,300,RC,86972,HCPCS,Outpatient,,,161.45,96.87,,50.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,96.87,60,,77.496,Percent of Total Billed Charges,60% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,23.28,14.42,,18.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,121.09,75,,96.872,Percent of Total Billed Charges,75% of Total Billed Charges,80.73,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,80.73,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,80.73,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,80.73,50,,64.584,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,22.6,14,,18.08,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,161.45,100,,129.16,Percent of Total Billed Charges,100% of Total Billed Charges,22.6,516.6,
"CULTURE, HERPES SIMPLEX",70070842,CDM,306,RC,87252,HCPCS,Outpatient,,,345.05,207.03,,30.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,83.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,93.85,360,,,Fee Schedule,360% of BCBS POS Rate,93.85,360,,,Fee schedule,360% of BCBS PPO Rate,93.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,207.03,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,21.9,100,,,Fee Schedule,100% of TX Mediciad 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,23.46,90,,,Fee Schedule,90% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.89,130,,,Fee Schedule,130% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,22.56,103,,,Fee Schedule,103% of TX Medicaid Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,258.79,75,,207.032,Percent of Total Billed Charges,75% of Total Billed Charges,44.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,44.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,44.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,39.1,150,,,Fee Schedule,150% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.11,90,,,Fee Schedule,90% of UHC fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,345.05,100,,276.04,Percent of Total Billed Charges,100% of Total Billed Charges,21.11,345.05,
CX FUNGI W PRESUMP OTH SOURCE,70071022,CDM,306,RC,87102,HCPCS,Outpatient,,,218.3,130.98,,9.76,100,,,Fee Schedule,100% of Aetna Fee Schedule,12.61,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,23.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,26.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,30.28,360,,,Fee Schedule,360% of BCBS POS Rate,30.28,360,,,Fee schedule,360% of BCBS PPO Rate,30.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,130.98,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,7.06,100,,,Fee Schedule,100% of TX Mediciad 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,7.56,90,,,Fee Schedule,90% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,10.93,130,,,Fee Schedule,130% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.27,103,,,Fee Schedule,103% of TX Medicaid Rate,8.66,103,,,Fee Schedule,103% of CMS OPPS Rate,8.66,103,,,Fee Schedule,103% of CMS OPPS Rate,163.73,75,,130.984,Percent of Total Billed Charges,75% of Total Billed Charges,14.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,14.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,14.29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,12.61,150,,,Fee Schedule,150% of CMS OPPS Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.81,90,,,Fee Schedule,90% of UHC fee schedule,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,7.06,100,,,Fee Schedule,100% of TX Medicaid Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,100,,174.64,Percent of Total Billed Charges,100% of Total Billed Charges,6.81,218.3,
"CULT,FUNG,BLD",70071030,CDM,306,RC,87103,HCPCS,Outpatient,,,246,147.60,,23.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,30.69,150,,,Fee Schedule ,150% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,57.29,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,65.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,73.66,360,,,Fee Schedule,360% of BCBS POS Rate,73.66,360,,,Fee schedule,360% of BCBS PPO Rate,73.66,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.6,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,17.19,100,,,Fee Schedule,100% of TX Mediciad 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,18.41,90,,,Fee Schedule,90% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,130,,,Fee Schedule,130% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.71,103,,,Fee Schedule,103% of TX Medicaid Rate,21.07,103,,,Fee Schedule,103% of CMS OPPS Rate,21.07,103,,,Fee Schedule,103% of CMS OPPS Rate,184.5,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,34.78,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,34.78,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,34.78,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,34.78,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,30.69,150,,,Fee Schedule,150% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.57,90,,,Fee Schedule,90% of UHC fee schedule,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,17.19,100,,,Fee Schedule,100% of TX Medicaid Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,246,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,16.57,246,
"CULTURE, CHLAMYDIA",70071105,CDM,306,RC,87110,HCPCS,Outpatient,,,246,147.60,,22.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,29.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,62.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,70.56,360,,,Fee Schedule,360% of BCBS POS Rate,70.56,360,,,Fee schedule,360% of BCBS PPO Rate,70.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.6,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,16.46,100,,,Fee Schedule,100% of TX Mediciad 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,17.64,90,,,Fee Schedule,90% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,130,,,Fee Schedule,130% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.95,103,,,Fee Schedule,103% of TX Medicaid Rate,20.18,103,,,Fee Schedule,103% of CMS OPPS Rate,20.18,103,,,Fee Schedule,103% of CMS OPPS Rate,184.5,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,33.32,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,33.32,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,33.32,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,33.32,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,29.4,150,,,Fee Schedule,150% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.88,90,,,Fee Schedule,90% of UHC fee schedule,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,16.46,100,,,Fee Schedule,100% of TX Medicaid Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,246,100,,196.8,Percent of Total Billed Charges,100% of Total Billed Charges,15.88,246,
CULT AFB,70071162,CDM,306,RC,87116,HCPCS,Outpatient,,,227,136.20,,12.52,100,,,Fee Schedule,100% of Aetna Fee Schedule,16.2,150,,,Fee Schedule ,150% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30.24,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,34.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,38.88,360,,,Fee Schedule,360% of BCBS POS Rate,38.88,360,,,Fee schedule,360% of BCBS PPO Rate,38.88,360,,,Fee Schedule,360% of BCBS Traditional Rate,136.2,60,,108.96,Percent of Total Billed Charges,60% of Total Billed Charges,9.07,100,,,Fee Schedule,100% of TX Mediciad 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,9.72,90,,,Fee Schedule,90% of CMS OPPS Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.04,130,,,Fee Schedule,130% of CMS OPPS Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.34,103,,,Fee Schedule,103% of TX Medicaid Rate,11.12,103,,,Fee Schedule,103% of CMS OPPS Rate,11.12,103,,,Fee Schedule,103% of CMS OPPS Rate,170.25,75,,136.2,Percent of Total Billed Charges,75% of Total Billed Charges,18.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,18.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,18.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,16.2,150,,,Fee Schedule,150% of CMS OPPS Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.75,90,,,Fee Schedule,90% of UHC fee schedule,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,9.07,100,,,Fee Schedule,100% of TX Medicaid Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,227,100,,181.6,Percent of Total Billed Charges,100% of Total Billed Charges,8.75,227,
OVA AND PARASITES,70071774,CDM,306,RC,87177,HCPCS,Outpatient,,,164,98.40,,10.32,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.35,150,,,Fee Schedule ,150% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,24.92,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,28.48,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,32.04,360,,,Fee Schedule,360% of BCBS POS Rate,32.04,360,,,Fee schedule,360% of BCBS PPO Rate,32.04,360,,,Fee Schedule,360% of BCBS Traditional Rate,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.48,100,,,Fee Schedule,100% of TX Mediciad 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,8.01,90,,,Fee Schedule,90% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,130,,,Fee Schedule,130% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.7,103,,,Fee Schedule,103% of TX Medicaid Rate,9.16,103,,,Fee Schedule,103% of CMS OPPS Rate,9.16,103,,,Fee Schedule,103% of CMS OPPS Rate,123,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.13,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.13,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,15.13,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.13,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.35,150,,,Fee Schedule,150% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.21,90,,,Fee Schedule,90% of UHC fee schedule,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,7.48,100,,,Fee Schedule,100% of TX Medicaid Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,164,100,,131.2,Percent of Total Billed Charges,100% of Total Billed Charges,7.21,164,
"VISCOSITY, SERUM",70071923,CDM,305,RC,85810,HCPCS,Outpatient,,,124.12,74.47,,13.54,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,32.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,37.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,42.01,360,,,Fee Schedule,360% of BCBS POS Rate,42.01,360,,,Fee schedule,360% of BCBS PPO Rate,42.01,360,,,Fee Schedule,360% of BCBS Traditional Rate,74.47,60,,59.576,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,100,,,Fee Schedule,100% of TX Mediciad 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,10.5,90,,,Fee Schedule,90% of CMS OPPS Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,15.17,130,,,Fee Schedule,130% of CMS OPPS Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,10.09,103,,,Fee Schedule,103% of TX Medicaid Rate,12.02,103,,,Fee Schedule,103% of CMS OPPS Rate,12.02,103,,,Fee Schedule,103% of CMS OPPS Rate,93.09,75,,74.472,Percent of Total Billed Charges,75% of Total Billed Charges,19.83,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.83,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,19.83,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.83,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.5,150,,,Fee Schedule,150% of CMS OPPS Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,9.45,90,,,Fee Schedule,90% of UHC fee schedule,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,9.8,100,,,Fee Schedule,100% of TX Medicaid Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,124.12,100,,99.296,Percent of Total Billed Charges,100% of Total Billed Charges,9.45,124.12,
CX VIRAL,70072509,CDM,306,RC,87252,HCPCS,Outpatient,,,345.05,207.03,,30.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,39.1,150,,,Fee Schedule ,150% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,73,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,83.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,93.85,360,,,Fee Schedule,360% of BCBS POS Rate,93.85,360,,,Fee schedule,360% of BCBS PPO Rate,93.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,207.03,60,,165.624,Percent of Total Billed Charges,60% of Total Billed Charges,21.9,100,,,Fee Schedule,100% of TX Mediciad 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,23.46,90,,,Fee Schedule,90% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.89,130,,,Fee Schedule,130% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,22.56,103,,,Fee Schedule,103% of TX Medicaid Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,26.85,103,,,Fee Schedule,103% of CMS OPPS Rate,258.79,75,,207.032,Percent of Total Billed Charges,75% of Total Billed Charges,44.31,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,44.31,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.31,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,44.31,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,39.1,150,,,Fee Schedule,150% of CMS OPPS Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.11,90,,,Fee Schedule,90% of UHC fee schedule,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,21.9,100,,,Fee Schedule,100% of TX Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,345.05,100,,276.04,Percent of Total Billed Charges,100% of Total Billed Charges,21.11,345.05,
DFA LEGIONELLA,70072780,CDM,306,RC,87278,HCPCS,Outpatient,,,192.16,115.30,,18.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,23.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,49.92,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,56.16,360,,,Fee Schedule,360% of BCBS POS Rate,56.16,360,,,Fee schedule,360% of BCBS PPO Rate,56.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,115.3,60,,92.24,Percent of Total Billed Charges,60% of Total Billed Charges,13.1,100,,,Fee Schedule,100% of TX Mediciad 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,14.04,90,,,Fee Schedule,90% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,130,,,Fee Schedule,130% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.49,103,,,Fee Schedule,103% of TX Medicaid Rate,16.06,103,,,Fee Schedule,103% of CMS OPPS Rate,16.06,103,,,Fee Schedule,103% of CMS OPPS Rate,144.12,75,,115.296,Percent of Total Billed Charges,75% of Total Billed Charges,26.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,26.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,26.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,23.4,150,,,Fee Schedule,150% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.64,90,,,Fee Schedule,90% of UHC fee schedule,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,13.1,100,,,Fee Schedule,100% of TX Medicaid Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,192.16,100,,153.728,Percent of Total Billed Charges,100% of Total Billed Charges,12.64,192.16,
IF RSV SMEAR,70072806,CDM,306,RC,87280,HCPCS,Outpatient,,,139.77,83.86,,15.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,37.58,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,48.31,360,,,Fee Schedule,360% of BCBS POS Rate,48.31,360,,,Fee schedule,360% of BCBS PPO Rate,48.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.86,60,,67.088,Percent of Total Billed Charges,60% of Total Billed Charges,11.27,100,,,Fee Schedule,100% of TX Mediciad 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,12.07,90,,,Fee Schedule,90% of CMS OPPS Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.44,130,,,Fee Schedule,130% of CMS OPPS Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.61,103,,,Fee Schedule,103% of TX Medicaid Rate,13.82,103,,,Fee Schedule,103% of CMS OPPS Rate,13.82,103,,,Fee Schedule,103% of CMS OPPS Rate,104.83,75,,83.864,Percent of Total Billed Charges,75% of Total Billed Charges,22.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,22.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.13,150,,,Fee Schedule,150% of CMS OPPS Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,10.87,90,,,Fee Schedule,90% of UHC fee schedule,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,11.27,100,,,Fee Schedule,100% of TX Medicaid Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,139.77,100,,111.816,Percent of Total Billed Charges,100% of Total Billed Charges,10.87,139.77,
EIA GIARDIA,70073283,CDM,306,RC,87329,HCPCS,Outpatient,,,136.75,82.05,,13.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.97,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,43.13,360,,,Fee Schedule,360% of BCBS POS Rate,43.13,360,,,Fee schedule,360% of BCBS PPO Rate,43.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,82.05,60,,65.64,Percent of Total Billed Charges,60% of Total Billed Charges,10.06,100,,,Fee Schedule,100% of TX Mediciad 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,10.78,90,,,Fee Schedule,90% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,130,,,Fee Schedule,130% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.36,103,,,Fee Schedule,103% of TX Medicaid Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,12.33,103,,,Fee Schedule,103% of CMS OPPS Rate,102.56,75,,82.048,Percent of Total Billed Charges,75% of Total Billed Charges,20.36,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.36,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.36,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.36,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.97,150,,,Fee Schedule,150% of CMS OPPS Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,90,,,Fee Schedule,90% of UHC fee schedule,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,10.06,100,,,Fee Schedule,100% of TX Medicaid Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,136.75,100,,109.4,Percent of Total Billed Charges,100% of Total Billed Charges,9.7,136.75,
HISTOPLASMA ANTIGEN,70073861,CDM,306,RC,87385,HCPCS,Outpatient,,,260.67,156.40,,15.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,42.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,47.7,360,,,Fee Schedule,360% of BCBS POS Rate,47.7,360,,,Fee schedule,360% of BCBS PPO Rate,47.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,156.4,60,,125.12,Percent of Total Billed Charges,60% of Total Billed Charges,11.13,100,,,Fee Schedule,100% of TX Mediciad 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,11.92,90,,,Fee Schedule,90% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,130,,,Fee Schedule,130% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.46,103,,,Fee Schedule,103% of TX Medicaid Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,13.64,103,,,Fee Schedule,103% of CMS OPPS Rate,195.5,75,,156.4,Percent of Total Billed Charges,75% of Total Billed Charges,22.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.87,150,,,Fee Schedule,150% of CMS OPPS Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,90,,,Fee Schedule,90% of UHC fee schedule,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,11.13,100,,,Fee Schedule,100% of TX Medicaid Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,260.67,100,,208.536,Percent of Total Billed Charges,100% of Total Billed Charges,10.74,260.67,
NUC ACD CHLAMYDIA AMPL PROBE,70074927,CDM,306,RC,87491,HCPCS,Outpatient,,,212,127.20,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,127.2,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,159,75,,127.2,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212,100,,169.6,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,212,
NUC ACD C DIFFICILE,70074935,CDM,306,RC,87493,HCPCS,Outpatient,,,292.33,175.40,,43.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,55.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,104.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,119.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,134.17,360,,,Fee Schedule,360% of BCBS POS Rate,134.17,360,,,Fee schedule,360% of BCBS PPO Rate,134.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,175.4,60,,140.32,Percent of Total Billed Charges,60% of Total Billed Charges,31.31,100,,,Fee Schedule,100% of TX Mediciad 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,33.54,90,,,Fee Schedule,90% of CMS OPPS Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.45,130,,,Fee Schedule,130% of CMS OPPS Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,32.25,103,,,Fee Schedule,103% of TX Medicaid Rate,38.38,103,,,Fee Schedule,103% of CMS OPPS Rate,38.38,103,,,Fee Schedule,103% of CMS OPPS Rate,219.25,75,,175.4,Percent of Total Billed Charges,75% of Total Billed Charges,63.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,63.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,63.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,63.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,55.9,150,,,Fee Schedule,150% of CMS OPPS Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,30.19,90,,,Fee Schedule,90% of UHC fee schedule,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,31.31,100,,,Fee Schedule,100% of TX Medicaid Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,292.33,100,,233.864,Percent of Total Billed Charges,100% of Total Billed Charges,30.19,292.33,
NUC ACD HEP C RNA QL,70075213,CDM,306,RC,87521,HCPCS,Outpatient,,,436.57,261.94,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,261.94,60,,209.552,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,327.43,75,,261.944,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,436.57,100,,349.256,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,436.57,
HEP C QUANT,70075221,CDM,300,RC,87522,HCPCS,Outpatient,,,563.83,338.30,,49.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,64.26,150,,,Fee Schedule ,150% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,137.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,154.22,360,,,Fee Schedule,360% of BCBS POS Rate,154.22,360,,,Fee schedule,360% of BCBS PPO Rate,154.22,360,,,Fee Schedule,360% of BCBS Traditional Rate,338.3,60,,270.64,Percent of Total Billed Charges,60% of Total Billed Charges,35.99,100,,,Fee Schedule,100% of TX Mediciad 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,38.55,90,,,Fee Schedule,90% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,130,,,Fee Schedule,130% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,37.07,103,,,Fee Schedule,103% of TX Medicaid Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,44.12,103,,,Fee Schedule,103% of CMS OPPS Rate,422.87,75,,338.296,Percent of Total Billed Charges,75% of Total Billed Charges,72.82,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,72.82,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,72.82,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,72.82,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,64.26,150,,,Fee Schedule,150% of CMS OPPS Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.7,90,,,Fee Schedule,90% of UHC fee schedule,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,35.99,100,,,Fee Schedule,100% of TX Medicaid Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,563.83,100,,451.064,Percent of Total Billed Charges,100% of Total Billed Charges,34.7,563.83,
AFB AMPLIFIED MTB,70075569,CDM,306,RC,87556,HCPCS,Outpatient,,,423.25,253.95,,48.34,100,,,Fee Schedule,100% of Aetna Fee Schedule,62.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,116.7,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,133.38,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,150.05,360,,,Fee Schedule,360% of BCBS POS Rate,150.05,360,,,Fee schedule,360% of BCBS PPO Rate,150.05,360,,,Fee Schedule,360% of BCBS Traditional Rate,253.95,60,,203.16,Percent of Total Billed Charges,60% of Total Billed Charges,35.01,100,,,Fee Schedule,100% of TX Mediciad 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,37.51,90,,,Fee Schedule,90% of CMS OPPS Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,54.18,130,,,Fee Schedule,130% of CMS OPPS Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,36.06,103,,,Fee Schedule,103% of TX Medicaid Rate,42.93,103,,,Fee Schedule,103% of CMS OPPS Rate,42.93,103,,,Fee Schedule,103% of CMS OPPS Rate,317.44,75,,253.952,Percent of Total Billed Charges,75% of Total Billed Charges,70.85,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,70.85,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,70.85,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,70.85,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,62.52,150,,,Fee Schedule,150% of CMS OPPS Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,33.76,90,,,Fee Schedule,90% of UHC fee schedule,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,35.01,100,,,Fee Schedule,100% of TX Medicaid Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,423.25,100,,338.6,Percent of Total Billed Charges,100% of Total Billed Charges,33.76,423.25,
NUC ACD NEISSERIA GON AMPL,70075924,CDM,306,RC,87591,HCPCS,Outpatient,,,209.54,125.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,125.72,60,,100.576,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,157.16,75,,125.728,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,209.54,100,,167.632,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,209.54,
PROMETH TPMT 6MT HPLC,70086708,CDM,301,RC,82542,HCPCS,Outpatient,,,271,162.60,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,162.6,60,,130.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,203.25,75,,162.6,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271,100,,216.8,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,271,
PROMETH TPMT ENZYME ACT RBC,70086709,CDM,301,RC,82657,HCPCS,Outpatient,,,229.97,137.98,,25.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,79.81,360,,,Fee Schedule,360% of BCBS POS Rate,79.81,360,,,Fee schedule,360% of BCBS PPO Rate,79.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,137.98,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,100,,,Fee Schedule,100% of TX Mediciad 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,19.95,90,,,Fee Schedule,90% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,28.82,130,,,Fee Schedule,130% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,19.18,103,,,Fee Schedule,103% of TX Medicaid Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,172.48,75,,137.984,Percent of Total Billed Charges,75% of Total Billed Charges,37.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,37.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,33.25,150,,,Fee Schedule,150% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,90,,,Fee Schedule,90% of UHC fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,229.97,100,,183.976,Percent of Total Billed Charges,100% of Total Billed Charges,17.96,229.97,
INFLUENZA DNA AMP PROB ADDL,70086717,CDM,306,RC,87503,HCPCS,Outpatient,,,157.16,94.30,,33.9,100,,,Fee Schedule,100% of Aetna Fee Schedule,43.83,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,81.82,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,105.19,360,,,Fee Schedule,360% of BCBS POS Rate,105.19,360,,,Fee schedule,360% of BCBS PPO Rate,105.19,360,,,Fee Schedule,360% of BCBS Traditional Rate,94.3,60,,75.44,Percent of Total Billed Charges,60% of Total Billed Charges,24.54,100,,,Fee Schedule,100% of TX Mediciad Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,90,,,Fee Schedule,90% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,37.98,130,,,Fee Schedule,130% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,25.28,103,,,Fee Schedule,103% of TX Medicaid Rate,30.09,103,,,Fee Schedule,103% of CMS OPPS Rate,30.09,103,,,Fee Schedule,103% of CMS OPPS Rate,117.87,75,,94.296,Percent of Total Billed Charges,75% of Total Billed Charges,49.67,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.67,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,49.67,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.67,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,43.83,150,,,Fee Schedule,150% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,23.67,90,,,Fee Schedule,90% of UHC fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,157.16,100,,125.728,Percent of Total Billed Charges,100% of Total Billed Charges,23.67,157.16,
IMMUNOASSAY NONANTIBODY,70086718,CDM,301,RC,83516,HCPCS,Outpatient,,,310,186.00,,13.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,17.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,36.9,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,41.51,360,,,Fee Schedule,360% of BCBS POS Rate,41.51,360,,,Fee schedule,360% of BCBS PPO Rate,41.51,360,,,Fee Schedule,360% of BCBS Traditional Rate,186,60,,148.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.69,100,,,Fee Schedule,100% of TX Mediciad 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,10.37,90,,,Fee Schedule,90% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,130,,,Fee Schedule,130% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.98,103,,,Fee Schedule,103% of TX Medicaid Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,11.87,103,,,Fee Schedule,103% of CMS OPPS Rate,232.5,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,19.6,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,19.6,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,19.6,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,17.29,150,,,Fee Schedule,150% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,90,,,Fee Schedule,90% of UHC fee schedule,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,9.69,100,,,Fee Schedule,100% of TX Medicaid Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,310,100,,248,Percent of Total Billed Charges,100% of Total Billed Charges,9.34,310,
ASSAY NEPHELOMETRY NOT SPEC,70086731,CDM,301,RC,83883,HCPCS,Outpatient,,,155,93.00,,15.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,20.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,43.52,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,48.96,360,,,Fee Schedule,360% of BCBS POS Rate,48.96,360,,,Fee schedule,360% of BCBS PPO Rate,48.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,93,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.42,100,,,Fee Schedule,100% of TX Mediciad 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,12.24,90,,,Fee Schedule,90% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,130,,,Fee Schedule,130% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.76,103,,,Fee Schedule,103% of TX Medicaid Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,14,103,,,Fee Schedule,103% of CMS OPPS Rate,116.25,75,,93,Percent of Total Billed Charges,75% of Total Billed Charges,23.12,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,23.12,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.12,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,23.12,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,20.4,150,,,Fee Schedule,150% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.02,90,,,Fee Schedule,90% of UHC fee schedule,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,11.42,100,,,Fee Schedule,100% of TX Medicaid Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,155,100,,124,Percent of Total Billed Charges,100% of Total Billed Charges,11.02,155,
IMMUNOASSAY QUANT NOS NONAB,70086732,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
MOPATH PROCEDURE LEVEL 6,70086733,CDM,310,RC,81405,HCPCS,Outpatient,,,1392.22,835.33,,349.56,100,,,Fee Schedule,100% of Aetna Fee Schedule,452.02,150,,,Fee Schedule ,150% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,843.78,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,964.32,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,1084.86,360,,,Fee Schedule,360% of BCBS POS Rate,1084.86,360,,,Fee schedule,360% of BCBS PPO Rate,1084.86,360,,,Fee Schedule,360% of BCBS Traditional Rate,835.33,60,,668.264,Percent of Total Billed Charges,60% of Total Billed Charges,253.13,100,,,Fee Schedule,100% of TX Mediciad 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,271.21,90,,,Fee Schedule,90% of CMS OPPS Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,391.75,130,,,Fee Schedule,130% of CMS OPPS Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,260.72,103,,,Fee Schedule,103% of TX Medicaid Rate,310.39,103,,,Fee Schedule,103% of CMS OPPS Rate,310.39,103,,,Fee Schedule,103% of CMS OPPS Rate,1044.17,75,,835.336,Percent of Total Billed Charges,75% of Total Billed Charges,512.29,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,512.29,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,512.29,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,512.29,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,452.02,150,,,Fee Schedule,150% of CMS OPPS Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,244.1,90,,,Fee Schedule,90% of UHC fee schedule,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,253.13,100,,,Fee Schedule,100% of TX Medicaid Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1392.22,100,,1113.776,Percent of Total Billed Charges,100% of Total Billed Charges,244.1,1392.22,
MOPATH PROCEDURE LEVEL 7,70086734,CDM,310,RC,81406,HCPCS,Outpatient,,,1563.11,937.87,,328.14,100,,,Fee Schedule,100% of Aetna Fee Schedule,424.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,792.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,905.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,1018.37,360,,,Fee Schedule,360% of BCBS POS Rate,1018.37,360,,,Fee schedule,360% of BCBS PPO Rate,1018.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,937.87,60,,750.296,Percent of Total Billed Charges,60% of Total Billed Charges,237.62,100,,,Fee Schedule,100% of TX Mediciad Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,254.59,90,,,Fee Schedule,90% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,367.74,130,,,Fee Schedule,130% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,244.75,103,,,Fee Schedule,103% of TX Medicaid Rate,291.36,103,,,Fee Schedule,103% of CMS OPPS Rate,291.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1172.33,75,,937.864,Percent of Total Billed Charges,75% of Total Billed Charges,480.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,480.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,480.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,480.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,424.32,150,,,Fee Schedule,150% of CMS OPPS Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,229.13,90,,,Fee Schedule,90% of UHC fee schedule,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,237.62,100,,,Fee Schedule,100% of TX Medicaid Rate,282.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.11,100,,1250.488,Percent of Total Billed Charges,100% of Total Billed Charges,229.13,1563.11,
MOPATH PROCEDURE LEVEL 8,70086737,CDM,310,RC,81407,HCPCS,Outpatient,,,1734,1040.40,,981.68,100,,,Fee Schedule,100% of Aetna Fee Schedule,1269.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2369.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2708.06,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,3046.57,360,,,Fee Schedule,360% of BCBS POS Rate,3046.57,360,,,Fee schedule,360% of BCBS PPO Rate,3046.57,360,,,Fee Schedule,360% of BCBS Traditional Rate,1040.4,60,,832.32,Percent of Total Billed Charges,60% of Total Billed Charges,710.87,100,,,Fee Schedule,100% of TX Mediciad Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,761.64,90,,,Fee Schedule,90% of CMS OPPS Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1100.15,130,,,Fee Schedule,130% of CMS OPPS Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,732.2,103,,,Fee Schedule,103% of TX Medicaid Rate,871.65,103,,,Fee Schedule,103% of CMS OPPS Rate,871.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1300.5,75,,1040.4,Percent of Total Billed Charges,75% of Total Billed Charges,1438.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1438.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1438.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1438.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1269.4,150,,,Fee Schedule,150% of CMS OPPS Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,685.48,90,,,Fee Schedule,90% of UHC fee schedule,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,710.87,100,,,Fee Schedule,100% of TX Medicaid Rate,846.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1734,100,,1387.2,Percent of Total Billed Charges,100% of Total Billed Charges,685.48,3046.57,
M/PHMTRC ALYSISHQUANT/SEMIQ,70086738,CDM,312,RC,88369,HCPCS,Outpatient,,,442.82,265.69,,101.96,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,222.01,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,253.73,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,285.44,360,,,Fee Schedule,360% of BCBS POS Rate,285.44,360,,,Fee schedule,360% of BCBS PPO Rate,285.44,360,,,Fee Schedule,360% of BCBS Traditional Rate,265.69,60,,212.552,Percent of Total Billed Charges,60% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,63.85,14.42,,51.08,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.12,75,,265.696,Percent of Total Billed Charges,75% of Total Billed Charges,221.41,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,221.41,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,221.41,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,221.41,50,,177.128,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,66.95,90,,,Fee Schedule,90% of UHC fee schedule,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,61.99,14,,49.592,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,442.82,100,,354.256,Percent of Total Billed Charges,100% of Total Billed Charges,61.99,442.82,
RESP VIRUS 12-25 TARGETS,70086739,CDM,306,RC,87633,HCPCS,Outpatient,,,1604.15,962.49,,483.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,625.16,150,,,Fee Schedule ,150% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.98,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,1333.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,1500.41,360,,,Fee Schedule,360% of BCBS POS Rate,1500.41,360,,,Fee schedule,360% of BCBS PPO Rate,1500.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,962.49,60,,769.992,Percent of Total Billed Charges,60% of Total Billed Charges,350.1,100,,,Fee Schedule,100% of TX Mediciad 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,375.1,90,,,Fee Schedule,90% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,541.81,130,,,Fee Schedule,130% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,360.6,103,,,Fee Schedule,103% of TX Medicaid Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,429.28,103,,,Fee Schedule,103% of CMS OPPS Rate,1203.11,75,,962.488,Percent of Total Billed Charges,75% of Total Billed Charges,708.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,708.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,708.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,708.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,625.16,150,,,Fee Schedule,150% of CMS OPPS Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,337.59,90,,,Fee Schedule,90% of UHC fee schedule,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,350.1,100,,,Fee Schedule,100% of TX Medicaid Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.15,100,,1283.32,Percent of Total Billed Charges,100% of Total Billed Charges,337.59,1604.15,
CHYLMD PNEUM DNA AMP PROBE,70086740,CDM,306,RC,87486,HCPCS,Outpatient,,,345.73,207.44,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,207.44,60,,165.952,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,259.3,75,,207.44,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,345.73,100,,276.584,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,345.73,
AMPL PROBE EA ORGANISM,70086744,CDM,306,RC,87798,HCPCS,Outpatient,,,369.54,221.72,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,221.72,60,,177.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,277.16,75,,221.728,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,369.54,100,,295.632,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,369.54,
M/PHMTRC ALYS ISHQUANT/SEMIQ,70086745,CDM,311,RC,88377,HCPCS,Outpatient,,,900,540.00,,428.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,540,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,129.78,14.42,,103.824,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,675,75,,540,Percent of Total Billed Charges,75% of Total Billed Charges,450,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,450,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,450,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,450,50,,360,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,126,14,,100.8,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,720,Percent of Total Billed Charges,100% of Total Billed Charges,116.24,900,
PROM CROHNS IMMUNOFLUORO EA,70086747,CDM,312,RC,88346,HCPCS,Outpatient,,,334,200.40,,130.2,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,793.55,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,906.91,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,1020.28,360,,,Fee Schedule,360% of BCBS POS Rate,1020.28,360,,,Fee schedule,360% of BCBS PPO Rate,1020.28,360,,,Fee Schedule,360% of BCBS Traditional Rate,200.4,60,,160.32,Percent of Total Billed Charges,60% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,48.16,14.42,,38.528,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,250.5,75,,200.4,Percent of Total Billed Charges,75% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,229.56,90,,,Fee Schedule,90% of UHC fee schedule,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,46.76,14,,37.408,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,267.2,Percent of Total Billed Charges,100% of Total Billed Charges,46.76,1020.28,
DQB1 HIGH RES TYPING,70086750,CDM,310,RC,81382,HCPCS,Outpatient,,,499.91,299.95,,143.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,185.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,346.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,395.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,445.25,360,,,Fee Schedule,360% of BCBS POS Rate,445.25,360,,,Fee schedule,360% of BCBS PPO Rate,445.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,299.95,60,,239.96,Percent of Total Billed Charges,60% of Total Billed Charges,103.89,100,,,Fee Schedule,100% of TX Mediciad 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,111.31,90,,,Fee Schedule,90% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,160.78,130,,,Fee Schedule,130% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,107.01,103,,,Fee Schedule,103% of TX Medicaid Rate,127.39,103,,,Fee Schedule,103% of CMS OPPS Rate,127.39,103,,,Fee Schedule,103% of CMS OPPS Rate,374.93,75,,299.944,Percent of Total Billed Charges,75% of Total Billed Charges,210.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,210.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,210.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,210.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,185.52,150,,,Fee Schedule,150% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,100.18,90,,,Fee Schedule,90% of UHC fee schedule,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,499.91,100,,399.928,Percent of Total Billed Charges,100% of Total Billed Charges,100.18,499.91,
PROM CELIAC IGA,70086751,CDM,301,RC,82784,HCPCS,Outpatient,,,147.33,88.40,,10.78,100,,,Fee Schedule,100% of Aetna Fee Schedule,13.95,150,,,Fee Schedule ,150% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,29.76,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,33.48,360,,,Fee Schedule,360% of BCBS POS Rate,33.48,360,,,Fee schedule,360% of BCBS PPO Rate,33.48,360,,,Fee Schedule,360% of BCBS Traditional Rate,88.4,60,,70.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.81,100,,,Fee Schedule,100% of TX Mediciad 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,8.37,90,,,Fee Schedule,90% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,130,,,Fee Schedule,130% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,8.04,103,,,Fee Schedule,103% of TX Medicaid Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,9.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.5,75,,88.4,Percent of Total Billed Charges,75% of Total Billed Charges,15.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,15.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,15.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,13.95,150,,,Fee Schedule,150% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,90,,,Fee Schedule,90% of UHC fee schedule,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,7.81,100,,,Fee Schedule,100% of TX Medicaid Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,147.33,100,,117.864,Percent of Total Billed Charges,100% of Total Billed Charges,7.53,147.33,
PROM CELIAC IMMUNOASSAY QT EA,70086752,CDM,301,RC,83520,HCPCS,Outpatient,,,215.4,129.24,,20.04,100,,,Fee Schedule,100% of Aetna Fee Schedule,25.9,150,,,Fee Schedule ,150% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.36,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,55.26,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,62.17,360,,,Fee Schedule,360% of BCBS POS Rate,62.17,360,,,Fee schedule,360% of BCBS PPO Rate,62.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,129.24,60,,103.392,Percent of Total Billed Charges,60% of Total Billed Charges,14.51,100,,,Fee Schedule,100% of TX Mediciad 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,15.54,90,,,Fee Schedule,90% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,130,,,Fee Schedule,130% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.95,103,,,Fee Schedule,103% of TX Medicaid Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,17.78,103,,,Fee Schedule,103% of CMS OPPS Rate,161.55,75,,129.24,Percent of Total Billed Charges,75% of Total Billed Charges,29.35,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,29.35,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,29.35,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,25.9,150,,,Fee Schedule,150% of CMS OPPS Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.99,90,,,Fee Schedule,90% of UHC fee schedule,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,14.51,100,,,Fee Schedule,100% of TX Medicaid Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,215.4,100,,172.32,Percent of Total Billed Charges,100% of Total Billed Charges,13.99,215.4,
ANALYSIS GENE SNRPN/UBE3A,70086753,CDM,310,RC,81331,HCPCS,Outpatient,,,979.94,587.96,,59.24,100,,,Fee Schedule,100% of Aetna Fee Schedule,76.6,150,,,Fee Schedule ,150% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,143,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,163.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,183.85,360,,,Fee Schedule,360% of BCBS POS Rate,183.85,360,,,Fee schedule,360% of BCBS PPO Rate,183.85,360,,,Fee Schedule,360% of BCBS Traditional Rate,587.96,60,,470.368,Percent of Total Billed Charges,60% of Total Billed Charges,42.9,100,,,Fee Schedule,100% of TX Mediciad 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,45.96,90,,,Fee Schedule,90% of CMS OPPS Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,66.39,130,,,Fee Schedule,130% of CMS OPPS Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,44.19,103,,,Fee Schedule,103% of TX Medicaid Rate,52.6,103,,,Fee Schedule,103% of CMS OPPS Rate,52.6,103,,,Fee Schedule,103% of CMS OPPS Rate,734.96,75,,587.968,Percent of Total Billed Charges,75% of Total Billed Charges,86.81,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,86.81,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,86.81,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,86.81,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,76.6,150,,,Fee Schedule,150% of CMS OPPS Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,41.36,90,,,Fee Schedule,90% of UHC fee schedule,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,42.9,100,,,Fee Schedule,100% of TX Medicaid Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,979.94,100,,783.952,Percent of Total Billed Charges,100% of Total Billed Charges,41.36,979.94,
DQA1 HIGH RES TYPING,70086754,CDM,310,RC,81382,HCPCS,Outpatient,,,499.91,299.95,,143.46,100,,,Fee Schedule,100% of Aetna Fee Schedule,185.52,150,,,Fee Schedule ,150% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,346.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,395.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,445.25,360,,,Fee Schedule,360% of BCBS POS Rate,445.25,360,,,Fee schedule,360% of BCBS PPO Rate,445.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,299.95,60,,239.96,Percent of Total Billed Charges,60% of Total Billed Charges,103.89,100,,,Fee Schedule,100% of TX Mediciad 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,111.31,90,,,Fee Schedule,90% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,160.78,130,,,Fee Schedule,130% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,107.01,103,,,Fee Schedule,103% of TX Medicaid Rate,127.39,103,,,Fee Schedule,103% of CMS OPPS Rate,127.39,103,,,Fee Schedule,103% of CMS OPPS Rate,374.93,75,,299.944,Percent of Total Billed Charges,75% of Total Billed Charges,210.25,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,210.25,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,210.25,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,210.25,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,185.52,150,,,Fee Schedule,150% of CMS OPPS Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,100.18,90,,,Fee Schedule,90% of UHC fee schedule,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,103.89,100,,,Fee Schedule,100% of TX Medicaid Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,499.91,100,,399.928,Percent of Total Billed Charges,100% of Total Billed Charges,100.18,499.91,
TARGETED GENOMIC SEQ ANALYS,70086755,CDM,310,RC,81455,HCPCS,Outpatient,,,5000,3000.00,,3386.74,100,,,Fee Schedule,100% of Aetna Fee Schedule,4379.4,150,,,Fee Schedule ,150% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,8174.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,9342.72,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,10510.56,360,,,Fee Schedule,360% of BCBS POS Rate,10510.56,360,,,Fee schedule,360% of BCBS PPO Rate,10510.56,360,,,Fee Schedule,360% of BCBS Traditional Rate,3000,60,,2400,Percent of Total Billed Charges,60% of Total Billed Charges,2452.46,100,,,Fee Schedule,100% of TX Mediciad 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,2627.64,90,,,Fee Schedule,90% of CMS OPPS Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3795.48,130,,,Fee Schedule,130% of CMS OPPS Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2526.03,103,,,Fee Schedule,103% of TX Medicaid Rate,3007.18,103,,,Fee Schedule,103% of CMS OPPS Rate,3007.18,103,,,Fee Schedule,103% of CMS OPPS Rate,3750,75,,3000,Percent of Total Billed Charges,75% of Total Billed Charges,4963.32,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,4963.32,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4963.32,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,4963.32,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,4379.4,150,,,Fee Schedule,150% of CMS OPPS Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2364.88,90,,,Fee Schedule,90% of UHC fee schedule,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2452.46,100,,,Fee Schedule,100% of TX Medicaid Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5000,100,,4000,Percent of Total Billed Charges,100% of Total Billed Charges,2364.88,10510.56,
IMMUNOASSAY INFECTIOUS AGENT,70086758,CDM,302,RC,86317,HCPCS,Outpatient,,,127.76,76.66,,17.38,100,,,Fee Schedule,100% of Aetna Fee Schedule,22.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,41.97,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,47.97,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,53.96,360,,,Fee Schedule,360% of BCBS POS Rate,53.96,360,,,Fee schedule,360% of BCBS PPO Rate,53.96,360,,,Fee Schedule,360% of BCBS Traditional Rate,76.66,60,,61.328,Percent of Total Billed Charges,60% of Total Billed Charges,12.59,100,,,Fee Schedule,100% of TX Mediciad 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,13.49,90,,,Fee Schedule,90% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,19.48,130,,,Fee Schedule,130% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.97,103,,,Fee Schedule,103% of TX Medicaid Rate,15.43,103,,,Fee Schedule,103% of CMS OPPS Rate,15.43,103,,,Fee Schedule,103% of CMS OPPS Rate,95.82,75,,76.656,Percent of Total Billed Charges,75% of Total Billed Charges,25.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,25.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,25.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,22.48,150,,,Fee Schedule,150% of CMS OPPS Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,12.14,90,,,Fee Schedule,90% of UHC fee schedule,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,12.59,100,,,Fee Schedule,100% of TX Medicaid Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,127.76,100,,102.208,Percent of Total Billed Charges,100% of Total Billed Charges,12.14,127.76,
PROTEIN WESTERN BLOT TEST,70086759,CDM,301,RC,84182,HCPCS,Outpatient,,,446.22,267.73,,33.88,100,,,Fee Schedule,100% of Aetna Fee Schedule,43.81,150,,,Fee Schedule ,150% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,81.79,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,93.47,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,105.16,360,,,Fee Schedule,360% of BCBS POS Rate,105.16,360,,,Fee schedule,360% of BCBS PPO Rate,105.16,360,,,Fee Schedule,360% of BCBS Traditional Rate,267.73,60,,214.184,Percent of Total Billed Charges,60% of Total Billed Charges,24.54,100,,,Fee Schedule,100% of TX Mediciad 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,26.28,90,,,Fee Schedule,90% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,37.97,130,,,Fee Schedule,130% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,25.28,103,,,Fee Schedule,103% of TX Medicaid Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,30.08,103,,,Fee Schedule,103% of CMS OPPS Rate,334.67,75,,267.736,Percent of Total Billed Charges,75% of Total Billed Charges,49.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,49.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,49.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,43.81,150,,,Fee Schedule,150% of CMS OPPS Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,23.66,90,,,Fee Schedule,90% of UHC fee schedule,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,24.54,100,,,Fee Schedule,100% of TX Medicaid Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,446.22,100,,356.976,Percent of Total Billed Charges,100% of Total Billed Charges,23.66,446.22,
AB HEV IGM,70086760,CDM,302,RC,86790,HCPCS,Outpatient,,,158.75,95.25,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,95.25,60,,76.2,Percent of Total Billed Charges,60% of Total Billed Charges,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,119.06,75,,95.248,Percent of Total Billed Charges,75% of Total Billed Charges,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,158.75,100,,127,Percent of Total Billed Charges,100% of Total Billed Charges,10.43,158.75,
THIOPURINE METHYLTRANSFERASE,70086761,CDM,301,RC,82657,HCPCS,Outpatient,,,229.97,137.98,,25.72,100,,,Fee Schedule,100% of Aetna Fee Schedule,33.25,150,,,Fee Schedule ,150% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.08,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,70.94,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,79.81,360,,,Fee Schedule,360% of BCBS POS Rate,79.81,360,,,Fee schedule,360% of BCBS PPO Rate,79.81,360,,,Fee Schedule,360% of BCBS Traditional Rate,137.98,60,,110.384,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,100,,,Fee Schedule,100% of TX Mediciad 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,19.95,90,,,Fee Schedule,90% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,28.82,130,,,Fee Schedule,130% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,19.18,103,,,Fee Schedule,103% of TX Medicaid Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,22.83,103,,,Fee Schedule,103% of CMS OPPS Rate,172.48,75,,137.984,Percent of Total Billed Charges,75% of Total Billed Charges,37.68,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,37.68,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,37.68,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,37.68,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,33.25,150,,,Fee Schedule,150% of CMS OPPS Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,90,,,Fee Schedule,90% of UHC fee schedule,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,18.62,100,,,Fee Schedule,100% of TX Medicaid Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,229.97,100,,183.976,Percent of Total Billed Charges,100% of Total Billed Charges,17.96,229.97,
TARGETED GENOMIC SEQ ANALYS,70086762,CDM,310,RC,81450,HCPCS,Outpatient,,,1296.8,778.08,,881.06,100,,,Fee Schedule,100% of Aetna Fee Schedule,1139.29,150,,,Fee Schedule ,150% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.68,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2430.5,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,2734.31,360,,,Fee Schedule,360% of BCBS POS Rate,2734.31,360,,,Fee schedule,360% of BCBS PPO Rate,2734.31,360,,,Fee Schedule,360% of BCBS Traditional Rate,778.08,60,,622.464,Percent of Total Billed Charges,60% of Total Billed Charges,638.01,100,,,Fee Schedule,100% of TX Mediciad 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,683.57,90,,,Fee Schedule,90% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.38,130,,,Fee Schedule,130% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,657.15,103,,,Fee Schedule,103% of TX Medicaid Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,782.31,103,,,Fee Schedule,103% of CMS OPPS Rate,972.6,75,,778.08,Percent of Total Billed Charges,75% of Total Billed Charges,1291.2,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,1291.2,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.2,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,1291.2,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,1139.29,150,,,Fee Schedule,150% of CMS OPPS Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,615.22,90,,,Fee Schedule,90% of UHC fee schedule,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,638.01,100,,,Fee Schedule,100% of TX Medicaid Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.8,100,,1037.44,Percent of Total Billed Charges,100% of Total Billed Charges,615.22,2734.31,
CALR GENE COM VARIANTS,70086763,CDM,310,RC,81219,HCPCS,Outpatient,,,331.36,198.82,,141.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,182.44,150,,,Fee Schedule ,150% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,340.56,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,389.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,437.87,360,,,Fee Schedule,360% of BCBS POS Rate,437.87,360,,,Fee schedule,360% of BCBS PPO Rate,437.87,360,,,Fee Schedule,360% of BCBS Traditional Rate,198.82,60,,159.056,Percent of Total Billed Charges,60% of Total Billed Charges,102.17,100,,,Fee Schedule,100% of TX Mediciad 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,109.46,90,,,Fee Schedule,90% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,158.11,130,,,Fee Schedule,130% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,105.24,103,,,Fee Schedule,103% of TX Medicaid Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,125.27,103,,,Fee Schedule,103% of CMS OPPS Rate,248.52,75,,198.816,Percent of Total Billed Charges,75% of Total Billed Charges,206.77,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,206.77,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,206.77,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,206.77,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,182.44,150,,,Fee Schedule,150% of CMS OPPS Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.52,90,,,Fee Schedule,90% of UHC fee schedule,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,102.17,100,,,Fee Schedule,100% of TX Medicaid Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,331.36,100,,265.088,Percent of Total Billed Charges,100% of Total Billed Charges,98.52,437.87,
MLH1 GENE,70086765,CDM,310,RC,81288,HCPCS,Outpatient,,,3250.67,1950.40,,223.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,288.48,150,,,Fee Schedule ,150% of CMS OPPS Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,538.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,615.42,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,692.35,360,,,Fee Schedule,360% of BCBS POS Rate,692.35,360,,,Fee schedule,360% of BCBS PPO Rate,692.35,360,,,Fee Schedule,360% of BCBS Traditional Rate,1950.4,60,,1560.32,Percent of Total Billed Charges,60% of Total Billed Charges,161.55,100,,,Fee Schedule,100% of TX Mediciad Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,173.08,90,,,Fee Schedule,90% of CMS OPPS Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,250.01,130,,,Fee Schedule,130% of CMS OPPS Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,166.4,103,,,Fee Schedule,103% of TX Medicaid Rate,198.08,103,,,Fee Schedule,103% of CMS OPPS Rate,198.08,103,,,Fee Schedule,103% of CMS OPPS Rate,2438,75,,1950.4,Percent of Total Billed Charges,75% of Total Billed Charges,326.94,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,326.94,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,326.94,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,326.94,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,288.48,150,,,Fee Schedule,150% of CMS OPPS Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,155.78,90,,,Fee Schedule,90% of UHC fee schedule,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,161.55,100,,,Fee Schedule,100% of TX Medicaid Rate,192.32,100,,,Fee Schedule,100% of CMS OPPS Rate,3250.67,100,,2600.536,Percent of Total Billed Charges,100% of Total Billed Charges,155.78,3250.67,
MGMT GENE METHYLATION ANAL,70086766,CDM,310,RC,81287,HCPCS,Outpatient,,,628.16,376.90,,144.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,186.96,150,,,Fee Schedule ,150% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,348.99,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,398.85,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,448.7,360,,,Fee Schedule,360% of BCBS POS Rate,448.7,360,,,Fee schedule,360% of BCBS PPO Rate,448.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,376.9,60,,301.52,Percent of Total Billed Charges,60% of Total Billed Charges,104.7,100,,,Fee Schedule,100% of TX Mediciad Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,112.17,90,,,Fee Schedule,90% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,162.03,130,,,Fee Schedule,130% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,107.84,103,,,Fee Schedule,103% of TX Medicaid Rate,128.37,103,,,Fee Schedule,103% of CMS OPPS Rate,128.37,103,,,Fee Schedule,103% of CMS OPPS Rate,471.12,75,,376.896,Percent of Total Billed Charges,75% of Total Billed Charges,211.88,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,211.88,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,211.88,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,211.88,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,186.96,150,,,Fee Schedule,150% of CMS OPPS Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,100.96,90,,,Fee Schedule,90% of UHC fee schedule,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,104.7,100,,,Fee Schedule,100% of TX Medicaid Rate,124.64,100,,,Fee Schedule,100% of CMS OPPS Rate,628.16,100,,502.528,Percent of Total Billed Charges,100% of Total Billed Charges,100.96,628.16,
IHC ANTIBODY SLIDE ADDL SINGLE,70086767,CDM,312,RC,88341,HCPCS,Outpatient,,,290.09,174.05,,77.66,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.63,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,206.43,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,232.24,360,,,Fee Schedule,360% of BCBS POS Rate,232.24,360,,,Fee schedule,360% of BCBS PPO Rate,232.24,360,,,Fee Schedule,360% of BCBS Traditional Rate,174.05,60,,139.24,Percent of Total Billed Charges,60% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,41.83,14.42,,33.464,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.57,75,,174.056,Percent of Total Billed Charges,75% of Total Billed Charges,145.05,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,145.05,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,145.05,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,145.05,50,,116.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,52.33,90,,,Fee Schedule,90% of UHC fee schedule,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,40.61,14,,32.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,290.09,100,,232.072,Percent of Total Billed Charges,100% of Total Billed Charges,40.61,290.09,
IHC ANTIBODY SLIDE SINGLE,70086768,CDM,312,RC,88342,HCPCS,Outpatient,,,334.72,200.83,,84.1,100,,,Fee Schedule,100% of Aetna Fee Schedule,235.05,150,,,Fee Schedule ,150% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,401.8,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,459.2,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,516.6,360,,,Fee Schedule,360% of BCBS POS Rate,516.6,360,,,Fee schedule,360% of BCBS PPO Rate,516.6,360,,,Fee Schedule,360% of BCBS Traditional Rate,200.83,60,,160.664,Percent of Total Billed Charges,60% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,141.03,90,,,Fee Schedule,90% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,203.71,130,,,Fee Schedule,130% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,48.27,14.42,,38.616,Percent of Total Billed Charges,14.42% of Total Billed Charges,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,161.4,103,,,Fee Schedule,103% of CMS OPPS Rate,251.04,75,,200.832,Percent of Total Billed Charges,75% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,167.36,50,,133.888,Percent of Total Billed Charges,50% of Total Billed Charges,235.05,150,,,Fee Schedule,150% of CMS OPPS Rate,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,116.24,90,,,Fee Schedule,90% of UHC fee schedule,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,46.86,14,,37.488,Percent of Total Billed Charges,14% of Total Billed Charges,156.7,100,,,Fee Schedule,100% of CMS OPPS Rate,334.72,100,,267.776,Percent of Total Billed Charges,100% of Total Billed Charges,46.86,516.6,
FLUORESCENT ANTIBODY TITER,70086769,CDM,302,RC,86256,HCPCS,Outpatient,,,173.1,103.86,,13.98,100,,,Fee Schedule,100% of Aetna Fee Schedule,18.07,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.74,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.56,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,43.38,360,,,Fee Schedule,360% of BCBS POS Rate,43.38,360,,,Fee schedule,360% of BCBS PPO Rate,43.38,360,,,Fee Schedule,360% of BCBS Traditional Rate,103.86,60,,83.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.12,100,,,Fee Schedule,100% of TX Mediciad 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,10.84,90,,,Fee Schedule,90% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.66,130,,,Fee Schedule,130% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.42,103,,,Fee Schedule,103% of TX Medicaid Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,12.41,103,,,Fee Schedule,103% of CMS OPPS Rate,129.83,75,,103.864,Percent of Total Billed Charges,75% of Total Billed Charges,20.48,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,20.48,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,20.48,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,18.07,150,,,Fee Schedule,150% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,90,,,Fee Schedule,90% of UHC fee schedule,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,10.12,100,,,Fee Schedule,100% of TX Medicaid Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.1,100,,138.48,Percent of Total Billed Charges,100% of Total Billed Charges,9.77,173.1,
STREP B DNA AMP PROBE,70086770,CDM,302,RC,87653,HCPCS,Outpatient,,,214,128.40,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,128.4,60,,102.72,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,160.5,75,,128.4,Percent of Total Billed Charges,75% of Total Billed Charges,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214,100,,171.2,Percent of Total Billed Charges,100% of Total Billed Charges,28.42,214,
NRAS GENE VARIANTS EXON 2&3,70086771,CDM,310,RC,81311,HCPCS,Outpatient,,,591.58,354.95,,343.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,443.68,150,,,Fee Schedule ,150% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,828.21,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,946.53,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,1064.84,360,,,Fee Schedule,360% of BCBS POS Rate,1064.84,360,,,Fee schedule,360% of BCBS PPO Rate,1064.84,360,,,Fee Schedule,360% of BCBS Traditional Rate,354.95,60,,283.96,Percent of Total Billed Charges,60% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,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,266.21,90,,,Fee Schedule,90% of CMS OPPS Rate,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,384.52,130,,,Fee Schedule,130% of CMS OPPS Rate,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,85.31,14.42,,68.248,Percent of Total Billed Charges,14.42% of Total Billed Charges,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,304.66,103,,,Fee Schedule,103% of CMS OPPS Rate,443.69,75,,354.952,Percent of Total Billed Charges,75% of Total Billed Charges,502.84,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,502.84,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,502.84,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,502.84,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,443.68,150,,,Fee Schedule,150% of CMS OPPS Rate,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,239.59,90,,,Fee Schedule,90% of UHC fee schedule,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,82.82,14,,66.256,Percent of Total Billed Charges,14% of Total Billed Charges,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,591.58,100,,473.264,Percent of Total Billed Charges,100% of Total Billed Charges,82.82,1064.84,
KRAS GENE ADDL VARIANTS,70086772,CDM,310,RC,81276,HCPCS,Outpatient,,,394.38,236.63,,224.18,100,,,Fee Schedule,100% of Aetna Fee Schedule,289.87,150,,,Fee Schedule ,150% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,541.1,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,618.4,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,695.7,360,,,Fee Schedule,360% of BCBS POS Rate,695.7,360,,,Fee schedule,360% of BCBS PPO Rate,695.7,360,,,Fee Schedule,360% of BCBS Traditional Rate,236.63,60,,189.304,Percent of Total Billed Charges,60% of Total Billed Charges,162.33,100,,,Fee Schedule,100% of TX Mediciad 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,173.92,90,,,Fee Schedule,90% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,251.22,130,,,Fee Schedule,130% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,167.2,103,,,Fee Schedule,103% of TX Medicaid Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,199.04,103,,,Fee Schedule,103% of CMS OPPS Rate,295.79,75,,236.632,Percent of Total Billed Charges,75% of Total Billed Charges,328.52,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,328.52,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,328.52,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,328.52,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,289.87,150,,,Fee Schedule,150% of CMS OPPS Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,156.54,90,,,Fee Schedule,90% of UHC fee schedule,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,162.33,100,,,Fee Schedule,100% of TX Medicaid Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,394.38,100,,315.504,Percent of Total Billed Charges,100% of Total Billed Charges,156.54,695.7,
COLUMN CHROMOTOGRAPHY QUAL,70086773,CDM,301,RC,82542,HCPCS,Outpatient,,,246.36,147.82,,27.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,36.13,150,,,Fee Schedule ,150% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.45,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,77.09,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,86.72,360,,,Fee Schedule,360% of BCBS POS Rate,86.72,360,,,Fee schedule,360% of BCBS PPO Rate,86.72,360,,,Fee Schedule,360% of BCBS Traditional Rate,147.82,60,,118.256,Percent of Total Billed Charges,60% of Total Billed Charges,20.24,100,,,Fee Schedule,100% of TX Mediciad 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,21.68,90,,,Fee Schedule,90% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,130,,,Fee Schedule,130% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.85,103,,,Fee Schedule,103% of TX Medicaid Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,24.81,103,,,Fee Schedule,103% of CMS OPPS Rate,184.77,75,,147.816,Percent of Total Billed Charges,75% of Total Billed Charges,40.95,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,40.95,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.95,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,40.95,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,36.13,150,,,Fee Schedule,150% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,90,,,Fee Schedule,90% of UHC fee schedule,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,20.24,100,,,Fee Schedule,100% of TX Medicaid Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,246.36,100,,197.088,Percent of Total Billed Charges,100% of Total Billed Charges,19.51,246.36,
FIB-4 with Reflex to Enhanc Liver Fibrosis (ELF),70086890,CDM,301,RC,84450,HCPCS,Outpatient,,,109.2,65.52,,6,100,,,Fee Schedule,100% of Aetna Fee Schedule,7.77,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,16.58,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,18.65,360,,,Fee Schedule,360% of BCBS POS Rate,18.65,360,,,Fee schedule,360% of BCBS PPO Rate,18.65,360,,,Fee Schedule,360% of BCBS Traditional Rate,65.52,60,,52.416,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,100,,,Fee Schedule,100% of TX Mediciad 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,4.66,90,,,Fee Schedule,90% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.73,130,,,Fee Schedule,130% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.48,103,,,Fee Schedule,103% of TX Medicaid Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5.33,103,,,Fee Schedule,103% of CMS OPPS Rate,81.9,75,,65.52,Percent of Total Billed Charges,75% of Total Billed Charges,8.8,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,8.8,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,8.8,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,8.8,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,7.77,150,,,Fee Schedule,150% of CMS OPPS Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,4.19,90,,,Fee Schedule,90% of UHC fee schedule,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,4.35,100,,,Fee Schedule,100% of TX Medicaid Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,109.2,100,,87.36,Percent of Total Billed Charges,100% of Total Billed Charges,4.19,109.2,
HOMOGENIZATION TISSUE FOR CX,70087176,CDM,306,RC,87176,HCPCS,Outpatient,,,74.77,44.86,,6.82,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.82,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.82,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,21.17,360,,,Fee Schedule,360% of BCBS POS Rate,21.17,360,,,Fee schedule,360% of BCBS PPO Rate,21.17,360,,,Fee Schedule,360% of BCBS Traditional Rate,44.86,60,,35.888,Percent of Total Billed Charges,60% of Total Billed Charges,4.94,100,,,Fee Schedule,100% of TX Mediciad Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.29,90,,,Fee Schedule,90% of CMS OPPS Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7.64,130,,,Fee Schedule,130% of CMS OPPS Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.09,103,,,Fee Schedule,103% of TX Medicaid Rate,6.05,103,,,Fee Schedule,103% of CMS OPPS Rate,6.05,103,,,Fee Schedule,103% of CMS OPPS Rate,56.08,75,,44.864,Percent of Total Billed Charges,75% of Total Billed Charges,9.99,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.99,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,9.99,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.99,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.82,150,,,Fee Schedule,150% of CMS OPPS Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,90,,,Fee Schedule,90% of UHC fee schedule,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,4.94,100,,,Fee Schedule,100% of TX Medicaid Rate,5.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.77,100,,59.816,Percent of Total Billed Charges,100% of Total Billed Charges,4.76,74.77,
MYCOPLASMA PNEUMONIAE DNA,70438767,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,70462734,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
T CELLS;T4/T8,70463609,CDM,302,RC,86360,HCPCS,Outpatient,,,,,,54.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,70.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,150.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,169.13,360,,,Fee Schedule,360% of BCBS POS Rate,169.13,360,,,Fee schedule,360% of BCBS PPO Rate,169.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,39.46,100,,,Fee Schedule,100% of TX Mediciad 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,42.28,90,,,Fee Schedule,90% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.07,130,,,Fee Schedule,130% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,40.64,103,,,Fee Schedule,103% of TX Medicaid Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,79.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,79.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,79.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,70.46,150,,,Fee Schedule,150% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.05,90,,,Fee Schedule,90% of UHC fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.05,169.13,
HISTO/CYTOCHEMISTRY ID ENZYM,70483193,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
RHEUMATOID FACTOR QT,70664321,CDM,302,RC,86431,HCPCS,Outpatient,,,184,110.40,,6.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,8.5,150,,,Fee Schedule ,150% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,15.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,18.14,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,20.41,360,,,Fee Schedule,360% of BCBS POS Rate,20.41,360,,,Fee schedule,360% of BCBS PPO Rate,20.41,360,,,Fee Schedule,360% of BCBS Traditional Rate,110.4,60,,88.32,Percent of Total Billed Charges,60% of Total Billed Charges,4.76,100,,,Fee Schedule,100% of TX Mediciad 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,5.1,90,,,Fee Schedule,90% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7.37,130,,,Fee Schedule,130% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.9,103,,,Fee Schedule,103% of TX Medicaid Rate,5.84,103,,,Fee Schedule,103% of CMS OPPS Rate,5.84,103,,,Fee Schedule,103% of CMS OPPS Rate,138,75,,110.4,Percent of Total Billed Charges,75% of Total Billed Charges,9.63,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,9.63,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,9.63,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,9.63,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,8.5,150,,,Fee Schedule,150% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,90,,,Fee Schedule,90% of UHC fee schedule,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,4.76,100,,,Fee Schedule,100% of TX Medicaid Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,184,100,,147.2,Percent of Total Billed Charges,100% of Total Billed Charges,4.59,184,
MYCOPLASMA PNEUMONIAE DNA,70838768,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,70862735,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
T CELLS;T4/T8,70863600,CDM,302,RC,86360,HCPCS,Outpatient,,,,,,54.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,70.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,150.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,169.13,360,,,Fee Schedule,360% of BCBS POS Rate,169.13,360,,,Fee schedule,360% of BCBS PPO Rate,169.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,39.46,100,,,Fee Schedule,100% of TX Mediciad 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,42.28,90,,,Fee Schedule,90% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.07,130,,,Fee Schedule,130% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,40.64,103,,,Fee Schedule,103% of TX Medicaid Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,79.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,79.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,79.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,70.46,150,,,Fee Schedule,150% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.05,90,,,Fee Schedule,90% of UHC fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.05,169.13,
COXSACKIE B AB,70866587,CDM,302,RC,86658,HCPCS,Outpatient,,,,,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.56,46.91,
HISTO/CYTOCHEMISTRY ID ENZYM,70883194,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
MYCOPLASMA PNEUMONIAE DNA,70938774,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,70962733,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
T CELLS;T4/T8,70963608,CDM,302,RC,86360,HCPCS,Outpatient,,,,,,54.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,70.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,150.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,169.13,360,,,Fee Schedule,360% of BCBS POS Rate,169.13,360,,,Fee schedule,360% of BCBS PPO Rate,169.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,39.46,100,,,Fee Schedule,100% of TX Mediciad 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,42.28,90,,,Fee Schedule,90% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.07,130,,,Fee Schedule,130% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,40.64,103,,,Fee Schedule,103% of TX Medicaid Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,79.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,79.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,79.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,70.46,150,,,Fee Schedule,150% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.05,90,,,Fee Schedule,90% of UHC fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.05,169.13,
COXSACKIE B AB,70966585,CDM,302,RC,86658,HCPCS,Outpatient,,,,,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.56,46.91,
HISTO/CYTOCHEMISTRY ID ENZYM,70983192,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
MYCOPLASMA PNEUMONIAE DNA,71038772,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,71062731,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
COXSACKIE B AB,71066575,CDM,302,RC,86658,HCPCS,Outpatient,,,,,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.56,46.91,
HISTO/CYTOCHEMISTRY ID ENZYM,71083190,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
MYCOPLASMA PNEUMONIAE DNA,71138762,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,71162739,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
HISTO/CYTOCHEMISTRY ID ENZYM,71183206,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
MYCOPLASMA PNEUMONIAE DNA,71238760,CDM,306,RC,87581,HCPCS,Outpatient,,,,,,40.7,100,,,Fee Schedule,100% of Aetna Fee Schedule,52.63,150,,,Fee Schedule ,150% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.25,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,112.29,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,126.32,360,,,Fee Schedule,360% of BCBS POS Rate,126.32,360,,,Fee schedule,360% of BCBS PPO Rate,126.32,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,29.48,100,,,Fee Schedule,100% of TX Mediciad 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,31.58,90,,,Fee Schedule,90% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.61,130,,,Fee Schedule,130% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,30.36,103,,,Fee Schedule,103% of TX Medicaid Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,36.14,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,59.65,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,59.65,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,59.65,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,59.65,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,52.63,150,,,Fee Schedule,150% of CMS OPPS Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,28.42,90,,,Fee Schedule,90% of UHC fee schedule,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,29.48,100,,,Fee Schedule,100% of TX Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.42,126.32,
VARIC ZOSTE IGM,71262737,CDM,302,RC,86787,HCPCS,Outpatient,,,,,,14.94,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.32,150,,,Fee Schedule ,150% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,36.06,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.22,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,46.37,360,,,Fee Schedule,360% of BCBS POS Rate,46.37,360,,,Fee schedule,360% of BCBS PPO Rate,46.37,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.82,100,,,Fee Schedule,100% of TX Mediciad 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,11.59,90,,,Fee Schedule,90% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16.74,130,,,Fee Schedule,130% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,11.14,103,,,Fee Schedule,103% of TX Medicaid Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,13.26,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.89,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,21.89,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,21.89,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,21.89,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.32,150,,,Fee Schedule,150% of CMS OPPS Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,10.43,90,,,Fee Schedule,90% of UHC fee schedule,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,10.82,100,,,Fee Schedule,100% of TX Medicaid Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.43,46.37,
T CELLS;T4/T8,71263602,CDM,302,RC,86360,HCPCS,Outpatient,,,,,,54.5,100,,,Fee Schedule,100% of Aetna Fee Schedule,70.46,150,,,Fee Schedule ,150% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.54,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,150.34,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,169.13,360,,,Fee Schedule,360% of BCBS POS Rate,169.13,360,,,Fee schedule,360% of BCBS PPO Rate,169.13,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,39.46,100,,,Fee Schedule,100% of TX Mediciad 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,42.28,90,,,Fee Schedule,90% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.07,130,,,Fee Schedule,130% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,40.64,103,,,Fee Schedule,103% of TX Medicaid Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,48.38,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.86,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,79.86,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,79.86,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,79.86,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,70.46,150,,,Fee Schedule,150% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.05,90,,,Fee Schedule,90% of UHC fee schedule,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,39.46,100,,,Fee Schedule,100% of TX Medicaid Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.05,169.13,
COXSACKIE B AB,71266589,CDM,302,RC,86658,HCPCS,Outpatient,,,,,,15.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,19.54,150,,,Fee Schedule ,150% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,41.7,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,46.91,360,,,Fee Schedule,360% of BCBS POS Rate,46.91,360,,,Fee schedule,360% of BCBS PPO Rate,46.91,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,10.95,100,,,Fee Schedule,100% of TX Mediciad 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,11.72,90,,,Fee Schedule,90% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.93,130,,,Fee Schedule,130% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,11.28,103,,,Fee Schedule,103% of TX Medicaid Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,13.42,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.15,80,,,Fee Schedule,80% of Scott and White EPO fee schedule,22.15,80,,,Fee Schedule,80% of Scott and White HMO fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,170,,,Fee Schedule,170% of Scott and White PPO fee schedule,22.15,170,,,Fee Schedule,170% of Scott and White SWHP fee schedule,19.54,150,,,Fee Schedule,150% of CMS OPPS Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,90,,,Fee Schedule,90% of UHC fee schedule,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,10.95,100,,,Fee Schedule,100% of TX Medicaid Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.56,46.91,
HISTO/CYTOCHEMISTRY ID ENZYM,71283196,CDM,312,RC,88319,HCPCS,Outpatient,,,,,,122.12,100,,,Fee Schedule,100% of Aetna Fee Schedule,1183.36,150,,,Fee Schedule ,150% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.96,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,2010.24,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,,,,,Other,Not Seperately Reimbusable,2261.52,360,,,Fee Schedule,360% of BCBS POS Rate,2261.52,360,,,Fee schedule,360% of BCBS PPO Rate,2261.52,360,,,Fee Schedule,360% of BCBS Traditional Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,710.01,90,,,Fee Schedule,90% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.58,130,,,Fee Schedule,130% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,812.57,103,,,Fee Schedule,103% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1183.36,150,,,Fee Schedule,150% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,508.84,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,788.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.12,2261.52,
OBS-DISC DAY,80000000,CDM,987,RC,99217,HCPCS,Outpatient,,,220,132.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INIT OBS-HI CPLX,80000001,CDM,987,RC,99220,HCPCS,Outpatient,,,570,342.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INIT HOSP-MOD CPLX,80000002,CDM,987,RC,99222,HCPCS,Outpatient,,,405,243.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INIT HOSP-HI CPLX,80000003,CDM,987,RC,99223,HCPCS,Outpatient,,,620,372.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSEQUENT OBSERVATION CARE,80000004,CDM,987,RC,99226,HCPCS,Outpatient,,,320,192.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HOSP SUB CARE-MOD CPLX,80000005,CDM,987,RC,99232,HCPCS,Outpatient,,,220,132.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HOSP SUB CARE-HI CPLX,80000006,CDM,987,RC,99233,HCPCS,Outpatient,,,320,192.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HOSP DISC <30MIN,80000007,CDM,987,RC,99238,HCPCS,Outpatient,,,220,132.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HOSP DISC >30MIN,80000008,CDM,987,RC,99239,HCPCS,Outpatient,,,330,198.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CRITICAL CARE 1ST HR,80000009,CDM,987,RC,99291,HCPCS,Outpatient,,,850,510.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NURSING FAC CARE SUBSEQ,80000010,CDM,987,RC,99309,HCPCS,Outpatient,,,280,168.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BEHAV CHNG SMOKING 3-10 MIN,80000011,CDM,987,RC,99406,HCPCS,Outpatient,,,50,30.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADVNCD CARE PLAN 30 MIN,80000012,CDM,987,RC,99497,HCPCS,Outpatient,,,260,156.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADV CARE PLN TLKD & ALT DCSN MAKER DOCD,80000013,CDM,960,RC,1123F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADV CARE PLN/ NO ALT DCSN MKR DOCD OR REFUSAL,80000014,CDM,960,RC,1124F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADV CARE NOT DOC NO REASON,80000015,CDM,960,RC,1123F,HCPCS,Outpatient,,,0.01,0.01,8P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LIST CURRENT MEDICATIONS DOCUMENTED BY PROVIDER,80000016,CDM,960,RC,G8427,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PROV DOC PT NOT ELIG FOR MEDICATION ASSESSMENT,80000017,CDM,960,RC,G8430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CURR MEDS NOT DOC BY PROVIDER REASON NOT SPEC,80000018,CDM,960,RC,G8428,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ACE INHIBITOR/ARB THERAPY RXD/CURRENTLY TAKEN,80000019,CDM,960,RC,4010F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DOCU OF MED REASON(S) FOR NOT PRESC,80000020,CDM,960,RC,4010F,HCPCS,Outpatient,,,0.01,0.01,1P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DOCU OF PAT REASON(S) FOR NOT PRESC,80000021,CDM,960,RC,4010F,HCPCS,Outpatient,,,0.01,0.01,2P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DOCU OF SYS REASON(S) FOR NOT PRESC,80000022,CDM,960,RC,4010F,HCPCS,Outpatient,,,0.01,0.01,3P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NO THERAPY NO REASON,80000023,CDM,960,RC,4010F,HCPCS,Outpatient,,,0.01,0.01,8P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CALCULATED BMI W/I NORMAL PARAMETERS&DOCUMENTED,80000024,CDM,960,RC,G8420,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CALCULATED BMI W/I NORMAL PARAMETERS&DOCUMENTED,80000025,CDM,960,RC,G8417,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CALC BMI BELOW LOWER PARAM & F/U PLAN DOC IN MR,80000026,CDM,960,RC,G8418,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL LIM,80000027,CDM,960,RC,G9716,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BMI NOT CALCULATED,80000028,CDM,960,RC,G8421,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CALC BMI OUTSIDE NL PARAM NO F/U PLAN DOC IN MR,80000029,CDM,960,RC,G8419,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
"NORMAL BLOOD PRESSURE READING DOCUMENTED, FOLLOW",80000030,CDM,960,RC,G8783,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE,80000031,CDM,960,RC,G8950,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DOCUMENTED REASON FOR NOT SCREENING OR RECOMMEND,80000032,CDM,960,RC,G9745,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
"BLOOD PRESSURE READING NOT DOCUMENTED, REASON NO",80000033,CDM,960,RC,G8785,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE,80000034,CDM,960,RC,G8952,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PT SCRND TOBACCO USE RCVD TOBACCO CESSATION TALK,80000035,CDM,960,RC,4004F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CURRENT TOBACCO NON-USER CAD CAP COPD PV DM,80000036,CDM,960,RC,1036F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DOCU OF MED REASON(S) FOR NOT PRESC,80000037,CDM,960,RC,4004F,HCPCS,Outpatient,,,0.01,0.01,1P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NO INTERVENTION NO REASON,80000038,CDM,960,RC,4004F,HCPCS,Outpatient,,,0.01,0.01,8P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MOST RECENT HEMOGLOBIN A1C LEVEL >9.0%,80000039,CDM,960,RC,3046F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NOT PERF DURING MEAS PERIOD 12MONTHS,80000040,CDM,960,RC,3046F,HCPCS,Outpatient,,,0.01,0.01,8P   ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MOST RECENT HEMOGLOBIN A1C LEVEL < 7.0%,80000041,CDM,960,RC,3044F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MOST RECENT HEMOGLOBIN A1C LEVEL GT 7.0-9.0 %,80000042,CDM,960,RC,3051F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INIT OBS CARE 50 MINS,80000043,CDM,960,RC,99219,HCPCS,Outpatient,,,405,243.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSEQUENT HOSPITAL CARE 15 MIN,80000044,CDM,960,RC,99231,HCPCS,Outpatient,,,180,108.00,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DRSG FM MPLX 4X4IN SIL ADH,82545303,CDM,272,RC,A6214,HCPCS,Outpatient,,,21.23,12.74,,8.75,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.49,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,38.27,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,43.06,360,,,Fee Schedule,360% of BCBS POS Rate,43.06,360,,,Fee schedule,360% of BCBS PPO Rate,43.06,360,,,Fee Schedule,360% of BCBS Traditional Rate,12.74,60,,10.192,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,3.06,14.42,,2.448,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.92,75,,12.736,Percent of Total Billed Charges,75% of Total Billed Charges,10.62,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,10.62,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.62,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,10.62,50,,8.496,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.86,70,,11.888,Percent of Total Billed Charges,70% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,2.97,14,,2.376,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.23,100,,16.984,Percent of Total Billed Charges,100% of Total Billed Charges,2.97,43.06,
OINTMENT BARRIER PERINL 20Z,82545305,CDM,271,RC,A6250,HCPCS,Outpatient,,,26.38,15.83,,0.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.39,28,,5.912,Percent of Total Billed Charges,28% of Total Billed Charges,312.57,32,,250.056,Percent of Total Billed Charges,32% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% Total Bille Charges,9.5,36,,7.6,Percent of Total Billed Charges,36% of Total Billed Charges,15.83,60,,12.664,Percent of Total Billed Charges,60% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.8,14.42,,3.04,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.79,75,,15.832,Percent of Total Billed Charges,75% of Total Billed Charges,13.19,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,13.19,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.19,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,13.19,50,,10.552,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.47,70,,14.776,Percent of Total Billed Charges,70% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,3.69,14,,2.952,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.38,100,,21.104,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,312.57,
OINTMENT BARRIER PERINL 2.5OZ,82545308,CDM,271,RC,A6250,HCPCS,Outpatient,,,28.95,17.37,,0.03,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.11,28,,6.488,Percent of Total Billed Charges,28% of Total Billed Charges,312.65,32,,250.12,Percent of Total Billed Charges,32% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,10.42,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,10.42,36,,8.336,Percent of Total Billed Charges,36% Total Bille Charges,10.42,36,,8.336,Percent of Total Billed Charges,36% of Total Billed Charges,17.37,60,,13.896,Percent of Total Billed Charges,60% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.17,14.42,,3.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.71,75,,17.368,Percent of Total Billed Charges,75% of Total Billed Charges,14.48,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,14.48,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,14.48,50,,11.584,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.27,70,,16.216,Percent of Total Billed Charges,70% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,4.05,14,,3.24,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.95,100,,23.16,Percent of Total Billed Charges,100% of Total Billed Charges,0.03,312.65,
DRSG FM ALVN 5X5 PU ADH,82545309,CDM,272,RC,,,Outpatient,,,30.64,18.38,,18.38,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.58,28,,6.864,Percent of Total Billed Charges,28% of Total Billed Charges,31.37,32,,25.096,Percent of Total Billed Charges,32% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% Total Bille Charges,11.03,36,,8.824,Percent of Total Billed Charges,36% of Total Billed Charges,18.38,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.42,14.42,,3.536,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,75,,18.384,Percent of Total Billed Charges,75% of Total Billed Charges,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,15.32,50,,12.256,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.45,70,,17.16,Percent of Total Billed Charges,70% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,4.29,14,,3.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.64,100,,24.512,Percent of Total Billed Charges,100% of Total Billed Charges,4.29,31.37,
DRSG FOAM 4 X 8 SILICONE,82545311,CDM,272,RC,,,Outpatient,,,35.48,21.29,,21.29,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.93,28,,7.944,Percent of Total Billed Charges,28% of Total Billed Charges,31.41,32,,25.128,Percent of Total Billed Charges,32% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,12.77,36,,10.216,Percent of Total Billed Charges,36% of Total Billed Charges,12.77,36,,10.216,Percent of Total Billed Charges,36% Total Bille Charges,12.77,36,,10.216,Percent of Total Billed Charges,36% of Total Billed Charges,21.29,60,,17.032,Percent of Total Billed Charges,60% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,5.12,14.42,,4.096,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.61,75,,21.288,Percent of Total Billed Charges,75% of Total Billed Charges,17.74,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,17.74,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.74,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,17.74,50,,14.192,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.84,70,,19.872,Percent of Total Billed Charges,70% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,4.97,14,,3.976,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.48,100,,28.384,Percent of Total Billed Charges,100% of Total Billed Charges,4.97,35.48,
DRSG GRMCDL BIOPTCH 1IN 4MM C-,82545315,CDM,272,RC,A6209,HCPCS,Outpatient,,,40.06,24.04,,6.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.3,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,27.78,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,31.25,360,,,Fee Schedule,360% of BCBS POS Rate,31.25,360,,,Fee schedule,360% of BCBS PPO Rate,31.25,360,,,Fee Schedule,360% of BCBS Traditional Rate,24.04,60,,19.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.78,14.42,,4.624,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.05,75,,24.04,Percent of Total Billed Charges,75% of Total Billed Charges,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,20.03,50,,16.024,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.04,70,,22.432,Percent of Total Billed Charges,70% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,5.61,14,,4.488,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.06,100,,32.048,Percent of Total Billed Charges,100% of Total Billed Charges,5.61,40.06,
DRSG BURN ACTCT SLCR 4X4,82545318,CDM,272,RC,A6206,HCPCS,Outpatient,,,57.62,34.57,,2.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.13,28,,12.904,Percent of Total Billed Charges,28% of Total Billed Charges,31.46,32,,25.168,Percent of Total Billed Charges,32% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% Total Bille Charges,20.74,36,,16.592,Percent of Total Billed Charges,36% of Total Billed Charges,34.57,60,,27.656,Percent of Total Billed Charges,60% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.31,14.42,,6.648,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.22,75,,34.576,Percent of Total Billed Charges,75% of Total Billed Charges,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,28.81,50,,23.048,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.33,70,,32.264,Percent of Total Billed Charges,70% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,8.07,14,,6.456,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.62,100,,46.096,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,57.62,
SPLINT TRAC BOOT LEG UN FM BKS,82545320,CDM,271,RC,,,Outpatient,,,81.83,49.10,,49.1,60,,39.28,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.91,28,,18.328,Percent of Total Billed Charges,28% of Total Billed Charges,31.52,32,,25.216,Percent of Total Billed Charges,32% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,29.46,36,,23.568,Percent of Total Billed Charges,36% of Total Billed Charges,29.46,36,,23.568,Percent of Total Billed Charges,36% Total Bille Charges,29.46,36,,23.568,Percent of Total Billed Charges,36% of Total Billed Charges,49.1,60,,39.28,Percent of Total Billed Charges,60% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.8,14.42,,9.44,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.37,75,,49.096,Percent of Total Billed Charges,75% of Total Billed Charges,40.92,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,40.92,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.92,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,40.92,50,,32.736,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.28,70,,45.824,Percent of Total Billed Charges,70% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,11.46,14,,9.168,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.83,100,,65.464,Percent of Total Billed Charges,100% of Total Billed Charges,11.46,81.83,
BMCC CATH INTMT BARDX 16FR 10M,82545321,CDM,272,RC,,,Outpatient,,,98.3,58.98,,58.98,60,,47.184,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.52,28,,22.016,Percent of Total Billed Charges,28% of Total Billed Charges,31.52,32,,25.216,Percent of Total Billed Charges,32% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,35.39,36,,28.312,Percent of Total Billed Charges,36% of Total Billed Charges,35.39,36,,28.312,Percent of Total Billed Charges,36% Total Bille Charges,35.39,36,,28.312,Percent of Total Billed Charges,36% of Total Billed Charges,58.98,60,,47.184,Percent of Total Billed Charges,60% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,14.17,14.42,,11.336,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.73,75,,58.984,Percent of Total Billed Charges,75% of Total Billed Charges,49.15,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,49.15,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.15,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,49.15,50,,39.32,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.81,70,,55.048,Percent of Total Billed Charges,70% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,13.76,14,,11.008,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,98.3,100,,78.64,Percent of Total Billed Charges,100% of Total Billed Charges,13.76,98.3,
SLEEVE COMPR SCD EXPR KNEE MED,82545323,CDM,271,RC,,,Outpatient,,,135.29,81.17,,81.17,60,,64.936,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.88,28,,30.304,Percent of Total Billed Charges,28% of Total Billed Charges,31.57,32,,25.256,Percent of Total Billed Charges,32% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,48.7,36,,38.96,Percent of Total Billed Charges,36% of Total Billed Charges,48.7,36,,38.96,Percent of Total Billed Charges,36% Total Bille Charges,48.7,36,,38.96,Percent of Total Billed Charges,36% of Total Billed Charges,81.17,60,,64.936,Percent of Total Billed Charges,60% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,19.51,14.42,,15.608,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.47,75,,81.176,Percent of Total Billed Charges,75% of Total Billed Charges,67.65,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,67.65,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,67.65,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,67.65,50,,54.12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.7,70,,75.76,Percent of Total Billed Charges,70% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,18.94,14,,15.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,135.29,100,,108.232,Percent of Total Billed Charges,100% of Total Billed Charges,18.94,135.29,
SLEEVE COMPR SCD EXPR KNEE LG,82545324,CDM,271,RC,,,Outpatient,,,168.19,100.91,,100.91,60,,80.728,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.09,28,,37.672,Percent of Total Billed Charges,28% of Total Billed Charges,31.6,32,,25.28,Percent of Total Billed Charges,32% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,60.55,36,,48.44,Percent of Total Billed Charges,36% of Total Billed Charges,60.55,36,,48.44,Percent of Total Billed Charges,36% Total Bille Charges,60.55,36,,48.44,Percent of Total Billed Charges,36% of Total Billed Charges,100.91,60,,80.728,Percent of Total Billed Charges,60% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,24.25,14.42,,19.4,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.14,75,,100.912,Percent of Total Billed Charges,75% of Total Billed Charges,84.1,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,84.1,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.1,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,84.1,50,,67.28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,117.73,70,,94.184,Percent of Total Billed Charges,70% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,23.55,14,,18.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,168.19,100,,134.552,Percent of Total Billed Charges,100% of Total Billed Charges,23.55,168.19,
DRSG GEL IDSRB 40G 0.9 CDXMR,82545325,CDM,272,RC,,,Outpatient,,,175.1,105.06,,105.06,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.03,28,,39.224,Percent of Total Billed Charges,28% of Total Billed Charges,31.6,32,,25.28,Percent of Total Billed Charges,32% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,63.04,36,,50.432,Percent of Total Billed Charges,36% of Total Billed Charges,63.04,36,,50.432,Percent of Total Billed Charges,36% Total Bille Charges,63.04,36,,50.432,Percent of Total Billed Charges,36% of Total Billed Charges,105.06,60,,84.048,Percent of Total Billed Charges,60% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,25.25,14.42,,20.2,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.33,75,,105.064,Percent of Total Billed Charges,75% of Total Billed Charges,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,87.55,50,,70.04,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,122.57,70,,98.056,Percent of Total Billed Charges,70% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,24.51,14,,19.608,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.1,100,,140.08,Percent of Total Billed Charges,100% of Total Billed Charges,24.51,175.1,
BOOT PROTCT HL FT INFL VI,82545328,CDM,271,RC,,,Outpatient,,,159.6,95.76,,95.76,60,,76.608,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,44.69,28,,35.752,Percent of Total Billed Charges,28% of Total Billed Charges,315.82,32,,252.656,Percent of Total Billed Charges,32% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,57.46,36,,45.968,Percent of Total Billed Charges,36% of Total Billed Charges,57.46,36,,45.968,Percent of Total Billed Charges,36% Total Bille Charges,57.46,36,,45.968,Percent of Total Billed Charges,36% of Total Billed Charges,95.76,60,,76.608,Percent of Total Billed Charges,60% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,23.01,14.42,,18.408,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,75,,95.76,Percent of Total Billed Charges,75% of Total Billed Charges,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,79.8,50,,63.84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,111.72,70,,89.376,Percent of Total Billed Charges,70% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,22.34,14,,17.872,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,159.6,100,,127.68,Percent of Total Billed Charges,100% of Total Billed Charges,22.34,315.82,
DRSG HYDRCL AQCL AG 4.7X4,82545330,CDM,272,RC,,,Outpatient,,,70,42.00,,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.6,28,,15.68,Percent of Total Billed Charges,28% of Total Billed Charges,316.05,32,,252.84,Percent of Total Billed Charges,32% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% Total Bille Charges,25.2,36,,20.16,Percent of Total Billed Charges,36% of Total Billed Charges,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,10.09,14.42,,8.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,35,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49,70,,39.2,Percent of Total Billed Charges,70% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,9.8,14,,7.84,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70,100,,56,Percent of Total Billed Charges,100% of Total Billed Charges,9.8,316.05,
RETAINER DRSNG ELAS CHST LG,82545331,CDM,271,RC,,,Outpatient,,,127.2,76.32,,76.32,60,,61.056,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.62,28,,28.496,Percent of Total Billed Charges,28% of Total Billed Charges,316.32,32,,253.056,Percent of Total Billed Charges,32% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,45.79,36,,36.632,Percent of Total Billed Charges,36% of Total Billed Charges,45.79,36,,36.632,Percent of Total Billed Charges,36% Total Bille Charges,45.79,36,,36.632,Percent of Total Billed Charges,36% of Total Billed Charges,76.32,60,,61.056,Percent of Total Billed Charges,60% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,18.34,14.42,,14.672,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.4,75,,76.32,Percent of Total Billed Charges,75% of Total Billed Charges,63.6,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,63.6,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,63.6,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,63.6,50,,50.88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.04,70,,71.232,Percent of Total Billed Charges,70% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,17.81,14,,14.248,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,127.2,100,,101.76,Percent of Total Billed Charges,100% of Total Billed Charges,17.81,316.32,
DRESSING AQUACEL AG 6X6,82545332,CDM,272,RC,A6197,HCPCS,Outpatient,,,139.86,83.92,,13.97,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,53.48,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,61.12,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,68.76,360,,,Fee Schedule,360% of BCBS POS Rate,68.76,360,,,Fee schedule,360% of BCBS PPO Rate,68.76,360,,,Fee Schedule,360% of BCBS Traditional Rate,83.92,60,,67.136,Percent of Total Billed Charges,60% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,20.17,14.42,,16.136,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.9,75,,83.92,Percent of Total Billed Charges,75% of Total Billed Charges,69.93,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,69.93,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.93,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,69.93,50,,55.944,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.9,70,,78.32,Percent of Total Billed Charges,70% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,19.58,14,,15.664,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.86,100,,111.888,Percent of Total Billed Charges,100% of Total Billed Charges,13.97,139.86,
DRESSING SILVERLON 4X4 ISLAND,82545333,CDM,272,RC,A6206,HCPCS,Outpatient,,,72.78,43.67,,2.35,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.38,28,,16.304,Percent of Total Billed Charges,28% of Total Billed Charges,31.73,32,,25.384,Percent of Total Billed Charges,32% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% Total Bille Charges,26.2,36,,20.96,Percent of Total Billed Charges,36% of Total Billed Charges,43.67,60,,34.936,Percent of Total Billed Charges,60% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.49,14.42,,8.392,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.59,75,,43.672,Percent of Total Billed Charges,75% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,36.39,50,,29.112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.95,70,,40.76,Percent of Total Billed Charges,70% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,10.19,14,,8.152,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.78,100,,58.224,Percent of Total Billed Charges,100% of Total Billed Charges,2.35,72.78,
DRESSING SILVERLON 4X10 ISLAND,82545334,CDM,272,RC,,,Outpatient,,,150,90.00,,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42,28,,33.6,Percent of Total Billed Charges,28% of Total Billed Charges,31.9,32,,25.52,Percent of Total Billed Charges,32% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,54,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,54,36,,43.2,Percent of Total Billed Charges,36% Total Bille Charges,54,36,,43.2,Percent of Total Billed Charges,36% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21.63,14.42,,17.304,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,21,14,,16.8,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150,100,,120,Percent of Total Billed Charges,100% of Total Billed Charges,21,150,
DRESSING SILVERLON 4X6 ISLAND,82545335,CDM,272,RC,A6255,HCPCS,Outpatient,,,87.3,52.38,,2.58,100,,,Fee Schedule,100% of Aetna Fee Schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.88,280,,,Fee Schedule,280% of BCBS BULE Fee Schedule,11.3,320,,,Fee Schedule,320% of BCBS Blue Essentials Rate,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.71,360,,,Fee Schedule,360% of BCBS POS Rate,12.71,360,,,Fee schedule,360% of BCBS PPO Rate,12.71,360,,,Fee Schedule,360% of BCBS Traditional Rate,52.38,60,,41.904,Percent of Total Billed Charges,60% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.59,14.42,,10.072,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.48,75,,52.384,Percent of Total Billed Charges,75% of Total Billed Charges,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,43.65,50,,34.92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.11,70,,48.888,Percent of Total Billed Charges,70% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,12.22,14,,9.776,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,87.3,100,,69.84,Percent of Total Billed Charges,100% of Total Billed Charges,2.58,87.3,
DRSG ALGISITE M 4 X 4,82545336,CDM,272,RC,,,Outpatient,,,21.7,13.02,,13.02,60,,10.416,Percent of Total Billed Charges,60% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.08,28,,4.864,Percent of Total Billed Charges,28% of Total Billed Charges,31.92,32,,25.536,Percent of Total Billed Charges,32% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,7.81,36,,6.248,Percent of Total Billed Charges,36% of Total Billed Charges,7.81,36,,6.248,Percent of Total Billed Charges,36% Total Bille Charges,7.81,36,,6.248,Percent of Total Billed Charges,36% of Total Billed Charges,13.02,60,,10.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.13,14.42,,2.504,Percent of Total Billed Charges,14.42% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.28,75,,13.024,Percent of Total Billed Charges,75% of Total Billed Charges,10.85,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,10.85,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.85,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,10.85,50,,8.68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.19,70,,12.152,Percent of Total Billed Charges,70% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,3.04,14,,2.432,Percent of Total Billed Charges,14% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.7,100,,17.36,Percent of Total Billed Charges,100% of Total Billed Charges,3.04,31.92,
ICU PRIVATE ROOM,99000100,CDM,110,RC,,,Inpatient,,,1128.02,676.81,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.85,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,317.03,32,,253.624,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.02,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,315.85,5900,
ICU TELEMETRY MONITORING,99000101,CDM,206,RC,,,Inpatient,,,1856.5,1113.90,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.82,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,317.03,32,,253.624,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.5,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,317.03,5900,
ICU STEP DOWN,99000102,CDM,206,RC,,,Inpatient,,,2197.97,1318.78,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,615.43,28,,492.344,Percent of Total Billed Charges,28% of Total Billed Charges,317.76,32,,254.208,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,791.27,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,791.27,36,,633.016,Percent of Total Billed Charges,36% Total Bille Charges,791.27,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2197.97,100,,1758.376,Percent of Total Billed Charges,100% of Total Billed Charges,317.76,5900,
ICU CRITICAL CARE LEVEL II,99000103,CDM,200,RC,,,Inpatient,,,2754.11,1652.47,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,771.15,28,,616.92,Percent of Total Billed Charges,28% of Total Billed Charges,319.2,32,,255.36,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,991.48,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,991.48,36,,793.184,Percent of Total Billed Charges,36% Total Bille Charges,991.48,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2754.11,100,,2203.288,Percent of Total Billed Charges,100% of Total Billed Charges,319.2,5900,
ICU CRITICAL CARE LEVEL III,99000104,CDM,200,RC,,,Inpatient,,,3554.07,2132.44,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,995.14,28,,796.112,Percent of Total Billed Charges,28% of Total Billed Charges,319.67,32,,255.736,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1279.47,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,1279.47,36,,1023.576,Percent of Total Billed Charges,36% Total Bille Charges,1279.47,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3554.07,100,,2843.256,Percent of Total Billed Charges,100% of Total Billed Charges,319.67,5900,
HOSPICE,99000105,CDM,115,RC,,,Inpatient,,,790.3,474.18,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.28,28,,177.024,Percent of Total Billed Charges,28% of Total Billed Charges,319.67,32,,255.736,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,284.51,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,284.51,36,,227.608,Percent of Total Billed Charges,36% Total Bille Charges,284.51,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.3,100,,632.24,Percent of Total Billed Charges,100% of Total Billed Charges,221.28,5900,
3N PRIVATE ROOM,99010100,CDM,110,RC,,,Inpatient,,,1128.02,676.81,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.85,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,319.67,32,,255.736,Percent of Total Billed Charges,32% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.02,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,315.85,5900,
TELEMETRY MONITORING,99010101,CDM,206,RC,,,Inpatient,,,1856.51,1113.91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.82,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,1092,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.51,100,,1485.208,Percent of Total Billed Charges,100% of Total Billed Charges,519.82,5900,
3N STEP DOWN,99010102,CDM,206,RC,,,Inpatient,,,1998.15,1198.89,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.48,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,1092,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.15,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,559.48,5900,
3W STEP DOWN,99020102,CDM,206,RC,,,Inpatient,,,1998.15,1198.89,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.48,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,2100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.15,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,559.48,5900,
5E PRIVATE ROOM,99030100,CDM,110,RC,,,Inpatient,,,1128.02,676.81,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.85,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,2100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.02,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,315.85,5900,
5E TELEMETRY MONITORING,99030101,CDM,206,RC,,,Inpatient,,,1856.5,1113.90,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.82,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,2960,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.5,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,519.82,5900,
5E STEP DOWN,99030102,CDM,206,RC,,,Inpatient,,,1998.15,1198.89,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.48,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,2960,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.15,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,559.48,5900,
5W PRIVATE ROOM,99040100,CDM,110,RC,,,Inpatient,,,1128.02,676.81,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.85,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,2960,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.02,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,315.85,5900,
5W TELEMETRY MONITORING,99040101,CDM,206,RC,,,Inpatient,,,1856.5,1113.90,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.82,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,2960,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.5,100,,1485.2,Percent of Total Billed Charges,100% of Total Billed Charges,519.82,5900,
5W STEP DOWN,99040102,CDM,206,RC,,,Inpatient,,,1998.15,1198.89,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.48,28,,447.584,Percent of Total Billed Charges,28% of Total Billed Charges,462,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% Total Bille Charges,719.33,36,,575.464,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1998.15,100,,1598.52,Percent of Total Billed Charges,100% of Total Billed Charges,462,5900,
5W HOSPICE,99040105,CDM,115,RC,,,Inpatient,,,790.3,474.18,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.28,28,,177.024,Percent of Total Billed Charges,28% of Total Billed Charges,462,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,284.51,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,284.51,36,,227.608,Percent of Total Billed Charges,36% Total Bille Charges,284.51,36,,227.608,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790.3,100,,632.24,Percent of Total Billed Charges,100% of Total Billed Charges,221.28,5900,
DS PRIVATE ROOM,99050100,CDM,110,RC,,,Inpatient,,,955.95,573.57,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.67,28,,214.136,Percent of Total Billed Charges,28% of Total Billed Charges,756,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,344.14,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,344.14,36,,275.312,Percent of Total Billed Charges,36% Total Bille Charges,344.14,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,955.95,100,,764.76,Percent of Total Billed Charges,100% of Total Billed Charges,267.67,5900,
EHLD PRIVATE ROOM,99060100,CDM,110,RC,,,Inpatient,,,1128.02,676.81,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.85,28,,252.68,Percent of Total Billed Charges,28% of Total Billed Charges,756,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% Total Bille Charges,406.09,36,,324.872,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1128.02,100,,902.416,Percent of Total Billed Charges,100% of Total Billed Charges,315.85,5900,
EHLD TELEMETRY MONITORING,99060101,CDM,206,RC,,,Inpatient,,,1856.51,1113.91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,519.82,28,,415.856,Percent of Total Billed Charges,28% of Total Billed Charges,2656,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% Total Bille Charges,668.34,36,,534.672,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1856.51,100,,1485.208,Percent of Total Billed Charges,100% of Total Billed Charges,519.82,5900,
EHLD STEP DOWN,99060102,CDM,206,RC,,,Inpatient,,,2197.97,1318.78,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,615.43,28,,492.344,Percent of Total Billed Charges,28% of Total Billed Charges,2656,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,791.27,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,791.27,36,,633.016,Percent of Total Billed Charges,36% Total Bille Charges,791.27,36,,633.016,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2197.97,100,,1758.376,Percent of Total Billed Charges,100% of Total Billed Charges,615.43,5900,
EHLD CRITICAL CARE LEVEL ll,99060103,CDM,200,RC,,,Inpatient,,,2754.11,1652.47,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,771.15,28,,616.92,Percent of Total Billed Charges,28% of Total Billed Charges,2656,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,991.48,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,991.48,36,,793.184,Percent of Total Billed Charges,36% Total Bille Charges,991.48,36,,793.184,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2754.11,100,,2203.288,Percent of Total Billed Charges,100% of Total Billed Charges,771.15,5900,
EHLD CRITICAL CARE LEVEL III,99060104,CDM,200,RC,,,Inpatient,,,3554.07,2132.44,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,995.14,28,,796.112,Percent of Total Billed Charges,28% of Total Billed Charges,2656,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1279.47,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,1279.47,36,,1023.576,Percent of Total Billed Charges,36% Total Bille Charges,1279.47,36,,1023.576,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3554.07,100,,2843.256,Percent of Total Billed Charges,100% of Total Billed Charges,995.14,5900,
OR PRIVATE ROOM,99070100,CDM,110,RC,,,Inpatient,,,955.95,573.57,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.67,28,,214.136,Percent of Total Billed Charges,28% of Total Billed Charges,2656,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,344.14,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,344.14,36,,275.312,Percent of Total Billed Charges,36% Total Bille Charges,344.14,36,,275.312,Percent of Total Billed Charges,36% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays Based on per visit rate,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,955.95,100,,764.76,Percent of Total Billed Charges,100% of Total Billed Charges,267.67,5900,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,CDM,,,,,Inpatient,,,,,,371034.03,100,,,Case Rate,100% of CMS IPPS Rate,268923.63,145,MS-DRG,215138.904,Case Rate,145% of CMS IPPS Rate,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,375511.61,100,,,Case Rate,100% of CMS IPPS Rate,429172.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,482804.66,100,,,Case Rate,100% of CMS IPPS Rate,482804.66,100,,,Case Rate,100% of CMS IPPS Rate,482804.66,100,,,Case Rate,100% CMS IPPS Rate,334938.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,168761.48,100,MS-DRG,135009.184,Case Rate,100% of CMS IPPS Rate,168761.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,168761.48,100,MS-DRG,135009.184,Case Rate,100% of CMS IPPS Rate,168761.48,100,MS-DRG,135009.184,Case Rate,100% of CMS IPPS Rate,292359.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,241103.94,130,MS-DRG,192883.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191028.51,103,MS-DRG,152822.808,Case Rate,103% of CMS IPPS Rate,191028.51,103,MS-DRG,152822.808,Case Rate,103% of CMS IPPS Rate,356048.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,196464.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,278196.86,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,379380.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185464.57,100,MS-DRG,148371.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,482804.66,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,CDM,,,,,Inpatient,,,,,,167646.22,100,,,Case Rate,100% of CMS IPPS Rate,121509.14,145,MS-DRG,97207.312,Case Rate,145% of CMS IPPS Rate,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,125371.39,100,,,Case Rate,100% of CMS IPPS Rate,143286.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,161193.13,100,,,Case Rate,100% of CMS IPPS Rate,161193.13,100,,,Case Rate,100% of CMS IPPS Rate,161193.13,100,,,Case Rate,100% CMS IPPS Rate,151337.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,76252.51,100,MS-DRG,61002.008,Case Rate,100% of CMS IPPS Rate,76252.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,76252.51,100,MS-DRG,61002.008,Case Rate,100% of CMS IPPS Rate,76252.51,100,MS-DRG,61002.008,Case Rate,100% of CMS IPPS Rate,110184.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,108939.23,130,MS-DRG,87151.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86313.39,103,MS-DRG,69050.712,Case Rate,103% of CMS IPPS Rate,86313.39,103,MS-DRG,69050.712,Case Rate,103% of CMS IPPS Rate,170434.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,88769.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,125699.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,171417.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83799.41,100,MS-DRG,67039.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,171417.4,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,CDM,,,,,Inpatient,,,,,,291917.55,100,,,Case Rate,100% of CMS IPPS Rate,211580.39,145,MS-DRG,169264.312,Case Rate,145% of CMS IPPS Rate,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,285704.66,100,,,Case Rate,100% of CMS IPPS Rate,326531.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,367337.62,100,,,Case Rate,100% of CMS IPPS Rate,367337.62,100,,,Case Rate,100% of CMS IPPS Rate,367337.62,100,,,Case Rate,100% CMS IPPS Rate,263518.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,132776.11,100,MS-DRG,106220.888,Case Rate,100% of CMS IPPS Rate,132776.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,132776.11,100,MS-DRG,106220.888,Case Rate,100% of CMS IPPS Rate,132776.11,100,MS-DRG,106220.888,Case Rate,100% of CMS IPPS Rate,195822.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,189692.76,130,MS-DRG,151754.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150295.04,103,MS-DRG,120236.032,Case Rate,103% of CMS IPPS Rate,150295.04,103,MS-DRG,120236.032,Case Rate,103% of CMS IPPS Rate,255999.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,154572.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,218876.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,298484.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145917.51,100,MS-DRG,116734.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,367337.62,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,CDM,,,,,Inpatient,,,,,,201272.4,100,,,Case Rate,100% of CMS IPPS Rate,145881.24,145,MS-DRG,116704.992,Case Rate,145% of CMS IPPS Rate,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,188367.03,100,,,Case Rate,100% of CMS IPPS Rate,215284.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,242188.2,100,,,Case Rate,100% of CMS IPPS Rate,242188.2,100,,,Case Rate,100% of CMS IPPS Rate,242188.2,100,,,Case Rate,100% CMS IPPS Rate,181692,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,91547.04,100,MS-DRG,73237.632,Case Rate,100% of CMS IPPS Rate,91547.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,91547.04,100,MS-DRG,73237.632,Case Rate,100% of CMS IPPS Rate,91547.04,100,MS-DRG,73237.632,Case Rate,100% of CMS IPPS Rate,137687.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,130790.08,130,MS-DRG,104632.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103625.98,103,MS-DRG,82900.784,Case Rate,103% of CMS IPPS Rate,103625.98,103,MS-DRG,82900.784,Case Rate,103% of CMS IPPS Rate,173706.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,106575,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,150911.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,205800,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100607.75,100,MS-DRG,80486.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,242188.2,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,CDM,,,,,Inpatient,,,,,,141712.2,100,,,Case Rate,100% of CMS IPPS Rate,102712.32,145,MS-DRG,82169.856,Case Rate,145% of CMS IPPS Rate,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,141967.15,100,,,Case Rate,100% of CMS IPPS Rate,162254.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,182530.72,100,,,Case Rate,100% of CMS IPPS Rate,182530.72,100,,,Case Rate,100% of CMS IPPS Rate,182530.72,100,,,Case Rate,100% CMS IPPS Rate,127926,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,64456.67,100,MS-DRG,51565.336,Case Rate,100% of CMS IPPS Rate,64456.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,64456.67,100,MS-DRG,51565.336,Case Rate,100% of CMS IPPS Rate,64456.67,100,MS-DRG,51565.336,Case Rate,100% of CMS IPPS Rate,90571.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,92086.9,130,MS-DRG,73669.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72961.16,103,MS-DRG,58368.928,Case Rate,103% of CMS IPPS Rate,72961.16,103,MS-DRG,58368.928,Case Rate,103% of CMS IPPS Rate,144298.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,75037.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,106254.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70836.08,100,MS-DRG,56668.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,182530.72,
LIVER TRANSPLANT WITHOUT MCC,6,CDM,,,,,Inpatient,,,,,,66226.83,100,,,Case Rate,100% of CMS IPPS Rate,48000.89,145,MS-DRG,38400.712,Case Rate,145% of CMS IPPS Rate,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,64644.69,100,,,Case Rate,100% of CMS IPPS Rate,73882.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83115.29,100,,,Case Rate,100% of CMS IPPS Rate,83115.29,100,,,Case Rate,100% of CMS IPPS Rate,83115.29,100,,,Case Rate,100% CMS IPPS Rate,59784.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30122.88,100,MS-DRG,24098.304,Case Rate,100% of CMS IPPS Rate,30122.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,30122.88,100,MS-DRG,24098.304,Case Rate,100% of CMS IPPS Rate,30122.88,100,MS-DRG,24098.304,Case Rate,100% of CMS IPPS Rate,59094.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,43035.28,130,MS-DRG,34428.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34097.18,103,MS-DRG,27277.744,Case Rate,103% of CMS IPPS Rate,34097.18,103,MS-DRG,27277.744,Case Rate,103% of CMS IPPS Rate,60837.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,35067.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,49656.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33104.06,100,MS-DRG,26483.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,83115.29,
LUNG TRANSPLANT,7,CDM,,,,,Inpatient,,,,,,167951.55,100,,,Case Rate,100% of CMS IPPS Rate,121730.46,145,MS-DRG,97384.368,Case Rate,145% of CMS IPPS Rate,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,174220.17,100,,,Case Rate,100% of CMS IPPS Rate,199116.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,223999.23,100,,,Case Rate,100% of CMS IPPS Rate,223999.23,100,,,Case Rate,100% of CMS IPPS Rate,223999.23,100,,,Case Rate,100% CMS IPPS Rate,151612.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,76391.38,100,MS-DRG,61113.104,Case Rate,100% of CMS IPPS Rate,76391.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,76391.38,100,MS-DRG,61113.104,Case Rate,100% of CMS IPPS Rate,76391.38,100,MS-DRG,61113.104,Case Rate,100% of CMS IPPS Rate,110384.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,109137.65,130,MS-DRG,87310.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86470.6,103,MS-DRG,69176.48,Case Rate,103% of CMS IPPS Rate,86470.6,103,MS-DRG,69176.48,Case Rate,103% of CMS IPPS Rate,154422.35,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,88931.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,125928.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83952.04,100,MS-DRG,67161.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,223999.23,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,CDM,,,,,Inpatient,,,,,,72043.2,100,,,Case Rate,100% of CMS IPPS Rate,52216.54,145,MS-DRG,41773.232,Case Rate,145% of CMS IPPS Rate,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,72535.3,100,,,Case Rate,100% of CMS IPPS Rate,82900.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,93260.45,100,,,Case Rate,100% of CMS IPPS Rate,93260.45,100,,,Case Rate,100% of CMS IPPS Rate,93260.45,100,,,Case Rate,100% CMS IPPS Rate,65034.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32768.39,100,MS-DRG,26214.712,Case Rate,100% of CMS IPPS Rate,32768.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,32768.39,100,MS-DRG,26214.712,Case Rate,100% of CMS IPPS Rate,32768.39,100,MS-DRG,26214.712,Case Rate,100% of CMS IPPS Rate,47349.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,46814.83,130,MS-DRG,37451.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37091.75,103,MS-DRG,29673.4,Case Rate,103% of CMS IPPS Rate,37091.75,103,MS-DRG,29673.4,Case Rate,103% of CMS IPPS Rate,70727.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,38147.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,54017.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36011.41,100,MS-DRG,28809.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,93260.45,
PANCREAS TRANSPLANT,10,CDM,,,,,Inpatient,,,,,,65907.81,100,,,Case Rate,100% of CMS IPPS Rate,47769.66,145,MS-DRG,38215.728,Case Rate,145% of CMS IPPS Rate,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,106288.06,100,,,Case Rate,100% of CMS IPPS Rate,121476.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,136657.22,100,,,Case Rate,100% of CMS IPPS Rate,136657.22,100,,,Case Rate,100% of CMS IPPS Rate,136657.22,100,,,Case Rate,100% CMS IPPS Rate,59496.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29977.77,100,MS-DRG,23982.216,Case Rate,100% of CMS IPPS Rate,29977.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,29977.77,100,MS-DRG,23982.216,Case Rate,100% of CMS IPPS Rate,29977.77,100,MS-DRG,23982.216,Case Rate,100% of CMS IPPS Rate,43317.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,42827.97,130,MS-DRG,34262.376,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33932.93,103,MS-DRG,27146.344,Case Rate,103% of CMS IPPS Rate,33932.93,103,MS-DRG,27146.344,Case Rate,103% of CMS IPPS Rate,52457.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,34898.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,49416.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32944.59,100,MS-DRG,26355.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,136657.22,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,CDM,,,,,Inpatient,,,,,,70600.06,100,,,Case Rate,100% of CMS IPPS Rate,51170.57,145,MS-DRG,40936.456,Case Rate,145% of CMS IPPS Rate,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,71932.74,100,,,Case Rate,100% of CMS IPPS Rate,82211.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,92485.73,100,,,Case Rate,100% of CMS IPPS Rate,92485.73,100,,,Case Rate,100% of CMS IPPS Rate,92485.73,100,,,Case Rate,100% CMS IPPS Rate,63731.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32112,100,MS-DRG,25689.6,Case Rate,100% of CMS IPPS Rate,32112,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,32112,100,MS-DRG,25689.6,Case Rate,100% of CMS IPPS Rate,32112,100,MS-DRG,25689.6,Case Rate,100% of CMS IPPS Rate,47332.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,45877.07,130,MS-DRG,36701.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36348.75,103,MS-DRG,29079,Case Rate,103% of CMS IPPS Rate,36348.75,103,MS-DRG,29079,Case Rate,103% of CMS IPPS Rate,65339.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,37383.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,52935.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,72188.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35290.05,100,MS-DRG,28232.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,92485.73,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,CDM,,,,,Inpatient,,,,,,54835.09,100,,,Case Rate,100% of CMS IPPS Rate,39744.21,145,MS-DRG,31795.368,Case Rate,145% of CMS IPPS Rate,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,54706.42,100,,,Case Rate,100% of CMS IPPS Rate,62523.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,70337.42,100,,,Case Rate,100% of CMS IPPS Rate,70337.42,100,,,Case Rate,100% of CMS IPPS Rate,70337.42,100,,,Case Rate,100% CMS IPPS Rate,49500.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24941.47,100,MS-DRG,19953.176,Case Rate,100% of CMS IPPS Rate,24941.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24941.47,100,MS-DRG,19953.176,Case Rate,100% of CMS IPPS Rate,24941.47,100,MS-DRG,19953.176,Case Rate,100% of CMS IPPS Rate,28739.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,35632.74,130,MS-DRG,28506.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28232.09,103,MS-DRG,22585.672,Case Rate,103% of CMS IPPS Rate,28232.09,103,MS-DRG,22585.672,Case Rate,103% of CMS IPPS Rate,49455.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,29035.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,41114.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,56068.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27409.8,100,MS-DRG,21927.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,70337.42,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,CDM,,,,,Inpatient,,,,,,36772.6,100,,,Case Rate,100% of CMS IPPS Rate,26652.61,145,MS-DRG,21322.088,Case Rate,145% of CMS IPPS Rate,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,35327.15,100,,,Case Rate,100% of CMS IPPS Rate,40375.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45421,100,,,Case Rate,100% of CMS IPPS Rate,45421,100,,,Case Rate,100% of CMS IPPS Rate,45421,100,,,Case Rate,100% CMS IPPS Rate,33195.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16725.91,100,MS-DRG,13380.728,Case Rate,100% of CMS IPPS Rate,16725.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16725.91,100,MS-DRG,13380.728,Case Rate,100% of CMS IPPS Rate,16725.91,100,MS-DRG,13380.728,Case Rate,100% of CMS IPPS Rate,24168.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,23895.44,130,MS-DRG,19116.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18932.54,103,MS-DRG,15146.032,Case Rate,103% of CMS IPPS Rate,18932.54,103,MS-DRG,15146.032,Case Rate,103% of CMS IPPS Rate,35778,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,19471.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27571.67,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,37599.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18381.11,100,MS-DRG,14704.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45421,
ALLOGENEIC BONE MARROW TRANSPLANT,14,CDM,,,,,Inpatient,,,,,,156922.64,100,,,Case Rate,100% of CMS IPPS Rate,113736.77,145,MS-DRG,90989.416,Case Rate,145% of CMS IPPS Rate,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,174660.1,100,,,Case Rate,100% of CMS IPPS Rate,199619.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,224564.85,100,,,Case Rate,100% of CMS IPPS Rate,224564.85,100,,,Case Rate,100% of CMS IPPS Rate,224564.85,100,,,Case Rate,100% CMS IPPS Rate,141656.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,71374.99,100,MS-DRG,57099.992,Case Rate,100% of CMS IPPS Rate,71374.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,71374.99,100,MS-DRG,57099.992,Case Rate,100% of CMS IPPS Rate,71374.99,100,MS-DRG,57099.992,Case Rate,100% of CMS IPPS Rate,127935.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,101970.9,130,MS-DRG,81576.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80792.32,103,MS-DRG,64633.856,Case Rate,103% of CMS IPPS Rate,80792.32,103,MS-DRG,64633.856,Case Rate,103% of CMS IPPS Rate,141591.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,83091.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,117658.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78439.15,100,MS-DRG,62751.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,224564.85,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,CDM,,,,,Inpatient,,,,,,84575.48,100,,,Case Rate,100% of CMS IPPS Rate,61299.9,145,MS-DRG,49039.92,Case Rate,145% of CMS IPPS Rate,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,80464.58,100,,,Case Rate,100% of CMS IPPS Rate,91962.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,103455.33,100,,,Case Rate,100% of CMS IPPS Rate,103455.33,100,,,Case Rate,100% of CMS IPPS Rate,103455.33,100,,,Case Rate,100% CMS IPPS Rate,76347.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,43611.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,54958.53,130,MS-DRG,43966.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43544.06,103,MS-DRG,34835.248,Case Rate,103% of CMS IPPS Rate,43544.06,103,MS-DRG,34835.248,Case Rate,103% of CMS IPPS Rate,76967.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,44783.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,63413.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,103455.33,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,CDM,,,,,Inpatient,,,,,,84575.48,100,,,Case Rate,100% of CMS IPPS Rate,61299.9,145,MS-DRG,49039.92,Case Rate,145% of CMS IPPS Rate,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,80464.58,100,,,Case Rate,100% of CMS IPPS Rate,91962.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,103455.33,100,,,Case Rate,100% of CMS IPPS Rate,103455.33,100,,,Case Rate,100% of CMS IPPS Rate,103455.33,100,,,Case Rate,100% CMS IPPS Rate,76347.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,38468.59,100,MS-DRG,30774.872,Case Rate,100% of CMS IPPS Rate,55586.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,54958.53,130,MS-DRG,43966.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43544.06,103,MS-DRG,34835.248,Case Rate,103% of CMS IPPS Rate,43544.06,103,MS-DRG,34835.248,Case Rate,103% of CMS IPPS Rate,55281.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,44783.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,63413.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42275.79,100,MS-DRG,33820.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,103455.33,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,CDM,,,,,Inpatient,,,,,,504450.25,100,,,Case Rate,100% of CMS IPPS Rate,365623.05,145,MS-DRG,292498.44,Case Rate,145% of CMS IPPS Rate,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,502749.34,100,,,Case Rate,100% of CMS IPPS Rate,574592.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,646397.39,100,,,Case Rate,100% of CMS IPPS Rate,646397.39,100,,,Case Rate,100% of CMS IPPS Rate,646397.39,100,,,Case Rate,100% CMS IPPS Rate,455375.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,229444.53,100,MS-DRG,183555.624,Case Rate,100% of CMS IPPS Rate,229444.53,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,229444.53,100,MS-DRG,183555.624,Case Rate,100% of CMS IPPS Rate,229444.53,100,MS-DRG,183555.624,Case Rate,100% of CMS IPPS Rate,241239.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,327799.98,130,MS-DRG,262239.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259718.44,103,MS-DRG,207774.752,Case Rate,103% of CMS IPPS Rate,259718.44,103,MS-DRG,207774.752,Case Rate,103% of CMS IPPS Rate,457236.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,267109.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,378230.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,515797.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252153.83,100,MS-DRG,201723.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,646397.39,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,CDM,,,,,Inpatient,,,,,,109447,100,,,Case Rate,100% of CMS IPPS Rate,79326.64,145,MS-DRG,63461.312,Case Rate,145% of CMS IPPS Rate,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,105678.84,100,,,Case Rate,100% of CMS IPPS Rate,120780.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,135873.92,100,,,Case Rate,100% of CMS IPPS Rate,135873.92,100,,,Case Rate,100% of CMS IPPS Rate,135873.92,100,,,Case Rate,100% CMS IPPS Rate,98799.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49781.15,100,MS-DRG,39824.92,Case Rate,100% of CMS IPPS Rate,49781.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,49781.15,100,MS-DRG,39824.92,Case Rate,100% of CMS IPPS Rate,49781.15,100,MS-DRG,39824.92,Case Rate,100% of CMS IPPS Rate,71933.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,71120.44,130,MS-DRG,56896.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56349.27,103,MS-DRG,45079.416,Case Rate,103% of CMS IPPS Rate,56349.27,103,MS-DRG,45079.416,Case Rate,103% of CMS IPPS Rate,90252.69,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,57952.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,82062.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,111909,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54708.03,100,MS-DRG,43766.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,135873.92,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,CDM,,,,,Inpatient,,,,,,115730.26,100,,,Case Rate,100% of CMS IPPS Rate,83880.72,145,MS-DRG,67104.576,Case Rate,145% of CMS IPPS Rate,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,106793.45,100,,,Case Rate,100% of CMS IPPS Rate,122045.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,137304.72,100,,,Case Rate,100% of CMS IPPS Rate,137304.72,100,,,Case Rate,100% of CMS IPPS Rate,137304.72,100,,,Case Rate,100% CMS IPPS Rate,104471.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52639.03,100,MS-DRG,42111.224,Case Rate,100% of CMS IPPS Rate,52639.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,52639.03,100,MS-DRG,42111.224,Case Rate,100% of CMS IPPS Rate,52639.03,100,MS-DRG,42111.224,Case Rate,100% of CMS IPPS Rate,93983.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,75203.4,130,MS-DRG,60162.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59584.23,103,MS-DRG,47667.384,Case Rate,103% of CMS IPPS Rate,59584.23,103,MS-DRG,47667.384,Case Rate,103% of CMS IPPS Rate,117686.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,61279.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,86773.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,118333.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57848.77,100,MS-DRG,46279.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,137304.72,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,CDM,,,,,Inpatient,,,,,,84088.05,100,,,Case Rate,100% of CMS IPPS Rate,60946.6,145,MS-DRG,48757.28,Case Rate,145% of CMS IPPS Rate,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,70756.24,100,,,Case Rate,100% of CMS IPPS Rate,80861.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,90971.55,100,,,Case Rate,100% of CMS IPPS Rate,90971.55,100,,,Case Rate,100% of CMS IPPS Rate,90971.55,100,,,Case Rate,100% CMS IPPS Rate,75907.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38246.88,100,MS-DRG,30597.504,Case Rate,100% of CMS IPPS Rate,38246.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38246.88,100,MS-DRG,30597.504,Case Rate,100% of CMS IPPS Rate,38246.88,100,MS-DRG,30597.504,Case Rate,100% of CMS IPPS Rate,73745.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,54641.78,130,MS-DRG,43713.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43293.1,103,MS-DRG,34634.48,Case Rate,103% of CMS IPPS Rate,43293.1,103,MS-DRG,34634.48,Case Rate,103% of CMS IPPS Rate,85883.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,44525.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,63048.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,85979.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42032.14,100,MS-DRG,33625.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,90971.55,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,CDM,,,,,Inpatient,,,,,,47602.98,100,,,Case Rate,100% of CMS IPPS Rate,38928.45,145,MS-DRG,31142.76,Case Rate,145% of CMS IPPS Rate,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,36590.98,100,,,Case Rate,100% of CMS IPPS Rate,41816.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47045.15,100,,,Case Rate,100% of CMS IPPS Rate,47045.15,100,,,Case Rate,100% of CMS IPPS Rate,47045.15,100,,,Case Rate,100% CMS IPPS Rate,42972.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24429.55,100,MS-DRG,19543.64,Case Rate,100% of CMS IPPS Rate,24429.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24429.55,100,MS-DRG,19543.64,Case Rate,100% of CMS IPPS Rate,24429.55,100,MS-DRG,19543.64,Case Rate,100% of CMS IPPS Rate,35768.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,34901.37,130,MS-DRG,27921.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27652.63,103,MS-DRG,22122.104,Case Rate,103% of CMS IPPS Rate,27652.63,103,MS-DRG,22122.104,Case Rate,103% of CMS IPPS Rate,55135.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,25206.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,40270.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,48673.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26847.21,100,MS-DRG,21477.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,55135.03,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,CDM,,,,,Inpatient,,,,,,77617.21,100,,,Case Rate,100% of CMS IPPS Rate,56256.58,145,MS-DRG,45005.264,Case Rate,145% of CMS IPPS Rate,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,75581.16,100,,,Case Rate,100% of CMS IPPS Rate,86375.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,97174.97,100,,,Case Rate,100% of CMS IPPS Rate,97174.97,100,,,Case Rate,100% of CMS IPPS Rate,97174.97,100,,,Case Rate,100% CMS IPPS Rate,70066.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35303.68,100,MS-DRG,28242.944,Case Rate,100% of CMS IPPS Rate,35303.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,35303.68,100,MS-DRG,28242.944,Case Rate,100% of CMS IPPS Rate,35303.68,100,MS-DRG,28242.944,Case Rate,100% of CMS IPPS Rate,50381.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,50436.93,130,MS-DRG,40349.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39961.57,103,MS-DRG,31969.256,Case Rate,103% of CMS IPPS Rate,39961.57,103,MS-DRG,31969.256,Case Rate,103% of CMS IPPS Rate,72502.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,41098.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,58196.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,79363.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38797.64,100,MS-DRG,31038.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,97174.97,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,CDM,,,,,Inpatient,,,,,,51876.25,100,,,Case Rate,100% of CMS IPPS Rate,37599.65,145,MS-DRG,30079.72,Case Rate,145% of CMS IPPS Rate,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,50680.46,100,,,Case Rate,100% of CMS IPPS Rate,57922.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,65161.14,100,,,Case Rate,100% of CMS IPPS Rate,65161.14,100,,,Case Rate,100% of CMS IPPS Rate,65161.14,100,,,Case Rate,100% CMS IPPS Rate,46829.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23595.66,100,MS-DRG,18876.528,Case Rate,100% of CMS IPPS Rate,23595.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23595.66,100,MS-DRG,18876.528,Case Rate,100% of CMS IPPS Rate,23595.66,100,MS-DRG,18876.528,Case Rate,100% of CMS IPPS Rate,36966.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,33710.03,130,MS-DRG,26968.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26708.71,103,MS-DRG,21366.968,Case Rate,103% of CMS IPPS Rate,26708.71,103,MS-DRG,21366.968,Case Rate,103% of CMS IPPS Rate,49952.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,27468.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,38896.19,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,53043.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25930.79,100,MS-DRG,20744.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,65161.14,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,CDM,,,,,Inpatient,,,,,,60463.87,100,,,Case Rate,100% of CMS IPPS Rate,43823.92,145,MS-DRG,35059.136,Case Rate,145% of CMS IPPS Rate,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,59249.03,100,,,Case Rate,100% of CMS IPPS Rate,67710.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,76176.69,100,,,Case Rate,100% of CMS IPPS Rate,76176.69,100,,,Case Rate,100% of CMS IPPS Rate,76176.69,100,,,Case Rate,100% CMS IPPS Rate,54581.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27501.66,100,MS-DRG,22001.328,Case Rate,100% of CMS IPPS Rate,27501.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,27501.66,100,MS-DRG,22001.328,Case Rate,100% of CMS IPPS Rate,27501.66,100,MS-DRG,22001.328,Case Rate,100% of CMS IPPS Rate,37175.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,39290.41,130,MS-DRG,31432.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31130.09,103,MS-DRG,24904.072,Case Rate,103% of CMS IPPS Rate,31130.09,103,MS-DRG,24904.072,Case Rate,103% of CMS IPPS Rate,57437.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,32016,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,45335.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,61824,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30223.39,100,MS-DRG,24178.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,76176.69,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,CDM,,,,,Inpatient,,,,,,40433.85,100,,,Case Rate,100% of CMS IPPS Rate,29306.25,145,MS-DRG,23445,Case Rate,145% of CMS IPPS Rate,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,40774.2,100,,,Case Rate,100% of CMS IPPS Rate,46600.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52424.4,100,,,Case Rate,100% of CMS IPPS Rate,52424.4,100,,,Case Rate,100% of CMS IPPS Rate,52424.4,100,,,Case Rate,100% CMS IPPS Rate,36500.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18391.19,100,MS-DRG,14712.952,Case Rate,100% of CMS IPPS Rate,18391.19,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18391.19,100,MS-DRG,14712.952,Case Rate,100% of CMS IPPS Rate,18391.19,100,MS-DRG,14712.952,Case Rate,100% of CMS IPPS Rate,23592.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,26274.57,130,MS-DRG,21019.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20817.55,103,MS-DRG,16654.04,Case Rate,103% of CMS IPPS Rate,20817.55,103,MS-DRG,16654.04,Case Rate,103% of CMS IPPS Rate,38247.28,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,21409.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30316.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,41343.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20211.21,100,MS-DRG,16168.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,52424.4,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,CDM,,,,,Inpatient,,,,,,33311.27,100,,,Case Rate,100% of CMS IPPS Rate,24143.85,145,MS-DRG,19315.08,Case Rate,145% of CMS IPPS Rate,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,32898.24,100,,,Case Rate,100% of CMS IPPS Rate,37599.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42298.09,100,,,Case Rate,100% of CMS IPPS Rate,42298.09,100,,,Case Rate,100% of CMS IPPS Rate,42298.09,100,,,Case Rate,100% CMS IPPS Rate,30070.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15151.55,100,MS-DRG,12121.24,Case Rate,100% of CMS IPPS Rate,15151.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15151.55,100,MS-DRG,12121.24,Case Rate,100% of CMS IPPS Rate,15151.55,100,MS-DRG,12121.24,Case Rate,100% of CMS IPPS Rate,21974.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,21646.21,130,MS-DRG,17316.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17150.46,103,MS-DRG,13720.368,Case Rate,103% of CMS IPPS Rate,17150.46,103,MS-DRG,13720.368,Case Rate,103% of CMS IPPS Rate,31566.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,17638.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24976.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,34060.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16650.93,100,MS-DRG,13320.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,42298.09,
SPINAL PROCEDURES WITH MCC,28,CDM,,,,,Inpatient,,,,,,82509.36,100,,,Case Rate,100% of CMS IPPS Rate,59802.38,145,MS-DRG,47841.904,Case Rate,145% of CMS IPPS Rate,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,81045.81,100,,,Case Rate,100% of CMS IPPS Rate,92627.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,104202.63,100,,,Case Rate,100% of CMS IPPS Rate,104202.63,100,,,Case Rate,100% of CMS IPPS Rate,104202.63,100,,,Case Rate,100% CMS IPPS Rate,74482.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37528.83,100,MS-DRG,30023.064,Case Rate,100% of CMS IPPS Rate,37528.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37528.83,100,MS-DRG,30023.064,Case Rate,100% of CMS IPPS Rate,37528.83,100,MS-DRG,30023.064,Case Rate,100% of CMS IPPS Rate,34556.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,53615.93,130,MS-DRG,42892.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42480.31,103,MS-DRG,33984.248,Case Rate,103% of CMS IPPS Rate,42480.31,103,MS-DRG,33984.248,Case Rate,103% of CMS IPPS Rate,74350.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,43689.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,61864.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,84365.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41243.02,100,MS-DRG,32994.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,104202.63,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,CDM,,,,,Inpatient,,,,,,46938.91,100,,,Case Rate,100% of CMS IPPS Rate,34021.09,145,MS-DRG,27216.872,Case Rate,145% of CMS IPPS Rate,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,44748.17,100,,,Case Rate,100% of CMS IPPS Rate,51142.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,57533.84,100,,,Case Rate,100% of CMS IPPS Rate,57533.84,100,,,Case Rate,100% of CMS IPPS Rate,57533.84,100,,,Case Rate,100% CMS IPPS Rate,42372.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21349.95,100,MS-DRG,17079.96,Case Rate,100% of CMS IPPS Rate,21349.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21349.95,100,MS-DRG,17079.96,Case Rate,100% of CMS IPPS Rate,21349.95,100,MS-DRG,17079.96,Case Rate,100% of CMS IPPS Rate,21762.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,30501.67,130,MS-DRG,24401.336,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24166.7,103,MS-DRG,19333.36,Case Rate,103% of CMS IPPS Rate,24166.7,103,MS-DRG,19333.36,Case Rate,103% of CMS IPPS Rate,43232.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,24854.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35194.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,47994.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23462.82,100,MS-DRG,18770.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,57533.84,
SPINAL PROCEDURES WITHOUT CC/MCC,30,CDM,,,,,Inpatient,,,,,,31751.75,100,,,Case Rate,100% of CMS IPPS Rate,23013.5,145,MS-DRG,18410.8,Case Rate,145% of CMS IPPS Rate,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,29666.81,100,,,Case Rate,100% of CMS IPPS Rate,33906.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38143.36,100,,,Case Rate,100% of CMS IPPS Rate,38143.36,100,,,Case Rate,100% of CMS IPPS Rate,38143.36,100,,,Case Rate,100% CMS IPPS Rate,28662.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14442.22,100,MS-DRG,11553.776,Case Rate,100% of CMS IPPS Rate,14442.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14442.22,100,MS-DRG,11553.776,Case Rate,100% of CMS IPPS Rate,14442.22,100,MS-DRG,11553.776,Case Rate,100% of CMS IPPS Rate,15814.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,20632.79,130,MS-DRG,16506.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16347.52,103,MS-DRG,13078.016,Case Rate,103% of CMS IPPS Rate,16347.52,103,MS-DRG,13078.016,Case Rate,103% of CMS IPPS Rate,29616.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,16812.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23807.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,32466,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15871.38,100,MS-DRG,12697.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38143.36,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,CDM,,,,,Inpatient,,,,,,56364.49,100,,,Case Rate,100% of CMS IPPS Rate,40852.71,145,MS-DRG,32682.168,Case Rate,145% of CMS IPPS Rate,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,55864.89,100,,,Case Rate,100% of CMS IPPS Rate,63847.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,71826.88,100,,,Case Rate,100% of CMS IPPS Rate,71826.88,100,,,Case Rate,100% of CMS IPPS Rate,71826.88,100,,,Case Rate,100% CMS IPPS Rate,50881.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25637.09,100,MS-DRG,20509.672,Case Rate,100% of CMS IPPS Rate,25637.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25637.09,100,MS-DRG,20509.672,Case Rate,100% of CMS IPPS Rate,25637.09,100,MS-DRG,20509.672,Case Rate,100% of CMS IPPS Rate,19621.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,36626.56,130,MS-DRG,29301.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29019.51,103,MS-DRG,23215.608,Case Rate,103% of CMS IPPS Rate,29019.51,103,MS-DRG,23215.608,Case Rate,103% of CMS IPPS Rate,52130.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,29845.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,42261.42,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,57632.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28174.28,100,MS-DRG,22539.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,71826.88,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,CDM,,,,,Inpatient,,,,,,29489.83,100,,,Case Rate,100% of CMS IPPS Rate,21374.07,145,MS-DRG,17099.256,Case Rate,145% of CMS IPPS Rate,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,28469.68,100,,,Case Rate,100% of CMS IPPS Rate,32538,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36604.18,100,,,Case Rate,100% of CMS IPPS Rate,36604.18,100,,,Case Rate,100% of CMS IPPS Rate,36604.18,100,,,Case Rate,100% CMS IPPS Rate,26620.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13413.41,100,MS-DRG,10730.728,Case Rate,100% of CMS IPPS Rate,13413.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13413.41,100,MS-DRG,10730.728,Case Rate,100% of CMS IPPS Rate,13413.41,100,MS-DRG,10730.728,Case Rate,100% of CMS IPPS Rate,17312.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,19162.96,130,MS-DRG,15330.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15182.96,103,MS-DRG,12146.368,Case Rate,103% of CMS IPPS Rate,15182.96,103,MS-DRG,12146.368,Case Rate,103% of CMS IPPS Rate,25989.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,15615.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22111.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,30153.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14740.74,100,MS-DRG,11792.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36604.18,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,CDM,,,,,Inpatient,,,,,,22220.75,100,,,Case Rate,100% of CMS IPPS Rate,16105.48,145,MS-DRG,12884.384,Case Rate,145% of CMS IPPS Rate,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,21269.61,100,,,Case Rate,100% of CMS IPPS Rate,24309.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27346.87,100,,,Case Rate,100% of CMS IPPS Rate,27346.87,100,,,Case Rate,100% of CMS IPPS Rate,27346.87,100,,,Case Rate,100% CMS IPPS Rate,20059.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10107.14,100,MS-DRG,8085.712,Case Rate,100% of CMS IPPS Rate,10107.14,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10107.14,100,MS-DRG,8085.712,Case Rate,100% of CMS IPPS Rate,10107.14,100,MS-DRG,8085.712,Case Rate,100% of CMS IPPS Rate,12014.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,14439.4,130,MS-DRG,11551.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11440.45,103,MS-DRG,9152.36,Case Rate,103% of CMS IPPS Rate,11440.45,103,MS-DRG,9152.36,Case Rate,103% of CMS IPPS Rate,21486.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,11766.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16660.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,22720.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11107.23,100,MS-DRG,8885.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27346.87,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,CDM,,,,,Inpatient,,,,,,53417.97,100,,,Case Rate,100% of CMS IPPS Rate,38717.07,145,MS-DRG,30973.656,Case Rate,145% of CMS IPPS Rate,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,51840.26,100,,,Case Rate,100% of CMS IPPS Rate,59248.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,66652.32,100,,,Case Rate,100% of CMS IPPS Rate,66652.32,100,,,Case Rate,100% of CMS IPPS Rate,66652.32,100,,,Case Rate,100% CMS IPPS Rate,48221.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24296.9,100,MS-DRG,19437.52,Case Rate,100% of CMS IPPS Rate,24296.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24296.9,100,MS-DRG,19437.52,Case Rate,100% of CMS IPPS Rate,24296.9,100,MS-DRG,19437.52,Case Rate,100% of CMS IPPS Rate,27273.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,34711.86,130,MS-DRG,27769.488,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27502.47,103,MS-DRG,22001.976,Case Rate,103% of CMS IPPS Rate,27502.47,103,MS-DRG,22001.976,Case Rate,103% of CMS IPPS Rate,50592.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,28285.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,40052.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,54619.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26701.43,100,MS-DRG,21361.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,66652.32,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,CDM,,,,,Inpatient,,,,,,31484.75,100,,,Case Rate,100% of CMS IPPS Rate,22820,145,MS-DRG,18256,Case Rate,145% of CMS IPPS Rate,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,30325.36,100,,,Case Rate,100% of CMS IPPS Rate,34658.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38990.07,100,,,Case Rate,100% of CMS IPPS Rate,38990.07,100,,,Case Rate,100% of CMS IPPS Rate,38990.07,100,,,Case Rate,100% CMS IPPS Rate,28421.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14320.78,100,MS-DRG,11456.624,Case Rate,100% of CMS IPPS Rate,14320.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14320.78,100,MS-DRG,11456.624,Case Rate,100% of CMS IPPS Rate,14320.78,100,MS-DRG,11456.624,Case Rate,100% of CMS IPPS Rate,19335.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,20459.31,130,MS-DRG,16367.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16210.07,103,MS-DRG,12968.056,Case Rate,103% of CMS IPPS Rate,16210.07,103,MS-DRG,12968.056,Case Rate,103% of CMS IPPS Rate,28890.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,16671.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23606.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,32193,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15737.93,100,MS-DRG,12590.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38990.07,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,CDM,,,,,Inpatient,,,,,,24757.87,100,,,Case Rate,100% of CMS IPPS Rate,17944.37,145,MS-DRG,14355.496,Case Rate,145% of CMS IPPS Rate,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,24437.06,100,,,Case Rate,100% of CMS IPPS Rate,27929.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31419.33,100,,,Case Rate,100% of CMS IPPS Rate,31419.33,100,,,Case Rate,100% of CMS IPPS Rate,31419.33,100,,,Case Rate,100% CMS IPPS Rate,22349.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11261.13,100,MS-DRG,9008.904,Case Rate,100% of CMS IPPS Rate,11261.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11261.13,100,MS-DRG,9008.904,Case Rate,100% of CMS IPPS Rate,11261.13,100,MS-DRG,9008.904,Case Rate,100% of CMS IPPS Rate,17865.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,16088.06,130,MS-DRG,12870.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12746.69,103,MS-DRG,10197.352,Case Rate,103% of CMS IPPS Rate,12746.69,103,MS-DRG,10197.352,Case Rate,103% of CMS IPPS Rate,23790.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,13109.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18563.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,25314.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12375.43,100,MS-DRG,9900.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31419.33,
EXTRACRANIAL PROCEDURES WITH MCC,37,CDM,,,,,Inpatient,,,,,,46218.72,100,,,Case Rate,100% of CMS IPPS Rate,33499.1,145,MS-DRG,26799.28,Case Rate,145% of CMS IPPS Rate,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,44270.92,100,,,Case Rate,100% of CMS IPPS Rate,50597.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,56920.23,100,,,Case Rate,100% of CMS IPPS Rate,56920.23,100,,,Case Rate,100% of CMS IPPS Rate,56920.23,100,,,Case Rate,100% CMS IPPS Rate,41722.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21022.38,100,MS-DRG,16817.904,Case Rate,100% of CMS IPPS Rate,21022.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21022.38,100,MS-DRG,16817.904,Case Rate,100% of CMS IPPS Rate,21022.38,100,MS-DRG,16817.904,Case Rate,100% of CMS IPPS Rate,30376.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,30033.68,130,MS-DRG,24026.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23795.91,103,MS-DRG,19036.728,Case Rate,103% of CMS IPPS Rate,23795.91,103,MS-DRG,19036.728,Case Rate,103% of CMS IPPS Rate,42668.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,24473.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34654.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,47258.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23102.83,100,MS-DRG,18482.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,56920.23,
EXTRACRANIAL PROCEDURES WITH CC,38,CDM,,,,,Inpatient,,,,,,21905.83,100,,,Case Rate,100% of CMS IPPS Rate,15877.24,145,MS-DRG,12701.792,Case Rate,145% of CMS IPPS Rate,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,21480.24,100,,,Case Rate,100% of CMS IPPS Rate,24549.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27617.68,100,,,Case Rate,100% of CMS IPPS Rate,27617.68,100,,,Case Rate,100% of CMS IPPS Rate,27617.68,100,,,Case Rate,100% CMS IPPS Rate,19774.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9963.91,100,MS-DRG,7971.128,Case Rate,100% of CMS IPPS Rate,9963.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9963.91,100,MS-DRG,7971.128,Case Rate,100% of CMS IPPS Rate,9963.91,100,MS-DRG,7971.128,Case Rate,100% of CMS IPPS Rate,15409.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,14234.77,130,MS-DRG,11387.816,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11278.31,103,MS-DRG,9022.648,Case Rate,103% of CMS IPPS Rate,11278.31,103,MS-DRG,9022.648,Case Rate,103% of CMS IPPS Rate,20689.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,11599.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16424.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,22398.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10949.82,100,MS-DRG,8759.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27617.68,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,CDM,,,,,Inpatient,,,,,,15622.57,100,,,Case Rate,100% of CMS IPPS Rate,11323.17,145,MS-DRG,9058.536,Case Rate,145% of CMS IPPS Rate,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,15173.34,100,,,Case Rate,100% of CMS IPPS Rate,17341.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19508.75,100,,,Case Rate,100% of CMS IPPS Rate,19508.75,100,,,Case Rate,100% of CMS IPPS Rate,19508.75,100,,,Case Rate,100% CMS IPPS Rate,14102.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7106.02,100,MS-DRG,5684.816,Case Rate,100% of CMS IPPS Rate,7106.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7106.02,100,MS-DRG,5684.816,Case Rate,100% of CMS IPPS Rate,7106.02,100,MS-DRG,5684.816,Case Rate,100% of CMS IPPS Rate,13139.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,10151.8,130,MS-DRG,8121.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8043.35,103,MS-DRG,6434.68,Case Rate,103% of CMS IPPS Rate,8043.35,103,MS-DRG,6434.68,Case Rate,103% of CMS IPPS Rate,14581.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,8272.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11713.62,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,15974,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7809.08,100,MS-DRG,6247.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19508.75,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,CDM,,,,,Inpatient,,,,,,52721.05,100,,,Case Rate,100% of CMS IPPS Rate,38211.95,145,MS-DRG,30569.56,Case Rate,145% of CMS IPPS Rate,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,50285.87,100,,,Case Rate,100% of CMS IPPS Rate,57471.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,64653.79,100,,,Case Rate,100% of CMS IPPS Rate,64653.79,100,,,Case Rate,100% of CMS IPPS Rate,64653.79,100,,,Case Rate,100% CMS IPPS Rate,47592.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23979.9,100,MS-DRG,19183.92,Case Rate,100% of CMS IPPS Rate,23979.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23979.9,100,MS-DRG,19183.92,Case Rate,100% of CMS IPPS Rate,23979.9,100,MS-DRG,19183.92,Case Rate,100% of CMS IPPS Rate,27995.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,34258.99,130,MS-DRG,27407.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27143.66,103,MS-DRG,21714.928,Case Rate,103% of CMS IPPS Rate,27143.66,103,MS-DRG,21714.928,Case Rate,103% of CMS IPPS Rate,47923.26,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,27916.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,39529.61,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,53907,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26353.07,100,MS-DRG,21082.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,64653.79,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,CDM,,,,,Inpatient,,,,,,30542.74,100,,,Case Rate,100% of CMS IPPS Rate,22137.22,145,MS-DRG,17709.776,Case Rate,145% of CMS IPPS Rate,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,29916.63,100,,,Case Rate,100% of CMS IPPS Rate,34189.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38463.92,100,,,Case Rate,100% of CMS IPPS Rate,38463.92,100,,,Case Rate,100% of CMS IPPS Rate,38463.92,100,,,Case Rate,100% CMS IPPS Rate,27571.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13892.32,100,MS-DRG,11113.856,Case Rate,100% of CMS IPPS Rate,13892.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13892.32,100,MS-DRG,11113.856,Case Rate,100% of CMS IPPS Rate,13892.32,100,MS-DRG,11113.856,Case Rate,100% of CMS IPPS Rate,19204.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,19847.17,130,MS-DRG,15877.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15725.06,103,MS-DRG,12580.048,Case Rate,103% of CMS IPPS Rate,15725.06,103,MS-DRG,12580.048,Case Rate,103% of CMS IPPS Rate,29576.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,16172.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22900.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,31229.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15267.05,100,MS-DRG,12213.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38463.92,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,CDM,,,,,Inpatient,,,,,,23821.34,100,,,Case Rate,100% of CMS IPPS Rate,17265.59,145,MS-DRG,13812.472,Case Rate,145% of CMS IPPS Rate,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,23430.57,100,,,Case Rate,100% of CMS IPPS Rate,26778.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30125.26,100,,,Case Rate,100% of CMS IPPS Rate,30125.26,100,,,Case Rate,100% of CMS IPPS Rate,30125.26,100,,,Case Rate,100% CMS IPPS Rate,21503.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10835.15,100,MS-DRG,8668.12,Case Rate,100% of CMS IPPS Rate,10835.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10835.15,100,MS-DRG,8668.12,Case Rate,100% of CMS IPPS Rate,10835.15,100,MS-DRG,8668.12,Case Rate,100% of CMS IPPS Rate,13654.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,15479.49,130,MS-DRG,12383.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12264.52,103,MS-DRG,9811.616,Case Rate,103% of CMS IPPS Rate,12264.52,103,MS-DRG,9811.616,Case Rate,103% of CMS IPPS Rate,23398.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,12613.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17860.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,24357.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11907.3,100,MS-DRG,9525.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30125.26,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,CDM,,,,,Inpatient,,,,,,26624.09,100,,,Case Rate,100% of CMS IPPS Rate,19297.01,145,MS-DRG,15437.608,Case Rate,145% of CMS IPPS Rate,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,26828.64,100,,,Case Rate,100% of CMS IPPS Rate,30662.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34494.25,100,,,Case Rate,100% of CMS IPPS Rate,34494.25,100,,,Case Rate,100% of CMS IPPS Rate,34494.25,100,,,Case Rate,100% CMS IPPS Rate,24034.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12109.96,100,MS-DRG,9687.968,Case Rate,100% of CMS IPPS Rate,12109.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12109.96,100,MS-DRG,9687.968,Case Rate,100% of CMS IPPS Rate,12109.96,100,MS-DRG,9687.968,Case Rate,100% of CMS IPPS Rate,35028.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,17300.76,130,MS-DRG,13840.608,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13707.53,103,MS-DRG,10966.024,Case Rate,103% of CMS IPPS Rate,13707.53,103,MS-DRG,10966.024,Case Rate,103% of CMS IPPS Rate,22520.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,14097.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19962.42,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,27223,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13308.28,100,MS-DRG,10646.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35028.65,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,CDM,,,,,Inpatient,,,,,,13470.19,100,,,Case Rate,100% of CMS IPPS Rate,9763.13,145,MS-DRG,7810.504,Case Rate,145% of CMS IPPS Rate,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,12283.18,100,,,Case Rate,100% of CMS IPPS Rate,14038.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15792.8,100,,,Case Rate,100% of CMS IPPS Rate,15792.8,100,,,Case Rate,100% of CMS IPPS Rate,15792.8,100,,,Case Rate,100% CMS IPPS Rate,12159.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6127.04,100,MS-DRG,4901.632,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,4901.632,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,4901.632,Case Rate,100% of CMS IPPS Rate,8853.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,8753.15,130,MS-DRG,7002.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6935.19,103,MS-DRG,5548.152,Case Rate,103% of CMS IPPS Rate,6935.19,103,MS-DRG,5548.152,Case Rate,103% of CMS IPPS Rate,12938.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,7132.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10099.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,13773.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,15792.8,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,CDM,,,,,Inpatient,,,,,,20175.16,100,,,Case Rate,100% of CMS IPPS Rate,14622.86,145,MS-DRG,11698.288,Case Rate,145% of CMS IPPS Rate,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,19984.5,100,,,Case Rate,100% of CMS IPPS Rate,22840.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25694.57,100,,,Case Rate,100% of CMS IPPS Rate,25694.57,100,,,Case Rate,100% of CMS IPPS Rate,25694.57,100,,,Case Rate,100% CMS IPPS Rate,18212.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9176.72,100,MS-DRG,7341.376,Case Rate,100% of CMS IPPS Rate,9176.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9176.72,100,MS-DRG,7341.376,Case Rate,100% of CMS IPPS Rate,9176.72,100,MS-DRG,7341.376,Case Rate,100% of CMS IPPS Rate,9652.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,13110.15,130,MS-DRG,10488.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10387.27,103,MS-DRG,8309.816,Case Rate,103% of CMS IPPS Rate,10387.27,103,MS-DRG,8309.816,Case Rate,103% of CMS IPPS Rate,17545.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,10682.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15127.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,20629,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10084.73,100,MS-DRG,8067.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25694.57,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,CDM,,,,,Inpatient,,,,,,14694.25,100,,,Case Rate,100% of CMS IPPS Rate,10650.32,145,MS-DRG,8520.256,Case Rate,145% of CMS IPPS Rate,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,14544.12,100,,,Case Rate,100% of CMS IPPS Rate,16622.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18699.74,100,,,Case Rate,100% of CMS IPPS Rate,18699.74,100,,,Case Rate,100% of CMS IPPS Rate,18699.74,100,,,Case Rate,100% CMS IPPS Rate,13264.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6683.79,100,MS-DRG,5347.032,Case Rate,100% of CMS IPPS Rate,6683.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6683.79,100,MS-DRG,5347.032,Case Rate,100% of CMS IPPS Rate,6683.79,100,MS-DRG,5347.032,Case Rate,100% of CMS IPPS Rate,7691.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,9548.57,130,MS-DRG,7638.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7565.4,103,MS-DRG,6052.32,Case Rate,103% of CMS IPPS Rate,7565.4,103,MS-DRG,6052.32,Case Rate,103% of CMS IPPS Rate,12755,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,7780.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11017.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,15024.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7345.05,100,MS-DRG,5876.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18699.74,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,CDM,,,,,Inpatient,,,,,,32778.65,100,,,Case Rate,100% of CMS IPPS Rate,23757.82,145,MS-DRG,19006.256,Case Rate,145% of CMS IPPS Rate,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,33382.16,100,,,Case Rate,100% of CMS IPPS Rate,38152.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42920.27,100,,,Case Rate,100% of CMS IPPS Rate,42920.27,100,,,Case Rate,100% of CMS IPPS Rate,42920.27,100,,,Case Rate,100% CMS IPPS Rate,29589.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14909.29,100,MS-DRG,11927.432,Case Rate,100% of CMS IPPS Rate,14909.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14909.29,100,MS-DRG,11927.432,Case Rate,100% of CMS IPPS Rate,14909.29,100,MS-DRG,11927.432,Case Rate,100% of CMS IPPS Rate,21075.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,21300.11,130,MS-DRG,17040.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16876.24,103,MS-DRG,13500.992,Case Rate,103% of CMS IPPS Rate,16876.24,103,MS-DRG,13500.992,Case Rate,103% of CMS IPPS Rate,28219.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,17356.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24577.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,33516,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16384.7,100,MS-DRG,13107.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,42920.27,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,CDM,,,,,Inpatient,,,,,,18664.93,100,,,Case Rate,100% of CMS IPPS Rate,13528.25,145,MS-DRG,10822.6,Case Rate,145% of CMS IPPS Rate,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,17788.89,100,,,Case Rate,100% of CMS IPPS Rate,20330.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22871.62,100,,,Case Rate,100% of CMS IPPS Rate,22871.62,100,,,Case Rate,100% of CMS IPPS Rate,22871.62,100,,,Case Rate,100% CMS IPPS Rate,16849.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8489.81,100,MS-DRG,6791.848,Case Rate,100% of CMS IPPS Rate,8489.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8489.81,100,MS-DRG,6791.848,Case Rate,100% of CMS IPPS Rate,8489.81,100,MS-DRG,6791.848,Case Rate,100% of CMS IPPS Rate,14605.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,12128.78,130,MS-DRG,9703.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9609.72,103,MS-DRG,7687.776,Case Rate,103% of CMS IPPS Rate,9609.72,103,MS-DRG,7687.776,Case Rate,103% of CMS IPPS Rate,16463.98,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,9883.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13994.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,19084.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9329.83,100,MS-DRG,7463.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22871.62,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,CDM,,,,,Inpatient,,,,,,23658.41,100,,,Case Rate,100% of CMS IPPS Rate,17147.48,145,MS-DRG,13717.984,Case Rate,145% of CMS IPPS Rate,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,24607.69,100,,,Case Rate,100% of CMS IPPS Rate,28124.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31638.73,100,,,Case Rate,100% of CMS IPPS Rate,31638.73,100,,,Case Rate,100% of CMS IPPS Rate,31638.73,100,,,Case Rate,100% CMS IPPS Rate,21356.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10761.04,100,MS-DRG,8608.832,Case Rate,100% of CMS IPPS Rate,10761.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10761.04,100,MS-DRG,8608.832,Case Rate,100% of CMS IPPS Rate,10761.04,100,MS-DRG,8608.832,Case Rate,100% of CMS IPPS Rate,14067.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,15373.61,130,MS-DRG,12298.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12180.63,103,MS-DRG,9744.504,Case Rate,103% of CMS IPPS Rate,12180.63,103,MS-DRG,9744.504,Case Rate,103% of CMS IPPS Rate,21825.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,12527.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17738.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,24190.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11825.85,100,MS-DRG,9460.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31638.73,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,CDM,,,,,Inpatient,,,,,,16255.14,100,,,Case Rate,100% of CMS IPPS Rate,11781.66,145,MS-DRG,9425.328,Case Rate,145% of CMS IPPS Rate,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,16311.81,100,,,Case Rate,100% of CMS IPPS Rate,18642.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20972.5,100,,,Case Rate,100% of CMS IPPS Rate,20972.5,100,,,Case Rate,100% of CMS IPPS Rate,20972.5,100,,,Case Rate,100% CMS IPPS Rate,14673.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7393.75,100,MS-DRG,5915,Case Rate,100% of CMS IPPS Rate,7393.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7393.75,100,MS-DRG,5915,Case Rate,100% of CMS IPPS Rate,7393.75,100,MS-DRG,5915,Case Rate,100% of CMS IPPS Rate,11211.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,10562.86,130,MS-DRG,8450.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8369.04,103,MS-DRG,6695.232,Case Rate,103% of CMS IPPS Rate,8369.04,103,MS-DRG,6695.232,Case Rate,103% of CMS IPPS Rate,14465.28,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,8607.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12187.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,16620.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8125.28,100,MS-DRG,6500.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20972.5,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,CDM,,,,,Inpatient,,,,,,12287.2,100,,,Case Rate,100% of CMS IPPS Rate,8905.71,145,MS-DRG,7124.568,Case Rate,145% of CMS IPPS Rate,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,11896.58,100,,,Case Rate,100% of CMS IPPS Rate,13596.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15295.74,100,,,Case Rate,100% of CMS IPPS Rate,15295.74,100,,,Case Rate,100% of CMS IPPS Rate,15295.74,100,,,Case Rate,100% CMS IPPS Rate,11091.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5588.96,100,MS-DRG,4471.168,Case Rate,100% of CMS IPPS Rate,5588.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5588.96,100,MS-DRG,4471.168,Case Rate,100% of CMS IPPS Rate,5588.96,100,MS-DRG,4471.168,Case Rate,100% of CMS IPPS Rate,8672.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,7984.43,130,MS-DRG,6387.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6326.13,103,MS-DRG,5060.904,Case Rate,103% of CMS IPPS Rate,6326.13,103,MS-DRG,5060.904,Case Rate,103% of CMS IPPS Rate,11464.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,6506.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9212.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,12563.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6141.87,100,MS-DRG,4913.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5588.96,15295.74,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,CDM,,,,,Inpatient,,,,,,38375.94,100,,,Case Rate,100% of CMS IPPS Rate,27814.7,145,MS-DRG,22251.76,Case Rate,145% of CMS IPPS Rate,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,36039.03,100,,,Case Rate,100% of CMS IPPS Rate,41189,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46336.28,100,,,Case Rate,100% of CMS IPPS Rate,46336.28,100,,,Case Rate,100% of CMS IPPS Rate,46336.28,100,,,Case Rate,100% CMS IPPS Rate,34642.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17455.17,100,MS-DRG,13964.136,Case Rate,100% of CMS IPPS Rate,17455.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17455.17,100,MS-DRG,13964.136,Case Rate,100% of CMS IPPS Rate,17455.17,100,MS-DRG,13964.136,Case Rate,100% of CMS IPPS Rate,22124.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,24937.32,130,MS-DRG,19949.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19758.03,103,MS-DRG,15806.424,Case Rate,103% of CMS IPPS Rate,19758.03,103,MS-DRG,15806.424,Case Rate,103% of CMS IPPS Rate,37097.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,20320.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28773.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,39239.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19182.55,100,MS-DRG,15346.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46336.28,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,CDM,,,,,Inpatient,,,,,,25627.32,100,,,Case Rate,100% of CMS IPPS Rate,18574.56,145,MS-DRG,14859.648,Case Rate,145% of CMS IPPS Rate,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,23741.18,100,,,Case Rate,100% of CMS IPPS Rate,27133.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30524.63,100,,,Case Rate,100% of CMS IPPS Rate,30524.63,100,,,Case Rate,100% of CMS IPPS Rate,30524.63,100,,,Case Rate,100% CMS IPPS Rate,23134.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11656.59,100,MS-DRG,9325.272,Case Rate,100% of CMS IPPS Rate,11656.59,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11656.59,100,MS-DRG,9325.272,Case Rate,100% of CMS IPPS Rate,11656.59,100,MS-DRG,9325.272,Case Rate,100% of CMS IPPS Rate,14286.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,16653.05,130,MS-DRG,13322.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13194.34,103,MS-DRG,10555.472,Case Rate,103% of CMS IPPS Rate,13194.34,103,MS-DRG,10555.472,Case Rate,103% of CMS IPPS Rate,24252.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,13569.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19215.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,26203.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12810.04,100,MS-DRG,10248.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30524.63,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,CDM,,,,,Inpatient,,,,,,20357.27,100,,,Case Rate,100% of CMS IPPS Rate,14754.85,145,MS-DRG,11803.88,Case Rate,145% of CMS IPPS Rate,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,18727.39,100,,,Case Rate,100% of CMS IPPS Rate,21403.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24078.27,100,,,Case Rate,100% of CMS IPPS Rate,24078.27,100,,,Case Rate,100% of CMS IPPS Rate,24078.27,100,,,Case Rate,100% CMS IPPS Rate,18376.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9259.55,100,MS-DRG,7407.64,Case Rate,100% of CMS IPPS Rate,9259.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9259.55,100,MS-DRG,7407.64,Case Rate,100% of CMS IPPS Rate,9259.55,100,MS-DRG,7407.64,Case Rate,100% of CMS IPPS Rate,12703.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,13228.49,130,MS-DRG,10582.792,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10481.03,103,MS-DRG,8384.824,Case Rate,103% of CMS IPPS Rate,10481.03,103,MS-DRG,8384.824,Case Rate,103% of CMS IPPS Rate,19999.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,10779.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15263.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,20815.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10175.76,100,MS-DRG,8140.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24078.27,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,CDM,,,,,Inpatient,,,,,,27425.08,100,,,Case Rate,100% of CMS IPPS Rate,19877.56,145,MS-DRG,15902.048,Case Rate,145% of CMS IPPS Rate,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,26518.03,100,,,Case Rate,100% of CMS IPPS Rate,30307.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34094.89,100,,,Case Rate,100% of CMS IPPS Rate,34094.89,100,,,Case Rate,100% of CMS IPPS Rate,34094.89,100,,,Case Rate,100% CMS IPPS Rate,24757.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12474.27,100,MS-DRG,9979.416,Case Rate,100% of CMS IPPS Rate,12474.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12474.27,100,MS-DRG,9979.416,Case Rate,100% of CMS IPPS Rate,12474.27,100,MS-DRG,9979.416,Case Rate,100% of CMS IPPS Rate,18043.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,17821.26,130,MS-DRG,14257.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14119.92,103,MS-DRG,11295.936,Case Rate,103% of CMS IPPS Rate,14119.92,103,MS-DRG,11295.936,Case Rate,103% of CMS IPPS Rate,24945.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,14521.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20562.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,28042,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13708.66,100,MS-DRG,10966.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34094.89,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,CDM,,,,,Inpatient,,,,,,13916.55,100,,,Case Rate,100% of CMS IPPS Rate,10086.65,145,MS-DRG,8069.32,Case Rate,145% of CMS IPPS Rate,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,13556.29,100,,,Case Rate,100% of CMS IPPS Rate,15493.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17429.67,100,,,Case Rate,100% of CMS IPPS Rate,17429.67,100,,,Case Rate,100% of CMS IPPS Rate,17429.67,100,,,Case Rate,100% CMS IPPS Rate,12562.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6330.05,100,MS-DRG,5064.04,Case Rate,100% of CMS IPPS Rate,6330.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6330.05,100,MS-DRG,5064.04,Case Rate,100% of CMS IPPS Rate,6330.05,100,MS-DRG,5064.04,Case Rate,100% of CMS IPPS Rate,9769.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,9043.2,130,MS-DRG,7234.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7165,103,MS-DRG,5732,Case Rate,103% of CMS IPPS Rate,7165,103,MS-DRG,5732,Case Rate,103% of CMS IPPS Rate,12857.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,7368.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10434.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,14229.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6956.31,100,MS-DRG,5565.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17429.67,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,CDM,,,,,Inpatient,,,,,,9413.25,100,,,Case Rate,100% of CMS IPPS Rate,6822.67,145,MS-DRG,5458.136,Case Rate,145% of CMS IPPS Rate,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,9175.73,100,,,Case Rate,100% of CMS IPPS Rate,10486.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11797.46,100,,,Case Rate,100% of CMS IPPS Rate,11797.46,100,,,Case Rate,100% of CMS IPPS Rate,11797.46,100,,,Case Rate,100% CMS IPPS Rate,8497.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4281.77,100,MS-DRG,3425.416,Case Rate,100% of CMS IPPS Rate,4281.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4281.77,100,MS-DRG,3425.416,Case Rate,100% of CMS IPPS Rate,4281.77,100,MS-DRG,3425.416,Case Rate,100% of CMS IPPS Rate,7495.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,6116.88,130,MS-DRG,4893.504,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4846.45,103,MS-DRG,3877.16,Case Rate,103% of CMS IPPS Rate,4846.45,103,MS-DRG,3877.16,Case Rate,103% of CMS IPPS Rate,8836.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,4984.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7057.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,9625,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4705.29,100,MS-DRG,3764.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4281.77,11797.46,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,CDM,,,,,Inpatient,,,,,,19400.19,100,,,Case Rate,100% of CMS IPPS Rate,14061.16,145,MS-DRG,11248.928,Case Rate,145% of CMS IPPS Rate,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,19395.27,100,,,Case Rate,100% of CMS IPPS Rate,22166.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24936.99,100,,,Case Rate,100% of CMS IPPS Rate,24936.99,100,,,Case Rate,100% of CMS IPPS Rate,24936.99,100,,,Case Rate,100% CMS IPPS Rate,17512.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8824.23,100,MS-DRG,7059.384,Case Rate,100% of CMS IPPS Rate,8824.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8824.23,100,MS-DRG,7059.384,Case Rate,100% of CMS IPPS Rate,8824.23,100,MS-DRG,7059.384,Case Rate,100% of CMS IPPS Rate,6847.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,12606.56,130,MS-DRG,10085.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9988.27,103,MS-DRG,7990.616,Case Rate,103% of CMS IPPS Rate,9988.27,103,MS-DRG,7990.616,Case Rate,103% of CMS IPPS Rate,17888.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,10272.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14546.03,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,19836.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9697.35,100,MS-DRG,7757.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24936.99,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,CDM,,,,,Inpatient,,,,,,11925.73,100,,,Case Rate,100% of CMS IPPS Rate,8643.71,145,MS-DRG,6914.968,Case Rate,145% of CMS IPPS Rate,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,11751.28,100,,,Case Rate,100% of CMS IPPS Rate,13430.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15108.91,100,,,Case Rate,100% of CMS IPPS Rate,15108.91,100,,,Case Rate,100% of CMS IPPS Rate,15108.91,100,,,Case Rate,100% CMS IPPS Rate,10765.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5424.55,100,MS-DRG,4339.64,Case Rate,100% of CMS IPPS Rate,5424.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5424.55,100,MS-DRG,4339.64,Case Rate,100% of CMS IPPS Rate,5424.55,100,MS-DRG,4339.64,Case Rate,100% of CMS IPPS Rate,7911.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,7749.53,130,MS-DRG,6199.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6140.02,103,MS-DRG,4912.016,Case Rate,103% of CMS IPPS Rate,6140.02,103,MS-DRG,4912.016,Case Rate,103% of CMS IPPS Rate,11431.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,6314.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8941.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,12194,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5961.18,100,MS-DRG,4768.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5424.55,15108.91,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,CDM,,,,,Inpatient,,,,,,10935.8,100,,,Case Rate,100% of CMS IPPS Rate,7926.22,145,MS-DRG,6340.976,Case Rate,145% of CMS IPPS Rate,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,10666.13,100,,,Case Rate,100% of CMS IPPS Rate,12190.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13713.71,100,,,Case Rate,100% of CMS IPPS Rate,13713.71,100,,,Case Rate,100% of CMS IPPS Rate,13713.71,100,,,Case Rate,100% CMS IPPS Rate,9871.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.3,100,MS-DRG,3979.44,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,3979.44,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,3979.44,Case Rate,100% of CMS IPPS Rate,7178.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,7106.27,130,MS-DRG,5685.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5630.35,103,MS-DRG,4504.28,Case Rate,103% of CMS IPPS Rate,5630.35,103,MS-DRG,4504.28,Case Rate,103% of CMS IPPS Rate,10093.44,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,5790.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8199.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,11181.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.3,13713.71,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,CDM,,,,,Inpatient,,,,,,24501.83,100,,,Case Rate,100% of CMS IPPS Rate,17758.82,145,MS-DRG,14207.056,Case Rate,145% of CMS IPPS Rate,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,23179.94,100,,,Case Rate,100% of CMS IPPS Rate,26492.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29803.03,100,,,Case Rate,100% of CMS IPPS Rate,29803.03,100,,,Case Rate,100% of CMS IPPS Rate,29803.03,100,,,Case Rate,100% CMS IPPS Rate,22118.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11144.67,100,MS-DRG,8915.736,Case Rate,100% of CMS IPPS Rate,11144.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11144.67,100,MS-DRG,8915.736,Case Rate,100% of CMS IPPS Rate,11144.67,100,MS-DRG,8915.736,Case Rate,100% of CMS IPPS Rate,13401.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,15921.7,130,MS-DRG,12737.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12614.88,103,MS-DRG,10091.904,Case Rate,103% of CMS IPPS Rate,12614.88,103,MS-DRG,10091.904,Case Rate,103% of CMS IPPS Rate,21811.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,12973.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18371.19,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,25053,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12247.46,100,MS-DRG,9797.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29803.03,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,CDM,,,,,Inpatient,,,,,,14538.17,100,,,Case Rate,100% of CMS IPPS Rate,10537.19,145,MS-DRG,8429.752,Case Rate,145% of CMS IPPS Rate,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,14049.54,100,,,Case Rate,100% of CMS IPPS Rate,16057.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18063.85,100,,,Case Rate,100% of CMS IPPS Rate,18063.85,100,,,Case Rate,100% of CMS IPPS Rate,18063.85,100,,,Case Rate,100% CMS IPPS Rate,13123.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6612.8,100,MS-DRG,5290.24,Case Rate,100% of CMS IPPS Rate,6612.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6612.8,100,MS-DRG,5290.24,Case Rate,100% of CMS IPPS Rate,6612.8,100,MS-DRG,5290.24,Case Rate,100% of CMS IPPS Rate,8452.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,9447.14,130,MS-DRG,7557.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7485.04,103,MS-DRG,5988.032,Case Rate,103% of CMS IPPS Rate,7485.04,103,MS-DRG,5988.032,Case Rate,103% of CMS IPPS Rate,13522.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,7698.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10900.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,14865.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7267.03,100,MS-DRG,5813.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18063.85,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,CDM,,,,,Inpatient,,,,,,10720.84,100,,,Case Rate,100% of CMS IPPS Rate,7770.41,145,MS-DRG,6216.328,Case Rate,145% of CMS IPPS Rate,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,10000.92,100,,,Case Rate,100% of CMS IPPS Rate,11430.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12858.43,100,,,Case Rate,100% of CMS IPPS Rate,12858.43,100,,,Case Rate,100% of CMS IPPS Rate,12858.43,100,,,Case Rate,100% CMS IPPS Rate,9677.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4876.52,100,MS-DRG,3901.216,Case Rate,100% of CMS IPPS Rate,4876.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4876.52,100,MS-DRG,3901.216,Case Rate,100% of CMS IPPS Rate,4876.52,100,MS-DRG,3901.216,Case Rate,100% of CMS IPPS Rate,7112.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,6966.57,130,MS-DRG,5573.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5519.67,103,MS-DRG,4415.736,Case Rate,103% of CMS IPPS Rate,5519.67,103,MS-DRG,4415.736,Case Rate,103% of CMS IPPS Rate,9765.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,5676.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8038.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,10962,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5358.9,100,MS-DRG,4287.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4876.52,12858.43,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,CDM,,,,,Inpatient,,,,,,20716,100,,,Case Rate,100% of CMS IPPS Rate,15014.84,145,MS-DRG,12011.872,Case Rate,145% of CMS IPPS Rate,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,20604.39,100,,,Case Rate,100% of CMS IPPS Rate,23548.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26491.58,100,,,Case Rate,100% of CMS IPPS Rate,26491.58,100,,,Case Rate,100% of CMS IPPS Rate,26491.58,100,,,Case Rate,100% CMS IPPS Rate,18700.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9422.71,100,MS-DRG,7538.168,Case Rate,100% of CMS IPPS Rate,9422.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9422.71,100,MS-DRG,7538.168,Case Rate,100% of CMS IPPS Rate,9422.71,100,MS-DRG,7538.168,Case Rate,100% of CMS IPPS Rate,16623.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,13461.58,130,MS-DRG,10769.264,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10665.71,103,MS-DRG,8532.568,Case Rate,103% of CMS IPPS Rate,10665.71,103,MS-DRG,8532.568,Case Rate,103% of CMS IPPS Rate,18966.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,10969.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15532.59,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,21182,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10355.06,100,MS-DRG,8284.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26491.58,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,CDM,,,,,Inpatient,,,,,,14050.73,100,,,Case Rate,100% of CMS IPPS Rate,10183.89,145,MS-DRG,8147.112,Case Rate,145% of CMS IPPS Rate,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,13896.23,100,,,Case Rate,100% of CMS IPPS Rate,15882.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17866.74,100,,,Case Rate,100% of CMS IPPS Rate,17866.74,100,,,Case Rate,100% of CMS IPPS Rate,17866.74,100,,,Case Rate,100% CMS IPPS Rate,12683.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6391.09,100,MS-DRG,5112.872,Case Rate,100% of CMS IPPS Rate,6391.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6391.09,100,MS-DRG,5112.872,Case Rate,100% of CMS IPPS Rate,6391.09,100,MS-DRG,5112.872,Case Rate,100% of CMS IPPS Rate,7779.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,9130.38,130,MS-DRG,7304.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7234.07,103,MS-DRG,5787.256,Case Rate,103% of CMS IPPS Rate,7234.07,103,MS-DRG,5787.256,Case Rate,103% of CMS IPPS Rate,12948.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,7439.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10535.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,14366.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7023.37,100,MS-DRG,5618.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17866.74,
VIRAL MENINGITIS WITH CC/MCC,75,CDM,,,,,Inpatient,,,,,,26203.75,100,,,Case Rate,100% of CMS IPPS Rate,18992.35,145,MS-DRG,15193.88,Case Rate,145% of CMS IPPS Rate,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,22158.79,100,,,Case Rate,100% of CMS IPPS Rate,25325.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28490.11,100,,,Case Rate,100% of CMS IPPS Rate,28490.11,100,,,Case Rate,100% of CMS IPPS Rate,28490.11,100,,,Case Rate,100% CMS IPPS Rate,23654.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11918.77,100,MS-DRG,9535.016,Case Rate,100% of CMS IPPS Rate,11918.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11918.77,100,MS-DRG,9535.016,Case Rate,100% of CMS IPPS Rate,11918.77,100,MS-DRG,9535.016,Case Rate,100% of CMS IPPS Rate,7837.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,17027.62,130,MS-DRG,13622.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13491.12,103,MS-DRG,10792.896,Case Rate,103% of CMS IPPS Rate,13491.12,103,MS-DRG,10792.896,Case Rate,103% of CMS IPPS Rate,23086.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,13875.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19647.26,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,26793.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13098.17,100,MS-DRG,10478.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28490.11,
VIRAL MENINGITIS WITHOUT CC/MCC,76,CDM,,,,,Inpatient,,,,,,12630.87,100,,,Case Rate,100% of CMS IPPS Rate,9154.81,145,MS-DRG,7323.848,Case Rate,145% of CMS IPPS Rate,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,12223.19,100,,,Case Rate,100% of CMS IPPS Rate,13969.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15715.67,100,,,Case Rate,100% of CMS IPPS Rate,15715.67,100,,,Case Rate,100% of CMS IPPS Rate,15715.67,100,,,Case Rate,100% CMS IPPS Rate,11402.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5745.27,100,MS-DRG,4596.216,Case Rate,100% of CMS IPPS Rate,5745.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5745.27,100,MS-DRG,4596.216,Case Rate,100% of CMS IPPS Rate,5745.27,100,MS-DRG,4596.216,Case Rate,100% of CMS IPPS Rate,4850.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,8207.76,130,MS-DRG,6566.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6503.07,103,MS-DRG,5202.456,Case Rate,103% of CMS IPPS Rate,6503.07,103,MS-DRG,5202.456,Case Rate,103% of CMS IPPS Rate,12489.35,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,6688.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9470.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,12915,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6313.66,100,MS-DRG,5050.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4850.52,15715.67,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,CDM,,,,,Inpatient,,,,,,20687.24,100,,,Case Rate,100% of CMS IPPS Rate,14994.02,145,MS-DRG,11995.216,Case Rate,145% of CMS IPPS Rate,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,20613.73,100,,,Case Rate,100% of CMS IPPS Rate,23559.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26503.58,100,,,Case Rate,100% of CMS IPPS Rate,26503.58,100,,,Case Rate,100% of CMS IPPS Rate,26503.58,100,,,Case Rate,100% CMS IPPS Rate,18674.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9409.65,100,MS-DRG,7527.72,Case Rate,100% of CMS IPPS Rate,9409.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9409.65,100,MS-DRG,7527.72,Case Rate,100% of CMS IPPS Rate,9409.65,100,MS-DRG,7527.72,Case Rate,100% of CMS IPPS Rate,13596.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,13442.91,130,MS-DRG,10754.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10650.92,103,MS-DRG,8520.736,Case Rate,103% of CMS IPPS Rate,10650.92,103,MS-DRG,8520.736,Case Rate,103% of CMS IPPS Rate,19787.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,10954.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15511.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,21152.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10340.7,100,MS-DRG,8272.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26503.58,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,CDM,,,,,Inpatient,,,,,,13923.39,100,,,Case Rate,100% of CMS IPPS Rate,10091.61,145,MS-DRG,8073.288,Case Rate,145% of CMS IPPS Rate,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,13303,100,,,Case Rate,100% of CMS IPPS Rate,15204,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17104.01,100,,,Case Rate,100% of CMS IPPS Rate,17104.01,100,,,Case Rate,100% of CMS IPPS Rate,17104.01,100,,,Case Rate,100% CMS IPPS Rate,12568.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6333.16,100,MS-DRG,5066.528,Case Rate,100% of CMS IPPS Rate,6333.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6333.16,100,MS-DRG,5066.528,Case Rate,100% of CMS IPPS Rate,6333.16,100,MS-DRG,5066.528,Case Rate,100% of CMS IPPS Rate,6351.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,9047.65,130,MS-DRG,7238.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7168.52,103,MS-DRG,5734.816,Case Rate,103% of CMS IPPS Rate,7168.52,103,MS-DRG,5734.816,Case Rate,103% of CMS IPPS Rate,12558.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,7372.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10439.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,14236.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6959.73,100,MS-DRG,5567.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17104.01,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,CDM,,,,,Inpatient,,,,,,10143.03,100,,,Case Rate,100% of CMS IPPS Rate,7351.62,145,MS-DRG,5881.296,Case Rate,145% of CMS IPPS Rate,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,8819.79,100,,,Case Rate,100% of CMS IPPS Rate,10080.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11339.82,100,,,Case Rate,100% of CMS IPPS Rate,11339.82,100,,,Case Rate,100% of CMS IPPS Rate,11339.82,100,,,Case Rate,100% CMS IPPS Rate,9156.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4613.71,100,MS-DRG,3690.968,Case Rate,100% of CMS IPPS Rate,4613.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4613.71,100,MS-DRG,3690.968,Case Rate,100% of CMS IPPS Rate,4613.71,100,MS-DRG,3690.968,Case Rate,100% of CMS IPPS Rate,6666.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,6591.1,130,MS-DRG,5272.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5222.18,103,MS-DRG,4177.744,Case Rate,103% of CMS IPPS Rate,5222.18,103,MS-DRG,4177.744,Case Rate,103% of CMS IPPS Rate,9283.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,5370.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7605.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,10371.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5070.08,100,MS-DRG,4056.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4613.71,11339.82,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,CDM,,,,,Inpatient,,,,,,30241.52,100,,,Case Rate,100% of CMS IPPS Rate,21918.9,145,MS-DRG,17535.12,Case Rate,145% of CMS IPPS Rate,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,26248.74,100,,,Case Rate,100% of CMS IPPS Rate,29999.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33748.66,100,,,Case Rate,100% of CMS IPPS Rate,33748.66,100,,,Case Rate,100% of CMS IPPS Rate,33748.66,100,,,Case Rate,100% CMS IPPS Rate,27299.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13755.31,100,MS-DRG,11004.248,Case Rate,100% of CMS IPPS Rate,13755.31,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13755.31,100,MS-DRG,11004.248,Case Rate,100% of CMS IPPS Rate,13755.31,100,MS-DRG,11004.248,Case Rate,100% of CMS IPPS Rate,12139.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,19651.42,130,MS-DRG,15721.136,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15569.97,103,MS-DRG,12455.976,Case Rate,103% of CMS IPPS Rate,15569.97,103,MS-DRG,12455.976,Case Rate,103% of CMS IPPS Rate,25803.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,16013.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22674.72,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,30921.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15116.48,100,MS-DRG,12093.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33748.66,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,CDM,,,,,Inpatient,,,,,,12452.87,100,,,Case Rate,100% of CMS IPPS Rate,9025.79,145,MS-DRG,7220.632,Case Rate,145% of CMS IPPS Rate,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,12061.89,100,,,Case Rate,100% of CMS IPPS Rate,13785.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15508.27,100,,,Case Rate,100% of CMS IPPS Rate,15508.27,100,,,Case Rate,100% of CMS IPPS Rate,15508.27,100,,,Case Rate,100% CMS IPPS Rate,11241.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5664.32,100,MS-DRG,4531.456,Case Rate,100% of CMS IPPS Rate,5664.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5664.32,100,MS-DRG,4531.456,Case Rate,100% of CMS IPPS Rate,5664.32,100,MS-DRG,4531.456,Case Rate,100% of CMS IPPS Rate,4694.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,8092.08,130,MS-DRG,6473.664,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6411.42,103,MS-DRG,5129.136,Case Rate,103% of CMS IPPS Rate,6411.42,103,MS-DRG,5129.136,Case Rate,103% of CMS IPPS Rate,11366.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,6593.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9337.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,12733,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6224.68,100,MS-DRG,4979.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4694.86,15508.27,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,CDM,,,,,Inpatient,,,,,,31194.48,100,,,Case Rate,100% of CMS IPPS Rate,22609.6,145,MS-DRG,18087.68,Case Rate,145% of CMS IPPS Rate,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,30930.59,100,,,Case Rate,100% of CMS IPPS Rate,35350.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39768.23,100,,,Case Rate,100% of CMS IPPS Rate,39768.23,100,,,Case Rate,100% of CMS IPPS Rate,39768.23,100,,,Case Rate,100% CMS IPPS Rate,28159.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14188.75,100,MS-DRG,11351,Case Rate,100% of CMS IPPS Rate,14188.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14188.75,100,MS-DRG,11351,Case Rate,100% of CMS IPPS Rate,14188.75,100,MS-DRG,11351,Case Rate,100% of CMS IPPS Rate,19037.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,20270.68,130,MS-DRG,16216.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16060.61,103,MS-DRG,12848.488,Case Rate,103% of CMS IPPS Rate,16060.61,103,MS-DRG,12848.488,Case Rate,103% of CMS IPPS Rate,28656.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,16517.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23389.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,31896.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15592.83,100,MS-DRG,12474.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39768.23,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,CDM,,,,,Inpatient,,,,,,18571.83,100,,,Case Rate,100% of CMS IPPS Rate,13460.77,145,MS-DRG,10768.616,Case Rate,145% of CMS IPPS Rate,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,18535.42,100,,,Case Rate,100% of CMS IPPS Rate,21184.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23831.46,100,,,Case Rate,100% of CMS IPPS Rate,23831.46,100,,,Case Rate,100% of CMS IPPS Rate,23831.46,100,,,Case Rate,100% CMS IPPS Rate,16765.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8447.47,100,MS-DRG,6757.976,Case Rate,100% of CMS IPPS Rate,8447.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8447.47,100,MS-DRG,6757.976,Case Rate,100% of CMS IPPS Rate,8447.47,100,MS-DRG,6757.976,Case Rate,100% of CMS IPPS Rate,10295.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,12068.28,130,MS-DRG,9654.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9561.79,103,MS-DRG,7649.432,Case Rate,103% of CMS IPPS Rate,9561.79,103,MS-DRG,7649.432,Case Rate,103% of CMS IPPS Rate,17054.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,9833.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13924.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,18989.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9283.29,100,MS-DRG,7426.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23831.46,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,CDM,,,,,Inpatient,,,,,,12592.53,100,,,Case Rate,100% of CMS IPPS Rate,9127.01,145,MS-DRG,7301.608,Case Rate,145% of CMS IPPS Rate,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,12745.77,100,,,Case Rate,100% of CMS IPPS Rate,14567.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16387.55,100,,,Case Rate,100% of CMS IPPS Rate,16387.55,100,,,Case Rate,100% of CMS IPPS Rate,16387.55,100,,,Case Rate,100% CMS IPPS Rate,11367.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5727.84,100,MS-DRG,4582.272,Case Rate,100% of CMS IPPS Rate,5727.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5727.84,100,MS-DRG,4582.272,Case Rate,100% of CMS IPPS Rate,5727.84,100,MS-DRG,4582.272,Case Rate,100% of CMS IPPS Rate,7097.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,8182.84,130,MS-DRG,6546.272,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6483.32,103,MS-DRG,5186.656,Case Rate,103% of CMS IPPS Rate,6483.32,103,MS-DRG,5186.656,Case Rate,103% of CMS IPPS Rate,11593.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,6667.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9441.74,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,12875.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6294.49,100,MS-DRG,5035.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5727.84,16387.55,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,CDM,,,,,Inpatient,,,,,,31119.18,100,,,Case Rate,100% of CMS IPPS Rate,22555.03,145,MS-DRG,18044.024,Case Rate,145% of CMS IPPS Rate,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,30208.05,100,,,Case Rate,100% of CMS IPPS Rate,34524.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38839.24,100,,,Case Rate,100% of CMS IPPS Rate,38839.24,100,,,Case Rate,100% of CMS IPPS Rate,38839.24,100,,,Case Rate,100% CMS IPPS Rate,28091.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14154.5,100,MS-DRG,11323.6,Case Rate,100% of CMS IPPS Rate,14154.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14154.5,100,MS-DRG,11323.6,Case Rate,100% of CMS IPPS Rate,14154.5,100,MS-DRG,11323.6,Case Rate,100% of CMS IPPS Rate,17616.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,20221.75,130,MS-DRG,16177.4,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16021.85,103,MS-DRG,12817.48,Case Rate,103% of CMS IPPS Rate,16021.85,103,MS-DRG,12817.48,Case Rate,103% of CMS IPPS Rate,29546.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,16477.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23332.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,31819.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15555.19,100,MS-DRG,12444.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38839.24,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,CDM,,,,,Inpatient,,,,,,18033.73,100,,,Case Rate,100% of CMS IPPS Rate,13070.76,145,MS-DRG,10456.608,Case Rate,145% of CMS IPPS Rate,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,17484.94,100,,,Case Rate,100% of CMS IPPS Rate,19983.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22480.82,100,,,Case Rate,100% of CMS IPPS Rate,22480.82,100,,,Case Rate,100% of CMS IPPS Rate,22480.82,100,,,Case Rate,100% CMS IPPS Rate,16279.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8202.72,100,MS-DRG,6562.176,Case Rate,100% of CMS IPPS Rate,8202.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8202.72,100,MS-DRG,6562.176,Case Rate,100% of CMS IPPS Rate,8202.72,100,MS-DRG,6562.176,Case Rate,100% of CMS IPPS Rate,13564.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,11718.62,130,MS-DRG,9374.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9284.75,103,MS-DRG,7427.8,Case Rate,103% of CMS IPPS Rate,9284.75,103,MS-DRG,7427.8,Case Rate,103% of CMS IPPS Rate,16441.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,9548.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13521.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,18439.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9014.32,100,MS-DRG,7211.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22480.82,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,CDM,,,,,Inpatient,,,,,,12133.85,100,,,Case Rate,100% of CMS IPPS Rate,8794.55,145,MS-DRG,7035.64,Case Rate,145% of CMS IPPS Rate,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,11784.6,100,,,Case Rate,100% of CMS IPPS Rate,13468.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15151.76,100,,,Case Rate,100% of CMS IPPS Rate,15151.76,100,,,Case Rate,100% of CMS IPPS Rate,15151.76,100,,,Case Rate,100% CMS IPPS Rate,10953.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5519.21,100,MS-DRG,4415.368,Case Rate,100% of CMS IPPS Rate,5519.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5519.21,100,MS-DRG,4415.368,Case Rate,100% of CMS IPPS Rate,5519.21,100,MS-DRG,4415.368,Case Rate,100% of CMS IPPS Rate,8287.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,7884.77,130,MS-DRG,6307.816,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6247.17,103,MS-DRG,4997.736,Case Rate,103% of CMS IPPS Rate,6247.17,103,MS-DRG,4997.736,Case Rate,103% of CMS IPPS Rate,11035.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,6424.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9097.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,12406.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6065.21,100,MS-DRG,4852.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5519.21,15151.76,
CONCUSSION WITH MCC,88,CDM,,,,,Inpatient,,,,,,21000.79,100,,,Case Rate,100% of CMS IPPS Rate,15221.27,145,MS-DRG,12177.016,Case Rate,145% of CMS IPPS Rate,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,18806.04,100,,,Case Rate,100% of CMS IPPS Rate,21493.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24179.4,100,,,Case Rate,100% of CMS IPPS Rate,24179.4,100,,,Case Rate,100% of CMS IPPS Rate,24179.4,100,,,Case Rate,100% CMS IPPS Rate,18957.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9552.25,100,MS-DRG,7641.8,Case Rate,100% of CMS IPPS Rate,9552.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9552.25,100,MS-DRG,7641.8,Case Rate,100% of CMS IPPS Rate,9552.25,100,MS-DRG,7641.8,Case Rate,100% of CMS IPPS Rate,13802.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,13646.66,130,MS-DRG,10917.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10812.35,103,MS-DRG,8649.88,Case Rate,103% of CMS IPPS Rate,10812.35,103,MS-DRG,8649.88,Case Rate,103% of CMS IPPS Rate,19940.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,11120.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15746.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,21473.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10497.43,100,MS-DRG,8397.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24179.4,
CONCUSSION WITH CC,89,CDM,,,,,Inpatient,,,,,,15744.43,100,,,Case Rate,100% of CMS IPPS Rate,11411.49,145,MS-DRG,9129.192,Case Rate,145% of CMS IPPS Rate,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,14292.17,100,,,Case Rate,100% of CMS IPPS Rate,16334.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18375.79,100,,,Case Rate,100% of CMS IPPS Rate,18375.79,100,,,Case Rate,100% of CMS IPPS Rate,18375.79,100,,,Case Rate,100% CMS IPPS Rate,14212.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7161.45,100,MS-DRG,5729.16,Case Rate,100% of CMS IPPS Rate,7161.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7161.45,100,MS-DRG,5729.16,Case Rate,100% of CMS IPPS Rate,7161.45,100,MS-DRG,5729.16,Case Rate,100% of CMS IPPS Rate,11819.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,10230.99,130,MS-DRG,8184.792,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8106.09,103,MS-DRG,6484.872,Case Rate,103% of CMS IPPS Rate,8106.09,103,MS-DRG,6484.872,Case Rate,103% of CMS IPPS Rate,14771.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,8336.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11804.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,16098.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7869.99,100,MS-DRG,6295.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18375.79,
CONCUSSION WITHOUT CC/MCC,90,CDM,,,,,Inpatient,,,,,,12799.28,100,,,Case Rate,100% of CMS IPPS Rate,9276.85,145,MS-DRG,7421.48,Case Rate,145% of CMS IPPS Rate,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,11428.67,100,,,Case Rate,100% of CMS IPPS Rate,13061.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14694.12,100,,,Case Rate,100% of CMS IPPS Rate,14694.12,100,,,Case Rate,100% of CMS IPPS Rate,14694.12,100,,,Case Rate,100% CMS IPPS Rate,11554.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5821.88,100,MS-DRG,4657.504,Case Rate,100% of CMS IPPS Rate,5821.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5821.88,100,MS-DRG,4657.504,Case Rate,100% of CMS IPPS Rate,5821.88,100,MS-DRG,4657.504,Case Rate,100% of CMS IPPS Rate,11095.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,8317.18,130,MS-DRG,6653.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6589.76,103,MS-DRG,5271.808,Case Rate,103% of CMS IPPS Rate,6589.76,103,MS-DRG,5271.808,Case Rate,103% of CMS IPPS Rate,10412.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,6777.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9596.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,13087.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6397.83,100,MS-DRG,5118.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5821.88,14694.12,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,CDM,,,,,Inpatient,,,,,,24497.73,100,,,Case Rate,100% of CMS IPPS Rate,17755.83,145,MS-DRG,14204.664,Case Rate,145% of CMS IPPS Rate,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,24301.08,100,,,Case Rate,100% of CMS IPPS Rate,27773.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31244.51,100,,,Case Rate,100% of CMS IPPS Rate,31244.51,100,,,Case Rate,100% of CMS IPPS Rate,31244.51,100,,,Case Rate,100% CMS IPPS Rate,22114.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11142.81,100,MS-DRG,8914.248,Case Rate,100% of CMS IPPS Rate,11142.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11142.81,100,MS-DRG,8914.248,Case Rate,100% of CMS IPPS Rate,11142.81,100,MS-DRG,8914.248,Case Rate,100% of CMS IPPS Rate,14333.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,15919.02,130,MS-DRG,12735.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12612.76,103,MS-DRG,10090.208,Case Rate,103% of CMS IPPS Rate,12612.76,103,MS-DRG,10090.208,Case Rate,103% of CMS IPPS Rate,21851.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,12971.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18368.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,25048.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12245.4,100,MS-DRG,9796.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31244.51,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,CDM,,,,,Inpatient,,,,,,14049.36,100,,,Case Rate,100% of CMS IPPS Rate,10182.9,145,MS-DRG,8146.32,Case Rate,145% of CMS IPPS Rate,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,14113.53,100,,,Case Rate,100% of CMS IPPS Rate,16130.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18146.12,100,,,Case Rate,100% of CMS IPPS Rate,18146.12,100,,,Case Rate,100% of CMS IPPS Rate,18146.12,100,,,Case Rate,100% CMS IPPS Rate,12682.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6390.47,100,MS-DRG,5112.376,Case Rate,100% of CMS IPPS Rate,6390.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6390.47,100,MS-DRG,5112.376,Case Rate,100% of CMS IPPS Rate,6390.47,100,MS-DRG,5112.376,Case Rate,100% of CMS IPPS Rate,8624.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,9129.5,130,MS-DRG,7303.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7233.37,103,MS-DRG,5786.696,Case Rate,103% of CMS IPPS Rate,7233.37,103,MS-DRG,5786.696,Case Rate,103% of CMS IPPS Rate,12577.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,7439.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10534.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,14365.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7022.69,100,MS-DRG,5618.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18146.12,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,CDM,,,,,Inpatient,,,,,,10603.08,100,,,Case Rate,100% of CMS IPPS Rate,7685.07,145,MS-DRG,6148.056,Case Rate,145% of CMS IPPS Rate,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,10522.16,100,,,Case Rate,100% of CMS IPPS Rate,12025.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13528.6,100,,,Case Rate,100% of CMS IPPS Rate,13528.6,100,,,Case Rate,100% of CMS IPPS Rate,13528.6,100,,,Case Rate,100% CMS IPPS Rate,9571.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4822.96,100,MS-DRG,3858.368,Case Rate,100% of CMS IPPS Rate,4822.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4822.96,100,MS-DRG,3858.368,Case Rate,100% of CMS IPPS Rate,4822.96,100,MS-DRG,3858.368,Case Rate,100% of CMS IPPS Rate,5397.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,6890.07,130,MS-DRG,5512.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5459.05,103,MS-DRG,4367.24,Case Rate,103% of CMS IPPS Rate,5459.05,103,MS-DRG,4367.24,Case Rate,103% of CMS IPPS Rate,9674.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,5614.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7950.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,10841.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5300.05,100,MS-DRG,4240.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4822.96,13528.6,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,CDM,,,,,Inpatient,,,,,,49602.01,100,,,Case Rate,100% of CMS IPPS Rate,35951.29,145,MS-DRG,28761.032,Case Rate,145% of CMS IPPS Rate,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,48640.82,100,,,Case Rate,100% of CMS IPPS Rate,55591.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,62538.72,100,,,Case Rate,100% of CMS IPPS Rate,62538.72,100,,,Case Rate,100% of CMS IPPS Rate,62538.72,100,,,Case Rate,100% CMS IPPS Rate,44776.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22561.25,100,MS-DRG,18049,Case Rate,100% of CMS IPPS Rate,22561.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22561.25,100,MS-DRG,18049,Case Rate,100% of CMS IPPS Rate,22561.25,100,MS-DRG,18049,Case Rate,100% of CMS IPPS Rate,26075.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,32232.19,130,MS-DRG,25785.752,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25537.81,103,MS-DRG,20430.248,Case Rate,103% of CMS IPPS Rate,25537.81,103,MS-DRG,20430.248,Case Rate,103% of CMS IPPS Rate,45204.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,26264.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37190.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,50717.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24793.99,100,MS-DRG,19835.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,62538.72,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,CDM,,,,,Inpatient,,,,,,32644.47,100,,,Case Rate,100% of CMS IPPS Rate,23660.55,145,MS-DRG,18928.44,Case Rate,145% of CMS IPPS Rate,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,31957.07,100,,,Case Rate,100% of CMS IPPS Rate,36523.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41088.01,100,,,Case Rate,100% of CMS IPPS Rate,41088.01,100,,,Case Rate,100% of CMS IPPS Rate,41088.01,100,,,Case Rate,100% CMS IPPS Rate,29468.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14848.27,100,MS-DRG,11878.616,Case Rate,100% of CMS IPPS Rate,14848.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14848.27,100,MS-DRG,11878.616,Case Rate,100% of CMS IPPS Rate,14848.27,100,MS-DRG,11878.616,Case Rate,100% of CMS IPPS Rate,17905.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,21212.91,130,MS-DRG,16970.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16807.15,103,MS-DRG,13445.72,Case Rate,103% of CMS IPPS Rate,16807.15,103,MS-DRG,13445.72,Case Rate,103% of CMS IPPS Rate,32343.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,17285.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24476.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,33378.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16317.62,100,MS-DRG,13054.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41088.01,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,CDM,,,,,Inpatient,,,,,,29844.45,100,,,Case Rate,100% of CMS IPPS Rate,21631.11,145,MS-DRG,17304.888,Case Rate,145% of CMS IPPS Rate,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,31957.07,100,,,Case Rate,100% of CMS IPPS Rate,36523.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41088.01,100,,,Case Rate,100% of CMS IPPS Rate,41088.01,100,,,Case Rate,100% of CMS IPPS Rate,41088.01,100,,,Case Rate,100% CMS IPPS Rate,26941.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13574.71,100,MS-DRG,10859.768,Case Rate,100% of CMS IPPS Rate,13574.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13574.71,100,MS-DRG,10859.768,Case Rate,100% of CMS IPPS Rate,13574.71,100,MS-DRG,10859.768,Case Rate,100% of CMS IPPS Rate,19884.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,19393.41,130,MS-DRG,15514.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15365.55,103,MS-DRG,12292.44,Case Rate,103% of CMS IPPS Rate,15365.55,103,MS-DRG,12292.44,Case Rate,103% of CMS IPPS Rate,28896.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,15802.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22377.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,30515.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14918.01,100,MS-DRG,11934.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41088.01,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,CDM,,,,,Inpatient,,,,,,49796.43,100,,,Case Rate,100% of CMS IPPS Rate,36092.21,145,MS-DRG,28873.768,Case Rate,145% of CMS IPPS Rate,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,47786.3,100,,,Case Rate,100% of CMS IPPS Rate,54614.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,61440.04,100,,,Case Rate,100% of CMS IPPS Rate,61440.04,100,,,Case Rate,100% of CMS IPPS Rate,61440.04,100,,,Case Rate,100% CMS IPPS Rate,44952.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22649.67,100,MS-DRG,18119.736,Case Rate,100% of CMS IPPS Rate,22649.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22649.67,100,MS-DRG,18119.736,Case Rate,100% of CMS IPPS Rate,22649.67,100,MS-DRG,18119.736,Case Rate,100% of CMS IPPS Rate,30692.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,32358.53,130,MS-DRG,25886.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25637.92,103,MS-DRG,20510.336,Case Rate,103% of CMS IPPS Rate,25637.92,103,MS-DRG,20510.336,Case Rate,103% of CMS IPPS Rate,49185.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,26367.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37336.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,50916.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24891.18,100,MS-DRG,19912.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,61440.04,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,CDM,,,,,Inpatient,,,,,,29499.41,100,,,Case Rate,100% of CMS IPPS Rate,21381.02,145,MS-DRG,17104.816,Case Rate,145% of CMS IPPS Rate,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,28918.94,100,,,Case Rate,100% of CMS IPPS Rate,33051.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37181.8,100,,,Case Rate,100% of CMS IPPS Rate,37181.8,100,,,Case Rate,100% of CMS IPPS Rate,37181.8,100,,,Case Rate,100% CMS IPPS Rate,26629.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13417.78,100,MS-DRG,10734.224,Case Rate,100% of CMS IPPS Rate,13417.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13417.78,100,MS-DRG,10734.224,Case Rate,100% of CMS IPPS Rate,13417.78,100,MS-DRG,10734.224,Case Rate,100% of CMS IPPS Rate,18888.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,19169.19,130,MS-DRG,15335.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15187.9,103,MS-DRG,12150.32,Case Rate,103% of CMS IPPS Rate,15187.9,103,MS-DRG,12150.32,Case Rate,103% of CMS IPPS Rate,26365.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,15620.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22118.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,30163,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14745.53,100,MS-DRG,11796.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37181.8,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,CDM,,,,,Inpatient,,,,,,18076.18,100,,,Case Rate,100% of CMS IPPS Rate,13101.52,145,MS-DRG,10481.216,Case Rate,145% of CMS IPPS Rate,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,18574.08,100,,,Case Rate,100% of CMS IPPS Rate,21228.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23881.16,100,,,Case Rate,100% of CMS IPPS Rate,23881.16,100,,,Case Rate,100% of CMS IPPS Rate,23881.16,100,,,Case Rate,100% CMS IPPS Rate,16317.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8222.03,100,MS-DRG,6577.624,Case Rate,100% of CMS IPPS Rate,8222.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8222.03,100,MS-DRG,6577.624,Case Rate,100% of CMS IPPS Rate,8222.03,100,MS-DRG,6577.624,Case Rate,100% of CMS IPPS Rate,11533.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,11746.19,130,MS-DRG,9396.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9306.6,103,MS-DRG,7445.28,Case Rate,103% of CMS IPPS Rate,9306.6,103,MS-DRG,7445.28,Case Rate,103% of CMS IPPS Rate,17691.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,9571.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13553.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,18482.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9035.53,100,MS-DRG,7228.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23881.16,
SEIZURES WITH MCC,100,CDM,,,,,Inpatient,,,,,,27144.39,100,,,Case Rate,100% of CMS IPPS Rate,19674.11,145,MS-DRG,15739.288,Case Rate,145% of CMS IPPS Rate,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,26466.03,100,,,Case Rate,100% of CMS IPPS Rate,30248.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34028.04,100,,,Case Rate,100% of CMS IPPS Rate,34028.04,100,,,Case Rate,100% of CMS IPPS Rate,34028.04,100,,,Case Rate,100% CMS IPPS Rate,24503.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12346.62,100,MS-DRG,9877.296,Case Rate,100% of CMS IPPS Rate,12346.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12346.62,100,MS-DRG,9877.296,Case Rate,100% of CMS IPPS Rate,12346.62,100,MS-DRG,9877.296,Case Rate,100% of CMS IPPS Rate,14210.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,17638.86,130,MS-DRG,14111.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13975.4,103,MS-DRG,11180.32,Case Rate,103% of CMS IPPS Rate,13975.4,103,MS-DRG,11180.32,Case Rate,103% of CMS IPPS Rate,24300.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,14373.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20352.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,27755,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13568.35,100,MS-DRG,10854.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34028.04,
SEIZURES WITHOUT MCC,101,CDM,,,,,Inpatient,,,,,,12454.24,100,,,Case Rate,100% of CMS IPPS Rate,9026.79,145,MS-DRG,7221.432,Case Rate,145% of CMS IPPS Rate,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,12287.18,100,,,Case Rate,100% of CMS IPPS Rate,14043.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15797.94,100,,,Case Rate,100% of CMS IPPS Rate,15797.94,100,,,Case Rate,100% of CMS IPPS Rate,15797.94,100,,,Case Rate,100% CMS IPPS Rate,11242.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5664.94,100,MS-DRG,4531.952,Case Rate,100% of CMS IPPS Rate,5664.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5664.94,100,MS-DRG,4531.952,Case Rate,100% of CMS IPPS Rate,5664.94,100,MS-DRG,4531.952,Case Rate,100% of CMS IPPS Rate,6143.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,8092.98,130,MS-DRG,6474.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6412.13,103,MS-DRG,5129.704,Case Rate,103% of CMS IPPS Rate,6412.13,103,MS-DRG,5129.704,Case Rate,103% of CMS IPPS Rate,11403.98,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,6594.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9338.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,12734.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6225.37,100,MS-DRG,4980.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5664.94,15797.94,
HEADACHES WITH MCC,102,CDM,,,,,Inpatient,,,,,,16520.77,100,,,Case Rate,100% of CMS IPPS Rate,11974.16,145,MS-DRG,9579.328,Case Rate,145% of CMS IPPS Rate,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,15457.29,100,,,Case Rate,100% of CMS IPPS Rate,17666.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19873.83,100,,,Case Rate,100% of CMS IPPS Rate,19873.83,100,,,Case Rate,100% of CMS IPPS Rate,19873.83,100,,,Case Rate,100% CMS IPPS Rate,14913.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7514.56,100,MS-DRG,6011.648,Case Rate,100% of CMS IPPS Rate,7514.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7514.56,100,MS-DRG,6011.648,Case Rate,100% of CMS IPPS Rate,7514.56,100,MS-DRG,6011.648,Case Rate,100% of CMS IPPS Rate,7217,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,10735.45,130,MS-DRG,8588.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8505.78,103,MS-DRG,6804.624,Case Rate,103% of CMS IPPS Rate,8505.78,103,MS-DRG,6804.624,Case Rate,103% of CMS IPPS Rate,14546.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,8747.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12387.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,16892.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8258.04,100,MS-DRG,6606.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19873.83,
HEADACHES WITHOUT MCC,103,CDM,,,,,Inpatient,,,,,,11534.14,100,,,Case Rate,100% of CMS IPPS Rate,8359.89,145,MS-DRG,6687.912,Case Rate,145% of CMS IPPS Rate,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,11334.02,100,,,Case Rate,100% of CMS IPPS Rate,12953.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14572.43,100,,,Case Rate,100% of CMS IPPS Rate,14572.43,100,,,Case Rate,100% of CMS IPPS Rate,14572.43,100,,,Case Rate,100% CMS IPPS Rate,10412.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5246.44,100,MS-DRG,4197.152,Case Rate,100% of CMS IPPS Rate,5246.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5246.44,100,MS-DRG,4197.152,Case Rate,100% of CMS IPPS Rate,5246.44,100,MS-DRG,4197.152,Case Rate,100% of CMS IPPS Rate,7287.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,7495.07,130,MS-DRG,5996.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5938.4,103,MS-DRG,4750.72,Case Rate,103% of CMS IPPS Rate,5938.4,103,MS-DRG,4750.72,Case Rate,103% of CMS IPPS Rate,10531.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,6107.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8648.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,11793.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5765.44,100,MS-DRG,4612.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5246.44,14572.43,
ORBITAL PROCEDURES WITH CC/MCC,113,CDM,,,,,Inpatient,,,,,,34329.95,100,,,Case Rate,100% of CMS IPPS Rate,24882.17,145,MS-DRG,19905.736,Case Rate,145% of CMS IPPS Rate,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,29824.11,100,,,Case Rate,100% of CMS IPPS Rate,34085.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38345.61,100,,,Case Rate,100% of CMS IPPS Rate,38345.61,100,,,Case Rate,100% of CMS IPPS Rate,38345.61,100,,,Case Rate,100% CMS IPPS Rate,30990.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15614.9,100,MS-DRG,12491.92,Case Rate,100% of CMS IPPS Rate,15614.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15614.9,100,MS-DRG,12491.92,Case Rate,100% of CMS IPPS Rate,15614.9,100,MS-DRG,12491.92,Case Rate,100% of CMS IPPS Rate,15843.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,22308.16,130,MS-DRG,17846.528,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17674.92,103,MS-DRG,14139.936,Case Rate,103% of CMS IPPS Rate,17674.92,103,MS-DRG,14139.936,Case Rate,103% of CMS IPPS Rate,28403.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,18177.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25740.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,35102.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17160.12,100,MS-DRG,13728.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38345.61,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,CDM,,,,,Inpatient,,,,,,16865.81,100,,,Case Rate,100% of CMS IPPS Rate,12224.25,145,MS-DRG,9779.4,Case Rate,145% of CMS IPPS Rate,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,15758.58,100,,,Case Rate,100% of CMS IPPS Rate,18010.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20261.19,100,,,Case Rate,100% of CMS IPPS Rate,20261.19,100,,,Case Rate,100% of CMS IPPS Rate,20261.19,100,,,Case Rate,100% CMS IPPS Rate,15225.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7671.49,100,MS-DRG,6137.192,Case Rate,100% of CMS IPPS Rate,7671.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7671.49,100,MS-DRG,6137.192,Case Rate,100% of CMS IPPS Rate,7671.49,100,MS-DRG,6137.192,Case Rate,100% of CMS IPPS Rate,12419.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,10959.68,130,MS-DRG,8767.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8683.44,103,MS-DRG,6946.752,Case Rate,103% of CMS IPPS Rate,8683.44,103,MS-DRG,6946.752,Case Rate,103% of CMS IPPS Rate,16480.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,8930.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12645.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,17245.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8430.52,100,MS-DRG,6744.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20261.19,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,CDM,,,,,Inpatient,,,,,,21419.76,100,,,Case Rate,100% of CMS IPPS Rate,15524.95,145,MS-DRG,12419.96,Case Rate,145% of CMS IPPS Rate,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,20409.76,100,,,Case Rate,100% of CMS IPPS Rate,23326.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26241.34,100,,,Case Rate,100% of CMS IPPS Rate,26241.34,100,,,Case Rate,100% of CMS IPPS Rate,26241.34,100,,,Case Rate,100% CMS IPPS Rate,19335.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9742.82,100,MS-DRG,7794.256,Case Rate,100% of CMS IPPS Rate,9742.82,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9742.82,100,MS-DRG,7794.256,Case Rate,100% of CMS IPPS Rate,9742.82,100,MS-DRG,7794.256,Case Rate,100% of CMS IPPS Rate,14078.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,13918.92,130,MS-DRG,11135.136,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11028.07,103,MS-DRG,8822.456,Case Rate,103% of CMS IPPS Rate,11028.07,103,MS-DRG,8822.456,Case Rate,103% of CMS IPPS Rate,19216.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,11341.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16060.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,21901.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10706.86,100,MS-DRG,8565.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26241.34,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,CDM,,,,,Inpatient,,,,,,25067.31,100,,,Case Rate,100% of CMS IPPS Rate,18168.66,145,MS-DRG,14534.928,Case Rate,145% of CMS IPPS Rate,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,22244.11,100,,,Case Rate,100% of CMS IPPS Rate,25422.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28599.8,100,,,Case Rate,100% of CMS IPPS Rate,28599.8,100,,,Case Rate,100% of CMS IPPS Rate,28599.8,100,,,Case Rate,100% CMS IPPS Rate,22628.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11401.87,100,MS-DRG,9121.496,Case Rate,100% of CMS IPPS Rate,11401.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11401.87,100,MS-DRG,9121.496,Case Rate,100% of CMS IPPS Rate,11401.87,100,MS-DRG,9121.496,Case Rate,100% of CMS IPPS Rate,16475.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,16289.14,130,MS-DRG,13031.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12906.01,103,MS-DRG,10324.808,Case Rate,103% of CMS IPPS Rate,12906.01,103,MS-DRG,10324.808,Case Rate,103% of CMS IPPS Rate,23864.23,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,13273.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18795.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,25631.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12530.11,100,MS-DRG,10024.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28599.8,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,CDM,,,,,Inpatient,,,,,,16408.49,100,,,Case Rate,100% of CMS IPPS Rate,11892.8,145,MS-DRG,9514.24,Case Rate,145% of CMS IPPS Rate,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,13493.64,100,,,Case Rate,100% of CMS IPPS Rate,15421.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17349.11,100,,,Case Rate,100% of CMS IPPS Rate,17349.11,100,,,Case Rate,100% of CMS IPPS Rate,17349.11,100,,,Case Rate,100% CMS IPPS Rate,14812.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7463.5,100,MS-DRG,5970.8,Case Rate,100% of CMS IPPS Rate,7463.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7463.5,100,MS-DRG,5970.8,Case Rate,100% of CMS IPPS Rate,7463.5,100,MS-DRG,5970.8,Case Rate,100% of CMS IPPS Rate,8330.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,10662.51,130,MS-DRG,8530.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8447.99,103,MS-DRG,6758.392,Case Rate,103% of CMS IPPS Rate,8447.99,103,MS-DRG,6758.392,Case Rate,103% of CMS IPPS Rate,12558.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,8688.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12302.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,16777.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.93,100,MS-DRG,6561.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17349.11,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,CDM,,,,,Inpatient,,,,,,17542.19,100,,,Case Rate,100% of CMS IPPS Rate,12714.48,145,MS-DRG,10171.584,Case Rate,145% of CMS IPPS Rate,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,15506.62,100,,,Case Rate,100% of CMS IPPS Rate,17722.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19937.25,100,,,Case Rate,100% of CMS IPPS Rate,19937.25,100,,,Case Rate,100% of CMS IPPS Rate,19937.25,100,,,Case Rate,100% CMS IPPS Rate,15835.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7979.14,100,MS-DRG,6383.312,Case Rate,100% of CMS IPPS Rate,7979.14,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7979.14,100,MS-DRG,6383.312,Case Rate,100% of CMS IPPS Rate,7979.14,100,MS-DRG,6383.312,Case Rate,100% of CMS IPPS Rate,4360.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,11399.19,130,MS-DRG,9119.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9031.67,103,MS-DRG,7225.336,Case Rate,103% of CMS IPPS Rate,9031.67,103,MS-DRG,7225.336,Case Rate,103% of CMS IPPS Rate,15500.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,9288.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13152.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,17936.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8768.61,100,MS-DRG,7014.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4360.85,19937.25,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,CDM,,,,,Inpatient,,,,,,10193.69,100,,,Case Rate,100% of CMS IPPS Rate,7388.33,145,MS-DRG,5910.664,Case Rate,145% of CMS IPPS Rate,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,9042.42,100,,,Case Rate,100% of CMS IPPS Rate,10334.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11626.06,100,,,Case Rate,100% of CMS IPPS Rate,11626.06,100,,,Case Rate,100% of CMS IPPS Rate,11626.06,100,,,Case Rate,100% CMS IPPS Rate,9202.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4636.76,100,MS-DRG,3709.408,Case Rate,100% of CMS IPPS Rate,4636.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4636.76,100,MS-DRG,3709.408,Case Rate,100% of CMS IPPS Rate,4636.76,100,MS-DRG,3709.408,Case Rate,100% of CMS IPPS Rate,3224.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,6624.02,130,MS-DRG,5299.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5248.26,103,MS-DRG,4198.608,Case Rate,103% of CMS IPPS Rate,5248.26,103,MS-DRG,4198.608,Case Rate,103% of CMS IPPS Rate,8738.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,5397.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7643.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,10423,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5095.4,100,MS-DRG,4076.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3224.22,11626.06,
NEUROLOGICAL EYE DISORDERS,123,CDM,,,,,Inpatient,,,,,,11008.37,100,,,Case Rate,100% of CMS IPPS Rate,7978.8,145,MS-DRG,6383.04,Case Rate,145% of CMS IPPS Rate,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,10707.46,100,,,Case Rate,100% of CMS IPPS Rate,12237.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13766.85,100,,,Case Rate,100% of CMS IPPS Rate,13766.85,100,,,Case Rate,100% of CMS IPPS Rate,13766.85,100,,,Case Rate,100% CMS IPPS Rate,9937.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5007.3,100,MS-DRG,4005.84,Case Rate,100% of CMS IPPS Rate,5007.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5007.3,100,MS-DRG,4005.84,Case Rate,100% of CMS IPPS Rate,5007.3,100,MS-DRG,4005.84,Case Rate,100% of CMS IPPS Rate,6902.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,7153.41,130,MS-DRG,5722.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5667.7,103,MS-DRG,4534.16,Case Rate,103% of CMS IPPS Rate,5667.7,103,MS-DRG,4534.16,Case Rate,103% of CMS IPPS Rate,10041.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,5829,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8253.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,11256,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5502.62,100,MS-DRG,4402.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5007.3,13766.85,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,CDM,,,,,Inpatient,,,,,,18099.45,100,,,Case Rate,100% of CMS IPPS Rate,13118.38,145,MS-DRG,10494.704,Case Rate,145% of CMS IPPS Rate,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,17382.29,100,,,Case Rate,100% of CMS IPPS Rate,19866.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22348.85,100,,,Case Rate,100% of CMS IPPS Rate,22348.85,100,,,Case Rate,100% of CMS IPPS Rate,22348.85,100,,,Case Rate,100% CMS IPPS Rate,16338.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8232.6,100,MS-DRG,6586.08,Case Rate,100% of CMS IPPS Rate,8232.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8232.6,100,MS-DRG,6586.08,Case Rate,100% of CMS IPPS Rate,8232.6,100,MS-DRG,6586.08,Case Rate,100% of CMS IPPS Rate,11895.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,11761.31,130,MS-DRG,9409.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9318.57,103,MS-DRG,7454.856,Case Rate,103% of CMS IPPS Rate,9318.57,103,MS-DRG,7454.856,Case Rate,103% of CMS IPPS Rate,17718.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,9583.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13570.74,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,18506.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9047.16,100,MS-DRG,7237.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22348.85,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,CDM,,,,,Inpatient,,,,,,10919.37,100,,,Case Rate,100% of CMS IPPS Rate,7914.3,145,MS-DRG,6331.44,Case Rate,145% of CMS IPPS Rate,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,11007.41,100,,,Case Rate,100% of CMS IPPS Rate,12580.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14152.5,100,,,Case Rate,100% of CMS IPPS Rate,14152.5,100,,,Case Rate,100% of CMS IPPS Rate,14152.5,100,,,Case Rate,100% CMS IPPS Rate,9857.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4966.83,100,MS-DRG,3973.464,Case Rate,100% of CMS IPPS Rate,4966.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4966.83,100,MS-DRG,3973.464,Case Rate,100% of CMS IPPS Rate,4966.83,100,MS-DRG,3973.464,Case Rate,100% of CMS IPPS Rate,5670.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,7095.58,130,MS-DRG,5676.464,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5621.88,103,MS-DRG,4497.504,Case Rate,103% of CMS IPPS Rate,5621.88,103,MS-DRG,4497.504,Case Rate,103% of CMS IPPS Rate,10905.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,5781.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8187.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,11165,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5458.14,100,MS-DRG,4366.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4966.83,14152.5,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,CDM,,,,,Inpatient,,,,,,36312.55,100,,,Case Rate,100% of CMS IPPS Rate,26319.15,145,MS-DRG,21055.32,Case Rate,145% of CMS IPPS Rate,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,32142.37,100,,,Case Rate,100% of CMS IPPS Rate,36735.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41326.25,100,,,Case Rate,100% of CMS IPPS Rate,41326.25,100,,,Case Rate,100% of CMS IPPS Rate,41326.25,100,,,Case Rate,100% CMS IPPS Rate,32779.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16516.66,100,MS-DRG,13213.328,Case Rate,100% of CMS IPPS Rate,16516.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16516.66,100,MS-DRG,13213.328,Case Rate,100% of CMS IPPS Rate,16516.66,100,MS-DRG,13213.328,Case Rate,100% of CMS IPPS Rate,23865.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,23596.48,130,MS-DRG,18877.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18695.67,103,MS-DRG,14956.536,Case Rate,103% of CMS IPPS Rate,18695.67,103,MS-DRG,14956.536,Case Rate,103% of CMS IPPS Rate,31001.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,19227.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27226.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,37129.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18151.14,100,MS-DRG,14520.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41326.25,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,CDM,,,,,Inpatient,,,,,,12858.16,100,,,Case Rate,100% of CMS IPPS Rate,10363.53,145,MS-DRG,8290.824,Case Rate,145% of CMS IPPS Rate,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,13040.38,100,,,Case Rate,100% of CMS IPPS Rate,14903.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16766.35,100,,,Case Rate,100% of CMS IPPS Rate,16766.35,100,,,Case Rate,100% of CMS IPPS Rate,16766.35,100,,,Case Rate,100% CMS IPPS Rate,11607.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6503.8,100,MS-DRG,5203.04,Case Rate,100% of CMS IPPS Rate,6503.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6503.8,100,MS-DRG,5203.04,Case Rate,100% of CMS IPPS Rate,6503.8,100,MS-DRG,5203.04,Case Rate,100% of CMS IPPS Rate,9397.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,9291.44,130,MS-DRG,7433.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7361.68,103,MS-DRG,5889.344,Case Rate,103% of CMS IPPS Rate,7361.68,103,MS-DRG,5889.344,Case Rate,103% of CMS IPPS Rate,14677.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,6808.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10720.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,13147.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7147.26,100,MS-DRG,5717.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16766.35,
MOUTH PROCEDURES WITH CC/MCC,137,CDM,,,,,Inpatient,,,,,,20602.35,100,,,Case Rate,100% of CMS IPPS Rate,14932.48,145,MS-DRG,11945.984,Case Rate,145% of CMS IPPS Rate,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,18644.74,100,,,Case Rate,100% of CMS IPPS Rate,21309.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23972,100,,,Case Rate,100% of CMS IPPS Rate,23972,100,,,Case Rate,100% of CMS IPPS Rate,23972,100,,,Case Rate,100% CMS IPPS Rate,18598.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9371.03,100,MS-DRG,7496.824,Case Rate,100% of CMS IPPS Rate,9371.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9371.03,100,MS-DRG,7496.824,Case Rate,100% of CMS IPPS Rate,9371.03,100,MS-DRG,7496.824,Case Rate,100% of CMS IPPS Rate,10844.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,13387.74,130,MS-DRG,10710.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10607.21,103,MS-DRG,8485.768,Case Rate,103% of CMS IPPS Rate,10607.21,103,MS-DRG,8485.768,Case Rate,103% of CMS IPPS Rate,18969.94,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,10909.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15447.39,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,21065.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10298.26,100,MS-DRG,8238.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23972,
MOUTH PROCEDURES WITHOUT CC/MCC,138,CDM,,,,,Inpatient,,,,,,11853.16,100,,,Case Rate,100% of CMS IPPS Rate,8591.12,145,MS-DRG,6872.896,Case Rate,145% of CMS IPPS Rate,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,10844.77,100,,,Case Rate,100% of CMS IPPS Rate,12394.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13943.39,100,,,Case Rate,100% of CMS IPPS Rate,13943.39,100,,,Case Rate,100% of CMS IPPS Rate,13943.39,100,,,Case Rate,100% CMS IPPS Rate,10700.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5391.55,100,MS-DRG,4313.24,Case Rate,100% of CMS IPPS Rate,5391.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5391.55,100,MS-DRG,4313.24,Case Rate,100% of CMS IPPS Rate,5391.55,100,MS-DRG,4313.24,Case Rate,100% of CMS IPPS Rate,6184.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,7702.38,130,MS-DRG,6161.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6102.66,103,MS-DRG,4882.128,Case Rate,103% of CMS IPPS Rate,6102.66,103,MS-DRG,4882.128,Case Rate,103% of CMS IPPS Rate,11186.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,6276.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8887.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,12119.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5924.91,100,MS-DRG,4739.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5391.55,13943.39,
SALIVARY GLAND PROCEDURES,139,CDM,,,,,Inpatient,,,,,,16261.99,100,,,Case Rate,100% of CMS IPPS Rate,11786.6,145,MS-DRG,9429.28,Case Rate,145% of CMS IPPS Rate,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,18303.46,100,,,Case Rate,100% of CMS IPPS Rate,20919.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23533.22,100,,,Case Rate,100% of CMS IPPS Rate,23533.22,100,,,Case Rate,100% of CMS IPPS Rate,23533.22,100,,,Case Rate,100% CMS IPPS Rate,14679.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7396.86,100,MS-DRG,5917.488,Case Rate,100% of CMS IPPS Rate,7396.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7396.86,100,MS-DRG,5917.488,Case Rate,100% of CMS IPPS Rate,7396.86,100,MS-DRG,5917.488,Case Rate,100% of CMS IPPS Rate,10687.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,10567.3,130,MS-DRG,8453.84,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8372.55,103,MS-DRG,6698.04,Case Rate,103% of CMS IPPS Rate,8372.55,103,MS-DRG,6698.04,Case Rate,103% of CMS IPPS Rate,15907.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,8610.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12193.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,16627.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8128.69,100,MS-DRG,6502.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23533.22,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,CDM,,,,,Inpatient,,,,,,51729.75,100,,,Case Rate,100% of CMS IPPS Rate,37493.46,145,MS-DRG,29994.768,Case Rate,145% of CMS IPPS Rate,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,56379.47,100,,,Case Rate,100% of CMS IPPS Rate,64436.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,72488.49,100,,,Case Rate,100% of CMS IPPS Rate,72488.49,100,,,Case Rate,100% of CMS IPPS Rate,72488.49,100,,,Case Rate,100% CMS IPPS Rate,46697.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23529.02,100,MS-DRG,18823.216,Case Rate,100% of CMS IPPS Rate,23529.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23529.02,100,MS-DRG,18823.216,Case Rate,100% of CMS IPPS Rate,23529.02,100,MS-DRG,18823.216,Case Rate,100% of CMS IPPS Rate,4157.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,33614.83,130,MS-DRG,26891.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26633.29,103,MS-DRG,21306.632,Case Rate,103% of CMS IPPS Rate,26633.29,103,MS-DRG,21306.632,Case Rate,103% of CMS IPPS Rate,52577.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,27391.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,38786.34,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,52893.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25857.56,100,MS-DRG,20686.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4157.36,72488.49,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,CDM,,,,,Inpatient,,,,,,28365.72,100,,,Case Rate,100% of CMS IPPS Rate,20559.33,145,MS-DRG,16447.464,Case Rate,145% of CMS IPPS Rate,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,28641.65,100,,,Case Rate,100% of CMS IPPS Rate,32734.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36825.29,100,,,Case Rate,100% of CMS IPPS Rate,36825.29,100,,,Case Rate,100% of CMS IPPS Rate,36825.29,100,,,Case Rate,100% CMS IPPS Rate,25606.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12902.11,100,MS-DRG,10321.688,Case Rate,100% of CMS IPPS Rate,12902.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12902.11,100,MS-DRG,10321.688,Case Rate,100% of CMS IPPS Rate,12902.11,100,MS-DRG,10321.688,Case Rate,100% of CMS IPPS Rate,3336.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,18432.51,130,MS-DRG,14746.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14604.22,103,MS-DRG,11683.376,Case Rate,103% of CMS IPPS Rate,14604.22,103,MS-DRG,11683.376,Case Rate,103% of CMS IPPS Rate,28242.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,15019.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21268.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,29003.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14178.85,100,MS-DRG,11343.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3336.91,36825.29,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,CDM,,,,,Inpatient,,,,,,21154.14,100,,,Case Rate,100% of CMS IPPS Rate,15332.42,145,MS-DRG,12265.936,Case Rate,145% of CMS IPPS Rate,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,20961.66,100,,,Case Rate,100% of CMS IPPS Rate,23957.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26950.94,100,,,Case Rate,100% of CMS IPPS Rate,26950.94,100,,,Case Rate,100% of CMS IPPS Rate,26950.94,100,,,Case Rate,100% CMS IPPS Rate,19096.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9622.01,100,MS-DRG,7697.608,Case Rate,100% of CMS IPPS Rate,9622.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9622.01,100,MS-DRG,7697.608,Case Rate,100% of CMS IPPS Rate,9622.01,100,MS-DRG,7697.608,Case Rate,100% of CMS IPPS Rate,20596.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,13746.3,130,MS-DRG,10997.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10891.3,103,MS-DRG,8713.04,Case Rate,103% of CMS IPPS Rate,10891.3,103,MS-DRG,8713.04,Case Rate,103% of CMS IPPS Rate,21526.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,11201.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15861.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,21630,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10574.08,100,MS-DRG,8459.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26950.94,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,CDM,,,,,Inpatient,,,,,,45534.12,100,,,Case Rate,100% of CMS IPPS Rate,33002.9,145,MS-DRG,26402.32,Case Rate,145% of CMS IPPS Rate,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,44017.63,100,,,Case Rate,100% of CMS IPPS Rate,50307.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,56594.57,100,,,Case Rate,100% of CMS IPPS Rate,56594.57,100,,,Case Rate,100% of CMS IPPS Rate,56594.57,100,,,Case Rate,100% CMS IPPS Rate,41104.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20711,100,MS-DRG,16568.8,Case Rate,100% of CMS IPPS Rate,20711,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20711,100,MS-DRG,16568.8,Case Rate,100% of CMS IPPS Rate,20711,100,MS-DRG,16568.8,Case Rate,100% of CMS IPPS Rate,11127.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,29588.81,130,MS-DRG,23671.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23443.44,103,MS-DRG,18754.752,Case Rate,103% of CMS IPPS Rate,23443.44,103,MS-DRG,18754.752,Case Rate,103% of CMS IPPS Rate,40133.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,24110.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34140.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,46558.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22760.62,100,MS-DRG,18208.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,56594.57,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,CDM,,,,,Inpatient,,,,,,23694.01,100,,,Case Rate,100% of CMS IPPS Rate,17173.31,145,MS-DRG,13738.648,Case Rate,145% of CMS IPPS Rate,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,23418.57,100,,,Case Rate,100% of CMS IPPS Rate,26765.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% CMS IPPS Rate,21388.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10777.24,100,MS-DRG,8621.792,Case Rate,100% of CMS IPPS Rate,10777.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10777.24,100,MS-DRG,8621.792,Case Rate,100% of CMS IPPS Rate,10777.24,100,MS-DRG,8621.792,Case Rate,100% of CMS IPPS Rate,8913.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,15396.76,130,MS-DRG,12317.408,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12198.97,103,MS-DRG,9759.176,Case Rate,103% of CMS IPPS Rate,12198.97,103,MS-DRG,9759.176,Case Rate,103% of CMS IPPS Rate,22887.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,12546.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17765.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,24227,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11843.66,100,MS-DRG,9474.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30109.84,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,CDM,,,,,Inpatient,,,,,,16719.3,100,,,Case Rate,100% of CMS IPPS Rate,12118.07,145,MS-DRG,9694.456,Case Rate,145% of CMS IPPS Rate,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,15794.57,100,,,Case Rate,100% of CMS IPPS Rate,18051.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20307.47,100,,,Case Rate,100% of CMS IPPS Rate,20307.47,100,,,Case Rate,100% of CMS IPPS Rate,20307.47,100,,,Case Rate,100% CMS IPPS Rate,15092.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7604.86,100,MS-DRG,6083.888,Case Rate,100% of CMS IPPS Rate,7604.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7604.86,100,MS-DRG,6083.888,Case Rate,100% of CMS IPPS Rate,7604.86,100,MS-DRG,6083.888,Case Rate,100% of CMS IPPS Rate,4013.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,10864.48,130,MS-DRG,8691.584,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8608.01,103,MS-DRG,6886.408,Case Rate,103% of CMS IPPS Rate,8608.01,103,MS-DRG,6886.408,Case Rate,103% of CMS IPPS Rate,15278.67,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,8852.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12535.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,17095.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8357.29,100,MS-DRG,6685.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4013.05,20307.47,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,CDM,,,,,Inpatient,,,,,,28903.81,100,,,Case Rate,100% of CMS IPPS Rate,20949.34,145,MS-DRG,16759.472,Case Rate,145% of CMS IPPS Rate,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,30582.65,100,,,Case Rate,100% of CMS IPPS Rate,34952.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39320.87,100,,,Case Rate,100% of CMS IPPS Rate,39320.87,100,,,Case Rate,100% of CMS IPPS Rate,39320.87,100,,,Case Rate,100% CMS IPPS Rate,26091.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13146.88,100,MS-DRG,10517.504,Case Rate,100% of CMS IPPS Rate,13146.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13146.88,100,MS-DRG,10517.504,Case Rate,100% of CMS IPPS Rate,13146.88,100,MS-DRG,10517.504,Case Rate,100% of CMS IPPS Rate,12139.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,18782.17,130,MS-DRG,15025.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14881.25,103,MS-DRG,11905,Case Rate,103% of CMS IPPS Rate,14881.25,103,MS-DRG,11905,Case Rate,103% of CMS IPPS Rate,25479.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,15304.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21671.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,29554,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14447.82,100,MS-DRG,11558.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39320.87,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,CDM,,,,,Inpatient,,,,,,16920.57,100,,,Case Rate,100% of CMS IPPS Rate,12263.96,145,MS-DRG,9811.168,Case Rate,145% of CMS IPPS Rate,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,16594.43,100,,,Case Rate,100% of CMS IPPS Rate,18965.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21335.87,100,,,Case Rate,100% of CMS IPPS Rate,21335.87,100,,,Case Rate,100% of CMS IPPS Rate,21335.87,100,,,Case Rate,100% CMS IPPS Rate,15274.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7696.41,100,MS-DRG,6157.128,Case Rate,100% of CMS IPPS Rate,7696.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7696.41,100,MS-DRG,6157.128,Case Rate,100% of CMS IPPS Rate,7696.41,100,MS-DRG,6157.128,Case Rate,100% of CMS IPPS Rate,11120.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,10995.27,130,MS-DRG,8796.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8711.64,103,MS-DRG,6969.312,Case Rate,103% of CMS IPPS Rate,8711.64,103,MS-DRG,6969.312,Case Rate,103% of CMS IPPS Rate,15320.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,8959.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12686.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,17301.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8457.9,100,MS-DRG,6766.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21335.87,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,CDM,,,,,Inpatient,,,,,,12181.77,100,,,Case Rate,100% of CMS IPPS Rate,8829.3,145,MS-DRG,7063.44,Case Rate,145% of CMS IPPS Rate,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,10175.55,100,,,Case Rate,100% of CMS IPPS Rate,11629.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13082.96,100,,,Case Rate,100% of CMS IPPS Rate,13082.96,100,,,Case Rate,100% of CMS IPPS Rate,13082.96,100,,,Case Rate,100% CMS IPPS Rate,10996.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5541.01,100,MS-DRG,4432.808,Case Rate,100% of CMS IPPS Rate,5541.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5541.01,100,MS-DRG,4432.808,Case Rate,100% of CMS IPPS Rate,5541.01,100,MS-DRG,4432.808,Case Rate,100% of CMS IPPS Rate,8006.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,7915.92,130,MS-DRG,6332.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6271.85,103,MS-DRG,5017.48,Case Rate,103% of CMS IPPS Rate,6271.85,103,MS-DRG,5017.48,Case Rate,103% of CMS IPPS Rate,10342.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,6450.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9133.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,12455.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6089.17,100,MS-DRG,4871.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5541.01,13082.96,
DYSEQUILIBRIUM,149,CDM,,,,,Inpatient,,,,,,10196.43,100,,,Case Rate,100% of CMS IPPS Rate,7390.32,145,MS-DRG,5912.256,Case Rate,145% of CMS IPPS Rate,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,9964.92,100,,,Case Rate,100% of CMS IPPS Rate,11388.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12812.15,100,,,Case Rate,100% of CMS IPPS Rate,12812.15,100,,,Case Rate,100% of CMS IPPS Rate,12812.15,100,,,Case Rate,100% CMS IPPS Rate,9204.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,6851.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,6625.8,130,MS-DRG,5300.64,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5249.67,103,MS-DRG,4199.736,Case Rate,103% of CMS IPPS Rate,5249.67,103,MS-DRG,4199.736,Case Rate,103% of CMS IPPS Rate,9550.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,5399.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7645.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,10425.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4638,12812.15,
EPISTAXIS WITH MCC,150,CDM,,,,,Inpatient,,,,,,17998.13,100,,,Case Rate,100% of CMS IPPS Rate,13044.95,145,MS-DRG,10435.96,Case Rate,145% of CMS IPPS Rate,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,18426.11,100,,,Case Rate,100% of CMS IPPS Rate,21059.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23690.91,100,,,Case Rate,100% of CMS IPPS Rate,23690.91,100,,,Case Rate,100% of CMS IPPS Rate,23690.91,100,,,Case Rate,100% CMS IPPS Rate,16247.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8186.53,100,MS-DRG,6549.224,Case Rate,100% of CMS IPPS Rate,8186.53,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8186.53,100,MS-DRG,6549.224,Case Rate,100% of CMS IPPS Rate,8186.53,100,MS-DRG,6549.224,Case Rate,100% of CMS IPPS Rate,11829.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,11695.48,130,MS-DRG,9356.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9266.42,103,MS-DRG,7413.136,Case Rate,103% of CMS IPPS Rate,9266.42,103,MS-DRG,7413.136,Case Rate,103% of CMS IPPS Rate,17448.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,9530.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13494.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,18403,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8996.52,100,MS-DRG,7197.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23690.91,
EPISTAXIS WITHOUT MCC,151,CDM,,,,,Inpatient,,,,,,10552.42,100,,,Case Rate,100% of CMS IPPS Rate,7648.34,145,MS-DRG,6118.672,Case Rate,145% of CMS IPPS Rate,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,10104.9,100,,,Case Rate,100% of CMS IPPS Rate,11548.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12992.12,100,,,Case Rate,100% of CMS IPPS Rate,12992.12,100,,,Case Rate,100% of CMS IPPS Rate,12992.12,100,,,Case Rate,100% CMS IPPS Rate,9525.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4799.92,100,MS-DRG,3839.936,Case Rate,100% of CMS IPPS Rate,4799.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4799.92,100,MS-DRG,3839.936,Case Rate,100% of CMS IPPS Rate,4799.92,100,MS-DRG,3839.936,Case Rate,100% of CMS IPPS Rate,10325.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,6857.14,130,MS-DRG,5485.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5432.96,103,MS-DRG,4346.368,Case Rate,103% of CMS IPPS Rate,5432.96,103,MS-DRG,4346.368,Case Rate,103% of CMS IPPS Rate,9753.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,5587.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7912.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,10789.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5274.72,100,MS-DRG,4219.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4799.92,12992.12,
OTITIS MEDIA AND URI WITH MCC,152,CDM,,,,,Inpatient,,,,,,16268.83,100,,,Case Rate,100% of CMS IPPS Rate,11791.57,145,MS-DRG,9433.256,Case Rate,145% of CMS IPPS Rate,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,15128.02,100,,,Case Rate,100% of CMS IPPS Rate,17289.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19450.47,100,,,Case Rate,100% of CMS IPPS Rate,19450.47,100,,,Case Rate,100% of CMS IPPS Rate,19450.47,100,,,Case Rate,100% CMS IPPS Rate,14686.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7399.98,100,MS-DRG,5919.984,Case Rate,100% of CMS IPPS Rate,7399.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7399.98,100,MS-DRG,5919.984,Case Rate,100% of CMS IPPS Rate,7399.98,100,MS-DRG,5919.984,Case Rate,100% of CMS IPPS Rate,6325.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,10571.76,130,MS-DRG,8457.408,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8376.08,103,MS-DRG,6700.864,Case Rate,103% of CMS IPPS Rate,8376.08,103,MS-DRG,6700.864,Case Rate,103% of CMS IPPS Rate,15150.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,8614.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12198.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,16634.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8132.12,100,MS-DRG,6505.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19450.47,
OTITIS MEDIA AND URI WITHOUT MCC,153,CDM,,,,,Inpatient,,,,,,10060.88,100,,,Case Rate,100% of CMS IPPS Rate,7292.09,145,MS-DRG,5833.672,Case Rate,145% of CMS IPPS Rate,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,9487.67,100,,,Case Rate,100% of CMS IPPS Rate,10843.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12198.54,100,,,Case Rate,100% of CMS IPPS Rate,12198.54,100,,,Case Rate,100% of CMS IPPS Rate,12198.54,100,,,Case Rate,100% CMS IPPS Rate,9082.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4576.34,100,MS-DRG,3661.072,Case Rate,100% of CMS IPPS Rate,4576.34,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4576.34,100,MS-DRG,3661.072,Case Rate,100% of CMS IPPS Rate,4576.34,100,MS-DRG,3661.072,Case Rate,100% of CMS IPPS Rate,3124.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,6537.74,130,MS-DRG,5230.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5179.9,103,MS-DRG,4143.92,Case Rate,103% of CMS IPPS Rate,5179.9,103,MS-DRG,4143.92,Case Rate,103% of CMS IPPS Rate,8734.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,5327.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7543.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,10287.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5029.03,100,MS-DRG,4023.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3124.5,12198.54,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,CDM,,,,,Inpatient,,,,,,21061.03,100,,,Case Rate,100% of CMS IPPS Rate,15264.93,145,MS-DRG,12211.944,Case Rate,145% of CMS IPPS Rate,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,21680.21,100,,,Case Rate,100% of CMS IPPS Rate,24778.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27874.78,100,,,Case Rate,100% of CMS IPPS Rate,27874.78,100,,,Case Rate,100% of CMS IPPS Rate,27874.78,100,,,Case Rate,100% CMS IPPS Rate,19012.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9579.66,100,MS-DRG,7663.728,Case Rate,100% of CMS IPPS Rate,9579.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9579.66,100,MS-DRG,7663.728,Case Rate,100% of CMS IPPS Rate,9579.66,100,MS-DRG,7663.728,Case Rate,100% of CMS IPPS Rate,9204.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,13685.8,130,MS-DRG,10948.64,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10843.37,103,MS-DRG,8674.696,Case Rate,103% of CMS IPPS Rate,10843.37,103,MS-DRG,8674.696,Case Rate,103% of CMS IPPS Rate,19011.69,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,11151.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15791.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,21534.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10527.54,100,MS-DRG,8422.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27874.78,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,CDM,,,,,Inpatient,,,,,,12960.85,100,,,Case Rate,100% of CMS IPPS Rate,9393.96,145,MS-DRG,7515.168,Case Rate,145% of CMS IPPS Rate,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,12445.82,100,,,Case Rate,100% of CMS IPPS Rate,14224.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16001.9,100,,,Case Rate,100% of CMS IPPS Rate,16001.9,100,,,Case Rate,100% of CMS IPPS Rate,16001.9,100,,,Case Rate,100% CMS IPPS Rate,11699.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5895.36,100,MS-DRG,4716.288,Case Rate,100% of CMS IPPS Rate,5895.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5895.36,100,MS-DRG,4716.288,Case Rate,100% of CMS IPPS Rate,5895.36,100,MS-DRG,4716.288,Case Rate,100% of CMS IPPS Rate,6184.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,8422.17,130,MS-DRG,6737.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6672.95,103,MS-DRG,5338.36,Case Rate,103% of CMS IPPS Rate,6672.95,103,MS-DRG,5338.36,Case Rate,103% of CMS IPPS Rate,11629.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,6862.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9717.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,13252.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6478.59,100,MS-DRG,5182.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5895.36,16001.9,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,CDM,,,,,Inpatient,,,,,,8975.11,100,,,Case Rate,100% of CMS IPPS Rate,6505.12,145,MS-DRG,5204.096,Case Rate,145% of CMS IPPS Rate,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,8963.76,100,,,Case Rate,100% of CMS IPPS Rate,10244.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11524.94,100,,,Case Rate,100% of CMS IPPS Rate,11524.94,100,,,Case Rate,100% of CMS IPPS Rate,11524.94,100,,,Case Rate,100% CMS IPPS Rate,8101.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4082.49,100,MS-DRG,3265.992,Case Rate,100% of CMS IPPS Rate,4082.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4082.49,100,MS-DRG,3265.992,Case Rate,100% of CMS IPPS Rate,4082.49,100,MS-DRG,3265.992,Case Rate,100% of CMS IPPS Rate,5366.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,5832.18,130,MS-DRG,4665.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4620.88,103,MS-DRG,3696.704,Case Rate,103% of CMS IPPS Rate,4620.88,103,MS-DRG,3696.704,Case Rate,103% of CMS IPPS Rate,8623.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,4752.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6729.44,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,9177,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4486.29,100,MS-DRG,3589.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4082.49,11524.94,
DENTAL AND ORAL DISEASES WITH MCC,157,CDM,,,,,Inpatient,,,,,,23372.24,100,,,Case Rate,100% of CMS IPPS Rate,16940.09,145,MS-DRG,13552.072,Case Rate,145% of CMS IPPS Rate,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,21829.51,100,,,Case Rate,100% of CMS IPPS Rate,24948.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28066.75,100,,,Case Rate,100% of CMS IPPS Rate,28066.75,100,,,Case Rate,100% of CMS IPPS Rate,28066.75,100,,,Case Rate,100% CMS IPPS Rate,21098.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10630.89,100,MS-DRG,8504.712,Case Rate,100% of CMS IPPS Rate,10630.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10630.89,100,MS-DRG,8504.712,Case Rate,100% of CMS IPPS Rate,10630.89,100,MS-DRG,8504.712,Case Rate,100% of CMS IPPS Rate,16198.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,15187.67,130,MS-DRG,12150.136,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12033.3,103,MS-DRG,9626.64,Case Rate,103% of CMS IPPS Rate,12033.3,103,MS-DRG,9626.64,Case Rate,103% of CMS IPPS Rate,21148.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,12375.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17524.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,23898,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11682.82,100,MS-DRG,9346.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28066.75,
DENTAL AND ORAL DISEASES WITH CC,158,CDM,,,,,Inpatient,,,,,,12849.94,100,,,Case Rate,100% of CMS IPPS Rate,9313.57,145,MS-DRG,7450.856,Case Rate,145% of CMS IPPS Rate,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,12539.14,100,,,Case Rate,100% of CMS IPPS Rate,14330.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16121.88,100,,,Case Rate,100% of CMS IPPS Rate,16121.88,100,,,Case Rate,100% of CMS IPPS Rate,16121.88,100,,,Case Rate,100% CMS IPPS Rate,11599.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5844.93,100,MS-DRG,4675.944,Case Rate,100% of CMS IPPS Rate,5844.93,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5844.93,100,MS-DRG,4675.944,Case Rate,100% of CMS IPPS Rate,5844.93,100,MS-DRG,4675.944,Case Rate,100% of CMS IPPS Rate,5799.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,8350.1,130,MS-DRG,6680.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6615.84,103,MS-DRG,5292.672,Case Rate,103% of CMS IPPS Rate,6615.84,103,MS-DRG,5292.672,Case Rate,103% of CMS IPPS Rate,11753.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,6804.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9634.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,13139,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6423.15,100,MS-DRG,5138.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5799.87,16121.88,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,CDM,,,,,Inpatient,,,,,,9244.84,100,,,Case Rate,100% of CMS IPPS Rate,6700.62,145,MS-DRG,5360.496,Case Rate,145% of CMS IPPS Rate,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,8793.13,100,,,Case Rate,100% of CMS IPPS Rate,10049.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11305.54,100,,,Case Rate,100% of CMS IPPS Rate,11305.54,100,,,Case Rate,100% of CMS IPPS Rate,11305.54,100,,,Case Rate,100% CMS IPPS Rate,8345.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4205.17,100,MS-DRG,3364.136,Case Rate,100% of CMS IPPS Rate,4205.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4205.17,100,MS-DRG,3364.136,Case Rate,100% of CMS IPPS Rate,4205.17,100,MS-DRG,3364.136,Case Rate,100% of CMS IPPS Rate,6469.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,6007.46,130,MS-DRG,4805.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4759.75,103,MS-DRG,3807.8,Case Rate,103% of CMS IPPS Rate,4759.75,103,MS-DRG,3807.8,Case Rate,103% of CMS IPPS Rate,9486.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,4895.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6931.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,9452.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4621.12,100,MS-DRG,3696.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4205.17,11305.54,
MAJOR CHEST PROCEDURES WITH MCC,163,CDM,,,,,Inpatient,,,,,,64538.61,100,,,Case Rate,100% of CMS IPPS Rate,46777.28,145,MS-DRG,37421.824,Case Rate,145% of CMS IPPS Rate,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,61445.25,100,,,Case Rate,100% of CMS IPPS Rate,70225.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,79001.69,100,,,Case Rate,100% of CMS IPPS Rate,79001.69,100,,,Case Rate,100% of CMS IPPS Rate,79001.69,100,,,Case Rate,100% CMS IPPS Rate,58260.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29355,100,MS-DRG,23484,Case Rate,100% of CMS IPPS Rate,29355,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,29355,100,MS-DRG,23484,Case Rate,100% of CMS IPPS Rate,29355,100,MS-DRG,23484,Case Rate,100% of CMS IPPS Rate,30312.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,41938.25,130,MS-DRG,33550.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33228,103,MS-DRG,26582.4,Case Rate,103% of CMS IPPS Rate,33228,103,MS-DRG,26582.4,Case Rate,103% of CMS IPPS Rate,61272.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,34173.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,48390.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,65990.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32260.19,100,MS-DRG,25808.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,79001.69,
MAJOR CHEST PROCEDURES WITH CC,164,CDM,,,,,Inpatient,,,,,,34920.08,100,,,Case Rate,100% of CMS IPPS Rate,25309.91,145,MS-DRG,20247.928,Case Rate,145% of CMS IPPS Rate,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,33554.13,100,,,Case Rate,100% of CMS IPPS Rate,38349.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43141.38,100,,,Case Rate,100% of CMS IPPS Rate,43141.38,100,,,Case Rate,100% of CMS IPPS Rate,43141.38,100,,,Case Rate,100% CMS IPPS Rate,31522.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15883.3,100,MS-DRG,12706.64,Case Rate,100% of CMS IPPS Rate,15883.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15883.3,100,MS-DRG,12706.64,Case Rate,100% of CMS IPPS Rate,15883.3,100,MS-DRG,12706.64,Case Rate,100% of CMS IPPS Rate,20940.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,22691.64,130,MS-DRG,18153.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17978.76,103,MS-DRG,14383.008,Case Rate,103% of CMS IPPS Rate,17978.76,103,MS-DRG,14383.008,Case Rate,103% of CMS IPPS Rate,32671.16,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,18490.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26182.67,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,35705.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17455.11,100,MS-DRG,13964.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43141.38,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,CDM,,,,,Inpatient,,,,,,25691.67,100,,,Case Rate,100% of CMS IPPS Rate,18621.2,145,MS-DRG,14896.96,Case Rate,145% of CMS IPPS Rate,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,24848.98,100,,,Case Rate,100% of CMS IPPS Rate,28399.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31948.96,100,,,Case Rate,100% of CMS IPPS Rate,31948.96,100,,,Case Rate,100% of CMS IPPS Rate,31948.96,100,,,Case Rate,100% CMS IPPS Rate,23192.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11685.86,100,MS-DRG,9348.688,Case Rate,100% of CMS IPPS Rate,11685.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11685.86,100,MS-DRG,9348.688,Case Rate,100% of CMS IPPS Rate,11685.86,100,MS-DRG,9348.688,Case Rate,100% of CMS IPPS Rate,17583.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,16694.87,130,MS-DRG,13355.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13227.48,103,MS-DRG,10581.984,Case Rate,103% of CMS IPPS Rate,13227.48,103,MS-DRG,10581.984,Case Rate,103% of CMS IPPS Rate,24375.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,13603.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19263.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,26269.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12842.21,100,MS-DRG,10273.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31948.96,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,CDM,,,,,Inpatient,,,,,,55559.4,100,,,Case Rate,100% of CMS IPPS Rate,40269.17,145,MS-DRG,32215.336,Case Rate,145% of CMS IPPS Rate,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,51328.35,100,,,Case Rate,100% of CMS IPPS Rate,58663.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,65994.14,100,,,Case Rate,100% of CMS IPPS Rate,65994.14,100,,,Case Rate,100% of CMS IPPS Rate,65994.14,100,,,Case Rate,100% CMS IPPS Rate,50154.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25270.9,100,MS-DRG,20216.72,Case Rate,100% of CMS IPPS Rate,25270.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25270.9,100,MS-DRG,20216.72,Case Rate,100% of CMS IPPS Rate,25270.9,100,MS-DRG,20216.72,Case Rate,100% of CMS IPPS Rate,43791.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,36103.39,130,MS-DRG,28882.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28605,103,MS-DRG,22884,Case Rate,103% of CMS IPPS Rate,28605,103,MS-DRG,22884,Case Rate,103% of CMS IPPS Rate,46372.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,29419.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,41657.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,56809.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27771.84,100,MS-DRG,22217.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,65994.14,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,CDM,,,,,Inpatient,,,,,,24916.7,100,,,Case Rate,100% of CMS IPPS Rate,18059.5,145,MS-DRG,14447.6,Case Rate,145% of CMS IPPS Rate,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,24358.4,100,,,Case Rate,100% of CMS IPPS Rate,27839.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31318.21,100,,,Case Rate,100% of CMS IPPS Rate,31318.21,100,,,Case Rate,100% of CMS IPPS Rate,31318.21,100,,,Case Rate,100% CMS IPPS Rate,22492.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11333.37,100,MS-DRG,9066.696,Case Rate,100% of CMS IPPS Rate,11333.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11333.37,100,MS-DRG,9066.696,Case Rate,100% of CMS IPPS Rate,11333.37,100,MS-DRG,9066.696,Case Rate,100% of CMS IPPS Rate,14864.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,16191.28,130,MS-DRG,12953.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12828.47,103,MS-DRG,10262.776,Case Rate,103% of CMS IPPS Rate,12828.47,103,MS-DRG,10262.776,Case Rate,103% of CMS IPPS Rate,24048.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,13193.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18682.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,25477.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12454.83,100,MS-DRG,9963.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31318.21,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,CDM,,,,,Inpatient,,,,,,18562.24,100,,,Case Rate,100% of CMS IPPS Rate,13453.84,145,MS-DRG,10763.072,Case Rate,145% of CMS IPPS Rate,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,18048.84,100,,,Case Rate,100% of CMS IPPS Rate,20628.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23205.85,100,,,Case Rate,100% of CMS IPPS Rate,23205.85,100,,,Case Rate,100% of CMS IPPS Rate,23205.85,100,,,Case Rate,100% CMS IPPS Rate,16756.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8443.11,100,MS-DRG,6754.488,Case Rate,100% of CMS IPPS Rate,8443.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8443.11,100,MS-DRG,6754.488,Case Rate,100% of CMS IPPS Rate,8443.11,100,MS-DRG,6754.488,Case Rate,100% of CMS IPPS Rate,11777.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,12062.06,130,MS-DRG,9649.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9556.87,103,MS-DRG,7645.496,Case Rate,103% of CMS IPPS Rate,9556.87,103,MS-DRG,7645.496,Case Rate,103% of CMS IPPS Rate,17932.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,9828.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13917.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,18979.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9278.51,100,MS-DRG,7422.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23205.85,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,CDM,,,,,Inpatient,,,,,,42102.9,100,,,Case Rate,100% of CMS IPPS Rate,30515.96,145,MS-DRG,24412.768,Case Rate,145% of CMS IPPS Rate,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,40907.51,100,,,Case Rate,100% of CMS IPPS Rate,46753.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52595.8,100,,,Case Rate,100% of CMS IPPS Rate,52595.8,100,,,Case Rate,100% of CMS IPPS Rate,52595.8,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19150.35,100,MS-DRG,15320.28,Case Rate,100% of CMS IPPS Rate,19150.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19150.35,100,MS-DRG,15320.28,Case Rate,100% of CMS IPPS Rate,19150.35,100,MS-DRG,15320.28,Case Rate,100% of CMS IPPS Rate,27672.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,27359.14,130,MS-DRG,21887.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21676.85,103,MS-DRG,17341.48,Case Rate,103% of CMS IPPS Rate,21676.85,103,MS-DRG,17341.48,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,22293.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,31568.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21045.49,100,MS-DRG,16836.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,52595.8,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,CDM,,,,,Inpatient,,,,,,19209.88,100,,,Case Rate,100% of CMS IPPS Rate,13923.22,145,MS-DRG,11138.576,Case Rate,145% of CMS IPPS Rate,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,18784.71,100,,,Case Rate,100% of CMS IPPS Rate,21469.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24151.97,100,,,Case Rate,100% of CMS IPPS Rate,24151.97,100,,,Case Rate,100% of CMS IPPS Rate,24151.97,100,,,Case Rate,100% CMS IPPS Rate,17341.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8737.68,100,MS-DRG,6990.144,Case Rate,100% of CMS IPPS Rate,8737.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8737.68,100,MS-DRG,6990.144,Case Rate,100% of CMS IPPS Rate,8737.68,100,MS-DRG,6990.144,Case Rate,100% of CMS IPPS Rate,9412.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,12482.89,130,MS-DRG,9986.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9890.29,103,MS-DRG,7912.232,Case Rate,103% of CMS IPPS Rate,9890.29,103,MS-DRG,7912.232,Case Rate,103% of CMS IPPS Rate,17669.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,10171.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14403.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,19642,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9602.22,100,MS-DRG,7681.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24151.97,
PULMONARY EMBOLISM WITHOUT MCC,176,CDM,,,,,Inpatient,,,,,,11167.2,100,,,Case Rate,100% of CMS IPPS Rate,8093.94,145,MS-DRG,6475.152,Case Rate,145% of CMS IPPS Rate,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,10858.1,100,,,Case Rate,100% of CMS IPPS Rate,12409.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13960.53,100,,,Case Rate,100% of CMS IPPS Rate,13960.53,100,,,Case Rate,100% of CMS IPPS Rate,13960.53,100,,,Case Rate,100% CMS IPPS Rate,10080.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5079.55,100,MS-DRG,4063.64,Case Rate,100% of CMS IPPS Rate,5079.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5079.55,100,MS-DRG,4063.64,Case Rate,100% of CMS IPPS Rate,5079.55,100,MS-DRG,4063.64,Case Rate,100% of CMS IPPS Rate,5469.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,7256.64,130,MS-DRG,5805.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5749.49,103,MS-DRG,4599.592,Case Rate,103% of CMS IPPS Rate,5749.49,103,MS-DRG,4599.592,Case Rate,103% of CMS IPPS Rate,10342.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,5913.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8373.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,11418.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5582.03,100,MS-DRG,4465.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5079.55,13960.53,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,CDM,,,,,Inpatient,,,,,,23227.11,100,,,Case Rate,100% of CMS IPPS Rate,16834.89,145,MS-DRG,13467.912,Case Rate,145% of CMS IPPS Rate,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,21549.56,100,,,Case Rate,100% of CMS IPPS Rate,24628.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27706.81,100,,,Case Rate,100% of CMS IPPS Rate,27706.81,100,,,Case Rate,100% of CMS IPPS Rate,27706.81,100,,,Case Rate,100% CMS IPPS Rate,20967.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10564.89,100,MS-DRG,8451.912,Case Rate,100% of CMS IPPS Rate,10564.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10564.89,100,MS-DRG,8451.912,Case Rate,100% of CMS IPPS Rate,10564.89,100,MS-DRG,8451.912,Case Rate,100% of CMS IPPS Rate,10481.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,15093.35,130,MS-DRG,12074.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11958.58,103,MS-DRG,9566.864,Case Rate,103% of CMS IPPS Rate,11958.58,103,MS-DRG,9566.864,Case Rate,103% of CMS IPPS Rate,22515.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,12298.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17415.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,23749.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11610.27,100,MS-DRG,9288.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27706.81,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,CDM,,,,,Inpatient,,,,,,13509.9,100,,,Case Rate,100% of CMS IPPS Rate,9791.91,145,MS-DRG,7833.528,Case Rate,145% of CMS IPPS Rate,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,13225.69,100,,,Case Rate,100% of CMS IPPS Rate,15115.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17004.59,100,,,Case Rate,100% of CMS IPPS Rate,17004.59,100,,,Case Rate,100% of CMS IPPS Rate,17004.59,100,,,Case Rate,100% CMS IPPS Rate,12195.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6145.09,100,MS-DRG,4916.072,Case Rate,100% of CMS IPPS Rate,6145.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6145.09,100,MS-DRG,4916.072,Case Rate,100% of CMS IPPS Rate,6145.09,100,MS-DRG,4916.072,Case Rate,100% of CMS IPPS Rate,6512.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,8778.95,130,MS-DRG,7023.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6955.63,103,MS-DRG,5564.504,Case Rate,103% of CMS IPPS Rate,6955.63,103,MS-DRG,5564.504,Case Rate,103% of CMS IPPS Rate,13750.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,7153.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10129.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,13813.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6753.04,100,MS-DRG,5402.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17004.59,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,CDM,,,,,Inpatient,,,,,,10451.1,100,,,Case Rate,100% of CMS IPPS Rate,7574.9,145,MS-DRG,6059.92,Case Rate,145% of CMS IPPS Rate,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,10260.87,100,,,Case Rate,100% of CMS IPPS Rate,11727.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13192.66,100,,,Case Rate,100% of CMS IPPS Rate,13192.66,100,,,Case Rate,100% of CMS IPPS Rate,13192.66,100,,,Case Rate,100% CMS IPPS Rate,9434.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4753.83,100,MS-DRG,3803.064,Case Rate,100% of CMS IPPS Rate,4753.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4753.83,100,MS-DRG,3803.064,Case Rate,100% of CMS IPPS Rate,4753.83,100,MS-DRG,3803.064,Case Rate,100% of CMS IPPS Rate,5571.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,6791.29,130,MS-DRG,5433.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5380.79,103,MS-DRG,4304.632,Case Rate,103% of CMS IPPS Rate,5380.79,103,MS-DRG,4304.632,Case Rate,103% of CMS IPPS Rate,9935.31,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,5533.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7836.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,10686.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5224.07,100,MS-DRG,4179.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4753.83,13192.66,
RESPIRATORY NEOPLASMS WITH MCC,180,CDM,,,,,Inpatient,,,,,,23799.43,100,,,Case Rate,100% of CMS IPPS Rate,17249.71,145,MS-DRG,13799.768,Case Rate,145% of CMS IPPS Rate,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,23299.92,100,,,Case Rate,100% of CMS IPPS Rate,26629.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29957.29,100,,,Case Rate,100% of CMS IPPS Rate,29957.29,100,,,Case Rate,100% of CMS IPPS Rate,29957.29,100,,,Case Rate,100% CMS IPPS Rate,21484.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10825.19,100,MS-DRG,8660.152,Case Rate,100% of CMS IPPS Rate,10825.19,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10825.19,100,MS-DRG,8660.152,Case Rate,100% of CMS IPPS Rate,10825.19,100,MS-DRG,8660.152,Case Rate,100% of CMS IPPS Rate,13777.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,15465.26,130,MS-DRG,12372.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12253.24,103,MS-DRG,9802.592,Case Rate,103% of CMS IPPS Rate,12253.24,103,MS-DRG,9802.592,Case Rate,103% of CMS IPPS Rate,21427.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,12601.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17844.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,24334.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11896.35,100,MS-DRG,9517.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29957.29,
RESPIRATORY NEOPLASMS WITH CC,181,CDM,,,,,Inpatient,,,,,,15076.26,100,,,Case Rate,100% of CMS IPPS Rate,10927.21,145,MS-DRG,8741.768,Case Rate,145% of CMS IPPS Rate,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,14801.41,100,,,Case Rate,100% of CMS IPPS Rate,16916.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19030.54,100,,,Case Rate,100% of CMS IPPS Rate,19030.54,100,,,Case Rate,100% of CMS IPPS Rate,19030.54,100,,,Case Rate,100% CMS IPPS Rate,13609.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6857.54,100,MS-DRG,5486.032,Case Rate,100% of CMS IPPS Rate,6857.54,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6857.54,100,MS-DRG,5486.032,Case Rate,100% of CMS IPPS Rate,6857.54,100,MS-DRG,5486.032,Case Rate,100% of CMS IPPS Rate,8234.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,9796.81,130,MS-DRG,7837.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7762.09,103,MS-DRG,6209.672,Case Rate,103% of CMS IPPS Rate,7762.09,103,MS-DRG,6209.672,Case Rate,103% of CMS IPPS Rate,14341.31,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,7982.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11304.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,15415.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7536.01,100,MS-DRG,6028.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19030.54,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,CDM,,,,,Inpatient,,,,,,10392.23,100,,,Case Rate,100% of CMS IPPS Rate,7927.21,145,MS-DRG,6341.768,Case Rate,145% of CMS IPPS Rate,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,11164.71,100,,,Case Rate,100% of CMS IPPS Rate,12760.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14354.75,100,,,Case Rate,100% of CMS IPPS Rate,14354.75,100,,,Case Rate,100% of CMS IPPS Rate,14354.75,100,,,Case Rate,100% CMS IPPS Rate,9381.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.92,100,MS-DRG,3979.936,Case Rate,100% of CMS IPPS Rate,4974.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4974.92,100,MS-DRG,3979.936,Case Rate,100% of CMS IPPS Rate,4974.92,100,MS-DRG,3979.936,Case Rate,100% of CMS IPPS Rate,7188.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,7107.15,130,MS-DRG,5685.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5631.05,103,MS-DRG,4504.84,Case Rate,103% of CMS IPPS Rate,5631.05,103,MS-DRG,4504.84,Case Rate,103% of CMS IPPS Rate,11226.88,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,5502.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8200.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,10626,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5467.04,100,MS-DRG,4373.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.92,14354.75,
MAJOR CHEST TRAUMA WITH MCC,183,CDM,,,,,Inpatient,,,,,,21558.05,100,,,Case Rate,100% of CMS IPPS Rate,15625.17,145,MS-DRG,12500.136,Case Rate,145% of CMS IPPS Rate,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,21160.3,100,,,Case Rate,100% of CMS IPPS Rate,24184.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27206.32,100,,,Case Rate,100% of CMS IPPS Rate,27206.32,100,,,Case Rate,100% of CMS IPPS Rate,27206.32,100,,,Case Rate,100% CMS IPPS Rate,19460.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9805.71,100,MS-DRG,7844.568,Case Rate,100% of CMS IPPS Rate,9805.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9805.71,100,MS-DRG,7844.568,Case Rate,100% of CMS IPPS Rate,9805.71,100,MS-DRG,7844.568,Case Rate,100% of CMS IPPS Rate,11992.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,14008.77,130,MS-DRG,11207.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11099.26,103,MS-DRG,8879.408,Case Rate,103% of CMS IPPS Rate,11099.26,103,MS-DRG,8879.408,Case Rate,103% of CMS IPPS Rate,19002.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,11415.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16163.97,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,22043,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10775.98,100,MS-DRG,8620.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27206.32,
MAJOR CHEST TRAUMA WITH CC,184,CDM,,,,,Inpatient,,,,,,14402.61,100,,,Case Rate,100% of CMS IPPS Rate,10438.94,145,MS-DRG,8351.152,Case Rate,145% of CMS IPPS Rate,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,14238.84,100,,,Case Rate,100% of CMS IPPS Rate,16273.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18307.23,100,,,Case Rate,100% of CMS IPPS Rate,18307.23,100,,,Case Rate,100% of CMS IPPS Rate,18307.23,100,,,Case Rate,100% CMS IPPS Rate,13001.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6551.15,100,MS-DRG,5240.92,Case Rate,100% of CMS IPPS Rate,6551.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6551.15,100,MS-DRG,5240.92,Case Rate,100% of CMS IPPS Rate,6551.15,100,MS-DRG,5240.92,Case Rate,100% of CMS IPPS Rate,6814.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,9359.05,130,MS-DRG,7487.24,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7415.25,103,MS-DRG,5932.2,Case Rate,103% of CMS IPPS Rate,7415.25,103,MS-DRG,5932.2,Case Rate,103% of CMS IPPS Rate,13221.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,7626.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10798.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,14726.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7199.27,100,MS-DRG,5759.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18307.23,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,CDM,,,,,Inpatient,,,,,,10347.04,100,,,Case Rate,100% of CMS IPPS Rate,7499.49,145,MS-DRG,5999.592,Case Rate,145% of CMS IPPS Rate,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,10367.52,100,,,Case Rate,100% of CMS IPPS Rate,11849.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13329.78,100,,,Case Rate,100% of CMS IPPS Rate,13329.78,100,,,Case Rate,100% of CMS IPPS Rate,13329.78,100,,,Case Rate,100% CMS IPPS Rate,9340.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4706.5,100,MS-DRG,3765.2,Case Rate,100% of CMS IPPS Rate,4706.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4706.5,100,MS-DRG,3765.2,Case Rate,100% of CMS IPPS Rate,4706.5,100,MS-DRG,3765.2,Case Rate,100% of CMS IPPS Rate,5857.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,6723.68,130,MS-DRG,5378.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5327.22,103,MS-DRG,4261.776,Case Rate,103% of CMS IPPS Rate,5327.22,103,MS-DRG,4261.776,Case Rate,103% of CMS IPPS Rate,9550.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,5478.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7758.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,10579.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5172.06,100,MS-DRG,4137.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4706.5,13329.78,
PLEURAL EFFUSION WITH MCC,186,CDM,,,,,Inpatient,,,,,,21251.35,100,,,Case Rate,100% of CMS IPPS Rate,15402.87,145,MS-DRG,12322.296,Case Rate,145% of CMS IPPS Rate,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,21062.98,100,,,Case Rate,100% of CMS IPPS Rate,24072.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27081.2,100,,,Case Rate,100% of CMS IPPS Rate,27081.2,100,,,Case Rate,100% of CMS IPPS Rate,27081.2,100,,,Case Rate,100% CMS IPPS Rate,19183.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9666.22,100,MS-DRG,7732.976,Case Rate,100% of CMS IPPS Rate,9666.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9666.22,100,MS-DRG,7732.976,Case Rate,100% of CMS IPPS Rate,9666.22,100,MS-DRG,7732.976,Case Rate,100% of CMS IPPS Rate,14058.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,13809.47,130,MS-DRG,11047.576,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10941.35,103,MS-DRG,8753.08,Case Rate,103% of CMS IPPS Rate,10941.35,103,MS-DRG,8753.08,Case Rate,103% of CMS IPPS Rate,19314.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,11252.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15934.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,21729.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10622.67,100,MS-DRG,8498.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27081.2,
PLEURAL EFFUSION WITH CC,187,CDM,,,,,Inpatient,,,,,,13641.34,100,,,Case Rate,100% of CMS IPPS Rate,9887.17,145,MS-DRG,7909.736,Case Rate,145% of CMS IPPS Rate,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,13384.32,100,,,Case Rate,100% of CMS IPPS Rate,15296.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17208.56,100,,,Case Rate,100% of CMS IPPS Rate,17208.56,100,,,Case Rate,100% of CMS IPPS Rate,17208.56,100,,,Case Rate,100% CMS IPPS Rate,12314.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6204.88,100,MS-DRG,4963.904,Case Rate,100% of CMS IPPS Rate,6204.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6204.88,100,MS-DRG,4963.904,Case Rate,100% of CMS IPPS Rate,6204.88,100,MS-DRG,4963.904,Case Rate,100% of CMS IPPS Rate,7211.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,8864.36,130,MS-DRG,7091.488,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7023.3,103,MS-DRG,5618.64,Case Rate,103% of CMS IPPS Rate,7023.3,103,MS-DRG,5618.64,Case Rate,103% of CMS IPPS Rate,13230.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,7223.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10228.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,13948.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6818.74,100,MS-DRG,5454.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17208.56,
PLEURAL EFFUSION WITHOUT CC/MCC,188,CDM,,,,,Inpatient,,,,,,10221.08,100,,,Case Rate,100% of CMS IPPS Rate,7408.2,145,MS-DRG,5926.56,Case Rate,145% of CMS IPPS Rate,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,9787.62,100,,,Case Rate,100% of CMS IPPS Rate,11186.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12584.19,100,,,Case Rate,100% of CMS IPPS Rate,12584.19,100,,,Case Rate,100% of CMS IPPS Rate,12584.19,100,,,Case Rate,100% CMS IPPS Rate,9226.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4649.2,100,MS-DRG,3719.36,Case Rate,100% of CMS IPPS Rate,4649.2,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4649.2,100,MS-DRG,3719.36,Case Rate,100% of CMS IPPS Rate,4649.2,100,MS-DRG,3719.36,Case Rate,100% of CMS IPPS Rate,5984.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,6641.83,130,MS-DRG,5313.464,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5262.37,103,MS-DRG,4209.896,Case Rate,103% of CMS IPPS Rate,5262.37,103,MS-DRG,4209.896,Case Rate,103% of CMS IPPS Rate,9158.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,5412.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7663.65,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,10451,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5109.1,100,MS-DRG,4087.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4649.2,12584.19,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,CDM,,,,,Inpatient,,,,,,16868.54,100,,,Case Rate,100% of CMS IPPS Rate,12226.24,145,MS-DRG,9780.992,Case Rate,145% of CMS IPPS Rate,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,16495.78,100,,,Case Rate,100% of CMS IPPS Rate,18853.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21209.04,100,,,Case Rate,100% of CMS IPPS Rate,21209.04,100,,,Case Rate,100% of CMS IPPS Rate,21209.04,100,,,Case Rate,100% CMS IPPS Rate,15227.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7672.75,100,MS-DRG,6138.2,Case Rate,100% of CMS IPPS Rate,7672.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7672.75,100,MS-DRG,6138.2,Case Rate,100% of CMS IPPS Rate,7672.75,100,MS-DRG,6138.2,Case Rate,100% of CMS IPPS Rate,6653.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,10961.46,130,MS-DRG,8769.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8684.85,103,MS-DRG,6947.88,Case Rate,103% of CMS IPPS Rate,8684.85,103,MS-DRG,6947.88,Case Rate,103% of CMS IPPS Rate,15268.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,8932,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12647.84,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,17248,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8431.89,100,MS-DRG,6745.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21209.04,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,CDM,,,,,Inpatient,,,,,,15088.58,100,,,Case Rate,100% of CMS IPPS Rate,10936.13,145,MS-DRG,8748.904,Case Rate,145% of CMS IPPS Rate,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,14970.71,100,,,Case Rate,100% of CMS IPPS Rate,17110.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19248.22,100,,,Case Rate,100% of CMS IPPS Rate,19248.22,100,,,Case Rate,100% of CMS IPPS Rate,19248.22,100,,,Case Rate,100% CMS IPPS Rate,13620.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6863.15,100,MS-DRG,5490.52,Case Rate,100% of CMS IPPS Rate,6863.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6863.15,100,MS-DRG,5490.52,Case Rate,100% of CMS IPPS Rate,6863.15,100,MS-DRG,5490.52,Case Rate,100% of CMS IPPS Rate,7738.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,9804.81,130,MS-DRG,7843.848,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7768.42,103,MS-DRG,6214.736,Case Rate,103% of CMS IPPS Rate,7768.42,103,MS-DRG,6214.736,Case Rate,103% of CMS IPPS Rate,13731.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,7989.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11313.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,15428,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7542.16,100,MS-DRG,6033.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19248.22,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,CDM,,,,,Inpatient,,,,,,11624.51,100,,,Case Rate,100% of CMS IPPS Rate,8425.4,145,MS-DRG,6740.32,Case Rate,145% of CMS IPPS Rate,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,11452.66,100,,,Case Rate,100% of CMS IPPS Rate,13089.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14724.97,100,,,Case Rate,100% of CMS IPPS Rate,14724.97,100,,,Case Rate,100% of CMS IPPS Rate,14724.97,100,,,Case Rate,100% CMS IPPS Rate,10493.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5287.56,100,MS-DRG,4230.048,Case Rate,100% of CMS IPPS Rate,5287.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5287.56,100,MS-DRG,4230.048,Case Rate,100% of CMS IPPS Rate,5287.56,100,MS-DRG,4230.048,Case Rate,100% of CMS IPPS Rate,5867.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,7553.81,130,MS-DRG,6043.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5984.94,103,MS-DRG,4787.952,Case Rate,103% of CMS IPPS Rate,5984.94,103,MS-DRG,4787.952,Case Rate,103% of CMS IPPS Rate,10932.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,6155.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8715.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,11886,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5810.62,100,MS-DRG,4648.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5287.56,14724.97,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,CDM,,,,,Inpatient,,,,,,8787.53,100,,,Case Rate,100% of CMS IPPS Rate,6369.15,145,MS-DRG,5095.32,Case Rate,145% of CMS IPPS Rate,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,8627.82,100,,,Case Rate,100% of CMS IPPS Rate,9860.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11093.01,100,,,Case Rate,100% of CMS IPPS Rate,11093.01,100,,,Case Rate,100% of CMS IPPS Rate,11093.01,100,,,Case Rate,100% CMS IPPS Rate,7932.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3997.16,100,MS-DRG,3197.728,Case Rate,100% of CMS IPPS Rate,3997.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3997.16,100,MS-DRG,3197.728,Case Rate,100% of CMS IPPS Rate,3997.16,100,MS-DRG,3197.728,Case Rate,100% of CMS IPPS Rate,4111.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,5710.28,130,MS-DRG,4568.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4524.3,103,MS-DRG,3619.44,Case Rate,103% of CMS IPPS Rate,4524.3,103,MS-DRG,3619.44,Case Rate,103% of CMS IPPS Rate,8249.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,4653.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6588.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,8985.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4392.52,100,MS-DRG,3514.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3997.16,11093.01,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,CDM,,,,,Inpatient,,,,,,18163.81,100,,,Case Rate,100% of CMS IPPS Rate,13165.04,145,MS-DRG,10532.032,Case Rate,145% of CMS IPPS Rate,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,17566.26,100,,,Case Rate,100% of CMS IPPS Rate,20076.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22585.38,100,,,Case Rate,100% of CMS IPPS Rate,22585.38,100,,,Case Rate,100% of CMS IPPS Rate,22585.38,100,,,Case Rate,100% CMS IPPS Rate,16396.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8261.88,100,MS-DRG,6609.504,Case Rate,100% of CMS IPPS Rate,8261.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8261.88,100,MS-DRG,6609.504,Case Rate,100% of CMS IPPS Rate,8261.88,100,MS-DRG,6609.504,Case Rate,100% of CMS IPPS Rate,9033.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,11803.14,130,MS-DRG,9442.512,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9351.72,103,MS-DRG,7481.376,Case Rate,103% of CMS IPPS Rate,9351.72,103,MS-DRG,7481.376,Case Rate,103% of CMS IPPS Rate,16428.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,9617.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13619.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,18572.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9079.34,100,MS-DRG,7263.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22585.38,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,CDM,,,,,Inpatient,,,,,,11257.56,100,,,Case Rate,100% of CMS IPPS Rate,8159.43,145,MS-DRG,6527.544,Case Rate,145% of CMS IPPS Rate,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,10931.42,100,,,Case Rate,100% of CMS IPPS Rate,12493.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14054.8,100,,,Case Rate,100% of CMS IPPS Rate,14054.8,100,,,Case Rate,100% of CMS IPPS Rate,14054.8,100,,,Case Rate,100% CMS IPPS Rate,10162.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5120.65,100,MS-DRG,4096.52,Case Rate,100% of CMS IPPS Rate,5120.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5120.65,100,MS-DRG,4096.52,Case Rate,100% of CMS IPPS Rate,5120.65,100,MS-DRG,4096.52,Case Rate,100% of CMS IPPS Rate,6231.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,7315.35,130,MS-DRG,5852.28,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5796.01,103,MS-DRG,4636.808,Case Rate,103% of CMS IPPS Rate,5796.01,103,MS-DRG,4636.808,Case Rate,103% of CMS IPPS Rate,10628.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,5960.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8440.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,11510.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5627.19,100,MS-DRG,4501.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5120.65,14054.8,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,CDM,,,,,Inpatient,,,,,,8565.72,100,,,Case Rate,100% of CMS IPPS Rate,6208.39,145,MS-DRG,4966.712,Case Rate,145% of CMS IPPS Rate,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,8301.21,100,,,Case Rate,100% of CMS IPPS Rate,9487.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10673.08,100,,,Case Rate,100% of CMS IPPS Rate,10673.08,100,,,Case Rate,100% of CMS IPPS Rate,10673.08,100,,,Case Rate,100% CMS IPPS Rate,7732.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3896.29,100,MS-DRG,3117.032,Case Rate,100% of CMS IPPS Rate,3896.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3896.29,100,MS-DRG,3117.032,Case Rate,100% of CMS IPPS Rate,3896.29,100,MS-DRG,3117.032,Case Rate,100% of CMS IPPS Rate,4375.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,5566.15,130,MS-DRG,4452.92,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4410.1,103,MS-DRG,3528.08,Case Rate,103% of CMS IPPS Rate,4410.1,103,MS-DRG,3528.08,Case Rate,103% of CMS IPPS Rate,8118.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,4535.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6422.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,8758.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4281.65,100,MS-DRG,3425.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3896.29,10673.08,
INTERSTITIAL LUNG DISEASE WITH MCC,196,CDM,,,,,Inpatient,,,,,,25951.82,100,,,Case Rate,100% of CMS IPPS Rate,18809.75,145,MS-DRG,15047.8,Case Rate,145% of CMS IPPS Rate,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,25116.94,100,,,Case Rate,100% of CMS IPPS Rate,28706.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32293.47,100,,,Case Rate,100% of CMS IPPS Rate,32293.47,100,,,Case Rate,100% of CMS IPPS Rate,32293.47,100,,,Case Rate,100% CMS IPPS Rate,23427.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11804.18,100,MS-DRG,9443.344,Case Rate,100% of CMS IPPS Rate,11804.18,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11804.18,100,MS-DRG,9443.344,Case Rate,100% of CMS IPPS Rate,11804.18,100,MS-DRG,9443.344,Case Rate,100% of CMS IPPS Rate,10163.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,16863.91,130,MS-DRG,13491.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13361.41,103,MS-DRG,10689.128,Case Rate,103% of CMS IPPS Rate,13361.41,103,MS-DRG,10689.128,Case Rate,103% of CMS IPPS Rate,21981.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,13741.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19458.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,26535.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12972.24,100,MS-DRG,10377.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32293.47,
INTERSTITIAL LUNG DISEASE WITH CC,197,CDM,,,,,Inpatient,,,,,,13657.77,100,,,Case Rate,100% of CMS IPPS Rate,9899.08,145,MS-DRG,7919.264,Case Rate,145% of CMS IPPS Rate,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,13197.69,100,,,Case Rate,100% of CMS IPPS Rate,15083.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16968.6,100,,,Case Rate,100% of CMS IPPS Rate,16968.6,100,,,Case Rate,100% of CMS IPPS Rate,16968.6,100,,,Case Rate,100% CMS IPPS Rate,12329.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,6212.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,8604.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,8875.04,130,MS-DRG,7100.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7031.76,103,MS-DRG,5625.408,Case Rate,103% of CMS IPPS Rate,7031.76,103,MS-DRG,5625.408,Case Rate,103% of CMS IPPS Rate,12442.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,7231.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10240.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,13965,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6826.95,100,MS-DRG,5461.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16968.6,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,CDM,,,,,Inpatient,,,,,,10655.11,100,,,Case Rate,100% of CMS IPPS Rate,7722.77,145,MS-DRG,6178.216,Case Rate,145% of CMS IPPS Rate,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,8971.76,100,,,Case Rate,100% of CMS IPPS Rate,10253.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11535.22,100,,,Case Rate,100% of CMS IPPS Rate,11535.22,100,,,Case Rate,100% of CMS IPPS Rate,11535.22,100,,,Case Rate,100% CMS IPPS Rate,9618.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4846.62,100,MS-DRG,3877.296,Case Rate,100% of CMS IPPS Rate,4846.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4846.62,100,MS-DRG,3877.296,Case Rate,100% of CMS IPPS Rate,4846.62,100,MS-DRG,3877.296,Case Rate,100% of CMS IPPS Rate,7002.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,6923.87,130,MS-DRG,5539.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5485.83,103,MS-DRG,4388.664,Case Rate,103% of CMS IPPS Rate,5485.83,103,MS-DRG,4388.664,Case Rate,103% of CMS IPPS Rate,8992.89,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,5641.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7989.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,10894.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5326.05,100,MS-DRG,4260.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4846.62,11535.22,
PNEUMOTHORAX WITH MCC,199,CDM,,,,,Inpatient,,,,,,24290.98,100,,,Case Rate,100% of CMS IPPS Rate,17605.99,145,MS-DRG,14084.792,Case Rate,145% of CMS IPPS Rate,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,23533.21,100,,,Case Rate,100% of CMS IPPS Rate,26896.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30257.24,100,,,Case Rate,100% of CMS IPPS Rate,30257.24,100,,,Case Rate,100% of CMS IPPS Rate,30257.24,100,,,Case Rate,100% CMS IPPS Rate,21927.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11048.77,100,MS-DRG,8839.016,Case Rate,100% of CMS IPPS Rate,11048.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11048.77,100,MS-DRG,8839.016,Case Rate,100% of CMS IPPS Rate,11048.77,100,MS-DRG,8839.016,Case Rate,100% of CMS IPPS Rate,9116.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,15784.68,130,MS-DRG,12627.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12506.32,103,MS-DRG,10005.056,Case Rate,103% of CMS IPPS Rate,12506.32,103,MS-DRG,10005.056,Case Rate,103% of CMS IPPS Rate,22246.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,12862.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18213.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,24837.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12142.06,100,MS-DRG,9713.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30257.24,
PNEUMOTHORAX WITH CC,200,CDM,,,,,Inpatient,,,,,,14746.28,100,,,Case Rate,100% of CMS IPPS Rate,10688.02,145,MS-DRG,8550.416,Case Rate,145% of CMS IPPS Rate,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,14764.08,100,,,Case Rate,100% of CMS IPPS Rate,16873.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18982.55,100,,,Case Rate,100% of CMS IPPS Rate,18982.55,100,,,Case Rate,100% of CMS IPPS Rate,18982.55,100,,,Case Rate,100% CMS IPPS Rate,13311.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6707.45,100,MS-DRG,5365.96,Case Rate,100% of CMS IPPS Rate,6707.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6707.45,100,MS-DRG,5365.96,Case Rate,100% of CMS IPPS Rate,6707.45,100,MS-DRG,5365.96,Case Rate,100% of CMS IPPS Rate,6615.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,9582.37,130,MS-DRG,7665.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7592.18,103,MS-DRG,6073.744,Case Rate,103% of CMS IPPS Rate,7592.18,103,MS-DRG,6073.744,Case Rate,103% of CMS IPPS Rate,13560.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,7808.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11056.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,15078,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7371.05,100,MS-DRG,5896.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18982.55,
PNEUMOTHORAX WITHOUT CC/MCC,201,CDM,,,,,Inpatient,,,,,,9667.92,100,,,Case Rate,100% of CMS IPPS Rate,7007.26,145,MS-DRG,5605.808,Case Rate,145% of CMS IPPS Rate,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,9026.42,100,,,Case Rate,100% of CMS IPPS Rate,10316.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11605.49,100,,,Case Rate,100% of CMS IPPS Rate,11605.49,100,,,Case Rate,100% of CMS IPPS Rate,11605.49,100,,,Case Rate,100% CMS IPPS Rate,8727.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4397.61,100,MS-DRG,3518.088,Case Rate,100% of CMS IPPS Rate,4397.61,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4397.61,100,MS-DRG,3518.088,Case Rate,100% of CMS IPPS Rate,4397.61,100,MS-DRG,3518.088,Case Rate,100% of CMS IPPS Rate,4489.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,6282.37,130,MS-DRG,5025.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4977.57,103,MS-DRG,3982.056,Case Rate,103% of CMS IPPS Rate,4977.57,103,MS-DRG,3982.056,Case Rate,103% of CMS IPPS Rate,9207.94,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,5119.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7248.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,9885.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4832.59,100,MS-DRG,3866.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4397.61,11605.49,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,CDM,,,,,Inpatient,,,,,,13110.09,100,,,Case Rate,100% of CMS IPPS Rate,9502.13,145,MS-DRG,7601.704,Case Rate,145% of CMS IPPS Rate,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,12887.08,100,,,Case Rate,100% of CMS IPPS Rate,14728.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16569.24,100,,,Case Rate,100% of CMS IPPS Rate,16569.24,100,,,Case Rate,100% of CMS IPPS Rate,16569.24,100,,,Case Rate,100% CMS IPPS Rate,11834.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5963.25,100,MS-DRG,4770.6,Case Rate,100% of CMS IPPS Rate,5963.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5963.25,100,MS-DRG,4770.6,Case Rate,100% of CMS IPPS Rate,5963.25,100,MS-DRG,4770.6,Case Rate,100% of CMS IPPS Rate,6119.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,8519.15,130,MS-DRG,6815.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6749.79,103,MS-DRG,5399.832,Case Rate,103% of CMS IPPS Rate,6749.79,103,MS-DRG,5399.832,Case Rate,103% of CMS IPPS Rate,11711.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,6941.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9829.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,13405,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6553.19,100,MS-DRG,5242.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16569.24,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,CDM,,,,,Inpatient,,,,,,9514.57,100,,,Case Rate,100% of CMS IPPS Rate,6896.11,145,MS-DRG,5516.888,Case Rate,145% of CMS IPPS Rate,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,9286.37,100,,,Case Rate,100% of CMS IPPS Rate,10613.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11939.72,100,,,Case Rate,100% of CMS IPPS Rate,11939.72,100,,,Case Rate,100% of CMS IPPS Rate,11939.72,100,,,Case Rate,100% CMS IPPS Rate,8588.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4327.86,100,MS-DRG,3462.288,Case Rate,100% of CMS IPPS Rate,4327.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4327.86,100,MS-DRG,3462.288,Case Rate,100% of CMS IPPS Rate,4327.86,100,MS-DRG,3462.288,Case Rate,100% of CMS IPPS Rate,3514.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,6182.72,130,MS-DRG,4946.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4898.62,103,MS-DRG,3918.896,Case Rate,103% of CMS IPPS Rate,4898.62,103,MS-DRG,3918.896,Case Rate,103% of CMS IPPS Rate,8438.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,5038.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7133.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,9728.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4755.94,100,MS-DRG,3804.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3514.46,11939.72,
RESPIRATORY SIGNS AND SYMPTOMS,204,CDM,,,,,Inpatient,,,,,,11267.15,100,,,Case Rate,100% of CMS IPPS Rate,8166.37,145,MS-DRG,6533.096,Case Rate,145% of CMS IPPS Rate,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,10811.44,100,,,Case Rate,100% of CMS IPPS Rate,12356.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13900.54,100,,,Case Rate,100% of CMS IPPS Rate,13900.54,100,,,Case Rate,100% of CMS IPPS Rate,13900.54,100,,,Case Rate,100% CMS IPPS Rate,10171.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5125.01,100,MS-DRG,4100.008,Case Rate,100% of CMS IPPS Rate,5125.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5125.01,100,MS-DRG,4100.008,Case Rate,100% of CMS IPPS Rate,5125.01,100,MS-DRG,4100.008,Case Rate,100% of CMS IPPS Rate,4301.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,7321.57,130,MS-DRG,5857.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5800.94,103,MS-DRG,4640.752,Case Rate,103% of CMS IPPS Rate,5800.94,103,MS-DRG,4640.752,Case Rate,103% of CMS IPPS Rate,10238.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,5966.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8447.97,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,11520.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5631.98,100,MS-DRG,4505.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4301.66,13900.54,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,CDM,,,,,Inpatient,,,,,,24786.63,100,,,Case Rate,100% of CMS IPPS Rate,17965.24,145,MS-DRG,14372.192,Case Rate,145% of CMS IPPS Rate,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,25166.26,100,,,Case Rate,100% of CMS IPPS Rate,28762.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32356.89,100,,,Case Rate,100% of CMS IPPS Rate,32356.89,100,,,Case Rate,100% of CMS IPPS Rate,32356.89,100,,,Case Rate,100% CMS IPPS Rate,22375.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11274.21,100,MS-DRG,9019.368,Case Rate,100% of CMS IPPS Rate,11274.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11274.21,100,MS-DRG,9019.368,Case Rate,100% of CMS IPPS Rate,11274.21,100,MS-DRG,9019.368,Case Rate,100% of CMS IPPS Rate,13010.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,16106.77,130,MS-DRG,12885.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12761.51,103,MS-DRG,10209.208,Case Rate,103% of CMS IPPS Rate,12761.51,103,MS-DRG,10209.208,Case Rate,103% of CMS IPPS Rate,22529.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,13124.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18584.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,25344.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12389.82,100,MS-DRG,9911.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32356.89,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,CDM,,,,,Inpatient,,,,,,12507.64,100,,,Case Rate,100% of CMS IPPS Rate,9065.47,145,MS-DRG,7252.376,Case Rate,145% of CMS IPPS Rate,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,12075.22,100,,,Case Rate,100% of CMS IPPS Rate,13800.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15525.41,100,,,Case Rate,100% of CMS IPPS Rate,15525.41,100,,,Case Rate,100% of CMS IPPS Rate,15525.41,100,,,Case Rate,100% CMS IPPS Rate,11290.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5689.23,100,MS-DRG,4551.384,Case Rate,100% of CMS IPPS Rate,5689.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5689.23,100,MS-DRG,4551.384,Case Rate,100% of CMS IPPS Rate,5689.23,100,MS-DRG,4551.384,Case Rate,100% of CMS IPPS Rate,4441.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,8127.67,130,MS-DRG,6502.136,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6439.61,103,MS-DRG,5151.688,Case Rate,103% of CMS IPPS Rate,6439.61,103,MS-DRG,5151.688,Case Rate,103% of CMS IPPS Rate,11301.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,6622.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9378.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,12789,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6252.05,100,MS-DRG,5001.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4441.92,15525.41,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,CDM,,,,,Inpatient,,,,,,94584.34,100,,,Case Rate,100% of CMS IPPS Rate,68554.26,145,MS-DRG,54843.408,Case Rate,145% of CMS IPPS Rate,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,86214.24,100,,,Case Rate,100% of CMS IPPS Rate,98534.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,110847.81,100,,,Case Rate,100% of CMS IPPS Rate,110847.81,100,,,Case Rate,100% of CMS IPPS Rate,110847.81,100,,,Case Rate,100% CMS IPPS Rate,85382.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43021.01,100,MS-DRG,34416.808,Case Rate,100% of CMS IPPS Rate,43021.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,43021.01,100,MS-DRG,34416.808,Case Rate,100% of CMS IPPS Rate,43021.01,100,MS-DRG,34416.808,Case Rate,100% of CMS IPPS Rate,53584.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,61462.44,130,MS-DRG,49169.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48697.16,103,MS-DRG,38957.728,Case Rate,103% of CMS IPPS Rate,48697.16,103,MS-DRG,38957.728,Case Rate,103% of CMS IPPS Rate,83058.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,50083,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,70918.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,96712,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47278.8,100,MS-DRG,37823.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,110847.81,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,CDM,,,,,Inpatient,,,,,,37020.43,100,,,Case Rate,100% of CMS IPPS Rate,26832.24,145,MS-DRG,21465.792,Case Rate,145% of CMS IPPS Rate,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,35777.74,100,,,Case Rate,100% of CMS IPPS Rate,40890.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46000.33,100,,,Case Rate,100% of CMS IPPS Rate,46000.33,100,,,Case Rate,100% of CMS IPPS Rate,46000.33,100,,,Case Rate,100% CMS IPPS Rate,33418.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16838.63,100,MS-DRG,13470.904,Case Rate,100% of CMS IPPS Rate,16838.63,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16838.63,100,MS-DRG,13470.904,Case Rate,100% of CMS IPPS Rate,16838.63,100,MS-DRG,13470.904,Case Rate,100% of CMS IPPS Rate,17779.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,24056.49,130,MS-DRG,19245.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19060.14,103,MS-DRG,15248.112,Case Rate,103% of CMS IPPS Rate,19060.14,103,MS-DRG,15248.112,Case Rate,103% of CMS IPPS Rate,32891.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,19602.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27757.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,37853.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18504.99,100,MS-DRG,14803.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46000.33,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,CDM,,,,,Inpatient,,,,,,147472.42,100,,,Case Rate,100% of CMS IPPS Rate,106887.29,145,MS-DRG,85509.832,Case Rate,145% of CMS IPPS Rate,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,145226.58,100,,,Case Rate,100% of CMS IPPS Rate,165979.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,186721.45,100,,,Case Rate,100% of CMS IPPS Rate,186721.45,100,,,Case Rate,100% of CMS IPPS Rate,186721.45,100,,,Case Rate,100% CMS IPPS Rate,133125.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67076.65,100,MS-DRG,53661.32,Case Rate,100% of CMS IPPS Rate,67076.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,67076.65,100,MS-DRG,53661.32,Case Rate,100% of CMS IPPS Rate,67076.65,100,MS-DRG,53661.32,Case Rate,100% of CMS IPPS Rate,7439.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,95829.98,130,MS-DRG,76663.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75926.83,103,MS-DRG,60741.464,Case Rate,103% of CMS IPPS Rate,75926.83,103,MS-DRG,60741.464,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,78087.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,110573.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73715.37,100,MS-DRG,58972.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,186721.45,
OTHER HEART ASSIST SYSTEM IMPLANT,215,CDM,,,,,Inpatient,,,,,,139861.04,100,,,Case Rate,100% of CMS IPPS Rate,101370.6,145,MS-DRG,81096.48,Case Rate,145% of CMS IPPS Rate,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,141239.28,100,,,Case Rate,100% of CMS IPPS Rate,161422.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,181594.87,100,,,Case Rate,100% of CMS IPPS Rate,181594.87,100,,,Case Rate,100% of CMS IPPS Rate,181594.87,100,,,Case Rate,100% CMS IPPS Rate,126254.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,63614.68,100,MS-DRG,50891.744,Case Rate,100% of CMS IPPS Rate,63614.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,63614.68,100,MS-DRG,50891.744,Case Rate,100% of CMS IPPS Rate,63614.68,100,MS-DRG,50891.744,Case Rate,100% of CMS IPPS Rate,84042.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,90883.99,130,MS-DRG,72707.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72008.08,103,MS-DRG,57606.464,Case Rate,103% of CMS IPPS Rate,72008.08,103,MS-DRG,57606.464,Case Rate,103% of CMS IPPS Rate,130335.48,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,74057.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,104866.14,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,143007.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69910.76,100,MS-DRG,55928.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,181594.87,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,CDM,,,,,Inpatient,,,,,,132884.97,100,,,Case Rate,100% of CMS IPPS Rate,96314.38,145,MS-DRG,77051.504,Case Rate,145% of CMS IPPS Rate,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,128658.81,100,,,Case Rate,100% of CMS IPPS Rate,147044.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,165419.85,100,,,Case Rate,100% of CMS IPPS Rate,165419.85,100,,,Case Rate,100% of CMS IPPS Rate,165419.85,100,,,Case Rate,100% CMS IPPS Rate,119957.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60441.68,100,MS-DRG,48353.344,Case Rate,100% of CMS IPPS Rate,60441.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,60441.68,100,MS-DRG,48353.344,Case Rate,100% of CMS IPPS Rate,60441.68,100,MS-DRG,48353.344,Case Rate,100% of CMS IPPS Rate,81353.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,86350.82,130,MS-DRG,69080.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68416.42,103,MS-DRG,54733.136,Case Rate,103% of CMS IPPS Rate,68416.42,103,MS-DRG,54733.136,Case Rate,103% of CMS IPPS Rate,123235.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,70363.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,99635.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,135874.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66423.71,100,MS-DRG,53138.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,165419.85,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,CDM,,,,,Inpatient,,,,,,87153.69,100,,,Case Rate,100% of CMS IPPS Rate,63168.57,145,MS-DRG,50534.856,Case Rate,145% of CMS IPPS Rate,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,86090.26,100,,,Case Rate,100% of CMS IPPS Rate,98392.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,110688.41,100,,,Case Rate,100% of CMS IPPS Rate,110688.41,100,,,Case Rate,100% of CMS IPPS Rate,110688.41,100,,,Case Rate,100% CMS IPPS Rate,78675.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39641.26,100,MS-DRG,31713.008,Case Rate,100% of CMS IPPS Rate,39641.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,39641.26,100,MS-DRG,31713.008,Case Rate,100% of CMS IPPS Rate,39641.26,100,MS-DRG,31713.008,Case Rate,100% of CMS IPPS Rate,80900.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,56633.89,130,MS-DRG,45307.112,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44871.47,103,MS-DRG,35897.176,Case Rate,103% of CMS IPPS Rate,44871.47,103,MS-DRG,35897.176,Case Rate,103% of CMS IPPS Rate,80312.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,46148.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,65346.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,89114.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43564.53,100,MS-DRG,34851.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,110688.41,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,CDM,,,,,Inpatient,,,,,,77999.22,100,,,Case Rate,100% of CMS IPPS Rate,56533.44,145,MS-DRG,45226.752,Case Rate,145% of CMS IPPS Rate,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,79310.12,100,,,Case Rate,100% of CMS IPPS Rate,90643.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,101971,100,,,Case Rate,100% of CMS IPPS Rate,101971,100,,,Case Rate,100% of CMS IPPS Rate,101971,100,,,Case Rate,100% CMS IPPS Rate,70411.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35477.43,100,MS-DRG,28381.944,Case Rate,100% of CMS IPPS Rate,35477.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,35477.43,100,MS-DRG,28381.944,Case Rate,100% of CMS IPPS Rate,35477.43,100,MS-DRG,28381.944,Case Rate,100% of CMS IPPS Rate,51264.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,50685.15,130,MS-DRG,40548.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40158.24,103,MS-DRG,32126.592,Case Rate,103% of CMS IPPS Rate,40158.24,103,MS-DRG,32126.592,Case Rate,103% of CMS IPPS Rate,75124.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,41301.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,58482.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,79753.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38988.58,100,MS-DRG,31190.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,101971,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,CDM,,,,,Inpatient,,,,,,105581.75,100,,,Case Rate,100% of CMS IPPS Rate,76525.13,145,MS-DRG,61220.104,Case Rate,145% of CMS IPPS Rate,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,103148.61,100,,,Case Rate,100% of CMS IPPS Rate,117888.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,132620.75,100,,,Case Rate,100% of CMS IPPS Rate,132620.75,100,,,Case Rate,100% of CMS IPPS Rate,132620.75,100,,,Case Rate,100% CMS IPPS Rate,95310.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48023.08,100,MS-DRG,38418.464,Case Rate,100% of CMS IPPS Rate,48023.08,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,48023.08,100,MS-DRG,38418.464,Case Rate,100% of CMS IPPS Rate,48023.08,100,MS-DRG,38418.464,Case Rate,100% of CMS IPPS Rate,61985.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,68608.74,130,MS-DRG,54886.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54359.23,103,MS-DRG,43487.384,Case Rate,103% of CMS IPPS Rate,54359.23,103,MS-DRG,43487.384,Case Rate,103% of CMS IPPS Rate,102823,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,55906.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,79163.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,107956.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52775.95,100,MS-DRG,42220.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,132620.75,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,CDM,,,,,Inpatient,,,,,,71809.06,100,,,Case Rate,100% of CMS IPPS Rate,52046.85,145,MS-DRG,41637.48,Case Rate,145% of CMS IPPS Rate,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,70610.31,100,,,Case Rate,100% of CMS IPPS Rate,80700.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,90785.44,100,,,Case Rate,100% of CMS IPPS Rate,90785.44,100,,,Case Rate,100% of CMS IPPS Rate,90785.44,100,,,Case Rate,100% CMS IPPS Rate,64823.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32661.9,100,MS-DRG,26129.52,Case Rate,100% of CMS IPPS Rate,32661.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,32661.9,100,MS-DRG,26129.52,Case Rate,100% of CMS IPPS Rate,32661.9,100,MS-DRG,26129.52,Case Rate,100% of CMS IPPS Rate,42942.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,46662.69,130,MS-DRG,37330.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36971.21,103,MS-DRG,29576.968,Case Rate,103% of CMS IPPS Rate,36971.21,103,MS-DRG,29576.968,Case Rate,103% of CMS IPPS Rate,68754.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,38023.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,53841.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,73424.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35894.38,100,MS-DRG,28715.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,90785.44,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,CDM,,,,,Inpatient,,,,,,63648.63,100,,,Case Rate,100% of CMS IPPS Rate,46132.23,145,MS-DRG,36905.784,Case Rate,145% of CMS IPPS Rate,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,61223.95,100,,,Case Rate,100% of CMS IPPS Rate,69972.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,78717.16,100,,,Case Rate,100% of CMS IPPS Rate,78717.16,100,,,Case Rate,100% of CMS IPPS Rate,78717.16,100,,,Case Rate,100% CMS IPPS Rate,57456.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28950.21,100,MS-DRG,23160.168,Case Rate,100% of CMS IPPS Rate,28950.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28950.21,100,MS-DRG,23160.168,Case Rate,100% of CMS IPPS Rate,28950.21,100,MS-DRG,23160.168,Case Rate,100% of CMS IPPS Rate,32901.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,41359.93,130,MS-DRG,33087.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32769.79,103,MS-DRG,26215.832,Case Rate,103% of CMS IPPS Rate,32769.79,103,MS-DRG,26215.832,Case Rate,103% of CMS IPPS Rate,59854.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,33702.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,47723,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,65080.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31815.33,100,MS-DRG,25452.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,78717.16,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,CDM,,,,,Inpatient,,,,,,68989.88,100,,,Case Rate,100% of CMS IPPS Rate,50003.53,145,MS-DRG,40002.824,Case Rate,145% of CMS IPPS Rate,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,66432.37,100,,,Case Rate,100% of CMS IPPS Rate,75925.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,85413.76,100,,,Case Rate,100% of CMS IPPS Rate,85413.76,100,,,Case Rate,100% of CMS IPPS Rate,85413.76,100,,,Case Rate,100% CMS IPPS Rate,62278.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31379.62,100,MS-DRG,25103.696,Case Rate,100% of CMS IPPS Rate,31379.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,31379.62,100,MS-DRG,25103.696,Case Rate,100% of CMS IPPS Rate,31379.62,100,MS-DRG,25103.696,Case Rate,100% of CMS IPPS Rate,52060.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,44830.75,130,MS-DRG,35864.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35519.75,103,MS-DRG,28415.8,Case Rate,103% of CMS IPPS Rate,35519.75,103,MS-DRG,28415.8,Case Rate,103% of CMS IPPS Rate,62343,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,36530.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,51727.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,70541.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34485.19,100,MS-DRG,27588.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,85413.76,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,CDM,,,,,Inpatient,,,,,,43535.08,100,,,Case Rate,100% of CMS IPPS Rate,31554.02,145,MS-DRG,25243.216,Case Rate,145% of CMS IPPS Rate,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,41410.09,100,,,Case Rate,100% of CMS IPPS Rate,47327.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53241.98,100,,,Case Rate,100% of CMS IPPS Rate,53241.98,100,,,Case Rate,100% of CMS IPPS Rate,53241.98,100,,,Case Rate,100% CMS IPPS Rate,39299.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19801.76,100,MS-DRG,15841.408,Case Rate,100% of CMS IPPS Rate,19801.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19801.76,100,MS-DRG,15841.408,Case Rate,100% of CMS IPPS Rate,19801.76,100,MS-DRG,15841.408,Case Rate,100% of CMS IPPS Rate,34595.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,28289.81,130,MS-DRG,22631.848,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22414.23,103,MS-DRG,17931.384,Case Rate,103% of CMS IPPS Rate,22414.23,103,MS-DRG,17931.384,Case Rate,103% of CMS IPPS Rate,41756.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,23052.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32642.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,44514.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21761.39,100,MS-DRG,17409.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,53241.98,
CORONARY BYPASS WITH PTCA WITH MCC,231,CDM,,,,,Inpatient,,,,,,111113.32,100,,,Case Rate,100% of CMS IPPS Rate,80534.38,145,MS-DRG,64427.504,Case Rate,145% of CMS IPPS Rate,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,112965.56,100,,,Case Rate,100% of CMS IPPS Rate,129108.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,145242.65,100,,,Case Rate,100% of CMS IPPS Rate,145242.65,100,,,Case Rate,100% of CMS IPPS Rate,145242.65,100,,,Case Rate,100% CMS IPPS Rate,100303.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,50539.06,100,MS-DRG,40431.248,Case Rate,100% of CMS IPPS Rate,50539.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,50539.06,100,MS-DRG,40431.248,Case Rate,100% of CMS IPPS Rate,50539.06,100,MS-DRG,40431.248,Case Rate,100% of CMS IPPS Rate,73028.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,72203.24,130,MS-DRG,57762.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57207.18,103,MS-DRG,45765.744,Case Rate,103% of CMS IPPS Rate,57207.18,103,MS-DRG,45765.744,Case Rate,103% of CMS IPPS Rate,106173.98,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,58835.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,83311.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,113612.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55540.95,100,MS-DRG,44432.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,145242.65,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,CDM,,,,,Inpatient,,,,,,81448.23,100,,,Case Rate,100% of CMS IPPS Rate,59033.27,145,MS-DRG,47226.616,Case Rate,145% of CMS IPPS Rate,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,81435.08,100,,,Case Rate,100% of CMS IPPS Rate,93072.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,104703.12,100,,,Case Rate,100% of CMS IPPS Rate,104703.12,100,,,Case Rate,100% of CMS IPPS Rate,104703.12,100,,,Case Rate,100% CMS IPPS Rate,73524.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37046.18,100,MS-DRG,29636.944,Case Rate,100% of CMS IPPS Rate,37046.18,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37046.18,100,MS-DRG,29636.944,Case Rate,100% of CMS IPPS Rate,37046.18,100,MS-DRG,29636.944,Case Rate,100% of CMS IPPS Rate,61991.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,52926.38,130,MS-DRG,42341.104,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41933.98,103,MS-DRG,33547.184,Case Rate,103% of CMS IPPS Rate,41933.98,103,MS-DRG,33547.184,Case Rate,103% of CMS IPPS Rate,74101.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,43127.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,61068.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,83280.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40712.6,100,MS-DRG,32570.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,104703.12,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,CDM,,,,,Inpatient,,,,,,106792.12,100,,,Case Rate,100% of CMS IPPS Rate,77402.41,145,MS-DRG,61921.928,Case Rate,145% of CMS IPPS Rate,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,104200.43,100,,,Case Rate,100% of CMS IPPS Rate,119090.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,133973.1,100,,,Case Rate,100% of CMS IPPS Rate,133973.1,100,,,Case Rate,100% of CMS IPPS Rate,133973.1,100,,,Case Rate,100% CMS IPPS Rate,96403.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48573.61,100,MS-DRG,38858.888,Case Rate,100% of CMS IPPS Rate,48573.61,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,48573.61,100,MS-DRG,38858.888,Case Rate,100% of CMS IPPS Rate,48573.61,100,MS-DRG,38858.888,Case Rate,100% of CMS IPPS Rate,61054.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,69395.26,130,MS-DRG,55516.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54982.4,103,MS-DRG,43985.92,Case Rate,103% of CMS IPPS Rate,54982.4,103,MS-DRG,43985.92,Case Rate,103% of CMS IPPS Rate,97972.99,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,56547.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,80071.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,109194.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53380.97,100,MS-DRG,42704.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,133973.1,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,CDM,,,,,Inpatient,,,,,,71169.65,100,,,Case Rate,100% of CMS IPPS Rate,51583.42,145,MS-DRG,41266.736,Case Rate,145% of CMS IPPS Rate,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,70923.59,100,,,Case Rate,100% of CMS IPPS Rate,81058.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,91188.23,100,,,Case Rate,100% of CMS IPPS Rate,91188.23,100,,,Case Rate,100% of CMS IPPS Rate,91188.23,100,,,Case Rate,100% CMS IPPS Rate,64246.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32371.07,100,MS-DRG,25896.856,Case Rate,100% of CMS IPPS Rate,32371.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,32371.07,100,MS-DRG,25896.856,Case Rate,100% of CMS IPPS Rate,32371.07,100,MS-DRG,25896.856,Case Rate,100% of CMS IPPS Rate,49456.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,46247.2,130,MS-DRG,36997.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36642.01,103,MS-DRG,29313.608,Case Rate,103% of CMS IPPS Rate,36642.01,103,MS-DRG,29313.608,Case Rate,103% of CMS IPPS Rate,65606.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,37684.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,53362.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,72770.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35574.77,100,MS-DRG,28459.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,91188.23,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,CDM,,,,,Inpatient,,,,,,80517.18,100,,,Case Rate,100% of CMS IPPS Rate,58358.44,145,MS-DRG,46686.752,Case Rate,145% of CMS IPPS Rate,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,78442.27,100,,,Case Rate,100% of CMS IPPS Rate,89651.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,100855.19,100,,,Case Rate,100% of CMS IPPS Rate,100855.19,100,,,Case Rate,100% of CMS IPPS Rate,100855.19,100,,,Case Rate,100% CMS IPPS Rate,72684.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36622.71,100,MS-DRG,29298.168,Case Rate,100% of CMS IPPS Rate,36622.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,36622.71,100,MS-DRG,29298.168,Case Rate,100% of CMS IPPS Rate,36622.71,100,MS-DRG,29298.168,Case Rate,100% of CMS IPPS Rate,50105.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,52321.36,130,MS-DRG,41857.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41454.62,103,MS-DRG,33163.696,Case Rate,103% of CMS IPPS Rate,41454.62,103,MS-DRG,33163.696,Case Rate,103% of CMS IPPS Rate,75773.5,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,42634.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,60370.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,82328.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40247.2,100,MS-DRG,32197.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100855.19,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,CDM,,,,,Inpatient,,,,,,55332.11,100,,,Case Rate,100% of CMS IPPS Rate,40104.45,145,MS-DRG,32083.56,Case Rate,145% of CMS IPPS Rate,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,54818.41,100,,,Case Rate,100% of CMS IPPS Rate,62651.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,70481.39,100,,,Case Rate,100% of CMS IPPS Rate,70481.39,100,,,Case Rate,100% of CMS IPPS Rate,70481.39,100,,,Case Rate,100% CMS IPPS Rate,49949.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25167.52,100,MS-DRG,20134.016,Case Rate,100% of CMS IPPS Rate,25167.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25167.52,100,MS-DRG,20134.016,Case Rate,100% of CMS IPPS Rate,25167.52,100,MS-DRG,20134.016,Case Rate,100% of CMS IPPS Rate,38433.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,35955.71,130,MS-DRG,28764.568,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28487.99,103,MS-DRG,22790.392,Case Rate,103% of CMS IPPS Rate,28487.99,103,MS-DRG,22790.392,Case Rate,103% of CMS IPPS Rate,51591.76,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,29298.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,41487.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,56576.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27658.24,100,MS-DRG,22126.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,70481.39,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,CDM,,,,,Inpatient,,,,,,65814.71,100,,,Case Rate,100% of CMS IPPS Rate,47702.17,145,MS-DRG,38161.736,Case Rate,145% of CMS IPPS Rate,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,67146.91,100,,,Case Rate,100% of CMS IPPS Rate,76742.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,86332.47,100,,,Case Rate,100% of CMS IPPS Rate,86332.47,100,,,Case Rate,100% of CMS IPPS Rate,86332.47,100,,,Case Rate,100% CMS IPPS Rate,59412.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29935.43,100,MS-DRG,23948.344,Case Rate,100% of CMS IPPS Rate,29935.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,29935.43,100,MS-DRG,23948.344,Case Rate,100% of CMS IPPS Rate,29935.43,100,MS-DRG,23948.344,Case Rate,100% of CMS IPPS Rate,35028.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,42767.47,130,MS-DRG,34213.976,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33884.99,103,MS-DRG,27107.992,Case Rate,103% of CMS IPPS Rate,33884.99,103,MS-DRG,27107.992,Case Rate,103% of CMS IPPS Rate,58823.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,34849.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,49347.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,67295.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32898.05,100,MS-DRG,26318.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,86332.47,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,CDM,,,,,Inpatient,,,,,,38463.57,100,,,Case Rate,100% of CMS IPPS Rate,27878.19,145,MS-DRG,22302.552,Case Rate,145% of CMS IPPS Rate,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,38822.54,100,,,Case Rate,100% of CMS IPPS Rate,44370.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49915.11,100,,,Case Rate,100% of CMS IPPS Rate,49915.11,100,,,Case Rate,100% of CMS IPPS Rate,49915.11,100,,,Case Rate,100% CMS IPPS Rate,34721.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17495.02,100,MS-DRG,13996.016,Case Rate,100% of CMS IPPS Rate,17495.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17495.02,100,MS-DRG,13996.016,Case Rate,100% of CMS IPPS Rate,17495.02,100,MS-DRG,13996.016,Case Rate,100% of CMS IPPS Rate,29553.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,24994.24,130,MS-DRG,19995.392,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19803.13,103,MS-DRG,15842.504,Case Rate,103% of CMS IPPS Rate,19803.13,103,MS-DRG,15842.504,Case Rate,103% of CMS IPPS Rate,34334.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,20366.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28839.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,39328.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19226.34,100,MS-DRG,15381.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49915.11,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,CDM,,,,,Inpatient,,,,,,19029.14,100,,,Case Rate,100% of CMS IPPS Rate,13833.9,145,MS-DRG,11067.12,Case Rate,145% of CMS IPPS Rate,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,20128.48,100,,,Case Rate,100% of CMS IPPS Rate,23004.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25879.69,100,,,Case Rate,100% of CMS IPPS Rate,25879.69,100,,,Case Rate,100% of CMS IPPS Rate,25879.69,100,,,Case Rate,100% CMS IPPS Rate,17177.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8681.62,100,MS-DRG,6945.296,Case Rate,100% of CMS IPPS Rate,8681.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8681.62,100,MS-DRG,6945.296,Case Rate,100% of CMS IPPS Rate,8681.62,100,MS-DRG,6945.296,Case Rate,100% of CMS IPPS Rate,12544.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,12402.81,130,MS-DRG,9922.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9826.84,103,MS-DRG,7861.472,Case Rate,103% of CMS IPPS Rate,9826.84,103,MS-DRG,7861.472,Case Rate,103% of CMS IPPS Rate,19593.59,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,10076.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14310.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,19457.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9540.62,100,MS-DRG,7632.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25879.69,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,CDM,,,,,Inpatient,,,,,,47307.23,100,,,Case Rate,100% of CMS IPPS Rate,34288.03,145,MS-DRG,27430.424,Case Rate,145% of CMS IPPS Rate,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,45218.75,100,,,Case Rate,100% of CMS IPPS Rate,51680.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58138.88,100,,,Case Rate,100% of CMS IPPS Rate,58138.88,100,,,Case Rate,100% of CMS IPPS Rate,58138.88,100,,,Case Rate,100% CMS IPPS Rate,42705.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21517.48,100,MS-DRG,17213.984,Case Rate,100% of CMS IPPS Rate,21517.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21517.48,100,MS-DRG,17213.984,Case Rate,100% of CMS IPPS Rate,21517.48,100,MS-DRG,17213.984,Case Rate,100% of CMS IPPS Rate,29397.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,30741,130,MS-DRG,24592.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24356.33,103,MS-DRG,19485.064,Case Rate,103% of CMS IPPS Rate,24356.33,103,MS-DRG,19485.064,Case Rate,103% of CMS IPPS Rate,43939.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,25049.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35470.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,48371.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23646.92,100,MS-DRG,18917.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58138.88,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,CDM,,,,,Inpatient,,,,,,31184.9,100,,,Case Rate,100% of CMS IPPS Rate,22602.66,145,MS-DRG,18082.128,Case Rate,145% of CMS IPPS Rate,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,30032.08,100,,,Case Rate,100% of CMS IPPS Rate,34323.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38612.99,100,,,Case Rate,100% of CMS IPPS Rate,38612.99,100,,,Case Rate,100% of CMS IPPS Rate,38612.99,100,,,Case Rate,100% CMS IPPS Rate,28151.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14184.39,100,MS-DRG,11347.512,Case Rate,100% of CMS IPPS Rate,14184.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14184.39,100,MS-DRG,11347.512,Case Rate,100% of CMS IPPS Rate,14184.39,100,MS-DRG,11347.512,Case Rate,100% of CMS IPPS Rate,20444.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,20264.45,130,MS-DRG,16211.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16055.68,103,MS-DRG,12844.544,Case Rate,103% of CMS IPPS Rate,16055.68,103,MS-DRG,12844.544,Case Rate,103% of CMS IPPS Rate,29651.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,16512.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23382.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,31886.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15588.04,100,MS-DRG,12470.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38612.99,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,CDM,,,,,Inpatient,,,,,,25049.51,100,,,Case Rate,100% of CMS IPPS Rate,18155.77,145,MS-DRG,14524.616,Case Rate,145% of CMS IPPS Rate,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,24058.46,100,,,Case Rate,100% of CMS IPPS Rate,27496.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30932.56,100,,,Case Rate,100% of CMS IPPS Rate,30932.56,100,,,Case Rate,100% of CMS IPPS Rate,30932.56,100,,,Case Rate,100% CMS IPPS Rate,22612.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11393.78,100,MS-DRG,9115.024,Case Rate,100% of CMS IPPS Rate,11393.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11393.78,100,MS-DRG,9115.024,Case Rate,100% of CMS IPPS Rate,11393.78,100,MS-DRG,9115.024,Case Rate,100% of CMS IPPS Rate,17774.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,16277.59,130,MS-DRG,13022.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12896.86,103,MS-DRG,10317.488,Case Rate,103% of CMS IPPS Rate,12896.86,103,MS-DRG,10317.488,Case Rate,103% of CMS IPPS Rate,24048.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,13263.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18781.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,25613,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12521.22,100,MS-DRG,10016.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30932.56,
AICD GENERATOR PROCEDURES,245,CDM,,,,,Inpatient,,,,,,62043.93,100,,,Case Rate,100% of CMS IPPS Rate,44969.14,145,MS-DRG,35975.312,Case Rate,145% of CMS IPPS Rate,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,65145.93,100,,,Case Rate,100% of CMS IPPS Rate,74455.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,83759.75,100,,,Case Rate,100% of CMS IPPS Rate,83759.75,100,,,Case Rate,100% of CMS IPPS Rate,83759.75,100,,,Case Rate,100% CMS IPPS Rate,56008.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28220.32,100,MS-DRG,22576.256,Case Rate,100% of CMS IPPS Rate,28220.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28220.32,100,MS-DRG,22576.256,Case Rate,100% of CMS IPPS Rate,28220.32,100,MS-DRG,22576.256,Case Rate,100% of CMS IPPS Rate,40778.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,40317.16,130,MS-DRG,32253.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31943.6,103,MS-DRG,25554.88,Case Rate,103% of CMS IPPS Rate,31943.6,103,MS-DRG,25554.88,Case Rate,103% of CMS IPPS Rate,61681.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,32852.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,46519.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,63439.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31013.2,100,MS-DRG,24810.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,83759.75,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,CDM,,,,,Inpatient,,,,,,32187.15,100,,,Case Rate,100% of CMS IPPS Rate,23329.09,145,MS-DRG,18663.272,Case Rate,145% of CMS IPPS Rate,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,30829.27,100,,,Case Rate,100% of CMS IPPS Rate,35234.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39637.96,100,,,Case Rate,100% of CMS IPPS Rate,39637.96,100,,,Case Rate,100% of CMS IPPS Rate,39637.96,100,,,Case Rate,100% CMS IPPS Rate,29055.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14640.27,100,MS-DRG,11712.216,Case Rate,100% of CMS IPPS Rate,14640.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14640.27,100,MS-DRG,11712.216,Case Rate,100% of CMS IPPS Rate,14640.27,100,MS-DRG,11712.216,Case Rate,100% of CMS IPPS Rate,22010.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,20915.74,130,MS-DRG,16732.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16571.7,103,MS-DRG,13257.36,Case Rate,103% of CMS IPPS Rate,16571.7,103,MS-DRG,13257.36,Case Rate,103% of CMS IPPS Rate,30609.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,17043.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24133.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,32911.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16089.03,100,MS-DRG,12871.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39637.96,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,CDM,,,,,Inpatient,,,,,,21727.83,100,,,Case Rate,100% of CMS IPPS Rate,15748.23,145,MS-DRG,12598.584,Case Rate,145% of CMS IPPS Rate,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,20831.02,100,,,Case Rate,100% of CMS IPPS Rate,23807.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26782.96,100,,,Case Rate,100% of CMS IPPS Rate,26782.96,100,,,Case Rate,100% of CMS IPPS Rate,26782.96,100,,,Case Rate,100% CMS IPPS Rate,19614.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9882.95,100,MS-DRG,7906.36,Case Rate,100% of CMS IPPS Rate,9882.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9882.95,100,MS-DRG,7906.36,Case Rate,100% of CMS IPPS Rate,9882.95,100,MS-DRG,7906.36,Case Rate,100% of CMS IPPS Rate,16971.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,14119.11,130,MS-DRG,11295.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11186.68,103,MS-DRG,8949.344,Case Rate,103% of CMS IPPS Rate,11186.68,103,MS-DRG,8949.344,Case Rate,103% of CMS IPPS Rate,20560.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,11505.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16291.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,22216.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10860.85,100,MS-DRG,8688.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26782.96,
OTHER VASCULAR PROCEDURES WITH MCC,252,CDM,,,,,Inpatient,,,,,,45920.23,100,,,Case Rate,100% of CMS IPPS Rate,33282.75,145,MS-DRG,26626.2,Case Rate,145% of CMS IPPS Rate,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,45730.66,100,,,Case Rate,100% of CMS IPPS Rate,52265.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58797.06,100,,,Case Rate,100% of CMS IPPS Rate,58797.06,100,,,Case Rate,100% of CMS IPPS Rate,58797.06,100,,,Case Rate,100% CMS IPPS Rate,41452.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20886.61,100,MS-DRG,16709.288,Case Rate,100% of CMS IPPS Rate,20886.61,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20886.61,100,MS-DRG,16709.288,Case Rate,100% of CMS IPPS Rate,20886.61,100,MS-DRG,16709.288,Case Rate,100% of CMS IPPS Rate,38623.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,29839.71,130,MS-DRG,23871.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23642.23,103,MS-DRG,18913.784,Case Rate,103% of CMS IPPS Rate,23642.23,103,MS-DRG,18913.784,Case Rate,103% of CMS IPPS Rate,42292.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,24315.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34430.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,46953.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22953.62,100,MS-DRG,18362.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58797.06,
OTHER VASCULAR PROCEDURES WITH CC,253,CDM,,,,,Inpatient,,,,,,34929.66,100,,,Case Rate,100% of CMS IPPS Rate,25316.86,145,MS-DRG,20253.488,Case Rate,145% of CMS IPPS Rate,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,34034.04,100,,,Case Rate,100% of CMS IPPS Rate,38897.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43758.42,100,,,Case Rate,100% of CMS IPPS Rate,43758.42,100,,,Case Rate,100% of CMS IPPS Rate,43758.42,100,,,Case Rate,100% CMS IPPS Rate,31531.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15887.67,100,MS-DRG,12710.136,Case Rate,100% of CMS IPPS Rate,15887.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15887.67,100,MS-DRG,12710.136,Case Rate,100% of CMS IPPS Rate,15887.67,100,MS-DRG,12710.136,Case Rate,100% of CMS IPPS Rate,23772.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,22697.87,130,MS-DRG,18158.296,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17983.7,103,MS-DRG,14386.96,Case Rate,103% of CMS IPPS Rate,17983.7,103,MS-DRG,14386.96,Case Rate,103% of CMS IPPS Rate,33826.1,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,18495.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26189.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,35715.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17459.9,100,MS-DRG,13967.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43758.42,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,CDM,,,,,Inpatient,,,,,,23756.99,100,,,Case Rate,100% of CMS IPPS Rate,17218.95,145,MS-DRG,13775.16,Case Rate,145% of CMS IPPS Rate,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,23321.25,100,,,Case Rate,100% of CMS IPPS Rate,26653.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29984.72,100,,,Case Rate,100% of CMS IPPS Rate,29984.72,100,,,Case Rate,100% of CMS IPPS Rate,29984.72,100,,,Case Rate,100% CMS IPPS Rate,21445.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10805.89,100,MS-DRG,8644.712,Case Rate,100% of CMS IPPS Rate,10805.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10805.89,100,MS-DRG,8644.712,Case Rate,100% of CMS IPPS Rate,10805.89,100,MS-DRG,8644.712,Case Rate,100% of CMS IPPS Rate,16840.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,15437.68,130,MS-DRG,12350.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12231.39,103,MS-DRG,9785.112,Case Rate,103% of CMS IPPS Rate,12231.39,103,MS-DRG,9785.112,Case Rate,103% of CMS IPPS Rate,23130.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,12579.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17812.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,24291.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11875.14,100,MS-DRG,9500.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29984.72,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,CDM,,,,,Inpatient,,,,,,37617.4,100,,,Case Rate,100% of CMS IPPS Rate,27264.92,145,MS-DRG,21811.936,Case Rate,145% of CMS IPPS Rate,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,34880.56,100,,,Case Rate,100% of CMS IPPS Rate,39864.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,44846.81,100,,,Case Rate,100% of CMS IPPS Rate,44846.81,100,,,Case Rate,100% of CMS IPPS Rate,44846.81,100,,,Case Rate,100% CMS IPPS Rate,33957.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17110.16,100,MS-DRG,13688.128,Case Rate,100% of CMS IPPS Rate,17110.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17110.16,100,MS-DRG,13688.128,Case Rate,100% of CMS IPPS Rate,17110.16,100,MS-DRG,13688.128,Case Rate,100% of CMS IPPS Rate,24723.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,24444.41,130,MS-DRG,19555.528,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19367.49,103,MS-DRG,15493.992,Case Rate,103% of CMS IPPS Rate,19367.49,103,MS-DRG,15493.992,Case Rate,103% of CMS IPPS Rate,32454.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,19918.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28205.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,38463.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18803.39,100,MS-DRG,15042.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,44846.81,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,CDM,,,,,Inpatient,,,,,,22450.77,100,,,Case Rate,100% of CMS IPPS Rate,16272.2,145,MS-DRG,13017.76,Case Rate,145% of CMS IPPS Rate,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,22578.71,100,,,Case Rate,100% of CMS IPPS Rate,25805.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29030.02,100,,,Case Rate,100% of CMS IPPS Rate,29030.02,100,,,Case Rate,100% of CMS IPPS Rate,29030.02,100,,,Case Rate,100% CMS IPPS Rate,20266.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10211.76,100,MS-DRG,8169.408,Case Rate,100% of CMS IPPS Rate,10211.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10211.76,100,MS-DRG,8169.408,Case Rate,100% of CMS IPPS Rate,10211.76,100,MS-DRG,8169.408,Case Rate,100% of CMS IPPS Rate,14755.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,14588.87,130,MS-DRG,11671.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11558.88,103,MS-DRG,9247.104,Case Rate,103% of CMS IPPS Rate,11558.88,103,MS-DRG,9247.104,Case Rate,103% of CMS IPPS Rate,20647.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,11887.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16833.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,22955.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11222.21,100,MS-DRG,8977.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29030.02,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,CDM,,,,,Inpatient,,,,,,13568.77,100,,,Case Rate,100% of CMS IPPS Rate,9834.58,145,MS-DRG,7867.664,Case Rate,145% of CMS IPPS Rate,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,10566.15,100,,,Case Rate,100% of CMS IPPS Rate,12076.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13585.16,100,,,Case Rate,100% of CMS IPPS Rate,13585.16,100,,,Case Rate,100% of CMS IPPS Rate,13585.16,100,,,Case Rate,100% CMS IPPS Rate,12248.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6171.87,100,MS-DRG,4937.496,Case Rate,100% of CMS IPPS Rate,6171.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6171.87,100,MS-DRG,4937.496,Case Rate,100% of CMS IPPS Rate,6171.87,100,MS-DRG,4937.496,Case Rate,100% of CMS IPPS Rate,8917.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,8817.21,130,MS-DRG,7053.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6985.94,103,MS-DRG,5588.752,Case Rate,103% of CMS IPPS Rate,6985.94,103,MS-DRG,5588.752,Case Rate,103% of CMS IPPS Rate,13266.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,7184.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10173.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,13874,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6782.47,100,MS-DRG,5425.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,13874,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,CDM,,,,,Inpatient,,,,,,37086.15,100,,,Case Rate,100% of CMS IPPS Rate,26879.85,145,MS-DRG,21503.88,Case Rate,145% of CMS IPPS Rate,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,37400.12,100,,,Case Rate,100% of CMS IPPS Rate,42744.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48086.27,100,,,Case Rate,100% of CMS IPPS Rate,48086.27,100,,,Case Rate,100% of CMS IPPS Rate,48086.27,100,,,Case Rate,100% CMS IPPS Rate,33478.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16868.52,100,MS-DRG,13494.816,Case Rate,100% of CMS IPPS Rate,16868.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16868.52,100,MS-DRG,13494.816,Case Rate,100% of CMS IPPS Rate,16868.52,100,MS-DRG,13494.816,Case Rate,100% of CMS IPPS Rate,24374.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,24099.18,130,MS-DRG,19279.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19093.96,103,MS-DRG,15275.168,Case Rate,103% of CMS IPPS Rate,19093.96,103,MS-DRG,15275.168,Case Rate,103% of CMS IPPS Rate,36068.95,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,19637.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27806.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,37920.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18537.83,100,MS-DRG,14830.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48086.27,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,CDM,,,,,Inpatient,,,,,,25557.49,100,,,Case Rate,100% of CMS IPPS Rate,18523.94,145,MS-DRG,14819.152,Case Rate,145% of CMS IPPS Rate,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,23431.9,100,,,Case Rate,100% of CMS IPPS Rate,26780.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30126.98,100,,,Case Rate,100% of CMS IPPS Rate,30126.98,100,,,Case Rate,100% of CMS IPPS Rate,30126.98,100,,,Case Rate,100% CMS IPPS Rate,23071.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11624.82,100,MS-DRG,9299.856,Case Rate,100% of CMS IPPS Rate,11624.82,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11624.82,100,MS-DRG,9299.856,Case Rate,100% of CMS IPPS Rate,11624.82,100,MS-DRG,9299.856,Case Rate,100% of CMS IPPS Rate,16797.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,16607.67,130,MS-DRG,13286.136,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13158.38,103,MS-DRG,10526.704,Case Rate,103% of CMS IPPS Rate,13158.38,103,MS-DRG,10526.704,Case Rate,103% of CMS IPPS Rate,25225.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,13532.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19162.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,26132.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12775.13,100,MS-DRG,10220.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30126.98,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,CDM,,,,,Inpatient,,,,,,45391.72,100,,,Case Rate,100% of CMS IPPS Rate,32899.7,145,MS-DRG,26319.76,Case Rate,145% of CMS IPPS Rate,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,45408.05,100,,,Case Rate,100% of CMS IPPS Rate,51896.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58382.27,100,,,Case Rate,100% of CMS IPPS Rate,58382.27,100,,,Case Rate,100% of CMS IPPS Rate,58382.27,100,,,Case Rate,100% CMS IPPS Rate,40975.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20646.23,100,MS-DRG,16516.984,Case Rate,100% of CMS IPPS Rate,20646.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20646.23,100,MS-DRG,16516.984,Case Rate,100% of CMS IPPS Rate,20646.23,100,MS-DRG,16516.984,Case Rate,100% of CMS IPPS Rate,25908.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,29496.29,130,MS-DRG,23597.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23370.13,103,MS-DRG,18696.104,Case Rate,103% of CMS IPPS Rate,23370.13,103,MS-DRG,18696.104,Case Rate,103% of CMS IPPS Rate,44257.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,24035.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34034.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,46412.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22689.45,100,MS-DRG,18151.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58382.27,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,CDM,,,,,Inpatient,,,,,,25765.61,100,,,Case Rate,100% of CMS IPPS Rate,18674.78,145,MS-DRG,14939.824,Case Rate,145% of CMS IPPS Rate,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,25296.91,100,,,Case Rate,100% of CMS IPPS Rate,28911.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32524.86,100,,,Case Rate,100% of CMS IPPS Rate,32524.86,100,,,Case Rate,100% of CMS IPPS Rate,32524.86,100,,,Case Rate,100% CMS IPPS Rate,23259.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11719.48,100,MS-DRG,9375.584,Case Rate,100% of CMS IPPS Rate,11719.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11719.48,100,MS-DRG,9375.584,Case Rate,100% of CMS IPPS Rate,11719.48,100,MS-DRG,9375.584,Case Rate,100% of CMS IPPS Rate,17257.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,16742.91,130,MS-DRG,13394.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13265.53,103,MS-DRG,10612.424,Case Rate,103% of CMS IPPS Rate,13265.53,103,MS-DRG,10612.424,Case Rate,103% of CMS IPPS Rate,24171.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,13643.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19318.74,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,26345.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12879.16,100,MS-DRG,10303.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32524.86,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,CDM,,,,,Inpatient,,,,,,22527.45,100,,,Case Rate,100% of CMS IPPS Rate,16327.78,145,MS-DRG,13062.224,Case Rate,145% of CMS IPPS Rate,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,20233.79,100,,,Case Rate,100% of CMS IPPS Rate,23125.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26015.09,100,,,Case Rate,100% of CMS IPPS Rate,26015.09,100,,,Case Rate,100% of CMS IPPS Rate,26015.09,100,,,Case Rate,100% CMS IPPS Rate,20335.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10246.65,100,MS-DRG,8197.32,Case Rate,100% of CMS IPPS Rate,10246.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10246.65,100,MS-DRG,8197.32,Case Rate,100% of CMS IPPS Rate,10246.65,100,MS-DRG,8197.32,Case Rate,100% of CMS IPPS Rate,18663.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,14638.7,130,MS-DRG,11710.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11598.36,103,MS-DRG,9278.688,Case Rate,103% of CMS IPPS Rate,11598.36,103,MS-DRG,9278.688,Case Rate,103% of CMS IPPS Rate,21211.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,11928.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16890.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,23034.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11260.54,100,MS-DRG,9008.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26015.09,
VEIN LIGATION AND STRIPPING,263,CDM,,,,,Inpatient,,,,,,38682.64,100,,,Case Rate,100% of CMS IPPS Rate,28036.98,145,MS-DRG,22429.584,Case Rate,145% of CMS IPPS Rate,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,35755.08,100,,,Case Rate,100% of CMS IPPS Rate,40864.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45971.19,100,,,Case Rate,100% of CMS IPPS Rate,45971.19,100,,,Case Rate,100% of CMS IPPS Rate,45971.19,100,,,Case Rate,100% CMS IPPS Rate,34919.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17594.67,100,MS-DRG,14075.736,Case Rate,100% of CMS IPPS Rate,17594.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17594.67,100,MS-DRG,14075.736,Case Rate,100% of CMS IPPS Rate,17594.67,100,MS-DRG,14075.736,Case Rate,100% of CMS IPPS Rate,25424.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,25136.61,130,MS-DRG,20109.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19915.93,103,MS-DRG,15932.744,Case Rate,103% of CMS IPPS Rate,19915.93,103,MS-DRG,15932.744,Case Rate,103% of CMS IPPS Rate,35242.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,20482.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29003.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,39552.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19335.85,100,MS-DRG,15468.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45971.19,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,CDM,,,,,Inpatient,,,,,,44718.07,100,,,Case Rate,100% of CMS IPPS Rate,32411.44,145,MS-DRG,25929.152,Case Rate,145% of CMS IPPS Rate,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,46593.18,100,,,Case Rate,100% of CMS IPPS Rate,53251.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,59906.01,100,,,Case Rate,100% of CMS IPPS Rate,59906.01,100,,,Case Rate,100% of CMS IPPS Rate,59906.01,100,,,Case Rate,100% CMS IPPS Rate,40367.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20339.83,100,MS-DRG,16271.864,Case Rate,100% of CMS IPPS Rate,20339.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20339.83,100,MS-DRG,16271.864,Case Rate,100% of CMS IPPS Rate,20339.83,100,MS-DRG,16271.864,Case Rate,100% of CMS IPPS Rate,32543.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,29058.54,130,MS-DRG,23246.832,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23023.3,103,MS-DRG,18418.64,Case Rate,103% of CMS IPPS Rate,23023.3,103,MS-DRG,18418.64,Case Rate,103% of CMS IPPS Rate,41867.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,23678.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33529.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,45724,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22352.72,100,MS-DRG,17882.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,59906.01,
AICD LEAD PROCEDURES,265,CDM,,,,,Inpatient,,,,,,48388.9,100,,,Case Rate,100% of CMS IPPS Rate,35072.02,145,MS-DRG,28057.616,Case Rate,145% of CMS IPPS Rate,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,47554.34,100,,,Case Rate,100% of CMS IPPS Rate,54349.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,61141.81,100,,,Case Rate,100% of CMS IPPS Rate,61141.81,100,,,Case Rate,100% of CMS IPPS Rate,61141.81,100,,,Case Rate,100% CMS IPPS Rate,43681.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22009.46,100,MS-DRG,17607.568,Case Rate,100% of CMS IPPS Rate,22009.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22009.46,100,MS-DRG,17607.568,Case Rate,100% of CMS IPPS Rate,22009.46,100,MS-DRG,17607.568,Case Rate,100% of CMS IPPS Rate,31803.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,31443.88,130,MS-DRG,25155.104,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24913.23,103,MS-DRG,19930.584,Case Rate,103% of CMS IPPS Rate,24913.23,103,MS-DRG,19930.584,Case Rate,103% of CMS IPPS Rate,42783.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,25622.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,36281.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,49477.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24187.6,100,MS-DRG,19350.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,61141.81,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,CDM,,,,,Inpatient,,,,,,85521.6,100,,,Case Rate,100% of CMS IPPS Rate,61985.64,145,MS-DRG,49588.512,Case Rate,145% of CMS IPPS Rate,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,79863.35,100,,,Case Rate,100% of CMS IPPS Rate,91275.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,102682.31,100,,,Case Rate,100% of CMS IPPS Rate,102682.31,100,,,Case Rate,100% of CMS IPPS Rate,102682.31,100,,,Case Rate,100% CMS IPPS Rate,77201.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38898.92,100,MS-DRG,31119.136,Case Rate,100% of CMS IPPS Rate,38898.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38898.92,100,MS-DRG,31119.136,Case Rate,100% of CMS IPPS Rate,38898.92,100,MS-DRG,31119.136,Case Rate,100% of CMS IPPS Rate,41961.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,55573.34,130,MS-DRG,44458.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44031.18,103,MS-DRG,35224.944,Case Rate,103% of CMS IPPS Rate,44031.18,103,MS-DRG,35224.944,Case Rate,103% of CMS IPPS Rate,83498.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,45284.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,64123.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,87445.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42748.72,100,MS-DRG,34198.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,102682.31,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,CDM,,,,,Inpatient,,,,,,66819.7,100,,,Case Rate,100% of CMS IPPS Rate,48430.58,145,MS-DRG,38744.464,Case Rate,145% of CMS IPPS Rate,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,62718.36,100,,,Case Rate,100% of CMS IPPS Rate,71680.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,80638.56,100,,,Case Rate,100% of CMS IPPS Rate,80638.56,100,,,Case Rate,100% of CMS IPPS Rate,80638.56,100,,,Case Rate,100% CMS IPPS Rate,60319.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30392.54,100,MS-DRG,24314.032,Case Rate,100% of CMS IPPS Rate,30392.54,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,30392.54,100,MS-DRG,24314.032,Case Rate,100% of CMS IPPS Rate,30392.54,100,MS-DRG,24314.032,Case Rate,100% of CMS IPPS Rate,3473.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,43420.52,130,MS-DRG,34736.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34402.41,103,MS-DRG,27521.928,Case Rate,103% of CMS IPPS Rate,34402.41,103,MS-DRG,27521.928,Case Rate,103% of CMS IPPS Rate,65281.59,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,35381.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,50100.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,68322.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33400.4,100,MS-DRG,26720.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3473.92,80638.56,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,CDM,,,,,Inpatient,,,,,,93854.55,100,,,Case Rate,100% of CMS IPPS Rate,68025.3,145,MS-DRG,54420.24,Case Rate,145% of CMS IPPS Rate,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,88885.78,100,,,Case Rate,100% of CMS IPPS Rate,101587.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,114282.66,100,,,Case Rate,100% of CMS IPPS Rate,114282.66,100,,,Case Rate,100% of CMS IPPS Rate,114282.66,100,,,Case Rate,100% CMS IPPS Rate,84724.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42689.09,100,MS-DRG,34151.272,Case Rate,100% of CMS IPPS Rate,42689.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,42689.09,100,MS-DRG,34151.272,Case Rate,100% of CMS IPPS Rate,42689.09,100,MS-DRG,34151.272,Case Rate,100% of CMS IPPS Rate,13499.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,60988.2,130,MS-DRG,48790.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48321.42,103,MS-DRG,38657.136,Case Rate,103% of CMS IPPS Rate,48321.42,103,MS-DRG,38657.136,Case Rate,103% of CMS IPPS Rate,87548.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,49696.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,70371,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,95965.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46914,100,MS-DRG,37531.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,114282.66,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,CDM,,,,,Inpatient,,,,,,56939.55,100,,,Case Rate,100% of CMS IPPS Rate,41269.51,145,MS-DRG,33015.608,Case Rate,145% of CMS IPPS Rate,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,55466.29,100,,,Case Rate,100% of CMS IPPS Rate,63392.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,71314.4,100,,,Case Rate,100% of CMS IPPS Rate,71314.4,100,,,Case Rate,100% of CMS IPPS Rate,71314.4,100,,,Case Rate,100% CMS IPPS Rate,51400.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25898.65,100,MS-DRG,20718.92,Case Rate,100% of CMS IPPS Rate,25898.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25898.65,100,MS-DRG,20718.92,Case Rate,100% of CMS IPPS Rate,25898.65,100,MS-DRG,20718.92,Case Rate,100% of CMS IPPS Rate,3671.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,37000.25,130,MS-DRG,29600.2,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29315.58,103,MS-DRG,23452.464,Case Rate,103% of CMS IPPS Rate,29315.58,103,MS-DRG,23452.464,Case Rate,103% of CMS IPPS Rate,54095.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,30149.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,42692.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,58220.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28461.73,100,MS-DRG,22769.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3671.74,71314.4,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,CDM,,,,,Inpatient,,,,,,69239.07,100,,,Case Rate,100% of CMS IPPS Rate,50184.14,145,MS-DRG,40147.312,Case Rate,145% of CMS IPPS Rate,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,68428.02,100,,,Case Rate,100% of CMS IPPS Rate,78206.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,87979.62,100,,,Case Rate,100% of CMS IPPS Rate,87979.62,100,,,Case Rate,100% of CMS IPPS Rate,87979.62,100,,,Case Rate,100% CMS IPPS Rate,62503.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31492.98,100,MS-DRG,25194.384,Case Rate,100% of CMS IPPS Rate,31492.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,31492.98,100,MS-DRG,25194.384,Case Rate,100% of CMS IPPS Rate,31492.98,100,MS-DRG,25194.384,Case Rate,100% of CMS IPPS Rate,3666.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,44992.68,130,MS-DRG,35994.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35648.04,103,MS-DRG,28518.432,Case Rate,103% of CMS IPPS Rate,35648.04,103,MS-DRG,28518.432,Case Rate,103% of CMS IPPS Rate,64674.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,36662.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,51914.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,70796.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34609.75,100,MS-DRG,27687.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3666.87,87979.62,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,CDM,,,,,Inpatient,,,,,,47322.29,100,,,Case Rate,100% of CMS IPPS Rate,34298.95,145,MS-DRG,27439.16,Case Rate,145% of CMS IPPS Rate,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,45917.3,100,,,Case Rate,100% of CMS IPPS Rate,52478.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,59037.02,100,,,Case Rate,100% of CMS IPPS Rate,59037.02,100,,,Case Rate,100% of CMS IPPS Rate,59037.02,100,,,Case Rate,100% CMS IPPS Rate,42718.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21524.34,100,MS-DRG,17219.472,Case Rate,100% of CMS IPPS Rate,21524.34,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21524.34,100,MS-DRG,17219.472,Case Rate,100% of CMS IPPS Rate,21524.34,100,MS-DRG,17219.472,Case Rate,100% of CMS IPPS Rate,4212.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,30750.79,130,MS-DRG,24600.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24364.08,103,MS-DRG,19491.264,Case Rate,103% of CMS IPPS Rate,24364.08,103,MS-DRG,19491.264,Case Rate,103% of CMS IPPS Rate,44070.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,25057.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35481.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,48386.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23654.45,100,MS-DRG,18923.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4212.49,59037.02,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,CDM,,,,,Inpatient,,,,,,33401.63,100,,,Case Rate,100% of CMS IPPS Rate,24209.35,145,MS-DRG,19367.48,Case Rate,145% of CMS IPPS Rate,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,33356.83,100,,,Case Rate,100% of CMS IPPS Rate,38123.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42887.71,100,,,Case Rate,100% of CMS IPPS Rate,42887.71,100,,,Case Rate,100% of CMS IPPS Rate,42887.71,100,,,Case Rate,100% CMS IPPS Rate,30152.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15192.66,100,MS-DRG,12154.128,Case Rate,100% of CMS IPPS Rate,15192.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15192.66,100,MS-DRG,12154.128,Case Rate,100% of CMS IPPS Rate,15192.66,100,MS-DRG,12154.128,Case Rate,100% of CMS IPPS Rate,21047.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,21704.93,130,MS-DRG,17363.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17196.98,103,MS-DRG,13757.584,Case Rate,103% of CMS IPPS Rate,17196.98,103,MS-DRG,13757.584,Case Rate,103% of CMS IPPS Rate,32844.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,17686.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25044.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,34153,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16696.1,100,MS-DRG,13356.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,42887.71,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,CDM,,,,,Inpatient,,,,,,53357.72,100,,,Case Rate,100% of CMS IPPS Rate,38673.41,145,MS-DRG,30938.728,Case Rate,145% of CMS IPPS Rate,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,52128.21,100,,,Case Rate,100% of CMS IPPS Rate,59577.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67022.54,100,,,Case Rate,100% of CMS IPPS Rate,67022.54,100,,,Case Rate,100% of CMS IPPS Rate,67022.54,100,,,Case Rate,100% CMS IPPS Rate,48166.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24269.49,100,MS-DRG,19415.592,Case Rate,100% of CMS IPPS Rate,24269.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24269.49,100,MS-DRG,19415.592,Case Rate,100% of CMS IPPS Rate,24269.49,100,MS-DRG,19415.592,Case Rate,100% of CMS IPPS Rate,37727.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,34672.72,130,MS-DRG,27738.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27471.46,103,MS-DRG,21977.168,Case Rate,103% of CMS IPPS Rate,27471.46,103,MS-DRG,21977.168,Case Rate,103% of CMS IPPS Rate,50764.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,28253.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,40006.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,54558,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26671.32,100,MS-DRG,21337.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,67022.54,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,CDM,,,,,Inpatient,,,,,,44373.03,100,,,Case Rate,100% of CMS IPPS Rate,32161.36,145,MS-DRG,25729.088,Case Rate,145% of CMS IPPS Rate,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,41606.05,100,,,Case Rate,100% of CMS IPPS Rate,47551.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53493.94,100,,,Case Rate,100% of CMS IPPS Rate,53493.94,100,,,Case Rate,100% of CMS IPPS Rate,53493.94,100,,,Case Rate,100% CMS IPPS Rate,40056.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20182.89,100,MS-DRG,16146.312,Case Rate,100% of CMS IPPS Rate,20182.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20182.89,100,MS-DRG,16146.312,Case Rate,100% of CMS IPPS Rate,20182.89,100,MS-DRG,16146.312,Case Rate,100% of CMS IPPS Rate,29020.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,28834.33,130,MS-DRG,23067.464,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22845.66,103,MS-DRG,18276.528,Case Rate,103% of CMS IPPS Rate,22845.66,103,MS-DRG,18276.528,Case Rate,103% of CMS IPPS Rate,42497.68,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,23495.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33270.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,45371.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22180.25,100,MS-DRG,17744.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,53493.94,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,CDM,,,,,Inpatient,,,,,,96334.17,100,,,Case Rate,100% of CMS IPPS Rate,69822.53,145,MS-DRG,55858.024,Case Rate,145% of CMS IPPS Rate,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,94210.18,100,,,Case Rate,100% of CMS IPPS Rate,107672.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,121128.38,100,,,Case Rate,100% of CMS IPPS Rate,121128.38,100,,,Case Rate,100% of CMS IPPS Rate,121128.38,100,,,Case Rate,100% CMS IPPS Rate,86962.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43816.91,100,MS-DRG,35053.528,Case Rate,100% of CMS IPPS Rate,43816.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,43816.91,100,MS-DRG,35053.528,Case Rate,100% of CMS IPPS Rate,43816.91,100,MS-DRG,35053.528,Case Rate,100% of CMS IPPS Rate,42262.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,62599.51,130,MS-DRG,50079.608,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49598.07,103,MS-DRG,39678.456,Case Rate,103% of CMS IPPS Rate,49598.07,103,MS-DRG,39678.456,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,51009.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,72230.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48153.47,100,MS-DRG,38522.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,121128.38,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,CDM,,,,,Inpatient,,,,,,85030.06,100,,,Case Rate,100% of CMS IPPS Rate,61629.36,145,MS-DRG,49303.488,Case Rate,145% of CMS IPPS Rate,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,82577.55,100,,,Case Rate,100% of CMS IPPS Rate,94377.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,106172.02,100,,,Case Rate,100% of CMS IPPS Rate,106172.02,100,,,Case Rate,100% of CMS IPPS Rate,106172.02,100,,,Case Rate,100% CMS IPPS Rate,76758.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38675.35,100,MS-DRG,30940.28,Case Rate,100% of CMS IPPS Rate,38675.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38675.35,100,MS-DRG,30940.28,Case Rate,100% of CMS IPPS Rate,38675.35,100,MS-DRG,30940.28,Case Rate,100% of CMS IPPS Rate,32469.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,55253.91,130,MS-DRG,44203.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43778.1,103,MS-DRG,35022.48,Case Rate,103% of CMS IPPS Rate,43778.1,103,MS-DRG,35022.48,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,45023.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,63754.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42503.01,100,MS-DRG,34002.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,106172.02,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,CDM,,,,,Inpatient,,,,,,65480.62,100,,,Case Rate,100% of CMS IPPS Rate,47460.04,145,MS-DRG,37968.032,Case Rate,145% of CMS IPPS Rate,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,62014.48,100,,,Case Rate,100% of CMS IPPS Rate,70876.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,79733.57,100,,,Case Rate,100% of CMS IPPS Rate,79733.57,100,,,Case Rate,100% of CMS IPPS Rate,79733.57,100,,,Case Rate,100% CMS IPPS Rate,59110.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29783.47,100,MS-DRG,23826.776,Case Rate,100% of CMS IPPS Rate,29783.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,29783.47,100,MS-DRG,23826.776,Case Rate,100% of CMS IPPS Rate,29783.47,100,MS-DRG,23826.776,Case Rate,100% of CMS IPPS Rate,38161.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,42550.38,130,MS-DRG,34040.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33712.99,103,MS-DRG,26970.392,Case Rate,103% of CMS IPPS Rate,33712.99,103,MS-DRG,26970.392,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,34672.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,49096.59,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32731.06,100,MS-DRG,26184.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,79733.57,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,CDM,,,,,Inpatient,,,,,,61071.8,100,,,Case Rate,100% of CMS IPPS Rate,44264.53,145,MS-DRG,35411.624,Case Rate,145% of CMS IPPS Rate,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,66698.99,100,,,Case Rate,100% of CMS IPPS Rate,76230.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,85756.56,100,,,Case Rate,100% of CMS IPPS Rate,85756.56,100,,,Case Rate,100% of CMS IPPS Rate,85756.56,100,,,Case Rate,100% CMS IPPS Rate,55130.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27778.16,100,MS-DRG,22222.528,Case Rate,100% of CMS IPPS Rate,27778.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,27778.16,100,MS-DRG,22222.528,Case Rate,100% of CMS IPPS Rate,27778.16,100,MS-DRG,22222.528,Case Rate,100% of CMS IPPS Rate,30362.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,39685.44,130,MS-DRG,31748.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31443.08,103,MS-DRG,25154.464,Case Rate,103% of CMS IPPS Rate,31443.08,103,MS-DRG,25154.464,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,32337.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,45790.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30527.26,100,MS-DRG,24421.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,85756.56,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,CDM,,,,,Inpatient,,,,,,43822.62,100,,,Case Rate,100% of CMS IPPS Rate,31762.41,145,MS-DRG,25409.928,Case Rate,145% of CMS IPPS Rate,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,42717.86,100,,,Case Rate,100% of CMS IPPS Rate,48822.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54923.42,100,,,Case Rate,100% of CMS IPPS Rate,54923.42,100,,,Case Rate,100% of CMS IPPS Rate,54923.42,100,,,Case Rate,100% CMS IPPS Rate,39559.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19932.53,100,MS-DRG,15946.024,Case Rate,100% of CMS IPPS Rate,19932.53,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19932.53,100,MS-DRG,15946.024,Case Rate,100% of CMS IPPS Rate,19932.53,100,MS-DRG,15946.024,Case Rate,100% of CMS IPPS Rate,21304.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,28476.64,130,MS-DRG,22781.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22562.26,103,MS-DRG,18049.808,Case Rate,103% of CMS IPPS Rate,22562.26,103,MS-DRG,18049.808,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,23204.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32857.67,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21905.11,100,MS-DRG,17524.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54923.42,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,CDM,,,,,Inpatient,,,,,,21722.36,100,,,Case Rate,100% of CMS IPPS Rate,15744.26,145,MS-DRG,12595.408,Case Rate,145% of CMS IPPS Rate,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,21881.5,100,,,Case Rate,100% of CMS IPPS Rate,25008.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28133.6,100,,,Case Rate,100% of CMS IPPS Rate,28133.6,100,,,Case Rate,100% of CMS IPPS Rate,28133.6,100,,,Case Rate,100% CMS IPPS Rate,19609.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9880.46,100,MS-DRG,7904.368,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,7904.368,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,7904.368,Case Rate,100% of CMS IPPS Rate,11903.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,14115.54,130,MS-DRG,11292.432,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11183.85,103,MS-DRG,8947.08,Case Rate,103% of CMS IPPS Rate,11183.85,103,MS-DRG,8947.08,Case Rate,103% of CMS IPPS Rate,20320.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,11502.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16287.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,22211,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28133.6,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,CDM,,,,,Inpatient,,,,,,12500.8,100,,,Case Rate,100% of CMS IPPS Rate,9060.51,145,MS-DRG,7248.408,Case Rate,145% of CMS IPPS Rate,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,12288.52,100,,,Case Rate,100% of CMS IPPS Rate,14044.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15799.65,100,,,Case Rate,100% of CMS IPPS Rate,15799.65,100,,,Case Rate,100% of CMS IPPS Rate,15799.65,100,,,Case Rate,100% CMS IPPS Rate,11284.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5686.11,100,MS-DRG,4548.888,Case Rate,100% of CMS IPPS Rate,5686.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5686.11,100,MS-DRG,4548.888,Case Rate,100% of CMS IPPS Rate,5686.11,100,MS-DRG,4548.888,Case Rate,100% of CMS IPPS Rate,9085.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,8123.22,130,MS-DRG,6498.576,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6436.09,103,MS-DRG,5148.872,Case Rate,103% of CMS IPPS Rate,6436.09,103,MS-DRG,5148.872,Case Rate,103% of CMS IPPS Rate,11620.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,6619.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9372.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,12782,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6248.63,100,MS-DRG,4998.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5686.11,15799.65,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,CDM,,,,,Inpatient,,,,,,9832.23,100,,,Case Rate,100% of CMS IPPS Rate,7126.36,145,MS-DRG,5701.088,Case Rate,145% of CMS IPPS Rate,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,9666.31,100,,,Case Rate,100% of CMS IPPS Rate,11047.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12428.21,100,,,Case Rate,100% of CMS IPPS Rate,12428.21,100,,,Case Rate,100% of CMS IPPS Rate,12428.21,100,,,Case Rate,100% CMS IPPS Rate,8875.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4472.34,100,MS-DRG,3577.872,Case Rate,100% of CMS IPPS Rate,4472.34,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4472.34,100,MS-DRG,3577.872,Case Rate,100% of CMS IPPS Rate,4472.34,100,MS-DRG,3577.872,Case Rate,100% of CMS IPPS Rate,7115.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,6389.15,130,MS-DRG,5111.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5062.17,103,MS-DRG,4049.736,Case Rate,103% of CMS IPPS Rate,5062.17,103,MS-DRG,4049.736,Case Rate,103% of CMS IPPS Rate,9066.26,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,5206.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7372.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,10053.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4914.73,100,MS-DRG,3931.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4472.34,12428.21,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,CDM,,,,,Inpatient,,,,,,26992.41,100,,,Case Rate,100% of CMS IPPS Rate,19563.97,145,MS-DRG,15651.176,Case Rate,145% of CMS IPPS Rate,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,26067.44,100,,,Case Rate,100% of CMS IPPS Rate,29792.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33515.56,100,,,Case Rate,100% of CMS IPPS Rate,33515.56,100,,,Case Rate,100% of CMS IPPS Rate,33515.56,100,,,Case Rate,100% CMS IPPS Rate,24366.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12277.48,100,MS-DRG,9821.984,Case Rate,100% of CMS IPPS Rate,12277.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12277.48,100,MS-DRG,9821.984,Case Rate,100% of CMS IPPS Rate,12277.48,100,MS-DRG,9821.984,Case Rate,100% of CMS IPPS Rate,18729.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,17540.11,130,MS-DRG,14032.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13897.16,103,MS-DRG,11117.728,Case Rate,103% of CMS IPPS Rate,13897.16,103,MS-DRG,11117.728,Case Rate,103% of CMS IPPS Rate,24270.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,14292.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20238.59,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,27599.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13492.39,100,MS-DRG,10793.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33515.56,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,CDM,,,,,Inpatient,,,,,,10127.97,100,,,Case Rate,100% of CMS IPPS Rate,7340.7,145,MS-DRG,5872.56,Case Rate,145% of CMS IPPS Rate,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,9878.27,100,,,Case Rate,100% of CMS IPPS Rate,11289.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12700.74,100,,,Case Rate,100% of CMS IPPS Rate,12700.74,100,,,Case Rate,100% of CMS IPPS Rate,12700.74,100,,,Case Rate,100% CMS IPPS Rate,9142.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4606.86,100,MS-DRG,3685.488,Case Rate,100% of CMS IPPS Rate,4606.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4606.86,100,MS-DRG,3685.488,Case Rate,100% of CMS IPPS Rate,4606.86,100,MS-DRG,3685.488,Case Rate,100% of CMS IPPS Rate,6656.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,6581.32,130,MS-DRG,5265.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5214.43,103,MS-DRG,4171.544,Case Rate,103% of CMS IPPS Rate,5214.43,103,MS-DRG,4171.544,Case Rate,103% of CMS IPPS Rate,9302.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,5362.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7593.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,10355.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5062.55,100,MS-DRG,4050.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4606.86,12700.74,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,CDM,,,,,Inpatient,,,,,,6691.28,100,,,Case Rate,100% of CMS IPPS Rate,4849.8,145,MS-DRG,3879.84,Case Rate,145% of CMS IPPS Rate,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,7484.02,100,,,Case Rate,100% of CMS IPPS Rate,8553.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9622.4,100,,,Case Rate,100% of CMS IPPS Rate,9622.4,100,,,Case Rate,100% of CMS IPPS Rate,9622.4,100,,,Case Rate,100% CMS IPPS Rate,6040.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3043.72,100,MS-DRG,2434.976,Case Rate,100% of CMS IPPS Rate,3043.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3043.72,100,MS-DRG,2434.976,Case Rate,100% of CMS IPPS Rate,3043.72,100,MS-DRG,2434.976,Case Rate,100% of CMS IPPS Rate,4398.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,4348.1,130,MS-DRG,3478.48,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3445.03,103,MS-DRG,2756.024,Case Rate,103% of CMS IPPS Rate,3445.03,103,MS-DRG,2756.024,Case Rate,103% of CMS IPPS Rate,6853.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,3543.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5017.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,6841.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3344.69,100,MS-DRG,2675.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3043.72,9622.4,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,CDM,,,,,Inpatient,,,,,,29514.48,100,,,Case Rate,100% of CMS IPPS Rate,21391.94,145,MS-DRG,17113.552,Case Rate,145% of CMS IPPS Rate,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,29505.5,100,,,Case Rate,100% of CMS IPPS Rate,33721.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37935.96,100,,,Case Rate,100% of CMS IPPS Rate,37935.96,100,,,Case Rate,100% of CMS IPPS Rate,37935.96,100,,,Case Rate,100% CMS IPPS Rate,26643.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13424.63,100,MS-DRG,10739.704,Case Rate,100% of CMS IPPS Rate,13424.63,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13424.63,100,MS-DRG,10739.704,Case Rate,100% of CMS IPPS Rate,13424.63,100,MS-DRG,10739.704,Case Rate,100% of CMS IPPS Rate,15378.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,19178.98,130,MS-DRG,15343.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15195.65,103,MS-DRG,12156.52,Case Rate,103% of CMS IPPS Rate,15195.65,103,MS-DRG,12156.52,Case Rate,103% of CMS IPPS Rate,26830.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,15628.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22129.59,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,30178.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14753.06,100,MS-DRG,11802.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37935.96,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,CDM,,,,,Inpatient,,,,,,14809.27,100,,,Case Rate,100% of CMS IPPS Rate,10733.68,145,MS-DRG,8586.944,Case Rate,145% of CMS IPPS Rate,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,14526.79,100,,,Case Rate,100% of CMS IPPS Rate,16602.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18677.46,100,,,Case Rate,100% of CMS IPPS Rate,18677.46,100,,,Case Rate,100% of CMS IPPS Rate,18677.46,100,,,Case Rate,100% CMS IPPS Rate,13368.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6736.11,100,MS-DRG,5388.888,Case Rate,100% of CMS IPPS Rate,6736.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6736.11,100,MS-DRG,5388.888,Case Rate,100% of CMS IPPS Rate,6736.11,100,MS-DRG,5388.888,Case Rate,100% of CMS IPPS Rate,10339.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,9623.3,130,MS-DRG,7698.64,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7624.62,103,MS-DRG,6099.696,Case Rate,103% of CMS IPPS Rate,7624.62,103,MS-DRG,6099.696,Case Rate,103% of CMS IPPS Rate,13917.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,7841.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11103.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,15142.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7402.54,100,MS-DRG,5922.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18677.46,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,CDM,,,,,Inpatient,,,,,,35503.36,100,,,Case Rate,100% of CMS IPPS Rate,25732.67,145,MS-DRG,20586.136,Case Rate,145% of CMS IPPS Rate,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,36413.63,100,,,Case Rate,100% of CMS IPPS Rate,41617.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46817.91,100,,,Case Rate,100% of CMS IPPS Rate,46817.91,100,,,Case Rate,100% of CMS IPPS Rate,46817.91,100,,,Case Rate,100% CMS IPPS Rate,32049.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16148.6,100,MS-DRG,12918.88,Case Rate,100% of CMS IPPS Rate,16148.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16148.6,100,MS-DRG,12918.88,Case Rate,100% of CMS IPPS Rate,16148.6,100,MS-DRG,12918.88,Case Rate,100% of CMS IPPS Rate,23334.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,23070.67,130,MS-DRG,18456.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18279.07,103,MS-DRG,14623.256,Case Rate,103% of CMS IPPS Rate,18279.07,103,MS-DRG,14623.256,Case Rate,103% of CMS IPPS Rate,34110.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,18799.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26620.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,36302,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17746.67,100,MS-DRG,14197.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46817.91,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,CDM,,,,,Inpatient,,,,,,20232.67,100,,,Case Rate,100% of CMS IPPS Rate,14664.53,145,MS-DRG,11731.624,Case Rate,145% of CMS IPPS Rate,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,21018.99,100,,,Case Rate,100% of CMS IPPS Rate,24022.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27024.64,100,,,Case Rate,100% of CMS IPPS Rate,27024.64,100,,,Case Rate,100% of CMS IPPS Rate,27024.64,100,,,Case Rate,100% CMS IPPS Rate,18264.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9202.88,100,MS-DRG,7362.304,Case Rate,100% of CMS IPPS Rate,9202.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9202.88,100,MS-DRG,7362.304,Case Rate,100% of CMS IPPS Rate,9202.88,100,MS-DRG,7362.304,Case Rate,100% of CMS IPPS Rate,13297.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,13147.51,130,MS-DRG,10518.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10416.87,103,MS-DRG,8333.496,Case Rate,103% of CMS IPPS Rate,10416.87,103,MS-DRG,8333.496,Case Rate,103% of CMS IPPS Rate,20329.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,10713.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15170.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,20687.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10113.47,100,MS-DRG,8090.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27024.64,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,CDM,,,,,Inpatient,,,,,,14037.04,100,,,Case Rate,100% of CMS IPPS Rate,10768.43,145,MS-DRG,8614.744,Case Rate,145% of CMS IPPS Rate,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,13051.05,100,,,Case Rate,100% of CMS IPPS Rate,14916.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16780.06,100,,,Case Rate,100% of CMS IPPS Rate,16780.06,100,,,Case Rate,100% of CMS IPPS Rate,16780.06,100,,,Case Rate,100% CMS IPPS Rate,12671.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6757.9,100,MS-DRG,5406.32,Case Rate,100% of CMS IPPS Rate,6757.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6757.9,100,MS-DRG,5406.32,Case Rate,100% of CMS IPPS Rate,6757.9,100,MS-DRG,5406.32,Case Rate,100% of CMS IPPS Rate,9765.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,9654.45,130,MS-DRG,7723.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7649.3,103,MS-DRG,6119.44,Case Rate,103% of CMS IPPS Rate,7649.3,103,MS-DRG,6119.44,Case Rate,103% of CMS IPPS Rate,15252.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,7432.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11139.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,14352.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7426.5,100,MS-DRG,5941.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16780.06,
HEART FAILURE AND SHOCK WITH MCC,291,CDM,,,,,Inpatient,,,,,,17579.16,100,,,Case Rate,100% of CMS IPPS Rate,12741.3,145,MS-DRG,10193.04,Case Rate,145% of CMS IPPS Rate,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,17394.29,100,,,Case Rate,100% of CMS IPPS Rate,19879.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22364.27,100,,,Case Rate,100% of CMS IPPS Rate,22364.27,100,,,Case Rate,100% of CMS IPPS Rate,22364.27,100,,,Case Rate,100% CMS IPPS Rate,15869,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7995.96,100,MS-DRG,6396.768,Case Rate,100% of CMS IPPS Rate,7995.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7995.96,100,MS-DRG,6396.768,Case Rate,100% of CMS IPPS Rate,7995.96,100,MS-DRG,6396.768,Case Rate,100% of CMS IPPS Rate,8646.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,11423.23,130,MS-DRG,9138.584,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9050.71,103,MS-DRG,7240.568,Case Rate,103% of CMS IPPS Rate,9050.71,103,MS-DRG,7240.568,Case Rate,103% of CMS IPPS Rate,16189.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,9308.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13180.65,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,17974.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8787.1,100,MS-DRG,7029.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22364.27,
HEART FAILURE AND SHOCK WITH CC,292,CDM,,,,,Inpatient,,,,,,11727.2,100,,,Case Rate,100% of CMS IPPS Rate,8499.81,145,MS-DRG,6799.848,Case Rate,145% of CMS IPPS Rate,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,11480.66,100,,,Case Rate,100% of CMS IPPS Rate,13121.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14760.97,100,,,Case Rate,100% of CMS IPPS Rate,14760.97,100,,,Case Rate,100% of CMS IPPS Rate,14760.97,100,,,Case Rate,100% CMS IPPS Rate,10586.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5334.25,100,MS-DRG,4267.4,Case Rate,100% of CMS IPPS Rate,5334.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5334.25,100,MS-DRG,4267.4,Case Rate,100% of CMS IPPS Rate,5334.25,100,MS-DRG,4267.4,Case Rate,100% of CMS IPPS Rate,6424.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,7620.52,130,MS-DRG,6096.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6037.8,103,MS-DRG,4830.24,Case Rate,103% of CMS IPPS Rate,6037.8,103,MS-DRG,4830.24,Case Rate,103% of CMS IPPS Rate,10914.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,6209.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8792.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,11991,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5861.94,100,MS-DRG,4689.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5334.25,14760.97,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,CDM,,,,,Inpatient,,,,,,7688.06,100,,,Case Rate,100% of CMS IPPS Rate,5572.26,145,MS-DRG,4457.808,Case Rate,145% of CMS IPPS Rate,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,7314.72,100,,,Case Rate,100% of CMS IPPS Rate,8359.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9404.72,100,,,Case Rate,100% of CMS IPPS Rate,9404.72,100,,,Case Rate,100% of CMS IPPS Rate,9404.72,100,,,Case Rate,100% CMS IPPS Rate,6940.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3497.08,100,MS-DRG,2797.664,Case Rate,100% of CMS IPPS Rate,3497.08,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3497.08,100,MS-DRG,2797.664,Case Rate,100% of CMS IPPS Rate,3497.08,100,MS-DRG,2797.664,Case Rate,100% of CMS IPPS Rate,3061.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,4995.82,130,MS-DRG,3996.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3958.23,103,MS-DRG,3166.584,Case Rate,103% of CMS IPPS Rate,3958.23,103,MS-DRG,3166.584,Case Rate,103% of CMS IPPS Rate,7087.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,4070.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5764.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,7861,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3842.94,100,MS-DRG,3074.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3061.27,9404.72,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,CDM,,,,,Inpatient,,,,,,14974.94,100,,,Case Rate,100% of CMS IPPS Rate,10853.77,145,MS-DRG,8683.016,Case Rate,145% of CMS IPPS Rate,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,16370.47,100,,,Case Rate,100% of CMS IPPS Rate,18709.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21047.92,100,,,Case Rate,100% of CMS IPPS Rate,21047.92,100,,,Case Rate,100% of CMS IPPS Rate,21047.92,100,,,Case Rate,100% CMS IPPS Rate,13518.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6811.47,100,MS-DRG,5449.176,Case Rate,100% of CMS IPPS Rate,6811.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6811.47,100,MS-DRG,5449.176,Case Rate,100% of CMS IPPS Rate,6811.47,100,MS-DRG,5449.176,Case Rate,100% of CMS IPPS Rate,9842.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,9730.97,130,MS-DRG,7784.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7709.92,103,MS-DRG,6167.936,Case Rate,103% of CMS IPPS Rate,7709.92,103,MS-DRG,6167.936,Case Rate,103% of CMS IPPS Rate,14604.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,7929.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11228.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,15311.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7485.36,100,MS-DRG,5988.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21047.92,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,CDM,,,,,Inpatient,,,,,,8646.5,100,,,Case Rate,100% of CMS IPPS Rate,7910.33,145,MS-DRG,6328.264,Case Rate,145% of CMS IPPS Rate,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,10528.82,100,,,Case Rate,100% of CMS IPPS Rate,12033.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13537.17,100,,,Case Rate,100% of CMS IPPS Rate,13537.17,100,,,Case Rate,100% of CMS IPPS Rate,13537.17,100,,,Case Rate,100% CMS IPPS Rate,7805.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4964.33,100,MS-DRG,3971.464,Case Rate,100% of CMS IPPS Rate,4964.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4964.33,100,MS-DRG,3971.464,Case Rate,100% of CMS IPPS Rate,4964.33,100,MS-DRG,3971.464,Case Rate,100% of CMS IPPS Rate,7173.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,7092.02,130,MS-DRG,5673.616,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5619.06,103,MS-DRG,4495.248,Case Rate,103% of CMS IPPS Rate,5619.06,103,MS-DRG,4495.248,Case Rate,103% of CMS IPPS Rate,11204.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,4578.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8183.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,8841,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5455.4,100,MS-DRG,4364.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4578.38,13537.17,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,CDM,,,,,Inpatient,,,,,,21951.01,100,,,Case Rate,100% of CMS IPPS Rate,15909.98,145,MS-DRG,12727.984,Case Rate,145% of CMS IPPS Rate,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,21841.51,100,,,Case Rate,100% of CMS IPPS Rate,24962.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28082.18,100,,,Case Rate,100% of CMS IPPS Rate,28082.18,100,,,Case Rate,100% of CMS IPPS Rate,28082.18,100,,,Case Rate,100% CMS IPPS Rate,19815.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9984.45,100,MS-DRG,7987.56,Case Rate,100% of CMS IPPS Rate,9984.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9984.45,100,MS-DRG,7987.56,Case Rate,100% of CMS IPPS Rate,9984.45,100,MS-DRG,7987.56,Case Rate,100% of CMS IPPS Rate,15777.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,14264.12,130,MS-DRG,11411.296,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11301.57,103,MS-DRG,9041.256,Case Rate,103% of CMS IPPS Rate,11301.57,103,MS-DRG,9041.256,Case Rate,103% of CMS IPPS Rate,20724.5,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,11623.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16458.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,22444.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10972.4,100,MS-DRG,8777.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28082.18,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,CDM,,,,,Inpatient,,,,,,9975.99,100,,,Case Rate,100% of CMS IPPS Rate,7230.56,145,MS-DRG,5784.448,Case Rate,145% of CMS IPPS Rate,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,9390.36,100,,,Case Rate,100% of CMS IPPS Rate,10732.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12073.42,100,,,Case Rate,100% of CMS IPPS Rate,12073.42,100,,,Case Rate,100% of CMS IPPS Rate,12073.42,100,,,Case Rate,100% CMS IPPS Rate,9005.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4537.74,100,MS-DRG,3630.192,Case Rate,100% of CMS IPPS Rate,4537.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4537.74,100,MS-DRG,3630.192,Case Rate,100% of CMS IPPS Rate,4537.74,100,MS-DRG,3630.192,Case Rate,100% of CMS IPPS Rate,6556.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,6482.57,130,MS-DRG,5186.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5136.19,103,MS-DRG,4108.952,Case Rate,103% of CMS IPPS Rate,5136.19,103,MS-DRG,4108.952,Case Rate,103% of CMS IPPS Rate,8049.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,5282.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7479.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,10200.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4986.59,100,MS-DRG,3989.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4537.74,12073.42,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,CDM,,,,,Inpatient,,,,,,6009.42,100,,,Case Rate,100% of CMS IPPS Rate,4363.53,145,MS-DRG,3490.824,Case Rate,145% of CMS IPPS Rate,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,5888.3,100,,,Case Rate,100% of CMS IPPS Rate,6729.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7570.74,100,,,Case Rate,100% of CMS IPPS Rate,7570.74,100,,,Case Rate,100% of CMS IPPS Rate,7570.74,100,,,Case Rate,100% CMS IPPS Rate,5424.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2738.56,100,MS-DRG,2190.848,Case Rate,100% of CMS IPPS Rate,2738.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,2738.56,100,MS-DRG,2190.848,Case Rate,100% of CMS IPPS Rate,2738.56,100,MS-DRG,2190.848,Case Rate,100% of CMS IPPS Rate,3957.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,3912.13,130,MS-DRG,3129.704,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3099.61,103,MS-DRG,2479.688,Case Rate,103% of CMS IPPS Rate,3099.61,103,MS-DRG,2479.688,Case Rate,103% of CMS IPPS Rate,6179.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,3182.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,4514,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,6144.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3009.33,100,MS-DRG,2407.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2738.56,7570.74,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,CDM,,,,,Inpatient,,,,,,21581.33,100,,,Case Rate,100% of CMS IPPS Rate,15642.03,145,MS-DRG,12513.624,Case Rate,145% of CMS IPPS Rate,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,21564.23,100,,,Case Rate,100% of CMS IPPS Rate,24645.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27725.66,100,,,Case Rate,100% of CMS IPPS Rate,27725.66,100,,,Case Rate,100% of CMS IPPS Rate,27725.66,100,,,Case Rate,100% CMS IPPS Rate,19481.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9816.31,100,MS-DRG,7853.048,Case Rate,100% of CMS IPPS Rate,9816.31,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9816.31,100,MS-DRG,7853.048,Case Rate,100% of CMS IPPS Rate,9816.31,100,MS-DRG,7853.048,Case Rate,100% of CMS IPPS Rate,11332.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,14023.89,130,MS-DRG,11219.112,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11111.24,103,MS-DRG,8888.992,Case Rate,103% of CMS IPPS Rate,11111.24,103,MS-DRG,8888.992,Case Rate,103% of CMS IPPS Rate,19455.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,11427.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16181.42,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,22066.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10787.61,100,MS-DRG,8630.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27725.66,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,CDM,,,,,Inpatient,,,,,,14609.36,100,,,Case Rate,100% of CMS IPPS Rate,10588.78,145,MS-DRG,8471.024,Case Rate,145% of CMS IPPS Rate,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,14272.17,100,,,Case Rate,100% of CMS IPPS Rate,16311.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18350.08,100,,,Case Rate,100% of CMS IPPS Rate,18350.08,100,,,Case Rate,100% of CMS IPPS Rate,18350.08,100,,,Case Rate,100% CMS IPPS Rate,13188.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6645.19,100,MS-DRG,5316.152,Case Rate,100% of CMS IPPS Rate,6645.19,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6645.19,100,MS-DRG,5316.152,Case Rate,100% of CMS IPPS Rate,6645.19,100,MS-DRG,5316.152,Case Rate,100% of CMS IPPS Rate,7382.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,9493.39,130,MS-DRG,7594.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7521.69,103,MS-DRG,6017.352,Case Rate,103% of CMS IPPS Rate,7521.69,103,MS-DRG,6017.352,Case Rate,103% of CMS IPPS Rate,13043.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,7735.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10953.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,14938,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7302.61,100,MS-DRG,5842.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18350.08,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,CDM,,,,,Inpatient,,,,,,9718.58,100,,,Case Rate,100% of CMS IPPS Rate,7043.97,145,MS-DRG,5635.176,Case Rate,145% of CMS IPPS Rate,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,9510.34,100,,,Case Rate,100% of CMS IPPS Rate,10869.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12227.68,100,,,Case Rate,100% of CMS IPPS Rate,12227.68,100,,,Case Rate,100% of CMS IPPS Rate,12227.68,100,,,Case Rate,100% CMS IPPS Rate,8773.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4420.66,100,MS-DRG,3536.528,Case Rate,100% of CMS IPPS Rate,4420.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4420.66,100,MS-DRG,3536.528,Case Rate,100% of CMS IPPS Rate,4420.66,100,MS-DRG,3536.528,Case Rate,100% of CMS IPPS Rate,5203.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,6315.28,130,MS-DRG,5052.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5003.65,103,MS-DRG,4002.92,Case Rate,103% of CMS IPPS Rate,5003.65,103,MS-DRG,4002.92,Case Rate,103% of CMS IPPS Rate,9059.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,5146.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7286.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,9937.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4857.91,100,MS-DRG,3886.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4420.66,12227.68,
ATHEROSCLEROSIS WITH MCC,302,CDM,,,,,Inpatient,,,,,,15350.1,100,,,Case Rate,100% of CMS IPPS Rate,11125.68,145,MS-DRG,8900.544,Case Rate,145% of CMS IPPS Rate,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,15507.95,100,,,Case Rate,100% of CMS IPPS Rate,17724.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19938.96,100,,,Case Rate,100% of CMS IPPS Rate,19938.96,100,,,Case Rate,100% of CMS IPPS Rate,19938.96,100,,,Case Rate,100% CMS IPPS Rate,13856.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6982.1,100,MS-DRG,5585.68,Case Rate,100% of CMS IPPS Rate,6982.1,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6982.1,100,MS-DRG,5585.68,Case Rate,100% of CMS IPPS Rate,6982.1,100,MS-DRG,5585.68,Case Rate,100% of CMS IPPS Rate,10088.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,9974.74,130,MS-DRG,7979.792,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7903.07,103,MS-DRG,6322.456,Case Rate,103% of CMS IPPS Rate,7903.07,103,MS-DRG,6322.456,Case Rate,103% of CMS IPPS Rate,15253.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,8127.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11509.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,15695.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7672.88,100,MS-DRG,6138.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19938.96,
ATHEROSCLEROSIS WITHOUT MCC,303,CDM,,,,,Inpatient,,,,,,9010.71,100,,,Case Rate,100% of CMS IPPS Rate,6530.92,145,MS-DRG,5224.736,Case Rate,145% of CMS IPPS Rate,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,8963.76,100,,,Case Rate,100% of CMS IPPS Rate,10244.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11524.94,100,,,Case Rate,100% of CMS IPPS Rate,11524.94,100,,,Case Rate,100% of CMS IPPS Rate,11524.94,100,,,Case Rate,100% CMS IPPS Rate,8134.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4098.68,100,MS-DRG,3278.944,Case Rate,100% of CMS IPPS Rate,4098.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4098.68,100,MS-DRG,3278.944,Case Rate,100% of CMS IPPS Rate,4098.68,100,MS-DRG,3278.944,Case Rate,100% of CMS IPPS Rate,4910.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,5855.3,130,MS-DRG,4684.24,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4639.2,103,MS-DRG,3711.36,Case Rate,103% of CMS IPPS Rate,4639.2,103,MS-DRG,3711.36,Case Rate,103% of CMS IPPS Rate,8552.67,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,4771.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6756.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,9213.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4504.08,100,MS-DRG,3603.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4098.68,11524.94,
HYPERTENSION WITH MCC,304,CDM,,,,,Inpatient,,,,,,15732.11,100,,,Case Rate,100% of CMS IPPS Rate,11402.55,145,MS-DRG,9122.04,Case Rate,145% of CMS IPPS Rate,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,15661.26,100,,,Case Rate,100% of CMS IPPS Rate,17899.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20136.07,100,,,Case Rate,100% of CMS IPPS Rate,20136.07,100,,,Case Rate,100% of CMS IPPS Rate,20136.07,100,,,Case Rate,100% CMS IPPS Rate,14201.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7155.85,100,MS-DRG,5724.68,Case Rate,100% of CMS IPPS Rate,7155.85,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7155.85,100,MS-DRG,5724.68,Case Rate,100% of CMS IPPS Rate,7155.85,100,MS-DRG,5724.68,Case Rate,100% of CMS IPPS Rate,8138.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,10222.98,130,MS-DRG,8178.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8099.74,103,MS-DRG,6479.792,Case Rate,103% of CMS IPPS Rate,8099.74,103,MS-DRG,6479.792,Case Rate,103% of CMS IPPS Rate,13897.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,8330.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11795.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,16086,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7863.83,100,MS-DRG,6291.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20136.07,
HYPERTENSION WITHOUT MCC,305,CDM,,,,,Inpatient,,,,,,10316.92,100,,,Case Rate,100% of CMS IPPS Rate,7477.65,145,MS-DRG,5982.12,Case Rate,145% of CMS IPPS Rate,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,10007.58,100,,,Case Rate,100% of CMS IPPS Rate,11437.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12867,100,,,Case Rate,100% of CMS IPPS Rate,12867,100,,,Case Rate,100% of CMS IPPS Rate,12867,100,,,Case Rate,100% CMS IPPS Rate,9313.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4692.81,100,MS-DRG,3754.248,Case Rate,100% of CMS IPPS Rate,4692.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4692.81,100,MS-DRG,3754.248,Case Rate,100% of CMS IPPS Rate,4692.81,100,MS-DRG,3754.248,Case Rate,100% of CMS IPPS Rate,5963.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,6704.1,130,MS-DRG,5363.28,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5311.71,103,MS-DRG,4249.368,Case Rate,103% of CMS IPPS Rate,5311.71,103,MS-DRG,4249.368,Case Rate,103% of CMS IPPS Rate,9431.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,5462.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7735.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,10549,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5157,100,MS-DRG,4125.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4692.81,12867,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,CDM,,,,,Inpatient,,,,,,21041.87,100,,,Case Rate,100% of CMS IPPS Rate,15251.04,145,MS-DRG,12200.832,Case Rate,145% of CMS IPPS Rate,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,19961.84,100,,,Case Rate,100% of CMS IPPS Rate,22814.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25665.44,100,,,Case Rate,100% of CMS IPPS Rate,25665.44,100,,,Case Rate,100% of CMS IPPS Rate,25665.44,100,,,Case Rate,100% CMS IPPS Rate,18994.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9570.94,100,MS-DRG,7656.752,Case Rate,100% of CMS IPPS Rate,9570.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9570.94,100,MS-DRG,7656.752,Case Rate,100% of CMS IPPS Rate,9570.94,100,MS-DRG,7656.752,Case Rate,100% of CMS IPPS Rate,8091.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,13673.35,130,MS-DRG,10938.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10833.5,103,MS-DRG,8666.8,Case Rate,103% of CMS IPPS Rate,10833.5,103,MS-DRG,8666.8,Case Rate,103% of CMS IPPS Rate,18668.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,11141.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15776.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,21515.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10517.96,100,MS-DRG,8414.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25665.44,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,CDM,,,,,Inpatient,,,,,,12906.08,100,,,Case Rate,100% of CMS IPPS Rate,9354.25,145,MS-DRG,7483.4,Case Rate,145% of CMS IPPS Rate,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,12349.84,100,,,Case Rate,100% of CMS IPPS Rate,14114.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15878.5,100,,,Case Rate,100% of CMS IPPS Rate,15878.5,100,,,Case Rate,100% of CMS IPPS Rate,15878.5,100,,,Case Rate,100% CMS IPPS Rate,11650.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5870.45,100,MS-DRG,4696.36,Case Rate,100% of CMS IPPS Rate,5870.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5870.45,100,MS-DRG,4696.36,Case Rate,100% of CMS IPPS Rate,5870.45,100,MS-DRG,4696.36,Case Rate,100% of CMS IPPS Rate,7228.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,8386.57,130,MS-DRG,6709.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6644.75,103,MS-DRG,5315.8,Case Rate,103% of CMS IPPS Rate,6644.75,103,MS-DRG,5315.8,Case Rate,103% of CMS IPPS Rate,11529.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,6833.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9676.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,13196.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6451.21,100,MS-DRG,5160.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5870.45,15878.5,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,CDM,,,,,Inpatient,,,,,,16460.52,100,,,Case Rate,100% of CMS IPPS Rate,11930.51,145,MS-DRG,9544.408,Case Rate,145% of CMS IPPS Rate,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,16075.85,100,,,Case Rate,100% of CMS IPPS Rate,18373.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20669.13,100,,,Case Rate,100% of CMS IPPS Rate,20669.13,100,,,Case Rate,100% of CMS IPPS Rate,20669.13,100,,,Case Rate,100% CMS IPPS Rate,14859.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7487.16,100,MS-DRG,5989.728,Case Rate,100% of CMS IPPS Rate,7487.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7487.16,100,MS-DRG,5989.728,Case Rate,100% of CMS IPPS Rate,7487.16,100,MS-DRG,5989.728,Case Rate,100% of CMS IPPS Rate,9459.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,10696.32,130,MS-DRG,8557.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8474.78,103,MS-DRG,6779.824,Case Rate,103% of CMS IPPS Rate,8474.78,103,MS-DRG,6779.824,Case Rate,103% of CMS IPPS Rate,14833.39,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,8715.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12341.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,16830.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8227.94,100,MS-DRG,6582.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20669.13,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,CDM,,,,,Inpatient,,,,,,10196.43,100,,,Case Rate,100% of CMS IPPS Rate,7390.32,145,MS-DRG,5912.256,Case Rate,145% of CMS IPPS Rate,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,9855.61,100,,,Case Rate,100% of CMS IPPS Rate,11263.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12671.6,100,,,Case Rate,100% of CMS IPPS Rate,12671.6,100,,,Case Rate,100% of CMS IPPS Rate,12671.6,100,,,Case Rate,100% CMS IPPS Rate,9204.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,4638,100,MS-DRG,3710.4,Case Rate,100% of CMS IPPS Rate,4818.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,6625.8,130,MS-DRG,5300.64,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5249.67,103,MS-DRG,4199.736,Case Rate,103% of CMS IPPS Rate,5249.67,103,MS-DRG,4199.736,Case Rate,103% of CMS IPPS Rate,9330.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,5399.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7645.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,10425.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5096.77,100,MS-DRG,4077.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4638,12671.6,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,CDM,,,,,Inpatient,,,,,,7571.68,100,,,Case Rate,100% of CMS IPPS Rate,5487.92,145,MS-DRG,4390.336,Case Rate,145% of CMS IPPS Rate,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,7458.69,100,,,Case Rate,100% of CMS IPPS Rate,8524.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9589.83,100,,,Case Rate,100% of CMS IPPS Rate,9589.83,100,,,Case Rate,100% of CMS IPPS Rate,9589.83,100,,,Case Rate,100% CMS IPPS Rate,6835.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3444.15,100,MS-DRG,2755.32,Case Rate,100% of CMS IPPS Rate,3444.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3444.15,100,MS-DRG,2755.32,Case Rate,100% of CMS IPPS Rate,3444.15,100,MS-DRG,2755.32,Case Rate,100% of CMS IPPS Rate,3816.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,4920.2,130,MS-DRG,3936.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3898.31,103,MS-DRG,3118.648,Case Rate,103% of CMS IPPS Rate,3898.31,103,MS-DRG,3118.648,Case Rate,103% of CMS IPPS Rate,6972.68,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,4009.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5677.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,7742,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3784.77,100,MS-DRG,3027.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3444.15,9589.83,
ANGINA PECTORIS,311,CDM,,,,,Inpatient,,,,,,9558.39,100,,,Case Rate,100% of CMS IPPS Rate,6927.88,145,MS-DRG,5542.304,Case Rate,145% of CMS IPPS Rate,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,9309.04,100,,,Case Rate,100% of CMS IPPS Rate,10639.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11968.86,100,,,Case Rate,100% of CMS IPPS Rate,11968.86,100,,,Case Rate,100% of CMS IPPS Rate,11968.86,100,,,Case Rate,100% CMS IPPS Rate,8628.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4347.79,100,MS-DRG,3478.232,Case Rate,100% of CMS IPPS Rate,4347.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4347.79,100,MS-DRG,3478.232,Case Rate,100% of CMS IPPS Rate,4347.79,100,MS-DRG,3478.232,Case Rate,100% of CMS IPPS Rate,4146.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,6211.21,130,MS-DRG,4968.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4921.19,103,MS-DRG,3936.952,Case Rate,103% of CMS IPPS Rate,4921.19,103,MS-DRG,3936.952,Case Rate,103% of CMS IPPS Rate,8451.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,5061.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7166.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,9773.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4777.85,100,MS-DRG,3822.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4146.01,11968.86,
SYNCOPE AND COLLAPSE,312,CDM,,,,,Inpatient,,,,,,11823.04,100,,,Case Rate,100% of CMS IPPS Rate,8569.28,145,MS-DRG,6855.424,Case Rate,145% of CMS IPPS Rate,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,11615.3,100,,,Case Rate,100% of CMS IPPS Rate,13275.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14934.08,100,,,Case Rate,100% of CMS IPPS Rate,14934.08,100,,,Case Rate,100% of CMS IPPS Rate,14934.08,100,,,Case Rate,100% CMS IPPS Rate,10672.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5377.84,100,MS-DRG,4302.272,Case Rate,100% of CMS IPPS Rate,5377.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5377.84,100,MS-DRG,4302.272,Case Rate,100% of CMS IPPS Rate,5377.84,100,MS-DRG,4302.272,Case Rate,100% of CMS IPPS Rate,6363.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,7682.81,130,MS-DRG,6146.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6087.15,103,MS-DRG,4869.72,Case Rate,103% of CMS IPPS Rate,6087.15,103,MS-DRG,4869.72,Case Rate,103% of CMS IPPS Rate,10786.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,6260.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8864.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,12089,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5909.85,100,MS-DRG,4727.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5377.84,14934.08,
CHEST PAIN,313,CDM,,,,,Inpatient,,,,,,9907.53,100,,,Case Rate,100% of CMS IPPS Rate,7180.92,145,MS-DRG,5744.736,Case Rate,145% of CMS IPPS Rate,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,9510.34,100,,,Case Rate,100% of CMS IPPS Rate,10869.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12227.68,100,,,Case Rate,100% of CMS IPPS Rate,12227.68,100,,,Case Rate,100% of CMS IPPS Rate,12227.68,100,,,Case Rate,100% CMS IPPS Rate,8943.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4506.6,100,MS-DRG,3605.28,Case Rate,100% of CMS IPPS Rate,4506.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4506.6,100,MS-DRG,3605.28,Case Rate,100% of CMS IPPS Rate,4506.6,100,MS-DRG,3605.28,Case Rate,100% of CMS IPPS Rate,5358.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,6438.07,130,MS-DRG,5150.456,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5100.93,103,MS-DRG,4080.744,Case Rate,103% of CMS IPPS Rate,5100.93,103,MS-DRG,4080.744,Case Rate,103% of CMS IPPS Rate,9151.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,5246.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7428.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,10130.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4952.36,100,MS-DRG,3961.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4506.6,12227.68,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,CDM,,,,,Inpatient,,,,,,28664.2,100,,,Case Rate,100% of CMS IPPS Rate,20775.67,145,MS-DRG,16620.536,Case Rate,145% of CMS IPPS Rate,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,28708.31,100,,,Case Rate,100% of CMS IPPS Rate,32810.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36910.99,100,,,Case Rate,100% of CMS IPPS Rate,36910.99,100,,,Case Rate,100% of CMS IPPS Rate,36910.99,100,,,Case Rate,100% CMS IPPS Rate,25875.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13037.88,100,MS-DRG,10430.304,Case Rate,100% of CMS IPPS Rate,13037.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13037.88,100,MS-DRG,10430.304,Case Rate,100% of CMS IPPS Rate,13037.88,100,MS-DRG,10430.304,Case Rate,100% of CMS IPPS Rate,15438.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,18626.47,130,MS-DRG,14901.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14757.89,103,MS-DRG,11806.312,Case Rate,103% of CMS IPPS Rate,14757.89,103,MS-DRG,11806.312,Case Rate,103% of CMS IPPS Rate,26344.89,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,15177.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21492.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,29309,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14328.05,100,MS-DRG,11462.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36910.99,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,CDM,,,,,Inpatient,,,,,,13244.27,100,,,Case Rate,100% of CMS IPPS Rate,9599.36,145,MS-DRG,7679.488,Case Rate,145% of CMS IPPS Rate,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,12828.42,100,,,Case Rate,100% of CMS IPPS Rate,14661.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16493.82,100,,,Case Rate,100% of CMS IPPS Rate,16493.82,100,,,Case Rate,100% of CMS IPPS Rate,16493.82,100,,,Case Rate,100% CMS IPPS Rate,11955.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6024.27,100,MS-DRG,4819.416,Case Rate,100% of CMS IPPS Rate,6024.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6024.27,100,MS-DRG,4819.416,Case Rate,100% of CMS IPPS Rate,6024.27,100,MS-DRG,4819.416,Case Rate,100% of CMS IPPS Rate,8577.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,8606.33,130,MS-DRG,6885.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6818.86,103,MS-DRG,5455.088,Case Rate,103% of CMS IPPS Rate,6818.86,103,MS-DRG,5455.088,Case Rate,103% of CMS IPPS Rate,12251.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,7012.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9930.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,13542.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6620.25,100,MS-DRG,5296.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16493.82,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,CDM,,,,,Inpatient,,,,,,9484.45,100,,,Case Rate,100% of CMS IPPS Rate,6874.28,145,MS-DRG,5499.424,Case Rate,145% of CMS IPPS Rate,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,9101.07,100,,,Case Rate,100% of CMS IPPS Rate,10401.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11701.48,100,,,Case Rate,100% of CMS IPPS Rate,11701.48,100,,,Case Rate,100% of CMS IPPS Rate,11701.48,100,,,Case Rate,100% CMS IPPS Rate,8561.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4314.16,100,MS-DRG,3451.328,Case Rate,100% of CMS IPPS Rate,4314.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4314.16,100,MS-DRG,3451.328,Case Rate,100% of CMS IPPS Rate,4314.16,100,MS-DRG,3451.328,Case Rate,100% of CMS IPPS Rate,5619.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,6163.14,130,MS-DRG,4930.512,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4883.11,103,MS-DRG,3906.488,Case Rate,103% of CMS IPPS Rate,4883.11,103,MS-DRG,3906.488,Case Rate,103% of CMS IPPS Rate,8627.3,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,5022.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7111.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,9697.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4740.88,100,MS-DRG,3792.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4314.16,11701.48,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82470.9,100,,,Case Rate,100% of CMS IPPS Rate,94255.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,106034.9,100,,,Case Rate,100% of CMS IPPS Rate,106034.9,100,,,Case Rate,100% of CMS IPPS Rate,106034.9,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45349.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,106034.9,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,CDM,,,,,Inpatient,,,,,,59723.13,,,,Case Rate,100% of CMS IPPS Rate,43287.04,145,MS-DRG,34629.632,Case Rate,145% of CMS IPPS Rate,29853.13,100,MS-DRG,23882.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29853.13,100,,23882.504,Case Rate,100% of CMS IPPS Rate,58560.42,100,,,Case Rate,100% of CMS IPPS Rate,66928.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,75292.59,100,,,Case Rate,100% of CMS IPPS Rate,75292.59,100,,,Case Rate,100% of CMS IPPS Rate,75292.59,100,,,Case Rate,100% CMS IPPS Rate,53913.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27164.74,100,,21731.792,Case Rate,100% of CMS IPPS Rate,27164.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,27164.74,100,MS-DRG,21731.792,Case Rate,100% of CMS IPPS Rate,27164.74,100,MS-DRG,21731.792,Case Rate,100% of CMS IPPS Rate,39252.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29853.13,100,MS-DRG,23882.504,Case Rate,100% of CMS IPPS Rate,38809.07,130,MS-DRG,31047.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30748.72,103,MS-DRG,24598.976,Case Rate,103% of CMS IPPS Rate,30748.72,103,MS-DRG,24598.976,Case Rate,103% of CMS IPPS Rate,54478.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29853.13,100,MS-DRG,23882.504,Case Rate,100% of CMS IPPS Rate,31623.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,44779.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29853.13,100,MS-DRG,23882.504,Case Rate,100% of CMS IPPS Rate,61066.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29853.13,100,MS-DRG,23882.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,75292.59,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,CDM,,,,,Inpatient,,,,,,30478.39,,,,Case Rate,100% of CMS IPPS Rate,22090.61,145,MS-DRG,17672.488,Case Rate,145% of CMS IPPS Rate,15234.9,100,MS-DRG,12187.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15234.9,100,,12187.92,Case Rate,100% of CMS IPPS Rate,30858.6,100,,,Case Rate,100% of CMS IPPS Rate,35268.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39675.67,100,,,Case Rate,100% of CMS IPPS Rate,39675.67,100,,,Case Rate,100% of CMS IPPS Rate,39675.67,100,,,Case Rate,100% CMS IPPS Rate,27513.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13863.06,100,,11090.448,Case Rate,100% of CMS IPPS Rate,13863.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13863.06,100,MS-DRG,11090.448,Case Rate,100% of CMS IPPS Rate,13863.06,100,MS-DRG,11090.448,Case Rate,100% of CMS IPPS Rate,20032.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15234.9,100,MS-DRG,12187.92,Case Rate,100% of CMS IPPS Rate,19805.37,130,MS-DRG,15844.296,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15691.95,103,MS-DRG,12553.56,Case Rate,103% of CMS IPPS Rate,15691.95,103,MS-DRG,12553.56,Case Rate,103% of CMS IPPS Rate,31263.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15234.9,100,MS-DRG,12187.92,Case Rate,100% of CMS IPPS Rate,16138.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22852.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15234.9,100,MS-DRG,12187.92,Case Rate,100% of CMS IPPS Rate,31164,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15234.9,100,MS-DRG,12187.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39675.67,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,CDM,,,,,Inpatient,,,,,,39360.39,,,,Case Rate,100% of CMS IPPS Rate,28528.23,145,MS-DRG,22822.584,Case Rate,145% of CMS IPPS Rate,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19674.64,100,,15739.712,Case Rate,100% of CMS IPPS Rate,37950.69,100,,,Case Rate,100% of CMS IPPS Rate,43373.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48794.15,100,,,Case Rate,100% of CMS IPPS Rate,48794.15,100,,,Case Rate,100% of CMS IPPS Rate,48794.15,100,,,Case Rate,100% CMS IPPS Rate,35531.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17902.94,100,,14322.352,Case Rate,100% of CMS IPPS Rate,17902.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17902.94,100,MS-DRG,14322.352,Case Rate,100% of CMS IPPS Rate,17902.94,100,MS-DRG,14322.352,Case Rate,100% of CMS IPPS Rate,27739.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,25577.03,130,MS-DRG,20461.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20264.88,103,MS-DRG,16211.904,Case Rate,103% of CMS IPPS Rate,20264.88,103,MS-DRG,16211.904,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,20841.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29511.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48794.15,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,CDM,,,,,Inpatient,,,,,,24965.99,,,,Case Rate,100% of CMS IPPS Rate,18095.25,145,MS-DRG,14476.2,Case Rate,145% of CMS IPPS Rate,12479.48,100,MS-DRG,9983.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12479.48,100,,9983.584,Case Rate,100% of CMS IPPS Rate,24118.45,100,,,Case Rate,100% of CMS IPPS Rate,27564.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31009.69,100,,,Case Rate,100% of CMS IPPS Rate,31009.69,100,,,Case Rate,100% of CMS IPPS Rate,31009.69,100,,,Case Rate,100% CMS IPPS Rate,22537.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11355.79,100,,9084.632,Case Rate,100% of CMS IPPS Rate,11355.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11355.79,100,MS-DRG,9084.632,Case Rate,100% of CMS IPPS Rate,11355.79,100,MS-DRG,9084.632,Case Rate,100% of CMS IPPS Rate,20334.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12479.48,100,MS-DRG,9983.584,Case Rate,100% of CMS IPPS Rate,16223.32,130,MS-DRG,12978.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12853.86,103,MS-DRG,10283.088,Case Rate,103% of CMS IPPS Rate,12853.86,103,MS-DRG,10283.088,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12479.48,100,MS-DRG,9983.584,Case Rate,100% of CMS IPPS Rate,13219.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18719.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12479.48,100,MS-DRG,9983.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12479.48,100,MS-DRG,9983.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31009.69,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,CDM,,,,,Inpatient,,,,,,56684.88,,,,Case Rate,100% of CMS IPPS Rate,41084.92,145,MS-DRG,32867.936,Case Rate,145% of CMS IPPS Rate,28334.43,100,MS-DRG,22667.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28334.43,100,,22667.544,Case Rate,100% of CMS IPPS Rate,56782.06,100,,,Case Rate,100% of CMS IPPS Rate,64896.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,73006.12,100,,,Case Rate,100% of CMS IPPS Rate,73006.12,100,,,Case Rate,100% of CMS IPPS Rate,73006.12,100,,,Case Rate,100% CMS IPPS Rate,51170.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25782.82,100,,20626.256,Case Rate,100% of CMS IPPS Rate,25782.82,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25782.82,100,MS-DRG,20626.256,Case Rate,100% of CMS IPPS Rate,25782.82,100,MS-DRG,20626.256,Case Rate,100% of CMS IPPS Rate,52020.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28334.43,100,MS-DRG,22667.544,Case Rate,100% of CMS IPPS Rate,36834.76,130,MS-DRG,29467.808,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29184.46,103,MS-DRG,23347.568,Case Rate,103% of CMS IPPS Rate,29184.46,103,MS-DRG,23347.568,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28334.43,100,MS-DRG,22667.544,Case Rate,100% of CMS IPPS Rate,30015,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,42501.65,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28334.43,100,MS-DRG,22667.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28334.43,100,MS-DRG,22667.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,73006.12,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,CDM,,,,,Inpatient,,,,,,40646.07,,,,Case Rate,100% of CMS IPPS Rate,29460.07,145,MS-DRG,23568.056,Case Rate,145% of CMS IPPS Rate,20317.29,100,MS-DRG,16253.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20317.29,100,,16253.832,Case Rate,100% of CMS IPPS Rate,42593.88,100,,,Case Rate,100% of CMS IPPS Rate,48680.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54764.01,100,,,Case Rate,100% of CMS IPPS Rate,54764.01,100,,,Case Rate,100% of CMS IPPS Rate,54764.01,100,,,Case Rate,100% CMS IPPS Rate,36691.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18487.71,100,,14790.168,Case Rate,100% of CMS IPPS Rate,18487.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18487.71,100,MS-DRG,14790.168,Case Rate,100% of CMS IPPS Rate,18487.71,100,MS-DRG,14790.168,Case Rate,100% of CMS IPPS Rate,27346.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20317.29,100,MS-DRG,16253.832,Case Rate,100% of CMS IPPS Rate,26412.48,130,MS-DRG,21129.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20926.81,103,MS-DRG,16741.448,Case Rate,103% of CMS IPPS Rate,20926.81,103,MS-DRG,16741.448,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20317.29,100,MS-DRG,16253.832,Case Rate,100% of CMS IPPS Rate,21522.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30475.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20317.29,100,MS-DRG,16253.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20317.29,100,MS-DRG,16253.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54764.01,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,CDM,,,,,Inpatient,,,,,,36205.76,,,,Case Rate,100% of CMS IPPS Rate,26241.77,145,MS-DRG,20993.416,Case Rate,145% of CMS IPPS Rate,18097.77,100,MS-DRG,14478.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18097.77,100,,14478.216,Case Rate,100% of CMS IPPS Rate,38154.66,100,,,Case Rate,100% of CMS IPPS Rate,43606.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49056.39,100,,,Case Rate,100% of CMS IPPS Rate,49056.39,100,,,Case Rate,100% of CMS IPPS Rate,49056.39,100,,,Case Rate,100% CMS IPPS Rate,32683.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16468.09,100,,13174.472,Case Rate,100% of CMS IPPS Rate,16468.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16468.09,100,MS-DRG,13174.472,Case Rate,100% of CMS IPPS Rate,16468.09,100,MS-DRG,13174.472,Case Rate,100% of CMS IPPS Rate,23796.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18097.77,100,MS-DRG,14478.216,Case Rate,100% of CMS IPPS Rate,23527.1,130,MS-DRG,18821.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18640.7,103,MS-DRG,14912.56,Case Rate,103% of CMS IPPS Rate,18640.7,103,MS-DRG,14912.56,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18097.77,100,MS-DRG,14478.216,Case Rate,100% of CMS IPPS Rate,19171.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27146.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18097.77,100,MS-DRG,14478.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18097.77,100,MS-DRG,14478.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49056.39,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,CDM,,,,,Inpatient,,,,,,69541.67,,,,Case Rate,100% of CMS IPPS Rate,50403.46,145,MS-DRG,40322.768,Case Rate,145% of CMS IPPS Rate,34761.01,100,MS-DRG,27808.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34761.01,100,,27808.808,Case Rate,100% of CMS IPPS Rate,67708.15,100,,,Case Rate,100% of CMS IPPS Rate,77383.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,87054.06,100,,,Case Rate,100% of CMS IPPS Rate,87054.06,100,,,Case Rate,100% of CMS IPPS Rate,87054.06,100,,,Case Rate,100% CMS IPPS Rate,62776.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31630.6,100,,25304.48,Case Rate,100% of CMS IPPS Rate,31630.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,31630.6,100,MS-DRG,25304.48,Case Rate,100% of CMS IPPS Rate,31630.6,100,MS-DRG,25304.48,Case Rate,100% of CMS IPPS Rate,34412.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34761.01,100,MS-DRG,27808.808,Case Rate,100% of CMS IPPS Rate,45189.31,130,MS-DRG,36151.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35803.84,103,MS-DRG,28643.072,Case Rate,103% of CMS IPPS Rate,35803.84,103,MS-DRG,28643.072,Case Rate,103% of CMS IPPS Rate,64752.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34761.01,100,MS-DRG,27808.808,Case Rate,100% of CMS IPPS Rate,36822.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,52141.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34761.01,100,MS-DRG,27808.808,Case Rate,100% of CMS IPPS Rate,71106,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34761.01,100,MS-DRG,27808.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,87054.06,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,CDM,,,,,Inpatient,,,,,,34194.4,,,,Case Rate,100% of CMS IPPS Rate,24783.94,145,MS-DRG,19827.152,Case Rate,145% of CMS IPPS Rate,17092.37,100,MS-DRG,13673.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17092.37,100,,13673.896,Case Rate,100% of CMS IPPS Rate,32369,100,,,Case Rate,100% of CMS IPPS Rate,36994.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41617.63,100,,,Case Rate,100% of CMS IPPS Rate,41617.63,100,,,Case Rate,100% of CMS IPPS Rate,41617.63,100,,,Case Rate,100% CMS IPPS Rate,30867.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15553.23,100,,12442.584,Case Rate,100% of CMS IPPS Rate,15553.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15553.23,100,MS-DRG,12442.584,Case Rate,100% of CMS IPPS Rate,15553.23,100,MS-DRG,12442.584,Case Rate,100% of CMS IPPS Rate,22090.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17092.37,100,MS-DRG,13673.896,Case Rate,100% of CMS IPPS Rate,22220.08,130,MS-DRG,17776.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17605.14,103,MS-DRG,14084.112,Case Rate,103% of CMS IPPS Rate,17605.14,103,MS-DRG,14084.112,Case Rate,103% of CMS IPPS Rate,32400.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17092.37,100,MS-DRG,13673.896,Case Rate,100% of CMS IPPS Rate,18106.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25638.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17092.37,100,MS-DRG,13673.896,Case Rate,100% of CMS IPPS Rate,34963.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17092.37,100,MS-DRG,13673.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41617.63,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,CDM,,,,,Inpatient,,,,,,21870.23,,,,Case Rate,100% of CMS IPPS Rate,15851.43,145,MS-DRG,12681.144,Case Rate,145% of CMS IPPS Rate,10932.02,100,MS-DRG,8745.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10932.02,100,,8745.616,Case Rate,100% of CMS IPPS Rate,21242.95,100,,,Case Rate,100% of CMS IPPS Rate,24278.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27312.59,100,,,Case Rate,100% of CMS IPPS Rate,27312.59,100,,,Case Rate,100% of CMS IPPS Rate,27312.59,100,,,Case Rate,100% CMS IPPS Rate,19742.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9947.72,100,,7958.176,Case Rate,100% of CMS IPPS Rate,9947.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9947.72,100,MS-DRG,7958.176,Case Rate,100% of CMS IPPS Rate,9947.72,100,MS-DRG,7958.176,Case Rate,100% of CMS IPPS Rate,16503.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10932.02,100,MS-DRG,8745.616,Case Rate,100% of CMS IPPS Rate,14211.63,130,MS-DRG,11369.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11259.98,103,MS-DRG,9007.984,Case Rate,103% of CMS IPPS Rate,11259.98,103,MS-DRG,9007.984,Case Rate,103% of CMS IPPS Rate,20969.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10932.02,100,MS-DRG,8745.616,Case Rate,100% of CMS IPPS Rate,11580.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16398.03,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10932.02,100,MS-DRG,8745.616,Case Rate,100% of CMS IPPS Rate,22362.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10932.02,100,MS-DRG,8745.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27312.59,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,CDM,,,,,Inpatient,,,,,,61844.03,,,,Case Rate,100% of CMS IPPS Rate,44824.24,145,MS-DRG,35859.392,Case Rate,145% of CMS IPPS Rate,30913.27,100,MS-DRG,24730.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30913.27,100,,24730.616,Case Rate,100% of CMS IPPS Rate,61214.62,100,,,Case Rate,100% of CMS IPPS Rate,69962.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,78705.17,100,,,Case Rate,100% of CMS IPPS Rate,78705.17,100,,,Case Rate,100% of CMS IPPS Rate,78705.17,100,,,Case Rate,100% CMS IPPS Rate,55827.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28129.4,100,,22503.52,Case Rate,100% of CMS IPPS Rate,28129.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28129.4,100,MS-DRG,22503.52,Case Rate,100% of CMS IPPS Rate,28129.4,100,MS-DRG,22503.52,Case Rate,100% of CMS IPPS Rate,36872.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30913.27,100,MS-DRG,24730.616,Case Rate,100% of CMS IPPS Rate,40187.25,130,MS-DRG,32149.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31840.67,103,MS-DRG,25472.536,Case Rate,103% of CMS IPPS Rate,31840.67,103,MS-DRG,25472.536,Case Rate,103% of CMS IPPS Rate,58484.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30913.27,100,MS-DRG,24730.616,Case Rate,100% of CMS IPPS Rate,32746.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,46369.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30913.27,100,MS-DRG,24730.616,Case Rate,100% of CMS IPPS Rate,63235.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30913.27,100,MS-DRG,24730.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,78705.17,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,CDM,,,,,Inpatient,,,,,,32478.79,,,,Case Rate,100% of CMS IPPS Rate,23540.46,145,MS-DRG,18832.368,Case Rate,145% of CMS IPPS Rate,16234.8,100,MS-DRG,12987.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16234.8,100,,12987.84,Case Rate,100% of CMS IPPS Rate,31510.48,100,,,Case Rate,100% of CMS IPPS Rate,36013.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40513.82,100,,,Case Rate,100% of CMS IPPS Rate,40513.82,100,,,Case Rate,100% of CMS IPPS Rate,40513.82,100,,,Case Rate,100% CMS IPPS Rate,29319.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14772.92,100,,11818.336,Case Rate,100% of CMS IPPS Rate,14772.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14772.92,100,MS-DRG,11818.336,Case Rate,100% of CMS IPPS Rate,14772.92,100,MS-DRG,11818.336,Case Rate,100% of CMS IPPS Rate,18642.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16234.8,100,MS-DRG,12987.84,Case Rate,100% of CMS IPPS Rate,21105.24,130,MS-DRG,16884.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16721.84,103,MS-DRG,13377.472,Case Rate,103% of CMS IPPS Rate,16721.84,103,MS-DRG,13377.472,Case Rate,103% of CMS IPPS Rate,31060.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16234.8,100,MS-DRG,12987.84,Case Rate,100% of CMS IPPS Rate,17197.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24352.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16234.8,100,MS-DRG,12987.84,Case Rate,100% of CMS IPPS Rate,33209.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16234.8,100,MS-DRG,12987.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40513.82,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,CDM,,,,,Inpatient,,,,,,22893.02,,,,Case Rate,100% of CMS IPPS Rate,16592.74,145,MS-DRG,13274.192,Case Rate,145% of CMS IPPS Rate,11443.27,100,MS-DRG,9154.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11443.27,100,,9154.616,Case Rate,100% of CMS IPPS Rate,22009.48,100,,,Case Rate,100% of CMS IPPS Rate,25154.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28298.14,100,,,Case Rate,100% of CMS IPPS Rate,28298.14,100,,,Case Rate,100% of CMS IPPS Rate,28298.14,100,,,Case Rate,100% CMS IPPS Rate,20665.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10412.92,100,,8330.336,Case Rate,100% of CMS IPPS Rate,10412.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10412.92,100,MS-DRG,8330.336,Case Rate,100% of CMS IPPS Rate,10412.92,100,MS-DRG,8330.336,Case Rate,100% of CMS IPPS Rate,15818.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11443.27,100,MS-DRG,9154.616,Case Rate,100% of CMS IPPS Rate,14876.25,130,MS-DRG,11901,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11786.57,103,MS-DRG,9429.256,Case Rate,103% of CMS IPPS Rate,11786.57,103,MS-DRG,9429.256,Case Rate,103% of CMS IPPS Rate,21616.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11443.27,100,MS-DRG,9154.616,Case Rate,100% of CMS IPPS Rate,12122,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17164.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11443.27,100,MS-DRG,9154.616,Case Rate,100% of CMS IPPS Rate,23408,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11443.27,100,MS-DRG,9154.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28298.14,
RECTAL RESECTION WITH MCC,332,CDM,,,,,Inpatient,,,,,,49669.1,,,,Case Rate,100% of CMS IPPS Rate,36264.89,145,MS-DRG,29011.912,Case Rate,145% of CMS IPPS Rate,25010.27,100,MS-DRG,20008.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25010.27,100,,20008.216,Case Rate,100% of CMS IPPS Rate,46241.24,100,,,Case Rate,100% of CMS IPPS Rate,52849.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,59453.52,100,,,Case Rate,100% of CMS IPPS Rate,59453.52,100,,,Case Rate,100% of CMS IPPS Rate,59453.52,100,,,Case Rate,100% CMS IPPS Rate,44837.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22758.03,100,,18206.424,Case Rate,100% of CMS IPPS Rate,22758.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22758.03,100,MS-DRG,18206.424,Case Rate,100% of CMS IPPS Rate,22758.03,100,MS-DRG,18206.424,Case Rate,100% of CMS IPPS Rate,32885.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25010.27,100,MS-DRG,20008.216,Case Rate,100% of CMS IPPS Rate,32513.35,130,MS-DRG,26010.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25760.58,103,MS-DRG,20608.464,Case Rate,103% of CMS IPPS Rate,25760.58,103,MS-DRG,20608.464,Case Rate,103% of CMS IPPS Rate,51362.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25010.27,100,MS-DRG,20008.216,Case Rate,100% of CMS IPPS Rate,26300.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37515.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25010.27,100,MS-DRG,20008.216,Case Rate,100% of CMS IPPS Rate,50786.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25010.27,100,MS-DRG,20008.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,59453.52,
RECTAL RESECTION WITH CC,333,CDM,,,,,Inpatient,,,,,,28472.51,,,,Case Rate,100% of CMS IPPS Rate,20636.73,145,MS-DRG,16509.384,Case Rate,145% of CMS IPPS Rate,14232.23,100,MS-DRG,11385.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14232.23,100,,11385.784,Case Rate,100% of CMS IPPS Rate,28332.37,100,,,Case Rate,100% of CMS IPPS Rate,32381.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36427.64,100,,,Case Rate,100% of CMS IPPS Rate,36427.64,100,,,Case Rate,100% of CMS IPPS Rate,36427.64,100,,,Case Rate,100% CMS IPPS Rate,25702.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12950.69,100,,10360.552,Case Rate,100% of CMS IPPS Rate,12950.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12950.69,100,MS-DRG,10360.552,Case Rate,100% of CMS IPPS Rate,12950.69,100,MS-DRG,10360.552,Case Rate,100% of CMS IPPS Rate,28229.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14232.23,100,MS-DRG,11385.784,Case Rate,100% of CMS IPPS Rate,18501.9,130,MS-DRG,14801.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14659.2,103,MS-DRG,11727.36,Case Rate,103% of CMS IPPS Rate,14659.2,103,MS-DRG,11727.36,Case Rate,103% of CMS IPPS Rate,28248.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14232.23,100,MS-DRG,11385.784,Case Rate,100% of CMS IPPS Rate,15076.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21348.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14232.23,100,MS-DRG,11385.784,Case Rate,100% of CMS IPPS Rate,29113,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14232.23,100,MS-DRG,11385.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36427.64,
RECTAL RESECTION WITHOUT CC/MCC,334,CDM,,,,,Inpatient,,,,,,21977.03,,,,Case Rate,100% of CMS IPPS Rate,15928.84,145,MS-DRG,12743.072,Case Rate,145% of CMS IPPS Rate,10985.41,100,MS-DRG,8788.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10985.41,100,,8788.328,Case Rate,100% of CMS IPPS Rate,22110.8,100,,,Case Rate,100% of CMS IPPS Rate,25270.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28428.4,100,,,Case Rate,100% of CMS IPPS Rate,28428.4,100,,,Case Rate,100% of CMS IPPS Rate,28428.4,100,,,Case Rate,100% CMS IPPS Rate,19839.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9996.29,100,,7997.032,Case Rate,100% of CMS IPPS Rate,9996.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9996.29,100,MS-DRG,7997.032,Case Rate,100% of CMS IPPS Rate,9996.29,100,MS-DRG,7997.032,Case Rate,100% of CMS IPPS Rate,19158.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10985.41,100,MS-DRG,8788.328,Case Rate,100% of CMS IPPS Rate,14281.03,130,MS-DRG,11424.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11314.97,103,MS-DRG,9051.976,Case Rate,103% of CMS IPPS Rate,11314.97,103,MS-DRG,9051.976,Case Rate,103% of CMS IPPS Rate,21688.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10985.41,100,MS-DRG,8788.328,Case Rate,100% of CMS IPPS Rate,11636.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16478.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10985.41,100,MS-DRG,8788.328,Case Rate,100% of CMS IPPS Rate,22471.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10985.41,100,MS-DRG,8788.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28428.4,
PERITONEAL ADHESIOLYSIS WITH MCC,335,CDM,,,,,Inpatient,,,,,,48948.9,,,,Case Rate,100% of CMS IPPS Rate,35477.92,145,MS-DRG,28382.336,Case Rate,145% of CMS IPPS Rate,24467.53,100,MS-DRG,19574.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24467.53,100,,19574.024,Case Rate,100% of CMS IPPS Rate,48303.55,100,,,Case Rate,100% of CMS IPPS Rate,55206.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,62105.08,100,,,Case Rate,100% of CMS IPPS Rate,62105.08,100,,,Case Rate,100% of CMS IPPS Rate,62105.08,100,,,Case Rate,100% CMS IPPS Rate,44187,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22264.17,100,,17811.336,Case Rate,100% of CMS IPPS Rate,22264.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22264.17,100,MS-DRG,17811.336,Case Rate,100% of CMS IPPS Rate,22264.17,100,MS-DRG,17811.336,Case Rate,100% of CMS IPPS Rate,22912.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24467.53,100,MS-DRG,19574.024,Case Rate,100% of CMS IPPS Rate,31807.79,130,MS-DRG,25446.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25201.56,103,MS-DRG,20161.248,Case Rate,103% of CMS IPPS Rate,25201.56,103,MS-DRG,20161.248,Case Rate,103% of CMS IPPS Rate,46600.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24467.53,100,MS-DRG,19574.024,Case Rate,100% of CMS IPPS Rate,25918.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,36701.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24467.53,100,MS-DRG,19574.024,Case Rate,100% of CMS IPPS Rate,50050,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24467.53,100,MS-DRG,19574.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,62105.08,
PERITONEAL ADHESIOLYSIS WITH CC,336,CDM,,,,,Inpatient,,,,,,28825.77,,,,Case Rate,100% of CMS IPPS Rate,20892.77,145,MS-DRG,16714.216,Case Rate,145% of CMS IPPS Rate,14408.81,100,MS-DRG,11527.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14408.81,100,,11527.048,Case Rate,100% of CMS IPPS Rate,28159.07,100,,,Case Rate,100% of CMS IPPS Rate,32183,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36204.82,100,,,Case Rate,100% of CMS IPPS Rate,36204.82,100,,,Case Rate,100% of CMS IPPS Rate,36204.82,100,,,Case Rate,100% CMS IPPS Rate,26021.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13111.36,100,,10489.088,Case Rate,100% of CMS IPPS Rate,13111.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13111.36,100,MS-DRG,10489.088,Case Rate,100% of CMS IPPS Rate,13111.36,100,MS-DRG,10489.088,Case Rate,100% of CMS IPPS Rate,15496.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14408.81,100,MS-DRG,11527.048,Case Rate,100% of CMS IPPS Rate,18731.45,130,MS-DRG,14985.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14841.07,103,MS-DRG,11872.856,Case Rate,103% of CMS IPPS Rate,14841.07,103,MS-DRG,11872.856,Case Rate,103% of CMS IPPS Rate,26906.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14408.81,100,MS-DRG,11527.048,Case Rate,100% of CMS IPPS Rate,15263.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21613.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14408.81,100,MS-DRG,11527.048,Case Rate,100% of CMS IPPS Rate,29474.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14408.81,100,MS-DRG,11527.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36204.82,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,CDM,,,,,Inpatient,,,,,,20488.71,,,,Case Rate,100% of CMS IPPS Rate,14850.12,145,MS-DRG,11880.096,Case Rate,145% of CMS IPPS Rate,10241.46,100,MS-DRG,8193.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10241.46,100,,8193.168,Case Rate,100% of CMS IPPS Rate,20464.42,100,,,Case Rate,100% of CMS IPPS Rate,23388.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26311.61,100,,,Case Rate,100% of CMS IPPS Rate,26311.61,100,,,Case Rate,100% of CMS IPPS Rate,26311.61,100,,,Case Rate,100% CMS IPPS Rate,18495.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9319.34,100,,7455.472,Case Rate,100% of CMS IPPS Rate,9319.34,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9319.34,100,MS-DRG,7455.472,Case Rate,100% of CMS IPPS Rate,9319.34,100,MS-DRG,7455.472,Case Rate,100% of CMS IPPS Rate,12814.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10241.46,100,MS-DRG,8193.168,Case Rate,100% of CMS IPPS Rate,13313.9,130,MS-DRG,10651.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10548.7,103,MS-DRG,8438.96,Case Rate,103% of CMS IPPS Rate,10548.7,103,MS-DRG,8438.96,Case Rate,103% of CMS IPPS Rate,19930.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10241.46,100,MS-DRG,8193.168,Case Rate,100% of CMS IPPS Rate,10848.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15362.19,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10241.46,100,MS-DRG,8193.168,Case Rate,100% of CMS IPPS Rate,20949.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10241.46,100,MS-DRG,8193.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26311.61,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,CDM,,,,,Inpatient,,,,,,37521.56,,,,Case Rate,100% of CMS IPPS Rate,27195.43,145,MS-DRG,21756.344,Case Rate,145% of CMS IPPS Rate,18755.47,100,MS-DRG,15004.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18755.47,100,,15004.376,Case Rate,100% of CMS IPPS Rate,35920.38,100,,,Case Rate,100% of CMS IPPS Rate,41053.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46183.73,100,,,Case Rate,100% of CMS IPPS Rate,46183.73,100,,,Case Rate,100% of CMS IPPS Rate,46183.73,100,,,Case Rate,100% CMS IPPS Rate,33871.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17066.56,100,,13653.248,Case Rate,100% of CMS IPPS Rate,17066.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17066.56,100,MS-DRG,13653.248,Case Rate,100% of CMS IPPS Rate,17066.56,100,MS-DRG,13653.248,Case Rate,100% of CMS IPPS Rate,19248.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18755.47,100,MS-DRG,15004.376,Case Rate,100% of CMS IPPS Rate,24382.11,130,MS-DRG,19505.688,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19318.13,103,MS-DRG,15454.504,Case Rate,103% of CMS IPPS Rate,19318.13,103,MS-DRG,15454.504,Case Rate,103% of CMS IPPS Rate,33301.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18755.47,100,MS-DRG,15004.376,Case Rate,100% of CMS IPPS Rate,19867.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28133.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18755.47,100,MS-DRG,15004.376,Case Rate,100% of CMS IPPS Rate,38365.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18755.47,100,MS-DRG,15004.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46183.73,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,CDM,,,,,Inpatient,,,,,,21093.9,,,,Case Rate,100% of CMS IPPS Rate,15288.76,145,MS-DRG,12231.008,Case Rate,145% of CMS IPPS Rate,10543.97,100,MS-DRG,8435.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10543.97,100,,8435.176,Case Rate,100% of CMS IPPS Rate,19845.86,100,,,Case Rate,100% of CMS IPPS Rate,22681.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25516.32,100,,,Case Rate,100% of CMS IPPS Rate,25516.32,100,,,Case Rate,100% of CMS IPPS Rate,25516.32,100,,,Case Rate,100% CMS IPPS Rate,19041.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9594.61,100,,7675.688,Case Rate,100% of CMS IPPS Rate,9594.61,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9594.61,100,MS-DRG,7675.688,Case Rate,100% of CMS IPPS Rate,9594.61,100,MS-DRG,7675.688,Case Rate,100% of CMS IPPS Rate,12651.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10543.97,100,MS-DRG,8435.176,Case Rate,100% of CMS IPPS Rate,13707.16,130,MS-DRG,10965.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10860.29,103,MS-DRG,8688.232,Case Rate,103% of CMS IPPS Rate,10860.29,103,MS-DRG,8688.232,Case Rate,103% of CMS IPPS Rate,19626.48,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10543.97,100,MS-DRG,8435.176,Case Rate,100% of CMS IPPS Rate,11169.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15815.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10543.97,100,MS-DRG,8435.176,Case Rate,100% of CMS IPPS Rate,21568.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10543.97,100,MS-DRG,8435.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25516.32,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,CDM,,,,,Inpatient,,,,,,17632.56,,,,Case Rate,100% of CMS IPPS Rate,12780,145,MS-DRG,10224,Case Rate,145% of CMS IPPS Rate,8813.79,100,MS-DRG,7051.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8813.79,100,,7051.032,Case Rate,100% of CMS IPPS Rate,16601.09,100,,,Case Rate,100% of CMS IPPS Rate,18973.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21344.44,100,,,Case Rate,100% of CMS IPPS Rate,21344.44,100,,,Case Rate,100% of CMS IPPS Rate,21344.44,100,,,Case Rate,100% CMS IPPS Rate,15917.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8020.24,100,,6416.192,Case Rate,100% of CMS IPPS Rate,8020.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8020.24,100,MS-DRG,6416.192,Case Rate,100% of CMS IPPS Rate,8020.24,100,MS-DRG,6416.192,Case Rate,100% of CMS IPPS Rate,7376.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8813.79,100,MS-DRG,7051.032,Case Rate,100% of CMS IPPS Rate,11457.93,130,MS-DRG,9166.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9078.2,103,MS-DRG,7262.56,Case Rate,103% of CMS IPPS Rate,9078.2,103,MS-DRG,7262.56,Case Rate,103% of CMS IPPS Rate,15821.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8813.79,100,MS-DRG,7051.032,Case Rate,100% of CMS IPPS Rate,9336.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13220.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8813.79,100,MS-DRG,7051.032,Case Rate,100% of CMS IPPS Rate,18029.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8813.79,100,MS-DRG,7051.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21344.44,
ANAL AND STOMAL PROCEDURES WITH MCC,347,CDM,,,,,Inpatient,,,,,,34902.28,,,,Case Rate,100% of CMS IPPS Rate,25296.99,145,MS-DRG,20237.592,Case Rate,145% of CMS IPPS Rate,17446.2,100,MS-DRG,13956.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17446.2,100,,13956.96,Case Rate,100% of CMS IPPS Rate,31551.81,100,,,Case Rate,100% of CMS IPPS Rate,36060.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40566.95,100,,,Case Rate,100% of CMS IPPS Rate,40566.95,100,,,Case Rate,100% of CMS IPPS Rate,40566.95,100,,,Case Rate,100% CMS IPPS Rate,31506.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15875.21,100,,12700.168,Case Rate,100% of CMS IPPS Rate,15875.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15875.21,100,MS-DRG,12700.168,Case Rate,100% of CMS IPPS Rate,15875.21,100,MS-DRG,12700.168,Case Rate,100% of CMS IPPS Rate,15338.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17446.2,100,MS-DRG,13956.96,Case Rate,100% of CMS IPPS Rate,22680.06,130,MS-DRG,18144.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17969.59,103,MS-DRG,14375.672,Case Rate,103% of CMS IPPS Rate,17969.59,103,MS-DRG,14375.672,Case Rate,103% of CMS IPPS Rate,32108.23,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17446.2,100,MS-DRG,13956.96,Case Rate,100% of CMS IPPS Rate,18480.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26169.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17446.2,100,MS-DRG,13956.96,Case Rate,100% of CMS IPPS Rate,35687.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17446.2,100,MS-DRG,13956.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40566.95,
ANAL AND STOMAL PROCEDURES WITH CC,348,CDM,,,,,Inpatient,,,,,,17818.77,,,,Case Rate,100% of CMS IPPS Rate,12914.96,145,MS-DRG,10331.968,Case Rate,145% of CMS IPPS Rate,8906.87,100,MS-DRG,7125.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8906.87,100,,7125.496,Case Rate,100% of CMS IPPS Rate,16782.4,100,,,Case Rate,100% of CMS IPPS Rate,19180.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21577.55,100,,,Case Rate,100% of CMS IPPS Rate,21577.55,100,,,Case Rate,100% of CMS IPPS Rate,21577.55,100,,,Case Rate,100% CMS IPPS Rate,16085.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8104.95,100,,6483.96,Case Rate,100% of CMS IPPS Rate,8104.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8104.95,100,MS-DRG,6483.96,Case Rate,100% of CMS IPPS Rate,8104.95,100,MS-DRG,6483.96,Case Rate,100% of CMS IPPS Rate,9644.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8906.87,100,MS-DRG,7125.496,Case Rate,100% of CMS IPPS Rate,11578.93,130,MS-DRG,9263.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9174.08,103,MS-DRG,7339.264,Case Rate,103% of CMS IPPS Rate,9174.08,103,MS-DRG,7339.264,Case Rate,103% of CMS IPPS Rate,17469.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8906.87,100,MS-DRG,7125.496,Case Rate,100% of CMS IPPS Rate,9435.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13360.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8906.87,100,MS-DRG,7125.496,Case Rate,100% of CMS IPPS Rate,18219.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8906.87,100,MS-DRG,7125.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21577.55,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,CDM,,,,,Inpatient,,,,,,13360.65,,,,Case Rate,100% of CMS IPPS Rate,9683.72,145,MS-DRG,7746.976,Case Rate,145% of CMS IPPS Rate,6678.43,100,MS-DRG,5342.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6678.43,100,,5342.744,Case Rate,100% of CMS IPPS Rate,11743.28,100,,,Case Rate,100% of CMS IPPS Rate,13421.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15098.63,100,,,Case Rate,100% of CMS IPPS Rate,15098.63,100,,,Case Rate,100% of CMS IPPS Rate,15098.63,100,,,Case Rate,100% CMS IPPS Rate,12060.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6077.22,100,,4861.776,Case Rate,100% of CMS IPPS Rate,6077.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6077.22,100,MS-DRG,4861.776,Case Rate,100% of CMS IPPS Rate,6077.22,100,MS-DRG,4861.776,Case Rate,100% of CMS IPPS Rate,9183.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6678.43,100,MS-DRG,5342.744,Case Rate,100% of CMS IPPS Rate,8681.96,130,MS-DRG,6945.568,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6878.78,103,MS-DRG,5503.024,Case Rate,103% of CMS IPPS Rate,6878.78,103,MS-DRG,5503.024,Case Rate,103% of CMS IPPS Rate,12614.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6678.43,100,MS-DRG,5342.744,Case Rate,100% of CMS IPPS Rate,7074.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10017.65,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6678.43,100,MS-DRG,5342.744,Case Rate,100% of CMS IPPS Rate,13661.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6678.43,100,MS-DRG,5342.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,15098.63,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,CDM,,,,,Inpatient,,,,,,32860.8,,,,Case Rate,100% of CMS IPPS Rate,23817.34,145,MS-DRG,19053.872,Case Rate,145% of CMS IPPS Rate,16425.75,100,MS-DRG,13140.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16425.75,100,,13140.6,Case Rate,100% of CMS IPPS Rate,32243.69,100,,,Case Rate,100% of CMS IPPS Rate,36851.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41456.52,100,,,Case Rate,100% of CMS IPPS Rate,41456.52,100,,,Case Rate,100% of CMS IPPS Rate,41456.52,100,,,Case Rate,100% CMS IPPS Rate,29664,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14946.66,100,,11957.328,Case Rate,100% of CMS IPPS Rate,14946.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14946.66,100,MS-DRG,11957.328,Case Rate,100% of CMS IPPS Rate,14946.66,100,MS-DRG,11957.328,Case Rate,100% of CMS IPPS Rate,21597.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16425.75,100,MS-DRG,13140.6,Case Rate,100% of CMS IPPS Rate,21353.48,130,MS-DRG,17082.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16918.52,103,MS-DRG,13534.816,Case Rate,103% of CMS IPPS Rate,16918.52,103,MS-DRG,13534.816,Case Rate,103% of CMS IPPS Rate,29816.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16425.75,100,MS-DRG,13140.6,Case Rate,100% of CMS IPPS Rate,17400,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24638.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16425.75,100,MS-DRG,13140.6,Case Rate,100% of CMS IPPS Rate,33600,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16425.75,100,MS-DRG,13140.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41456.52,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,CDM,,,,,Inpatient,,,,,,19930.08,,,,Case Rate,100% of CMS IPPS Rate,14445.22,145,MS-DRG,11556.176,Case Rate,145% of CMS IPPS Rate,9962.22,100,MS-DRG,7969.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9962.22,100,,7969.776,Case Rate,100% of CMS IPPS Rate,20056.49,100,,,Case Rate,100% of CMS IPPS Rate,22922.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25787.13,100,,,Case Rate,100% of CMS IPPS Rate,25787.13,100,,,Case Rate,100% of CMS IPPS Rate,25787.13,100,,,Case Rate,100% CMS IPPS Rate,17991.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9065.25,100,,7252.2,Case Rate,100% of CMS IPPS Rate,9065.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9065.25,100,MS-DRG,7252.2,Case Rate,100% of CMS IPPS Rate,9065.25,100,MS-DRG,7252.2,Case Rate,100% of CMS IPPS Rate,14596.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9962.22,100,MS-DRG,7969.776,Case Rate,100% of CMS IPPS Rate,12950.89,130,MS-DRG,10360.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10261.09,103,MS-DRG,8208.872,Case Rate,103% of CMS IPPS Rate,10261.09,103,MS-DRG,8208.872,Case Rate,103% of CMS IPPS Rate,18598.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9962.22,100,MS-DRG,7969.776,Case Rate,100% of CMS IPPS Rate,10553.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14943.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9962.22,100,MS-DRG,7969.776,Case Rate,100% of CMS IPPS Rate,20378.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9962.22,100,MS-DRG,7969.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25787.13,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,CDM,,,,,Inpatient,,,,,,15184.43,,,,Case Rate,100% of CMS IPPS Rate,11005.6,145,MS-DRG,8804.48,Case Rate,145% of CMS IPPS Rate,7590.07,100,MS-DRG,6072.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7590.07,100,,6072.056,Case Rate,100% of CMS IPPS Rate,14698.76,100,,,Case Rate,100% of CMS IPPS Rate,16799.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18898.56,100,,,Case Rate,100% of CMS IPPS Rate,18898.56,100,,,Case Rate,100% of CMS IPPS Rate,18898.56,100,,,Case Rate,100% CMS IPPS Rate,13707.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6906.75,100,,5525.4,Case Rate,100% of CMS IPPS Rate,6906.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6906.75,100,MS-DRG,5525.4,Case Rate,100% of CMS IPPS Rate,6906.75,100,MS-DRG,5525.4,Case Rate,100% of CMS IPPS Rate,13454.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7590.07,100,MS-DRG,6072.056,Case Rate,100% of CMS IPPS Rate,9867.09,130,MS-DRG,7893.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7817.77,103,MS-DRG,6254.216,Case Rate,103% of CMS IPPS Rate,7817.77,103,MS-DRG,6254.216,Case Rate,103% of CMS IPPS Rate,13941.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7590.07,100,MS-DRG,6072.056,Case Rate,100% of CMS IPPS Rate,8040.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11385.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7590.07,100,MS-DRG,6072.056,Case Rate,100% of CMS IPPS Rate,15526,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7590.07,100,MS-DRG,6072.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18898.56,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,CDM,,,,,Inpatient,,,,,,40039.52,,,,Case Rate,100% of CMS IPPS Rate,29020.45,145,MS-DRG,23216.36,Case Rate,145% of CMS IPPS Rate,20014.1,100,MS-DRG,16011.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20014.1,100,,16011.28,Case Rate,100% of CMS IPPS Rate,39099.82,100,,,Case Rate,100% of CMS IPPS Rate,44687.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,50271.62,100,,,Case Rate,100% of CMS IPPS Rate,50271.62,100,,,Case Rate,100% of CMS IPPS Rate,50271.62,100,,,Case Rate,100% CMS IPPS Rate,36144.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18211.83,100,,14569.464,Case Rate,100% of CMS IPPS Rate,18211.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18211.83,100,MS-DRG,14569.464,Case Rate,100% of CMS IPPS Rate,18211.83,100,MS-DRG,14569.464,Case Rate,100% of CMS IPPS Rate,26669.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20014.1,100,MS-DRG,16011.28,Case Rate,100% of CMS IPPS Rate,26018.33,130,MS-DRG,20814.664,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20614.52,103,MS-DRG,16491.616,Case Rate,103% of CMS IPPS Rate,20614.52,103,MS-DRG,16491.616,Case Rate,103% of CMS IPPS Rate,36277.67,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20014.1,100,MS-DRG,16011.28,Case Rate,100% of CMS IPPS Rate,21201.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30021.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20014.1,100,MS-DRG,16011.28,Case Rate,100% of CMS IPPS Rate,40940.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20014.1,100,MS-DRG,16011.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,50271.62,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,CDM,,,,,Inpatient,,,,,,23520.12,,,,Case Rate,100% of CMS IPPS Rate,17047.26,145,MS-DRG,13637.808,Case Rate,145% of CMS IPPS Rate,11756.73,100,MS-DRG,9405.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11756.73,100,,9405.384,Case Rate,100% of CMS IPPS Rate,22677.36,100,,,Case Rate,100% of CMS IPPS Rate,25917.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29156.85,100,,,Case Rate,100% of CMS IPPS Rate,29156.85,100,,,Case Rate,100% of CMS IPPS Rate,29156.85,100,,,Case Rate,100% CMS IPPS Rate,21232.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10698.15,100,,8558.52,Case Rate,100% of CMS IPPS Rate,10698.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10698.15,100,MS-DRG,8558.52,Case Rate,100% of CMS IPPS Rate,10698.15,100,MS-DRG,8558.52,Case Rate,100% of CMS IPPS Rate,15354.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11756.73,100,MS-DRG,9405.384,Case Rate,100% of CMS IPPS Rate,15283.75,130,MS-DRG,12227,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12109.43,103,MS-DRG,9687.544,Case Rate,103% of CMS IPPS Rate,12109.43,103,MS-DRG,9687.544,Case Rate,103% of CMS IPPS Rate,22162.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11756.73,100,MS-DRG,9405.384,Case Rate,100% of CMS IPPS Rate,12454.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17635.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11756.73,100,MS-DRG,9405.384,Case Rate,100% of CMS IPPS Rate,24049.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11756.73,100,MS-DRG,9405.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29156.85,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,CDM,,,,,Inpatient,,,,,,18656.72,,,,Case Rate,100% of CMS IPPS Rate,13522.29,145,MS-DRG,10817.832,Case Rate,145% of CMS IPPS Rate,9325.72,100,MS-DRG,7460.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9325.72,100,,7460.576,Case Rate,100% of CMS IPPS Rate,17772.89,100,,,Case Rate,100% of CMS IPPS Rate,20312.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22851.05,100,,,Case Rate,100% of CMS IPPS Rate,22851.05,100,,,Case Rate,100% of CMS IPPS Rate,22851.05,100,,,Case Rate,100% CMS IPPS Rate,16841.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8486.07,100,,6788.856,Case Rate,100% of CMS IPPS Rate,8486.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8486.07,100,MS-DRG,6788.856,Case Rate,100% of CMS IPPS Rate,8486.07,100,MS-DRG,6788.856,Case Rate,100% of CMS IPPS Rate,12939.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9325.72,100,MS-DRG,7460.576,Case Rate,100% of CMS IPPS Rate,12123.44,130,MS-DRG,9698.752,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9605.49,103,MS-DRG,7684.392,Case Rate,103% of CMS IPPS Rate,9605.49,103,MS-DRG,7684.392,Case Rate,103% of CMS IPPS Rate,17359.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9325.72,100,MS-DRG,7460.576,Case Rate,100% of CMS IPPS Rate,9878.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13988.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9325.72,100,MS-DRG,7460.576,Case Rate,100% of CMS IPPS Rate,19076.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9325.72,100,MS-DRG,7460.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22851.05,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,CDM,,,,,Inpatient,,,,,,58583.96,,,,Case Rate,100% of CMS IPPS Rate,42461.37,145,MS-DRG,33969.096,Case Rate,145% of CMS IPPS Rate,29283.7,100,MS-DRG,23426.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29283.7,100,,23426.96,Case Rate,100% of CMS IPPS Rate,56866.05,100,,,Case Rate,100% of CMS IPPS Rate,64992.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,73114.1,100,,,Case Rate,100% of CMS IPPS Rate,73114.1,100,,,Case Rate,100% of CMS IPPS Rate,73114.1,100,,,Case Rate,100% CMS IPPS Rate,52884.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26646.59,100,,21317.272,Case Rate,100% of CMS IPPS Rate,26646.59,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,26646.59,100,MS-DRG,21317.272,Case Rate,100% of CMS IPPS Rate,26646.59,100,MS-DRG,21317.272,Case Rate,100% of CMS IPPS Rate,30815.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29283.7,100,MS-DRG,23426.96,Case Rate,100% of CMS IPPS Rate,38068.81,130,MS-DRG,30455.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30162.21,103,MS-DRG,24129.768,Case Rate,103% of CMS IPPS Rate,30162.21,103,MS-DRG,24129.768,Case Rate,103% of CMS IPPS Rate,53414.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29283.7,100,MS-DRG,23426.96,Case Rate,100% of CMS IPPS Rate,31020.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,43925.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29283.7,100,MS-DRG,23426.96,Case Rate,100% of CMS IPPS Rate,59901.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29283.7,100,MS-DRG,23426.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,73114.1,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,CDM,,,,,Inpatient,,,,,,30078.59,,,,Case Rate,100% of CMS IPPS Rate,21800.81,145,MS-DRG,17440.648,Case Rate,145% of CMS IPPS Rate,15035.04,100,MS-DRG,12028.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15035.04,100,,12028.032,Case Rate,100% of CMS IPPS Rate,30021.41,100,,,Case Rate,100% of CMS IPPS Rate,34311.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38599.28,100,,,Case Rate,100% of CMS IPPS Rate,38599.28,100,,,Case Rate,100% of CMS IPPS Rate,38599.28,100,,,Case Rate,100% CMS IPPS Rate,27152.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13681.21,100,,10944.968,Case Rate,100% of CMS IPPS Rate,13681.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13681.21,100,MS-DRG,10944.968,Case Rate,100% of CMS IPPS Rate,13681.21,100,MS-DRG,10944.968,Case Rate,100% of CMS IPPS Rate,15111.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15035.04,100,MS-DRG,12028.032,Case Rate,100% of CMS IPPS Rate,19545.55,130,MS-DRG,15636.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15486.09,103,MS-DRG,12388.872,Case Rate,103% of CMS IPPS Rate,15486.09,103,MS-DRG,12388.872,Case Rate,103% of CMS IPPS Rate,28414.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15035.04,100,MS-DRG,12028.032,Case Rate,100% of CMS IPPS Rate,15926.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22552.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15035.04,100,MS-DRG,12028.032,Case Rate,100% of CMS IPPS Rate,30755.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15035.04,100,MS-DRG,12028.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38599.28,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,CDM,,,,,Inpatient,,,,,,17540.82,,,,Case Rate,100% of CMS IPPS Rate,12713.51,145,MS-DRG,10170.808,Case Rate,145% of CMS IPPS Rate,8767.94,100,MS-DRG,7014.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8767.94,100,,7014.352,Case Rate,100% of CMS IPPS Rate,18064.84,100,,,Case Rate,100% of CMS IPPS Rate,20646.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23226.41,100,,,Case Rate,100% of CMS IPPS Rate,23226.41,100,,,Case Rate,100% of CMS IPPS Rate,23226.41,100,,,Case Rate,100% CMS IPPS Rate,15834.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7978.52,100,,6382.816,Case Rate,100% of CMS IPPS Rate,7978.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7978.52,100,MS-DRG,6382.816,Case Rate,100% of CMS IPPS Rate,7978.52,100,MS-DRG,6382.816,Case Rate,100% of CMS IPPS Rate,12077.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8767.94,100,MS-DRG,7014.352,Case Rate,100% of CMS IPPS Rate,11398.32,130,MS-DRG,9118.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9030.98,103,MS-DRG,7224.784,Case Rate,103% of CMS IPPS Rate,9030.98,103,MS-DRG,7224.784,Case Rate,103% of CMS IPPS Rate,17548.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8767.94,100,MS-DRG,7014.352,Case Rate,100% of CMS IPPS Rate,9287.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13151.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8767.94,100,MS-DRG,7014.352,Case Rate,100% of CMS IPPS Rate,17935.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8767.94,100,MS-DRG,7014.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23226.41,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,CDM,,,,,Inpatient,,,,,,22619.18,,,,Case Rate,100% of CMS IPPS Rate,16394.28,145,MS-DRG,13115.424,Case Rate,145% of CMS IPPS Rate,11306.4,100,MS-DRG,9045.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11306.4,100,,9045.12,Case Rate,100% of CMS IPPS Rate,22262.77,100,,,Case Rate,100% of CMS IPPS Rate,25444.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28623.8,100,,,Case Rate,100% of CMS IPPS Rate,28623.8,100,,,Case Rate,100% of CMS IPPS Rate,28623.8,100,,,Case Rate,100% CMS IPPS Rate,20418.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10288.37,100,,8230.696,Case Rate,100% of CMS IPPS Rate,10288.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10288.37,100,MS-DRG,8230.696,Case Rate,100% of CMS IPPS Rate,10288.37,100,MS-DRG,8230.696,Case Rate,100% of CMS IPPS Rate,11788.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11306.4,100,MS-DRG,9045.12,Case Rate,100% of CMS IPPS Rate,14698.32,130,MS-DRG,11758.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11645.59,103,MS-DRG,9316.472,Case Rate,103% of CMS IPPS Rate,11645.59,103,MS-DRG,9316.472,Case Rate,103% of CMS IPPS Rate,22190.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11306.4,100,MS-DRG,9045.12,Case Rate,100% of CMS IPPS Rate,11977,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16959.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11306.4,100,MS-DRG,9045.12,Case Rate,100% of CMS IPPS Rate,23128,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11306.4,100,MS-DRG,9045.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28623.8,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,CDM,,,,,Inpatient,,,,,,13531.8,,,,Case Rate,100% of CMS IPPS Rate,9807.79,145,MS-DRG,7846.232,Case Rate,145% of CMS IPPS Rate,6763.99,100,MS-DRG,5411.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6763.99,100,,5411.192,Case Rate,100% of CMS IPPS Rate,13565.63,100,,,Case Rate,100% of CMS IPPS Rate,15504.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17441.66,100,,,Case Rate,100% of CMS IPPS Rate,17441.66,100,,,Case Rate,100% of CMS IPPS Rate,17441.66,100,,,Case Rate,100% CMS IPPS Rate,12215.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6155.06,100,,4924.048,Case Rate,100% of CMS IPPS Rate,6155.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6155.06,100,MS-DRG,4924.048,Case Rate,100% of CMS IPPS Rate,6155.06,100,MS-DRG,4924.048,Case Rate,100% of CMS IPPS Rate,5927.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6763.99,100,MS-DRG,5411.192,Case Rate,100% of CMS IPPS Rate,8793.19,130,MS-DRG,7034.552,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6966.91,103,MS-DRG,5573.528,Case Rate,103% of CMS IPPS Rate,6966.91,103,MS-DRG,5573.528,Case Rate,103% of CMS IPPS Rate,12929.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6763.99,100,MS-DRG,5411.192,Case Rate,100% of CMS IPPS Rate,7165.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10145.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6763.99,100,MS-DRG,5411.192,Case Rate,100% of CMS IPPS Rate,13836.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6763.99,100,MS-DRG,5411.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17441.66,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,CDM,,,,,Inpatient,,,,,,10182.74,,,,Case Rate,100% of CMS IPPS Rate,7380.4,145,MS-DRG,5904.32,Case Rate,145% of CMS IPPS Rate,5089.93,100,MS-DRG,4071.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5089.93,100,,4071.944,Case Rate,100% of CMS IPPS Rate,9305.04,100,,,Case Rate,100% of CMS IPPS Rate,10634.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11963.72,100,,,Case Rate,100% of CMS IPPS Rate,11963.72,100,,,Case Rate,100% of CMS IPPS Rate,11963.72,100,,,Case Rate,100% CMS IPPS Rate,9192.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4631.77,100,,3705.416,Case Rate,100% of CMS IPPS Rate,4631.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4631.77,100,MS-DRG,3705.416,Case Rate,100% of CMS IPPS Rate,4631.77,100,MS-DRG,3705.416,Case Rate,100% of CMS IPPS Rate,5071.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5089.93,100,MS-DRG,4071.944,Case Rate,100% of CMS IPPS Rate,6616.91,130,MS-DRG,5293.528,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5242.63,103,MS-DRG,4194.104,Case Rate,103% of CMS IPPS Rate,5242.63,103,MS-DRG,4194.104,Case Rate,103% of CMS IPPS Rate,9471.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5089.93,100,MS-DRG,4071.944,Case Rate,100% of CMS IPPS Rate,5391.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7634.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5089.93,100,MS-DRG,4071.944,Case Rate,100% of CMS IPPS Rate,10411.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5089.93,100,MS-DRG,4071.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4631.77,11963.72,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,CDM,,,,,Inpatient,,,,,,23929.51,,,,Case Rate,100% of CMS IPPS Rate,17343.99,145,MS-DRG,13875.192,Case Rate,145% of CMS IPPS Rate,11961.37,100,MS-DRG,9569.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11961.37,100,,9569.096,Case Rate,100% of CMS IPPS Rate,23302.59,100,,,Case Rate,100% of CMS IPPS Rate,26632.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29960.72,100,,,Case Rate,100% of CMS IPPS Rate,29960.72,100,,,Case Rate,100% of CMS IPPS Rate,29960.72,100,,,Case Rate,100% CMS IPPS Rate,21601.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10884.35,100,,8707.48,Case Rate,100% of CMS IPPS Rate,10884.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10884.35,100,MS-DRG,8707.48,Case Rate,100% of CMS IPPS Rate,10884.35,100,MS-DRG,8707.48,Case Rate,100% of CMS IPPS Rate,9941.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11961.37,100,MS-DRG,9569.096,Case Rate,100% of CMS IPPS Rate,15549.78,130,MS-DRG,12439.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12320.21,103,MS-DRG,9856.168,Case Rate,103% of CMS IPPS Rate,12320.21,103,MS-DRG,9856.168,Case Rate,103% of CMS IPPS Rate,21401.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11961.37,100,MS-DRG,9569.096,Case Rate,100% of CMS IPPS Rate,12670.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17942.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11961.37,100,MS-DRG,9569.096,Case Rate,100% of CMS IPPS Rate,24467.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11961.37,100,MS-DRG,9569.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29960.72,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,CDM,,,,,Inpatient,,,,,,14271.17,,,,Case Rate,100% of CMS IPPS Rate,10343.68,145,MS-DRG,8274.944,Case Rate,145% of CMS IPPS Rate,7133.57,100,MS-DRG,5706.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7133.57,100,,5706.856,Case Rate,100% of CMS IPPS Rate,13721.6,100,,,Case Rate,100% of CMS IPPS Rate,15682.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17642.2,100,,,Case Rate,100% of CMS IPPS Rate,17642.2,100,,,Case Rate,100% of CMS IPPS Rate,17642.2,100,,,Case Rate,100% CMS IPPS Rate,12882.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6491.35,100,,5193.08,Case Rate,100% of CMS IPPS Rate,6491.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6491.35,100,MS-DRG,5193.08,Case Rate,100% of CMS IPPS Rate,6491.35,100,MS-DRG,5193.08,Case Rate,100% of CMS IPPS Rate,7279.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7133.57,100,MS-DRG,5706.856,Case Rate,100% of CMS IPPS Rate,9273.64,130,MS-DRG,7418.912,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7347.58,103,MS-DRG,5878.064,Case Rate,103% of CMS IPPS Rate,7347.58,103,MS-DRG,5878.064,Case Rate,103% of CMS IPPS Rate,12877.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7133.57,100,MS-DRG,5706.856,Case Rate,100% of CMS IPPS Rate,7556.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10700.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7133.57,100,MS-DRG,5706.856,Case Rate,100% of CMS IPPS Rate,14592.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7133.57,100,MS-DRG,5706.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17642.2,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,CDM,,,,,Inpatient,,,,,,9810.32,,,,Case Rate,100% of CMS IPPS Rate,7110.47,145,MS-DRG,5688.376,Case Rate,145% of CMS IPPS Rate,4903.77,100,MS-DRG,3923.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4903.77,100,,3923.016,Case Rate,100% of CMS IPPS Rate,9670.31,100,,,Case Rate,100% of CMS IPPS Rate,11052.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12433.36,100,,,Case Rate,100% of CMS IPPS Rate,12433.36,100,,,Case Rate,100% of CMS IPPS Rate,12433.36,100,,,Case Rate,100% CMS IPPS Rate,8855.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4462.39,100,,3569.912,Case Rate,100% of CMS IPPS Rate,4462.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4462.39,100,MS-DRG,3569.912,Case Rate,100% of CMS IPPS Rate,4462.39,100,MS-DRG,3569.912,Case Rate,100% of CMS IPPS Rate,4304.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4903.77,100,MS-DRG,3923.016,Case Rate,100% of CMS IPPS Rate,6374.9,130,MS-DRG,5099.92,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5050.88,103,MS-DRG,4040.704,Case Rate,103% of CMS IPPS Rate,5050.88,103,MS-DRG,4040.704,Case Rate,103% of CMS IPPS Rate,9183.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4903.77,100,MS-DRG,3923.016,Case Rate,100% of CMS IPPS Rate,5194.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7355.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4903.77,100,MS-DRG,3923.016,Case Rate,100% of CMS IPPS Rate,10031,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4903.77,100,MS-DRG,3923.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4304.1,12433.36,
DIGESTIVE MALIGNANCY WITH MCC,374,CDM,,,,,Inpatient,,,,,,28739.51,,,,Case Rate,100% of CMS IPPS Rate,20830.25,145,MS-DRG,16664.2,Case Rate,145% of CMS IPPS Rate,14365.69,100,MS-DRG,11492.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14365.69,100,,11492.552,Case Rate,100% of CMS IPPS Rate,28147.07,100,,,Case Rate,100% of CMS IPPS Rate,32169.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36189.4,100,,,Case Rate,100% of CMS IPPS Rate,36189.4,100,,,Case Rate,100% of CMS IPPS Rate,36189.4,100,,,Case Rate,100% CMS IPPS Rate,25943.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13072.14,100,,10457.712,Case Rate,100% of CMS IPPS Rate,13072.14,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13072.14,100,MS-DRG,10457.712,Case Rate,100% of CMS IPPS Rate,13072.14,100,MS-DRG,10457.712,Case Rate,100% of CMS IPPS Rate,20836.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14365.69,100,MS-DRG,11492.552,Case Rate,100% of CMS IPPS Rate,18675.4,130,MS-DRG,14940.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14796.66,103,MS-DRG,11837.328,Case Rate,103% of CMS IPPS Rate,14796.66,103,MS-DRG,11837.328,Case Rate,103% of CMS IPPS Rate,25215.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14365.69,100,MS-DRG,11492.552,Case Rate,100% of CMS IPPS Rate,15217.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21548.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14365.69,100,MS-DRG,11492.552,Case Rate,100% of CMS IPPS Rate,29386,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14365.69,100,MS-DRG,11492.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36189.4,
DIGESTIVE MALIGNANCY WITH CC,375,CDM,,,,,Inpatient,,,,,,16407.12,,,,Case Rate,100% of CMS IPPS Rate,11891.8,145,MS-DRG,9513.44,Case Rate,145% of CMS IPPS Rate,8201.24,100,MS-DRG,6560.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8201.24,100,,6560.992,Case Rate,100% of CMS IPPS Rate,16379.8,100,,,Case Rate,100% of CMS IPPS Rate,18720.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21059.92,100,,,Case Rate,100% of CMS IPPS Rate,21059.92,100,,,Case Rate,100% of CMS IPPS Rate,21059.92,100,,,Case Rate,100% CMS IPPS Rate,14810.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7462.87,100,,5970.296,Case Rate,100% of CMS IPPS Rate,7462.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7462.87,100,MS-DRG,5970.296,Case Rate,100% of CMS IPPS Rate,7462.87,100,MS-DRG,5970.296,Case Rate,100% of CMS IPPS Rate,7355.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8201.24,100,MS-DRG,6560.992,Case Rate,100% of CMS IPPS Rate,10661.61,130,MS-DRG,8529.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8447.28,103,MS-DRG,6757.824,Case Rate,103% of CMS IPPS Rate,8447.28,103,MS-DRG,6757.824,Case Rate,103% of CMS IPPS Rate,15238.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.24,100,MS-DRG,6560.992,Case Rate,100% of CMS IPPS Rate,8687.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12301.86,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.24,100,MS-DRG,6560.992,Case Rate,100% of CMS IPPS Rate,16776.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8201.24,100,MS-DRG,6560.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21059.92,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,CDM,,,,,Inpatient,,,,,,12205.05,,,,Case Rate,100% of CMS IPPS Rate,8846.16,145,MS-DRG,7076.928,Case Rate,145% of CMS IPPS Rate,6100.8,100,MS-DRG,4880.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6100.8,100,,4880.64,Case Rate,100% of CMS IPPS Rate,11771.27,100,,,Case Rate,100% of CMS IPPS Rate,13453.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15134.62,100,,,Case Rate,100% of CMS IPPS Rate,15134.62,100,,,Case Rate,100% of CMS IPPS Rate,15134.62,100,,,Case Rate,100% CMS IPPS Rate,11017.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5551.6,100,,4441.28,Case Rate,100% of CMS IPPS Rate,5551.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5551.6,100,MS-DRG,4441.28,Case Rate,100% of CMS IPPS Rate,5551.6,100,MS-DRG,4441.28,Case Rate,100% of CMS IPPS Rate,6202.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6100.8,100,MS-DRG,4880.64,Case Rate,100% of CMS IPPS Rate,7931.04,130,MS-DRG,6344.832,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6283.82,103,MS-DRG,5027.056,Case Rate,103% of CMS IPPS Rate,6283.82,103,MS-DRG,5027.056,Case Rate,103% of CMS IPPS Rate,11104.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6100.8,100,MS-DRG,4880.64,Case Rate,100% of CMS IPPS Rate,6462.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9151.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6100.8,100,MS-DRG,4880.64,Case Rate,100% of CMS IPPS Rate,12479.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6100.8,100,MS-DRG,4880.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5551.6,15134.62,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,CDM,,,,,Inpatient,,,,,,24512.79,,,,Case Rate,100% of CMS IPPS Rate,17766.75,145,MS-DRG,14213.4,Case Rate,145% of CMS IPPS Rate,12252.93,100,MS-DRG,9802.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12252.93,100,,9802.344,Case Rate,100% of CMS IPPS Rate,24238.42,100,,,Case Rate,100% of CMS IPPS Rate,27702.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31163.95,100,,,Case Rate,100% of CMS IPPS Rate,31163.95,100,,,Case Rate,100% of CMS IPPS Rate,31163.95,100,,,Case Rate,100% CMS IPPS Rate,22128.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11149.66,100,,8919.728,Case Rate,100% of CMS IPPS Rate,11149.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11149.66,100,MS-DRG,8919.728,Case Rate,100% of CMS IPPS Rate,11149.66,100,MS-DRG,8919.728,Case Rate,100% of CMS IPPS Rate,11976.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12252.93,100,MS-DRG,9802.344,Case Rate,100% of CMS IPPS Rate,15928.81,130,MS-DRG,12743.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12620.52,103,MS-DRG,10096.416,Case Rate,103% of CMS IPPS Rate,12620.52,103,MS-DRG,10096.416,Case Rate,103% of CMS IPPS Rate,22491.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12252.93,100,MS-DRG,9802.344,Case Rate,100% of CMS IPPS Rate,12979.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18379.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12252.93,100,MS-DRG,9802.344,Case Rate,100% of CMS IPPS Rate,25064.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12252.93,100,MS-DRG,9802.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31163.95,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,CDM,,,,,Inpatient,,,,,,13470.19,,,,Case Rate,100% of CMS IPPS Rate,9763.13,145,MS-DRG,7810.504,Case Rate,145% of CMS IPPS Rate,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6733.19,100,,5386.552,Case Rate,100% of CMS IPPS Rate,13143.03,100,,,Case Rate,100% of CMS IPPS Rate,15021.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16898.33,100,,,Case Rate,100% of CMS IPPS Rate,16898.33,100,,,Case Rate,100% of CMS IPPS Rate,16898.33,100,,,Case Rate,100% CMS IPPS Rate,12159.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6127.04,100,,4901.632,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,4901.632,Case Rate,100% of CMS IPPS Rate,6127.04,100,MS-DRG,4901.632,Case Rate,100% of CMS IPPS Rate,7136.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,8753.15,130,MS-DRG,7002.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6935.19,103,MS-DRG,5548.152,Case Rate,103% of CMS IPPS Rate,6935.19,103,MS-DRG,5548.152,Case Rate,103% of CMS IPPS Rate,12460.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,7132.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10099.79,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,13773.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6733.19,100,MS-DRG,5386.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16898.33,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,CDM,,,,,Inpatient,,,,,,8669.77,,,,Case Rate,100% of CMS IPPS Rate,6283.81,145,MS-DRG,5027.048,Case Rate,145% of CMS IPPS Rate,4333.66,100,MS-DRG,3466.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4333.66,100,,3466.928,Case Rate,100% of CMS IPPS Rate,8487.85,100,,,Case Rate,100% of CMS IPPS Rate,9700.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10913.04,100,,,Case Rate,100% of CMS IPPS Rate,10913.04,100,,,Case Rate,100% of CMS IPPS Rate,10913.04,100,,,Case Rate,100% CMS IPPS Rate,7826.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3943.6,100,,3154.88,Case Rate,100% of CMS IPPS Rate,3943.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3943.6,100,MS-DRG,3154.88,Case Rate,100% of CMS IPPS Rate,3943.6,100,MS-DRG,3154.88,Case Rate,100% of CMS IPPS Rate,4820.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4333.66,100,MS-DRG,3466.928,Case Rate,100% of CMS IPPS Rate,5633.76,130,MS-DRG,4507.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4463.67,103,MS-DRG,3570.936,Case Rate,103% of CMS IPPS Rate,4463.67,103,MS-DRG,3570.936,Case Rate,103% of CMS IPPS Rate,8017.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4333.66,100,MS-DRG,3466.928,Case Rate,100% of CMS IPPS Rate,4590.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6500.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4333.66,100,MS-DRG,3466.928,Case Rate,100% of CMS IPPS Rate,8864.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4333.66,100,MS-DRG,3466.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3943.6,10913.04,
COMPLICATED PEPTIC ULCER WITH MCC,380,CDM,,,,,Inpatient,,,,,,26678.86,,,,Case Rate,100% of CMS IPPS Rate,19336.71,145,MS-DRG,15469.368,Case Rate,145% of CMS IPPS Rate,13335.66,100,MS-DRG,10668.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13335.66,100,,10668.528,Case Rate,100% of CMS IPPS Rate,25652.84,100,,,Case Rate,100% of CMS IPPS Rate,29318.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32982.5,100,,,Case Rate,100% of CMS IPPS Rate,32982.5,100,,,Case Rate,100% of CMS IPPS Rate,32982.5,100,,,Case Rate,100% CMS IPPS Rate,24083.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12134.87,100,,9707.896,Case Rate,100% of CMS IPPS Rate,12134.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12134.87,100,MS-DRG,9707.896,Case Rate,100% of CMS IPPS Rate,12134.87,100,MS-DRG,9707.896,Case Rate,100% of CMS IPPS Rate,13357.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13335.66,100,MS-DRG,10668.528,Case Rate,100% of CMS IPPS Rate,17336.36,130,MS-DRG,13869.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13735.73,103,MS-DRG,10988.584,Case Rate,103% of CMS IPPS Rate,13735.73,103,MS-DRG,10988.584,Case Rate,103% of CMS IPPS Rate,24086.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13335.66,100,MS-DRG,10668.528,Case Rate,100% of CMS IPPS Rate,14126.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20003.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13335.66,100,MS-DRG,10668.528,Case Rate,100% of CMS IPPS Rate,27279,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13335.66,100,MS-DRG,10668.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32982.5,
COMPLICATED PEPTIC ULCER WITH CC,381,CDM,,,,,Inpatient,,,,,,14691.52,,,,Case Rate,100% of CMS IPPS Rate,10648.35,145,MS-DRG,8518.68,Case Rate,145% of CMS IPPS Rate,7343.69,100,MS-DRG,5874.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7343.69,100,,5874.952,Case Rate,100% of CMS IPPS Rate,14518.79,100,,,Case Rate,100% of CMS IPPS Rate,16593.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18667.17,100,,,Case Rate,100% of CMS IPPS Rate,18667.17,100,,,Case Rate,100% of CMS IPPS Rate,18667.17,100,,,Case Rate,100% CMS IPPS Rate,13262.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6682.55,100,,5346.04,Case Rate,100% of CMS IPPS Rate,6682.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6682.55,100,MS-DRG,5346.04,Case Rate,100% of CMS IPPS Rate,6682.55,100,MS-DRG,5346.04,Case Rate,100% of CMS IPPS Rate,7277,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7343.69,100,MS-DRG,5874.952,Case Rate,100% of CMS IPPS Rate,9546.8,130,MS-DRG,7637.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7564,103,MS-DRG,6051.2,Case Rate,103% of CMS IPPS Rate,7564,103,MS-DRG,6051.2,Case Rate,103% of CMS IPPS Rate,13352.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7343.69,100,MS-DRG,5874.952,Case Rate,100% of CMS IPPS Rate,7779.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11015.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7343.69,100,MS-DRG,5874.952,Case Rate,100% of CMS IPPS Rate,15022,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7343.69,100,MS-DRG,5874.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18667.17,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,CDM,,,,,Inpatient,,,,,,10366.21,,,,Case Rate,100% of CMS IPPS Rate,7513.38,145,MS-DRG,6010.704,Case Rate,145% of CMS IPPS Rate,5181.64,100,MS-DRG,4145.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5181.64,100,,4145.312,Case Rate,100% of CMS IPPS Rate,9988.92,100,,,Case Rate,100% of CMS IPPS Rate,11416.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12843,100,,,Case Rate,100% of CMS IPPS Rate,12843,100,,,Case Rate,100% of CMS IPPS Rate,12843,100,,,Case Rate,100% CMS IPPS Rate,9357.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4715.22,100,,3772.176,Case Rate,100% of CMS IPPS Rate,4715.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4715.22,100,MS-DRG,3772.176,Case Rate,100% of CMS IPPS Rate,4715.22,100,MS-DRG,3772.176,Case Rate,100% of CMS IPPS Rate,6000.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5181.64,100,MS-DRG,4145.312,Case Rate,100% of CMS IPPS Rate,6736.13,130,MS-DRG,5388.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5337.09,103,MS-DRG,4269.672,Case Rate,103% of CMS IPPS Rate,5337.09,103,MS-DRG,4269.672,Case Rate,103% of CMS IPPS Rate,9737.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5181.64,100,MS-DRG,4145.312,Case Rate,100% of CMS IPPS Rate,5488.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7772.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5181.64,100,MS-DRG,4145.312,Case Rate,100% of CMS IPPS Rate,10599.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5181.64,100,MS-DRG,4145.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4715.22,12843,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,CDM,,,,,Inpatient,,,,,,19144.15,,,,Case Rate,100% of CMS IPPS Rate,13875.59,145,MS-DRG,11100.472,Case Rate,145% of CMS IPPS Rate,9569.37,100,MS-DRG,7655.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9569.37,100,,7655.496,Case Rate,100% of CMS IPPS Rate,16853.05,100,,,Case Rate,100% of CMS IPPS Rate,19261.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21668.39,100,,,Case Rate,100% of CMS IPPS Rate,21668.39,100,,,Case Rate,100% of CMS IPPS Rate,21668.39,100,,,Case Rate,100% CMS IPPS Rate,17281.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8707.79,100,,6966.232,Case Rate,100% of CMS IPPS Rate,8707.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8707.79,100,MS-DRG,6966.232,Case Rate,100% of CMS IPPS Rate,8707.79,100,MS-DRG,6966.232,Case Rate,100% of CMS IPPS Rate,12582.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9569.37,100,MS-DRG,7655.496,Case Rate,100% of CMS IPPS Rate,12440.18,130,MS-DRG,9952.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9856.45,103,MS-DRG,7885.16,Case Rate,103% of CMS IPPS Rate,9856.45,103,MS-DRG,7885.16,Case Rate,103% of CMS IPPS Rate,17204,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9569.37,100,MS-DRG,7655.496,Case Rate,100% of CMS IPPS Rate,10136.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14354.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9569.37,100,MS-DRG,7655.496,Case Rate,100% of CMS IPPS Rate,19574.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9569.37,100,MS-DRG,7655.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21668.39,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,CDM,,,,,Inpatient,,,,,,11990.08,,,,Case Rate,100% of CMS IPPS Rate,8690.34,145,MS-DRG,6952.272,Case Rate,145% of CMS IPPS Rate,5993.34,100,MS-DRG,4794.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5993.34,100,,4794.672,Case Rate,100% of CMS IPPS Rate,11592.64,100,,,Case Rate,100% of CMS IPPS Rate,13249.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14904.94,100,,,Case Rate,100% of CMS IPPS Rate,14904.94,100,,,Case Rate,100% of CMS IPPS Rate,14904.94,100,,,Case Rate,100% CMS IPPS Rate,10823.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5453.83,100,,4363.064,Case Rate,100% of CMS IPPS Rate,5453.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5453.83,100,MS-DRG,4363.064,Case Rate,100% of CMS IPPS Rate,5453.83,100,MS-DRG,4363.064,Case Rate,100% of CMS IPPS Rate,8191.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5993.34,100,MS-DRG,4794.672,Case Rate,100% of CMS IPPS Rate,7791.34,130,MS-DRG,6233.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6173.14,103,MS-DRG,4938.512,Case Rate,103% of CMS IPPS Rate,6173.14,103,MS-DRG,4938.512,Case Rate,103% of CMS IPPS Rate,11405.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5993.34,100,MS-DRG,4794.672,Case Rate,100% of CMS IPPS Rate,6348.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8990.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5993.34,100,MS-DRG,4794.672,Case Rate,100% of CMS IPPS Rate,12259.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5993.34,100,MS-DRG,4794.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5453.83,14904.94,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,CDM,,,,,Inpatient,,,,,,21453.99,,,,Case Rate,100% of CMS IPPS Rate,15549.76,145,MS-DRG,12439.808,Case Rate,145% of CMS IPPS Rate,10723.97,100,MS-DRG,8579.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10723.97,100,,8579.176,Case Rate,100% of CMS IPPS Rate,21660.21,100,,,Case Rate,100% of CMS IPPS Rate,24755.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27849.07,100,,,Case Rate,100% of CMS IPPS Rate,27849.07,100,,,Case Rate,100% of CMS IPPS Rate,27849.07,100,,,Case Rate,100% CMS IPPS Rate,19366.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9758.4,100,,7806.72,Case Rate,100% of CMS IPPS Rate,9758.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9758.4,100,MS-DRG,7806.72,Case Rate,100% of CMS IPPS Rate,9758.4,100,MS-DRG,7806.72,Case Rate,100% of CMS IPPS Rate,12890.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10723.97,100,MS-DRG,8579.176,Case Rate,100% of CMS IPPS Rate,13941.16,130,MS-DRG,11152.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11045.69,103,MS-DRG,8836.552,Case Rate,103% of CMS IPPS Rate,11045.69,103,MS-DRG,8836.552,Case Rate,103% of CMS IPPS Rate,20603.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10723.97,100,MS-DRG,8579.176,Case Rate,100% of CMS IPPS Rate,11360.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16085.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10723.97,100,MS-DRG,8579.176,Case Rate,100% of CMS IPPS Rate,21936.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10723.97,100,MS-DRG,8579.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27849.07,
INFLAMMATORY BOWEL DISEASE WITH CC,386,CDM,,,,,Inpatient,,,,,,13303.15,,,,Case Rate,100% of CMS IPPS Rate,9642.07,145,MS-DRG,7713.656,Case Rate,145% of CMS IPPS Rate,6649.7,100,MS-DRG,5319.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6649.7,100,,5319.76,Case Rate,100% of CMS IPPS Rate,13231.02,100,,,Case Rate,100% of CMS IPPS Rate,15121.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17011.45,100,,,Case Rate,100% of CMS IPPS Rate,17011.45,100,,,Case Rate,100% of CMS IPPS Rate,17011.45,100,,,Case Rate,100% CMS IPPS Rate,12008.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6051.05,100,,4840.84,Case Rate,100% of CMS IPPS Rate,6051.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6051.05,100,MS-DRG,4840.84,Case Rate,100% of CMS IPPS Rate,6051.05,100,MS-DRG,4840.84,Case Rate,100% of CMS IPPS Rate,7648.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6649.7,100,MS-DRG,5319.76,Case Rate,100% of CMS IPPS Rate,8644.61,130,MS-DRG,6915.688,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6849.19,103,MS-DRG,5479.352,Case Rate,103% of CMS IPPS Rate,6849.19,103,MS-DRG,5479.352,Case Rate,103% of CMS IPPS Rate,12520.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6649.7,100,MS-DRG,5319.76,Case Rate,100% of CMS IPPS Rate,7044.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9974.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6649.7,100,MS-DRG,5319.76,Case Rate,100% of CMS IPPS Rate,13602.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6649.7,100,MS-DRG,5319.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17011.45,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,CDM,,,,,Inpatient,,,,,,9366.7,,,,Case Rate,100% of CMS IPPS Rate,6788.93,145,MS-DRG,5431.144,Case Rate,145% of CMS IPPS Rate,4682.02,100,MS-DRG,3745.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4682.02,100,,3745.616,Case Rate,100% of CMS IPPS Rate,8935.77,100,,,Case Rate,100% of CMS IPPS Rate,10212.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11488.94,100,,,Case Rate,100% of CMS IPPS Rate,11488.94,100,,,Case Rate,100% of CMS IPPS Rate,11488.94,100,,,Case Rate,100% CMS IPPS Rate,8455.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4260.61,100,,3408.488,Case Rate,100% of CMS IPPS Rate,4260.61,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4260.61,100,MS-DRG,3408.488,Case Rate,100% of CMS IPPS Rate,4260.61,100,MS-DRG,3408.488,Case Rate,100% of CMS IPPS Rate,5485.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4682.02,100,MS-DRG,3745.616,Case Rate,100% of CMS IPPS Rate,6086.63,130,MS-DRG,4869.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4822.48,103,MS-DRG,3857.984,Case Rate,103% of CMS IPPS Rate,4822.48,103,MS-DRG,3857.984,Case Rate,103% of CMS IPPS Rate,8748.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4682.02,100,MS-DRG,3745.616,Case Rate,100% of CMS IPPS Rate,4959.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7023.03,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4682.02,100,MS-DRG,3745.616,Case Rate,100% of CMS IPPS Rate,9577.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4682.02,100,MS-DRG,3745.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4260.61,11488.94,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,CDM,,,,,Inpatient,,,,,,19901.32,,,,Case Rate,100% of CMS IPPS Rate,14424.38,145,MS-DRG,11539.504,Case Rate,145% of CMS IPPS Rate,9947.85,100,MS-DRG,7958.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9947.85,100,,7958.28,Case Rate,100% of CMS IPPS Rate,19595.24,100,,,Case Rate,100% of CMS IPPS Rate,22395.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25194.09,100,,,Case Rate,100% of CMS IPPS Rate,25194.09,100,,,Case Rate,100% of CMS IPPS Rate,25194.09,100,,,Case Rate,100% CMS IPPS Rate,17965.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9052.18,100,,7241.744,Case Rate,100% of CMS IPPS Rate,9052.18,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9052.18,100,MS-DRG,7241.744,Case Rate,100% of CMS IPPS Rate,9052.18,100,MS-DRG,7241.744,Case Rate,100% of CMS IPPS Rate,10697.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9947.85,100,MS-DRG,7958.28,Case Rate,100% of CMS IPPS Rate,12932.21,130,MS-DRG,10345.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10246.29,103,MS-DRG,8197.032,Case Rate,103% of CMS IPPS Rate,10246.29,103,MS-DRG,8197.032,Case Rate,103% of CMS IPPS Rate,18562.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9947.85,100,MS-DRG,7958.28,Case Rate,100% of CMS IPPS Rate,10537.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14921.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9947.85,100,MS-DRG,7958.28,Case Rate,100% of CMS IPPS Rate,20349,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9947.85,100,MS-DRG,7958.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25194.09,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,CDM,,,,,Inpatient,,,,,,10904.31,,,,Case Rate,100% of CMS IPPS Rate,7903.38,145,MS-DRG,6322.704,Case Rate,145% of CMS IPPS Rate,5450.61,100,MS-DRG,4360.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5450.61,100,,4360.488,Case Rate,100% of CMS IPPS Rate,10686.13,100,,,Case Rate,100% of CMS IPPS Rate,12213.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13739.42,100,,,Case Rate,100% of CMS IPPS Rate,13739.42,100,,,Case Rate,100% of CMS IPPS Rate,13739.42,100,,,Case Rate,100% CMS IPPS Rate,9843.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4959.97,100,,3967.976,Case Rate,100% of CMS IPPS Rate,4959.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4959.97,100,MS-DRG,3967.976,Case Rate,100% of CMS IPPS Rate,4959.97,100,MS-DRG,3967.976,Case Rate,100% of CMS IPPS Rate,4839.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5450.61,100,MS-DRG,4360.488,Case Rate,100% of CMS IPPS Rate,7085.79,130,MS-DRG,5668.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5614.13,103,MS-DRG,4491.304,Case Rate,103% of CMS IPPS Rate,5614.13,103,MS-DRG,4491.304,Case Rate,103% of CMS IPPS Rate,10209.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5450.61,100,MS-DRG,4360.488,Case Rate,100% of CMS IPPS Rate,5773.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8175.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5450.61,100,MS-DRG,4360.488,Case Rate,100% of CMS IPPS Rate,11149.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5450.61,100,MS-DRG,4360.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4839.17,13739.42,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,CDM,,,,,Inpatient,,,,,,7653.83,,,,Case Rate,100% of CMS IPPS Rate,5547.45,145,MS-DRG,4437.96,Case Rate,145% of CMS IPPS Rate,3825.83,100,MS-DRG,3060.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3825.83,100,,3060.664,Case Rate,100% of CMS IPPS Rate,7294.72,100,,,Case Rate,100% of CMS IPPS Rate,8337.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9379.01,100,,,Case Rate,100% of CMS IPPS Rate,9379.01,100,,,Case Rate,100% of CMS IPPS Rate,9379.01,100,,,Case Rate,100% CMS IPPS Rate,6909.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3481.52,100,,2785.216,Case Rate,100% of CMS IPPS Rate,3481.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3481.52,100,MS-DRG,2785.216,Case Rate,100% of CMS IPPS Rate,3481.52,100,MS-DRG,2785.216,Case Rate,100% of CMS IPPS Rate,3719.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3825.83,100,MS-DRG,3060.664,Case Rate,100% of CMS IPPS Rate,4973.58,130,MS-DRG,3978.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3940.6,103,MS-DRG,3152.48,Case Rate,103% of CMS IPPS Rate,3940.6,103,MS-DRG,3152.48,Case Rate,103% of CMS IPPS Rate,7153.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3825.83,100,MS-DRG,3060.664,Case Rate,100% of CMS IPPS Rate,4052.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5738.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3825.83,100,MS-DRG,3060.664,Case Rate,100% of CMS IPPS Rate,7826,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3825.83,100,MS-DRG,3060.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3481.52,9379.01,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,CDM,,,,,Inpatient,,,,,,17466.88,,,,Case Rate,100% of CMS IPPS Rate,12659.91,145,MS-DRG,10127.928,Case Rate,145% of CMS IPPS Rate,8730.97,100,MS-DRG,6984.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8730.97,100,,6984.776,Case Rate,100% of CMS IPPS Rate,17123.67,100,,,Case Rate,100% of CMS IPPS Rate,19570.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22016.33,100,,,Case Rate,100% of CMS IPPS Rate,22016.33,100,,,Case Rate,100% of CMS IPPS Rate,22016.33,100,,,Case Rate,100% CMS IPPS Rate,15767.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7944.9,100,,6355.92,Case Rate,100% of CMS IPPS Rate,7944.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7944.9,100,MS-DRG,6355.92,Case Rate,100% of CMS IPPS Rate,7944.9,100,MS-DRG,6355.92,Case Rate,100% of CMS IPPS Rate,9163.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8730.97,100,MS-DRG,6984.776,Case Rate,100% of CMS IPPS Rate,11350.26,130,MS-DRG,9080.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8992.9,103,MS-DRG,7194.32,Case Rate,103% of CMS IPPS Rate,8992.9,103,MS-DRG,7194.32,Case Rate,103% of CMS IPPS Rate,16242.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8730.97,100,MS-DRG,6984.776,Case Rate,100% of CMS IPPS Rate,9248.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13096.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8730.97,100,MS-DRG,6984.776,Case Rate,100% of CMS IPPS Rate,17859.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8730.97,100,MS-DRG,6984.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22016.33,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,CDM,,,,,Inpatient,,,,,,10756.44,,,,Case Rate,100% of CMS IPPS Rate,7796.22,145,MS-DRG,6236.976,Case Rate,145% of CMS IPPS Rate,5376.7,100,MS-DRG,4301.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5376.7,100,,4301.36,Case Rate,100% of CMS IPPS Rate,10402.18,100,,,Case Rate,100% of CMS IPPS Rate,11888.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13374.34,100,,,Case Rate,100% of CMS IPPS Rate,13374.34,100,,,Case Rate,100% of CMS IPPS Rate,13374.34,100,,,Case Rate,100% CMS IPPS Rate,9710.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4892.7,100,,3914.16,Case Rate,100% of CMS IPPS Rate,4892.7,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4892.7,100,MS-DRG,3914.16,Case Rate,100% of CMS IPPS Rate,4892.7,100,MS-DRG,3914.16,Case Rate,100% of CMS IPPS Rate,5379.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5376.7,100,MS-DRG,4301.36,Case Rate,100% of CMS IPPS Rate,6989.71,130,MS-DRG,5591.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5538,103,MS-DRG,4430.4,Case Rate,103% of CMS IPPS Rate,5538,103,MS-DRG,4430.4,Case Rate,103% of CMS IPPS Rate,9963.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5376.7,100,MS-DRG,4301.36,Case Rate,100% of CMS IPPS Rate,5695.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8065.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5376.7,100,MS-DRG,4301.36,Case Rate,100% of CMS IPPS Rate,10998.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5376.7,100,MS-DRG,4301.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4892.7,13374.34,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,CDM,,,,,Inpatient,,,,,,22175.56,,,,Case Rate,100% of CMS IPPS Rate,16072.74,145,MS-DRG,12858.192,Case Rate,145% of CMS IPPS Rate,11084.65,100,MS-DRG,8867.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11084.65,100,,8867.72,Case Rate,100% of CMS IPPS Rate,22076.14,100,,,Case Rate,100% of CMS IPPS Rate,25230.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28383.84,100,,,Case Rate,100% of CMS IPPS Rate,28383.84,100,,,Case Rate,100% of CMS IPPS Rate,28383.84,100,,,Case Rate,100% CMS IPPS Rate,20018.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10086.58,100,,8069.264,Case Rate,100% of CMS IPPS Rate,10086.58,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10086.58,100,MS-DRG,8069.264,Case Rate,100% of CMS IPPS Rate,10086.58,100,MS-DRG,8069.264,Case Rate,100% of CMS IPPS Rate,12602.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11084.65,100,MS-DRG,8867.72,Case Rate,100% of CMS IPPS Rate,14410.05,130,MS-DRG,11528.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11417.19,103,MS-DRG,9133.752,Case Rate,103% of CMS IPPS Rate,11417.19,103,MS-DRG,9133.752,Case Rate,103% of CMS IPPS Rate,20382.95,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11084.65,100,MS-DRG,8867.72,Case Rate,100% of CMS IPPS Rate,11742.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16626.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11084.65,100,MS-DRG,8867.72,Case Rate,100% of CMS IPPS Rate,22674.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11084.65,100,MS-DRG,8867.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28383.84,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,CDM,,,,,Inpatient,,,,,,12828.03,,,,Case Rate,100% of CMS IPPS Rate,9297.69,145,MS-DRG,7438.152,Case Rate,145% of CMS IPPS Rate,6412.2,100,MS-DRG,5129.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6412.2,100,,5129.76,Case Rate,100% of CMS IPPS Rate,12548.47,100,,,Case Rate,100% of CMS IPPS Rate,14341.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16133.88,100,,,Case Rate,100% of CMS IPPS Rate,16133.88,100,,,Case Rate,100% of CMS IPPS Rate,16133.88,100,,,Case Rate,100% CMS IPPS Rate,11580.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5834.96,100,,4667.968,Case Rate,100% of CMS IPPS Rate,5834.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5834.96,100,MS-DRG,4667.968,Case Rate,100% of CMS IPPS Rate,5834.96,100,MS-DRG,4667.968,Case Rate,100% of CMS IPPS Rate,7075.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6412.2,100,MS-DRG,5129.76,Case Rate,100% of CMS IPPS Rate,8335.86,130,MS-DRG,6668.688,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6604.57,103,MS-DRG,5283.656,Case Rate,103% of CMS IPPS Rate,6604.57,103,MS-DRG,5283.656,Case Rate,103% of CMS IPPS Rate,11928.95,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6412.2,100,MS-DRG,5129.76,Case Rate,100% of CMS IPPS Rate,6792.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9618.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6412.2,100,MS-DRG,5129.76,Case Rate,100% of CMS IPPS Rate,13116.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6412.2,100,MS-DRG,5129.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5834.96,16133.88,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,CDM,,,,,Inpatient,,,,,,8865.57,,,,Case Rate,100% of CMS IPPS Rate,6425.72,145,MS-DRG,5140.576,Case Rate,145% of CMS IPPS Rate,4431.53,100,MS-DRG,3545.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4431.53,100,,3545.224,Case Rate,100% of CMS IPPS Rate,8483.85,100,,,Case Rate,100% of CMS IPPS Rate,9696.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10907.9,100,,,Case Rate,100% of CMS IPPS Rate,10907.9,100,,,Case Rate,100% of CMS IPPS Rate,10907.9,100,,,Case Rate,100% CMS IPPS Rate,8003.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4032.67,100,,3226.136,Case Rate,100% of CMS IPPS Rate,4032.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4032.67,100,MS-DRG,3226.136,Case Rate,100% of CMS IPPS Rate,4032.67,100,MS-DRG,3226.136,Case Rate,100% of CMS IPPS Rate,5473.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4431.53,100,MS-DRG,3545.224,Case Rate,100% of CMS IPPS Rate,5760.99,130,MS-DRG,4608.792,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4564.48,103,MS-DRG,3651.584,Case Rate,103% of CMS IPPS Rate,4564.48,103,MS-DRG,3651.584,Case Rate,103% of CMS IPPS Rate,8157.99,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4431.53,100,MS-DRG,3545.224,Case Rate,100% of CMS IPPS Rate,4694.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6647.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4431.53,100,MS-DRG,3545.224,Case Rate,100% of CMS IPPS Rate,9065,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4431.53,100,MS-DRG,3545.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4032.67,10907.9,
APPENDIX PROCEDURES WITH MCC,397,CDM,,,,,Inpatient,,,,,,30760.45,,,,Case Rate,100% of CMS IPPS Rate,22295.01,145,MS-DRG,17836.008,Case Rate,145% of CMS IPPS Rate,15375.87,100,MS-DRG,12300.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15375.87,100,,12300.696,Case Rate,100% of CMS IPPS Rate,33031.55,100,,,Case Rate,100% of CMS IPPS Rate,37751.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42469.49,100,,,Case Rate,100% of CMS IPPS Rate,42469.49,100,,,Case Rate,100% of CMS IPPS Rate,42469.49,100,,,Case Rate,100% CMS IPPS Rate,27767.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13991.33,100,,11193.064,Case Rate,100% of CMS IPPS Rate,13991.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13991.33,100,MS-DRG,11193.064,Case Rate,100% of CMS IPPS Rate,13991.33,100,MS-DRG,11193.064,Case Rate,100% of CMS IPPS Rate,18567.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15375.87,100,MS-DRG,12300.696,Case Rate,100% of CMS IPPS Rate,19988.63,130,MS-DRG,15990.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15837.15,103,MS-DRG,12669.72,Case Rate,103% of CMS IPPS Rate,15837.15,103,MS-DRG,12669.72,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15375.87,100,MS-DRG,12300.696,Case Rate,100% of CMS IPPS Rate,16287.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23063.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15375.87,100,MS-DRG,12300.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15375.87,100,MS-DRG,12300.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,42469.49,
APPENDIX PROCEDURES WITH CC,398,CDM,,,,,Inpatient,,,,,,20720.1,,,,Case Rate,100% of CMS IPPS Rate,15017.82,145,MS-DRG,12014.256,Case Rate,145% of CMS IPPS Rate,10357.12,100,MS-DRG,8285.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10357.12,100,,8285.696,Case Rate,100% of CMS IPPS Rate,20172.47,100,,,Case Rate,100% of CMS IPPS Rate,23055.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25936.25,100,,,Case Rate,100% of CMS IPPS Rate,25936.25,100,,,Case Rate,100% of CMS IPPS Rate,25936.25,100,,,Case Rate,100% CMS IPPS Rate,18704.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9424.6,100,,7539.68,Case Rate,100% of CMS IPPS Rate,9424.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9424.6,100,MS-DRG,7539.68,Case Rate,100% of CMS IPPS Rate,9424.6,100,MS-DRG,7539.68,Case Rate,100% of CMS IPPS Rate,18407.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10357.12,100,MS-DRG,8285.696,Case Rate,100% of CMS IPPS Rate,13464.26,130,MS-DRG,10771.408,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10667.83,103,MS-DRG,8534.264,Case Rate,103% of CMS IPPS Rate,10667.83,103,MS-DRG,8534.264,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10357.12,100,MS-DRG,8285.696,Case Rate,100% of CMS IPPS Rate,10971.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15535.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10357.12,100,MS-DRG,8285.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10357.12,100,MS-DRG,8285.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25936.25,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,CDM,,,,,Inpatient,,,,,,15240.57,,,,Case Rate,100% of CMS IPPS Rate,11046.3,145,MS-DRG,8837.04,Case Rate,145% of CMS IPPS Rate,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7618.14,100,,6094.512,Case Rate,100% of CMS IPPS Rate,14981.38,100,,,Case Rate,100% of CMS IPPS Rate,17122.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19261.93,100,,,Case Rate,100% of CMS IPPS Rate,19261.93,100,,,Case Rate,100% of CMS IPPS Rate,19261.93,100,,,Case Rate,100% CMS IPPS Rate,13757.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6932.27,100,,5545.816,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,5545.816,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,5545.816,Case Rate,100% of CMS IPPS Rate,20438.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,9903.58,130,MS-DRG,7922.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7846.68,103,MS-DRG,6277.344,Case Rate,103% of CMS IPPS Rate,7846.68,103,MS-DRG,6277.344,Case Rate,103% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,8069.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11427.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20438.18,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52153.54,100,,,Case Rate,100% of CMS IPPS Rate,59606.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67055.11,100,,,Case Rate,100% of CMS IPPS Rate,67055.11,100,,,Case Rate,100% of CMS IPPS Rate,67055.11,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10614.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,67055.11,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,CDM,,,,,Inpatient,,,,,,75377.2,,,,Case Rate,100% of CMS IPPS Rate,54633.03,145,MS-DRG,43706.424,Case Rate,145% of CMS IPPS Rate,37677.95,100,MS-DRG,30142.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37677.95,100,,30142.36,Case Rate,100% of CMS IPPS Rate,72370,100,,,Case Rate,100% of CMS IPPS Rate,82711.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,93047.92,100,,,Case Rate,100% of CMS IPPS Rate,93047.92,100,,,Case Rate,100% of CMS IPPS Rate,93047.92,100,,,Case Rate,100% CMS IPPS Rate,68044.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34284.83,100,,27427.864,Case Rate,100% of CMS IPPS Rate,34284.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,34284.83,100,MS-DRG,27427.864,Case Rate,100% of CMS IPPS Rate,34284.83,100,MS-DRG,27427.864,Case Rate,100% of CMS IPPS Rate,55499.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37677.95,100,MS-DRG,30142.36,Case Rate,100% of CMS IPPS Rate,48981.34,130,MS-DRG,39185.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38808.29,103,MS-DRG,31046.632,Case Rate,103% of CMS IPPS Rate,38808.29,103,MS-DRG,31046.632,Case Rate,103% of CMS IPPS Rate,70105.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37677.95,100,MS-DRG,30142.36,Case Rate,100% of CMS IPPS Rate,39912.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,56516.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37677.95,100,MS-DRG,30142.36,Case Rate,100% of CMS IPPS Rate,77072.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37677.95,100,MS-DRG,30142.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,93047.92,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,CDM,,,,,Inpatient,,,,,,39534.28,,,,Case Rate,100% of CMS IPPS Rate,28654.25,145,MS-DRG,22923.4,Case Rate,145% of CMS IPPS Rate,19761.55,100,MS-DRG,15809.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19761.55,100,,15809.24,Case Rate,100% of CMS IPPS Rate,37438.78,100,,,Case Rate,100% of CMS IPPS Rate,42788.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48135.98,100,,,Case Rate,100% of CMS IPPS Rate,48135.98,100,,,Case Rate,100% of CMS IPPS Rate,48135.98,100,,,Case Rate,100% CMS IPPS Rate,35688.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17982.02,100,,14385.616,Case Rate,100% of CMS IPPS Rate,17982.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17982.02,100,MS-DRG,14385.616,Case Rate,100% of CMS IPPS Rate,17982.02,100,MS-DRG,14385.616,Case Rate,100% of CMS IPPS Rate,23505.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19761.55,100,MS-DRG,15809.24,Case Rate,100% of CMS IPPS Rate,25690.02,130,MS-DRG,20552.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20354.4,103,MS-DRG,16283.52,Case Rate,103% of CMS IPPS Rate,20354.4,103,MS-DRG,16283.52,Case Rate,103% of CMS IPPS Rate,37060.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19761.55,100,MS-DRG,15809.24,Case Rate,100% of CMS IPPS Rate,20933.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29642.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19761.55,100,MS-DRG,15809.24,Case Rate,100% of CMS IPPS Rate,40423.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19761.55,100,MS-DRG,15809.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48135.98,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,CDM,,,,,Inpatient,,,,,,29451.49,,,,Case Rate,100% of CMS IPPS Rate,21346.29,145,MS-DRG,17077.032,Case Rate,145% of CMS IPPS Rate,14721.58,100,MS-DRG,11777.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14721.58,100,,11777.264,Case Rate,100% of CMS IPPS Rate,28472.35,100,,,Case Rate,100% of CMS IPPS Rate,32541.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36607.61,100,,,Case Rate,100% of CMS IPPS Rate,36607.61,100,,,Case Rate,100% of CMS IPPS Rate,36607.61,100,,,Case Rate,100% CMS IPPS Rate,26586.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13395.97,100,,10716.776,Case Rate,100% of CMS IPPS Rate,13395.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13395.97,100,MS-DRG,10716.776,Case Rate,100% of CMS IPPS Rate,13395.97,100,MS-DRG,10716.776,Case Rate,100% of CMS IPPS Rate,22054.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14721.58,100,MS-DRG,11777.264,Case Rate,100% of CMS IPPS Rate,19138.05,130,MS-DRG,15310.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15163.23,103,MS-DRG,12130.584,Case Rate,103% of CMS IPPS Rate,15163.23,103,MS-DRG,12130.584,Case Rate,103% of CMS IPPS Rate,28155.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14721.58,100,MS-DRG,11777.264,Case Rate,100% of CMS IPPS Rate,15594.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22082.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14721.58,100,MS-DRG,11777.264,Case Rate,100% of CMS IPPS Rate,30114,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14721.58,100,MS-DRG,11777.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36607.61,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,CDM,,,,,Inpatient,,,,,,50964.36,,,,Case Rate,100% of CMS IPPS Rate,36938.72,145,MS-DRG,29550.976,Case Rate,145% of CMS IPPS Rate,25474.98,100,MS-DRG,20379.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25474.98,100,,20379.984,Case Rate,100% of CMS IPPS Rate,46675.83,100,,,Case Rate,100% of CMS IPPS Rate,53345.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60012.28,100,,,Case Rate,100% of CMS IPPS Rate,60012.28,100,,,Case Rate,100% of CMS IPPS Rate,60012.28,100,,,Case Rate,100% CMS IPPS Rate,46006.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23180.9,100,,18544.72,Case Rate,100% of CMS IPPS Rate,23180.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23180.9,100,MS-DRG,18544.72,Case Rate,100% of CMS IPPS Rate,23180.9,100,MS-DRG,18544.72,Case Rate,100% of CMS IPPS Rate,47833.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25474.98,100,MS-DRG,20379.984,Case Rate,100% of CMS IPPS Rate,33117.47,130,MS-DRG,26493.976,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26239.23,103,MS-DRG,20991.384,Case Rate,103% of CMS IPPS Rate,26239.23,103,MS-DRG,20991.384,Case Rate,103% of CMS IPPS Rate,46419.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25474.98,100,MS-DRG,20379.984,Case Rate,100% of CMS IPPS Rate,26985.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,38212.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25474.98,100,MS-DRG,20379.984,Case Rate,100% of CMS IPPS Rate,52110.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25474.98,100,MS-DRG,20379.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60012.28,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,CDM,,,,,Inpatient,,,,,,26799.35,,,,Case Rate,100% of CMS IPPS Rate,19424.04,145,MS-DRG,15539.232,Case Rate,145% of CMS IPPS Rate,13395.89,100,MS-DRG,10716.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13395.89,100,,10716.712,Case Rate,100% of CMS IPPS Rate,27948.44,100,,,Case Rate,100% of CMS IPPS Rate,31942.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35934.01,100,,,Case Rate,100% of CMS IPPS Rate,35934.01,100,,,Case Rate,100% of CMS IPPS Rate,35934.01,100,,,Case Rate,100% CMS IPPS Rate,24192.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12189.67,100,,9751.736,Case Rate,100% of CMS IPPS Rate,12189.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12189.67,100,MS-DRG,9751.736,Case Rate,100% of CMS IPPS Rate,12189.67,100,MS-DRG,9751.736,Case Rate,100% of CMS IPPS Rate,16712.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13395.89,100,MS-DRG,10716.712,Case Rate,100% of CMS IPPS Rate,17414.66,130,MS-DRG,13931.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13797.77,103,MS-DRG,11038.216,Case Rate,103% of CMS IPPS Rate,13797.77,103,MS-DRG,11038.216,Case Rate,103% of CMS IPPS Rate,26962.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13395.89,100,MS-DRG,10716.712,Case Rate,100% of CMS IPPS Rate,14190.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20093.84,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13395.89,100,MS-DRG,10716.712,Case Rate,100% of CMS IPPS Rate,27402.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13395.89,100,MS-DRG,10716.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35934.01,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,CDM,,,,,Inpatient,,,,,,21430.72,,,,Case Rate,100% of CMS IPPS Rate,15532.88,145,MS-DRG,12426.304,Case Rate,145% of CMS IPPS Rate,10712.33,100,MS-DRG,8569.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10712.33,100,,8569.864,Case Rate,100% of CMS IPPS Rate,20677.71,100,,,Case Rate,100% of CMS IPPS Rate,23632.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26585.85,100,,,Case Rate,100% of CMS IPPS Rate,26585.85,100,,,Case Rate,100% of CMS IPPS Rate,26585.85,100,,,Case Rate,100% CMS IPPS Rate,19345.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9747.81,100,,7798.248,Case Rate,100% of CMS IPPS Rate,9747.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9747.81,100,MS-DRG,7798.248,Case Rate,100% of CMS IPPS Rate,9747.81,100,MS-DRG,7798.248,Case Rate,100% of CMS IPPS Rate,20100.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10712.33,100,MS-DRG,8569.864,Case Rate,100% of CMS IPPS Rate,13926.03,130,MS-DRG,11140.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11033.7,103,MS-DRG,8826.96,Case Rate,103% of CMS IPPS Rate,11033.7,103,MS-DRG,8826.96,Case Rate,103% of CMS IPPS Rate,21475.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10712.33,100,MS-DRG,8569.864,Case Rate,100% of CMS IPPS Rate,11347.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16068.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10712.33,100,MS-DRG,8569.864,Case Rate,100% of CMS IPPS Rate,21912.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10712.33,100,MS-DRG,8569.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26585.85,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,CDM,,,,,Inpatient,,,,,,39439.81,,,,Case Rate,100% of CMS IPPS Rate,30172.6,145,MS-DRG,24138.08,Case Rate,145% of CMS IPPS Rate,20808.69,100,MS-DRG,16646.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20808.69,100,,16646.952,Case Rate,100% of CMS IPPS Rate,36172.34,100,,,Case Rate,100% of CMS IPPS Rate,41341.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46507.68,100,,,Case Rate,100% of CMS IPPS Rate,46507.68,100,,,Case Rate,100% of CMS IPPS Rate,46507.68,100,,,Case Rate,100% CMS IPPS Rate,35602.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18934.86,100,,15147.888,Case Rate,100% of CMS IPPS Rate,18934.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18934.86,100,MS-DRG,15147.888,Case Rate,100% of CMS IPPS Rate,18934.86,100,MS-DRG,15147.888,Case Rate,100% of CMS IPPS Rate,27360.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20808.69,100,MS-DRG,16646.952,Case Rate,100% of CMS IPPS Rate,27051.3,130,MS-DRG,21641.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21432.95,103,MS-DRG,17146.36,Case Rate,103% of CMS IPPS Rate,21432.95,103,MS-DRG,17146.36,Case Rate,103% of CMS IPPS Rate,42734.23,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20808.69,100,MS-DRG,16646.952,Case Rate,100% of CMS IPPS Rate,20883.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,31213.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20808.69,100,MS-DRG,16646.952,Case Rate,100% of CMS IPPS Rate,40327,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20808.69,100,MS-DRG,16646.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46507.68,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,CDM,,,,,Inpatient,,,,,,28006.99,,,,Case Rate,100% of CMS IPPS Rate,20503.75,145,MS-DRG,16403,Case Rate,145% of CMS IPPS Rate,14140.52,100,MS-DRG,11312.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14140.52,100,,11312.416,Case Rate,100% of CMS IPPS Rate,28416.36,100,,,Case Rate,100% of CMS IPPS Rate,32477.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36535.62,100,,,Case Rate,100% of CMS IPPS Rate,36535.62,100,,,Case Rate,100% of CMS IPPS Rate,36535.62,100,,,Case Rate,100% CMS IPPS Rate,25282.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12867.24,100,,10293.792,Case Rate,100% of CMS IPPS Rate,12867.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12867.24,100,MS-DRG,10293.792,Case Rate,100% of CMS IPPS Rate,12867.24,100,MS-DRG,10293.792,Case Rate,100% of CMS IPPS Rate,18592.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14140.52,100,MS-DRG,11312.416,Case Rate,100% of CMS IPPS Rate,18382.68,130,MS-DRG,14706.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14564.74,103,MS-DRG,11651.792,Case Rate,103% of CMS IPPS Rate,14564.74,103,MS-DRG,11651.792,Case Rate,103% of CMS IPPS Rate,29040.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14140.52,100,MS-DRG,11312.416,Case Rate,100% of CMS IPPS Rate,14829.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21210.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14140.52,100,MS-DRG,11312.416,Case Rate,100% of CMS IPPS Rate,28637,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14140.52,100,MS-DRG,11312.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36535.62,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,CDM,,,,,Inpatient,,,,,,20669.44,,,,Case Rate,100% of CMS IPPS Rate,14981.1,145,MS-DRG,11984.88,Case Rate,145% of CMS IPPS Rate,10331.79,100,MS-DRG,8265.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10331.79,100,,8265.432,Case Rate,100% of CMS IPPS Rate,22162.79,100,,,Case Rate,100% of CMS IPPS Rate,25329.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28495.25,100,,,Case Rate,100% of CMS IPPS Rate,28495.25,100,,,Case Rate,100% of CMS IPPS Rate,28495.25,100,,,Case Rate,100% CMS IPPS Rate,18658.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9401.55,100,,7521.24,Case Rate,100% of CMS IPPS Rate,9401.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9401.55,100,MS-DRG,7521.24,Case Rate,100% of CMS IPPS Rate,9401.55,100,MS-DRG,7521.24,Case Rate,100% of CMS IPPS Rate,13585.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10331.79,100,MS-DRG,8265.432,Case Rate,100% of CMS IPPS Rate,13431.33,130,MS-DRG,10745.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10641.74,103,MS-DRG,8513.392,Case Rate,103% of CMS IPPS Rate,10641.74,103,MS-DRG,8513.392,Case Rate,103% of CMS IPPS Rate,20498.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.79,100,MS-DRG,8265.432,Case Rate,100% of CMS IPPS Rate,10944.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15497.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.79,100,MS-DRG,8265.432,Case Rate,100% of CMS IPPS Rate,21134.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.79,100,MS-DRG,8265.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28495.25,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,CDM,,,,,Inpatient,,,,,,48267.04,,,,Case Rate,100% of CMS IPPS Rate,34983.72,145,MS-DRG,27986.976,Case Rate,145% of CMS IPPS Rate,24126.7,100,MS-DRG,19301.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24126.7,100,,19301.36,Case Rate,100% of CMS IPPS Rate,46709.16,100,,,Case Rate,100% of CMS IPPS Rate,53383.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60055.13,100,,,Case Rate,100% of CMS IPPS Rate,60055.13,100,,,Case Rate,100% of CMS IPPS Rate,60055.13,100,,,Case Rate,100% CMS IPPS Rate,43571.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21954.05,100,,17563.24,Case Rate,100% of CMS IPPS Rate,21954.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21954.05,100,MS-DRG,17563.24,Case Rate,100% of CMS IPPS Rate,21954.05,100,MS-DRG,17563.24,Case Rate,100% of CMS IPPS Rate,31723.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24126.7,100,MS-DRG,19301.36,Case Rate,100% of CMS IPPS Rate,31364.71,130,MS-DRG,25091.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24850.5,103,MS-DRG,19880.4,Case Rate,103% of CMS IPPS Rate,24850.5,103,MS-DRG,19880.4,Case Rate,103% of CMS IPPS Rate,44713.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24126.7,100,MS-DRG,19301.36,Case Rate,100% of CMS IPPS Rate,25557.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,36190.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24126.7,100,MS-DRG,19301.36,Case Rate,100% of CMS IPPS Rate,49352.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24126.7,100,MS-DRG,19301.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60055.13,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,CDM,,,,,Inpatient,,,,,,27052.65,,,,Case Rate,100% of CMS IPPS Rate,19607.64,145,MS-DRG,15686.112,Case Rate,145% of CMS IPPS Rate,13522.51,100,MS-DRG,10818.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13522.51,100,,10818.008,Case Rate,100% of CMS IPPS Rate,26370.05,100,,,Case Rate,100% of CMS IPPS Rate,30138.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33904.63,100,,,Case Rate,100% of CMS IPPS Rate,33904.63,100,,,Case Rate,100% of CMS IPPS Rate,33904.63,100,,,Case Rate,100% CMS IPPS Rate,24420.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12304.89,100,,9843.912,Case Rate,100% of CMS IPPS Rate,12304.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12304.89,100,MS-DRG,9843.912,Case Rate,100% of CMS IPPS Rate,12304.89,100,MS-DRG,9843.912,Case Rate,100% of CMS IPPS Rate,26482.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13522.51,100,MS-DRG,10818.008,Case Rate,100% of CMS IPPS Rate,17579.26,130,MS-DRG,14063.408,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13928.19,103,MS-DRG,11142.552,Case Rate,103% of CMS IPPS Rate,13928.19,103,MS-DRG,11142.552,Case Rate,103% of CMS IPPS Rate,25300,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13522.51,100,MS-DRG,10818.008,Case Rate,100% of CMS IPPS Rate,14324.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20283.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13522.51,100,MS-DRG,10818.008,Case Rate,100% of CMS IPPS Rate,27661.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13522.51,100,MS-DRG,10818.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33904.63,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,CDM,,,,,Inpatient,,,,,,18336.33,,,,Case Rate,100% of CMS IPPS Rate,13290.08,145,MS-DRG,10632.064,Case Rate,145% of CMS IPPS Rate,9165.57,100,MS-DRG,7332.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9165.57,100,,7332.456,Case Rate,100% of CMS IPPS Rate,18266.14,100,,,Case Rate,100% of CMS IPPS Rate,20876.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23485.23,100,,,Case Rate,100% of CMS IPPS Rate,23485.23,100,,,Case Rate,100% of CMS IPPS Rate,23485.23,100,,,Case Rate,100% CMS IPPS Rate,16552.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8340.35,100,,6672.28,Case Rate,100% of CMS IPPS Rate,8340.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8340.35,100,MS-DRG,6672.28,Case Rate,100% of CMS IPPS Rate,8340.35,100,MS-DRG,6672.28,Case Rate,100% of CMS IPPS Rate,11519.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9165.57,100,MS-DRG,7332.456,Case Rate,100% of CMS IPPS Rate,11915.24,130,MS-DRG,9532.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9440.54,103,MS-DRG,7552.432,Case Rate,103% of CMS IPPS Rate,9440.54,103,MS-DRG,7552.432,Case Rate,103% of CMS IPPS Rate,17411.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9165.57,100,MS-DRG,7332.456,Case Rate,100% of CMS IPPS Rate,9709.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13748.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9165.57,100,MS-DRG,7332.456,Case Rate,100% of CMS IPPS Rate,18748.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9165.57,100,MS-DRG,7332.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23485.23,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,CDM,,,,,Inpatient,,,,,,31735.32,,,,Case Rate,100% of CMS IPPS Rate,23001.6,145,MS-DRG,18401.28,Case Rate,145% of CMS IPPS Rate,15863.17,100,MS-DRG,12690.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15863.17,100,,12690.536,Case Rate,100% of CMS IPPS Rate,31681.12,100,,,Case Rate,100% of CMS IPPS Rate,36208.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40733.21,100,,,Case Rate,100% of CMS IPPS Rate,40733.21,100,,,Case Rate,100% of CMS IPPS Rate,40733.21,100,,,Case Rate,100% CMS IPPS Rate,28648.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14434.75,100,,11547.8,Case Rate,100% of CMS IPPS Rate,14434.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14434.75,100,MS-DRG,11547.8,Case Rate,100% of CMS IPPS Rate,14434.75,100,MS-DRG,11547.8,Case Rate,100% of CMS IPPS Rate,18110.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15863.17,100,MS-DRG,12690.536,Case Rate,100% of CMS IPPS Rate,20622.12,130,MS-DRG,16497.696,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16339.07,103,MS-DRG,13071.256,Case Rate,103% of CMS IPPS Rate,16339.07,103,MS-DRG,13071.256,Case Rate,103% of CMS IPPS Rate,30077.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15863.17,100,MS-DRG,12690.536,Case Rate,100% of CMS IPPS Rate,16804.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23794.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15863.17,100,MS-DRG,12690.536,Case Rate,100% of CMS IPPS Rate,32449.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15863.17,100,MS-DRG,12690.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40733.21,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,CDM,,,,,Inpatient,,,,,,22382.31,,,,Case Rate,100% of CMS IPPS Rate,16222.59,145,MS-DRG,12978.072,Case Rate,145% of CMS IPPS Rate,11187.99,100,MS-DRG,8950.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11187.99,100,,8950.392,Case Rate,100% of CMS IPPS Rate,22108.13,100,,,Case Rate,100% of CMS IPPS Rate,25267.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28424.98,100,,,Case Rate,100% of CMS IPPS Rate,28424.98,100,,,Case Rate,100% of CMS IPPS Rate,28424.98,100,,,Case Rate,100% CMS IPPS Rate,20204.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10180.62,100,,8144.496,Case Rate,100% of CMS IPPS Rate,10180.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10180.62,100,MS-DRG,8144.496,Case Rate,100% of CMS IPPS Rate,10180.62,100,MS-DRG,8144.496,Case Rate,100% of CMS IPPS Rate,14370.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11187.99,100,MS-DRG,8950.392,Case Rate,100% of CMS IPPS Rate,14544.39,130,MS-DRG,11635.512,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11523.63,103,MS-DRG,9218.904,Case Rate,103% of CMS IPPS Rate,11523.63,103,MS-DRG,9218.904,Case Rate,103% of CMS IPPS Rate,21011.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11187.99,100,MS-DRG,8950.392,Case Rate,100% of CMS IPPS Rate,11851.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16781.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11187.99,100,MS-DRG,8950.392,Case Rate,100% of CMS IPPS Rate,22885.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11187.99,100,MS-DRG,8950.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28424.98,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,CDM,,,,,Inpatient,,,,,,17980.33,,,,Case Rate,100% of CMS IPPS Rate,13032.05,145,MS-DRG,10425.64,Case Rate,145% of CMS IPPS Rate,8987.62,100,MS-DRG,7190.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8987.62,100,,7190.096,Case Rate,100% of CMS IPPS Rate,17564.93,100,,,Case Rate,100% of CMS IPPS Rate,20074.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22583.66,100,,,Case Rate,100% of CMS IPPS Rate,22583.66,100,,,Case Rate,100% of CMS IPPS Rate,22583.66,100,,,Case Rate,100% CMS IPPS Rate,16231.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8178.44,100,,6542.752,Case Rate,100% of CMS IPPS Rate,8178.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8178.44,100,MS-DRG,6542.752,Case Rate,100% of CMS IPPS Rate,8178.44,100,MS-DRG,6542.752,Case Rate,100% of CMS IPPS Rate,12091.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8987.62,100,MS-DRG,7190.096,Case Rate,100% of CMS IPPS Rate,11683.91,130,MS-DRG,9347.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9257.25,103,MS-DRG,7405.8,Case Rate,103% of CMS IPPS Rate,9257.25,103,MS-DRG,7405.8,Case Rate,103% of CMS IPPS Rate,16508.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8987.62,100,MS-DRG,7190.096,Case Rate,100% of CMS IPPS Rate,9520.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13481.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8987.62,100,MS-DRG,7190.096,Case Rate,100% of CMS IPPS Rate,18384.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8987.62,100,MS-DRG,7190.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22583.66,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,CDM,,,,,Inpatient,,,,,,43825.35,,,,Case Rate,100% of CMS IPPS Rate,31764.4,145,MS-DRG,25411.52,Case Rate,145% of CMS IPPS Rate,21906.48,100,MS-DRG,17525.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21906.48,100,,17525.184,Case Rate,100% of CMS IPPS Rate,47051.76,100,,,Case Rate,100% of CMS IPPS Rate,53775.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60495.63,100,,,Case Rate,100% of CMS IPPS Rate,60495.63,100,,,Case Rate,100% of CMS IPPS Rate,60495.63,100,,,Case Rate,100% CMS IPPS Rate,39561.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19933.79,100,,15947.032,Case Rate,100% of CMS IPPS Rate,19933.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19933.79,100,MS-DRG,15947.032,Case Rate,100% of CMS IPPS Rate,19933.79,100,MS-DRG,15947.032,Case Rate,100% of CMS IPPS Rate,26015.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21906.48,100,MS-DRG,17525.184,Case Rate,100% of CMS IPPS Rate,28478.42,130,MS-DRG,22782.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22563.67,103,MS-DRG,18050.936,Case Rate,103% of CMS IPPS Rate,22563.67,103,MS-DRG,18050.936,Case Rate,103% of CMS IPPS Rate,41254.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21906.48,100,MS-DRG,17525.184,Case Rate,100% of CMS IPPS Rate,23205.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32859.72,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21906.48,100,MS-DRG,17525.184,Case Rate,100% of CMS IPPS Rate,44811.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21906.48,100,MS-DRG,17525.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60495.63,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,CDM,,,,,Inpatient,,,,,,23407.84,,,,Case Rate,100% of CMS IPPS Rate,16965.9,145,MS-DRG,13572.72,Case Rate,145% of CMS IPPS Rate,11700.62,100,MS-DRG,9360.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11700.62,100,,9360.496,Case Rate,100% of CMS IPPS Rate,21830.85,100,,,Case Rate,100% of CMS IPPS Rate,24950.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28068.46,100,,,Case Rate,100% of CMS IPPS Rate,28068.46,100,,,Case Rate,100% of CMS IPPS Rate,28068.46,100,,,Case Rate,100% CMS IPPS Rate,21130.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10647.07,100,,8517.656,Case Rate,100% of CMS IPPS Rate,10647.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10647.07,100,MS-DRG,8517.656,Case Rate,100% of CMS IPPS Rate,10647.07,100,MS-DRG,8517.656,Case Rate,100% of CMS IPPS Rate,15384.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11700.62,100,MS-DRG,9360.496,Case Rate,100% of CMS IPPS Rate,15210.81,130,MS-DRG,12168.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12051.64,103,MS-DRG,9641.312,Case Rate,103% of CMS IPPS Rate,12051.64,103,MS-DRG,9641.312,Case Rate,103% of CMS IPPS Rate,22916.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11700.62,100,MS-DRG,9360.496,Case Rate,100% of CMS IPPS Rate,12394.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17550.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11700.62,100,MS-DRG,9360.496,Case Rate,100% of CMS IPPS Rate,23934.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11700.62,100,MS-DRG,9360.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28068.46,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,CDM,,,,,Inpatient,,,,,,19319.41,,,,Case Rate,100% of CMS IPPS Rate,14002.61,145,MS-DRG,11202.088,Case Rate,145% of CMS IPPS Rate,9656.97,100,MS-DRG,7725.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9656.97,100,,7725.576,Case Rate,100% of CMS IPPS Rate,19588.57,100,,,Case Rate,100% of CMS IPPS Rate,22387.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25185.52,100,,,Case Rate,100% of CMS IPPS Rate,25185.52,100,,,Case Rate,100% of CMS IPPS Rate,25185.52,100,,,Case Rate,100% CMS IPPS Rate,17439.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8787.51,100,,7030.008,Case Rate,100% of CMS IPPS Rate,8787.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8787.51,100,MS-DRG,7030.008,Case Rate,100% of CMS IPPS Rate,8787.51,100,MS-DRG,7030.008,Case Rate,100% of CMS IPPS Rate,12697.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9656.97,100,MS-DRG,7725.576,Case Rate,100% of CMS IPPS Rate,12554.06,130,MS-DRG,10043.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9946.68,103,MS-DRG,7957.344,Case Rate,103% of CMS IPPS Rate,9946.68,103,MS-DRG,7957.344,Case Rate,103% of CMS IPPS Rate,17527.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9656.97,100,MS-DRG,7725.576,Case Rate,100% of CMS IPPS Rate,10229.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14485.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9656.97,100,MS-DRG,7725.576,Case Rate,100% of CMS IPPS Rate,19754,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9656.97,100,MS-DRG,7725.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25185.52,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,CDM,,,,,Inpatient,,,,,,53548.04,,,,Case Rate,100% of CMS IPPS Rate,38811.35,145,MS-DRG,31049.08,Case Rate,145% of CMS IPPS Rate,26766.45,100,MS-DRG,21413.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26766.45,100,,21413.16,Case Rate,100% of CMS IPPS Rate,54222.51,100,,,Case Rate,100% of CMS IPPS Rate,61970.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,69715.24,100,,,Case Rate,100% of CMS IPPS Rate,69715.24,100,,,Case Rate,100% of CMS IPPS Rate,69715.24,100,,,Case Rate,100% CMS IPPS Rate,48338.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24356.06,100,,19484.848,Case Rate,100% of CMS IPPS Rate,24356.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24356.06,100,MS-DRG,19484.848,Case Rate,100% of CMS IPPS Rate,24356.06,100,MS-DRG,19484.848,Case Rate,100% of CMS IPPS Rate,67118.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26766.45,100,MS-DRG,21413.16,Case Rate,100% of CMS IPPS Rate,34796.39,130,MS-DRG,27837.112,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27569.44,103,MS-DRG,22055.552,Case Rate,103% of CMS IPPS Rate,27569.44,103,MS-DRG,22055.552,Case Rate,103% of CMS IPPS Rate,49738.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26766.45,100,MS-DRG,21413.16,Case Rate,100% of CMS IPPS Rate,28354.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,40149.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26766.45,100,MS-DRG,21413.16,Case Rate,100% of CMS IPPS Rate,54752.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26766.45,100,MS-DRG,21413.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,69715.24,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,CDM,,,,,Inpatient,,,,,,28579.31,,,,Case Rate,100% of CMS IPPS Rate,21154.76,145,MS-DRG,16923.808,Case Rate,145% of CMS IPPS Rate,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14589.49,100,,11671.592,Case Rate,100% of CMS IPPS Rate,30438.67,100,,,Case Rate,100% of CMS IPPS Rate,34788.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39135.76,100,,,Case Rate,100% of CMS IPPS Rate,39135.76,100,,,Case Rate,100% of CMS IPPS Rate,39135.76,100,,,Case Rate,100% CMS IPPS Rate,25799.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13275.79,100,,10620.632,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,10620.632,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,10620.632,Case Rate,100% of CMS IPPS Rate,21513.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,18966.34,130,MS-DRG,15173.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15027.17,103,MS-DRG,12021.736,Case Rate,103% of CMS IPPS Rate,15027.17,103,MS-DRG,12021.736,Case Rate,103% of CMS IPPS Rate,29962.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,15132.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21884.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,29222.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39135.76,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,CDM,,,,,Inpatient,,,,,,21933.21,,,,Case Rate,100% of CMS IPPS Rate,15897.09,145,MS-DRG,12717.672,Case Rate,145% of CMS IPPS Rate,10963.51,100,MS-DRG,8770.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10963.51,100,,8770.808,Case Rate,100% of CMS IPPS Rate,20607.06,100,,,Case Rate,100% of CMS IPPS Rate,23551.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26495.01,100,,,Case Rate,100% of CMS IPPS Rate,26495.01,100,,,Case Rate,100% of CMS IPPS Rate,26495.01,100,,,Case Rate,100% CMS IPPS Rate,19799.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9976.35,100,,7981.08,Case Rate,100% of CMS IPPS Rate,9976.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9976.35,100,MS-DRG,7981.08,Case Rate,100% of CMS IPPS Rate,9976.35,100,MS-DRG,7981.08,Case Rate,100% of CMS IPPS Rate,14415.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10963.51,100,MS-DRG,8770.808,Case Rate,100% of CMS IPPS Rate,14252.56,130,MS-DRG,11402.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11292.42,103,MS-DRG,9033.936,Case Rate,103% of CMS IPPS Rate,11292.42,103,MS-DRG,9033.936,Case Rate,103% of CMS IPPS Rate,18097.09,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10963.51,100,MS-DRG,8770.808,Case Rate,100% of CMS IPPS Rate,11613.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16445.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10963.51,100,MS-DRG,8770.808,Case Rate,100% of CMS IPPS Rate,22426.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10963.51,100,MS-DRG,8770.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26495.01,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139647.56,100,,,Case Rate,100% of CMS IPPS Rate,159603.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,179548.36,100,,,Case Rate,100% of CMS IPPS Rate,179548.36,100,,,Case Rate,100% of CMS IPPS Rate,179548.36,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12318.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,179548.36,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94686.09,100,,,Case Rate,100% of CMS IPPS Rate,108216.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,121740.28,100,,,Case Rate,100% of CMS IPPS Rate,121740.28,100,,,Case Rate,100% of CMS IPPS Rate,121740.28,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11857.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,121740.28,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73375.16,100,,,Case Rate,100% of CMS IPPS Rate,83860.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,94340.27,100,,,Case Rate,100% of CMS IPPS Rate,94340.27,100,,,Case Rate,100% of CMS IPPS Rate,94340.27,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9380.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,94340.27,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111188.54,100,,,Case Rate,100% of CMS IPPS Rate,127077.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,142957.88,100,,,Case Rate,100% of CMS IPPS Rate,142957.88,100,,,Case Rate,100% of CMS IPPS Rate,142957.88,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,142957.88,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72927.24,100,,,Case Rate,100% of CMS IPPS Rate,83348.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,93764.37,100,,,Case Rate,100% of CMS IPPS Rate,93764.37,100,,,Case Rate,100% of CMS IPPS Rate,93764.37,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,93764.37,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,CDM,,,,,Inpatient,,,,,,26233.87,,,,Case Rate,100% of CMS IPPS Rate,19014.18,145,MS-DRG,15211.344,Case Rate,145% of CMS IPPS Rate,13113.23,100,MS-DRG,10490.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13113.23,100,,10490.584,Case Rate,100% of CMS IPPS Rate,26116.76,100,,,Case Rate,100% of CMS IPPS Rate,29848.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33578.97,100,,,Case Rate,100% of CMS IPPS Rate,33578.97,100,,,Case Rate,100% of CMS IPPS Rate,33578.97,100,,,Case Rate,100% CMS IPPS Rate,23681.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11932.47,100,,9545.976,Case Rate,100% of CMS IPPS Rate,11932.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11932.47,100,MS-DRG,9545.976,Case Rate,100% of CMS IPPS Rate,11932.47,100,MS-DRG,9545.976,Case Rate,100% of CMS IPPS Rate,17565.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13113.23,100,MS-DRG,10490.584,Case Rate,100% of CMS IPPS Rate,17047.2,130,MS-DRG,13637.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13506.63,103,MS-DRG,10805.304,Case Rate,103% of CMS IPPS Rate,13506.63,103,MS-DRG,10805.304,Case Rate,103% of CMS IPPS Rate,23885.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13113.23,100,MS-DRG,10490.584,Case Rate,100% of CMS IPPS Rate,13891,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19669.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13113.23,100,MS-DRG,10490.584,Case Rate,100% of CMS IPPS Rate,26824,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13113.23,100,MS-DRG,10490.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33578.97,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,CDM,,,,,Inpatient,,,,,,14116.45,,,,Case Rate,100% of CMS IPPS Rate,10231.53,145,MS-DRG,8185.224,Case Rate,145% of CMS IPPS Rate,7056.23,100,MS-DRG,5644.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7056.23,100,,5644.984,Case Rate,100% of CMS IPPS Rate,14261.5,100,,,Case Rate,100% of CMS IPPS Rate,16299.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18336.37,100,,,Case Rate,100% of CMS IPPS Rate,18336.37,100,,,Case Rate,100% of CMS IPPS Rate,18336.37,100,,,Case Rate,100% CMS IPPS Rate,12743.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6420.98,100,,5136.784,Case Rate,100% of CMS IPPS Rate,6420.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6420.98,100,MS-DRG,5136.784,Case Rate,100% of CMS IPPS Rate,6420.98,100,MS-DRG,5136.784,Case Rate,100% of CMS IPPS Rate,8430.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7056.23,100,MS-DRG,5644.984,Case Rate,100% of CMS IPPS Rate,9173.1,130,MS-DRG,7338.48,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7267.92,103,MS-DRG,5814.336,Case Rate,103% of CMS IPPS Rate,7267.92,103,MS-DRG,5814.336,Case Rate,103% of CMS IPPS Rate,13153.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7056.23,100,MS-DRG,5644.984,Case Rate,100% of CMS IPPS Rate,7474.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10584.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7056.23,100,MS-DRG,5644.984,Case Rate,100% of CMS IPPS Rate,14434,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7056.23,100,MS-DRG,5644.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18336.37,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,CDM,,,,,Inpatient,,,,,,9166.79,,,,Case Rate,100% of CMS IPPS Rate,6644.05,145,MS-DRG,5315.24,Case Rate,145% of CMS IPPS Rate,4582.1,100,MS-DRG,3665.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4582.1,100,,3665.68,Case Rate,100% of CMS IPPS Rate,9285.04,100,,,Case Rate,100% of CMS IPPS Rate,10611.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11938.01,100,,,Case Rate,100% of CMS IPPS Rate,11938.01,100,,,Case Rate,100% of CMS IPPS Rate,11938.01,100,,,Case Rate,100% CMS IPPS Rate,8275.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4169.68,100,,3335.744,Case Rate,100% of CMS IPPS Rate,4169.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4169.68,100,MS-DRG,3335.744,Case Rate,100% of CMS IPPS Rate,4169.68,100,MS-DRG,3335.744,Case Rate,100% of CMS IPPS Rate,4542.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4582.1,100,MS-DRG,3665.68,Case Rate,100% of CMS IPPS Rate,5956.73,130,MS-DRG,4765.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4719.56,103,MS-DRG,3775.648,Case Rate,103% of CMS IPPS Rate,4719.56,103,MS-DRG,3775.648,Case Rate,103% of CMS IPPS Rate,7940.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4582.1,100,MS-DRG,3665.68,Case Rate,100% of CMS IPPS Rate,4853.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6873.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4582.1,100,MS-DRG,3665.68,Case Rate,100% of CMS IPPS Rate,9373,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4582.1,100,MS-DRG,3665.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4169.68,11938.01,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,CDM,,,,,Inpatient,,,,,,24096.55,,,,Case Rate,100% of CMS IPPS Rate,17465.06,145,MS-DRG,13972.048,Case Rate,145% of CMS IPPS Rate,12044.87,100,MS-DRG,9635.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12044.87,100,,9635.896,Case Rate,100% of CMS IPPS Rate,24323.74,100,,,Case Rate,100% of CMS IPPS Rate,27799.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31273.64,100,,,Case Rate,100% of CMS IPPS Rate,31273.64,100,,,Case Rate,100% of CMS IPPS Rate,31273.64,100,,,Case Rate,100% CMS IPPS Rate,21752.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10960.33,100,,8768.264,Case Rate,100% of CMS IPPS Rate,10960.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10960.33,100,MS-DRG,8768.264,Case Rate,100% of CMS IPPS Rate,10960.33,100,MS-DRG,8768.264,Case Rate,100% of CMS IPPS Rate,14498.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12044.87,100,MS-DRG,9635.896,Case Rate,100% of CMS IPPS Rate,15658.33,130,MS-DRG,12526.664,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12406.22,103,MS-DRG,9924.976,Case Rate,103% of CMS IPPS Rate,12406.22,103,MS-DRG,9924.976,Case Rate,103% of CMS IPPS Rate,22114.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12044.87,100,MS-DRG,9635.896,Case Rate,100% of CMS IPPS Rate,12759.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18067.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12044.87,100,MS-DRG,9635.896,Case Rate,100% of CMS IPPS Rate,24638.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12044.87,100,MS-DRG,9635.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31273.64,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,CDM,,,,,Inpatient,,,,,,15070.78,,,,Case Rate,100% of CMS IPPS Rate,10923.24,145,MS-DRG,8738.592,Case Rate,145% of CMS IPPS Rate,7533.27,100,MS-DRG,6026.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7533.27,100,,6026.616,Case Rate,100% of CMS IPPS Rate,15033.37,100,,,Case Rate,100% of CMS IPPS Rate,17181.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19328.78,100,,,Case Rate,100% of CMS IPPS Rate,19328.78,100,,,Case Rate,100% of CMS IPPS Rate,19328.78,100,,,Case Rate,100% CMS IPPS Rate,13604.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6855.05,100,,5484.04,Case Rate,100% of CMS IPPS Rate,6855.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6855.05,100,MS-DRG,5484.04,Case Rate,100% of CMS IPPS Rate,6855.05,100,MS-DRG,5484.04,Case Rate,100% of CMS IPPS Rate,8857.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7533.27,100,MS-DRG,6026.616,Case Rate,100% of CMS IPPS Rate,9793.25,130,MS-DRG,7834.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7759.27,103,MS-DRG,6207.416,Case Rate,103% of CMS IPPS Rate,7759.27,103,MS-DRG,6207.416,Case Rate,103% of CMS IPPS Rate,13920.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7533.27,100,MS-DRG,6026.616,Case Rate,100% of CMS IPPS Rate,7980.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11299.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7533.27,100,MS-DRG,6026.616,Case Rate,100% of CMS IPPS Rate,15409.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7533.27,100,MS-DRG,6026.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19328.78,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,CDM,,,,,Inpatient,,,,,,11379.42,,,,Case Rate,100% of CMS IPPS Rate,8247.75,145,MS-DRG,6598.2,Case Rate,145% of CMS IPPS Rate,5688.1,100,MS-DRG,4550.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5688.1,100,,4550.48,Case Rate,100% of CMS IPPS Rate,10467.5,100,,,Case Rate,100% of CMS IPPS Rate,11963.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13458.33,100,,,Case Rate,100% of CMS IPPS Rate,13458.33,100,,,Case Rate,100% of CMS IPPS Rate,13458.33,100,,,Case Rate,100% CMS IPPS Rate,10272.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5176.07,100,,4140.856,Case Rate,100% of CMS IPPS Rate,5176.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5176.07,100,MS-DRG,4140.856,Case Rate,100% of CMS IPPS Rate,5176.07,100,MS-DRG,4140.856,Case Rate,100% of CMS IPPS Rate,7478.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5688.1,100,MS-DRG,4550.48,Case Rate,100% of CMS IPPS Rate,7394.53,130,MS-DRG,5915.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5858.74,103,MS-DRG,4686.992,Case Rate,103% of CMS IPPS Rate,5858.74,103,MS-DRG,4686.992,Case Rate,103% of CMS IPPS Rate,10700.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5688.1,100,MS-DRG,4550.48,Case Rate,100% of CMS IPPS Rate,6025.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8532.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5688.1,100,MS-DRG,4550.48,Case Rate,100% of CMS IPPS Rate,11635.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5688.1,100,MS-DRG,4550.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5176.07,13458.33,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,CDM,,,,,Inpatient,,,,,,22849.21,,,,Case Rate,100% of CMS IPPS Rate,16561,145,MS-DRG,13248.8,Case Rate,145% of CMS IPPS Rate,11421.38,100,MS-DRG,9137.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11421.38,100,,9137.104,Case Rate,100% of CMS IPPS Rate,22178.78,100,,,Case Rate,100% of CMS IPPS Rate,25348.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28515.82,100,,,Case Rate,100% of CMS IPPS Rate,28515.82,100,,,Case Rate,100% of CMS IPPS Rate,28515.82,100,,,Case Rate,100% CMS IPPS Rate,20626.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10392.99,100,,8314.392,Case Rate,100% of CMS IPPS Rate,10392.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10392.99,100,MS-DRG,8314.392,Case Rate,100% of CMS IPPS Rate,10392.99,100,MS-DRG,8314.392,Case Rate,100% of CMS IPPS Rate,14339.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11421.38,100,MS-DRG,9137.104,Case Rate,100% of CMS IPPS Rate,14847.79,130,MS-DRG,11878.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11764.02,103,MS-DRG,9411.216,Case Rate,103% of CMS IPPS Rate,11764.02,103,MS-DRG,9411.216,Case Rate,103% of CMS IPPS Rate,20966.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11421.38,100,MS-DRG,9137.104,Case Rate,100% of CMS IPPS Rate,12098.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17132.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11421.38,100,MS-DRG,9137.104,Case Rate,100% of CMS IPPS Rate,23363.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11421.38,100,MS-DRG,9137.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28515.82,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,CDM,,,,,Inpatient,,,,,,11709.4,,,,Case Rate,100% of CMS IPPS Rate,8486.92,145,MS-DRG,6789.536,Case Rate,145% of CMS IPPS Rate,5853.05,100,MS-DRG,4682.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5853.05,100,,4682.44,Case Rate,100% of CMS IPPS Rate,11467.33,100,,,Case Rate,100% of CMS IPPS Rate,13106.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14743.83,100,,,Case Rate,100% of CMS IPPS Rate,14743.83,100,,,Case Rate,100% of CMS IPPS Rate,14743.83,100,,,Case Rate,100% CMS IPPS Rate,10570.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5326.16,100,,4260.928,Case Rate,100% of CMS IPPS Rate,5326.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5326.16,100,MS-DRG,4260.928,Case Rate,100% of CMS IPPS Rate,5326.16,100,MS-DRG,4260.928,Case Rate,100% of CMS IPPS Rate,6429.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5853.05,100,MS-DRG,4682.44,Case Rate,100% of CMS IPPS Rate,7608.97,130,MS-DRG,6087.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6028.64,103,MS-DRG,4822.912,Case Rate,103% of CMS IPPS Rate,6028.64,103,MS-DRG,4822.912,Case Rate,103% of CMS IPPS Rate,11002.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5853.05,100,MS-DRG,4682.44,Case Rate,100% of CMS IPPS Rate,6200.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8779.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5853.05,100,MS-DRG,4682.44,Case Rate,100% of CMS IPPS Rate,11972.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5853.05,100,MS-DRG,4682.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5326.16,14743.83,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,CDM,,,,,Inpatient,,,,,,8428.8,,,,Case Rate,100% of CMS IPPS Rate,6109.14,145,MS-DRG,4887.312,Case Rate,145% of CMS IPPS Rate,4213.2,100,MS-DRG,3370.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4213.2,100,,3370.56,Case Rate,100% of CMS IPPS Rate,8199.9,100,,,Case Rate,100% of CMS IPPS Rate,9371.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10542.81,100,,,Case Rate,100% of CMS IPPS Rate,10542.81,100,,,Case Rate,100% of CMS IPPS Rate,10542.81,100,,,Case Rate,100% CMS IPPS Rate,7608.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3834,100,,3067.2,Case Rate,100% of CMS IPPS Rate,3834,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3834,100,MS-DRG,3067.2,Case Rate,100% of CMS IPPS Rate,3834,100,MS-DRG,3067.2,Case Rate,100% of CMS IPPS Rate,4390.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4213.2,100,MS-DRG,3370.56,Case Rate,100% of CMS IPPS Rate,5477.16,130,MS-DRG,4381.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4339.6,103,MS-DRG,3471.68,Case Rate,103% of CMS IPPS Rate,4339.6,103,MS-DRG,3471.68,Case Rate,103% of CMS IPPS Rate,7670.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4213.2,100,MS-DRG,3370.56,Case Rate,100% of CMS IPPS Rate,4463.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6319.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4213.2,100,MS-DRG,3370.56,Case Rate,100% of CMS IPPS Rate,8618.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4213.2,100,MS-DRG,3370.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3834,10542.81,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,CDM,,,,,Inpatient,,,,,,25031.71,,,,Case Rate,100% of CMS IPPS Rate,18142.85,145,MS-DRG,14514.28,Case Rate,145% of CMS IPPS Rate,12512.31,100,MS-DRG,10009.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12512.31,100,,10009.848,Case Rate,100% of CMS IPPS Rate,25200.92,100,,,Case Rate,100% of CMS IPPS Rate,28802.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32401.46,100,,,Case Rate,100% of CMS IPPS Rate,32401.46,100,,,Case Rate,100% of CMS IPPS Rate,32401.46,100,,,Case Rate,100% CMS IPPS Rate,22596.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11385.68,100,,9108.544,Case Rate,100% of CMS IPPS Rate,11385.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11385.68,100,MS-DRG,9108.544,Case Rate,100% of CMS IPPS Rate,11385.68,100,MS-DRG,9108.544,Case Rate,100% of CMS IPPS Rate,14870.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12512.31,100,MS-DRG,10009.848,Case Rate,100% of CMS IPPS Rate,16266,130,MS-DRG,13012.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12887.68,103,MS-DRG,10310.144,Case Rate,103% of CMS IPPS Rate,12887.68,103,MS-DRG,10310.144,Case Rate,103% of CMS IPPS Rate,23969.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12512.31,100,MS-DRG,10009.848,Case Rate,100% of CMS IPPS Rate,13254.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18768.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12512.31,100,MS-DRG,10009.848,Case Rate,100% of CMS IPPS Rate,25594.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12512.31,100,MS-DRG,10009.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32401.46,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,CDM,,,,,Inpatient,,,,,,13027.94,,,,Case Rate,100% of CMS IPPS Rate,9442.57,145,MS-DRG,7554.056,Case Rate,145% of CMS IPPS Rate,6512.12,100,MS-DRG,5209.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6512.12,100,,5209.696,Case Rate,100% of CMS IPPS Rate,12880.41,100,,,Case Rate,100% of CMS IPPS Rate,14721.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16560.67,100,,,Case Rate,100% of CMS IPPS Rate,16560.67,100,,,Case Rate,100% of CMS IPPS Rate,16560.67,100,,,Case Rate,100% CMS IPPS Rate,11760.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5925.88,100,,4740.704,Case Rate,100% of CMS IPPS Rate,5925.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5925.88,100,MS-DRG,4740.704,Case Rate,100% of CMS IPPS Rate,5925.88,100,MS-DRG,4740.704,Case Rate,100% of CMS IPPS Rate,7285.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6512.12,100,MS-DRG,5209.696,Case Rate,100% of CMS IPPS Rate,8465.76,130,MS-DRG,6772.608,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6707.48,103,MS-DRG,5365.984,Case Rate,103% of CMS IPPS Rate,6707.48,103,MS-DRG,5365.984,Case Rate,103% of CMS IPPS Rate,11966.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6512.12,100,MS-DRG,5209.696,Case Rate,100% of CMS IPPS Rate,6898.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9768.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6512.12,100,MS-DRG,5209.696,Case Rate,100% of CMS IPPS Rate,13321,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6512.12,100,MS-DRG,5209.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16560.67,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,CDM,,,,,Inpatient,,,,,,9785.67,,,,Case Rate,100% of CMS IPPS Rate,7092.6,145,MS-DRG,5674.08,Case Rate,145% of CMS IPPS Rate,4891.45,100,MS-DRG,3913.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4891.45,100,,3913.16,Case Rate,100% of CMS IPPS Rate,9367.69,100,,,Case Rate,100% of CMS IPPS Rate,10706.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12044.28,100,,,Case Rate,100% of CMS IPPS Rate,12044.28,100,,,Case Rate,100% of CMS IPPS Rate,12044.28,100,,,Case Rate,100% CMS IPPS Rate,8833.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4451.16,100,,3560.928,Case Rate,100% of CMS IPPS Rate,4451.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4451.16,100,MS-DRG,3560.928,Case Rate,100% of CMS IPPS Rate,4451.16,100,MS-DRG,3560.928,Case Rate,100% of CMS IPPS Rate,5354.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4891.45,100,MS-DRG,3913.16,Case Rate,100% of CMS IPPS Rate,6358.89,130,MS-DRG,5087.112,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5038.19,103,MS-DRG,4030.552,Case Rate,103% of CMS IPPS Rate,5038.19,103,MS-DRG,4030.552,Case Rate,103% of CMS IPPS Rate,8246.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4891.45,100,MS-DRG,3913.16,Case Rate,100% of CMS IPPS Rate,5181.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7337.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4891.45,100,MS-DRG,3913.16,Case Rate,100% of CMS IPPS Rate,10005.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4891.45,100,MS-DRG,3913.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4451.16,12044.28,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,CDM,,,,,Inpatient,,,,,,22361.77,,,,Case Rate,100% of CMS IPPS Rate,16207.71,145,MS-DRG,12966.168,Case Rate,145% of CMS IPPS Rate,11177.73,100,MS-DRG,8942.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11177.73,100,,8942.184,Case Rate,100% of CMS IPPS Rate,22454.74,100,,,Case Rate,100% of CMS IPPS Rate,25663.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28870.62,100,,,Case Rate,100% of CMS IPPS Rate,28870.62,100,,,Case Rate,100% of CMS IPPS Rate,28870.62,100,,,Case Rate,100% CMS IPPS Rate,20186.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10171.28,100,,8137.024,Case Rate,100% of CMS IPPS Rate,10171.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10171.28,100,MS-DRG,8137.024,Case Rate,100% of CMS IPPS Rate,10171.28,100,MS-DRG,8137.024,Case Rate,100% of CMS IPPS Rate,11005.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11177.73,100,MS-DRG,8942.184,Case Rate,100% of CMS IPPS Rate,14531.05,130,MS-DRG,11624.84,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11513.06,103,MS-DRG,9210.448,Case Rate,103% of CMS IPPS Rate,11513.06,103,MS-DRG,9210.448,Case Rate,103% of CMS IPPS Rate,21058.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11177.73,100,MS-DRG,8942.184,Case Rate,100% of CMS IPPS Rate,11840.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16766.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11177.73,100,MS-DRG,8942.184,Case Rate,100% of CMS IPPS Rate,22864.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11177.73,100,MS-DRG,8942.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28870.62,
DISORDERS OF THE BILIARY TRACT WITH CC,445,CDM,,,,,Inpatient,,,,,,14880.47,,,,Case Rate,100% of CMS IPPS Rate,10785.29,145,MS-DRG,8628.232,Case Rate,145% of CMS IPPS Rate,7438.13,100,MS-DRG,5950.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7438.13,100,,5950.504,Case Rate,100% of CMS IPPS Rate,14457.47,100,,,Case Rate,100% of CMS IPPS Rate,16523.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18588.33,100,,,Case Rate,100% of CMS IPPS Rate,18588.33,100,,,Case Rate,100% of CMS IPPS Rate,18588.33,100,,,Case Rate,100% CMS IPPS Rate,13432.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6768.48,100,,5414.784,Case Rate,100% of CMS IPPS Rate,6768.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6768.48,100,MS-DRG,5414.784,Case Rate,100% of CMS IPPS Rate,6768.48,100,MS-DRG,5414.784,Case Rate,100% of CMS IPPS Rate,7759.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7438.13,100,MS-DRG,5950.504,Case Rate,100% of CMS IPPS Rate,9669.57,130,MS-DRG,7735.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7661.27,103,MS-DRG,6129.016,Case Rate,103% of CMS IPPS Rate,7661.27,103,MS-DRG,6129.016,Case Rate,103% of CMS IPPS Rate,13909.94,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7438.13,100,MS-DRG,5950.504,Case Rate,100% of CMS IPPS Rate,7879.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11157.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7438.13,100,MS-DRG,5950.504,Case Rate,100% of CMS IPPS Rate,15215.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7438.13,100,MS-DRG,5950.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18588.33,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,CDM,,,,,Inpatient,,,,,,10974.14,,,,Case Rate,100% of CMS IPPS Rate,7954,145,MS-DRG,6363.2,Case Rate,145% of CMS IPPS Rate,5485.52,100,MS-DRG,4388.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5485.52,100,,4388.416,Case Rate,100% of CMS IPPS Rate,10628.81,100,,,Case Rate,100% of CMS IPPS Rate,12147.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13665.72,100,,,Case Rate,100% of CMS IPPS Rate,13665.72,100,,,Case Rate,100% of CMS IPPS Rate,13665.72,100,,,Case Rate,100% CMS IPPS Rate,9906.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4991.74,100,,3993.392,Case Rate,100% of CMS IPPS Rate,4991.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4991.74,100,MS-DRG,3993.392,Case Rate,100% of CMS IPPS Rate,4991.74,100,MS-DRG,3993.392,Case Rate,100% of CMS IPPS Rate,6236.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5485.52,100,MS-DRG,4388.416,Case Rate,100% of CMS IPPS Rate,7131.18,130,MS-DRG,5704.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5650.09,103,MS-DRG,4520.072,Case Rate,103% of CMS IPPS Rate,5650.09,103,MS-DRG,4520.072,Case Rate,103% of CMS IPPS Rate,10268.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5485.52,100,MS-DRG,4388.416,Case Rate,100% of CMS IPPS Rate,5810.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8228.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5485.52,100,MS-DRG,4388.416,Case Rate,100% of CMS IPPS Rate,11221,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5485.52,100,MS-DRG,4388.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4991.74,13665.72,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89380.36,100,,,Case Rate,100% of CMS IPPS Rate,102152.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,114918.56,100,,,Case Rate,100% of CMS IPPS Rate,114918.56,100,,,Case Rate,100% of CMS IPPS Rate,114918.56,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,114918.56,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54437.14,100,,,Case Rate,100% of CMS IPPS Rate,62216.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,69991.19,100,,,Case Rate,100% of CMS IPPS Rate,69991.19,100,,,Case Rate,100% of CMS IPPS Rate,69991.19,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,69991.19,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68655.98,100,,,Case Rate,100% of CMS IPPS Rate,78466.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,88272.71,100,,,Case Rate,100% of CMS IPPS Rate,88272.71,100,,,Case Rate,100% of CMS IPPS Rate,88272.71,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,88272.71,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41139.47,100,,,Case Rate,100% of CMS IPPS Rate,47018.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52894.04,100,,,Case Rate,100% of CMS IPPS Rate,52894.04,100,,,Case Rate,100% of CMS IPPS Rate,52894.04,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,52894.04,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,CDM,,,,,Inpatient,,,,,,115415.34,,,,Case Rate,100% of CMS IPPS Rate,83652.49,145,MS-DRG,66921.992,Case Rate,145% of CMS IPPS Rate,57691.37,100,MS-DRG,46153.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,57691.37,100,,46153.096,Case Rate,100% of CMS IPPS Rate,112199.96,100,,,Case Rate,100% of CMS IPPS Rate,128223.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,144255.88,100,,,Case Rate,100% of CMS IPPS Rate,144255.88,100,,,Case Rate,100% of CMS IPPS Rate,144255.88,100,,,Case Rate,100% CMS IPPS Rate,104187.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52495.79,100,,41996.632,Case Rate,100% of CMS IPPS Rate,52495.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,52495.79,100,MS-DRG,41996.632,Case Rate,100% of CMS IPPS Rate,52495.79,100,MS-DRG,41996.632,Case Rate,100% of CMS IPPS Rate,49619.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,57691.37,100,MS-DRG,46153.096,Case Rate,100% of CMS IPPS Rate,74998.78,130,MS-DRG,59999.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59422.11,103,MS-DRG,47537.688,Case Rate,103% of CMS IPPS Rate,59422.11,103,MS-DRG,47537.688,Case Rate,103% of CMS IPPS Rate,106882.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57691.37,100,MS-DRG,46153.096,Case Rate,100% of CMS IPPS Rate,61113.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,86537.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57691.37,100,MS-DRG,46153.096,Case Rate,100% of CMS IPPS Rate,118011.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57691.37,100,MS-DRG,46153.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,144255.88,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,CDM,,,,,Inpatient,,,,,,83183.01,,,,Case Rate,100% of CMS IPPS Rate,60290.64,145,MS-DRG,48232.512,Case Rate,145% of CMS IPPS Rate,41579.75,100,MS-DRG,33263.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41579.75,100,,33263.8,Case Rate,100% of CMS IPPS Rate,76035.57,100,,,Case Rate,100% of CMS IPPS Rate,86894.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,97759.2,100,,,Case Rate,100% of CMS IPPS Rate,97759.2,100,,,Case Rate,100% of CMS IPPS Rate,97759.2,100,,,Case Rate,100% CMS IPPS Rate,75090.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37835.24,100,,30268.192,Case Rate,100% of CMS IPPS Rate,37835.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37835.24,100,MS-DRG,30268.192,Case Rate,100% of CMS IPPS Rate,37835.24,100,MS-DRG,30268.192,Case Rate,100% of CMS IPPS Rate,52443.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41579.75,100,MS-DRG,33263.8,Case Rate,100% of CMS IPPS Rate,54053.68,130,MS-DRG,43242.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42827.14,103,MS-DRG,34261.712,Case Rate,103% of CMS IPPS Rate,42827.14,103,MS-DRG,34261.712,Case Rate,103% of CMS IPPS Rate,76365.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41579.75,100,MS-DRG,33263.8,Case Rate,100% of CMS IPPS Rate,44045.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,62369.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41579.75,100,MS-DRG,33263.8,Case Rate,100% of CMS IPPS Rate,85054.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41579.75,100,MS-DRG,33263.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,97759.2,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,CDM,,,,,Inpatient,,,,,,62038.45,,,,Case Rate,100% of CMS IPPS Rate,44965.17,145,MS-DRG,35972.136,Case Rate,145% of CMS IPPS Rate,31010.46,100,MS-DRG,24808.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31010.46,100,,24808.368,Case Rate,100% of CMS IPPS Rate,57563.26,100,,,Case Rate,100% of CMS IPPS Rate,65789.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,74010.52,100,,,Case Rate,100% of CMS IPPS Rate,74010.52,100,,,Case Rate,100% of CMS IPPS Rate,74010.52,100,,,Case Rate,100% CMS IPPS Rate,56003.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28217.83,100,,22574.264,Case Rate,100% of CMS IPPS Rate,28217.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28217.83,100,MS-DRG,22574.264,Case Rate,100% of CMS IPPS Rate,28217.83,100,MS-DRG,22574.264,Case Rate,100% of CMS IPPS Rate,39677.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31010.46,100,MS-DRG,24808.368,Case Rate,100% of CMS IPPS Rate,40313.6,130,MS-DRG,32250.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31940.77,103,MS-DRG,25552.616,Case Rate,103% of CMS IPPS Rate,31940.77,103,MS-DRG,25552.616,Case Rate,103% of CMS IPPS Rate,60885.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31010.46,100,MS-DRG,24808.368,Case Rate,100% of CMS IPPS Rate,32849.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,46515.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31010.46,100,MS-DRG,24808.368,Case Rate,100% of CMS IPPS Rate,63434,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31010.46,100,MS-DRG,24808.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,74010.52,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,CDM,,,,,Inpatient,,,,,,93358.9,,,,Case Rate,100% of CMS IPPS Rate,67666.06,145,MS-DRG,54132.848,Case Rate,145% of CMS IPPS Rate,46666.25,100,MS-DRG,37333,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46666.25,100,,37333,Case Rate,100% of CMS IPPS Rate,79366.12,100,,,Case Rate,100% of CMS IPPS Rate,90700.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,102041.3,100,,,Case Rate,100% of CMS IPPS Rate,102041.3,100,,,Case Rate,100% of CMS IPPS Rate,102041.3,100,,,Case Rate,100% CMS IPPS Rate,84276.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42463.64,100,,33970.912,Case Rate,100% of CMS IPPS Rate,42463.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,42463.64,100,MS-DRG,33970.912,Case Rate,100% of CMS IPPS Rate,42463.64,100,MS-DRG,33970.912,Case Rate,100% of CMS IPPS Rate,61359.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46666.25,100,MS-DRG,37333,Case Rate,100% of CMS IPPS Rate,60666.13,130,MS-DRG,48532.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48066.24,103,MS-DRG,38452.992,Case Rate,103% of CMS IPPS Rate,48066.24,103,MS-DRG,38452.992,Case Rate,103% of CMS IPPS Rate,81152.28,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46666.25,100,MS-DRG,37333,Case Rate,100% of CMS IPPS Rate,49434.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,69999.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46666.25,100,MS-DRG,37333,Case Rate,100% of CMS IPPS Rate,95459,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46666.25,100,MS-DRG,37333,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,102041.3,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,CDM,,,,,Inpatient,,,,,,38971.54,,,,Case Rate,100% of CMS IPPS Rate,28246.38,145,MS-DRG,22597.104,Case Rate,145% of CMS IPPS Rate,19480.26,100,MS-DRG,15584.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19480.26,100,,15584.208,Case Rate,100% of CMS IPPS Rate,37939.62,100,,,Case Rate,100% of CMS IPPS Rate,43357.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48779.11,100,,,Case Rate,100% of CMS IPPS Rate,48779.11,100,,,Case Rate,100% of CMS IPPS Rate,48779.11,100,,,Case Rate,100% CMS IPPS Rate,35180.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17726.07,100,,14180.856,Case Rate,100% of CMS IPPS Rate,17726.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17726.07,100,MS-DRG,14180.856,Case Rate,100% of CMS IPPS Rate,17726.07,100,MS-DRG,14180.856,Case Rate,100% of CMS IPPS Rate,23878.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19480.26,100,MS-DRG,15584.208,Case Rate,100% of CMS IPPS Rate,25324.34,130,MS-DRG,20259.472,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20064.67,103,MS-DRG,16051.736,Case Rate,103% of CMS IPPS Rate,20064.67,103,MS-DRG,16051.736,Case Rate,103% of CMS IPPS Rate,37767.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19480.26,100,MS-DRG,15584.208,Case Rate,100% of CMS IPPS Rate,20635.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29220.39,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19480.26,100,MS-DRG,15584.208,Case Rate,100% of CMS IPPS Rate,39848.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19480.26,100,MS-DRG,15584.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48779.11,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,CDM,,,,,Inpatient,,,,,,77547.38,,,,Case Rate,100% of CMS IPPS Rate,56205.97,145,MS-DRG,44964.776,Case Rate,145% of CMS IPPS Rate,38762.74,100,MS-DRG,31010.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38762.74,100,,31010.192,Case Rate,100% of CMS IPPS Rate,71552.45,100,,,Case Rate,100% of CMS IPPS Rate,81771.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,91995.23,100,,,Case Rate,100% of CMS IPPS Rate,91995.23,100,,,Case Rate,100% of CMS IPPS Rate,91995.23,100,,,Case Rate,100% CMS IPPS Rate,70003.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35271.92,100,,28217.536,Case Rate,100% of CMS IPPS Rate,35271.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,35271.92,100,MS-DRG,28217.536,Case Rate,100% of CMS IPPS Rate,35271.92,100,MS-DRG,28217.536,Case Rate,100% of CMS IPPS Rate,44542.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38762.74,100,MS-DRG,31010.192,Case Rate,100% of CMS IPPS Rate,50391.56,130,MS-DRG,40313.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39925.62,103,MS-DRG,31940.496,Case Rate,103% of CMS IPPS Rate,39925.62,103,MS-DRG,31940.496,Case Rate,103% of CMS IPPS Rate,66306.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38762.74,100,MS-DRG,31010.192,Case Rate,100% of CMS IPPS Rate,41061.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,58144.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38762.74,100,MS-DRG,31010.192,Case Rate,100% of CMS IPPS Rate,79291.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38762.74,100,MS-DRG,31010.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,91995.23,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,CDM,,,,,Inpatient,,,,,,41095.17,,,,Case Rate,100% of CMS IPPS Rate,29785.57,145,MS-DRG,23828.456,Case Rate,145% of CMS IPPS Rate,20541.77,100,MS-DRG,16433.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20541.77,100,,16433.416,Case Rate,100% of CMS IPPS Rate,39063.05,100,,,Case Rate,100% of CMS IPPS Rate,44641.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,50223.5,100,,,Case Rate,100% of CMS IPPS Rate,50223.5,100,,,Case Rate,100% of CMS IPPS Rate,50223.5,100,,,Case Rate,100% CMS IPPS Rate,37097.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18691.99,100,,14953.592,Case Rate,100% of CMS IPPS Rate,18691.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18691.99,100,MS-DRG,14953.592,Case Rate,100% of CMS IPPS Rate,18691.99,100,MS-DRG,14953.592,Case Rate,100% of CMS IPPS Rate,30050.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20541.77,100,MS-DRG,16433.416,Case Rate,100% of CMS IPPS Rate,26704.3,130,MS-DRG,21363.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21158.02,103,MS-DRG,16926.416,Case Rate,103% of CMS IPPS Rate,21158.02,103,MS-DRG,16926.416,Case Rate,103% of CMS IPPS Rate,37788.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20541.77,100,MS-DRG,16433.416,Case Rate,100% of CMS IPPS Rate,21760.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30812.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20541.77,100,MS-DRG,16433.416,Case Rate,100% of CMS IPPS Rate,42019.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20541.77,100,MS-DRG,16433.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,50223.5,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,CDM,,,,,Inpatient,,,,,,25614.99,,,,Case Rate,100% of CMS IPPS Rate,18565.63,145,MS-DRG,14852.504,Case Rate,145% of CMS IPPS Rate,12803.88,100,MS-DRG,10243.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12803.88,100,,10243.104,Case Rate,100% of CMS IPPS Rate,22999.85,100,,,Case Rate,100% of CMS IPPS Rate,26284.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29570.99,100,,,Case Rate,100% of CMS IPPS Rate,29570.99,100,,,Case Rate,100% of CMS IPPS Rate,29570.99,100,,,Case Rate,100% CMS IPPS Rate,23123.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11650.98,100,,9320.784,Case Rate,100% of CMS IPPS Rate,11650.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11650.98,100,MS-DRG,9320.784,Case Rate,100% of CMS IPPS Rate,11650.98,100,MS-DRG,9320.784,Case Rate,100% of CMS IPPS Rate,18604.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12803.88,100,MS-DRG,10243.104,Case Rate,100% of CMS IPPS Rate,16645.04,130,MS-DRG,13316.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13188,103,MS-DRG,10550.4,Case Rate,103% of CMS IPPS Rate,13188,103,MS-DRG,10550.4,Case Rate,103% of CMS IPPS Rate,25207.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12803.88,100,MS-DRG,10243.104,Case Rate,100% of CMS IPPS Rate,13563.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19205.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12803.88,100,MS-DRG,10243.104,Case Rate,100% of CMS IPPS Rate,26191.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12803.88,100,MS-DRG,10243.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29570.99,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,CDM,,,,,Inpatient,,,,,,71014.93,,,,Case Rate,100% of CMS IPPS Rate,51471.27,145,MS-DRG,41177.016,Case Rate,145% of CMS IPPS Rate,35497.43,100,MS-DRG,28397.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35497.43,100,,28397.944,Case Rate,100% of CMS IPPS Rate,67493.26,100,,,Case Rate,100% of CMS IPPS Rate,77132.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,86776.32,100,,,Case Rate,100% of CMS IPPS Rate,86776.32,100,,,Case Rate,100% of CMS IPPS Rate,86776.32,100,,,Case Rate,100% CMS IPPS Rate,64106.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32300.71,100,,25840.568,Case Rate,100% of CMS IPPS Rate,32300.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,32300.71,100,MS-DRG,25840.568,Case Rate,100% of CMS IPPS Rate,32300.71,100,MS-DRG,25840.568,Case Rate,100% of CMS IPPS Rate,61745.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35497.43,100,MS-DRG,28397.944,Case Rate,100% of CMS IPPS Rate,46146.66,130,MS-DRG,36917.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36562.35,103,MS-DRG,29249.88,Case Rate,103% of CMS IPPS Rate,36562.35,103,MS-DRG,29249.88,Case Rate,103% of CMS IPPS Rate,66350.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35497.43,100,MS-DRG,28397.944,Case Rate,100% of CMS IPPS Rate,37602.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,53246.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35497.43,100,MS-DRG,28397.944,Case Rate,100% of CMS IPPS Rate,72612.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35497.43,100,MS-DRG,28397.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,86776.32,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,CDM,,,,,Inpatient,,,,,,47734.42,,,,Case Rate,100% of CMS IPPS Rate,34597.68,145,MS-DRG,27678.144,Case Rate,145% of CMS IPPS Rate,23860.47,100,MS-DRG,19088.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23860.47,100,,19088.376,Case Rate,100% of CMS IPPS Rate,45377.05,100,,,Case Rate,100% of CMS IPPS Rate,51857.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58341.43,100,,,Case Rate,100% of CMS IPPS Rate,58341.43,100,,,Case Rate,100% of CMS IPPS Rate,58341.43,100,,,Case Rate,100% CMS IPPS Rate,43090.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21711.78,100,,17369.424,Case Rate,100% of CMS IPPS Rate,21711.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21711.78,100,MS-DRG,17369.424,Case Rate,100% of CMS IPPS Rate,21711.78,100,MS-DRG,17369.424,Case Rate,100% of CMS IPPS Rate,30405.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23860.47,100,MS-DRG,19088.376,Case Rate,100% of CMS IPPS Rate,31018.61,130,MS-DRG,24814.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24576.28,103,MS-DRG,19661.024,Case Rate,103% of CMS IPPS Rate,24576.28,103,MS-DRG,19661.024,Case Rate,103% of CMS IPPS Rate,45867.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23860.47,100,MS-DRG,19088.376,Case Rate,100% of CMS IPPS Rate,25275.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35790.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23860.47,100,MS-DRG,19088.376,Case Rate,100% of CMS IPPS Rate,48808.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23860.47,100,MS-DRG,19088.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58341.43,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,CDM,,,,,Inpatient,,,,,,36552.16,,,,Case Rate,100% of CMS IPPS Rate,26492.82,145,MS-DRG,21194.256,Case Rate,145% of CMS IPPS Rate,18270.91,100,MS-DRG,14616.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18270.91,100,,14616.728,Case Rate,100% of CMS IPPS Rate,34753.48,100,,,Case Rate,100% of CMS IPPS Rate,39716.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,44682.67,100,,,Case Rate,100% of CMS IPPS Rate,44682.67,100,,,Case Rate,100% of CMS IPPS Rate,44682.67,100,,,Case Rate,100% CMS IPPS Rate,32996.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16625.65,100,,13300.52,Case Rate,100% of CMS IPPS Rate,16625.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16625.65,100,MS-DRG,13300.52,Case Rate,100% of CMS IPPS Rate,16625.65,100,MS-DRG,13300.52,Case Rate,100% of CMS IPPS Rate,22876.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18270.91,100,MS-DRG,14616.728,Case Rate,100% of CMS IPPS Rate,23752.18,130,MS-DRG,19001.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18819.04,103,MS-DRG,15055.232,Case Rate,103% of CMS IPPS Rate,18819.04,103,MS-DRG,15055.232,Case Rate,103% of CMS IPPS Rate,35284.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18270.91,100,MS-DRG,14616.728,Case Rate,100% of CMS IPPS Rate,19354.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27406.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18270.91,100,MS-DRG,14616.728,Case Rate,100% of CMS IPPS Rate,37374.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18270.91,100,MS-DRG,14616.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,44682.67,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,CDM,,,,,Inpatient,,,,,,45591.62,,,,Case Rate,100% of CMS IPPS Rate,33044.59,145,MS-DRG,26435.672,Case Rate,145% of CMS IPPS Rate,22789.37,100,MS-DRG,18231.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22789.37,100,,18231.496,Case Rate,100% of CMS IPPS Rate,43303.74,100,,,Case Rate,100% of CMS IPPS Rate,49488.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55675.77,100,,,Case Rate,100% of CMS IPPS Rate,55675.77,100,,,Case Rate,100% of CMS IPPS Rate,55675.77,100,,,Case Rate,100% CMS IPPS Rate,41156.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20737.16,100,,16589.728,Case Rate,100% of CMS IPPS Rate,20737.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20737.16,100,MS-DRG,16589.728,Case Rate,100% of CMS IPPS Rate,20737.16,100,MS-DRG,16589.728,Case Rate,100% of CMS IPPS Rate,26777.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22789.37,100,MS-DRG,18231.496,Case Rate,100% of CMS IPPS Rate,29626.18,130,MS-DRG,23700.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23473.05,103,MS-DRG,18778.44,Case Rate,103% of CMS IPPS Rate,23473.05,103,MS-DRG,18778.44,Case Rate,103% of CMS IPPS Rate,40877.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22789.37,100,MS-DRG,18231.496,Case Rate,100% of CMS IPPS Rate,24141.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34184.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22789.37,100,MS-DRG,18231.496,Case Rate,100% of CMS IPPS Rate,46617.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22789.37,100,MS-DRG,18231.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,55675.77,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,CDM,,,,,Inpatient,,,,,,25764.24,,,,Case Rate,100% of CMS IPPS Rate,18673.78,145,MS-DRG,14939.024,Case Rate,145% of CMS IPPS Rate,12878.47,100,MS-DRG,10302.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12878.47,100,,10302.776,Case Rate,100% of CMS IPPS Rate,24979.1,100,,,Case Rate,100% of CMS IPPS Rate,28546.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32115.72,100,,,Case Rate,100% of CMS IPPS Rate,32115.72,100,,,Case Rate,100% of CMS IPPS Rate,32115.72,100,,,Case Rate,100% CMS IPPS Rate,23257.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11718.86,100,,9375.088,Case Rate,100% of CMS IPPS Rate,11718.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11718.86,100,MS-DRG,9375.088,Case Rate,100% of CMS IPPS Rate,11718.86,100,MS-DRG,9375.088,Case Rate,100% of CMS IPPS Rate,16794.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12878.47,100,MS-DRG,10302.776,Case Rate,100% of CMS IPPS Rate,16742.01,130,MS-DRG,13393.608,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13264.82,103,MS-DRG,10611.856,Case Rate,103% of CMS IPPS Rate,13264.82,103,MS-DRG,10611.856,Case Rate,103% of CMS IPPS Rate,24185.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12878.47,100,MS-DRG,10302.776,Case Rate,100% of CMS IPPS Rate,13642.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19317.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12878.47,100,MS-DRG,10302.776,Case Rate,100% of CMS IPPS Rate,26343.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12878.47,100,MS-DRG,10302.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32115.72,
CERVICAL SPINAL FUSION WITH MCC,471,CDM,,,,,Inpatient,,,,,,67350.95,,,,Case Rate,100% of CMS IPPS Rate,48815.63,145,MS-DRG,39052.504,Case Rate,145% of CMS IPPS Rate,33665.95,100,MS-DRG,26932.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33665.95,100,,26932.76,Case Rate,100% of CMS IPPS Rate,64349.51,100,,,Case Rate,100% of CMS IPPS Rate,73539.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,82734.39,100,,,Case Rate,100% of CMS IPPS Rate,82734.39,100,,,Case Rate,100% of CMS IPPS Rate,82734.39,100,,,Case Rate,100% CMS IPPS Rate,60798.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30634.17,100,,24507.336,Case Rate,100% of CMS IPPS Rate,30634.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,30634.17,100,MS-DRG,24507.336,Case Rate,100% of CMS IPPS Rate,30634.17,100,MS-DRG,24507.336,Case Rate,100% of CMS IPPS Rate,33828.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33665.95,100,MS-DRG,26932.76,Case Rate,100% of CMS IPPS Rate,43765.74,130,MS-DRG,35012.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34675.93,103,MS-DRG,27740.744,Case Rate,103% of CMS IPPS Rate,34675.93,103,MS-DRG,27740.744,Case Rate,103% of CMS IPPS Rate,63718.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33665.95,100,MS-DRG,26932.76,Case Rate,100% of CMS IPPS Rate,35662.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,50498.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33665.95,100,MS-DRG,26932.76,Case Rate,100% of CMS IPPS Rate,68866,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33665.95,100,MS-DRG,26932.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,82734.39,
CERVICAL SPINAL FUSION WITH CC,472,CDM,,,,,Inpatient,,,,,,40465.34,,,,Case Rate,100% of CMS IPPS Rate,29329.08,145,MS-DRG,23463.264,Case Rate,145% of CMS IPPS Rate,20226.95,100,MS-DRG,16181.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20226.95,100,,16181.56,Case Rate,100% of CMS IPPS Rate,38382.11,100,,,Case Rate,100% of CMS IPPS Rate,43863.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49348.01,100,,,Case Rate,100% of CMS IPPS Rate,49348.01,100,,,Case Rate,100% of CMS IPPS Rate,49348.01,100,,,Case Rate,100% CMS IPPS Rate,36528.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18405.52,100,,14724.416,Case Rate,100% of CMS IPPS Rate,18405.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18405.52,100,MS-DRG,14724.416,Case Rate,100% of CMS IPPS Rate,18405.52,100,MS-DRG,14724.416,Case Rate,100% of CMS IPPS Rate,23701.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20226.95,100,MS-DRG,16181.56,Case Rate,100% of CMS IPPS Rate,26295.04,130,MS-DRG,21036.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20833.76,103,MS-DRG,16667.008,Case Rate,103% of CMS IPPS Rate,20833.76,103,MS-DRG,16667.008,Case Rate,103% of CMS IPPS Rate,38848.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20226.95,100,MS-DRG,16181.56,Case Rate,100% of CMS IPPS Rate,21426.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30340.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20226.95,100,MS-DRG,16181.56,Case Rate,100% of CMS IPPS Rate,41375.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20226.95,100,MS-DRG,16181.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49348.01,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,CDM,,,,,Inpatient,,,,,,33690.54,,,,Case Rate,100% of CMS IPPS Rate,24418.74,145,MS-DRG,19534.992,Case Rate,145% of CMS IPPS Rate,16840.51,100,MS-DRG,13472.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16840.51,100,,13472.408,Case Rate,100% of CMS IPPS Rate,31363.32,100,,,Case Rate,100% of CMS IPPS Rate,35842.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40323.92,100,,,Case Rate,100% of CMS IPPS Rate,40323.92,100,,,Case Rate,100% of CMS IPPS Rate,40323.92,100,,,Case Rate,100% CMS IPPS Rate,30413.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15324.06,100,,12259.248,Case Rate,100% of CMS IPPS Rate,15324.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15324.06,100,MS-DRG,12259.248,Case Rate,100% of CMS IPPS Rate,15324.06,100,MS-DRG,12259.248,Case Rate,100% of CMS IPPS Rate,18764.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16840.51,100,MS-DRG,13472.408,Case Rate,100% of CMS IPPS Rate,21892.66,130,MS-DRG,17514.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17345.73,103,MS-DRG,13876.584,Case Rate,103% of CMS IPPS Rate,17345.73,103,MS-DRG,13876.584,Case Rate,103% of CMS IPPS Rate,32069.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16840.51,100,MS-DRG,13472.408,Case Rate,100% of CMS IPPS Rate,17839.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25260.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16840.51,100,MS-DRG,13472.408,Case Rate,100% of CMS IPPS Rate,34448.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16840.51,100,MS-DRG,13472.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40323.92,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,CDM,,,,,Inpatient,,,,,,58913.94,,,,Case Rate,100% of CMS IPPS Rate,42700.54,145,MS-DRG,34160.432,Case Rate,145% of CMS IPPS Rate,29448.65,100,MS-DRG,23558.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29448.65,100,,23558.92,Case Rate,100% of CMS IPPS Rate,59785.54,100,,,Case Rate,100% of CMS IPPS Rate,68328.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,76867.76,100,,,Case Rate,100% of CMS IPPS Rate,76867.76,100,,,Case Rate,100% of CMS IPPS Rate,76867.76,100,,,Case Rate,100% CMS IPPS Rate,53182.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26796.69,100,,21437.352,Case Rate,100% of CMS IPPS Rate,26796.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,26796.69,100,MS-DRG,21437.352,Case Rate,100% of CMS IPPS Rate,26796.69,100,MS-DRG,21437.352,Case Rate,100% of CMS IPPS Rate,38720.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29448.65,100,MS-DRG,23558.92,Case Rate,100% of CMS IPPS Rate,38283.25,130,MS-DRG,30626.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30332.11,103,MS-DRG,24265.688,Case Rate,103% of CMS IPPS Rate,30332.11,103,MS-DRG,24265.688,Case Rate,103% of CMS IPPS Rate,51825.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29448.65,100,MS-DRG,23558.92,Case Rate,100% of CMS IPPS Rate,31195.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,44172.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29448.65,100,MS-DRG,23558.92,Case Rate,100% of CMS IPPS Rate,60239.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29448.65,100,MS-DRG,23558.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,76867.76,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,CDM,,,,,Inpatient,,,,,,29365.23,,,,Case Rate,100% of CMS IPPS Rate,21283.77,145,MS-DRG,17027.016,Case Rate,145% of CMS IPPS Rate,14678.46,100,MS-DRG,11742.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14678.46,100,,11742.768,Case Rate,100% of CMS IPPS Rate,28758.97,100,,,Case Rate,100% of CMS IPPS Rate,32868.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36976.12,100,,,Case Rate,100% of CMS IPPS Rate,36976.12,100,,,Case Rate,100% of CMS IPPS Rate,36976.12,100,,,Case Rate,100% CMS IPPS Rate,26508.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13356.74,100,,10685.392,Case Rate,100% of CMS IPPS Rate,13356.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13356.74,100,MS-DRG,10685.392,Case Rate,100% of CMS IPPS Rate,13356.74,100,MS-DRG,10685.392,Case Rate,100% of CMS IPPS Rate,13399.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14678.46,100,MS-DRG,11742.768,Case Rate,100% of CMS IPPS Rate,19082,130,MS-DRG,15265.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15118.81,103,MS-DRG,12095.048,Case Rate,103% of CMS IPPS Rate,15118.81,103,MS-DRG,12095.048,Case Rate,103% of CMS IPPS Rate,28098.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14678.46,100,MS-DRG,11742.768,Case Rate,100% of CMS IPPS Rate,15549.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22017.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14678.46,100,MS-DRG,11742.768,Case Rate,100% of CMS IPPS Rate,30025.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14678.46,100,MS-DRG,11742.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36976.12,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,CDM,,,,,Inpatient,,,,,,16114.11,,,,Case Rate,100% of CMS IPPS Rate,11679.43,145,MS-DRG,9343.544,Case Rate,145% of CMS IPPS Rate,8054.78,100,MS-DRG,6443.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8054.78,100,,6443.824,Case Rate,100% of CMS IPPS Rate,15505.29,100,,,Case Rate,100% of CMS IPPS Rate,17720.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19935.53,100,,,Case Rate,100% of CMS IPPS Rate,19935.53,100,,,Case Rate,100% of CMS IPPS Rate,19935.53,100,,,Case Rate,100% CMS IPPS Rate,14546.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7329.6,100,,5863.68,Case Rate,100% of CMS IPPS Rate,7329.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7329.6,100,MS-DRG,5863.68,Case Rate,100% of CMS IPPS Rate,7329.6,100,MS-DRG,5863.68,Case Rate,100% of CMS IPPS Rate,10591.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8054.78,100,MS-DRG,6443.824,Case Rate,100% of CMS IPPS Rate,10471.21,130,MS-DRG,8376.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8296.42,103,MS-DRG,6637.136,Case Rate,103% of CMS IPPS Rate,8296.42,103,MS-DRG,6637.136,Case Rate,103% of CMS IPPS Rate,15527.88,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8054.78,100,MS-DRG,6443.824,Case Rate,100% of CMS IPPS Rate,8532.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12082.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8054.78,100,MS-DRG,6443.824,Case Rate,100% of CMS IPPS Rate,16476.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8054.78,100,MS-DRG,6443.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19935.53,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,CDM,,,,,Inpatient,,,,,,46128.35,,,,Case Rate,100% of CMS IPPS Rate,33433.59,145,MS-DRG,26746.872,Case Rate,145% of CMS IPPS Rate,23057.65,100,MS-DRG,18446.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23057.65,100,,18446.12,Case Rate,100% of CMS IPPS Rate,45845.31,100,,,Case Rate,100% of CMS IPPS Rate,52396.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58944.46,100,,,Case Rate,100% of CMS IPPS Rate,58944.46,100,,,Case Rate,100% of CMS IPPS Rate,58944.46,100,,,Case Rate,100% CMS IPPS Rate,41640.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20981.29,100,,16785.032,Case Rate,100% of CMS IPPS Rate,20981.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20981.29,100,MS-DRG,16785.032,Case Rate,100% of CMS IPPS Rate,20981.29,100,MS-DRG,16785.032,Case Rate,100% of CMS IPPS Rate,25947,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23057.65,100,MS-DRG,18446.12,Case Rate,100% of CMS IPPS Rate,29974.95,130,MS-DRG,23979.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23749.38,103,MS-DRG,18999.504,Case Rate,103% of CMS IPPS Rate,23749.38,103,MS-DRG,18999.504,Case Rate,103% of CMS IPPS Rate,43045.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23057.65,100,MS-DRG,18446.12,Case Rate,100% of CMS IPPS Rate,24425.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34586.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23057.65,100,MS-DRG,18446.12,Case Rate,100% of CMS IPPS Rate,47166,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23057.65,100,MS-DRG,18446.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58944.46,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,CDM,,,,,Inpatient,,,,,,32637.62,,,,Case Rate,100% of CMS IPPS Rate,23655.59,145,MS-DRG,18924.472,Case Rate,145% of CMS IPPS Rate,16314.2,100,MS-DRG,13051.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16314.2,100,,13051.36,Case Rate,100% of CMS IPPS Rate,31175.88,100,,,Case Rate,100% of CMS IPPS Rate,35630.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40083.6,100,,,Case Rate,100% of CMS IPPS Rate,40083.6,100,,,Case Rate,100% of CMS IPPS Rate,40083.6,100,,,Case Rate,100% CMS IPPS Rate,29462.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14845.16,100,,11876.128,Case Rate,100% of CMS IPPS Rate,14845.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14845.16,100,MS-DRG,11876.128,Case Rate,100% of CMS IPPS Rate,14845.16,100,MS-DRG,11876.128,Case Rate,100% of CMS IPPS Rate,20399.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16314.2,100,MS-DRG,13051.36,Case Rate,100% of CMS IPPS Rate,21208.46,130,MS-DRG,16966.768,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16803.63,103,MS-DRG,13442.904,Case Rate,103% of CMS IPPS Rate,16803.63,103,MS-DRG,13442.904,Case Rate,103% of CMS IPPS Rate,29713.59,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16314.2,100,MS-DRG,13051.36,Case Rate,100% of CMS IPPS Rate,17281.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24471.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16314.2,100,MS-DRG,13051.36,Case Rate,100% of CMS IPPS Rate,33371.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16314.2,100,MS-DRG,13051.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40083.6,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,CDM,,,,,Inpatient,,,,,,25521.89,,,,Case Rate,100% of CMS IPPS Rate,18498.14,145,MS-DRG,14798.512,Case Rate,145% of CMS IPPS Rate,12757.34,100,MS-DRG,10205.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12757.34,100,,10205.872,Case Rate,100% of CMS IPPS Rate,23673.19,100,,,Case Rate,100% of CMS IPPS Rate,27056.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30437.21,100,,,Case Rate,100% of CMS IPPS Rate,30437.21,100,,,Case Rate,100% of CMS IPPS Rate,30437.21,100,,,Case Rate,100% CMS IPPS Rate,23039.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11608.64,100,,9286.912,Case Rate,100% of CMS IPPS Rate,11608.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11608.64,100,MS-DRG,9286.912,Case Rate,100% of CMS IPPS Rate,11608.64,100,MS-DRG,9286.912,Case Rate,100% of CMS IPPS Rate,12592.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12757.34,100,MS-DRG,10205.872,Case Rate,100% of CMS IPPS Rate,16584.54,130,MS-DRG,13267.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13140.06,103,MS-DRG,10512.048,Case Rate,103% of CMS IPPS Rate,13140.06,103,MS-DRG,10512.048,Case Rate,103% of CMS IPPS Rate,22370.26,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12757.34,100,MS-DRG,10205.872,Case Rate,100% of CMS IPPS Rate,13514,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19136.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12757.34,100,MS-DRG,10205.872,Case Rate,100% of CMS IPPS Rate,26096,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12757.34,100,MS-DRG,10205.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30437.21,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,CDM,,,,,Inpatient,,,,,,40376.34,,,,Case Rate,100% of CMS IPPS Rate,29264.57,145,MS-DRG,23411.656,Case Rate,145% of CMS IPPS Rate,20182.46,100,MS-DRG,16145.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20182.46,100,,16145.968,Case Rate,100% of CMS IPPS Rate,39206.47,100,,,Case Rate,100% of CMS IPPS Rate,44809.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,50408.74,100,,,Case Rate,100% of CMS IPPS Rate,50408.74,100,,,Case Rate,100% of CMS IPPS Rate,50408.74,100,,,Case Rate,100% CMS IPPS Rate,36448.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18365.04,100,,14692.032,Case Rate,100% of CMS IPPS Rate,18365.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18365.04,100,MS-DRG,14692.032,Case Rate,100% of CMS IPPS Rate,18365.04,100,MS-DRG,14692.032,Case Rate,100% of CMS IPPS Rate,33016.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20182.46,100,MS-DRG,16145.968,Case Rate,100% of CMS IPPS Rate,26237.2,130,MS-DRG,20989.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20787.93,103,MS-DRG,16630.344,Case Rate,103% of CMS IPPS Rate,20787.93,103,MS-DRG,16630.344,Case Rate,103% of CMS IPPS Rate,37519.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20182.46,100,MS-DRG,16145.968,Case Rate,100% of CMS IPPS Rate,21379.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30273.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20182.46,100,MS-DRG,16145.968,Case Rate,100% of CMS IPPS Rate,41284.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20182.46,100,MS-DRG,16145.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,50408.74,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,CDM,,,,,Inpatient,,,,,,28409.53,,,,Case Rate,100% of CMS IPPS Rate,20591.09,145,MS-DRG,16472.872,Case Rate,145% of CMS IPPS Rate,14200.75,100,MS-DRG,11360.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14200.75,100,,11360.6,Case Rate,100% of CMS IPPS Rate,27660.49,100,,,Case Rate,100% of CMS IPPS Rate,31613.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35563.79,100,,,Case Rate,100% of CMS IPPS Rate,35563.79,100,,,Case Rate,100% of CMS IPPS Rate,35563.79,100,,,Case Rate,100% CMS IPPS Rate,25645.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12922.04,100,,10337.632,Case Rate,100% of CMS IPPS Rate,12922.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12922.04,100,MS-DRG,10337.632,Case Rate,100% of CMS IPPS Rate,12922.04,100,MS-DRG,10337.632,Case Rate,100% of CMS IPPS Rate,22159.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14200.75,100,MS-DRG,11360.6,Case Rate,100% of CMS IPPS Rate,18460.98,130,MS-DRG,14768.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14626.77,103,MS-DRG,11701.416,Case Rate,103% of CMS IPPS Rate,14626.77,103,MS-DRG,11701.416,Case Rate,103% of CMS IPPS Rate,26721.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14200.75,100,MS-DRG,11360.6,Case Rate,100% of CMS IPPS Rate,15043.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21301.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14200.75,100,MS-DRG,11360.6,Case Rate,100% of CMS IPPS Rate,29048.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14200.75,100,MS-DRG,11360.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35563.79,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,CDM,,,,,Inpatient,,,,,,21748.37,,,,Case Rate,100% of CMS IPPS Rate,15763.11,145,MS-DRG,12610.488,Case Rate,145% of CMS IPPS Rate,10871.11,100,MS-DRG,8696.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10871.11,100,,8696.888,Case Rate,100% of CMS IPPS Rate,21148.3,100,,,Case Rate,100% of CMS IPPS Rate,24170.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27190.9,100,,,Case Rate,100% of CMS IPPS Rate,27190.9,100,,,Case Rate,100% of CMS IPPS Rate,27190.9,100,,,Case Rate,100% CMS IPPS Rate,19632.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9892.28,100,,7913.824,Case Rate,100% of CMS IPPS Rate,9892.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9892.28,100,MS-DRG,7913.824,Case Rate,100% of CMS IPPS Rate,9892.28,100,MS-DRG,7913.824,Case Rate,100% of CMS IPPS Rate,14665.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10871.11,100,MS-DRG,8696.888,Case Rate,100% of CMS IPPS Rate,14132.44,130,MS-DRG,11305.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11197.24,103,MS-DRG,8957.792,Case Rate,103% of CMS IPPS Rate,11197.24,103,MS-DRG,8957.792,Case Rate,103% of CMS IPPS Rate,20823.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10871.11,100,MS-DRG,8696.888,Case Rate,100% of CMS IPPS Rate,11515.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16306.67,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10871.11,100,MS-DRG,8696.888,Case Rate,100% of CMS IPPS Rate,22237.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10871.11,100,MS-DRG,8696.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27190.9,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,CDM,,,,,Inpatient,,,,,,34013.67,,,,Case Rate,100% of CMS IPPS Rate,24652.94,145,MS-DRG,19722.352,Case Rate,145% of CMS IPPS Rate,17002.03,100,MS-DRG,13601.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17002.03,100,,13601.624,Case Rate,100% of CMS IPPS Rate,33970.05,100,,,Case Rate,100% of CMS IPPS Rate,38824.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43676.15,100,,,Case Rate,100% of CMS IPPS Rate,43676.15,100,,,Case Rate,100% of CMS IPPS Rate,43676.15,100,,,Case Rate,100% CMS IPPS Rate,30704.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15471.04,100,,12376.832,Case Rate,100% of CMS IPPS Rate,15471.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15471.04,100,MS-DRG,12376.832,Case Rate,100% of CMS IPPS Rate,15471.04,100,MS-DRG,12376.832,Case Rate,100% of CMS IPPS Rate,18979.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17002.03,100,MS-DRG,13601.624,Case Rate,100% of CMS IPPS Rate,22102.64,130,MS-DRG,17682.112,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17512.09,103,MS-DRG,14009.672,Case Rate,103% of CMS IPPS Rate,17512.09,103,MS-DRG,14009.672,Case Rate,103% of CMS IPPS Rate,29823.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17002.03,100,MS-DRG,13601.624,Case Rate,100% of CMS IPPS Rate,18010.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25503.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17002.03,100,MS-DRG,13601.624,Case Rate,100% of CMS IPPS Rate,34778.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17002.03,100,MS-DRG,13601.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43676.15,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,CDM,,,,,Inpatient,,,,,,45101.45,,,,Case Rate,100% of CMS IPPS Rate,32689.31,145,MS-DRG,26151.448,Case Rate,145% of CMS IPPS Rate,22544.35,100,MS-DRG,18035.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22544.35,100,,18035.48,Case Rate,100% of CMS IPPS Rate,42916.49,100,,,Case Rate,100% of CMS IPPS Rate,49049.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55178.8,100,,,Case Rate,100% of CMS IPPS Rate,55178.8,100,,,Case Rate,100% of CMS IPPS Rate,55178.8,100,,,Case Rate,100% CMS IPPS Rate,40713.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20514.21,100,,16411.368,Case Rate,100% of CMS IPPS Rate,20514.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20514.21,100,MS-DRG,16411.368,Case Rate,100% of CMS IPPS Rate,20514.21,100,MS-DRG,16411.368,Case Rate,100% of CMS IPPS Rate,29642.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22544.35,100,MS-DRG,18035.48,Case Rate,100% of CMS IPPS Rate,29307.66,130,MS-DRG,23446.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23220.68,103,MS-DRG,18576.544,Case Rate,103% of CMS IPPS Rate,23220.68,103,MS-DRG,18576.544,Case Rate,103% of CMS IPPS Rate,41125.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22544.35,100,MS-DRG,18035.48,Case Rate,100% of CMS IPPS Rate,23881.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33816.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22544.35,100,MS-DRG,18035.48,Case Rate,100% of CMS IPPS Rate,46116,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22544.35,100,MS-DRG,18035.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,55178.8,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,CDM,,,,,Inpatient,,,,,,27497.64,,,,Case Rate,100% of CMS IPPS Rate,19930.16,145,MS-DRG,15944.128,Case Rate,145% of CMS IPPS Rate,13744.94,100,MS-DRG,10995.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13744.94,100,,10995.952,Case Rate,100% of CMS IPPS Rate,28273.72,100,,,Case Rate,100% of CMS IPPS Rate,32314.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36352.23,100,,,Case Rate,100% of CMS IPPS Rate,36352.23,100,,,Case Rate,100% of CMS IPPS Rate,36352.23,100,,,Case Rate,100% CMS IPPS Rate,24822.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12507.29,100,,10005.832,Case Rate,100% of CMS IPPS Rate,12507.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12507.29,100,MS-DRG,10005.832,Case Rate,100% of CMS IPPS Rate,12507.29,100,MS-DRG,10005.832,Case Rate,100% of CMS IPPS Rate,12578.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13744.94,100,MS-DRG,10995.952,Case Rate,100% of CMS IPPS Rate,17868.42,130,MS-DRG,14294.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14157.29,103,MS-DRG,11325.832,Case Rate,103% of CMS IPPS Rate,14157.29,103,MS-DRG,11325.832,Case Rate,103% of CMS IPPS Rate,26387.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13744.94,100,MS-DRG,10995.952,Case Rate,100% of CMS IPPS Rate,14560.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20617.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13744.94,100,MS-DRG,10995.952,Case Rate,100% of CMS IPPS Rate,28116.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13744.94,100,MS-DRG,10995.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36352.23,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,CDM,,,,,Inpatient,,,,,,21152.77,,,,Case Rate,100% of CMS IPPS Rate,15331.42,145,MS-DRG,12265.136,Case Rate,145% of CMS IPPS Rate,10573.39,100,MS-DRG,8458.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10573.39,100,,8458.712,Case Rate,100% of CMS IPPS Rate,21065.65,100,,,Case Rate,100% of CMS IPPS Rate,24075.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27084.63,100,,,Case Rate,100% of CMS IPPS Rate,27084.63,100,,,Case Rate,100% of CMS IPPS Rate,27084.63,100,,,Case Rate,100% CMS IPPS Rate,19094.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9621.38,100,,7697.104,Case Rate,100% of CMS IPPS Rate,9621.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9621.38,100,MS-DRG,7697.104,Case Rate,100% of CMS IPPS Rate,9621.38,100,MS-DRG,7697.104,Case Rate,100% of CMS IPPS Rate,10496.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10573.39,100,MS-DRG,8458.712,Case Rate,100% of CMS IPPS Rate,13745.41,130,MS-DRG,10996.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10890.59,103,MS-DRG,8712.472,Case Rate,103% of CMS IPPS Rate,10890.59,103,MS-DRG,8712.472,Case Rate,103% of CMS IPPS Rate,20290.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10573.39,100,MS-DRG,8458.712,Case Rate,100% of CMS IPPS Rate,11200.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15860.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10573.39,100,MS-DRG,8458.712,Case Rate,100% of CMS IPPS Rate,21628.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10573.39,100,MS-DRG,8458.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27084.63,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,CDM,,,,,Inpatient,,,,,,28843.57,,,,Case Rate,100% of CMS IPPS Rate,20905.68,145,MS-DRG,16724.544,Case Rate,145% of CMS IPPS Rate,14417.71,100,MS-DRG,11534.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14417.71,100,,11534.168,Case Rate,100% of CMS IPPS Rate,26200.75,100,,,Case Rate,100% of CMS IPPS Rate,29944.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33686.96,100,,,Case Rate,100% of CMS IPPS Rate,33686.96,100,,,Case Rate,100% of CMS IPPS Rate,33686.96,100,,,Case Rate,100% CMS IPPS Rate,26037.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13119.46,100,,10495.568,Case Rate,100% of CMS IPPS Rate,13119.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13119.46,100,MS-DRG,10495.568,Case Rate,100% of CMS IPPS Rate,13119.46,100,MS-DRG,10495.568,Case Rate,100% of CMS IPPS Rate,20755.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14417.71,100,MS-DRG,11534.168,Case Rate,100% of CMS IPPS Rate,18743.02,130,MS-DRG,14994.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14850.24,103,MS-DRG,11880.192,Case Rate,103% of CMS IPPS Rate,14850.24,103,MS-DRG,11880.192,Case Rate,103% of CMS IPPS Rate,28705.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14417.71,100,MS-DRG,11534.168,Case Rate,100% of CMS IPPS Rate,15272.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21626.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14417.71,100,MS-DRG,11534.168,Case Rate,100% of CMS IPPS Rate,29492.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14417.71,100,MS-DRG,11534.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33686.96,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,CDM,,,,,Inpatient,,,,,,16946.59,,,,Case Rate,100% of CMS IPPS Rate,12282.81,145,MS-DRG,9826.248,Case Rate,145% of CMS IPPS Rate,8470.9,100,MS-DRG,6776.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8470.9,100,,6776.72,Case Rate,100% of CMS IPPS Rate,16509.11,100,,,Case Rate,100% of CMS IPPS Rate,18868.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21226.18,100,,,Case Rate,100% of CMS IPPS Rate,21226.18,100,,,Case Rate,100% of CMS IPPS Rate,21226.18,100,,,Case Rate,100% CMS IPPS Rate,15297.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7708.23,100,,6166.584,Case Rate,100% of CMS IPPS Rate,7708.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7708.23,100,MS-DRG,6166.584,Case Rate,100% of CMS IPPS Rate,7708.23,100,MS-DRG,6166.584,Case Rate,100% of CMS IPPS Rate,13149.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8470.9,100,MS-DRG,6776.72,Case Rate,100% of CMS IPPS Rate,11012.17,130,MS-DRG,8809.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8725.03,103,MS-DRG,6980.024,Case Rate,103% of CMS IPPS Rate,8725.03,103,MS-DRG,6980.024,Case Rate,103% of CMS IPPS Rate,16818.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8470.9,100,MS-DRG,6776.72,Case Rate,100% of CMS IPPS Rate,8973.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12706.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8470.9,100,MS-DRG,6776.72,Case Rate,100% of CMS IPPS Rate,17327.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8470.9,100,MS-DRG,6776.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21226.18,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,CDM,,,,,Inpatient,,,,,,47403.07,,,,Case Rate,100% of CMS IPPS Rate,34357.52,145,MS-DRG,27486.016,Case Rate,145% of CMS IPPS Rate,23694.84,100,MS-DRG,18955.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23694.84,100,,18955.872,Case Rate,100% of CMS IPPS Rate,47341.05,100,,,Case Rate,100% of CMS IPPS Rate,54106.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60867.57,100,,,Case Rate,100% of CMS IPPS Rate,60867.57,100,,,Case Rate,100% of CMS IPPS Rate,60867.57,100,,,Case Rate,100% CMS IPPS Rate,42791.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21561.07,100,,17248.856,Case Rate,100% of CMS IPPS Rate,21561.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21561.07,100,MS-DRG,17248.856,Case Rate,100% of CMS IPPS Rate,21561.07,100,MS-DRG,17248.856,Case Rate,100% of CMS IPPS Rate,30100.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23694.84,100,MS-DRG,18955.872,Case Rate,100% of CMS IPPS Rate,30803.29,130,MS-DRG,24642.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24405.69,103,MS-DRG,19524.552,Case Rate,103% of CMS IPPS Rate,24405.69,103,MS-DRG,19524.552,Case Rate,103% of CMS IPPS Rate,44096.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23694.84,100,MS-DRG,18955.872,Case Rate,100% of CMS IPPS Rate,25100.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35542.26,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23694.84,100,MS-DRG,18955.872,Case Rate,100% of CMS IPPS Rate,48469.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23694.84,100,MS-DRG,18955.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60867.57,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,CDM,,,,,Inpatient,,,,,,32884.08,,,,Case Rate,100% of CMS IPPS Rate,23834.23,145,MS-DRG,19067.384,Case Rate,145% of CMS IPPS Rate,16437.4,100,MS-DRG,13149.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16437.4,100,,13149.92,Case Rate,100% of CMS IPPS Rate,32007.73,100,,,Case Rate,100% of CMS IPPS Rate,36581.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41153.14,100,,,Case Rate,100% of CMS IPPS Rate,41153.14,100,,,Case Rate,100% of CMS IPPS Rate,41153.14,100,,,Case Rate,100% CMS IPPS Rate,29685.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14957.25,100,,11965.8,Case Rate,100% of CMS IPPS Rate,14957.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14957.25,100,MS-DRG,11965.8,Case Rate,100% of CMS IPPS Rate,14957.25,100,MS-DRG,11965.8,Case Rate,100% of CMS IPPS Rate,24368.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16437.4,100,MS-DRG,13149.92,Case Rate,100% of CMS IPPS Rate,21368.62,130,MS-DRG,17094.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16930.52,103,MS-DRG,13544.416,Case Rate,103% of CMS IPPS Rate,16930.52,103,MS-DRG,13544.416,Case Rate,103% of CMS IPPS Rate,30053.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16437.4,100,MS-DRG,13149.92,Case Rate,100% of CMS IPPS Rate,17412.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24656.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16437.4,100,MS-DRG,13149.92,Case Rate,100% of CMS IPPS Rate,33623.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16437.4,100,MS-DRG,13149.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41153.14,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,CDM,,,,,Inpatient,,,,,,25593.09,,,,Case Rate,100% of CMS IPPS Rate,18549.75,145,MS-DRG,14839.8,Case Rate,145% of CMS IPPS Rate,12792.93,100,MS-DRG,10234.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12792.93,100,,10234.344,Case Rate,100% of CMS IPPS Rate,25134.27,100,,,Case Rate,100% of CMS IPPS Rate,28725.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32315.76,100,,,Case Rate,100% of CMS IPPS Rate,32315.76,100,,,Case Rate,100% of CMS IPPS Rate,32315.76,100,,,Case Rate,100% CMS IPPS Rate,23103.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11641.01,100,,9312.808,Case Rate,100% of CMS IPPS Rate,11641.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11641.01,100,MS-DRG,9312.808,Case Rate,100% of CMS IPPS Rate,11641.01,100,MS-DRG,9312.808,Case Rate,100% of CMS IPPS Rate,17501.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12792.93,100,MS-DRG,10234.344,Case Rate,100% of CMS IPPS Rate,16630.81,130,MS-DRG,13304.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13176.72,103,MS-DRG,10541.376,Case Rate,103% of CMS IPPS Rate,13176.72,103,MS-DRG,10541.376,Case Rate,103% of CMS IPPS Rate,23893.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12792.93,100,MS-DRG,10234.344,Case Rate,100% of CMS IPPS Rate,13551.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19189.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12792.93,100,MS-DRG,10234.344,Case Rate,100% of CMS IPPS Rate,26168.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12792.93,100,MS-DRG,10234.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32315.76,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,CDM,,,,,Inpatient,,,,,,49033.79,,,,Case Rate,100% of CMS IPPS Rate,35539.46,145,MS-DRG,28431.568,Case Rate,145% of CMS IPPS Rate,24509.97,100,MS-DRG,19607.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24509.97,100,,19607.976,Case Rate,100% of CMS IPPS Rate,46933.12,100,,,Case Rate,100% of CMS IPPS Rate,53639.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60343.08,100,,,Case Rate,100% of CMS IPPS Rate,60343.08,100,,,Case Rate,100% of CMS IPPS Rate,60343.08,100,,,Case Rate,100% CMS IPPS Rate,44263.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22302.8,100,,17842.24,Case Rate,100% of CMS IPPS Rate,22302.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22302.8,100,MS-DRG,17842.24,Case Rate,100% of CMS IPPS Rate,22302.8,100,MS-DRG,17842.24,Case Rate,100% of CMS IPPS Rate,32226.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24509.97,100,MS-DRG,19607.976,Case Rate,100% of CMS IPPS Rate,31862.96,130,MS-DRG,25490.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25245.27,103,MS-DRG,20196.216,Case Rate,103% of CMS IPPS Rate,25245.27,103,MS-DRG,20196.216,Case Rate,103% of CMS IPPS Rate,46987.16,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24509.97,100,MS-DRG,19607.976,Case Rate,100% of CMS IPPS Rate,25963.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,36764.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24509.97,100,MS-DRG,19607.976,Case Rate,100% of CMS IPPS Rate,50136.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24509.97,100,MS-DRG,19607.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60343.08,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,CDM,,,,,Inpatient,,,,,,27212.85,,,,Case Rate,100% of CMS IPPS Rate,19723.73,145,MS-DRG,15778.984,Case Rate,145% of CMS IPPS Rate,13602.57,100,MS-DRG,10882.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13602.57,100,,10882.056,Case Rate,100% of CMS IPPS Rate,26302.06,100,,,Case Rate,100% of CMS IPPS Rate,30060.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33817.22,100,,,Case Rate,100% of CMS IPPS Rate,33817.22,100,,,Case Rate,100% of CMS IPPS Rate,33817.22,100,,,Case Rate,100% CMS IPPS Rate,24565.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12377.75,100,,9902.2,Case Rate,100% of CMS IPPS Rate,12377.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12377.75,100,MS-DRG,9902.2,Case Rate,100% of CMS IPPS Rate,12377.75,100,MS-DRG,9902.2,Case Rate,100% of CMS IPPS Rate,19304.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13602.57,100,MS-DRG,10882.056,Case Rate,100% of CMS IPPS Rate,17683.34,130,MS-DRG,14146.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14010.65,103,MS-DRG,11208.52,Case Rate,103% of CMS IPPS Rate,14010.65,103,MS-DRG,11208.52,Case Rate,103% of CMS IPPS Rate,26561.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13602.57,100,MS-DRG,10882.056,Case Rate,100% of CMS IPPS Rate,14409.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20403.86,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13602.57,100,MS-DRG,10882.056,Case Rate,100% of CMS IPPS Rate,27825,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13602.57,100,MS-DRG,10882.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33817.22,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,CDM,,,,,Inpatient,,,,,,19543.96,,,,Case Rate,100% of CMS IPPS Rate,14165.37,145,MS-DRG,11332.296,Case Rate,145% of CMS IPPS Rate,9769.22,100,MS-DRG,7815.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9769.22,100,,7815.376,Case Rate,100% of CMS IPPS Rate,17898.2,100,,,Case Rate,100% of CMS IPPS Rate,20455.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23012.16,100,,,Case Rate,100% of CMS IPPS Rate,23012.16,100,,,Case Rate,100% of CMS IPPS Rate,23012.16,100,,,Case Rate,100% CMS IPPS Rate,17642.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8889.63,100,,7111.704,Case Rate,100% of CMS IPPS Rate,8889.63,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8889.63,100,MS-DRG,7111.704,Case Rate,100% of CMS IPPS Rate,8889.63,100,MS-DRG,7111.704,Case Rate,100% of CMS IPPS Rate,11066.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9769.22,100,MS-DRG,7815.376,Case Rate,100% of CMS IPPS Rate,12699.99,130,MS-DRG,10159.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10062.3,103,MS-DRG,8049.84,Case Rate,103% of CMS IPPS Rate,10062.3,103,MS-DRG,8049.84,Case Rate,103% of CMS IPPS Rate,19249.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9769.22,100,MS-DRG,7815.376,Case Rate,100% of CMS IPPS Rate,10348.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14653.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9769.22,100,MS-DRG,7815.376,Case Rate,100% of CMS IPPS Rate,19983.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9769.22,100,MS-DRG,7815.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23012.16,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,CDM,,,,,Inpatient,,,,,,35749.81,,,,Case Rate,100% of CMS IPPS Rate,25911.28,145,MS-DRG,20729.024,Case Rate,145% of CMS IPPS Rate,17869.85,100,MS-DRG,14295.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17869.85,100,,14295.88,Case Rate,100% of CMS IPPS Rate,33659.44,100,,,Case Rate,100% of CMS IPPS Rate,38469.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43276.79,100,,,Case Rate,100% of CMS IPPS Rate,43276.79,100,,,Case Rate,100% of CMS IPPS Rate,43276.79,100,,,Case Rate,100% CMS IPPS Rate,32271.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16260.71,100,,13008.568,Case Rate,100% of CMS IPPS Rate,16260.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16260.71,100,MS-DRG,13008.568,Case Rate,100% of CMS IPPS Rate,16260.71,100,MS-DRG,13008.568,Case Rate,100% of CMS IPPS Rate,23496.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17869.85,100,MS-DRG,14295.88,Case Rate,100% of CMS IPPS Rate,23230.81,130,MS-DRG,18584.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18405.95,103,MS-DRG,14724.76,Case Rate,103% of CMS IPPS Rate,18405.95,103,MS-DRG,14724.76,Case Rate,103% of CMS IPPS Rate,32423.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17869.85,100,MS-DRG,14295.88,Case Rate,100% of CMS IPPS Rate,18929.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26804.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17869.85,100,MS-DRG,14295.88,Case Rate,100% of CMS IPPS Rate,36554,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17869.85,100,MS-DRG,14295.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43276.79,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,CDM,,,,,Inpatient,,,,,,17659.94,,,,Case Rate,100% of CMS IPPS Rate,12799.85,145,MS-DRG,10239.88,Case Rate,145% of CMS IPPS Rate,8827.48,100,MS-DRG,7061.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8827.48,100,,7061.984,Case Rate,100% of CMS IPPS Rate,14646.77,100,,,Case Rate,100% of CMS IPPS Rate,16739.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18831.72,100,,,Case Rate,100% of CMS IPPS Rate,18831.72,100,,,Case Rate,100% of CMS IPPS Rate,18831.72,100,,,Case Rate,100% CMS IPPS Rate,15941.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8032.71,100,,6426.168,Case Rate,100% of CMS IPPS Rate,8032.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8032.71,100,MS-DRG,6426.168,Case Rate,100% of CMS IPPS Rate,8032.71,100,MS-DRG,6426.168,Case Rate,100% of CMS IPPS Rate,15133.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8827.48,100,MS-DRG,7061.984,Case Rate,100% of CMS IPPS Rate,11475.72,130,MS-DRG,9180.576,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9092.3,103,MS-DRG,7273.84,Case Rate,103% of CMS IPPS Rate,9092.3,103,MS-DRG,7273.84,Case Rate,103% of CMS IPPS Rate,16681.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827.48,100,MS-DRG,7061.984,Case Rate,100% of CMS IPPS Rate,9351.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13241.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827.48,100,MS-DRG,7061.984,Case Rate,100% of CMS IPPS Rate,18057.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8827.48,100,MS-DRG,7061.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18831.72,
SOFT TISSUE PROCEDURES WITH MCC,500,CDM,,,,,Inpatient,,,,,,44400.42,,,,Case Rate,100% of CMS IPPS Rate,32181.21,145,MS-DRG,25744.968,Case Rate,145% of CMS IPPS Rate,22193.94,100,MS-DRG,17755.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22193.94,100,,17755.152,Case Rate,100% of CMS IPPS Rate,42241.94,100,,,Case Rate,100% of CMS IPPS Rate,48278.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54311.52,100,,,Case Rate,100% of CMS IPPS Rate,54311.52,100,,,Case Rate,100% of CMS IPPS Rate,54311.52,100,,,Case Rate,100% CMS IPPS Rate,40081.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20195.36,100,,16156.288,Case Rate,100% of CMS IPPS Rate,20195.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20195.36,100,MS-DRG,16156.288,Case Rate,100% of CMS IPPS Rate,20195.36,100,MS-DRG,16156.288,Case Rate,100% of CMS IPPS Rate,22386.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22193.94,100,MS-DRG,17755.152,Case Rate,100% of CMS IPPS Rate,28852.12,130,MS-DRG,23081.696,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22859.76,103,MS-DRG,18287.808,Case Rate,103% of CMS IPPS Rate,22859.76,103,MS-DRG,18287.808,Case Rate,103% of CMS IPPS Rate,40536.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22193.94,100,MS-DRG,17755.152,Case Rate,100% of CMS IPPS Rate,23510.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33290.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22193.94,100,MS-DRG,17755.152,Case Rate,100% of CMS IPPS Rate,45399.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22193.94,100,MS-DRG,17755.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54311.52,
SOFT TISSUE PROCEDURES WITH CC,501,CDM,,,,,Inpatient,,,,,,23765.2,,,,Case Rate,100% of CMS IPPS Rate,17224.91,145,MS-DRG,13779.928,Case Rate,145% of CMS IPPS Rate,11879.25,100,MS-DRG,9503.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11879.25,100,,9503.4,Case Rate,100% of CMS IPPS Rate,23791.84,100,,,Case Rate,100% of CMS IPPS Rate,27191.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30589.76,100,,,Case Rate,100% of CMS IPPS Rate,30589.76,100,,,Case Rate,100% of CMS IPPS Rate,30589.76,100,,,Case Rate,100% CMS IPPS Rate,21453.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10809.62,100,,8647.696,Case Rate,100% of CMS IPPS Rate,10809.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10809.62,100,MS-DRG,8647.696,Case Rate,100% of CMS IPPS Rate,10809.62,100,MS-DRG,8647.696,Case Rate,100% of CMS IPPS Rate,16935.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11879.25,100,MS-DRG,9503.4,Case Rate,100% of CMS IPPS Rate,15443.03,130,MS-DRG,12354.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12235.63,103,MS-DRG,9788.504,Case Rate,103% of CMS IPPS Rate,12235.63,103,MS-DRG,9788.504,Case Rate,103% of CMS IPPS Rate,22236.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11879.25,100,MS-DRG,9503.4,Case Rate,100% of CMS IPPS Rate,12583.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17818.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11879.25,100,MS-DRG,9503.4,Case Rate,100% of CMS IPPS Rate,24299.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11879.25,100,MS-DRG,9503.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30589.76,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,CDM,,,,,Inpatient,,,,,,18931.93,,,,Case Rate,100% of CMS IPPS Rate,13721.77,145,MS-DRG,10977.416,Case Rate,145% of CMS IPPS Rate,9463.29,100,MS-DRG,7570.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9463.29,100,,7570.632,Case Rate,100% of CMS IPPS Rate,18626.07,100,,,Case Rate,100% of CMS IPPS Rate,21287.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23948.01,100,,,Case Rate,100% of CMS IPPS Rate,23948.01,100,,,Case Rate,100% of CMS IPPS Rate,23948.01,100,,,Case Rate,100% CMS IPPS Rate,17090.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8611.25,100,,6889,Case Rate,100% of CMS IPPS Rate,8611.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8611.25,100,MS-DRG,6889,Case Rate,100% of CMS IPPS Rate,8611.25,100,MS-DRG,6889,Case Rate,100% of CMS IPPS Rate,13633.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9463.29,100,MS-DRG,7570.632,Case Rate,100% of CMS IPPS Rate,12302.28,130,MS-DRG,9841.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9747.19,103,MS-DRG,7797.752,Case Rate,103% of CMS IPPS Rate,9747.19,103,MS-DRG,7797.752,Case Rate,103% of CMS IPPS Rate,17387.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9463.29,100,MS-DRG,7570.632,Case Rate,100% of CMS IPPS Rate,10024.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14194.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9463.29,100,MS-DRG,7570.632,Case Rate,100% of CMS IPPS Rate,19357.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9463.29,100,MS-DRG,7570.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23948.01,
FOOT PROCEDURES WITH MCC,503,CDM,,,,,Inpatient,,,,,,36720.57,,,,Case Rate,100% of CMS IPPS Rate,26614.88,145,MS-DRG,21291.904,Case Rate,145% of CMS IPPS Rate,18355.09,100,MS-DRG,14684.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18355.09,100,,14684.072,Case Rate,100% of CMS IPPS Rate,35281.82,100,,,Case Rate,100% of CMS IPPS Rate,40323.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45362.72,100,,,Case Rate,100% of CMS IPPS Rate,45362.72,100,,,Case Rate,100% of CMS IPPS Rate,45362.72,100,,,Case Rate,100% CMS IPPS Rate,33148.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16702.24,100,,13361.792,Case Rate,100% of CMS IPPS Rate,16702.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16702.24,100,MS-DRG,13361.792,Case Rate,100% of CMS IPPS Rate,16702.24,100,MS-DRG,13361.792,Case Rate,100% of CMS IPPS Rate,24134.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18355.09,100,MS-DRG,14684.072,Case Rate,100% of CMS IPPS Rate,23861.62,130,MS-DRG,19089.296,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18905.74,103,MS-DRG,15124.592,Case Rate,103% of CMS IPPS Rate,18905.74,103,MS-DRG,15124.592,Case Rate,103% of CMS IPPS Rate,32046.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18355.09,100,MS-DRG,14684.072,Case Rate,100% of CMS IPPS Rate,19443.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27532.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18355.09,100,MS-DRG,14684.072,Case Rate,100% of CMS IPPS Rate,37546.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18355.09,100,MS-DRG,14684.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45362.72,
FOOT PROCEDURES WITH CC,504,CDM,,,,,Inpatient,,,,,,23647.45,,,,Case Rate,100% of CMS IPPS Rate,17139.55,145,MS-DRG,13711.64,Case Rate,145% of CMS IPPS Rate,11820.38,100,MS-DRG,9456.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11820.38,100,,9456.304,Case Rate,100% of CMS IPPS Rate,23395.91,100,,,Case Rate,100% of CMS IPPS Rate,26739.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30080.7,100,,,Case Rate,100% of CMS IPPS Rate,30080.7,100,,,Case Rate,100% of CMS IPPS Rate,30080.7,100,,,Case Rate,100% CMS IPPS Rate,21346.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10756.07,100,,8604.856,Case Rate,100% of CMS IPPS Rate,10756.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10756.07,100,MS-DRG,8604.856,Case Rate,100% of CMS IPPS Rate,10756.07,100,MS-DRG,8604.856,Case Rate,100% of CMS IPPS Rate,17851.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11820.38,100,MS-DRG,9456.304,Case Rate,100% of CMS IPPS Rate,15366.49,130,MS-DRG,12293.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12174.99,103,MS-DRG,9739.992,Case Rate,103% of CMS IPPS Rate,12174.99,103,MS-DRG,9739.992,Case Rate,103% of CMS IPPS Rate,22451.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11820.38,100,MS-DRG,9456.304,Case Rate,100% of CMS IPPS Rate,12521.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17730.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11820.38,100,MS-DRG,9456.304,Case Rate,100% of CMS IPPS Rate,24179.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11820.38,100,MS-DRG,9456.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30080.7,
FOOT PROCEDURES WITHOUT CC/MCC,505,CDM,,,,,Inpatient,,,,,,23354.44,,,,Case Rate,100% of CMS IPPS Rate,16927.18,145,MS-DRG,13541.744,Case Rate,145% of CMS IPPS Rate,11673.92,100,MS-DRG,9339.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11673.92,100,,9339.136,Case Rate,100% of CMS IPPS Rate,23395.91,100,,,Case Rate,100% of CMS IPPS Rate,26739.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30080.7,100,,,Case Rate,100% of CMS IPPS Rate,30080.7,100,,,Case Rate,100% of CMS IPPS Rate,30080.7,100,,,Case Rate,100% CMS IPPS Rate,21082.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10622.79,100,,8498.232,Case Rate,100% of CMS IPPS Rate,10622.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10622.79,100,MS-DRG,8498.232,Case Rate,100% of CMS IPPS Rate,10622.79,100,MS-DRG,8498.232,Case Rate,100% of CMS IPPS Rate,17560.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11673.92,100,MS-DRG,9339.136,Case Rate,100% of CMS IPPS Rate,15176.1,130,MS-DRG,12140.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12024.14,103,MS-DRG,9619.312,Case Rate,103% of CMS IPPS Rate,12024.14,103,MS-DRG,9619.312,Case Rate,103% of CMS IPPS Rate,22350.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11673.92,100,MS-DRG,9339.136,Case Rate,100% of CMS IPPS Rate,12366.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17510.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11673.92,100,MS-DRG,9339.136,Case Rate,100% of CMS IPPS Rate,23879.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11673.92,100,MS-DRG,9339.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30080.7,
MAJOR THUMB OR JOINT PROCEDURES,506,CDM,,,,,Inpatient,,,,,,20025.92,,,,Case Rate,100% of CMS IPPS Rate,14514.7,145,MS-DRG,11611.76,Case Rate,145% of CMS IPPS Rate,10010.14,100,MS-DRG,8008.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10010.14,100,,8008.112,Case Rate,100% of CMS IPPS Rate,19984.5,100,,,Case Rate,100% of CMS IPPS Rate,22840.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25694.57,100,,,Case Rate,100% of CMS IPPS Rate,25694.57,100,,,Case Rate,100% of CMS IPPS Rate,25694.57,100,,,Case Rate,100% CMS IPPS Rate,18077.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9108.85,100,,7287.08,Case Rate,100% of CMS IPPS Rate,9108.85,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9108.85,100,MS-DRG,7287.08,Case Rate,100% of CMS IPPS Rate,9108.85,100,MS-DRG,7287.08,Case Rate,100% of CMS IPPS Rate,9096.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10010.14,100,MS-DRG,8008.112,Case Rate,100% of CMS IPPS Rate,13013.18,130,MS-DRG,10410.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10310.44,103,MS-DRG,8248.352,Case Rate,103% of CMS IPPS Rate,10310.44,103,MS-DRG,8248.352,Case Rate,103% of CMS IPPS Rate,17833.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10010.14,100,MS-DRG,8008.112,Case Rate,100% of CMS IPPS Rate,10603.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15015.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10010.14,100,MS-DRG,8008.112,Case Rate,100% of CMS IPPS Rate,20476.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10010.14,100,MS-DRG,8008.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25694.57,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,CDM,,,,,Inpatient,,,,,,29187.24,,,,Case Rate,100% of CMS IPPS Rate,21154.76,145,MS-DRG,16923.808,Case Rate,145% of CMS IPPS Rate,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14589.49,100,,11671.592,Case Rate,100% of CMS IPPS Rate,25838.14,100,,,Case Rate,100% of CMS IPPS Rate,29530.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33220.75,100,,,Case Rate,100% of CMS IPPS Rate,33220.75,100,,,Case Rate,100% of CMS IPPS Rate,33220.75,100,,,Case Rate,100% CMS IPPS Rate,26347.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13275.79,100,,10620.632,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,10620.632,Case Rate,100% of CMS IPPS Rate,13275.79,100,MS-DRG,10620.632,Case Rate,100% of CMS IPPS Rate,19183.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,18966.34,130,MS-DRG,15173.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15027.17,103,MS-DRG,12021.736,Case Rate,103% of CMS IPPS Rate,15027.17,103,MS-DRG,12021.736,Case Rate,103% of CMS IPPS Rate,23463.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,15454.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21884.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,29843.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14589.49,100,MS-DRG,11671.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33220.75,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,CDM,,,,,Inpatient,,,,,,19634.33,,,,Case Rate,100% of CMS IPPS Rate,14230.85,145,MS-DRG,11384.68,Case Rate,145% of CMS IPPS Rate,9814.38,100,MS-DRG,7851.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9814.38,100,,7851.504,Case Rate,100% of CMS IPPS Rate,16550.44,100,,,Case Rate,100% of CMS IPPS Rate,18915.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21279.31,100,,,Case Rate,100% of CMS IPPS Rate,21279.31,100,,,Case Rate,100% of CMS IPPS Rate,21279.31,100,,,Case Rate,100% CMS IPPS Rate,17724.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8930.74,100,,7144.592,Case Rate,100% of CMS IPPS Rate,8930.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8930.74,100,MS-DRG,7144.592,Case Rate,100% of CMS IPPS Rate,8930.74,100,MS-DRG,7144.592,Case Rate,100% of CMS IPPS Rate,12904.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9814.38,100,MS-DRG,7851.504,Case Rate,100% of CMS IPPS Rate,12758.69,130,MS-DRG,10206.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10108.81,103,MS-DRG,8087.048,Case Rate,103% of CMS IPPS Rate,10108.81,103,MS-DRG,8087.048,Case Rate,103% of CMS IPPS Rate,18319.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9814.38,100,MS-DRG,7851.504,Case Rate,100% of CMS IPPS Rate,10396.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14721.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9814.38,100,MS-DRG,7851.504,Case Rate,100% of CMS IPPS Rate,20076,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9814.38,100,MS-DRG,7851.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21279.31,
ARTHROSCOPY,509,CDM,,,,,Inpatient,,,,,,18158.33,,,,Case Rate,100% of CMS IPPS Rate,13557.02,145,MS-DRG,10845.616,Case Rate,145% of CMS IPPS Rate,9349.67,100,MS-DRG,7479.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9349.67,100,,7479.736,Case Rate,100% of CMS IPPS Rate,23418.57,100,,,Case Rate,100% of CMS IPPS Rate,26765.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% CMS IPPS Rate,16391.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8507.87,100,,6806.296,Case Rate,100% of CMS IPPS Rate,8507.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8507.87,100,MS-DRG,6806.296,Case Rate,100% of CMS IPPS Rate,8507.87,100,MS-DRG,6806.296,Case Rate,100% of CMS IPPS Rate,12293.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9349.67,100,MS-DRG,7479.736,Case Rate,100% of CMS IPPS Rate,12154.57,130,MS-DRG,9723.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9630.16,103,MS-DRG,7704.128,Case Rate,103% of CMS IPPS Rate,9630.16,103,MS-DRG,7704.128,Case Rate,103% of CMS IPPS Rate,19201.44,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9349.67,100,MS-DRG,7479.736,Case Rate,100% of CMS IPPS Rate,9614.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14024.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9349.67,100,MS-DRG,7479.736,Case Rate,100% of CMS IPPS Rate,18566.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9349.67,100,MS-DRG,7479.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30109.84,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,CDM,,,,,Inpatient,,,,,,37250.46,,,,Case Rate,100% of CMS IPPS Rate,26998.94,145,MS-DRG,21599.152,Case Rate,145% of CMS IPPS Rate,18619.96,100,MS-DRG,14895.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18619.96,100,,14895.968,Case Rate,100% of CMS IPPS Rate,38101.33,100,,,Case Rate,100% of CMS IPPS Rate,43546.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48987.83,100,,,Case Rate,100% of CMS IPPS Rate,48987.83,100,,,Case Rate,100% of CMS IPPS Rate,48987.83,100,,,Case Rate,100% CMS IPPS Rate,33626.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16943.26,100,,13554.608,Case Rate,100% of CMS IPPS Rate,16943.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16943.26,100,MS-DRG,13554.608,Case Rate,100% of CMS IPPS Rate,16943.26,100,MS-DRG,13554.608,Case Rate,100% of CMS IPPS Rate,24482.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18619.96,100,MS-DRG,14895.968,Case Rate,100% of CMS IPPS Rate,24205.95,130,MS-DRG,19364.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19178.56,103,MS-DRG,15342.848,Case Rate,103% of CMS IPPS Rate,19178.56,103,MS-DRG,15342.848,Case Rate,103% of CMS IPPS Rate,36534.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18619.96,100,MS-DRG,14895.968,Case Rate,100% of CMS IPPS Rate,19724.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27929.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18619.96,100,MS-DRG,14895.968,Case Rate,100% of CMS IPPS Rate,38088.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18619.96,100,MS-DRG,14895.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48987.83,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,CDM,,,,,Inpatient,,,,,,27299.11,,,,Case Rate,100% of CMS IPPS Rate,19786.25,145,MS-DRG,15829,Case Rate,145% of CMS IPPS Rate,13645.69,100,MS-DRG,10916.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13645.69,100,,10916.552,Case Rate,100% of CMS IPPS Rate,26144.76,100,,,Case Rate,100% of CMS IPPS Rate,29880.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33614.97,100,,,Case Rate,100% of CMS IPPS Rate,33614.97,100,,,Case Rate,100% of CMS IPPS Rate,33614.97,100,,,Case Rate,100% CMS IPPS Rate,24643.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12416.99,100,,9933.592,Case Rate,100% of CMS IPPS Rate,12416.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12416.99,100,MS-DRG,9933.592,Case Rate,100% of CMS IPPS Rate,12416.99,100,MS-DRG,9933.592,Case Rate,100% of CMS IPPS Rate,19614.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13645.69,100,MS-DRG,10916.552,Case Rate,100% of CMS IPPS Rate,17739.4,130,MS-DRG,14191.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14055.06,103,MS-DRG,11244.048,Case Rate,103% of CMS IPPS Rate,14055.06,103,MS-DRG,11244.048,Case Rate,103% of CMS IPPS Rate,25034.35,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13645.69,100,MS-DRG,10916.552,Case Rate,100% of CMS IPPS Rate,14455.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20468.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13645.69,100,MS-DRG,10916.552,Case Rate,100% of CMS IPPS Rate,27913.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13645.69,100,MS-DRG,10916.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33614.97,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,CDM,,,,,Inpatient,,,,,,22096.15,,,,Case Rate,100% of CMS IPPS Rate,16015.18,145,MS-DRG,12812.144,Case Rate,145% of CMS IPPS Rate,11044.95,100,MS-DRG,8835.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11044.95,100,,8835.96,Case Rate,100% of CMS IPPS Rate,21433.58,100,,,Case Rate,100% of CMS IPPS Rate,24496.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27557.69,100,,,Case Rate,100% of CMS IPPS Rate,27557.69,100,,,Case Rate,100% of CMS IPPS Rate,27557.69,100,,,Case Rate,100% CMS IPPS Rate,19946.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10050.47,100,,8040.376,Case Rate,100% of CMS IPPS Rate,10050.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10050.47,100,MS-DRG,8040.376,Case Rate,100% of CMS IPPS Rate,10050.47,100,MS-DRG,8040.376,Case Rate,100% of CMS IPPS Rate,15357.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11044.95,100,MS-DRG,8835.96,Case Rate,100% of CMS IPPS Rate,14358.44,130,MS-DRG,11486.752,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11376.3,103,MS-DRG,9101.04,Case Rate,103% of CMS IPPS Rate,11376.3,103,MS-DRG,9101.04,Case Rate,103% of CMS IPPS Rate,20322.23,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11044.95,100,MS-DRG,8835.96,Case Rate,100% of CMS IPPS Rate,11700.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16567.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11044.95,100,MS-DRG,8835.96,Case Rate,100% of CMS IPPS Rate,22593.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11044.95,100,MS-DRG,8835.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27557.69,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,CDM,,,,,Inpatient,,,,,,22194.73,,,,Case Rate,100% of CMS IPPS Rate,16086.62,145,MS-DRG,12869.296,Case Rate,145% of CMS IPPS Rate,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11094.22,100,,8875.376,Case Rate,100% of CMS IPPS Rate,20071.15,100,,,Case Rate,100% of CMS IPPS Rate,22939.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25805.98,100,,,Case Rate,100% of CMS IPPS Rate,25805.98,100,,,Case Rate,100% of CMS IPPS Rate,25805.98,100,,,Case Rate,100% CMS IPPS Rate,20035.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10095.32,100,,8076.256,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,8076.256,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,8076.256,Case Rate,100% of CMS IPPS Rate,13153.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,14422.49,130,MS-DRG,11537.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11427.05,103,MS-DRG,9141.64,Case Rate,103% of CMS IPPS Rate,11427.05,103,MS-DRG,9141.64,Case Rate,103% of CMS IPPS Rate,20164.1,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,11752.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16641.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,22694,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25805.98,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,CDM,,,,,Inpatient,,,,,,14260.22,,,,Case Rate,100% of CMS IPPS Rate,10335.73,145,MS-DRG,8268.584,Case Rate,145% of CMS IPPS Rate,7128.09,100,MS-DRG,5702.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7128.09,100,,5702.472,Case Rate,100% of CMS IPPS Rate,13592.29,100,,,Case Rate,100% of CMS IPPS Rate,15534.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17475.94,100,,,Case Rate,100% of CMS IPPS Rate,17475.94,100,,,Case Rate,100% of CMS IPPS Rate,17475.94,100,,,Case Rate,100% CMS IPPS Rate,12872.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6486.37,100,,5189.096,Case Rate,100% of CMS IPPS Rate,6486.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6486.37,100,MS-DRG,5189.096,Case Rate,100% of CMS IPPS Rate,6486.37,100,MS-DRG,5189.096,Case Rate,100% of CMS IPPS Rate,8704.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7128.09,100,MS-DRG,5702.472,Case Rate,100% of CMS IPPS Rate,9266.52,130,MS-DRG,7413.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7341.93,103,MS-DRG,5873.544,Case Rate,103% of CMS IPPS Rate,7341.93,103,MS-DRG,5873.544,Case Rate,103% of CMS IPPS Rate,13063.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7128.09,100,MS-DRG,5702.472,Case Rate,100% of CMS IPPS Rate,7550.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10692.14,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7128.09,100,MS-DRG,5702.472,Case Rate,100% of CMS IPPS Rate,14581,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7128.09,100,MS-DRG,5702.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17475.94,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,CDM,,,,,Inpatient,,,,,,43287.26,,,,Case Rate,100% of CMS IPPS Rate,31374.39,145,MS-DRG,25099.512,Case Rate,145% of CMS IPPS Rate,21637.51,100,MS-DRG,17310.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21637.51,100,,17310.008,Case Rate,100% of CMS IPPS Rate,41224.78,100,,,Case Rate,100% of CMS IPPS Rate,47115.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53003.74,100,,,Case Rate,100% of CMS IPPS Rate,53003.74,100,,,Case Rate,100% of CMS IPPS Rate,53003.74,100,,,Case Rate,100% CMS IPPS Rate,39076.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19689.04,100,,15751.232,Case Rate,100% of CMS IPPS Rate,19689.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19689.04,100,MS-DRG,15751.232,Case Rate,100% of CMS IPPS Rate,19689.04,100,MS-DRG,15751.232,Case Rate,100% of CMS IPPS Rate,26954.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21637.51,100,MS-DRG,17310.008,Case Rate,100% of CMS IPPS Rate,28128.76,130,MS-DRG,22503.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22286.64,103,MS-DRG,17829.312,Case Rate,103% of CMS IPPS Rate,22286.64,103,MS-DRG,17829.312,Case Rate,103% of CMS IPPS Rate,39440.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21637.51,100,MS-DRG,17310.008,Case Rate,100% of CMS IPPS Rate,22920.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32456.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21637.51,100,MS-DRG,17310.008,Case Rate,100% of CMS IPPS Rate,44261,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21637.51,100,MS-DRG,17310.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,53003.74,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,CDM,,,,,Inpatient,,,,,,27942.63,,,,Case Rate,100% of CMS IPPS Rate,20252.69,145,MS-DRG,16202.152,Case Rate,145% of CMS IPPS Rate,13967.37,100,MS-DRG,11173.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13967.37,100,,11173.896,Case Rate,100% of CMS IPPS Rate,26817.97,100,,,Case Rate,100% of CMS IPPS Rate,30650.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34480.54,100,,,Case Rate,100% of CMS IPPS Rate,34480.54,100,,,Case Rate,100% of CMS IPPS Rate,34480.54,100,,,Case Rate,100% CMS IPPS Rate,25224.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12709.68,100,,10167.744,Case Rate,100% of CMS IPPS Rate,12709.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12709.68,100,MS-DRG,10167.744,Case Rate,100% of CMS IPPS Rate,12709.68,100,MS-DRG,10167.744,Case Rate,100% of CMS IPPS Rate,20805.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13967.37,100,MS-DRG,11173.896,Case Rate,100% of CMS IPPS Rate,18157.58,130,MS-DRG,14526.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14386.39,103,MS-DRG,11509.112,Case Rate,103% of CMS IPPS Rate,14386.39,103,MS-DRG,11509.112,Case Rate,103% of CMS IPPS Rate,25727.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13967.37,100,MS-DRG,11173.896,Case Rate,100% of CMS IPPS Rate,14795.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20951.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13967.37,100,MS-DRG,11173.896,Case Rate,100% of CMS IPPS Rate,28571.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13967.37,100,MS-DRG,11173.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34480.54,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,CDM,,,,,Inpatient,,,,,,20461.32,,,,Case Rate,100% of CMS IPPS Rate,14830.25,145,MS-DRG,11864.2,Case Rate,145% of CMS IPPS Rate,10227.76,100,MS-DRG,8182.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10227.76,100,,8182.208,Case Rate,100% of CMS IPPS Rate,19775.29,100,,,Case Rate,100% of CMS IPPS Rate,22599.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25425.16,100,,,Case Rate,100% of CMS IPPS Rate,25425.16,100,,,Case Rate,100% of CMS IPPS Rate,25425.16,100,,,Case Rate,100% CMS IPPS Rate,18470.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9306.88,100,,7445.504,Case Rate,100% of CMS IPPS Rate,9306.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9306.88,100,MS-DRG,7445.504,Case Rate,100% of CMS IPPS Rate,9306.88,100,MS-DRG,7445.504,Case Rate,100% of CMS IPPS Rate,16544.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10227.76,100,MS-DRG,8182.208,Case Rate,100% of CMS IPPS Rate,13296.09,130,MS-DRG,10636.872,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10534.59,103,MS-DRG,8427.672,Case Rate,103% of CMS IPPS Rate,10534.59,103,MS-DRG,8427.672,Case Rate,103% of CMS IPPS Rate,19100.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10227.76,100,MS-DRG,8182.208,Case Rate,100% of CMS IPPS Rate,10834.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15341.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10227.76,100,MS-DRG,8182.208,Case Rate,100% of CMS IPPS Rate,20921.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10227.76,100,MS-DRG,8182.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25425.16,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,CDM,,,,,Inpatient,,,,,,50000.45,,,,Case Rate,100% of CMS IPPS Rate,36240.07,145,MS-DRG,28992.056,Case Rate,145% of CMS IPPS Rate,24993.15,100,MS-DRG,19994.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24993.15,100,,19994.52,Case Rate,100% of CMS IPPS Rate,47480.83,100,,,Case Rate,100% of CMS IPPS Rate,54261.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,61046.27,100,,,Case Rate,100% of CMS IPPS Rate,61046.27,100,,,Case Rate,100% of CMS IPPS Rate,61046.27,100,,,Case Rate,100% CMS IPPS Rate,45136.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22742.48,100,,18193.984,Case Rate,100% of CMS IPPS Rate,22742.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22742.48,100,MS-DRG,18193.984,Case Rate,100% of CMS IPPS Rate,22742.48,100,MS-DRG,18193.984,Case Rate,100% of CMS IPPS Rate,29125.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24993.15,100,MS-DRG,19994.52,Case Rate,100% of CMS IPPS Rate,32491.1,130,MS-DRG,25992.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25742.94,103,MS-DRG,20594.352,Case Rate,103% of CMS IPPS Rate,25742.94,103,MS-DRG,20594.352,Case Rate,103% of CMS IPPS Rate,47155.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24993.15,100,MS-DRG,19994.52,Case Rate,100% of CMS IPPS Rate,26475.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37489.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24993.15,100,MS-DRG,19994.52,Case Rate,100% of CMS IPPS Rate,51125.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24993.15,100,MS-DRG,19994.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,61046.27,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,CDM,,,,,Inpatient,,,,,,26954.07,,,,Case Rate,100% of CMS IPPS Rate,19536.17,145,MS-DRG,15628.936,Case Rate,145% of CMS IPPS Rate,13473.22,100,MS-DRG,10778.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13473.22,100,,10778.576,Case Rate,100% of CMS IPPS Rate,26287.4,100,,,Case Rate,100% of CMS IPPS Rate,30043.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33798.37,100,,,Case Rate,100% of CMS IPPS Rate,33798.37,100,,,Case Rate,100% of CMS IPPS Rate,33798.37,100,,,Case Rate,100% CMS IPPS Rate,24331.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12260.05,100,,9808.04,Case Rate,100% of CMS IPPS Rate,12260.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12260.05,100,MS-DRG,9808.04,Case Rate,100% of CMS IPPS Rate,12260.05,100,MS-DRG,9808.04,Case Rate,100% of CMS IPPS Rate,17996.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13473.22,100,MS-DRG,10778.576,Case Rate,100% of CMS IPPS Rate,17515.19,130,MS-DRG,14012.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13877.42,103,MS-DRG,11101.936,Case Rate,103% of CMS IPPS Rate,13877.42,103,MS-DRG,11101.936,Case Rate,103% of CMS IPPS Rate,25291.15,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13473.22,100,MS-DRG,10778.576,Case Rate,100% of CMS IPPS Rate,14272.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20209.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13473.22,100,MS-DRG,10778.576,Case Rate,100% of CMS IPPS Rate,27560.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13473.22,100,MS-DRG,10778.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33798.37,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,CDM,,,,,Inpatient,,,,,,19600.1,,,,Case Rate,100% of CMS IPPS Rate,14206.06,145,MS-DRG,11364.848,Case Rate,145% of CMS IPPS Rate,9797.28,100,MS-DRG,7837.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9797.28,100,,7837.824,Case Rate,100% of CMS IPPS Rate,19105.99,100,,,Case Rate,100% of CMS IPPS Rate,21836.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24565.05,100,,,Case Rate,100% of CMS IPPS Rate,24565.05,100,,,Case Rate,100% of CMS IPPS Rate,24565.05,100,,,Case Rate,100% CMS IPPS Rate,17693.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8915.15,100,,7132.12,Case Rate,100% of CMS IPPS Rate,8915.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8915.15,100,MS-DRG,7132.12,Case Rate,100% of CMS IPPS Rate,8915.15,100,MS-DRG,7132.12,Case Rate,100% of CMS IPPS Rate,14621.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9797.28,100,MS-DRG,7837.824,Case Rate,100% of CMS IPPS Rate,12736.46,130,MS-DRG,10189.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10091.2,103,MS-DRG,8072.96,Case Rate,103% of CMS IPPS Rate,10091.2,103,MS-DRG,8072.96,Case Rate,103% of CMS IPPS Rate,18719.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9797.28,100,MS-DRG,7837.824,Case Rate,100% of CMS IPPS Rate,10378.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14695.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9797.28,100,MS-DRG,7837.824,Case Rate,100% of CMS IPPS Rate,20041,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9797.28,100,MS-DRG,7837.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24565.05,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,CDM,,,,,Inpatient,,,,,,40996.59,,,,Case Rate,100% of CMS IPPS Rate,29714.13,145,MS-DRG,23771.304,Case Rate,145% of CMS IPPS Rate,20492.5,100,MS-DRG,16394,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20492.5,100,,16394,Case Rate,100% of CMS IPPS Rate,38855.87,100,,,Case Rate,100% of CMS IPPS Rate,44408.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49957.96,100,,,Case Rate,100% of CMS IPPS Rate,49957.96,100,,,Case Rate,100% of CMS IPPS Rate,49957.96,100,,,Case Rate,100% CMS IPPS Rate,37008.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18647.15,100,,14917.72,Case Rate,100% of CMS IPPS Rate,18647.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18647.15,100,MS-DRG,14917.72,Case Rate,100% of CMS IPPS Rate,18647.15,100,MS-DRG,14917.72,Case Rate,100% of CMS IPPS Rate,27456.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20492.5,100,MS-DRG,16394,Case Rate,100% of CMS IPPS Rate,26640.25,130,MS-DRG,21312.2,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21107.28,103,MS-DRG,16885.824,Case Rate,103% of CMS IPPS Rate,21107.28,103,MS-DRG,16885.824,Case Rate,103% of CMS IPPS Rate,38192.88,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20492.5,100,MS-DRG,16394,Case Rate,100% of CMS IPPS Rate,21707.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30738.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20492.5,100,MS-DRG,16394,Case Rate,100% of CMS IPPS Rate,41918.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20492.5,100,MS-DRG,16394,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49957.96,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,CDM,,,,,Inpatient,,,,,,28920.24,,,,Case Rate,100% of CMS IPPS Rate,20961.26,145,MS-DRG,16769.008,Case Rate,145% of CMS IPPS Rate,14456.04,100,MS-DRG,11564.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14456.04,100,,11564.832,Case Rate,100% of CMS IPPS Rate,28103.08,100,,,Case Rate,100% of CMS IPPS Rate,32119.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36132.83,100,,,Case Rate,100% of CMS IPPS Rate,36132.83,100,,,Case Rate,100% of CMS IPPS Rate,36132.83,100,,,Case Rate,100% CMS IPPS Rate,26106.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13154.34,100,,10523.472,Case Rate,100% of CMS IPPS Rate,13154.34,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13154.34,100,MS-DRG,10523.472,Case Rate,100% of CMS IPPS Rate,13154.34,100,MS-DRG,10523.472,Case Rate,100% of CMS IPPS Rate,18850.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14456.04,100,MS-DRG,11564.832,Case Rate,100% of CMS IPPS Rate,18792.85,130,MS-DRG,15034.28,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14889.72,103,MS-DRG,11911.776,Case Rate,103% of CMS IPPS Rate,14889.72,103,MS-DRG,11911.776,Case Rate,103% of CMS IPPS Rate,27487.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14456.04,100,MS-DRG,11564.832,Case Rate,100% of CMS IPPS Rate,15313.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21684.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14456.04,100,MS-DRG,11564.832,Case Rate,100% of CMS IPPS Rate,29570.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14456.04,100,MS-DRG,11564.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36132.83,
FRACTURES OF FEMUR WITH MCC,533,CDM,,,,,Inpatient,,,,,,22337.13,,,,Case Rate,100% of CMS IPPS Rate,16189.84,145,MS-DRG,12951.872,Case Rate,145% of CMS IPPS Rate,11165.41,100,MS-DRG,8932.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11165.41,100,,8932.328,Case Rate,100% of CMS IPPS Rate,20328.44,100,,,Case Rate,100% of CMS IPPS Rate,23233.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26136.79,100,,,Case Rate,100% of CMS IPPS Rate,26136.79,100,,,Case Rate,100% of CMS IPPS Rate,26136.79,100,,,Case Rate,100% CMS IPPS Rate,20164.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10160.07,100,,8128.056,Case Rate,100% of CMS IPPS Rate,10160.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10160.07,100,MS-DRG,8128.056,Case Rate,100% of CMS IPPS Rate,10160.07,100,MS-DRG,8128.056,Case Rate,100% of CMS IPPS Rate,14681.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11165.41,100,MS-DRG,8932.328,Case Rate,100% of CMS IPPS Rate,14515.03,130,MS-DRG,11612.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11500.37,103,MS-DRG,9200.296,Case Rate,103% of CMS IPPS Rate,11500.37,103,MS-DRG,9200.296,Case Rate,103% of CMS IPPS Rate,18042.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11165.41,100,MS-DRG,8932.328,Case Rate,100% of CMS IPPS Rate,11827.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16748.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11165.41,100,MS-DRG,8932.328,Case Rate,100% of CMS IPPS Rate,22839.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11165.41,100,MS-DRG,8932.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26136.79,
FRACTURES OF FEMUR WITHOUT MCC,534,CDM,,,,,Inpatient,,,,,,11090.52,,,,Case Rate,100% of CMS IPPS Rate,8038.37,145,MS-DRG,6430.696,Case Rate,145% of CMS IPPS Rate,5543.7,100,MS-DRG,4434.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5543.7,100,,4434.96,Case Rate,100% of CMS IPPS Rate,10851.43,100,,,Case Rate,100% of CMS IPPS Rate,12402.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13951.96,100,,,Case Rate,100% of CMS IPPS Rate,13951.96,100,,,Case Rate,100% of CMS IPPS Rate,13951.96,100,,,Case Rate,100% CMS IPPS Rate,10011.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5044.67,100,,4035.736,Case Rate,100% of CMS IPPS Rate,5044.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5044.67,100,MS-DRG,4035.736,Case Rate,100% of CMS IPPS Rate,5044.67,100,MS-DRG,4035.736,Case Rate,100% of CMS IPPS Rate,4664.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5543.7,100,MS-DRG,4434.96,Case Rate,100% of CMS IPPS Rate,7206.81,130,MS-DRG,5765.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5710.01,103,MS-DRG,4568.008,Case Rate,103% of CMS IPPS Rate,5710.01,103,MS-DRG,4568.008,Case Rate,103% of CMS IPPS Rate,10068.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5543.7,100,MS-DRG,4434.96,Case Rate,100% of CMS IPPS Rate,5872.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8315.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5543.7,100,MS-DRG,4434.96,Case Rate,100% of CMS IPPS Rate,11340,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5543.7,100,MS-DRG,4434.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4664.05,13951.96,
FRACTURES OF HIP AND PELVIS WITH MCC,535,CDM,,,,,Inpatient,,,,,,17754.42,,,,Case Rate,100% of CMS IPPS Rate,12868.32,145,MS-DRG,10294.656,Case Rate,145% of CMS IPPS Rate,8874.7,100,MS-DRG,7099.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8874.7,100,,7099.76,Case Rate,100% of CMS IPPS Rate,17728.9,100,,,Case Rate,100% of CMS IPPS Rate,20262.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22794.49,100,,,Case Rate,100% of CMS IPPS Rate,22794.49,100,,,Case Rate,100% of CMS IPPS Rate,22794.49,100,,,Case Rate,100% CMS IPPS Rate,16027.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8075.67,100,,6460.536,Case Rate,100% of CMS IPPS Rate,8075.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8075.67,100,MS-DRG,6460.536,Case Rate,100% of CMS IPPS Rate,8075.67,100,MS-DRG,6460.536,Case Rate,100% of CMS IPPS Rate,11668.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8874.7,100,MS-DRG,7099.76,Case Rate,100% of CMS IPPS Rate,11537.11,130,MS-DRG,9229.688,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9140.94,103,MS-DRG,7312.752,Case Rate,103% of CMS IPPS Rate,9140.94,103,MS-DRG,7312.752,Case Rate,103% of CMS IPPS Rate,16312.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8874.7,100,MS-DRG,7099.76,Case Rate,100% of CMS IPPS Rate,9401.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13312.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8874.7,100,MS-DRG,7099.76,Case Rate,100% of CMS IPPS Rate,18153.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8874.7,100,MS-DRG,7099.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22794.49,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,CDM,,,,,Inpatient,,,,,,10776.97,,,,Case Rate,100% of CMS IPPS Rate,7811.09,145,MS-DRG,6248.872,Case Rate,145% of CMS IPPS Rate,5386.96,100,MS-DRG,4309.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5386.96,100,,4309.568,Case Rate,100% of CMS IPPS Rate,10810.11,100,,,Case Rate,100% of CMS IPPS Rate,12354.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13898.83,100,,,Case Rate,100% of CMS IPPS Rate,13898.83,100,,,Case Rate,100% of CMS IPPS Rate,13898.83,100,,,Case Rate,100% CMS IPPS Rate,9728.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4902.05,100,,3921.64,Case Rate,100% of CMS IPPS Rate,4902.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4902.05,100,MS-DRG,3921.64,Case Rate,100% of CMS IPPS Rate,4902.05,100,MS-DRG,3921.64,Case Rate,100% of CMS IPPS Rate,5540.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5386.96,100,MS-DRG,4309.568,Case Rate,100% of CMS IPPS Rate,7003.05,130,MS-DRG,5602.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5548.57,103,MS-DRG,4438.856,Case Rate,103% of CMS IPPS Rate,5548.57,103,MS-DRG,4438.856,Case Rate,103% of CMS IPPS Rate,9830.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5386.96,100,MS-DRG,4309.568,Case Rate,100% of CMS IPPS Rate,5706.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8080.44,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5386.96,100,MS-DRG,4309.568,Case Rate,100% of CMS IPPS Rate,11019.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5386.96,100,MS-DRG,4309.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4902.05,13898.83,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,CDM,,,,,Inpatient,,,,,,13240.16,,,,Case Rate,100% of CMS IPPS Rate,9596.4,145,MS-DRG,7677.12,Case Rate,145% of CMS IPPS Rate,6618.21,100,MS-DRG,5294.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6618.21,100,,5294.568,Case Rate,100% of CMS IPPS Rate,12251.19,100,,,Case Rate,100% of CMS IPPS Rate,14001.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15751.66,100,,,Case Rate,100% of CMS IPPS Rate,15751.66,100,,,Case Rate,100% of CMS IPPS Rate,15751.66,100,,,Case Rate,100% CMS IPPS Rate,11952.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6022.41,100,,4817.928,Case Rate,100% of CMS IPPS Rate,6022.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6022.41,100,MS-DRG,4817.928,Case Rate,100% of CMS IPPS Rate,6022.41,100,MS-DRG,4817.928,Case Rate,100% of CMS IPPS Rate,8702.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6618.21,100,MS-DRG,5294.568,Case Rate,100% of CMS IPPS Rate,8603.67,130,MS-DRG,6882.936,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6816.76,103,MS-DRG,5453.408,Case Rate,103% of CMS IPPS Rate,6816.76,103,MS-DRG,5453.408,Case Rate,103% of CMS IPPS Rate,12566.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6618.21,100,MS-DRG,5294.568,Case Rate,100% of CMS IPPS Rate,7010.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9927.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6618.21,100,MS-DRG,5294.568,Case Rate,100% of CMS IPPS Rate,13538,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6618.21,100,MS-DRG,5294.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,15751.66,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,CDM,,,,,Inpatient,,,,,,9709,,,,Case Rate,100% of CMS IPPS Rate,7037.02,145,MS-DRG,5629.616,Case Rate,145% of CMS IPPS Rate,4853.12,100,MS-DRG,3882.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4853.12,100,,3882.496,Case Rate,100% of CMS IPPS Rate,8951.77,100,,,Case Rate,100% of CMS IPPS Rate,10230.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11509.51,100,,,Case Rate,100% of CMS IPPS Rate,11509.51,100,,,Case Rate,100% of CMS IPPS Rate,11509.51,100,,,Case Rate,100% CMS IPPS Rate,8764.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4416.29,100,,3533.032,Case Rate,100% of CMS IPPS Rate,4416.29,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4416.29,100,MS-DRG,3533.032,Case Rate,100% of CMS IPPS Rate,4416.29,100,MS-DRG,3533.032,Case Rate,100% of CMS IPPS Rate,6381.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4853.12,100,MS-DRG,3882.496,Case Rate,100% of CMS IPPS Rate,6309.06,130,MS-DRG,5047.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4998.71,103,MS-DRG,3998.968,Case Rate,103% of CMS IPPS Rate,4998.71,103,MS-DRG,3998.968,Case Rate,103% of CMS IPPS Rate,8806.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4853.12,100,MS-DRG,3882.496,Case Rate,100% of CMS IPPS Rate,5140.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7279.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4853.12,100,MS-DRG,3882.496,Case Rate,100% of CMS IPPS Rate,9927.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4853.12,100,MS-DRG,3882.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4416.29,11509.51,
OSTEOMYELITIS WITH MCC,539,CDM,,,,,Inpatient,,,,,,27170.4,,,,Case Rate,100% of CMS IPPS Rate,19692.97,145,MS-DRG,15754.376,Case Rate,145% of CMS IPPS Rate,13581.36,100,MS-DRG,10865.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13581.36,100,,10865.088,Case Rate,100% of CMS IPPS Rate,26960.61,100,,,Case Rate,100% of CMS IPPS Rate,30813.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34663.94,100,,,Case Rate,100% of CMS IPPS Rate,34663.94,100,,,Case Rate,100% of CMS IPPS Rate,34663.94,100,,,Case Rate,100% CMS IPPS Rate,24527.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12358.45,100,,9886.76,Case Rate,100% of CMS IPPS Rate,12358.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12358.45,100,MS-DRG,9886.76,Case Rate,100% of CMS IPPS Rate,12358.45,100,MS-DRG,9886.76,Case Rate,100% of CMS IPPS Rate,15761.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13581.36,100,MS-DRG,10865.088,Case Rate,100% of CMS IPPS Rate,17655.77,130,MS-DRG,14124.616,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13988.8,103,MS-DRG,11191.04,Case Rate,103% of CMS IPPS Rate,13988.8,103,MS-DRG,11191.04,Case Rate,103% of CMS IPPS Rate,25248.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13581.36,100,MS-DRG,10865.088,Case Rate,100% of CMS IPPS Rate,14386.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20372.04,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13581.36,100,MS-DRG,10865.088,Case Rate,100% of CMS IPPS Rate,27781.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13581.36,100,MS-DRG,10865.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34663.94,
OSTEOMYELITIS WITH CC,540,CDM,,,,,Inpatient,,,,,,17774.95,,,,Case Rate,100% of CMS IPPS Rate,12883.21,145,MS-DRG,10306.568,Case Rate,145% of CMS IPPS Rate,8884.97,100,MS-DRG,7107.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8884.97,100,,7107.976,Case Rate,100% of CMS IPPS Rate,17251.65,100,,,Case Rate,100% of CMS IPPS Rate,19716.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22180.87,100,,,Case Rate,100% of CMS IPPS Rate,22180.87,100,,,Case Rate,100% of CMS IPPS Rate,22180.87,100,,,Case Rate,100% CMS IPPS Rate,16045.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8085.01,100,,6468.008,Case Rate,100% of CMS IPPS Rate,8085.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8085.01,100,MS-DRG,6468.008,Case Rate,100% of CMS IPPS Rate,8085.01,100,MS-DRG,6468.008,Case Rate,100% of CMS IPPS Rate,9252.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8884.97,100,MS-DRG,7107.976,Case Rate,100% of CMS IPPS Rate,11550.46,130,MS-DRG,9240.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9151.52,103,MS-DRG,7321.216,Case Rate,103% of CMS IPPS Rate,9151.52,103,MS-DRG,7321.216,Case Rate,103% of CMS IPPS Rate,17034.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8884.97,100,MS-DRG,7107.976,Case Rate,100% of CMS IPPS Rate,9411.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13327.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8884.97,100,MS-DRG,7107.976,Case Rate,100% of CMS IPPS Rate,18174.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8884.97,100,MS-DRG,7107.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22180.87,
OSTEOMYELITIS WITHOUT CC/MCC,541,CDM,,,,,Inpatient,,,,,,11746.37,,,,Case Rate,100% of CMS IPPS Rate,8513.7,145,MS-DRG,6810.96,Case Rate,145% of CMS IPPS Rate,5871.52,100,MS-DRG,4697.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5871.52,100,,4697.216,Case Rate,100% of CMS IPPS Rate,11663.29,100,,,Case Rate,100% of CMS IPPS Rate,13329.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14995.79,100,,,Case Rate,100% of CMS IPPS Rate,14995.79,100,,,Case Rate,100% of CMS IPPS Rate,14995.79,100,,,Case Rate,100% CMS IPPS Rate,10603.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5342.97,100,,4274.376,Case Rate,100% of CMS IPPS Rate,5342.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5342.97,100,MS-DRG,4274.376,Case Rate,100% of CMS IPPS Rate,5342.97,100,MS-DRG,4274.376,Case Rate,100% of CMS IPPS Rate,6073.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5871.52,100,MS-DRG,4697.216,Case Rate,100% of CMS IPPS Rate,7632.98,130,MS-DRG,6106.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6047.67,103,MS-DRG,4838.136,Case Rate,103% of CMS IPPS Rate,6047.67,103,MS-DRG,4838.136,Case Rate,103% of CMS IPPS Rate,10347.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5871.52,100,MS-DRG,4697.216,Case Rate,100% of CMS IPPS Rate,6219.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8807.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5871.52,100,MS-DRG,4697.216,Case Rate,100% of CMS IPPS Rate,12010.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5871.52,100,MS-DRG,4697.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5342.97,14995.79,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,CDM,,,,,Inpatient,,,,,,24970.1,,,,Case Rate,100% of CMS IPPS Rate,18098.2,145,MS-DRG,14478.56,Case Rate,145% of CMS IPPS Rate,12481.52,100,MS-DRG,9985.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12481.52,100,,9985.216,Case Rate,100% of CMS IPPS Rate,24863.65,100,,,Case Rate,100% of CMS IPPS Rate,28416.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31967.81,100,,,Case Rate,100% of CMS IPPS Rate,31967.81,100,,,Case Rate,100% of CMS IPPS Rate,31967.81,100,,,Case Rate,100% CMS IPPS Rate,22540.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11357.66,100,,9086.128,Case Rate,100% of CMS IPPS Rate,11357.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11357.66,100,MS-DRG,9086.128,Case Rate,100% of CMS IPPS Rate,11357.66,100,MS-DRG,9086.128,Case Rate,100% of CMS IPPS Rate,20948.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12481.52,100,MS-DRG,9985.216,Case Rate,100% of CMS IPPS Rate,16225.98,130,MS-DRG,12980.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12855.97,103,MS-DRG,10284.776,Case Rate,103% of CMS IPPS Rate,12855.97,103,MS-DRG,10284.776,Case Rate,103% of CMS IPPS Rate,23124.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12481.52,100,MS-DRG,9985.216,Case Rate,100% of CMS IPPS Rate,13221.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18722.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12481.52,100,MS-DRG,9985.216,Case Rate,100% of CMS IPPS Rate,25531.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12481.52,100,MS-DRG,9985.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31967.81,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,CDM,,,,,Inpatient,,,,,,14933.86,,,,Case Rate,100% of CMS IPPS Rate,10823.99,145,MS-DRG,8659.192,Case Rate,145% of CMS IPPS Rate,7464.82,100,MS-DRG,5971.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7464.82,100,,5971.856,Case Rate,100% of CMS IPPS Rate,14142.86,100,,,Case Rate,100% of CMS IPPS Rate,16163.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18183.83,100,,,Case Rate,100% of CMS IPPS Rate,18183.83,100,,,Case Rate,100% of CMS IPPS Rate,18183.83,100,,,Case Rate,100% CMS IPPS Rate,13481.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6792.78,100,,5434.224,Case Rate,100% of CMS IPPS Rate,6792.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6792.78,100,MS-DRG,5434.224,Case Rate,100% of CMS IPPS Rate,6792.78,100,MS-DRG,5434.224,Case Rate,100% of CMS IPPS Rate,9260.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7464.82,100,MS-DRG,5971.856,Case Rate,100% of CMS IPPS Rate,9704.27,130,MS-DRG,7763.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7688.76,103,MS-DRG,6151.008,Case Rate,103% of CMS IPPS Rate,7688.76,103,MS-DRG,6151.008,Case Rate,103% of CMS IPPS Rate,13775.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7464.82,100,MS-DRG,5971.856,Case Rate,100% of CMS IPPS Rate,7907.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11197.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7464.82,100,MS-DRG,5971.856,Case Rate,100% of CMS IPPS Rate,15269.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7464.82,100,MS-DRG,5971.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18183.83,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,CDM,,,,,Inpatient,,,,,,10508.61,,,,Case Rate,100% of CMS IPPS Rate,7616.59,145,MS-DRG,6093.272,Case Rate,145% of CMS IPPS Rate,5252.82,100,MS-DRG,4202.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5252.82,100,,4202.256,Case Rate,100% of CMS IPPS Rate,10074.24,100,,,Case Rate,100% of CMS IPPS Rate,11513.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12952.7,100,,,Case Rate,100% of CMS IPPS Rate,12952.7,100,,,Case Rate,100% of CMS IPPS Rate,12952.7,100,,,Case Rate,100% CMS IPPS Rate,9486.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4779.99,100,,3823.992,Case Rate,100% of CMS IPPS Rate,4779.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4779.99,100,MS-DRG,3823.992,Case Rate,100% of CMS IPPS Rate,4779.99,100,MS-DRG,3823.992,Case Rate,100% of CMS IPPS Rate,6411.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5252.82,100,MS-DRG,4202.256,Case Rate,100% of CMS IPPS Rate,6828.67,130,MS-DRG,5462.936,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5410.4,103,MS-DRG,4328.32,Case Rate,103% of CMS IPPS Rate,5410.4,103,MS-DRG,4328.32,Case Rate,103% of CMS IPPS Rate,9842.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5252.82,100,MS-DRG,4202.256,Case Rate,100% of CMS IPPS Rate,5564.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7879.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5252.82,100,MS-DRG,4202.256,Case Rate,100% of CMS IPPS Rate,10745,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5252.82,100,MS-DRG,4202.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4779.99,12952.7,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,CDM,,,,,Inpatient,,,,,,34136.89,,,,Case Rate,100% of CMS IPPS Rate,24742.25,145,MS-DRG,19793.8,Case Rate,145% of CMS IPPS Rate,17063.62,100,MS-DRG,13650.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17063.62,100,,13650.896,Case Rate,100% of CMS IPPS Rate,33686.1,100,,,Case Rate,100% of CMS IPPS Rate,38499.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43311.07,100,,,Case Rate,100% of CMS IPPS Rate,43311.07,100,,,Case Rate,100% of CMS IPPS Rate,43311.07,100,,,Case Rate,100% CMS IPPS Rate,30815.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15527.08,100,,12421.664,Case Rate,100% of CMS IPPS Rate,15527.08,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15527.08,100,MS-DRG,12421.664,Case Rate,100% of CMS IPPS Rate,15527.08,100,MS-DRG,12421.664,Case Rate,100% of CMS IPPS Rate,23335.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17063.62,100,MS-DRG,13650.896,Case Rate,100% of CMS IPPS Rate,22182.71,130,MS-DRG,17746.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17575.53,103,MS-DRG,14060.424,Case Rate,103% of CMS IPPS Rate,17575.53,103,MS-DRG,14060.424,Case Rate,103% of CMS IPPS Rate,31733.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17063.62,100,MS-DRG,13650.896,Case Rate,100% of CMS IPPS Rate,18075.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25595.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17063.62,100,MS-DRG,13650.896,Case Rate,100% of CMS IPPS Rate,34904.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17063.62,100,MS-DRG,13650.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43311.07,
CONNECTIVE TISSUE DISORDERS WITH CC,546,CDM,,,,,Inpatient,,,,,,16420.82,,,,Case Rate,100% of CMS IPPS Rate,11901.73,145,MS-DRG,9521.384,Case Rate,145% of CMS IPPS Rate,8208.09,100,MS-DRG,6566.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8208.09,100,,6566.472,Case Rate,100% of CMS IPPS Rate,15433.3,100,,,Case Rate,100% of CMS IPPS Rate,17638.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19842.98,100,,,Case Rate,100% of CMS IPPS Rate,19842.98,100,,,Case Rate,100% of CMS IPPS Rate,19842.98,100,,,Case Rate,100% CMS IPPS Rate,14823.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7469.1,100,,5975.28,Case Rate,100% of CMS IPPS Rate,7469.1,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7469.1,100,MS-DRG,5975.28,Case Rate,100% of CMS IPPS Rate,7469.1,100,MS-DRG,5975.28,Case Rate,100% of CMS IPPS Rate,10175.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8208.09,100,MS-DRG,6566.472,Case Rate,100% of CMS IPPS Rate,10670.52,130,MS-DRG,8536.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8454.33,103,MS-DRG,6763.464,Case Rate,103% of CMS IPPS Rate,8454.33,103,MS-DRG,6763.464,Case Rate,103% of CMS IPPS Rate,15250.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8208.09,100,MS-DRG,6566.472,Case Rate,100% of CMS IPPS Rate,8694.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12312.14,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8208.09,100,MS-DRG,6566.472,Case Rate,100% of CMS IPPS Rate,16790.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8208.09,100,MS-DRG,6566.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19842.98,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,CDM,,,,,Inpatient,,,,,,11137.07,,,,Case Rate,100% of CMS IPPS Rate,8170.33,145,MS-DRG,6536.264,Case Rate,145% of CMS IPPS Rate,5634.71,100,MS-DRG,4507.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5634.71,100,,4507.768,Case Rate,100% of CMS IPPS Rate,9947.59,100,,,Case Rate,100% of CMS IPPS Rate,11369.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12789.87,100,,,Case Rate,100% of CMS IPPS Rate,12789.87,100,,,Case Rate,100% of CMS IPPS Rate,12789.87,100,,,Case Rate,100% CMS IPPS Rate,10053.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5127.49,100,,4101.992,Case Rate,100% of CMS IPPS Rate,5127.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5127.49,100,MS-DRG,4101.992,Case Rate,100% of CMS IPPS Rate,5127.49,100,MS-DRG,4101.992,Case Rate,100% of CMS IPPS Rate,6425.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5634.71,100,MS-DRG,4507.768,Case Rate,100% of CMS IPPS Rate,7325.12,130,MS-DRG,5860.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5803.75,103,MS-DRG,4643,Case Rate,103% of CMS IPPS Rate,5803.75,103,MS-DRG,4643,Case Rate,103% of CMS IPPS Rate,11572.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5634.71,100,MS-DRG,4507.768,Case Rate,100% of CMS IPPS Rate,5897.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8452.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5634.71,100,MS-DRG,4507.768,Case Rate,100% of CMS IPPS Rate,11387.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5634.71,100,MS-DRG,4507.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5127.49,12789.87,
SEPTIC ARTHRITIS WITH MCC,548,CDM,,,,,Inpatient,,,,,,26696.66,,,,Case Rate,100% of CMS IPPS Rate,19349.61,145,MS-DRG,15479.688,Case Rate,145% of CMS IPPS Rate,13344.56,100,MS-DRG,10675.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13344.56,100,,10675.648,Case Rate,100% of CMS IPPS Rate,26856.63,100,,,Case Rate,100% of CMS IPPS Rate,30694.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34530.24,100,,,Case Rate,100% of CMS IPPS Rate,34530.24,100,,,Case Rate,100% of CMS IPPS Rate,34530.24,100,,,Case Rate,100% CMS IPPS Rate,24099.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12142.97,100,,9714.376,Case Rate,100% of CMS IPPS Rate,12142.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12142.97,100,MS-DRG,9714.376,Case Rate,100% of CMS IPPS Rate,12142.97,100,MS-DRG,9714.376,Case Rate,100% of CMS IPPS Rate,17546.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13344.56,100,MS-DRG,10675.648,Case Rate,100% of CMS IPPS Rate,17347.93,130,MS-DRG,13878.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13744.9,103,MS-DRG,10995.92,Case Rate,103% of CMS IPPS Rate,13744.9,103,MS-DRG,10995.92,Case Rate,103% of CMS IPPS Rate,24539.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13344.56,100,MS-DRG,10675.648,Case Rate,100% of CMS IPPS Rate,14136.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20016.84,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13344.56,100,MS-DRG,10675.648,Case Rate,100% of CMS IPPS Rate,27297.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13344.56,100,MS-DRG,10675.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34530.24,
SEPTIC ARTHRITIS WITH CC,549,CDM,,,,,Inpatient,,,,,,16515.29,,,,Case Rate,100% of CMS IPPS Rate,11970.21,145,MS-DRG,9576.168,Case Rate,145% of CMS IPPS Rate,8255.32,100,MS-DRG,6604.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8255.32,100,,6604.256,Case Rate,100% of CMS IPPS Rate,16065.19,100,,,Case Rate,100% of CMS IPPS Rate,18360.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20655.41,100,,,Case Rate,100% of CMS IPPS Rate,20655.41,100,,,Case Rate,100% of CMS IPPS Rate,20655.41,100,,,Case Rate,100% CMS IPPS Rate,14908.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7512.06,100,,6009.648,Case Rate,100% of CMS IPPS Rate,7512.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7512.06,100,MS-DRG,6009.648,Case Rate,100% of CMS IPPS Rate,7512.06,100,MS-DRG,6009.648,Case Rate,100% of CMS IPPS Rate,9592.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8255.32,100,MS-DRG,6604.256,Case Rate,100% of CMS IPPS Rate,10731.92,130,MS-DRG,8585.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8502.98,103,MS-DRG,6802.384,Case Rate,103% of CMS IPPS Rate,8502.98,103,MS-DRG,6802.384,Case Rate,103% of CMS IPPS Rate,15328.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8255.32,100,MS-DRG,6604.256,Case Rate,100% of CMS IPPS Rate,8744.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12382.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8255.32,100,MS-DRG,6604.256,Case Rate,100% of CMS IPPS Rate,16886.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8255.32,100,MS-DRG,6604.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20655.41,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,CDM,,,,,Inpatient,,,,,,12607.59,,,,Case Rate,100% of CMS IPPS Rate,9363.2,145,MS-DRG,7490.56,Case Rate,145% of CMS IPPS Rate,6457.38,100,MS-DRG,5165.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6457.38,100,,5165.904,Case Rate,100% of CMS IPPS Rate,11492.66,100,,,Case Rate,100% of CMS IPPS Rate,13134.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14776.39,100,,,Case Rate,100% of CMS IPPS Rate,14776.39,100,,,Case Rate,100% of CMS IPPS Rate,14776.39,100,,,Case Rate,100% CMS IPPS Rate,11381.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5876.06,100,,4700.848,Case Rate,100% of CMS IPPS Rate,5876.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5876.06,100,MS-DRG,4700.848,Case Rate,100% of CMS IPPS Rate,5876.06,100,MS-DRG,4700.848,Case Rate,100% of CMS IPPS Rate,5016.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6457.38,100,MS-DRG,5165.904,Case Rate,100% of CMS IPPS Rate,8394.59,130,MS-DRG,6715.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6651.1,103,MS-DRG,5320.88,Case Rate,103% of CMS IPPS Rate,6651.1,103,MS-DRG,5320.88,Case Rate,103% of CMS IPPS Rate,13261,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6457.38,100,MS-DRG,5165.904,Case Rate,100% of CMS IPPS Rate,6675.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9686.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6457.38,100,MS-DRG,5165.904,Case Rate,100% of CMS IPPS Rate,12891.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6457.38,100,MS-DRG,5165.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5016.72,14776.39,
MEDICAL BACK PROBLEMS WITH MCC,551,CDM,,,,,Inpatient,,,,,,23302.41,,,,Case Rate,100% of CMS IPPS Rate,16889.47,145,MS-DRG,13511.576,Case Rate,145% of CMS IPPS Rate,11647.91,100,MS-DRG,9318.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11647.91,100,,9318.328,Case Rate,100% of CMS IPPS Rate,22748.02,100,,,Case Rate,100% of CMS IPPS Rate,25998.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29247.7,100,,,Case Rate,100% of CMS IPPS Rate,29247.7,100,,,Case Rate,100% of CMS IPPS Rate,29247.7,100,,,Case Rate,100% CMS IPPS Rate,21035.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10599.13,100,,8479.304,Case Rate,100% of CMS IPPS Rate,10599.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10599.13,100,MS-DRG,8479.304,Case Rate,100% of CMS IPPS Rate,10599.13,100,MS-DRG,8479.304,Case Rate,100% of CMS IPPS Rate,10999,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11647.91,100,MS-DRG,9318.328,Case Rate,100% of CMS IPPS Rate,15142.28,130,MS-DRG,12113.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11997.35,103,MS-DRG,9597.88,Case Rate,103% of CMS IPPS Rate,11997.35,103,MS-DRG,9597.88,Case Rate,103% of CMS IPPS Rate,21168.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.91,100,MS-DRG,9318.328,Case Rate,100% of CMS IPPS Rate,12338.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17471.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.91,100,MS-DRG,9318.328,Case Rate,100% of CMS IPPS Rate,23826.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.91,100,MS-DRG,9318.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29247.7,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,CDM,,,,,Inpatient,,,,,,13230.58,,,,Case Rate,100% of CMS IPPS Rate,9589.46,145,MS-DRG,7671.568,Case Rate,145% of CMS IPPS Rate,6613.42,100,MS-DRG,5290.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6613.42,100,,5290.736,Case Rate,100% of CMS IPPS Rate,12848.42,100,,,Case Rate,100% of CMS IPPS Rate,14684.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16519.53,100,,,Case Rate,100% of CMS IPPS Rate,16519.53,100,,,Case Rate,100% of CMS IPPS Rate,16519.53,100,,,Case Rate,100% CMS IPPS Rate,11943.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6018.05,100,,4814.44,Case Rate,100% of CMS IPPS Rate,6018.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6018.05,100,MS-DRG,4814.44,Case Rate,100% of CMS IPPS Rate,6018.05,100,MS-DRG,4814.44,Case Rate,100% of CMS IPPS Rate,6314.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6613.42,100,MS-DRG,5290.736,Case Rate,100% of CMS IPPS Rate,8597.45,130,MS-DRG,6877.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6811.82,103,MS-DRG,5449.456,Case Rate,103% of CMS IPPS Rate,6811.82,103,MS-DRG,5449.456,Case Rate,103% of CMS IPPS Rate,12150.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6613.42,100,MS-DRG,5290.736,Case Rate,100% of CMS IPPS Rate,7005.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9920.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6613.42,100,MS-DRG,5290.736,Case Rate,100% of CMS IPPS Rate,13528.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6613.42,100,MS-DRG,5290.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16519.53,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,CDM,,,,,Inpatient,,,,,,18504.74,,,,Case Rate,100% of CMS IPPS Rate,13412.14,145,MS-DRG,10729.712,Case Rate,145% of CMS IPPS Rate,9249.75,100,MS-DRG,7399.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9249.75,100,,7399.8,Case Rate,100% of CMS IPPS Rate,17410.29,100,,,Case Rate,100% of CMS IPPS Rate,19898.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22384.84,100,,,Case Rate,100% of CMS IPPS Rate,22384.84,100,,,Case Rate,100% of CMS IPPS Rate,22384.84,100,,,Case Rate,100% CMS IPPS Rate,16704.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8416.95,100,,6733.56,Case Rate,100% of CMS IPPS Rate,8416.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8416.95,100,MS-DRG,6733.56,Case Rate,100% of CMS IPPS Rate,8416.95,100,MS-DRG,6733.56,Case Rate,100% of CMS IPPS Rate,12162.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9249.75,100,MS-DRG,7399.8,Case Rate,100% of CMS IPPS Rate,12024.68,130,MS-DRG,9619.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9527.24,103,MS-DRG,7621.792,Case Rate,103% of CMS IPPS Rate,9527.24,103,MS-DRG,7621.792,Case Rate,103% of CMS IPPS Rate,16772.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9249.75,100,MS-DRG,7399.8,Case Rate,100% of CMS IPPS Rate,9798.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13874.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9249.75,100,MS-DRG,7399.8,Case Rate,100% of CMS IPPS Rate,18921,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9249.75,100,MS-DRG,7399.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22384.84,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,CDM,,,,,Inpatient,,,,,,11252.09,,,,Case Rate,100% of CMS IPPS Rate,8155.45,145,MS-DRG,6524.36,Case Rate,145% of CMS IPPS Rate,5624.45,100,MS-DRG,4499.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5624.45,100,,4499.56,Case Rate,100% of CMS IPPS Rate,11126.05,100,,,Case Rate,100% of CMS IPPS Rate,12715.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14305.04,100,,,Case Rate,100% of CMS IPPS Rate,14305.04,100,,,Case Rate,100% of CMS IPPS Rate,14305.04,100,,,Case Rate,100% CMS IPPS Rate,10157.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5118.15,100,,4094.52,Case Rate,100% of CMS IPPS Rate,5118.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5118.15,100,MS-DRG,4094.52,Case Rate,100% of CMS IPPS Rate,5118.15,100,MS-DRG,4094.52,Case Rate,100% of CMS IPPS Rate,5345.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5624.45,100,MS-DRG,4499.56,Case Rate,100% of CMS IPPS Rate,7311.79,130,MS-DRG,5849.432,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5793.18,103,MS-DRG,4634.544,Case Rate,103% of CMS IPPS Rate,5793.18,103,MS-DRG,4634.544,Case Rate,103% of CMS IPPS Rate,10375.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5624.45,100,MS-DRG,4499.56,Case Rate,100% of CMS IPPS Rate,5958.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8436.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5624.45,100,MS-DRG,4499.56,Case Rate,100% of CMS IPPS Rate,11505.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5624.45,100,MS-DRG,4499.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5118.15,14305.04,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,CDM,,,,,Inpatient,,,,,,19155.11,,,,Case Rate,100% of CMS IPPS Rate,13883.52,145,MS-DRG,11106.816,Case Rate,145% of CMS IPPS Rate,9574.84,100,MS-DRG,7659.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9574.84,100,,7659.872,Case Rate,100% of CMS IPPS Rate,17951.52,100,,,Case Rate,100% of CMS IPPS Rate,20516.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23080.72,100,,,Case Rate,100% of CMS IPPS Rate,23080.72,100,,,Case Rate,100% of CMS IPPS Rate,23080.72,100,,,Case Rate,100% CMS IPPS Rate,17291.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8712.76,100,,6970.208,Case Rate,100% of CMS IPPS Rate,8712.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8712.76,100,MS-DRG,6970.208,Case Rate,100% of CMS IPPS Rate,8712.76,100,MS-DRG,6970.208,Case Rate,100% of CMS IPPS Rate,8644.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9574.84,100,MS-DRG,7659.872,Case Rate,100% of CMS IPPS Rate,12447.29,130,MS-DRG,9957.832,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9862.09,103,MS-DRG,7889.672,Case Rate,103% of CMS IPPS Rate,9862.09,103,MS-DRG,7889.672,Case Rate,103% of CMS IPPS Rate,16839.68,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9574.84,100,MS-DRG,7659.872,Case Rate,100% of CMS IPPS Rate,10142.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14362.26,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9574.84,100,MS-DRG,7659.872,Case Rate,100% of CMS IPPS Rate,19586,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9574.84,100,MS-DRG,7659.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23080.72,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,CDM,,,,,Inpatient,,,,,,11287.68,,,,Case Rate,100% of CMS IPPS Rate,8181.25,145,MS-DRG,6545,Case Rate,145% of CMS IPPS Rate,5642.24,100,MS-DRG,4513.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5642.24,100,,4513.792,Case Rate,100% of CMS IPPS Rate,10884.76,100,,,Case Rate,100% of CMS IPPS Rate,12440.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13994.81,100,,,Case Rate,100% of CMS IPPS Rate,13994.81,100,,,Case Rate,100% of CMS IPPS Rate,13994.81,100,,,Case Rate,100% CMS IPPS Rate,10189.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5134.35,100,,4107.48,Case Rate,100% of CMS IPPS Rate,5134.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5134.35,100,MS-DRG,4107.48,Case Rate,100% of CMS IPPS Rate,5134.35,100,MS-DRG,4107.48,Case Rate,100% of CMS IPPS Rate,6057.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5642.24,100,MS-DRG,4513.792,Case Rate,100% of CMS IPPS Rate,7334.91,130,MS-DRG,5867.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5811.51,103,MS-DRG,4649.208,Case Rate,103% of CMS IPPS Rate,5811.51,103,MS-DRG,4649.208,Case Rate,103% of CMS IPPS Rate,10221.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5642.24,100,MS-DRG,4513.792,Case Rate,100% of CMS IPPS Rate,5976.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8463.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5642.24,100,MS-DRG,4513.792,Case Rate,100% of CMS IPPS Rate,11541.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5642.24,100,MS-DRG,4513.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5134.35,13994.81,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,CDM,,,,,Inpatient,,,,,,21315.71,,,,Case Rate,100% of CMS IPPS Rate,15449.52,145,MS-DRG,12359.616,Case Rate,145% of CMS IPPS Rate,10654.84,100,MS-DRG,8523.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10654.84,100,,8523.872,Case Rate,100% of CMS IPPS Rate,20659.05,100,,,Case Rate,100% of CMS IPPS Rate,23611.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26561.86,100,,,Case Rate,100% of CMS IPPS Rate,26561.86,100,,,Case Rate,100% of CMS IPPS Rate,26561.86,100,,,Case Rate,100% CMS IPPS Rate,19242.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9695.5,100,,7756.4,Case Rate,100% of CMS IPPS Rate,9695.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9695.5,100,MS-DRG,7756.4,Case Rate,100% of CMS IPPS Rate,9695.5,100,MS-DRG,7756.4,Case Rate,100% of CMS IPPS Rate,7262.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10654.84,100,MS-DRG,8523.872,Case Rate,100% of CMS IPPS Rate,13851.29,130,MS-DRG,11081.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10974.49,103,MS-DRG,8779.592,Case Rate,103% of CMS IPPS Rate,10974.49,103,MS-DRG,8779.592,Case Rate,103% of CMS IPPS Rate,18113.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10654.84,100,MS-DRG,8523.872,Case Rate,100% of CMS IPPS Rate,11286.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15982.26,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10654.84,100,MS-DRG,8523.872,Case Rate,100% of CMS IPPS Rate,21795.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10654.84,100,MS-DRG,8523.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26561.86,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,CDM,,,,,Inpatient,,,,,,12027.05,,,,Case Rate,100% of CMS IPPS Rate,8717.15,145,MS-DRG,6973.72,Case Rate,145% of CMS IPPS Rate,6011.83,100,MS-DRG,4809.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6011.83,100,,4809.464,Case Rate,100% of CMS IPPS Rate,11515.32,100,,,Case Rate,100% of CMS IPPS Rate,13160.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14805.53,100,,,Case Rate,100% of CMS IPPS Rate,14805.53,100,,,Case Rate,100% of CMS IPPS Rate,14805.53,100,,,Case Rate,100% CMS IPPS Rate,10857.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5470.63,100,,4376.504,Case Rate,100% of CMS IPPS Rate,5470.63,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5470.63,100,MS-DRG,4376.504,Case Rate,100% of CMS IPPS Rate,5470.63,100,MS-DRG,4376.504,Case Rate,100% of CMS IPPS Rate,3861.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6011.83,100,MS-DRG,4809.464,Case Rate,100% of CMS IPPS Rate,7815.38,130,MS-DRG,6252.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6192.18,103,MS-DRG,4953.744,Case Rate,103% of CMS IPPS Rate,6192.18,103,MS-DRG,4953.744,Case Rate,103% of CMS IPPS Rate,10992.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6011.83,100,MS-DRG,4809.464,Case Rate,100% of CMS IPPS Rate,6368.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9017.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6011.83,100,MS-DRG,4809.464,Case Rate,100% of CMS IPPS Rate,12297.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6011.83,100,MS-DRG,4809.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3861.45,14805.53,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,CDM,,,,,Inpatient,,,,,,25337.05,,,,Case Rate,100% of CMS IPPS Rate,18364.16,145,MS-DRG,14691.328,Case Rate,145% of CMS IPPS Rate,12664.94,100,MS-DRG,10131.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12664.94,100,,10131.952,Case Rate,100% of CMS IPPS Rate,24746.34,100,,,Case Rate,100% of CMS IPPS Rate,28282.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31816.98,100,,,Case Rate,100% of CMS IPPS Rate,31816.98,100,,,Case Rate,100% of CMS IPPS Rate,31816.98,100,,,Case Rate,100% CMS IPPS Rate,22872.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11524.56,100,,9219.648,Case Rate,100% of CMS IPPS Rate,11524.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11524.56,100,MS-DRG,9219.648,Case Rate,100% of CMS IPPS Rate,11524.56,100,MS-DRG,9219.648,Case Rate,100% of CMS IPPS Rate,22284.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12664.94,100,MS-DRG,10131.952,Case Rate,100% of CMS IPPS Rate,16464.42,130,MS-DRG,13171.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13044.89,103,MS-DRG,10435.912,Case Rate,103% of CMS IPPS Rate,13044.89,103,MS-DRG,10435.912,Case Rate,103% of CMS IPPS Rate,22580.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12664.94,100,MS-DRG,10131.952,Case Rate,100% of CMS IPPS Rate,13416.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18997.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12664.94,100,MS-DRG,10131.952,Case Rate,100% of CMS IPPS Rate,25907,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12664.94,100,MS-DRG,10131.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31816.98,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,CDM,,,,,Inpatient,,,,,,15500.71,,,,Case Rate,100% of CMS IPPS Rate,11234.83,145,MS-DRG,8987.864,Case Rate,145% of CMS IPPS Rate,7748.16,100,MS-DRG,6198.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7748.16,100,,6198.528,Case Rate,100% of CMS IPPS Rate,15180.01,100,,,Case Rate,100% of CMS IPPS Rate,17349.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19517.32,100,,,Case Rate,100% of CMS IPPS Rate,19517.32,100,,,Case Rate,100% of CMS IPPS Rate,19517.32,100,,,Case Rate,100% CMS IPPS Rate,13992.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7050.59,100,,5640.472,Case Rate,100% of CMS IPPS Rate,7050.59,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7050.59,100,MS-DRG,5640.472,Case Rate,100% of CMS IPPS Rate,7050.59,100,MS-DRG,5640.472,Case Rate,100% of CMS IPPS Rate,13019.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7748.16,100,MS-DRG,6198.528,Case Rate,100% of CMS IPPS Rate,10072.61,130,MS-DRG,8058.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7980.6,103,MS-DRG,6384.48,Case Rate,103% of CMS IPPS Rate,7980.6,103,MS-DRG,6384.48,Case Rate,103% of CMS IPPS Rate,13859.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7748.16,100,MS-DRG,6198.528,Case Rate,100% of CMS IPPS Rate,8207.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11622.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7748.16,100,MS-DRG,6198.528,Case Rate,100% of CMS IPPS Rate,15849.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7748.16,100,MS-DRG,6198.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19517.32,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,CDM,,,,,Inpatient,,,,,,10682.5,,,,Case Rate,100% of CMS IPPS Rate,7742.62,145,MS-DRG,6194.096,Case Rate,145% of CMS IPPS Rate,5339.74,100,MS-DRG,4271.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5339.74,100,,4271.792,Case Rate,100% of CMS IPPS Rate,10899.43,100,,,Case Rate,100% of CMS IPPS Rate,12456.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14013.66,100,,,Case Rate,100% of CMS IPPS Rate,14013.66,100,,,Case Rate,100% of CMS IPPS Rate,14013.66,100,,,Case Rate,100% CMS IPPS Rate,9643.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4859.09,100,,3887.272,Case Rate,100% of CMS IPPS Rate,4859.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4859.09,100,MS-DRG,3887.272,Case Rate,100% of CMS IPPS Rate,4859.09,100,MS-DRG,3887.272,Case Rate,100% of CMS IPPS Rate,8191.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5339.74,100,MS-DRG,4271.792,Case Rate,100% of CMS IPPS Rate,6941.66,130,MS-DRG,5553.328,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5499.93,103,MS-DRG,4399.944,Case Rate,103% of CMS IPPS Rate,5499.93,103,MS-DRG,4399.944,Case Rate,103% of CMS IPPS Rate,9996.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5339.74,100,MS-DRG,4271.792,Case Rate,100% of CMS IPPS Rate,5656.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8009.61,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5339.74,100,MS-DRG,4271.792,Case Rate,100% of CMS IPPS Rate,10922.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5339.74,100,MS-DRG,4271.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4859.09,14013.66,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,CDM,,,,,Inpatient,,,,,,20821.42,,,,Case Rate,100% of CMS IPPS Rate,15091.27,145,MS-DRG,12073.016,Case Rate,145% of CMS IPPS Rate,10407.77,100,MS-DRG,8326.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10407.77,100,,8326.216,Case Rate,100% of CMS IPPS Rate,19509.92,100,,,Case Rate,100% of CMS IPPS Rate,22297.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25084.39,100,,,Case Rate,100% of CMS IPPS Rate,25084.39,100,,,Case Rate,100% of CMS IPPS Rate,25084.39,100,,,Case Rate,100% CMS IPPS Rate,18795.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9470.67,100,,7576.536,Case Rate,100% of CMS IPPS Rate,9470.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9470.67,100,MS-DRG,7576.536,Case Rate,100% of CMS IPPS Rate,9470.67,100,MS-DRG,7576.536,Case Rate,100% of CMS IPPS Rate,9599.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10407.77,100,MS-DRG,8326.216,Case Rate,100% of CMS IPPS Rate,13530.1,130,MS-DRG,10824.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10720,103,MS-DRG,8576,Case Rate,103% of CMS IPPS Rate,10720,103,MS-DRG,8576,Case Rate,103% of CMS IPPS Rate,18504.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10407.77,100,MS-DRG,8326.216,Case Rate,100% of CMS IPPS Rate,11025.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15611.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10407.77,100,MS-DRG,8326.216,Case Rate,100% of CMS IPPS Rate,21289.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10407.77,100,MS-DRG,8326.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25084.39,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,CDM,,,,,Inpatient,,,,,,12262.56,,,,Case Rate,100% of CMS IPPS Rate,8887.85,145,MS-DRG,7110.28,Case Rate,145% of CMS IPPS Rate,6129.55,100,MS-DRG,4903.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6129.55,100,,4903.64,Case Rate,100% of CMS IPPS Rate,11915.25,100,,,Case Rate,100% of CMS IPPS Rate,13617.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15319.73,100,,,Case Rate,100% of CMS IPPS Rate,15319.73,100,,,Case Rate,100% of CMS IPPS Rate,15319.73,100,,,Case Rate,100% CMS IPPS Rate,11069.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5577.75,100,,4462.2,Case Rate,100% of CMS IPPS Rate,5577.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5577.75,100,MS-DRG,4462.2,Case Rate,100% of CMS IPPS Rate,5577.75,100,MS-DRG,4462.2,Case Rate,100% of CMS IPPS Rate,6288.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6129.55,100,MS-DRG,4903.64,Case Rate,100% of CMS IPPS Rate,7968.42,130,MS-DRG,6374.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6313.44,103,MS-DRG,5050.752,Case Rate,103% of CMS IPPS Rate,6313.44,103,MS-DRG,5050.752,Case Rate,103% of CMS IPPS Rate,10894.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6129.55,100,MS-DRG,4903.64,Case Rate,100% of CMS IPPS Rate,6493.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9194.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6129.55,100,MS-DRG,4903.64,Case Rate,100% of CMS IPPS Rate,12538.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6129.55,100,MS-DRG,4903.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5577.75,15319.73,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,CDM,,,,,Inpatient,,,,,,21385.53,,,,Case Rate,100% of CMS IPPS Rate,15500.14,145,MS-DRG,12400.112,Case Rate,145% of CMS IPPS Rate,10689.75,100,MS-DRG,8551.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10689.75,100,,8551.8,Case Rate,100% of CMS IPPS Rate,20919.01,100,,,Case Rate,100% of CMS IPPS Rate,23908.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26896.09,100,,,Case Rate,100% of CMS IPPS Rate,26896.09,100,,,Case Rate,100% of CMS IPPS Rate,26896.09,100,,,Case Rate,100% CMS IPPS Rate,19305.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9727.26,100,,7781.808,Case Rate,100% of CMS IPPS Rate,9727.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9727.26,100,MS-DRG,7781.808,Case Rate,100% of CMS IPPS Rate,9727.26,100,MS-DRG,7781.808,Case Rate,100% of CMS IPPS Rate,18387.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10689.75,100,MS-DRG,8551.8,Case Rate,100% of CMS IPPS Rate,13896.68,130,MS-DRG,11117.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11010.44,103,MS-DRG,8808.352,Case Rate,103% of CMS IPPS Rate,11010.44,103,MS-DRG,8808.352,Case Rate,103% of CMS IPPS Rate,19649.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10689.75,100,MS-DRG,8551.8,Case Rate,100% of CMS IPPS Rate,11323.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16034.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10689.75,100,MS-DRG,8551.8,Case Rate,100% of CMS IPPS Rate,21866.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10689.75,100,MS-DRG,8551.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26896.09,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,CDM,,,,,Inpatient,,,,,,13683.78,,,,Case Rate,100% of CMS IPPS Rate,9917.94,145,MS-DRG,7934.352,Case Rate,145% of CMS IPPS Rate,6839.96,100,MS-DRG,5471.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6839.96,100,,5471.968,Case Rate,100% of CMS IPPS Rate,13593.62,100,,,Case Rate,100% of CMS IPPS Rate,15536.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17477.66,100,,,Case Rate,100% of CMS IPPS Rate,17477.66,100,,,Case Rate,100% of CMS IPPS Rate,17477.66,100,,,Case Rate,100% CMS IPPS Rate,12352.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6224.19,100,,4979.352,Case Rate,100% of CMS IPPS Rate,6224.19,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6224.19,100,MS-DRG,4979.352,Case Rate,100% of CMS IPPS Rate,6224.19,100,MS-DRG,4979.352,Case Rate,100% of CMS IPPS Rate,8322.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6839.96,100,MS-DRG,5471.968,Case Rate,100% of CMS IPPS Rate,8891.95,130,MS-DRG,7113.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7045.16,103,MS-DRG,5636.128,Case Rate,103% of CMS IPPS Rate,7045.16,103,MS-DRG,5636.128,Case Rate,103% of CMS IPPS Rate,12490.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6839.96,100,MS-DRG,5471.968,Case Rate,100% of CMS IPPS Rate,7245.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10259.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6839.96,100,MS-DRG,5471.968,Case Rate,100% of CMS IPPS Rate,13991.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6839.96,100,MS-DRG,5471.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17477.66,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,CDM,,,,,Inpatient,,,,,,10275.85,,,,Case Rate,100% of CMS IPPS Rate,7447.9,145,MS-DRG,5958.32,Case Rate,145% of CMS IPPS Rate,5136.48,100,MS-DRG,4109.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5136.48,100,,4109.184,Case Rate,100% of CMS IPPS Rate,9972.92,100,,,Case Rate,100% of CMS IPPS Rate,11398.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12822.43,100,,,Case Rate,100% of CMS IPPS Rate,12822.43,100,,,Case Rate,100% of CMS IPPS Rate,12822.43,100,,,Case Rate,100% CMS IPPS Rate,9276.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4674.12,100,,3739.296,Case Rate,100% of CMS IPPS Rate,4674.12,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4674.12,100,MS-DRG,3739.296,Case Rate,100% of CMS IPPS Rate,4674.12,100,MS-DRG,3739.296,Case Rate,100% of CMS IPPS Rate,5433.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5136.48,100,MS-DRG,4109.184,Case Rate,100% of CMS IPPS Rate,6677.42,130,MS-DRG,5341.936,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5290.57,103,MS-DRG,4232.456,Case Rate,103% of CMS IPPS Rate,5290.57,103,MS-DRG,4232.456,Case Rate,103% of CMS IPPS Rate,9395.16,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5136.48,100,MS-DRG,4109.184,Case Rate,100% of CMS IPPS Rate,5441.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7704.72,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5136.48,100,MS-DRG,4109.184,Case Rate,100% of CMS IPPS Rate,10507,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5136.48,100,MS-DRG,4109.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4674.12,12822.43,
SKIN DEBRIDEMENT WITH MCC,570,CDM,,,,,Inpatient,,,,,,40010.76,,,,Case Rate,100% of CMS IPPS Rate,28999.61,145,MS-DRG,23199.688,Case Rate,145% of CMS IPPS Rate,19999.73,100,MS-DRG,15999.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19999.73,100,,15999.784,Case Rate,100% of CMS IPPS Rate,40128.98,100,,,Case Rate,100% of CMS IPPS Rate,45863.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,51594.83,100,,,Case Rate,100% of CMS IPPS Rate,51594.83,100,,,Case Rate,100% of CMS IPPS Rate,51594.83,100,,,Case Rate,100% CMS IPPS Rate,36118.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18198.76,100,,14559.008,Case Rate,100% of CMS IPPS Rate,18198.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18198.76,100,MS-DRG,14559.008,Case Rate,100% of CMS IPPS Rate,18198.76,100,MS-DRG,14559.008,Case Rate,100% of CMS IPPS Rate,26296.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19999.73,100,MS-DRG,15999.784,Case Rate,100% of CMS IPPS Rate,25999.65,130,MS-DRG,20799.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20599.72,103,MS-DRG,16479.776,Case Rate,103% of CMS IPPS Rate,20599.72,103,MS-DRG,16479.776,Case Rate,103% of CMS IPPS Rate,36901.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19999.73,100,MS-DRG,15999.784,Case Rate,100% of CMS IPPS Rate,21185.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29999.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19999.73,100,MS-DRG,15999.784,Case Rate,100% of CMS IPPS Rate,40910.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19999.73,100,MS-DRG,15999.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,51594.83,
SKIN DEBRIDEMENT WITH CC,571,CDM,,,,,Inpatient,,,,,,23165.49,,,,Case Rate,100% of CMS IPPS Rate,16790.23,145,MS-DRG,13432.184,Case Rate,145% of CMS IPPS Rate,11579.47,100,MS-DRG,9263.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11579.47,100,,9263.576,Case Rate,100% of CMS IPPS Rate,22320.09,100,,,Case Rate,100% of CMS IPPS Rate,25509.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28697.5,100,,,Case Rate,100% of CMS IPPS Rate,28697.5,100,,,Case Rate,100% of CMS IPPS Rate,28697.5,100,,,Case Rate,100% CMS IPPS Rate,20911.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10536.85,100,,8429.48,Case Rate,100% of CMS IPPS Rate,10536.85,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10536.85,100,MS-DRG,8429.48,Case Rate,100% of CMS IPPS Rate,10536.85,100,MS-DRG,8429.48,Case Rate,100% of CMS IPPS Rate,10909.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11579.47,100,MS-DRG,9263.576,Case Rate,100% of CMS IPPS Rate,15053.31,130,MS-DRG,12042.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11926.85,103,MS-DRG,9541.48,Case Rate,103% of CMS IPPS Rate,11926.85,103,MS-DRG,9541.48,Case Rate,103% of CMS IPPS Rate,20854.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11579.47,100,MS-DRG,9263.576,Case Rate,100% of CMS IPPS Rate,12266.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17369.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11579.47,100,MS-DRG,9263.576,Case Rate,100% of CMS IPPS Rate,23686.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11579.47,100,MS-DRG,9263.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28697.5,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,CDM,,,,,Inpatient,,,,,,15603.4,,,,Case Rate,100% of CMS IPPS Rate,11309.28,145,MS-DRG,9047.424,Case Rate,145% of CMS IPPS Rate,7799.5,100,MS-DRG,6239.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7799.5,100,,6239.6,Case Rate,100% of CMS IPPS Rate,15229.33,100,,,Case Rate,100% of CMS IPPS Rate,17405.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19580.74,100,,,Case Rate,100% of CMS IPPS Rate,19580.74,100,,,Case Rate,100% of CMS IPPS Rate,19580.74,100,,,Case Rate,100% CMS IPPS Rate,14085.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7097.3,100,,5677.84,Case Rate,100% of CMS IPPS Rate,7097.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7097.3,100,MS-DRG,5677.84,Case Rate,100% of CMS IPPS Rate,7097.3,100,MS-DRG,5677.84,Case Rate,100% of CMS IPPS Rate,10541.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7799.5,100,MS-DRG,6239.6,Case Rate,100% of CMS IPPS Rate,10139.35,130,MS-DRG,8111.48,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8033.49,103,MS-DRG,6426.792,Case Rate,103% of CMS IPPS Rate,8033.49,103,MS-DRG,6426.792,Case Rate,103% of CMS IPPS Rate,15225.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7799.5,100,MS-DRG,6239.6,Case Rate,100% of CMS IPPS Rate,8262.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11699.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7799.5,100,MS-DRG,6239.6,Case Rate,100% of CMS IPPS Rate,15954.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7799.5,100,MS-DRG,6239.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19580.74,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,CDM,,,,,Inpatient,,,,,,85138.23,,,,Case Rate,100% of CMS IPPS Rate,61707.77,145,MS-DRG,49366.216,Case Rate,145% of CMS IPPS Rate,42557.08,100,MS-DRG,34045.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42557.08,100,,34045.664,Case Rate,100% of CMS IPPS Rate,82094.96,100,,,Case Rate,100% of CMS IPPS Rate,93826.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,105551.55,100,,,Case Rate,100% of CMS IPPS Rate,105551.55,100,,,Case Rate,100% of CMS IPPS Rate,105551.55,100,,,Case Rate,100% CMS IPPS Rate,76855.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38724.54,100,,30979.632,Case Rate,100% of CMS IPPS Rate,38724.54,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,38724.54,100,MS-DRG,30979.632,Case Rate,100% of CMS IPPS Rate,38724.54,100,MS-DRG,30979.632,Case Rate,100% of CMS IPPS Rate,55956.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42557.08,100,MS-DRG,34045.664,Case Rate,100% of CMS IPPS Rate,55324.2,130,MS-DRG,44259.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43833.79,103,MS-DRG,35067.032,Case Rate,103% of CMS IPPS Rate,43833.79,103,MS-DRG,35067.032,Case Rate,103% of CMS IPPS Rate,74261.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42557.08,100,MS-DRG,34045.664,Case Rate,100% of CMS IPPS Rate,45081.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,63835.62,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42557.08,100,MS-DRG,34045.664,Case Rate,100% of CMS IPPS Rate,87053.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42557.08,100,MS-DRG,34045.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,105551.55,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,CDM,,,,,Inpatient,,,,,,46632.21,,,,Case Rate,100% of CMS IPPS Rate,33798.79,145,MS-DRG,27039.032,Case Rate,145% of CMS IPPS Rate,23309.51,100,MS-DRG,18647.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23309.51,100,,18647.608,Case Rate,100% of CMS IPPS Rate,46190.58,100,,,Case Rate,100% of CMS IPPS Rate,52791.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,59388.39,100,,,Case Rate,100% of CMS IPPS Rate,59388.39,100,,,Case Rate,100% of CMS IPPS Rate,59388.39,100,,,Case Rate,100% CMS IPPS Rate,42095.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21210.46,100,,16968.368,Case Rate,100% of CMS IPPS Rate,21210.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21210.46,100,MS-DRG,16968.368,Case Rate,100% of CMS IPPS Rate,21210.46,100,MS-DRG,16968.368,Case Rate,100% of CMS IPPS Rate,15082.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23309.51,100,MS-DRG,18647.608,Case Rate,100% of CMS IPPS Rate,30302.36,130,MS-DRG,24241.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24008.8,103,MS-DRG,19207.04,Case Rate,103% of CMS IPPS Rate,24008.8,103,MS-DRG,19207.04,Case Rate,103% of CMS IPPS Rate,45598.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23309.51,100,MS-DRG,18647.608,Case Rate,100% of CMS IPPS Rate,24692.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34964.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23309.51,100,MS-DRG,18647.608,Case Rate,100% of CMS IPPS Rate,47681.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23309.51,100,MS-DRG,18647.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,59388.39,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,CDM,,,,,Inpatient,,,,,,28013.83,,,,Case Rate,100% of CMS IPPS Rate,20304.29,145,MS-DRG,16243.432,Case Rate,145% of CMS IPPS Rate,14002.96,100,MS-DRG,11202.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14002.96,100,,11202.368,Case Rate,100% of CMS IPPS Rate,26618.01,100,,,Case Rate,100% of CMS IPPS Rate,30421.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34223.44,100,,,Case Rate,100% of CMS IPPS Rate,34223.44,100,,,Case Rate,100% of CMS IPPS Rate,34223.44,100,,,Case Rate,100% CMS IPPS Rate,25288.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12742.07,100,,10193.656,Case Rate,100% of CMS IPPS Rate,12742.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12742.07,100,MS-DRG,10193.656,Case Rate,100% of CMS IPPS Rate,12742.07,100,MS-DRG,10193.656,Case Rate,100% of CMS IPPS Rate,18412.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14002.96,100,MS-DRG,11202.368,Case Rate,100% of CMS IPPS Rate,18203.85,130,MS-DRG,14563.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14423.05,103,MS-DRG,11538.44,Case Rate,103% of CMS IPPS Rate,14423.05,103,MS-DRG,11538.44,Case Rate,103% of CMS IPPS Rate,25927.44,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14002.96,100,MS-DRG,11202.368,Case Rate,100% of CMS IPPS Rate,14833.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21004.44,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14002.96,100,MS-DRG,11202.368,Case Rate,100% of CMS IPPS Rate,28644,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14002.96,100,MS-DRG,11202.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34223.44,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,CDM,,,,,Inpatient,,,,,,77813.01,,,,Case Rate,100% of CMS IPPS Rate,56398.48,145,MS-DRG,45118.784,Case Rate,145% of CMS IPPS Rate,38895.5,100,MS-DRG,31116.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38895.5,100,,31116.4,Case Rate,100% of CMS IPPS Rate,71924.74,100,,,Case Rate,100% of CMS IPPS Rate,82202.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,92475.44,100,,,Case Rate,100% of CMS IPPS Rate,92475.44,100,,,Case Rate,100% of CMS IPPS Rate,92475.44,100,,,Case Rate,100% CMS IPPS Rate,70243.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35392.74,100,,28314.192,Case Rate,100% of CMS IPPS Rate,35392.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,35392.74,100,MS-DRG,28314.192,Case Rate,100% of CMS IPPS Rate,35392.74,100,MS-DRG,28314.192,Case Rate,100% of CMS IPPS Rate,51141.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38895.5,100,MS-DRG,31116.4,Case Rate,100% of CMS IPPS Rate,50564.15,130,MS-DRG,40451.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40062.37,103,MS-DRG,32049.896,Case Rate,103% of CMS IPPS Rate,40062.37,103,MS-DRG,32049.896,Case Rate,103% of CMS IPPS Rate,71459.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38895.5,100,MS-DRG,31116.4,Case Rate,100% of CMS IPPS Rate,41202.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,58343.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38895.5,100,MS-DRG,31116.4,Case Rate,100% of CMS IPPS Rate,79563.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38895.5,100,MS-DRG,31116.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,92475.44,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,CDM,,,,,Inpatient,,,,,,36271.48,,,,Case Rate,100% of CMS IPPS Rate,26289.37,145,MS-DRG,21031.496,Case Rate,145% of CMS IPPS Rate,18130.6,100,MS-DRG,14504.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18130.6,100,,14504.48,Case Rate,100% of CMS IPPS Rate,35497.79,100,,,Case Rate,100% of CMS IPPS Rate,40570.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45640.39,100,,,Case Rate,100% of CMS IPPS Rate,45640.39,100,,,Case Rate,100% of CMS IPPS Rate,45640.39,100,,,Case Rate,100% CMS IPPS Rate,32742.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16497.99,100,,13198.392,Case Rate,100% of CMS IPPS Rate,16497.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16497.99,100,MS-DRG,13198.392,Case Rate,100% of CMS IPPS Rate,16497.99,100,MS-DRG,13198.392,Case Rate,100% of CMS IPPS Rate,26390.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18130.6,100,MS-DRG,14504.48,Case Rate,100% of CMS IPPS Rate,23569.78,130,MS-DRG,18855.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18674.52,103,MS-DRG,14939.616,Case Rate,103% of CMS IPPS Rate,18674.52,103,MS-DRG,14939.616,Case Rate,103% of CMS IPPS Rate,33126.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18130.6,100,MS-DRG,14504.48,Case Rate,100% of CMS IPPS Rate,19205.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27195.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18130.6,100,MS-DRG,14504.48,Case Rate,100% of CMS IPPS Rate,37087.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18130.6,100,MS-DRG,14504.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45640.39,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,CDM,,,,,Inpatient,,,,,,22050.97,,,,Case Rate,100% of CMS IPPS Rate,15982.44,145,MS-DRG,12785.952,Case Rate,145% of CMS IPPS Rate,11022.37,100,MS-DRG,8817.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11022.37,100,,8817.896,Case Rate,100% of CMS IPPS Rate,22534.72,100,,,Case Rate,100% of CMS IPPS Rate,25754.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28973.46,100,,,Case Rate,100% of CMS IPPS Rate,28973.46,100,,,Case Rate,100% of CMS IPPS Rate,28973.46,100,,,Case Rate,100% CMS IPPS Rate,19905.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10029.91,100,,8023.928,Case Rate,100% of CMS IPPS Rate,10029.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10029.91,100,MS-DRG,8023.928,Case Rate,100% of CMS IPPS Rate,10029.91,100,MS-DRG,8023.928,Case Rate,100% of CMS IPPS Rate,14071.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11022.37,100,MS-DRG,8817.896,Case Rate,100% of CMS IPPS Rate,14329.08,130,MS-DRG,11463.264,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11353.04,103,MS-DRG,9082.432,Case Rate,103% of CMS IPPS Rate,11353.04,103,MS-DRG,9082.432,Case Rate,103% of CMS IPPS Rate,21663.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11022.37,100,MS-DRG,8817.896,Case Rate,100% of CMS IPPS Rate,11676.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16533.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11022.37,100,MS-DRG,8817.896,Case Rate,100% of CMS IPPS Rate,22547,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11022.37,100,MS-DRG,8817.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28973.46,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,CDM,,,,,Inpatient,,,,,,45761.4,,,,Case Rate,100% of CMS IPPS Rate,33167.65,145,MS-DRG,26534.12,Case Rate,145% of CMS IPPS Rate,22874.24,100,MS-DRG,18299.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22874.24,100,,18299.392,Case Rate,100% of CMS IPPS Rate,43451.06,100,,,Case Rate,100% of CMS IPPS Rate,49660.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55866.12,100,,,Case Rate,100% of CMS IPPS Rate,55866.12,100,,,Case Rate,100% of CMS IPPS Rate,55866.12,100,,,Case Rate,100% CMS IPPS Rate,41309.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20814.38,100,,16651.504,Case Rate,100% of CMS IPPS Rate,20814.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20814.38,100,MS-DRG,16651.504,Case Rate,100% of CMS IPPS Rate,20814.38,100,MS-DRG,16651.504,Case Rate,100% of CMS IPPS Rate,22205.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22874.24,100,MS-DRG,18299.392,Case Rate,100% of CMS IPPS Rate,29736.51,130,MS-DRG,23789.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23560.47,103,MS-DRG,18848.376,Case Rate,103% of CMS IPPS Rate,23560.47,103,MS-DRG,18848.376,Case Rate,103% of CMS IPPS Rate,39869.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22874.24,100,MS-DRG,18299.392,Case Rate,100% of CMS IPPS Rate,24230.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34311.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22874.24,100,MS-DRG,18299.392,Case Rate,100% of CMS IPPS Rate,46790.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22874.24,100,MS-DRG,18299.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,55866.12,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,CDM,,,,,Inpatient,,,,,,23914.45,,,,Case Rate,100% of CMS IPPS Rate,17333.07,145,MS-DRG,13866.456,Case Rate,145% of CMS IPPS Rate,11953.84,100,MS-DRG,9563.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11953.84,100,,9563.072,Case Rate,100% of CMS IPPS Rate,23635.86,100,,,Case Rate,100% of CMS IPPS Rate,27013.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30389.22,100,,,Case Rate,100% of CMS IPPS Rate,30389.22,100,,,Case Rate,100% of CMS IPPS Rate,30389.22,100,,,Case Rate,100% CMS IPPS Rate,21587.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10877.5,100,,8702,Case Rate,100% of CMS IPPS Rate,10877.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10877.5,100,MS-DRG,8702,Case Rate,100% of CMS IPPS Rate,10877.5,100,MS-DRG,8702,Case Rate,100% of CMS IPPS Rate,17115.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11953.84,100,MS-DRG,9563.072,Case Rate,100% of CMS IPPS Rate,15539.99,130,MS-DRG,12431.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12312.46,103,MS-DRG,9849.968,Case Rate,103% of CMS IPPS Rate,12312.46,103,MS-DRG,9849.968,Case Rate,103% of CMS IPPS Rate,21962.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11953.84,100,MS-DRG,9563.072,Case Rate,100% of CMS IPPS Rate,12662.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17930.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11953.84,100,MS-DRG,9563.072,Case Rate,100% of CMS IPPS Rate,24452.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11953.84,100,MS-DRG,9563.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30389.22,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,CDM,,,,,Inpatient,,,,,,18439.02,,,,Case Rate,100% of CMS IPPS Rate,13364.51,145,MS-DRG,10691.608,Case Rate,145% of CMS IPPS Rate,9216.9,100,MS-DRG,7373.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9216.9,100,,7373.52,Case Rate,100% of CMS IPPS Rate,19185.98,100,,,Case Rate,100% of CMS IPPS Rate,21927.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24667.89,100,,,Case Rate,100% of CMS IPPS Rate,24667.89,100,,,Case Rate,100% of CMS IPPS Rate,24667.89,100,,,Case Rate,100% CMS IPPS Rate,16645.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8387.06,100,,6709.648,Case Rate,100% of CMS IPPS Rate,8387.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8387.06,100,MS-DRG,6709.648,Case Rate,100% of CMS IPPS Rate,8387.06,100,MS-DRG,6709.648,Case Rate,100% of CMS IPPS Rate,17863.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9216.9,100,MS-DRG,7373.52,Case Rate,100% of CMS IPPS Rate,11981.97,130,MS-DRG,9585.576,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9493.41,103,MS-DRG,7594.728,Case Rate,103% of CMS IPPS Rate,9493.41,103,MS-DRG,7594.728,Case Rate,103% of CMS IPPS Rate,17855.48,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9216.9,100,MS-DRG,7373.52,Case Rate,100% of CMS IPPS Rate,9763.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13825.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9216.9,100,MS-DRG,7373.52,Case Rate,100% of CMS IPPS Rate,18853.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9216.9,100,MS-DRG,7373.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24667.89,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,CDM,,,,,Inpatient,,,,,,22825.93,,,,Case Rate,100% of CMS IPPS Rate,17280.48,145,MS-DRG,13824.384,Case Rate,145% of CMS IPPS Rate,11917.57,100,MS-DRG,9534.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11917.57,100,,9534.056,Case Rate,100% of CMS IPPS Rate,23345.25,100,,,Case Rate,100% of CMS IPPS Rate,26681.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30015.57,100,,,Case Rate,100% of CMS IPPS Rate,30015.57,100,,,Case Rate,100% of CMS IPPS Rate,30015.57,100,,,Case Rate,100% CMS IPPS Rate,20605.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10844.49,100,,8675.592,Case Rate,100% of CMS IPPS Rate,10844.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10844.49,100,MS-DRG,8675.592,Case Rate,100% of CMS IPPS Rate,10844.49,100,MS-DRG,8675.592,Case Rate,100% of CMS IPPS Rate,27701.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11917.57,100,MS-DRG,9534.056,Case Rate,100% of CMS IPPS Rate,15492.84,130,MS-DRG,12394.272,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12275.1,103,MS-DRG,9820.08,Case Rate,103% of CMS IPPS Rate,12275.1,103,MS-DRG,9820.08,Case Rate,103% of CMS IPPS Rate,24475.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11917.57,100,MS-DRG,9534.056,Case Rate,100% of CMS IPPS Rate,12086.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17876.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11917.57,100,MS-DRG,9534.056,Case Rate,100% of CMS IPPS Rate,23339.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11917.57,100,MS-DRG,9534.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30015.57,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,CDM,,,,,Inpatient,,,,,,20837.85,,,,Case Rate,100% of CMS IPPS Rate,15103.19,145,MS-DRG,12082.552,Case Rate,145% of CMS IPPS Rate,10415.99,100,MS-DRG,8332.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10415.99,100,,8332.792,Case Rate,100% of CMS IPPS Rate,21898.83,100,,,Case Rate,100% of CMS IPPS Rate,25028.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28155.88,100,,,Case Rate,100% of CMS IPPS Rate,28155.88,100,,,Case Rate,100% of CMS IPPS Rate,28155.88,100,,,Case Rate,100% CMS IPPS Rate,18810.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9478.15,100,,7582.52,Case Rate,100% of CMS IPPS Rate,9478.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9478.15,100,MS-DRG,7582.52,Case Rate,100% of CMS IPPS Rate,9478.15,100,MS-DRG,7582.52,Case Rate,100% of CMS IPPS Rate,22914.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10415.99,100,MS-DRG,8332.792,Case Rate,100% of CMS IPPS Rate,13540.79,130,MS-DRG,10832.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10728.47,103,MS-DRG,8582.776,Case Rate,103% of CMS IPPS Rate,10728.47,103,MS-DRG,8582.776,Case Rate,103% of CMS IPPS Rate,19111.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10415.99,100,MS-DRG,8332.792,Case Rate,100% of CMS IPPS Rate,11033.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15623.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10415.99,100,MS-DRG,8332.792,Case Rate,100% of CMS IPPS Rate,21306.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10415.99,100,MS-DRG,8332.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28155.88,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,CDM,,,,,Inpatient,,,,,,26817.15,,,,Case Rate,100% of CMS IPPS Rate,19436.95,145,MS-DRG,15549.56,Case Rate,145% of CMS IPPS Rate,13404.79,100,MS-DRG,10723.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13404.79,100,,10723.832,Case Rate,100% of CMS IPPS Rate,27293.89,100,,,Case Rate,100% of CMS IPPS Rate,31194.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35092.44,100,,,Case Rate,100% of CMS IPPS Rate,35092.44,100,,,Case Rate,100% of CMS IPPS Rate,35092.44,100,,,Case Rate,100% CMS IPPS Rate,24208.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12197.77,100,,9758.216,Case Rate,100% of CMS IPPS Rate,12197.77,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12197.77,100,MS-DRG,9758.216,Case Rate,100% of CMS IPPS Rate,12197.77,100,MS-DRG,9758.216,Case Rate,100% of CMS IPPS Rate,29477.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13404.79,100,MS-DRG,10723.832,Case Rate,100% of CMS IPPS Rate,17426.23,130,MS-DRG,13940.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13806.93,103,MS-DRG,11045.544,Case Rate,103% of CMS IPPS Rate,13806.93,103,MS-DRG,11045.544,Case Rate,103% of CMS IPPS Rate,27017.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13404.79,100,MS-DRG,10723.832,Case Rate,100% of CMS IPPS Rate,14199.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20107.19,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13404.79,100,MS-DRG,10723.832,Case Rate,100% of CMS IPPS Rate,27420.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13404.79,100,MS-DRG,10723.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35092.44,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,CDM,,,,,Inpatient,,,,,,23057.33,,,,Case Rate,100% of CMS IPPS Rate,16711.84,145,MS-DRG,13369.472,Case Rate,145% of CMS IPPS Rate,11525.41,100,MS-DRG,9220.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11525.41,100,,9220.328,Case Rate,100% of CMS IPPS Rate,26463.37,100,,,Case Rate,100% of CMS IPPS Rate,30244.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34024.61,100,,,Case Rate,100% of CMS IPPS Rate,34024.61,100,,,Case Rate,100% of CMS IPPS Rate,34024.61,100,,,Case Rate,100% CMS IPPS Rate,20814.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10487.64,100,,8390.112,Case Rate,100% of CMS IPPS Rate,10487.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10487.64,100,MS-DRG,8390.112,Case Rate,100% of CMS IPPS Rate,10487.64,100,MS-DRG,8390.112,Case Rate,100% of CMS IPPS Rate,22241.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11525.41,100,MS-DRG,9220.328,Case Rate,100% of CMS IPPS Rate,14983.03,130,MS-DRG,11986.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11871.17,103,MS-DRG,9496.936,Case Rate,103% of CMS IPPS Rate,11871.17,103,MS-DRG,9496.936,Case Rate,103% of CMS IPPS Rate,23289.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11525.41,100,MS-DRG,9220.328,Case Rate,100% of CMS IPPS Rate,12209,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17288.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11525.41,100,MS-DRG,9220.328,Case Rate,100% of CMS IPPS Rate,23576,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11525.41,100,MS-DRG,9220.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34024.61,
SKIN ULCERS WITH MCC,592,CDM,,,,,Inpatient,,,,,,28617.65,,,,Case Rate,100% of CMS IPPS Rate,20741.93,145,MS-DRG,16593.544,Case Rate,145% of CMS IPPS Rate,14304.78,100,MS-DRG,11443.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14304.78,100,,11443.824,Case Rate,100% of CMS IPPS Rate,27412.54,100,,,Case Rate,100% of CMS IPPS Rate,31329.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35244.98,100,,,Case Rate,100% of CMS IPPS Rate,35244.98,100,,,Case Rate,100% of CMS IPPS Rate,35244.98,100,,,Case Rate,100% CMS IPPS Rate,25833.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13016.71,100,,10413.368,Case Rate,100% of CMS IPPS Rate,13016.71,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13016.71,100,MS-DRG,10413.368,Case Rate,100% of CMS IPPS Rate,13016.71,100,MS-DRG,10413.368,Case Rate,100% of CMS IPPS Rate,18808.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14304.78,100,MS-DRG,11443.824,Case Rate,100% of CMS IPPS Rate,18596.21,130,MS-DRG,14876.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14733.92,103,MS-DRG,11787.136,Case Rate,103% of CMS IPPS Rate,14733.92,103,MS-DRG,11787.136,Case Rate,103% of CMS IPPS Rate,22567.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14304.78,100,MS-DRG,11443.824,Case Rate,100% of CMS IPPS Rate,15153.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21457.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14304.78,100,MS-DRG,11443.824,Case Rate,100% of CMS IPPS Rate,29261.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14304.78,100,MS-DRG,11443.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35244.98,
SKIN ULCERS WITH CC,593,CDM,,,,,Inpatient,,,,,,16565.95,,,,Case Rate,100% of CMS IPPS Rate,12006.91,145,MS-DRG,9605.528,Case Rate,145% of CMS IPPS Rate,8280.63,100,MS-DRG,6624.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8280.63,100,,6624.504,Case Rate,100% of CMS IPPS Rate,16299.81,100,,,Case Rate,100% of CMS IPPS Rate,18629.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20957.08,100,,,Case Rate,100% of CMS IPPS Rate,20957.08,100,,,Case Rate,100% of CMS IPPS Rate,20957.08,100,,,Case Rate,100% CMS IPPS Rate,14954.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7535.11,100,,6028.088,Case Rate,100% of CMS IPPS Rate,7535.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7535.11,100,MS-DRG,6028.088,Case Rate,100% of CMS IPPS Rate,7535.11,100,MS-DRG,6028.088,Case Rate,100% of CMS IPPS Rate,10887.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8280.63,100,MS-DRG,6624.504,Case Rate,100% of CMS IPPS Rate,10764.82,130,MS-DRG,8611.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8529.05,103,MS-DRG,6823.24,Case Rate,103% of CMS IPPS Rate,8529.05,103,MS-DRG,6823.24,Case Rate,103% of CMS IPPS Rate,14571.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8280.63,100,MS-DRG,6624.504,Case Rate,100% of CMS IPPS Rate,8771.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12420.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8280.63,100,MS-DRG,6624.504,Case Rate,100% of CMS IPPS Rate,16938.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8280.63,100,MS-DRG,6624.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20957.08,
SKIN ULCERS WITHOUT CC/MCC,594,CDM,,,,,Inpatient,,,,,,10781.08,,,,Case Rate,100% of CMS IPPS Rate,7814.08,145,MS-DRG,6251.264,Case Rate,145% of CMS IPPS Rate,5389.02,100,MS-DRG,4311.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5389.02,100,,4311.216,Case Rate,100% of CMS IPPS Rate,11314.02,100,,,Case Rate,100% of CMS IPPS Rate,12930.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14546.72,100,,,Case Rate,100% of CMS IPPS Rate,14546.72,100,,,Case Rate,100% of CMS IPPS Rate,14546.72,100,,,Case Rate,100% CMS IPPS Rate,9732.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4903.92,100,,3923.136,Case Rate,100% of CMS IPPS Rate,4903.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4903.92,100,MS-DRG,3923.136,Case Rate,100% of CMS IPPS Rate,4903.92,100,MS-DRG,3923.136,Case Rate,100% of CMS IPPS Rate,7085.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5389.02,100,MS-DRG,4311.216,Case Rate,100% of CMS IPPS Rate,7005.73,130,MS-DRG,5604.584,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5550.69,103,MS-DRG,4440.552,Case Rate,103% of CMS IPPS Rate,5550.69,103,MS-DRG,4440.552,Case Rate,103% of CMS IPPS Rate,9789.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5389.02,100,MS-DRG,4311.216,Case Rate,100% of CMS IPPS Rate,5708.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8083.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5389.02,100,MS-DRG,4311.216,Case Rate,100% of CMS IPPS Rate,11023.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5389.02,100,MS-DRG,4311.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4903.92,14546.72,
MAJOR SKIN DISORDERS WITH MCC,595,CDM,,,,,Inpatient,,,,,,29780.1,,,,Case Rate,100% of CMS IPPS Rate,21584.47,145,MS-DRG,17267.576,Case Rate,145% of CMS IPPS Rate,14885.84,100,MS-DRG,11908.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14885.84,100,,11908.672,Case Rate,100% of CMS IPPS Rate,28196.4,100,,,Case Rate,100% of CMS IPPS Rate,32225.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36252.81,100,,,Case Rate,100% of CMS IPPS Rate,36252.81,100,,,Case Rate,100% of CMS IPPS Rate,36252.81,100,,,Case Rate,100% CMS IPPS Rate,26883,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13545.44,100,,10836.352,Case Rate,100% of CMS IPPS Rate,13545.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13545.44,100,MS-DRG,10836.352,Case Rate,100% of CMS IPPS Rate,13545.44,100,MS-DRG,10836.352,Case Rate,100% of CMS IPPS Rate,19573.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14885.84,100,MS-DRG,11908.672,Case Rate,100% of CMS IPPS Rate,19351.59,130,MS-DRG,15481.272,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15332.42,103,MS-DRG,12265.936,Case Rate,103% of CMS IPPS Rate,15332.42,103,MS-DRG,12265.936,Case Rate,103% of CMS IPPS Rate,27088.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14885.84,100,MS-DRG,11908.672,Case Rate,100% of CMS IPPS Rate,15768.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22328.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14885.84,100,MS-DRG,11908.672,Case Rate,100% of CMS IPPS Rate,30450,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14885.84,100,MS-DRG,11908.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36252.81,
MAJOR SKIN DISORDERS WITHOUT MCC,596,CDM,,,,,Inpatient,,,,,,13815.23,,,,Case Rate,100% of CMS IPPS Rate,10013.22,145,MS-DRG,8010.576,Case Rate,145% of CMS IPPS Rate,6905.67,100,MS-DRG,5524.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6905.67,100,,5524.536,Case Rate,100% of CMS IPPS Rate,14412.14,100,,,Case Rate,100% of CMS IPPS Rate,16471.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18530.05,100,,,Case Rate,100% of CMS IPPS Rate,18530.05,100,,,Case Rate,100% of CMS IPPS Rate,18530.05,100,,,Case Rate,100% CMS IPPS Rate,12471.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6283.97,100,,5027.176,Case Rate,100% of CMS IPPS Rate,6283.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6283.97,100,MS-DRG,5027.176,Case Rate,100% of CMS IPPS Rate,6283.97,100,MS-DRG,5027.176,Case Rate,100% of CMS IPPS Rate,5593.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6905.67,100,MS-DRG,5524.536,Case Rate,100% of CMS IPPS Rate,8977.37,130,MS-DRG,7181.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7112.84,103,MS-DRG,5690.272,Case Rate,103% of CMS IPPS Rate,7112.84,103,MS-DRG,5690.272,Case Rate,103% of CMS IPPS Rate,13811.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6905.67,100,MS-DRG,5524.536,Case Rate,100% of CMS IPPS Rate,7315.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10358.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6905.67,100,MS-DRG,5524.536,Case Rate,100% of CMS IPPS Rate,14126,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6905.67,100,MS-DRG,5524.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5593.14,18530.05,
MALIGNANT BREAST DISORDERS WITH MCC,597,CDM,,,,,Inpatient,,,,,,21914.05,,,,Case Rate,100% of CMS IPPS Rate,15883.18,145,MS-DRG,12706.544,Case Rate,145% of CMS IPPS Rate,10953.92,100,MS-DRG,8763.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10953.92,100,,8763.136,Case Rate,100% of CMS IPPS Rate,23418.57,100,,,Case Rate,100% of CMS IPPS Rate,26765.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% of CMS IPPS Rate,30109.84,100,,,Case Rate,100% CMS IPPS Rate,19782.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9967.64,100,,7974.112,Case Rate,100% of CMS IPPS Rate,9967.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9967.64,100,MS-DRG,7974.112,Case Rate,100% of CMS IPPS Rate,9967.64,100,MS-DRG,7974.112,Case Rate,100% of CMS IPPS Rate,9932.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10953.92,100,MS-DRG,8763.136,Case Rate,100% of CMS IPPS Rate,14240.1,130,MS-DRG,11392.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11282.54,103,MS-DRG,9026.032,Case Rate,103% of CMS IPPS Rate,11282.54,103,MS-DRG,9026.032,Case Rate,103% of CMS IPPS Rate,21302.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10953.92,100,MS-DRG,8763.136,Case Rate,100% of CMS IPPS Rate,11603.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16430.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10953.92,100,MS-DRG,8763.136,Case Rate,100% of CMS IPPS Rate,22407,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10953.92,100,MS-DRG,8763.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30109.84,
MALIGNANT BREAST DISORDERS WITH CC,598,CDM,,,,,Inpatient,,,,,,16413.97,,,,Case Rate,100% of CMS IPPS Rate,11896.76,145,MS-DRG,9517.408,Case Rate,145% of CMS IPPS Rate,8204.66,100,MS-DRG,6563.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8204.66,100,,6563.728,Case Rate,100% of CMS IPPS Rate,14141.52,100,,,Case Rate,100% of CMS IPPS Rate,16162.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18182.11,100,,,Case Rate,100% of CMS IPPS Rate,18182.11,100,,,Case Rate,100% of CMS IPPS Rate,18182.11,100,,,Case Rate,100% CMS IPPS Rate,14817.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7465.99,100,,5972.792,Case Rate,100% of CMS IPPS Rate,7465.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7465.99,100,MS-DRG,5972.792,Case Rate,100% of CMS IPPS Rate,7465.99,100,MS-DRG,5972.792,Case Rate,100% of CMS IPPS Rate,8699.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8204.66,100,MS-DRG,6563.728,Case Rate,100% of CMS IPPS Rate,10666.06,130,MS-DRG,8532.848,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8450.8,103,MS-DRG,6760.64,Case Rate,103% of CMS IPPS Rate,8450.8,103,MS-DRG,6760.64,Case Rate,103% of CMS IPPS Rate,13511.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8204.66,100,MS-DRG,6563.728,Case Rate,100% of CMS IPPS Rate,8691.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12306.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8204.66,100,MS-DRG,6563.728,Case Rate,100% of CMS IPPS Rate,16783.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8204.66,100,MS-DRG,6563.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18182.11,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,CDM,,,,,Inpatient,,,,,,8508.21,,,,Case Rate,100% of CMS IPPS Rate,6676.79,145,MS-DRG,5341.432,Case Rate,145% of CMS IPPS Rate,4604.68,100,MS-DRG,3683.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4604.68,100,,3683.744,Case Rate,100% of CMS IPPS Rate,11396.67,100,,,Case Rate,100% of CMS IPPS Rate,13025.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14652.99,100,,,Case Rate,100% of CMS IPPS Rate,14652.99,100,,,Case Rate,100% of CMS IPPS Rate,14652.99,100,,,Case Rate,100% CMS IPPS Rate,7680.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4190.23,100,,3352.184,Case Rate,100% of CMS IPPS Rate,4190.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4190.23,100,MS-DRG,3352.184,Case Rate,100% of CMS IPPS Rate,4190.23,100,MS-DRG,3352.184,Case Rate,100% of CMS IPPS Rate,6054.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4604.68,100,MS-DRG,3683.744,Case Rate,100% of CMS IPPS Rate,5986.08,130,MS-DRG,4788.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4742.82,103,MS-DRG,3794.256,Case Rate,103% of CMS IPPS Rate,4742.82,103,MS-DRG,3794.256,Case Rate,103% of CMS IPPS Rate,9457.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4604.68,100,MS-DRG,3683.744,Case Rate,100% of CMS IPPS Rate,4505.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6907.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4604.68,100,MS-DRG,3683.744,Case Rate,100% of CMS IPPS Rate,8699.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4604.68,100,MS-DRG,3683.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4190.23,14652.99,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,CDM,,,,,Inpatient,,,,,,14041.15,,,,Case Rate,100% of CMS IPPS Rate,10176.96,145,MS-DRG,8141.568,Case Rate,145% of CMS IPPS Rate,7018.59,100,MS-DRG,5614.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7018.59,100,,5614.872,Case Rate,100% of CMS IPPS Rate,12752.43,100,,,Case Rate,100% of CMS IPPS Rate,14574.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16396.12,100,,,Case Rate,100% of CMS IPPS Rate,16396.12,100,,,Case Rate,100% of CMS IPPS Rate,16396.12,100,,,Case Rate,100% CMS IPPS Rate,12675.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6386.74,100,,5109.392,Case Rate,100% of CMS IPPS Rate,6386.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6386.74,100,MS-DRG,5109.392,Case Rate,100% of CMS IPPS Rate,6386.74,100,MS-DRG,5109.392,Case Rate,100% of CMS IPPS Rate,4634.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7018.59,100,MS-DRG,5614.872,Case Rate,100% of CMS IPPS Rate,9124.17,130,MS-DRG,7299.336,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7229.15,103,MS-DRG,5783.32,Case Rate,103% of CMS IPPS Rate,7229.15,103,MS-DRG,5783.32,Case Rate,103% of CMS IPPS Rate,13169.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7018.59,100,MS-DRG,5614.872,Case Rate,100% of CMS IPPS Rate,7434.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10527.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7018.59,100,MS-DRG,5614.872,Case Rate,100% of CMS IPPS Rate,14357,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7018.59,100,MS-DRG,5614.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4634.06,16396.12,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,CDM,,,,,Inpatient,,,,,,8524.64,,,,Case Rate,100% of CMS IPPS Rate,6286.79,145,MS-DRG,5029.432,Case Rate,145% of CMS IPPS Rate,4335.72,100,MS-DRG,3468.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4335.72,100,,3468.576,Case Rate,100% of CMS IPPS Rate,7991.93,100,,,Case Rate,100% of CMS IPPS Rate,9133.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10275.43,100,,,Case Rate,100% of CMS IPPS Rate,10275.43,100,,,Case Rate,100% of CMS IPPS Rate,10275.43,100,,,Case Rate,100% CMS IPPS Rate,7695.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3945.48,100,,3156.384,Case Rate,100% of CMS IPPS Rate,3945.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3945.48,100,MS-DRG,3156.384,Case Rate,100% of CMS IPPS Rate,3945.48,100,MS-DRG,3156.384,Case Rate,100% of CMS IPPS Rate,3830.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4335.72,100,MS-DRG,3468.576,Case Rate,100% of CMS IPPS Rate,5636.44,130,MS-DRG,4509.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4465.79,103,MS-DRG,3572.632,Case Rate,103% of CMS IPPS Rate,4465.79,103,MS-DRG,3572.632,Case Rate,103% of CMS IPPS Rate,8904.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4335.72,100,MS-DRG,3468.576,Case Rate,100% of CMS IPPS Rate,4513.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6503.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4335.72,100,MS-DRG,3468.576,Case Rate,100% of CMS IPPS Rate,8716.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4335.72,100,MS-DRG,3468.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3830.64,10275.43,
CELLULITIS WITH MCC,602,CDM,,,,,Inpatient,,,,,,20366.85,,,,Case Rate,100% of CMS IPPS Rate,14761.8,145,MS-DRG,11809.44,Case Rate,145% of CMS IPPS Rate,10180.55,100,MS-DRG,8144.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10180.55,100,,8144.44,Case Rate,100% of CMS IPPS Rate,19585.91,100,,,Case Rate,100% of CMS IPPS Rate,22384.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25182.09,100,,,Case Rate,100% of CMS IPPS Rate,25182.09,100,,,Case Rate,100% of CMS IPPS Rate,25182.09,100,,,Case Rate,100% CMS IPPS Rate,18385.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9263.91,100,,7411.128,Case Rate,100% of CMS IPPS Rate,9263.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9263.91,100,MS-DRG,7411.128,Case Rate,100% of CMS IPPS Rate,9263.91,100,MS-DRG,7411.128,Case Rate,100% of CMS IPPS Rate,8460.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10180.55,100,MS-DRG,8144.44,Case Rate,100% of CMS IPPS Rate,13234.72,130,MS-DRG,10587.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10485.97,103,MS-DRG,8388.776,Case Rate,103% of CMS IPPS Rate,10485.97,103,MS-DRG,8388.776,Case Rate,103% of CMS IPPS Rate,18231.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10180.55,100,MS-DRG,8144.44,Case Rate,100% of CMS IPPS Rate,10784.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15270.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10180.55,100,MS-DRG,8144.44,Case Rate,100% of CMS IPPS Rate,20825,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10180.55,100,MS-DRG,8144.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25182.09,
CELLULITIS WITHOUT MCC,603,CDM,,,,,Inpatient,,,,,,12113.31,,,,Case Rate,100% of CMS IPPS Rate,8779.68,145,MS-DRG,7023.744,Case Rate,145% of CMS IPPS Rate,6054.95,100,MS-DRG,4843.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6054.95,100,,4843.96,Case Rate,100% of CMS IPPS Rate,11741.94,100,,,Case Rate,100% of CMS IPPS Rate,13419.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15096.91,100,,,Case Rate,100% of CMS IPPS Rate,15096.91,100,,,Case Rate,100% of CMS IPPS Rate,15096.91,100,,,Case Rate,100% CMS IPPS Rate,10934.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5509.88,100,,4407.904,Case Rate,100% of CMS IPPS Rate,5509.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5509.88,100,MS-DRG,4407.904,Case Rate,100% of CMS IPPS Rate,5509.88,100,MS-DRG,4407.904,Case Rate,100% of CMS IPPS Rate,5175.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6054.95,100,MS-DRG,4843.96,Case Rate,100% of CMS IPPS Rate,7871.44,130,MS-DRG,6297.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6236.6,103,MS-DRG,4989.28,Case Rate,103% of CMS IPPS Rate,6236.6,103,MS-DRG,4989.28,Case Rate,103% of CMS IPPS Rate,11154.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6054.95,100,MS-DRG,4843.96,Case Rate,100% of CMS IPPS Rate,6414.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9082.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6054.95,100,MS-DRG,4843.96,Case Rate,100% of CMS IPPS Rate,12385.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6054.95,100,MS-DRG,4843.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5175.62,15096.91,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,CDM,,,,,Inpatient,,,,,,20622.89,,,,Case Rate,100% of CMS IPPS Rate,14947.38,145,MS-DRG,11957.904,Case Rate,145% of CMS IPPS Rate,10308.54,100,MS-DRG,8246.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10308.54,100,,8246.832,Case Rate,100% of CMS IPPS Rate,19805.87,100,,,Case Rate,100% of CMS IPPS Rate,22636.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25464.9,100,,,Case Rate,100% of CMS IPPS Rate,25464.9,100,,,Case Rate,100% of CMS IPPS Rate,25464.9,100,,,Case Rate,100% CMS IPPS Rate,18616.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9380.37,100,,7504.296,Case Rate,100% of CMS IPPS Rate,9380.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9380.37,100,MS-DRG,7504.296,Case Rate,100% of CMS IPPS Rate,9380.37,100,MS-DRG,7504.296,Case Rate,100% of CMS IPPS Rate,10652.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10308.54,100,MS-DRG,8246.832,Case Rate,100% of CMS IPPS Rate,13401.1,130,MS-DRG,10720.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10617.8,103,MS-DRG,8494.24,Case Rate,103% of CMS IPPS Rate,10617.8,103,MS-DRG,8494.24,Case Rate,103% of CMS IPPS Rate,19091.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10308.54,100,MS-DRG,8246.832,Case Rate,100% of CMS IPPS Rate,10919.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15462.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10308.54,100,MS-DRG,8246.832,Case Rate,100% of CMS IPPS Rate,21086.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10308.54,100,MS-DRG,8246.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25464.9,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,CDM,,,,,Inpatient,,,,,,12443.29,,,,Case Rate,100% of CMS IPPS Rate,9018.83,145,MS-DRG,7215.064,Case Rate,145% of CMS IPPS Rate,6219.88,100,MS-DRG,4975.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6219.88,100,,4975.904,Case Rate,100% of CMS IPPS Rate,12313.84,100,,,Case Rate,100% of CMS IPPS Rate,14073.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15832.22,100,,,Case Rate,100% of CMS IPPS Rate,15832.22,100,,,Case Rate,100% of CMS IPPS Rate,15832.22,100,,,Case Rate,100% CMS IPPS Rate,11232.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5659.96,100,,4527.968,Case Rate,100% of CMS IPPS Rate,5659.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5659.96,100,MS-DRG,4527.968,Case Rate,100% of CMS IPPS Rate,5659.96,100,MS-DRG,4527.968,Case Rate,100% of CMS IPPS Rate,6324.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6219.88,100,MS-DRG,4975.904,Case Rate,100% of CMS IPPS Rate,8085.84,130,MS-DRG,6468.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6406.48,103,MS-DRG,5125.184,Case Rate,103% of CMS IPPS Rate,6406.48,103,MS-DRG,5125.184,Case Rate,103% of CMS IPPS Rate,11516.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6219.88,100,MS-DRG,4975.904,Case Rate,100% of CMS IPPS Rate,6588.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9329.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6219.88,100,MS-DRG,4975.904,Case Rate,100% of CMS IPPS Rate,12723.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6219.88,100,MS-DRG,4975.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5659.96,15832.22,
MINOR SKIN DISORDERS WITH MCC,606,CDM,,,,,Inpatient,,,,,,21712.77,,,,Case Rate,100% of CMS IPPS Rate,15737.31,145,MS-DRG,12589.848,Case Rate,145% of CMS IPPS Rate,10853.32,100,MS-DRG,8682.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10853.32,100,,8682.656,Case Rate,100% of CMS IPPS Rate,21466.91,100,,,Case Rate,100% of CMS IPPS Rate,24534.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27600.54,100,,,Case Rate,100% of CMS IPPS Rate,27600.54,100,,,Case Rate,100% of CMS IPPS Rate,27600.54,100,,,Case Rate,100% CMS IPPS Rate,19600.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9876.1,100,,7900.88,Case Rate,100% of CMS IPPS Rate,9876.1,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9876.1,100,MS-DRG,7900.88,Case Rate,100% of CMS IPPS Rate,9876.1,100,MS-DRG,7900.88,Case Rate,100% of CMS IPPS Rate,6363.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10853.32,100,MS-DRG,8682.656,Case Rate,100% of CMS IPPS Rate,14109.32,130,MS-DRG,11287.456,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11178.92,103,MS-DRG,8943.136,Case Rate,103% of CMS IPPS Rate,11178.92,103,MS-DRG,8943.136,Case Rate,103% of CMS IPPS Rate,19416.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10853.32,100,MS-DRG,8682.656,Case Rate,100% of CMS IPPS Rate,11497.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16279.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10853.32,100,MS-DRG,8682.656,Case Rate,100% of CMS IPPS Rate,22201.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10853.32,100,MS-DRG,8682.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27600.54,
MINOR SKIN DISORDERS WITHOUT MCC,607,CDM,,,,,Inpatient,,,,,,12233.8,,,,Case Rate,100% of CMS IPPS Rate,8867,145,MS-DRG,7093.6,Case Rate,145% of CMS IPPS Rate,6115.17,100,MS-DRG,4892.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6115.17,100,,4892.136,Case Rate,100% of CMS IPPS Rate,11520.65,100,,,Case Rate,100% of CMS IPPS Rate,13166.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14812.39,100,,,Case Rate,100% of CMS IPPS Rate,14812.39,100,,,Case Rate,100% of CMS IPPS Rate,14812.39,100,,,Case Rate,100% CMS IPPS Rate,11043.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5564.68,100,,4451.744,Case Rate,100% of CMS IPPS Rate,5564.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5564.68,100,MS-DRG,4451.744,Case Rate,100% of CMS IPPS Rate,5564.68,100,MS-DRG,4451.744,Case Rate,100% of CMS IPPS Rate,4364.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6115.17,100,MS-DRG,4892.136,Case Rate,100% of CMS IPPS Rate,7949.72,130,MS-DRG,6359.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6298.63,103,MS-DRG,5038.904,Case Rate,103% of CMS IPPS Rate,6298.63,103,MS-DRG,5038.904,Case Rate,103% of CMS IPPS Rate,10729.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6115.17,100,MS-DRG,4892.136,Case Rate,100% of CMS IPPS Rate,6477.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9172.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6115.17,100,MS-DRG,4892.136,Case Rate,100% of CMS IPPS Rate,12509,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6115.17,100,MS-DRG,4892.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4364.09,14812.39,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,CDM,,,,,Inpatient,,,,,,30839.86,,,,Case Rate,100% of CMS IPPS Rate,22352.58,145,MS-DRG,17882.064,Case Rate,145% of CMS IPPS Rate,15415.57,100,MS-DRG,12332.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15415.57,100,,12332.456,Case Rate,100% of CMS IPPS Rate,30381.35,100,,,Case Rate,100% of CMS IPPS Rate,34722.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39062.06,100,,,Case Rate,100% of CMS IPPS Rate,39062.06,100,,,Case Rate,100% of CMS IPPS Rate,39062.06,100,,,Case Rate,100% CMS IPPS Rate,27839.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14027.46,100,,11221.968,Case Rate,100% of CMS IPPS Rate,14027.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14027.46,100,MS-DRG,11221.968,Case Rate,100% of CMS IPPS Rate,14027.46,100,MS-DRG,11221.968,Case Rate,100% of CMS IPPS Rate,20326.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15415.57,100,MS-DRG,12332.456,Case Rate,100% of CMS IPPS Rate,20040.24,130,MS-DRG,16032.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15878.04,103,MS-DRG,12702.432,Case Rate,103% of CMS IPPS Rate,15878.04,103,MS-DRG,12702.432,Case Rate,103% of CMS IPPS Rate,29726.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15415.57,100,MS-DRG,12332.456,Case Rate,100% of CMS IPPS Rate,16329.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23123.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15415.57,100,MS-DRG,12332.456,Case Rate,100% of CMS IPPS Rate,31533.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15415.57,100,MS-DRG,12332.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39062.06,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,CDM,,,,,Inpatient,,,,,,20142.3,,,,Case Rate,100% of CMS IPPS Rate,14599.05,145,MS-DRG,11679.24,Case Rate,145% of CMS IPPS Rate,10068.31,100,MS-DRG,8054.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10068.31,100,,8054.648,Case Rate,100% of CMS IPPS Rate,19103.32,100,,,Case Rate,100% of CMS IPPS Rate,21833.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24561.62,100,,,Case Rate,100% of CMS IPPS Rate,24561.62,100,,,Case Rate,100% of CMS IPPS Rate,24561.62,100,,,Case Rate,100% CMS IPPS Rate,18182.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9161.78,100,,7329.424,Case Rate,100% of CMS IPPS Rate,9161.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9161.78,100,MS-DRG,7329.424,Case Rate,100% of CMS IPPS Rate,9161.78,100,MS-DRG,7329.424,Case Rate,100% of CMS IPPS Rate,14326.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10068.31,100,MS-DRG,8054.648,Case Rate,100% of CMS IPPS Rate,13088.8,130,MS-DRG,10471.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10370.36,103,MS-DRG,8296.288,Case Rate,103% of CMS IPPS Rate,10370.36,103,MS-DRG,8296.288,Case Rate,103% of CMS IPPS Rate,18668.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10068.31,100,MS-DRG,8054.648,Case Rate,100% of CMS IPPS Rate,10665.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15102.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10068.31,100,MS-DRG,8054.648,Case Rate,100% of CMS IPPS Rate,20595.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10068.31,100,MS-DRG,8054.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24561.62,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,CDM,,,,,Inpatient,,,,,,54188.83,,,,Case Rate,100% of CMS IPPS Rate,39275.79,145,MS-DRG,31420.632,Case Rate,145% of CMS IPPS Rate,27086.75,100,MS-DRG,21669.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27086.75,100,,21669.4,Case Rate,100% of CMS IPPS Rate,51524.32,100,,,Case Rate,100% of CMS IPPS Rate,58887.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,66246.1,100,,,Case Rate,100% of CMS IPPS Rate,66246.1,100,,,Case Rate,100% of CMS IPPS Rate,66246.1,100,,,Case Rate,100% CMS IPPS Rate,48917.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24647.51,100,,19718.008,Case Rate,100% of CMS IPPS Rate,24647.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24647.51,100,MS-DRG,19718.008,Case Rate,100% of CMS IPPS Rate,24647.51,100,MS-DRG,19718.008,Case Rate,100% of CMS IPPS Rate,42702.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27086.75,100,MS-DRG,21669.4,Case Rate,100% of CMS IPPS Rate,35212.78,130,MS-DRG,28170.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27899.35,103,MS-DRG,22319.48,Case Rate,103% of CMS IPPS Rate,27899.35,103,MS-DRG,22319.48,Case Rate,103% of CMS IPPS Rate,47620.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27086.75,100,MS-DRG,21669.4,Case Rate,100% of CMS IPPS Rate,28693.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,40630.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27086.75,100,MS-DRG,21669.4,Case Rate,100% of CMS IPPS Rate,55407.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27086.75,100,MS-DRG,21669.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,66246.1,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,CDM,,,,,Inpatient,,,,,,27171.77,,,,Case Rate,100% of CMS IPPS Rate,19693.97,145,MS-DRG,15755.176,Case Rate,145% of CMS IPPS Rate,13582.05,100,MS-DRG,10865.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13582.05,100,,10865.64,Case Rate,100% of CMS IPPS Rate,25750.16,100,,,Case Rate,100% of CMS IPPS Rate,29429.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33107.62,100,,,Case Rate,100% of CMS IPPS Rate,33107.62,100,,,Case Rate,100% of CMS IPPS Rate,33107.62,100,,,Case Rate,100% CMS IPPS Rate,24528.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12359.07,100,,9887.256,Case Rate,100% of CMS IPPS Rate,12359.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12359.07,100,MS-DRG,9887.256,Case Rate,100% of CMS IPPS Rate,12359.07,100,MS-DRG,9887.256,Case Rate,100% of CMS IPPS Rate,14417.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13582.05,100,MS-DRG,10865.64,Case Rate,100% of CMS IPPS Rate,17656.67,130,MS-DRG,14125.336,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13989.51,103,MS-DRG,11191.608,Case Rate,103% of CMS IPPS Rate,13989.51,103,MS-DRG,11191.608,Case Rate,103% of CMS IPPS Rate,24591.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13582.05,100,MS-DRG,10865.64,Case Rate,100% of CMS IPPS Rate,14387.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20373.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13582.05,100,MS-DRG,10865.64,Case Rate,100% of CMS IPPS Rate,27783,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13582.05,100,MS-DRG,10865.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33107.62,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,CDM,,,,,Inpatient,,,,,,15903.26,,,,Case Rate,100% of CMS IPPS Rate,11526.6,145,MS-DRG,9221.28,Case Rate,145% of CMS IPPS Rate,7949.38,100,MS-DRG,6359.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7949.38,100,,6359.504,Case Rate,100% of CMS IPPS Rate,16598.43,100,,,Case Rate,100% of CMS IPPS Rate,18970.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21341.01,100,,,Case Rate,100% of CMS IPPS Rate,21341.01,100,,,Case Rate,100% of CMS IPPS Rate,21341.01,100,,,Case Rate,100% CMS IPPS Rate,14356.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7233.69,100,,5786.952,Case Rate,100% of CMS IPPS Rate,7233.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7233.69,100,MS-DRG,5786.952,Case Rate,100% of CMS IPPS Rate,7233.69,100,MS-DRG,5786.952,Case Rate,100% of CMS IPPS Rate,10452.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7949.38,100,MS-DRG,6359.504,Case Rate,100% of CMS IPPS Rate,10334.19,130,MS-DRG,8267.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8187.86,103,MS-DRG,6550.288,Case Rate,103% of CMS IPPS Rate,8187.86,103,MS-DRG,6550.288,Case Rate,103% of CMS IPPS Rate,14837.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7949.38,100,MS-DRG,6359.504,Case Rate,100% of CMS IPPS Rate,8420.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11924.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7949.38,100,MS-DRG,6359.504,Case Rate,100% of CMS IPPS Rate,16261,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7949.38,100,MS-DRG,6359.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21341.01,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,CDM,,,,,Inpatient,,,,,,35441.74,,,,Case Rate,100% of CMS IPPS Rate,25826.94,145,MS-DRG,20661.552,Case Rate,145% of CMS IPPS Rate,17811.68,100,MS-DRG,14249.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17811.68,100,,14249.344,Case Rate,100% of CMS IPPS Rate,36346.97,100,,,Case Rate,100% of CMS IPPS Rate,41540.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46732.21,100,,,Case Rate,100% of CMS IPPS Rate,46732.21,100,,,Case Rate,100% of CMS IPPS Rate,46732.21,100,,,Case Rate,100% CMS IPPS Rate,31993.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16207.76,100,,12966.208,Case Rate,100% of CMS IPPS Rate,16207.76,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16207.76,100,MS-DRG,12966.208,Case Rate,100% of CMS IPPS Rate,16207.76,100,MS-DRG,12966.208,Case Rate,100% of CMS IPPS Rate,28906.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17811.68,100,MS-DRG,14249.344,Case Rate,100% of CMS IPPS Rate,23155.18,130,MS-DRG,18524.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18346.03,103,MS-DRG,14676.824,Case Rate,103% of CMS IPPS Rate,18346.03,103,MS-DRG,14676.824,Case Rate,103% of CMS IPPS Rate,36580.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17811.68,100,MS-DRG,14249.344,Case Rate,100% of CMS IPPS Rate,18766.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26717.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17811.68,100,MS-DRG,14249.344,Case Rate,100% of CMS IPPS Rate,36239,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17811.68,100,MS-DRG,14249.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46732.21,
O.R. PROCEDURES FOR OBESITY WITH CC,620,CDM,,,,,Inpatient,,,,,,22211.16,,,,Case Rate,100% of CMS IPPS Rate,16098.54,145,MS-DRG,12878.832,Case Rate,145% of CMS IPPS Rate,11102.44,100,MS-DRG,8881.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11102.44,100,,8881.952,Case Rate,100% of CMS IPPS Rate,21289.61,100,,,Case Rate,100% of CMS IPPS Rate,24331.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27372.58,100,,,Case Rate,100% of CMS IPPS Rate,27372.58,100,,,Case Rate,100% of CMS IPPS Rate,27372.58,100,,,Case Rate,100% CMS IPPS Rate,20050.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10102.79,100,,8082.232,Case Rate,100% of CMS IPPS Rate,10102.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10102.79,100,MS-DRG,8082.232,Case Rate,100% of CMS IPPS Rate,10102.79,100,MS-DRG,8082.232,Case Rate,100% of CMS IPPS Rate,15535.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11102.44,100,MS-DRG,8881.952,Case Rate,100% of CMS IPPS Rate,14433.17,130,MS-DRG,11546.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11435.51,103,MS-DRG,9148.408,Case Rate,103% of CMS IPPS Rate,11435.51,103,MS-DRG,9148.408,Case Rate,103% of CMS IPPS Rate,21322.84,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11102.44,100,MS-DRG,8881.952,Case Rate,100% of CMS IPPS Rate,11760.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16653.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11102.44,100,MS-DRG,8881.952,Case Rate,100% of CMS IPPS Rate,22710.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11102.44,100,MS-DRG,8881.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27372.58,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,CDM,,,,,Inpatient,,,,,,20774.87,,,,Case Rate,100% of CMS IPPS Rate,15057.53,145,MS-DRG,12046.024,Case Rate,145% of CMS IPPS Rate,10384.5,100,MS-DRG,8307.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10384.5,100,,8307.6,Case Rate,100% of CMS IPPS Rate,19487.26,100,,,Case Rate,100% of CMS IPPS Rate,22271.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25055.25,100,,,Case Rate,100% of CMS IPPS Rate,25055.25,100,,,Case Rate,100% of CMS IPPS Rate,25055.25,100,,,Case Rate,100% CMS IPPS Rate,18753.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9449.49,100,,7559.592,Case Rate,100% of CMS IPPS Rate,9449.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9449.49,100,MS-DRG,7559.592,Case Rate,100% of CMS IPPS Rate,9449.49,100,MS-DRG,7559.592,Case Rate,100% of CMS IPPS Rate,14370.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10384.5,100,MS-DRG,8307.6,Case Rate,100% of CMS IPPS Rate,13499.85,130,MS-DRG,10799.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10696.04,103,MS-DRG,8556.832,Case Rate,103% of CMS IPPS Rate,10696.04,103,MS-DRG,8556.832,Case Rate,103% of CMS IPPS Rate,19670.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10384.5,100,MS-DRG,8307.6,Case Rate,100% of CMS IPPS Rate,11000.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15576.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10384.5,100,MS-DRG,8307.6,Case Rate,100% of CMS IPPS Rate,21242.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10384.5,100,MS-DRG,8307.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25055.25,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,CDM,,,,,Inpatient,,,,,,52380.12,,,,Case Rate,100% of CMS IPPS Rate,37964.86,145,MS-DRG,30371.888,Case Rate,145% of CMS IPPS Rate,26182.66,100,MS-DRG,20946.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26182.66,100,,20946.128,Case Rate,100% of CMS IPPS Rate,49884.6,100,,,Case Rate,100% of CMS IPPS Rate,57013.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,64137.88,100,,,Case Rate,100% of CMS IPPS Rate,64137.88,100,,,Case Rate,100% of CMS IPPS Rate,64137.88,100,,,Case Rate,100% CMS IPPS Rate,47284.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23824.84,100,,19059.872,Case Rate,100% of CMS IPPS Rate,23824.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23824.84,100,MS-DRG,19059.872,Case Rate,100% of CMS IPPS Rate,23824.84,100,MS-DRG,19059.872,Case Rate,100% of CMS IPPS Rate,34426.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26182.66,100,MS-DRG,20946.128,Case Rate,100% of CMS IPPS Rate,34037.46,130,MS-DRG,27229.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26968.14,103,MS-DRG,21574.512,Case Rate,103% of CMS IPPS Rate,26968.14,103,MS-DRG,21574.512,Case Rate,103% of CMS IPPS Rate,45806.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26182.66,100,MS-DRG,20946.128,Case Rate,100% of CMS IPPS Rate,27735.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,39273.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26182.66,100,MS-DRG,20946.128,Case Rate,100% of CMS IPPS Rate,53558.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26182.66,100,MS-DRG,20946.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,64137.88,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,CDM,,,,,Inpatient,,,,,,25486.29,,,,Case Rate,100% of CMS IPPS Rate,18472.33,145,MS-DRG,14777.864,Case Rate,145% of CMS IPPS Rate,12739.54,100,MS-DRG,10191.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12739.54,100,,10191.632,Case Rate,100% of CMS IPPS Rate,25499.54,100,,,Case Rate,100% of CMS IPPS Rate,29143.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32785.39,100,,,Case Rate,100% of CMS IPPS Rate,32785.39,100,,,Case Rate,100% of CMS IPPS Rate,32785.39,100,,,Case Rate,100% CMS IPPS Rate,23006.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11592.45,100,,9273.96,Case Rate,100% of CMS IPPS Rate,11592.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11592.45,100,MS-DRG,9273.96,Case Rate,100% of CMS IPPS Rate,11592.45,100,MS-DRG,9273.96,Case Rate,100% of CMS IPPS Rate,15758.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12739.54,100,MS-DRG,10191.632,Case Rate,100% of CMS IPPS Rate,16561.4,130,MS-DRG,13249.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13121.73,103,MS-DRG,10497.384,Case Rate,103% of CMS IPPS Rate,13121.73,103,MS-DRG,10497.384,Case Rate,103% of CMS IPPS Rate,23840.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12739.54,100,MS-DRG,10191.632,Case Rate,100% of CMS IPPS Rate,13495.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19109.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12739.54,100,MS-DRG,10191.632,Case Rate,100% of CMS IPPS Rate,26059.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12739.54,100,MS-DRG,10191.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32785.39,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,CDM,,,,,Inpatient,,,,,,15259.73,,,,Case Rate,100% of CMS IPPS Rate,11060.18,145,MS-DRG,8848.144,Case Rate,145% of CMS IPPS Rate,7627.71,100,MS-DRG,6102.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7627.71,100,,6102.168,Case Rate,100% of CMS IPPS Rate,13276.34,100,,,Case Rate,100% of CMS IPPS Rate,15173.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17069.73,100,,,Case Rate,100% of CMS IPPS Rate,17069.73,100,,,Case Rate,100% of CMS IPPS Rate,17069.73,100,,,Case Rate,100% CMS IPPS Rate,13775.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6940.99,100,,5552.792,Case Rate,100% of CMS IPPS Rate,6940.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6940.99,100,MS-DRG,5552.792,Case Rate,100% of CMS IPPS Rate,6940.99,100,MS-DRG,5552.792,Case Rate,100% of CMS IPPS Rate,10029.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7627.71,100,MS-DRG,6102.168,Case Rate,100% of CMS IPPS Rate,9916.02,130,MS-DRG,7932.816,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7856.54,103,MS-DRG,6285.232,Case Rate,103% of CMS IPPS Rate,7856.54,103,MS-DRG,6285.232,Case Rate,103% of CMS IPPS Rate,12510.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7627.71,100,MS-DRG,6102.168,Case Rate,100% of CMS IPPS Rate,8080.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11441.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7627.71,100,MS-DRG,6102.168,Case Rate,100% of CMS IPPS Rate,15603,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7627.71,100,MS-DRG,6102.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17069.73,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,CDM,,,,,Inpatient,,,,,,39997.07,,,,Case Rate,100% of CMS IPPS Rate,28989.68,145,MS-DRG,23191.744,Case Rate,145% of CMS IPPS Rate,19992.88,100,MS-DRG,15994.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19992.88,100,,15994.304,Case Rate,100% of CMS IPPS Rate,38221.31,100,,,Case Rate,100% of CMS IPPS Rate,43683.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49142.09,100,,,Case Rate,100% of CMS IPPS Rate,49142.09,100,,,Case Rate,100% of CMS IPPS Rate,49142.09,100,,,Case Rate,100% CMS IPPS Rate,36106.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18192.53,100,,14554.024,Case Rate,100% of CMS IPPS Rate,18192.53,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18192.53,100,MS-DRG,14554.024,Case Rate,100% of CMS IPPS Rate,18192.53,100,MS-DRG,14554.024,Case Rate,100% of CMS IPPS Rate,19362.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19992.88,100,MS-DRG,15994.304,Case Rate,100% of CMS IPPS Rate,25990.74,130,MS-DRG,20792.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20592.67,103,MS-DRG,16474.136,Case Rate,103% of CMS IPPS Rate,20592.67,103,MS-DRG,16474.136,Case Rate,103% of CMS IPPS Rate,36396.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19992.88,100,MS-DRG,15994.304,Case Rate,100% of CMS IPPS Rate,21178.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29989.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19992.88,100,MS-DRG,15994.304,Case Rate,100% of CMS IPPS Rate,40896.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19992.88,100,MS-DRG,15994.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49142.09,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,CDM,,,,,Inpatient,,,,,,20427.09,,,,Case Rate,100% of CMS IPPS Rate,14805.46,145,MS-DRG,11844.368,Case Rate,145% of CMS IPPS Rate,10210.66,100,MS-DRG,8168.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10210.66,100,,8168.528,Case Rate,100% of CMS IPPS Rate,20120.48,100,,,Case Rate,100% of CMS IPPS Rate,22995.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25869.4,100,,,Case Rate,100% of CMS IPPS Rate,25869.4,100,,,Case Rate,100% of CMS IPPS Rate,25869.4,100,,,Case Rate,100% CMS IPPS Rate,18439.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9291.32,100,,7433.056,Case Rate,100% of CMS IPPS Rate,9291.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9291.32,100,MS-DRG,7433.056,Case Rate,100% of CMS IPPS Rate,9291.32,100,MS-DRG,7433.056,Case Rate,100% of CMS IPPS Rate,14536.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10210.66,100,MS-DRG,8168.528,Case Rate,100% of CMS IPPS Rate,13273.86,130,MS-DRG,10619.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10516.98,103,MS-DRG,8413.584,Case Rate,103% of CMS IPPS Rate,10516.98,103,MS-DRG,8413.584,Case Rate,103% of CMS IPPS Rate,20482.88,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10210.66,100,MS-DRG,8168.528,Case Rate,100% of CMS IPPS Rate,10816.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15315.99,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10210.66,100,MS-DRG,8168.528,Case Rate,100% of CMS IPPS Rate,20886.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10210.66,100,MS-DRG,8168.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25869.4,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,CDM,,,,,Inpatient,,,,,,16923.31,,,,Case Rate,100% of CMS IPPS Rate,12265.93,145,MS-DRG,9812.744,Case Rate,145% of CMS IPPS Rate,8459.26,100,MS-DRG,6767.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8459.26,100,,6767.408,Case Rate,100% of CMS IPPS Rate,16889.04,100,,,Case Rate,100% of CMS IPPS Rate,19302.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21714.67,100,,,Case Rate,100% of CMS IPPS Rate,21714.67,100,,,Case Rate,100% of CMS IPPS Rate,21714.67,100,,,Case Rate,100% CMS IPPS Rate,15276.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7697.65,100,,6158.12,Case Rate,100% of CMS IPPS Rate,7697.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7697.65,100,MS-DRG,6158.12,Case Rate,100% of CMS IPPS Rate,7697.65,100,MS-DRG,6158.12,Case Rate,100% of CMS IPPS Rate,12656.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8459.26,100,MS-DRG,6767.408,Case Rate,100% of CMS IPPS Rate,10997.04,130,MS-DRG,8797.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8713.04,103,MS-DRG,6970.432,Case Rate,103% of CMS IPPS Rate,8713.04,103,MS-DRG,6970.432,Case Rate,103% of CMS IPPS Rate,16140.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8459.26,100,MS-DRG,6767.408,Case Rate,100% of CMS IPPS Rate,8961,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12688.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8459.26,100,MS-DRG,6767.408,Case Rate,100% of CMS IPPS Rate,17304,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8459.26,100,MS-DRG,6767.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21714.67,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,CDM,,,,,Inpatient,,,,,,54966.53,,,,Case Rate,100% of CMS IPPS Rate,39839.48,145,MS-DRG,31871.584,Case Rate,145% of CMS IPPS Rate,27475.5,100,MS-DRG,21980.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27475.5,100,,21980.4,Case Rate,100% of CMS IPPS Rate,52600.13,100,,,Case Rate,100% of CMS IPPS Rate,60116.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67629.3,100,,,Case Rate,100% of CMS IPPS Rate,67629.3,100,,,Case Rate,100% of CMS IPPS Rate,67629.3,100,,,Case Rate,100% CMS IPPS Rate,49619.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25001.24,100,,20000.992,Case Rate,100% of CMS IPPS Rate,25001.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25001.24,100,MS-DRG,20000.992,Case Rate,100% of CMS IPPS Rate,25001.24,100,MS-DRG,20000.992,Case Rate,100% of CMS IPPS Rate,36126.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27475.5,100,MS-DRG,21980.4,Case Rate,100% of CMS IPPS Rate,35718.15,130,MS-DRG,28574.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28299.77,103,MS-DRG,22639.816,Case Rate,103% of CMS IPPS Rate,28299.77,103,MS-DRG,22639.816,Case Rate,103% of CMS IPPS Rate,46106.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27475.5,100,MS-DRG,21980.4,Case Rate,100% of CMS IPPS Rate,29105.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,41213.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27475.5,100,MS-DRG,21980.4,Case Rate,100% of CMS IPPS Rate,56203,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27475.5,100,MS-DRG,21980.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,67629.3,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,CDM,,,,,Inpatient,,,,,,30982.26,,,,Case Rate,100% of CMS IPPS Rate,22455.79,145,MS-DRG,17964.632,Case Rate,145% of CMS IPPS Rate,15486.75,100,MS-DRG,12389.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15486.75,100,,12389.4,Case Rate,100% of CMS IPPS Rate,29982.75,100,,,Case Rate,100% of CMS IPPS Rate,34267.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38549.57,100,,,Case Rate,100% of CMS IPPS Rate,38549.57,100,,,Case Rate,100% of CMS IPPS Rate,38549.57,100,,,Case Rate,100% CMS IPPS Rate,27968.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14092.22,100,,11273.776,Case Rate,100% of CMS IPPS Rate,14092.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14092.22,100,MS-DRG,11273.776,Case Rate,100% of CMS IPPS Rate,14092.22,100,MS-DRG,11273.776,Case Rate,100% of CMS IPPS Rate,16114.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15486.75,100,MS-DRG,12389.4,Case Rate,100% of CMS IPPS Rate,20132.78,130,MS-DRG,16106.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15951.35,103,MS-DRG,12761.08,Case Rate,103% of CMS IPPS Rate,15951.35,103,MS-DRG,12761.08,Case Rate,103% of CMS IPPS Rate,28384.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15486.75,100,MS-DRG,12389.4,Case Rate,100% of CMS IPPS Rate,16405.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23230.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15486.75,100,MS-DRG,12389.4,Case Rate,100% of CMS IPPS Rate,31679.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15486.75,100,MS-DRG,12389.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38549.57,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,CDM,,,,,Inpatient,,,,,,19118.14,,,,Case Rate,100% of CMS IPPS Rate,13856.74,145,MS-DRG,11085.392,Case Rate,145% of CMS IPPS Rate,9556.37,100,MS-DRG,7645.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9556.37,100,,7645.096,Case Rate,100% of CMS IPPS Rate,18680.73,100,,,Case Rate,100% of CMS IPPS Rate,21350.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24018.28,100,,,Case Rate,100% of CMS IPPS Rate,24018.28,100,,,Case Rate,100% of CMS IPPS Rate,24018.28,100,,,Case Rate,100% CMS IPPS Rate,17258.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8695.95,100,,6956.76,Case Rate,100% of CMS IPPS Rate,8695.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8695.95,100,MS-DRG,6956.76,Case Rate,100% of CMS IPPS Rate,8695.95,100,MS-DRG,6956.76,Case Rate,100% of CMS IPPS Rate,12565.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9556.37,100,MS-DRG,7645.096,Case Rate,100% of CMS IPPS Rate,12423.28,130,MS-DRG,9938.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9843.06,103,MS-DRG,7874.448,Case Rate,103% of CMS IPPS Rate,9843.06,103,MS-DRG,7874.448,Case Rate,103% of CMS IPPS Rate,17763.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9556.37,100,MS-DRG,7645.096,Case Rate,100% of CMS IPPS Rate,10123.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14334.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9556.37,100,MS-DRG,7645.096,Case Rate,100% of CMS IPPS Rate,19548.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9556.37,100,MS-DRG,7645.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24018.28,
DIABETES WITH MCC,637,CDM,,,,,Inpatient,,,,,,19843.82,,,,Case Rate,100% of CMS IPPS Rate,14382.7,145,MS-DRG,11506.16,Case Rate,145% of CMS IPPS Rate,9919.1,100,MS-DRG,7935.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9919.1,100,,7935.28,Case Rate,100% of CMS IPPS Rate,19413.94,100,,,Case Rate,100% of CMS IPPS Rate,22188.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24960.98,100,,,Case Rate,100% of CMS IPPS Rate,24960.98,100,,,Case Rate,100% of CMS IPPS Rate,24960.98,100,,,Case Rate,100% CMS IPPS Rate,17913.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9026.02,100,,7220.816,Case Rate,100% of CMS IPPS Rate,9026.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9026.02,100,MS-DRG,7220.816,Case Rate,100% of CMS IPPS Rate,9026.02,100,MS-DRG,7220.816,Case Rate,100% of CMS IPPS Rate,9478.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9919.1,100,MS-DRG,7935.28,Case Rate,100% of CMS IPPS Rate,12894.83,130,MS-DRG,10315.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10216.67,103,MS-DRG,8173.336,Case Rate,103% of CMS IPPS Rate,10216.67,103,MS-DRG,8173.336,Case Rate,103% of CMS IPPS Rate,17655.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9919.1,100,MS-DRG,7935.28,Case Rate,100% of CMS IPPS Rate,10507.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14878.65,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9919.1,100,MS-DRG,7935.28,Case Rate,100% of CMS IPPS Rate,20290.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9919.1,100,MS-DRG,7935.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24960.98,
DIABETES WITH CC,638,CDM,,,,,Inpatient,,,,,,12314.58,,,,Case Rate,100% of CMS IPPS Rate,8925.56,145,MS-DRG,7140.448,Case Rate,145% of CMS IPPS Rate,6155.56,100,MS-DRG,4924.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6155.56,100,,4924.448,Case Rate,100% of CMS IPPS Rate,12227.19,100,,,Case Rate,100% of CMS IPPS Rate,13974.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15720.81,100,,,Case Rate,100% of CMS IPPS Rate,15720.81,100,,,Case Rate,100% of CMS IPPS Rate,15720.81,100,,,Case Rate,100% CMS IPPS Rate,11116.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5601.42,100,,4481.136,Case Rate,100% of CMS IPPS Rate,5601.42,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5601.42,100,MS-DRG,4481.136,Case Rate,100% of CMS IPPS Rate,5601.42,100,MS-DRG,4481.136,Case Rate,100% of CMS IPPS Rate,4972.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6155.56,100,MS-DRG,4924.448,Case Rate,100% of CMS IPPS Rate,8002.23,130,MS-DRG,6401.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6340.23,103,MS-DRG,5072.184,Case Rate,103% of CMS IPPS Rate,6340.23,103,MS-DRG,5072.184,Case Rate,103% of CMS IPPS Rate,11081.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6155.56,100,MS-DRG,4924.448,Case Rate,100% of CMS IPPS Rate,6520.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9233.34,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6155.56,100,MS-DRG,4924.448,Case Rate,100% of CMS IPPS Rate,12591.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6155.56,100,MS-DRG,4924.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4972.94,15720.81,
DIABETES WITHOUT CC/MCC,639,CDM,,,,,Inpatient,,,,,,8523.27,,,,Case Rate,100% of CMS IPPS Rate,6177.61,145,MS-DRG,4942.088,Case Rate,145% of CMS IPPS Rate,4260.42,100,MS-DRG,3408.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4260.42,100,,3408.336,Case Rate,100% of CMS IPPS Rate,8353.2,100,,,Case Rate,100% of CMS IPPS Rate,9546.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10739.92,100,,,Case Rate,100% of CMS IPPS Rate,10739.92,100,,,Case Rate,100% of CMS IPPS Rate,10739.92,100,,,Case Rate,100% CMS IPPS Rate,7694.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3876.98,100,,3101.584,Case Rate,100% of CMS IPPS Rate,3876.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3876.98,100,MS-DRG,3101.584,Case Rate,100% of CMS IPPS Rate,3876.98,100,MS-DRG,3101.584,Case Rate,100% of CMS IPPS Rate,3670.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4260.42,100,MS-DRG,3408.336,Case Rate,100% of CMS IPPS Rate,5538.55,130,MS-DRG,4430.84,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4388.23,103,MS-DRG,3510.584,Case Rate,103% of CMS IPPS Rate,4388.23,103,MS-DRG,3510.584,Case Rate,103% of CMS IPPS Rate,7600.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4260.42,100,MS-DRG,3408.336,Case Rate,100% of CMS IPPS Rate,4513.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6390.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4260.42,100,MS-DRG,3408.336,Case Rate,100% of CMS IPPS Rate,8715,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4260.42,100,MS-DRG,3408.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3670.12,10739.92,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,CDM,,,,,Inpatient,,,,,,18007.72,,,,Case Rate,100% of CMS IPPS Rate,13051.9,145,MS-DRG,10441.52,Case Rate,145% of CMS IPPS Rate,9001.31,100,MS-DRG,7201.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9001.31,100,,7201.048,Case Rate,100% of CMS IPPS Rate,17703.57,100,,,Case Rate,100% of CMS IPPS Rate,20233.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22761.92,100,,,Case Rate,100% of CMS IPPS Rate,22761.92,100,,,Case Rate,100% of CMS IPPS Rate,22761.92,100,,,Case Rate,100% CMS IPPS Rate,16255.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8190.88,100,,6552.704,Case Rate,100% of CMS IPPS Rate,8190.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8190.88,100,MS-DRG,6552.704,Case Rate,100% of CMS IPPS Rate,8190.88,100,MS-DRG,6552.704,Case Rate,100% of CMS IPPS Rate,10549.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9001.31,100,MS-DRG,7201.048,Case Rate,100% of CMS IPPS Rate,11701.7,130,MS-DRG,9361.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9271.35,103,MS-DRG,7417.08,Case Rate,103% of CMS IPPS Rate,9271.35,103,MS-DRG,7417.08,Case Rate,103% of CMS IPPS Rate,16006.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9001.31,100,MS-DRG,7201.048,Case Rate,100% of CMS IPPS Rate,9535.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13501.97,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9001.31,100,MS-DRG,7201.048,Case Rate,100% of CMS IPPS Rate,18412.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9001.31,100,MS-DRG,7201.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22761.92,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,CDM,,,,,Inpatient,,,,,,10698.93,,,,Case Rate,100% of CMS IPPS Rate,7754.53,145,MS-DRG,6203.624,Case Rate,145% of CMS IPPS Rate,5347.95,100,MS-DRG,4278.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5347.95,100,,4278.36,Case Rate,100% of CMS IPPS Rate,10416.84,100,,,Case Rate,100% of CMS IPPS Rate,11905.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13393.2,100,,,Case Rate,100% of CMS IPPS Rate,13393.2,100,,,Case Rate,100% of CMS IPPS Rate,13393.2,100,,,Case Rate,100% CMS IPPS Rate,9658.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4866.56,100,,3893.248,Case Rate,100% of CMS IPPS Rate,4866.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4866.56,100,MS-DRG,3893.248,Case Rate,100% of CMS IPPS Rate,4866.56,100,MS-DRG,3893.248,Case Rate,100% of CMS IPPS Rate,5488.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5347.95,100,MS-DRG,4278.36,Case Rate,100% of CMS IPPS Rate,6952.34,130,MS-DRG,5561.872,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5508.39,103,MS-DRG,4406.712,Case Rate,103% of CMS IPPS Rate,5508.39,103,MS-DRG,4406.712,Case Rate,103% of CMS IPPS Rate,9743.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5347.95,100,MS-DRG,4278.36,Case Rate,100% of CMS IPPS Rate,5665.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8021.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5347.95,100,MS-DRG,4278.36,Case Rate,100% of CMS IPPS Rate,10939.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5347.95,100,MS-DRG,4278.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4866.56,13393.2,
INBORN AND OTHER DISORDERS OF METABOLISM,642,CDM,,,,,Inpatient,,,,,,17844.78,,,,Case Rate,100% of CMS IPPS Rate,12933.81,145,MS-DRG,10347.048,Case Rate,145% of CMS IPPS Rate,8919.87,100,MS-DRG,7135.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8919.87,100,,7135.896,Case Rate,100% of CMS IPPS Rate,16545.1,100,,,Case Rate,100% of CMS IPPS Rate,18909.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21272.45,100,,,Case Rate,100% of CMS IPPS Rate,21272.45,100,,,Case Rate,100% of CMS IPPS Rate,21272.45,100,,,Case Rate,100% CMS IPPS Rate,16108.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8116.78,100,,6493.424,Case Rate,100% of CMS IPPS Rate,8116.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8116.78,100,MS-DRG,6493.424,Case Rate,100% of CMS IPPS Rate,8116.78,100,MS-DRG,6493.424,Case Rate,100% of CMS IPPS Rate,10346.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8919.87,100,MS-DRG,7135.896,Case Rate,100% of CMS IPPS Rate,11595.83,130,MS-DRG,9276.664,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9187.47,103,MS-DRG,7349.976,Case Rate,103% of CMS IPPS Rate,9187.47,103,MS-DRG,7349.976,Case Rate,103% of CMS IPPS Rate,17751.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8919.87,100,MS-DRG,7135.896,Case Rate,100% of CMS IPPS Rate,9448.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13379.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8919.87,100,MS-DRG,7135.896,Case Rate,100% of CMS IPPS Rate,18246.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8919.87,100,MS-DRG,7135.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21272.45,
ENDOCRINE DISORDERS WITH MCC,643,CDM,,,,,Inpatient,,,,,,22524.71,,,,Case Rate,100% of CMS IPPS Rate,16325.8,145,MS-DRG,13060.64,Case Rate,145% of CMS IPPS Rate,11259.17,100,MS-DRG,9007.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11259.17,100,,9007.336,Case Rate,100% of CMS IPPS Rate,22093.47,100,,,Case Rate,100% of CMS IPPS Rate,25250.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28406.12,100,,,Case Rate,100% of CMS IPPS Rate,28406.12,100,,,Case Rate,100% of CMS IPPS Rate,28406.12,100,,,Case Rate,100% CMS IPPS Rate,20333.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10245.4,100,,8196.32,Case Rate,100% of CMS IPPS Rate,10245.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10245.4,100,MS-DRG,8196.32,Case Rate,100% of CMS IPPS Rate,10245.4,100,MS-DRG,8196.32,Case Rate,100% of CMS IPPS Rate,11635.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11259.17,100,MS-DRG,9007.336,Case Rate,100% of CMS IPPS Rate,14636.92,130,MS-DRG,11709.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11596.95,103,MS-DRG,9277.56,Case Rate,103% of CMS IPPS Rate,11596.95,103,MS-DRG,9277.56,Case Rate,103% of CMS IPPS Rate,20792.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11259.17,100,MS-DRG,9007.336,Case Rate,100% of CMS IPPS Rate,11926.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16888.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11259.17,100,MS-DRG,9007.336,Case Rate,100% of CMS IPPS Rate,23031.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11259.17,100,MS-DRG,9007.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28406.12,
ENDOCRINE DISORDERS WITH CC,644,CDM,,,,,Inpatient,,,,,,14536.8,,,,Case Rate,100% of CMS IPPS Rate,10536.21,145,MS-DRG,8428.968,Case Rate,145% of CMS IPPS Rate,7266.35,100,MS-DRG,5813.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7266.35,100,,5813.08,Case Rate,100% of CMS IPPS Rate,13776.26,100,,,Case Rate,100% of CMS IPPS Rate,15744.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17712.48,100,,,Case Rate,100% of CMS IPPS Rate,17712.48,100,,,Case Rate,100% of CMS IPPS Rate,17712.48,100,,,Case Rate,100% CMS IPPS Rate,13122.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6612.16,100,,5289.728,Case Rate,100% of CMS IPPS Rate,6612.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6612.16,100,MS-DRG,5289.728,Case Rate,100% of CMS IPPS Rate,6612.16,100,MS-DRG,5289.728,Case Rate,100% of CMS IPPS Rate,6751.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7266.35,100,MS-DRG,5813.08,Case Rate,100% of CMS IPPS Rate,9446.26,130,MS-DRG,7557.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7484.34,103,MS-DRG,5987.472,Case Rate,103% of CMS IPPS Rate,7484.34,103,MS-DRG,5987.472,Case Rate,103% of CMS IPPS Rate,12891.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7266.35,100,MS-DRG,5813.08,Case Rate,100% of CMS IPPS Rate,7697.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10899.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7266.35,100,MS-DRG,5813.08,Case Rate,100% of CMS IPPS Rate,14863.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7266.35,100,MS-DRG,5813.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17712.48,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,CDM,,,,,Inpatient,,,,,,10418.24,,,,Case Rate,100% of CMS IPPS Rate,7551.09,145,MS-DRG,6040.872,Case Rate,145% of CMS IPPS Rate,5207.65,100,MS-DRG,4166.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5207.65,100,,4166.12,Case Rate,100% of CMS IPPS Rate,10380.85,100,,,Case Rate,100% of CMS IPPS Rate,11864.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13346.92,100,,,Case Rate,100% of CMS IPPS Rate,13346.92,100,,,Case Rate,100% of CMS IPPS Rate,13346.92,100,,,Case Rate,100% CMS IPPS Rate,9404.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4738.89,100,,3791.112,Case Rate,100% of CMS IPPS Rate,4738.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4738.89,100,MS-DRG,3791.112,Case Rate,100% of CMS IPPS Rate,4738.89,100,MS-DRG,3791.112,Case Rate,100% of CMS IPPS Rate,4213.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5207.65,100,MS-DRG,4166.12,Case Rate,100% of CMS IPPS Rate,6769.95,130,MS-DRG,5415.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5363.88,103,MS-DRG,4291.104,Case Rate,103% of CMS IPPS Rate,5363.88,103,MS-DRG,4291.104,Case Rate,103% of CMS IPPS Rate,9393.89,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5207.65,100,MS-DRG,4166.12,Case Rate,100% of CMS IPPS Rate,5516.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7811.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5207.65,100,MS-DRG,4166.12,Case Rate,100% of CMS IPPS Rate,10652.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5207.65,100,MS-DRG,4166.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4213.3,13346.92,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,CDM,,,,,Inpatient,,,,,,61579.77,,,,Case Rate,100% of CMS IPPS Rate,44632.71,145,MS-DRG,35706.168,Case Rate,145% of CMS IPPS Rate,30781.18,100,MS-DRG,24624.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30781.18,100,,24624.944,Case Rate,100% of CMS IPPS Rate,61419.92,100,,,Case Rate,100% of CMS IPPS Rate,70196.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,78969.12,100,,,Case Rate,100% of CMS IPPS Rate,78969.12,100,,,Case Rate,100% of CMS IPPS Rate,78969.12,100,,,Case Rate,100% CMS IPPS Rate,55589.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28009.22,100,,22407.376,Case Rate,100% of CMS IPPS Rate,28009.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28009.22,100,MS-DRG,22407.376,Case Rate,100% of CMS IPPS Rate,28009.22,100,MS-DRG,22407.376,Case Rate,100% of CMS IPPS Rate,17325.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30781.18,100,MS-DRG,24624.944,Case Rate,100% of CMS IPPS Rate,40015.53,130,MS-DRG,32012.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31704.62,103,MS-DRG,25363.696,Case Rate,103% of CMS IPPS Rate,31704.62,103,MS-DRG,25363.696,Case Rate,103% of CMS IPPS Rate,58745.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30781.18,100,MS-DRG,24624.944,Case Rate,100% of CMS IPPS Rate,32606.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,46171.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30781.18,100,MS-DRG,24624.944,Case Rate,100% of CMS IPPS Rate,62965,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30781.18,100,MS-DRG,24624.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,78969.12,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,CDM,,,,,Inpatient,,,,,,47352.41,,,,Case Rate,100% of CMS IPPS Rate,34320.79,145,MS-DRG,27456.632,Case Rate,145% of CMS IPPS Rate,23669.51,100,MS-DRG,18935.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23669.51,100,,18935.608,Case Rate,100% of CMS IPPS Rate,46291.9,100,,,Case Rate,100% of CMS IPPS Rate,52907.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,59518.65,100,,,Case Rate,100% of CMS IPPS Rate,59518.65,100,,,Case Rate,100% of CMS IPPS Rate,59518.65,100,,,Case Rate,100% CMS IPPS Rate,42745.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21538.04,100,,17230.432,Case Rate,100% of CMS IPPS Rate,21538.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21538.04,100,MS-DRG,17230.432,Case Rate,100% of CMS IPPS Rate,21538.04,100,MS-DRG,17230.432,Case Rate,100% of CMS IPPS Rate,124590.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23669.51,100,MS-DRG,18935.608,Case Rate,100% of CMS IPPS Rate,30770.36,130,MS-DRG,24616.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24379.6,103,MS-DRG,19503.68,Case Rate,103% of CMS IPPS Rate,24379.6,103,MS-DRG,19503.68,Case Rate,103% of CMS IPPS Rate,44859.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23669.51,100,MS-DRG,18935.608,Case Rate,100% of CMS IPPS Rate,25073.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35504.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23669.51,100,MS-DRG,18935.608,Case Rate,100% of CMS IPPS Rate,48417.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23669.51,100,MS-DRG,18935.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,124590.18,
KIDNEY TRANSPLANT,652,CDM,,,,,Inpatient,,,,,,41136.24,,,,Case Rate,100% of CMS IPPS Rate,29815.34,145,MS-DRG,23852.272,Case Rate,145% of CMS IPPS Rate,20562.3,100,MS-DRG,16449.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20562.3,100,,16449.84,Case Rate,100% of CMS IPPS Rate,40944.83,100,,,Case Rate,100% of CMS IPPS Rate,46795.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52643.8,100,,,Case Rate,100% of CMS IPPS Rate,52643.8,100,,,Case Rate,100% of CMS IPPS Rate,52643.8,100,,,Case Rate,100% CMS IPPS Rate,37134.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18710.67,100,,14968.536,Case Rate,100% of CMS IPPS Rate,18710.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18710.67,100,MS-DRG,14968.536,Case Rate,100% of CMS IPPS Rate,18710.67,100,MS-DRG,14968.536,Case Rate,100% of CMS IPPS Rate,31782.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20562.3,100,MS-DRG,16449.84,Case Rate,100% of CMS IPPS Rate,26730.99,130,MS-DRG,21384.792,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21179.17,103,MS-DRG,16943.336,Case Rate,103% of CMS IPPS Rate,21179.17,103,MS-DRG,16943.336,Case Rate,103% of CMS IPPS Rate,39026.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20562.3,100,MS-DRG,16449.84,Case Rate,100% of CMS IPPS Rate,21781.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30843.45,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20562.3,100,MS-DRG,16449.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20562.3,100,MS-DRG,16449.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,52643.8,
MAJOR BLADDER PROCEDURES WITH MCC,653,CDM,,,,,Inpatient,,,,,,74123.01,,,,Case Rate,100% of CMS IPPS Rate,53723.99,145,MS-DRG,42979.192,Case Rate,145% of CMS IPPS Rate,37051.03,100,MS-DRG,29640.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37051.03,100,,29640.824,Case Rate,100% of CMS IPPS Rate,74314.99,100,,,Case Rate,100% of CMS IPPS Rate,84934.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,95548.64,100,,,Case Rate,100% of CMS IPPS Rate,95548.64,100,,,Case Rate,100% of CMS IPPS Rate,95548.64,100,,,Case Rate,100% CMS IPPS Rate,66912.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33714.38,100,,26971.504,Case Rate,100% of CMS IPPS Rate,33714.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,33714.38,100,MS-DRG,26971.504,Case Rate,100% of CMS IPPS Rate,33714.38,100,MS-DRG,26971.504,Case Rate,100% of CMS IPPS Rate,48716.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37051.03,100,MS-DRG,29640.824,Case Rate,100% of CMS IPPS Rate,48166.34,130,MS-DRG,38533.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38162.56,103,MS-DRG,30530.048,Case Rate,103% of CMS IPPS Rate,38162.56,103,MS-DRG,30530.048,Case Rate,103% of CMS IPPS Rate,70292.26,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37051.03,100,MS-DRG,29640.824,Case Rate,100% of CMS IPPS Rate,39248.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,55576.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37051.03,100,MS-DRG,29640.824,Case Rate,100% of CMS IPPS Rate,75790.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37051.03,100,MS-DRG,29640.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,95548.64,
MAJOR BLADDER PROCEDURES WITH CC,654,CDM,,,,,Inpatient,,,,,,37481.85,,,,Case Rate,100% of CMS IPPS Rate,27166.65,145,MS-DRG,21733.32,Case Rate,145% of CMS IPPS Rate,18735.62,100,MS-DRG,14988.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18735.62,100,,14988.496,Case Rate,100% of CMS IPPS Rate,37621.42,100,,,Case Rate,100% of CMS IPPS Rate,42997.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,48370.79,100,,,Case Rate,100% of CMS IPPS Rate,48370.79,100,,,Case Rate,100% of CMS IPPS Rate,48370.79,100,,,Case Rate,100% CMS IPPS Rate,33835.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17048.5,100,,13638.8,Case Rate,100% of CMS IPPS Rate,17048.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17048.5,100,MS-DRG,13638.8,Case Rate,100% of CMS IPPS Rate,17048.5,100,MS-DRG,13638.8,Case Rate,100% of CMS IPPS Rate,17902.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18735.62,100,MS-DRG,14988.496,Case Rate,100% of CMS IPPS Rate,24356.31,130,MS-DRG,19485.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19297.69,103,MS-DRG,15438.152,Case Rate,103% of CMS IPPS Rate,19297.69,103,MS-DRG,15438.152,Case Rate,103% of CMS IPPS Rate,35957.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18735.62,100,MS-DRG,14988.496,Case Rate,100% of CMS IPPS Rate,19846.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28103.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18735.62,100,MS-DRG,14988.496,Case Rate,100% of CMS IPPS Rate,38325,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18735.62,100,MS-DRG,14988.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,48370.79,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,CDM,,,,,Inpatient,,,,,,28860,,,,Case Rate,100% of CMS IPPS Rate,20917.6,145,MS-DRG,16734.08,Case Rate,145% of CMS IPPS Rate,14425.93,100,MS-DRG,11540.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14425.93,100,,11540.744,Case Rate,100% of CMS IPPS Rate,27692.49,100,,,Case Rate,100% of CMS IPPS Rate,31649.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35604.92,100,,,Case Rate,100% of CMS IPPS Rate,35604.92,100,,,Case Rate,100% of CMS IPPS Rate,35604.92,100,,,Case Rate,100% CMS IPPS Rate,26052.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13126.94,100,,10501.552,Case Rate,100% of CMS IPPS Rate,13126.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13126.94,100,MS-DRG,10501.552,Case Rate,100% of CMS IPPS Rate,13126.94,100,MS-DRG,10501.552,Case Rate,100% of CMS IPPS Rate,23203.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14425.93,100,MS-DRG,11540.744,Case Rate,100% of CMS IPPS Rate,18753.71,130,MS-DRG,15002.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14858.71,103,MS-DRG,11886.968,Case Rate,103% of CMS IPPS Rate,14858.71,103,MS-DRG,11886.968,Case Rate,103% of CMS IPPS Rate,27307.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14425.93,100,MS-DRG,11540.744,Case Rate,100% of CMS IPPS Rate,15281.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21638.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14425.93,100,MS-DRG,11540.744,Case Rate,100% of CMS IPPS Rate,29509.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14425.93,100,MS-DRG,11540.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35604.92,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,CDM,,,,,Inpatient,,,,,,42960.02,,,,Case Rate,100% of CMS IPPS Rate,31137.21,145,MS-DRG,24909.768,Case Rate,145% of CMS IPPS Rate,21473.94,100,MS-DRG,17179.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21473.94,100,,17179.152,Case Rate,100% of CMS IPPS Rate,43432.4,100,,,Case Rate,100% of CMS IPPS Rate,49638.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,55842.12,100,,,Case Rate,100% of CMS IPPS Rate,55842.12,100,,,Case Rate,100% of CMS IPPS Rate,55842.12,100,,,Case Rate,100% CMS IPPS Rate,38780.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19540.2,100,,15632.16,Case Rate,100% of CMS IPPS Rate,19540.2,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19540.2,100,MS-DRG,15632.16,Case Rate,100% of CMS IPPS Rate,19540.2,100,MS-DRG,15632.16,Case Rate,100% of CMS IPPS Rate,17408.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21473.94,100,MS-DRG,17179.152,Case Rate,100% of CMS IPPS Rate,27916.12,130,MS-DRG,22332.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22118.16,103,MS-DRG,17694.528,Case Rate,103% of CMS IPPS Rate,22118.16,103,MS-DRG,17694.528,Case Rate,103% of CMS IPPS Rate,41812.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21473.94,100,MS-DRG,17179.152,Case Rate,100% of CMS IPPS Rate,22747.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32210.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21473.94,100,MS-DRG,17179.152,Case Rate,100% of CMS IPPS Rate,43926.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21473.94,100,MS-DRG,17179.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,55842.12,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,CDM,,,,,Inpatient,,,,,,25250.79,,,,Case Rate,100% of CMS IPPS Rate,18301.64,145,MS-DRG,14641.312,Case Rate,145% of CMS IPPS Rate,12621.82,100,MS-DRG,10097.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12621.82,100,,10097.456,Case Rate,100% of CMS IPPS Rate,24370.4,100,,,Case Rate,100% of CMS IPPS Rate,27852.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31333.63,100,,,Case Rate,100% of CMS IPPS Rate,31333.63,100,,,Case Rate,100% of CMS IPPS Rate,31333.63,100,,,Case Rate,100% CMS IPPS Rate,22794.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11485.32,100,,9188.256,Case Rate,100% of CMS IPPS Rate,11485.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11485.32,100,MS-DRG,9188.256,Case Rate,100% of CMS IPPS Rate,11485.32,100,MS-DRG,9188.256,Case Rate,100% of CMS IPPS Rate,17617.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12621.82,100,MS-DRG,10097.456,Case Rate,100% of CMS IPPS Rate,16408.37,130,MS-DRG,13126.696,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13000.47,103,MS-DRG,10400.376,Case Rate,103% of CMS IPPS Rate,13000.47,103,MS-DRG,10400.376,Case Rate,103% of CMS IPPS Rate,23756.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12621.82,100,MS-DRG,10097.456,Case Rate,100% of CMS IPPS Rate,13370.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18932.73,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12621.82,100,MS-DRG,10097.456,Case Rate,100% of CMS IPPS Rate,25818.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12621.82,100,MS-DRG,10097.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31333.63,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,CDM,,,,,Inpatient,,,,,,20269.64,,,,Case Rate,100% of CMS IPPS Rate,14691.34,145,MS-DRG,11753.072,Case Rate,145% of CMS IPPS Rate,10131.96,100,MS-DRG,8105.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10131.96,100,,8105.568,Case Rate,100% of CMS IPPS Rate,20049.82,100,,,Case Rate,100% of CMS IPPS Rate,22914.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25778.56,100,,,Case Rate,100% of CMS IPPS Rate,25778.56,100,,,Case Rate,100% of CMS IPPS Rate,25778.56,100,,,Case Rate,100% CMS IPPS Rate,18297.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9219.7,100,,7375.76,Case Rate,100% of CMS IPPS Rate,9219.7,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9219.7,100,MS-DRG,7375.76,Case Rate,100% of CMS IPPS Rate,9219.7,100,MS-DRG,7375.76,Case Rate,100% of CMS IPPS Rate,15858.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10131.96,100,MS-DRG,8105.568,Case Rate,100% of CMS IPPS Rate,13171.55,130,MS-DRG,10537.24,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10435.92,103,MS-DRG,8348.736,Case Rate,103% of CMS IPPS Rate,10435.92,103,MS-DRG,8348.736,Case Rate,103% of CMS IPPS Rate,19974.35,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10131.96,100,MS-DRG,8105.568,Case Rate,100% of CMS IPPS Rate,10732.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15197.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10131.96,100,MS-DRG,8105.568,Case Rate,100% of CMS IPPS Rate,20725.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10131.96,100,MS-DRG,8105.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25778.56,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,CDM,,,,,Inpatient,,,,,,35447.22,,,,Case Rate,100% of CMS IPPS Rate,25691.97,145,MS-DRG,20553.576,Case Rate,145% of CMS IPPS Rate,17718.6,100,MS-DRG,14174.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17718.6,100,,14174.88,Case Rate,100% of CMS IPPS Rate,34451.3,100,,,Case Rate,100% of CMS IPPS Rate,39374.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,44294.9,100,,,Case Rate,100% of CMS IPPS Rate,44294.9,100,,,Case Rate,100% of CMS IPPS Rate,44294.9,100,,,Case Rate,100% CMS IPPS Rate,31998.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16123.07,100,,12898.456,Case Rate,100% of CMS IPPS Rate,16123.07,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16123.07,100,MS-DRG,12898.456,Case Rate,100% of CMS IPPS Rate,16123.07,100,MS-DRG,12898.456,Case Rate,100% of CMS IPPS Rate,15580.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17718.6,100,MS-DRG,14174.88,Case Rate,100% of CMS IPPS Rate,23034.18,130,MS-DRG,18427.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18250.16,103,MS-DRG,14600.128,Case Rate,103% of CMS IPPS Rate,18250.16,103,MS-DRG,14600.128,Case Rate,103% of CMS IPPS Rate,32597.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17718.6,100,MS-DRG,14174.88,Case Rate,100% of CMS IPPS Rate,18769.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,26577.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17718.6,100,MS-DRG,14174.88,Case Rate,100% of CMS IPPS Rate,36244.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17718.6,100,MS-DRG,14174.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,44294.9,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,CDM,,,,,Inpatient,,,,,,18428.06,,,,Case Rate,100% of CMS IPPS Rate,13356.56,145,MS-DRG,10685.248,Case Rate,145% of CMS IPPS Rate,9211.42,100,MS-DRG,7369.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9211.42,100,,7369.136,Case Rate,100% of CMS IPPS Rate,17863.54,100,,,Case Rate,100% of CMS IPPS Rate,20416.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22967.6,100,,,Case Rate,100% of CMS IPPS Rate,22967.6,100,,,Case Rate,100% of CMS IPPS Rate,22967.6,100,,,Case Rate,100% CMS IPPS Rate,16635.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8382.08,100,,6705.664,Case Rate,100% of CMS IPPS Rate,8382.08,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8382.08,100,MS-DRG,6705.664,Case Rate,100% of CMS IPPS Rate,8382.08,100,MS-DRG,6705.664,Case Rate,100% of CMS IPPS Rate,11146.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9211.42,100,MS-DRG,7369.136,Case Rate,100% of CMS IPPS Rate,11974.85,130,MS-DRG,9579.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9487.76,103,MS-DRG,7590.208,Case Rate,103% of CMS IPPS Rate,9487.76,103,MS-DRG,7590.208,Case Rate,103% of CMS IPPS Rate,17851.68,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9211.42,100,MS-DRG,7369.136,Case Rate,100% of CMS IPPS Rate,9757.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13817.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9211.42,100,MS-DRG,7369.136,Case Rate,100% of CMS IPPS Rate,18842.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9211.42,100,MS-DRG,7369.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22967.6,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,CDM,,,,,Inpatient,,,,,,14354.69,,,,Case Rate,100% of CMS IPPS Rate,10404.2,145,MS-DRG,8323.36,Case Rate,145% of CMS IPPS Rate,7175.31,100,MS-DRG,5740.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7175.31,100,,5740.248,Case Rate,100% of CMS IPPS Rate,13685.6,100,,,Case Rate,100% of CMS IPPS Rate,15641.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17595.92,100,,,Case Rate,100% of CMS IPPS Rate,17595.92,100,,,Case Rate,100% of CMS IPPS Rate,17595.92,100,,,Case Rate,100% CMS IPPS Rate,12958.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6529.35,100,,5223.48,Case Rate,100% of CMS IPPS Rate,6529.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6529.35,100,MS-DRG,5223.48,Case Rate,100% of CMS IPPS Rate,6529.35,100,MS-DRG,5223.48,Case Rate,100% of CMS IPPS Rate,9484.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7175.31,100,MS-DRG,5740.248,Case Rate,100% of CMS IPPS Rate,9327.9,130,MS-DRG,7462.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7390.57,103,MS-DRG,5912.456,Case Rate,103% of CMS IPPS Rate,7390.57,103,MS-DRG,5912.456,Case Rate,103% of CMS IPPS Rate,13635.44,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7175.31,100,MS-DRG,5740.248,Case Rate,100% of CMS IPPS Rate,7600.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10762.97,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7175.31,100,MS-DRG,5740.248,Case Rate,100% of CMS IPPS Rate,14677.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7175.31,100,MS-DRG,5740.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17595.92,
MINOR BLADDER PROCEDURES WITH MCC,662,CDM,,,,,Inpatient,,,,,,41030.82,,,,Case Rate,100% of CMS IPPS Rate,29738.93,145,MS-DRG,23791.144,Case Rate,145% of CMS IPPS Rate,20509.61,100,MS-DRG,16407.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20509.61,100,,16407.688,Case Rate,100% of CMS IPPS Rate,41587.39,100,,,Case Rate,100% of CMS IPPS Rate,47530.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,53469.94,100,,,Case Rate,100% of CMS IPPS Rate,53469.94,100,,,Case Rate,100% of CMS IPPS Rate,53469.94,100,,,Case Rate,100% CMS IPPS Rate,37039.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18662.72,100,,14930.176,Case Rate,100% of CMS IPPS Rate,18662.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18662.72,100,MS-DRG,14930.176,Case Rate,100% of CMS IPPS Rate,18662.72,100,MS-DRG,14930.176,Case Rate,100% of CMS IPPS Rate,26966.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20509.61,100,MS-DRG,16407.688,Case Rate,100% of CMS IPPS Rate,26662.49,130,MS-DRG,21329.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21124.9,103,MS-DRG,16899.92,Case Rate,103% of CMS IPPS Rate,21124.9,103,MS-DRG,16899.92,Case Rate,103% of CMS IPPS Rate,38439.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20509.61,100,MS-DRG,16407.688,Case Rate,100% of CMS IPPS Rate,21726.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,30764.42,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20509.61,100,MS-DRG,16407.688,Case Rate,100% of CMS IPPS Rate,41953.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20509.61,100,MS-DRG,16407.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,53469.94,
MINOR BLADDER PROCEDURES WITH CC,663,CDM,,,,,Inpatient,,,,,,19976.63,,,,Case Rate,100% of CMS IPPS Rate,14478.98,145,MS-DRG,11583.184,Case Rate,145% of CMS IPPS Rate,9985.5,100,MS-DRG,7988.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9985.5,100,,7988.4,Case Rate,100% of CMS IPPS Rate,20361.77,100,,,Case Rate,100% of CMS IPPS Rate,23271.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26179.64,100,,,Case Rate,100% of CMS IPPS Rate,26179.64,100,,,Case Rate,100% of CMS IPPS Rate,26179.64,100,,,Case Rate,100% CMS IPPS Rate,18033.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9086.44,100,,7269.152,Case Rate,100% of CMS IPPS Rate,9086.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9086.44,100,MS-DRG,7269.152,Case Rate,100% of CMS IPPS Rate,9086.44,100,MS-DRG,7269.152,Case Rate,100% of CMS IPPS Rate,13129.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9985.5,100,MS-DRG,7988.4,Case Rate,100% of CMS IPPS Rate,12981.15,130,MS-DRG,10384.92,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10285.07,103,MS-DRG,8228.056,Case Rate,103% of CMS IPPS Rate,10285.07,103,MS-DRG,8228.056,Case Rate,103% of CMS IPPS Rate,19291.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9985.5,100,MS-DRG,7988.4,Case Rate,100% of CMS IPPS Rate,10577.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14978.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9985.5,100,MS-DRG,7988.4,Case Rate,100% of CMS IPPS Rate,20426,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9985.5,100,MS-DRG,7988.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26179.64,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,CDM,,,,,Inpatient,,,,,,14535.43,,,,Case Rate,100% of CMS IPPS Rate,10535.21,145,MS-DRG,8428.168,Case Rate,145% of CMS IPPS Rate,7265.66,100,MS-DRG,5812.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7265.66,100,,5812.528,Case Rate,100% of CMS IPPS Rate,14394.81,100,,,Case Rate,100% of CMS IPPS Rate,16451.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18507.77,100,,,Case Rate,100% of CMS IPPS Rate,18507.77,100,,,Case Rate,100% of CMS IPPS Rate,18507.77,100,,,Case Rate,100% CMS IPPS Rate,13121.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6611.55,100,,5289.24,Case Rate,100% of CMS IPPS Rate,6611.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6611.55,100,MS-DRG,5289.24,Case Rate,100% of CMS IPPS Rate,6611.55,100,MS-DRG,5289.24,Case Rate,100% of CMS IPPS Rate,9553.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7265.66,100,MS-DRG,5812.528,Case Rate,100% of CMS IPPS Rate,9445.36,130,MS-DRG,7556.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7483.63,103,MS-DRG,5986.904,Case Rate,103% of CMS IPPS Rate,7483.63,103,MS-DRG,5986.904,Case Rate,103% of CMS IPPS Rate,14252.76,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7265.66,100,MS-DRG,5812.528,Case Rate,100% of CMS IPPS Rate,7696.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10898.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7265.66,100,MS-DRG,5812.528,Case Rate,100% of CMS IPPS Rate,14862.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7265.66,100,MS-DRG,5812.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18507.77,
PROSTATECTOMY WITH MCC,665,CDM,,,,,Inpatient,,,,,,42295.96,,,,Case Rate,100% of CMS IPPS Rate,30655.9,145,MS-DRG,24524.72,Case Rate,145% of CMS IPPS Rate,21142,100,MS-DRG,16913.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21142,100,,16913.6,Case Rate,100% of CMS IPPS Rate,45773.32,100,,,Case Rate,100% of CMS IPPS Rate,52314.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,58851.9,100,,,Case Rate,100% of CMS IPPS Rate,58851.9,100,,,Case Rate,100% of CMS IPPS Rate,58851.9,100,,,Case Rate,100% CMS IPPS Rate,38181.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19238.15,100,,15390.52,Case Rate,100% of CMS IPPS Rate,19238.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19238.15,100,MS-DRG,15390.52,Case Rate,100% of CMS IPPS Rate,19238.15,100,MS-DRG,15390.52,Case Rate,100% of CMS IPPS Rate,27798.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21142,100,MS-DRG,16913.6,Case Rate,100% of CMS IPPS Rate,27484.6,130,MS-DRG,21987.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21776.26,103,MS-DRG,17421.008,Case Rate,103% of CMS IPPS Rate,21776.26,103,MS-DRG,17421.008,Case Rate,103% of CMS IPPS Rate,38712.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21142,100,MS-DRG,16913.6,Case Rate,100% of CMS IPPS Rate,22395.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,31713,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21142,100,MS-DRG,16913.6,Case Rate,100% of CMS IPPS Rate,43247.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21142,100,MS-DRG,16913.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,58851.9,
PROSTATECTOMY WITH CC,666,CDM,,,,,Inpatient,,,,,,23514.64,,,,Case Rate,100% of CMS IPPS Rate,17043.3,145,MS-DRG,13634.64,Case Rate,145% of CMS IPPS Rate,11754,100,MS-DRG,9403.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11754,100,,9403.2,Case Rate,100% of CMS IPPS Rate,21960.16,100,,,Case Rate,100% of CMS IPPS Rate,25098.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28234.72,100,,,Case Rate,100% of CMS IPPS Rate,28234.72,100,,,Case Rate,100% of CMS IPPS Rate,28234.72,100,,,Case Rate,100% CMS IPPS Rate,21227.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10695.65,100,,8556.52,Case Rate,100% of CMS IPPS Rate,10695.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10695.65,100,MS-DRG,8556.52,Case Rate,100% of CMS IPPS Rate,10695.65,100,MS-DRG,8556.52,Case Rate,100% of CMS IPPS Rate,15454.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11754,100,MS-DRG,9403.2,Case Rate,100% of CMS IPPS Rate,15280.2,130,MS-DRG,12224.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12106.62,103,MS-DRG,9685.296,Case Rate,103% of CMS IPPS Rate,12106.62,103,MS-DRG,9685.296,Case Rate,103% of CMS IPPS Rate,21782.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11754,100,MS-DRG,9403.2,Case Rate,100% of CMS IPPS Rate,12451.15,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17631,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11754,100,MS-DRG,9403.2,Case Rate,100% of CMS IPPS Rate,24043.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11754,100,MS-DRG,9403.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28234.72,
PROSTATECTOMY WITHOUT CC/MCC,667,CDM,,,,,Inpatient,,,,,,14371.12,,,,Case Rate,100% of CMS IPPS Rate,10416.12,145,MS-DRG,8332.896,Case Rate,145% of CMS IPPS Rate,7183.53,100,MS-DRG,5746.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7183.53,100,,5746.824,Case Rate,100% of CMS IPPS Rate,13701.6,100,,,Case Rate,100% of CMS IPPS Rate,15659.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17616.49,100,,,Case Rate,100% of CMS IPPS Rate,17616.49,100,,,Case Rate,100% of CMS IPPS Rate,17616.49,100,,,Case Rate,100% CMS IPPS Rate,12973.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6536.81,100,,5229.448,Case Rate,100% of CMS IPPS Rate,6536.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6536.81,100,MS-DRG,5229.448,Case Rate,100% of CMS IPPS Rate,6536.81,100,MS-DRG,5229.448,Case Rate,100% of CMS IPPS Rate,9445.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7183.53,100,MS-DRG,5746.824,Case Rate,100% of CMS IPPS Rate,9338.59,130,MS-DRG,7470.872,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7399.04,103,MS-DRG,5919.232,Case Rate,103% of CMS IPPS Rate,7399.04,103,MS-DRG,5919.232,Case Rate,103% of CMS IPPS Rate,12446.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7183.53,100,MS-DRG,5746.824,Case Rate,100% of CMS IPPS Rate,7609.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10775.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7183.53,100,MS-DRG,5746.824,Case Rate,100% of CMS IPPS Rate,14694.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7183.53,100,MS-DRG,5746.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17616.49,
TRANSURETHRAL PROCEDURES WITH MCC,668,CDM,,,,,Inpatient,,,,,,38584.06,,,,Case Rate,100% of CMS IPPS Rate,27965.54,145,MS-DRG,22372.432,Case Rate,145% of CMS IPPS Rate,19286.58,100,MS-DRG,15429.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19286.58,100,,15429.264,Case Rate,100% of CMS IPPS Rate,38877.2,100,,,Case Rate,100% of CMS IPPS Rate,44432.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49985.38,100,,,Case Rate,100% of CMS IPPS Rate,49985.38,100,,,Case Rate,100% of CMS IPPS Rate,49985.38,100,,,Case Rate,100% CMS IPPS Rate,34830.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17549.83,100,,14039.864,Case Rate,100% of CMS IPPS Rate,17549.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17549.83,100,MS-DRG,14039.864,Case Rate,100% of CMS IPPS Rate,17549.83,100,MS-DRG,14039.864,Case Rate,100% of CMS IPPS Rate,25359.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19286.58,100,MS-DRG,15429.264,Case Rate,100% of CMS IPPS Rate,25072.55,130,MS-DRG,20058.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19865.18,103,MS-DRG,15892.144,Case Rate,103% of CMS IPPS Rate,19865.18,103,MS-DRG,15892.144,Case Rate,103% of CMS IPPS Rate,35709.69,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19286.58,100,MS-DRG,15429.264,Case Rate,100% of CMS IPPS Rate,20430.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28929.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19286.58,100,MS-DRG,15429.264,Case Rate,100% of CMS IPPS Rate,39452,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19286.58,100,MS-DRG,15429.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49985.38,
TRANSURETHRAL PROCEDURES WITH CC,669,CDM,,,,,Inpatient,,,,,,21011.74,,,,Case Rate,100% of CMS IPPS Rate,15229.21,145,MS-DRG,12183.368,Case Rate,145% of CMS IPPS Rate,10502.9,100,MS-DRG,8402.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10502.9,100,,8402.32,Case Rate,100% of CMS IPPS Rate,20629.72,100,,,Case Rate,100% of CMS IPPS Rate,23577.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26524.15,100,,,Case Rate,100% of CMS IPPS Rate,26524.15,100,,,Case Rate,100% of CMS IPPS Rate,26524.15,100,,,Case Rate,100% CMS IPPS Rate,18967.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9557.24,100,,7645.792,Case Rate,100% of CMS IPPS Rate,9557.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9557.24,100,MS-DRG,7645.792,Case Rate,100% of CMS IPPS Rate,9557.24,100,MS-DRG,7645.792,Case Rate,100% of CMS IPPS Rate,8951.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10502.9,100,MS-DRG,8402.32,Case Rate,100% of CMS IPPS Rate,13653.77,130,MS-DRG,10923.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10817.99,103,MS-DRG,8654.392,Case Rate,103% of CMS IPPS Rate,10817.99,103,MS-DRG,8654.392,Case Rate,103% of CMS IPPS Rate,19913.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10502.9,100,MS-DRG,8402.32,Case Rate,100% of CMS IPPS Rate,11125.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15754.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10502.9,100,MS-DRG,8402.32,Case Rate,100% of CMS IPPS Rate,21484.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10502.9,100,MS-DRG,8402.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26524.15,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,CDM,,,,,Inpatient,,,,,,13179.92,,,,Case Rate,100% of CMS IPPS Rate,9552.75,145,MS-DRG,7642.2,Case Rate,145% of CMS IPPS Rate,6588.1,100,MS-DRG,5270.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6588.1,100,,5270.48,Case Rate,100% of CMS IPPS Rate,12740.44,100,,,Case Rate,100% of CMS IPPS Rate,14561.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16380.7,100,,,Case Rate,100% of CMS IPPS Rate,16380.7,100,,,Case Rate,100% of CMS IPPS Rate,16380.7,100,,,Case Rate,100% CMS IPPS Rate,11897.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5995,100,,4796,Case Rate,100% of CMS IPPS Rate,5995,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5995,100,MS-DRG,4796,Case Rate,100% of CMS IPPS Rate,5995,100,MS-DRG,4796,Case Rate,100% of CMS IPPS Rate,8662.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6588.1,100,MS-DRG,5270.48,Case Rate,100% of CMS IPPS Rate,8564.53,130,MS-DRG,6851.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6785.74,103,MS-DRG,5428.592,Case Rate,103% of CMS IPPS Rate,6785.74,103,MS-DRG,5428.592,Case Rate,103% of CMS IPPS Rate,12491.88,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6588.1,100,MS-DRG,5270.48,Case Rate,100% of CMS IPPS Rate,6978.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9882.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6588.1,100,MS-DRG,5270.48,Case Rate,100% of CMS IPPS Rate,13476.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6588.1,100,MS-DRG,5270.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16380.7,
URETHRAL PROCEDURES WITH CC/MCC,671,CDM,,,,,Inpatient,,,,,,23439.33,,,,Case Rate,100% of CMS IPPS Rate,16988.72,145,MS-DRG,13590.976,Case Rate,145% of CMS IPPS Rate,11716.36,100,MS-DRG,9373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11716.36,100,,9373.088,Case Rate,100% of CMS IPPS Rate,22978.64,100,,,Case Rate,100% of CMS IPPS Rate,26262.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29544.22,100,,,Case Rate,100% of CMS IPPS Rate,29544.22,100,,,Case Rate,100% of CMS IPPS Rate,29544.22,100,,,Case Rate,100% CMS IPPS Rate,21159.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10661.4,100,,8529.12,Case Rate,100% of CMS IPPS Rate,10661.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10661.4,100,MS-DRG,8529.12,Case Rate,100% of CMS IPPS Rate,10661.4,100,MS-DRG,8529.12,Case Rate,100% of CMS IPPS Rate,15405.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11716.36,100,MS-DRG,9373.088,Case Rate,100% of CMS IPPS Rate,15231.27,130,MS-DRG,12185.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12067.85,103,MS-DRG,9654.28,Case Rate,103% of CMS IPPS Rate,12067.85,103,MS-DRG,9654.28,Case Rate,103% of CMS IPPS Rate,23168.48,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11716.36,100,MS-DRG,9373.088,Case Rate,100% of CMS IPPS Rate,12411.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17574.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11716.36,100,MS-DRG,9373.088,Case Rate,100% of CMS IPPS Rate,23966.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11716.36,100,MS-DRG,9373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29544.22,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,CDM,,,,,Inpatient,,,,,,12633.61,,,,Case Rate,100% of CMS IPPS Rate,9303.65,145,MS-DRG,7442.92,Case Rate,145% of CMS IPPS Rate,6416.31,100,MS-DRG,5133.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6416.31,100,,5133.048,Case Rate,100% of CMS IPPS Rate,14589.45,100,,,Case Rate,100% of CMS IPPS Rate,16674.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18758.02,100,,,Case Rate,100% of CMS IPPS Rate,18758.02,100,,,Case Rate,100% of CMS IPPS Rate,18758.02,100,,,Case Rate,100% CMS IPPS Rate,11404.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5838.7,100,,4670.96,Case Rate,100% of CMS IPPS Rate,5838.7,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5838.7,100,MS-DRG,4670.96,Case Rate,100% of CMS IPPS Rate,5838.7,100,MS-DRG,4670.96,Case Rate,100% of CMS IPPS Rate,8436.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6416.31,100,MS-DRG,5133.048,Case Rate,100% of CMS IPPS Rate,8341.2,130,MS-DRG,6672.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6608.8,103,MS-DRG,5287.04,Case Rate,103% of CMS IPPS Rate,6608.8,103,MS-DRG,5287.04,Case Rate,103% of CMS IPPS Rate,13177.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6416.31,100,MS-DRG,5133.048,Case Rate,100% of CMS IPPS Rate,6689.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9624.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6416.31,100,MS-DRG,5133.048,Case Rate,100% of CMS IPPS Rate,12917.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6416.31,100,MS-DRG,5133.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5838.7,18758.02,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,CDM,,,,,Inpatient,,,,,,50633.02,,,,Case Rate,100% of CMS IPPS Rate,36698.56,145,MS-DRG,29358.848,Case Rate,145% of CMS IPPS Rate,25309.35,100,MS-DRG,20247.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25309.35,100,,20247.48,Case Rate,100% of CMS IPPS Rate,55851.56,100,,,Case Rate,100% of CMS IPPS Rate,63832.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,71809.74,100,,,Case Rate,100% of CMS IPPS Rate,71809.74,100,,,Case Rate,100% of CMS IPPS Rate,71809.74,100,,,Case Rate,100% CMS IPPS Rate,45707.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23030.17,100,,18424.136,Case Rate,100% of CMS IPPS Rate,23030.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23030.17,100,MS-DRG,18424.136,Case Rate,100% of CMS IPPS Rate,23030.17,100,MS-DRG,18424.136,Case Rate,100% of CMS IPPS Rate,30242.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25309.35,100,MS-DRG,20247.48,Case Rate,100% of CMS IPPS Rate,32902.16,130,MS-DRG,26321.728,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26068.63,103,MS-DRG,20854.904,Case Rate,103% of CMS IPPS Rate,26068.63,103,MS-DRG,20854.904,Case Rate,103% of CMS IPPS Rate,44199.1,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25309.35,100,MS-DRG,20247.48,Case Rate,100% of CMS IPPS Rate,26810.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37964.03,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25309.35,100,MS-DRG,20247.48,Case Rate,100% of CMS IPPS Rate,51772,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25309.35,100,MS-DRG,20247.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,71809.74,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,CDM,,,,,Inpatient,,,,,,32617.08,,,,Case Rate,100% of CMS IPPS Rate,23640.68,145,MS-DRG,18912.544,Case Rate,145% of CMS IPPS Rate,16303.92,100,MS-DRG,13043.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16303.92,100,,13043.136,Case Rate,100% of CMS IPPS Rate,30773.28,100,,,Case Rate,100% of CMS IPPS Rate,35170.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39565.98,100,,,Case Rate,100% of CMS IPPS Rate,39565.98,100,,,Case Rate,100% of CMS IPPS Rate,39565.98,100,,,Case Rate,100% CMS IPPS Rate,29443.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14835.81,100,,11868.648,Case Rate,100% of CMS IPPS Rate,14835.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14835.81,100,MS-DRG,11868.648,Case Rate,100% of CMS IPPS Rate,14835.81,100,MS-DRG,11868.648,Case Rate,100% of CMS IPPS Rate,20131.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16303.92,100,MS-DRG,13043.136,Case Rate,100% of CMS IPPS Rate,21195.1,130,MS-DRG,16956.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16793.04,103,MS-DRG,13434.432,Case Rate,103% of CMS IPPS Rate,16793.04,103,MS-DRG,13434.432,Case Rate,103% of CMS IPPS Rate,29986.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16303.92,100,MS-DRG,13043.136,Case Rate,100% of CMS IPPS Rate,17270.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,24455.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16303.92,100,MS-DRG,13043.136,Case Rate,100% of CMS IPPS Rate,33350.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16303.92,100,MS-DRG,13043.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39565.98,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,CDM,,,,,Inpatient,,,,,,21722.36,,,,Case Rate,100% of CMS IPPS Rate,15744.26,145,MS-DRG,12595.408,Case Rate,145% of CMS IPPS Rate,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10858.11,100,,8686.488,Case Rate,100% of CMS IPPS Rate,20867.01,100,,,Case Rate,100% of CMS IPPS Rate,23848.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26829.24,100,,,Case Rate,100% of CMS IPPS Rate,26829.24,100,,,Case Rate,100% of CMS IPPS Rate,26829.24,100,,,Case Rate,100% CMS IPPS Rate,19609.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9880.46,100,,7904.368,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,7904.368,Case Rate,100% of CMS IPPS Rate,9880.46,100,MS-DRG,7904.368,Case Rate,100% of CMS IPPS Rate,14276.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,14115.54,130,MS-DRG,11292.432,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11183.85,103,MS-DRG,8947.08,Case Rate,103% of CMS IPPS Rate,11183.85,103,MS-DRG,8947.08,Case Rate,103% of CMS IPPS Rate,21332.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,11502.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16287.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,22211,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10858.11,100,MS-DRG,8686.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26829.24,
RENAL FAILURE WITH MCC,682,CDM,,,,,Inpatient,,,,,,20548.95,,,,Case Rate,100% of CMS IPPS Rate,14893.79,145,MS-DRG,11915.032,Case Rate,145% of CMS IPPS Rate,10271.58,100,MS-DRG,8217.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10271.58,100,,8217.264,Case Rate,100% of CMS IPPS Rate,20021.83,100,,,Case Rate,100% of CMS IPPS Rate,22882.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25742.57,100,,,Case Rate,100% of CMS IPPS Rate,25742.57,100,,,Case Rate,100% of CMS IPPS Rate,25742.57,100,,,Case Rate,100% CMS IPPS Rate,18549.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9346.74,100,,7477.392,Case Rate,100% of CMS IPPS Rate,9346.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9346.74,100,MS-DRG,7477.392,Case Rate,100% of CMS IPPS Rate,9346.74,100,MS-DRG,7477.392,Case Rate,100% of CMS IPPS Rate,10884.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10271.58,100,MS-DRG,8217.264,Case Rate,100% of CMS IPPS Rate,13353.05,130,MS-DRG,10682.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10579.73,103,MS-DRG,8463.784,Case Rate,103% of CMS IPPS Rate,10579.73,103,MS-DRG,8463.784,Case Rate,103% of CMS IPPS Rate,18805.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10271.58,100,MS-DRG,8217.264,Case Rate,100% of CMS IPPS Rate,10880.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15407.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10271.58,100,MS-DRG,8217.264,Case Rate,100% of CMS IPPS Rate,21011.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10271.58,100,MS-DRG,8217.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25742.57,
RENAL FAILURE WITH CC,683,CDM,,,,,Inpatient,,,,,,12333.75,,,,Case Rate,100% of CMS IPPS Rate,8939.44,145,MS-DRG,7151.552,Case Rate,145% of CMS IPPS Rate,6165.13,100,MS-DRG,4932.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6165.13,100,,4932.104,Case Rate,100% of CMS IPPS Rate,11849.93,100,,,Case Rate,100% of CMS IPPS Rate,13543.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15235.75,100,,,Case Rate,100% of CMS IPPS Rate,15235.75,100,,,Case Rate,100% of CMS IPPS Rate,15235.75,100,,,Case Rate,100% CMS IPPS Rate,11133.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5610.14,100,,4488.112,Case Rate,100% of CMS IPPS Rate,5610.14,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5610.14,100,MS-DRG,4488.112,Case Rate,100% of CMS IPPS Rate,5610.14,100,MS-DRG,4488.112,Case Rate,100% of CMS IPPS Rate,5923.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6165.13,100,MS-DRG,4932.104,Case Rate,100% of CMS IPPS Rate,8014.67,130,MS-DRG,6411.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6350.08,103,MS-DRG,5080.064,Case Rate,103% of CMS IPPS Rate,6350.08,103,MS-DRG,5080.064,Case Rate,103% of CMS IPPS Rate,11320.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6165.13,100,MS-DRG,4932.104,Case Rate,100% of CMS IPPS Rate,6530.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9247.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6165.13,100,MS-DRG,4932.104,Case Rate,100% of CMS IPPS Rate,12611.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6165.13,100,MS-DRG,4932.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5610.14,15235.75,
RENAL FAILURE WITHOUT CC/MCC,684,CDM,,,,,Inpatient,,,,,,8331.58,,,,Case Rate,100% of CMS IPPS Rate,6038.68,145,MS-DRG,4830.944,Case Rate,145% of CMS IPPS Rate,4164.61,100,MS-DRG,3331.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4164.61,100,,3331.688,Case Rate,100% of CMS IPPS Rate,8097.25,100,,,Case Rate,100% of CMS IPPS Rate,9254.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10410.84,100,,,Case Rate,100% of CMS IPPS Rate,10410.84,100,,,Case Rate,100% of CMS IPPS Rate,10410.84,100,,,Case Rate,100% CMS IPPS Rate,7521.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3789.79,100,,3031.832,Case Rate,100% of CMS IPPS Rate,3789.79,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3789.79,100,MS-DRG,3031.832,Case Rate,100% of CMS IPPS Rate,3789.79,100,MS-DRG,3031.832,Case Rate,100% of CMS IPPS Rate,4621.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4164.61,100,MS-DRG,3331.688,Case Rate,100% of CMS IPPS Rate,5413.99,130,MS-DRG,4331.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4289.55,103,MS-DRG,3431.64,Case Rate,103% of CMS IPPS Rate,4289.55,103,MS-DRG,3431.64,Case Rate,103% of CMS IPPS Rate,7650.72,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4164.61,100,MS-DRG,3331.688,Case Rate,100% of CMS IPPS Rate,4411.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6246.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4164.61,100,MS-DRG,3331.688,Case Rate,100% of CMS IPPS Rate,8519,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4164.61,100,MS-DRG,3331.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3789.79,10410.84,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,CDM,,,,,Inpatient,,,,,,25185.06,,,,Case Rate,100% of CMS IPPS Rate,18254.01,145,MS-DRG,14603.208,Case Rate,145% of CMS IPPS Rate,12588.97,100,MS-DRG,10071.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12588.97,100,,10071.176,Case Rate,100% of CMS IPPS Rate,25138.27,100,,,Case Rate,100% of CMS IPPS Rate,28730.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32320.9,100,,,Case Rate,100% of CMS IPPS Rate,32320.9,100,,,Case Rate,100% of CMS IPPS Rate,32320.9,100,,,Case Rate,100% CMS IPPS Rate,22734.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11455.43,100,,9164.344,Case Rate,100% of CMS IPPS Rate,11455.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11455.43,100,MS-DRG,9164.344,Case Rate,100% of CMS IPPS Rate,11455.43,100,MS-DRG,9164.344,Case Rate,100% of CMS IPPS Rate,16631.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12588.97,100,MS-DRG,10071.176,Case Rate,100% of CMS IPPS Rate,16365.66,130,MS-DRG,13092.528,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12966.64,103,MS-DRG,10373.312,Case Rate,103% of CMS IPPS Rate,12966.64,103,MS-DRG,10373.312,Case Rate,103% of CMS IPPS Rate,21477.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12588.97,100,MS-DRG,10071.176,Case Rate,100% of CMS IPPS Rate,13335.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18883.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12588.97,100,MS-DRG,10071.176,Case Rate,100% of CMS IPPS Rate,25751.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12588.97,100,MS-DRG,10071.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32320.9,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,CDM,,,,,Inpatient,,,,,,14312.25,,,,Case Rate,100% of CMS IPPS Rate,10373.46,145,MS-DRG,8298.768,Case Rate,145% of CMS IPPS Rate,7154.11,100,MS-DRG,5723.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7154.11,100,,5723.288,Case Rate,100% of CMS IPPS Rate,14033.54,100,,,Case Rate,100% of CMS IPPS Rate,16038.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18043.28,100,,,Case Rate,100% of CMS IPPS Rate,18043.28,100,,,Case Rate,100% of CMS IPPS Rate,18043.28,100,,,Case Rate,100% CMS IPPS Rate,12919.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6510.03,100,,5208.024,Case Rate,100% of CMS IPPS Rate,6510.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6510.03,100,MS-DRG,5208.024,Case Rate,100% of CMS IPPS Rate,6510.03,100,MS-DRG,5208.024,Case Rate,100% of CMS IPPS Rate,6163.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7154.11,100,MS-DRG,5723.288,Case Rate,100% of CMS IPPS Rate,9300.34,130,MS-DRG,7440.272,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7368.73,103,MS-DRG,5894.984,Case Rate,103% of CMS IPPS Rate,7368.73,103,MS-DRG,5894.984,Case Rate,103% of CMS IPPS Rate,13153.47,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7154.11,100,MS-DRG,5723.288,Case Rate,100% of CMS IPPS Rate,7578.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10731.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7154.11,100,MS-DRG,5723.288,Case Rate,100% of CMS IPPS Rate,14634.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7154.11,100,MS-DRG,5723.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18043.28,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,CDM,,,,,Inpatient,,,,,,10692.08,,,,Case Rate,100% of CMS IPPS Rate,7749.57,145,MS-DRG,6199.656,Case Rate,145% of CMS IPPS Rate,5344.53,100,MS-DRG,4275.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5344.53,100,,4275.624,Case Rate,100% of CMS IPPS Rate,9654.31,100,,,Case Rate,100% of CMS IPPS Rate,11033.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12412.79,100,,,Case Rate,100% of CMS IPPS Rate,12412.79,100,,,Case Rate,100% of CMS IPPS Rate,12412.79,100,,,Case Rate,100% CMS IPPS Rate,9651.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4863.45,100,,3890.76,Case Rate,100% of CMS IPPS Rate,4863.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4863.45,100,MS-DRG,3890.76,Case Rate,100% of CMS IPPS Rate,4863.45,100,MS-DRG,3890.76,Case Rate,100% of CMS IPPS Rate,7027.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5344.53,100,MS-DRG,4275.624,Case Rate,100% of CMS IPPS Rate,6947.89,130,MS-DRG,5558.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5504.87,103,MS-DRG,4403.896,Case Rate,103% of CMS IPPS Rate,5504.87,103,MS-DRG,4403.896,Case Rate,103% of CMS IPPS Rate,10959.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5344.53,100,MS-DRG,4275.624,Case Rate,100% of CMS IPPS Rate,5661.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8016.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5344.53,100,MS-DRG,4275.624,Case Rate,100% of CMS IPPS Rate,10932.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5344.53,100,MS-DRG,4275.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4863.45,12412.79,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,CDM,,,,,Inpatient,,,,,,16079.88,,,,Case Rate,100% of CMS IPPS Rate,11654.62,145,MS-DRG,9323.696,Case Rate,145% of CMS IPPS Rate,8037.67,100,MS-DRG,6430.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8037.67,100,,6430.136,Case Rate,100% of CMS IPPS Rate,15601.27,100,,,Case Rate,100% of CMS IPPS Rate,17830.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20058.94,100,,,Case Rate,100% of CMS IPPS Rate,20058.94,100,,,Case Rate,100% of CMS IPPS Rate,20058.94,100,,,Case Rate,100% CMS IPPS Rate,14515.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7314.03,100,,5851.224,Case Rate,100% of CMS IPPS Rate,7314.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7314.03,100,MS-DRG,5851.224,Case Rate,100% of CMS IPPS Rate,7314.03,100,MS-DRG,5851.224,Case Rate,100% of CMS IPPS Rate,8928.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8037.67,100,MS-DRG,6430.136,Case Rate,100% of CMS IPPS Rate,10448.97,130,MS-DRG,8359.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8278.8,103,MS-DRG,6623.04,Case Rate,103% of CMS IPPS Rate,8278.8,103,MS-DRG,6623.04,Case Rate,103% of CMS IPPS Rate,14510.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8037.67,100,MS-DRG,6430.136,Case Rate,100% of CMS IPPS Rate,8514.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12056.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8037.67,100,MS-DRG,6430.136,Case Rate,100% of CMS IPPS Rate,16441.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8037.67,100,MS-DRG,6430.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20058.94,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,CDM,,,,,Inpatient,,,,,,11048.07,,,,Case Rate,100% of CMS IPPS Rate,8007.58,145,MS-DRG,6406.064,Case Rate,145% of CMS IPPS Rate,5522.47,100,MS-DRG,4417.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5522.47,100,,4417.976,Case Rate,100% of CMS IPPS Rate,10699.46,100,,,Case Rate,100% of CMS IPPS Rate,12228.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13756.56,100,,,Case Rate,100% of CMS IPPS Rate,13756.56,100,,,Case Rate,100% of CMS IPPS Rate,13756.56,100,,,Case Rate,100% CMS IPPS Rate,9973.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5025.35,100,,4020.28,Case Rate,100% of CMS IPPS Rate,5025.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5025.35,100,MS-DRG,4020.28,Case Rate,100% of CMS IPPS Rate,5025.35,100,MS-DRG,4020.28,Case Rate,100% of CMS IPPS Rate,4878.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5522.47,100,MS-DRG,4417.976,Case Rate,100% of CMS IPPS Rate,7179.21,130,MS-DRG,5743.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5688.14,103,MS-DRG,4550.512,Case Rate,103% of CMS IPPS Rate,5688.14,103,MS-DRG,4550.512,Case Rate,103% of CMS IPPS Rate,10064.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5522.47,100,MS-DRG,4417.976,Case Rate,100% of CMS IPPS Rate,5850.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8283.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5522.47,100,MS-DRG,4417.976,Case Rate,100% of CMS IPPS Rate,11296.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5522.47,100,MS-DRG,4417.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4878.08,13756.56,
URINARY STONES WITH MCC,693,CDM,,,,,Inpatient,,,,,,19391.98,,,,Case Rate,100% of CMS IPPS Rate,14055.2,145,MS-DRG,11244.16,Case Rate,145% of CMS IPPS Rate,9693.24,100,MS-DRG,7754.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9693.24,100,,7754.592,Case Rate,100% of CMS IPPS Rate,19601.9,100,,,Case Rate,100% of CMS IPPS Rate,22403.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25202.66,100,,,Case Rate,100% of CMS IPPS Rate,25202.66,100,,,Case Rate,100% of CMS IPPS Rate,25202.66,100,,,Case Rate,100% CMS IPPS Rate,17505.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8820.5,100,,7056.4,Case Rate,100% of CMS IPPS Rate,8820.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8820.5,100,MS-DRG,7056.4,Case Rate,100% of CMS IPPS Rate,8820.5,100,MS-DRG,7056.4,Case Rate,100% of CMS IPPS Rate,10432.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9693.24,100,MS-DRG,7754.592,Case Rate,100% of CMS IPPS Rate,12601.21,130,MS-DRG,10080.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9984.04,103,MS-DRG,7987.232,Case Rate,103% of CMS IPPS Rate,9984.04,103,MS-DRG,7987.232,Case Rate,103% of CMS IPPS Rate,18099.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9693.24,100,MS-DRG,7754.592,Case Rate,100% of CMS IPPS Rate,10268.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14539.86,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9693.24,100,MS-DRG,7754.592,Case Rate,100% of CMS IPPS Rate,19828.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9693.24,100,MS-DRG,7754.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25202.66,
URINARY STONES WITHOUT MCC,694,CDM,,,,,Inpatient,,,,,,10716.73,,,,Case Rate,100% of CMS IPPS Rate,7767.43,145,MS-DRG,6213.944,Case Rate,145% of CMS IPPS Rate,5356.85,100,MS-DRG,4285.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5356.85,100,,4285.48,Case Rate,100% of CMS IPPS Rate,10416.84,100,,,Case Rate,100% of CMS IPPS Rate,11905.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13393.2,100,,,Case Rate,100% of CMS IPPS Rate,13393.2,100,,,Case Rate,100% of CMS IPPS Rate,13393.2,100,,,Case Rate,100% CMS IPPS Rate,9674.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4874.65,100,,3899.72,Case Rate,100% of CMS IPPS Rate,4874.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4874.65,100,MS-DRG,3899.72,Case Rate,100% of CMS IPPS Rate,4874.65,100,MS-DRG,3899.72,Case Rate,100% of CMS IPPS Rate,4431.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5356.85,100,MS-DRG,4285.48,Case Rate,100% of CMS IPPS Rate,6963.91,130,MS-DRG,5571.128,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5517.56,103,MS-DRG,4414.048,Case Rate,103% of CMS IPPS Rate,5517.56,103,MS-DRG,4414.048,Case Rate,103% of CMS IPPS Rate,10083.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5356.85,100,MS-DRG,4285.48,Case Rate,100% of CMS IPPS Rate,5674.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8035.28,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5356.85,100,MS-DRG,4285.48,Case Rate,100% of CMS IPPS Rate,10957.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5356.85,100,MS-DRG,4285.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4431.38,13393.2,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,CDM,,,,,Inpatient,,,,,,16375.63,,,,Case Rate,100% of CMS IPPS Rate,11868.98,145,MS-DRG,9495.184,Case Rate,145% of CMS IPPS Rate,8185.5,100,MS-DRG,6548.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8185.5,100,,6548.4,Case Rate,100% of CMS IPPS Rate,15034.7,100,,,Case Rate,100% of CMS IPPS Rate,17183.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19330.49,100,,,Case Rate,100% of CMS IPPS Rate,19330.49,100,,,Case Rate,100% of CMS IPPS Rate,19330.49,100,,,Case Rate,100% CMS IPPS Rate,14782.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7448.56,100,,5958.848,Case Rate,100% of CMS IPPS Rate,7448.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7448.56,100,MS-DRG,5958.848,Case Rate,100% of CMS IPPS Rate,7448.56,100,MS-DRG,5958.848,Case Rate,100% of CMS IPPS Rate,10763.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8185.5,100,MS-DRG,6548.4,Case Rate,100% of CMS IPPS Rate,10641.15,130,MS-DRG,8512.92,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8431.07,103,MS-DRG,6744.856,Case Rate,103% of CMS IPPS Rate,8431.07,103,MS-DRG,6744.856,Case Rate,103% of CMS IPPS Rate,14526,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8185.5,100,MS-DRG,6548.4,Case Rate,100% of CMS IPPS Rate,8671,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12278.25,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8185.5,100,MS-DRG,6548.4,Case Rate,100% of CMS IPPS Rate,16744,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8185.5,100,MS-DRG,6548.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19330.49,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,CDM,,,,,Inpatient,,,,,,9476.23,,,,Case Rate,100% of CMS IPPS Rate,6868.33,145,MS-DRG,5494.664,Case Rate,145% of CMS IPPS Rate,4736.78,100,MS-DRG,3789.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4736.78,100,,3789.424,Case Rate,100% of CMS IPPS Rate,9222.39,100,,,Case Rate,100% of CMS IPPS Rate,10540.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11857.45,100,,,Case Rate,100% of CMS IPPS Rate,11857.45,100,,,Case Rate,100% of CMS IPPS Rate,11857.45,100,,,Case Rate,100% CMS IPPS Rate,8554.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4310.43,100,,3448.344,Case Rate,100% of CMS IPPS Rate,4310.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4310.43,100,MS-DRG,3448.344,Case Rate,100% of CMS IPPS Rate,4310.43,100,MS-DRG,3448.344,Case Rate,100% of CMS IPPS Rate,5377.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4736.78,100,MS-DRG,3789.424,Case Rate,100% of CMS IPPS Rate,6157.81,130,MS-DRG,4926.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4878.88,103,MS-DRG,3903.104,Case Rate,103% of CMS IPPS Rate,4878.88,103,MS-DRG,3903.104,Case Rate,103% of CMS IPPS Rate,8766.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4736.78,100,MS-DRG,3789.424,Case Rate,100% of CMS IPPS Rate,5017.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7105.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4736.78,100,MS-DRG,3789.424,Case Rate,100% of CMS IPPS Rate,9689.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4736.78,100,MS-DRG,3789.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4310.43,11857.45,
URETHRAL STRICTURE,697,CDM,,,,,Inpatient,,,,,,15240.57,,,,Case Rate,100% of CMS IPPS Rate,11046.3,145,MS-DRG,8837.04,Case Rate,145% of CMS IPPS Rate,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7618.14,100,,6094.512,Case Rate,100% of CMS IPPS Rate,12968.4,100,,,Case Rate,100% of CMS IPPS Rate,14821.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16673.79,100,,,Case Rate,100% of CMS IPPS Rate,16673.79,100,,,Case Rate,100% of CMS IPPS Rate,16673.79,100,,,Case Rate,100% CMS IPPS Rate,13757.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6932.27,100,,5545.816,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,5545.816,Case Rate,100% of CMS IPPS Rate,6932.27,100,MS-DRG,5545.816,Case Rate,100% of CMS IPPS Rate,10016.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,9903.58,130,MS-DRG,7922.864,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7846.68,103,MS-DRG,6277.344,Case Rate,103% of CMS IPPS Rate,7846.68,103,MS-DRG,6277.344,Case Rate,103% of CMS IPPS Rate,12553.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,8069.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11427.21,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,15583.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7618.14,100,MS-DRG,6094.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16673.79,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,CDM,,,,,Inpatient,,,,,,22652.04,,,,Case Rate,100% of CMS IPPS Rate,16418.07,145,MS-DRG,13134.456,Case Rate,145% of CMS IPPS Rate,11322.81,100,MS-DRG,9058.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11322.81,100,,9058.248,Case Rate,100% of CMS IPPS Rate,22408.08,100,,,Case Rate,100% of CMS IPPS Rate,25610.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28810.63,100,,,Case Rate,100% of CMS IPPS Rate,28810.63,100,,,Case Rate,100% of CMS IPPS Rate,28810.63,100,,,Case Rate,100% CMS IPPS Rate,20448.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10303.32,100,,8242.656,Case Rate,100% of CMS IPPS Rate,10303.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10303.32,100,MS-DRG,8242.656,Case Rate,100% of CMS IPPS Rate,10303.32,100,MS-DRG,8242.656,Case Rate,100% of CMS IPPS Rate,11755.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11322.81,100,MS-DRG,9058.248,Case Rate,100% of CMS IPPS Rate,14719.65,130,MS-DRG,11775.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11662.49,103,MS-DRG,9329.992,Case Rate,103% of CMS IPPS Rate,11662.49,103,MS-DRG,9329.992,Case Rate,103% of CMS IPPS Rate,20271.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11322.81,100,MS-DRG,9058.248,Case Rate,100% of CMS IPPS Rate,11994.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16984.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11322.81,100,MS-DRG,9058.248,Case Rate,100% of CMS IPPS Rate,23161.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11322.81,100,MS-DRG,9058.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28810.63,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,CDM,,,,,Inpatient,,,,,,13976.79,,,,Case Rate,100% of CMS IPPS Rate,10130.31,145,MS-DRG,8104.248,Case Rate,145% of CMS IPPS Rate,6986.42,100,MS-DRG,5589.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6986.42,100,,5589.136,Case Rate,100% of CMS IPPS Rate,13596.29,100,,,Case Rate,100% of CMS IPPS Rate,15539.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17481.09,100,,,Case Rate,100% of CMS IPPS Rate,17481.09,100,,,Case Rate,100% of CMS IPPS Rate,17481.09,100,,,Case Rate,100% CMS IPPS Rate,12617.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6357.46,100,,5085.968,Case Rate,100% of CMS IPPS Rate,6357.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6357.46,100,MS-DRG,5085.968,Case Rate,100% of CMS IPPS Rate,6357.46,100,MS-DRG,5085.968,Case Rate,100% of CMS IPPS Rate,6293.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6986.42,100,MS-DRG,5589.136,Case Rate,100% of CMS IPPS Rate,9082.35,130,MS-DRG,7265.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7196.01,103,MS-DRG,5756.808,Case Rate,103% of CMS IPPS Rate,7196.01,103,MS-DRG,5756.808,Case Rate,103% of CMS IPPS Rate,12803.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6986.42,100,MS-DRG,5589.136,Case Rate,100% of CMS IPPS Rate,7400.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10479.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6986.42,100,MS-DRG,5589.136,Case Rate,100% of CMS IPPS Rate,14291.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6986.42,100,MS-DRG,5589.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17481.09,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,CDM,,,,,Inpatient,,,,,,9698.04,,,,Case Rate,100% of CMS IPPS Rate,7029.09,145,MS-DRG,5623.272,Case Rate,145% of CMS IPPS Rate,4847.65,100,MS-DRG,3878.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4847.65,100,,3878.12,Case Rate,100% of CMS IPPS Rate,9254.38,100,,,Case Rate,100% of CMS IPPS Rate,10576.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11898.59,100,,,Case Rate,100% of CMS IPPS Rate,11898.59,100,,,Case Rate,100% of CMS IPPS Rate,11898.59,100,,,Case Rate,100% CMS IPPS Rate,8754.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4411.31,100,,3529.048,Case Rate,100% of CMS IPPS Rate,4411.31,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4411.31,100,MS-DRG,3529.048,Case Rate,100% of CMS IPPS Rate,4411.31,100,MS-DRG,3529.048,Case Rate,100% of CMS IPPS Rate,6269.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4847.65,100,MS-DRG,3878.12,Case Rate,100% of CMS IPPS Rate,6301.95,130,MS-DRG,5041.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4993.08,103,MS-DRG,3994.464,Case Rate,103% of CMS IPPS Rate,4993.08,103,MS-DRG,3994.464,Case Rate,103% of CMS IPPS Rate,9371.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4847.65,100,MS-DRG,3878.12,Case Rate,100% of CMS IPPS Rate,5135.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7271.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4847.65,100,MS-DRG,3878.12,Case Rate,100% of CMS IPPS Rate,9916.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4847.65,100,MS-DRG,3878.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4411.31,11898.59,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,CDM,,,,,Inpatient,,,,,,26862.33,,,,Case Rate,100% of CMS IPPS Rate,19469.7,145,MS-DRG,15575.76,Case Rate,145% of CMS IPPS Rate,13427.38,100,MS-DRG,10741.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13427.38,100,,10741.904,Case Rate,100% of CMS IPPS Rate,25870.14,100,,,Case Rate,100% of CMS IPPS Rate,29566.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33261.88,100,,,Case Rate,100% of CMS IPPS Rate,33261.88,100,,,Case Rate,100% of CMS IPPS Rate,33261.88,100,,,Case Rate,100% CMS IPPS Rate,24249.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12218.33,100,,9774.664,Case Rate,100% of CMS IPPS Rate,12218.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12218.33,100,MS-DRG,9774.664,Case Rate,100% of CMS IPPS Rate,12218.33,100,MS-DRG,9774.664,Case Rate,100% of CMS IPPS Rate,17581.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13427.38,100,MS-DRG,10741.904,Case Rate,100% of CMS IPPS Rate,17455.59,130,MS-DRG,13964.472,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13830.2,103,MS-DRG,11064.16,Case Rate,103% of CMS IPPS Rate,13830.2,103,MS-DRG,11064.16,Case Rate,103% of CMS IPPS Rate,25240.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13427.38,100,MS-DRG,10741.904,Case Rate,100% of CMS IPPS Rate,14223.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20141.07,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13427.38,100,MS-DRG,10741.904,Case Rate,100% of CMS IPPS Rate,27466.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13427.38,100,MS-DRG,10741.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33261.88,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,CDM,,,,,Inpatient,,,,,,19969.78,,,,Case Rate,100% of CMS IPPS Rate,14474,145,MS-DRG,11579.2,Case Rate,145% of CMS IPPS Rate,9982.07,100,MS-DRG,7985.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9982.07,100,,7985.656,Case Rate,100% of CMS IPPS Rate,19763.21,100,,,Case Rate,100% of CMS IPPS Rate,22587.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25410.05,100,,,Case Rate,100% of CMS IPPS Rate,25410.05,100,,,Case Rate,100% of CMS IPPS Rate,25410.05,100,,,Case Rate,100% CMS IPPS Rate,18027.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9083.32,100,,7266.656,Case Rate,100% of CMS IPPS Rate,9083.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9083.32,100,MS-DRG,7266.656,Case Rate,100% of CMS IPPS Rate,9083.32,100,MS-DRG,7266.656,Case Rate,100% of CMS IPPS Rate,16542.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9982.07,100,MS-DRG,7985.656,Case Rate,100% of CMS IPPS Rate,12976.69,130,MS-DRG,10381.352,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10281.53,103,MS-DRG,8225.224,Case Rate,103% of CMS IPPS Rate,10281.53,103,MS-DRG,8225.224,Case Rate,103% of CMS IPPS Rate,18781.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9982.07,100,MS-DRG,7985.656,Case Rate,100% of CMS IPPS Rate,10574.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14973.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9982.07,100,MS-DRG,7985.656,Case Rate,100% of CMS IPPS Rate,20419,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9982.07,100,MS-DRG,7985.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25410.05,
PENIS PROCEDURES WITH CC/MCC,709,CDM,,,,,Inpatient,,,,,,29027.04,,,,Case Rate,100% of CMS IPPS Rate,21542.78,145,MS-DRG,17234.224,Case Rate,145% of CMS IPPS Rate,14857.09,100,MS-DRG,11885.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14857.09,100,,11885.672,Case Rate,100% of CMS IPPS Rate,29956.09,100,,,Case Rate,100% of CMS IPPS Rate,34236.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38515.29,100,,,Case Rate,100% of CMS IPPS Rate,38515.29,100,,,Case Rate,100% of CMS IPPS Rate,38515.29,100,,,Case Rate,100% CMS IPPS Rate,26203.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13519.28,100,,10815.424,Case Rate,100% of CMS IPPS Rate,13519.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13519.28,100,MS-DRG,10815.424,Case Rate,100% of CMS IPPS Rate,13519.28,100,MS-DRG,10815.424,Case Rate,100% of CMS IPPS Rate,19535.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14857.09,100,MS-DRG,11885.672,Case Rate,100% of CMS IPPS Rate,19314.22,130,MS-DRG,15451.376,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15302.8,103,MS-DRG,12242.24,Case Rate,103% of CMS IPPS Rate,15302.8,103,MS-DRG,12242.24,Case Rate,103% of CMS IPPS Rate,30511.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14857.09,100,MS-DRG,11885.672,Case Rate,100% of CMS IPPS Rate,15370,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22285.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14857.09,100,MS-DRG,11885.672,Case Rate,100% of CMS IPPS Rate,29680,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14857.09,100,MS-DRG,11885.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38515.29,
PENIS PROCEDURES WITHOUT CC/MCC,710,CDM,,,,,Inpatient,,,,,,16900.04,,,,Case Rate,100% of CMS IPPS Rate,12874.27,145,MS-DRG,10299.416,Case Rate,145% of CMS IPPS Rate,8878.81,100,MS-DRG,7103.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8878.81,100,,7103.048,Case Rate,100% of CMS IPPS Rate,20015.16,100,,,Case Rate,100% of CMS IPPS Rate,22875.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25734,100,,,Case Rate,100% of CMS IPPS Rate,25734,100,,,Case Rate,100% of CMS IPPS Rate,25734,100,,,Case Rate,100% CMS IPPS Rate,15255.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8079.4,100,,6463.52,Case Rate,100% of CMS IPPS Rate,8079.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8079.4,100,MS-DRG,6463.52,Case Rate,100% of CMS IPPS Rate,8079.4,100,MS-DRG,6463.52,Case Rate,100% of CMS IPPS Rate,12459.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8878.81,100,MS-DRG,7103.048,Case Rate,100% of CMS IPPS Rate,11542.45,130,MS-DRG,9233.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9145.17,103,MS-DRG,7316.136,Case Rate,103% of CMS IPPS Rate,9145.17,103,MS-DRG,7316.136,Case Rate,103% of CMS IPPS Rate,18233.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8878.81,100,MS-DRG,7103.048,Case Rate,100% of CMS IPPS Rate,8948.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13318.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8878.81,100,MS-DRG,7103.048,Case Rate,100% of CMS IPPS Rate,17280.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8878.81,100,MS-DRG,7103.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25734,
TESTES PROCEDURES WITH CC/MCC,711,CDM,,,,,Inpatient,,,,,,29066.75,,,,Case Rate,100% of CMS IPPS Rate,21067.43,145,MS-DRG,16853.944,Case Rate,145% of CMS IPPS Rate,14529.26,100,MS-DRG,11623.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14529.26,100,,11623.408,Case Rate,100% of CMS IPPS Rate,25430.22,100,,,Case Rate,100% of CMS IPPS Rate,29064.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32696.26,100,,,Case Rate,100% of CMS IPPS Rate,32696.26,100,,,Case Rate,100% of CMS IPPS Rate,32696.26,100,,,Case Rate,100% CMS IPPS Rate,26239.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13220.98,100,,10576.784,Case Rate,100% of CMS IPPS Rate,13220.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13220.98,100,MS-DRG,10576.784,Case Rate,100% of CMS IPPS Rate,13220.98,100,MS-DRG,10576.784,Case Rate,100% of CMS IPPS Rate,19103.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14529.26,100,MS-DRG,11623.408,Case Rate,100% of CMS IPPS Rate,18888.04,130,MS-DRG,15110.432,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14965.14,103,MS-DRG,11972.112,Case Rate,103% of CMS IPPS Rate,14965.14,103,MS-DRG,11972.112,Case Rate,103% of CMS IPPS Rate,25849.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14529.26,100,MS-DRG,11623.408,Case Rate,100% of CMS IPPS Rate,15391.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21793.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14529.26,100,MS-DRG,11623.408,Case Rate,100% of CMS IPPS Rate,29720.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14529.26,100,MS-DRG,11623.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32696.26,
TESTES PROCEDURES WITHOUT CC/MCC,712,CDM,,,,,Inpatient,,,,,,16271.57,,,,Case Rate,100% of CMS IPPS Rate,11793.56,145,MS-DRG,9434.848,Case Rate,145% of CMS IPPS Rate,8133.49,100,MS-DRG,6506.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8133.49,100,,6506.792,Case Rate,100% of CMS IPPS Rate,11812.6,100,,,Case Rate,100% of CMS IPPS Rate,13500.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15187.75,100,,,Case Rate,100% of CMS IPPS Rate,15187.75,100,,,Case Rate,100% of CMS IPPS Rate,15187.75,100,,,Case Rate,100% CMS IPPS Rate,14688.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7401.21,100,,5920.968,Case Rate,100% of CMS IPPS Rate,7401.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7401.21,100,MS-DRG,5920.968,Case Rate,100% of CMS IPPS Rate,7401.21,100,MS-DRG,5920.968,Case Rate,100% of CMS IPPS Rate,8180.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8133.49,100,MS-DRG,6506.792,Case Rate,100% of CMS IPPS Rate,10573.54,130,MS-DRG,8458.832,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8377.49,103,MS-DRG,6701.992,Case Rate,103% of CMS IPPS Rate,8377.49,103,MS-DRG,6701.992,Case Rate,103% of CMS IPPS Rate,15706.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8133.49,100,MS-DRG,6506.792,Case Rate,100% of CMS IPPS Rate,8615.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12200.24,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8133.49,100,MS-DRG,6506.792,Case Rate,100% of CMS IPPS Rate,16637.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8133.49,100,MS-DRG,6506.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16637.6,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,CDM,,,,,Inpatient,,,,,,19862.98,,,,Case Rate,100% of CMS IPPS Rate,14396.59,145,MS-DRG,11517.272,Case Rate,145% of CMS IPPS Rate,9928.68,100,MS-DRG,7942.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9928.68,100,,7942.944,Case Rate,100% of CMS IPPS Rate,19276.63,100,,,Case Rate,100% of CMS IPPS Rate,22031.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24784.44,100,,,Case Rate,100% of CMS IPPS Rate,24784.44,100,,,Case Rate,100% of CMS IPPS Rate,24784.44,100,,,Case Rate,100% CMS IPPS Rate,17930.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9034.74,100,,7227.792,Case Rate,100% of CMS IPPS Rate,9034.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9034.74,100,MS-DRG,7227.792,Case Rate,100% of CMS IPPS Rate,9034.74,100,MS-DRG,7227.792,Case Rate,100% of CMS IPPS Rate,13054.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9928.68,100,MS-DRG,7942.944,Case Rate,100% of CMS IPPS Rate,12907.28,130,MS-DRG,10325.824,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10226.54,103,MS-DRG,8181.232,Case Rate,103% of CMS IPPS Rate,10226.54,103,MS-DRG,8181.232,Case Rate,103% of CMS IPPS Rate,18746.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9928.68,100,MS-DRG,7942.944,Case Rate,100% of CMS IPPS Rate,10517.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14893.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9928.68,100,MS-DRG,7942.944,Case Rate,100% of CMS IPPS Rate,20309.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9928.68,100,MS-DRG,7942.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24784.44,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,CDM,,,,,Inpatient,,,,,,13123.78,,,,Case Rate,100% of CMS IPPS Rate,9512.06,145,MS-DRG,7609.648,Case Rate,145% of CMS IPPS Rate,6560.04,100,MS-DRG,5248.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6560.04,100,,5248.032,Case Rate,100% of CMS IPPS Rate,12527.14,100,,,Case Rate,100% of CMS IPPS Rate,14317.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16106.46,100,,,Case Rate,100% of CMS IPPS Rate,16106.46,100,,,Case Rate,100% of CMS IPPS Rate,16106.46,100,,,Case Rate,100% CMS IPPS Rate,11847.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5969.47,100,,4775.576,Case Rate,100% of CMS IPPS Rate,5969.47,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5969.47,100,MS-DRG,4775.576,Case Rate,100% of CMS IPPS Rate,5969.47,100,MS-DRG,4775.576,Case Rate,100% of CMS IPPS Rate,8625.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6560.04,100,MS-DRG,5248.032,Case Rate,100% of CMS IPPS Rate,8528.05,130,MS-DRG,6822.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6756.84,103,MS-DRG,5405.472,Case Rate,103% of CMS IPPS Rate,6756.84,103,MS-DRG,5405.472,Case Rate,103% of CMS IPPS Rate,12121.23,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6560.04,100,MS-DRG,5248.032,Case Rate,100% of CMS IPPS Rate,6949.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9840.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6560.04,100,MS-DRG,5248.032,Case Rate,100% of CMS IPPS Rate,13419,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6560.04,100,MS-DRG,5248.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16106.46,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,CDM,,,,,Inpatient,,,,,,30225.09,,,,Case Rate,100% of CMS IPPS Rate,21906.99,145,MS-DRG,17525.592,Case Rate,145% of CMS IPPS Rate,15108.27,100,MS-DRG,12086.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15108.27,100,,12086.616,Case Rate,100% of CMS IPPS Rate,30105.4,100,,,Case Rate,100% of CMS IPPS Rate,34407.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38707.26,100,,,Case Rate,100% of CMS IPPS Rate,38707.26,100,,,Case Rate,100% of CMS IPPS Rate,38707.26,100,,,Case Rate,100% CMS IPPS Rate,27284.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13747.83,100,,10998.264,Case Rate,100% of CMS IPPS Rate,13747.83,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13747.83,100,MS-DRG,10998.264,Case Rate,100% of CMS IPPS Rate,13747.83,100,MS-DRG,10998.264,Case Rate,100% of CMS IPPS Rate,19865,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15108.27,100,MS-DRG,12086.616,Case Rate,100% of CMS IPPS Rate,19640.75,130,MS-DRG,15712.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15561.52,103,MS-DRG,12449.216,Case Rate,103% of CMS IPPS Rate,15561.52,103,MS-DRG,12449.216,Case Rate,103% of CMS IPPS Rate,28249.98,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15108.27,100,MS-DRG,12086.616,Case Rate,100% of CMS IPPS Rate,16004.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22662.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15108.27,100,MS-DRG,12086.616,Case Rate,100% of CMS IPPS Rate,30905,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15108.27,100,MS-DRG,12086.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38707.26,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,CDM,,,,,Inpatient,,,,,,19472.76,,,,Case Rate,100% of CMS IPPS Rate,14113.76,145,MS-DRG,11291.008,Case Rate,145% of CMS IPPS Rate,9733.63,100,MS-DRG,7786.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9733.63,100,,7786.904,Case Rate,100% of CMS IPPS Rate,18920.69,100,,,Case Rate,100% of CMS IPPS Rate,21624.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24326.8,100,,,Case Rate,100% of CMS IPPS Rate,24326.8,100,,,Case Rate,100% of CMS IPPS Rate,24326.8,100,,,Case Rate,100% CMS IPPS Rate,17578.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8857.25,100,,7085.8,Case Rate,100% of CMS IPPS Rate,8857.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8857.25,100,MS-DRG,7085.8,Case Rate,100% of CMS IPPS Rate,8857.25,100,MS-DRG,7085.8,Case Rate,100% of CMS IPPS Rate,12797.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9733.63,100,MS-DRG,7786.904,Case Rate,100% of CMS IPPS Rate,12653.72,130,MS-DRG,10122.976,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10025.64,103,MS-DRG,8020.512,Case Rate,103% of CMS IPPS Rate,10025.64,103,MS-DRG,8020.512,Case Rate,103% of CMS IPPS Rate,16625.9,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9733.63,100,MS-DRG,7786.904,Case Rate,100% of CMS IPPS Rate,10310.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14600.45,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9733.63,100,MS-DRG,7786.904,Case Rate,100% of CMS IPPS Rate,19910.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9733.63,100,MS-DRG,7786.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24326.8,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,CDM,,,,,Inpatient,,,,,,24833.18,,,,Case Rate,100% of CMS IPPS Rate,17998.97,145,MS-DRG,14399.176,Case Rate,145% of CMS IPPS Rate,12413.08,100,MS-DRG,9930.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12413.08,100,,9930.464,Case Rate,100% of CMS IPPS Rate,24735.67,100,,,Case Rate,100% of CMS IPPS Rate,28270.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31803.27,100,,,Case Rate,100% of CMS IPPS Rate,31803.27,100,,,Case Rate,100% of CMS IPPS Rate,31803.27,100,,,Case Rate,100% CMS IPPS Rate,22417.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11295.38,100,,9036.304,Case Rate,100% of CMS IPPS Rate,11295.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11295.38,100,MS-DRG,9036.304,Case Rate,100% of CMS IPPS Rate,11295.38,100,MS-DRG,9036.304,Case Rate,100% of CMS IPPS Rate,20670.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12413.08,100,MS-DRG,9930.464,Case Rate,100% of CMS IPPS Rate,16137,130,MS-DRG,12909.6,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12785.47,103,MS-DRG,10228.376,Case Rate,103% of CMS IPPS Rate,12785.47,103,MS-DRG,10228.376,Case Rate,103% of CMS IPPS Rate,22394.3,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12413.08,100,MS-DRG,9930.464,Case Rate,100% of CMS IPPS Rate,13149.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18619.62,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12413.08,100,MS-DRG,9930.464,Case Rate,100% of CMS IPPS Rate,25391.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12413.08,100,MS-DRG,9930.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31803.27,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,CDM,,,,,Inpatient,,,,,,16099.05,,,,Case Rate,100% of CMS IPPS Rate,11668.51,145,MS-DRG,9334.808,Case Rate,145% of CMS IPPS Rate,8047.25,100,MS-DRG,6437.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8047.25,100,,6437.8,Case Rate,100% of CMS IPPS Rate,16422.46,100,,,Case Rate,100% of CMS IPPS Rate,18769.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21114.77,100,,,Case Rate,100% of CMS IPPS Rate,21114.77,100,,,Case Rate,100% of CMS IPPS Rate,21114.77,100,,,Case Rate,100% CMS IPPS Rate,14532.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7322.74,100,,5858.192,Case Rate,100% of CMS IPPS Rate,7322.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7322.74,100,MS-DRG,5858.192,Case Rate,100% of CMS IPPS Rate,7322.74,100,MS-DRG,5858.192,Case Rate,100% of CMS IPPS Rate,10580.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8047.25,100,MS-DRG,6437.8,Case Rate,100% of CMS IPPS Rate,10461.43,130,MS-DRG,8369.144,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8288.67,103,MS-DRG,6630.936,Case Rate,103% of CMS IPPS Rate,8288.67,103,MS-DRG,6630.936,Case Rate,103% of CMS IPPS Rate,16052.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8047.25,100,MS-DRG,6437.8,Case Rate,100% of CMS IPPS Rate,8524.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12070.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8047.25,100,MS-DRG,6437.8,Case Rate,100% of CMS IPPS Rate,16461.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8047.25,100,MS-DRG,6437.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21114.77,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,CDM,,,,,Inpatient,,,,,,25669.76,,,,Case Rate,100% of CMS IPPS Rate,18605.31,145,MS-DRG,14884.248,Case Rate,145% of CMS IPPS Rate,12831.25,100,MS-DRG,10265,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12831.25,100,,10265,Case Rate,100% of CMS IPPS Rate,23047.97,100,,,Case Rate,100% of CMS IPPS Rate,26341.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29633.35,100,,,Case Rate,100% of CMS IPPS Rate,29633.35,100,,,Case Rate,100% of CMS IPPS Rate,29633.35,100,,,Case Rate,100% CMS IPPS Rate,23172.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11675.89,100,,9340.712,Case Rate,100% of CMS IPPS Rate,11675.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11675.89,100,MS-DRG,9340.712,Case Rate,100% of CMS IPPS Rate,11675.89,100,MS-DRG,9340.712,Case Rate,100% of CMS IPPS Rate,16871.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12831.25,100,MS-DRG,10265,Case Rate,100% of CMS IPPS Rate,16680.63,130,MS-DRG,13344.504,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13216.19,103,MS-DRG,10572.952,Case Rate,103% of CMS IPPS Rate,13216.19,103,MS-DRG,10572.952,Case Rate,103% of CMS IPPS Rate,21475.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12831.25,100,MS-DRG,10265,Case Rate,100% of CMS IPPS Rate,13592.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19246.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12831.25,100,MS-DRG,10265,Case Rate,100% of CMS IPPS Rate,26247.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12831.25,100,MS-DRG,10265,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29633.35,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,CDM,,,,,Inpatient,,,,,,15257,,,,Case Rate,100% of CMS IPPS Rate,11058.19,145,MS-DRG,8846.552,Case Rate,145% of CMS IPPS Rate,7626.34,100,MS-DRG,6101.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7626.34,100,,6101.072,Case Rate,100% of CMS IPPS Rate,14969.38,100,,,Case Rate,100% of CMS IPPS Rate,17108.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19246.51,100,,,Case Rate,100% of CMS IPPS Rate,19246.51,100,,,Case Rate,100% of CMS IPPS Rate,19246.51,100,,,Case Rate,100% CMS IPPS Rate,13772.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6939.75,100,,5551.8,Case Rate,100% of CMS IPPS Rate,6939.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6939.75,100,MS-DRG,5551.8,Case Rate,100% of CMS IPPS Rate,6939.75,100,MS-DRG,5551.8,Case Rate,100% of CMS IPPS Rate,10027.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7626.34,100,MS-DRG,6101.072,Case Rate,100% of CMS IPPS Rate,9914.24,130,MS-DRG,7931.392,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7855.13,103,MS-DRG,6284.104,Case Rate,103% of CMS IPPS Rate,7855.13,103,MS-DRG,6284.104,Case Rate,103% of CMS IPPS Rate,14577.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7626.34,100,MS-DRG,6101.072,Case Rate,100% of CMS IPPS Rate,8078.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11439.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7626.34,100,MS-DRG,6101.072,Case Rate,100% of CMS IPPS Rate,15600.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7626.34,100,MS-DRG,6101.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19246.51,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,CDM,,,,,Inpatient,,,,,,11083.67,,,,Case Rate,100% of CMS IPPS Rate,8033.39,145,MS-DRG,6426.712,Case Rate,145% of CMS IPPS Rate,5540.27,100,MS-DRG,4432.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5540.27,100,,4432.216,Case Rate,100% of CMS IPPS Rate,8757.13,100,,,Case Rate,100% of CMS IPPS Rate,10008.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11259.27,100,,,Case Rate,100% of CMS IPPS Rate,11259.27,100,,,Case Rate,100% of CMS IPPS Rate,11259.27,100,,,Case Rate,100% CMS IPPS Rate,10005.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5041.55,100,,4033.24,Case Rate,100% of CMS IPPS Rate,5041.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5041.55,100,MS-DRG,4033.24,Case Rate,100% of CMS IPPS Rate,5041.55,100,MS-DRG,4033.24,Case Rate,100% of CMS IPPS Rate,7284.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5540.27,100,MS-DRG,4432.216,Case Rate,100% of CMS IPPS Rate,7202.35,130,MS-DRG,5761.88,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5706.48,103,MS-DRG,4565.184,Case Rate,103% of CMS IPPS Rate,5706.48,103,MS-DRG,4565.184,Case Rate,103% of CMS IPPS Rate,9678.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5540.27,100,MS-DRG,4432.216,Case Rate,100% of CMS IPPS Rate,5868.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8310.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5540.27,100,MS-DRG,4432.216,Case Rate,100% of CMS IPPS Rate,11333,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5540.27,100,MS-DRG,4432.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5041.55,11333,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,CDM,,,,,Inpatient,,,,,,16990.4,,,,Case Rate,100% of CMS IPPS Rate,12314.56,145,MS-DRG,9851.648,Case Rate,145% of CMS IPPS Rate,8492.8,100,MS-DRG,6794.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8492.8,100,,6794.24,Case Rate,100% of CMS IPPS Rate,16831.72,100,,,Case Rate,100% of CMS IPPS Rate,19236.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21640.96,100,,,Case Rate,100% of CMS IPPS Rate,21640.96,100,,,Case Rate,100% of CMS IPPS Rate,21640.96,100,,,Case Rate,100% CMS IPPS Rate,15337.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7728.16,100,,6182.528,Case Rate,100% of CMS IPPS Rate,7728.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7728.16,100,MS-DRG,6182.528,Case Rate,100% of CMS IPPS Rate,7728.16,100,MS-DRG,6182.528,Case Rate,100% of CMS IPPS Rate,11166.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8492.8,100,MS-DRG,6794.24,Case Rate,100% of CMS IPPS Rate,11040.64,130,MS-DRG,8832.512,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8747.58,103,MS-DRG,6998.064,Case Rate,103% of CMS IPPS Rate,8747.58,103,MS-DRG,6998.064,Case Rate,103% of CMS IPPS Rate,15803.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8492.8,100,MS-DRG,6794.24,Case Rate,100% of CMS IPPS Rate,8996.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12739.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8492.8,100,MS-DRG,6794.24,Case Rate,100% of CMS IPPS Rate,17372.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8492.8,100,MS-DRG,6794.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21640.96,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,CDM,,,,,Inpatient,,,,,,10007.48,,,,Case Rate,100% of CMS IPPS Rate,7253.38,145,MS-DRG,5802.704,Case Rate,145% of CMS IPPS Rate,5002.33,100,MS-DRG,4001.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5002.33,100,,4001.864,Case Rate,100% of CMS IPPS Rate,9923.6,100,,,Case Rate,100% of CMS IPPS Rate,11341.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12759.02,100,,,Case Rate,100% of CMS IPPS Rate,12759.02,100,,,Case Rate,100% of CMS IPPS Rate,12759.02,100,,,Case Rate,100% CMS IPPS Rate,9033.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4552.06,100,,3641.648,Case Rate,100% of CMS IPPS Rate,4552.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4552.06,100,MS-DRG,3641.648,Case Rate,100% of CMS IPPS Rate,4552.06,100,MS-DRG,3641.648,Case Rate,100% of CMS IPPS Rate,6577.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5002.33,100,MS-DRG,4001.864,Case Rate,100% of CMS IPPS Rate,6503.03,130,MS-DRG,5202.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5152.4,103,MS-DRG,4121.92,Case Rate,103% of CMS IPPS Rate,5152.4,103,MS-DRG,4121.92,Case Rate,103% of CMS IPPS Rate,9760.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5002.33,100,MS-DRG,4001.864,Case Rate,100% of CMS IPPS Rate,5299.03,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7503.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5002.33,100,MS-DRG,4001.864,Case Rate,100% of CMS IPPS Rate,10232.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5002.33,100,MS-DRG,4001.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4552.06,12759.02,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,CDM,,,,,Inpatient,,,,,,22194.73,,,,Case Rate,100% of CMS IPPS Rate,16086.62,145,MS-DRG,12869.296,Case Rate,145% of CMS IPPS Rate,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11094.22,100,,8875.376,Case Rate,100% of CMS IPPS Rate,19588.57,100,,,Case Rate,100% of CMS IPPS Rate,22387.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25185.52,100,,,Case Rate,100% of CMS IPPS Rate,25185.52,100,,,Case Rate,100% of CMS IPPS Rate,25185.52,100,,,Case Rate,100% CMS IPPS Rate,20035.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10095.32,100,,8076.256,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,8076.256,Case Rate,100% of CMS IPPS Rate,10095.32,100,MS-DRG,8076.256,Case Rate,100% of CMS IPPS Rate,14587.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,14422.49,130,MS-DRG,11537.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11427.05,103,MS-DRG,9141.64,Case Rate,103% of CMS IPPS Rate,11427.05,103,MS-DRG,9141.64,Case Rate,103% of CMS IPPS Rate,18175.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,11752.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16641.33,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,22694,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11094.22,100,MS-DRG,8875.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25185.52,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,CDM,,,,,Inpatient,,,,,,10954.97,,,,Case Rate,100% of CMS IPPS Rate,7940.1,145,MS-DRG,6352.08,Case Rate,145% of CMS IPPS Rate,5475.93,100,MS-DRG,4380.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5475.93,100,,4380.744,Case Rate,100% of CMS IPPS Rate,10892.76,100,,,Case Rate,100% of CMS IPPS Rate,12449.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14005.09,100,,,Case Rate,100% of CMS IPPS Rate,14005.09,100,,,Case Rate,100% of CMS IPPS Rate,14005.09,100,,,Case Rate,100% CMS IPPS Rate,9889.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4983.01,100,,3986.408,Case Rate,100% of CMS IPPS Rate,4983.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4983.01,100,MS-DRG,3986.408,Case Rate,100% of CMS IPPS Rate,4983.01,100,MS-DRG,3986.408,Case Rate,100% of CMS IPPS Rate,4231.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5475.93,100,MS-DRG,4380.744,Case Rate,100% of CMS IPPS Rate,7118.71,130,MS-DRG,5694.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5640.21,103,MS-DRG,4512.168,Case Rate,103% of CMS IPPS Rate,5640.21,103,MS-DRG,4512.168,Case Rate,103% of CMS IPPS Rate,10394.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5475.93,100,MS-DRG,4380.744,Case Rate,100% of CMS IPPS Rate,5800.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8213.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5475.93,100,MS-DRG,4380.744,Case Rate,100% of CMS IPPS Rate,11201.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5475.93,100,MS-DRG,4380.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4231.94,14005.09,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,CDM,,,,,Inpatient,,,,,,13745.4,,,,Case Rate,100% of CMS IPPS Rate,9962.6,145,MS-DRG,7970.08,Case Rate,145% of CMS IPPS Rate,6870.76,100,MS-DRG,5496.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6870.76,100,,5496.608,Case Rate,100% of CMS IPPS Rate,14676.1,100,,,Case Rate,100% of CMS IPPS Rate,16773.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18869.43,100,,,Case Rate,100% of CMS IPPS Rate,18869.43,100,,,Case Rate,100% of CMS IPPS Rate,18869.43,100,,,Case Rate,100% CMS IPPS Rate,12408.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6252.21,100,,5001.768,Case Rate,100% of CMS IPPS Rate,6252.21,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6252.21,100,MS-DRG,5001.768,Case Rate,100% of CMS IPPS Rate,6252.21,100,MS-DRG,5001.768,Case Rate,100% of CMS IPPS Rate,9033.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6870.76,100,MS-DRG,5496.608,Case Rate,100% of CMS IPPS Rate,8931.99,130,MS-DRG,7145.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7076.88,103,MS-DRG,5661.504,Case Rate,103% of CMS IPPS Rate,7076.88,103,MS-DRG,5661.504,Case Rate,103% of CMS IPPS Rate,13634.17,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6870.76,100,MS-DRG,5496.608,Case Rate,100% of CMS IPPS Rate,7278.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10306.14,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6870.76,100,MS-DRG,5496.608,Case Rate,100% of CMS IPPS Rate,14054.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6870.76,100,MS-DRG,5496.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18869.43,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,CDM,,,,,Inpatient,,,,,,8510.95,,,,Case Rate,100% of CMS IPPS Rate,6168.69,145,MS-DRG,4934.952,Case Rate,145% of CMS IPPS Rate,4254.27,100,MS-DRG,3403.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4254.27,100,,3403.416,Case Rate,100% of CMS IPPS Rate,8090.58,100,,,Case Rate,100% of CMS IPPS Rate,9246.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10402.27,100,,,Case Rate,100% of CMS IPPS Rate,10402.27,100,,,Case Rate,100% of CMS IPPS Rate,10402.27,100,,,Case Rate,100% CMS IPPS Rate,7682.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3871.37,100,,3097.096,Case Rate,100% of CMS IPPS Rate,3871.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3871.37,100,MS-DRG,3097.096,Case Rate,100% of CMS IPPS Rate,3871.37,100,MS-DRG,3097.096,Case Rate,100% of CMS IPPS Rate,4078.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4254.27,100,MS-DRG,3403.416,Case Rate,100% of CMS IPPS Rate,5530.55,130,MS-DRG,4424.44,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4381.9,103,MS-DRG,3505.52,Case Rate,103% of CMS IPPS Rate,4381.9,103,MS-DRG,3505.52,Case Rate,103% of CMS IPPS Rate,8295.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4254.27,100,MS-DRG,3403.416,Case Rate,100% of CMS IPPS Rate,4506.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6381.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4254.27,100,MS-DRG,3403.416,Case Rate,100% of CMS IPPS Rate,8702.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4254.27,100,MS-DRG,3403.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3871.37,10402.27,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,CDM,,,,,Inpatient,,,,,,29760.93,,,,Case Rate,100% of CMS IPPS Rate,21570.58,145,MS-DRG,17256.464,Case Rate,145% of CMS IPPS Rate,14876.26,100,MS-DRG,11901.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14876.26,100,,11901.008,Case Rate,100% of CMS IPPS Rate,28032.43,100,,,Case Rate,100% of CMS IPPS Rate,32038.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36041.99,100,,,Case Rate,100% of CMS IPPS Rate,36041.99,100,,,Case Rate,100% of CMS IPPS Rate,36041.99,100,,,Case Rate,100% CMS IPPS Rate,26865.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13536.72,100,,10829.376,Case Rate,100% of CMS IPPS Rate,13536.72,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13536.72,100,MS-DRG,10829.376,Case Rate,100% of CMS IPPS Rate,13536.72,100,MS-DRG,10829.376,Case Rate,100% of CMS IPPS Rate,17993.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14876.26,100,MS-DRG,11901.008,Case Rate,100% of CMS IPPS Rate,19339.14,130,MS-DRG,15471.312,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15322.55,103,MS-DRG,12258.04,Case Rate,103% of CMS IPPS Rate,15322.55,103,MS-DRG,12258.04,Case Rate,103% of CMS IPPS Rate,27642.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14876.26,100,MS-DRG,11901.008,Case Rate,100% of CMS IPPS Rate,15758.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22314.39,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14876.26,100,MS-DRG,11901.008,Case Rate,100% of CMS IPPS Rate,30430.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14876.26,100,MS-DRG,11901.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36041.99,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,CDM,,,,,Inpatient,,,,,,17254.66,,,,Case Rate,100% of CMS IPPS Rate,12506.09,145,MS-DRG,10004.872,Case Rate,145% of CMS IPPS Rate,8624.89,100,MS-DRG,6899.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8624.89,100,,6899.912,Case Rate,100% of CMS IPPS Rate,16182.5,100,,,Case Rate,100% of CMS IPPS Rate,18494.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20806.25,100,,,Case Rate,100% of CMS IPPS Rate,20806.25,100,,,Case Rate,100% of CMS IPPS Rate,20806.25,100,,,Case Rate,100% CMS IPPS Rate,15576.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7848.37,100,,6278.696,Case Rate,100% of CMS IPPS Rate,7848.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7848.37,100,MS-DRG,6278.696,Case Rate,100% of CMS IPPS Rate,7848.37,100,MS-DRG,6278.696,Case Rate,100% of CMS IPPS Rate,14118.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8624.89,100,MS-DRG,6899.912,Case Rate,100% of CMS IPPS Rate,11212.36,130,MS-DRG,8969.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8883.64,103,MS-DRG,7106.912,Case Rate,103% of CMS IPPS Rate,8883.64,103,MS-DRG,7106.912,Case Rate,103% of CMS IPPS Rate,16093.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8624.89,100,MS-DRG,6899.912,Case Rate,100% of CMS IPPS Rate,9136.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12937.34,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8624.89,100,MS-DRG,6899.912,Case Rate,100% of CMS IPPS Rate,17642.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8624.89,100,MS-DRG,6899.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20806.25,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,CDM,,,,,Inpatient,,,,,,53223.54,,,,Case Rate,100% of CMS IPPS Rate,38576.16,145,MS-DRG,30860.928,Case Rate,145% of CMS IPPS Rate,26604.25,100,MS-DRG,21283.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26604.25,100,,21283.4,Case Rate,100% of CMS IPPS Rate,52492.15,100,,,Case Rate,100% of CMS IPPS Rate,59993.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67490.46,100,,,Case Rate,100% of CMS IPPS Rate,67490.46,100,,,Case Rate,100% of CMS IPPS Rate,67490.46,100,,,Case Rate,100% CMS IPPS Rate,48045.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24208.46,100,,19366.768,Case Rate,100% of CMS IPPS Rate,24208.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24208.46,100,MS-DRG,19366.768,Case Rate,100% of CMS IPPS Rate,24208.46,100,MS-DRG,19366.768,Case Rate,100% of CMS IPPS Rate,34980.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26604.25,100,MS-DRG,21283.4,Case Rate,100% of CMS IPPS Rate,34585.53,130,MS-DRG,27668.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27402.38,103,MS-DRG,21921.904,Case Rate,103% of CMS IPPS Rate,27402.38,103,MS-DRG,21921.904,Case Rate,103% of CMS IPPS Rate,53954.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26604.25,100,MS-DRG,21283.4,Case Rate,100% of CMS IPPS Rate,28182.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,39906.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26604.25,100,MS-DRG,21283.4,Case Rate,100% of CMS IPPS Rate,54420.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26604.25,100,MS-DRG,21283.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,67490.46,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,CDM,,,,,Inpatient,,,,,,27025.27,,,,Case Rate,100% of CMS IPPS Rate,19587.79,145,MS-DRG,15670.232,Case Rate,145% of CMS IPPS Rate,13508.82,100,MS-DRG,10807.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13508.82,100,,10807.056,Case Rate,100% of CMS IPPS Rate,26640.67,100,,,Case Rate,100% of CMS IPPS Rate,30447.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34252.58,100,,,Case Rate,100% of CMS IPPS Rate,34252.58,100,,,Case Rate,100% of CMS IPPS Rate,34252.58,100,,,Case Rate,100% CMS IPPS Rate,24396.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12292.43,100,,9833.944,Case Rate,100% of CMS IPPS Rate,12292.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12292.43,100,MS-DRG,9833.944,Case Rate,100% of CMS IPPS Rate,12292.43,100,MS-DRG,9833.944,Case Rate,100% of CMS IPPS Rate,18783.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13508.82,100,MS-DRG,10807.056,Case Rate,100% of CMS IPPS Rate,17561.47,130,MS-DRG,14049.176,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13914.08,103,MS-DRG,11131.264,Case Rate,103% of CMS IPPS Rate,13914.08,103,MS-DRG,11131.264,Case Rate,103% of CMS IPPS Rate,25597.28,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13508.82,100,MS-DRG,10807.056,Case Rate,100% of CMS IPPS Rate,14310.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20263.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13508.82,100,MS-DRG,10807.056,Case Rate,100% of CMS IPPS Rate,27633.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13508.82,100,MS-DRG,10807.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34252.58,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,CDM,,,,,Inpatient,,,,,,18684.1,,,,Case Rate,100% of CMS IPPS Rate,13542.14,145,MS-DRG,10833.712,Case Rate,145% of CMS IPPS Rate,9339.41,100,MS-DRG,7471.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9339.41,100,,7471.528,Case Rate,100% of CMS IPPS Rate,20221.79,100,,,Case Rate,100% of CMS IPPS Rate,23111.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25999.67,100,,,Case Rate,100% of CMS IPPS Rate,25999.67,100,,,Case Rate,100% of CMS IPPS Rate,25999.67,100,,,Case Rate,100% CMS IPPS Rate,16866.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8498.54,100,,6798.832,Case Rate,100% of CMS IPPS Rate,8498.54,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8498.54,100,MS-DRG,6798.832,Case Rate,100% of CMS IPPS Rate,8498.54,100,MS-DRG,6798.832,Case Rate,100% of CMS IPPS Rate,12887.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9339.41,100,MS-DRG,7471.528,Case Rate,100% of CMS IPPS Rate,12141.23,130,MS-DRG,9712.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9619.59,103,MS-DRG,7695.672,Case Rate,103% of CMS IPPS Rate,9619.59,103,MS-DRG,7695.672,Case Rate,103% of CMS IPPS Rate,17758.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9339.41,100,MS-DRG,7471.528,Case Rate,100% of CMS IPPS Rate,9893.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14009.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9339.41,100,MS-DRG,7471.528,Case Rate,100% of CMS IPPS Rate,19104.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9339.41,100,MS-DRG,7471.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25999.67,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,CDM,,,,,Inpatient,,,,,,49514.38,,,,Case Rate,100% of CMS IPPS Rate,35887.78,145,MS-DRG,28710.224,Case Rate,145% of CMS IPPS Rate,24750.19,100,MS-DRG,19800.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24750.19,100,,19800.152,Case Rate,100% of CMS IPPS Rate,53069.38,100,,,Case Rate,100% of CMS IPPS Rate,60652.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,68232.63,100,,,Case Rate,100% of CMS IPPS Rate,68232.63,100,,,Case Rate,100% of CMS IPPS Rate,68232.63,100,,,Case Rate,100% CMS IPPS Rate,44697.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22521.38,100,,18017.104,Case Rate,100% of CMS IPPS Rate,22521.38,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,22521.38,100,MS-DRG,18017.104,Case Rate,100% of CMS IPPS Rate,22521.38,100,MS-DRG,18017.104,Case Rate,100% of CMS IPPS Rate,32542.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24750.19,100,MS-DRG,19800.152,Case Rate,100% of CMS IPPS Rate,32175.25,130,MS-DRG,25740.2,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25492.7,103,MS-DRG,20394.16,Case Rate,103% of CMS IPPS Rate,25492.7,103,MS-DRG,20394.16,Case Rate,103% of CMS IPPS Rate,49364.1,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24750.19,100,MS-DRG,19800.152,Case Rate,100% of CMS IPPS Rate,26218.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,37125.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24750.19,100,MS-DRG,19800.152,Case Rate,100% of CMS IPPS Rate,50628.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24750.19,100,MS-DRG,19800.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,68232.63,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,CDM,,,,,Inpatient,,,,,,24467.6,,,,Case Rate,100% of CMS IPPS Rate,17734.01,145,MS-DRG,14187.208,Case Rate,145% of CMS IPPS Rate,12230.35,100,MS-DRG,9784.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12230.35,100,,9784.28,Case Rate,100% of CMS IPPS Rate,24239.76,100,,,Case Rate,100% of CMS IPPS Rate,27703.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31165.66,100,,,Case Rate,100% of CMS IPPS Rate,31165.66,100,,,Case Rate,100% of CMS IPPS Rate,31165.66,100,,,Case Rate,100% CMS IPPS Rate,22087.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11129.1,100,,8903.28,Case Rate,100% of CMS IPPS Rate,11129.1,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11129.1,100,MS-DRG,8903.28,Case Rate,100% of CMS IPPS Rate,11129.1,100,MS-DRG,8903.28,Case Rate,100% of CMS IPPS Rate,19784.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12230.35,100,MS-DRG,9784.28,Case Rate,100% of CMS IPPS Rate,15899.46,130,MS-DRG,12719.568,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12597.26,103,MS-DRG,10077.808,Case Rate,103% of CMS IPPS Rate,12597.26,103,MS-DRG,10077.808,Case Rate,103% of CMS IPPS Rate,22800.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12230.35,100,MS-DRG,9784.28,Case Rate,100% of CMS IPPS Rate,12955.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18345.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12230.35,100,MS-DRG,9784.28,Case Rate,100% of CMS IPPS Rate,25018,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12230.35,100,MS-DRG,9784.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31165.66,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,CDM,,,,,Inpatient,,,,,,17790.02,,,,Case Rate,100% of CMS IPPS Rate,12894.11,145,MS-DRG,10315.288,Case Rate,145% of CMS IPPS Rate,8892.49,100,MS-DRG,7113.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8892.49,100,,7113.992,Case Rate,100% of CMS IPPS Rate,18311.46,100,,,Case Rate,100% of CMS IPPS Rate,20928.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23543.5,100,,,Case Rate,100% of CMS IPPS Rate,23543.5,100,,,Case Rate,100% of CMS IPPS Rate,23543.5,100,,,Case Rate,100% CMS IPPS Rate,16059.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8091.86,100,,6473.488,Case Rate,100% of CMS IPPS Rate,8091.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8091.86,100,MS-DRG,6473.488,Case Rate,100% of CMS IPPS Rate,8091.86,100,MS-DRG,6473.488,Case Rate,100% of CMS IPPS Rate,12294.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8892.49,100,MS-DRG,7113.992,Case Rate,100% of CMS IPPS Rate,11560.24,130,MS-DRG,9248.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9159.26,103,MS-DRG,7327.408,Case Rate,103% of CMS IPPS Rate,9159.26,103,MS-DRG,7327.408,Case Rate,103% of CMS IPPS Rate,16608.19,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8892.49,100,MS-DRG,7113.992,Case Rate,100% of CMS IPPS Rate,9419.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13338.74,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8892.49,100,MS-DRG,7113.992,Case Rate,100% of CMS IPPS Rate,18190.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8892.49,100,MS-DRG,7113.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23543.5,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,CDM,,,,,Inpatient,,,,,,24397.77,,,,Case Rate,100% of CMS IPPS Rate,17683.39,145,MS-DRG,14146.712,Case Rate,145% of CMS IPPS Rate,12195.44,100,MS-DRG,9756.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12195.44,100,,9756.352,Case Rate,100% of CMS IPPS Rate,24351.74,100,,,Case Rate,100% of CMS IPPS Rate,27831.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31309.64,100,,,Case Rate,100% of CMS IPPS Rate,31309.64,100,,,Case Rate,100% of CMS IPPS Rate,31309.64,100,,,Case Rate,100% CMS IPPS Rate,22024.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11097.35,100,,8877.88,Case Rate,100% of CMS IPPS Rate,11097.35,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11097.35,100,MS-DRG,8877.88,Case Rate,100% of CMS IPPS Rate,11097.35,100,MS-DRG,8877.88,Case Rate,100% of CMS IPPS Rate,14605.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12195.44,100,MS-DRG,9756.352,Case Rate,100% of CMS IPPS Rate,15854.07,130,MS-DRG,12683.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12561.3,103,MS-DRG,10049.04,Case Rate,103% of CMS IPPS Rate,12561.3,103,MS-DRG,10049.04,Case Rate,103% of CMS IPPS Rate,22796.57,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12195.44,100,MS-DRG,9756.352,Case Rate,100% of CMS IPPS Rate,12918.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18293.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12195.44,100,MS-DRG,9756.352,Case Rate,100% of CMS IPPS Rate,24946.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12195.44,100,MS-DRG,9756.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31309.64,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,CDM,,,,,Inpatient,,,,,,15910.1,,,,Case Rate,100% of CMS IPPS Rate,11531.56,145,MS-DRG,9225.248,Case Rate,145% of CMS IPPS Rate,7952.8,100,MS-DRG,6362.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7952.8,100,,6362.24,Case Rate,100% of CMS IPPS Rate,15979.87,100,,,Case Rate,100% of CMS IPPS Rate,18263.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20545.72,100,,,Case Rate,100% of CMS IPPS Rate,20545.72,100,,,Case Rate,100% of CMS IPPS Rate,20545.72,100,,,Case Rate,100% CMS IPPS Rate,14362.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7236.8,100,,5789.44,Case Rate,100% of CMS IPPS Rate,7236.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7236.8,100,MS-DRG,5789.44,Case Rate,100% of CMS IPPS Rate,7236.8,100,MS-DRG,5789.44,Case Rate,100% of CMS IPPS Rate,9932.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7952.8,100,MS-DRG,6362.24,Case Rate,100% of CMS IPPS Rate,10338.64,130,MS-DRG,8270.912,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8191.38,103,MS-DRG,6553.104,Case Rate,103% of CMS IPPS Rate,8191.38,103,MS-DRG,6553.104,Case Rate,103% of CMS IPPS Rate,14808.09,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7952.8,100,MS-DRG,6362.24,Case Rate,100% of CMS IPPS Rate,8424.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11929.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7952.8,100,MS-DRG,6362.24,Case Rate,100% of CMS IPPS Rate,16268,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7952.8,100,MS-DRG,6362.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20545.72,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,CDM,,,,,Inpatient,,,,,,25773.82,,,,Case Rate,100% of CMS IPPS Rate,18680.73,145,MS-DRG,14944.584,Case Rate,145% of CMS IPPS Rate,12883.26,100,MS-DRG,10306.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12883.26,100,,10306.608,Case Rate,100% of CMS IPPS Rate,26048.77,100,,,Case Rate,100% of CMS IPPS Rate,29771.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33491.56,100,,,Case Rate,100% of CMS IPPS Rate,33491.56,100,,,Case Rate,100% of CMS IPPS Rate,33491.56,100,,,Case Rate,100% CMS IPPS Rate,23266.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11723.22,100,,9378.576,Case Rate,100% of CMS IPPS Rate,11723.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11723.22,100,MS-DRG,9378.576,Case Rate,100% of CMS IPPS Rate,11723.22,100,MS-DRG,9378.576,Case Rate,100% of CMS IPPS Rate,18224.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12883.26,100,MS-DRG,10306.608,Case Rate,100% of CMS IPPS Rate,16748.24,130,MS-DRG,13398.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13269.76,103,MS-DRG,10615.808,Case Rate,103% of CMS IPPS Rate,13269.76,103,MS-DRG,10615.808,Case Rate,103% of CMS IPPS Rate,24013.5,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12883.26,100,MS-DRG,10306.608,Case Rate,100% of CMS IPPS Rate,13647.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19324.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12883.26,100,MS-DRG,10306.608,Case Rate,100% of CMS IPPS Rate,26353.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12883.26,100,MS-DRG,10306.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33491.56,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,CDM,,,,,Inpatient,,,,,,14183.54,,,,Case Rate,100% of CMS IPPS Rate,10280.17,145,MS-DRG,8224.136,Case Rate,145% of CMS IPPS Rate,7089.77,100,MS-DRG,5671.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7089.77,100,,5671.816,Case Rate,100% of CMS IPPS Rate,13661.61,100,,,Case Rate,100% of CMS IPPS Rate,15613.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17565.07,100,,,Case Rate,100% of CMS IPPS Rate,17565.07,100,,,Case Rate,100% of CMS IPPS Rate,17565.07,100,,,Case Rate,100% CMS IPPS Rate,12803.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6451.5,100,,5161.2,Case Rate,100% of CMS IPPS Rate,6451.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6451.5,100,MS-DRG,5161.2,Case Rate,100% of CMS IPPS Rate,6451.5,100,MS-DRG,5161.2,Case Rate,100% of CMS IPPS Rate,12147.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7089.77,100,MS-DRG,5671.816,Case Rate,100% of CMS IPPS Rate,9216.7,130,MS-DRG,7373.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7302.46,103,MS-DRG,5841.968,Case Rate,103% of CMS IPPS Rate,7302.46,103,MS-DRG,5841.968,Case Rate,103% of CMS IPPS Rate,14557.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7089.77,100,MS-DRG,5671.816,Case Rate,100% of CMS IPPS Rate,7510.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10634.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7089.77,100,MS-DRG,5671.816,Case Rate,100% of CMS IPPS Rate,14502.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7089.77,100,MS-DRG,5671.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17565.07,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,CDM,,,,,Inpatient,,,,,,22949.16,,,,Case Rate,100% of CMS IPPS Rate,16633.44,145,MS-DRG,13306.752,Case Rate,145% of CMS IPPS Rate,11471.34,100,MS-DRG,9177.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11471.34,100,,9177.072,Case Rate,100% of CMS IPPS Rate,22324.09,100,,,Case Rate,100% of CMS IPPS Rate,25514.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28702.64,100,,,Case Rate,100% of CMS IPPS Rate,28702.64,100,,,Case Rate,100% of CMS IPPS Rate,28702.64,100,,,Case Rate,100% CMS IPPS Rate,20716.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10438.45,100,,8350.76,Case Rate,100% of CMS IPPS Rate,10438.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10438.45,100,MS-DRG,8350.76,Case Rate,100% of CMS IPPS Rate,10438.45,100,MS-DRG,8350.76,Case Rate,100% of CMS IPPS Rate,12636.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11471.34,100,MS-DRG,9177.072,Case Rate,100% of CMS IPPS Rate,14912.74,130,MS-DRG,11930.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11815.48,103,MS-DRG,9452.384,Case Rate,103% of CMS IPPS Rate,11815.48,103,MS-DRG,9452.384,Case Rate,103% of CMS IPPS Rate,19777.01,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11471.34,100,MS-DRG,9177.072,Case Rate,100% of CMS IPPS Rate,12151.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17207.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11471.34,100,MS-DRG,9177.072,Case Rate,100% of CMS IPPS Rate,23465.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11471.34,100,MS-DRG,9177.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28702.64,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,CDM,,,,,Inpatient,,,,,,12147.54,,,,Case Rate,100% of CMS IPPS Rate,8804.49,145,MS-DRG,7043.592,Case Rate,145% of CMS IPPS Rate,6072.06,100,MS-DRG,4857.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6072.06,100,,4857.648,Case Rate,100% of CMS IPPS Rate,12733.77,100,,,Case Rate,100% of CMS IPPS Rate,14553.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16372.13,100,,,Case Rate,100% of CMS IPPS Rate,16372.13,100,,,Case Rate,100% of CMS IPPS Rate,16372.13,100,,,Case Rate,100% CMS IPPS Rate,10965.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5525.43,100,,4420.344,Case Rate,100% of CMS IPPS Rate,5525.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5525.43,100,MS-DRG,4420.344,Case Rate,100% of CMS IPPS Rate,5525.43,100,MS-DRG,4420.344,Case Rate,100% of CMS IPPS Rate,11535.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6072.06,100,MS-DRG,4857.648,Case Rate,100% of CMS IPPS Rate,7893.68,130,MS-DRG,6314.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6254.22,103,MS-DRG,5003.376,Case Rate,103% of CMS IPPS Rate,6254.22,103,MS-DRG,5003.376,Case Rate,103% of CMS IPPS Rate,12379.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6072.06,100,MS-DRG,4857.648,Case Rate,100% of CMS IPPS Rate,6432.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9108.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6072.06,100,MS-DRG,4857.648,Case Rate,100% of CMS IPPS Rate,12420.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6072.06,100,MS-DRG,4857.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5525.43,16372.13,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,CDM,,,,,Inpatient,,,,,,19235.89,,,,Case Rate,100% of CMS IPPS Rate,13942.08,145,MS-DRG,11153.664,Case Rate,145% of CMS IPPS Rate,9615.23,100,MS-DRG,7692.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9615.23,100,,7692.184,Case Rate,100% of CMS IPPS Rate,18160.82,100,,,Case Rate,100% of CMS IPPS Rate,20756,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23349.82,100,,,Case Rate,100% of CMS IPPS Rate,23349.82,100,,,Case Rate,100% of CMS IPPS Rate,23349.82,100,,,Case Rate,100% CMS IPPS Rate,17364.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8749.51,100,,6999.608,Case Rate,100% of CMS IPPS Rate,8749.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8749.51,100,MS-DRG,6999.608,Case Rate,100% of CMS IPPS Rate,8749.51,100,MS-DRG,6999.608,Case Rate,100% of CMS IPPS Rate,14227.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9615.23,100,MS-DRG,7692.184,Case Rate,100% of CMS IPPS Rate,12499.8,130,MS-DRG,9999.84,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9903.69,103,MS-DRG,7922.952,Case Rate,103% of CMS IPPS Rate,9903.69,103,MS-DRG,7922.952,Case Rate,103% of CMS IPPS Rate,17927.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9615.23,100,MS-DRG,7692.184,Case Rate,100% of CMS IPPS Rate,10185.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14422.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9615.23,100,MS-DRG,7692.184,Case Rate,100% of CMS IPPS Rate,19668.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9615.23,100,MS-DRG,7692.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23349.82,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,CDM,,,,,Inpatient,,,,,,34465.5,,,,Case Rate,100% of CMS IPPS Rate,24980.43,145,MS-DRG,19984.344,Case Rate,145% of CMS IPPS Rate,17227.88,100,MS-DRG,13782.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17227.88,100,,13782.304,Case Rate,100% of CMS IPPS Rate,34508.63,100,,,Case Rate,100% of CMS IPPS Rate,39439.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,44368.6,100,,,Case Rate,100% of CMS IPPS Rate,44368.6,100,,,Case Rate,100% of CMS IPPS Rate,44368.6,100,,,Case Rate,100% CMS IPPS Rate,31112.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15676.55,100,,12541.24,Case Rate,100% of CMS IPPS Rate,15676.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15676.55,100,MS-DRG,12541.24,Case Rate,100% of CMS IPPS Rate,15676.55,100,MS-DRG,12541.24,Case Rate,100% of CMS IPPS Rate,15052.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17227.88,100,MS-DRG,13782.304,Case Rate,100% of CMS IPPS Rate,22396.24,130,MS-DRG,17916.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17744.72,103,MS-DRG,14195.776,Case Rate,103% of CMS IPPS Rate,17744.72,103,MS-DRG,14195.776,Case Rate,103% of CMS IPPS Rate,31956.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17227.88,100,MS-DRG,13782.304,Case Rate,100% of CMS IPPS Rate,18249.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25841.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17227.88,100,MS-DRG,13782.304,Case Rate,100% of CMS IPPS Rate,35240.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17227.88,100,MS-DRG,13782.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,44368.6,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,CDM,,,,,Inpatient,,,,,,18621.12,,,,Case Rate,100% of CMS IPPS Rate,13496.5,145,MS-DRG,10797.2,Case Rate,145% of CMS IPPS Rate,9307.93,100,MS-DRG,7446.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9307.93,100,,7446.344,Case Rate,100% of CMS IPPS Rate,17190.32,100,,,Case Rate,100% of CMS IPPS Rate,19646.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22102.03,100,,,Case Rate,100% of CMS IPPS Rate,22102.03,100,,,Case Rate,100% of CMS IPPS Rate,22102.03,100,,,Case Rate,100% CMS IPPS Rate,16809.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8469.88,100,,6775.904,Case Rate,100% of CMS IPPS Rate,8469.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8469.88,100,MS-DRG,6775.904,Case Rate,100% of CMS IPPS Rate,8469.88,100,MS-DRG,6775.904,Case Rate,100% of CMS IPPS Rate,11182.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9307.93,100,MS-DRG,7446.344,Case Rate,100% of CMS IPPS Rate,12100.31,130,MS-DRG,9680.248,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9587.17,103,MS-DRG,7669.736,Case Rate,103% of CMS IPPS Rate,9587.17,103,MS-DRG,7669.736,Case Rate,103% of CMS IPPS Rate,18051.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9307.93,100,MS-DRG,7446.344,Case Rate,100% of CMS IPPS Rate,9860,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13961.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9307.93,100,MS-DRG,7446.344,Case Rate,100% of CMS IPPS Rate,19040,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9307.93,100,MS-DRG,7446.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22102.03,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,CDM,,,,,Inpatient,,,,,,25364.43,,,,Case Rate,100% of CMS IPPS Rate,18384.01,145,MS-DRG,14707.208,Case Rate,145% of CMS IPPS Rate,12678.63,100,MS-DRG,10142.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12678.63,100,,10142.904,Case Rate,100% of CMS IPPS Rate,24119.78,100,,,Case Rate,100% of CMS IPPS Rate,27566.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31011.4,100,,,Case Rate,100% of CMS IPPS Rate,31011.4,100,,,Case Rate,100% of CMS IPPS Rate,31011.4,100,,,Case Rate,100% CMS IPPS Rate,22896.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11537.02,100,,9229.616,Case Rate,100% of CMS IPPS Rate,11537.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11537.02,100,MS-DRG,9229.616,Case Rate,100% of CMS IPPS Rate,11537.02,100,MS-DRG,9229.616,Case Rate,100% of CMS IPPS Rate,8931.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12678.63,100,MS-DRG,10142.904,Case Rate,100% of CMS IPPS Rate,16482.22,130,MS-DRG,13185.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13058.99,103,MS-DRG,10447.192,Case Rate,103% of CMS IPPS Rate,13058.99,103,MS-DRG,10447.192,Case Rate,103% of CMS IPPS Rate,21971.79,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12678.63,100,MS-DRG,10142.904,Case Rate,100% of CMS IPPS Rate,13430.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19017.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12678.63,100,MS-DRG,10142.904,Case Rate,100% of CMS IPPS Rate,25935,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12678.63,100,MS-DRG,10142.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31011.4,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,CDM,,,,,Inpatient,,,,,,14851.71,,,,Case Rate,100% of CMS IPPS Rate,10764.45,145,MS-DRG,8611.56,Case Rate,145% of CMS IPPS Rate,7423.76,100,MS-DRG,5939.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7423.76,100,,5939.008,Case Rate,100% of CMS IPPS Rate,14798.74,100,,,Case Rate,100% of CMS IPPS Rate,16913.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19027.11,100,,,Case Rate,100% of CMS IPPS Rate,19027.11,100,,,Case Rate,100% of CMS IPPS Rate,19027.11,100,,,Case Rate,100% CMS IPPS Rate,13406.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6755.41,100,,5404.328,Case Rate,100% of CMS IPPS Rate,6755.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6755.41,100,MS-DRG,5404.328,Case Rate,100% of CMS IPPS Rate,6755.41,100,MS-DRG,5404.328,Case Rate,100% of CMS IPPS Rate,5899.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7423.76,100,MS-DRG,5939.008,Case Rate,100% of CMS IPPS Rate,9650.89,130,MS-DRG,7720.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7646.47,103,MS-DRG,6117.176,Case Rate,103% of CMS IPPS Rate,7646.47,103,MS-DRG,6117.176,Case Rate,103% of CMS IPPS Rate,13675.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7423.76,100,MS-DRG,5939.008,Case Rate,100% of CMS IPPS Rate,7864.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11135.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7423.76,100,MS-DRG,5939.008,Case Rate,100% of CMS IPPS Rate,15185.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7423.76,100,MS-DRG,5939.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5899.59,19027.11,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,CDM,,,,,Inpatient,,,,,,13550.97,,,,Case Rate,100% of CMS IPPS Rate,9821.68,145,MS-DRG,7857.344,Case Rate,145% of CMS IPPS Rate,6773.57,100,MS-DRG,5418.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6773.57,100,,5418.856,Case Rate,100% of CMS IPPS Rate,12731.11,100,,,Case Rate,100% of CMS IPPS Rate,14550.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16368.7,100,,,Case Rate,100% of CMS IPPS Rate,16368.7,100,,,Case Rate,100% of CMS IPPS Rate,16368.7,100,,,Case Rate,100% CMS IPPS Rate,12232.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6163.78,100,,4931.024,Case Rate,100% of CMS IPPS Rate,6163.78,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6163.78,100,MS-DRG,4931.024,Case Rate,100% of CMS IPPS Rate,6163.78,100,MS-DRG,4931.024,Case Rate,100% of CMS IPPS Rate,8906.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6773.57,100,MS-DRG,5418.856,Case Rate,100% of CMS IPPS Rate,8805.64,130,MS-DRG,7044.512,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6976.78,103,MS-DRG,5581.424,Case Rate,103% of CMS IPPS Rate,6976.78,103,MS-DRG,5581.424,Case Rate,103% of CMS IPPS Rate,12609.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6773.57,100,MS-DRG,5418.856,Case Rate,100% of CMS IPPS Rate,7175.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10160.36,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6773.57,100,MS-DRG,5418.856,Case Rate,100% of CMS IPPS Rate,13855.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6773.57,100,MS-DRG,5418.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16368.7,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,CDM,,,,,Inpatient,,,,,,20422.99,,,,Case Rate,100% of CMS IPPS Rate,14802.47,145,MS-DRG,11841.976,Case Rate,145% of CMS IPPS Rate,10208.6,100,MS-DRG,8166.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10208.6,100,,8166.88,Case Rate,100% of CMS IPPS Rate,18867.36,100,,,Case Rate,100% of CMS IPPS Rate,21563.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24258.24,100,,,Case Rate,100% of CMS IPPS Rate,24258.24,100,,,Case Rate,100% of CMS IPPS Rate,24258.24,100,,,Case Rate,100% CMS IPPS Rate,18436.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9289.44,100,,7431.552,Case Rate,100% of CMS IPPS Rate,9289.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9289.44,100,MS-DRG,7431.552,Case Rate,100% of CMS IPPS Rate,9289.44,100,MS-DRG,7431.552,Case Rate,100% of CMS IPPS Rate,9729.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10208.6,100,MS-DRG,8166.88,Case Rate,100% of CMS IPPS Rate,13271.18,130,MS-DRG,10616.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10514.86,103,MS-DRG,8411.888,Case Rate,103% of CMS IPPS Rate,10514.86,103,MS-DRG,8411.888,Case Rate,103% of CMS IPPS Rate,17358.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10208.6,100,MS-DRG,8166.88,Case Rate,100% of CMS IPPS Rate,10814.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15312.9,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10208.6,100,MS-DRG,8166.88,Case Rate,100% of CMS IPPS Rate,20882.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10208.6,100,MS-DRG,8166.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24258.24,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,CDM,,,,,Inpatient,,,,,,13590.68,,,,Case Rate,100% of CMS IPPS Rate,9850.46,145,MS-DRG,7880.368,Case Rate,145% of CMS IPPS Rate,6793.42,100,MS-DRG,5434.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6793.42,100,,5434.736,Case Rate,100% of CMS IPPS Rate,13588.29,100,,,Case Rate,100% of CMS IPPS Rate,15530.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17470.8,100,,,Case Rate,100% of CMS IPPS Rate,17470.8,100,,,Case Rate,100% of CMS IPPS Rate,17470.8,100,,,Case Rate,100% CMS IPPS Rate,12268.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6181.84,100,,4945.472,Case Rate,100% of CMS IPPS Rate,6181.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6181.84,100,MS-DRG,4945.472,Case Rate,100% of CMS IPPS Rate,6181.84,100,MS-DRG,4945.472,Case Rate,100% of CMS IPPS Rate,5806.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6793.42,100,MS-DRG,5434.736,Case Rate,100% of CMS IPPS Rate,8831.45,130,MS-DRG,7065.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6997.22,103,MS-DRG,5597.776,Case Rate,103% of CMS IPPS Rate,6997.22,103,MS-DRG,5597.776,Case Rate,103% of CMS IPPS Rate,12087.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6793.42,100,MS-DRG,5434.736,Case Rate,100% of CMS IPPS Rate,7196.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10190.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6793.42,100,MS-DRG,5434.736,Case Rate,100% of CMS IPPS Rate,13896.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6793.42,100,MS-DRG,5434.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5806.36,17470.8,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,CDM,,,,,Inpatient,,,,,,8847.77,,,,Case Rate,100% of CMS IPPS Rate,6412.81,145,MS-DRG,5130.248,Case Rate,145% of CMS IPPS Rate,4422.63,100,MS-DRG,3538.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4422.63,100,,3538.104,Case Rate,100% of CMS IPPS Rate,8531.84,100,,,Case Rate,100% of CMS IPPS Rate,9751.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10969.6,100,,,Case Rate,100% of CMS IPPS Rate,10969.6,100,,,Case Rate,100% of CMS IPPS Rate,10969.6,100,,,Case Rate,100% CMS IPPS Rate,7987.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4024.57,100,,3219.656,Case Rate,100% of CMS IPPS Rate,4024.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4024.57,100,MS-DRG,3219.656,Case Rate,100% of CMS IPPS Rate,4024.57,100,MS-DRG,3219.656,Case Rate,100% of CMS IPPS Rate,4356.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4422.63,100,MS-DRG,3538.104,Case Rate,100% of CMS IPPS Rate,5749.42,130,MS-DRG,4599.536,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4555.31,103,MS-DRG,3644.248,Case Rate,103% of CMS IPPS Rate,4555.31,103,MS-DRG,3644.248,Case Rate,103% of CMS IPPS Rate,7848.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4422.63,100,MS-DRG,3538.104,Case Rate,100% of CMS IPPS Rate,4684.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6633.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4422.63,100,MS-DRG,3538.104,Case Rate,100% of CMS IPPS Rate,9046.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4422.63,100,MS-DRG,3538.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4024.57,10969.6,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,CDM,,,,,Inpatient,,,,,,13629.02,,,,Case Rate,100% of CMS IPPS Rate,9878.24,145,MS-DRG,7902.592,Case Rate,145% of CMS IPPS Rate,6812.58,100,MS-DRG,5450.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6812.58,100,,5450.064,Case Rate,100% of CMS IPPS Rate,13139.03,100,,,Case Rate,100% of CMS IPPS Rate,15016.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16893.18,100,,,Case Rate,100% of CMS IPPS Rate,16893.18,100,,,Case Rate,100% of CMS IPPS Rate,16893.18,100,,,Case Rate,100% CMS IPPS Rate,12303.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6199.28,100,,4959.424,Case Rate,100% of CMS IPPS Rate,6199.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6199.28,100,MS-DRG,4959.424,Case Rate,100% of CMS IPPS Rate,6199.28,100,MS-DRG,4959.424,Case Rate,100% of CMS IPPS Rate,4669.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6812.58,100,MS-DRG,5450.064,Case Rate,100% of CMS IPPS Rate,8856.35,130,MS-DRG,7085.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7016.96,103,MS-DRG,5613.568,Case Rate,103% of CMS IPPS Rate,7016.96,103,MS-DRG,5613.568,Case Rate,103% of CMS IPPS Rate,12227.49,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6812.58,100,MS-DRG,5450.064,Case Rate,100% of CMS IPPS Rate,7216.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10218.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6812.58,100,MS-DRG,5450.064,Case Rate,100% of CMS IPPS Rate,13935.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6812.58,100,MS-DRG,5450.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4669.73,16893.18,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,CDM,,,,,Inpatient,,,,,,8291.88,,,,Case Rate,100% of CMS IPPS Rate,6009.92,145,MS-DRG,4807.936,Case Rate,145% of CMS IPPS Rate,4144.77,100,MS-DRG,3315.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4144.77,100,,3315.816,Case Rate,100% of CMS IPPS Rate,8450.52,100,,,Case Rate,100% of CMS IPPS Rate,9658.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10865.05,100,,,Case Rate,100% of CMS IPPS Rate,10865.05,100,,,Case Rate,100% of CMS IPPS Rate,10865.05,100,,,Case Rate,100% CMS IPPS Rate,7485.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3771.74,100,,3017.392,Case Rate,100% of CMS IPPS Rate,3771.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3771.74,100,MS-DRG,3017.392,Case Rate,100% of CMS IPPS Rate,3771.74,100,MS-DRG,3017.392,Case Rate,100% of CMS IPPS Rate,3894.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4144.77,100,MS-DRG,3315.816,Case Rate,100% of CMS IPPS Rate,5388.2,130,MS-DRG,4310.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4269.11,103,MS-DRG,3415.288,Case Rate,103% of CMS IPPS Rate,4269.11,103,MS-DRG,3415.288,Case Rate,103% of CMS IPPS Rate,7156.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4144.77,100,MS-DRG,3315.816,Case Rate,100% of CMS IPPS Rate,4390.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6217.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4144.77,100,MS-DRG,3315.816,Case Rate,100% of CMS IPPS Rate,8478.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4144.77,100,MS-DRG,3315.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3771.74,10865.05,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,12088.3,145,MS-DRG,9670.64,Case Rate,145% of CMS IPPS Rate,8336.76,100,MS-DRG,6669.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8336.76,100,,6669.408,Case Rate,100% of CMS IPPS Rate,13480.31,100,,,Case Rate,100% of CMS IPPS Rate,15406.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17331.97,100,,,Case Rate,100% of CMS IPPS Rate,17331.97,100,,,Case Rate,100% of CMS IPPS Rate,17331.97,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7586.17,100,,6068.936,Case Rate,100% of CMS IPPS Rate,7586.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7586.17,100,MS-DRG,6068.936,Case Rate,100% of CMS IPPS Rate,7586.17,100,MS-DRG,6068.936,Case Rate,100% of CMS IPPS Rate,4487.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8336.76,100,MS-DRG,6669.408,Case Rate,100% of CMS IPPS Rate,10837.79,130,MS-DRG,8670.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8586.86,103,MS-DRG,6869.488,Case Rate,103% of CMS IPPS Rate,8586.86,103,MS-DRG,6869.488,Case Rate,103% of CMS IPPS Rate,14507.02,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8336.76,100,MS-DRG,6669.408,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,12505.14,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8336.76,100,MS-DRG,6669.408,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8336.76,100,MS-DRG,6669.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4000,17331.97,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,CDM,,,,,Inpatient,,,,,,21139.08,,,,Case Rate,100% of CMS IPPS Rate,15321.5,145,MS-DRG,12257.2,Case Rate,145% of CMS IPPS Rate,10566.55,100,MS-DRG,8453.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10566.55,100,,8453.24,Case Rate,100% of CMS IPPS Rate,18347.46,100,,,Case Rate,100% of CMS IPPS Rate,20969.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23589.78,100,,,Case Rate,100% of CMS IPPS Rate,23589.78,100,,,Case Rate,100% of CMS IPPS Rate,23589.78,100,,,Case Rate,100% CMS IPPS Rate,19082.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9615.16,100,,7692.128,Case Rate,100% of CMS IPPS Rate,9615.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9615.16,100,MS-DRG,7692.128,Case Rate,100% of CMS IPPS Rate,9615.16,100,MS-DRG,7692.128,Case Rate,100% of CMS IPPS Rate,10268.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10566.55,100,MS-DRG,8453.24,Case Rate,100% of CMS IPPS Rate,13736.52,130,MS-DRG,10989.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10883.55,103,MS-DRG,8706.84,Case Rate,103% of CMS IPPS Rate,10883.55,103,MS-DRG,8706.84,Case Rate,103% of CMS IPPS Rate,21015.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10566.55,100,MS-DRG,8453.24,Case Rate,100% of CMS IPPS Rate,11193.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15849.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10566.55,100,MS-DRG,8453.24,Case Rate,100% of CMS IPPS Rate,21614.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10566.55,100,MS-DRG,8453.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23589.78,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,CDM,,,,,Inpatient,,,,,,10935.8,,,,Case Rate,100% of CMS IPPS Rate,7926.22,145,MS-DRG,6340.976,Case Rate,145% of CMS IPPS Rate,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5466.36,100,,4373.088,Case Rate,100% of CMS IPPS Rate,14344.16,100,,,Case Rate,100% of CMS IPPS Rate,16393.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18442.64,100,,,Case Rate,100% of CMS IPPS Rate,18442.64,100,,,Case Rate,100% of CMS IPPS Rate,18442.64,100,,,Case Rate,100% CMS IPPS Rate,9871.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.3,100,,3979.44,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,3979.44,Case Rate,100% of CMS IPPS Rate,4974.3,100,MS-DRG,3979.44,Case Rate,100% of CMS IPPS Rate,5891.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,7106.27,130,MS-DRG,5685.016,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5630.35,103,MS-DRG,4504.28,Case Rate,103% of CMS IPPS Rate,5630.35,103,MS-DRG,4504.28,Case Rate,103% of CMS IPPS Rate,10952.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,5790.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8199.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,11181.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5466.36,100,MS-DRG,4373.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4974.3,18442.64,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,CDM,,,,,Inpatient,,,,,,9813.06,,,,Case Rate,100% of CMS IPPS Rate,7112.45,145,MS-DRG,5689.96,Case Rate,145% of CMS IPPS Rate,4905.14,100,MS-DRG,3924.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4905.14,100,,3924.112,Case Rate,100% of CMS IPPS Rate,9511.67,100,,,Case Rate,100% of CMS IPPS Rate,10870.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12229.39,100,,,Case Rate,100% of CMS IPPS Rate,12229.39,100,,,Case Rate,100% of CMS IPPS Rate,12229.39,100,,,Case Rate,100% CMS IPPS Rate,8858.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4463.62,100,,3570.896,Case Rate,100% of CMS IPPS Rate,4463.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4463.62,100,MS-DRG,3570.896,Case Rate,100% of CMS IPPS Rate,4463.62,100,MS-DRG,3570.896,Case Rate,100% of CMS IPPS Rate,3539.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4905.14,100,MS-DRG,3924.112,Case Rate,100% of CMS IPPS Rate,6376.68,130,MS-DRG,5101.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5052.29,103,MS-DRG,4041.832,Case Rate,103% of CMS IPPS Rate,5052.29,103,MS-DRG,4041.832,Case Rate,103% of CMS IPPS Rate,8818.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4905.14,100,MS-DRG,3924.112,Case Rate,100% of CMS IPPS Rate,5196.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7357.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4905.14,100,MS-DRG,3924.112,Case Rate,100% of CMS IPPS Rate,10033.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4905.14,100,MS-DRG,3924.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3539.59,12229.39,
ABORTION WITHOUT D&C,779,CDM,,,,,Inpatient,,,,,,13544.13,,,,Case Rate,100% of CMS IPPS Rate,9816.72,145,MS-DRG,7853.376,Case Rate,145% of CMS IPPS Rate,6770.15,100,MS-DRG,5416.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6770.15,100,,5416.12,Case Rate,100% of CMS IPPS Rate,12461.82,100,,,Case Rate,100% of CMS IPPS Rate,14242.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16022.47,100,,,Case Rate,100% of CMS IPPS Rate,16022.47,100,,,Case Rate,100% of CMS IPPS Rate,16022.47,100,,,Case Rate,100% CMS IPPS Rate,12226.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6160.67,100,,4928.536,Case Rate,100% of CMS IPPS Rate,6160.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6160.67,100,MS-DRG,4928.536,Case Rate,100% of CMS IPPS Rate,6160.67,100,MS-DRG,4928.536,Case Rate,100% of CMS IPPS Rate,3490.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6770.15,100,MS-DRG,5416.12,Case Rate,100% of CMS IPPS Rate,8801.2,130,MS-DRG,7040.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6973.25,103,MS-DRG,5578.6,Case Rate,103% of CMS IPPS Rate,6973.25,103,MS-DRG,5578.6,Case Rate,103% of CMS IPPS Rate,12885.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6770.15,100,MS-DRG,5416.12,Case Rate,100% of CMS IPPS Rate,7171.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10155.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6770.15,100,MS-DRG,5416.12,Case Rate,100% of CMS IPPS Rate,13848.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6770.15,100,MS-DRG,5416.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3490.95,16022.47,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,17583.15,145,MS-DRG,14066.52,Case Rate,145% of CMS IPPS Rate,12126.31,100,MS-DRG,9701.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12126.31,100,,9701.048,Case Rate,100% of CMS IPPS Rate,24557.04,100,,,Case Rate,100% of CMS IPPS Rate,28066.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31573.59,100,,,Case Rate,100% of CMS IPPS Rate,31573.59,100,,,Case Rate,100% of CMS IPPS Rate,31573.59,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11034.45,100,,8827.56,Case Rate,100% of CMS IPPS Rate,11034.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11034.45,100,MS-DRG,8827.56,Case Rate,100% of CMS IPPS Rate,11034.45,100,MS-DRG,8827.56,Case Rate,100% of CMS IPPS Rate,9580.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12126.31,100,MS-DRG,9701.048,Case Rate,100% of CMS IPPS Rate,15764.2,130,MS-DRG,12611.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12490.1,103,MS-DRG,9992.08,Case Rate,103% of CMS IPPS Rate,12490.1,103,MS-DRG,9992.08,Case Rate,103% of CMS IPPS Rate,24410.71,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12126.31,100,MS-DRG,9701.048,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18189.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12126.31,100,MS-DRG,9701.048,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12126.31,100,MS-DRG,9701.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31573.59,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,10163.05,145,MS-DRG,8130.44,Case Rate,145% of CMS IPPS Rate,7009,100,MS-DRG,5607.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7009,100,,5607.2,Case Rate,100% of CMS IPPS Rate,14437.47,100,,,Case Rate,100% of CMS IPPS Rate,16500.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18562.62,100,,,Case Rate,100% of CMS IPPS Rate,18562.62,100,,,Case Rate,100% of CMS IPPS Rate,18562.62,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6378.01,100,,5102.408,Case Rate,100% of CMS IPPS Rate,6378.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6378.01,100,MS-DRG,5102.408,Case Rate,100% of CMS IPPS Rate,6378.01,100,MS-DRG,5102.408,Case Rate,100% of CMS IPPS Rate,7238.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7009,100,MS-DRG,5607.2,Case Rate,100% of CMS IPPS Rate,9111.7,130,MS-DRG,7289.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7219.27,103,MS-DRG,5775.416,Case Rate,103% of CMS IPPS Rate,7219.27,103,MS-DRG,5775.416,Case Rate,103% of CMS IPPS Rate,13206.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7009,100,MS-DRG,5607.2,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10513.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7009,100,MS-DRG,5607.2,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7009,100,MS-DRG,5607.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18562.62,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,8597.06,145,MS-DRG,6877.648,Case Rate,145% of CMS IPPS Rate,5929.01,100,MS-DRG,4743.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5929.01,100,,4743.208,Case Rate,100% of CMS IPPS Rate,11644.63,100,,,Case Rate,100% of CMS IPPS Rate,13308.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14971.79,100,,,Case Rate,100% of CMS IPPS Rate,14971.79,100,,,Case Rate,100% of CMS IPPS Rate,14971.79,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5395.28,100,,4316.224,Case Rate,100% of CMS IPPS Rate,5395.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5395.28,100,MS-DRG,4316.224,Case Rate,100% of CMS IPPS Rate,5395.28,100,MS-DRG,4316.224,Case Rate,100% of CMS IPPS Rate,6137.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5929.01,100,MS-DRG,4743.208,Case Rate,100% of CMS IPPS Rate,7707.71,130,MS-DRG,6166.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6106.88,103,MS-DRG,4885.504,Case Rate,103% of CMS IPPS Rate,6106.88,103,MS-DRG,4885.504,Case Rate,103% of CMS IPPS Rate,11538.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5929.01,100,MS-DRG,4743.208,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8893.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5929.01,100,MS-DRG,4743.208,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5929.01,100,MS-DRG,4743.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5395.28,14971.79,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,17361.85,145,MS-DRG,13889.48,Case Rate,145% of CMS IPPS Rate,11973.69,100,MS-DRG,9578.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11973.69,100,,9578.952,Case Rate,100% of CMS IPPS Rate,21541.56,100,,,Case Rate,100% of CMS IPPS Rate,24619.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27696.53,100,,,Case Rate,100% of CMS IPPS Rate,27696.53,100,,,Case Rate,100% of CMS IPPS Rate,27696.53,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10895.57,100,,8716.456,Case Rate,100% of CMS IPPS Rate,10895.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10895.57,100,MS-DRG,8716.456,Case Rate,100% of CMS IPPS Rate,10895.57,100,MS-DRG,8716.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11973.69,100,MS-DRG,9578.952,Case Rate,100% of CMS IPPS Rate,15565.8,130,MS-DRG,12452.64,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12332.9,103,MS-DRG,9866.32,Case Rate,103% of CMS IPPS Rate,12332.9,103,MS-DRG,9866.32,Case Rate,103% of CMS IPPS Rate,20429.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11973.69,100,MS-DRG,9578.952,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17960.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11973.69,100,MS-DRG,9578.952,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11973.69,100,MS-DRG,9578.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27696.53,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,10431,145,MS-DRG,8344.8,Case Rate,145% of CMS IPPS Rate,7193.79,100,MS-DRG,5755.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7193.79,100,,5755.032,Case Rate,100% of CMS IPPS Rate,14154.86,100,,,Case Rate,100% of CMS IPPS Rate,16177.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18199.25,100,,,Case Rate,100% of CMS IPPS Rate,18199.25,100,,,Case Rate,100% of CMS IPPS Rate,18199.25,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6546.15,100,,5236.92,Case Rate,100% of CMS IPPS Rate,6546.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6546.15,100,MS-DRG,5236.92,Case Rate,100% of CMS IPPS Rate,6546.15,100,MS-DRG,5236.92,Case Rate,100% of CMS IPPS Rate,7406.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7193.79,100,MS-DRG,5755.032,Case Rate,100% of CMS IPPS Rate,9351.93,130,MS-DRG,7481.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7409.6,103,MS-DRG,5927.68,Case Rate,103% of CMS IPPS Rate,7409.6,103,MS-DRG,5927.68,Case Rate,103% of CMS IPPS Rate,13476.05,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7193.79,100,MS-DRG,5755.032,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10790.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7193.79,100,MS-DRG,5755.032,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7193.79,100,MS-DRG,5755.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18199.25,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,CDM,,,,,Inpatient,,,,,,8843,,,,Case Rate,100% of CMS IPPS Rate,8484.92,145,MS-DRG,6787.936,Case Rate,145% of CMS IPPS Rate,5851.67,100,MS-DRG,4681.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5851.67,100,,4681.336,Case Rate,100% of CMS IPPS Rate,12060.56,100,,,Case Rate,100% of CMS IPPS Rate,13784.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15506.56,100,,,Case Rate,100% of CMS IPPS Rate,15506.56,100,,,Case Rate,100% of CMS IPPS Rate,15506.56,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5324.9,100,,4259.92,Case Rate,100% of CMS IPPS Rate,5324.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5324.9,100,MS-DRG,4259.92,Case Rate,100% of CMS IPPS Rate,5324.9,100,MS-DRG,4259.92,Case Rate,100% of CMS IPPS Rate,6834.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5851.67,100,MS-DRG,4681.336,Case Rate,100% of CMS IPPS Rate,7607.17,130,MS-DRG,6085.736,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6027.22,103,MS-DRG,4821.776,Case Rate,103% of CMS IPPS Rate,6027.22,103,MS-DRG,4821.776,Case Rate,103% of CMS IPPS Rate,11035.86,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5851.67,100,MS-DRG,4681.336,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8777.51,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5851.67,100,MS-DRG,4681.336,Case Rate,100% of CMS IPPS Rate,7500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5851.67,100,MS-DRG,4681.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5324.9,15506.56,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,18055.55,145,MS-DRG,14444.44,Case Rate,145% of CMS IPPS Rate,12452.1,100,MS-DRG,9961.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12452.1,100,,9961.68,Case Rate,100% of CMS IPPS Rate,24030.46,100,,,Case Rate,100% of CMS IPPS Rate,27464.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30896.56,100,,,Case Rate,100% of CMS IPPS Rate,30896.56,100,,,Case Rate,100% of CMS IPPS Rate,30896.56,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11330.89,100,,9064.712,Case Rate,100% of CMS IPPS Rate,11330.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11330.89,100,MS-DRG,9064.712,Case Rate,100% of CMS IPPS Rate,11330.89,100,MS-DRG,9064.712,Case Rate,100% of CMS IPPS Rate,18567.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12452.1,100,MS-DRG,9961.68,Case Rate,100% of CMS IPPS Rate,16187.73,130,MS-DRG,12950.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12825.66,103,MS-DRG,10260.528,Case Rate,103% of CMS IPPS Rate,12825.66,103,MS-DRG,10260.528,Case Rate,103% of CMS IPPS Rate,23096.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12452.1,100,MS-DRG,9961.68,Case Rate,100% of CMS IPPS Rate,13190.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18678.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12452.1,100,MS-DRG,9961.68,Case Rate,100% of CMS IPPS Rate,2800,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12452.1,100,MS-DRG,9961.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2800,30896.56,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,CDM,,,,,Inpatient,,,,,,82153.37,,,,Case Rate,100% of CMS IPPS Rate,59544.37,145,MS-DRG,47635.496,Case Rate,145% of CMS IPPS Rate,41065.08,100,MS-DRG,32852.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41065.08,100,,32852.064,Case Rate,100% of CMS IPPS Rate,79250.13,100,,,Case Rate,100% of CMS IPPS Rate,90574.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,101893.87,100,,,Case Rate,100% of CMS IPPS Rate,101893.87,100,,,Case Rate,100% of CMS IPPS Rate,101893.87,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37366.91,100,,29893.528,Case Rate,100% of CMS IPPS Rate,37366.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37366.91,100,MS-DRG,29893.528,Case Rate,100% of CMS IPPS Rate,37366.91,100,MS-DRG,29893.528,Case Rate,100% of CMS IPPS Rate,5652.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41065.08,100,MS-DRG,32852.064,Case Rate,100% of CMS IPPS Rate,53384.6,130,MS-DRG,42707.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42297.03,103,MS-DRG,33837.624,Case Rate,103% of CMS IPPS Rate,42297.03,103,MS-DRG,33837.624,Case Rate,103% of CMS IPPS Rate,76166.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41065.08,100,MS-DRG,32852.064,Case Rate,100% of CMS IPPS Rate,43500.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,61597.62,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41065.08,100,MS-DRG,32852.064,Case Rate,100% of CMS IPPS Rate,4500,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41065.08,100,MS-DRG,32852.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4500,101893.87,
PREMATURITY WITH MAJOR PROBLEMS,791,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,40665.13,145,MS-DRG,32532.104,Case Rate,145% of CMS IPPS Rate,28044.92,100,MS-DRG,22435.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28044.92,100,,22435.936,Case Rate,100% of CMS IPPS Rate,54122.53,100,,,Case Rate,100% of CMS IPPS Rate,61856.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,69586.69,100,,,Case Rate,100% of CMS IPPS Rate,69586.69,100,,,Case Rate,100% of CMS IPPS Rate,69586.69,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25519.39,100,,20415.512,Case Rate,100% of CMS IPPS Rate,25519.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25519.39,100,MS-DRG,20415.512,Case Rate,100% of CMS IPPS Rate,25519.39,100,MS-DRG,20415.512,Case Rate,100% of CMS IPPS Rate,2451.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28044.92,100,MS-DRG,22435.936,Case Rate,100% of CMS IPPS Rate,36458.4,130,MS-DRG,29166.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28886.27,103,MS-DRG,23109.016,Case Rate,103% of CMS IPPS Rate,28886.27,103,MS-DRG,23109.016,Case Rate,103% of CMS IPPS Rate,52018.07,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28044.92,100,MS-DRG,22435.936,Case Rate,100% of CMS IPPS Rate,29708.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,42067.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28044.92,100,MS-DRG,22435.936,Case Rate,100% of CMS IPPS Rate,3900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28044.92,100,MS-DRG,22435.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2451.61,69586.69,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,24536.83,145,MS-DRG,19629.464,Case Rate,145% of CMS IPPS Rate,16921.95,100,MS-DRG,13537.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16921.95,100,,13537.56,Case Rate,100% of CMS IPPS Rate,32656.95,100,,,Case Rate,100% of CMS IPPS Rate,37323.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41987.86,100,,,Case Rate,100% of CMS IPPS Rate,41987.86,100,,,Case Rate,100% of CMS IPPS Rate,41987.86,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15398.17,100,,12318.536,Case Rate,100% of CMS IPPS Rate,15398.17,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15398.17,100,MS-DRG,12318.536,Case Rate,100% of CMS IPPS Rate,15398.17,100,MS-DRG,12318.536,Case Rate,100% of CMS IPPS Rate,1669.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16921.95,100,MS-DRG,13537.56,Case Rate,100% of CMS IPPS Rate,21998.54,130,MS-DRG,17598.832,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17429.61,103,MS-DRG,13943.688,Case Rate,103% of CMS IPPS Rate,17429.61,103,MS-DRG,13943.688,Case Rate,103% of CMS IPPS Rate,31387.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16921.95,100,MS-DRG,13537.56,Case Rate,100% of CMS IPPS Rate,17925.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25382.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16921.95,100,MS-DRG,13537.56,Case Rate,100% of CMS IPPS Rate,2800,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16921.95,100,MS-DRG,13537.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,1669.27,41987.86,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,41772.64,145,MS-DRG,33418.112,Case Rate,145% of CMS IPPS Rate,28808.72,100,MS-DRG,23046.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28808.72,100,,23046.976,Case Rate,100% of CMS IPPS Rate,55596.94,100,,,Case Rate,100% of CMS IPPS Rate,63541.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,71482.37,100,,,Case Rate,100% of CMS IPPS Rate,71482.37,100,,,Case Rate,100% of CMS IPPS Rate,71482.37,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26214.4,100,,20971.52,Case Rate,100% of CMS IPPS Rate,26214.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,26214.4,100,MS-DRG,20971.52,Case Rate,100% of CMS IPPS Rate,26214.4,100,MS-DRG,20971.52,Case Rate,100% of CMS IPPS Rate,37879.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28808.72,100,MS-DRG,23046.976,Case Rate,100% of CMS IPPS Rate,37451.34,130,MS-DRG,29961.072,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29672.98,103,MS-DRG,23738.384,Case Rate,103% of CMS IPPS Rate,29672.98,103,MS-DRG,23738.384,Case Rate,103% of CMS IPPS Rate,53433.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28808.72,100,MS-DRG,23046.976,Case Rate,100% of CMS IPPS Rate,30517.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,43213.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28808.72,100,MS-DRG,23046.976,Case Rate,100% of CMS IPPS Rate,3900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28808.72,100,MS-DRG,23046.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3900,71482.37,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,14785.61,145,MS-DRG,11828.488,Case Rate,145% of CMS IPPS Rate,10196.97,100,MS-DRG,8157.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10196.97,100,,8157.576,Case Rate,100% of CMS IPPS Rate,19679.22,100,,,Case Rate,100% of CMS IPPS Rate,22491.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25302.07,100,,,Case Rate,100% of CMS IPPS Rate,25302.07,100,,,Case Rate,100% of CMS IPPS Rate,25302.07,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9278.85,100,,7423.08,Case Rate,100% of CMS IPPS Rate,9278.85,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9278.85,100,MS-DRG,7423.08,Case Rate,100% of CMS IPPS Rate,9278.85,100,MS-DRG,7423.08,Case Rate,100% of CMS IPPS Rate,25205.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10196.97,100,MS-DRG,8157.576,Case Rate,100% of CMS IPPS Rate,13256.06,130,MS-DRG,10604.848,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10502.88,103,MS-DRG,8402.304,Case Rate,103% of CMS IPPS Rate,10502.88,103,MS-DRG,8402.304,Case Rate,103% of CMS IPPS Rate,18913.02,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10196.97,100,MS-DRG,8157.576,Case Rate,100% of CMS IPPS Rate,10801.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15295.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10196.97,100,MS-DRG,8157.576,Case Rate,100% of CMS IPPS Rate,2800,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10196.97,100,MS-DRG,8157.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2800,25302.07,
NORMAL NEWBORN,795,CDM,,,,,Inpatient,,,,,,4162,,,,Case Rate,100% of CMS IPPS Rate,2001.64,145,MS-DRG,1601.312,Case Rate,145% of CMS IPPS Rate,1380.44,100,MS-DRG,1104.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,1380.44,100,,1104.352,Case Rate,100% of CMS IPPS Rate,2663.53,100,,,Case Rate,100% of CMS IPPS Rate,3044.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3424.57,100,,,Case Rate,100% of CMS IPPS Rate,3424.57,100,,,Case Rate,100% of CMS IPPS Rate,3424.57,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1256.37,100,,1005.096,Case Rate,100% of CMS IPPS Rate,1256.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,1256.37,100,MS-DRG,1005.096,Case Rate,100% of CMS IPPS Rate,1256.37,100,MS-DRG,1005.096,Case Rate,100% of CMS IPPS Rate,1023.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,1380.44,100,MS-DRG,1104.352,Case Rate,100% of CMS IPPS Rate,1794.57,130,MS-DRG,1435.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1421.85,103,MS-DRG,1137.48,Case Rate,103% of CMS IPPS Rate,1421.85,103,MS-DRG,1137.48,Case Rate,103% of CMS IPPS Rate,2560.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1380.44,100,MS-DRG,1104.352,Case Rate,100% of CMS IPPS Rate,1462.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,2070.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1380.44,100,MS-DRG,1104.352,Case Rate,100% of CMS IPPS Rate,750,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1380.44,100,MS-DRG,1104.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,750,5900,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,14076.05,145,MS-DRG,11260.84,Case Rate,145% of CMS IPPS Rate,9707.62,100,MS-DRG,7766.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9707.62,100,,7766.096,Case Rate,100% of CMS IPPS Rate,14144.19,100,,,Case Rate,100% of CMS IPPS Rate,16165.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18185.54,100,,,Case Rate,100% of CMS IPPS Rate,18185.54,100,,,Case Rate,100% of CMS IPPS Rate,18185.54,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8833.58,100,,7066.864,Case Rate,100% of CMS IPPS Rate,8833.58,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8833.58,100,MS-DRG,7066.864,Case Rate,100% of CMS IPPS Rate,8833.58,100,MS-DRG,7066.864,Case Rate,100% of CMS IPPS Rate,12763.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9707.62,100,MS-DRG,7766.096,Case Rate,100% of CMS IPPS Rate,12619.91,130,MS-DRG,10095.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9998.85,103,MS-DRG,7999.08,Case Rate,103% of CMS IPPS Rate,9998.85,103,MS-DRG,7999.08,Case Rate,103% of CMS IPPS Rate,16609.45,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9707.62,100,MS-DRG,7766.096,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,14561.43,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9707.62,100,MS-DRG,7766.096,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9707.62,100,MS-DRG,7766.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4000,18185.54,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,9883.21,145,MS-DRG,7906.568,Case Rate,145% of CMS IPPS Rate,6816.01,100,MS-DRG,5452.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6816.01,100,,5452.808,Case Rate,100% of CMS IPPS Rate,12907.07,100,,,Case Rate,100% of CMS IPPS Rate,14751.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16594.95,100,,,Case Rate,100% of CMS IPPS Rate,16594.95,100,,,Case Rate,100% of CMS IPPS Rate,16594.95,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6202.4,100,,4961.92,Case Rate,100% of CMS IPPS Rate,6202.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6202.4,100,MS-DRG,4961.92,Case Rate,100% of CMS IPPS Rate,6202.4,100,MS-DRG,4961.92,Case Rate,100% of CMS IPPS Rate,8961.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6816.01,100,MS-DRG,5452.808,Case Rate,100% of CMS IPPS Rate,8860.81,130,MS-DRG,7088.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7020.49,103,MS-DRG,5616.392,Case Rate,103% of CMS IPPS Rate,7020.49,103,MS-DRG,5616.392,Case Rate,103% of CMS IPPS Rate,11737.94,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6816.01,100,MS-DRG,5452.808,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,10224.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6816.01,100,MS-DRG,5452.808,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6816.01,100,MS-DRG,5452.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4000,16594.95,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,8287.45,145,MS-DRG,6629.96,Case Rate,145% of CMS IPPS Rate,5715.48,100,MS-DRG,4572.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5715.48,100,,4572.384,Case Rate,100% of CMS IPPS Rate,12907.07,100,,,Case Rate,100% of CMS IPPS Rate,14751.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16594.95,100,,,Case Rate,100% of CMS IPPS Rate,16594.95,100,,,Case Rate,100% of CMS IPPS Rate,16594.95,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5200.98,100,,4160.784,Case Rate,100% of CMS IPPS Rate,5200.98,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5200.98,100,MS-DRG,4160.784,Case Rate,100% of CMS IPPS Rate,5200.98,100,MS-DRG,4160.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5715.48,100,MS-DRG,4572.384,Case Rate,100% of CMS IPPS Rate,7430.12,130,MS-DRG,5944.096,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5886.94,103,MS-DRG,4709.552,Case Rate,103% of CMS IPPS Rate,5886.94,103,MS-DRG,4709.552,Case Rate,103% of CMS IPPS Rate,11737.94,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5715.48,100,MS-DRG,4572.384,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,8573.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5715.48,100,MS-DRG,4572.384,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5715.48,100,MS-DRG,4572.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4000,16594.95,
SPLENIC PROCEDURES WITH MCC,799,CDM,,,,,Inpatient,,,,,,67838.38,,,,Case Rate,100% of CMS IPPS Rate,49168.92,145,MS-DRG,39335.136,Case Rate,145% of CMS IPPS Rate,33909.6,100,MS-DRG,27127.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33909.6,100,,27127.68,Case Rate,100% of CMS IPPS Rate,63386.24,100,,,Case Rate,100% of CMS IPPS Rate,72444.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,81497.27,100,,,Case Rate,100% of CMS IPPS Rate,81497.27,100,,,Case Rate,100% of CMS IPPS Rate,81497.27,100,,,Case Rate,100% CMS IPPS Rate,61238.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30855.89,100,,24684.712,Case Rate,100% of CMS IPPS Rate,30855.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,30855.89,100,MS-DRG,24684.712,Case Rate,100% of CMS IPPS Rate,30855.89,100,MS-DRG,24684.712,Case Rate,100% of CMS IPPS Rate,40702.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33909.6,100,MS-DRG,27127.68,Case Rate,100% of CMS IPPS Rate,44082.48,130,MS-DRG,35265.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34926.89,103,MS-DRG,27941.512,Case Rate,103% of CMS IPPS Rate,34926.89,103,MS-DRG,27941.512,Case Rate,103% of CMS IPPS Rate,65877.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33909.6,100,MS-DRG,27127.68,Case Rate,100% of CMS IPPS Rate,35920.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,50864.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33909.6,100,MS-DRG,27127.68,Case Rate,100% of CMS IPPS Rate,69364.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33909.6,100,MS-DRG,27127.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,81497.27,
SPLENIC PROCEDURES WITH CC,800,CDM,,,,,Inpatient,,,,,,38579.95,,,,Case Rate,100% of CMS IPPS Rate,27962.55,145,MS-DRG,22370.04,Case Rate,145% of CMS IPPS Rate,19284.52,100,MS-DRG,15427.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19284.52,100,,15427.616,Case Rate,100% of CMS IPPS Rate,38843.87,100,,,Case Rate,100% of CMS IPPS Rate,44394.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49942.53,100,,,Case Rate,100% of CMS IPPS Rate,49942.53,100,,,Case Rate,100% of CMS IPPS Rate,49942.53,100,,,Case Rate,100% CMS IPPS Rate,34826.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17547.96,100,,14038.368,Case Rate,100% of CMS IPPS Rate,17547.96,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17547.96,100,MS-DRG,14038.368,Case Rate,100% of CMS IPPS Rate,17547.96,100,MS-DRG,14038.368,Case Rate,100% of CMS IPPS Rate,21582.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19284.52,100,MS-DRG,15427.616,Case Rate,100% of CMS IPPS Rate,25069.88,130,MS-DRG,20055.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19863.06,103,MS-DRG,15890.448,Case Rate,103% of CMS IPPS Rate,19863.06,103,MS-DRG,15890.448,Case Rate,103% of CMS IPPS Rate,33630.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19284.52,100,MS-DRG,15427.616,Case Rate,100% of CMS IPPS Rate,20428.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28926.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19284.52,100,MS-DRG,15427.616,Case Rate,100% of CMS IPPS Rate,39447.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19284.52,100,MS-DRG,15427.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,49942.53,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,CDM,,,,,Inpatient,,,,,,24504.57,,,,Case Rate,100% of CMS IPPS Rate,17760.79,145,MS-DRG,14208.632,Case Rate,145% of CMS IPPS Rate,12248.82,100,MS-DRG,9799.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12248.82,100,,9799.056,Case Rate,100% of CMS IPPS Rate,21885.5,100,,,Case Rate,100% of CMS IPPS Rate,25012.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28138.74,100,,,Case Rate,100% of CMS IPPS Rate,28138.74,100,,,Case Rate,100% of CMS IPPS Rate,28138.74,100,,,Case Rate,100% CMS IPPS Rate,22120.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11145.92,100,,8916.736,Case Rate,100% of CMS IPPS Rate,11145.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11145.92,100,MS-DRG,8916.736,Case Rate,100% of CMS IPPS Rate,11145.92,100,MS-DRG,8916.736,Case Rate,100% of CMS IPPS Rate,16105.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12248.82,100,MS-DRG,9799.056,Case Rate,100% of CMS IPPS Rate,15923.47,130,MS-DRG,12738.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12616.28,103,MS-DRG,10093.024,Case Rate,103% of CMS IPPS Rate,12616.28,103,MS-DRG,10093.024,Case Rate,103% of CMS IPPS Rate,22719.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12248.82,100,MS-DRG,9799.056,Case Rate,100% of CMS IPPS Rate,12975.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18373.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12248.82,100,MS-DRG,9799.056,Case Rate,100% of CMS IPPS Rate,25055.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12248.82,100,MS-DRG,9799.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28138.74,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,CDM,,,,,Inpatient,,,,,,46419.99,,,,Case Rate,100% of CMS IPPS Rate,34046.9,145,MS-DRG,27237.52,Case Rate,145% of CMS IPPS Rate,23480.62,100,MS-DRG,18784.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23480.62,100,,18784.496,Case Rate,100% of CMS IPPS Rate,47788.97,100,,,Case Rate,100% of CMS IPPS Rate,54618.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,61443.47,100,,,Case Rate,100% of CMS IPPS Rate,61443.47,100,,,Case Rate,100% of CMS IPPS Rate,61443.47,100,,,Case Rate,100% CMS IPPS Rate,41904.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21366.16,100,,17092.928,Case Rate,100% of CMS IPPS Rate,21366.16,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21366.16,100,MS-DRG,17092.928,Case Rate,100% of CMS IPPS Rate,21366.16,100,MS-DRG,17092.928,Case Rate,100% of CMS IPPS Rate,45114.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23480.62,100,MS-DRG,18784.496,Case Rate,100% of CMS IPPS Rate,30524.81,130,MS-DRG,24419.848,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24185.04,103,MS-DRG,19348.032,Case Rate,103% of CMS IPPS Rate,24185.04,103,MS-DRG,19348.032,Case Rate,103% of CMS IPPS Rate,48221.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23480.62,100,MS-DRG,18784.496,Case Rate,100% of CMS IPPS Rate,24579.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,35220.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23480.62,100,MS-DRG,18784.496,Case Rate,100% of CMS IPPS Rate,47464.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23480.62,100,MS-DRG,18784.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,61443.47,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,CDM,,,,,Inpatient,,,,,,25442.47,,,,Case Rate,100% of CMS IPPS Rate,18440.58,145,MS-DRG,14752.464,Case Rate,145% of CMS IPPS Rate,12717.64,100,MS-DRG,10174.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12717.64,100,,10174.112,Case Rate,100% of CMS IPPS Rate,23729.18,100,,,Case Rate,100% of CMS IPPS Rate,27120.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30509.2,100,,,Case Rate,100% of CMS IPPS Rate,30509.2,100,,,Case Rate,100% of CMS IPPS Rate,30509.2,100,,,Case Rate,100% CMS IPPS Rate,22967.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11572.5,100,,9258,Case Rate,100% of CMS IPPS Rate,11572.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11572.5,100,MS-DRG,9258,Case Rate,100% of CMS IPPS Rate,11572.5,100,MS-DRG,9258,Case Rate,100% of CMS IPPS Rate,12729.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12717.64,100,MS-DRG,10174.112,Case Rate,100% of CMS IPPS Rate,16532.93,130,MS-DRG,13226.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13099.17,103,MS-DRG,10479.336,Case Rate,103% of CMS IPPS Rate,13099.17,103,MS-DRG,10479.336,Case Rate,103% of CMS IPPS Rate,25974.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12717.64,100,MS-DRG,10174.112,Case Rate,100% of CMS IPPS Rate,13471.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19076.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12717.64,100,MS-DRG,10174.112,Case Rate,100% of CMS IPPS Rate,26014.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12717.64,100,MS-DRG,10174.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30509.2,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,CDM,,,,,Inpatient,,,,,,16572.8,,,,Case Rate,100% of CMS IPPS Rate,12011.89,145,MS-DRG,9609.512,Case Rate,145% of CMS IPPS Rate,8284.06,100,MS-DRG,6627.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8284.06,100,,6627.248,Case Rate,100% of CMS IPPS Rate,14738.75,100,,,Case Rate,100% of CMS IPPS Rate,16844.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18949.98,100,,,Case Rate,100% of CMS IPPS Rate,18949.98,100,,,Case Rate,100% of CMS IPPS Rate,18949.98,100,,,Case Rate,100% CMS IPPS Rate,14960.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7538.23,100,,6030.584,Case Rate,100% of CMS IPPS Rate,7538.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7538.23,100,MS-DRG,6030.584,Case Rate,100% of CMS IPPS Rate,7538.23,100,MS-DRG,6030.584,Case Rate,100% of CMS IPPS Rate,14052.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8284.06,100,MS-DRG,6627.248,Case Rate,100% of CMS IPPS Rate,10769.28,130,MS-DRG,8615.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8532.58,103,MS-DRG,6826.064,Case Rate,103% of CMS IPPS Rate,8532.58,103,MS-DRG,6826.064,Case Rate,103% of CMS IPPS Rate,15961.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8284.06,100,MS-DRG,6627.248,Case Rate,100% of CMS IPPS Rate,8775.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12426.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8284.06,100,MS-DRG,6627.248,Case Rate,100% of CMS IPPS Rate,16945.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8284.06,100,MS-DRG,6627.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18949.98,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,10005.26,145,MS-DRG,8004.208,Case Rate,145% of CMS IPPS Rate,6900.18,100,MS-DRG,5520.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6900.18,100,,5520.144,Case Rate,100% of CMS IPPS Rate,13304.34,100,,,Case Rate,100% of CMS IPPS Rate,15205.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17105.72,100,,,Case Rate,100% of CMS IPPS Rate,17105.72,100,,,Case Rate,100% of CMS IPPS Rate,17105.72,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6279,100,,5023.2,Case Rate,100% of CMS IPPS Rate,6279,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6279,100,MS-DRG,5023.2,Case Rate,100% of CMS IPPS Rate,6279,100,MS-DRG,5023.2,Case Rate,100% of CMS IPPS Rate,4460.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6900.18,100,MS-DRG,5520.144,Case Rate,100% of CMS IPPS Rate,8970.23,130,MS-DRG,7176.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7107.19,103,MS-DRG,5685.752,Case Rate,103% of CMS IPPS Rate,7107.19,103,MS-DRG,5685.752,Case Rate,103% of CMS IPPS Rate,12720.84,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6900.18,100,MS-DRG,5520.144,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,10350.27,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6900.18,100,MS-DRG,5520.144,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6900.18,100,MS-DRG,5520.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4000,17105.72,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,7410.18,145,MS-DRG,5928.144,Case Rate,145% of CMS IPPS Rate,5110.47,100,MS-DRG,4088.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5110.47,100,,4088.376,Case Rate,100% of CMS IPPS Rate,9646.31,100,,,Case Rate,100% of CMS IPPS Rate,11024.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12402.5,100,,,Case Rate,100% of CMS IPPS Rate,12402.5,100,,,Case Rate,100% of CMS IPPS Rate,12402.5,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4650.46,100,,3720.368,Case Rate,100% of CMS IPPS Rate,4650.46,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4650.46,100,MS-DRG,3720.368,Case Rate,100% of CMS IPPS Rate,4650.46,100,MS-DRG,3720.368,Case Rate,100% of CMS IPPS Rate,3976.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5110.47,100,MS-DRG,4088.376,Case Rate,100% of CMS IPPS Rate,6643.61,130,MS-DRG,5314.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5263.78,103,MS-DRG,4211.024,Case Rate,103% of CMS IPPS Rate,5263.78,103,MS-DRG,4211.024,Case Rate,103% of CMS IPPS Rate,8827.17,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5110.47,100,MS-DRG,4088.376,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,7665.71,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5110.47,100,MS-DRG,4088.376,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5110.47,100,MS-DRG,4088.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3976.57,12402.5,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,CDM,,,,,Inpatient,,,,,,5202,,,,Case Rate,100% of CMS IPPS Rate,6493.2,145,MS-DRG,5194.56,Case Rate,145% of CMS IPPS Rate,4478.07,100,MS-DRG,3582.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4478.07,100,,3582.456,Case Rate,100% of CMS IPPS Rate,8495.85,100,,,Case Rate,100% of CMS IPPS Rate,9709.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10923.32,100,,,Case Rate,100% of CMS IPPS Rate,10923.32,100,,,Case Rate,100% of CMS IPPS Rate,10923.32,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4075.01,100,,3260.008,Case Rate,100% of CMS IPPS Rate,4075.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4075.01,100,MS-DRG,3260.008,Case Rate,100% of CMS IPPS Rate,4075.01,100,MS-DRG,3260.008,Case Rate,100% of CMS IPPS Rate,3401.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4478.07,100,MS-DRG,3582.456,Case Rate,100% of CMS IPPS Rate,5821.49,130,MS-DRG,4657.192,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4612.41,103,MS-DRG,3689.928,Case Rate,103% of CMS IPPS Rate,4612.41,103,MS-DRG,3689.928,Case Rate,103% of CMS IPPS Rate,7987.21,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4478.07,100,MS-DRG,3582.456,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,4000,100,,,Case Rate,100% of CMS IPPS Rate,6717.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4478.07,100,MS-DRG,3582.456,Case Rate,100% of CMS IPPS Rate,6000,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4478.07,100,MS-DRG,3582.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3401.77,10923.32,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,CDM,,,,,Inpatient,,,,,,29986.85,,,,Case Rate,100% of CMS IPPS Rate,21734.31,145,MS-DRG,17387.448,Case Rate,145% of CMS IPPS Rate,14989.18,100,MS-DRG,11991.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14989.18,100,,11991.344,Case Rate,100% of CMS IPPS Rate,30531.99,100,,,Case Rate,100% of CMS IPPS Rate,34895.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,39255.74,100,,,Case Rate,100% of CMS IPPS Rate,39255.74,100,,,Case Rate,100% of CMS IPPS Rate,39255.74,100,,,Case Rate,100% CMS IPPS Rate,27069.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13639.48,100,,10911.584,Case Rate,100% of CMS IPPS Rate,13639.48,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13639.48,100,MS-DRG,10911.584,Case Rate,100% of CMS IPPS Rate,13639.48,100,MS-DRG,10911.584,Case Rate,100% of CMS IPPS Rate,17639.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14989.18,100,MS-DRG,11991.344,Case Rate,100% of CMS IPPS Rate,19485.93,130,MS-DRG,15588.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15438.86,103,MS-DRG,12351.088,Case Rate,103% of CMS IPPS Rate,15438.86,103,MS-DRG,12351.088,Case Rate,103% of CMS IPPS Rate,27083.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14989.18,100,MS-DRG,11991.344,Case Rate,100% of CMS IPPS Rate,15878.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22483.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14989.18,100,MS-DRG,11991.344,Case Rate,100% of CMS IPPS Rate,30661.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14989.18,100,MS-DRG,11991.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39255.74,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,CDM,,,,,Inpatient,,,,,,16490.64,,,,Case Rate,100% of CMS IPPS Rate,11952.34,145,MS-DRG,9561.872,Case Rate,145% of CMS IPPS Rate,8242.99,100,MS-DRG,6594.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8242.99,100,,6594.392,Case Rate,100% of CMS IPPS Rate,16510.44,100,,,Case Rate,100% of CMS IPPS Rate,18869.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21227.89,100,,,Case Rate,100% of CMS IPPS Rate,21227.89,100,,,Case Rate,100% of CMS IPPS Rate,21227.89,100,,,Case Rate,100% CMS IPPS Rate,14886.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7500.86,100,,6000.688,Case Rate,100% of CMS IPPS Rate,7500.86,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7500.86,100,MS-DRG,6000.688,Case Rate,100% of CMS IPPS Rate,7500.86,100,MS-DRG,6000.688,Case Rate,100% of CMS IPPS Rate,8715.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8242.99,100,MS-DRG,6594.392,Case Rate,100% of CMS IPPS Rate,10715.89,130,MS-DRG,8572.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8490.28,103,MS-DRG,6792.224,Case Rate,103% of CMS IPPS Rate,8490.28,103,MS-DRG,6792.224,Case Rate,103% of CMS IPPS Rate,15378.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8242.99,100,MS-DRG,6594.392,Case Rate,100% of CMS IPPS Rate,8731.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12364.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8242.99,100,MS-DRG,6594.392,Case Rate,100% of CMS IPPS Rate,16861.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8242.99,100,MS-DRG,6594.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21227.89,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,CDM,,,,,Inpatient,,,,,,13753.61,,,,Case Rate,100% of CMS IPPS Rate,9968.55,145,MS-DRG,7974.84,Case Rate,145% of CMS IPPS Rate,6874.86,100,MS-DRG,5499.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6874.86,100,,5499.888,Case Rate,100% of CMS IPPS Rate,12688.45,100,,,Case Rate,100% of CMS IPPS Rate,14501.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16313.85,100,,,Case Rate,100% of CMS IPPS Rate,16313.85,100,,,Case Rate,100% of CMS IPPS Rate,16313.85,100,,,Case Rate,100% CMS IPPS Rate,12415.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6255.95,100,,5004.76,Case Rate,100% of CMS IPPS Rate,6255.95,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6255.95,100,MS-DRG,5004.76,Case Rate,100% of CMS IPPS Rate,6255.95,100,MS-DRG,5004.76,Case Rate,100% of CMS IPPS Rate,5970.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6874.86,100,MS-DRG,5499.888,Case Rate,100% of CMS IPPS Rate,8937.32,130,MS-DRG,7149.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7081.11,103,MS-DRG,5664.888,Case Rate,103% of CMS IPPS Rate,7081.11,103,MS-DRG,5664.888,Case Rate,103% of CMS IPPS Rate,11875.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6874.86,100,MS-DRG,5499.888,Case Rate,100% of CMS IPPS Rate,7282.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10312.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6874.86,100,MS-DRG,5499.888,Case Rate,100% of CMS IPPS Rate,14063,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6874.86,100,MS-DRG,5499.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,16313.85,
RED BLOOD CELL DISORDERS WITH MCC,811,CDM,,,,,Inpatient,,,,,,19218.09,,,,Case Rate,100% of CMS IPPS Rate,13929.18,145,MS-DRG,11143.344,Case Rate,145% of CMS IPPS Rate,9606.33,100,MS-DRG,7685.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9606.33,100,,7685.064,Case Rate,100% of CMS IPPS Rate,18755.38,100,,,Case Rate,100% of CMS IPPS Rate,21435.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24114.27,100,,,Case Rate,100% of CMS IPPS Rate,24114.27,100,,,Case Rate,100% of CMS IPPS Rate,24114.27,100,,,Case Rate,100% CMS IPPS Rate,17348.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8741.41,100,,6993.128,Case Rate,100% of CMS IPPS Rate,8741.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8741.41,100,MS-DRG,6993.128,Case Rate,100% of CMS IPPS Rate,8741.41,100,MS-DRG,6993.128,Case Rate,100% of CMS IPPS Rate,10036.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9606.33,100,MS-DRG,7685.064,Case Rate,100% of CMS IPPS Rate,12488.23,130,MS-DRG,9990.584,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9894.52,103,MS-DRG,7915.616,Case Rate,103% of CMS IPPS Rate,9894.52,103,MS-DRG,7915.616,Case Rate,103% of CMS IPPS Rate,17587.3,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9606.33,100,MS-DRG,7685.064,Case Rate,100% of CMS IPPS Rate,10176.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14409.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9606.33,100,MS-DRG,7685.064,Case Rate,100% of CMS IPPS Rate,19650.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9606.33,100,MS-DRG,7685.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24114.27,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,CDM,,,,,Inpatient,,,,,,12332.38,,,,Case Rate,100% of CMS IPPS Rate,8938.45,145,MS-DRG,7150.76,Case Rate,145% of CMS IPPS Rate,6164.45,100,MS-DRG,4931.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6164.45,100,,4931.56,Case Rate,100% of CMS IPPS Rate,12303.18,100,,,Case Rate,100% of CMS IPPS Rate,14061.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15818.51,100,,,Case Rate,100% of CMS IPPS Rate,15818.51,100,,,Case Rate,100% of CMS IPPS Rate,15818.51,100,,,Case Rate,100% CMS IPPS Rate,11132.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5609.52,100,,4487.616,Case Rate,100% of CMS IPPS Rate,5609.52,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5609.52,100,MS-DRG,4487.616,Case Rate,100% of CMS IPPS Rate,5609.52,100,MS-DRG,4487.616,Case Rate,100% of CMS IPPS Rate,5879.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6164.45,100,MS-DRG,4931.56,Case Rate,100% of CMS IPPS Rate,8013.79,130,MS-DRG,6411.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6349.38,103,MS-DRG,5079.504,Case Rate,103% of CMS IPPS Rate,6349.38,103,MS-DRG,5079.504,Case Rate,103% of CMS IPPS Rate,11359.7,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6164.45,100,MS-DRG,4931.56,Case Rate,100% of CMS IPPS Rate,6530.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9246.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6164.45,100,MS-DRG,4931.56,Case Rate,100% of CMS IPPS Rate,12609.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6164.45,100,MS-DRG,4931.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5609.52,15818.51,
COAGULATION DISORDERS,813,CDM,,,,,Inpatient,,,,,,21359.52,,,,Case Rate,100% of CMS IPPS Rate,15481.27,145,MS-DRG,12385.016,Case Rate,145% of CMS IPPS Rate,10676.74,100,MS-DRG,8541.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10676.74,100,,8541.392,Case Rate,100% of CMS IPPS Rate,20636.39,100,,,Case Rate,100% of CMS IPPS Rate,23585.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26532.72,100,,,Case Rate,100% of CMS IPPS Rate,26532.72,100,,,Case Rate,100% of CMS IPPS Rate,26532.72,100,,,Case Rate,100% CMS IPPS Rate,19281.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9715.42,100,,7772.336,Case Rate,100% of CMS IPPS Rate,9715.42,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9715.42,100,MS-DRG,7772.336,Case Rate,100% of CMS IPPS Rate,9715.42,100,MS-DRG,7772.336,Case Rate,100% of CMS IPPS Rate,9234.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10676.74,100,MS-DRG,8541.392,Case Rate,100% of CMS IPPS Rate,13879.76,130,MS-DRG,11103.808,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10997.04,103,MS-DRG,8797.632,Case Rate,103% of CMS IPPS Rate,10997.04,103,MS-DRG,8797.632,Case Rate,103% of CMS IPPS Rate,19798.52,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10676.74,100,MS-DRG,8541.392,Case Rate,100% of CMS IPPS Rate,11310,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16015.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10676.74,100,MS-DRG,8541.392,Case Rate,100% of CMS IPPS Rate,21840,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10676.74,100,MS-DRG,8541.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26532.72,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,CDM,,,,,Inpatient,,,,,,29137.95,,,,Case Rate,100% of CMS IPPS Rate,21119.05,145,MS-DRG,16895.24,Case Rate,145% of CMS IPPS Rate,14564.86,100,MS-DRG,11651.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14564.86,100,,11651.888,Case Rate,100% of CMS IPPS Rate,27868.46,100,,,Case Rate,100% of CMS IPPS Rate,31850.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,35831.17,100,,,Case Rate,100% of CMS IPPS Rate,35831.17,100,,,Case Rate,100% of CMS IPPS Rate,35831.17,100,,,Case Rate,100% CMS IPPS Rate,26303.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13253.36,100,,10602.688,Case Rate,100% of CMS IPPS Rate,13253.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13253.36,100,MS-DRG,10602.688,Case Rate,100% of CMS IPPS Rate,13253.36,100,MS-DRG,10602.688,Case Rate,100% of CMS IPPS Rate,11585.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14564.86,100,MS-DRG,11651.888,Case Rate,100% of CMS IPPS Rate,18934.32,130,MS-DRG,15147.456,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15001.81,103,MS-DRG,12001.448,Case Rate,103% of CMS IPPS Rate,15001.81,103,MS-DRG,12001.448,Case Rate,103% of CMS IPPS Rate,23770.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14564.86,100,MS-DRG,11651.888,Case Rate,100% of CMS IPPS Rate,15428.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21847.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14564.86,100,MS-DRG,11651.888,Case Rate,100% of CMS IPPS Rate,29793.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14564.86,100,MS-DRG,11651.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,35831.17,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,CDM,,,,,Inpatient,,,,,,13612.59,,,,Case Rate,100% of CMS IPPS Rate,9866.34,145,MS-DRG,7893.072,Case Rate,145% of CMS IPPS Rate,6804.37,100,MS-DRG,5443.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6804.37,100,,5443.496,Case Rate,100% of CMS IPPS Rate,13545.63,100,,,Case Rate,100% of CMS IPPS Rate,15481.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17415.95,100,,,Case Rate,100% of CMS IPPS Rate,17415.95,100,,,Case Rate,100% of CMS IPPS Rate,17415.95,100,,,Case Rate,100% CMS IPPS Rate,12288.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6191.8,100,,4953.44,Case Rate,100% of CMS IPPS Rate,6191.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6191.8,100,MS-DRG,4953.44,Case Rate,100% of CMS IPPS Rate,6191.8,100,MS-DRG,4953.44,Case Rate,100% of CMS IPPS Rate,6481.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6804.37,100,MS-DRG,5443.496,Case Rate,100% of CMS IPPS Rate,8845.68,130,MS-DRG,7076.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7008.5,103,MS-DRG,5606.8,Case Rate,103% of CMS IPPS Rate,7008.5,103,MS-DRG,5606.8,Case Rate,103% of CMS IPPS Rate,13043.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6804.37,100,MS-DRG,5443.496,Case Rate,100% of CMS IPPS Rate,7207.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10206.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6804.37,100,MS-DRG,5443.496,Case Rate,100% of CMS IPPS Rate,13918.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6804.37,100,MS-DRG,5443.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17415.95,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,CDM,,,,,Inpatient,,,,,,9724.06,,,,Case Rate,100% of CMS IPPS Rate,7047.94,145,MS-DRG,5638.352,Case Rate,145% of CMS IPPS Rate,4860.65,100,MS-DRG,3888.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4860.65,100,,3888.52,Case Rate,100% of CMS IPPS Rate,8790.46,100,,,Case Rate,100% of CMS IPPS Rate,10046.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11302.12,100,,,Case Rate,100% of CMS IPPS Rate,11302.12,100,,,Case Rate,100% of CMS IPPS Rate,11302.12,100,,,Case Rate,100% CMS IPPS Rate,8778.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4423.15,100,,3538.52,Case Rate,100% of CMS IPPS Rate,4423.15,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4423.15,100,MS-DRG,3538.52,Case Rate,100% of CMS IPPS Rate,4423.15,100,MS-DRG,3538.52,Case Rate,100% of CMS IPPS Rate,4193.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4860.65,100,MS-DRG,3888.52,Case Rate,100% of CMS IPPS Rate,6318.85,130,MS-DRG,5055.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5006.47,103,MS-DRG,4005.176,Case Rate,103% of CMS IPPS Rate,5006.47,103,MS-DRG,4005.176,Case Rate,103% of CMS IPPS Rate,9221.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4860.65,100,MS-DRG,3888.52,Case Rate,100% of CMS IPPS Rate,5148.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7290.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4860.65,100,MS-DRG,3888.52,Case Rate,100% of CMS IPPS Rate,9942.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4860.65,100,MS-DRG,3888.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4193.03,11302.12,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,CDM,,,,,Inpatient,,,,,,30875.46,,,,Case Rate,100% of CMS IPPS Rate,27953.62,145,MS-DRG,22362.896,Case Rate,145% of CMS IPPS Rate,19278.36,100,MS-DRG,15422.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19278.36,100,,15422.688,Case Rate,100% of CMS IPPS Rate,29140.23,100,,,Case Rate,100% of CMS IPPS Rate,33304.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37466.33,100,,,Case Rate,100% of CMS IPPS Rate,37466.33,100,,,Case Rate,100% of CMS IPPS Rate,37466.33,100,,,Case Rate,100% CMS IPPS Rate,27871.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17542.36,100,,14033.888,Case Rate,100% of CMS IPPS Rate,17542.36,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17542.36,100,MS-DRG,14033.888,Case Rate,100% of CMS IPPS Rate,17542.36,100,MS-DRG,14033.888,Case Rate,100% of CMS IPPS Rate,9911.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19278.36,100,MS-DRG,15422.688,Case Rate,100% of CMS IPPS Rate,25061.87,130,MS-DRG,20049.496,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19856.71,103,MS-DRG,15885.368,Case Rate,103% of CMS IPPS Rate,19856.71,103,MS-DRG,15885.368,Case Rate,103% of CMS IPPS Rate,39591.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19278.36,100,MS-DRG,15422.688,Case Rate,100% of CMS IPPS Rate,16348.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28917.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19278.36,100,MS-DRG,15422.688,Case Rate,100% of CMS IPPS Rate,31570,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19278.36,100,MS-DRG,15422.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,39591.97,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,CDM,,,,,Inpatient,,,,,,16062.09,,,,Case Rate,100% of CMS IPPS Rate,14202.08,145,MS-DRG,11361.664,Case Rate,145% of CMS IPPS Rate,9794.54,100,MS-DRG,7835.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9794.54,100,,7835.632,Case Rate,100% of CMS IPPS Rate,13189.69,100,,,Case Rate,100% of CMS IPPS Rate,15074.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16958.32,100,,,Case Rate,100% of CMS IPPS Rate,16958.32,100,,,Case Rate,100% of CMS IPPS Rate,16958.32,100,,,Case Rate,100% CMS IPPS Rate,14499.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8912.68,100,,7130.144,Case Rate,100% of CMS IPPS Rate,8912.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8912.68,100,MS-DRG,7130.144,Case Rate,100% of CMS IPPS Rate,8912.68,100,MS-DRG,7130.144,Case Rate,100% of CMS IPPS Rate,8771.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9794.54,100,MS-DRG,7835.632,Case Rate,100% of CMS IPPS Rate,12732.9,130,MS-DRG,10186.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10088.38,103,MS-DRG,8070.704,Case Rate,103% of CMS IPPS Rate,10088.38,103,MS-DRG,8070.704,Case Rate,103% of CMS IPPS Rate,20114.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9794.54,100,MS-DRG,7835.632,Case Rate,100% of CMS IPPS Rate,8504.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14691.81,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9794.54,100,MS-DRG,7835.632,Case Rate,100% of CMS IPPS Rate,16423.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9794.54,100,MS-DRG,7835.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20114.77,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,CDM,,,,,Inpatient,,,,,,12421.38,,,,Case Rate,100% of CMS IPPS Rate,9002.96,145,MS-DRG,7202.368,Case Rate,145% of CMS IPPS Rate,6208.94,100,MS-DRG,4967.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6208.94,100,,4967.152,Case Rate,100% of CMS IPPS Rate,9003.76,100,,,Case Rate,100% of CMS IPPS Rate,10290.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11576.36,100,,,Case Rate,100% of CMS IPPS Rate,11576.36,100,,,Case Rate,100% of CMS IPPS Rate,11576.36,100,,,Case Rate,100% CMS IPPS Rate,11212.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5649.99,100,,4519.992,Case Rate,100% of CMS IPPS Rate,5649.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5649.99,100,MS-DRG,4519.992,Case Rate,100% of CMS IPPS Rate,5649.99,100,MS-DRG,4519.992,Case Rate,100% of CMS IPPS Rate,6114.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6208.94,100,MS-DRG,4967.152,Case Rate,100% of CMS IPPS Rate,8071.62,130,MS-DRG,6457.296,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6395.21,103,MS-DRG,5116.168,Case Rate,103% of CMS IPPS Rate,6395.21,103,MS-DRG,5116.168,Case Rate,103% of CMS IPPS Rate,11239.53,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6208.94,100,MS-DRG,4967.152,Case Rate,100% of CMS IPPS Rate,6577.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9313.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6208.94,100,MS-DRG,4967.152,Case Rate,100% of CMS IPPS Rate,12700.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6208.94,100,MS-DRG,4967.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5649.99,12700.8,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,CDM,,,,,Inpatient,,,,,,82791.42,,,,Case Rate,100% of CMS IPPS Rate,60006.81,145,MS-DRG,48005.448,Case Rate,145% of CMS IPPS Rate,41384.01,100,MS-DRG,33107.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41384.01,100,,33107.208,Case Rate,100% of CMS IPPS Rate,77617.08,100,,,Case Rate,100% of CMS IPPS Rate,88708.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,99794.22,100,,,Case Rate,100% of CMS IPPS Rate,99794.22,100,,,Case Rate,100% of CMS IPPS Rate,99794.22,100,,,Case Rate,100% CMS IPPS Rate,74737.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37657.13,100,,30125.704,Case Rate,100% of CMS IPPS Rate,37657.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37657.13,100,MS-DRG,30125.704,Case Rate,100% of CMS IPPS Rate,37657.13,100,MS-DRG,30125.704,Case Rate,100% of CMS IPPS Rate,50836.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41384.01,100,MS-DRG,33107.208,Case Rate,100% of CMS IPPS Rate,53799.21,130,MS-DRG,43039.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42625.53,103,MS-DRG,34100.424,Case Rate,103% of CMS IPPS Rate,42625.53,103,MS-DRG,34100.424,Case Rate,103% of CMS IPPS Rate,67267.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41384.01,100,MS-DRG,33107.208,Case Rate,100% of CMS IPPS Rate,43838.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,62076.02,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41384.01,100,MS-DRG,33107.208,Case Rate,100% of CMS IPPS Rate,84653.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41384.01,100,MS-DRG,33107.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,99794.22,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,CDM,,,,,Inpatient,,,,,,30561.91,,,,Case Rate,100% of CMS IPPS Rate,22151.13,145,MS-DRG,17720.904,Case Rate,145% of CMS IPPS Rate,15276.64,100,MS-DRG,12221.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15276.64,100,,12221.312,Case Rate,100% of CMS IPPS Rate,29760.12,100,,,Case Rate,100% of CMS IPPS Rate,34012.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38263.34,100,,,Case Rate,100% of CMS IPPS Rate,38263.34,100,,,Case Rate,100% of CMS IPPS Rate,38263.34,100,,,Case Rate,100% CMS IPPS Rate,27588.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13901.04,100,,11120.832,Case Rate,100% of CMS IPPS Rate,13901.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13901.04,100,MS-DRG,11120.832,Case Rate,100% of CMS IPPS Rate,13901.04,100,MS-DRG,11120.832,Case Rate,100% of CMS IPPS Rate,15971.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15276.64,100,MS-DRG,12221.312,Case Rate,100% of CMS IPPS Rate,19859.63,130,MS-DRG,15887.704,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15734.94,103,MS-DRG,12587.952,Case Rate,103% of CMS IPPS Rate,15734.94,103,MS-DRG,12587.952,Case Rate,103% of CMS IPPS Rate,27354.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15276.64,100,MS-DRG,12221.312,Case Rate,100% of CMS IPPS Rate,16182.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22914.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15276.64,100,MS-DRG,12221.312,Case Rate,100% of CMS IPPS Rate,31249.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15276.64,100,MS-DRG,12221.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,38263.34,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,CDM,,,,,Inpatient,,,,,,16961.65,,,,Case Rate,100% of CMS IPPS Rate,12293.71,145,MS-DRG,9834.968,Case Rate,145% of CMS IPPS Rate,8478.42,100,MS-DRG,6782.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8478.42,100,,6782.736,Case Rate,100% of CMS IPPS Rate,15246.66,100,,,Case Rate,100% of CMS IPPS Rate,17425.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19603.02,100,,,Case Rate,100% of CMS IPPS Rate,19603.02,100,,,Case Rate,100% of CMS IPPS Rate,19603.02,100,,,Case Rate,100% CMS IPPS Rate,15311.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7715.09,100,,6172.072,Case Rate,100% of CMS IPPS Rate,7715.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7715.09,100,MS-DRG,6172.072,Case Rate,100% of CMS IPPS Rate,7715.09,100,MS-DRG,6172.072,Case Rate,100% of CMS IPPS Rate,12127.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8478.42,100,MS-DRG,6782.736,Case Rate,100% of CMS IPPS Rate,11021.95,130,MS-DRG,8817.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8732.77,103,MS-DRG,6986.216,Case Rate,103% of CMS IPPS Rate,8732.77,103,MS-DRG,6986.216,Case Rate,103% of CMS IPPS Rate,15243.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8478.42,100,MS-DRG,6782.736,Case Rate,100% of CMS IPPS Rate,8981.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12717.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8478.42,100,MS-DRG,6782.736,Case Rate,100% of CMS IPPS Rate,17343.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8478.42,100,MS-DRG,6782.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19603.02,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,CDM,,,,,Inpatient,,,,,,61640.01,,,,Case Rate,100% of CMS IPPS Rate,44676.37,145,MS-DRG,35741.096,Case Rate,145% of CMS IPPS Rate,30811.29,100,MS-DRG,24649.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30811.29,100,,24649.032,Case Rate,100% of CMS IPPS Rate,62382.41,100,,,Case Rate,100% of CMS IPPS Rate,71296.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,80206.63,100,,,Case Rate,100% of CMS IPPS Rate,80206.63,100,,,Case Rate,100% of CMS IPPS Rate,80206.63,100,,,Case Rate,100% CMS IPPS Rate,55643.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28036.6,100,,22429.28,Case Rate,100% of CMS IPPS Rate,28036.6,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28036.6,100,MS-DRG,22429.28,Case Rate,100% of CMS IPPS Rate,28036.6,100,MS-DRG,22429.28,Case Rate,100% of CMS IPPS Rate,38191.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30811.29,100,MS-DRG,24649.032,Case Rate,100% of CMS IPPS Rate,40054.68,130,MS-DRG,32043.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31735.63,103,MS-DRG,25388.504,Case Rate,103% of CMS IPPS Rate,31735.63,103,MS-DRG,25388.504,Case Rate,103% of CMS IPPS Rate,54728.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30811.29,100,MS-DRG,24649.032,Case Rate,100% of CMS IPPS Rate,32638.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,46216.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30811.29,100,MS-DRG,24649.032,Case Rate,100% of CMS IPPS Rate,63026.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30811.29,100,MS-DRG,24649.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,80206.63,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,CDM,,,,,Inpatient,,,,,,30572.87,,,,Case Rate,100% of CMS IPPS Rate,22159.06,145,MS-DRG,17727.248,Case Rate,145% of CMS IPPS Rate,15282.11,100,MS-DRG,12225.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15282.11,100,,12225.688,Case Rate,100% of CMS IPPS Rate,29320.2,100,,,Case Rate,100% of CMS IPPS Rate,33510.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37697.72,100,,,Case Rate,100% of CMS IPPS Rate,37697.72,100,,,Case Rate,100% of CMS IPPS Rate,37697.72,100,,,Case Rate,100% CMS IPPS Rate,27598.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13906.02,100,,11124.816,Case Rate,100% of CMS IPPS Rate,13906.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13906.02,100,MS-DRG,11124.816,Case Rate,100% of CMS IPPS Rate,13906.02,100,MS-DRG,11124.816,Case Rate,100% of CMS IPPS Rate,22375.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15282.11,100,MS-DRG,12225.688,Case Rate,100% of CMS IPPS Rate,19866.74,130,MS-DRG,15893.392,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15740.57,103,MS-DRG,12592.456,Case Rate,103% of CMS IPPS Rate,15740.57,103,MS-DRG,12592.456,Case Rate,103% of CMS IPPS Rate,28972.3,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15282.11,100,MS-DRG,12225.688,Case Rate,100% of CMS IPPS Rate,16188.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22923.17,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15282.11,100,MS-DRG,12225.688,Case Rate,100% of CMS IPPS Rate,31260.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15282.11,100,MS-DRG,12225.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37697.72,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,CDM,,,,,Inpatient,,,,,,17681.85,,,,Case Rate,100% of CMS IPPS Rate,12815.71,145,MS-DRG,10252.568,Case Rate,145% of CMS IPPS Rate,8838.42,100,MS-DRG,7070.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8838.42,100,,7070.736,Case Rate,100% of CMS IPPS Rate,16407.79,100,,,Case Rate,100% of CMS IPPS Rate,18752.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21095.91,100,,,Case Rate,100% of CMS IPPS Rate,21095.91,100,,,Case Rate,100% of CMS IPPS Rate,21095.91,100,,,Case Rate,100% CMS IPPS Rate,15961.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8042.67,100,,6434.136,Case Rate,100% of CMS IPPS Rate,8042.67,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8042.67,100,MS-DRG,6434.136,Case Rate,100% of CMS IPPS Rate,8042.67,100,MS-DRG,6434.136,Case Rate,100% of CMS IPPS Rate,11561.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8838.42,100,MS-DRG,7070.736,Case Rate,100% of CMS IPPS Rate,11489.95,130,MS-DRG,9191.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9103.57,103,MS-DRG,7282.856,Case Rate,103% of CMS IPPS Rate,9103.57,103,MS-DRG,7282.856,Case Rate,103% of CMS IPPS Rate,16654.99,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8838.42,100,MS-DRG,7070.736,Case Rate,100% of CMS IPPS Rate,9362.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13257.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8838.42,100,MS-DRG,7070.736,Case Rate,100% of CMS IPPS Rate,18079.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8838.42,100,MS-DRG,7070.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21095.91,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,CDM,,,,,Inpatient,,,,,,60091.45,,,,Case Rate,100% of CMS IPPS Rate,45924.81,145,MS-DRG,36739.848,Case Rate,145% of CMS IPPS Rate,31672.28,100,MS-DRG,25337.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31672.28,100,,25337.824,Case Rate,100% of CMS IPPS Rate,63662.19,100,,,Case Rate,100% of CMS IPPS Rate,72759.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,81852.07,100,,,Case Rate,100% of CMS IPPS Rate,81852.07,100,,,Case Rate,100% of CMS IPPS Rate,81852.07,100,,,Case Rate,100% CMS IPPS Rate,54245.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28820.06,100,,23056.048,Case Rate,100% of CMS IPPS Rate,28820.06,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,28820.06,100,MS-DRG,23056.048,Case Rate,100% of CMS IPPS Rate,28820.06,100,MS-DRG,23056.048,Case Rate,100% of CMS IPPS Rate,43736.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31672.28,100,MS-DRG,25337.824,Case Rate,100% of CMS IPPS Rate,41173.96,130,MS-DRG,32939.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32622.45,103,MS-DRG,26097.96,Case Rate,103% of CMS IPPS Rate,32622.45,103,MS-DRG,26097.96,Case Rate,103% of CMS IPPS Rate,65045.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31672.28,100,MS-DRG,25337.824,Case Rate,100% of CMS IPPS Rate,31818.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,47508.42,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31672.28,100,MS-DRG,25337.824,Case Rate,100% of CMS IPPS Rate,61443.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31672.28,100,MS-DRG,25337.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,81852.07,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,CDM,,,,,Inpatient,,,,,,31727.1,,,,Case Rate,100% of CMS IPPS Rate,22995.64,145,MS-DRG,18396.512,Case Rate,145% of CMS IPPS Rate,15859.06,100,MS-DRG,12687.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15859.06,100,,12687.248,Case Rate,100% of CMS IPPS Rate,31459.83,100,,,Case Rate,100% of CMS IPPS Rate,35955.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,40448.69,100,,,Case Rate,100% of CMS IPPS Rate,40448.69,100,,,Case Rate,100% of CMS IPPS Rate,40448.69,100,,,Case Rate,100% CMS IPPS Rate,28640.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14431.02,100,,11544.816,Case Rate,100% of CMS IPPS Rate,14431.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,14431.02,100,MS-DRG,11544.816,Case Rate,100% of CMS IPPS Rate,14431.02,100,MS-DRG,11544.816,Case Rate,100% of CMS IPPS Rate,19431.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15859.06,100,MS-DRG,12687.248,Case Rate,100% of CMS IPPS Rate,20616.78,130,MS-DRG,16493.424,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16334.83,103,MS-DRG,13067.864,Case Rate,103% of CMS IPPS Rate,16334.83,103,MS-DRG,13067.864,Case Rate,103% of CMS IPPS Rate,30798.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15859.06,100,MS-DRG,12687.248,Case Rate,100% of CMS IPPS Rate,16799.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,23788.59,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15859.06,100,MS-DRG,12687.248,Case Rate,100% of CMS IPPS Rate,32440.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15859.06,100,MS-DRG,12687.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,40448.69,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,CDM,,,,,Inpatient,,,,,,22460.36,,,,Case Rate,100% of CMS IPPS Rate,16279.15,145,MS-DRG,13023.32,Case Rate,145% of CMS IPPS Rate,11227,100,MS-DRG,8981.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11227,100,,8981.6,Case Rate,100% of CMS IPPS Rate,21368.26,100,,,Case Rate,100% of CMS IPPS Rate,24421.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27473.71,100,,,Case Rate,100% of CMS IPPS Rate,27473.71,100,,,Case Rate,100% of CMS IPPS Rate,27473.71,100,,,Case Rate,100% CMS IPPS Rate,20275.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10216.13,100,,8172.904,Case Rate,100% of CMS IPPS Rate,10216.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10216.13,100,MS-DRG,8172.904,Case Rate,100% of CMS IPPS Rate,10216.13,100,MS-DRG,8172.904,Case Rate,100% of CMS IPPS Rate,17005.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11227,100,MS-DRG,8981.6,Case Rate,100% of CMS IPPS Rate,14595.1,130,MS-DRG,11676.08,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11563.81,103,MS-DRG,9251.048,Case Rate,103% of CMS IPPS Rate,11563.81,103,MS-DRG,9251.048,Case Rate,103% of CMS IPPS Rate,21999.62,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11227,100,MS-DRG,8981.6,Case Rate,100% of CMS IPPS Rate,11892.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16840.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11227,100,MS-DRG,8981.6,Case Rate,100% of CMS IPPS Rate,22965.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11227,100,MS-DRG,8981.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27473.71,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,CDM,,,,,Inpatient,,,,,,43181.83,,,,Case Rate,100% of CMS IPPS Rate,31297.97,145,MS-DRG,25038.376,Case Rate,145% of CMS IPPS Rate,21584.81,100,MS-DRG,17267.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21584.81,100,,17267.848,Case Rate,100% of CMS IPPS Rate,41110.14,100,,,Case Rate,100% of CMS IPPS Rate,46984.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,52856.33,100,,,Case Rate,100% of CMS IPPS Rate,52856.33,100,,,Case Rate,100% of CMS IPPS Rate,52856.33,100,,,Case Rate,100% CMS IPPS Rate,38980.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19641.09,100,,15712.872,Case Rate,100% of CMS IPPS Rate,19641.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19641.09,100,MS-DRG,15712.872,Case Rate,100% of CMS IPPS Rate,19641.09,100,MS-DRG,15712.872,Case Rate,100% of CMS IPPS Rate,21933.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21584.81,100,MS-DRG,17267.848,Case Rate,100% of CMS IPPS Rate,28060.25,130,MS-DRG,22448.2,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22232.35,103,MS-DRG,17785.88,Case Rate,103% of CMS IPPS Rate,22232.35,103,MS-DRG,17785.88,Case Rate,103% of CMS IPPS Rate,40033.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21584.81,100,MS-DRG,17267.848,Case Rate,100% of CMS IPPS Rate,22865.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32377.22,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21584.81,100,MS-DRG,17267.848,Case Rate,100% of CMS IPPS Rate,44153.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21584.81,100,MS-DRG,17267.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,52856.33,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,CDM,,,,,Inpatient,,,,,,21649.79,,,,Case Rate,100% of CMS IPPS Rate,15691.67,145,MS-DRG,12553.336,Case Rate,145% of CMS IPPS Rate,10821.84,100,MS-DRG,8657.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10821.84,100,,8657.472,Case Rate,100% of CMS IPPS Rate,19496.59,100,,,Case Rate,100% of CMS IPPS Rate,22282.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25067.25,100,,,Case Rate,100% of CMS IPPS Rate,25067.25,100,,,Case Rate,100% of CMS IPPS Rate,25067.25,100,,,Case Rate,100% CMS IPPS Rate,19543.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9847.44,100,,7877.952,Case Rate,100% of CMS IPPS Rate,9847.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9847.44,100,MS-DRG,7877.952,Case Rate,100% of CMS IPPS Rate,9847.44,100,MS-DRG,7877.952,Case Rate,100% of CMS IPPS Rate,9692.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10821.84,100,MS-DRG,8657.472,Case Rate,100% of CMS IPPS Rate,14068.39,130,MS-DRG,11254.712,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11146.5,103,MS-DRG,8917.2,Case Rate,103% of CMS IPPS Rate,11146.5,103,MS-DRG,8917.2,Case Rate,103% of CMS IPPS Rate,18601.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10821.84,100,MS-DRG,8657.472,Case Rate,100% of CMS IPPS Rate,11463.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16232.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10821.84,100,MS-DRG,8657.472,Case Rate,100% of CMS IPPS Rate,22136.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10821.84,100,MS-DRG,8657.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25067.25,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,CDM,,,,,Inpatient,,,,,,13826.18,,,,Case Rate,100% of CMS IPPS Rate,10671.14,145,MS-DRG,8536.912,Case Rate,145% of CMS IPPS Rate,7359.41,100,MS-DRG,5887.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7359.41,100,,5887.528,Case Rate,100% of CMS IPPS Rate,15343.98,100,,,Case Rate,100% of CMS IPPS Rate,17536.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19728.14,100,,,Case Rate,100% of CMS IPPS Rate,19728.14,100,,,Case Rate,100% of CMS IPPS Rate,19728.14,100,,,Case Rate,100% CMS IPPS Rate,12481.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6696.87,100,,5357.496,Case Rate,100% of CMS IPPS Rate,6696.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6696.87,100,MS-DRG,5357.496,Case Rate,100% of CMS IPPS Rate,6696.87,100,MS-DRG,5357.496,Case Rate,100% of CMS IPPS Rate,4787.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7359.41,100,MS-DRG,5887.528,Case Rate,100% of CMS IPPS Rate,9567.23,130,MS-DRG,7653.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7580.19,103,MS-DRG,6064.152,Case Rate,103% of CMS IPPS Rate,7580.19,103,MS-DRG,6064.152,Case Rate,103% of CMS IPPS Rate,15114.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7359.41,100,MS-DRG,5887.528,Case Rate,100% of CMS IPPS Rate,7321.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11039.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7359.41,100,MS-DRG,5887.528,Case Rate,100% of CMS IPPS Rate,14137.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7359.41,100,MS-DRG,5887.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4787.28,19728.14,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,CDM,,,,,Inpatient,,,,,,10100.59,,,,Case Rate,100% of CMS IPPS Rate,7320.85,145,MS-DRG,5856.68,Case Rate,145% of CMS IPPS Rate,5048.86,100,MS-DRG,4039.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5048.86,100,,4039.088,Case Rate,100% of CMS IPPS Rate,9963.59,100,,,Case Rate,100% of CMS IPPS Rate,11387.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12810.44,100,,,Case Rate,100% of CMS IPPS Rate,12810.44,100,,,Case Rate,100% of CMS IPPS Rate,12810.44,100,,,Case Rate,100% CMS IPPS Rate,9117.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4594.4,100,,3675.52,Case Rate,100% of CMS IPPS Rate,4594.4,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4594.4,100,MS-DRG,3675.52,Case Rate,100% of CMS IPPS Rate,4594.4,100,MS-DRG,3675.52,Case Rate,100% of CMS IPPS Rate,3529.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5048.86,100,MS-DRG,4039.088,Case Rate,100% of CMS IPPS Rate,6563.52,130,MS-DRG,5250.816,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5200.33,103,MS-DRG,4160.264,Case Rate,103% of CMS IPPS Rate,5200.33,103,MS-DRG,4160.264,Case Rate,103% of CMS IPPS Rate,8861.33,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5048.86,100,MS-DRG,4039.088,Case Rate,100% of CMS IPPS Rate,5348.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7573.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5048.86,100,MS-DRG,4039.088,Case Rate,100% of CMS IPPS Rate,10327.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5048.86,100,MS-DRG,4039.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3529.05,12810.44,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,CDM,,,,,Inpatient,,,,,,7007.57,,,,Case Rate,100% of CMS IPPS Rate,5079.05,145,MS-DRG,4063.24,Case Rate,145% of CMS IPPS Rate,3502.79,100,MS-DRG,2802.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3502.79,100,,2802.232,Case Rate,100% of CMS IPPS Rate,6929.45,100,,,Case Rate,100% of CMS IPPS Rate,7919.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8909.37,100,,,Case Rate,100% of CMS IPPS Rate,8909.37,100,,,Case Rate,100% of CMS IPPS Rate,8909.37,100,,,Case Rate,100% CMS IPPS Rate,6325.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3187.57,100,,2550.056,Case Rate,100% of CMS IPPS Rate,3187.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3187.57,100,MS-DRG,2550.056,Case Rate,100% of CMS IPPS Rate,3187.57,100,MS-DRG,2550.056,Case Rate,100% of CMS IPPS Rate,2421.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3502.79,100,MS-DRG,2802.232,Case Rate,100% of CMS IPPS Rate,4553.63,130,MS-DRG,3642.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3607.87,103,MS-DRG,2886.296,Case Rate,103% of CMS IPPS Rate,3607.87,103,MS-DRG,2886.296,Case Rate,103% of CMS IPPS Rate,6375.6,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3502.79,100,MS-DRG,2802.232,Case Rate,100% of CMS IPPS Rate,3710.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5254.19,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3502.79,100,MS-DRG,2802.232,Case Rate,100% of CMS IPPS Rate,7165.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3502.79,100,MS-DRG,2802.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,2421.61,8909.37,
ACUTE LEUKEMIA WITH MCC,834,CDM,,,,,Inpatient,,,,,,76661.51,,,,Case Rate,100% of CMS IPPS Rate,55563.88,145,MS-DRG,44451.104,Case Rate,145% of CMS IPPS Rate,38319.92,100,MS-DRG,30655.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38319.92,100,,30655.936,Case Rate,100% of CMS IPPS Rate,73684.44,100,,,Case Rate,100% of CMS IPPS Rate,84213.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,94737.92,100,,,Case Rate,100% of CMS IPPS Rate,94737.92,100,,,Case Rate,100% of CMS IPPS Rate,94737.92,100,,,Case Rate,100% CMS IPPS Rate,69203.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34868.99,100,,27895.192,Case Rate,100% of CMS IPPS Rate,34868.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,34868.99,100,MS-DRG,27895.192,Case Rate,100% of CMS IPPS Rate,34868.99,100,MS-DRG,27895.192,Case Rate,100% of CMS IPPS Rate,68687.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,38319.92,100,MS-DRG,30655.936,Case Rate,100% of CMS IPPS Rate,49815.9,130,MS-DRG,39852.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39469.52,103,MS-DRG,31575.616,Case Rate,103% of CMS IPPS Rate,39469.52,103,MS-DRG,31575.616,Case Rate,103% of CMS IPPS Rate,69954.5,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38319.92,100,MS-DRG,30655.936,Case Rate,100% of CMS IPPS Rate,40592.75,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,57479.88,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38319.92,100,MS-DRG,30655.936,Case Rate,100% of CMS IPPS Rate,78386,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38319.92,100,MS-DRG,30655.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,94737.92,
ACUTE LEUKEMIA WITH CC,835,CDM,,,,,Inpatient,,,,,,30608.47,,,,Case Rate,100% of CMS IPPS Rate,22184.87,145,MS-DRG,17747.896,Case Rate,145% of CMS IPPS Rate,15299.91,100,MS-DRG,12239.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15299.91,100,,12239.928,Case Rate,100% of CMS IPPS Rate,28473.68,100,,,Case Rate,100% of CMS IPPS Rate,32542.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36609.33,100,,,Case Rate,100% of CMS IPPS Rate,36609.33,100,,,Case Rate,100% of CMS IPPS Rate,36609.33,100,,,Case Rate,100% CMS IPPS Rate,27630.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13922.22,100,,11137.776,Case Rate,100% of CMS IPPS Rate,13922.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13922.22,100,MS-DRG,11137.776,Case Rate,100% of CMS IPPS Rate,13922.22,100,MS-DRG,11137.776,Case Rate,100% of CMS IPPS Rate,20162.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15299.91,100,MS-DRG,12239.928,Case Rate,100% of CMS IPPS Rate,19889.88,130,MS-DRG,15911.904,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15758.91,103,MS-DRG,12607.128,Case Rate,103% of CMS IPPS Rate,15758.91,103,MS-DRG,12607.128,Case Rate,103% of CMS IPPS Rate,26528.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15299.91,100,MS-DRG,12239.928,Case Rate,100% of CMS IPPS Rate,16207.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22949.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15299.91,100,MS-DRG,12239.928,Case Rate,100% of CMS IPPS Rate,31297,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15299.91,100,MS-DRG,12239.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36609.33,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,CDM,,,,,Inpatient,,,,,,16393.43,,,,Case Rate,100% of CMS IPPS Rate,14011.54,145,MS-DRG,11209.232,Case Rate,145% of CMS IPPS Rate,9663.13,100,MS-DRG,7730.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9663.13,100,,7730.504,Case Rate,100% of CMS IPPS Rate,16562.43,100,,,Case Rate,100% of CMS IPPS Rate,18929.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21294.74,100,,,Case Rate,100% of CMS IPPS Rate,21294.74,100,,,Case Rate,100% of CMS IPPS Rate,21294.74,100,,,Case Rate,100% CMS IPPS Rate,14798.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8793.09,100,,7034.472,Case Rate,100% of CMS IPPS Rate,8793.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8793.09,100,MS-DRG,7034.472,Case Rate,100% of CMS IPPS Rate,8793.09,100,MS-DRG,7034.472,Case Rate,100% of CMS IPPS Rate,20749.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9663.13,100,MS-DRG,7730.504,Case Rate,100% of CMS IPPS Rate,12562.07,130,MS-DRG,10049.656,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9953.02,103,MS-DRG,7962.416,Case Rate,103% of CMS IPPS Rate,9953.02,103,MS-DRG,7962.416,Case Rate,103% of CMS IPPS Rate,19845.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9663.13,100,MS-DRG,7730.504,Case Rate,100% of CMS IPPS Rate,8680.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14494.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9663.13,100,MS-DRG,7730.504,Case Rate,100% of CMS IPPS Rate,16762.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9663.13,100,MS-DRG,7730.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21294.74,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,CDM,,,,,Inpatient,,,,,,65127.37,,,,Case Rate,100% of CMS IPPS Rate,48071.34,145,MS-DRG,38457.072,Case Rate,145% of CMS IPPS Rate,33152.65,100,MS-DRG,26522.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33152.65,100,,26522.12,Case Rate,100% of CMS IPPS Rate,66750.98,100,,,Case Rate,100% of CMS IPPS Rate,76289.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,85823.41,100,,,Case Rate,100% of CMS IPPS Rate,85823.41,100,,,Case Rate,100% of CMS IPPS Rate,85823.41,100,,,Case Rate,100% CMS IPPS Rate,58791.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30167.1,100,,24133.68,Case Rate,100% of CMS IPPS Rate,30167.1,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,30167.1,100,MS-DRG,24133.68,Case Rate,100% of CMS IPPS Rate,30167.1,100,MS-DRG,24133.68,Case Rate,100% of CMS IPPS Rate,37498.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33152.65,100,MS-DRG,26522.12,Case Rate,100% of CMS IPPS Rate,43098.45,130,MS-DRG,34478.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34147.23,103,MS-DRG,27317.784,Case Rate,103% of CMS IPPS Rate,34147.23,103,MS-DRG,27317.784,Case Rate,103% of CMS IPPS Rate,68084.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33152.65,100,MS-DRG,26522.12,Case Rate,100% of CMS IPPS Rate,34485.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,49728.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33152.65,100,MS-DRG,26522.12,Case Rate,100% of CMS IPPS Rate,66592.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33152.65,100,MS-DRG,26522.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,85823.41,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,CDM,,,,,Inpatient,,,,,,26732.26,,,,Case Rate,100% of CMS IPPS Rate,19864.65,145,MS-DRG,15891.72,Case Rate,145% of CMS IPPS Rate,13699.76,100,MS-DRG,10959.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13699.76,100,,10959.808,Case Rate,100% of CMS IPPS Rate,27037.93,100,,,Case Rate,100% of CMS IPPS Rate,30901.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34763.35,100,,,Case Rate,100% of CMS IPPS Rate,34763.35,100,,,Case Rate,100% of CMS IPPS Rate,34763.35,100,,,Case Rate,100% CMS IPPS Rate,24131.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12466.18,100,,9972.944,Case Rate,100% of CMS IPPS Rate,12466.18,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12466.18,100,MS-DRG,9972.944,Case Rate,100% of CMS IPPS Rate,12466.18,100,MS-DRG,9972.944,Case Rate,100% of CMS IPPS Rate,9667.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13699.76,100,MS-DRG,10959.808,Case Rate,100% of CMS IPPS Rate,17809.69,130,MS-DRG,14247.752,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14110.75,103,MS-DRG,11288.6,Case Rate,103% of CMS IPPS Rate,14110.75,103,MS-DRG,11288.6,Case Rate,103% of CMS IPPS Rate,28134.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13699.76,100,MS-DRG,10959.808,Case Rate,100% of CMS IPPS Rate,14154.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20549.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13699.76,100,MS-DRG,10959.808,Case Rate,100% of CMS IPPS Rate,27333.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13699.76,100,MS-DRG,10959.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34763.35,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,CDM,,,,,Inpatient,,,,,,17842.05,,,,Case Rate,100% of CMS IPPS Rate,12931.83,145,MS-DRG,10345.464,Case Rate,145% of CMS IPPS Rate,8918.5,100,MS-DRG,7134.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8918.5,100,,7134.8,Case Rate,100% of CMS IPPS Rate,18268.8,100,,,Case Rate,100% of CMS IPPS Rate,20879.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23488.66,100,,,Case Rate,100% of CMS IPPS Rate,23488.66,100,,,Case Rate,100% of CMS IPPS Rate,23488.66,100,,,Case Rate,100% CMS IPPS Rate,16106.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8115.54,100,,6492.432,Case Rate,100% of CMS IPPS Rate,8115.54,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8115.54,100,MS-DRG,6492.432,Case Rate,100% of CMS IPPS Rate,8115.54,100,MS-DRG,6492.432,Case Rate,100% of CMS IPPS Rate,8232.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8918.5,100,MS-DRG,7134.8,Case Rate,100% of CMS IPPS Rate,11594.05,130,MS-DRG,9275.24,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9186.06,103,MS-DRG,7348.848,Case Rate,103% of CMS IPPS Rate,9186.06,103,MS-DRG,7348.848,Case Rate,103% of CMS IPPS Rate,17389.96,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8918.5,100,MS-DRG,7134.8,Case Rate,100% of CMS IPPS Rate,9447.48,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13377.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8918.5,100,MS-DRG,7134.8,Case Rate,100% of CMS IPPS Rate,18243.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8918.5,100,MS-DRG,7134.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,23488.66,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,CDM,,,,,Inpatient,,,,,,42790.24,,,,Case Rate,100% of CMS IPPS Rate,31014.15,145,MS-DRG,24811.32,Case Rate,145% of CMS IPPS Rate,21389.07,100,MS-DRG,17111.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21389.07,100,,17111.256,Case Rate,100% of CMS IPPS Rate,42512.56,100,,,Case Rate,100% of CMS IPPS Rate,48587.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54659.46,100,,,Case Rate,100% of CMS IPPS Rate,54659.46,100,,,Case Rate,100% of CMS IPPS Rate,54659.46,100,,,Case Rate,100% CMS IPPS Rate,38627.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19462.97,100,,15570.376,Case Rate,100% of CMS IPPS Rate,19462.97,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,19462.97,100,MS-DRG,15570.376,Case Rate,100% of CMS IPPS Rate,19462.97,100,MS-DRG,15570.376,Case Rate,100% of CMS IPPS Rate,33858.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21389.07,100,MS-DRG,17111.256,Case Rate,100% of CMS IPPS Rate,27805.79,130,MS-DRG,22244.632,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22030.74,103,MS-DRG,17624.592,Case Rate,103% of CMS IPPS Rate,22030.74,103,MS-DRG,17624.592,Case Rate,103% of CMS IPPS Rate,39303.55,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21389.07,100,MS-DRG,17111.256,Case Rate,100% of CMS IPPS Rate,22657.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,32083.61,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21389.07,100,MS-DRG,17111.256,Case Rate,100% of CMS IPPS Rate,43752.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21389.07,100,MS-DRG,17111.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54659.46,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,CDM,,,,,Inpatient,,,,,,21544.36,,,,Case Rate,100% of CMS IPPS Rate,15615.24,145,MS-DRG,12492.192,Case Rate,145% of CMS IPPS Rate,10769.13,100,MS-DRG,8615.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10769.13,100,,8615.304,Case Rate,100% of CMS IPPS Rate,20903.01,100,,,Case Rate,100% of CMS IPPS Rate,23890.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26875.52,100,,,Case Rate,100% of CMS IPPS Rate,26875.52,100,,,Case Rate,100% of CMS IPPS Rate,26875.52,100,,,Case Rate,100% CMS IPPS Rate,19448.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9799.5,100,,7839.6,Case Rate,100% of CMS IPPS Rate,9799.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9799.5,100,MS-DRG,7839.6,Case Rate,100% of CMS IPPS Rate,9799.5,100,MS-DRG,7839.6,Case Rate,100% of CMS IPPS Rate,16872.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10769.13,100,MS-DRG,8615.304,Case Rate,100% of CMS IPPS Rate,13999.87,130,MS-DRG,11199.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11092.2,103,MS-DRG,8873.76,Case Rate,103% of CMS IPPS Rate,11092.2,103,MS-DRG,8873.76,Case Rate,103% of CMS IPPS Rate,20174.22,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10769.13,100,MS-DRG,8615.304,Case Rate,100% of CMS IPPS Rate,11407.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16153.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10769.13,100,MS-DRG,8615.304,Case Rate,100% of CMS IPPS Rate,22029,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10769.13,100,MS-DRG,8615.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26875.52,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,CDM,,,,,Inpatient,,,,,,14601.15,,,,Case Rate,100% of CMS IPPS Rate,10582.84,145,MS-DRG,8466.272,Case Rate,145% of CMS IPPS Rate,7298.51,100,MS-DRG,5838.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7298.51,100,,5838.808,Case Rate,100% of CMS IPPS Rate,14022.88,100,,,Case Rate,100% of CMS IPPS Rate,16026.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18029.57,100,,,Case Rate,100% of CMS IPPS Rate,18029.57,100,,,Case Rate,100% of CMS IPPS Rate,18029.57,100,,,Case Rate,100% CMS IPPS Rate,13180.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6641.44,100,,5313.152,Case Rate,100% of CMS IPPS Rate,6641.44,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6641.44,100,MS-DRG,5313.152,Case Rate,100% of CMS IPPS Rate,6641.44,100,MS-DRG,5313.152,Case Rate,100% of CMS IPPS Rate,8604.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7298.51,100,MS-DRG,5838.808,Case Rate,100% of CMS IPPS Rate,9488.06,130,MS-DRG,7590.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7517.47,103,MS-DRG,6013.976,Case Rate,103% of CMS IPPS Rate,7517.47,103,MS-DRG,6013.976,Case Rate,103% of CMS IPPS Rate,13961.81,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7298.51,100,MS-DRG,5838.808,Case Rate,100% of CMS IPPS Rate,7731.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10947.77,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7298.51,100,MS-DRG,5838.808,Case Rate,100% of CMS IPPS Rate,14929.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7298.51,100,MS-DRG,5838.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18029.57,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,CDM,,,,,Inpatient,,,,,,25475.34,,,,Case Rate,100% of CMS IPPS Rate,18464.4,145,MS-DRG,14771.52,Case Rate,145% of CMS IPPS Rate,12734.07,100,MS-DRG,10187.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12734.07,100,,10187.256,Case Rate,100% of CMS IPPS Rate,25239.58,100,,,Case Rate,100% of CMS IPPS Rate,28846.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32451.16,100,,,Case Rate,100% of CMS IPPS Rate,32451.16,100,,,Case Rate,100% of CMS IPPS Rate,32451.16,100,,,Case Rate,100% CMS IPPS Rate,22997.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11587.45,100,,9269.96,Case Rate,100% of CMS IPPS Rate,11587.45,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11587.45,100,MS-DRG,9269.96,Case Rate,100% of CMS IPPS Rate,11587.45,100,MS-DRG,9269.96,Case Rate,100% of CMS IPPS Rate,16872.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12734.07,100,MS-DRG,10187.256,Case Rate,100% of CMS IPPS Rate,16554.29,130,MS-DRG,13243.432,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13116.09,103,MS-DRG,10492.872,Case Rate,103% of CMS IPPS Rate,13116.09,103,MS-DRG,10492.872,Case Rate,103% of CMS IPPS Rate,24508.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12734.07,100,MS-DRG,10187.256,Case Rate,100% of CMS IPPS Rate,13489.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19101.11,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12734.07,100,MS-DRG,10187.256,Case Rate,100% of CMS IPPS Rate,26048.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12734.07,100,MS-DRG,10187.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32451.16,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,CDM,,,,,Inpatient,,,,,,15844.38,,,,Case Rate,100% of CMS IPPS Rate,11483.93,145,MS-DRG,9187.144,Case Rate,145% of CMS IPPS Rate,7919.95,100,MS-DRG,6335.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7919.95,100,,6335.96,Case Rate,100% of CMS IPPS Rate,15933.21,100,,,Case Rate,100% of CMS IPPS Rate,18210.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20485.73,100,,,Case Rate,100% of CMS IPPS Rate,20485.73,100,,,Case Rate,100% of CMS IPPS Rate,20485.73,100,,,Case Rate,100% CMS IPPS Rate,14302.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7206.91,100,,5765.528,Case Rate,100% of CMS IPPS Rate,7206.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7206.91,100,MS-DRG,5765.528,Case Rate,100% of CMS IPPS Rate,7206.91,100,MS-DRG,5765.528,Case Rate,100% of CMS IPPS Rate,11564.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7919.95,100,MS-DRG,6335.96,Case Rate,100% of CMS IPPS Rate,10295.94,130,MS-DRG,8236.752,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8157.55,103,MS-DRG,6526.04,Case Rate,103% of CMS IPPS Rate,8157.55,103,MS-DRG,6526.04,Case Rate,103% of CMS IPPS Rate,14428.59,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7919.95,100,MS-DRG,6335.96,Case Rate,100% of CMS IPPS Rate,8389.7,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11879.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7919.95,100,MS-DRG,6335.96,Case Rate,100% of CMS IPPS Rate,16200.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7919.95,100,MS-DRG,6335.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20485.73,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,CDM,,,,,Inpatient,,,,,,11842.21,,,,Case Rate,100% of CMS IPPS Rate,8583.19,145,MS-DRG,6866.552,Case Rate,145% of CMS IPPS Rate,5919.44,100,MS-DRG,4735.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5919.44,100,,4735.552,Case Rate,100% of CMS IPPS Rate,11155.38,100,,,Case Rate,100% of CMS IPPS Rate,12749.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14342.75,100,,,Case Rate,100% of CMS IPPS Rate,14342.75,100,,,Case Rate,100% of CMS IPPS Rate,14342.75,100,,,Case Rate,100% CMS IPPS Rate,10690.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5386.57,100,,4309.256,Case Rate,100% of CMS IPPS Rate,5386.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5386.57,100,MS-DRG,4309.256,Case Rate,100% of CMS IPPS Rate,5386.57,100,MS-DRG,4309.256,Case Rate,100% of CMS IPPS Rate,7782.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5919.44,100,MS-DRG,4735.552,Case Rate,100% of CMS IPPS Rate,7695.27,130,MS-DRG,6156.216,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6097.02,103,MS-DRG,4877.616,Case Rate,103% of CMS IPPS Rate,6097.02,103,MS-DRG,4877.616,Case Rate,103% of CMS IPPS Rate,10695.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5919.44,100,MS-DRG,4735.552,Case Rate,100% of CMS IPPS Rate,6270.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8879.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5919.44,100,MS-DRG,4735.552,Case Rate,100% of CMS IPPS Rate,12108.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5919.44,100,MS-DRG,4735.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5386.57,14342.75,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,CDM,,,,,Inpatient,,,,,,33463.25,,,,Case Rate,100% of CMS IPPS Rate,24253.99,145,MS-DRG,19403.192,Case Rate,145% of CMS IPPS Rate,16726.89,100,MS-DRG,13381.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16726.89,100,,13381.512,Case Rate,100% of CMS IPPS Rate,34044.71,100,,,Case Rate,100% of CMS IPPS Rate,38909.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43772.13,100,,,Case Rate,100% of CMS IPPS Rate,43772.13,100,,,Case Rate,100% of CMS IPPS Rate,43772.13,100,,,Case Rate,100% CMS IPPS Rate,30207.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15220.69,100,,12176.552,Case Rate,100% of CMS IPPS Rate,15220.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15220.69,100,MS-DRG,12176.552,Case Rate,100% of CMS IPPS Rate,15220.69,100,MS-DRG,12176.552,Case Rate,100% of CMS IPPS Rate,14558.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16726.89,100,MS-DRG,13381.512,Case Rate,100% of CMS IPPS Rate,21744.96,130,MS-DRG,17395.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17228.7,103,MS-DRG,13782.96,Case Rate,103% of CMS IPPS Rate,17228.7,103,MS-DRG,13782.96,Case Rate,103% of CMS IPPS Rate,30473.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16726.89,100,MS-DRG,13381.512,Case Rate,100% of CMS IPPS Rate,17719,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25090.34,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16726.89,100,MS-DRG,13381.512,Case Rate,100% of CMS IPPS Rate,34216,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16726.89,100,MS-DRG,13381.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,43772.13,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,CDM,,,,,Inpatient,,,,,,16602.92,,,,Case Rate,100% of CMS IPPS Rate,12033.72,145,MS-DRG,9626.976,Case Rate,145% of CMS IPPS Rate,8299.12,100,MS-DRG,6639.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8299.12,100,,6639.296,Case Rate,100% of CMS IPPS Rate,16939.7,100,,,Case Rate,100% of CMS IPPS Rate,19360.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21779.8,100,,,Case Rate,100% of CMS IPPS Rate,21779.8,100,,,Case Rate,100% of CMS IPPS Rate,21779.8,100,,,Case Rate,100% CMS IPPS Rate,14987.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7551.94,100,,6041.552,Case Rate,100% of CMS IPPS Rate,7551.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7551.94,100,MS-DRG,6041.552,Case Rate,100% of CMS IPPS Rate,7551.94,100,MS-DRG,6041.552,Case Rate,100% of CMS IPPS Rate,8788.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8299.12,100,MS-DRG,6639.296,Case Rate,100% of CMS IPPS Rate,10788.86,130,MS-DRG,8631.088,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8548.09,103,MS-DRG,6838.472,Case Rate,103% of CMS IPPS Rate,8548.09,103,MS-DRG,6838.472,Case Rate,103% of CMS IPPS Rate,15408.97,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8299.12,100,MS-DRG,6639.296,Case Rate,100% of CMS IPPS Rate,8791.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12448.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8299.12,100,MS-DRG,6639.296,Case Rate,100% of CMS IPPS Rate,16976.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8299.12,100,MS-DRG,6639.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21779.8,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,CDM,,,,,Inpatient,,,,,,10399.07,,,,Case Rate,100% of CMS IPPS Rate,8298.36,145,MS-DRG,6638.688,Case Rate,145% of CMS IPPS Rate,5723.01,100,MS-DRG,4578.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5723.01,100,,4578.408,Case Rate,100% of CMS IPPS Rate,10916.76,100,,,Case Rate,100% of CMS IPPS Rate,12476.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14035.95,100,,,Case Rate,100% of CMS IPPS Rate,14035.95,100,,,Case Rate,100% of CMS IPPS Rate,14035.95,100,,,Case Rate,100% CMS IPPS Rate,9387.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5207.84,100,,4166.272,Case Rate,100% of CMS IPPS Rate,5207.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5207.84,100,MS-DRG,4166.272,Case Rate,100% of CMS IPPS Rate,5207.84,100,MS-DRG,4166.272,Case Rate,100% of CMS IPPS Rate,5041.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5723.01,100,MS-DRG,4578.408,Case Rate,100% of CMS IPPS Rate,7439.91,130,MS-DRG,5951.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5894.7,103,MS-DRG,4715.76,Case Rate,103% of CMS IPPS Rate,5894.7,103,MS-DRG,4715.76,Case Rate,103% of CMS IPPS Rate,11753.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5723.01,100,MS-DRG,4578.408,Case Rate,100% of CMS IPPS Rate,5506.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8584.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5723.01,100,MS-DRG,4578.408,Case Rate,100% of CMS IPPS Rate,10633,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5723.01,100,MS-DRG,4578.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5041.04,14035.95,
RADIOTHERAPY,849,CDM,,,,,Inpatient,,,,,,36850.65,,,,Case Rate,100% of CMS IPPS Rate,26709.17,145,MS-DRG,21367.336,Case Rate,145% of CMS IPPS Rate,18420.12,100,MS-DRG,14736.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18420.12,100,,14736.096,Case Rate,100% of CMS IPPS Rate,35608.43,100,,,Case Rate,100% of CMS IPPS Rate,40696.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45782.65,100,,,Case Rate,100% of CMS IPPS Rate,45782.65,100,,,Case Rate,100% of CMS IPPS Rate,45782.65,100,,,Case Rate,100% CMS IPPS Rate,33265.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16761.41,100,,13409.128,Case Rate,100% of CMS IPPS Rate,16761.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,16761.41,100,MS-DRG,13409.128,Case Rate,100% of CMS IPPS Rate,16761.41,100,MS-DRG,13409.128,Case Rate,100% of CMS IPPS Rate,24220.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18420.12,100,MS-DRG,14736.096,Case Rate,100% of CMS IPPS Rate,23946.16,130,MS-DRG,19156.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18972.72,103,MS-DRG,15178.176,Case Rate,103% of CMS IPPS Rate,18972.72,103,MS-DRG,15178.176,Case Rate,103% of CMS IPPS Rate,29587.09,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18420.12,100,MS-DRG,14736.096,Case Rate,100% of CMS IPPS Rate,19512.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,27630.18,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18420.12,100,MS-DRG,14736.096,Case Rate,100% of CMS IPPS Rate,37679.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18420.12,100,MS-DRG,14736.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45782.65,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122803.84,100,,,Case Rate,100% of CMS IPPS Rate,140352.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,157891.97,100,,,Case Rate,100% of CMS IPPS Rate,157891.97,100,,,Case Rate,100% of CMS IPPS Rate,157891.97,100,,,Case Rate,100% CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,157891.97,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,CDM,,,,,Inpatient,,,,,,68450.42,,,,Case Rate,100% of CMS IPPS Rate,49612.52,145,MS-DRG,39690.016,Case Rate,145% of CMS IPPS Rate,34215.53,100,MS-DRG,27372.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34215.53,100,,27372.424,Case Rate,100% of CMS IPPS Rate,66672.33,100,,,Case Rate,100% of CMS IPPS Rate,76199.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,85722.28,100,,,Case Rate,100% of CMS IPPS Rate,85722.28,100,,,Case Rate,100% of CMS IPPS Rate,85722.28,100,,,Case Rate,100% CMS IPPS Rate,61791.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31134.26,100,,24907.408,Case Rate,100% of CMS IPPS Rate,31134.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,31134.26,100,MS-DRG,24907.408,Case Rate,100% of CMS IPPS Rate,31134.26,100,MS-DRG,24907.408,Case Rate,100% of CMS IPPS Rate,40719.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34215.53,100,MS-DRG,27372.424,Case Rate,100% of CMS IPPS Rate,44480.19,130,MS-DRG,35584.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35242,103,MS-DRG,28193.6,Case Rate,103% of CMS IPPS Rate,35242,103,MS-DRG,28193.6,Case Rate,103% of CMS IPPS Rate,61997.65,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34215.53,100,MS-DRG,27372.424,Case Rate,100% of CMS IPPS Rate,36244.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,51323.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34215.53,100,MS-DRG,27372.424,Case Rate,100% of CMS IPPS Rate,69990.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34215.53,100,MS-DRG,27372.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,85722.28,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,CDM,,,,,Inpatient,,,,,,27907.03,,,,Case Rate,100% of CMS IPPS Rate,20226.89,145,MS-DRG,16181.512,Case Rate,145% of CMS IPPS Rate,13949.58,100,MS-DRG,11159.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13949.58,100,,11159.664,Case Rate,100% of CMS IPPS Rate,26636.67,100,,,Case Rate,100% of CMS IPPS Rate,30443.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34247.43,100,,,Case Rate,100% of CMS IPPS Rate,34247.43,100,,,Case Rate,100% of CMS IPPS Rate,34247.43,100,,,Case Rate,100% CMS IPPS Rate,25192.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12693.49,100,,10154.792,Case Rate,100% of CMS IPPS Rate,12693.49,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12693.49,100,MS-DRG,10154.792,Case Rate,100% of CMS IPPS Rate,12693.49,100,MS-DRG,10154.792,Case Rate,100% of CMS IPPS Rate,13160.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13949.58,100,MS-DRG,11159.664,Case Rate,100% of CMS IPPS Rate,18134.45,130,MS-DRG,14507.56,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14368.07,103,MS-DRG,11494.456,Case Rate,103% of CMS IPPS Rate,14368.07,103,MS-DRG,11494.456,Case Rate,103% of CMS IPPS Rate,26003.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13949.58,100,MS-DRG,11159.664,Case Rate,100% of CMS IPPS Rate,14776.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20924.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13949.58,100,MS-DRG,11159.664,Case Rate,100% of CMS IPPS Rate,28534.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13949.58,100,MS-DRG,11159.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34247.43,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,CDM,,,,,Inpatient,,,,,,23301.05,,,,Case Rate,100% of CMS IPPS Rate,16888.48,145,MS-DRG,13510.784,Case Rate,145% of CMS IPPS Rate,11647.23,100,MS-DRG,9317.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11647.23,100,,9317.784,Case Rate,100% of CMS IPPS Rate,21670.87,100,,,Case Rate,100% of CMS IPPS Rate,24767.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27862.78,100,,,Case Rate,100% of CMS IPPS Rate,27862.78,100,,,Case Rate,100% of CMS IPPS Rate,27862.78,100,,,Case Rate,100% CMS IPPS Rate,21034.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10598.5,100,,8478.8,Case Rate,100% of CMS IPPS Rate,10598.5,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10598.5,100,MS-DRG,8478.8,Case Rate,100% of CMS IPPS Rate,10598.5,100,MS-DRG,8478.8,Case Rate,100% of CMS IPPS Rate,15314.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11647.23,100,MS-DRG,9317.784,Case Rate,100% of CMS IPPS Rate,15141.4,130,MS-DRG,12113.12,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11996.65,103,MS-DRG,9597.32,Case Rate,103% of CMS IPPS Rate,11996.65,103,MS-DRG,9597.32,Case Rate,103% of CMS IPPS Rate,19325.41,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.23,100,MS-DRG,9317.784,Case Rate,100% of CMS IPPS Rate,12338.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17470.85,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.23,100,MS-DRG,9317.784,Case Rate,100% of CMS IPPS Rate,23825.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11647.23,100,MS-DRG,9317.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27862.78,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,CDM,,,,,Inpatient,,,,,,60633.65,,,,Case Rate,100% of CMS IPPS Rate,43946.96,145,MS-DRG,35157.568,Case Rate,145% of CMS IPPS Rate,30308.25,100,MS-DRG,24246.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30308.25,100,,24246.6,Case Rate,100% of CMS IPPS Rate,60144.14,100,,,Case Rate,100% of CMS IPPS Rate,68738.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,77328.82,100,,,Case Rate,100% of CMS IPPS Rate,77328.82,100,,,Case Rate,100% of CMS IPPS Rate,77328.82,100,,,Case Rate,100% CMS IPPS Rate,54735.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27578.87,100,,22063.096,Case Rate,100% of CMS IPPS Rate,27578.87,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,27578.87,100,MS-DRG,22063.096,Case Rate,100% of CMS IPPS Rate,27578.87,100,MS-DRG,22063.096,Case Rate,100% of CMS IPPS Rate,25720,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30308.25,100,MS-DRG,24246.6,Case Rate,100% of CMS IPPS Rate,39400.73,130,MS-DRG,31520.584,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31217.5,103,MS-DRG,24974,Case Rate,103% of CMS IPPS Rate,31217.5,103,MS-DRG,24974,Case Rate,103% of CMS IPPS Rate,55820.66,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30308.25,100,MS-DRG,24246.6,Case Rate,100% of CMS IPPS Rate,32105.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,45462.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30308.25,100,MS-DRG,24246.6,Case Rate,100% of CMS IPPS Rate,61997.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30308.25,100,MS-DRG,24246.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,77328.82,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,CDM,,,,,Inpatient,,,,,,29242,,,,Case Rate,100% of CMS IPPS Rate,21194.46,145,MS-DRG,16955.568,Case Rate,145% of CMS IPPS Rate,14616.87,100,MS-DRG,11693.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14616.87,100,,11693.496,Case Rate,100% of CMS IPPS Rate,29046.92,100,,,Case Rate,100% of CMS IPPS Rate,33197.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37346.35,100,,,Case Rate,100% of CMS IPPS Rate,37346.35,100,,,Case Rate,100% of CMS IPPS Rate,37346.35,100,,,Case Rate,100% CMS IPPS Rate,26397.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13300.69,100,,10640.552,Case Rate,100% of CMS IPPS Rate,13300.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13300.69,100,MS-DRG,10640.552,Case Rate,100% of CMS IPPS Rate,13300.69,100,MS-DRG,10640.552,Case Rate,100% of CMS IPPS Rate,13149.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14616.87,100,MS-DRG,11693.496,Case Rate,100% of CMS IPPS Rate,19001.93,130,MS-DRG,15201.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15055.38,103,MS-DRG,12044.304,Case Rate,103% of CMS IPPS Rate,15055.38,103,MS-DRG,12044.304,Case Rate,103% of CMS IPPS Rate,26678.85,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14616.87,100,MS-DRG,11693.496,Case Rate,100% of CMS IPPS Rate,15483.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21925.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14616.87,100,MS-DRG,11693.496,Case Rate,100% of CMS IPPS Rate,29899.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14616.87,100,MS-DRG,11693.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37346.35,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,CDM,,,,,Inpatient,,,,,,17572.31,,,,Case Rate,100% of CMS IPPS Rate,12736.31,145,MS-DRG,10189.048,Case Rate,145% of CMS IPPS Rate,8783.66,100,MS-DRG,7026.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8783.66,100,,7026.928,Case Rate,100% of CMS IPPS Rate,17175.66,100,,,Case Rate,100% of CMS IPPS Rate,19630.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22083.18,100,,,Case Rate,100% of CMS IPPS Rate,22083.18,100,,,Case Rate,100% of CMS IPPS Rate,22083.18,100,,,Case Rate,100% CMS IPPS Rate,15862.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7992.84,100,,6394.272,Case Rate,100% of CMS IPPS Rate,7992.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7992.84,100,MS-DRG,6394.272,Case Rate,100% of CMS IPPS Rate,7992.84,100,MS-DRG,6394.272,Case Rate,100% of CMS IPPS Rate,9947.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8783.66,100,MS-DRG,7026.928,Case Rate,100% of CMS IPPS Rate,11418.76,130,MS-DRG,9135.008,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9047.17,103,MS-DRG,7237.736,Case Rate,103% of CMS IPPS Rate,9047.17,103,MS-DRG,7237.736,Case Rate,103% of CMS IPPS Rate,17894.69,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8783.66,100,MS-DRG,7026.928,Case Rate,100% of CMS IPPS Rate,9304.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13175.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8783.66,100,MS-DRG,7026.928,Case Rate,100% of CMS IPPS Rate,17967.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8783.66,100,MS-DRG,7026.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22083.18,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,CDM,,,,,Inpatient,,,,,,25220.66,,,,Case Rate,100% of CMS IPPS Rate,18279.82,145,MS-DRG,14623.856,Case Rate,145% of CMS IPPS Rate,12606.77,100,MS-DRG,10085.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12606.77,100,,10085.416,Case Rate,100% of CMS IPPS Rate,24511.71,100,,,Case Rate,100% of CMS IPPS Rate,28014.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31515.32,100,,,Case Rate,100% of CMS IPPS Rate,31515.32,100,,,Case Rate,100% of CMS IPPS Rate,31515.32,100,,,Case Rate,100% CMS IPPS Rate,22767.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11471.63,100,,9177.304,Case Rate,100% of CMS IPPS Rate,11471.63,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11471.63,100,MS-DRG,9177.304,Case Rate,100% of CMS IPPS Rate,11471.63,100,MS-DRG,9177.304,Case Rate,100% of CMS IPPS Rate,10618.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12606.77,100,MS-DRG,10085.416,Case Rate,100% of CMS IPPS Rate,16388.8,130,MS-DRG,13111.04,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12984.97,103,MS-DRG,10387.976,Case Rate,103% of CMS IPPS Rate,12984.97,103,MS-DRG,10387.976,Case Rate,103% of CMS IPPS Rate,23138.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12606.77,100,MS-DRG,10085.416,Case Rate,100% of CMS IPPS Rate,13354.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18910.16,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12606.77,100,MS-DRG,10085.416,Case Rate,100% of CMS IPPS Rate,25788,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12606.77,100,MS-DRG,10085.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31515.32,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,CDM,,,,,Inpatient,,,,,,13767.31,,,,Case Rate,100% of CMS IPPS Rate,9978.47,145,MS-DRG,7982.776,Case Rate,145% of CMS IPPS Rate,6881.7,100,MS-DRG,5505.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6881.7,100,,5505.36,Case Rate,100% of CMS IPPS Rate,13329.67,100,,,Case Rate,100% of CMS IPPS Rate,15234.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17138.29,100,,,Case Rate,100% of CMS IPPS Rate,17138.29,100,,,Case Rate,100% of CMS IPPS Rate,17138.29,100,,,Case Rate,100% CMS IPPS Rate,12427.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6262.18,100,,5009.744,Case Rate,100% of CMS IPPS Rate,6262.18,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6262.18,100,MS-DRG,5009.744,Case Rate,100% of CMS IPPS Rate,6262.18,100,MS-DRG,5009.744,Case Rate,100% of CMS IPPS Rate,5818.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6881.7,100,MS-DRG,5505.36,Case Rate,100% of CMS IPPS Rate,8946.21,130,MS-DRG,7156.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7088.15,103,MS-DRG,5670.52,Case Rate,103% of CMS IPPS Rate,7088.15,103,MS-DRG,5670.52,Case Rate,103% of CMS IPPS Rate,12724.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6881.7,100,MS-DRG,5505.36,Case Rate,100% of CMS IPPS Rate,7289.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10322.55,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6881.7,100,MS-DRG,5505.36,Case Rate,100% of CMS IPPS Rate,14077,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6881.7,100,MS-DRG,5505.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5818.52,17138.29,
FEVER AND INFLAMMATORY CONDITIONS,864,CDM,,,,,Inpatient,,,,,,12087.3,,,,Case Rate,100% of CMS IPPS Rate,8760.81,145,MS-DRG,7008.648,Case Rate,145% of CMS IPPS Rate,6041.94,100,MS-DRG,4833.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6041.94,100,,4833.552,Case Rate,100% of CMS IPPS Rate,11971.24,100,,,Case Rate,100% of CMS IPPS Rate,13681.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15391.72,100,,,Case Rate,100% of CMS IPPS Rate,15391.72,100,,,Case Rate,100% of CMS IPPS Rate,15391.72,100,,,Case Rate,100% CMS IPPS Rate,10911.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5498.04,100,,4398.432,Case Rate,100% of CMS IPPS Rate,5498.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5498.04,100,MS-DRG,4398.432,Case Rate,100% of CMS IPPS Rate,5498.04,100,MS-DRG,4398.432,Case Rate,100% of CMS IPPS Rate,6047.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6041.94,100,MS-DRG,4833.552,Case Rate,100% of CMS IPPS Rate,7854.52,130,MS-DRG,6283.616,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6223.2,103,MS-DRG,4978.56,Case Rate,103% of CMS IPPS Rate,6223.2,103,MS-DRG,4978.56,Case Rate,103% of CMS IPPS Rate,10729.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6041.94,100,MS-DRG,4833.552,Case Rate,100% of CMS IPPS Rate,6400.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9062.91,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6041.94,100,MS-DRG,4833.552,Case Rate,100% of CMS IPPS Rate,12359.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6041.94,100,MS-DRG,4833.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5498.04,15391.72,
VIRAL ILLNESS WITH MCC,865,CDM,,,,,Inpatient,,,,,,22453.51,,,,Case Rate,100% of CMS IPPS Rate,16274.19,145,MS-DRG,13019.352,Case Rate,145% of CMS IPPS Rate,11223.58,100,MS-DRG,8978.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11223.58,100,,8978.864,Case Rate,100% of CMS IPPS Rate,19336.62,100,,,Case Rate,100% of CMS IPPS Rate,22099.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24861.57,100,,,Case Rate,100% of CMS IPPS Rate,24861.57,100,,,Case Rate,100% of CMS IPPS Rate,24861.57,100,,,Case Rate,100% CMS IPPS Rate,20269.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10213.01,100,,8170.408,Case Rate,100% of CMS IPPS Rate,10213.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10213.01,100,MS-DRG,8170.408,Case Rate,100% of CMS IPPS Rate,10213.01,100,MS-DRG,8170.408,Case Rate,100% of CMS IPPS Rate,13935.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11223.58,100,MS-DRG,8978.864,Case Rate,100% of CMS IPPS Rate,14590.65,130,MS-DRG,11672.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11560.29,103,MS-DRG,9248.232,Case Rate,103% of CMS IPPS Rate,11560.29,103,MS-DRG,9248.232,Case Rate,103% of CMS IPPS Rate,21160.92,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11223.58,100,MS-DRG,8978.864,Case Rate,100% of CMS IPPS Rate,11889.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16835.37,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11223.58,100,MS-DRG,8978.864,Case Rate,100% of CMS IPPS Rate,22958.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11223.58,100,MS-DRG,8978.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24861.57,
VIRAL ILLNESS WITHOUT MCC,866,CDM,,,,,Inpatient,,,,,,12565.15,,,,Case Rate,100% of CMS IPPS Rate,9107.16,145,MS-DRG,7285.728,Case Rate,145% of CMS IPPS Rate,6280.8,100,MS-DRG,5024.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6280.8,100,,5024.64,Case Rate,100% of CMS IPPS Rate,11795.27,100,,,Case Rate,100% of CMS IPPS Rate,13480.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15165.47,100,,,Case Rate,100% of CMS IPPS Rate,15165.47,100,,,Case Rate,100% of CMS IPPS Rate,15165.47,100,,,Case Rate,100% CMS IPPS Rate,11342.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5715.39,100,,4572.312,Case Rate,100% of CMS IPPS Rate,5715.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5715.39,100,MS-DRG,4572.312,Case Rate,100% of CMS IPPS Rate,5715.39,100,MS-DRG,4572.312,Case Rate,100% of CMS IPPS Rate,5824.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6280.8,100,MS-DRG,5024.64,Case Rate,100% of CMS IPPS Rate,8165.04,130,MS-DRG,6532.032,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6469.22,103,MS-DRG,5175.376,Case Rate,103% of CMS IPPS Rate,6469.22,103,MS-DRG,5175.376,Case Rate,103% of CMS IPPS Rate,11381.21,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6280.8,100,MS-DRG,5024.64,Case Rate,100% of CMS IPPS Rate,6653.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9421.2,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6280.8,100,MS-DRG,5024.64,Case Rate,100% of CMS IPPS Rate,12847.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6280.8,100,MS-DRG,5024.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5715.39,15165.47,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,CDM,,,,,Inpatient,,,,,,28647.77,,,,Case Rate,100% of CMS IPPS Rate,20763.75,145,MS-DRG,16611,Case Rate,145% of CMS IPPS Rate,14319.83,100,MS-DRG,11455.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14319.83,100,,11455.864,Case Rate,100% of CMS IPPS Rate,28585.66,100,,,Case Rate,100% of CMS IPPS Rate,32670.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36753.3,100,,,Case Rate,100% of CMS IPPS Rate,36753.3,100,,,Case Rate,100% of CMS IPPS Rate,36753.3,100,,,Case Rate,100% CMS IPPS Rate,25860.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13030.41,100,,10424.328,Case Rate,100% of CMS IPPS Rate,13030.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13030.41,100,MS-DRG,10424.328,Case Rate,100% of CMS IPPS Rate,13030.41,100,MS-DRG,10424.328,Case Rate,100% of CMS IPPS Rate,27212.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14319.83,100,MS-DRG,11455.864,Case Rate,100% of CMS IPPS Rate,18615.78,130,MS-DRG,14892.624,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14749.42,103,MS-DRG,11799.536,Case Rate,103% of CMS IPPS Rate,14749.42,103,MS-DRG,11799.536,Case Rate,103% of CMS IPPS Rate,26734.51,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14319.83,100,MS-DRG,11455.864,Case Rate,100% of CMS IPPS Rate,15169.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21479.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14319.83,100,MS-DRG,11455.864,Case Rate,100% of CMS IPPS Rate,29292.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14319.83,100,MS-DRG,11455.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36753.3,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,CDM,,,,,Inpatient,,,,,,14862.67,,,,Case Rate,100% of CMS IPPS Rate,10772.37,145,MS-DRG,8617.896,Case Rate,145% of CMS IPPS Rate,7429.22,100,MS-DRG,5943.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7429.22,100,,5943.376,Case Rate,100% of CMS IPPS Rate,13998.88,100,,,Case Rate,100% of CMS IPPS Rate,15999.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17998.71,100,,,Case Rate,100% of CMS IPPS Rate,17998.71,100,,,Case Rate,100% of CMS IPPS Rate,17998.71,100,,,Case Rate,100% CMS IPPS Rate,13416.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6760.39,100,,5408.312,Case Rate,100% of CMS IPPS Rate,6760.39,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6760.39,100,MS-DRG,5408.312,Case Rate,100% of CMS IPPS Rate,6760.39,100,MS-DRG,5408.312,Case Rate,100% of CMS IPPS Rate,7811.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7429.22,100,MS-DRG,5943.376,Case Rate,100% of CMS IPPS Rate,9657.99,130,MS-DRG,7726.392,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7652.1,103,MS-DRG,6121.68,Case Rate,103% of CMS IPPS Rate,7652.1,103,MS-DRG,6121.68,Case Rate,103% of CMS IPPS Rate,13354.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7429.22,100,MS-DRG,5943.376,Case Rate,100% of CMS IPPS Rate,7869.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11143.83,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7429.22,100,MS-DRG,5943.376,Case Rate,100% of CMS IPPS Rate,15197,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7429.22,100,MS-DRG,5943.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17998.71,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,CDM,,,,,Inpatient,,,,,,9457.06,,,,Case Rate,100% of CMS IPPS Rate,6854.44,145,MS-DRG,5483.552,Case Rate,145% of CMS IPPS Rate,4727.2,100,MS-DRG,3781.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4727.2,100,,3781.76,Case Rate,100% of CMS IPPS Rate,9592.99,100,,,Case Rate,100% of CMS IPPS Rate,10963.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12333.94,100,,,Case Rate,100% of CMS IPPS Rate,12333.94,100,,,Case Rate,100% of CMS IPPS Rate,12333.94,100,,,Case Rate,100% CMS IPPS Rate,8537.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4301.7,100,,3441.36,Case Rate,100% of CMS IPPS Rate,4301.7,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4301.7,100,MS-DRG,3441.36,Case Rate,100% of CMS IPPS Rate,4301.7,100,MS-DRG,3441.36,Case Rate,100% of CMS IPPS Rate,3721.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4727.2,100,MS-DRG,3781.76,Case Rate,100% of CMS IPPS Rate,6145.36,130,MS-DRG,4916.288,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4869.02,103,MS-DRG,3895.216,Case Rate,103% of CMS IPPS Rate,4869.02,103,MS-DRG,3895.216,Case Rate,103% of CMS IPPS Rate,9371.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4727.2,100,MS-DRG,3781.76,Case Rate,100% of CMS IPPS Rate,5007.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7090.8,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4727.2,100,MS-DRG,3781.76,Case Rate,100% of CMS IPPS Rate,9669.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4727.2,100,MS-DRG,3781.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3721.19,12333.94,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,CDM,,,,,Inpatient,,,,,,95363.41,,,,Case Rate,100% of CMS IPPS Rate,69118.93,145,MS-DRG,55295.144,Case Rate,145% of CMS IPPS Rate,47668.23,100,MS-DRG,38134.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47668.23,100,,38134.584,Case Rate,100% of CMS IPPS Rate,92737.1,100,,,Case Rate,100% of CMS IPPS Rate,105989.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,119234.41,100,,,Case Rate,100% of CMS IPPS Rate,119234.41,100,,,Case Rate,100% of CMS IPPS Rate,119234.41,100,,,Case Rate,100% CMS IPPS Rate,86086.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43375.37,100,,34700.296,Case Rate,100% of CMS IPPS Rate,43375.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,43375.37,100,MS-DRG,34700.296,Case Rate,100% of CMS IPPS Rate,43375.37,100,MS-DRG,34700.296,Case Rate,100% of CMS IPPS Rate,60840.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47668.23,100,MS-DRG,38134.584,Case Rate,100% of CMS IPPS Rate,61968.7,130,MS-DRG,49574.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49098.28,103,MS-DRG,39278.624,Case Rate,103% of CMS IPPS Rate,49098.28,103,MS-DRG,39278.624,Case Rate,103% of CMS IPPS Rate,85904.89,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47668.23,100,MS-DRG,38134.584,Case Rate,100% of CMS IPPS Rate,50495.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,71502.35,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47668.23,100,MS-DRG,38134.584,Case Rate,100% of CMS IPPS Rate,97508.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47668.23,100,MS-DRG,38134.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,119234.41,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,CDM,,,,,Inpatient,,,,,,27145.76,,,,Case Rate,100% of CMS IPPS Rate,19675.11,145,MS-DRG,15740.088,Case Rate,145% of CMS IPPS Rate,13569.04,100,MS-DRG,10855.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13569.04,100,,10855.232,Case Rate,100% of CMS IPPS Rate,26156.76,100,,,Case Rate,100% of CMS IPPS Rate,29894.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33630.39,100,,,Case Rate,100% of CMS IPPS Rate,33630.39,100,,,Case Rate,100% of CMS IPPS Rate,33630.39,100,,,Case Rate,100% CMS IPPS Rate,24504.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12347.24,100,,9877.792,Case Rate,100% of CMS IPPS Rate,12347.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12347.24,100,MS-DRG,9877.792,Case Rate,100% of CMS IPPS Rate,12347.24,100,MS-DRG,9877.792,Case Rate,100% of CMS IPPS Rate,13869.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13569.04,100,MS-DRG,10855.232,Case Rate,100% of CMS IPPS Rate,17639.75,130,MS-DRG,14111.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13976.11,103,MS-DRG,11180.888,Case Rate,103% of CMS IPPS Rate,13976.11,103,MS-DRG,11180.888,Case Rate,103% of CMS IPPS Rate,24758.58,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13569.04,100,MS-DRG,10855.232,Case Rate,100% of CMS IPPS Rate,14373.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20353.56,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13569.04,100,MS-DRG,10855.232,Case Rate,100% of CMS IPPS Rate,27756.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13569.04,100,MS-DRG,10855.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33630.39,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,CDM,,,,,Inpatient,,,,,,14101.39,,,,Case Rate,100% of CMS IPPS Rate,10220.62,145,MS-DRG,8176.496,Case Rate,145% of CMS IPPS Rate,7048.7,100,MS-DRG,5638.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7048.7,100,,5638.96,Case Rate,100% of CMS IPPS Rate,13744.26,100,,,Case Rate,100% of CMS IPPS Rate,15708.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17671.34,100,,,Case Rate,100% of CMS IPPS Rate,17671.34,100,,,Case Rate,100% of CMS IPPS Rate,17671.34,100,,,Case Rate,100% CMS IPPS Rate,12729.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6414.14,100,,5131.312,Case Rate,100% of CMS IPPS Rate,6414.14,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6414.14,100,MS-DRG,5131.312,Case Rate,100% of CMS IPPS Rate,6414.14,100,MS-DRG,5131.312,Case Rate,100% of CMS IPPS Rate,6596.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7048.7,100,MS-DRG,5638.96,Case Rate,100% of CMS IPPS Rate,9163.31,130,MS-DRG,7330.648,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7260.16,103,MS-DRG,5808.128,Case Rate,103% of CMS IPPS Rate,7260.16,103,MS-DRG,5808.128,Case Rate,103% of CMS IPPS Rate,13004.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7048.7,100,MS-DRG,5638.96,Case Rate,100% of CMS IPPS Rate,7466.78,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10573.05,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7048.7,100,MS-DRG,5638.96,Case Rate,100% of CMS IPPS Rate,14418.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7048.7,100,MS-DRG,5638.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17671.34,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,CDM,,,,,Inpatient,,,,,,51091.7,,,,Case Rate,100% of CMS IPPS Rate,37031,145,MS-DRG,29624.8,Case Rate,145% of CMS IPPS Rate,25538.62,100,MS-DRG,20430.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25538.62,100,,20430.896,Case Rate,100% of CMS IPPS Rate,52385.5,100,,,Case Rate,100% of CMS IPPS Rate,59871.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,67353.34,100,,,Case Rate,100% of CMS IPPS Rate,67353.34,100,,,Case Rate,100% of CMS IPPS Rate,67353.34,100,,,Case Rate,100% CMS IPPS Rate,46121.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23238.82,100,,18591.056,Case Rate,100% of CMS IPPS Rate,23238.82,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23238.82,100,MS-DRG,18591.056,Case Rate,100% of CMS IPPS Rate,23238.82,100,MS-DRG,18591.056,Case Rate,100% of CMS IPPS Rate,29907.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25538.62,100,MS-DRG,20430.896,Case Rate,100% of CMS IPPS Rate,33200.21,130,MS-DRG,26560.168,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26304.78,103,MS-DRG,21043.824,Case Rate,103% of CMS IPPS Rate,26304.78,103,MS-DRG,21043.824,Case Rate,103% of CMS IPPS Rate,40433.2,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25538.62,100,MS-DRG,20430.896,Case Rate,100% of CMS IPPS Rate,27053.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,38307.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25538.62,100,MS-DRG,20430.896,Case Rate,100% of CMS IPPS Rate,52241,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25538.62,100,MS-DRG,20430.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,67353.34,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,CDM,,,,,Inpatient,,,,,,13070.38,,,,Case Rate,100% of CMS IPPS Rate,9473.34,145,MS-DRG,7578.672,Case Rate,145% of CMS IPPS Rate,6533.34,100,MS-DRG,5226.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6533.34,100,,5226.672,Case Rate,100% of CMS IPPS Rate,12779.1,100,,,Case Rate,100% of CMS IPPS Rate,14605.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16430.4,100,,,Case Rate,100% of CMS IPPS Rate,16430.4,100,,,Case Rate,100% of CMS IPPS Rate,16430.4,100,,,Case Rate,100% CMS IPPS Rate,11798.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5945.19,100,,4756.152,Case Rate,100% of CMS IPPS Rate,5945.19,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5945.19,100,MS-DRG,4756.152,Case Rate,100% of CMS IPPS Rate,5945.19,100,MS-DRG,4756.152,Case Rate,100% of CMS IPPS Rate,5883.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6533.34,100,MS-DRG,5226.672,Case Rate,100% of CMS IPPS Rate,8493.34,130,MS-DRG,6794.672,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6729.34,103,MS-DRG,5383.472,Case Rate,103% of CMS IPPS Rate,6729.34,103,MS-DRG,5383.472,Case Rate,103% of CMS IPPS Rate,11463.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6533.34,100,MS-DRG,5226.672,Case Rate,100% of CMS IPPS Rate,6920.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9800.01,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6533.34,100,MS-DRG,5226.672,Case Rate,100% of CMS IPPS Rate,13364.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6533.34,100,MS-DRG,5226.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5883.37,16430.4,
DEPRESSIVE NEUROSES,881,CDM,,,,,Inpatient,,,,,,12411.8,,,,Case Rate,100% of CMS IPPS Rate,8996.02,145,MS-DRG,7196.816,Case Rate,145% of CMS IPPS Rate,6204.15,100,MS-DRG,4963.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6204.15,100,,4963.32,Case Rate,100% of CMS IPPS Rate,12185.87,100,,,Case Rate,100% of CMS IPPS Rate,13927.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15667.67,100,,,Case Rate,100% of CMS IPPS Rate,15667.67,100,,,Case Rate,100% of CMS IPPS Rate,15667.67,100,,,Case Rate,100% CMS IPPS Rate,11204.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5645.64,100,,4516.512,Case Rate,100% of CMS IPPS Rate,5645.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5645.64,100,MS-DRG,4516.512,Case Rate,100% of CMS IPPS Rate,5645.64,100,MS-DRG,4516.512,Case Rate,100% of CMS IPPS Rate,3596.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6204.15,100,MS-DRG,4963.32,Case Rate,100% of CMS IPPS Rate,8065.4,130,MS-DRG,6452.32,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6390.27,103,MS-DRG,5112.216,Case Rate,103% of CMS IPPS Rate,6390.27,103,MS-DRG,5112.216,Case Rate,103% of CMS IPPS Rate,10822.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6204.15,100,MS-DRG,4963.32,Case Rate,100% of CMS IPPS Rate,6572.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9306.23,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6204.15,100,MS-DRG,4963.32,Case Rate,100% of CMS IPPS Rate,12691,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6204.15,100,MS-DRG,4963.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3596.34,15667.67,
NEUROSES EXCEPT DEPRESSIVE,882,CDM,,,,,Inpatient,,,,,,12860.9,,,,Case Rate,100% of CMS IPPS Rate,9321.51,145,MS-DRG,7457.208,Case Rate,145% of CMS IPPS Rate,6428.63,100,MS-DRG,5142.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6428.63,100,,5142.904,Case Rate,100% of CMS IPPS Rate,12824.42,100,,,Case Rate,100% of CMS IPPS Rate,14657.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,16488.68,100,,,Case Rate,100% of CMS IPPS Rate,16488.68,100,,,Case Rate,100% of CMS IPPS Rate,16488.68,100,,,Case Rate,100% CMS IPPS Rate,11609.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5849.9,100,,4679.92,Case Rate,100% of CMS IPPS Rate,5849.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5849.9,100,MS-DRG,4679.92,Case Rate,100% of CMS IPPS Rate,5849.9,100,MS-DRG,4679.92,Case Rate,100% of CMS IPPS Rate,11322.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6428.63,100,MS-DRG,5142.904,Case Rate,100% of CMS IPPS Rate,8357.22,130,MS-DRG,6685.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6621.49,103,MS-DRG,5297.192,Case Rate,103% of CMS IPPS Rate,6621.49,103,MS-DRG,5297.192,Case Rate,103% of CMS IPPS Rate,11049.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6428.63,100,MS-DRG,5142.904,Case Rate,100% of CMS IPPS Rate,6809.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9642.95,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6428.63,100,MS-DRG,5142.904,Case Rate,100% of CMS IPPS Rate,13150.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6428.63,100,MS-DRG,5142.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5849.9,16488.68,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,CDM,,,,,Inpatient,,,,,,25677.98,,,,Case Rate,100% of CMS IPPS Rate,18611.29,145,MS-DRG,14889.032,Case Rate,145% of CMS IPPS Rate,12835.37,100,MS-DRG,10268.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12835.37,100,,10268.296,Case Rate,100% of CMS IPPS Rate,24714.34,100,,,Case Rate,100% of CMS IPPS Rate,28246.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31775.85,100,,,Case Rate,100% of CMS IPPS Rate,31775.85,100,,,Case Rate,100% of CMS IPPS Rate,31775.85,100,,,Case Rate,100% CMS IPPS Rate,23179.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11679.64,100,,9343.712,Case Rate,100% of CMS IPPS Rate,11679.64,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11679.64,100,MS-DRG,9343.712,Case Rate,100% of CMS IPPS Rate,11679.64,100,MS-DRG,9343.712,Case Rate,100% of CMS IPPS Rate,13924.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12835.37,100,MS-DRG,10268.296,Case Rate,100% of CMS IPPS Rate,16685.98,130,MS-DRG,13348.784,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13220.43,103,MS-DRG,10576.344,Case Rate,103% of CMS IPPS Rate,13220.43,103,MS-DRG,10576.344,Case Rate,103% of CMS IPPS Rate,20423.43,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12835.37,100,MS-DRG,10268.296,Case Rate,100% of CMS IPPS Rate,13596.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19253.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12835.37,100,MS-DRG,10268.296,Case Rate,100% of CMS IPPS Rate,26255.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12835.37,100,MS-DRG,10268.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31775.85,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,CDM,,,,,Inpatient,,,,,,24055.47,,,,Case Rate,100% of CMS IPPS Rate,17435.28,145,MS-DRG,13948.224,Case Rate,145% of CMS IPPS Rate,12024.33,100,MS-DRG,9619.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12024.33,100,,9619.464,Case Rate,100% of CMS IPPS Rate,22265.44,100,,,Case Rate,100% of CMS IPPS Rate,25447.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28627.23,100,,,Case Rate,100% of CMS IPPS Rate,28627.23,100,,,Case Rate,100% of CMS IPPS Rate,28627.23,100,,,Case Rate,100% CMS IPPS Rate,21715.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10941.65,100,,8753.32,Case Rate,100% of CMS IPPS Rate,10941.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10941.65,100,MS-DRG,8753.32,Case Rate,100% of CMS IPPS Rate,10941.65,100,MS-DRG,8753.32,Case Rate,100% of CMS IPPS Rate,14309.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12024.33,100,MS-DRG,9619.464,Case Rate,100% of CMS IPPS Rate,15631.63,130,MS-DRG,12505.304,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12385.06,103,MS-DRG,9908.048,Case Rate,103% of CMS IPPS Rate,12385.06,103,MS-DRG,9908.048,Case Rate,103% of CMS IPPS Rate,19860.5,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12024.33,100,MS-DRG,9619.464,Case Rate,100% of CMS IPPS Rate,12737.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18036.5,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12024.33,100,MS-DRG,9619.464,Case Rate,100% of CMS IPPS Rate,24596.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12024.33,100,MS-DRG,9619.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28627.23,
PSYCHOSES,885,CDM,,,,,Inpatient,,,,,,18708.75,,,,Case Rate,100% of CMS IPPS Rate,13560.01,145,MS-DRG,10848.008,Case Rate,145% of CMS IPPS Rate,9351.73,100,MS-DRG,7481.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9351.73,100,,7481.384,Case Rate,100% of CMS IPPS Rate,18791.38,100,,,Case Rate,100% of CMS IPPS Rate,21476.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24160.54,100,,,Case Rate,100% of CMS IPPS Rate,24160.54,100,,,Case Rate,100% of CMS IPPS Rate,24160.54,100,,,Case Rate,100% CMS IPPS Rate,16888.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8509.75,100,,6807.8,Case Rate,100% of CMS IPPS Rate,8509.75,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8509.75,100,MS-DRG,6807.8,Case Rate,100% of CMS IPPS Rate,8509.75,100,MS-DRG,6807.8,Case Rate,100% of CMS IPPS Rate,5054.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9351.73,100,MS-DRG,7481.384,Case Rate,100% of CMS IPPS Rate,12157.25,130,MS-DRG,9725.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9632.28,103,MS-DRG,7705.824,Case Rate,103% of CMS IPPS Rate,9632.28,103,MS-DRG,7705.824,Case Rate,103% of CMS IPPS Rate,16388.08,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9351.73,100,MS-DRG,7481.384,Case Rate,100% of CMS IPPS Rate,9906.4,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14027.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9351.73,100,MS-DRG,7481.384,Case Rate,100% of CMS IPPS Rate,19129.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9351.73,100,MS-DRG,7481.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5054.82,24160.54,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,CDM,,,,,Inpatient,,,,,,23025.84,,,,Case Rate,100% of CMS IPPS Rate,16689.01,145,MS-DRG,13351.208,Case Rate,145% of CMS IPPS Rate,11509.66,100,MS-DRG,9207.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11509.66,100,,9207.728,Case Rate,100% of CMS IPPS Rate,23949.14,100,,,Case Rate,100% of CMS IPPS Rate,27371.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30792.01,100,,,Case Rate,100% of CMS IPPS Rate,30792.01,100,,,Case Rate,100% of CMS IPPS Rate,30792.01,100,,,Case Rate,100% CMS IPPS Rate,20785.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10473.32,100,,8378.656,Case Rate,100% of CMS IPPS Rate,10473.32,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10473.32,100,MS-DRG,8378.656,Case Rate,100% of CMS IPPS Rate,10473.32,100,MS-DRG,8378.656,Case Rate,100% of CMS IPPS Rate,9027.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11509.66,100,MS-DRG,9207.728,Case Rate,100% of CMS IPPS Rate,14962.56,130,MS-DRG,11970.048,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11854.95,103,MS-DRG,9483.96,Case Rate,103% of CMS IPPS Rate,11854.95,103,MS-DRG,9483.96,Case Rate,103% of CMS IPPS Rate,17267.25,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11509.66,100,MS-DRG,9207.728,Case Rate,100% of CMS IPPS Rate,12192.33,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17264.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11509.66,100,MS-DRG,9207.728,Case Rate,100% of CMS IPPS Rate,23543.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11509.66,100,MS-DRG,9207.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30792.01,
OTHER MENTAL DISORDER DIAGNOSES,887,CDM,,,,,Inpatient,,,,,,17739.36,,,,Case Rate,100% of CMS IPPS Rate,12857.4,145,MS-DRG,10285.92,Case Rate,145% of CMS IPPS Rate,8867.17,100,MS-DRG,7093.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8867.17,100,,7093.736,Case Rate,100% of CMS IPPS Rate,15855.89,100,,,Case Rate,100% of CMS IPPS Rate,18121.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20386.32,100,,,Case Rate,100% of CMS IPPS Rate,20386.32,100,,,Case Rate,100% of CMS IPPS Rate,20386.32,100,,,Case Rate,100% CMS IPPS Rate,16013.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8068.82,100,,6455.056,Case Rate,100% of CMS IPPS Rate,8068.82,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8068.82,100,MS-DRG,6455.056,Case Rate,100% of CMS IPPS Rate,8068.82,100,MS-DRG,6455.056,Case Rate,100% of CMS IPPS Rate,17047.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8867.17,100,MS-DRG,7093.736,Case Rate,100% of CMS IPPS Rate,11527.32,130,MS-DRG,9221.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9133.19,103,MS-DRG,7306.552,Case Rate,103% of CMS IPPS Rate,9133.19,103,MS-DRG,7306.552,Case Rate,103% of CMS IPPS Rate,16400.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8867.17,100,MS-DRG,7093.736,Case Rate,100% of CMS IPPS Rate,9393.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13300.76,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8867.17,100,MS-DRG,7093.736,Case Rate,100% of CMS IPPS Rate,18138.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8867.17,100,MS-DRG,7093.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20386.32,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,CDM,,,,,Inpatient,,,,,,7866.05,,,,Case Rate,100% of CMS IPPS Rate,5701.27,145,MS-DRG,4561.016,Case Rate,145% of CMS IPPS Rate,3931.91,100,MS-DRG,3145.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3931.91,100,,3145.528,Case Rate,100% of CMS IPPS Rate,8319.88,100,,,Case Rate,100% of CMS IPPS Rate,9508.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10697.07,100,,,Case Rate,100% of CMS IPPS Rate,10697.07,100,,,Case Rate,100% of CMS IPPS Rate,10697.07,100,,,Case Rate,100% CMS IPPS Rate,7100.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3578.05,100,,2862.44,Case Rate,100% of CMS IPPS Rate,3578.05,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3578.05,100,MS-DRG,2862.44,Case Rate,100% of CMS IPPS Rate,3578.05,100,MS-DRG,2862.44,Case Rate,100% of CMS IPPS Rate,3532.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3931.91,100,MS-DRG,3145.528,Case Rate,100% of CMS IPPS Rate,5111.48,130,MS-DRG,4089.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4049.87,103,MS-DRG,3239.896,Case Rate,103% of CMS IPPS Rate,4049.87,103,MS-DRG,3239.896,Case Rate,103% of CMS IPPS Rate,7233.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.91,100,MS-DRG,3145.528,Case Rate,100% of CMS IPPS Rate,4165.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,5897.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.91,100,MS-DRG,3145.528,Case Rate,100% of CMS IPPS Rate,8043,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.91,100,MS-DRG,3145.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3532.29,10697.07,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,CDM,,,,,Inpatient,,,,,,22027.69,,,,Case Rate,100% of CMS IPPS Rate,15965.56,145,MS-DRG,12772.448,Case Rate,145% of CMS IPPS Rate,11010.73,100,MS-DRG,8808.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11010.73,100,,8808.584,Case Rate,100% of CMS IPPS Rate,18707.39,100,,,Case Rate,100% of CMS IPPS Rate,21380.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24052.56,100,,,Case Rate,100% of CMS IPPS Rate,24052.56,100,,,Case Rate,100% of CMS IPPS Rate,24052.56,100,,,Case Rate,100% CMS IPPS Rate,19884.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10019.33,100,,8015.464,Case Rate,100% of CMS IPPS Rate,10019.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10019.33,100,MS-DRG,8015.464,Case Rate,100% of CMS IPPS Rate,10019.33,100,MS-DRG,8015.464,Case Rate,100% of CMS IPPS Rate,5119.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11010.73,100,MS-DRG,8808.584,Case Rate,100% of CMS IPPS Rate,14313.95,130,MS-DRG,11451.16,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11341.05,103,MS-DRG,9072.84,Case Rate,103% of CMS IPPS Rate,11341.05,103,MS-DRG,9072.84,Case Rate,103% of CMS IPPS Rate,19717.56,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11010.73,100,MS-DRG,8808.584,Case Rate,100% of CMS IPPS Rate,11663.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16516.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11010.73,100,MS-DRG,8808.584,Case Rate,100% of CMS IPPS Rate,22523.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11010.73,100,MS-DRG,8808.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5119.68,24052.56,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,CDM,,,,,Inpatient,,,,,,24345.75,,,,Case Rate,100% of CMS IPPS Rate,17645.67,145,MS-DRG,14116.536,Case Rate,145% of CMS IPPS Rate,12169.43,100,MS-DRG,9735.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12169.43,100,,9735.544,Case Rate,100% of CMS IPPS Rate,23739.84,100,,,Case Rate,100% of CMS IPPS Rate,27132.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,30522.91,100,,,Case Rate,100% of CMS IPPS Rate,30522.91,100,,,Case Rate,100% of CMS IPPS Rate,30522.91,100,,,Case Rate,100% CMS IPPS Rate,21977.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11073.68,100,,8858.944,Case Rate,100% of CMS IPPS Rate,11073.68,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11073.68,100,MS-DRG,8858.944,Case Rate,100% of CMS IPPS Rate,11073.68,100,MS-DRG,8858.944,Case Rate,100% of CMS IPPS Rate,9611.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12169.43,100,MS-DRG,9735.544,Case Rate,100% of CMS IPPS Rate,15820.26,130,MS-DRG,12656.208,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12534.51,103,MS-DRG,10027.608,Case Rate,103% of CMS IPPS Rate,12534.51,103,MS-DRG,10027.608,Case Rate,103% of CMS IPPS Rate,22208.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12169.43,100,MS-DRG,9735.544,Case Rate,100% of CMS IPPS Rate,12891.23,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18254.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12169.43,100,MS-DRG,9735.544,Case Rate,100% of CMS IPPS Rate,24893.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12169.43,100,MS-DRG,9735.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,30522.91,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,CDM,,,,,Inpatient,,,,,,11714.88,,,,Case Rate,100% of CMS IPPS Rate,8490.9,145,MS-DRG,6792.72,Case Rate,145% of CMS IPPS Rate,5855.79,100,MS-DRG,4684.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5855.79,100,,4684.632,Case Rate,100% of CMS IPPS Rate,11760.61,100,,,Case Rate,100% of CMS IPPS Rate,13441.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15120.91,100,,,Case Rate,100% of CMS IPPS Rate,15120.91,100,,,Case Rate,100% of CMS IPPS Rate,15120.91,100,,,Case Rate,100% CMS IPPS Rate,10575.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5328.65,100,,4262.92,Case Rate,100% of CMS IPPS Rate,5328.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5328.65,100,MS-DRG,4262.92,Case Rate,100% of CMS IPPS Rate,5328.65,100,MS-DRG,4262.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5855.79,100,MS-DRG,4684.632,Case Rate,100% of CMS IPPS Rate,7612.53,130,MS-DRG,6090.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6031.46,103,MS-DRG,4825.168,Case Rate,103% of CMS IPPS Rate,6031.46,103,MS-DRG,4825.168,Case Rate,103% of CMS IPPS Rate,10768.95,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5855.79,100,MS-DRG,4684.632,Case Rate,100% of CMS IPPS Rate,6203.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8783.69,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5855.79,100,MS-DRG,4684.632,Case Rate,100% of CMS IPPS Rate,11978.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5855.79,100,MS-DRG,4684.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5328.65,15120.91,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,CDM,,,,,Inpatient,,,,,,59256.24,,,,Case Rate,100% of CMS IPPS Rate,42948.64,145,MS-DRG,34358.912,Case Rate,145% of CMS IPPS Rate,29619.75,100,MS-DRG,23695.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29619.75,100,,23695.8,Case Rate,100% of CMS IPPS Rate,59063,100,,,Case Rate,100% of CMS IPPS Rate,67503.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,75938.77,100,,,Case Rate,100% of CMS IPPS Rate,75938.77,100,,,Case Rate,100% of CMS IPPS Rate,75938.77,100,,,Case Rate,100% CMS IPPS Rate,53491.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26952.37,100,,21561.896,Case Rate,100% of CMS IPPS Rate,26952.37,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,26952.37,100,MS-DRG,21561.896,Case Rate,100% of CMS IPPS Rate,26952.37,100,MS-DRG,21561.896,Case Rate,100% of CMS IPPS Rate,38946.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29619.75,100,MS-DRG,23695.8,Case Rate,100% of CMS IPPS Rate,38505.68,130,MS-DRG,30804.544,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30508.34,103,MS-DRG,24406.672,Case Rate,103% of CMS IPPS Rate,30508.34,103,MS-DRG,24406.672,Case Rate,103% of CMS IPPS Rate,55642.29,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29619.75,100,MS-DRG,23695.8,Case Rate,100% of CMS IPPS Rate,31376.55,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,44429.63,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29619.75,100,MS-DRG,23695.8,Case Rate,100% of CMS IPPS Rate,60589.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29619.75,100,MS-DRG,23695.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,75938.77,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,CDM,,,,,Inpatient,,,,,,25805.31,,,,Case Rate,100% of CMS IPPS Rate,18703.56,145,MS-DRG,14962.848,Case Rate,145% of CMS IPPS Rate,12899.01,100,MS-DRG,10319.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12899.01,100,,10319.208,Case Rate,100% of CMS IPPS Rate,25296.91,100,,,Case Rate,100% of CMS IPPS Rate,28911.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32524.86,100,,,Case Rate,100% of CMS IPPS Rate,32524.86,100,,,Case Rate,100% of CMS IPPS Rate,32524.86,100,,,Case Rate,100% CMS IPPS Rate,23294.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11737.55,100,,9390.04,Case Rate,100% of CMS IPPS Rate,11737.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11737.55,100,MS-DRG,9390.04,Case Rate,100% of CMS IPPS Rate,11737.55,100,MS-DRG,9390.04,Case Rate,100% of CMS IPPS Rate,15787.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12899.01,100,MS-DRG,10319.208,Case Rate,100% of CMS IPPS Rate,16768.71,130,MS-DRG,13414.968,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13285.98,103,MS-DRG,10628.784,Case Rate,103% of CMS IPPS Rate,13285.98,103,MS-DRG,10628.784,Case Rate,103% of CMS IPPS Rate,25069.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12899.01,100,MS-DRG,10319.208,Case Rate,100% of CMS IPPS Rate,13664.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19348.52,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12899.01,100,MS-DRG,10319.208,Case Rate,100% of CMS IPPS Rate,26385.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12899.01,100,MS-DRG,10319.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,32524.86,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,CDM,,,,,Inpatient,,,,,,16998.62,,,,Case Rate,100% of CMS IPPS Rate,12320.53,145,MS-DRG,9856.424,Case Rate,145% of CMS IPPS Rate,8496.92,100,MS-DRG,6797.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8496.92,100,,6797.536,Case Rate,100% of CMS IPPS Rate,16251.82,100,,,Case Rate,100% of CMS IPPS Rate,18574.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20895.37,100,,,Case Rate,100% of CMS IPPS Rate,20895.37,100,,,Case Rate,100% of CMS IPPS Rate,20895.37,100,,,Case Rate,100% CMS IPPS Rate,15344.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7731.9,100,,6185.52,Case Rate,100% of CMS IPPS Rate,7731.9,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7731.9,100,MS-DRG,6185.52,Case Rate,100% of CMS IPPS Rate,7731.9,100,MS-DRG,6185.52,Case Rate,100% of CMS IPPS Rate,13339.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8496.92,100,MS-DRG,6797.536,Case Rate,100% of CMS IPPS Rate,11046,130,MS-DRG,8836.8,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8751.83,103,MS-DRG,7001.464,Case Rate,103% of CMS IPPS Rate,8751.83,103,MS-DRG,7001.464,Case Rate,103% of CMS IPPS Rate,15377.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8496.92,100,MS-DRG,6797.536,Case Rate,100% of CMS IPPS Rate,9000.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12745.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8496.92,100,MS-DRG,6797.536,Case Rate,100% of CMS IPPS Rate,17381,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8496.92,100,MS-DRG,6797.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,20895.37,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,CDM,,,,,Inpatient,,,,,,44583.89,,,,Case Rate,100% of CMS IPPS Rate,32314.18,145,MS-DRG,25851.344,Case Rate,145% of CMS IPPS Rate,22285.64,100,MS-DRG,17828.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22285.64,100,,17828.512,Case Rate,100% of CMS IPPS Rate,51472.32,100,,,Case Rate,100% of CMS IPPS Rate,58827.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,66179.25,100,,,Case Rate,100% of CMS IPPS Rate,66179.25,100,,,Case Rate,100% of CMS IPPS Rate,66179.25,100,,,Case Rate,100% CMS IPPS Rate,40246.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20278.8,100,,16223.04,Case Rate,100% of CMS IPPS Rate,20278.8,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20278.8,100,MS-DRG,16223.04,Case Rate,100% of CMS IPPS Rate,20278.8,100,MS-DRG,16223.04,Case Rate,100% of CMS IPPS Rate,28403.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22285.64,100,MS-DRG,17828.512,Case Rate,100% of CMS IPPS Rate,28971.33,130,MS-DRG,23177.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22954.21,103,MS-DRG,18363.368,Case Rate,103% of CMS IPPS Rate,22954.21,103,MS-DRG,18363.368,Case Rate,103% of CMS IPPS Rate,44931.54,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22285.64,100,MS-DRG,17828.512,Case Rate,100% of CMS IPPS Rate,23607.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33428.46,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22285.64,100,MS-DRG,17828.512,Case Rate,100% of CMS IPPS Rate,45586.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22285.64,100,MS-DRG,17828.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,66179.25,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,CDM,,,,,Inpatient,,,,,,21684.02,,,,Case Rate,100% of CMS IPPS Rate,15716.46,145,MS-DRG,12573.168,Case Rate,145% of CMS IPPS Rate,10838.94,100,MS-DRG,8671.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10838.94,100,,8671.152,Case Rate,100% of CMS IPPS Rate,21972.15,100,,,Case Rate,100% of CMS IPPS Rate,25111.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28250.15,100,,,Case Rate,100% of CMS IPPS Rate,28250.15,100,,,Case Rate,100% of CMS IPPS Rate,28250.15,100,,,Case Rate,100% CMS IPPS Rate,19574.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9863.02,100,,7890.416,Case Rate,100% of CMS IPPS Rate,9863.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9863.02,100,MS-DRG,7890.416,Case Rate,100% of CMS IPPS Rate,9863.02,100,MS-DRG,7890.416,Case Rate,100% of CMS IPPS Rate,14251.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10838.94,100,MS-DRG,8671.152,Case Rate,100% of CMS IPPS Rate,14090.62,130,MS-DRG,11272.496,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11164.11,103,MS-DRG,8931.288,Case Rate,103% of CMS IPPS Rate,11164.11,103,MS-DRG,8931.288,Case Rate,103% of CMS IPPS Rate,19732.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10838.94,100,MS-DRG,8671.152,Case Rate,100% of CMS IPPS Rate,11481.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16258.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10838.94,100,MS-DRG,8671.152,Case Rate,100% of CMS IPPS Rate,22171.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10838.94,100,MS-DRG,8671.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28250.15,
HAND PROCEDURES FOR INJURIES,906,CDM,,,,,Inpatient,,,,,,25762.87,,,,Case Rate,100% of CMS IPPS Rate,18672.81,145,MS-DRG,14938.248,Case Rate,145% of CMS IPPS Rate,12877.8,100,MS-DRG,10302.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12877.8,100,,10302.24,Case Rate,100% of CMS IPPS Rate,29094.91,100,,,Case Rate,100% of CMS IPPS Rate,33252.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37408.05,100,,,Case Rate,100% of CMS IPPS Rate,37408.05,100,,,Case Rate,100% of CMS IPPS Rate,37408.05,100,,,Case Rate,100% CMS IPPS Rate,23256.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11718.24,100,,9374.592,Case Rate,100% of CMS IPPS Rate,11718.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11718.24,100,MS-DRG,9374.592,Case Rate,100% of CMS IPPS Rate,11718.24,100,MS-DRG,9374.592,Case Rate,100% of CMS IPPS Rate,10379.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12877.8,100,MS-DRG,10302.24,Case Rate,100% of CMS IPPS Rate,16741.14,130,MS-DRG,13392.912,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13264.13,103,MS-DRG,10611.304,Case Rate,103% of CMS IPPS Rate,13264.13,103,MS-DRG,10611.304,Case Rate,103% of CMS IPPS Rate,22615.67,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12877.8,100,MS-DRG,10302.24,Case Rate,100% of CMS IPPS Rate,13641.6,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19316.7,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12877.8,100,MS-DRG,10302.24,Case Rate,100% of CMS IPPS Rate,26342.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12877.8,100,MS-DRG,10302.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37408.05,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,CDM,,,,,Inpatient,,,,,,50927.39,,,,Case Rate,100% of CMS IPPS Rate,36911.93,145,MS-DRG,29529.544,Case Rate,145% of CMS IPPS Rate,25456.5,100,MS-DRG,20365.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25456.5,100,,20365.2,Case Rate,100% of CMS IPPS Rate,53106.7,100,,,Case Rate,100% of CMS IPPS Rate,60695.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,68280.62,100,,,Case Rate,100% of CMS IPPS Rate,68280.62,100,,,Case Rate,100% of CMS IPPS Rate,68280.62,100,,,Case Rate,100% CMS IPPS Rate,45973.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23164.08,100,,18531.264,Case Rate,100% of CMS IPPS Rate,23164.08,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,23164.08,100,MS-DRG,18531.264,Case Rate,100% of CMS IPPS Rate,23164.08,100,MS-DRG,18531.264,Case Rate,100% of CMS IPPS Rate,30420.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25456.5,100,MS-DRG,20365.2,Case Rate,100% of CMS IPPS Rate,33093.45,130,MS-DRG,26474.76,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26220.2,103,MS-DRG,20976.16,Case Rate,103% of CMS IPPS Rate,26220.2,103,MS-DRG,20976.16,Case Rate,103% of CMS IPPS Rate,48901.11,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25456.5,100,MS-DRG,20365.2,Case Rate,100% of CMS IPPS Rate,26966.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,38184.75,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25456.5,100,MS-DRG,20365.2,Case Rate,100% of CMS IPPS Rate,52073,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25456.5,100,MS-DRG,20365.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,68280.62,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,CDM,,,,,Inpatient,,,,,,27440.14,,,,Case Rate,100% of CMS IPPS Rate,19888.48,145,MS-DRG,15910.784,Case Rate,145% of CMS IPPS Rate,13716.19,100,MS-DRG,10972.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13716.19,100,,10972.952,Case Rate,100% of CMS IPPS Rate,26889.96,100,,,Case Rate,100% of CMS IPPS Rate,30732.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,34573.09,100,,,Case Rate,100% of CMS IPPS Rate,34573.09,100,,,Case Rate,100% of CMS IPPS Rate,34573.09,100,,,Case Rate,100% CMS IPPS Rate,24770.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12481.12,100,,9984.896,Case Rate,100% of CMS IPPS Rate,12481.12,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12481.12,100,MS-DRG,9984.896,Case Rate,100% of CMS IPPS Rate,12481.12,100,MS-DRG,9984.896,Case Rate,100% of CMS IPPS Rate,15839.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13716.19,100,MS-DRG,10972.952,Case Rate,100% of CMS IPPS Rate,17831.05,130,MS-DRG,14264.84,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14127.68,103,MS-DRG,11302.144,Case Rate,103% of CMS IPPS Rate,14127.68,103,MS-DRG,11302.144,Case Rate,103% of CMS IPPS Rate,26014.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13716.19,100,MS-DRG,10972.952,Case Rate,100% of CMS IPPS Rate,14529.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20574.29,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13716.19,100,MS-DRG,10972.952,Case Rate,100% of CMS IPPS Rate,28057.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13716.19,100,MS-DRG,10972.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,34573.09,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,CDM,,,,,Inpatient,,,,,,18570.46,,,,Case Rate,100% of CMS IPPS Rate,13459.78,145,MS-DRG,10767.824,Case Rate,145% of CMS IPPS Rate,9282.61,100,MS-DRG,7426.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9282.61,100,,7426.088,Case Rate,100% of CMS IPPS Rate,16907.71,100,,,Case Rate,100% of CMS IPPS Rate,19323.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21738.66,100,,,Case Rate,100% of CMS IPPS Rate,21738.66,100,,,Case Rate,100% of CMS IPPS Rate,21738.66,100,,,Case Rate,100% CMS IPPS Rate,16763.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8446.84,100,,6757.472,Case Rate,100% of CMS IPPS Rate,8446.84,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8446.84,100,MS-DRG,6757.472,Case Rate,100% of CMS IPPS Rate,8446.84,100,MS-DRG,6757.472,Case Rate,100% of CMS IPPS Rate,9246.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9282.61,100,MS-DRG,7426.088,Case Rate,100% of CMS IPPS Rate,12067.39,130,MS-DRG,9653.912,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9561.09,103,MS-DRG,7648.872,Case Rate,103% of CMS IPPS Rate,9561.09,103,MS-DRG,7648.872,Case Rate,103% of CMS IPPS Rate,17263.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9282.61,100,MS-DRG,7426.088,Case Rate,100% of CMS IPPS Rate,9833.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13923.92,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9282.61,100,MS-DRG,7426.088,Case Rate,100% of CMS IPPS Rate,18988.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9282.61,100,MS-DRG,7426.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,21738.66,
TRAUMATIC INJURY WITH MCC,913,CDM,,,,,Inpatient,,,,,,20462.69,,,,Case Rate,100% of CMS IPPS Rate,14831.25,145,MS-DRG,11865,Case Rate,145% of CMS IPPS Rate,10228.45,100,MS-DRG,8182.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10228.45,100,,8182.76,Case Rate,100% of CMS IPPS Rate,21573.56,100,,,Case Rate,100% of CMS IPPS Rate,24656.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27737.66,100,,,Case Rate,100% of CMS IPPS Rate,27737.66,100,,,Case Rate,100% of CMS IPPS Rate,27737.66,100,,,Case Rate,100% CMS IPPS Rate,18472.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9307.51,100,,7446.008,Case Rate,100% of CMS IPPS Rate,9307.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9307.51,100,MS-DRG,7446.008,Case Rate,100% of CMS IPPS Rate,9307.51,100,MS-DRG,7446.008,Case Rate,100% of CMS IPPS Rate,13448.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10228.45,100,MS-DRG,8182.76,Case Rate,100% of CMS IPPS Rate,13296.99,130,MS-DRG,10637.592,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10535.3,103,MS-DRG,8428.24,Case Rate,103% of CMS IPPS Rate,10535.3,103,MS-DRG,8428.24,Case Rate,103% of CMS IPPS Rate,19153.37,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10228.45,100,MS-DRG,8182.76,Case Rate,100% of CMS IPPS Rate,10835.13,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15342.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10228.45,100,MS-DRG,8182.76,Case Rate,100% of CMS IPPS Rate,20923,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10228.45,100,MS-DRG,8182.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,27737.66,
TRAUMATIC INJURY WITHOUT MCC,914,CDM,,,,,Inpatient,,,,,,12428.23,,,,Case Rate,100% of CMS IPPS Rate,9007.92,145,MS-DRG,7206.336,Case Rate,145% of CMS IPPS Rate,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6212.36,100,,4969.888,Case Rate,100% of CMS IPPS Rate,12216.53,100,,,Case Rate,100% of CMS IPPS Rate,13962.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15707.1,100,,,Case Rate,100% of CMS IPPS Rate,15707.1,100,,,Case Rate,100% of CMS IPPS Rate,15707.1,100,,,Case Rate,100% CMS IPPS Rate,11219.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5653.11,100,,4522.488,Case Rate,100% of CMS IPPS Rate,5653.11,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5653.11,100,MS-DRG,4522.488,Case Rate,100% of CMS IPPS Rate,5653.11,100,MS-DRG,4522.488,Case Rate,100% of CMS IPPS Rate,6102.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,8076.07,130,MS-DRG,6460.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6398.73,103,MS-DRG,5118.984,Case Rate,103% of CMS IPPS Rate,6398.73,103,MS-DRG,5118.984,Case Rate,103% of CMS IPPS Rate,11247.12,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,6580.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9318.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,12707.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6212.36,100,MS-DRG,4969.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5653.11,15707.1,
ALLERGIC REACTIONS WITH MCC,915,CDM,,,,,Inpatient,,,,,,24289.61,,,,Case Rate,100% of CMS IPPS Rate,17604.99,145,MS-DRG,14083.992,Case Rate,145% of CMS IPPS Rate,12141.37,100,MS-DRG,9713.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12141.37,100,,9713.096,Case Rate,100% of CMS IPPS Rate,23167.94,100,,,Case Rate,100% of CMS IPPS Rate,26478.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29787.61,100,,,Case Rate,100% of CMS IPPS Rate,29787.61,100,,,Case Rate,100% of CMS IPPS Rate,29787.61,100,,,Case Rate,100% CMS IPPS Rate,21926.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11048.13,100,,8838.504,Case Rate,100% of CMS IPPS Rate,11048.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11048.13,100,MS-DRG,8838.504,Case Rate,100% of CMS IPPS Rate,11048.13,100,MS-DRG,8838.504,Case Rate,100% of CMS IPPS Rate,10287.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12141.37,100,MS-DRG,9713.096,Case Rate,100% of CMS IPPS Rate,15783.78,130,MS-DRG,12627.024,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12505.61,103,MS-DRG,10004.488,Case Rate,103% of CMS IPPS Rate,12505.61,103,MS-DRG,10004.488,Case Rate,103% of CMS IPPS Rate,23024.27,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12141.37,100,MS-DRG,9713.096,Case Rate,100% of CMS IPPS Rate,12861.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18212.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12141.37,100,MS-DRG,9713.096,Case Rate,100% of CMS IPPS Rate,24836,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12141.37,100,MS-DRG,9713.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29787.61,
ALLERGIC REACTIONS WITHOUT MCC,916,CDM,,,,,Inpatient,,,,,,9020.29,,,,Case Rate,100% of CMS IPPS Rate,6537.86,145,MS-DRG,5230.288,Case Rate,145% of CMS IPPS Rate,4508.87,100,MS-DRG,3607.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4508.87,100,,3607.096,Case Rate,100% of CMS IPPS Rate,8853.12,100,,,Case Rate,100% of CMS IPPS Rate,10118.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11382.67,100,,,Case Rate,100% of CMS IPPS Rate,11382.67,100,,,Case Rate,100% of CMS IPPS Rate,11382.67,100,,,Case Rate,100% CMS IPPS Rate,8142.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4103.04,100,,3282.432,Case Rate,100% of CMS IPPS Rate,4103.04,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4103.04,100,MS-DRG,3282.432,Case Rate,100% of CMS IPPS Rate,4103.04,100,MS-DRG,3282.432,Case Rate,100% of CMS IPPS Rate,3478.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4508.87,100,MS-DRG,3607.096,Case Rate,100% of CMS IPPS Rate,5861.53,130,MS-DRG,4689.224,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4644.14,103,MS-DRG,3715.312,Case Rate,103% of CMS IPPS Rate,4644.14,103,MS-DRG,3715.312,Case Rate,103% of CMS IPPS Rate,8402.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4508.87,100,MS-DRG,3607.096,Case Rate,100% of CMS IPPS Rate,4776.3,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6763.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4508.87,100,MS-DRG,3607.096,Case Rate,100% of CMS IPPS Rate,9223.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4508.87,100,MS-DRG,3607.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3478.79,11382.67,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,CDM,,,,,Inpatient,,,,,,21851.06,,,,Case Rate,100% of CMS IPPS Rate,15837.54,145,MS-DRG,12670.032,Case Rate,145% of CMS IPPS Rate,10922.44,100,MS-DRG,8737.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10922.44,100,,8737.952,Case Rate,100% of CMS IPPS Rate,21858.84,100,,,Case Rate,100% of CMS IPPS Rate,24982.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28104.46,100,,,Case Rate,100% of CMS IPPS Rate,28104.46,100,,,Case Rate,100% of CMS IPPS Rate,28104.46,100,,,Case Rate,100% CMS IPPS Rate,19725.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9938.99,100,,7951.192,Case Rate,100% of CMS IPPS Rate,9938.99,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9938.99,100,MS-DRG,7951.192,Case Rate,100% of CMS IPPS Rate,9938.99,100,MS-DRG,7951.192,Case Rate,100% of CMS IPPS Rate,9952.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10922.44,100,MS-DRG,8737.952,Case Rate,100% of CMS IPPS Rate,14199.17,130,MS-DRG,11359.336,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11250.11,103,MS-DRG,9000.088,Case Rate,103% of CMS IPPS Rate,11250.11,103,MS-DRG,9000.088,Case Rate,103% of CMS IPPS Rate,19259.63,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10922.44,100,MS-DRG,8737.952,Case Rate,100% of CMS IPPS Rate,11570.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16383.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10922.44,100,MS-DRG,8737.952,Case Rate,100% of CMS IPPS Rate,22342.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10922.44,100,MS-DRG,8737.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28104.46,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,CDM,,,,,Inpatient,,,,,,11787.44,,,,Case Rate,100% of CMS IPPS Rate,8543.49,145,MS-DRG,6834.792,Case Rate,145% of CMS IPPS Rate,5892.06,100,MS-DRG,4713.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5892.06,100,,4713.648,Case Rate,100% of CMS IPPS Rate,11792.6,100,,,Case Rate,100% of CMS IPPS Rate,13477.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15162.04,100,,,Case Rate,100% of CMS IPPS Rate,15162.04,100,,,Case Rate,100% of CMS IPPS Rate,15162.04,100,,,Case Rate,100% CMS IPPS Rate,10640.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5361.65,100,,4289.32,Case Rate,100% of CMS IPPS Rate,5361.65,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5361.65,100,MS-DRG,4289.32,Case Rate,100% of CMS IPPS Rate,5361.65,100,MS-DRG,4289.32,Case Rate,100% of CMS IPPS Rate,4867.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5892.06,100,MS-DRG,4713.648,Case Rate,100% of CMS IPPS Rate,7659.68,130,MS-DRG,6127.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6068.82,103,MS-DRG,4855.056,Case Rate,103% of CMS IPPS Rate,6068.82,103,MS-DRG,4855.056,Case Rate,103% of CMS IPPS Rate,10343.91,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5892.06,100,MS-DRG,4713.648,Case Rate,100% of CMS IPPS Rate,6241.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8838.09,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5892.06,100,MS-DRG,4713.648,Case Rate,100% of CMS IPPS Rate,12052.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5892.06,100,MS-DRG,4713.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4867.54,15162.04,
COMPLICATIONS OF TREATMENT WITH MCC,919,CDM,,,,,Inpatient,,,,,,24983.79,,,,Case Rate,100% of CMS IPPS Rate,18108.12,145,MS-DRG,14486.496,Case Rate,145% of CMS IPPS Rate,12488.36,100,MS-DRG,9990.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12488.36,100,,9990.688,Case Rate,100% of CMS IPPS Rate,24310.41,100,,,Case Rate,100% of CMS IPPS Rate,27784.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,31256.5,100,,,Case Rate,100% of CMS IPPS Rate,31256.5,100,,,Case Rate,100% of CMS IPPS Rate,31256.5,100,,,Case Rate,100% CMS IPPS Rate,22553.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11363.88,100,,9091.104,Case Rate,100% of CMS IPPS Rate,11363.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11363.88,100,MS-DRG,9091.104,Case Rate,100% of CMS IPPS Rate,11363.88,100,MS-DRG,9091.104,Case Rate,100% of CMS IPPS Rate,12475.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12488.36,100,MS-DRG,9990.688,Case Rate,100% of CMS IPPS Rate,16234.87,130,MS-DRG,12987.896,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12863.01,103,MS-DRG,10290.408,Case Rate,103% of CMS IPPS Rate,12863.01,103,MS-DRG,10290.408,Case Rate,103% of CMS IPPS Rate,22689.04,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12488.36,100,MS-DRG,9990.688,Case Rate,100% of CMS IPPS Rate,13229.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,18732.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12488.36,100,MS-DRG,9990.688,Case Rate,100% of CMS IPPS Rate,25545.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12488.36,100,MS-DRG,9990.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,31256.5,
COMPLICATIONS OF TREATMENT WITH CC,920,CDM,,,,,Inpatient,,,,,,14154.79,,,,Case Rate,100% of CMS IPPS Rate,10259.33,145,MS-DRG,8207.464,Case Rate,145% of CMS IPPS Rate,7075.4,100,MS-DRG,5660.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7075.4,100,,5660.32,Case Rate,100% of CMS IPPS Rate,13542.96,100,,,Case Rate,100% of CMS IPPS Rate,15478.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17412.53,100,,,Case Rate,100% of CMS IPPS Rate,17412.53,100,,,Case Rate,100% of CMS IPPS Rate,17412.53,100,,,Case Rate,100% CMS IPPS Rate,12777.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6438.42,100,,5150.736,Case Rate,100% of CMS IPPS Rate,6438.42,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6438.42,100,MS-DRG,5150.736,Case Rate,100% of CMS IPPS Rate,6438.42,100,MS-DRG,5150.736,Case Rate,100% of CMS IPPS Rate,6711.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7075.4,100,MS-DRG,5660.32,Case Rate,100% of CMS IPPS Rate,9198.02,130,MS-DRG,7358.416,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7287.66,103,MS-DRG,5830.128,Case Rate,103% of CMS IPPS Rate,7287.66,103,MS-DRG,5830.128,Case Rate,103% of CMS IPPS Rate,12925.77,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7075.4,100,MS-DRG,5660.32,Case Rate,100% of CMS IPPS Rate,7495.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10613.1,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7075.4,100,MS-DRG,5660.32,Case Rate,100% of CMS IPPS Rate,14473.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7075.4,100,MS-DRG,5660.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,17412.53,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,CDM,,,,,Inpatient,,,,,,9554.28,,,,Case Rate,100% of CMS IPPS Rate,6924.88,145,MS-DRG,5539.904,Case Rate,145% of CMS IPPS Rate,4775.78,100,MS-DRG,3820.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4775.78,100,,3820.624,Case Rate,100% of CMS IPPS Rate,9167.73,100,,,Case Rate,100% of CMS IPPS Rate,10477.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11787.18,100,,,Case Rate,100% of CMS IPPS Rate,11787.18,100,,,Case Rate,100% of CMS IPPS Rate,11787.18,100,,,Case Rate,100% CMS IPPS Rate,8624.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4345.92,100,,3476.736,Case Rate,100% of CMS IPPS Rate,4345.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4345.92,100,MS-DRG,3476.736,Case Rate,100% of CMS IPPS Rate,4345.92,100,MS-DRG,3476.736,Case Rate,100% of CMS IPPS Rate,3957.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4775.78,100,MS-DRG,3820.624,Case Rate,100% of CMS IPPS Rate,6208.51,130,MS-DRG,4966.808,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4919.05,103,MS-DRG,3935.24,Case Rate,103% of CMS IPPS Rate,4919.05,103,MS-DRG,3935.24,Case Rate,103% of CMS IPPS Rate,9207.94,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4775.78,100,MS-DRG,3820.624,Case Rate,100% of CMS IPPS Rate,5059.05,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,7163.67,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4775.78,100,MS-DRG,3820.624,Case Rate,100% of CMS IPPS Rate,9769.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4775.78,100,MS-DRG,3820.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3957.92,11787.18,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,CDM,,,,,Inpatient,,,,,,23891.17,,,,Case Rate,100% of CMS IPPS Rate,17316.19,145,MS-DRG,13852.952,Case Rate,145% of CMS IPPS Rate,11942.2,100,MS-DRG,9553.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11942.2,100,,9553.76,Case Rate,100% of CMS IPPS Rate,22521.39,100,,,Case Rate,100% of CMS IPPS Rate,25739.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28956.32,100,,,Case Rate,100% of CMS IPPS Rate,28956.32,100,,,Case Rate,100% of CMS IPPS Rate,28956.32,100,,,Case Rate,100% CMS IPPS Rate,21566.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10866.91,100,,8693.528,Case Rate,100% of CMS IPPS Rate,10866.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10866.91,100,MS-DRG,8693.528,Case Rate,100% of CMS IPPS Rate,10866.91,100,MS-DRG,8693.528,Case Rate,100% of CMS IPPS Rate,18734.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11942.2,100,MS-DRG,9553.76,Case Rate,100% of CMS IPPS Rate,15524.86,130,MS-DRG,12419.888,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12300.47,103,MS-DRG,9840.376,Case Rate,103% of CMS IPPS Rate,12300.47,103,MS-DRG,9840.376,Case Rate,103% of CMS IPPS Rate,19680.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11942.2,100,MS-DRG,9553.76,Case Rate,100% of CMS IPPS Rate,12650.53,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17913.3,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11942.2,100,MS-DRG,9553.76,Case Rate,100% of CMS IPPS Rate,24428.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11942.2,100,MS-DRG,9553.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28956.32,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,CDM,,,,,Inpatient,,,,,,13848.09,,,,Case Rate,100% of CMS IPPS Rate,10037.02,145,MS-DRG,8029.616,Case Rate,145% of CMS IPPS Rate,6922.08,100,MS-DRG,5537.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6922.08,100,,5537.664,Case Rate,100% of CMS IPPS Rate,13596.29,100,,,Case Rate,100% of CMS IPPS Rate,15539.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17481.09,100,,,Case Rate,100% of CMS IPPS Rate,17481.09,100,,,Case Rate,100% of CMS IPPS Rate,17481.09,100,,,Case Rate,100% CMS IPPS Rate,12500.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6298.91,100,,5039.128,Case Rate,100% of CMS IPPS Rate,6298.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6298.91,100,MS-DRG,5039.128,Case Rate,100% of CMS IPPS Rate,6298.91,100,MS-DRG,5039.128,Case Rate,100% of CMS IPPS Rate,5032.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6922.08,100,MS-DRG,5537.664,Case Rate,100% of CMS IPPS Rate,8998.7,130,MS-DRG,7198.96,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7129.74,103,MS-DRG,5703.792,Case Rate,103% of CMS IPPS Rate,7129.74,103,MS-DRG,5703.792,Case Rate,103% of CMS IPPS Rate,11931.48,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6922.08,100,MS-DRG,5537.664,Case Rate,100% of CMS IPPS Rate,7332.65,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10383.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6922.08,100,MS-DRG,5537.664,Case Rate,100% of CMS IPPS Rate,14159.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6922.08,100,MS-DRG,5537.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5032.93,17481.09,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,CDM,,,,,Inpatient,,,,,,360903.32,,,,Case Rate,100% of CMS IPPS Rate,261580.93,145,MS-DRG,209264.744,Case Rate,145% of CMS IPPS Rate,180400.64,100,MS-DRG,144320.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,180400.64,100,,144320.512,Case Rate,100% of CMS IPPS Rate,268117.07,100,,,Case Rate,100% of CMS IPPS Rate,306431,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,344724.82,100,,,Case Rate,100% of CMS IPPS Rate,344724.82,100,,,Case Rate,100% of CMS IPPS Rate,344724.82,100,,,Case Rate,100% CMS IPPS Rate,325793.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,164153.62,100,,131322.896,Case Rate,100% of CMS IPPS Rate,164153.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,164153.62,100,MS-DRG,131322.896,Case Rate,100% of CMS IPPS Rate,164153.62,100,MS-DRG,131322.896,Case Rate,100% of CMS IPPS Rate,237201.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,180400.64,100,MS-DRG,144320.512,Case Rate,100% of CMS IPPS Rate,234520.83,130,MS-DRG,187616.664,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185812.66,103,MS-DRG,148650.128,Case Rate,103% of CMS IPPS Rate,185812.66,103,MS-DRG,148650.128,Case Rate,103% of CMS IPPS Rate,240124.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180400.64,100,MS-DRG,144320.512,Case Rate,100% of CMS IPPS Rate,191100.58,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,270600.96,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180400.64,100,MS-DRG,144320.512,Case Rate,100% of CMS IPPS Rate,369021.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180400.64,100,MS-DRG,144320.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,369021.8,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,CDM,,,,,Inpatient,,,,,,94744.53,,,,Case Rate,100% of CMS IPPS Rate,68670.38,145,MS-DRG,54936.304,Case Rate,145% of CMS IPPS Rate,47358.88,100,MS-DRG,37887.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47358.88,100,,37887.104,Case Rate,100% of CMS IPPS Rate,89036.42,100,,,Case Rate,100% of CMS IPPS Rate,101759.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,114476.35,100,,,Case Rate,100% of CMS IPPS Rate,114476.35,100,,,Case Rate,100% of CMS IPPS Rate,114476.35,100,,,Case Rate,100% CMS IPPS Rate,85527.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,43093.88,100,,34475.104,Case Rate,100% of CMS IPPS Rate,43093.88,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,43093.88,100,MS-DRG,34475.104,Case Rate,100% of CMS IPPS Rate,43093.88,100,MS-DRG,34475.104,Case Rate,100% of CMS IPPS Rate,38422.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47358.88,100,MS-DRG,37887.104,Case Rate,100% of CMS IPPS Rate,61566.54,130,MS-DRG,49253.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48779.65,103,MS-DRG,39023.72,Case Rate,103% of CMS IPPS Rate,48779.65,103,MS-DRG,39023.72,Case Rate,103% of CMS IPPS Rate,78319.95,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47358.88,100,MS-DRG,37887.104,Case Rate,100% of CMS IPPS Rate,50167.83,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,71038.32,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47358.88,100,MS-DRG,37887.104,Case Rate,100% of CMS IPPS Rate,96875.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47358.88,100,MS-DRG,37887.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,114476.35,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,CDM,,,,,Inpatient,,,,,,44026.63,,,,Case Rate,100% of CMS IPPS Rate,31910.28,145,MS-DRG,25528.224,Case Rate,145% of CMS IPPS Rate,22007.09,100,MS-DRG,17605.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22007.09,100,,17605.672,Case Rate,100% of CMS IPPS Rate,42397.91,100,,,Case Rate,100% of CMS IPPS Rate,48456.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54512.06,100,,,Case Rate,100% of CMS IPPS Rate,54512.06,100,,,Case Rate,100% of CMS IPPS Rate,54512.06,100,,,Case Rate,100% CMS IPPS Rate,39743.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20025.33,100,,16020.264,Case Rate,100% of CMS IPPS Rate,20025.33,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20025.33,100,MS-DRG,16020.264,Case Rate,100% of CMS IPPS Rate,20025.33,100,MS-DRG,16020.264,Case Rate,100% of CMS IPPS Rate,17704.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22007.09,100,MS-DRG,17605.672,Case Rate,100% of CMS IPPS Rate,28609.22,130,MS-DRG,22887.376,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22667.3,103,MS-DRG,18133.84,Case Rate,103% of CMS IPPS Rate,22667.3,103,MS-DRG,18133.84,Case Rate,103% of CMS IPPS Rate,37175.82,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22007.09,100,MS-DRG,17605.672,Case Rate,100% of CMS IPPS Rate,23312.38,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33010.64,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22007.09,100,MS-DRG,17605.672,Case Rate,100% of CMS IPPS Rate,45017,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22007.09,100,MS-DRG,17605.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54512.06,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,CDM,,,,,Inpatient,,,,,,41514.14,,,,Case Rate,100% of CMS IPPS Rate,30089.25,145,MS-DRG,24071.4,Case Rate,145% of CMS IPPS Rate,20751.21,100,MS-DRG,16600.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20751.21,100,,16600.968,Case Rate,100% of CMS IPPS Rate,57681.9,100,,,Case Rate,100% of CMS IPPS Rate,65924.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,74163.07,100,,,Case Rate,100% of CMS IPPS Rate,74163.07,100,,,Case Rate,100% of CMS IPPS Rate,74163.07,100,,,Case Rate,100% CMS IPPS Rate,37475.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18882.55,100,,15106.04,Case Rate,100% of CMS IPPS Rate,18882.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18882.55,100,MS-DRG,15106.04,Case Rate,100% of CMS IPPS Rate,18882.55,100,MS-DRG,15106.04,Case Rate,100% of CMS IPPS Rate,27284.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20751.21,100,MS-DRG,16600.968,Case Rate,100% of CMS IPPS Rate,26976.57,130,MS-DRG,21581.256,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21373.75,103,MS-DRG,17099,Case Rate,103% of CMS IPPS Rate,21373.75,103,MS-DRG,17099,Case Rate,103% of CMS IPPS Rate,38367.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20751.21,100,MS-DRG,16600.968,Case Rate,100% of CMS IPPS Rate,21982,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,31126.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20751.21,100,MS-DRG,16600.968,Case Rate,100% of CMS IPPS Rate,42448,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20751.21,100,MS-DRG,16600.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,74163.07,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,CDM,,,,,Inpatient,,,,,,28650.51,,,,Case Rate,100% of CMS IPPS Rate,20765.75,145,MS-DRG,16612.6,Case Rate,145% of CMS IPPS Rate,14321.21,100,MS-DRG,11456.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14321.21,100,,11456.968,Case Rate,100% of CMS IPPS Rate,28605.66,100,,,Case Rate,100% of CMS IPPS Rate,32693.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36779.01,100,,,Case Rate,100% of CMS IPPS Rate,36779.01,100,,,Case Rate,100% of CMS IPPS Rate,36779.01,100,,,Case Rate,100% CMS IPPS Rate,25863.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13031.66,100,,10425.328,Case Rate,100% of CMS IPPS Rate,13031.66,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13031.66,100,MS-DRG,10425.328,Case Rate,100% of CMS IPPS Rate,13031.66,100,MS-DRG,10425.328,Case Rate,100% of CMS IPPS Rate,5255.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14321.21,100,MS-DRG,11456.968,Case Rate,100% of CMS IPPS Rate,18617.57,130,MS-DRG,14894.056,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14750.85,103,MS-DRG,11800.68,Case Rate,103% of CMS IPPS Rate,14750.85,103,MS-DRG,11800.68,Case Rate,103% of CMS IPPS Rate,23731.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14321.21,100,MS-DRG,11456.968,Case Rate,100% of CMS IPPS Rate,15170.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,21481.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14321.21,100,MS-DRG,11456.968,Case Rate,100% of CMS IPPS Rate,29295,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14321.21,100,MS-DRG,11456.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5255.88,36779.01,
NON-EXTENSIVE BURNS,935,CDM,,,,,Inpatient,,,,,,27946.74,,,,Case Rate,100% of CMS IPPS Rate,20255.66,145,MS-DRG,16204.528,Case Rate,145% of CMS IPPS Rate,13969.42,100,MS-DRG,11175.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13969.42,100,,11175.536,Case Rate,100% of CMS IPPS Rate,29280.21,100,,,Case Rate,100% of CMS IPPS Rate,33464.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37646.3,100,,,Case Rate,100% of CMS IPPS Rate,37646.3,100,,,Case Rate,100% of CMS IPPS Rate,37646.3,100,,,Case Rate,100% CMS IPPS Rate,25228,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12711.56,100,,10169.248,Case Rate,100% of CMS IPPS Rate,12711.56,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,12711.56,100,MS-DRG,10169.248,Case Rate,100% of CMS IPPS Rate,12711.56,100,MS-DRG,10169.248,Case Rate,100% of CMS IPPS Rate,13114.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13969.42,100,MS-DRG,11175.536,Case Rate,100% of CMS IPPS Rate,18160.25,130,MS-DRG,14528.2,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14388.5,103,MS-DRG,11510.8,Case Rate,103% of CMS IPPS Rate,14388.5,103,MS-DRG,11510.8,Case Rate,103% of CMS IPPS Rate,25604.87,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13969.42,100,MS-DRG,11175.536,Case Rate,100% of CMS IPPS Rate,14797.98,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,20954.13,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13969.42,100,MS-DRG,11175.536,Case Rate,100% of CMS IPPS Rate,28575.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13969.42,100,MS-DRG,11175.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,37646.3,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,CDM,,,,,Inpatient,,,,,,44023.89,,,,Case Rate,100% of CMS IPPS Rate,31908.29,145,MS-DRG,25526.632,Case Rate,145% of CMS IPPS Rate,22005.72,100,MS-DRG,17604.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22005.72,100,,17604.576,Case Rate,100% of CMS IPPS Rate,42312.59,100,,,Case Rate,100% of CMS IPPS Rate,48359.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,54402.36,100,,,Case Rate,100% of CMS IPPS Rate,54402.36,100,,,Case Rate,100% of CMS IPPS Rate,54402.36,100,,,Case Rate,100% CMS IPPS Rate,39741.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,20024.09,100,,16019.272,Case Rate,100% of CMS IPPS Rate,20024.09,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,20024.09,100,MS-DRG,16019.272,Case Rate,100% of CMS IPPS Rate,20024.09,100,MS-DRG,16019.272,Case Rate,100% of CMS IPPS Rate,28934.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22005.72,100,MS-DRG,17604.576,Case Rate,100% of CMS IPPS Rate,28607.44,130,MS-DRG,22885.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22665.89,103,MS-DRG,18132.712,Case Rate,103% of CMS IPPS Rate,22665.89,103,MS-DRG,18132.712,Case Rate,103% of CMS IPPS Rate,39178.32,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22005.72,100,MS-DRG,17604.576,Case Rate,100% of CMS IPPS Rate,23310.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,33008.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22005.72,100,MS-DRG,17604.576,Case Rate,100% of CMS IPPS Rate,45014.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22005.72,100,MS-DRG,17604.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,54402.36,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,CDM,,,,,Inpatient,,,,,,29665.09,,,,Case Rate,100% of CMS IPPS Rate,21501.11,145,MS-DRG,17200.888,Case Rate,145% of CMS IPPS Rate,14828.35,100,MS-DRG,11862.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14828.35,100,,11862.68,Case Rate,100% of CMS IPPS Rate,28147.07,100,,,Case Rate,100% of CMS IPPS Rate,32169.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,36189.4,100,,,Case Rate,100% of CMS IPPS Rate,36189.4,100,,,Case Rate,100% of CMS IPPS Rate,36189.4,100,,,Case Rate,100% CMS IPPS Rate,26779.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13493.13,100,,10794.504,Case Rate,100% of CMS IPPS Rate,13493.13,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,13493.13,100,MS-DRG,10794.504,Case Rate,100% of CMS IPPS Rate,13493.13,100,MS-DRG,10794.504,Case Rate,100% of CMS IPPS Rate,23107.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,14828.35,100,MS-DRG,11862.68,Case Rate,100% of CMS IPPS Rate,19276.86,130,MS-DRG,15421.488,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15273.2,103,MS-DRG,12218.56,Case Rate,103% of CMS IPPS Rate,15273.2,103,MS-DRG,12218.56,Case Rate,103% of CMS IPPS Rate,27871.75,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14828.35,100,MS-DRG,11862.68,Case Rate,100% of CMS IPPS Rate,15707.85,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,22242.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14828.35,100,MS-DRG,11862.68,Case Rate,100% of CMS IPPS Rate,30332.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14828.35,100,MS-DRG,11862.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,36189.4,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,CDM,,,,,Inpatient,,,,,,25412.35,,,,Case Rate,100% of CMS IPPS Rate,18418.76,145,MS-DRG,14735.008,Case Rate,145% of CMS IPPS Rate,12702.59,100,MS-DRG,10162.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12702.59,100,,10162.072,Case Rate,100% of CMS IPPS Rate,26052.77,100,,,Case Rate,100% of CMS IPPS Rate,29775.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,33496.7,100,,,Case Rate,100% of CMS IPPS Rate,33496.7,100,,,Case Rate,100% of CMS IPPS Rate,33496.7,100,,,Case Rate,100% CMS IPPS Rate,22940.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11558.81,100,,9247.048,Case Rate,100% of CMS IPPS Rate,11558.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,11558.81,100,MS-DRG,9247.048,Case Rate,100% of CMS IPPS Rate,11558.81,100,MS-DRG,9247.048,Case Rate,100% of CMS IPPS Rate,19440.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,12702.59,100,MS-DRG,10162.072,Case Rate,100% of CMS IPPS Rate,16513.37,130,MS-DRG,13210.696,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13083.67,103,MS-DRG,10466.936,Case Rate,103% of CMS IPPS Rate,13083.67,103,MS-DRG,10466.936,Case Rate,103% of CMS IPPS Rate,23875.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12702.59,100,MS-DRG,10162.072,Case Rate,100% of CMS IPPS Rate,13456,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,19053.89,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12702.59,100,MS-DRG,10162.072,Case Rate,100% of CMS IPPS Rate,25984,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12702.59,100,MS-DRG,10162.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,33496.7,
REHABILITATION WITH CC/MCC,945,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,14980.12,145,MS-DRG,11984.096,Case Rate,145% of CMS IPPS Rate,10331.12,100,MS-DRG,8264.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10331.12,100,,8264.896,Case Rate,100% of CMS IPPS Rate,20349.77,100,,,Case Rate,100% of CMS IPPS Rate,23257.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26164.21,100,,,Case Rate,100% of CMS IPPS Rate,26164.21,100,,,Case Rate,100% of CMS IPPS Rate,26164.21,100,,,Case Rate,100% CMS IPPS Rate,18657.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9400.92,100,,7520.736,Case Rate,100% of CMS IPPS Rate,9400.92,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9400.92,100,MS-DRG,7520.736,Case Rate,100% of CMS IPPS Rate,9400.92,100,MS-DRG,7520.736,Case Rate,100% of CMS IPPS Rate,13583.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10331.12,100,MS-DRG,8264.896,Case Rate,100% of CMS IPPS Rate,13430.46,130,MS-DRG,10744.368,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10641.05,103,MS-DRG,8512.84,Case Rate,103% of CMS IPPS Rate,10641.05,103,MS-DRG,8512.84,Case Rate,103% of CMS IPPS Rate,19040.78,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.12,100,MS-DRG,8264.896,Case Rate,100% of CMS IPPS Rate,10943.88,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15496.68,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.12,100,MS-DRG,8264.896,Case Rate,100% of CMS IPPS Rate,21133,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10331.12,100,MS-DRG,8264.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,26164.21,
REHABILITATION WITHOUT CC/MCC,946,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,10049.94,145,MS-DRG,8039.952,Case Rate,145% of CMS IPPS Rate,6930.99,100,MS-DRG,5544.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6930.99,100,,5544.792,Case Rate,100% of CMS IPPS Rate,14884.06,100,,,Case Rate,100% of CMS IPPS Rate,17010.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19136.81,100,,,Case Rate,100% of CMS IPPS Rate,19136.81,100,,,Case Rate,100% of CMS IPPS Rate,19136.81,100,,,Case Rate,100% CMS IPPS Rate,12516.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6307.03,100,,5045.624,Case Rate,100% of CMS IPPS Rate,6307.03,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6307.03,100,MS-DRG,5045.624,Case Rate,100% of CMS IPPS Rate,6307.03,100,MS-DRG,5045.624,Case Rate,100% of CMS IPPS Rate,9113.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6930.99,100,MS-DRG,5544.792,Case Rate,100% of CMS IPPS Rate,9010.29,130,MS-DRG,7208.232,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7138.92,103,MS-DRG,5711.136,Case Rate,103% of CMS IPPS Rate,7138.92,103,MS-DRG,5711.136,Case Rate,103% of CMS IPPS Rate,14200.89,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6930.99,100,MS-DRG,5544.792,Case Rate,100% of CMS IPPS Rate,7342.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,10396.49,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6930.99,100,MS-DRG,5544.792,Case Rate,100% of CMS IPPS Rate,14177.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6930.99,100,MS-DRG,5544.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19136.81,
SIGNS AND SYMPTOMS WITH MCC,947,CDM,,,,,Inpatient,,,,,,17136.91,,,,Case Rate,100% of CMS IPPS Rate,12420.76,145,MS-DRG,9936.608,Case Rate,145% of CMS IPPS Rate,8566.04,100,MS-DRG,6852.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8566.04,100,,6852.832,Case Rate,100% of CMS IPPS Rate,17146.33,100,,,Case Rate,100% of CMS IPPS Rate,19596.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,22045.47,100,,,Case Rate,100% of CMS IPPS Rate,22045.47,100,,,Case Rate,100% of CMS IPPS Rate,22045.47,100,,,Case Rate,100% CMS IPPS Rate,15469.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7794.81,100,,6235.848,Case Rate,100% of CMS IPPS Rate,7794.81,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,7794.81,100,MS-DRG,6235.848,Case Rate,100% of CMS IPPS Rate,7794.81,100,MS-DRG,6235.848,Case Rate,100% of CMS IPPS Rate,13688.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8566.04,100,MS-DRG,6852.832,Case Rate,100% of CMS IPPS Rate,11135.85,130,MS-DRG,8908.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8823.02,103,MS-DRG,7058.416,Case Rate,103% of CMS IPPS Rate,8823.02,103,MS-DRG,7058.416,Case Rate,103% of CMS IPPS Rate,15377.34,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8566.04,100,MS-DRG,6852.832,Case Rate,100% of CMS IPPS Rate,9074.1,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,12849.06,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8566.04,100,MS-DRG,6852.832,Case Rate,100% of CMS IPPS Rate,17522.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8566.04,100,MS-DRG,6852.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,22045.47,
SIGNS AND SYMPTOMS WITHOUT MCC,948,CDM,,,,,Inpatient,,,,,,10967.29,,,,Case Rate,100% of CMS IPPS Rate,7949.05,145,MS-DRG,6359.24,Case Rate,145% of CMS IPPS Rate,5482.1,100,MS-DRG,4385.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5482.1,100,,4385.68,Case Rate,100% of CMS IPPS Rate,10591.48,100,,,Case Rate,100% of CMS IPPS Rate,12105,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,13617.73,100,,,Case Rate,100% of CMS IPPS Rate,13617.73,100,,,Case Rate,100% of CMS IPPS Rate,13617.73,100,,,Case Rate,100% CMS IPPS Rate,9900.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4988.62,100,,3990.896,Case Rate,100% of CMS IPPS Rate,4988.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,4988.62,100,MS-DRG,3990.896,Case Rate,100% of CMS IPPS Rate,4988.62,100,MS-DRG,3990.896,Case Rate,100% of CMS IPPS Rate,7599.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5482.1,100,MS-DRG,4385.68,Case Rate,100% of CMS IPPS Rate,7126.73,130,MS-DRG,5701.384,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5646.56,103,MS-DRG,4517.248,Case Rate,103% of CMS IPPS Rate,5646.56,103,MS-DRG,4517.248,Case Rate,103% of CMS IPPS Rate,9836.64,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5482.1,100,MS-DRG,4385.68,Case Rate,100% of CMS IPPS Rate,5807.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8223.15,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5482.1,100,MS-DRG,4385.68,Case Rate,100% of CMS IPPS Rate,11214,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5482.1,100,MS-DRG,4385.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4988.62,13617.73,
AFTERCARE WITH CC/MCC,949,CDM,,,,,Inpatient,,,,,,14186.28,,,,Case Rate,100% of CMS IPPS Rate,10646.35,145,MS-DRG,8517.08,Case Rate,145% of CMS IPPS Rate,7342.31,100,MS-DRG,5873.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7342.31,100,,5873.848,Case Rate,100% of CMS IPPS Rate,14384.15,100,,,Case Rate,100% of CMS IPPS Rate,16439.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18494.06,100,,,Case Rate,100% of CMS IPPS Rate,18494.06,100,,,Case Rate,100% of CMS IPPS Rate,18494.06,100,,,Case Rate,100% CMS IPPS Rate,12806.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6681.3,100,,5345.04,Case Rate,100% of CMS IPPS Rate,6681.3,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6681.3,100,MS-DRG,5345.04,Case Rate,100% of CMS IPPS Rate,6681.3,100,MS-DRG,5345.04,Case Rate,100% of CMS IPPS Rate,13954.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7342.31,100,MS-DRG,5873.848,Case Rate,100% of CMS IPPS Rate,9545,130,MS-DRG,7636,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7562.58,103,MS-DRG,6050.064,Case Rate,103% of CMS IPPS Rate,7562.58,103,MS-DRG,6050.064,Case Rate,103% of CMS IPPS Rate,15078.8,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7342.31,100,MS-DRG,5873.848,Case Rate,100% of CMS IPPS Rate,7511.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11013.47,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7342.31,100,MS-DRG,5873.848,Case Rate,100% of CMS IPPS Rate,14505.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7342.31,100,MS-DRG,5873.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,18494.06,
AFTERCARE WITHOUT CC/MCC,950,CDM,,,,,Inpatient,,,,,,8601.31,,,,Case Rate,100% of CMS IPPS Rate,6337.4,145,MS-DRG,5069.92,Case Rate,145% of CMS IPPS Rate,4370.62,100,MS-DRG,3496.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4370.62,100,,3496.496,Case Rate,100% of CMS IPPS Rate,7813.3,100,,,Case Rate,100% of CMS IPPS Rate,8929.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10045.75,100,,,Case Rate,100% of CMS IPPS Rate,10045.75,100,,,Case Rate,100% of CMS IPPS Rate,10045.75,100,,,Case Rate,100% CMS IPPS Rate,7764.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3977.24,100,,3181.792,Case Rate,100% of CMS IPPS Rate,3977.24,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3977.24,100,MS-DRG,3181.792,Case Rate,100% of CMS IPPS Rate,3977.24,100,MS-DRG,3181.792,Case Rate,100% of CMS IPPS Rate,10961.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4370.62,100,MS-DRG,3496.496,Case Rate,100% of CMS IPPS Rate,5681.81,130,MS-DRG,4545.448,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4501.74,103,MS-DRG,3601.392,Case Rate,103% of CMS IPPS Rate,4501.74,103,MS-DRG,3601.392,Case Rate,103% of CMS IPPS Rate,8975.18,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4370.62,100,MS-DRG,3496.496,Case Rate,100% of CMS IPPS Rate,4554.45,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6555.93,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4370.62,100,MS-DRG,3496.496,Case Rate,100% of CMS IPPS Rate,8794.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4370.62,100,MS-DRG,3496.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3977.24,10961.7,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,CDM,,,,,Inpatient,,,,,,8078.28,,,,Case Rate,100% of CMS IPPS Rate,5855.1,145,MS-DRG,4684.08,Case Rate,145% of CMS IPPS Rate,4038,100,MS-DRG,3230.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4038,100,,3230.4,Case Rate,100% of CMS IPPS Rate,7558.68,100,,,Case Rate,100% of CMS IPPS Rate,8638.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9718.38,100,,,Case Rate,100% of CMS IPPS Rate,9718.38,100,,,Case Rate,100% of CMS IPPS Rate,9718.38,100,,,Case Rate,100% CMS IPPS Rate,7292.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3674.57,100,,2939.656,Case Rate,100% of CMS IPPS Rate,3674.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,3674.57,100,MS-DRG,2939.656,Case Rate,100% of CMS IPPS Rate,3674.57,100,MS-DRG,2939.656,Case Rate,100% of CMS IPPS Rate,3159.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,4038,100,MS-DRG,3230.4,Case Rate,100% of CMS IPPS Rate,5249.4,130,MS-DRG,4199.52,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4159.14,103,MS-DRG,3327.312,Case Rate,103% of CMS IPPS Rate,4159.14,103,MS-DRG,3327.312,Case Rate,103% of CMS IPPS Rate,7200.38,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4038,100,MS-DRG,3230.4,Case Rate,100% of CMS IPPS Rate,4277.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,6057,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4038,100,MS-DRG,3230.4,Case Rate,100% of CMS IPPS Rate,8260,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4038,100,MS-DRG,3230.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,3159.36,9718.38,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,CDM,,,,,Inpatient,,,,,,83387.02,,,,Case Rate,100% of CMS IPPS Rate,60438.49,145,MS-DRG,48350.792,Case Rate,145% of CMS IPPS Rate,41681.72,100,MS-DRG,33345.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41681.72,100,,33345.376,Case Rate,100% of CMS IPPS Rate,91028.07,100,,,Case Rate,100% of CMS IPPS Rate,104035.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,117037.06,100,,,Case Rate,100% of CMS IPPS Rate,117037.06,100,,,Case Rate,100% of CMS IPPS Rate,117037.06,100,,,Case Rate,100% CMS IPPS Rate,75274.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,37928.02,100,,30342.416,Case Rate,100% of CMS IPPS Rate,37928.02,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,37928.02,100,MS-DRG,30342.416,Case Rate,100% of CMS IPPS Rate,37928.02,100,MS-DRG,30342.416,Case Rate,100% of CMS IPPS Rate,101974.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41681.72,100,MS-DRG,33345.376,Case Rate,100% of CMS IPPS Rate,54186.24,130,MS-DRG,43348.992,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42932.17,103,MS-DRG,34345.736,Case Rate,103% of CMS IPPS Rate,42932.17,103,MS-DRG,34345.736,Case Rate,103% of CMS IPPS Rate,85210.4,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41681.72,100,MS-DRG,33345.376,Case Rate,100% of CMS IPPS Rate,44153.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,62522.58,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41681.72,100,MS-DRG,33345.376,Case Rate,100% of CMS IPPS Rate,85262.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41681.72,100,MS-DRG,33345.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,117037.06,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,CDM,,,,,Inpatient,,,,,,53100.31,,,,Case Rate,100% of CMS IPPS Rate,38486.84,145,MS-DRG,30789.472,Case Rate,145% of CMS IPPS Rate,26542.65,100,MS-DRG,21234.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26542.65,100,,21234.12,Case Rate,100% of CMS IPPS Rate,50956.41,100,,,Case Rate,100% of CMS IPPS Rate,58238.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,65515.94,100,,,Case Rate,100% of CMS IPPS Rate,65515.94,100,,,Case Rate,100% of CMS IPPS Rate,65515.94,100,,,Case Rate,100% CMS IPPS Rate,47934.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24152.41,100,,19321.928,Case Rate,100% of CMS IPPS Rate,24152.41,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,24152.41,100,MS-DRG,19321.928,Case Rate,100% of CMS IPPS Rate,24152.41,100,MS-DRG,19321.928,Case Rate,100% of CMS IPPS Rate,70790.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,26542.65,100,MS-DRG,21234.12,Case Rate,100% of CMS IPPS Rate,34505.45,130,MS-DRG,27604.36,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27338.93,103,MS-DRG,21871.144,Case Rate,103% of CMS IPPS Rate,27338.93,103,MS-DRG,21871.144,Case Rate,103% of CMS IPPS Rate,48123.13,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26542.65,100,MS-DRG,21234.12,Case Rate,100% of CMS IPPS Rate,28116.95,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,39813.98,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26542.65,100,MS-DRG,21234.12,Case Rate,100% of CMS IPPS Rate,54294.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26542.65,100,MS-DRG,21234.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,70790.19,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,CDM,,,,,Inpatient,,,,,,99027.39,,,,Case Rate,100% of CMS IPPS Rate,71774.55,145,MS-DRG,57419.64,Case Rate,145% of CMS IPPS Rate,49499.69,100,MS-DRG,39599.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49499.69,100,,39599.752,Case Rate,100% of CMS IPPS Rate,99505.25,100,,,Case Rate,100% of CMS IPPS Rate,113724.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,127936.39,100,,,Case Rate,100% of CMS IPPS Rate,127936.39,100,,,Case Rate,100% of CMS IPPS Rate,127936.39,100,,,Case Rate,100% CMS IPPS Rate,89393.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45041.89,100,,36033.512,Case Rate,100% of CMS IPPS Rate,45041.89,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,45041.89,100,MS-DRG,36033.512,Case Rate,100% of CMS IPPS Rate,45041.89,100,MS-DRG,36033.512,Case Rate,100% of CMS IPPS Rate,69953.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,49499.69,100,MS-DRG,39599.752,Case Rate,100% of CMS IPPS Rate,64349.6,130,MS-DRG,51479.68,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50984.68,103,MS-DRG,40787.744,Case Rate,103% of CMS IPPS Rate,50984.68,103,MS-DRG,40787.744,Case Rate,103% of CMS IPPS Rate,93742.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49499.69,100,MS-DRG,39599.752,Case Rate,100% of CMS IPPS Rate,52435.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,74249.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49499.69,100,MS-DRG,39599.752,Case Rate,100% of CMS IPPS Rate,101255,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49499.69,100,MS-DRG,39599.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,127936.39,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,CDM,,,,,Inpatient,,,,,,55381.4,,,,Case Rate,100% of CMS IPPS Rate,40140.16,145,MS-DRG,32112.128,Case Rate,145% of CMS IPPS Rate,27682.87,100,MS-DRG,22146.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27682.87,100,,22146.296,Case Rate,100% of CMS IPPS Rate,54787.74,100,,,Case Rate,100% of CMS IPPS Rate,62616.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,70441.97,100,,,Case Rate,100% of CMS IPPS Rate,70441.97,100,,,Case Rate,100% of CMS IPPS Rate,70441.97,100,,,Case Rate,100% CMS IPPS Rate,49993.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25189.94,100,,20151.952,Case Rate,100% of CMS IPPS Rate,25189.94,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,25189.94,100,MS-DRG,20151.952,Case Rate,100% of CMS IPPS Rate,25189.94,100,MS-DRG,20151.952,Case Rate,100% of CMS IPPS Rate,37343.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,27682.87,100,MS-DRG,22146.296,Case Rate,100% of CMS IPPS Rate,35987.73,130,MS-DRG,28790.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28513.36,103,MS-DRG,22810.688,Case Rate,103% of CMS IPPS Rate,28513.36,103,MS-DRG,22810.688,Case Rate,103% of CMS IPPS Rate,52756.83,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27682.87,100,MS-DRG,22146.296,Case Rate,100% of CMS IPPS Rate,29324.8,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,41524.31,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27682.87,100,MS-DRG,22146.296,Case Rate,100% of CMS IPPS Rate,56627.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27682.87,100,MS-DRG,22146.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,70441.97,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,CDM,,,,,Inpatient,,,,,,34673.62,,,,Case Rate,100% of CMS IPPS Rate,25131.27,145,MS-DRG,20105.016,Case Rate,145% of CMS IPPS Rate,17331.91,100,MS-DRG,13865.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17331.91,100,,13865.528,Case Rate,100% of CMS IPPS Rate,35245.83,100,,,Case Rate,100% of CMS IPPS Rate,40282.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45316.45,100,,,Case Rate,100% of CMS IPPS Rate,45316.45,100,,,Case Rate,100% of CMS IPPS Rate,45316.45,100,,,Case Rate,100% CMS IPPS Rate,31300.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15771.22,100,,12616.976,Case Rate,100% of CMS IPPS Rate,15771.22,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15771.22,100,MS-DRG,12616.976,Case Rate,100% of CMS IPPS Rate,15771.22,100,MS-DRG,12616.976,Case Rate,100% of CMS IPPS Rate,28782.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17331.91,100,MS-DRG,13865.528,Case Rate,100% of CMS IPPS Rate,22531.48,130,MS-DRG,18025.184,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17851.87,103,MS-DRG,14281.496,Case Rate,103% of CMS IPPS Rate,17851.87,103,MS-DRG,14281.496,Case Rate,103% of CMS IPPS Rate,32494.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17331.91,100,MS-DRG,13865.528,Case Rate,100% of CMS IPPS Rate,18359.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25997.87,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17331.91,100,MS-DRG,13865.528,Case Rate,100% of CMS IPPS Rate,35453.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17331.91,100,MS-DRG,13865.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45316.45,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,CDM,,,,,Inpatient,,,,,,37438.04,,,,Case Rate,100% of CMS IPPS Rate,27134.91,145,MS-DRG,21707.928,Case Rate,145% of CMS IPPS Rate,18713.73,100,MS-DRG,14970.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18713.73,100,,14970.984,Case Rate,100% of CMS IPPS Rate,36216.33,100,,,Case Rate,100% of CMS IPPS Rate,41391.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,46564.24,100,,,Case Rate,100% of CMS IPPS Rate,46564.24,100,,,Case Rate,100% of CMS IPPS Rate,46564.24,100,,,Case Rate,100% CMS IPPS Rate,33795.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17028.57,100,,13622.856,Case Rate,100% of CMS IPPS Rate,17028.57,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17028.57,100,MS-DRG,13622.856,Case Rate,100% of CMS IPPS Rate,17028.57,100,MS-DRG,13622.856,Case Rate,100% of CMS IPPS Rate,20635.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18713.73,100,MS-DRG,14970.984,Case Rate,100% of CMS IPPS Rate,24327.85,130,MS-DRG,19462.28,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19275.14,103,MS-DRG,15420.112,Case Rate,103% of CMS IPPS Rate,19275.14,103,MS-DRG,15420.112,Case Rate,103% of CMS IPPS Rate,35080.98,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18713.73,100,MS-DRG,14970.984,Case Rate,100% of CMS IPPS Rate,19823.68,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28070.6,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18713.73,100,MS-DRG,14970.984,Case Rate,100% of CMS IPPS Rate,38280.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18713.73,100,MS-DRG,14970.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,46564.24,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,CDM,,,,,Inpatient,,,,,,20551.69,,,,Case Rate,100% of CMS IPPS Rate,14895.76,145,MS-DRG,11916.608,Case Rate,145% of CMS IPPS Rate,10272.94,100,MS-DRG,8218.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10272.94,100,,8218.352,Case Rate,100% of CMS IPPS Rate,19997.83,100,,,Case Rate,100% of CMS IPPS Rate,22855.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,25711.71,100,,,Case Rate,100% of CMS IPPS Rate,25711.71,100,,,Case Rate,100% of CMS IPPS Rate,25711.71,100,,,Case Rate,100% CMS IPPS Rate,18552.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9348,100,,7478.4,Case Rate,100% of CMS IPPS Rate,9348,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,9348,100,MS-DRG,7478.4,Case Rate,100% of CMS IPPS Rate,9348,100,MS-DRG,7478.4,Case Rate,100% of CMS IPPS Rate,15307.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10272.94,100,MS-DRG,8218.352,Case Rate,100% of CMS IPPS Rate,13354.82,130,MS-DRG,10683.856,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10581.13,103,MS-DRG,8464.904,Case Rate,103% of CMS IPPS Rate,10581.13,103,MS-DRG,8464.904,Case Rate,103% of CMS IPPS Rate,18525.93,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10272.94,100,MS-DRG,8218.352,Case Rate,100% of CMS IPPS Rate,10882.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,15409.41,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10272.94,100,MS-DRG,8218.352,Case Rate,100% of CMS IPPS Rate,21014,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10272.94,100,MS-DRG,8218.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,25711.71,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,CDM,,,,,Inpatient,,,,,,13088.18,,,,Case Rate,100% of CMS IPPS Rate,9486.26,145,MS-DRG,7589.008,Case Rate,145% of CMS IPPS Rate,6542.25,100,MS-DRG,5233.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6542.25,100,,5233.8,Case Rate,100% of CMS IPPS Rate,12165.87,100,,,Case Rate,100% of CMS IPPS Rate,13904.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15641.96,100,,,Case Rate,100% of CMS IPPS Rate,15641.96,100,,,Case Rate,100% of CMS IPPS Rate,15641.96,100,,,Case Rate,100% CMS IPPS Rate,11814.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5953.28,100,,4762.624,Case Rate,100% of CMS IPPS Rate,5953.28,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5953.28,100,MS-DRG,4762.624,Case Rate,100% of CMS IPPS Rate,5953.28,100,MS-DRG,4762.624,Case Rate,100% of CMS IPPS Rate,9936.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6542.25,100,MS-DRG,5233.8,Case Rate,100% of CMS IPPS Rate,8504.93,130,MS-DRG,6803.944,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6738.52,103,MS-DRG,5390.816,Case Rate,103% of CMS IPPS Rate,6738.52,103,MS-DRG,5390.816,Case Rate,103% of CMS IPPS Rate,11510.24,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6542.25,100,MS-DRG,5233.8,Case Rate,100% of CMS IPPS Rate,6930.28,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,9813.38,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6542.25,100,MS-DRG,5233.8,Case Rate,100% of CMS IPPS Rate,13382.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6542.25,100,MS-DRG,5233.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,15641.96,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,CDM,,,,,Inpatient,,,,,,94099.64,,,,Case Rate,100% of CMS IPPS Rate,68202.95,145,MS-DRG,54562.36,Case Rate,145% of CMS IPPS Rate,47036.52,100,MS-DRG,37629.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47036.52,100,,37629.216,Case Rate,100% of CMS IPPS Rate,84309.24,100,,,Case Rate,100% of CMS IPPS Rate,96357.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,108398.5,100,,,Case Rate,100% of CMS IPPS Rate,108398.5,100,,,Case Rate,100% of CMS IPPS Rate,108398.5,100,,,Case Rate,100% CMS IPPS Rate,84945.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,42800.55,100,,34240.44,Case Rate,100% of CMS IPPS Rate,42800.55,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,42800.55,100,MS-DRG,34240.44,Case Rate,100% of CMS IPPS Rate,42800.55,100,MS-DRG,34240.44,Case Rate,100% of CMS IPPS Rate,61846.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,47036.52,100,MS-DRG,37629.216,Case Rate,100% of CMS IPPS Rate,61147.48,130,MS-DRG,48917.984,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48447.62,103,MS-DRG,38758.096,Case Rate,103% of CMS IPPS Rate,48447.62,103,MS-DRG,38758.096,Case Rate,103% of CMS IPPS Rate,91682.14,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47036.52,100,MS-DRG,37629.216,Case Rate,100% of CMS IPPS Rate,49826.35,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,70554.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47036.52,100,MS-DRG,37629.216,Case Rate,100% of CMS IPPS Rate,96216.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47036.52,100,MS-DRG,37629.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,108398.5,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,CDM,,,,,Inpatient,,,,,,32921.04,,,,Case Rate,100% of CMS IPPS Rate,27584.47,145,MS-DRG,22067.576,Case Rate,145% of CMS IPPS Rate,19023.77,100,MS-DRG,15219.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19023.77,100,,15219.016,Case Rate,100% of CMS IPPS Rate,35371.14,100,,,Case Rate,100% of CMS IPPS Rate,40425.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,45477.56,100,,,Case Rate,100% of CMS IPPS Rate,45477.56,100,,,Case Rate,100% of CMS IPPS Rate,45477.56,100,,,Case Rate,100% CMS IPPS Rate,29718.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17310.69,100,,13848.552,Case Rate,100% of CMS IPPS Rate,17310.69,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,17310.69,100,MS-DRG,13848.552,Case Rate,100% of CMS IPPS Rate,17310.69,100,MS-DRG,13848.552,Case Rate,100% of CMS IPPS Rate,25013.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19023.77,100,MS-DRG,15219.016,Case Rate,100% of CMS IPPS Rate,24730.9,130,MS-DRG,19784.72,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19594.48,103,MS-DRG,15675.584,Case Rate,103% of CMS IPPS Rate,19594.48,103,MS-DRG,15675.584,Case Rate,103% of CMS IPPS Rate,39068.26,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19023.77,100,MS-DRG,15219.016,Case Rate,100% of CMS IPPS Rate,17431.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,28535.66,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19023.77,100,MS-DRG,15219.016,Case Rate,100% of CMS IPPS Rate,33661.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19023.77,100,MS-DRG,15219.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,45477.56,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,CDM,,,,,Inpatient,,,,,,39932.72,,,,Case Rate,100% of CMS IPPS Rate,28943.04,145,MS-DRG,23154.432,Case Rate,145% of CMS IPPS Rate,19960.72,100,MS-DRG,15968.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19960.72,100,,15968.576,Case Rate,100% of CMS IPPS Rate,39809.03,100,,,Case Rate,100% of CMS IPPS Rate,45497.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,51183.47,100,,,Case Rate,100% of CMS IPPS Rate,51183.47,100,,,Case Rate,100% of CMS IPPS Rate,51183.47,100,,,Case Rate,100% CMS IPPS Rate,36047.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,18163.26,100,,14530.608,Case Rate,100% of CMS IPPS Rate,18163.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,18163.26,100,MS-DRG,14530.608,Case Rate,100% of CMS IPPS Rate,18163.26,100,MS-DRG,14530.608,Case Rate,100% of CMS IPPS Rate,24521.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19960.72,100,MS-DRG,15968.576,Case Rate,100% of CMS IPPS Rate,25948.94,130,MS-DRG,20759.152,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20559.54,103,MS-DRG,16447.632,Case Rate,103% of CMS IPPS Rate,20559.54,103,MS-DRG,16447.632,Case Rate,103% of CMS IPPS Rate,36343.45,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19960.72,100,MS-DRG,15968.576,Case Rate,100% of CMS IPPS Rate,21144.63,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,29941.08,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19960.72,100,MS-DRG,15968.576,Case Rate,100% of CMS IPPS Rate,40831,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19960.72,100,MS-DRG,15968.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,51183.47,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,CDM,,,,,Inpatient,,,,,,18666.3,,,,Case Rate,100% of CMS IPPS Rate,13529.25,145,MS-DRG,10823.4,Case Rate,145% of CMS IPPS Rate,9330.52,100,MS-DRG,7464.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9330.52,100,,7464.416,Case Rate,100% of CMS IPPS Rate,18948.68,100,,,Case Rate,100% of CMS IPPS Rate,21656.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24362.8,100,,,Case Rate,100% of CMS IPPS Rate,24362.8,100,,,Case Rate,100% of CMS IPPS Rate,24362.8,100,,,Case Rate,100% CMS IPPS Rate,16850.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8490.43,100,,6792.344,Case Rate,100% of CMS IPPS Rate,8490.43,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8490.43,100,MS-DRG,6792.344,Case Rate,100% of CMS IPPS Rate,8490.43,100,MS-DRG,6792.344,Case Rate,100% of CMS IPPS Rate,11623.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9330.52,100,MS-DRG,7464.416,Case Rate,100% of CMS IPPS Rate,12129.68,130,MS-DRG,9703.744,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9610.44,103,MS-DRG,7688.352,Case Rate,103% of CMS IPPS Rate,9610.44,103,MS-DRG,7688.352,Case Rate,103% of CMS IPPS Rate,17402.61,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9330.52,100,MS-DRG,7464.416,Case Rate,100% of CMS IPPS Rate,9883.93,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,13995.78,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9330.52,100,MS-DRG,7464.416,Case Rate,100% of CMS IPPS Rate,19086.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9330.52,100,MS-DRG,7464.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24362.8,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,CDM,,,,,Inpatient,,,,,,11573.85,,,,Case Rate,100% of CMS IPPS Rate,8388.67,145,MS-DRG,6710.936,Case Rate,145% of CMS IPPS Rate,5785.29,100,MS-DRG,4628.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5785.29,100,,4628.232,Case Rate,100% of CMS IPPS Rate,13370.99,100,,,Case Rate,100% of CMS IPPS Rate,15281.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17191.42,100,,,Case Rate,100% of CMS IPPS Rate,17191.42,100,,,Case Rate,100% of CMS IPPS Rate,17191.42,100,,,Case Rate,100% CMS IPPS Rate,10447.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5264.51,100,,4211.608,Case Rate,100% of CMS IPPS Rate,5264.51,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,5264.51,100,MS-DRG,4211.608,Case Rate,100% of CMS IPPS Rate,5264.51,100,MS-DRG,4211.608,Case Rate,100% of CMS IPPS Rate,7606.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5785.29,100,MS-DRG,4628.232,Case Rate,100% of CMS IPPS Rate,7520.88,130,MS-DRG,6016.704,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5958.85,103,MS-DRG,4767.08,Case Rate,103% of CMS IPPS Rate,5958.85,103,MS-DRG,4767.08,Case Rate,103% of CMS IPPS Rate,11673.42,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5785.29,100,MS-DRG,4628.232,Case Rate,100% of CMS IPPS Rate,6128.43,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,8677.94,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5785.29,100,MS-DRG,4628.232,Case Rate,100% of CMS IPPS Rate,11834.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5785.29,100,MS-DRG,4628.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5264.51,17191.42,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,CDM,,,,,Inpatient,,,,,,19389.24,,,,Case Rate,100% of CMS IPPS Rate,14053.23,145,MS-DRG,11242.584,Case Rate,145% of CMS IPPS Rate,9691.88,100,MS-DRG,7753.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9691.88,100,,7753.504,Case Rate,100% of CMS IPPS Rate,19221.97,100,,,Case Rate,100% of CMS IPPS Rate,21968.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,24714.17,100,,,Case Rate,100% of CMS IPPS Rate,24714.17,100,,,Case Rate,100% of CMS IPPS Rate,24714.17,100,,,Case Rate,100% CMS IPPS Rate,17503,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,8819.26,100,,7055.408,Case Rate,100% of CMS IPPS Rate,8819.26,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,8819.26,100,MS-DRG,7055.408,Case Rate,100% of CMS IPPS Rate,8819.26,100,MS-DRG,7055.408,Case Rate,100% of CMS IPPS Rate,12743.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,9691.88,100,MS-DRG,7753.504,Case Rate,100% of CMS IPPS Rate,12599.44,130,MS-DRG,10079.552,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9982.64,103,MS-DRG,7986.112,Case Rate,103% of CMS IPPS Rate,9982.64,103,MS-DRG,7986.112,Case Rate,103% of CMS IPPS Rate,16443.74,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9691.88,100,MS-DRG,7753.504,Case Rate,100% of CMS IPPS Rate,10266.73,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,14537.82,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9691.88,100,MS-DRG,7753.504,Case Rate,100% of CMS IPPS Rate,19825.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9691.88,100,MS-DRG,7753.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,24714.17,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,CDM,,,,,Inpatient,,,,,,64905.56,,,,Case Rate,100% of CMS IPPS Rate,47043.22,145,MS-DRG,37634.576,Case Rate,145% of CMS IPPS Rate,32443.6,100,MS-DRG,25954.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32443.6,100,,25954.88,Case Rate,100% of CMS IPPS Rate,63374.24,100,,,Case Rate,100% of CMS IPPS Rate,72430.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,81481.85,100,,,Case Rate,100% of CMS IPPS Rate,81481.85,100,,,Case Rate,100% of CMS IPPS Rate,81481.85,100,,,Case Rate,100% CMS IPPS Rate,58591.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29521.91,100,,23617.528,Case Rate,100% of CMS IPPS Rate,29521.91,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,29521.91,100,MS-DRG,23617.528,Case Rate,100% of CMS IPPS Rate,29521.91,100,MS-DRG,23617.528,Case Rate,100% of CMS IPPS Rate,42231.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,32443.6,100,MS-DRG,25954.88,Case Rate,100% of CMS IPPS Rate,42176.68,130,MS-DRG,33741.344,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33416.91,103,MS-DRG,26733.528,Case Rate,103% of CMS IPPS Rate,33416.91,103,MS-DRG,26733.528,Case Rate,103% of CMS IPPS Rate,57942.06,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32443.6,100,MS-DRG,25954.88,Case Rate,100% of CMS IPPS Rate,34367.9,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,48665.4,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32443.6,100,MS-DRG,25954.88,Case Rate,100% of CMS IPPS Rate,66365.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32443.6,100,MS-DRG,25954.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,81481.85,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,CDM,,,,,Inpatient,,,,,,34038.31,,,,Case Rate,100% of CMS IPPS Rate,24670.81,145,MS-DRG,19736.648,Case Rate,145% of CMS IPPS Rate,17014.35,100,MS-DRG,13611.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17014.35,100,,13611.48,Case Rate,100% of CMS IPPS Rate,32638.29,100,,,Case Rate,100% of CMS IPPS Rate,37302.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,41963.86,100,,,Case Rate,100% of CMS IPPS Rate,41963.86,100,,,Case Rate,100% of CMS IPPS Rate,41963.86,100,,,Case Rate,100% CMS IPPS Rate,30726.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,15482.25,100,,12385.8,Case Rate,100% of CMS IPPS Rate,15482.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,15482.25,100,MS-DRG,12385.8,Case Rate,100% of CMS IPPS Rate,15482.25,100,MS-DRG,12385.8,Case Rate,100% of CMS IPPS Rate,21569.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,17014.35,100,MS-DRG,13611.48,Case Rate,100% of CMS IPPS Rate,22118.66,130,MS-DRG,17694.928,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17524.78,103,MS-DRG,14019.824,Case Rate,103% of CMS IPPS Rate,17524.78,103,MS-DRG,14019.824,Case Rate,103% of CMS IPPS Rate,31728.73,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17014.35,100,MS-DRG,13611.48,Case Rate,100% of CMS IPPS Rate,18023.5,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,25521.53,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17014.35,100,MS-DRG,13611.48,Case Rate,100% of CMS IPPS Rate,34804,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17014.35,100,MS-DRG,13611.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,41963.86,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,CDM,,,,,Inpatient,,,,,,22389.16,,,,Case Rate,100% of CMS IPPS Rate,16227.54,145,MS-DRG,12982.032,Case Rate,145% of CMS IPPS Rate,11191.41,100,MS-DRG,8953.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11191.41,100,,8953.128,Case Rate,100% of CMS IPPS Rate,22238.77,100,,,Case Rate,100% of CMS IPPS Rate,25416.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,28592.95,100,,,Case Rate,100% of CMS IPPS Rate,28592.95,100,,,Case Rate,100% of CMS IPPS Rate,28592.95,100,,,Case Rate,100% CMS IPPS Rate,20211.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10183.74,100,,8146.992,Case Rate,100% of CMS IPPS Rate,10183.74,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10183.74,100,MS-DRG,8146.992,Case Rate,100% of CMS IPPS Rate,10183.74,100,MS-DRG,8146.992,Case Rate,100% of CMS IPPS Rate,10935.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11191.41,100,MS-DRG,8953.128,Case Rate,100% of CMS IPPS Rate,14548.83,130,MS-DRG,11639.064,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11527.15,103,MS-DRG,9221.72,Case Rate,103% of CMS IPPS Rate,11527.15,103,MS-DRG,9221.72,Case Rate,103% of CMS IPPS Rate,21128.03,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11191.41,100,MS-DRG,8953.128,Case Rate,100% of CMS IPPS Rate,11855.2,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,16787.12,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11191.41,100,MS-DRG,8953.128,Case Rate,100% of CMS IPPS Rate,22892.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11191.41,100,MS-DRG,8953.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,28592.95,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,CDM,,,,,Inpatient,,,,,,46233.78,,,,Case Rate,100% of CMS IPPS Rate,33510.02,145,MS-DRG,26808.016,Case Rate,145% of CMS IPPS Rate,23110.36,100,MS-DRG,18488.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23110.36,100,,18488.288,Case Rate,100% of CMS IPPS Rate,46694.49,100,,,Case Rate,100% of CMS IPPS Rate,53367.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,60036.28,100,,,Case Rate,100% of CMS IPPS Rate,60036.28,100,,,Case Rate,100% of CMS IPPS Rate,60036.28,100,,,Case Rate,100% CMS IPPS Rate,41736.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,21029.23,100,,16823.384,Case Rate,100% of CMS IPPS Rate,21029.23,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,21029.23,100,MS-DRG,16823.384,Case Rate,100% of CMS IPPS Rate,21029.23,100,MS-DRG,16823.384,Case Rate,100% of CMS IPPS Rate,32230.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,23110.36,100,MS-DRG,18488.288,Case Rate,100% of CMS IPPS Rate,30043.47,130,MS-DRG,24034.776,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23803.67,103,MS-DRG,19042.936,Case Rate,103% of CMS IPPS Rate,23803.67,103,MS-DRG,19042.936,Case Rate,103% of CMS IPPS Rate,41977.76,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23110.36,100,MS-DRG,18488.288,Case Rate,100% of CMS IPPS Rate,24481.08,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,34665.54,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23110.36,100,MS-DRG,18488.288,Case Rate,100% of CMS IPPS Rate,47273.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23110.36,100,MS-DRG,18488.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,60036.28,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,CDM,,,,,Inpatient,,,,,,23235.32,,,,Case Rate,100% of CMS IPPS Rate,16840.85,145,MS-DRG,13472.68,Case Rate,145% of CMS IPPS Rate,11614.38,100,MS-DRG,9291.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11614.38,100,,9291.504,Case Rate,100% of CMS IPPS Rate,22876,100,,,Case Rate,100% of CMS IPPS Rate,26144.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,29412.24,100,,,Case Rate,100% of CMS IPPS Rate,29412.24,100,,,Case Rate,100% of CMS IPPS Rate,29412.24,100,,,Case Rate,100% CMS IPPS Rate,20974.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,10568.62,100,,8454.896,Case Rate,100% of CMS IPPS Rate,10568.62,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,10568.62,100,MS-DRG,8454.896,Case Rate,100% of CMS IPPS Rate,10568.62,100,MS-DRG,8454.896,Case Rate,100% of CMS IPPS Rate,15160.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,11614.38,100,MS-DRG,9291.504,Case Rate,100% of CMS IPPS Rate,15098.69,130,MS-DRG,12078.952,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11962.81,103,MS-DRG,9570.248,Case Rate,103% of CMS IPPS Rate,11962.81,103,MS-DRG,9570.248,Case Rate,103% of CMS IPPS Rate,21459.46,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11614.38,100,MS-DRG,9291.504,Case Rate,100% of CMS IPPS Rate,12303.25,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,17421.57,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11614.38,100,MS-DRG,9291.504,Case Rate,100% of CMS IPPS Rate,23758,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11614.38,100,MS-DRG,9291.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,29412.24,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,CDM,,,,,Inpatient,,,,,,14791.47,,,,Case Rate,100% of CMS IPPS Rate,10720.79,145,MS-DRG,8576.632,Case Rate,145% of CMS IPPS Rate,7393.65,100,MS-DRG,5914.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7393.65,100,,5914.92,Case Rate,100% of CMS IPPS Rate,15403.97,100,,,Case Rate,100% of CMS IPPS Rate,17605.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,19805.27,100,,,Case Rate,100% of CMS IPPS Rate,19805.27,100,,,Case Rate,100% of CMS IPPS Rate,19805.27,100,,,Case Rate,100% CMS IPPS Rate,13352.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,6728.01,100,,5382.408,Case Rate,100% of CMS IPPS Rate,6728.01,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,6728.01,100,MS-DRG,5382.408,Case Rate,100% of CMS IPPS Rate,6728.01,100,MS-DRG,5382.408,Case Rate,100% of CMS IPPS Rate,7954.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,7393.65,100,MS-DRG,5914.92,Case Rate,100% of CMS IPPS Rate,9611.75,130,MS-DRG,7689.4,Case Rate,130% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7615.46,103,MS-DRG,6092.368,Case Rate,103% of CMS IPPS Rate,7615.46,103,MS-DRG,6092.368,Case Rate,103% of CMS IPPS Rate,13945.36,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7393.65,100,MS-DRG,5914.92,Case Rate,100% of CMS IPPS Rate,7832.18,100,,,Case Rate,100% of CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,11090.48,150,MS-DRG,,Case Rate,150% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7393.65,100,MS-DRG,5914.92,Case Rate,100% of CMS IPPS Rate,15124.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7393.65,100,MS-DRG,5914.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,5900,19805.27,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,100,,0.2,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,0.2,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,0.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,5900,
UNGROUPABLE,999,CDM,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,100,,0.2,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,0.2,Case Rate,100% of CMS IPPS Rate,0.25,100,MS-DRG,0.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% CMS IPPS Rate,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5900,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.25,5900,